1. HIV Nutrition Essentials For Program and Administrative Grantees Marcy Fenton, M.S., R.D. Program Manager, Care Services Division County of Los Angeles Department of Public Health Office of AIDS Programs and Policy August 29, 2006

2. 2 Los Angeles County Square Miles:4,086 Population:9.9 Million Latino/a 45.7% White 31.0% Asian/PI 13.2% African-American9.7% Native American0.3% Proportion of California Population: 29% Proportion of California AIDS Cases:35% Living with HIV/AIDS: 58,000 (Estimated) 2 SPA 6: South SPA 8: South Bay SPA 5: West SPA 2: San Fernando SPA 4: Metro SPA 3: San Gabriel SPA 1: Antelope Valley SPA 7: East

3. 3 HIV Nutrition Essentials Overview Current nutrition issues and treatments Medical nutrition therapy (MNT) program necessary ingredients Lessons learned monitoring Los Angeles County medical outpatient services’ MNT programs

4. 4 HIV Nutrition Essentials Handout Materials Presentation slides Guides and resources  Diet, nutrition, fact sheets  Professional competency Weight & nutrition HIV nutrition screen & referral forms  ADA 2005  Nutrition quick screen Request copies of handouts: MFenton@ladhs.orgMFenton@ladhs.org

5. 5 HIV Nutrition Essentials Current HIV Nutrition Issues

6. 6 HIV MNT Overall Goals Optimize nutrition status, immunity and quality of life Prevent nutrient deficiencies Achieve and maintain optimal body weight and composition Manage co-morbidities Maximize effectiveness of medications

7. 7 Vicious Cycle of Malnutrition and HIV Poor Nutrition resulting in weight loss, muscle wasting, weakness, nutrient deficiencies Increased Nutritional needs, Reduced food intake and increased loss of nutrients Increased vulnerability to infections e.g. Enteric infections, flu, TB hence Increased HIV replication, Hastened disease progression Increased morbidity Impaired immune system Poor ability to fight HIV and other infections, Increased oxidative stress HIV Source: Fanta Project www.fantaproject.org Adapted from RCQHC and FANTA 2003www.fantaproject.org

8. 8 HIV Nutrition Issues Poor Immune Function Food and water safety, sanitation Optimized nutrient and fluid intake Vitamin mineral supplementation Exercise: aerobic and progressive resistance training Medication adherence Stress reduction Establishment of trusting relationships

9. 9 Nutrition Issues and Treatments Common Side Effects GI distress  Diarrhea  Nausea/vomiting  Gas Anorexia Fatigue Taste alterations Mouth pain Anemia Hyperlipidemia Insulin resistance Hypertension Liver toxicity Renal impairment Obesity Lipodystrophy Peripheral neuropathy Cancer

10. 10 Causes of Weight Loss 1-Inadequate Intake Oral and upper gastrointestinal Anorexia Psychosocial-economic Malabsorption Source: Mangili A et al. CID 2006:42 (15 March) p 836-42

11. 11 Causes of Weight Loss 2-Altered Metabolism Uncontrolled HIV infection Metabolic demands of HAART Opportunistic infections or malignancies (AIDS-defining conditions) Hormonal deficiencies (testosterone or thyroid) Cytokine dysregulation Source: Mangili A et al. CID 2006:42 (15 March) p 836-42

12. 12 Resting Energy Expenditure Grunfeld et al. AJCN 1992;55:455-60.

13. 13 Impact of Viral Load on Resting Energy Expenditure

14. 14 HIV Wasting Definitions CDC Nutrition for Healthy Living (Tufts) Grinspoon, Mulligan & DHHS Working Group Polsky, Kotler & Steinhart

15. 15 Calories Needed and Weight Change Relation to Viral Load Not on HAART  0.92 kg body weight decrease per each HIV RNA log 10 increase  22 Kcal increase in REE per increase in per 1-log copy/ml Stable HAART  0.35 kg body weight decrease per each 100-cell/mm 3 CD4 cell decrease  81 kcal higher REE Source: Wanke et al. CID 2006:42 (15 March)

16. 16 Outcomes of Weight Loss Morbidity and mortality independent of CD4 and viral load Weight loss of >5% associated with increase risk of mortality even with ART Adverse pregnancy outcomes Weight loss & wasting continue to be common problems

17. 17 International Nutrition Feeding Safely and Adequately Access to nutritious food Access to safe water Malnutrition  Linked with HIV infection  Linked with poor prognosis  Linked with poor prognosis despite ART Breast feeding Access to HIV medications

