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HIV and Nutrition

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Title: HIV and Nutrition


1
HIV and Nutrition
  • Developed by
  • Colette Nelson, MS, RD, CDE

2
Patient Nutrition Concerns
  • "How much protein should I eat?"
  • "Is it really important to eat vegetables so I
    can get these new phytochemicals I keep hearing
    about? Why can't I just take the supplements
    advertised on TV and in magazines instead of
    worrying about eating my vegetables?"
  • "Sugar? It can't be that bad--it seems to be
    added to everything I eat."
  • "If there is an HIV/AIDS diet that is scientific
    and not just a matter of opinion, why can't the
    nutritionists just give it to PWA/HIVs who really
    need it?
  • We have the Food Pyramid that the government says
    is the best way for the general public to eat.
    Why can't they do the same thing for an HIV
    disease diet?"

3
Issues in the Nutrition Profession
  • Difficulty with figuring out what is effective
    and what is the nutrition fad of the day.
  • Another problem is that approaches that show
    great promise for improving the health of
    PWA/HIVs but have a very low probability of
    profit are often very poorly studied.

4
General Nutrition Guidelines
  • High calorie/ high protein diet to help maintain
    weight
  • Provide adequate fluid, potassium when needed.
  • Increase Omega 3 fatty acids
  • Small frequent feedings
  • Lactose or gluten are not tolerated
  • Sucrose , fat and D-xylose may also need to be
    limited
  • A general multi/mineral supplement may be
    indicated 2-5X RDA ( Vit C, B12, Se, Vit A,
    Zinc, B- complex )
  • Nutritious snacks may be beneficial
  • Increase green/orange vegetables
  • Food safety concerns
  • Modify diet with meds
  • Smoking substance cessation

5
Goals of Nutritional Therapy
  • Determine what the person was like physically
    before becoming HIV-positive Was he or she obese
    or heavily muscled? A couch potato or an athlete?
    On a good diet?
  • Help meet or exceed the amount of muscle the
    person had before becoming positive. Introduce
    the person to proper eating and exercise.
  • Help get the person back to her or his original
    weight, or to maintain it.
  • Teach about food and water safety.
  • Advise about the ability of food to ease some of
    the GI side effects of medications.
  • Teach the importance of maintaining eating and
    medication schedules to ensure maximum absorption
    of medications.

6
Major Nutrition Concerns
  • Prevent the development of specific nutrient
    deficiencies which can impair immune function
  • Prevent loss of lean body mass wt loss gt 60 of
    IBW death becomes a near certainty

7
Establish Baseline Status
  • Infected with HIV (no signs of disease)
  • Eat a wide variety of healthy foods each day.
  • Try to choose all of your foods from the basic
    groups of foods described later in this
    information with an emphasis on protein.
  • HIV infection is causing minor health problems
  • Eating may be uncomfortable or your appetite may
    be poor right now, but it is so important to eat
    well.
  • You may need to avoid certain foods eat others
    or change the time that you eat or the amount
    that you eat can make you feel a lot better.
  • HIV infection is causing serious health problems
  • You may even need assistance in shopping, cooking
    or eating.
  • You may need to consider nutritional supplements
    such as protein drinks, Peptimen, NuBasics, and
    other liquid meal replacements

8
What We Know About Nutrition
  • Nutritional status predictor of survival may
    help decrease disease progression
  • Malnutrition related to adverse outcome
  • 88 of PWA considered malnourished

9
Causes of Wasting
  • Malabsorption of fat and carbohydrates may
    develop even if symptoms are absent
  • Increased Excretion
  • Increased Requirements
  • Altered metabolism high levels of cytokines
  • Low food intake
  • Proteins that produce inflammation in order to
    get rid of infection

10
Preventing Wasting
  • Nutrition Education
  • Appetite Stimulants
  • Anabolic Hormones

11
Concern About Calorie Requirements
  • If you are able to maintain a stable healthy
    weight, you're eating enough calories
  • Keep in mind that a stable weight does not
    indicate that you are necessarily maintaining
    your lean body mass and this partly has to do
    with making sure you eat plenty of protein.
  • For example
  • You weigh 140 pounds and have lost 10 pounds in
    the last 6 months. You may need 25 calories per
    pound to gain weight 140 x 25 3,500 calories
    per day

12
Calories
  • Estimation of Calorie Needs
  • 17-20 cal/lb if your weight is stable and there
    is no opportunistic infection
  • 20 cal/lb if you have an opportunistic infection
  • 25 cal/lb if you're losing weight

13
High Nutrient Foods
14
Protein
  • Eat twice the RDA (Recommended Dietary
    Allowances) Protein (1.0- 1.5 gm/kg BW)
  • Females at least 100 grams of protein per day
  • Males at least 125 grams of protein per day
  • Rule of thumb Eat a good source of protein
    (meat, fish, poultry, eggs, dairy, beans) at
    least 5-6 times per day
  • For example, a reasonable goal would be to eat 30
    grams per meal, in addition to two high-protein
    snacks

15
Protein Foods
  • Meats, fish, poultry, eggs and cheese are in this
    group
  • They give you protein as well as many vitamins
    and minerals
  • Eat three servings or more each day
  • One serving is considered to be
  • Two ounces of meat, fish, chicken or turkey. An
    ounce is the size of a slice of bologna or other
    cold cut. A typical chicken leg has about two
    ounces of meat on it. A typical hamburger patty
    is three ounces
  • Two eggs
  • Two slices of cheese or two 1-inch cubes
  • One cup of cooked beans or peas. This would be
    about the size of two scoops of ice cream.
  • Two handfuls of nuts
  • A thick coating of peanut butter on a typical
    slice of bread

16
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

17
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)

18
Why Reduce Fat in Your Diet?
  • Fat can be hard for your body to digest when you
    are sick, it can cause diarrhea, nausea, gas and
    bloating.

