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HIV Nutrition Essentials For Program and Administrative Grantees. Marcy Fenton, M.S., R.D. Program Manager, Care Services Division County of Los Angeles Department of Public Health Office of AIDS Programs and Policy August 29, 2006. SPA 1: Antelope Valley. SPA 2: San Fernando. SPA 3:

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hiv nutrition essentials for program and administrative grantees

HIV Nutrition Essentials For Program and Administrative Grantees

Marcy Fenton, M.S., R.D.

Program Manager, Care Services Division

County of Los Angeles

Department of Public Health

Office of AIDS Programs and Policy

August 29, 2006

los angeles county

SPA 1: Antelope Valley

SPA 2:

San Fernando

SPA 3:

San Gabriel

SPA 4:


SPA 5:


SPA 7:


SPA 6: South

SPA 8:

South Bay

Los Angeles County
  • Square Miles: 4,086
  • Population: 9.9 Million
  • Latino/a 45.7% White 31.0%Asian/PI 13.2%African-American 9.7%Native American 0.3%
  • Proportion of California Population: 29%
  • Proportion of California AIDS Cases: 35%
  • Living with HIV/AIDS:
  • 58,000 (Estimated)


hiv nutrition essentials
HIV Nutrition Essentials
  • Overview
    • Current nutrition issues and treatments
    • Medical nutrition therapy (MNT) program necessary ingredients
    • Lessons learned monitoring Los Angeles County medical outpatient services’ MNT programs
hiv nutrition essentials4
HIV Nutrition Essentials
  • Handout Materials
    • Presentation slides
    • Guides and resources
      • Diet, nutrition, fact sheets
      • Professional competency
    • Weight & nutrition
    • HIV nutrition screen & referral forms
      • ADA 2005
      • Nutrition quick screen

Request copies of handouts:

hiv nutrition essentials5
HIV Nutrition Essentials
  • Current HIV Nutrition Issues
hiv mnt
  • Overall Goals
    • Optimize nutrition status, immunity and quality of life
    • Prevent nutrient deficiencies
    • Achieve and maintain optimal body weight and composition
    • Manage co-morbidities
    • Maximize effectiveness of medications
vicious cycle of malnutrition and hiv

Poor Nutrition

resulting in weight loss, muscle wasting, weakness, nutrient deficiencies

Impaired immune system

Poor ability to fight HIV and other infections, Increased oxidative stress

Increased Nutritional needs,

Reduced food intake and increased loss of nutrients


Increased vulnerability to infections e.g. Enteric infections, flu, TB hence Increased HIV replication, Hastened disease progression Increased morbidity

Vicious Cycle of Malnutrition and HIV

Source: Fanta Project Adapted from RCQHC and FANTA 2003

hiv nutrition issues
HIV Nutrition Issues
  • Poor Immune Function
    • Food and water safety, sanitation
    • Optimized nutrient and fluid intake
    • Vitamin mineral supplementation
    • Exercise: aerobic and progressive resistance training
    • Medication adherence
    • Stress reduction
    • Establishment of trusting relationships
nutrition issues and treatments
Common Side Effects

GI distress






Taste alterations

Mouth pain



Insulin resistance


Liver toxicity

Renal impairment



Peripheral neuropathy


Nutrition Issues and Treatments
causes of weight loss
Causes of Weight Loss
  • 1-Inadequate Intake
    • Oral and upper gastrointestinal
    • Anorexia
    • Psychosocial-economic
    • Malabsorption

Source: Mangili A et al. CID 2006:42 (15 March) p 836-42

causes of weight loss11
Causes of Weight Loss
  • 2-Altered Metabolism
    • Uncontrolled HIV infection
    • Metabolic demands of HAART
    • Opportunistic infections or malignancies (AIDS-defining conditions)
    • Hormonal deficiencies (testosterone or thyroid)
    • Cytokine dysregulation

Source: Mangili A et al. CID 2006:42 (15 March) p 836-42

resting energy expenditure
Resting Energy Expenditure

Grunfeld et al. AJCN 1992;55:455-60.

