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

1. Nathan Billing
Specialist HIV Dietician

2. Some of these slides have been downloaded from
http://clinicaloptions.com/HIV.aspx
And
http://www.hivtrislide.com/

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

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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

12. Calculating Cardiovascular risk

14. Dyslipidemia/CHD Lipoatrophy
Liver
Bone density ? Gastrointestinal
Renal

16.  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

17. ⇓ nutrient intake
70 - 90%
Caus e s o f
We ig ht Lo s s
⇑ metabolic ⇓ absorption/
rate diarrhoea
0 - 10% 10 - 30%

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

19.  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

20.  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

21.  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

22.  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

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

25.  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.

26.  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.

27. 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

30.  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

31.  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.

33.  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

35. Discussion and Questions

36. 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

38. 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

39.  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

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

41. ↓ 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

42.  Cardiovascular disease
 Metabolic syndrome/ diabetes mellitus
 Body Composition Changes
 Bone disease
 Renal Dysfunction
 Cancer

44.  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.

46. 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”.

47. 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

49.  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.

50.  Most important 1st line non-drug option
▪ 11% decrease in cholesterol, LANCET, 1998
 Evidence 1A (Hooper, 2001, systematic review, BMJ)
 “Mediterranean Diet”

51. Fruit and
Vegetables
Pulses, Alcohol
Beans,
Legumes
Mediterranean Fish
Diet
Pasta, Low
Bread Saturated
Nuts, Seeds, Fat
Olive Oil

52. • 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

53.  5 portions a day
 10-20g/ day - 5% LDL reduction
 Bile acid losses
Cup of beans = 6g
3-4 portions fruit = 10g

56. 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.

57.  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

58. 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.

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

60.  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

62. 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

63. Questions ?

64.  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

65.  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.