Role of Nutrition in the

Management of HIV

13 March 2006

Louise Houtzager MSc APD

Simon Sadler MPH APD
Albion Street Centre
Sydney Australia
 Outline
• Comprehensive Care
• Factors contributing to poor nutrition
• Nutritional requirements of ODHA
• Nutrition assessment in HIV
• Nutrition interventions
• Case Studies
 Key elements of
Comprehensive Care
• Mobilisation and coordination of key
program partners including ODHA –
participation of ODHA in planning,
implementation and evaluation of services
• HIV testing and counselling
• Clinical Care – ART, OI prophylaxis, support
for drug adherence
 Key elements of
Comprehensive Care
• Psychological support and education – group,
individual, family
• Socio-economic support – eg income
generating activities
• HIV prevention and health promotion
• Palliative Care – end of life care, including
nutrition, symptom and pain relief
• Food and Nutrition support
 Factors Affecting Nutritional
Status in ODHA
Changes in the Nervous System
(e.g. Neuropathy, Dementia)

Metabolic Changes Effect of Medication AE

(Immunity, Hormonal, OI) (ART, OI prophylaxis)

Personal Beliefs NUTRITIONAL Pre-existing

(Religious, Cultural) Malnutrition
STATUS (Nutrient Deficiencies)

Individual/ Household Gastrointestinal

factors Problems
(Poverty, skills, (e.g. diarrhoea, nausea)
depression, support, Infrastructure and
discrimination)
Support
(available/accessible food
supply/welfare services)
Effect of Body Composition on
Long-term Survival
 Energy Requirements

Stage I (asymptomatic)*
• Resting Energy Expenditure + 10%

Stage II, III and IV (symptomatic)*

• REE + 20 – 50%

* Depending on the patients gender, age and level of activity

 Protein Requirements

According to WHO (2005) deficiency of protein stores and

abnormal protein metabolism occur in HIV/AIDS but no

evidence exists for increased protein intake over and

above that necessary to accompany the required

increase in energy in HIV related illness.

 Micronutrient
Requirements
• Infection increases demand for and utilization of

antioxidant vitamins (A, E,C) and minerals (zinc,

selenium and iron)

• Studies have shown deficiencies in Vitamin A, E

B1, B2, Folate, B6 and B12

• Micronutrient status depends on stage of disease

and access to treatments.

Supplementation Recommendations

• In Australia Dietitians recommend:

 Daily micronutrient supplementation up to

recommended daily intake (RDI)

 Discourage megadosing (> 10 X RDI)

 No additional benefit of taking high dose

multivitamins

 WHO recommends more research needed

 Nutrition Assessment
• Wt (kgs)____Ht (m)_____BMI____ Wt/Ht2
• Mid upper arm circumference (cm):
• Symptoms (tick):
□ Weight loss □ Poor appetite
□ Anaemia □ Sore mouth
□ Nausea □ Difficulty in swallowing
□ Vomiting □ Diarrhoea
 Body Composition

Skinfold Anthropometry Bioelectrical Impedance Analysis

Psychosocial Assessment

• Budget • Family members

• Mental Health • Income

• Supports • Housing

• Access to services • Level of Education

 Nutrition Assessment
• Diet history or 24 hour recall
• What did the client eat in the last 24 hours?
– Portions of energy foods
– Portions of protective foods
– Portions of body building foods
• How long has the client been eating in this frequency?
_____days_____weeks_____months
• Has food intake in this period? (please circle)
Increased Decreased Not changed
 Diet History
Breakfast Rice
Noodles
Starchy Vegetables
Morning Tea Meat
Chicken
Fish
Lunch Eggs
Green Leafy Vegetable
Coloured Vegetable
Afternoon Tea Fruit
Fats and Oil
Snack foods
Dinner
Alcohol
 Nutrition Monitoring
Energy levels (Client to cross on scale below)

1 2 3 4 5
No energy High energy

Nausea (Client to cross on scale below)

1 2 3 4 5
Nil Moderate Severe
 Nutritional Interventions and
Stage of HIV infection
When (WHO Staging): Intervention
Clinical Stage I Healthy eating
(Prior to commencement of ART, Food and personal hygiene
e.g. as part of post test Food security interventions
counselling)

