TREATMENT ISSUES, Volume 6, Number 9 - October 1992; The Gay Men's Health Crisis Newsletter of Experimental Therapies
Lark Lands, Ph.D.

Additionally, it has been shown that nutrient supplementation may restore immune function in important ways and even boost T4 counts in people with early stages of disease.[4] The lack of education on nutrition in most Western medical schools combined with a lack of funding have prevented serious attention from being focused on this aspect of HIV infection. Since nutrients cannot be patented, pharmaceutical companies have little profit motive to fund such research. Even though thousands of published articles confirm the influence of nutrient status on immune functions, many doctors have largely ignored this part of patient health.[5] Recent published research supports the need for medical attention concerning nutrient deficiencies in order to achieve a complete HIV management strategy.[6] This article will explore the role and treatment of malnutrition in people with HIV disease.

IMPORTANCE OF NUTRITION

Historically, nutrition has played a peripheral role in medical treatment. Recently, however, many doctors are recognizing that this omission is an oversight, since replacement therapy has been shown to benefit people with HIV/AIDS. According to Marcy Fenton, M.S., a registered dietician and nutrition consultant to AIDS Project Los Angeles, "Practitioners must be aware that good nutrition is not an 'alternative' therapy; it is a fundamental component of medical care."[7] She asserts that an individually-designed nutritional program can boost immune function, increase the efficacy of other medical treatments, and improve energy levels and general quality of life. Indeed studies have shown that nutritional supplements like zinc, selenium, and vitamins C, A, E, and B together with AZT may increase AZT's antiviral effect while at the same time strengthening the immune system.[8] Conversely, malnutrition may contribute to development of opportunistic infections and physical deterioration and can be the underlying cause of death. Dr. Paul Cimoch, the Director of Medical Services at the Center for Special Immunology in Fort Lauderdale, sees a primary role for nutrition in treatment regimens and explains that good nutrition helps people with HIV, just as with any other infection, by providing the nutrients that an active immune system needs to function most efficiently.[9] Various nutritional therapies are being tested in the U.S. and abroad, and volunteer groups like the Treatment Alternative Research project are pushing for the development of clinical trials of nutrients and other "alternative" and non-pharmaceutical treatments.[10]

MALNUTRITION

The word "malnutrition" often conjures up images of emaciated people who do not have access to daily meals, but the technical application of the word is much more subtle than that. Most people with HIV disease do not know they are malnourished, since malnutrition is specific to the absence of vitamins and minerals essential to healthy body function. More than two dozen studies presented at the VIIth International Conference on AIDS in 1991 documented the importance of nutrient replenishment for people living with HIV.[11] A number of those studies reported that a large percentage of even asymptomatic people suffer from malnutrition, while those with advanced disease suffer almost universal nutritional deficiencies. University of Miami Medical School researchers presented evidence that nutrient deficiencies begin very early and have a significant influence on how well the immune system functions and how quickly HIV disease progresses.[12] They reported that correcting deficiencies in nutrients such as B-6, B-12, and zinc actually resulted in T4 cell increases. Other studies have shown that for people with HIV or AIDS the effects of malnutrition can be quite devastating. Ill effects include inefficient drug absorption due to changes in the digestive tract, increased risk of drug toxicity, increased fatigue, and decreased activation and elimination of drugs which are dependent on fat, protein, carbohydrates, vitamins, and minerals for proper use by the body.

Malnutrition in AIDS can result from many different factors. Inability to take in a proper amount of nutrients can be the result of impaired swallowing and taste due to infections in the mouth or esophagus (such as thrush or herpes), AIDS medications leading to anorexia (loss of appetite), nausea and vomiting, or limited financial resources that make three square meals difficult to manage. Diarrhea and changes in absorption caused by bacteria, viruses, or parasites may impair nutritional intake. Some medications, particularly antibiotics, may change the normal bacterial composition of the intestine and interfere with breakdown of food. Finally, an increase in metabolism often occurs in many people with HIV and leads to an increased need for nutrients. The presence of HIV itself as well as some of its associated infections can increase the metabolic rate. For example, fevers increase a person's caloric requirements by 7% for every degree Fahrenheit above normal. The interplay of these three factors--namely, diminished intake, malabsorption, and hypermetabolism--usually occur simultaneously to deplete the body of nutrients.[14]

