MAINTAINING YOUR NUTRITIONAL HEALTH

You need to balance the amount of energy you eat as food with the amount of energy your body needs to maintain itself, and to conduct your daily activities. If you take in more food energy than is necessary, you will gain weight; if you take in less, you lose weight. If you are HIV+ there may be a number of reasons why you take in less food energy. Drugs or opportunistic illnesses may cause symptoms that make eating unappealing. Your energy level may be low and you may not be active enough to stimulate your appetite or to feel like preparing complete meals. Some drugs also alter your sense of taste or smell, and this may, in turn, affect your diet.

Your body may also be less capable of taking in nutrients and therefore energy.This is called malabsorption. Malabsorption may be caused by bacterial or parasitic infections in your intestines. It may be caused by changes in your intestines due to HIV. Malabsorption may occur when you have diarrhea caused by drugs you are taking.

People with HIV need to pay attention to their diet to get the best possible nutrient balance. They may also need to supplement certain specific nutrients. If a person with HIV does not take in enough nutrients, their energy intake is decreased and they may begin to lose weight. We will discuss the problem of weight loss and how to deal with it later in this guide. First, let's talk about eating to stay healthy and get the nutrients you need.

MAKING NUTRITION DECISIONS
There is some conflicting advice about how people with HIV should eat, and even more around what nutrients they should supplement. HIV is a relatively new disease and there are many uncertainties about how to treat it. As well, research into nutrition has often been of lower priority than research into drugs that can be patented and sold. Lastly and probably most significantly, there are many differences between individuals with HIV. The immune destruction seen in HIV leaves people vulnerable to different diseases. Different disease processes will change your body's nutritional needs in different ways. This phenomenon means many of the studies done on HIV+ people have produced conflicting results.

So how do you find out what is right for you? First, we encourage you to do as much research as you can. It is useful to get information from many sources, and not to trust just one article or person for all of your information. Talk to other people living with HIV/AIDS about what works for them. Discuss what's right for you with your doctor. There are a number of existing tests that your doctor can use to help assess your nutritional health and some new tests on the horizon that may provide more insights in the future.

In the case of nutrition-related questions, you may also wish to seek the help of a registered dietitian. Dietitians specialize in nutrition and can help you figure out the diet and supplements that are appropriate for your specific health needs. They are educated in nutritional sciences and are registered with provincial regulatory bodies. If you choose to see an unregistered nutritionist, it is wise to ask for references and to speak to other clients whom the nutritionist has worked with.

Most hospitals employ dietitians, so if your doctor is associated with a hospital he or she may be able to help you make an appointment. Call your local health unit; they may also be able to refer you to a dietitian.

EATING WELL
The foods we eat are made up of three components: proteins, fat, and carbohydrates. One of the goals of good nutrition is to take in the right balance of protein, fat, and carbohydrates. Another frequent challenge for HIV+ people is to take in enough food to maintain their body weight, muscle mass and energy.

Our bodies must take in protein to make protein. Many important functions of our body are carried out by proteins. Proteins make up our muscles, skin, and hair. They also make up parts of our immune system and the connective tissues that hold our bodies together.

Our bodies must also take in fat to create fat. Fat cushions our internal organs, and stores energy for future use. Fats act as carriers for the fat-soluble vitamins A, D, E, and K. Fats are also used to make our cell membranes and many of our hormones.

Our bodies also need carbohydrates. Carbohydrates provide quick energy for day to day activities.

Proteins
Proteins are made up of building blocks called amino acids. You build the proteins your body needs by combining the amino acids you eat, with amino acids created by your body. Most people get the majority of their protein from meat including fish and poultry, although vegetarians rely solely on plant proteins - particularly beans and peas. Vegetarians need to derive protein from a variety of sources to ensure that all the amino acids which their bodies don't make are available in their food. Vegetarians also need to ensure that their diets contain adequate iron and vitamin B12, which may be limited in a strict vegetarian diet. Canada's Food Guide to Healthy Eating recommends that Canadians have 2-3 servings of meat or meat alternatives daily. One serving is a fist-sized piece of meat, 2 tablespoons of peanut butter, ½ cup of beans, 1/3 cup of tofu or 2 eggs.

