Bone loss in patients with HIV infection.

The prognosis of HIV infection has been considerably improved by the introduction of antiretroviral drugs. However, the longer survival times are associated with the emergence of new complications including decreased bone mineral density (BMD) values and/or bone insufficiency fractures. A meta-analysis of studies published between 1966 and 2005 showed bone absorptiometry results indicating osteoporosis in 15% of HIV patients and osteopenia in 52%. Longitudinal studies found no evidence that antiretroviral drug therapy contributed to the occurrence of bone loss. Available data indicate uncoupling with increases in bone resorption markers and decreases in bone formation markers. In addition to conventional risk factors for osteoporotic fractures, factors in HIV-infected patients may include malnutrition (wasting syndrome), hypogonadism, disorders in calcium and phosphate metabolism, and HIV infection per se. In patients with established bone insufficiency, bisphosphonate therapy should be considered. Alendronate in combination with vitamin D and calcium supplementation has been found effective in improving BMD values.

Nutritional supplementation according to energy and protein requirements in malnourished HIV-infected patients.

To evaluate the effects of nutritional supplements on nitrogen and energy balances, body composition and immune parameters, HIV-infected malnourished adult outpatients were prospectively studied. Forty-six patients (4 females and 42 males; 37 +/- 12 y) were supplemented with a polymeric diet (PD) or regular foods (RF) on two consecutive 45-day periods on a crossover design. Weight, skinfold thicknesses, plasma albumin (PA), CD4 and CD8 lymphocyte counts (LC), resting energy expenditure (REE) and urinary nitrogen excretion were measured at baseline, 45 and 90-day. Food intake was weekly recorded by food surveys. Thirty-five patients completed the protocol (18 in Group 1:PD-->RF; 17 in Group 2:RF-->PD). In both groups, weight, fat free mass (FFM), energy balance (EB) and nitrogen balance (NB) increased significantly after PD, whereas LC and PA remained unchanged in both groups. The best results in terms of weight gain were obtained in the PD group and PD plus zidovudine subgroup (n = 8) during the first 45 days (weight gain/FFM gain: 4.8/2.6 kg and 6.8/3.1 kg, respectively). Nutritional supplement with PD, according to the EB and NB goals, was well tolerated and permitted to achieve a significant weight and FFM gain over a 90-day follow-up.

Nutritional supplementation according to energy and protein requirements in malnourished HIV-infected patients

To evaluate the effects of nutritional supplements on nitrogen and energy balances, body composition and immune parameters, HIV-infected malnourished adult outpatients were prospectively studied. Forty-six patients (4 females and 42 males; 37 +/- 12 y) were supplemented with a polymeric diet (PD) or regular foods (RF) on two consecutive 45-day periods on a crossover design. Weight, skinfold thicknesses, plasma albumin (PA), CD4 and CD8 lymphocyte counts (LC), resting energy expenditure (REE) and urinary nitrogen excretion were measured at baseline, 45 and 90-day. Food intake was weekly recorded by food surveys. Thirty-five patients completed the protocol (18 in Group 1:PD-->RF; 17 in Group 2:RF-->PD). In both groups, weight, fat free mass (FFM), energy balance (EB) and nitrogen balance (NB) increased significantly after PD, whereas LC and PA remained unchanged in both groups. The best results in terms of weight gain were obtained in the PD group and PD plus zidovudine subgroup (n = 8) during the first 45 days (weight gain/FFM gain: 4.8/2.6 kg and 6.8/3.1 kg, respectively). Nutritional supplement with PD, according to the EB and NB goals, was well tolerated and permitted to achieve a significant weight and FFM gain over a 90-day follow-up.

The role of exercise in the prevention and treatment of wasting in acquired immune deficiency syndrome.

Involuntary weight loss with lean tissue depletion is a serious and AIDS-defining complication of HIV infection. This article explores definitions of AIDS wasting syndrome (AWS), its etiology, methods of assessing body composition, and pharmacological treatments. Recent research literature on the role of exercise in the prevention and treatment of AWS is reviewed. Included are studies of the safety of exercise, the effects of exercise on the immune system, and the effects of exercise on weight gain and body composition as well as studies of exercise in combination with medications and other interventions. Implications for clinical practice are discussed.

Micronutrient supplementation in the AIDS diarrhoea-wasting syndrome in Zambia: a randomized controlled trial.

