BEING ALIVE: February 1995
Jennifer Jensen, MS, RD

Often, more specialized blood labs should be used; these can have nutritional consequences or provide additional necessary nutritional information. This is especially important when a nutrition-related situation needs to be closely monitored. Often, special lab values need to be routinely and closely evaluated.

Prior to your first appointment, besides reviewing lab values, some dietitians ask you to keep a diet record-often a three-day diary of everything you eat and drink, and how much. Others will settle for the "recall" technique-having you describe your dietary habits during the appointment. Either way, knowing what and how you eat gives us an edge for making "kinder, gentler" changes for improvement. If the soft-touch is insufficient, we may have to become a bit more strict. What's important is that we know the medical "you" rather than sending you out with a non-specific "diet" or "menu" plan not custom-tailored for your specific requirements.

The Appointment: What to Expect

For most of us, the "general you" may be someone helpful to know about. When were you diagnosed, what course has HIV/AIDS taken with you, what is your history with medical therapies, alternative treatments, and any ongoing health concern you may have in addition to those of HIV/AIDS. We should also know any history of opportunistic infections (OIs) and/or hospitalizations.

Problem Solving

Some of the best things about dietitians is that we know a lot of little "tricks" to help people feel better. These suggestions are based on your answers to our questions; honesty is a virtue here. Here are some of the questions we all tend to ask. Any problems with diarrhea, constipation? (We need to know how frequent your bowels are and their consistency-be descriptive.) How are you feeling? How's the mouth-dry? Mouth sores? Taste buds OK? Any trouble chewing or swallowing? Feel full fast? Nausea? Vomiting? Low Appetite, Fatigue, Peripheral Neuropathy, Gas? On your List (see below), include your own problems. If you can think of it, we can ask it, and we probably will. We really may be able to help-and we can handle the "be descriptive" part.

Your Questions. Start writing them now, and don't forget to take The List to all nutrition appointments. You will forget some List items during your appointment if you don't. Why not start keeping a diary now of foods and their quantities? Just by writing your food entry, you'll think up a few more questions for The List. Make us work! Get our "take" on food and diet issues; they may not be "issues" at all. But, we can't help if you don't ask!

Be prepared to give an overall picture of your health status, a brief HIV/AIDS medical history, your own nutrition-related problems and questions, and The List.

Weight Control

Often, we need to help you gain weight. Since HIV/AIDS is often "seen" outwardly as serious weight loss, the weight-gain strategies you can learn from your dietitian can be invaluable in preventing wasting. As with most of my colleagues, I hold the position that wasting can be prevented. It has also been noted that most HIV-related causes-of-death are really due to, or include an element of, malnutrition; many authorities have said that malnutrition and/or major weight loss is a "co-factor" in disease progression. Weight loss needs to be managed-fast, and consistently and with expertise.

If you want to lose weight, we want to watch closely.

Desired-but-accelerated weight loss can mask underlying health problems as surely as obesity will mask malnutrition: A 500-lb. person who eats nothing but donuts, will be seriously malnourished. Weight loss at any time during HIV-infection may present a risk; do it with care, and get professional guidance and monitor weight loss very closely.

BIA, Skinfolds, and The Tank

Many dietitians are measuring body composition: lean mass, fat mass and water weight (hydration)-very important and useful. The more familiar method is done by dunking you into a water tank for a few minutes (holding your breath is a challenge, believe this!). Obviously, we don't all have water tanks in our offices. New technology is amazing! Now we have Bioimpedence Analysis (BIA). This is a quick and easy method for determining how much of you is what, and we also get an estimate of body cell mass-a number more closely linked with survival than CD4 counts. Ah . . . now I've got your attention!

BIA is calibrated carefully and has been documented to be about 98% as accurate as the tank method. Works for me-and you! Seeing your BIA results on paper can be very motivating. Perhaps the scale says you're at an OK weight but BIA says that more is fat than you thought. Those graphs are truly a manifestation of the old-school thought that "a picture is worth a thousand words." (Don't put off your appointment to avoid unwelcome news-it's important information, and if corrective action is taken, it can help save your life if you get sick.)

A Two-Sided Coin

Specialty HIV/AIDS nutrition healthcare includes exercise. It's like a two-sided coin: Like an "In and Out" door. Energy In (food) and Energy Out (physical movement) are equal to what you eat and what you do. The better you do both, the better you'll be! One-sided coins are illegal.

A Case In Point

I met with a client a few days ago. He had been putting off making his nutrition check-up appointment because he thought I'd tell him to lay off his beloved egg and bacon breakfasts. But havingread my January column dis-mything the "egg rule," he found comfort and signed up for Tuesday. Only then did he admit to a fear of losing his favorite breakfast! Now where have I heard that before . . . ?

He was so relieved when he got to have all the eggs he wanted! He was even OK with the reduction-of-bacon part. By the time we finished revamping dinner, he was loving the idea of "minimum-restriction" Nutrition Power! I don't do "rule" very well, so I've developed what I call The Nutrition Power "Two-Rule" Rule. Rule #1 is on food safety. Don't eat anything that can cause harm. Rule #2 is on quality of life: Don't eat anything you don't like. As I mentioned earlier, I know no perfect people.

The Balanced Diet

The "balanced diet" for HIV/AIDS is so different from that for uninfected people that the specialty dietitian is the best information resource for you. Many of us provide meal plans, suggest dietary patterns, and provide recipes to help it all work. We tend to emphasize diets that provide adequate protein (about 90-150 grams/day, depending on weight), moderate-to-low fat (this can have a lot to do with blood chemistry), selective and specialized fat types, and high in carbohydrates (the body's energy powerhouse nutrient).

We also tend to emphasize nutrient density. This means that bite-for-bite there's a good calorie, protein and/or vitamin and mineral provision. Your dietitian can be of tremendous help in finding enjoyable replacements for things you may be eating that aren't dense enough to qualify. Also, dietitians are familiar with micronutrients (vitamins and minerals), and we can even tell you where to find them in food! Also we can recommend supplements at safe, yet appropriate levels. Especially, we can recommend against something that could potentially cause harm (Breaking Rule #1) .

How to Use Your Dietitian

Each HIV/AIDS dietitian works a little differently, and each client has individual needs. Depending, some of us want to see you weekly, monthly, quarterly, or twice a year. Your current physical condition is probably the determinant. For some clients, weekly monitoring is advised, especially if "urgent" work is necessary.

When we want to see you less often, perhaps every six months-to-a-year, it's because we tend to feel that you may need us less intensively in early HIV stages and more (maybe a whole lot more) in later HIV disease. And we agree that nutrition strategy should be started as early as possibly-ideally, right after diagnosis-for maximum benefit. On this we all agree! Here, it really does depend. It's about staying alive. What Will You Get For Using a Nutritionist?

We can't prove anything, but what we expect and believe is that you'll get a much better and longer life-in that order. As always, first do no harm. It may be harmful to wait: Get your Nutrition Power act together.

For referrals to nutritionists/dietitians, call the APLA Hotline 312.465.1462, or the ADA hotline 800.366.1655. Or call me. Special thanks to the dozens of dietitians who added their advice and insight to help me provide you a complete idea of The Nutrition Appointment.

(Jennifer Jensen, MS, RD, CNSD is in private practice. In acknowledgement of HIV/AIDS-related financial conditions, she offers a "sliding scale" fee-for-service. Call her anytime: 310.450.5581.)

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