Module a 5 Session 3

8/9/2019 Module a 5 Session 3

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Part A/Module A5/Session 3

Part A: Module A5

Session 3

Nutrition


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Objectives

1. Understand the interaction between HIV and

nutrition.

2. Discuss the influence of infectious diseases on

nutritional status, the cycle of micronutrient

deficiencies, HIV pathogenesis and the symptomsand causes of poor nutrition.

3. Describe the processes that lead to weight loss

and wasting.


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Objectives, continued

4. Discuss the role of vitamins and minerals in the

body and list locally available sources of these

nutrients

5. Carry out a nutritional assessment for children andadults

6. Discuss options for nutritional support programs

7. Give recommendations for nutrition care andsupport for adults and children with HIV/AIDS and

adapt these to their local situation


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HIV and Nutrition:The Interaction


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Introduction

Malnutrition is a serious danger for people living withHIV/AIDS

The risk of malnutrition increases significantly during thecourse of the infection

Good nutrition cannot cure AIDS or prevent HIV infection,but it can help to maintain and improve the nutritionalstatus of a person with HIV/AIDS and delay theprogression of HIV disease

Many of the conditions associated with HIV/AIDS affectfood intake, digestion and absorption, while othersinfluence the functions of the body


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Malnutrition Takes Many Forms

Protein-energy malnutrition is usually measured in

terms of body size

Indicators in children

Stunting: low height-for-age Underweight: low weight-for-age

Wasting or acute malnutrition: low weight-for-height

Indicators in adults

Low body mass index (BMI)


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Malnutrition Forms, continued

in its mild and moderate forms is not always

recognized

often referred to as hidden hunger

Most commonly reported micronutrientdeficiencies in both adults and children are

iron

vitamin A

iodine deficiency

Micronutrient malnutrition


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Malnutrition Forms, continued

Deficiencies in other vitamins and minerals that arevital for the bodys normal functions and for the work

of the immune system are not commonly measured,

but they occur frequently in populations

with high infectious disease burden

monotonous, poor quality diets

diets characterized by limited consumption of

animal products and seasonal or periodic food

insecurity


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The Clinical Context

Infections affect nutritional status by reducing dietaryintake and nutrient absorption, and by increasing theutilization and excretion of protein and micronutrientsas the body responds to invading pathogens.

Anorexia, fever, and catabolism of muscle tissuefrequently accompany the acute phase response

Even mild infectious diseases influence nutritional

status

Almost any nutrient deficiency, if sufficiently severe,will impair resistance to disease.


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Clinical Context, continued

Infections also result in the release of pro-oxidantcytokines and other reactive oxygen species.

The relationship between HIV and nutrition iscomplicated by the fact that the virus directlyattacks and destroys the cells of the immunesystem.

The vicious cycle of micronutrient deficienciesand HIV pathogenesis:

Nutritional deficiencies affect immunefunctions that may influence viral expressionand replication, further affecting HIV disease

HIV affects the production of hormones whichare involved in the metabolism ofcarbohydrates, proteins and fats


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The Vicious Cycle

The Vicious Cycle of Micronutrient

Deficiencies and HIV Pathogenesis

Insufficient dietary intake

Malabsorption, diarrhea

Altered metabolism andnutrient storage

Nutritionaldeficiencies

Increasedoxidative stress

Immunesuppression

Increased HIVreplication

Hastened diseaseprogression

Increased morbidity


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Symptoms of Malnutrition in PLHA

Weight loss

Loss of muscle tissue and subcutaneous fat

Vitamin and mineral deficiencies Reduced immune competence

Increased susceptibility to infection


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Causes of Poor Nutritional Status

Depressed appetite, poor nutrient intake, and limited

food availability

Chronic infection, malabsorption, metabolic

disturbances, and muscle and tissue catabolism Fever, nausea, vomiting, and diarrhea

Depression

Side effects from drugs used to treat HIV-related

infections


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To understand the relationship between nutrition

and HIV/AIDS, one must consider the effect of

the disease on body size and composition as

well as the effect on the functioning of the

immune system Nutrition plays a role in each of these conditions

Keep in mind that malnutrition may be a

contributorto HIV disease progression as well

as a consequence of the disease

Weight Loss and Wasting in HIV/AIDS


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Wasting

The wasting syndrome typically found in adult AIDS

patients is a severe nutritional manifestation of the

disease.

