Nutrition and AIDS: Interview with Kristin Weaver (Part 2)

Weaver, R.N., M.S.N., C.N.S.N., of the Bay Area Nutrition
Counseling Center and Clinic (BANC) at San Francisco General
Hospital. Part I appeared in our last issue, #204; copies are
available from AIDS TREATMENT NEWS, 800/TREAT-1-2. Note the
resource list at the end of the interview.]

Nutritional Supplements

ATN: What about nutritional supplements like Ensure?

KW: People should be working with a dietitian or physician
who really knows these products and knows which will be
appropriate for each individual, because they can be
expensive (about $20 a six pack for some kinds). Ensure is a
good supplement but may not be appropriate for someone with
fat malabsorption (often present in HIV disease). Because of
its high percentage of fat, Ensure can exacerbate the
diarrhea. Advera is fairly new, with fish oil and medium-
chain triglycerides. It has a different kind of protein, a
peptide, that is easily digested. Other supplements include,
but are not limited to, Vivonex, Nutren, Peptamen, etc.

In general, you might want to look at supplements which have
a large percentage of medium-chain triglycerides (MCTs),
which are a form of fat that is readily absorbed. We did a
study for fat-malabsorbing diarrhea using a product with a
high percentage of MCTs. The diarrhea decreased by at least
half its original amount following the use of the MCT product
and a low fat diet.

ATN: Which product?

KW: Lipisorb. Nutren is also excellent, and perhaps more
tasty. I say this because our nutritionists routinely involve
us in taste tests of all liquid supplements; if we're going
to recommend supplements for our patients, we need to know
how they taste, too.

ATN: What about fluids? Are there increased needs in HIV
disease?

KW: If a person is having fevers or diarrhea, they're going
to be losing a lot of fluid. It's very important that you
replace electrolytes [as well as the water]. People can die
from electrolyte imbalance -- sodium, potassium, chloride
especially. The infant formula Pedialite is one option, but
it is expensive and heavy to carry. We were recommending
Gatorade, because that does have electrolyte replacement, but
it can be expensive if you're drinking a lot, and it has
sugar which could exacerbate the diarrhea. People say, why
not just drink water? But that will wash out even more of the
acid and electrolytes in the stomach, leading to further
metabolic imbalances.

A while ago our pharmacy obtained oral rehydration salts from
the World Health Organization. The formula is pretty bland;
you can taste a little salt. I believe it would be good to
add that to the water, then dilute your nectars or other
juices you may be drinking to replace your electrolytes. It
comes in little packets for about 50 cents. Hopefully we'll
see people using more of this.

[Note: For information on how to obtain rehydration salts,
see the resource section at the end of this interview.]

Food Advice; Deficiencies

ATN: Any general dietary advice?

KW: Eat a more healthy diet -- including, for example,
skinless chicken, and a variety of fresh fruits and
vegetables. You need meat and other sources of protein. We do
not advocate very restricted diets because it's hard to get
the full protein, carbohydrate, fat, vitamins and so on that
you need, with alternative diet therapy. It's difficult to
say generically, "Eat more healthily," because you have to
consider a person's individual lifestyle, how much money they
have, where they're living, do they have a significant other
who can shop and cook for them -- any number of things need
to be considered.

ATN: What about vitamin and mineral deficiencies?

KW: Several micronutrient deficiencies have been identified
in HIV disease: B-6, B-12, zinc, copper, selenium, thiamin
and folate. Deficiencies may be because of intestinal damage
from infections or illnesses; vitamin B-12 especially may not
be absorbed. Selenium deficiencies may lead to
cardiomyopathy. Zinc deficiency may contribute to anorexia
and diarrhea, as well as altered immunity; conversely, zinc
excess can further contribute to immune dysregulation.

A study by Dr. Beach looked at people with some cognitive
deficiencies and found that they were deficient in B-6 and B-
12 in particular. When they supplemented these back up to a
normal level, the dysfunction cleared up. There are many
possible reasons why a person's cognitive function is "not
quite right" -- general malnutrition or even micronutrient
deficiency might be the cause. However -- you don't want to
automatically tell someone to take extra B-6 and B-12,
without documenting serum levels of these vitamins.

ATN: What about toxicities from overdoses of certain
vitamins, especially fat-soluble vitamins (A, D, E, K)?

KW: Fat-soluble vitamins not immediately needed by the body
are stored in the liver. When probably over 60 percent of HIV
patients have some form of liver disorder, and they are
storing fat-soluble vitamins on top of that, it may
exacerbate some liver-related problems. Other toxicities
could be causing diarrhea, such as high-dose vitamin C or
zinc, etc. Anemia, hair loss -- these could be caused by
deficiencies, but they could also be caused by toxic levels
of various micronutrients.