hiv wasting
HIV Wasting
  • Definitions
    • CDC
    • Nutrition for Healthy Living (Tufts)
    • Grinspoon, Mulligan & DHHS Working Group
    • Polsky, Kotler & Steinhart
calories needed and weight change
Calories Needed and Weight Change
  • Relation to Viral Load
    • Not on HAART
      • 0.92 kg body weight decrease per each HIV RNA log10 increase
      • 22 Kcal increase in REE per increase in per 1-log copy/ml
    • Stable HAART
      • 0.35 kg body weight decrease per each 100-cell/mm3 CD4 cell decrease
      • 81 kcal higher REE

Source: Wanke et al. CID 2006:42 (15 March)

outcomes of weight loss
Outcomes of Weight Loss
  • Morbidity and mortality independent of CD4 and viral load
  • Weight loss of >5% associated with increase risk of mortality even with ART
  • Adverse pregnancy outcomes
  • Weight loss & wasting continue to be common problems
international nutrition
International Nutrition
  • Feeding Safely and Adequately
    • Access to nutritious food
    • Access to safe water
    • Malnutrition
      • Linked with HIV infection
      • Linked with poor prognosis
      • Linked with poor prognosis despite ART
    • Breast feeding
    • Access to HIV medications
overweight obesity and hiv
Overweight, Obesity and HIV

Sources: (1) Amorosa et al. JAIDS 2005;Aug15;39(5):557-61.

(2) NHANES 1999-2000; 7/03

weight classification using bmi
Weight Classification Using BMI

(1) National Heart, Lung and Blood Institute, (2) Magili et al. CID 2006 March, (3) Amorosa; Grinspoon, Mulligan & DHHS Working Group 2003 April-S CID

conditions associated with obesity
BMI: HIV vs. General PopulationsConditions Associated with Obesity




Mood Disorders

Heart Disease


Sleep Disorders


Non-Insulin Dependent DM

Eating Disorders


Some Cancers

Gall Bladder

Contemporary Diagnosis and Management of Obesity. Geroge A. Bray, MD

desirable girth measurements
Waist circumference

Men: <40 inches

Women: <35 inches

NHANES methodology

Waist to Hip Ratio?

Less accurate

Not recommended

Hip circumference ok

Monitor waist & hip from baseline

Desirable Girth Measurements
overweight obesity hiv
Overweight, Obesity & HIV
  • Fuel of Metabolic Abnormalities
    • BMI positive correlation with
      • Total cholesterol
      • Triglycerides
      • Glucose
    • Obesity not correlated with
      • Age, income, employment, education
      • Past/current IVD use
      • HIV treatment, viral load

Source: Amorosa et al. JAIDS 2005;Aug15;39(5):557-61.

treatment of obesity
Treatment of Obesity
  • Therapeutic Lifestyle Changes
    • Nutrition counseling
    • Dietary intake
      • Limit saturated fats
      • Increase fiber to 35 g/day
      • Portion control
      • Reduce excess carbohydrates and high sugar drinks
      • Plenty of fruits and vegetables
      • Small meals: maximum 5 hours apart
      • Eat slowly
treatment of obesity24
Treatment of Obesity
  • Therapeutic Lifestyle Changes
    • Physical activity
      • Walking or other exercise
        • 30-60 minutes/day
      • Progressive resistance training
hiv and diabetes mellitus
HIV and Diabetes Mellitus
  • An Increasing HIV Nutrition Problem
    • HIV-positive men who are taking highly active antiretroviral therapy (HAART) are more than four times more likely to develop diabetes than HIV-negative men.
    • HIV-positive women taking protease inhibitors are three times more likely to develop diabetes than HIV-positive women on non-protease inhibitor combinations or HIV-negative women
  • Sources: Brown TT et al. Antiretroviral therapy and the prevalence and incidence of diabetes mellitus in the Multicenter AIDS Cohort Study. Arch Intern Med 165: 1179-1184, 2005.
  • Justman JE et al. Protease inhibitor use and the incidence of diabetes mellitus in a large cohort of HIV-infected women. Journal of Acquired Immune Deficiency Syndromes, 32: 298 – 302, 2003
diabetes major risk factors
General Population

