Tessa Englund and Xiaolu Hou Source httphivhealthgovtt Objectives Examine HIVs history etiology amp effects on the human body Explain the impact of HIV on nutritional status amp vice versa ID: 737955
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Slide1
HIV/AIDS and Nutrition
Ali Aziz, Aurielle Lowery, Sarah Vacher, Tessa Englund, and Xiaolu Hou
Source: http://hiv.health.gov.tt/Slide2
Objectives
Examine HIV’s history, etiology, & effects on the human bodyExplain the impact of HIV on nutritional status & vice versa Discuss nutrition assessment methods for an HIV patient
Identify nutrition diagnoses for the case patient & other common diagnoses for HIV/AIDS patients
Identify nutrition interventions for HIV/AIDS patients
Discuss common goals/outcomes as well as time frames
for nutrition monitoring & evaluation
Use a male case patient with AIDS-Stage 3 with oral thrush
to facilitate more detailed exploration of the topics aboveSlide3
Case Patient T.L.
32-year-old African American male, 6’1”, 151# CBW, and 160-165# UBW HIV diagnosed 4 years ago but had never been treated for it PTAAdmitted with very sore mouth/ throat, likely PNA & progression
to AIDS, mild malnutrition, & 8.5% weight loss compared to UBW.
Diagnosis of AIDS-Stage 3 with thrush & no clinical evidence of PNA. HAART initiated with Atripla.
Sources: http://remediesforthrush.blogspot.com/2013/09/oral-thrush-infection-and-solution.html
http://recommendpills.com/candidiasis-symptoms-and-treatment/04/11/2012/Slide4
HIV/AIDS and Nutritional Status
The first cases of AIDS were described in 1981. Soon after, HIV was identified as leading to AIDS.At the end of 2008 an estimated 33.4 million people lived with either AIDS or HIV.
Epidemiology and Trends
Acquired immune deficiency syndrome (AIDS) is caused by Human Immunodeficiency virus (HIV) .
HIV affects the body’s ability to fight off infection and disease.
Nutritional status plays an important role in maintaining a healthy immune system.Slide5
HIV Transmission
HIV is transmitted via direct contact with infected fluidsBlood, semen, pre-seminal fluid, vaginal fluid,
breast milk
Cerebrospinal fluid, synovial fluid,
amniotic fluid
Sexual transmission is most common
Saliva, tears, and urine do NOT contain enough HIV for transmission
Source: http://www.prideglv.org/how-do-you-get-hiv/Slide6
HIV-1 vs HIV-2
HIV-1 infection is what we are referring to unless specified otherwiseHIV-2 is endemic in West Africa
Lower viral loads, longer asymptomatic period, lower mortality
rates than HIV-1
Rarely seen outside of Africa or areas with strong ties to affected areas in Africa
Sources: http://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv-guidelines/24/hiv-2-infection
http://jack-wi-sept2012.wikispaces.com/AIDS+in+Africa+-+Linda
Slide7
Stages of HIV Infection
HIV progresses through four clinical stagesAcute HIV infection
Clinical Latency
Symptomatic HIV infection*
Progression of HIV to AIDS*
Two main biomarkers to assess disease progression
HIV RNA (viral load)
CD4 (T-helper cell) count Slide8
1: Acute HIV I
nfectionTime from transmission of HIV to the host until production of detectable antibodies
This is called seroconversion
Non-specific clinical features and very short diagnostic window
Acute HIV infection is rarely discovered Slide9
2: Clinical Latency
Also called asymptomatic HIV infection
Further evidence of illness might not show for as long as 10 years post-infection
Virus is active and replicating at a slow rate
Long-term non-progression
Here CD4 count levels remain WNL and viral loads can be undetectable for years
Not everyone experiences clinical latency for so longSlide10
3: Symptomatic HIV infection
Over time HIV breaks down the immune system and the body is incapable of fighting off the virusHere CD4 counts fall below 500 cells/mm
3
Pt likely to develop s/s
Persistent fevers, chronic diarrhea, unexplained weight loss, recurrent fungal or bacterial infectionsSlide11
4: Progression of HIV to AIDS
Immunodeficiency continues to worsen and CD4 counts fall lowerIncreased risk of opportunistic infections (OIs)
CDC defines AIDS as:
L
ab confirmation of HIV infection in person with a CD4+ count below 200 cells/mm
3
(or less than 14%)
Documentation of an AIDS-defining condition
Krause, pg 866, Box 38-1Slide12
Case Study Patient
Pt believes HIV has progressed to AIDS because he is experiencing: exhaustionsore mouth and throat (thrush)unintended weight loss
possible pneumonia diagnosis Slide13
Source: http://www.cell.com/cms/attachment/531402/3640755/gr2.jpg Slide14
Opportunistic Infections
Candidiasis of bronchi, trachea, esophagus, or lungs - infection caused by yeast (commonly known as thrush)Cryptococcosis - parasitic infection in small intestineCryptosporidiosis - chronic intestinal infection
(greater than 1 month's duration)
Tuberculosis
- bacterial lung infection
Pneumonia
, recurrent
PCP
- form of PNA caused by fungus
These typically present themselves during
the symptomatic HIV infection stage.