19
Fat lt 30
  • Abnormal lipid metabolism elevated triglyceride
    levels have long been recognized
  • Fat intolerance occurs avoid high fat foods
    such as bacon, sausage, bologna, hot dogs, cream
    ice cream, whole milk, fried foods, mayonnaise,
    butter, margarine, sauces , oils, nuts.       

20
Types of Fats
  • Saturated Fats
  • Animal fats (butter, red meat,coconut, palm
    kernel oils, lard, hydrogenated oils)
  • Recently, both high triglyceride and cholesterol
    levels have been observed in some HIV people on
    antiretroviral therapy
  • Polyunsaturated Fats
  • Vegetable oils (corn peanut oil, and in most
    margarines)
  • In some studies, polyunsaturated fats been shown
    to reduce T-cells, and with them the functioning
    of the immune system. Remain less likely to
    increase cholesterol than saturated fats

21
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

22
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).

23
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).

24
Omega-3 Warning
  • Make sure these fish oil supplements are not cod
    liver oil, or any other fish oil containing
    vitamins A and D.
  • Vitamins A and D should be removed from omega-3
    fatty acid supplements because the usual doses
    may result in an excessive intake of these
    vitamins.

25
Low-Fat Suggestions
  • Try reduced fat foods or fat free
  • Substitute mashed, boiled, or baked for french
    fries
  • Use seasoning to sauces or gravies to improve
    taste and moisture
  • Low fat yogurt, low fat cottage cheese, skim milk
    (try Plus ), buttermilk.
  • Hot and cold cereals. No granola.
  • Toast with jelly or honey. No butter or
    margarine.
  • Soups with broth. No cream soups.

26
Low-Fat Suggestions
  • Tuna packed in water. No tuna packed in oil.
  • Foods which are baked, broiled, boiled, stewed,
    grilled or roasted. No fried foods. No french
    fries. No doughnuts. No fried chicken or fried
    fish.
  • Pretzels and plain crackers. No chips.
  • Plain cooked vegetables. No cream sauce, butter,
    margarine or meat fat added.
  • Fresh fruit and fruit juice.

27
Low-Fat Suggestions
  • Puddings made with skim milk.
  • Sherbet, Popsicles, fruit ice. No ice cream.
  • Angel food cake.
  • No pound, layer or cheese cake.
  • Hard candy, jelly candy. No chocolate bars.
  • Vanilla wafers, ginger snaps, graham crackers.
  • Fat-free chili, spaghetti and soups,
    refrigerating overnight to make the fat get hard
    on top. Then you can remove it easily.
  • Mustard vs. mayonnaise or salad dressing.
  • No peanut butter.

28
The Use of MCT Oil
  • Try substituting with MCT oil- it is easier to
    digest and absorb
  • MCT OIL, comes from fractionated coconut oil,
    which means broken down coconut oil, it is not
    the same as the usual highly saturated coconut
    oil
  • Use MCT oil while on a low-fat diet and it is
    treated more like a carbohydrate

29
Fruits Vegetables
  • Salads, cooked vegetables, raw or cooked fruits
    and juices are in this group.
  • They supply many of the vitamins and minerals
    your body needs.
  • Eat four servings or more each day.
  • One serving is considered to be
  • A piece of fruit or raw vegetable.
  • A half cup of cooked vegetable or fruit. This
    would be like the size of a scoop of ice cream.
  • A small glass of juice.

30
Carbohydrates
  • Bread, grains and cereals are in this group
  • They have a variety of vitamins, minerals and
    some protein in them.
  • Eat four servings or more each day.
  • One serving is considered to be
  • One slice of bread choose whole grains
  • One bowl of breakfast cereal gt 5 gm of fiber
  • One half cup of noodles, macaroni, rice or grits.
    This would be like the size of a scoop of ice
    cream. A typical plateful of spaghetti would be
    two or more servings.
  • One pancake, waffle, tortilla or slice of
    cornbread
  • One biscuit
  • 5 crackers

31
Dairy Products
  • Milk, cheese and yogurt are in this group
  • They give you protein, vitamins and a lot of
    calcium. Eat two servings or more each day.
  • One serving is considered to be
  • 8 ounce glass of milk. This is about the size of
    a coffee mug.
  • 8 ounces of yogurt. This is the size of the
    typical container of yogurt at the store.
  • Two slices of cheese, or two 1-inch cubes.
  • One bowl of pudding or custard, the size of a
    cereal bowl.
  • One and one half cups of ice cream. This would
    the amount in three scoops, or three ice cream
    bars.

