A nutrition specialist based in Chicago is on the phone trying to set up an appointment with someone who needs her expertise. “Well, Wednesday I’m in Chicago, Thursday I’m in Charlotte, and Friday, I think, I’m in your area. Monday I’m in Indianapolis.......”
Meet Cade Fields-Gardner, R.D., the woman whom every person infected with the human immunodeficiency virus (HIV) wants to see. She is the director of services for Cutting Edge Consultants, a group of dietitians who use their expertise to set up and monitor HIV nutritional programs for hospitals, industries and individuals across the country. And she is someone who is trying to make a difference in the lives of those who are infected with HIV, the virus that destroys the immune system and causes AIDS.
Fields-Gardner is hot. Physicians speak of her with respect. People who test positive for HIV speak of her with reverence. She can read lab reports the same way a Wall Street broker reads the Dow-Jones. She has the information that may help people stay alive.
Studies show that the majority of those who are HIV-positive are likely to have major deficiencies of a slew of vitamins and minerals at different stages of the disease. But figuring out exactly what that means and how to correct it has turned Fields-Gardner and her colleagues in HIV care into nothing less than medical detectives. “Almost all of us in HIV care are often flying by the seat of our pants,” says Fields-Gardner.
A study at the University of Miami of 112 men who were HIV-positive, for example, found that 67 percent had at least one nutrient deficiency, while 36 percent had more than one. Thirty percent were deficient in vitamin B6, 30 percent in zinc, 20 percent in vitamin E, 16 percent in vitamin A and 11 percent in vitamin B12.
None of these men had any symptoms of nutritional deficiency—fatigue or memory loss, for example—and the majority of them were eating balanced diets that provided all of the Recommended Dietary Allowances. Many were also taking supplements. Yet when vitamin B12 was measured, for example, only those men taking 25 times the Recommended Dietary Allowance demonstrated even adequate B12 levels.
A Body That Can’t Fight Back
Why would a well-nourished body experience almost a half-dozen nutrient deficiencies?
“Nutrition in HIV is complex,” says Fields-Gardner. In some cases, the virus may indirectly injure the intestinal wall, which can make it difficult for the body to absorb nutrients. Doctors know that opportunistic infections, such as intestinal viruses and bacteria from undercooked foods, are common in people with HIV and can also affect the body’s ability to absorb nutrients. Medication-induced diarrhea and malabsorption as well as metabolic changes resulting from additional liver or pancreatic disease, often seen in people with HIV, also contribute to lower blood levels of nutrients. Compounding the situation is the fact that the body seems to increase the rate at which it uses nutrients. And it may actually use them differently.
All of these factors add up to malnutrition, which has three major effects on those who are HIV-positive, experts agree. It contributes to the weight loss that frequently leads to a wasting syndrome in which more than 10 percent of total body weight, mostly lean muscle, is lost. It can decrease the effectiveness of drugs designed to prolong life, or it can increase the toxicity of other drugs. And it can sabotage already compromised immune system cells, which are charged with fighting off HIV as well as any opportunistic infections and even the cancers that frequently try to gain a foothold during HIV infection.
“Any type of malnutrition can contribute to immune dysfunction,” says Fields-Gardner.
A vitamin B6 deficiency, for example, can reduce the number of natural killer cells that the immune system has available to target marauding viruses. And it directly reduces the number of what are known as CD4 cells, the immune system’s first line of defense against HIV. In fact, since HIV attacks CD4 cells first, doctors can count the number of CD4 cells in a blood sample as a means of tracking how well—or how poorly—a person’s immune system is fighting the HIV invasion.
The Beta-Carotene Lesson
Although malnutrition is common in those with HIV, there’s a wide spectrum of opinion about why it exists and what should be done about it.
“Although it may seem obvious that any deficiency should be corrected, we don’t know if there’s a purpose for the deficiency, so we have to proceed cautiously,” says Fields-Gardner. “We have to play detective, do trial and error, then monitor the results closely with appropriate blood tests and other tests.”
Studies at Oregon Health Sciences University in Portland, for example, revealed that levels of carotenoids—lutein, alpha-carotene, beta-cryptoxanthin and the more well known beta-carotene—are reduced early in an HIV infection and that the more advanced the disease, the lower the levels of these nutrients.