Overweight, obesity

Especially VAT

Parent or sibling


Alaska Native, American Indian, African American, Latino American, Asian America


Exercise <3x/wk

History of impaired glucose tolerance or impaired fasting glucose


Cardio-vascular disease

Polycystic ovarian syndrome

Diabetes Major Risk Factors
diabetes additional risk factors
Diabetes Additional Risk Factors
  • HIV Population
    • Medications leading to insulin resistance
      • HAART
      • Steroids, growth hormone, others
    • HCV co-infection
    • Morphological changes
      • Lipodystrophy: > visceral adipose tissue
    • Physical inactivity
      • Neuropathy, fatigue avascular necrosis, wasting, etc.
heart disease prevalence
Heart Disease Prevalence
  • General Population
    • Leading cause of death in the U.S.
      • Women: 51% of heart disease deaths
      • Men: 340,933 died from heart disease in 2002
    • 57 million Americans live with CVD
      • 8.9% all white men
      • 7.4% black men
      • 5.6% Mexican American men
  • 1. National Center for Health Statistics. Health, United States, 2005 with Chartbook on Trends in the Health of Americans. Hyatsville, MD: 2005.
  • 2. American Heart Association. Heart Disease and Stroke Statistics—2005 Update. Dallas, Texas: American Heart Association, 2005.
heart disease major risk factors
General Population

Increasing age


Heredity, family history of premature heart disease


High blood pressure

Tobacco use

Hyper- or dyslipidemia

Especially high LDL & low HDL


Metabolic syndrome

Physical inactivity

Poor nutrition

An atherogenic diet

Heart Disease Major Risk Factors

Source: Preventing chronic diseases: Investing wisely in health preventing heart disease and stroke. July 2005. CDC. February 6, 2006.

heart disease risk factors
Heart Disease Risk Factors
  • HIV Population
    • Inflammation due to HIV
    • Lipid abnormalities due to HAART
    • Other drug effects:
      • Insulin resistance
      • Morphological changes
      • Metabolic syndrome
heart disease
Heart Disease
  • Prevention & Treatment
    • Therapeutic Lifestyle Change (TLC)
      • Diet
      • Physical exercise
    • Management of concomitant diseases
      • Diabetes, hypertension, obesity, etc.
    • Smoking cessation
    • Stress reduction
liver disease
Liver Disease
  • Fueled by Overweight & Obesity
    • Waist>hip, insulin resistance & diabetes
      • Predicts advanced forms of chronic hepatitis C
      • Complicates nonalcoholic steatohepatitis (NASH)
    • Fitness inversely related
    • Tx: Healthy diet, exercise, weight loss

Sources: Charlton MR et al. Hepatology June 2006;46(6)1177-1186;

Church TS et al. Gastroenterology. 2006 Jun; 130(7):2023-2030.

renal disease and hiv
Renal Disease and HIV
  • A Growing Nutrition Problem
    • Dialysis
      • HIV: 1.5%, AIDS: 0.4%
      • Dialysis centers treating PLWH/A
        • 1985: 11%
        • 2000: 37%
      • Number initiated since 1995: stable
    • Abnormal kidney function
      • 30% PLWH/A
    • HIV and CKD nutrition guidelines
      • Not set yet
      • Individualize
hiv nutrition essentials34
HIV Nutrition Essentials
  • Medical Nutrition Therapy (MNT)
  • Program Necessary Ingredients
continuum of care
Continuum of Care

County of Los Angeles. Continuum of Care, Office of AIDS Programs and Policy.

hiv registered dietitian
HIV Registered Dietitian
  • Standards of Professional Practice
    • Provides quality service based on client expectations and needs
    • Effectively applies, participates in or generates research to enhance practice
    • Effectively applies knowledge and communicates with others
hiv registered dietitian37
HIV Registered Dietitian
  • Standards of Professional Practice
    • Uses resources effectively and efficiently in practice
    • Systematically evaluates the quality and effectiveness of practice and revises practice as needed to incorporate the results of evaluation
    • Engages in lifelong self-development to improve knowledge and enhance professional competence
hiv registered dietitian38
HIV Registered Dietitian
  • Care Responsibility
    • Create screening tools for medical providers to identify clients at risk
    • Monitor nutrition-related abnormal laboratory values
    • Assess clients regularly, consistently
    • Ensure adequate nutrient & caloric intake
hiv registered dietitian39
HIV Registered Dietitian
  • Care Responsibility
    • With medical team, identify and correct causes of cachexia, weight loss/gain, other nutrition problems and barriers
    • Refer to providers and other disciplines
    • Communicate: document, speak, share
    • Participate in team case conferences
    • Promote continuity of care