VITAMIN THERAPY AND MEGADOSING

For people who want to take supplemental vitamins and minerals in addition to a balanced diet, a multivitamin which provides at least 100% of the U.S. Recommended Daily Allowance (RDA) is preferable over individual vitamins because of lower cost and lower risk of toxicity. Individual vitamins can be used as supplements when needed. Multivitamins are also preferable because single-nutrient deficiencies are unusual. Clinical studies of people with immune dysfunction due to malnutrition usually reveal multiple deficiencies.[15] Therefore, a single, good multivitamin may be more cost-effective, safe, and logical than daily handfuls of a variety of vitamins. Furthermore, some vitamins like C are water-soluble and are excreted in the urine when super-saturation from megadosing occurs. Despite the high cost and time involved, megadosing has been effective for many people. Most studies of high nutrient intake in humans and animals have shown megadosing to be safe, and have demonstrated heightened immune function when supplements are given at two to five times the RDA.[16] The dangers of megadosing or vitamin supplementation have been overstated but caution should be exercised since toxic effects are possible when vitamins are used improperly. Routine blood tests can be used to monitor levels and ensure that supplementation does not produce toxic levels of vitamins and minerals.

AUTOIMMUNITY AND HIV

There is increasing evidence for an autoimmune aspect of HIV infection,[17] which may be treated with antioxidants and other nutrients that protect cell membranes and dampen the inflammatory response of the body to the infection (e.g., glutathione, coenzyme Q-10, vitamins C, E, and A, selenium, zinc, etc.).[18] According to Dr. Russell Jaffe, deficits in any of the 42 nutrients essential to immune competence can contribute to immune dysfunction and possibly cause autoimmune conditions.[20] Although reports in the medical literature are still controversial, some suggest that vitamin C leads to improved immune function. At the Linus Pauling Institute in Palo Alto, California, researchers have shown that vitamin C, a water-soluble antioxidant, may block the infection of cultured cells by HIV through some unknown mechanism. Vitamin C is distributed widely through the body and may increase the effectiveness of compounds such as N-acetyl-cysteine (NAC), a glutathione replenisher.[21]

Researchers at the National Institutes of Health (NIH) and Cornell Medical College demonstrated that, in vitro, NAC slows HIV replication by inhibiting viral transcription (production of messenger RNA, the template for protein production). At Stanford Medical School, an inverse relationship between viral production and glutathione level was demonstrated. Clinical trials with antioxidants (NAC) and other glutathione precursors) in people with HIV are underway at a few research sites. In addition to antioxidants, it may be very important to address the other elements that can contribute to autoimmune conditions such as food and chemical hypersensitivities. Appropriate discovery of such sensitivities via tests like the serum ELISA/ACT--followed by elimination of the foods or other items to which sensitivity is found--may help counter the possible autoimmune component of the disease. Test kits are available to physicians through the Serammune Physicians Laboratory, 800-553-5472.

HOW TO FIND OUT MORE

Registered dieticians and naturopaths may know more about general nutrition than medical doctors, since they have much more extensive training in the area. Many are specifically knowledgeable about nutrition in people with HIV. Unfortunately, naturopathy is not covered by all health insurance and office visits may be as expensive as an appointment with a medical doctor (about $60-$100). Basic nutrition analysis can start at under one hundred dollars, but extensive comprehensive analysis can extend to several hundred dollars. Some naturopaths will work on a sliding fee scale and will find inexpensive ways to supplement the patient's diet. The American Association of Naturopathic Physicians in Seattle (206) 323-7610 can recommend a certified naturopath in your area who is a graduate of a four-year school with a course of studies similar to American medical schools. The author also has further information, available by sending a self-addressed envelope and $5.00-$10.00 to cover postage and handling to: Carl Vogel Foundation, 1413 K St. NW, Washington, D.C. 20005.

