HIV Nutrition Essentials For Program and Administrative Grantees

HIV Nutrition Essentials For Program and Administrative Grantees Marcy Fenton, M.S., R.D. Program Manager, Care Services Division County of Los Angeles Department of Public Health Office of AIDS Programs and Policy August 29, 2006 Los Angeles County Square Miles: 4,086 Population: 9.9 Million SPA 1: Antelope Valley Latino/a 45.7% White 31.0% Asian/PI 13.2% African-American 9.7% Native American 0.3% Proportion of California Population: 29% SPA 2: San Fernando SPA 5: West SPA 4: Metro SPA 7: East SPA 3: San Gabriel Proportion of California AIDS Cases: 35% Living with HIV/AIDS: 58,000 (Estimated) 2 SPA 6: South SPA 8: South Bay 2 HIV Nutrition Essentials Overview • Current nutrition issues and treatments • Medical nutrition therapy (MNT) program necessary ingredients • Lessons learned monitoring Los Angeles County medical outpatient services’ MNT programs 3 HIV Nutrition Essentials Handout Materials • Presentation slides • Guides and resources  Diet, nutrition, fact sheets  Professional competency • Weight & nutrition • HIV nutrition screen & referral forms  ADA 2005  Nutrition quick screen 4 HIV Nutrition Essentials Current HIV Nutrition Issues 5 HIV MNT Overall Goals • Optimize nutrition status, immunity and quality of life • Prevent nutrient deficiencies • Achieve and maintain optimal body weight and composition • Manage co-morbidities • Maximize effectiveness of medications 6 Vicious Cycle of Malnutrition and HIV Poor Nutrition resulting in weight loss, muscle wasting, weakness, nutrient deficiencies Increased Nutritional needs, Reduced food intake and increased loss of nutrients Impaired immune system Poor ability to fight HIV and other infections, Increased oxidative stress HIV Increased vulnerability to infections e.g. Enteric infections, flu, TB hence Increased HIV replication, Hastened disease progression Increased morbidity Source: Fanta Project www.fantaproject.org Adapted from RCQHC and FANTA 2003 7 HIV Nutrition Issues Poor Immune Function • Food and water safety, sanitation • Optimized nutrient and fluid intake • Vitamin mineral supplementation • Exercise: aerobic and progressive resistance training • Medication adherence • Stress reduction • Establishment of trusting relationships 8 Nutrition Issues and Treatments Common Side Effects • GI distress • Hyperlipidemia • Insulin resistance  Diarrhea  Nausea/vomiting • Hypertension • Liver toxicity  Gas • Renal impairment • Anorexia • Obesity • Fatigue • Taste alterations • Lipodystrophy • Peripheral neuropathy • Mouth pain • Cancer • Anemia 9 Causes of Weight Loss 1-Inadequate Intake • Oral and upper gastrointestinal • Anorexia • Psychosocial-economic • Malabsorption Source: Mangili A et al. CID 2006:42 (15 March) p 836-42 10 Causes of Weight Loss 2-Altered Metabolism • Uncontrolled HIV infection • Metabolic demands of HAART • Opportunistic infections or malignancies (AIDS-defining conditions) • Hormonal deficiencies (testosterone or thyroid) • Cytokine dysregulation Source: Mangili A et al. CID 2006:42 (15 March) p 836-42 11 Resting Energy Expenditure 140 REE (KJoules/kg BW 120 100 80 60 40 20 0 CON HIV+ AIDS AIDS-SI 12 Grunfeld et al. AJCN 1992;55:455-60. Impact of Viral Load on Resting Energy Expenditure 8900 8700 REE (kjoules/day) 8500 8300 8100 7900 1 3 5 7 9 11 HIV RNA (log 10 copies/ml) 13 HIV Wasting Definitions • CDC • Nutrition for Healthy Living (Tufts) • Grinspoon, Mulligan & DHHS Working Group • Polsky, Kotler & Steinhart 14 Calories Needed and Weight Change Relation to Viral Load • Not on HAART  0.92 kg body weight decrease per each HIV RNA log10 increase  22 Kcal increase in REE per increase in per 1-log copy/ml • Stable HAART  0.35 kg body weight decrease