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HIV/AIDS, Immunity and Nutrition Fred Hardinge, DrPH, RD Associate Health Ministries Director General Conference of Seventh-day Adventists Malnutrition and HIV Malnutrition and HIV are prevalent worldwide with the highest rates of both in sub-Saharan Africa Malnutrition influences immune function, the virulence of infectious agents, progression of chronic infections such as HIV, and genetic factors that determine the outcome of sepsis The association between HIV morbidity and malnutrition is bi-directional Malnutrition affects HIV disease progression HIV affects nutritional status Types of Malnutrition: Protein-Energy Malnutrition Primary PEM caused by inadequate intake Secondary PEM is the result of illness, injuries, or treatments causing altered appetite, digestion, absorption Most common form of malnutrition in HIV disease Types of Malnutrition Protein-Energy Malnutrition (2) Used to describe nutritional macrodeficiency syndromes Marasmus: deficiency of calories Kwashiorkor: deficiency of protein Nutritional dwarfism in children and wasting syndromes in adults Measured as body size by weight or body mass index [weight (kg) divided by height in (meters)2] < 16: severely malnourished 16-16.9: moderately malnourished 17-18.4: mildly malnourished 18.5-24.9: normal nutritional status Types of Malnutrition Micronutrient Nutrition Alterations in the stores of fat- and watersoluble vitamins and trace elements Clinical symptoms are subtle unless deficiency is severe Often accompanies infectious diseases Most common examples in children and adults: Iron -> anemia Vitamin A -> susceptibility to infection, associated with HIV-disease progression and increased mortality, increased maternal-fetal transmission Iodine -> thyroid enlargement and hypothyroidism Effect of HIV/AIDS on Nutrition: Reduced Intake HIV is associated with reduced intake of food/nutrients Cognitive impairment and/or depression -> reduced motivation and ability to access and prepare foods Family instability or poverty -> reduced access to food HIV-, OI-, or medication-induced -> anorexia and nausea OIs of mouth and esophagus -> painful swallowing Effect of HIV/AIDS on Nutrition: Reduced Absorption HIV is associated with reduced absorption of food/nutrients Caused by HIV infection, OIs and ART Mediated by diarrhea and damage to intestinal cells Results in poor absorption of fats Reduces absorption of fat-soluble vitamins, such as vitamins A and E Effect of HIV/AIDS on Nutrition: Altered Metabolism HIV is associated with altered metabolism of food/nutrients HIV and OIs increase catabolism and energy needs by 10 – 15% Adult man needs an additional 400 calories/day (from 2100->2500) Protein requirements increase by 50% Men: 57 -> 85 of protein grams/day Women: 48 -> 72 grams/day. Effect of HIV/AIDS on Nutrition: Wasting Severe malnutrition in HIV-infected persons is recognized as “wasting”, defined as: Body weight loss of > 10% With associated fatigue, fever, and diarrhea unexplained by another cause Etiology is multifactorial Any weight loss of > 5% is associated with accelerated disease progression, impaired functional status, and increased mortality “Wasting” is a WHO Stage 4 diagnosis and is a criterion for ARV initiation The Vicious Cycle of Malnutrition and HIV Insufficient dietary intake Malabsorption, diarrhea Altered metabolism and nutrient storage Increased HIV replication Hastened disease progression Increased morbidity Nutritional deficiencies Increased oxidative stress Immune suppression Source: Semba and Tang 1999. Similarities: Malnutrition and HIV/AIDS Affect the ability of the immune system to fight infection and keep the body healthy through: Disrupts CD4 number / function Disrupts CD8 number / function Alters delayed type cutaneous hypersensitivity Alters CD4 / CD8 ratio Impairs antibody response Impairs resistance to bacteria Similarities: Malnutrition and HIV/AIDS Low BMI is associated with disease progression and death Nutrient deficiencies (vitamins A, B12, E, selenium, and zinc) are associated with worse outcomes HIV transmission Disease progression Mortality Psychosocial Factors for Malnutrition Food scarcity Financial constraints Family disruption Loss of financial breadwinner Loss of primary caregiver due to illness or death Mental health factors: depression Role of Nutrition Care and Support Clinical outcome of HIV is poorer in individuals with compromised nutrition Improving nutrition can help prevent weight loss, strengthen the immune system, and delay HIV disease progression Nutrition care is part of comprehensive care along with OI management and ART therapy Goals of Nutrition Care and Support Improve eating habits and diet to help: Maintain weight, prevent weight loss Preserve muscle mass Build stores of essential nutrients Support the immune system to help prevent OI Prevent food-borne illnesses by promoting Hygiene Food and water safety Manage symptoms affecting food intake by Treating opportunistic infections Treating pain Components of Nutritional Care and Support Nutrition assessment: Weight, height, mid-arm circumference, BMI Access to food Symptoms that may impede intake, absorption Other infections