Slide 2
The objectives in this tutorial, are to:
- Review goals and components of nutrition care and support during HIV
infection
- Discuss nutrition recommendations for the symptoms associated with
each stage of HIV disease and
- Provide information on how to manage nutrition-related symptoms of
HIV
Slide 3
Role of Nutrition Care and Support. HIV compromises the nutritional
status of infected persons. Malnutrition exacerbates the effects of HIV,
further weakening the immune system. Studies have shown that clinical
outcome of HIV is poorer in individuals with compromised nutrition.
Improving nutrition by maintaining a healthy diet can help to strengthen
the immune system, prevent weight loss and delay HIV disease progression.
This makes it possible for the HIV-infected individuals to remain
productive, and improve or prolong their quality of life. Thus the role of
nutrition care and support plays an important part in the overall care of
people living with HIV. Nutrition Care should be part of a comprehensive
program to provide healthcare, emotional, psychological and spiritual
support for the HIV-infected individual and their family.
Slide 4
Goals of Nutrition Care and Support. The goals of nutrition care and
support include the following:
- Improve nutritional status by maintaining weight, preventing weight
loss and preventing loss of muscle mass
- Ensure adequate nutrient intake by improving eating habits and
building stores of essential nutrients. These nutrients include
carbohydrates, protein, important antioxidant nutrients and other
vitamins and minerals necessary for the functioning of the immune
system.
- Prevent food-borne illnesses by promoting hygiene, and food and
water safety.
- Enhance the quality of life by promptly treating infections and
managing the symptoms that affect food intake to minimize the
nutritional impact of secondary infections when they occur.
- And provide palliative care during the advanced stages of the
disease.
Slide 5
Components of Nutritional Care and Support. Programs that provide
nutrition care and support should include the following components:
- A nutrition assessment. This is important to gather information
about the current nutritional status and diet and to identify risk
factors for developing future nutritional complications. The
assessment should include measurements of weight, mid-arm
circumference, height and a calculation of body mass index. A body
mass index of less than 18 indicates nutritional risk.
- Nutrition education and counseling. This should be an integral part
of the care and support of HIV infected individuals. It is important
to help individuals understand the need for maintaining an adequate
diet, how to handle food safely and how to manage the nutritional
complications of the disease.
- Counseling on hygiene. This can help prevent infections, in
particular those infections that cause diarrhea, which is a common
cause of HIV disease progression. Proper hygiene is especially
important because the immune system of a person infected with HIV is
weakened, making the individual more susceptible to other infections.
Slide 6
Additional components of nutrition care and support include providing
food and nutritional supplements especially in those areas of high poverty
and household food insecurity. Families affected by HIV, living in
conditions of food insecurity can get the nutrition care and support they
need through interventions like food-for-work programs and/or community
kitchens. For those HIV-infected individuals who are unable to leave their
homes or prepare their own meals, delivering food baskets or ready to eat
meals to their homes is another way of providing nutrition care and
support.
Slide 7
Stages of HIV Disease and Nutrition. Recommendations for nutrition care
will vary depending on the underlying nutritional status of the individual
and the extent of the HIV disease progression. The disease progression may
be categorized into three stages:
- The early stage, in which the individual does not have any symptoms
and has a stable weight.
- The middle stage, in which the individual has experienced
significant, unintentional or undesirable weight loss as a result of
opportunistic infections
- And the late stage of the disease in which the individual has
full-blown AIDS disease.
Slide 8
Nutrition Care and Support priorities by stage of disease. Because the
symptoms will vary according to the stage of disease, the nutrition
priorities will also vary. During the early stage when the person has no
symptoms, the main objective is to stay healthy by building stores of
essential nutrients, maintaining weight, preserving lean body mass and
ensuring an understanding of food safety issues through proper nutrition
education and counseling. During the middle stage, if the individual has
or has had an acute infection accompanied by weight loss, the main
objective is to "minimize consequences." This can be done by:
- maintaining food intake during an infection
- increasing food intake during the recovery period to gain weight,
and
- continuing physical activity as much as possible to preserve lean
body mass.
In the late stage of the disease the individual has progressed to AIDS
and the main objective is to provide comfort or palliative care. This care
includes treating opportunistic infections, modifying the diet according
to symptoms and encouraging eating. Providing psychological and emotional
support are also important priorities at all stages of the disease.
Slide 9
Recommendations for nutrition care and support in the early stage of
infection. In the early stage of the disease, the objective for the
HIV-infected person is to remain as healthy as possible. The following
practices can help achieve this.
- Provide information about a proper diet based on foods that are
locally available and acceptable.
- Suggest a diet that provides adequate protein, energy in the form of
carbohydrates and other essential nutrients to meet the increased
nutritional requirements during HIV-infection.