Source: Mahan LK, Escott-Stump S, Raymond JL.
Krause's Food & the Nutrition Care Process
. 13th ed. St. Louis, MO: Saunders; 2012.Slide15
Other Common ComplicationsHALS
- HIV-associated lipodystrophy syndromeWasting - unintentional weight lossObesityKaposi’s sarcoma - cancerous connective tissue tumor (pictured)Lymphoma - blood cell tumorsHIV encephalopathy - neurodegenerative disorders (also called HIV-associated dementia)
Chronic liver disease
AIDS-Defining Conditions
Source: http://www.dermis.net/dermisroot/en/1270069/image.htmSlide16
Impact on Nutritional Status
Vitamin and mineral deficiencies are common Resultant of:malabsorption
drug-nutrient interactions
altered metabolism
altered gut & gut barrier function
Commonly low:
Vitamin A, zinc, and seleniumSlide17
Impact on Nutritional Status
Low levels of vitamin A, vitamin B12, and zinc are associated with faster disease progressionHigher intakes of
vitamins B and C have been associated with increased CD4 counts and slower disease progression
No evidence that megadosing is helpfulSlide18
Case Study Patient - Vitamins
Pt diet should be assessed to ensure that he is receiving DRI’s, especially for:Vitamin B12Vitamin A Vitamin E
Vitamin D
Selenium
Zinc
Iron
Because pt is a “picky eater” and has mouth sores that make eating uncomfortable, RD needs to work with him to get adequate nutrients while being sensitive to preferences/pain. Slide19
CD4 Count
Indicator of immune function & stage of HIV infection
Used to determine
whether to initiate
antiretroviral
therapy (ART)
, which suppresses viral loads to increase quality of life and reduce
M&M
Case patient has low T-helper cell counts (CD4) indicating immune suppression and progression to AIDS.
Source: http://www.bio.davidson.edu/Courses/Molbio/MolStudents/spring2003/Cobain/geneprotein.htmlSlide20
Treatment Types: HAART HAART =
Highly Active Antiretroviral Therapy (also commonly referred to as ART) Goals: Reach and maintain viral suppressionReduce HIV related M & M
Increase quality of life
Gain and maintain immune functionSlide21
Classes of Antiretroviral Drugs
Nucleoside and nucleotide reverse transcriptase inhibitors (NRTIs)Nonnucleoside reverse transcriptase inhibitors (NNRTIs)Protease inhibitors (PIs)Fusion inhibitors
CCR5 (chemokine receptor 5) antagonists
Integrase strand transfer inhibitors (INSTIs)
Most common treatment is the
combination of NRTIs + NNRTI
or
PISlide22
Predictors of Adherence
Patients must have the ability and commitment to a lifelong treatmentUnderstanding of the pros and cons of therapy and importance of adherenceBarriers include:homelessness
low literacy level
depression
dementia/psychosis
illicit drug useSlide23
ART Side Effects
ART medications commonly cause the following side effects:diarrhea fatiguegastroesophageal reflux
nauseavomiting
dyslipidemia
insulin resistance
Many ART drugs must be taken on a strict schedule, with or without food. Consider this when evaluating patient lifestyle, willingness to take medication, and access to health care.
