Download - Hiv Case Study Presentation
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Obstacles to Adequate Nutrition in Human Immunodeficiency VirusPrepared by: Jessica McGovern
+Objectives Explain HIV’s effect on the immune system
Examine HIV’s effect on the body
Identify risk factors for contracting the virus
State methods of assessing an HIV patient
Discuss obstacles to maintaining nutritional status
Identify nutrition interventions for HIV
Examine methods of monitoring nutritional status in this population
Discuss a case study of an HIV patient with oral feeding difficulty
Explain various oral issues and associated medical nutrition therapy
+Patient AW
46 year old Hispanic male, 5’7”, UBW-180lbs
Admitted on September 14th with sore throat, ulcers in the oral cavity and esophagus, and significant weight loss.
Admitting diagnosis of esophagitis.
HIV test reveals patient is HIV positive.
http://www.health.com/health/static/hw/media/medical/hw/n5551186.jpg
+What is HIV?
A retro-virus (contains RNA) that uses the body’s own cells to reproduce.
Transmitted through sexual contact, infectious bodily fluids, needle/syringe sharing, tainted blood transfusions, or through birth/breast feeding.
Not easily transmitted.
Often asymptomatic in the earliest stages .
(1)
http://www.hivnorfolk.com/images/illustrations/hiv_virus.jpg
+Overview of Immune Cells
B Cells- Identify foreign cells, produces antibodies, able to neutralize and destroy invaders that are not already incorporated into the host cells
Helper T (CD4)- Directs the immune response once a foreign entity is identified
Cytotoxic T (CD8)- kills the targeted cells based on the presence of a foreign antigen on the surface of the cell
Macrophages- engulf foreign material
(2)
+How the virus works. Helper T cells are the
primary target
Identifies the T cells
Fuses to the surface
Injects RNA, enzymes, and other substances that help to penetrate the cells surface
RNA is transcribed to DNA
DNA carried to the nucleus and integrated into the host DNA using enzymes
The virus can remain dormant
Once activated the cells become a “viral factory” manufacturing, assembling, and releasing the virus.
CD4 cells becomes destroyed
Macrophages infected with HIV become dysfunctional
Leads to compromised immune system and the progression of the disease
(1,2)
+Illustration of How HIV Works
http://www.virxsys.com/media/MOAsmall.jpg
+Facts about HIV
1.1 million people are living with HIV in the United States
There are two types of HIV- HIV1 and HIV2.
1/70th the size of a Helper T cell
Contains 9 genes
6 of the genes are primarily used to penetrate, infect, and produce copies in the T cell
The virus also targets other cells of the body including gastrointestinal cells, organ cells, and the immune cells
HIV is not a death sentence
Infection depends on the level of exposure and the dose
HIV can reproduce rapidly between 1 billion and 1 trillion virons per day
Initial infection is often followed by flu-like symptoms
21% of those infected within the United States are undiagnosed
(2,3,4)
+Diagnosis of HIV ELISA- “rapid test” to identify
possibility of infection- more sensitive than specific
EIA- determines the concentration of antibodies
Tests vary greatly and can measure serum, plasma, urine, saliva.
Can determine if the infection is recent or long standing
Measure reduction in CD4 count, viral load increase, HIV antibodies, and antigens.
Pheno and genotype of the virus are tested to track mutations and decide which treatment will be effective
Category CD4 Count
1 >500
2 200-499
3 <200
Immune Cell Category of HIV Infection
(2,3)
http://hypochondriaoasis.com/wp-content/uploads/2008/05/hiv-test.jpg
+Stages of HIV Disease
(4)
+What does HIV effect?
Neurological
Pulmonary
Renal
Cardiac
GI Tract
Immune system
Hematological
Musculoskeletal
Hepatic
All Systems of the Body
(5)
http://wpcontent.answers.com/wikipedia/commons/thumb/4/4a/Symptoms_of_acute_HIV_infection.png/300px-Symptoms_of_acute_HIV_infection.png
+ Treatments
Fusion Inhibitors
Non-nucleocide Reverse Transcriptase Inhibitor
Nucleotide/nucleocide Reverse Transcriptase Inhibitor
Intergrase Inhibitor
Protease Inhibitor
HAART-highly active anti-retroviral therapy
Successful if adherence is 95%
Side effects/symptoms
Pill burden
Complex regimens
Food/Medication Interactions
Knowledge deficit
Anti-retrovirals Limitations
(6)
+What are the risk factors?
