Update on Micronutrient Needs in HIV
Micronutrient deficiencies appear to be common in persons living with HIV/AIDS (PLWHA) as a result of HIV infection itself, malabsorption, and/or eating less due to being HIV positive. Even PLWHA who are asymptomatic or appear to eat a well-balanced diet may be deficient or in the low normal range for certain nutrients.
Whole foods, fruits and vegetables, and lean protein are a paramount part of a PWLHA's diet. There are many vitamins, minerals, and antioxidants, like vitamin A and C, available in fruits and vegetables for optimal health. There are many other antioxidants, such as polyphenols, flavonoids, allium compounds, and glucosinolates in fruits/vegetables as well. Research on these nutrients is continuing and new findings are emerging. By consuming whole foods, such as whole-grains, fruits and vegetables, a PLWHA is including these and other antioxidants as well that may turn out to be very beneficial.
In a perfect world, eating a variety of healthy foods is all a PLWHA would need to do in order to meet all their nutritional needs. But we do not live in a perfect world and a prudent amount of "insurance" in the form of a supplement makes sense, especially if a PLWHA has a poor appetite or is experiencing nausea. There are certain micronutrients like vitamin E that cannot be eaten in high enough quantities in foods for an antioxidant level dosage. Remember, however, that taking supplements is no excuse for poor dietary habits. PLWHA should discuss their eating habits with a Registered Dietitian (RD) and have the RD compare their eating habits and intake to their estimated needs.
Much of the published research conducted on micronutrient intake in PLWHA to predict morbidity and mortality studied individuals before the advent of highly active antiretroviral therapy (HAART). It is still too soon to tell what effects HAART may have on micronutrient needs. One recent study by Rosseau et al. evaluated 44 patients while on HAART in 1998 and found HAART contributed to selenium and zinc deficiencies. This is consistent with published data that shows people with AIDS tend to have more severe selenium deficiencies than those who have a healthier immune system.
It is outside the scope of this article to review every micronutrient in depth, but rather to highlight certain micronutrients (selenium, vitamin B12, vitamin A, C, and E) that have considerable amounts of research in relation to HIV in the medical literature.
Selenium is part of the body's antioxidant defense system. It is a component of the enzyme gluthathione peroxidase. Selenium is the most studied micronutrient to date, with profound nutritional implications for PLWHA. Low selenium levels are associated with low gluthathione activity. A landmark study by Baum et al. in 1997 looked at 125 HIV positive intravenous drug users in Miami. This cohort was followed in 6-month intervals for 3.5 years. Only a selenium deficiency and CD4 count were shown to be significantly associated with mortality. The relative risk of mortality with selenium deficiency was almost 11 times greater, and was statistically significant. These results indicate that selenium deficiency is an independent predictor of survival.
A recommended daily selenium intake can range from the Daily Value (DV) of 70 mcg to 200 mcg. Keep in mind however that the DV is established by the FDA (Food and Drug Administration) to represent the minimum amount required to prevent a clear deficiency in a healthy sedentary adult population without chronic diseases. I hazard to state that the DV's do not apply to the majority of PLWHA. The Upper Tolerable Limit (UTL) set by the National Academy of Sciences for selenium is 400 mcg. The best sources of selenium from food are Brazil nuts, seafood, liver, meat and grains.
B12 is a water-soluble vitamin and important in the formation of proteins, messengers in the nervous system, red blood cells, proper functioning of a large number of enzymes and in maintaining a good immune system. B12 absorption requires intrinsic factor, a glycoprotein made in the gastrointestinal tract that allows it to be absorbed in the small intestine. B12 deficiencies may occur in malabsorption and in PLWHA. The symptoms of a B12 deficiency include anemia and changes in mental function that can lead to dementia. Tang et al. studied 310 HIV positive participants for nine years from 1984-1993 and found that people with low serum B12 levels (<120pmol/L) had significantly shorter AIDS-free time than those with normal B12 levels (>120pmol/L). The average AIDS-free time was 4 years vs. 8 years respectively. The risk of progression to AIDS for those with low B12 levels was significant with a relative hazard of 2.21 (the risk was more than doubled), which shows that low B12 levels precede disease progression.
