1. Food: One Pillar supporting Quality of Life for people with HIV/AIDS
Wanda Agnew, PhD, LRD
Bismarck-Burleigh Public Health
May 14, 2009
Medora , ND
Our 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 survival
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.

2. Outline Infections and Nutrition – general
Medications and Nutrient connection (disconnect)
Malnutrition , Weight Loss, Wasting
Nutrition Assessment for Needs
Nutritional Interventions
Summary
Resources
Today 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

3. Natural 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

4. Opportunistic 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 nephropathy
And 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.

5. Manifestations of HIV Infection
Primary Infection
Clinical Latency
Advanced Disease
often asymptomatic or overlooked
symptoms 1-6 weeks after infection
viral like syndrome: sore throat, fever, lymphadenopathy, rash
differential includes EBV, CMV, hepatitis, toxoplasmosis
antibody (ELISA, Western Blot) may not be detected
usually asymptomatic
lymph nodes site of ongoing viral latency
massive viral production
destruction of CD4 cells
a decrease in lean body mass without apparent total body weight change
vitamin B12 deficiency
increased susceptibility to food and water-borne pathogens.
Symptomatic
Plasma viremia begins to rise
CD4 cell count falls further
A decline in nutrient status or body composition
Opportunistic infections develop:
fever, weight loss, lymphadenopathy, thrush, diarrhea, malignancies, wasting syndrome, neurologic syndrome including dementia
So 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 infection
Most often, they are viral like syndrome such as sore throat, fever, lymphadenopathy, and rash
A differential at that time may include EBV, CMV, hepatitis, toxoplasmosis
An antibody for the virus may or may not be detected at that time
During 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 change
Pts at this stage may present with a vitamin 12 deficiency and increased susceptibility to food and waterborne pathogens
As the disease progresses, pts become more symptomatic with increase plasma viremia, cd4 counts falls even further, and nutritional status and body composition begins to decline
At this stage, opportunistic infections develop which may bring about symptoms such as fever, weight loss, lymphadenopathy, thrush, diarrhea, malignancies, wasting syndrome, and dementia

6. Antiviral Drug Therapy
Nucleoside/
Nucleotide
Analogues
Nonnucleoside Reverse Transcriptase Inhibitors
Protease Inhibitors
Fusion Inhibitors
Abacavir Didanosine Emtricitabine Lamivudine Stavudine Tenofovir Zalcitabine Zidovudine
Delavirdine Efavirenz Nevirapine
Amprenavir Atazanavir Fosamprenavir Indinavir Lopinavir/Ritonavir Nelfinavir Ritonavir Saquinavir
Enfuvirtide
These 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 Inhibitors
Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
Protease Inhibitors (PIs)
Fusion Inhibitors (one approved by FDA)
Integrase Inhibitors (in clinical trials)

7. How 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 cell
Currently there is one fusion inhibitor on the market and basically work by preventing HIV from fusing with a host cell
Nucleoside 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.

8. Adverse Drug Effects Mitochondrial dysfunction Metabolic abnormalities
Hematologic
complications
Allergic
reactions
Lactic acidosis
Hepatic toxicity
Pancreatitis
Peripheral neuropathy
Lipodystrophy
Fat accumulation
Lipoatrophy
Hyperlipidemia/
? Premature CAD
Hyperglycemia
Insulin resistance/DM
Bone disorders: oesteoporosis and osteopenia
Bone marrow
suppression
Hypersensitivity
Skin rashes
Although 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 risk
Hepatic toxicity, pancreatitis, and peripheral neuropathy have been observed
Metabolic abnormalities mostly associated with PI inhibitors include:
Lipodystropy
Hyperlipidemia
Hyperglycemia
Insulin resistance
Decreased glucose tolerance
New onset diabetes mellitus
DKA
Exacerbation of existing DM
And bone disorders which women have been found to be at her risk for
Bone marrow suppression as well as skin hypersensitivity have been observed

