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Nutrition and HIV/AIDS


[PubMed] Further Reading Morley JE, Argiles JM, Evans WJ, et al. Nutritional recommendations for the management of sarcopenia. J Am Med Dir Assoc 2010;11:391-396. – PowerPoint PPT presentation

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Title: Nutrition and HIV/AIDS

Nutrition and HIV/AIDS
New York State Department of Health AIDS Institute
  • Peter Wasserman, RD, MA
  • Metabolic Support, Infectious Disease Division,
    Department of Medicine, New York Hospital Queens,
    Flushing, NY
  • Sorana Segal-Maurer, MD
  • Attending Physician, Infectious Disease Division,
    Department of Medicine, New York Hospital Queens,
    Flushing, NY
  • Associate Professor of Clinical Medicine, Weill
    Medical College of Cornell University, New York,
  • David S. Rubin, MD
  • Medical Director, AIDS Designated Center,
    Attending Physician, Infectious Disease Division,
    Department of Medicine, New York Hospital Queens,
    Flushing, NY
  • Clinical Assistant Professor of Medicine, Weill
    Medical College of Cornell University, New York,

The Implications of HIV on Nutrition
  • In New York State over 35 of persons living with
    HIV infection are over 50 years old and 38 are
    between the ages of 40 and 49 years old. Seventy
    percent of persons living with HIV/AIDS are men
    and 57 of new cases occur in men who have sex
    with men.1 This demographic has broad
    implications for the nutritional care of persons
    with HIV infection.
  • Wasting disease was the prominent nutritional
    issue in patient management prior to the advent
    of antiretroviral therapy (ART). Although wasting
    disease still occurs, HIV infection has become a
    chronic disease for most patients.
  • Increasingly, newly diagnosed persons with
    HIV/AIDS live in urban poverty areas and
    experience food and housing insecurity, as well
    as limited access to fresh food stuffs.2,3

Key Point
  • Comorbidities including cardiovascular disease,
    osteopenia/osteoporosis, and sarcopenia are now
    predominant in HIV infection, have a significant
    dietary component, and are associated with aging.

Multicausation Model of Malnutrition
Manifestations of Malnutrition
  • Malnutrition may manifest as overnutrition,
    undernutrition, or single nutrient deficiency. It
    can occur in association with
  • Food insecurity
  • Poor-quality, calorie-dense diet
  • Loss of perception of hunger or appetite
  • Malabsorption
  • Altered metabolism
  • Sedentary lifestyle

Food Insecurity
  • Recommendation Advise patients of organizations
    in their area offering congregate meals, home
    meal delivery, and/or food pantries. (AIII)
  • Food insecurity is defined as limited or
    uncertain availability of nutritionally adequate,
    safe foods or the inability to acquire personally
    acceptable foods in socially acceptable ways.4
  • Food insecurity may exist with or without hunger
    and may contribute to wasting or obesity.5
  • Association with obesity, while counterintuitive,
    is likely due to reliance on inexpensive
    calorie-dense convenience foods, fast food or
    take-out food, and sugar-sweetened beverage

Key Point
  • The United States Department Agriculture food
    security questionnaire (six-question short-form)
    may be used to assess household food security.7
    The questionnaire is available at
  • http//

Poor-Quality, Calorie-Dense Diet
  • Recommendation Ascertain where patients shop for
    food and ingredients used in meal preparation and
    counsel as needed. (AIII)
  • Dietary intake high in refined white flour,
    polished (white or yellow) rice, sugar,
    sugar-sweetened beverages, saturated and
    polyunsaturated fat, and salt is strongly
    associated with hyperlipidemia and insulin
    resistance in HIV-infected persons.8-10
  • Patient diet is likely associated with the large
    interindividual variability in lipid response to
    specific antiretrovirals.8

Appetite/Hunger Suppression
  • Febrile response to opportunistic or secondary
    infection, oropharyngeal or esophageal lesions,
    depression, or substance use may lead to
    decreased food intake.

Key Point
  • Decreased food intake may be a direct result of
    disease processes, loss of structure in daily
    life, and/or how a patient feels about living
    with HIV infection.

  • Opportunistic or secondary infection, as well as
    neoplastic disease, of the bowel may lead to
    nutrient malabsorption.
  • Patients with diarrheal disease or painful
    lesions of the alimentary track may reduce food
    intake to avoid urgent or painful bowel movements.

Key Point
  • Diarrheal disease should be viewed as
    undernutrition with fluid and electrolyte loss.

