Clinical Guide > Maintenance and Prevention > Nutrition

# Nutrition

January 2011

### Chapter Contents

      - Background
      - S: SubjectiveO: ObjectiveA: AssessmentP: PlanResources
References Nutrition-Related QuestionsDietary HistorySymptoms with Possible Relationship to Nutritional DeficienciesTable 1. Anthropometric Measurements for Adults and ChildrenTable 2. Bioelectrical Impedance AnalysisTable 3. Skinfold Thickness and Circumference MeasuresTable 4. Evaluating the Findings of Anthropometric TestsNutrition-Related Problem ListTable 5. Practical Interventions for Common Nutrition-Related ProblemsBackground
Maintaining good nutritional status is important to support overall health and immune system function for people with HIV/AIDS. Many HIV-related conditions affect and are affected by the body's nutritional status. These include conditions related to HIV itself (e.g., opportunistic infections and other illnesses), comorbid conditions, and adverse effects of therapies.

Inadequate nutrition in people with HIV infection may result from many factors, including conditions such as nausea, vomiting, and anorexia (see chapter *Nausea and Vomiting*) that may prevent adequate intake of nutrients and medications; diarrheal infections (see chapter *Diarrhea*) that prevent absorption of nutrients and medications; poor oral health conditions that interfere with chewing or tasting food (see chapter *Oral Health*); systemic illnesses (including HIV itself) that create a catabolic state; and psychological conditions (such as depression) that impair patients' ability to nourish themselves. In addition, financial constraints may limit patients' access to nutritious food.

Evaluation and enhancement of patients' nutritional status may help correct or compensate for deficiencies (e.g., in the case of weight loss or nutrient deficits), may be a key treatment modality for certain conditions (e.g., dyslipidemia, hyperglycemia), and may help to maintain good health and immune function. This chapter focuses on the evaluation of patients with nutritional deficiencies, particularly weight loss, and on simple strategies for maintaining good nutrition in individuals with barriers to maintaining adequate weight.

It should be noted that obesity and overweight conditions are increasingly common in HIV-infected individuals; many of the principles described here also may be applied to the evaluation of overweight patients. Recommendations for weight reduction for HIV-infected patients are the same as for the general population and will not be discussed in detail; for overweight patients with lipohypertrophy, diabetes, dyslipidemia, or coronary artery disease, see the respective chapters on these conditions.

Ideally, HIV-infected individuals will receive the services of HIV-experienced nutrition specialists, who may contribute to the patient care team in the following ways:
- Conducting routine screening to identify and treat nutritional problems
- Preparing a tailored nutritional plan to optimize patients' nutritional status, immune status, and overall well-being
- Screening and developing interventions for growth problems in children
- Developing strategies to prevent loss of weight and lean body mass
- Adapting dietary recommendations to help reduce the risk of comorbid conditions such as diabetes and heart disease, or treating these complications
- Educating patients about how to modify their dietary habits to maximize the effectiveness of medical and pharmacologic treatments
- Tailoring nutritional recommendations to fit patients' lifestyles and financial resources
- Counseling patients to promote nutrition self-care using available resources
- Providing nutritional support to patients may help to do the following:    - Address common problems associated with HIV disease and its treatment (e.g., weight loss, wasting, fatigue, loss of appetite, adverse changes in taste, dental problems, gastrointestinal complaints)
  - Treat chronic comorbid conditions (e.g., cardiovascular disease, hypertension, diabetes, cirrhosis)
  - Improve quality of life
  - Enhance immune responses, slow disease progression, and prolong life
S: SubjectiveHistory
Identify nutrition risk factors at the start of care through interview, questionnaire, or both. Update the history at least annually. The history should elicit signs and symptoms related to nutrition issues, indications regarding dietary habits, and symptoms that suggest nutritional deficiencies.
 Nutrition-Related QuestionsFactorAreas to ExploreSigns, Symptoms, and Comorbid Conditions- Poor or sporadic appetite
- Early satiety
- Weight gain or loss
- Trouble chewing or swallowing
- Dental problems including poor dental hygiene
- Gastrointestinal complaints, including nausea, diarrhea, constipation, heartburn, gas
- Changes in body contours with fat gain in abdomen, back of neck, and breasts (lipodystrophy) or fat loss in extremities and face (lipoatrophy)
- Depression, stress
- Fatigue
- Chronic pain
- Other diseases affecting diet and nutrition
- Medications, including over-the-counter and herbal products
Medication-Related Factors:- Medication side effects
- Difficulty coordinating meals with medicines
- Use of nutritional supplements
Social and Behavioral Factors:- Frequent eating out
- Smoking
- Alcohol or substance abuse
- Erratic meal patterns
- Unbalanced diet (e.g., high intake of low-nutrient foods; deficiency in key nutrients)
- Resources to ensure secure, continued food access
- Availability of food storage and preparation facilities
- Housing (stable, homeless, marginally housed, or in transition)
- Nutrition literacy

