Nutrition and AIDS: Interview with Kristin Weaver, Bay Area Nutrition Counseling Center and Clinic (BANC), at San Francis

Kristin Weaver, R.N., M.S.N., C.N.S.N., is the Clinical
Research Coordinator and Nursing Director of GI
(Gastrointestinal) Nutrition Services at San Francisco
General Hospital. We spoke with her recently about the
relationship between HIV disease and nutrition. This is part
I of the interview.

Note: Recently San Francisco General Hospital was rated best
in the U.S. for AIDS care, for the fifth year in a row, in a
poll of medical professionals conducted by U.S. News and
World Report, (published in the July 18, 1994, issue).

ATN: You work with both inpatients and outpatients who live
with HIV disease. Can you tell us about the GI Services at
San Francisco General Hospital and the Bay Area Nutrition
Clinic.

KW: When I became the Clinical Research Coordinator here at
SFGH, the physicians here were doing a lot of procedures for
patients with dysphasia, diarrhea and other GI-related
symptoms. We did an in-patient chart audit and found
approximately 70% of patients had a diet inappropriate for
the symptoms they were experiencing. In addition, nutrition
was often at the bottom of the list when it came to providing
care.

We formed a multi-disciplinary team under the auspices of the
Division of Gastroenterology, Hepatology, and Clinical
Nutrition. The team consists of a GI specialist,
pharmacologist, dietitian, and nurse, who work one-on-one
with hospitalized patients, to address the specific problems
interfering with optimal nutrient intake. But when patients
were discharged home, there would be no outpatient followup.
It was difficult to have much of an impact in the short time
that people were hospitalized; we wanted to expand our work
to reach outpatients earlier. That's why we started BANC,
which also is a multidisciplinary approach to assessing and
addressing the nutritional concerns of people with HIV. In
this outpatient clinic, we help to keep people from losing
more weight, or help to keep people nutritionally sound and
prevent the onset of weight loss. Patients are active
participants in their own care at BANC.

It's important to reach people early. It is well-documented
that during World War II children who were malnourished
developed pneumocystis. If you are malnourished, the immune
system suffers. If you are sick, your nutritional needs go up
overall. Currently 50-60% of all hospital patients are
malnourished. Malnutrition leads to increased length of
hospitalization due to repeated complications requiring
treatment. If almost all HIV-infected people eventually
develop malnutrition, one might speculate that malnutrition
is a cofactor in increasing health-care costs.

ATN: How do you know if people are malnourished? It's subtler
than our typical image of an emaciated individual.

KW: That's a very good point. One person was admitted to the
hospital with cryptococcal meningitis. He looked pretty well
buffed -- not like he had missed many meals. But when we
looked at his serum albumin and his body composition, he was
already mildly malnourished.

Many physicians won't address nutrition because, "You look
fine -- your weight is stable." But what you can't see from
the outside is that there may be changes already occurring
with loss of muscle mass; it is being replaced with fat. You
may maintain your overall weight, while inside there are
changes leading you down the path to malnutrition. In our
chart review we found that 34% of patients were already
severely malnourished when they were hospitalized with their
first AIDS-defining illness, and another 46% were moderately
malnourished. It is clear that changes in nutritional status
occur during the relatively quiet phase of "just" being HIV-
positive.

ATN: How can we explain body composition to our readers, and
how can people keep an eye on that? Is an expensive test
needed, or are there simple ways?

KW: Body composition will tell us what lean/fat ratio you
have. This reflects your muscle mass and fat pads. Men will
have fewer fat pads than women.

In simple starvation the body will start breaking down the
fat as a source of energy, and then eventually go to the
muscle. With AIDS we're seeing the opposite: The body breaks
down the muscle and leaves the fat intact until later. So
there are metabolic derangements going on that we don't
understand well. Eventually in some people, no matter what
you do, unless you're on TPN [explained below], the body
won't be able to utilize the protein, carbohydrate and fat
you're giving it, to put into muscle and fat.

ATN: How do health care providers keep an eye on lean body
mass?