Altered Metabolism
  • Metabolic abnormalities may alter nutrient
    utilization, storage, or excretion from the body.
  • Abnormalities may be due to HIV infection itself
    or may be associated with specific antiretroviral

Metabolic abnormalities documented in association
with HIV infection
  • Elevated resting energy expenditure/basal
    metabolic rate
  • Increased dietary protein requirement
  • Decreased total and HDL cholesterol
  • Increased serum triglycerides and VLDL
  • Low free testosterone (bioactive fraction) in
    association with wasting syndrome
  • Growth hormone resistance in association with
    wasting syndrome
  • Decreased visceral/abdominal and subcutaneous
    adipose tissue
  • Decreased bone mineral density

Metabolic abnormalities associated with some
antiretroviral medications
  • Elevations in serum LDL cholesterol or
    triglycerides (some protease inhibitors)
  • Renal excretion of phosphorus and/or glucose
  • Insulin resistance (protease inhibitor class

Sedentary Lifestyle
  • Recommendation Routinely counsel patients to
    engage in regularly scheduled resistance and
    aerobic exercise (AI).9,15
  • Lack of routine scheduled resistance and aerobic
    exercise may lead to abdominal adiposity,
    sarcopenia, or diminished bone mineral density.
  • Weight gain in middle age is associated with
    excess risk of type 2 diabetes mellitus and
    cardiovascular disease events.16

Centers for Disease Control and Prevention
exercise recommendations for adults are
  • 150 minutes/week moderate intensity aerobic
    exercise and 2 sessions/week of resistance
    exercise working all major muscle groups
  • or
  • 75 minutes/week vigorous aerobic exercise and 2
    sessions /week resistance exercise
  • or
  • Equivalent mix of moderate and vigorous aerobic
    exercise and 2 sessions/week resistance exercise

Key Point
  • Patients who are not obese or overweight should
    maintain a constant body weight throughout

Referral for Nutritional Services
  • Recommendation The following should prompt
    referral to a New York State certified
    nutritionist/registered dietitian for evaluation
    and patient-specific nutrition care plan
  • Entry into HIV care
  • Unintentional weight loss gt10 over 4 to 6 months
  • Chronic nausea, diarrhea, or vomiting
  • Severely dysfunctional psychosocial situation
  • Hyperglycemia
  • Dyslipidemia
  • New diagnosis of diabetes, hypertension, or renal
  • Two or more medical comorbidities
  • Annual or comprehensive visits
  • Abdominal adiposity

Key Point
  • Patients presenting with nutritional disorders
    may show involuntary weight loss, be over weight,
    and have increased dietary indiscretion.

Comprehensive Nutrition Consultation
Nutrition care consists of
  • Assessment and intervention (including education
    in nutrition and the disease state)
  • Dietary counseling and self-management training
  • Pharmacological intervention
  • Food support or tube feeding or intravenous
    alimentation and routine follow up/reassessment

  • Recommendation nutrition consultation should
    include the following (AIII)
  • Patient complaints
  • Dietary evaluation
  • Demographics and clinical history
  • Clinical and anthropometric parameters
  • Functional tests as needed
  • Review of laboratory results
  • Review of medications focused on potential side
  • Social history including supplement use
  • Family history
  • Energy, protein, and micronutrient requirements
  • Intervention as needed with routine follow-up

Investigation of Patient Complaints
  • Recommendation evaluate for (AIII)
  • Depression in patients complaining of loss of
    appetite or hyperphagia
  • Recent weight loss and period of time over which
    it occurred
  • Mistaken beliefs about nutrition, e.g., eating
    high fat foods will replace subcutaneous fat loss
    due to prior antiretroviral regimens with
    adipocyte /mitochondrial toxicity
  • Alimentary tract disease in those complaining of
    odynophagia or diarrhea
  • Access to cooking and refrigeration facilities
  • Ability to shop for ingredients and prepare meals

Dietary Assessment
  • Recommendation Evaluation of dietary intake
    should include who prepares meals, where and with
    whom they are consumed, meal frequency, meal
    completion, quality and source of ingredients,
    cooking method and portion sizes.

Nutritional Intake
  • Evaluate intake of concentrated protein (fish,
    poultry, meat, egg white), vegetables, whole
    grains and tubers, fruit, and sugar-sweetened
    beverages including juices or juicing.
  • Sugar-sweetened beverage intake should be
    discouraged due to linkage with diabetes,
    cardiovascular disease, diabetes and obesity.18
  • Evaluate for patient use of processed/convenience
    foods especially prepared meats and canned goods
    due to their high sodium content.
  • Portion size models, e.g., 3 oz size or ½ cup
    size, are helpful in ascertaining usual portion
    size during the clinical encounter.
  • Use of fresh seasonal foods, locally grown when
    possible or frozen, and prepared at home should
    be strongly encouraged.

