Click here for a complete list of CME opportunities.
HIV & Aging Clinical Recommendations
To download a PDF of this chapter, click here.
Chronic infection burdens repair and immune functions that are already slowing as a result of aging. Particularly important is the age-related shift in glutathione status, leaving a more pro-oxidant state in cells (Rebrin 2008). The slower protein assembly of aging plays out as impaired muscle, organ, and bone repair. Impaired protein assembly yields “immune senescence”—an inability to activate naïve T cells and generate memory T cells. Immune cell activity is sensitive to nutrition deficits; HIV infection alters gut cell structure, impeding all nutrient absorption, even in the HAART era (Knox 2000).
Nutrition is about providing materials for the formation, operation, and repair of cells. The Mediterranean Diet, or Cretan-Mediterranean Diet, is the food plan with the best data on both immune (anticancer) and cardiac benefits (de Lorgeril 2013). The D.A.S.H. Diet preserves cardiac health, and reduces the risk of developing diabetes (Jacobs 2015).
Plant-based vegetarian diets seem to reduce disease risks, but this is epidemiological data that does not incorporate HIV disease elements such as fibrosed intestinal mucosa, altered gut-associated lymphoid tissue (GALT) status, and the redox burden of chronic infection as operative factors in assessing outcomes.
In directing people toward a Cretan-Mediterranean diet, one must consider some key elements. The diet has more fish and seafood, and less meat than other diets. There are liberal amounts of fruit and vegetables, including many wild greens. Whole grains are eaten as cereals and sourdough bread, not as pasta. Legumes, rich in magnesium, are eaten almost daily. Fat sources are nuts, olives, and olive oil. Dairy is more cheese than milk, especially goat and sheep milk cheeses. Chemically, the diet contains more selenium and glutathione, plus a healthier balance of omega-6 to omega-3 fats. It is very high in fiber and rich in antioxidants like vitamins C and E, plus resveratrol from red grapes/wine, and the anti-inflammatory oleuropein from olive oil. One research article reported that people on the island of Crete seem to consume 245 kilograms of plant material per year, (compared to the 150 kg in Italy and France, and 90 in Finland) (Simopoulos 2011).
Assemble the Daily Diet in a Series of Five Steps.
Step 1. Determine desirable protein foods, and eat them three times a day—generally breakfast, lunch, and dinner. Research is showing that aging people need more protein, up to double the RDA (Gaffney-Stomberg 2009). Loss of muscle in aging, known as sarcopenia, is a much bigger problem than in the general population and medical and needs to be appreciated (Iannuzzi-Sucich 2002).
The American Heart Association stresses two 4-ounce servings per week of oily fish. As approximately 50% of Americans consume no fish each week, a daily fish-oil pill supplement should be considered. An average fish-oil pill will usually have 180 mg of DHA, the amount needed to replicate the 50% reduction in risk of senile dementia reported in Framingham studies. Up to 6 grams a day of fish oils have lowered triglyceride levels by almost 40% in an HIV population (Woods 2009).
As a matter of practicality, whey protein powder is a convenient and inexpensive additive to a meal, often added to breakfast cereal or protein-fruit smoothies. Trials of whey protein use in HIV populations have shown that it can sometimes raise CD4 counts (Sattler 2008) and frequently reverses glutathione (antioxidant enzyme) deficiency (Micke 2002). Whey can also improve osteoblast activity in bones (Xu 2009). Consumed dairy products should be fat-free or low-fat.
Step 2. Urge the eating of vegetables at both lunch and dinner. Three cups a day would be just a minimum amount to eat for the sake of obtaining Cretan-diet levels of minerals and phytochemicals. HIV-infected people consuming a dietary pattern that included higher intake of vegetables, fruits, and low-fat dairy foods, have significantly higher CD4 counts (Hendricks 2008).
Step 3. Encourage eating fruit three times per day to improve glutathione and glutathione peroxidase levels (Gil 2005). Eating fruit, including the traditional “apple-a-day,” provides the water-soluble fiber pectin, supporting beneficial gut flora, which lower cholesterol numbers, C-reactive protein levels, and body percent fat (Davis 2006; Miller 1996).
Step 4. Nuts and seeds contain essential oils that form cell membranes. A target is eating one handful of nuts and one of seeds every day. A trial of a Mediterranean Diet, supplemented with mixed nuts, proved more useful in heart disease prevention than did a low-fat diet (Estruch 2013). The fatty acid gamma linolenic acid (GLA), prominent in seeds (and spinach), lowers LDL-cholesterol, raises HDL-cholesterol (Levy 2017) and lowers blood pressure (Das 2008). Low GLA levels seem to be a risk factor for development of type2 diabetes (Kroger 2012). Dry skin is a sign of low GLA levels. Consuming ¼ cup raw seeds daily, or taking 2 grams evening primrose oil covers GLA needs. People with a GLA deficiency gain fat in the abdomen, see cholesterol and triglyceride counts rise and HDL-cholesterol levels drop (Tremblay 2004) precisely the common body shape and blood lipid changes seen in lipodystrophy.
