+

Obstacles to Adequate Nutrition in Human Immunodeficiency VirusPrepared by: Jessica McGovern

+Objectives Explain HIV’s effect on the immune system

Examine HIV’s effect on the body

Identify risk factors for contracting the virus

State methods of assessing an HIV patient

Discuss obstacles to maintaining nutritional status

Identify nutrition interventions for HIV

Examine methods of monitoring nutritional status in this population

Discuss a case study of an HIV patient with oral feeding difficulty

Explain various oral issues and associated medical nutrition therapy

+Patient AW

46 year old Hispanic male, 5’7”, UBW-180lbs

Admitted on September 14th with sore throat, ulcers in the oral cavity and esophagus, and significant weight loss.

Admitting diagnosis of esophagitis.

HIV test reveals patient is HIV positive.

http://www.health.com/health/static/hw/media/medical/hw/n5551186.jpg

+What is HIV?

A retro-virus (contains RNA) that uses the body’s own cells to reproduce.

Transmitted through sexual contact, infectious bodily fluids, needle/syringe sharing, tainted blood transfusions, or through birth/breast feeding.

Not easily transmitted.

Often asymptomatic in the earliest stages .

(1)

http://www.hivnorfolk.com/images/illustrations/hiv_virus.jpg

+Overview of Immune Cells

B Cells- Identify foreign cells, produces antibodies, able to neutralize and destroy invaders that are not already incorporated into the host cells

Helper T (CD4)- Directs the immune response once a foreign entity is identified

Cytotoxic T (CD8)- kills the targeted cells based on the presence of a foreign antigen on the surface of the cell

Macrophages- engulf foreign material

(2)

+How the virus works. Helper T cells are the

primary target

Identifies the T cells

Fuses to the surface

Injects RNA, enzymes, and other substances that help to penetrate the cells surface

RNA is transcribed to DNA

DNA carried to the nucleus and integrated into the host DNA using enzymes

The virus can remain dormant

Once activated the cells become a “viral factory” manufacturing, assembling, and releasing the virus.

CD4 cells becomes destroyed

Macrophages infected with HIV become dysfunctional

Leads to compromised immune system and the progression of the disease

(1,2)

+Illustration of How HIV Works

http://www.virxsys.com/media/MOAsmall.jpg

+Facts about HIV

1.1 million people are living with HIV in the United States

There are two types of HIV- HIV1 and HIV2.

1/70th the size of a Helper T cell

Contains 9 genes

6 of the genes are primarily used to penetrate, infect, and produce copies in the T cell

The virus also targets other cells of the body including gastrointestinal cells, organ cells, and the immune cells

HIV is not a death sentence

Infection depends on the level of exposure and the dose

HIV can reproduce rapidly between 1 billion and 1 trillion virons per day

Initial infection is often followed by flu-like symptoms

21% of those infected within the United States are undiagnosed

(2,3,4)

+Diagnosis of HIV ELISA- “rapid test” to identify

possibility of infection- more sensitive than specific

EIA- determines the concentration of antibodies

Tests vary greatly and can measure serum, plasma, urine, saliva.

Can determine if the infection is recent or long standing

Measure reduction in CD4 count, viral load increase, HIV antibodies, and antigens.

Pheno and genotype of the virus are tested to track mutations and decide which treatment will be effective

Category CD4 Count

1 >500

2 200-499

3 <200

Immune Cell Category of HIV Infection

(2,3)

http://hypochondriaoasis.com/wp-content/uploads/2008/05/hiv-test.jpg

+Stages of HIV Disease

(4)

+What does HIV effect?

Neurological

Pulmonary

Renal

Cardiac

GI Tract

Immune system

Hematological

Musculoskeletal

Hepatic

All Systems of the Body

(5)

http://wpcontent.answers.com/wikipedia/commons/thumb/4/4a/Symptoms_of_acute_HIV_infection.png/300px-Symptoms_of_acute_HIV_infection.png

+ Treatments

Fusion Inhibitors

Non-nucleocide Reverse Transcriptase Inhibitor

Nucleotide/nucleocide Reverse Transcriptase Inhibitor

Intergrase Inhibitor

Protease Inhibitor

HAART-highly active anti-retroviral therapy

Successful if adherence is 95%

Side effects/symptoms

Pill burden

Complex regimens

Food/Medication Interactions

Knowledge deficit

Anti-retrovirals Limitations

(6)

+What are the risk factors?

