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HIV Should we review our current recommendations and prescribe

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HIV Should we review our current recommendations and prescribe

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									"HIV: Should we review our current recommendations and prescribe food combinations?"
The information explosion in the science of nutrition very often creates the impression that available information is contradictory. Consequently, it is no longer easy to distinguish between fact, misinformation and fiction. The Nutrition Information Centre of the University of Stellenbosch (NICUS) was established to act as a reliable and independent source of nutrition information.

The nutritional status of an individual is known to play an important role in decelerating the progression of HIV to AIDS, improving quality of life, and decreasing the prevalence and severity of the infectious complications of HIV/AIDS. The need for low cost interventions to reduce the morbidity and mortality related to HIV infection in developing countries is an urgent one. Recent press headlines, however, make it all seem very simple and more and more individuals are advised to use certain food combinations to treat HIV related symptoms and to boost their immunity. The most commonly "prescribed or recommended" foods are garlic, virgin olive oil, the African potato and onions.

What are the claimed nutritional benefits in these foodstuffs? GARLIC
Garlic (Allium sativum) has been cultivated for medicinal and culinary purposes for the past 5 000 years. A medium sized clove of garlic contains about 0.2g of protein, 0.01g of fat, 0.001mg of carbohydrate, 0.05g of fibre and the vitamins, thiamin, riboflavin, niacin and vitamin C as well as potassium, phosphorus, calcium, sodium, iron, manganese and zinc. Recent interest centres on its sulphur-containing compounds [S-allyl cysteine (SAC), S-allyl mercaptocysteine (SAMC), Allicin, alliin and diallyl polysulfides], which are considered to be the primary active ingredients in garlic. Many studies have focused on the effect of garlic on the management of hyperlipidaemia, hypertension, platelet aggregation, cancer and bacterial and fungal infections, which, together with its “antiviral” properties, form the basis of the media and marketing claims. The possible link with HIV: Garlic has been used worldwide for centuries as both a topical and oral antibacterial, antifungal and antiviral agent. The popularity of garlic supplements may also be related to claims that garlic reduces serum cholesterol, against a background of the antiretroviral therapy induced hypercholesterolemia. Garlic’s “antiviral” activity In vitro and/or animal studies have reported that garlic has several immune enhancing effects such as stimulation of lymphocyte proliferation and macrophage phagocytosis. Other effects on the immune system documented for garlic and/or its constituents include increased natural killer cell activity and increased interleukin-2 production by garlic fractions in vitro. For instance, in an in vitro study, garlic extract exerted a dose-dependent antiviral effect against human cytomegalovirus. Other in vitro studies have documented a virucidal activity of garlic extract against herpes simplex types 1 and 2, parainfluenza virus type 3, vaccinia virus, vesicular stomatitis virus and human rhinovirus type 2. Additionally, garlic extract in vitro has been reported to inhibit the growth of Candida Albicans.