32
Lactose Intolerance
  • You should not eat these foods
  • Regular (whole) milk, skim milk, low fat milk,
    evaporated milk
  • Powdered milk , goat milk
  • Cheese (unless label says it has been aged 90
    days)
  • Instant coffee, cocoa or other chocolate
    beverages
  • Whipping cream, sour cream
  • Pudding and pudding pies
  • Custard and custard pies
  • Ice cream or ice milk
  • Gravy made with milk or cream
  • Soups made with milk or cream
  • Party dips made with sour cream
  • Cream sauce on meats or vegetables

33
You Might Be Able to Use These Foods Instead
  • Sweet acidophillus milk (it says "acidophillus"
    on the label)
  • Lactose-reduced milk (it says "lactose reduced"
    on the label)
  • Buttermilk
  • Regular milk with "Lact-aid" added to it. You can
    buy Lact-aid at drug stores. It is a powder you
    add to milk. It digests the lactose for you and
    the milk tastes just fine
  • Natural cheese which has been aged for 90 days or
    longer. Many cheddar and Swiss cheeses are aged
    for 90 days. Just read the label
  • more...

34
You Might Be Able to Use These Foods Instead
  • Yogurt , frozen yogurt desserts , Sherbet
  • Powdered coffee creamer such as "Coffee mate."
    You can use this in place of milk in many
    recipes.
  • Soybean milk. You can buy this canned at drug
    stores and at many grocery stores. Try soybean
    infant formulas ("Prosobee," "Nursoy," or
    "Isomil").
  • Special dietetic products that say "lactose free"
    on the label.
  • Kosher foods marked "pareve" are milk-free.

35
Liquid Supplements
  • Allow you to get a large amount of calories in
    one glass of liquid.
  • Supplements which contain MCT (medium chain
    triglycerides) may be preferable because they are
    easier to absorb than those that contain the more
    common long chain triglycerides.
  • Look for a liquid supplement that is as high in
    protein as possible.

36
Commonly Used Liquid Supplements
  • Instant Breakfast
  • Slender
  • EnsureSustacalEnrich
  • MagnacalEnsure PlusRepleat
    NutramentAlbaMeriteneCitrotein
  • Nutri1000Resource

37
Techniques in Mixing Liquid Supplements
  • Increase the protein content of a liquid
    supplement by sprinkling whey protein or other
    protein powder into the supplement.
  • Choose to take just whey protein or soy protein
    powder to increase protein intake thus avoiding
    the diarrhea that may be caused by the long chain
    fats in many liquid supplements.
  • Some provincial and private insurers cover the
    cost of a limited selection of liquid supplements

38
Enteral Nutrition
  • This is a fairly uncommon way of dealing with HIV
    related weight loss.
  • It is generally done via a nose tube if a person
    is having trouble swallowing or breathing, or if
    someone is too sick to eat.
  • If the treatment is expected to be long term, a
    tube may be inserted through the abdominal wall
    directly into the stomach.
  • This allows a person who cannot eat an adequate
    diet to use enteral nutrition on an ongoing
    basis, probably at home. This procedure is of
    more limited value in the case of severe
    malabsorption, however special formulas of an
    elemental diet are available for people
    experiencing malabsorption or diarrhea.

39
Total Parenteral Nutrition
  • Allows nutrients to be delivered directly into
    the blood stream with an intravenous tube.
  • This is an uncommon way to treat HIV people
    because it is extremely expensive, however, it
    may be useful during periods of serious illness.
  • This is particularly appropriate for illnesses
    that affect the gastrointestinal tract and
    prevent normal food intake.
  • Severe malabsorption with uncontrollable diarrhea
    may be treated in this way in rare instances

40
Nutritionist View on Supplements
  • Nutritionist agree on emphasizing the need to eat
    food and drink water first, when possible, and to
    use supplements as supplements, not as main
    courses.

41
Common Deficiencies
  • Vitamin A, zinc, iron- detrimental to the immune
    function
  • Depletion of antioxidants- Vit A, Vit. C, and B
    vitamins can also compromise immune function b/c
    of their roles as cofactors in many enzyme
    functions including those involved in nucleic
    acid synthesis

42
Vitamin/Mineral Toxicity
  • Beware of excess iron or zinc, vitamin E and PUFA
    because of their effect on immunity when taken in
    large doses
  • Potential iron is not appropriate in cachexic
    patients, or in sepsis, expect in careful
    consideration by physician.

43
What About Supplements?
  • Start with a diet with lots of variety and many
    different colors of vegetables
  • A multi-vitamin taken once or twice a day with
    meal
  • NAC and higher doses B vitamins
  • Regular injections of vitamin B12
  • Higher doses of other vitamins like C, E, and the
    mineral selenium

44
Guidelines Taking Vitamins
  • Take a daily multi-vitamin and mineral pill. -
    Look for one that includes iron.
  • Pills cannot make up for not eating right. When
    you are infected with HIV, your body may need the
    extra vitamins and minerals that you get from
    both healthy food and a vitamin/mineral pill.
  • It is better to take one multi-vitamin and
    mineral pill each day than to take several pills
    containing different vitamins and minerals. These
    can cause dangerous side effects.

