HIV and Nutrition Presentation

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Talk to community based practice nurses. (Auckland June 2009)

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HIV and Nutrition Presentation

  1. 1. Nathan Billing Specialist HIV Dietician
  2. 2. Some of these slides have been downloaded from http://clinicaloptions.com/HIV.aspx And http://www.hivtrislide.com/
  3. 3.  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
  4. 4. Established Additional  Blood Pressure  Adiposity  LDL-C  Ethnicity  HDL-C  Socioeconomic status:  Age • Income  Smoking • health insurance  Gender • education  Family history  Geographic region  Physical inactivity  ARV combination Greenlund KJ et al. Arch Intern Med. 2004;164:181-8.
  5. 5. Unmodifiable Modifiable Diet Family history Weight and Exercise Host Genetics Lipids Age Diabetes Sex Smoking Adreno-steroids Hypertension Hyperthyroidism Modified from Dubé. Clin Infect Dis 2000;31:1216.
  6. 6. 100 90 80 60 PAR 50 (%) 40 36 33 20 18 20 14 12 10 7 0 Smoking Fruits/ Exercise Alcohol Hyper- Diabetes Abdominal Psycho- Lipids All 9 risk veg tension obesity social factors Lifestyle factors N = 15,152 patients and 14,820 controls in 52 countries PAR = population attributable risk, adjusted for all risk factors Yusuf S et al. Lancet. 2004;364:937-52.
  7. 7. Prevalence in USA General Non HIV Population (2002) Threshold N (Millions) Overweight/Obesity BMI ≥25 kg/m2 134.75 High Cholesterol levels Total-Cholesterol ≥5.1mmol/ 106.9 L Blood Pressure BP ≥140/90 mm Hg 65 Diabetes Fasting Blood Sugar level 13.9 (diagnosed) ≥7mmol/l 5.9 (undiagnosed) AHA. Heart Disease and Stroke Statistics–2005 Update.
  8. 8. Duration of Combination Antiretroviral Therapy Is Associated With a Small Increase in Incident CVD 10 RR per Year of ART Incidence of MI per 1000 8 Overall: 1.17 Men: 1.14 Patient-Year 6 Women: 1.38 4 2 0 None <1 1-2 2-3 3-4 4-5 5-6 >6 Exposure to ART (Years) El-Sadr W, et al. CROI 2005. Abstract 42.
  9. 9. Observed Predicted 8 7 MI per 1000 Years 6 5 4 3 2 1 0 0 <1 1-2 2-3 3-4 4+ Duration of HAART (Years) Law MG, et al. 11th CROI. 2004. Abstract 737.
  10. 10. 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
  11. 11. Calculating Cardiovascular risk
  12. 12. Dyslipidemia/CHD Lipoatrophy Liver Bone density ? Gastrointestinal Renal
  13. 13.  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
  14. 14. ⇓ nutrient intake 70 - 90% Caus e s o f We ig ht Lo s s ⇑ metabolic ⇓ absorption/ rate diarrhoea 0 - 10% 10 - 30%
  15. 15.  Nausea & Vomiting  Diarrhoea  Poor appetite  Sore mouth & throat  Difficulty chewing or swallowing  Dry mouth  Heartburn or reflux
  16. 16.  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
  17. 17.  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
  18. 18.  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
  19. 19.  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
  20. 20. http://www.aidsinfonet.org/fact_sheets/view/401
  21. 21.  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 Food & Drink Daily Activities must equal the amount you use up with your daily activities.  To lose weight you must change eating habits permanently.
  22. 22.  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.
  23. 23. 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
  24. 24.  Too many calories, too little activity  When ‘treat’ foods, energy-dense foods, become the staple diet  When ‘virtual’ world replaces ‘real’ world  When wheels replace legs and feet  When family nutrition, health and wellbeing come second to taste, pleasure and convenience  It’s no accident that the richest nations are  also the most obese R Bree 2006 Food Industrial Work Group
  25. 25.  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.
  26. 26.  Waist circumference is known to be a significant cardiac risk factor in non HIV-infected patients ▪ Yusuf S et al Lancet 2005; 366:1640-1649  Central 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
  27. 27. Discussion and Questions
  28. 28. Inactivity Loss of fitness Weight gain Further Further fat gain Decrease in patient power- weight ratio Motivational barrier against Increased difficulty to undertake physical activity normal activities
  29. 29. 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
