Joseph Cofrancesco, Jr., M.D., M.P.H.
Critical Nutrition Practice considerations for PLWHA in Zambia:
- Periodic nutritional status assessment: For symptomatic patients, weigh at least every 2nd month, for patients on ART every 3 months, and every 4-6 months for asymptomatic patients not on ART.
- Maintain high levels of sanitation, food safety and hygiene. De-worm biannually using appropriate broad spectrum anti-helminth drugs such as albendazole or mebendazole if in worm-infested area.
- Nutritional status can be measured using anthropometric screening done through serial measurements of weight, height, mid-upper arm circumference (MUAC), and triceps skin-fold thickness.
- BMI = Weight (kgs)/ height(m)2; WHO Cut-off points: <18.5 = underweight, 18.5-24.9 = normal weight, 25-29.5 = overweight, >30 = Obese.
- MUAC recommended for adults who cannot stand up for weight and height measurements. Cut-off points in men: MUAC <25 cm and in women MAUC <22 cm; <16 cm indicates severe malnutrition; <18.5 cm indicates moderate malnutrition, and <22 cm recommended for pregnant women.
- Patients who have lost 10% of body weight or 6-7 kgs in 1 month should be referred to clinician to assess ART eligibility.
- HIV+ patients with BMI <18.5 should be supported with therapeutic food supplements (where available) to improve nutritional status and/or referred to other community support groups offering nutrition services.
- Provide therapeutic feeding for moderately and severely malnourished adults and children: Therapeutic food formulations include F75 and F100 therapeutic milk, Plumpynut (RUTF paste), HEPs and locally produced nutrient-dense foods.
- Dietary assessment is proxy indicator of patient's nutrient intake, energy intake, and possible nutrient deficiencies. Assess food intolerance (e.g. intolerance to lactose), reduced food intake due to loss of appetite, chewing and swallowing problems, regurgitation, nausea, vomiting or diarrhea, allergies, depression, fatigue, etc.
- Assessment of patient's food intake based on 24 hour recall or by having patient record food consumed over last 3 consecutive days.
- Discourage consumption of dairy products in lactose intolerant patients.
- When weight has unintentionally declined in 2 -3 months, refer to nutrition clinic.
- HAART should improve overall nutritional status with increase in total body weight and intracellular water.
- If weight not changed within 6 weeks to 12 months, consider following possibilities: Poor adherence to ART; health complications, including TB; ARV resistance; inadequate nutrient intake; drug-drug or food-drug interactions; drug side effects.
- Patients with BMI <16 should be nutritionally stabilised before starting ARVs.
Recommendations for Nutritional Support for HIV+ patients experiencing weight loss: Refer patient to nutritionist/dietician for counseling; ascertain circumstances that may have led to weight loss; for any clinical conditions, refer to physician for further investigations; nutritionist/dietician should provide specific advice on how to maintain intake during these periods; increase intake to promote nutritional recovery following periods of appetite loss, fever or acute diarrhea; minimize nutritional impact of infection by advising on dietary management; advise all PLWHA to avoid unhealthy lifestyles, including excessive alcohol consumption, tobacco and illicit drug use, which may affect nutrition.
- Weight loss can be caused by but not limited to: infections (e.g TB, malaria), poor appetite, oropharyngeal candidiasis, poor absorption of nutrients due to diarrhea and other conditions, poor quality of diet, nausea/vomiting, malignancies, DM, thyroid disease, depression, and decreased intake (due to financial constrictions).
- Recommendations for patients with weight loss include: eat regular balanced meal, eat nutritious snacks in between meals e.g. roasted peanuts, boiled eggs, fruits and sandwiches, exercise regularly to increase lean body mass and appetite, increase nutrient density of foods without visibly increasing volume of meal by adding peanut butter, skimmed milk powder, or eggs in soups or porridge, eat fat if tolerated (e.g. fried meat, chicken, fish), and use oil in cooking.
- Human growth hormone, testosterone, and anabolic steroids not readily available in Zambia.
Zambia Information Author: Larry William Chang, MD, MPH
Wasting: Unintentional weight loss >10%. Many experts act when pts lose >5% weight from baseline: usually loss of muscle (men), loss of muscle and fat (women).
Wasting syndrome: Unintentional weight loss >10% plus diarrhea or chronic weakness and documented fever for >30 days.
- Wasting syndrome is an AIDS-defining condition (category C); wasting is evidence of symptomatic HIV infection (category B).
- Must be differentiated from lipoatrophy, which is isolated fat loss (see Lipodystrophy). Wasting/weight loss is consequence of AIDS disease progression and OIs, while lipoatrophy often seen in pts on successful ART.
- Less common in HAART era.
- Rule out OIs or other infections.
- Evaluate for GI problems (diarrhea and malabsorption) and malnutrition; check stool O+P, occult blood and WBC if there are bowel complaints (at minimum).
- Perform age and gender-appropriate cancer screening.
- Rule out depression and substance abuse.
- Consider endocrine abnormalities: thyroid disorders, adrenal insufficiency, hypogonadism in men. Check TSH and AM free testosterone level.
