Nutrition in the era of highly active antiretroviral therapy [Shevitz AH and Knox TA. CID 2001;32:1769]: The authors from Tufts review multiple aspects of nutrition and HIV infection and make the following observations:

• Nutritional Assessment: Assessment should include the following: 1) clinical assessment (premorbid weight, weight since HIV infection, exercise/weight training, OIs, diarrhea, fever, history of eating disorders, issues regarding food availability); 2) dietary intake (diet history and intake according to 24 hour recall and three day food record and/or food frequency questionnaire; use of alcohol, narcotics, and stimulants); 3) anthropometry (height, weight, BMI, waist measurement, hip circumference, and waist-hip ratio); and 4) biochemical measurement (albumin, B12 level, free testosterone, fasting lipid profile, and fasting glucose). Calculation of BMI is weight (kg)/height (m)². Overweight is defined as a BMI exceeding 25 kg/m², obesity is 30 kg/m².
• Fat Redistribution: The recommendation is for dual-energy x-ray absorptiometry (DEXA) to measure whole body fat as well as regional fat. The authors prefer this technique over CT scans and MRI. The most practical method for assessing fat redistribution is the waist-hip circumference measurement, with a ratio of >0.85 for women and >0.95 for men, as indicative of lipodystrophy.
  § Energy Balance: To maintain stable weight, there must be a caloric intake that equals the total energy expenditure. Caloric requirements in kcal/day-the estimated resting energy expenditure for men and women can be determined from the following equation:
  • Men = 66 + 13.7 Wt (kg) + 5 Ht (cm) + 1.8 Age (yrs)
  • Women = 665 + 9.5 Wt (kg) + 1.8 (ht (cm) + 1.8 Age (yrs)
• Weight Loss: HIV-associated factors that result in weight loss are summarized as follows: 1) malabsorption with or without diarrhea; 2) hypermetabolism (high viral load, HAART, secondary infections, fever, drug abuse especially with stimulants such as cocaine); 3) inadequate intake (nausea, anorexia, vomiting, oral pathology, inadequate access to food, or eating disorder); 4) extreme over activity. It is noted that weight gain associated with HAART has been shown to be largely increases in body fat [AIDS 1998;12:1645]. The authors point out that this weight gain can be directed to lean body mass with exercise or testosterone replacement in hypogonadal states [AIDS 1999;13:231; Ann Intern Med 1998;129:18]. "Supraphysiologic androgen therapy" also increases lean body mass [JAMA 1999;281:1282].
• Protein Requirement: The recommended daily allowance for protein for persons 25-50 years in good health is 0.8 g/kg/day, which is easily achieved with the average American diet. For wasted persons, a protein intake of up to 1.5 g/kg/day may be helpful, but protein intake above this is not advocated and may be dangerous.
  
• Exercise: The authors advocate strength training with weight lifting for increasing muscle/lean body mass, and aerobic exercise for increasing energy expenditure for persons with weight gain and cardiovascular fitness.
  
• Management of Weight Loss: 1) record weight at each clinic visit; 2) reduce HIV RNA levels; 3) treat opportunistic infections; 4) treat nausea, vomiting, diarrhea, and oral lesions; 5) evaluate for and treat hypogonadism; 6) treat substance abuse; 7) improve access to food; 8) maximize calorie intake with caloric supplements and "consider use of Megace and dronabinol;" 9) strength training with experienced trainers; and 10) consider anabolic therapy with androgens (testosterone, oxandrolone, or nandrolone) or growth hormone.
  posted 7/6/2001
  

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