- Energy requirements are increased by 10-15%. In the presence of
a fever, acute infection or the need for weight gain, these
requirements may be even higher, about 30-50%.
- Protein requirements are increased by about 50%. Extra protein
is required to maintain muscle mass and strengthen the immune
system.
- The diet should contain foods that are sufficient in BOTH energy
(in the form of carbohydrates) and protein. If carbohydrate intake
is insufficient, protein will be used to provide the body with
energy. When this happens, protein is not available to maintain
muscle and strengthen the immune system. This can lead to muscle
wasting and increased susceptibility to infection of an already
weakened immune system.
Additional practices that can help:
- Encourage maintenance of physical activity to help preserve muscle
mass, increase energy and stimulate appetite.
- Weight-bearing exercises can help to build lean body mass.
- Provide information on safe food handling practices to prevent
food-borne illnesses and bacterial infections.
Slide 10
Recommendations for Safe Food Handling Practices. Improper food
handling can cause infection in anyone. But, for the HIV-infected
individuals, these food-borne illnesses can cause even more damage because
these individuals are immune-compromised. To prevent food-borne
infections, it is important to do the following practices:
- Wash hands thoroughly before preparing and eating food and after
using the toilet or changing diapers or nappies
- Wash food preparation surfaces, utensils and dishes
- Wash all fruit and vegetables before eating, cooking or serving
- Avoid letting raw food come into contact with cooked food
- Cook food thoroughly especially meats and chicken, and
- Serve all food immediately after preparation.
Slide 11
In addition, keep food covered and away from insects, rodents and other
animals Do not store food after it has been cooked Use safe water for
drinking, cooking, and cleaning dishes and utensils. This means always
using boiled or bottled water only. Do not use bottles with teats for
feeding infants. Instead, use a cup.
Slide 12
Recommendations for nutrition care and support in the middle stage
During this stage the HIV-infected person may go through periods of weight
loss as a result of opportunistic infections. The main objective of this
stage is to minimize the consequences. The following practices should be
promoted:
- Counsel and support individuals to maintain their food intake even
during periods of acute illness and depressed appetite and to increase
intake gradually once they have recovered so as to replenish nutrient
stores and promote weight and muscle mass gain.
- Increase their nutrient intake of protein and energy in the form of
carbohydrates to promote weight and muscle mass gain, and nutrient
repletion.
- "Make every bite count." This phrase means limiting
the intake of low- calorie foods such as tea, coffee, salads,
clear soups and most fruits and vegetables because they make the
patient feel full, but do not help to maintain or promote weight
gain. Instead, include a source of protein with each meal and
snack to help maximize nutrient intake.
- If available, provide a multivitamin supplement daily
- Recommend continued physical activity as the person is able. Walking
for example, can help stimulate appetite, increase energy and also
help to preserve and build lean body mass.
Slide 13
Further recommendations in the middle stage.
- Commonly occurring symptoms such as loss of appetite, mouth and
throat sores, nausea and vomiting, high fever, and persistent diarrhea
can affect food intake and contribute to malnutrition, so managing and
treating these symptoms is important.
- Seek medical attention immediately especially
- If diarrhea is persistent and/or accompanied with fever,
- If fever lasts for more than 3 days, and
- If mouth and throat sores cause a complete loss of appetite or
inability to eat food because of the pain.
- Avoid unhealthy behaviors such as
- Drinking alcohol, smoking and using drugs because these
behaviors affect the metabolism, decrease appetite and hence
increase risk of health status deterioration.
- Unsafe sexual practices also increase risk of health status
deterioration.
Slide 14
Recommendations for Nutrition Care and Support in the Late Stage.
Providing comfort care or palliative care is the main objective at this
stage of the disease. The focus should be on reducing nutritional
consequences of AIDS as much as possible and preserving independence and
dignity of the individual. During this stage of the disease the following
should be promoted:
- Immediately treat all infections that affect intake.
- Consider food and nutritional interactions with medications and also
side effects of medications such as nausea or vomiting that have an
impact on food intake.
- Maintain intake as much as possible even during periods of acute
illness and depressed appetite.
- Modify the diet to take care of AIDS-related symptoms that affect
the ability to eat. For example, mashing or moistening food can make
it easier to chew and swallow for someone with mouth and throat sores.
- Encourage individuals to do as much physical activity as they are
able, and
- Provide psychological and emotional support
Slide 15
Recommendation for Symptom-Based Nutrition Care and Support. Managing
the common symptoms that occur with HIV/AIDS disease will maximize and
improve nutritional intake, maintain weight and muscle mass, and improve
quality of life.
- Loss of appetite also known as anorexia is common among people
living with HIV. To help manage this symptom, the individual can:
- eat smaller and more frequent meals, about 5-6 meals per day
- "make every bite count" by providing high protein and
high carbohydrate snacks between meals and with meals
- drink plenty of fluids
- take walks before meals, to help stimulate appetite
Getting assistance with shopping and cooking and using appropriate
community supports may also help to improve intake.
