Professional Documents
Culture Documents
TL Miller, P Graham, J Nebhrajani, G Somarriba, SC Tapia, and D Neri, Miller School of Medicine at the University
of Miami, Miami, FL, USA
2016 Elsevier Ltd. All rights reserved.
Introduction
Human immunodeficiency virus (HIV) infection is a worldwide
problem of great magnitude. The World Health Organization
(WHO) estimates that about 35 million adults and children
were living with HIV in 2013, the majority of whom are in
developing nations. In 2013, HIV and its related complications
were the cause of death in 1.5 million people worldwide. However, the number of individuals infected with and dying from
HIV has been steadily declining in the last 15 years. This trend
reflects the expansion of services to prevent the transmission of
HIV from mother to child, the wider use of antiretroviral therapy
(ART), and the improved prophylactic regimens worldwide. In
developed nations, HIV has become a chronic illness with
highly active antiretroviral therapy or now what is currently
called combination antiretroviral therapy (cART) as the mainstay of treatment. With more individuals living with HIV, the
necessity of appropriate supportive care is paramount.
Clinicians who care for those with HIV should be aware of
potential nutritional and metabolic problems and their consequences. In the past, and currently in some subpopulations,
wasting syndrome is the primary nutritional concern for
HIV-infected individuals. Malnutrition can have additive
destructive effects on the immune system and host defense
mechanisms. T cell-mediated immune responses are targeted
primarily and have been termed the nutritionally acquired
immune deficiency syndrome. It has been long thought that
aggressive nutritional rehabilitation can combat and potentially reverse these effects. However, as we approach 20 years
since the advent of cART, expanding cardiometabolic and
related nutritional issues often prevails that can also alter
immune responses and produce additional comorbidities.
Knowledge and implementation of effective nutritional therapies are important to improve medical outcomes and quality of
life. The problem of malnutrition in patients with the acquired
immunodeficiency syndrome (AIDS) is multifactorial, and
proper nutritional support will replenish body cell mass in
these patients, which is associated with functional improvement. With appropriate combinations of ART, nutritional and
other supportive care, many HIV-infected individuals are now
able to lead relatively normal lives.
http://dx.doi.org/10.1016/B978-0-12-384947-2.00378-0
343
344
Macronutrients
Although the WHO has played a prominent role in efforts to
fully integrate food and nutrition in all aspects of prevention,
care, and treatment of HIV and AIDS, nutrition-specific recommendations for this patient group are limited. Knowledge
about the nutritional needs of people infected with HIV over
and above those required by uninfected people remains limited. This section discusses existing macronutrients recommendations for people living with HIV.
Patient groups vary in terms of their response to the virus,
stage of the disease, susceptibility and exposure to opportunistic infections, nutritional status, and individual response to the
various treatments received. Although compelling evidence
exists for the direct association between BMI < 18 kg m 2 and
accelerated disease progression, limited data exist regarding the
role of macro- and micronutrients in disease progression.
