What Is The Role Of Early Intervention And Supplementation?
by Carl Germano, M.A., R.D., CNS
Gastrointestinal disorders are well described in HIV disease. HIV is known to infect the intestinal mucosa and very early in HIV infection. Infection probably occurs around the time of primary HIV infection which is a time of extensive viral insult in the bloodstream. It appears that the nutritional disorders in HIV infection with malabsorption have their own continuum. The spectrum of illness starts very early in HIV infection with malabsorption of certain nutrients and trace elements and progress to wasting, weight loss and malnutrition seen so often in advanced disease.
The purpose of this article is to discuss the role of several macro and micronutrition as a component of early intervention medical care for HIV. Once we have this understanding, we will be in a better position to address the best ways to prevent and manage the myriad of nutrition problems that occur in HIV/AIDS. I have tried to examine as much of the medical and nutritional scientific evidence that is currently available. My conclusion is that nutritional deficiencies are very much a medical condition within the spectrum of HIV infection. As such, they need to be included in the medical evaluation and treatment of the patient with HIV/AIDS. If your present practitioner does not address the nutrient deficiencies and nutritional concerns in HIV, it is time to get another practitioner - they will do more harm than good!
The increase interest in and acceptance of nutritional care and nutrient supplementation has led to the development of a new "middle ground" for nutritionists and physicians. One cannot ignore the significant research and data emerging on the benefits of nutrition/nutrients and their importance in early intervention medical care of patients with HIV/AIDS. The data available on the therapeutic amounts of nutrients needed that are greater than the RDA has overshadowed that archaic concept that "if you eat a good diet, you will get all the nutrients you will need". One must realize that what is ingested is not necessarily entirely absorbed or utilized and that the RDA does not take into consideration the increased nutrient needs necessary for the prevention of disease or during periods of increased needs during illness. This cannot be overemphasized, especially in the medical care and treatment of those with HIV/AIDS. Unfortunately, most of the typical aggressive nutritional intervention models practiced by most physicians address only the "end stage" nutritional deficiencies of HIV disease with emphasis on total parenteral nutrition (TPN).
There seems to be agreement among many health care providers that when it comes to the use of nutritional supplements, individual recommendations should come from nutritionally oriented physicians or certified nutritionists. More likely than not, many patients being treated for HIV/AIDS are taking one or many nutritional supplements of which their physician is not familiar with. It is imperative that physicians become more familiar with nutritional supplements and understand that nutrient replacement therapy plays a significant role in the medical care and treatment of HIV/AIDS. Nutrient replacement has been deemed necessary due to the increased needs from a variety of factors including the presence of malabsorption, malnutrition, drug therapy and the consequences of the illness. It has been well established that malnutrition can adversely affect the immune system which may result in a marked increase in the incidence and severity of sepsis, infection and progression of the disease. Since many micronutrients play an important roles in key cellular and metabolic processes, it is no surprise that micronutrient deficiencies would alter immune response. Several factors leading to alterations of the GI tract which have profound effects on nutrient malabsorption include drug therapy and pathogen exposure affecting the GI mucosa.
It is also necessary to understand that nutrient replacement therapy and support is a critical component of the medical care that is to be provided. Many researchers and physicians treating HIV/AIDS have come to the conclusion that many of the nutritional abnormalities occur early in the course of HIV-1 infection and appears to facilitate disease progression. Others have suggested that nutrient intakes much greater than the RDA are an essential part of the medical therapy especially when malabsorption exists. Several studies have shown that nutrient deficiencies have a significant impact on the ability of the individual to respond to any immunological challenges. Finally, there is a consensus that nutritional intervention be addressed as early as possible since deficiencies may occur well before overt classical deficiency symptoms appear.
Therefore, the following provides a brief review of several selected nutrients, in supplement form, identified to be important in HIV/AIDS due to increased needs because of malabsorption and the consequences of immunosuppression. While the list is not all inclusive, it represents a major portion of the nutrients reviewed in the research. One should not discount the benefits of other nutrients, amino acids, herbs, Chinese medicine, acupuncture and meditation not covered in this article or other complimentary modalities of healing in the totality of appropriate care for the individual with HIV/AIDS.
Vitamin A/Beta Carotene
Vitamin A is a family of compounds that includes retinol, retinal and the precursor carotenoids such as beta carotene. Retinol and retinal are found in foods of animal origin whereas the carotenoids are a group of fat soluble pigments found in the plant kingdom. Vitamin A exerts important effects on immune responses. It's precursor carotenoids, beta carotene, lycopene, luetein, capsanthin, etc. act as potent antioxidants and immunostimulants and have been shown to increase the number of CD4+ helper cells in healthy human volunteers. Recent studies have demonstrated that beta carotene administration up to 180mg per day significantly increased the total white blood cell count, percent change in helper cells and percent change in the helper suppressor ratio compared to those not taking beta carotene.
Factors that affect fat absorption also influence vitamin A and beta carotene absorption. The preformed vitamin A is primarily found as either the fish liver oil or the synthetic, water miscible palmitate form (preferable for those with fat malabsorption) in most supplements. These forms of vitamin A are not readily excreted and can accumulate in the body to toxic levels if large amounts are consumed over long periods of time (100,000 IU). Therefore a combination of preformed with beta carotene/carotenoids is preferred. Beta carotene is relatively non toxic and is regulated by the body's ability to convert and release vitamin A but more importantly it exhibits it's own beneficial effects independent of it's conversion to vitamin A. A more complete sources of the carotene's can be found in products containing the family of mixed carotenoids from the palm plant or from the algae D.salina.