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These in vitro studies, promising as they may appear to be, they cannot by any means imply in vivo activity, and, in this regard, there are no human studies to date, which have consistently and conclusive documented that garlic can improve immunity or the immune response. Other potential effects of garlic Regarding the claimed hypocholesterolemic effect of garlic, one meta-analysis of 13 randomised, double-blind, placebo controlled trials of subjects with hypercholesterolemia (n=796 subjects) suggested that garlic was superior to placebo in reducing total cholesterol levels. However, the use of garlic in the management of hypercholesterolemia is debatable because of the marginal nature of the beneficial effect. Similarly, in another meta-analysis of 16 trials (n=952 subjects) a statically significant 12 percent average reduction in total cholesterol (-0.77 mmol/L) with garlic therapy beyond the levels achieved with placebo has been reported. Dried garlic powders also significantly reduced triglycerides levels (-0.3 mmol/L) compared to placebo. Despite these positive associations, the authors acknowledge that many of the trials used in the meta-analysis had methodological limitations, which cast doubt on the clinical significance of such findings. A meta-analysis of eight randomised (n=415 subjects), controlled trials testing the antihypertensive effect of garlic suggested that garlic preparations may be of some clinical use in subjects with mild hypertension. The authors concluded “there is still insufficient evidence to recommend garlic extract supplements as a routine clinical therapy for the treatment of hypertensive subjects”. The authors of these meta-analyses have criticised many of the studies, which were included in the meta-analyses, for methodological limitations and concluded that further well-designed and wellcontrolled trials would be needed to verify any beneficial effects of garlic extract supplements on cholesterol and blood pressure control. The amount of garlic used in most studies was equivalent to 2 to 5g of raw garlic (1 raw clove ≈ 3 g), 400mg - 1200mg of dried garlic powder, or 1 - 7.2g of aged garlic extract. In this regard, it should also be borne in mind that there has been some controversy regarding the presence of allicin in any such supplements in order for garlic to elicit its biological effects. It is known that allicin is a highly unstable compound, which is formed by crushing the bulb of garlic and decomposes quickly. Furthermore, allicin and some of garlic’s active compounds are also known to be destroyed by cooking. Nevertheless, a number of sulphur-containing compound as well as some non-sulphur compounds in garlic are thought to contribute to its potential beneficial effects, and some suggest that allicin activity may be important only in lowering blood cholesterol levels but it makes little or no contribution to garlic’s claimed anticarcinogenic properties. Safety Experimental data have reported that dried raw garlic powder and dried boiled garlic powder caused significant damage/reddening of the gut mucosa, whereas aged garlic extract had no such deleterious effects. Garlic supplements in most studies in humans have been reported to have been relatively welltolerated with the only reported side effects being mild gastrointestinal discomfort at high does as well as the presence of an undesirable body odour even when using supplements of the “odourfree” varieties. More importantly, an increase in bleeding time has been reported in 50 healthy individuals supplemented with 10g of raw garlic (3 cloves) daily for two months. Because of the latter findings, it is currently recommended that individuals on drug anti-platelet therapy and patients who have to undergo surgery should discuss the use of garlic supplements with their doctors and discontinue any such supplements and/or limit the dietary use of garlic at least seven days prior to surgery. Of equal importance and in relation to HIV/AIDS, garlic extract supplements have been documented to induce drug-nutrient interactions. In this regard, recent evidence indicates that garlic supplements sharply reduced blood levels of the anti-HIV drug saquinavir. Although more research is needed in this area, it is currently recommended that any patients using saquinavir as the sole protease inhibitor should avoid using garlic supplements.

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VIRGIN OLIVE OIL
Body shape changes and a number of metabolic abnormalities have been reported in patients with HIV/AIDS. The most frequently reported changes in body shape include an increase in waist size and thinning of the extremities as well as an increase in the fat pad at the back of the neck (buffalo hump) and the axillary fat pads. Women may experience a significant enlargement of the breasts and a marked decrease in the size of the thighs. Although this so called lipodystrophy syndrome is thought to be due to specific drugs used in the treatment of these patients, the exact mechanism remains unknown. Among the metabolic abnormalities, the most notable ones from the nutritional point of view include elevated blood levels of triglycerides and cholesterol as well as resistance to insulin resulting in diabetes mellitus. It is generally accepted that replacing saturated fat with monounsaturated fat lowers serum cholesterol, LDL-cholesterol and triglycerides levels to about the same extend as polyunsaturated fatty acids in healthy individuals. In epidemiologic studies, high monounsaturated fat (mainly olive oil) diets of people in Mediterranean countries have been associated with lower blood cholesterol levels and coronary heart disease incidence. However, it should be borne in mind that such diets are also inherently high in fruit and vegetable intake. Extra-virgin olive oil is a unique dietary lipid, in the sense that it is not extracted from seeds by means of solvents. Rather, it is obtained from the whole fruit (drupe), by using the cold-press technique, which does not alter the chemical nature of the drupe or that of the resulting oil. Oleic acid and mainly the unsaponifiable fraction of olive oil, which contains phenols, tocopherols, chlorophyll, squalene and aroma components, exhibit a high nutritional and biological value. It has been proposed that high consumption of extra-virgin olive oils, which are particularly rich in phenolic antioxidants (as well as squalene and oleic acid), could afford considerable protection against cancer (colon, breast, skin), coronary heart disease and aging by inhibiting oxidative stress. It is the unique profile of the phenolic fraction, along with high intakes of squalene and the monounsaturated fatty acid, oleic acid, which are believed to confer the extra-virgin oil’s healthpromoting properties. Thus although the substitution of saturated fat or polyunsaturated fat with extra-virgin olive oil may have health benefits for people with HIV/AIDS, there is no convincing or consistent scientific evidence that virgin olive oil boosts immunity or alters the course of HIV/AIDS, adversely or beneficially. In theory, it might be beneficial to treat those patients with the lipodystrophy syndrome (elevated blood levels of triglycerides and cholesterol as well as resistance to insulin resulting in Diabetes Mellitus), but again intervention controlled studies in humans testing the effectiveness of extra-virgin olive oil in the management of this syndrome are not available and specific recommendations cannot be made. Irrespective, such patients are often financially insecure and as such the purchase of a relatively expensive product, such as virgin olive oil, may limit the purchase of other affordable wholesome foods, which in turn is likely to adversely affect their nutritional status.

