BackgroundMaintaining good nutritional status is important to support overall health and immune system function in people with HIV/AIDS. Many HIV-related conditions affect and are affected by the body's nutritional status. These include conditions related to HIV itself (eg, opportunistic infections and other illnesses), comorbid conditions, and adverse effects of therapies. Inadequate nutrition in people with HIV infection may result from many factors-including conditions such as nausea, vomiting, or anorexia-that may prevent adequate intake of nutrients and medications; diarrheal infections that prevent absorption of nutrients and medications; systemic illnesses (including HIV itself) that create a catabolic state; and psychological conditions (such as depression) that impair patients' ability to nourish themselves. In addition, financial constraints may limit patients' access to nutritious food. Evaluation and enhancement of patients' nutritional status may help correct or compensate for deficiencies (eg, in the case of weight loss or nutrient deficits), may be a key treatment modality for certain conditions (eg, dyslipidemia, hyperglycemia), and may help to maintain good health and immune function. This chapter focuses on the evaluation of patients with nutritional deficiencies, particularly weight loss, and simple strategies for maintaining good nutrition in individuals with barriers to maintaining adequate weight. Ideally, HIV-infected individuals will receive the services of HIV-experienced nutrition specialists, who may contribute to the patient care team in the following ways: - Conducting routine screening to identify and treat nutritional problems
- Preparing a tailored nutritional plan to optimize patients' nutritional status, immune status, and overall well-being
- Screening and developing interventions for growth problems in children
- Developing strategies to prevent loss of weight and lean body mass
- Adapting dietary recommendations to help reduce the risk of comorbid conditions such as diabetes and heart disease, or treating these complications
- Educating patients about how to modify their dietary habits to maximize the effectiveness of medical and pharmacologic treatments
- Tailoring nutritional recommendations to fit patients' lifestyles and financial resources
- Counseling patients to promote nutrition self-care using available resources
- Providing nutritional support to patients may help to do the following:
- Treat common problems associated with HIV disease and its treatment (eg, weight loss, wasting, fatigue, loss of appetite, adverse changes in taste, dental problems, gastrointestinal complaints)
- Treat chronic comorbid conditions (eg, cardiovascular disease, hypertension, diabetes, cirrhosis)
- Improve quality of life
- Enhance immune responses, slow disease progression, and prolong life
S: Subjective HistoryIdentify nutrition risk factors through interview, questionnaire, or both at the start of care. Update the history at least annually. The history should record nutrition-related signs, symptoms, and habits (Table 1); dietary habits (Table 2); and symptoms suggesting nutritional deficiencies (Table 3).  |
| Table 1. Nutrition-Related Questions for Patient History |
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| Signs, Symptoms, and Comorbid Conditions:- Poor or sporadic appetite
- Early satiety
- Weight gain or loss
- Trouble chewing or swallowing
- Dental problems including poor dental hygiene
- Gastrointestinal complaints, including nausea, diarrhea, constipation, heartburn, gas
- Changes in body contours with fat gain in abdomen, back of neck, and breasts (lipodystrophy) and/or fat loss in extremities and face (lipoatrophy)
- Depression, stress
- Fatigue
- Chronic pain
- Other diseases affecting diet and nutrition
Medication-Related Factors:- Medications, including over-the-counter and herbal products
- Medication side effects
- Difficulty coordinating meals with medicines
- Use of nutritional supplements
Social and Behavioral Factors:- Frequent eating out
- Smoking
- Alcohol or substance abuse
- Erratic meal patterns
- Unbalanced diet (eg, high intake of low-nutrient foods; deficiency in key nutrients)
- Resources to ensure secure, continued food access
- Availability of food storage and preparation facilities
- Housing: stable, or homeless/marginally housed/in transition
- Nutrition literacy
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To develop a specific dietary history, use the following questions. |
| Table 2. Questions for Dietary History |
