Hiv&Nutrition

8/18/2019 Hiv&Nutrition

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Ninuk D.K


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2

Learning Objectives

Describe the effect of HIV/AIDS on

nutrition

Describe the impact of malnutrition onHIV infection in adults

Identify the effect of micronutrient

supplementation on HIV progression


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Learning Objectives

Describe Goals of nutrition care and

support in HIV/AIDS

Describe essential components of nutritioncare and support in HIV/AIDS

Describe key actions for HIV-infected

people

Describe appropriate assessments

inter!entions follo"-up and re!ie" for

nutritional care in HIV/AIDS


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Learning objective

Describe e!idence-based nutritional care

for #$%HIV


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Evidence-based NutritionalCare


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Malnutrition and HIV


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&'

Malnutrition and HIV

(alnutrition and HIV are pre!alent "orld"ide"ith the highest rates of both in sub-Saharan

Africa

(alnutrition influences immune function the!irulence of infectious agents progression ofchronic infections such as HIV and geneticfactors that determine the outcome of sepsis

)he association bet"een HIV morbidity andmalnutrition is bi-directional– (alnutrition affects HIV disease progression

– HIV affects nutritional status

T M l i i


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&&

Types o Malnutrition!"rotein#$nergy Malnutrition

#rimary #*( caused by inade+uate

intake

Secondary #*( is the result of illness

in,uries or treatments causing altered

appetite digestion absorption

(ost common form of malnutrition in HIV

disease

" i $ M l i i


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&2

"rotein#$nergy Malnutrition%&'

sed to describe nutritional macrodeficiency

syndromes

– (arasmus. deficiency of calories

– "ashiorkor. deficiency of protein

– 0utritional d"arfism in children and "asting syndromes inadults

(easured as body si1e by "eight or body mass inde

3"eight 4kg5 di!ided by height in 4meters52 6

– 7 &8. se!erely malnourished– &8-&89:. moderately malnourished

– &;-&


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&?

Types o Malnutrition!Micronutrient Nutrition

Alterations in the stores of fat- and "ater-soluble!itamins and trace elements

@linical symptoms are subtle unless deficiency is

se!ere ften accompanies infectious diseases

(ost common eamples in children and adults.– Iron -B anemia

– Vitamin A -B susceptibility to infection associated "ithHIV-disease progression and increased mortalityincreased maternal-fetal transmission

– Iodine -B thyroid enlargement and hypothyroidism

N t iti


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&=

Nutrition!+educed Intake

HIV is associated "ith reduced intake of

food/nutrients

– @ogniti!e impairment and/or depression -B

reduced moti!ation and ability to access andprepare foods

– Camily instability or po!erty -B reduced access tofood

– HIV- I- or medication-induced -B anoreia andnausea

– Is of mouth and esophagus -B painful s"allo"ing


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N t iti


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&8

Nutrition!)ltered Metabolis,

HIV is associated "ith altered

metabolism of food/nutrients

– HIV and Is increase catabolism andenergy needs by &' E &>F

– Adult man needs an additional =''calories/day 4from 2&''-B2>''5

– #rotein re+uirements increase by >'F (en. >; -B of protein grams/day

%omen. =< -B ;2 grams/day9

$ t HIV N t iti


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&;

$ects o HIV on Nutrition!-asting

Se!ere malnutrition in HIV-infected persons is

recogni1ed as "asting defined as.

– ody "eight loss of B &'F

– %ith associated fatigue fe!er and diarrhea uneplained by

another cause

*tiology is multifactorial

Any "eight loss of B >F is associated "ith accelerated

disease progression impaired functional status and

increased mortality %asting is a %H Stage = diagnosis and is a

criterion for AV initiation


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&:

Malnutrition and HIV()ID*

Affect the body in similar "ays Affect the ability of the immune system to fight

infection and keep the body healthy through.

