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HIV Nutrition Essentials For Program and Administrative Grantees

HIV Nutrition Essentials For Program and Administrative Grantees. Marcy Fenton, M.S., R.D. Program Manager, Care Services Division County of Los Angeles Department of Public Health Office of AIDS Programs and Policy August 29, 2006. SPA 1: Antelope Valley. SPA 2: San Fernando. SPA 3:

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HIV Nutrition Essentials For Program and Administrative Grantees

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  1. HIV Nutrition Essentials For Program and Administrative Grantees Marcy Fenton, M.S., R.D. Program Manager, Care Services Division County of Los Angeles Department of Public Health Office of AIDS Programs and Policy August 29, 2006

  2. SPA 1: Antelope Valley SPA 2: San Fernando SPA 3: San Gabriel SPA 4: Metro SPA 5: West SPA 7: East SPA 6: South SPA 8: South Bay Los Angeles County • Square Miles: 4,086 • Population: 9.9 Million • Latino/a 45.7% White 31.0%Asian/PI 13.2%African-American 9.7%Native American 0.3% • Proportion of California Population: 29% • Proportion of California AIDS Cases: 35% • Living with HIV/AIDS: • 58,000 (Estimated) 2

  3. HIV Nutrition Essentials • Overview • Current nutrition issues and treatments • Medical nutrition therapy (MNT) program necessary ingredients • Lessons learned monitoring Los Angeles County medical outpatient services’ MNT programs

  4. HIV Nutrition Essentials • Handout Materials • Presentation slides • Guides and resources • Diet, nutrition, fact sheets • Professional competency • Weight & nutrition • HIV nutrition screen & referral forms • ADA 2005 • Nutrition quick screen Request copies of handouts: MFenton@ladhs.org

  5. HIV Nutrition Essentials • Current HIV Nutrition Issues

  6. HIV MNT • Overall Goals • Optimize nutrition status, immunity and quality of life • Prevent nutrient deficiencies • Achieve and maintain optimal body weight and composition • Manage co-morbidities • Maximize effectiveness of medications

  7. Poor Nutrition resulting in weight loss, muscle wasting, weakness, nutrient deficiencies Impaired immune system Poor ability to fight HIV and other infections, Increased oxidative stress Increased Nutritional needs, Reduced food intake and increased loss of nutrients HIV Increased vulnerability to infections e.g. Enteric infections, flu, TB hence Increased HIV replication, Hastened disease progression Increased morbidity Vicious Cycle of Malnutrition and HIV Source: Fanta Project www.fantaproject.org Adapted from RCQHC and FANTA 2003

  8. HIV Nutrition Issues • Poor Immune Function • Food and water safety, sanitation • Optimized nutrient and fluid intake • Vitamin mineral supplementation • Exercise: aerobic and progressive resistance training • Medication adherence • Stress reduction • Establishment of trusting relationships

  9. Common Side Effects GI distress Diarrhea Nausea/vomiting Gas Anorexia Fatigue Taste alterations Mouth pain Anemia Hyperlipidemia Insulin resistance Hypertension Liver toxicity Renal impairment Obesity Lipodystrophy Peripheral neuropathy Cancer Nutrition Issues and Treatments

  10. Causes of Weight Loss • 1-Inadequate Intake • Oral and upper gastrointestinal • Anorexia • Psychosocial-economic • Malabsorption Source: Mangili A et al. CID 2006:42 (15 March) p 836-42

  11. Causes of Weight Loss • 2-Altered Metabolism • Uncontrolled HIV infection • Metabolic demands of HAART • Opportunistic infections or malignancies (AIDS-defining conditions) • Hormonal deficiencies (testosterone or thyroid) • Cytokine dysregulation Source: Mangili A et al. CID 2006:42 (15 March) p 836-42

