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HIV and Nutrition. Unit 16 HIV Care and ART: A Course for Physicians. Learning Objectives. Describe the effect of HIV/AIDS on nutrition Describe the impact of malnutrition on HIV infection in adults Identify the effect of micronutrient supplementation on HIV progression.

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hiv and nutrition

HIV and Nutrition

Unit 16

HIV Care and ART:

A Course for Physicians

learning objectives
Learning Objectives
  • Describe the effect of HIV/AIDS on nutrition
  • Describe the impact of malnutrition on HIV infection in adults
  • Identify the effect of micronutrient supplementation on HIV progression
learning objectives 2
Learning Objectives (2)
  • Review goals and components of nutrition care and support
  • Discuss nutrition recommendations for the symptoms associated with each stage of HIV disease
  • Provide information on how to manage nutrition-related symptoms of HIV
malnutrition and hiv
Malnutrition and HIV
  • Malnutrition and HIV are prevalent worldwide with the highest rates of both in sub-Saharan Africa
  • Malnutrition influences immune function, the virulence of infectious agents, progression of chronic infections such as HIV, and genetic factors that determine the outcome of sepsis
  • The association between HIV morbidity and malnutrition is bi-directional
    • Malnutrition affects HIV disease progression
    • HIV affects nutritional status
types of malnutrition protein energy malnutrition
Types of Malnutrition: Protein-Energy Malnutrition
  • Primary PEM caused by inadequate intake
  • Secondary PEM is the result of illness, injuries, or treatments causing altered appetite, digestion, absorption
  • Most common form of malnutrition in HIV disease
types of malnutrition protein energy malnutrition 2
Types of Malnutrition: Protein-Energy Malnutrition (2)
  • Used to describe nutritional macrodeficiency syndromes
    • Marasmus: deficiency of calories
    • Kwashiorkor: deficiency of protein
    • Nutritional dwarfism in children and wasting syndromes in adults
  • Measured as body size by weight or body mass index [weight (kg) divided by height in (meters)2 ]
    • < 16: severely malnourished
    • 16-16.9: moderately malnourished
    • 17-18.4: mildly malnourished
    • 18.5-24.9: normal nutritional status
types of malnutrition micronutrient nutrition
Types of Malnutrition: Micronutrient Nutrition
  • Alterations in the stores of fat- and water-soluble vitamins and trace elements
  • Clinical symptoms are subtle unless deficiency is severe
  • Often accompanies infectious diseases
  • Most common examples in children and adults:
    • Iron -> anemia
    • Vitamin A -> susceptibility to infection, associated with HIV-disease progression and increased mortality, increased maternal-fetal transmission
    • Iodine -> thyroid enlargement and hypothyroidism
effect of hiv aids on nutrition reduced intake
Effect of HIV/AIDS on Nutrition: Reduced Intake
  • HIV is associated with reduced intake of food/nutrients
    • Cognitive impairment and/or depression -> reduced motivation and ability to access and prepare foods
    • Family instability or poverty -> reduced access to food
    • HIV-, OI-, or medication-induced -> anorexia and nausea
    • OIs of mouth and esophagus -> painful swallowing
effect of hiv aids on nutrition reduced absorption
Effect of HIV/AIDS on Nutrition: Reduced Absorption
  • HIV is associated with reduced absorption of food/nutrients
    • Caused by HIV infection, OIs and ART
    • Mediated by diarrhea and damage to intestinal cells
    • Results in poor absorption of fats
      • Reduces absorption of fat-soluble vitamins, such as vitamins A and E
effect of hiv aids on nutrition altered metabolism
Effect of HIV/AIDS on Nutrition: Altered Metabolism
  • HIV is associated with altered metabolism of food/nutrients
    • HIV and OIs increase catabolism and energy needs by 10 – 15%
    • Adult man needs an additional 400 calories/day (from 2100->2500)
    • Protein requirements increase by 50%
      • Men: 57 -> 85 of protein grams/day
      • Women: 48 -> 72 grams/day.
effects of hiv on nutrition wasting
Effects of HIV on Nutrition: Wasting
  • Severe malnutrition in HIV-infected persons is recognized as “wasting”, defined as:
    • Body weight loss of > 10%
    • With associated fatigue, fever, and diarrhea unexplained by another cause
  • Etiology is multifactorial
  • Any weight loss of > 5% is associated with accelerated disease progression, impaired functional status, and increased mortality
  • “Wasting” is a WHO Stage 4 diagnosis and is a criterion for ARV initiation
the vicious cycle of malnutrition and hiv
The Vicious Cycle of Malnutrition and HIV
  • Insufficient dietary intake
  • Malabsorption, diarrhea
  • Altered metabolism and

