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HIV Nutrition& Health Benefits

Jenn Messina, RDHIV/AIDS Program

St. Paul’s Hospital, Vancouver February 7th, 2013

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Outline

Personal intro

HIV Globally

Nutritional issues in HIV

Asymptomatic & symptomatic infection

Provincial health benefits

Questions

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Personal Introduction

UBC Integrated Internship Graduated UBC in 2007 Currently working in the

Immunodeficiency Clinic, St. Paul’s Hospital, Outpatient Clinic

B.C. Centre for Excellence in HIV/AIDS Care

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HIV Global Statistics The number of people living with HIV

(including AIDS) continues to rise 34 million people were living with HIV/AIDS

worldwide at the end of 2011 In Canada it is prevalence of HIV has risen

from an estimated 64,000 in 2008 to 71,300 in 2011 (an 11.4% increase)

It is estimated that between 2,250- 4100 new HIV infections occur in Canada each year

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Nutritional Issues Malnutrition and wasting Loss of appetite Gastrointestinal complications Side effect of medications Metabolic abnormalities Mental health Disordered eating Substance use Socioeconomic factors- food insecurity Special needs groups: pregnancy, children,

adolescents

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HIV Nutrition Assessment Anthropometrics:

Height, weight, BMI, weight history Biochemical: immune status, lipid profile, fasting

blood sugar, renal status, nutritional labs, bone density (if available)

Clinical: Patient medical history, medications, social history

Diet history: Intake of key nutrients e.g. energy, protein, fat, fibre,

calcium, vitamin D Knowledge, beliefs Allergies, intolerances Supplement intake Physical activity Food security Food/support resources

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Symptomatic & Asymptomatic HIV Infection

Symptomatic HIV infection: Fever Opportunistic infections, e.g. Pneumocyctis iirovecii

pneumonia, (PCP), cytomegalovirus (CMV), and Mycobacterium avium (MAC), have nutrition implications

Oral thrush Weight loss

Usually CD4+ T helper cells <200

Asymptomatic infection: a phase of chronic infection which the person does not display symptomsUsually CD4+T helper cells >200

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Symptomatic HIV Infection

HIV Associated Weight Loss

Inadequate nutrient intake Oral and upper GI symptoms Anorexia Psychosocial Malabsorption

Altered metabolism Uncontrolled HIV infection AIDS defining illnesses

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HIV Wasting Syndrome

HIV Wasting: Infection induced cachexia characterized by inappropriate catabolism of skeletal or other lean proteins

Centre for Disease Control definition: Involuntary weight loss >10% (of

baseline body weight) associated with either chronic diarrhea (two or more loose stools per day for ≥1 month) or chronic weakness and documented

fever for ≥1 month

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Symptomatic HIV InfectionCaloric recommendations: 20-30% higher than non-infected person with

same age, sex, physical activity to maintain weight

Affected by age, activity level, HIV status, nutritional status, infection, comorbidities, etc.

Initiation of anti-retroviral therapy may also increase energy needs as the individual transitions to a anabolic state

Metabolic cart is the gold standard

Protein recommendations: 1.5- 2g protein/kg/day Needs to be individualized

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Symptomatic HIV: Recommendations

HIV control and treat concurrent infections Addressing psychosocial factors, depression Diet counseling:

Symptom management of GI side effects High calorie, high protein diet Homemade/commercial nutrition supplements Nutrition support (tube feeding) in hospital may be

needed Address food security, community resources, funding,

connect with RD as needed if in hospital

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Asymptomatic Infection

Caloric recommendations: 10% higher than non-infected person with

same age, sex, physical activity to maintain weight Affected by age, activity level, HIV status,

nutritional status, infection, comorbidities, etc.

Protein recommendations 1.0- 1.2g protein/kg/day when stable Needs to be individualized

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Asymptomatic recommendations Nutrient rich,

balanced diet

Individual energy, protein, micronutrient needs

Food and Water safety

Encourage exercise

Ensure food security

Address any nutritional issues identified

Consider social factors affecting healthy eating

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Metabolic Complications of HIV

Dyslipidemia

Insulin resistance

Reduced bone density

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Dyslipidemia and Insulin Resistance

Therapeutic lifestyle and diet are the first line strategy

Traditional approaches to treat dyslipidemia and hyperglycemia should be initiated

Dietitian counselling works best if it is regular and sustained

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Bone Health: Screening, Prevention & Treatment

HIV positive people at higher risk for osteopenia and osteoporosis, cause is multifactoral

Assess Determine if risk further increased

with traditional risk factors i.e. menopause, underweight/obese, medications, diet

Prevention Adequate calcium and vitamin D

depends on age Maintain healthy body weight

Nutrient treatment 1000-1200 mg calcium 1000 IU vitamin D (?more)

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Ministry of Social Development (MSD)

Provincial Nutrition Programs

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Types of Health Supplements Diet Supplement (also known as ‘Diet Allowance’)

Short Term Nutritional Supplement Monthly Nutritional Supplement Other Health Supplements

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Diet Supplements

Diet supplements assist clients to meet costs associated with an unusually expensive therapeutic diet that is required as a result of a specific medical condition or a special dietary need.

