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Program Manager, Care Services Division County of Los Angeles Department of Public Health Office of AIDS Programs and Policy August 29, 2006Los Angeles County: Los Angeles County Square Miles: 4,086 Population: 9.9 Million Latino/a 45.7% White 31.0% Asian/PI 13.2% African-American 9.7% Native American 0.3% Proportion of California Population: 29% Proportion of California AIDS Cases: 35% Living with HIV/AIDS: 58,000 (Estimated) 2HIV Nutrition Essentials: HIV Nutrition Essentials Overview Current nutrition issues and treatments Medical nutrition therapy (MNT) program necessary ingredients Lessons learned monitoring Los Angeles County medical outpatient services’ MNT programsHIV Nutrition Essentials: HIV Nutrition Essentials Handout Materials Presentation slides Guides and resources Diet, nutrition, fact sheets Professional competency Weight & nutrition HIV nutrition screen & referral forms ADA 2005 Nutrition quick screen Request copies of handouts: MFenton@ladhs.org HIV Nutrition Essentials: HIV Nutrition Essentials Current HIV Nutrition Issues HIV MNT: HIV MNT Overall Goals Optimize nutrition status, immunity and quality of life Prevent nutrient deficiencies Achieve and maintain optimal body weight and composition Manage co-morbidities Maximize effectiveness of medicationsVicious Cycle of Malnutrition and HIV: Vicious Cycle of Malnutrition and HIV Source: Fanta Project www.fantaproject.org Adapted from RCQHC and FANTA 2003HIV Nutrition Issues: HIV Nutrition Issues Poor Immune Function Food and water safety, sanitation Optimized nutrient and fluid intake Vitamin mineral supplementation Exercise: aerobic and progressive resistance training Medication adherence Stress reduction Establishment of trusting relationshipsNutrition Issues and Treatments: Nutrition Issues and Treatments Common Side Effects GI distress Diarrhea Nausea/vomiting Gas Anorexia Fatigue Taste alterations Mouth pain Anemia Hyperlipidemia Insulin resistance Hypertension Liver toxicity Renal impairment Obesity Lipodystrophy Peripheral neuropathy CancerCauses of Weight Loss: Causes of Weight Loss 1-Inadequate Intake Oral and upper gastrointestinal Anorexia Psychosocial-economic Malabsorption Source: Mangili A et al. CID 2006:42 (15 March) p 836-42Causes of Weight Loss: Causes of Weight Loss 2-Altered Metabolism Uncontrolled HIV infection Metabolic demands of HAART Opportunistic infections or malignancies (AIDS-defining conditions) Hormonal deficiencies (testosterone or thyroid) Cytokine dysregulation Source: Mangili A et al. CID 2006:42 (15 March) p 836-42Resting Energy Expenditure: Resting Energy Expenditure Grunfeld et al. AJCN 1992;55:455-60.Impact of Viral Load on Resting Energy Expenditure: Impact of Viral Load on Resting Energy ExpenditureHIV Wasting: HIV Wasting Definitions CDC Nutrition for Healthy Living (Tufts) Grinspoon, Mulligan & DHHS Working Group Polsky, Kotler & Steinhart Calories Needed and Weight Change: Calories Needed and Weight Change Relation to Viral Load Not on HAART 0.92 kg body weight decrease per each HIV RNA log10 increase 22 Kcal increase in REE per increase in per 1-log copy/ml Stable HAART 0.35 kg body weight decrease per each 100-cell/mm3 CD4 cell decrease 81 kcal higher REE Source: Wanke et al. CID 2006:42 (15 March)Outcomes of Weight Loss: Outcomes of Weight Loss Morbidity and mortality independent of CD4 and viral load Weight loss of >5% associated with increase risk of mortality even with ART Adverse pregnancy outcomes Weight loss & wasting continue to be common problemsInternational Nutrition: International Nutrition Feeding Safely and Adequately Access to nutritious food Access to safe water Malnutrition Linked with HIV infection Linked with poor prognosis Linked with poor prognosis despite ART Breast feeding Access to HIV medicationsOverweight, Obesity and HIV: Overweight, Obesity and HIV Sources: (1) Amorosa et al. JAIDS 2005;Aug15;39(5):557-61. (2) NHANES 1999-2000; www.cdc.gov 7/03Weight Classification Using BMI: Weight Classification Using BMI (1) National Heart, Lung and Blood Institute, (2) Magili et al. CID 2006 March, (3) Amorosa; Grinspoon, Mulligan & DHHS Working Group 2003 April-S CIDConditions Associated with Obesity: Conditions Associated with Obesity Obesity Hyperlipidemia Heart Disease Stroke