Nathan BillingSpecialist HIV Dietician

Some of these slides have been downloaded from

http://clinicaloptions.com/HIV.aspx

And

http://www.hivtrislide.com/

Cardiovascular risk Coping with the side effects of medication Medications with or without food Lipodystrophy  or middle age spread?

▪ Discussion Healthy eating for cardiovascular risk

reduction

Blood Pressure LDL-C HDL-C Age Smoking Gender Family history Physical

inactivityGreenlund KJ et al. Arch Intern Med. 2004;164:181-8.

Adiposity Ethnicity Socioeconomic status:

• Income• health insurance• education

Geographic region ARV combination

Established Additional

Modified from Dubé. Clin Infect Dis 2000;31:1216.

Family historyHost Genetics

AgeSex

DietWeight and Exercise

LipidsDiabetesSmoking

Adreno-steroidsHypertension

Hyperthyroidism

Unmodifiable Modifiable

Yusuf S et al. Lancet. 2004;364:937-52.N = 15,152 patients and 14,820 controls in 52 countriesPAR = population attributable risk, adjusted for all risk factors

36

127

10

20

33

0

20

40

60

80

100

Smoking Fruits/veg

Exercise Alcohol Psycho-social

Lipids All 9 risk factors

PAR(%)

1418

90

Diabetes Abdominalobesity

Hyper-tension

Lifestyle factors

50

Threshold N (Millions)

Overweight/Obesity BMI ≥25 kg/m2 134.75

High Cholesterol levels Total-Cholesterol ≥5.1mmol/L

106.9

Blood Pressure BP ≥140/90 mm Hg 65

Diabetes Fasting Blood Sugar level

≥7mmol/l

13.9 (diagnosed) 5.9 (undiagnosed)

Prevalence in USA General Non HIV Population (2002)

AHA. Heart Disease and Stroke Statistics–2005 Update.

Exposure to ART (Years)

0

2

4

6

8

Incid

en

ce o

f M

I p

er

1000 P

ati

en

t-Y

ear

10

None < 1 1-2 2-3 3-4 4-5 5-6 > 6

RR per Year of ARTOverall: 1.17

Men: 1.14Women: 1.38

El-Sadr W, et al. CROI 2005. Abstract 42.

Duration of Combination Antiretroviral Therapy Is Associated

With a Small Increase in Incident CVD

Law MG, et al. 11th CROI. 2004. Abstract 737.

Observed Predicted

MI

per

1000 Y

ears

0

1

2

3

4

5

67

8

Duration of HAART (Years)< 1 1-2 2-3 3-4 4+0

Developed for use in general population

– Thought to be reasonable predictor in HIV-infected population

However, does not include HIV-specific factors

– Immune status– Increased

inflammatory markers– Insulin resistance

Calculating Cardiovascular riskCalculating Cardiovascular risk

http://www.cphiv.dk/TOOLS/Framingham/tabid/302/Default.aspx

LipoatrophyDyslipidemia/CHDLiver

GastrointestinalRenal

Bone density ?

Retrospective cohort study of 394 patients from Singapore HIV observational Cohort Study (SCHOCS)

Impact of malnutrition at time of starting antiretroviral therapy significantly associated with decreased survival

The higher risk of death was associated with a BMI below 17.5kg/m2

People who were malnourished when they started powerful anti-HIV treatment were six times more likely to die than people who were well nourished.

Paton et al 2006 HIV Medicine 7(5):323-330

nutrient intake 70 - 90%

metabolicrate

0 - 10%

absorption/diarrhoea10 - 30%

Causes of Weight Loss

Nausea & Vomiting Diarrhoea Poor appetite Sore mouth & throat Difficulty chewing or swallowing Dry mouth Heartburn or reflux

Nausea & Vomiting:• Ginger• Dry Biscuits/Crackers• Cold Foods/Fluids

Diarrhoea:• alter lactose content of diet• alter fibre content of diet (soluble vs insoluble)• alter fat content of diet

Eat little and often

Enriching meals Add extra mono/polyunsaturated fats:

e.g. spreading margarine thickly, using extra olive or rapeseed oil in cooking

Changing behaviour to overcoming barriers to eating Less time/facilities/motivation re food preparation e.g. use of snacks easily bought in dairy /corner

shop + foods which don’t require cooking/preparation

Vast improvement in dietary restrictions and anti retroviral medication

Some drugs taken without food Didanosine (ddI) at least 30 minutes before

or 2hr after eating

Some drugs need to be taken with food Most protease inhibitors to be taken with

food

Stocrin (Efavirenz)food may increase drug levels by up to 50% High fat meals may also increase absorption, which may lead to increased side-effects.“Take on an empty stomach before going to sleep”

Abacavir absorption boosted by alcohol

http://www.aidsinfonet.org/fact_sheets/view/401

Weight gain is dependent on a person's energy intake being greater than energy expenditure.

