AIDS TREATMENT NEWS Issue #205, August 19, 1994
Tadd Tobias and John S. James

Nutritional Supplements

ATN: What about nutritional supplements like Ensure?

KW: People should be working with a dietitian or physician who really knows these products and knows which will be appropriate for each individual, because they can be expensive (about $20 a six pack for some kinds). Ensure is a good supplement but may not be appropriate for someone with fat malabsorption (often present in HIV disease). Because of its high percentage of fat, Ensure can exacerbate the diarrhea. Advera is fairly new, with fish oil and medium- chain triglycerides. It has a different kind of protein, a peptide, that is easily digested. Other supplements include, but are not limited to, Vivonex, Nutren, Peptamen, etc.

In general, you might want to look at supplements which have a large percentage of medium-chain triglycerides (MCTs), which are a form of fat that is readily absorbed. We did a study for fat-malabsorbing diarrhea using a product with a high percentage of MCTs. The diarrhea decreased by at least half its original amount following the use of the MCT product and a low fat diet.

ATN: Which product?

KW: Lipisorb. Nutren is also excellent, and perhaps more tasty. I say this because our nutritionists routinely involve us in taste tests of all liquid supplements; if we're going to recommend supplements for our patients, we need to know how they taste, too.

ATN: What about fluids? Are there increased needs in HIV disease?

KW: If a person is having fevers or diarrhea, they're going to be losing a lot of fluid. It's very important that you replace electrolytes [as well as the water]. People can die from electrolyte imbalance -- sodium, potassium, chloride especially. The infant formula Pedialite is one option, but it is expensive and heavy to carry. We were recommending Gatorade, because that does have electrolyte replacement, but it can be expensive if you're drinking a lot, and it has sugar which could exacerbate the diarrhea. People say, why not just drink water? But that will wash out even more of the acid and electrolytes in the stomach, leading to further metabolic imbalances.

A while ago our pharmacy obtained oral rehydration salts from the World Health Organization. The formula is pretty bland; you can taste a little salt. I believe it would be good to add that to the water, then dilute your nectars or other juices you may be drinking to replace your electrolytes. It comes in little packets for about 50 cents. Hopefully we'll see people using more of this.

[Note: For information on how to obtain rehydration salts, see the resource section at the end of this interview.]

Food Advice; Deficiencies

ATN: Any general dietary advice?

KW: Eat a more healthy diet -- including, for example, skinless chicken, and a variety of fresh fruits and vegetables. You need meat and other sources of protein. We do not advocate very restricted diets because it's hard to get the full protein, carbohydrate, fat, vitamins and so on that you need, with alternative diet therapy. It's difficult to say generically, "Eat more healthily," because you have to consider a person's individual lifestyle, how much money they have, where they're living, do they have a significant other who can shop and cook for them -- any number of things need to be considered.

ATN: What about vitamin and mineral deficiencies?

KW: Several micronutrient deficiencies have been identified in HIV disease: B-6, B-12, zinc, copper, selenium, thiamin and folate. Deficiencies may be because of intestinal damage from infections or illnesses; vitamin B-12 especially may not be absorbed. Selenium deficiencies may lead to cardiomyopathy. Zinc deficiency may contribute to anorexia and diarrhea, as well as altered immunity; conversely, zinc excess can further contribute to immune dysregulation.

A study by Dr. Beach looked at people with some cognitive deficiencies and found that they were deficient in B-6 and B- 12 in particular. When they supplemented these back up to a normal level, the dysfunction cleared up. There are many possible reasons why a person's cognitive function is "not quite right" -- general malnutrition or even micronutrient deficiency might be the cause. However -- you don't want to automatically tell someone to take extra B-6 and B-12, without documenting serum levels of these vitamins.

ATN: What about toxicities from overdoses of certain vitamins, especially fat-soluble vitamins (A, D, E, K)?

KW: Fat-soluble vitamins not immediately needed by the body are stored in the liver. When probably over 60 percent of HIV patients have some form of liver disorder, and they are storing fat-soluble vitamins on top of that, it may exacerbate some liver-related problems. Other toxicities could be causing diarrhea, such as high-dose vitamin C or zinc, etc. Anemia, hair loss -- these could be caused by deficiencies, but they could also be caused by toxic levels of various micronutrients.

