À la Carte -- 4. Vitamins, Minerals and Supplements
Part of A Practical Guide to Nutrition for People Living With HIV
Vitamins and minerals are called micronutrients because they are needed in very small amounts. They cannot adequately be made by the body and must be obtained from diet and/or supplements. Vitamins and minerals do not provide energy but perform vital functions that regulate the many activities and chemical reactions that take place inside the body. Without adequate intake of these micronutrients, symptoms of a deficiency can develop. If not treated, some deficiencies can cause sickness and death.
Recommended intake levels have been developed for each vitamin and mineral to give guidance as to how much should be taken every day to prevent deficiency. These are usually described as the RDA (recommended daily allowance). For many micronutrients, experts have also set an Upper Tolerable Limit (UL), which is the maximum daily amount a person should consume. Remember that these recommendations are set for the general population and do not take into consideration any disease state, like HIV. In this chapter, we try to provide guidance about your specific needs as a person living with HIV.
Micronutrients and HIV
A person with HIV might be deficient in a micronutrient for any number of reasons: side effects make it hard to eat, nutrients from food are not absorbed, or the body needs more nutrients to fight the virus. Several studies have shown that people with HIV are at increased risk of developing micronutrient deficiencies. In turn, these deficiencies can increase the rate of HIV disease progression to AIDS and can increase the risk of dying. For this reason it is believed that the micronutrient requirements for people with HIV are higher than the RDAs for the general population.
However, there are still unresolved issues. Some scientists and healthcare experts say that micronutrients have therapeutic value at very high doses, up to 10 times the RDA, but others disagree and prefer to take a more conservative approach. Studies are difficult to interpret, but recent clinical trials of multivitamins have demonstrated benefits, and many healthcare providers now believe that everyone living with HIV will benefit from taking a multivitamin-mineral each day. When making decisions about supplementation, be well informed and involve your healthcare team in your decisions.
Antioxidants and HIV
Antioxidants are molecules are made by the body or found in some foods and supplements, Antioxidants protect the body by neutralizing other, unstable molecules, called free radicals, that are produced during normal cell functioning.
Long-term infections such as HIV can upset this balance by causing the body to produce more free radicals than usual. In turn, this can lead to a condition known as oxidative stress, in which the body cannot deal with all the free radicals it produces. Oxidative stress can cause a lot of damage to cells. Two ways to lessen the effects of oxidative stress are to increase antioxidant intake and to decrease exposure to things that increase oxidative stress, such as pollution and cigarette smoke.
The Big Chart of Vitamins and Minerals
This table lists the RDA (recommended daily allowance), UL (upper tolerable limit) and experimental high dose, toxicity, function and food sources. The RDA usually includes all intake, from both food and supplements, while the UL is from supplements only. Caution should be exercised when taking doses above the UL.
Key Vitamins and Minerals for HIV
This section deals with some vitamins, minerals and other nutrients that have been studied in HIV. You will also find information in "The big chart of vitamins and minerals," just above. Before beginning to take any of these supplements, be sure to discuss it with your doctor and other members of your healthcare team.
Several studies have shown that vitamin and mineral supplements can have many benefits in people living with HIV. Taking a multivitamin every day is an important part of a nutritional health plan. Check out Appendix E for a list of studies looking at the affect of micronutrient supplements in people with HIV/AIDS.
B vitamins may help slow disease progression in people with HIV. They are also important for healthy mitochondria, the power-producing structures in cells, and may help decrease the impact of mitochondrial toxicity (see "Mitochondrial toxicity," Chapter 5). B vitamins are depleted quickly in times of stress, fever or infection, as well as with high consumption of alcohol. Keep in mind that the RDA is very low and taking a total of 50 mg of B1, B2 and B3 will more than cover B-vitamin needs. Check the multivitamin you take; if it has 30 to 50 mg of these vitamins, you don't have to take a B-complex supplement in addition to the multivitamin.
Levels of vitamin B12 in the blood may be low in people with HIV. It can also be low in people over the age of 50 years. B12 deficiency is associated with an increased risk of peripheral neuropathy, decreased ability to think clearly, and a form of anemia. People with low B12 levels usually feel extremely tired and have low energy. This deficiency is also linked with HIV disease progression and death. Ask your doctor to check your blood levels. If they're low, ask about B12 injections to get them back into the ideal range.