Vitamin E is a family of fat soluble compounds, including the tocopherols. Deficiency has been found to impair T cell mediated function which is reversible by supplementation. Yet, the main role of vitamin E in enhancing immune response and phagocytosis is the prevention of lipid peroxidation of cell membranes. Another important in HIV treatment is that vitamin E has also been shown to enhance the activity of AZT. Alpha tocopherol is the most common and most potent form of the vitamin. The issue of natural vs. synthetic is important when choosing the best available form. Natural vitamin E is designated as "d" alpha tocopherol whereas synthetic is designated as the "dl" form. Studies have shown that the natural form is better absorbed and utilized. Esterified forms of natural vitamin E, such as d alpha tocopherol succinate, is more stable and preferable when fat malabsorption exists. The major source of vitamin E on the market is from soybean oil.
The involvement of ascorbic acid (Vitamin C) in maintaining cellular immune function is supported by reports that deficiency of this vitamin is accompanied by decreased resistance to microbial infections. Vitamin C shares a long history of safe use in amounts much greater than the RDA yet continues to be controversial despite numerous positive reports. In recent studies, those patients who ingested elevated levels of vitamin C were associated with a decreased rate of progression of HIV. Lastly, vitamin C can increase the availability of the powerful antioxidant known as glutathione which is critical to recovery in the HIV deficient individual. Vitamin C supplements exist as plain ascorbic acid or in buffered mineral ascorbate forms (vitamin C complexed with calcium, magnesium, potassium or zinc). The mineral ascorbates are the preferred choice when large amounts are required or if GI problems exist with the ascorbic form.. The powdered buffered form is desirable when large quantities are prescribed and may yield from 2,000 - 4,000 mg vitamin C per teaspoon.
With poor diet, malabsorption and hypermetabolism, the need for B vitamins is increased. Special emphasis being placed on vitamin B-12 , folate and thiamine to correct neurological problems associated with deficiencies. Vitamin B-12 status is particularly important in maintaining cognitive performance and is an important factor in neurological function. Vitamin B-6 has a positive influence on humoral and cell mediated immunity and is also an important factor in neurological function observed in HIV infected subjects. There appears to be significant impairment of folic acid absorption in patients with HIV disease which account for some of the neurological manifestations seen in both adults and children infected with the virus. B vitamin supplements are available individually or as a complex. Aside from the special increased requirement for B-12, folate or B-6, a full B complex is preferred. The absorption issue of B-12 has been traditionally handled with intra muscular injection but individuals may utilize B-12 in sublingual tablets, mucosal sprays and nasal gels as alternatives.
Zinc deficiencies are known to impair immune function in AIDS and adequate zinc status is essential in maintaining normal cell mediated immunity. It has been suggested that zinc deficiency is responsible for the many immune abnormalities occurring in malnourished states found in AIDS and that sufficient amounts are required to maintain adequate blood levels in those with HIV. As with all minerals, a more bioavailable form compared to standard inorganic forms is essential for efficient absorption and utilization since absorption of zinc is only 30-40%. A fully reacted chelate form such as zinc citrate or zinc histidinate has better absorption when compared to the typical inorganic forms commonly found in some supplements. Use of zinc above 50mg amounts require monitoring of immune function and possible additional supplementation of copper since excess may have a reverse effect on immune function.
Glutathione is a potent antioxidant protecting against oxidative stress which may be exacerbated by drug and radiation treatment commonly used to treat HIV/AIDS. Glutathione also has a powerful influence on T-cell function which is an important immune function during viral illness. It is known that AIDS patients have low glutathione levels as a consequence of the illness and drug therapy. N-acetyl-L-cysteine has been shown to inhibit HIV replication and replenish intracellular glutathione levels in HIV infected cells. The beneficial effect of NAC is enhanced by the addition of vitamin C to the nutrition protocol . Therefore, NAC and vitamin C may be very useful as a therapeutic agent and may benefit glutathione deficient patients undergoing radiation treatment. NAC is the preferred choice to raise glutathione due to the better absorption and non toxic effects at higher doses.
The most important function of selenium is as a component of the antioxidant enzyme glutathione peroxidase. Research suggests that those with HIV/AIDS possess less plasma and erythrocyte selenium and less erythrocyte glutathione peroxidase. Although lower glutathione peroxidase is probably related to the malabsorption and decreased intake of selenium, nutrient replacement therapy may assist the impaired immune system. It is apparent that serum selenium levels probably decrease during viral infections and that it would be useful to give selenium supplements early in AIDS patients. Lastly, another important aspect of adequate selenium nutriture in HIV is it's role in preventing cardiovascular problems such as cardiomyopathy. The organic form of selenium, selenomethionine, is better absorbed and less likely to cause toxic symptoms than the inorganic forms such as sodium selenite and selenate.
Reports out of the ninth International Conference on AIDS in Berlin emphasized several important issues at hand: firstly, early administration of AZT did not result in any clear survival benefit and secondly, antioxidant nutrients are critical adjunct therapy to the medical treatment in HIV/AIDS. Importantly, multiple nutritional abnormalities occur relatively early in the course of HIV infection and appear to facilitate the progression of the disease. Adequate nutrient supplementation, corrective dietary manipulation and adjunct complimentary therapies are a reasonable appropriate approach to one's medical care for HIV/AIDS.
Copyright 1995 Reproduced with permission of the copyright owner