Table 1
Nutrient
Energy
Advanced disease
Overweight or obesity
Protein
Fat
Carbohydrate
Fiber
345
Nutrition recommendations
Children, adolescents, and adults: target energy intake of 110% of that recommended for uninfected
population (based on actual weight rather than on expected weight for age) (WHO 2009)
Pregnant and lactating women: the 10% increase in REE currently recommended is likely
reasonable for asymptomatic HIV-positive pregnant and lactating women. Energy requirements
may be higher for pregnant adolescents (Raiten et al., 2011)
Standard methods of assessing energy needs calorie levels based on the Estimated Energy
Requirements (EERs) and activity levels from the Institute of Medicine Dietary Reference Intakes
(DRIs) (Macronutrients Report, 2002)
Children: energy requirements can increase by up to 2030% during infections and recovery (WHO,
2009). Equations for estimating catchup growth requirements for both calories and protein can be
used
Adults: increase energy intake by 600960 kcal day 1 in adults with weight loss may increase
body weight (Grobler et al., 2013), which is better achieved by providing a balanced nutritional
supplement
Pregnancy and lactation: the energy needs may be even greater than 10% above those of
nonpregnant adult females for women with inadequate rate of weight gain during pregnancy,
excessive weight loss postpartum, or other ongoing health issues (Raiten et al., 2011)
Up to 50100% additional energy to recover and regain weight (WHO 2003)
For critically ill patients: energy requirements may be calculated by predictive equations or
measured by indirect calorimetry (Singer, 2009), with special attention to the prevention of
complications related to under- or overfeeding (Fraipont and Preiser, 2013)
This is best achieved through enteral or parenteral (if enteral has failed) feeding
Weight management:
Counseling on changing eating habits and patterns
Regular exercise: physical activity counseling or physical activity program participation
As in asymptomatic children, protein should contribute about 1015% of the energy intake and
there is no need for additional protein other than what is present in a balanced diet (WHO, 2009)
Acceptable Macronutrient Distribution Ranges (AMDRs) can be used to ensure sufficient intakes
of essential nutrients (Food and Nutrition Board, 2005)
Use equation for estimating catchup growth requirements
Provide anticipatory guidance regarding the importance of a low-fat, low-saturated-fat, lowcholesterol diet for all otherwise healthy HIV-infected patients older than 2 years and their families
due to increased risk of CVD in HIV-infected populations
AMDR: Food and Nutrition Board (2005)
13 years: 3040% of total calories
418 years: 2535% of total calories
Pregnancy and lactation: essential fatty acid needs are 30% higher than those of nonpregnant
women, and adequate fatty acid intake should be ensured in a manner consistent with
recommendations for uninfected women (Raiten et al., 2011)
In these cases, dietary modification of fat may be required
Supplemental MCT and enteral formulas containing MCT can be used to supplement caloric intake
Dietary intervention with NCEP Therapeutic Lifestyle Changes (NCEP 2002) and exercise have been
shown to reduce triglycerides in both HIV-infected (Stradling et al., 2012) and HIV-uninfected
(Kelley et al., 2011) populations and to reduce LDL cholesterol in the general population (Yu-Poth
et al., 1999)
Counseling on changing eating habits and patterns per AHA/AAP
AMDR: Food and Nutrition Board (2005), 4565% of total calories
Added sugars should comprise no more than 10% of total calories consumed
A reasonable intake is 0.5 g kg 1 day 1 to a maximum of 35 g daily
BMR, basal metabolic rate; EER, Estimated Energy Requirement; FTT, failure to thrive; DRI, dietary reference intake.
Acceptable Macronutrient Distribution Range (AMDR) is the range of intake for a particular energy source that is associated with reduced risk of chronic disease while providing intakes
of essential nutrients.
needs are greater than that recommended for uninfected population. As for uninfected individuals, the estimation of energy
requirements for critically ill patients may be calculated by
predictive equations or measured by indirect calorimetry,
with special attention to the increased risk of overfeeding
during the early phase of acute illness and the increased risk
of underfeeding during the late phase. Once the secondary
infections are successfully treated and energy intake is
increased sufficiently, patients are able to regain weight and
remain weight-stable.
346
Micronutrients
In addition to macronutrient intake, careful attention to
micronutrient status (vitamins and minerals) is a critical
component in the nutritional treatment and care of people
living with HIV infection. The WHO has long taken the
lead in the establishment and dissemination of specific
requirements for micronutrient consumption among people
living with HIV throughout all stages of the life cycle. The
importance of the role specific micronutrients serve in the
Table 2
Population
Comments
Children and
adolescents
Vitamin D intake:
Children on antiretroviral treatment (ART) should be given two
to three times more vitamin D than the RDA for their age group
Adults
Pregnant and
lactating
women
Source: Raiten, D. J., Mulligan, K., Papathakis, P. and Wanke, C. (2011). Executive summary nutritional care of HIV-infected adolescents and adults, including pregnant and lactating
women: what do we know, what can we do, and where do we go from here? The American Journal of Clinical Nutrition 94(6): 1667S1676S. http://dx.doi.org/10.3945/
ajcn.111.019711; Holick, M. F., Binkley, N. C., Bischoff-Ferrari, H. A., et al. (2011). Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical
practice guideline. Journal of Clinical Endocrinology and Metabolism 96(7): 19111930. http://dx.doi.org/10.1210/jc.2011-0385; Irlam, J. H., Siegfried, N., Visser, M. E. and Rollins, N.
