Zusammenfassung
Der Schwerpunkt einer ernährungsmedizinischen Betreuung von HIV-(human immunodeficiency virus) infizierten Patienten in den westlichen Industrienationen hat sich aufgrund der besseren antiretroviralen Therapiemöglichkeiten (highly active antiretroviral therapy - HAART) gewandelt. Während früher die ernährungsmedizinische Betreuung von HIV-infizierten Patienten durch das so genannte „Wasting-Syndrom” geprägt war, treten jetzt die metabolischen Nebenwirkungen der HAART wie Lipodystrophie, Hyperlipidämie oder gestörte Glukosetoleranz zunehmend in den Vordergrund. Zu den bisherigen Zielen einer Ernährungstherapie, wie Optimierung oder Erhalt des Ernährungszustandes, müssen künftige Empfehlungen für Patienten mit HIV-Infektion die ungünstigen Nebeneffekte der medikamentösen Therapie einbeziehen. Dieser Artikel soll auf die unterschiedlichen ernährungsmedizinischen Therapiemöglichkeiten wie Gewichtsmonitoring und verschiedene Diätregime bei HIV hinweisen und führt auf, wann ein zusätzliches körperliches Trainingsprogramm sinnvoll sein kann.
Abstract
Patients with human immunodeficiency virus (HIV) infection commonly experience a variety of nutritional problems. However, the availability of new highly active antiretroviral therapy (HAART) for the treatment of AIDS decreased the incidence of the wasting syndrome parallel to a decrease in morbidity and mortality. But therapy side effects such as nutritional and metabolic problems of HAART, like hyperlipidemia, fat redistribution and diabetes mellitus, make the use of HAART problematic. In this report we discuss basic dietary and metabolic problems appearing in HAART therapy and provide practical suggestions for their management. This information is intended to raise health care providers' attention to focus on nutritional problems in their patients, including monitoring of weight, dietary issues and relevant symptoms. Additionally we encourage physicians to cooperate with experienced dietitians and exercise trainers.
Schlüsselwörter
HIV-Infektion - Ernährung - Mangelernährung - Ernährungszustand - Stoffwechsel - Therapie
Key words
Acquired immunodeficiency syndrome - nutrition - body composition - metabolism - therapy
Literatur
-
1
Palella F J, Delaney K M, Moorman A C. et al .
Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators.
N Engl J Med.
1998;
338
853-860
-
2
Moore R D, Chaisson R E.
Natural history of HIV infection in the era of combination antiretroviral therapy.
AIDS.
1999;
13
1942
-
3
Wanke C A, Silva M, Knox T A. et al .
Weight loss and wasting remain common complications in individuals infected with HIV in the era of highly active antiretroviral therapy.
Clin Infect Dis.
2000;
31
805
-
4
Süttmann U, Ockenga J, Selberg O, Hoogestraat L, Deicher H, Müller M J.
Incidence an prognostic value of malnutrition and wasting in human immunodeficiency virus-infected outpatients.
J Acquir Immune Defic Syndr Hum Retrovirol.
1995;
8
239-246
-
5
Carr A, Samaras K, Thorisdottir A. et al .
Diagnosis, prediction, and natural course of HIV-1 protease-inhibitor-associated lipodystrophy, hyperlipidaemia, and diabetes mellitus: a cohort study.
Lancet.
1999;
353
2093-2099
-
6
Wanke C A.
Epidemiological and clinical aspects of the metabolic complications of HIV infection: the fat redistribution syndrome.
AIDS.
1999;
13
1287-1293
-
7
Schwenk A, Steuck H, Kremer G.
Oral supplements as adjunctive treatment to nutritional counseling in malnourished HIV-infected patients: randomized controlled trial.
Clin Nutr.
1999;
18
371-374
-
8
Palenicek J P, Graham N M, He Y D. et al .
Weight loss prior to clinical AIDS as a predictor of survival. Multicenter AIDS Cohort Study Investigators.
J Acquir Immune Defic Syndr Hum Retrovirol.
