Erni Juwita Nelwan, MD, FACP, FINASIM

Consultant of Tropical and Infectious Diseases

Division of Tropical and Infectious Disease

Department of Internal Medicine

Faculty of Medicine University of Indonesia

JAKARTA

erni.juwita@ui.ac.id

Erni Juwita Nelwan

Divisi Tropik dan Penyakit Infeksi

Departemen Ilmu Penyakit Dalam

FKUI / RSCM

Intervensi nutrisi yang dapat memodulasi sistem imun

Immunonutrisi

Pengaruh infeksi HIV/AIDS pada status gizi

Pengaruh malnutrisi pada infeksi HIV

Defisiensi mikronutrien pada infeksi HIV

Komponen tatalaksana nutrisi

Outline

Metabolisme Gizi pada ODHA Asupan gizi tidak adekuat

(gangguan kognitif/depresi, poverty, anorexis, nausea, jamur

mulut )

Memperburuk status gizi (Malnutrition)

Depress antibody production, the function of phagocyte cells,

and levels of complement.

Absorption of amino acids

GIZI & HIV

HIV

Gizi terganggu

sistem imun

menurun

Resiko terhadap penyakit infeksi

meningkat

Kebutuhan zat gizi

meningkat

EFEK HIV PADA GIZI

HIV-GIZI

Kebutuhan nutrisi

meningkat

Kebutuhan energi

meningkat

Infeksi sekunder berulang

Anoreksia

Diare berulang

Multifarmasi

Malabsorbsi

Respon peradangan

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Stages of HIV Disease and Nutrition

Specific nutrition recommendations vary according to the underlying nutritional status and extent (stage) of HIV disease progression

The disease progression may be categorized into three stages:

Early (I): no symptoms, stable weight

Middle (II/III): significant weight loss

Late (IV): symptomatic, full-blown AIDS disease

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Early Stage (I)

No symptoms, stable weight

Increased nutritional requirements during HIV-infection Energy increase: 10 - 15%

Protein increase: ~ 50%

Vitamins and minerals used by the immune system are also increased

Main objective: remain as healthy as possible Build stores of essential nutrients

Identify locally available and acceptable foods

Maintain weight and lean body mass, preserve muscle mass, and increase energy

Adequate diet

Maintain physical activity

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Middle Stage (II/III)

Significant, unintentional or undesirable weight loss as a result of opportunistic infections

Main objective: minimize consequences Increase nutrient intake for recovery/weight gain

Maintain intake during periods of acute illness and depressed appetite

Increase nutrition intake gradually to promote weight and muscle mass gain, and nutritional recovery Make every bite count

Daily vitamin-mineral supplements

Continue physical activity as able

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Late Stage (IV)

Symptomatic, full-blown AIDS disease

Main objective: provide comfort or palliative care

Treat all infections that affect intake

Modify diet according to symptoms

Maintain intake during periods of acute illness and depressed appetite

Encourage eating and physical activity as able

Provide psychological and emotional support

Kejadian HIV dan malnutrisi tinggi di berbagai

negara (~ wasting)

Malnutrisi:

Mempercepat progresivitas infeksi HIV

Infeksi HIV menurunkan status nutrisi

Malnutrisi:

Primer (intake tidak adekuat)

Sekunder (gangguan metabolisme dan penyerapan makanan)

HIV dan Malnutrisi

Banyak ditemukan pada penyakit infeksi termasuk

HIV

Difficult to measure (hidden hunger)

Contoh defisiensi mikronutrien:

Zat besi anemia

Iodine gangguan tiroid

Vitamin A

Vitamin D

Mikronutrien Defisiensi

REKOMENDASI GIZI

Manifestasi Klinis Gangguan Gizi Rekomendasi Gizi

Anoreksia Penurunan nafsu makan, kesulitan menelan karena infeksi jamur mulut (kandidiasis oral).

makanan lunak, porsi kecil dan sering, minum menggunakan sedotan.

Diare Kehilangan zat gizi dalam tubuh

rendah serat, lemak, dan banyak mengkonsumsi cairan, buah-buahan tinggi kalium dan magnesium : pisang

REKOMENDASI GIZI Manifestasi Klinis Gangguan Gizi Rekomendasi

Sesak Nafas Asupan kalori tidak mencukupi, pasien lemah

Makanan diberikan dalam posisi setengah tidur

Malabsobsi Lemak Gangguan penyerapan lemak

sumber lemak nabati

Demam Peningkatan pemakaian kalori dan kehilangan cairan

minum lebih dari 2 liter/ hari (`bb)

BB turun Gangguan makan secara oral

Tinggi kalori protein, padat kalori,rendah serat, porsi kecil dan sering

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The Vicious Cycle of Malnutrition and HIV

• Increased HIV replication • Hastened disease progression • Increased morbidity

Nutritional deficiencies

• Increased oxidative stress • Immune suppression

• Insufficient dietary intake • Malabsorption, diarrhea • Altered metabolism and nutrient storage

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Key Points

HIV can lead to malnutrition by multiple mechanisms

Malnutrition is associated with increased HIV transmission, progression, and mortality

Nutritional supplementation is associated with improved HIV-related outcomes

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Key Points (2)

Maintaining adequate nutrition prolongs well-being of HIV-infected persons but is difficult

HIV affects nutrition in three, sometimes overlapping, ways:

Reduces amount and type of food consumed

Interferes with the digestion and absorption of nutrients

Alters metabolism of nutrients

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Key Points (3)

Counseling and other interventions to prevent or reverse weight loss are likely to have their greatest impact early in the course of HIV infection

Nutritional care and support should be part of a comprehensive program that deals with the needs of the patient and his or her family

Nutritional supplements, particularly antioxidant vitamins and minerals, may improve immune function and other HIV-related outcomes, particularly in nutritionally vulnerable populations

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Key Points (4)

Managing common symptoms related to HIV/AIDS such as diarrhea, nausea, and loss of appetite, can minimize their impact on nutritional status

Prevention of food- and water-borne infections reduces the risk of diarrhea, a common cause of weight loss, malnutrition and HIV disease progression in people living with HIV and AIDS

Continuing physical activity and exercise, as appropriate, increases energy, stimulates appetite and preserves and builds lean body mass