To develop a specific dietary history, ask about the following:
Dietary HistoryUsual Dietary IntakeFactors That May Affect or Limit Intake - Frequency of intake of foods providing key nutrients (e.g., dairy products, fortified or whole grains, fruits and vegetables, fluids, meat, eggs, beans) as well as those that perhaps should be limited (fast-food items, highly processed or salted products)
- Usual meal patterns (number of times per day, snacks) and whether meals are prepared and eaten at home or eaten at restaurants or fast-food establishments
- Specific information about nutritional supplements (e.g., vitamins, minerals, herbs, protein), including contents, amounts, formulation (pills, powders, drinks), cost, and overlap among products
- Amount of money available for food, or participation in food assistance programs (e.g., food stamps, food pantries)
- Appetite, general well-being (e.g., fatigue, pain, depression)
- Food allergies, intolerances
- Problems with dentition, swallowing, heartburn, diarrhea, constipation
- Coordination of foods and supplements with medications (HIV or other)

Elicit symptoms that may be related to nutritional deficiencies.
Symptoms with Possible Relationship to Nutritional Deficiencies- General symptoms (e.g., fatigue, decreased cognitive function, headache)
- Behavioral changes (e.g., irritability, apathy, decreased responsiveness, anxiety, attention deficit)
- Body habitus changes (e.g., loss or gain of fat)
- Gastrointestinal symptoms (e.g., diarrhea, constipation, bloating)
- Changes in skin, nails, hair (e.g., dryness, breaking, thinning)
- Muscle loss
- Neurologic symptoms (e.g., weakness, sensory changes, gait abnormalities)
O: ObjectivePhysical Examination
Perform a careful physical examination, if possible with anthropometric and body composition testing as described below (Table 1). Compare current findings with past assessments and review at least every 6 months.

The physical examination should include the following:
- Vital signs, with orthostatic vital signs if dehydration is suspected
- Weight (compare with previous values) and body mass index (BMI)
- General appearance and gross nutritional status (e.g., obesity, cachexia, wasting)
- Body habitus: loss of subcutaneous fat in face, buttocks, arms and legs and/or increased fat in abdomen, breasts, back of neck, and upper back ("buffalo hump")
- Muscle mass
- Mouth: breakdown in oral mucosa, cheilosis, angular stomatitis, glossitis, papillar atrophy
- Abdomen: hepatomegaly (may be caused by fatty infiltration)
- Skin: dryness, peeling, breakdown, pallor, hypopigmentation or hyperpigmentation
- Nails: pale nail beds, fissures or ridges
- Neurologic system, including strength, sensation, coordination, gait, deep tendon reflexes

Anthropometric and body composition tests are usually performed by registered dietitians. They can provide important information about patients' nutritional status.
Table 1. Anthropometric Measurements for Adults and Children Height  Weight  Assessment for Changes over Time 
* BMI (body mass index) is useful as an evaluative index. See chapter *Initial Physical Examination*, and the CDC's online calculator.