1995;
10
366-373
-
9
Süttmann U, Ockenga J, Schneider H. et al .
Weight gain and increased concentrations of receptor proteins for tumor necrosis factor after patients with symptomatic HIV infection received fortified nutrition support.
J Am Diet Assoc.
1996;
96
565-569
-
10
Bica J, McGovern B, Stone D. et al .
Increasing mortality due to endstage liver diseases in patients with human immunodeficiency virus infection.
Clin Infect Dis.
2001;
32
492-497
-
11
Crawford D H, Shepherd R W, Halliday J W. et al .
Body composition in nonalcoholic cirrhosis: the effect of disease etiology and severity on nutritional compartments.
Gastroenterology.
1994;
106
1617
-
12
Carbonnel F, Beaugerie L, Abou Rached A. et al .
Macronutrient intake and malabsorption in HIV infection: a comparison with other malabsorptive states.
Gut.
1997;
41
805-810
-
13
Knox T A, Spiegelmann D, Skinner S. et al .
Diarrhea and abnormalities of gastrointestinal function in a cohort of men and women with HIV infection.
Am J Gastroenterol.
2000;
95
3482-3489
-
14
Center for Disease Control and Preventing .
1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults.
MMWR.
1992;
41
1-9
-
15
Penerstorfer-Schoen H, Schindler K, Parschalk B. et al .
Beneficial effects of protease inhibitors on body composition and energy expenditure: a comparison between HI-infected and AIDS patients.
AIDS.
1999;
13
2389-2396
-
16
Shevitz A H, Knox T A, Spiegelmann D. et al .
Elevated resting energy expenditure among HIV-seropositive persons receiving highly active antiretroviral therapy.
AIDS.
1999;
13
1351-1357
-
17
Coors M, Süttmann U, Trimborn P, Ockenga J, Müller M J, Selberg O.
Acute phase response and energy balance in stable human immunodeficiency virus-infected patients; a doubly labeled water study.
J Lab Clin Med.
2001;
138
94-100
-
18 American Diatetic Association .HIV/AIDS Medical Nutrition Therapy Protocol: medical nutrition therapy across the continuum of care. Chicago; 1998
-
19
Winnick A, Andrasy R, Armstrong D. et al .
Guidelines for nutrition supports in AIDS.
AIDS.
1989;
5
39-46
-
20 Ockenga J, Schwenk A, Süttmann U. AIDS. In: Lochs H, Lübke H, Weiman A (Hrsg) Leitlinie Enterale Ernährung. Stuttgart; Thieme Verlag 2002
-
21
Ockenga J, Rohde F, Süttmann U, Herbarth L, Ballmaier M, Schedel I.
Ketotifen in HIV-infected patients: effects on body weight and release of TNF-alpha.
Eur J Clin Pharmacol.
1996;
50
167-170
-
22 Ockenga J. AIDS. In: Weimann A, Bischoff SC (Hrsg) Künstliche Ernährung. Enteral - Parenteral. München, Jena; Urban & Fischer Verlag 2001: 109-111
-
23
Selberg O, Suttmann U, Melzer A. et al .
Effect of increased protein intake and nutritional status on whole-body protein metabolism of AIDS patients with weight loss.
Metabolism.
1995;
44
1159-1165
-
24
Rabeneck L, Palmer A, Knowles J B. et al .
A randomized controlled trial evaluating nutrition counseling with or without oral supplementation in malnourished HIV-infected patients.
J Am Diet Assoc.
1998;
98
434-438
-
25
Pichard C, Sudre P, Karsegard V. et al .
A randomized double-blind controlled study of 6 months of oral nutritional supplementation with arginine and omega-3 fatty acids in HIV-infected patients. Swiss HIV Cohort Study.
AIDS.
1998;
12
53-63
-
26
Ockenga J, Bischoff S C, Manns M P.
Management of the human immunodeficiency virus associated Malnutrition.
Gastroenterology International.
1997;
10
81-88
-
27
Melchior J, Salmon D, Rigaud D. et al .
