Nutrition for patients suffering from hiv

Parrilla Saldaña J, Muñoz Sánchez I, Peñalver Jiménez C, Castro Rodríguez E, Quero Haro A, Largo García E. Nutrición en enfermos con VIH. Revista Rol de Enfermería 2002;25(12):16-20

ABSTRACT

The authors carried out a research project in a nursing consultancy on patients suffering from HIV. Their study comprised 108 patients.
The authors analysed the causes which provoke nutritional problems since the signs and symptoms derived from this desease are associated with opportunistic infections which directly affect nutritional requirements.

The authors selected variables which would determine general parameters for a nutritional study: anthropological measurement parameters such as weight, height and other basic vital measurements; Biochemical parameters such as albumin and ferritin; clinical parameters such as diarrhoea, vomiting, anorexia, fever, and dysphagia. The biochemical parameters provided evidence in the albumin measurements that 65,28% of these patients suffer from severe malnutrition. With regards to anthropological measurements, basic vitals showed that 16,8 of these patients have a normal range while 52,64% fall below the 10th percentile which demostrate important levels of cachexia.


1. INTRODUCTION

Numerous studies have shown that the complications of HIV infection compromise the nutritional condition during the development of the disease, in which many patients experience: significant weight loss, cachexia being a common sign; a decrease in the measurements of the tricipital fold and the muscular circumference of the arm; a reduction in the body mass and in the visceral protein and a diminution in the iron binding capacity.
Other factors contribute towards malnutrition: deficient ingesta of energy and/or proteins, lack of appetite, infections with fever that increase needs and caloric consumption, gastrointestinal complications, nausea and vomiting, malabsorption…
We hereby raise the following as subject matter for study and analysis: nutritional assessment and alimentary habits in HIV patients due to their difficulties in attaining regulated habits that facilitate healthy conduct and that help to prevent the complications of the opportunistic infections that they contract and that have a direct bearing on making the ability to feed themselves adequately more difficult.
Our proposal, from the viewpoint of nursing consultations, is aimed at helping them to manage healthy conduct, which provides them with the tools for treating opportunistic infections that diminish, and even nullify, the appetite, due to their being directly related to the mechanism of deglutition and alimentary absorption, like, for example, oesophageal candidiasis; episodes of diarrhoea; vomiting; malabsorption syndrome; everything normally associated with complex problems like drug addiction; and social marginalisation, etc.
Tackling this piece of work entails difficulties, fundamentally as a result of two main issues: the first, because their socio-familial situation in many cases makes collaboration and treatment difficult; the second, because the standardised parameters for assessing the nutritional condition in any patient are not adequate for HIV patients.
It has also been borne in mind that the quality of the alimentary habits of a population determine the nutritional condition of this same population, that the psychological component of man takes charge of governing his appetite, that the physical pain of hunger has nothing to do with the choice of adequate nutrients and that, although we eat to satisfy the aforementioned need, the food is intimately linked to the physical, economic, psychological, intellectual and social life of man, thus constituting an integral part of the framework of his daily life.
The choice of food is the result of the culture and traditions of the individual, of the desires, the emotions, the character and the experience of each and every one of us. Man does not have an innate instinct or a natural desire that instructs him so as to avoid malnutrition with the aim of achieving balanced ingesta.
For this reason we approach our work with a great interest in making patients easily understand the importance of a complete diet including all the food groups, which constitute the essential elements for achieving and maintaining healthy conduct.
With an alimentation which is complete and adapted to the characteristics of the person, not only does he know about the contribution of the sufficient nutrients for covering his needs but he also tackles special circumstances like illness, and he is able to draw up a balanced diet within his individual preferences, which provides him with sufficient supplies of energy, proteins, vitamins and minerals. It was also considered relevant to provide them with information on alternative diets and dietetic supplements.


2. OBJECTIVES

The general objective was defined as the analysing of nutritional parameters in HIV patients. The specific objectives were: discovering the degree of nutrition in relation to the albumin values, and iron deficiency, so as to be able to determine the degree of anaemia in relation to the ferritin values; establishing the deviations between the optimum weight and the actual weight; and defining the determination of the fat values in relation to the fold.


