Transcript HIV Wasting - UBC Dietetics Major

HIV Nutrition
& Health Benefits
Jenn Messina, RD
HIV/AIDS Program
St. Paul’s Hospital, Vancouver
February 7th, 2013
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Outline
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Personal intro
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HIV Globally
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Nutritional issues in HIV
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Asymptomatic & symptomatic infection
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Provincial health benefits
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Questions
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Personal Introduction
UBC Integrated Internship
 Graduated UBC in 2007
 Currently working in the
Immunodeficiency Clinic, St. Paul’s
Hospital, Outpatient Clinic
 B.C. Centre for Excellence in HIV/AIDS
Care
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HIV Global Statistics
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The number of people living with HIV (including
AIDS) continues to rise
34 million people were living with HIV/AIDS
worldwide at the end of 2011
In Canada it is prevalence of HIV has risen
from an estimated 64,000 in 2008 to 71,300 in
2011 (an 11.4% increase)
It is estimated that between 2,250- 4100 new
HIV infections occur in Canada each year
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Nutritional Issues
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Malnutrition and wasting
Loss of appetite
Gastrointestinal complications
Side effect of medications
Metabolic abnormalities
Mental health
Disordered eating
Substance use
Socioeconomic factors- food insecurity
Special needs groups: pregnancy, children, adolescents
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HIV Nutrition Assessment
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Anthropometrics:
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Height, weight, BMI, weight history
Biochemical: immune status, lipid profile, fasting blood
sugar, renal status, nutritional labs, bone density (if
available)
Clinical:
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Patient medical history, medications, social history
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Intake of key nutrients e.g. energy, protein, fat, fibre,
calcium, vitamin D
Knowledge, beliefs
Allergies, intolerances
Supplement intake
Physical activity
Food security
Food/support resources
Diet history:
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Symptomatic & Asymptomatic HIV
Infection
Symptomatic HIV infection:
 Fever
 Opportunistic infections, e.g. Pneumocyctis iirovecii
pneumonia, (PCP), cytomegalovirus (CMV), and
Mycobacterium avium (MAC), have nutrition implications
 Oral thrush
 Weight loss
Usually CD4+ T helper cells <200
Asymptomatic infection: a phase of chronic infection
which the person does not display symptoms
Usually CD4+T helper cells >200
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Symptomatic HIV Infection
HIV Associated Weight Loss
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Inadequate nutrient intake
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Oral and upper GI symptoms
Anorexia
Psychosocial
Malabsorption
Altered metabolism
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Uncontrolled HIV infection
AIDS defining illnesses
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HIV Wasting Syndrome
HIV Wasting: Infection induced cachexia
characterized by inappropriate
catabolism of skeletal or other lean
proteins
Centre for Disease Control definition:
Involuntary weight loss >10% (of
baseline body weight) associated with
either chronic diarrhea (two or more
loose stools per day for ≥1 month) or
chronic weakness and documented
fever for ≥1 month
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Symptomatic HIV Infection
Caloric recommendations:
 20-30% higher than non-infected person with
same age, sex, physical activity to maintain weight
Affected by age, activity level, HIV status, nutritional
status, infection, comorbidities, etc.
 Initiation
of anti-retroviral therapy may also
increase energy needs as the individual
transitions to a anabolic state
 Metabolic cart is the gold standard
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Protein recommendations:
 1.5- 2g protein/kg/day
 Needs to be individualized
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Symptomatic HIV:
Recommendations
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HIV control and treat concurrent infections
Addressing psychosocial factors, depression
Diet counseling:
 Symptom management of GI side effects
 High calorie, high protein diet
 Homemade/commercial nutrition supplements
 Nutrition support (tube feeding) in hospital may be
needed
 Address food security, community resources, funding,
connect with RD as needed if in hospital
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Asymptomatic Infection
Caloric recommendations:
 10% higher than non-infected person with
same age, sex, physical activity to maintain
weight
 Affected
by age, activity level, HIV status,
nutritional status, infection, comorbidities, etc.
Protein recommendations
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1.0- 1.2g protein/kg/day when stable
Needs to be individualized
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Asymptomatic recommendations
Nutrient rich,
balanced diet
Individual energy,
protein,
micronutrient needs
Food and Water
safety
Encourage exercise
Ensure food security
Address any
nutritional issues
identified
Consider social
factors affecting
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healthy eating
Metabolic Complications of HIV
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Dyslipidemia
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Insulin resistance
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Reduced bone density
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Dyslipidemia and Insulin
Resistance
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Therapeutic lifestyle and diet are the first
line strategy
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Traditional approaches to treat dyslipidemia
and hyperglycemia should be initiated
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Dietitian counselling works best if it is
regular and sustained
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Bone Health: Screening, Prevention &
Treatment
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HIV positive people at higher risk
for osteopenia and osteoporosis,
cause is multifactoral
Assess
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Prevention
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Determine if risk further increased
with traditional risk factors i.e.
menopause, underweight/obese,
medications, diet
Adequate calcium and vitamin D
depends on age
Maintain healthy body weight
Nutrient treatment
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1000-1200 mg calcium
1000 IU vitamin D (?more)
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Ministry of Social Development
(MSD) Provincial Nutrition
Programs
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Types of Health Supplements
Diet Supplement (also known as ‘Diet Allowance’)
 Short Term Nutritional Supplement
 Monthly Nutritional Supplement
 Other Health Supplements
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Diet Supplements
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Diet supplements assist clients to meet costs associated
with an unusually expensive therapeutic diet that is
required as a result of a specific medical condition or a
special dietary need.
