**2. The foundations of good nutrition**

*Nutrition and HIV/AIDS - Implication for Treatment, Prevention and Cure*

mentation in HIV seropositives [3, 4].

treatment to stop the infection from progressing [1, 2]. Studies indicate that multiple nutritional abnormalities occur relatively early in human immunodeficiency virus (HIV) infection, and also that decreased plasma levels of vitamins B6, B12, A, E and zinc are correlated with dietary intake and associated with significant alterations in immune response and cognitive function for people living with HIV infection. To determine the level of intake consistent with normal plasma nutrient levels, there is a need to examine nutrition status in relation to food consumption and nutrient supple-

In developing countries where most families live in abject poverty and are exposed to infections due to poor nutrition and sanitation and contaminated drinking water, the benefits of HIV-positive mothers breastfeeding infants will greatly reduce the risk of HIV infection when ARVs are combined with good nutrition. In this instance, the nutrients and antibodies present in breast milk will make the healthiest food for such babies, thereby providing them with unmatched protections from HIV infection, diseases and even death. Therefore, good nutrition will lay the foundation for healthy thriving and productivity of people living with HIV. Now more than ever, there is global recognition that good nutrition is the key to sustainable development. But good nutrition is more than about just ending hunger: it is also crucial to achieving some targets, including ending poverty, achieving gender equality, ensuring healthy lives, promoting lifelong learning, improving economic growth, building inclusive societies and ensuring sustainable consumption [5–7]. Nutritional status may have an impact at all stages of HIV disease since most of the clinical features of HIV infection originate from nutritional problems which are exacerbated by the presence of malnutrition. However, inadequate food intake, due to a variety of etiologies, malabsorption and altered metabolism, may also contribute to malnutrition. Additionally, factors in food, including reduced micronutrient levels, can negatively affect the immune functions and result in increase in the progression of HIV infection at all stages [8–11]. The frequent weight loss in people living with HIV worsens the prognosis of the infection. Their reduced dietary intake, increased digestive problems and energy expenditure result in severe malnutrition. Therefore, the nutritional support and its association with anabolic agents to promote tissue growth and physical activity should be carefully selected [12–14]. The adverse effects of some new antiretroviral drugs could influence the patients' nutritional state as well as compliance to treatments. In cases where lipodystrophy, whose etiology is still unknown and no treatment has yet been found, and metabolic disorders like dyslipidemia, glucose intolerance and others occur, particular attention should be given since these conditions are likely to increase cardiovascular risks

and, moreover, they are generally sensitive to a dietary approach [2, 15, 16].

and guarantee security in livelihood should not be underestimated.

Achieving and maintaining optimal nutrition is considered an important strategy for ensuring food security for people infected with HIV. A good nutrition can improve an individual's immune function, limit disease complications, and improve quality of life and survival. This is necessary because macronutrient interventions, such as balanced diet of high protein, high carbohydrate and high fat, will reduce morbidity and mortality of people living with HIV infection. Evidence has shown that macronutrient supplementation will reduce HIV-related complications, such as opportunistic infections or death. Food insecurity has been recognized as the key driver of HIV epidemic and a potential cause of poor health outcomes among people living with HIV and AIDS. Food insecurity is linked with heart disease, diabetes, obesity, depression and is independently associated with incomplete HIV RNA suppression among HIV-infected individuals [17]. These call for holistic and comprehensive response in minimizing chronic nutrition insecurity among HIVpositive persons. Therefore, the need to elucidate ways of sustaining long-term nutritional support for HIV-positive individuals to minimize nutritional insecurity

