Living with a chronic illness like HIV can present certain nutritional challenges. Without effective HIV medication treatment, replicating virus can tax the body, destroying lean body mass and impairing immune function and quality of life.1,2
While this destruction of lean tissue can be controlled with effective HIV antiretroviral combination therapy, other challenges like fat accumulation and increases in lipids (cholesterol and triglycerides) and/or insulin resistance may arise in some patients after treatment initiation.3 Although limited research has been done on the effects of nutritional approaches on pre- and post-HAART (highly active antiretroviral therapy) metabolic issues, general suggestions can be extracted from studies regarding other conditions like diabetes, cardiovascular disease, and obesity. These suggestions are aimed at helping the body deal with the effects of HIV or its medications on metabolism, body shape, and quality of life as we live longer with HIV.
Foods are made up of many different components -- some are "micro" or smaller quantity nutrients, like vitamins, and some are "macro" or larger quantity nutrients. The three macro groups that compose the majority of our diets are carbohydrates, proteins, and fats. These three units are the basic materials that fuel our activities and metabolism and maintain body composition. Selecting the best sources and amounts of these three macronutrients may help to minimize metabolic disorders (such as high cholesterol and blood sugar) and prevent loss of lean body mass and accumulation of body fat.4-6
Carbohydrates provide our body's main source of quick energy. After carbohydrates are digested and after some processing by the liver, they are released into the bloodstream as a sugar called glucose to be delivered to the cells.
Throughout the majority of the last million years of our evolution, the human diet consisted of animal carcasses, some seeds, nuts, and fibrous vegetable and fruit carbohydrate sources that are generally nutrient-rich with lots of water, but are not calorie-dense like processed foods of today. The majority of these carbohydrate sources are vegetables, leaves, roots, and fruits (all rich in fiber). Because vegetable fiber tends to slow down digestion, a majority of the carbohydrates in these foods are absorbed relatively slowly, inducing less blood sugar (glucose) and insulin spikes than processed sweets that contain no fiber. Some people call these "slow carbs."
It was only after the advent of agriculture that human beings were introduced to higher intakes of grains as carbohydrate sources. Higher intakes of grains deliver lots of calories. Additionally, some grains deliver their sugar energy relatively quickly, especially if the grain is milled (which removes the fiber that slows down sugar absorption), as are the grains in breads and pasta. Unless you are very active and exercise enough to metabolize nutrients more rapidly, this quick glucose release into the bloodstream can create a dysfunctional hormonal environment that can ultimately promote obesity, cardiovascular disease, and diabetes. This hormonal shift also has a profound effect on lean body mass and fat metabolism, and possibly immune function.7-9 The key hormone involved in this problem is called insulin, produced by an organ called the pancreas.
The hormone insulin is produced by the pancreas to control blood sugar and store it in muscles for later use as glycogen. Insulin's main job in the body is to promote the delivery of sugar energy as glucose to cells. When a small amount of glucose is delivered into the bloodstream, a small amount of insulin is produced by the pancreas to accompany it. When there is a large amount of glucose, the pancreas works to produce a large amount of insulin to facilitate its delivery so that cells can take in as much glucose as possible. Extra glucose that cannot be taken in by the cells circulates in the bloodstream and can be toxic to brain cells, so under normal circumstances, most of it is soon converted into triglycerides (fat) in the liver to be stored for later use. But we have to be careful with high blood levels of triglycerides, since they are what feed fat cells.
The correct amount of carbohydrate sources will provide enough sugar to give a healthy amount of glucose to the cells, but not too much at once. Thus, levels of glucose and insulin in the bloodstream are not unusually elevated for any long period of time. The pancreas works, but it is not overworked trying to keep up with an unusual demand for insulin.10 However, in the U.S., much of the diet consists not only of large amounts of high-calorie carbohydrate sources, but also of carbohydrates from sweets and sodas, which are very concentrated sources of sugar. The net effect that intake of these calorie-dense carbohydrate foods creates is a bloodstream that is occasionally flooded with large amounts of glucose, a pancreas that is overworked, and large amounts of insulin and triglycerides circulating in the bloodstream. Note that excess insulin causes increased production of cholesterol.
Over time, these occasional glucose, triglyceride, and insulin floods can cause a decrease in the sensitivity of the cells' response to insulin, which reduces the cells' ability to take in glucose. Insensitivity to insulin is called insulin resistance, and it is a serious consideration in HIV because we are now seeing it as one of the core components of lipodystrophy and metabolic problems.11 Some HIV medications can worsen insulin resistance, so we need to be aware of nutritional considerations that can help. Ways to decrease insulin resistance are to exercise, choose more metabolic-friendly HIV medications, and follow a proper diet. For instance, a prominent study from Tufts School of Medicine found that HIV-positive people consuming an overall high-quality diet, rich in fiber and adequate in energy and protein, were less likely to develop fat deposition.12 This is why it is best to select the majority of your carbohydrate intake from fiber-rich, slow-releasing carbohydrate sources that do not contain an excessive amount of calories. And these good carbs should be accompanied by good sources of protein and fats.
