Download aids case study - Nicole Karetov

Case Study #3: AIDS
6. What are the common nutritional complications of HIV and AIDS?
HIV/AIDS is highly impacted by nutritional status. It is important for an HIV positive
individual to achieve adequate nutrition for disease management and for improved clinical
outcomes. Weight loss may occur with HIV disease as a result of a lifelong inflammatory
process. AIDS-related wasting syndrome may eventually occur in which an individual
unintentionally loses 10% of their body weight with fever or diarrhea for more than one month.
In addition, factors such as suppression of the immune system, side effects of HIV
medications and opportunistic infections could cause a variety of other nutritional problems.
These problems include increased energy expenditure, inadequate oral food/beverage intake,
excessive bioactive substances, increased nutritional needs, malnutrition, inadequate proteinenergy intake, difficulty swallowing, altered GI function, impaired nutrient utilization, altered
nutrition-related lab values, food-medication interactions, underweight, impaired ability to
prepare food/meals, physical inactivity and intake of unsafe food.
7. Are there specific recommendations for energy, protein, vitamin and mineral intakes for
someone with AIDS?
Nutrition recommendations are highly individualized between patients. Fluid
maintenance is important due to fluid losses in diarrhea or sweating and to prevent dehydration.
Calorie needs depends on the individual, and it is essential to maintain calorie intake to maintain
a healthy weight. Calories may be increased depending on if the patient desires to gain weight, or
if there is an increase in metabolic rate due to an opportunistic condition. In addition, calories
may be decreased to achieve weight loss. Generally, 25 kcal/kg is recommended for weight loss,
30 kcal/kg for maintenance and 35-40 kcal/kg for weight gain. Protein intake is dependent on
need for protein stores maintenance. In HIV infection, protein turnover rates are elevated due to
the breakdown of labile protein stores in muscle to enhance the amino acid pool and maintain
immune and healing responses. Increased protein intake is recommended for someone with
HIV/AIDS (1.0-1.4 g/kg for maintenance and 1.5-2.0 g/kg for repletion).
A decrease in micronutrients is associated with an increase in disease progression and
morbidity. Supplementation of vitamins and minerals is recommended. Anemias, diarrhea, and
potential dietary deficiencies can be treated with micronutrients. Some important micronutrients
in HIV infection include Vitamin A, riboflavin, Vitamin B12, ascorbic acid, iron, selenium and
zinc.
8. Evaluate the patients anthropometric information
a. Calculate % UBW and BMI
% UBW = 151 lbs/ 160-165 lbs x 100 = 94.4-91.5%
BMI = 68.6 kg/1.854 m² = 19.95 = 20
b. Compare the TSF to population standards. What does this comparison mean? Is this a
viable comparison? Explain
The patient's TSF is 7mm, meaning he is between the 15th to 20th percentile for his age
group. A normal TSF range is 11-12.5mm, meaning the patient is well below a normal reading.
This is not a viable comparison for Mr. Long. Lipodystrophy can occur in HIV positive
individuals, so additional skin fold measurements throughout the body should be taken to note
fat patterning and changes in fat distribution.
c. Using MAC and TSF, calculate upper muscle area. What can you infer from this
calculation?
AMA = [MAC (cm)- (3.14 x TSF in cm)]² – 10/(4 x 3.14)
[25.4 – (3.14 x .07)]²
– 10 / (4 x 3.14) = 40.48 mm²
According to this calculation, Mr. Long has marginal muscle mass and is at 75% of the standard.
He is not yet at depleted or wasted muscle mass.
d. Mr. Long's body fat percentage is 12.5%. What does this mean? Compare this to the
standards
A normal range for men aged 20-40 years is 8-19% body fat. This means Mr. Long's body
fat is within a normal range at 12.5%.
9. Determine Mr. Long's energy and protein requirements.
Harris Benedict Equation =
REE = 66.5 + (13.8 x 68.6 kg) + (5.0 x 185.4 cm) – (6.8 x 32 yrs) = 1723 kcal
TEE = 1723 kcal x 1.2 = 2066 kcal/day
or 35-40 kcal x 68.6 kg = 2401 – 2744 kcal for weight gain
Protein = 1.5-2.0 g/68.6 kg = 103 – 137 g/day
13. Using this patient's lab values, identify those labs used to monitor his disease status. What do
these specifically measure, and how would you interpret them for him? Explain how the virus
affects these lab values.
T-helper cell, T-suppressor cell count and HIV-1 RNA Quant are used to monitor the
patient's disease status. HIV causes a decrease in CD4 count (T-helper cells) due to cell damage
and alterations. A reduction of CD4+ cells to <200 cells/microliter indicates AIDS diagnosis. Tsuppressor cells are CD8 cells and are produced in the immune response. In HIV infection it is
common to see a decrease in CD8 count as well. HIV-1 RNA Quant measures viral load. Mr.
Long's viral load is 29000 copies/mL, indicating a prognostic for immune deficits. High viral
loads cause a further decrease in CD4 cell count, thus increasing risk for opportunistic infections
and cancers. Mr. Long's CD4 and CD8 counts are both low, while his viral load is high. His CD4
count is 153 mm³, indicating an AIDS diagnosis.
14. What lab values can be used to evaluate nutritional status? Do any of Mr. Long's values
indicate nutritional risk?
Viral load and CD4 count can be associated with weight change. In Mr. Long's case, his
CD4 count is low and his viral load is high, indicating nutritional risk factors. Albumin,
prealbumin and transferrin can be used to evaluate nutritional status also. All three lab values
would be decreased with malnutrition. Mr. Long's albumin is within normal limits, but his
prealbumin and transferrin are decreased. Mr. Long has sores in his mouth and throat, which
makes it difficult for him to eat or drink. His weight loss over time and the pain he experiences
while eating and drinking could be causing him to become malnourished.
