1. Managing Nutrition and Food-Related Problems Deon Bent R.D March 29, 2006

2. Outline Overview of common nutritional problems and dietary strategies for management Overview of common nutritional problems and dietary strategies for management Anorexia Anorexia Constipation, diarrhea, malabsorption Constipation, diarrhea, malabsorption Nausea, vomiting Nausea, vomiting Oral and swallowing problems Oral and swallowing problems Fatigue Fatigue

3. Causes of Food-Related Problems Opportunistic infection Opportunistic infection Food or water borne pathogen Food or water borne pathogen HIV-enteropathy HIV-enteropathy Antiretroviral therapy Antiretroviral therapy Depression Depression

4. Anorexia Make every bite count Make every bite count Small frequent meals and snacks Small frequent meals and snacks Eat on schedule Eat on schedule Enhance the eating environment Enhance the eating environment Use available community and family supports and services Use available community and family supports and services Use nutritional supplements if available/affordable Use nutritional supplements if available/affordable Consider appetite stimulants if available Consider appetite stimulants if available Take a multivitamin-mineral supplement Take a multivitamin-mineral supplement

5. Constipation Increase fibre such as wheat bran, whole grains, fruits and vegetables, legumes, provisions Increase fibre such as wheat bran, whole grains, fruits and vegetables, legumes, provisions Prunes contain a natural laxative as well as fibre Prunes contain a natural laxative as well as fibre Increase fluids Increase fluids Exercise such as walking after meals can stimulate bowel movements Exercise such as walking after meals can stimulate bowel movements Avoid laxative dependency Avoid laxative dependency

6. Diarrhea & Malabsorption Goals of nutrition therapy are to slow intestinal transit slow intestinal transit decrease exposure to intestinal irritants decrease exposure to intestinal irritants replace lost nutrients, electrolytes, fluids replace lost nutrients, electrolytes, fluids Low lactose, low residue, low fat diet is the most effective strategy

7. Diarrhea & Malabsorption Small frequent meals Small frequent meals Emphasize soluble fibre (oats, rice, provisions) Emphasize soluble fibre (oats, rice, provisions) Replace fluids and electrolytes Replace fluids and electrolytes Reduce intake of the following Reduce intake of the following Insoluble fibre Insoluble fibre High fat foods High fat foods Fluids high in sugar, especially juices, soft drink Fluids high in sugar, especially juices, soft drink Lactose Lactose

8. Diarrhea & Malabsorption Pro-biotic e.g. Acidophilus or Bifida-bacteria Sorbitol can worsen diarrhea Medium Chain Triglycerides improve fat absorption Liquid nutritional supplements that are lower in osmolality and contain a portion of fat as MCT can replace fluids and nutrients Liquid nutritional supplements that are lower in osmolality and contain a portion of fat as MCT can replace fluids and nutrients

9. Diarrhea & Malabsorption Rice porridge: 1 cup rice cooked for 1 hour in 6 cups broth Rice porridge: 1 cup rice cooked for 1 hour in 6 cups broth Rice water: 1/2 cup rice cooked in 4 cups water. Drink the cooled water. Rice water: 1/2 cup rice cooked in 4 cups water. Drink the cooled water. Clove tonic: 12 cloves simmered in 1 cup green tea. Clove tonic: 12 cloves simmered in 1 cup green tea.

10. Nausea and Vomiting Small frequent meals and snacks Small frequent meals and snacks Eat to tolerance Eat to tolerance Eat bland, low fat, low sugar foods, cold foods and salty foods Eat bland, low fat, low sugar foods, cold foods and salty foods Avoid foods that make it worse (e.g. spicy foods) Avoid foods that make it worse (e.g. spicy foods) Avoid cooking odors Avoid cooking odors Avoid gastric irritants like coffee, alcohol Avoid gastric irritants like coffee, alcohol

11. Nausea and Vomiting Avoid drinking and eating solids at the same time Avoid drinking and eating solids at the same time Do not lay down after eating Do not lay down after eating Wear loose clothing Wear loose clothing Replace fluids and electrolytes if vomiting Replace fluids and electrolytes if vomiting Ginger is an effective anti-nausea agent Ginger is an effective anti-nausea agent Use anti-emetic medications if required Use anti-emetic medications if required

12. Stomatitis Soft moist foods are better tolerated Soft moist foods are better tolerated Avoid acidic, spicy, coarse or dry foods Avoid acidic, spicy, coarse or dry foods Avoid irritants like tobacco, alcohol Avoid irritants like tobacco, alcohol Blenderized foods may be helpful Blenderized foods may be helpful Cold or room temperature foods are better Cold or room temperature foods are better Keep lips moist with lip balm Keep lips moist with lip balm Limit sugar containing foods and fluids Limit sugar containing foods and fluids

13. Dysguesia Malnutrition causes decreased number of taste receptors Malnutrition causes decreased number of taste receptors Medications can leave a bitter residue in the mouth Medications can leave a bitter residue in the mouth Medications and/or HIV can cause abnormal tastes such as persistent metallic or sweet taste Medications and/or HIV can cause abnormal tastes such as persistent metallic or sweet taste Children are especially susceptible to loss of appetite due to decreased taste acuity Children are especially susceptible to loss of appetite due to decreased taste acuity