Excessive amounts of vitamin C [can cause] a nutrient
imbalance; particularly if taken with large doses of zinc,
this can lead to copper depletion, which can further
contribute to immune dysregulation. Unless people are
familiar with these interactions it is important to get help
from a qualified registered dietitian or physician to make
educated decisions.

We recommend, as part of an individualized therapy plan, to
take one multivitamin a day. Often we recommend prenatal
vitamins [because they include low or moderate doses of all
the known vitamins, etc. that you need, whereas other
multivitamins usually have some missing].

Some articles in the literature report taking 20 to 200 times
the RDA of certain vitamins, etc. might be beneficial. More
work needs to be done in this area; I would not recommend
that you can take these treatments without concern. And in
addition to the issues already discussed, taking megadoses
can be expensive, and limited funds may be spent on
supplements rather than on quality food. Whatever water-
soluble vitamins your body can't use are flushed out through
the kidneys... in other words, you end up with every
expensive urine and little benefit from the megadosing.

ATN: With HIV disease the body experiences hypermetabolism,
which may cause nutrient needs to be different than the U.S.
RDA. What guidance can you give people who can't access a
dietitian? Is there something you can refer them to that
explains these interactions?

KW: That's a good question. The ADA Consumer Nutrition
Hotline is available to you. (See below.)

People can "guestimate" what their metabolic needs are for 24
hours with the following: calories: multiply 30-35 calories
times your weight in kilograms; for protein needs, multiply
1.5 to 2.0 grams of protein times your weight in kilograms.
These amounts will most likely help to maintain weight during
relatively non-stressful times. If an opportunistic infection
occurs, the body's needs may rise by 60%. Fever will raise
the body's metabolism 7% for each degree Fahrenheit above
normal. A registered dietitian can calculate your body's
needs using an equation that takes into account your age,
sex, height, and weight. This method also considers factors
such as degree of illness and level of activity.

Other Topics

ATN: What about special "alternative" diets?

KW: Some alternative therapy diets work for some people, but
they may not have enough protein, carbohydrate, and fat. And
they can be dangerous; for example, there's one that
encourages you to eat moldy food to see if you're really
sensitive to it. This could be even more detrimental to
somebody who is immune compromised.

ATN: What about Chinese herbal remedies, teas, etc.

KW: I think there is something to a history of thousands of
years of herbology -- and there are certainly conditions that
western medicine cannot do a thing about, yet there may be
some relief from non-traditional therapies. I do believe that
HIV disease would benefit from a combination of eastern and
western medicine.

The concern I have is that people will go into a sports
nutrition shop or health food store and buy whatever is
recommended to them. People may spend a great deal of their
money on supplements rather than quality foods. Here is where
it is vitally important that people align themselves with a
medical professional who can advise them on what to take.

ATN: And antioxidants?

KW: It's too early to have definitive answers. Antioxidants
occur in foods. If you are already taking a multivitamin, you
will be getting some that way, also. Examples of antioxidants
are vitamins C and E, beta carotene, zinc, selenium.
Antioxidants are said to neutralize free radicals in the body
that contribute to immune dysfunction, aging, heart disease,
and cancer.

ATN: In choosing a multivitamin, what potency (dose) should
you look for?

KW: If your multivitamins are a bit more potent than the RDA,
that won't hurt, as long as you are only taking one a day.
When you do take your vitamins and minerals, take them with
food. In order to be effective, vitamins, minerals, and trace
metals need to chemically interact with food.

ATN: What about exercise?

KW: One of the simplest things we recommend is for folks to
just walk and swing their arms. When watching TV, it's a
simple matter to pick up soup cans or something like that --
or putting a two to five pound weight on your foot and
lifting it. Low resistance, many repetitions, is the key so
the movement doesn't exhaust you but does stimulate the
muscles.

ATN: Because if you don't use it, you'll lose it?

KW: Yes, muscle tends to be exchanged for fat. We want to
take a look at what impact exercise is going to have on the
development and maintenance of lean body mass. Currently we
don't have much data to go on.

Dr. Hellerstein here is doing work with anabolic steroids.
The problem with some of the steroids is that they may put
some weight on you, but unless you are exercising it will be
mostly fat, not lean body mass. But on the other side, people
with HIV disease often fatigue easily, so you can't expect
them to have a rigorous routine.

ATN: What about differences between men and women?

