Transcript 1578 KB - I-TECH

Unit 6:
Nutrition
Training on Clinical Care of HIV and AIDS
and Opportunistic Infections
Learning Objectives
Participants will be able to:
• Explain the interaction between nutrition
and HIV
• Assess, monitor and counsel patients on
nutrition
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 2
Nutrition Basics
• Calories (Energy)
• Macronutrients – CHO, proteins, and fats
• Some made by body, others needed from food
• Cellular and immunity protection
• Micronutrients – vitamins and minerals
• Not made by body, need all from food
• Protect, build the immune system, organs, and
bones
• Drink at least 2 litres of fluids per day
• Clean water, juice, and other non-caffeinated/nonalcoholic drinks
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 3
Namibian Food Groups
Food Group
Types of Foods
Benefits
Grains & Staple Foods
cereals, white or brown
bread, rice, macaroni,
mahangu, maize, potato
•Energy mostly from CHO
(fibre)
•B Vitamins and some
minerals
Animals Foods, Beans
and
Peas
beans, peas, eggs, milk,
yoghurt, meats, worms, fish,
chicken, nuts
•Protein to build immune
system
•Iron to prevent anaemia
•Calcium for bones
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Slide 4
Namibian Food Groups
Food Group
Types of Foods
Benefits
Vegetables & Fruits
Spinach, pumpkin, carrots,
asparagus, mushrooms,
apples, bananas, oranges,
other wild fruits
•Vitamins and minerals to
protect immune system, heal
wounds & infections
Fats & Sweets
Butter, margarine, oils, peanut
butter
•Fat provides concentrated
form of energy to help with
weight gain
•Vitamins A and E in oils
Table sugar, candies
•Sugar (simple CHO) adds
calories but are not nutritious
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Slide 5
Use Namibian Food Groups for Every
Meal
Grains:
mahangu, sorghum,
cassava, maize, wheat,
rice, potato
spices,
herbs
Balanced Meal
equals
Healthy Meal
Fats:
oilseeds,
oil, butter,
avocado
Protein Foods:
beans, peas,
nuts, milk,
Mopani worms,
egg, meat, fish,
etc.
Fruit:
paw-paw,
banana,
eenyandi,
eembe, guava,
etc
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Vegetables:
pumpkin,
spinach,
carrots, etc
Slide 6
Importance of Hygiene
• Water
• Boiled, treated or preserved
• Foods
• Preparation and storage
• Personal
• Wash hands with soap often
• Especially after using the bathroom and after handling raw
meat.
• Cleanliness of environment
• Garbage, latrines
• Cooking area and utensils
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 7
The Nutrition and HIV Link
• The Immune
System:
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
• Cells to fight
infections
• HIV attacks these
cells
• Causes weakening of
immune system and
infections
• Nutrition helps keep
the cells healthy and
fight infections
Unit 6: Nutrition, Slide 8
HIV Impact on Nutrition
• What’s the problem?
• Extra burden on body
• Decreased food intake and decreased
absorption
• What can we do?
• Early nutrition assessment, education and
treatment of nutrition-related problems
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 9
Daily Nutrition Requirements for
HIV
• Eat at least 3 times a day
• Calories/Energy: increase to fight infections and
prevent weight loss
• 10 percent increase for all HIV patients
• 20-30 percent increase with other infections
• Protein: 12-15% of calories
• Some research suggests an increase with serious infections
(i.e. TB)
• Micronutrients:
• At least 1 Recommended Daily Allowance (RDA) preferably
from food, but some may need a multivitamin/mineral
supplement
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 10
Effects of Malnutrition and HIV on the
Immune System
Malnutrition
