A study of dietary advice and care provided to HIV positive patients referred for lipid lowering: as part of a service improvement initiative
Authors: Billing N.A. , Hunt C.A. 
Published: July 2008

Background:  Combination antiretroviral therapy (ART) has dramatically reduced mortality in HIV‐infected patients. As life expectancy of HIV infected patients has increased, concerns about the long‐term effects of treatment grow (Sax, 2006). HIV positive patients have a greater risk of myocardial infarction (MI) and ART has been associated with a 26% increase in the rate of MI per year of exposure (DAD Study Group, 2003). The aim of this study was to evaluate provision of dietetic care to patients referred for lipid lowering advice and identify potential areas for service improvement.

Methods:  Departmental activity statistics identified 117 new clients referred for lipid lowering advice in the previous 11 months. The biochemical data and dietetic record cards were screened, of the initial sample 30 were excluded as they did not have follow up biochemistry after their dietetic consultation and a further seven were excluded as they were seen primarily for other conditions. The remaining cards (n = 80) had their dietetic record cards audited to check dietary topics discussed, risk factors identified length before follow up and clinical outcomes.

Results:  There were 68 men and 12 women in this sample with a mean age of 46 years and mean body mass index (BMI) of 25.4 kg m−2 (3.7 kg m−2). Of the clients referred, only 48.8% of the sample had high density lipoprotein (HDL): cholesterol ratios taken to calculate cardiovascular risk and most patients were seen an average of 30.7 days (35.3 days) after high was identified. Following their dietetic consultation, 77% of clients had a reduction in their cholesterol levels and 61% had a reduction in triglyceride levels. This sample's average percentage change in cholesterol was −10% (16%) and triglyceride was −6% (32%).The most popular dietary advice was reducing saturated fat intake (90%), increasing fibre intake (76%), benefits of plant stanols (40%), importance of regular meals (29%), exercise (26%) and benefits of omega three (11%). Additional risk factors identified 11% of clients seen were smokers, however most records (66%) did not have documentation on whether smoking behaviour was discussed. Only 20% of clients had a follow up appointments and not all were seen within 3 months with average time between follow up being 14.9 weeks (13.2 weeks).

Discussion:  Improvement in biochemical results were comparable to a study by Henry et al., (1998) which showed that in HIV infected clients receiving ART, diet modification and increased exercise were successful in reducing cholesterol levels by 11% and triglyceride levels by 21%. The level of smoking was considerably lower than other studies (DAD Study Group, 2003) which reported 56% of HIV positive clients to be smokers. A large number of clients were lost to follow up and were not seen within 3 months. Lazzaretti et al., (2007) showed in a randomized trial that seeing patients at regular 3 month intervals for dietary intervention prevented an increase in lipid blood levels in individuals who start ART.

Conclusions:  Not all clients are having their cardiovascular risk calculated before referral for dietary advice. Clients are not being seen at regular intervals by dietitians, some are lost to follow up and smoking status is not regularly documented during dietetic consultation.

References  Data Collection on Adverse Events of Anti‐HIV Drugs (DAD) Study Group. (2003) Combination antiretroviral therapy and the risk of myocardial infarction. N. Engl. J. Med.349, 1993–2003.

Friis‐Moller, N., Weber, R., Reiss, P., Thiebaut, R., Kirk, O., d’Arminio, M.A. et al. (2003) Cardiovascular disease risk factors in HIV patients’ association with antiretroviral therapy. Results from the DAD study. AIDS17, 1179–1193.

Henry, K., Melroe, H., Huebesch, J., Hermundson, J. & Simpson, J. (1998) Atorvastatin and gemfibrozil for protease inhibitor‐related lipid abnormalities. Lancet352, 1031–1032.

Sax, P.E. (2006)Strategies for management and treatment of dyslipidemia in HIV/AIDS. AIDS Care 18, 149–157.

Lazzaretti, R., Pinto‐Ribeiro, J., Kummer, R., Polanczyk, C. & Sprinz, E. (2007) Dietary intervention when starting HAART prevents the increase in lipids independently of drug regimen: a randomized trial. Oral abstract session: 4th IAS Conference on HIV Pathogenesis, Treatment and Prevention: Abstract no.WEAB303.