Protein is important to HIV+ people because it is the primary component of muscle, and plays a crucial part in many of our metabolic processes. When HIV+ people lose weight, they often lose muscle. This is called muscle wasting. It is important to eat enough food to prevent your body from using the energy stored in your body as muscle. Research also suggests that a high protein diet and regular exercise may help people with HIV avoid muscle wasting. Eating more protein may also help you regain lost muscle mass. For this reason, if you can, you may want to exceed the Canada's Food Guide protein requirements. Foods that are high in protein include red meat, poultry, fish, eggs, nuts, beans, peas, grains, and other seeds. Try to take in protein from many different foods, so that you get a variety of amino acids. A few studies have shown that some people with HIV have low levels of some amino acids.

Because many of the weight loss problems seen in HIV are related to low food intake, dietitians often suggest you eat many small meals throughout the day, rather than 2 or 3 large ones, to help you take in enough food. Make sure to include some protein-containing food in each of these meals. You can also buy protein powders at drug and health food stores to increase your protein intake.

Fats
Fat is a vital part of the human diet. Fats are part of every food group in Canada's Food Guide to Healthy Eating but are found primarily in butter, vegetable oil, and the animal fat present in meat. Because the North American diet is very high in fat, we are often taught that fat is bad. In truth, like most things, fat is really only a problem when eaten in excess. There are a number of different types of fat. These are explained in the following table. Use the table to help you decide which fats you want to eat and which ones you don't. Although you may wish to modify what you eat, there is no increased need for fats when you are HIV+.

Some HIV+ people have difficulty absorbing fats. This condition is called steatorrhea. It may be due to intestinal damage caused by opportunistic infections, or by HIV itself. Steatorrhea can cause diarrhea, bloating, or changes in the colour of your stool. If you have steatorrhea, you are probably absorbing very little of the fat you eat. Since it is still important to have some fat in your diet, you may want to drink liquid supplements or other products that contain a type of fat called MCT (medium-chain triglycerides). This type of fat is easy to absorb. Liquid supplements are discussed in the weight loss section of this guide. You can find liquid supplements and other MCT containing products in many drug or health food stores.

Types of Fat
Saturated Fats are animal fats like those found in butter, or as part of red meat. Many North Americans try to avoid animal fats because excessive amounts can raise the body's cholesterol levels. High triglyceride and cholesterol levels are associated with a higher risk of heat attacks and stroke. Until recently, this was not too much of a concern for HIV+ people, because people with HIV had been observed to have low cholesterol levels. Cholesterol is necessary for your body. It is used to create cell membranes, and to make your body's hormones. Because of this, people with HIV may want to take advantage of their low cholesterol levels, and eat animal fats both as a source of cholesterol and energy. Recently, both high triglyceride and cholesterol levels have been observed in some HIV+ people on antiretroviral therapy. The nutritional concerns of these individuals are discussed in the section on "Body Shape Changes Associated with Protease Inhibitors." If your cholesterol and triglycerides are both high, you should consider limiting your saturated fat intake.

Polyunsaturated Fats are found in some vegetable oils such as corn and peanut oil, and in most margarines. In some studies, polyunsaturated fats been shown to reduce T-cells, and with them the functioning of the immune system. While these studies were not HIV-specific, it may still be wise for HIV+ people to avoid eating a lot of polyunsaturated fat. Polyunsaturated fats are much less likely to increase cholesterol than saturated fats.

Monounsaturated Fats are also found in vegetable oils like olive oil and canola oil. These are not suspected of being immune suppressive. Monounsaturated fats do not normally increase your cholesterol levels like saturated fats, but they are sometimes modified when heated during processing. For this reason, many people look for olive oil that is "cold pressed."

Omega-3 Fatty Acids are called essential fatty acids because they must be present in your diet. Your body can't manufacture them. They are found in the oils of most fish and seafood, as well as in flaxseed and some beans and peas. Eating foods rich in omega-3 fatty acids has been shown to reduce the risk of heart attack, and to have a positive influence on cell-mediated immunity (the part of the immune system most damaged by HIV infection). Health Canada has recommended that all Canadians increase the amount of omega-3 fatty acids in their diet. The only clear study of omega-3 acids to date, in people with HIV who were experiencing wasting, used very extreme dosages. Using omega-3 fatty acids reduced their triglyceride levels and, if they had no new opportunistic illnesses during the study, it helped them gain weight. Many people with HIV who wish to supplement their food intake of omega-3 fatty acids take omega-3 fish oil supplements (about 3 g daily).

