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HIV and Nutrition

September 1998

A note from TheBody.com: Since this article was written, the HIV pandemic has changed, as has our understanding of HIV/AIDS and its treatment. As a result, parts of this article may be outdated. Please keep this in mind, and be sure to visit other parts of our site for more recent information!

What a difference 15 years makes.

The prevalence and severity of "AIDS wasting" has decreased dramatically. Combination triple drug therapy, better medical care, and early and aggressive attention to nutrition have made a big difference. As people live longer with HIV/AIDS, medical professionals associate it as a chronic illness in the same sense as diabetes and heart disease. Therefore it is important to take medications seriously and eat as though your life depended on it.


Take Your Meds

Taking medications on a regular basis, especially antivirals, go along with the territory. A rule of thumb is to take all medications with food unless there are special orders to take them on an empty stomach, as is the case with Videx/ddI.

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Taking Crixivan on an empty stomach with water one hour before or two hours after a meal is the best may to maximize absorption of the drug. If you feel nauseous or too hungry to wait to eat you can have a light snack. The snack should be low in calories, fat and protein, and carbohydrate is allowed.

Here are some examples:

  • Fat-free pudding cup

  • 1 cup pretzels & 1/2 can soda or juice

  • Dry cereal (with less that 2 gms fat/serving; e.g. Cheerios), 1/2 c skim milk,1/2 medium banana

  • 1/2 bagel (no seeds or nuts), 1/2 cup juice

  • 1/2 cup cream of rice, 1/2 cup skim milk, 2 tsp. brown sugar, 1 Tbsp. raisins

  • 1 corn tortilla, 1/2 cup rice (without butter or oil), 3 Tbsp. salsa

  • Medium baked potato (no skin) 1/4 cup salsa

  • 1/2 cup steamed rice, 1/2 cup steamed vegetables, 1 Tbsp. soy sauce

  • 3 cups fat-free popcorn and 1 can soda or juice

  • 2 sl. white, rye, whole wheat, raisin bread or a fat-free (3oz muffin) with 1 tsp. jam or preserves

The goal is to keep total calories under 300, 6 grams protein and 3 or less grams of fat. Carbohydrates should not exceed 65 grams. Always take vitamin and mineral supplements with food. Fatty foods have been shown to improve absorption of certain drugs and in others to decrease side effects.

All prescription drugs can have undesirable side effects. This may or may not happen to you, but it is a good idea to be prepared to deal with nausea, vomiting, diarrhea, taste changes, etc., before you start taking the drugs. The good thing is that side effects are usually temporary until your body adapts to the drug. Managing side effects might involve using more medications, but should also include diet modifications so that you don't miss a beat in your goal to stay well-nourished. You should always be able to eat something.


Taste Changes

Sometimes medications can leave a horrible taste in your mouth. The bad taste can make even food that you love taste like it is spoiled. Toothpaste and mouthwashes clean your mouth but leave a taste of their own that doesn't mix well with food. Baking soda is a great mouth cleaner that has no aftertaste and can leave you refreshed, ready to dig into your favorite foods. Chew foods thoroughly to release flavors. Here are the ingredients for a good baking soda rinse: 1 tsp. baking soda with one cup water (filtered from your tap, distilled or spring). If food still doesn't taste right try spiking up the flavor of foods with herbs and spices, lemons and limes, or condiments with strong flavors like salsas, flavored vinegar and spicy mustards.

If foods taste metallic try using plastic utensils, avoid canned food, and use glass cookware.


Fats Are Important

One thing that most people living with HIV/AIDS on antiretroviral therapy have in common is that they are gaining weight. The difference is that some are gaining muscle (e.g. lean body mass) and the gain is total body, and others are gaining fat and the gain is in the abdominal area, breast enlargement and sometimes the back of the neck "buffalo hump" with thinning in the extremities. In the fat gainers, we are also seeing high cholesterol and triglycerides "body fats" and sometimes diabetes.

Fats have always been a nutritional management issue concerning HIV and AIDS. When PLWAs were uniformly "wasting," nutritionists advocated high fat diets across the board. Fats have twice as many calories as carbohydrates We weren't particular about what kind. Just as medical management was in its infancy during the early days of AIDS, little was known about the effects of fats. Now we know there are good fats and bad fats, and they do make a difference in the management of chronic disease.