If you get B12 shots and your vision is getting worse, mention it to your doctor, especially if you are a smoker. Some forms of injectable B12 can damage your eyes if you have a rare genetic condition called Lerber's hereditary optic atrophy.
Vitamin C is one of the most important antioxidants. It is very effective at cleaning up molecules that damage cells and tissues (see "Antioxidants and HIV," this chapter). Vitamin C has been studied for cancer prevention and for effects on immunity, heart disease, cataracts and a range of other conditions. Although vitamin C cannot cure the common cold, supplements of 1,000 mg per day have been found to decrease the duration and severity of symptoms.
In people with HIV, there is some evidence that vitamin C can inhibit replication of the virus in test-tube experiments, but it is unclear what this means in the human body. The most important benefit for people with HIV is the widespread antioxidant action of vitamin C. The daily experimental high dose is between 500 mg and 2,000 mg, the upper tolerable limit.
Calcium -- see "Bone health," Chapter 5.
Vitamin D is emerging as a very important nutrient, with more diverse functions than just its traditional role in calcium metabolism. Mounting evidence suggests that 1,000 IU per day should be the recommended daily intake.
Vitamin D is found in some foods, but these sources generally do not provide enough vitamin D on a daily basis. Also, people who live in northern climates (like Canada) probably do not get enough sun exposure to make adequate vitamin D. And the use of sunscreen, which is highly recommended to prevent skin cancer, blocks the skin's ability to make vitamin D.
For people with HIV, vitamin D supplements are a sure way to get the recommended daily allowance. Vitamin D is found in multivitamins and calcium supplements as well as individual vitamin D pills. Look for vitamin D3; it is the active form of the vitamin. Be sure to add up all the vitamin D from different supplements to be sure you are not getting too much.
Vitamin E has been used as an antioxidant, typically at doses of 400 IU per day. However, studies have found that people who take more than 200 IU per day may be at higher risk of developing heart disease. Until this is fully studied, it may be a good idea to reduce vitamin E supplements to 200 IU unless your doctor suggests you take more.
Vitamin E deficiency is associated with faster HIV disease progression. People with poor fat absorption or malnutrition are more at risk of being deficient in vitamin E. Use supplements from natural sources and those with "mixed tocopherols" for better effect.
Iron supplements to treat iron-deficiency anemia (low levels of red blood cells) should only be taken if prescribed by your doctor. Iron-deficiency anemia is diagnosed by having a low hemoglobin level in the blood. This can be confusing in someone on HAART because some anti-HIV drugs, especially AZT, can cause low hemoglobin levels. There are other blood tests that can help determine whether there really is an iron deficiency. The important point is to not take high doses of iron unless they are prescribed. Iron is a pro-oxidant (the opposite of an antioxidant), which means it can damage different tissues in the body( see "Antioxidants and HIV," this chapter).
Zinc is a critical mineral for the immune system; a deficiency can cause severe immune suppression. People with chronic diarrhea, new immigrants from refugee camps and malnourished people with HIV, especially children, are at high risk of having a deficiency. Be aware that high doses of zinc supplements in people who are not deficient can decrease immune function.
Selenium helps regenerate glutathione, the major antioxidant in cells. Studies have shown that low selenium levels in the blood are associated with an increased risk of disease progression and death. Deficiency is associated with low CD4+ cells. One small study found that a daily supplement of 200 micrograms might have a positive effect in some people with HIV. Studies of the general population suggest that selenium supplementation may provide some protection from cancer.
Multiplying the Benefits of Multivitamins
Other Supplements for HIV
This section covers some of the other supplements used by people with HIV. In some cases, the benefits of these supplements have been described in small human studies, animal studies and case reports. The therapeutic doses are not really known for HIV disease and recommendations given here are based on doses used for other conditions or in studies.
These and other supplements can be quite expensive and should not be seen as a replacement for a healthy diet and lifestyle. Before starting any new supplement, get information from a knowledgeable healthcare professional. And be sure to discuss it with your doctor.
Also, it is best to start only one new supplement at time, so you can be more aware of any side effects.
Alpha lipoic acid is a powerful antioxidant made by the body that is used to regenerate glutathione (the major antioxidant in cells) as well as the activated form of vitamins C and E. It also plays an important role in energy production in the mitochondria. Lipoic acid is used to treat diabetic neuropathy (a nerve condition associated with diabetes) and liver disorders, and it may also have a role in slowing the hardening of the arteries (arteriosclerosis). The dose recommended for diabetic neuropathy is 100 mg 3 times per day; the dosage for HIV is unknown.
