Prospective analysis of patterns of weight change in stage IV human immunodeficiency virus infection

Benefit of oral zinc supplementation as an adjunct to zidovudine (AZT) therapy against opportunistic infections in AIDS

Zinc is perhaps the most important trace element for immune function. Congenital or acquired zinc deficiencies are associated with immune abnormalities and increased susceptibility to infectious diseases. AIDS subjects suffer from reduced zinc bioavailability, more severe in stage IV than in stage III. Such zinc deficiency causes, among other effects, a profound reduction in the biological activity of one of the thymic hormones, thymulin (zinc-facteur-timique-serique, ZnFTS). With these premises, zinc sulphate was administered orally at a daily dose of 200 mg for 30 days to AZT-treated stage III subjects with generalized lymphadenopathy (17 subjects) and stage IV subgroup C1 (12 subjects) AIDS patients. 18 stage III subjects with generalized lymphoadenopathy and 10 stage IV subgroup C1 subjects treated only with AZT served as controls. Zinc sulphate supplementation of stage III and in stage IV C1 patients was followed by an increase or a stabilization in the body weight and an increase of the number of CD4+ cells and the plasma level of active zinc-bound thymulin. The frequency of opportunistic infectious episodes in the 24 months following entry into the study was reduced after zinc supplementation in stage IV C1 subjects (11 infections vs 25 in controls) and delayed in stage III zinc-treated subjects (1 infection/24 months vs 13 infections/24 months in controls). The effect of zinc on opportunistic infections is restricted to infections due to Pneumocystis carinii and Candida, whereas no variations have been observed in the frequencies of cytomegalovirus and toxoplasma infections. These data may support the benefit of zinc as an adjunct to AZT therapy in AIDS pathology.

Nutritional support in HIV infection and AIDS

Weight loss and wasting are common features of HIV infection and AIDS. Patterns of weight loss can be acute or chronic which appear to be related primarily to systemic infections and gastrointestinal pathology, respectively. However, weight loss is not inevitable. and periods of weight stability and weight gain have been documented. Reduced food intake appears to be a major cause of weight loss in HIV infection. Since time of death has been associated with degree of wasting, it seems reasonable to suggest that nutritional support may contribute to enhancing survival and quality of life. All patients should have early access to a qualified dietitian such that assessment of individual situations can be made and appropriate dietary advice given, within a multi-disciplinary approach. Choice of nutritional therapy should be made based on an assessment of the causes of weight loss and an assessment of gut function. Treating infections and alleviating symptoms is vital for ensuring effective nutritional support. Enhancing the energy and protein density of foods and use of oral supplements should be considered if a normal diet alone cannot meet nutritional requirements. Unnecessary dietary restrictions should be avoided. Enteral feeding is indicated for patients unable to meet their needs via the oral route, and in cases of inadequate gut function, parenteral nutrition may be necessary. There is currently insufficient clinical evidence to justify the need for special enteral formulae specifically for patients with HIV infection.

Energy expenditure and wasting in human immunodeficiency virus infection

BACKGROUND

Increased expenditure of energy at rest has been considered a contributing factor to the negative energy balance and weight loss that occur in patients with human immunodeficiency virus (HIV) infection. However, the true determinant of energy balance is not resting but total energy expenditure. We sought to determine the contribution of total energy expenditure to weight changes in patients with HIV-associated wasting.

METHODS

We performed 51 assessments of energy metabolism in 27 men with HIV infection at different stages of disease, including periods of both rapid and slow weight loss. Resting energy expenditure was measured by indirect calorimetry, total energy expenditure by the doubly-labeled-water technique, and energy intake by recording the weight of food consumed. The results were compared with the rate of weight loss or gain.

RESULTS

The mean (+/- SD) total energy expended by the HIV-infected men was 2750 +/- 670 kcal per day, no more than that expended by normal men. There was a significant positive relation between total energy expenditure and the rate of weight change (r = 0.61, P < 0.001); thus, during rapid weight loss, total energy expenditure was reduced to 2180 +/- 580 kcal per day (P = 0.009), primarily because of reduced physical activity. During rapid weight loss, the negative energy balance (-850 +/- 580 kcal per day) was primarily the result of the reduction in energy intake, to 1330 +/- 610 kcal per day; intake correlated strongly with the rate of weight change (r = 0.84, P < 0.001).

CONCLUSIONS

In patients with HIV infection, total energy expenditure is reduced during episodes of weight loss. Reduced energy intake, not elevated energy expenditure, is the prime determinant of weight loss in HIV-associated wasting.