Hypertension Gout Non-Insulin Dependent DM Osteoarthritis Mood Disorders Sleep Disorders Eating Disorders Some Cancers Gall Bladder BMI: HIV vs. General Populations Contemporary Diagnosis and Management of Obesity. Geroge A. Bray, MDDesirable Girth Measurements: Desirable Girth Measurements Waist circumference Men: <40 inches Women: <35 inches NHANES methodology Waist to Hip Ratio? Less accurate Not recommended Hip circumference ok Monitor waist & hip from baselineOverweight, Obesity & HIV: Overweight, Obesity & HIV Fuel of Metabolic Abnormalities BMI positive correlation with Total cholesterol Triglycerides Glucose Obesity not correlated with Age, income, employment, education Past/current IVD use HIV treatment, viral load Source: Amorosa et al. JAIDS 2005;Aug15;39(5):557-61.Treatment of Obesity: Treatment of Obesity Therapeutic Lifestyle Changes Nutrition counseling Dietary intake Limit saturated fats Increase fiber to 35 g/day Portion control Reduce excess carbohydrates and high sugar drinks Plenty of fruits and vegetables Small meals: maximum 5 hours apart Eat slowlyTreatment of Obesity: Treatment of Obesity Therapeutic Lifestyle Changes Physical activity Walking or other exercise 30-60 minutes/day Progressive resistance trainingHIV and Diabetes Mellitus: HIV and Diabetes Mellitus An Increasing HIV Nutrition Problem HIV-positive men who are taking highly active antiretroviral therapy (HAART) are more than four times more likely to develop diabetes than HIV-negative men. HIV-positive women taking protease inhibitors are three times more likely to develop diabetes than HIV-positive women on non-protease inhibitor combinations or HIV-negative women Sources: Brown TT et al. Antiretroviral therapy and the prevalence and incidence of diabetes mellitus in the Multicenter AIDS Cohort Study. Arch Intern Med 165: 1179-1184, 2005. Justman JE et al. Protease inhibitor use and the incidence of diabetes mellitus in a large cohort of HIV-infected women. Journal of Acquired Immune Deficiency Syndromes, 32: 298 – 302, 2003Diabetes Major Risk Factors: Diabetes Major Risk Factors General Population Overweight, obesity Especially VAT Parent or sibling Ethnicity Alaska Native, American Indian, African American, Latino American, Asian America Inactivity Exercise <3x/wk History of impaired glucose tolerance or impaired fasting glucose Hypertension Cardio-vascular disease Polycystic ovarian syndromeDiabetes Additional Risk Factors: Diabetes Additional Risk Factors HIV Population Medications leading to insulin resistance HAART Steroids, growth hormone, others HCV co-infection Morphological changes Lipodystrophy: > visceral adipose tissue Physical inactivity Neuropathy, fatigue avascular necrosis, wasting, etc.Heart Disease Prevalence: Heart Disease Prevalence General Population Leading cause of death in the U.S. Women: 51% of heart disease deaths Men: 340,933 died from heart disease in 2002 57 million Americans live with CVD 8.9% all white men 7.4% black men 5.6% Mexican American men 1. National Center for Health Statistics. Health, United States, 2005 with Chartbook on Trends in the Health of Americans. Hyatsville, MD: 2005. 2. American Heart Association. Heart Disease and Stroke Statistics—2005 Update. Dallas, Texas: American Heart Association, 2005.Heart Disease Major Risk Factors: Heart Disease Major Risk Factors General Population Increasing age Gender Heredity, family history of premature heart disease Overweight/obesity High blood pressure Tobacco use Hyper- or dyslipidemia Especially high LDL & low HDL Diabetes Metabolic syndrome Physical inactivity Poor nutrition An atherogenic diet Source: Preventing chronic diseases: Investing wisely in health preventing heart disease and stroke. July 2005. CDC. February 6, 2006. http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/cvh.htmHeart Disease Risk Factors: Heart Disease Risk Factors HIV Population Inflammation due to HIV Lipid abnormalities due to HAART Other drug effects: Insulin resistance Morphological changes Metabolic syndrome Heart Disease: Heart Disease Prevention & Treatment Therapeutic Lifestyle Change (TLC) Diet Physical exercise Management of concomitant diseases Diabetes, hypertension, obesity, etc. Smoking cessation Stress reductionLiver Disease: Liver Disease Fueled by Overweight & Obesity Waist>hip, insulin resistance & diabetes Predicts advanced forms of chronic hepatitis C Complicates nonalcoholic steatohepatitis (NASH) Fitness inversely related Tx: Healthy diet, exercise, weight loss Sources: Charlton MR et al. Hepatology June 2006;46(6)1177-1186; Church TS et al. Gastroenterology. 