歌德妙语录社会人类就像江河54
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resistance training
•Medication adherence •Stress reduction • Establishment of trusting relationships
9
Nutrition Issues and Treatments
Common Side Effects
Desirable Girth Measurements
• 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
20
0
CON
HIV+
Grunfeld et al. AJCN 1992;55:455-60.
AIDS AIDS-SI
13
Impact of Viral Load on Resting Energy Expenditure
REE (kjoules/day)
8900
8700
8500
8300
8100
7900
•Manage co-morbidities •Maximize effectiveness of medications
7
Vicious Cycle of Malnutrition and HIV
Increased Nutritional needs,
Reduced food intake and increased loss of
• Physical activity
▪ Walking or other exercise
• 30-60 minutes/day
▪ Progressive resistance training
25
HIV and Diabetes Mellitus
An Increasing HIV Nutrition Problem
▪ Age, income, employment, education ▪ Past/current IVD use ▪ HIV treatment, viral load
23 Source: Amorosa et al. JAIDS 2019;Aug15;39(5):557-61.
Treatment of Obesity
1
3
5
7
9
11
HIV RNA (log 10 copies/ml)
14
HIV Wasting
Definitions
• CDC •Nutrition for Healthy Living (Tufts) • Grinspoon, Mulligan & DHHS Working
Group
•Polsky, Kotler & Steinhart
high sugar drinks
▪ Plenty of fruits and vegetables
▪ Small meals: maximum 5 hours apart
▪ Eat slowly
24
Treatment of Obesity
Therapeutic Lifestyle Changes
HIV MNT
Overall Goals
• Optimize nutrition status, immunity and
quality of life
•Prevent nutrient deficiencies •Achieve and maintain optimal body
weight and composition
Wasting3 <20.0
Normal
18.5-24.9
Overweight
25.0-29.9
Obesity (I)
30.0-34.9
Obesity (II)
35.9-39.9
Extreme Obesity (III) >40.0
(1) National Heart, Lung and Blood Institute, (2) Magili et al. CID 2019 March, (3)
Sources: (1) Amorosa et al. JAIDS 2019;Aug15;39(5):557-61.
(2) NHANES 2019-2000; 7/03
19
Weight Classification Using BMI
BMI1
Note
Underweight
<18.5 Malnutrition2 <18.5
22
Overweight, Obesity & HIV
Fuel of Metabolic Abnormalities
•BMI positive correlation with
▪ Total cholesterol ▪ Triglycerides ▪ Glucose
•Obesity not correlated with
Increased vulnerability to infections e.g. Enteric
infections, flu, TB hence Increased HIV replication, Hastened disease progression
Increased morbidity
Stroke
Mood Disorders
Heart Disease
Sleep Disorders
Eating Disorders
Obesity
Hyperlipidemia
Non-Insulin Dependent DM
Some Cancers
Gall Bladder
Osteoarthritis
Contemporary Diagnosis and Management of Obesity. Geroge A. Bray, MD 21
10
Causes of Weight Loss 1-Inadequate Intake
•Oral and upper gastrointestinal • Anorexia • Psychosocial-economic • Malabsorption
Source: Mangili A et al. CID 2019:42 (15 March) p 836-42 11
Amorosa; Grinspoon, Mulligan & DHHS Working Group 2019 April-S CID
20
Conditions Associated with Obesity
BMI: HIV vs. General Populations
Hypertension
Gout
•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
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 2019:42 (15 March)
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
50 45 40 35 30 25 20 15 10
5 0
Study (n=1669)
NHANES Men
BMI <18.5 (1) Wasting (2) Underweight BMI: 18.5-24.9 Healthy Weight
BMI: 25-29.9 Overweight
NHANES BMI: = or >30 Women Obese
• GI distress
• Hyperlipidemia
▪ Diarrhea
• Insulin resistance
▪ Nausea/vomiting ▪ Gas
• Anorexia • Fatigue • Taste alterations • Mouth pain • Anemia
• Hypertension • Liver toxicity • Renal impairment • Obesity • Lipodystrophy • Peripheral neuropathy • Cancer
•
thyroid) Cytokine
dysregulation
Source: Mangili A et al. CID 2019:42 (15 March) p 836-42 12
Resting Energy Expenditure
REE (KJoules/kg BW
140
120
100
80
60
40
▪ Linked with HIV infection ▪ Linked with poor proБайду номын сангаасnosis ▪ Linked with poor prognosis despite ART
• Breast feeding • Access to HIV medications
18
Overweight, Obesity and HIV
Therapeutic Lifestyle Changes
••
Nutrition counseling Dietary intake
▪ Limit saturated fats
▪ Increase fiber to 35 g/day
▪ Portion control
▪ Reduce excess carbohydrates and
Source: Fanta Project Adapted from RCQHC and FANTA 2019
8
HIV Nutrition Issues
Poor Immune Function
•Food and water safety, sanitation •Optimized nutrient and fluid intake •Vitamin mineral supplementation •Exercise: aerobic and progressive
nutrients
Poor Nutrition resulting in weight loss, muscle wasting, weakness,
nutrient deficiencies
HIV
Impaired immune system
Poor ability to fight HIV and other infections, Increased oxidative stress
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
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
•Medication adherence •Stress reduction • Establishment of trusting relationships
9
Nutrition Issues and Treatments
Common Side Effects
Desirable Girth Measurements
• 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
20
0
CON
HIV+
Grunfeld et al. AJCN 1992;55:455-60.
