Nutrition in Cancer, AIDS, and Other Special Problems

PREVENTION: 30% to 40% of all

cancers may be prevented by changes in diet and physical activity

Role of Weight: Yo-yo dieting has been shown to decrease

immunity and may increase susceptibility to cancer

Being overweight increases the chance of getting several types of cancers, including breast and prostate

Maintain a Healthy Weight and be Physically Active

A body mass index (BMI) of 18.5 – 25 is recommended

Healthy weight results from a balance of calories (energy) in and energy expended.

ACS Guidelines: Choose a diet rich in plant-based foods.

Using the “plate method” think of ¾ of your dinner plate contents as being of plant origin and ¼ animal or other protein source, especially limiting red meats.

Eat Plenty of Vegetables, Fruits, Grains and Legumes

Eat 5 - 9 servings daily Eat a variety of fruits and veggies; choose

100% juices. Include dark green and orange vegetables,

as well as dry beans and peas each week. Enjoy whole grains, beans and peas with

each meal

Limit High Fat Foods from Animal Sources

Choose fish, poultry, or beans as an alternative to beef, pork, and lamb

When you eat meat, select lean cuts and smaller portions

Prepare and Store Foods Safely Use safe storage methods

and promptly chill or freeze leftovers.

Avoid burning of meat juices.

Consume only occasionally meat and fish grilled in direct flame, and cured or smoked meats.

Alcohol and Cancer Risk Increases risk of:

Mouth and esophageal cancers Pharynx and larynx cancers Liver cancer Breast cancer in women

Combined use of alcohol and tobacco greatly increases risk compared to drinking or smoking alone

**Drink alcohol in moderation, if at all.**

What about Sugar? You CAN eat sugar: sugar does not “feed”

cancer cells BUT Stick with mostly naturally occurring sugars

such as in fruit and dairy foods Avoid foods and beverages high in processed

sugars but low in other nutrients e.g.: soda and sweets

Choose whole grains over refined versions

Cancer Treatment Side-effects: Appetite changes Weight loss→ muscle loss, weakness,

decreased immune strength Nausea and vomiting Diarrhea or constipation Dry mouth and mouth sores Difficulty swallowing

Nutrition Education: Studies show cancer patients who receive

nutrition counseling lose less weight, experience fewer side-effects and have overall better Quality-of-Life during treatment than those who do not.

What about supplements?

High-calorie drinks and barsCanned or powdered typesHomemade creationsSpecialized formulas

Vitamins and MineralsHerbs and other dietary supplements

Lancet 2003; 362: 1234-37

‘A new variant famine’? Secondary effects of the AIDS epidemic on food security,

famine and nutrition could be as great as the primary effects Present southern Africa drought and food crisis compounds

AIDS epidemic Historical coping strategies are in danger of collapsing. Present food crisis more intractable

High degree of vulnerability in areas not affected by drought Household impoverishment has occurred more rapidly Despite early rains in early 2003, high levels of vulnerability persist

Nutrition and HIV Sub-Saharan Africa vs. Europe / N. America

At risk populations for HIV/AIDS also at high risk of food insufficiency

Poor quality of food as well as limited quantity – limited choices

Higher burden of infectious diseases and therefore need for effective antioxidant systems

Chronic malnutrition in the general population introduces complex issues of equity and distribution

Adults and children with HIV infection have increased energy needs from the time they first become infected – these need to be met in ways that are appropriate and adequate

Monitoring weight is a very useful way of following disease progression in an individual

HIV infected adults and children are susceptible to misinformation and commercial exploitation – know your facts

TEE

HIV-associated wastingTotal energy expenditure

Resting Energy

Expenditure

(αBMR)

Activity-related Energy

Expenditure – (AEE)

AEE

REE

ILLNESS …Appetite and Food intake

Growth in HIV-infected children: sub-Saharan Africa experience

Growth is severely affected in HIV-infected children Growth faltering is common and occurs early in life.

Indus. countries >50% by 5yr vs. SSA 50% by 1 yr Decreases in length- and wt- for-age observed by 3 mos

of age (Bobat 1998, Bobat 2001)

While both wt and length are severely affected, a disproportionate effect on wt (wasting) is reported in some cohorts by age 1 year

Growth faltering has marked effect on survival Poor growth strongly and independently

associated with poor survival in US, European, African, and HIV+ haemophilia populations.

In US children on antiretrovirals, poor growth is an independent risk factor for death (McKinney1994, Benjamin 2003, Carey 1998).

Ugandan infants with low wt. had a 5-fold increase in risk of death by age 25 mos. (Berhane 1997).

Body Mass Index at time of HIV Diagnosis

BMI

<16

≥ 22

Median Survival time

0.8 yrs

8.9 yrs

BMI <18 is a significant independent predictor of mortality and is comparable to CD4 count.

J Acquir Immune Defic Syndr, 37(2) 2004

Body composition abnormalities HIV-infected children

HIV-infected children have disproportionate decreases of lean body mass with preservation of body fat (Miller 1993, Arpadi 1998).

Reduced lean body mass is detectable prior to decelerations in linear growth.

Diarrhoea has marked impact on growth

Diarrhoea reported 90% of HIV-infected children

Chronic diarrhoea 6 times more likely to develop in HIV-infected vs. uninfected children (Keusch 1992).

Persistent diarrhoea associated with 11-fold increased risk of death (Thea 1990).

The mean growth for HIV-infected infants with >1 episodes of diarrhoea / yr was 1.4 cm/yr less than infants with <1 episode (Villamor 2004).