per each 100-cell/mm3 CD4 cell decrease  81 kcal higher REE Source: Wanke et al. CID 2006:42 (15 March) 15 Outcomes of Weight Loss • Morbidity and mortality independent of CD4 and viral load • Weight loss of >5% associated with increase risk of mortality even with ART • Adverse pregnancy outcomes • Weight loss & wasting continue to be common problems 16 International Nutrition Feeding Safely and Adequately • Access to nutritious food • Access to safe water • Malnutrition  Linked with HIV infection  Linked with poor prognosis  Linked with poor prognosis despite ART • Breast feeding • Access to HIV medications 17 Overweight, Obesity and HIV 50 45 40 35 30 25 20 15 10 5 0 BMI <18.5 (1) Wasting (2) Underweight BMI: 18.5-24.9 Healthy Weight BMI: 25-29.9 Overweight BMI: = or >30 Obese M en 69 ) (n =1 6 N ES N H A ud Sources: (1) Amorosa et al. JAIDS 2005;Aug15;39(5):557-61. (2) NHANES 1999-2000; www.cdc.gov 7/03 N H A St N ES y W om en 18 Weight Classification Using BMI BMI1 Underweight Normal Overweight <18.5 18.5-24.9 25.0-29.9 Note Malnutrition2 <18.5 Wasting3 <20.0 Obesity (I) Obesity (II) Extreme Obesity (III) 30.0-34.9 35.9-39.9 >40.0 19 (1) National Heart, Lung and Blood Institute, (2) Magili et al. CID 2006 March, (3) Amorosa; Grinspoon, Mulligan & DHHS Working Group 2003 April-S CID Conditions Associated with Obesity BMI: HIV vs. General Populations Hypertension Gout Stroke Heart Disease Mood Disorders Sleep Disorders Obesity Hyperlipidemia Non-Insulin Dependent DM Osteoarthritis Eating Disorders Some Cancers Gall Bladder Contemporary Diagnosis and Management of Obesity. Geroge A. Bray, MD 20 Desirable Girth Measurements • Waist circumference  Men: <40 inches  Women: <35 inches  NHANES methodology • Waist to Hip Ratio?     Less accurate Not recommended Hip circumference ok Monitor waist & hip from baseline 21 Overweight, Obesity & HIV Fuel of Metabolic Abnormalities • BMI positive correlation with  Total cholesterol  Triglycerides  Glucose • Obesity not correlated with  Age, income, employment, education  Past/current IVD use  HIV treatment, viral load 22 Source: Amorosa et al. JAIDS 2005;Aug15;39(5):557-61. Treatment of Obesity Therapeutic Lifestyle Changes • • Nutrition counseling Dietary intake  Limit saturated fats  Increase fiber to 35 g/day  Portion control  Reduce excess carbohydrates and high sugar drinks  Plenty of fruits and vegetables  Small meals: maximum 5 hours apart  Eat slowly 23 Treatment of Obesity Therapeutic Lifestyle Changes • Physical activity  Walking or other exercise  Progressive resistance training • 30-60 minutes/day 24 HIV and Diabetes Mellitus An Increasing HIV Nutrition Problem • • HIV-positive men who are taking highly active antiretroviral therapy (HAART) are more than four times more likely to develop diabetes than HIV-negative men. HIV-positive women taking protease inhibitors are three times more likely to develop diabetes than HIV-positive women on non-protease inhibitor combinations or HIV-negative women Sources: Brown TT et al. Antiretroviral therapy and the prevalence and incidence of diabetes mellitus in the Multicenter AIDS Cohort Study. Arch Intern Med 165: 1179-1184, 2005. Justman JE et al. Protease inhibitor use and the incidence of diabetes mellitus in a large cohort of HIVinfected women. Journal of Acquired Immune Deficiency Syndromes, 32: 298 – 302, 2003 25 Diabetes Major Risk Factors General Population • Overweight, obesity • History of impaired glucose tolerance  Especially VAT or impaired fasting • Parent or sibling glucose • Ethnicity • Hypertension  Alaska Native, • Cardio-vascular American Indian, disease African American, Latino American, • Polycystic ovarian Asian America syndrome • Inactivity  Exercise <3x/wk 26 Diabetes Additional