Nutrition and HIV/AIDS: A Training Manual
Session 3
To provide general nutrition and dietary
guidelines to mitigate the effects of HIV on
nutrition and reduce the progression of
HIV/AIDS morbidity, mortality, and related
Session Outline
 Goals of nutrition care and support in
 Essential components of nutrition care
and support in HIV/AIDS
 Key actions for HIV-infected people
 Appropriate assessments, interventions,
follow-up and review for nutritional care
Goals of
Nutrition Care and Support
• Improve nutritional status
 Maintain weight and prevent weight loss
 Preserve muscle mass
• Ensure adequate nutrient intake
 Improve eating habits and diet
 Replenish stores of essential nutrients
• Prevent food-borne illnesses
• Enhance quality of life
 Treat opportunistic infections
 Manage symptoms affecting food intake
• Provide palliative care
Components of
Nutritional Care and Support
1. Nutritional
2. Intervention
3. Follow up and review
Nutritional Assessment
Why Measure?
 To identify and track body composition changes
over time and trends
 Changes in weight
 Changes in body cell mass and fat-free mass
 Serum nutrient levels, cholesterol, etc.
 To use results to design appropriate interventions
 To address client concerns about their health
 To meet increasing emphasis on physical nutrition
assessment as part of clinical trials
What to Measure?
Laboratory tests
Clinical assessments
Diet history and lifestyle
Anthropometric Measurements
To assess and monitor weight
 Weight and height
 Percentage of weight and/or body mass index
changes over time
To assess and monitor body composition
Lean body mass
Body cell mass
Skinfold (triceps, biceps, mid-thigh)
Circumferences (waist, mid-upper arm, hips
[buttocks], mid-thigh, breast size for women,
neck circumferencve (buffalo hump])
Laboratory Measurements
To assess and monitor nutrient levels
 Serum micronutrients (e.g. retinol, zinc)
 Haemoglobin (and ferritin)
To assess and monitor body composition
 Fasting blood sugar,
 Lipid profiles (e.g., cholesterol and
 Serum insulin
Clinical Assessments in HIV/AIDS
Symptoms and illnesses associated
 Diarrhea and vomiting
 Fever (temperature)
 Mouth and throat sores
 Oral thrush
 Muscle wasting
 Fatigue and lethargy
 Skin rashes
 Edema
 Palm pallor
Diet History in HIV/AIDS
24-hour food consumption or food
frequency recalls can be used (in the
absence of acute food stress) to assess
 Types and amounts of food eaten (including
food access and utilization and food handling)
 Use of supplements and medications
 Factors affecting food intake (appetite, eating
patterns, medication side effects, lifestyle,
taboos, hygiene, psychological factors, stigma,
economic factors)
Stages of HIV Disease and
Specific nutrition recommendations vary
according to underlying nutritional
status and HIV disease progression
 Early stage: No symptoms, stable weight
 Middle stage: Weight loss, opportunistic
infections associated effects
 Late stage: Symptomatic AIDS
Nutrition Care and Support
Priorities by Stage of Disease
Asymptomatic: Counsel to stay healthy
 Encourage building stores of essential nutrients and
maintaining weight and lean body mass
 Ensure understanding of food and water safety
 Encourage physical activity
Middle stage – Counsel to minimize consequences
 Counsel to maintain dietary intake during acute illness
 Advise increased nutrient intake to recover and gain weight
 Encourage continued physical activity
stage: Provide comfort
Advise on treating opportunistic infections
Counsel to modify diet according to symptoms
Encourage eating and physical activity
Nutrition Actions for HIVInfected People
To prevent weight loss
 Promote adequate energy and protein intake
 Individualize meal plan and modify to match
medication regime or health changes
 Advise changing lifestyles that negatively affect
energy and nutrient intake
To improve body composition
 Promote regular exercise to preserve muscle mass
 Promote steroids
To improve immunity and prevent infections
 Promote increased vitamin and mineral intake
 Promote food safety
 Promote use of ARVs to reduce viral load
Algorithm for Managing Weight
Loss in Patients with HIV/AIDS
DX Profile=starved
metabolism, decreased
body fat/lean
RX=Feed (IV, enteral,
appetite stimulation),
make meal plans,
promote positive
lifestyles, treat
symptoms that may
affect food intake
Diarrhea or malabsorption?
