Transcript Slide 1

New York State Department of Health AIDS Institute
Nutrition and HIV/AIDS
Peter Wasserman, RD, MA
Metabolic Support, Infectious Disease Division, Department of Medicine, New York Hospital Queens,
Flushing, NY
Sorana Segal-Maurer, MD
Attending Physician, Infectious Disease Division, Department of Medicine, New York Hospital Queens,
Flushing, NY
Associate Professor of Clinical Medicine, Weill Medical College of Cornell University, New York, NY
David S. Rubin, MD
Medical Director, AIDS Designated Center, Attending Physician, Infectious Disease Division,
Department of Medicine, New York Hospital Queens, Flushing, NY
Clinical Assistant Professor of Medicine, Weill Medical College of Cornell University, New York, NY
The Implications of HIV on Nutrition
• In New York State over 35% of persons living with HIV infection are
over 50 years old and 38% are between the ages of 40 and 49 years
old. Seventy percent of persons living with HIV/AIDS are men and
57% of new cases occur in men who have sex with men.1 This
demographic has broad implications for the nutritional care of
persons with HIV infection.
• Wasting disease was the prominent nutritional issue in patient
management prior to the advent of antiretroviral therapy (ART).
Although wasting disease still occurs, HIV infection has become a
chronic disease for most patients.
• Increasingly, newly diagnosed persons with HIV/AIDS live in urban
poverty areas and experience food and housing insecurity, as well
as limited access to fresh food stuffs.2,3
New York State Department of
Health AIDS Institute
2
Key Point
Comorbidities including cardiovascular
disease, osteopenia/osteoporosis, and
sarcopenia are now predominant in HIV
infection, have a significant dietary
component, and are associated with
aging.
New York State Department of
Health AIDS Institute
3
Multicausation Model of
Malnutrition
New York State Department of
Health AIDS Institute
4
Manifestations of Malnutrition
Malnutrition may manifest as overnutrition,
undernutrition, or single nutrient
deficiency. It can occur in association with:
– Food insecurity
– Poor-quality, calorie-dense diet
– Loss of perception of hunger or appetite
– Malabsorption
– Altered metabolism
– Sedentary lifestyle
New York State Department of
Health AIDS Institute
5
Food Insecurity
Recommendation: Advise patients of organizations in their area
offering congregate meals, home meal delivery, and/or food
pantries. (AIII)
• Food insecurity is defined as limited or uncertain availability of
nutritionally adequate, safe foods or the inability to acquire
personally acceptable foods in socially acceptable ways.4
• Food insecurity may exist with or without hunger and may
contribute to wasting or obesity.5
• Association with obesity, while counterintuitive, is likely due to
reliance on inexpensive calorie-dense convenience foods, fast
food or take-out food, and sugar-sweetened beverage intake.6
New York State Department of
Health AIDS Institute
6
Key Point
The United States Department Agriculture
food security questionnaire (six-question
short-form) may be used to assess
household food security.7 The
questionnaire is available at:
http://www.ers.usda.gov/Publications/err108/err108.pdf
New York State Department of
Health AIDS Institute
7
Poor-Quality, Calorie-Dense Diet
Recommendation: Ascertain where patients shop for food
and ingredients used in meal preparation and counsel as
needed. (AIII)
• Dietary intake high in refined white flour, polished (white
or yellow) rice, sugar, sugar-sweetened beverages,
saturated and polyunsaturated fat, and salt is strongly
associated with hyperlipidemia and insulin resistance in
HIV-infected persons.8-10
• Patient diet is likely associated with the large
interindividual variability in lipid response to specific
antiretrovirals.8
New York State Department of
Health AIDS Institute
8
Appetite/Hunger Suppression
Febrile response to opportunistic or
secondary infection, oropharyngeal or
esophageal lesions, depression, or
substance use may lead to decreased
food intake.
New York State Department of
Health AIDS Institute
9
Key Point
Decreased food intake may be a direct
result of disease processes, loss of
structure in daily life, and/or how a patient
feels about living with HIV infection.
New York State Department of
Health AIDS Institute
10
Malabsorption
• Opportunistic or secondary infection, as
well as neoplastic disease, of the bowel
may lead to nutrient malabsorption.
