1
Q
Describer lipodystrophy often seen in HIV patients?
A
loss of fat from face, bottom of feet and limbs.
Large accumulation of visceral fat and hump back.
2
Q
What can nutritional interventions for HIV infection include?
A
- weight loss
- addressing micronutrient deficiencies
- managing GI complaints
- Managing metabolic diseases: i.e. dyslipidaemia, insulin resistance and osteoporosis
3
Q
How does poor nutrition affect progression of HIV?
A
poor nutrition increases rate of progression/decline
Better nourished = slower disease progression and better health for longer
4
Q
What is often seen in patients with advanced HIV?
A
muscle wasting
5
Q
Name reasons for HIV outpatient referrals to dietitian? (12)
A
- Dyslipidaemia/ Hypertension
- Diabetes / impaired glucose tolerance
- Lypodystrophy
- pancreatic insufficiency
- malnutrition / weight gain
- obesity / weight reduction advice
- healthy eating advice
- micronutrient deficiencies and supplementation
- exercise nutrition advice
- symptom control
- osteoporosis (common)
- co-infection with hepatitis C = treatment is aggressive; a lot of nausea, weight loss and malnutrition
6
Q
Reasons for inpatient HIV referral to dietitian? (7)
A
- weight loss - need to gain weight
- poor oral intake
- symptom control
- pancreatic insufficiency
- chemo patients and side effect management
- short term enteral nutrition = aggressive feeding to support overcoming infection
- PN in lymphoma and mucositis
7
Q
What anthropologist measures for HIV patient assessment? (7)
A
- weight, height, BMI
- waist circumference (in outpatient)
- mid upper arm circumference (inpatients)
- tricep skin fold
- mid arm muscle circumference
- hip circumference
- wait to hip ratio
8
Q
Why can actual body weight be difficult in HIV patients undergoing chemo?
A
Often on a lot of IV fluids to protect kidneys during chemo treatment.
9
Q
What CVD measures need to be taken in HIV patients and how frequently?
A
Q-RISK
Blood pressure
annually
10
Q
Where would you look to understand evidence for nutritional supplements and contraindications with. medicines?
A
Natural Medicines Database
11
Q
What biochem measures would you assess in HIV patients? (9)
A
- CD4 and viral load
- Electrolyte, urea and creatinine
- Lipid profiles
- glucose
- ferritin, folate and B12
- vitamin D and bone profile
- Albumin
- LFT’s
- testosterone
12
Q
When HIV patient is inpatient, how often do you measure electrolytes, urea and creatinine?
A
daily
13
Q
Why assess lipid profiles in HIV patients?
A
screen for acute pancreatitis
14
Q
what symptoms would indicate the need to assess folate, ferritin and vitamin B12?
A
- diarrhoea
- pancreatic insufficiencies
- pancreatitis
- Crohn’s
15
Q
What clinical assessment factors need to be considered in assessment for HIV patients? (7)
A
- current medical status
- current medications including side effects and medication history
- dehydration
- functional capacity
- bowel history (frequency, consistency, other changes in GI function)_
- use of other supplements (medication/supplement interactions
- appetite, nausea, vomiting, early satiety, chewing, swallowing difficulties, dentition
16
Q
What nutritional supplements can interact with HIV medications so should be avoided? (7)
A
- calcium
- zinc
- cations
- multivitamins
- vitamin C
- St John’s wart
- Gaviscon/ antacids
17
Q
What factors need to be accounted for when assessing diet history?
A
- diet history
- good allergies and aversion
- alcohol intake
- smoking (history and frequency)
- substance misuse (historical and current) = often chaotic lifestyle
- eating out
- erratic meal patterns
- current nutritional knowledge
18
Q
What economic and social factors need to assessed ? (4)
A
- Psychosocial = mental illness, substance misuse, dementia; specialist HIV mental health nurse may be needed
- Educational = understanding of bodily functions and nutrition
- living environment = homeless, temp accommodation, food cooking and storage facilities
- cultural factors = food restrictions
19
Q
At what CD4 count level would you recommend increased food safety?
A
CD4 <200 = very immunologically vulnerable
20
Q
What food safety advice would you give to HIV patient with CD4 <200? (6)
A
- keep clean
- separate raw and cooked foods
- cook thoroughly
- keep food at safe temperatures
- boil and cool tap water for drinking
- use safe water and raw materials
21
Q
What are aims of nutrition symptom control in HIV (7)
A
- opportunistic infections affect nutritional status
- weight loss
- poor appetite
- nausea
- vomiting
- taste changes
- diarrhoea /malabsorption
22
Q
Name common causes of HIV weight loss and wasting?
A
- increased energy requirements (cytokine dysregulation)
- reduced food intake
- malabsorption (vicious atrophy and HIV enteropathy)
- testosterone deficiency and metabolic disturbances = HUGE INCREASE in energy requirements
23
Q
Describe the key aspects of the cycle of malnutrition in HIV (4)
A
- poor nutrition = weight loss, muscle wasting, weakness, nutrient deficiencies
- impaired immune system = poor ability to fight HIV and other infections. increased oxidative stress.
