Presentation on theme: "Food: One Pillar supporting Quality of Life for people with HIV/AIDS"— Presentation transcript:
1Food: One Pillar supporting Quality of Life for people with HIV/AIDS Wanda Agnew, PhD, LRDBismarck-Burleigh Public HealthMay 14, 2009Medora , NDOur topic today is Nutrition in HIV Infection and AIDS progression.As you are probably aware, malnutrition is a complication of HIV infection that hastens disease progression and shortens survivalWeight loss and wasting have been predominant features of HIV disease progression since the beginning of the HIV/AIDS epidemic and have long been established as strong predictors of morbidity and mortality in patients infected with HIV.
2Outline Infections and Nutrition – general Medications and Nutrient connection (disconnect)Malnutrition , Weight Loss, WastingNutrition Assessment for NeedsNutritional InterventionsSummaryResourcesToday we would like to cover:Trends and prevalence of HIV/AIDS in the world and in the US and do a quick overview of the disease and the impact of HAARTtherapy on nutrition (highly active antiviral therapy) specifically it’s effect on AIDS wasting and HIV associated lipodystrophy.We’ll also talk about some nutritional interventions to combat AIDS wasting.And finish our presentation with our case study and discussion
3Natural History of Untreated HIV Infection This graph shows a good representation of how CD4 counts decline overtime in untreated HIV infection.From this graph you can see that a person infected with HIV has an initial drop in cd4 cell count and as the disease progresses over time and cd4 cells decline, the immune system is further compromised thus increasing the risk of Early opportunistic infections such as bacterial infections, varicella zoster, candida, followed by pcp, and cmv, mac, and fungi infections
4Opportunistic Infections Thus HIV infected pts are at risk for a whole host of opportunistic infections including: fungal, viral, mycobacterial, parasitic, and bacterial infections as well as lymphoma’s kaposi’s sarcoma, neurologic manifestations, and HIV nephropathyAnd as a note, Most of these conditions are opportunistic infections that generally do not affect healthy people. However, In people with AIDS, these infections are often severe and sometimes fatal because the immune system is so ravaged by HIV that the body cannot fight off certain bacteria, fungi, and microbes.
5Manifestations of HIV Infection Primary InfectionClinical LatencyAdvanced Diseaseoften asymptomatic or overlookedsymptoms 1-6 weeks after infectionviral like syndrome: sore throat, fever, lymphadenopathy, rashdifferential includes EBV, CMV, hepatitis, toxoplasmosisantibody (ELISA, Western Blot) may not be detectedusually asymptomaticlymph nodes site of ongoing viral latencymassive viral productiondestruction of CD4 cellsa decrease in lean body mass without apparent total body weight changevitamin B12 deficiencyincreased susceptibility to food and water-borne pathogens.SymptomaticPlasma viremia begins to riseCD4 cell count falls furtherA decline in nutrient status or body compositionOpportunistic infections develop:fever, weight loss, lymphadenopathy, thrush, diarrhea, malignancies, wasting syndrome, neurologic syndrome including dementiaSo how is HIV manifested?Well, in the primary infection phase when a person first becomes infected with HIV, he or she may not have any symptoms;Symptoms usually present 1-6 weeks after infectionMost often, they are viral like syndrome such as sore throat, fever, lymphadenopathy, and rashA differential at that time may include EBV, CMV, hepatitis, toxoplasmosisAn antibody for the virus may or may not be detected at that timeDuring the clinical latency period which can last several years, pts may still be asymptomatic with ongoing massive viral production and destruction of cd4 cells. Pt may also notice a decrease in lean body mass without any apparent total body weight changePts at this stage may present with a vitamin 12 deficiency and increased susceptibility to food and waterborne pathogensAs the disease progresses, pts become more symptomatic with increase plasma viremia, cd4 counts falls even further, and nutritional status and body composition begins to declineAt this stage, opportunistic infections develop which may bring about symptoms such as fever, weight loss, lymphadenopathy, thrush, diarrhea, malignancies, wasting syndrome, and dementia