• Patients with diarrheal disease or painful
lesions of the alimentary track may reduce
food intake to avoid urgent or painful
bowel movements.
New York State Department of
Health AIDS Institute
11
Key Point
Diarrheal disease should be viewed as
undernutrition with fluid and electrolyte
loss.
New York State Department of
Health AIDS Institute
12
Altered Metabolism
• Metabolic abnormalities may alter nutrient
utilization, storage, or excretion from the
body.
• Abnormalities may be due to HIV infection
itself or may be associated with specific
antiretroviral medications.11-13
New York State Department of
Health AIDS Institute
13
Metabolic abnormalities documented in
association with HIV infection:
•
•
•
•
•
Elevated resting energy expenditure/basal metabolic rate
Increased dietary protein requirement
Decreased total and HDL cholesterol
Increased serum triglycerides and VLDL cholesterol
Low free testosterone (bioactive fraction) in association
with wasting syndrome
• Growth hormone resistance in association with wasting
syndrome
• Decreased visceral/abdominal and subcutaneous
adipose tissue
• Decreased bone mineral density
New York State Department of
Health AIDS Institute
14
Metabolic abnormalities associated
with some antiretroviral medications:
• Elevations in serum LDL cholesterol or
triglycerides (some protease inhibitors)
• Renal excretion of phosphorus and/or
glucose (tenofovir)
• Insulin resistance (protease inhibitor class
effect)
New York State Department of
Health AIDS Institute
15
Sedentary Lifestyle
Recommendation: Routinely counsel patients to engage in
regularly scheduled resistance and aerobic exercise
(AI).9,15
• Lack of routine scheduled resistance and aerobic
exercise may lead to abdominal adiposity, sarcopenia, or
diminished bone mineral density.
• Weight gain in middle age is associated with excess risk
of type 2 diabetes mellitus and cardiovascular disease
events.16
New York State Department of
Health AIDS Institute
16
Centers for Disease Control and Prevention
exercise recommendations for adults are:
• 150 minutes/week moderate intensity aerobic exercise and 2
sessions/week of resistance exercise working all major
muscle groups
or
• 75 minutes/week vigorous aerobic exercise and 2 sessions
/week resistance exercise
or
• Equivalent mix of moderate and vigorous aerobic exercise
and 2 sessions/week resistance exercise
New York State Department of
Health AIDS Institute
17
Key Point
Patients who are not obese or
overweight should maintain a
constant body weight throughout
adulthood.
New York State Department of
Health AIDS Institute
18
Referral for Nutritional Services
New York State Department of
Health AIDS Institute
19
Recommendation: The following should prompt referral to
a New York State certified nutritionist/registered dietitian
for evaluation and patient-specific nutrition care plan
(AIII)16:
• Entry into HIV care
• Unintentional weight loss >10% over 4 to 6 months
• Chronic nausea, diarrhea, or vomiting
• Severely dysfunctional psychosocial situation
• Hyperglycemia
• Dyslipidemia
• New diagnosis of diabetes, hypertension, or renal
disease
• Two or more medical comorbidities
• Annual or comprehensive visits
• Abdominal adiposity
New York State Department of
Health AIDS Institute
20
Key Point
Patients presenting with nutritional disorders
may show involuntary weight loss, be over
weight, and have increased dietary
indiscretion.
New York State Department of
Health AIDS Institute
21
Comprehensive Nutrition
Consultation
New York State Department of
Health AIDS Institute
22
Nutrition care consists of:
• Assessment and intervention (including
education in nutrition and the disease
state)
• Dietary counseling and self-management
training
• Pharmacological intervention
• Food support or tube feeding or
intravenous alimentation and routine follow
up/reassessment
New York State Department of
Health AIDS Institute
23
Recommendation: nutrition consultation should include
the following (AIII):
• Patient complaints
• Dietary evaluation
• Demographics and clinical history
• Clinical and anthropometric parameters
• Functional tests as needed
• Review of laboratory results
• Review of medications focused on potential side effects
• Social history including “supplement” use
• Family history
• Energy, protein, and micronutrient requirements
• Intervention as needed with routine follow-up
New York State Department of
Health AIDS Institute
24
Investigation of Patient Complaints
Recommendation: evaluate for (AIII):
• Depression in patients complaining of “loss of appetite”
or hyperphagia
• Recent weight loss and period of time over which it
occurred
• Mistaken beliefs about nutrition, e.g., eating high fat
foods will replace subcutaneous fat loss due to prior
antiretroviral regimens with adipocyte /mitochondrial
toxicity
• Alimentary tract disease in those complaining of
odynophagia or “diarrhea”
• Access to cooking and refrigeration facilities
• Ability to shop for ingredients and prepare meals
New York State Department of
Health AIDS Institute
25
Dietary Assessment
Recommendation: Evaluation of dietary
intake should include who prepares meals,
where and with whom they are consumed,
meal frequency, meal completion, quality
and source of ingredients, cooking method
and portion sizes.