C. (2013). Micronutrient supplementation for children with HIV infection. Cochrane Database of Systematic Reviews 10: CD010666. http://dx.doi.org/10.1002/14651858.CD010666;
Irlam, J. H., Visser, M. M., Rollins, N. N. and Siegfried, N. (2010). Micronutrient supplementation in children and adults with HIV infection. Cochrane Database of Systematic Reviews (12):
CD003650. http://dx.doi.org/10.1002/14651858.CD003650.pub3; Roberfroid, D., Huybregts, L., Lanou, H., et al. (2012). Impact of prenatal multiple micronutrients on survival and
growth during infancy: a randomized controlled trial. American Journal of Clinical Nutrition 95(4): 916924. http://dx.doi.org/10.3945/ajcn.111.029033.
Micronutrient deficiencies are often observed in conjunction with a wide range of impaired immune responses and
clinical manifestations including increased susceptibility to
infection, inadequate intake, malabsorption, diarrhea, and
subsequently increased morbidity and mortality among various groups of people living with HIV. Although malnutrition
likely plays a role in disease outcomes, current data regarding
the role of micronutrients in disease progression remain limited. In conjunction with cART, inexpensive micronutrient
supplements could provide several cellular and clinical benefits, ranging from the prevention of mitochondrial toxicity and
oxidative stress to facilitation of immune reconstitution. Per
the established WHO guidelines, HIV-infected children and
adults should consume diets that provide micronutrient
intakes at the Recommended Dietary Allowance (RDA).
These recommendations state that in cases where dietary
intakes are insufficient, the use of micronutrient supplements
at the RDA in HIV-infected individuals of all ages is supported.
Low levels of vitamins, minerals, and other micronutrients
are often observed among HIV-infected children. This may
frequently be the result of inadequate nutritional intake from
their diet or their bodies may demand increased micronutrient
levels for the purpose of fighting the HIV infection itself or
opportunistic infections. Vitamin A supplements, as in children without HIV infection, reduce diarrheal morbidity and
mortality especially in young children. As stated in the 2003
WHO guidelines, HIV-infected 659-month-old children living in resource-limited settings should be given periodic (every
46 months) vitamin A supplements (100 000 IU for infants
612 months and 200 000 IU for children >12 months) in
order to reduce all-cause mortality and diarrhea morbidity.
This level is consistent with WHO recommendations for the
prevention of vitamin A deficiency in children. Furthermore,
studies have shown that vitamin A supplements are beneficial
and safe and can half mortality overall in an analysis of three
trials in different African countries.
Micronutrient supplements in adults are also shown to
reduce the metabolic and cellular complications of cART. A
greater intake of vitamin E and vitamin A in those on cART was
associated with fewer metabolic complications, dyslipidemia,
and insulin resistance. In addition, a daily supplement of
vitamins C and E for 3 months reduced oxidative stress
baseline CD4 counts <100 cell per ml.
Zinc is another important nutritional factor for HIVinfected individuals. Zinc supplements have been shown to
help HIV-infected children recover from diarrheal illnesses,
are safe, and appear to have similar benefits on diarrheal
morbidity in children with HIV as in children without HIV
infection. Long-term (18-month) zinc supplementation potentially reduces the likelihood of opportunistic infection in
adults and children and improves CD4 counts in adults.
There has been considerable growth in clinical interest and
research with respect to vitamin D deficiency and its effects on
the progression of HIV infection. With mounting evidence that
vitamin D deficiency can exacerbate immune dysfunction,
contribute to skeletal fractures, and increase cardiovascular
disease (CVD) and metabolic risk, there has been a great
focus on how this nutrient contributes to disease progression
in HIV. A number of clinical studies among populations in
both developed and developing nations have associated
347
348
randomized, controlled trials remains few and less clear. Additional research is warranted to determine the long-term clinical
advantages, potential adverse effects, and optimal composition
of micronutrient supplementation among more diverse groups
of HIV-positive research participants.