Since carotenoids are known to boost levels of body chemicals that may help fight off the destructive effects of HIV, logic seems to dictate that you do everything you can to raise levels of these chemicals as high as you can, such as taking beta-carotene supplements.
But such may not be the case. Researchers in Oregon did exactly that and found that there may be one group of HIV-positive people for whom beta-carotene is beneficial and a subgroup for whom beta-carotene is actually harmful. The problem is, no one can tell who falls into which group.
The bodies of people with a particular disease may not use nutrients in the same way that the bodies of healthy people do, explains Fields-Gardner. Healthy people, for example, will turn orange if they get more beta-carotene than their bodies can use. “But we’ve had reports of people who’ve had signs of toxicity, including high levels of triglycerides, without even turning orange first. This is worrisome in people who may have problems with the pancreas.” (Triglycerides are fat molecules in the blood that are markers for heart disease.)
Aggressive Nutrition
Keeping in mind that supplementing various nutrients in those who are HIV-positive can have unexpected problems, HIV experts are increasingly viewing aggressive nutrition as the defining battle in the war against AIDS. Nutrition may not be the primary therapy directed against the virus; an alphabet soup of drugs designed to slow the virus bears that standard. But many experts feel that winning the nutrition battle can at least raise the quality of life on the battlefield or even prolong the war.
A six-year study at Johns Hopkins School of Hygiene and Public Health in Baltimore of 281 HIV-positive men, for example, found that the highest levels of thiamin, niacin and vitamin C from both foods and supplements were associated with slower progression to AIDS. Between 9,000 and 20,000 international units of vitamin A a day, two to four times the Daily Value, was associated with a 43 percent decrease in the risk of progression to AIDS, although amounts of vitamin A over that amount were associated with an increased risk. (The Daily Value for vitamin A is 5,000 international units.)
Consumption of vitamins B12, D and E, plus calcium, folic acid, iron and copper, was not associated with AIDS in one way or another. But increasing consumption of zinc was actually associated with an increased risk of AIDS. Men with higher zinc intakes were more likely to develop AIDS.
“There’s a growing body of evidence suggesting that micronutrient intake may be significant in helping the body to keep its immune system at the best level to help control the virus,” says Neil M. H. Graham, M.D., associate professor of epidemiology at Johns Hopkins School of Hygiene and Public Health and the study’s senior investigator.
“On the other hand, it’s worth pointing out that nutritional supplements are certainly not a cure. There seems to be progression to AIDS despite supplementation, but at a slower pace,” he says.
Nutrients against AIDS
But if proper nutrition can slow the progression of HIV to AIDS, won’t it also slow the progression of AIDS to death? In short, won’t it buy people with AIDS more time?
Alice M. Tang, a doctoral candidate working with Dr. Graham and lead author of the study at Johns Hopkins, had the same question. She followed the survivors of the initial study for another two years and launched the first study in the nation to examine the relationship between nutrients and survival in people with AIDS.
The result? “There was a 40 to 50 percent increase in survival during the study among those who consumed the highest levels of certain vitamins,” says Tang.
The highest consumption of thiamin, riboflavin, vitamin B6 and niacin was associated with more than one year of increased survival time. Much of the protective effect appears to be from supplements rather than foods. The intake of B6 supplements at a level more than twice the Recommended Dietary Allowance was associated with a 37 percent decrease in mortality. Similar effects were seen with thiamin and riboflavin at levels more than five times the Recommended Dietary Allowances.
“We don’t know if the supplements are bringing the nutrients up to normal levels in the patients’ bodies or if they’re giving nutrient levels an extra boost,” says Tang.
A Nutritional Surprise
Although increased levels of B vitamins seem to prolong life, more is not always better when it comes to nutrients.
“We also looked at beta-carotene and vitamin A,” says Tang. Between 7,622 and 11,179 international units of beta-carotene a day was associated with a 42 percent increase in survival. But in one of those odd nutritional quirks found so often in HIV, more or less beta-carotene did not result in any improvement.
The same thing occurred with vitamin A, which is chemically related to beta-carotene. Between 9,098 and 20,762 international units a day was associated with protection.
Those therapeutic windows were not the only nutritional surprises found by Tang and her colleagues. “The intake of zinc in the population we studied appeared to be harmful,” she says. “Scientists have done studies in which very high levels of zinc were toxic to the immune system. But never has anybody found that ranges around the Recommended Dietary Allowance, about 15 milligrams a day, could be harmful. Yet when we looked at zinc supplements separately from food, people who were taking any zinc supplement had a 50 percent increase in their risk of mortality.”