Foods like whole milk, butter and red meat are high in saturated fat. Because saturated fat raises cholesterol, eaten in excess it can increase the risk of heart disease. Also, saturated fat has recently been linked to colon and prostate cancer. Other bad fats are trans fats, polyunsaturated fats that are chemically changed from liquid to oil to a solid fat like stick margarine or Crisco.

The process is called hydrogenation and, essentially, it changes polyunsaturated fats to saturated fats. This kind of fat makes pie crust flakier and french fries crispier. It makes oils more stable so they can be used and re-used many more times (a plus for fast food restaurants). Due to the chemical change that occurs, trans fats raise cholesterol as much as saturated fats.

There is a problem with labeling at this time because the FDA does not demand that manufacturers list this type of fat. Dietitians think it should be a separate listing or at least included in the saturated fat profile, but it is not. Ingredient lists avoid it too (e.g., you never see Crisco or vegetable shortening in the ingredient list). The package may even claim that the food inside is low in cholesterol. It is low in dietary cholesterol, but because of the trans fat it can raise the serum cholesterol of people who eat it.

Fast food restaurants are notorious for using shortening to make anything fried (e.g., french fries, fried fish and chicken, onion rings, doughnuts, etc.). Baked foods like cakes, cookies, pies and some crackers can also be high in trans fat. Movie theater popcorn is another biggie for trans fat.

Recommendations: If you use margarine, buy tubs rather than sticks. To cut fat and calories get light, low-fat or fat-free brands or use light whipped butter. Use canola, olive and peanut oil or peanut butter instead of butter and margarine whenever possible. Make your own fried foods in healthy fats.

The good news is that fat tastes good and that nobody, no matter how fat you think you are, should ever eliminate fat entirely from your diet unless you doctor has ordered you to do so. Fats have a role in your diet, and cholesterol that is made from fat is a structural component of brain and nerve cells. It is also a key component in steroids including testosterone and estrogen.

Monounsaturated fat is the good fat that everyone is talking about. It is found in olive, canola and peanut oils, avocados, all nuts, including peanuts and peanut butter. White meat poultry, pork, veal and red salmon and ocean perch are higher in monounsaturates than other animal foods. These fats do not raise total cholesterol, and in normal weight people they have been shown to raise good cholesterol (HDL). This cholesterol unlike the bad one (LDL) is protective against heart disease. And in women this fat has been shown to protect against breast cancer. The other good fat is omega 3 polyunsaturated fat. This fat is most commonly found in fish oils (e.g., salmon is the best, but it's also in flaxseed oil and soybeans). Omega 3s are protective of heart and immune function. If you are underweight you may want to increase these fats in your diet. If you are normal or overweight go easy, but do not go without.

One of the most important functions of omega 3 fatty acids is lowering triglycerides (TG) on those body fats that are elevated in PLWAs taking protease inhibitors. People with diabetes will have higher triglycerides if their blood sugars are out of control because sugar above and beyond what can be utilized in the body goes into the liver, and comes out of the liver as fat (triglycerides). People living with HIV who have very high TG and eat high sugar diets should try to avoid simple sugar, even if they are not diabetics because of this potential.

Regardless of your weight, it is important that you try to include a wide variety of foods from each food category in adequate amounts. Protein, carbohydrates, fruits and vegetables, fat and water are all part of a healthy eating plan


Protein Power

Protein is an essential building block of the body. It performs a structural roll, not only in all body tissues including muscle, but also in the formation of enzymes, hormones, various fluids, and body secretions. Your immune system is also made up of protein. PLWAs need more protein than the general population, especially if recovering from an illness that is AIDS-related and if a lot of lean body mass has been lost. Opportunistic infections, AIDS-related cancers, and stepped up viral activity cause wasting, specifically muscle cells. AIDS weight loss is typically due to lost protein from muscle wasting. The reason for eating protein is to make new body tissues including muscles, blood cells, hormones, enzymes, collegen, skin, etc., all of which gets used up quickly because there is rapid turnover.

Following an illness, protein needs are increased because illnesses deplete them. Protein needs are also increased for PLWAs who consistently have high viral loads from, for example, failing Highly Active Antiretroviral Drug Therapy (HAART) or refusing treatment. Heavy exercise, especially endurance and strength training, increases protein needs. Under these conditions, a PLWA can go up to having one gram of protein per pound of body weight (e.g., 120 x 1 = 120 grams/day).

If everything is in order (viral load is undetectable, health is stable and a moderate activity level is being enjoyed) -- PLWAs should be able to handle twice the recommended daily allowance for protein intake for the general population -- that means 100-120 grams for men and 80-100 grams for women. After all, a healthy immune system is very active making new cells and PLWAs just need more insurance. The exceptions are PLWAs living with kidney disease, and when an advanced liver disease protein has to be modified.