& Referral



Identify risk factors


Use appropriate tools

and methods





Nutrition Diagnosis


Identify and label problem

Nutrition Assessment


Determine cause/contributing risk


Obtain/collect timely and





Cluster signs and symptoms/


Analyze/interpret with

defining characteristics



based standards







Nutrition Intervention




Plan nutrition intervention



Formulate goals and

determine a plan of action

Implement the nutrition intervention



Care is delivered and actions

Nutrition Monitoring and


are carried out






Monitor progress


Measure outcome indicators


Evaluate outcomes




Management Sys



Monitor the success of the Nutrition Care

Process implementation


Evaluate the impact with aggregate data


Identify and analyze causes of less than

optimal performance and outcomes


Refine the use of the Nutrition Care


screening and referral
Screening and Referral
  • Screen for Referral Criteria
    • New/re-entry into care, MNT >6 months
    • Medical diagnosis, nutrition status change
    • Physical changes, weight concerns
    • Oral, GI symptoms
    • Metabolic, other medical conditions
    • Barriers to nutrition, living environment, functional status
    • Behavioral concerns, unusual behaviors

Source: ADA MNT Evidence Based Guides for Practice, March 2005

screening and referral42
Screening and Referral
  • Referral Documentation
    • Physician’s order for MNT
    • Signature and date of physician or authorized person to refer for MNT
    • Medical diagnoses and information
    • Current labs and measurements
    • Consent to release medical information
    • Proof of residency, income, diagnosis
  • Source: ADA MNT Evidence Based Guides for Practice, March 2005
nutrition care process
Nutrition Care Process
    • Nutrition Assessment
    • Nutrition Diagnosis
    • Nutrition Intervention
    • Nutrition Monitoring
    • Nutrition Evaluation
    • Documentation: clear and explicit
nutrition care process44
Nutrition Care Process
  • Nutrition Assessment
    • Reason for referral
    • Assess data (ABCD)
      • Anthropometric
      • Biochemistry
      • Clinical
      • Dietary
    • Client input
nutrition care process45
Nutrition Care Process
  • Nutrition Diagnosis
    • Problem
      • Diagnostic label
      • Intake, clinical, or behavioral/environmental
    • Etiology
      • Cause or contributing risk factors
    • Signs/Symptoms
      • Defining characteristics
    • PES statement
nutrition care process46
Nutrition Care Process
  • Nutrition Diagnosis PES Statement
    • (P) Increased nutrient needs (E) as related to inadequate intake of foods and malabsorption due to AIDS enteropathy (S) as evidenced by 25 pound weight loss in 6 months and now 91% IBW
nutrition care process47
Nutrition Care Process
  • Nutrition Intervention
    • Interventions
      • Food and/or Nutrient Delivery
      • Nutrition Education
      • Nutrition Counseling
      • Coordination of Nutrition Care
    • Receptivity and adherence potential
    • Plan and follow-up date
nutrition care process48
Nutrition Care Process
  • Nutrition Monitoring
    • Review and measure status of intervention at scheduled time
    • Track outcomes with tools
      • ADA HIV MNT Protocol Progress Note
      • Weight and nutrition flow sheet
      • Electronic health record data fields
        • Format
        • Terminology: diagnosis, interventions, etc
      • Other tools
nutrition care process49
Nutrition Care Process
  • Nutrition Evaluation
    • Systematic comparisons
    • Reference standards
    • Evaluate changes
      • Signs and symptoms
      • Previous status and intervention goals
      • Progress toward goal
hiv mnt tools
  • Basics
    • HIV MNT Protocols (ADA,1998)
      • Adult (18 years-adult)
      • Children (under 18 years)
    • Health Care and HIV: Nutritional Guide for Providers and Clients (HRSA/HAB, 2002)
    • Integrating Nutrition into Medical Management of HIV, (CID-S April 1 2003)
    • Nutrition intervention in the care of persons with human immunodeficiency virus. (ADA & Dietitians of Canada Joint Position, 2004)
hiv mnt tools51
  • New: ADA Evidence Analysis Library

