nutrition and hiv/aids peter wasserman, rd, ma metabolic support, infectious disease division,...

Nutrition and HIV/AIDSNutrition and HIV/AIDSPeter Wasserman, RD, MA Peter Wasserman, RD, MA

Metabolic Support, Infectious Disease Division, Department of Medicine, New York Hospital Queens, Metabolic Support, Infectious Disease Division, Department of Medicine, New York Hospital Queens, Flushing, NYFlushing, NY

Sorana Segal-Maurer, MDSorana Segal-Maurer, MDAttending Physician, Infectious Disease Division, Department of Medicine, New York Hospital Queens, Attending Physician, Infectious Disease Division, Department of Medicine, New York Hospital Queens,

Flushing, NY Flushing, NY Associate Professor of Clinical Medicine, Weill Medical College of Cornell University, New York, NYAssociate Professor of Clinical Medicine, Weill Medical College of Cornell University, New York, NY

David S. Rubin, MD David S. Rubin, MD Medical Director, AIDS Designated Center, Attending Physician, Infectious Disease Division, Medical Director, AIDS Designated Center, Attending Physician, Infectious Disease Division,

Department of Medicine, New York Hospital Queens, Flushing, NY Department of Medicine, New York Hospital Queens, Flushing, NY Clinical Assistant Professor of Medicine, Weill Medical College of Cornell University, New York, NYClinical Assistant Professor of Medicine, Weill Medical College of Cornell University, New York, NY

New York State Department of Health AIDS InstituteNew York State Department of Health AIDS Institute

New York State Department of Health AIDS Institute

2

The Implications of HIV on Nutrition

• In New York State over 35% of persons living with HIV infection are over 50 years old and 38% are between the ages of 40 and 49 years old. Seventy percent of persons living with HIV/AIDS are men and 57% of new cases occur in men who have sex with men.1 This demographic has broad implications for the nutritional care of persons with HIV infection.

• Wasting disease was the prominent nutritional issue in patient management prior to the advent of antiretroviral therapy (ART). Although wasting disease still occurs, HIV infection has become a chronic disease for most patients.

• Increasingly, newly diagnosed persons with HIV/AIDS live in urban poverty areas and experience food and housing insecurity, as well as limited access to fresh food stuffs.2,3


3

Key Point

Comorbidities including cardiovascular disease, osteopenia/osteoporosis, and sarcopenia are now predominant in HIV infection, have a significant dietary component, and are associated with aging.


4

Multicausation Model of Malnutrition


5

Manifestations of Malnutrition

Malnutrition may manifest as overnutrition, undernutrition, or single nutrient deficiency. It can occur in association with:– Food insecurity– Poor-quality, calorie-dense diet– Loss of perception of hunger or appetite– Malabsorption– Altered metabolism– Sedentary lifestyle


6

Food Insecurity

Recommendation: Advise patients of organizations in their area offering congregate meals, home meal delivery, and/or food pantries. (AIII)

• Food insecurity is defined as limited or uncertain availability of nutritionally adequate, safe foods or the inability to acquire personally acceptable foods in socially acceptable ways.4

• Food insecurity may exist with or without hunger and may contribute to wasting or obesity.5

• Association with obesity, while counterintuitive, is likely due to reliance on inexpensive calorie-dense convenience foods, fast food or take-out food, and sugar-sweetened beverage intake.6


7

Key Point

The United States Department Agriculture food security questionnaire (six-question short-form) may be used to assess household food security.7 The questionnaire is available at:

http://www.ers.usda.gov/Publications/err108/err108.pdf



8

Poor-Quality, Calorie-Dense Diet

Recommendation: Ascertain where patients shop for food and ingredients used in meal preparation and counsel as needed. (AIII)

• Dietary intake high in refined white flour, polished (white or yellow) rice, sugar, sugar-sweetened beverages, saturated and polyunsaturated fat, and salt is strongly associated with hyperlipidemia and insulin resistance in HIV-infected persons.8-10

• Patient diet is likely associated with the large interindividual variability in lipid response to specific antiretrovirals.8


9

Febrile response to opportunistic or secondary infection, oropharyngeal or esophageal lesions, depression, or substance use may lead to decreased food intake.