2006 Jun; 130(7):2023-2030.Renal Disease and HIV: Renal Disease and HIV A Growing Nutrition Problem Dialysis HIV: 1.5%, AIDS: 0.4% Dialysis centers treating PLWH/A 1985: 11% 2000: 37% Number initiated since 1995: stable Abnormal kidney function 30% PLWH/A HIV and CKD nutrition guidelines Not set yet IndividualizeHIV Nutrition Essentials: HIV Nutrition Essentials Medical Nutrition Therapy (MNT) Program Necessary Ingredients Continuum of Care: Continuum of Care County of Los Angeles. Continuum of Care, Office of AIDS Programs and Policy. HIV Registered Dietitian: HIV Registered Dietitian Standards of Professional Practice Provides quality service based on client expectations and needs Effectively applies, participates in or generates research to enhance practice Effectively applies knowledge and communicates with othersHIV Registered Dietitian: HIV Registered Dietitian Standards of Professional Practice Uses resources effectively and efficiently in practice Systematically evaluates the quality and effectiveness of practice and revises practice as needed to incorporate the results of evaluation Engages in lifelong self-development to improve knowledge and enhance professional competenceHIV Registered Dietitian: HIV Registered Dietitian Care Responsibility Create screening tools for medical providers to identify clients at risk Monitor nutrition-related abnormal laboratory values Assess clients regularly, consistently Ensure adequate nutrient & caloric intakeHIV Registered Dietitian: HIV Registered Dietitian Care Responsibility With medical team, identify and correct causes of cachexia, weight loss/gain, other nutrition problems and barriers Refer to providers and other disciplines Communicate: document, speak, share Participate in team case conferences Promote continuity of careNCP: Relationship Between Patient/Client/Group & Dietetics Professional - Nutrition Diagnosis Ø Identify and label problem Ø Determine cause/contributing risk factors Ø Cluster signs and symptoms/ defining characteristics Nutrition Assessment Ø Obtain/collect timely and appropriate data Ø Analyze/interpret with evidence - based standards Ø Identify risk factors Ø Use appropriate tools and methods Ø Involve interdisciplinary collaboration Screening & Referral System Outcomes Management Sys tem Ø Monitor the success of the Nutrition Care Process implementation Ø Evaluate the impact with aggregate data Ø Identify and analyze causes of less than optimal performance and outcomes Ø Refine the use of the Nutrition Care Process ADA NUTRITION CARE PROCESS AND MODEL Ø Document Nutrition Monitoring and Evaluation Ø Monitor progress Ø Measure outcome indicators Ø Evaluate outcomes Ø Document Nutrition Intervention Ø Plan nutrition intervention · Formulate goals and determine a plan of action Ø Implement the nutrition intervention · Care is delivered and actions are carried out Ø Documen t Document NCPScreening and Referral : Screening and Referral Screen for Referral Criteria New/re-entry into care, MNT >6 months Medical diagnosis, nutrition status change Physical changes, weight concerns Oral, GI symptoms Metabolic, other medical conditions Barriers to nutrition, living environment, functional status Behavioral concerns, unusual behaviors Source: ADA MNT Evidence Based Guides for Practice, March 2005 Screening and Referral: Screening and Referral Referral Documentation Physician’s order for MNT Signature and date of physician or authorized person to refer for MNT Medical diagnoses and information Current labs and measurements Consent to release medical information Proof of residency, income, diagnosis Source: ADA MNT Evidence Based Guides for Practice, March 2005Nutrition Care Process: Nutrition Care Process ADIME Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring Nutrition Evaluation Documentation: clear and explicitNutrition Care Process: Nutrition Care Process Nutrition Assessment Reason for referral Assess data (ABCD) Anthropometric Biochemistry Clinical Dietary Client inputNutrition Care Process: Nutrition Care Process