HIV Nutritional Considerations in 2014

Nelson Vergel, BsChE, MBA

Director

Program for Wellness Restoration (PoWeR)

Agenda Evolution of Nutritional Guidelines Food Considerations of ARVs Nutrition Complications in HIV Measuring Body Composition/Biochemical Assesment HIV Wasting HIV Lipodystrophy- Then and Now Insulin Resistance Nutritional Considerations for Optimal Body Composition and

Metabolism Micronutrients and HIV Interactions Between Medications and Micronutrients Exercise Considerations Questions and Answers

LGBTQ Policy Journal at the Harvard Kennedy School: 2011 EditionHIV and Aging: Emerging Issues in the HAART Era

HIV+ Aging Population in the United States (People over 50 years of age)

Evolution of Nutrition Guidelines in the U.S.1984 1992

2005 2011

What Americans Eat: Top 10 Sources of Calories

Grain-based desserts (cakes, cookies, donuts, pies, crisps, cobblers, and granola bars)

Yeast breads Chicken and chicken-mixed dishes Soda, energy drinks, and sports drinks Pizza Alcoholic beverages Pasta and pasta dishes Mexican mixed dishes Beef and beef-mixed dishes Dairy desserts

Source: Report of the 2010 Dietary Guidelines Advisory Committee

Food Considerations of ARVs

Food Considerations of ARVs

Food Considerations of ARVs

Nutrition Complications in HIVMalnutrition

Malabsorption Hypermetabolism Diminished intake

Dysphagia – mouth lesions Odynophagia – lesions to esophagus Dysgeusia (distortion of sense of taste) Diarrhea – intestinal dysfunction due to pathogen Anorexia – neuropsychiatric, endocrinologic, or gastrointestinal Early satiety and/or bloating Nausea and vomiting – side effect of medication Fever – opportunistic infections Fatigue – lean body mass depletion Apathy Depression Others: financial or time restrictions

Micronutrient deficiencies

McMahon Casey, Kathleen. (1997). Malnutrition Associated With HIV/AIDS. Part One: Definition and Scope, Epidemiology, and Pathophysiology. Journal of the Association of Nurses in AIDS Care, 8(3), 24-32.

Nutrition ComplicationsMalnutrition leads to:

Malabsorption Complications with treatment regimens Decreased immune function Organ dysfunction Micronutrient deficiencies Weight Loss – AIDS Wasting

A well-nourished HIV positive person with a

controlled viral load is more likely to be able to withstand the effects of HIV infection.

Measuring Body Composition

Anthroprometrics Tricep skinfold Midarm Circumference

Bioelectrical impedance analysis (BIA) Convenient, inexpensive, and non-invasive method for

evaluating body composition – body cell mass

Dual energy x-ray absorptiometry (DEXA) Measures subcutaneous and visceral fat stores

Abbaticola, Marcie M. (2000). A Team Approach to the Treatment of AIDS Wasting. Journal of the Association of Nurses in AIDS Care, 11(1), 45-56.Nelms, M., Sucher, K., Long, S. (2007). Nutrition Therapy and Pathophysiology. Belmont: Thomson Brooks/Cole.

DEXA

BONE

SCAN

Biochemical Assessment

Selected biochemical measures for HIV Immunologic

CD4 count Viral Load

Hematologic Hemoglobin Hematocrit Mean Corpuscular Volume Ferritin

Transferrin Albumin Prealbumin

(Transthyretin)

Biochemical Assessment

Organ Function AST ALT BUN Creatinine

Endocrine Glucose Insulin Glycosilated Hemoglobin A1C Testosterone Thyroid

Cardiovascular Total Cholesterol HDL LDL Triglycerides C-Reactive Protein

Electrolytes Sodium Potassium

Fields-Gardner, Cade, & Fergusson, Pamela. (2004). Position of the American Dietetic Association and Dietitians of Canada: Nutrition Intervention in the care of Persons with Human Immunodeficiency Virus Infection. Journal of The American Dietetic Association, 104(9), 1425-1441.

Measuring Body Composition

Anthroprometrics Tricep skinfold Midarm Circumference

Bioelectrical impedance analysis (BIA) Convenient, inexpensive, and non-invasive method for

evaluating body composition – body cell mass

Dual energy x-ray absorptiometry (DEXA) Measures subcutaneous and visceral fat stores

Abbaticola, Marcie M. (2000). A Team Approach to the Treatment of AIDS Wasting. Journal of the Association of Nurses in AIDS Care, 11(1), 45-56.Nelms, M., Sucher, K., Long, S. (2007). Nutrition Therapy and Pathophysiology. Belmont: Thomson Brooks/Cole.