Systematic review of scientific research

      • Select topic and expert working group
      • Define questions, analytical framework, inclusion and exclusion criteria
      • Conduct literature review per question
      • Analyze articles
      • Complete evidence summaries and tables
      • Draft proposed conclusion statements
      • Reach consensus on conclusion statements and grades (strength and quality of the evidence)
      • Publish to online library (EAL)
hiv mnt tools52
  • New: ADA EAL Current Projects
    • Diseases and conditions
      • Adult weight management
      • Determinants of pediatric overweight
      • Chronic kidney disease (revision)
      • Chronic obstructive pulmonary disease
      • Critical illness
      • Disorders of lipid metabolism (hyperlipidemia revision)
hiv mnt tools53
  • New: ADA EAL Current Projects
    • Diseases and conditions (cont.)
      • Gestational diabetes
      • Gluten intolerance/Celiac
      • Heart failure
      • HIV/AIDS
      • Hydration
      • Hypertension
hiv mnt tools54
  • New: ADA EAL Current Projects
    • Diseases and conditions (cont.)
      • Nutrition in athletic performance
      • Nutrition care in bariatric surgery
      • Oncology
      • Pediatric weight management
      • Spinal cord injury & nutrition
      • Unintended weight loss
hiv mnt tools55
  • New: ADA EAL Current Projects
    • Assessment
      • Estimating energy expenditure
    • Foods
      • Non-nutritive sweetener
hiv mnt tools56
  • Emerging: HIV Nutrition Evidence Analysis
    • Questions
      • What are the caloric needs of people with HIV/AIDS?
      • What is the evidence to support a particular macronutrient composition of a diet for people with HIV/AIDS? 
    • Focus
      • Both children and adults
      • People with HIV/AIDS
      • Past 10 years of research
hiv mnt tools57
  • New and Emerging
    • Nutrition Care Manual
      • Web based
      • UsesADA Evidence Analysis Library
    • Evidence-based MNT protocols
    • Evidence-based guidelines
    • ADA position papers
  • MNT, Supplements
    • Medicare
    • Medicaid
    • Managed Care
    • HMOs, Kaiser Permanente
    • RWCA
personal professional competence
Personal Professional Competence
  • Dietetics Professionals’ Ethical Obligation
    • Code of Ethics for the Profession of Dietetics,(6)
    • Standards of Professional Practice,(7)
      • Guided by the nutrition care process
    • Professional Development Portfolio(8)
      • 75 credits every five years
ryan white care act and mnt
Ryan White CARE Act and MNT
  • Current Status
    • MNT by RD
      • Defined by HRSA guidance
      • Required in Title III services
      • RWCA reauthorization
        • Expected after Labor Day 2006
        • ADA and others working to get MNT as core medical service
    • AIDS Education Training
      • HIV nutrition training for providers
current procedural terminology
Current Procedural Terminology
  • MNT CPT Codes
    • 97802
        • Initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes
    • 97803
        • Re-assessment and intervention, individual, fact-to-face with the patient, each 15 minutes
    • 97804
        • Group (2 or more individuals), each 30 minutes
hiv nutrition essentials62
HIV Nutrition Essentials
  • Lessons Learned Monitoring
  • Los Angeles County
  • Medical Outpatient Services’
  • MNT Programs
monitoring hiv mnt services
Monitoring HIV MNT Services
  • MNT Program Evaluation Items
    • Screening for nutrition related problems
    • Referral for baseline MNT (06-07)
    • Appropriate referral for MNT
    • MNT provided by an RD
    • MNT documentation (05-06)
    • Outcome: maintain or 5% towards goal weight after 3 months of care (07-08)
    • RD qualifications
monitoring mnt programs
Monitoring MNT Programs
  • Yr 14 2004-2005
  • Yr 15 2005-2006
  • Clients (>1 visit)
  • 16,143
  • 16,487
  • Sites (of 37)
  • 36
  • 36
  • Charts Reviewed
  • (average, range)
  • 154
  • (4.3, 2-8)
  • 244
  • (6.8, 4-10)
  • Screened
  • 2 (.1, 0-1)
  • 29 (.8, 0-10)
  • Referral to MNT
  • 38 (1, 0-4)
  • 77 (2.1, 0-8)
  • MNT Provided
