Improved body weight status as a result of nutrition intervention in adult, HIV-positive outpatients

Practice Paper of the Academy of Nutrition and Dietetics: Nutrition Intervention and Human Immunodeficiency Virus Infection

Nutrition is an integral component of medical care for people living with human immunodeficiency virus (HIV)/autoimmune deficiency syndrome (AIDS) (PLWHA). The Academy of Nutrition and Dietetics supports integration of medical nutrition therapy into routine care for this population. Fewer PLWHA experience wasting and undernutrition, while the prevalence of obesity and other chronic diseases has increased significantly. Improved understanding of HIV infection's impact on metabolism and chronic inflammation has only increased the complexity of managing chronic HIV infection. Nutrition assessment should encompass food insecurity risk, changes in body composition, biochemical indices, and clinical indicators of comorbid disease. Side effects from current antiretroviral therapy regimens are less prevalent than with previous generations of therapy. However, micronutrient deficiencies and chronic anemia also remain significant nutritional risks for PLWHA, making vitamin and mineral supplementation necessary in cases of acute deficiency or food insecurity. Additional factors can impact HIV-related nutrition care among the pediatric population, older adults, minority groups, those co-infected with tuberculosis or hepatitis, and PLWHA in rural or underserved areas. Registered dietitian nutritionists and nutrition and dietetic technicians, registered should participate in multidisciplinary care to incorporate nutrition into the medical management of PLWHA.

Effects of nutrition counseling and monitoring on the weight and hemoglobin of patients receiving antiretroviral therapy in Ebonyi State, Southeast Nigeria

Introduction

The relationship between human immunodeficiency virus (HIV) and malnutrition is easily explained, and the etiology of malnutrition in HIV disease is believed to be multifactorial.

It therefore follows that ongoing assessment of nutritional and medical status is crucial to quality nutrition care for every person living with HIV. The aim of this study was to find out the effect of nutritional counseling and monitoring, using personalized dietary prescriptions, on the body mass index (BMI) and hemoglobin of patients who are HIV-infected and also receiving highly active antiretroviral drugs.

Methods

A total of 84 patients were selected using simple random sampling and allocated into intervention and control groups. Nutritional counseling and monitoring was done for the intervention group, while only weight, height, and hemoglobin concentration were monitored for the control group. At the end of 6 months, the differences in mean body mass index (BMI) and hemoglobin concentrations of the intervention and control groups were compared using the Student’s t-test. Statistical level of significance was put at P<0.05.

Results

Among respondents, 30.96% were males and 69.04% were females, and the mean age of the intervention group was 33.8 years and was 35.3 in the control group. After 6 months of study, the difference in the mean BMI among the males of both groups (24.9 kg/m² [intervention] and 24.3 kg/m² [control]) was not significant (P=0.53) but was significant among the females (24.9 kg/m² [intervention group] versus 21.8 kg/m² [control group]) (P=0.0005). The difference in mean hemoglobin concentration between the intervention and control groups for both males and females were statistically significant (12.2 mg/dL for males in the intervention group and 11.0 mg/dL for males in the control group [P=0.005]; 11.9 mg/dL for females in the intervention group and 11.0 mg/dL for females in the control group [P=0.010

Conclusion

Nutrition intervention is important in the management of people living with HIV/acquired immunodeficiency disease (AIDS) while on antiretroviral therapy. This can be achieved through nutritional counseling and monitoring.

A group intervention to improve body image satisfaction and dietary habits in gay and bisexual men living with HIV/AIDS

A healthy diet is essential to maintaining a strong immune system for people living with HIV and AIDS. Prior studies have shown that HIV-positive gay and bisexual men are more susceptible to poor body image, which can negatively impact dietary habits. Interventions that simultaneously address body image and nutrition are therefore critical for this population. This paper describes the curriculum for a 14-week group designed to improve body image satisfaction and dietary habits in gay and bisexual men living with HIV/AIDS.

Nutritional counselling: an intervention for HIV-positive patients

AIM

This paper reports an investigation of the effectiveness of nutritional counselling as an intervention to improve health outcomes for HIV-positive patients in Ghana, West Africa.

BACKGROUND

In Ghana, like many developing countries, more patients with HIV and AIDS die because of their poor nutritional status than from the disease itself. With the lack of highly active anti-retroviral therapy for most HIV-infected patients in developing countries, nutritional counselling about high protein diet can be an essential intervention to reduce weight loss and improve weight gain and survival outcomes.

METHOD

We used secondary-analytic data collected in summer 2003. Recorded monthly weights of HIV-positive patients were obtained and analysed for 25 people, whose ages ranged from 21 to 60 years, with a mean of 39.4 years (sd = 10.13).

