Transcript Lecture 20 Nutrition in Cancer, AIDS, and Other Special Problems

The Truth about Cancer Patients
and Nutrition:
I Can Cope Program
PREVENTION:

30% to 40% of all
cancers may be
prevented by
changes in diet
and physical
activity
Role of Weight:

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Yo-yo dieting has been shown to decrease
immunity and may increase susceptibility
to cancer
Being overweight increases the chance of
getting several types of cancers, including
breast and prostate
Maintain a Healthy Weight and
be Physically Active

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A body mass index
(BMI) of 18.5 – 25 is
recommended
Healthy weight
results from a balance
of calories (energy) in
and energy expended.
ACS Guidelines: Choose a diet
rich in plant-based foods.

Using the “plate
method” think of ¾
of your dinner plate
contents as being of
plant origin and ¼
animal or other
protein source,
especially limiting
red meats.
Eat Plenty of Vegetables, Fruits,
Grains and Legumes
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Eat 5 - 9 servings daily
Eat a variety of fruits and veggies; choose
100% juices.
Include dark green and orange vegetables,
as well as dry beans and peas each week.
Enjoy whole grains, beans and peas with
each meal
Limit High Fat Foods
from Animal Sources

Choose fish, poultry, or
beans as an alternative to
beef, pork, and lamb

When you eat meat, select
lean cuts and smaller
portions
Prepare and Store Foods Safely
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Use safe storage methods
and promptly chill or
freeze leftovers.
Avoid burning of meat
juices.
Consume only
occasionally meat and fish
grilled in direct flame, and
cured or smoked meats.
Alcohol and Cancer Risk
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Increases risk of:
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Mouth and esophageal cancers
Pharynx and larynx cancers
Liver cancer
Breast cancer in women
Combined use of alcohol and tobacco greatly
increases risk compared to drinking or smoking
alone
**Drink alcohol in moderation, if at all.**
What about Sugar?

You CAN eat sugar: sugar does not “feed”
cancer cells BUT
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Stick with mostly naturally occurring sugars
such as in fruit and dairy foods
Avoid foods and beverages high in processed
sugars but low in other nutrients e.g.: soda
and sweets
Choose whole grains over refined versions
Cancer Treatment Side-effects:
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Appetite changes
Weight loss→ muscle loss, weakness,
decreased immune strength
Nausea and vomiting
Diarrhea or constipation
Dry mouth and mouth sores
Difficulty swallowing
Nutrition Education:

Studies show cancer patients who receive
nutrition counseling lose less weight,
experience fewer side-effects and have
overall better Quality-of-Life during
treatment than those who do not.
What about supplements?
High-calorie drinks and bars
Canned or powdered types
Homemade creations
Specialized formulas
Vitamins and Minerals
Herbs and other dietary supplements
Nutrition and HIV
Lancet 2003; 362: 1234-37
‘A new variant famine’?
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Secondary effects of the AIDS epidemic on food security,
famine and nutrition could be as great as the primary effects
Present southern Africa drought and food crisis compounds
AIDS epidemic
Historical coping strategies are in danger of collapsing.
Present food crisis more intractable
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High degree of vulnerability in areas not affected by drought
Household impoverishment has occurred more rapidly
Despite early rains in early 2003, high levels of vulnerability persist
Nutrition and HIV
Sub-Saharan Africa vs. Europe / N. America
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At risk populations for HIV/AIDS also at high
risk of food insufficiency
Poor quality of food as well as limited quantity –
limited choices
Higher burden of infectious diseases and
therefore need for effective antioxidant systems
Chronic malnutrition in the general population
introduces complex issues of equity and
distribution

Adults and children with HIV infection have increased
energy needs from the time they first become infected –
these need to be met in ways that are appropriate and
adequate