9. Medication Side Effects and how they relate to eating, food --------- MALNUTRITION
Anorexia
Sore/dry/painful mouth
Swallowing difficulties
Constipation/Diarrhea
Nausea/Vomiting/Altered Taste
Depression/Tiredness/Lethargy
In addition to metabolic side effects, medication can interfere with eating which may contribute to malnutrition. Some of these side effects include:
Anorexia
Sore/dry/painful mouth
Swallowing difficulties
Constipation/Diarrhea
Nausea/Vomiting/Altered Taste
Depression/Tiredness/Lethargy
Attached in your packet are management strategies for avoiding weight loss

10. Pathogenesis 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.

11. Malnutrition can... Contribute to impaired immune response
Result in more rapid disease progression & shortened survival
Contribute to increased frequency and severity of infections
Result in fatigue, loss of appetite, sense of taste and smell, and decreased quality of life
Decrease tolerance to therapy and lessen medication efficacy
Malnutrition 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.

12. Weight 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.

13. Weight 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 that
1/3 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

14. Weight 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.

15. Pathophysiology AIDS Wasting
Oxidative Stress
Micronutrient Deficiency
Intestinal Parasites
Malabsorption/
Dysphagia
Opportunistic Infection
Immune Function
HIV
Pro-inflammatory
Cytokines (TNF alpha)
Anorexia
Dietary Intake
So 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 activity
A 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 activity
This 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 diarrhea
Diarrhea 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 Energy
Balance
Metabolic Rate
Endocrine Disorder
Fat Loss
Skeletal Protein Breakdown
Protein Loss
J AIDS 1988

16. Potential Mechanisms of AIDS Wasting
Increased energy expenditure
Decreased energy intake
Altered metabolism
Hormonal Alterations
The literature has cited 4 potential mechanisms for AIDs wasting, these include
Increased energy expenditure
Decreased energy intake
Inefficient use of energy substrate
And hormonal factors

17. AIDS-related Wasting Syndrome
Profound involuntary weight loss > 10% of baseline BW accompanied by fever or weakness and chronic diarrhea for >30 days
Weight loss or wasting even with adequate or increased calorie intake
Decrease in LBM without weight loss during pre-symptom phase
It 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 weight
Either chronic diarrhea, or chronic weakness and fever, defined as occurring constantly or intermittently for more than 30 days
Patients should also be free of illnesses or conditions other than HIV infection that could explain their weight loss (i.e. TB or enteritis)

18. Wasting is diagnosed …. Lose 7.5% over 6 months OR 10% over 12 months
BMI drops below 20

19. Nutritional 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 taste
Depression often leads to isolation, apathy, neglect of self-care, and diminished appetite – all which can affect immunocompetence
Socioeconomic 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 immunocompetence
Socioeconomic factors play an important role in whether the patient can aford adequate and nutritious food.

20. Altered Metabolism
Early studies documented weight loss and protein depletion in untreated patients
The application of HAART has led to a decreased incidence of malnutrition
Syndrome of altered body fat distribution has emerged (lipodystrophy) associated with PIs
Hypertriglyceridemia, 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.

21. HIV-Associated Lipodystrophy
Hyperlipidemia
Insulin resistance
Fat
accumulation
Fat
atrophy
Many researchers investigating HIV-related metabolic disorders agree that this syndrome most likely has a multifactorial etiology
Four distinct sets of issues have been noted: dyslipidemias, glucose dysregulation, fat depletion, and fat accumulation
A 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 fat
Facial thinning / atrophy /pleat
Similar findings have been reported in HIV patients not taking protease inhibitors
May be associated with insulin resistance and hyperlipidemia
High 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.

22. Nutritional Problems
Decreased 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 immunocompetence
Socioeconomic factors play an important role in whether the patient can aford adequate and nutritious food.

23. What Causes Lipodystrophy?
Syndrome most likely has a multi-factorial etiology
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).
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).

