Medical Nutrition Therapy is Vital

Medical nutrition therapy should eventually become more available and more a part of your total HIV medical care.

In September, the Los Angeles County Commission on HIV Health Services (LACHHS) approved a document titled "Guidelines for Implementing HIV/AIDS Medical Nutrition Therapy Protocols." First approved in October 1997, and drafted by the commission's Standards of Care Committee, this 62-page revised document is part of an evolving collection of standards of care for those infected and at risk for HIV disease.

Medical nutrition therapy includes the following components: nutrition screening, nutrition referral, nutrition assessment, nutrition intervention, communication with the health care team, and nutrition outcomes evaluation.

The document was designed for medical practitioners, administrators, third-party payers, and people living with HIV and their families to easily understand the role of HIV medical nutrition therapy in the comprehensive medical management of HIV disease. While not legally binding, it was the vision of the committee that these documents would apply to any "public or private" entity providing HIV care within Los Angeles County.

Cultural sensitivities and linguistic differences are recognized to be extremely important and that must be served throughout all care.

Know Your Rights

Rights of clients in regard to medical nutrition therapy are spelled out in the guidelines.

First, "all HIV-infected individuals" have the right to access "early and ongoing medical nutrition therapy." Individuals "have the right to be informed that medical nutrition therapy is available to them," that it be available "at a time and location that is convenient to when and where medical services are received," and that it is provided "without excessive cost."

Secondly, clients have the right to adequate medical nutrition therapy "provided by a qualified, HIV-knowledgeable and capable registered dietitian. This dietitian should be culturally and linguistically competent, and able to communicate and educate effectively in collaboration with the clients' medical team."

Further, all HIV-infected individuals also "have the right to self-determination and the right to refuse medical nutrition therapy."

Finally, "clients have the right to receive medical nutrition therapy in an environment that safeguards and maintains their confidentiality."

When to See a Dietitian

According to the guidelines, referral to a registered dietitian is automatic for an HIV-infected adult, when any one of the following conditions exist:

• Newly diagnosed HIV infection or never been seen by a registered dietitian

• Not seen by a registered dietitian in six months.

• Diagnosed HIV with symptoms, AIDS, or to receive palliative care.

• Greater than 5 percent unintentional weight loss from usual body weight in last six months or since last visit. (% weight loss formula: usual body weight minus current body weight divided by usual body weight x 100)

• Visible wasting, less than 90 percent ideal body weight, or less than 20 body mass index, or decrease in body cell mass (BCM)

• Poor oral intake of food or fluid

• Persistent diarrhea, constipation, or change in stools (color, consistency, frequency, or smell)

• Persistent nausea or vomiting

• Persistent gas, bloating, heartburn

• Difficulty chewing, swallowing, mouth sores, thrush, severe dental cavities (molecular decay or death of bone)

• Changes in perception of taste or smell

• Food allergies or food intolerances (fat, lactose, wheat, etc.)

• Financially unable to meet caloric and nutrient needs

• Concomitant hypo- or hyperglycemia, insulin resistance, hyperlipidemias, hypertension, hepatic or renal insufficiency, heart disease, cancer, pregnancy, anemia or other nutrition-related condition

• Albumin greater than 3.5 mg/dL, prealbumin 19-43 mg/dL (these are laboratory values reflecting protein status)

• Cholesterol less than 120 mg/dl or greater than 200 mg/dl

• Triglycerides greater than 200 mg/dl

• Scheduled chemotherapy or radiation therapy

• Medication involving food or meal modification

• Need for enteral or parenteral nutrition

• Client or M.D.-initiated weight management, or obesity: body mass index greater than 30 [BMI = (current weight in pounds x 703) divided by (height in inches x height in inches)]

• Client initiated vitamin/mineral supplementation, complementary or alternative diet-related therapies

• Vegetarianism

A screening criteria for specifically for children and adolescents is included in the document as well.

Implications

Medical nutrition therapy is a medically necessary service and needs to be treated as such.

An HIV-infected adult, adolescent or child should receive appropriate medical nutrition therapy at the same location on the same visit as when medical care is received, according to the guidelines. A registered dietitian should be available on site during clinic hours for comprehensive consultations and for frequent quick follow-up visits as required.

When this happens, clients gain information, self-management skills and nutrition support, and the medical health care team gains nutrition knowledge and perspective. For the most part medical practitioners have not been adequately assessing the nutritional considerations when deliberating treatment strategies.

The document lists the following benefits of establishing the guidelines and providing medical nutrition therapy in HIV care:

• Preventing malnutrition and opportunistic infections.

• Promoting normal growth and development in children.

• Improving and supporting quality of life.

• Increasing nutrition self-management skills for people living with HIV disease and/or their care-givers.

• Decreasing hospitalizations, emergency room visits, morbidity and mortality, and cost of care.

• Decreasing or delaying invasive or expensive treatments by providing early appropriate nutrition interventions.

• Improving tolerance and adherence to medications.

In order to implement these guidelines, numerous barriers will need to be overcome. Physicians, administrators, and third-party payers, seen as responsible for providing medical care, and to some extent clients, will need to be educated and convinced of the cost-benefit in order to change their old familiar HIV health care routines.

One problem, the lack of reimbursement for outpatient nutrition services, may be nearing resolution. If passed, the Medicare Medical Therapy Act of 1999 (HR 1187/S 660), co-sponsored by a majority of representatives in Congress would require reimbursement for medical nutrition therapy under Medicare Part B. The hope is that if Medicare covers nutrition, other health care plans will follow. Calling or writing your legislators in support of this bill is needed and greatly encouraged.

Development of Standards

Over the last the last three and one-half years, the Standards of Care Committee has developed standards of care in the following areas: counseling and testing, mental health, treatment education and advocates, case managers, dentistry, opportunistic infection prophylaxis, medical social work and anti-retroviral treatment guidelines. An internet web site is planned to house these documents.

For copies of the individual documents or for information on the Standards of Care Committee and the Los Angeles County Commission on HIV Health Services, call Diane Walker at (213) 351-8025. For more information about providing HIV medical nutrition therapy, call Marcy Fenton, M.S., R.D. at (323) 993-1612.

Marcy Fenton, M.S., R.D., is AIDS Project Los Angeles' HIV nutrition advocate. She can be reached at mfenton@apla.org or by calling (323) 993-1612. For upcoming free community forums on nutrition, see the calendar of this edition of Positive Living.