Source: http://www.pwnfitness.com/harmful-dangerous-side-effects-zinc/Slide24
Drug-Nutrient InteractionsBe aware of patient’s
medications, vitamins & supplements, and recreational substances consumed/used in order to prevent interactions with ART. Ex: Grapefruit juice and protease inhibitors (PIs) both compete for cytochrome P450 enzyme. Grapefruit consumption can lead to either increased or decreased blood levels of the drug.
Tables 38-2 through 38-5 in the Krause textbook
break down specific drugs, interactions, and side effects.
Source: www.lovewithlife.comSlide25
Cost of Therapy
According to the CDC treatment usually costs $2000 - $5000 a month About half of those diagnosed with HIV do not have regular health care42% are on Medicaid & 24% are uninsured
For the uninsured many will qualify for theAIDS Drug Assistance Program
Many states have an income cutoff of about $22,000/year
Estimated survival time of 24.2 years after HIV diagnosis yields the following costs:
Lifetime on discounted treatment: $385,200
Lifetime without discount: $618,900
Source: http://blogs.scientificamerican.com/observations/2011/01/12/cost-of-cancer-care-projected-to-jump-nearly-40-percent-by-2020/Slide26
Cost Breakdown
Just FYI...HIV/AIDS costs the US about $12 billion annually in health care-related expenses!ART Drugs 73%
Inpatient Costs 13%
Outpatient Costs
9%
Other HIV-related
Medication & Lab Costs
5%Slide27
Nutritional ImplicationsRDs need to take into consideration:
Medications Disease Complications & CombinationsImmunity
Quality of LifeAltered Metabolism
Dietary Habits
Health Care Access Slide28
Energy Expenditure
Research suggests that patients may have up to a 10% increase in resting energy expenditure in asymptomatic HIV patients. That number can rise to up to 20 - 50% after an opportunistic infection (OI). Opportunistic Infections: These infections take advantage of a weakened immune system. Those with immuno-deficiencies can face serious threats from viruses and other microbes that healthy individuals would not even experience symptoms from.
Source: http://www.healthline.com/health-slideshow/hiv-opportunistic-infectionsSlide29
Nutrient Breakdown
PROTEIN: DRI of 0.8 g/kg IBW is recommended for healthy or asymptomatic individuals, however it should increase if REE is calculated at an increased rate.Also increase by 10% after an OI FAT/CHO: Keep intake relative to total calories. There is evidence to support increasing Omega-3 fatty acids in the diet and keeping saturated fats low.
MICRONUTRIENTS: There is NO evidence to support doses of micronutrients
above
the DRI.
It is important to monitor individual nutrients and to do so on a patient-by-patient basis Slide30
Special Considerations: Wasting, Obesity, & HALS
Wasting: unintentional weight loss and loss of LBM which are associated with disease acceleration and mortality. Caused by a combination of possible factors such as poor dietary intake, nutrient malabsorption, increased metabolic rate, or various other metabolic complications. Case Pt: Recent undesired weight loss of 6-9% UBW (9-14 lb.)Obesity: some ART medications increase risk of hyperlipidemia, insulin resistance, and diabetes. Monitor these values and encourage both aerobic and resistance training activities.
HALS: HIV-Associated Lipodystrophy Syndrome
HALS refers to the abnormalities in fat distribution similar to metabolic syndrome. Fat accumulation in the abdominal or dorsocervical region are common. Fat atrophy in the extremities, face, and buttocks are also common. Slide31
Nutritional Implications of HALS
Common problems associated with HALS include: Insulin Resistance HyperglycaemiaDyslipidemiahigh total cholesterol and triglycerides, lowered HDL cholesterol, elevated LDL cholesterol
Type II diabetes mellitus
Nutritional interventions should be targeted towards patients
individual
symptoms and problems. There are no current major nutritional treatments for the lipodystrophy itself, but increasing
fiber intake
and
physical activity
may offer slight benefit.Slide32
Examples of HALS
Source: http://www.nature.com/nrendo/journal/v8/n1/images/nrendo.2011.151-f2.jpg
http://1.bp.blogspot.com/-ewQ6BFHZA6o/T-UahEZ-KFI/AAAAAAAAfwA/-4HonrykycM/s640/collage1.jpgSlide33
Case Patient Information for Nutrition Diagnoses
32-year-old African American male, 6’1”, 151# CBW, and 160-165# UBW HIV diagnosed 4 years ago but had never been treated PTA
Admitted with very sore mouth/ throat, difficulty eating, likely PNA & progression to AIDS,
mild malnutrition
, &
recent 6-9% (9-14 lb.) weight loss
from UBW.