  30. 30.  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
  31. 31. From: AIDS New Zealand, Issue 63 March 2009 pp 2
  32. 32. ↓ taste and smell – ↓ vision ↓ LBM, muscle tone & loss of taste buds mobility Gastrointestinal Bone loss - ↑ changes osteoporosis & Ageing and the ↓digestive fracture risk body capacity Skin thinning ↑ water lost via skin Thirst mechanism less ↑ risk of pressure sores Increased risk of kidneys unable to sensitive - High risk of disease concentrate urine efficiently dehydration
  33. 33.  Cardiovascular disease  Metabolic syndrome/ diabetes mellitus  Body Composition Changes  Bone disease  Renal Dysfunction  Cancer
  34. 34.  Death certificates of 68,669 Overall deaths HIV-infected New York City HIV-related deaths Non-HIV–related deaths residents examined for causes of per 10,000 Persons With AIDS Cardiovascular-related deaths death Age-Adjusted Mortality 900 Cancer-related deaths 800 Substance abuse–related deaths 700  Deaths from non-HIV–related causes 600 500 increased from 19.8% to 26.3% 400 between 1999 and 2006 300 200 100 ▪ Due to CVD, substance abuse and non-AIDS–defining cancers 30 20  Among individuals ≥ 55 years, CVD 10 1999 2000 2001 2002 2003 2004 leading cause of death Sackoff JE, et al. Ann Intern Med. 2006;145:397-406.
  35. 35. 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”.
  36. 36. Pre vio us Expe rie nc e Curre nt Living S tate o f He alth Co nditio ns 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 Tim available to prepare e Poor dentition and eat Willingness to experiment Social networking Polypharmacy
  37. 37.  Randomized trial of NCEP 220 Diet Control diet in adults initiating 200 TC (mg/dL) ART 180 160 (N = 90) 140  95% on ZDV/3TC 120  75% on EFV 100  15- to 30-minute session 240 0 6 12 with a dietician every 3 220 200 months 180 TG (mg/dL) 160 140  Other outcomes 120 100  Reduced fat, calorie intake 80 60  Reduced BMI 40  Increased dietary fiber intake 0 6 12 Months Lazzaretti F, et al. IAS 2007. Abstract WEAB303.
  38. 38.  Most important 1st line non-drug option ▪ 11% decrease in cholesterol, LANCET, 1998  Evidence 1A (Hooper, 2001, systematic review, BMJ)  “Mediterranean Diet”
  39. 39. Fruit and Vegetables Pulses, Alcohol Beans, Legumes Mediterranean Fish Diet Pasta, Low Bread Saturated Nuts, Seeds, Fat Olive Oil
  40. 40. • 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
  41. 41.  5 portions a day  10-20g/ day - 5% LDL reduction  Bile acid losses Cup of beans = 6g 3-4 portions fruit = 10g
  42. 42. APROCO Cohort (HIV+) MONICA sample (HIV-) 70 60 P < .0001 50 P < .0001 Patients (%) P = NS 40 30 20 P <.01 P = NS 10 0 Smoking Hypertension Blood Glucose HDL-C LDL-C 126 mg/dL < 40 mg/dL (1.04 > 160 mg/dL (6.99 mmol/L) mmol/L) (4.14 mmol/L)  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 Savès M, et al. Clin Infect Dis. 2003;37:292-298.
  43. 43.  New England clinics: More than 70% of HIV+ smoke Niaura R et al. Smoking among HIV-positive persons. Ann Behav Med 1999; 21(Suppl):S116  Swiss HIV Cohort Study  72% are current/former smokers  96% among IDUs 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
  44. 44. 60 % of Cohort With Risk Factor 50 40 30 20 10 0 Family Previous Current BMI HTN DM Hyper- Increased Hx of CHD Hx of CHD Smoking > 30 mg/m2 cholesterolemia TG Friis-Moller N, et al. AIDS. 2003;17:1179-1193.
  45. 45.  Cardiovascular diseases  Cancers  Lung diseases  GI tract  Age-related disorders  ….  Single most preventable cause of death
  46. 46.  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
  47. 47. Lifestyle Goals • No smoking • Saturated Fat: <10% total Smoking cessation 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 Healthy eating, average maximum heart rate Increasing on four-five days of the week Weight Physical activity management • Weight reduction ≥ 5% • Waist <94 cm in men and <80 cm in women
  48. 48. Questions ?
  49. 49.  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-Gallagher Powderly, W., 2008 Aging and the HIV Patient: A Video Lecture With William Powderly, MD [online] Available at: http://www.medscape.com/viewprogram/8867
  50. 50.  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/L Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497.

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