Key Points
  • Food Stamp electronic benefits transfer (EBT)
    cards may be used at New York City farmers or
  • Dietary sodium intake is largely from hidden
    sodium added during food processing, restaurant,
    fast food, and takeout meals.
  • Institute of Medicine (IOM) guidelines now
    recommend that most adults limit sodium intake to
    1500 mg per day.

  • Recommendations (AIII)
  • NYC clinics should post the locations of
    greenmarkets participating in the Food Stamp
    (EBT) program in waiting rooms (available at
  • Adult patients should be referred to NYS
    certified nutritionist/registered dietitian for
    evaluation and education to achieve sodium intake
    reduction (to IOM recommendation).

Demographics and Clinical History
  • Recommendation National Institutes for Health
    and World Health Organization assessment
    instruments should used to determine need for
    intervention and goals (AIII).

Demographics and Clinical History
  • Nutritional interventions and their intensity
    should be based on assessment of potential
    benefit to the patient and the degree of disease
    event risk associated with the target
    abnormality. The patients willingness to execute
    dietary and other health behavior change is
  • National Cholesterol Education Program Adult
    Treatment Panel III (NCEP/ATPIII) should be used
    in evaluation.
  • WHO Fracture risk assessment tool (FRAX) should
    be used where clinically appropriate (men gt50 y
    and postmenopausal women).
  • Clinical history should including duration of HIV
    infection, nadir CD4 count, history of
    opportunistic infection, wasting, and
    antiretroviral treatment history.

Key Point Osteoporosis
  • Patients age and ethnicity (e.g., FRAX) may drive
    absolute osteoporosis risk. Historically,
    osteoporosis has been more prevalent in older
    Caucasian women and less so in African Americans.

Clinical and Anthropometric Assessment
  • Patients with HIV infection may present with
    wasting (involuntary loss of lean body mass and
    adipose tissue), sarcopenia (age-related loss of
    skeletal muscle with preservation or increase in
    adipose tissue), or lipodystrophy (focal or
    global loss of subcutaneous adipose tissue with
    preservation of visceral adipose tissue and
    skeletal muscle).

  • Recommendation evaluate for (AIII)
  • Body mass index (BMI), weight in kilograms/height
    in meters squared (NIH guidelines
    undernutrition, lt18.5 normal, 18.5 to 29.9
    obese, gt30)
  • documented usual weight
  • Temporal wasting and facial lipoatrophy
  • Oral cavity for missing dentition, oral mucosal
    ulcers, (e.g., apthous or viral ulcers),
    malignancy (e.g., Kaposis sarcoma), fungal
    infections (e.g., oral candidiasis)
  • Neck circumference
  • Increase may associate with upper trunk adiposity
    and/or sleep apnea
  • Shoulders for angularity/prominent acromium
    process due to deltoid muscle loss
  • Trunk for increased clavicle prominence
    (subclavicular muscle loss)
  • Visible articulations of the ribs at the junction
    with the sternum consistent with subcutaneous fat

  • Recommendation (continued) evaluate for (AIII)
  • Waist and hip circumferences
  • ATP III abdominal obesity, male gt40 inches,
    female gt35 inches
  • Loss of hip circumference reflects
    gluteal-femoral subcutaneous fat loss and is
    associated with insulin resistance/type 2
    diabetes mellitus.
  • Mid-upper arm circumference (non-dominant arm)
  • Less than 10th percentile NHANES may be
    consistent with wasting or lipodystrophy. Delayed
    skin-fold return is suggestive of dehydration.
  • Prominence of extremity vasculature consistent
    with subcutaneous fat loss
  • Mass of the interosseus dorsalis muscle by having
    the patient press the tip of his forefinger and
    thumb together
  • Muscle mass at the insertion of the quadriceps
    femoris and the vastus medialis with the
    patients leg positioned at a right angle.
  • Lower extremity edema (sacral edema bed rest
  • In profoundly wasted patients peri-orbital
    edema, ascities, and scrotal edema.

Additional Anthropomorphic Tests
  • Bioelectrical impedance analysis (BIA) may be
    additive to physical examination. BIA indirectly
    measures tissue compartments, lean body mass
    (LBM), body cell mass (BCM), fat mass and
    extracellular (interstitial) mass (ECM).
    Phase-angle is a geometrical expression of the
    resistance and capacitance components of this
  • Phase angle lt5.6º and lt4.8º are associated with
    diminished and non-survival, respectively.19
  • ECM-to-BCM ratio of 1.3 or greater associated
    with non-survival.19
  • Serial BIA over time describes weight loss or
    gain over time by soft tissue compartment
    quantifying response to clinical intervention.

