Nutritinal Problems

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NUTRITIONAL PROBLEMS

NUTRITIONAL GUIDELINES
The statement purports that efforts to optimize nutritional status, including medical nutrition therapy and nutrition-related education, should be components of the total health care provided to people with HIV.

"Identifying the nutritional needs of HIV patients early on is crucial to successful prevention and treatment," & "Allowing dietitians to screen for nutritional status is a strategic part of early intervention efforts to prevent the loss of essential body tissues."

HIV attacks the immune system, making an infected person prone to illness. Malnutrition can make an infected person even more susceptible to infection and reduce the efficacy and tolerance to medications and other therapies. By combining nutrition intervention with medication therapy, they can work together to manage disease and improve the effectiveness of treatment by preserving vital organ and muscle tissues.By combining nutrition intervention with medication therapy, they can work together to manage disease and improve the effectiveness of treatment by preserving vital organ and muscle tissues.

Medical nutrition therapy in HIV disease includes early assessment and treatment of nutrient deficiencies, maintenance and restoration of lean body mass and support for activities of daily living and quality of life.

A complete nutrition care plan is developed for the patient addressing the problems identified in the initial nutrition assessment and outlining plans for monitoring and adjusting interventions. Continued nutrition therapy is crucial as medication regimens may change which in turn can affect nutritional status.

Children and adolescents infected with HIV are at greater risk for disease complications and should have a full nutrition evaluation as soon as possible after the diagnosis of HIV infection. These children may suffer from growth failure, failure-to-thrive, developmental delay and malnutrition due to their immature immune systems and the immune-suppressing effects of HIV.

"Nutrition education and counseling is a must for both the patient and the primary caregiver," & " It is important that children and adolescents learn to make appropriate food choices, especially when eating outside the home, with peers or in other social situations. In addition, many children and adolescents rebel against taking medications and adhering to meal schedules. It is necessary to stress the importance of following the prescribed medication and nutrition regimen."

Recommended counseling guidelines include education on the following:

Adequate nutrient intake;
Recommended portion sizes;
Food and water safety issues;
Perinatal nutrition and breast-feeding issues;
Nutrition strategies for symptom management such as swallowing problems, anorexia, thrush and other barriers to food intake;
Food-medication interactions including meal timing and foods to emphasize or avoid to reduce unwanted interactions;
Psychosocial and economic issues;
Alternative feeding methods (supplementation or tube feeding);
Guidelines for evaluating nutrition information.

"All of the guidelines are important, but dietitians pay extra attention to educating patients on food and water safety, since HIV-infected people are more susceptible to food borne illness," & "Dietitians also provide guidelines for evaluating nutrition-related complementary and alternative therapies so clients can make informed decisions about their use."

"Most people who die of AIDS actually die of starvation,". The nutritional dilemma of persons with AIDS, or PLWHAs, is that they must eat abundantly - yet they must also avoid food borne illness, juggle foods and medications, and surmount the poor appetite and indigestion caused by their medications and by AIDS itself. Malnutrition is almost universal among PLWHAs, hospitalized or not, largely because of AIDS-related malabsorption.

Malnutrition invites opportunistic infections and contributes to wasting - severe loss of nonfatty tissues (collectively referred to as lean body mass, or LBM). Wasting is the principal cause of death in PLWHAs.

There is no known nutritional means of curing or preventing infection by HIV, the retrovirus that causes AIDS. Neither can nutritional measures alone prevent wasting. Adequate nutrition may, however, help to retard it.

The aims of nutritional therapy in AIDS include:

minimizing loss of lean body mass,
preventing vitamin and mineral deficiencies,
preventing food poisoning,
surmounting obstacles to nutrient intake and absorption, and
preventing or moderating the use of nutritional methods that are dubious, disproved, or dangerous.

Fighting Weight Loss

During active phases of infection, PLWHAs lose weight and LBM(Lean Body Mass) rapidly. The probability of imminent death is high when a PLWHA's weight falls to 66 percent of his or her desirable weight, or when LBM falls to 54 percent of normal. Loss of LBM is perhaps the best single predictor of death from AIDS. But combinations, or cocktails, of antiretroviral agents and protease inhibitors, plus a balanced, high-protein diet can arrest LBM losses, adds Bell. Protease inhibitors - restrain proliferation of HIV by inhibiting enzymes (specifically, protein-splitting enzymes, or proteases) essential for the maturation of the virus. Antiretroviral drugs - such as AZT - inhibit replication, or "reproduction," of HIV because of their tendency to prevent viral takeover of uninfected cells. "Once the quantity of the virus is substantially decreased, we can actually make PLWHAs gain weight," Bell states.

The hypothesis that strength training to maintain LBM can benefit PLWHAs is plausible, but sound exercise recommendations for PLWHAs remain to be identified. Until such time, , to limit muscular atrophy, walking is advisable for every PLWHA who is not bedridden.

And although nutrition cannot single-handedly stop wasting, "Nutrition therapy can reverse immune dysfunction related to malnutrition.

