Few crises have affected human health

Few crises have affected human health and threatened national, social and economic progress in quite the way that HIV/AIDS has. The pandemic has had a devastating impact on household food security and nutrition through its effects on the availability, stability and access to food and its use for good nutrition.

Meeting immediate food, nutrition and other basic needs is essential if HIV/AIDS-affected households are to live with dignity and security. Providing nutritional care and support for people living with HIV/AIDS is an important part of caring at all stages of the disease. This manual provides home care agents and local service providers with practical recommendations for a healthy and well balanced diet for people living with HIV/AIDS. It deals with common complications that people living with HIV/AIDS are experiencing at different stages of infection and helps provide local solutions that emphasize using local food resources and home-based care and support.

For persons living with HIV/AIDS,

For persons living with HIV/AIDS, practicing sound nutrition can play a key role in preventing malnutrition and wasting syndrome, which can weaken an already compromised immune system. Immuno-compromised persons with poor nutrition have an increased susceptibility to opportunistic infections and a more rapid disease progression. Optimal nutritional practices can potentially slow progression of the disease and in addition, control the costs of health care.

Staff from the CDC National AIDS Clearinghouse (CDC NAC) have developed "Locating Basic Resources on HIV/AIDS and Nutrition" to assist individuals in finding information on HIV/AIDS and nutrition. It includes references to national organizations working in nutrition, listings of newsletters, World Wide Web sites, and descriptions of selected educational materials and journal articles. Resources in this guide will direct you to information on these topics:

• Food safety for persons with HIV/AIDS
• Malnutrition, weight loss, and wasting syndrome
• Suggested recipes
• Vitamins and dietary supplements

For more information, or a customized search of any of the databases, contact the CDC National AIDS Clearinghouse at 1-800-458-5231.

Nutrition and HIV

Nutrition and HIV

In her presentation entitled "Building Health and Healing with HIV/AIDS," Jan Zimmerman provided practical advice about food and supplement choices. These choices are just one part of healthy living, however. Ms. Zimmerman views emotional and spiritual health as the foundation for health and healing. You can use support groups, conversations with friends, meditation, or church, among other resources, to support your emotional and spiritual health, but your emotional health must be well established before you undertake healing nutrition and exercise. The final component of health and healing, especially in HIV disease, is medication and side effect management. These three elements of health and healing must be practiced daily.

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HIV nutrition specialists can help you do more than just gain or lose weight. They can provide guidance on both HIV-related and medication-related ailments, including appetite loss, bloating/gas, diarrhea, kidney disease, lipodystrophy, and wasting. Some of these conditions can be treated without pharmaceutical interventions.

Ms. Zimmerman explained the general principles of Nutritional Healing in HIV/AIDS upon which she bases her practice:

1. Maintain normal body weight.
   • Be aware of the caloric intake you need to achieve and maintain a normal weight.
2. Build muscles/maintain lean body mass (avoid wasting).
   • Use strength training and, if necessary, steroids or hormones to build/maintain muscle mass.
3. Optimize digestion.
   • The digestive tract is your center of health -- simple steps like chewing your food carefully can make its job much easier!
   • Eating 4-6 small meals is more efficient than eating 1-3 large meals.
4. Eat more "healing foods," fewer processed foods.
5. Drink 6-10 cups of non-caffeinated fluids daily.
6. Use supplements rationally and consistently.
7. Address social and emotional isolation, as these factors can negatively influence your food choices.

Is consuming great quantities at one time wrong?

Is consuming great quantities at one time wrong?

Occasional splurges happen, but they should be the rare exception, not the rule. No one benefits from consuming such huge quantities. Carbonated and juice drinks that are served in large-sized containers are examples of profitable marketing and not healthful food options. If you are so thirsty that you need to drink a lot, drink water.

Are exaggerated marketing promotions harmful? As a professional dietitian and health advocate, I say yes. Weight gain and obesity in the U.S. has increased dramatically in both children and adults. Obesity is associated with the promotion of insulin resistance and diabetes, hypertension, cardiovascular diseases, cancer and other chronic and life-threatening conditions. Now these nutritional concerns are increasingly facing many people with HIV.

Maintaining control over ingredients and portion sizes is easier when food is prepared and eaten at home. Children and adults are increasingly eating alone and eating outside the home. Such indiscriminate eating can add up to excessive calorie and fat intake. Take steps to establish meal times for your family, whatever your family structure.

Nutrition studies have shown that overweight people tend to under-report what they are eating and underweight folks tend to over-report. Even though individuals' self-reporting on dietary intakes may not be one hundred percent accurate, just writing down everything you eat and drink over one day is an important step in increasing your awareness to help you make changes. Being aware of what you are eating is a necessary step to improving dietary intake and behaviors.

Individuals can envision the amounts they serve themselves, and they become familiar with how to quantify them. How much meat, bread, mayonnaise, and lettuce is on that sandwich?

By using plastic models of foods and samples of various sized cans, drinking glasses, and containers, individuals get a clear idea of what standard serving sizes look like and ultimately a reality check as to what they think they are eating.

The unavailabilty of small portions is a public health disservice. Getting a larger amount of drink or food for just a few pennies more may seem like a real deal and good value for your money. The opposite is more often the truth. These greater amounts actually contribute to damaging your health. If you are extremely thirsty, quench it to your heart's content with safe drinking water. Don't drink excessive amounts of fruit juice or sodas. Don't be lured into going back for free refills of soda. Soda should be seen a treat to enjoy once in a while, not something to have with every meal.

Nutrition & HIV: Sizing Up Serving Sizes

Does Size Matter?

Yes. The terms "small," "medium," and "large" mean different things to different people, and there are no standard definitions.

Not so long ago, a small drink meant six ounces, medium was eight ounces, large was twelve ounces and extra large was sixteen ounces. Now, in too many settings, small, medium, large, and extra large can mean more than twice these amounts.

Does this mean that these new sizes are the right amounts to consume? No. It just means that is the amount being sold.

A "glass" or "cup" can mean four ounces, twelve ounces, or even as much as forty-four ounces. A bowl of cereal can be as little as a half-cup dessert bowl or as much as a small mixing bowl.

You want to make sure your food and drink intake provides adequate calories, protein, vitamins and minerals, fiber, fluid, and other important substances. Meeting your nutritional needs is necessary to maintain weight and lean body mass, and to avoid nutrient deficiencies.

What you eat and the amount you eat matters, especially when you have trouble maintaining weight or you need to gain or lose weight. If you are running high blood sugar levels or if you are running abnormal blood lipids, that also makes a big difference.

Where can our readers get more information?

Where can our readers get more information?

Francis: We have a booklet, Food for People Living with HIV, which is applicable everywhere in the world. It has recipes, it has a vitamin and mineral chart, it gives the kinds of herbs and spices that can be used as therapies -- what's cooling, what's heating, remedies that can be used to treat sores.

What vitamin and mineral supplements do you include?

Francis: We call it ZACES; that's an acronym that we developed to help people remember the vitamins and minerals. It's zinc, vitamin A, vitamin C, vitamin E, and selenium. We call this the infection fighting, immune boosting combination. We recommend that all our patients take supplements of these. Even an adequate food intake is not enough to deal with the level of immune suppression that happens in HIV disease. We give them diet sheets, and recommend that the supplements be taken in a balance.

For the vitamin A, could they use beta-carotene instead? I am reluctant to suggest vitamin A, because people might take too much.

Francis: We have a problem getting beta-carotene, because it is very expensive for us. So we recommend that they take vitamin A. It really works -- especially when it is supplemented with 20 mg of zinc daily, which is very cheap for us to get.

is the mission of your organization (The Centre, in Harare, Zimbabwe)?

Francis: Our mission, basically, is to teach long-term survival techniques to people living with the virus, based on nutrition and a holistic approach.

I urge people to look more to nutrition as an adjunct to therapy, or as an alternative to therapy. It's amazing the resuscitation that we see -- people who come in and they are terminally ill, and you put them onto an adequate nutrition regime and give them vitamin supplements, and it's like Lazarus, it's like the way people describe what happened with the antiretrovirals. We have seen people recover completely just from getting their nutrition intake adequate, and getting help on coming to terms with and managing their disease.

The proteins you take in should be as much as possible beans

The proteins you take in should be as much as possible beans, lentils, peas, nuts, soya proteins, plus chicken and fish. Pork should be avoided, and fatty beef products should be avoided.

As far as possible avoid foods that have additives, like coloring, flavoring, or preservatives. And eat foods which are fresh and preferably indigenous, grown where you live. It's a rule of thumb that if it grows locally, it's going to be good for you and it's going to be appropriate because it will grow at the right season.

Clean water of course is an absolute must; so if you don't have access to clean water, it's vital that you properly filter, purify, or boil.

We recommend a low-fat diet. One of the big exceptions to that is yogurt. Yogurt is like a magic food, as is garlic. Yogurt helps to control thrush. Sugar feeds thrush, so we advise people to cut sugar out of their diet as much as possible.

Garlic is a natural antibiotic and antiviral. It is also extremely good for thrush. And you can use it for vaginal as well as for oral thrush.