Key Point
  • Patients with skeletal muscle loss may not always
    demonstrate weight loss if concurrent
    compartmental shift occurs, e.g., expansion
    adipose tissue or extracellular fluid depots.

Functional Tests
  • There are concerns that long-term HIV infection
    may interfere with the normal aging process and
    accelerate it. Increased rates of cellular
    senescence may lead to loss of functional reserve
    over time. Several methods are available to
    evaluate for this.
  • Nutritional interventions such as protein,
    vitamin D, and calcium supplementation are
    first-line therapy for sarcopenia and osteopenia.
    Clinical investigators have documented decreased
    bone mineral density and increased non-traumatic
    fracture (fragility) risk in aging HIV-infected
    patients.20 Propensity to fall due to diminished
    hip, knee and ankle musculature often leads to
    fracture in older patients. Mid-life handgrip
    strength (Jamar Hand-grip dynamometer) and usual
    gait speed (timed walk) reflect total skeletal
    muscle and are predictive of future

Key Point
  • Muscle function in addition to body mass should
    be evaluated in middle-aged and older patients.

Laboratory Panels for Nutritional Aassessment
  • Recommendation Nutritional assessment should
    include evaluation of the following laboratory
    panels (AIII).
  • Complete metabolic panel
  • Lipid panel
  • Testosterone panel (men)
  • 25-OH vitamin D
  • Complete blood count

  • Recommendation Evaluate complete blood count for
    findings consistent with vitamin and/or mineral
    deficiency. Clinicians should be mindful of the
    bone marrow suppressive effect of HIV infection
    itself and elevated ferritin, an acute phase
    reactant, during opportunistic or secondary

Key Points
  • Patients with wasting and/or diarrheal disease
    may demonstrate profound hypophosphatemia,
    hypokalemia, and low magnesium. Hospitalized
    patients should receive intravenous replacement,
    as needed.
  • Return to health effect during the first two
    years of cART may manifest in elevation of total
    and LDL cholesterol in association with return to
    pre-illness diet. HDL cholesterol frequently
    remains low in spite of immune reconstitution
    with antiretroviral therapy.11
  • HIV-infected men with wasting frequently
    demonstrate low free testosterone (hypogonadism).
    Repletion of skeletal muscle may be blunted in
    the absence of replacement therapy.23
  • Low testosterone in older men in the general
    population has been linked to cardiovascular
    disease risk, sarcopenia, and insulin resistance.
  • Vitamin D deficiency is prevalent in HIV-infected
    patients in care.24

Medication and Supplement Review
  • Recommendation Nutrition consultation should
    include review of current medications, vitamins,
    and supplements (AIII).
  • Herbal products and some vitamins at high dosage
    may interact with antiretroviral medications,
    enhance viral replication or contain undeclared
    prescription ingredients or other chemicals.25
    Patients may disclose usage of what they consider
    to be dietary enhancements to their
    nutritionist/registered dietitian while
    neglecting to disclose them to their doctor
    during medication review.

Key Point
  • Herbal products are nonstandardized
    pharmaceuticals that may interact with
    antiretroviral medications and/or lead to

Social History
  • Recommendation evaluate for the following
  • Tobacco use, alcohol use, other substance use
  • Scheduled routine resistance and aerobic exercise

Key Points
  • Patients should be counseled to engage in
    scheduled resistance exercise (in addition to
    aerobic) to achieve optimal peak bone density,
    maintain skeletal muscle and lessen fall risk
    later in life.26
  • Education regarding diet and behavior, and bone
    mineral density should be provided to patients.26

Centers for Disease Control and Prevention
exercise recommendations for adults are
  • 150 minutes/week moderate intensity aerobic
    exercise and 2 sessions/week of resistance
    exercise working all major muscle groups
  • or
  • 75 minutes/week vigorous aerobic exercise and 2
    sessions /week resistance exercise
  • or
  • Equivalent mix of moderate and vigorous aerobic
    exercise and 2 sessions/week resistance exercise

Family History
  • Recommendation At least annually, update family
    history for cardiovascular disease, diabetes
    mellitus, end-stage kidney disease, and cancer(s)
    especially when occurring among first degree
    relatives (parents, siblings, offspring) (AIII).
  • Evolving health history of a patients siblings
    may inform evaluation of seemingly minor clinical

Macronutrient Requirements Caloric Requirement
  • Recommendations
  • Maintenance energy requirement (protein and
    non-protein calorie) should be calculated for
    persons who are hospitalized or in custodial care
    to insure provision of adequate nutrition (AIII).
  • Maintenance energy requirement should considered
    in determining planned caloric deficit for
    persons participating in programs of caloric
    restriction to achieve weight loss (AIII).