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Nutrition is defined as the sum total of the processes by which a living organism receives materials from its environment and uses them to promote its own vital activities. The materials which it receives are known as nutrients. Nutrition is also the science that interprets the relationship between the food consumed and its function on the living organism. It relates to food intake and functions in the body for the overall well-being of the individual. It includes the intake of food, liberation of energy, elimination of waste and all the synthesis or processes that are essential for the maintenance of growth and reproduction of the individual [18]. The relationship between nutrition and HIV is a vicious cycle, similar to the relationship between nutrition and other infections. Compromises in nutritional status and poor nutrition further weaken the immune system and thereby increase susceptibility to opportunistic infections. Poor nutrition increases the body's vulnerability to infections, and infections aggravate poor nutrition. Inadequate dietary intake leads to poor nutrition and lowers immune system functioning. Poor nutrition reduces the body's ability to fight infections and therefore helps increase the incidence, severity and length of infections. Research has shown that clinically, there are synergistic interactions between infection, nutritional status and immune functions. Infectious diseases, no matter how mild, will influence nutritional status and conversely cause nutrient deficiencies that are sufficiently severe to impair resistance to infection [19, 20].

The foundations of good nutrition include improving women's nutrition before, during and after pregnancy; promoting and supporting exclusive breastfeeding for the first 6 months of a child's life, and continued breastfeeding up to age 2 or beyond; providing timely, safe, appropriate and high-quality complementary foods as well as micronutrient interventions. In this regard, nutritional status should be assessed using biochemical measurement of nutrient levels, dietary history, anthropometry and clinical examination for the signs and symptoms of nutritional deficiency or excess. In managing emergencies, UNICEF's programs have concentrated their interventions on foundations of good nutrition, prevention and treatment of malnutrition to vulnerable groups including those living with HIV and AIDS irrespective of whether or not they are using highly active antiretroviral therapy (HAART) which has been postulated to reduce the occurrence of human immunodeficiency virus (HIV)-associated weight loss and wasting. To this assumption, studies have shown that there is no difference in the extent of wasting experienced between those who received HAART and those who did not. It has been shown that the weight loss or wasting in HIV infection can be radically reduced with nutrition intervention. The good news is that the goal of nutritional intervention is usually to preserve lean body mass and provide adequate nutrients as well as minimize symptoms of malabsorption and thereby improve quality of life. This is why specific nutritional therapy ranges from oral supplements to home total parenteral nutrition (TPN) which is individualized [21, 22].

Following interventions proffered by several organizations and researchers to reduce malnutrition among persons living with HIV, the definition of wasting developed by the Centers for Disease Control and Prevention (CDC) in 1987 has been adopted by researchers. This definition requires an involuntary weight loss of >10% of baseline body weight plus diarrhea, fever, or weakness for >30 days to be termed as wasting. Most researchers have now dropped the comorbid conditions of wasting and have simply espoused weight loss >10% as the definition of HIV-associated wasting. In the CDC definition, "baseline weight" is neither defined nor time frame specified for the weight loss. Presently, most researchers are using the definition of wasting as that which will require a weight loss >5% in a 6-month period and that in which the weight loss is sustained. Some other studies have

shown that this level of weight loss can predict mortality and infectious complications in individuals with AIDS and that reduction in a body mass index to <20 kg/ m2 in a 6-month period should be used as an index of wasting among HIV and AIDS clients when intervening for malnutrition. Because of the uncertainty as to which of these definitions given above should be adopted as the standard definition of wasting for intervention, the three presented criteria are now being used. Therefore, weight loss and wasting continue to be common problems for individuals infected with HIV as well as for those treated with HAART in whom either HAART has failed or there is lack of tolerance for HAART regimens [23, 24].

Studies have been done to determine whether specific nutrient abnormalities occur in earlier stages of HIV infection, thereby preceding the marked wasting and malnutrition that accompany later stages of the infection. It has been found that even as life expectancy increases with antiretroviral therapy (ART), age-related comorbidities now contribute to the main burden of disease associated with HIV infection. These comorbidities have been reported to occur regularly among HIVinfected individuals, thereby resulting in conditions associated with nutritional deficiencies that are typically seen in the elderly and in middle-aged HIV-infected individuals. This suggests that age decline occurs independent of chronological age in the HIV-infected individuals. These observations have led to the conclusion that HIV infection accelerates the biological aging process. Therefore, aging in HIV infection is a multifactorial process involving complex interplay of biological and non-biological constructs which may differ depending on the socioeconomic and nutritional statuses of HIV individuals. The prolonged nutritional deficiencies with chronic coinfections and exposures to more toxic antiretroviral drugs constitute risks to people living with HIV and AIDS [24]. However, evidence has shown that patients who enrolled in food supplement intervention while on treatment regimens self-reported greater adherence to their medications, fewer side effects, increased weight gain, recovery of physical strength and the resumption of labor activities. Therefore, promoting sound feeding practices is one of the strategies to ensure good health for people living positively with HIV and AIDS.

