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Nutrition
Nutrition and HIV,
revisited
Looking back at the role of nutrition in HIV treatment over the years
by Diana Johansen
Deciding to retire after 17 years of work in the HIV
field has made me think about how nutrition has
evolved over the past 25 years. Not only has our
overall understanding of nutrition and health grown dramatically,
but the specific nutrition issues facing people
living with HIV have also morphed and changed as HIV
has become more of a chronic illness.
Nutrition has always been an HIV issue. Before scientists
identified the human immunodeficiency virus, when infected
individuals were dying of wasting and malnutrition, some
researchers were looking for a nutritional disease. At that
time, vitamin and mineral (or micronutrient) deficiencies
were prevalent, especially zinc. People with HIV died of
opportunistic infections, and it was the loss of body cell mass
due to profound wasting that ultimately led to people’s death.
Without antiretroviral treatment, the only way to stay
healthy and prolong life was nutritional therapy. The
main focus of nutrition at that time was to get in enough
calories and protein to prevent wasting, and to supplement
with micronutrients to prevent deficiencies.
Key learnings pre-HAART
The era before highly active antiretroviral therapy (HAART)
was a period of vigorous nutrition research, and many
important findings helped guide nutrition education and
intervention at that time—and still guide it today. Every
major HIV conference had significant nutrition-related
content. In 1995 there was the first of four international
HIV nutrition conferences.
At the time, we learned that the timing of death is
related to body cell mass and survival is contingent on
maintaining a body cell mass greater than 54 percent of
the body. Body cell mass is the metabolically active tissue
that does most of the work of keeping us alive. It
includes muscle, organs, and other active cells types.
It was also discovered that the body composition of PWAs
changed over time. Body cell mass progressively declined
even in those people who maintained the same weight.
When weight loss did occur, body cell mass was preferentially
lost over fat. These findings led to greater understanding
about how chronic inflammation with abnormal cytokine
activity affects the wasting process. Bioelectrical impedance
analysis (BIA) became a common clinical procedure used by
HIV dietitians to monitor body composition. A lot of BIA
research was published at the time.
Another key learning was that gut infection by HIV was
considered a factor in wasting because of malabsorption. Also,
futile cycling of nutrients contributed to wasting because
the body did not use calories, protein, and fats properly.
During this period, there was a lot of research on
calorie and protein requirements. Earlier in the epidemic
it was thought that PWAs had extraordinarily high calorie
requirements. The educational materials of the day suggested
consuming 3,000 or more calories a day; many people
were living on whipped cream, ice cream, and other fatty
foods to increase calories.
Studies showed that there was a 10 percent increase in
calorie requirements for people with asymptomatic HIV (that
is, people with HIV but no symptoms) and 20 – 30 percent
increase for people with AIDS and/or opportunistic infections.
However, this didn’t necessarily translate into a real increase
because PWAs tended to decrease physical activity, which
also has a significant impact on calorie requirements. The
conclusion from all this was that there is an increase in
requirements; with the amount depending on the individual.
The studies on protein requirements concurred that
PWAs needed higher protein to preserve body cell mass and
provide substrate for an overstimulated immune system.
The educational material of the day recommended protein
intakes of about one gram per pound of body weight, but
this was probably too high as the body can really only
efficiently use about 0.5 – 0.75 grams per pound. Whey protein
became a popular supplement to boost protein intake.
Micronutrient deficiencies were common even among
people who ate well. Deficiencies were associated with
faster disease progression and increased risk of mortality.
Initially this phenomenon was felt to be from malabsorption,
but in the late 1990s the concept of increased turnover
due to chronic inflammation became more popular. During
this period, we learned a lot about oxidative stress and
28 living5 MayqJune 2010