Film Producer

with HIV
Infection

Case Study

Three years ago, Darrell Meckler, a 34 year old film

producer, sought medical help when he began feeling run-down
and developed a painful white fungal infection over his mouth
and tongue. The presence of thrush, recent weight loss, and
anemia alerted Mr. Meckler's physician to the possibility of HIV
infection. When Mr. Meckler tested positive for HIV, he and his
family and friends were devastated by the news, but those close
to him have remained supportive. During the three years since
Mr. Meckler began antiretroviral drug therapy, he has
maintained his weight but has also developed lipodystrophy and
hypertriglyceridemia. Mr. Meckler is 6 feet tall and currently
weighs 185 lbs. He occasionally develops diarrhea and
sometimes anorexia.

Assessment and Analysis

At first Mr. Darrell Meckler was not aware about his

condition but with the continuous run down feeling and
developing a painful white fungal infection over his mouth
and tongue, it resulted to the initial seeking of medical help
and eventually diagnosed with HIV infection. After knowing
about his problem he closely abided to the treatment
regimen and seem to follow the diet as well as considering
that he has maintained his weight.

HIV Human immunodeficiency

virus
it attacks the immune system and
disables a persons defenses against
infections and certain cancers. Patients
may expect an ever-worsening course of
illness and possibly death. In recent
years, however , treatment options have
expanded and patients have benefited
by vast improvements of quality. life.

The disease has still no cure, but

remarkable progress has been
made in
understanding and treating HIV infection.
Without a cure, the best course is prevention.
HIV is most often sexually transmitted and can
be spread by direct contact with contaminated
body fluids, such as blood, semen, vaginal
secretions, and breast milk.

CONSEQUENCES

OF

HIV

HIV infection destroys immune cells that have a protein

called CD4 + T cells because the presence of CD4 is a primary
characteristic. Early symptoms of HIV infection are nonspecific
and may include, fever, sore throat, malaise, skin rashes,
nausea, muscle and joint pain and diarrhea. Afterward, many
people remain symptom-free for five to ten years or even
longer. However, if the HIV infection is not treated, the
depletion of t- cells eventually increases the persons
susceptibility to opportunistic infections, that is infection
caused by microorganisms that normally do not cause disease
in
healthy
individual.

The term Aids applies to the

advanced stages of HIV infection, in which
the inability to fight illness allows a
number of serious diseases and
complications to develop such AIDSdefining illness include severe infections,
certain cancers, and wasting of lean
tissue.

Nutrition in Practice
1a) Describe lipodystrophy and discuss its typical pattern in people who have
HIV infection.
Lipodystrophy is a problem with the way the body produces, uses, and stores fat. It is
also called fat redistribution. Since the widespread use of antiretroviral theraphy
began, the numbers of HIV positive people with lipodystrophy has increased.
Today, lipodystrophy occurs in 30% to 50% of people who are infected with HIV.
Abnormalities of Lipodystrophy:
1) Fat build up or Fat redistribution ( lipohypertrophy, lipoaccumulation, or
hyperadiposity)
- is when fat accumulates in certain areas of the body.
- Some people see the amount of visceral fat ( fat deep within the body ) around their
gut increase significantly.
- The medical term for this is LIPOHYPERTROPHY ( excessive fat growth ).
- Increased dorsocervical fat pads : a buildup fat on the back of the neck and
shoulders, sometimes called buffalo hump has also been seen, as well as
increased fat tissue in the breasts. Some people have also reported round,
movable, flattened lumps of fat under the skin (lipomas).

 Abdomen ( central obesity )

Breasts ( occurs in both men and
women )
Back of the neck and shoulders (
buffalo hump )

Fatty growths in different parts

of the body ( lipomas )
2) Insulin resistance
Obesity is characterized by increased body adiposity and leads to insulin
resistance.
Paradoxically, some conditions characterized by a paucity of fat also
cause insulin resistance, namely the syndromes of lipoatrophy.
The resemblance between the metabolic abnormalities of these extreme
states of adiposity underscores the importance of fat tissue in energy
homeostasis.

