Clinical Guide > Maintenance and Prevention > Nutrition

Nutrition

January 2011

Chapter Contents

Background

Maintaining good nutritional status is important to support overall health and immune system function for people with HIV/AIDS. Many HIV-related conditions affect and are affected by the body's nutritional status. These include conditions related to HIV itself (e.g., opportunistic infections and other illnesses), comorbid conditions, and adverse effects of therapies.

Inadequate nutrition in people with HIV infection may result from many factors, including conditions such as nausea, vomiting, and anorexia (see chapter Nausea and Vomiting) that may prevent adequate intake of nutrients and medications; diarrheal infections (see chapter Diarrhea) that prevent absorption of nutrients and medications; poor oral health conditions that interfere with chewing or tasting food (see chapter Oral Health); systemic illnesses (including HIV itself) that create a catabolic state; and psychological conditions (such as depression) that impair patients' ability to nourish themselves. In addition, financial constraints may limit patients' access to nutritious food.

Evaluation and enhancement of patients' nutritional status may help correct or compensate for deficiencies (e.g., in the case of weight loss or nutrient deficits), may be a key treatment modality for certain conditions (e.g., dyslipidemia, hyperglycemia), and may help to maintain good health and immune function. This chapter focuses on the evaluation of patients with nutritional deficiencies, particularly weight loss, and on simple strategies for maintaining good nutrition in individuals with barriers to maintaining adequate weight.

It should be noted that obesity and overweight conditions are increasingly common in HIV-infected individuals; many of the principles described here also may be applied to the evaluation of overweight patients. Recommendations for weight reduction for HIV-infected patients are the same as for the general population and will not be discussed in detail; for overweight patients with lipohypertrophy, diabetes, dyslipidemia, or coronary artery disease, see the respective chapters on these conditions.

Ideally, HIV-infected individuals will receive the services of HIV-experienced nutrition specialists, who may contribute to the patient care team in the following ways:

S: Subjective

History

Identify nutrition risk factors at the start of care through interview, questionnaire, or both. Update the history at least annually. The history should elicit signs and symptoms related to nutrition issues, indications regarding dietary habits, and symptoms that suggest nutritional deficiencies.

Nutrition-Related Questions

FactorAreas to Explore
Signs, Symptoms, and Comorbid Conditions
  • Poor or sporadic appetite
  • Early satiety
  • Weight gain or loss
  • Trouble chewing or swallowing
  • Dental problems including poor dental hygiene
  • Gastrointestinal complaints, including nausea, diarrhea, constipation, heartburn, gas
  • Changes in body contours with fat gain in abdomen, back of neck, and breasts (lipodystrophy) or fat loss in extremities and face (lipoatrophy)
  • Depression, stress
  • Fatigue
  • Chronic pain
  • Other diseases affecting diet and nutrition
  • Medications, including over-the-counter and herbal products
Medication-Related Factors:
  • Medication side effects
  • Difficulty coordinating meals with medicines
  • Use of nutritional supplements
Social and Behavioral Factors:
  • Frequent eating out
  • Smoking
  • Alcohol or substance abuse
  • Erratic meal patterns
  • Unbalanced diet (e.g., high intake of low-nutrient foods; deficiency in key nutrients)
  • Resources to ensure secure, continued food access
  • Availability of food storage and preparation facilities
  • Housing (stable, homeless, marginally housed, or in transition)
  • Nutrition literacy

To develop a specific dietary history, ask about the following:

Dietary History

Usual Dietary IntakeFactors That May Affect or Limit Intake
  • Frequency of intake of foods providing key nutrients (e.g., dairy products, fortified or whole grains, fruits and vegetables, fluids, meat, eggs, beans) as well as those that perhaps should be limited (fast-food items, highly processed or salted products)
  • Usual meal patterns (number of times per day, snacks) and whether meals are prepared and eaten at home or eaten at restaurants or fast-food establishments
  • Specific information about nutritional supplements (e.g., vitamins, minerals, herbs, protein), including contents, amounts, formulation (pills, powders, drinks), cost, and overlap among products
  • Amount of money available for food, or participation in food assistance programs (e.g., food stamps, food pantries)
  • Appetite, general well-being (e.g., fatigue, pain, depression)
  • Food allergies, intolerances
  • Problems with dentition, swallowing, heartburn, diarrhea, constipation
  • Coordination of foods and supplements with medications (HIV or other)

Elicit symptoms that may be related to nutritional deficiencies.