6Antiviral Drug Therapy Nucleoside/NucleotideAnaloguesNonnucleoside Reverse Transcriptase InhibitorsProtease InhibitorsFusion InhibitorsAbacavir Didanosine Emtricitabine Lamivudine Stavudine Tenofovir Zalcitabine ZidovudineDelavirdine Efavirenz NevirapineAmprenavir Atazanavir Fosamprenavir Indinavir Lopinavir/Ritonavir Nelfinavir Ritonavir SaquinavirEnfuvirtideThese are 4 classes of antiviral drugs on the market to help treat HIV/AIDS.A Combination of these drugs is the standard of care for people with HIV. They are often referred to HAART which stands for r Highly Active Anti-Retroviral Therapy.Because each classes of drugs work in different ways they are often prescribed in combination. And Because HIV can become resistant to each class of drugs, combination treatment using both is necessary to effectively suppress the virus.Nucleoside Reverse Transcriptase Inhibitors (NRTIs)Nucleotide Reverse Transcriptase InhibitorsNon-nucleoside Reverse Transcriptase Inhibitors (NNRTIs)Protease Inhibitors (PIs)Fusion Inhibitors (one approved by FDA)Integrase Inhibitors (in clinical trials)
7How HIV Drugs Work HIV drugs work in different ways: The entry inhibitors work by stopping HIV from getting into the CD4 cell,The nucleoside analogues and the Non-Nucleoside Reverse-Transcriptase Inhibitor prevent viral replication by interfering with the virus’s ability to make key enzymes like reverse transcriptase,Likewise the protease inhibitors inhibit protease replication and work by stopping any new HIV virus from leaving the CD4 cellCurrently there is one fusion inhibitor on the market and basically work by preventing HIV from fusing with a host cellNucleoside Analogue: This is a class of drugs that fight HIV by interfering with the virus's ability to make a key enzyme called "reverse transcriptase." AZT was the first nucleoside analogue licensed, and many others, such as ddI, ddC, d4T, and 3TC have followed it. These drugs act at the DNA level. They also affect normal cell growth, such as bone marrow cells, so there can be significant toxic effects.NNRTI (Non-Nucleoside Reverse-Transcriptase Inhibitor): A class of drugs that inhibit an enzyme used by HIV called "reverse transcriptase".Protease Inhibitors: Antiviral drugs that act by inhibiting the virus protease enzyme, thereby preventing viral replication. Specifically, these drugs block the protease enzyme from breaking apart long strands of viral proteins to make the smaller, active HIV proteins that comprise the virion. If the larger HIV proteins are not broken apart, they cannot assemble themselves into new functional HIV particles.T-20 IS A FUSION INHIBITOR and prevents HIV from fusing to a host cell. During infection, the HIV binds to the CD4 cell. T-20 interferes with this process. There is no oral formulation of T-20; the current delivery method is by subcutaneous injection.
8Adverse Drug Effects Mitochondrial dysfunction Metabolic abnormalities HematologiccomplicationsAllergicreactionsLactic acidosisHepatic toxicityPancreatitisPeripheral neuropathyLipodystrophyFat accumulationLipoatrophyHyperlipidemia/? Premature CADHyperglycemiaInsulin resistance/DMBone disorders: oesteoporosis and osteopeniaBone marrowsuppressionHypersensitivitySkin rashesAlthough HIV treatment has increased survival, researchers have found some adverse complications associated with HAART including:Lactic acidosis is a rare but serious complication the NRTIs – women, especially pregnant women, overweight people, pts with long history of NRTI use are at higher riskHepatic toxicity, pancreatitis, and peripheral neuropathy have been observedMetabolic abnormalities mostly associated with PI inhibitors include:LipodystropyHyperlipidemiaHyperglycemiaInsulin resistanceDecreased glucose toleranceNew onset diabetes mellitusDKAExacerbation of existing DMAnd bone disorders which women have been found to be at her risk forBone marrow suppression as well as skin hypersensitivity have been observed
9Medication Side Effects and how they relate to eating, food --------- MALNUTRITION AnorexiaSore/dry/painful mouthSwallowing difficultiesConstipation/DiarrheaNausea/Vomiting/Altered TasteDepression/Tiredness/LethargyIn addition to metabolic side effects, medication can interfere with eating which may contribute to malnutrition. Some of these side effects include:AnorexiaSore/dry/painful mouthSwallowing difficultiesConstipation/DiarrheaNausea/Vomiting/Altered TasteDepression/Tiredness/LethargyAttached in your packet are management strategies for avoiding weight loss
10Pathogenesis of Malnutrition in HIV Infection Many studies have shown that the development of malnutrition in HIV/AIDS is multifactorial and is influenced by the disease stage as well as specific disease complications which may lead to alterations in caloric intake, nutrient absorption, or energy expenditure.