– Disrupts @D= number / function

– Disrupts @D< number / function

– Alters delayed type cutaneous hypersensiti!ity

– Alters @D= / @D< ratio

– Impairs antibody response– Impairs bacteria killing


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2'

Malnutrition and HIV()ID* %&'

$o" (I is associated "ith disease

progression and death

0utrient deficiencies 4!itamins A &2 *

selenium and 1inc5 are associated "ith

"orse outcomes

– HIV transmission

– Disease progression

– (ortality

" 4 i l 0 t


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2&

"syc4osocial 0actors orMalnutrition

Cood scarcity

Cinancial constraints

Camily disruption $oss of financial bread"inner

$oss of primary caregi!er due to illness

or death (ental health factors. depression

8 l


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8oals o Nutrition are and *upport

• Improve nutritional status− Maintain weight and prevent weight loss

− Preserve muscle mass

• Ensure adequate nutrient intake

−Improve eating haits and diet

− !eplenish stores of essential nutrients

• Prevent food"orne illnesses

• Enhance quality of life− #reat opportunistic infections

− Manage symptoms affecting food intake

• Provide palliative care

t


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o,ponents o Nutritional are and *upport

&9 0utritional

assessment

29 Inter!ention

?9 Collo" up and re!ie"


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Nutritional )ssess,ent


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-4y Measure9

)o identify and track body composition changes o!er

time and trends

− @hanges in "eight

−@hanges in body cell mass and fat-free mass

− Serum nutrient le!els cholesterol etc9

)o use results to design appropriate inter!entions

)o address client concerns about their health

)o meet increasing emphasis on physical nutrition

assessment as part of clinical trials


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-4at to Measure9

Anthropometry

$aboratory tests

@linical assessments

Diet history and lifestyle

) t4 t i M t


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)nt4ropo,etric Measure,entsin HIV()ID*

)o assess and monitor "eight %eight and height

#ercentage of "eight and/or body mass indechanges o!er time

)o assess and monitor body composition $ean body mass

ody cell mass Skinfold 4triceps biceps mid-thigh5

@ircumferences 4"aist mid-upper arm hips3buttocks6 mid-thigh breast si1e for "omen

neck circumferenc!e 4buffalo hump65

L b M


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Laboratory Measure,entsin HIV()ID*

#o assess and monitor nutrient levels

$erum micronutrients %e&g& retinol' (inc)

Haemogloin %and ferritin)#o assess and monitor ody composition

*asting lood sugar'

+ipid profiles %e&g&' cholesterol andtriglycerides)

$erum insulin


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linical )ssess,ents in HIV()ID*

Symptoms and illnesses associated

"ith HIV/AIDS Diarrhea and !omiting

Ce!er 4temperature5 (outh and throat sores

ral thrush

(uscle "asting Catigue and lethargy

Skin rashes

*dema

#alm pallor


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Diet History in HIV()ID*

2=-hour food consumption or foodfre+uency recalls can be used 4in theabsence of acute food stress5 to assess

)ypes and amounts of food eaten 4including food

access and utili1ation and food handling5

se of supplements and medications

Cactors affecting food intake 4appetite eating

patterns medication side effects lifestyle

taboos hygiene psychological factors stigma

economic factors5


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Interventions

*tages o HIV Disease and


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*tages o HIV Disease andNutrition

$pecific nutrition recommendations varyaccording to underlying nutritional

status and HIV disease progression $arly stage! ,o symptoms' stale weight

Middle stage! -eight loss' opportunistic

infections associated effects

Late stage! $ymptomatic .I/$

N t iti d * t


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Nutrition are and *upport"riorities by *tage o Disease

.symptomatic0 Counsel to stay healthy

Encourage uilding stores of essential nutrients andmaintaining weight and lean ody mass

Ensure understanding of food and water safety

Encourage physical activity

Middle stage 1 Counsel to minimi(e consequences

Counsel to maintain dietary intake during acute illness

.dvise increased nutrient intake to recover and gain weight

Encourage continued physical activity

+ate stage0 Provide comfort

.dvise on treating opportunistic infections

Counsel to modify diet according to symptoms

Encourage eating and physical activity

N t iti ) ti HIV


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Nutrition )ctions or HIV#Inected "eople

To prevent 3eig4t loss Promote adequate energy and protein intake

Individuali(e meal plan and modify to match medicationregime or health changes

.dvise changing lifestyles that negatively affect energyand nutrient intake

To i,prove body co,position Promote regular e2ercise to preserve muscle mass

Promote steroidsTo i,prove i,,unity and prevent inections

Promote increased vitamin and mineral intake Promote food safety Promote use of .!Vs to reduce viral load

)lgorit4, or Managing -eig4t


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)lgorit4, or Managing -eig4tLoss in "atients 3it4 HIV()ID*

DX Profile=starved

metabolism, decreased

body fatlean

!X="eed #IV, enteral,

a$$etite stimulation%,

ma&e meal $lans,$romote $ositive

lifestyles, treat

sym$toms t'at may

affect food inta&e

D: "roile;starved,etabolis,5 decreased

body at(lean

+:; Treat 8I disordersand ot4er inections5

consider supple,entsand drug#oodinteractions5 counsel on4ygiene and ood4andling

D: "roile;abnor,al,etabolis,5 relatively4ig4 at(lean ratio< lo3

testosterone.