New York State Department of
Health AIDS Institute
26
Nutritional Intake
• Evaluate intake of concentrated protein (fish, poultry, meat, egg
white), vegetables, whole grains and tubers, fruit, and sugarsweetened beverages including juices or “juicing.”
• Sugar-sweetened beverage intake should be discouraged due to
linkage with diabetes, cardiovascular disease, diabetes and
obesity.18
• Evaluate for patient use of processed/convenience foods especially
prepared meats and canned goods due to their high sodium content.
• Portion size models, e.g., 3 oz size or ½ cup size, are helpful in
ascertaining usual portion size during the clinical encounter.
• Use of fresh seasonal foods, locally grown when possible or frozen,
and prepared at home should be strongly encouraged.
New York State Department of
Health AIDS Institute
27
Key Points
• Food Stamp electronic benefits transfer (EBT)
cards may be used at New York City farmers or
“greenmarkets.”
• Dietary sodium intake is largely from hidden
sodium added during food processing,
restaurant, fast food, and takeout meals.
• Institute of Medicine (IOM) guidelines now
recommend that most adults limit sodium intake
to 1500 mg per day.
New York State Department of
Health AIDS Institute
28
Recommendations (AIII):
• NYC clinics should post the locations of
greenmarkets participating in the Food
Stamp (EBT) program in waiting rooms
(available at grownyc.org).
• Adult patients should be referred to NYS
certified nutritionist/registered dietitian for
evaluation and education to achieve
sodium intake reduction (to IOM
recommendation).
New York State Department of
Health AIDS Institute
29
Demographics and Clinical History
Recommendation: National Institutes for
Health and World Health Organization
assessment instruments should used to
determine need for intervention and goals
(AIII).
New York State Department of
Health AIDS Institute
30
Demographics and Clinical History
• Nutritional interventions and their intensity should be based on
assessment of potential benefit to the patient and the degree of
disease event risk associated with the target abnormality. The
patient’s willingness to execute dietary and other health behavior
change is paramount.
• National Cholesterol Education Program Adult Treatment Panel III
(NCEP/ATPIII) should be used in evaluation.
• WHO Fracture risk assessment tool (FRAX) should be used where
clinically appropriate (men >50 y and postmenopausal women).
• Clinical history should including duration of HIV infection, nadir CD4
count, history of opportunistic infection, wasting, and antiretroviral
treatment history.
New York State Department of
Health AIDS Institute
31
Key Point: Osteoporosis
Patients age and ethnicity (e.g., FRAX) may
drive absolute osteoporosis risk.
Historically, osteoporosis has been more
prevalent in older Caucasian women and
less so in African Americans.
New York State Department of
Health AIDS Institute
32
Clinical and Anthropometric
Assessment
Patients with HIV infection may present with
wasting (involuntary loss of lean body
mass and adipose tissue), sarcopenia
(age-related loss of skeletal muscle with
preservation or increase in adipose
tissue), or lipodystrophy (focal or global
loss of subcutaneous adipose tissue with
preservation of visceral adipose tissue and
skeletal muscle).
