Protecting Body Composition in HIV Infection: Interview with Nutritionist Cade Fields Newman
The importance of malnutrition in AIDS progression is slowlyreceiving more attention. Specific micronutrient deficiencies
have been found with HIV that effect immune system function or
are related to brain and nervous system impairment. [See AIDS
TREATMENT NEWS #134, September 6, 1991, "Zinc and B Vitamins in
HIV: Overview and Interview," by Denny Smith; and AIDS TREATMENT
NEWS #158, September 4, 1992, "Nutrition at VIII International
Conference on AIDS," by Jason Heyman]. A broader issue is the
loss of the protein stores located in lean body mass as AIDS
progresses.
Each individual seems to require a minimum store of protein
to support life. There is an increasing awareness that death
among people with AIDS frequently occurs when that limit is
approached. People with AIDS may be dying from a process similar
to starvation. Many generalized symptoms of advanced AIDS,
including lack of energy and decreased ability to concentrate or
cope independently, could arise from tissue disintegration caused
by a loss of protein stores.
The chronic, progressively debilitating aspects of AIDS and
HIV infection require treatment as much as do the acute, life-
threatening opportunistic infections. The two are interrelated.
Ensuring proper nutrition is not just a matter of eating the
right foods. It is a complex task requiring, among other things,
management of illnesses, mental attitude and drug interactions.
Sufficient physical exercise is also necessary to maintain or
recover body composition.
We spoke with Cade Fields Newman, M. S., R. D., about the
multifaceted nature of nutritional support and its potential
benefits. Ms. Newman is the founder of The Cutting Edge, a
nutritional consulting firm in Fremont, California that
specializes in advising patients with HIV. Besides working with
individual doctors, she is currently organizing a nutritional
assessment service for the Physicians Association for AIDS Care
(PAAC). It will supply member physicians with an evaluation of
the nutritional status of their patients and recommend ways to
control nutritional deficits and wasting.
* * *
ATN: How important would you say proper nutrition is?
CFN: Well, if I said I had a drug that would extend a
patient's life two or three years, that would improve their
quality of life, that would keep them in a situation where they
could provide their own care and keep them working, you would
think people would be flocking to it. Yet, we do have that; it's
called "nutrition." Although not a stand-alone therapy, it is a
very important part of overall treatment. And in conjunction with
all the other things that are done, I believe that we can start
dealing with HIV as a chronic manageable disease, where a person
can live a normal, quality lifespan.
ATN: It seems obvious that the earlier one starts a
nutrition plan the better. Once you become sick and lose
considerable amounts of weight, it will be hard to recover. So,
where does one start?
CFN: Yes, prevention is absolutely key for a person to have
this vague thing called quality of life. But nutrition is not
even a good stand-alone therapy to support nutritional stores.
What is required is a strong partnership between patient and
physician, hopefully with a multidisciplinary team's input. The
patient has to be captain of a team. For instance, I'm a
dietitian, but I cannot solve swallowing problems. You may need
a speech therapist to evaluate that. Or there might be a problem
with peripheral neuropathy and carrying out the tasks of daily
living. Then, an occupational therapist should come in, or if
there are problems with range of motion or movement, a physical
therapist. There should be a pharmacist to advise on the effects
of medications on nutrient utilization. Also, there are the
nurses. Patients see them more than anyone else, especially
home-care patients.
All of us are simply advisers. It's the patient's choice.
It is very important that they can assemble this team and that it
does what they want. Otherwise people get advice on nutrition
from persons who do not have access to their medical records.
There is no way such persons can put together nutritional advice
that matches that person's individual medical profile.
ATN: But nutritional advice is not all that common at a
physician's office. Most doctors don't have much nutritional
training. How common is this ideal sort of team that you are
talking about?
CFN: It varies from place to place. It occurs when you
have strong-minded, assertive patients who insist on it. It's a
growing phenomenon. A lot of us talked about team work for years
without doing anything about it, but now patients are insisting
on it.