Step 5. Starches (carbohydrates) are the remaining part of fuel and food needs. Legumes, technically a protein-rich starch, are an important component of the Mediterranean diet, providing fiber, plant protein, and magnesium. Higher magnesium intake is inversely related to cardiac and cancer mortality (Guasch-Ferre 2014). In both the D.A.S.H. Diet and Mediterranean Diet, higher magnesium intake is correlated with preservation of cognitive function in aging (Wengreen 2013). Select starch portion sizes wisely in aging; oversized servings of starches tend to turn to fat faster than smaller amounts (Wolever 2003). At least half of grains consumed should be whole grains.
In addition to assembling a diet that focuses on variety, nutrient density, and amounts, the calories from added sugars and saturated fats, along with sodium should be limited (USDG 2015).
Insufficient antioxidant activity coupled with mitochondrial damage underlie the faster rates of deterioration occurring in this population.
Common concerns are osteoporosis, vascular disease risk, sarcopenia, loss of cognitive function, fatigue/frailty, and immune senescence.
Subtle nutrient deficiencies play a role in all of these problems. Using comprehensive nutrition therapy to treat degenerative processes offers the opportunity to avoid increased pharmacologic burden in a population where side effects are especially likely.
In the internet age, many consumers are familiar with nutritional supplements in HIV treatment. Below is a review of conditions and studies that could improve clinicians’ comfort level with the vitamin, mineral, and other supplement interventions their HIV-infected patients are utilizing. Nutrition therapy can help in situations where treatments are nonexistent or have low efficacy.
Cholesterol levels do not account for all cardiac and vascular disease risk. Carotid artery occlusion is associated with longer time on HAART. Subtle B-vitamin deficiencies, seen as higher homocysteine levels, were a cause of carotid artery narrowing in the Framingham study (Selhub 1996). B-vitamin-dependent enzymatic deficiencies in the elderly cannot be detected in serum B-vitamin-level tests. This speaks to the utility of supplementing with B-complex vitamins in this population.
As stated above, the American Heart Association recommends eating fish twice a week in general, and consuming 1 gram a day of EPA/DHA for people with heart disease. Low HDL is common in this population. This can be reflective of essential fat deficiency, and of lower redox capacity. In HIV-uninfected people, N-acetylcysteine at 1200 mg to 3600 mg/day range can raise HDL cholesterol by 10 points (Franceschini 1993). Improving HDL level is an important marker for reducing risk from cardiac events even into a patient’s 80s. The amino acid L-Glutamine, along with EPA/DHA fatty acids, improves exercise capacity in patients with heart failure (Shahzad 2011).
Chronic inflammation along with some HAART initiates systemic bone loss. Vitamin D and calcium supplements are generally not enough to reverse thinning bones. Newer research, using an algae-derived calcium, with strontium, boron, magnesium, plus vitamins D and K2 supplements, is reversing osteoporosis in just 6 to 12 months in older people (Michalek 2011). Safety measures to reduce falls at home and increased fitness activity can lower fracture rates (Ringe 2010).
Many older people come late to care, with very low CD4 counts. Adequate glutathione levels are necessary for generating T cells. Supplementing N-acetylcysteine at 1 to 2 grams per day, or L-glutamine at 5 to 10 grams per day, is helpful for this. A B-complex 25 with vitamin C pill improves T-cell numbers in HIV disease (Fawzi 1998) Use of protease inhibitor therapy puts people at risk for low vitamin B12 levels (Woods 2003) as does taking proton pump inhibitors (Marcuard 1994). A multivitamin improves T-cell and NK-cell counts and reduces sick days in the elderly (Barringer 2003; Chandra 1992).Vitamin E at 200 units improves immune responses to vaccines. (Meydani 1997) Co-enzyme Q10 reverses lymphadenopathy and improves immune function (Folkers 1988). It protects endothelium in people with diabetes (Hamilton 2009).
From a nutrition perspective, frailty is simply failure to achieve adequate repair of many cell and organ systems. L-glutamine plus antioxidant vitamin supplementation reverses HIV wasting (Shabert 1999). Glutamine alone raises both glutathione and mood levels (Young 1993). L-carnitine supplements reverse both neuropathy symptoms (Youle 2007) and lipodystrophy problems (Benedini 2009). At 2 grams per day it has improved muscle action in heart failure trials (Rizos 2000). Coenzyme Q10 can increase ejection fractions in seniors, improving constitutional energy levels (Langsjoen 1994).
US Dietary Guidelines. 2015.