Mod3-Nutrition Actions in HIV

8/6/2019 Mod3-Nutrition Actions in HIV

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Nutrition and HIV/AIDS: A Training ManualSession 3


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Purpose

To provide general nutrition and dietary

guidelines to mitigate the effects of HIV onnutrition and reduce the progression of

HIV/AIDS morbidity, mortality, and related

discomfort


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Session Outline

Goals of nutrition care and support in

HIV/AIDS

Essential components of nutrition careand support in HIV/AIDS

Key actions for HIV-infected people

Appropriate assessments, interventions,

follow-up and review for nutritional care

in HIV/AIDS


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Goals ofNutrition Care and Support

Improve nutritional status Maintain weight and prevent weight loss

Preserve muscle mass

Ensure adequate nutrient intake Improve eating habits and diet

Replenish stores of essential nutrients

Prevent food-borne illnesses

Enhance quality of life Treat opportunistic infections

Manage symptoms affecting food intake

Provide palliative care


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Components ofNutritional Care and Support

1. Nutritionalassessment

2. Intervention

3. Follow up and review


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Nutritional Assessment


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Why Measure?

To identify and track body composition changes

over time and trends

Changes in weight

Changes in body cell mass and fat-free mass

Serum nutrient levels, cholesterol, etc.

To use results to design appropriate interventions

To address client concerns about their health

To meet increasing emphasis on physical nutrition

assessment as part of clinical trials


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What to Measure?

Anthropometry

Laboratory testsClinical assessments

Diet history and lifestyle


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Anthropometric Measurementsin HIV/AIDS

To assess and monitor weight

Weight and height

Percentage of weight and/or body mass indexchanges over time

To assess and monitor body composition

Lean body mass

Body cell mass

Skinfold (triceps, biceps, mid-thigh)

Circumferences (waist, mid-upper arm, hips[buttocks], mid-thigh, breast size for women,

neck circumferencve (buffalo hump])


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Laboratory Measurementsin HIV/AIDS

To assess and monitor nutrient levels

Serum micronutrients (e.g. retinol, zinc)

Haemoglobin (and ferritin)

To assess and monitor body composition

Fasting blood sugar,

Lipid profiles (e.g., cholesterol andtriglycerides)

Serum insulin


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Clinical Assessments in HIV/AIDS

Symptoms and illnesses associated

with HIV/AIDS

Diarrhea and vomiting

Fever (temperature)

Mouth and throat sores

Oral thrush

Muscle wastingFatigue and lethargy

Skin rashes

Edema

Palm pallor


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Diet History in HIV/AIDS

24-hour food consumption or foodfrequency recalls can be used (in theabsence of acute food stress) to assess

Types and amounts of food eaten (including

food access and utilization and food handling)

Use of supplements and medications

Factors affecting food intake (appetite, eating

patterns, medication side effects, lifestyle,

taboos, hygiene, psychological factors, stigma,

economic factors)


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Interventions


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Stages of HIV Disease andNutrition

Specific nutrition recommendations varyaccording to underlying nutritional

status and HIV disease progressionEarly stage: No symptoms, stable weight

Middle stage: Weight loss, opportunistic

infections associated effects

Late stage: Symptomatic AIDS


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Nutrition Care and SupportPriorities by Stage of Disease

Asymptomatic: Counsel to stay healthy

Encourage building stores of essential nutrients andmaintaining weight and lean body mass

Ensure understanding of food and water safety

Encourage physical activity

Middle stage Counsel to minimize consequences

Counsel to maintain dietary intake during acute illness

Advise increased nutrient intake to recover and gain weight

Encourage continued physical activity

Late stage: Provide comfort

Advise on treating opportunistic infections

Counsel to modify diet according to symptoms

Encourage eating and physical activity


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Nutrition Actions for HIV-Infected People

To prevent weight loss

Promote adequate energy and protein intake

Individualize meal plan and modify to matchmedication regime or health changes

Advise changing lifestyles that negatively affectenergy and nutrient intake

To improve body compositionPromote regular exercise to preserve muscle mass

Promote steroids

To improve immunity and prevent infectionsPromote increased vitamin and mineral intakePromote food safety

Promote use of ARVs to reduce viral load


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Algorithm for Managing WeightLoss in Patients with HIV/AIDS

DX Profile=starved

metabolism, decreased

body fat/lean

RX=Feed (IV, enteral,

appetite stimulation),

make meal plans,

promote positive

lifestyles, treat

symptoms that may

affect food intake

DX Profile=starvedmetabolism, decreased

body fat/lean

RX= Treat GI disordersand other infections,consider supplementsand drug-foodinteractions, counsel onhygiene and foodhandling

DX Profile=abnormalmetabolism, relativelyhigh fat/lean ratio; low

testosterone.