nutrient storage

  • Increased HIV replication
  • Hastened disease

progression

  • Increased morbidity

Nutritional deficiencies

  • Increased oxidative stress
  • Immune suppression
malnutrition and hiv aids
Malnutrition and HIV/AIDS
  • Affect the body in similar ways
  • Affect the ability of the immune system to fight infection and keep the body healthy through:
    • Disrupts CD4 number / function
    • Disrupts CD8 number / function
    • Alters delayed type cutaneous hypersensitivity
    • Alters CD4 / CD8 ratio
    • Impairs antibody response
    • Impairs bacteria killing
malnutrition and hiv aids 2
Malnutrition and HIV/AIDS (2)
  • Low BMI is associated with disease progression and death
  • Nutrient deficiencies (vitamins A, B12, E, selenium, and zinc) are associated with worse outcomes
    • HIV transmission
    • Disease progression
    • Mortality
psychosocial factors for malnutrition
Psychosocial Factors for Malnutrition
  • Food scarcity
  • Financial constraints
  • Family disruption
  • Loss of financial breadwinner
  • Loss of primary caregiver due to illness or death
  • Mental health factors: depression
role of nutrition care and support
Role of Nutrition Care and Support
  • Clinical outcome of HIV is poorer in individuals with compromised nutrition
  • Improving nutrition can help prevent weight loss, strengthen the immune system, and delay HIV disease progression
  • Nutrition is part of comprehensive care along with OI management and ART therapy
goals of nutrition care and support
Goals of Nutrition Care and Support
  • Improve eating habits and diet to:
    • Maintain weight, prevent weight loss
    • Preserve muscle mass
    • Build stores of essential nutrients
goals of nutrition care and support 2
Goals of Nutrition Care and Support (2)
  • Prevent food-borne illnesses by promoting
    • Hygiene
    • Food and water safety
  • Manage symptoms affecting food intake by
    • Treating opportunistic infections
    • Treating pain
components of nutritional care and support
Components of Nutritional Care and Support
  • Nutrition assessment:
    • Weight, height, mid-arm circumference, BMI
    • Access to food
    • Symptoms that may impede intake, absorption
    • Other infections such as TB
  • Nutrition supplementation
    • Food
    • Vitamin and mineral supplements
  • Food and nutrition support for families
    • Food-for-work
    • Community kitchens
    • Home-based care
components of nutritional care and support 2
Components of Nutritional Care and Support (2)
  • Education and counseling
    • Adequate diet
    • Food handling and safety
    • Sanitation to avoid fecal-oral transmission
      • Water purification – boiling
      • Hand washing after defecation
  • Treat infections which will impact nutritional status such as tuberculosis
stages of hiv disease and nutrition
Stages of HIV Disease and Nutrition
  • Specific nutrition recommendations vary according to the underlying nutritional status and extent (stage) of HIV disease progression
  • The disease progression may be categorized into three stages:
    • Early: no symptoms, stable weight
    • Middle: significant weight loss
    • Late: symptomatic, full-blown AIDS disease
early stage
Early Stage
  • No symptoms, stable weight
  • Increased nutritional requirements during HIV-infection
    • Energy increase: 10 - 15%
    • Protein increase: ~ 50%
    • Vitamins and minerals used by the immune system are also increased
  • Main objective: remain as healthy as possible
    • Build stores of essential nutrients
      • Identify locally available and acceptable foods
    • Maintain weight and lean body mass, preserve muscle mass, and increase energy
      • Adequate diet
      • Maintain physical activity
early stage 2
Early Stage (2)
  • Safe food and water handling practices
    • Wash hands before preparing and eating food, after using the toilet or changing nappies or diapers
    • Wash all food preparation surfaces, utensils and dishes
    • Wash all fruit and vegetables before eating, cooking or serving
    • Avoid letting raw food come in contact with cooked food
    • Cook food thoroughly (especially chicken and meats)
early stage 3
