IRS Exam Issues

Homework
Constructive Dividends, Redemptions, and Related Party Losses
Suppose you are a CPA hired to represent a client
that is currently under examination by the IRS. The client is the
president and 95% shareholder of a building supply sales and
warehousing business. He also owns 50% of the stock of a
construction company. The client’s son owns the remaining 50%
of the stock of the construction company. The client has
received a Notice of Proposed Adjustments (NPA) on three (3)
significant issues related to the building supply business for the
years under examination. The issues identified in the NPA are
unreasonable compensation, stock redemptions, and a rental
loss. Additional facts regarding the issues are reflected below:
· Unreasonable compensation: The taxpayer receives a salary of
$10 million composed of a $5 million base salary plus 5% of
gross receipts not to exceed $5 million. The total gross receipts
of the building supply business are $300 million. The NPA by
the IRS disallows the salary based on 5% of gross receipts as a
constructive dividend.
· Stock redemptions: During the audit period, the construction
company redeemed 50% of the outstanding stock owned by the
client and 50% of the stock owned by the client’s son, leaving
each with the same ownership percentage of 50%. The IRS
treated the redemption as a distribution under Section 301 of
the IRC.
· Rental loss: The rental loss results from a building leased to
the construction company owned by the client and his son.
Use the Internet to research the rules and
income tax laws regarding unreasonable compensation, stock
redemptions treated as dividends and related party losses. Be
sure to use the six (6) step tax research process in Chapter 1 and
demonstrated in Appendix A of your textbook as a guide for
your written response.

Write a four to five (4-5) page paper in which you:
1. Based on your research and the facts stated in the scenario,
prepare a recommendation for the client in which you advise
either acceptance of the proposed adjustments or further appeal
of the issue based on the potential for prevailing on appeal.
2. Create a tax plan for the future redemption of the client’s
stock owned in the construction company that will not be taxed
according to Section 301 of the IRC.
3. Propose a strategy for the client to receive similar amounts in
compensation in the future and avoid the taxation as a
constructive dividend.
4. Use the six (6) step tax research process, located in Chapter 1
and demonstrated in Appendix A of the textbook, to record your
research for communications to the client.
The specific course learning outcomes associated with this
assignment are:
· Analyze tax issues regarding corporate formations, capital
structures, income tax, non-liquidating distributions, or other
corporate levies.
· Prepare client, internal, and administrative documents that
appropriately convey the results of tax research and planning.
· Create an approach to tax research that results in credible and
current resources.
· Use technology and information resources to research issues in
organizational tax research and planning.
· Write clearly and concisely about organizational tax research
and planning using proper writing mechanics.
ADDITIONAL INSTRUCTIONS

Question 1. He can fall into 2 different categories and explain
why you put him in this category.
Question 2. Talk about 1 major clinical complication at a time
a) Explain what the complication is
b) Explain how it affects his nutrition
c) Explain 3 major clinical complication
Question 3. Explain why the goal of nutritional therapy is
appropriate for him
Question 4. What is the best option for him and explain why
the GI Tract works or not. And, if he uses alternative therapy
explain why
Question 5. Explain when he is able to tolerate a diet and gain
weight to be able to reduce symptoms. List nutritional
supplements that he may need
Appendix: Use ADIME and only use nutrition diagnosis no
medical diagnosis
Unit 6 Assignment: Medical Nutrition Therapy for an HIV
Patient
View a video introduction to the Assignment by clicking here.
Be sure to adjust your audio settings. A transcript of this video
presentation is available in Doc Sharing.
Unit outcomes addressed in this Assignment:
· Describe common nutritional side effects from cancer and HIV
· Name nutritional goals for cancer and HIV treatment
Course outcome assessed in this Assignment:
NS335-2: Explain the use of parenteral and enteral nutrition in
special populations.
GEL-8.3: Formulate a logical solution to a problem.
Instructions:

Review the following case study patient details
Mr. W is a 25 year old male who was in a drug rehabilitation
program last year. He has been admitted to the hospital with a
history of weight loss, weakness, and intractable diarrhea. His
height is 70 inches and his weight has dropped from 180 lbs. to
110 lbs. He is also suffering from fever and night sweats.
Physical examination reveals swollen lymph glands, tongue
lesions of herpes simplex and ulcers in the perianal region.
Further tests indicated depressed T-cell levels and the presence
ofPneumocystis carinni. He was tested for HIV infection and the
blood test for HIV infection antibodies was positive.
While in the hospital he developed several other symptoms:
anorexia, fever, fatigue, nausea, vomiting, watery diarrhea, and
rectal incontinence. His temperature was 103°F (39.8°C) and
was treated with antibiotics to which he did not respond. The
amount of diarrhea increased markedly, necessitating
intravenous hydration. He developed esophageal candiasis and a
duodenal infection.
The patient did not tolerate a soft diet or nutritional
supplements, continued to lose weight, and had severe anorexia,
abdominal cramping, and bloating. Nutritional assessment was
deficient in all aspects, showing a decreased BMI, decreased
muscle mass, and depleted total protein and serum albumin.
1. In which stage of HIV infection would you categorize Mr.
W?
2. Name and describe the major clinical complications in the
final stage of AIDS and explain how these complications
profoundly compromise a patient’s nutritional status.
3. What should be the goal of nutritional therapy based on
assessment data and the patient’s history?
4. Utilize your critical thinking skills to determine the most
appropriate route of feeding to administer nutrition support.
Defend your choice with evidence from the patient description
and the knowledge you have gained regarding alternative
feeding routes.
5. List several nutritional supplements that might be used to

alleviate some of Mr. W’s symptoms and increase his caloric
intake when he is able to tolerate a diet again.
6. Write a Nutrition Care Plan/Chart note on the HIV patient
that addresses the patient’s current clinical situation. Write this
note as though you were a nutrition professional caring for this
patient in a hospital setting. Please refer to Table 11-3 and 11-4
in your textbook for information on the ADIME chart note
process.
Requirements
Paper format: Answer questions numbers 1–5 in a 2–3 page
paper using APA format and citation guidelines. Include a title
page, introduction, body, conclusion, and reference page.
Include number 6, the Nutrition Care Plan/ Chart note, as an
appendix. Be aware that the title page, reference page, and
appendix/chart note DO NOT count towards the 2–3 page
minimum.
Please organize your paper in the following paragraph format.
Please see KUs Writing Center for more information regarding
essay and paragraph format.
Section 1: Introductory paragraph (incorporate your answer to
question 1)
Section 2: Body paragraph(s) (incorporate your answer to
question 2)
question 3)
question 4)
Section 5: Concluding paragraph (incorporate your answer to
question 5)
Appendix: Nutrition Care Plan/Chart note
References: Include a minimum of 4 quality references. Your
textbook may count towards this requirement. You can use
reputable websites or other textbooks/ scientific or medical
journal articles. Please use APA style citations within the paper
itself and also on the reference page. See Writing Center
Resources found in Doc Sharing and the Kaplan University

Writing Center for complete details and examples regarding
APA style references.
Submitting Your Work
Put your responses in a Microsoft Word document. Save it in a
location and with the proper naming convention: username-
CourseName-section-Unit 6_Assignment.doc (username is your
Kaplan username, section is your course section, 6 is your unit
number). When you are ready to submit it, go to the Dropbox
and complete the steps below:
1. Click the link that says "Submit an Assignment."
2. In the "Submit to Basket" menu, select Unit 6: Assignment.
3. In the "Comments" field, make sure to add at least the title of
your paper.
4. Click the "Add Attachments" button.
5. Follow the steps listed to attach your Word document.
To view your graded work, come back to the Dropbox or go to
the Gradebook after your instructor has evaluated it. Make sure
that you save a copy of your submitted project.
Please click on the View/Print icon below to print the
Assignment directions and grading rubric
CHAPTER 38 Medical Nutrition Therapy for HIV and AIDS
Kimberly R. Dong, MS, RD
Cindy Mari Imai, MS, RD
Key Terms
acquired immune deficiency syndrome (AIDS)
acute HIV infection
antiretroviral therapy (ART)
asymptomatic HIV infection
CD4+ cells
CD4 count
clinical latency
drug resistance
HIV-associated lipodystrophy syndrome (HALS)
human immunodeficiency virus (HIV)

long-term nonprogression
opportunistic infections (OIs)
seroconversion
symptomatic HIV infection
T-helper lymphocyte cells
viral load
Acquired immune deficiency syndrome (AIDS) is caused by the
human immunodeficiency virus (HIV). HIV affects the body's
ability to fight off infection and disease, which can ultimately
lead to death. Medications used to treat HIV have enhanced the
quality of life and increased life expectancy of HIV-infected
individuals. These antiretroviral therapy (ART) medications
slow the replication of the virus but do not eliminate HIV
infection. With increased access to ART, people are living
longer with HIV. Unfortunately, health issues such as
cardiovascular disease and insulin resistance are increasingly
prevalent in this population.
Nutritional status plays an important role in maintaining a
healthy immune system and delaying the progression of HIV to
AIDS. To develop appropriate nutrition recommendations, the
nutrition professional should be familiar with the
pathophysiology of HIV infection, the medication and nutrient
interactions, and the barriers to adequate nutrition. Mental
health status and illicit drug use should be considered since it
may affect nutrition intake.
Epidemiology and Trends
Global Status of HIV and AIDS
The first cases of AIDS were described in 1981. Soon after,
HIV was isolated and identified as the core agent leading to
AIDS. Since then, the number of people with HIV has gradually
increased, leading to a global pandemic affecting socioeconomic
development worldwide. The continuing rise in the population
of people living with HIV is reflective of new HIV infections
and the widespread use of ART, which has delayed the
progression of HIV infection to death. At the end of 2008 an
estimated 33.4 million people were living with HIV or AIDS.