She suspects that taking zinc supplements may be like feeding HIV a spoonful of fertilizer.
“Studies show that the virus has something called zinc fingers,” says Tang. The fingers may actually grab zinc as the virus replicates itself.
If that’s true, she adds, giving the body even a milligram more zinc than it needs to carry out basic functions might be counterproductive.
“There may be a fine balance between boosting your immune system and not giving the virus too much to work with,” she concludes. It should be noted that these findings have yet to be confirmed by other studies, so the issue remains controversial.
The Nuances of Nutrition
Given the surprises that frequently emerge in HIV nutrition, many experts are reluctant to recommend even the Daily Value of a particular vitamin or mineral.
Others say that since people with HIV are running out of time, they’re willing to suggest whopping doses that may in fact prove toxic just on the chance that they might help.
“Everyone may be well-meaning, but the issue is very emotional,” says Fields-Gardner. “If you suggest small amounts of vitamins and minerals, people say you’re allowing your patients to die. If you suggest large amounts, people say you’re killing them.”
But there is a middle ground, one that’s based solidly on the available research.
“There are very preliminary data and no clinical trials, so you have to be careful,” says Dr. Graham. “But anything you can do to tip the immune system in your favor seems to be a good idea.”
His recommendation? Load up on B vitamins, keep zinc at or below the Daily Value of 15 milligrams and do not exceed twice the Daily Values of fat-soluble nutrients such as vitamins A, D and E. Vitamin D in doses exceeding 600 international units daily should be taken only under medical supervision. And research has found that taking 10,000 international units of vitamin A daily in early pregnancy can cause birth defects. For this reason, women of childbearing age should consult their doctors before supplementing this much vitamin A. Women who are pregnant should not use this therapy.
“If you’re going to take B vitamins, take all of them in reasonably solid doses,” says Dr. Graham. Take thiamin, riboflavin, vitamin B6, vitamin B12, folic acid and niacin in the range of two to four times their Daily Values. You should check with your doctor before supplementing B12 if you have any kind of infection. And folic acid in doses exceeding 400 micrograms daily should be taken only under your doctor’s supervision, as this vitamin can mask signs of a B12 deficiency.
“It’s also suggested that if you’re going to take supplements, you should start very early, because the virus is replicating right from the word go,” says Dr. Graham.
The Promise of Selenium
Scientists originally thought that HIV invaded the immune system and then laid low until some unknown trigger finally catapulted it into rabid replication.
Scientists now realize, however, that there is a “titanic struggle” going on between the immune system and the virus all of the time, says Dr. Graham.
In fact, the body’s immune system seems to be able to mount a vigorous response and keep the virus in check for years. Eventually, however, HIV destroys more immune cells than the body can replace, and the virus spreads throughout the body, usually precipitating a drop in the immune system’s CD4 cells (the fighters) and the onset of full-blown AIDS. CD4 cells are a type of white blood cell called a T-helper lymphocyte. These cells are often referred to as the conductors of the immune system, because they coordinate the response of all other immune cells by using chemical messengers called cytokines. They also help other cells increase their antiviral effects.
What causes HIV to suddenly overwhelm the immune system is a matter of intense speculation in the scientific community. But one theory suggested by Gerhard N. Schrauzer, Ph.D., a researcher at the University of California, San Diego, is that HIV breaks out of its immune system hosts only after it has exhausted their available supplies of selenium.
In other words, the virus is hungry. For selenium.
What makes Dr. Schrauzer think this might be the case? For one thing, studies indicate that the less selenium in the body, the more advanced an HIV infection is likely to be. For another, a group of French scientists has found that adding selenium to HIV in cell cultures blocks the virus’s replication. And third, an ongoing investigation by Dr. Schrauzer and a colleague in Germany seems to indicate that supplementing the diet with somewhere between 100 and 300 micrograms of selenium a day reduces symptoms and prevents life-threatening weight loss in those with AIDS.
But the proof of Dr. Schrauzer’s theory may actually come from research conducted by Will Taylor, Ph.D., an AIDS researcher at the University of Georgia in Athens. Dr. Taylor has found theoretical genetic evidence supporting the idea that there are actually selenium-containing proteins on the genes that may regulate HIV replication.