Early Stage (3)
  • Safe food and water handling practices continued
    • Serve food immediately after preparation
    • Keep food covered and away from insects, rodents and other animals
    • Do not store cooked food
    • Use safe water for drinking, cooking, and cleaning dishes and utensils
    • Never use bottles with teats for feeding infants; use a cup instead
middle stage
Middle Stage
  • Significant, unintentional or undesirable weight loss as a result of opportunistic infections
  • Main objective: minimize consequences
    • Increase nutrient intake for recovery/weight gain
    • Maintain intake during periods of acute illness and depressed appetite
    • Increase nutrition intake gradually to promote weight and muscle mass gain, and nutritional recovery
      • Make every bite count
      • Daily vitamin-mineral supplements
    • Continue physical activity as able
middle stage 2
Middle Stage (2)
  • Manage and treat the symptoms that affect food intake:
  • Seek medical attention immediately if
    • Diarrhea is persistent and/or accompanied by fever
    • Fever lasts for more than 3 days
    • Mouth and throat sores are present
  • Avoid unhealthy behaviors
    • Alcohol, smoking and drug use
    • Unsafe sexual practices
late stage
Late Stage
  • Symptomatic, full-blown AIDS disease
  • Main objective: provide comfort or palliative care
    • Treat all infections that affect intake
    • Modify diet according to symptoms
    • Maintain intake during periods of acute illness and depressed appetite
    • Encourage eating and physical activity as able
    • Provide psychological and emotional support
symptom based nutrition care and support
Symptom-based Nutrition Care and Support
  • Managing the common symptoms that occur with HIV/AIDS disease will
    • Maximize and improve nutritional intake
    • Maintain weight and muscle mass
    • Improve quality of life
loss of appetite
Loss of Appetite
  • Eat small, frequent meals throughout the day (5-6 meals/d)
  • “Make every bite count”
  • Drink plenty of liquids
  • Take walks before meals – the fresh air helps to stimulate appetite
  • Have family or friends assist with food preparation
  • Mouth care is advisable
sore mouth and throat
Sore Mouth and Throat
  • Avoid citrus fruits, and acidic or spicy foods
  • Eat foods at room temperature or cold
  • Eat soft and moist foods
  • Avoid caffeine and alcohol
  • Frequent mouth care
nausea and vomiting
Nausea and vomiting
  • Eat small, frequent meals and snacks to avoid an empty stomach
  • Eat dry bread or toast, and other plain dry foods, in the morning preferably before getting out of bed
  • Avoid foods with strong or unpleasant odors
  • Avoid fried foods
  • Avoid alcohol and coffee
  • Drink plenty of liquids
  • Avoid lying down immediately (at least 1 to 2 hours) after eating
diarrhea
Diarrhea
  • Eat foods that travel slowly through the digestive tract and decrease stimulation of the bowel
    • Bananas, mashed fruits, soft white rice, porridge
  • Eat smaller meals, more often
  • Eliminate milk and milk products to see if symptoms improve
  • Avoid intake of fried and high fat foods
  • Don’t eat foods with insoluble fiber (roughage)
    • For example: Take the skin off fruits and vegetables
diarrhea 2
Diarrhea (2)
  • Drink plenty of fluids (8-10 cups/day) to prevent dehydration
  • Avoid sweet drinks, drink diluted juice instead
  • Avoid very hot or very cold foods
  • If diarrhea is severe
    • Give oral rehydration solution
    • Food may be withheld for 24 hrs or restricted to only clear fluids (soups or tea) or soft foods (mashed fruit, potatoes, white rice, porridge)
fever
Fever
  • Drink plenty of fluids
  • Eat small frequent meals, including snacks between meals
    • As tolerated at regular intervals
  • Mouth care is advisable
  • Add snacks between meals
altered taste
Altered Taste
  • Use flavor enhancers such as salt and a variety of herbs and spices
  • Try different textures of food
  • Chew food well and move it around the mouth
    • This stimulates taste receptors
poor fat absorption
Poor Fat Absorption
  • Eliminate oils, butter, margarine, ghee, and foods that contain or were prepared with them
