Hiv: Nutrition And The Life Cycle

The importance of good nutrition throughout the life cycle seems fairly obvious. After all, we have to eat to live. However, the importance of nutrition at specific times during the course of growth, development and aging is becoming increasingly appreciated. Being HIV with a long life in the picture makes the issue of nutrition even more critical every step of the way.

The effect of nutrition during pregnancy on the health of the infant and of the mother post child-bearing years has long been recognized. The nutritional status of the mother and possibly the father before the pregnancy directly affects the outcome of the child. Low birth weight babies are frequently borne to malnourished mothers. Miscarriages and abortions, stillbirths, neonatal deaths and malformations have all been associated with a poor maternal nutritional status. Studies clearly show that HIV+ mothers who are vitamin A deficient are more likely to transmit the virus to their newborn than those with adequate serum vitamin A levels. The good news is that on average there is about a one in seven chance that a child of an HIV infected mother will be born positive. Good nutrition before during and after pregnancy can make a big difference in quality of life for mother and baby.

Breast feeding doubles the risk of virus transmission to the infant and therefore is not recommended for HIV+ infected mothers. Modified infant formulas are tolerated by most infants. Food safety is critical throughout the life cycle of HIV infected individuals. It is crucial for infants that appropriate washing techniques be used for bottles, nipples and feeding utensils. Do not reuse infant formulas that have been at room temperature for longer than two hours and do not combine old formulas with new ones. If reconstituting be sure to use only filtered water (absolute one micron), boiled or bottled water. (see related articles on food safety and water safety on this website)

Providing proper nutrition to children with HIV/AIDS is critical for two simple reasons; it provides the greatest opportunity for normal growth and development and it supports the optimal functioning of the immune system. In addition, establishing good food habits during childhood lessens the possibility of inappropriate eating behavior, which occurs with disturbing frequency during adolescence. Although the influence of proper nutrition usually remains unacknowledged until adulthood, it now appears even more obvious that prevention of degenerative diseases that appear later in life should begin in childhood.

Children and teenagers should eat according to the food guide pyramid the same as adults, portion size, however is likely to vary. Protein, carbohydrates, fats and the micronutrients: vitamins and minerals are needed for growth and development as well as maintenance. Food and water safety emphasized to avoid "preventable" food borne illness

Unlike the early days of the HIV pandemic, malnutrition is not predictable in the era of HAART. Children living with HIV (CLWHIV) and adolescents on effective therapy can expect to live a long life and excess weight gain is common, especially if kids eat the wrong foods and are not active. It is never advisable to eat sugary, fatty foods ( e.g. cake, ice cream, candy) in place of healthy nutrient dense meals and snacks ( e.g. peanut butter and jelly sandwiches, cheese and crackers, fruit and yogurt, etc.) There is nothing wrong with sugar, however, it should never replace foods that promote growth, maturation and a healthy immune system. Early studies indicate that exercise, too, can improve immunity.

Adolescents/ teenagers who are not HIV+ need extra nutrition during these year to support an amazing period of growth and development. Extra calories and protein are needed based on degree of activity and level of growth rate, in adolescents who are HIV+ add the needs of a struggling immune system and the free radical damage of the virus.

Lipodystrophy is described as the changes in body habitus associated with highly active retroviral therapy (HAART) an/or partial immune reconstitution. Outwardly the syndrome includes fat maldistribution; thinning of the arms, legs and face and re- deposition of the fat in the abdominal area. In some cases we see buffalo humps (fat in the upper back, in the neck area). In women there can be a significant enlargement of breast size. The syndrome also manifests metabolically in high cholesterol, triglycerides, hypertension and diabetes. The syndrome is not predictable for everyone on therapy and may never happen in others. To date, the cause remains only speculation, but many think there may be an association with insulin ( a hormone that regulates sugar metabolism) sensitivity.

Adolescence and teen years are a period in life when body image is everything. Young women do not want to be too fat nor young men too thin. Indeed, the potential for lypodystrophy syndrome is a reason that this population might resist HAART and in doing so put them at high risk for a compromised immune system and the all too familiar opportunistic infections.