  12. Resting Energy Expenditure Grunfeld et al. AJCN 1992;55:455-60.

  13. Impact of Viral Load on Resting Energy Expenditure

  14. HIV Wasting • Definitions • CDC • Nutrition for Healthy Living (Tufts) • Grinspoon, Mulligan & DHHS Working Group • Polsky, Kotler & Steinhart

  15. Calories Needed and Weight Change • Relation to Viral Load • Not on HAART • 0.92 kg body weight decrease per each HIV RNA log10 increase • 22 Kcal increase in REE per increase in per 1-log copy/ml • Stable HAART • 0.35 kg body weight decrease per each 100-cell/mm3 CD4 cell decrease • 81 kcal higher REE Source: Wanke et al. CID 2006:42 (15 March)

  16. Outcomes of Weight Loss • Morbidity and mortality independent of CD4 and viral load • Weight loss of >5% associated with increase risk of mortality even with ART • Adverse pregnancy outcomes • Weight loss & wasting continue to be common problems

  17. International Nutrition • Feeding Safely and Adequately • Access to nutritious food • Access to safe water • Malnutrition • Linked with HIV infection • Linked with poor prognosis • Linked with poor prognosis despite ART • Breast feeding • Access to HIV medications

  18. Overweight, Obesity and HIV Sources: (1) Amorosa et al. JAIDS 2005;Aug15;39(5):557-61. (2) NHANES 1999-2000; www.cdc.gov 7/03

  19. Weight Classification Using BMI (1) National Heart, Lung and Blood Institute, (2) Magili et al. CID 2006 March, (3) Amorosa; Grinspoon, Mulligan & DHHS Working Group 2003 April-S CID

  20. BMI: HIV vs. General Populations Conditions Associated with Obesity Hypertension Gout Stroke Mood Disorders Heart Disease Hyperlipidemia Sleep Disorders Obesity Non-Insulin Dependent DM Eating Disorders Osteoarthritis Some Cancers Gall Bladder Contemporary Diagnosis and Management of Obesity. Geroge A. Bray, MD

  21. Waist circumference Men: <40 inches Women: <35 inches NHANES methodology Waist to Hip Ratio? Less accurate Not recommended Hip circumference ok Monitor waist & hip from baseline Desirable Girth Measurements

  22. Overweight, Obesity & HIV • Fuel of Metabolic Abnormalities • BMI positive correlation with • Total cholesterol • Triglycerides • Glucose • Obesity not correlated with • Age, income, employment, education • Past/current IVD use • HIV treatment, viral load Source: Amorosa et al. JAIDS 2005;Aug15;39(5):557-61.

  23. Treatment of Obesity • Therapeutic Lifestyle Changes • Nutrition counseling • Dietary intake • Limit saturated fats • Increase fiber to 35 g/day • Portion control • Reduce excess carbohydrates and high sugar drinks • Plenty of fruits and vegetables • Small meals: maximum 5 hours apart • Eat slowly

  24. Treatment of Obesity • Therapeutic Lifestyle Changes • Physical activity • Walking or other exercise • 30-60 minutes/day • Progressive resistance training

  25. HIV and Diabetes Mellitus • An Increasing HIV Nutrition Problem • HIV-positive men who are taking highly active antiretroviral therapy (HAART) are more than four times more likely to develop diabetes than HIV-negative men. • HIV-positive women taking protease inhibitors are three times more likely to develop diabetes than HIV-positive women on non-protease inhibitor combinations or HIV-negative women • Sources: Brown TT et al. Antiretroviral therapy and the prevalence and incidence of diabetes mellitus in the Multicenter AIDS Cohort Study. Arch Intern Med 165: 1179-1184, 2005. • Justman JE et al. Protease inhibitor use and the incidence of diabetes mellitus in a large cohort of HIV-infected women. Journal of Acquired Immune Deficiency Syndromes, 32: 298 – 302, 2003

  26. General Population Overweight, obesity Especially VAT Parent or sibling Ethnicity Alaska Native, American Indian, African American, Latino American, Asian America Inactivity Exercise <3x/wk History of impaired glucose tolerance or impaired fasting glucose Hypertension Cardio-vascular disease Polycystic ovarian syndrome Diabetes Major Risk Factors

  27. Diabetes Additional Risk Factors • HIV Population • Medications leading to insulin resistance • HAART • Steroids, growth hormone, others • HCV co-infection • Morphological changes • Lipodystrophy: > visceral adipose tissue • Physical inactivity • Neuropathy, fatigue avascular necrosis, wasting, etc.

