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À la Carte -- 6. Managing Symptoms and Side Effects
Part of A Practical Guide to Nutrition for People Living With HIV

October 2007

Symptoms and side effects are common with HIV. They can be due to HIV infection itself, to co-infection or opportunistic infection, or to HAART. It is important to discuss with your doctor any symptoms you are experiencing, as they may indicate an underlying problem that requires medical treatment. Likewise, make sure you discuss with your healthcare team any side effects you experience -- particularly those from anti-HIV drugs -- because managing side effects is an important part of staying on your therapy. There are many ways to help you. This section of the guide provides dietary strategies for managing the most common symptoms or side effects.

CATIE also publishes a Practical Guide to HIV Drug Side Effects. Find it online at www.catie.ca or [if you're in Canada] call 1-800-263-1638 to speak with a treatment information educator.

Constipation

Constipation occurs when the remains of digestion move too slowly though the intestinal tract. Too much water gets reabsorbed in the colon, making the stools hard to pass. People on methadone and those in recovery from some street drugs frequently report constipation problems. The main dietary strategy to counter constipation is to speed movement through the tract by increasing fibre, fluids and exercise.

Figuring Out Fibre

There are two kinds of fibre, and each kind acts differently in the gut. Insoluble fibre is found in foods like wheat bran, the roughage in whole grains and the skins and seeds of fruits and vegetables. This kind of fibre does not dissolve in water and makes food and waste move more quickly through the intestines. Therefore, it is the best kind for treating constipation. Soluble fibre, on the other hand, will absorb water and swell. It is found in foods like oatmeal and some fruits. Soluble fibre is good for treating diarrhea and high cholesterol or blood sugar levels. It will not speed up movement through the gut, but it helps constipation by increasing the bulk of the stool.

Keeping Your Bowels Moving

Diarrhea

Diarrhea can occur from HIV infection of some immune cells within the intestine, an opportunistic infection or the side effect of medications. It can result in poor absorption of carbohydrates, fats, proteins and micronutrients, especially if it persists for a long time. Diarrhea occurs when substances pass through the intestines too quickly. There is not enough time to absorb all the nutrients, water and electrolytes. The end result is liquid stools and inadequate absorption. The main dietary strategies to counter diarrhea are to decrease the intake of substances that irritate the intestines and to slow down passage through the tract.

Calming the Gut

Gas and Bloating

Intestinal gas is a normal by-product of digestion and absorption. When it occurs in normal amounts, it may cause some discomfort but is usually quite manageable. The main dietary strategies to treat gas are 1) avoid foods and beverages that create more gas, and 2) eat in a way that regulates contractions of the bowel. While gas and bloating are common side effects of some anti-HIV drugs, they may also be the result of another gastrointestinal problem. If you are experiencing these symptoms, be sure to tell your doctor, as they may require investigation.

Decreasing Tummy Rumbles

Lack of Appetite

Not eating enough due to a lack of appetite is often the driving force behind weight loss and wasting in HIV disease. Lack of appetite may arise due to illness, fatigue, depression, drug side effects or addiction. It is a very common problem and can be difficult to overcome. Dealing with persistent lack of appetite can be depressing and a source of anxiety and stress. In some cases, in spite of best efforts, it is not possible to overcome the lack of appetite, and nutritional status continues to decline.

Eating When Not Hungry

Boosting the Appetite

Appetite stimulants may be effective at improving food intake and promoting weight gain. Sometimes a short course of appetite stimulants can help restore normal appetite. Discuss this option with your doctor if you think you need more help with an appetite problem.

Megestrol acetate (Megace) is an appetite stimulant that has been used for many years to improve appetite in people with HIV. Studies of Megace in HIV disease have found that people do gain weight, although most of the weight gained is fat, not lean tissue. In spite of this, food intake increases and people feel stronger and more able to be active, which will eventually restore lean body mass. Megace is a drug that mimics the female sex hormone progestin. It should not be used for a long period, as it may affect the levels of other hormones, testosterone in particular.

Marinol, a derivative of THC (the active compound in marijuana), decreases nausea and sometimes increases appetite but has not been found to be that effective at promoting weight gain in people with HIV. The side effects are sleepiness and impaired ability to think clearly, which some people find unacceptable. Taking it at night may decrease these side effects and make it more tolerable.

Marijuana is effective at treating nausea and increasing appetite. In Canada, it is possible to obtain a permit from the federal government to possess and grow marijuana for its therapeutic value. Smoking or eating marijuana prior to meals and snacks increases food intake, but the food choices may not always be the healthiest. Planning ahead can ensure that the appetite-stimulating effects are used to the best nutritional benefit. For more information on medicinal marijuana, read "Cultivating Compassion" in the Summer 2007 issue of CATIE's The Positive Side, available at www.positiveside.ca.

Nausea and Vomiting

Nausea can occur from stomach disorders, opportunistic infection and most commonly as a side effect of many medications. Vomiting, though not as common, is more serious because it can result in nutrient loss and dehydration. The main strategy to counter nausea is to eat foods that are easy to tolerate and to eat often enough to get adequate nutrition.

Nausea is one condition for which it can be best to follow your culture's habits and treatments. For example, people who eat a typical North American diet often prefer bland foods. People who eat a South Asian diet often turn to sweet, salty, sour or bitter foods to settle an upset stomach.

Keeping Food Down

Problems in the Mouth or Throat

People with HIV may experience problems in the mouth or throat due to side effects of medications, damaged or diseased teeth and gums, or opportunistic infections like thrush, chancres or herpes. Anti-HIV drugs sometimes cause abnormal tastes or dry mouth. The most common cause of swallowing problems is esophageal candidiasis (thrush in the throat). The overall strategy to address painful chewing and swallowing is to adjust textures and tastes for more soothing foods and beverages.

Dealing With Painful Chewing

Dealing With Dry Mouth and Altered Tastes

Dealing With Swallowing Problems

Weight Loss and Wasting

Severe weight loss is called wasting syndrome. While wasting has several definitions, the following criteria can be used to diagnose wasting:

Unwanted weight loss remains a serious risk for people with HIV because, as discussed in Chapter 3, even small losses of body cell mass can be dangerous. The primary strategy for treating weight loss and wasting is to increase food intake to the level needed to promote weight gain. This is achieved with a high-calorie, high-protein diet and a daily multivitamin-mineral supplement.

Increasing Calories and Protein

Nutrition Support

Sometimes, no matter how hard a person with HIV tries, it is impossible to gain weight. For people who cannot eat enough, who continue to lose weight or who remain seriously underweight, nutrition support is an option. Nutrition support can be delivered through a feeding tube into the stomach or via an intravenous line directly into the bloodstream. Feeding tubes are used when the digestive system is working but the person is malnourished and cannot eat enough.

For short-term use, a nasogastric tube is placed through the nose and into the stomach. This is most often used during a hospital admission. For the longer term, especially for home-tube feeding, a gastrostomy tube, or PEG (percutaneous endoscopic gastrostomy), is surgically placed through the abdominal wall. Special formula is dripped into the stomach and may provide total nutrition or be a supplement to regular food intake.

Most people are reluctant to have a feeding tube because it is seen as invasive and psychologically is a symbol of serious illness. However, studies have shown that people with HIV who do accept this type of feeding gain weight and body cell mass, have improved functional ability and better quality of life. This type of nutrition support can save your life if you really need it.


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