Warning: These fish oil supplements are not cod liver oil, or any other fish oil containing vitamins A and D. Vitamins A and D should be removed from omega-3 fatty acid supplements because the usual doses may result in an excessive intake of these vitamins.

Carbohydrates
Carbohydrates make up most of an average Canadian's diet. Carbohydrates can be simple sugars like the sugar you put in your coffee. They can also be complex carbohydrates, which are long strings of sugar molecules linked together. Complex carbohydrates are found in breads, cereals, and pastas, as well as in fruits and vegetables. Because foods rich in complex carbohydrates are often rich in vitamins and minerals, they are usually the most desirable sources of carbohydrates. Most people also include some simple sugars in their diet just because they taste good. Simple sugars are fine in moderation, especially if they help increase your food intake of other nutrients by making your meals more appealing.

Canada's Food Guide to Healthy Eating suggests that you eat 5-12 servings of grain products per day, and 5-10 servings from the fruit and vegetable group. This should be the source of most of the carbohydrates in your diet. Although it sounds like a lot, "servings" are actually quite small. For example, a bagel represents two servings of a grain product. One serving of grain is a slice of bread, half of a bagel, or half a cup of pasta or rice. A serving of a fruit or vegetable is usually about half a cup of fruit or tomato sauce or one medium sized fresh fruit or vegetable.

Carbohydrates are important because they provide the body with quick, easily used energy. Carbohydrates help you maintain the energy balance we talked about in the introduction, so that your body does not have to draw on stored energy sources like fat and muscle.

Fluids
Our bodies are primarily water. Regardless of HIV status, people should drink 8 glasses (8 oz) of water a day. This helps replace water lost in sweat and urine. Water also transports nutrients throughout the body and keeps your kidneys functioning in a health way. For people taking particular drugs, like indinavir, fluid intake can be critical. If you are sweating a lot or losing fluid in other ways, like vomiting or diarrhea, you also lose important minerals. If you have become dehydrated you should consider drinks like Gatorade and other sports drinks, which also replace these minerals.

Alcoholic drinks are fine in moderation, if they don't interfere with any medications you are taking. This is something you should discuss with your doctor. Unlike most fluids, alcohol actually removes water from your system instead of increasing it; therefore, alcoholic drinks "don't count" as part of the 8 glasses of water you need every day.

EATING SAFELY
Food safety tips
People with HIV are vulnerable to many infections because their immune system is damaged. This includes food poisoning infections like Salmonella. The following are very practical list of suggestions for avoiding food poisoning.

• Shopping
• Buy only pasteurized milk and cheese.
• Avoid ripe, imported, and moldy cheeses like blue or Roquefort. Hard cheeses, such as cheddar and parmesan, can be kept for up to six months. Soft cheeses should not be kept for more than seven days.
• Never buy products whose "sell by" or "best used by" labels have passed.
• Put packaged meats into a plastic bag before placing in your shopping cart. This prevents meat drippings from touching other foods.
• Put chilled or frozen foods in the refrigerator as soon as possible.
• Leave eggs in their original containers. The egg rack in your refrigerator door may have a higher temperature.
• Food preparation
• Wash hands with soapy water frequently.
• Carefully wash all cutting boards after chopping raw meats or vegetables.
• Never thaw frozen foods by letting them sit out at room temperature. Thaw in the refrigerator, under cold water, or defrost in the microwave.
• Cook all meats to 160 degrees F or higher at the thickest point. Poultry should be cooked to 185 degrees F.
• Keep your refrigerator temperature 40 degrees F or lower.
• Wrap and cover foods in refrigerator. Use air-tight containers when possible.
• Store hot leftovers in a shallow, small container. Reheat until hot to touch throughout.
• Don't keep leftovers for more than three days. When in doubt, throw it out.
• Foods
• Never consume raw meat, poultry, or fish. Avoid steak tartare, carpaccio, raw oysters, sushi, sashimi.
• Avoid raw eggs or foods that contain raw eggs such as Caesar salad dressing, Hollandaise sauces, homemade eggnogs, and mayonnaise. When cooking eggs, make sure yolk and whites are not runny. Egg substitutes (like Eggbeaters) or pasteurized egg products are available at grocery stores.
• Wash all fruits and vegetables. Peeling eliminates some risk of bacteria.