Clinical Stage II Weight gain advice (if

unintentional wt loss)

Clinical Stage III/IV Management of: diarrhoea,

(or on commencement of ART) weight loss, sore mouth +
healthy eating
 Nutritional Interventions and
Stage of HIV infection
When: Intervention

During first 6 weeks of Managing side effects of

treatment treatment e.g. diarrhoea, nausea,
reflux, loss of appetite, taste
changes, weight loss

At treatment reviews or when Nutritional assessment and

treatment changes dietary modification if indicated.
 Weight Loss
• Dependent on what is causing weight loss

• Three strategies to help gain weight

– Encouraging regular meals and snacks

– Substituting foods with low energy for high

energy foods

– Food fortification
 Diarrhoea

• Increase fluid intake

• High energy/protein

• Modify fat, fibre, lactose as necessary

• Eliminate caffeine

• Use of soluble fibre

 Nausea and Vomiting
 If available – anti nausea medication 30 minutes
prior to meal time
 Small frequent meals and snacks
 Energy dense foods (not high fat)
 Rinse mouth and brush teeth prior to meal
 Salty foods
 Ginger and lemon may be useful
 Small amounts of liquids with meals or fluids after
meals
 Environment
 Nutrition Interventions
Tertiary Level
Government and MOH
District and Specialist Hospitals
Universities and other Education
Facilities
Intermediate Level
Community Hospitals
District Health Centres
Ambulatory Care Centres
Community Level
Home-based Care
Non-Government Organisation
Community Based Organisation
PLWHA Self Help Groups
Examples of Nutrition Interventions
• Inpatient Dietetic Interventions
• Food Service Interventions
• Nutrition and HIV policy development
• HCW Education and curriculum development
• Individual and group nutrition counselling
• IEC Resource Development
• Nutrition research (clinical and social)
• HCW training
• Individual and group nutrition counselling
• Food Security Projects
• Food Distribution Projects
• Volunteer and PLWHA peer education
• Nutrition skills building activities
 Joko 1
• 23 year old male, indications of IDU,
recently unemployed, with limited funds
presents to hospital with an unrelated
illness.
• Family very upset (because of IDU) and at
this time not supportive
• Otherwise asymptomatic
• Has just received a positive diagnosis
during VCT
 Joko 1
24 hour food recall
Breakfast
Coffee (milk + sugar)

11am
Pastry
Coffee

1pm
Coto Makassar
Coca-cola

Evening
Coffee
Coca-cola
 Joko 2
• 25 year old male, history of IDU, client known to
be HIV + (2 years now), CD4 500
• Presents for HIV monitoring medical review
– Poor appetite
– Not noticing recent weight loss
– BMI 17
• Lack of awareness about issues relating to self
care
 Joko 2
24 hour food recall
Breakfast
Rice porridge (1/4 cup)
Snake fruit

1pm
Boiled egg with Rice (small amount)

6pm
Soup
Mee Goreng (1/2 cup)
 Joko 3
• 27 year old male, history of IDU, presents
for ongoing outpatient care.
• CD4 250
• Experiencing mild weight loss (around 5%
of usual weight), frequent diarrhoea (up to
6 times a day)
• Working with local HIV CBO
 Joko 3
24 hour food recall
Breakfast
Nasi goring with chili sambal (~ 1 cup)
Juice and Coffee

10am
Coca Cola

12
Spicy Mee Goreng (1 cup)
Coffee

3pm
Coffee

6pm
Fruit
Coffee
 Joko 4
• 29 year old male living with HIV is admitted to
hospital with severe dehydration related to
frequent severe diarrhoea
• CD4 50 has commenced ART (first line) within
the past 2 weeks
• C/o poor oral intake, nausea and diarrhoea
(worse immediately after taking medication)
 Joko 4
24 hour food recall
Breakfast
Rice porridge (1/2 bowl)
Juice

Nil during the day

3pm
Papaya juice

6pm
Soup
Nasi goring
 Joko 5
• 35 yr old male is admitted to hospital with
severe wasting and chronic diarrhoea
(cryptosporidium), candidiasis, HSV, TB,
appetite poor
• BMI 13
• Family providing some support
 Joko 5
24 hour food recall
Breakfast
Water (small amount)

Lunch
1 egg

Dinner
Rice dans chicken (small)