24. What does Lipodystrophy look like?
Central obesity with peripheral fat wasting
Visceral 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).

25. Nutrition Assessment
Screen for Nutrition Concerns at initial visit and each visit there after including:
Assess HIV infection-related symptoms experiencing
Assess dietary patterns, food availability, nutrient intake, erratic and/or inadequate intakes
Assess use of non-traditional therapies
Assess psychosocial conditions, income, and insurance
Assess anthropometric measurements
Assess lab values
DIETITIAN

26. WHO
Screening nurse may assess nutritional status, but need tools to ask right questions
Physicians 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.

27. Nutrition Assessment - Physical
Height, Weight, BMI
Use accurate techniques
Check routinely – record and monitor change
Body composition
BMI
Fat distribution changes
Shape changes
RED FLAGS – wt change since last time and/or BMI <20
Ask questions about why weight changes, look for clinical signs of deficiencies/excesses

28. Lab Values related to nutrients
Albumin
Iron
Lipid Profile
Renal Function Tests
Blood Sugar

29. Complimentary and Alternative Therapies
St Johns Wart decreases blood levels of indinivir – may cause drug resistance and treatment failure
Garlic supplements have been shown to reduce blood level of saquinavir
Milk thistle (silymarin) could lessen metabolism of medication and increase toxicity
High use of any Complimentary/Alternative Therapy is costly and may lead to toxicity or interfere with medications

30. INDIVIDUALIZE! Diet Therapy
Help maintain your health and quality of life by having your nutrition reassessed
every 3-6 months.

31. Nutrition Care Process
Prioritize most urgent issues
Intervention goals
Prevent adverse events to therapies
Restore adequate nutritional status
Do Diet Prescription
Patients 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

32. Nutrition is important for
- health
- immune system.
NEED:
high-quality foods for energy & strength

33. High-quality foods from all the food groups
Grains: choose whole grains for fiber
Whole grain breads and cereal, whole wheat pasta, oatmeal, brown rice, couscous, barley, quinoa, whole wheat tortillas
Hepatitis C: plan a diet high in carbohydrates to help spare your protein
Fats & Oils: Choose heart healthy fats
Olive oil, canola oil
Fat offers twice as many calories as protein and carbohydrates

34. High-quality foods from all the food groups
Fruits & Vegetables: VARIETY is important
Aim for as many colors and types of fruits and vegetables possible
Choose 100% juice for immune system support

35. High-quality foods from all the food groups
Dairy Products: calcium is important
Low-fat/non-fat milk, cheese, yogurt, soy products

36. High-quality foods from all the food groups
Meat & Protein: bake, roast, or grill—Don’t fry
Chicken, turkey, fish rich in omega-3’s (salmon, sardines, mackerel), eggs, nuts, seeds, tofu, lentils, beans
HIV/AIDS: increase protein to fight fever & infections
Hepatitis C: keep protein at individual recommended levels to spare your liver

37. High-quality foods from all the food groups
Fats & Oils: Choose heart healthy fats
Olive oil, canola oil
Fat offers twice as many calories as
protein and carbohydrates

38. Diet Therapy: Fat Varies in tolerance bases on individual
Assess fat for malabsorption – diarrhea
MCT to reduce steatorhea, abdominal cramps
Omega-3 fatty acids may improve immune function
Follow usual guidelines for elevated cholesterol & triglyceride
Include soluble fiber, plant sterols, soy protein, and cholesterol saturated factors
MCT – Palm and coconut oils

39. DIET THERAPY: Calories
500 calories above Energy Expenditure at Rest (EER)
= calories/kg
Example 180 pound man – 82 kgs = 3600 calories/day

40. Diet Therapy: Protein 1.0 g/kg to 1.4 g/kg for maintenance
1.5 g/kg to 2.0 g/kg for replacing
Only restrict is severe liver or kidney disease with doctors order