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| Usual Dietary Intake- Frequency of intake of foods providing key nutrients (eg, dairy products, fortified or whole grains, fruits and vegetables, fluids, meat, eggs, beans) as well as those that perhaps should be limited (fast-food items, highly processed or salted products)
- Usual meal patterns (number of times per day, snacks) and whether meals are prepared and eaten at home or eaten at restaurants or fast-food establishments
- Specific information about nutritional supplements (eg, vitamins, minerals, herbs, protein), including contents, amounts, formulation (pills, powders, drinks), cost, and overlap among products
Factors That May Affect or Limit Intake- Amount of money available for food, or participation in food assistance programs (eg, food stamps, food pantries)
- Appetite, general well-being (eg, fatigue, pain, depression)
- Food allergies, intolerances
- Problems with dentition, swallowing, heartburn, diarrhea, constipation
- Coordination of foods and supplements with medications (HIV or other)
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Elicit symptoms that may be related to nutritional deficiencies. | Table 3. Symptoms with Possible Relationship to Nutritional
Deficiencies |
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| - General symptoms (eg, fatigue, decreased cognitive function, headache)
- Behaviorial changes (eg, irritability, apathy, decreased responsiveness, anxiety, attention deficit)
- Body habitus changes (eg, loss or gain of fat)
- Gastrointestinal symptoms (eg, diarrhea, constipation, bloating)
- Changes in skin, nails, hair (eg, dryness, breaking, thinning)
- Muscle loss
- Neurologic symptoms (eg, weakness, sensory changes, gait abnormalities)
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O: Objective Physical ExaminationPerform a careful physical examination, if possible with anthropometric and body composition testing as described below (Table 4). Compare current findings with past assessments and review at least every 6 months. The physical examination should include the following: - Vital signs, with orthostatic vital signs if dehydration is suspected
- Weight (compare with previous values) and body mass index (BMI)
- General appearance and gross nutritional status (eg, obesity, cachexia, wasting)
- Body habitus: loss of subcutaneous fat in face, buttocks, arms and legs and/or increase fat in abdomen, breasts, back of neck, and upper back ("buffalo hump")
- Muscle mass
- Mouth: breakdown in oral mucosa, cheilosis, angular stomatitis, glossitis, papillar atrophy
- Abdomen: hepatomegaly (due to fatty infiltration)
- Skin: dryness, peeling, breakdown, pallor, hypopigmentation or hyperpigmentation
- Nails: pale nail beds, fissures or ridges
- Neurologic system, including strength, sensation, coordination, gait, deep tendon reflexes
Anthropometric and body composition tests are usually performed by registered dietitians. They can provide important information about patients' nutritional status. |
| | | Adults | Measure at baseline (self-report is not accurate). | Measure at least quarterly and consider intervention when small changes are observed. Do not wait until major amounts of weight have been lost or gained. Record sequentially at the front of the patient's chart and monitor for trends. | Use healthy, premorbid weight to assess change, not the first clinic weight or the ideal weight. (Use the patient's weight at a time when she or he is healthy, feels well, and can easily maintain that weight.)#* | | Children | Measure at least quarterly using length board (0-2 years) or wall-mounted stadiometer (≥2 years). | Measure at least quarterly and consider intervention when small changes are observed. Do not wait until the patient has dropped significantly on the growth chart. Calculate age and plot the measurements on growth charts specific for age, sex, and country.* | Assessment of optimal growth is based on the observed pattern over time. General goals include a weight relatively "matched" for length or height (about the same percentile) and relative stability of percentile tracking over time. |
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Body Composition TestingBody composition is commonly tested by bioelectrical impedance analysis (Table 5) or skinfold thickness and circumference (Table 6). |
| Table 5. Bioelectrical Impedance Analysis |
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| Bioelectrical impedance analysis (BIA) testing is the standard of care for adults but has not been well validated for children: - BIA is useful for assessing disease progression or health maintenance, documenting response to treatment, and justifying the cost of nutritional supplements and AIDS-wasting medications.