# Growth charts for children in the United States are available online from the U.S. Centers for Disease Control and Prevention (CDC) at www.cdc.gov/growthcharts/. A variety of growth charts are available for children from specific ethnic groups (e.g., Chinese, Vietnamese, Thai), children with selected conditions affecting growth (e.g., Down syndrome), or those who are born prematurely. Percentiles for both height and weight should be recorded sequentially.
 Adults Measure at baseline (self-report is not accurate).- Measure at least quarterly and consider intervention when small changes are observed. Do not wait until major amounts of weight have been lost or gained.
- Record sequentially at the front of the patient's chart and monitor for trends.
Use healthy, premorbid weight to assess change, not the first clinic weight or the ideal weight. (Use the patient's weight at a time when the patient is healthy, feels well, and can easily maintain that weight.) * Children Measure at least quarterly using length board (0-2 years) or wall-mounted stadiometer (≥2 years).- Measure at least quarterly and consider intervention when small changes are observed. Do not wait until the patient has dropped significantly on the growth chart.
- Calculate age and plot the measurements on growth charts specific for age, sex, and country. #
Assessment of optimal growth is based on the observed pattern over time. General goals include a weight relatively "matched" for length or height (about the same percentile) and relative stability of percentile tracking over time.* #Body Composition Testing
Body composition commonly is tested by bioelectrical impedance analysis (BIA) (Table 2) or skinfold thickness and circumference (Table 3).
Table 2. Bioelectrical Impedance Analysis
BIA testing is the standard of care for adults but has not been well validated for children: 
- BIA is useful for assessing disease progression or health maintenance, documenting response to treatment, and justifying the cost of nutritional supplements and AIDS-wasting medications.
- The test is simple, noninvasive, and quick (<5 minutes). However, staff training and specialized software are required to interpret the results.
- Perform BIA at baseline. Update every 6-12 months or more frequently if the patient is ill, has a decline in immune status, or has a weight change of 5-10%.
- The BIA test reports the following:    - Body cell mass (BCM):  the target component, reflecting cells in muscles, organs, and the circulation; losses may indicate AIDS wasting. BCM is recorded in pounds. Monitor for trends.
  - Fat:  an index of energy stores; recorded in pounds and percentage.
  - Phase angle:  a measure of cellular integrity, an independent indicator of morbidity and mortality in HIV-infected patients.
Table 3. Skinfold Thickness and Circumference Measures
Skinfold thickness and circumference measures can be used for adults and children in resource-limited settings, and for situations in which bioelectrical impedance analysis is not available. Circumference measures also can be used to monitor changes over time associated with lipodystrophy in adults.
- Skinfold thickness is measured with calipers.
- Circumference measures are taken at specific anatomical landmarks with nonstretchable tape.
- Techniques and protocols for taking anthropometric measurements can be found at the  CDC website .
Laboratory Testing
Perform basic laboratory (blood) tests, including the following:
- Hemoglobin and/or hematocrit
- Total protein, albumin
- Fasting blood glucose
- Fasting lipids (triglycerides, total cholesterol,low-density lipoprotein cholesterol [LDL], high-density lipoprotein cholesterol [HDL])
- CD4 cell count and HIV viral load, if no recent values are available
- Specific vitamin and nutrient tests as indicated by symptoms (e.g., iron studies in case of anemia, vitamin B12 in case of peripheral neuropathy)
- Others tests, such as testosterone and thyroid hormone levels as appropriate, to rule out other causes of symptoms
A: Assessment
Assess subjective information and objective findings to evaluate nutritional status.
Identify Nutrition Concerns
Several factors may influence nutrition, including the following:
- Barriers to good nutrition (e.g., lack of knowledge or motivation for self-care, poor appetite, lack of money for food, lack of facilities for food storage and preparation)
- Lifestyle factors (e.g., smoking, substance abuse, frequent eating out, erratic eating patterns, hectic schedule, high stress)
- Physical problems affecting food and nutrient intake (e.g., poor appetite, nausea, fatigue, pain, weakness, mouth or throat pain, acid reflux, missing or decayed teeth, poorly fitting dentures, poor eyesight, constipation)
- Nutrient losses (e.g., owing to diarrhea, vomiting)
- Potential confounding factors (e.g., use of multiple overlapping or questionable supplements, eating disorders)
Evaluate Dietary Intake
Assess the following diet-related issues:
- Expected excesses or deficiencies from dietary history or interview
- Rating of food security, including access to cooking and refrigeration
- Food intolerances, aversions, or allergies likely to affect adequacy of intake
- Special needs related to other conditions (e.g., documented cardiovascular disease, diabetes, hypertension)
Evaluate Weight, Body Composition, and Weight Distribution
Assess physical findings of malnutrition and confirm with nutrition history, laboratory tests, and anthropometric evidence. Normal and abnormal findings of anthropometric tests and recommendations for monitoring changes over time are presented in Table 4.
Table 4. Evaluating the Findings of Anthropometric Tests Monitoring Trends and Recommendations 
Abbreviations: BCM = body cell mass; BIA = bioelectrical impedance analysis; BMI = body mass index
**Adults****Children**- Chart trends over time relative to previous measurements and the following population norms:    - BMI  (healthy range: 19-25)
  - BIA:     - BCM  (percentage of weight): women 30-35%; men 40-45%
    - Fat  (percentage of weight): women 20-30%; men 15-25%
    - Phase angle:  women >5; men >6
- Skinfold thicknesses and circumferences:  Chart changes in absolute measures and percentiles
- Changes in body contours:  Evaluate lipodystrophy (excess accumulation of fat in abdomen, breasts, dorsocervical area) and lipoatrophy (loss of subcutaneous fat in face, extremities, buttocks)
- Plot measurements on growth charts and track percentiles over time  (the consistency of percentiles rather than the absolute percentile is important)
- Skinfold thicknesses and circumferences:  Chart changes in absolute measures and percentiles
Evaluate Laboratory Findings- Evidence of malnutrition (e.g., low iron or protein stores)
- Evidence of disease or risk of disease for which dietary treatment is indicated (e.g., high fasting glucose, hypertension, hyperlipidemia)
Develop a Problem List
The following suggests a useful format for a nutrition-related problem list.
Nutrition-Related Problem ListProblem NumberDescription of Problem (circle/describe)**Nutrition barriers:** insufficient knowledge, poor appetite, food insecurity, no food preparation or storage facilities, homelessness**Lifestyle:** substance abuse, smoking, erratic eating, frequent fast-food intake, high stress**Weight or body composition:** undesirable weight gain or loss (adult), changes in growth trajectory (children), loss of lean body mass (wasting), gain of excess fat (obesity), lipoatrophy or lipodystrophy**Physical problems:** fatigue, pain, early satiety, poor dentition, clinical signs of malnutrition**Laboratory findings:** low hematocrit or hemoglobin, low protein or albumin, low or high fasting glucose, high total cholesterol, high LDL, high triglycerides, low HDL, low testosterone**Gastrointestinal:** diarrhea, vomiting, reflux, constipation**Poor diet:** poor food choices, bingeing, skipping meals, high sugar intake, high alcohol consumption, high intake of refined foods, low fruit and vegetable intake, insufficient protein, insufficient calcium, food allergies or intolerances that limit intake**Comorbid conditions:** diabetes, hypertension, cardiovascular disease, cancer, gastroesophageal reflux disease (GERD)**Medications:** drug-drug or drug-nutrient interactions or difficulty coordinating medicines with meals**Supplements:** insufficient or excessive intakes, cost of supplements unaffordable, supplements with potential or unknown risksP: Plan
Develop a nutritional plan and provide practical nutrition education for common problems (see "Resources," below).