Resting energy expenditure is increased in stable, malnourished HIV-infected patients.
Am J Clin Nutr.
1991;
53
437-441
-
28
Melchior J, Raguin G, Boulier A. et al .
Resting energy expenditure in human immunodeficiency virus-infected patients: comparison between patients with and without secondary infections.
Am J Clin Nutr.
1993;
57
614-619
-
29
Kotler D P, Fogleman L, Tierney A R.
Comparison of total parenteral nutrition and an oral, semielemental diet on body composition, physical function, and nutrition-related costs in patients with malabsorption due to acquired immunodeficiency syndrome.
JPEN J Parenter Enteral Nutr.
1998;
22
120-126
-
30
Wanke C A, Pleskow D, Degirolami P C, Lambl B B, Merkel K, Akrabawi S.
A medium chain triglyceride-based diet in patients with HIV and chronic diarrhea reduces diarrhea and malabsorption: a prospective, controlled trial.
Nutrition.
1996;
12
766-771
-
31
Kotler D P, Tierney A R, Ferraro R. et al .
Enteral alimentation and repletion of body cell mass in malnourished patients with acquired immunodeficiency syndrome.
Am J Clin Nutr.
1991;
53
149-154
-
32
Cappell M S, Godil A.
A multicenter case-controlled study of percutaneous endoscopic gastrostomy in HIV-seropositive patients.
Am J Gastroenterol.
1993;
88
2059-2066
-
33
Brantsma A, Kelson K, Malcom J.
Percutaneous endoscopic gastrostomy feeding in HIV disease.
Aust J Adv Nurs.
1991;
8
36-41
-
34
Dowling S, Kane D, Chua A. et al .
An evaluation of percutaneous endoscopic gastrostomy feeding in AIDS.
Int J STD AIDS.
1996;
7
106-109
-
35
Süttmann U, Selberg O, Müller M J.
Home enteral nutrition in patients with Acquired Immunodeficiency Syndrome.
Clin Nutr.
1993;
12
287-292
-
36
Macallan D C, Noble C, Baldwin C. et al .
Energy expenditure and wasting in human immunodeficiency virus infection.
N Engl J Med.
1995;
333
83-88
-
37
Kotler D P, Tierney A R, Culpepper-Morgan J A. et al .
Effect of home parenteral nutrition on body composition in patients with acquired immunodeficiency syndrome.
J Parenter Enteral Nutr.
1990;
14
454-458
-
38
Ockenga J, Suttmann U, Selberg O. et al .
Percutaneous endoscopic gastrostomy in AIDS and control patients: risks and outcome.
Am J Gastroenterol.
1996;
91
1817-1822
-
39
Ockenga J, Gastell S, Pirlich M, Lochs H.
Tumoranorexie - Tumorkachexie in der Gastroenterologie: Standards und Visionen.
Z Gastroenterology.
2002;
40
929-936
-
40
Fairfield W P, Treat M, Rosenthal D I. et al .
Effects of testosterone and exercise on muscle leanness in eugonadal men with AIDS wasting.
J Appl Physiol.
2001;
90
2166-2171
-
41
Schambelan M, Mulligan K, Grunfeld C. et al .
Recombinant human growth hormone in patients with HIV-associated wasting.
Ann Intern Med.
1996;
125
882
-
42
Caan B, Armstrong M A, Selby J V. et al .
Changes in measurements of body fat distribution accompanying weight change.
Int J Obes Relat Metab Disord.
1994;
18
397-404
-
43
Safrin S, Grunfeld C.
Fat distribution and metabolic changes in patients with HIV infection.
AIDS.
1999;
13
2493-2505
-
44
Vigouroux C, Gharakhanian S, Salhi Y. et al .
Adverse metabolic disorders during higly active antiretroviral treatments (HAART) of HIV disease.
Diab Metabol.
1999;
25
383-392
-
45
Lo J C, Mulligan K, Thai V, Algren H, Schambelan M.
Body shape changes in HIV-infected patients.
