Case Study Project from my Dietetic Internship

1. Obstacles to Adequate Nutrition in Human Immunodeficiency Virus Prepared by: Jessica McGovern

2. Objectives Explain HIV’s effect on the immune system Examine HIV’s effect on the body Identify risk factors for contracting the virus State methods of assessing an HIV patient Discuss obstacles to maintaining nutritional status Identify nutrition interventions for HIV Examine methods of monitoring nutritional status in this population Discuss a case study of an HIV patient with oral feeding difficulty Explain various oral issues and associated medical nutrition therapy

3. Patient AW 46 year old Hispanic male, 5’7”, UBW-180lbs Admitted on September 14th with sore throat, ulcers in the oral cavity and esophagus, and significant weight loss. Admitting diagnosis of esophagitis. HIV test reveals patient is HIV positive. http://www.health.com/health/static/hw/media/medical/hw/n5551186.jpg

4. What is HIV? A retro-virus (contains RNA) that uses the body’s own cells to reproduce. Transmitted through sexual contact, infectious bodily fluids, needle/syringe sharing, tainted blood transfusions, or through birth/breast feeding. Not easily transmitted. Often asymptomatic in the earliest stages . http://www.hivnorfolk.com/images/illustrations/hiv_virus.jpg (1)

5. Overview of Immune Cells B Cells- Identify foreign cells, produces antibodies, able to neutralize and destroy invaders that are not already incorporated into the host cells Helper T (CD4)- Directs the immune response once a foreign entity is identified Cytotoxic T (CD8)- kills the targeted cells based on the presence of a foreign antigen on the surface of the cell Macrophages- engulf foreign material (2)

6. How the virus works. Helper T cells are the primary target Identifies the T cells Fuses to the surface Injects RNA, enzymes, and other substances that help to penetrate the cells surface RNA is transcribed to DNA DNA carried to the nucleus and integrated into the host DNA using enzymes The virus can remain dormant Once activated the cells become a “viral factory” manufacturing, assembling, and releasing the virus. CD4 cells becomes destroyed Macrophages infected with HIV become dysfunctional Leads to compromised immune system and the progression of the disease (1,2)

7. Illustration of How HIV Works http://www.virxsys.com/media/MOAsmall.jpg

8. Facts about HIV 1/70th the size of a Helper T cell Contains 9 genes 6 of the genes are primarily used to penetrate, infect, and produce copies in the T cell The virus also targets other cells of the body including gastrointestinal cells, organ cells, and the immune cells HIV is not a death sentence Infection depends on the level of exposure and the dose HIV can reproduce rapidly between 1 billion and 1 trillion virons per day Initial infection is often followed by flu-like symptoms 1.1 million people are living with HIV in the United States There are two types of HIV- HIV1 and HIV2. 21% of those infected within the United States are undiagnosed (2,3,4)

9. Diagnosis of HIV ELISA- “rapid test” to identify possibility of infection- more sensitive than specific EIA- determines the concentration of antibodies Tests vary greatly and can measure serum, plasma, urine, saliva. Can determine if the infection is recent or long standing Measure reduction in CD4 count, viral load increase, HIV antibodies, and antigens. Pheno and genotype of the virus are tested to track mutations and decide which treatment will be effective Immune Cell Category of HIV Infection http://hypochondriaoasis.com/wp-content/uploads/2008/05/hiv-test.jpg (2,3)

10. Stages of HIV Disease (4)

11. What does HIV effect? Neurological Pulmonary Renal Cardiac GI Tract Immune system Hematological Musculoskeletal Hepatic All Systems of the Body (5) http://wpcontent.answers.com/wikipedia/commons/thumb/4/4a/Symptoms_of_acute_HIV_infection.png/ 300px-Symptoms_of_acute_HIV_infection.png

12. Treatments Fusion Inhibitors Non-nucleocide Reverse Transcriptase Inhibitor Nucleotide/nucleocide Reverse Transcriptase Inhibitor Intergrase Inhibitor Protease Inhibitor HAART-highly active anti-retroviral therapy Successful if adherence is 95% Side effects/symptoms Pill burden Complex regimens Food/Medication Interactions Knowledge deficit Anti-retrovirals Limitations (6)

13. What are the risk factors? (6)

15. -20% of HIV/AIDS cases in the United States are related to injection drug use

16. -Both drug abuse and HIV are identified as leading to nutritional deficiencies in macro and micronutrients