A diet supplement may provided for a maximum of 12 months for acute (short-term) conditions and 24 months for chronic (ongoing, recurring, long-term) conditions

Eligibility: For those on MSD income assistance & disability assistance

http://www.eia.gov.bc.ca/mhr/hsp.htm

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Diet SupplementsMonthly Allowance:

$10: Restricted sodium diet $35: Diabetes $30: Kidney dialysis $40: High protein diet (plus $30 towards the purchase

of a blender) $40: Gluten-free diet $40: Dysphagia (plus $30 towards the purchase of a

blender) $40: Ketogenic diet $40: Phenylalanine diet $50: Cystic fibrosis

Note: If client has multiple medical conditions- highest amount ‘trumps’ and only 1 diet

supplement will be given

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Diet SupplementsFunding for high-protein diets is available for

individuals who need additional nutritional support and have been diagnosed with:

Cancer (requiring nutritional support during radiation, chemotherapy, surgical cancer therapy)

Chronic inflammatory bowel disease Crohn's disease Ulcerative colitis HIV/AIDS, chronic bacterial infection and tuberculosis Hyperthyroidism Osteoporosis Hepatitis B or hepatitis C.

http://www.gov.bc.ca/meia/online_resource/health_supplements_and_programs/dietsupp/policy.html

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Diet Supplements

To be eligible for a diet supplement, recipients must provide written confirmation of the need for the diet supplement from a medical practitioner, nurse practitioner or from a dietitian who is registered with the College of Dietitians of British Columbia

Diet allowance form available through MSD

Letter can also be done and include: the specific medical condition the diet required expected duration of need

http://www.gov.bc.ca/meia/online_resource/health_supplements_and_programs/dietsupp/faqs.html

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Diet SupplementsHIV/AIDS ProgramSt. Pauls Hospital 1081 Burrard StreetVancouver, B.C.

To Whom It May Concern at the Ministry of Social Development:

Re: Jane SmithDOB: 1/1/1951

My client is HIV positive and requires a high protein diet to help improve nutritional status. Please provide the $40 High Protein Diet Supplement and the initial $30 for purchase of a blender. She will need this diet supplement for 2 years, the maximum allowable time for a chronic condition as she will require this diet as long as she is living.

Sincerely,

Jenn Messina, CDBC #1046Clinical Dietitian604-682-2344 ext 62641

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Short-term Nutrition Supplement Nutritional supplements may be for those

who need additional calories above a regular diet to recover from surgery, severe injury, serious disease, or the side effects of medical treatment

Eligibility: for those on MSD income assistance & disability assistance

http://www.gov.bc.ca/meia/online_resource/health_supplements_and_programs/nutsupp/

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Short-term Nutrition Supplement To be eligible for a nutritional supplement, recipients must

provide written confirmation of the need from a medical practitioner or nurse practitioner

Include: The diagnosis The reason the product is required The name of the product required, the amount of product

required and the expected duration of need (up to a maximum of 3 months)

Letter must confirm acute, short-term need to prevent critical weight loss

For those on MSD income assistance & disability assistance, but NOT getting Monthly Nutritional Supplement (MNS)

http://www.healthlinkbc.ca/healthyeating/bc-nutrition-programs.html

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Short-term Nutrition Supplement

To whom it may concern at the Ministry of Social Development, Re: John SmithDate of birth: 1/1/1951

I am writing as the dietitian for the Immunodeficiency Clinic where John Smith attends for his medical care. John is being followed by the dietitian due to malnutrition and weight loss due to his advanced lung cancer with bone metastasis. This person is also HIV positive and on anti-retroviral therapy for immune reconstitution and viral suppression. John has lost 7.6kg over the past few months, 12% of total body weight, and has visible muscle wasting. His BMI is low at 18.2. Weight loss occurred during his radiation therapy for his cancer and he has had ongoing poor appetite, nausea and weight loss after this therapy has been completed. He is at ongoing high nutrition risk due to upcoming chemotherapy cancer treatment.

He urgently requires 3 bottles of Ensure Plus daily for 3 months to optimize his oral intake, prevent further weight loss, malnutrition, and muscle wasting. Malnutrition and unintentional weight loss increase the risk of morbidity and mortality in HIV positive people.

Please call me with any questions or concerns. Thank you.