KW: In a Rhode Island study, the diagnosis of wasting
syndrome was the second most common index diagnosis of AIDS
in women. Moreover, women were greater than two and a half
times more likely than gay men to have the diagnosis of
wasting. To my knowledge, studies have not been conducted to
determine whether the pattern of weight loss, i.e., muscle
loss and fat preservation, is the same for women as it is for
men.

ATN: What can you bring to our readers about options, a note
of optimism, things to think about?

KW: The key again is to start working with people early in
HIV disease, because we have a much better chance of keeping
them nutritionally sound if we start earlier rather than
later. We have also seen the possibility of moving someone
from merely surviving, because they're so weak from
malnutrition, to living a meaningful life due to optimal
nutrition. We shouldn't give up hope; help is out there.

I think the pervasive attitude is that weight loss and
malnutrition are inevitable. You see that in both the health
care provider and the client perspective. It is important for
folks to hear that there is work being done in the field of
nutrition and HIV disease. Moreover, creative and
individualized approaches to symptoms which interfere with
optimal nutrient intake can be successful.

Nutritional Resources

The following list of nutritional information was prepared in
conjunction with the interview with Kristin Weaver, above.

Upcoming Conference

Third International Symposium on Nutrition and HIV/AIDS,
Philadelphia, October 13-14.

Organized by the Physicians Association for AIDS Care (see
below), Philadelphia FIGHT (community-based research trials
group), and the Pennsylvania AIDS Education and Training
Center, this meeting includes many faculty members who are
leading experts in the field. According to conference
materials the symposium objectives are: "to disseminate the
latest scientific information about the role of nutrition in
the course of HIV disease and the prevention and treatment of
AIDS-associated malnutrition; to improve the knowledge of
those responsible for reimbursement decisions affecting
nutritional strategies for insurance companies, managed care
organizations, state Medicaid agencies, and Medicare
administrators; to provide a forum to exchange information
and to examine research, policy, management, and practice
issues; and to improve communications between researchers and
the users of research."

Registration costs $75.00 and will be limited; organizers
suggest registration by September 15th. For more information
contact: Monica Patel, Philadelphia FIGHT, 201 North Broad
St., 6th Floor, Philadelphia, PA, 19107, 215/557-8265.

How to Get Rehydration Salts

Oral rehydration salts based on the World Health Organization
(WHO) formula are available in pharmacies and directly from
Jianas Brothers, 2533 Southwest Blvd., Kansas City, MO 64108-
2395, 816/421-2880, fax 816/421-2883. The cost is about 50
cents per packet which dissolves in one liter of water.

Food Safety and Nutrition Advice and Referrals

CDC National AIDS Clearinghouse, 800/458-5231.

Persons may request the free brochure "Eating Defensively.
Food Safety Advice for Persons with AIDS." The materials
prepared by the Food and Drug Administration for the general
public are intended to help individuals lower the risk of
food-borne illness. This includes information on how to avoid
food poisoning, food handling and preparation, and tips for
traveling abroad, shopping, and dining out. A fifteen minute
video is also available for $12.00.

Consumer Nutrition Hotline, 800/366-1655.

Sponsored by the American Dietetic Association. Callers can
speak with a registered dietitian, or ask for a referral to a
registered dietitian. Referrals can be made to practitioners
with specific specialties but callers need to know that the
referral database contains only registered dietitians who
have paid a fee to be included; it is not comprehensive.
Clinics, hospital dietetic departments, public health
departments, and AIDS service organizations may also be able
to provide referrals. Diet counseling is not offered on the
hotline, only general nutrition information.

Meat and Poultry Hotline, 800/535-4555.

This hotline, a service of the U.S. Department of
Agriculture, is staffed by home economists and registered
dietitians, Monday through Friday, 10:00 a.m. to 4:00 p.m.,
EST. Callers can get information about food safety. During
other hours, a voice mail response system provides answers to
commonly asked questions.

Nutritional Counseling

San Francisco Area: Bay Area Nutrition Counseling Center and
Clinic, University of California San Francisco, San Francisco
General Hospital.

Patients are evaluated in-person by a physician and a
dietitian at an initial visit and followed monthly
thereafter. In addition to in- depth evaluation and
counseling, clients receive a personalized manual outlining
the results of laboratory and dietary assessments and the
prescribed nutritional care plan, as well as extensive
practical information. For more information or to schedule an
appointment, contact Violet Garcia, patient liaison, 415/206-
8822.

Illinois: The Cutting Edge.

Under the direction of Cade Fields Gardner, RD (formerly Cade
Fields Newman, RD), this organization provides education for
professional dietitians and patients, nationwide referral,
and direct patient care. The multidisciplinary approach
emphasizes a healthcare team approach to treating individuals
with HIV disease. This includes cooperative involvement by
physicians, social workers, pharmacists, dentists, and other
healthcare providers in a variety of settings. Services are
available in several languages. Physician referral required.
Contact: The Cutting Edge, P.O. Box 922, Carey, IL 60013,
708/516-2455, fax 708/516-2263.