Wasting is usually preceded by:

decrease in appetite

repeated infections

weight fluctuations

subtle changes in body composition


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Weight Loss Patterns

Weight loss typically follows two patterns in PLHA:

Slow and progressive weight loss from

anorexia and gastrointestinal disturbances

Rapid, episodic weight loss from secondaryinfection

Even relatively small losses in weight (5 percent)

have been associated with decreased survival and

are therefore important to monitor


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Overlapping Processes

1. Reductions in food intake, due to:

Painful sores in the mouth, pharynx, and/or

esophagus Fatigue, depression, changes in mental state, and

other psychosocial factors

Economic factors affecting food availability andnutritional quality of the diet

Side effects from medications, including nausea,vomiting, metallic taste, diarrhea, abdominalcramps, anorexia

Weight loss and wasting in PLHA develop as a result of threeoverlapping processes:


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Overlapping Processes, continued

2.Nutrient malabsorption

Malabsorption accompanies frequent bouts ofdiarrhea due to Giardia, cryptosporidium, and otherpathogens

Some HIV-infected individuals have increasedintestinal permeability and other intestinal defectseven when asymptomatic

HIV infection itself may cause epithelial damage tothe intestinal walls and malabsorption

Malabsorption of fats and carbohydrates is common

at all stages of HIV infection in adults and children Fat malabsorption in turn affects the absorption and

utilization of fat-soluble vitamins (e.g., vitamins A, E),further compromising nutrition and immune status.


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Metabolic alterations

Infection results in increased energy andprotein requirements, as well as inefficientutilization and loss of nutrients

HIV-related metabolic changes come fromsevere reductions in food intake and theimmune systems response to the infection

Wasting is also due to cachexia, which ischaracterized by a significant loss of lean

body mass resulting from metabolic changesthat occur during the acute phase response toinfection

Overlapping Processes, continued


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Overlapping Processes, continuedMetabolic Alterations that Accompany Acute Infections

Protein Increased urinary nitrogen loss

Increased protein turnoverDecreased skeletal muscle protein synthesisIncreased skeletal muscle breakdownIncreased hepatic protein synthesis

Lipid (fat) Hypertriglyceridemia

Increased hepatic de novo fatty acid synthesisIncreased hepatic triglyceride esterificationIncreased very low-density lipoprotein productionDecreased peripheral lipoprotein lipase activityIncreased adipocyte triglyceride lipase

Carbohydrate Hyperglycemia

Insulin resistance

Increased peripheral glucose utilization

Increased gluconeogenesis

Source: Babameto and Kotler (1997)


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Micronutrients:Vitamins and Minerals in HIV/AIDS


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Many vitamins and minerals are important to the

HIV/nutrition relationship

This is because of their critical roles in

cellular differentiation enzymatic processes

immune system reactions

other body functions

Micronutrients:

Vitamins and Minerals


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Roles of Different Vitamins and Minerals

Nutrient Its Role Sources

Vitamin

A Required for maintenance ofepithelial cells, mucousmembranes, and skin.

Needed for immune systemfunction and resistance toinfections.

Ensures good vision. Neededfor bone growth

Full-cream milk (whenfortified), cheese,butter, red palm oil, fishoil, eggs, liver, carrots,

mangoes, papaya,pumpkin, green leafyvegetables, yellowsweet potatoes.

VitaminB1

Thiamine

Used in energy metabolism,supports appetite, and centralnervous system functions.

Whole grain cereals,meat, poultry, fish, liver,milk, eggs, oil, seeds,and legumes.


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Vitamin B2

Riboflavin

Used in energymetabolism, supportsnormal vision, healthand integrity of skin.

Milk, eggs, liver, fish,yogurt, green leaves,whole-grained cereals,and legumes.

Vitamin B3

Niacin

Essential for energymetabolism, supportshealth and integrity of

skin, nervous anddigestive system.

Milk, eggs, meat,poultry, fish, peanuts,whole-grained cereals,

unpolished rice.

Vitamin B6 Facilitatesmetabolism andabsorption of fats and

proteins, convertstryptophan to niacin,helps make red bloodcells. Some TBdrugs cause B6deficiency.