Jenn Messina, Clinical Dietitian Dr. Sarah StoneCDBC #1046

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Monthly Nutritional Supplement

The Monthly Nutritional Supplement is monetary allowance to financially assist those who have a severe medical condition causing a chronic, progressive deterioration of health with symptoms of wasting. This supplement is intended to prevent imminent danger to the person’s life by providing essential, specified items to supplement regular nutritional needs

Eligibility: for those on MSD Disability Assistance ONLY

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Monthly Nutritional SupplementWritten confirmation by the recipient’s medical practitioner or

nurse practitioner is needed to confirm:

1) the person has a severe medical condition causing a chronic, progressive deterioration of health

2) as a result of this deterioration of health, the person displays two or more of the following symptoms:

malnutrition underweight status significant weight loss significant muscle mass loss significant neurological degeneration significant deterioration of a vital organ moderate to severe immune suppression

http://www.gov.bc.ca/meia/online_resource/health_supplements_and_programs/mns/policy.html

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Monthly Nutritional Supplement3) to alleviate these symptoms, the person

requires one or both of the following items:

additional nutritional items that are part of a caloric supplementation to a regular dietary intake

vitamins and minerals

4) failure to obtain these items will result in imminent danger to the person’s life

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Monthly Nutritional SupplementHow to Apply: Client needs to pick up “Monthly

Nutritional Supplement Application form” from MSD

MSD needs to complete part A Client needs to sign part B RD/MD/NP completes part C

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Monthly Nutritional SupplementTips and tricks for a successful form Make sure to discuss the form first with

the persons MD/NP, they take a lot of time!

Be specific for vitamins and minerals Leave the ‘duration of need’ open ended

if you aren’t sure the time frame they may need items for

Don’t ‘overpromise’

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Monthly Nutritional Supplement

Tips and tricks for a successful form

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Other Supplements Tube feed supplement: provides liquid

nutritional tube feed, equipment and supplies to those who are unable to take food orally or process it through GT tractEligibility: on MSD income assistance or disabilityhttp://www.gov.bc.ca/meia/online_resource/health_supplements_and_programs/tubesupp/policy.html

Department of Veteran's Affairs (DVA): May cover tube feed supplements/supplies depending on coverage1-866-522-2122 (English) or http://www.veterans.gc.ca/eng

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First Nations

Some bands will cover a short-term supply of Ensure/Boost Individual bands vary with coverage, speak with health

department of band department

For Status First Nations: Tube feed formula /supplies and liquid supplements for

some patients. MD to write a prescription and fax to pharmacy. Local pharmacy will then fax ‘letter of exception’ for Non-insured health benefits (NIHB) program to MD to complete.

For further information call NIHB at 1-800-317-7878http://www.hc-sc.gc.ca/fniah-spnia/pubs/nihb-ssna/yhb-vss/index-eng.php

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Resources CATIE: www.catie.ca Position Statement ADA HIV Nutrition The Body: www.thebody.ca Ministry of Social Development:

http://www.gov.bc.ca/hsd/ AIDS Vancouver: www.aidsvancouver.org Positive Living BC: www.positivelivingbc.org DIAC (Dietitian’s in AIDS Care) Practice

Group

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Good Articles/Resources B.C. Centre of Excellence in HIV/AIDS. (1997). The therapeutic guidelines for the

treatment of HIV/AIDS and related conditions: Section 9: Therapeutic nutrition guidelines. Vancouver, B.C.

Food and Nutrition Technical Assistance Project. (2004). HIV/AIDS: A guide for nutritional care and support, 2nd Edition. Academy for Educational Development, Washington, DC.

Gerrior, J. & Neff, L. (2005). Nutrition assessment in HIV infection. Nutrition in Critical Care, 8 (1), 6-15.

Holick, M.F. et al (2011). Evaluation, treatment and prevention of Vitamin D deficiency: an Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology Metabolism, 96,7, 1911-1930.

Mangili, A., Murman, D., Zampini, M, and Wanke, C. (2006). Nutrition and HIV infection: review of weight loss and wasting in the era of Highly Active Antiretroviral Therapy from the Nutrition for Healthy Living Cohort. Clinical Infectious Diseases, 42, 836-842.

McComsey, G.A. et al (2010). Bone disease in HIV infection: A practical review and recommendations for HIV Care Providers. Clinical Infectious Diseases, 51, 8, 000-000.

Pribram, V. (2001). Nutrition and HIV. Oxford, U.K: Blackwell Publishing. Ockenga, J. et al. (2006). ESPEN guidelines on enteral nutrition: wasting in HIV and

other chronic diseases. Clinical Nutrition, 25, 319-329. World Health Organization. (2003). Nutrient requirements for people living with

HIV/AIDS: Report of a technical consultation. Geneva, Switzerland.

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Acknowledgements

Cheryl Collier, HIV RD at Oaktree Clinic

Alena Barron, HIV RD at St. Paul’s 10C

Clients of 10C, IDC, and Providence Crosstown Clinic

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Questions?

Contact: jmessina@providencehealth.bc.ca