Concerns about medication toxicities and side effects run high in the HIV community. Multiple medications are being prescribed not just for HIV infection, but also for prevention and treatment of other infections, high cholesterol and fat accumulation, diabetes, heart, liver, kidney, and digestive diseases, cancer, hormonal deficiencies, pain syndromes, and mental health concerns. Nutritional risk factors, such as poor quality diet, weight loss, mild to moderate nutrient and hormonal deficiencies, dehydration, high levels of oxidative and emotional stress, and substance use aggravate these conditions and worsen toxicities. Seldom addressed by primary care providers, alternative therapies flourish in this environment, with susceptible consumers searching for anything from a prayer to a cure. Limited income dollars are spent on supplements that may be covered by state Medicaid or ADAP programs, on products that are irrelevant or on formulations that contain inadequate levels of nutrients. Use of extreme "detox" diets and enemas is also common practice.

Research suggests that aggressive nutrition support boosts the immune system and detoxification, improves digestion, and produces positive health outcomes. Eastern approaches such as traditional Chinese medicine and Indian Ayurvedic medicine focus on the value of whole food choices and mind-body practice as the basis of healing and longevity. These concepts are integrated with a harm reduction philosophy that relates success to the continual cycle of involvement and motivation for personal change, growth, and development.

This article will focus on healing nutrition strategies for four conditions often experienced in HIV disease: lipodystrophy (fat gain, high blood cholesterol and/or triglycerides), fatigue (low energy), nausea, and diarrhea. Interventions are designed to be both preventive and therapeutic, as well as useful for daily practice. All of these symptoms/side effects strongly impact on medication adherence, self-esteem, independence, and emotional health. Nutritional therapy, introduced when someone is motivated, can often re-focus attention from misery to the healing, dynamic, and restorative nature of food, nutrient, and fluid choices.

Balancing Metabolism

Lipodystrophy, fatigue and diarrhea can all be related to metabolic imbalance and/or toxicity. Cellular metabolism is a complex orchestration of distinct, highly regulated reactions. These reactions dictate how food is broken down, burned for energy, used for structure, and how toxic by-products are excreted. How well this system works depends on environmental factors inside and outside the cell, including pH balance, hydration, availability of nutrients, oxidative stress level, and the activity of hormones such as insulin, cortisol and testosterone.

Internal metabolic reactions work best in an environment that maintains a pH balance that is slightly alkaline. pH means hydrogen potential and measures the amount of hydrogen ions in a solution. Rated on a scale of 0 (most acidic, least alkaline) to 14 (least acidic, most alkaline), a neutral pH is around 7. An elaborate, internal buffer system tries to keep pH balanced at 7.4 for blood, 6.4 for saliva, and 5.5-6.0 for urine. Before HAART (Highly Active Antiretroviral Therapy) became available, PWA health activists tested salivary pH and noted that an acidic salivary pH less than 6.0 was strongly related to wasting, fatigue, neuropathy, and swollen lymph glands. These symptoms were reported greatly improved with the regular use of a highly alkalinizing whole lemon drink, which increased salivary pH levels. Today, clinicians, researchers, and people on HAART have concerns about lactic acidosis, a potentially fatal condition that comes from the build up of lactic acid in the blood. Lactic acid is a toxic by-product usually neutralized by cell buffer systems. These systems rely on the availability of calcium, magnesium, potassium, and sodium, minerals that are most abundant in vegetables and fruits, whole grains, nuts, seeds, low-fat dairy, and enriched foods. Few people eat enough of these foods, especially large quantities of fruits and vegetables, which also happen to be the most potent alkaline-forming foods.

The considerations of acid/base balance may also be connected to traditional Chinese medical theories about food and its impact on health conditions. Both contain distinct, natural properties characterized by yin/yang, hot/cold, dry/damp. Very yang food choices, mostly unhealthy fats and processed carbohydrates, create a very damp, hot environment. Disease and infection thrive in this environment. Chinese medicine teaches that cutting down on unhealthy fats and processed carbohydrates, and radically increasing consumption of vegetables, especially dark greens, fruits, whole grains, and unrefined essential fats can improve physical balance and detoxification.

This basic dietary recommendation is now backed by a decade's worth of medical research. High consumption of vegetables and fruit and low intake of saturated fat have been connected to improved health outcomes for cancer, hypertension, heart disease, and diabetes, all associated risk factors in HIV infection. In addition, naturally occurring compounds in plant foods have been discovered that defend cells against disease. Anthocyanins, indoles, flavonoids, sulfaforaphane, lycopene, and limonoids are a few of these new and exciting "phytochemicals."

Hydration is also key for a balanced metabolism. Drink 8 cups of water-based, non-caffeine fluids and reduce or avoid alcohol and sugar-based drinks. Timing and distribution of calories is also important. Eating small meals 5-6 times a day feeds the metabolic system in a gentler, more consistent manner than the traditional 1-3 large meals. It may also have an effect on blood sugar levels and insulin, the hormone that instructs blood sugar to enter the cell and be stored as fat or burned for energy. Flooding the system with large doses of sugar and refined carbohydrate may promote insulin resistance, a condition in which cells reject insulin and cannot access blood sugar for energy. Over time, blood levels of both sugar and insulin increase and sugar is stored as fat-carrying triglycerides in the blood. Also known as Syndrome X, this pre-diabetic state may be responsible for many of the metabolic symptoms of lipodystrophy, including high LDL (bad) cholesterol, low HDL (good) cholesterol, high triglycerides, high blood pressure, and fat gain around the abdomen. In HIV, insulin resistance is also related to fatigue, high levels of the stress hormone cortisol, testosterone changes, and an increased risk for diabetes and heart disease.