Excessive amounts of vitamin C [can cause] a nutrient imbalance; particularly if taken with large doses of zinc, this can lead to copper depletion, which can further contribute to immune dysregulation. Unless people are familiar with these interactions it is important to get help from a qualified registered dietitian or physician to make educated decisions.

We recommend, as part of an individualized therapy plan, to take one multivitamin a day. Often we recommend prenatal vitamins [because they include low or moderate doses of all the known vitamins, etc. that you need, whereas other multivitamins usually have some missing].

Some articles in the literature report taking 20 to 200 times the RDA of certain vitamins, etc. might be beneficial. More work needs to be done in this area; I would not recommend that you can take these treatments without concern. And in addition to the issues already discussed, taking megadoses can be expensive, and limited funds may be spent on supplements rather than on quality food. Whatever water- soluble vitamins your body can't use are flushed out through the kidneys... in other words, you end up with every expensive urine and little benefit from the megadosing.

ATN: With HIV disease the body experiences hypermetabolism, which may cause nutrient needs to be different than the U.S. RDA. What guidance can you give people who can't access a dietitian? Is there something you can refer them to that explains these interactions?

KW: That's a good question. The ADA Consumer Nutrition Hotline is available to you. (See below.)

People can "guestimate" what their metabolic needs are for 24 hours with the following: calories: multiply 30-35 calories times your weight in kilograms; for protein needs, multiply 1.5 to 2.0 grams of protein times your weight in kilograms. These amounts will most likely help to maintain weight during relatively non-stressful times. If an opportunistic infection occurs, the body's needs may rise by 60%. Fever will raise the body's metabolism 7% for each degree Fahrenheit above normal. A registered dietitian can calculate your body's needs using an equation that takes into account your age, sex, height, and weight. This method also considers factors such as degree of illness and level of activity.

Other Topics

ATN: What about special "alternative" diets?

KW: Some alternative therapy diets work for some people, but they may not have enough protein, carbohydrate, and fat. And they can be dangerous; for example, there's one that encourages you to eat moldy food to see if you're really sensitive to it. This could be even more detrimental to somebody who is immune compromised.

ATN: What about Chinese herbal remedies, teas, etc.

KW: I think there is something to a history of thousands of years of herbology -- and there are certainly conditions that western medicine cannot do a thing about, yet there may be some relief from non-traditional therapies. I do believe that HIV disease would benefit from a combination of eastern and western medicine.

The concern I have is that people will go into a sports nutrition shop or health food store and buy whatever is recommended to them. People may spend a great deal of their money on supplements rather than quality foods. Here is where it is vitally important that people align themselves with a medical professional who can advise them on what to take.

ATN: And antioxidants?

KW: It's too early to have definitive answers. Antioxidants occur in foods. If you are already taking a multivitamin, you will be getting some that way, also. Examples of antioxidants are vitamins C and E, beta carotene, zinc, selenium. Antioxidants are said to neutralize free radicals in the body that contribute to immune dysfunction, aging, heart disease, and cancer.

ATN: In choosing a multivitamin, what potency (dose) should you look for?

KW: If your multivitamins are a bit more potent than the RDA, that won't hurt, as long as you are only taking one a day. When you do take your vitamins and minerals, take them with food. In order to be effective, vitamins, minerals, and trace metals need to chemically interact with food.

ATN: What about exercise?

KW: One of the simplest things we recommend is for folks to just walk and swing their arms. When watching TV, it's a simple matter to pick up soup cans or something like that -- or putting a two to five pound weight on your foot and lifting it. Low resistance, many repetitions, is the key so the movement doesn't exhaust you but does stimulate the muscles.

ATN: Because if you don't use it, you'll lose it?

KW: Yes, muscle tends to be exchanged for fat. We want to take a look at what impact exercise is going to have on the development and maintenance of lean body mass. Currently we don't have much data to go on.

Dr. Hellerstein here is doing work with anabolic steroids. The problem with some of the steroids is that they may put some weight on you, but unless you are exercising it will be mostly fat, not lean body mass. But on the other side, people with HIV disease often fatigue easily, so you can't expect them to have a rigorous routine.

ATN: What about differences between men and women?

KW: In a Rhode Island study, the diagnosis of wasting syndrome was the second most common index diagnosis of AIDS in women. Moreover, women were greater than two and a half times more likely than gay men to have the diagnosis of wasting. To my knowledge, studies have not been conducted to determine whether the pattern of weight loss, i.e., muscle loss and fat preservation, is the same for women as it is for men.

