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Case 7: Physiology 2 (Nutrition and HIV) - Coggle Diagram
Case 7: Physiology 2 (Nutrition and HIV)
Old era of HIV Nutrition
Outline the features of the Old era of HIV Nutrition
During the Old era of HIV Nutrition patients presented late with AID or advanced stage HIV
ARVs were only started once clinically indicated
This meant that patients were represented with clinical signs and symptoms
Patients presented with profound malnutrition (undernutrition) and wasting
The nutritional approaches were:
to avoid malnutrition
as an adjunct therapy to delay HIV progression
to delay breastfeeding transmission of HIV
New era of HIV Nutrition
Outline the features of the New era of HIV Nutrition
Increased awareness and Universal ARV roll-out
ARVs have improved viral suppression and Prevention of Mother-to-Child-Transmission
Increased occurrence of obesity and Metabolic complications
Due to ARVs HIV-positive individuals can have a longer lifespan
Although a longer lifespan is positive, it increases the risk of NCDs
HIV Malnutrition
Describe the HIV Malnutrition
HIV malnutrition is a result of disease causing a higher energy and nutrient requirement
HIV Enteropathy refers to Gastrointestinal side effects of disease caused by the disease itself
These side effects include:
Nausea, Loss of appetite, Changes in taste which then Reduces Dietary Intake
Diarrhoea, Vomiting, and Impaired absorption/ Malabsorption which then Reduces Absorption of nutrients
Both of these side effects are exacerbated by opportunistic infections, and ARV side effects
People living with HIV/AIDS experience difficulty with chewing, swallowing, procuring and preparing food
And may even further find difficulty in meeting the increased energy and nutrient requirement
Define Opportunistic Infections
Opportunistic Infections are infections that occur more often or are more severe in people with weakened immune systems than in people with healthy immune systems.
People with weakened immune systems include people living with HIV.
Example of an Opportunistic Infection is Tuberculosis
HIV Malnutrition
Describe the Types of Weight loss with regards to HIV Malnutrition
There are 2 types of weight loss with regards to HIV Malnutrition:
Starvation-related wasting
Starvation-related wasting is due to a lack of nutrient substrates in the body due to decreased intake or increased losses or malabsorption or even a combination of these.
Cachexia-related Wasting
Cachexia-related wasting is the disproportionate loss of lean body mass (LBM) due to altered metabolism
It is important to note that the body responds differently after illness and this brings about the altered metabolism,
As a result the Amino Acids are used for energy and the Fat continues to accumulate
Nutrient intake may be adequate, but inadequate nutrient storage and use occurs
And an increased Resting Energy Expenditure may occur resulting in an increased energy and nutrient requirement
HIV Malnutrition: HIV Wasting Syndrome
Describe the HIV Wasting Syndrome
HIV Wasting Syndrome is defined as the involuntary weight loss of greater than 10% body weight from baseline
And either:
Diarrhoea which lasts for more than 1 month
Or:
Weakness and Fever which lasts for more than 1 month
In the absence of a diagnosed concurrent illness example, TB or Cancer
So not having any other explained conditions
HIV Malnutrition: Interactions between HIV and Nutrition
Explain the interaction between HIV and Malnutrition
Malnutrition and Weight loss is an indication of a poor or an impaired nutritional status
A poor nutritional status weakens or Suppresses the Immune System
A suppressed immune system accelerates HIV progression and increases the risk of Opportunistic Infections
HIV Progression and Opportunistic Infections can cause the following:
Malabsorption due to Diarrhoea
Malabsorption results in a decrease in nutrient absorption
Fever, which causes an increased metabolic rate
Increased metabolic rate results in an increased nutrient requirements
Anorexia, Vomiting and Nausea
Anorexia with a decreased Appetite, Vomiting and Nausea results in a decreased Food intake and Nutrient intake
Medication
ARVs are being used treat HIV.
These medications also have GI side effects including Nausea, Vomiting which decreases Food intake and Nutrient intake
Dementia
Dementia with Increasing physical disability
Due to Dementia and physical disability individuals with advanced stage HIV forget to eat food or take medication thus resulting in decreased Food intake and Nutrient intake
Oral and Oesophageal Infections
Oral and Oesophageal Infections may include painful oral cavities or difficulty chewing, and swallowing food.