Appetite/Hunger Suppression


10

Key Point

Decreased food intake may be a direct result of disease processes, loss of structure in daily life, and/or how a patient feels about living with HIV infection.


11

Malabsorption

• Opportunistic or secondary infection, as well as neoplastic disease, of the bowel may lead to nutrient malabsorption.

• Patients with diarrheal disease or painful lesions of the alimentary track may reduce food intake to avoid urgent or painful bowel movements.


12

Key Point

Diarrheal disease should be viewed as undernutrition with fluid and electrolyte loss.


13

Altered Metabolism

• Metabolic abnormalities may alter nutrient utilization, storage, or excretion from the body.

• Abnormalities may be due to HIV infection itself or may be associated with specific antiretroviral medications.11-13


14

Metabolic abnormalities documented in association with HIV infection:

• Elevated resting energy expenditure/basal metabolic rate• Increased dietary protein requirement• Decreased total and HDL cholesterol • Increased serum triglycerides and VLDL cholesterol• Low free testosterone (bioactive fraction) in association

with wasting syndrome• Growth hormone resistance in association with wasting

syndrome• Decreased visceral/abdominal and subcutaneous

adipose tissue• Decreased bone mineral density


15

Metabolic abnormalities associated with some antiretroviral medications:

• Elevations in serum LDL cholesterol or triglycerides (some protease inhibitors)

• Renal excretion of phosphorus and/or glucose (tenofovir)

• Insulin resistance (protease inhibitor class effect)


16

Sedentary Lifestyle

Recommendation: Routinely counsel patients to engage in regularly scheduled resistance and aerobic exercise (AI).9,15

• Lack of routine scheduled resistance and aerobic exercise may lead to abdominal adiposity, sarcopenia, or diminished bone mineral density.

• Weight gain in middle age is associated with excess risk of type 2 diabetes mellitus and cardiovascular disease events.16


17

Centers for Disease Control and Prevention exercise recommendations for adults are:

• 150 minutes/week moderate intensity aerobic exercise and 2 sessions/week of resistance exercise working all major muscle groups

or

• 75 minutes/week vigorous aerobic exercise and 2 sessions /week resistance exercise

or

• Equivalent mix of moderate and vigorous aerobic exercise and 2 sessions/week resistance exercise


18

Key Point

Patients who are not obese or overweight should maintain a constant body weight throughout adulthood.


19

Referral for Nutritional Services


20

Recommendation: The following should prompt referral to a New York State certified nutritionist/registered dietitian for evaluation and patient-specific nutrition care plan (AIII)16:

• Entry into HIV care• Unintentional weight loss >10% over 4 to 6 months• Chronic nausea, diarrhea, or vomiting • Severely dysfunctional psychosocial situation• Hyperglycemia• Dyslipidemia• New diagnosis of diabetes, hypertension, or renal

disease• Two or more medical comorbidities• Annual or comprehensive visits• Abdominal adiposity


21

Key Point

Patients presenting with nutritional disorders may show involuntary weight loss, be over weight, and have increased dietary indiscretion.


22

Comprehensive Nutrition Consultation


23

Nutrition care consists of:

• Assessment and intervention (including education in nutrition and the disease state)

• Dietary counseling and self-management training

• Pharmacological intervention• Food support or tube feeding or

intravenous alimentation and routine follow up/reassessment


24

Recommendation: nutrition consultation should include the following (AIII):

• Patient complaints• Dietary evaluation• Demographics and clinical history• Clinical and anthropometric parameters• Functional tests as needed • Review of laboratory results• Review of medications focused on potential side effects • Social history including “supplement” use• Family history• Energy, protein, and micronutrient requirements• Intervention as needed with routine follow-up


25

Investigation of Patient Complaints

Recommendation: evaluate for (AIII):• Depression in patients complaining of “loss of appetite”

or hyperphagia• Recent weight loss and period of time over which it

occurred • Mistaken beliefs about nutrition, e.g., eating high fat

foods will replace subcutaneous fat loss due to prior antiretroviral regimens with adipocyte /mitochondrial toxicity

• Alimentary tract disease in those complaining of odynophagia or “diarrhea”

• Access to cooking and refrigeration facilities • Ability to shop for ingredients and prepare meals


26

Dietary Assessment

Recommendation: Evaluation of dietary intake should include who prepares meals, where and with whom they are consumed, meal frequency, meal completion, quality and source of ingredients, cooking method and portion sizes.


