Download Then and Now

6/13/16
Mountain West AIDS Education and Training Center
HIV NUTRITION
FROM THE BOTTOM UP
Joanne Maurice, RDN, LD, MS
Legacy Health System
NO CONFLICTS
OF INTEREST OR RELATIONSHIPS
TO DISCLOSE
Th i s p re s e n ta ti o n i s i n te nd e d fo r e d uc a tio n a l u se o n yl , an d d oe s no t i n a n y wa y co n sti tu te me d i c al
c o n s u l ta ti o n o r ad v ci e rel a te d to an y sp e ci fi c p a tie n t.
HIV:
Then and Now
Then
Now
Short life expectancy
Almost normal life expectancy
Wasting
Weight management issues
Multiple OIs
Rarely seen
Multiple medications, difficult regimens Single-tablet regimens, once-a-day
which led to adherence (and resistance) dosing, more med regimen options
issues
Debilitating side effects, complicated
food-drug interactions
Minimal side effects
HIV viremia–primary concern
Chronic diseases, diseases of aging
Leaky gut
Leaky gut
Journal of the Academy of Nutrition and Dietetics:
HIV Medical Nutrition Therapy 2010
Primary Goals
1)Comprehensive nutrition assessment
food security, macro/micro intake, risk factors
2) Anthropometric measurements
weight, height, BMI, fat/muscle mass assessment
3) Review labs: vitamin/mineral, lipids, glucose, protein
4) Medical history, risk of co-morbid conditions
5) Food/drug interactions
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Basic Nutrition Guidelines for Health
• Recommendations
- 70-100 gms protein/day
- 30% or less of calories from fat, choose more monounsaturated
- 5-13 servings fruits/vegetables/da y
fats
- 30+ gms fiber/day
- 30 minutes moderate intensity exercise/day
- General MVI, preferably without iron
But…
• What happens when none of that works?
• Why do some clients do so well, and others don’t?
• Why do some respond well to ARVs, but others show little
CD4 gain even with effective meds and adherence?
• What are we missing?........
Enter the Gut Microbiome
• The gut microbiome – the other “organ”
• Research on the impact of the gut microbiome on health is
relatively new, within the past decade or so
• Over a thousand species; bacterial genome dwarfs the
human genome
• How does this over-looked system impact our health?
• Future directions?
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Gut Biome Basics
• There are thousands of species, but only a few are
dominant in the human gut
- Bacteriodetes – Most prevalent
• Bacteriodes, Prevotella, Xylanibacter
- Firmicutes – Most prevalent
• Lactobacillus, Clostridium, Ruminiococcus
- Actinobacteria
• Bifidobacterium
- Proteobacteria
• Escherichia
- Verrucomicrobia
• Akkermansia
- Small subsets of other species
Host-Microbiome Relationship
• Symbiotic relationship between the host and the microbiota.
The host provides nutrients in terms of food, the microbiota
breaks down food to release nutrients, protects against
pathogens, interacts with the immune system
• Breakdown of this relationship leads to various diseases,
chronic conditions
• Bacteria types can alter the gene expression and promote
or down-regulate diseases
Beginning to End
• What influences the microbial population
• Birth – will see different species in vaginal vs caesarean births
• Infant feeding – breast feeding vs bottle feeding
• Diet – composition, amount
• Environment
- pollution
• Sleep – circadian rhythm, hours of sleep/day may affect microbiome
• Exercise – intensity, may favor one population over another
• Disease – acute, chronic
• Medications – antibiotics for one may shift species
• Age – bacterial populations
will shift in their ratio, create “inflam-aging”
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Leaky Gut – Old Theory, New Ideas
• Way back when, the RDs knew this was important
• Leaky gut –T-cell destruction and immune activation in the gut
leads to high levels of CD8 T-cell infiltration and mucosal
damage, allowing for microbial translocation, chronic
inflammation, increased morbidity and mortality
• Implications of this could explain pathogenesis of co-morbid
conditions associated with HIV,
i.e. diabetes, CVD, metabolic syndrome, etc.
• Leaky gut has also been associated with progression to AIDS
HIV+ vs HIV- : Is There a Difference?