3. MATERIAL AND METHOD

A prospective, descriptive study is carried out on patients with the Human Immunodeficiency Virus pertaining to the Nursing Consultancy of the Virgen de Valme University Hospital. The section of the population of the study is made up of those patients belonging to the hospital area of Valme with HIV pathology. Patients of both sexes ageing between 22 and 45, who find themselves in different stages of the disease and with different aetiology. Transmission through parenteral means (drug addiction) is the dominant aetiology, and they have attended the consultancy in periods understood to be within the development of the aforementioned study.
The size of the sample is selected through a simple sampling in which patients of both sexes who have been informed and consulted, if they wish to be included, are incorporated, the only measure of exclusion being that of those patients not wishing to belong to the study. The sample was made up of 108 patients.
The SPSS programme has been used to analyse the data (realisation and analysis of the frequency complemented with histograms on the basis of the average and the standard deviation (SD) of the groups). In the histograms we have been able to appreciate the magnitude of the standard deviation, detecting: in the albumin item, a dispersion of the value referring to women, while the distribution in the group of men is much closer to the Gauss curve; in the ferritin item, we have found an elevated peak in the frequency and the standard deviation has suffered dispersion in both sexes; as regards the weight criteria, we observe a slight margin of dispersion and a greater approach towards the average; in the histogram referring to the tricipital fold we have found the frequency to be better distributed in the case of women as opposed to that of men; lastly, the standard deviation is less disperse in the female sex histogram than in that for the male sex.

3.1. Variables of the Study and Measurement Instruments
A series of general parameters have been determined for the nutritional study; anthropometric and biochemical parameters have been selected in order to assess the nutritional condition as well as symptoms, stages of HIV that allow for the evaluation of an index of their general state.

3.2. The Anthropometric or Biometric Parameters

3.2.1. Weight- Height
A scales-meter was used. They were weighed in upright position and in everyday clothes; height was measured on the scales-meter standing upright and barefoot.
The relation between body weight and height is the most commonly used parameter as a biometric parameter since Broca, a French doctor from the last century, indicated the 'ideal weight' as being, in kilograms, the centimetres over and above a metre in height. Nowadays authors give preference to the 'optimum weight'.

3.2.2. Tricipital Fold
Measurement of the cutaneous fold in order to evaluate the diminution of the body mass measured in terms of fat. The fat fold of the triceps, as compared with normal values, provides an indication as to the total body fat, given that half of it is subcutaneous fat.
The measurement of the fat fold of the triceps, when it is less than the percentile 10, indicates a substantial deficiency in fat deposits. The percentage was calculated once the aforementioned fold had been measured with Skinfol Holtain callipers, assessing the difference between the result obtained with the value considered normal for the population, in subjects of the same age group, percentile 50 of the Alastrue Vidal table.

3.3. Biochemical Parameter

3.3.1. Albumin
The levels of albumin constitute the best reflection of the visceral protein changes in patients in general. During severe malnutrition its levels are weakened as a response to the diminution of the hepatic synthesis rate. In spite of this controversy, the albumin levels are always present in the biochemical evaluations of the nutritional condition. Normal values: 3,92 g/dl to 1,80 g/dl.

3.3.2. Ferritin
This is the main means of storing iron. The concentration of ferritin correlates with the total iron pool. This protein assures iron binding in the liver, spleen and bone marrow. Anaemia as a result of iron deficiency is the most noteworthy nutritional deficiency.

3.4. Clinical Parameter
It intervenes leading to possible potential complications; within this same parameter we find the symptoms that could affect the nutritional condition, always understood as acute episodes of a pluripathology so complex that encompasses HIV: Diarrhoea; Vomiting; Anorexia; Fever; Dysphagia.