RESULTS

HIV-positive patients responded favourably to nutritional counselling about protein dietary intake as an intervention to improve weight gain. Repeated measures showed a statistically significant weight gain (P = 0.008).

CONCLUSION

In the absence of anti-retroviral therapy, high protein nutrition can be an effective intervention for HIV-positive patients in developing countries. The health and nutritional status of the patients can be improved through nutritious food, allowing them to lead longer and better quality lives.

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

Infection with the human immunodeficiency virus (HIV) and the development of acquired immunodeficiency syndrome (AIDS) have had a significant impact on domestic and global health, social, political, and economic outcomes. Prevention and treatment efforts to control HIV infection are more demanding than in previous decades. Achieving food and nutrition security, and managing nutrition-related complications of HIV infection and the multiple aspects of disease initiated by or surrounding HIV infection, referred to as HIV disease, remain challenges for patients and for those involved with HIV/AIDS prevention, care, and treatment efforts. Confounding clinical issues include medication interactions, coinfection with other infections and diseases, wasting, lipodystrophy, and others. Dietetics professionals, other health care professionals, and people infected with HIV will need to understand and address multiple complex aspects of HIV infection and treatment to improve survival, body functions, and overall quality of life. Individualized nutrition care plans will be an essential feature of the medical management of persons with HIV infection and AIDS.

Difficulty Swallowing and Lack of Receipt of Highly Active Antiretroviral Therapy Predict Acute Weight Loss in Human Immunodeficiency Virus Disease

In human immunodeficiency virus (HIV) disease, symptoms of underlying illness may promote weight loss through decreased caloric intake, increased metabolic needs, or nutrient malabsorption. We evaluated disease symptoms as predictors of acute weight loss (i.e., loss of > or =5% of weight). HIV-infected men and women (n=415) were telephoned every 5 weeks to obtain information about weight and recent symptoms. Weight change between each pair of consecutive calls (telephone intervals, 2814) was calculated. Acute weight loss occurred across 4.5% of intervals and among 24% of individuals. Patients reported > or =1 symptom before 58% of telephone intervals. The most common symptoms or symptom complexes before intervals were diarrhea (21% of patients), anorexia (17%), upper respiratory symptoms (16%), skin symptoms (12%), and abdominal pain (12%). Trouble swallowing (6%) and oral symptoms (7%) were less common. Risk of acute weight loss was significantly increased when oral symptoms or trouble swallowing were present, and it was decreased when highly active antiretroviral therapy (HAART) was used or when diarrhea was not present. Even when HAART is being administered, clinicians should remain vigilant regarding weight loss, oral symptoms, and trouble swallowing.

Assessment of nutritional status, body composition, and human immunodeficiency virus-associated morphologic changes

Nutritional status should be assessed at regular intervals as part of management of human immunodeficiency virus (HIV) infection. The simplest approach to assessment is serial weight measurement. A comprehensive nutritional assessment includes (1) anthropometric measurements of body composition; (2) biochemical measurements of serum protein, micronutrients, and metabolic parameters; (3) clinical assessment of altered nutritional requirements and social or psychological issues that may preclude adequate intake; and (4) measurement of dietary intake. Techniques for measuring body composition of fat and lean body mass include anthropometry and bioelectric impedance analysis. Other techniques, including dual X-ray absorptiometry (DXA), hydrodensitometry, total body potassium measurement, and cross-sectional computed tomography or magnetic resonance imaging are available in research centers. Anthropometry, including waist-hip ratios, regional DXA, and cross-sectional imaging, is best for detecting morphologic changes associated with fat redistribution syndrome. Nutritional assessment and intervention in children with HIV can help to prevent stunted growth and development.

General nutrition management in patients infected with human immunodeficiency virus

Nutritional management is integral to the care of all patients infected with human immunodeficiency virus (HIV). HIV infection results in complicated nutritional issues for patients, and there is growing evidence that nutritional interventions influence health outcomes in HIV-infected patients. We define levels of nutritional care, and we discuss when patients should be referred to providers (i.e., registered dietitians) with nutritional and HIV expertise.

Nutrient intake and body weight in a large HIV cohort that includes women and minorities

OBJECTIVE

Evaluate the baseline nutrient intake of an HIV positive population that includes significant representation from women and minorities, and determine the relationship between state of disease and nutritional intake.

DESIGN

Baseline data from a prospective study (Nutrition for Healthy Living).

SUBJECTS

Individuals with HIV in the Boston and Rhode Island area (n = 516); 25% were women and 30% were minorities.

METHODS

Nutrient intakes from 3-day food records, which included vitamin/mineral supplements, were estimated by gender and nonwhite vs white categories, after grouping by CD4 lymphocyte counts.

STATISTICAL ANALYSES

Spearman correlation coefficients, Wilcoxon signed rank test, Wilcoxon rank sum test, chi2 test, and restricted cubic spline model were used for data analyses as indicated.