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OTHER USEFUL HINTS

* Water is critical for proper absorption of many vitamins and minerals. It also helps remove toxic substances (like cell wastes) from the blood. Drinking adequate amounts of water is recommended for people with HIV. Filtered water is best when available since contaminants have been removed. Drink at least eight glasses a day>

* Boiling all drinking water was recommended to patients with less than 200 T4 by Dr. Brian Gazzard at the International Conference. This strategy is thought to inhibit cryptosporidia that causes diarrhea.

* Diarrhea results in nutrient excretion before absorption into the body through the walls of the small intestines can occur. A strategy for controlling diarrhea followed at San Francisco General Hospital includes the "BRAT" diet: Bananas, Rice, Apples, Tea, and Toast. Because of the limited protein and caloric benefits of this diet, it should only be used as a supplement to control diarrhea and not as a standard menu.

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TREATING SYMPTOMS [19]

SYMPTOM SUGGESTED THERAPY

Loss of appetite Zinc, multiple nutrients

Weight loss Enteral and parenteral formulas, multiple nutrients

Depression B-12, multiple nutrients

Loss of sense of smell or Zinc, essential fatty acids, taste

Potassium muscle cramps Magnesium, calcium, Vitamin E

Nerve pain (some types) B-12, thiamine, choline, inositol Cognitive dysfunction B-12 (memory and concentration loss)

Fatigue B-12, essential fatty acids, ascorbate, magnesium chromium, coenzyme Q-10

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SUGGESTED NUTRIENT SUPPLEMENTATION LIST

[Editors Note: This chart describes nutritional regimens recommended by the author, a trained nutritionist, with some additions from published articles and abstracts containing the latest nutritional research in AIDS Treatment Issues urges readers, as always, to consult with a trained professional and a doctor before changing treatment regimens, and to inform all healthcare providers when making significant nutritional alterations in your diet. It is important to note that not all trained nutritionists subscribe to the following regimens.]

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Paragraph Labels:

NUT = Nutrient ACT = Activity AMT = Amount RDA = U.S. Recommended Daily Allowance HH = Helpful Hints

NUT Acidophilus ACT Helps digestion; prevents yeast infections AMT 1/4 teaspoons or 2-4 capsules before meals RDA N/A HH Must be refrigerated. Can be found in health food stores

NUT Antioxidant Formulas ACT Clears the blood of free radicals AMT 400-800 mg/day RDA 60 mg/day HH More than 1000 mg/day can be toxic, so check total daily intake from all supplements, including multi-vitamins. Examples of antioxidants are beta carotene, selenium, & glutathione.

NUT Vitamin C (Ascorbic Acid; Ascorbate) ACT Works against bacteria, viruses & fungi; may stimulate white blood cells to combat stress. AMT 6-20 grams/day RDA 60 mg/day HH Generally non-toxic, but can cause diarrhea and urinary stones (rarely) in high-doses.

NUT Beta Carotene (precursor to Vitamin A) ACT Helps thymic function; fights bacteria and viruses; lubricates the lungs. AMT 20,000-50,000 i.u.day RDA 5,000 i.u./day HH Considered non-toxic, even in large amounts

NUT Coenzyme Q-10 ACT Keeps immune function, heart muscle, thymus & cell respiration healthy. AMT 30-180 mg/day RDA N/A HH Completely non-toxic in high doses; may help people taking AZT.

NUT Essential fatty acids. ACT Counters fatigue & immune dysfunction; alleviates skin problems. AMT Omega-6 fatty acids such as gamma linolenic acid found in primrose oil & borage oil, 240 mg/day; Omega-3 fatty acids, such as eicosapen taenoic or docosa-hexanocic acid (Max EPA, 300 mg/day) RDA N/A

NUT Folic Acid (B-Complex Vitamin) ACT Helps red and white blood cell formation & synthesis of hemoglobin. AMT 400-800 mcg/day for people taking AZT, ddI or ddC. RDA of 400 mcg is sufficient for people not taking those drugs. RDA N/A HH Should be balanced with B-12 intake.

