This month's column was written by Amanda Bell-Kirson, MS, RD, LD. Amanda is the Clinical Nutrition Therapist at APP Specialty Pharmacy located in Atlanta, Georgia.
This is something that we are seeing more of with all the protease inhibitors. The symptoms include: a belly larger in appearance, decreased muscle mass in arms and legs, increased triglycerides, cholesterol, liver enzymes and blood sugar. The larger belly appearance is due to fat deposits. Stress on the liver and toxicity of the protease inhibitors seem to be the cause of increased triglycerides, cholesterol, liver enzymes and blood sugar. These are all symptoms in decreases insulin sensitivity. Protease inhibitors lower testosterone, and low testosterone is known to correlate with increased insulin resistance in men. In women, insulin resistance increases with elevated testosterone. HIV+ women with low testosterone is associated with low body cell mass, and increased fat mass.
- Exercise helps improve insulin sensitivity.
- Have testosterone levels checked, both total and free. Free testosterone seems to be more correlative to lean muscle mass than total in both men and women.
- Take 1000 mcg. of chromium per day in the polynicotinate or picolinate form. In one study, this level was shown to increase insulin sensitivity by 40% without toxicity.
- Take 600 mg. per day of the anti-oxidant alpha lipoic acid, also known as thiotic acid. This lowers blood sugar and improves insulin dependent and non-insulin dependent glucose uptake.
- 3 - 4 grams per day of L-carnitine, or the prescription form is Carnitor, can be taken to lower triglycerides; also EPA, which is an omega-3 fatty acid, may lower triglycerides.
- Ask your doctor about the medication metformin, which improves insulin sensitivity.
- Both thiotic acid and milk thistle, also known as silymarin, can help lower liver enzymes. To cleanse the liver a combination of beet juice, carrot juice, black radish extract and dandelion extract are useful, but can be very powerful, go easy. chlorophyll and distilled water with lemon juice are also excellent purifiers that may be more mild.
- For muscle loss, 12 to 36 grams (1 tablespoon is 12 grams) of L-Glutamine have been used.
If nausea and/or vomiting is a result from either a medication, a treatment or therapy, and infection or other, it is important to find out what the cause is and call your physician if it goes on longer than a day. In determining the cause, do not stop any medications without speaking to your doctor first.
- Before getting out of bed, have a few dry crackers (leave them by the side of your bed) and stay in bed, propped up on a few pillows. This provides a better angle to reduce nausea.
- Try smaller frequent meals or snacks throughout the day (i.e., 4 to 8 dry crackers, a bowl of cream of wheat or grits, diluted juice or liquid nutritional supplement, 1/2 cup potato or rice, 1/2 cup well-cooked carrots or green beans).
- Drink fluids away from solid food, drink either half an hour before or after solid food.
- Ginger can settle the stomach. Sprinkle some extra ginger in ginger ale or snack on a small piece of ginger or ginger candy. Ginger tea can be bought or made, although fresh ginger tea from just boiling ginger root for about 10 minutes with added lemon or honey is the most potent and effective.
- Try chamomile or peppermint tea, they are calming on the stomach.
- Avoid hot, spicy, strong-smelling and greasy foods.
- Cold, carbonated beverages such as ginger ale or lemon-lime soda, sometimes work well to avoid nausea, especially if sipped slowly.
- If you are under chemo or radiation therapy, eat a small meal two hours prior to treatment, and save your favorite foods for later to avoid developing an aversion to those foods.
- If vomiting occurs, replace fluids and salt with broths, carbonated beverages, juices, gelatins or popsicles.
- The following herbs can help to reduce nausea: nutmeg, cinnamon, catmint, ground ivy and ginger.
- Medications that are used for nausea and vomiting: Compazine, Tigan, Marinol, Phenergan, Torecan, Scoplamine, Ativan, and Zofran.
Diarrhea may be caused by many medications and is one of the most common side effects of most anti-viral medications. It also can be caused by infectious organisms, changes in the intestinal lining, food intolerances, allergies, stress, or it can be related to fat distribution (gall bladder) lactose, pancreas/digestive enzymes, roughage and others. Diarrhea can cause dehydration and electrolyte imbalances and for a longer duration malabsorption and malnutrition can occur. Remember to let your doctor know if diarrhea persists for more than a few days.