  • Eat lean meats
    • Trim all visible fat and remove skin from chicken
  • Avoid deep fried, greasy, and high fat foods
  • Eat fruits and vegetables and other low-fat foods.
fatigue lethargy
Fatigue, Lethargy
  • If possible, have someone pre-cook foods
    • This will help the patient conserve energy
  • Eat fresh fruits that don’t require preparation in-between meals
  • Eat smaller, more frequent meals and snacks throughout the day
  • Exercise as able
    • This will increase energy
  • Try to eat at the same time each day.
foods to avoid
Foods to Avoid
  • Raw eggs
  • Undercooked chicken and meats
    • No raw, rare, or medium rare meats
  • Water that is not boiled or juices that are made from water that is not boiled.
  • Alcohol and coffee
  • “Junk” foods such as chips, biscuits, and sweets with little nutritional value
  • Foods that aggravate symptoms related to diarrhea, nausea/vomiting, bloating, loss of appetite, and mouth sores
nutrition and medication
Nutrition and Medication
  • Medications used to treat HIV opportunistic infections may cause drug-nutrient interactions or side effects:
    • Vitamin B6 supplementation should be administered with isoniazid therapy for tuberculosis to avoid Vitamin B6 deficiency
    • Iron- and zinc-containing supplements should not be taken with ciprofloxacin
    • Sulfadoxine and Pyrimethamine (Fansidar) is not recommended unless folinic acid supplement is given
nutrition and medication 2
Nutrition and Medication (2)
  • Antiretroviral drugs may have:
    • Dietary requirements (e.g., with or without food)
    • Side effects with nutritional consequences such as diarrhea or nausea/vomiting
    • An effect on red blood cell production causing anemia (e.g., Zidovudine - AZT)
the multidisciplinary team
The Multidisciplinary Team
  • A multidisciplinary team is crucial to address the many complex and varied factors in the care of HIV-infected patients and their families
  • Each member of the team can help address these issues in their own way:
    • Nurses and nutritionists
    • Counselors
    • Community workers and agencies
group discussion implementation issues
Group Discussion: Implementation Issues
  • Who will have the expertise, time and resources for nutritional assessment and counseling?
    • Are nutritionists part of military, police and civilian medical institutions?
    • Are clinical nutritionists available for HIV clinics?
  • How is malnutrition currently treated at your site?
    • Are resources for inpatient or outpatient management available?
    • Do you use them?
key points
Key Points
  • HIV can lead to malnutrition by multiple mechanisms
  • Malnutrition is associated with increased HIV transmission, progression, and mortality
  • Nutritional supplementation is associated with improved HIV-related outcomes in children, pregnant women and other adults
key points 2
Key Points (2)
  • Maintaining adequate nutrition prolongs well-being of HIV-infected persons but is difficult
  • HIV affects nutrition in three, sometimes overlapping, ways:
    • Reduces amount and type of food consumed
    • Interferes with the digestion and absorption of nutrients
    • Alters metabolism of nutrients
key points 3
Key Points (3)
  • Counseling and other interventions to prevent or reverse weight loss are likely to have their greatest impact early in the course of HIV infection
  • Nutritional care and support should be part of a comprehensive program that deals with the needs of the patient and his or her family
  • Nutritional supplements, particularly antioxidant vitamins and minerals, may improve immune function and other HIV-related outcomes, particularly in nutritionally vulnerable populations
key points 4
Key Points (4)
  • Managing common symptoms related to HIV/AIDS such as diarrhea, nausea, and loss of appetite, can minimize their impact on nutritional status
  • Prevention of food- and water-borne infections reduces the risk of diarrhea, a common cause of weight loss, malnutrition and HIV disease progression in people living with HIV and AIDS
  • Continuing physical activity and exercise, as appropriate, increases energy, stimulates appetite and preserves and builds lean body mass