11Malnutrition can... Contribute to impaired immune response Result in more rapid disease progression & shortened survivalContribute to increased frequency and severity of infectionsResult in fatigue, loss of appetite, sense of taste and smell, and decreased quality of lifeDecrease tolerance to therapy and lessen medication efficacyMalnutrition is:In a nutshell, malnutrition in HIV infected persons may lead to poor outcomes. So the goals of nutrition therapy are to minimize nutritional losses, to replete after losses, and improve functional status and quality of life.
12Weight Loss: Independent Predictor of Mortality Weight loss and wasting have been predominant features of HIV disease progression since the beginning of the HIV/AIDS epidemic and have long been established as strong predictors of morbidity and mortality in patients infected with HIV.
13Weight Loss: Independent Predictor of Mortality With the advent of HAART and prophylaxis for opportunistic infections, many AIDS-defining illnesses that were previously frequent are now rarely seen in successfully treated patients.Weight loss and wasting have been predominant features of HIV disease progression since the beginning of the HIV/AIDS epidemic and have long been established as strong predictors of morbidity and mortality in patients infected with HIV.Several studies in the pre-HAART era showed that HIV-related wasting was strongly associated with more rapid disease progression and increased mortality in HIV-infected patients.With the advent of HAART and prophylaxis for opportunistic infections, many AIDS-defining illnesses that were previously frequent are now rarely seen in successfully treated patients.So the prevalence of HIV-related wasting syndrome has greatly diminished ; however, several studies have concluded that patients treated with HAART were still at risk for wasting.For example, in a large longitudinal study being conducted at Tufts University Nutrition for healthy living, Wanke et al. found that1/3 of HIV-infected patients in the NFHL study who were treated with HAART were still at risk for wasting. This was a longitidinal study looking at the causes and consequences of malnutrition in HIV.Thus weight loss, regardless of treatment status, remains a strong predictor of death.NFHL – the Tufts University Nutrition for Healthy Living study ongoing longitudinal study of the causes and consequences of malnutrition in HIV infection. First phase includes HIV + adults living in greater Boston and RI ~678 participants
14Weight Loss: Independent Predictor of Mortality So the prevalence of HIV-related wasting syndrome has greatly diminished ; however, several studies have concluded that patients treated with HAART were still at risk for wasting.Wanke et al. found that ~1/3 of HIV-infected patients in the NFHL study who were treated with HAART were still at risk for wasting.Thus weight loss, regardless of treatment status, remains a strong predictor of death.