We recommend that food be prepared freshly if possible, and that much of the vegetable and fruit intake be raw -- salads and raw fruit and vegetables, which maintains all the vitamin and mineral content. At least 30% of your intake of food daily should be vegetables and fruits. Fifty percent should be whole grains. Fifteen percent should be proteins. And then 5% is the cherry on the cake -- it's whatever else you want, avocados, cheese and eggs -- with a proviso that when you have diarrhea, you should avoid dairy products, and avoid all fat.

AIDS Treatment News: What are some of the most

AIDS Treatment News: What are some of the most important lessons you have learned about nutrition and HIV treatment, both for Africa and elsewhere?

Lynde Francis: In the developing world, nutrition is often the only form of therapy available. We have learned that with correct nutrition, which includes vitamin supplementation and a holistic approach to HIV, you can maintain health almost indefinitely if you start early enough. And if you start when someone is already ill, nutrition together with treatment of opportunistic infections can put them back on their feet and back in employment.

Also, when people are on pharmaceutical treatment, nutrition supports them; you can use nutrition as a way of avoiding side effects, and reconstituting the immune system together with the drugs.

ATN: What approaches to nutrition do you recommend?

Francis: The rule of thumb is unrefined, unprocessed foods, low fat, no sugar, and avoiding stimulants like caffeine. By unrefined food I mean, if you eat bread, it should by whole wheat bread; if you eat rice, it should be unpolished, brown rice. If your staple is maise meal, as it is in many parts of Africa, it should be stone ground maise meal. It could include other grains like rye, like wheat used as a rice which is delicious; it could include sorghum, which is the traditional grain which was used throughout Africa before maise came in.

What can we do to help prevent wasting?

What can we do to help prevent wasting? Aside from visiting your doctor regularly, nutritionally you can do a number of things. First, you can eat a variety of foods. Use the food guide pyramid to make sure you are getting enough vitamins and minerals, calories, and protein daily, which recommends the following:

• Breads and cereal group: 6 to 11 servings
• Meat, poultry, fish, egg, or alternative: 2 to 3 servings
• Fruits and vegetables: 3 to 5 servings each
• Milk/Dairy: 2 to 4 servings
• Fats, sweets, and oils: sparingly

If you need to gain weight, or to keep from losing weight, eat the higher number of servings for extra calories.

Art by Russell McGonagle

Because women are more susceptible to osteoporosis, it is essential we get enough calcium. Calcium is a mineral responsible for bone health. Lack of adequate calcium can lead to loss of bone mass and tissue. Calcium is found in dairy foods, and can also be found in calcium-enriched juices and cereals, sardine (with bones), salmon (with bones), collard greens, broccoli, and turnip greens. Women need 1000 mg daily of calcium, 1200 mg for pregnant women and the elderly (51+years). This is equal to 3 cups of milk or calcium-fortified orange juice.

When cooking, preparing, and/or handling foods, your primary goal should be to avoid food infection. It is critical that hands are washed with hot soapy water before and after handling any type of food, whether you are cooking or eating. Keep foods at a safe temperature -- cold foods should be cold, and hot foods hot. Food left at a temperature between 40-140 degrees F are in the "danger zone," where bacteria may grow. Heat leftovers to at least 140 degrees F. Check food labels -- do not use packaged food past the recommended date on the label. Finally, avoid eating raw foods, including eggs, fish, and meats. Check to be sure milk products and juices are pasteurized because not all milk and juice is. If the item has not gone through the pasteurization process it may contain harmful bacteria. Food safety is especially important in the immune compromised patient, as it can be hard to fight infection. Symptoms of food borne illness can include nausea, vomiting, fever, diarrhea and dehydration, and can lead to hospitalization.

Women must learn to make their own mental and physical health a priority. Without good health, we are putting family, job/financial security, and ourselves on the line. Kids want and need healthy moms, and co-workers need healthy colleagues. Proper nutrition is one way to help obtain and keep good health. It is a crucial part of the overall healthcare of the HIV-infected person, and should be taken seriously.

Eventually something serious occurs, most obviously presented by unexplained weight loss. This is a visible indication of what has already been a prog

Eventually something serious occurs, most obviously presented by unexplained weight loss. This is a visible indication of what has already been a progression of body changes from HIV disease itself.

HIV-infected women are all at risk for poor nutrition status. Women who play "superwoman" and do not take care of their health may be at increased risk for compromised nutritional status. Unfortunately, unless there has been some significant weight loss, we may not know what's going on inside the body. It is not until this time that a woman thinks about her diet and food intake.

Art by Russell McGonagle

Unintentional weight loss is called wasting. In the context of HIV disease, it can be considered AIDS-related wasting. The cause of wasting can be complex and varied. Researchers believe that aside from the changes in food intake, absorption, and metabolism all playing a role in wasting, hormonal changes may also contribute to the difference in body wasting in women. Wasting in a woman appears different than in a man. Women tend to lose fat tissue, whereas men appear to lose lean tissue quicker. It is important not only to monitor weight and to measure what the body is made of, or your body composition (body fat, body cell mass), but we must preserve body cell mass, and preserve a certain amount of fat to live and function. Be sure to ask your registered dietitian to test and monitor your body composition. Although some women initially may be somewhat excited about some weight loss, it is not something to be taken lightly. Weight loss may indicate an infection or other problem, and can become life threatening.

Women, HIV, and Weight Loss

Women, HIV, and Weight Loss

Society's glamorizing of thin women might lead doctors -- and some women with HIV -- not to be alarmed by unplanned weight loss. Any weight loss that is unplanned and can't be explained should be cause for alarm. Your weight should be monitored with the same watchful eye as your lab results.

Malnutrition and weight loss are common problems with HIV disease. Malnutrition can result from loss of appetite and food intake due to depression, fatigue, illness or side effects from therapy. Without monitoring, it can persist undetected for a long time.

Weight loss is an obvious sign of malnutrition. It can begin and become severe anywhere in the course of HIV infection, though it's an increasing threat when CD4+ cell counts fall below 100. Wasting is an extreme type of weight loss and is an unexplained loss of 10% or more of a person's normal weight.

In addition, individuals should eat complex

In addition, individuals should eat complex carbohydrates such as rice or legumes (pod plants like peas or beans). High-calorie foods made from white flour or refined sugars should be eaten sparingly as numerous or excessive portions eventually may cause problems with maintaining blood sugar levels (an early sign of diabetes). Certainly, people who are insulin-resistant or who have diabetes should avoid these foods most of the time.

Fiber (found in fruits, vegetables and whole grains) is also important, according to Carter, to prevent constipation, colon cancer and other illnesses of the gastrointestinal system. Individuals should take at least 20 grams to 30 grams of fiber each day. Eating several servings daily of fruits and vegetables (at each meal and as snacks) is also important to provide natural sources of several vitamins and minerals. Calcium is another key nutrient and can be found in a variety of foods, including dairy, as well as in dietary supplements.

Consulting with a certified nutritionist can help you determine the best ways to incorporate adequate levels of vitamins, minerals, protein, fiber and other essential nutrients into your daily eating. Many clinics offer nutrition services, or your healthcare provider may be able to make a referral.

Because of the dangers of wasting, especially as an AIDS-

Because of the dangers of wasting, especially as an AIDS-associated condition, HIV-positive people should have their body cell mass (BCM) monitored by their healthcare provider. BCM is the total amount of all the cells that make up the active tissues of the body. BCM is determined based on a person's height and includes bones, muscles and organs, as well as water inside of and between the body's cells. The loss of 54% or more of BCM can cause death in an HIV-positive person -- even if the person does not have an opportunistic infection. Losing weight for no apparent reason is a red flag that BCM may be decreasing. A loss of 10% of total body weight is significant and should be brought to the attention of a healthcare provider as soon as possible.

Maintaining a healthy BCM can be accomplished by eating protein, which can come from a variety of sources including meats and fish. Obviously, lean sources of protein such as chicken breast (no skin) and fish will have the greatest benefits for those who are trying to maintain heart-healthy diets. Carter recommends 100 to 150 grams of protein daily for men and 80 to 100 grams daily for women.

tion can affect a person's ability to survive with HIV/AIDS.

Nutrition can affect a person's ability to survive with HIV/AIDS. Staying nutritionally fit is difficult for everyone, but for HIV-positive people the task is even more challenging. Both HIV disease and HIV medications can have negative effects on nutrition. Unfortunately, keeping up with what is considered a healthy eating plan can be hard. However, there are some general nutrition guidelines for positive people to stay healthy. First, speak with a healthcare provider about what he or she recommends. Second, speak with a nutritionist that works with HIV-positive people. A nutritionist can provide tailored eating plans that include all important vitamins and minerals.

Positive people should take a multivitamin daily. This has been a recommendation for quite some time, and recent research confirms that taking a multivitamin that includes vitamins B, C and E slows the progression of HIV disease. Taking a vitamin B complex supplement has also been shown to help the body's immune system better withstand the daily assault from HIV. According to Sheila Carter, R.D., a specialist in the nutritional care of individuals with HIV at Houston's Thomas Street Clinic, it is also important to make sure selenium is included in the multivitamin chosen. Selenium is a mineral that strengthens immune cells. In addition to selenium, Carter recommends L-glutamine or glutamine, a chemical found naturally in the body (and available in supplements) that aids in reducing diarrhea and wasting, as well as slowing HIV progression. Those with advanced HIV disease or AIDS tend to have low levels of selenium and L-glutamine.