Food and fluid recommendations:
- If you think that it is medication related, due to the start of a new medication, soluble fiber tends to work well for this cause of diarrhea. Metamucil or psyllium can be supplemented, although remember to take these supplements away from any medications or vitamins; they can interfere with absorption. You can also get soluble fiber from food sources, such as: oatmeal, cooked barley, apricots, grapes, peeled pears, apples, oranges, papayas and mangos.
- If diarrhea seems to be caused by milk or milk products, lactase (an enzyme to break down milk sugar) can be taken or dairy may need to be eliminated from diet. Yogurt seems to be easier to handle and aged cheeses in small amounts.
- Try and reduce insoluble fiber in diet until diarrhea has subsided, such as wheat fiber, raw vegetables, nuts and seeds, beans, peas, skins of fruits, bran and corn.
- Limit dietary fat if you think it is contributing to diarrhea. Decrease cream, butter, margarine, mayonnaise, rich sauces, oils, nuts, avocados, high-fat salad dressings, high-fat meats and bacon.
- Avoid caffeinated beverages such as coffee, tea, many brands of carbonated beverages (especially colas) and chocolate beverages.
- Rice, cream of wheat, pastas or noodles, bagels, soft dinner rolls, cream of rice, white toast and saltine crackers.
- The B.R.A.T. diet for a short amount of time helps to reduce diarrhea, which includes bananas, rice, applesauce and toast.
- Make sure you replace fluids, water is important although electrolytes are important also. Try sport drinks such as Gatorade, Recharge, Exceed and Ultrafuel (dilute this one a lot). Try non-acidic nectars such as mango, apricot and juices that contain banana (dilute these). Water with a pinch of salt and a little lemon juice also works, although does not have many calories.
- Ask your doctor about bile acid sequestrants (Questran).
- Or ask about pancreatic enzymes.
- Doctor may prescribe appropriate anti-bacterial or anti-parasitic, etc., to treat if this is the cause.
- Lomotil or Immodium can be taken; if severe diarrhea persists, tincture of opium may be prescribed.
Nutritional supplements and herbs:
- Take L-Glutamine, 30 grams (3 grams per teaspoon, so 10 teaspoons) per day; after 7 days you can cut back to 10 to 15 grams per day (1 to 2 rounded teaspoons).
- Probiotics (good bacteria in gut): acidophilus, lactobacillus, bifidum, s. Boulardii -- any of these in powder form can be taken, 1/4 to 1/2 teaspoon twice a day dissolved in room temperature water. You can do a swish and swallow, this will help to control thrush, also.
- Use digestive enzymes with each meal.
- Herbs that may be helpful: ginger root, meadowsweet, bayberry root bark and black walnut tincture (two droppers full in water or juice, three times daily).
Dry mouth can occur with a number of medications, or it can be from HIV itself. Allergies can cause it, and dry mouth occurs with some infections, too. Decreased saliva can make chewing and swallowing difficult; it is also a problem because in the mouth digestion starts and saliva contains digestive enzymes. Without saliva, you can get food build-up which promotes decay and also thrush. Decreased saliva also effects the taste of food. Each time you eat you produce food acids, with normal salivary flow it returns to normal pH within two hours; this environment in your mouth can cause various oral health problems.
- Rinse your mouth often with salted warm water or mouthwash.
- Try chewing sugarless gum, which stimulates saliva and helps return acid level to normal.
- Suck on sugarless candies -- making sure they are smooth and flat -- lozenges or sour drops or crushed ice. Try to avoid sticky sweet foods and sugar containing gums and candies; they can make you even drier.
- Drink plenty of liquids at and between meals, such as water, fruit juice diluted, and also try fruit ices, popsicles, applesauce, pudding or gelatin.
- If you can get or afford one, purchase a humidifier or place a pan of water near a heat source in winter to humidify room.
- Try Biotene chewing gum.
- Try synthetic saliva -- ask your doctor or pharmacist.
- Pilocarpine -- medication prescribed by doctor to treat dry mouth.
- Herbs to try: demulcents chickweed, slippery elm, marshmallow, licorice.