NUT Glutathione ACT Helps with the function of many immune system activities including growth. Long thought to be critical to healthy immunity. AMT 300-1200 mg/day RDA N/A HH Not known if oral forms can produce high enough levels in blood to be of use.

NUT Vitamin B-6 ACT Helps in DNA production, red cell proliferation, protein metabolism. AMT 100 mg/day RDA 2 mg/day HH Most important of the B vitamins for people who are immune- deficient.

NUT Vitamin B-12* ACT Most common deficient vitamin in people with HIV. Involved in red blood cell production. A recent study shows it may help with brain functions.** Helps people with anemia who are not taking AZT. AMT 500 mcg/day oral plus nasal or under the tongue to bypass absorption problems. RDA 6 mcg/day HH "Ener-B" is a nasal B-12 gel. It must be taken 2-7 times a week.

NUT Vitamin E ACT Helps remove toxic substances from the blood; may increase efficacy of AZT, may enhance resistance to OIs & slow disease progression. AMT 800-1600 i.u./day RDA 30 i.u./day HH Doses over 800 may cause fatigue in some people. Check multiple vitamins for E & keep track of total intake. Avoid acetate esterfied form which has no antioxidant activity.

NUT Multiple Vitamin/Mineral ACT Helps absorption & metabolism. AMT 3 capsules/day RDA N/A HH Use a bioavailable, hypoallergenic multiple with advanced forms of minerals (citrates, picolinates, ascorbates) & vitamin B-6 in the form of pyridoxal phosphate rather than pyridoxine) in amounts at least equal to the RDA. Take with three meals a day.

NUT Zinc ACT May help in skin or taste/smell disorders. AMT 25-50 mg/day HH Toxicities are possible at more than 100 mg/day for long-term use. Balance long term use with copper (2-4 mg day). Use bioavailable forms of zinc, such as citrate or picolinate.

* Ideally B-12 is taken by intramuscular injection. Dr. Pamela Jo Harris reports a need for very frequent injections (2000 mcg, an average of three times per week) to maintain B-12 levels in the blood. This recommendation far exceeds the infrequent and inadequate intervals (once per month or less) often practiced by physicians. For more information see Harris PJ & Candeloro P. HIV infected patients with B-12 deficiency and autoantibiodies to intrinsic fact.r AIDS Patient Care 5(3):125-128, 1991.

** Beach R, Hommes JT, Cheeks R, & Kotler D. HIV & Nutrition: Round Table Discussion, VIII Int'l Conf on AIDS, Amsterdam, July, 1992.

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FOOTNOTES ---------

1. VIII Int'l Conf on AIDS, Abstract # PoB. 3675 & PoB. 3458, Amsterdam, July, 1992; Singer P et al. Nutritional aspects of the acquired immunodeficiency syndrome. Amer Journ Gastroent 87 (3): 265-273,1992. Beach R. Malnutrition in patients with HIV infection and AIDS. Nutr MD 15 (8):1-7, 1989.

2. VIII Int'l Conf on AIDS, Abstract # PuB.7318, PoB3711, & PoB.3698, Amsterdam,July, 1992; V Int'l Conf on AIDS. Abstract # 468, Montreal June, 1989; Harriman GR et al. Vitamin B12 malabsorption in patients with AIDS. Arch Intern Med 149:2039-2041,1989; Beach RS et al. Altered folate metabolism in early HIV infection. JAMA 259:519,1988.

3. Beach R and Lefkowitz M. Nutritional aspects of HIV infection. PAACNOTES 1(6):221-223, November/December, 1989.

4. Brighthorpe IE. AIDS: Remissions using nutrient therapies and megadose intravenous ascorbate. Int'l Clin Nut Rev 8:53-75,1987; and Baum MK et al. Association of vitamin B6 status with parameters of immune function in early HIV-1 infection. J AIDS 4:1122-1132,1991.