KW: One simple way is to use a small caliper and test 12
different sites on the body--pulling the skin and fat away
from the muscle and pinching, and adding all the numbers.
Then you look on a chart for age, sex, height, weight, etc.,
to estimate the percent of body fat for the individual. We
use that plus something we call the Futrex, a machine that
bounces infrared light off the arm and computes the percent
of fat, lean muscle, and water the individual has.

ATN: Can you explain more about the nutritional assessment?

KW: There are many things to consider. We look at serum
albumin -- your protein level. It has many important
functions in your body, but the problem of albumin is
affected by all kinds of things and may not be accurate.
Also, the albumin level measures your nutritional status from
three weeks ago. More sensitive indicators include pre-
albumin (which indicates nutritional status about three days
ago), and transferin, another protein, which is very
sensitive; it indicates where you were hours ago with your
nutritional status. We also look at triglycerides,
cholesterol and zinc. Other information that helps us
determine the level of malnutrition is the amount of weight
lost over a period of time, and the person's percentage of
usual body weight.

Getting Help Early

ATN: You've said that early, aggressive nutritional
intervention can prevent weight loss, increase the function
of the gut, reduce the chance for opportunistic infections,
enhance response to therapies and improve a person's quality
of life and sense of well-being. Can you define "early,
aggressive nutritional intervention" a little more?

KW: When somebody is first diagnosed as being HIV-positive,
they should sit down with a registered dietitian or someone
in the nutrition field and ask, where am I now? They should
align themselves with a physician and tell the doctor, I want
to maintain my weight, I want to keep an eye on this. Then,
as soon as they start losing weight, even if there are no
other symptoms or obvious causes, go to the doctor or
dietitian and ask, "Where am I with my body composition and
what do I do now?"

Through each change that goes on the person needs to be in
touch with a physician or someone who's going to be able to
give them some direction. The earlier we can get that weight
back up and keep an eye on body composition, the better off
we will be in prolonging nutritional status and quality of
life.

ATN: What can we say to people at an earlier stage now?

KW: Align themselves with a registered dietitian, not a
nutritionist. A nutritionist is someone who may have gone to
school or read books, but has never taken a test to confirm
their knowledge. A registered dietitian has had four years of
college, and many of them will go an extra year of training,
and there is a standard test they have to pass, so you know
their knowledge base is probably stronger. Their experience
and exposure to different types of patients is much more
structured and solid than the nutritionists. The nutritionist
may be good, but to get the total picture you should choose a
registered dietitian who is familiar with HIV disease or who
has worked with oncology patients, because there are many
similarities in certain aspects of the nutritional component.

People who are still feeling good when they find out they are
HIV-positive should talk with a registered dietitian and ask,
where am I now? How is my body composition -- what percent
fat? Am I overweight or underweight? Dietitians can help with
eating more healthy foods. It is recommended that people come
back occasionally, perhaps every three months, to check on
how things are going.

As soon as someone starts to lose weight, they should see the
doctor or the dietitian. There may be other things going on
at that point, or perhaps they may need to add a liquid
supplement. As with any health care provider, find a
dietitian you can communicate well with, whom you feel
comfortable with.

ATN: How does one find a registered dietitian?

KW: If you don't have a referral, the American Dietetic
Association has a list; or you can look in the yellow pages
for a registered dietitian.

ATN: Will insurance pay?

KW: At this point it's probably an out-of-pocket expense,
unless a physician is also seeing the person in the same
clinic. There is legislation underway now, though, to put
registered dietitians in the category of being licensed
practitioners, to facilitate payment by insurance.

ATN: What about people who can't afford a dietitian?

KW: It's a difficult situation. However, if somebody is
hospitalized for some reason, they can ask for a nutrition
consult and assessment from a registered dietitian or
nutritional team, and have that during their hospitalization.

Nutritional Status in HIV Disease

ATN: HIV related complications often occur in the lower
gastrointestinal tract. Can you explain why this is the case?

KW: Immune globulins in the gut -- a kind of antibody called
IgA -- normally act at the mucosal layer to protect against
invading organisms. When somebody is immunocompromised, the
body doesn't produce enough of the antibodies to be
protective. This creates open portals of entry in the gut for
bacteria, funguses and viruses. Critical care patients get
septic because they are not using their gut and they are
malnourished; these problems allow the translocation of
bacteria, etc., into a person's system. That's why we want to
keep the gut functioning as long as possible -- stimulate it
and keep those immune globulins and macrophages working, so
there isn't the opportunity for pathogens to enter.