ANTIOXIDANTS
The process of breaking food down into energy involves a chemical reaction called oxidation. Food break down is one of many oxidative processes in our bodies. During this process, molecules called free radicals are produced. Although free radicals are a normal part of the oxidation process, they can damage the membranes of our body's cells in much the same way that rust damages the body of a car. To control this process our body produces an antioxidant, called glutathione, in the walls of our cells. Other antioxidants like beta-carotene, selenium and vitamins A, C and E are present in what we eat.

During HIV infection, many researchers have observed an increase in free radicals. The cause of this increase is not completely understood. A decrease in antioxidants in general and glutathione in particular, has also been observed. Having low levels of glutathione in your body is associated with a lower survival time for people living with HIV.

Many people living with HIV choose to supplement their body's supply of glutathione by taking NAC (N-acetyl-cysteine). NAC is converted to glutathione by the body, and has been recommended by some researchers and dietitians. Supplementation with NAC has been shown to increase survival time in HIV+ people, and to increase CD4+ counts in healthy volunteers.Most people living with HIV who take NAC take around 1.5-2 grams. NAC has no significant side effects at this dosage although it is quite acidic and may be irritating to the stomach. It is probably wise to take it with food, and to avoid taking it at the same time as drugs like aspirin that irritate the stomach. Acidic beverages like orange juice will help absorption. At very high dosages of 6-8 g, NAC can cause diarrhea, nausea, and other gastrointestinal problems.

VITAMINS AND MINERALS
Vitamins and minerals play many important roles in our bodies. They help us break down other foods, keep our skin, bones and eyes healthy, and help our immune system function properly. Although many people think of vitamins as pills, the best and cheapest way to take in vitamins and minerals is in the food you eat. One simple way to get a variety of vitamins and minerals is to eat a variety of foods. Choose as many different colours of fruits and vegetables as possible. This insures a variety of vitamins and minerals in your diet.

Many studies have shown vitamin and mineral deficiencies among people with HIV. Significant deficiencies in vitamins A, B1, B6, B12, C, E and folate have been observed in some people, as well as deficiencies in the minerals iron, selenium, magnesium and zinc. HIV+ people who are deficient in vitamins A, the B vitamins, E and the mineral selenium have been observed to get ill more quickly than those without deficiencies.

It may not be possible for some HIV+ people to take in enough vitamins and minerals from their food. This is particularly true if you are having problems eating enough in general. You may also be having problems absorbing vitamins, and this may not be obvious. For these reasons, many people with HIV choose to take supplements.

There are no studies which prove a cause and effect relationship between vitamin supplements and improved health in HIV+ people who have no signs of deficiency. Only in cases of deficiency have supplements been proven beneficial. However, studies surveying HIV+ people who take nutritional supplements show that these people live longer and have more signs of a healthy immune system. Virtually all dietitians now recommend a multivitamin with minerals to their HIV+ clients.

Larger amounts of vitamin and mineral supplements (beyond what is contained in a standard multivitamin) are expensive, and may involve taking many more pills every day in addition to any prescription medications you are taking. You will also need to be careful about interactions between vitamins and prescription drugs (see below). For both of these reasons, it is a good idea to get as many of your vitamins and minerals from food as possible.

EXERCISE
Several studies have shown aerobic exercise improves quality of life for people with HIV. Some studies have also suggested exercise has beneficial effects on the immune system such as increasing CD4+ cells. Exercising to the point of exhaustion, however, has been shown to be immune suppressive. The biggest benefit of exercise for HIV+ people may be the building and retention of muscle mass. Exercise, including working out with weights, and swimming, has been shown to improve muscle function and to build lean muscle mass in HIV+ people. Any type of exercise also has the benefit of releasing stress, and may help increase your appetite.

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