Diet and Supplements to Balance Metabolism and Improve Insulin Resistance

A diet to reduce the symptoms of insulin resistance/Syndrome X scales down total daily carbohydrate intake from 55%-60% (normal intake) to 45% of daily calories. The easiest way to do this is to avoid large quantities of refined carbohydrates like white flour and sugar. Try to eat smaller portions of these foods, as their sugars and insulin response can quickly overwhelm the system. Eat more healthy carbohydrates, like vegetables, fruits, whole grains, beans, nuts and seeds. These foods contain fiber, protein, or essential fats that keep blood sugar and insulin from rising too rapidly.

Proper balancing of fats is also critical to metabolism. Focus on increasing the healthy fats, also known as omega-3 fats and monounsaturated fats. Omega-3 fats, found in fatty fish (salmon, sardines, herring, trout), walnuts and flax and pumpkin seeds, decrease insulin resistance in diabetics and are anti-inflammatory. These healing fats are also linked to reduced risk of heart attack, stroke and breast, prostate, and colon cancer. They may also be useful in mental health conditions such as manic depression and schizophrenia. Scientists suspect a lack of omega-3s may increase the risk of Alzheimer's and Parkinson's disease. Monounsaturated fats such as olive oil, canola oil, nuts, seeds, and avocados are also healthy fats, as they boost levels of the "good" HDL cholesterol. Finally, decrease saturated fat from dairy, beef, pork, poultry skin, palm oil, and hydrogenated oils ("trans fat") from margarine, processed foods, and fried foods. These unhealthy fats increase blood levels of "bad" LDL cholesterol (clogs your arteries) and raise the risk of heart disease.

Eating enough protein is always important for someone living with HIV. Choose low-fat protein sources such as lean meats, skinless poultry, eggs (4 per week) or egg whites, low-fat dairy, beans, nuts, seeds, and soy-based foods. Be sure to eat protein throughout the day, but especially in the morning, and in combination with healthy carbohydrates and fats.

Progressive declines of vitamins, mineral, and antioxidants are well documented in HIV disease. Clinical assessment of nutrient levels may be difficult to measure, because blood levels may not reflect concentration and availability inside of cells. Many of these nutrients are essential for various metabolic reactions, especially energy production and detoxification. While a basic multivitamin/mineral pill may cover possible deficiencies, consistent and rational use of additional supplements may improve fatigue, insulin resistance, and overall immunity. Focus on vitamins (particularly B vitamins), minerals (selenium, calcium, magnesium, zinc) antioxidant compounds (selenium, coenzyme Q10, vitamins C and E, L-carnitine, alpha lipoic acid), and the amino acids cysteine and glutamine. Boosting levels of glutathione, the body's most important antioxidant, is critical to pathways that detoxify most medications.

Balancing Emotions and Metabolism

Cortisol is the primary hormone generated in times of stress. High levels of cortisol wreak havoc with metabolism and have been related to insulin resistance, fat accumulation, depression, and decreased immunity. Consider mind-body practices and therapies that address emotional issues and life stress. Chronic overeating and under-eating, common responses to anxiety, depression, isolation, and substance use, aggravate the metabolic response. Learning to nourish oneself physically and emotionally is critical. Recognizing food/mood connections and addressing underlying emotional development is usually necessary to transform poor food habits into healthy practice.

Balancing Digestion

For centuries, practitioners of Chinese medicine have focused on the digestive system as a central axis of health, balance, and detoxification. As with cell metabolism, natural properties of food and fluids impact tremendously on the digestive process, creating internal conditions that are ultimately friendly or hostile to the steady stream of bacteria, virus, fungi, and other toxins that pass through the intestinal track. Modern scientists have confirmed the critical importance of the digestive environment to health. Considered the largest organ of the immune system, the gut is a primary barrier against invading organisms, and home to highly concentrated areas of activated CD4+, CD8+ and B cells. In spite of (or because of) this powerful intestinal immune system, the digestive process plays a fundamental role in the progression of HIV disease. Vaccine researchers regard the intestines as a principal point of access for HIV infection and location of primary viral replication and persistence, even in early stages of the disease.

Virtually everyone with HIV has gastrointestinal symptoms at some point. People suffer enormously, displaying symptoms ranging throughout the length of the digestive tract, including dental problems, thrush, ulcers, heartburn, nausea and vomiting, severe gas, lactose intolerance, diarrhea, colitis, diverticulitis, constipation, hemorrhoids, anal warts and herpes. Many of these conditions can be greatly improved with aggressive nutrition interventions that use dietary change, supplements, and stress reduction to support digestion and boost intestinal immunity.

As HIV treatment and research continue to evolve, it is critical to integrate nutrition, healing, and mind-body therapies into primary care models, clinical research, and treatment education curricula. These interventions can reduce the risk of heart disease, stroke, cancers and diabetes, improve wellness and enhance quality of life. These nutritional strategies are offered as concrete, natural options for feeling better, maintaining adherence, and long-term survival.

Jan Zimmerman M.S., R.D. has been practicing HIV nutrition for 12 years at the Village Center for Care AIDS Day Treatment Program, an integrated health care model for people living with AIDS in New York City. She was recently promoted to Program Director, and maintains a private practice and consulting business in the area of nutritional health and healing.