4. RESULTS

The following shows the results obtained for each variable:
As regards the albumin value, 31 patients from our study, i.e. 34.72%, are found to be within the range of normality (there is no evidence of malnutrition), and 65.28% are found to be within a phase of severe malnutrition, not forgetting that the values may be seen to be altered due to the presence of pathologies associated with HIV, but which constitutes a very clear reflection of the nutritional condition.
As regards the ferritin values: 16 patients, i.e. 17.92%, are found to be within the range of normality. Having hepatic or hepatocellular lesions notably alters the ferritin values; in our study not taking into consideration pathologies associated with HIV (cirrhosis, hepatitis etc.) we do not value this data as a reliable indicator of the nutritional degree.
As regards the objective on the optimum weight, stemming from the analysis, we perceive that only 5 of the patients from the study would achieve it, thus supposing 5.6% of the total sample. 48 subjects (56.73) show actual weight loss that oscillates between -0,10 kg and -2,48 kg.
Bearing in mind that a patient with HIV registers real losses of 10% of his weight, i.e. a person weighing 70kg on the outbreak of being affected by HIV starts from a basal weight of 63kg.
Transferring this to our scale of values we can accept as optimum weight subjects those whose weight losses are inferior to 10kg. This means that 38 subjects, i.e. 42.56%, would obtain 'optimum weight'. As a consequence we can reiterate what we have observed in previous studies related to objective weight loss and considering this premise we do not observe a marked nutritional deficiency based on the weight loss value.
As regards the tricipital fold, 15 subjects, i.e. 16.8% of the total sample, are found to be within the range of normality (percentile 50). What could be considered to be noteworthy is that 47 subjects, i.e. 52.64%, are found to be within values under the percentile 10, indicating important levels of cachexia.

5. CONCLUSIONS

Before the evidence of how, in many cases, the disease limits the alternatives in the choice of food due to the complications that arise cyclically and before the inappetence that these factors generate in our patients, it is of great importance to be able to administer them with a nutrition that covers their needs and that helps them to confront the periods of special circumstances.
Due to the current situation in the subject of research and its repercussions in the quality of life of patients it seems to us highly relevant to continue promoting, through nursing consultancy, the implementation of information appropriate to their knowledge, capabilities and prospects of health. For this reason, being aware of the importance of the subject that we are concerned with and of how we can intervene in the well-being of the patients, we will continue to advance along these lines of investigation. We will continue to work on alimentary surveys aimed at discovering, as objectively as possible, the everyday reality of the patients and to be able to continue assessing and comparing the advances or retrogressions produced.

6. BIBLIOGRAPHY

Aranda Sánchez M. SIDA y asistencia primaria. Aten Primaria 1992; 10(1):525.
Berk RA. Use of primary care takers as proxies to measure fue health care needs of patients with AIDS. Public Health Nurse 1995; 12(2):109-16.
Castano Barroeta C, Cossent Aquinaco L, Martinez Alonso C. El síndrome socio- sanitario. Estrategias de intervención ante un problema nuevo en salud pública. Rev Sanid Hig Pública 1994; 68(2):261-5.
Faura Vendrell T (ed). VIH-SIDA. Una guía para los cuidados de enfermería. Barcelona: Ed. ROL; 2001.
Gatell Artigas JM, Clotet Sala B, Podzarnczer Palter O, Miro Meda JM. Guia práctica del SIDA. Clinica, diagnóstico y tratamiento. Masson-Salvat; 1994.
Gil Canada 1, Bacaicoa A, Cos Blanco A, Weisz P, López Guzmán A, Mejías A, Gómez Candela C. Valoración y soporte nutricional en pacientes con sindrome de inmunodeticiencia adquirida. Nutr Hosp 1995; 10(1):35-9.
Henriquez Martínez T, Armero Fuster M. Valoración nutricional para pacientes hospitalizados. Nutr Hosp 1991; 6(2):109-16.
López Matheu C, Isla Perea P, Roige Bote A. Información para afectados por el VIH. Rev ROL Enf 1992; 15(170):29-31.
Sala Álvarez MC. SIDA y Enfermería. Abordaje desde atención primaria. Rev ROL Enf 1994; 17(190):23-8.
Salvador Roig C. Toxicómanos con SIDA. La enfermera ante situaciones conflictivas. Rev ROL Enf 1991; 14(159):21-5.
Serrano Corredor S, López Soriano F, Rivas López FA, de la Rubia Nieto A. Parámetros nutricionales y morbimortalidad en hospitalización clínica. Nutr Hosp 1993; 8(2):109-14.






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Parrilla Saldaña J, Muñoz Sánchez I, Peñalver Jiménez C, Castro Rodríguez E, Quero Haro A, Largo García E. Hábitos alimentarios en enfermos con VIH. Revista Rol de Enfermería 2003;26(1):68-70



ABSTRACT

The authors analyze the eating habits of a group of 108 patients suffering from HIV. The authors elaborate a chart about the composition and distribution of foods which contains all the required food groups necessary for a complete diet. This food chart lists the variable of this study as well as the frequency of their consummation. Once this chart was drawn up, it was approved by the Nutrition and Dietetic Unit at the Virgen de Valma University Hospital. Among the results obtained, there is a relationship between the necessity these patients have regarding eating a complete diet and diverse nutrients that are easy to chew as well as an abundance of liquids.
The article 'Nutrition for Patients suffering from HIV' written by the same authors published in the Revista Rol de Enfermería 2002;25(12):816-820, is recommended in order to have a more complete understanding of this topic, nutrition for patients suffering from HIV.