THE AFRICAN POTATO
Hypoxoside is thought to be the major, non-toxic compound in extracts of the African Potato (Hypoxis species), which has led to the claimed anticarcinogenic properties of this plant. Hypoxoside itself has been shown to be devoid of any anti-cancer activity. However, upon hydrolysis, hypoxoside is converted to rooperol, which has been shown to be cytotoxic (hence the anti-cancer claim) and to possess potent antioxidant properties. It should, however, be borne in mind that, although present in large amounts in the plant extract, neither hypoxoside nor rooperol could be detected in the blood of human volunteers with lung cancer, who received Hypoxis plant extract supplements in large doses (1 200 – 3200 mg of standardised plant extract). As such and at best, the role of these compounds, therefore, in the prevention or treatment of cancer, or for that matter any other disease, is almost totally unknown. Interestingly, the long-term administration of the extract was in associated with a decrease in blood lymphocyte counts these cancer patients, an effect that was attributed to the underlying malignancy. Nevertheless, the safety of the plant extract has been questioned and remains a cause of serious concern. A study on the safety and efficacy of the Hypoxis plant extract in HIV positive patients was terminated prematurely, and

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reported to the Medicines Control Council, because most of the HIV positive patients who received the plant extract showed severe bone marrow suppression after 8 weeks of receiving the plant extract supplement. Indeed, the total lymphocyte count as well as the absolute CD4 cell numbers decreased significantly in these patients after an initial transient increase. Of far greater concern though is that the suspicion of Hypoxis-induced immune suppression has been experimentally confirmed in the Feline Immunodeficiency Virus model. Cats, which were treated with Hypoxis plant extract supplements progressed, and succumbed, to full blown Feline AIDS faster than their non-treated Hypoxis plant extract controls. At best, therefore, HIV/AIDS patients should avoid any such supplements, until such time that their safety and efficacy, or otherwise, has been fully documented.

ONIONS
Onions is a food source of phytochemicals such as, flavonoids and organosulphur compounds. Onions and garlic both contain diallyl sulphide and other organosulphur compounds. The antioxidant properties of these phytochemicals are well documented. However, there are no scientific studies in humans to show that the ingestion of onions will enhance immunity or treat HIV related symptoms efficaciously. Onions is also a food source of fructooligosaccharides (FOSs). As prebiotics, FOSs selectively stimulate the growth and activity of beneficial colonic bacteria (Bifidobacterium, Lactobacillus) and have been investigated for their potential role in intestinal health. FOSs have been documented to have stool-bulking properties which may help prevent constipation, but further controlled clinical trials are needed in humans to test the role of FOSs on intestinal health and disease. In terms of safety, the ingestion of large quantities of onions is known to cause gastrointestinal discomfort and distension and should be used with caution by individuals with chronic diarrhoea and gastrointestinal discomfort. In summary, there is no convincing or consistent scientific evidence that any one of these foods, singly or in combination, alter the course of disease, any disease. The necessary long-term intervention studies to make such claims are not available. Until such time that the data is available, to make such claims, it is best to be careful and avoid raising false hopes in people. Of course, if people do think these foods are of any help or eating these foods makes them feel better, and they like them, then there is nothing wrong with consuming them, unless safety concerns have not been resolved, as is the case with the African Potato.

OTHER ALTERNATIVE DIETARY THERAPIES
The plethora of diets advocated for HIV-related or other disease symptom, such as the antiCandida diet, the macrobiotic diet, amino acid supplements and herbal mixtures have also not been subjected to formal clinical research and many of these may imply, or result, in some food elimination and or restriction, an ill-advised practice. For weight maintenance and for the prevention of vitamin and mineral deficiencies, it is best to eat a varied diet, within the financial constraints of a given individual, and include culturally accepted energy- and protein-rich foods. Doctors and patients alike should not assume that dietary supplements are benign therapies devoid of potential harm. Some of these products may have potent pharmacological actions and may alter the blood levels of concomitant medications. It is, therefore, prudent for doctors who prescribe supplements, any supplements, and individuals who consume them to obtain information on their safety profile before using them, for whatever reason.

