ESPEN Congress Lisbon 2004

Nutrition and AIDS

How relevant is nutrition ?

Cora Jonkers

Relevant?

How relevant is nutrition ?How relevant is nutrition ?

Cora F Jonkers RDCora F Jonkers RDAcademic Medical CenterAcademic Medical Center

NL AmsterdamNL Amsterdam

Relevant?

Changing timesChanging times

1984 1984 -- 20042004

Relevant?

1984

• Male pt, 26 years, HIV since 1983• 185 cm, 54 kg, BMI 15,8 kg/m2, weight loss 30%• Usual weight (<6mo) 74 kg, BMI 21,7 kg/m2

• Referral: diarrhea (15xday / >3 ltr) candidasis in mouth and throat, night sweating, fever, depressed

• Intake: 1 liter yoghurt / day, 3 glasses of tomato juice, 2 liter ORS and some soup

• 18 kcal/kg/ 0,6 g protein/kg bw

Relevant?

Dietary treatment 1984• Nutritional problems:

– disturbed energy balance due to:– Anorexia (depression – treatable)– Swallowing problems (candidasis - treatable)– Diarrhea (untreatable) – Low immunity (untreatable)

• Nutritional intervention:– Restore energy balance if possible

• Future of the patient:– new opportunistic infection– High mortality

Relevant?

2004

• Male pt, 46 years, HIV since ’94• 185 cm, 102 kg, BMI 30, 15 cigarettes/day• Referral: obese, glucose (>15mmol/l) & TG

(>10 mmol/l)• Drugs: 3 dd 4mg Amaryl, 1x30mg Pioglitazon,

1x500mg Metformine 2dd150mg Epivir, 2dd 300mg Abacavir, 4x200mg Efavirenz

• Intake: high on sugar, SFA & alcohol• Activities: low due to depression and tiredness

Relevant?

Dietary treatment 2004

• Nutritional problems:– disturbed energy balance (high intake, low in activities

due to depression)– High TG due to HAART– High glucose due to HAART

• Nutritional intervention:– Low caloric diet (low sugar, high PUFA)

• Future of the patient– Cardiovascular problems due to HAART– lipodistrophy– low mortality

Relevant?

Nutritional goalsHealthy adults

• good nutritional status– good weight: balance

between intake & activities

– 100% DRI Micronutrients

– Good Fluid intake– Good Fiber intake

Prevention diseases!

HIV infected adults• Good nutritional status

– Protect LBM– REE ± increased– Micronutrient need

unknown– HAART influence

No cure!

Relevant?

Relevant?

HIV treatment1. Highly Active Anti Retroviral Therapy

(HAART)– Immunity low

2. Non HAART– Good immunity status, mild infection– End stage– Poor, no access to health care

Relevant?

Is nutritional status relevant to prognosis in HIV?

• HIV infection does not lead invariably to weight loss, but weight loss is a feature of seroconversion illness and opportunistic infections (Palenicek 1995)

• Body composition changes during HIV under HAART are different from starvation in non-HIV (Salomon 2002)

Relevant?

Effect of HIV infection, AIDS and secondary infections on

Resting Energy Expenditure in non-HAART

patients.

Grunfeld, J Clin Endocr Metab 1992

Relevant?

Incidence of wasting in HAART% pt

>10% BW loss since initial visit 18

> 5% BW loss 6 months 21

BMI < 20 since last study visit 8

Pt meeting wasting definition 33,6

CA Wanke, CID 2000

Relevant?

HIV

death

CD4 cellsMalnutrition

wasting 506 d

Non wasting907 d

> 100 1199 d

< 100 659 d

Salomon, Clin Chem Lab Med 2002

Relevant?

Nutritional problemsNon-HAART HAART

related to energy balance

related to complementary diseases

Wasting:Malabsorptiondepression, REE

Overweight : intake, activities

Wasting: Anorexia, malabsorption, intake, REE, depression

related to therapyAnorexia, nausea, malabsorption, diarrhea

TG, Glucose, lipodistrophy, nausea, saliva production, diarrhea, lactic acidosis

Chronic liver failure, (opportunistic) infections

Relevant?

