State Registered Dietitian
UK
Aim:
To
provide an overview of the role of nutrition in the management of HIV
Objectives:
At
the end of the presentation participants will be able to:
1.
Discuss the primary nutritional problems caused by HIV
2.
Describe the nutritional problems associated with combination
anti-retroviral therapy
3. List practical suggestions for improving nutritional status in symptomatic AIDS
Weight
loss and malnutrition are common manifestations of HIV, and are a major cause of
morbidity and mortality. There is a progressive depletion of body weight and
lean body mass (LBM) as patients near death. Kotler et al demonstrated that at
time of death body weight was depleted to 66% of ideal and lean body mass 54% of
ideal. (3) There was no relationship between time of death and body fat content.
This data suggests that lean body mass rather than fat affects survival in AIDS
wasting.
The
most common risk factors for malnutrition are anorexia, acute infection, fever
and diarrhoea. (7) Weight loss occurs when the energy (calorie) intake from food
and drink is lower than the minimum amount of calories required for basic
metabolic functions of your body.
Weight
loss in HIV infected patients is not a continuous process. It is often episodic,
coinciding with secondary infection, especially Pneumocystis carinii pneumonia
(PCP), cytomegalovirus (CMV), gastrointestinal infection and bacterial
infections. (5,6) During such episodes, profound reduction of calorie intake
(6,7), and metabolic alterations are likely to act synergistically to promote
rapid loss of lean tissue.
Opportunistic
infection will alter resting energy expenditure, body composition (with losses
of fat and fat free mass) and reduce food intake to different degrees depending
on the specific infection.
The
distinction between a nutritional starvation response, (as seen in patients with
protozoal diarrhoea), and a nutritional cachectic response, (as seen in patients
with systemic Mycobacterium avium intracellulare) is an important determinant
over success with nutritional intervention. (8) In the situation of cachexia
increasing nutrition will not replete lean body mass until the underlying
stimulus driving the cachexia is treated.
The
nutritional management of patients with symptomatic disease is therefore best
co-ordinated with knowledge of current infection, because of this varied
metabolic response in different opportunistic diseases. Increased knowledge
about the cause of nutritional problems will allow the clinician to advise the
patient on the reason for nutritional intervention and the likelihood of
intervention being successful.
Optimal
nutritional management of patients with opportunistic infections should include
aggressive therapy both of opportunistic infection and associated weight loss.
Nutritional intervention should therefore be started at diagnosis of any events
to minimise nutritional losses.
Introduction
of combination anti-retroviral therapy has led to malnutrition no longer being a
major complication of HIV disease. However this has not resulted in
normalisation of nutritional status.
Side
effects possibly associated with therapy such as a fat redistribution syndrome
and metabolic complications are reported. This is known as Lipodystrophy. In
this scenario we see abnormal redistribution of body fat, with accumulation in
the abdominal area, in the axillary pads, and in the dorsocervical pads. In
contrast there is a decrease in body fat in the legs, arms and nasolabial and
cheek pads. Coupled with the body composition change we see metabolic
alterations such as hyperlipidaemia and insulin resistance. (9)
Treatment
is based on the increased morbidity likely to be associated with atherosclerotic
disease. The precise nature of the risk is uncertain and investigators argue
that the risk of morbidity is low in relation to the benefits from
anti-retroviral therapy.
Future
research will more clearly define the mechanism behind Lypodystrophy.
The
complex relationship between the factors involved in HIV wasting complicates the
design of nutritional approaches. Dietary advice needs to be individualised to
maximise the chance of effectiveness. Specific advice should be offered to the
patient if they experience a profound loss of appetite, vomiting, diarrhoea, or
a sore mouth. Patients experiencing acute symptoms are anxious. Individualising
advice will allow the advice to be kept as simple as possible, and provide the
best chance of the patient totally understanding the purpose of the advice.
Dietary
advice should begin with suggestions about food intake. In some patients very
severe eating problems it is necessary to consider liquid instead of solids, as
these will be consumed easier. Sometimes specialised supplement drinks are
helpful if problems with eating persist. In
situations where it is difficult to access ready-made drinks it is possible to
make up soups and drinks at home using cooled boiled water, fruit juice, soy
products, fruits or vegetables.
Summary
Studies
in HIV wasting have demonstrated that opportunistic illness is associated with
gross nutritional depletion. Dietary intervention should take place early to
minimise nutritional losses.
Patients
who can access combination therapy face different nutritional challenges. Future
research will more clearly define the mechanism behind lipodystrophy.
Assessment
of nutritional status and attention to diet ideally should be prioritised at
onset of opportunistic illness. Advice should be relevant to the individual, to
local need and resources.
Anorexia
|
·
Investigate cause of anorexia ·
Encourage foods without strong smell ·
Encourage cold foods ·
Provide foods of choice |
|
|
Vomiting |
·
Ice cubes ·
from cooled
boiled water ·
Fluids ·
cooled
boiled water, green tea, diluted fruit juices ·
Chilled
foods ·
Soups,
puddings ·
Light foods ·
Try use of
ginger |
|
|
|
Increase
|
Decrease |
|
Sore
mouth |
·
Try to eat
soft foods ·
soups,
puddings, mash foods ·
Encourage
fluids ·
Use a straw
if this helps |
·
Avoid spicy
foods ·
Avoid very
hard foods ·
Avoid acid
foods ·
Avoid
extremes of temperatures |
|
Diarrhoea |
·
Encourage
fluids ·
Increase low
fibre starchy foods ·
rice,
noodles, potatoes ·
Increase
protein foods ·
eggs, pork,
chicken, tofu |
·
Avoid
heavily spiced foods ·
Avoid very
fatty foods ·
Avoid green
vegetables |
1.
Sharpstone DS, Murray CP, Ross HM et al: Energy balance in asymptomatic
HIV infection. AIDS 1996, 10:1377-1384
2.
Sharpstone D, Murray C, Ross H et al: The influence of nutrition and
metabolic status on progression from asymptomatic HIV infection to AIDS-defining
diagnosis. AIDS 1999, 1221-1226
3.
Kotler DP, Tierney AR, Wang J et al: Magnitude of body-cell-mass
depletion and the timing of death from wasting in AIDS. Am J Clin Nutr 1989,
50:444-447
4.
Schwenk A, Burger B, Wessel D et al: Clinical risk factors for
malnutrition in HIV-1 infected patients. AIDS 1993, 7: 1213-1219
5.
Macallan DC, Noble C, Baldwin C et al: Prospective analysis of patterns
of weight change in stage IV human immunodeficiency virus infection. Am J Clin
Nut 1993, 58: 417-424
6.
Grunfield C, Pang M, Shimzu L et al: Resting energy expenditure, calorie
intake, and short-term weight change in human immunodeficiency virus infection
and the acquired immunodeficiency syndrome. Am J Clin Nutr 1992, 55: 455-460
7.
Macallan DC, Noble C, Baldwin C et al: Energy expenditure and wasting in
human immunodeficiency virus infection. N Eng J Med 1995, 333:83-88
8.
Sharpstone DS, Ross HM, Gazzard BG: The metabolic response to
opportunistic infections in AIDS. AIDS 1996, 10:1529-1533
9.
Kotler DP. Fat Redistribution and Metabolic Abnormalities. Medscape
HIV/AIDS: Annual Update 2000