GUIDELINES FOR THE NUTRITIONAL MANAGEMENT OF HIV/AIDS
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Nutritional assessment Although body weight per se, may underestimate the degree of wasting in HIV/AIDS, it is important to keep track of the changes in body weight. The patient's weight should be charted regularly to assess whether the weight loss is acute (a lot of weight lost within a short time) or chronic (slow progressive weight loss). Dietary intake should also be assessed regularly in combination with

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physical and work related activity as well as employment status to determine food and nutrient intake.
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Nutrient needs: Energy Acute infectious illness, such as HIV/AIDS, is accompanied by a complex variety of nutritional and metabolic responses within the body. The response to infection is associated with an increase in the energy requirements of the patient and various degrees of lean tissue breakdown. Individual energy and protein needs depend on the health status of the HIV/AIDS patient. Even more energy will be required in the presence of secondary disease (opportunistic infections). It is generally recommended that individuals with HIV/AIDS need approximately 30-35 kCal per kilogram for maintenance of body weight or 40 - 45 kCal per kilogram if severe weight loss has occurred (See nutritional recommendations).

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Protein HIV/AIDS patients are known to have high losses of protein (nitrogen), which may result in malabsorption due to diarrhoea, loss of fluids, electrolytes and other nutritional reserves. The breakdown of protein and other reserves due to fever may also worsen undernutrition and further impair resistance against the infection. An increase in protein breakdown for example leads to muscle wasting in these patients. The protein intake of the diet is important to ameliorate the wasting of muscle tissue. An intake of 1.0 - 1.4 g per kilogram body weight or 15 percent of energy of total daily intake or approximately 75 - 105 g per day is usually sufficient. In the presence of severe wasting, malabsorption or secondary opportunistic infections, 1,5 - 2,0 g per kilogram of body weight may be needed. (See nutritional recommendations) Fat Tolerance of fat varies from person to person. In the presence of malabsorption or diarrhoea, a low fat diet may relieve some of the symptoms. A low fat diet according to the prudent dietary guidelines as part of a varied diet is indicated. Vitamins and Minerals The response to infection includes a profound impact on the micronutrient status of the patient. Vitamins and minerals are compounds that are essential for normal growth and maintenance of body functions, playing key roles in many different metabolic processes in both health and disease. The increased energy needs and tissues breakdown associated with infection are thought to increase the requirements of micronutrients such as vitamin A, E, B6, C, D and folate. It is also known that a decrease in blood levels of trace elements such as iron, zinc and selenium as well as magnesium occur during the infection. Importantly, these apparent deficits are reported to occur early in the course of the infection and deserve attention early in the management of these patients. A number of studies have reported low blood levels of vitamins A, B6, B12, C, E, folate and carotenoids as well as selenium, zinc and magnesium in the HIV/AIDS patient. Some studies reported these low blood levels despite the fact that the patients were eating an apparently adequate diet. It would appear that the intake of micronutrients at levels recommended for the general healthy individual may not be adequate for HIV infected people. Despite extensive studies, little is known about the exact vitamin and trace element requirements in HIV/AIDS. A good multivitamin and mineral supplement, therefore, which provides 100 to 150 percent of the Recommended Dietary Allowance (RDA), is advisable since it will be most unlikely that a person with HIV will be able to meet the requirements for vitamins and minerals with diet alone due to a poor appetite. • Special Nutritional Concerns for Children with HIV/AIDS The nutritional sequalae of HIV/AIDS in children are more devastating because of the additional nutrient demands for growth and development. The rapid growth periods of infancy and childhood

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can only be maintained if a child's nutrient intake is optimal. Insufficient intake can cause impaired growth and result in malnutrition, the effects of which, if severe, may be irreversible. In meeting children’s nutrient requirements, it should be born in mind that children have limited stomach capacity and appetites and as such eating enough food to meet requirements presents a difficult challenge (See recommendations.) The best way to monitor weight gain and detect malnutrition at an early stage in children is to use the "Road to Health" card (curve that illustrate the growth pattern of a child). Additionally, a supportive home environment and quality care are essential for the prevention and management of infected children. General nutritional recommendations for children include high-energy, high-protein and micronutrient dense food. Protein needs may vary from 150% - 200% and energy from 100% 200% of The Recommended Dietary Allowance (RDA). A multivitamin and mineral supplement proving a 100% of RDA should be given.
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Nutritional Counselling Food safety is important, since immunosuppressed people are highly susceptible to food- born pathogens. Therefore, special care should be taken with uncooked food products such as eggs, fish, meat and unpasteurised milk. The following can be used to increase the safety of food and drinking water: • Always wash your hands before touching food or water • Wash all vegetables and fruit thoroughly • Avoid touching farm animals • Boil water for one minute at rapid boil and store in a clean, closed container or use bottled water • Cook all meat fish and eggs completely before eating in a hygienically prepared kitchen • Use only pasteurised milk and dairy products • Thaw all foods in the refrigerator and not at room temperature • Keep shelves, counter tops, other kitchen utensils, sponges and towels clean at all times • Use different cutting boards for foods intended to be served raw than for foods that will be cooked • Exercise caution consuming foods or beverages out of home or when travelling