- Sores in the mouth or throat are a common ailment in people living
with HIV. The sores are uncomfortable, but do not necessarily indicate
serious illness. Nevertheless, for some the sores can make eating
painful which can result in loss of appetite, reduced food intake, and
weight loss. Strategies to help maximize intake during this period
include:
- avoiding citrus fruits, acidic and spicy foods
- eating foods at room temperature or cold
- eating soft and moist foods
- avoiding caffeine and alcohol
Slide 16
Recommendation for Symptom-based Nutrition Care and Support continued.
Nausea. This is sometimes a side effect of medications and can have a
significant effect on nutritional intake. To help relieve nausea :
- Avoid having an empty stomach as this makes the nausea worse. To do
this, eat smaller more frequent meals and snacks that are bland.
- Have something to eat such as dry bread or toast before getting out
of bed in the morning.
- Avoid foods with strong or unpleasant smells, fried foods, alcohol,
and coffee.
- Avoid lying down immediately after eating. Wait for at least 1 to 2
hours.
If the person is vomiting, they should drink plenty of fluids to
replace losses and prevent dehydration.
Slide 17
Recommendation for Symptom-Based Nutrition Care and Support continued.
Diarrhea occurs when a person has several loose or watery bowel
movements a day. More than four loose and/or watery bowel movements per
day is considered abnormal. Intractable, chronic or recurrent diarrhea has
great nutritional implications due to nutrient losses and poor nutrient
absorption. In addition, diarrhea is a common cause of HIV disease
progression. The following are recommendations to help relieve the
diarrhea while maintaining nutrient intake.
- Dietary strategies, such as eating bananas or boiled white rice,
that travel slowly through the digestive tract and decrease
stimulation of the bowel can be effective in reducing diarrhea.
- Avoid foods with insoluble fiber (roughage), for example take the
skin off fruits and vegetables.
- Drink 8-10 cups of liquids per day to prevent dehydration.
- Avoid eating fried foods.
- Avoid drinking sweet drinks. Provide diluted juices instead.
- Eat food at room temperature. Very hot or cold foods stimulate the
bowels and make the diarrhea worse.
- For some patients, lactose intolerance, which is the inability to
digest the sugar lactose in milk, may occur but only for a short
period during episodes of diarrhea. Avoid milk and milk products to
see if symptoms improve.
If the diarrhea is severe, drinking an oral rehydration solution is
important to replace electrolyte losses and prevent dehydration.
Slide 18
Recommendations for Symptom-Based Nutrition Care and Support continued.
Fever: Fever is common in people with infection. Very high fever increases
nutrient requirements, in particular energy and protein requirements.
- Eat small and frequent meals, including snacks between meals as
tolerated at regular intervals.
- Drinking plenty of fluids throughout the day is important in the
presence of a fever to prevent dehydration.
Altered taste: A number of HIV-infected individuals experience a loss
of taste or abnormal taste sensations. In particular, malnourished
individuals are most susceptible to decreased taste perception because
malnutrition reduces the capacity for taste receptors to turn over. This
results in the loss of a number of taste receptors which changes the taste
of foods. To help improve taste:
- Use flavor enhancers like salt, spices and herbs to increase taste
acuity and mask unpleasant taste sensations.
- Chew food well and move it around in the mouth to stimulate taste
receptors.
Slide 19
Recommendations for Symptom-Based Nutrition Care and Support continued.
Poor fat absorption: Poor fat absorption, also known as steatorrhea or
fat loss in the stools, causes an increase in stool bulk. The patient may
have 1-3 large bowel movements a day rather than small watery stools that
are seen with diarrhea. Therefore, the patient may not complain of
diarrhea. Because the stools contain fat, they may be frothy and float and
have a foul smell, and may be accompanied by passing a lot of gas. Poor
fat absorption increases the person’s risk of developing deficiencies of
the fat soluble vitamins A, D, E and K, which are poorly absorbed as a
result. To help decrease poor fat absorption:
- Eliminate from the diet oils and foods that contain or are prepared
with oil
- Eat lean meat. Trim all visible fat and remove the skin from
chicken, and
- Avoid deep fried foods
Lack of energy: Lack of energy or lethargy is common among HIV-infected
persons. To help increase energy:
- If possible, have someone pre-cook foods for the patient. This will
help the patient conserve energy.
- Eat smaller more frequent meals and snacks throughout the day
- Exercise as able, and
- Try to eat at the same time each day.