15Pathophysiology AIDS Wasting Oxidative StressMicronutrient DeficiencyIntestinal ParasitesMalabsorption/DysphagiaOpportunistic InfectionImmune FunctionHIVPro-inflammatoryCytokines (TNF alpha)AnorexiaDietary IntakeSo what are some of the causes of HIV wasting?Hiv wasting occurs for many reasons, one of which is a rise in the level of tumor necrosis factor, a cytokine that helps regulate the immune system. The increase in TNF causes decreased appetite, increased metabolic needs, and an alteration in metabolism that spares fat tissue but accelerates muscle breakdown.HIV not only suppresses the immune function but also increases cytokine activityA person infected with HIV has a decreased immune function which puts him or her at risk for developing opportunistic infections which may lead to increased oxidative stress and pro-inflammatory cytokine activityThis increase in inflammatory cytokines can alter metabolism and contribute to anorexia. Poor intake coupled with altered metabolism resulting in negative energy balance, fat and protein loss.The HIV infection itself may cause appetite depression by prompting the immune system to release cytokines, which can alter metabolism and contribute to anorexia.When patients do eat, food is often not absorbed properly because of opportunistic infections of the GI tract or intestinal damage inflicted by HIV itself. The malabsorption leads to chronic diarrheaDiarrhea and malabsorption can result from direct HIV infection in the intestine but are more often caused by opportunistic pathogens that take advantage of the depressed immune system leading to micronutrient deficiencies which further depresses the immune system.Negative EnergyBalanceMetabolic RateEndocrine DisorderFat LossSkeletal Protein BreakdownProtein LossJ AIDS 1988
16Potential Mechanisms of AIDS Wasting Increased energy expenditureDecreased energy intakeAltered metabolismHormonal AlterationsThe literature has cited 4 potential mechanisms for AIDs wasting, these includeIncreased energy expenditureDecreased energy intakeInefficient use of energy substrateAnd hormonal factors
17AIDS-related Wasting Syndrome Profound involuntary weight loss > 10% of baseline BW accompanied by fever or weakness and chronic diarrhea for >30 daysWeight loss or wasting even with adequate or increased calorie intakeDecrease in LBM without weight loss during pre-symptom phaseIt is important to not that a patient’s weight loss alone does not constitute wasting. Diagnosis of the syndrome is based on 2 criteria:Involuntary loss of more than 10 percent of the baseline body weightEither chronic diarrhea, or chronic weakness and fever, defined as occurring constantly or intermittently for more than 30 daysPatients should also be free of illnesses or conditions other than HIV infection that could explain their weight loss (i.e. TB or enteritis)
18Wasting is diagnosed …. Lose 7.5% over 6 months OR 10% over 12 months BMI drops below 20
19Nutritional Problems (cont) Diarrhea and malabsorption can result from direct HIV infection in the intestine but are more often caused by other pathogens such as bacteria, Crytosporidium, or herpes simplex that take advantage of the depressed immune system.Medications can interfere with eating by causing GI discomfort, nausea, vomiting, diarrhea, and altered tasteDepression often leads to isolation, apathy, neglect of self-care, and diminished appetite – all which can affect immunocompetenceSocioeconomic factors play an important role in whether the patient can afford adequate and nutritious food.Diarrhea and malabsorption can result from direct HIV infection in the intestine but are more often caused by other pathogens such as bacteria, Crytosporidium, or herpes simplex that take advantage of the depressed immune system.Medications can interfere with eating by causing GI discomfort, nausea, vomiting, diarrhea, and altered taste.Depression often leads to isolation, apathy, neglect of self-care, and diminished appetite – all which can affect immunocompetenceSocioeconomic factors play an important role in whether the patient can aford adequate and nutritious food.
20Altered MetabolismEarly studies documented weight loss and protein depletion in untreated patientsThe application of HAART has led to a decreased incidence of malnutritionSyndrome of altered body fat distribution has emerged (lipodystrophy) associated with PIsHypertriglyceridemia, hypercholesterolemia, and insulin resistance are commonly seen in patients treated with HAART therapy.The 3rd potential contributor for AIDS wasting is an alteration in metabolism.Early studies have associated body cell mass depletion in untreated patients as mentioned before and with HAART the incidence of malnutrition in HIV infected patients has fallen substantially but has not disappeared.But with the advent of HAART therapy the syndrome of altered body fat distribution has emerged and is referred to lipodystrophy which has been strongly associated with Protease inhibitors (PIs)hypertriglyceridemia, hypercholesterolemia, and insulin resistance are also common metabolic alterations seen in patients treated with HAART therapy.Why HARRT decreases Malnutrition ? Bcz less prone to have Opportunistic infections that may lead to poor nutrition and thus at lower risk for malnutrition.