Cardiometabolic Complications
Obesity and Cardiometabolic Disease
Obesity is an emerging health problem among adolescents and
adults living with HIV/AIDS. With the institution of cART, the
immune and disease status of HIV-infected individuals has
improved and eating patterns (healthy or not) often parallel
those in healthy uninfected individuals. Poverty and food
insecurity are among other factors that can contribute to
childhood obesity that influence both HIV-infected and HIVuninfected populations equally. Immigrant families are particularly vulnerable. As the prevalence of obesity increases among
patients with HIV, the cumulative risk for CVD also increases.
Fat Redistribution
Coincident with the introduction of cART, a clinical syndrome
of body fat redistribution and metabolic changes was first
described initially in adults, but is now commonly reported
among children. HIV-infected patients receiving cART regimens have developed a syndrome of peripheral insulin resistance, hyperlipidemia, and lipodystrophy (truncal obesity,
dorsocervical fat pad, and extremity and facial wasting). Clinical and biochemical abnormalities associated with the fat
redistribution syndrome or commonly termed, lipodystrophy
syndrome, are shown in Table 3. Risk factors associated with
developing the fat redistribution syndrome in adults include
female gender, increasing age, family history of premature
CVD, higher pretherapy body weight, and behavioral patterns
such as tobacco and alcohol use. Complications associated
with the fat redistribution syndrome include higher rates of
diabetes mellitus and premature CVD. Lipodystrophy is almost
exclusive to patients receiving ART and can improve after PI
and NRTI switching. Medical compliance with drug therapy
may be poorer owing to the cosmetic side effects of therapy.
Table 3
Clinical and biochemical abnormalities of the fat
redistribution syndrome
Clinical features
Laboratory features
Hyperlipidemia
Increased triglycerides
Increased total cholesterol
Increased LDL-C
Decreased HDL-C
Insulin resistance
Normal to increased serum
glucose
Increased insulin
Increased C-peptide
Lipodystrophy is described in children, as well. Early studies showed a beneficial nutritional effect of cART in both adults
and children. Early initiation of cART is associated with more
rapid restoration of growth in children of developing nations.
Growth hormone levels are significantly lower in lipodystrophic HIV-infected adults with visceral adiposity. In addition to the positive improvement in growth and lean body
mass, however, cART is also associated with abnormalities in
fat distribution though some studies report similar lean mass
in HIV-infected and HIV-uninfected individuals. Both peripheral lipoatrophy and central obesity occur in both HIV-infected
adults and children. Fat redistribution can develop fairly rapidly after initiating a cART regimen and changes can progress
over time. Metabolic abnormalities are associated with specific
classes of drugs with many NRTIs and PIs implicated. Newer
agents often have less impact on fat redistribution and are the
preferred therapy if the virus is sensitive to the therapy.
Cardiometabolic Risk
Atherosclerotic CVD is a leading comorbidity and cause of
mortality among HIV-infected adults. Several studies show
that HIV-infected children, compared to healthy peers, have
higher rates of CVD risk factors, including dyslipidemia, insulin resistance, obesity, and central adiposity. HIV infection also
results in prolonged chronic inflammation, thereby increasing
CVD risk. In adults with cART-related fat redistribution, several
studies have suggested an increase in the risk of myocardial
infarction relating to the level of viral control (increased
inflammation) or to ARV exposures (including PIs and certain
NRTIs). Exogenous obesity, common among all individuals
with HIV, can also contribute to CVD risk. Children, compared
to adults with HIV, may be at even greater risk of developing
premature CVD as the lifetime exposures to factors associated
with CVD risk are longer in children.