New York State Department of
Health AIDS Institute
33
Recommendation: evaluate for (AIII):
• Body mass index (BMI), weight in kilograms/height in meters
squared (NIH guidelines: undernutrition, <18.5; normal, 18.5 to
29.9; obese, >30)
• % documented usual weight
• Temporal wasting and facial lipoatrophy
• Oral cavity for missing dentition, oral mucosal ulcers, (e.g.,
apthous or viral ulcers), malignancy (e.g., Kaposi’s sarcoma),
fungal infections (e.g., oral candidiasis)
• Neck circumference
• Increase may associate with upper trunk adiposity and/or sleep
apnea
• Shoulders for angularity/prominent acromium process due to
deltoid muscle loss
• Trunk for increased clavicle prominence (subclavicular muscle
loss)
• Visible articulations of the ribs at the junction with the sternum
consistent with subcutaneous fat loss
New York State Department of
Health AIDS Institute
34
Recommendation (continued): evaluate for (AIII):
• Waist and hip circumferences
– ATP III: abdominal obesity, male >40 inches, female >35 inches
– Loss of hip circumference reflects gluteal-femoral subcutaneous fat loss
and is associated with insulin resistance/type 2 diabetes mellitus.
• Mid-upper arm circumference (non-dominant arm)
• Less than 10th percentile NHANES may be consistent with wasting
or lipodystrophy. Delayed skin-fold return is suggestive of
dehydration.
• Prominence of extremity vasculature consistent with subcutaneous
fat loss
• Mass of the interosseus dorsalis muscle by having the patient press
the tip of his forefinger and thumb together
• Muscle mass at the insertion of the quadriceps femoris and the
vastus medialis with the patient’s leg positioned at a right angle.
• Lower extremity edema (sacral edema bed rest patients).
• In profoundly wasted patients; peri-orbital edema, ascities, and
scrotal edema.
New York State Department of
Health AIDS Institute
35
Additional Anthropomorphic Tests
• Bioelectrical impedance analysis (BIA) may be additive
to physical examination. BIA indirectly measures tissue
compartments, lean body mass (LBM), body cell mass
(BCM), fat mass and extracellular (interstitial) mass
(ECM). Phase-angle is a geometrical expression of the
resistance and capacitance components of this assay.
• Phase angle <5.6º and <4.8º are associated with
diminished and non-survival, respectively.19
• ECM-to-BCM ratio of 1.3 or greater associated with nonsurvival.19
• Serial BIA over time describes weight loss or gain over
time by soft tissue compartment quantifying response to
clinical intervention.
New York State Department of
Health AIDS Institute
36
Key Point
Patients with skeletal muscle loss may not
always demonstrate weight loss if
concurrent compartmental shift occurs,
e.g., expansion adipose tissue or
extracellular fluid depots.
New York State Department of
Health AIDS Institute
37
Functional Tests
• There are concerns that long-term HIV infection may interfere
with the normal aging process and accelerate it. Increased
rates of cellular senescence may lead to loss of functional
reserve over time. Several methods are available to evaluate
for this.
• Nutritional interventions such as protein, vitamin D, and
calcium supplementation are first-line therapy for sarcopenia
and osteopenia. Clinical investigators have documented
decreased bone mineral density and increased non-traumatic
fracture (fragility) risk in aging HIV-infected patients.20
Propensity to fall due to diminished hip, knee and ankle
musculature often leads to fracture in older patients. Mid-life
handgrip strength (Jamar Hand-grip dynamometer) and usual
gait speed (timed walk) reflect total skeletal muscle and are
predictive of future disability.21,22
New York State Department of
Health AIDS Institute
38
Key Point
Muscle function in addition to body mass
should be evaluated in middle-aged and
older patients.
New York State Department of
Health AIDS Institute
39
Laboratory Panels for Nutritional
Aassessment
Recommendation: Nutritional assessment
should include evaluation of the following
laboratory panels (AIII).
• Complete metabolic panel
• Lipid panel
• Testosterone panel (men)
• 25-[OH] vitamin D
• Complete blood count
New York State Department of
Health AIDS Institute
40
Recommendation: Evaluate complete
blood count for findings consistent with
vitamin and/or mineral deficiency.
Clinicians should be mindful of the bone
marrow suppressive effect of HIV infection
itself and elevated ferritin, an acute phase
reactant, during opportunistic or secondary
infection.
New York State Department of
Health AIDS Institute
41
Key Points
• Patients with wasting and/or diarrheal disease may demonstrate
profound hypophosphatemia, hypokalemia, and low magnesium.
Hospitalized patients should receive intravenous replacement, as
needed.
