Nutrition and HIV: More than 3 decades later

HIV Nutritional
Considerations in 2014
Nelson Vergel, BsChE, MBA
Director
Program for Wellness Restoration (PoWeR)

Agenda
 Evolution of Nutritional Guidelines
 Food Considerations of ARVs
 Nutrition Complications in HIV
 Measuring Body Composition/Biochemical Assesment
 HIV Wasting
 HIV Lipodystrophy- Then and Now
 Insulin Resistance
 Nutritional Considerations for Optimal Body Composition and
Metabolism
 Micronutrients and HIV
 Interactions Between Medications and Micronutrients
 Exercise Considerations
 Questions and Answers

LGBTQ Policy Journal at the Harvard Kennedy School: 2011 Edition
HIV and Aging: Emerging Issues in the HAART Era
HIV+ Aging Population in the United States
(People over 50 years of age)

Evolution of Nutrition Guidelines in the U.S.
1984 1992

What Americans Eat:
Top 10 Sources of Calories
 Grain-based desserts (cakes, cookies, donuts, pies, crisps,
cobblers, and granola bars)
 Yeast breads
 Chicken and chicken-mixed dishes
 Soda, energy drinks, and sports drinks
 Pizza
 Alcoholic beverages
 Pasta and pasta dishes
 Mexican mixed dishes
 Beef and beef-mixed dishes
 Dairy desserts
Source: Report of the 2010 Dietary Guidelines Advisory Committee

Nutrition Complications in HIV
 Malnutrition
 Malabsorption
 Hypermetabolism
 Diminished intake
 Dysphagia – mouth lesions
 Odynophagia – lesions to esophagus
 Dysgeusia (distortion of sense of taste)
 Diarrhea – intestinal dysfunction due to pathogen
 Anorexia – neuropsychiatric, endocrinologic, or gastrointestinal
 Early satiety and/or bloating
 Nausea and vomiting – side effect of medication
 Fever – opportunistic infections
 Fatigue – lean body mass depletion
 Apathy
 Depression
 Others: financial or time restrictions
 Micronutrient deficiencies
McMahon Casey, Kathleen. (1997). Malnutrition Associated With HIV/AIDS. Part One: Definition and Scope, Epidemiology,
and Pathophysiology. Journal of the Association of Nurses in AIDS Care, 8(3), 24-32.

Nutrition Complications
 Malnutrition leads to:
 Malabsorption
 Complications with treatment regimens
 Decreased immune function
 Organ dysfunction
 Micronutrient deficiencies
 Weight Loss – AIDS Wasting
 A well-nourished HIV positive person with a
controlled viral load is more likely to be able
to withstand the effects of HIV infection.

Measuring Body Composition
 Anthroprometrics
 Tricep skinfold
 Midarm Circumference
 Bioelectrical impedance analysis (BIA)
 Convenient, inexpensive, and non-invasive method for
evaluating body composition – body cell mass
 Dual energy x-ray absorptiometry (DEXA)
 Measures subcutaneous and visceral fat stores
Abbaticola, Marcie M. (2000). A Team Approach to the Treatment of AIDS Wasting. Journal of the Association of Nurses in
AIDS Care, 11(1), 45-56.
Nelms, M., Sucher, K., Long, S. (2007). Nutrition Therapy and Pathophysiology. Belmont: Thomson Brooks/Cole.

Biochemical Assessment
 Selected biochemical measures for HIV
 Immunologic
 CD4 count
 Viral Load
 Hematologic
 Hemoglobin
 Hematocrit
 Mean Corpuscular Volume
 Ferritin
 Transferrin
 Albumin
 Prealbumin
(Transthyretin)

Biochemical Assessment
 Organ Function
 AST
 ALT
 BUN
 Creatinine
 Endocrine
 Glucose
 Insulin
 Glycosilated Hemoglobin A1C
 Testosterone
 Thyroid
 Cardiovascular
 Total Cholesterol
 HDL
 LDL
 Triglycerides
 C-Reactive Protein
 Electrolytes
 Sodium
 Potassium
Fields-Gardner, Cade, & Fergusson, Pamela. (2004). Position of the American Dietetic Association and Dietitians of Canada:
Nutrition Intervention in the care of Persons with Human Immunodeficiency Virus Infection. Journal of The American Dietetic
Association, 104(9), 1425-1441.