Symptoms with Possible Relationship to Nutritional Deficiencies

  • General symptoms (e.g., fatigue, decreased cognitive function, headache)
  • Behavioral changes (e.g., irritability, apathy, decreased responsiveness, anxiety, attention deficit)
  • Body habitus changes (e.g., loss or gain of fat)
  • Gastrointestinal symptoms (e.g., diarrhea, constipation, bloating)
  • Changes in skin, nails, hair (e.g., dryness, breaking, thinning)
  • Muscle loss
  • Neurologic symptoms (e.g., weakness, sensory changes, gait abnormalities)

O: Objective

Physical Examination

Perform a careful physical examination, if possible with anthropometric and body composition testing as described below (Table 1). Compare current findings with past assessments and review at least every 6 months.

The physical examination should include the following:

Anthropometric and body composition tests are usually performed by registered dietitians. They can provide important information about patients' nutritional status.

Table 1. Anthropometric Measurements for Adults and Children

Height Weight Assessment for Changes over Time

* BMI (body mass index) is useful as an evaluative index. See chapter Initial Physical Examination, and the CDC's online calculator.

# Growth charts for children in the United States are available online from the U.S. Centers for Disease Control and Prevention (CDC) at www.cdc.gov/growthcharts/. A variety of growth charts are available for children from specific ethnic groups (e.g., Chinese, Vietnamese, Thai), children with selected conditions affecting growth (e.g., Down syndrome), or those who are born prematurely. Percentiles for both height and weight should be recorded sequentially.

Adults Measure at baseline (self-report is not accurate).
  • Measure at least quarterly and consider intervention when small changes are observed. Do not wait until major amounts of weight have been lost or gained.
  • Record sequentially at the front of the patient's chart and monitor for trends.
Use healthy, premorbid weight to assess change, not the first clinic weight or the ideal weight. (Use the patient's weight at a time when the patient is healthy, feels well, and can easily maintain that weight.) *
Children Measure at least quarterly using length board (0-2 years) or wall-mounted stadiometer (≥2 years).
  • Measure at least quarterly and consider intervention when small changes are observed. Do not wait until the patient has dropped significantly on the growth chart.
  • Calculate age and plot the measurements on growth charts specific for age, sex, and country.#
Assessment of optimal growth is based on the observed pattern over time. General goals include a weight relatively "matched" for length or height (about the same percentile) and relative stability of percentile tracking over time.* #

Body Composition Testing

Body composition commonly is tested by bioelectrical impedance analysis (BIA) (Table 2) or skinfold thickness and circumference (Table 3).

Table 2. Bioelectrical Impedance Analysis

BIA testing is the standard of care for adults but has not been well validated for children:

  • BIA is useful for assessing disease progression or health maintenance, documenting response to treatment, and justifying the cost of nutritional supplements and AIDS-wasting medications.
  • The test is simple, noninvasive, and quick (<5 minutes). However, staff training and specialized software are required to interpret the results.
  • Perform BIA at baseline. Update every 6-12 months or more frequently if the patient is ill, has a decline in immune status, or has a weight change of 5-10%.
  • The BIA test reports the following:
    • Body cell mass (BCM): the target component, reflecting cells in muscles, organs, and the circulation; losses may indicate AIDS wasting. BCM is recorded in pounds. Monitor for trends.
    • Fat: an index of energy stores; recorded in pounds and percentage.
    • Phase angle: a measure of cellular integrity, an independent indicator of morbidity and mortality in HIV-infected patients.

Table 3. Skinfold Thickness and Circumference Measures

Skinfold thickness and circumference measures can be used for adults and children in resource-limited settings, and for situations in which bioelectrical impedance analysis is not available. Circumference measures also can be used to monitor changes over time associated with lipodystrophy in adults.