27

Nutritional Intake• Evaluate intake of concentrated protein (fish, poultry, meat, egg

white), vegetables, whole grains and tubers, fruit, and sugar-sweetened beverages including juices or “juicing.”

• Sugar-sweetened beverage intake should be discouraged due to linkage with diabetes, cardiovascular disease, diabetes and obesity.18

• Evaluate for patient use of processed/convenience foods especially prepared meats and canned goods due to their high sodium content.

• Portion size models, e.g., 3 oz size or ½ cup size, are helpful in ascertaining usual portion size during the clinical encounter.

• Use of fresh seasonal foods, locally grown when possible or frozen, and prepared at home should be strongly encouraged.


28

Key Points

• Food Stamp electronic benefits transfer (EBT) cards may be used at New York City farmers or “greenmarkets.”

• Dietary sodium intake is largely from hidden sodium added during food processing, restaurant, fast food, and takeout meals.

• Institute of Medicine (IOM) guidelines now

recommend that most adults limit sodium intake to 1500 mg per day.


29

Recommendations (AIII):

• NYC clinics should post the locations of greenmarkets participating in the Food Stamp (EBT) program in waiting rooms (available at grownyc.org).

• Adult patients should be referred to NYS certified nutritionist/registered dietitian for evaluation and education to achieve sodium intake reduction (to IOM recommendation).


30

Demographics and Clinical History

Recommendation: National Institutes for Health and World Health Organization assessment instruments should used to determine need for intervention and goals (AIII).


31

Demographics and Clinical History

• Nutritional interventions and their intensity should be based on assessment of potential benefit to the patient and the degree of disease event risk associated with the target abnormality. The patient’s willingness to execute dietary and other health behavior change is paramount.

• National Cholesterol Education Program Adult Treatment Panel III (NCEP/ATPIII) should be used in evaluation.

• WHO Fracture risk assessment tool (FRAX) should be used where clinically appropriate (men >50 y and postmenopausal women).

• Clinical history should including duration of HIV infection, nadir CD4 count, history of opportunistic infection, wasting, and antiretroviral treatment history.


32

Key Point: Osteoporosis

Patients age and ethnicity (e.g., FRAX) may drive absolute osteoporosis risk. Historically, osteoporosis has been more prevalent in older Caucasian women and less so in African Americans.


33

Clinical and Anthropometric Assessment

Patients with HIV infection may present with wasting (involuntary loss of lean body mass and adipose tissue), sarcopenia (age-related loss of skeletal muscle with preservation or increase in adipose tissue), or lipodystrophy (focal or global loss of subcutaneous adipose tissue with preservation of visceral adipose tissue and skeletal muscle).


34

Recommendation: evaluate for (AIII):• Body mass index (BMI), weight in kilograms/height in meters

squared (NIH guidelines: undernutrition, <18.5; normal, 18.5 to 29.9; obese, >30)

• % documented usual weight • Temporal wasting and facial lipoatrophy• Oral cavity for missing dentition, oral mucosal ulcers, (e.g.,

apthous or viral ulcers), malignancy (e.g., Kaposi’s sarcoma), fungal infections (e.g., oral candidiasis)

• Neck circumference• Increase may associate with upper trunk adiposity and/or sleep

apnea • Shoulders for angularity/prominent acromium process due to

deltoid muscle loss • Trunk for increased clavicle prominence (subclavicular muscle

loss)• Visible articulations of the ribs at the junction with the sternum

consistent with subcutaneous fat loss


35

Recommendation (continued): evaluate for (AIII):• Waist and hip circumferences

– ATP III: abdominal obesity, male >40 inches, female >35 inches– Loss of hip circumference reflects gluteal-femoral subcutaneous fat loss

and is associated with insulin resistance/type 2 diabetes mellitus. • Mid-upper arm circumference (non-dominant arm) • Less than 10th percentile NHANES may be consistent with wasting

or lipodystrophy. Delayed skin-fold return is suggestive of dehydration.