Risk Factors HIV Population • Medications leading to insulin resistance  HAART  Steroids, growth hormone, others • HCV co-infection • Morphological changes  Lipodystrophy: > visceral adipose tissue • Physical inactivity  Neuropathy, fatigue avascular necrosis, wasting, etc. 27 Heart Disease Prevalence General Population • Leading cause of death in the U.S. 2002  Women: 51% of heart disease deaths  Men: 340,933 died from heart disease in  8.9% all white men  7.4% black men  5.6% Mexican American men • 57 million Americans live with CVD 1. National Center for Health Statistics. Health, United States, 2005 with Chartbook on Trends in the Health of Americans. Hyatsville, MD: 2005. 2. American Heart Association. Heart Disease and Stroke Statistics—2005 Update. Dallas, Texas: American Heart Association, 2005. 28 Heart Disease Major Risk Factors General Population • Increasing age • Gender • Heredity, family history of premature heart disease • Overweight/obesity • High blood pressure • Tobacco use • Hyper- or dyslipidemia  Especially high LDL • Diabetes • Metabolic syndrome • Physical inactivity • Poor nutrition  An atherogenic diet 29 & low HDL Source: Preventing chronic diseases: Investing wisely in health preventing heart disease and stroke. July 2005. CDC. February 6, 2006. http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/cvh.htm Heart Disease Risk Factors HIV Population • Inflammation due to HIV • Lipid abnormalities due to HAART • Other drug effects:  Insulin resistance  Morphological changes  Metabolic syndrome 30 Heart Disease Prevention & Treatment • Therapeutic Lifestyle Change (TLC)  Diet  Physical exercise • Management of concomitant diseases  Diabetes, hypertension, obesity, etc. • Smoking cessation • Stress reduction 31 Liver Disease Fueled by Overweight & Obesity • Waist>hip, insulin resistance & diabetes  Predicts advanced forms of chronic hepatitis C  Complicates nonalcoholic steatohepatitis (NASH) • Fitness inversely related • Tx: Healthy diet, exercise, weight loss Sources: Charlton MR et al. Hepatology June 2006;46(6)1177-1186; Church TS et al. Gastroenterology. 2006 Jun; 130(7):2023-2030. 32 Renal Disease and HIV A Growing Nutrition Problem • Dialysis  HIV: 1.5%, AIDS: 0.4%  Dialysis centers treating PLWH/A • 1985: 11% • 2000: 37%  Number initiated since 1995: stable • Abnormal kidney function  30% PLWH/A • HIV and CKD nutrition guidelines  Not set yet  Individualize 33 HIV Nutrition Essentials Medical Nutrition Therapy (MNT) Program Necessary Ingredients 34 Continuum of Care County of Los Angeles. Continuum of Care, Office of AIDS Programs and Policy. 35 HIV Registered Dietitian Standards of Professional Practice • Provides quality service based on client expectations and needs • Effectively applies, participates in or generates research to enhance practice • Effectively applies knowledge and communicates with others 36 HIV Registered Dietitian Standards of Professional Practice • Uses resources effectively and efficiently in practice • Systematically evaluates the quality and effectiveness of practice and revises practice as needed to incorporate the results of evaluation • Engages in lifelong self-development to improve knowledge and enhance 37 professional competence HIV Registered Dietitian Care Responsibility • Create screening tools for medical providers to identify clients at risk • Monitor nutrition-related abnormal laboratory values • Assess clients regularly, consistently • Ensure adequate nutrient & caloric intake 38 HIV Registered Dietitian Care Responsibility • With medical team, identify and correct causes of cachexia, weight loss/gain, other nutrition problems and barriers • Refer to providers and other disciplines • Communicate: document, speak, share • Participate in team case conferences • Promote continuity of care 39 NCP Screening & Referral System    ADA NUTRITION CARE PROCESS AND MODEL Identify risk factors Use appropriate tools and methods Involve interdisciplinary collaboration Nutrition Assessment  Obtain/collect timely and appropriate data  Analyze/interpret with evidence- based standards Document Nutrition Diagnosis  Identify and label problem  Determine cause/contributing risk factors  Cluster signs and symptoms/ defining characteristics  Document Relationship Between Patient/Client/Group & Dietetics Professional Nutrition Monitoring and Evaluation  Monitor progress  Measure outcome indicators  Evaluate outcomes  Document Nutrition Intervention  Plan nutrition intervention  Formulate goals and determine a plan of action Implement the nutrition intervention  Care is delivered and actions are carried out  Document     Outcomes Management System Monitor the success of the Nutrition Care Process implementation Evaluate the impact with aggregate data Identify and analyze causes of less than optimal performance and outcomes Refine the use of the Nutrition Care Process 40 Screening and Referral Screen for Referral Criteria • New/re-entry into care, MNT >6 months • Medical diagnosis, nutrition status change • Physical changes, weight concerns • Oral, GI symptoms • Metabolic, other medical conditions • Barriers to nutrition, living environment, functional status • Behavioral concerns, unusual behaviors Source: ADA MNT Evidence Based Guides for Practice, March 2005 41 Screening and Referral Referral Documentation • Physician’s order for MNT • Signature and date of physician or authorized person to refer for MNT • Medical diagnoses and information • Current labs and measurements • Consent to release medical information • Proof of residency, income, diagnosis Source: ADA MNT Evidence Based Guides for Practice, March 2005 42 Nutrition Care Process ADIME • Nutrition Assessment • Nutrition Diagnosis • Nutrition Intervention • Nutrition Monitoring • Nutrition Evaluation • Documentation: clear and explicit 43 Nutrition Care Process Nutrition Assessment • Reason for referral • Assess data (ABCD)  Anthropometric  Biochemistry  Clinical  Dietary • Client input 44 Nutrition Care Process Nutrition Diagnosis • Problem  Diagnostic label  Intake, clinical, or behavioral/environmental • Etiology  Cause or contributing risk factors • Signs/Symptoms  Defining characteristics • PES statement 45 Nutrition Care Process Nutrition Diagnosis PES Statement • (P) Increased nutrient needs (E) as related to inadequate intake of foods and malabsorption due to AIDS enteropathy (S) as evidenced by 25 pound weight loss in 6 months and now 91% IBW 46 Nutrition Care Process Nutrition Intervention • Interventions  Food and/or Nutrient Delivery  Nutrition Education  Nutrition Counseling  Coordination of Nutrition Care • Receptivity and adherence potential • Plan and follow-up date 47 Nutrition Care Process Nutrition Monitoring • Review and measure status of intervention at scheduled time • Track outcomes with tools  ADA HIV MNT Protocol Progress Note  Weight and nutrition flow sheet  Electronic health record data fields  Other tools • Format • Terminology: diagnosis, interventions, etc 48 Nutrition Care Process Nutrition Evaluation • Systematic comparisons • Reference standards • Evaluate changes  Signs and symptoms  Previous status and intervention goals  Progress toward goal 49 HIV MNT Tools Basics • HIV MNT Protocols (ADA,1998)  Adult (18 years-adult)  Children (under 18 years) • Health Care and HIV: Nutritional Guide for Providers and Clients (HRSA/HAB, 2002) • Integrating Nutrition into Medical Management of HIV, (CID-S April 1 2003) • Nutrition intervention