5. Gross RL & Newberne PM. Role of nutrition in immunologic function. Physiol Rev 60:188-302, 1980; Bedich A. Micronutrients and immune responses. Ann NY Acad Sci 587:168-180,1990; Beisel WR. Vitamins and the immune system. Ann NY Acad Sci 587:5 8,1990; and Beisel WR. Single nutrients and immunity. Am J Clin Nutr 35 [suppl]:417 468,1982.

6. VIII Int'l Conf on AIDS, Abstract # PoB. 3675, Amsterdam, July, 1992; and Newman CF. Nutrition in AIDS management: current choices, effective strategies. AIDS Patient Care 4:6-9,1990.

7. Fenton M. A Guide to AIDS Research and Counseling. Focus 5 (2),1990.

8. VII Int'l Conf on AIDS, Abstracts # W.B. 2076, Florence, June, 1991.

9. Cimoch PJ. Supplemental parenteral nutrition for the treatment of protein-calorie malnutrition in HIV/AIDS patients. PAACNOTES 2 (1):15-17.

10. For more general information and information about trials, contact Treatment Alternative Research Project, c/o PWA Health Group, 150 West 26th Street, Suite 201 New York, New York 10001. Contacts for information are Jon Greenberg (212 673 0491) or Sandy Katz (212 388 9929), or the office (212 255 0520) or fax (212 255 2080).

11. VII Int'l Conf on AIDS, Abstracts # M.C. 3127, #W.B. 90, #W.B. 2421, #M.B. 3128, #T.U.A. 66, #W.B. 2166, #W. B. 2076; Florence, June 1991.

12. VII Int'l Conf on AIDS, Abstracts # M.C. 3127, Florence, June 1991.

13. Raiten DJ. Nutrition and HIV infection: A review evaluation of the existent knowledge of the relationship between nutrition and HIV infection. Special Report prepared for the Food and Drug Administration, November 1990: 48-51.

14. Task Force on Nutrition Support in AIDS. Guidelines for Nutritional Support in AIDS. Nutrition 5(1):39 46,1989; Resler S S. Nutrition Care of AIDS Patients. J. Am. Diet. Assoc. 88(7): 828-832,1988.

15. Raiten DI. Nutrition and HIV Infection: A Review Evaluation of the Existent Knowledge of the Relationship between Nutrition and HIV Infection. Special Report prepared for the Food and Drug Administration, November 1990, 43.

16. Watson RR, ed, Nutrition, Disease Resistance, and Immune Function. Volume in Immunology Series. New York City, M. Dekker Inc. 1984.

17. Hoffman G W et al. An Idiotypic Network Model of AIDS Immunopathogenesis. Proc Nat'l Acad Sci 88: 3060-3064,1991; Kion TA and Hoffman GW Anti-HlV and Anti-Anti-MHC Antibodies in Alloimmune and Autoimmune Mice. Science 253:1138-1140,1991; Maddox J. AIDS Research Turned Upside Down. Nature 353:297,1991; Ascher MS and Sheppard HW. AIDS and Autoimmunity. JAIDS 3:177-191,1990; and Ascher MS and Sheppard HW. AIDS as Immune System Activation II: The Panergic Amnesia Hypothesis. JAIDS 2:95-114,1990.

18. VII Int'l Conf on AIDS, Abstract # T. U.A. 66, Florence, July 1991.

19. Standish L. One Year Open Trial of Naturopathic Treatment of HIV Infection Class IV-A in Men. Journ Naturopathic Med 3(1): 42 64,1992. Pulse TL and Uhlig E. A Significant Improvement in a Clinical Pilot Study Utilizing Nutritional Supplements, Essential Fatty Acids and Stabilized Aloe Vera Juice in 29 HIV Seropositive, ARC and AIDS Patients. Journ Adv Med 3(4): 209-230,1990; Jaffe R. M. Personal Communication, April 2,1992; Askanazi J. Personal Communication, May 4, 1992; and Lands LE. Personal Compilation of Data, 1985-1992.

20. Jaffe RM. Host Defenses: An Approach to Risk Identification and Risk Reduction in HIV+ Individuals. Manuscript in Preparation.

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