Assessment of nutritional, clinical, and immunologic status of HIV-infected, inner-city patients with multiple risk factors

OBJECTIVE

To evaluate the nutritional, clinical, and immunologic factors associated with human immunodeficiency virus (HIV)-infected, inner-city patients with multiple risk factors.

DESIGN

Prospective cross-sectional nutrition evaluation of patients with HIV infection.

SETTING

Patients were interviewed at the outpatient clinic at Mt Sinai Medical Center, New York City, NY.

SUBJECTS

Our subjects were men and women older than 18 years of age and at all stages of HIV infection (n = 56).

OUTCOME MEASURES

Anthropometric measurements, history of weight changes (maintenance of preillness body weight or decrease from preillness weight status), 3-day food records, and clinical laboratory tests.

STATISTICAL ANALYSES

Tests were used to compare patients who were at a stable weight with patients who had lost weight with regard to the anthropometric, dietary, and clinical variables. Spearman's rank correlation coefficient and chi 2 tests were applied to examine correlations between pairs and differences in proportions, respectively.

RESULTS

Patients were classified into groups according to whether they were at a stable weight (n = 25) or had lost weight (n = 31). All anthropometric measurements, CD4 lymphocytes, and CD8 lymphocytes were significantly lower in the patients who had lost weight. No differences were observed between the groups for absolute lymphocyte count or transferrin, hemoglobin, and albumin levels. The mean energy intake of the 56 patients was 74% of the Recommended Dietary Allowance (RDA). Forty-seven patients (84%) took vitamin and/or mineral supplements within a range of 2% to 50,000% of the RDA. No significant positive correlations were observed between nutrient intake, CD4 cells, and absolute lymphocyte count.

CONCLUSIONS/APPLICATIONS

All anthropometric measurements, CD4 lymphocytes, and CD8 lymphocytes were notably lower in patients with weight loss. The mean energy intake of the subjects was only 74% of the RDA. Megadoses of vitamin supplements were taken by a large number of patients, but no significant positive effects were observed for absolute lymphocyte count and CD4 cells. Although supplementation of micronutrients may influence the progression of HIV infection, a balanced, nutritious diet may be more beneficial in maintaining or improving the physiologic status of the patients. However, members of a high-risk population may benefit less from HIV-related social services and food or nutrition resources. With the growing number of injection-drug users in the acquired immunodeficiency syndrome population, it will be essential to develop comprehensive strategies to address the interconnected needs for medical and nutrition care. Ensuring that patients have adequate meals during an extended course of treatment in the outpatient clinic or that dietitians have meals available in group settings or through home-delivery service may be the most appropriate nutrition intervention in these high-risk patients.

Dietary intake and counseling, weight maintenance, and the course of HIV infection

OBJECTIVE

To define relationships among dietary intake and counseling, weight maintenance, and the clinical course of patients infected with the human immunodeficiency virus (HIV).

DESIGN

A prospective cohort study in an HIV clinic in a county hospital.

SUBJECTS

HIV-infected patients (68 with and 40 without acquired immunodeficiency syndrome [AIDS]) who had a good performance status and no chronic diarrhea were assessed at entry to the study and after 6 months. The following assessments were made: energy and nutrient intake based on 7-day food records, anthropometric measurements, immunologic function as lymphocyte T-cell subpopulations (ratio of CD4 to CD8), and serum cholesterol level. Patients were monitored to determine clinical outcome.

INTERVENTION

All patients received standardized dietary counseling designed to address identified intake deficiencies and maintain body weight.

MAIN OUTCOME MEASURES

Changes in energy and nutrient intake, body weight, and clinical outcome (ie, time to AIDS-defining illness and overall survival time).

STATISTICAL ANALYSES PERFORMED

Group differences (HIV group vs AIDS group) were sought using chi 2 analyses and Student's t test. A multivariate regression model was used to determined the best predictors of clinical outcome.

RESULTS

At baseline, total energy intake (based on 30 kcal/kg usual body weight) was adequate in both HIV and AIDS patients (101 +/- 4% and 103 +/- 5% [mean +/- standard deviation] of need, respectively). Despite dietary counseling and continued maintenance of energy intake, body weight, serum cholesterol level, and CD4 level progressively decreased. Consequently, saturated fat intake was found to be inversely related (P < .01) to serum cholesterol level. Clinical outcome (after 3.5 years) was associated with baseline ratio of CD4 to CD8 (P < .001), weight (P < .01), and serum cholesterol level (P < .001). Multivariate analysis related ratio of CD4 to CD8 (P < .001) and weight maintenance (P < .001) to favorable outcome in the final model.

