Positive Diet: Good nutrition fuels effective treatment

Good nutrition is increasingly recognised as an important component in the effective treatment of HIV infections. As Edward Low plucks generic names of HIV drugs out effortlessly with nary a glimpse at the fact sheet on his laptop, traces of the average guy who spent most of his life – including the initial years when HIV became part of it – putting his health on the back burner are barely detectable. “I’d never been overly concerned (before),” he says. “I started learning only when I started treatment and gained experience on the ways to take care of myself.” Low was just about to start taking medications for his HIV infection four years ago (seven years after his diagnosis), when an opportunistic infection hospitalised him. His CD4+ count plunged and he weighed 25kg less after he survived the infection. (The CD4+ count is a marker used to estimate the levels of white blood cells in a person’s blood following HIV infection; this tells you how well his immune system is functioning.)

“I started treatment with a very low CD4+ count, and for the first few weeks, I experienced lots of side effects. I felt drowsy, sleepy, and upset. I was generally in a bad mood.
“But since then, it has been okay so far,” he recalls.
His family’s encouragement helped him deal with the initial challenges to stay on treatment. But he realised drugs alone weren’t enough – a healthy lifestyle and balanced diet matter too.
Now, supplements and nutritious foods are part of his daily diet, and he avoids coffee or tea after noon because they will keep him awake at night.
“Many people do not know or are not concerned about their diet. But it is an advantage, especially for people living with HIV (PLWH),” he says.

Life-saving drugs, life-sustaining nutrition
It should be common sense: people who are nursing infections benefit from good nutrition. Not only does it help them replace the energy spent fending off microbial invaders, adequate nutrition will increase the body’s ability to keep up the fight.
But ever since the use of anti-retroviral drugs (ARV) in highly-active anti-retroviral therapies (HAART) came into the HIV management picture, treatment of the infection has revolved around medications to weaken the virus and control its spread. This trend, however, is starting to change.
“Nutrition is one area we may have neglected in the early 1990s. At the time, patients would have died without the (anti-retroviral) drugs. But as our ability to control the virus gets better with drugs that have less toxicity and side effects, we need to pay attention to the finer details,” says consultant infectious disease physician Dr Christopher Lee.

Dr Lee, who is also Malaysian Society of HIV Medicine president, explains: “When patients have only up to one year to live, nutrition takes a back seat. But as our patients grow older with us, we need to address other problems like high cholesterol levels, cardiovascular disease, osteoporosis, and diabetes too.
“Nowadays, if patients are having problems with their weight, cholesterol, or lipodystrophy (abnormal body fat changes) due to some of the drugs, we refer them to the dietetic department for counselling,” he adds.
While there are many ways good nutrition can help PLWH live longer, one of the most important ones clinical dietitian Diana Johansen emphasises is it helps them stay on their medications, which they have to take for life once they start.
After working with PLWH for about 15 years in the Oak Tree Clinic in Vancouver, Canada, clinical dietitian Diana Johansen has seen how good nutrition and appropriate nutritional counselling can make a difference in patients’ lives.
“They can tolerate (drug) side effects better and take the right foods with their medication. Also, we can help them with their metabolic problems,” she explained after her lecture at the American Overseas Dietetic Association Conference in Kuala Lumpur earlier this year.
This is being demonstrated in a four-year nutrition study by the Tamil Nadu State AIDS Control Society (TNSACS), which is evaluating a programme that provides free clinical care, nutritional supplements, and home-based care to 650 HIV-infected children in Tamil Nadu, India.
After six months on The Tamil Nadu Family Continuum Care and Treatment (TNFCC), the children are already showing significant improvements in their quality of life. They have fewer opportunistic infections, adhere more to their medications, and have gained weight.
And it’s not just the children who are benefiting. Their families are, too. Speaking to the Times of India, TNSACS project director Vijaya Kumar notes: “While adults earned more money, children were back in school, recording good attendance.”
“People who learn how to take care of themselves have more self-control and empowerment to take care of their health. And in the long run, with HIV, they do much better,” says Johansen.

Eat well, stay well
It is more evident now that drugs for HIV do save lives, but you need good nutrition and a healthy lifestyle to sustain it.
As more PLWH live longer and lead productive lives, an HIV infection is increasingly viewed as a chronic, manageable disease. Treatment no longer stops at prolonging survival – it now includes helping PLWH deal with the complications HIV infection and its treatment brings.
Malnutrition is one of them.