21HIV-Associated Lipodystrophy HyperlipidemiaInsulin resistanceFataccumulationFatatrophyMany researchers investigating HIV-related metabolic disorders agree that this syndrome most likely has a multifactorial etiologyFour distinct sets of issues have been noted: dyslipidemias, glucose dysregulation, fat depletion, and fat accumulationA build up of fat: Some people see an increase in the amount of fat around their gut, and/or on the back of their neck & shoulders (sometimes referred to as a "Buffalo Hump"), and/or in their breasts. The medical term for this is lipohypertrophy (excessive fat growth). The gut fat has been given unscientific nicknames by its earliest sufferers, such as "Crixy Belly", or "Protease Paunch", since it first became prevalent in those taking Crixivan, one of the earliest and most commonly used protease inhibitors. It is important to note that a build up of fat around the gut and waist isn't always lipodystrophy. Lipodystrophy usually makes the abdomen look bloated or descended and often feels hard. This is because the fat associated with lipodystrophy builds up deep within the body, around internal organs, causing the abdomen to look swollen. If the fat around your gut or waist feels doughy, fleshy, or soft – a good test is to see if you can "pinch an inch" around your waist – it's probably not lipodystrophy but instead typical weight gain that comes with getting older. A loss of fat: Some people see the fat in their legs, arms, buttocks, or face diminish. This can cause veins to protrude in the arms and legs and sunken cheeks in the face. The medical term for this is lipoatrophy (decrease in fat tissue).Loss of buttock fatFacial thinning / atrophy /pleatSimilar findings have been reported in HIV patients not taking protease inhibitorsMay be associated with insulin resistance and hyperlipidemiaHigh levels of fats in the blood: Some people have an increased amount of fat, or lipids, in their blood. The two types of lipids that increase are triglycerides and cholesterol. Increased cholesterol levels can increase the risk of a heart attack or stroke. Increased triglycerides can increase the risk of damage to the pancreas (pancreatitis). High levels of sugar in the blood: Some people have seen the amount of sugar, or glucose, in their blood increase. This may also be associated with an increase in the amount of insulin � a hormone produced by the pancreas to help control glucose levels � in the blood. This can lead to diabetes, a potentially dangerous problem that requires medical attention.
22Nutritional ProblemsDecreased appetite may result from fever, pain, fatigue, emotional stress, and altered sensations of taste and smell due to medication side effects.Lactose intolerance is an early effect of HIV on the intestinal tract due to the loss of lactase. The HIV infection changes the structure of the gut wall, resulting in a decreased lactase level. Intolerance results in fermentation causing abdominal cramping and a bloated feeling.Oral Lesions, caused by Candida albicans, herpes, or Kaposi’s sarcoma can make chewing and swallowing difficult and painful.The 2nd potential mechanism for AIDS wasting as I mentioned before is decreased energy intake. So some of the contributors that may affect intake include:Decreased appetite which may result from fever, pain, fatigue, emotional stress, and altered sensations of taste and smell due to medication side effects.Lactose intolreance is an early effect of HIV on the intestinal tract due to the loss of lactasek. The HIV infection changes the structure of the gut wall, resulting in a decreased lactase level. Intolerance results in fermentation causing abdominal cramping and a bloated feeling.Oral Lesions, caused by Candida albicans, herpes, or Kaposi’s sarcoma can make chewing and swallowing difficult and painful.Diarrhea and malabsorption can result from direct HIV infection in the intestine but are more often caused by other pathogens such as bacteria, Crytosporidium, or herpes simplex that take advantage of the depressed immune system.Medications can interfere with eating by causing GI discomfort, nausea, vomiting, diarrhea, and altered taste.Depression often leads to isolation, apathy, neglect of self-care, and diminished appetite – all which can affect immunocompetenceSocioeconomic factors play an important role in whether the patient can aford adequate and nutritious food.
23What Causes Lipodystrophy? Syndrome most likely has a multi-factorial etiologyMost patients who have lipodystrophy started noticing symptoms while they were on triple-drug therapy.Lipodystrophy was first reported among patients taking combinations of drugs that included a protease inhibitor (PI).There are also some patients who have experienced one or more symptoms of lipodystrophy without taking any anti-HIV drugs at all.It's still not clear what role these anti-HIV drugs play in the development of lipodystrophy.What Causes Lipodystrophy?We don't really know what causes lipodystrophy. All we know is that a large number of HIV-positive people are experiencing one or more of the symptoms mentioned above. We also know that most patients who have lipodystrophy started noticing symptoms while they were on triple-drug therapy. Lipodystrophy was first reported among patients taking combinations of drugs that included a protease inhibitor (PI).