- The test is simple, noninvasive, and quick (<5 minutes). However, staff training and specialized software are required to interpret the results.
- Perform BIA at baseline. Update every 6-12 months, or more frequently if the patient is ill, has a decline in immune status, or has a weight change of 5-10%.
- The BIA test reports the following:
- Body cell mass (BCM): the target component, reflecting cells in muscles, organs, and the circulation; losses may indicate AIDS wasting. BCM is recorded in pounds. Monitor for trends.
- Fat: an index of energy stores; recorded in pounds and percentage.
- Phase angle: a measure of cellular integrity, an independent indicator of morbidity and mortality in HIV-infected patients.
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| Table 6. Skinfold Thickness and Circumference
Measures |
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| Skinfold thickness and circumference measures can be used for adults and children in resource-limited settings, and when bioelectrical impedance analysis is not available. Circumference measures also can also be used to monitor changes over time associated with lipodystrophy in adults. - Skinfold thicknesses are measured with calipers.
- Circumference measures are taken at specific anatomical landmarks with nonstretchable tape.
- Tables of age- and sex-specific reference values (percentiles) are available at: http://www.cdc.gov/nchs/products/pubs/pubd/series/ser.htm (select Series 11, #238 and go to pages 41-50).
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Laboratory TestingPerform basic laboratory (blood) tests, including the following: - Hemoglobin or hematocrit
- Total protein, albumin
- Fasting glucose
- Lipids (fasting triglycerides, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol)
- CD4 cell count and HIV viral load, if no recent values are available
- Specific vitamin and nutrient tests as indicated by symptoms (eg, iron studies in case of anemia, vitamin B12 in case of peripheral neuropathy)
- Others tests, such as testosterone and thyroid hormone levels as appropriate, to rule out other causes of symptoms
A: AssessmentAssess subjective information and objective findings to evaluate nutritional status. Identify Nutrition ConcernsSeveral factors may influence nutrition: - Barriers to good nutrition (eg, lack of knowledge or motivation for self-care, poor appetite, lack of money for food, lack of facilities for food storage and preparation)
- Lifestyle factors (eg, smoking, substance abuse, frequent eating out, erratic eating patterns, hectic schedule, high stress)
- Physical problems affecting food and nutrient intake (eg, poor appetite, nausea, fatigue, pain, weakness, mouth or throat pain, acid reflux, missing or decayed teeth, poorly fitting dentures, poor eyesight, constipation)
- Nutrient losses (eg, due to diarrhea, vomiting)
- Potential confounding factors (eg, use of multiple overlapping or questionable supplements)
Evaluate Dietary IntakeAssess the following diet-related issues: - Expected excesses or deficiencies from dietary history or interview
- Rating of food security, including access to cooking and refrigeration
- Food intolerances, aversions, or allergies likely to affect adequacy of intake
- Special needs related to other conditions (eg, documented cardiovascular disease, diabetes, hypertension)
Evaluate Weight, Body Composition, and Weight DistributionAssess physical findings of malnutrition and confirm with nutrition history, laboratory tests, and anthropometric evidence. Table 7 describes normal and abnormal findings of anthropometric tests and recommendations for monitoring changes over time. |
| | | Adults | - Chart trends over time relative to previous measurements and the following population norms:
- BMI (healthy range: 19-25)
- BIA:
- BCM (% of weight): women 30-35%; men: 40-45%
- Fat (% of weight): women 20-30%; men 15-25%
- Phase angle: women >5; men >6
- Skinfold thicknesses and circumferences: Chart changes in absolute measures and percentiles
- Changes in body contours: Evaluate lipodystrophy (excess accumulation of fat in abdomen, breasts, dorsocervical area) and lipoatrophy (loss of subcutaneous fat in face, extremities, buttocks)
