Improved body weight status as a result of nutrition intervention in adult, HIV-positive outpatients

RESEARCH

Improved body weight status as aresult of nutrition intervention inadult, HIV-positive outpatients MARYANN J. McKINLEY, RD; JODIEGOODMAN-BLOCK, MS, RD; MARTIN L. LESSER, PhD; ARLINE D. SALBE, PhD, RD

ABSTRACT Objective Malnutrition is an important consequence of infection with the human immunodeficiency virus (HIV); involuntary weight loss greater than 10% is one criterion that the Centers for Disease Control and Prevention uses for the diagnosis of acquired immunodeficiency syndrome (AIDS). This study was designed to determine whether nutrition intervention in a group of adult, HIV-positive outpatients affected weight maintenance. Methods We undertook a retrospective review of 175 patient charts from the AIDS Reproductive Health Clinic and the Center for Special Studies at The New York Hospital. Fortynine charts were excluded because the patient expressed a desire to reduce weight, discontinued medical care, or died. Seven charts were eliminated because of missing data. In the remaining patients (n=119), weights were recorded for the initial clinic contact and for a follow-up visit at least 6 months later. Nutrition intervention completed by a registered dietitian was indicated on 42 patient charts (intervention group); intervention included dietary assessment, intake analysis, appropriate counseling, follow-up, and provision of supplements as needed. The remaining 77 charts did not indicate nutrition intervention; this group was called the nonintervention group. Differences between the intervention and nonintervention groups were analyzed using the two-tailed Fisher exact test and the Mann-Whitney nonparametric test. Results Forty-two subjects (35% of the total) received nutrition intervention, including all of those with gastrointestinal problems (n=10) and wasting (n=11). Individuals in the intervention group gained a significant (P<.02) 1.2±11.4 lb (mean + standard deviation; median= +3 lb) compared with those in the nonintervention group who lost a mean of 3.5±12.8 lb (median= -4 lb). Twenty-six subjects (63%) in the intervention group maintained or gained weight compared with 32 subjects (42%) in the nonintervention group. Conclusion The results of this study suggest that nutrition intervention in HIV-infected persons can improve nutritional status and may lead to an enhanced ability to fight infection. JAm DietAssoc. 1994; 94:1014-1017.

1014 / SEPTEMBER 1994 VOLUME 94 NUMBER 9

alnutrition is an important consequence of infection with the human immunodeficiency virus (HIV); it occurs to some degree throughout the course of the disease (1). Severe malnutrition, or wasting, is a major source of morbidity in HIV-infected persons, often resulting in a greatly diminished quality of life. Involuntary weight loss greater than 10% is one criterion that the Centers for Disease Control and Prevention (CDC) uses for the diagnosis of acquired immunodeficiency syndrome (AIDS) (2); as a result, weight loss is the AIDSdefining diagnosis in close to 20% of reported cases (3). Death from wasting in HIV-infected persons appears to be the result of a depletion of body cell mass, which occurs disproportionate to the loss of body weight and body fat (4). This pattern contrasts with the pattern of weight loss seen in starvation where body fat is depleted in an effort to spare protein stores. Changes in body composition appear to occur at earlier stages of the disease process (Walter Reed classification 2, asymptomatic persons [5]) than previously recognized (6). The etiology of malnutrition in HIV disease is believed to be multifactorial (7). Implicating factors include altered nutrient intake, malabsorption, or metabolic changes (7). Inadequate food intake may occur secondary to anorexia, dysgeusia, dysphagia, depression, or lack of access to adequate foods (1). Nutrient malabsorption has frequently been documented in HIV-infected persons (8). Indications ofa malabsorptive process include symptoms such as diarrhea, flatus, or abdominal bloating. Causative factors of malabsorption may also be multifactorial, including enteric pathogens, abnormal gastrointestinal motility, autonomic dysfunction, or bacterial overgrowth. Approximately half of the patients with an infectious cause of diarrhea do not respond to treatment (8). Malnutrition may also occur as a result of metabolic

A.D. Salbe is an assistantprofessor in the Department of Medicine, Cornell University Medical College, New York, NY MJ. McKinley is a clinicaldietitianwith the Centerfor Special Studies and J. Goodman-Block is a clinical dietitianwith the Department of Obstetrics and Gynecology in the Division of Women's Health, The New York Hospital, New York, NY. ML. Lesser is the directorand an associate professor, Divisionof Biostatisticsand Department of Public Health, North Shore University Hospital-Cornell University Medical College, Manhasset, NY Address correspondence to: A.D. Salbe, PhD, RD, Department of Medicine, Cornell UniversityMedical College, 525 E 68th St, F 263, New York, NY 10021.