1. INTRODUCTION

We hereby propose the study of the alimentary habits of patients with the Human Immunodeficiency Virus due to its being a subject matter of great relevance as a result of the difficulties that they present for the aforementioned patients in being able to attain and/or control these habits, given that they are found to be immersed in different problems provoked by the opportunistic infections that compromise the nutritional condition during the development of the disease: oesophageal candidiasis, episodes of diarrhoea, vomiting and malabsorption syndrome. All of which undermine the mastication and deglutition capacity, making it difficult for them to feed themselves adequately.
Complete alimentation constitutes an essential element as regards healthy conduct which facilitates the maintenance and promotion of this same conduct, for which reason we will try to facilitate the tools necessary for patients to attain an alimentation which adapts to their characteristics as far as is possible, one which contributes sufficient nutrients so as to cover their needs, and which helps them to tackle special circumstances as they arise in this disease.
We will stress the importance of drawing up and of consuming a diet that contains all the food groups and that provides sufficient values of energy, proteins, vitamins and minerals, bearing in mind individual preferences as well as facilitating information on alternative diets and dietetic supplements.


2. OBJECTIVES

As a general objective we propose finding out about the alimentary habits of patients affected by HIV, and more specifically, assessing and measuring alimentation through the frequency with which they consume each food group; and verifying whether the meals are regulated and if they are had at home or outwith the home.


3. MATERIAL AND METHOD

We are dealing with a prospective, descriptive study of patients with the Human Immunodeficiency Virus pertaining to the Nursing Consultancy of the Virgen de Valme University Hospital. The section of the population of the study is made up of those patients belonging to the hospital area of Valme with HIV pathology. Patients of both sexes ageing between 22 and 45, who find themselves in different stages of the disease and with different aetiology. Transmission through parenteral means (drug addiction) is the dominant aetiology, and they have attended the consultancy in periods understood to be within the development of the aforementioned study.
The size of the sample is selected through a simple sampling in which patients of both sexes who have been informed and consulted, if they wish to be included, are incorporated, the only measure of exclusion being that of those patients not wishing to belong to the study. The sample was made up of 108 patients.
The SPSS programme has been used to analyse the data.

3.1. Variables of the Study and Measurement Instruments

We have carried out the selection of variables bearing in mind the food groups that should be included in a healthy diet and bearing in mind the group of patients that make up the study sample so as to facilitate the consumption of these same food groups while at the same time taking into consideration their needs and deficiencies. Once the variables had been selected we drew up the questionnaire (fig. 1) which was validated by the Nutrition and Dietetics Unit of the Virgen de Valme Hospital. This was then handed over to patients attending the nursing consultancy, having previously been informed and consulted as to whether they wished to be included in the study.
The aforementioned questionnaire contains the variables selected as well as the frequency of their consumption; data which is of great interest for us to be able to adapt the alimentary habits to the needs detected.
The variables have been listed in food groups: alcohol, sandwiches, meat, sweets, fruit, fats, eggs, dairy products, fish, vegetables and juices. Also the frequency of the consumption which may oscillate between: daily, 2-3 times per week, once a week, 2-3 times per month, once a month and not at all.
Finally we have decided to stress the most frequent alimentation in our care area and the knowledge of tastes in general of the sector of the population of the study.