A diet supplement may provided for a maximum of 12
months for acute (short-term) conditions and 24 months
for chronic (ongoing, recurring, long-term) conditions
Eligibility: For those on MSD income assistance & disability assistance
http://www.eia.gov.bc.ca/mhr/hsp.htm
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Diet Supplements
Monthly Allowance:
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$10: Restricted sodium diet
$35: Diabetes
$30: Kidney dialysis
$40: High protein diet (plus $30 towards the purchase of a
blender)
$40: Gluten-free diet
$40: Dysphagia (plus $30 towards the purchase of a blender)
$40: Ketogenic diet
$40: Phenylalanine diet
$50: Cystic fibrosis
Note: If client has multiple medical conditions- highest
amount ‘trumps’ and only 1 diet supplement will be given
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Diet Supplements
Funding for high-protein diets is available for
individuals who need additional nutritional support and
have been diagnosed with:
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Cancer (requiring nutritional support during radiation,
chemotherapy, surgical cancer therapy)
Chronic inflammatory bowel disease
Crohn's disease
Ulcerative colitis
HIV/AIDS, chronic bacterial infection and tuberculosis
Hyperthyroidism
Osteoporosis
Hepatitis B or hepatitis C.
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http://www.gov.bc.ca/meia/online_resource/health_supplements_and_programs/dietsupp/policy.html
Diet Supplements
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To be eligible for a diet supplement, recipients must
provide written confirmation of the need for the diet
supplement from a medical practitioner, nurse
practitioner or from a dietitian who is registered with
the College of Dietitians of British Columbia
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Diet allowance form available through MSD
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Letter can also be done and include:
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the specific medical condition
the diet required
expected duration of need
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http://www.gov.bc.ca/meia/online_resource/health_supplements_and_programs/dietsupp/faqs.html
Diet Supplements
HIV/AIDS Program
St. Pauls Hospital
1081 Burrard Street
Vancouver, B.C.
To Whom It May Concern at the Ministry of Social Development:
Re: Jane Smith
DOB: 1/1/1951
My client is HIV positive and requires a high protein diet to help improve nutritional status.
Please provide the $40 High Protein Diet Supplement and the initial $30 for purchase
of a blender. She will need this diet supplement for 2 years, the maximum allowable
time for a chronic condition as she will require this diet as long as she is living.
Sincerely,
Jenn Messina, CDBC #1046
Clinical Dietitian
604-682-2344 ext 62641
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Short-term Nutrition Supplement
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Nutritional supplements may be for those who
need additional calories above a regular diet
to recover from surgery, severe injury,
serious disease, or the side effects of
medical treatment
Eligibility: for those on MSD income assistance &
disability assistance
http://www.gov.bc.ca/meia/online_resource/health_supplements_and_programs/nutsupp/
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Short-term Nutrition Supplement
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To be eligible for a nutritional supplement, recipients must
provide written confirmation of the need from a medical
practitioner or nurse practitioner
Include:
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The diagnosis
The reason the product is required
The name of the product required, the amount of product required
and the expected duration of need (up to a maximum of 3 months)
Letter must confirm acute, short-term need to prevent critical
weight loss
For those on MSD income assistance & disability assistance, but NOT
getting Monthly Nutritional Supplement (MNS)
http://www.healthlinkbc.ca/healthyeating/bc-nutrition-programs.html
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Short-term Nutrition Supplement
To whom it may concern at the Ministry of Social Development,
Re: John Smith
Date of birth: 1/1/1951
I am writing as the dietitian for the Immunodeficiency Clinic where John Smith attends for
his medical care. John is being followed by the dietitian due to malnutrition and weight
loss due to his advanced lung cancer with bone metastasis. This person is also HIV positive
and on anti-retroviral therapy for immune reconstitution and viral suppression. John has
lost 7.6kg over the past few months, 12% of total body weight, and has visible muscle
wasting. His BMI is low at 18.2. Weight loss occurred during his radiation therapy for his
cancer and he has had ongoing poor appetite, nausea and weight loss after this therapy has
been completed. He is at ongoing high nutrition risk due to upcoming chemotherapy cancer
treatment.
He urgently requires 3 bottles of Ensure Plus daily for 3 months to optimize his oral intake,
prevent further weight loss, malnutrition, and muscle wasting. Malnutrition and
unintentional weight loss increase the risk of morbidity and mortality in HIV positive
people.
Please call me with any questions or concerns. Thank you.