[Editor's note: These are two nutritional counseling centers
that we contacted while writing this article. Many others
could be listed as well.]

Professional Organizations and Selected Resource Materials

American Society for Parenteral and Enteral Nutrition
(ASPEN).

This is a multidisciplinary, professional, and scientific
organization working to promote quality patient care,
education, and research in the field of nutrition and
metabolic support. Many peer-reviewed periodical and
reference materials are available including Standards and
Clinical Guidelines (for physicians, nurses, dietitians, and
pharmacists). For a complete list of publications and
programs contact: ASPEN, 8630 Fenton St., Suite 412, Silver
Spring, MD 20910, 301/587-6315, fax 301/587-2365.

Physicians Association for AIDS Care.

In addition to their monthly journal, they have available
Nutrition and HIV/AIDS: Proceedings of the 1992 International
Symposium on Nutrition and HIV/AIDS, including the
Nutritional Algorithm and the Nutritional Initiative of the
Physicians Association for AIDS Care. This technical volume
includes articles by some of the most respected experts in
the field of nutrition and HIV, including Donald Kotler,
Richard Beach, Cade Fields Newman, and Mark Hellerstein.
Topics covered include nutrition and wasting, metabolic
changes in HIV disease, and issues specific to developing
countries. It also includes "An Overview of the PAAC
Initiative," which presents strategies for coping with
nutritional problems and an in-depth bibliography. ($25.00
including shipping and handling.) Contact: PAAC Publishing,
Inc., 101 W. Grand Ave., Suite 200, Chicago, IL 60610,
312/222-1326, toll-free 800/243-3059, fax 312/222-0329.

For less technical information, HIV Disease Nutrition
Guidelines: Practical Steps for a Healthier Life presents
practical information focusing on good nutrition, regular
exercise, and stress management. Also included are
recommendations for dealing with commonly occurring symptoms
of HIV disease. It is published by the Physicians Association
for AIDS Care with an educational grant from Stadtlanders
Pharmacy. Free copies are available in English or Spanish
from Stadtlanders Pharmacy, 800/238-7828.

Bibliography and References

Baum MK, Shor-Posner G, Bonvehi P, and others. Influence of
HIV infection on vitamin status and requirements. Annals of
the New York Academy of Sciences. September 30, 1992; volume
669, pages165-173, and discussion on pages 173-174.

Beach RS, Mantero-Atienza E, Shor-Posner G, and others.
Specific nutrient abnormalities in asymptomatic HIV-1
infection. AIDS. July 1992; volume 6, number 7, pages 701-
708.

Beach RS, Morgan R, Wilkie F, and others. Plasma vitamin B12
level as a potential cofactor in studies of human
immunodeficiency virus type1-related cognitive changes.
Archives of Neurology. May 1992; volume 49, number 5, pages
501-506.

Carpenter CC, Mayer KH, Fisher A, Desai MB, and Durand L
Natural history of AIDS in Rhode Island. American Journal of
Medicine. June 1989; volume 86, number 6 part 2, pages 771-
775.

Chandra, RK. Micronutrients and immune functions: An
overview. Annals of the New York Academy of Sciences. 1990;
volume 587, pages 9-16.

Chlebowski RT, Grosvenor MB, Bernhard NH, Morales LS, and
Bulcavage LM. Nutritional status, gastrointestinal
dysfunction, and survival in patients with AIDS. American
Journal of Gastroenterology. October 1989; volume 84, number
10, pages 1288-1293.

Grunfeld C and Feingold KR. Metabolic disturbances and
wasting in the acquired immunodeficiency syndrome. New
England Journal of Medicine. July 30, 1992; volume 327,
number 5, pages 329-337.

Kotler DP. Nutritional effects and support in the patient
with acquired immunodeficiency syndrome. Journal of
Nutrition. March 1992; volume 122, number 3 (supplement),
pages 723-727.

Kotler DP, Tierney AR, Wang J, and Pierson RN Jr. Magnitude
of body-cell-mass depletion and the timing of death from
wasting in AIDS. American Journal of Clinical Nutrition.
September 5, 1989; volume 50, number 3, pages 444-447.

Smith E and Orbolm M. Trends and patterns of opportunistic
diseases in Danish AIDS patients, 1980-1990. Scandinavian
Journal of Infectious Diseases. 1990; volume 22, number 6,
pages 665-672.


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