(6)
+ Assessing Dietary Intake of Drug-Abusing Hispanic Adults with and with out Human Immunodeficiency Virus InfectionSahni S, Forrester JE, Tucker KL. Assessing Dietary Intake of Drug-Abusing Hispanic Adults with and without Human Immunodeficiency Virus Infection. J Am Diet Assoc. 2007;107(6):968-976.
-Objective:
--20% of HIV/AIDS cases in the United States are related to injection drug use
--Both drug abuse and HIV are identified as leading to nutritional deficiencies in macro and micronutrients
--Drug abuse among Hispanics in the Northeastern United States is a significant risk factor
--The dietary assessment of a drug user often proves difficult to obtain and may be inaccurate
--Develop an assessment method tailored to the Hispanic population
Design used 3 groups:
-HIV infected drug users
-HIV –non-infected drug users
-HIV infected non drug users
7)
+Assessing Dietary Intake of Drug-Abusing Hispanic Adults with and with out Human Immunodeficiency Virus Infection
24 hour recall and FFQ recorded by interviewer on 1st visit
Half of 3 day records not completed
Total kcal, protein, carbohydrates, fat, saturated fat, cholesterol, fiber, Vitamins A, D, K, Riboflavin, Niacin, Folate, B6, B12, C and Zeaxanthhin, Calcium, Iron, Zinc, Sodium, Potassium, Magnesium, Phosphorus
Conclusion-24 hour recall and FFQ most effective
3 assessment methods 3 day recall, 24 hour recall, and FFQ
286 participated
282 FFQ
142 3 day records
270 24 hour recalls
28% of subject women
24% reported homelessness
>50% has less than a high school education
(7)
+HIV Time-line
(1)
+Race/Method of Contraction in the United States
RaceMethod of Contracting the
Virus
(3)
+Incidence of HIV
(4)
+HIV Rates and AIDS Related Deaths
(4)
+Nutrition Assessment
Lifestyle choices (smoking, drug abuse, alcohol)
Economic status
Lack of healthcare
Access to safe food
Food insecurity
Social History
(1,6)
+Nutrition Assessment
Food recall/frequency/questionnaire
Meals per day
Intake analysis
Food allergies
Appetite
Ability to chew/swallow
Signs/symptoms of GI distress
Taste changes/dry mouth
Dietary History
(1,6)
+Nutrition Assessment
Weight- change
Height
BMI
Clinical signs of deficiency
Anthropometrics
Body composition analysis
Lipodystrophy
Physical Assessment
(1,6)
+Nutrition Assessment
Past and current medical diagnosis
Family history
Medications
Surgery
Medical History
(1,6)
+Nutrition Assessment
Immunologic profile
Hematologic profile
Liver function
Lipid profile
Renal profile
Glucose/Insulin
Inflammatory markers
Biochemical Assessment
(1)
+Nutrition Assessment
Kcals- BEE x 1.3 for weight maintenance, BEE x 1.5 for weight gain
Protein- 1-1.4g/kg body weight for maintenance, 1.5-2g/kg for repletion
Fluids- 30-35mL/kg body weight
Vitamins-A,C, B6, B12, and Folate may be poorly absorbed
Minerals-Selenium and Zinc may be deficient
Calculating Estimated Needs
(1,6)
+Nutrition’s relation to immunity
HIV causes dysfunction of the GI tract
Increases risk for malabsorption of nutrients
Malnutrition continues leading to a decline in health and wasting process
Breakdown of protein stores to feed the inflammatory process
Opportunistic diseases/cancers increase catabolic state causing weight loss
(1)
+
Nutrient Intake and body weight in a large HIV cohort that includes women and minorities Woods MN, Spiegelman D, Knox TA, Forrester JE, Connors JL, Skinner SC, Silva M, Kim JH, Gorbach SL. Nutrient Intake and Body Weight in a Large Cohort That Includes Women and Minorities. J Am Diet Assoc. 2002;102:203-211.