The immune system helps us navigate safely

The immune system helps us navigate safely in our environment and avoid over- and under-reacting to foreign substances. My first suggestion to boost immune function in people living with HIV is to identify and treat underlying food and environmental sensitivities and limit immune taxing behaviors. Stress and sugar consumption have been clinically shown to depress immune function. This is exactly what we don't want to have happen in people living with HIV. Many relaxation techniques exist to help us cope with life issues and lessen the physiological response in the body; yoga, meditation, exercise, support groups, counseling and prayer can all be helpful. Local resources exist to help you find the closest and best group for you. In the meantime, for a quick "stress break," I recommend the 4/8 Time-out. It's easy to do, free and can help diffuse a stressful moment in about a minute.

Herbs and Nutrients for Immune Stimulation

Herbs and Nutrients for Immune Stimulation

Astragalus

is a Chinese herb that has been used for centuries for its immuno-modulating qualities. There is mixed scientific evidence on its efficacy with HIV, but well documented studies on its ability to stimulate the immune system. Many patients use this synergistically with other immune boosters such as reishi, maitake and shitake mushrooms.

Glycerrhiza (Licorice) also has been used as a complementary immune modulator, although it should be avoided in people with hypertension. In my experience the immune modulators work much better when combined together rather than used as singular treatments. Licorice can be consumed as a tea daily and the mushrooms may be included in food preparation or taken in liquid tincture form for a more consistent higher dose.

Boxwood has been shown in research to foster immune stimulation and promotion of t-cell activation. This can be found in capsule form and taken as directed by a healthcare professional.

Echinacea has been documented to stimulate the chemicals that promote t-cell activation and antibody production. It is very effective in lessening the course of the common cold and respiratory infections when used short term. There are some conflicting studies on its use long term as well as a caution that it may briefly increase viral load. Clinically, I have no problem in its short-term use for respiratory infections -- but avoid long term use as well as use prior to viral load blood counts. During the acute onset of a cold, 2 to 4 cups of strong echinacea tea or 3 capsules 3 times daily can help limit the course of the illness.

Pau D'arco and Una de Gato (Cat's Claw) are also clinically used to stimulate immune function and may be consumed in tea form daily or liquid tincture either during acute illness or as a preventative measure.

antiretroviral therapy has changed the face of HIV

antiretroviral therapy has changed the face of HIV over the last decade and a half. Patient life expectancy has increased tremendously and we no longer associate many of the opportunistic infections as early-onset symptoms. Drug regimen pill burdens have also decreased for most, making adherence to protocols easier as well.

When changing protocols or adding in new therapies, however, sometimes side effects can interfere with quality of life and the likelihood that a patient will want to maintain the therapy. I have worked for almost 10 years with HIV-positive patients and have seen firsthand how natural therapies dramatically help manage side effects of medications, improve quality of life, protect the body from the chemical processing of the medications, and possibly prevent 'drug failure'. The following is a review of natural therapies for optimizing the benefits of antiretroviral drug treatment.

Since many people with HIV/AIDS use dietary

Once such an assessment is complete, promptly address any underlying problems -- such as infections, hormone imbalances, or metabolic disorders -- that may be interfering with proper nutrition. The next step is to develop an appropriate, individualized nutrition plan. Seniors, growing children, pregnant or breast-feeding women, and people with active OIs are among the many groups that have special nutritional needs. While supplements can offer important benefits, they do not replace a well-balanced diet. When it comes to good nutrition, there is no "quick fix." It's better to develop long-term healthy eating habits, such as cutting back on saturated fat and consuming more fruits, vegetables, and whole grains. But set realistic goals: it's fine to splurge occasionally if one normally adheres to a healthy diet. Fortunately, small changes in eating habits can often make a big difference in terms of health.

Since many people with HIV/AIDS use dietary supplements in addition to HAART, it's crucial to learn more about how nutritional supplementation impacts HIV disease and vice versa. According to Tang and colleagues, areas ripe for further research include the role of micronutrient supplementation in people with well-controlled HIV disease, whether micronutrients can enhance CD4 cell responses, the role of antioxidants in countering increased oxidative stress due to HIV infection or its treatment, whether micronutrient supplementation can help reduce morbidity associated with coinfections such as hepatitis B or C, the role supplements might play in addressing metabolic manifestation such as lipodystrophy and bone loss, and the appropriate doses of supplements for HIV positive people at various stages of disease.

"Attempts to improve dietary quality and micronutrient status may play an overall role in maximizing health for the HIV-infected individual, particularly in undernourished populations," Tang and colleagues concluded, "and may also play a role in the more subtle management of HIV infection in the future."

Nutritional management should be a regular part of HIV/AIDS care.

Nutritional management should be a regular part of HIV/AIDS care. Even if an HIV positive person has no obvious nutritional problems such as wasting, a healthy diet can still help stave off illness and improve quality of life. But, as Tang and colleagues noted in their review, dealing with nutritional issues "may not be part of the traditional care or thought process of the HIV care provider." A registered dietitian (RD) who has experience working with people with HIV/AIDS can be an invaluable resource.

The American Dietetic Association recommends a baseline nutritional and body composition assessment soon after HIV diagnosis. Follow-up assessments should be conducted at least once annually for asymptomatic individuals with well-controlled HIV disease, and every few months for patients with AIDS or known nutritional problems. Tasmin Knox, MD, from Tufts recommends anthropometric measurements of body composition (see "Weights and Measurements" above for an explanation of various methods); laboratory tests of protein and micronutrient levels in the blood; tests of metabolic parameters such as blood lipids, blood glucose, and liver enzymes; and clinical assessment of eating patterns, supplement use, functional status, physical symptoms, and psychological or socioeconomic issues that may impede adequate nutrient intake. Some experts recommend that people keep a daily diary of everything they eat, along with any dietary problems they encounter.

With all this conflicting data, it can be difficult for HIV positive people

With all this conflicting data, it can be difficult for HIV positive people to make informed decisions about supplements. The bottom line, according to Judith Nerad, Mary Romeyn, and colleagues in the April 2003 CID special issue: "[T]here is little documentation in the literature that supplementation beyond what is recommended has had any impact on clinical outcome." But, "[i]f a patient's vitamin or mineral status is deficient, supplementation is clearly necessary."

People with HIV/AIDS commonly have subtle nutritional deficiencies, and research to date has shown that daily multivitamin use is safe and at least potentially beneficial in this population. Different experts have suggested various supplementation regimens. For example, Romeyn -- in her book Nutrition and HIV: A New Model for Treatment -- suggests a basic regimen that includes:

• a multivitamin, without extra iron, twice daily;
• a trace element supplement once daily;
• an antioxidant supplement once daily.

Others, such as nutritionist Margaret Davis, RD, recommend only the multivitamin, plus increased consumption of fruits and vegetables.

As previously noted, nutritional needs vary widely from person to person, and there is no one diet or supplement regimen appropriate for all people with HIV/AIDS. Further, the presence of a nutrient deficiency does not necessarily mean supplementation is the solution, since poor absorption, underlying infections, metabolic changes, or hormone imbalances could be contributing to the problem.

When using supplements, do not take more than the recommended dose on the label unless advised to do so by a knowledgeable healthcare provider. As some of the studies discussed above illustrate, more is not necessarily better. A recent case underscores this warning. As reported in the September 2005 International Journal of STD and AIDS, an HIV positive man in London developed severe liver inflammation with skyrocketing ALT levels after taking more than a dozen dietary supplements, many at high doses -- as much as 67 times the recommended daily value; fortunately, once he stopped taking the supplements, his liver function returned to normal.

Certain vitamins and minerals (including the fat-soluble vitamins A, D, and E) can be toxic at high doses, and they may cause deleterious effects even at lower doses beyond what is provided in a typical multivitamin pill. Remember that "natural" does not necessarily mean "safe." Beware of any supplement touted as a "cure" for a range of ailments -- if something sounds too good to be true, it probably is. Verify that health claims are supported by reliable research. Some supplements may not be harmful, but simply a waste of money. Seek medical advice before starting a new supplement or beginning any unusual diet. Tell healthcare providers about any use of supplements (as well as over-the-counter medications, recreational drugs, and herbal remedies), since these can potentially interact with antiretroviral drugs.

Vitamin C, vitamin E, selenium, and zinc act as

Vitamin C, vitamin E, selenium, and zinc act as antioxidants, helping prevent cell damage caused by highly reactive free radicals (oxidative stress). While free radicals play a role in immune defense against invading pathogens, they can also harm surrounding cells. Research has shown that people with HIV and other chronic infections have higher levels of free radicals, which promote viral replication. Conversely, antioxidants appear to reduce oxidative stress, inhibit HIV activity, and possibly slow HIV disease progression. Antioxidants may also reduce liver fibrosis in people with hepatitis B or C and protect the liver from toxicity as it metabolizes drugs.