Caloric Requirement (continued)
  • Total energy expenditure (TEE) consists of basal
    metabolic rate (BMR) or measured resting energy
    expenditure (REE) by indirect calorimetry (after
    a 12h fast, in a thermoneutral environment, upon
    awakening and prior to ambulation), dietary
    thermogenesis (DT), the thermic effect of food
    intake and energy expenditure of voluntary
    activity (EEA). To maintain weight stability
    (maintenance energy requirement) a patients
    caloric intake should equal TEE.
  • Weight Stability TEE REE DT EEA

Caloric Requirement (continued)
  • The Harris-Benedict equation may be used to
    calculate REE in the absence of indirect
    calorimetry. Disease effect on REE may be
    estimated by an increase of 10 or 25, HIV
    infection or AIDS, respectively, DT 10 or 20,
    HIV or AIDS, respectively, and EEA 20-30
    depending on level of activity.27 This may be
    expressed as a factor for calculation of
    maintenance energy requirement. Maintenance
    energy requirement may range from 1.4 to 1.75
    times predicted BMR or measured REE.

Caloric Requirement (continued)
  • Convalescent patients demonstrating wasting may
    require additional energy (approximately 20) for
    anabolism. Emphasis should be on achieving this
    additional intake from food/additional meals.
    Nutrient dense ready-to-use supplementary foods
    may be of value where lesions or patient
    resources limit meal intake.

Key Point
  • Persons with HIV infection continue to
    demonstrate elevation of basal metabolic rate in
    spite of cART, immune restoration and viral

Macronutrient Requirements Protein Requirement
  • Recommendation Higher dietary protein intake
    should also be considered for older patients and
    those demonstrating sarcopenia, frailty or
    wasting (AII).
  • Asymptomatic HIV-infected persons demonstrate a
    higher rate of amino acid oxidation, consistent
    with a predisposition toward muscle protein
    loss.29 Clinicians should be mindful of this in
    conjunction with the early initiation of cART.
    During AIDS wasting muscle protein synthesis
    represents a decreased fraction of whole body
    protein synthesis.29

Protein Requirement (continued)
  • High-nitrogen feeding (amino acids 1.5 to
    1.8g/kg/body weight) significantly improves
    nitrogen balance in patients with wasting
    syndrome.30 Higher dietary protein intake should
    also be considered for older persons
    demonstrating sarcopenia or frailty.31

Clinical Intervention Mediterranean Diet
  • Recommendation Persons with HIV-infection should
    be advised to follow and receive instruction in
    the Mediterranean diet (AI).
  • A Mediterranean diet has demonstrated efficacy in
    primary and secondary prevention trials for
    cardiovascular disease and type 2 diabetes
    mellitus among HIV-negative individuals.32-35
    Persons with HIV infection receiving combination
    antiretroviral therapy demonstrated better
    metabolic parameters and lower risk for abdominal
    adiposity than those on a typical western

The Mediterranean diet is characterized by
  • High intake of dark green leafy and other
  • Fresh fruit as the typical daily desert
  • Use of whole grains for starches, beans, nuts,
    seeds, potato
  • Olive oil as the principal source of fat
  • Dairy products (principally cheese and yogurt)
  • Fish two or more times a week
  • Poultry consumed in moderate amounts
  • Egg yolks limited to four/week
  • Red meat consumed in low amounts
  • Wine consumed in low to moderate amounts,
    normally with meals
  • Low saturated fat (7-8 of energy), with total
    fat ranging from lt25 to gt35 of energy
    throughout the region

Key Point
  • Adherence to a Mediterranean diet may
    significantly reduce cardiovascular disease
    events and incidence of type 2 diabetes
  • Attention should be given to identifying
    foodstuffs with which the patient is culturally
    familiar that may be part of a Mediterranean diet
    and are within their financial capability (e.g.,
    collard greens, kale, and mustard greens).
  • Evaluation of diet and intervention as needed
    should be considered prior to antiretroviral
    regimen change due to abnormalities of
    nutritional-metabolism, e.g., dyslipidemia.

Clinical Intervention Multivitamin
  • Recommendation A daily multivitamin with
    minerals meeting the recommended daily allowances
    is prudent.