RX=Make an exerciseplan, provide metabolicsteroids (?) and ARVs (?)

Etiology unknownor unclear

RX=Continue to

feed and observe

Diarrhea or mal-absorption?

Metabolicparameters

Energyintake?

OK NONormal

LOW YES Abnormal

Source: Adapted from Hellerstein and Kotler 1998


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Promote AdequateNutrient Intake

Identify locally available and acceptable foods

Promote a diet adequate in energy, protein and

other essential nutrients

Increase energy intake by 10%-15%

Increase protein intake

Increase eating a variety of foods (especiallymore fruits and vegetables) and/or promote

multiple micronutrient supplements for

improved immune function


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Support Individualized Meal Plans

Consider

Stage of illness and symptoms

Food security (availability and accessibility ofbasic foods)

Resources (money, time, other caretakers)

Food likes and dislikes

Knowledge, attitudes, and practices(especially traditional dietary taboos)


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Modify Meal Plans to SuitMedication and Health Status

Flexibility to change depending on client context

Possible food and drug interactionsChanges in medication regimens

Absence of opportunistic infections and otherinfections that may affect food intake orutilization

Changes in food accessibility in terms of qualityand quantity (especially in resource-poor settings)

Consider


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Promote Lifestyle Changes forNutritional Well-being

Eliminate foods and practices that aggravate

infection

Raw eggs and unpasteurized dairy products

Foods not thoroughly cooked, especially meats

Unboiled water or juices made from unboiled water

Avoid foods that may affect food intake

Alcohol and coffee

Junk foods with little nutritional value

Foods that aggravate symptoms related to diarrhea, nauseaand vomiting, bloating, loss of appetite, and mouth sores(e.g., expired foods, fatty foods)


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Recommend Regular Exercise

Muscle loss can be restored by reducing

viral load or maintaining physical activity

Physical activity improves Lean body mass

Body composition

Bone density

Strength Functional capacity

Quality of life

Appetite


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Therapeutic Regimensfor HIV-Related Weight Loss

Therapy Nitrogenretention(g/day)

Rate of change in bodycomposition

LBM (kg/wk) Weight (kg/wk)

Megestrol acetate NA 0.00-0.05 0.45

Parental nutrition NA 0.00 0.30

rGH 4.0 0.25 0.13

Nandrolone (hypogonadal) 3.7 0.25 0.41

Resistance exercise alone 3.8 0.48 0.53

Resistance exercise and

oxandrolone

5.6 0.86 0.84

Source: Adapted from Hellerstein and Kotler 1998


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ExercisesThat Build Muscle Mass

Weight bearing exercises

Resistance training

Weight training

Exercises generating high force on bone

Aerobics

Jogging

Stair climbing

Hiking

Skipping

Relaxation exercises

Yoga


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Strategies to increase vitamin and mineral intake toreplenish or build body stores and optimize immunefunction

Food-based approaches

Include local vegetables, vitamin-enriched or fortified localproducts (maize meal, wheat or soy flour, margarine, cereals)

Have no undesirable side effects

Are affordable

Nutrient supplements

Are more absorbable by sick person

Multivitamin and multiple-micronutrient supplements arebetter than than single vitamins and minerals

IncreaseVitamin and Mineral Intake


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Suggested Nutrient SupplementIntake in HIV/AIDS

Source: Serono 1999; Tang et al 1996. Excerpts fromEat

up

Vitamin A

RDA=5,000 IU)

2-4 RDA (13,000-20,000IU)

Vitamin E 400-800 IU

Vitamin B High-potency B complex

(e.g., B-25 or B-50 with

niacin and B6)

Vitamin C 1,500-2,000mgSelenium 200mcg

Zinc 1 RDA (12-19mg)


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Adverse Effects of Too MuchIntake of Nutrient Supplements

Vitamin E: Malabsorption of vitamins A and K andgastrointestinal upsets

Vitamin C: Gastrointestinal upsets, iron overabsorptionand abdominal bloating

Iron: Gastrointestinal bleeding (manifested by vomiting andbloody diarrhea) and possible stimulation of viral replication

Zinc: Gastric distress, nausea, reduced immunefunction that favors viral replication (HDL reported insupplements of > 300mg/day)