Weight Loss – AIDS Wasting AIDS Wasting: “involuntary loss of greater than 10%

of baseline body weight, accompanied by either chronic diarrhea (at least two loose stools per day for greater than 30 days) or chronic weakness and fever for 30 days or longer In the absence of concurrent illness or conditions” – CDC 1987 Recommended revisions:

Time frames for weight loss Inclusion of body composition alterations Guidelines for determining competing diagnoses

Fields-Gardner, Cade, & Fergusson, Pamela. (2004). Position of the American Dietetic Association and Dietitians of Canada: Nutrition Intervention in the care of Persons with Human Immunodeficiency Virus Infection. Journal of The American Dietetic Association, 104(9), 1425-1441.

McMahon Casey, Kathleen. (1997). Malnutrition Associated With HIV/AIDS. Part One: Definition and Scope, Epidemiology, and Pathophysiology. Journal of the Association of Nurses in AIDS Care, 8(3), 24-32.

Weight Loss – AIDS Wasting

Caused by: HIV replication- depletion of lean body mass Infections (PCP, etc) Reduced food intake Malabsorption Abnormal nutrient utilization and metabolism Oxidative stress Hormonal abnormalities Psychosocial difficulties

Abbaticola, Marcie M. (2000). A Team Approach to the Treatment of AIDS Wasting. Journal of the Association of Nurses in AIDS Care, 11(1), 45-56.

AIDS Wasting

More important than weight loss is body composition alterations Decreased Body Cell Mass (BCM)– metabolically

active, cellular component of the body, which makes up lean body mass

A loss of body cell mass of 54% is likely to result in death in HIV-infected patients regardless of the presence or absence of infectious complications.

Fields-Gardner, Cade, & Fergusson, Pamela. (2004). Position of the American Dietetic Association and Dietitians of Canada: Nutrition Intervention in the care of Persons with Human Immunodeficiency Virus Infection. Journal of The American Dietetic Association, 104(9), 1425-1441.

Preventing/Reversing Wasting

Main goal: Get to undetectable viral load Nutrition Education Appetite Stimulants

Marinol Medicinal Marijuana Megace

Anabolic Hormones Testosterone Nandrolone Decanoate Oxandrolone Human Growth Hormone.

Resistance Exercise

HIV-Associated Lipodystrophy Lipodystrophy syndrome

Fat accumulation (hypertrophy): Abdomen Dorsocervical – “buffalo hump” Upper trunk and breast areas

Subcutaneous fat loss (lipoatrophy): Limbs Face Upper trunk Buttocks

Lipid abnormalities Increased LDL and triglycerides

Glucose abnormalities/Insulin resistance

Abbaticola, Marcie M. (2000). A Team Approach to the Treatment of AIDS Wasting. Journal of the Association of Nurses in AIDS Care, 11(1), 45-56.

Fat Compartments

DAD Study: Lipodystrophy Incidence 2000-2002 vs 2003-2006

2000-2002

2003-2006

Adult DHHS Guidelines (2014)-Lipodystrophy and Switching ARVs

“Lipohypertophy: Trunk fat increase observed with EFV-, PI-, and RAL-containing regimens; however, causal relationship has not been established.”

“Lipohypertrophy has been observed during ART, particularly during use of older PI-based regimens (e.g., indinavir), but whether ART directly causes increases in fat depots remains unclear. There is no clinical evidence that switching to any currently recommended first line regimen will reverse weight or visceral fat gain.”

Increased LDL or Triglycerides in HIV- ARV Effect

LDL Cholesterol/Triglycerides

Higher Risk

StavudineAZTDidanosineLopinavir/rAmprenavir/rDuranavir/rAtazanavir/rEfavirenz

Lower Risk

NevirapineTenofovirAbacavirLamivudineEmtricitabineEnfurvitideRaltegravirMaravirocEtravirineElvitegravirDolutegravir

DIET Study (Dietary Intervention: Effects on Tryglicerides in HIV Lipodystrophy)

Using food records that began from 6 to 24 months before development of fat deposition the following factors were identified.

When compared to people with HIV who developed fat deposition, patients without fat deposition had:

- greater overall energy intakes from their diet (p = 0.03)- greater intakes of total protein (p = 0.01)- more total dietary fiber (p = 0.01)- more soluble dietary fiber (p = 0.01)- insoluble dietary fiber (p = 0.03)- pectin (P = 0.02)

Those without fat deposition also were currently doing moreresistance training exercise and were less likely to be smoking (only borderline statistical significance (p = 0.05))

Hendricks at al, Am J Clin Nutr, 2003 Oct;78(4):790-5

Scandinavian Journal of Infectious Diseases, Vol. 38, No. 8, August 2006, pp. 682-689

Source: Goodfoodeating.com

Scandinavian Journal of Infectious Diseases, Vol. 38, No. 8, August 2006, pp. 682-689

Insulin Resistance in HIV

Possible Causes Of Insulin Resistance

HIV replication High simple and refined carbohydrate intake Some medications ( Protease Inhibitors,

Efavirenz, Anti-psychotics, etc) Family history/genetics Obesity/overweight Testosterone and/or thyroid hormone deficiency

Dietary Modification for Insulin Resistance

Consume moderate portion sizes. Eat balanced meals consisting of a complex starch

(brown rice, whole wheat bread), lean protein, fat and vegetable or fruit. Macronutrient combinations decrease glucose uptake.