Legumes (whitebeans), potatoes,meats, fish, poultry,

shellfish, watermelon,oil seeds, maize,avocado, broccoli,green leafyvegetables. Alcoholdestroys vitamin B6.


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Folate

(folic acid)

Required for synthesis of

new cells, especially redblood cells andgastrointestinal cells.

Liver, green leafy

vegetables, fish,legumes, groundnuts,oil seeds.

Vitamin

B12

Required for synthesis ofnew cells, helps tomaintain nerve cells.

Works together with folate.

Meat, fish, poultry,shellfish, cheese,eggs, milk.

Vitamin C

Helps the body to usecalcium and other nutrientsto build bones and bloodvessel walls. Increases

non-heme iron absorption.Increases resistance toinfection and acts as anantioxidant. Important forprotein metabolism.

Citrus fruits: baobob,guava, oranges andlemons; cabbage,green leaves,yams,tomatoes,

peppers, potatoes.Cooking plantains,and fresh milk.Vitamin C is lost whenfood is cut up, heated,or left standing after

cooking.


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Vitamin D Required for mineralization of

bones and teeth.

Produced by skin on

exposure to sunshine;milk, butter, cheese, fatty

fish, eggs, liver.

Vitamin E Acts as an antioxidant. Protects cellmembranes and metabolism,

especially red and white blood

cells. Protects vitamin A and other

fats from oxidation. Facilitates

resistance against diseases,

particularly in lungs.

Green leafy vegetables,vegetable oils, wheat

germ, whole-grain

products, butter, liver, egg

yolk, peanuts, milk fat,

nuts, seeds.


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Calcium Required for building strongbones and teeth. Important fornormal heart and musclefunctions, blood clotting andpressure, and immunedefenses.

Milk, yogurt, cheese,green leafy vegetables,broccoli, dried fish withbones that are eaten,legumes, peas.

Zinc Important for function of manyenzymes. Acts as an anti-oxidant. Involved with makinggenetic material and proteins,immune reactions, transport of

vitamin A, taste perception,wound healing, and spermproduction.

Meats, fish, poultry,shellfish, whole graincereals, legumes,peanuts, milk, cheese,yogurt, vegetables.

Selenium Acts as an antioxidant togetherwith vitamin E. Prevents theimpairing of heart muscles.

Meat, eggs, seafood,whole grains, plantsgrown in selenium rich

soil.


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Magnesium Important for buildingstrong bones and teeth,

protein synthesis,

muscle contraction,

transmission of nerve

impulses.

Nuts, legumes,whole grain cereals,

dark green

vegetables, seafood.

Iodine Ensures the

development and proper

functioning of the brain

and of the nervous

system. Important for

growth, development,

metabolism.

Seafood, iodized

salt, plants grown in

iodine-rich soil.

Source: Piwoz & Prebel, pp. 15-16


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Nutritional Assessment


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Identify risk factors

Determine weight gain or loss, linear growth, growth

failure, or body mass index (BMI)

Weight loss may be so gradual that it is not obvious.

Elements of a Nutritional Assessment


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Nutritional Assessment , continued

Other helpful information:

Length of time it takes the patient to eat

Appetite

Any chewing, sucking, or swallowingproblems

Nausea, vomiting, or diarrhea

Abdominal pain

Any feeding refusal, food intolerance,allergies, and/or fatigue


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Growth failure is defined as:

Crossing two major percentile lines on the NCHS

growth chart over time

For a child


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Nutritional Assessment in Adults

Formula for determining ideal body weight

Male: 48 kg + 1.07 kg/cm if over 152 cm

Female: 45.5 kg + 0.9 kg/cm if over 152 cm

BMI

Weight (kg)/height (meters squared)

Malnutrition in an adult is defined as

involuntary weight loss greater than 10 percent

weight less than 90 percent estimated idealweight

BMI less than 20


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Goals of a program to provide nutrition support toP

LHAmay vary from prevention of nutrition depletion to theprovision ofpalliative nutrition care and supportforPLHAand their families.