Jenn Messina, Clinical Dietitian
CDBC #1046
Dr. Sarah Stone
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Monthly Nutritional Supplement
The Monthly Nutritional Supplement is
monetary allowance to financially assist those
who have a severe medical condition causing a
chronic, progressive deterioration of health
with symptoms of wasting. This supplement is
intended to prevent imminent danger to the
person’s life by providing essential, specified
items to supplement regular nutritional needs
Eligibility: for those on MSD Disability Assistance ONLY
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Monthly Nutritional Supplement
Written confirmation by the recipient’s medical practitioner or
nurse practitioner is needed to confirm:
1) the person has a severe medical condition causing a chronic,
progressive deterioration of health
2) as a result of this deterioration of health, the person displays two
or more of the following symptoms:
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malnutrition
underweight status
significant weight loss
significant muscle mass loss
significant neurological degeneration
significant deterioration of a vital organ
moderate to severe immune suppression
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http://www.gov.bc.ca/meia/online_resource/health_supplements_and_programs/mns/policy.html
Monthly Nutritional Supplement
3) to alleviate these symptoms, the person
requires one or both of the following items:
 additional
nutritional items that are part of
a caloric supplementation to a regular
dietary intake
 vitamins
and minerals
4) failure to obtain these items will result in
imminent danger to the person’s life
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Monthly Nutritional Supplement
How to Apply:
 Client needs to pick up “Monthly
Nutritional Supplement Application
form” from MSD
 MSD needs to complete part A
 Client needs to sign part B
 RD/MD/NP completes part C
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Monthly Nutritional Supplement
Tips and tricks for a successful form
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Make sure to discuss the form first with
the persons MD/NP, they take a lot of
time!
Be specific for vitamins and minerals
Leave the ‘duration of need’ open ended
if you aren’t sure the time frame they
may need items for
Don’t ‘overpromise’
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Monthly Nutritional Supplement
Tips and tricks for a successful form
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Other Supplements
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Tube feed supplement: provides liquid nutritional
tube feed, equipment and supplies to those who
are unable to take food orally or process it
through GT tract
Eligibility: on MSD income assistance or disability
http://www.gov.bc.ca/meia/online_resource/health_supplements_and_programs/
tubesupp/policy.html
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Department of Veteran's Affairs (DVA): May
cover tube feed supplements/supplies depending
on coverage
1-866-522-2122 (English) or http://www.veterans.gc.ca/eng
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First Nations
Some bands will cover a short-term supply of
Ensure/Boost
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Individual bands vary with coverage, speak with health
department of band department
For Status First Nations:
Tube feed formula /supplies and liquid supplements for some
patients. MD to write a prescription and fax to pharmacy.
Local pharmacy will then fax ‘letter of exception’ for Noninsured health benefits (NIHB) program to MD to complete.
For further information call NIHB at 1-800-317-7878
http://www.hc-sc.gc.ca/fniah-spnia/pubs/nihb-ssna/yhbvss/index-eng.php
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Resources
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CATIE: www.catie.ca
Position Statement ADA HIV Nutrition
The Body: www.thebody.ca
Ministry of Social Development:
http://www.gov.bc.ca/hsd/
AIDS Vancouver: www.aidsvancouver.org
Positive Living BC: www.positivelivingbc.org
DIAC (Dietitian’s in AIDS Care) Practice Group
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Good Articles/Resources
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B.C. Centre of Excellence in HIV/AIDS. (1997). The therapeutic guidelines for the
treatment of HIV/AIDS and related conditions: Section 9: Therapeutic nutrition
guidelines. Vancouver, B.C.
Food and Nutrition Technical Assistance Project. (2004). HIV/AIDS: A guide for
nutritional care and support, 2nd Edition. Academy for Educational Development,
Washington, DC.
Gerrior, J. & Neff, L. (2005). Nutrition assessment in HIV infection. Nutrition in Critical
Care, 8 (1), 6-15.
Holick, M.F. et al (2011). Evaluation, treatment and prevention of Vitamin D
deficiency: an Endocrine Society clinical practice guideline. Journal of Clinical
Endocrinology Metabolism, 96,7, 1911-1930.
Mangili, A., Murman, D., Zampini, M, and Wanke, C. (2006). Nutrition and HIV
infection: review of weight loss and wasting in the era of Highly Active Antiretroviral
Therapy from the Nutrition for Healthy Living Cohort. Clinical Infectious Diseases, 42,
836-842.
McComsey, G.A. et al (2010). Bone disease in HIV infection: A practical review and
recommendations for HIV Care Providers. Clinical Infectious Diseases, 51, 8, 000000.
Pribram, V. (2001). Nutrition and HIV. Oxford, U.K: Blackwell Publishing.
Ockenga, J. et al. (2006). ESPEN guidelines on enteral nutrition: wasting in HIV and
other chronic diseases. Clinical Nutrition, 25, 319-329.
World Health Organization. (2003). Nutrient requirements for people living with
HIV/AIDS: Report of a technical consultation. Geneva, Switzerland.
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Acknowledgements
Cheryl Collier, HIV RD at Oaktree Clinic
 Alena Barron, HIV RD at St. Paul’s 10C
 Clients of 10C, IDC, and Providence
Crosstown Clinic
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Questions?
Contact: [email protected]
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