The doctor has to be in tune with what's happening. If the
patient cannot maintain adequate nutritional stores, then medical
therapies will fail. Drug therapies depend on your protein
stores, for instance on your serum albumin to carry that drug
where it needs to go. Oral drugs depend on your ability to
absorb. That, too, is based on nutritional status. At least,
primary care physicians need to monitor overall treatments to
make sure that they do not conflict. That cannot be done unless
people are working together as a team.
ATN: I want to talk about what this team will advise in
nutritional support. But first can we briefly describe the
sources of inadequate nutritional balance in HIV infection and
AIDS?
CFN: There are three major reasons for malnutrition in HIV-
related disease. The first is decreased intake. That could be
because of anorexia -- just a lack of appetite -- which could
happen with depression or some of the drug interactions, a number
of different things. The second part of this is malabsorption,
which happens quite often with HIV-related diseases in the
gastrointestinal track. These two considered together would be
reasons for the body to starve.
Besides this, the inflammatory response of the body to HIV
uses up protein stores in muscle tissue. This creates a major
risk for malnutrition. Also, the altered metabolism of nutrients
allows a person to hold onto and even generate fat stores while
maintaining or building lean tissue is difficult.
Nutrient transport within the body may also undergo
alterations. For instance, in a number of patients with advanced
disease, there are indications of an iron deficiency although
there may be other signs that there is plenty of iron. It looks
like iron is not going where it needs to go, and just
supplementing with iron is not going to help.
The picture is much more complex than not getting enough
food or malabsorption, and that's what makes nutritional
intervention so difficult. Often we talk about this particular
chemical in the body doing that particular thing, but there may
be many different metabolic pathways that have to be set right.
ATN: OK, so let's start at the simplest level. What are
the first steps an asymptomatic person with HIV should consider
for nutritional intervention?
CFN: Well, I know it's not hi-tech, but food is going to be
the best thing a person can do. When we second-guess nutrition
and try to package it into little things to give people, we
sometimes get into trouble. Food has many substances in it that
we don't know much about and that might be very important.
If I were to prioritize what a person needs, the number one
priority would be fluids because without adequate hydration,
nothing works. The second priority would be calories, because
without enough energy it doesn't matter what you are getting in
terms of protein. It will not go where it needs to go. The
third priority is protein, and the fourth priority is vitamins
and minerals, which cannot be used by the body without the first
three.
ATN: It's important to stress that problems with food
intake might be problems with energy -- not preparing food or
feeling energetic enough to eat.
CFN: Absolutely. You need to figure out for each person
what they need, what they're getting, and strategies for getting
it. And when they're having a bad day, they should have a stash
of food on board. Many people do not have that, and when they go
through two or three bad days, they get behind. At least if they
had a supply of food supplements, even instant breakfast, they
could get through better.
Cooking can be very energy-draining; don't feel strange
about asking for help. If someone wants to cook for you, let
them do it. Nutrition covers quite a span. Sometimes we get so
caught up in the biochemical changes in the liver, when a simple
chair in the kitchen or a better pair of eyeglasses would make
the biggest difference.
For a person who is completely asymptomatic, a basic piece
of advice is to learn fundamental nutritional principles. Learn
how nutrition interacts with immunity -- from a serious source,
not from some popular magazine. Food safety -- proper storage,
cleaning and cooking -- is another very important skill to learn.
There are a number of opportunistic infections that could be
prevented if food safety were higher on people's lists.
ATN: Isn't there data that you should start collecting to
check on your nutritional status?
CFN: Yes, you should develop some individual strategies you
can put together to make sure you are getting what you need on a
day to day basis, but you should also develop a good contact that
will answer your questions and monitor your body composition
every six months. Weight is not a good early indicator; its loss
shows that a lot of things have already happened. It is very
important to get baseline data so you can know what the trends
are in mid-arm circumference and triceps skinfold [a measurement
of fat stores] and so forth. These measurements reveal more than
weight alone does about the present state of body composition.
