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THE FOLLOWING MEDICAL AND SCIENTIFIC MATERIAL IS FOR CONSUMER INFORMATIONAL AND EDUCATIONAL PURPOSES ONLY UNDER SECTION 5 OF DSHEA.
Nutrition and HIV/AIDS
After years of wandering in the dark and searching for ways to prevent HIV infection from causing complete immune system destruction, we are now able to treat this condition more successfully than ever before. Now, due to the benefits of aggressive research and new technologies, we are on the verge of being able to stabilize and rebuild our patients' immune systems even if they have declined to previously irretrievable levels. At last, many HIV(+) individuals can now hope to be alive what for amounts to a normal and healthy lifespan.
In 2007, the United Nations Program on AIDS (UNAIDS) estimated that there were 33.2 million people living with HIV globally, with over two million deaths occurring annually. Over half a million have died from the disease in the US since the early 1980's and over one million people now live with HIV/AIDS in the United States.
Where effective antiretroviral drug combinations are available, people can live for many years with HIV infection without developing a compromised immune system. If HIV disease progression occurs, it results in the gradual destruction of a key immune system cell known as the CD4 cell. These cells are the generals of the immune system. When the CD4 cell count drops to a level below 200 cell/mm3, or a person develops an opportunistic infection or several different types of cancer, a diagnosis of AIDS applies. The initials "AIDS" stands for Acquired Immune Deficiency Syndrome.
Improving your nutritional status is one of the most important things a person can do to support their health, especially if they have HIV infection. Although the availability of HAART (highly active antiretroviral therapy) has greatly slowed the progression of this disease and had many positive benefits, it is not without its shortcomings. Many people taking HAART suffer from a long list of side effects and even more HIV-positive individuals are living with nutrient deficiencies that are often unrecognized.
In fact, nutrient deficiencies are very common in HIV disease. Multiple studies have found deficiencies in one or more nutrients, including studies in which data was collected before the widespread availability of HAART,1,2,3,4,5 during the HAART era,6,7,8,9 or both.10 In one study that specifically compared micronutrient levels in HIV-positive people before starting an effective drug combination and afterwards, no significant differences were found in the before and after micronutrient levels.11 Nutrient deficiencies in people living with HIV are a major concern since these have clearly been shown to be associated with faster disease progression, a greater incidence of mortality, and more frequent opportunistic infections.12,13,14,15,16,17
There are many factors that contribute to this high level of micronutrient deficiencies in HIV disease, including increased levels of oxidative stress,18,19,20 altered metabolism,21 decreased absorption,22 and poor dietary intake.23 There can be significant barriers to HIV-positive individuals eating an adequate diet including nausea, loss of appetite, oral or esophageal conditions that make eating painful, substance use, depression, and economic barriers to good nutrition. All of these barriers should be addressed to the greatest extent possible to improve dietary intake.
A diet that is rich in the nutrients necessary for optimal immune function and overall good health is crucial for anyone living with HIV. In general, this is a diet that is rich in fruits, vegetables, and whole grains, along with healthy fats, especially monounsaturated fats like olive oil and the omega-3 fatty acids found in fish. A significant intake of healthy protein sources, including low-fat meat, poultry, eggs, fish, nuts, seeds, and beans is also critically important to supporting immune system health.
Foods to avoid include nutrient-poor, low-fiber "white" foods and others that are high on the glycemic index, as well as "trans fats" that are found in foods containing partially hydrogenated oils (including most margarines, shortenings, and fried and baked foods). These unhealthy ingredients are found in large concentrations in what are referred to as "fast", and the aptly termed "junk", foods.
With wholesome, unprocessed foods as the basis for a good diet, certain adjustments may be necessary for some people living with HIV.
• People with advanced liver or kidney disease may require restricted protein and/or salt intake.
• People with fat malabsorption may need to lower fat intake to prevent diarrhea.
• People with lactose intolerance, a problem common in those living with HIV disease, may need to limit or even eliminate dairy products completely to prevent gas and diarrhea.
• People who need to gain or lose weight may need to adjust total caloric intake. In those with serious weight loss and wasting, a comprehensive approach that may include appetite stimulants, hormone therapies, exercise, and other approaches may be needed to restore body cell mass and weight to normal levels.
• People on certain HAART regimens may need dietary adjustments.
• People with metabolic complications such as elevated blood fats, insulin resistance/high blood sugar, and/or bone problems will need dietary adjustments related to carbohydrate and fat intake, and supplementation with the nutrients needed to support bone health, cardiovascular health, and/or blood sugar normalization.
Calculating Your Protein Need
A good rule of thumb for calculating the amount of protein intake to support healthy immune function is as follows:
Ideal Weight X 0.5 = Number of grams of protein to consume each day.
People who have unusually high HIV viral loads and those who exercise more than 3 times a week should add 10-20% to this value.
Not consuming enough protein is one of the most common reasons for a falling or stuck CD4 count even when one's viral load is generally low.