18. 18 Overweight, Obesity and HIV Sources: (1) Amorosa et al. JAIDS 2005;Aug15;39(5):557-61. (2) NHANES 1999-2000; www.cdc.gov 7/03www.cdc.gov

19. 19 Weight Classification Using BMI BMI 1 Note Underweight<18.5 Malnutrition 2 <18.5 Wasting 3 <20.0 Normal18.5-24.9 Overweight25.0-29.9 Obesity (I) 30.0-34.9 Obesity (II) 35.9-39.9 Extreme Obesity (III) >40.0 (1) National Heart, Lung and Blood Institute, (2) Magili et al. CID 2006 March, (3) Amorosa; Grinspoon, Mulligan & DHHS Working Group 2003 April-S CID

20. 20 Conditions Associated with Obesity Obesity Hyperlipidemia Heart Disease Stroke Hypertension Gout Non-Insulin Dependent DM Osteoarthritis Mood Disorders Sleep Disorders Eating Disorders Some Cancers Gall Bladder BMI: HIV vs. General Populations Contemporary Diagnosis and Management of Obesity. Geroge A. Bray, MD

21. 21 Desirable Girth Measurements Waist circumference  Men: <40 inches  Women: <35 inches  NHANES methodology Waist to Hip Ratio?  Less accurate  Not recommended  Hip circumference ok  Monitor waist & hip from baseline

22. 22 Overweight, Obesity & HIV Fuel of Metabolic Abnormalities BMI positive correlation with  Total cholesterol  Triglycerides  Glucose Obesity not correlated with  Age, income, employment, education  Past/current IVD use  HIV treatment, viral load Source: Amorosa et al. JAIDS 2005;Aug15;39(5):557-61.

23. 23 Treatment of Obesity Therapeutic Lifestyle Changes Nutrition counseling Dietary intake  Limit saturated fats  Increase fiber to 35 g/day  Portion control  Reduce excess carbohydrates and high sugar drinks  Plenty of fruits and vegetables  Small meals: maximum 5 hours apart  Eat slowly

24. 24 Treatment of Obesity Therapeutic Lifestyle Changes Physical activity  Walking or other exercise 30-60 minutes/day  Progressive resistance training

25. 25 HIV and Diabetes Mellitus An Increasing HIV Nutrition Problem HIV-positive men who are taking highly active antiretroviral therapy (HAART) are more than four times more likely to develop diabetes than HIV-negative men. HIV-positive women taking protease inhibitors are three times more likely to develop diabetes than HIV-positive women on non-protease inhibitor combinations or HIV-negative women Sources: Brown TT et al. Antiretroviral therapy and the prevalence and incidence of diabetes mellitus in the Multicenter AIDS Cohort Study. Arch Intern Med 165: 1179-1184, 2005. Justman JE et al. Protease inhibitor use and the incidence of diabetes mellitus in a large cohort of HIV- infected women. Journal of Acquired Immune Deficiency Syndromes, 32: 298 – 302, 2003

26. 26 Diabetes Major Risk Factors General Population Overweight, obesity  Especially VAT Parent or sibling Ethnicity  Alaska Native, American Indian, African American, Latino American, Asian America Inactivity  Exercise <3x/wk History of impaired glucose tolerance or impaired fasting glucose Hypertension Cardio-vascular disease Polycystic ovarian syndrome

27. 27 Diabetes Additional Risk Factors HIV Population Medications leading to insulin resistance  HAART  Steroids, growth hormone, others HCV co-infection Morphological changes  Lipodystrophy: > visceral adipose tissue Physical inactivity  Neuropathy, fatigue avascular necrosis, wasting, etc.

28. 28 Heart Disease Prevalence General Population Leading cause of death in the U.S.  Women: 51% of heart disease deaths  Men: 340,933 died from heart disease in 2002 57 million Americans live with CVD  8.9% all white men  7.4% black men  5.6% Mexican American men 1. National Center for Health Statistics. Health, United States, 2005 with Chartbook on Trends in the Health of Americans. Hyatsville, MD: 2005. 2. American Heart Association. Heart Disease and Stroke Statistics—2005 Update. Dallas, Texas: American Heart Association, 2005.