Efforts are being made to determine the etiology of the syndrome so that preventive measures, if possible, can be outlined. Nutrition and exercise are being studied and may make a difference.

Personal observations by this author are based on research in the general population and experience in counseling on the above referenced conditions to HIV- and HIV+ clients and patients. Avoidance of simple sugar and refined carbohydrates (white bread, white rice and pasta) and low intake of saturated fat intake (whole milk, butter, cheese, red meat and poultry skins, commercial fried foods). Increase intake of complex carbohydrates ( high fiber foods such as whole grains, nuts and legumes), concentrate on monounsaturated fats (olive, canola and peanut oil), eat a wide variety of colorful fruits and vegetables ( vitamins, antioxidants, phytochemicals), lean protein ( chicken, fish, lean meats etc.). Resistance and aerobic exercise ( daily if possible).

Adults with HIV/AIDS have been studied extensively since the beginning of the epidemic. It is safe to say that initially everyone with the virus was uniformly "wasting". The etiology of weight loss was multifactorial; fevers, diarrhea, oral and esophageal ulcers, nausea and vomiting. There were any number of reasons why one could not eat and equally problematic was the internal mechanism of wasting associated with the opportunistic infections and cancers that used to plague PLWA and ultimately claim lives.

HAART has made the difference between life and death in PLWHIV/AIDS. However, taking the number of pills necessary to make the difference requires discipline. Sometimes this is a TID (three times a day) regimen. Pills themselves have side effects. Diarrhea, nausea and vomiting and anorexia (lack of appetite) can make it even more complicated. One thing I always tell my patients and clients is to demand information on the side effects, be prepared with nutritional management strategies and medications to get you through the first couple weeks. Problems should subside or become manageable with time.

Because of the changes that took place in 1997 that included the emergence of HAART, better understanding of the disease and widespread use of prophylaxis drugs as well as attention to nutrition, psychological and social issues, wasting and death is not the norm anymore. When people ( including children and teenagers) were uniformly wasting it was generally recommended that everyone with the disease eat as much and anything with calories, protein and fat. This is no longer the case. The primary goal of therapy today is preservation of lean body mass (muscle), maintenance of nutritional health status and prevention of metabolic complications that have been labeled the lipodystrophy syndrome ( see above).

One of the newer populations with a significant infection rate is senior citizens. In general nutrition needs change in the healthy elderly. Their calorie needs are lower, but protein needs may even be increased. Most PLWHIV/AIDS( including the elderly) have increased protein needs because of the virus that lives to destroy the immune system and a fighting immune system often with the aid of HAART that strives to restore it. The immune system, the skeletal (muscle) and visceral (organs) all require protein for growth, repair maintenance and survival.

One of the concerns for all PLWHIV/AIDS ,regardless of age, on HAART is the potential for heart disease. High blood lipids, hypertension and diabetes are all risk factors that require careful attention, dietary modifications and additional medical therapy. The elderly may already have these conditions making the addition of HAART an added burden.

In conclusion, the nutritional needs for PLWHIV/AIDS throughout the life cycle has changed along with medical therapy and improved longevity. As people live with a healthier immune system we no longer have to contend with the opportunistic infections and cancers that not only made people sick but caused early death. While we have some diarrhea and nausea and vomiting due to drug side effects, it is predictable and is usually manageable. However, lipodystrophy has added a new dimension to nutritional management. For some, it might mean a dramatic change in diet. However healthy food choices, exercise and attention to mental health and social issues in addition to your medical regimen are in order every step of the way through the life cycle so that every day is the best possible.

Donna Tinnerello, MS, RD, CD/N.

Donna Tinnerello MS,RD,CD/N is registered dietician with more than 10 years experience in HIV and nutrition. She works on the AIDS unit at Cabrini Medical Center in lower Manhattan, subspecialties in cardiovascular, renal, and gastrointestinal disease, diabetes and weight loss.