• Prominence of extremity vasculature consistent with subcutaneous fat loss

• Mass of the interosseus dorsalis muscle by having the patient press the tip of his forefinger and thumb together

• Muscle mass at the insertion of the quadriceps femoris and the vastus medialis with the patient’s leg positioned at a right angle.

• Lower extremity edema (sacral edema bed rest patients).• In profoundly wasted patients; peri-orbital edema, ascities, and

scrotal edema.


36

Additional Anthropomorphic Tests

• Bioelectrical impedance analysis (BIA) may be additive to physical examination. BIA indirectly measures tissue compartments, lean body mass (LBM), body cell mass (BCM), fat mass and extracellular (interstitial) mass (ECM). Phase-angle is a geometrical expression of the resistance and capacitance components of this assay.

• Phase angle <5.6º and <4.8º are associated with diminished and non-survival, respectively.19

• ECM-to-BCM ratio of 1.3 or greater associated with non-survival.19

• Serial BIA over time describes weight loss or gain over time by soft tissue compartment quantifying response to clinical intervention.


37

Key Point

Patients with skeletal muscle loss may not always demonstrate weight loss if concurrent compartmental shift occurs, e.g., expansion adipose tissue or extracellular fluid depots.


38

Functional Tests• There are concerns that long-term HIV infection may interfere

with the normal aging process and accelerate it. Increased rates of cellular senescence may lead to loss of functional reserve over time. Several methods are available to evaluate for this.

• Nutritional interventions such as protein, vitamin D, and calcium supplementation are first-line therapy for sarcopenia and osteopenia. Clinical investigators have documented decreased bone mineral density and increased non-traumatic fracture (fragility) risk in aging HIV-infected patients.20 Propensity to fall due to diminished hip, knee and ankle musculature often leads to fracture in older patients. Mid-life handgrip strength (Jamar Hand-grip dynamometer) and usual gait speed (timed walk) reflect total skeletal muscle and are predictive of future disability.21,22


39

Key Point

Muscle function in addition to body mass should be evaluated in middle-aged and older patients.


40

Laboratory Panels for Nutritional Aassessment

Recommendation: Nutritional assessment should include evaluation of the following laboratory panels (AIII).

• Complete metabolic panel

• Lipid panel

• Testosterone panel (men)

• 25-[OH] vitamin D

• Complete blood count


41

Recommendation: Evaluate complete blood count for findings consistent with vitamin and/or mineral deficiency. Clinicians should be mindful of the bone marrow suppressive effect of HIV infection itself and elevated ferritin, an acute phase reactant, during opportunistic or secondary infection.


42

Key Points• Patients with wasting and/or diarrheal disease may demonstrate

profound hypophosphatemia, hypokalemia, and low magnesium. Hospitalized patients should receive intravenous replacement, as needed.

• “Return to health effect” during the first two years of cART may manifest in elevation of total and LDL cholesterol in association with return to pre-illness diet. HDL cholesterol frequently remains low in spite of immune reconstitution with antiretroviral therapy.11

• HIV-infected men with wasting frequently demonstrate low free testosterone (hypogonadism). Repletion of skeletal muscle may be blunted in the absence of replacement therapy.23

• Low testosterone in older men in the general population has been linked to cardiovascular disease risk, sarcopenia, and insulin resistance.

• Vitamin D deficiency is prevalent in HIV-infected patients in care.24


43

Medication and “Supplement” Review

Recommendation: Nutrition consultation should include review of current medications, vitamins, and “supplements” (AIII).

Herbal products and some vitamins at high dosage may interact with antiretroviral medications, enhance viral replication or contain undeclared prescription ingredients or other chemicals.25 Patients may disclose usage of what they consider to be dietary enhancements to their nutritionist/registered dietitian while neglecting to disclose them to their doctor during medication review.


44

Key Point

Herbal products are nonstandardized pharmaceuticals that may interact with antiretroviral medications and/or lead to toxicity.


