Module 9 Nutrition HIVAIDS and Oral Health Nutrition

Module 9 Nutrition, HIV/AIDS and Oral Health

Nutrition, HIV/AIDS and Oral Health Deborah E. Fleming, RDH, MS Marion Manski, RDH, BS University of Maryland, Baltimore College of Dental Surgery

Objective To develop a protocol for healthcare providers to become proactive in managing nutrition as it relates to oral health, specifically in the client with HIV/AIDS.

Goal As healthcare providers we need to assist our clients in every venue possible, this includes a thorough approach to good nutrition.

Nutritional considerations for dental clients with HIV/AIDS Clients with HIV/AIDS have nutritional concerns that can profoundly influence the progression of their disease. Thuita FM and Mirie W. East African Medical Journal 1999: 76: 507 -509

Roles of the Oral Healthcare Provider • Educate clients about the interrelationship between the oral cavity and overall health. • Educate clients regarding the influence nutrition has on oral and systemic manifestations associated with the disease. Sumpter J. Nursing Times 1997: 93: 67 -71

Educate clients about relationship of nutrition and the body’s ability to absorb medications. Sumpter J. Nursing Times 1997: 93: 67 -71

• Recognize when the client’s needs are too great and make an appropriate referral to a dietician. • Continue to provide motivation and support to the client. Sumpter J. Nursing Times 1997: 93: 67 -71 Thuita FM and Mirie W. East African Medical Journal 1999: 76: 507 -509

Nutrition Screening Information can be collected from a client about nutritional status. Screening can determine the client’s understanding of nutrition and the role it can play in overall health.

Nutrition Defined as the process by which living organisms utilize food to obtain nutrients for energy, growth, development and maintenance. Nutrients are biochemical substances from an outside source. They are known to produce physiological and biochemical reactions within the body for digestion, absorption and elimination. Davis J. R and Stegeman C. A. The Dental Hygienist’s Guide to Nutritional Care 1998 W. B. Saunders, Philadelphia

Malnutrition Defined as the inadequate intake or excess of nutrients required for development and maintenance body functions. Unfortunately, malnutrition is common in clients with HIV. It can occur at any time during the disease process, therefore, healthcare providers of all disciplines have a responsibility to identify nutritional problems and treat or refer accordingly. Lands L. Positively Well: Living with HIV as a chronic, manageable survival disease 1995 Irvington Publishers. New York

Malnutrition Research has shown that malnutrition can result in the inability to absorb medications necessary to control or arrest disease. One way to increase or improve absorption is to increase the nutrients that the client receives. Thuita FM and Mirie W. East African Medical Journal 1999 76: 507 -509

Malabsorption Defined as a condition that occurs when the tissue and cells lining the intestinal tract have lost their ability to properly transfer nutrients. Lands L. Positively Well: Living with HIV as a chronic, manageable survival disease 1995 Irvington Publishers. New York

Eating Well Eating a balanced diet as recommended by the Dietary Guidelines for Americans and the Food Guide Pyramid can be an enormous task for the client living with HIV/AIDS. The first step is to understand the functions of nutrients. Heslin KC. Aids Alert 2001: 16: 69, 72 -73 Davis J. R and Stegeman C. A. The Dental Hygienist’s Guide to Nutritional Care 1998 W. B. Saunders, Philadelphia

Functions of Nutrients • Provide energy • Build and maintain tissue • Regulate metabolic processes Davis J. R and Stegeman C. A. The Dental Hygienist’s Guide to Nutritional Care 1998 W. B. Saunders, Philadelphia

Classes of Nutrients • • • Protein Lipids/Fats Carbohydrates Minerals Vitamins Water Davis J. R and Stegeman C. A. The Dental. Hygienist’s. Guide to Nutritional Care 1998 W. B. Saunders, Philadelphia

Nutrients that provide energy to fuel our bodies • Protein • Carbohydrates • Fats Davis J. R and Stegeman C. A. The Dental Hygienist’s Guide to Nutritional Care 1998 W. B. Saunders, Philadelphia

Nutrients that build and maintain tissue and also regulate metabolic processes • • Protein Vitamins Minerals Water Davis J. R and Stegeman C. A. The Dental Hygienist’s Guide to Nutritional Care 1998 W. B. Saunders, Philadelphia

To increase the quality of life and to possibly extend the life of a client with HIV/AIDS, these nutrients need to be obtained through food sources or supplements. Hyman and Kaufman S. 1989. Journal of the American Dietary Association 89: 520 -527.