• “Return to health effect” during the first two years of cART may
manifest in elevation of total and LDL cholesterol in association with
return to pre-illness diet. HDL cholesterol frequently remains low in
spite of immune reconstitution with antiretroviral therapy.11
• HIV-infected men with wasting frequently demonstrate low free
testosterone (hypogonadism). Repletion of skeletal muscle may be
blunted in the absence of replacement therapy.23
• Low testosterone in older men in the general population has been
linked to cardiovascular disease risk, sarcopenia, and insulin
resistance.
• Vitamin D deficiency is prevalent in HIV-infected patients in care.24
New York State Department of
Health AIDS Institute
42
Medication and “Supplement”
Review
Recommendation: Nutrition consultation should include
review of current medications, vitamins, and
“supplements” (AIII).
Herbal products and some vitamins at high dosage may
interact with antiretroviral medications, enhance viral
replication or contain undeclared prescription ingredients
or other chemicals.25 Patients may disclose usage of
what they consider to be dietary enhancements to their
nutritionist/registered dietitian while neglecting to
disclose them to their doctor during medication review.
New York State Department of
Health AIDS Institute
43
Key Point
Herbal products are nonstandardized
pharmaceuticals that may interact with
antiretroviral medications and/or lead to
toxicity.
New York State Department of
Health AIDS Institute
44
Social History
Recommendation: evaluate for the
following (AIII):
• Tobacco use, alcohol use, other
substance use
• Scheduled routine resistance and aerobic
exercise program
New York State Department of
Health AIDS Institute
45
Key Points
• Patients should be counseled to engage in
scheduled resistance exercise (in addition
to aerobic) to achieve optimal peak bone
density, maintain skeletal muscle and
lessen fall risk later in life.26
• Education regarding diet and behavior,
and bone mineral density should be
provided to patients.26
New York State Department of
Health AIDS Institute
46
Centers for Disease Control and Prevention
exercise recommendations for adults are:
• 150 minutes/week moderate intensity aerobic exercise and 2
sessions/week of resistance exercise working all major
muscle groups
or
• 75 minutes/week vigorous aerobic exercise and 2 sessions
/week resistance exercise
or
• Equivalent mix of moderate and vigorous aerobic exercise
and 2 sessions/week resistance exercise
New York State Department of
Health AIDS Institute
47
Family History
Recommendation: At least annually, update
family history for cardiovascular disease,
diabetes mellitus, end-stage kidney disease, and
cancer(s) especially when occurring among first
degree relatives (parents, siblings, offspring)
(AIII).
Evolving health history of a patient’s siblings may
inform evaluation of seemingly minor clinical
findings.
New York State Department of
Health AIDS Institute
48
Macronutrient Requirements:
Caloric Requirement
Recommendations:
• Maintenance energy requirement (protein and
non-protein calorie) should be calculated for
persons who are hospitalized or in custodial
care to insure provision of adequate nutrition
(AIII).
• Maintenance energy requirement should
considered in determining planned caloric deficit
for person’s participating in programs of caloric
restriction to achieve weight loss (AIII).
New York State Department of
Health AIDS Institute
49
Caloric Requirement (continued)
• Total energy expenditure (TEE) consists of: basal
metabolic rate (BMR) or measured resting energy
expenditure (REE) by indirect calorimetry (after a 12h
fast, in a thermoneutral environment, upon awakening
and prior to ambulation), dietary thermogenesis (DT), the
thermic effect of food intake and energy expenditure of
voluntary activity (EEA). To maintain weight stability
(maintenance energy requirement) a patient’s caloric
intake should equal TEE.
• Weight Stability: TEE = REE + DT + EEA
New York State Department of
Health AIDS Institute
50
Caloric Requirement (continued)
The Harris-Benedict equation may be used to
calculate REE in the absence of indirect
calorimetry. Disease effect on REE may be
estimated by an increase of 10 or 25%, HIV
infection or AIDS, respectively, DT 10 or 20%,
HIV or AIDS, respectively, and EEA 20-30%
depending on level of activity.27 This may be
expressed as a factor for calculation of
maintenance energy requirement. Maintenance
energy requirement may range from 1.4 to 1.75
times predicted BMR or measured REE.
New York State Department of
Health AIDS Institute
51
Caloric Requirement (continued)
Convalescent patients demonstrating
wasting may require additional energy
(approximately 20%) for anabolism.