#### **2.1 Nutrition for sustainable development**

Ideally, good nutrition lays the foundation for healthy and productive environments for people living positively with HIV infection. Well-nourished HIV individuals are more resistant to diseases and crises, and can perform their daily duties better than those that are poorly nourished. This shows that well-nourished HIV persons are better able to participate in and contribute to the development of their communities. Therefore, the benefits of good nutrition for people living positively with HIV act as the "glue" binding together and supporting their contributions to various facets of a nation's development, especially now that there is a global recognition that good nutrition is the key to sustainable development. Specifically, the objective of Goal 2 of the 2015 Sustainable Development Goals (SDGs) aims to "end hunger, achieve food security, improve nutrition, and sustainable agriculture" and thereby promote good health. Therefore, good nutrition is more than just about ending hunger: it also includes achieving many SDG targets, such as ending poverty, achieving gender equality, ensuring healthy lives, promoting lifelong learning, improving economic growth, building inclusive societies and guaranteeing sustainable consumption of quality foods. This will reduce inequalities among persons living with HIV and make sure that guidelines on appropriate feeding are available to all, including those with limited access to health care services. Convinced that it is now time for governments in developing countries to renew their commitment to protect and promote optimal feeding that will guarantee good health for persons living with HIV and AIDS.

**69**

having these in the diet:

*Basic Principles of Nutrition, HIV and AIDS: Making Improvements in Diet to Enhance Health*

The level of total intake (diet plus supplements) for all nutrients that would guarantee optimal health for persons living with HIV should be clearly emphasized to achieve normal plasma nutrient values since persons living with HIV and AIDS appear to require nutrient intake in multiples of the recommended dietary allowance (RDA) for vitamins A, E, B6, B12, iron, zinc and others. Therefore, effective program for nutritional supplements may be beneficial in maintaining adequate plasma nutrient levels for persons living with HIV and AIDS. This means that the biochemical measurements of nutrient status, dietary history, anthropometry, clinical signs or symptoms that will show nutritional excesses or deficiencies among persons living with HIV and AIDS should be regularly done to ascertain their health statuses since provision of nutritional supplements acts as an adjunct to ART. Though studies have identified the fear of persons living with HIV developing too much appetite but not having enough to eat as the major obstacle to their non-acceptance of nutritional supplements, it should be emphasized that this obstacle should not preclude the provision of adequate dietary supplements to improve both adherence and prognosis to those living positively with HIV and AIDS [25, 26]. Therefore, the need to increase and integrate nutritional supplements into ART programs to improve adherence and

maximize the benefits of therapy should not be underestimated.

guarantee optimal health for HIV-positive persons should include:

• a diet high in vegetables, fruits, whole grains and legumes

• limited sweets, soft drinks and foods with added sugar

• 25 calories per pound if there is loss of body weight

• 100–150 grams a day, if an HIV-positive man

• 80–100 grams a day, if an HIV-positive woman

• proteins, carbohydrates and a little good fat in all meals and snacks

• 17 calories per pound of the body weight so as to maintain body weight

Specifically, the HIV-positive individuals should be encouraged to add foods rich in calories. Foods rich in calories will provide the body with fuel to maintain lean body mass. To get enough calories, they need to consume the following in these proportions:

• 20 calories per pound of the body weight if an opportunistic infection has occurred

Protein will help to build the muscles and organs and guarantee strong immune system for HIV-positive persons and should be consumed in enough quantity. To get the right proportion and types of protein, HIV-positive persons should aim at

• If there is kidney problem, more than 15–20% of the calories from protein should not be consumed. This is because too much of such calories will put

stress on the kidney and thereby compromise kidney function.