The body manufactures certain antioxidants as needed, but this process requires adequate amounts of several nutrients. Studies suggest that a major intracellular antioxidant, glutathione, may help reduce the rate of HIV disease progression. Nutrients that help raise glutathione levels include selenium, alpha-lipoic acid, N-acetyl-cysteine (NAC), acetyl-L-carnitine, L-glutamine, and coenzyme Q10. In one small study, high-dose NAC supplementation led to decreased HIV viral load. There have been several case reports and small studies in which supplementation with antioxidants or precursors including NAC, acetyl-L-carnitine, and coenzyme Q10 seemed to counter lactic acidosis (a sign of mitochondrial toxicity) related to antiretroviral therapy. What's more, Andrew Hart, MD, and colleagues from the Royal Free and University College Medical School reported in the July 23, 2004 issue of AIDS that acetyl-L-carnitine supplements helped reverse nerve damage and alleviated the pain of peripheral neuropathy associated with certain NRTI drugs.

treatment for people with HIV/AIDS

Zinc deficiency has been linked to impaired immune function and supplementation has been suggested as a treatment for people with HIV/AIDS, but studies to date have produced conflicting results. While some suggest that zinc enhances the body's ability to fight HIV and improves disease symptoms, others have found it has a detrimental effect. In one study of injection drug users, lower zinc levels were associated with reduced CD4 cell counts, but this does not necessarily mean one caused the other. In an early nutritional survey of nearly 300 HIV positive men followed for seven years, high doses of zinc were associated with faster HIV disease progression. Some researchers have hypothesized that this may be related to the fact that HIV requires zinc-containing structures called "zinc fingers" to produce functional viral progeny.

More recently, Raziya Bobat, MD, and colleagues reported in the November 26, 2005 issue of The Lancet that in a randomized, placebo-controlled trial of 96 HIV positive South African children aged six months to five years, zinc supplementation for six months reduced the incidence of diarrhea and pneumonia, and did not appear to promote viral replication. Given the degree of uncertainty, most experts do not recommend zinc supplementation beyond the amount contained in a multivitamin and mineral pill.

vaginal HIV viral loads than women

December 15, 2004 issue of JAIDS, Scott McClellend, MD, from the University of Washington and colleagues found that in a study of 400 nonpregnant HIV positive women in Kenya, supplementation with a multivitamin plus selenium led to increased vaginal shedding of HIV, which has implications for sexual and perinatal transmission. Among women who started out with normal selenium levels, those who received supplements were more than twice as likely to shed HIV in their vaginal secretions and had higher vaginal HIV viral loads than women who received a placebo; a similar effect was not seen, however, in selenium-deficient women brought up to normal levels. While supplementation resulted in higher CD4 and CD8 cell counts, the authors concluded that, "The potential benefit of micronutrient supplementation in HIV-1-seropositive women should be considered in relation to the potential for increased infectivity."

treatment for HIV/AIDS

he trace element selenium -- also known to play a role in proper immune function -- has received considerable attention as a treatment for HIV/AIDS and a variety of other diseases. Some in vitro research indicates that HIV requires selenium in order to replicate. A study of 125 HIV positive injection drug users by Marianna Baum, PhD, and colleagues from the University of Miami (published in 1997) revealed that after adjusting for various factors including CD4 cell count, selenium deficiency was significantly associated with increased mortality. "When all nutrient factors that are associated with survival are considered together," Baum concluded in a later review article, "only selenium deficiency is a significant predictor of mortality." And in a study of 670 HIV positive pregnant women in Tanzania (reported in the June 1, 2005 issue of JAIDS), Roland Kupka, DSc, from Harvard School of Public Health and colleagues found that low plasma selenium levels were associated with increased risk of miscarriage, infant death, and mother-to-child HIV transmission.

But the fact that low selenium levels are linked to worse disease progression does not necessarily mean supplementation will improve matters. HIV nutrition expert Mary Romeyn, MD, has reported anecdotal evidence that selenium supplementation leads to clearance of thrush. On the other hand, while low selenium levels were linked to increased likelihood of cervical dysplasia (precancerous cell changes) among HIV positive women in one study, selenium supplements did not reduce the risk.

May 20, 2005 issue of AIDS that addition of vitamin

itamin E plays a role in metabolism and proper immune function, and laboratory studies suggest it has an antiviral effect. For example, Alonso Heredia, PhD, from the University of Maryland and colleagues reported in the May 20, 2005 issue of AIDS that addition of vitamin E to cell cultures from 10 HIV positive individuals significantly reduced HIV production, as indicated by p24 antigen levels. The authors suggested that supplementation might slow HIV replication enough to inhibit the emergence of drug-resistant virus in resting cells and to delay viral rebound after treatment interruption. But while low (or decreasing) levels of vitamin E have been linked to CD4 cell declines and HIV disease progression, this does not imply causality.

The jury is still out on the benefits and risks of high-dose vitamin E supplementation, but data from recent large studies in the HIV negative population do not look good. In the Women's Health Study (a primary prevention trial that included nearly 40,000 healthy, HIV negative women), subjects randomly assigned to receive 600 IU of vitamin E every other day not only did not have reduced rates of cancer or cardiovascular disease relative to women in the placebo arm, but actually showed a nonsignificant increase in total mortality. Results of a meta-analysis of 19 clinical trials with a total of nearly 136,000 subjects published in the January 4, 2004 Annals of Internal Medicine led authors Edgar Miller, MD, and colleagues to conclude that, "High-dosage [400 IU or more daily] vitamin E supplements may increase all-cause mortality and should be avoided." In the absence of large controlled studies in the HIV positive population, the same advice is sound for people with HIV/AIDS as well.

HIV positive women in Malawi was associated with

Richard Semba, MD, from Johns Hopkins and colleagues reported in 1993 that among a cohort of 179 HIV positive and HIV negative injection drug users in Baltimore, vitamin A deficiency was linked to lower CD4 cell counts and increased risk of mortality. Two years later, he reported that vitamin A deficiency among pregnant HIV positive women in Malawi was associated with increased risk of mother-to-child HIV transmission (32% among deficient women vs 7% among women with normal levels) and higher infant mortality. Similarly, a U.S. study found that vitamin A-deficient women were about five times more likely to transmit HIV to their babies. Some studies have found vitamin A deficiency to be associated with greater vaginal shedding of HIV and higher levels of virus in breast milk -- although Fawzi's study described above actually found a significantly higher rate of mother-to-child transmission via breast-feeding in women given vitamin A supplements.

Several large controlled studies looking at supplementation with vitamin A or beta-carotene (a vitamin A precursor) for HIV positive pregnant women in parts of Africa where frank deficiency is common, however, have failed to detect decreased rates of mother-to-child transmission; results have been mixed concerning reductions in miscarriages, premature births, and infant morbidity and mortality. In Fawzi's Tanzanian study, vitamin A alone did not produce outcomes significantly different from those seen in the placebo arm, and adding vitamin A to the multivitamin seemed to reduce its beneficial effects. Since the benefits are unclear and high doses can cause liver toxicity and other problems, most experts do not recommend vitamin A supplementation -- beyond the amount found in a typical multivitamin pill -- for people with HIV/AIDS.

In a June 10, 2005 AIDS editorial reviewing the

In a June 10, 2005 AIDS editorial reviewing the current state of knowledge about micronutrient supplementation in people with HIV/AIDS, Tang and colleagues concluded that "a combination of vitamins may afford some benefits to undernourished HIV-infected populations, particularly those with more advanced disease," but conceded that "the role of individual micronutrients ... is less clear." Most healthcare providers agree that HIV positive people can benefit from a daily multivitamin and mineral supplement. (Due to the potential harmful effects of iron, many recommend an iron-free supplement for anyone other than menstruating women and people with iron deficiency). But when it comes to specific nutrients, expert opinion -- and the little relevant research conducted to date -- remains sharply divided.

Higher amounts of various substances have been proposed to improve immune response, ameliorate symptoms and drug side effects, and slow HIV disease progression, on the basis of theoretical understandings about how an agent is expected to behave, laboratory research looking at the effects of a substance in vitro, cross-sectional studies showing specific nutritional deficiencies in a population, or -- less commonly -- controlled trials. Several nutrients that have received the most attention with regard to HIV/AIDS are discussed below.

More recently, researchers in Thailand showed that a low-cost

More recently, researchers in Thailand showed that a low-cost multivitamin and mineral supplement improved the survival of HIV positive people who were not taking HAART. As reported in the November 21, 2003 issue of AIDS, Sukhum Jiamton, MD, and colleagues conducted a double-blind, placebo-controlled trial in which nearly 500 HIV positive individuals with CD4 cell counts of 50-550 cells/mm³ were randomly assigned to receive either a placebo or a supplement containing 12 vitamins, eight minerals, and the amino acid cysteine twice daily. After 48 weeks, about twice as many people died in the placebo arm compared with the supplement arm (15 vs 8 deaths); among those with baseline CD4 counts below 200 cells/mm³, the mortality rate was significantly lower in the supplement arm. On the other hand, an earlier study in Zambia found that multivitamin supplementation had no effect on CD4 cell count or mortality.

In the July 1, 2004 New England Journal of Medicine, Wafaie Fawzi, DrPH, from Harvard School of Public Health and colleagues reported on a double-blind, placebo-controlled study in which 1,078 HIV positive pregnant women in Tanzania received either daily supplements of vitamin A; a multivitamin supplement containing vitamins B, C, and E; or both. After a median follow-up of 71 months, 67 out of 271 women (24.7%) who received the multivitamin either died or progressed to advanced HIV disease (stage IV as defined by the World Health Organization), compared with 83 out of 267 women (31.1%) who received the placebo. Women in the multivitamin arm -- but not those receiving vitamin A alone -- also had significantly lower HIV viral load, higher CD4 and CD8 cell counts, and improved birth outcomes.

