HIV Infection and AIDS
Manual of Clinical Nutrition Management III- 48 Copyright © 2013 Compass Group, Inc.
related to ART is likely to require exercise and lipid-lowering medications in addition to dietary modifications
(1). A heart-healthy diet and regular exercise reduce blood lipid levels in HIV-positive patients (1,25). Research
on several lifestyle modification interventions for the treatment of hyperlipidemia in people with HIV
infection found improvements in serum lipid profiles (Grade I) (1,21). Patients with lipodystrophy often require
nutrition intervention to support a healthy body weight and reduce their intake of saturated fat, trans fatty
acids, salt, and dietary cholesterol (1). Patients with HIV and hypertriglyceridemia benefit from increasing
fiber intake, limiting simple carbohydrates, and avoiding alcohol (1,25). Routine anthropometric measures,
blood lipid levels, and blood pressure monitoring should be used to evaluate and monitor lipodystrophy in
HIV-infected patients. Applying practice guidelines for cardiovascular disease risk-factor management is the
current recommended approach for treatment (1).
Abnormal glucose intolerance has been associated with HIV and AIDS medication therapies (1,26). Patients
with insulin resistance may benefit from diabetes education programs, which provide strategies for
regulating blood glucose levels through diet and exercise (1). The treatment of insulin resistance with oral
antidiabetic medications has been explored with mixed results (1). Metformin and glitazones are being
investigated for their potential to improve insulin sensitivity, but their effect on peripheral subcutaneous fat
losses in patients receiving ART is still being researched (27-29). In addition to nutrition therapy strategies,
medication support may be indicated to help reduce insulin resistance and increase lean body mass (LBM) (1).
Nutrition Assessment and Diagnosis
All patients who are newly diagnosed with HIV infection should receive a comprehensive nutrition assessment.
Early referral of HIV-infected patients to medical nutrition therapy can improve their nutritional status and
outcomes (1). A review of evidence has shown that medical nutrition therapy (in the form of an increased number
of nutrition counseling sessions) prevents progressive weight loss, improves cardiovascular risk indexes, and
improves energy intake and other symptoms (Grade I) (1). Studies have also reported improved outcomes related to
weight gain, CD4 count, and quality of life with nutrition counseling (Grade I) (1). Symptoms that may affect
nutritional status and that are used as indicators for identifying nutrition diagnoses include nausea, vomiting,
diarrhea, anorexia, pain, chewing or swallowing difficulties, taste changes, and weight changes (1,9). Providing
specific nutrition intervention strategies to resolve the nutrition diagnoses and support patients through
these challenges is an important part of medical nutrition therapy (1,9). The following types of nutrition
assessment data should be collected and used to determine nutrition diagnoses, nutrition interventions, and
counseling strategies.
Biochemical assessment: The levels of serum proteins, fasting lipids (total cholesterol, low-density lipoprotein
cholesterol, high-density lipoprotein cholesterol, and triglycerides), fasting glucose, and micronutrients should be
routinely evaluated due to metabolic and immune abnormalities associated with HIV and AIDS (1,9). Altered levels
of plasma proteins, micronutrients, and other nutrition-related markers have been documented early in the
disease process and are associated with increased risk of mortality in HIV infection (1). Alterations in zinc, iron,
selenium, vitamin B 12 , carbohydrate, and fat have been reported in symptomatic and asymptomatic disease states
(1,30,31). Indicators of disease complications and prognosis include nutrition-related laboratory values such as
albumin, transthyretin, hemoglobin, hematocrit, creatinine, urea nitrogen, transferrin, glucose, vitamin B 12 , and C-
reactive protein (1,32,33). Serum iron, total iron-binding capacity, folate, and vitamin B 12 are measured to
distinguish types of anemias, including anemia of chronic disease or anemia related to medication therapy (1,34).
Serum lipids in men and women and levels of total and free testosterone in men should be monitored regularly
for changes indicative of lipodystrophy and decreases in LBM (1). Alterations in nutrition-related laboratory
values may reflect inflammatory responses rather than purely nutritional compromise (1). Levels of zinc and
albumin, which are both acute-phase reactants, may fall rapidly during the physical stress of infection and quickly
increase when the infection is resolved (1). Therefore, biochemical values should be used in conjunction with
other nutrition assessment parameters, such as weight, body composition, and nutrient intake (1).
Anthropometry: Routine anthropometric measures, including height, weight, BMI, waist-to-hip ratio, waist
circumference, hip circumference, and other circumference measures, should be used to evaluate and monitor
risk for wasting syndrome and lipodystrophy (1,9). Body composition measures such as skin folds and BCM, a
component of LBM composed of highly functional protein stores (muscles and organs), are also important to
monitor (1,9). In a review of 27 studies evaluating the assessment of body composition in persons with HIV
infection, the majority of studies reported that fat-free mass and fat mass are generally lower in people (men,
women, children, and adolescents) with HIV infection (Grade I) (1,21). Assessment of BCM can detect early changes in
LBM and alterations in fat patterns and potential muscle wasting that may not be reflected by weight change or
weight records (1,9). Body composition, particularly BCM, can be evaluated by bioelectric impedance analysis,