There were 2.7 million new infections reported, an average of
7400 infections daily, and 2 million HIV-related deaths (Joint
United Nations Programme on HIV/AIDS [UNAIDS] and the
World Health Organization [WHO], 2009).
Despite increased prevention efforts and availability of ART,
geographic variations in HIV infection is evident. The
FIGURE 38-1 Global prevalence of HIV and AIDS.
(UNAIDS and WHO: 2009 AIDS epidemic update. Accessed 12
July 2010
fromhttp://data.unaids.org/pub/Report/2009/JC1700_Epi_Updat
e_2009_en.pdf. From UNAIDS/ONUSIDA 2009.)
FIGURE 38-2 Estimated Percentage of HIV diagnoses by route
of transmission in the United States, 2008.
(Centers for Disease Control and Prevention (CDC): HIV
surveillance report, 2008a. Accessed from 12 July 2010
fromhttp://www.cdc.gov/hiv/surveillance/resources/reports/2008
report/pdf/2008SurveillanceReport.pdf)
majority of infections continue to occur in the developing world
(Figure 38-1) where more than 97% occur in low- and middle-
income countries (UNAIDS and WHO, 2009). Sub-Saharan
Africa remains the region most heavily affected by HIV,
accounting for two thirds of current HIV infections and 72% of
HIV-related deaths (UNAIDS and WHO, 2009). However,
increases in new infections are being seen in higher-income
countries in eastern Europe such as Ukraine and the Russian
Federation. Within sub-Saharan Africa, heterosexual
transmission is the most prevalent mode of HIV transmission
(UNAIDS and WHO, 2009). In other regions, populations
affected by HIV include injection drug users, men who have sex
with men, sex workers, and clients of sex workers.
The United States
Within the United States, more than 1.2 million people are
living with HIV or AIDS and 21% may be unaware of their HIV
status (Centers for Disease Control and Prevention [CDC],

2006, UNAIDS, 2008). Although more people are living with a
diagnosis of HIV or AIDS, incidence has remained relatively
stable since the 1990s. In 2008 men accounted for 75% of all
diagnoses of HIV infection. The rate of new infections in men
has been trending up since 2005, whereas the rate among women
has remained stable (CDC, 2010). The largest percentage of
persons living with HIV infection is among those aged 40-44;
this same group accounts for the highest rate of new HIV
infections. Ethnic populations disproportionately affected by
HIV include blacks and Latinos, who accounted for 52% and
25% of HIV diagnoses, respectively, in 2008 (CDC, 2010). The
most common route of transmission among men is male-to-male
sexual contact and among women is heterosexual contact
(Figure 38-2).
Pathophysiology and Classification
Primary infection with human immunodeficiency virus (HIV) is
the underlying cause of AIDS. HIV invades the genetic core of
the CD4+ cells, T-helper lymphocyte cells, which are the
principal agents involved in protection against infection. HIV
infection causes a progressive depletion of CD4+ cells, which
eventually leads to immunodeficiency.
BOX 38-1
2008 CDC Case Definition AIDS-Defining Clinical Conditions
Bacterial infections, multiple or recurrent (among children <13
years)
Candidiasis (bronchi, trachea, or lungs)
Candidiasis (esophagus)
Cervical cancer (invasive)
Coccidioidomycosis (disseminated or extrapulmonary)
Cryptococcosis (extrapulmonary)
Cryptosporidiosis (intestinal, >1 month duration)
Cytomegalovirus disease (other than liver, spleen, or nodes)
Cytomegalovirus retinitis (with loss of vision)
Encephalopathy (HIV related)
Herpes simplex: chronic ulcers (>1 month duration)
Herpes simplex: bronchitis, pneumonitis, or esophagitis

Histoplasmosis (disseminated or extrapulmonary)
Isosporiasis (intestinal, >1 month duration)
Kaposi's sarcoma
Lymphoid interstitial pneumonia or pulmonary lymphoid
hyperplasia complex
Lymphoma, Burkitt (or equivalent term)
Lymphoma, immunoblastic (or equivalent term)
Lymphoma, primary (brain)
Mycobacterium avium complex (disseminated or
extrapulmonary)
Mycobacterium kansasii (disseminated or extrapulmonary)
Mycobacterium tuberculosis (any site, pulmonary, disseminated,
or extrapulmonary)
Pneumocystis jiroveci pneumonia
Pneumonia (recurrent)
Progressive multifocal leukoencephalopathy
Salmonella septicemia (recurrent)
Toxoplasmosis (brain)
Wasting syndrome attributed to HIV: >10% involuntary weight
loss of baseline body weight plus (1) diarrhea (two loose stools
per day for ≥30 days) or (2) chronic weakness and documented
fever (≥30 days, intermittent or constant) in the absence of
concurrent illness or condition other than HIV infection that
could explain the findings (e.g., cancer, tuberculosis).
AIDS, Acquired immune deficiency syndrome; CDC, Centers
for Disease Control and Prevention; HIV, human
immunodeficiency virus.
Source: Schneider E et al: Revised surveillance case definitions
for HIV infection among adults, adolescents, and children aged
<18 months and for HIV infection and AIDS among children
aged 18 months to <13 years—United States, 2008. MMWR
Recomm Rep 57(RR-10):1, 2008.
HIV infection progresses through four clinical stages: acute
HIV infection, clinical latency, symptomatic HIV infection, and
progression of HIV to AIDS. The two main biomarkers used to
assess disease progression are HIV ribonucleic acid (RNA)

(viral load) and CD4+ T-cell count (CD4 count).
Acute HIV infection is the time from transmission of HIV to the
host until the production of detectable antibodies against the
virus (seroconversion) occurs. Half of individuals experience
physical symptoms such as fever, malaise, myalgia, pharyngitis,
or swollen lymph glands at 2-4 weeks following infection, but
these generally subside after 1-2 weeks. Because of the
nonspecific clinical features and short diagnostic window, acute
HIV infection is rarely diagnosed. HIV seroconversion occurs
within 3 weeks to 3 months after exposure. If HIV testing is
done before seroconversion occurs, a “false negative” may
result despite HIV being present. During the acute stage, the
virus replicates rapidly and causes a significant decline in CD4+
cell counts. Eventually, the immune response reaches a viral
setpoint where viral load stabilizes and CD4+cell counts return
closer to normal.
A period of clinical latency or asymptomatic HIV infection,
then follows. Further evidence of illness may not be exhibited
for as long as 10 years postinfection. The virus is still active
and replicating, although at a decreased rate compared with the
acute stage, and CD4+ cell counts continue to steadily decline.
In 3% to 5% of HIV-infected individuals, long-term
nonprogression occurs, in which CD4+ cell counts remain
normal and viral loads can be undetectable for years without
medical intervention (Department of Health and Human
Services [DHHS], 2010). It has been suggested that this unique
population has different and fewer receptor sites for the virus to
penetrate cell membranes (Wanke et al., 2009).
In the majority of cases, HIV slowly breaks down the immune
system, making it incapable of fighting the virus. When CD4+
cell counts fall below 500 cells/ mm3 individuals are more
susceptible to developing signs and symptoms such as persistent
fevers, chronic diarrhea, unexplained weight loss, and recurrent
fungal or bacterial infections, all of which are indicative of
symptomatic HIV infection.
As immunodeficiency worsens and CD4 counts fall to even

lower levels, the infection becomes symptomatic and progresses
to AIDS. The progression of HIV to AIDS increases risk of
opportunistic infections (OIs), which generally do not occur in
individuals with healthy immune systems. The CDC classifies
AIDS cases as positive laboratory confirmation of HIV infection
in persons with a CD4+ cell count less than 200 cells/mm3 (or
less than 14%) or documentation of an AIDS-defining condition
(Box 38-1).
HIV is transmitted via direct contact with infected body fluids
like blood, semen, preseminal fluid, vaginal fluid, and breast
milk. Cerebrospinal fluid surrounding the brain and spinal cord,
synovial fluid surrounding joints, and amniotic fluid
surrounding a fetus are other fluids that can transmit HIV.
Saliva, tears, and urine do not contain enough HIV for
transmission. Sexual transmission is the most common way HIV
is transmitted and injection drug use is the second most
prevalent method of transmission (see Figure 38-2).
Most people have HIV-1 infection, which, unless specified, is
the type discussed in this chapter. HIV-1 mutates readily and
has become distributed unevenly throughout the world in
different strains, subtypes, and groups. HIV-2, first isolated in
western Africa, is less easily transmitted and the time between
infection and illness takes longer.
Medical Management
HIV-related morbidity and mortality stem from the HIV virus
weakening the immune system as well as the virus's effects on
organs (such as the brain and kidney). If untreated, the HIV
virion (virus particle) can replicate at millions of particles per
day and rapidly progress through the stages of HIV disease. The
introduction of three-drug combination ART in 1996
transformed the treatment of patients infected with HIV and has
significantly decreased AIDS-defining conditions and mortality.
Most drugs are formulated as individual medications, but
increasingly many are available as fixed-dose combinations to
simplify treatment regimens, decrease pill burden, and
potentially improve patient medication adherence.

CD4 count is used as the major indicator of immune function in
people with HIV infection. It is used to determine when to
initiate ART and is the strongest predictor of disease
progression. CD4 counts are generally monitored every 3 to 4
months. In addition, HIV RNA (viral load) is monitored on a
regular basis because it is the primary indicator to gauge the
efficacy of ART. Table 38-1 provides the current guidelines on
when to initiate ART.
The fundamental goals of ART are to achieve and maintain viral
suppression, reduce HIV-related morbidity and mortality,
improve the quality of life, and restore and preserve immune
function. This can generally be achieved within 12-24 weeks if
there are no complications with adherence, or resistance to
medications (DHHS, 2010). Because the guidelines for HIV
management evolve rapidly, it is beneficial to frequently check
for updated recommendations.
TABLE 38-1 Indications for the Initiation of ART in HIV-
infected Individuals
Clinical Category
CD4 Count
Recommendation
Asymptomatic, AIDS
<350 cells/mm3
Treat
Asymptomatic
350-500 cells/mm3
Treatment recommended
Asymptomatic
>500 cells/mm3
Some clinicians recommend initiating therapy and some view
treatment as optional
Symptomatic (AIDS, severe symptoms)
Any value
Treat
Pregnancy, HIV-associated nephropathy, HBV coinfection when
treatment of HBV is indicated

Any value
Treat
From National Institutes of Health: Guidelines for the use of
antiretroviral agents in HIV-1-infected adults and adolescents,
2009. Accessed 23 October 2010 from
http://www.aidsinfo.nih.gov/contentfiles/AdultandAdolescentG
L.pdf.
AIDS, Acquired immune deficiency syndrome; ART,
antiretroviral therapy; HBV, hepatitis B virus; HIV, human
immunodeficiency virus.
Classes of Antiretroviral Therapy Drugs
Currently antiretroviral therapy (ART) includes more than 20
antiretroviral agents from six mechanistic classes of drugs:
• Nucleoside and nucleotide reverse transcriptase inhibitors
(NRTIs)
• Nonnucleoside reverse transcriptase inhibitors (NNRTIs)
• Protease inhibitors (PIs)
• Fusion inhibitors
• CCR5 (chemokine receptor 5) antagonists
• Integrase strand transfer inhibitors (INSTIs)
The most widely studied combination regimen for treatment of
naïve patients consists of two NRTIs plus either one NNRTI or
a PI (with or without ritonavir boosting). Recently, a regimen
consisting of raltegravir was approved for treatment-naïve
patients, making the combination of an INSTI with two NRTIs
another option (DHHS, 2010).
Although a reasonable number of different antiretroviral
medications are currently available for the treatment of HIV
infections, there is a growing need for new drugs that have
fewer long-term toxicities and greater potency. However,
because eradication of HIV is not yet possible, and the need for
treatment is lifelong, adverse effects of medications, including
metabolic complications and other toxicities, become
increasingly important because they may lead to nonadherence
to the prescribed regimen. Nonadherence to ART can lead to
drug resistance.

