AIDS TREATMENT UPDATE, July 1995
Keith Alcorn

Weight loss which occurs in AIDS is not uniform all over the body. HIV-related wasting occurs first of all in lean muscle tissue because during periods of illness it is this tissue which is raided for energy, along with fat stores. As HIV disease progresses, the demands on these energy stores grow as the body uses energy less efficiently. Maintaining or increasing lean muscle mass is therefore very important.

A third factor is malabsorption. The lining of the gut consists of millions of finger-like projections called villi, which extract nutrients and water from food passing through the gut. The wall of the gut has a vast surface area through which to draw nutrients, but due to HIV infection, gut infections and other health problems, it may begin to malfunction. It may no longer draw nutrients out of food with the same efficiency; it may be unable to produce the antibodies needed to combat microbes (mucosal immunity), and it may become inflamed or perforated.

Malabsorption can be made much worse by diarrhoea. Even low-level diarrhoea which does not prevent you from going about your daily life may make it difficult to maintain an adequate supply of energy and nutrients, since food can't be absorbed, and may contribute to gradual but significant weight loss if it is not investigated and treated.

AIDS Treatment Update spoke to Christine Baldwin of Kings College Hospital, London, and Hazel Ross of the Chelsea and Westminster Hospital for dietary strategies for dealing with diarrhoea and weight loss.

What dietary adjustments would you recommend someone to make if diarrhoea is a problem and they seem to be losing weight?

HR: There seems to be a lot of individuality in diarrhoea - if the diarrhoea is concentrated in the small bowel, where fat absorption takes place, I tend to recommend a low fat, low lactose diet because lactose [the sugar in milk] adds to diarrhoea. People can put on weight with a low fat diet despite diarrhoea. I've rarely found that people can't tolerate milk at all.

CB: With diarrhoea I always consider malabsorption as a cause of weight loss. Diarrhoea cuts down on the absorption of food. If it's cryptosporidiosis I would try a peptide-based elemental feed which gets absorbed very easily in the first two or three inches of the gut. You can see results very quickly - I've seen people gain 10-15 kg in weight when they were technically terminally ill. Nutritionally this is one of the biggest challenges, but it's easier to overcome than a state of chronic infection or wasting.

HR: A major problem with diarrhoea is that people are eating less than they need, often a thousand calories too little. They rarely get enough from the food they are eating so supplements are needed. If you can reverse the intake deficiency, you can see a gain of 5-7 kg quite often.

But people complain about the taste of these supplements - they're too sweet, too metallic or just horrible - so are they realistic replacements for proper food?

HR: It's the protein amino-acids in the drinks which make them taste foul, but you can get round this by making up drinks with protein powders or short-chain fats [more easily absorbed in diarrhoea]. We can play around with them to make them more palatable. If you really can't drink the supplements you can have a nasogastric or PEG tube [tubes directly into the stomach], which delivers the supplement for instance whilst you're asleep.

People can do really well. We've had people regain their normal weight and have the tube taken out after three months, and we've also had people travel round the world. Out of about 25 people in the past year, we've had only two or three of them experience tube infections, all of which were treatable.

It's not as much of a problem as we thought. It's more the hassle and the psychological factor of being hooked up to a tube that some people find difficult.

What about loss of appetite? It's a common problem with illness and with drug side- effects, isn't it?

CB: With loss of appetite, you need to look at the causes. It could be drug side-effects, and it's common for people when they're very stressed to lose appetite. But the response to acute infection is also one of shutting off appetite, and there's some speculation that might actually be beneficial.

Doctors tend to prescribe drugs when people say they can't eat, but I think it's more important to find out why people feel they can't eat. In this situation I would prefer to refer someone to refer someone for counselling before relying on appetite stimulants. Counselling can often help people to identify the problems or stresses which are putting them off eating.

In anorexia there's some indication that artificial feeding, such as nasogastric feeding, can break the problem by removing the stress of worrying about food and weight loss for a while; it allows people to develop a calmer feeling about weight loss and eating.

In this issue we discuss the use of anabolic steroids. Do you think that more people could benefit from anabolic steroids to help them recover lost weight?

CB: A small number of people fall into that group. I think you have to be clear about why the weight has been lost. When you give steroids, are you doing something with steroids which you could have achieved with a nasogastric feed anyway - we don't know. In some people it's clearly a defective calorie intake which is preventing weight gain, and it may be that increasing food intake alone will help weight gain.

Do you think that too little attention is given to aggressive treatment of weight loss, even though it's one of the most visible symptoms to people with AIDS and their carers?

CB: I don't think food and nutrition get the attention they deserve. I don't think some doctors automatically think about correcting weight loss when they see a patient who has lost weight. People don't lose weight for no reason.

Food is too low a priority in many hospital budgets. The problem with food in hospitals is the lack of money available. There are two things you put inside patients in hospital, drugs and food, but the sum budgeted to feed patients is only around £1.70 a day...

...which is bizarre, given that when you're nursing someone at home one of the most fundamental things is to make sure they're eating properly...

CB: It's a problem that affects the whole health service, not just HIV services.

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