Body composition changes in clients with HIV/AIDS • • • Wasting Syndrome Fat redistribution syndrome Elevated Cholesterol levels Elevated Triglycerides levels Elevated blood sugars levels http: //www. hivdent. org/nutr. Nand. H 012002. htm

Wasting Syndrome • A condition characterized by weight loss associated with chronic fever and diarrhea. • Over a period of one month, the client may lose 10% of baseline body weight. • Malnutrition coupled with HIV/AIDS exacerbates the condition. Karlsson A and Nordstrom G. Journal of Clinical Nursing 2001 10: 609 -617

Wasting Syndrome • Opportunistic infections usually have significant impact on the client’s gastrointestinal tract as do the medications given for the treatment of HIV/AIDS. • It would be ideal to create the best environment possible in the GI tract to enhance the effectiveness of the drugs and to minimize the secondary infection that may contribute to wasting syndrome. Kotler DP. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1997: 16 Suppl 1: S 30 -S 35

Nutritional recommendations for combating body composition changes • High protein diet will help the client fight wasting syndrome. • Low saturated fat diet will help keep cholesterol level down. • A diet high in grains and low in sugar will help the client maintain adequate sugar and triglyceride levels. Stack JA, Bell SJ, Burke PA, and Forse RA. Journal of American Dietetic Association 1996: 337 -341

Additional Recommendations In addition to a heart healthy diet, 1 or 2 multivitamins and minerals should be taken to insure that micronutrient needs are met. http: //www. hiv. org/nutr. Nand. H 012002. htm

Functions and Deficiencies of Nutrients • A review of the functions of various nutrients helps focus efforts to improve dietary intake. • Healthcare providers, specifically oral healthcare providers, are in a position to identify nutritional deficiencies by observing clinical signs and symptoms associated with specific nutritional deficiencies. Wardlaw, G. M, Insel, P. M, Seyler, M. F Contemporary Nutrition issues and insights 2 ed. 1994 Mosby, St. Louis, Missouri

Vitamin A Functions • Help to maintain epithelial tissues and the development and maintenance of salivary glands. • Foods rich in vitamin A may suppress lesions in the oral cavity. Wardlaw, G. M, Insel, P. M, Seyler, M. F Contemporary Nutrition issues and insights 2 ed. 1994 Mosby, St. Louis, Missouri

Vitamin A Deficiency • Without vitamin A, mucus forming cells deteriorate and no longer synthesize mucus. • Contributes to poor health of cells in general, which increases risk of infection in the oral cavity. • Reduces activity of certain immune cells. • Vitamin A deficient individuals are at a great risk for infection. Wardlaw, G. M, Insel, P. M, Seyler, M. F Contemporary Nutrition issues and insights 2 ed. 1994 Mosby, St. Louis, Missouri

Vitamin A Food Sources • Recommend foods such as yellow/orange vegetables and fruits, green leafy vegetables, and dairy. • Additional recommendations could include organ meats. Wardlaw, G. M, Insel, P. M, Seyler, M. F Contemporary Nutrition issues and insights 2 ed. 1994 Mosby, St. Louis, Missouri

Vitamin B 6 Functions • Coenzymes in metabolizing protein • Converts tryptophan to niacin • Involved in synthesis of hemoglobin and fatty acids • Production of energy from glycogen • Helps proper function of the nervous system Wardlaw, G. M, Insel, P. M, Seyler, M. F Contemporary Nutrition issues and insights 2 ed. 1994 Mosby, St. Louis, Missouri

Vitamin B 6 Deficiency Symptoms in the Oral Cavity • Glossitis • Pain in the tongue § Feels as if tongue is scalded • Edema • Papillary changes • Smooth, purple tongue Wardlaw, G. M, Insel, P. M, Seyler, M. F Contemporary Nutrition issues and insights 2 ed. 1994 Mosby, St. Louis, Missouri

Vitamin B 6 Deficiency • Deficiency results in overall risk for opportunistic infections, due to its role in immune function. • HIV/AIDS clients, even with proper RDA, tend to be deficient in B 6; supplementation may be indicated to decrease risk of infection. • Recommend foods such as poultry, fish, whole grains. Thuita FM and Mirie W. East African Medical Journal 1999: 76: 507 -509