APPLICATIONS

Weight loss in patients with HIV infection is independently prognostic of clinical outcome, and development of hypocholesterolemia is not favorable for clinical outcome. Because weight loss progresses despite conventional dietary counseling to identify energy need, interventions earlier in the disease course should be considered along with increased target levels for energy intake.

Position of the American Dietetic Association and the Canadian Dietetic Association: nutrition intervention in the care of persons with human immunodeficiency virus infection

The goals of medical nutrition therapy in HIV disease include 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. The maintenance and restoration of nutritional stores are closely interrelated and interdependent with each of the other recommended medical therapies. Therefore, it is vital to the health of persons with HIV/AIDS to have access to the services of a registered dietitian, who is the essential member of the health care team for providing medical nutrition, therapy (49). The registered dietitian should take an active role in developing nutrition care protocols for HIV/AIDS in their practice setting. Dietetics professionals must take responsibility for obtaining and maintaining current knowledge in this area and should take the lead in translating current knowledge and research into practical and realistic nutrition guidelines for persons with HIV/AIDS. Further research is needed in the area of HIV/AIDS and nutrition. Registered dietitians and other members of the health care team are encouraged to conduct nutrition research in the area of nutrition interventions and the outcomes of nutrition therapy. Additionally, government health-related agencies, national AIDS-related organizations, and private industry should be encouraged to provide funding sources and support to the issue of research in nutrition-related problems and interventions in HIV/AIDS.

Wasting syndrome: nutritional support in HIV infection

Malnutrition and wasting are common in patients with HIV infection. Nutritional needs vary with the stage of HIV disease. Severe weight loss is associated with increased mortality in patients with AIDS and is multifactorial in development. Possible causes of weight loss include decreased food intake due to oral or GI pathology or anorexia, nutrient malabsorption, and systemic infections. Severe malabsorption is limited to patients with advanced HIV disease with CD4+ cell counts < 100 and usually < 50 cells/microliters. The spectrum of GI pathogens continues to broaden. For hypermetabolic patients, evaluation for systemic infection followed by effective antiinfective treatment is critical. For nonhypermetabolic patients, a variety of metabolic and endocrinological abnormalities may be present. It is important to recognize that micronutrient deficiencies often accompany macronutrient deficits. Providing appropriate nutritional support to patients with AIDS is fundamental to optimal medical care. Overall indications for nutritional support in a patient with AIDS are the same as in any other chronic disease. Nutritional repletion is well documented, and there are a variety of approaches to achieving appropriate intake, including volitional (megestrol or dronabinol therapy) and nonvolitional (feeding tubes and total parenteral nutrition). Parenteral nutrition should not be undertaken without preset limits. The value of nutritional pharmacology with supraphysiological doses of micronutrients has not been established.

Antioxidant status and lipid peroxidation in patients infected with HIV

Deficiency in antioxidant micronutrients have been observed in patients with AIDS. These observations concerning only some isolated nutrients demonstrate a defect in zinc, selenium, and glutathione. An increase in free radical production and lipid peroxidation has been also found in these patients, and takes a great importance with recent papers presenting an immunodeficiency and more important an increase in HIV-1 replication secondary to free radicals overproduction. We have assessed different studies, trying to obtain a global view of the antioxidant status of these patients. In adults we observe a progressive decrease for zinc, selenium, and vitamin E with the severity of disease, except that selenium remains normal at stage II. However, the main dramatic decrease concerns carotenoids whose level at stage II is only half the normal value. To understand if these decreases in antioxidant and increases in oxidative stress occur secondary to the aggravation of the disease or, conversely, are responsible for it, we undertook a longitudinal survey of asymptotic patients. The preliminary results of this evaluation are presented. Paradoxically, lipid peroxidation is higher at stage II than at stage IV. This may be consecutive to a more intense overproduction of oxygen free radicals by more viable polymorphonuclear (PMN) at the asymptomatic stage. The free radicals production and lipid peroxidation seem secondary to a direct induction by the virus of PMN stimulation and cytokines secretion. N-Acetyl cysteine or ascorbate have been demonstrated in cell culture to be capable of blocking the expression of HIV-1 after oxidative stress and N-acetyl cysteine inhibits in vitro TNF-induced apoptosis of infected cells. In regard to all these experimental data, few serious and large trials of antioxidants have been conducted in HIV-infected patients, although some preliminary studies using zinc or selenium have been performed. In our opinion it is now time to evaluate in humans the beneficial effect of antioxidants. The more promising candidates for presenting synergistic effects when associated with N-acetyl cysteine seem to be beta-carotene, selenium and zinc.