Dyslipidemia
Prior to the introduction of any ART, elevated triglycerides and
LDL cholesterol and lower HDL cholesterol were reported and
associated with HIV infection. This profile persists in the current era and suggests that chronic immune activation can
influence lipid metabolism. Proinflammatory cytokines (as a
response to the chronic viral infection) may affect lipid pathways. After PI therapy became widespread, several investigators
in the United States and abroad reported a 2050% rise in lipid
levels of HIV-infected individuals. In hepatocyte cell lines, PIs
have been shown to interfere with cholesterol synthesis by the
inhibition of the proteasome, a potent regulator of apolipoprotein B production, among other mechanisms. Other factors
associated with dyslipidemia include successful viral suppression, better CD4 T-cell counts, and demographic factors. The
impact of PIs on lipid levels, independent of HIV, is effectively
described in HIV-seronegative volunteers who developed dyslipidemia following PI treatment.
transcriptase inhibitor (NNRTI) use both singly and in combination, although exact mechanisms have not been well defined.
HIV-uninfected adults treated with indinavir (a PI) showed a
rapid onset of insulin resistance but not hyperlipidemia or body
shape changes. Leptin, a hormone secreted by adipocytes, is low
in congenital and HIV lipoatrophies. These patients also tend to
have increased intramyocellular lipid in direct correlation to
their degree of insulin resistance. A possible mechanism by
which cART causes insulin resistance is by direct inhibition of
the transport function of glucose transporter type 4 (GLUT4),
which is responsible for insulin-stimulated glucose uptake into
the muscle and fat. Other potential causes of insulin resistance
include NRTI or NNRTI therapy associated with mitochondrial
DNA (mtDNA) mutations or depletions. Although there are
limited data in adults, there are striking similarities between
rare mitochondrial disorders, such as multiple symmetric lipomatosis (MSL), a condition that is phenotypically very similar to
cART-associated lipodystrophy. These mtDNA mutations in
MSL lead to an impaired function of cytochrome c oxidase
and a subsequent decrease in fat turnover. Inflammatory cytokines have been linked to both insulin resistance and diminished adiponectin, which affects insulin signaling and glucose
homeostasis. The adipose tissue is a major determinant of insulin sensitivity and changes associated with lipodystrophy can
alter the secretion of adiponectin. In one study, patients with PIinduced lipodystrophy had increased levels of circulating
inflammatory cytokines.
Nutritional Interventions
People living with HIV are faced with many obstacles that
challenge their ability to sustain proper nutritional status.
Decreased energy intake, increased energy expenditure, and
accelerated protein turnover are common in people with HIV.
349
Promoting and supporting adequate nutrition and food security are critical for this population. Presently, there are a number of different strategies to improve nutritional outcomes for
people living with HIV. Regardless, nutritional interventions in
HIV should be designed under the premise that (1) ARVs are
essential to prolong life and to halt the spread of HIV and (2)
food and sound nutrition are essential to human health.
Table 4 shows the gastrointestinal and nutritional side effects
of current ARVs.
Overall dietary goals for HIV-infected individuals are consistent with those for non-HIV-infected and include meeting the
needs of normal growth of children and adolescents, meeting
the needs of adequate weight gain of pregnant women, consumption of a high-quality, nutrient-dense diet, building good
eating habits, avoiding obesity through limiting intake of
energy-dense but nutritionally poor foods, engaging in physical
activity, and avoiding cigarettes, alcohol, and drugs. The diet
plan should be individualized based on the patients nutritional
status, age, symptoms, and ability to meet nutrient requirements. Regular nutritional assessments are necessary in order
to determine the appropriateness and effectiveness of the interventions. This assessment should include a review of the medical and dietary history, nutrient analysis of usual intake,
anthropometric measurements, body composition, and measurement of biochemical values. In order to guarantee optimal
nutrition care, the team should be multidisciplinary and be
composed of a physician, nurse specialist, social worker, and
dietician.