• HIV + see more Prevotella, less Bacteroides, than HIV-,
regardless of being on ART. Some of this could be related
to sexual practice. MSM had more Prevotella than nonMSM
• Pro-inflammatory Proteobacteria is increased in HIV
infection
• Long-term ARV treatment didn’t change the gut composition
to resemble the gut of someone HIV• Less microbial diversity also present in HIV+ group, even if
on ART
HIV+ vs HIV• Bacteroides, protective in high fat diets, positively correlated
with red meat intake in HIV- individuals, but not HIV+
• Could indicate HIV+ individuals are not able to mount an
adaptive response, enabling the gut to select for protective
bacteria that may protect against metabolic diseases
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Metabolic Syndrome
Indicator
Criteria
Increased central adiposity
Waist > 40 inches men, >35 inches women
Dyslipidemia
Triglycerides > 150mg/dL
Dyslipidemia
HDL < 40 mg/dL male, < 50 mg/dL female
Hypertension
>130/85 mmHg
Insulin Resistance
Fasting Plasma Glucose >110 mg/dL
Prevalence in HIV 12 – 45 %, increased risk for diabetes and CVD
HIV and Metabolic Syndrome
• Since the advent of ART, see increased life span, but also
greater prevalence of the metabolic syndrome;
lipodystrophy, obesity, diabetes, etc.
• HIV + individuals that eat high fat, high protein, low carb
diets may have an increase in inflammation due to the lack
of protective bacteria in relative proportion to the proinflammatory bacteria increasing the risk of developing
metabolic syndrome
Dietary Guidelines for Metabolic Syndrome
1) Lose weight – regular exercise, calorie control
2) Adopt a Mediterranean Diet – less meat, lots of fruits,
vegetables, whole grains, healthy fats, less sugar and
processed foods
3) Get regular physical exercise, both anaerobic and
aerobic. 30 minutes/day at least 5 X/week.
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Let’s Talk About “Diet”
• “Western” diet plays a role in gut health
• HF, HS, low fiber, promotes the bad bacteria
• In 20+ years of HIV MNT, it was exceedingly rare to find someone who
ate well. Fast foods with low price were a staple
• Barriers to healthy eating
• Food deserts – lack of areas to get good food
• Lack of resources – money, housing
• Lack of skill – cooking challenged, knowing how to shop
• Ease/prevalenc e of cheap but low-nutritiona l value foods
• Knowledge deficits – from store to plate
Western Diet and Gut Health
• High Fat:
- Promotes species Firmicutes and Proteobacteria while decreasing
Bacteriodetes
- Body fat percentage negatively associated with Akkermansia
- Studies done in rodents suggest there is “obese” microbiota and “lean”
microbiota. Transferring ‘obese microbiota’ into lean germ-free mice
resulted in more weight gain. ‘Obese microbiota’ are more efficient at
harvesting calorie from food.
High Fat Diet
• HFD also associated with low-grade chronic inflammation
due to increase in lipoprotein polysaccharides (LPS)
• HFD – see less diversity in microbiota
• LPS’s associated with a decrease in gut tight junctions, and
hence leaky gut, increase inflammation
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Implications of Selected Species
• Prevotello produce more trimethylamine (TMA) from Lcarnitine (found in red meat)
• TMA converted to TMAO trimethylamine-N-oxide (proatherosclerotic compound)
• HIV + individuals that eat high fat, high protein, low carb
diets may have in increase in inflammation due to the lack
of protective bacteria in relative proportion to the proinflammatory bacteria
Gut Supplementation
• Changing the bacteria population can decrease
inflammatory process
• Adding bifidobacteria with a HFD resulted in decreased fat
mass, increased glucose tolerance, decrease in LPS,
decrease in inflammation
• Supplementing with sacchromyces bolardii also resulted in
decrease in body weight, fat mass, inflammation
Microbiota and GI Disorders
• Theorized that Crohn’s disease may be d/t changes in
microbiota leading to intestinal permeability, aka leaky gut,
leading to adaptive immune response and tissue damage
• IBD - studies show a decrease in diversity, a change to
more pro-inflammatory bacteria such as Escheria and less
anti-inflammatory bacteria such as Bacteroides
• Bacteria type also being used to predict course of the
disease
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Microbiota and Mental Health
• Gut – Brain Axis – bidirectional
The brain impacts GI function and microbiome makeup and
the gut bacteria make neuroactive compounds
• GI disorders such as IBD, are correlated with depression,
anxiety, autism, and ADHD
• Most of the studies have been done in mice, but by
changing the microflora, by adding Bifidiobacteria or
Lactobacillus, there were reductions in anxiety, stress, and
depression
Mental Health
• Bacteria populations in depressed individuals are different
than non-depressed, less diversity
• The use of antibiotics, pre- and post-birth may change the
relative abundance of one species over another to
contribute to mental health issues
• Treatment with Lactobacillus has been shown to be helpful
in treating depression, anxiety
• Changes in the microbiome may play a role in age-related
cognitive decline
Food and the Gut
• In the past few generations, shift from foods made at home to
fast, convenient foods
• Fiber intake lost along the way
• Antibiotics in food supply, residual pesticides may impact the gut
• Fad diets with their elimination of different foods may select for
different species
• Dieting may also have a harmful impact on the microbiome, due
to the lack of food source
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Road to a Healthy Gut
• With studies and research pointing to the association of
poor diets leading to gut dysbiosis, is it possible to reverse
this?
