Overview of wasting
Alvin Fisher, MD, specialist in internal medicine, Associate Director, Brown University AIDS Program, Staff physician, Rhode Island Hospital, Clinical Associate Professor of Medicine, Brown University School of Medicine, Chairman, Brown University AIDS Program Clinical Task Force, founding member, Primary Provider AIDS Education Program, Brown University, Medical Consultant, Newport, Rhode Island, Jazz, Folk, and Rhythm and Blues Festival

Viral load is not a good indicator of nutritional status. Though viral load may be below limits of detection, doctors are still seeing loss of body cell mass (BCM). As the affect of HIV on the metabolic system begins with initial infection, doctors need to do nutritional assessments as part of the first visit. Take a history, BCM, and measure micronutrient levels as part of the blood work.

Risk assessment for wasting:

Causes of wasting:

• inadequate nutrition,
• untreated complications of AIDS,
• altered metabolism,
• drugs that affect appetite: protease inhibitors; antivirals, especially AZT and ddI; antidiarrheals; chemotherapies, especially interferon and doxorubicin; and analgesics.

The importance of a GI workup. Half of people who are infected with cryptosporidiosis won’t show any sign of infection in a stool sample. If you suspect infection with cryptosporidiosis and don’t find anything, it’s important to do endoscopies and colonoscopies. Fifty percent of people on nelfinavir and ritonavir will have diarrhea that’s not related to an infection.

Psychodietetics. A nutritionist invented this word, and its meaning includes the psychological complications of HIV which affect nutritional status, such as anxiety, denial, depression and non-adherence. Eating is a social function, and social factors must be included in an assessment as well, such as isolation, financial means, and lack of access. Other complications of HIV infection that affect nutrition status are battle fatigue, and fear of adverse drug reactions (ADR). If someone is afraid of ADR, he or she will experience less GI dyspepsia and diarrhea just by eating less. Protease inhibitor side effects are primarily gastrointestinal and can also be affected by not eating as much as well. Not eating clearly contributes to weight loss.

For someone who is asymptomatic, a bio impedance analysis (BIA) should be done every 3 months. Someone who is symptomatic should have a monthly BIA. If there is weight loss, BIAs should be done twice a month.

Treatments. Therapies for weight loss include appetite stimulants, androgens, anabolics, and other agents. This doctor doesn’t use Megace because of the tendency to put on fat and side effects. Dronabinol (Marinol), which is a prescription drug containing the active ingredient of marijuana, leads mostly to putting on body fat as well and is better used as an antiemetic pill. Smoking marijuana works better as an appetite stimulant because you get more immediate absorption of its effects into the blood stream.

rHGH is a useful treatment for someone who is wasting as it helps with gain of lean body mass and loss of fat. A sustained improvement has been seen over 3 months. The major problem is cost, as this is a very expensive drug.

Anabolics such as nandrolone and oxandrolone are derived from testosterone and are protein building. Testosterone is primarily androgenic, or masculanizing. Oxandrolone is an oral anabolic with 95% bioabailability and is a good therapy for promoting weight gain. After weight loss, the treatment dose is 2.5-3 mg/day. There is some potential for androgenic effects. Oxandrolone does not use the liver very much so even in patients with liver disease it’s well tolerated at high dose. This doctor is currently conducting an open label study of oxandrolone at 20 mg/day for a year.

For a patient who doesn’t respond to therapy, he’ll add glutamine, the most abundant amino acid. HIV affects levels of glutamine, and low glutamine levels may be related to the onset of malabsorption.

Lost weight may not be recoverable in the presence of active OIs. He has seen patients on HAART and OI prophylaxis with documented weight loss which can be very expensive to treat.

Nutritional Therapies in HIV Related Wasting
Norma Muurahainen, MD, PhD, board-certified general internist involved in patient care, teaching and clinical research. Medical Director of the HIV Intervention Program, Assistant Director of Ambulatory Care Services, Director of Division of HIV Nutrition Research, Allegheny University Hospitals, Graduate, Philadelphia, PA.

It’s not the virus stupid, it’s also the host! This slide was the beginning of this research doctor’s presentation. Yes, it’s the virus, but as important is how well you – the host – are doing. And nutrition is an essential part of how well you do. Unfortunately, the importance of nutrition is not thoroughly understood, and is used as part of someone’s treatment both too little and too late.

Wasting used to be the second most frequent AIDS defining infection after PCP. With the use of protease inhibitors as part of combination treatments, that has changed. At the HIV Wasting Clinic in Philadelphia, weight loss is seen in 5-9% of clients who will progress to an opportunistic infection in 7 months.

Treatment with protease inhibitors can have undesirable outcomes including: obesity, new-onset diabetes, elevated lipids or fats such as cholesterol and triglycerides, high blood pressure, and vascular disease. Optimal nutritional management can help offset or avoid many side effects of drugs and symptoms of HIV infection.

Optimal nutritional management

• Assess food and water safety and make changes necessary.
• Monitor for changes in weight and symptoms.
• If there is a change, re-assess the diet, consider diseases or drug interactions, decreased oral intake, malabsorption, altered metabolism.
• Talk about how to eat on a treatment schedule and nutrient/drug interactions.