41. Diet Therapy: FLUIDS & ELECTROLYTES
Fluid = 30 to 35 ml/kg
During times of diarrhea extra fluid (2 cups/day) and electrolytes for night sweats, diarrhea, and fever
Pedialyte, kool-ade with salt, jello, broth

42. Diet Therapy: Vitamins and Minerals
Actual status is seldom identifiable in labs
Gather patient self-reported intake
Suggest 100% One-A-Day with minerals (calcium, Iron, Magnesium)
Suggest Basic Vitamin B-Supplement
Go for higher doses if diarrhea is prolonged, anemia develops or dietary deficiencies are evident
Cheapest - Nature Made or other brands – difficult to find with most V&M at 100%

43. Nutrition Counseling Medicaid – 4 sessions/year
Medicare – 4 sessions/year
Public Health – sliding scale
Diet order from physician
Receive an assessment
Receive a Diet Prescription – not just nutrition but food
Carbs will be added after Protein, fat and glucose tolerance is considered

44. Macronutrients VS. Micronutrients
Carbohydrate
Protein
Fat
Water
MICRO
Vitamins
Minerals
Antioxidants
Macronutritents are difficult to get – unless you eat food and micro do not have calories or give energy

45. High 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)

46. High 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)

47. Diet Prescription Increase calories Increase protein Increase fiber
Increased fruit and veggies
Food safety
Drug-nutrient interactions
Perhaps anti-diarrheal, pancreatic or lactase enzymes
Burleigh Diet

48. Food Security Shop wise Food Stamps (SNAP) Food Pantries
Senior Nutrition Programs
Growing own Food
Food handout

49. Nutritional Supplements in HIV Infection to counteract AIDS Wasting
MVI
Glutamine
Carnitine
Appetite Stimulant
Insulin Sensitizing Agents
Anti-catabolic medications
Resistance Training

50. Role of Micronutrients in the Pathogenesis of HIV infection
Micronutrients play important roles in maintaining immune function and SLOW reactive oxidant destruction
Micronutrient deficiencies are common among HIV infected persons – nature of disease and malnutrition
Micronutrient deficiency has been associated with further immunopression, oxidative stress, speeds up HIV replication and CD4+ T-cell depletion. (semba)

51. Vitamin E and C
Conclusion: 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 therapies
Aids - 10 September Volume 12 - Issue 13 - p

52. Glutamine 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 syndrome
Glutamine 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

53. Glutamine 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:

54. L-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

55. Appetite Stimulant: Dronabinol
Derived from delta-9-tetrahydrocannabinol (major active component of Marijuana)
Useful in decreasing nausea and increasing appetite
Insignificant gains or even loss of total BW
May 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

56. Appetite Stimulant: Megestrol Acetate (Megace)
A synthetic derivative of the natural steroid hormone, progesterone.
Improved appetite in a number of studies
Takes two weeks for effect.
Considerable increases in BW, although mostly in body fat
May be due to testosterone lowering effect, not reversed by supplementation w/testosterone
May induce or exacerbate DM, cause adrenal insufficiency when abruptly discontinued after long-term use
Treatment Guidelines for HIV Associated Wasting, Mayo Clinic Proceedings, April 2000

57. Appetite Stimulants Sips of wine (Mogan David) Chocolate
Culantro – long leafed different than cilantro

58. Resistance Training
Supervised 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), pp
The New England Journal of Medicine, June

59. Summary HIV/AIDS remains an epidemic worldwide
Malnutrition is a complication in HIV related morbidity and mortality
Weight loss is an independent predictor of mortality
Despite HAART, patients remain at risk for AIDS wasting syndrome
Contributors of AIDS wasting syndrome include increased energy expenditure, decreased energy intake, altered metabolism, and hormonal factors
Good 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

60. Summary (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.

61. Discussion
Questions?

62. References
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63. References
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64. References
Morretti, et al. Effect of L-Carnitine on Human Immunodeficiency Virus-1 Infection-Associated Apoptosis: A Pilot Study, Blood, Vol 91, No. 10, May 15, 1998: pp
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