Download A HIV Immunity Nutrition - Adventist AIDS International Ministry

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