12-month growth velocity(cm/yr) vs HIV viral load (HIV RNA copies/ml) performed in HIV-infected children (n=42)

Growth velocity and FFM are inversely related to level of viral replication

Viral replication remains a negative determinant of growth rate even after adjusting for food intake.

Arpadi 2000

Growth velocity is inversely related to viral load

Potentially modifiable factors involved in HIV-associated growth abnormalities

Dietary deficiencies prevention and treatment

Diarrhoeal illnesses prevention, detection, and nutritional

management HIV replication and immune suppression

use of anti-retroviral medications

Growth, body composition and dietary intake?

In contrast to simple malnutrition, pre-HAART studies found enteral supplements improved wt and fat stores but not ht or lean body mass (Miller 1995, Henderson 1994).

Viral suppression improves growth and body composition abnormalities

Large studies detect improvements in growth

(wt>ht) attributable to protease inhibitor use (Buchacz 2001, European Collaborative 2003)

Improvements in gut absorption reported (Canani 1999)

Dietary intake is stable with ART (Miller 2001).

WHO Technical Review Growth abnormalities in HIV-infected children

HIV impairs the growth of children early in life, especially height growth. Often occurs before the onset of OIs /other symptoms. Growth failure associated with increased risk of death.

The exact mechanisms of wasting are complex but insufficient food intake and diarrhoea are major causes of poor growth, especially in resource-poor countries

Cotrimoxazole improves growth and survival ART, when clinically indicated, improves weight, growth and

development of infected children

WHO Technical Review Energy and protein needs

Energy needs increase by about 10% in adults and children from the time of infection

During and after severe illnesses, these needs might increase by a further 20-30%. In children this may be up to 150%.

No evidence for increased protein requirements other than in a balanced diet i.e. 12-15% of the total energy intake

Anorexia and poor dietary intake are important causes of weight loss

Improving the diet alone, though, may not result in weight recovery and improvement in clinical status

Micronutrients and HIV infection

viral load

HIV+ HIV+++

CD4

Oxidativestress

NAIDS

InfectionsMicronutrientdeficiencies

Henrik Friis

Increased micronutrient status / intake may affectTransmission of HIV infection

mother-to-child transmissionssexual transmission

Infectiousness and susceptibility

Progression of HIV infectionHIV load, CD4 counts, AIDS, deathMorbidity from other infectionsDrug acceptability, efficiency, safety

Does micronutrient status / intake affect HIV infection?

Multiple micronutrients and HIV infectionIntervention trial

Randomised trial in Thailand (Jiamton S, 2003)

481 HIV+ adults

Multimicronutrient or placebo for 48 wks minerals: zinc 30 mg, iron 10 mg, selenium 0.4 mg, copper

3 mg, iodine 0.3 mg, chromium 0.15 mg, manganese 8 mg, magnesium 80 mg

vitamins A, B-complex, C, D, E, K

Mortality reduced RR 0.53 (95% CI: 0.22, 1.25) RR 0.26 (95% CI: 0.07, 0.97) among those with CD4<100

No effects on HIV load and CD4 counts

NEJM 2004;351:23-32

vs. RNI (daily intake which meets nutrient requirement for 97.5% apparently healthy individuals in an age and sex-specific population)

Vitamin Tz supplement RNI

A 10,000 RE 800RE

B1 (thiamine) 20mg 1.4mg

B2 (ribofl) 20mg 1.4mg

B6 25mg 1.9mg

Niacin 100mg 18mg

B12 50ug 2.6ug

Vit C 500mg 55mg

Vit E 30mg 7.5mg

Folic acid 0.8mg 0.6mg

Iron 120mg 100mg*

x12-15

x20

299 progressed to WHO stage 4 or died of ‘AIDS-related causes’ 67 of 271 (24.7%) MVS 70 of 268 (26.1%) MVS + Vit A 79 of 272 (29.0%) Vit A only 83 of 267 (31.1%) placebo

MVS vs. placebo RR 0.71 [95%CI 0.51-0.98; P=0.04] + reduced progression to stages 3 or 4

MVS group cf. placebo - higher CD4 and CD8 counts and reduced VL

Adding Vit A reduced the benefit

“ Neither zinc nor MMN had significant effects on culture conversion, but MMN supplementation increased weight gain in TB patients” (independent from culture conversion rates)

WHO Technical Review Micronutrients requirements

HIV-infected adults and children frequently have low levels of micronutrients i.e. low body status

Micronutrient intakes at RDA need to be assured in HIV-infected adults and children through consumption of diversified diets, fortified foods and micronutrient supplements as needed

WHO recommendations on vitamin A, zinc, iron, folate and multiple micronutrients remain the same

Vitamin A supplements reduce diarrhoeal morbidity and mortality especially in young children

WHO Technical Review Micronutrients and HIV -ctd

Micronutrients are not an alternative to comprehensive HIV treatment including ARV therapy

Studies have shown that some micronutrient supplements may prevent HIV disease progression and adverse pregnancy outcomes. Additional research is urgently required

Nutritional assessment

Food and Nutrition History 24h dietary recall inclusive of determination of food

access

Anthropometric measurement Yearly height, weight, BMI, WHR*, consider MUAC

and skinfolds

Biochemical Assessment Yearly fasting lipids, glucose and with change in ARV,

yearly hemoglobin; consider OGT in patients with IGT

Nutrition focused medical history and exam Obtain weight and growth history at each visit