Weight Loss – AIDS Wasting
 AIDS Wasting: “involuntary loss of greater than 10%
of baseline body weight, accompanied by either
chronic diarrhea (at least two loose stools per day
for greater than 30 days) or chronic weakness and
fever for 30 days or longer In the absence of
concurrent illness or conditions” – CDC 1987
 Recommended revisions:
 Time frames for weight loss
 Inclusion of body composition alterations
 Guidelines for determining competing diagnoses
Fields-Gardner, Cade, & Fergusson, Pamela. (2004). Position of the American Dietetic Association and Dietitians of Canada:
Nutrition Intervention in the care of Persons with Human Immunodeficiency Virus Infection. Journal of The American Dietetic
Association, 104(9), 1425-1441.
McMahon Casey, Kathleen. (1997). Malnutrition Associated With HIV/AIDS. Part One: Definition and Scope, Epidemiology, and
Pathophysiology. Journal of the Association of Nurses in AIDS Care, 8(3), 24-32.

Weight Loss – AIDS Wasting
 Caused by:
 HIV replication- depletion of lean body mass
 Infections (PCP, etc)
 Reduced food intake
 Malabsorption
 Abnormal nutrient utilization and metabolism
 Oxidative stress
 Hormonal abnormalities
 Psychosocial difficulties
AIDS Care, 11(1), 45-56.

AIDS Wasting
 More important than weight loss is body
composition alterations
 Decreased Body Cell Mass (BCM)– metabolically
active, cellular component of the body, which
makes up lean body mass
 A loss of body cell mass of 54% is likely to result
in death in HIV-infected patients regardless of the
presence or absence of infectious complications.
Fields-Gardner, Cade, & Fergusson, Pamela. (2004). Position of the American Dietetic Association and Dietitians of
Canada: Nutrition Intervention in the care of Persons with Human Immunodeficiency Virus Infection. Journal of The
American Dietetic Association, 104(9), 1425-1441.

Preventing/Reversing Wasting
 Main goal: Get to undetectable viral load
 Nutrition Education
 Appetite Stimulants
 Marinol
 Medicinal Marijuana
 Megace
 Anabolic Hormones
 Testosterone
 Nandrolone Decanoate
 Oxandrolone
 Human Growth Hormone.
 Resistance Exercise

HIV-Associated Lipodystrophy
 Lipodystrophy syndrome
 Fat accumulation (hypertrophy):
 Abdomen
 Dorsocervical – “buffalo hump”
 Upper trunk and breast areas
 Subcutaneous fat loss (lipoatrophy):
 Limbs
 Face
 Upper trunk
 Buttocks
 Lipid abnormalities
 Increased LDL and triglycerides
 Glucose abnormalities/Insulin resistance
AIDS Care, 11(1), 45-56.

DAD Study:
Lipodystrophy Incidence 2000-2002 vs 2003-2006
2000-2002
2003-2006

Adult DHHS Guidelines (2014)-
Lipodystrophy and Switching ARVs
 “Lipohypertophy: Trunk fat increase observed
with EFV-, PI-, and RAL-containing regimens;
however, causal relationship has not been
established.”
 “Lipohypertrophy has been observed during
ART, particularly during use of older PI-based
regimens (e.g., indinavir), but whether ART
directly causes increases in fat depots remains
unclear. There is no clinical evidence that
switching to any currently recommended first line
regimen will reverse weight or visceral fat gain.”

Increased LDL or Triglycerides in
HIV- ARV Effect
LDL Cholesterol/
Triglycerides
Higher Risk
Stavudine
AZT
Didanosine
Lopinavir/r
Amprenavir/r
Duranavir/r
Atazanavir/r
Efavirenz
Lower Risk
Nevirapine
Tenofovir
Abacavir
Lamivudine
Emtricitabine
Enfurvitide
Raltegravir
Maraviroc
Etravirine
Elvitegravir
Dolutegravir

DIET Study (Dietary Intervention:
Effects on Tryglicerides in HIV
Lipodystrophy)
Using food records that began from 6 to 24 months before development
of fat deposition the following factors were identified.
When compared to people with HIV who developed fat deposition,
patients without fat deposition had:
- greater overall energy intakes from their diet (p = 0.03)
- greater intakes of total protein (p = 0.01)
- more total dietary fiber (p = 0.01)
- more soluble dietary fiber (p = 0.01)
- insoluble dietary fiber (p = 0.03)
- pectin (P = 0.02)
Those without fat deposition also were currently doing more
resistance training exercise and were less likely to be smoking
(only borderline statistical significance (p = 0.05))
Hendricks at al, Am J Clin Nutr, 2003 Oct;78(4):790-5

Scandinavian Journal of Infectious Diseases, Vol. 38, No. 8, August 2006, pp. 682-689

Scandinavian Journal of Infectious Diseases, Vol. 38, No. 8, August 2006, pp. 682-689
Insulin Resistance in HIV

Possible Causes Of Insulin
Resistance
 HIV replication
 High simple and refined carbohydrate intake
 Some medications ( Protease Inhibitors,
Efavirenz, Anti-psychotics, etc)
 Family history/genetics
 Obesity/overweight
 Testosterone and/or thyroid hormone deficiency

Dietary Modification for Insulin Resistance
 Consume moderate portion sizes.
 Eat balanced meals consisting of a complex starch
(brown rice, whole wheat bread), lean protein, fat and
vegetable or fruit. Macronutrient combinations
decrease glucose uptake.
 Consume high fiber foods in the form of whole grains
(multi-grain/whole wheat bread, wild-black rice, etc.)
and vegetables to reduce the rate of glucose
absorption from the gut into the blood stream.
 Increase consumption of rich-colored vegetables and
fruits for their protective vitamins, antioxidants, and
phytochemicals.