45
Guidelines Taking Vitamins (cont.)
  • 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 vitamins and minerals in pills work best in
    your body when taken with a meal- try taking with
    largest meal which may be in the evening

46
Vitamin/Mineral Drug Interactions
  • Iron supplements may decrease the absorption of
    tetracyclines and other antibiotics
  • Zinc and copper interact when taking large
    quantities, take separately
  • Isoniazid (a TB drug) increases the need for
    Vitamin B6
  • The antibiotic ciprofloxicin should not be taken
    within 2 hours of calcium, iron magnesium or
    aluminum supplements because absorption is
    decreased
  • Agenerase has a significant amount of Vitamin E
    (109 IU) to improve it's bioavailability, this
    may interfere with blood thinning medications

47
Poor Appetite
  • Eat very small meals many times during the day.
    How small?
  • Here is a sample menu
  • Breakfast 3 crackers with peanut butter and a
    1/2 cup of apple juice
  • Snack 1 carton yogurt
  • Lunch 1/2 ham and cheese sandwich, 1 cup cocoa
  • Snack 2 oatmeal cookies, glass of milk
  • Supper cottage cheese with canned peaches
  • Snack 1 bowl of cereal and milk

48
Poor Appetite (cont)
  • Watch the clock. Eat something every hour or two
    whether you feel like it or not.
  • Eat food that you really love at this time.
    Spaghetti and meatballs, pizza, and tacos are
    favorites for many people.
  • If you can find one thing you enjoy eating, just
    eat it all day.
  • Sometimes you can't eat solid food but you'll be
    able to drink things. Try milkshakes. Try ice
    cream floats--mix ice cream with your favorite
    juice or soft drink in a tall glass. You might
    also try chocolate milk, egg nog or hot cocoa.
    Creamy soups might go down easy as well.
  • Keep snacks right beside you in your home. You
    might be able to nibble enough to finish quite a
    bit of food.

49
Weight Loss
  • Increase the number of times you eat each day.
  • Eat more foods that are high in calories and
    protein, such as milk, cheese, meats, and peanut
    butter.
  • Make your snacks count. Eat healthy foods high in
    calories and protein between meals.
  • Add extra fat to your food. It can increase
    calories a lot without your having to eat a
    larger amount of food.

50
Weight Loss (cont.)
  • Add sugar, honey, syrup, brown sugar and other
    sweet things to your food. Put jams and jellies
    on breads, toast, rolls, pancakes and waffles.
    Put sugar or honey in your coffee and tea. Add it
    to your cereal.
  • Eat dried fruit such as raisins, prunes, dried
    apricots, dried apples, dried peaches, figs and
    dates. These are good by themselves or mixed with
    nuts for a snack. Add them to hot cereal such as
    oatmeal and cream of wheat.

51
Nausea Vomiting
  • Nausea may be caused by the medicines you are
    taking or by infections in your body.
  • Eat small amounts of food real often during the
    day. Try watching the clock and eating
  • Don't skip meals
  • Eat something every 2 to 3 hours. Eat more food
    at times of the day when you feel good
  • Don't eat your favorite foods when you are
    nauseated. This could cause you to be "turned
    off" by them later.

52
Nausea Vomiting (cont.)
  • Eat salty foods, avoid very sweet foods
  • Eat dry foods such as toast, crackers or dry
    cereals right from the box. This is especially
    good to do soon after waking up in the morning
  • Plain, simple foods are best to eat now. Try
    these soups, puddings and custards, ice cream,
    rice, macaroni, noodles, toast, yogurt,
    soft-cooked eggs, cream of wheat farina, oatmeal,
    bananas, canned fruit, mashed potatoes, crackers,
    cottage cheese and fruit, eggs

53
Nausea Vomiting (cont.)
  • Stay away from fried and greasy foods. Use only
    small amounts of margarine, butter, cream or oil
    in your food.
  • Do not drink liquids at the same time that you
    eat your meals. Drink them 30 - 60 minutes before
    or after eating.
  • Sometimes just the smell of food can make you
    feel sick. Open the windows for some fresh air.
    Avoid making foods that will produce a strong
    smell in your home, like brewing coffee, frying
    meats or fish, or cooking spaghetti sauce or
    chili.
  • Some medicines cause nausea. If possible, take
    them at a time of day when nausea will not
    interfere with meals.
  • Do not lie down flat for at least 2 hours after
    eating. If you wish to rest, sit down. If you
    must lay down after eating, prop your head up at
    least 4 inches higher than your feet.

54
Diarrhea
  • Infections, medicines and emotional stress can
    all cause diarrhea. It can make you feel weak and
    become dehydrated.
  • Replace fluids lost to your body in the diarrhea.
    Drink a lot of liquids--8 or more glasses per
    day.
  • Replace the potassium lost to your body in
    diarrhea. If you do not have enough potassium you
    can feel very weak. These foods are high in
    potassium bananas, potatoes, melons, dried
    Fruit, juice
  • Some foods can actually help stop the diarrhea.
    It would be good for you to eat plain white rice,
    cream of wheat or farina cereal, toasted white
    bread, plain macaroni or noodles, boiled eggs,
    oatmeal, ice cream, jello, applesauce, bananas,
    canned fruit, mashed potatoes, yogurt, and plain
    crackers.

55
Diarrhea (cont.)
  • Don't skip meals, even though you don't feel like
    eating. Eat small amounts of food every couple of
    hours.
  • Stay away from fatty, greasy foods and fried
    foods.
  • Stay away from spicy foods.
  • Avoid foods with a lot of crunchy fiber. They can
    irritate your intestines. Do not eat raw fruits
    or raw vegetables or the skins or seeds of any
    fruit or vegetable. Do not eat corn. Do not eat
    whole wheat breads. Do not eat nuts.
  • If you have cramps, stay away from foods that can
    cause gas. Do not eat dried beans, canned beans,
    cabbage, broccoli, cauliflower, carbonated
    drinks, or beer. No chewing gum.

