Your diet and HIV

Good nutrition supports the entire immune system and improves the immune response to everyday infections and the healing process. Prior to the development of effective treatment diet and nutrition played a vital role in keeping people living with HIV well and to help support the immune system in the absence of effective treatment.

The same is true today, but for different reasons. For the majority of people, prompt diagnosis and the use of effective treatment means the importance of diet and living well with HIV may not appear to be obvious. Whilst everyone can benefit from making changes to diet there are some specific areas where it might be important for people living with HIV to consider making changes to their diet, which we expand upon below.

Return to health

Prior to diagnosis the immune system and the whole body has to work hard to keep HIV under control, which for many people increases their daily energy requirement. Over time this can mean a gradual loss in weight. Starting treatment allows the immune system and the body to return to near normal functioning and there is a return to health. A good diet that is well balanced has an important role to play in the return to health.

• As with any recovery from illness the body undergoes a state of repair. This requires a good balance of the major food groups (carbohydrate, protein and fat) together with those vitamins and minerals that promote and aid the repair process
• Vitamin and mineral supplements aren’t generally required by the majority of people post diagnosis, although there can be situations where iron and vitamin B supplementation may be required where there are deficiencies
• The calories we consume each day may need to change after starting treatment. Some people find they gain weight quite quickly, which in itself is often a good sign, as it suggests the immune system repair and wider recovery is underway
• Some people find the return to health effect results in an unexpected increase in body fat. This can be the case where there has been a loss in muscle tissue. Managing your diet, calorie intake and daily activity after starting treatment can help prevent this unwanted increase in body fat
• For some people weight gain due to an increase in body fat can become problematic. Changes of this type are different to those seen with lipodystrophy, which was caused by older drugs. Unexpected changes in body fat may require further investigation with your clinic team in the first instance
• Ongoing low weight can also be a problem for some people which may require specialist help from a dietician, or further investigation by your clinic team

Food absorption and other changes

HIV can impact on the function of the digestive system and change how well food is digested and absorbed. This can result in vitamin and mineral deficiency and in some cases cause weight loss over time. This is often seen prior to starting treatment but can persist to a lesser extend over time. It’s important to stress that many people don’t experience any difficulties with food absorption, or other changes outlined below. It can be helpful to be aware of the impact HIV may have on food absorption and metabolism.

• Some people find there can be a change to bowel habit, which may be either HIV related, or a side effect of some drugs used to treat HIV. Changes to diet can often help improve things, but may require some experimentation
• It is possible for food intolerances to develop or become more pronounced due to HIV. An allergy to particular foods is an immune response, which can be brought about by HIV related immune activation. Identifying food intolerances can be difficult, but they often respond well to changes in the diet
• There is some evidence that HIV related inflammation may impact on the way fat cells store and release fats for the body to use as an energy source. For some people it is possible this mechanism may make it more difficult to maintain a healthy weight, and may require additional diet and exercise help and support
• It is also possible that some people living with HIV may have difficulty absorbing fat which can lead to deficiencies in fat soluble vitamins (A, D, E and K) and also contribute to feelings of bloating and change in bowel habit. Keeping an eye on the fat content of your diet and including natural oils and fats (oily fish, olive oil) can help improve these symptoms
• Some people experience a lack of energy at times, regardless of how long they’ve been living with HIV. This may be linked to changes in food absorption, or poorer absorption of some vitamins and mineral, particularly B vitamins, which are essential for energy release. Making changes to diet might be more beneficial than taking a vitamin supplement, although this should be guided by clinical advice
• Iron deficiency (anaemia) can also be a cause of tiredness. Vitamin C is needed to help the body absorb iron and increasing foods rich in both iron and vitamin C may help improve a feeling of tiredness
• Moving to a more balanced diet and ensuring you eat at regular times throughout the day can help improve energy levels. Little and often or ‘grazing’ tends to even out the peaks and troughs in energy levels and may improve digestion and absorption

Being more aware of what you eat and making small changes to your diet can really help offset and in many cases help prevent some of the difficulties people living with HIV may encounter either as a result of HIV or your treatment.

Treatment

Starting or changing treatment can often improve some of the difficulties highlighted above, although there can be short-term gastrointestinal side effects for the first few weeks after commencing treatment. Some drugs are also known to have an impact on blood fats such as cholesterol and triglycerides, which can sometimes be offset by changes in diet.