(6)

+ Assessing Dietary Intake of Drug-Abusing Hispanic Adults with and with out Human Immunodeficiency Virus InfectionSahni S, Forrester JE, Tucker KL. Assessing Dietary Intake of Drug-Abusing Hispanic Adults with and without Human Immunodeficiency Virus Infection. J Am Diet Assoc. 2007;107(6):968-976.

-Objective:

--20% of HIV/AIDS cases in the United States are related to injection drug use

--Both drug abuse and HIV are identified as leading to nutritional deficiencies in macro and micronutrients

--Drug abuse among Hispanics in the Northeastern United States is a significant risk factor

--The dietary assessment of a drug user often proves difficult to obtain and may be inaccurate

--Develop an assessment method tailored to the Hispanic population

Design used 3 groups:

-HIV infected drug users

-HIV –non-infected drug users

-HIV infected non drug users

7)

+Assessing Dietary Intake of Drug-Abusing Hispanic Adults with and with out Human Immunodeficiency Virus Infection

24 hour recall and FFQ recorded by interviewer on 1st visit

Half of 3 day records not completed

Total kcal, protein, carbohydrates, fat, saturated fat, cholesterol, fiber, Vitamins A, D, K, Riboflavin, Niacin, Folate, B6, B12, C and Zeaxanthhin, Calcium, Iron, Zinc, Sodium, Potassium, Magnesium, Phosphorus

Conclusion-24 hour recall and FFQ most effective

3 assessment methods 3 day recall, 24 hour recall, and FFQ

286 participated

282 FFQ

142 3 day records

270 24 hour recalls

28% of subject women

24% reported homelessness

>50% has less than a high school education

(7)

+HIV Time-line

(1)

+Race/Method of Contraction in the United States

RaceMethod of Contracting the

Virus

(3)

+Incidence of HIV

(4)

+HIV Rates and AIDS Related Deaths

(4)

+Nutrition Assessment

Lifestyle choices (smoking, drug abuse, alcohol)

Economic status

Lack of healthcare

Access to safe food

Food insecurity

Social History

(1,6)

+Nutrition Assessment

Food recall/frequency/questionnaire

Meals per day

Intake analysis

Food allergies

Appetite

Ability to chew/swallow

Signs/symptoms of GI distress

Taste changes/dry mouth

Dietary History

(1,6)

+Nutrition Assessment

Weight- change

Height

BMI

Clinical signs of deficiency

Anthropometrics

Body composition analysis

Lipodystrophy

Physical Assessment

(1,6)

+Nutrition Assessment

Past and current medical diagnosis

Family history

Medications

Surgery

Medical History

(1,6)

+Nutrition Assessment

Immunologic profile

Hematologic profile

Liver function

Lipid profile

Renal profile

Glucose/Insulin

Inflammatory markers

Biochemical Assessment

(1)

+Nutrition Assessment

Kcals- BEE x 1.3 for weight maintenance, BEE x 1.5 for weight gain

Protein- 1-1.4g/kg body weight for maintenance, 1.5-2g/kg for repletion

Fluids- 30-35mL/kg body weight

Vitamins-A,C, B6, B12, and Folate may be poorly absorbed

Minerals-Selenium and Zinc may be deficient

Calculating Estimated Needs

(1,6)

+Nutrition’s relation to immunity

HIV causes dysfunction of the GI tract

Increases risk for malabsorption of nutrients

Malnutrition continues leading to a decline in health and wasting process

Breakdown of protein stores to feed the inflammatory process

Opportunistic diseases/cancers increase catabolic state causing weight loss

(1)

+

Nutrient Intake and body weight in a large HIV cohort that includes women and minorities Woods MN, Spiegelman D, Knox TA, Forrester JE, Connors JL, Skinner SC, Silva M, Kim JH, Gorbach SL. Nutrient Intake and Body Weight in a Large Cohort That Includes Women and Minorities. J Am Diet Assoc. 2002;102:203-211.