56
Fluids
  • Here are some hints about getting the fluids you
    need
  • Drink at least 2 liters/day (water, broth,
    bouillon, fruit juice, punch, ginger ale or 7-up)
  • Carbonated drinks may cause cramps (stirring it
    in a glass or remove the top from the bottle
    let it sit for a couple of hours will reduce
    bubbles)
  • Sugar free beverages may cause headaches or
    diarrhea. If calorie intake compromised you could
    use the use the sugar in drinks for energy

57
Fluids (cont.)
  • Avoid beverages that contain caffeine-causes
    dehydration. Some beverages that contain caffeine
    are colas and other carbonated drinks, coffee,
    tea, cocoa, and hot chocolate.
  • Avoid beverages that contain alcohol-cause
    dehydration.
  • Sip your beverages-using a straw might be
    helpful.
  • Many people can take liquids best when they are
    at room temperature.
  • Suck on ice cubes and Popsicles, or eat jello or
    sherbet.
  • You can freeze your favorite beverage in ice cube
    trays to make your own Popsicles.

58
Mouth Problems
  • Your doctor can treat most of your HIV-related
    mouth and eye problems. Sometimes you may also
    need to see a special dentist or an eye doctor.
  • Visit a dentist at least twice a year or more
    often if mouth problems develop.
  • Your mouth and throat are some of the most
    sensitive areas of your body. An HIV infection
    can allow sores to develop there. These sores can
    make it hurt to chew or swallow and that makes it
    hard to eat.

59
Mouth Problems (cont.)
  • Eat soft foods that are smooth in texture. Try
    mashed potatoes, yogurt, pudding, custards,
    oatmeal, cream of wheat, ice cream, applesauce,
    mashed banana, cream soups (cream of mushroom,
    cream of chicken, cheddar cheese).
  • Put your food in a blender to make it smooth.
  • Try baby food.
  • Use a straw or drink your food from a cup instead
    of using a spoon.
  • Try tilting your head forward or back to make
    swallowing easier.

60
Mouth Problems (cont.)
  • If you are able to handle some lumps, try
    scrambled eggs, cottage cheese, macaroni and
    cheese, baked fish, tuna salad, and canned
    fruits. Most stews, casseroles and hearty soups
    would be soft enough to eat, too.
  • Moisten your food to help it slide down. Cut
    meats up in small pieces and add gravy to them.
  • Soak dry foods in milk, coffee or other warm
    beverage before eating. This works well with
    toast, crackers, and cookies.
  • Do not eat spicy foods.

61
Mouth Problems (cont.)
  • Try cooked vegetables and soft fruits like
    bananas or canned pears
  • Avoid acidic fruits ( oranges grapefruit,
    tomatoes or their juice)
  • Avoid very hot foods and beverages. If really
    cold foods feel good, try adding ice to milk and
    other beverages to make them extra cold. Try
    eating a lot of ice cream, sherbet or Popsicles
    to numb some of the pain.
  • Rinse your mouth whenever you feel you need it.
    This can moisten your mouth, remove bits of food,
    and give it a fresher taste.

62
Dry Mouth
  • Here are some ideas for moistening a dry mouth
    and a list of foods that are easy to swallow
  • Drink mild beverages such as apple juice or punch
    throughout the day.
  • Suck on hard candy, especially sour candy. This
    will help keep your mouth wet.
  • Talk to your dentist or doctor. They can
    prescribe artificial saliva drops for you.

63
Dry Mouth (cont.)
  • Avoid dry foods like crackers, toast or cookies.
    You may also try soaking them in milk or other
    liquids before eating.
  • Add gravy, creamy sauces or juice to your foods
    to moisten before eating.
  • Enjoy soups, casseroles and stews, oatmeal or
    other soft cereals, yogurt, pudding, applesauce
    and similar moist foods. They are all easy to
    swallow.

64
Taste Changes
  • Marinate meat, chicken or fish in sweet fruit
    juices, sweet wines, beer, Italian dressing, soy
    sauce or sweet and sour sauce for better taste.
  • Meat, chicken, fish, tofu or beans may taste
    better cold.
  • Add herbs and spices try basil, oregano or
    garlic
  • Add lemon juice, lime juice or vinegar to food to
    enhance flavor.

65
Taste Changes (cont.)
  • Sip liquids or try hard candy to get a better
    taste in your mouth.
  • Use a mouth wash and brush your teeth at least 2
    times daily with a soft toothbrush.
  • Eat a tart Granny Smith apple wedge or suck on
    lemon wedges just before meals. This can help to
    stimulate saliva and help you overcome the
    metallic taste.

66
Fatigue
  • Fix simple snacks, rather than meals, for
    yourself.
  • Let family or friends cook or bring you food.
    Don't be embarrassed to ask for their help.
    People like doing things for others.
  • Try take-out restaurants. Hamburgers, pizza,
    Mexican food, chicken and Chinese food can all be
    obtained this way. Some of them are quite low in
    cost.

67
Fatigue (cont.)
  • Call a home food delivery service. Many large
    towns and cities have these. Look in the phone
    book for "Meals on Wheels." Call your county
    health department or local AIDS service
    organization for more information.
  • If you are going to spend the day in bed, put
    some favorite foods and drinks in a cooler with
    ice beside you. Then you can get your rest but
    not be without food. A food warmer or crock pot
    could be used in the same way to keep hot foods
    hot at your bedside.