in the care of persons with human immunodeficiency virus. (ADA & Dietitians of Canada Joint Position, 2004) 50 HIV MNT Tools New: ADA Evidence Analysis Library Systematic review of scientific research  Select topic and expert working group  Define questions, analytical framework, inclusion and exclusion criteria  Conduct literature review per question  Analyze articles  Complete evidence summaries and tables  Draft proposed conclusion statements  Reach consensus on conclusion statements and grades (strength and quality of the evidence)  Publish to online library (EAL) 51 HIV MNT Tools New: ADA EAL Current Projects • Diseases and conditions  Adult weight management  Determinants of pediatric overweight  Chronic kidney disease (revision)  Chronic obstructive pulmonary disease  Critical illness  Disorders of lipid metabolism (hyperlipidemia revision) 52 HIV MNT Tools New: ADA EAL Current Projects • Diseases and conditions (cont.)  Gestational diabetes  Gluten intolerance/Celiac  Heart failure  HIV/AIDS  Hydration  Hypertension 53 HIV MNT Tools New: ADA EAL Current Projects • Diseases and conditions (cont.)  Nutrition in athletic performance  Nutrition care in bariatric surgery  Oncology  Pediatric weight management  Spinal cord injury & nutrition  Unintended weight loss 54 HIV MNT Tools New: ADA EAL Current Projects • Assessment  Estimating energy expenditure • Foods  Non-nutritive sweetener 55 HIV MNT Tools Emerging: HIV Nutrition Evidence Analysis • Questions  What are the caloric needs of people with HIV/AIDS?  What is the evidence to support a particular macronutrient composition of a diet for people with HIV/AIDS? • Focus  Both children and adults  People with HIV/AIDS  Past 10 years of research 56 HIV MNT Tools Emerging: HIV Nutrition Evidence Analysis • Questions  What are the caloric needs of people with HIV/AIDS?  What is the evidence to support a particular macronutrient composition of a diet for people with HIV/AIDS? • Focus  Both children and adults  People with HIV/AIDS  Past 10 years of research 57 HIV MNT Tools New and Emerging • Nutrition Care Manual  Web based  Using ADA Evidence Library • Evidence-based MNT protocols • Evidence-based guidelines • ADA position papers 58 Reimbursement MNT, Supplements • Medicare • Medicaid • Managed Care • HMOs, Kaiser Permanente • RWCA 59 Personal Professional Competence Dietetics Professionals’ Ethical Obligation • Code of Ethics for the Profession of Dietetics,(6) • Standards of Professional Practice,(7)  Guided by the nutrition care process • Professional Development Portfolio(8)  75 credits every five years 60 Ryan White CARE Act and MNT Current Status • MNT by RD  Defined by HRSA guidance  Required in Title III services  RWCA reauthorization medical service • Expected after Labor Day 2006 • ADA and others working to get MNT as core • AIDS Education Training  HIV nutrition training for providers 61 CPT Codes MNT • 97802 • 97803 • 97804 • Initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes • Re-assessment and intervention, individual, fact-to-face with the patient, each 15 minutes • Group (2 or more individuals), each 30 minutes 62 HIV Nutrition Essentials Lessons Learned Monitoring Los Angeles County Medical Outpatient Services’ MNT Programs 63 Monitoring HIV MNT Services MNT Program Evaluation Items • Screening for nutrition related problems • Referral for baseline MNT (06-07) • Appropriate referral for MNT • MNT provided by an RD • MNT documentation (05-06) • Outcome: maintain or 5% towards goal weight after 3 months of care (07-08) • RD qualifications 64 Monitoring MNT Programs Yr 14 2004-2005 Yr 15 2005-2006 Clients (>1 visit) Sites (of 37) Charts Reviewed (average, range) Screened 16,143 36 154 (4.3, 2-8) 2 (.1, 0-1) 38 (1, 