Dietary Considerations and Combination Therapy

Diet is an important part of the battle against HIV infection. In general, a good diet of whole foods provides the body with the right nutrients it needs to perform its many functions. Diet is especially important when taking combination therapy for HIV infection. In many instances it can be the difference between success and failure with these medications, since many HIV medications have special dietary needs for their absorption in the body. Dietary management can also help alleviate some of the side effects of these medications.

The hardest part is setting up a system that is right for you. You must be realisitic about your daily schedule and your available time. Are you an early riser with time to spare? Do you have time to eat in the morning, or do you jump out of bed at the last minute and rush out the door. Do you have to get kids ready for school? Do they eat before they leave? Is it important to eat with them? Do other duties or habits have priority? The more complex your daily life is, the more important it is to set up a realisitc medication/eating schedule. Make sure you discuss these issues with your healthcare provider.

In order for medications to get into the body they must be absorbed by the gastrointestinal tract (through the stomach and intestines). Some drugs require stomach acid (with no food in the stomach) to be absorbed while others need to be absorbed in the presence of food. So what you eat or don't eat can directly affect whether your HIV medications get into your body and thus are able to suppress the virus.

When you start sorting out your HIV medications, particularly your antiretroviral medications, you find that they can be divided into three "eating requirement categories." The first and easiest category is those medications that have no specific eating requirements. These medications can be taken on a full or empty stomach, with or without food. These medications include the non-nucleoside reverse transcriptase inhibitors nevirapine (Viramune™) and delavirdine (Rescriptor™), and the nucleoside analogues AZT + 3TC (Combivir™), 3TC (Epivir™), d4T (Zerit™), ddC (Hivid™) and AZT (Retrovir™).

The second category is medications that should be taken on an empty stomach. They are the nucleoside analogue ddI (Videx™) and the protease inhibitor indinivar (Crixivan™). Taking indinivar on an empty stomach may be a problem for some people because of stomach upset. If you need to , you can take indinivar with a light snack. The manufacturer Merck says that a low fat, low protein, low calorie snack will not interfere significantly with absorption. According to Merck's guidelines a "snack" has no more than 301 calories, with no more than 23 calories from fat, 23 from protein and the remainder of the 255 calories from carbohydrates. (See Table 1 for a list of snacks you can eat with Crixivan™.)

Table 1

Light Snacks that can be taken with Crixivan™
Food Items	Calories	Fat Grams	Protein Grams	Carbo. Grams
1 cup instant oatmeal, regular and 1/2 banana	197	2.6	2.5	38.5
1 cup Cheerios, 1/2 cup skin milk, 1/2 banana	184.5	1.7	7.5	35.5
1/2 bagel, 1 oz nonfat cream cheese, 1 TBSP jam	146	1.4	7.5	33
1 egg white, 1 slice wheat toast, 1/2 grapefruit	135	1.2	7	21.2
1 english muffin, 1 TBSP jam, 1 orange	244	1.4	5.2	49
1 pkg cream of wheat (mix & eat), 1 peeled apple	165	2.2	3.2	37
1 cup white rice (instant), 1/2 cup vegetables	199	0.4	5	43
1 cup white rice (instant), 1/2 cup vegetables	199	0.4	5	43
1 cup white rice (instant), 1/4 cup black beans	218	0.4	7	45
1 baked potato, 1 TBSP low fat sour cream, 1/2 cup corn kernels (can or frozen)	241	1.9	5.2	54
1/2 cup macaroni, 1/3 cup tomato sauce, 1 TBSP parmesan cheese (grated)	147	2	6.5	26.2
1 cup vegetarian vegetable soup, 2 rice cakes	210	4	4	40
1/2 cup spaghetti, 1/2 cup mushrooms (sliced), 1/2 cup tomatoes (chopped)	127	2.2	6.6	30
1 bagel	187	1	7	36
1 bagel with 1 oz nonfat cream cheese	92	1.2	5.5	19
1 cup white rice (steamed)	267	1	6	58
2/3 cup mashed potatoes & gravy (KFC)	124	1	4	210
1/3 cup baked beans (KFC)	105	1	5	18
1 banana	60	0	0	15

The third category is medications that should be taken with food. They are the protease inhibitors Invirase, Fortovase, Norvir and Viracept. The amounts and types of food vary from drug to drug. Invirase and Fortovase should be taken within two hours of a meal. A "meal" is considered to be about one third of the calories you need each day if you eat three meals a day. The definition of a meal changes if you eat more or fewer than three meals a day. The total daily caloric intake usually is between 1500 and 2500 calories depending on your size, age, sex and activity level. The average meal is considered to be 600-900 calories with 25-30 grams of fat. Norvir should be taken with food if possible and is best absorbed with a full meal. This means the more food you eat the better absorbed the drug will be. Viracept should also be taken with food, preferably a substantial snack or a light meal. The manufacturer of Viracept, Agouron, says that the more food you take with your medication the better it is absorbed since it stays in your small intestine longer. They also say that the more food you eat, the less diarrhea you may experience, although there are no studies to prove this.

It is important to define some terms that on first appearance may seem very simple. When you need to take your medications on an empty stomach, this doesn't mean that five minutes after you take you medications you can eat -- one hour is more appropriate. You must allow your body to digest the pills without anything else in your stomach, or you will not let the medications get absorbed. On the other hand as described above, if you have to take your medicine with food, eating a tangerine or a banana on the run won't give you enough food in your stomach to absorb the medication. It is also important to drink plenty of pure water with your medications to get proper absorption, and in the case of Crixivan to avoid kidney stones.