• lean and low-fat sources of protein

This means that the principles of healthy eating for HIV-positive persons to ensure sustainable development will require that all the necessary food nutrients are added in the daily meals and in the right proportions. Therefore, meals that will

*DOI: http://dx.doi.org/10.5772/intechopen.84719*

#### *Basic Principles of Nutrition, HIV and AIDS: Making Improvements in Diet to Enhance Health DOI: http://dx.doi.org/10.5772/intechopen.84719*

The level of total intake (diet plus supplements) for all nutrients that would guarantee optimal health for persons living with HIV should be clearly emphasized to achieve normal plasma nutrient values since persons living with HIV and AIDS appear to require nutrient intake in multiples of the recommended dietary allowance (RDA) for vitamins A, E, B6, B12, iron, zinc and others. Therefore, effective program for nutritional supplements may be beneficial in maintaining adequate plasma nutrient levels for persons living with HIV and AIDS. This means that the biochemical measurements of nutrient status, dietary history, anthropometry, clinical signs or symptoms that will show nutritional excesses or deficiencies among persons living with HIV and AIDS should be regularly done to ascertain their health statuses since provision of nutritional supplements acts as an adjunct to ART. Though studies have identified the fear of persons living with HIV developing too much appetite but not having enough to eat as the major obstacle to their non-acceptance of nutritional supplements, it should be emphasized that this obstacle should not preclude the provision of adequate dietary supplements to improve both adherence and prognosis to those living positively with HIV and AIDS [25, 26]. Therefore, the need to increase and integrate nutritional supplements into ART programs to improve adherence and maximize the benefits of therapy should not be underestimated.

This means that the principles of healthy eating for HIV-positive persons to ensure sustainable development will require that all the necessary food nutrients are added in the daily meals and in the right proportions. Therefore, meals that will guarantee optimal health for HIV-positive persons should include:


Specifically, the HIV-positive individuals should be encouraged to add foods rich in calories. Foods rich in calories will provide the body with fuel to maintain lean body mass. To get enough calories, they need to consume the following in these proportions:


Protein will help to build the muscles and organs and guarantee strong immune system for HIV-positive persons and should be consumed in enough quantity. To get the right proportion and types of protein, HIV-positive persons should aim at having these in the diet:


*Nutrition and HIV/AIDS - Implication for Treatment, Prevention and Cure*

failed or there is lack of tolerance for HAART regimens [23, 24].

health for people living positively with HIV and AIDS.

**2.1 Nutrition for sustainable development**

good health for persons living with HIV and AIDS.

shown that this level of weight loss can predict mortality and infectious complications in individuals with AIDS and that reduction in a body mass index to <20 kg/

 in a 6-month period should be used as an index of wasting among HIV and AIDS clients when intervening for malnutrition. Because of the uncertainty as to which of these definitions given above should be adopted as the standard definition of wasting for intervention, the three presented criteria are now being used. Therefore, weight loss and wasting continue to be common problems for individuals infected with HIV as well as for those treated with HAART in whom either HAART has

Studies have been done to determine whether specific nutrient abnormalities occur in earlier stages of HIV infection, thereby preceding the marked wasting and malnutrition that accompany later stages of the infection. It has been found that even as life expectancy increases with antiretroviral therapy (ART), age-related comorbidities now contribute to the main burden of disease associated with HIV infection. These comorbidities have been reported to occur regularly among HIVinfected individuals, thereby resulting in conditions associated with nutritional deficiencies that are typically seen in the elderly and in middle-aged HIV-infected individuals. This suggests that age decline occurs independent of chronological age in the HIV-infected individuals. These observations have led to the conclusion that HIV infection accelerates the biological aging process. Therefore, aging in HIV infection is a multifactorial process involving complex interplay of biological and non-biological constructs which may differ depending on the socioeconomic and nutritional statuses of HIV individuals. The prolonged nutritional deficiencies with chronic coinfections and exposures to more toxic antiretroviral drugs constitute risks to people living with HIV and AIDS [24]. However, evidence has shown that patients who enrolled in food supplement intervention while on treatment regimens self-reported greater adherence to their medications, fewer side effects, increased weight gain, recovery of physical strength and the resumption of labor activities. Therefore, promoting sound feeding practices is one of the strategies to ensure good