Examples of protein foods and their nutritional value are:

  • 8 oz. milk -- 8 grams,
  • 3 oz. hamburger -- 21 grams,
  • one chicken breast or chicken, white meat portion -- 26 grams,
  • 3 Tbsp. peanut butter -- 12 grams,
  • 2 cups rice and beans -- 20 grams,
  • 4 oz. firm tofu -- 13 grams.

If you are a normal weight or overweight choose lean protein (e.g., skim vs. whole milk). If you need to gain weight, select higher fat protein sources (e.g., peanut butter).


Milk the Right Way

Dairy foods are an important source of protein and calcium, and one of the first foods that grown-up people tend to omit from their diets. If you are someone who leaves out milk and dairy because of intolerance or dislike, you may want to try soy milk or think of a protein supplement. Rice milk or Rice Dream tastes good, but is not a substitute for milk because it is very low in protein and does not have calcium naturally.

In addition to bone health, we need calcium throughout life for numerous body functions including nerve transmission, blood clotting and regulating our heartbeat. If we don't take in calcium every day, systemic calcium requirements are drawn from the bone; this can lead to problems in old age. One result from not getting adequate amounts of calcium is bone demineralization, commonly called osteoporosis or thinning of the bone. This increases the likelihood of fracture and disability. Adults need about 1000-1500 mg/calcium/day. Needs are increased on a high-protein diet.

If you you feel gassy and bloated after drinking milk or eating dairy products, you are probably lactose intolerant. You are missing the enzyme lactase needed to digest milk. You can buy tablets, plus lactose-treated milk is available in the grocer's dairy case (e.g., Lactaid or Dairy Ease). Eat the pills, then drink the milk or eat the food.

Good sources of calcium are:

  • 8 oz. milk -- 300 mg.
  • 8 oz. low fat yogurt -- 415 mg.
  • 1 oz. Swiss cheese -- 270 mg.
  • 8 oz. calcium fortified orange juice -- 300 mg.
  • 1/2 cup tofu -- 258 mg.


Carbohydrates

Carbohydrates are a major source of energy and calories. Protein is important, but calories from carbohydrate and fat are important, too. If you don't take in enough calories, protein gets broken down for energy rather than sparing it to build and maintain body tissue. You should try to eat at least 6 to 11 servings/day. A serving is a slice of bread, 1/2 cup rice, pasta or cereal, or a medium potato.

Carbohydrates range from the simple (e.g., sugar, syrups, sodas, candy) to the complex (e.g., cereals, pasta, bread, rice, potatoes). Cereals and breads can be further broken down to whole grains vs. refined. Refined means that in the milling process the outer bran layer containing the B vitamins and vitamin E containing germ are removed, and we are left with the inner kernel. Vitamins and minerals are added back to white flour but the bran is not. Whole grains are the best source of dietary fiber. Essentially, fiber normalizes bowel function, protects against colon cancer, lowers cholesterol, triglycerides and blood sugar. There are two kinds of dietary fiber: soluble and insoluble.

Soluble fiber is oatbran, dried beans, fruit and potatoes. In fruit, pectin is the soluble fiber; specifically, the white of the apple, peaches, bananas, citrus fruits and strawberries (the part without the seeds or skin). Soluble fiber lowers cholesterol and triglycerides, decreases glucose absorption (good for diabetics) and feeds the friendly bacteria that live in the large intestine. Soluble fiber also slows down the bowel if there is diarrhea.

Insoluble fiber are whole grains, vegetables and fruits with edible seeds and skins (e.g., the skin of the apple, pear, peach, and the seeds of strawberries, raspberries, kiwi, etc.). Insoluble fiber helps to keep things moving through the bowel. It relieves constipation and decreases the exposure time of potential cancer causes in the intestine. The role of soluble fiber is to lower cholesterol, decrease absorption of sugers (good for diabetics), feed the friendly bacteria in the large intestine, and to slow down the bowel if there is diarrhea. Insoluble fiber helps to keep things moving through the bowel. It helps to relieve constipation, and decreases exposure time of potential cancer causes in the intestine.

Fruits and vegetables are another source of carbohydrates, but their most valuable contribution is vitamins, minerals, antioxidants, phytochemicals and dietary fiber. A healthy daily goal is 5-9 servings/day. A serving is a piece of fresh fruit, 1/2 cup cooked fruit, or a 3/4 cup of juice.