In addition to antiretroviral therapy for HIV infection, additional drugs used to treat other aspects of HIV infection (especially antibiotics) may also have dietary restrictions or requirements. Poor medication absorption due to faulty eating habits did not start with the HIV epidemic. It has been around for as long as people have been taking meication. For example, if you were prescribed the antibotic tetracycline for a specific infection and you succeeded in completing the regimen 100%, but you took the pills with a glass of milk or with meals, you may have neutralized the antibacterial activity of the drug. You probably did not get good results. Tetracycline needs to be taken on an empty stomach one hour before or two hours after eating. Always ask your doctor or pharmacist for instructions on how to best take your medication. The pharmacist has over 50 instruction labels that can be put on your medication containers to help remind you how your medications should be taken.

Managing Side Effects with Diet

Diet is not only an important consideration when taking combination therapy for proper absorption, but diet can also be helpful in managing some gastrointestinal side effects of therapy.

Diarrhea

Many HIV medications, especially the protease inhibitors, can cause diarrhea. If diarrhea continues for more than two weeks or begins after you have been on medications for some time, it may be caused by something other than the medications. If this is the case your doctor should do a complete GI work up to check for parasitic or bacterial infection. Besides prescription medications that can relieve diarrhea, diet can be helpful to manage diarrhea.

Many individuals can not tolerate milk or milk products because of a sugar called lactose which can be hard to digest. This condition is known as lactose intolerance, which has symptoms that include diarrhea, cramping, abdominal pain, gas and bloating. People who are lactose intolerant do not produce enough lactase -- the enzyme which breaks down lactose so that it can be absorbed.

For people who are lactose intolerant, avoiding milk products is the best bet, but if you can not do without milk, there is a supplement called lactase which provides the necessary enzyme to digest the lactose in milk. Lactase can be purchased at your local pharmacy.

Try and avoid foods with lots of fat, especially deep fried foods; these can cause diarrhea all by themselves and can aggravate an already sensitive intestine. Avoid synthetic fats like Olestra, which is known to cause diarrhea. Beverages or foods with caffeine like coffee, tea, soda, hot chocolate, or foods with chocolate should also be avoided since caffeine stimulates the intestine. Don't drink anything with alcohol, including over the counter medications like cough syrup with alcohol. Raw fruits and vegetables and other foods high in insoluble fiber can irritate the intestine, causing or aggravating diarrhea. Sometimes the diarrhea may have several causes so you may have to experiment with a few things to get relief. You can also try the BRAT diet listed at the end of this article.

Nausea and vomiting

Many HIV positive individuals experience nausea and vomiting as a result of certain medications or opportunistic infections. Most people don't even want to think about eating or drinking when they feel nauseated. But not eating with certain medications can reduce the effectiveness of the medication, leading to possible drug resistance. To help relieve nausea, eat small meals throughout the day. Choose cold foods rather than hot foods. Try foods like clear soups or broth, rice, noodles, oatmeal or cream of wheat without butter or sauce, mashed potatoes, plain eggs, cottage cheese, cheese or yogurt, pudding or Jell-O, plain crackers, pretzels, unbuttered popcorn, canned fruit, fruit ices or a chilled nutritional supplement. Avoid greasy foods, foods with strong odors and sweet or spicy foods. Instead, try foods that are salty or bland.

Loss of appetite (Anorexia)

Many people with HIV suffer from anorexia from time to time, but since not eating can reduce the absorption of medications and therefore their effectiveness, it is important to deal with this problem as soon as possible. Instead of trying to eat three large meals, eat more smaller meals throughout the day. Remember that the meals must be large enough to meet the minimum guidelines necessary for absorbing medication. Try eating while watching a video or listening to music. Eat with friends. We usually eat more when we eat with friends. Don't drink anything that may fill you up right before you eat. Ask you doctor for an appetite stimulant such as Megace™ or Marinol™.

You should keep in mind that taking the current HIV medications on a daily basis is something you have to do until better medications are developed. So having a diet that you can live with will make all the difference. Ask others how they are managing. Go to congregate meal programs to give yourself a break from cooking everyday. At first this may all seem so complicated, but with time it will eventually fit into your daily routine.

BRAT Diet for Diarrhea The BRAT diet is used to help slow down or stop diarrhea. It is not meant to be used for more than a couple of days at a time, because it does not contain all the nutrients you need to stay If you are allergic to any food on this list, don't eat it. All foods are to be eaten plain. B - bananas, boiled potatoes without skin, baked sweet potatoes without skin. R - rice (steamed)*, cream of rice cereal, rice water.** A - apple sauce, baked apple without the peel. T - tea without caffeine and white bread toast, unsalted plain crackers. While on this diet, don't eat or drink anything with caffeine like chocolate, cola, coffee, tea, hot chocolate or chocolate soda. Don't eat synthetic fats like olestra or Olean at any time. *Cooked, plain white rice is very easy to find when you are out in the world making your rounds. Any Chinese restaurant has it for take-out. Small containers are very cheap. **Rice water is made by cooking white rice with more water than it needs. For example, four cups of water to 1/2 cup of rice. When the rice is soft, pour the extra water into a container that can be covered, and put it into the refrigerator until it cools off. Refrigerate the rice in a closed container until you need it. Drink the water and eat the rice. Rice water is easier to drink when cold.

Edwin Krales is a nutritionist and the coordinator of Nutritional Services at the Momentum AIDS Project in NYC.

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