| Unintentional
weight loss has long been recognized as a reason for concern
in people living with HIV/AIDS (PLWHA). Both studies and experience
have helped us to understand that unintentional weight loss
can be a signal of a potential secondary problem and ultimately
an indication of increased risk for disease progression and
poor outcome.
Different factors contribute
to unintentional weight loss and malnutrition. Unintentional
weight loss can result from starvation, a condition called
cachexia, or a combination of the two.
Starvation is a form of weight
loss that occurs because of decreased intake of calories and
protein. It can also occur in an individual who is eating
enough, but who is losing many calories because of altered
bowel function and diarrhea, more commonly referred to as
malabsorption. Starvation can result from a combination of
both decreased intake of food and increased calorie losses.
If the bowel can absorb normally, starvation can be corrected
by increased intake of calories and protein. If the bowel
cannot absorb normally, then the reason for the bowel problem
needs to be identified and the problem corrected, so the individual
can eat and absorb nutrients. Initially, starvation mainly
causes a decrease in body fat, rather than skeletal muscle.
If starvation progresses over a long period of time, more
muscle tissue will be lost and the individual will begin to
experience loss of body muscle or “wasting.”
Cachexia differs from starvation.
The loss of weight is mostly from loss of muscle tissue, known
as a loss of “Lean Body Mass” (LBM) or “Body Cell Mass” (BCM).
Both the muscle and protein tissues in our body are the tissues
in which most of our metabolic function occurs, including
immune tissue, organ tissue, tissue that produces energy and
support movement, and tissue that supports body functions.
No protein tissue can be considered storage tissue. All protein
tissues have a role and are part of body function homeostasis
or balance. Loss of LBM alters the balance and can affect
the body functions that support maintenance of optimal health.
Cachexia is caused by metabolic alterations. These metabolic
alterations affect how the body uses the nutrients that come
from food. The end result of cachexia is that the body uses
protein tissues for energy. When an individual suffers from
cachexia simply eating adequate protein, calories and micronutrients
may not reverse this form of unintentional weight loss. This
is defined as “wasting syndrome.”
Designing a treatment
plan
Weight loss can be caused
by a number of factors including:
• decreased intake of food, medication
side effects
• decreased absorption of nutrients
• untreated secondary infection
• alterations in metabolism
Identifying the cause of
the weight loss is the first step in developing an appropriate
treatment plan. Whether the cause is related to decreased
intake, increased nutrient losses or changes in metabolic
function, nutrition plays an important role in stopping the
weight loss, and in regaining lost weight and lost LBM.
Both food and food supplements
can play a valuable role in developing a successful treatment
plan. The use of oral supplements can be particularly useful
when an individual is unable to take in food as a source of
calories and protein because of difficulty with chewing, swallowing
and fatigue. Additionally, in the real world, not all people
will take the time (or have the time) to prepare meals properly
(even when they can), and in these instances supplements can
also be helpful to those individuals. Second line nutrition
supplements, which include micronutrient supplements or amino
acid supplements, can also be useful in specific situations
to support the treatment of weight loss. We know that specific
foods and nutrition supplements are helpful to specific symptom
management such as diarrhea, decreased intake, or when a patient
is wasting secondary to metabolic changes. Research continues
to help us understand options for nutrition and its role in
conjunction with medical care, in treating unintentional weight
loss.
Adequate calories, protein
and micronutrients
The first line in nutrition
treatment for unintentional weight loss is assuring the intake
of adequate calories, protein and micronutrients, preferably
from food. However, both medical symptoms and social conditions
can affect an individual’s ability to eat enough food to meet
optimal energy and nutrient needs. Side effects of HIV/AIDS
and/or medications can cause symptoms such as nausea, vomiting,
and diarrhea, thereby also making the consumption of adequate
nutrients difficult. In addition, alterations in metabolism
can cause increased energy needs. Other issues such as economic
and social conditions, including a physical inability to prepare
meals can also affect the ability to eat properly. All of
these symptoms and conditions can affect intake, in addition
to making one feel overwhelmed by attempting to eat what appears
to be so much.
Depending on the specific
symptom(s), dietary intakes can be adjusted to help manage
the symptoms. Examples of dietary strategies for diarrhea
symptom management include:
• identification of lactose intolerance
• reduced intake of fatty foods
• addition of foods high in soluble
fiber, e.g. applesauce, canned pears or peaches, fruit nectars
and bananas
• low-fat yogurt with lactobacillus
• oatbran
• white rice
• glutamine
If an individual needs to
add calories and protein, other strategies can come into play.
Altering your meal plan to include 6 small meals per day can
be helpful, as well as the inclusion of high calorie, high
protein nutrient dense snacks. Suggestions for such foods
include:
• 1/2 tuna sandwich made with canola
oil mayonnaise
• instant breakfast, soy milk, or
lactase treated milk
• peanut butter on crackers
• yogurt
• a bowl of cereal
• low fat cheese and crackers
• leftovers from last night’s dinner
You can also whip up healthy
shakes with milk or soymilk, yogurt, sherbet, wheat germ,
fruit nectar or ice cream. If you are lactose tolerant, adding
dried milk powder to shakes, soups, and milk is also a great
way to add extra calories and protein. Work with your dietitian
to find creative, simple ways to add extra calories and protein
to your meals and to identify strategies for meal planning
that meet your individual needs.
Commercial Nutrition Supplements
A number of commercial nutritional
supplements are also available and can help a person living
with HIV/AIDS (PLWHA) gain back lost weight. Studies have
been conducted that support use of nutrition supplements to
induce weight gain. However, it is important to differentiate
weight gain from gain of BCM or lost lean tissue. In the case
of significant losses of lean tissue (LBM), the goal is to
regain the lost lean tissue. Clinical studies performed to
evaluate the effect of using oral liquid supplements on weight
gain and body cell mass have produced conflicting results.
Some studies have shown weight gain only in fat tissue. Others
conclude with no weight gain. Still others claim an increase
in both weight and BCM. In choosing a supplement consideration
should be given to a number of things, including presence
of diarrhea, lactose intolerance, individual nutrient requirements,
and taste, as well as weight gain and body cell mass goals.
For those who are lactose
tolerant, instant breakfast mixes or sports shakes are an
inexpensive alternative. They can also be mixed with soy milk
or lactase treated milk. In the presence of diarrhea, a low
fat supplement, one with MCT oil, and a semi-elemental formula
might be the best choice. The amino acid glutamine is also
commonly used to manage diarrhea, which can be helpful in
managing weight loss when the loss is associated with altered
GI function and malabsorption. There are also juice-based
supplements on the market. (See list)
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