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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
the role of antioxidants in preserving health and immune function. Depletion of glutathione was thought to be a driving force in increasing oxidative stress. Studies showed that high doses of N-acetyl cysteine increased intracellular glutathione, and thus it became a popular supplement. PWAs used numerous supplements. During this era, a big part of nutrition intervention was symptom and side effect management, including loss of appetite, thrush, esophageal candidiasis, diarrhea, nausea, and weight loss. PWAs were awarded Schedule C benefits. An expert work group led by BCPWA worked with government to create the Monthly Nutritional Supplement Benefit. The era before 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. The advent of HAART The 1996 World AIDS conference in Vancouver was a turning point with the release of protease inhibitors and the initiation of triple therapy. Early experience with HAART saw huge pill burdens. People had to take many pills three times a day, which led to numerous nutrition issues. For example, with the early indinavir (Crixivan) regimens, people lost weight due to the complex medication regimens with three periods a day of restricted food intake, especially those on both didanosine (ddI, Videx), and indinavir. Dietitians developed food lists of low protein low-fat foods that could be eaten with indinavir. Severe nausea was common, as were kidney stones if people didn’t drink enough liquids. Ritonavir (Norvir) liquid tasted so bad that food lists were developed to mask the taste. Saquinavir (Fortovase) had a huge pill burden and needed fatty foods to enhance absorption. Nelfinavir (Viracept) caused diarrhea, which required dietary modifications. The nutrition interventions generally focused on managing side effects and appropriate food/medication routines. The HAART era Once people began HAART, they started to show signs of altered body fat distribution, which came to be known as lipodystrophy. “Crix belly”—from Crixivan—became the marker for visceral fat accumulation. People also developed buffalo humps behind the shoulders, and lipomas, which are benign tumours of fat cells. Women developed enlarged breasts and fat on the back. PWAs and clinicians also began to notice lipoatrophy (loss of fat tissue) especially in the face, arms, legs, and buttocks. These trends generated a lot of research on body composition, using more sophisticated technology such as DEXA, MRA, and CT scans, as well as studies of the mechanism of these changes. It turned out that lipoatrophy and lipoaccumulation (a type of lipodystrophy) were two distinct conditions caused by different drugs and different mechanisms. Symptoms varied between individuals but the devastating effects on quality of life and adherence were captured in numerous studies and testimonials. Also in the HAART era, metabolic abnormalities— notably insulin resistance, diabetes, and dyslipidemia— especially elevated triglycerides and low HDL cholesterol—became commonplace. Researchers found that PWAs have decreased bone density with an increased risk of osteopenia/osteoporosis and fracture. Bones appear to age prematurely and lose bone density at an accelerated rate. This is likely due to a combination of factors related to the virus, HAART, genetics, and nutrition. There was a greater prevalence of obesity among PWAs. Research at the Oak Tree Clinic found that 19 percent of patients were obese and 40 percent were overweight compared to 17 percent and 23 percent, respectively, in the overall BC population. Years ago dietitians wouldn’t have told people to reduce calories and lose weight, but now there can be more health risks from excess weight. Where are we now The most common nutritional issues today are related to managing HIV as a chronic illness. Many PWAs enjoy good quality of life, with great nutrition and active lifestyles. Dyslipidemia, insulin resistance and diabetes, osteopenia/osteoporosis, and obesity are prevalent. Many PWAs have low levels of vitamin D and/or B12. Some individuals still struggle with poor appetites, unwanted weight loss, chronic diarrhea and depression, all of which profoundly affect food intake. People living with HIV are aging with all that entails. Poverty and food insecurity remain huge—and often insurmountable—barriers to good nutrition. In 25 years, nutrition issues have changed significantly but they haven’t necessarily gotten any easier. 5 Diana Johansen was the dietitian at Oak Tree Clinic at BC Women’s Hospital and Health Centre. MayqJune 2010 living5 29
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