[pronut-hiv] Nutrition of PLWHA

["Salome Kruger" <VGEHSK@puknet.puk.ac.za>]

Nutrition of PLWHA
Dr HS Kruger
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Nutritionists agree that nutritional problems should be managed by
offering the best foods available.  The foods available, however, are
not always nutrient dense enough to provide the necessary nutrients,
especially for sick people.  In the dry North West Province of South
Africa, where I live and work,  vegetables are scarce and expensive for
low-income households.  All households cannot make vegetable gardens,
because they have to fetch water from a remote water source, and/or the
stand they live on may have rocky soil or clay - difficult to dig and
plant in.  For AIDS patients in such households nutrient supplements
from local companies or abroad are necessary to enrich their diets of
mainly staple foods: maize meal, bread (so far not generally fortified
with vitamins and minerals in SA), sugar, oil and tea.  Feeding schemes
provide mainly dry products (easy to store and distribute in large
quantities), such as maize meal, sugar, oil and tinned food.  Poor
people buy vegetables as often as they can afford these, but it is still
not sufficient to provide enough vitamin A, C and most of the B-vitamins
for sick members of the family.
You will notice that sugar is one of the foods mostly available in most
households and also provided by feeding schemes helping PLWHA.  Can we talk about sugar again?  The average sugar intake of black adults in the
North West Province is approximately 50-60g/day (MacIntyre et al., 2002)
and for children aged 10-15y mean sugar intake ranges between 30-45g/d
(Kruger, 2003).  Should nutritionists advise the feeding schemes not to
provide sugar to PLWHA and should nutritionists advise the patients not
to use sugar?   We have to consider the need to have an adequate energy
intake by eating what is available and affordable, as well as possible
problems associated with sugar intake.
For people living on a monotonous low-energy diet consisting of mainly
maize meal, taking the sugar away will  cause  even lower energy intake,
associated with wasting.  Less palatable food will not help people with
anorexia to have an adequate energy intake.  Wasting is the loss of
muscle when there is not enough energy from food to provide for the
energy requirements of the body.  Eating carbohydrate food is known to
be protein-sparing.  If enough energy is provided from carbohydrates and
fat, the body can use the dietary protein to restore body protein. 
Scientists agree that reduced energy intake is the most important
determinant of weight loss in HIV-associated wasting (Macallan et al.,
1995).
Will sugar impair immune function?  Studies done in the 1970s (Sanchez
et al., 1973; Bernstein et al., 1977) indicated depression of lymphocyte
transformation following oral glucose ingestion.  This finding is used
in the lay press to advise people to stay away from sugar.  I think
nutritionists as scientists should rather keep themselves up to date
with scientific reading material, written by nutrition specialists and
peer reviewed by fellow scientists, such as Chandra (1991 and 2002) and
Scrimshaw &Giovanni (1997). These authors, as well as Macallan (1999)
agree that the most important factor is nutrition support: providing
sufficient macro- and micronutrients which can result in improvements in
immune function and NOT taking all sugar out of the diet.   A South
African study (Robson, 2000) showed that athletes, known to have an
increased susceptibility to infection during intensive training, 
experienced an attenuation of suppression of the immune system on a high
carbohydrate diet.  The carbohydrate feeding was in the form of
sweetened drinks (mixtures of sugar, glucose, fructose,
oligosaccharides).  I do not say that all HIV-infected patients are
athletes, but that under circumstances of immunosuppression, sugar and
other carbohydrates did not suppress, but helped the immune system.
How much sugar can PLWHA eat daily?  In a Prize Medal Lecture, dr Derek
Macallan (Macallan, 1998) of London explained that insulin sensitivity
is actually increased in HIV-infected individuals.  This means that
their ability to handle carbohydrates is improved.  On the other hand,
fat metabolism is deranged.  This means that the HIV-infected person can
utilize carbohydrates (sugar and complex carbohydrates) for energy
better than fats.   At the levels of sugar intake of poor households in
SA, it would be unwise to advise to reduce sugar intake, because if they
eat less or no sugar, they will have to increase the intake of oil. 
Patients treated with some types of HAART, however, experience
side-effects of increased blood glucose, which may cause glucose
intolerance and necessitate low intake of simple sugars and more complex
carbohydrates in the diet.
Will sugar intake cause or aggravate diarrhoea?  Patients with diarrhoea
for more than a few days showed changes in the structure of their
intestines and deficiency of enzymes necessary to digest sugar and
lactose (milk sugar).  In a quarter of patients tested enzyme
deficiencies were sufficiently severe to advise withdrawal of lactose
and probably sugar (Taylor et al., 2000).  Small sips of rehydration
solution (sugar and salt-mixture) will probably be tolerated by most
patients with diarrhoea, but in severe cases sugar may be replaced by
glucose, especially in children.
Can sugar cause or aggravate Candida infection?  Another story****this
message is long already!
All references available on request.   

Dr HS Kruger
Associate Professor 
School of Physiology, Nutrition and Consumer Science
Potchefstroom University for CHE
2520 Potchefstroom South Africa
Tel 027-18-299-2482 Fax 027-18-299-2464

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