For a healthy weight, the amount of energy you eat from food & drink must equal the amount you use up with your daily activities.

To lose weight you must change eating habits permanently.

Food & Drink Daily Activities

One pound (0.45 kg) is equal to 14647kj (3,500 calories)excess.

Therefore, a person consuming 2031kj (500cal) more than he or she expends daily will gain 1 lb a week.

The last 30 Years, a Major Societal Shift NZ Family life, family structures, family

traditions, decline of home cooking Work dominating life, commuting, family time

pressured, convenience driven Leisure-Consumerism, 7 day shopping, gadgets,

technology, subscriber television, spectation replaces participation

Competition, education, academic qualifications, decline of physical work, physical activity generally

It’s a very different world from 1970’s in New Zealand

R Bree 2006 Food Industrial Work Group

Too many calories, too little activityWhen ‘treat’ foods, energy-dense foods,

become the staple dietWhen ‘virtual’ world replaces ‘real’ worldWhen wheels replace legs and feetWhen family nutrition, health and wellbeing

come second to taste, pleasure and convenience

It’s no accident that the richest nations arealso the most obese

R Bree 2006 Food Industrial Work Group

Lipodystrophy is a side effect of some anti-HIV drugs. It can mean losing some fat from your face, legs arms or buttocks and gaining fat on your belly. Fat loss and gain can be difficult to live with. Many people HIV find these changes harder

to accept than other illnesses and side effects.

Waist circumference is known to be a significant cardiac risk factor in non HIV-infected patients

▪ Yusuf S et al Lancet 2005; 366:1640-1649Central adiposity is associated with

significant metabolic abnormalities▪ Hadigan C et al Clin Infect Dis 2001; 32:130-139▪ Dolan SE et al AIDS 2005; 39:44-54

Discussion and Questions

Further

Inactivity Loss of fitness Weight gain

Decrease in patient power-weight ratio

Increased difficulty to undertake normal activities

Motivational barrier against physical activity

Further fat gain

WHO classification: 45-59 years – Middle aged 60-74 years – Elderly 75-89 years – old 90+ years – Very old

In the UK, normal retirement age (65 years) generally accepted as elderly.

Population Ageing. In Europe, 20% of the population is elderly

(aged over 60 years). 25% by 2020

One of every seven new AIDS cases over age 50

15% of those diagnosed with AIDS in the U.S. today are over 50 (CDC, 2008). As many as 1 in 5, or even 1 in 4 in specific areas.– 24% of people with AIDS in N.Y.C. age 50 or older– This trend is also highlighted when looking at

those 40-50 More than 118,000 people age 50 or older

living with HIV in 2005

From: AIDS New Zealand, Issue 63 March 2009 pp 2

Ageing and the body

↓ taste and smell – loss of taste buds

↓ vision ↓ LBM, muscle tone & mobility

Skin thinning ↑ water lost via skin↑ risk of pressure sores kidneys unable to concentrate urine efficiently

Thirst mechanism less sensitive - High risk of dehydration

Bone loss - ↑ osteoporosis &

fracture risk

Gastrointestinal changes

↓digestive capacity

Increased risk of disease

Cardiovascular diseaseMetabolic syndrome/ diabetes mellitusBody Composition ChangesBone diseaseRenal DysfunctionCancer

Death certificates of 68,669 HIV-infected New York City residents examined for causes of death Deaths from non-HIV–related

causes increased from 19.8% to 26.3% between 1999 and 2006

▪ Due to CVD, substance abuse and non-AIDS–defining cancers

Among individuals ≥ 55 years, CVD leading cause of death

Sackoff JE, et al. Ann Intern Med. 2006;145:397-406.

2030

400500600700800900

1999 2000 2003 2004Ag

e-A

dju

ste

d M

ort

ality

per

10,0

00 P

ers

on

s W

ith

A

IDS

Overall deathsHIV-related deathsNon-HIV–related deaths

2001 2002

100200300

10

Cardiovascular-related deathsCancer-related deaths

Substance abuse–related deaths

Kcal requirements and absorption.. ….means that Nutrient requirements

5 main issues re. nutrition for older people: Fluid balance and renal function Skeletal changes Physical fitness and strength Changes in the immune system Gastrointestinal changes.

“Good nutrition contributes to the health of elderly people and to their ability to recover from illness”.

Previous Experience Current Living Conditions

State of Health

Budgetary skill Food availability Confusion

Cultural traditions Cooking ability Depression

Education Cooking facilities Medicines

Habit Cooking for self / others Dysphagia

Individual likes/dislikes Cost of food items Loss of senses

Nutrition knowledge Eating alone / others Pain

Previous food experience

Living conditions Physical illness

Religious beliefs Time available to prepare and eat

Poor dentition

Willingness to experiment

Social networking Polypharmacy

Randomized trial of NCEP diet in adults initiating ART (N = 90) 95% on ZDV/3TC 75% on EFV

15- to 30-minute session with a dietician every 3 months

Other outcomes Reduced fat, calorie intake Reduced BMI Increased dietary fiber intake

Lazzaretti F, et al. IAS 2007. Abstract WEAB303.

