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Care of Women with HIV Living in Limited-Resource Settings

HIV and Nutrition: Care and Support

Dorcas Lwanga, MSc, RDNutrition Advisor

Academy for Educational Development

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Objectives

Review goals and components of nutrition care and support

Discuss nutrition recommendations for the symptoms associated with each stage of HIV disease

Provide information on how to manage nutrition-related symptoms of HIV

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Role of Nutrition Care and Support

Studies have shown that the clinical outcome of HIV is poorer in individuals with compromised nutrition

Improving nutrition can help prevent weight loss, strengthen the immune system and delay HIV disease progression.

Nutrition care should be part of a comprehensive program that helps the HIV-infected individual and her family

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Goals of Nutrition Care and Support

Improve nutritional status Maintain weight, prevent weight loss Preserve muscle mass

Ensure adequate nutrient intake Improve eating habits and diet Replenish stores of essential nutrients

Prevent food-borne illnesses Enhance quality of life

Treat opportunistic infections Manage symptoms affecting food intake

Provide palliative care

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Components of Nutritional Care and Support

Nutrition assessment Weight Mid-arm circumference

Nutrition education and counseling Adequate diet Proper food handling and safety

Hygiene Water Sanitation

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Components of Nutritional Care and Support continued

Nutrition supplementation Food Vitamin and mineral supplements

Food and nutrition support for families Food-for-work Community kitchens

Home-based care Food baskets Home-delivered, ready to eat meals

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Stages of HIV Disease and Nutrition

Specific nutrition recommendations vary according to the underlying nutritional status and extent of HIV disease progression: Early - no symptoms, stable weight Middle - weight loss Late - symptomatic AIDS

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Nutrition Care and Support Priorities by Stage of Disease

Early stage – “stay healthy” Build stores of essential nutrients Maintain weight and lean body mass Ensure understanding of food and water safety

Middle stage – “minimize consequences” Maintain dietary intake during acute illness Increase nutrient intake for recovery/weight gain Continue physical activity

Late stage – “provide comfort” Treat opportunistic infections Modify diet according to symptoms Encourage eating and physical activity

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Recommendations for Nutrition Care and Support: Early Stage

Identify locally available and acceptable foods Promote a diet adequate in energy, protein and other

essential nutrients Energy requirements are increased by 10-15% Protein requirements are increased ~ 50% Requirements for vitamins and minerals used by the immune

system are also increased

Maintain physical activity Weight-bearing exercise builds lean body mass Exercise stimulates appetite

Prevent food-borne illnesses through safe food handling practices

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Recommendations for Safe Food Handling Practices

Wash hands before preparing and eating food, after using the toilet or changing nappies or diapers

Wash all food preparation surfaces, utensils and dishes

Wash all fruit and vegetables before eating, cooking or serving

Avoid letting raw food come in contact with cooked food

Cook food thoroughly Serve food immediately after preparation

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Recommendations For Safe Food Handling Practices continued

Keep food covered and away from insects, rodents and other animals

Do not store cooked food Always use boiled or bottled water for drinking,

cooking, and cleaning dishes and utensils Never use bottles with teats for feeding infants. Use

a cup instead

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Recommendations for Nutrition Care and Support: Middle Stage

Maintain intake during periods of acute illness and depressed appetite

Increase nutrition intake 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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Recommendations for Nutrition Care and Support: Middle Stage continued

Manage the symptoms that affect food intake Loss of appetite Nausea Mouth sores Diarrhea

Seek medical attention immediately High fever or fever for more than 3 days Persistent diarrhea Other symptoms of infection

Avoid unhealthy behaviors Alcohol, smoking and drug use Unsafe sexual practices

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Recommendations for Nutrition Care and Support: Late Stage

Treat all infections that affect appetite, ability to eat and retention of nutrients Consider the food and nutritional interactions with medicines Consider the side effects of medications that affect intake

Maintain intake during periods of acute illness and depressed appetite

Modify diet according to symptoms Encourage physical activity Provide psychological and emotional support

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Recommendations for Symptom-Based Nutrition Care and Support

Symptom Nutritional StrategyLoss of appetite Eat small, frequent meals throughout the day (5-6 meals/d)

Eat nutritious snacks whenever possible - “make every bite count” Drink plenty of liquids Take walks before meals – the fresh air helps to stimulate appetite Have family or friends assist with food preparation

Sore mouth and throat

Avoid citrus fruits, acidic and spicy foods Eat foods at room temperature or cold Eat soft and moist foods Avoid caffeine and alcohol

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Recommendations for Symptom-based Nutrition Care and Support continued

Symptom Nutritional StrategyNausea and vomiting

Eat small, frequent meals (avoid an empty stomach as this makes the nausea worse)

Eat dry bread or toast, and other plain dry foods, preferably in the morning before getting out of bed

Avoid foods with strong or unpleasant odors Avoid fried foods Drink plenty of liquids Rest and relax after and between meals Avoid lying down immediately after eating (wait for at least 1-2

hours) Avoid coffee and alcohol

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Recommendations for Symptom-Based Nutrition Care and Support continued