Consumption of a well-balanced diet remains the optimal
choice for achieving adequate nutritional status for all HIVinfected individuals regardless of age for overall health and
wellness, as well as growth and development in pediatric and
pregnant populations. However, the increased metabolic
demands of HIV infection and symptomatic HIV often present
significant challenges for achieving or maintaining healthy
body weight and immune system function. In circumstances
where malnutrition and food insecurity are present, supplemental food sources and/or enteral nutrition supplements may
be necessary to achieve positive health outcomes and are often
effective when given in the appropriate amounts. Some data
suggest that body weight and lean body mass tend to increase
with nutritional support. Food-based interventions can treat
malnourished HIV-infected patients and are necessary in order
to address both the individual needs of the patients and the
food security of their households. Ready-to-use therapeutic
foods effectively treat malnutrition of HIV-infected individuals
in developing nations.
Incentives provided through food supplements can be a
helpful method to improve clinical adherence. There is limited
evidence regarding the use of balanced nutritional supplements (consisting of 5060% carbohydrate, 1530% protein,
and 2030% fat) for improving energy intake and protein
among HIV-infected adults with weight loss, but no effects on
anthropometric or immunologic parameters. It is likely that
decreased energy intake, not changes in energy expenditure,
plays a major role in the weight loss experienced by those with
HIV and secondary infection. Therefore, with appropriate treatment and nutritional resources, most patients with HIV-related
weight loss will gradually increase ad libitum caloric intake and
gain weight.
350
Table 4
Medication
Action
Side effects
Abacavir
Aciclovir
Atazanavir
Atripla (tenofovir, emtricitabine, and
efavirenz)
Azithromycin
Ciprofloxacin
NRTI
Antiviral
PI
Combination
Antibacterial
Antibacterial
Clarithromycin
Combivir (zidovudinelamivudine)
Complera (rilpivirine, tenofovir,
emtricitabine)
Darunavir
Didanosine (ddI)
Edurant
Efavirenz
Emtricitabine
Epzicom (zidovudine, abacavir)
Erythromycin
Etravirine
Fosamprenavir
Enfuvirtide
Ganciclovir
Indinavir
Ketoconazole
Lamivudine
Antibacterial
Combination
Combination
PI
NRTI
NNRTI
NNRTI
NRTI
Combination
Antibacterial
NNRTI
PI
FI
Antiviral
PI
Antifungal
NRTI
Lopinavir/ritonavir
Maraviroc
Nelfinavir
Nevirapine
PI
EI
PI
NNRTI
Pentamidine
Raltegravir
Rifampin
Rilpivirine
Ritonavir
Saquinavir
Antiparasitic
II
Antibacterial
NNRTI
PI
PI
Stavudine
NRTI
Combination
Antibacterial
NRTI
PI
II
Nausea,
vomiting,
abdominal
pain,
Combination
Combination
PE
II
NRTI
HBV, hepatitis B virus; FI, fusion inhibitor; II, integrase inhibitor; EE, entry inhibitor; NRTI, nucleoside reverse transcriptase inhibitor; NNRTI, nonnucleoside reverse transcriptase
inhibitor; PI, protease inhibitor; PE, pharmacokinetic enhancer of PIs.
351
Summary
The multidimensional nature of nutritional problems associated with HIV infection is a microcosm for most nutritional
disorders that span a vast array of both acute and chronic
disease states in humans. With improved therapies and survival of HIV-infected individuals, the state of nutrition will
continue to evolve. Future research and treatments in this
field will focus on using nutrition to augment and optimize
the clinical care of those chronically infected with HIV.
Further Reading
Botros D, Somarriba G, Neri D, and Miller TL (2012) Interventions to address chronic
disease and HIV: strategies to promote exercise and nutrition among HIV-infected
individuals. Current HIV/AIDS Reports 9(4): 351363. http://dx.doi.org/10.1007/
s11904-012-0135-7.
Brenchley JM, Price DA, Schacker TW, et al. (2006) Microbial translocation is a cause
of systemic immune activation in chronic HIV infection. Nature Medicine 12(12):
13651371. http://dx.doi.org/10.1038/nm1511.
Brinkman K, Smeitink JA, Romijn JA, and Reiss P (1999) Mitochondrial toxicity induced
by nucleoside-analogue reverse-transcriptase inhibitors is a key factor in the
pathogenesis of antiretroviral-therapy-related lipodystrophy. Lancet 354(9184):
11121115. http://dx.doi.org/10.1016/S0140-6736(99)06102-4.