DX Profile=starved
metabolism, decreased
body fat/lean
RX= Treat GI disorders
and other infections,
consider supplements
and drug-food
interactions, counsel on
hygiene and food
Source: Adapted from Hellerstein and Kotler 1998
DX Profile=abnormal
metabolism, relatively
high fat/lean ratio; low
RX=Make an exercise
plan, provide metabolic
steroids (?) and ARVs (?)
Etiology unknown
or unclear
RX=Continue to
feed and observe
Promote Adequate
Nutrient Intake
 Identify locally available and acceptable foods
 Promote a diet adequate in energy, protein and
other essential nutrients
 Increase energy intake by 10%-15%
 Increase protein intake
 Increase eating a variety of foods (especially
more fruits and vegetables) and/or promote
multiple micronutrient supplements for
improved immune function
Support Individualized Meal Plans
• Stage of illness and symptoms
• Food security (availability and accessibility of
basic foods)
• Resources (money, time, other caretakers)
• Food likes and dislikes
• Knowledge, attitudes, and practices
(especially traditional dietary taboos)
Modify Meal Plans to Suit
Medication and Health Status
 Flexibility to change depending on client context
 Possible food and drug interactions
 Changes in medication regimens
 Absence of opportunistic infections and other
infections that may affect food intake or
 Changes in food accessibility in terms of quality
and quantity (especially in resource-poor settings)
Promote Lifestyle Changes for
Nutritional Well-being
 Eliminate foods and practices that aggravate
 Raw eggs and unpasteurized dairy products
 Foods not thoroughly cooked, especially meats
 Unboiled water or juices made from unboiled water
 Avoid foods that may affect food intake
 Alcohol and coffee
 “Junk” foods with little nutritional value
 Foods that aggravate symptoms related to diarrhea, nausea
and vomiting, bloating, loss of appetite, and mouth sores
(e.g., expired foods, fatty foods)
Recommend Regular Exercise
Muscle loss can be restored by reducing
viral load or maintaining physical activity
Physical activity improves
Lean body mass
Body composition
Bone density
Functional capacity
Quality of life
Therapeutic Regimens
for HIV-Related Weight Loss
Rate of change in body
LBM (kg/wk) Weight (kg/wk)
Megestrol acetate
Parental nutrition
Nandrolone (hypogonadal)
Resistance exercise alone
Resistance exercise and
Source: Adapted from Hellerstein and Kotler 1998
That Build Muscle Mass
 Weight bearing exercises
 Resistance training
 Weight training
 Exercises generating high force on bone
Stair climbing
 Relaxation exercises
 Yoga
Vitamin and Mineral Intake
Strategies to increase vitamin and mineral intake to
replenish or build body stores and optimize immune
Food-based approaches
 Include local vegetables, vitamin-enriched or fortified local
products (maize meal, wheat or soy flour, margarine, cereals)
 Have no undesirable side effects
 Are affordable
Nutrient supplements
 Are more absorbable by sick person
 Multivitamin and multiple-micronutrient supplements are
better than than single vitamins and minerals
Suggested Nutrient Supplement
Intake in HIV/AIDS
Vitamin A
RDA=5,000 IU)
Vitamin E
2-4 RDA (13,000-20,000IU)
Vitamin B
Vitamin C
High-potency B complex
(e.g., B-25 or B-50 with
niacin and B6)
1 RDA (12-19mg)
400-800 IU
Source: Serono 1999; Tang et al 1996. Excerpts from Eat up
Adverse Effects of Too Much
Intake of Nutrient Supplements
Vitamin E: Malabsorption of vitamins A and K and
gastrointestinal upsets
Vitamin C: Gastrointestinal upsets, iron overabsorption
and abdominal bloating
Iron: Gastrointestinal bleeding (manifested by vomiting and
bloody diarrhea) and possible stimulation of viral replication
Zinc: Gastric distress, nausea, reduced immune
function that favors viral replication (HDL reported in
supplements of > 300mg/day)
Vitamin B: Gastrointestinal upsets
Selenium: Skin lesions, nausea, and vomiting
Source: Afacan et al 2002, Tang et al 1996; Ziegler and Filler 1996
Promote Food Safety
to Prevent Food-Borne Illness
Educate clients to avoid products that
 Contain raw or undercooked meat
 Have expired
 Are in damaged or bulging packing
 Are displayed unsafely (e.g., mixing raw and cooked