OBJECTIVE: As HIV has spread through sub-Saharan Africa, persistent diarrhoea has emerged as a major problem in hospitals and in the community in severely affected areas. We have previously demonstrated that antiprotozoal therapy with albendazole reduces diarrhoea in AIDS patients in urban Zambia. This trial was designed to test the hypothesis that the clinical response to albendazole might be improved by oral micronutrient supplementation. DESIGN: Randomized, placebo-controlled trial. SETTING: Home care service of Ndola Central Hospital, Zambia. PATIENTS: HIV-seropositive patients with persistent diarrhoea. INTERVENTION: Patients were randomized to albendazole plus vitamins A, C and E, selenium and zinc orally or albendazole plus placebo, for 2 weeks. MAIN OUTCOME MEASURES: Time with diarrhoea following completion of treatment; mortality; adverse events. RESULTS: Serum vitamin A and E concentrations before treatment were powerful predictors of early mortality, but supplementation did not reduce time with diarrhoea or mortality during the first month, even after taking into account initial vitamin A or E concentrations, CD4 cell count or clinical markers of illness severity. Serum concentrations of vitamins A and E did not increase significantly in supplemented patients compared with those given placebo, and there were no changes in CD4 cell count or haematological parameters. No adverse events were detected except those attributable to underlying disease. CONCLUSIONS: Although micronutrient deficiency is predictive of early death in Zambian patients with the diarrhoea-wasting syndrome, short-term oral supplementation does not overcome it nor influence morbidity or mortality.

De novo lipogenesis predicts short-term body-composition response by bioelectrical impedance analysis to oral nutritional supplements in HIV-associated wasting.

We studied the effects of enteral supplements on protein and energy intakes, body composition, energy expenditure, and gastrointestinal histology in 49 subjects with human immunodeficiency virus-associated weight loss (12.7 +/- 0.9% of body wt). We also determined whether a stable-isotope mass spectrometric measurement at baseline might predict the short-term response of fat-free mass (FFM) measured by bioelectrical impedance analysis. Thirty-nine subjects completed the study after being randomly assigned to receive either a whole-protein-based (n = 22) or a peptide-based (n = 17) formula. A nonsupplemented, nonrandomly assigned group (n = 13) was followed concurrently. Both formulas were well tolerated. Voluntary intakes of energy and protein from nonsupplement sources decreased significantly during supplementation [by 819-1638 kJ (196-382 kcal)/d and 5.6-14.4 g protein/d, respectively; P < 0.01] but to a lesser extent than the intake from the supplement [2300-2510 kJ(550-600 kcal)/d and 19-28 g protein/d, respectively], so that net increases in intakes of protein and energy (P < 0.03), as well as of several vitamins and trace elements were increased. Nevertheless, the mean FFM did not increase for the group as a whole, although there was considerable interindividual heterogeneity. Changes in FFM at 6 wk were significantly inversely correlated (r = 0.65, P < 0.01) with baseline synthesis of fat (de novo hepatic lipogenesis), but not with other potential measures of energy intake (insulin-like growth factor 1 or its binding protein) or inflammation (soluble tumor necrosis factor receptors I or II). The prospective identification of FFM response by measurement of de novo hepatic lipogenesis supported the hypothesis that the subset of wasting patients whose FFM is unresponsive to nutrient supplementation have altered nutrient metabolism.

AIDS wasting syndrome as an enterometabolic disorder: the gut hypothesis.

There is an interesting relationship between the HIV virus, the health of the gastrointestinal tract, and AIDS wasting syndrome, involving Tumor Necrosis Factor alpha (TNF alpha), specific and non-specific immunity in the gut, gut permeability, and oxidative stress. It is hypothesized that the progression of HIV to full-blown AIDS may be impacted by maintaining a healthy gut. A therapeutic protocol which decreases oxidative stress, inhibits TNF alpha, enhances phase I and II liver detoxification, and improves specific and non-specific immunity in the gut should be part of a therapeutic protocol for HIV-infected individuals. Through a better understanding of the pathophysiology of HIV advancing to AIDS, the practitioner can develop a treatment strategy of nutritional and lifestyle changes which could theoretically prevent an HIV infection from advancing to full-blown AIDS.

HIV infection and malnutrition.

Weight loss, anorexia, metabolic disorder and malabsorption are leading symptoms of HIV infection. Recent data help us to understand wasting as being intrinsically linked to immunodysregulation and enteropathy. In therapy, the role played by anabolic steroids and growth hormone has been newly defined. The new antiviral drugs may efficiently prevent clinical progression, including wasting. New metabolic side effects have, however, been encountered.