- increased vulnerability to infections. Hastened disease progression and increased morbidity
- increased nutritional needs = increase in energy requirements, diarrhoea = increased loss of nutrients.
24
Q
What are main principles of treating HIV wasting (4)
A
- food first (fortification)
- consider nutritional supplements
- consider EN if above unsuccessful
- discuss pharmacological with medical team i.e. magestrol to increase appetite and help with muscle mass
25
What needs to be considered in HIV patients with significant diarrhoea?
pancreatic insufficiency (freon - but inform patient of sourcing from pigs)
26
Describe dietary management of diarrhoea in HIV patients? (11)
1. fibre manipulation (increase in soluble, decrease insoluble)
2. reduction in oily fatty foods
3. avoid spicy food
4. PERT = can try without testing to see if there is improvement
5. lactose free (if malabsorption evident) = can be transient because of opportunistic infections
6. consider probiotics (if CD4 > 200)
7. semi elemental
8. MCT based feed
9. fluid provision
10. electrolyte provision
11. limit products with "no added sugar" labels because they use fructose which can cause osmotic diarrhoea
27
Why would you not recommend probiotics in patients with CD4 < 200
risk of bacterial translocation = huge bacterial load + impaired gut barrier can leak into blood stream and cause sepsis because of impaired immune system
28
What symptom can MCT feeds be beneficial for in HIV patients and why
colic leaks = need super low fat diet (~10g/fat/day)
MCT feeds can help manage severe weight loss = absorbed differently to long chain fatty acids therefore better.
29
What are aims of nutrition therapy in HIV patients with lymphoma (cancer)?
1. maintain physical strength = PRIORITY to help withstand chemo
2. prevent and treat under-nutrition
3. reduce adverse effects of anti-tumour therapies
4. relax dietary restriction if also have diabetes
30
What are nutritional interventions for HIV patients with lymphoma? (7)
1. relax previous dietary restrictions (with diabetes for example)
2. food fortification
3. symptom control advice
4. consistency modification (soft diet easier)
5. ONS
6. EN
7. PN
31
What are potential complications of nutritional management in HIV patients?
1. HIV infections and side effects of ARV's can = metabolic disturbances (increased cholesterol and triglycerides can affect bone disease)
2. increase risk of CVD
3. increased risk of diabetes (impaired glucose metabolism)
4. increased risk of lipodystrophy
5. increased risk of bone fracture
32
How would you calculate CVD risk in HIV patients?
1. Q-RISK score (tick rheumatoid arthritis box to make more accurate)
2. Framingham equation (not accurate for young HIV population because derived mainly from caucasian population)
33
What are modifiable risk factors in CVD for HIV patients? (11)
1. smoking
2. diet
3. weight
4. exercise behaviours
5. anabolic steroids
6. hypertension
7. lipids/dyslipidaemia
8. diabetes
9. hyperthyroidism
10. other medications
11. scan heart to assess calcium in heart and CV system
34
Name symptoms of dyslipidaemia? Advice is same as general CVD risk management
1. hypertriglyceridaemia
2. raised total of LDL cholesterol
3. suppressed HDL cholesterol
4. Calculate HDL: total cholesterol ratio
35
What are the lipid values/cut offs that indicate OK lipid profile?
total cholesterol
LDL
triglycerides
HDL
HDL: cholesterol ratio
total cholesterol = < 5 mmol/L
LDL = < 3 mmol/L
triglycerides = 0-2 mmol/L
HDL = 3 - 5 mmol/L
HDL: cholesterol ratio = < 5 mmol/L
36
What dietary interventions are appropriate for managing CVD risk in patients? (5)
1. low saturated fats intake (< 30% of total energy from fat and <10% from saturated fat)
2. Fibre = soluble fibre, mediterranean diet = 50-60% CHO and high in soluble fibre
3. Avoid high cholesterol foods (< 300 mg/day)
4. decrease alcohol intake = helps with triglyceridaemia
5. Plant sterols and stannous (2g/day needed)
37
How would you manage impaired glucose tolerance? What reasons for increased risk in HIV patients? (5)
1. central fat accumulation increases risk = ART drugs increase this
2. develop impaired glucose tolerance and diabetes occurs with ART use
3. risk increases with duration on ARVs
4. take baseline fasting blood glucose levels and monitor every 6 month after this
5. refer to diabetes management for nutritional management
38
What dietary recommendations can be made to HIV patients with lipodystrophy? (6)
1. reduced saturated fats
2. replace with monounsaturated fats
3. 5 portions fruit and veg daily
4. more soluble fibre
5. choose starchy foods with higher fibre
6. reduce sugary foods
39
Reduced bone mineral density including osteopenia and osteoporosis are more common in HIV infected patients than general pop. What dietary management would you recommend?
1. adequate dietary intake of calcium (NOT SUPPLEMENTS BECAUSE REDUCE ARV EFFICACY)
2. Protein = ensure adequate but not excessive (excessive intake increases risk of kidney stones)
3. Vitamin D = advise supplementation if inadequate
4. alcohol = stick with standard recommendations
5. smoking cessation
6. body weight = encourage ideal body weight maintenance = lower BMI increases osteoporosis risk
7. exercise = weight bearing
Clinical Dietetics 2
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