Emphasis should be on achieving this
additional intake from food/additional
meals. Nutrient dense ready-to-use
supplementary foods may be of value
where lesions or patient resources limit
meal intake.
New York State Department of
Health AIDS Institute
52
Key Point
Persons with HIV infection continue to
demonstrate elevation of basal metabolic
rate in spite of cART, immune restoration
and viral suppression.28
New York State Department of
Health AIDS Institute
53
Macronutrient Requirements:
Protein Requirement
Recommendation: Higher dietary protein intake should
also be considered for older patients and those
demonstrating sarcopenia, frailty or wasting (AII).
Asymptomatic HIV-infected persons demonstrate a higher
rate of amino acid oxidation, consistent with a
predisposition toward muscle protein loss.29 Clinicians
should be mindful of this in conjunction with the early
initiation of cART. During AIDS wasting muscle protein
synthesis represents a decreased fraction of whole body
protein synthesis.29
New York State Department of
Health AIDS Institute
54
Protein Requirement (continued)
High-nitrogen feeding (amino acids 1.5 to
1.8g/kg/body weight) significantly
improves nitrogen balance in patients with
wasting syndrome.30 Higher dietary protein
intake should also be considered for older
person’s demonstrating sarcopenia or
frailty.31
New York State Department of
Health AIDS Institute
55
Clinical Intervention: Mediterranean
Diet
Recommendation: Persons with HIV-infection should be
advised to follow and receive instruction in the
Mediterranean diet (AI).
A Mediterranean diet has demonstrated efficacy in primary
and secondary prevention trials for cardiovascular
disease and type 2 diabetes mellitus among HIVnegative individuals.32-35 Persons’ with HIV infection
receiving combination antiretroviral therapy
demonstrated better metabolic parameters and lower
risk for abdominal adiposity than those on a typical
western diet.36-37
New York State Department of
Health AIDS Institute
56
The Mediterranean diet is
characterized by:
•
•
•
•
•
•
•
•
•
•
•
High intake of dark green leafy and other vegetables
Fresh fruit as the typical daily desert
Use of whole grains for starches, beans, nuts, seeds, potato
Olive oil as the principal source of fat
Dairy products (principally cheese and yogurt)
Fish two or more times a week
Poultry consumed in moderate amounts
Egg yolks limited to four/week
Red meat consumed in low amounts
Wine consumed in low to moderate amounts, normally with meals
Low saturated fat (≤7-8% of energy), with total fat ranging from
<25% to >35% of energy throughout the region
New York State Department of
Health AIDS Institute
57
Key Point
• Adherence to a Mediterranean diet may significantly
reduce cardiovascular disease events and incidence of
type 2 diabetes mellitus.36
• Attention should be given to identifying foodstuffs with
which the patient is culturally familiar that may be part of
a Mediterranean diet and are within their financial
capability (e.g., collard greens, kale, and mustard
greens).
• Evaluation of diet and intervention as needed should be
considered prior to antiretroviral regimen change due to
abnormalities of nutritional-metabolism, e.g.,
dyslipidemia.
New York State Department of
Health AIDS Institute
58
Clinical Intervention: Multivitamin
Supplementation
Recommendation: A daily multivitamin with
minerals meeting the recommended daily
allowances is prudent.
New York State Department of
Health AIDS Institute
59
Key Point
Tolerable upper intake levels of
micronutrients for people with HIV
infection have not been established.
New York State Department of
Health AIDS Institute
60
Clinical Intervention: Vitamin D and
Calcium
Recommendation: Advise patients that
adequate calcium intake and weight
bearing (resistance) exercise are required
along with vitamin D for maintenance of
bone density (AIII).
New York State Department of
Health AIDS Institute
61
Vitamin D and Calcium (continued)
• Vitamin D insufficiency and deficiency are defined by
serum 25-[OH] vitamin D and vitamin D supplementation
should be prescribed as needed.
• High intakes of animal protein and/or salt increase
urinary calcium loss. Conversely low protein intake in
older persons’ is associated with osteoporosis.38
• The new Institute of Medicine daily adult reference
intakes (DRI) for vitamin D is 600 IU/d for adult men and
women (800 IU after age 70) and Calcium 1000mg/d for
men and women (1200 mg for women after age 51).39
New York State Department of
Health AIDS Institute
62
Key Point
In addition to hypertension, high sodium
intake may contribute to loss of bone
mineral density.40
New York State Department of
Health AIDS Institute
63
Clinical Intervention: Testosterone
Replacement Therapy
• Topical testosterone preparations: Testim®,
Androgel®, and Androderm™ may be used for
replacement therapy in hypogonadal men.