Key Point
  • Tolerable upper intake levels of micronutrients
    for people with HIV infection have not been

Clinical Intervention Vitamin D and Calcium
  • Recommendation Advise patients that adequate
    calcium intake and weight bearing (resistance)
    exercise are required along with vitamin D for
    maintenance of bone density (AIII).

Vitamin D and Calcium (continued)
  • Vitamin D insufficiency and deficiency are
    defined by serum 25-OH vitamin D and vitamin D
    supplementation should be prescribed as needed.
  • High intakes of animal protein and/or salt
    increase urinary calcium loss. Conversely low
    protein intake in older persons is associated
    with osteoporosis.38
  • The new Institute of Medicine daily adult
    reference intakes (DRI) for vitamin D is 600 IU/d
    for adult men and women (800 IU after age 70) and
    Calcium 1000mg/d for men and women (1200 mg for
    women after age 51).39

Key Point
  • In addition to hypertension, high sodium intake
    may contribute to loss of bone mineral density.40

Clinical Intervention Testosterone Replacement
  • Topical testosterone preparations Testim,
    Androgel, and Androderm may be used for
    replacement therapy in hypogonadal men.
  • Male hypogonadism is also associated with
    osteoporosis and several cardiovascular disease
    risk factors (e.g., increased total cholesterol,
    low density lipoprotein cholesterol, and
    increased arterial wall thickness).

Key Point
  • Testosterone replacement therapy in men may
    improve nutritional parameters in soft and hard
    tissue, and lipid panel.26,41

Clinical Intervention Orexigenic Agents
  • Profound loss of hunger sensation may be
    medically managed with Megestrol acetate Megace
    or Megace ES.
  • Megestrol acetate is a synthetic progesterone
    derivative and may lead to male hypogonadism,
    hyperglycemia and adrenal insufficiency. For
    these reasons treatment with megestrol acetate
    should be of short duration.
  • Presentations associated with chronic mild nausea
    may be medically managed with Dronabinol
    Marinol. Dose-related euphoria and somnolence in
    patients receiving dronabinol have been

Key Point
  • Differentiate between prolonged absence of hunger
    feelings and chronic mild nausea in patients
    complaining of loss of appetite.

Clinical Intervention Supraphysiological Growth
Hormone Administration
  • Patients with clinically significant dietary
    intake who present with profound wasting disease
    may be candidates for treatment with recombinant
    human growth hormone, Serostim.14
  • Candidates for recombinant human growth hormone
    should be screened for impaired glucose tolerance
    and diabetes mellitus.

Key Point
  • Recombinant human growth hormone may be
    appropriate for ambulatory outpatients with
    profound skeletal muscle loss who are free of
    clinically active opportunistic or secondary
    infection, and who are able to achieve clinically
    significant dietary intake.

Clinical Intervention Non-volitional Alimentation
  • Patients with panenteritis may be candidates for
    intravenous alimentation. Patients with
    neurological disease, oropharyngeal or esophageal
    lesions, partial small bowel disease, and those
    unable to achieve clinically significant
    volitional intake may be candidates for
    intragastric tube feeding.

Key Point
  • Intravenous alimentation may be considered for
    patients in whom clinically significant caloric
    intake can not be achieved due to impaired small
    intestine function or lack of access to the small

  • 1. Centers for Disease Control and Prevention.
    Prevalence and awareness of HIV infection among
    men who have sex with men 21 cities, United
    States, 2008. MMWR Morb Mortal Wkly Rep
    201059(37)1201-1207. Available at
  • 2. Normen L, Chan K, Braitstein P, et al. Food
    insecurity and hunger are prevalent among
    HIV-positive individuals in British Columbia,
    Canada. J Nutr 2005135820-825. PubMed
  • 3. Denning P, DiNenno E. Communities in crisis
    Is there a generalized HIV epidemic in
    impoverished urban areas of the United States?
    International Conference on AIDS, Vienna,
    Austria, July 2010. Poster available at
  • 4. United Nations Subcommittee on Nutrition
    Nutrition and HIV/AIDS Statement by the
    Administrative Committee on Coordination,
    Sub-committee on Nutrition. 28th Session.
    Nairobi, Kenya 2001.
  • 5. Adams EJ, Grummer-Strawn L, Chavez G. Food
    insecurity is associated with increased risk of
    obesity in California women. J Nutr
    20031331070-1074. PubMed
  • 6. Brownell KD, Farley T, Willett WC, et al. The
    public health and economic benefits of taxing
    sugar-sweetened beverages. NEJM
    20093611599-1605. PubMed
  • 7. Nord M, Coleman-Jensen A, Andrews M, et al.
    Household Food Security in the United States,
    2009. Economic Research Report Number 108. US
    Department of Agriculture 2009. Available at
  • 8. Hadigan C, Jeste S, Anderson EJ, et al.
    Modifiable dietary habits and their relation to
    metabolic abnormalities in men and women with
    human immunodeficiency virus infection and fat
    redistribution. Clin Infect Dis 200121710-717.
  • 9. Fitch KV, Anderson EJ, Hubbard JL, et al.
    Effects of a life style modification program in
    HIV-infected patients with the metabolic
    syndrome. AIDS 2006201843-1850 PubMed
  • 10. Joy T, Keogh HM, Hadigan C, et al. Dietary
    fat intake and relationship to serum lipid levels
    in HIV-infected patients with metabolic
    abnormalities in the HAART era. AIDS
    2007211591-1600 PubMed