  28. Heart Disease Prevalence • General Population • Leading cause of death in the U.S. • Women: 51% of heart disease deaths • Men: 340,933 died from heart disease in 2002 • 57 million Americans live with CVD • 8.9% all white men • 7.4% black men • 5.6% Mexican American men • 1. National Center for Health Statistics. Health, United States, 2005 with Chartbook on Trends in the Health of Americans. Hyatsville, MD: 2005. • 2. American Heart Association. Heart Disease and Stroke Statistics—2005 Update. Dallas, Texas: American Heart Association, 2005.

  29. General Population Increasing age Gender Heredity, family history of premature heart disease Overweight/obesity High blood pressure Tobacco use Hyper- or dyslipidemia Especially high LDL & low HDL Diabetes Metabolic syndrome Physical inactivity Poor nutrition An atherogenic diet Heart Disease Major Risk Factors Source: Preventing chronic diseases: Investing wisely in health preventing heart disease and stroke. July 2005. CDC. February 6, 2006. http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/cvh.htm

  30. Heart Disease Risk Factors • HIV Population • Inflammation due to HIV • Lipid abnormalities due to HAART • Other drug effects: • Insulin resistance • Morphological changes • Metabolic syndrome

  31. Heart Disease • Prevention & Treatment • Therapeutic Lifestyle Change (TLC) • Diet • Physical exercise • Management of concomitant diseases • Diabetes, hypertension, obesity, etc. • Smoking cessation • Stress reduction

  32. Liver Disease • Fueled by Overweight & Obesity • Waist>hip, insulin resistance & diabetes • Predicts advanced forms of chronic hepatitis C • Complicates nonalcoholic steatohepatitis (NASH) • Fitness inversely related • Tx: Healthy diet, exercise, weight loss Sources: Charlton MR et al. Hepatology June 2006;46(6)1177-1186; Church TS et al. Gastroenterology. 2006 Jun; 130(7):2023-2030.

  33. Renal Disease and HIV • A Growing Nutrition Problem • Dialysis • HIV: 1.5%, AIDS: 0.4% • Dialysis centers treating PLWH/A • 1985: 11% • 2000: 37% • Number initiated since 1995: stable • Abnormal kidney function • 30% PLWH/A • HIV and CKD nutrition guidelines • Not set yet • Individualize

  34. HIV Nutrition Essentials • Medical Nutrition Therapy (MNT) • Program Necessary Ingredients

  35. Continuum of Care County of Los Angeles. Continuum of Care, Office of AIDS Programs and Policy.

  36. HIV Registered Dietitian • Standards of Professional Practice • Provides quality service based on client expectations and needs • Effectively applies, participates in or generates research to enhance practice • Effectively applies knowledge and communicates with others

  37. HIV Registered Dietitian • Standards of Professional Practice • Uses resources effectively and efficiently in practice • Systematically evaluates the quality and effectiveness of practice and revises practice as needed to incorporate the results of evaluation • Engages in lifelong self-development to improve knowledge and enhance professional competence

  38. HIV Registered Dietitian • Care Responsibility • Create screening tools for medical providers to identify clients at risk • Monitor nutrition-related abnormal laboratory values • Assess clients regularly, consistently • Ensure adequate nutrient & caloric intake

  39. HIV Registered Dietitian • Care Responsibility • With medical team, identify and correct causes of cachexia, weight loss/gain, other nutrition problems and barriers • Refer to providers and other disciplines • Communicate: document, speak, share • Participate in team case conferences • Promote continuity of care