24What does Lipodystrophy look like? Central obesity with peripheral fat wastingVisceral fat accumulation, dorsocervical fat accumulation (buffalo hump)For most people, the changes are subtle. But for others, lipodystrophy can be quite disfiguring. Here are two pictures. The first shows the body changes that can occur, including extensive buildup of fat in the gut and on the back of the neck & shoulders, along with some loss of fat in the arms. The second shows a loss of fat in the face (facial lipoatrophy).Lipodystrophy usually makes the abdomen look bloated or descended and often feels hard. This is because the fat associated with lipodystrophy builds up deep within the body, around internal organs, causing the abdomen to look swollen.A loss of fat: Some people see the fat in their legs, arms, buttocks, or face diminish. This can cause veins to protrude in the arms and legs and sunken cheeks in the face. The medical term for this is lipoatrophy (decrease in fat tissue).
25Nutrition AssessmentScreen for Nutrition Concerns at initial visit and each visit there after including:Assess HIV infection-related symptoms experiencingAssess dietary patterns, food availability, nutrient intake, erratic and/or inadequate intakesAssess use of non-traditional therapiesAssess psychosocial conditions, income, and insuranceAssess anthropometric measurementsAssess lab valuesDIETITIAN
26WHOScreening nurse may assess nutritional status, but need tools to ask right questionsPhysicians may assess nutritional status – generally physicians refer to:DIETITIAN -Ryan White Services pay for Nutrition Counseling for HIV patients Others are charged, based on income, as assessed, using a sliding fee scale discussed during the appointment.
27Nutrition Assessment - Physical Height, Weight, BMIUse accurate techniquesCheck routinely – record and monitor changeBody compositionBMIFat distribution changesShape changesRED FLAGS – wt change since last time and/or BMI <20Ask questions about why weight changes, look for clinical signs of deficiencies/excesses
28Lab Values related to nutrients AlbuminIronLipid ProfileRenal Function TestsBlood Sugar
29Complimentary and Alternative Therapies St Johns Wart decreases blood levels of indinivir – may cause drug resistance and treatment failureGarlic supplements have been shown to reduce blood level of saquinavirMilk thistle (silymarin) could lessen metabolism of medication and increase toxicityHigh use of any Complimentary/Alternative Therapy is costly and may lead to toxicity or interfere with medications
30INDIVIDUALIZE! Diet Therapy Help maintain your health and quality of life by having your nutrition reassessedevery 3-6 months.
31Nutrition Care Process Prioritize most urgent issuesIntervention goalsPrevent adverse events to therapiesRestore adequate nutritional statusDo Diet PrescriptionPatients often tend to eat high fat and low fiber – advise on tolerable good nutrition – base macronutrient ratio on lipid level tolerated or advice by medications and how much glucose or carbs that can be tolerated
32Nutrition is important for - health- immune system.NEED:high-quality foods for energy & strength
33High-quality foods from all the food groups Grains: choose whole grains for fiberWhole grain breads and cereal, whole wheat pasta, oatmeal, brown rice, couscous, barley, quinoa, whole wheat tortillasHepatitis C: plan a diet high in carbohydrates to help spare your proteinFats & Oils: Choose heart healthy fatsOlive oil, canola oilFat offers twice as many calories as protein and carbohydrates
34High-quality foods from all the food groups Fruits & Vegetables: VARIETY is importantAim for as many colors and types of fruits and vegetables possibleChoose 100% juice for immune system support
35High-quality foods from all the food groups Dairy Products: calcium is importantLow-fat/non-fat milk, cheese, yogurt, soy products
36High-quality foods from all the food groups Meat & Protein: bake, roast, or grill—Don’t fryChicken, turkey, fish rich in omega-3’s (salmon, sardines, mackerel), eggs, nuts, seeds, tofu, lentils, beansHIV/AIDS: increase protein to fight fever & infectionsHepatitis C: keep protein at individual recommended levels to spare your liver