RESULTS

Macronutrient but not micronutrient intake was statistically and inversely associated with decreasing CD4 cell counts. The median intake of micronutrients was higher in the study sample compared with the same age and gender group in NHANES III data; however, 25% to 35% of the women in our study sample had dietary intakes of less than 75% of the DRIs for vitamins A, C, E and B-6, and iron and zinc. White men had statistically higher values of all micronutrients compared with nonwhite men. Body mass index for men and women ranged from 23 to 25.

CONCLUSIONS/APPLICATIONS

Median values for micronutrient intake from food plus vitamin/mineral supplements were adequate in the overall population studied, but a large percent of women and minorities had inadequate nutrient intakes and would benefit from dietary assessment and counseling.

Adesão de pacientes HIV positivos à dietoterapia ambulatorial

É conhecida a importância do estado nutricional para a evolução clínica de pacientes HIV positivos. Entretanto, é desconhecida a expectativa do paciente com relação à dietoterapia. Por um período de 30 semanas foram acompanhados 50,0% dos pacientes HIV positivo (grupos II e IV) atendidos pelo ambulatório de Doenças Sexualmente Transmissíveis do Hospital e Maternidade Celso Pierro. Neste período foram realizadas duas entrevistas, sendo o intervalo entre elas de 10 semanas. Na primeira foram colhidos dados socioeconômicos, antropométricos, verificadas as modificações voluntárias feitas na alimentação e também a expectativa do paciente quanto a este tipo de tratamento. Na segunda foram colhidos indicadores diretos e indiretos de adesão ao tratamento. A adesão foi maior entre os pacientes do grupo IV (64,7%) do que entre os do grupo II (35,3%). No entanto, 81,3% dos pacientes do grupo II, após tomarem conhecimento da sorologia positiva para HIV, modificaram voluntariamente sua alimentação, demostrando ser este um importante período para sensibilização do paciente para o tratamento.

Complementary medicine and HIV infection

The social role of alternative medicine is critical in empowering the large proportion of HIV-positive patients who choose to use nontraditionally prescribed medicines. Working toward an open scientific dialogue with HIV-related complementary therapies is a worthy goal for all providers.

HIV and medical nutrition therapy

In those who are infected with human immunodeficiency virus, poor nutritional status can result from numerous causes, including anorexia, catabolism, chronic infection, fever, poor nutrient intake, nausea, vomiting, diarrhea, malabsorption, metabolic disturbances, lack of access to food, depression, and side effects of drug, radiation, and chemotherapy treatments. A compromised immune system may not be reversed by any medical treatments at this time, but malnutrition may be prevented and reversed by using current therapies, including medical nutrition therapy that includes nutrition assessment, the development of an individualized nutrition therapy plan, and implementation of the therapy. There is substantial evidence that medical nutrition therapy saves lives, reduces morbidity, improves health outcomes, reduces costs, and shortens hospital stays.

Malnutrition in HIV infection

Malnutrition is a common complication of HIV infection and plays a significant and independent role in morbidity and mortality. Many studies have been conducted to assess the appropriate role of nutrition in the clinical management of HIV infection. The complex nature of AIDS wasting, however, requires individualized strategies when providing nutritional support. Algorithms to assist in the diagnosis and treatment of malnutrition in HIV infection serve as general guidelines.

Decreased fat and nitrogen losses in patients with AIDS receiving medium-chain-triglyceride-enriched formula vs those receiving long-chain-triglyceride-containing formula

OBJECTIVE

The purpose of this study was to compare two enteral formulas, differing only in fat source, for product acceptance, tolerance, and effect on fat malabsorption and nutritional status in subjects with acquired immune deficiency syndrome (AIDS).

DESIGN

The double-blind, randomized 15-day trial was divided into a 3-day period in which solid food was consumed followed by a 12-day experimental period in which liquid formulas were consumed.

SETTING/SUBJECTS

Twenty-three men and one woman with AIDS and fat malabsorption completed the study. The study was conducted in the General Clinical Research Center, University of Alabama Hospital, University of Alabama at Birmingham. Laboratory assays were performed in the Department of Nutrition Sciences.

INTERVENTIONS

After 3 days of consuming a controlled, solid food diet containing 100 g fat per day from mixed sources to document fat malabsorption, subjects were randomly assigned to one of two groups. Each group received a liquid formula containing 35% of energy as fat for 12 days. One group received a formula containing 85% medium-chain triglycerides (MCTs) and the control group received a formula containing 100% long-chain triglycerides.

MAIN OUTCOME MEASURES

Determinations included stool number, consistency, weight, and fat and nitrogen content; urine nitrogen and creatinine levels; and body weight.