Monitoring weight is a very useful way of following
disease progression in an individual
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HIV infected adults and children are susceptible to
misinformation and commercial exploitation – know your
facts
HIV-associated wasting
Total energy
expenditure
Activity-related
Energy
Expenditure –
(AEE)
Resting
Energy
Expenditure
(αBMR)
TEE
Appetite
ILLNESS and
…
Food intake
AEE
REE
Growth in HIV-infected
children: sub-Saharan Africa
experience
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Growth is severely affected in HIV-infected children
Growth faltering is common and occurs early in life.
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Indus. countries >50% by 5yr vs. SSA 50% by 1 yr
Decreases in length- and wt- for-age observed by 3 mos
of age (Bobat 1998, Bobat 2001)
While both wt and length are severely affected, a
disproportionate effect on wt (wasting) is reported in
some cohorts by age 1 year
Growth faltering has marked
effect on survival
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Poor growth strongly and independently
associated with poor survival in US, European,
African, and HIV+ haemophilia populations.
In US children on antiretrovirals, poor growth is
an independent risk factor for death (McKinney1994,
Benjamin 2003, Carey 1998).
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Ugandan infants with low wt. had a 5-fold
increase in risk of death by age 25 mos. (Berhane
1997).
Body Mass Index at time of
HIV Diagnosis
BMI
Median Survival time
<16
0.8 yrs
≥ 22
8.9 yrs
BMI <18 is a significant independent predictor
of mortality and is comparable to CD4 count.
J Acquir Immune Defic Syndr, 37(2) 2004
Body composition abnormalities
HIV-infected children
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HIV-infected children have disproportionate
decreases of lean body mass with preservation
of body fat (Miller 1993, Arpadi 1998).
Reduced lean body mass is detectable prior to
decelerations in linear growth.
Diarrhoea has marked impact
on growth
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Diarrhoea reported 90% of HIV-infected children
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Chronic diarrhoea 6 times more likely to develop in
HIV-infected vs. uninfected children (Keusch 1992).
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Persistent diarrhoea associated with 11-fold increased
risk of death (Thea 1990).
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The mean growth for HIV-infected infants with >1
episodes of diarrhoea / yr was 1.4 cm/yr less than
infants with <1 episode (Villamor 2004).
Growth velocity is inversely related
to viral load
12-month growth velocity(cm/yr) vs HIV viral load (HIV RNA copies/ml)
performed in HIV-infected children (n=42)
Arpadi 2000
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Growth velocity and
FFM are inversely
related to level of viral
replication
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Viral replication
remains a negative
determinant of growth
rate even after
adjusting for food
intake.
Potentially modifiable factors involved in
HIV-associated growth abnormalities
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Dietary deficiencies
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Diarrhoeal illnesses
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prevention and treatment
prevention, detection, and nutritional
management
HIV replication and immune suppression
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use of anti-retroviral medications
Growth, body composition and dietary
intake?
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In contrast to simple malnutrition, pre-HAART studies
found enteral supplements improved wt and fat stores
but not ht or lean body mass
(Miller 1995, Henderson 1994).
Viral suppression improves growth
and body composition abnormalities
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Large studies detect improvements in growth
(wt>ht) attributable to protease inhibitor use
(Buchacz 2001, European Collaborative 2003)
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Improvements in gut absorption reported
(Canani
1999)
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Dietary intake is stable with ART
(Miller 2001).
WHO Technical Review
Growth abnormalities in HIV-infected children
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HIV impairs the growth of children early in life, especially height
growth. Often occurs before the onset of OIs /other symptoms.
Growth failure associated with increased risk of death.
The exact mechanisms of wasting are complex but insufficient
food intake and diarrhoea are major causes of poor growth,
especially in resource-poor countries
Cotrimoxazole improves growth and survival
ART, when clinically indicated, improves weight, growth and
development of infected children
WHO Technical Review
Energy and protein needs
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Energy needs increase by about 10% in adults and children
from the time of infection
During and after severe illnesses, these needs might increase
by a further 20-30%. In children this may be up to 150%.
No evidence for increased protein requirements other than in a
balanced diet i.e. 12-15% of the total energy intake
Anorexia and poor dietary intake are important causes of
weight loss
Improving the diet alone, though, may not result in weight
recovery and improvement in clinical status
Micronutrients and HIV infection
 viral load
Oxidative
stress
HIV+
Micronutrient
deficiencies
Infections
HIV+++
NAIDS
 CD4
Henrik Friis
Does micronutrient status /
intake affect HIV infection?
Increased micronutrient status / intake may affect
Transmission of HIV infection
mother-to-child transmissions
sexual transmission
Infectiousness and susceptibility
Progression of HIV infection
HIV load, CD4 counts, AIDS, death
Morbidity from other infections