HIV
 CD4 T-lymphocyte number
 CD8 T-lymphocyte number
 Delayed cutaneous hypersensitivity
 CD4 / CD8 ratio
 Serologic response after immunizations
 Bacteria killing
Good Nutrition
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
ART
Unit 6: Nutrition, Slide 11
Weight Loss Associated with
Survival
Weight loss over a 4-month time
interval independently predicted
illness and death in US HIV+ adults
Wheeler et al, JAIDS, 1998
3
Adj RR
2.22
1.89
2
1.19
1.26
1
0
0-5% loss
5-10% loss
Illness
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Death
Slide 12
Daily micronutrient supplementation reduced mortality
in HIV+ Thai adults, particularly those with low CD4 cell
counts : Jiamton et al, AIDS, 2003
0.6
Adjusted Mortality Risk
0.53
(P=0.10)
0.37
0.3
(P=0.05)
0.26
(P=0.03)
0
Overall
<200
CD4 < 100
There was
no effect on HIVCD4
viral
load, genital shedding
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 13
Micronutrients and CD4
Percent change in CD4
count
Kaiser et al. 2006, MN Supplements
Increase CD4 Count in HIV-infected
on HAART
140
120
124
100
100100
100
Day 1 CD4%
80
60
Day 12 CD4%
40
20
0
MN Supp
Placebo
Tre atm e nt
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 14
Vitamin A Deficiency and
Supplementation
• Vitamin A Deficiency
• Most significant in children and post-partum women
• Indications for supplementation:
• Routine preventative vitamin A supplement
immediately after birth to all women and to all
children 0-5 years old
• Treatment doses for children presenting with
diarrhoea, malnutrition, measles, pneumonia
• Unclear if beneficial in addition to multivitamin for
HIV-infected people; best taken in multivitamin
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 15
Zinc and Selenium Supplementation
• Zinc and Selenium
• Some research indicates deficiency in
patients on HAART
• Ensure adequate levels in MVM supplement
• Zinc supplements (20mg) beneficial in
diarrhoea treatment and a request to acquire
this has been submitted to the NEMlist
Committee
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 16
Iron Deficiency and Anaemia
• Anaemia has multiple causes
• Chronic illness, low serum Fe
• Nutrient deficiency (Fe, folate, B12)
• Hookworm, malaria, malignancy, OI, and AZT use
• Iron supplements, especially if anaemia
is not iron deficiency related, may be
harmful
• Recommend:
• multivitamin/mineral supplement and
• encourage iron-rich foods
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 17
Nutrition Supplements
• Safest and most beneficial option is daily
intake of nutritious foods and 1 daily
multivitamin/mineral supplement
• Discourage use of “immune boosting”
supplements or high-dose supplements, as
some may cause adverse effects
• Micronutrient fortified cereals have not shown
negative effects if taken as indicated, but not
fully researched
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 18
Specific Issues for HIV Positive
Persons
•
•
•
•
•
•
•
•
Loss of weight, or wasting syndrome
Loss of appetite, or anorexia
Nausea and/or vomiting
Sores of the mouth or throat
Changes in taste
Diarrhoea or malabsorption
Metabolic or endocrine changes
Micronutrient deficiencies
Refer to Handout 5.1
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 19
Management of Nutrition-Related
Complications
Symptom:
Causes/Etiology:
Leads to…
Loss of weight,
wasting
syndrome
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
Inadequate food
intake due to side
effects or food
insecurity
Infections (HIV or
other opportunistic
infections)
Loss of physical or
emotional well
being
Depression
Fever or other
symptoms of
infections
Adverse effects of
medications
Medications
Infections