-Clinical Status Questionnaire-Physical Activity Questionnaire-Physical Exam-Blood Tests-CD4-Stool Specimen-fecal fat-Serum Vit levels

Objectives:

-To evaluate the connection between state of HIV disease and nutritional intake

Subjects:

-516 total subjects

-25% women, 30% minorities

-Categorized by CD4 count, gender, and white VS non-white

Methods:-3 day food record-Included Vitamin/Mineral supplements

(8)

+ Nutrient Intake and body weight in a large HIV cohort that includes women and minorities

Results:

-As CD4 count decreased, macronutrient intake increased in men

-25-30% of women consumed <75% DRI’s for A, C, E, B6, and Iron.

-White men had higher micronutrient intakes

-Macronutrient intake was higher among white vs non-white men

-25% of men did not meet DRI of Zinc, Folate, and vitamin E

-90% of the subjects provided a 3 day recall-The remaining submitted a 1-2 day recall-Nutrition Data Software was used to analyze the diet

(8)

+Obstacles to maintaining nutritional status

Polypharmacy

Disease complications

Co-Infections/opportunistic infections

Symptoms

(6)

+Antiretroviral Medication Interactions

Drug-Brand Name

Diarrhea Nausea/ Vomiting

Loss of Appetite

Taste Change

Lipid Alteration

Glucose Intolerance

Abd Pain Lipodystrophy

Ziagen X X X XReyetaz X X X X XPrezista X X X X X XVidex X X X X X XEmtriva X X X XNorvir X X X X X X X XFortovase X X X X X XZerit X X X X X XAptivus X X X X X XSustiva X X X X X X

(1)

+Nutrition Related Disease Complications

Nephropathy

Anemia

Protein Energy Malnutrition

Lipodystrophy

Abnormal protein metabolism

Hormonal/nutrient alterations

Medication/Food Interactions

Reduction in intestinal enzyme production

Malabsorption

Rapid intestinal cell turnover

Immature enterocytes

Other system malfunctions that may cause dietary restrictions.

(6)

+The fat redistribution syndrome in patients infected with HIV: Measurements of body shape abnormalitiesGerrior J, Kantaros J, Coakley E, Albrecht M, Wanke C. The Fat Redistribution Syndrome in Patients Infected with HIV: Measurements of Body Shape Abnormalies. J Am Diet Assoc. 2001;101:1175-1180.

Objective:

To document the body shape and metabolic abnormalities of fat redistribution syndrome

Subjects:

39 patients

90% on protease inhibitors

22% women and 26% men had CD4 counts <200

Methods:

Medication records

Exercise habits

Waist circumference

Hip circumference

Waist/hip ratio

Chest circumference

Mid-arm and Mid- thigh circumference

Lab results used from primary physicians

(9)

+

The fat redistribution syndrome in patients infected with HIV: Measurements of body shape abnormalities

Results:

-Mean glucose levels were within a normal range

-Triglyceride and cholesterol levels were moderately elevated

-The waist/hip ratio was abnormal

-BMI was within normal parameters

-Mean mid arm circumference and triceps skinfold were below national levels

(9)

+Opportunistic Diseases

Fungal infections-Thrush

Viral infections- Herpes

Bacterial infections- salivary gland disease, periodontal disease, pneumonia, upper respiratory tract infection

Various cancers- Kaposi’s sarcoma, Hodgkins Disease

(1,5)

+Symptoms

Nausea

Vomiting

Diarrhea

Abdominal Pain

Anorexia

Taste changes

Fatigue

Chills

Sore Throat

Headache

Weight loss

Fever

Anxiety

Frequent infections

(1,5,6)

+Goals of Nutrition Intervention in HIV

Restore macro/micro nutrient deficiencies

Manage symptoms of disease and/or medications

Weight maintenance

Hydration

Alter diet if co-disease exists that warrants nutritional therapy

Avoid fatigue during meal times by providing small, frequent meals

Initiate tube feeding if necessary

(5)