| | Children | - Plot measurements on growth charts and track percentiles over time (the consistency of percentiles rather than the absolute percentile is important)
- Skinfold thicknesses and circumferences: Chart changes in absolute measures and percentiles
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Evaluate Laboratory Findings- Evidence of malnutrition (eg, low iron or protein stores)
- Evidence of disease or risk of disease for which dietary treatment is indicated (eg, high fasting glucose, hypertension, hyperlipidemia)
Develop a Problem ListTable 8 suggests a useful format for a nutrition-related problem list. |
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| Nutrition barriers: insufficient knowledge, poor appetite, food insecurity, no food preparation or storage facilities, homelessness | | Lifestyle: substance abuse, smoking, erratic eating, frequent fast-food intake, high stress | | Weight or body composition: undesirable weight gain or loss (adult), changes in growth trajectory (children), loss of lean body mass (wasting), gain of excess fat (obesity), lipoatrophy or lipodystrophy | | Physical problems: fatigue, pain, early satiety, poor dentition, clinical signs of malnutrition | | Laboratory findings: low hematocrit or hemoglobin, low protein or albumin, low or high fasting glucose, high total cholesterol, high low-density lipoprotein, high triglycerides, low high-density lipoprotein, low testosterone | | Gastrointestinal: diarrhea, vomiting, reflux, constipation | | Poor diet: poor food choices, bingeing, skipping meals, high sugar intake, high alcohol consumption, high intake of refined foods, low fruit and vegetable intake, insufficient protein, insufficient calcium, food allergies or intolerances limiting intake | | Comorbid conditions: diabetes, hypertension, cardiovascular disease, cancer, gastroesophageal reflux disease (GERD) | | Medications: drug-drug or drug-nutrient interactions or difficulty coordinating medicines with meals | | Supplements: insufficient or excessive intakes, cost of supplements unaffordable, supplements with potential or unknown risks |
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P: PlanDevelop a nutritional plan and provide practical nutrition education for common problems. Some useful online sources for patient handouts include: Evaluate and treat concurrent medical problems (eg, diarrhea, nausea, infections, malignancies, depression). For severe or persistent nutritional problems, or for specific needs, refer to a nutrition specialist for evaluation and treatment. Table 9 lists of common nutrition-related problems and some simple suggestions that may help resolve them and help patients maintain adequate nutrition. |
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| Weight Loss (decrease in both body cell mass and fat) | - Early identification and ongoing monitoring are key.
- Identify and treat underlying risk factors.
- Try to add calories without adding "bulk" :
- Fat (9 calories/gram): butter, margarine, avocado, cream, mayonnaise, salad dressing
- Carbohydrate (4 calories/gram): jam, jelly, sugar, icing, gum drops
- Protein (4 calories/gram): protein powders, cheese, nut butters, trail mix, powdered breakfast drinks, nonfat dry milk
- Eat more frequently.
- Maximize good days.
- Use canned supplements (eg, Ensure, Boost).
- For wasting or substantial weight loss, consider referral for therapies such as appetite stimulants or human growth hormone.
| | Diarrhea | - Increase soluble fiber; decrease insoluble fiber.
- Replenish beneficial bacteria (eg, with lactobacilli preparations).
- Avoid intestinal irritants and stimulants.
- Decrease dietary fat.
- Decrease or eliminate lactose.
- Increase fluids and provide electrolytes (sodium, potassium).
- Treat with pancreatic enzymes.
| | Early Fullness | - Take small, frequent meals.
- Concentrate on solid foods, with liquids between meals.
- Eat lower-fat, lower-fiber foods.
- Wear loose-fitting clothing.
- Sit up while eating.
- Eat, walk, and eat again.
| | Nausea | - Take small, frequent meals.
- Try dry snack foods.
- Avoid fried foods, very sweet foods, spicy foods, and foods with strong odors.
- Try cool, clear beverages, popsicles.
- Try ginger-containing foods and drinks.