References (continued)
  • 11. Grunfeld C. Dyslipidemia and its treatment in
    HIV infection. Top HIV Med 201018112-118.
  • 12. Anastos K, Dalian L, Shi Q, et al.
    Association of serum lipid levels with HIV
    serostaus, specific antiretroviral agents, and
    treatment regimens. J Acquir Immune Defic Syndr
    20074534-42. PubMed
  • 13. Bacchetti P, Gripshover B, Grunfeld C, et al.
    Fat distribution in men with HIV infection. From
    the Study of Fat Redistribution and Metabolic
    Change in HIV Infection (FRAM). J Acquir Immune
    Defic Syndr 200540121-131. PubMed
  • 14. Schambelan M, Mulligan K, Grunfeld C, et al.
    Recombinant human growth hormone in patients with
    HIV-associated wasting a randomized placebo
    controlled trial. Ann Intern Med
    1996125873-882. PubMed
  • 15. Dolan SE, Frontera W, Libbizzi J, et al.
    Effects of a supervised home-based aerobic and
    progressive resistance training regimen in women
    infected with human immunodeficiency virus a
    randomized trial. Arch Intern Med
    20061661225-1231. PubMed
  • 16. Colditz GA, Willett WC, Rotnitzky A, et al.
    Weight gain as a risk factor for clinical
    diabetes mellitus in women. Ann Intern Med
    1996122481-486. PubMed
  • 17. US Department of Health and Human Services,
    Health Resources and Services Administration,
    HIV/AIDS Bureau. Nutrition and HIV/AIDS.
    Providing HIV/AIDS care in a changing environment
    August 2004. HRSA Care Action. Rockville, MD
    HIV/AIDS Bureau, HRSA.
  • 18. Schultze MB, Manson JE, Ludwig DS, et al.
    Sugar-sweetened beverages, weight gain, and
    incidence of type 2 diabetes in young and
    middle-aged women. JAMA 2004292927-934.
  • 19. Ott M, Fischer H, Polat H, et al.
    Bioelectrical impedance analysis as a predictor
    of survival in patients with immunodeficiency
    virus infection. J Acquir Immuno Defic Syndr Hum
    Retrovirol 1995920-25. PubMed
  • 20. Arnsten JH, Freeman R, Howard AA, et al.
    Decreased bone mineral density and increased
    fracture risk in aging men with or at risk for
    HIV infection. AIDS 200721617-623. PubMed

References (continued)
  • 21. Rantanen T, Guralnik JM, Foley D, et al.
    Midlife hand-grip strength as a predictor of old
    age disability. JAMA 1999281558-560. PubMed
  • 22. Guralnik JM, Ferrucci L, Pieper CF, et al.
    Lower extremity function and subsequent
    disability Consistency across studies,
    predictive models, and value of gait speed alone
    compared to with the short physical performance
    battery. J Gerontol 200055AM221-M231. PubMed
  • 23. Rietschel P, Corcoran C, Stanley T, et al.
    Prevalence of hypogonadism among men with weight
    loss related to human immunodeficiency virus
    infection who were receiving highly active
    antiretroviral therapy. Clin Infect Dis
    200031240-1244. PubMed
  • 24. Wasserman P. Rubin DS. Highly prevalent
    vitamin D deficiency and insufficiency in an
    urban cohort of HIV-infected men under care. AIDS
    Patient Care STDS 201024223-227. PubMed
  • 25. Mills E, Montori V, Perri D, et al. Natural
    health product-HIV drug interactions a
    systematic review. Int J STD AIDS 200516181-186
  • 26. Rao SS, Budhwar N, Ashfaque A. Osteoporosis
    in men. Am Fam Physician 201082503-508 PubMed
  • 27. Grunfeld C, Pang M, Shimizu L, et al. Resting
    energy expenditure, caloric intake, and short
    term weight change in human immunodeficiency
    virus infection and the acquired immunodeficiency
    syndrome. Am J Clin Nutr 199255455-460.
  • 28. Fitch KV, Guggina LM, Keough HM, et al.
    Decreased respiratory quotient in relation to
    resting energy expenditure in HIV-infected and
    non-infected subjects. Metabolism
    200958608-615. PubMed
  • 29. Yarasheski K, Zachweija J, Gischler J, et al.
    Increased plasma Gln and Leu Ra and
    inappropriately low muscle protein synthesis rate
    in AIDS wasting. Am J Physiol 1998275(4 Pt
    1)E577-E583. PubMed
  • 30. Selberg O, Suttmann U, Melzer A, et al.
    Effect of increased protein intake and
    nutritional status on whole-body protein
    metabolism in AIDS patients with weight loss.
    Metabolism 1995441159-1165. PubMed