+Methods of Monitoring and Evaluating HIV Patients

Weight records

Reports of GI distress and symptoms

Food records

Laboratory results

(1,5)

+Nutrition Education

Food Safety

Protein sources

Fluids

Kilocalories

Micronutrients

Exercise

Food/Medication Interactions

Symptom management

Weight changes

Management of nutritionally pertinent co-diseases

The relationship between nutrition and immunity

Additional resources for educational information on the disease process

(1,5,6)

+ Application of a Five-Step Message Development Model for Food Safety Education Materials Targeting People with HIV/AIDS

Objective:

-Assess the needs of those with HIV

-Develop educational materials on food safety

-Evaluate effectiveness and how the material is received by the audience of HIV participants

Needs Assessment:

-8 focus groups

-65 HIV infected people

-18 health care providers interviewed

Assessment of Acceptance:

-4 focus groups

-32 HIV infected people

-25 health care provider surveys(10)

Hoffman EW, Bergmann V, Armstrong J, Kendall P, Medieros LC, Hillers VN. Applications of a Five-Step Message Development Model for Food Safety Education Materials Targeting people with HIV/AIDS.

J Am Diet Assoc. 2005;105:1597-1604.

+Application of a Five-Step Message Development Model for Food Safety Education Materials Targeting People with HIV/AIDS

Steps 1 and 2 stated issues and established food safety recommendations

Step 3 involved needs assessment focus groups

Step 4 used data, recommendations on safety, and the Health Belief Model to make 5 prototype educational materials for HIV/AIDS

Step 5 evaluated the materials during sessions and surveys

Needs Assessment groups initially were resistant to and confused by food safety recommendations

Prototype material groups on average rated the materials 5.6-6.4 on a scale of 1-7.

19 of 32 participants reported increased confidence of knowledge after reviewing the educational packets

Resistance was greatest for the encouragement to avoid unheated deli meats, use of a thermometer and avoidance of soft cheeses

21 of 25 Health care providers showed interest in using the materials for their clients educational benefit

5 Step Method Results

(10)

+In Depth-Initial Visit to Doctor

Visit primary doctor with c/o 10 lbs weight loss and sore throat since the beginning of August

Pt placed on antibiotics (amoxicillan, levaquin, Diflucan)

Return to primary doctor- patient is no longer able to swallow liquids and still losing weight

Admitted to the hospital with diagnosis of esophagitis

+Signs/Symptoms on Admission

Unable to swallow

Pain in the mouth and throat

Dizziness

Unable to open mouth all of the way

18 lb weight loss by the time of admission

N/V/D

Chewing/Swallowing difficulty due to mouth ulcers

+Past Medical History/ Social History

HTN

Hepatitis C

IV Drug Abuse (Heroin, Cocaine)

Tobacco use (quit in January of 2003)

Married with one son

Lives at home with his wife

Maintained on Methadone

+Physical Exam

Physician Notes:

General: Well developed, well nourished, in no distress, alert and oriented

Vital Signs: Tmax is 100.2. All other vitals are stable

HEENT: Significant for thrush, small ulcer inside of left side of pharynx. Looks normal but is unable to open mouth. Nodes are slightly swollen.

Neck: Supple

Chest: Clear

Extremities: - for cyanosis, clubbing, edema

Abdomen: Soft, non tender, + for bowel sounds

Neurologic: Grossly intact

Skin: Warm, no rashes

+Tests/Procedures Biopsy of ulcer to r/o cancer

Full lab work-up- HIV +

CT scan of throat/abdomen to r/o perforations

Esophageal gastroduodenoscopy

Speech therapy evaluation for swallowing to r/o aspiration pneumonia

Chest X-ray

MRI of brain

EKG

CT scan of the head because of change in mental status

EEG because of seizure

+Medications Zovirax (Antiviral)- N/V/D anorexia

Diflucan (Antifungal)- Taste changes, dry mouth, dyspepsia, N/V/D

Mycostatin (Antifungal)- N/V/D

Dapasone (Antibacterial)- N/V anorexia

Dilaudid (Opioid)- dry mouth, dysphagia, N/V/D, dysmotility, taste changes, upset stomach