45

Social History

Recommendation: evaluate for the following (AIII):

• Tobacco use, alcohol use, other substance use

• Scheduled routine resistance and aerobic exercise program


46

Key Points

• Patients should be counseled to engage in scheduled resistance exercise (in addition to aerobic) to achieve optimal peak bone density, maintain skeletal muscle and lessen fall risk later in life.26

• Education regarding diet and behavior, and bone mineral density should be provided to patients.26


47

Centers for Disease Control and Prevention exercise recommendations for adults are:

• 150 minutes/week moderate intensity aerobic exercise and 2 sessions/week of resistance exercise working all major muscle groups

or

• 75 minutes/week vigorous aerobic exercise and 2 sessions /week resistance exercise

or

• Equivalent mix of moderate and vigorous aerobic exercise and 2 sessions/week resistance exercise


48

Family History

Recommendation: At least annually, update family history for cardiovascular disease, diabetes mellitus, end-stage kidney disease, and cancer(s) especially when occurring among first degree relatives (parents, siblings, offspring) (AIII).

Evolving health history of a patient’s siblings may inform evaluation of seemingly minor clinical findings.


49

Macronutrient Requirements: Caloric Requirement

Recommendations: • Maintenance energy requirement (protein and

non-protein calorie) should be calculated for persons who are hospitalized or in custodial care to insure provision of adequate nutrition (AIII).

• Maintenance energy requirement should considered in determining planned caloric deficit for person’s participating in programs of caloric restriction to achieve weight loss (AIII).


50

Caloric Requirement (continued)

• Total energy expenditure (TEE) consists of: basal metabolic rate (BMR) or measured resting energy expenditure (REE) by indirect calorimetry (after a 12h fast, in a thermoneutral environment, upon awakening and prior to ambulation), dietary thermogenesis (DT), the thermic effect of food intake and energy expenditure of voluntary activity (EEA). To maintain weight stability (maintenance energy requirement) a patient’s caloric intake should equal TEE.

• Weight Stability: TEE = REE + DT + EEA


51


The Harris-Benedict equation may be used to calculate REE in the absence of indirect calorimetry. Disease effect on REE may be estimated by an increase of 10 or 25%, HIV infection or AIDS, respectively, DT 10 or 20%, HIV or AIDS, respectively, and EEA 20-30% depending on level of activity.27 This may be expressed as a factor for calculation of maintenance energy requirement. Maintenance energy requirement may range from 1.4 to 1.75 times predicted BMR or measured REE.


52


Convalescent patients demonstrating wasting may require additional energy (approximately 20%) for anabolism. Emphasis should be on achieving this additional intake from food/additional meals. Nutrient dense ready-to-use supplementary foods may be of value where lesions or patient resources limit meal intake.


53

Key Point

Persons with HIV infection continue to demonstrate elevation of basal metabolic rate in spite of cART, immune restoration and viral suppression.28


54

Macronutrient Requirements: Protein Requirement

Recommendation: Higher dietary protein intake should also be considered for older patients and those demonstrating sarcopenia, frailty or wasting (AII).

Asymptomatic HIV-infected persons demonstrate a higher rate of amino acid oxidation, consistent with a predisposition toward muscle protein loss.29 Clinicians should be mindful of this in conjunction with the early initiation of cART. During AIDS wasting muscle protein synthesis represents a decreased fraction of whole body protein synthesis.29


55

Protein Requirement (continued)

High-nitrogen feeding (amino acids 1.5 to 1.8g/kg/body weight) significantly improves nitrogen balance in patients with wasting syndrome.30 Higher dietary protein intake should also be considered for older person’s demonstrating sarcopenia or frailty.31


56

Clinical Intervention: Mediterranean Diet

Recommendation: Persons with HIV-infection should be advised to follow and receive instruction in the Mediterranean diet (AI).

A Mediterranean diet has demonstrated efficacy in primary and secondary prevention trials for cardiovascular disease and type 2 diabetes mellitus among HIV-negative individuals.32-35 Persons’ with HIV infection receiving combination antiretroviral therapy demonstrated better metabolic parameters and lower risk for abdominal adiposity than those on a typical western diet.36-37


57

The Mediterranean diet is characterized by:

• High intake of dark green leafy and other vegetables • Fresh fruit as the typical daily desert • Use of whole grains for starches, beans, nuts, seeds, potato • Olive oil as the principal source of fat • Dairy products (principally cheese and yogurt) • Fish two or more times a week • Poultry consumed in moderate amounts• Egg yolks limited to four/week • Red meat consumed in low amounts• Wine consumed in low to moderate amounts, normally with meals • Low saturated fat (≤7-8% of energy), with total fat ranging from

<25% to >35% of energy throughout the region


58

Key Point

• Adherence to a Mediterranean diet may significantly reduce cardiovascular disease events and incidence of type 2 diabetes mellitus.36

• Attention should be given to identifying foodstuffs with which the patient is culturally familiar that may be part of a Mediterranean diet and are within their financial capability (e.g., collard greens, kale, and mustard greens).