foods or meats with fruits and vegetables)
 Are sold in unsanitary conditions or by workers with
poor personal hygiene or food handling practices
Follow up and Review
Monitor the Client’s Well-being
Follow up
 Integrate with other care and support activities where
 Do continuously in facility and home
 Include monitoring of health, nutrition, and dietary
 Include counseling to address barriers to good nutrition
 Offer support and encouragement
Meal plans
Exercise regimens
Use of medicines
Compliance with meal requirements
Factors to Consider in Care
and Support of People
Living with HIV/AIDS
Factors in Design and
• Social: Support, stigma, gender roles,
education, information, traditions, beliefs
• Economic: Household resources, food
security, financial access to health and
• Client rights: Privacy, nondiscrimination in
public services
• Quality of support and care: Counseling,
infrastructure, consistency, access to VCT and
ARVs, information on ARVs
Nutritional and
Antiretroviral Therapy
Common Antiretroviral Drugs
Reverse transcriptase inhibitors (RTIs)
 Nucleoside reverse transcriptase inhibitors, or NRTIs:
Zidovudine (AZT,ZDV), Lamivudine (3TC), Abacavir (ABC)
 Non-nucleoside reverse transcriptase inhibitors, or NNRTIs:
Nevirapine (NVP), Efavirenz (EFV), Delavirdine (DLV)
Protease inhibitors (PIs)
 Saquinavir (SQV)
 Ritonavir (RTV)
 Indinavir (IDV)
Often taken in combination to increase effectiveness
and reduce resistance
Promote Use of ARVs
 Reduces viral load, associated opportunistic
infections, and immunity to other infections
 Reduces HIV-related wasting and the negative
effects on body composition
 Reduces deficiencies of micronutrients such
as zinc and selenium (Rousseau et al 2000)
Educate on Nutrition-Related
Side Effects of ARVs
 Lipodystrophy (fat maldistribution)
 Hyperglycemia/insulin resistance
 Hyperlipidemia
 Means fat maldistribution
 Is observed in 6%-80% of patients on ARVs
 Is caused by metabolic changes associated with immune
reconstitution and ARV mitochondrial toxicity
 Results in
 Hyperlipidemia
 Hyperglycemia, insulin resistance, and glucose intolerance
 Peripheral wasting (extremities, face)
 Visceral and subcutaneous central adiposity (buffalo hump,
breast enlargement)
 Managed by exercise training
and Insulin Resistance
 Hyperglycemia: Increased blood sugar levels
from pancreatic problems or insulin resistance
 Insulin resistance (impaired message system)
reported in 28%-35% of adult patients on ARVs
 Few cases of diabetes (3%-9%)
 Management with
 Antidiabetic agents
 Antioxidants (e.g., vitamin C and selenium) to
support glutathione, which is crucial in insulin
 Changes triglycerides or cholesterol with or without
fat maldistribution
 Is caused by ARV interference with normal cellular
proteins involved with lipid metabolism
 Increases levels of triglycerides or cholesterol and
risk of cardiovascular problems and pancreatitis
 Is managed by
Lipid-lowering drugs
Decreased fat intake
Lifestyle changes (e.g., quitting smoking)
Nutritional Care and Support
Strategies with ARV Therapy
 Promote a nutritionally adequate diet (quality, diversity,
and quantity)
 Promote safe water, food, and hygiene practices
 Discourage excessive fat intake (promote modest fats,
starches, and sugars and high-protein food but fewer
fried eggs and yolks), fatty meats, and animal fats
 Prevent muscle wasting with regular exercise to burn fat
and build muscle mass (anabolic agents?)
 Encourage increased fluid intake
 Address nutritional consequences of drug-nutrient
interactions and side effects of medications
 Good nutrition and healthy lifestyle can preserve
health, improve quality of life, prolong
independence, and delay disease progression
 Appropriate physical activity, increases energy,
stimulates appetite, and preserves and builds lean
body mass
 Preventing food- and water-borne infections reduces
the risk of diarrhea (a common cause of weight
loss), malnutrition, and HIV disease progression
 Antiretroviral therapy can help improve quality of
life, but patients should be educated on adverse
nutrition-related effects
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