HIV and Nutrition

1、hiv and nutritionnigel rollinsdepartment of paediatrics and child healthnew 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 prima

2、ry 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 despite e

3、arly 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 sick

4、 member results in 30-35% on average reduction in annual income four proposed new factorshousehold-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 dependen

5、cy 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 adultsloss of assets and skills skills are lost not just in the labour market but also in the home. food security, preparation and coping strate

6、giesthe burden of care sick adults and of orphans major expenditure diversion of resources and labourmalnutrition and hiv “undernourished individuals are more susceptible to being infected with hiv and for transmission” ? “malnutrition thus threatens to accelerate progression from hiv to aids for mi

7、llions 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 virgin olive

8、oil arvs no comment in who draft guidelines on arvs in developing countrieswhat is known? growth and hiv energy expenditure / why wasting interventions micronutrients transmission disease progressionenergy expenditure resting energy expenditure (ree) basal metabolic rate (bmr) total energy expenditu

9、re (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 early nutritiona

10、l interventions might help prevent early progression or deathbobat 2001growth 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 cm differencear

11、vs improve growth newell 2003growth 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 yearswhat is the effect of early aggressive nutritional intervention?behrane 1997growth of infants born to hiv-infected women infants born to

12、 hiv-infected women are smaller ree and tee normal increased hiv rna associated with poor growthdaily intake seems inadequate for growth but not the sole factorwhat is the role of anabolic steroids? arpadiintake and expenditure ree normal intake normal body composition normal.not hypermetabolic when

13、 there is no intercurrent infectionalfaro 1995expenditure and growth decreased ree in hiv-infected children with decreased growthhenderson 1998body composition and disease progressionmiller 1993adult: decreased lbm predicts death loss of lean body mass precedes a decline in weightwhole body protein

14、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 heighthenderson 1999adults ree an

15、d teeincreased 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 controls with similar body comp. h

16、ommes 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. ree 11% higher in malnourished h

17、iv 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. schwenk nutrition 1996 12;595-601. inc

18、reased 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;1965-72. increase in ree with first dia

19、gnosis 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 1995;333:83-8.current consensus r

20、esting 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 to energy requirement reduced intake

21、, especially during concurrent infections is probably the main factor that results in wastingwho recommendations adults: energy needs are increased by 10 percent over accepted requirements for otherwise healthy people symptomatic hiv infected adults those who have transitioned to aids, an increase i

22、n 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 recommendations children: energy intake sh

23、ould 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 loss need to be increased by 50 to 10

24、0 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 claims of need to increase intake by

25、 25-100%. protein should provide 12-15% of total calorie intaketube 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 arm muscle areatube feeding was not suf

26、ficient to correct linear growthhenderson 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 but not height, skinfolds, amc, hospital

27、 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 failmiller 1995 n-3 fatty acid enriched feeds enterotropic pe

28、ptide-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 nsn-3 fatty acid and peptide enriched formula may increase cd4 countsde luis ro

29、man 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 xylose levels. similar trends with tpnnutri

30、tional support may improve cd4 counts and restore intestinal absorptionbetter to provide support before terminal stageguarino 2002 nutritional rehabilitation and mortality retrospective study (c di) of 193 malnourished children (80 hiv+) malnutrition programme (oral feeds excl. vitamins and micronut

31、rient supplements) improved outcomes in hiv- but not hiv+clinical studies to improve the nutritional management of hiv-infected children in developing countries are neededbeau 1998 fawzi w. global strategies for the prevention of hiv transmissionfrom mothers to infants. 1999; canada: p.45micronutrie

32、nts and vertical transmissionmultivitamins resulted in large and significant reductions in the risk of: foetal death low birth weight severe prematuritysignificant and sustained improvements in cd4 and cd8 cell countsrisk of vertical transmission of hiv-1 among 700 women in malawi vitamin a trialinf

33、ant hiv statuspositive at 6 weekspositive at 12 monthsvitamin an (%)62 (26.6)65 (27.3)placebon (%)66 (27.8)80 (32.0)p0.760.25kumwenda, clin infect dis 2002;35:618estimated probabilities of hiv infection by treatment gp. south african vitamin a study n=630hiv transmission(km analysis estimate)at 1 da

34、yat 1 monthat 3 monthsvitamin a%7.212.020.3placebo%6.116.122.3rr(95%ci)0.91(0.67-1.24)* estimated with the delta-method approximation from reported proportions and 95% cis in coutsoudis aids 1999;13:1517outcometotal hiv infectiondeath by 24 mo (+fetal deaths)death by 24 mo (among live births)total h

35、iv infection or death by 24 momultivitaminsn (n)128 (442)173 (520)126 (483)239 (520)nomultivitaminsn (n)140 (456)149 (521)121 (501)223 (521)rr (95%ci)1.04 (0.82-1.32)0.82 (0.66-1.02)0.91 (0.71-1.17)0.90 (0.75-1.08)p0.760.080.460.27effect of multivitamin supplementation on hiv infection and mortality

36、 outcomes of offspringfawzi, aids 2002;16:1935outcometotal hiv infectiondeath by 24 mo (+fetal deaths)death by 24 mo (among live births)total hiv infection or death by 24 movitamin an (n)155 (453)159 (514)117 (483)216 (514)no vitamin an (n)113 (445)163 (527)130 (501)246 (527)rr (95%ci)1.38 (0.09-1.7

37、6)1.00 (0.80-1.24)1.08 (0.84-1.39)1.13 (0.94-1.36)p0.0090.970.530.19fawzi, aids 2002;16:1935effect of vitamin a supplementation on hiv infection of offspringinfection by breastfeedingdeath by 24 monthsdeath or infectionvitamin arr (95% ci)1.33 (0.95-1.87)1.03 (0.66-1.62)1.28 (0.94-1.73)multivitamins

38、rr (95% ci)0.85 (0.61-1.19)0.78 (0.50-1.21)0.82 (0.61-1.12)effect of vitamin supplements on hiv infection through breastfeeding and/or death by 24 months (survival analysis)fawzi, aids 2002;16:1935why the difference of effect? ? iron supplementation lymph0.990.371.010.481.030.511.070.270.00.20.40.60

39、.81.01.21.41.61.8 lymphhb 85 g/lhb 85 g/lesr 81 mm/hesr 81 mm/hbw 2500 gbw 2500 grelative riskp=0.03p=0.06p=0.06p=0.04fawzi, aids 2002;16:1935multivitamins decreased the risk ofdeath by 24 months in population subgroupsfawzi, aids 2002;16:1935 lymph lymphvit e 9.6 mol/lrelative risk0.960.301.310.310

40、.00.51.01.52.02.53.0vit e 9.6 mol/lp=0.05p=0.008cochrane review of micronutrients and hiv disease progressionin progress32 trials included1/7 studies reporting on all-cause mortality found a reduction due to vitamin a supplements of 63% in hiv-infected children (rr=0.37 0.14, 0.95)multivitamin suppl

41、ementation (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 of all diarrhoea in hiv-infected children due to vita

42、min 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 subsetsthe effect of micronutrients on all-cause mortality and on morbidity in hiv-infected adults and children appea

43、rs 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 mortality, and with increased risks of hiv transmissio

44、n (?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, fetal 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