Diagnosis of AIDS
-Stage 3 w/ oral thrush & no evidence of PNA.
HAART initiated.
Sources: http://remediesforthrush.blogspot.com/2013/09/oral-thrush-infection-and-solution.html
http://recommendpills.com/candidiasis-symptoms-and-treatment/04/11/2012/Slide34
Case Patient Information for Nutrition Diagnoses
32-year-old AA male151# (69 kg) CBW,160-165# (73-75 kg) UBW, 6’1” (185 cm)Family hx of CAD & HTN
EEN:
2360-2740 kcal/d
(MSJx1.4-1.5,
rebuild LBM/infection)
100-125 g protein/d
(1.2-1.5 g/kg IBW)
2,398 mL fluid
(35 ml/kg/d)
24-hr recall shows intake of ~2,000 kcal & 71 g protein
HAART regimen Atripla w/ side efx including N/V/D; anorexia; dysgeusia; increased cholesterol & TG; & known interaction w/ alcohol, SJW, garlic, & milk thistle
PTA took MVI, vit C & E, ginseng, milk thistle, & echinacea supplements
2-3 beers 3-4 times/weekSlide35
Nutrition Diagnoses for Case Patient
Sample PES Statements for Patient T.L.Unintended weight loss (NC-3.2) r/t inadequate oral intake and mouth pain AEB caloric intake ~73-85% of EEN according to 24-hr recall; mild malnutrition (82% IBW); and recent undesired significant weight loss of 6-9% (9-14 lb.).Predicted food-medication interaction (NC 2.4)
r/t concurrent use of Atripla, alcohol, milk thistle, and St. John’s wort AEB pt report of regular alcohol consumption and herbal supplementation along with recent initiation of HAART using Atripla (which has known DNIs with alcohol, milk thistle, SJW).
Food and nutrition-related knowledge deficit (NB-1.1)
r/t lack of prior nutrition-related education AEB self-reported usual dietary intake (before mouth sores) high in processed foods and low in fresh nutrient-dense foods; high alcohol consumption; and
excessive vitamin C and E supplementation.Slide36
Common Nutrition Diagnoses for HIV/AIDS Patients
Inadequate oral intake (NI-2.1) Inadequate protein-energy intake (NI-5.3)Increased energy expenditure (NI-1.1)
Increased nutrient needs (NI-5.1)
Malnutrition (NI-5.2)
Unintended weight loss (NC-3.2)
Swallowing difficulty (NC-1.1)
Altered GI function (NC-1.4)
Predicted / Food-medication interaction (NC-2.4 or NC-2.3)
Altered nutrient-related laboratory values (NC-2.2)
Food and nutrition-related knowledge deficit (NB-1.1)
Limited access to food or water (NB-3.2)Slide37
Nutrition Interventions for Case Patient
Adjust meals to a texture modified diet (ND- 1.2) to ease pain from oral thrush and mouth sores by recommending soft foods (prepared mashed, pureed, or cooked until very soft). Refer pt to another provider (ND-1.5) for treatment of oral thrush, likely with antifungal medication.
Promote a general/healthful diet (ND-1.1)
with small, frequent meals to prevent further weight loss and promote weight regain to achieve IBW of 184# or at least UBW of 160-165#.Slide38
Nutrition Interventions for Case Patient
Refer pt to another provider (or community program if necessary) (ND-1.5; ND-1.6) if necessary to decrease alcohol intake & receive more education on living with AIDS. Instruction intended to lead to nutrition-related knowledge. Purpose of nutrition education (E-1.1) should be to improve pt’s food choices to improve PO intake toward meeting EEN; minimize DNIs w/ current medications; and stop excessive supplementation & alcohol consumption. Slide39
Nutrition Interventions
Highly individualized: Very important to tailor intervention to pt needs using clinical judgment & collaborating w/ team of healthcare providers!Energy/nutrient needs:
NO specific nutrition therapy for HIV/AIDS except for meeting additional energy, protein, fluid, & micronutrient needs.