The overall program objectives should be to:

Improve or develop better eating habits and diet Build or replenish body stores of micronutrients

Prevent or stabilize weight loss

Preserve (and gain) muscle mass

Prevent food-borne illness

Prepare for and manage symptoms that affect food-consumptionand dietary intake

Provide nutritious food for PLHA and families

Program Goals


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Holistic Approach

When possible, include a nutritionist on the HIV careteam to provide education and counseling and to

assist with referrals for food support

Components of care

Appropriate treatment of opportunistic infections

Stress management

Physical exercise

Emotional, psychological, and spiritual

counseling and support


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Nutrition care and support programs may include:

Holistic Approach, continued

Nutrition education and counseling in healthfacilities, community settings, or at home

Programs to change dietary habits, increaseconsumption of foods and nutrients, or to manageanorexia and other conditions that affect eating

patterns

Water, hygiene, and food safety interventions toprevent diarrhea

Food-for-work programs for healthy family membersaffected by HIV/AIDS, including orphan caregivers

Food baskets for home preparation, including home-delivered, ready-to-eat foods, for homeboundpatients who are unable to prepare their own meals.


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Recommendations forNutritional Care

1. Recommendations for nutritional support of HIV-

positive, asymptomatic individuals

2. Recommendations for nutritional support for HIV-

positive individuals experiencing weight loss

3. Recommendations for nutritional support for

people with AIDS


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Nutritional Support of

HIV-positive,

Asymptomatic Individuals


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Promote a diet adequate in energy, protein, fat,

and other essential nutrients

Even asymptomatic HIV-infected persons may

have increased body metabolism, which increases

their daily energy, protein and micronutrient

requirements

Therefore, a person with HIV requires 10% to 15%

more energy and 50% to 100% more protein a

day.

Promote a Healthy Diet


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HIV-positive adults (men and women) shouldincrease their energy intakes to an additional 300 to400 kcal/day

Protein intake should be increased to about 25-30additional grams/day

Care should be taken to select foods that are rich inmicronutrients containing anti-oxidants and B-vitamins

A PLHA may need to consume 2 to 5 times the

recommended daily allowance for healthy adults inorder to delay HIV progression

Healthy Diet, continued


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Daily multivitamin-mineral supplements of these

micronutrients may be needed to reverse underlying

nutrition deficiencies and build nutrient stores; caution

is advised with zinc and iron supplements.

The HIV virus requires zinc for gene expression,

replication, and integration

Although anemia is common in PLHA, advanced

HIV disease may also be characterized by

increases in iron stores in bone marrow, muscle,liver, and other cells



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In summary, a healthy diet should contain a balance of:

carbohydrates and fats to produce energy andgrowth: (rice, maize/millet porridge, barley, oats,wheat, bread, cassava, plantain, bananas, yams,potatoes, etc)

proteins to build and repair tissue: (meat, chicken,liver, fish, eggs, milk, beans, soybeans,groundnuts, etc.)

vitamins and minerals (found in fruits andvegetables) to protect against opportunisticinfections by ensuring that the lining of skin, lungsand gut remain healthy and that the immunesystem functions properly



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Nutrition Counseling and Support

All personnel who work with PLHA should be familiarwith these algorithms and foods

Home-based care providers should be familiar with thebasic nutritional advice and practices forPLHA

Providers need to access existing local sources ofsocial support to household food security issues offamilies affected by HIV/AIDS

Nutrition counseling should include information onlocally available foods and diets to meet estimatedrequirements for an individuals age, sex, andphysiologic state

Develop algorithms for the nutritional management ofPLHAand identify appropriate locally available foods.


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Exercise

Exercise is important for preventing weight loss andwasting because it

stimulates the appetite reduces nausea improves functioning of the digestive system

strengthens muscles reduces stress increases alertness

Exercise is the only way to strengthen and build up muscles

everyday activities such as cleaning, working in the fieldand collecting firewood and water might provide enough

exercise.


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Hygiene and

Safe Food Handling and Preparation

Important hygiene and food safety messages are:

Always wash hands before food preparation and

eating and after defecating Keep all food preparation surfaces clean and use

clean utensils to prepare and serve foods.