STATISTICAL ANALYSIS PERFORMED

Subject demographic and other baseline characteristics were compared using two-sample t tests; stool and urine assessments were compared between groups at the initial experimental period using two-sample t tests; changes from initial to final experimental periods were assessed by means of analysis of covariance; changes in pooled intake, body weight, and the number and consistency of bowel movements were also assessed using analysis of covariance. All statistical tests were two-tailed and considered significant at P < .05.

RESULTS

Within-group comparisons indicated that subjects fed the MCT formula showed significantly decreased stool fat and stool nitrogen content (P = .01 and P = .03, respectively) and increased fat absorption (P = .03), whereas those fed the control formula did not. Differences in stool fat between the groups were not statistically significant. However, the difference in fat absorption from the initial to final formula period was significant (P = .04). Subjects consuming the MCT formula also tended to have a decreased number of bowel movements and abdominal symptoms, whereas subjects fed the control formula showed no improvement. All subjects maintained their body weights.

APPLICATIONS

There may be advantages to using an MCT-based formula in the treatment of AIDS-associated malabsorption.

Nutrition support in clinical practice: review of published data and recommendations for future research directions. National Institutes of Health, American Society for Parenteral and Enteral Nutrition, and American Society for Clinical Nutrition

In the last 30 years, marked advances in enteral feeding techniques, venous access, and enteral and parenteral nutrient formulations have made it possible to provide nutrition support to almost all patients. Despite the abundant medical literature and widespread use of nutritional therapy, many areas of nutrition support remain controversial. Therefore, the leadership at the National Institutes of Health, The American Society for Parenteral and Enteral Nutrition, and The American Society for Clinical Nutrition convened an advisory committee to perform a critical review of the current medical literature evaluating the clinical use of nutrition support; the goal was to assess our current body of knowledge and to identify the issues that deserve further investigation. The panel was divided into five groups to evaluate the following areas: nutrition assessment, nutrition support in patients with gastrointestinal diseases, nutrition support in wasting diseases, nutrition support in critically ill patients, and perioperative nutrition support. The findings from each group are summarized in this report. This document is not meant to establish practice guidelines for nutrition support. The use of nutritional therapy requires a careful integration of data from pertinent clinical trials, clinical expertise in the illness or injury being treated, clinical expertise in nutritional therapy, and input from the patient and his/her family.

Body composition in clinically stable men with HIV infection

Clinically stable HIV-infected men (N = 106) receiving investigational antiretrovirals were recruited. Subjects were divided into three HIV disease severity groups by CD4+ cell count. Standard measures of body composition were assessed, as well as serum measures of visceral protein stores and kilocalorie intake. Group 1 subjects (CD4+ T cells < 200) had significantly lower measures of body fat as compared with Group 2 (CD4 between 200 and 600) and Group 3 (CD4 > 600) despite adequate kilocalorie intake. Group 2 and Group 3 were not significantly different from each other. Our entire cohort had significantly lower muscle mass compared to norms. Our data demonstrate that people with advanced HIV disease have reduced muscle and fat.

Primary care of the HIV patient: standard practice and new developments in the era of managed care

It is easy when taking care of the patient with AIDS to lose sight of the whole person and become focused on the details of micromanagement, distracted by the array of new therapies, and overwhelmed by the financial risks of the disease. It is therefore critical that a healing and respectful relationship is developed with patients and they are engaged in the decisions regarding their care. Physicians must also continue the search for new therapies and struggle to ensure that patients have access to state-of-the-art treatment. In this, the primary care physician plays a critical role, through identifying study centers, becoming an investigator in expanded access programs, and using referrals to clinical trials to provide new therapies to patients and improve understanding of HIV treatment. Finally, quality of life must be at the forefront of physicians' medical conscience. Ultimately, the physician must know when the best treatment he of she can offer is the assurance of a dignified and comfortable death.

A review of mechanisms of wasting in HIV disease

According to estimates, between 50% to 90% of patients infected with the Human Immunodeficiency Virus (HIV) will experience some form of malnutrition. The degree and types of malnutrition are attributed to alterations in nutrient intake, absorption, and metabolism. Causes for each of these changes are complex and multifactorial. Research on treatment modalities generally concentrates on a single mechanism and reports varying degrees of short-term benefit. Appetite stimulation along with special diets, oral supplements, and nonvolitional enteral or parenteral nutrient provision may improve nutrient intake and body weight. Therapies aimed at the rehabilitation and improvement of the pool of functioning protein stores, such as alteration of inflammatory response, restoration of hormonal balance, and exercise are under investigation. Longer term studies will allow researchers to observe effects of therapies on overall body functions. With the development of clinical standards of care, the maintenance and restoration of nutritional status is emerging as the foundation for HIV disease management.

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.