Taste changes can occur from many medications or again candida (thrush) or other infections or possible nutritional deficiencies.
- Increasing level of zinc supplement regimen up to 50 to 75 mg. a day.
- Try rinsing your mouth with 1/2 teaspoon of baking soda in one cup of warm water before meals. This may freshen your mouth but may also change the pH.
- Use of tangy and or sour or spicy seasonings help: barbecue sauce, lemon and garlic, Italian dressing, soy sauce, fruit juices, vinegar and lemon help stimulate taste buds.
- Generally foods served at room temperature the flavor is maximized.
Have sores checked out by medical provider to try and find out what is causing them. Whether from candida, bacteria, herpes or other types of infection, or certain medications such as AZT or ddI, apthous ulcers can become severe in the mouth and lower down in the esophagus.
Possible medical treatments or medications:
- Aspirin, Tylenol or Motrin for pain -- taken orally.
- Miracle mouthwash, which is Nystatin or tetracycline (according to if apthous ulcers are fungal or bacterial infection), Maalox, Lidocaine and Benadryl -- applied topically.
- Thalidomide is also successfully being used.
- Avoid foods that are going to sting such as orange, grapefruit and tomato juice, spicy foods, hot sauces, and very salty or very hot soups.
- Eat room temperature or cold foods and fluids.
- Drink through a straw to bypass mouth sores.
- Tilt your head back to help swallow.
- Eat sitting up, not lying down, to avoid choking.
- If choking on liquid occurs, try thicker foods or beverages such as Jello, cooked cereal, potato with gravy, pudding, custard, cottage cheese, squash pie, Indian pudding, thick milk shakes, thick soups, or soup with mashed potato.
- Artichoke extract.
- Activated charcoal.
- Digestive enzymes with each meal.
- L-Glutamine, 30 grams (3 grams per teaspoon, so 10 teaspoons) per day; after 7 days you can cut back to 10 to 15 grams per day (1 to 2 rounded teaspoons).
- Probiotics (good bacteria in gut): acidophilus, lactobacillus, bifidum, s. Boulardii -- any of these in powder form can be taken, 1/4 to 1/2 teaspoon twice a day dissolved in room temperature water. You can do a swish and swallow, this will help to control thrush also.
- Some people have had success with taking liver herbs, milk thistle and dandelion to help reduce gas.
Peripheral Neuropathy can be caused by many medications such as: ddI, ddC, D4T, Vincristine, INH, Dapsone and others. It can also occur with nutritional deficiencies and overdoses, with diabetes and miscellaneous conditions. Peripheral neuropathies can vary from slight tingling and numbness to extreme discomfort, and this is why the treatments also vary.
Nutritional supplements associated with peripheral neuropathies:
- Inositol, 2-6 grams per day, or rich in cantaloupe, peanuts, grapefruit and whole grains.
- Vitamin B6 up to, but no more than, 200 mg./day.
- Vitamin B12, either weekly intramuscular injections, or 1000-5000 mcg. orally taken in the sublingual or nasal form.
- Acetyl-L-carnitine helps to raise inositol levels.
- Biotin, 10-15 mg./day.
- Thiamine, 50-100 mg./day.
- Gamma Linolenic Acid, 500 mg./day.
- Alpha Lipoic Acid, up to 600 mg./day.
- Chromium, 200 to 400 mcg./day.
Medical management of peripheral neuropathies:
- Elavil, 50-75 mg. taken before bed each night.
- Neurontin (gabapentin) 200-400 mg. three times per day.
- Capsaicin cream (Zostrix) rubbed in to affected area, or cayenne pepper soaks. Remember, don't rub eyes afterwards!
- Manual massage to affected areas, if not too painful.
- Both thioctic acid and milk thistle, also known as silymarin, can help lower liver enzymes. To cleanse the liver a combination of beet juice, carrot juice, black radish extract and dandelion extract are useful, but can be very powerful, go easy. Chlorophyll and distilled water with lemon juice are also excellent purifiers that may be more mild.
- Other herbs and food supplements that may be used: dandelion, celandine, glycerrhizin, chickory and astragalus.
- Alpha Interferon.
- Beta Interferon.