17. -Drug abuse among Hispanics in the Northeastern United States is a significant risk factor

18. -The dietary assessment of a drug user often proves difficult to obtain and may be inaccurate

19. -Develop an assessment method tailored to the Hispanic populationDesign used 3 groups: -HIV infected drug users -HIV –non-infected drug users -HIV infected non drug users 7)

20. Assessing Dietary Intake of Drug-Abusing Hispanic Adults with and with out Human Immunodeficiency Virus Infection 24 hour recall and FFQ recorded by interviewer on 1st visit Half of 3 day records not completed Total kcal, protein, carbohydrates, fat, saturated fat, cholesterol, fiber, Vitamins A, D, K, Riboflavin, Niacin, Folate, B6, B12, C and Zeaxanthhin, Calcium, Iron, Zinc, Sodium, Potassium, Magnesium, Phosphorus Conclusion-24 hour recall and FFQ most effective 3 assessment methods 3 day recall, 24 hour recall, and FFQ 286 participated 282 FFQ 142 3 day records 270 24 hour recalls 28% of subject women 24% reported homelessness >50% has less than a high school education (7)

21. HIV Time-line (1)

22. Race/Method of Contraction in the United States Race Method of Contracting the Virus (3)

23. Incidence of HIV (4)

24. HIV Rates and AIDS Related Deaths (4)

25. Nutrition Assessment Lifestyle choices (smoking, drug abuse, alcohol) Economic status Lack of healthcare Access to safe food Food insecurity Social History (1,6)

26. Nutrition Assessment Food recall/frequency/questionnaire Meals per day Intake analysis Food allergies Appetite Ability to chew/swallow Signs/symptoms of GI distress Taste changes/dry mouth Dietary History (1,6)

27. Nutrition Assessment Weight- change Height BMI Clinical signs of deficiency Anthropometrics Body composition analysis Lipodystrophy Physical Assessment (1,6)

28. Nutrition Assessment Past and current medical diagnosis Family history Medications Surgery Medical History (1,6)

29. Nutrition Assessment Immunologic profile Hematologic profile Liver function Lipid profile Renal profile Glucose/Insulin Inflammatory markers Biochemical Assessment (1)

30. Nutrition Assessment Kcals- BEE x 1.3 for weight maintenance, BEE x 1.5 for weight gain Protein- 1-1.4g/kg body weight for maintenance, 1.5-2g/kg for repletion Fluids- 30-35mL/kg body weight Vitamins-A,C, B6, B12, and Folate may be poorly absorbed Minerals-Selenium and Zinc may be deficient Calculating Estimated Needs (1,6)

31. Nutrition’s relation to immunity HIV causes dysfunction of the GI tract Increases risk for malabsorption of nutrients Malnutrition continues leading to a decline in health and wasting process Breakdown of protein stores to feed the inflammatory process Opportunistic diseases/cancers increase catabolic state causing weight loss (1)

32. Methods: -3 day food record -Included Vitamin/Mineral supplements Objectives: -To evaluate the connection between state of HIV disease and nutritional intake Subjects: -516 total subjects -25% women, 30% minorities -Categorized by CD4 count, gender, and white VS non-white -Clinical Status Questionnaire -Physical Activity Questionnaire -Physical Exam -Blood Tests-CD4 -Stool Specimen-fecal fat -Serum Vit levels Nutrient Intake and body weight in a large HIV cohort that includes women and minoritiesWoods MN, Spiegelman D, Knox TA, Forrester JE, Connors JL, Skinner SC, Silva M, Kim JH, Gorbach SL. Nutrient Intake and Body Weight in a Large Cohort That Includes Women and Minorities. J Am Diet Assoc. 2002;102:203-211. (8)

33. Nutrient Intake and body weight in a large HIV cohort that includes women and minorities Results: -As CD4 count decreased, macronutrient intake increased in men -25-30% of women consumed <75% DRI’s for A, C, E, B6, and Iron. -White men had higher micronutrient intakes -Macronutrient intake was higher among white vs non-white men -25% of men did not meet DRI of Zinc, Folate, and vitamin E -90% of the subjects provided a 3 day recall -The remaining submitted a 1-2 day recall -Nutrition Data Software was used to analyze the diet (8)

34. Obstacles to maintaining nutritional status Polypharmacy Disease complications Co-Infections/opportunistic infections Symptoms (6)