Specific diet/recommendations:
Diet adjustments & nutrition counseling often needed to
manage HIV/AIDS complications & comorbidities
such as:
Cardiovascular disease/risk
Liver or renal disease (
e.g.
, hepatitis B & C)
Diabetes, insulin resistance, and/or altered sex hormonesSlide40
Nutrition Interventions
Provide adequate nutrition/reduce or eliminate malnutritionPRIORITY of treatment to prevent weight loss/wastingnecessary for body to properly process meds & nutrients
may significantly slow progression to AIDS
decrease disease severity, maintain immune fxn, improve lifespan & quality of life
can be challenging to balance important health priorities
Minimize drug-nutrient interactions
many drugs need to be taken w/ regard to food
common HAART side efx of N/V/D, anorexia, dyslipidemia
potential interactions w/ alcohol, grapefruit, supplements
Source: "Position of the American Dietetic Association: nutrition intervention and human immunodeficiency virus infection." JADA 110.7 (2010): 1105-1119.Slide41
Nutrition Interventions
Management of N/V/D Small, frequent lower-fat meals w/ snacksReplenish fluids & nutrients when lost
Avoid lying down within 1 hour of eating
Limit or avoid lactose, caffeine, & insoluble fiber
Nutrition supplements and medication as needed
Adjunct Therapies
Common Medications:
antiemetic, antidiarrheal, appetite- stimulating, lipid-lowering, antidiabetic, anabolic, & pain
Exercise:
maintain/increase LBM, promote healthy BMI &
body shape, & promote CV health
Sources: http://coveville.com/how-to-get-rid-of-diarrhea/
Nutrition Care ManualSlide42
Nutrition Interventions
Education & CounselingGeneral nutrition & PA principlesFood safety & access issues
Meal preparation, timing, & content
Medical adherence & potential DNIs
Micronutrient supplementation
Body image & changes to body weight/shape
Other psychosocial issues
Referral to Other Providers
Last but NOT least...this is key to any plan of care
for HIV/AIDS patients!
Sources: http://www.school-counselor.org/topics/new-school-counselor.html
Nutrition Care ManualSlide43
Nutrition Support
Enteral nutrition (EN) & parenteral nutrition (PN) support are both viable options for HIV/AIDS patients if needed.Criteria for initiating either EN or PN remain the same as for other disease states & ASPEN Guidelines should be followed.“If the gut works, use it!” still applies here...even when PN has been initiated, it is important to stimulate the gut regularly with water & a little food if at all possible to prevent GI dysfunction & reduce risk of bacterial translocation.
Catheter infection & refeeding syndrome are the primary risks of NS but minimized with proper monitoring & adjustment.
Especially for highly immunocompromised HIV/AIDS patients, additional sanitary precautions including the use of sterile water may be needed to reduce risk of infection.Slide44
Nutrition Monitoring & Evaluation
Nutrition reassessments should generally be carried out at least every 3-6 months in HIV/AIDS patients.Treatment for this population is highly individualized, so F/U may be appropriate sooner than 3 months depending on the initial nutrition assessment, diagnosis, & intervention.
During reassessments, it is important to monitor:
Food intake
Body weight, distribution, & composition
Anthropometric measurements can help identify HALS even when weight is stable!
Pertinent lab values
Medications
SupplementsSlide45
Nutrition M&E for Case Patient
Monitor weight over next 2 monthsEncourage 0.5-1 lb. weekly weight gainTarget weight 184 lb. (acceptable range is 166-202 lb.)With changes and disease progression, monitor & evaluate:
Food intake
Lab values
Body composition
Medications
Supplements
Ensure that education is continual and appropriate
M&E should take place at least semiannually after initial F/U