Symptom Nutritional StrategyDiarrhea Eat bananas, mashed fruits, soft white rice, porridge

Eat smaller meals, more often Eliminate milk and milk products to see if symptoms improve Avoid intake of fried and high fat foods Don’t eat foods with insoluble fiber (“roughage”) - take the skin off

fruits and vegetables Drink plenty of fluids (8-10 cups/day) Give oral rehydration solution if diarrhea is severe Avoid sweet drinks Drink diluted juice Avoid very hot or very cold foods (they stimulate the bowels)

If diarrhea is severe, food may be withheld for 24 hrs or restricted to only clear fluids, such as, soups, tea or soft foods (mashed fruit, potatoes, white rice, porridge)

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Recommendations for Symptom-Based Nutrition Care and Support continued

Symptom Nutritional Strategy

Fever Drink plenty of fluids Eat small frequent meals as tolerated Add snacks between meals

Altered Taste Use a variety of herbs and spices to enhance the flavor of the food

Try different textures of food Chew food well and move around mouth to stimulate

receptors

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Recommendations for Symptom-Based Nutrition Care and Support continued

Symptom Nutritional StrategyPoor fat absorption

Eliminate oils, butter, margarine, ghee and foods that contain or were prepared with them

Eat lean meats. Trim all visible fat and remove skin from chicken Avoid deep fried, greasy and high fat foods Eat fruit and vegetables and other low-fat foods

Fatigue, lethargy

If possible, have someone pre-cook foods Eat fresh fruits that don’t require preparation in between meals Eat smaller, more frequent meals and snacks throughout the day Exercise as able to increase energy Try to eat at the same time each day

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Source of Various Vitamins and Minerals

Vitamin Source

Vitamin A Cheese, butter, red palm oil, eggs, liver, carrots, mangos, papaya, pumpkin, green leafy vegetables, yellow sweet potatoes

Beta-Carotene Carrots, dark green vegetables, orange fruits, sweet potato, pumpkin, mango, papaya (paw-paw)

Vitamin B6Beans, potatoes, meats, fish, chicken, shellfish, watermelon, maize, avocado, broccoli, green leafy vegetables

Folate (Folic Acid)

Liver, green leafy vegetables, fish, legumes, groundnuts, meat, beans

Vitamin B12Meat, fish, chicken, shellfish, cheese, eggs, milk

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Source of Various Vitamins and Minerals continued

Vitamin Source

Vitamin C Citrus fruits; cabbage, green leaves, tomatoes, peppers, potatoes

Vitamin E Vegetable oils, green leafy vegetables, whole grain products, butter, liver, eggs, milk fat, groundnuts, other nuts

Iron Red meat, liver, fish, chicken, shellfish.

Zinc Meats, fish, chicken, shellfish, whole grain cereals, legumes, groundnuts, milk, cheese, yoghurt, vegetables

Selenium Meat, eggs, seafood, whole cereals, dark green vegetables, seafood

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Some Recommended Foods

Food Group FoodProtein(body-building foods)

All animal products, fish, dairy products, legumes (beans, lentils), groundnuts and cooked eggs

Carbohydrate(energy-giving foods)

Breads, cereals (maize, millet, wheat, sorghum), rice, noodles, potatoes, cassava, yam, sweet potatoes, plantain

Fruits/Vegetables (source of many vitamins and minerals)

Any fruits or vegetables

Fats/Oils(source of fat soluble vitamins A, E, D & K and energy)

Palm oil, vegetable oils, lard, margarine, butter, ghee

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Recommendations on Foods to Avoid

The aim of good nutrition care and support is to ensure adequate intake and to maintain weight and lean body mass. Therefore, other than the following, no foods should be eliminated unnecessarily.

Raw eggs Foods that have not been thoroughly cooked, especially meats

and chicken Water that is not boiled or juices that are made from water that is

not boiled Alcohol and coffee “Junk” foods such as chips, biscuits and sweets with little

nutritional value Foods that aggravate symptoms related to diarrhea,

nausea/vomiting, bloating, loss of appetite, and mouth sores

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Nutrition and Medication

Medications used to treat HIV opportunistic infections may result in negative drug-nutrient interactions or cause side effects.

Vitamin B6 supplementation should be administered with isoniazid therapy for tuberculosis to avoid Vitamin B6 deficiency

Iron and zinc-containing supplements should not be taken with ciproflaxacin

Sulfadoxine and Pyrimethamine (Fansidar) used for treatment of malaria is not recommended if the patient is folate deficient.

Some antiretroviral drugs have: Dietary requirements Side effects with nutritional consequences An effect on red blood cell production, increasing risk of anemia (e.g.

Zidovudine (AZT)).

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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 healthy lifestyle can: Preserve health Improve quality of life Prolong independence Delay disease progression

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.

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Summary continued

Managing common symptoms related to HIV/AIDS can minimize their impact on nutritional status.

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

Providing psychosocial and emotional support as part of nutrition care at all stages of HIV disease can help to improve quality of life.

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