68
Fatigue (cont.)
  • Eat canned foods. Try creamed soups, spaghetti,
    chili, chow- mein and other things. If you eat a
    piece of fruit for dessert and drink a glass of
    milk or juice, you've got a balanced meal.
  • Eat frozen foods. Frozen dinners, pizza, egg
    rolls, macaroni and cheese, fried chicken and
    fish. Just pop them in the oven, and set a timer.
    Drink a glass of milk or juice, add a piece of
    toast or fruit.
  • Cook extra food and freeze it in little plastic
    containers. You'll be grateful to have these to
    heat up on days that you are tired.
  • Make as few dirty dishes as possible. Use paper
    cups and dishes, cook in the foil pans that
    frozen food comes in.

69
Food Safety Guidelines
  • Wash all fresh fruits and vegetables thoroughly.
    Use a vegetable brush designed for this purpose.
  • Throw away any fruit or vegetable which has a
    rotten or moldy spot on it.
  • Don't let hot foods cool down at room
    temperature. Put them in the refrigerator right
    away. If it is a large amount of food, put it in
    2 or 3 containers so the refrigerator can cool it
    all quickly.
  • Keep your refrigerator cold. You might wish to
    get a refrigerator thermometer. Keep it set no
    higher than 40 degrees. Your freezer should be at
    0 degrees.
  • Don't taste anything that you think might be
    spoiled. If in doubt, throw it out.

70
Sanitation
  • Use hot, sudsy water to wash your dishes. Let it
    out of the sink when it gets dirty and replace it
    with new. Any food germs left on your plate can
    make you sick the next time you eat from it.
  • Keep everything clean. Clean your counters often
    and clean them well. Wash your hands with soap
    and water a lot during cooking.
  • If you have old dishes, cups or plastic
    containers with a lot of scratches in them, throw
    t hem out. Germs love to hide in scratches and
    they are very difficult to clean out of there.
  • Wear rubber gloves when handling raw meat. This
    will prevent germs from entering any open cuts or
    sores on your hands.

71
Handling Animal Products
  • Cook meat thoroughly. You might want to buy a
    meat thermometer to help you know for sure that
    it is done. Put the thermometer in the thickest
    part of the meat and not touching a bone. Cook
    the meat till it reaches 165 to 212 degrees on
    your thermometer.
  • Thaw frozen meats and other frozen foods In the
    refrigerator or in a microwave oven set to
    defrost. Never thaw foods at room temperature.
    Germs that grow at room temperature can make you
    very sick.
  • Use different cutting boards for raw foods and
    cooked foods.
  • Throw away moldy cheese. It is not good enough to
    just cut off the moldy part.

72
Safe Food Shopping
  • Diary Products should be pasteurized
  • Avoid Sell by" or "best used by" date that has
    passed.
  • Put packaged meat, poultry or fish into plastic
    bag before placing it in the shopping cart
  • After shopping, get chilled and frozen foods into
    refrigerator or freezer as soon as possible.
  • Storing food for 2 hours in warm temperatures
    allow bacteria to grow.
  • Sale of food products with damaged packaging, the
    unsafe displaying of products (such as cooked
    shrimp on the same bed of ice as raw seafood),
    workers with poor personal hygiene, and
    unsanitary store conditions can add to the risk
    of food-borne illness

73
Rules for Eating Eggs
  • Pasteurized eggs should be used in place of shell
    eggs when making homemade ice cream, eggnog and
    mayonnaise.
  • Don't eat raw eggs. If you wish to add a an egg
    to a milkshake or make egg nog, use a frozen
    product called "Eggbeaters" instead.
  • Don't use cracked eggs. Look for cracks in the
    shells before you buy them.

74
Rules for Eating Eggs (cont.)
  • COOKING INSTRUCTIONS
  • Scrambled-1 minute at medium stove top setting
    (250 deg F for electric frying pans).
  • Sunnyside-7 minutes at medium setting (250 deg F)
    or cook covered 4 minutes at 250 deg F.
  • Fried, over easy-3 minutes at medium setting (250
    deg F) on one side, then turn and fry for another
    minute on the other side.
  • Poached-5 minutes in boiling water.
  • Boiled-7 minutes in boiling water.

75
Eating Out
  • Always order food well-done if it served medium
    to rare, send it back.
  • Order fried eggs cooked on both sides instead of
    sunny side up, and avoid scrambled eggs that look
    runny.
  • Caesar salad should also be avoided since it
    contains raw eggs.
  • Raw seafood (sushi) poses a serious risk of food
    poisoning for persons with AIDS.
  • Raw shellfish, like raw meat and poultry, should
    be assumed to harbor harmful bacteria.
  • Oysters on the half shell, raw clams, sushi and
    sashimi should not be eaten. Lightly steamed
    seafood, such as mussels and snails, should be
    avoided.

76
Traveling Abroad
  • Boil all water before drinking. Drink only
    beverages made with boiled water or canned or
    carbonated bottled drinks. Ice, too, should be
    made only from boiled water.
  • Avoid uncooked vegetables and salads. All fruit
    should be peeled. Eat cooked foods while they are
    still hot.
  • A good rule of thumb is "Boil it, cook it, peel
    it, or forget it."