As a rule, it's usually best to obtain nutrients from food

What About Supplements?

As a rule, it's usually best to obtain nutrients from food. Swallowing handfuls of pills will not make up for a poor diet. But even HIV positive people who eat well can have low levels of various important nutrients -- at a time when their nutritional needs may be increased -- and thus may benefit from supplementation. The U.S. government's Daily Values (formerly known as Recommended Dietary Allowances) for nutrients do not necessarily reflect the amount required for optimal health, just the minimum needed to stave off deficiency symptoms in the average healthy person. It is not yet known whether accepted recommended nutrient levels for the general population are adequate for people with HIV/AIDS.

Dietary supplements are products such as vitamins, minerals, amino acids, herbs, and antioxidants; they are usually taken orally in the form of tablets, capsules, powders, or liquids. Due to the lack of strict quality control and labeling requirements, marketed products can vary widely in contents, strength, and purity. Although regulated by the U.S. Food and Drug Administration (FDA), supplements do not need to undergo rigorous clinical trials of safety and efficacy as required for approval of pharmaceutical drugs. In fact -- because there is little financial incentive to spend money developing products that cannot be patented -- there have been few rigorous, controlled studies on the use of nutritional supplements in people with HIV.

In the mid-1980s, Barbara Abrams, DrPH, and colleagues from the University of California at Berkeley began a large observational study of dietary intake in 296 HIV positive men; results were reported in the August 1993 issue of JAIDS. By one measure, the risk of developing AIDS decreased as consumption of 11 different micronutrients increased -- significantly so for riboflavin, vitamin E, and iron, and approaching significance for thiamin, niacin, and vitamin C. This study was susceptible to selection bias, however, since people who ate healthier diets or took supplements might have had healthier lifestyles overall.

Lipodystrophy syndrome also includes elevated blood lipid levels and blood glucose

Lipodystrophy syndrome also includes elevated blood lipid levels and blood glucose abnormalities (see "Insulin Resistance and Diabetes" in the Winter 2004 issue of BETA). While most research indicates that lipodystrophy is associated with antiretroviral therapy -- in particular protease inhibitors (PIs) -- it is likely a multifactorial condition related to long-term HIV infection or immune reconstitution, since some people who develop the syndrome have never taken HAART. In a recent study by Peter Bacchetti, PhD, and colleagues, for example, abdominal fat accumulation was not linked to HAART, and was actually more common among HIV negative than HIV positive men (see "News Briefs," in this issue.)

Obesity, and in particular visceral abdominal fat, has been linked to increased risk of cardiovascular disease in the general population. While it is still uncertain whether HIV positive people on HAART have higher rates of heart attacks and strokes (studies have yielded mixed data), it is likely that traditional cardiovascular risk factors -- advancing age, male sex, cigarette smoking, high LDL cholesterol and triglyceride levels, insulin resistance, elevated blood pressure, and being overweight -- are as important for HIV positive people as for anyone else (see "Cardiovascular Disease in People with HIV" in the Summer/Autumn 2002 issue of BETA).

While early nutritional guidelines for people with AIDS often emphasized packing on the calories -- adding cream, cheese, peanut butter, gravy, and the like to foods -- many HIV positive people today would be better served by adopting a balanced, low-fat diet.

Lifestyle changes, including diet modification, weight loss (if needed), exercise, and smoking cessation, are the first line of defense against cardiovascular disease. In order to lose weight, HIV positive people must follow the same rules as everyone else: burn more calories than one takes in. But reducing the amount of fat and cholesterol in the diet is not always enough to reverse fat accumulation or bring blood lipids within a healthy range, and exercise may not have much effect on visceral fat. When this is the case, lipid-lowering medications (including the statin and fibrate classes) are often used. Altering one's antiretroviral regimen to include drugs less linked to high blood fat -- such as substituting atazanavir (Reyataz) for another PI -- is often effective. Researchers have tried treating lipodystrophy with human growth hormone and anabolic steroids, with mixed results. Although it is not yet clear what are the best interventions to address increased cardiovascular risk among HIV positive people on HAART, experts agree that a healthy diet certainly can't hurt, and is likely to be part of the solution.

Too Much of a Good Thing

Too Much of a Good Thing

For many HIV positive people in the developing world today, severe overall wasting due to protein/calorie malnutrition is not a major concern. In fact, some research suggests obesity may be a bigger problem. For example, Valerianna Amorosa, MD, and colleagues from the University of Philadelphia reported in the August 15, 2005 issue of JAIDS that in a cohort of nearly 1,700 HIV positive individuals, 31% of men and 30% of women were overweight, and 11% and 28%, respectively, were obese (in contrast, just 9% overall experienced wasting). Obesity was not associated with age, income, employment status, education, history of injection drug use, HIV treatment, or viral load, but in women it was more common among African-Americans. In Tang's study discussed above, the proportion of patients categorized as overweight was greater in the HAART era than before the advent of effective antiretroviral therapy (35% vs 30%). And HIV positive people are hardly alone: the National Center for Health Statistics reports that two-thirds of all Americans are overweight and nearly one-third of adults are obese -- double the proportion in 1980.

While "garden variety" obesity remains common, HIV positive people on HAART may also experience accumulation of fat in specific areas of the body including the belly, breasts, and back of the neck ("buffalo hump"). This abdominal or truncal lipohypertrophy is composed of deep visceral fat surrounding the internal organs. Both lipoatrophy (described above) and lipohypertrophy are features of lipodystrophy syndrome; however, as discussed in an article by Denise Jacobson, PhD, and colleagues from Tufts in the June 15, 2005 issue of CID, experts now recognize that these are two distinct processes, not simply redistribution of fat from one area to another.

Since HIV positive people and their clinicians may

Since HIV positive people and their clinicians may not recognize the early signs of wasting, it is important to monitor weight regularly to detect subtle changes. Underlying factors contributing to weight loss -- such as OIs or hormone imbalances -- should be promptly addressed. But, as Grinspoon and Mulligan point out, "no therapeutic guidelines currently exist for the management of weight loss and wasting in HIV-infected patients."

When it comes to weight loss, prevention is often easier than cure. To add calories, focus on proteins and complex carbohydrates rather than "junk food" that contains mostly sugar and fat. Consider eating several small meals and snacks throughout the day rather than two or three large meals. Nutritional supplements such as Ensure or Boost may benefit individuals who find it difficult to eat solid foods. Some cities offer food delivery programs for people with HIV/AIDS who are unable to shop or prepare meals (e.g., Project Open Hand in San Francisco, God's Love We Deliver in New York City, Moveable Feast in Baltimore).

The appetite stimulant megestrol acetate (Megace) tends to promote fat rather than muscle gain and can cause side effects including edema (swelling). Certain antidepressants and other medications may also enhance appetite. Some patients swear by medical cannabis or dronabinol (Marinol), a pill that contains a synthetic version of marijuana's active ingredient, THC.

While recombinant human growth hormone (HGH, Serostim) is FDA-approved for the treatment of HIV-related wasting, it is extremely expensive and can cause side effects including carpal tunnel syndrome, joint pain, and insulin resistance. Anabolic (muscle-building) steroids such as testosterone and oxandrolone (Oxandrin) help some patients gain weight, but can also cause adverse effects. Hormone replacement therapy is most useful for individuals who have low levels; there is little evidence that "supraphysiological" doses (higher than the natural physiological range) are beneficial, and they may be harmful (see "HIV and Hormones" in the Summer 2004 issue of BETA). Research has shown that anabolic steroids work better when combined with resistance exercise; in fact, some studies suggest resistance exercise works better than steroids, without the cost or side effects.

Waste Not, Want Notaa

Waste Not, Want Not

Wasting -- also known as cachexia -- was a prominent feature of AIDS in the early years of the epidemic; even today, AIDS is referred to as "slim disease" in Africa. Experts define wasting as involuntary or unwanted loss of 10% or more of body weight. As Steven Grinspoon, MD, and Kathleen Mulligan, MD, discuss in an April 2003 special issue of Clinical Infectious Diseases (CID) devoted to nutrition and HIV, "wasting ... has been associated with increased mortality, accelerated disease progression, loss of muscle protein mass, and impairment of strength and functional status." Even a 5% loss has been linked to increased illness and death.

In classic HIV-related wasting, lost weight is in the form of lean body mass rather than fat, especially in men. People with HIV/AIDS (and other chronic illnesses) require more calories simply to maintain their weight, due to increased metabolism, higher energy demands, hormone and cytokine imbalances, inefficient absorption and utilization of nutrients, and/or accelerated tissue breakdown (catabolism).

While effective antiretroviral therapy has dramatically reduced the incidence of severe wasting, moderate weight loss is still a prominent feature of HIV disease. For example, as reported in the September 1, 2005 Journal of Acquired Immune Deficiency Syndromes (JAIDS), Alice Tang, MD, from Tufts University Medical School and colleagues found a steady increase in the rate of 5% or greater loss of body weight between 1995-1997 (pre-HAART) and 1998-2003 (HAART era). In an analysis of 713 HIV positive participants in the Nutrition for Healthy Living cohort, 53% lost at least 5% of their body weight during any six-month period. Weight loss was significantly associated with nausea, diarrhea, thrush, poverty, history of drug use, CD4 cell count below 200 cells/mm³, and HIV viral load above 100,000 copies/mL. The authors were unable to pinpoint the reasons for the increased rate of wasting in the HAART era.