-Clinical Status Questionnaire-Physical Activity Questionnaire-Physical Exam-Blood Tests-CD4-Stool Specimen-fecal fat-Serum Vit levels
Objectives:
-To evaluate the connection between state of HIV disease and nutritional intake
Subjects:
-516 total subjects
-25% women, 30% minorities
-Categorized by CD4 count, gender, and white VS non-white
Methods:-3 day food record-Included Vitamin/Mineral supplements
(8)
+ Nutrient Intake and body weight in a large HIV cohort that includes women and minorities
Results:
-As CD4 count decreased, macronutrient intake increased in men
-25-30% of women consumed <75% DRI’s for A, C, E, B6, and Iron.
-White men had higher micronutrient intakes
-Macronutrient intake was higher among white vs non-white men
-25% of men did not meet DRI of Zinc, Folate, and vitamin E
-90% of the subjects provided a 3 day recall-The remaining submitted a 1-2 day recall-Nutrition Data Software was used to analyze the diet
(8)
+Obstacles to maintaining nutritional status
Polypharmacy
Disease complications
Co-Infections/opportunistic infections
Symptoms
(6)
+Antiretroviral Medication Interactions
Drug-Brand Name
Diarrhea Nausea/ Vomiting
Loss of Appetite
Taste Change
Lipid Alteration
Glucose Intolerance
Abd Pain Lipodystrophy
Ziagen X X X XReyetaz X X X X XPrezista X X X X X XVidex X X X X X XEmtriva X X X XNorvir X X X X X X X XFortovase X X X X X XZerit X X X X X XAptivus X X X X X XSustiva X X X X X X
(1)
+Nutrition Related Disease Complications
Nephropathy
Anemia
Protein Energy Malnutrition
Lipodystrophy
Abnormal protein metabolism
Hormonal/nutrient alterations
Medication/Food Interactions
Reduction in intestinal enzyme production
Malabsorption
Rapid intestinal cell turnover
Immature enterocytes
Other system malfunctions that may cause dietary restrictions.
(6)
+The fat redistribution syndrome in patients infected with HIV: Measurements of body shape abnormalitiesGerrior J, Kantaros J, Coakley E, Albrecht M, Wanke C. The Fat Redistribution Syndrome in Patients Infected with HIV: Measurements of Body Shape Abnormalies. J Am Diet Assoc. 2001;101:1175-1180.
Objective:
To document the body shape and metabolic abnormalities of fat redistribution syndrome
Subjects:
39 patients
90% on protease inhibitors
22% women and 26% men had CD4 counts <200
Methods:
Medication records
Exercise habits
Waist circumference
Hip circumference
Waist/hip ratio
Chest circumference
Mid-arm and Mid- thigh circumference
Lab results used from primary physicians
(9)
+
The fat redistribution syndrome in patients infected with HIV: Measurements of body shape abnormalities
Results:
-Mean glucose levels were within a normal range
-Triglyceride and cholesterol levels were moderately elevated
-The waist/hip ratio was abnormal
-BMI was within normal parameters
-Mean mid arm circumference and triceps skinfold were below national levels
(9)
+Opportunistic Diseases
Fungal infections-Thrush
Viral infections- Herpes
Bacterial infections- salivary gland disease, periodontal disease, pneumonia, upper respiratory tract infection
Various cancers- Kaposi’s sarcoma, Hodgkins Disease
(1,5)
+Symptoms
Nausea
Vomiting
Diarrhea
Abdominal Pain
Anorexia
Taste changes
Fatigue
Chills
Sore Throat
Headache
Weight loss
Fever
Anxiety
Frequent infections
(1,5,6)
+Goals of Nutrition Intervention in HIV
Restore macro/micro nutrient deficiencies
Manage symptoms of disease and/or medications
Weight maintenance
Hydration
