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1、HIV and Nutrition,Nigel Rollins Department of Paediatrics and Child Health,New variant famine: AIDS and food crisis in southern Africa. Alex de Waal and Alan Whiteside. Lancet 2003; 362: 1234-37,Secondary effects of the AIDS epidemic on food security, famine and nutrition could be as great as the pr
2、imary effects Present southern Africa drought and food crisis compounds AIDS epidemic Historical coping strategies are in danger of collapsing. Present food crisis more intractable High degree of vulnerability in areas not affected by drought Household impoverishment has occurred more rapidly Despit
3、e early rains in early 2003, high levels of vulnerability persist,Hypothesis: HIV accounts for why many households are facing food shortage and explains grim trajectory of limited recovery Already known: Household affected by AIDS morbidity and mortality lose income, assets, and skills; chronically
4、sick member results in 30-35% on average reduction in annual income Four proposed new factors,Household-level labour shortages are attributable to adult morbidity and mortality as is the rise in number of dependants,Contest: Projections do not suggest demographic effect of HIV/AIDS on changes in dep
5、endency But these do not consider: Cluster effects at the level of the household Age and sex distribution of population affected by HIV Non-productivity of sick adults,Loss of assets and skills,Skills are lost not just in the labour market but also in the home. Food security, preparation and coping
6、strategies,The burden of care,Sick adults and of orphans Major expenditure Diversion of resources and labour,Malnutrition and HIV,“Undernourished individuals are more susceptible to being infected with HIV and for transmission” ? “Malnutrition thus threatens to accelerate progression from HIV to AID
7、S for millions of individuals” ? “This fact implies that plans for introduction of ARV Rx. on a large scale should be combined with nutritional support programmes.”,Other influences,Various guidelines emerging Some recommending up to 100% extra protein Opportunistic market Ipap; Moducare; Extra virg
8、in olive oil ARVs No comment in WHO draft guidelines on ARVs in developing countries,What is known?,Growth and HIV Energy expenditure / why wasting Interventions Micronutrients Transmission Disease progression,Energy expenditure,Resting energy expenditure (REE) Basal metabolic rate (BMR) Total energ
9、y expenditure (TEE) Exercise and additional metabolic demands (Activity-related energy expenditure - AEE),Growth of infants born to HIV-infected women,No difference in growth parameters at birth Progressive weight and linear growth failure Infants who died were severely malnourished and stunted,Earl
10、y nutritional interventions might help prevent early progression or death,Bobat 2001,Growth of infants born to HIV-infected women,No difference in growth patterns between HIV-uninfected children of infected mothers and un-exposed infants Progressive loss in growth velocity By 10 years, 7kg and 7.5 c
11、m difference,ARVs improve growth,Newell 2003,Growth of infants born to HIV-infected women,Reduced W/A and L/A of infected children who died W/A z-score -1.5 x5 death over two years,What is the effect of early aggressive nutritional intervention?,Behrane 1997,Growth of infants born to HIV-infected wo
12、men,Infants born to HIV-infected women are smaller REE and TEE normal Increased HIV RNA associated with poor growth,Daily intake seems inadequate for growth but not the sole factor What is the role of anabolic steroids?,Arpadi,Intake and expenditure,REE normal Intake normal Body composition normal,n
13、ot hypermetabolic when there is no intercurrent infection,Alfaro 1995,Expenditure and growth,Decreased REE in HIV-infected children with decreased growth,Henderson 1998,Body composition and disease progression,Miller 1993,Adult: decreased LBM predicts death,Loss of lean body mass precedes a decline
14、in weight,Whole body protein turnover,Associated with W/A and H/A and dietary protein intake Not related to REE or CD4 counts Protein balance varied with energy and protein intake,Can achieve positive protein balance if adequate intake Suggested adequate intake may result in adequate weight and heig
15、ht,Henderson 1999,Adults REE and TEE,Increased REE 5% higher than predicted, very ill patients CD4=30. Paton Clin Sci 1996;91:241-5. Increased REE 14% higher than predicted in malnourished HIV patients. Melchior AJCN 1991;53:437-41 Increased REE by 9% in patients with HIV AIDS and ARC compared to co
16、ntrols with similar body comp. Hommes Metabolism 1990;39:1186-90 Increased REE by 8% in early stage HIV patients with normal CD4 . Hommes AJCN 1991;54:311-5. Increased REE HIV (11%), AIDS (25%), AIDSSI (29%). Caloric intake reduced 36% in AIDS SI (secondary infection). Grunfeld AJCN 1992;55:455-60.