Predictors of Adherence
When initiating ART, patients must be willing and able to
commit to lifelong treatment and should understand the benefits
and risks of therapy and the importance of adherence. The
patient's understanding about HIV disease and the specific
regimen prescribed is critical. A number of factors have been
associated with poor adherence, including low levels of literacy,
certain age-related challenges (e.g., vision loss, cognitive
impairment), psychosocial issues (e.g., depression,
homelessness, low social support, stressful life events,
dementia, or psychosis), active substance use, stigma, difficulty
with taking medication (e.g., trouble swallowing pills, daily
schedule issues), complex regimens (e.g., pill burden, dosing
frequency, food requirements), adverse drug effects, and
treatment fatigue (DHHS, 2010).
When using boosted PIs and efavirenz, their longer half-lives
may permit more lapses in adherence since drug levels stay high
in the body for many days (Bangsberg, 2006; Raffa, 2008).
However, these drugs are more likely to contribute to drug
resistance if discontinued due to rapid viral mutation. Continued
encouragement is needed to help patients adhere as closely as
possible to the prescribed doses for all ART regimens.
Illicit Drug Use
In the United States, injection drug use is the second most
common mode of HIV transmission. The most commonly used
illicit drugs associated with HIV infection are heroin, cocaine,
methamphetamine, and amyl nitrate (poppers). The chaotic
lifestyle associated with drug use is associated with poor or
inadequate nutrition, food insecurity, and depression. This
complicates treatment of HIV if the individual is using drugs,
and can potentially lead to poor adherence with ART
medications. Special considerations should be taken into
account if the liver is damaged from drug use or coinfection
with hepatitis, and increased nutrient excretion from diuresis
and diarrhea (Hendricks, 2009; Tang, 2010).
Injection drug use is strongly linked with transmission of

bloodborne infections such as HIV, hepatitis B virus, and
hepatitis C virus (HCV), especially if needles are reused or
shared (see Focus On: HIV and Hepatitis C Virus Coinfection).
Coinfection of HIV and HCV increases the risk of cirrhosis.
Chronic HCV infection also complicates HIV treatment because
of ART-associated hepatotoxicity.
Focus on
HIV and Hepatitis C Virus Coinfection
An estimated 200,000 to 300,000 people in the United States
have human immunodeficiency virus (HIV) and hepatitis C
virus (HCV). According to the CDC, 50% to 90% of HIV-
infected injection drug users are also infected with HCV (CDC,
2007). Although it is unknown if HCV accelerates HIV disease
progression, it has been shown to damage the liver more quickly
in HIV-infected persons. In the presence of hepatic impairment,
the metabolism and excretion of antiretroviral medications may
be impaired, affecting the efficacy of HIV treatment. In
addition, three classes of anti-HIV medications (nucleoside and
nucleotide reverse transcriptase inhibitors, nonnucleoside
reverse transcriptase inhibitors, and protease inhibitors) are
associated with hepatotoxicity. Therefore it is important for
HIV-infected patients to be tested for HCV to appropriately
manage treatment and prolong healthy liver function.
HCV is viewed as an opportunistic infection (not an acquired
immune deficiency syndrome–defining illness) in HIV-infected
persons because it is associated with higher titers of HCV, more
rapid progression to liver disease, and increased risk of
cirrhosis (CDC, 2007). Nutrition recommendations (see Chapter
30) and dosing and choice of HIV medications must be adjusted
for those with liver failure.
Food-Drug Interactions
Some ART medications require attention to dietary intake. It is
important to ask individuals with HIV to report all medications,
including vitamins, supplements, and recreational substances
that they consume to fully assess their needs and prevent drug
interactions and nutrient deficiencies. Some nutrients can affect

how drugs are absorbed or metabolized. Interactions between
food and drugs can influence the efficacy of the drug or may
cause additional or worsening adverse effects. For example,
grapefruit juice and PIs both compete for the cytochrome P450
enzymes; thus individuals taking PIs who also drink grapefruit
juice may have either increased or decreased blood levels of the
drug. Tables 38-2, 38-3, 38-4, and 38-5 provide potential
nutrient interactions with ART medications.
Some ART medications can cause diarrhea, fatigue,
gastroesophageal reflux, nausea, vomiting, dyslipidemia, and
insulin resistance. Timing is also important for ART efficacy,
so patients with HIV must take medications on a schedule.
Some medications indicate that they must be taken with food or
on an empty stomach. Sometimes food needs to be taken within
a specific time frame of administering a medication.
Medical Nutrition Therapy
For people living with HIV, adequate and balanced nutrition
intake is essential to maintain a healthy immune system and
prolong lifespan. It has been documented that both children and
adults who are living with HIV have lower fat-free and total fat
mass (American Dietetic Association, 2010). Proper nutrition
may help maintain lean body mass, reduce the severity of HIV-
related symptoms, improve quality of life, and enhance
adherence and effectiveness of ART. Therefore medical
nutrition therapy (MNT) is integral to successfully manage HIV.
See Pathophysiology and Care Management Algorithm: Human
Immunodeficiency Virus Disease.
A registered dietitian (RD) can help the patient manage many of
the necessary requirements for medications, minimize adverse
effects, and address nutritional concerns. Some common
nutrition diagnoses in this population include:
• Inadequate oral food and beverage intake
• Increased nutrient needs
• Swallowing difficulty
TABLE 38-2 Medication Interactions and Common Adverse

Effects with NRTI Medications
Medication Name
Timing Considerations
Common Adverse Effects with Nutrition Implications
emtricitabine (Emtriva, FTC)*
Timing of food intake is not a consideration.
Snacks may limit GI upset.
NRTIs in general can potentially lead to anemia, loss of
appetite, low vitamin B12, low copper, low zinc, and low
carnitine.
lamivudine (Epivir, 3TC)†
carnitine.
zidovudine (Retrovir, ZDV, AZT)†
Constipation
Taste alterations
Macrocytic anemia or neutropenia
carnitine.
abacavir, lamivudine, and zidovudine (Trizivir)†
Nausea
Vomiting
Diarrhea
Abdominal pain
Fat maldistribution
appetite, low vitamin B-12, low copper, low zinc, and low
carnitine.
didanosine (Videx, Videx EC, DDL)‡
Take 30 minutes before or 2 hours after a meal.

Do not mix with acids such as grapefruit juice, oranges, or other
citrus; tomatoes or tomato juice.
Do not take antacids with magnesium or aluminum within 2
hours.
Pancreatitis
Nausea
carnitine.
tenofovir (Viread, TDF)*
Diarrhea
Nausea
Vomiting
Flatus
Renal issues
carnitine.
stavudine (Zerit, Zerit XR, d4T)‡
Hyperlipidemia
Lipodystrophy: significantly associated with lipoatrophy
Pancreatitis
Mouth and esophageal ulcers
carnitine.
abacavir (Ziagen, ABC)†
Alcohol can increase drug levels
Nausea
Vomiting
Diarrhea

Loss of appetite
carnitine.
Hammer SH et al: 2006 recommendations of the International
AIDS Society-USA Panel, JAMA 296:827, 2006.
National Institutes of Health: Guidelines for the use of
2009. Accessed 23 October 2010 at
L.pdf.
GI, Gastrointestinal; NRTI, nucleoside and nucleotide reverse
transcriptase inhibitor.
* Made by Gilead (www.gilead.com).
† Made by Glaxosmithkline (www.gsk.com)
‡ Made by Bristol-Myers Squibb Company (www.bms.com)
Effects with NNRTI Medications
Medication Name
etravirine (Intelence, ETV)*
Take after a meal.
Nausea
delavirdine (Rescriptor, DLV)†
Avoid St. John's wort.
Fat maldistribution
Constipation
Decreased appetite
Diarrhea
Dry mouth
Flatus
Hypertriglyceridemia
Hyperglycemia
efavirenz (Sustiva)‡

Take on empty stomach.§
Take at bedtime to decrease adverse effects.
Taste alterations
Potential loss of appetite
Flatus
Hypertriglyceridemia
nevirapine (Viramune, NVP)¶
Nausea
Loss of appetite
Liver toxicity
AIDS Society-USA Panel, JAMA 296:827, 2006.
L.pdf.
* Made by Tibotec Therapeutics
(www.tibotectherapeutics.com).
† Made by Pfizer (www.pfizer.com).
‡ Made by Bristol-Myers Squibb Company (www.bms.com).
§ Empty stomach refers to 1 hour before meals or 2 hours
after meals.
¶ Made by Boehringer Ingelheim Pharmaceuticals, Inc
(www.Boehringer-ingelheim.com).
Effects with Protease Inhibitor Medications
Medication Name
amprenavir (Agenerase)*
Take on an empty stomach.†
Low-fat food limits GI upset.
Avoid high-fat meals.

Avoid grapefruit juice.
Increase fluid intake.
Avoid taking antacids within 2 hours.
Anemia
Gas
Nausea
Vomiting
Diarrhea
Hyperlipidemia
Fat maldistribution
tipranavir (Aptivus, TPV)‡
Take with fatty meal.
Hyperlipidemia (especially hypertriglyceridemia)
Hyperglycemia
Fat maldistribution
Hepatotoxicity
indinavir (Crixivan)§
Avoid grapefruit juice.
Avoid St. John's wort.
Unboosted:
Take on empty stomach but if not tolerated, may take with
nonfat milk, low-fat meal, or light snack.
RTV-boosted:
Loss of appetite
Nausea
Hyperlipidemia
Metallic taste
Hyperglycemia
Fat maldistribution
lopinavir, ritonavir (Kaletra)¶
Take without regard to food.
Nausea
Vomiting
Diarrhea
Hyperlipidemia (especially hypertriglyceridemia)

Hyperglycemia
Fat maldistribution
fosamprenavir (Lexiva, fAPV)*
Diarrhea
Nausea
Vomiting
Hyperlipidemia
Hyperglycemia
Fat maldistribution
ritonavir Norvir, RTV)¶
Take with a full meal to limit GI upset.
Nausea
Vomiting
Diarrhea
Hyperlipidemia (primarily hypertriglyceridemia)
Hyperglycemia
Fat maldistribution
darunavir (Prezista)¶
Take with a meal or light snack.
Nausea
Diarrhea
Hyperlipidemia
Hyperglycemia
Fat maldistribution
atazanavir (Reyataz, ATV)**
Take with a light meal.
Avoid taking with any mediation that interferes with acid
secretion (antacids, H2 blockers, and proton pump inhibitors).
Hyperglycemia
Fat maldistribution
Hyperbilirubinemia
fortovase (FTV) soft gel, invirase (INV) (Saquinavir)††
Avoid garlic supplements.
FTV: Take with full meals to lessen adverse effects.
INV: Take within 2 hours after a full meal. Grapefruit juice

increases absorption.
Gas
Mouth/esophageal ulcers
Nausea
Diarrhea
Hyperlipidemia
Hyperglycemia
Fat maldistribution
nelfinavir (Viracept)‡‡
Take with meals or snack.
Increase fluid intake.
Diarrhea
Hyperlipidemia
Hyperglycemia
Fat maldistribution
AIDS Society—USA Panel, JAMA 296:827, 2006.
L.pdf.
GI, Gastrointestinal.
* Made by Galaxosmithkline (www.gsk.com).
† “Empty stomach” refers to 1 hour before meals or 2 hours
after meals. Examples of low-fat food are fruit, cereal, nonfat
milk, nonfat or low-fat yogurt. Light snack: <300 calories.
Light meal: approximately 350 calories. Full meal or fatty meal:
900-1200 calories, 40%-50% of calories from fat for fatty meal.
‡ Made by Boehringer Ingelheim Pharmaceuticals, Inc
(www.Boehringer-ingelheim.com).
§ Made by Merck (www.merck.com).
¶ Made by Abbott Laboratories (www.abbott.com).
¶ Made by Tibotec Therapeutics
(www.tibotectherapeutics.com).
** Made by Bristol-Myers Squibb Company (www.bms.com).

†† Made by Roche Laboratories, Inc (www.roche.com).
‡‡ Made by Pfizer (www.pfizer.com).
Effects with Entry Inhibitor, INSTIs, and Combination
Medications
Class of Medication
Medication Name
Fusion inhibitors
enfuvirtide (Fuzeon, T20)*
Nausea
Vomiting
CCR5 antagonists
selzentry (Maraviroc, MVC)†
Abdominal pain
Hepatotoxicity
Integrase inhibitors
isentress (Raltegravir, RAL)‡
Nausea
Diarrhea
Combinations
efavirenz, tenofovir, and emtricitabine (Atripla)§
Take on empty stomach.
Nausea
Take at bedtime to decrease adverse effects.
Vomiting
Gas
AIDS Society—USA Panel, JAMA 296:827, 2006.