Alter diet if co-disease exists that warrants nutritional therapy
Avoid fatigue during meal times by providing small, frequent meals
Initiate tube feeding if necessary
(5)
+Methods of Monitoring and Evaluating HIV Patients
Weight records
Reports of GI distress and symptoms
Food records
Laboratory results
(1,5)
+Nutrition Education
Food Safety
Protein sources
Fluids
Kilocalories
Micronutrients
Exercise
Food/Medication Interactions
Symptom management
Weight changes
Management of nutritionally pertinent co-diseases
The relationship between nutrition and immunity
Additional resources for educational information on the disease process
(1,5,6)
+ Application of a Five-Step Message Development Model for Food Safety Education Materials Targeting People with HIV/AIDS
Objective:
-Assess the needs of those with HIV
-Develop educational materials on food safety
-Evaluate effectiveness and how the material is received by the audience of HIV participants
Needs Assessment:
-8 focus groups
-65 HIV infected people
-18 health care providers interviewed
Assessment of Acceptance:
-4 focus groups
-32 HIV infected people
-25 health care provider surveys(10)
Hoffman EW, Bergmann V, Armstrong J, Kendall P, Medieros LC, Hillers VN. Applications of a Five-Step Message Development Model for Food Safety Education Materials Targeting people with HIV/AIDS.
J Am Diet Assoc. 2005;105:1597-1604.
+Application of a Five-Step Message Development Model for Food Safety Education Materials Targeting People with HIV/AIDS
Steps 1 and 2 stated issues and established food safety recommendations
Step 3 involved needs assessment focus groups
Step 4 used data, recommendations on safety, and the Health Belief Model to make 5 prototype educational materials for HIV/AIDS
Step 5 evaluated the materials during sessions and surveys
Needs Assessment groups initially were resistant to and confused by food safety recommendations
Prototype material groups on average rated the materials 5.6-6.4 on a scale of 1-7.
19 of 32 participants reported increased confidence of knowledge after reviewing the educational packets
Resistance was greatest for the encouragement to avoid unheated deli meats, use of a thermometer and avoidance of soft cheeses
21 of 25 Health care providers showed interest in using the materials for their clients educational benefit
5 Step Method Results
(10)
+In Depth-Initial Visit to Doctor
Visit primary doctor with c/o 10 lbs weight loss and sore throat since the beginning of August
Pt placed on antibiotics (amoxicillan, levaquin, Diflucan)
Return to primary doctor- patient is no longer able to swallow liquids and still losing weight
Admitted to the hospital with diagnosis of esophagitis
+Signs/Symptoms on Admission
Unable to swallow
Pain in the mouth and throat
Dizziness
Unable to open mouth all of the way
18 lb weight loss by the time of admission
N/V/D
Chewing/Swallowing difficulty due to mouth ulcers
+Past Medical History/ Social History
HTN
Hepatitis C
IV Drug Abuse (Heroin, Cocaine)
Tobacco use (quit in January of 2003)
Married with one son
Lives at home with his wife
Maintained on Methadone
+Physical Exam
Physician Notes:
General: Well developed, well nourished, in no distress, alert and oriented
Vital Signs: Tmax is 100.2. All other vitals are stable
HEENT: Significant for thrush, small ulcer inside of left side of pharynx. Looks normal but is unable to open mouth. Nodes are slightly swollen.