such as TB Nutrition supplementation Food Vitamin and mineral supplements (if available) Food and nutrition support for families Food-for-work Community kitchens Home-based care Components of Nutritional Care and Support-2 Education and counseling Adequate diet Food handling and safety Sanitation to avoid fecal-oral transmission Water purification – boiling Hand washing after defecation Treat infections which will impact nutritional status such as tuberculosis Stages of HIV Disease and Nutrition Specific nutrition recommendations vary according to the underlying nutritional status and extent (stage) of HIV disease progression The disease progression may be categorized into three stages: Early: no symptoms, stable weight Middle: significant weight loss Late: symptomatic, full-blown AIDS disease Early Stage No symptoms, stable weight Increased nutritional requirements during HIVinfection Energy increase: 10 - 15% Protein increase: ~ 50% Vitamins and minerals used by the immune system also increased Main objective: remain as healthy as possible Build stores of essential nutrients Identify locally available and acceptable foods Maintain weight and lean body mass, preserve muscle mass, and increase energy Adequate diet Maintain physical activity Early Stage-2 Safe food and water handling practices Wash hands before preparing and eating food, after using the toilet or changing nappies or diapers Wash all food preparation surfaces, utensils and dishes Wash all fruit and vegetables before eating, cooking or serving Avoid letting raw food come in contact with cooked food Cook food thoroughly (especially chicken and meats) Serve food immediately after preparation Keep food covered and away from insects, rodents and other animals Do not store cooked food Use safe water for drinking, cooking, and cleaning dishes and utensils Never use bottles with teats for feeding infants; use a cup instead Middle Stage Significant, unintentional or undesirable weight loss as a result of opportunistic infections Main objective: minimize consequences Increase nutrient intake for recovery/weight gain Maintain intake during periods of acute illness and depressed appetite Increase nutrition intake gradually to promote weight and muscle mass gain, and nutritional recovery Make “every bite count” Daily vitamin-mineral supplements (when available) Continue physical activity as able Middle Stage-2 Manage and treat the symptoms that affect food intake Seek medical attention immediately if Diarrhea is persistent and/or accompanied by fever Fever lasts for more than 3 days Mouth and throat sores are present Avoid unhealthy behaviors Alcohol, smoking and drug use Unsafe sexual practices Late Stage Symptomatic, full-blown AIDS disease Main objective: provide comfort or palliative care Treat all infections that affect intake Modify diet according to symptoms Maintain intake during periods of acute illness and depressed appetite Encourage eating and physical activity as able Provide psychological and emotional support Symptom-based Nutrition Care and Support Managing the common symptoms that occur with HIV/AIDS disease will Maximize and improve nutritional intake Maintain weight and muscle mass Improve quality of life Loss of Appetite Eat small, frequent meals throughout the day (5-6 meals/d) “Make every bite count” Drink plenty of liquids Take walks before meals – the fresh air helps to stimulate appetite Have family or friends assist with food preparation Proper mouth care is advisable Sore Mouth and Throat Avoid citrus fruits, and acidic or spicy foods Eat foods at room temperature or cool Eat soft and moist foods Avoid caffeine and alcohol Frequent mouth care Nausea and Vomiting Eat small, frequent meals and snacks to avoid an empty stomach Eat dry bread or toast, and other plain dry foods, in the morning preferably before getting out of bed Avoid foods with strong or unpleasant odors Avoid fried foods Avoid alcohol and coffee Drink plenty of liquids Avoid lying down immediately (at least 1 to 2 hours) after eating Diarrhea Eat foods that travel slowly through the digestive tract and decrease stimulation of the bowel Bananas, mashed fruits, soft white rice, porridge Eat smaller meals, more often Eliminate milk and milk products to see if symptoms improve (replace lost nutrients) Avoid intake of fried and high fat foods Avoid foods with insoluble fiber (roughage) For example: Take the skin off fruits and vegetables Diarrhea-2 Drink plenty of fluids (8-10 cups/day) to prevent dehydration Avoid very sweet drinks, drink diluted juice instead Avoid very hot or very cold foods If diarrhea is severe Give oral rehydration solution Food may be withheld for 24 hrs or restricted to only clear fluids (soups or tea) or soft foods (mashed fruit, potatoes, white rice, porridge) Fever Drink plenty of fluids Eat small frequent meals Mouth care is recommended Add snacks between meals as tolerated Focus on nutrient dense foods Altered Taste Use flavor enhancers such as salt, herbs and spices Try different textures of food Encourage good mastication and move food around the mouth to stimulate taste receptors Poor Fat Absorption Eliminate oils, butter, margarine, ghee, and foods that contain or