J Acquir Immune Defic Syndr.
1998;
19
307-308
-
46
Dong K L, Bausserman L L, Flynn M M. et al .
Changes in body habitus and serum lipid abnormalities in HIV-positive women on highly active antiretroviral therapy (HAART).
J Acquir Immune Defic Syndr.
1999;
21
107-113
-
47
Strawford A, Hellerstein M.
The etiology of wasting in the human immunodeficiency virus and acquired immunodeficiency syndrome.
Semin Oncol.
1998;
25
76-81
-
48
Purnell J Q, Zambon A, Knopp R H. et al .
Effect of ritonavir on lipids and post-heparin lipase activities in normal subjects.
AIDS.
2000;
14
51-57
-
49
Moyle G J, Lloyd M, Reynolds B, Baldwin C, Mandalia S, Gazzard B G.
Dietary advice with or without pravastatin for the management of hypercholesterolaemia associated with protease inhibitor therapy.
AIDS.
2001;
15
1503-1508
-
50
Behrens G, Schmidt H, Meyer D, Stoll M, Schmidt R E.
Vascular complications associated with use of HIV protease inhibitors.
Lancet.
1998;
351
58
-
51
Mercie P, Thiébaut R, Lavignolle V. et al .
Evaluation of cardiovascular risk factors in HIV-1 infected patients using carotid intima-media thickness measurement.
Ann Med.
2002;
34
55-63
-
52
Grunfeld C, Feingold K R.
Metabolic disturbances and wasting in the acquired immunodeficiency syndrome.
N Engl J Med.
1992;
327
329-337
-
53
Markowitz M, Saag M, Powderly W G. et al .
A preliminary study of ritonavir, an inhibitor of HIV-1 protease, to treat HIV-1 infection.
N Engl J Med.
1995;
333
1534-1539
-
54
Berthold H K, Parhofer K G, Ritter M M. et al .
Influence of protease inhibitor therapy on lipoprotein metabolism.
J Intern Med.
1999;
246
567-575
-
55
Thiébaut R, Dabis F, Malvy D. et al .
HIV infection and highly active antiretroviral therapy. Aquitaine Cohort, France.
J Acquir Immune Defic Syndr.
2000;
23
261-265
-
56
Martinez E, Conget I, Lozano L, Casamitjana R, Gatell J M.
Reversion of metabolic abnormalities after switching from HIV-1 protease inhibitors to nevirapine.
AIDS.
1999;
13
805-810
-
57
Thiébaut R, Dequae-Merchadou L, Ekouevi D K. et al .
Incidence and risk factors of severe hypertriglyceridaemia in the era of highly active antiretroviral therapy: the Aquitaine Cohort, France, 1996 - 99.
HIV Medicine.
2001;
2
84-88
-
58
Dube M P, Johnson D L, Curier J S, Leedom J M.
Protease inhibitor-associated hyperglycaemia.
Lancet.
1997;
350
713-714
-
59
Rodriguez-Rosado R, Soriano V, Blanco F, Dona C, Gonzalez-Lahoz J.
Diabetes mellitus associated with protease inhibitor use.
Eur J Clin Microbiol infect Dis.
1999;
18
675-677
-
60
Vigouroux C, Gharakhanian S, Salhi Y. et al .
Diabetes, insulin resistance and dyslipidaemia in lipodystrophic HIV-infected patients on highly active antiretroviral therapy (HAART).
Diab Metabol.
1999;
25
225-232
-
61
Behrens G, Dejam A, Schmidt H. et al .
Impaired glucose tolerance, beta cell function and lipid metabolism in HIV patients under treatment with protease inhibitors.
AIDS.
1999;
13
F63-F70
-
62
Yarasheski K E, Tebas P, Sigmund C. et al .
Insulin resistance in HIV protease inhibitor-associated diabetes.
J Acquir Immune Defic Syndr.
1999;
21
209-216
-
63
Ockenga J, Manns M P.
The impact of body composition analysis in HIV-infected patients: quantifying therapeutic effects.