Carnitine (also known as L-carnitine) is a natural substance found in foods and made by the body. It works with the mitochondria to process fats and produce energy for the cells. It does this mainly by supplying the building blocks needed by the mitochondria to make an energy molecule called ATP, the basic fuel for cells. Most of the research suggests that carnitine has a protective effect on the central and peripheral nervous systems and the heart, probably because of its role in mitochondrial function. It may be helpful in the treatment of peripheral neuropathy (numbness, tingling or burning in the feet and sometimes hands), dementia and mitochondrial toxicity (see Chapter 5).
Over-the-counter supplements may contain a version of carnitine called acetyl-l-carnitine but beware that some have very little L-carnitine in them; be sure to buy from a reliable source. In Canada, L-carnitine is available by prescription and is called Carnitor. Prescription L-carnitine is very expensive and usually not covered by insurance plans for any of these indications. Check with your private insurer or provincial provider for more details.
The therapeutic dose for L-carnitine is somewhere between 500 and 3,000 mg daily. The dosage is not defined because it has not been studied enough or approved for these applications. Some people with HIV who have mitochondrial toxicity and/or peripheral neuropathy appear to benefit from 1,500 mg of acetyl-l-carnitine once or twice daily for many months. Carnitine supplements should be spread out over 3 daily doses to prevent side effects, most commonly diarrhea.
N-acetyl cysteine (NAC), a derivative of the amino acid L-cysteine, is a potent antioxidant that regenerates glutathione in the cell (see "Antioxidants and HIV," this chapter). In this role, NAC protects liver cells by decreasing oxidation. Cysteine appears to decline in people with HIV who have low CD4+ cell counts and in those with wasting (see "Weight loss and wasting," Chapter 6). NAC supplements may be able to replenish low glutathione and improve the antioxidant capacity of cells. Study doses have been as high as 2,000 mg per day, but this is expensive and may not be well tolerated. Side effects include nausea, vomiting, diarrhea and headache. The most beneficial dose is not certain, although a dose of 500 mg per day may offer some benefit with a reduced risk of toxicity.
L-glutamine is an amino acid that is used to provide fuel for intestinal cells, muscle cells and immune cells. It plays an important role in immunity because it helps to maintain the intestinal barrier and is a preferred fuel for various cells of the immune system. Glutamine levels decline during periods of physiological stress like opportunistic infection, surgery, burn and cancer. It may have a therapeutic role in treating intestinal disease and wasting, and some people with HIV have found it to be a good treatment for chronic diarrhea. The dose for treating diarrhea is 10 to 30 grams per day; the maintenance dose is 5 grams per day. It is best absorbed if dissolved in water and taken on an empty stomach.
Probiotics are live organisms, including the bacteria Lactobacillus and Bifidobacterium species and yeasts. They help build a healthy population of good bacteria (microflora) in the intestines. Microflora keep the gut healthy by preventing the growth of disease-causing bacteria and maintaining the intestinal barrier. Probiotic supplements are helpful after a course of antibiotics because they replace the microflora that were damaged by the antibiotic. Probiotics may also reduce chronic diarrhea and improve symptoms of irritable bowel syndrome. The most common type of probiotic is L. acidophilus but some products now contain mixed organisms. These are found in foods that contain live culture, such as yogurt and kefir. Purchase supplements that are refrigerated and have a long shelf life.
Coenzyme Q10 (CoQ10) is a substance that plays a role as an antioxidant as well as a cofactor in mitochondrial energy production. It has been used to treat congestive heart failure and gum disease (gingivitis) and may help protect the heart and nerves. Statins, a class of cholesterol-lowering drugs, reduce CoQ10 levels. The usual CoQ10 dosage range is 60 to 240 mg daily.
CATIE provides fact sheets on many vitamins and supplements used by people with HIV. Also, its Practical Guide to Herbal Therapies covers many common herbal therapies used by people with HIV. To find out more, visit www.catie.ca or [if you are in Canada] call 1-800-263-1638 to speak with a treatment information educator. Also check out the Web resources listed in Appendix D.
This article was provided by Canadian AIDS Treatment Information Exchange. Visit CATIE's Web site to find out more about their activities, publications and services.
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