The complications of these infections then cause a decreased food intake and nutrient intake
Depression, Anxiety, Isolation and Poverty
Since there is no cure for HIV, HIV patients are often left feeling hopeless this increases their feelings of Depression, Anxiety, Isolation
Poverty and further food insecurity also impacts on these feelings thus resulting in Decreased Food intake and Nutrient intake
Therefore, together, a Decreased nutrient absorption, Increased energy requirements and Decreased food and nutrient intake ALL impact on an impaired or poor nutritional status
This then further impacts on an already compromised Immune System
Then the cycle continues.
Metabolic Complications of HIV
Describe the Metabolic Complications of HIV
Metabolic complications in HIV are caused by a combination of HIV-related chronic inflammation of ART effects
Metabolic complications of HIV have a multifactorial aetiology and varied presentation
Metabolic Complications of HIV are caused by a combination of disease-related and drug-related factors
Dyslipidaemia which is due to an elevated Triglyceride and low High Density Lipoprotein is mainly from Protease Inhibitors (PIs)
Insulin resistance is from some protease Inhibitors and Nucleotide Reverse Transcriptase Inhibitors (NRTIs)
All of these factors place people living with HIV/AIDS at risk of developing obesity and insulin resistance
This then further exacerbates the already prevalent Obesity and Insulin resistance in SA
HIV-associated Lipodystrophy Syndrome
Describe the HIV-associated Lipodystrophy Syndrome
HIV-associated Lipodystrophy Syndrome refers to an abnormal accumulation of fat or a redistribution of fat
There are two types of Fat Redistribution:
Lipohypertrophy
Lipohypertrophy is the abnormal accumulation of fat
Lipohypertrophy results in an:
Increased waist circumference: Visceral fat central adiposity
Increased neck circumference (Buffalo hump): Dorsocervical fat pad
Increased breast size in women: Breast Hypertrophy
Peripheral Subcutaneous Lipoatrophy
Peripheral Subcutaneous Lipoatrophy is known as wasting or loss of fat
It is often found in Facial Wasting as well as Appendices like the fat loss in Arms, Legs and Buttocks
Peripheral Subcutaneous Lipoatrophy is more rare with newer type ARVs
Nutrition Therapy Goals
Outline the purpose of Nutrition Therapy Goals
The purpose of Nutrition Therapy Goals is to:
Optimize nutritional status
Prevent, rather than reverse any problems with nutritional status
Maintain lean body/muscle mass (and growth in children)
Maintain normal bodyweight to reduce comorbidities
Prevent macronutrient and micronutrient deficiencies
Reduce the severity of HIV-related symptoms such as nausea and diarrhoea by nutritional management
Enhance adherence and the effectiveness of ARVs
By looking at drug-nutrient interactions and replacing ineffective drugs to ensure adherence and effectiveness
Manage metabolic complications such as Diabetes, Hypertension
Improve quality of life
Nutrition Care Process
Outline the Nutrition Care Process
Nutrition Care process is as follows:
Screening and Referral
Patient is screened by a medical professional
Then based on the outcome the patient is referred to a dietitian
Assessment (ABCD)
Anthropometric
Biochemical
Clinical
Dietary
Diagnosis
Based on the Assessment a Diagnosis is made
Intervention
An intervention is made and implemented according to the diagnosis
Monitoring and Evaluation
The patient is then monitored and evaluated for progress, adherence and effectiveness of intervention programme
Anthropometrical Assessment
Describe the Anthropometrical Assessment
Anthropometrical assessment refers to body measurements
Body Mass Index (BMI) is calculated using the measurement of Weight and Height
BMI is an indicator of weight status
And looks at individual's weight in relation to their height
Waist Circumference
Waist circumference is used to classify Over-weight, and Obesity
Mid-Upper Arm Circumference (MUAC)
Mid-Upper Arm Circumference is used to indicate muscle wasting if it is less than 23 cm in adults
Bioelectrical Impedance Analysis (BIA)
Bioelectrical impedance analysis is used to measure the body composition
BIA can be used to diagnose Sarcopenic obesity, which is the presence of both the loss of muscle mass and the presence of obesity
Measurement of Skinfold thickness
Measurement of skinfold thickness can be used to measure the percentage of body fat
Biochemical Assessment
Describe the Biochemical Assessment
Biochemical assessments involve blood and lab tests
Biochemical assessments are an important part of a nutritional assessment, but they will depend on the resources available
They are not routinely assed at Primary Health Care facilities
Biochemical Assessments are used to evaluate:
Serum Protein
Inflammatory markers
Inflammatory markers including C-reactive protein (CRP), Erythrocyte Sedimentation Rate (ESR) and Plasma Viscosity (PV)
These inflammatory markers are commonly used in primary healthcare levels for the diagnosis and monitoring such as Infections, Autoimmune conditions and Cancers