You also need to monitor medical therapies. Many people are
taking many medicines. Drug interactions with the body, such as
nausea, vomiting, diarrhea, and toxicities to liver, kidney and
pancreas, can put you at risk nutritionally Another factor to
monitor is markers of nutritional status. Albumin in the blood is
a good general indication of the state of the body's protein
stores, although infections can make this go down without any
relation to nutrition.
ATN: Are there specific nutrients that you would suggest
emphasizing in the diet?
CFN: I would concentrate on a nutrient-dense diet. This
means that calorie per calorie you get a good amount of the other
things you need, like protein and vitamins and minerals. Your
priorities are still fluids, calories and proteins, and then
micronutrients [vitamins, minerals, etc.]. Most people ask about
vitamins, but you need the first three to get any benefits at all
from the last one. I would concentrate on fluid-containing,
calorie-containing and protein-containing foods and then make
sure I got adequate micronutrients.
A group from the University of Miami in Florida did
recommend some very specific things in regard to supplementation
[M. K. Baum and others, "Interim Dietary Recommendations to
Maintain Adequate Blood Nutrient Levels in Early HIV-1
Infection," VIII International Conference on AIDS, Amsterdam,
July 19-24, 1992, abstract #PoB3675]. In early HIV infection,
increased intake of zinc and vitamins B2, B6, B12, A [or beta
carotene equivalent], C, and E, on the order of six to 25 times
the RDA [depending on the nutrient; more than six times for some
of them could be harmful. See full report in M. K. Baum and
others, "Influence of HIV Infection on Vitamin Status and
Requirements," ANNALS OF THE NEW YORK ACADEMY OF SCIENCES, volume
669, pages 166-174], was found necessary to maintain adequate
blood levels of these substances in some patients. We don't know
yet how helpful normalizing these values is going to be. This is
just an interim recommendation. But we have seen people improve
cognitive function by normalizing B12 -- an important nutrient to
pay attention to if there is a decline in its level. Similarly,
B6 seems to be important in protecting against neuropathy,
although an overdose of B6 also causes neuropathy.
A generic recommendation would be just to eat adequate foods
and from there add a multivitamin maybe once or twice a day. You
have to be careful about what you're taking. Nutrients, like
drugs, can be very toxic, especially for people with HIV. A
number of HIV-positive people may already have problems with
chronic hepatitis or other organ infections. If you have liver
or kidney dysfunction or any pancreatic dysfunction -- maybe you
have been on ddI -- nutrients are not metabolized in the normal
way. And a number of drugs are toxic to the liver. This adds to
the potential compromise and toxicity when you take something
like vitamin A.
ATN: Do you favor other special dietary supplementation?
CFN: If a person cannot take in enough calories -- maybe
there's a problem with swallowing or someone just cannot fit in
the nutrients they need -- you can go to the calorie-packed
liquid supplements. You can use those to augment nutrition,
preferably, and in some cases replace whole meals. Stocking up on
these oral supplements is another way of preparing for bad days.
A different kind of supplementation is exercise. Regular
exercise is highly beneficial. Also, if you want or need to gain
weight, then you need to do so along with exercise because
padding yourself with fat is not particularly helpful. If an
opportunistic infection occurs, you need protein stores to resist
it and make your drug therapies work.
There is a high correlation between muscle mass and clinical
well-being. Protein makes the body function; immunity is based
on protein stores, too. And exercise promotes protein formation
in tissues throughout the body. Here, resistance exercise, like
body building, is more important than aerobic exercise.
Another strategy that promotes protein-building is regular,
frequent meals. One study found that people who eat at least
four times a day, including a snack an hour or so before
sleeping, did better in terms of nitrogen balance than anyone who
ate less than four times a day. Fortifying protein stores should
be a central preparation for coping with AIDS.