29. 29 Heart Disease Major Risk Factors General Population Increasing age Gender Heredity, family history of premature heart disease Overweight/obesity High blood pressure Tobacco use Hyper- or dyslipidemia  Especially high LDL & low HDL Diabetes Metabolic syndrome Physical inactivity Poor nutrition  An atherogenic diet Source: Preventing chronic diseases: Investing wisely in health preventing heart disease and stroke. July 2005. CDC. February 6, 2006. http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/cvh.htm http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/cvh.htm

30. 30 Heart Disease Risk Factors HIV Population Inflammation due to HIV Lipid abnormalities due to HAART Other drug effects:  Insulin resistance  Morphological changes  Metabolic syndrome

31. 31 Heart Disease Prevention & Treatment Therapeutic Lifestyle Change (TLC)  Diet  Physical exercise Management of concomitant diseases  Diabetes, hypertension, obesity, etc. Smoking cessation Stress reduction

32. 32 Liver Disease Fueled by Overweight & Obesity Waist>hip, insulin resistance & diabetes  Predicts advanced forms of chronic hepatitis C  Complicates nonalcoholic steatohepatitis (NASH) Fitness inversely related Tx: Healthy diet, exercise, weight loss Sources: Charlton MR et al. Hepatology June 2006;46(6)1177-1186; Church TS et al. Gastroenterology. 2006 Jun; 130(7):2023-2030.

33. 33 Renal Disease and HIV A Growing Nutrition Problem Dialysis  HIV: 1.5%, AIDS: 0.4%  Dialysis centers treating PLWH/A 1985: 11% 2000: 37%  Number initiated since 1995: stable Abnormal kidney function  30% PLWH/A HIV and CKD nutrition guidelines  Not set yet  Individualize

34. 34 HIV Nutrition Essentials Medical Nutrition Therapy (MNT) Program Necessary Ingredients

35. 35 Continuum of Care County of Los Angeles. Continuum of Care, Office of AIDS Programs and Policy.

36. 36 HIV Registered Dietitian Standards of Professional Practice Provides quality service based on client expectations and needs Effectively applies, participates in or generates research to enhance practice Effectively applies knowledge and communicates with others

37. 37 HIV Registered Dietitian Standards of Professional Practice Uses resources effectively and efficiently in practice Systematically evaluates the quality and effectiveness of practice and revises practice as needed to incorporate the results of evaluation Engages in lifelong self-development to improve knowledge and enhance professional competence

38. 38 HIV Registered Dietitian Care Responsibility Create screening tools for medical providers to identify clients at risk Monitor nutrition-related abnormal laboratory values Assess clients regularly, consistently Ensure adequate nutrient & caloric intake

39. 39 HIV Registered Dietitian Care Responsibility With medical team, identify and correct causes of cachexia, weight loss/gain, other nutrition problems and barriers Refer to providers and other disciplines Communicate: document, speak, share Participate in team case conferences Promote continuity of care

40. 40 Relationship Between Patient/Client/Group & Dietetics Professional - Nutrition Diagnosis   Identify and label problem   Determine cause/contributing risk factors   Cluster signs and symptoms/ defining characteristics Nutrition Assessment   Obtain/collect timely and appropriatedata   Analyze/interpret with evidence-based standards   Identify risk factors  Use appropriate tools and methods  Involve interdisciplinary collaboration Screening & Referral System Outcomes Management System  Monitor the success of the Nutrition Care Process implementation  Evaluate the impact with aggregate data  Identify and analyze causes of less than optimal performance and outcomes  Refine the use of the Nutrition Care Process ADA NUTRITION CARE PROCESS AND MODEL  Document Nutrition Monitoring and Evaluation  Monitor progress  Measure outcome indicators  Evaluate outcomes  Document Nutrition Intervention  Plan nutrition intervention  Formulate goals and determine a plan of action  Implement the nutrition intervention  Care is delivered and actions are carried out  Document Document NCP

41. 41 Screening and Referral Screen for Referral Criteria New/re-entry into care, MNT >6 months Medical diagnosis, nutrition status change Physical changes, weight concerns Oral, GI symptoms Metabolic, other medical conditions Barriers to nutrition, living environment, functional status Behavioral concerns, unusual behaviors Source: ADA MNT Evidence Based Guides for Practice, March 2005

42. 42 Screening and Referral Referral Documentation Physician’s order for MNT Signature and date of physician or authorized person to refer for MNT Medical diagnoses and information Current labs and measurements Consent to release medical information Proof of residency, income, diagnosis Source: ADA MNT Evidence Based Guides for Practice, March 2005

43. 43 Nutrition Care Process ADIME Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring Nutrition Evaluation Documentation: clear and explicit