Nutrition Diagnosis Problem Diagnostic label Intake, clinical, or behavioral/environmental Etiology Cause or contributing risk factors Signs/Symptoms Defining characteristics PES statementNutrition Care Process: Nutrition Care Process Nutrition Diagnosis PES Statement (P) Increased nutrient needs (E) as related to inadequate intake of foods and malabsorption due to AIDS enteropathy (S) as evidenced by 25 pound weight loss in 6 months and now 91% IBWNutrition Care Process: Nutrition Care Process Nutrition Intervention Interventions Food and/or Nutrient Delivery Nutrition Education Nutrition Counseling Coordination of Nutrition Care Receptivity and adherence potential Plan and follow-up dateNutrition Care Process: Nutrition Care Process Nutrition Monitoring Review and measure status of intervention at scheduled time Track outcomes with tools ADA HIV MNT Protocol Progress Note Weight and nutrition flow sheet Electronic health record data fields Format Terminology: diagnosis, interventions, etc Other toolsNutrition Care Process: Nutrition Care Process Nutrition Evaluation Systematic comparisons Reference standards Evaluate changes Signs and symptoms Previous status and intervention goals Progress toward goal HIV MNT Tools: HIV MNT Tools Basics HIV MNT Protocols (ADA,1998) Adult (18 years-adult) Children (under 18 years) Health Care and HIV: Nutritional Guide for Providers and Clients (HRSA/HAB, 2002) Integrating Nutrition into Medical Management of HIV, (CID-S April 1 2003) Nutrition intervention in the care of persons with human immunodeficiency virus. (ADA & Dietitians of Canada Joint Position, 2004)HIV MNT Tools: HIV MNT Tools New: ADA Evidence Analysis Library Systematic review of scientific research Select topic and expert working group Define questions, analytical framework, inclusion and exclusion criteria Conduct literature review per question Analyze articles Complete evidence summaries and tables Draft proposed conclusion statements Reach consensus on conclusion statements and grades (strength and quality of the evidence) Publish to online library (EAL)HIV MNT Tools: HIV MNT Tools New: ADA EAL Current Projects Diseases and conditions Adult weight management Determinants of pediatric overweight Chronic kidney disease (revision) Chronic obstructive pulmonary disease Critical illness Disorders of lipid metabolism (hyperlipidemia revision)HIV MNT Tools: HIV MNT Tools New: ADA EAL Current Projects Diseases and conditions (cont.) Gestational diabetes Gluten intolerance/Celiac Heart failure HIV/AIDS Hydration HypertensionHIV MNT Tools: HIV MNT Tools New: ADA EAL Current Projects Diseases and conditions (cont.) Nutrition in athletic performance Nutrition care in bariatric surgery Oncology Pediatric weight management Spinal cord injury & nutrition Unintended weight lossHIV MNT Tools: HIV MNT Tools New: ADA EAL Current Projects Assessment Estimating energy expenditure Foods Non-nutritive sweetenerHIV MNT Tools: HIV MNT Tools Emerging: HIV Nutrition Evidence Analysis Questions What are the caloric needs of people with HIV/AIDS? What is the evidence to support a particular macronutrient composition of a diet for people with HIV/AIDS? Focus Both children and adults People with HIV/AIDS Past 10 years of researchHIV MNT Tools: HIV MNT Tools New and Emerging Nutrition Care Manual Web based Uses ADA Evidence Analysis Library Evidence-based MNT protocols Evidence-based guidelines ADA position papersReimbursement: Reimbursement MNT, Supplements Medicare Medicaid Managed Care HMOs, Kaiser Permanente RWCAPersonal Professional Competence: Personal Professional Competence Dietetics Professionals’ Ethical Obligation Code of Ethics for the Profession of Dietetics,(6) Standards of Professional Practice,(7) Guided by the nutrition care process Professional Development Portfolio(8) 75 credits every five yearsRyan White CARE Act and MNT: Ryan White CARE Act and MNT Current Status MNT by RD Defined by HRSA guidance Required in Title III services RWCA reauthorization Expected after Labor Day 2006 ADA and others working to get MNT as core medical service AIDS Education Training HIV nutrition training for providersCurrent Procedural Terminology: Current Procedural Terminology MNT CPT Codes 97802 Initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97803 Re-assessment and