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Cheryl Gregory May 6, 2013 Case Study 29 II. Understanding the Nutrition Therapy 6.

What are common nutritional complications of HIV and AIDS? - increased energy expenditure - inadequate oral food/beverage intake - excessive bioactive substances - increased nutrient needs - malnutrition - inadequate protein-energy intake - swallowing difficulty - altered GI function - impaired nutrient utilization - altered nutrition-related laboratory values - food-medication interaction - underweight - changes in body composition - involuntary weight loss - impaired ability to prepare foods/meals - physical inactivity - intake of unsafe food - lower serum Se, Zn, Mg, Ca, Fe, Manganese, Cu, carotene, choline, glutathione and vitamins: a, b6, b12, and e d/t acute-phase protein production 7. Are there specific recommendations for energy, protein, vitamin, and mineral requirements for someone with AIDS? Recommendations for energy, protein, vitamin, and mineral requirements are very patient specific and depend on the patients current complications, nutritional status, and medications. Although, most patients will have higher energy and protein needs due to wasting syndrome or opportunistic infections. III. Nutrition Assessment A. Evaluation of Weight/Body Composition Anthropometrics: MAC 10; TSF 7 mm; body fat 12.5%, Ht 61, Wt 151 lbs, UBW 160165 lbs 8. Evaluate the patients anthropometric information. a. Calculate percent UBW and BMI. UBW: 160-165 lbs CBW: 151 lbs % UBW: 100% x 151lbs / 162.5lbs = 92.9% The pt has lost 7.1% of his body weight. If the patient had lost this percent of weight in less than 6 months and had an accompanying fever, then he may be experiencing AIDS wasting syndrome. However, the timeframe for the pts

weight-loss is unclear. Physicians should continue to monitor his weight closely to evaluate whether Terry is experiencing weight loss secondary to infection or is experiencing AIDS wasting syndrome. BMI: 151lbs = 68.49kg 61 = 1.85m 68.49kg/(1.85m) = 20.01 kg/m This is within the healthy range.

b. Compare the TSF to population standards. What does this comparison mean? Is this a viable comparison? Explain. MAC: 10 = 25.4cm TSF: 7mm At 32yrs, the mean TSF for men is 13.1mm. Terry is in 20th percentile or so. Only patients in the bottom 5% and top 95% are seen as at risk. AMA: [25.4cm (3.14 0.7cm)] / (4 x 3.14) = 41.94 cm A normal and adequate AMA for men is 5411. At 42 cm, Terry is near the 75% and his muscle mass is considered marginal. TAA: (25.4cm) /(4 x 3.14) = 51.34cm AFA: 51.34cm - 41.94cm = 9.4cm Terrys AFA measurement is in the 15th percentile for his gender and age group. This means that he is below average but not necessarily experiencing total body wasting. Comparisons for both the TSF and AMA should be age and race specific as well as gender specific. These reference standards were created for a healthy population and do not relate as well to a diseased population. The measurements can be helpful to estimate body composition, but the best use is to monitor changes and fat patterns over time within a single individual. Also, measurements can be influenced by hydration status. 9. From the information gathered after assessing weight and body composition, list possible nutrition problems using the diagnostic term. - Involuntary weight loss related to AIDS as evidenced by a 7.1% change in usual body weight. - Underweight compared to usual body weight. B. Calculation of Nutrient Requirements 10. Determine Mr. Longs energy and protein requirements. UBW: 162.5lbs = 73.71kg BEE: Men 30-60 years: 11.6 x 73.71kg + 879 = 1734 kcal/day Kcal needs: BEE x 1.5 (because the pt is experiencing wt loss and infxn) 1734 x 1.5 = 2601 kcal/day= 2600kcal/day Prot: The pt is experiencing infxn and has low prealbumin lab values which could indicate he is experiencing acute catabolism, therefore, his protein needs are higher. 1.5g/kg/day x 73.71kg = 111g prot/day

C. Intake Domain

11. Evaluate Mr. Longs dietary information. What tools could you use to evaluate his dietary intake? Usual dietary intake, a 24 hr diet recall, labs, and pt observation can all be used to evaluate dietary intake. Mr. Long is currently experiencing inadequate oral intake as evidenced by his 24 hr recall in which he only eats approximately 2 cups of food. His low prealbumin levels also indicate possible malnutrition. He has inadequate protein energy intake as he has increased protein energy requirements and the only protein he ate in the last 24 hours was rice which is an incomplete protein. He is also likely experiencing difficulty swallowing related to his throat sores as evidenced by his consumption of only soft foods and small amounts of liquids. Mr. Longs usual dietary intake is also inadequate in nutrients. He consumes foods high in refined grains and sugars with limited variety and few fruits and vegetables to add fiber to the diet.