Vitamin B: Gastrointestinal upsets

Selenium: Skin lesions, nausea, and vomiting

Source: Afacan et al 2002, Tang et al 1996; Ziegler and Filler 1996


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Promote Food Safetyto Prevent Food-Borne Illness

Educate clients to avoid products that

Contain raw or undercooked meat

Have expired

Are in damaged or bulging packing

Are displayed unsafely (e.g., mixing raw and cooked

foods or meats with fruits and vegetables)

Are sold in unsanitary conditions or by workers with

poor personal hygiene or food handling practices


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Follow up and Review


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Monitor the Clients Well-being

Follow up

Integrate with other care and support activities whereavailable

Do continuously in facility and home

Include monitoring of health, nutrition, and dietaryindicators

Include counseling to address barriers to good nutrition

Offer support and encouragement

ReviewMeal plans

Exercise regimens

Use of medicines

Compliance with meal requirements


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Factors to Consider in Careand Support ofPeopleLiving with HIV/AIDS


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Factors in Design andImplementation

Social: Support, stigma, gender roles,education, information, traditions, beliefs

Economic: Household resources, foodsecurity, financial access to health andnutrition

Client rights: Privacy, nondiscrimination in

public services Quality of support and care: Counseling,

infrastructure, consistency, access to VCT andARVs, information on ARVs


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Nutritional andAntiretroviral Therapy


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Common Antiretroviral Drugs

Reverse transcriptase inhibitors (RTIs)

Nucleoside reverse transcriptase inhibitors, or NRTIs:Zidovudine (AZT,ZDV), Lamivudine (3TC), Abacavir (ABC)

Non-nucleoside reverse transcriptase inhibitors, or NNRTIs:Nevirapine (NVP), Efavirenz (EFV), Delavirdine (DLV)

Protease inhibitors (PIs)

Saquinavir (SQV)

Ritonavir (RTV)

Indinavir (IDV)

Often taken in combination to increase effectiveness

and reduce resistance


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Promote Use of ARVs

Reduces viral load, associated opportunisticinfections, and immunity to other infections

Reduces HIV-related wasting and the negativeeffects on body composition

Reduces deficiencies of micronutrients suchas zinc and selenium (Rousseau et al 2000)


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Educate on Nutrition-RelatedSide Effects of ARVs

Lipodystrophy (fat maldistribution)

Hyperglycemia/insulin resistance

Hyperlipidemia


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Means fat maldistribution

Is observed in 6%-80% of patients on ARVs

Is caused by metabolic changes associated with immune

reconstitution and ARV mitochondrial toxicity

Results in

Hyperlipidemia

Hyperglycemia, insulin resistance, and glucose intolerance

Peripheral wasting (extremities, face)

Visceral and subcutaneous central adiposity (buffalo hump,breast enlargement)

Managed by exercise training

Lipodystrophy


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Hyperglycemia: Increased blood sugar levelsfrom pancreatic problems or insulin resistance

Insulin resistance (impaired message system)reported in 28%-35% of adult patients on ARVs

Few cases of diabetes (3%-9%)

Management with

Antidiabetic agents

Antioxidants (e.g., vitamin C and selenium) tosupport glutathione, which is crucial in insulinaction

Hyperglycemiaand Insulin Resistance


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Changes triglycerides or cholesterol with or withoutfat maldistribution

Is caused by ARV interference with normal cellular

proteins involved with lipid metabolismIncreases levels of triglycerides or cholesterol andrisk of cardiovascular problems and pancreatitis

Is managed by

Lipid-lowering drugs Decreased fat intake Exercise

Lifestyle changes (e.g., quitting smoking)

Hyperlipidemia


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Promote a nutritionally adequate diet (quality, diversity,and quantity)

Promote safe water, food, and hygiene practices

Discourage excessive fat intake (promote modest fats,starches, and sugars and high-protein food but fewerfried eggs and yolks), fatty meats, and animal fats

Prevent muscle wasting with regular exercise to burn fat

and build muscle mass (anabolic agents?)Encourage increased fluid intake

Address nutritional consequences of drug-nutrientinteractions and side effects of medications

Nutritional Care and SupportStrategies with ARV Therapy


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Conclusions

Good nutrition and healthy lifestyle can preservehealth, improve quality of life, prolongindependence, and delay disease progression

Appropriate physical activity, increases energy,stimulates appetite, and preserves and builds leanbody mass

Preventing food- and water-borne infections reducesthe risk of diarrhea (a common cause of weightloss), malnutrition, and HIV disease progression

Antiretroviral therapy can help improve quality oflife, but patients should be educated on adversenutrition-related effects

Documents

Mod3-Nutrition Actions in HIV