YES!
• Changing the diet can change the bacterial population
within days
• Changing to high fiber, low fat, diverse diet will support the
good bacteria
• Incorporating pre- and probiotics in the diet supports the
anti-inflammatory species
Why Are These Foods Beneficial?
• Fruits, vegetables, whole grains, and legumes contain the
indigestible carbohydrate sources, inulin,
fructooligosaccharides that are broken down to short chain
fatty acids (SCFAs)
• SCFAs – acetate, propionate, and butyrate – the type of
fiber in the food will determine what is produced
• SCFAs might play a key role in the prevention and
treatment of metabolic syndrome, GI disorders
Prebiotics
• Indigestible carbohydrates that serve as food source for
microbiota
• Includes inulins (large string of glucose and fructose)
• FOS- fructooligosaccharides – shorter length
• Prebiotics just as important, if not more so than probiotics
for promoting good gut health
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Prebiotic Sources
Inulin Sources
FOS
Garlic
Nutrition Bars
Onion family – leeks, onions, shallots
Acidophilus Yogurt
Asparagus
Diet Soda
Banana
Brown Sugar
Wheat
Endive
Rye
Blue Agave
Chicory Root
Jicama
Probiotics
Source
Information
Yogurt
Look for live and active cultures seal,
20 billion cultures per 8 oz.
Kefir
Contains 20 different bacteria
Sauerkraut
Pasteurized form will kill good bacteria
Miso
Fermented soybean paste, loaded with
B vitamins
Cheeses
Gouda, cheddar, Swiss, parmesan
Sourdough
Bread
Sour bite due to lactobacillus
Acidophilus Milk Enriched with acidophilus
Buttermilk
Cultured with Lactococcus lactis
Pickles/Olives
Brined in water, sea salt – not vinegar
Tempeh
Fermented soy beans
Kombucha
1 B bacillus coagulans, saccharomyces
bolardii
Artificial Sweeteners:
Friend or Foe?
• Why do we chose the diet products? To control weight gain
– of course!
• But…. with so many low calorie products out there, why are
so many overweight/obese?
• What happened?
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Artificial Sweeteners: the Theories
• Theory 1: low calorie products created a sense of “safety”,
OK to eat more now, calorie intake didn’t change, neither
did weight
• Theory 2: artificial sweeteners changed satiety signals,
calorie intake changed or increased with lack of satiety
feedback
• Theory 3: artificial sweeteners may be promoting the
bacteria more associated with weight gain and the
metabolic syndrome
Artificial Sweeteners: the Studies
• Study with mice given artificial sweeteners (sucaralose,
aspartame, saccharin) showed weight gain – why?
• Artificial sweeteners promoted Firmicutes, the bacteria
more efficient at extracting calories from food and
promoting fat gain
• New studies looking at role of artificial sweeteners
increasing risk of developing diabetes
• Better to use smaller amounts of “real” sugar,
i.e. white cane sugar, brown sugar, maple syrup
Aging
• Estimated that about 30-40% of HIV infected people are 50
years old or older
• “Inflam-aging” may be a greater concern in HIV+ people as
there are two inflammatory processes going on – that
related to HIV and also to the changing gut MB that may
contribute to the inflammatory process
• See decrease in microbial diversity with age, increase in
Proteobacteria (inflammatory), decrease in bifidobacteria
(anti-inflammatory)
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New Directions
• Stool genome studies, to determine population mix and
abundance. Design nutrition plan/goals based on results.
• Use of pre-probiotics to support beneficial bacterial
populations
• Use of antibiotics to target and decrease inflammatory
bacteria
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