Candida infections
Herpes
Aphthous ulcers


Loss of
appetite, or
anorexia




Nausea/
Vomiting
Mouth or
Throat Sores
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

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


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
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What to do?
Client
 Increase food intake, use fats, oils and sugar if
tolerated to help increase energy content of foods.
 Increase protein intake: meat, fish, dairy products,
beans, lentils, nuts, seeds
 Continue various forms of exercise to maintain or
increase muscle mass
Physician
 Provide nutrition support by encouraging optimal
nutrition and side effect management
 Complete nutrition assessment, including weight
measurement at each visit
 Investigate reason for weight loss and counsel on
appropriate intervention
Decreased food
intake
Weight loss
Micronutrient
deficiencies
Malnutrition
Potential noncompliance to ART



Eat with family and friends
Eat when you want, not only at mealtimes
Eat snacks, eat small amounts oftenAvoid alcohol
and cigarettes: these decrease appetite
Drink liquids that provide energy; milk, juice, or tea
with milk after or between meals
Add herbs or spices to meals to increase flavour
Exercise prior to a meal to stimulate the appetite



Counsel on nutrition management of appetite loss
Monitor for improvement
If available and if anorexia does not improve,
prescribe appetite stimulant such as megesterol
acetate (Megace)
Decreased food
intake
Weight loss
Potential noncompliance to ART

Eat small frequent meals: minimally spiced, not fried
or high in fat, and cold or room temperature.
Eat dry salty biscuits, dry toast to calm the stomach
Drink herbal and spice teas or juices
Avoid lying down until 20-30 minutes after eating;
Rest between meals.
Rinse mouth or gargle often with mouthwash or salt
and warm water mixture.
Eat soft mashed foods such as soft porridge, noodles,
oatmeal, yoghurt, mince meat, eggs, pumpkin, sour
milk and paw-paw.
Avoid foods that irritate like spicy foods (chillies,
curries) and acid foods (oranges, tomatoes, lemons,
vinegar).
Avoid sugary foods (cakes, sweets, etc) with ulcers.


Counsel on nutrition management of nausea and
vomiting
Prescribe anti-nausea medication if available and if
nausea persists




Prescribe medicated mouthwash
Counsel on nutrition management of mouth sores
Monitor for improvement
Dental referral
Loss of immune
function
Increased risk of
infection
Shortens survival
Decreased food
intake due to pain
Weight loss
Micronutrient
deficiencies
Malnutrition
Further GI tract
infection if untreated