Filgrastin (Increases production of neutrophils)

Multivitamin and Folic Acid

Magic Mouth Wash- numbs mouth

Zofran (Antiemetic)- dry mouth, diarrhea

Oxycodone (Opioid)- anorexia, dry mouth, upset stomach, N/V/D, constipation

(11)

+Laboratory Values

Hgb-11.4 L

Hct-33 L

BUN- 20 H

Na-130 L

K- 3.2 L

Alb-1.7 L

Total P- 5.5 L

AST- 193 H

ALT- 99 H

BUN- 4 L

Ca- 8.2 L

WBC- 1.4 L

RBC- 2.65 L

Hgb- 7.7 L

Hct- 22 L

RDW- 15.1 H

Initial Labs 9/14 Follow up Labs 10/1

(12)

+Diet Placed on a full fluid diet

Patient cannot tolerate acidic foods

Cannot manage solid foods

<50% consumption of meals

Neutrapenic precautions due to low WBC count

Food recall taken

(13,14)

+Progression of Dx during hospitalization

Seizure

Change in Mental Status

Temporary pacemaker placed

Developed Kidney stones- had a stent placed in ureter

Tachycardia- 200+ heart rate- transferred to CCU

Changed to a nectar thick liquids due to aspiration risk

Total weight loss of 30 lbs

Ulcers not healing

Low WBC count

PICC line insertion

Sonography of gallbladder reveals gallstones

Consult for drug rehab

Respiratory Arrest

+Assessment

46 year old male admitted with esophagitis. Pt reports signs of N/V/D, 18 lbs weight loss over 1 month, painful swallowing/chewing and dizziness. Pmhx of IV drug abuse, Hep C, HTN. Patient on a full fluid diet. Reports appetite is poor with less than 50% consumption of meals. Ht- 5’7, Wt- 150#, UBW- 180#, %UBW- 83, IBW- 148, % IBW 98.6, BMI- 23, 10% weight changes over 2 months. Labs- Alb-1.7 L, Total P- 5.5 L, AST- 193 H, ALT- 99 H, BUN- 4 L, Ca- 8.2 L, WBC- 1.4 L, RBC- 2.65 L, Hgb- 7.7 L, Hct- 22 L, RDW- 15.1 H. Meds- Zovirax, Diflucan, Mycostatin, Dapasone, Dilaudid, Filgrastin, MVT, Magic Mouth Wash, Zofran, Oxycodone. Estimated needs- Kcals (30kcal/kg) 2045kcals, Protein (2g/kg) 147g, Fluids (30mL/kg) 2209mL. Diet recall- Total kcals- 700, 151g CHO (604kcals), 6g protein (24kcals), 8g fat (72kcals). Diet recall reveals pt is consuming 34% estimated kcals needs and 4% estimated protein needs. Patient is at high nutritional risk related to weight loss, diagnosis, inadequate intake, and lab values.

+PES/Nutrition Diagnosis

Inadequate caloric intake related to difficulty swallowing as evidenced by 10% weight loss and pt meeting only 34% of kcal needs.

Increased energy expenditure related to increased energy needs associated with diagnosis as evidenced by 18lbs weight loss.

Inadequate protein intake related to decreased appetite and consumption of meals as evidenced by pt meeting only 4% of protein needs and Alb 1.7 L.

Swallowing difficulty related to mouth ulcers as evidenced by pt inability to swallow due to pain.