Carr A, Samaras K, Chisholm DJ, and Cooper DA (1998) Pathogenesis of HIV-1protease inhibitor-associated peripheral lipodystrophy, hyperlipidaemia, and insulin
resistance. Lancet 351(9119): 18811883. http://dx.doi.org/10.1016/S0140-6736
(98)03391-1.
Chandrasekhar A and Gupta A (2011) Nutrition and disease progression pre-highly
active antiretroviral therapy (HAART) and post-HAART: can good nutrition delay
time to HAART and affect response to HAART? American Journal of Clinical
Nutrition 94(6): 1703S1715S. http://dx.doi.org/10.3945/ajcn.111.019018.
Drain P, Lupta R, Mugusi F, and Fawzi W (2007) Micronutrients in HIV positive persons
receiving highly active antiretroviral therapy. American Journal of Clinical Nutrition
85(2): 333345.
352
lactating women: what do we know, what can we do, and where do we go from here?
The American Journal of Clinical Nutrition 94(6): 1667S1676S. http://dx.doi.org/
10.3945/ajcn.111.019711.
Roberfroid D, Huybregts L, Lanou H, et al. (2012) Impact of prenatal multiple
micronutrients on survival and growth during infancy: a randomized controlled trial.
American Journal of Clinical Nutrition 95(4): 916924. http://dx.doi.org/10.3945/
ajcn.111.029033.
Singer P, Berger MM, Van den Berghe G, Biolo G, Calder P, Forbes A, and ESPEN
(2009) ESPEN Guidelines on Parenteral Nutrition: intensive care. Clinical Nutrition
28(4): 387400. http://dx.doi.org/10.1016/j.clnu.2009.04.024.
Stradling C, Chen YF, Russell T, Connock M, Thomas GN, and Taheri S (2012) The
effects of dietary intervention on HIV dyslipidaemia: a systematic review and
meta-analysis. PLoS One 7(6): e38121. http://dx.doi.org/10.1371/journal.
pone.0038121.
Wanke C, Kotler D, and HIV Wasting Collaborative Consensus Committee (2004)
Collaborative recommendations: the approach to diagnosis and treatment of HIV
wasting. Journal of Acquired Immune Deficiency Syndromes 37(Suppl. 5):
S284S288. PubMed PMID:15722872.
Yu-Poth S, Zhao G, Etherton T, Naglak M, Jonnalagadda S, and Kris-Etherton PM
(1999) Effects of the National Cholesterol Education Programs Step I
and Step II dietary intervention programs on cardiovascular disease
risk factors: a meta-analysis. American Journal of Clinical Nutrition 69(4):
632646.
Relevant Websites
www.unaids.org Global Report: UNAIDS report on the global AIDS epidemic, 2010.
http://www.who.int Nutrient Requirements for People Living with HIV/AIDS: Report of
a technical consultation, 2003.
http://www.who.int Macronutrients in HIV/AIDS: a review of current research, 2005.
http://www.who.int WHO: Guidelines for an integrated approach to the nutritional care
of HIV-infected children (6 months14 years), 2009.
http://www.who.int/nutrition/publications/hivaids/9789241597524/en/index.html
WHO. Nutrient Requirements for People Living with HIV/AIDS: Report of a technical
consultation. 2003. Guidelines for an integrated approach to the nutritional care of
HIV-infected children (6 months14 years), 2009.
http://www.who.int/nutrition/publications/hivaids/9789241597524/en/index.html
Guidelines for an integrated approach to the nutritional care of HIV-infected children
(6 months14 years), 2009.
http://www.who.int/nutrition/publications/hivaids/9241591196/en/ HIV/AIDS
evidence-based nutrition practice guideline. American Dietetic Association. HIV/
AIDS evidence-based nutrition practice guideline. Chicago (IL): American Dietetic
Association, December 2010.
http://www.who.int/gho/hiv/epidemic_status/deaths/en/ Number of deaths due to
HIV/AIDS, 2015.