disturbances that accompany infection such as abnormal lipid metabolism, primary increase in gluconeogenesis, abnormal protein metabolism, or futile substrate cycles (3). A person with HIV infection, wasting, and malnutrition resulting from inadequate intake or nutrient malabsorption may regain weight in the form of both increased body-cell mass and body fat (9). In persons with systemic infections, however, weight gained is generally deposited as fat rather than as lean body mass (10). Early intervention to prevent malnutrition in HIV-infected persons is generally viewed as the best prevention to wasting (11). We undertook our study, therefore, to determine the effects of nutrition intervention on weight in a group of adult, H1V-positive outpatients in New ork City, NY. MATERIALS AND METHODS We undertook a retrospective review of patient charts from the files of the AIDS Reproductive Health Clinic and the Center for Special Studies at The New York Hospital. Charts of clinic patients are kept separate from general hospital records and filed alphabetically. Because of limited resources, a review of a maximum of 175 patient charts was determined to be feasible. All charts in alphabetical order from letters A through G were selected for this review. No chart s were excluded in the initial selection process. The AIDS Reproductive Health Clinic is open one afternoon a week, and approximately 20 patients are seen at each clinic meeting. The AIDS Clinic at the Center for Special Studies meets 4 days a week, and approximately 650 patients are seen each year. Patients are directed to these clinics as a result of self-referral, emergency room contact, or physician referral. The clinics have been in operation for more than 5 years. 01f the original 175 charts, 49 were excluded because the patient expressed a desire to reduce weight, discontinued medical care, or died. Seven subjects were eliminated from the study during statistical analysis because of missing data. For the remaining patients (n= 119), charts were reviewed and information was collected about the initial clinic contact and the follow-up contact, which was at least 6 months later. Chart review included notation of gender, age, weight, mode of transmission of HIV, presence and identity of opportunistic infections, CD4 lymphocyte count (an indicator of immune system status during HIV infection), use of supplements or an appetite stimulant, and whether nutrition intervention was completed by a registered dietitian. Nutrition intervention completed by a registered dietitian included a thorough assessment of nutritional status based on patient interview, anthropometric data, laboratory parameters, medical diagnosis and related conditions, drug and nutrient interactions, an(d psychosocial factors pertinent to nutrient intake. The dietitian developed an individualized care plan, and provided in-dept h instructions on the proposed dietary regimen. The dietitian also provided written educational materials about food safety and properfood handling, menu patterns for overcoming anorexia, and sample dietary plans for increasing intake. Where appropriate, the dietitian arranged for provision of nutrition supplements. Family members identified as food providers attended the counseling session. Follow-up sessions with a registered dietitian were scheduled within 3 weeks of the initial visit for persons at nutri ional risk. Patients given nutrition supplements were also monitored closely by the dietitian to assess tolerance to the products provided. Of the 119 patients, 42 received nutrition intervention (intervention group) and 77 did not (nonintervention grout)). Weights at the time of the initial clinic visit were obtained from the charts (whether or not the patient was seen by a registered dietitian) and at the time of the latest visit that occurred before the start of chart review A minimum of 6 months elapsed between

Table 1 Characteristics of study subjects Characteristic

Interv ention group' (n=42) No. %

Age (y)

Gender Women Men

Nonintervention group (n = 77) No. %

36.0 ±7 0'

36 5 6.3

17 25

40 60

30 47

39 61

Intravenous drug abuse

15

36

20

26

Heterosexual contact Homosexual contact

12 10

29 24

26 21

34 27

4

10

5

6

1

2

1

1

0 0

0 0

1 3

1 4

Opportunistic infections or complications Pneumocystis pneumonia 11

26

7

9

Wasting syndrome Gastrointestinal problems

11 10

26 24

0 0

0 0

Substance abuse Kaposi's sarcoma

4 1

10 2

6 3

8 4

Tuberculosis Asymptomatic

2 3

5 7

1 66

1 86

Mode of transmission

Blood transfusion Intravenous drug abuse and homosexual contact Blood transfusion and heterosexual contact Transmission unknown

intervention is defined as assessment and counseling by a registered dietitian and provision of supplements in the form of nutrition formulas. bMean standard deviation. CThe number of subjects reflects the number of individuals with these diagnoses. As some individuals had more than one opportunistic infection, the numbers may be greater than the group total, and the percentage totals may be greater than 100%.