In addition, AST/ALT and BUN could be assessed to determine liver function, and
creatinine could be assessed for kidney function. Mr. Long's AST, ALT, BUN and creatinine are
within a normal range, indicating that his liver and kidneys are functioning properly. Glucose and
insulin values will be elevated in diabetes, pancreatitis and/or chronic malnutrition. Mr. Long's
are within a normal range.
16. Mr. Long is taking several vitamin and herbal supplements. What would you tell Mr. Long
about these supplements? Do they pose any risks?
Ginseng – Used for anti dementia, antibacterial, anticancer, and antioxidant and reduces gastric
acidity. Taking ginseng may increase serum T4 (thyroid) and may potentiate barbiturate drugs.
Milk thistle – Detoxifies and protects the liver, strengthens the spleen and gallbladder, and may
slow the growth of cancer cells. Taking milk thistle may cause allergic reactions in the skin,
blood clots, constipation, diarrhea, increased creatinine, increased levels of lactate
dehydrogenase, loss of appetite, nausea, sweating, and vomiting, to name a few.
Echinacea – Used for anticancer, immunostimulatory and fighting off infection. Taking
echinacea may inhibit drugs using the cytochrome p450 pathway. May also cause fever, nausea,
vomiting, unpleasant taste, stomach pain, diarrhea, sore throat, dry mouth, headache, numbness
of the tongue, dizziness, insomnia, disorientation, and joint and muscle aches.
St. John's wort – antidepressant, anti HIV, and anti anxiety. May cause some side effects such as
trouble sleeping, vivid dreams, restlessness, anxiety, irritability, stomach upset, fatigue, dry
mouth, dizziness, headache, skin rash, diarrhea, and tingling. May also reduce effectiveness of
oral
contraceptives and antagonistic to antihypertensive medications
*St. John's wort should not be taken with Atripla, the HAART regimen Mr. Long is current
taking. It may decrease the effectiveness of Atripla, therefore increasing viral load.
Vitamin C – Improves antioxidant capacity of body and immune system, increases iron
absorption from non-heme sources, upper limit is 2,000 in adults and less in children. May
increase urinary losses of oxalate and calcium
Vitamin E – Used to build strong immunity, for healthy skin and eyes, and as an antioxidant. Too
much Vitamin E can interfere with blood clotting. Continuous large doses may cause nausea,
diarrhea, muscle weakness and fatigue.
17. Select two high-priority nutrition problems and complete the PES statement for each.
1) Weight loss
PES Statement #1: Unintentional weight loss related to AIDS diagnosis as evidenced by a
decreased BMI and a recent weight loss of 15 pounds.
2) Pain while eating or drinking
PES Statement #2: Swallowing difficult related to oral thrush as evidenced by presence of mouth
and throat sores and complaint of pain while eating and drinking.
18. Identify 3 interventions you would recommend for improving Mr. Long's tolerance of food
until his oral thrush has subsided.
 Avoid spicy or acid-containing foods that would irritate the mouth/throat
 Small, frequent meals
 Eat moist, soft, or finely diced foods and keep mouth moist between meals
19. Describe at least 2 areas of nutrition education that you would want to ensure that Mr. Long
receives. Explain your rationale for these choices.
I would make sure Mr. Long receives nutrition education on food-drug interactions. He
states that he is taking more supplements because he is unable to eat without pain. However,
some of the supplements he is taking, like St. John's wort, can have negative outcomes when
taken with HIV medications. St. John's wort may actually increase viral load. In addition, some
of these herbal supplements may have side effects that may exacerbate HIV symptoms, such as
nausea, vomiting, diarrhea, sore throat, dry mouth and fatigue. Knowing these food-drug
interactions and possible side effects is important for management of HIV disease.
I would also educate Mr. Long on general nutrient guidelines. Adhering to a balanced,
nutrient rich diet is beneficial in HIV disease management. A nutrition assessment should be
performed in order to determine his fluid, kcal and protein needs. Because Mr. Long is losing
weight, it is important to monitor his calorie intake. Adequate protein, carbohydrates and fat
should be consumed through the diet. In addition, fiber has potential benefits, including
improvement of glucose intolerance, reducing potential for cardiovascular risk and improve
altered fat distribution associated with lipodystrophy.
20. Patients with AIDS are at increased risk for infections. What nutritional practices would you
teach Mr. Long to help him prevent illness related to food and water intake?
Food safety is a big concern for patients with AIDS due to their compromised immune
systems. It is important to thoroughly wash all fruits and vegetables, to avoid eating raw eggs,
meat or seafood, to use separate cutting boards for meats. Patients should be advised to wash
hands, utensils and cutting boards with hot water and soap after each use. Foods should be
cooked to safe temperatures, and leftovers should be chilled to 40°F or below. Lastly, filtered
water should be consumed.
22. One of the more recent complications for AIDS and prescribed HAART is the development of
lipodystrophy. Define this condition and describe the most common signs and symptoms.
Adhering to a HAART regimen can cause a complication called lipodystrophy. This is
characterized by an uneven redistribution of body fat or loss or absence of body fat. Fat loss
usually occurs in the face and arms, and fat deposits may take place in the dorsocervical area
(mimicking a buffalo hump), breast area and abdominal region.
23. How would the clinician monitor Mr. Long for the development of this disorder?
The clinician could monitor fat distribution by routinely measuring skin folds throughout
the body. Skin fold measurements could be taken in the arms, abdomen, face and back and be
recorded over time to note any changes in fat patterning. A baseline measurement should be
taken along with subsequent follow-up measurements to assess fat accumulation or loss.
Changes in body fat can also be accomplished with a bioelectrical impedance analysis, a DEXA
scan, or a CT scan.