3) High levels of fats in the blood or abnormal blood lipid

-Some people have an increased amount of fat, or lipids, in their blood.
-The two types of lipids that increase are triglycerides and cholesterol.
-Increased cholesterol levels can increase the risk of a heart attack or stroke.
-Increased triglycerides can increase the risk of damage to the pancreas. (
Pancreatitis)
Its typical pattern:

A pot belly

Buffalo hump

Breast enlargement

Tissue lipomas

Low HDL

Hypertriglyceridemia

Hyperinsulinemia

1b) What adjustments in treatment and lifestyle may be helpful?

TREATMENT
1)

HAART : HAART induced adipocyte inflammation, oxidative stress and

macrophage infiltration, as well as altered adipocyte function and
mitochondrial toxicity, have been shown to be central to the development of
HIV-associated lipodystrophy syndrome (HALS).

1)

Appetite stimulant

MEGESTEROL it can be used as an appetite stimulant for people

experiencing loss of appetite and weight loss. It may help relieve bone pain,
and it can improve appetite and weight gain.

 DRONABINOL is a man-made form of cannabis (also known as marijuana).

It is also used to treat loss of appetite and weight loss in patients with HIV
infection.

3) Testosterone and Human Growth Hormone

This human growth hormone generates some changes in our body.
It decreases fat mass and increases muscle mass.
Testosterone also decreases body fat, increases lean body mass and increases
endurance.

LIFESTYLE
1.

Physical activity / resistance training

- Lifestyle modification (smoking, diet, exercise).

- Exercise is also recommended although consistent changes in plasma lipids will not
be seen in the short-term.
- Regular exercise should be encouraged to improve metabolic status.
- Lifestyle modifications alone may not be sufficient and may need to be implemented
along with pharmacotheraphy.

2. Dietary management
A diet with :

High CHON
Trans-fat and less fiber
A Mediterranean diet
High in Omega-3
Fresh fruit
Vegetables
A balanced low-fat
Low CHO diet is preferable since hypertriglyceridemia is present
in the patient.

2a) What strategies may improve his problems with diarrhea and anorexia?
Anorexia resulted from thrush and dysphagia
Use cold or frozen foods; they are often soothing.
Try soft foods such as ice cream, milk shakes, bananas, applesauce,
mashed potatoes, cottage cheese, and macaroni and cheese.
Avoid foods that irritate mouth sores such as citrus fruits and juices,
tomatoes and tomato-based products, spicy foods, foods that are very
salty, foods with seeds ( such as poppy seeds and sesame seeds ) that can
scrape the sore, and coarse foods such as raw vegetables and toast.
Ask your doctor about using a local anaesthetic solution such as lidocaine
before eating to reduce pain.
Use a straw for drinking liquids in order to bypass sores

Anorexia from lost of appetite

Eat small meals and snacks at regular times each day.
Eat the largest meal at the time of the day when you feel the best.
Include nutrient-dense foods in meals and consume them before other
foods
Indulge in favorite foods throughout the day. Serve foods attractively.
Avoid drinking large amounts of liquids before or with meals.
Eat in a pleasant and relaxed environment. Eat with family and friends
when possible.
Listen to your favorite music or enjoy a program on tv while you eat.
Take a walk before you eat.

Diarrhea
Drink plenty of fluids. Salty broths and soups, diluted fruit juices and
sports drinks are good choices. For severe diarrhea, try oral rehydration
formulas that are commercially prepared.
Avoid foods and beverages that increase gas, such as legumes, onions,
vegetables of the cabbage family, foods that contain sorbitol or mannitol,
and carbonated beverages.
Avoid high-fat foods if you are fat intolerant.
Avoid caffeine.
Eat smaller meals and eat more frequently.