+Interventions

Provide patient with Ensure Plus 3x day for an extra 1050kcals

Recommend diet be advanced as tolerated to soft foods to increase calories

Provide patient with Prostat 3x day for an additional 45g protein

Educate patient on high biological value proteins and high calorie foods

+Outcomes/Monitoring and Evaluation

Patient will consume 80% of meals

Patient will consume 100% of supplements

Diet will be upgraded to soft by the doctor

Albumin will be 3.5 or above in 3 weeks

Patient will maintain current weight

Monitor weight

Monitor intake by calorie count or visiting during meals

Monitor tolerance to supplement and adherence

Monitor lab values

Monitor for diet change

Outcomes Monitoring/Evaluation

+Nutritional Complications Caused by Oral Issues

Burning

Mouth Pain

Dysphagia

Chronic Ulcers

Swollen oral cavitiy

Painful Chewing

Oral Malignancy

Herpes Simplex

Cytomegalovirus

Kaposi’s Sarcoma

Stomatitis

Periodontitis

Esphageal Candidiasis

Esophagitis

Symptoms leading to decrease intake/appetite Causes

(15)

+MNT for Oral Issues

Avoid irritating foods- spicy/acidic

Soft, moist foods

Temperatures may be an issue, experiment for tolerance

Avoidance of very hot or very cold foods should be initially done. Room temperature food will often be best accepted

Patients with persistently painful oral cavities should consume foods that are nutrient and calorically dense

(1,6)

+Summary of Prognosis

Doctors debating about opioids and heart condition

Anti-retroviral therapy being determined

Awaiting psych consult for rehab for opioids

Will transfer when patient is stable

+Conclusion

What do you think?

Weight loss most likely impaired health

Nutrition and immunity are very closely related

HIV is complex, every patient differs

+References1. Nelms MN, Sucher K, Long S. Nutrition Therapy and Pathophysiology. Belmont,

CA: Thomson Wadsworth; 2007

2. Price SA, Wilson LM. Pathophysiology: Clinical Concepts of Disease Processes. St. Louis, MO: Mosby; 2003 

3. Center for Disease Control and Prevention-HIV/AIDS. http://www.cdc.gov/hiv/. Updated August 21, 2009. Accessed November 21, 2009.

4. WHO and HIV/AIDS. http://www.who.int/hiv/en/. Updated December 2008. Accessed November 21, 2009.

5. Escott- Stump S. Nutrition Diagnosis- Related Care. 6th ed. Philidelphia, PA: Williams and Wilkins; 2008 

6. Mahan LK, Escott-Stump S. Krause’s Food, Nutrition, and Diet Therapy. Philidelphia, PA: Saunders; 2004

7. Sahni S, Forrester JE, Tucker KL. Assessing Dietary Intake of Drug-Abusing Hispanic Adults with and without Human Immunodeficiency Virus Infection. J Am Diet Assoc. 2007;107(6):968-976.

8. Woods MN, Spiegelman D, Knox TA, Forrester JE, Connors JL, Skinner SC, Silva M, Kim JH, Gorbach SL. Nutrient Intake and Body Weight in a Large Cohort That Includes Women and Minorities. J Am Diet Assoc. 2002;102:203-211.

9. Gerrior J, Kantaros J, Coakley E, Albrecht M, Wanke C. The Fat Redistribution Syndrome in Patients Infected with HIV: Measurements of Body Shape Abnormalies. J Am Diet Assoc. 2001;101:1175-1180.

+References

10. Hoffman EW, Bergmann V, Armstrong J, Kendall P, Medieros LC, Hillers VN. Applications of a Five-Step Message Development Model for Food Safety Education Materials Targeting people with HIV/AIDS. J Am Diet Assoc. 2005;105:1597-1604.

11. 11. Pagana KD, Pagana TJ. Mosby’s Diagnostic and Laboratory Test Reference. 9th ed. St. Louis, MO: Mosby; 2009.

12. Pronzky ZM. Food Medication Interactions. 15th ed. Burchrunville, PA: Food Medication Interactions; 2009.

13. American Diabetes Association and American Dietetic Association. Exchange Lists for Meal Planning. 2008.

14. Sodium Content of Foods. www.nal.usda.gov/fnic/foodcomp/Data/SR17/wtrank/sr17a307.pdf. Accessed November 11, 2009.

15. Decker R, Mobley CC. Position of the American Dietetic Association: Oral Health and Nutrition. J Am Diet Assoc. 2007;107:1418-1428.