+:;Make an e7ercise

plan5 provide ,etabolicsteroids %9' and )+Vs %9'

$tiology unkno3nor unclear

+:;ontinue toeed and observe

Diarr4ea or ,al#absorption9

Metabolicpara,eters

$nergyintake9

OK NONor,al

LO- =$* )bnor,al

$ource0 .dapted from Hellerstein and 3otler 4556

"ro,ote )de>uate


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"ro,ote )de>uateNutrient Intake

Identify locally availale and acceptale foods

Promote a diet adequate in energy' protein and

other essential nutrients− Increase energy intake y 478"498

− Increase protein intake

−Increase eating a variety of foods %especiallymore fruits and vegetales) and:or promote

multiple micronutrient supplements for

improved immune function


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*upport Individuali?ed Meal "lans

Consider

• $tage of illness and symptoms

• *ood security %availaility and accessiility of

asic foods)

• !esources %money' time' other caretakers)

• *ood likes and dislikes

• 3nowledge' attitudes' and practices%especially traditional dietary taoos)

Modi Meal "lans to * it


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Modiy Meal "lans to *uitMedication and Healt4 *tatus

*le2iility to change depending on client conte2t

Possile food and drug interactions Changes in medication regimens

.sence of opportunistic infections and otherinfections that may affect food intake orutili(ation

Changes in food accessiility in terms of qualityand quantity %especially in resource"poor settings)

Consider

"ro,ote Liestyle 4anges or


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"ro,ote Liestyle 4anges orNutritional -ell#being

$li,inate oods and practices t4at aggravate

inection

− !aw eggs and unpasteuri(ed dairy products

−*oods not thoroughly cooked' especially meats

− ;noiled water or unk? foods with little nutritional value

− *oods that aggravate symptoms related to diarrhea' nauseaand vomiting' loating' loss of appetite' and mouth sores%e&g&' e2pired foods' fatty foods)


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+eco,,end +egular $7ercise

Muscle loss can e restored y reducing

viral load or maintaining physical activity

Physical activity improves• +ean ody mass

• @ody composition

• @one density

• $trength• *unctional capacity

• Auality of life

• .ppetite

T4erapeutic +egi,ens


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T4erapeutic +egi,ensor HIV#+elated -eig4t Loss

T4erapy Nitrogenretention%g(day'

+ate o c4ange in bodyco,position

+@M %kg:wk) -eight %kg:wk)

Megestrol acetate ,. 7&77"7&79 7&B9

Parental nutrition ,. 7&77 7&7

rDH B&7 7&9 7&4

,androlone %hypogonadal) &F 7&9 7&B4

!esistance e2ercise alone &6 7&B6 7&9

!esistance e2ercise ando2androlone

9&G 7&6G 7&6B

Source! )dapted ro, Hellerstein and Kotler @AAB


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Increase


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$trategies to increase vitamin and mineral intake toreplenish or uild ody stores and optimi(e immunefunction

0ood#based approac4es

− Include local vegetales' vitamin"enriched or fortified localproducts %mai(e meal' wheat or soy flour' margarine' cereals)

− Have no undesirale side effects

− .re affordale

Nutrient supple,ents

− .re more asorale y sick person

− Multivitamin and multiple"micronutrient supplements are

etter than than single vitamins and minerals

IncreaseVita,in and Mineral Intake

*uggested Nutrient *upple,ent


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*uggested Nutrient *upple,entIntake in HIV()ID*

Source0 $erono 4555 #ang et al 455G& E2cerpts from Eat up

Vitamin . !/.9'777 I;)

"B !/. %4'777"7'777I;)

Vitamin E B77"677 I;

Vitamin @ High"potency @ comple2%e&g&' @"9 or @"97 withniacin and @G)

Vitamin C 4'977"'777mg$elenium 77mcg

Jinc 4 !/. %4"45mg)

)dverse $ects o Too Muc4


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)dverse $ects o Too Muc4Intake o Nutrient *upple,ents

Vita,in $0 Malasorption of vitamins . and 3 andgastrointestinal upsets

Vita,in 0 Dastrointestinal upsets' iron overasorption

and adominal loatingIron0 Dastrointestinal leeding %manifested y vomiting and

loody diarrhea) and possile stimulation of viral replication

Cinc0 Dastric distress' nausea' reduced immune

function that favors viral replication %H/+ reported insupplements of K 77mg:day)