ATN: What can you bring to our readers about options, a note of optimism, things to think about?

KW: The key again is to start working with people early in HIV disease, because we have a much better chance of keeping them nutritionally sound if we start earlier rather than later. We have also seen the possibility of moving someone from merely surviving, because they're so weak from malnutrition, to living a meaningful life due to optimal nutrition. We shouldn't give up hope; help is out there.

I think the pervasive attitude is that weight loss and malnutrition are inevitable. You see that in both the health care provider and the client perspective. It is important for folks to hear that there is work being done in the field of nutrition and HIV disease. Moreover, creative and individualized approaches to symptoms which interfere with optimal nutrient intake can be successful.

Nutritional Resources

The following list of nutritional information was prepared in conjunction with the interview with Kristin Weaver, above.

Upcoming Conference

Third International Symposium on Nutrition and HIV/AIDS, Philadelphia, October 13-14.

Organized by the Physicians Association for AIDS Care (see below), Philadelphia FIGHT (community-based research trials group), and the Pennsylvania AIDS Education and Training Center, this meeting includes many faculty members who are leading experts in the field. According to conference materials the symposium objectives are: "to disseminate the latest scientific information about the role of nutrition in the course of HIV disease and the prevention and treatment of AIDS-associated malnutrition; to improve the knowledge of those responsible for reimbursement decisions affecting nutritional strategies for insurance companies, managed care organizations, state Medicaid agencies, and Medicare administrators; to provide a forum to exchange information and to examine research, policy, management, and practice issues; and to improve communications between researchers and the users of research."

Registration costs $75.00 and will be limited; organizers suggest registration by September 15th. For more information contact: Monica Patel, Philadelphia FIGHT, 201 North Broad St., 6th Floor, Philadelphia, PA, 19107, 215/557-8265.

How to Get Rehydration Salts

Oral rehydration salts based on the World Health Organization (WHO) formula are available in pharmacies and directly from Jianas Brothers, 2533 Southwest Blvd., Kansas City, MO 64108- 2395, 816/421-2880, fax 816/421-2883. The cost is about 50 cents per packet which dissolves in one liter of water.

Food Safety and Nutrition Advice and Referrals

CDC National AIDS Clearinghouse, 800/458-5231.

Persons may request the free brochure "Eating Defensively. Food Safety Advice for Persons with AIDS." The materials prepared by the Food and Drug Administration for the general public are intended to help individuals lower the risk of food-borne illness. This includes information on how to avoid food poisoning, food handling and preparation, and tips for traveling abroad, shopping, and dining out. A fifteen minute video is also available for $12.00.

Consumer Nutrition Hotline, 800/366-1655.

Sponsored by the American Dietetic Association. Callers can speak with a registered dietitian, or ask for a referral to a registered dietitian. Referrals can be made to practitioners with specific specialties but callers need to know that the referral database contains only registered dietitians who have paid a fee to be included; it is not comprehensive. Clinics, hospital dietetic departments, public health departments, and AIDS service organizations may also be able to provide referrals. Diet counseling is not offered on the hotline, only general nutrition information.

Meat and Poultry Hotline, 800/535-4555.

This hotline, a service of the U.S. Department of Agriculture, is staffed by home economists and registered dietitians, Monday through Friday, 10:00 a.m. to 4:00 p.m., EST. Callers can get information about food safety. During other hours, a voice mail response system provides answers to commonly asked questions.

Nutritional Counseling

San Francisco Area: Bay Area Nutrition Counseling Center and Clinic, University of California San Francisco, San Francisco General Hospital.

Patients are evaluated in-person by a physician and a dietitian at an initial visit and followed monthly thereafter. In addition to in- depth evaluation and counseling, clients receive a personalized manual outlining the results of laboratory and dietary assessments and the prescribed nutritional care plan, as well as extensive practical information. For more information or to schedule an appointment, contact Violet Garcia, patient liaison, 415/206- 8822.

Illinois: The Cutting Edge.

Under the direction of Cade Fields Gardner, RD (formerly Cade Fields Newman, RD), this organization provides education for professional dietitians and patients, nationwide referral, and direct patient care. The multidisciplinary approach emphasizes a healthcare team approach to treating individuals with HIV disease. This includes cooperative involvement by physicians, social workers, pharmacists, dentists, and other healthcare providers in a variety of settings. Services are available in several languages. Physician referral required. Contact: The Cutting Edge, P.O. Box 922, Carey, IL 60013, 708/516-2455, fax 708/516-2263.