  • Skinfold thickness is measured with calipers.
  • Circumference measures are taken at specific anatomical landmarks with nonstretchable tape.
  • Techniques and protocols for taking anthropometric measurements can be found at the CDC website.

Laboratory Testing

Perform basic laboratory (blood) tests, including the following:

A: Assessment

Assess subjective information and objective findings to evaluate nutritional status.

Identify Nutrition Concerns

Several factors may influence nutrition, including the following:

Evaluate Dietary Intake

Assess the following diet-related issues:

Evaluate Weight, Body Composition, and Weight Distribution

Assess physical findings of malnutrition and confirm with nutrition history, laboratory tests, and anthropometric evidence. Normal and abnormal findings of anthropometric tests and recommendations for monitoring changes over time are presented in Table 4.

Table 4. Evaluating the Findings of Anthropometric Tests

Monitoring Trends and Recommendations

Abbreviations: BCM = body cell mass; BIA = bioelectrical impedance analysis; BMI = body mass index

AdultsChildren
  • Chart trends over time relative to previous measurements and the following population norms:
    • BMI (healthy range: 19-25)
    • BIA:
      • BCM (percentage of weight): women 30-35%; men 40-45%
      • Fat (percentage of weight): women 20-30%; men 15-25%
      • Phase angle: women >5; men >6
  • Skinfold thicknesses and circumferences: Chart changes in absolute measures and percentiles
  • Changes in body contours: Evaluate lipodystrophy (excess accumulation of fat in abdomen, breasts, dorsocervical area) and lipoatrophy (loss of subcutaneous fat in face, extremities, buttocks)
  • Plot measurements on growth charts and track percentiles over time (the consistency of percentiles rather than the absolute percentile is important)
  • Skinfold thicknesses and circumferences: Chart changes in absolute measures and percentiles

Evaluate Laboratory Findings

Develop a Problem List

The following suggests a useful format for a nutrition-related problem list.

Nutrition-Related Problem List

Problem NumberDescription of Problem (circle/describe)
Nutrition barriers: insufficient knowledge, poor appetite, food insecurity, no food preparation or storage facilities, homelessness
Lifestyle: substance abuse, smoking, erratic eating, frequent fast-food intake, high stress
Weight or body composition: undesirable weight gain or loss (adult), changes in growth trajectory (children), loss of lean body mass (wasting), gain of excess fat (obesity), lipoatrophy or lipodystrophy
Physical problems: fatigue, pain, early satiety, poor dentition, clinical signs of malnutrition
Laboratory findings: low hematocrit or hemoglobin, low protein or albumin, low or high fasting glucose, high total cholesterol, high LDL, high triglycerides, low HDL, low testosterone
Gastrointestinal: diarrhea, vomiting, reflux, constipation
Poor diet: poor food choices, bingeing, skipping meals, high sugar intake, high alcohol consumption, high intake of refined foods, low fruit and vegetable intake, insufficient protein, insufficient calcium, food allergies or intolerances that limit intake
Comorbid conditions: diabetes, hypertension, cardiovascular disease, cancer, gastroesophageal reflux disease (GERD)
Medications: drug-drug or drug-nutrient interactions or difficulty coordinating medicines with meals
Supplements: insufficient or excessive intakes, cost of supplements unaffordable, supplements with potential or unknown risks

P: Plan

Develop a nutritional plan and provide practical nutrition education for common problems (see "Resources," below).

Evaluate and treat concurrent medical problems (e.g., diarrhea, nausea, infections, malignancies, depression, pain). For severe or persistent nutritional problems, or for specific needs, refer to a nutrition specialist for evaluation and treatment.

Common nutrition-related problems are presented in Table 5, along with simple management suggestions that may help resolve them and help patients maintain adequate nutrition.