Patients should not stop their medications just because of side effects
It’s a vicious circle – untreated HIV infections can lead to malnutrition, and malnutrition in turn weakens the body’s immune system, making it more vulnerable to the complications of the infection.
As the World Health Organisation (WHO) and Food and Agriculture Organisation of the United Nations (FAO) joint manual on nutritional care and support for people living with HIV/AIDS notes, many of the conditions associated with HIV/AIDS affect food intake, digestion, and absorption.
Common symptoms like diarrhoea, weight loss, sore mouth and throat, nausea, or vomiting can be managed with appropriate nutrition; and good nutrition will complement and reinforce the effect of any medication taken.
“Nutrition and food are very important adjunct therapies because it has been shown that even when you start on anti-retroviral therapy, your survival is linked to your nutritional status when you start,” says Johansen. So, a person who starts therapy with a normal, healthier BMI (above 18.5) would have a better chance of surviving longer than those who are grossly underweight.
While there are many ways good nutrition can help PLWH live longer, Johansen emphasises that one of the most important ones is by helping them stay on their medications, which they have to take for life once they start. (Not all PLWH require medications – In Malaysia, treatment is usually recommended only when a person’s CD4+ count drops below 350 cells/µL.)
“Adherence to HIV drugs is a life-long commitment,” she says. “You have to take every single dose every day at the right time of the day. If you don’t get this right, you can get resistant to a drug very quickly and run out of drugs to take.”

Don’t stop because of side effects
Many PLWH have trouble sticking to the strict requirement of their medications.
“The reality is, the drugs are not easy to take,” says Johansen. “Sometimes people don’t remember, and when they don’t have food to take with their medicines, they feel sick,” says Johansen.
Apart from the common side effects PLWH experience when they start treatment (nausea, diarrhoea, fatigue, and taste problems), PLWH on HAART also face long-term complications like metabolic changes, accelerated ageing, and body fat changes.
While patients are in danger of losing too much weight before they start treatment, they tend to gain weight faster after it.
“It is due to the side effects of medication for HIV, plus the fact that when they are on medication, they are less worried,” says Assoc Prof Dr Mary Huang, lecturer at Universiti Putra Malaysia’s department of nutrition and dietetics at the medical faculty.
“But most importantly, I think it is due to the fact that the multiplication of the virus is curtailed. Therefore their immume systems are better able to fight off some infections. Basically they do not fall ill so often,” she says.
The good news is the initial symptoms usually do not last that long, and long-term complications can be controlled or delayed, if not prevented, by balanced diets and healthy lifestyles.
“The drugs may have side effects, but we cannot deny that they save lives,” says Dr Lee.
In any case, patients should not stop their medications just because of the side effects, he explains. Instead, they should discuss side effects they experience with their doctors, especially when they are severe.

Recommended diet
The dietary recommendations for PLWH are generally the same as the general population, says Johansen, but those recommendations are very important to them as they’ve got to keep their immune systems strong.
She explains, “For somebody who is very healthy, the consequences of not paying attention to health all the time are not as severe as someone who has HIV. So, if you have it, you would want to protect the immune system by giving it the best nutrition that you can consistently.”
Well aware of this, Monica (not her real name), a volunteer at a shelter home who has lived with HIV for four years, is taking the necessary precautions.
“I now avoid raw food, because I know that my immune system may not be able to fight off food-borne infections as it is already compromised,” she says.
“Wherever I go, my medications follow. I also monitor my food intake as, lately, it has been easy for me to gain weight. Also, as my medications can affect my heart, I cut down meat and exercise whenever I can.”

Would supplements and traditional preparations help?
According to the WHO and FAO, multivitamin and mineral supplements – often in the form of pills – can help to meet increased requirements when food intake is low. However, if they are expensive and taken at the expense of a person’s financial ability to obtain nutritious food, then a good mixed diet is better than nutrients that come in pills.
As there is still a dearth of research on the effects these remedies have on PLWH and their interaction with HIV drugs, it is always wise to consult your doctor or nutritionist before taking them.

The need for dietitians
To help PLWH with their diets and lifestyles, Johansen stresses the importance of having dietitians in HIV centres and clinics.
“Doctors have a lot to think about when they are prescribing medicines to save a patient’s life. That’s why it’s important dietitians share the workload,” she explains.
“Doctors need to know that there are issues with nutrition with HIV and HAART, and they need help from a dietitian to help patients deal with them.”
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The Star Online > Health
http://thestar.com.my/health/story.asp?file=/2009/12/20/health/5303453&s...
Sunday December 20, 2009
A positive diet
Stories by LIM WEY WEN