Neck: Supple
Chest: Clear
Extremities: - for cyanosis, clubbing, edema
Abdomen: Soft, non tender, + for bowel sounds
Neurologic: Grossly intact
Skin: Warm, no rashes
+Tests/Procedures Biopsy of ulcer to r/o cancer
Full lab work-up- HIV +
CT scan of throat/abdomen to r/o perforations
Esophageal gastroduodenoscopy
Speech therapy evaluation for swallowing to r/o aspiration pneumonia
Chest X-ray
MRI of brain
EKG
CT scan of the head because of change in mental status
EEG because of seizure
+Medications Zovirax (Antiviral)- N/V/D anorexia
Diflucan (Antifungal)- Taste changes, dry mouth, dyspepsia, N/V/D
Mycostatin (Antifungal)- N/V/D
Dapasone (Antibacterial)- N/V anorexia
Dilaudid (Opioid)- dry mouth, dysphagia, N/V/D, dysmotility, taste changes, upset stomach
Filgrastin (Increases production of neutrophils)
Multivitamin and Folic Acid
Magic Mouth Wash- numbs mouth
Zofran (Antiemetic)- dry mouth, diarrhea
Oxycodone (Opioid)- anorexia, dry mouth, upset stomach, N/V/D, constipation
(11)
+Laboratory Values
Hgb-11.4 L
Hct-33 L
BUN- 20 H
Na-130 L
K- 3.2 L
Alb-1.7 L
Total P- 5.5 L
AST- 193 H
ALT- 99 H
BUN- 4 L
Ca- 8.2 L
WBC- 1.4 L
RBC- 2.65 L
Hgb- 7.7 L
Hct- 22 L
RDW- 15.1 H
Initial Labs 9/14 Follow up Labs 10/1
(12)
+Diet Placed on a full fluid diet
Patient cannot tolerate acidic foods
Cannot manage solid foods
<50% consumption of meals
Neutrapenic precautions due to low WBC count
Food recall taken
(13,14)
+Progression of Dx during hospitalization
Seizure
Change in Mental Status
Temporary pacemaker placed
Developed Kidney stones- had a stent placed in ureter
Tachycardia- 200+ heart rate- transferred to CCU
Changed to a nectar thick liquids due to aspiration risk
Total weight loss of 30 lbs
Ulcers not healing
Low WBC count
PICC line insertion
Sonography of gallbladder reveals gallstones
Consult for drug rehab
Respiratory Arrest
+Assessment
46 year old male admitted with esophagitis. Pt reports signs of N/V/D, 18 lbs weight loss over 1 month, painful swallowing/chewing and dizziness. Pmhx of IV drug abuse, Hep C, HTN. Patient on a full fluid diet. Reports appetite is poor with less than 50% consumption of meals. Ht- 5’7, Wt- 150#, UBW- 180#, %UBW- 83, IBW- 148, % IBW 98.6, BMI- 23, 10% weight changes over 2 months. Labs- Alb-1.7 L, Total P- 5.5 L, AST- 193 H, ALT- 99 H, BUN- 4 L, Ca- 8.2 L, WBC- 1.4 L, RBC- 2.65 L, Hgb- 7.7 L, Hct- 22 L, RDW- 15.1 H. Meds- Zovirax, Diflucan, Mycostatin, Dapasone, Dilaudid, Filgrastin, MVT, Magic Mouth Wash, Zofran, Oxycodone. Estimated needs- Kcals (30kcal/kg) 2045kcals, Protein (2g/kg) 147g, Fluids (30mL/kg) 2209mL. Diet recall- Total kcals- 700, 151g CHO (604kcals), 6g protein (24kcals), 8g fat (72kcals). Diet recall reveals pt is consuming 34% estimated kcals needs and 4% estimated protein needs. Patient is at high nutritional risk related to weight loss, diagnosis, inadequate intake, and lab values.
+PES/Nutrition Diagnosis
Inadequate caloric intake related to difficulty swallowing as evidenced by 10% weight loss and pt meeting only 34% of kcal needs.
Increased energy expenditure related to increased energy needs associated with diagnosis as evidenced by 18lbs weight loss.
Inadequate protein intake related to decreased appetite and consumption of meals as evidenced by pt meeting only 4% of protein needs and Alb 1.7 L.
Swallowing difficulty related to mouth ulcers as evidenced by pt inability to swallow due to pain.