Diet & Blood Glucose
 Reduce consumption of simple sugars (sodas, sweets, etc.) and
refined starches (white bread, pasta, and others made from
white flour) to prevent blood glucose levels from rising too
rapidly. High fiber lowers glucose uptake.
 Consume mostly unsaturated fats like olive or canola oils and
omega-3 fatty acids from cold water fish (tuna, sardines,
salmon, and mackerel, for example).
 Include lean protein from chicken, lean beef, fish, nuts, low-fat
cottage cheese, beans, and whey protein shakes to help build
and maintain lean body mass and manufacture antibodies to
fight disease.
 Limit alcohol consumption. Alcohol may interfere with the liver's
ability to break down glucose.

Complementary Approaches For
Improving Insulin Sensitivity
 Weight Loss
 Regular resistance (weight-bearing) and cardiovascular
exercise.
 Testosterone and thyroid replacement if deficient.
 Adequate soluble fiber intake (30 grams per day or
more)
 Smoke cessation

Rollins C. Functional and meal replacement foods. In: Berardi R, Newton G, McDermott JH, et al, eds. Handbook of Nonprescription Drugs.
16th ed. Washington, DC: American Pharmacists Association; 2009:425-433.

J. Nutr. March 2008vol. 138 no. 3 439-442
Metabolic Effects of Dietary Fiber Consumption

N Engl J Med 2008; 359:229-241

N Engl J Med 2008; 359:229-241
Inflammatory Markers, Insulin and Glucose

Increase Protein in Your Diet
 Include beans and tofu (soy)
 Super fortify your milk- add several tbsp of dry milk
solids, skim milk plus has 11gm vs. 8 gm of protein
 Use lactose reducing labels if this is your main source of
protein
 Eat larger portions of meat, fish, poultry, eggs, milk,
yogurt, cheese, dried beans
 Choose deserts that contain eggs, milk, soy protein (ice
cream, pudding, or custard
 Add hard boiled eggs to tuna, diced meat to potato
salad, cooked seafood, vegetables, salads
 Add nonfat dry milk – casseroles, meatloaf, macaroni,
meatballs, mashed potatoes, hot cereals

Protein and Carbohydrate
Supplementation in HIV
 CD4 lymphocyte counts increased
significantly with whey protein consumption.
The increased intake of rapidly assimilable
carbohydrate with the control supplement
resulted in short-term increases in fasting
triglycerides and waist-to-hip ratio—a
surrogate for central adiposity.
Am J Clin Nutr. November 2008. vol. 88 no. 5 1313-1321

Increase Protein- Cont.
 Add peanut butter or soy nut butter
 Try cottage cheese- tofu, salads, vegetables, rice, pasta,
soups, casseroles, tacos, burritos, toast
 Prepare canned soups with milk, not water
 Add chopped meat , cheese, ham to scrambled eggs,
omelets, salads
 Top fruit salad with yogurt, cottage cheese
 NEVER EAT RAW EGGS-Caesar salad dressing, some
desserts
 If protein is a problem, try a predigested form of protein
called peptides (Petamen meal replacement supplements)
 Add grated cheese (nonfat has higher protein content)

Fat is not a Four Letter Word
 Fats are needed for energy, immune function,
vitamin absorption, and hormones
 Good Fats- monounsaturated- Olive Oil
Essential Fatty Acids- polyunsaturated
Omega 3’s- cold water fish (salmon)
Omega 6’s- high oleic sunflower oil, nuts
Omega 3’s and 6’s- Flaxseed oil
 Bad Fats-processed/hydrogenated oils, margarine,
artificial creamers, any man-made oil, burned oils,
rancid oils, lard

The Healthiest Fat
Monounsaturated Fats
 Found in vegetable oils like olive oil, canola oil,
avocados, nuts, nut butters
 Not suspected of being immune suppressive
 Do not normally increase your cholesterol levels
like saturated fats, but they are sometimes
modified when heated during processing. For
this reason, many people look for olive oil that is
“cold pressed”

Omega-3 Fatty Acids
 Essential fatty acids: must be present in your
diet. Found in most fish and seafood, as well as
in flaxseed and some beans and peas.
 Reduce risk of heart attack and to have a
positive influence on cell-mediated immunity (the
part of the immune system most damaged by
HIV infection).