  40. NCP Ø ADA NUTRITION CARE PROCESS AND MODEL Screening & Referral System Ø Identify risk factors Ø Use appropriate tools and methods Ø Involve interdisciplinary collaboration Nutrition Diagnosis Ø Identify and label problem Nutrition Assessment Ø Determine cause/contributing risk Ø Obtain/collect timely and factors appropriate data Ø Cluster signs and symptoms/ Ø Analyze/interpret with defining characteristics evidence - based standards Ø Document Document Relationship Between Patient/Client/Group Nutrition Intervention Dietetics & Ø Plan nutrition intervention · Professional Formulate goals and determine a plan of action Implement the nutrition intervention Ø · Care is delivered and actions Nutrition Monitoring and - are carried out Evaluation Ø Documen t Ø Monitor progress Ø Measure outcome indicators Ø Evaluate outcomes Ø Document Outcomes Management Sys tem Ø Monitor the success of the Nutrition Care Process implementation Ø Evaluate the impact with aggregate data Ø Identify and analyze causes of less than optimal performance and outcomes Ø Refine the use of the Nutrition Care Process

  41. Screening and Referral • Screen for Referral Criteria • New/re-entry into care, MNT >6 months • Medical diagnosis, nutrition status change • Physical changes, weight concerns • Oral, GI symptoms • Metabolic, other medical conditions • Barriers to nutrition, living environment, functional status • Behavioral concerns, unusual behaviors Source: ADA MNT Evidence Based Guides for Practice, March 2005

  42. Screening and Referral • Referral Documentation • Physician’s order for MNT • Signature and date of physician or authorized person to refer for MNT • Medical diagnoses and information • Current labs and measurements • Consent to release medical information • Proof of residency, income, diagnosis • Source: ADA MNT Evidence Based Guides for Practice, March 2005

  43. Nutrition Care Process • ADIME • Nutrition Assessment • Nutrition Diagnosis • Nutrition Intervention • Nutrition Monitoring • Nutrition Evaluation • Documentation: clear and explicit

  44. Nutrition Care Process • Nutrition Assessment • Reason for referral • Assess data (ABCD) • Anthropometric • Biochemistry • Clinical • Dietary • Client input

  45. Nutrition Care Process • Nutrition Diagnosis • Problem • Diagnostic label • Intake, clinical, or behavioral/environmental • Etiology • Cause or contributing risk factors • Signs/Symptoms • Defining characteristics • PES statement

  46. Nutrition Care Process • Nutrition Diagnosis PES Statement • (P) Increased nutrient needs (E) as related to inadequate intake of foods and malabsorption due to AIDS enteropathy (S) as evidenced by 25 pound weight loss in 6 months and now 91% IBW

  47. Nutrition Care Process • Nutrition Intervention • Interventions • Food and/or Nutrient Delivery • Nutrition Education • Nutrition Counseling • Coordination of Nutrition Care • Receptivity and adherence potential • Plan and follow-up date

  48. Nutrition Care Process • Nutrition Monitoring • Review and measure status of intervention at scheduled time • Track outcomes with tools • ADA HIV MNT Protocol Progress Note • Weight and nutrition flow sheet • Electronic health record data fields • Format • Terminology: diagnosis, interventions, etc • Other tools

  49. Nutrition Care Process • Nutrition Evaluation • Systematic comparisons • Reference standards • Evaluate changes • Signs and symptoms • Previous status and intervention goals • Progress toward goal

  50. HIV MNT Tools • Basics • HIV MNT Protocols (ADA,1998) • Adult (18 years-adult) • Children (under 18 years) • Health Care and HIV: Nutritional Guide for Providers and Clients (HRSA/HAB, 2002) • Integrating Nutrition into Medical Management of HIV, (CID-S April 1 2003) • Nutrition intervention in the care of persons with human immunodeficiency virus. (ADA & Dietitians of Canada Joint Position, 2004)

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