37High-quality foods from all the food groups Fats & Oils: Choose heart healthy fatsOlive oil, canola oilFat offers twice as many calories asprotein and carbohydrates
38Diet Therapy: Fat Varies in tolerance bases on individual Assess fat for malabsorption – diarrheaMCT to reduce steatorhea, abdominal crampsOmega-3 fatty acids may improve immune functionFollow usual guidelines for elevated cholesterol & triglycerideInclude soluble fiber, plant sterols, soy protein, and cholesterol saturated factorsMCT – Palm and coconut oils
39DIET THERAPY: Calories 500 calories above Energy Expenditure at Rest (EER)= calories/kgExample 180 pound man – 82 kgs = 3600 calories/day
40Diet Therapy: Protein 1.0 g/kg to 1.4 g/kg for maintenance 1.5 g/kg to 2.0 g/kg for replacingOnly restrict is severe liver or kidney disease with doctors order
41Diet Therapy: FLUIDS & ELECTROLYTES Fluid = 30 to 35 ml/kgDuring times of diarrhea extra fluid (2 cups/day) and electrolytes for night sweats, diarrhea, and feverPedialyte, kool-ade with salt, jello, broth
42Diet Therapy: Vitamins and Minerals Actual status is seldom identifiable in labsGather patient self-reported intakeSuggest 100% One-A-Day with minerals (calcium, Iron, Magnesium)Suggest Basic Vitamin B-SupplementGo for higher doses if diarrhea is prolonged, anemia develops or dietary deficiencies are evidentCheapest - Nature Made or other brands – difficult to find with most V&M at 100%
43Nutrition Counseling Medicaid – 4 sessions/year Medicare – 4 sessions/yearPublic Health – sliding scaleDiet order from physicianReceive an assessmentReceive a Diet Prescription – not just nutrition but foodCarbs will be added after Protein, fat and glucose tolerance is considered
44Macronutrients VS. Micronutrients CarbohydrateProteinFatWaterMICROVitaminsMineralsAntioxidantsMacronutritents are difficult to get – unless you eat food and micro do not have calories or give energy
45High Quality, High Calorie Snack Ideas: Boost, Vanilla (8 oz)(240 calories, 10 g protein)Whole grain cereal/ whole milk(350 calories, 15 g protein)Cheese pizza + medium soda(420 calories, 12 g protein)Mixed Nuts, 2 oz(350 calories, 20 g protein)Kraft® Macaroni & Cheese,3/4 C.(250 calories, 10 g protein)Carnation Instant Breakfast, 1 packet (130 calories, 6 g protein)Cheese & crackers, 3 cheese slices + 5 butter crackers(425 calories, 22 g protein)Eggnog, 1 cup(350 calories, 10 g protein)Ensure, Homemade Van.(8 oz) (250 calories, 9 g protein)
46High Calories Snack Ideas: Glazed donut, 2(360 calories, 6 g protein)Dairy Queen® blizzard, small (520 calories, 10 g protein)· McDonalds® McFlurry, 12 oz (600 calories, 15 g protein)Snickers®, king-size(540 calories, 9 g protein)
47Diet Prescription Increase calories Increase protein Increase fiber Increased fruit and veggiesFood safetyDrug-nutrient interactionsPerhaps anti-diarrheal, pancreatic or lactase enzymesBurleigh Diet
49Nutritional Supplements in HIV Infection to counteract AIDS Wasting MVIGlutamineCarnitineAppetite StimulantInsulin Sensitizing AgentsAnti-catabolic medicationsResistance Training
50Role of Micronutrients in the Pathogenesis of HIV infection Micronutrients play important roles in maintaining immune function and SLOW reactive oxidant destructionMicronutrient deficiencies are common among HIV infected persons – nature of disease and malnutritionMicronutrient deficiency has been associated with further immunopression, oxidative stress, speeds up HIV replication and CD4+ T-cell depletion. (semba)
51Vitamin E and CConclusion: Supplements of vitamin E &C reduce oxidative stress in HIV and produce a trend towards a reduction in viral load.This is worthy of larger clinical trials, especially in HIV-infected persons who cannot afford new combination therapiesAids - 10 September Volume 12 - Issue 13 - p
52Glutamine Application in HIV/AIDS Glutamine is the most abundant amino acid in the body and is considered a conditionally essential amino acid during periods of catabolism.During periods of increased metabolic stress, glutamine is released freely from the skeletal muscle, and intracellular glutamine concentrations fall by more than 50%Increased synthesis of glutamine in the skeletal muscle often results in muscle-wasting syndromeGlutamine synthesis cannot keep up with the higher requirements during stress. – ADD - high-protein foods including beef, chicken, fish, beans, and dairy products.Individuals deficient in glutamine manifest changes in gut morphology including increased membrane permeability resulting in bacterial translocation, malabsorption, and diarrhea
