Being Alive; February 1994
Gary Cohan MD and reported by Jim Stoecker

Despite these facts, very little is being said about malnutrition at most of the conferences on HIV disease and its treatment. We neither hear nor read much about treatments or interventions for malnutrition, but people with AIDS are dying from it.

Many health care providers may be distracted by all the drugs that are being developed. They may be concentrating on the symptoms that the patient presents and are focusing on their treatment. Meanwhile, the patient is losing weight and seeming to starve. We need to look more closely at our patients and begin to provide the interventions that will prevent further weight loss.

Malnutrition: a Cofactor in HIV Disease Progression

To put it dramatically, for people with AIDS, skinny equals death. Studies have shown that survival with HIV infection decreases as lean body mass or muscle mass decreases. PWAs will die sooner if they lose too much weight and, in this sense, malnutrition is a cofactor in disease progression.

Nutritional status can be measured by the blood protein, serum albumin. If the serum albumin level is within the normal range, 70% of this group with HIV infection will be alive after 2.5 years. For those who are moderately malnourished, with serum albumin between 2.5 and 3.5, only 50% will be alive after 18 months. And when there is severe malnourishment and serum albumin is less than 2.5, studies show that only 20% will be alive at 6 months and all will be dead at 14 months.

The amount of wasting, rather than the specific cause of the weight loss, is the primary determinant of death in most people with AIDS. There is a critical level of body cell mass below which survival is impossible. Studies indicate that death occurs for those with wasting syndrome either when their body weight approaches 66% of their ideal body mass or when body cell mass approaches 54% of normal. When a person is not just burning up fat stores, but there is also lean tissue mass wasting, then the threat to survival is greatest.

The awful truth is that people with AIDS do not necessarily die of PCP, MAC or some other opportunistic infection. Too often they die from the starvation that is secondary to the other complications of AIDS.

The Causes of Malnutrition in HIV Disease

There is usually a combination of reasons why people with AIDS become malnourished. First of all, there is the impact of HIV itself. The virus can cause changes in the body's metabolism. Metabolic disturbances may cause the metabolic rate to go up. This results in the body burning calories more quickly than is normal and thus requiring more calories than is normal. If the HIV+ patient is not taking in enough calories to make up for this increased metabolic rate, he/she can quickly become malnourished.

Another metabolic deregulation that we sometimes find with HIV is cachexia. Normally, when someone is malnourished, their body burns fat and preserves the lean tissue mass. With cachexia, there is accelerated tissue loss, with an almost immediate depletion of lean tissue mass. This speeds up the wasting and brings on immediate threats.

Diarrhea is a common symptom of HIV disease and can contribute to malnutrition. Some of the causes of diarrhea are amoebas, cryptosporidiosis.html">cryptosporidium and microsporidium. With these conditions, the body is not able to absorb the calories that it is taking in. Besides the absorption problems, diarrhea can also cause someone to cut down or stop eating. For these reasons, chronic diarrhea can bring on severe wasting in many PWAs.

Many people with AIDS suffer from nausea. Chemotherapy for lymphoma or KS can bring this on, as well as many of the drugs used to fight opportunistic infections. When people are nauseous, they simply do not want to eat. This is very dangerous for PWAs, and can start the weight loss that can become life threatening.

A host of oral problems can also stop someone from eating. Gum disease, herpes in the mouth, lesions in the mouth or esophagus, oral candida, and oral ulcers are all problems that people with HIV may face. All of these conditions make it painful to eat or swallow; without realizing it, someone with any one of these conditions can begin to avoid eating and become malnourished.

AIDS-related dementia can also play a part in bringing on weight loss. Neuropsychiatric impairment may make someone unable to care properly for themselves. They may forget to eat or be unable to prepare balanced meals.

Finally, we need to be aware of psychological conditions that can cause a person to become malnourished. Depression in general can cause someone to stop eating regularly, and thus contributes to weight loss. Many people with HIV can become depressed because of all they have to face. Clinical depression is treatable and should be dealt with quickly, so that problems are not compounded.

Diagnosing Malnutrition

The Centers for Disease Control define wasting as involuntary weight loss of greater than 10% of a person's usual body weight. By the time a patient meets this definition, however, weight loss may be quite significant and possibly irreversible. Health care providers need to intervene before their patients reach this point.

We need to be measuring each patient's nutritional status. This involves keeping a history that includes what normal body weight is so that any deviations can be quickly dealt with. There should also be regular physical measurements, as well as regular tests for the serum albumin in the blood. And any patient with any of the conditions outlined above needs to be closely monitored for possible weight loss. Ways to Intervene

The goal of intervention is to minimize tissue breakdown and nutrient depletion. In addition, we want to rebuild the body's cell mass. There are a number of products that might be considered when a patient is malnourished. What is best depends on the patient's particular situation and the causes of the malnutrition. It may be a question of a more intelligent diet or specific interventions may be required.

Megace is a hormone analog. We think that this product has two problems. First, it is difficult to take; the patient is required to take handfuls of pills. Second, a more significant problem is that the patient may just gain weight from fat and not put on lean tissue mass. Fat weight gain is not correlated with increased survival.

marinol.html">Marinol is an appetite stimulator. It contains the active ingredient in marijuana, with the psychoactive effect reduced. Many patients take marinol at bedtime; they report sleeping well and waking up hungry. Some patients feel that smoking marijuana itself is more stimulating to their appetite than marinol. Besides the legal issue of using marijuana, there are also other side effects to the drug to be considered, however, including its possible immunosuppressive qualities.

Certain caloric formulations may also be useful for someone who is malnourished. Ensure is widely used; a low cost alternative is Carnation Instant Breakfast.

Finally, there is TPN or Total Parenteral Nutrition. This is where nutrition is given through the veins directly into the blood stream. This procedure is fraught with complications and should only be used as a last resort.

Concluding Thoughts

I call malnutrition the silent plague because too many people with AIDS are dying from it and too few health care providers are doing something about it. That situation must now change. We cannot continue to let our patients starve to death. Nutritional analysis and nutritional intervention, if called for, should be a part of the treatment program for anyone with HIV disease.
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