Consume high fiber foods in the form of whole grains (multi-grain/whole wheat bread, wild-black rice, etc.) and vegetables to reduce the rate of glucose absorption from the gut into the blood stream.

Increase consumption of rich-colored vegetables and fruits for their protective vitamins, antioxidants, and phytochemicals.

Diet & Blood Glucose

Reduce consumption of simple sugars (sodas, sweets, etc.) and refined starches (white bread, pasta, and others made from white flour) to prevent blood glucose levels from rising too rapidly. High fiber lowers glucose uptake.

Consume mostly unsaturated fats like olive or canola oils and omega-3 fatty acids from cold water fish (tuna, sardines, salmon, and mackerel, for example).

Include lean protein from chicken, lean beef, fish, nuts, low-fat cottage cheese, beans, and whey protein shakes to help build and maintain lean body mass and manufacture antibodies to fight disease.

Limit alcohol consumption. Alcohol may interfere with the liver's ability to break down glucose.

Complementary Approaches For Improving Insulin Sensitivity

Weight Loss Regular resistance (weight-bearing) and cardiovascular

exercise. Testosterone and thyroid replacement if deficient. Adequate soluble fiber intake (30 grams per day or

more) Smoke cessation

Rollins C. Functional and meal replacement foods. In: Berardi R, Newton G, McDermott JH, et al, eds. Handbook of Nonprescription Drugs. 16th ed. Washington, DC: American Pharmacists Association;  2009:425-433.

J. Nutr. March 2008vol. 138 no. 3 439-442

Metabolic Effects of Dietary Fiber Consumption

N Engl J Med 2008; 359:229-241

N Engl J Med 2008; 359:229-241

Inflammatory Markers, Insulin and Glucose

Increase Protein in Your Diet Include beans and tofu (soy) Super fortify your milk- add several tbsp of dry milk

solids, skim milk plus has 11gm vs. 8 gm of protein Use lactose reducing labels if this is your main source of

protein Eat larger portions of meat, fish, poultry, eggs, milk,

yogurt, cheese, dried beans Choose deserts that contain eggs, milk, soy protein (ice

cream, pudding, or custard Add hard boiled eggs to tuna, diced meat to potato

salad, cooked seafood, vegetables, salads Add nonfat dry milk – casseroles, meatloaf, macaroni,

meatballs, mashed potatoes, hot cereals

Protein and CarbohydrateSupplementation in HIV

CD4 lymphocyte counts increased significantly with whey protein consumption. The increased intake of rapidly assimilable carbohydrate with the control supplement resulted in short-term increases in fasting triglycerides and waist-to-hip ratio—a surrogate for central adiposity. 

Am J Clin Nutr. November 2008. vol. 88 no. 5 1313-1321

Increase Protein- Cont.

Add peanut butter or soy nut butter Try cottage cheese- tofu, salads, vegetables, rice, pasta,

soups, casseroles, tacos, burritos, toast Prepare canned soups with milk, not water Add chopped meat , cheese, ham to scrambled eggs,

omelets, salads Top fruit salad with yogurt, cottage cheese NEVER EAT RAW EGGS-Caesar salad dressing, some

desserts If protein is a problem, try a predigested form of protein

called peptides (Petamen meal replacement supplements) Add grated cheese (nonfat has higher protein content)

Fat is not a Four Letter Word

Fats are needed for energy, immune function, vitamin absorption, and hormones

Good Fats- monounsaturated- Olive Oil Essential Fatty Acids- polyunsaturatedOmega 3’s- cold water fish (salmon)Omega 6’s- high oleic sunflower oil, nutsOmega 3’s and 6’s- Flaxseed oil

Bad Fats-processed/hydrogenated oils, margarine, artificial creamers, any man-made oil, burned oils, rancid oils, lard

The Healthiest Fat

Monounsaturated Fats Found in vegetable oils like olive oil, canola oil,

avocados, nuts, nut butters Not suspected of being immune suppressive Do not normally increase your cholesterol levels

like saturated fats, but they are sometimes modified when heated during processing. For this reason, many people look for olive oil that is “cold pressed”

Omega-3 Fatty Acids

Essential fatty acids: must be present in your diet. Found in most fish and seafood, as well as in flaxseed and some beans and peas.