• Evaluation of diet and intervention as needed should be considered prior to antiretroviral regimen change due to abnormalities of nutritional-metabolism, e.g., dyslipidemia.


59

Clinical Intervention: Multivitamin Supplementation

Recommendation: A daily multivitamin with minerals meeting the recommended daily allowances is prudent.


60

Key Point

Tolerable upper intake levels of micronutrients for people with HIV infection have not been established.


61

Clinical Intervention: Vitamin D and Calcium

Recommendation: Advise patients that adequate calcium intake and weight bearing (resistance) exercise are required along with vitamin D for maintenance of bone density (AIII).


62

Vitamin D and Calcium (continued)

• Vitamin D insufficiency and deficiency are defined by serum 25-[OH] vitamin D and vitamin D supplementation should be prescribed as needed.

• High intakes of animal protein and/or salt increase urinary calcium loss. Conversely low protein intake in older persons’ is associated with osteoporosis.38

• The new Institute of Medicine daily adult reference intakes (DRI) for vitamin D is 600 IU/d for adult men and women (800 IU after age 70) and Calcium 1000mg/d for men and women (1200 mg for women after age 51).39


63

Key Point

In addition to hypertension, high sodium intake may contribute to loss of bone mineral density.40


64

Clinical Intervention: Testosterone Replacement Therapy

• Topical testosterone preparations: Testim®, Androgel®, and Androderm™ may be used for replacement therapy in hypogonadal men.

• Male hypogonadism is also associated with osteoporosis and several cardiovascular disease risk factors (e.g., increased total cholesterol, low density lipoprotein cholesterol, and increased arterial wall thickness).


65

Key Point

Testosterone replacement therapy in men may improve nutritional parameters in soft and hard tissue, and lipid panel.26,41


66

Clinical Intervention: Orexigenic Agents

• Profound loss of hunger sensation may be medically managed with Megestrol acetate: Megace™ or Megace ES®.

• Megestrol acetate is a synthetic progesterone derivative and may lead to male hypogonadism, hyperglycemia and adrenal insufficiency. For these reasons treatment with megestrol acetate should be of short duration.

• Presentations associated with chronic mild nausea may be medically managed with Dronabinol; Marinol®. Dose-related euphoria and somnolence in patients receiving dronabinol have been documented.


67

Key Point

Differentiate between prolonged absence of hunger feelings and chronic mild nausea in patients complaining of “loss of appetite.”


68

Clinical Intervention: Supraphysiological Growth Hormone Administration

• Patients with clinically significant dietary intake who present with profound wasting disease may be candidates for treatment with recombinant human growth hormone, Serostim®.14

• Candidates for recombinant human growth hormone should be screened for impaired glucose tolerance and diabetes mellitus.


69

Key Point

Recombinant human growth hormone may be appropriate for ambulatory outpatients’ with profound skeletal muscle loss who are free of clinically active opportunistic or secondary infection, and who are able to achieve clinically significant dietary intake.


70

Clinical Intervention: Non-volitional Alimentation

Patients with panenteritis may be candidates for intravenous alimentation. Patients with neurological disease, oropharyngeal or esophageal lesions, partial small bowel disease, and those unable to achieve clinically significant volitional intake may be candidates for intragastric tube feeding.


