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Take a better bite out of life
By: Janelle LÕHeureux, MS, RD and Joya Parenteau, RD
We conduct group nutrition classes and discussions quite often. At a recent class, we asked how quality of life affects nutrition. "Having control over what and when I eat," was by far the most common answer. Examples included having a drink without worrying about a disastrous interaction with medications, an occasional binge with a favorite food or eating sushi without worrying about food poisoning.
Celebration, depression, and recreation are some of the reasons why we eat. Having a medication or healthcare professional dictate what and when we eat may illicit feelings of anger, resentment, depression and loss of control. These emotions can create a negative self-image and affect one's overall quality of life.
Healthcare professionals need to be cognizant of how their message is perceived. If clients feel they are losing control, they may disregard any other recommendations provided, no matter how beneficial. Feeding the body and soul should be a gratifying experience, not a complicated or demeaning one.
Numerous consequences of living with HIV impact quality of life and nutritional well being. * Poverty, * loss of appetite, * recurring nausea, * diarrhea,* fatigue, * changes in body shape, and weight, * wasting, * decreased ability to function, and *drug side effects are demanding and debilitating. In the literature, it is well documented that malnutrition is wide spread in persons living with HIV. Nutrition is key in maintaining and promoting immunity, and its role cannot be underestimated. An impaired immune system co-exists with malnutrition and opens the door to further infections. HIV induced anorexia combined with gastrointestinal disturbances can interfere with digestion and absorption. These can lead to further nutritional deficiencies, weight loss, and loss of lean body mass. Ways to deal with these conditions and underlying causes must be addressed in such a manner that is easy to understand and follow.
A predicament clients often face is the limited time to adequately discuss their concerns with their primary care physician. Issues regarding nutrition are often overlooked or not discussed. To compound the problem, referral to a registered dietitian who is sensitive to and knowledgeable in HIV is frequently lacking from routine medical care. As one survey pointed out, many doctors do not even think to refer their clients to a dietitian, and further, are not providing nutrition information.1 As registered dietitians working within AIDS service organizations, we feel one of our greatest advantages is the time we can devote to our clients. We are able to address client's burning nutritional issues, and together, develop realistic and practical solutions. Many times, a client will tell us, "I never realized that lying down to watch TV after I eat could make my nausea worse," or, "I had no idea dairy products or caffeine could make my diarrhea worse."
Especially when taking highly active antiretroviral therapy (HAART), individual lifestyles must be taken into consideration to make adherence possible. This includes knowledge of their work or school schedules, standing appointments, and current eating patterns. The following are questions that need to be addressed.
* Do they get up at 6:00 a.m., or are they wiping the sleep from their eyes when some of us are returning from lunch? * Where do they eat their meals? * What kind of foods do they like? * How often do they eat? * If they take medications, are they aware of any dietary requirements or restrictions? Working together with a client on the timing of their meals and medications is imperative to reduce side effects, optimize nutrition, and retain control over their lives. Many times, clients are given a generic schedule which may not accurately reflect their daily or nocturnal habits and food preferences. Clients need to be reassured that it's ok if they don't want to eat an omelet, toast, and juice for breakfast when a bowl of chili, cornbread and diet soda is more their style. Using drug manufacturers' guidelines, I suggested a that client adjust his meal and medication schedule to minimize the severe drowsiness and GI distress he was experiencing. Upon follow up, the client had no side effects and was adhering to his new medication schedule.
Registered dietitians are trained in food science and production and can provide clients with information on food preparation. Finding out what type of cooking and storage facilities a client has is extremely valuable. If a client only has a hot plate and a small refrigerator, they may need food preparation and storage tips. Similarly, a client may have access to a full-sized kitchen, but lacks cooking experience. For example, clients may ask us, "How long does it take to boil an egg?" Knowing that 10 to 15 minutes is sufficient time to hard-boil an egg may be common knowledge to some, but not to others. In addition to explaining proper food handling techniques, reminding clients of the importance of drinking safe water, is critical in preventing infection from cryptosporidium and other water borne illnesses. Buying safe bottled water can be costly and inconvenient. Bringing tap water to a rapid boil for at least one minute will destroy cryptosporidium and may be a viable alternative.
Some things must be considered a daily priority. A diet regularly consisting of a variety of foods from all the food groups, with emphasis on getting adequate calories and protein and at least 8-10 glasses of water a day, is strongly encouraged. In addition to a healthy diet, taking a multivitamin and mineral supplement once or twice a day, plus a B-complex, is recommended. Some people experience pill fatigue (they don't have room for another pill), so food choices to maximize nutrient intake can be critical. Taking time to review actual food intake and comparing it to daily goals focuses attention on the diet. Clients are often surprised at what kind of foods and the quantity they are eating. After reviewing his diet, one client responded, "I just realized I eat crap all day!"
Physical and metabolic changes are becoming more recognized and prevalent in individuals with HIV infection. Theories to explain these manifestations are currently being researched. Changes include loss of subcutaneous fat in the limbs, face, abdomen and buttocks, but increasing fat in the abdomen (visceral fat), behind the neck (dorso cervical) and other areas, as well as breast enlargement. Metabolic changes include increased triglycerides, cholesterol and blood sugar levels. Dietitians can help with dietary changes if necessitated by abnormal blood lipid and glucose levels. Body composition changes can be monitored by taking the client's weight, measuring body cell mass, hip, waist, thigh, neck and breast size at each clinical visit. Incorporating some aerobic and weight resistance exercises help increase lean body mass, decrease stress, improve self-image, aid in digestion, and reduce the risk of cardiovascular disease. Food might seem like a basic part of life to many of us. For people "living" with HIV/AIDS, it is life sustaining and enhancing. For many individuals, food becomes a luxury when finances go towards medications, transportation, or other living expenses. Dietitians can also provide important information to clients about food pantries or meal provider agencies.
No one really knows you better than you do. Be active in your healthcare. Use all the resources available to you such as treatment advocates, dietitians, mental health specialists, etc., to clarify information, give support, or just lend a friendly ear. With so many drug-drug and drug-nutrient interactions, having a qualified professional assist you with scheduling of your medications, as well as explaining their purpose, will go far in promoting adherence to treatment. Self-advocacy regarding your medical and nutritional care is paramount in maintaining control, which in turn enhances quality of life.
1. JS. HIV and Medical Nutrition Therapy. Journal of The American Dietetic Assoc. 1997 (suppl 2); 97 (10):s.
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