Reduce risk of heart attack and to have a positive influence on cell-mediated immunity (the part of the immune system most damaged by HIV infection).

Study : Omega-3 fatty acids

Reduced triglyceride levels and if they had no new opportunistic illnesses during the study, it helped them gain weight.

Many people with HIV who wish to supplement their food intake of omega-3 fatty acids take omega-3 fish oil supplements (about 3 g daily).

Joint FAO/WHO Expert Consultation on the Risks and Benefits of Fish Consumption.

Seafood: The choice is yours

Good Carbohydrates Bad Carbohydrates

Provide energy and nutrients Bad carbs can worsen insulin resistance and

triglycerides Bad: Avoid/reduce high glycemic, high calorie

carbs – refined flour, especially milled grains, sugar, corn syrup

Good: Eat more fiber, nutrient, and fluid-rich, low calorie, low glycemic index carbs like vegetables, fruits, roots, greens, high fiber foods, etc

Sugar Content of Common Drinks

 U.S. Consumption of Caloric Sweeteners. Economic Research Service. 2013

Per Capita U.S. Consumption of Caloric Sweeteners

BMJ 2013;347:f6879

Dietary Fiber Intake and Risk of Cardiovascular Disease (non-HIV): systematic review and meta-analysis

HIV and Bone Density

Bone Disorders in HIV

Treatments for bone loss Resistance exercise, preventing wasting syndrome,

and avoiding tobacco Calcium (1000- 1500 mg/day) and Vitamin D (400-

1000 IU/day ). Get 20 minutes of sun daily Biophosphonates (Alendronate) Calcitonin (Intranasal and oral) Teriparatide Testosterone and/or thyroid replacement therapy

NNRTIs? Tenofovir?

Vitamin D and HIV

Parathyroid Hormone

Vitamin D TherapyDecreases Parathyroid Hormone (PTH) in Patients Taking Tenofovir Randomized trial of Vit D 50,000 IU/wk x 12 weeks vs. placebo in patients on (n=118) or not

on (n=85) TDF Higher baseline PTH levels at baseline in TDF group Vitamin D had no impact on PTH levels in patients not on TDF

TDF No TDF

Day 0 Change Day

0 Change

Vit D 47 -6 26 -2

PBO 37 +2 25 0

Changes in PTH on study

Havens P, et al. 18th CROI; Boston, MA; February 27-March 2, 2011. Abst. 80.

Mean Baseline PTH by Vitamin D status and Tenofovir Use PTH Differs by Tenofovir use, not Vitamin D status

52

35

43

27

P=0.001 P<0.001

Taking Vitamins

The most expensive may not be the best- look for USP government inspection

It is not Important for a vitamin to be "natural" instead of synthetic. Your body can't tell the difference.

No such thing as a special vitamin pill for HIV or AIDS. The FDA does not regulate supplement company. They

may do spot checks on ingredients if consumers report issues.

Nutrient Supplementation Specific micronutrient supplementation has shown

various results, and general multivitamin supplementation is recommended, while food should be considered the main source of nutritional needs. Double-blind, placebo-controlled trail in Thailand – 21

nutrient multivitamin (N=481) Significantly reduced risk of mortality in men and women

Observational study amount HIV-infected men in U.S. taking daily multivitamin supplement (N=296) 30% reduction in risk of progression to the diagnosis of

AIDS Significantly reduced risk for low CD4+ countsFields-Gardner, Cade, & Fergusson, Pamela. (2004). Position of the American Dietetic Association and Dietitians of

Canada: Nutrition Intervention in the care of Persons with Human Immunodeficiency Virus Infection. Journal of The American Dietetic Association, 104(9), 1425-1441.Fawzi, W., Msamanga, G., Spiegelman, D., Hunter, D. (2005). Studies of Vitamins and Minerals and HIV Transmission and Disease Progression. The Journal of Nutrition, 135, 938-944.

Taking Minerals with Integrase Inhibitors

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Certain Medications May Deplete Micronutrients

Exercise Several studies have shown aerobic exercise improves

quality of life for people with HIV. Studies have also suggested exercise has beneficial

effects on the immune system such as increasing CD4+ cells.

Exercising to the point of exhaustion, however, has been shown to be immune suppressive.

The biggest benefit of exercise for HIV+ people may be the building and retention of muscle mass and lowering lipids.

Exercise, including working out with weights, has been shown to improve muscle function and to build lean muscle mass in HIV+ people.

Any type of exercise also has the benefit of releasing stress, and may help increase your appetite.

Questions?

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