[Editor's note: These are two nutritional counseling centers that we contacted while writing this article. Many others could be listed as well.]

Professional Organizations and Selected Resource Materials

American Society for Parenteral and Enteral Nutrition (ASPEN).

This is a multidisciplinary, professional, and scientific organization working to promote quality patient care, education, and research in the field of nutrition and metabolic support. Many peer-reviewed periodical and reference materials are available including Standards and Clinical Guidelines (for physicians, nurses, dietitians, and pharmacists). For a complete list of publications and programs contact: ASPEN, 8630 Fenton St., Suite 412, Silver Spring, MD 20910, 301/587-6315, fax 301/587-2365.

Physicians Association for AIDS Care.

In addition to their monthly journal, they have available Nutrition and HIV/AIDS: Proceedings of the 1992 International Symposium on Nutrition and HIV/AIDS, including the Nutritional Algorithm and the Nutritional Initiative of the Physicians Association for AIDS Care. This technical volume includes articles by some of the most respected experts in the field of nutrition and HIV, including Donald Kotler, Richard Beach, Cade Fields Newman, and Mark Hellerstein. Topics covered include nutrition and wasting, metabolic changes in HIV disease, and issues specific to developing countries. It also includes "An Overview of the PAAC Initiative," which presents strategies for coping with nutritional problems and an in-depth bibliography. ($25.00 including shipping and handling.) Contact: PAAC Publishing, Inc., 101 W. Grand Ave., Suite 200, Chicago, IL 60610, 312/222-1326, toll-free 800/243-3059, fax 312/222-0329.

For less technical information, HIV Disease Nutrition Guidelines: Practical Steps for a Healthier Life presents practical information focusing on good nutrition, regular exercise, and stress management. Also included are recommendations for dealing with commonly occurring symptoms of HIV disease. It is published by the Physicians Association for AIDS Care with an educational grant from Stadtlanders Pharmacy. Free copies are available in English or Spanish from Stadtlanders Pharmacy, 800/238-7828.

Bibliography and References

Baum MK, Shor-Posner G, Bonvehi P, and others. Influence of HIV infection on vitamin status and requirements. Annals of the New York Academy of Sciences. September 30, 1992; volume 669, pages165-173, and discussion on pages 173-174.

Beach RS, Mantero-Atienza E, Shor-Posner G, and others. Specific nutrient abnormalities in asymptomatic HIV-1 infection. AIDS. July 1992; volume 6, number 7, pages 701- 708.

Beach RS, Morgan R, Wilkie F, and others. Plasma vitamin B12 level as a potential cofactor in studies of human immunodeficiency virus type1-related cognitive changes. Archives of Neurology. May 1992; volume 49, number 5, pages 501-506.

Carpenter CC, Mayer KH, Fisher A, Desai MB, and Durand L Natural history of AIDS in Rhode Island. American Journal of Medicine. June 1989; volume 86, number 6 part 2, pages 771- 775.

Chandra, RK. Micronutrients and immune functions: An overview. Annals of the New York Academy of Sciences. 1990; volume 587, pages 9-16.

Chlebowski RT, Grosvenor MB, Bernhard NH, Morales LS, and Bulcavage LM. Nutritional status, gastrointestinal dysfunction, and survival in patients with AIDS. American Journal of Gastroenterology. October 1989; volume 84, number 10, pages 1288-1293.

Grunfeld C and Feingold KR. Metabolic disturbances and wasting in the acquired immunodeficiency syndrome. New England Journal of Medicine. July 30, 1992; volume 327, number 5, pages 329-337.

Kotler DP. Nutritional effects and support in the patient with acquired immunodeficiency syndrome. Journal of Nutrition. March 1992; volume 122, number 3 (supplement), pages 723-727.

Kotler DP, Tierney AR, Wang J, and Pierson RN Jr. Magnitude of body-cell-mass depletion and the timing of death from wasting in AIDS. American Journal of Clinical Nutrition. September 5, 1989; volume 50, number 3, pages 444-447.

Smith E and Orbolm M. Trends and patterns of opportunistic diseases in Danish AIDS patients, 1980-1990. Scandinavian Journal of Infectious Diseases. 1990; volume 22, number 6, pages 665-672.

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