NUTRITIONAL RECOMMENDATIONS
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Decreased appetite: HIV/AIDS often adversely affects nutritional intake, due to poor appetite, thus placing patients at risk for malnutrition. Six smaller meals (or eat every two to three hours) per day are indicated instead of three meals. The meals should be appetizing in appearance and taste and provide enough energy and protein. Increase Energy and Protein Intake: Commercially available high energy and protein drinks (balanced in terms of micro- and macronutrients) may be used effectively to meet the increased requirements. Household ingredients, such as sugar, vegetable oil, peanut butter, eggs and non-fat dry milk powder can be used in porridge, soups, gravies, casseroles or milk based drinks to increase the protein and energy content without adding to the bulk of the meal. At least 500 - 750 ml of whole milk or yoghurt should be consumed daily (use in porridge and in the preparation of food: custards, puddings, cream soups). Add generous amounts of sugar, butter, peanut butter, margarine, cheese, mayonnaise and cream to foods (if tolerated) Dairy products are a good protein source. Cultured dairy products like yoghurt are easier to digest than milk. If milk cause cramps or a feeling of fullness it is best to avoid it in the diet, but it is quite possible that yoghurt and sour milk will be tolerated. Beans seeds and peas are good sources of protein and cheaper than meat, eggs and milk products. Cover desserts with whipped cream Use honey or jam on bread

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Vitamin and minerals: Try to eat at least 5-6 portions of fruit and vegetables per day. Pure fruit juice can be used to decrease the bulk of the diet. Approximately half a glass of fruit juice is equal to one portion of fruit. Alcohol should be avoided. A multivitamin (containing all the vitamins) and mineral supplement, providing 100-150 percent of the RDA per tablet is advisable, since it will be most unlikely that a person with AIDS will be able to meet the increased requirements for vitamins and minerals with diet alone (due to a poor appetite). Any supplements however should preferably be given after consulting an expert health professional.

Nutritional suggestions for symptoms caused by opportunistic infections and malignant diseases
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Nausea: Eat small, frequent meals (every two to three hours) and avoid high-fat greasy foods. Avoid lying down after eating. Food is best tolerated at cool or room temperature. Dry, salty crackers, pretzels, biscuits and cookies may also be tolerated. Simple foods such as rice, scrambled eggs, toast, noodles, bananas, mashed potatoes, custards may also be better tolerated. Allow plenty of fresh air in the house. Disperse cooking odours. Sore Mouth or throat: Eat soft, moist food at cool or room temperature (mashed potatoes, macaroni and casseroles). Drink through a straw. Avoid spicy or acidic foods. Also avoid carbonated beverages and salty or acidic foods. Dry Mouth: Serve food with a sauce or gravy and consume foods with liquids at mealtime. Drink extra liquids between meals. Concentrate on good oral hygiene. Chewing of sugarless gum or sucking of mints may help. Diarrhoea: Try and eat six small meals per day. Fluid replacement is very important to prevent dehydration. Try and drink water or re-hydration drinks after every loose stool. (Home recipe for oral rehydration therapy (remember hygiene): 1 litre of cooled cooked water, 8 teaspoons of sugar and 1/2 teaspoon of table salt). A low fat and dairy diet may be indicated (damaged to the surface of the gut may cause intolerance to lactose; drinking milk or eating milk products can cause cramps, abdominal distress and diarrhoea in some people). Avoid gas forming foods and drinks (e.g. peas, lentils, cabbage, cauliflower, broccoli, onion, nuts, cucumber, beans and bran, garlic, beer). Avoid alcohol and caffeine, since both may have a dehydrating effect. Moderate the intake of fibre. Concentrate on soluble fibre (fruit, oats, and legumes). Limit the intake of fructose (fruit sugar) by avoiding apple and pear juice as well as grapes, honey, dates, nuts, figs and soft drinks. Eat and drink bananas, potatoes, fish, meat, apricot juice, tomato juice to replenish sodium (salt) and potassium. Eat foods that have been brought to room temperature.

For further, personalized and more detailed information, please contact NICUS or a dietician registered with the Health Professions Council of South Africa. References from the scientific literature used to compile this document are available on request. NICUS Nutrition Information Centre University of Stellenbosch Division of Human Nutrition P.O. Box 19063, Tygerberg, 7505 Tel: (27) 021-933 1408 Fax: (27) 021-933 1405 E-Mail: nicus@sun.ac.za WEBSITE: http://www.sun.ac.za/nicus/

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