Protein, fiber, or fat will slow the absorption into the blood of glucose from carbohydrates, which helps to reduce the rise in blood sugar and insulin spikes. So, mixing carbohydrates with protein, fiber, and good fats is one way to reduce their problematic effect on blood sugar and insulin. Ensure that every meal and snack you consume has a mix of these three macronutrients. But what are the best fats, protein, and high-fiber carbohydrates sources out there?
There are a number of different kinds of fats. There is motor oil, there is butter, and there are essential fatty acids. The most important oil to keep a Honda running right is not the kind with essential fatty acids (EFAs), but if you want to help your body stay healthy and your immune system operating at its best, you had better consider getting these EFAs on a daily basis. They are called "essential" because your body cannot manufacture them, and must obtain them from an outside source, like food or supplements. These oils are necessary for every critical function in your metabolism, including building lean body mass and fighting infections.
The main point is that since we need EFAs and other fats for health, we should be getting them in our diets from fresh, high-quality sources. A proper diet reduces the amount of starchy carbohydrates while maintaining a certain amount of healthy fats so that there is a different macronutrient balance than the old high-carbohydrate, high-protein, low-fat diets contained. This means striving to get fatty acids from several sources, the least of which are the saturated fats in butter or animal fat. Understand that saturated fats are not the demons we have been led to believe. When we realize that we evolved getting a certain amount of saturated fat from foods in the wild, it is only logical that they would have a place in a healthy diet. One recent study showed that dietary saturated fat and mono-unsaturated fat were associated with healthy testosterone production in humans, while EFAs had no effect. So it appears that we need a little saturated fat for optimal hormonal health. However, most people get far too much saturated fat, which promotes insulin resistance and metabolic problems, and not enough EFAs, which are needed for healthy cells and immune function.13
The other important kind of fat that we should consciously include in our daily diet is mono-unsaturated fat, which we get from foods like olive oil. Recent data have shown that mono-unsaturated fats decrease the risk of certain cancers, and have an anti-inflammatory effect.14 AIDS is an inflammatory disease, so mono-unsaturated fat intake logically has a place of importance in managing AIDS, too.
EFAs include the omega-3 and omega-6 fatty acids. Most people get an imbalance of these two by consuming too small an amount of omega-3 fats, which have anti-inflammatory properties, and relatively too large an amount of omega-6 fats, which tend to promote inflammation when out of balance.15 To get more omega-3s, eat more fish, including salmon, tuna, sardines, anchovies, mackerel, rainbow trout, and herring. Omega-6s are contained in common vegetable oils, like sunflower, safflower, and corn oils. Try to reduce your intake of these.
Olive oil is one of the best oils to cook with. You can also cook with high-oleic sunflower oil, avocado, canola, macadamia, or any oil that is high in mono-unsaturated fatty acids.
Avoid cooking with oils made from corn and sesame. These oils contain more omega-6 fats, and less mono-unsaturated fats, so they have a higher potential for spoiling and turning to trans-fats, which are bad for the immune system. Try to avoid any intake of these oils when they are not absolutely fresh.
Also, choose oils that are minimally processed. Most of the clear oils in supermarkets are stripped of some of their natural components to make them more suitable for sitting on store shelves for long periods of time without spoiling. Do not use these stripped oils. When you do cook, do not overheat the oil so that it smokes, which causes the formation of carcinogens and destroys the beneficial fatty acids.
Do your best to avoid processed fats or oils, as they have negative effects on cellular health, overall metabolism, and your immune system. Look out for the words hydrogenated and partially-hydrogenated. These kinds of manipulated fats probably do increase the risk of cancer and heart disease. They also weaken healthy cellular immune metabolism, which means that they might increase HIV progression. Lastly, they are also likely to promote high lipid levels and insulin resistance.
Dairy protein fractions, such as caseine (contained in milk curd) and whey, are at the top of the list of proteins that optimally feed lean body mass growth. In dairy products, the amino acid balances, insulin-raising potential, and overall growth factor content add up to one thing: milk proteins were created to make mammals grow bigger. While there is a lot of hoopla related to which dairy protein fractions are best, there is more misinformation than reality in this area. Those with lactose intolerance should be careful in their selection of milk-based products. Aged cheeses and yogurt may be more tolerable for those who cannot digest lactose.