L.pdf.
INSTI, Integrase strand transfer inhibitor.
* Made by Roche Laboratories, Inc (www.roche.com).
† Made by Pfizer (www.pfizer.com).
‡ Made by Merck (www.merck.com).
§ Made by Gilead (www.gilead.com).
• Altered gastrointestinal (GI) function
• Food-medication interaction
• Involuntary weight loss
• Overweight and obesity
• Food- and nutrition-related knowledge deficit
• Oversupplementation
• Impaired ability to prepare foods or meals
• Inadequate access to food
• Intake of unsafe foods
All individuals with HIV infection should have access to a RD
or other qualified nutrition professional. Patients should
undergo a baseline nutrition assessment once they are diagnosed
with HIV. Follow-up should be ongoing and take into
consideration the multifactorial complications that may affect
patient care. The American Dietetic Association recommends
that a RD should provide at least one to two MNT encounters
per year for individuals with asymptomatic HIV infection and at
least two to six MNT encounters per year for symptomatic but
stable HIV infection. Individuals diagnosed with AIDS usually
need to be seen more often as they may require nutrition support
(see Chapter 14).
Ultimately, MNT should be individualized and frequency of
nutrition counseling should be determined by the patient's
needs. The major goals of MNT for persons living with HIV
infection are to optimize nutritional status, immunity, and well-
being; to maintain a healthy weight and lean body mass; to
prevent nutrient deficiencies and reduce the risk of
comorbidities; and to maximize the effectiveness of medical and
pharmacologic treatments. Thus screening should be performed

on all patients medically diagnosed with HIV to identify those
at risk for nutritional deficiencies or in need of MNT.
Patients who exhibit the various HIV-related symptoms or
conditions listed in Figure 38-3 should be referred to a dietitian
with expertise in managing this disease. A comprehensive
nutrition assessment should be performed at the initial visit. In
addition, regular monitoring and evaluation are essential to
detect and manage any undesirable nutritional consequences of
medical treatments or the disease process. Adverse nutrition
implications are summarized in Table 38-6. Key factors for
assessment are listed in Table 38-7.
Medical Factors
HIV infection should be confirmed by laboratory testing and not
based on patient report (CDC, 2008b). The presence of
comorbidities such as heart disease, diabetes, hepatitis, and OIs
may complicate the patient's treatment profile. The assessment
should include the patient's past medical history and pertinent
immediate family history for heart disease, diabetes, cancers, or
other disorders. Metabolic issues such as dyslipidemia and
insulin resistance are common in people with HIV, and should
be monitored. Biochemical measurements should be documented
to determine course of HIV treatment, need for ART, efficacy of
ART, and underlying malnutrition and nutrient deficiencies.
Some common biochemical measurements include CD4 count,
viral load, albumin, hemoglobin, iron status, lipid profile, liver
function, renal function, glucose, insulin, and vitamin levels.
See Table 38-8 for a list of common conditions associated with
HIV and their nutritional implications.
FIGURE 38-3 Nutrition screen and referral criteria for adults
with HIV and AIDS.
(From ADA MNT Evidence Based Guides for Practice © 2005,
American Dietetic Association, March 2005. For interim
revisions seewww.bivaidsdpg.org)
TABLE 38-6 Nutrition Recommendations for General Adverse
Effects

Adverse Effect
Nutrition Recommendations
Nausea, vomiting
Eat small, frequent meals.
Avoid drinking liquids with meals.
Drink cool, clear liquids.
Try dry crackers or toast.
Try bland foods such as potatoes, rice, or canned fruits.
Limit high-fat, greasy foods or foods that have strong odors
such as ripe cheese or fish.
Eat foods at room temperature or cooler.
Wear loose-fitting clothes.
Rest sitting up after meals.
Keep a log of when nausea and vomiting occur and which foods
seem to trigger it.
Diarrhea
Try plain carbohydrates such as white rice, rice congee,
noodles, crackers, or white toast.
Try low-fiber fruits like bananas and applesauce.
Drink fluids that will replace electrolytes such as broths and
oral hydration drinks.
Try small, frequent meals.
Avoid fatty, greasy foods.
Avoid highly spiced foods.
Avoid sugary items such as soda and fruit juice.
Avoid milk and milk products.
Limit caffeine.
Loss of appetite
Eat small, frequent meals.
Focus on nutrient-dense foods such as milkshakes, lean protein,
eggs, nut butters, vegetables, fruits, and whole grains.
Try to eat in a pleasant environment
Taste alterations
Add spices and herbs to foods.
Avoid canned foods or canned oral supplements.
Hyperlipidemia

NCEP diet (refer to Chapter 34).
Hyperglycemia
Diet for patients with diabetes (refer to Chapter 31)
Mouth and esophageal ulcers and sore throat
Try soft foods such as oatmeal, rice, applesauce, scrambled
eggs, milkshakes, or yogurt.
Avoid acidic foods such as citrus, vinegar, spicy, salty, or hot
foods.
Moisten foods with gravy or sauces.
Drink liquids with meals.
Avoid acidic beverages.
Try foods and beverages at room temperature.
Pancreatitis
Focus on low-fat foods and limit fat at each meal. See Chapter
30.
May need pancreatic enzymes to aid in digestion.
Weight loss
Eat small, frequent meals. See Chapter 22.
Focus on nutrient-dense foods such as milkshakes, lean protein,
eggs, nut butters, vegetables, fruits, whole grains, trail mixes,
and tofu.
Add rice, barley, and legumes to soups.
Add dry milk powder or protein powder to casseroles, hot
cereals, and milkshakes
Try oral supplements
NCEP, National Cholesterol Education Program.
TABLE 38-7 Factors to Consider in Nutrition Assessment
Medical
Stage of HIV disease
Comorbidities
Opportunistic infections
Metabolic complications
Biochemical measurements
Physical
Changes in body shape
Weight or growth concerns

Oral or gastrointestinal symptoms
Functional status (i.e., cognitive function, mobility)
Anthropometrics
Social
Living environment (support from family and friends)
Behavioral concerns or unusual eating behaviors
Mental health (i.e., depression)
Economical
Barriers to nutrition (i.e., access to food, financial resources)
Nutritional
Typical intake
Food shopping and preparation
Food allergies and intolerances
Vitamin, mineral, and other supplements
Alcohol and drug use
HIV, Human immunodeficiency virus.
TABLE 38-8 HIV-related Conditions with Specific Nutrition
Implications
Condition
Brief Description
Nutrition Implications
PCP
Potentially fatal fungal infection
Difficulty chewing and swallowing caused by shortness of
breath
TB
Bacterial infection that attacks the lungs
Prolonged fatigue, anorexia, nutrient malabsorption, altered
metabolism, weight loss
Cryptosporidiosis
Infection of small intestine caused by parasite
Watery diarrhea, abdominal cramping, malnutrition and weight
loss, electrolyte imbalance
Kaposi's Sarcoma
Type of cancer causing abnormal tissue growth under the skin
Difficulty chewing and swallowing caused by lesions in oral

cavity or esophagus
Diarrhea or intestinal obstruction caused by lesions in intestine
Lymphomas
Abnormal, malignant growth of lymph tissue
Brain
Changes in motor and cognitive abilities
Inability to prepare food and coordinate movement
Small bowel
Malabsorption
Weight loss, diarrhea, loss of appetite
Cytomegalovirus (disseminated)
Infection caused by herpes virus
Loss of appetite, weight loss, fatigue, enteritis, colitis
Candidiasis
Infection caused by fungi or yeast
Oral sores in mouth, difficulty chewing and swallowing, change
in taste
HIV-induced enteropathy
Idiopathic, direct or indirect effect of HIV on enteric mucosa
Chronic diarrhea, weight loss, malabsorption, changes in
cognition and behavior
HIV encephalopathy (AIDS dementia)
Degenerative disease of brain cause by HIV infection
Loss of coordination and cognitive function, inability to prepare
food
Pneumocystis jirovecii pneumonia
Infection caused by fungi
Fever, chills, shortness of breath, weight loss, fatigue
Mycobacterium avium complex (disseminated)
Bacterial infection in lungs or intestine, spreads quickly
through bloodstream
Fever, cachexia, abdominal pain, diarrhea, malabsorption
Coyne-Meyers K, Trombley LE: A review of nutrition in human
immunodeficiency virus infection in the era of highly active
antiretroviral therapy, Nutr Clin Prac 19:340, 2004.
Falcone EL et al: Micronutrient concentrations and subclincal

atherosclerosis in adults with HIV, Am J Clin Nutr 91:1213,
2010.
McDermid JM et al: Mortality in HIV infection is independently
predicted by host iron status and SLC11A1 and HP genotypes,
with new evidence of a gene-nutrient interaction, Am J Clin
Nutr 90:225, 2009.
Pitney CL et al: Selenium supplementation in HIV-infected
patients: is there any potential clinical benefit? J Assoc Nurses
AIDS Care 20:326, 2009.
Rodriguez M et al: High frequency of vitamin D deficiency in
ambulatory HIV-positive patients, AIDS Res Hum Retroviruses
25:9, 2009.
AIDS, Acquired immune deficiency syndrome; HIV, human
immunodeficiency virus; PCP, Pneumocystis pneumonia; TB,
tuberculosis.
Physical Changes
The physical presentation of the patient should be considered
during initial and follow-up assessments. Patients with HIV are
aware of changes in their body shape and are instrumental in
identifying these changes. Health care professionals should
remember to ask patients about body shape changes every 3 to 6
months. Changes in body shape and fat redistribution can be
monitored by anthropometric measurements. Commonly these
are taken as circumferences around the waist, hip, mid-upper
arm, and thigh, and as skinfold measurements of the tricep,
subscapular, suprailiac, thigh, and abdomen. See Chapter 6. If a
dorsocervical fat pad (fat behind the neck) is present,
measurement of the neck diameter can help track changes in this
area. These physical changes are referred to as HIV-associated
lipodystrophy syndrome (HALS). Unintentional weight changes
should be monitored closely because they can indicate
progression of HIV disease. Peripheral neuropathy is a potential
side effect, most frequently associated with NRTIs. The
resulting nerve damage causes stiffness, numbness, or tingling
generally in the lower extremities. Patients experiencing
neuropathy may be unable to work or be physically active.