• Male hypogonadism is also associated with
osteoporosis and several cardiovascular disease
risk factors (e.g., increased total cholesterol, low
density lipoprotein cholesterol, and increased
arterial wall thickness).
New York State Department of
Health AIDS Institute
64
Key Point
Testosterone replacement therapy in men
may improve nutritional parameters in soft
and hard tissue, and lipid panel.26,41
New York State Department of
Health AIDS Institute
65
Clinical Intervention: Orexigenic
Agents
• Profound loss of hunger sensation may be medically
managed with Megestrol acetate: Megace™ or Megace
ES®.
• Megestrol acetate is a synthetic progesterone derivative
and may lead to male hypogonadism, hyperglycemia
and adrenal insufficiency. For these reasons treatment
with megestrol acetate should be of short duration.
• Presentations associated with chronic mild nausea may
be medically managed with Dronabinol; Marinol®. Doserelated euphoria and somnolence in patients receiving
dronabinol have been documented.
New York State Department of
Health AIDS Institute
66
Key Point
Differentiate between prolonged absence of
hunger feelings and chronic mild nausea
in patients complaining of “loss of
appetite.”
New York State Department of
Health AIDS Institute
67
Clinical Intervention: Supraphysiological
Growth Hormone Administration
• Patients with clinically significant dietary
intake who present with profound wasting
disease may be candidates for treatment
with recombinant human growth hormone,
Serostim®.14
• Candidates for recombinant human growth
hormone should be screened for impaired
glucose tolerance and diabetes mellitus.
New York State Department of
Health AIDS Institute
68
Key Point
Recombinant human growth hormone may
be appropriate for ambulatory outpatients’
with profound skeletal muscle loss who
are free of clinically active opportunistic or
secondary infection, and who are able to
achieve clinically significant dietary intake.
New York State Department of
Health AIDS Institute
69
Clinical Intervention: Non-volitional
Alimentation
Patients with panenteritis may be candidates
for intravenous alimentation. Patients with
neurological disease, oropharyngeal or
esophageal lesions, partial small bowel
disease, and those unable to achieve
clinically significant volitional intake may
be candidates for intragastric tube feeding.
New York State Department of
Health AIDS Institute
70
Key Point
Intravenous alimentation may be considered
for patients in whom clinically significant
caloric intake can not be achieved due to
impaired small intestine function or lack of
access to the small bowel.42
New York State Department of
Health AIDS Institute
71
References
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United States, 2008. MMWR Morb Mortal Wkly Rep 2010;59(37):1201-1207. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5937a2.htm
2. Normen L, Chan K, Braitstein P, et al. Food insecurity and hunger are prevalent among HIV-positive individuals in British Columbia, Canada.
J Nutr 2005;135:820-825. [PubMed]
3. Denning P, DiNenno E. Communities in crisis: Is there a generalized HIV epidemic in impoverished urban areas of the United States?
International Conference on AIDS, Vienna, Austria, July 2010. Poster available at:
http://www.cdc.gov/hiv/topics/surveillance/resources/other/poverty.htm
4. United Nations Subcommittee on Nutrition: Nutrition and HIV/AIDS Statement by the Administrative Committee on Coordination, Subcommittee on Nutrition. 28th Session. Nairobi, Kenya; 2001.
5. Adams EJ, Grummer-Strawn L, Chavez G. Food insecurity is associated with increased risk of obesity in California women. J Nutr
2003;133;1070-1074. [PubMed]
6. Brownell KD, Farley T, Willett WC, et al. The public health and economic benefits of taxing sugar-sweetened beverages. NEJM
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Further Reading
•
Morley JE, Argiles JM, Evans WJ, et al. Nutritional recommendations for the management of sarcopenia. J Am
Med Dir Assoc 2010;11:391-396. [PubMed]
•
Mallon PWG. HIV and bone mineral density. Curr Opin Infect Dis 2010;23:1-8. [PubMed]
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