0-4) 32 (.9, 0-5) 16,487 36 244 (6.8, 4-10) 29 (.8, 0-10) 77 (2.1, 0-8) 66 (1.8, 0-6) Referral to MNT MNT Provided MNT Quality n/a 65 62 Access to MNT RD Availability Clinics, number Onsite >½ day/month Referral offsite None available 2004-2005 37 28 2005-2006 37 32 4 5 5 0 66 Changing Practices and Attitudes Establishing the Framework for MNT • Wheels of change move slowly • Develop infrastructure  Standards of care, guidelines, contracts  Indicators, monitoring tools, reports • MNT services: disparity in clinics  Providers, program managers, funding  Awareness, interpretation and abilities  Expectations, goal setting, reporting, access 67 Changing Practices and Attitudes Technical Assistance: Providers and RDs • Provider meetings, calls, emails • Provider and staff presentations • At each year’s program monitoring  Different and evolving TA focus  Always provide materials  Ex: HRSA Nutrition Manual CD, screening & referral forms, articles, standards of care, BMI chart, nutrition & weight flow chart 68 Changing Practices and Attitudes Technical Assistance: RDS • Dietitians in AIDS Care (DIAC)  DIAC listserve  Quarterly meetings since April 2005  Nutrition care process  When to provide/discontinue: nutritional supplements, food / meal services  Hyperlipidemia, insulin resistance, renal disease • Networking – long-lasting relationships • Training and problem solving 69 Personal Growth Lessons Learned • More medical records reviewed • Monitoring tools - streamlined and tally / comments sheets • Increase time spent monitoring • Evaluation report of MNT programs  Establish ongoing database  Baseline knowledge of programs 70 Screening for Nutrition Problems Lessons Learned • Newton’s laws of motion • Providers’ resistance  Problems? Don’t look and you won’t find  Screening vs. referring  Defining ―at risk‖ • Make it easy to look, think, document • Simple questions work 71 Height and Weight Measurements Lessons Learned • Routine measurements needed  Height not always measured  Weight usually measured  Accuracy questionable on both • Monitoring weight • Who measures? How trained? Shoes? • Calibration of scales? Stadiometer?  Adding/subtracting usually not done  BMI not usually done  Graphing not done 72 Reducing Barriers to MNT Lessons Learned • Reducing broken appointments  Set appointments with client  Coordinate with primary care visit  Reminders and follow-up calls and letters • Support MNT in clinic • Document in medical record  Include, discuss and referral from start  Incentives and rewards for MNT visit 73  Ask/respond to client request for MNT Needed: Proactive Healthy Clinic Lessons Learned • Take responsibility and power • Educate staff, promote  Nutrition and health knowledge  Clients’ food, nutrient and safety needs • Change the menu and food/ water safety practices for client and non-client events  Meetings, parties, fund raisers, vending machines, vouchers, board meetings, holidays, etc. 74 HIV Nutrition Essentials What has been your experience? What has worked well? What has been a challenge? 75 Acknowledgments Jill Strejc MS RD SRD Arcy Martinez RD AltaMed Health Services UCLA Corporation Caren Ongjoco RD Audra Gustafson RD CNSD Northeast Valley Health Los Angeles County Corporation Harbor-UCLA Medical Center Tammy Darke MS RD St Mary Medical CARE Jan B King MD MPH Program OAPP Medical Director 76 This presentation is available at www.LAPublicHealth.org/AIDS For Additional Information Marcy Fenton, M.S., R.D. Program Manager, Care Services Division Office of AIDS Programs and Policy 600 South Commonwealth Avenue 2nd Floor Los Angeles, California 90005-4001 Phone: 213/351-8368 Fax: 213/738-6566 E-mail: mfenton@ladhs.org This presentation is available at www.LAPublicHealth.org/AIDS