Diet Control

Months

100

120

140

160

180

200

220

0 6 12

TC

(m

g/d

L)

406080

100120140160180200220240

0 6 12

TG

(m

g/d

L)

Most important 1st line non-drug option▪ 11% decrease in cholesterol, LANCET, 1998

Evidence 1A (Hooper, 2001, systematic review, BMJ)

“Mediterranean Diet”

Mediterranean Diet

Mediterranean Diet

AlcoholAlcoholAlcoholAlcohol

FishFishFishFish

Pulses, Pulses, Beans, Beans,

LegumesLegumes

Pulses, Pulses, Beans, Beans,

LegumesLegumes

Fruit and Fruit and VegetablesVegetablesFruit and Fruit and

VegetablesVegetables

Nuts, Seeds, Nuts, Seeds, Olive OilOlive Oil

Nuts, Seeds, Nuts, Seeds, Olive OilOlive Oil

Pasta, Pasta, BreadBreadPasta, Pasta, BreadBread Low Low

Saturated Saturated FatFat

Low Low Saturated Saturated

FatFat

• Low in saturated fat• High in unsaturated fat particularly

monounsaturated fat• High in fibre particularly soluble fibre• High in Potassium• Low in salt• Good source of omega 3 fatty acids• Rich in antioxidants• Rich in B vitamins including folic acid• Higher levels of Vitamin D

5 portions a day

10-20g/ day - 5% LDL reduction

Bile acid losses

Cup of beans = 6g3-4 portions fruit = 10g

223 HIV+ men and women on PI-based regimens vs 527 HIV- male subjects

HIV+ patients had lower HDL and higher TG No difference in total cholesterol Predicted risk of CHD > in HIV+ men (RR: 1.2) and women (RR:

1.6); P < .0001

APROCO Cohort (HIV+) MONICA sample (HIV-)

Savès M, et al. Clin Infect Dis. 2003;37:292-298.

Blood Glucose126 mg/dL

(6.99 mmol/L)

P = NS

0

10

20

30

40

50

60

70P < .0001

Smoking

P <.01

Hypertension

Pati

en

ts (

%)

P = NSP < .0001

HDL-C < 40 mg/dL

(1.04 mmol/L)

LDL-C > 160 mg/dL (4.14 mmol/L)

New England clinics: More than 70% of HIV+ smoke

Swiss HIV Cohort Study 72% are current/former smokers 96% among IDUs

Niaura R et al. Smoking among HIV-positive persons. Ann Behav Med 1999; 21(Suppl):S116

Clifford, GM et al. Cancer risk in the Swiss HIV Cohort Study: Associations with immunodeficiency, smoking and Highly Active Antiretroviral Therapy. J Natl Cancer Inst 2005;97:425-432

Friis-Moller N, et al. AIDS. 2003;17:1179-1193.

% o

f C

oh

ort

Wit

h R

isk F

acto

r

FamilyHx of CHD

PreviousHx of CHD

CurrentSmoking

BMI> 30

mg/m2

HTN DM Hyper-cholesterolemia

IncreasedTG

0

10

20

30

40

50

60

Cardiovascular diseases Cancers Lung diseases GI tract Age-related disorders …. Single most preventable cause of

death

Significant changes in mortality and morbidity among people with HIV

As people with HIV live longer, they are increasingly becoming ill or dying of non-HIV/AIDS related conditions

Smoking is highly prevalent among PLWHA

Smoking is the single most preventable cause of death and disease … even for people with HIV

Smoking cessation

IncreasingPhysical activity

Healthy eating,Weight

management

Lifestyle GoalsLifestyle Goals

• No smoking• Saturated Fat: <10%

total Energy• Fruits and vegetables:

>400g/day• Fish: >20g/day• Oily Fish: >3 times/week• 30-45 minutes of physical

activity at 60–75% of the average maximum heart rate on four-five days of the week

• Weight reduction ≥ 5%• Waist <94 cm in men and

<80 cm in women

Questions ?

Some of the information used in this talk has been obtained from the internet

Linsk, N.L., 2008 HIV/AIDS and Aging Inter-relationships in the Older Fifty Population Midwest AIDS Training and Education Center [online] Available at: http://www.ryanwhite2008.com/PDF/PCC-607-GallagherDThur0800WilsonC.pdf

Powderly, W., 2008 Aging and the HIV Patient: A Video Lecture With William Powderly, MD [online] Available at: http://www.medscape.com/viewprogram/8867

Metabolic syndrome 3 out of following Waist circumference >102cm men

>88cm women Triglyceride levels >1.7mmol/L HDL cholesterol <1.0mmol/L in men

<1.3mmol/L women Blood pressure >130/85mmHg

or current antihypertensive treatment

Fasting glucose level >6.0mmol/LExpert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497.