Vitamin B 12 Functions • • • Coenzyme involved in folate metabolism Nucleic acid synthesis Involved in production of red blood cells Synthesis of myelin Catabolizes some amino and fatty acids Wardlaw, G. M, Insel, P. M, Seyler, M. F Contemporary Nutrition issues and insights 2 ed. 1994 Mosby, St. Louis, Missouri

Vitamin B 12 Deficiency • • Burning/itching of the tongue Red, smooth, shiny tongue Absence of papilla on tongue Painful lesions on buccal, pharyngeal mucosa and ventral surface of tongue • Pale, yellow mucosa Wardlaw, G. M, Insel, P. M, Seyler, M. F Contemporary Nutrition issues and insights 2 ed. 1994 Mosby, St. Louis, Missouri

Vitamin B 12 Deficiency • HIV/AIDS Clients: § Deficiency due to malabsorption • Poor diet • Bacteria overgrowth along digestive tract • Lowered GI function Thuita FM and Mirie W. East African Medical Journal 1999: 76: 507 -509

Vitamin B 12 Deficiency • If diet cannot provide, recommend supplementing. • Too much Vitamin C will interfere with absorption of B 12. • HIV/AIDS clients with B 12 deficiencies were shown to progress to advanced disease twice as quickly as those without deficiencies. • Recommend foods such as beef liver, lean beef, shrimp, protein fortified milk, whole eggs, chicken breast and cheddar cheese. Wardlaw, G. M, Insel, P. M, Seyler, M. F Contemporary Nutrition issues and insights 2 ed. 1994 Mosby, St. Louis, Missouri

Vitamin C Functions • Significant in collagen formation • Necessary for the use of proline and lysine in collagen formation. • Increases iron absorption. Vitamin C eaten with iron can double iron absorption. Wardlaw, G. M, Insel, P. M, Seyler, M. F Contemporary Nutrition issues and insights 2 ed. 1994 Mosby, St. Louis, Missouri

Vitamin C Deficiency • Local irritation must be present before C deficiency can produce worsening of gingival infection. • Gingival swelling and bleeding, slow wound healing. • Recommend foods such as tomatoes, green/red peppers, citrus fruit. Wardlaw, G. M, Insel, P. M, Seyler, M. F Contemporary Nutrition issues and insights 2 ed. 1994 Mosby, St. Louis, Missouri

Iron Functions • • • Major component of hemoglobin Transfers oxygen to tissues and lungs Catalyzes oxidative reactions Helps to metabolize energy RDA: 10 mg/d males, 15 mg/d females Wardlaw, G. M, Insel, P. M, Seyler, M. F Contemporary Nutrition issues and insights 2 ed. 1994 Mosby, St. Louis, Missouri

Iron Deficiency Anemia • Extremely common in HIV/AIDS clients • Involved in rapidly progressing cases • Reduces functional capacity Semba RD, Shah N, Strathdee SA, and Vlahov D. Journal of Acquired Immune Deficiency Syndrome 2002: 29: 142 -144.

Iron Deficiency Anemia/Oral Cavity • Oral healthcare provider should evaluate the diet to include RDA of iron. • Foods rich in iron include meats, egg yolk, dark green vegetables, enriched breads and cereals. Semba RD, Shah N, Strathdee SA, amd Vlahov D. Journal of Acquired Immune Deficiency Syndrome 2002: 29: 142 -144

Iron Deficiency Anemia/Oral Cavity • Symptoms: Pallor, glossitis soreness, and burning tongue. • Supplementation in HIV patients should be approached cautiously. § Could interfere with body’s response to interferon § Could accelerate progression of disease Semba RD, Shah N, Strathdee SA, amd Vlahov D. Journal of Acquired Immune Deficiency Syndrome 2002: 29: 142 -144

Folate Functions • • Involved in RNA and DNA synthesis Coenzyme Helps to maintain red blood cells RDA: 200 mcg/d males, 180 mcg/d females Davis J. R and Stegeman C. A. The Dental Hygienist’s Guide to Nutritional Care 1998 W. B. Saunders, Philadelphia