Social and Economic Factors
Depending on a patient's mental status, psychosocial issues may
take precedence over nutrition counseling. Depression is
common, so the need to treat and provide services for mental
health issues should be monitored. When individuals are unable
to care for themselves, discussion with caretakers may be
necessary to understand the patient's nutrition history.
Particular habits, food aversions, timing of meals with
medications, and related concerns should be documented.
Access to safe, affordable, and nutritious food should be
evaluated. Common barriers include cost, location of
supermarkets, lack of transportation, and lack of knowledge of
healthier choices. In addition, because medications are costly,
they often compete with food for available resources.
Nutrient Recommendations
When collecting the diet history, a review of current intake,
changes in intake, limitations with food access or preparation,
food intolerances or allergies, supplement use, current
medications, and alcohol and recreational drug use will help
determine the potential for any nutrient deficiencies and assist
in making individualized recommendations.
Adequate nutrition intake can help patients with HIV with
symptom management and improve the efficacy of medications,
disease complications, and overall quality of life. Refer to
Figure 38-3 for a sample nutrition screening form. Note that a
one-size-fits-all approach does not address the complexity of
HIV. RDs must provide recommendations to improve nutritional
status, immunity, and quality of life, address drug-nutrient
interactions or side effects, and identify barriers to desirable
food intake (Box 38-2).
In the early stages of nutrition therapy for HIV, the focus was
on treatment and prevention of unintentional weight loss and
wasting. Now with access to ART, new nutrition issues have
arisen caused by HALS. HIV-related death from OIs has shifted
to other chronic disease conditions such as heart disease and
diabetes in healthier individuals who are living with HIV

(Leyes, 2008).
Energy and Fluid
When determining energy needs, it is important to establish if
the individual needs to gain, lose, or maintain weight. Other
factors such as altered metabolism, nutrient deficiencies,
severity of disease, comorbidities, and OIs should be taken into
account when evaluating energy needs. Calculating energy and
protein needs for this population is difficult because of other
issues with wasting, obesity, HALS, and lack of accurate
prediction equations. Some research suggests that resting
energy expenditure is increased by approximately 10% in adults
with asymptomatic HIV (Polo, 2007). After an OI, nutritional
requirements increase by 20% to 50% in both adults and
children (WHO, 2005a). Continuous medical and nutrition
assessment is necessary to make adjustments as needed.
Individuals with well-controlled HIV are encouraged to follow
the same principles of healthy eating and fluid intake
recommended for everyone.
BOX 38-2
Education Needed by HIV Patients
Pregnancy, Lactation, Infancy, and Childhood
• Nutrition and food choices for healthy pregnancy and
lactation
• Transmission risk in breastfeeding and replacement
feeding alternatives
• Growth failure and developmental delay in children
• Support for normal growth trends in children
General Lifestyle Tips for Adults
• Basic nutrition concepts and healthy habits
• Physical activity recommendations
• Body image and altered body weight and shape
• Nutrition and food-related knowledge related to cultural or
ethnic practices
Nutrition Interactions
• Prevention, restoration, and maintenance of optimal body
composition with an emphasis on lean tissues

• Medication-nutrition interactions
• Management of barriers to nutritional wellness, nutrition-
related side effects of treatments, and symptoms requiring
attention
• Review of oral beverage or nutrient supplements
• Review of potential interactions with nonprescription
medications and herbal supplements
• Evaluation of interactions with alcohol and recreational
drugs
Life Skills and Socioeconomic Issues
• Safe food handling and water sources
• Access to adequate food choices
• Food preparation skills and abilities.
HIV, Human immunodeficiency virus.
Adapted from American Dietetic Association: Position paper on
nutrition intervention and Human Immunodeficiency Virus
infection, J Am Diet Assoc 110:1105, 2010.
Protein
The current recommended dietary reference intake (DRI) is
0.8 g of protein per kilogram of body weight per day for healthy
individuals. Deficiency of protein stores and abnormal protein
metabolism occur in HIV and AIDS, but no evidence exists for
increased protein intake over and above that necessary to
accompany the required increase in energy (WHO, 2005b). For
people with HIV who have adequate weight and are not
malnourished, protein supplementation may not be sufficient to
improve lean body mass (Sattler, 2008). However, with an OI,
an additional 10% increase in protein intake is recommended
because of increased protein turnover (WHO, 2005b). If other
comorbidities such as renal insufficiency, cirrhosis, or
pancreatitis are present, protein recommendations should be
adjusted accordingly.
Fat
There is evidence that dietary fat requirements are different
with HIV infection (WHO, 2005b). General heart-healthy
guidelines should be the focus for dietary fat intake. Recent

research has focused on immune function and ω-3 fatty acids.
There is some research to suggest increasing the intake of ω-3
fatty acids in individuals with HIV who have elevated serum
triglycerides. See below.
Micronutrients
Vitamins and minerals are important for optimal immune
function. Nutrient deficiencies can affect immune function and
lead to disease progression. Micronutrient deficiencies are
common in people with HIV infection as a result of
malabsorption, drug-nutrient interactions, altered metabolism,
gut infection, and altered gut barrier function. Vitamin A, zinc,
and selenium serum levels are often low during times of
response to infection, so it is important to assess dietary intake
to determine whether correction of serum micronutrients is
warranted (Coyne-Meyers and Trombley, 2004).
There are benefits to correcting some depleted serum levels of
micronutrients. Low levels of vitamins A, B12, and zinc are
associated with faster disease progression (Coyne-Meyers and
Trombley, 2004). Higher intakes of vitamins C and B have been
associated with increased CD4 counts and slower disease
progression to AIDS (Coyne-Meyers and Trombley, 2004). The
Nutrition for Healthy Living study found that minorities and
women tend to have lower micronutrient intakes and may
benefit from nutrition counseling and dietary assessment (Jones,
2006).
Studies on micronutrients are difficult to interpret because there
are a variety of study designs and outcomes. Serum
micronutrient levels reflect conditions such as acute infection,
liver disease, technical parameters, and recent intake. Adequate
micronutrient intake through consumption of a balanced,
healthy diet should be encouraged. However, diet alone may not
be sufficient in people with HIV. A multivitamin and mineral
supplement that provides 100% of the DRI may also be
recommended. Megadosing on some micronutrients such as
vitamins A, B6, D, E, and copper, iron, niacin, selenium, and
zinc may be detrimental to health outcomes and may not warrant

protection against prevention of chronic diseases. At this time,
there is no evidence to support micronutrient supplementation
in adults with HIV-infection above the recommended levels of
the DRI (Kawai, 2010, WHO, 2005c). See Table 38-9 for a
summary.
Special Considerations
Wasting
Wasting implies unintentional weight loss and loss of lean body
mass, which have been strongly associated with an increased
risk of disease progression and mortality. Despite the efficacy
of ART, wasting continues to be a common problem in the HIV
population. Wasting may be caused by a combination of factors
including inadequate dietary intake, malabsorption, and
increased metabolic rates from viral replication or
complications from the disease (WHO, 2005b). Until the
underlying cause of weight loss is discovered, it will remain
difficult to target effective nutrition therapy.
Obesity
Obesity in people with HIV has also been noted (Hendricks,
2006). Unintentional weight loss in HIV infection has been
associated with mortality, but there needs to be more careful
review in overweight or obese HIV-infected individuals. In the
era of ART, it is no longer believed that continuously gaining
body weight is a protective cushion against HIV-related wasting
and progression to AIDS.
Some of the ART medications increase the risk of
hyperlipidemia, insulin resistance, and diabetes. It is important
to monitor these risk factors and provide nutrition
recommendations to maintain a healthy weight. Physical
activity, aerobic exercise, and resistance training are
recommended to work synergistically with optimal nutrition
intake to achieve a healthy weight and maintain lean body mass.
HIV-Associated Lipodystrophy Syndrome (HALS)
HALS refers to the metabolic abnormalities and body shape
changes seen in patients with HIV, similar to the metabolic
syndrome found in the general population. The typical body

shape changes include fat deposition (generally visceral adipose
tissue in the abdominal region or as a dorsocervical fat pad and
breast hypertrophy) or fat atrophy seen as loss of subcutaneous
fat in the extremities, face, and buttocks. The metabolic
abnormalities include hyperlipidemia (particularly high
triglycerides and low-density lipoprotein [LDL] cholesterol and
low high-density lipoprotein [HDL] cholesterol) and insulin
resistance. There is no consensus on the clinical definition of
HALS and the manifestations vary greatly from patient to
patient. Each part of the syndrome may occur independently or
simultaneously.
TABLE 38-9 Common Micronutrient Deficiencies and
Indications for Supplementation
Vitamin or Mineral
Potential Cause for Deficiency
Results of Vitamin Deficiency
Supplementation Indications
B12
Malabsorption
Inadequate intake
Increased risk of progression to AIDS
Dementia
Peripheral neuropathy
Myelopathy
Diminished performance (information processing and problem-
solving skills)
Little evidence of benefits to supplementation beyond
correcting low serum levels
A
Inadequate intake
Increased risk of progression to AIDS
Necessary to correct low levels
Should not exceed DRI when serum levels are normal
High intakes beyond correcting low levels can be detrimental to
health
and potentially increase risk of mortality from AIDS (Coyne-

Meyers and Trombley, 2004)
Needs more research
β-carotene
Inadequate intake
Fat malabsorption
Potential relationship with oxidative stress
Potentially weakens Immune function
Recommend only amounts found in multivitamin supplement
Needs more research
E
Inadequate intake
Potential increased progression to AIDS
Oxidative stress
Impaired immune response
High intake: may be associated with increased surrogate
markers of atherosclerosis
Needs more research
D
Inadequate intake
Inadequate exposure to sunshine
Immune suppression
Correct low levels
Needs more research
Selenium
Inadequate intake
Potential increased progression to AIDS
Weakened immune function
Oxidative stress
Multivitamin providing DRI recommended
Higher doses not recommended at this time until further
research
Zinc
Inadequate intake
Increased risk for HIV-related mortality
Weakened immune system
Impaired healing processes

Lower CD4 counts
Recommend supplementing to intakes of DRI
High levels above DRI may lead to faster disease progression
Needs more research
Iron
Low levels during initial asymptomatic HIV infection caused by
inadequate absorption
Inadequate intake
Anemia
Progression and mortality in HIV infection
High levels of iron potentially increase viral load
Increase susceptibility to and severity from other infections
such as TB
Correct low levels as needed
Recommend intakes at DRI
Needs more research
Coyne-Meyers K, Trombley LE: A review of nutrition in human
immunodeficiency virus infection in the era of highly active
antiretroviral therapy, Nutr Clin Prac 19:340, 2004.
Falcone EL et al: Micronutrient concentrations and subclincal
atherosclerosis in adults with HIV, Am J Clin Nutr 91:1213,
2010.
McDermid JM et al: Mortality in HIV infection is independently
predicted by host iron status and SLC11A1 and HP genotypes,
with new evidence of a gene-nutrient interaction, Am J Clin
Nutr 90:225, 2009.
Pitney CL et al: Selenium supplementation in HIV-infected
patients: is there any potential clinical benefit? J Assoc Nurses
AIDS Care 20:326, 2009.
Rodriguez M et al: High frequency of vitamin D deficiency in
ambulatory HIV-positive patients, AIDS Res Hum Retroviruses
25:9, 2009.
AIDS, Acquired immune deficiency syndrome; DRI, dietary
reference intake; TB, tuberculosis.
The cause of HALS is multifactorial and includes duration of
HIV infection, duration of ART medications, age, gender, race

and ethnicity, increased viral load, and increased body mass
index. Physical changes should be discussed with the health
care team. It is important to monitor these changes by taking
anthropometric measurements. Monitoring trends with body
weight is important; however, doing so will not likely identify
body shape changes. Generally, there is a shift in body
composition even though weight remains stable. Taking waist,
hip, arm, mid-upper arm, and thigh circumference measurements
and tricep, subscapular, suprailiac, abdominal, and thigh
skinfold measurements are useful in monitoring exact locations
of either fat hypertrophy or atrophy.
Nutrition interventions associated with HALS are limited. For
nutrition recommendations, the guidelines set by the National
Cholesterol Education Program and American Diabetes
Association are followed (see Chapters 31 and 34).
Recommendations for physical activity, including aerobic
exercise and resistance training, should complement dietary
intake. In addition, special focus should be on achieving
adequate dietary fiber intake. This can potentially decrease the
risk of fat deposition (Dong et al., 2006; Hendricks, 2003) and
improve glycemic control.
For patients who have high triglycerides, ω-3 fatty acids may be
useful. Omega-3 fatty acids decrease serum triglycerides and
may reduce inflammation and improve depression. In some
studies, 2-4 g of fish oil supplements per day have been shown
to lower serum triglyceride levels in patients with HIV (Wohl,
2005; Woods, 2009). Potential side effects from
supplementation include GI distress, hyperglycemia, and
increased LDL cholesterol levels. Use of supplements should be
monitored and discussed with the health care team.
Hiv in Women
Around the world, 15.7 million women are living with HIV or
AIDS. In the United States, women accounted for more than
10,000 (25%) of the estimated number of new HIV infections in
2008 (CDC, 2010). The highest rate of new HIV infection is
seen in African American women, which is 15 times as high as