Table 5. Practical Interventions for Common Nutrition-Related Problems

ProblemSuggestions
Weight Loss (decrease in both body cell mass and fat)
  • Early identification and ongoing monitoring are key.
  • Identify and treat underlying risk factors.
  • Try to add calories without adding "bulk":
    • Fat (9 calories/gram): butter, margarine, avocado, cream, mayonnaise, salad dressing
    • Carbohydrate (4 calories/gram): jam, jelly, sugar, icing, gum drops
    • Protein (4 calories/gram): protein powders, cheese, nut butters, trail mix, powdered breakfast drinks, nonfat dry milk
  • Eat more frequently.
  • Maximize good days.
  • Use canned supplements (e.g., Ensure, Boost).
  • For wasting or substantial weight loss, consider referral for therapies such as appetite stimulants or human growth hormone.
Diarrhea
  • Increase soluble fiber; decrease insoluble fiber.
  • Replenish beneficial bacteria (e.g., with lactobacilli preparations).
  • Avoid intestinal irritants and stimulants.
  • Decrease dietary fat.
  • Decrease or eliminate lactose.
  • Increase fluids and provide electrolytes (sodium, potassium).
  • Treat with pancreatic enzymes.
Early Fullness
  • Take small, frequent meals.
  • Concentrate on solid foods, with liquids between meals.
  • Eat lower-fat, lower-fiber foods.
  • Wear loose-fitting clothing.
  • Sit up while eating.
  • Eat, walk, and eat again.
Nausea
  • Take small, frequent meals.
  • Try dry snack foods.
  • Avoid fried foods, very sweet foods, spicy foods, and foods with strong odors.
  • Try cool, clear beverages, popsicles.
  • Try ginger-containing foods and drinks.
  • Keep liquids to a minimum at meals.
Changes in Taste
  • Eat a variety of foods, not only favorite foods.
  • Try protein sources other than red meat.
  • Marinate foods, use sauces.
  • Use more and stronger seasonings.
  • Try tart foods.
  • Use sugar or salt to tone down the flavor of foods.
  • Try a mouth rinse of 1 teaspoon of baking soda in 1 cup of warm water before eating.
Loss of Appetite
  • Rely on favorite foods.
  • Ask family members and friends to prepare meals.
  • Eat small, frequent meals.
  • Keep snacks handy for nibbling.
  • Eat before bedtime.
  • Eat in a pleasant place, with other people.
  • Make the most of good days.
  • Try light exercise to stimulate appetite.
  • Add extra calories without adding bulk.
  • Consider appetite stimulants (e.g., megestrol, stimulants).
Difficulty Chewing or Swallowing or Sore Mouth and Throat
  • Choose soft, nutritious foods.
  • Blend or puree foods (e.g., soup or stew, smoothies).
  • Add cream sauces, butter, or gravy for lubrication.
  • Sip liquids with foods.
  • Use a straw or drink foods from a cup.
  • Choose bland, low-acid foods.
  • If hot foods cause pain, serve foods cold or at room temperature.
  • Avoid alcohol and tobacco.
  • Soothing lozenges or sprays may help.
Food Insecurity
  • Refer to social services for assistance with accessing resources such as food stamps, community meals, or a food pantry program.
  • Refer to a dietitian for assistance with low-cost food ideas.
  • Use materials at CheapCooking.com.
Unbalanced Diet and Other Conditions Requiring Dietary Modification
  • Refer to a dietitian for counseling and education.

Nutrition Specialists

Whenever possible, nutritional services should be provided by a registered dietitian (RD) who is a qualified HIV care provider. In the United States, holding this status requires a nutrition degree from an accredited college, graduation from an approved internship or master's degree program, and maintenance with 75 continuing-education units every 5 years, including specific and ongoing HIV training. An RD with HIV/AIDS expertise in the United States can be located by going to eatright.org, clicking on "Find a Registered Dietitian," entering the patient's zip code or city, and selecting "HIV/AIDS" under areas of specialty. Membership in the Infectious Diseases Nutrition Dietetic Practice Group also may indicate HIV experience.

Resources

The following online resources provide information, guidelines, and tools for providers and patients in managing issues related to nutrition and HIV:

References