Folate Deficiency: Oral Symptoms • • Glossitis Chronic Periodontitis Loosening of the teeth Deficiency impairs immune response § Oral cavity more prone to infections, such as candidiasis • Vitamin C helps with absorption of folate. Davis J. R and Stegeman C. A. The Dental Hygienist’s Guide to Nutritional Care 1998 W. B. Saunders, Philadelphia

Zinc Functions • • • Cell growth/maturity Immune response Taste/appetite Collagen synthesis Bone formation RDA: 15 mg/d males, 12 mg/d females Davis J. R and Stegeman C. A. The Dental Hygienist’s Guide to Nutritional Care 1998 W. B. Saunders, Philadelphia

Zinc Deficiency: Oral symptoms • • • Changes in tongue epithelium Flattened filiform papillae Loss of taste, appetite Impaired wound healing HIV/AIDS clients suffer from diarrhea and malabsorption, thus zinc deficiency • Supplementation indicated Davis J. R and Stegeman C. A. The Dental Hygienist’s Guide to Nutritional Care 1998 W. B. Saunders, Philadelphia

Protein Functions • Maintenance and growth (if protein is low, degeneration of connective tissue including periodontium). • Provides for enzyme and antibodies and their respective functions. • Supplies amino acids which are building blocks for tissue synthesis. • Participates in RBC production. • When infection is present, body’s protein needs are doubled. Karlsson A and Nordstrom G. Journal of Clinical Nursing 2001 10: 609 -617

Protein Deficiencies • Protein malnutrition and resulting loss of energy are the most frequent condition reported with HIV/AIDS. • Presents as a client with a low body weight and a general lack of energy, protein and other nutrients, and a small muscle mass. Karlsson A and Nordstrom G. Journal of Clinical Nursing 2001 10: 609 -617

Protein and Oral Health Amino Acids 10 Essential Amino Acids Cannot be manufactured by the body in adequate amounts. Davis J. R and Stegeman C. A. The Dental Hygienist’s Guide to Nutritional Care 1998 W. B. Saunders, Philadelphia

Protein and Oral Health Amino Acids 12 Nonessential Amino Acids • “Nonessential” does not mean they are not needed by the body. • Can be synthesized by the body so they are not essential in relation to dietary intake. Davis J. R and Stegeman C. A. The Dental Hygienist’s Guide to Nutritional Care 1998 W. B. Saunders, Philadelphia

Sources of Protein • Complete Proteins • Incomplete Proteins § Contain all 10 of the § Foods lacking at essential amino least 1 essential acids in an amount amino acid that will meet the § Plant Sources body’s needs § Legumes, nuts, § Animal sources grains, vegetables, § Egg, milk, cheese, fruit, seeds meat Davis J. R and Stegeman C. A. The Dental Hygienist’s Guide to Nutritional Care 1998 W. B. Saunders, Philadelphia

Protein Supplements • High protein drinks are easy for clients to take and often consumed by clients with HIV/AIDS. • Some brand name drinks include: • • Advera Nutren Resourse Ensure http: //www. projectinform. org

Protein Supplements • Supplements should not replace food. • Using them in combination with solid food and exercise is ideal. • Fiber intake may need to be reduced if liquid nutritional sources are abundant and controlling diarrhea is a concern. Karlsson A and Nordstrom G. Journal of Clinical Nursing 2001 10: 609 -617

Clinical Signs & Symptoms of Protein Deficiency • • Loss of appetite Flaking dermatitis Temporal muscle wasting Sparse, thin hair Parotid enlargement Abdominal distention Transverse lines on nails Karlsson A and Nordstrom G. Journal of Clinical Nursing 2001 10: 609 -617

Protein and Infection Interaction • Infection can produce malnutrition and malnutrition can worsen an infectious process. • Infection decreases the digestion of foods rich in protein and other nutrients. • Protein malnutrition can affect antibody formation, phagocytic activity, tissue integrity and non-specific resistance factors. Karlsson A and Nordstrom G. Journal of Clinical Nursing 2001 10: 609 -617

Protein and Infection Interaction • Protein deficient diets impair the production of white cells and therefore interfere with the phagocytic capacity of macrophages. • Decreased tissue resistance of skin, mucous membranes, as well as tissue edema and accumulation of debris which serves as a substrate for bacterial growth are produced by protein deficient diets. • Proteins also help in resisting viral infections. Karlsson A and Nordstrom G. Journal of Clinical Nursing 2001 10: 609 -617