4. RESULTS

We will emphasise what is most relevant as regards the food groups just as much as the frequency of consumption.
The results obtained closely accord with the needs of these patients in so far as the consumption of food: liquids as much as those of easy mastication. All of which motivated by the opportunistic infections that the patients contract cyclically, on an oropharyngeal level as much as on an oesophageal one.
As regards the food groups and the distribution of the frequency of consumption, the results concerning the variable «fruit» seem particularly relevant given that we find that 88% of the patients consume it on a daily basis. The same thing occurs with the consumption of the «dairy product» group, again reaching 88% of the sector of the population in the study on a daily basis.
As for the consumption of «fats», it is important to stress that 57% of the sample, i.e. somewhat more than half, say that they do not consume this food group. The results from the «juice» variable is also of interest given that 66% of those affected consume it daily. Observing the inverse of this same percentage we find the variable «alcohol», given that 66% of the sample never consumes it.
As regards the consumption of «sandwiches» the results are curious; we find ourselves with two percentages that are practically equal but diametrically opposed: 41.7% of the sample consume them on a daily basis while 42.9% never consume them.
Regarding the variables «meat, eggs and fish», the highest percentage as regards coincident consumption in the three variables is of 2-3 times per week and the percentage relating to the sector of the population of the study indicates: meat 77%; eggs 71.5%; fish 61.6%.
Finally, from among the food groups referred to another of easy consumption is that of «sweets», emphasising 38.5% on a daily basis; 30.8% 2-3 times per week; and 29.7% never.
As regards the habits of eating at home or outwith the home, we can only emphasise that the entire study sample eats at home, the meals thus being regulated.


5. CONCLUSIONS

In many periods of the disease these patients find themselves to be inappetent, and very easily susceptible to contracting infections on a cyclic basis, in the oropharyngeal as much as the oesophageal mucous.
Healthy alimentary habits constitute a subject matter of great interest to patients affected by HIV.
In the light of the results one may observe that it is of great importance that the patients consume liquids, dairy products and also those other foodstuffs which are easily masticated. Because of all that has been mentioned this alimentation could be considered to meet the recommendations for healthy ingesta.
The nurse is fundamental in order to provide the patients, in the programmed visits, with information suitable to their knowledge, capabilities and health prospects.
All this helps us to provide our patients with care that is adequate for the stage of the disease in which they find themselves.


6. BIBLOGRAPHY

Atkins R, Amenta MO. Family adaptation to AIDS a comporative study. Hosp J 1991; 7(1-2):71-83.
Capitán Camanes A. Impacto del SIDA en el personal sanitario. Nuevas perspectivas para un reto. Rev ROL Enf 1992; 15(172):69-72.
Faura Vendrell T (ed). VIH-SIDA. Una guía para los cuidados de enfermería. Barcelona: Ed ROL; 2001.
González López E. El futuro protagonismo de la atención primaria en el VIH/SIDA. Aten Primaria 1993; 11(1):52.
lribarren JA, Arrizabalaga J, Rodriguez Arrondo F, Von Wichmam MA, Oyarbide J, Huarte l. El enfermo de SIDA en los noventa (11). Enferm Infecc Microbiol Clin 1994; 12 (9):455-64.
Martinez Garcia F, Sebastián S, Martinez Marogna A. Asistencia a drogadictos en atención primaria. Aten Primaria 1993; 11(3):138-40.
Nabal Vicuna M, Pablo Cerezuela F, Aguirre Errasti JM, Ramos Pesa C. Consideraciones en el manejo del paciente VIH positivo asintomático. Atención Primaria 1992; 10(5):803-4.
Salvador Roig C. Toxicómanos con SIDA. La enfermera ante situaciones conflictivas. Rev Rol Enf 1991; 14(159):21-5.
Sanchis C. AIDS in Spain. Nurs-Times 1992; 88(51):50-1.
Sanchis Pinol C. SIDA: una encuesta. Rev ROL Enf 1992; 15(170):23-7.
Vázquez G, Rivera R, Navarrete P, Pérez de la Cruz A, Torres JM, de la Higuera J. Evolución y valor pronóstico de los parámetros nutricionales en la bronquitis crónica. Rev Clin Esp 1992; 190(1):5-8.



Josefa Parrilla Saldaña: Enfermera, Licenciada en Antropología Social. Profesora Titular.
Isabel Muñoz Sánchez: Enfermera, Consulta de Infecciosos. Profesora Asociada.
Carmen Peñalver Jiménez: Enfermera, Supervisora de Medicina Interna, Profesora Asociada.
Encarnación Castro Rodríguez: Enfermera, Consulta de Medicina Interna. Colaboradora Honoraria E.U.C.S.
Antonia Quero Haro: Enfermera, Medicina Interna.
E.U.C.S. Universidad de Sevilla. Hospital Universitario Virgen de Valme. Sevilla

With permission

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