35. Antiretroviral Medication Interactions (1)

36. Nutrition Related Disease Complications Nephropathy Anemia Protein Energy Malnutrition Lipodystrophy Abnormal protein metabolism Hormonal/nutrient alterations Medication/Food Interactions Reduction in intestinal enzyme production Malabsorption Rapid intestinal cell turnover Immature enterocytes Other system malfunctions that may cause dietary restrictions. (6)

37. The fat redistribution syndrome in patients infected with HIV: Measurements of body shape abnormalitiesGerrior J, Kantaros J, Coakley E, Albrecht M, Wanke C. The Fat Redistribution Syndrome in Patients Infected with HIV: Measurements of Body Shape Abnormalies. J Am Diet Assoc. 2001;101:1175-1180. Objective: To document the body shape and metabolic abnormalities of fat redistribution syndrome Subjects: 39 patients 90% on protease inhibitors 22% women and 26% men had CD4 counts <200 Methods: Medication records Exercise habits Waist circumference Hip circumference Waist/hip ratio Chest circumference Mid-arm and Mid- thigh circumference Lab results used from primary physicians (9)

38. The fat redistribution syndrome in patients infected with HIV: Measurements of body shape abnormalities Results: -Mean glucose levels were within a normal range -Triglyceride and cholesterol levels were moderately elevated -The waist/hip ratio was abnormal -BMI was within normal parameters -Mean mid arm circumference and triceps skinfold were below national levels (9)

39. Opportunistic Diseases Fungal infections-Thrush Viral infections- Herpes Bacterial infections- salivary gland disease, periodontal disease, pneumonia, upper respiratory tract infection Various cancers- Kaposi’s sarcoma, Hodgkins Disease (1,5)

40. Symptoms Nausea Vomiting Diarrhea Abdominal Pain Anorexia Taste changes Fatigue Chills Sore Throat Headache Weight loss Fever Anxiety Frequent infections (1,5,6)

41. Goals of Nutrition Intervention in HIV Restore macro/micro nutrient deficiencies Manage symptoms of disease and/or medications Weight maintenance Hydration Alter diet if co-disease exists that warrants nutritional therapy Avoid fatigue during meal times by providing small, frequent meals Initiate tube feeding if necessary (5)

42. Methods of Monitoring and Evaluating HIV Patients Weight records Reports of GI distress and symptoms Food records Laboratory results (1,5)

43. Nutrition Education Food Safety Protein sources Fluids Kilocalories Micronutrients Exercise Food/Medication Interactions Symptom management Weight changes Management of nutritionally pertinent co-diseases The relationship between nutrition and immunity Additional resources for educational information on the disease process (1,5,6)

45. Application of a Five-Step Message Development Model for Food Safety Education Materials Targeting People with HIV/AIDS 5 Step Method Results Steps 1 and 2 stated issues and established food safety recommendations Step 3 involved needs assessment focus groups Step 4 used data, recommendations on safety, and the Health Belief Model to make 5 prototype educational materials for HIV/AIDS Step 5 evaluated the materials during sessions and surveys Needs Assessment groups initially were resistant to and confused by food safety recommendations Prototype material groups on average rated the materials 5.6-6.4 on a scale of 1-7. 19 of 32 participants reported increased confidence of knowledge after reviewing the educational packets Resistance was greatest for the encouragement to avoid unheated deli meats, use of a thermometer and avoidance of soft cheeses 21 of 25 Health care providers showed interest in using the materials for their clients educational benefit (10)

46. In Depth-Initial Visit to Doctor Visit primary doctor with c/o 10 lbs weight loss and sore throat since the beginning of August Pt placed on antibiotics (amoxicillan, levaquin, Diflucan) Return to primary doctor- patient is no longer able to swallow liquids and still losing weight Admitted to the hospital with diagnosis of esophagitis

47. Signs/Symptoms on Admission Unable to swallow Pain in the mouth and throat Dizziness Unable to open mouth all of the way 18 lb weight loss by the time of admission N/V/D Chewing/Swallowing difficulty due to mouth ulcers

48. Past Medical History/ Social History HTN Hepatitis C IV Drug Abuse (Heroin, Cocaine) Tobacco use (quit in January of 2003) Married with one son Lives at home with his wife Maintained on Methadone