The lower the T4 cell count, the more malabsorption there will be even without symptoms. Malabsorption is when your body is unable to absorb the nutrients it needs to help cells grow and do their different jobs. Nutrients mostly come from what you eat and drink. If you’re not able to absorb enough nutrients from food, consider using an nutrition supplement. Of those widely available, Advera is better than Ensure as it contains medium chain triglycerides, a form of fat which your body more easily stores as energy.

Many people are put on IV nutrition feeding in the hospital. With TPN (total parenteral nutrition), all weight gain seen is fat. If the gut isn’t working well, there will be a slight increase in body cell mass. If the gut is not working at all due to an overwhelming infection, there will be no weight gain despite TPN.

Symptom management. Be aware of any food allergies, use anti-diarrheals or anti-emetics to control loss of fluids and nutrients. Your doctor can prescribe exercise and physical therapy. Did you know doctors can write prescriptions for physical therapy?

Weight loss is easier to prevent than treat when severe. Start early in assessing any need for treatment.

• lowered sex drive (low libido),
• can’t get an erection or have an orgasm (impotency),
• a small prostate - it should be large enough to feel,
• being irritable,
• less body and facial hair than usual,
• weight loss, and
• hypogonadism - which means all these things together.

• age,
• use of Megace,
• weight loss,
• hypopituitarism which means your adrenal glands are not working correctly - can be caused by tuberculosis infection and auto-immune diseases such as HIV infection,
• treatment with anticoagulants,
• cancer that’s spreading, called metastatic carcinoma,
• fungal infections, especially histoplasmosis,
• viral CMV,
• chemotherapies for tumors,
• treatment with ganciclovir and ketoconazole, and
• generalized stress and illness.

Anti-retroviral therapies and HIV-associated weight loss
Marisela Silva, MD, research Associate, Community Health Department, Nutrition Unit, Tufts University School of Medicine, Boston, MA.

This researcher reported on an observation study that looked at whether participants on antiretroviral therapy including a protease inhibitor experienced weight loss.

Five hundred participants were seen every six months, with phone interviews every month. The average age was 39, 75% were male, and 63% were white. In participants on antiretroviral treatment including a protease inhibitor, there was significant increase in weight and body mass, and an improvement in physical function. The increase was mostly fat and water though, not bone or muscle. The increase seen was due in part to an increase in the number of calories taken in, and the improvement in physical function was due possibly to the placebo effect. Because these participants chose to be in a study, they were naturally paying more attention to what and how much they ate. In participants who didn’t respond to treatment with protease inhibitors, lean body mass decreased significantly.

Whey Protein & L-Glutamine Use in HIV-Associated Weight Loss
Donald Kotler, MD, Associated Professor Medicine, Columbia College of Physicians and Surgeons, Director of Gastrointestinal Immunology, St. Luke’s-Roosevelt Hospital Center, Vice President, Board of Directors, Community Research Initiative on AIDS (CRIA)

How does HIV infection affect protein status? All living things are made up of protein. Treating weight loss with Megace will increase food intake more than 30% but weight gain will be mostly fat. With enteral feeding, there is also an increase in fat. TPN feeding results predominantly in a change in body fat. An increase in calorie intake is important, but feeding is not sufficient to replete body cell mass.

Two kinds of weight loss are starvation, due to an eating disorder or malabsorption, and cachexia (pronounced ka-ke-xia) due to chronic infection and/or tumors. HIV infection is a chronic infection, meaning it doesn’t go away.

HIV infection causes a metabolic change that will persist even if the viral load is undetectable. Stress changes due to infection persist. HIV abuses the body and the body remembers that abuse. All HIV infection includes a cachexic response. With HIV infection there is an increased protein turnover and a decrease in skeletal muscle due to in increase in protein synthesis in the liver which tries to clear the damage done by HIV.

In men, the loss of skeletal muscle accounts for nearly 60% of weight loss. The loss of protein in skeletal muscle leads to weakness which leads to a decrease in the quality of life and loss of independence.

Glutamine: Glutamine is an amino acid related to glutamate. Amino acids are the building blocks of proteins. Glutamine is considered a non-essential amino acid because a normal body can usually make all it needs. Glutamine is an energy source found in intestine and lymphoid cells. The cells serve as a nitrogen shuttle, bringing nitrogen from the muscles to the liver or kidney. Nitrogen basically equals protein since 98% of the nitrogen in the body is found in protein.

Whey protein. Whey is a milk protein that’s left over once the curd is removed. Curd is cottage cheese. Whey is highly biologically available and contains the milk globulins. Gamma globulins are antibodies. Antibodies fight infection. Whey has glutamine, argonine, and more essential amino acids. As a protein source, whey is as good as steak or egg albumin. In cachexia or damage to muscles, there is a release of glutamine. The immunologic effects of whey are mostly at the intestinal level and protect newborn animals from infection.

Studies needed. Glutamine has been shown to protect the intestine, and anecdotal reports say there is a reduction in protease inhibitor associated gas and diarrhea when 30 grams of glutamine are taken a day. Glutamine has been used for short bowel syndrome in an attempt to improve intestinal function. When whey protein by tube infusion was tried to treat cryptosporidiosis infection, it wasn’t stronger than the crypto. So there is no assurance that a nutrient will overcome damage done by an infection. And there is no proof that glutamine is a useful treatment for HIV-associated metabolic changes. No formal studies of whey protein have been done either. Studies need to be done to determine the difference of specific effects between whey and non-whey protein. In order to understand a treatment, different investigators using different methods need to get the same results.