There has been a lot of research and discussion about vitamin and mineral supplementation, especially before the advent of triple-drug therapy. Research has shown that PLWAs who take a multivitamin with a mineral supplement on a daily basis do better that those that don't. There is no good research showing that taking multiple and megadoses of separate supplements makes a difference.

By eating a well-balanced diet, including all the foods listed above in the amounts suggested, it is likely that you will get an additional dose of vitamins and minerals that can be five-to-six times the RDA (recommended daily allowance). Presently, PLWAs are having to take many pills throughout the day, and are taking more pills in the form of supplements that may or may not make a difference. This seems difficult, unnecessary, and expensive. If you are leaving out whole groups of food, you are missing more than vitamins and minerals. If at all possible, you should speak to a dietitian about solutions that work for you.


Eat Healthy and Safely

Not only is it important that you eat the right kinds of foods in adequate amounts, but that you remember the rules of food and water safety. In spite of high T-cells PLWAs are still getting food borne illness like e. coli.

Crypto and microsporidiosis are rarer, but giardia affects PLWAs in spite of high T-cells. Water safety still prevails. Boiling water for 1 minute is still the best protection. Water filters that filter down to "absolutely 1 micron," distilled water, and bottled water are all safer that tap water.

Here are some more important precautions to follow:

  • Meat, fish, and eggs should be thoroughly cooked. The center of meat must be gray (not red) and the juices run clear (not red).

  • Keep juices of uncooked meats and fish away from other food: Put meats and fish in plastic bags in the supermarket. Don't let them drip on other things in the refrigerator. Wash cutting boards, dishes, utensils that have handled raw meats and fish before using them for anything else, including the same meat or fish after it's cooked.

  • Serve food hot. Chill leftovers quickly and keep them cold.

  • Wash vegetables that will be served raw thoroughly in safe water.

  • Use safe water for making coffee (or anything else that's not going to be boiled), ice cubes, brushing teeth.

  • Use bottled, not tap water when you are out. Avoid ice cubes.

  • Use only pasteurized milk and milk products. Avoid soft imported cheese like Brie, camembert, mascarpone, mozzarella, ricotta, and feta. Health departments in Europe and other countires do not enforce pasteurization law. U.S. laws demand it! Never eat cheese with mold on it.

  • Buy produce with unbroken skins. Wash all fruits and vegetables well, even those with rinds and skins. When you cut the fruit with a knife, any surface bacteria can get drawn into the center of the fruit.

  • Read labels and look for expiration dates. Give yourself the most time to eat it, and after that date, throw it out!

  • Never defrost food at room temperature. Thaw in the refrigerator or the microwave. Refrigerate leftovers before they spend two hours at room temperature.

  • Sanitize all kitchen surfaces with water containing one Tbsp. bleach per gallon.

  • Avoid using cloth dish towels and rags. Use sponges and paper towels. A quick trick to sanitize sponges is to put them in the microwave oven 30-60 seconds

  • Buy only refrigerated uncracked Grade A eggs. Store in the carton in the back of the refrigerator. Avoid the door, it's never cold enough.

  • Never buy dented cans. Only buy pasteurized honey.

  • Wash hands thoroughly with warm soapy water before and after handling any food.


Symptom Management

Diarrhea Management

Stay well hydrated. Drinks lots of fluids and replace electrolytes; e.g., with Gatorade, diluted fruit juices (1/2 water and 1/2 juice), salty soups and broths. Avoid coffee and caffeinated sodas (they dehydrate you even more). Herbal teas are soothing and safe to drink. Avoid lactose. When you have diarrhea you become lactose intolerant because all the food rushes through your body and there is decreased exposure to the lactase enzyme in your small intestine needed to digest milk. You can take the enzyme (e.g., Lactaid milk or Lactaid pills) whenever you drink or eat dairy. You might be able to tolerate yogurt or you can try soy milk (both are lactose free). Rice milk is not a milk substitute because it's low in protein, but it is well-tolerated if you are lactose intolerant. Avoid supplements like Ensure or Sustacal. Even though they are usually lactose free they are very rich in fat and sugar, two things that increase diarrhea.

Some foods actually help to stop diarrhea (e.g., white bread, crackers, white rice, noodles, oatmeal, couscous, millet, barley, bananas, applesauce and other cooked, peeled fruits). Try starchy vegetables like peeled potatoes (white and sweet), cooked carrots, and baked winter squash. They work because of their high soluble fiber content. Metamucil is high in this kind fiber.