For in-depth dietary guidelines that are specific to HIV disease, there are several online resources that provide comprehensive information, including:
• Nutrition and Diet Tips, (an aidsmeds.com lesson), available in both English and Spanish; contains lay-friendly but in-depth information on why nutrition is important for HIV-infected patients, how to make informed choices within each food category, and what individual adjustments may be needed; available at: www.aidsmeds.com/articles/740_7670.shtml
• HIV Nutrition and Health, by Tufts University School of Medicine, available only in English; contains information on why nutrition is important and how to build a high-quality diet, along with links to comprehensive information on dietary aspects of fatigue, diarrhea, weight gain, weight loss, cardiovascular disease, nausea, lipodystrophy, food and water safety, and advice on what to do when money for food is limited or no kitchen is available; available at: www.tufts.edu/med/nutrition-infection/hiv/health.html
Standard Medical Therapies
There are currently a large number of drugs approved for the treatment of HIV, including nucleoside/nucleotide reverse transcriptase inhibitors (Combivir, Emtriva, Epivir, Epzicom, Retrovir, Trizivir, Truvada, Videx, Videx EC, Viread, Zerit, and Ziagen); non-nucleoside reverse transcriptase inhibitors (Intelence, Rescriptor, Sustiva, and Viramune); protease inhibitors (Agenerase, Aptivus, Crixivan, Invirase, Kaletra, Lexiva, Norvir, Prezista, Reyataz, and Viracept); entry inhibitors (Fuzeon and Selzentry); integrase inhibitors (Isentress); and multi-class combination drugs (Atripla). There are many additional drugs in the pipeline that will be approved in the near future, including a new class of antiviral drugs called maturation inhibitors.
In general, these drug combinations are highly effective for lowering HIV vital load (HIV-1 RNA), slowing disease progression and maintaining stabile health in those with HIV. However, they can also be difficult to take and require a high level of adherence to maintain their effectiveness. Drug resistance can develop over time, and there is substantial cross-resistance in which developing resistance to one drug in a medication class can result in resistance to other drugs in that same class. Many of these drugs also cause difficult side effects, ranging from nausea, diarrhea, intestinal gas, fatigue, headaches, and changes in body appearance (abnormal fat loss or gain to the face, trunk and extremities) to serious long-term complications that may include insulin resistance and diabetes, elevated blood fats and cardiovascular complications, damage to the nerves (neuropathy), bone problems, liver damage, and kidney damage.
It is very important to use these drugs in effective combinations when they are needed to prevent disease progression, but it is also important to do everything possible to help maintain health and slow disease progression with the other components of an integrated approach to HIV disease, including a good diet, nutrient supplementation, and exercise. For those currently taking antiretrovirals, it is also important to use nutrients that may help to counter drug side effects, thus improving the chances for long-term safe use of these medications.
Ingesting optimal amounts of all the key micronutrients used by the body to maintain healthy immune function is one of the most important components of an integrated approach to HIV/AIDS. As discussed above, there are many studies showing the need to maintain optimal micronutrient consumption in people living with HIV.
In addition to improving nutritional status by eating a healthy diet, there is general consensus that all HIV-positive individuals will benefit from daily multivitamin and mineral supplementation. Several prospective, randomized clinical trials have shown that HIV-positive people given micronutrient supplements have improved clinical outcomes, including both increased CD4 counts 24,25 as well as substantially decreased disease progression and mortality.26,27
Two large studies of HIV-infected patients given micronutrient supplements containing multiples of the recommended dietary allowances for vitamins and minerals, including an African study of patients not taking antiretrovirals,28 and a multi-site United States study of those on a stable HAART regimen,29 showed significant increases in the CD4 count in those given the high-dose supplements.
Because there are a large number of micronutrients that are required for healthy immune function, it is generally recommended to supplement with a broad spectrum of micronutrients, including a multivitamin/mineral formula that includes a potent amount of several potent antioxidants.
The mitochondria are small, energy-producing organelles present in virtually all of the body's cells, with especially high numbers found in tissues requiring large amounts of energy including muscle, heart, liver, and immune system cells. Unfortunately, some of the antiviral drugs used to treat HIV infection, most notably the nucleoside analogue reverse transcriptase inhibitors (AZT, D4T, DDI, abacavir, etc.), can damage the mitochondria 30,31,32,33 and lessen their ability to healthfully produce energy.
When the mitochondria burn fuel (glucose and fatty acids) they produce energy as well as toxic waste products (free radicals) that need to be neutralized. The mechanism that the body uses to safely neutralize these toxic free radicals is to combine them with antioxidants. The most potent antioxidant molecules used by the mitochondria are alpha lipoic acid, glutathione (provided as N-acetyl-cysteine or NAC), selenium, and acetyl-L-carnitine. These antioxidants, when supplemented in substantial dosages, have been shown to healthfully boost mitochondrial energy output thereby improving cellular function and health.34
At the same time that reverse transcriptase inhibitor drugs block the replication of HIV, they can also inhibit an important enzyme within the mitochondria called "mitochondrial DNA polymerase gamma". This enzyme helps the mitochondria produce DNA. A deficiency of this enzyme often leads to toxicity due to a precipitous rise of free radicals to unhealthy levels. When this happens, the mitochondria can become poisoned leading to their death and the subsequent death of the cells containing them. The end result of this process is often manifested in many of the side effects seen from these drugs, including nerve pain and damage (neuropathy), muscle aches and pains (myopathy), damage to the pancreas (pancreatitis), damage to blood cells, damage to the liver, and in extreme cases, lactic acidosis; a buildup of lactic acid in the bloodstream that can be fatal.