JOUlRNAL O)F THE AMERICAN DIETETIC ASSOCIATION / 1015

RESEARCH

Effect of nutritionintervention on weight change. Side-by-side box plots show distributionof weight changefor intervention and nonintervention groups. Median is indicatedby the center horizontalline. Mean is indicated by the central plus sign (+). Top and bottom horizontalbox edges indicate upper and lower quartiles. The centralvertical lines indicate the range of values. initial and final visits. The frequency of contact with a registered dietitian within that period was not documented. Data were analyzed using the Statistical Analysis System (version 6, 1989, SAS Institute, Cary, NC) (11). To investigate the comparability of the intervention and nonintervention groups with regard to baseline variables (eg, age, gender, mode of transmission, presence of opportunistic infection), the MannWhitney test was used to compare mean ages, and the two-tailed Fisher exact test was used for categoric variables. To compare the two groups with respect to the dependent variables (eg, weight change, weight ratio, CD4 changes), the Mann-Whitney test was used. Analysis of covariance was used to adjust for the varying length of time between the recording of initial and final weights. As the results for the analysis of covariance were similar to those for the Mann-Whitney test with no covariate adjustment, only the latter are presented.

RESULTS Table 1 shows that the population under investigation in this study was a varied group. Of the total subjects, 40% were women and 60% were men. This proportion was maintained in the intervention and nonintervention groups. Mean (standard deviation) age of the subjects was 35.2+6.5 years (range=24 to 58 years). There were no significant differences in the ages of the subjects receiving and those not receiving nutrition intervention. For the total group, heterosexual contact made up the largest percentage (32%) of mode of viral transmission, followed by intravenous drug abuse (29%), homosexual contact (26%), and blood transfusion (8%) (Table 1). In three subjects, more than 1016 / SEPTEMBER 1994 VOLUME 94 NUMBER 9

one mode of viral transmission was identified; in three additional subjects, mode of transmission was unknown. Mode of viral transmission was not a factor in the selection of subjects for intervention. Forty-two subjects (35%) received nutrition intervention. Table 1 indicates that patients with Pneumocystispneumonia, wasting syndrome, and gastrointestinal problems were more prevalent in the intervention group than in the nonintervention group. The majority of those in the noninterventiongroup were asymptomatic. The follow-up time between the initial contact and assessment of weight status was significantly (P<.02) different between the intervention and nonintervention groups. Those receiving intervention were assessed after 12.9+7.6 months; those not receiving intervention were assessed after 20.9±9.2 months of follow-up. The Figure shows that the persons who received nutrition intervention gained a mean of 1.2±11.4 lb (median gain=3 lb). Those who did not receive nutrition intervention lost a mean of 3.5±12.8 lb (median loss=4 lb). These results were statistically significant (P<.02). Twenty-six subjects (62%) in the intervention group maintained or gained weight, compared with 32 subjects (42%) in the nonintervention group. These results were also statistically significant (P<.03).The weight ratio, that is, the ratio of final weight to initial weight, differed significantly across the two groups. In the intervention group, there was a 1.3% increase, whereas in the nonintervention group, there was a 2% decrease (P<.02; data not shown). In the nonintervention group, weight losses greater than 30 lb and as much as 55 lb were observed. Table 2 indicates that there were no significant differences in initial CD4 lymphocyte counts between the intervention and

Table 2 Effect of nutrition intervention on CD4 lymphocyte counta Group

Median

CD4 change (final - initial) Mean ± SD Median

CD4 ratio (final to initial) Mean ± SD Median

230 t 213

140

- 67 ± 168

- 22

0.84

395 282

350

-80 + 184

-58

082 + 0 66

Initial CD4 count Mean ± SDb

Intervention group

Nonintervention group

0 66

0 80

0 76

aThere were no significant differences in initial CD4 lymphocyte counts, the change in CD4 counts, or the CD4 ratio between the intervention and non ntervention groups. bSD = standard deviation.

nonintervention groups. In addition, there were no significant differences in the change in CD4 counts (final-initial) or the CD4 ratio (final to initial) between the intervention and nonintervention groups. No correlation existed between change in CD4 counts and change in weight. No association was found between the use of either supplements or appetite stimulants alone and weight change.

nutrition intervention should be available and provided in all health care settings that dispense services to HV-inrlfected persons. Although the benefits of early intervention in tl e prevetio of wasting have not yet been scientifically documented, it seems obvious that excellent nutritional status at the outset of the disease process can only be of benefit in fighting this chronic