44. 44 Nutrition Care Process Nutrition Assessment Reason for referral Assess data (ABCD)  Anthropometric  Biochemistry  Clinical  Dietary Client input

45. 45 Nutrition Care Process Nutrition Diagnosis Problem  Diagnostic label  Intake, clinical, or behavioral/environmental Etiology  Cause or contributing risk factors Signs/Symptoms  Defining characteristics PES statement

46. 46 Nutrition Care Process Nutrition Diagnosis PES Statement (P) Increased nutrient needs (E) as related to inadequate intake of foods and malabsorption due to AIDS enteropathy (S) as evidenced by 25 pound weight loss in 6 months and now 91% IBW

47. 47 Nutrition Care Process Nutrition Intervention Interventions  Food and/or Nutrient Delivery  Nutrition Education  Nutrition Counseling  Coordination of Nutrition Care Receptivity and adherence potential Plan and follow-up date

48. 48 Nutrition Care Process Nutrition Monitoring Review and measure status of intervention at scheduled time Track outcomes with tools  ADA HIV MNT Protocol Progress Note  Weight and nutrition flow sheet  Electronic health record data fields Format Terminology: diagnosis, interventions, etc  Other tools

49. 49 Nutrition Care Process Nutrition Evaluation Systematic comparisons Reference standards Evaluate changes  Signs and symptoms  Previous status and intervention goals  Progress toward goal

50. 50 HIV MNT Tools Basics HIV MNT Protocols (ADA,1998)  Adult (18 years-adult)  Children (under 18 years) Health Care and HIV: Nutritional Guide for Providers and Clients (HRSA/HAB, 2002) Integrating Nutrition into Medical Management of HIV, (CID-S April 1 2003) Nutrition intervention in the care of persons with human immunodeficiency virus. (ADA & Dietitians of Canada Joint Position, 2004)

51. 51 HIV MNT Tools New: ADA Evidence Analysis Library Systematic review of scientific research  Select topic and expert working group  Define questions, analytical framework, inclusion and exclusion criteria  Conduct literature review per question  Analyze articles  Complete evidence summaries and tables  Draft proposed conclusion statements  Reach consensus on conclusion statements and grades (strength and quality of the evidence)  Publish to online library (EAL)

52. 52 HIV MNT Tools New: ADA EAL Current Projects Diseases and conditions  Adult weight management  Determinants of pediatric overweight  Chronic kidney disease (revision)  Chronic obstructive pulmonary disease  Critical illness  Disorders of lipid metabolism (hyperlipidemia revision)

53. 53 HIV MNT Tools New: ADA EAL Current Projects Diseases and conditions (cont.)  Gestational diabetes  Gluten intolerance/Celiac  Heart failure  HIV/AIDS  Hydration  Hypertension

54. 54 HIV MNT Tools New: ADA EAL Current Projects Diseases and conditions (cont.)  Nutrition in athletic performance  Nutrition care in bariatric surgery  Oncology  Pediatric weight management  Spinal cord injury & nutrition  Unintended weight loss

55. 55 HIV MNT Tools New: ADA EAL Current Projects Assessment  Estimating energy expenditure Foods  Non-nutritive sweetener

56. 56 HIV MNT Tools Emerging: HIV Nutrition Evidence Analysis Questions  What are the caloric needs of people with HIV/AIDS?  What is the evidence to support a particular macronutrient composition of a diet for people with HIV/AIDS? Focus  Both children and adults  People with HIV/AIDS  Past 10 years of research

57. 57 HIV MNT Tools New and Emerging Nutrition Care Manual  Web based  Uses ADA Evidence Analysis Library Evidence-based MNT protocols Evidence-based guidelines ADA position papers

58. 58 Reimbursement MNT, Supplements Medicare Medicaid Managed Care HMOs, Kaiser Permanente RWCA

59. 59 Personal Professional Competence Dietetics Professionals’ Ethical Obligation Code of Ethics for the Profession of Dietetics,(6) Standards of Professional Practice,(7)  Guided by the nutrition care process Professional Development Portfolio(8)  75 credits every five years

60. 60 Ryan White CARE Act and MNT Current Status MNT by RD  Defined by HRSA guidance  Required in Title III services  RWCA reauthorization Expected after Labor Day 2006 ADA and others working to get MNT as core medical service AIDS Education Training  HIV nutrition training for providers

61. 61 Current Procedural Terminology MNT CPT Codes 97802 Initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97803 Re-assessment and intervention, individual, fact-to-face with the patient, each 15 minutes 97804 Group (2 or more individuals), each 30 minutes