“This means that HIV may be regulated by selenium levels,” says Dr. Taylor. “And there may actually be a molecular switch controlling the virus that is sensitive to selenium levels and that would be turned on when selenium levels get too low.”
Dr. Schrauzer emphasizes that a person infected with HIV should seek a medical doctor open to all approaches of treatment and healing. “Selenium is important,” he says, “but any single agent or treatment has its limitations. The best results have been obtained with comprehensive treatments.”
The bottom line? “Selenium should be a key complementary therapy in any AIDS program,” says Dr. Schrauzer. “I recommend 200 to 400 micrograms a day.” Doses of selenium in excess of 100 micrograms a day should be taken only under medical supervision.
| Food Factors Although vitamins and minerals may play important roles in holding off the development of AIDS in those infected with the human immunodeficiency virus (HIV), medical experts say that these nutrients cannot do their jobs without three other dietary constituents. Here's what they recommend. Stay liquid. "For those who are HIV-positive, fluids are the number one priority, because they are the medium in which everything occurs," says HIV nutrition specialist Cade Fields-Gardner, R.D., director of services for the Chicago-based Cutting Edge Consultants, a group of dietitians who use their expertise to set up and monitor HIV nutritional programs for hospitals, industries and individuals across the country. All of the micronutrients in the world won't do you any good unless you have enough fluid in your body to process and transport them, she says. Try to get at least eight to ten glasses of fluids a day, preferably those that contain calories (juices and nectars are good sources). Coffee and alcoholic beverages don't count, since they may cause dehydration. Increase calories. "Calories are the number two priority," says Fields-Gardner. They give people the sheer raw energy with which to live and to be able to use vitamins and minerals. The nutrient-dense calories found in the basic food groups (grains, vegetables, fruits, dairy and meats) are preferable to the calories in foods that are high in fat and sugar. To increase calories, choose higher-calorie foods such as nonfat ice cream or frozen yogurt, dried fruits and low-fat condiments. Level out your protein intake. Protein is the third priority for those who are HIV-positive, because most of the body is made up of protein, says Fields-Gardner. And protein is a key player in keeping the immune system on its toes. To increase the amount of protein in your diet, try fortifying milk, soups, shakes and other foods with nonfat dry milk. Add eggs to soups and other items that will be cooked thoroughly. You should check with your dietitian to be sure you need additional protein before adding too much, however, since excess protein may cause dehydration. |
| Prescriptions for Healing The body's ability to absorb and use nutrients can be affected by the human immunodeficiency virus (HIV) in unexpected ways, according to experts. That's why they maintain that each individual who is HIV-positive needs a battery of blood tests to define his exact nutritional state as well as regular consultation with an HIV nutrition specialist, who can work with the individual's doctor to custom-tailor a nutritional plan. Based on evolving research, here are some recommendations for daily nutrient consumption that experts suggest you and your HIV health practitioners consider. Nutrient Daily Amount
Folic acid 800-1,600 micrograms Niacin 40-80 milligrams Riboflavin 3.4-6.8 milligrams Selenium 200-400 micrograms thiamin 3-6 milligrams Vitamin A 5,000-10,000 international units Vitamin B6 4-8 milligrams Vitamin B12 12-24 micrograms Vitamin D 400-800 international units Vitamin E 30-60 international units
MEDICAL ALERT: If you are HIV-positive, you should be under a doctor's care. Folic acid in doses exceeding 400 micrograms daily should be taken only under your doctor's supervision, as this vitamin can mask signs of a vitamin B12 deficiency. Doses of selenium in excess of 100 micrograms a day should be taken only under medical supervision. Vitamin A has been linked to birth defects when taken during early pregnancy in doses of 10,000 international units daily. Women of childbearing age should consult their doctors before taking this much vitamin A. Women who are pregnant should not use this therapy. You should check with your doctor before supplementing vitamin B12 if you have any kind of infection. Vitamin D in doses exceeding 600 international units daily should be taken only under medical supervision. If you are taking anticoagulant drugs, you should not take vitamin E supplements. A study at Johns Hopkins School of Hygiene and Public Health in Baltimore has found an association between zinc and the progression of HIV infection to AIDS. Do not take zinc supplements without first consulting your doctor. |
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