that of white women and nearly 4 times that of Hispanic women
(CDC, 2010).
Although HIV-infected women are a minority in the United
States, there are several factors that put them at higher risk of
contracting HIV. Biologically, women are more likely to get
HIV during unprotected vaginal sex because the lining of the
vagina provides a larger area that can be exposed to HIV-
infected semen. Barriers to receiving appropriate medical care
also exist. Social and cultural stigma, lack of financial
resources, responsibility to care for others, and fear of
disclosure may prevent women from seeking proper care.
Preconception and Prenatal Considerations
HIV-infected women of child-bearing age should receive
counseling prior to conception to learn how to decrease the risk
of mother-to-child transmission. Current recommendations
include prenatal screening for HIV, initiation of ART during
pregnancy, and ART for the child once it is born. In the United
States, these interventions have reduced the risk of mother-to-
child transmission to less than 2% (DHHS, 2010a). Similar to
HIV-negative women, adequate nutritional status and nutrient
deficiencies should be monitored during pregnancy.
Supplementation of vitamins B, C, and E have been shown to
reduce the incidence of adverse pregnancy outcomes (e.g., low
birth weight, fetal death) and decrease rates of mother-to-child
transmission in women with compromised immune and nutrition
status (Kawai, 2010). It is important to note if women have
deficient serum vitamin A levels prior to supplementation, since
different serum levels may affect risk of HIV transmission.
Benefits may only be noted in those needing repletion of low
levels.
Postpartum and Other Considerations
In the United States breastfeeding is not recommended for HIV-
infected women, including those on ART, where safe,
affordable, and feasible alternatives are available and culturally
appropriate (DHHS, 2009). In developing countries,
recommendations may differ depending on safety and

availability of formula and access to clean drinking water.
Hiv in Children
An estimated 430,000 new HIV infections occurred globally
among children younger than the age of 15 in 2008 (UNAIDS
and WHO, 2009). In the United States an estimated 200 HIV-
infected children are born each year. The majority of these
infections stem from mother-to-child transmission in utero,
during delivery, or through consumption of HIV-infected
breastmilk. Recently, premastication (chewing foods or
medicine before administering to a child) was reported as a
route of transmission through blood in saliva (CDC, 2011).
Growth is the most valuable indicator of nutritional status in
childhood. Poor growth may be an early indicator for
progression of HIV disease. Growth failure can result from HIV
infection itself and HIV-associated OIs (Guillen, 2007). Weight
and height of HIV-infected children generally lags behind
uninfected children of the same age. Loss of lean body mass
with no changes in total body weight can also occur. To
appropriately measure body changes, serial anthropometric
measurements should be recorded, along with tracking of height
and weight on growth charts (Sabery et al., 2009).
HIV treatment has improved the clinical outcomes for children,
with ART initiation resulting in significant catch-up in weight
and height but not to the level of uninfected children. The
presence of HALS seen in adults is also common in children.
With the increasing number of years on ART, more morphologic
and metabolic abnormalities, as described in the section on
HALS, are being documented in children (Sabery and Duggan,
2009). Multivitamin and micronutrient supplementation may be
beneficial at the DRI levels for children who are malnourished.
Research does not currently support any supplementation at
higher doses.
Complementary and Alternative Therapies
In general, any treatment method that is not practiced in
conventional medicine is considered complementary and
alternative medicine (CAM). Dietary supplements, herbal

treatments, megavitamins, acupuncture, yoga, and meditation
are just a few of the therapies that are categorized as CAM. See
Chapter 13.
The use of CAM is prevalent in patients with HIV infection. On
average 60% of people living with HIV use CAM to treat HIV-
related health concerns (Littlewood, 2008). People experiencing
greater HIV symptom severity and longer disease duration are
more likely to use CAM in an attempt to delay disease
progression and alleviate side effects of HIV infection and
treatment (Bormann, 2009). In addition, CAM use is more
common in men who have sex with men, nonminorities, the
better educated, and less impoverished individuals (Littlewood,
2008).
Despite the high percentage of CAM use, only one third of
patients disclose CAM use to their health care providers (Liu,
2009). Some patients with HIV have noted benefits with taking
dietary supplements; however, potential interactions with ART
medications should be addressed (Hendricks, 2007). Therefore
it is important that each patient be questioned carefully about
use of alternative therapies, particularly those taken orally or
subcutaneously. Information should be collected on the brands,
dosage, frequency, timing, duration, and cost of the
supplements. This should be compared with additional clinical
information such as current medications, biochemical
parameters, and nutrition intake. Each item should be
researched for potential drug-drug and drug-nutrient
interactions because they may interfere with ART use. For
example, garlic and St. John's wort (Hypericum perforatum)
decrease blood levels of ART medications, decreasing the
efficacy of ART and potentially leading to drug resistance.
A key point in counseling patients who are using alternative
therapies is to understand why they choose to use them. Most
studies have found that there may not be any additional benefit
to supplementing beyond correcting deficiencies. Food should
be recommended first and patients should keep in mind that
more is not always better. Caution should be used because

dietary supplement labels can make a statement of nutrition
support and health benefit, but it must be accompanied by the
disclaimer, “This statement has not been evaluated by the Food
and Drug Administration (FDA). This product is not intended to
diagnose, treat, cure, or prevent any disease.” Adverse event
reporting for dietary supplements is voluntary, leading to a
underreporting or underestimation of events.
Clinical Scenario
EW is a 42-year-old male who has been HIV positive for 20
years. His viral load is undetectable and his CD4+ count is 643.
His current HIV antiretroviral regimen is raltegravir (Isentress),
atazanavir (Reyataz), ritonavir (Norvir), and emtricitabine
(Emtriva); he also takes atorvastatin (Lipitor) and ranitidine
(Zantac). His height is 5′9″ and his weight is 188 lb. His fasting
lipid profile is total cholesterol 184 mg/dL, triglycerides
304 mg/dL, high-density lipoprotein 25 mg/dL, and low-density
lipoprotein 96 mg/dL. Since his last visit 6 months ago, he has
noticed changes in his body composition including loss of
buccal fat and increasing abdominal girth. He lives by himself
and doesn't like to cook; he also receives one meal per day from
a community program. He walks 30 minutes daily. Upon taking
a 24-hour recall, you find his caloric intake to be 2700 kcal/day.
Nutrition Diagnostic Statement
Excessive dietary intake caused by frequent intake of
prepackaged meals as evidenced by diet history.
Nutrition Care Questions
1 What factors might be contributing to the body shape
changes that the patient is experiencing?
2 What nutrition and lifestyle interventions would you
recommend to address his nutrition diagnosis?
3 What are some biochemical and nutritional parameters you
would monitor to determine if the nutrition intervention was
successful?
4 How would you evaluate your desired nutrition outcomes
to determine if the goals have been met?
5 The patient has also been complaining of nausea and

diarrhea. What recommendations do you suggest for these
symptoms? Are there any drug-nutrient interactions to be aware
of?
Useful Websites
American Dietetic Association Infectious Disease Dietetic
Practice Group.
http://www.hivaidsdpg.org/
Clinical Guidelines on HIV/AIDS Treatment, Prevention, and
Research.
http://www.aidsinfo.nih.gov
Centers for Disease Control and Prevention HIV Research,
Prevention, and Surveillance.
http://www.cdc.gov/hiv
Joint United Nations Programme on HIV/AIDS.
http://www.unaids.org/
The National Center for Complementary and Alternative
Medicine.
http://www.nccam.nih.gov
References
American Dietetic Association: Position paper on nutrition
intervention and human immunodeficiency virus infection. J Am
Diet Assoc. 110, 2010, 1105.
Bangsberg, DR: Less than 95% adherence to nonnucleoside
reverse-transcriptase inhibitor therapy can lead to viral
suppression. Clin Infect Dis. 43, 2006, 939.
Bormann, J, et al.: Predictors of complementary/alternative
medicine use and intensity of use among men with HIV
infection from two geographic areas in the United States. J
Assoc Nurses AIDS Care. 20, 2009, 468.
Centers for Disease Control and Prevention (CDC): Coinfection
with HIV and hepatitis C virus Accessed 12 July 2010 from
http://www.cdc.gov/hiv/resources/factsheets/coinfection.htm,
2007.
Centers for Disease Control and Prevention (CDC): HIV in the
United States: an overview Accessed 12 July 2010 from
http://www.cdc.gov/hiv/topics/surveillance/resources/factsheets

/pdf/us_overview.pdf, 2010.
Centers for Disease Control and Prevention (CDC): HIV
prevalence estimates—United States Accessed 12 July 2010
from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5739a2.htm,
2006.
Centers for Disease Control and Prevention (CDC): HIV
surveillance report Accessed 12 July 2010 from
http://www.cdc.gov/hiv/surveillance/resources/reports/2008repo
rt/pdf/2008SurveillanceReport.pdf, 2008.
Centers for Disease Control and Prevention (CDC): Revised
surveillance case definitions for HIV infection among adults,
adolescents, and children aged <18 months and for HIV
infection and AIDS among children aged 18 months to <13
years—United States. MMWR. 57(No.RR-10), 2008, 1.
Centers for Disease Control and Prevention (CDC):
Premastication of food by caregivers of HIV-exposed children—
nine U.S. sites, 2009–2010. MMWR Morb Mortal Wkly Rep.
60(9), 2011, 273–275.
Coyne-Meyers, K, Trombley, LE: A review of nutrition in
human immunodeficiency virus infection in the era of highly
active antiretroviral therapy. Nutr Clin Prac. 19, 2004, 340.
Department of Health and Human Services (DHHS): Panel on
antiretroviral guidelines for adults and adolescents: working
guidelines for the use of antiretroviral agents in HIV-1-infected
adults and adolescents Accessed 12 July2010 from
http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf.
Department of Health and Human Services (DHHS): Panel on
Treatment of HIV-Infected Pregnant Women and Prevention of
Perinatal Transmission. Recommendations for Use of
Antiretroviral Drugs in Pregnant HIV-1-Infected Women for
Maternal Health and Interventions to Reduce Perinatal HIV
Transmission in U.S. 2010, Accessed12 July 2010 from
http://aidsinfo.nih.gov/ContentFiles/PerinatalGL.pdf.
Dong, KR, et al.: Dietary glycemic index of human
immunodeficiency virus-positive men with and without fat