Ideally, good nutrition lays the foundation for healthy and productive environments for people living positively with HIV infection. Well-nourished HIV individuals are more resistant to diseases and crises, and can perform their daily duties better than those that are poorly nourished. This shows that well-nourished HIV persons are better able to participate in and contribute to the development of their communities. Therefore, the benefits of good nutrition for people living positively with HIV act as the "glue" binding together and supporting their contributions to various facets of a nation's development, especially now that there is a global recognition that good nutrition is the key to sustainable development. Specifically, the objective of Goal 2 of the 2015 Sustainable Development Goals (SDGs) aims to "end hunger, achieve food security, improve nutrition, and sustainable agriculture" and thereby promote good health. Therefore, good nutrition is more than just about ending hunger: it also includes achieving many SDG targets, such as ending poverty, achieving gender equality, ensuring healthy lives, promoting lifelong learning, improving economic growth, building inclusive societies and guaranteeing sustainable consumption of quality foods. This will reduce inequalities among persons living with HIV and make sure that guidelines on appropriate feeding are available to all, including those with limited access to health care services. Convinced that it is now time for governments in developing countries to renew their commitment to protect and promote optimal feeding that will guarantee

**68**

m2

Also, lean meat such as pork, beef, skinless chicken, fish and low-fat dairy products should be consumed. To get extra protein, there is need to add vegetable proteins such as legumes, nuts, vegetables and others. For carbohydrates which will give energy, HIV-positive persons should eat the right types and proportions of carbohydrates by:


Fat will provide extra energy. For HIV-positive persons to get enough of the right kinds of fat for energy, the following should be observed:


Omega-3 fatty acids are essential fats that must be present in the diet of HIVpositive individuals. Consuming these healthy fats that the body cannot produce unlike other fats has important benefits for the HIV persons' body and brain. However, most HIV-positive people whose meals are mainly made up of standard Western diet end up not eating enough omega-3 fats. Omega-3 fatty acids are polyunsaturated fats that the body needs but cannot produce on its own. For this reason, omega-3 fatty acids are classified as essential fatty acids. There are basically three important types of omega-3 fatty acids that are beneficial to the health of HIV-positive individuals. The first is eicosapentaenoic acid (EPA). This is a 20-carbon-long chain omega-3 fatty acid, primarily found in fatty fish, seafood and fish oils. EPA is important in the formation of signaling molecules like eicosanoids that will reduce inflammation. EPA is effective in protecting HIV persons against depression. The second type of omega-3 is docosahexaenoic acid (DHA). DHA is a 22-carbon-long chain omega-3 fatty acid primarily found in fatty fish, seafood, fish oils and algae. The main role of DHA is to serve as a structural component in cell membranes, particularly in the nerve cells of the brain and eyes. DHA constitutes about 40% of the polyunsaturated fats in the brain. DHA is very important during pregnancy and breastfeeding. It helps in the development of the nervous system

**71**

*Basic Principles of Nutrition, HIV and AIDS: Making Improvements in Diet to Enhance Health*

of the fetus. Breast milk contains significant amounts of DHA. The third type of omega-3 is alpha-linolenic acid (ALA), an 18-carbon-long chain omega-3 fatty acid found in high-fat plant foods like flax seeds, cotton seed, walnuts and others. Though it is the most common omega-3 fatty acid found in the diet, it is not very active in the body. ALA needs to be converted to EPA and DHA before it can be active. Unfortunately, only about 5% of ALA gets converted to EPA and as little as 0.5% will be converted to DHA. For this reason, HIV-positive persons' consumption of omega-3 fatty acids should consist mainly of EPA and DHA than ALA. Most of