14. Dysguesia Chew food well and move it around mouth to stimulate the most taste receptors Chew food well and move it around mouth to stimulate the most taste receptors Use flavor enhancers Use flavor enhancers Sugar masks salty; salt masks sweet; sour masks metallic tastes Sugar masks salty; salt masks sweet; sour masks metallic tastes Sugar-free candy and gum mask bitter taste Sugar-free candy and gum mask bitter taste Use of plastic utensils decreases a metallic taste Use of plastic utensils decreases a metallic taste

15. Mouth Rinses To 1 cup of lukewarm water add one of the following: 1/4 teaspoon salt or 1/4 teaspoon salt or 1/4 teaspoon baking soda or 1/4 teaspoon baking soda or 1/4 teaspoon glycerin or 1/4 teaspoon glycerin or 1 tablespoon 3% hydrogen peroxide 1 tablespoon 3% hydrogen peroxide Rinse mouth often; do not swallow Rinse mouth often; do not swallow

16. Dysphagia Feeding assessment for the following warning signs: Feeding assessment for the following warning signs:  Drooling Coughing or choking while eating Coughing or choking while eating Gurgly voice after eating or drinking Gurgly voice after eating or drinking Complaints that food catches in throat Complaints that food catches in throat Repeated swallows for one bite of food Repeated swallows for one bite of food Texture modifications: Texture modifications: minced, pureed or blenderized solids minced, pureed or blenderized solids thickened fluids thickened fluids

17. Conclusion Complications with nutritional implications are common Complications with nutritional implications are common Nutrition therapy can improve symptoms and adherence to antiretroviral medications Nutrition therapy can improve symptoms and adherence to antiretroviral medications Dietary modifications are the first line of nutrition therapy Dietary modifications are the first line of nutrition therapy

18. Food-Drug Interactions Deon Bent R.D March 29, 2006

19. Outline Food – drug interactions Food – drug interactions Strategies for managing food – drug interactions Strategies for managing food – drug interactions

20. Drug –Food Interactions Effects of food on medication efficacy Effects of food on medication efficacy Effect of medication on nutrient utilization Effect of medication on nutrient utilization Effect of medication side effect on food consumption Effect of medication side effect on food consumption

22. The Role of Nutrition Intervention Health care workers should know the food requirements for medications Health care workers should know the food requirements for medications Nutrition counsellors can help with: Nutrition counsellors can help with: Strategies to minimize or treat side effects Strategies to minimize or treat side effects Ideas for meals and foods to take with medications Ideas for meals and foods to take with medications Ensure that medications are taken appropriately with or without food Ensure that medications are taken appropriately with or without food

25. Pharmacokinetic Interactions Drug Absorption Drug Distribution Drug Metabolism Drug Excretion

26. Pharmacokinetic Interactions Drug Absorption Increased or decreased by Food Food Food components: phytates, acid, dairy Food components: phytates, acid, dairy Gastric emptying Gastric emptying Chelation of drug to minerals in food Chelation of drug to minerals in food Herbs Herbs

27. Pharmacokinetic Interactions Drug Metabolism Drugs are metabolized by cytochrome P450 enzyme system in liver Drugs are metabolized by cytochrome P450 enzyme system in liver Food can inhibit or enhance metabolism of drug by inhibiting or inducing CYP Food can inhibit or enhance metabolism of drug by inhibiting or inducing CYP e.g. Grapefruit juice inhibits CYP. e.g. Grapefruit juice inhibits CYP.

28. Pharmacokinetic Interactions Drug Distribution Serum albumin is main determinant of distribution Serum albumin is main determinant of distribution Low albumin means higher free fraction of drug Low albumin means higher free fraction of drug May have increased toxicity in someone with low albumin May have increased toxicity in someone with low albumin

29. Pharmacokinetic Interactions Drug Excretion Renal tubule reabsorption of drug can be altered by food or food components Renal tubule reabsorption of drug can be altered by food or food components Indinavir can cause renal stones if not enough fluids are consumed Indinavir can cause renal stones if not enough fluids are consumed

30. Causes of Food-Drug Interactions Alcohol or street drugs Alcohol or street drugs Malnutrition, low albumin, altered body composition Malnutrition, low albumin, altered body composition Non-nutrient components in food Non-nutrient components in food Herbal medicine Herbal medicine Special diets, tube feeding Special diets, tube feeding Poor adherence to medications Poor adherence to medications

31. Nutrition Status Affected by Food-Drug Interactions Side effects cause decreased intake Side effects cause decreased intake Gastrointestinal side effects cause increased losses Gastrointestinal side effects cause increased losses Drugs that must be taken on an empty stomach cause decreased intake Drugs that must be taken on an empty stomach cause decreased intake

34. Conclusion Adherence to food recommendations can make the drug have the strongest effect with the least amount of side effects. Adherence to food recommendations can make the drug have the strongest effect with the least amount of side effects. Treatment failure may be linked to non- adherence to dietary recommendations Treatment failure may be linked to non- adherence to dietary recommendations Nutritional status is linked to medication profile and side effects Nutritional status is linked to medication profile and side effects

35. Conclusion Appropriate dietary changes can help to manage ARV side effects and reduce its impact on nutritional status It is important for health care workers remain informed and render assistance where necessary

36. The End The End

37. Questions ?