Vita,in 60 Dastrointestinal upsets

*eleniu,0 $kin lesions' nausea' and vomiting

Source0 .facan et al 77' #ang et al 455G Jiegler and *iller 455G

"ro,ote 0ood *aety


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"ro,ote 0ood *aetyto "revent 0ood#6orne Illness

Educate clients to avoid products that

Contain raw or undercooked meat

Have e2pired

.re in damaged or ulging packing

.re displayed unsafely %e&g&' mi2ing raw and cooked

foods or meats with fruits and vegetales) .re sold in unsanitary conditions or y workers with

poor personal hygiene or food handling practices


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0ollo3 up and +evie3


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Monitor t4e lients -ell#being

*ollow up Integrate with other care and support activities where

availale

/o continuously in facility and home

Include monitoring of health' nutrition' and dietary indicators Include counseling to address arriers to good nutrition

Lffer support and encouragement

!eview

Meal plans E2ercise regimens

;se of medicines

Compliance with meal requirements


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0actors to onsider in areand *upport o "eopleLiving 3it4 HIV()ID*

0actors in Design and


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0actors in Design andI,ple,entation

• $ocial0 $upport' stigma' gender roles'education' information' traditions' eliefs

• Economic0 Household resources' food

security' financial access to health andnutrition

• Client rights0 Privacy' nondiscrimination in

pulic services• Auality of support and care0 Counseling'

infrastructure' consistency' access to VC# and

.!Vs information on AVs


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Nutritional and)ntiretroviral T4erapy


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o,,on )ntiretroviral Drugs

+everse transcriptase in4ibitors %+TIs'

,ucleoside reverse transcriptase inhiitors' or ,!#Is0Jidovudine %.J#'J/V)' +amivudine %#C)' .acavir %.@C)

,on"nucleoside reverse transcriptase inhiitors' or ,,!#Is0,evirapine %,VP)' Efaviren( %E*V)' /elavirdine %/+V)

"rotease in4ibitors %"Is' $aquinavir %$AV)

!itonavir %!#V) Indinavir %I/V)

Lften taken in comination to increase effectiveness

and reduce resistance


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"ro,ote Ese o )+Vs

!educes viral load' associated opportunisticinfections' and immunity to other infections

!educes HIV"related wasting and the negativeeffects on ody composition

!educes deficiencies of micronutrients suchas (inc and selenium %!ousseau et al 777)

$ducate on Nutrition#+elated


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$ducate on Nutrition +elated*ide $ects o )+Vs

+ipodystrophy %fat maldistriution)

Hyperglycemia:insulin resistance

Hyperlipidemia


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Means fat maldistriution

Is oserved in G8"678 of patients on .!Vs

Is caused y metaolic changes associated with immune reconstitutionand .!V mitochondrial to2icity

!esults in− Hyperlipidemia

− Hyperglycemia' insulin resistance' and glucose intolerance

− Peripheral wasting %e2tremities' face)

−

Visceral and sucutaneous central adiposity %uffalo hump' reastenlargement)

Managed y e2ercise training

Lipodystrop4y

Hyperglyce,ia


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Hyperglycemia0 Increased lood sugar levelsfrom pancreatic prolems or insulin resistance

Insulin resistance %impaired message system)

reported in 68"98 of adult patients on .!Vs

*ew cases of diaetes %8"58)

Management with

−.ntidiaetic agents

− .ntio2idants %e&g&' vitamin C and selenium) tosupport glutathione' which is crucial in insulinaction

Hyperglyce,iaand Insulin +esistance


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Changes triglycerides or cholesterol with or withoutfat maldistriution

Is caused y .!V interference with normal cellular

proteins involved with lipid metaolism Increases levels of triglycerides or cholesterol and

risk of cardiovascular prolems and pancreatitis

Is managed y

− +ipid"lowering drugs− /ecreased fat intake− E2ercise− +ifestyle changes %e&g&' quitting smoking)

Hyperlipide,ia

Nutritional are and *upport


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Promote a nutritionally adequate diet %quality' diversity'and quantity)

Promote safe water' food' and hygiene practices

/iscourage e2cessive fat intake %promote modest fats'starches' and sugars and high"protein food ut fewerfried eggs and yolks)' fatty meats' and animal fats