People currently taking HAART regimens that include nucleoside analogue reverse transcriptase inhibitors may benefit by supplementing their diet with micronutrients that have been shown to help counter mitochondrial toxicity. These include:people living with HIV. Multiple studies have shown increased levels of
• Antioxidants are particularly important for oxidative stress are present in HIV disease.35,36,37 Oxidative stress is a condition in which the body's supply of antioxidants is insufficient to counter the damaging effects of unstable molecules called free radicals and other reactive oxygen species. High levels of oxidative stress occur early in the course of HIV infection and continue throughout the disease making adequate supplementation with antioxidants very important to protect the body from damage. Because different antioxidants work in different places in the body and help to recycle and regenerate each other, a broad spectrum of antioxidants is best for complete protection. Your intake of antioxidants for best results should include vitamin C, vitamin E, carotenoids, selenium, zinc, N-acetyl-cysteine, and alpha-lipoic acid. A generous intake of antioxidants can help to counter nutrient deficiencies that are common in HIV disease, prevent damage that might otherwise be caused by ongoing oxidative stress, and help prevent the toxicity that nucleoside analogue drugs cause to the mitochondria, as discussed above.
• Acetyl-L-carnitine is a very important amino acid that is used for transporting free fatty acids across the mitochondrial membrane for fuel.38 Thus, it is very important for energy production in the body's cells, including high energy-demanding cells of the immune system. Multiple studies have shown deficiencies of carnitine in HIV-infected people, and beneficial effects in those given carnitine supplements, including immune system improvements and reductions in elevated triglycerides.39,40,41 In one study, high-dose carnitine yielded significant increases in CD4 counts and a decrease in CD4 cell death.42 In another, carnitine supplementation decreased oxidative stress levels in HIV-positive people using nucleoside analogue drugs.43,44
Low levels of acetyl-L-carnitine have also been associated with a condition known as peripheral neuropathy, a common side effect of nucleoside-analogue antiviral drugs in which there is pain, numbness, and tingling in the extremities.45 A study providing high doses of acetyl-L-carnitine supplements to HIV-positive patients with peripheral neuropathy (1500 mg twice daily) showed significant improvement in symptoms in 15 of 21 patients as well as significant increases in nerve fiber growth.46
• N-acetyl-cysteine and alpha-lipoic acid are two important micronutrients required to help cells maintain healthy levels of glutathione, the cell's most important antioxidant. Deficiencies of glutathione are known to occur early in the course of HIV disease.47,48 Boosting glutathione back toward optimal levels is very important for countering oxidative stress and mitochondrial toxicity. N-acetyl-cysteine provides the amino acid cysteine that is the rate-limiting factor in the body's production of glutathione. Alpha-lipoic acid is a powerful antioxidant that both directly reduces oxidative stress and indirectly recycles or regenerates other antioxidants, including glutathione. In one study of people with AIDS, supplementation with alpha-lipoic acid resulted in increased blood levels of both vitamin C and glutathione, as well as increases in CD4 cells.49
• Natural anti-inflammatories are also important for people living with HIV to consume since HIV infection causes a high level of inflammation in the body. One of the best nutritional supplements for providing a natural anti-inflammatory effect is fish oil. Scientists believe that part of the reason that a plentiful intake of fish oil is tied to heart health is due to its natural anti-inflammatory qualities. The generalized inflammation that is found in HIV disease is believed to be one of the causes of increased heart disease in HIV-infected people. Fish oil may help to prevent this, while also helping to maintain normal levels of blood fats.
In one double-blind, randomized, placebo-controlled study of HIV-infected patients on stable antiretroviral therapy, eight weeks of supplementation with fish oil (2000 mg three times daily) reduced triglyceride levels by approximately 25 percent. 50 Even in patients with very high triglycerides at baseline (> 10 g/L), treatment with fish oil resulted in very substantial reductions (triglycerides decreased by 43.6 percent at week eight and 38.7 percent at week sixteen). Total cholesterol also decreased significantly.
While standard medical treatment of HIV infection continues to improve, the importance of providing HIV-infected individuals with the proper diet and supplements necessary to keep the immune system strong is often neglected. This occurs despite the many studies which substantiate the need for nutritional counseling and supplementation to be part of the comprehensive treatment of this disease.
The goal of this paper has been to provide the reader with a referenced-based review of the many recently published findings in the field of HIV and nutrition, including the most important micronutrients to consume either through diet, supplementation, or both.
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