Evaluate and treat concurrent medical problems (e.g., diarrhea, nausea, infections, malignancies, depression, pain). For severe or persistent nutritional problems, or for specific needs, refer to a nutrition specialist for evaluation and treatment.

Common nutrition-related problems are presented in Table 5, along with simple management suggestions that may help resolve them and help patients maintain adequate nutrition.
Table 5. Practical Interventions for Common Nutrition-Related ProblemsProblemSuggestions**Weight Loss (decrease in both body cell mass and fat)**- Early identification and ongoing monitoring are key.
- Identify and treat underlying risk factors.
- Try to add calories without adding "bulk":    - Fat (9 calories/gram): butter, margarine, avocado, cream, mayonnaise, salad dressing
  - Carbohydrate (4 calories/gram): jam, jelly, sugar, icing, gum drops
  - Protein (4 calories/gram): protein powders, cheese, nut butters, trail mix, powdered breakfast drinks, nonfat dry milk
- Eat more frequently.
- Maximize good days.
- Use canned supplements (e.g., Ensure, Boost).
- For wasting or substantial weight loss, consider referral for therapies such as appetite stimulants or human growth hormone.
**Diarrhea**- Increase soluble fiber; decrease insoluble fiber.
- Replenish beneficial bacteria (e.g., with lactobacilli preparations).
- Avoid intestinal irritants and stimulants.
- Decrease dietary fat.
- Decrease or eliminate lactose.
- Increase fluids and provide electrolytes (sodium, potassium).
- Treat with pancreatic enzymes.
**Early Fullness**- Take small, frequent meals.
- Concentrate on solid foods, with liquids between meals.
- Eat lower-fat, lower-fiber foods.
- Wear loose-fitting clothing.
- Sit up while eating.
- Eat, walk, and eat again.
**Nausea**- Take small, frequent meals.
- Try dry snack foods.
- Avoid fried foods, very sweet foods, spicy foods, and foods with strong odors.
- Try cool, clear beverages, popsicles.
- Try ginger-containing foods and drinks.
- Keep liquids to a minimum at meals.
**Changes in Taste**- Eat a variety of foods, not only favorite foods.
- Try protein sources other than red meat.
- Marinate foods, use sauces.
- Use more and stronger seasonings.
- Try tart foods.
- Use sugar or salt to tone down the flavor of foods.
- Try a mouth rinse of 1 teaspoon of baking soda in 1 cup of warm water before eating.
**Loss of Appetite**- Rely on favorite foods.
- Ask family members and friends to prepare meals.
- Eat small, frequent meals.
- Keep snacks handy for nibbling.
- Eat before bedtime.
- Eat in a pleasant place, with other people.
- Make the most of good days.
- Try light exercise to stimulate appetite.
- Add extra calories without adding bulk.
- Consider appetite stimulants (e.g., megestrol, stimulants).
**Difficulty Chewing or Swallowing or Sore Mouth and Throat**- Choose soft, nutritious foods.
- Blend or puree foods (e.g., soup or stew, smoothies).
- Add cream sauces, butter, or gravy for lubrication.
- Sip liquids with foods.
- Use a straw or drink foods from a cup.
- Choose bland, low-acid foods.
- If hot foods cause pain, serve foods cold or at room temperature.
- Avoid alcohol and tobacco.
- Soothing lozenges or sprays may help.
**Food Insecurity**- Refer to social services for assistance with accessing resources such as food stamps, community meals, or a food pantry program.
- Refer to a dietitian for assistance with low-cost food ideas.
- Use materials at  CheapCooking.com .
**Unbalanced Diet and Other Conditions Requiring Dietary Modification**- Refer to a dietitian for counseling and education.
Nutrition Specialists
Whenever possible, nutritional services should be provided by a registered dietitian (RD) who is a qualified HIV care provider. In the United States, holding this status requires a nutrition degree from an accredited college, graduation from an approved internship or master's degree program, and maintenance with 75 continuing-education units every 5 years, including specific and ongoing HIV training. An RD with HIV/AIDS expertise in the United States can be located by going to eatright.org, clicking on "Find a Registered Dietitian," entering the patient's zip code or city, and selecting "HIV/AIDS" under areas of specialty. Membership in the Infectious Diseases Nutrition Dietetic Practice Group also may indicate HIV experience.
Resources
The following online resources provide information, guidelines, and tools for providers and patients in managing issues related to nutrition and HIV:
- 2000 CDC Growth Charts: United States  Center for Disease Control and Prevention, National Health and Nutrition Examination Survey.
- Center for Disease Control and Prevention National Center for Health Statistics
- CheapCooking.com . Website with recipes using low-cost ingredients and tips for frugal meal planning.
- Infectious Diseases Nutrition Dietetic Practice Group  Affiliate of the American Dietetic Association. Website includes screening tool (Nutrition Screen and Referral Criteria for Adults with HIV/AIDS). Formerly HIV/AIDS Dietetic Nutrition Practice Group.
- MyPyramid.gov . U.S. Department of Agriculture website with dietary guidelines, tips, resources, and consumer-oriented information.
- Health Care and HIV: Nutritional Guide for Providers and Clients  Manual from HRSA. 
- Nutrition and Food Safety
- Nutrition.gov
- Tufts University Nutrition and Infection Unit
References- Association of Nutrition Services Agencies.  ANSA Nutrition Guidelines and Fact Sheets . (Select "Nutrition Info.") Accessed June 30, 2010.
- Bartlett JG. Introduction.  Integrating nutrition therapy into medical management of human immunodeficiency virus . Clin Infect Dis. 2003 Apr 1;36(Suppl 2):S51.