ATN: When severe immune deficiency does come about, what
are the issues then?
CFN: Most people who lose weight in conjunction with an
opportunistic infection have a hard time gaining it back, if they
ever do. And when they do gain it back, they may not gain back
the protein stores they need, just fat and fluids. This is the
central problem.
ATN: Aren't there ways to recover?
CFN: Yes, there are four strategies for regaining lean body
mass, and nutritional support is only one of them. The first
defense is prompt and effective treatment for opportunistic
infections when prophylaxis fails. We can prevent much
malnutrition by stopping the cascade of events surrounding
opportunistic infections.
The second line of the defense is hormonal modulation and
anti-inflammatory therapies. Some patients have low testosterone
levels, for example. By replacing that, you can maintain or
increase lean body mass because that's one of the effects of
testosterone.
Elevated cytokines, such as some interleukins, have been
proposed as causing the wasting effect. I'm not so sure that
anti-cytokines will prove to be a good therapy by themselves, but
perhaps they will be helpful in conjunction with other
treatments.
Anti-inflammatory agents abound. You have to be careful to
block the harmful aspects of inflammation, those that drain
protein stores for energy, and not the beneficial ones. Simple
aspirin and fish oil reduce the level of inflammatory
prostaglandins to give the body an opportunity to recover lean
tissue. Fish oil may be more effective earlier rather than
later, though.
ATN: You mentioned how important exercise is early stages
of disease, but does it have an effect later on, when movement is
harder?
CFN: Yes, exercise is the third defense strategy. It is
still important in protecting body composition or gaining back
lean body mass after you have lost weight. It's tough when you
are experiencing a lot of fatigue or physical limitations, but
there are people who can put together exercise programs even for
those who are in wheelchairs.
ATN: And nutritional support is the fourth strategy?
CFN: Finally, we come to ensuring an adequate diet. In
AIDS, a host of opportunistic infections affect eating. We
mentioned aspirin before; that and other anti-inflammatories are
also used for pain management. Pain management is an issue that
is not fully addressed for many people with AIDS, and it can be
key, not only for overall quality of life, but also for the
ability to eat.
Just about everybody with AIDS will have diarrhea at some
point, despite attention to food safety. Treating the underlying
cause of diarrhea, if possible, is the most effective course of
action. Also, anti-diarrhea drugs may be combined with
nutritional strategies. Fasting during episodes of diarrhea is
not recommended. Emphasizing sources of soluble fibers (such as
bananas, oatmeal, applesauce and potatoes) while removing sources
of crude fiber and maintaining an overall balanced diet is more
appropriate. Replacing lost fluid and electrolytes, especially
potassium and sodium, is crucial.
ATN: Rehydration and electrolyte replacement can take place
intravenously as well as through the diet. Eventually, simple
dietary techniques may not be enough to provide sufficient
nutrition. Liquid food supplements can be added when someone
cannot or does not take in enough food for whatever reason.
Feeding through a tube to the stomach also has its place in
people physically unable to eat. But in the extreme case, there
is parenteral feeding (through a catheter attached to a vein),
which avoids the GI tract entirely. What role does it play?
CFN: Partial or total parenteral nutrition can help people
get over the hump when disease causes extreme malabsorption. It
is necessary to start early, though. Don't let people not eat
for three to fourteen days before introducing parenteral
nutrition.
Parenteral nutrition does not have to be permanent. People
feel that if they go on TPN [total parenteral nutrition], they're
stuck with it forever. That is not true. In certain diagnoses,
such as CMV colitis, people may be maintained on TPN throughout
their lifetime. Even then, they can modify oral intake and in
some cases reduce their dependency on TPN.
The second point I would like to make is that aggressive
support does not equal TPN. You can be aggressive with peas and
carrots and palliative with TPN. To find out what the appropriate
support is, the patient can be clinically profiled into
diagnostic sub-groupings. For instance, if the person is
experiencing some depression and is adequately absorbing
nutrients, they may simply need to focus on "maximizing food
intake," by eating nutrient-dense foods.