Micronutrients such as Vitamins and Minerals profiles
Lipids and Glucose
Lipids and glucose levels are used to investigate the metabolic complications such as Hyperglycaemia and Hyperlipidaemia
Clinical Assessment
Describe the Clinical Assessment
Clinical assessment involves the identification of symptoms, side-effects, illness associated with HIV/AIDS infection that can affect nutritional status
The Clinical Assessment involves the evaluation of a patient's physical conditions specifically Signs and Symptoms
Clinical Assessment can be used to inform the diagnosis and the planning of treatment
Signs and symptoms may include:
Appetite (Loss)
Presence or absence of Fever
Nausea, Vomiting
Difficulty swallowing
Mouth and/or throat sores, oral thrush
Muscle wasting
Fatigue lethargy
TB
Diet History Assessment
Describe the Diet History Assessment
Dietary History Assessment involves an in-depth review of the:
Current dietary intake, and recent changes that a patient may have made
Food access, Resources to acquire appropriate food to maintain a healthy nutritious diet, Food procurement
Supplement use
Assessment of the type and dosage of the supplement being used
Barriers to desirable food intake
Physical or Financial Barriers
Describe the types of Methods used in the Dietary History Assessment
There are two types of Methods used in the Dietary Assessment:
24-Hour recall of dietary intake
This involves the recall of everything an individual ate and drank in the previous 24 hours as well as the preparation methods and estimated portion size
Food frequency questionnaire
Food frequency questionnaire provides an overview of the individual's dietary pattern
This checks the frequency of intake of specific foods
Nutritional Requirements in HIV
Outline the Nutritional Requirements in HIV
It is important to note that when it come s to Nutritional Requirement for the HIV and non-HIV population there is no 'one size fits all" approach
A Nutritional Prescription needs to be individualized
Macronutrients:
Energy
Energy requirements in an individual with asymptomatic HIV is elevated by 10% which is an additional 40-182 kcal/day
In an individual with symptomatic HIV the energy requirement is elevated even further to between 20-30%
Protein
Protein requirement remains normal at 0.8g/kg of bodyweight
With an additional 10% for Infections, or more in Malnutrition or to increase Lean Mass
Resistance training is useful in reserving or building lean mass
Fat
Heart-healthy guideline for the non-HIV population are used
Omega-3 Fats may improve elevated Triglycerides to prevent Dyslipidaemia
Micronutrients:
Patients only benefit from micronutrients with Repletion, meaning that the patient needs to have an excess intake of micronutrients
However, intake is often inadequate
100% Recommended Dietary Allowance (RDA) supplement can be recommended
Mega-dosing mat be detrimental particularly for Vitamin A and Zinc
Possible benefit of Selenium, Vitamin D on delaying HIV progression
Investigate anaemia for nutrient origin
Route of Nutrition
List and Describe the Routes of Nutrition
The rationale for nutrition therapy in patients with HIV is straight-forward
As undernutrition and malnutrition have adverse effects that can be prevented by improving the nutritional status of an individual with HIV
The rule of thumb is: If the Gut Works, Use It.
The Routes of Nutrition in order of preference:
Oral diet based on food
Supplementation with macronutrient or micronutrient supplementation
Enteral nutrition via the Nasogastric tube or Gastrostomy tube
Enteral nutrition is used in patients that cannot eat enough to meet the energy and nutrient requirements
Nasogastric tube is inserted into the gastrointestinal tract
Gastrostomy tube is inserted through the abdomen that delivers nutrition directly to the stomach
When the patient does not absorb enough nutrients through Enteral nutrition to maintain a good nutritional status Total Parenteral Nutrition (TPN) is indicated
Parenteral feeding
Parenteral nutrition (PN) is an intravenous administration of nutrition where the needle is inserted straight into the vein
This may include Carbohydrates, Proteins, Fats, Electrolytes, Vitamins and other trace elements
Dietary Therapy used to address Metabolic Abnormalities
Describe the Dietary Therapy used to address Metabolic Abnormalities
When it comes to Dietary therapy to address metabolic abnormalities the same Lifestyle modifications used in the non-HIV population are used in the HIV population
These include: Nutrition education, Counselling, and Diet Manipulation to enable an individual to take on a more healthy diet
A healthy diet consists of the following:
Lower saturated fat
Refined Carbohydrate, and Salt
Higher or Rich in Healthy Fats, Wholegrains, Fruits and vegetables
Dietary Treatment: Malnutrition
Describe the Dietary Treatment for Malnutrition
Dietary treatment for Malnutrition is as follows:
Correct micronutrient deficiencies
Adjust diet according to gastro-intestinal disturbances such as Nausea, Vomiting, Diarrhoea or Mouth sores
Patient will be presented with the recommendations for the symptoms.