2b) Suggests reasons why people with HIV infection may develop diarrhea
and anorexia.
Most people who are suffering from HIV infection will have ongoing
problems regarding wasting and weight loss. The wasting is associated
with HIV infection which has many causes such as inadequate food intake
and anorexia.
EMOTIONAL DISTRESS, PAIN, AND FATIGUE: The physical and social
problems that accompany chronic illness may cause fear, anxiety, and
depression, which contribute to anorexia. Pain and fatigue, which may be
associated with some disease complications, can cause anorexia and
difficulty with eating.
ORAL INFECTIONS: The oral infections associated with HIV infection such
as THRUSH ( Herpes Simplex Virus ) can cause discomfort and interferes
with food consumption.

 RESPIRATORY DISORDERS: Respiratory infections, including pneumonia

and tuberculosis, are common in people with HIV infection. Symptoms
often include chest pain, shortness of breath, and cough, which interfere
with eating and contribute to anorexia.
MEDICATIONS: The medications given to treat HIV infection, other
infections, and cancer often cause anorexia, nausea and vomiting, altered
taste sensations, food aversions, and diarrhea.
GI TRACT COMPLICATIONS: Complications involving the GI tract may result
from opportunistic infections, medications, or the HIV infection itself. In
addition to the oral infections described previously, infections commonly
develop in the stomach and intestines. Advanced AIDS is often
accompanied by characteristic changes in the lining of the small intestine,
likely caused by GI infection: the villi appear shortened and flattened, and
the absorptive area is substantially reduced. These changes contribute to
malabsorption, steatorrhea, and diarrhea.

As described earlier, many patients are unable to tolerate

the medications used to suppress HIV and develop nausea,
vomiting, and diarrhea. Furthermore, medications that treat
GI viral, parasitic, and fungal infections contribute to bacterial
overgrowth. Thus HIV-infected patients face an extremely
high risk of malnutrition due to the combination of intestinal
malabsorption, bacterial overgrowth, and nutrient losses from
vomiting and diarrhea.

3a) Explain why an HIV infection can lead to wasting as the

disease progresses to the later stages.
Even with effective treatment of HIV infection, weight
loss and wasting are ongoing problems for HIV-infected
patients.
The Centers for Disease Control defines AIDS-related
wasting syndrome as a 10% weight loss within a six-month
period accompanied by diarrhea or fever for more than 30
days without a known cause. The wasting has been linked
with accelerated disease progression, reduced strength and
fatigue.

In later stages of AIDS, wasting is severe and

increases the risk of death. Much as in cancer, the
wasting associated with HIV infection has many
causes such as:

Anorexia and inadequate food intake

altered metabolism
malabsorption
chronic diarrhea
diet-drug interactions

3b) How should Mr.Meckler's diet change if wasting becomes a

problem for him?

A regular program of resistance training can

improve muscle mass and strength and correct
some of the metabolic abnormalities (altered blood
lipids and insulin resistance) that are common in HIVinfected patients. The medications megesterol
acetate and dronabinol are sometimes prescribed to
stimulate appetite and help with weight gain.

DIETARY MANAGEMENT

DIET

MANAGEMENT

RATIONALE

HIGH CALORIE

- Avoid foods that increase

gas.

- For energy supply and

wasting

HIGH PROTEIN

- provide lean meats

- For energy supply and

wasting

- more on unsaturated fats

- for abnormal blood lipid

levels

- give low fatcold milk or

shake

- diarrhea

LOW FAT / FAT Restricted

BLAND DIET

- can be in a form of
enteral/parenteral feeding

COLD & LIQUID DIET

- full in energy and

nutrients but cold in
temperature and soft in
consistency

- for hypertriglyceridemia
- because of thrush

- for malabsorption and GI

complication

- thrush and dysphagia

Vitamin Supplementation
- improve immunity
A / Beta Carotene

- enhances response, CD4

Tcells

B Vitamins

- reduced lymphoid tissue

- enhance function

- enhances immunity, skin

test response

Mineral Supplementation

Cu

- due to metabolic effect

that decreases the level
due to DM

Fe

- due to metabolic effect of

HIV treatment

- Lost of T-cell immunity

Zn

- due to metabolic effect of

HIV treatment

video