ATN: What about using Megace [synthetic progesterone] or
Marinol [synthetic THC, the active ingredient in marijuana] to
stimulate appetite?
CFN: Marinol seems to work well for nausea, and some
patients prefer it for increasing appetite. Some people complain
about feeling drugged out, though. Some say that smoking
marijuana works better. It's quicker, and avoids their queasy
stomach. But the smoke can present a problem, especially for
those with respiratory infections.
Patients on Megace tend to gain fat, according to studies
using therapeutic doses of 800 mg/day. Many people use a lot
less than that. It has been speculated that a slow weight gain
associated with lower than established therapeutic doses may
include more lean body mass. When used with people who have a
mechanical or pain reason not to eat (rather than reduced
appetite), Megace may be detrimental through increasing the
desire and not the ability to eat.
In advanced HIV infection, you may have "futile cycling" of
fat going on, where fat stores are broken down in the liver and
then rebuilt by the liver. This wasteful process results in
consumption of body protein for energy. If you throw
rehabilitative levels of calories at someone in this state, you
may just get more fat and not the protein stores that are needed.
ATN: Appetite is closely tied to mental outlook. And
mental outlook can be impaired by not eating. This brings up the
relation of mental health support to nutritional therapies.
CFN: Help in avoiding depression or handling stress becomes
more and more necessary as HIV infection progresses. It is key
to motivating HIV-positive people to follow other therapies.
Again, nutritional support, like medical support, will not be
most effective all by itself, as a stand-alone therapy.
ATN: Also, speaking of specific substances like Megace or
Marinol, I notice we haven't spoken much about specific vitamins
and minerals later on in the disease.
CFN: The significance of vitamin and mineral deficiencies
are not well established. Other micronutrients that we look at
besides the ones mentioned before in connection with the
University of Miami group include selenium and folate. One
doctor I know has had good results improving patients' quality of
life with magnesium supplements. But micronutrient deficiencies
seem to be geographically dependent. Some of this has to do with
the minerals in the local soil. A major factor is the variation
from place to place in the way physicians treat AIDS. Drug
interactions have a large influence on micronutrient absorption
and utilization. For example, pyrimethamine and trimetrexate,
which are used in treating toxoplasmosis and pneumocystis,
interfere with folate metabolism.
ATN: So, when taking vitamins and minerals, you have to
understand the roots of the deficiencies?
CFN: Oh yes. Blood indications of low iron may not be
resolved by iron supplementation if it is really a cellular level
nutrient transport problem due to low protein stores.
You need to see what is best for the patient. If
micronutrient levels normalize, is that valuable, or are other
things going on that are still disruptive? Again, addressing
problems that may cause alterations in nutritional, and
specifically micronutrient, status may be most effective.
ATN: Where patients find reliable information about
nutrition, and learn more about the full potential for dietary
changes to modify disease progression?
CFN: Patient information is available through a number
sources. To get a listing of educational pieces designed for HIV
patients you can contact the National AIDS Information
Clearinghouse at 1-800-458-5231.
To find dietitian services for evaluation and counseling,
request a referral from your physician. The next step is to
locate a dietitian who has training and experience in HIV-
related nutritional issues.
Also, contact major city public health departments and ask
for phone numbers of AIDS nutritional networks. In the New York
area, you can contact Nutritionists in AIDS Care at 212-439-
8073. Arizona, California and other states have networks as
well. Several AIDS support agencies have added dietitians to
their staffs, including the San Francisco AIDS Foundation, and
Bronx AIDS Services. Local home meal delivery services can also
be a place to start.
[Note: To contact HIV nutrition specialists at The Cutting
Edge, the organization founded by Cade Fields Newman, call 510-
797-9768.]
source: AIDS Treatment News