Prevent muscle wasting with regular e2ercise to urn fat

and uild muscle mass %anaolic agents) Encourage increased fluid intake

.ddress nutritional consequences of drug"nutrientinteractions and side effects of medications

Nutritional are and *upport*trategies 3it4 )+V T4erapy


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(ym$tom-based NutritionCare and (u$$ort


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8'

(anaging the common symptoms that

occur "ith HIV/AIDS disease "ill

– (aimi1e and impro!e nutritional intake

– (aintain "eight and muscle mass

– Impro!e +uality of life


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8&

Loss o )ppetite

*at small fre+uent meals throughout the day

4>-8 meals/d5

(ake e!ery bite count

Drink plenty of li+uids )ake "alks before meals E the fresh air helps

to stimulate appetite

Ha!e family or friends assist "ith foodpreparation

(outh care is ad!isable


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*ore Mout4 and T4roat

A!oid citrus fruits and acidic or spicy

foods

*at foods at room temperature or cold

*at soft and moist foods

A!oid caffeine and alcohol

Cre+uent mouth care


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8?

Nausea and vo,iting

*at small fre+uent meals and snacks to a!oid an

empty stomach

*at dry bread or toast and other plain dry foods in the

morning preferably before getting out of bed

A!oid foods "ith strong or unpleasant odors

A!oid fried foods

A!oid alcohol and coffee

Drink plenty of li+uids A!oid lying do"n immediately 4at least & to 2 hours5

after eating


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8=

Diarr4ea

*at foods that tra!el slo"ly through the digesti!e

tract and decrease stimulation of the bo"el

– ananas mashed fruits soft "hite rice porridge

*at smaller meals more often *liminate milk and milk products to see if

symptoms impro!e

A!oid intake of fried and high fat foods

DonLt eat foods "ith insoluble fiber 4roughage5

– Cor eample. )ake the skin off fruits and !egetables


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8>

Diarr4ea %&'

Drink plenty of fluids 4


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88

0ever

Drink plenty of fluids

*at small fre+uent meals including

snacks bet"een meals

– As tolerated at regular inter!als

(outh care is ad!isable

Add snacks bet"een meals


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8;

)ltered Taste

se fla!or enhancers such as salt and a

!ariety of herbs and spices

)ry different tetures of food

@he" food "ell and mo!e it around the

mouth

– )his stimulates taste receptors


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8<

"oor 0at )bsorption

*liminate oils butter margarine ghee and

foods that contain or "ere prepared "ith

them

*at lean meats– )rim all !isible fat and remo!e skin from chicken

A!oid deep fried greasy and high fat foods

*at fruits and !egetables and other lo"-fatfoods9


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8:

0atigue5 Let4argy

If possible ha!e someone pre-cook foods

– )his "ill help the patient conser!e energy

*at fresh fruits that donLt re+uire preparation

in-bet"een meals *at smaller more fre+uent meals and snacks

throughout the day

*ercise as able– )his "ill increase energy

)ry to eat at the same time each day9


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Levels of EvidenceLevels of Evidence

I Evidence - Systematic reviews, meta-analysis

RCTs, EB clinical practice gidelines!ased on RCTs

II Evidence - One well designed RCT

III Evidence - CTs without randomization IV Evidence - Well-designed case control or cohort

studies V Evidence - Systematic reviews o descri!tive or "ualitative studies

VI Evidence - Single descri!tive or "ualitative study VII Evidence " #pinions of at$orities, reports

of e%perts


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))N Levels o $vidence%)r,ola5 et al. 5 Nurse5 &11A'

$e!el A

$e!el

$e!el @

$e!el D

$e!el *

$e!el (

(eta-analysis or metasynthesis of multiplecontrolled studies supporting a specific action

@ontrolled randomi1ed or nonrandomi1ed studies

supporting a specific action Mualitati!e descripti!e or correlational studies or

systematic re!ie"s "ith consistent results

#eer-re!ie"ed prof9 organ9 standards "ith studiesto support them

)heory-based e!idence from epert opinion orcase studies

(anufacturerLs recommendations only


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onclusions

Dood nutrition and healthy lifestyle can preservehealth' improve quality of life' prolongindependence' and delay disease progression

.ppropriate physical activity' increases energy'stimulates appetite' and preserves and uilds leanody mass

Preventing food" and water"orne infections reducesthe risk of diarrhea %a common cause of weightloss)' malnutrition' and HIV disease progression

.ntiretroviral therapy can help improve quality oflife' ut patients should e educated on adversenutrition"related effects

Hiv&Nutrition

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