Food plays an important role in the correct absorption of some treatment options and can also reduce the impact of side effects such as nausea and a feeling of bloating. It is often a case of experimenting with type and amount of food taken alongside medication to improve these side effects. Here are some further points to consider:

• Treatment combinations that include rilpivirine, (Eviplera, Odefsey, Juluca) need to be taken with a meal of around 400 calories. Where rilpivirine is taken as a separate pill the calorie requirement should be increased to 500 calories
• Some treatment combinations have a requirement to be taken with some food to ensure correct absorption of a particular drug. A light snack is usually sufficient to increase stomach acid which in turn improves drug absorption
• Where treatment options can be taken with or without food some people find it be beneficial to take their medication with food or on an empty stomach. This approach can sometime help to avoid problems such as ongoing nausea or other gastrointestinal side effects
• Some treatment options can increase blood fats such as cholesterol and triglycerides. Cholesterol is often described as good cholesterol (HDL) and bad cholesterol (LDL). Some treatment options increase LDL cholesterol levels and there is some evidence that HIV itself can lower HDL cholesterol
• Making dietary changes such as reducing saturated fats and increasing soluble fibre known as beta glucan (found in porridge oats, barley and other wholegrains) can help reduce levels of LDL cholesterol and restore the balance between LDL and HDL cholesterol
• Maintaining and enhancing levels of dietary calcium may be beneficial for some groups who are at risk of changes in bone mineral density either as a result of treatment with tenofovir, post-menopausal women and those with other risk factors, such as smoking and heavy alcohol use. It’s important to check for drug interactions with supplements that contain calcium and your HIV medication

Nutritional value

• Brightly coloured fruits and vegetable contain antioxidants which may be beneficial when thinking about the effects of HIV related inflammation. Antioxidants can help protect cells from becoming damaged or dysfunctional thereby helping to offset the effect of HIV related inflammation
• Adequate dietary calcium intake has been shown to help reduce blood pressure and moderate LDL cholesterol, helping to lower total cholesterol and the ratio of HDL to total cholesterol. This in turn can help offset any additional cardiovascular risk caused by HIV related inflammation
• Many people living with HIV are deficient in the active form of vitamin D, with some studies showing up to 85% have low levels or a severe deficiency. It is thought HIV related inflammation may interfere with ability of the liver and kidneys to produce the active form of vitamin D known as calcitriol, which may require dietary supplementation
• For the majority of people living in the UK the daily use of vitamin and mineral supplements is likely to have very little health related benefit. There are however some exceptions where levels are low or clinically deficient. Folate (B12), iron and vitamin D supplementation is sometimes recommended, but should be guided by clinical necessity
• Vitamin D supplementation is likely to be more important in Winter months for the general population as well as those living with HIV. Public Health England recommend adults take a daily supplement which includes 10 micrograms of vitamin D. Some vitamin D supplements contain calcium carbonate, so it’s important to check for any interactions with your HIV medication
• Drugs from the integrase inhibitor class (raltegravir, dolutegravir, Triumeq, Stribild, Genvoya and Biktarvy, Juluca, Dovato) are particularly susceptible to interactions with mineral supplements that contain calcium, zinc, aluminium and iron. A separation of around 6 hours is required between taking your medication and taking any supplements that contain minerals

Your diet and understanding nutrition

A balanced diet should include enough carbohydrate, protein, fat and vitamins/minerals to provide sufficient nutrition to meet your daily activity levels, aid growth/repair and ensure your vital organs and hormone systems function properly thereby maintaining your overall health.

What does a balanced diet look like?

The NHS Eatwell Guide is a great source of information which outlines the food groups we should try to eat to achieve a healthy, balanced diet. It also includes information about average calorie intake. The key is to try to achieve balance within your diet over a week. It can be difficult if not impossible to do this for every individual meal or even each day.

Carbohydrate

Carbohydrates are the mainstay food group which the body uses for energy. All foods can be broken down to provide energy, but carbohydrates in particular can be easily broken down into simple sugars (glucose) which all cells in the body need as an energy source to function. Examples of foods rich in carbohydrate include:

• Starchy foods such as potatoes, pasta, rice and bread, which are sometimes referred to as simple carbohydrates
• Cakes, pastries, jam, fruit and fruit juices all contain significant amounts of simple sugars and should be taken in moderation
• Wholegrains, cereals, vegetables, beans and pulses are often referred to as complex carbohydrates as they take longer to be broken down into a form the body can use for energy (glucose)
• Including a balance of simple and complex carbohydrates helps the body regular blood sugar levels and helps maintain our energy levels throughout the day

Protein

Foods rich in protein provide the basic building blocks (amino acids) the body needs for the development, growth and repair of the body tissues, organs and muscles. They are essential for the production of hormones and enzymes which regulate the normal functioning of the body. Proteins are also needed to ensure the immune system can function effectively. Like all foods, protein can be broken down to produce energy where there is an energy deficiency from carbohydrate sources. Examples of foods rich in protein inlcude:

• Meat, fish chicken, eggs and dairy products are all foods that are rich in protein. These are sometimes referred to as complete protein foods as they contain all the essential amino acids the body needs
• Pulses, lentils, cereals, nuts, some fruits and vegetables are examples of plant foods that are also rich in protein. They are sometimes referred to as incomplete proteins as they don’t contain all the essential amino acids the body needs
• Soya protein (derived from soya beans) mycoprotein (derived from fungi) and whey protein (derived from milk) are often the mainstay of vegetarian or plant-based diets and contain high levels of protein gram for gram
• Including protein from different sources adds variety to the diet and can help reduce an over reliance on animal protein

Fat

Foods rich in fat form an essential component of a balanced diet. Fats and foods rich in fatty acids provide the building blocks for the cells in the body and are vital for many processes such as oxygen transportation and hormone production. Fats are essential for the absorption of vitamins A, D, E and K which are known as fat soluble vitamins.

Fatty acids such as Omega-3 and Omega-6 are essential for blood clotting, building cell membranes in the brain and are extremely important in the healing process. Fatty acids can also help prevent stroke and heart attack and can help lower cholesterol. Fat provides a very rich energy source to the body and has over twice the calorie content of carbohydrate and protein gram for gram. For this reason, foods rich in fat, whilst essential should make up a relatively small proportion of total dietary intake. Foods rich in fat include:

• Dairy products such as whole milk, butter and cheese. Visible fat on red meat, fat under the skin of chicken and oily fish such as mackerel, salmon, trout and sardines
• Cooking fats and oils, such as olive oil, sunflower oil, margarine, lard, and foods which are fried or roasted
• Egg yolks, mayonnaise and many thickened sauces and gravies can contain high levels of fat
• Other foods which contain high proportions of fat include, nuts, sunflower, pumpkin, flax seeds, avocado, coconut and coconut oil

Vitamins and minerals

Vitamins and minerals are often referred to as micro-nutrients as they are only needed in small quantities. Micro-nutrients play a very important part in regulating the body and are vital in the release of energy (B vitamins) transporting oxygen in the blood (iron) and keeping our bones strong and healthy (phosphorous, calcium and vitamin D). Vitamin C is essential for the growth and repair of all body tissues, immune function and the absorption of iron.

Minerals such as zinc, magnesium and aluminium, often called trace elements are essential for cellular reactions, energy production and cell transport systems. Foods rich in vitamins and minerals include:

• Iron rich foods include red meat, liver, most green leafy vegetables, spinach nuts, beans, wholegrains, fortified cereals to name a few
• Calcium rich foods include milk, cheese, other dairy products, canned fish where the bones are eaten, green vegetables (broccoli, cabbage, okra) and fortified flour
• Minerals and trace elements are found in foods such as red meat, fish, seafood, vegetables and fruit, cereals, nuts and seeds to name a few
• B vitamin complex and folate rich foods include fortified cereals and flour, fresh/dried fruits, peas, liver, eggs and wholegrain breads
• Vitamin C rich foods include oranges/orange juice, strawberries, blackcurrants potatoes, broccoli, brussels sprouts, red and green peppers
• Vitamin D rich foods include oily fish, red meat, liver, egg yolks and some fortified spreads and cereals. Supplements such as cod liver oil, and other vitamin D tablets or capsules

Other components of a balanced diet

In addition to the main food groups and micronutrients mentioned above, it’s important to include foods that are high in fibre, low in salt, added sugar and saturated fat.