77
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.
  • Exercise, including working out with weights, and
    swimming, 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.

78
Ritonavir (Norvir)
  • To lessen stomach upset and improve absorption ,
    Take on a full stomach, preferably a meal high in
    fat (e.g. lean red meat, peanut butter, avocado,
    cheese, bread with butter, whole or 2 milk
    products).
  • Each capsule should be taken separately with a
    good drink of milk or spoonful of yogurt.
  • Take every 12 hours.
  • What not to do
  • Don't miss a dose or take less than prescribed.
    If you miss a dose, take the next dose at the
    regular time scheduled. Do not double dose.
  • Limit/avoid alcohol. It can severely damage your
    liver.

79
Disguising the Taste of the Liquid
  • Disguise taste by mixing dose with chocolate
    milk, frozen juice concentrate, jam, Hershey
    chocolate syrup or take with 1 tsp. of peanut
    butter.
  • Taste tests show that very sweet foods can help
    with the after taste such as Nutella hazelnut
    spread on graham crackers or an oats and honey
    granola bar.
  • Also try drinking liquid solution with a straw
    placed at the back of the throat, bypassing the
    taste buds.
  • You can also numb the taste buds by sucking on a
    frozen Popsicle before and after dose.

80
Storing Norvir
  • Store capsules in the refrigerator between 36-46
    degrees F.
  • You can keep your daily dose at room temperature
    for up to 12 hours.
  • Keep away from light.
  • Storing Liquid Solution
  • Refrigeration is not required for solution kept
    below 77 degrees F and used within 30 days.

81
Indinavir (Crixivan)
  • Crixivan should be taken on an empty stomach or a
    low-protein, low-fat meal -300 calories, 5 grams
    protein and 2 grams fat.
  • Take every 8 hours exactly- one hour before a
    meal or two hours after a meal. (For example
    finish eating lunch by 12 noon, take Crixivan at
    2 PM, then have a light snack at 3 PM).
  • Drink at least 1 cup (8 ounces) of water or juice
    (not grapefruit) with each dose.
  • Drink at least a total of 10 cups total of water
    and/or juice every day to avoid kidney stones.
  • What not to do
  • Don't miss a dose or take less than prescribed.
    Do not double dose.
  • Don't take Crixivan with a big meal which
    contains fat and protein
  • Do not take Crixivan with grapefruit juice or a
    grapefruit. Other juices have no affect.

82
Saquinavir (Fortovase )
  • Take every 12 hours when taken along with
    Ritonavir.
  • Take within 2 hours of a high fat meal or snack
    (Taking it with high fat foods lets your body
    absorb 5 to 10 times more. )
  • Take your dose with at least 20 grams of fat
    (read labels).
  • What not to do
  • Don't take Saquinavir on an empty stomach. Don't
    take it with a meal low in fat and calories.
    Don't miss a dose or take less than prescribed.
    If you miss a dose, take next dose at the
    regular time scheduled. Do not double dose.

83
Nelfinavir Mesylate (Viracept )
  • Take 3 times a day. Space out with the meals you
    eat.
  • Be sure to wait at least 4 hours between doses
    and no longer than 12 hours between doses. Be
    sure that your evening dose and morning dose are
    not more than 12 hours apart.
  • Take Nelfinavir with food which contains at least
    500 calories. No specific foods help increase or
    decrease absorption.
  • What not to do
  • It's not recommended to take Nelfinavir on an
    empty stomach since you may get more severe side
    effects.

84
Side Effects- Protease Inhibitors
  • Nephrolithiasis (kidney stones, indicated by pain
    in the sides, blood in urine) occurred in 4 - 10
    of people in clinical studies.
  • Drinking those 6 extra large glasses of water
    throughout the day can help prevent
    nephrolithiasis.
  • Less common side effects include nausea,
    abdominal pain, headache, weakness/fatigue,
    diarrhea, taste changes and back pain.

85
Side Effects- Protease Inhibitors
  • Nausea, diarrhea, vomiting, stomach pain, taste
    change, fatigue, mild to severe skin sensitivity
    and numbness around the mouth.
  • Of all the protease inhibitors, Norvir is most
    likely to cause liver function problems and raise
    blood lipid (fat) levels.
  • Taking protease inhibitors such as Norvir also
    has been associated with fat deposits on the back
    (buffalo hump) and around the waist as well as
    breast enlargement.
  • Liver function tests should be monitored
    regularly.

86
Possible Causes Of Insulin Resistance
  • Testosterone deficiency
  • Some medications ( Protease Inhibitors)
  • Family history/genetics
  • Obesity/overweight
  • Depleted glutathione which can affect insulin
    sensitivity.

87
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.
  • Consume high fiber foods in the form of whole
    grains (whole wheat bread, brown rice, bran
    cereals 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.

88
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.
  • Reduce saturated fat intake.
  • 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.

89
Complementary Approaches For Improving Insulin
Sensitivity
  • Regular resistance (weight-bearing) exercise.
  • Testosterone replacement, when needed, will also
    promote muscle building.
  • A high-potency multiple vitamin and mineral
    formula.
  • Extra amounts of glutathione-boosting nutrients
    alpha-lipoic acid (600-1,200 mg daily),
    N-acetyl-cysteine (NAC) (1,500-3,000 mg daily),
    vitamin C (2,000-6,000 mg daily), vitamin E
    (1,200 IU daily), and glutamine (5-10 grams
    daily, increased to 30-40 grams in those with
    severe muscle loss) all taken in three divided
    doses.