17、REE 11% higher in malnourished HIV without secondary infection and 34% higher in HIV with secondary infection. Melchior AJCN 2003;57:614-9. REE increased 8% during weight loss in HIV patients. Suttman Metabolism 1993 42:1173-9.,REE not increased and was lower in HIV patients with weight loss. Schwen
18、k Nutrition 1996 12;595-601. Increased REE in asymptomatic HIV-infected men. Sharpstone AIDS 1996;10:1377-84. TEE the same but REE 10% higher in weight stable HIV patients. Heijligenberg Metabolism 1997 46;1324-6. REE decreased in HIV patients with malabsorption. Jimenez-Exposito AIDS 1998 12;1965-7
19、2. Increase in REE with first diagnosis of AIDS. Sharpstone AIDS 1999 13;1221. Increased REE/kg lean body mass 10% in HIV. Battterham EJCN 2003 57:209-217. REE and TEE decrease with weight loss, but decrease in caloric intake greater. More negative energy balance in weight loss group. Macallan; NEJM
20、 1995;333:83-8.,Current consensus,Resting energy expenditure in adults is raised by 10% from the time of infection Not similarly demonstrated in children Total energy expenditure may be decreased because of inactivity (Activity-related energy expenditure - AEE) Growth failure is not solely related t
21、o energy requirement Reduced intake, especially during concurrent infections is probably the main factor that results in wasting,WHO recommendations,Adults: energy needs are increased by 10 percent over accepted requirements for otherwise healthy people symptomatic HIV infected adults those who have
22、 transitioned to AIDS, an increase in energy intake of about 20 to 30 percent to maintain body weight is recommended during periods of symptomatic disease or opportunistic infection Hard to achieve during acute illness - requirements should therefore be maximized during the recovery phase,WHO recomm
23、endations,Children: Energy intake should be increased by 10 percent even though data not available to support Symptomatic HIV infected children with chronic illnesses e.g. LIP or TB should increase energy intake by about 20 to 30 percent Energy intakes for HIV-infected children experiencing weight l
24、oss need to be increased by 50 to 100 percent over established requirements for otherwise healthy uninfected children,These recommendations should be achieved as much as possible through dietary approaches rather than specific nutritional products Inadequate data on protein turnover to substantiate
25、claims of need to increase intake by 25-100%. Protein should provide 12-15% of total calorie intake,Tube feeding and growth,Tube fed for dysfunctional swallowing, aspiration or GOR (n=18) Median duration 8.5 months Resulted in significantly increased W/A, W/H and arm fat area Did not alter H/A or ar
26、m muscle area,Tube feeding was not sufficient to correct linear growth,Henderson 1994,NG and Gastrostomy feeding,Anthropometric data, caloric intake and CD4 counts (n=23), before and 6 months after NG changed to gastrostomy feeding Caloric intake improved with both Gastrostomy improved W/A and W/H b
27、ut not height, skinfolds, AMC, hospital days or CD4 Higher adjusted CD4 counts and lower W/H predicted response 2.8 fold risk reduction of dying for every positive unit change in weight z score (p= 0.005),Gastrostomy supplementation can improve weight and fat when other methods fail,Miller 1995,N-3
28、fatty acid enriched feeds,Enterotropic peptide-based, n-3 fatty acid-enriched formula RCT - standard vs. n-3 formula (n=74 adults) Both supplements improved weight over 3 months mainly fat CD4 576 (+-403) vs. 642 (+-394) (p0.05) Fewer hospital days in n-3 group NS,N-3 fatty acid and peptide enriched
29、 formula may increase CD4 counts,De Luis Roman 2001,Enteral and/or parenteral nutritional rehabilitation,Data collected by questionnaires circulated to HIV reference centres 16 children received EN and 46 TPN Children receiving TPN had worse baseline characteristics EN improved body weight, CD4 and
30、xylose levels. Similar trends with TPN,Nutritional support may improve CD4 counts and restore intestinal absorption Better to provide support before terminal stage,Guarino 2002,Nutritional rehabilitation and mortality,Retrospective study (C dI) of 193 malnourished children (80 HIV+) Malnutrition pro
31、gramme (oral feeds excl. vitamins and micronutrient supplements) improved outcomes in HIV- but not HIV+,Clinical studies to improve the nutritional management of HIV-infected children in developing countries are needed,Beau 1998,Fawzi W. Global Strategies for the Prevention of HIV Transmission from