Next on the list are egg proteins. The important thing to remember is that whole egg is probably somewhat better than egg white for lean body mass growth and overall health effect, because the yolk is a rich nutrient source, and its protein content complements the protein in the egg white. Together they are a better source of protein.
While real food like meat often seems to take a back seat to protein powders because of a mindset created by slick advertising, professional athletes know the value of real food related to lean body mass growth. If you do not make real food and meat fundamentals in your diet, you will not grow lean body mass tissue as well. Fish, chicken, turkey, and beef are vitally important foods, not only because of their protein content, but because they contain numerous other nutritional components that are important for a healthy metabolism. The message is: eat real food, then supplement food with protein powder drinks if you need them.
Lean red meat is a superior source for lean body mass growth and blood-building nutrients. These include creatine, carnitine, phenylalanine, conjugated linoleic acid (CLA), and heme- (blood) iron, the most absorbable form of iron. And meat, in general, is less likely to cause allergic reactions than eggs or dairy proteins, like casein and whey. The only caution about red meat is that the high amount of saturated fat most commercial red meat contains could promote metabolic problems. So be moderate about including it in your diet and choose leaner meats if you do.
Important details on meat: cooking kills bacteria in meats. Stewed meat is better for digestion (chicken soup, beef stew). Roasting is okay. Try not to fry or barbecue with charcoal. Charred foods are associated with increased risk of gastrointestinal system cancers. Any cooking of meat or vegetable protein that causes the formation of a hard outer skin renders the protein that becomes the skin to be much less digestible because it cross-links the protein.
It is very difficult to gain lean muscle weight on a vegetarian diet. In fact, it is almost impossible for most people, especially when they are fighting infections that burn lean body mass. While I know a very few HIV-positive people who can do well adhering to a vegetarian regime, I find that the vast majority cannot do it and keep their lean body mass. Additionally, vegetarian diets increase the potential for anemia because of a lack of blood-building components such as highly absorbable heme-iron and vitamin B12.
If you do choose a vegetarian diet, your best protein sources are beans, seeds and nuts. Digestion of nuts and seeds will be improved by soaking them overnight to reduce the enzymes they contain that inhibit digestion of proteins. If you can eat them without digestive problems, many nuts and seeds are ideal foods because they contain protein, healthy fat, and complex carbohydrates in a very good balance for overall health. They also make a great snack between meals. However, the amino acid balances in these proteins do not appear to be optimum for lean body mass growth for humans. Again, vegetarian or vegan diets present a challenge to people with HIV or AIDS who need a full spectrum of amino acids and micronutrients. Unless you are vegetarian for ethical reasons, consider eating eggs and fish.
People who are on HIV medications like tenofovir (in Viread, Truvada, Atripla, Complera, and the Quad), which may affect kidney function in some patients, should be careful about increasing their protein intake too high (over 1 gram per pound of body weight per day), as this can increase the potential for kidney problems. Ask your doctor if you are taking kidney burdening medicines, and, if so, only eat a higher protein diet under your doctor's direction. Those who have liver problems need good protein intake for the repair of liver tissue, but should also be careful about higher protein intake, and should also do so only under a doctor's supervision.
Bone loss has been reported in several HIV studies. It seems to be caused by the effect of the virus on the body. Certain medications like tenofovir (Viread) may make this problem worse. We also seem to have a high incidence of vitamin D deficiency due to potential HIV medication effects or metabolism issues. We know that calcium and vitamin D help to strengthen bone. Many of us chose to take calcium plus vitamin D supplements, but there are also foods that are rich in these nutrients. Calcium-rich foods include milk, cheese, spinach, fortified orange juice (be careful with the sugar, though!), fish, eggs, and beans. Vitamin D-rich foods include milk, most fish, and eggs. However, most of us do not consume the 1000 mg and 2000 IU needed per day for calcium and vitamin D, respectively, and need to take over-the-counter supplements. One word of caution: do not take your calcium supplements with your HIV medications since they may interfere with their absorption (at least two hours before or after is okay).
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2. Nuts, Grains, Oil
Nelson Vergel, a chemical engineer from Venezuela, has been HIV-positive since 1983, and is a leading treatment advocate on HIV disease. He created the Program for Wellness Restoration (PoWeR) and founded the Body Positive Wellness Center in Houston. Nelson has lectured extensively around the country and overseas, and with his research partner, Michael Mooney, co-authored the book Built to Survive. In 2010, he wrote and published Testosterone: A Man's Guide -- Practical Tips for Boosting Physical, Mental and Sexual Vitality. He is currently a member of the DHHS Panel on Antiretroviral Guidelines, the AIDS Treatment Activists Coalition, and moderates PozHealth, one of the largest HIV health discussion listservs online.