A recommended daily B12 intake can range from the DV of 6 mcg to 1000 mcg. The Physician's Desk Reference (PDR) for Nutritional Supplements states that oral vitamin B12 is well tolerated even at high doses. There is no established UTL for B12 and there is no documentation in the literature of overdosages. The best sources of B12 from food are meat, fish, poultry, milk and eggs. A PLWHA who is also a vegan (eats no animal products) vegetarian clearly needs a B12 supplement.
Vitamin A and Beta-Carotene
Vitamin A is a fat-soluble vitamin and beta-carotene (water-soluble) is the preferred source that can be converted into vitamin A in the body. Some studies show that a vitamin A deficiency appears to be an independent predictor of survival and levels may be low in PLWHA. In one study by Tang et al. in 1993 there seems to be a U-shape relationship between progression of HIV and vitamin A intake. This means that the highest and lowest quartiles of intake did the poorest, while the middle two quartiles were associated with slower progression to AIDS. Several clinical trials since have shown no benefit beyond correcting a vitamin A deficiency for sustained or significant improvements in the immune system. An excess of vitamin A is toxic, may promote free radicals, and therefore should be avoided.
A recommended daily vitamin A and beta-carotene intake can range from the DV of 5,000 IU to 10,000 IU, which is the UTL. The best sources of vitamin A and beta-carotene from food are green leafy vegetables, carrots, cantaloupe, peppers, oranges, meat, milk, and other red, green, orange or yellow colored fruits/vegetables.
Vitamin C is a water-soluble vitamin that is an important antioxidant. It also has the ability to regenerate the antioxidant form of vitamin E. Vitamin C has been shown in studies to reduce the symptoms and severities in acute viral infections, such as the cold and flu. The need for vitamin C increases with infection or injury. It is essential for the maintenance of bones, teeth, blood vessels and connective tissue.
A recommended daily vitamin C can range from the DV of 60 mg to 1,000 mg. 2000 mg of vitamin C is the UTL. The best sources of vitamin C from food are oranges and other red, green, orange or yellow colored fruits and vegetables.
Vitamin E is a fat-soluble antioxidant that plays an important role in protecting the cell membrane, bone marrow toxicity (possible side-effect of AZT), fats, the immune system and vitamin A from oxidative stress. Low levels of vitamin E in the body have been associated with an increase in oxidative stress in PLWHA. In vitro (in the test tube), vitamin E appears to have an anti-viral effect. One study by Abrams et al., with 296 HIV positive men followed over six years, showed a decreased risk of progression to AIDS with a doubling of vitamin E intake.
A recommended daily vitamin E intake can range from the DV of 30 IU to 800 IU. The UTL for vitamin E is 1000 IU. Be sure to avoid extra vitamin E if a PLWHA is on the protease inhibitor Agenerase (amprenavir), as it already has 1744 IU in the standard dose. The best sources of vitamin E from food are vegetable oils, eggs, and whole-grain cereals.
The body of research shows micronutrient needs are typically higher for PLWHA than for the general population. As a result, in some instances a supplement may be warranted, in addition to a healthy well-balanced eating plan to ensure optimal health and longevity. A basic multivitamin with minerals once or twice a day with meals is a good foundation. Beyond that make sure you discuss any plans on taking supplemental forms of micronutrients with your doctor and nutritionist.
Alan Lee, R.D., C.D.N., C.F.T., is a nutrition and fitness expert and currently works as a consultant for various AIDS Service Organizations and Astor Medical Group, LLP (www.astormedical.com) in New York City. He is currently the chair of Nutritionists In AIDS Care (NIAC), which is a special interest group of the Greater New York Dietetic Association (GNYDA). He coordinates the group's annual conference, as well as the NIAC lecture series for nutritionists on continuing education topics. He is a national speaker on nutrition and fitness and can be reached at AlanLeeRD@yahoo.com and (212) 229-2298. References are available from author upon request.
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