Achieving Optimal Intake

Because weight and LBM changes are major indicators of the health status of PLWHAs, optimal intake of calories and protein is vital. "One day without nutrition requires three days to catch up,". Intake of calorie-yielding nutrients - carbohydrates, protein, and fat - at levels that exceed the PLWHA's daily needs is advisable. But this is often very difficult. HIV commonly affects the gastrointestinal (GI) tract, and problems may extend from the mouth to the anus. These problems may include lack of appetite, difficulties with chewing and swallowing, indigestion, and malabsorption. Because it contributes to wasting, diarrhea - due to malnutrition, intestinal infections, medication side effects, or lactose intolerance, for example - is potentially deadly to PLWHAs.

In critical cases wherein GI disease has taken hold, replacement or augmentation of food intake is imperative. Alternate means of nourishment include tube feeding and hyper alimentation.

Nutrient Status of PLWHAs

Nutrients under investigation for their potential usefulness against AIDS include the trace elements selenium and zinc; the provitamin beta-carotene; folate; and vitamins A, B6, B12, C, and E

DAILY AMOUNTS, AND APPLICATIONS
• Folic acid: 800-1,600 micrograms
• Niacin: 40-80 milligrams
• Riboflavin: 3.4-6.8 milligrams
• Selenium: 200-400 micrograms
• Thiamine: 3-6 milligrams
• Vitamin A: 5,000-10,000 international units
• Vitamin B6: 4-8 milligrams
• Vitamin B12: 12-24 micrograms
• Vitamin D: 400-800 international units
• Vitamin E: 30-60 international units

If you are HIV-positive, you should be under a doctor's care.

• Folic acid in doses exceeding 400 micrograms daily should be taken only under your doctor's supervision, as this vitamin can mask signs of a vitamin B12 deficiency.
• Doses of selenium in excess of 100 micrograms a day should be taken only under medical supervision.
• Vitamin A has been linked to birth defects when taken during early pregnancy in doses of 10,000 international units daily. Women of childbearing age should consult their doctors before taking this much vitamin A. Women who are pregnant should not use this therapy.
• You should check with your doctor before supplementing vitamin B12 if you have any kind of infection.
• Vitamin D in doses exceeding 600 international units daily should be taken only under medical supervision.
• If you are taking anticoagulant drugs, you should not take vitamin E supplements.
• A study at Johns Hopkins School of Hygiene and Public Health in Baltimore has found an association between zinc and the progression of HIV infection to AIDS. Do not take zinc supplements without first consulting your doctor.

Because of malabsorption, the blood micronutrient levels of PLWHAs are often lower than those of comparable people without AIDS. But determining the micronutrient status of PLWHAs is difficult, since infection causes shifting of some nutrients between blood and tissue fluid. Micronutrient deficiencies can be caused by poor food intake, by malabsorption, or by increases in nutritional needs.

Many clinicians support the use of dietary supplements by PLWHAs except when they consider the intake dangerously high. The trouble is, the "danger zone" for micronutrients in HIV disease depends on absorbability and body stores. And AIDS itself might decrease a PLWHA's tolerance to high micronutrient intakes.

Preventing Food Poisoning

Food hygiene is critical for PLWHAs, whose gastric acidity may be lower than that necessary to destroy microorganisms. Moreover, PLWHAs are less resistant than healthy persons to pathogenic microorganisms or their toxins.

potential causes of food poisoning include drinking water contaminated with Cryptosporidium parvuum, drinking unpasteurized juices or dairy products, and eating unwashed produce, foods grown in manure (e.g., organic produce), under- or uncooked meat or eggs, or uncooked foods adulterated with juices from uncooked meat.

Most cases of food borne illness arise in the home, and using an unwashed can opener is the greatest single cause of food poisoning there,. Canned, pasteurized, and "shelf-stable" foods are seldom harmful if they are consumed before their expiration dates. Meats should be heated to temperatures above 165 degrees Fahrenheit. Other foods that require cooking should be heated to temperatures above 140 degrees F. Boiling water for one minute kills Cryptosporidium parvuum. PLWHAs should not consume any raw seafood.

Drug-Nutrient and Food-Drug Interactions

Often, PLWHAs must perform a balancing act to optimize the foods and drugs they take. For example, to maximize absorption of indinavir, one should take it on an empty stomach. And to prevent kidney stone formation - a possible side effect of indinavir - fluid intake should total at least 1 1/2 quarts daily. To maximize absorption of another protease inhibitor, ritonavir, one should take it with a full meal that is high in fat and protein. Possible side effects of both indinavir and ritonavir include nausea, vomiting, and diarrhea.

The drug-nutrient interactions of the many prescription medications, over-the-counter drugs, and dietary supplements that PLWHAs take are multitudinous. Collaboration between physician, pharmacist, dietitian, and patient may serve to optimize drug therapy without worsening nutritional status.

Common Sense

Commonsense approaches to encouraging food consumption have arisen from PLWHA "focus groups," and it is always better to ask a PLWHA, "What do you feel like eating?" than to dictate or criticize dietary habits.

It is recommended, providing PLWHA`s with individualized nutrition counseling to deal with symptoms that limit food consumption. For example, during periods of diarrhea, it may be appropriate to encourage consumption of high-soluble-fiber foods such as applesauce. And clients whose mouth and throat are sore from infections - thrush, for example - may tolerate soft, non acidic foods, such as mashed potatoes with gravy.

Companionship, encouragement, and individualized dietary counseling - in conjunction with judicious administration of supplemental foods and appetite-enhancing drugs - may increase a PLWHA's food intake, thus slowing the development of malnutrition and delaying the need for hospitalization.