Drug acceptability, efficiency, safety
Multiple micronutrients and HIV infection
Intervention trial
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Randomised trial in Thailand (Jiamton S, 2003)
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481 HIV+ adults
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Multimicronutrient or placebo for 48 wks
minerals: zinc 30 mg, iron 10 mg, selenium 0.4 mg, copper
3 mg, iodine 0.3 mg, chromium 0.15 mg, manganese 8 mg,
magnesium 80 mg
 vitamins A, B-complex, C, D, E, K
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Mortality reduced
RR 0.53 (95% CI: 0.22, 1.25)
 RR 0.26 (95% CI: 0.07, 0.97) among those with CD4<100
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No effects on HIV load and CD4 counts
NEJM 2004;351:23-32
vs. RNI
(daily intake which meets nutrient requirement for 97.5% apparently healthy
individuals in an age and sex-specific population)
Vitamin
A
B1 (thiamine)
B2 (ribofl)
B6
Tz supplement
RNI
10,000 RE
20mg
20mg
x12-15
25mg
Niacin
B12
Vit C
100mg
50ug
500mg
Vit E
Folic acid
Iron
30mg
0.8mg
120mg
x20
800RE
1.4mg
1.4mg
1.9mg
18mg
2.6ug
55mg
7.5mg
0.6mg
100mg*
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299 progressed to WHO stage 4 or died of ‘AIDS-related
causes’
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67 of 271 (24.7%) MVS
70 of 268 (26.1%) MVS + Vit A
79 of 272 (29.0%) Vit A only
83 of 267 (31.1%) placebo
MVS vs. placebo
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RR 0.71 [95%CI 0.51-0.98; P=0.04]
+ reduced progression to stages 3 or 4
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MVS group cf. placebo - higher CD4 and CD8 counts
and reduced VL
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Adding Vit A reduced the benefit
? Generalisability for policy
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Single study, urban
100 deaths excluded
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Possible misclassifications
Why not an intention to treat analysis?
Background maternal mortality 700/100,000!
Mixed staging criteria
Unusual composition based on ‘beneficial effects’ reported in
observational studies. ?Nutriceutical effect
No HIV uninfected comparison – mortality and pregnancy
outcomes may be true for all women with borderline
micronutrient deficiency
Are data true for HIV-infected men as well – do repeat study
in men
“ Neither zinc nor MMN had significant effects on culture
conversion, but MMN supplementation increased weight
gain in TB patients” (independent from culture conversion rates)
WHO Technical Review
Micronutrients requirements
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HIV-infected adults and children frequently have low levels
of micronutrients i.e. low body status
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Micronutrient intakes at RDA need to be assured in HIVinfected adults and children through consumption of
diversified diets, fortified foods and micronutrient
supplements as needed
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WHO recommendations on vitamin A, zinc, iron, folate and
multiple micronutrients remain the same
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Vitamin A supplements reduce diarrhoeal morbidity and
mortality especially in young children
WHO Technical Review
Micronutrients and HIV -ctd
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Micronutrients are not an alternative to comprehensive HIV
treatment including ARV therapy
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Studies have shown that some micronutrient supplements
may prevent HIV disease progression and adverse pregnancy
outcomes. Additional research is urgently required
‘Either… or…’
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‘Idealogical’ - optimising nutrition does not
eradicate HIV
Financial gain
Fear that ARVs may be displaced as the focus
for efforts – 3x5
Nutrition seen as a soft science and the data is
not substantial and therefore not worthy
WHO Technical Review
Nutrition and Antiretroviral therapy
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The benefits of ART are fully recognised but to achieve the full
benefits adequake dietary intake is needed
Dietary and nutritional assessment is an essential part of
comprehensive HIV care both before and during ART
Long term complications can occur with ART but the benefits
outweight the potential harm
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CVS, diabetes, bone
Little research has been conducted to fully understand the
relationship between nutrition and ART e.g.
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Pharmacokinetics in the severely malnourished
Potential benefit regarding adherence
Interactions with herbal treatments and other therapies
Impact of nutritional status on the development of longer term ARV
related complications such as lipodystrophy and bone problems

Adults and children with HIV infection have increased
energy needs from the time they first become infected –
these need to be met in ways that are appropriate and
adequate

Monitoring weight is a very useful way of following
disease progression in an individual

HIV infected adults and children are susceptible to
misinformation and commercial exploitation – know your
facts
Nutritional assessment

Food and Nutrition History
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
Anthropometric measurement
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Yearly height, weight, BMI, WHR*, consider MUAC and
skinfolds
Biochemical Assessment
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24h dietary recall inclusive of determination of food
access
Yearly fasting lipids, glucose and with change in ARV,
yearly hemoglobin; consider OGT in patients with IGT
Nutrition focused medical history and exam
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Obtain weight and growth history at each visit