It is important for these symptoms to be managed so that patient nutrient requirements are met, patient can adhere to drug treatment and to improve the patient's quality of life
Aim to meet Protein, Energy requirements:
This may slow down, but not reverse malnutrition until underlying cause is addressed.
Underlying causes may be the environment or lifestyle the patient is placed in such as Household food security, level care the patient receives, and access to heath services
Food safety
Describe the importance of food safety as part of the Dietary counselling
Food safety is an important component of dietary counselling
People living with HIV/AIDS (PLWHA) are more susceptible to food borne illness due to a compromised immune system.
The food-borne illness are likely to last longer and be more serious in PLWHA compared to people living without HIV/AIDS with a healthy immune system
Therefore, it is important to:
Practice safe food preparation
Food storage
Drink clean and safe water
Foods to avoid are:
Raw eggs, Cracked eggs
Raw or undercooked poultry, meat and seafood
Unpasteurized milk or dairy products and fruit juices
Food/Nutrient Drug Interaction
Outline the Food-Drug Interaction in HIV
Like any medication ARVs also have specific instructions to with regards to:
To be taken with, or without or after or with Fatty food
ARVs can cause side effects such as Diarrhoea, Vomiting, Fatigue, Reflux
Vitamins, Minerals, Foods and herbal products may interfere with drug pharmacokinetics and efficacy of the ARV treatment
Example:
Grapefruit and Protease Inhibitors compete for Cytochrome P450 enzymes
Adverse effects are also detected from the use of African Potato , St. Johns wort, Garlic, Echinacea
Antacids containing Magnesium, or Aluminium have negative effects on ARVs
Food Insecurity and HIV
Outline the negative interaction between Food Insecurity and HIV
HIV depletes the human, financial and physical capital thus reducing the earning capacity of the individual and the household
Food insecurity negatively impacts the individuals' ARV adherence
Food insecurity causes challenges with regards to food access and availability.
This then poses a further challenge on the HIV individual to follow a healthy diverse diet
As a result, the diet is more unhealthy:
Higher in defined Carbohydrates, Sugar and salt
Lower in Fruit and Vegetables, Proteins and diversity
Patients meeting the entry criteria based on their nutritional status have access to Nutrition Therapeutic Programme (NTP)
Nutrition Therapeutic Programme (NTP):
Provides access to nutritious foods
Stigma is attached to receiving products
An issue with regards to the NTP is that patients often share the products with the family, thus making it difficult for the product to have the intended effect on the patient's Nutritional Status
HIV in Children
List the effects of HIV in children
Growth faltering can be a sign of HIV progression in children
This may be secondary to disease or other opportunistic infections
Typically there are growth lags in non-HIV children
Therefore, it is important to:
Continue to monitor the growth curve: Both Weight-for-Age, Height-for-Age and Weight-for-height
Ensure optimal protein, energy and micronutrient intake
Ensure that children who qualify for nutritional supplementation program based on their nutritional status to be placed in the program
HIV children have long term risks of developing metabolic abnormalities
Perinatal Transmission of HIV
Describe the concept of Perinatal Transmission of HIV
HIV can be transmitted from mother-to-child, this is called Vertical Transmission
Perinatal refers to the period of time that extends from 22 weeks gestation to about 4 weeks after birth
Perinatal transmission is when the mother with HIV passes the viruses to her infant either during:
Pregnancy, or
Labor and Delivery, or
Breastfeeding through breast milk
Prevention of Mother-to-Child Transmission
Outline the need for the Prevention of Mother-to-Child Transmission
Perinatal transmission risk can be as high as 15-45%
More then 95% of pregnant women in SA receive ARVs
ARVs can be effective in the Prevention of Mother-to-Child Transmission during Pregnancy, Labour and Delivery, and Breastfeeding
The challenge is maintaining care and effective Anti-Retroviral Therapy of HIV-positive women throughout the breastfeeding period
As a result, more infant infections occur during the postnatal period rather than pregnancy or labour
Prevention of Mother-to-Child Transmission: Breastfeeding
Previously women were provided with a risk-based decision this involved:
Infant feeding counselling during pregnancy which is part of antenatal care
This was to allow women to make an informed decision around infant feeding options such as Breastfeeding or Formula Feeding in the context of HIV or non-HIV when the baby was born