intervention, individual, fact-to-face with the patient, each 15 minutes 97804 Group (2 or more individuals), each 30 minutesHIV Nutrition Essentials: HIV Nutrition Essentials Lessons Learned Monitoring Los Angeles County Medical Outpatient Services’ MNT ProgramsMonitoring HIV MNT Services: Monitoring HIV MNT Services MNT Program Evaluation Items Screening for nutrition related problems Referral for baseline MNT (06-07) Appropriate referral for MNT MNT provided by an RD MNT documentation (05-06) Outcome: maintain or 5% towards goal weight after 3 months of care (07-08) RD qualifications Monitoring MNT Programs: Monitoring MNT ProgramsAccess to MNT: Access to MNTChanging Practices and Attitudes: Changing Practices and Attitudes Establishing the Framework for MNT Wheels of change move slowly Develop infrastructure Standards of care, guidelines, contracts Indicators, monitoring tools, reports MNT services: disparity in clinics Providers, program managers, funding Awareness, interpretation and abilities Expectations, goal setting, reporting, accessChanging Practices and Attitudes: Changing Practices and Attitudes Technical Assistance: Providers and RDs Provider meetings, calls, emails Provider and staff presentations At each year’s program monitoring Different and evolving TA focus Always provide materials Ex: HRSA Nutrition Manual CD, screening & referral forms, articles, standards of care, BMI chart, nutrition & weight flow chartChanging Practices and Attitudes: Changing Practices and Attitudes Technical Assistance: RDS Dietitians in AIDS Care (DIAC) DIAC listserve Quarterly meetings since April 2005 Networking – long-lasting relationships Training and problem solving Nutrition care process When to provide/discontinue: nutritional supplements, food / meal services Hyperlipidemia, insulin resistance, renal diseasePersonal Growth: Personal Growth Lessons Learned More medical records reviewed Monitoring tools - streamlined and tally / comments sheets Increase time spent monitoring Evaluation report of MNT programs Establish ongoing database Baseline knowledge of programsScreening for Nutrition Problems: Screening for Nutrition Problems Lessons Learned Newton’s laws of motion Providers’ resistance Problems? Don’t look and you won’t find Screening vs. referring Defining “at risk” Make it easy to look, think, document Simple questions workHeight and Weight Measurements: Height and Weight Measurements Lessons Learned Routine measurements needed Height not always measured Weight usually measured Accuracy questionable on both Who measures? How trained? Shoes? Calibration of scales? Stadiometer? Monitoring weight Adding/subtracting usually not done BMI not usually done Graphing not doneReducing Barriers to MNT: Reducing Barriers to MNT Lessons Learned Reducing broken appointments Set appointments with client Coordinate with primary care visit Reminders and follow-up calls and letters Document in medical record Support MNT in clinic Include, discuss and referral from start Incentives and rewards for MNT visit Ask/respond to client request for MNTNeeded: Proactive Healthy Clinic: Needed: Proactive Healthy Clinic Lessons Learned Take responsibility and power Educate & support staff: promote: Nutrition and health knowledge Clients’ food, nutrient and safety needs Change the menu and food/ water safety practices for client and non-client events Meetings, parties, fund raisers, vending machines, vouchers, board meetings, holidays, etc.HIV Nutrition Essentials: HIV Nutrition Essentials What has been your experience? What has worked well? What has been a challenge?Acknowledgments: Acknowledgments Arcy Martinez RD AltaMed Health Services Corporation Audra Gustafson RD Northeast Valley Health Corporation Tammy Darke MS RD St Mary Medical CARE Program Jill Strejc MS RD SRD UCLA Caren Ongjoco RD CNSD Los Angeles County Harbor-UCLA Medical Center Jan B King MD MPH OAPP Medical DirectorFor Additional Information: Marcy Fenton, M.S., R.D. Program Manager, Care Services Division Office of AIDS Programs and Policy 600 South Commonwealth Avenue 2nd Floor Los Angeles, California 90005-4001 Phone: 213/351-8368 Fax: 213/738-6566 E-mail: firstname.lastname@example.org This presentation is available at www.LAPublicHealth.org/AIDS For Additional Information You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.