ATN: What can be said about nutritional status as an
indicator for survival?

KW: Kotler's research found that when a person is at 66% of
their ideal body weight and 54% of their body cell mass, they
die.

People maintain a certain weight, then develop an
opportunistic infection and drop their weight. They may gain
weight back, but not quite up to what it was before. Another
opportunistic infection will continue the downward spiral.

That's why it is important to keep nutrition under control,
especially while you are in the hospital. This is one disease
where everybody has to be their own advocate; go to the
doctor and ask about this drug or that trial, pushing,
pushing, pushing. Most doctors consider weight loss and
malnutrition inevitable. That's one of the most frustrating
things for us -- getting the doctors to buy into the fact
that there is a lot we can do.

ATN: Please explain how to meet the specialized nutritional
needs of persons with mildly to severely symptomatic HIV
disease.

KW: There are nutritional formulas specifically designed for
altered-gut problems. For supplementation people can use
nutritional formulas which you can get over-the-counter at
pharmacies; they come in cans and are taken orally. More
severe clinical situations may require peripheral parenteral
nutrition (PPN), or total parenteral nutrition (TPN). These
are formulated for individual patients and administered
intravenously into the arm (PPN), or with a catheter in the
chest (TPN).

ATN: Give us some examples of when intravenous feeding is
appropriate.

KW: PPN is for short-term use because it will irritate the
veins fairly quickly; 7-10 days is usually the maximum. We
used it on a patient with CMV esophagitis so bad he couldn't
swallow his own saliva. It was used as a "bridge" until the
CMV treatment could kick in and the patient could swallow
again. Then we worked him into an appropriate diet. In a
different instance we used TPN for a patient who couldn't eat
because of an obstructing lymphoma of the stomach. We put him
on TPN for two weeks while he was getting chemotherapy and
radiation. The tumor melted, and then we could feed him
normally.

In another case, there was relentless, severe cryptosporidium
diarrhea -- 20 liters of stool per day. The patient would die
in days if we didn't do something to put the gut at rest. In
the first couple of weeks we used TPN to give the gut a rest.
Then we reintroduced food in the form of pure amino acids;
the product was Vivonex, a chemically-defined liquid diet
very low in fat, to stimulate the gut and some digestive
enzymes. Basically, the body doesn't have to do any work, the
nutrients just get absorbed across the gut mucosa. It's an
easy, sort of passive way to get food into someone.

One thing to consider is that people on TPN tend to gain fat
weight, while on tube feeding (see below) they tend to gain
more lean weight -- we think this is because it's more
physiologic to have food going directly into the gut.

In the case of TPN, it is important to discuss the rationale
for it, as well as end-points for its use, before it is
started. We have seen TPN help people "over the hump" and
improve their nutritional status. However, its drawbacks
include the possibility of infection, metabolic and technical
problems, and great expense.

ATN: Where can one get more information to help make these
decisions?

KW: The American Society for Parenteral and Enteral Nutrition
(ASPEN) is a multidisciplinary society of physicians,
pharmacists, nurses, and dietitians, who are specifically
interested in nutrition. They put out guidelines about when
TPN should be used, when it would be helpful, when it's not a
good idea.

What Is Tube Feeding?

Tube feeding is a less expensive and more "normal" method of
feeding someone than PPN or TPN, because you use the
gastrointestinal tract. Tube feeding would be appropriate for
someone with a normal stomach and gut function, but who had
either dysphagia (difficulty in swallowing) or odynophagia
(pain on swallowing). The feeding could be given
continuously, or just at night to allow freedom to move about
during the day.

There is a wide range of formulas and ingredients for tube
feeding, for example: (1) intact protein and high fat and
carbohydrate; (2) various other forms of protein such as
peptides or pure amino acids for compromised gut function;
(3) medium chain triglycerides, a form of fat that is easily
absorbed; (4) fiber; (5) fish oils, etc. The registered
dietitian, working with the physician, can make the best
recommendation for each individual.

[Part II of this interview will look at liquid nutritional
supplements, oral rehydration salts, vitamins, and other
topics.]