DISCUSSION The results of this study show the positive effect of nutrition intervention on the maintenance of body weight in HJV-positive persons and support the principle of including nutrition intervention as a first line of defense in the care of HIV-infected patients (1,11). Evidence indicates that good nutritional status not only provides resistance to the development of infections, but it may also diminish the severity of existing infections (13). One shortcoming of this study is that the decision to provide nutrition intervention was not randomized, and those most in need of nutrition care were most likely to receive it. In fact, 100% of the persons most at risk for malnutrition - that is, those with marked wasting and those with gastrointestinal disturbances (Table 1) -- were seen by a registered dietitian and received the appropriate nutrition counseling and intervention. In persons with these complications, a positive weight outcome is often most difficult to attain; therefore, the lack of randomization might have led to biased results. This assumption, however, is not supported by the data. A positive outcome was obtained in the intervention group despite its concentration of severely compromised patients, which further supports the importance of nutrition intervention. Because our study was a retrospective review of the charts of clinic patients, body composition changes were not assessed in this population. Previous studies have indicated that weight gained by HIV-infected persons may be in the form of body fat, not lean body mass. It is not possible, therefore, to state definitively that this population attained a major benefit from the nutrition intervention received. We do know, however, that weight loss and the accompanying changes in body image may have an important effect on an individual's emotional well-being. Consequently, maintaining a healthful body weight and body image may offer psychological and physical benefits to the HIV-infected individual. The largest segment of our study population (32%) contracted the HIV virus through heterosexual contact (Table 1). This confirms a recent finding by the Centers for Disease Control and Prevention that sexual contact is the leading cause of AIDS in women (14).

This investigation was supported, in, part, by Public Health Service researchgrant RR00047frorm the General Clinical Research Centers Programof the Diviision o(f Researc:h Resources, National Institutes of Health.

APPLICATIONS Nutrition services rendered by a registered dietitian may have a notable effect on weight maintenance in persons with HIV. Early

condition. ·

References 1. Cuff PA. Acquired immunodeficiency syndrome and malnutrition: role of gastrointestinal pathology. Nutr Clin Pract. 1990; 5:43-53. 2. Classification system for human T-lymphotrophic virus type III/ lymphadenopathy-associated virus infections. MMWR. 1986; 35::334-

339. 3. Hellerstein MK. Pathophysiology of lean body wasting and nutrient unresponsiveness in HIV/AIDS: therapeutic implications ,slot' HIV/ AIDS. 1992; 1:17-24. 4. Kotler DP, Tierney AR, Wang J, Pierson RN Jr. Magnitude of bodycell mass depletion and the timing of death from wasting in AIDS. Arn J Clin Nutr. 1989; 50:444-447. 5. Redfield RR, Wright DC, Tramont EC. The Walter Reed staging classificaiton for HTLV-III/LAV infection. N ElI Medl 1986;314 131132. 6. Ott M. Lembcke B, Fischer H, Jager R, Polat H, Geier H, Rech M, Staszeswki S, Helm BE, Caspary WF. Early changes of body c omposition in early human immunodeficiency virus-infected patients: tetrapolar body impedance analysis indicates significant malnutrition. A , ./ Cli, Ntr. 1993; 57:15-19. 7. Kotler DP. Causes arnd consequences of malnutrition iri IIIV/AII)S. Nutr HIV/AIDS 1992; 1:5-8. 8. Simon I)M. AIDS-associated diarrhea. Noit HtI4AII )St'. 12 1::3:339. 9. Kotler DP, Tierney AR, Ferraro R, Cuff P, Wang J, Pierson RN J.Ir, Heymsfield SB. Enteral alimentation and repletion of body cell mass in malnourished patients with acquired immunodeficiency sylldror eI tn J Clin Nutlr 1991; 53:149-154. 10. Kotler )P, Tierney AR, Culpepper-Morgan IA, Watng I. Pier son RN Jr. Effect of home parenteral nutrition on body composition in patients with acquired immunodeficiency syndrome. .JPN. 1990: 14:454-458. 11. Position of The American Dietetic Association and The C(anadian Dietetic Association: nutrition intervention in the care of persons with human immunodeficiency virus infection JAm Diet ,lssi,oc. 1994; 94: 1042-1045. 12. SAS lser's Gaide,Statistics, V'osiro (i. Cary N(: SAS Insit:llte: 1989. 13. Chandra RK. Nutrition and inurrity: lessons from the iast anid new insights into the future. Am J C/li Nttr 1991; 5:1:1087-11 )1. 14. QuarterlySurteillanceReport. Atlanta, (;a: Centers for T)isease Control and Prevention: July 1993. JOIIRNAL ()F THE AMERICAN DIETETIC ASSO(IATI()N / 1017