- Differentiate lipoatrophy (fat loss, ART associated) from wasting (muscle +/- fat loss from advanced disease).
- Treat identified causes of weight loss.
- Control HIV with HAART.
- Treat/prevent OIs.
- Ensure adequate nutrition (use oral supplements as needed). Pts with active HIV have increased metabolic demands.
- Encourage exercise program/weight training.
- If no response to the above, consider pharmacologic intervention.
- If AM total testosterone <400 ng/dL or low free testosterone, consider testosterone supplementation (see below for doses). Supraphysiologic doses (generally with injections) may be necessary for 1st 3 mos. in wasted pts. Can also add additional anabolic agent (oxandrolone or nandrolone) for 3 mos. After 3 mos, stop anabolic agent; continue testosterone.
- If not hypogonadal (AM testosterone >400 ng/dL): use anabolic agent (oxandrolone, nandrolone or rhGH) for 3 mos.
- If no response to above, consider rhGH (can cause/exacerbate glucose intolerance and lipoatrophy).
- If appetite poor, consider appetite stimulant such as megastrol (may exacerbate or precipitate hypogonadism)
- Anabolic steroid use more controversial given androgenic effects of anabolic steroids. Ensure birth control. Consider oxandrolone OR low dose nandrolone x 3 mos OR rhGH.
- Consider appetite stimulant such as megastrol
- Consider in wasting pts, especially with anorexia.
- Megestrol suspension: 800 mg PO once daily. Excellent appetite stimulant but progesterone-related compound with potential for causing hypoadrenalism and hypogonadism. Most weight gain is fat, not muscle, unless coupled with exercise and/or testosterone/anabolics. Can cause hyperglycemia.
- Dronabinol: 2.5-10 mg PO twice daily-four times a day prn. Useful for nausea and anorexia, but most studies fail to demonstrate significant weight gain.
- Anabolic steroids can have appetite-stimulating effect.
- Consider nutrition consult.
IM injection: Testosterone enanthate or cypionate: 200 mg IM q2 wks (range 50-400 mg IM q 1-4 wks) for standard testosterone replacement. Titrate to amelioration of Sx and AM testosterone level >400 ng/dL. For greater anabolic effect, use higher doses (200-250mg IM q wk or 300-400mg IM q 2 wks).
Gels: Androgel (1% gel) 5-10 g qam: apply to shoulders, upper arms, abdomen. Titrate to Sx/testosterone levels. Testim (1% gel) 5-10 g qam (5 gm = 50 mg testosterone):titrate to Sx/testosterone levels. Available in new pump dispenser for easier titration. Difficult to obtain high levels and therefore anabolic effect with gels; for anabolic effects and supraphysiologic doses, injections generally required.
Buccal formulation: Striant, 1 unit placed against gum above incisor tooth q12 hrs, with rounded side held in place for 30 seconds for adhesion, rotating alternate sides of the mouth. Delivers replacement doses, not supraphysiologic doses.
- Oxandrolone (Oxandrin): 10 mg PO twice daily or 20 mg PO once daily, (consider lower doses in women). May have less androgenic effects.
- Nandrolone decanoate (Deca-Durabolin): 50-200 mg IM q 2 wks.
- Oxymetholone (Anadrol-50):up to 50 mg PO twice daily. Very potent but less often used, may be more hepatotoxic.
- rhGH : 0.1 mg/kg SC at bedtime or every other day (max 6 mg/d) x 3 mos. Can cause or exacerbate glucose intolerance and lipoatrophy. Can cause fluid retention, hypertension, carpal tunnel syndrome. Expensive.
growth hormone, human
||Can be used to treat wasting, though much more expensive and potentially more toxic than anabolic/androgenic steroids, which are usually effective.
||Preferred anabolic steroid for IM administration. Consider in pts with wasting but normal testosterone levels, or in addition to testosterone in pts with wasting despite testosterone therapy. May no longer be available in U.S.
||Preferred anabolic steroid for PO administration. Consider in pts with wasting but normal testosterone levels, or in addition to testosterone in pts with wasting despite testosterone therapy.
||Anabolic steroid. May be more hepatotoxic than oxandrolone or nandrolone.
||Drug of choice for pts with wasting and hypogonadism. Topical/buccal formulations provide steadier levels and may be less likely to suppress intrinsic testosterone production or cause testicular shrinkage. For supraphysiologic rather than replacement doses when anabolic effects needed, IM testosterone may be required.
- Monitor for LFT abnormalities, polycythemia, clotting factors. Baseline and yearly prostate exam and PSA recommended for men on testosterone.
- After 3 mos, consider stopping anabolic steroids and encouraging continued nutrition and exercise. Slight decrease in weight expected once anabolic agents are stopped.
- Sometimes necessary to repeat 3-month cycle of anabolic steroids if weight not maintained. If HIV cannot be controlled, longer courses of anabolic agents may be necessary.
- Unclear if chronic testosterone needed in HAART era, but reasonable to switch to replacement doses in topical form for men who were hypogonadal.