• Saturated fats are generally solid as room temperature and provide a rich source of dietary cholesterol. A diet that contains high levels of saturated fat and cholesterol can increase the risk of heart attack, stroke and other cardiovascular disease. The body can produce all the cholesterol it needs and therefore cholesterol from the diet is not an essential part of a balanced diet. The recommended daily intake of saturated fat should be no more than 20 grams a day for women and 30 grams for men. Making small changes to your diet can really help reduce your daily saturated fat intake. Some HIV medications can increase levels of cholesterol in the blood and therefore keeping an eye on how much dietary cholesterol you consume is important
• Sugar which is added to food provides very little nutritional value. Reducing your dietary intake of simple sugars such as glucose (table sugar) and fructose (sugar found in fruit) has several health benefits. Foods that contain a high proportion of simple sugar or where sugar is added can cause a spike in blood sugar levels, which then increases blood insulin levels. Consuming large quantities of foods high in simple sugars over time can add to the risk of developing obesity and type 2 diabetes. Whilst there is no recommended daily intake for added sugar adults should not exceed 30 grams (5 to 6 teaspoons) a day. It’s worth remembering that many drinks that are marketed as ‘healthy’ may contain high levels of simple fruits sugars. Many processed foods often contain high levels of added sugar to improve flavour and taste
• Salt is an essential part of your diet as it provides the body with sodium which it cannot produce itself. Sodium plays a vital role in the regulation of many bodily functions and is contained in body fluids that transport oxygen and nutrients. Many foods provide a natural source of salt and sodium as it is often added during processes such as curing, preservation and to enhance flavour. Some pre-prepared meals contain high levels of salt, although in recent years food manufacturers have been reducing the amount of salt they add to their products. Keeping your intake of added salt to a minimum can help prevent a rise in pressure, which in turn reduces the risk associated with heart attack and stroke. The recommended daily intake of salt for adults should not exceed 6 grams (teaspoon full). This equates to just under 3 grams of sodium
• Fibre is an important component of the diet as it aids the digestive process, help regulate blood glucose and cholesterol levels. Fibre helps with the movement of food through the digestive tract, which is important for good digestive health. The carbohydrate food group provide the main source of fibre, particularly wholegrains, wholemeal flour, bread and cereals together with some nuts, dried/fresh fruit and vegetables. There is overwhelming evidence that including enough fibre in the diet can help reduce the risk of developing heart disease, stroke, type 2 diabetes and bowel cancer. The recommended daily intake of dietary fibre is 30 grams
• Water is an essential component of each and every cell within the body. Drinking enough water throughout the day to maintain good levels of hydration can sometimes be challenging. Including enough water and other drinks is an important part of achieving a balanced diet, which is an area that is often overlooked. Many drinks, juices and smoothies which are marketed as ‘healthy’ can significantly add to your calorie intake, without adding much in the way of nutritional value as sometimes they contain high levels of simple sugars. The calorie content of alcoholic drinks is also often overlooked, which can significantly increase your daily calorie intake

Here are some ideas to consider when making changes to your diet:

• Plan for the changes you want to make to your diet and prioritise which are the most important. This can be something like reducing sugar intake, increasing healthy snacks, eating fewer fatty foods or increasing the variety of fruit and vegetable in your diet
• Be realistic and set yourself small achievable goals. Successful changes to diet are the ones you can sustain over time
• Avoid making too many changes at the same time. Keep the focus of your plan and then widen out to include any other changes you’d like to make as time goes on
• Think about using a food diary or a nutritional intake app before making any changes to your diet. This can help pinpoint where you can make changes which will have the most impact
• Plan your meals and try to eat at regular times, rather than go for long periods without eating. Make sure you include small snacks between your main meals as this helps even out the peaks and troughs in energy levels, preventing food cravings
• Plan your grocery shopping in advance as this helps make sure you have everything you need at home for your meals and you don’t buy foods that you don’t need
• Review your portion sizes as making small changes at each meal can have a significant impact on your calorie intake over time. Sometimes using a smaller plate can really help reduce portion sizes
• Drink plenty of water throughout the day. Little and often will help keep your body fully hydrated
• Be kind to yourself! If you don’t achieve your daily or weekly goal all isn’t lost, don’t feel guilty just focus on getting back on track

Your calorie intake and energy balance

Not all food groups contain the same amount of energy gram for gram. Having a basic understanding of each food group and their energy content can be helpful to move towards a more balanced approach to your energy intake. We’ve summarised some of the basic information relating to energy intake (calorie intake) and the energy each of the main food groups contain:

• Daily calorie requirement for men = 2500 Kcals
• Daily calorie requirement for women = 2000 Kcals
• Carbohydrate contains 4 calories per gram (400Kcal per 100 grams)
• Protein contains 4 calories per gram (400Kcal per 100 grams)
• Fat contains 9 calories per gram (900Kcal per 100 grams)

As we see from the above, fat is a very concentrated source of energy, and has over twice as many calories as that for carbohydrate or protein. Whilst foods that contain fat are an essential part of a balanced diet, the high calorie content should be considered when thinking about total calorie intake and achieving a good balance of the other major food groups.