In another study (reported in the October 15, 2005 issue of CID), Adriana Campa, PhD, from Florida International University and colleagues found that 17.6% of 119 HIV positive, mostly homeless drugs users in Miami showed evidence of HIV-related wasting. In this study, wasting was associated with cocaine and heavy alcohol use, "food insecurity" (not eating for one or more days in the past month), and higher HIV viral load. Participants taking HAART were more likely to experiencing wasting than those not receiving anti-HIV treatment (86% vs 67%).

Rather than dramatic whole-body weight loss, today many HIV positive people on HAART experience lipoatrophy, or fat loss in the face, limbs, and buttocks. Paradoxically, this may coincide with fat accumulation in other areas of the body (discussed below). Lipoatrophy is most strongly associated with use of nucleoside reverse transcriptase inhibitors (NRTIs), especially d4T (stavudine or Zerit). For this reason, U.S. government treatment guidelines no longer recommend d4T as part of a first-line regimen for people starting HAART.

Altered nutritional requirements

Altered nutritional requirements: By altering metabolism (how the body processes and uses nutrients), acute or chronic illness -- including HIV disease and OIs -- and the resulting immune response can increase the body's energy needs. People with HIV/AIDS may require more calories, macronutrients, and specific vitamins and minerals. Chronic illness may also alter hormone and cytokine levels, which may have nutritional implications.

Conversely, nutritional deficiencies can impair immune function, potentially worsening HIV disease progression. Research has shown that depletion of vitamins A, C, and E, the B-complex vitamins, and the minerals selenium and zinc can interfere with cell-mediated immunity (CD4 cell, natural killer cell, and neutrophil proliferation and activation), antibody production, and normal cytokine signaling.

Studies looking at the prevalence of nutritional deficiencies in people with HIV/AIDS have produced conflicting data, but on the whole, depletion of nutrients (e.g., vitamins A and E, and minerals including magnesium, selenium, and zinc) appears to be common, especially among individuals with advanced disease. In particular, having HIV seems to decrease the body's store of antioxidants, as they are needed to offset increased oxidative stress. Researchers have uncovered evidence of subtle nutritional deficiencies among people who appear to be eating an adequate diet and are not suffering from frank protein/calorie malnutrition.

Experts don't yet understand the clinical significance -- if any -- of subtle changes in laboratory values relative to the norms seen in the HIV negative population, nor do they know how much of any given nutrient people with HIV/AIDS need for optimal immune function and overall health. Due to a lack of research on nutritional status in the setting of HIV disease, and because nutritional requirements vary dramatically from person to person, there are few definitive recommendations for nutritional supplementation in the HIV positive population.

How HIV Impacts Nutrition ... and Vice Versa

How HIV Impacts Nutrition ... and Vice Versa

In the early years of the epidemic, healthcare providers soon learned that people with AIDS commonly experienced both overt protein/calorie malnutrition and deficiencies of specific nutrients. But nutrient depletion may also begin to occur earlier in the course of HIV disease, even among individuals with relatively intact immune systems. Several factors can contribute to nutritional problems in people with HIV/AIDS.

Malabsorption: HIV or associated infections can damage the lining of the gastrointestinal tract, which can interfere with absorption of nutrients. Some HIV positive people experience specific problems, such as fat malabsorption, which can impair absorption of fat-soluble vitamins.

Opportunistic infections: Various bacterial, viral, fungal, and parasitic infections can interfere with proper nutrition. Malignancies (cancers) and mycobacterial illnesses such as tuberculosis are often characterized by wasting. Several OIs cause vomiting and diarrhea, which can lead to poor absorption or loss of nutrients. Other infections -- such as thrush (oral candidiasis), gingivitis (gum inflammation), and cytomegalovirus esophagitis (throat inflammation) -- can make eating painful.

Medications: Antiretrovirals, OI drugs, and other medications can contribute to nutrient deficiencies and imbalances, either due to direct drug-nutrient interactions or drug side effects. Vomiting and diarrhea can lead to dehydration and depletion of nutrients. Loss of appetite (anorexia), fatigue, and taste alterations can make it difficult to eat enough. Antibiotics may interfere with nutrition by killing off beneficial bacteria in the gut. Food requirements -- the need to take medications either on a full or an empty stomach or with specific types of food -- can disrupt normal eating patterns. Finally, some antiretroviral medications are associated with metabolic changes such as blood lipid and glucose abnormalities.

Inadequate intake: Ill people often experience anorexia. OI symptoms and medication side effects -- nausea, diarrhea, sore mouth or throat, altered sense of taste or smell -- can further reduce the desire or ability to eat. This may be compounded by lack of money, depression, or feeling too fatigued to shop and prepare food.

Food for Life

Food for Life

Food is essential for life, providing the fuel the body needs to function and the building blocks that make up cells, tissues, and organs. The energy provided by food is expressed in terms of calories. The body requires a certain number of calories simply to carry out its basic metabolic functions such as respiration and maintenance of body temperature. Additional calories are needed to support physical activity, fight infection, and rebuild damaged tissues.

If a person does not take in enough calories, fat is broken down to provide fuel. Once the fat is consumed -- or if an individual's metabolism is disrupted due to illness -- lean body mass (muscles and organs) is then used for fuel and raw materials. Conversely, if a person takes in more calories than needed, the extra energy will be stored as fat. The average person needs about 10-20 calories per pound (depending on physical activity level and other factors) to maintain a stable body weight; this requirement is likely to be higher for people with HIV, especially those with advanced disease.

But all food is not equal. While all contain calories, different foods vary widely in the nutrients they provide. A balanced diet is comprised of the following components.

Protein: Protein provides the building blocks of lean body mass. When a protein-rich food is consumed, it is broken down into amino acids, which are reassembled to create enzymes, hormones, and bodily tissues. Most nutrition experts recommend that protein should contribute about 15-20% of the total calories in a person's diet. Good sources include meat, poultry, fish, eggs, dairy products, tofu, nuts, and legumes (e.g., dried beans, lentils).

Carbohydrates: Carbohydrates, which are converted to glucose in the body, are a primary source of energy. Carbohydrates are classified as simple or complex; complex carbohydrates take more time to break down, and thus provide fuel over a longer period of time. Despite the recent popularity of "low carb" diets, most nutrition experts recommend that carbohydrates -- primarily complex ones -- should make up at least 50% of one's total daily calorie intake. Simple carbohydrates are found in processed sugar, honey, fruit and juice, and lactose (milk sugar). Complex carbohydrates are found in grain products such as bread, pasta, and rice; legumes; and starchy foods such as corn, potatoes, winter squash, and root vegetables.

Nutrition and HIV

Good nutrition is key to a healthy lifestyle, regardless of whether one is living with HIV/AIDS. Optimal nutrition can help boost immune function, maximize the effectiveness of antiretroviral therapy, reduce the risk of chronic illnesses such as diabetes and cardiovascular disease, and contribute to a better overall quality of life.

In the early years of the AIDS epidemic, many people with HIV were dealing with wasting and opportunistic infections (OIs) linked to unsafe food or water. While these problems are less common today in developed countries with widespread access to highly active antiretroviral therapy (HAART), many HIV positive people have traded these concerns for worries about body shape changes, elevated blood lipids, and other metabolic complications associated with antiretroviral therapy.

Fortunately, maintaining a healthy diet can help address these problems. As HIV positive people live longer thanks to effective treatment, good nutrition can also help prevent problems (such as bone loss) associated with normal aging. But there is no single, optimal eating regimen appropriate for every person living with HIV/AIDS. Instead, HIV positive people should adopt a sensible balanced diet and consult an experienced nutrition specialist for individualized recommendations.

In addition to mother to child transmission

In addition to mother to child transmission, food insufficiency is associated with increased HIV risk-taking behavior and sex exchange. A recent study of food security and HIV risk behaviors interviewed 2,051 adults in Botswana and Swaziland. The individuals were asked information about their food intake over the previous 12 months. Condom use, sex exchange, and other HIV risk-taking behaviors were examined. For women, sex exchange was defined as exchanging sex for food, money or other resources; for men, sex exchange was defined by paying for or providing resources for sex. HIV risk behaviors included inconsistent condom use, intergenerational sex and lack of control over sexual relationships. Of all study participants, 32% of women and 22% of men experienced food insufficiency in the previous 12 months. This study sends a clear message that without adequate food, individuals may surrender long-term health and safety to survive in the present.³¹

A program in the Democratic Republic of Congo (DRC) demonstrates that when multiple institutions work together, societies can successfully diminish malnutrition and food insecurity. Bukavu, like other cities in the DRC and around the globe, suffers continual conflict and humanitarian crises. Many structures -- including society, economy, and health care system -- are near collapse. Because of the lack of infrastructure, and security, deploying effective social programs is difficult. However, in 2003, Médicins Sans Frontières (Doctors Without Borders) worked with the Food and Agriculture Organization of the United Nations and the World Food Programme of the UN to create a food security program for HIV-positive individuals in Bukavu. This included distribution of seeds, tools and agricultural support, as well as a nutrition support system which distributed food rations and nutrition education to over 200 families. This program improved the medical management of HIV, as demonstrated by overall weight gain. If many more medical and nutrition agencies collaborated together, using Bukavu as an example, there would be more success in overcoming the challenges of food insecurity, malnutrition and HIV.³²

Clearly there is overwhelming evidence that confronting malnutrition and food security in the HIV/AIDS community is necessary to successfully treat the disease. It is imperative that in addition to increasing access to HIV medications, organizations must also provide nutritious, safe and sustainable food assistance.

