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Nutrition and HIV/AIDS

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[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


1
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,
    NY
  • 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,
    NY

2
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

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.

4
Multicausation Model of Malnutrition
5
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

6
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
    intake.6

7
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//www.ers.usda.gov/Publications/err108/err108
    .pdf

8
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

9
Appetite/Hunger Suppression
  • Febrile response to opportunistic or secondary
    infection, oropharyngeal or esophageal lesions,
    depression, or substance use may lead to
    decreased food intake.

10
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.

11
Malabsorption
  • 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.

12
Key Point
  • Diarrheal disease should be viewed as
    undernutrition with fluid and electrolyte loss.

13
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
    medications.11-13

14
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
    cholesterol
  • 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

15
Metabolic abnormalities associated with some
antiretroviral medications
  • Elevations in serum LDL cholesterol or
    triglycerides (some protease inhibitors)
  • Renal excretion of phosphorus and/or glucose
    (tenofovir)
  • Insulin resistance (protease inhibitor class
    effect)

16
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

17
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

18
Key Point
  • Patients who are not obese or overweight should
    maintain a constant body weight throughout
    adulthood.

19
Referral for Nutritional Services
20
  • Recommendation The following should prompt
    referral to a New York State certified
    nutritionist/registered dietitian for evaluation
    and patient-specific nutrition care plan
    (AIII)16
  • 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
    disease
  • Two or more medical comorbidities
  • Annual or comprehensive visits
  • Abdominal adiposity

21
Key Point
  • Patients presenting with nutritional disorders
    may show involuntary weight loss, be over weight,
    and have increased dietary indiscretion.

22
Comprehensive Nutrition Consultation
23
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

24
  • 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
    effects
  • Social history including supplement use
  • Family history
  • Energy, protein, and micronutrient requirements
  • Intervention as needed with routine follow-up

25
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

26
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.

27
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.

28
Key Points
  • Food Stamp electronic benefits transfer (EBT)
    cards may be used at New York City farmers or
    greenmarkets.
  • 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.

29
  • Recommendations (AIII)
  • NYC clinics should post the locations of
    greenmarkets participating in the Food Stamp
    (EBT) program in waiting rooms (available at
    grownyc.org).
  • Adult patients should be referred to NYS
    certified nutritionist/registered dietitian for
    evaluation and education to achieve sodium intake
    reduction (to IOM recommendation).

30
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).

31
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
    paramount.
  • 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.

32
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.

33
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).

34
  • 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
    loss

35
  • 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
    patients).
  • In profoundly wasted patients peri-orbital
    edema, ascities, and scrotal edema.

36
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
    assay.
  • 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.

37
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.

38
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
    disability.21,22

39
Key Point
  • Muscle function in addition to body mass should
    be evaluated in middle-aged and older patients.

40
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

41
  • 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
    infection.

42
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

43
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.

44
Key Point
  • Herbal products are nonstandardized
    pharmaceuticals that may interact with
    antiretroviral medications and/or lead to
    toxicity.

45
Social History
  • Recommendation evaluate for the following
    (AIII)
  • Tobacco use, alcohol use, other substance use
  • Scheduled routine resistance and aerobic exercise
    program

46
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

47
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

48
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
    findings.

49
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).

50
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

51
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.

52
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.

53
Key Point
  • Persons with HIV infection continue to
    demonstrate elevation of basal metabolic rate in
    spite of cART, immune restoration and viral
    suppression.28

54
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

55
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

56
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
    diet.36-37

57
The Mediterranean diet is characterized by
  • High intake of dark green leafy and other
    vegetables
  • 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

58
Key Point
  • Adherence to a Mediterranean diet may
    significantly reduce cardiovascular disease
    events and incidence of type 2 diabetes
    mellitus.36
  • 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.

59
Clinical Intervention Multivitamin
Supplementation
  • Recommendation A daily multivitamin with
    minerals meeting the recommended daily allowances
    is prudent.

60
Key Point
  • Tolerable upper intake levels of micronutrients
    for people with HIV infection have not been
    established.

61
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).

62
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

63
Key Point
  • In addition to hypertension, high sodium intake
    may contribute to loss of bone mineral density.40

64
Clinical Intervention Testosterone Replacement
Therapy
  • 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).

65
Key Point
  • Testosterone replacement therapy in men may
    improve nutritional parameters in soft and hard
    tissue, and lipid panel.26,41

66
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
    documented.

67
Key Point
  • Differentiate between prolonged absence of hunger
    feelings and chronic mild nausea in patients
    complaining of loss of appetite.

68
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.

69
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.

70
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.

71
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
    bowel.42

72
References
  • 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
    http//www.cdc.gov/mmwr/preview/mmwrhtml/mm5937a2.
    htm
  • 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
    http//www.cdc.gov/hiv/topics/surveillance/resourc
    es/other/poverty.htm
  • 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
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  • Further Reading
  • Morley JE, Argiles JM, Evans WJ, et al.
    Nutritional recommendations for the management of
    sarcopenia. J Am Med Dir Assoc 201011391-396.
    PubMed
  • Mallon PWG. HIV and bone mineral density. Curr
    Opin Infect Dis 2010231-8. PubMed
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