Cook food thoroughly

Avoid contact between raw foodstuffs and cookedfoods

PLHA have an increased susceptibility to bacterialinfections


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Hygiene and

Safe Food Handling and Preparation

Serve food immediately after preparation andavoid storing cooked foods

Wash fruits and vegetables before serving

Use safe water that is boiled or filtered

Use clean cups and bowls, and never use bottlesfor feeding babies

Protect foods from insects, rodents, and otheranimals

Store non-perishable foodstuffs in a safe place

Encourage PLHA to seek immediate attention fordigestive and other health problems to prevent furthernutritional and physical deterioration


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Nutritional Support for

HIV-positive IndividualsExperiencing Weight Loss


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Assess what has led to the weight loss.

Identify and treat underlying infections early

Provide advice about maintaining intake during

infections

Increase intake to promote nutritional recovery

following periods of appetite loss, fever, or acute

diarrhea

Minimize the nutritional impact of infection

Advise avoidance of excessive alcohol

consumption, unsafe sexual practices


Weight Loss


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Practical Suggestions

How to Maximize Food Intake During and FollowingCommon HIV/AIDS-related Infections

Symptom Suggested Strategy

Fever and loss of

appetite

Drink high-energy, high-protein liquids and fruit juice

Eat small portions of soft, preferred foods with a pleasing

aroma and texture throughout the dayEat nutritious snacks whenever possible

Drink liquids often

Sore mouth and

throat

Avoid citrus fruits, tomato, and spicy foods

Avoid sweet foods

Drink high-energy, high-protein liquids with a straw

Eat foods at room temperature or cooler

Eat thick, smooth foods, such as pudding, porridge,mashed potatoes, mashed carrots or other non-acidicvegetables and fruits


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Nausea andvomiting

Eat small snacks throughout the day and avoidlarge meals

Eat crackers, toast, and other plain, dry foodsAvoid foods that have a strong aroma

Drink diluted fruits juices, other liquids, and soup

Eat simple boiled foods, such as porridge,potato, beans

Loose bowels Eat bananas, mashed fruits, soft rice, porridgeEat smaller meals, more oftenEliminate dairy products to see if they are thecause

Decrease high-fat foods

Dont eat foods with insoluble fiber (roughage)Drink liquids often

Fatmalabsorption

Eliminate oils, butter, margarine, and foods thatcontain or were prepared with them

Eat only lean meats

Eat fruits and vegetables and other low-fat foods


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Severediarrhea

Drink liquids frequentlyDrink oral rehydration solution

Drink diluted juices

Eat bananas, mashed fruits, soft, rice porridge

Fatigue,lethargy

Have someone pre-cook foods to avoid energyand time spent in preparation (care withreheating)

Eat fresh fruits that dont require preparation

Eat snack foods throughout the day

Drink high-energy, high-protein liquidsSet aside time each day for eating

Adapted from Woods (1999)


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Recommendations for

Nutritional Support forPeople with AIDS


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Mitigate the nutritional consequences of the diseaseat this stage and preserve functional independencewhenever possible.

Take the followingpoints into consideration:


People with AIDS

Preservation of lean body mass remains

important at this stage, and earlierrecommendations regarding energy and proteinconsumption should be maintained as long andas often as possible

During periods of nausea and vomiting, people

with AIDS should try to eat small snacksthroughout the day and avoid foods with strongor unpleasant aromas. Fluid intake must bemaintained to avoid dehydration.


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To minimize gastrointestinal discomfort, gas, andbloating, foods that are low in insoluble fiber and

low in fat should be consumed. If there is lactose

intolerance, milk and dairy products should be

avoided

During diarrhea, ensure that fluid intake is

maintained (30 ml/kg body weight per day for

adults and somewhat more for children)

For people with mouth and throat sores, hot and

spicy or very sweet foods should be avoided, asshould caffeine and alcohol


People with AIDS


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For patients with depressed appetites or lack of interestin eating, caregivers should increase dietary intake by

offering small portions of food several times a day

set specific eating times

find ways to make eating times pleasant

Treat all infections that affect appetite, ability to eat, and

nutrient retention

Avoid tobacco products

Follow the guidelines (section D.1.d.) for hygiene and

food safety


People with AIDS


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Nutritional Consequences, continued

Many antiretroviral drugs have dietary

requirements (e.g., to be taken on an empty or

full stomach) and most have side effects such as

nausea, vomiting, abdominal pain, and diarrhea,which must be managed nutritionally

Some drugs, such as ZDV, affect red blood cell

production and increase the risk of anemia


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Documents

Module a 5 Session 3