Our work with hundreds of clients in New York

Our work with hundreds of clients in New York City has demonstrated many similarities among our food insecure population. Food assistance programs are not geared towards people living with HIV/AIDS who have increased nutritional needs. In addition, there are few supermarkets or places that offer fresh, whole foods in low-income neighborhoods. Markets that do carry these types of foods tend to be very expensive. This makes it difficult for HIV-positive individuals to obtain nutritious foods through food stamps and other supplemental subsidies.

Due to the lack of nutritious foods accessible to low-income HIV-positive individuals, many eat foods that contain a high amount of refined carbohydrates, saturated and trans-fats, and calories with little micronutrient value. Because of this we see many obese clients with diseases characteristic of the general obese population.

Food insecurity in itself is a risk factor for HIV/AIDS transmission. Malnutrition has been shown to increase transmission of HIV from a pregnant woman to her fetus, which remains a major issue in the developing world.²⁹ In addition, because of food insecurity and decreased access to safe water supplies, HIV-positive mothers are forced to breastfeed their children, which further increases the risk of HIV transmission.³⁰

Food insecurity plays a major role in the development

Food insecurity plays a major role in the development of malnutrition in resource-poor and resource-adequate settings. In resource-poor settings, there is decreased or no adult labor in HIV/AIDS affected households. These households have less capacity to produce or purchase foods and have higher medical costs. In addition, children often stop their schooling to work, or simply because the family affected by HIV can no longer afford the education. Research in Tanzania showed that food consumption decreased 15 percent per capita when an adult died. Funeral costs deplete monies that could be used for food. The agricultural knowledge base of families and communities decreases as individuals with farming and science knowledge die from HIV/AIDS.²⁷

Women are especially vulnerable in HIV/AIDS-affected households. Usually, they care for the sick and dying in addition to maintaining heavy workloads related to gathering food and feeding the household. If the mother dies of HIV, often the family goes hungry because of decreased means of food gathering and preparation. One study showed that food insecurity and malnutrition were the most immediate problems faced by female-headed households affected by HIV/AIDS in Uganda

Protein is involved in nearly every biological process of the human body.

Protein is involved in nearly every biological process of the human body. It builds muscle tissue and helps your immune system fight off infections. We need protein to keep organs like our heart and lungs working well and to keep ourselves strong and active. Studies have shown that HIV weight loss tends to reduce protein stores more quickly than simple starvation, and a major nutritional goal for HIV-infected individuals should be to build or maintain your muscle mass.

Carbohydrates and fat are important because HIV can increase the body's metabolic rate--causing us to use more calories to do the same work we did with less calories before becoming HIV positive.

Finally, if you're not eating enough to maintain your weight, you're probably not getting adequate amounts of the vitamins, minerals, and phytochemicals that our bodies need to produce energy, to help with many chemical reactions that we carry out automatically, and to help protect us from chronic diseases such as heart disease, cancer and high blood pressure. Depending on the medication you are taking, you may not be eating enough to absorb those medications properly and get them into your bloodstream where they can work effectively. Not getting enough of these essential nutrients can further weaken your immune system. Even though it is a good idea to take a multivitamin every day, you must remember that supplements cannot take the place of real food. That's why they're called supplements.

Why Nutrition Matters

Why Nutrition Matters

Good nutrition is critical for people living with HIV and AIDS. Basically, nutrition should be viewed as an essential co-therapy that can help maximize your medical management of HIV. Eating well can help:

• 
  

• Prevent or delay the loss of muscle tissue or "wasting"
• Strengthen the immune system
• Reduce viral mutations
• Decrease the incidence and severity of opportunistic infections and hospitalizations
• Lessen the debilitating symptoms of HIV/AIDS
• 
  

If you're HIV infected, it's important to avoid any unplanned weight loss, which can further weaken the immune system's ability to fight off infection. Eating enough food--and the right foods--to maintain your proper weight, and keeping your body strong can make a real difference in staying healthy. Generally speaking, people with HIV/AIDS should try to eat a diet that is 30% protein, 30% fat, and 40% carbohydrates. And eat 3-5 vegetable servings and 2-4 fruit servings every day.

Why is good nutrition important in HIV?

• Good nutrition helps keep your immune system strong, enabling you to better fight disease. A healthy diet improves quality of life.
  
  
• Weight loss, wasting, and malnutrition continue to be common problems in HIV, despite more effective antiretroviral medications, and can contribute to HIV disease progression.
  
  
• Good nutrition helps the body process the many medications taken by people with HIV.
  
  
• Diet (and exercise) may help with symptoms such as diarrhea, nausea, and fatigue, and with fat redistribution and metabolic abnormalities such as high blood sugar, cholesterol, and triglycerides

Addiction and Recovery

Addiction and Recovery

Active use

People who use street drugs usually don’t get enough nutrition (macronutrients or micronutrients). In HIV-positive users, problems with nutrition, such as wasting, may be driven more by drug use than HIV status. Some people who regularly use substances such as heroin, cocaine, crack and crystal methamphetamine don’t have a regular place to live may find it hard to get food and to get the care they need for their health problems. And when it comes time to decide how to spend limited money, food is often a low priority. The downside is that malnutrition, HIV infection and addiction together place HIV-positive drug users at high risk of becoming sick and needing to go to the hospital. Eating better may help you stay healthier while you are using.

As children grow into their teenage years,

As children grow into their teenage years, the challenges continue. They gain independence but also must begin to take responsibility for their chronic condition. Good nutrition and even adhering to their HAART regimen may become less important to teens as they grapple with all the complexities of living with a chronic disease like HIV—and being a teenager.

Children living with HIV need ongoing nutrition care and support.

HIV-positive children should have ongoing nutritional care at a pediatric centre to make sure they stay healthy and grow properly. If growth is slow, boosting nutrition will be an integral part of the treatment plan. The first step will be to change the child’s diet to increase calories and protein.

In more severe cases where the child still doesn’t gain weight or grow quickly enough or even loses weight, a feeding tube may be required. A PEG (percutaneous endoscopic gastrostomy) is the preferred method because children often need extra help for a long time.

Children with HIV/AIDS

Children with HIV/AIDS

Thanks to better testing of pregnant women for HIV and more effective anti-HIV treatment, fewer HIV-positive infants are born in Canada than in the time before HAART. And many children who were born with HIV are now reaching their teenage years and adulthood.

Children with HIV are like other children—their bodies are especially sensitive to nutrition. All children must eat well to grow properly. On top of the normal demands of growth, HIV-positive children must cope with the extra demands that the virus places on their body.

Meeting these demands can sometimes be hard because children living with a chronic disease such as HIV can have a poor appetite and little interest in food and can feel full quickly. They often eat very slowly and tend to be picky eaters. Like HIV-positive adults, they experience problems such as diarrhea and nausea, which make it harder to eat. They can also have metabolic problems with blood lipids and fat redistribution.

As a parent or guardian of a child with HIV, it is easy to worry about your child’s nutritional needs. This can sometimes make meals very difficult. Not being able to get enough good food can make it even harder.

Do not breastfeed your children if you have HIV.

Breastfeeding

Do not breastfeed your children if you have HIV.

When an HIV-positive mother breastfeeds her baby, there is a risk of at least 16% that the baby will become HIV positive. In Canada, mothers with HIV are advised to completely avoid breastfeeding and to feed the baby commercial infant formula. Some provinces have subsidized formula programs that help pay for the formula. Ask your healthcare team about the programs in your province.

To deal with morning sickness or nausea from anti-HIV drugsa

• To deal with morning sickness or nausea from anti-HIV drugs:
  • Eat bland, low-fat foods. As well, salty foods, room-temperature foods and dry foods might also be easier to tolerate.
  • Eat every 2 to 3 hours to prevent low blood sugar.
  • Don’t brush your teeth immediately after eating.
  • Ginger may be helpful (ginger ale, ginger tea or ginger supplements).
  • If iron supplements increase nausea, take the supplement with plenty of food.
  • Ask your doctor about Diclectin, an anti-nausea medicine that is safe to use during pregnancy and can be taken with HAART.
  • See “Nausea and vomiting,” Chapter 6, for more ideas.
• For heartburn, eat small meals of foods that are not spicy or acidic. Avoid foods like black pepper, tomatoes, oranges and lemons.
• For constipation, increase fibre and fluids. Try high-fibre bran cereals once or twice a day (see “Constipation,” Chapter 6).
• Limit your intake of juice, soft drinks and sugar. This will help your insulin work well and will minimize the chance of developing gestational diabetes.
• Keep active and get plenty of rest.
• Alcohol, street drugs and tobacco are all harmful to the developing infant. Stopping use or cutting down during pregnancy will increase your chances of having a healthy baby.