AIDS AIDS-SI
13
Impact of Viral Load on Resting Energy Expenditure
REE (kjoules/day)
8900
8700
8500
8300
8100
7900
•Manage co-morbidities •Maximize effectiveness of medications
7
Vicious Cycle of Malnutrition and HIV
Increased Nutritional needs,
Reduced food intake and increased loss of
• Physical activity
▪ Walking or other exercise
• 30-60 minutes/day
▪ Progressive resistance training
25
HIV and Diabetes Mellitus
An Increasing HIV Nutrition Problem
▪ Age, income, employment, education ▪ Past/current IVD use ▪ HIV treatment, viral load
23 Source: Amorosa et al. JAIDS 2019;Aug15;39(5):557-61.
Treatment of Obesity
1
3
5
7
9
11
HIV RNA (log 10 copies/ml)
14
HIV Wasting
Definitions
• CDC •Nutrition for Healthy Living (Tufts) • Grinspoon, Mulligan & DHHS Working
Group
•Polsky, Kotler & Steinhart
high sugar drinks
▪ Plenty of fruits and vegetables
▪ Small meals: maximum 5 hours apart
▪ Eat slowly
24
Treatment of Obesity
Therapeutic Lifestyle Changes
HIV MNT
Overall Goals
• Optimize nutrition status, immunity and
quality of life
•Prevent nutrient deficiencies •Achieve and maintain optimal body
weight and composition
Wasting3 <20.0
Normal
18.5-24.9
Overweight
25.0-29.9
Obesity (I)
30.0-34.9
Obesity (II)
35.9-39.9
Extreme Obesity (III) >40.0
(1) National Heart, Lung and Blood Institute, (2) Magili et al. CID 2019 March, (3)
Sources: (1) Amorosa et al. JAIDS 2019;Aug15;39(5):557-61.
(2) NHANES 2019-2000; 7/03
19
Weight Classification Using BMI
BMI1
Note
Underweight
<18.5 Malnutrition2 <18.5
22
Overweight, Obesity & HIV
Fuel of Metabolic Abnormalities
•BMI positive correlation with
▪ Total cholesterol ▪ Triglycerides ▪ Glucose
•Obesity not correlated with
Increased vulnerability to infections e.g. Enteric
infections, flu, TB hence Increased HIV replication, Hastened disease progression
Increased morbidity
Stroke
Mood Disorders
Heart Disease
Sleep Disorders
Eating Disorders
Obesity
Hyperlipidemia
Non-Insulin Dependent DM
Some Cancers
Gall Bladder
Osteoarthritis
Contemporary Diagnosis and Management of Obesity. Geroge A. Bray, MD 21
10
Causes of Weight Loss 1-Inadequate Intake
•Oral and upper gastrointestinal • Anorexia • Psychosocial-economic • Malabsorption
Source: Mangili A et al. CID 2019:42 (15 March) p 836-42 11
Amorosa; Grinspoon, Mulligan & DHHS Working Group 2019 April-S CID
20
Conditions Associated with Obesity
BMI: HIV vs. General Populations
Hypertension
Gout
•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
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 2019:42 (15 March)
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
50 45 40 35 30 25 20 15 10
5 0
Study (n=1669)
NHANES Men
BMI <18.5 (1) Wasting (2) Underweight BMI: 18.5-24.9 Healthy Weight
BMI: 25-29.9 Overweight
NHANES BMI: = or >30 Women Obese
• GI distress
• Hyperlipidemia
▪ Diarrhea
• Insulin resistance
▪ Nausea/vomiting ▪ Gas
• Anorexia • Fatigue • Taste alterations • Mouth pain • Anemia
• Hypertension • Liver toxicity • Renal impairment • Obesity • Lipodystrophy • Peripheral neuropathy • Cancer
•
thyroid) Cytokine
dysregulation
Source: Mangili A et al. CID 2019:42 (15 March) p 836-42 12
Resting Energy Expenditure
REE (KJoules/kg BW
140
120
100
80
60
40
▪ Linked with HIV infection ▪ Linked with poor proБайду номын сангаасnosis ▪ Linked with poor prognosis despite ART
• Breast feeding • Access to HIV medications
18
Overweight, Obesity and HIV
Therapeutic Lifestyle Changes
••
Nutrition counseling Dietary intake
▪ Limit saturated fats
▪ Increase fiber to 35 g/day
▪ Portion control
▪ Reduce excess carbohydrates and
Source: Fanta Project Adapted from RCQHC and FANTA 2019
8
HIV Nutrition Issues
Poor Immune Function
•Food and water safety, sanitation •Optimized nutrient and fluid intake •Vitamin mineral supplementation •Exercise: aerobic and progressive
nutrients
Poor Nutrition resulting in weight loss, muscle wasting, weakness,
nutrient deficiencies
HIV
Impaired immune system
Poor ability to fight HIV and other infections, Increased oxidative stress
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
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