  • 32 (.9, 0-5)
  • 66 (1.8, 0-6)
  • MNT Quality
  • n/a
  • 62
changing practices and attitudes
Changing Practices and Attitudes
  • Establishing the Framework for MNT
    • Wheels of change move slowly
    • Develop infrastructure
      • Standards of care, guidelines, contracts
      • Indicators, monitoring tools, reports
    • MNT services: disparity in clinics
      • Providers, program managers, funding
      • Awareness, interpretation and abilities
      • Expectations, goal setting, reporting, access
changing practices and attitudes67
Changing Practices and Attitudes
  • Technical Assistance: Providers and RDs
    • Provider meetings, calls, emails
    • Provider and staff presentations
    • At each year’s program monitoring
      • Different and evolving TA focus
      • Always provide materials
          • Ex: HRSA Nutrition Manual CD, screening & referral forms, articles, standards of care, BMI chart, nutrition & weight flow chart
changing practices and attitudes68
Changing Practices and Attitudes
  • Technical Assistance: RDS
    • Dietitians in AIDS Care (DIAC)
      • DIAC listserve
      • Quarterly meetings since April 2005
        • Networking – long-lasting relationships
        • Training and problem solving
          • Nutrition care process
          • When to provide/discontinue: nutritional supplements, food / meal services
          • Hyperlipidemia, insulin resistance, renal disease
personal growth
Personal Growth
  • Lessons Learned
    • More medical records reviewed
    • Monitoring tools - streamlined andtally / comments sheets
    • Increase time spent monitoring
    • Evaluation report of MNT programs
      • Establish ongoing database
      • Baseline knowledge of programs
screening for nutrition problems
Screening for Nutrition Problems
  • Lessons Learned
    • Newton’s laws of motion
    • Providers’ resistance
      • Problems? Don’t look and you won’t find
      • Screening vs. referring
      • Defining “at risk”
    • Make it easy to look, think, document
    • Simple questions work
height and weight measurements
Height and Weight Measurements
  • Lessons Learned
    • Routine measurements needed
      • Height not always measured
      • Weight usually measured
      • Accuracy questionable on both
        • Who measures? How trained? Shoes?
        • Calibration of scales? Stadiometer?
    • Monitoring weight
      • Adding/subtracting usually not done
      • BMI not usually done
      • Graphing not done
reducing barriers to mnt
Reducing Barriers to MNT
  • Lessons Learned
    • Reducing broken appointments
      • Set appointments with client
      • Coordinate with primary care visit
      • Reminders and follow-up calls and letters
        • Document in medical record
    • Support MNT in clinic
      • Include, discuss and referral from start
      • Incentives and rewards for MNT visit
      • Ask/respond to client request for MNT
needed proactive healthy clinic
Needed: Proactive Healthy Clinic
  • Lessons Learned
    • Take responsibility and power
    • Educate & support staff: promote:
      • Nutrition and health knowledge
      • Clients’ food, nutrient and safety needs
    • Change the menu and food/ water safety practices for client and non-client events
      • Meetings, parties, fund raisers, vending machines, vouchers, board meetings, holidays, etc.
hiv nutrition essentials74
HIV Nutrition Essentials
  • What has been your experience?
  • What has worked well?
  • What has been a challenge?
Arcy Martinez RD

AltaMed Health Services Corporation

Audra Gustafson RD

Northeast Valley Health Corporation

Tammy Darke MS RD

St Mary Medical CARE Program

Jill Strejc MS RD SRD


Caren Ongjoco RD CNSD

Los Angeles County Harbor-UCLA Medical Center

Jan B King MD MPH

OAPP Medical Director

for additional information

For Additional Information

Marcy Fenton, M.S., R.D.

Program Manager, Care Services Division

Office of AIDS Programs and Policy

600 South Commonwealth Avenue 2nd Floor

Los Angeles, California 90005-4001

Phone: 213/351-8368

Fax: 213/738-6566


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