+Interventions
Provide patient with Ensure Plus 3x day for an extra 1050kcals
Recommend diet be advanced as tolerated to soft foods to increase calories
Provide patient with Prostat 3x day for an additional 45g protein
Educate patient on high biological value proteins and high calorie foods
+Outcomes/Monitoring and Evaluation
Patient will consume 80% of meals
Patient will consume 100% of supplements
Diet will be upgraded to soft by the doctor
Albumin will be 3.5 or above in 3 weeks
Patient will maintain current weight
Monitor weight
Monitor intake by calorie count or visiting during meals
Monitor tolerance to supplement and adherence
Monitor lab values
Monitor for diet change
Outcomes Monitoring/Evaluation
+Nutritional Complications Caused by Oral Issues
Burning
Mouth Pain
Dysphagia
Chronic Ulcers
Swollen oral cavitiy
Painful Chewing
Oral Malignancy
Herpes Simplex
Cytomegalovirus
Kaposi’s Sarcoma
Stomatitis
Periodontitis
Esphageal Candidiasis
Esophagitis
Symptoms leading to decrease intake/appetite Causes
(15)
+MNT for Oral Issues
Avoid irritating foods- spicy/acidic
Soft, moist foods
Temperatures may be an issue, experiment for tolerance
Avoidance of very hot or very cold foods should be initially done. Room temperature food will often be best accepted
Patients with persistently painful oral cavities should consume foods that are nutrient and calorically dense
(1,6)
+Summary of Prognosis
Doctors debating about opioids and heart condition
Anti-retroviral therapy being determined
Awaiting psych consult for rehab for opioids
Will transfer when patient is stable
+Conclusion
What do you think?
Weight loss most likely impaired health
Nutrition and immunity are very closely related
HIV is complex, every patient differs
+References1. Nelms MN, Sucher K, Long S. Nutrition Therapy and Pathophysiology. Belmont,
CA: Thomson Wadsworth; 2007
2. Price SA, Wilson LM. Pathophysiology: Clinical Concepts of Disease Processes. St. Louis, MO: Mosby; 2003
3. Center for Disease Control and Prevention-HIV/AIDS. http://www.cdc.gov/hiv/. Updated August 21, 2009. Accessed November 21, 2009.
4. WHO and HIV/AIDS. http://www.who.int/hiv/en/. Updated December 2008. Accessed November 21, 2009.
5. Escott- Stump S. Nutrition Diagnosis- Related Care. 6th ed. Philidelphia, PA: Williams and Wilkins; 2008
6. Mahan LK, Escott-Stump S. Krause’s Food, Nutrition, and Diet Therapy. Philidelphia, PA: Saunders; 2004
7. Sahni S, Forrester JE, Tucker KL. Assessing Dietary Intake of Drug-Abusing Hispanic Adults with and without Human Immunodeficiency Virus Infection. J Am Diet Assoc. 2007;107(6):968-976.
8. Woods MN, Spiegelman D, Knox TA, Forrester JE, Connors JL, Skinner SC, Silva M, Kim JH, Gorbach SL. Nutrient Intake and Body Weight in a Large Cohort That Includes Women and Minorities. J Am Diet Assoc. 2002;102:203-211.
9. Gerrior J, Kantaros J, Coakley E, Albrecht M, Wanke C. The Fat Redistribution Syndrome in Patients Infected with HIV: Measurements of Body Shape Abnormalies. J Am Diet Assoc. 2001;101:1175-1180.
+References
10. Hoffman EW, Bergmann V, Armstrong J, Kendall P, Medieros LC, Hillers VN. Applications of a Five-Step Message Development Model for Food Safety Education Materials Targeting people with HIV/AIDS. J Am Diet Assoc. 2005;105:1597-1604.
11. 11. Pagana KD, Pagana TJ. Mosby’s Diagnostic and Laboratory Test Reference. 9th ed. St. Louis, MO: Mosby; 2009.
12. Pronzky ZM. Food Medication Interactions. 15th ed. Burchrunville, PA: Food Medication Interactions; 2009.
13. American Diabetes Association and American Dietetic Association. Exchange Lists for Meal Planning. 2008.
14. Sodium Content of Foods. www.nal.usda.gov/fnic/foodcomp/Data/SR17/wtrank/sr17a307.pdf. Accessed November 11, 2009.
15. Decker R, Mobley CC. Position of the American Dietetic Association: Oral Health and Nutrition. J Am Diet Assoc. 2007;107:1418-1428.