Omega-3 fatty acids have both negative and positive effects when consumed in certain proportions. On the positive side, omega-3 fatty acids have several health benefits in various body systems. For example, studies have shown that omega-3 supplements will significantly lower blood triglycerides. Consuming foods such as salmon, sardines, cod liver oil and others that contain enough amounts of omega-3 has been linked to reduced risk of colon, prostrate and breast cancers. Taking omega-3 fatty acid supplement helps to reduce excess fat in the liver. Consuming omega-3 supplements like fish oil helps to reduce symptoms of depression and anxiety. Inflammation, pain and other symptoms of autoimmune diseases such as in rheumatoid arthritis have been reduced using omega-3 supplements. Omega-3 has been found effective in controlling menstrual pains and in preventing asthma in children and young adults. DHA if taken during pregnancy and breastfeeding has been found to improve the intellectual and eye development of the child. Studies have linked a higher intake of omega-3 to a reduced risk of Alzheimer's disease and dementia. However, for optimal health, mainstream health organizations like the World Health Organization and European Food Safety Authority recommend a minimum of 250–500 mg combined EPA and DHA each day for healthy adults. The American Heart Association recommends eating fatty fish at least two times per week in order to ensure optimal omega-3 intake for heart disease prevention. For pregnant and breastfeeding women, it is recommended to add an additional 200 mg of DHA to the recommended intake. On the negative side, consuming more than the upper limit of omega-3 fatty acid will have adverse health effects. According to food and drug agencies (FDA), taking up to 2000 mg of combined EPA and DHA per day from supplements will be safe, but in high doses, omega-3 fatty acids can cause blood thinning and excessive bleeding. Therefore, care should be taken in the consumption of omega-3 if an individual has a bleeding disorder or is taking blood-thinning medications. It has been shown that some omega-3 supplements, especially fish oil, can cause digestive problems and unpleasant fish oil burps because many omega-3 supplements are high in calories. For example, cod liver oil is very high in vitamin A, and can be harmful when taken in large doses. The bottom line is that taking up to 2000 mg of omega-3 per day from supplements is safe according to the FDA, but anything more than this is classified as lethal. The fact remains that getting enough omega-3 fatty acid is not difficult when one eats fishes. For instance, when one consumes salmon, one gets 4023 mg per serving (EPA and DHA). For cod liver oil, one gets 2664 mg per serving (EPA and DHA); for sardines, 2205 mg per serving (EPA and DHA); for anchovies, one gets 2338 mg of ALA per serving; for chia seeds or cotton seeds, one gets 2338 mg of ALA per serving; and for walnuts, 2542 mg of ALA per serving. Consuming other foods that are high in EPA and DHA such as fatty fish, meat, eggs and dairy products from grass-fed or pasture-raised animals and other common plant foods high in the ALA such as soya beans, hemp seeds, walnuts, spinach and Brussels sprouts can be deleterious to health. However, excess omega-3 in the body

*DOI: http://dx.doi.org/10.5772/intechopen.84719*

the ALA eaten is simply used for energy [27–29].

*2.1.1 Health effects of omega-3 fats*

#### *Basic Principles of Nutrition, HIV and AIDS: Making Improvements in Diet to Enhance Health DOI: http://dx.doi.org/10.5772/intechopen.84719*

of the fetus. Breast milk contains significant amounts of DHA. The third type of omega-3 is alpha-linolenic acid (ALA), an 18-carbon-long chain omega-3 fatty acid found in high-fat plant foods like flax seeds, cotton seed, walnuts and others. Though it is the most common omega-3 fatty acid found in the diet, it is not very active in the body. ALA needs to be converted to EPA and DHA before it can be active. Unfortunately, only about 5% of ALA gets converted to EPA and as little as 0.5% will be converted to DHA. For this reason, HIV-positive persons' consumption of omega-3 fatty acids should consist mainly of EPA and DHA than ALA. Most of the ALA eaten is simply used for energy [27–29].