were prepared with added fats Eat lean meats Trim all visible fat and remove skin from chicken Avoid fried, greasy, and high fat foods Focus on fruits, vegetables, grains and other low-fat foods Fatigue, Lethargy If possible, have someone pre-cook foods This will help the patient conserve energy Eat fresh fruits that don’t require preparation in-between meals Eat smaller, more frequent meals and snacks throughout the day Physical activity as able to increase energy Try to eat at the same time each day. Some Recommended Foods Food Group Food Dairy products, legumes (beans, Protein (bodylentils), groundnuts and cooked eggs, building foods) lean meats, fish Breads, cereals (maize, millet, wheat, Carbohydrate sorghum), rice, noodles, potatoes, (energy-giving foods) cassava, yam, sweet potatoes, plantain Some Recommended Foods-2 Food Group Fruits/Vegetables Food (source of many vitamins and minerals) Any fruits or vegetables Fats/Oils Palm oil, vegetable oils, lard, margarine, butter, ghee (source of fat soluble vitamins A, E, D &k and energy) Foods to Avoid Raw eggs Undercooked chicken and meats No raw, rare, or medium rare meats Water that is not boiled or juices that are made from water that is not boiled. Alcohol and coffee “Junk” foods such as chips, biscuits, and sweets with little nutritional value Foods that aggravate symptoms related to diarrhea, nausea/vomiting, bloating, loss of appetite, and mouth sores Nutrition and Medication Medications used to treat HIV opportunistic infections may cause drug-nutrient interactions or side effects: Vitamin B6 supplementation should be administered with isoniazid therapy for tuberculosis to avoid Vitamin B6 deficiency Iron- and zinc-containing supplements should not be taken with ciprofloxacin Sulfadoxine and Pyrimethamine (Fansidar®) is not recommended unless folic acid supplement is given Nutrition and Medication-2 Antiretroviral drugs may have: Dietary requirements (e.g., with or without food) Side effects with nutritional consequences such as diarrhea or nausea/vomiting An effect on red blood cell production causing anemia (e.g., Zidovudine - AZT) Nutrition-Related Complementary and Alternative Therapies Don’t Help Herbs/botanicals Astragalus Cat’s claw Echinacea Garlic Ginseng St. John’s wort Nutrition during pregnancy & early infancy for those affected by HIV (WHO, 2010) The best way to approach nutritional care and prevent mother-to-child transmission of HIV: Appropriate health care during pregnancy (with ART) Breastfeeding exclusively in the first 6 months and continue up to at least a year Replacement feeding if acceptable, feasible, affordable, sustainable and safe (AFASS) Asymptomatic HIV positive lactating women require the same increase in rations and micronutrients as HIV-ve lactating women, plus an additional 10% for maintaining health in the context of HIV Nutrition during childhood for those affected by HIV (WHO, 2010) After the first year of life, HIV exposed but uninfected children should transition to family foods with adequate protein, particularly milk Beyond the first year of life, children known to have contracted HIV should continue to breastfeed up to 24 months of age and beyond In this case, breast milk offers no additional risk, and provides the best source of nutrition Complementary foods should be added to the diet at 6 months to provide energy, nutrients, and dietary diversity. The Multidisciplinary Team A multidisciplinary team is crucial to address the many complex and varied factors in the care of HIV-infected patients and their families Each member of the team can help address these issues in their own way: Physicians Nurses Nutritionists Counselors Community workers Summary-1 HIV can lead to malnutrition by multiple mechanisms Malnutrition is associated with increased HIV transmission, progression, and mortality Nutritional supplementation is associated with improved HIV-related outcomes in children, pregnant women and other adults Summary-2 Maintaining adequate nutrition prolongs well-being of HIV-infected persons but is difficult HIV affects nutrition in three, sometimes overlapping, ways: Reduces amount and type of food consumed Interferes with the digestion and absorption of nutrients Alters metabolism of nutrients Summary-3 Counseling and other interventions to prevent or reverse weight loss are likely to have their greatest impact early in the course of HIV infection Nutritional care and support should be part of a comprehensive program that deals with the needs of the patient and family Nutritional supplements, particularly antioxidant vitamins and minerals, may improve immune function and other HIVrelated outcomes, particularly in nutritionally vulnerable populations Summary-4 Managing common symptoms related to HIV/AIDS such as diarrhea, nausea, and loss of appetite, can minimize their impact on nutritional status Prevention of food- and water-borne infections reduces the risk of diarrhea, a common cause of weight loss, malnutrition and HIV disease progression in people living with HIV and AIDS Continuing physical activity and exercise, as appropriate, increases energy, stimulates appetite and preserves and builds lean body mass The Most Important Nutrient