32、Mothers to Infants. 1999; Canada: p.45,Micronutrients and vertical transmission,Multivitamins resulted in large and significant reductions in the risk of: foetal death low birth weight severe prematurity Significant and sustained improvements in CD4 and CD8 cell counts,RISK OF VERTICAL TRANSMISSION
33、OF HIV-1 AMONG 700 WOMEN IN MALAWI VITAMIN A TRIAL,Kumwenda, Clin Infect Dis 2002;35:618,ESTIMATED PROBABILITIES OF HIV INFECTION BY TREATMENT GP. SOUTH AFRICAN VITAMIN A STUDY N=630,* Estimated with the delta-method approximation from reported proportions and 95% CIs in Coutsoudis AIDS 1999;13:1517
34、,EFFECT OF MULTIVITAMIN SUPPLEMENTATION ON HIV INFECTION AND MORTALITY OUTCOMES OF OFFSPRING,Fawzi, AIDS 2002;16:1935,Fawzi, AIDS 2002;16:1935,EFFECT OF VITAMIN A SUPPLEMENTATION ON HIV INFECTION OF OFFSPRING,EFFECT OF VITAMIN SUPPLEMENTS ON HIV INFECTION THROUGH BREASTFEEDING AND/OR DEATH BY 24 MON
35、THS (survival analysis),Fawzi, AIDS 2002;16:1935,Why the difference of effect?,? Iron supplementation,MULTIVITAMINS DECREASED THE RISK OF INFECTION THROUGH BREASTFEEDING IN POPULATION SUBGROUPS,Fawzi, AIDS 2002;16:1935,MULTIVITAMINS DECREASED THE RISK OF DEATH BY 24 MONTHS IN POPULATION SUBGROUPS,Fa
36、wzi, AIDS 2002;16:1935, LYMPH, LYMPH,VIT E 9.6 mol/L,RELATIVE RISK,VIT E 9.6 mol/L,P=0.05,P=0.008,Cochrane review of micronutrients and HIV disease progression,In progress 32 trials included 1/7 studies reporting on all-cause mortality found a reduction due to vitamin A supplements of 63% in HIV-inf
37、ected children (RR=0.37 0.14, 0.95) Multivitamin supplementation (B,C,E) of BF mothers reduced child mortality among immunologically and nutritionally compromised women in one trial One of four studies reporting on morbidity (including diarrhoea, RTIs and HIV-related symptoms), found a 49% reduction
38、 of all diarrhoea in HIV-infected children due to vitamin A Changes in HIV-1 viral load or CD4 counts and other lymphocyte subsets were reported in 8 and 10 studies respectively. No change in VL reported and variable responses in T-cell subsets,The effect of micronutrients on all-cause mortality and
39、 on morbidity in HIV-infected adults and children appears to be independent of their effect on HIV viral load or immune markers,Observational studies on micronutrients and HIV,Low blood levels and decreased dietary intakes of some micronutrients are associated with faster HIV disease progression and
40、 mortality, and with increased risks of HIV transmission (?causal: vitamin A and MTCT/ Zn and mortality) Micronutrient supplements, such as vitamins B-complex, C, and E, can improve immune status, prevent childhood diarrhea, and improve pregnancy outcomes, including maternal prenatal weight gain, fe
41、tal loss, prematurity, and low birth weight,WHO recommendations,HIV-infected adults and children are encouraged to consume diets, which ensure micronutrient intakes at RDA levels Several studies raise concerns that some micronutrient supplements, such as vitamin A, zinc, and iron, may produce advers
42、e outcomes in HIV-infected populations Safe upper limits for daily micronutrient intakes for PLWHA need to be established Adequate micronutrient intake is best achieved through an adequate diet,Research priorities,Impact of HIV Infection on Nutrition Effect of HIV infection on macronutrient needs, p
43、articularly protein and fat requirements? Do energy requirements for PLWHA vary in different stages of disease, and for those with opportunistic infections? Are there higher energy requirements for HIV infected children and pregnant and lactating women? What is the effect of HIV infection on micronu
44、trient requirements among children and adults? Does maternal HIV infection affect fetal endowment of nutrients and breast milk composition?,Role of Nutrition in HIV Infection Optimal levels of energy and protein intake during metabolic stress? Optimal nutrient guidelines for patients with chronic di
45、arrhea or GI infection? What is the effect of nutritional intervention on prevention of opportunistic infections and slowing of disease progression in HIV infection?,Operational Research Questions What should programs that provide food and nutrition support do differently because of HIV/AIDS? What are effective packages of nutritional interventions for food security and livelihood programs to mitigate the nutritional impacts of HIV caused by reduced agricultural productivity and/or earning capacity?,