USAID APHIA II

NUTRITION &

HIV/AIDS

USAID APHIA II

Objectives

• Participants should be able to:

• Relate nutrition and HIV/AIDS

• Identify the different food groups for healthy eating; for people with HIV/AIDS

• Nutritionally manage the HIV/AIDS related complications

• State the types of food – medication interaction.

USAID APHIA II

Goals of Nutrition intervention for HIV/AIDS patients• To provide adequate supply of all nutrients for

maintenance or improvement on nutritional status.

• Prevent deficiencies that may compromise immune functions.

• Educate individuals about the importance of consuming a well balanced, adequate diet through individual counseling.

USAID APHIA II

Cont’

• To minimize nutritional related complications that interfere with either intake or absorption of nutrients

• To preserve lean body mass and replenish nutrient loses incurred during infection

• To prevent protein energy malnutrition (PEM), vitamin and mineral deficiencies

USAID APHIA II

Relation between nutrition & HIV/AIDS

• HIV destroys body immune response and ability to resist disease

• HIV and frequent infection raises body’s energy and nutrient requirements

• HIV and opportunistic infections interfere with food intake and the way nutrients are absorbed and used in the body

USAID APHIA II

Relation between nutrition & HIV/AIDS

• If energy and nutrient needs are not met for a

person with HIV/AIDS, the person loses weight

and becomes malnourished

• If nutritional status is compromised, the immune

response is weakened making one vulnerable to

infections and hastens progression to AIDS

USAID APHIA II

Cycle of good nutrition & resistance to infection in the context of HIV/AIDS

Good nutrition-Good food intake-Maintenance of weight & muscle tissue-Good micronutrient status

Increased resistance to infections-Diarrhea-TB-Respiratory infections

Management of HIV related complications-Malabsorption-Diarrhea-Lack of appetite-Weight loss

Strengthening of the immune system-Ability to fight HIV & other infections

USAID APHIA II

Cycle of malnutrition & HIV infection

HIV

Poor nutrition

Poor ability to fight HIV & other infections

Increased vulnerability to infections, poor health, earlier & faster progression to the end stage of AIDS

Increased nutritional needs, reduced food intake and increased loss of nutrients

USAID APHIA II

Good nutrition helps:• Resist infections and reduce frequency of

infections

• Delay progression from HIV infections to AIDS

• PLWHA look well and maintain healthy weight

• PLWHA gain strength, build or maintain muscles and continue physical activity and continue to be productive

• Medicines to work effectively and may reduce side effects

• Reduce MTCT

USAID APHIA II

Critical nutritional interventions for PLWHA

• Periodic nutrition status assessment e.g. wt for every 2nd month for symptomatic & 4th month for assymptomatic clients – BMI less that 18.5 Kg/m2 and children wt/ht of less than –2 z

scores to be supported with therapeutic food supplements – MUAC for those who cannot stand and pregnant women and

children less than 22cm for women, less than 25cm for men or 23.3 cm for both, 12.5-13.5 for children 1-5 yrs, less than 12.5cm for those severely malnourished

– Triceps skin fold thick nesses less than 5mm for men, 8mm for women shows risks of malnutrition

USAID APHIA II

Cont’

– Waist & hip circumference ratio if greater this is associated with trunkal obesity posing cardiovascular risk or side effects of long-term ART use. 0.8 for women, 1.0 for men shows changes in body shape

– Dietary assessment for those who have lost more than 5% of their usual weight in 2 or 3 months

– Others include BIA for body composition, biochemical & microscopic investigations & clinical assessments

USAID APHIA II

Cont’ • Educate and counsel on increased energy needs for

disease stage• Educate and support clients to maintain high levels of

sanitation, food hygiene and water safety• Practice positive living behaviors- safer sex, avoid

alcohol, junk foods, smoking and manage depression which interferes with food intake

• Seek prompt treatment for all OIS • Carry out physical activities/exercises to strengthen or

build muscles, increase appetite or health• Manage food drug interactions and side effects by

food and nutrition intervention.

USAID APHIA II

For meals to provide adequate nutrition and promote well being they should comprise of a variety of foods :

USAID APHIA II

• Energy foodsRice, whole grain cereals, yams, cassavas,

bananas. Fats,sugars,oils for extra energy and fatty acids.