12. Does he seem to be consuming adequate amounts of food? Can you identify anything from his history that indicates he is having difficulty eating? Explain. He does not seem to consume adequate kcal, protein, or nutrients. He needs about 2600kcals/day and 110g prot/day. A conservative estimate of Terrys usual kcal intake shows he probably consumes 2000 kcals/day. Many of these calories provide little other nutritive value as they come from refined grains, simple sugars, or alcohol. Depending on the size of the pork chops, Terry may consume enough complete protein per day. He also seems to have difficulty eating as evidenced by the radical change from his normal diet to a diet primarily of soft foods, his decreased intake of liquids: only a few sips throughout the day, and his complaint of mouth sores. His 24 hour recall shows he is currently consuming significantly fewer calories than his body needs. 13. Mr. Long states that he consumes alcohol several times a week. Are there any contraindications for alcohol consumption for him? With AIDS, Terry is already susceptible to vitamin and mineral deficiencies. Alcohol can further promote nutrient degradation and impaired activation and can contribute to malabsorption and malnutrition. Alcohol metabolism can also increase the need for nutrients such as B-vitamins. Also, alcohol can negatively interact with HIV medication. Terry should ideally stop consuming alcohol altogether, but at the very least, he should decrease his intake. 14. From the information gathered within the intake domain, list possible nutrition problems using the diagnostic term. - inadequate protein-energy intake - inadequate oral food/beverage intake - increased nutrient needs - increased energy expenditure secondary to infection

D. Clinical Domain

15. Using this patients laboratory values, identify those labs used to monitor his disease status. What do these specifically measure, and how would you interpret them for him? Explain how the virus affects these laboratory values. T-Helper CD4 cell count: This is the type of cell that the virus invades and therefore, damages and renders dysfunctional. The fewer T-helper cells, the more advanced the disease and the more virus that is present. This count is better for determining morbidity and mortality rate than the viral load. Viral load: The amount of free virus found in the blood. A more advanced state of AIDS is associated with increased viral load. I would tell Terry has a low CD4 count and a high viral load. The low CD4 count and the presence of oral thrush shows, unfortunately, that he has moved from an HIV infection to AIDS.

16. What laboratory values can be used to evaluate nutritional status? Do any of Mr. Longs values indicate nutritional risk? The following labs are used to identify nutritional status and the overall health of the pt. Albumin: decreased in malnutrition and acute inflammation. Pts is normal. Prealbumin: decreased in acute catabolism, inflammation, malnutrition. Terrys is low indicating possible malnutrition. Transferrin: Elevated in FE deficiency, decreased in malnutrition. Sodium: decreased in diarrhea, vomiting, and AIDS Potassium: decreased in diarrhea, vomiting and chronic stress/fever. Glucose: elevated in diabetes, pancreatitis, chronic malnutrition. BUN: elevated in diabetes, low in malnutrition. Creatinine: elevated in renal disease and wasting. ALT: AST: elevated in hepatitis or due to medication interactions Cholesterol: elevated in hyperlipidemia, diabetes, obesity and infection. HDL-cholesterol: decreased in starvation, obesity, diabetes smoking, liver disease, and AIDS. Pts is low. LDL: elevated in hyperlipidemia and lower in advanced AIDS Triglycerides: elevated in hyperlipidemia and AIDS Glycated hemoglobin A1C: elevated in diabetes and Fe deficiency. Hemoglobin: decreased in anemia, elevated in dehydration and with chronic testosterone replacement. Hematocrit: decreased in anemia, elevated in dehydration and with chronic testosterone replacement. Mean Corpuscular volume: increased in folate or Vit. B12 deficiency anemia and associated with zidovudine. Decreased in Fe-deficiency anemia. (Can be used to assess the etiology of a pts anemia.) Ferritin: elevated in inflammation, decreased in Fe-deficiency anemia. E. BehavioralEnvironmental Domain