AIDS.
1999;
13
279-280
-
64
Schwenk A.
Methods of assessing body shape and composition in HIV-associated lipodystrophy.
Curr Opin Infect Dis.
2002;
15
9-16
-
65
Shor-Posner G, Campa A, Zhang G. et al .
When obesity is desirable: a longitudinal study of the Miami HIV-1-infected drug abusers (MI-DAS) cohort.
J Acquir Immune Defic Syndr.
2000;
23
81-88
-
66
Forrester J, Spiegelmann D, Woods M. et al .
Weight loss and body composition in a cohort of HIV-positive men and women.
Public Health Nutr.
2001;
4
743-747
-
67
Anonymous .
Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: executive summary.
J Clin Nutr.
1998;
68
899-917
-
68 Statistisches Bundesamt .Gesundheitsbericht. www.gbe-bund.de. 2002. Ref Type: Internet Communication.
-
69
Schneider R.
Relevanz und Kosten der Adipositas in Deutschland.
Ernährungs-Umschau.
1996;
43
369-374
-
70
Willett W, Dietz W, Colditz G.
Guidelines for healthy weight.
N Engl J Med.
1999;
341
427-434
-
71
Calle E, Thun M, Petrelli J. et al .
Body-mass index and mortality in a prospective cohort of overweight and obesity in adults: executive summary.
N Engl J Med.
1999;
341
1097-1105
-
72
Silva M, Skolnik P, Gorbach S. et al .
The effect of protease inhibitors on weight and body composition in HIV-infected patients.
AIDS.
1998;
12
1645-1651
-
73
Larrson B, Svardsudd K, Welin L. et al .
Abdominal adipose tissue distribution, obesity, and risk of cardiovaskular disease and death: 13 year follow-up of participants in the study of men born in 1913.
Br Med J Clin Res Ed.
1984;
288
1401-1404
-
74
Roubenoff R, Weiss L, McDermott A. et al .
A pilot study of exercise training to reduce trunk fat in adults with HIV-associated fat redistribution.
AIDS.
1999;
13
1373-1375
-
75
Tenzif S, Austin J, Ford P, Robinson G.
A study of the effectiveness of regular exercise on lean body mass, body cell mass and quality of life in people living with HIV/AIDS.
Antiviral Ther.
1999;
4
51
-
76
Fischer T, Schworer H, Ramadori G.
Benign symmetrical lipomatosis („peripheral lipodystrophy”) during antiretroviral therapy of HIV infection.
Dtsch Med Wschr.
1998;
123
1512-1516
-
77
Melroe N H, Kopaczewski J, Henry K, Huebsch J.
Intervention for hyperlipidemia associated with protease inhibitors.
J Assoc Nurses AIDS Care.
1999;
10
55-69
-
78
Dube M P, Sprecher D, Henry K. et al .
Preliminary guidelines for the evaluation and management of dyslipidemia in HIV-infected adults receiving antiretroviral therapy. Recommendations of the adult ACTG cardiovascular disease focus group.
Clin Infect Dis.
2000;
31
1467-1475
-
79
Roubenoff R, Schmitz H, Bairos L. et al .
Reduction of abdominal obesity in lipodystrophy associated with human immunodeficiency virus infection by means of diet and exercise: Case report and proof of principle.
CID.
2002;
34
390-393
-
80
Shevitz A H, Knox T A.
Nutrition in the era of highly activ antiretroviral therapy.
CID.
2001;
32
1769-1775
-
81
Jain G J, Furfine E S, Pedneault L, White A J, Lenhard J M.
Metabolic complications associated with antiretroviral therapy.
Antiviral Ther.
2001;
51
151-177
Dr. med. Johann Ockenga
Medizinische Klinik mit Schwerpunkt Gastroenterologie, Hepatologie und Endokrinologie · Humboldt Universität · Charité
Schumannstraße 20/21
10117 Berlin
Telefon: 030/450514-138
Fax: 030/450514-923
eMail: johann.ockenga@charite.de