• Body building foods Lean meat, chicken, fish, milk and milk products,

eggs, beans, peas e.t.c• Protective foodsFruits and vegetable – yellow or orange fruits, dark

green vegetables esp. traditional• Water Clean, safe or treated water for cleansing the body

of toxins and waste and for transportation of nutrients.

USAID APHIA II

Estimates of food quantities

• Servings are based on a 250ml cup • Energy foods 1 serving is equal to:

– 1slice of bread or – ½ cup of cooked pasta, rice, or cereal– 1 cup high fibre cereal or – 2cakes cereal– 1 cup potatoes/2cooked bananas– 3biscuits

USAID APHIA II

Cont’

• Body building foods, 1serving is equal to :

– 1cup cooked beans /peas– 1cup fresh milk, fermented/yoghurt– 60-90 g cooked meat/chicken/fish or 20g fillet

USAID APHIA II

Cont’

• Protective foods 1serving is equal to:– I piece whole fruit – Half cup fruit juice– 1 cup chopped veges– ½ cup cooked veges

USAID APHIA II

Nutrient requirements of PLWHAS

• Depends on the stage of the disease progression

and the intake levels are based on absence or

presence of symptoms.

USAID APHIA II

Energy requirements:HIV/AIDS increases body’s energy needs because

of

– Energy use for HIV infections and opportunistic infections

– Nutrients malabsorption

– Altered metabolism • PLWHAS without symptoms (WHO stage 1)

require 10% additional energy equivalent to 210 additional Kilocalories translated to food equivalent of 1 mug of porridge per day.

USAID APHIA II

Energy requirements:• PLWHAS with symptoms(WHO stage 2 & above)

require 20-30% additional energy which is 420 –630

kilocalories depending severity of

symptoms,translating to food equivalent to 2-3

mugs of porridge per day.

• Children who are asymptomatic need 10% more

energy to maintain growth. Those who are

symptomatic energy needs increase by 20-30%

more per day and those experiencing weight loss

require 50-100% additional energy per day.

USAID APHIA II

Strategies to meet energy requirements:

• Consume 2 or more snacks between meals

• Make dietary adjustments such as -:

– Use fats & oils in food preparation of low energy

e.g. potatoes

– Adopt food preparation methods that nutritional

value e.g. sweeten, add nuts, ferment to add bio-

availability of most nutrients

– Treat or manage condition that reduce food intake

USAID APHIA II

Protein requirements:• High protein is required on the onset of opportunistic

infections because of the body loses of nitrogen

• HIV infected persons often have pre-existing PEM which is not a deficiency of 1 nutrient (protein) but inadequate intake or poor utilization of food and energy.

• WHO recommends the same RDA for non-infected persons. 1g/Kg BWT optimum protein intake

– Adults 1.2-1.5g/Kg BWT; children 2.5-3g/Kg BWT

– Pregnant & lactating women have higher protein needs

• Therefore Protein recommended 12-15% total energy intake on average of 50-80g of protein daily

USAID APHIA II

Strategies to meet protein requirements.

• Eat both plant & animal source daily

• Consume animal protein as part of main meal as frequently as possible

• Fermented milk or yogurt is easily digested and helps in digestion & absorption of other foods and inhibits growth of harmful organisms

• Lactose intolerance patients take fermented milk or yoghurt

USAID APHIA II

Fat requirements:• WHO recommends same RDA for HIV non-infected

persons. Ie more than 30% of total daily energy.

• The intake changes in timing or in quantity due to certain ARVs or infections like diarrhea

• Fats provides more than twice the energy of equivalent CHO

• Fats add flavor and taste, stimulates appetite

• Fats maintain function and integrity of cell membrane structure

• Fats enhance absorption of fat soluble vitamins

USAID APHIA II

Micronutrient requirements:

• WHO guidelines – same micronutrients for healthy non HIV infected persons

• Deficiencies are common in HIV prevalent areas esp. Vit A, B complex, C, E, Selenium & Zinc, iron, iodine,magnesium, and calcium, which are strong for the immune system.

• Deficiencies of anti-oxidant Vit & minerals contribute to oxidative stress which accelerate cell death and increase rate of HIV replication.