Avoid excess fat. Eat white meat chicken or turkey without the skin, baked fish, plain lean meats. Tofu is another source of protein that is low in fat and may be well-tolerated. Water packed tuna salad made with fat-free mayonnaise should also be well-tolerated.

Avoid fried foods, excess table fats, and fried snack foods like chips and cheese snacks. Nuts are good for you, but not when you have diarrhea. They are crunchy. Peanut butter, on the other hand, is smooth, a good source of protein and you need some fat.

Avoid foods that are high in insoluble (crunchy) fiber like wheat bran, fresh vegetables and fruits with the skins, corn, peas etc. Gassy foods like dried beans, broccoli, cucumbers, onions and melon are not well-tolerated during bouts of diarrhea.

In general peeled and cooked foods are easier to tolerate. Eat well-cooked foods like noodle and rice soups, baked chicken and fish, potatoes and rice, cooked carrots, bananas, canned fruits and drink plenty of fluids.

Lactobacillus acidophilus is one of the friendly bacteria replacement supplements that may help to restore bacteria levels in the intestines after antibiotic therapy kills off the bad and good bacteria. This can help slow down or even stop drug induced diarrhea. These natural bacteria thrive on the soluble fiber in foods like oatmeal, potatoes and bananas that also help to stop diarrhea. There are other probiotic supplements, but acidophilus is the most widely available in the food supply and has the most research to back it up. Read labels for dosing suggestions.

Pancreatic enzyme therapy can help you digest food even when diarrhea causes food to move very rapidly through the intestine. For each food that you eat, your body has a specific enzyme that is needed to digest it (to break it down so you can absorb it and use it for fuel). Proper digestion takes time! Enzymes are taken with meals. This ensures adequate exposure and digestion just in case your natural enzymes don't have enough time to kick in and do their job. Taking enzymes with each meal seems do the trick.

Medicaid pays and ADAP is working on it. Over the counter enzymes may not be enterically coated. This can be bad, because these are enzymes that digest protein among other foods. Your stomach is lined with flesh that is made of protein.


Nausea and Vomiting

Eat cold foods, not hot! Sandwiches and cold plates are better tolerated because there is no smell. Most importantly, avoid foods that have strong smells (e.g., greasy, fatty and spicy). Don't eat your favorite food when you feel nausea. They may become associated with sickness and you could learn to dislike them as a result.

Eat foods that are dry and salty. Saltine crackers, baked pretzels, plain salted popcorn (without fat) seem to work the best. Eat dry plain cold cereal (not the kind that is sweetened) and dry toast. Avoid foods that are too sweet, because they can make you feel worse. This is not the time for milkshakes and sweetened supplements or your favorite desserts.

Drink cool liquids like diluted fruit juices. Ice cold treats like sorbet, popsicles and fruit ices work even though they are sweets. They seem to effect relief. Drink fluids 1/2 hour before or after eating solid foods -- never together. Eat small, frequent meals so that your stomach is never empty. Don't eat too much at one time. Eat slowly and chew your food well.

Try herbals teas. Ginger and mint tea seem to relieve nausea. Some people find relief with crystallized ginger candy. Sniffing cut lemons can also provide some relief.


Constipation

Eat foods that are high in insoluble (crunchy) fiber. Whole grains (bran cereal, whole grain breads and pastas, brown rice) nuts, fresh fruits with skins and seeds and fresh vegetables. Refined carbohydrates like pasta, rice and white bread can cause constipation. Prunes and prune juice work because they contain a chemical that works like a drug to increase the travel time through your intestines. Drink lots and lots of fluids. Warm liquids, especially in the morning seem to be effective. Exercise helps, too.

The content provided in this article is meant for information purposes only. It may or may not apply in your particular situation. Elevated cholesterol and triglyceride levels have been reported in the wake of protease inhibitor therapy. The dietary modifications suggested in this article are backed by research and have been demonstrated over time to be efficacious in the general population. Always discuss any nutrition issues you have with your provider.


Back to the September 1998 Issue of Body Positive Magazine.

A note from TheBody.com: Since this article was written, the HIV pandemic has changed, as has our understanding of HIV/AIDS and its treatment. As a result, parts of this article may be outdated. Please keep this in mind, and be sure to visit other parts of our site for more recent information!



  
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This article was provided by Body Positive. It is a part of the publication Body Positive.
 
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