19. Mr. Long is taking several vitamin and herbal supplements. Find out why someone with AIDS might take each of the supplements. What would you tell Mr. Long about these supplements? Do they pose any risk? Use the following table to organize your answers. Overall, Mr. Long should be sure to inform his doctors about any and all supplements so they may review their drug interactions. He should avoid St. Johns Wort as it can negatively interact with protease inhibitors such as indinivar. He should also talk with the doctor about what a safe dose of each of the supplements would be for someone with AIDS. Vitamin C: Use: improves antioxidant capacity of body and immune system, increases iron absorption from non-heme sources Risk: Upper limit is 2,000 in adults and increases urinary loss of oxalate and calcium Vitamin E: Use: antioxidant, anti-inflammatory, may improve the anti-viral effect of medications Risk: Safe dose is not yet known, Milk thistle: Use: antioxidant in the liver, helps promote liver regeneration Risk: may produce loose stools, if liver is damaged, it may be unable to process milk thistle. Ginseng: Use: used for antidementia, antibacterial, anticancer, and antioxidant Risk: reduces gastric acidity, possibly increases serum T4 and can potentiate barbiturate drugs Echinacea: Use: anticancer, immunostimulatory Risk: may inhibit metabolism of drugs using to the cytochrome P 450 enzyme pathway St. Johns wort: Use: antidepressant, antianxiety, anti-HIV Risk: contraindicated with use of meds processed by the CYP3A4 and Pglycoprotein pathways (such as protease inhibitors and NNRTIs) and antagonistic to antihypertensive meds. Multivitamin: Use: ensure micronutrient needs are met Risk: may overdose on some micronutrients, may interact with the effectiveness of some drugs

IV. Nutrition Diagnosis 21. Select two high-priority nutrition problems and complete the PES statement. 1. Involuntary weight loss related to AIDS as evidenced by a 7.1% change in usual body weight. 2. Inadequate oral food/beverage intake related to oral thrush as evidence by 24 hour diet recall in which patient consumed less than 1000 kcal by conservative estimates which is 1600 fewer kcal than estimated recommendations.

V. Nutrition Intervention 22. For each of the PES statements that you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology). 1. Ideal Goal: Increase weight to 160-165lbs. Expected Outcome: Increase kcal intake to 2600 per day. Intervention: Nutrition education for the purpose of training leading to in-depth knowledge of kcal dense foods which will help increase daily calorie consumption. 2. Ideal Goal: Increase kcal intake to 2600 per day. Expected Outcome: Decrease the pain associated with eating and drinking. Intervention: Modify the type of food consumed to be moist, soft food that is kcal dense. 23. Identify three interventions you would recommend for modifying Mr. Longs tolerance of food until his oral thrush has subsided. 1. Eat moist, soft foods and finely diced foods 2. Keep mouth moist between meals 3. Eat foods at cooler temperatures or room temperature

24. Describe at least two areas of nutrition education that you would want to ensure that Mr. Long receives. Explain your rationale for these choices. 1. The first area would be nutrition priorities which for Terry, includes adequate water and fluids. Water recommendations are important because all three of the antiretroviral medications he will receive can produce diarrhea as a side effect. indinavir, - take with lots of water, on empty stomach or with low fat snack. diarrhea, nv, abd pain stavudine, - no food restrictions, diarrhea, nv, appet. Loss, abd. Pain didanosine. take w/o food diarrhea, nv, appetite loss, abdominal pain, taste change, lipid alterations

2. The second area would be weight maintenance and kcal balance. Terry is currently underweight and has recently lost a significant amount of weight. He

needs to consume adequate kcal and exercise to regenerate his body cell mass and return to a healthy weight. This will decrease his morbidity and mortality risk. 3. The third area would be nutrition education for a balanced meal. As evidenced by his usual dietary intake, Terry does not consume enough fruits and vegetables. A variety of fruits and vegetables could help Terry receive the nutrients he needs and the fiber to help stay the possible diarrhea associated with his new meds. Although, he does not like vegetables, he should be encouraged to eat salad or add small quantities of vegetables to other foods such as soups so the flavors and textures are not as apparent.

25. Patients with AIDS are at increased risk for infection. What nutritional practices would you teach Mr. Long to help him prevent illness related to food or water intake? With AIDS, Mr. Long is more susceptible to opportunistic infections and food and water deemed safe for others may not be safe for him. Tap water can contain pathogens as can drinking fountains and shared drinking utensils. He should only consume purified or bottled water from unopened containers. Mr. Long should avoid sharing utensils with others as they may carry pathogens harmful to someone with immunodeficiency. He should be wary of eating at restaurants and be sure the kitchen is practicing safe food handling techniques. When handling food himself, he should be sure there is no cross contamination of foods, particularly that surfaces that have touched raw meat never come into contact with other foods. He should also check that meat is fully cooked to a safe internal temperature; for example, 165 Fahrenheit for chicken.

26. Why is exercise important as a component of the nutritional care plan? What general recommendations could you give to Mr. Long regarding physical activity? Exercise is important to help regenerate body cell mass, maintain and increase lean body mass, normalize lipid metabolism, and to promote cardiac health. This is especially important as Terry is already experiencing weight-loss. I would recommend Terry incorporate aerobic and resistance exercises into a routine at least 3 times per week. Because adherence is important, I would recommend he find an activity he enjoys doing, such as swimming or playing soccer, and find a location where he feels comfortable and could see himself exercising 3 or more times per week.