References (continued)
  • 31. Houston DK, Nicklas BJ, Ding J, et al.
    Dietary protein intake is associated with lean
    mass change in older, community dwelling adults
    the Health, Aging, Body Composition (Health ABC)
    Study. J Clin Nutr 200887150-155. PubMed
  • 32. de Longeril M, Salen P, Martin JL, et al.
    Mediterranean diet, traditional risk factors, and
    the rate of cardiovascular complications after
    myocardial infarction final report of the Lyon
    Diet Heart Study. Circulation. 199999779-785.
  • 33. Buckland G, González CA, Agudo A, et al.
    Adherence to the Mediterranean diet and risk of
    coronary heart disease in the Spanish EPIC Cohort
    Study. Am J Epidemiol 20091701518-1529.
  • 34. Esposito K, Marfella R, Citotola M, et al.
    Effect of a Mediterranean-style diet on
    endothelial dysfunction and markers of vascular
    inflammation in the metabolic syndrome a
    randomized trial. JAMA. 20042921440-1446.
  • 35. Martinez-Gonzalez MA, de la Fuente-Arrillaga
    C, Nunez-Cordoba JM, et al. Adherence to
    Mediterranean diet and risk of developing
    diabetes Prospective cohort study. BMJ.
    20083361348-1351. PubMed
  • 36. Tsiodras S, Poulia KA, Yannakoulia M, et al.
    Adherence to Mediterranean diet is favorably
    associated with metabolic parameters in
    HIV-positive patients with the highly active
    antiretroviral therapy-induced metabolic syndrome
    and lipodystrophy. Metabolism 200958854-859.
  • 37. Turcinov D, Stanley C, Rutherford GW, et al.
    Adherence to the Mediterranean diet is associated
    with a lower risk of body-shape changes in
    Croatian patients treated with combination
    antiretroviral therapy. Eur J Epidemiol
    200924267-274 PubMed

References (continued)
  • 38. World Health Organization and Food and
    Agriculture Organization of the United Nation.
    Joint FAO/WHO Expert Consultation on Human
    Vitamin and Mineral Requirement. Vitamin and
    Mineral Requirements in Human Nutrition, 2nd ed.
    2004. Available at http//
  • 39. Ross CA, Manson JE, Abrams SA, et al. The
    2011 report on dietary reference intakes for
    calcium and vitamin D from the Institute of
    Medicine What clinicians need to know. J Clin
    Endocrinol Metab 20119653-58. PubMed
  • 40. Lin PH, Ginty F, Appel LJ, et al. The DASH
    diet and sodium reduction improve markers of bone
    turnover and calcium metabolism in adults. J Nutr
    20031333130-3136. PubMed
  • 41. Traish AM, Saad F, Feely RJ, et al. The dark
    side of testosterone deficiency III.
    Cardiovascular disease. J Androl 200930477-494.
  • 42. Kotler DP, Fogelman L, Tierney AR. Comparison
    of total parenteral nutrition and oral
    semielemental diet upon body composition and
    quality of life in AIDS patients with
    malabsorption. J Parent Enteral Nutr
    199822120-126. PubMed
  • Further Reading
  • Morley JE, Argiles JM, Evans WJ, et al.
    Nutritional recommendations for the management of
    sarcopenia. J Am Med Dir Assoc 201011391-396.
  • Mallon PWG. HIV and bone mineral density. Curr
    Opin Infect Dis 2010231-8. PubMed