Lactic acidosis

• 0,8 – 1,3 / 1000 HIV pt / year• Drug/nutrient interaction: Stavudine 25pt/y• Mitochondrial dysfunction: increase of

production of lactate from pyruvate• Deplete vit B1 & B2• Liver disease• Treatment: vit B1 & B2 IV

Relevant?

Prevent weight loss in HIV HAART & non-HAART

1. Record weight at each clinic visit2. Control HIV infection and lower virus load3. Investigate and treat secondary infections4. Evaluate and treat nausea, vomiting, and diarrhea5. Examine the oral cavity regularly6. Evaluate for and treat hypogonadism7. Treat alcohol and drug abuse8. Address eating disorders and mental illness9. Provide services to improve access to food10. Stop cigarette use11. Maximize caloric intake (appetite stimulance??)12. Strength training of large muscle groups 13. Consider hormone therapy (anabolic)

Relevant?

Relevant?

dyslipidemia

• High TG & Cholesterol • Family history of premature

CHD• Treatment (Dubé CID 2003):

– Diet & exercise: chol – 25% (Jones 2002)

– Drugs (statin)– Smoking habits– Change of retroviral therapy

Relevant?

Insulin resistance

Type 2 diabetes mellitus

• treatment patient:Evaluate blood glucoseNormalize body weightBalance carbohydrates Fat intake: low on SFADrugs (metformine)

Relevant?

Reduced saliva productionIntake Weight loss!

Dry mucousEating & swallowing problemsChange of tasteDecreased appetite

Treatment: Change consistency of foodRestore energy balance

Relevant?

lipodistrophy

Relevant?

lipodystrophy

• Non reversible, non influensable by diets• Disproportional loss of subcutaneous fat

– limbs– face– buttocks

• Fat redistribution: feeling obese!– Neck– Belly

Relevant?

Treatment of lipodistrophy

Plastic surgery

Relevant?

Relevant?

100% RDA micronutrients

• Normal absorption: normal needs• Malabsorption: deficiencies• Very few controlled trials on

micronutrients and their optimal use

• Advice: multivitamin & trace element supplementation if nutritional problems are present (malabsorption, low intake)

(Singhal, AIDS care 2002)

Relevant?

Use of dietary supplements 90% (n=23)

Nutrient N (%) % RDIVit B1 70 200

Vit B2 70 150

Vit B12 70 250

Vit A 60 25

Selenium 50 30

Zinc 50 100

Relevant?

Nutrient Effects of low status

B1& B2 Lactic acidosis

B12 Neurological impairmentsCD4 progression AIDSabsorption in PI use

Vit A Immunity: B & T cell growthTransmission mother - child

Vit E Immunity, Oxidative stress

Selenium Glutation peroxidase activity

Zinc immunity

Relevant?

Always ask for non- prescribed complimentary medication

• Dietary supplements– Protein modules– Energy modules– Vitamins– trace-elements

• Herbal supplements– St Johns Worth– Garlic– Others

Relevant?

The relevance of nutrition?Relevant to maintain body cell mass: need for optimum protein intake (1,5 g / kg BW)

Relevant to maintain energy balance: possible to treat immunity status with HAART

Relevant to influence on immunity by using 100% DRI vitamins & trace elements

Relevant to side effects & toxic amounts of:• Vit A, D, niacin, vit B6, vit C, Cu, Fe, Se, Zn etc.

Relevant?

ESPEN guideline:Wasting in AIDS and other chronic infectious disease

Thanks to the working group:Ockenga, Grimble, MacAllen,

Melchior, Sauerwein, Schwenk.

Relevant?

Global relevance of Global relevance of nutrition & HIV:nutrition & HIV:

Fight HIV transmissionFight HIV transmission

TreatTreat HIV adequateHIV adequate

Fight malnutritionFight malnutrition

OptimalOptimal nutritionalnutritional balancebalance