USAID APHIA II

Cont’• Fruits & veges provide essential vit, minerals & trace

elements. Animal sources are important sources of micronutrients. WHO recommends 400g of veges & fruits daily

• Therapeutic intervention is required for those deficient in iron & vit A or those with infections like malabsorption, diarrhea, intolerances, severe malnutrition

• Use supplements that are registered with MOH

• Toxicity is possigle with supplements e.g. Vit A, B3 (viacin), B6 (Pyridoxine), D, Iron, Zinc, Selenium fatty liver is an example.

USAID APHIA II

Dietary fibre requirement

• Roughage, food component that enhances bowel movement and the health of digestive system

• Creates a sense of fullness therefore eats less and this is not desirable for PLWHA

• Not suitable for patients with diarrhea. Soluble fibre from fruits, binds water in the gut and is recommendable, insoluble – whole grains/cereals,legumes worsen diarrhea

• For constipation take insoluble fibre

USAID APHIA II

Water requirement

• Essential nutrient for transportation of nutrients, removal of waste, assists metabolic activities, provides lubrication and regulation of body temperatures.

• Use clean safe water. Boil for 5-8 minutes

• Store in a clean covered metallic or ceramic container

• Add suitable water treatment (chloride) to kill bacteria

• Use sterilized or bottled drinking water-cost for PLHWA

USAID APHIA II

CONT’ • Not all distilled water has minerals

• Take 8 glasses ( 2litres per day)

• Coffee & tea should not replace water (Tannins inhibit iron absorption) and caffeine causes dehydration soups and fruit juices are encouraged but artificial juices & fizzy drinks are not suitable due to unknown effects of preservatives and gases give a sense of satiety

• Extra water for people on medication to flush out bi-products e.g. those on indinavir need extra 1500ml

• Alcoholic beverages are not suitable-dehydrate, affect metabolism and effectiveness of medication, worsen side effects, interfere with food intake digestion, absorption & storage of certain nutrients. It increases risk of unfavorable behavior

USAID APHIA II

Management of AIDS related symptoms

1. Anorexia ( appetite loss)

Eat favorite foods Eat small frequent meals and use dense foods Prescribe or provide multivitamin supplements Avoid strong smelling foods Avoid hazards of smoking and alcohol use Seek medical treatment if appetite loss is due to

illness & refer to counselor if related to depression

USAID APHIA II

Diarrhea – 3 loose stools per day

• Drink lots of fluids-boiled water, low fat soups, fresh fruit juice, weak tea & fermented porridge.

• Consume foods rich in soluble fiber to help retain fluids e.g. millet, carrot juice, bananas, peas and lentils.

• Eat cereals and other starches, and boiled/steamed foods

• Avoid fatty foods, gas forming foods like cabbage, onion, carbonated drinks & alcohol

• Seek medical treatment if stools are bloody, dehydration & fever occurs.

• Take a glass of ORS after every episode of diarrhea (1/2 glass for children)

• Refer for treatment of bacterial, viral & fungal infections as indicated

USAID APHIA II

Fever:

• Take fluids (soups) that provide energy and nutrients e.g. porridge, potato & carrot soups

• Drink plenty of fluids

USAID APHIA II

Nausea & vomiting

• Eat small frequent meals

• Eat salty and dry foods like crackers, toasted bread

• Take soups, porridge (unsweetened) and fruits like bananas and other fluids after meals

• Avoid greasy, spicy foods, caffeine, sweetened foods

• Avoid empty stomach it worsens nausea

• Avoid lying down after eating and rest between the meals

USAID APHIA II

Mouth sores/Thrush:• Eat soft mashed foods e.g. potatoes, carrots,

scrambled eggs, bananas, etc• Eat foods at room temperature, drink plenty or

energy dense drinks.• Avoid alcohol, sugary, spicy & salty foods, citrus

fruits & juices that irritate the mouth sores• Eat fermented foods • Drink fluids with a straw to ease swallowing • Avoid alcohol and cigarettes • Advice practicing good oral hygiene & gargle small

amounts of bicarbonate soda in warm water or use garlic water

USAID APHIA II

Anemia- indicated by fatigue, pale hands & finger nails.