90
Complementary Approaches For Improving Insulin
Sensitivity (cont.)
  • Chromium 200-300 mcg, taken three times daily.
  • L-carnitine in doses of 3000-6000 mg per day.
  • Magnesium (500-1,000 mg daily) for carbohydrate
    metabolism.
  • Fish oil in soft gel form to increase insulin
    sensitivity and reduce triglyceride levels.
  • Milk thistle standardized for 80 silymarin has
    powerful effects as an antioxidant, a protector
    of the liver, and an agent that may help improve
    insulin sensitivity

91
St Johns Wort
  • May significantly decrease blood concentrations
    of all of the currently marketed HIV protease
    inhibitors (PIs) and possibly other drugs (to
    varying degrees) that are similarly metabolized,
    including the non nucleoside reverse
    transcriptase inhibitors (NNRTIs).
  • Concomitant use of St Johns Wort with PIs or
    NNRTIs is not recommended because this may result
    in suboptimal antiretroviral drug concentrations,
    leading to loss of virologic response and
    development of resistance or class
    cross-resistance.

92
Case Study Questions
  • Weight gain from Protease Inhibitors?
  • Using herbal Fat Burners to lose weight?
  • 20 weight loss in 2 months?
  • Drinking soda to meet fluid needs?

93
Q 1 Patient on crixivan for about 4 months -
gained about 35 lbs. When will I see a decrease
in my weight?
  • Now that protease-inhibitors are not the only
    cause of lipodystrophy, other drugs or just
    treating HIV may be the cause of body changes.
  • Decrease your calories, exercise aerobically, and
    have your doctor check your testosterone.
  • Include resistant type exercise to increase
    muscle mass which will enhance metabolism
  • By including exercise- this allows you to
    increase caloric expenditure without decreasing
    the intake of high nutrient foods

94
Q 2 Xenadrine Cholesterol Weight loss
  • CONTAINS THE FOLLOWING
  • Pantothenic acid - 40mg, bitter orange -85mg
  • Ma huang - 335 mg, Guarana extract - 910mg
  • White willow bark extract - 105mg, Ginger root -
    50mg
  • Tyrosine, actyl l-carnitine, , magnesium
    phosphate, DMAE, calcium
  • Most of these multi-ingredient products have
    multiple claims attached but little or no
    research to back up the claims.
  • All fat burners contain ephedrine derivative
    which can accelerate your heart rate, depress
    appetite, and contain diuretic herbs to increase
    urine output
  • They also contain large amounts of caffeine which
    can cause diarrhea and dehydration

95
Q 3 Patient lost 20 within 2 months
  • Lost strength in his body
  • Roommate prepared high calorie, protein shake to
    give him that extra nutrition and protein boost
  • Ingredients were soy protein, nutritional yeast,
    wheat germ, soy lecithin, bee pollen, yogurt and
    fruits.
  • It is high in calories, vitamins, and replenishes
    his friendly bacteria.
  • Estimated that the shake is about 75 protein.
  • Consumes this only once a day along with fresh
    fruits and veggies.
  • He's only been taking the protein shake for about
    2 weeks but I've seen dramatic results with his
    weight gain.
  • 1 cup plain yogurt, 2 scoops soy protein, 2 tbs
    bee pollen, 2tbs soy lecithin, 1tbs nutritional
    yeast, 1tbs wheat germ, 1 banana, handful of any
    berries.

96
Nutritional Concerns
  • In my view, the specific ingredients are not as
    important as the general effect more calories,
    more protein, and more micronutrients.
  • Patient needs to be encouraged to eat real food
  • Important not to rely on one source, like a
    shake, too much. He may develop taste fatigue of
    it, or you may go on vacation patient needs to
    have more variety
  • Plus, no single shake can provide everything that
    a person needs. So he should keep trying to find
    ways to maintain his food intake.
  • Also suggest weigh your roommate on a regular
    basis (same time of day, same scale, same
    clothing state), if this is feasible, to document
    how well the plan is working

97
Q 4 Soda Vs. Water?
  • Lots of calories (weight gain), worse
    triglycerides, tooth decay, less quenching of
    thirst due to the concentrated sugar, increase in
    BG if insulin resistant, added caffeine and
    dehydration.
  • Diet soda is a different story. There is little
    difference from water, physiologically. If it has
    caffeine in it, this is a potential issue. Some
    artificial sweeteners can cause headaches or
    loose stools.
  • Try flavored seltzer, lemon/lime/orange slices in
    water, slivers of ginger in water, herbal teas (
    iced or hot ).
  • Try Splenda (sucrolose)- this is going to be on
    the market 2001 is found in RC cola and some
    other products

98
Case Study - Conference
  • At a recent HIV/AIDS conference that I attended,
    a doctor described the miraculous recovery of one
    of his patients who had come back from severe
    wasting and TB and was healthy enough to begin
    fighting her HIV successfully. He talked about
    her medication schedule in detail, but failed to
    mention nutrition.
  • During the question-and-answer period that
    followed his presentation, I asked him about this
    patient's nutrition support. He apologized for
    his oversight and repeated to the audience an
    expression he had been told by one of his
    patients at his clinic in Haiti
  • "Taking medicine without eating properly is like
    washing your hands and drying them in the dirt."
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