deposition. J Am Diet Assoc. 106, 2006, 728.
Falcone, EL, et al.: Micronutrient concentrations and subclincal
atherosclerosis in adults with HIV. Am J Clin Nutr. 91, 2010,
1213.
Guillen, S, et al.: Impact on weight and height with the use of
HAART in HIV-infected children. Pediatr Infectious Dis J. 26,
2007, 334.
Hammer, SH, et al.: 2006 recommendations of the International
AIDS Society—USA Panel. JAMA. 296, 2007, 827.
Hendricks, K, Gorbach, S: Nutrition issues in chronic drug
users living with HIV infection. Addiction Sci Clin Prac. 5(1),
2009, 16.
Hendricks, KM, et al.: Dietary supplement use and nutrient
intake in HIV-infected persons. AIDS Reader. 1, 2007, 1.
Hendricks, KM, et al.: Obesity in HIV-infection: dietary
correlates. J Am Coll Nutr. 25, 2006, 321.
Hendricks, KM, et al.: High-fiber diet in HIV-positive men is
associated with lower risk of developing fat deposition. Am J
Clin Nutr. 78, 2003, 790.
Jones, CY, et al.: Micronutrient levels and HIV disease status in
HIV-infected patients on highly active antiretroviral therapy in
the Nutrition for Healthy Living cohort. J Acquir Immune Defic
Syndr. 43, 2006, 475.
Kawai, K, et al.: A randomized trial to determine the optimal
dosage of multivitamin supplements to reduce adverse
pregnancy outcomes among HIV-infected women in Tanzania.
Am J Clin Nutri. 91, 2010, 391.
Leyes, P, et al.: Use of diet, nutritional supplements and
exercise in HIV-infected patients receiving combination
antiretroviral therapies: a systematic review. Antiretroviral
Ther. 13, 2008, 149.
Littlewood, R, Vanable, P: Complementary and alternative
medicine use among HIV+ people: research synthesis and
implications for HIV care. AIDS Care. 20, 2008, 1002.
Liu, C, et al.: Disclosure of complementary and alternative
medicine use to health care providers among HIV-infected

women. Care STDS. 23, 2009, 965.
McDermid, JM, et al.: Mortality in HIV infection is
independently predicted by host iron status and SLC11A1 and
HP genotypes, with new evidence of a gene-nutrient interaction.
Am J Clin Nutr. 90, 2009, 225.
Pitney, CL, et al.: Selenium supplementation in HIV-infected
patients: is there any potential clinical benefit?. J Assoc Nurses
AIDS Care. 20, 2009, 326.
Polo, R, et al.: Recommendations from
SPNS/GEAM/SENBA/SENPE/AEDN/SEDCA/GESIDA on
nutrition in the HIV-infected patient. Nutr Hosp. 22, 2007, 229.
Raffa, JD, et al.: Intermediate highly active antiretroviral
therapy adherence thresholds and empirical models for the
development of drug resistance mutations. J Acquir Immune
Defic Syndr. 47, 2008, 397.
Rodriguez, M, et al.: High frequency of vitamin D deficiency in
ambulatory HIV-positive patients. AIDS Res Hum Retroviruses.
25, 2009, 9.
Sabery, N, Duggan, C: A.S.P.E.N. clinical guidelines: nutrition
support of children with human immunodeficiency virus
infection. JPEN J Parenteral Enteral Nutrition. 33, 2009, 588.
Sabery, N, et al.: Pediatric HIV. In Hendricks, K, et al. (Ed.):
Nutrition management of HIV and AIDS. 2009, American
Dietetic Association, Chicago.
Sattler, FR, et al.: Evaluation of high-protein supplementation
in weight-stable HIV-positive subjects with a history of weight
loss: a randomized, double-blind, multicenter trial. Am J Clin
Nutr. 88, 2008, 1313.
Tang, AM, et al.: Heavy injection drug use is associated with
lower percent body fat in a multi-ethnic cohort of HIV-positive
and HIV-negative drug users from three US cities. Am J Drug
Alcohol Abuse. 36, 2010, 78.
Joint United Nations Programme on HIV/AIDS (UNAIDS):
2008 Report on the global AIDS epidemic Accessed 12 July
2010 from
http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalRe

port/2008/2008_Global_report.pdf.
Joint United Nations Programme on HIV/AIDS (UNAIDS) and
World Health Organization (WHO): 2009 AIDS epidemic update
Accessed 12 July 2010 from
http://data.unaids.org/pub/Report/2009/JC1700_Epi_Update_20
09_en.pdf.
Wanke, C, et al.: Overview of HIV/AIDS today. In Hendricks,
K (Ed.): Nutrition management of HIV and AIDS. 2009,
American Dietetic Association, Chicago.
Wohl, DA: Fish oils curb hypertriglyceridemia in HIV patients.
Clin Infect Dis. 41, 2005, 1498.
Woods, MN, et al.: Effect of a dietary intervention and n-3 fatty
acid supplementation on measures of serum lipid and insulin
sensitivity in persons with HIV. Am J Clin Nutr. 90, 2009,
1566.
World Health Organization (WHO): Executive Summary of a
scientific review: Consultation on Nutrition and HIV/AIDS in
Africa: Evidence, lessons and recommendations for action.
Durban, South Africa Accessed on 26 July 2010 from
http://www.who.int/nutrition/topics/Executive_Summary_Durba
n.pdf, 2005.
World Health Organization (WHO): Macronutrients and
HIV/AIDS: a review of current evidence: Consultation on
Nutrition and HIV/AIDS in Africa: evidence, lessons, and
recommendations for action Durban, South Africa, Accessed on
26 July 2010 from
http://www.who.int/nutrition/topics/PN1_Macronutrients_Durba
n.pdf, 2005.
World Health Organization (WHO): Micronutrients and
HIV/AIDS: a review of current evidence: Consultation on
Nutrition and HIV/AIDS in Africa: evidence, lessons, and
recommendations for action Durban, South Africa, Accessed on
26 July 2010 from
http://www.who.int/nutrition/topics/PN2_Micronutrients_Durba
n.pdf, 2005.
World Health Organization (WHO): Rapid advice: revised WHO

principles and recommendations on infant feeding in the context
of HIV Accessed 12 July 2010 from
http://whqlibdoc.who.int/publications/2009/9789241598873_eng
.pdf, 2009.
(Mahan 864)
Mahan, L. K., Sylvia Escott-Stump, Janice Raymond. Krause's
Food & the Nutrition Care Process, 13th Edition. W.B. Saunders
Company, 2012. VitalBook file.
The citation provided is a guideline. Please check each citation
for accuracy before use.
CHAPTER 37 Medical Nutrition Therapy for Cancer
Prevention, Treatment, and Recovery
Barbara L. Grant, MS, RD, CSO, LD
Kathryn K. Hamilton, MA, RD, CSO, CDN
Key Terms
alternative medicine
angiogenesis
antiangiogenic therapy
antioxidants
apoptosis
biotherapy
cancer cachexia
cancer vaccines
carcinogen
carcinogenesis
chemoprevention
chemotherapy
classification
complementary therapy
control
cure
cytokines

drug resistance
dumping syndrome
emetogenic
epidemiologic studies
graft-versus-host disease (GVHD)
hematopoietic cell transplantation (HCT)
hematopoietic growth factors
hospice
initiation
integrative medicine
macrobiotic diet
malignant neoplasm
metabolic therapy
metastasis
monoclonal antibodies
mucositis
myelosuppression
N-nitroso compounds (NOCs)
neoplasm
neutropenia
nutrition impact symptoms
oncogenes
oncology
osteoradionecrosis
palliate (palliative care)
pancytopenia
phytochemicals
progression
promotion
radiation enteritis
radiation therapy
rate of tumor growth
sinusoidal obstructive syndrome (SOS)
staging
TNM staging system
trismus

tumor
tumor burden
tumor markers
tumor necrosis factor-α (cachectin)
tumor suppressor genes
Cancer involves the abnormal division and reproduction of cells
that can spread throughout the body. Usually thought of as a
single disease, cancer actually consists of more than 100
distinct types. The American Cancer Society (ACS) predicts the
lifetime risk for developing cancer in the United States is
slightly less than half of men and a little more than one third of
women (American Cancer Society [ACS], 2009a). Annually in
the United States, cancer is responsible for almost one out of
every four deaths (ACS, 2009a). Evidence suggests that one
third of the more than 560,000 cancer deaths may be attributed
to nutrition and lifestyle behaviors such as poor diet, physical
inactivity, alcohol use, and overweight and obesity. Almost an
additional 171,000 cancer deaths are caused by tobacco use
(ACS, 2010). It is estimated that 50% to 70% of cancer deaths
are potentially preventable by decreasing high-risk behaviors;
with approximately 30% of cancer deaths attributed to tobacco
use and at least an additional 30% to poor nutrition (Brawer
et al, 2009).
The cost of cancer care in the United States has doubled in the
past 20 years to more than $48 billion annually (NCI, 2010a).
Private insurance pays for 50% of the cost, Medicare coverage
accounts for 34%, and Medicaid payment and other public
programs cover the difference. Most medical care spending for
cancer has shifted away from an inpatient care setting to
outpatient care and treatment.
For dietetic professionals with interest in practicing in the area
of oncology, the Standards of Practice and Standards of
Professional Performance for Oncology Nutrition Practice
provide guidance (Robien et al., 2010).
Etiology
The most prevalent types of cancer diagnosed in the United

States are prostate, lung and bronchus, colorectal, and urinary
bladder cancers for men; and breast, lung and bronchus,
colorectal, and uterine cancers for women. The ACS established
2015 Challenge Goals to improve cancer prevention and early
detection efforts for lowering cancer incidence and mortality
rates. These national recommendations outline specific
measures to expand the use of established screening guidelines
for the early detection of cancer, and ways to influence
individual health behaviors such as protection from the sun,
reducing tobacco use, maintaining a healthy body weight,
improving diet, and increasing regular physical activity (ACS,
2010).
Overall, fewer Americans are dying from cancer, a trend that
began more than 15 years ago. For many, cancer is now a
chronic disease, like heart disease and diabetes. According to
the National Cancer Institute (NCI), there are 11.7 million
Americans living with a history of cancer; this means they are
cancer free, are living with evidence of disease, or are
undergoing cancer treatment (National Cancer Institute [NCI],
2010g). As a result of improvements in early detection of cancer
and the development of new anticancer therapies, the relative
survival rate for all cancers is now 66%, up from 50% in the
1970s (ACS, 2009a; NCI, 2010g). The Annual Report to the
Nation on the Status of Cancer, 1975-2006, released in
December 2009, found that rates of new diagnoses and rates of
death from common cancers have declined significantly for men
and women overall, as well as for most racial and ethnic
populations. Although cancer rates continue to be higher for
men than for women, men have experienced greater declines in
cancer mortality. For colorectal cancer, the third most
frequently diagnosed cancer in both men and women, overall
rates have declined. Unfortunately, the incidence in men and
women younger than 50 years old remains a concern.
Pathophysiology
Carcinogenesis is the origin or development of cancer.
Oncology is the study of all forms of cancer, and an oncologist