49. Physical Exam Physician Notes: General: Well developed, well nourished, in no distress, alert and oriented Vital Signs: Tmax is 100.2. All other vitals are stable HEENT: Significant for thrush, small ulcer inside of left side of pharynx. Looks normal but is unable to open mouth. Nodes are slightly swollen. Neck: Supple Chest: Clear Extremities: - for cyanosis, clubbing, edema Abdomen: Soft, non tender, + for bowel sounds Neurologic: Grossly intact Skin: Warm, no rashes

50. Tests/Procedures Biopsy of ulcer to r/o cancer Full lab work-up- HIV + CT scan of throat/abdomen to r/o perforations Esophageal gastroduodenoscopy Speech therapy evaluation for swallowing to r/o aspiration pneumonia Chest X-ray MRI of brain EKG CT scan of the head because of change in mental status EEG because of seizure

51. Medications Zovirax (Antiviral)- N/V/D anorexia Diflucan (Antifungal)- Taste changes, dry mouth, dyspepsia, N/V/D Mycostatin (Antifungal)- N/V/D Dapasone (Antibacterial)- N/V anorexia Dilaudid (Opioid)- dry mouth, dysphagia, N/V/D, dysmotility, taste changes, upset stomach Filgrastin (Increases production of neutrophils) Multivitamin and Folic Acid Magic Mouth Wash- numbs mouth Zofran (Antiemetic)- dry mouth, diarrhea Oxycodone (Opioid)- anorexia, dry mouth, upset stomach, N/V/D, constipation (11)

52. Laboratory Values Initial Labs 9/14 Follow up Labs 10/1 Alb-1.7 L Total P- 5.5 L AST- 193 H ALT- 99 H BUN- 4 L Ca- 8.2 L WBC- 1.4 L RBC- 2.65 L Hgb- 7.7 L Hct- 22 L RDW- 15.1 H Hgb-11.4 L Hct-33 L BUN- 20 H Na-130 L K- 3.2 L (12)

53. Diet Placed on a full fluid diet Patient cannot tolerate acidic foods Cannot manage solid foods <50% consumption of meals Neutrapenic precautions due to low WBC count Food recall taken

54. (13,14)

55. Progression of Dx during hospitalization Seizure Change in Mental Status Temporary pacemaker placed Developed Kidney stones- had a stent placed in ureter Tachycardia- 200+ heart rate- transferred to CCU Changed to a nectar thick liquids due to aspiration risk Total weight loss of 30 lbs Ulcers not healing Low WBC count PICC line insertion Sonography of gallbladder reveals gallstones Consult for drug rehab Respiratory Arrest

56. Assessment 46 year old male admitted with esophagitis. Pt reports signs of N/V/D, 18 lbs weight loss over 1 month, painful swallowing/chewing and dizziness. Pmhx of IV drug abuse, Hep C, HTN. Patient on a full fluid diet. Reports appetite is poor with less than 50% consumption of meals. Ht- 5’7, Wt- 150#, UBW- 180#, %UBW- 83, IBW- 148, % IBW 98.6, BMI- 23, 10% weight changes over 2 months. Labs- Alb-1.7 L, Total P- 5.5 L, AST- 193 H, ALT- 99 H, BUN- 4 L, Ca- 8.2 L, WBC- 1.4 L, RBC- 2.65 L, Hgb- 7.7 L, Hct- 22 L, RDW- 15.1 H. Meds- Zovirax, Diflucan, Mycostatin, Dapasone, Dilaudid, Filgrastin, MVT, Magic Mouth Wash, Zofran, Oxycodone. Estimated needs- Kcals (30kcal/kg) 2045kcals, Protein (2g/kg) 147g, Fluids (30mL/kg) 2209mL. Diet recall- Total kcals- 700, 151g CHO (604kcals), 6g protein (24kcals), 8g fat (72kcals). Diet recall reveals pt is consuming 34% estimated kcals needs and 4% estimated protein needs. Patient is at high nutritional risk related to weight loss, diagnosis, inadequate intake, and lab values.

57. PES/Nutrition Diagnosis Inadequate caloric intake related to difficulty swallowing as evidenced by 10% weight loss and pt meeting only 34% of kcal needs. Increased energy expenditure related to increased energy needs associated with diagnosis as evidenced by 18lbs weight loss. Inadequate protein intake related to decreased appetite and consumption of meals as evidenced by pt meeting only 4% of protein needs and Alb 1.7 L. Swallowing difficulty related to mouth ulcers as evidenced by pt inability to swallow due to pain.