Study : Omega-3 fatty acids
 Reduced triglyceride levels and if they had no
new opportunistic illnesses during the study, it
helped them gain weight.
 Many people with HIV who wish to supplement
their food intake of omega-3 fatty acids take
omega-3 fish oil supplements (about 3 g daily).

Joint FAO/WHO Expert Consultation on the Risks and Benefits of Fish Consumption.
Seafood: The choice is yours

Good Carbohydrates
Bad Carbohydrates
 Provide energy and nutrients
 Bad carbs can worsen insulin resistance and
triglycerides
 Bad: Avoid/reduce high glycemic, high calorie
carbs – refined flour, especially milled grains,
sugar, corn syrup
 Good: Eat more fiber, nutrient, and fluid-rich,
low calorie, low glycemic index carbs like
vegetables, fruits, roots, greens, high fiber
foods, etc

Sugar Content of Common Drinks

U.S. Consumption of Caloric Sweeteners. Economic Research Service. 2013
Per Capita U.S. Consumption of Caloric Sweeteners

BMJ 2013;347:f6879
Dietary Fiber Intake and Risk of Cardiovascular Disease
(non-HIV): systematic review and meta-analysis

Bone Disorders in HIV
Treatments for bone loss
 Resistance exercise, preventing wasting syndrome,
and avoiding tobacco
 Calcium (1000- 1500 mg/day) and Vitamin D (400-
1000 IU/day ). Get 20 minutes of sun daily
 Biophosphonates (Alendronate)
 Calcitonin (Intranasal and oral)
 Teriparatide
 Testosterone and/or thyroid replacement therapy

NNRTIs? Tenofovir?
Vitamin D and HIV

Vitamin D Therapy
Decreases Parathyroid Hormone (PTH) in
Patients Taking Tenofovir
 Randomized trial of Vit D 50,000 IU/wk x 12 weeks vs. placebo in patients on (n=118) or not
on (n=85) TDF
 Higher baseline PTH levels at baseline in TDF group
 Vitamin D had no impact on PTH levels in patients not on TDF
TDF No TDF
Day
0
Change
Day
0
Change
Vit D 47 -6 26 -2
PBO 37 +2 25 0
Changes in PTH on study
Havens P, et al. 18th CROI; Boston, MA; February 27-March 2, 2011. Abst. 80.
Mean Baseline PTH by Vitamin D status and Tenofovir Use
PTH Differs by Tenofovir use, not Vitamin D status
52
35
43
27
P=0.001 P<0.001

Taking Vitamins
 The most expensive may not be the best- look for USP
government inspection
 It is not Important for a vitamin to be "natural" instead of
synthetic. Your body can't tell the difference.
 No such thing as a special vitamin pill for HIV or AIDS.
 The FDA does not regulate supplement company. They
may do spot checks on ingredients if consumers report
issues.

Nutrient Supplementation
 Specific micronutrient supplementation has shown
various results, and general multivitamin
supplementation is recommended, while food should
be considered the main source of nutritional needs.
 Double-blind, placebo-controlled trail in Thailand – 21
nutrient multivitamin (N=481)
 Significantly reduced risk of mortality in men and women
 Observational study amount HIV-infected men in U.S.
taking daily multivitamin supplement (N=296)
 30% reduction in risk of progression to the diagnosis of
AIDS
 Significantly reduced risk for low CD4+ counts
Fields-Gardner, Cade, & Fergusson, Pamela. (2004). Position of the American Dietetic Association and Dietitians of
Canada: Nutrition Intervention in the care of Persons with Human Immunodeficiency Virus Infection. Journal of The
American Dietetic Association, 104(9), 1425-1441.
Fawzi, W., Msamanga, G., Spiegelman, D., Hunter, D. (2005). Studies of Vitamins and Minerals and HIV Transmission and
Disease Progression. The Journal of Nutrition, 135, 938-944.

Taking Minerals with Integrase
Inhibitors
 Leave this language for legal approval

Certain Medications May Deplete Micronutrients

Exercise
 Several studies have shown aerobic exercise improves
quality of life for people with HIV.
 Studies have also suggested exercise has beneficial
effects on the immune system such as increasing CD4+
cells.
 Exercising to the point of exhaustion, however, has been
shown to be immune suppressive.
 The biggest benefit of exercise for HIV+ people may be
the building and retention of muscle mass and lowering
lipids.
 Exercise, including working out with weights, has been
shown to improve muscle function and to build lean
muscle mass in HIV+ people.
 Any type of exercise also has the benefit of releasing
stress, and may help increase your appetite.

Nutrition and HIV: More than 3 decades later

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