62. 62 HIV Nutrition Essentials Lessons Learned Monitoring Los Angeles County Medical Outpatient Services’ MNT Programs

63. 63 Monitoring HIV MNT Services MNT Program Evaluation Items Screening for nutrition related problems Referral for baseline MNT (06-07) Appropriate referral for MNT MNT provided by an RD MNT documentation (05-06) Outcome: maintain or 5% towards goal weight after 3 months of care (07-08) RD qualifications

64. 64 29 (.8, 0-10)2 (.1, 0-1)Screened 77 (2.1, 0-8)38 (1, 0-4)Referral to MNT 66 (1.8, 0-6)32 (.9, 0-5)MNT Provided 62n/aMNT Quality 244 (6.8, 4-10) 154 (4.3, 2-8) Charts Reviewed (average, range) 36 Sites (of 37) 16,48716,143Clients (>1 visit) Yr 15 2005-2006Yr 14 2004-2005 Monitoring MNT Programs

65. 65 RD Availability2004-20052005-2006 Clinics, number37 Onsite >½ day/month 2832 Referral offsite45 None available50 Access to MNT

66. 66 Changing Practices and Attitudes Establishing the Framework for MNT Wheels of change move slowly Develop infrastructure  Standards of care, guidelines, contracts  Indicators, monitoring tools, reports MNT services: disparity in clinics  Providers, program managers, funding  Awareness, interpretation and abilities  Expectations, goal setting, reporting, access

67. 67 Changing Practices and Attitudes Technical Assistance: Providers and RDs Provider meetings, calls, emails Provider and staff presentations At each year’s program monitoring  Different and evolving TA focus  Always provide materials  Ex: HRSA Nutrition Manual CD, screening & referral forms, articles, standards of care, BMI chart, nutrition & weight flow chart

68. 68 Changing Practices and Attitudes Technical Assistance: RDS Dietitians in AIDS Care (DIAC)  DIAC listserve  Quarterly meetings since April 2005 Networking – long-lasting relationships Training and problem solving  Nutrition care process  When to provide/discontinue: nutritional supplements, food / meal services  Hyperlipidemia, insulin resistance, renal disease

69. 69 Personal Growth Lessons Learned More medical records reviewed Monitoring tools - streamlined and tally / comments sheets Increase time spent monitoring Evaluation report of MNT programs  Establish ongoing database  Baseline knowledge of programs

70. 70 Screening for Nutrition Problems Lessons Learned Newton’s laws of motion Providers’ resistance  Problems? Don’t look and you won’t find  Screening vs. referring  Defining “at risk” Make it easy to look, think, document Simple questions work

71. 71 Height and Weight Measurements Lessons Learned Routine measurements needed  Height not always measured  Weight usually measured  Accuracy questionable on both Who measures? How trained? Shoes? Calibration of scales? Stadiometer? Monitoring weight  Adding/subtracting usually not done  BMI not usually done  Graphing not done

72. 72 Reducing Barriers to MNT Lessons Learned Reducing broken appointments  Set appointments with client  Coordinate with primary care visit  Reminders and follow-up calls and letters Document in medical record Support MNT in clinic  Include, discuss and referral from start  Incentives and rewards for MNT visit  Ask/respond to client request for MNT

73. 73 Needed: Proactive Healthy Clinic Lessons Learned Take responsibility and power Educate & support staff: promote:  Nutrition and health knowledge  Clients’ food, nutrient and safety needs Change the menu and food/ water safety practices for client and non-client events  Meetings, parties, fund raisers, vending machines, vouchers, board meetings, holidays, etc.

74. 74 HIV Nutrition Essentials What has been your experience? What has worked well? What has been a challenge?

75. 75 Acknowledgments Arcy Martinez RD AltaMed Health Services Corporation Audra Gustafson RD Northeast Valley Health Corporation Tammy Darke MS RD St Mary Medical CARE Program Jill Strejc MS RD SRD UCLA Caren Ongjoco RD CNSD Los Angeles County Harbor-UCLA Medical Center Jan B King MD MPH OAPP Medical Director

76. Marcy Fenton, M.S., R.D. Program Manager, Care Services Division Office of AIDS Programs and Policy 600 South Commonwealth Avenue 2nd Floor Los Angeles, California 90005-4001 Phone: 213/351-8368 Fax: 213/738-6566 E-mail: mfenton@ladhs.org This presentation is available at www.LAPublicHealth.org/AIDS For Additional Information