53Glutamine Application in HIV/AIDS (cont…) Data suggest that glutamine supplementation offers the potential to limit skeletal muscle wasting, reduce diarrhea and malabsorption, enhance immune host defense, and reduce the incidence of opportunistic infections associated with HIV infection and AIDS Shabert J et al. Med Hypotheses. 1996;46:
54L-Carnitine in HIV Infection Carnitine is a conditionally essential amino acid found predominantly in red meat. It is also found in milk (human and cow’s), pork, lamb, tempeh, and supplements.It is conditionally essential because the body can make it from lysine and methionine with assistance from Vitamin C and other compounds produced in the body.Carnitine is synthesized in the Kidney and stored in the muscles.Carnitine’s function is to shuttle long-chain fatty acids into the mitochondria to be utilized as fuel.HIV/AIDS is a risk factor for carnitine deficiency
55Appetite Stimulant: Dronabinol Derived from delta-9-tetrahydrocannabinol (major active component of Marijuana)Useful in decreasing nausea and increasing appetiteInsignificant gains or even loss of total BWMay induce central nervous system events such as anxiety, confusion, emotional lability and hallucinations, possibly addictive.Treatment Guidelines for HIV Associated Wasting, Mayo Clinic Proceedings, April 2000
56Appetite Stimulant: Megestrol Acetate (Megace) A synthetic derivative of the natural steroid hormone, progesterone.Improved appetite in a number of studiesTakes two weeks for effect.Considerable increases in BW, although mostly in body fatMay be due to testosterone lowering effect, not reversed by supplementation w/testosteroneMay induce or exacerbate DM, cause adrenal insufficiency when abruptly discontinued after long-term useTreatment Guidelines for HIV Associated Wasting, Mayo Clinic Proceedings, April 2000
57Appetite Stimulants Sips of wine (Mogan David) Chocolate Culantro – long leafed different than cilantro
58Resistance TrainingSupervised exercise training is a promising anabolic strategy for pts with AIDS.Studies of exercise training have shown increased muscle function, wt gain, strength, LBM.Effects of resistance training alone in AIDS wasting pts remains unknown.However, use of resistance training with growth hormone replacement has been shown to be effective in AIDS pts with AIDS wasting.Journal of the American Medical Association, April , Volume 281(14), ppThe New England Journal of Medicine, June
59Summary HIV/AIDS remains an epidemic worldwide Malnutrition is a complication in HIV related morbidity and mortalityWeight loss is an independent predictor of mortalityDespite HAART, patients remain at risk for AIDS wasting syndromeContributors of AIDS wasting syndrome include increased energy expenditure, decreased energy intake, altered metabolism, and hormonal factorsGood food from variety of whole grains, beans and animal protein, More Matters for fruit and veggies, calcium – VITAL!Multivitamin supplementation could reduce the risk of or delay HIV-associated disease and mortality.Data suggest glutamine supplementation may help limit skeletal muscle wasting
60Summary (cont)Pts have been found to be deficient in Carnitine, may benefit from supplementation since it may have antiapoptic effect through antioxidant activity.Appetite Stimulants may result in wt gain, but mostly in adding fat and may also have some negative side effects.Testosterone deficiency may lead to wasting, supplementation may be beneficial leading to improved sense of well being, strength, etc, however Testosterone over use may damage liver.Correction of Growth Hormone resistance may help reverse wasting, but it is a costly intervention if pt does not have Medicaid. Short term use has been shown to be beneficial.Resistance training has been shown to increase wt and LBM, but one study found that training plus growth hormone was most beneficial.
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