- Keep liquids to a minimum at meals.
| | Changes in Taste | - Eat a variety of foods, not only favorite foods.
- Try protein sources other than red meat.
- Marinate foods, use sauces.
- Use more and stronger seasonings.
- Try tart foods.
- Use sugar or salt to tone down the flavor of foods.
- Try a mouth rinse of 1 teaspoon of baking soda in 1 cup of warm water before eating.
| | Loss of Appetite | - Rely on favorite foods.
- Ask family members and friends to prepare meals.
- Eat small, frequent meals.
- Keep snacks handy for nibbling.
- Eat before bedtime.
- Eat in a pleasant place, with other people.
- Make the most of good days.
- Try light exercise to stimulate appetite.
- Add extra calories without adding bulk.
- Consider appetite stimulants (megestrol, stimulants).
| | Difficulty Chewing or Swallowing or Sore Mouth and Throat | - Choose soft, nutritious foods.
- Blend or puree foods (eg, soup or stew, smoothies).
- Add cream sauces, butter, or gravy for lubrication.
- Sip liquids with foods.
- Use a straw or drink foods from a cup.
- Choose bland, low-acid foods.
- If hot foods cause pain, serve foods cold or at room temperature.
- Avoid alcohol and tobacco.
- Soothing lozenges or sprays may help.
| | Food Insecurity | - Refer to social services for assistance with accessing resources such as food stamps, community meals, or a food pantry program.
- Refer to a dietitian for assistance with low-cost food ideas.
- Use materials at http://www.cheapcooking.com/index.htm
| | Unbalanced Diet and/or Other Conditions Requiring Dietary Modification | - Refer to a dietitian for counseling and education.
- Use materials at http://www.mypyramid.gov to assist with general counseling about dietary adequacy, balance, and portion size.
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Nutrition SpecialistsWhenever possible, nutritional services should be provided by a registered dietitian (RD) who is a qualified HIV care provider. In the United States, holding this status requires a nutrition degree from an accredited college, graduation from an approved internship or master's degree program, and maintenance with 75 continuing-education units every 5 years, including specific and ongoing HIV training. An RD with HIV/AIDS expertise in the United States can be located by going to http://www.eatright.org, clicking on "Find a Nutrition Professional," entering the patient's zip code or city, and selecting "HIV/AIDS" under areas of specialty. Membership in the HIV/AIDS Dietetic Practice Group (http://www.hivaidsdpg.org) also may indicate HIV experience. ResourcesThe following online resources were referenced in this chapter: - 2000 CDC Growth Charts: United States. CDC, National Health and Nutrition Examination Survey. Available online at www.cdc.gov/growthcharts/.
- Anthropometric Reference Data and Prevalence of Overweight: United States, 1976-80. Najjar, M. F., Rowland, M. October 1987. 84 pp. PB91-213033. PC A05 MF A01. CDC, National Center for Health Statistics. National Health Survey, Series 11, No. 238. Tables 31-41. Available online at www.cdc.gov/nchs/products/pubs/pubd/series/sr11/240-221/240-221.htm.
- Body Mass Index Home. CDC, Division of Nutrition and Physical Activity, National Center for Chronic Disease Prevention and Health Promotion. Online calculators for calculating BMI in adults, children, and teens. Available online at www.cdc.gov/nccdphp/dnpa/bmi/index.htm.
- CheapCooking.com. Web site with recipes using low-cost ingredients and tips for frugal meal planning. Available online at www.cheapcooking.com.
- HIV/AIDS Dietetic Practice Group. Affiliate of the American Dietetic Association. Web site includes screening tool, Nutrition Screen and Referral Criteria for Adults (18+ Years) with HIV/AIDS. Available online at www.hivaidsdpg.org.
- MyPyramid.gov. U.S. Department of Agriculture Web site with dietary guidelines, tips, resources, and consumer-oriented information. Available online at www.mypyramid.gov.
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