is the medical doctor who specializes in cancer. Researchers
believe changes in gene function cause normal cells to
transform into cancerous cells. Thus the study of genetic
material and its function (genomics) is of great scientific
interest in cancer and its treatment. See Pathophysiology and
Care Management Algorithm: Cancer.
Oncogenes are altered genes that promote tumor growth and
change programmed cell death (apoptosis). Tumor suppressor
genes are the opposite of oncogenes; these genes become
deactivated in cancer cells. This loss in function can lead to
unregulated cell growth and, ultimately, cancer. Examples of
tumor suppressor genes include adenomatosis polyposis coli
(APC), breast cancer types BRCA1 and BCRA2; and tumor
suppressor p53, a protein that is involved in preventing cancer.
Only approximately 5% of all cancers have been shown to occur
as result of inherited genetic alterations. Factors observed in
families with hereditary cancers include:
• A cancer diagnosis at an earlier age than normal for certain
kinds of cancer
• Individuals with one type of cancer being diagnosed with a
second type of cancer
• Certain types of cancers observed in specific ethnic
populations (e.g., individuals of Ashkenazi Jewish ancestry with
breast and ovarian cancer)
• Recognized cancer syndromes such as hereditary
nonpolyposis colorectal cancer or Lynch syndrome, which cause
individuals to be at greater risk for developing gastrointestinal
(GI), ovarian, uterine, brain, or skin cancer (NCI, 2010b)
Genetic counselors assist individuals and their families to
evaluate their risk of hereditary predisposition, that is, testing
positive for gene mutations.
Phases of Carcinogenesis
A carcinogen is a physical, chemical, or viral agent that induces
cancer. Carcinogenesis is a biologic, multistage process that
proceeds on a continuum in three distinct phases: initiation,

promotion, and progression. Initiation involves transformation
of cells produced by the interaction of chemicals, radiation, or
viruses with cellular deoxyribonucleic acid (DNA).
Transformation occurs rapidly, but cells can remain dormant for
a variable period until they are activated by a promoting agent.
After the initial cellular damage has occurred, transformation
from normal cells to a detectable cancer can take many years or
even decades. During promotion, initiated cells multiply and
escape the mechanisms set in place to protect the body from the
growth and spread of such cells. A neoplasm, new and abnormal
tissue with no useful function, is established. In the third phase
(progression), tumor cells aggregate and grow into a fully
malignant neoplasm or a tumor.
In the process known as metastasis, the neoplasm has the
capacity for tissue invasion that can spread to distant tissues
and organs. For a cancer to metastasize, it must develop its own
blood supply to sustain its growth of rapidly dividing abnormal
cells. In normal cells, angiogenesis promotes the formation of
new blood vessels that are essential to supply the body's tissues
with oxygen and nutrients. In cancer cells, tumor angiogenesis
occurs when tumors release substances that aid in the
development of new blood vessels needed for their growth and
metastasis.
Nutrition and Carcinogenesis
Nutrition may modify the carcinogenic process at any stage,
including carcinogen metabolism, cellular and host defense, cell
differentiation, and tumor growth. Gene expression can be
promoted or altered by nutrients during pregnancy, childhood,
and throughout a lifetime. Thus nutrition and diet contribute
approximately 35% to causal factors for cancer (Greenwald
et al., 2006). The strong influence of diet and nutrients is
readily seen in studies of migration between cultures. Patterns
of cancer occurrence often change over time to resemble that of
the new country. For example, in Japan mortality from breast
and colon cancer is low, and mortality from stomach cancer is
high; the reverse is true among Japanese individuals living in

the United States. After two or three generations, the cancer
patterns become similar.
Studies looking at the role of nutrition and diet as causal factors
of cancer seek to identify relationships between the diets of
population groups and categories of individuals and the
incidence of specific cancers. Sets of individuals are compared
in case control, cohort, or cross-sectional studies. The strongest
evidence comes from consistent findings of these different types
of epidemiologic studies in diverse populations. In cancer
research, epidemiologists look at human populations and
evaluate how many people are diagnosed with cancer, what
types of cancer occur in different populations and cultures, and
what factors such as diet and lifestyle play a role in the
development of the cancers.
The sheer complexity of diet presents a difficult challenge.
There are literally thousands of chemicals in a normal diet;
some are well known, and others are little known and
unmeasured. Some naturally occurring dietary carcinogens are
natural pesticides produced by plants for protection against
fungi, insects, or animal predators, or mycotoxins that are
secondary metabolites produced by molds in foods (e.g.,
aflatoxins, fumonisins, or ochratoxin). Food preparation and
preservation methods may also provide dietary carcinogens.
Thus diets contain both inhibitors and enhancers of
carcinogenesis. Dietary carcinogen inhibitors include
antioxidants (e.g., vitamin C, vitamin A and the carotenoids,
vitamin E, selenium, zinc) and phytochemicals. See Table 37-1
and Table 12-5. Dietary enhancers of carcinogenesis may be the
fat in red meat or the polycyclic aromatic hydrocarbons (PAHs)
that form with the grilling of meat at high heat. Complicating
the study of nutrition, diet, and cancer is the fact that when one
major component of the diet is altered, other changes take place
simultaneously. For example, decreasing animal protein also
decreases animal fat. This makes the interpretation of research
findings difficult because the effects cannot be clearly
associated with a single factor.

TABLE 37-1 Cancer-Protective Phytochemicals in Vegetables
and Fruits
Color
Phytochemical
Vegetables and Fruits
Red
Lycopene
Tomatoes and tomato products, pink grapefruit, watermelon
Red and purple
Anthocyanins, polyphenols
Berries, grapes, red wine, plums
Orange
α- and β-carotene
Carrots, mangos, pumpkin
Orange and yellow
β-cryptoxanthin, flavonoids
Cantaloupe, peaches, oranges, papaya, nectarines
Yellow and green
Lutein, zeaxanthin
Spinach, avocado, honeydew, collard and turnip greens
Green
Sulforaphanes, indoles
Cabbage, broccoli, Brussels sprouts, cauliflower
White and green
Allyl sulphides
Leeks, onion, garlic, chives
Cancer cells can have a long latency or dormant period. This
makes the diet at the time of cancer cell initiation or
promotion—not at the time of diagnosis—most important. Some
prospective epidemiologic studies attempt to deal with this
challenge by measuring diet at one point in time and following
the same subjects for several years. Studies done with
laboratory animals test this effect, and since the early part of
the last century, laboratory scientists have shown that various
nutritional manipulations influence the occurrence of cancerous
tumors in animals. Epidemiologic research, together with

animal studies, provide a viable method for discovering the
links between nutrition and cancer in humans.
Alcohol
Alcohol consumption is associated with increased cancer risk
for cancers of the mouth, pharynx, larynx, esophagus, lung,
colon, rectum, liver, and breast (both pre- and postmenopausal
women) (World Cancer Research Fund [WCRF] and American
Institute for Cancer Research [AICR], 2007). For cancers of the
mouth, pharynx, larynx, and esophagus, daily consumption of
two to three drinks increases risk two to three times compared
with nondrinkers. When combined with tobacco use, the sum
total risk is higher than the risk for just alcohol or tobacco
alone, again compared with nondrinkers (Baan et al., 2007;
WCRF and AICR, 2007). In addition, malnutrition associated
with alcoholism is also likely to be important in the increased
risk for certain cancers. In the United States, if people choose
to drink, men are recommended to limit alcohol intake to two
drinks per day and women to one drink per day. Serving sizes of
popular alcoholic drinks include beer (12 oz), wine (5 oz),
spirits/liquors (1.5 oz of 80-proof spirits). Three to four
alcoholic drinks or more per week after breast cancer diagnosis
may increase recurrence risk, especially among postmenopausal
and overweight or obese women (Kwan, 2010).
Energy Intake and Body Weight
In animal studies chronic restriction of food inhibited the
growth of most experimentally induced cancers and the
occurrence of many spontaneous cancers. This effect was
observed even when underfed animals ingested more dietary fat
than control animals ingested. Caloric restriction, without
malnutrition, appears to have a positive effect on cancer
prevention in animals; it is unclear whether that effect
translates to humans (Longo et al., 2010).
Obesity is a risk factor for cancer and may account for 6% of all
cancers (Polednak, 2008). Currently 68% of all American adults
are overweight or obese (Flegal et al., 2010). See Chapter 22.
Obesity increases the risk for developing and dying from cancer

(Schelbert, 2009). The relationship between body weight, body
mass index (BMI), or relative body weight and site-specific
cancer has been widely investigated; a positive association has
been seen with cancers of the esophagus, pancreas, gallbladder,
liver, breast (postmenopausal), endometrium, kidney, colon, and
rectum (Toles et al., 2008; WCRF and AICR, 2007). For men,
increased BMI correlates with esophageal, thyroid, colon, and
kidney cancers; a weaker association exists between BMI and
malignant melanoma, multiple myeloma, rectal cancer,
leukemia, and non-Hodgkin's lymphoma (NHL) (Brawer et al.,
2009). In women, stronger correlations are found between
increased BMI and endometrium, gallbladder, kidney, and
esophageal cancers; and a weaker association between increased
BMI and leukemia, thyroid, postmenopausal breast, pancreas,
and colon cancers and NHL. Bariatric surgery using gastric
bypass may reduce cancer mortality by as much as 60% (Brawer
et al., 2009).
The median adult BMI should be between 21 and 23 depending
on the normal range with different populations (WCRF and
AICR, 2007). Body weight throughout childhood should be at
the lower end of normal BMI, because excessive weight in
adolescence has been correlated with twofold increased risk of
death for colon cancer in adulthood (Anderson et al., 2009).
Being overweight or obese also appears to increase risk of
cancer recurrence and decrease cancer survival (Anderson et al.,
2009).
Obesity, age, hyperglycemia, and the incidence of metabolic
syndrome play a role in the circulating levels of insulin-like
growth factor-1 (IGF-1), a potentially cancer-causing
compound. IGF-1 is a polypeptide secreted primarily by the
liver and plays a key role in normal growth and development. It
can promote the development and progression of prostate,
breast, lung, and colon cancer. It has been hypothesized to
stimulate the growth of cancer cells and inhibit their death
(Blackburn, 2007; Pollack, 2008). IGF-1 secretion is increased
when insulin levels are elevated. Obesity and high simple

carbohydrate intakes potentially increase insulin resistance and
raise circulating insulin levels. This area of research connects
several known risk factors between nutrition, diet, and cancer
(Parekh et al., 2010).
Overweight and obese cancer survivors are at risk for
recurrence and for developing additional problems after
surgery, including impaired wound healing, lymphedema
following lymph node dissections, second cancers, heart
disease, and diabetes mellitus (Anderson et al., 2009). Regular
physical activity reduces mortality, especially in women and
older individuals (Teucher, 2010). All types of physical activity
help to protect against colon cancer, postmenopausal breast
cancer, and endometrial cancer (Teucher, 2010). Therefore the
ACS encourages all Americans to strive for 45-60 minutes of
moderate to vigorous physical activity most days of the week
(Doyle et al., 2006). Achieving and maintaining a reasonable
weight should be a primary health goal for all cancer survivors
(Doyle et al., 2006).
Fat
Research shows a link between some types of cancers and the
amount of fat in the diet. Diets high in fat often contain
significant amounts of meat. The link between meat and
colorectal cancer risk results from a number of possible
mechanisms: production of carcinogens from a high-fat diet,
from heterocyclic amines (HCAs) and or polycyclic aromatic
hydrocarbons (PAHs) from cooking; formation of carcinogenic
N-nitroso compounds (NOCs) from processing and the influence
of heme-iron are also suspected (WCRF and AICR, 2007).
Diets high in fat also tend to be high in calories, and contribute
to overweight and obesity conditions. Because dietary fat intake
is correlated with intake of other nutrients and dietary
components, it is difficult to distinguish between the effects of
dietary fats and protein, total calories, and fiber. Saturated fat
in red meats may be associated with an increased risk of
colorectal, endometrial, and possibly lymphoid and hematologic
cancers (Ferguson, 2010; WCRF and AICR, 2007). Two large

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