Women had a choice between:
Exclusively Breastfeeding the infant
Exclusive Breastfeeding reduces the rik of HIV transmission and improved child survival
However, Breast feeding has a small risk of HIV transmission of 5%
Exclusively breastfeeding means that the infant was only fed breastmilk for the first 6 months
NO water, tea, juice or other fluids or foods
ONLY prescribed medication was allowed
Formula Feeding the infant
Formula feeding the infant has no risk of feeding transmission
However, Formula Feeding had a higher risk of infectious disease
Previously, Formula Feeding was providing free of charge to mothers on the PMTCT program
BUT it did not work
This is because in a developing country, there is a lack of access to basic services like clean safe water and sanitation, electricity, housing, as well as lack of access to heath services thus making it difficult to:
Prepare Formula Feeding with clean and safe water
Hygienically clean feeding utensils such as bottles and teats
Mothers also had to be counselled on the increased risk of infectious diseases on infants such as gastroenteritis
Gastroenteritis then leads to Diarrhoea disease in infants
Diarrhoea disease due to inadequate formula feeding or the use of inadequately cleaned feeding utensils poses a higher risk of infant morbidity and mortality compared to the risk of HIV in Breastmilk
Prevention of Mother-to-Child Transmission: Breastfeeding
Describe the guidelines used in Breastfeeding in the context of the PMTCT program
ARV drugs are given to women with HIV during pregnancy and to their infants after birth to reduce the risk of Mother-to-Child Transmission of HIV
ARV drugs were given for a duration of 6 weeks as a form of Post-Exposure prophylaxis
This made the transmission risk less than 1%
HIV-positive mother who chose to breastfeed their infants followed the following guidelines:
Exclusive Breastfeeding for the first 6 months of life
Introduction of complementary feeding at 6 months
Continuing to breastfeed for at least 2 years and more
This means that the Infant and young child guidelines of HIV-positive and HIV-negative mothers are completely aligned
Unless, if the HIV-positive Mother is on their second or third-line of ART for at least 3 months and the viral load is still above 1000 copies/ml
This case the Formula Feed is provided by the Department of Health
The Mother is educated on how to prepare the formula feed
Prevention of Mother-to-Child Transmission: Breastfeeding
Outline the currently, SA adapted WHO 2016 guidelines
PMTCT Guidelines focus on:
Prevention of re-infection
Adherence to ARVs
HIV-positive mothers who are breastfeeding should be supported to adhere to ARVs
As well as counselled and supported to practice Exclusive Breastfeeding according to the WHO 10 steps
Although Exclusive breastfeeding is the recommended feeding option
ART reduces the risk of postnatal HIV transmission within the context of mix feeding
Although, mixed feeding is discouraged, mix feeding is not contraindicated and it is not a reason to stop breastfeeding
A shorter duration of Breastfeeding of less than 12 months is still better than never initiating breastfeeding at all
There should be a gradual cessation of breastfeeding in the context of mixed feeding
Prevention of Mother-to-Child Transmission: Breastfeeding
Outline the Specific Conditions that should be present for Formula Feeding to take place
Formula feeding can be chosen by the mother in the context of PMTCT if the AFASS criteria adhered to
AFASS Criteria:
Acceptable
The family needs to be supportive of the practice of formula feeding
Feasible
Safe and Clean water, Sanitation and Electricity are assured at the household and community level
Affordable
Mother or Caregiver can reliably provide sufficient formula to support normal growth and development of the infant
Sustainable
Mother or Caregiver can in the first 6 months, exclusively give infant formula
Safe
Mother or caregiver can prepare formula cleanly and frequently so that it is safe, and carries a low risk if diarrhoea and malnutrition
Mother or Caregiver can access health care that can provide comprehensive child health services
ONLY if the entire criteria is met can Formula Feeding be granted as a safe infant feeding option in the context of HIV
Future of HIV in Nutrition
Wasting was the initial nutritional complication of HIV/AIDS to be recognised
Lipodystrophy followed with the application of Highly Active Anti-Retroviral Treatment
Now looking at the future of Nutrition in HIV:
Continued oxidative stress and systemic inflammation even with suppressed HIV and ARVs
poses as a risk factor for chronic diseases
Managing Sarcopenia and Frailty requires attention
Impaired GIT immunity and role of GIT microbiota needs to be looked at in future