Pregnancy

Pregnancy

If you are pregnant, good nutrition can help you have a healthier newborn. This is especially important if you are HIV positive because pregnant women with HIV are at higher risk of giving birth before they are due and having a newborn that is underweight.

Pregnant women with HIV, like all pregnant women, need more calories, protein and micronutrients, especially folic acid and iron. But it is sometimes hard to meet those needs, especially if you’re HIV positive; morning sickness and side effects of HAART may make it hard to eat enough or to keep food down.

Taking HAART while you are pregnant greatly reduces the risk of infecting your baby. Women taking HAART may be at higher risk of developing gestational diabetes, a type of diabetes that occurs only during pregnancy. Talk to your healthcare team about this. Dietary strategies may help decrease this risk.

Nutrition support

Nutrition support

Sometimes, no matter how hard a person with HIV tries, it is impossible to gain weight. For people who cannot eat enough, who continue to lose weight or who remain seriously underweight, nutrition support is an option. Nutrition support can be delivered through a feeding tube into the stomach or via an intravenous line directly into the bloodstream. Feeding tubes are used when the digestive system is working but the person is malnourished and cannot eat enough.

For short-term use, a nasogastric tube is placed through the nose and into the stomach. This is most often used during a hospital admission. For the longer term, especially for home-tube feeding, a gastrostomy tube, or PEG (percutaneous endoscopic gastrostomy), is surgically placed through the abdominal wall. Special formula is dripped into the stomach and may provide total nutrition or be a supplement to regular food intake.

Most people are reluctant to have a feeding tube because it is seen as invasive and psychologically is a symbol of serious illness. However, studies have shown that people with HIV who do accept this type of feeding gain weight and body cell mass, have improved functional ability and better quality of life. This type of nutrition support can save your life if you really need it.

Problems in the mouth or throat

People with HIV may experience problems in the mouth or throat due to side effects of medications, damaged or diseased teeth and gums, or opportunistic infections like thrush, chancres or herpes। Anti-HIV drugs sometimes cause abnormal tastes or dry mouth. The most common cause of swallowing problems is esophageal candidiasis (thrush in the throat). The overall strategy to address painful chewing and swallowing is to adjust textures and tastes for more soothing foods and beverages.

Weight loss and wasting

Severe weight loss is called wasting syndrome. While wasting has several definitions, the following criteria can be used to diagnose wasting:

• loss of 10% of body weight in 6 months or less OR
• 7.5% loss in 3 months or less OR
• 5% loss in 1 month OR
• BMI decreases to below 20 OR
• loss of 5% of body cell mass

Unwanted weight loss remains a serious risk for people with HIV because, as discussed in Chapter 3, even small losses of body cell mass can be dangerous. The primary strategy for treating weight loss and wasting is to increase food intake to the level needed to promote weight gain. This is achieved with a high-calorie, high-protein diet and a daily multivitamin-mineral supplement.

Boosting the appetiteaa

Boosting the appetite

Appetite stimulants may be effective at improving food intake and promoting weight gain. Sometimes a short course of appetite stimulants can help restore normal appetite. Discuss this option with your doctor if you think you need more help with an appetite problem.

Megestrol acetate (Megace) is an appetite stimulant that has been used for many years to improve appetite in people with HIV. Studies of Megace in HIV disease have found that people do gain weight, although most of the weight gained is fat, not lean tissue. In spite of this, food intake increases and people feel stronger and more able to be active, which will eventually restore lean body mass. Megace is a drug that mimics the female sex hormone progestin. It should not be used for a long period, as it may affect the levels of other hormones, testosterone in particular.

Marinol, a derivative of THC (the active compound in marijuana), decreases nausea and sometimes increases appetite but has not been found to be that effective at promoting weight gain in people with HIV. The side effects are sleepiness and impaired ability to think clearly, which some people find unacceptable. Taking it at night may decrease these side effects and make it more tolerable.

Marijuana is effective at treating nausea and increasing appetite. In Canada, it is possible to obtain a permit from the federal government to possess and grow marijuana for its therapeutic value. Smoking or eating marijuana prior to meals and snacks increases food intake, but the food choices may not always be the healthiest. Planning ahead can ensure that the appetite-stimulating effects are used to the best nutritional benefit.

Diarrhea

Diarrhea

Diarrhea can occur from HIV infection of some immune cells within the intestine, an opportunistic infection or the side effect of medications। It can result in poor absorption of carbohydrates, fats, proteins and micronutrients, especially if it persists for a long time. Diarrhea occurs when substances pass through the intestines too quickly. There is not enough time to absorb all the nutrients, water and electrolytes. The end result is liquid stools and inadequate absorption. The main dietary strategies to counter diarrhea are to decrease the intake of substances that irritate the intestines and to slow down passage through the tract.

Lack of appetite

Not eating enough due to a lack of appetite is often the driving force behind weight loss and wasting in HIV disease. Lack of appetite may arise due to illness, fatigue, depression, drug side effects or addiction. It is a very common problem and can be difficult to overcome. Dealing with persistent lack of appetite can be depressing and a source of anxiety and stress. In some cases, in spite of best efforts, it is not possible to overcome the lack of appetite, and nutritional status continues to decline

Managing Symptoms and Side Effects

Symptoms and side effects are common with HIV. They can be due to HIV infection itself, to co-infection or opportunistic infection, or to HAART. It is important to discuss with your doctor any symptoms you are experiencing, as they may indicate an underlying problem that requires medical treatment. Likewise, make sure you discuss with your healthcare team any side effects you experience—particularly those from anti-HIV drugs—because managing side effects is an important part of staying on your therapy. There are many ways to help you. This section of the guide provides dietary strategies for managing the most common symptoms or side effects.

Bone health

Bone health

In recent years, low bone mass and density, called osteopenia or osteoporosis, has become a widespread problem among people with HIV. Osteopenia is an early stage of bone mineral loss in which the bones become less dense and weaker. This condition does not cause pain or limit movement and is usually treated with diet and exercise rather than medications. Osteoporosis, the more advanced form of the disease, results in fragile bones that can fracture easily. The fracture causes pain, limits movement and reduces quality of life. Osteoporosis is sometimes treated with medications as well as diet and exercise. Note that osteoporosis medications may not be suitable for all people, especially women of childbearing age.

It is still not clear whether bone problems are caused by HAART or by the virus itself. However, many other factors are well known to increase the risk of developing osteopenia or osteoporosis. These include genetics (e.g. your mother had osteoporosis); getting older; low physical activity; being underweight; malnutrition; not enough calcium, vitamin D or protein; poor absorption of nutrients; diseases of the liver, gut or kidneys; and low levels of hormones such as estrogen or testosterone.

Getting enough calcium, vitamin D and protein helps to keep your bones healthy.

Some doctors recommend that people with HIV should have their bone density measured every two years by a special X-ray technique called a DEXA scan. The DEXA compares bone density to standards called T-scores. If the T-score is -1.0 to -2.5, it is considered osteopenia; if it’s below -2.5 (for example, -3.2), it is considered osteoporosis.

Nutrition is always the first line of treatment for osteopenia or osteoporosis, and studies have shown that increasing calcium and vitamin D can restore some bone mineralization.

Mitochondria are often called the “power plants” of human cells

Mitochondria are often called the “power plants” of human cells. All cells contain these microscopic structures, which produce energy for the cell to do its work and stay healthy. Mitochondria convert fats and carbohydrates into a molecule called ATP, the basic fuel for cells. Some cells, like nerve, heart and muscle cells, need a lot of ATP, so they have a lot of mitochondria.

One of the most troublesome toxicities of anti-HIV drugs is that they can damage mitochondria. Some anti-HIV drugs damage the DNA so that the cell can’t produce new mitochondria. When cells get low on mitochondria, they can’t make enough energy to function properly. This condition is called mitochondrial toxicity. It wreaks havoc throughout the body and is thought to contribute to nerve damage (neuropathy), muscle damage (myopathy), heart muscle damage (cardiomyopathy), fat wasting (lipoatrophy) and other health problems. Two anti-HIV drugs associated with the highest risk of mitochondrial toxicity—d4T (stavudine, Zerit) and ddI (didanosine)—are used much less frequently now that we have newer, safer drugs that are less likely to cause this effect.

People experiencing mitochondrial toxicity often have elevated levels of lactate (lactic acid) in the blood. High lactate levels can cause nausea, headaches and fatigue and can make you feel full on a small amount of food (early satiety). Very high lactate levels, called lactic acidosis, can be fatal. If lactic acidosis has occurred or is suspected by your doctor, HAART must be stopped temporarily. Once the acidosis subsides, you may restart HAART with a different combination of anti-HIV drugs.

There are no specific nutrition guidelines for treating mitochondrial toxicity, but some small studies have shown a benefit from B vitamins and L-carnitine supplementation. As well, treatment options for children born with defective mitochondria may provide some guidance. In these children, experts often recommend supplementation with all the cofactors that help the mitochondria function properly (see below). Although there is no scientific evidence that this strategy works for mitochondrial toxicity in HIV, it may offer benefits in terms of feeling better and being able to stay on medications.