58. Interventions Provide patient with Ensure Plus 3x day for an extra 1050kcals Recommend diet be advanced as tolerated to soft foods to increase calories Provide patient with Prostat 3x day for an additional 45g protein Educate patient on high biological value proteins and high calorie foods

59. Outcomes/Monitoring and Evaluation Patient will consume 80% of meals Patient will consume 100% of supplements Diet will be upgraded to soft by the doctor Albumin will be 3.5 or above in 3 weeks Patient will maintain current weight Monitor weight Monitor intake by calorie count or visiting during meals Monitor tolerance to supplement and adherence Monitor lab values Monitor for diet change Outcomes Monitoring/Evaluation

60. Nutritional Complications Caused by Oral Issues Burning Mouth Pain Dysphagia Chronic Ulcers Swollen oral cavitiy Painful Chewing Oral Malignancy Herpes Simplex Cytomegalovirus Kaposi’s Sarcoma Stomatitis Periodontitis EsphagealCandidiasis Esophagitis Symptoms leading to decrease intake/appetite Causes (15)

61. MNT for Oral Issues Avoid irritating foods- spicy/acidic Soft, moist foods Temperatures may be an issue, experiment for tolerance Avoidance of very hot or very cold foods should be initially done. Room temperature food will often be best accepted Patients with persistently painful oral cavities should consume foods that are nutrient and calorically dense (1,6)

62. Summary of Prognosis Doctors debating about opioids and heart condition Anti-retroviral therapy being determined Awaiting psych consult for rehab for opioids Will transfer when patient is stable

63. Conclusion What do you think? Weight loss most likely impaired health Nutrition and immunity are very closely related HIV is complex, every patient differs

64. References Nelms MN, Sucher K, Long S. Nutrition Therapy and Pathophysiology. Belmont, CA: Thomson Wadsworth; 2007 Price SA, Wilson LM. Pathophysiology: Clinical Concepts of Disease Processes. St. Louis, MO: Mosby; 2003 Center for Disease Control and Prevention-HIV/AIDS. http://www.cdc.gov/hiv/. Updated August 21, 2009. Accessed November 21, 2009. WHO and HIV/AIDS. http://www.who.int/hiv/en/. Updated December 2008. Accessed November 21, 2009. Escott- Stump S. Nutrition Diagnosis- Related Care. 6th ed. Philidelphia, PA: Williams and Wilkins; 2008 Mahan LK, Escott-Stump S. Krause’s Food, Nutrition, and Diet Therapy. Philidelphia, PA: Saunders; 2004 Sahni S, Forrester JE, Tucker KL. Assessing Dietary Intake of Drug-Abusing Hispanic Adults with and without Human Immunodeficiency Virus Infection. J Am Diet Assoc. 2007;107(6):968-976. Woods MN, Spiegelman D, Knox TA, Forrester JE, Connors JL, Skinner SC, Silva M, Kim JH, Gorbach SL. Nutrient Intake and Body Weight in a Large Cohort That Includes Women and Minorities. J Am Diet Assoc. 2002;102:203-211. Gerrior J, Kantaros J, Coakley E, Albrecht M, Wanke C. The Fat Redistribution Syndrome in Patients Infected with HIV: Measurements of Body Shape Abnormalies. J Am Diet Assoc. 2001;101:1175-1180.

65. References Hoffman EW, Bergmann V, Armstrong J, Kendall P, Medieros LC, Hillers VN. Applications of a Five-Step Message Development Model for Food Safety Education Materials Targeting people with HIV/AIDS. J Am Diet Assoc. 2005;105:1597-1604. 11. Pagana KD, Pagana TJ. Mosby’s Diagnostic and Laboratory Test Reference. 9th ed. St. Louis, MO: Mosby; 2009. Pronzky ZM. Food Medication Interactions. 15th ed. Burchrunville, PA: Food Medication Interactions; 2009. American Diabetes Association and American Dietetic Association. Exchange Lists for Meal Planning. 2008. Sodium Content of Foods. www.nal.usda.gov/fnic/foodcomp/Data/SR17/wtrank/sr17a307.pdf. Accessed November 11, 2009. Decker R, Mobley CC. Position of the American Dietetic Association: Oral Health and Nutrition. J Am Diet Assoc. 2007;107:1418-1428.