Slide 20
Sources of Various Vitamins and Minerals. Many vitamins and minerals
are important for HIV-infected individuals due to their role in immune
system function. Micronutrient deficiencies of vitamins A, C, E,
beta-carotene, B-6, B-12, folate, and minerals such as zinc, selenium and
iron are common among HIV-infected individuals due to excessive losses in
the urine. Ensuring adequate intake from a variety of food sources can
help provide the required nutrients. For example, Vitamin A is found in
green leafy vegetables, cheese and eggs Carrots and dark green vegetables
are some of the good sources of beta carotene. Vitamin B6 , folate and
Vitamin B12 are all found in meat, fish and chicken.
Slide 21
Source of Various Vitamins and Minerals continued.
- Citrus fruits are an excellent source of Vitamin C
- Vitamin E is found in vegetable oils and green leafy vegetables
- Red meat, liver, fish and chicken are some of the foods that are
rich in iron and zinc.
- Selenium is found in meat, seafood and dark green vegetables.
Refer to the tables for more food sources of these vitamins and
minerals.
Slide 22
Some recommended foods are listed in the table Protein is important for
strengthening the immune system. Good sources of protein in the diet that
are locally available and acceptable should be included as part of each
meal to meet the increased protein needs of the HIV-infected individual.
As noted, it is important to ensure adequate energy intake, so that
protein is not used to meet energy needs. Rich sources of protein include:
meat, fish and poultry, dairy products, legumes and nuts. Carbohydrates.
Energy is provided in the diet from carbohydrates also referred to as
starchy foods. Energy requirements as mentioned earlier will vary
depending on the clinical condition and activity level of the individual.
For example as noted, in the presence of fever, acute infection or need to
gain weight, energy requirements are significantly increased. Sources of
Carbohydrates in the diet include: breads,cereals, rice, yams, cassava,
plantain, sweet potatoes and potatoes. Fruits and Vegetables though low in
calories provide a wide variety of vitamins and minerals essential for
normal functioning of the immune system and other body functions. Locally
available and acceptable fruits and vegetables should be eaten between
meals as snacks. Fats and oils. In the absence of poor fat absorption and
diarrhea, fats can be a used as a source of energy in the diet and hence
provide extra needed calories. They also contain fat-soluble vitamins A,
D, E and K that are essential for body functions.
Slide 23
Recommendations on Foods to Avoid. Good nutrition can help prevent
weight loss and strengthen the immune system. There are some foods,
however, that should be avoided because they aggravate the commonly
occurring symptoms that have been discussed previously. They may speed up
disease progression through infections, or they do not have much
nutritional value and hence do not help to improve the nutritional status
of the HIV-infected person. These foods include: Raw eggs. They may
contain bacteria, particularly salmonella, that are harmful to the already
weakened immune system of the HIV-infected person. Undercooked meats and
chicken may have bacteria that are harmful to the already immune
compromised HIV-infected person. "Junk" foods such as chips,
biscuits, and sweets have little nutritional value. Alcohol and coffee
decrease appetite, interfere with metabolism and, in the case of alcohol,
may interact with some medications decreasing their efficacy. Foods that
have already been mentioned that aggravate symptoms related to diarrhea,
nausea or vomiting, loss of appetite, and mouth and throat sores should
also be avoided as indicated.
Slide 24
Nutrition and Medication interactions. Medications used to treat HIV
opportunistic infections may result in negative drug-nutrient interactions
or cause side effects. For example, Isonaizid therapy used for the
treatment of tuberculosis may interfere with Vitamin B6 metabolism. As a
result, vitamin B6 supplemention should be given to all patients receiving
this treatment. Iron- and zinc-containing supplements should not be taken
with ciproflaxacin. In malaria-prone areas caution should be taken not to
administer Fansidar, used for treatment of malaria, to persons with folate
deficiency. If the person is folate-deficient, provide a folic acid
supplement. Some antiretroviral medications have
- dietary requirements, or
- side effects that affect nutritional intake and nutrition status.
The most common side effects are nausea and vomiting and, for some,
altered taste.
- Some medications affect red blood cell production, increasing the
risk of anemia, for example AZT, also known as zidovudine.
Slide 25
In summary, maintaining adequate nutrition may be one of the most
important things a newly infected person can do to prolong well being.
Good nutrition and a healthy life style can
- preserve health,
- improve quality of life,
- prolong independence, and
- delay disease progression.
Prevention of food and water borne infections reduces the risk of
diarrhea, a common cause of weight loss, malnutrition and disease
progression in people living with HIV and AIDS.
Slide 26
In addition, managing common symptoms related to HIV/AIDS can minimize
their impact on nutritional status. Continuing physical activity and
exercise as able can help increase energy, stimulate appetite and preserve
and build lean body mass especially when weight bearing exercises are
included. Providing psychosocial and emotional support as part of the
nutrition care, at all stages of the disease can help to improve quality
of life. Nutrition care and support should be part of a comprehensive care
package that deals with the needs of the HIV-infected individual and their
family.