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

Currently under research
*Refer to the Guidelines for Nutrition Management with HIV/AIDS for more detail.
+
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Refer to Handout 5.1
Unit 6: Nutrition, Slide 20
Loss of Weight
• Extremely dangerous for persons with HIV and
AIDSdue to:
• Loss of immune function
• Increased risk of infection
• Shortens survival
• Key interventions:
• Identify and treat weight loss early
• Provide guidance on nutrition management of
weight loss
• Weigh client at each visit. Obtain height at first visit
to calculate body mass index
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 21
Body Mass Index (BMI)
• Used to assess an individual’s weight based on
their height
• A quick and easy tool for estimating weight
status (e.g. underweight, normal weight,
overweight)
• BMI < 16kg/m2 has been correlated with
increased mortality in HIV patients; therefore,
an important measurement in HIV and AIDS
care
Refer to Handout 5.2
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 22
Body Mass Index Calculation and
Reference Chart
Handout 5.2 – Body Mass Index Calculation and Reference Chart
Underweight
BMI
2
(kg/m )
16
17
18
Normal Weight
19
20
21
22
23
Overweight
24
25
26
27
28
Height
(cm.)
Obese
29
30
31
32
33
34
35
36
37
38
39
40
41
42
Weight (kg.)
152
37
40
42
44
46
48
50
53
56
58
60
62
64
67
70
72
74
76
78
81
84
86
88
90
92
94
97
154
38
40
42
45
48
50
52
54
57
60
62
64
66
68
71
74
76
78
80
83
86
88
90
92
95
98
100
156
39
42
44
46
48
51
54
56
58
61
64
66
68
70
73
76
78
80
82
85
88
90
92
95
94
100
102
158
40
42
45
48
50
52
55
58
60
62
65
68
70
72
75
78
80
82
85
88
90
92
95
98
100
102
105
160
41
44
46
48
51
54
56
59
62
64
66
69
72
74
77
80
82
84
87
90
92
94
97
100
102
105
108
162
42
44
47
50
52
55
58
60
63
66
68
71
74
76
79
82
84
86
89
92
94
97
100
102
105
108
110
164
43
46
48
51
54
56
59
62
64
67
70
72
75
78
81
84
86
89
92
94
97
100
102
105
108
110
113
166
44
47
50
52
55
58
61
64
66
69
72
74
77
80
83
86
88
91
94
96
99
102
105
108
110
113
116
168
45
48
51
54
56
59
62
65
68
70
73
76
79
82
85
88
90
93
96
99
102
104
107
110
113
116
118
170
46
49
52
55
58
61
64
66
69
72
75
78
81
84
87
90
92
95
98
101
104
107
110
113
116
118
120
172
47
50
53
56
59
62
65
68
71
74
77
80
83
86
90
94
97
100
103
106
108
110
112
115
118
120
124
174
48
51
55
58
61
64
67
70
73
76
79
82
85
88
91
94
97
100
103
106
109
112
115
118
120
124
127
176
50
53
56
59
62
65
68
71
74
77
81
84
87
90
93
96
99
102
105
108
111
115
118
120
124
127
130
178
51
54
57
60
63
67
71
74
76
79
82
85
89
92
95
98
101
105
108
111
114
117
120
124
127
130
133
180
52
55
58
61
65
68
71
75
78
81
84
87
97
94
97
101
104
107
110
113
117
120
123
126
130
133
136
182
53
56
59
63
66
69
73
76
79
83
86
89
93
96
98
103
106
109
113
116
119
123
126
129
132
136
139
184
55
57
61
64
68
71
74
78
81
85
88
91
95
98
102
105
108
112
115
118
122
125
129
132
135
139
142
186
55
59
63
66
67
73
76
79
83
87
90
93
97
101
104
107
111
114
117
120
124
128
131
135
138
142
145
188
57
60
63
67
71
74
77
81
85
89
92
95
99
103
106
109
113
117
120
124
127
131
134
138
141
145
148
190
57
61
65
69
73
76
79
83
87
91
94
97
101
104
108
112
115
119
123
126
130
133
137
141
144
148
152
192
59
63
67
70
73
77
81
85
89
93
96
99
103
107
111
115
118
120
125
129
133
136
140
144
147
151
155
194
61
64
67
71
75
79
83
87
91
94
97
101
105
109
113
117
120
124
128
132
135
139
143
147
151
154
158
196
61
65
69
73
77
81
85
89
93
96
99
103
107
111
115
119
123
127
131
134
138
142
146
150
154
157
161
198
63
67
71
75
79
83
87
91
95
98
101
105
109
113
117
120
125
129
133
137
141
145
149
153
157
161
165
200
63
67
71
75
79
83
87
91
95
99
103
107
111
115
119
124
128
132
136
140
144
148
152
156
160
164
168
Source: CDC, 2005
Refer to Handout 5.2
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 23
Weight Loss Calculation
•
•
•
•
Percent weight loss
UBW = Usual Body Weight
CBW = Current Body Weight
Formula:
% loss = UBW – CBW x 100
UBW
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 24
Diarrhoea or Malabsorption
• Treat dehydration (ORS, home solution)
• Eat easy-to-digest foods (porridge, rice, bread,
bananas)
• Eat/drink fermented foods, i.e. unsweetened
yoghurt/sour milk, oshikundu
• Small meals, frequently
• Avoid fatty foods (with fat malabsorption)
• Avoid high sugar foods
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 25
Positive Effects of Adequate
Nutrition
Maintenance
• Maintain a stable weight
• Avoid loss of muscle mass
• Replace lost nutrients, preventing
malnutrition
Fight other Infections
• Maximize the body’s capacity to fight
infections, including opportunistic infections,
and to heal wounds
• Slow the progression of HIV and help
recovery from other infections
Well Being
• Maintain activities
• Improve quality of life
• Improve productivity
Effectiveness of Treatment
• Improve the tolerance to and effectiveness
of medications.
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 26
Connection Between Nutrition and
HIV and AIDS
Optimal food
intake, balanced
diet
Slower
Maintain
progression
weight and
of HIV
prevent side
and better Stronger immune effects
health
system to fight
infections
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 27
Key Points
1. Encourage balanced meals with a variety of
locally available foods
•
Balance of staple foods, proteins, fats, fruits and
vegetables
2. Regular nutrition assessment is essential to
preventing nutrition-related conditions
•
•
Calculate BMI and % weight loss (if applicable) at
each visit
Provide counseling on management of nutritionrelated side effects
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 6: Nutrition, Slide 28