71

Key Point

Intravenous alimentation may be considered for patients in whom clinically significant caloric intake can not be achieved due to impaired small intestine function or lack of access to the small bowel.42


72

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United States, 2008. MMWR Morb Mortal Wkly Rep 2010;59(37):1201-1207. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5937a2.htm

2. Normen L, Chan K, Braitstein P, et al. Food insecurity and hunger are prevalent among HIV-positive individuals in British Columbia, Canada. J Nutr 2005;135:820-825. [PubMed]

3. Denning P, DiNenno E. Communities in crisis: Is there a generalized HIV epidemic in impoverished urban areas of the United States? International Conference on AIDS, Vienna, Austria, July 2010. Poster available at: http://www.cdc.gov/hiv/topics/surveillance/resources/other/poverty.htm

4. United Nations Subcommittee on Nutrition: Nutrition and HIV/AIDS Statement by the Administrative Committee on Coordination, Sub-committee on Nutrition. 28th Session. Nairobi, Kenya; 2001.

5. Adams EJ, Grummer-Strawn L, Chavez G. Food insecurity is associated with increased risk of obesity in California women. J Nutr 2003;133;1070-1074. [PubMed]

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8. Hadigan C, Jeste S, Anderson EJ, et al. Modifiable dietary habits and their relation to metabolic abnormalities in men and women with human immunodeficiency virus infection and fat redistribution. Clin Infect Dis 2001;21:710-717. [PubMed]

9. Fitch KV, Anderson EJ, Hubbard JL, et al. Effects of a life style modification program in HIV-infected patients with the metabolic syndrome. AIDS 2006;20:1843-1850 [PubMed]

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http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5937a2.htm

http://www.ncbi.nlm.nih.gov/pubmed/15795441

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13. Bacchetti P, Gripshover B, Grunfeld C, et al. Fat distribution in men with HIV infection. From the Study of Fat Redistribution and Metabolic Change in HIV Infection (FRAM). J Acquir Immune Defic Syndr 2005;40:121-131. [PubMed]

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17. US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau. Nutrition and HIV/AIDS. Providing HIV/AIDS care in a changing environment – August 2004. HRSA Care Action. Rockville, MD: HIV/AIDS Bureau, HRSA.

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20. Arnsten JH, Freeman R, Howard AA, et al. Decreased bone mineral density and increased fracture risk in aging men with or at risk for HIV infection. AIDS 2007;21:617-623. [PubMed]











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23. Rietschel P, Corcoran C, Stanley T, et al. Prevalence of hypogonadism among men with weight loss related to human immunodeficiency virus infection who were receiving highly active antiretroviral therapy. Clin Infect Dis 2000;3:1240-1244. [PubMed]

24. Wasserman P. Rubin DS. Highly prevalent vitamin D deficiency and insufficiency in an urban cohort of HIV-infected men under care. AIDS Patient Care STDS 2010;24:223-227. [PubMed]

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26. Rao SS, Budhwar N, Ashfaque A. Osteoporosis in men. Am Fam Physician 2010;82:503-508 [PubMed]

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29. Yarasheski K, Zachweija J, Gischler J, et al. Increased plasma Gln and Leu Ra and inappropriately low muscle protein synthesis rate in AIDS wasting. Am J Physiol 1998;275(4 Pt 1):E577-E583. [PubMed]

30. Selberg O, Suttmann U, Melzer A, et al. Effect of increased protein intake and nutritional status on whole-body protein metabolism in AIDS patients with weight loss. Metabolism 1995;44:1159-1165. [PubMed]






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32. de Longeril M, Salen P, Martin JL, et al. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation. 1999;99:779-785. [PubMed]

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Consultation on Human Vitamin and Mineral Requirement. Vitamin and Mineral Requirements in Human Nutrition, 2nd ed. 2004. Available at: http://whqlibdoc.who.int/publications/2004/9241546123.pdf

39. Ross CA, Manson JE, Abrams SA, et al. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: What clinicians need to know. J Clin Endocrinol Metab 2011;96:53-58. [PubMed]

40. Lin PH, Ginty F, Appel LJ, et al. The DASH diet and sodium reduction improve markers of bone turnover and calcium metabolism in adults. J Nutr 2003;133:3130-3136. [PubMed]

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Further Reading• Morley JE, Argiles JM, Evans WJ, et al. Nutritional recommendations for the management of sarcopenia. J Am

Med Dir Assoc 2010;11:391-396. [PubMed]

• Mallon PWG. HIV and bone mineral density. Curr Opin Infect Dis 2010;23:1-8. [PubMed]

nutrition and hiv/aids peter wasserman, rd, ma metabolic support, infectious disease division,...

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