Energy balance

The body uses energy obtained from the food and the drinks we consume each day in a variety of ways to keep us alive. Some of the more important areas of energy expenditure include:

• Basal Metabolic Rate (BMR) includes all the body processes that occur when we’re at rest, which includes heat production, brain and major organ functioning, to keep the heart beating. BMR accounts for around 70% of the energy the body needs each day
• Energy required for movement and day to day activities accounts for a further 20% of the energy the body needs each day
• The final 10% of the energy the body needs each day is used to digest and move food through the digestive system
• Any excess energy consumed over the daily requirement is stored by the body in the form of fat under the skin (adipose layer) and sometimes within the body cavity (visceral fat)
• Where there is an energy deficit (less than the daily requirement) body fat and in some situations muscle tissue is broken down to provide the energy the body needs for vital processes and daily activities

Factors that influence your daily energy requirement

We’re all different when it comes to how much energy our bodies require each day. Things which influence this include:

• Genetics – your genetic makeup will greatly influence energy expenditure due to your body type and shape (morphology)
• Gender – this is mostly linked to body composition. Men have a higher proportion of muscle tissue due to the effect of testosterone on the body, whereas women have much lower levels and therefore have a lower proportion of muscle mass
• Age – as we get older, the body uses less energy each day, mainly as a result of reduced muscle mass and daily activity levels
• Weight – daily energy expenditure is influenced by total body weight, particularly in relation to daily activities and exercise
• Illness – the immune system requires more energy when it is fighting infection. In addition, the subsequent tissue repair and the healing process can also temporarily increase energy requirement
• Daily activity – the more active you are, the more calories your body will require each day

Your body composition and weight management

There are several ways to measure body composition and weight. Some methods are more accurate and beneficial than others. Total body weight, whilst a very convenient indicator, doesn’t necessarily provide the best measurement. Body composition plays an important role in the determination of healthy weight on an individual basis. Here are some points to consider in relation to understanding body composition:

• The body is composed of distinct tissue types, these being bone, muscle, body fat and fluids. The measurement of total body weight is unable to distinguish between these different components which is particularly important when thinking about the amount and distribution of fat throughout the body
• The measurement of Body Mass Index (BMI) which is calculated using total body weight and height is a useful tool to help identify health risks such as obesity or being under weight, but may not be the best indicator for the majority of people
• It has now become easier to monitor body composition by a method known as bioelectrical impedance. This method essentially measures how quickly an electrical signal travels through the body. This is the basis upon which some modern weighing scales calculate body composition
• Lean muscle tissue is predominantly composed of water, which helps conduct the electrical signal, whereas fat cells act as an insulator, reducing the conduction of the signal. Other body fluids can also influence the outcome of bioelectrical impedance, and can help identify when the body is dehydrated
• As previously mentioned, lean muscle tissue is metabolically active and burns calories, whereas body fat is by comparison inactive. Increasing lean muscle mass can significantly increase the number of calories burned each day as there is an increase in BMR
• The distribution of body fat throughout the body plays a role when considering the risk associated with cardiovascular and liver disease together with the development of type 2 diabetes. Fat that is stored under the skin, often referred to as the adipose layer, is less of a health risk of fat which is stored within the body cavity, referred to as visceral fat
• A slim, lean body shape, with little fat located in the adipose layer doesn’t necessarily mean there isn’t fat located within the body cavity. The opposite is also true, a fuller body shape where fat located under the skin doesn’t necessarily mean visceral fat is present within the body cavity
• Calculation of waist to height ratio is a simple indicator of visceral fat distribution. It is also considered to be a more helpful measurement than BMI and can identify early onset of weight related health risks
• Calculation of waist to hip ratio can also help identify the distribution of body fat throughout the body and is also an indicator of abdominal fat, which can also predict health risks associated with increases in visceral fat

Here are some points to consider in relation to your weight and HIV:

• Not all weight gain is healthy, particularly where there is an increase in body fat. For some people increasing muscle mass though exercise is an important aspect of the return to health, and is a beneficial aspect of weight gain
• Rebalancing intake of carbohydrate, protein and fat and total calorie intake can really help maintain or move towards a healthier weight. This approach can significantly help offset and additional risk factors and help prevent the onset of other co-morbidities associated with HIV
• Moving towards a more balanced diet which includes plenty of fresh fruits and vegetables ensures the body is provided with sufficient micronutrients such as vitamins and minerals which may be beneficial to help offset the impact of HIV related inflammation
• It may be helpful to monitor your weight to identify the impact different treatment may have, particularly on an increase in body fat. Early intervention in weight gain of this type can be an important factor in the longer term and should be discussed with your clinic team
• Increasing your daily activity level to include activities that help build lean muscle mass can help lift your BMR and daily calorie burn. This approach can be very beneficial as a way of improving your body composition and reduce levels of body fat
• It can be beneficial to take body measurements rather than simply rely on total body weight when moving towards and maintaining a healthy individual body weight. As with everything, it’s the overall trend over time which counts