Protein Deficiency in Relation to Oral Health • Protein malnutrition even of the subclinical type can and very likely will exacerbate oral infections and parotid enlargement. Karlsson A and Nordstrom G. Journal of Clinical Nursing 2001 10: 609 -617

Fat • Fat : an essential nutrient § Involved in energy production. § HIV/AIDS clients should NOT be restricted regarding fat consumption. § Vitamin A deficiency is related to fat malabsorption in HIV/AIDS clients. Thuita FM and Mirie W. East African Medical Journal 1999 76: 507 -509

Meal Alternatives • The client with HIV/AIDS will need to eat small frequent meals and focus on increasing calorie levels. § Some foods that may benefit them include: High protein shakes and ice cream Yogurt Milk, fruits, peanut butter, wheat germ and fruit nectars. Liss M. Nutrition and HIV. ABCNews. com/Healthology Press. 1 -4 -2002 http: //www. hivdent. org Stack JA, Bell SJ, Burke PA, and Forse RA. Journal of American Dietetic Association 1996 96: 337 -341.

Oral Lesions and Eating • Oral infections and lesions of the oral cavity can impair the ability to eat. • Severe lesions can reduce pleasure associated with eating, resulting in poor nutrition, which can then exacerbate the disease. http: //www. hivdent. org/oralmolah 0698. htm

Anti-retroviral Therapy Anti-retroviral therapy (HAART) and the commitment to HIV/AIDS research continue to improve the number of clients living with HIV and the quality of life that these individuals maintain. HAART’s provide an additional benefit by reducing the likelihood of fungal infections that previously caused clients difficulty when eating. Schmidt-Westhausen AM, Priepke F, Bergmann FJ, and Reichart PA. Journal of Oral Pathology and Medicine 2000: 29: 336 -341 Reichart PA. International Dental Journal 1999: 49: 251 -259. Chapple, ILC; Hamburger, J. Sexually Transmitted Infections 2000: 76 (4): 236 -243

Oral Lesions Clients infected with the HIV/AIDS virus often develop oral lesions that have a unique clinical appearance. If these lesions go undiagnosed or untreated and are worsened by inadequate nutrition the client’s needs are not being met. Reichart PA. International Dental Journal 1999 49: 251 -259. Hyman C and Kaufman S. J Am Diet Assoc 1989 89: 520 -527

Oral signs and symptoms of nutritional deficiencies Xerostomia: vit A, B 12 Bleeding gingiva: vit C, vit K Angular Cheilosis: iron, B vitamins Nutritional deficiencies weaken the resistance of oral tissues to plaque bacteria, causing an increase in inflammation. Sifri R et al. The Journal of the American Board of Family Practice 1998: 11: 434 -444

Angular Cheilosis • http: //www. hivdent. org

Treating Oral Lesions • Providing palliative treatment for oral lesions is essential, as is addressing nutritional deficiencies that contribute to the lesions. • Optimal nutrition is necessary to minimize the likely discomfort as the progression of the disease continues. Heslin KC. Aids Alert 200116: 69, 72 -73 .

Oral Lesions and Eating • Some suggestions that can be made to clients so that they can continue to eat with mouth sores include: • Drink Apple juice, fruit nectar, milk. • Avoid carbonated beverages, and salty or acidic foods. • Choose soft, moist foods, such as mashed potatoes, macaroni and cheese. • Use melted butter or gravy to soften foods. • Drink water with meals. Heslin KC. Aids Alert 200116: 69, 72 -73 .

Summary • • • Assess nutritional status. Determine chief complaints. Examine for oral signs of malnutrition. Evaluate current food intake and eating habits. Advise clients to ingest adequate amounts of calories, protein and vitamins which will help decrease oral opportunistic infections. • Personalized dietary guidance for clients with HIV/AIDS infection shows supportive care and concern for the client’s comfort as he/she is living with HIV/AIDS.

Conclusion • Although actual practice of good nutrition is the client’s responsibility, oral healthcare providers with a good understanding of nutrition can recognize oral manifestations of nutritional problems in clients with HIV/AIDS. • The nutritional component should be considered as much a part of oral health assessment as oral hygiene instruction.

Conclusion Research is still needed to fully understand document the impact vitamin and nutritional deficiencies have on the client with HIV/AIDS. The degree to which supplements can be beneficial also needs continued research.