• Refer to assessment & other diagnostic investigations to rule out medical causes e.g. (malaria, infections)

• Recommend increased consumption of

– Lean meat, dark poultry meat & fish

– Dark green veges esp. traditional vegetables

– Vitamin C rich fruits e.g. citrus fruits, mangoes for absorption

• Avoid tea, coffee, milk and cocoa at meal times that inhibit absorption.

• Take iron, folate & vitamin B12 supplementation.

• Ensure de-worming every 4-6 months

• If the patient is taking zidovudine or lamivudine recommend assessment of hemoglobin

USAID APHIA II

Muscle wasting/ weight loss • Increase food intake by increasing quantity of food &

frequency of consumption

• Increase protein in the diet (HBV Protein)

• Improve quality & quantity of foods by offering a variety

• Eat small frequent meals

• Take nutrient dense snacks between meals and improve density of meals by adding peanut butter, whole milk, sugar, eggs in porridge or soups

• Recommend weight taking monthly & if BMI is less than 16kg/m2 refer for nutrition assessment or ARV Treatment assessment

USAID APHIA II

Constipation:• Have regular eating schedule and avoid skipping meals

• Eat high fiber foods

• Drink plenty of fluids ( 8 glasses per day esp. if on diuretics)

• Avoid processed or refined foods and use of laxatives

• Promote regular bowel habit

• Advice on regular exercises

Heartburn/bloatedness:• Eat small frequent meals

• Avoid gas forming foods

• Drink fluids between meals

USAID APHIA II

Loss of taste & / abnormal taste• Use flavor enhancers e.g. salt, spices, herbs, lemons

• Practice good oral hygiene (rinse mouth after meals)

• Chew food well & move around the mouth to stimulate receptors

• Use lemon, tonic water, vinegar or raw tomatoes to stimulate taste buds

• Take small sips of water between bites.

USAID APHIA II

Types of food-medication interactions• Medication affects nutrient absorption, metabolism,

distribution and excretion e.g. some ARVs lead to lipodystrophy syndrome or fat mal distribution, some protease inhibitors, e.g. indinavir affect glucose/sugar metabolism and cause insulin resistance

• Medication side effects affect food consumption and nutrient absorption e.g. protease inhibitor like ritonavir causes changes in taste thus an individual consumes less foods. Make use of flavor enhancers to stimulate taste buds.

USAID APHIA II

Cont’

• Medication and food causes unhealthy side

effects or reduce positive impacts of drugs e.g.

saquinavir taken with garlic supplements may

cause diarrhea, mouth ulceration, taste changes,

vomiting, flatulence. E.t.c.

USAID APHIA II

INTERACTION BETWEEN ARVs AND FOOD

• How have your eating habits changed since you started taking ARVs? What are the reasons for these changes?

• Have you experienced health problems that you think are related to these drugs?

• Are you also taking supplements or traditional herbs? If so describe them.

USAID APHIA II

• ARVs should be taken according to dosage and schedule from the doctor.

• ARVs, alter absorption and utilization of nutrients in the body.

• Some of them are taken with food, others not, and others have specific food restrictions.

• Some of them create create side effects that reduce food intake and absorption.

• Avoid alcohol with ARVs.

• Some traditional therapies reduce the drug effectiveness.

USAID APHIA II

Traditional / Herbal therapies • They are commonly used but have not been subjected to

clinical research and their effect on the course of HIV infection, toxicity is unknown

• Herbs & spices may be beneficial e.g. to enhance food taste, smell & improve appetite or maybe detrimental to a persons health (restrict food intake)

• There is a cost associated with the therapies.• They cannot be used as supplements and can be used if

they have potential to alleviate, prevent, or cure symptoms • Dietary management of side effects still apply when using

these therapies.• Be knowledgeable about the common traditional therapies

in your area.

USAID APHIA II

Dietary supplements

• They contain single or multiple micronutrients and sometimes selected a.a

• Some are health promoting bacterial cultures

(pro-biotics) & bacteria associated with good gut

flora (pre-biotics)• Patients on several formulations risk overload and

side effects esp. those on fat soluble vitamins

USAID APHIA II

THANK YOU ALL!