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04 July 2003

Problems that interfere with good nutrition

HIV/Aids may make it difficult to eat and digest food properly. Symptoms such as poor appetite, diarrhoea, nausea and mouth sores are often the result of immune system suppression, opportunistic infections and treatment side-effects.

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HIV/Aids may make it difficult to eat and digest food properly. Symptoms such as poor appetite, diarrhoea, nausea and mouth sores are often the result of immune system suppression, opportunistic infections and treatment side-effects. You can often manage these problems, however, by making some simple changes to your diet, as outlined in the sections below:

Poor appetite
Unwanted wieght loss (wasting)
Constipation
Diarrhoea
Gas and bloating
Lactose intolerance
Fatigue
Mouth and throat soreness
Dry mouth
Problems with fat digestion
Taste changes

Poor appetite
When you don't feel like eating, the following tips may help stimulate your appetite and maintain good nutrition:

  • Eat your favourite foods, or those with a strong flavour. Experiment with adding herbs and spices.
  • Six to eight small meals, every couple of hours, are easier to handle than three large meals a day.
  • Keep tasty, nutritious snacks on hand to nibble on throughout the day. Good snack ideas: fruit, nuts, yoghurt or dessert cups, cheese and biscuits, peanut butter.
  • Sip high-energy protein shakes (available from most pharmacies, health-food stores and supermarkets) or high-energy drinks such as milk or drinking yoghurt.
  • Pure fruit juice contains less bulk than whole fruit, but provides the same energy: half a glass of juice equals about one fruit portion.
  • Try sipping a little diluted lemon juice to stimulate your appetite.
  • Avoid too much high-fat food, which tends to make you feel full and lessen your appetite for later meals. High-fat foods include: fried foods, baked goods like doughnuts, fatty meats, full-cream milk products, snack foods like potato chips and fast foods like hamburgers. (That said, however, it's fine to eat high-fat foods occasionally, especially if they can tempt a dull appetite.) See Problems with fat digestion for tips on how to cut down on dietary fat.
  • Avoid alcohol - it suppresses appetite and causes nutrient loss.
  • Stress can reduce appetite, so try to relax, especially before and during mealtimes. Make mealtimes pleasant by eating with friends, for example, or playing background music.
  • Make food visually appealing, perhaps by adding garnishes or using attractive dishes and table settings.
  • Smells can affect appetite. For example, the aroma of baking bread can stimulate appetite, while that of greasy cooking may suppress it.
  • Remember that exercise improves appetite, so stay as active as possible.
  • Ask your doctor whether appetite stimulant medication would help in your case. Many of the tips under Unwanted weight loss also apply to poor appetite.

Unwanted weight loss (wasting)
Unwanted weight loss (wasting) is common in Aids patients.

  • Include high-calorie foods (e.g. desserts, cakes, sweet biscuits) and drinks like home-made milkshakes and liquid supplements.
  • Protect against muscle loss with protein-rich foods such as milk, milk products, meat, poultry, fish, chicken, eggs and peanut butter. Getting enough protein is especially important if you are below your ideal weight and struggle to maintain lean muscle mass.
  • The following are ideas for increasing the energy and protein content of meals without adding too much bulk. Add:
    • sugar, honey, jam, dried fruit or nuts to cereal
    • avocado, nuts, olives, salad dressing and low-fat cottage or grated cheese to salads and sandwiches
    • vegetable oil or margarine to cooked vegetables, pasta and rice
    • low-fat cheese to fruit and biscuits
    • low-fat milk to soups, puddings, cereals and stews
    • sugar, vegetable oil, peanut butter, egg or fat-free milk powder to soups, gravies, stews, porridge, desserts and drinks
    • powdered supplements to milk, milkshakes, lactose-free milk and juice
    • peanut butter to sauces, shakes, toast, biscuits and celery sticks
    • chopped chicken, low-fat grated cheese or egg to soups, sauces, vegetables, salads and stews
    • protein powder such as soy protein to shakes, juice, mashed potatoes and stews
  • If you are lactose intolerant, replace milk with lactose-free, soy or rice milk.
  • Try adding fat to your diet (if you have no problems digesting it), with butter, margarine, vegetable oil and peanut butter. Apart from being a good energy source, fat often improves the taste and texture of food.
  • Consider taking a multivitamin supplement.
  • Consult your doctor if you lose 2.5 kg or more when you didn't plan to.
  • Many of the tips under Poor appetite also apply to unwanted weight loss.

Constipation
Constipation occurs when you don't have regular bowel movements and you find it difficult to pass stools. Causes of constipation include:

  • side-effects from certain medications
  • not enough fibre in the diet
  • not enough fluid intake
  • lack of exercise
  • stress.
  • Lower-gut infections can also make it uncomfortable to pass stools.

To help manage constipation

  • Drink at least eight cups of fluid (water and other beverages) a day. Prune juice is a natural laxative that often brings relief.
  • Eat foods high in insoluble fibre. Fibre, or roughage, is the part of food that doesn’t get digested by the body, but which helps keep the digestive tract working properly. Insoluble fibre is a type of fibre that passes through the digestive tract easily. It speeds up the movement of food through the gut and produces less dense stools that are easier to pass.

Tips for increasing fibre intake:

  • Eat foods high in insoluble fibre, which include: nuts, seeds, fresh fruits and vegetables, fruit and vegetable peels, dried fruit, fruits with small seeds (berries, figs), prunes and prune juice, seeds, nuts, corn, whole grain breads and cereals, brown rice, bran, wheat germ, dried beans, peas and lentils.
  • Add a little bran to stews, porridge or cereals.
  • Eat more fruit and vegetables raw. Otherwise, steam or bake them only slightly to preserve their fibre.
  • Increase fibre intake gradually over several weeks.
  • Make sure you drink plenty of fluid to help the fibre pass easily through your system.
  • Exercise regularly to strengthen your abdominal muscles, stimulate intestinal movement and reduce stress.
  • Don’t skip meals.
  • Don't resist the urge to pass stools: this can worsen constipation.
  • If the above measures don't provide relief, talk to your doctor about laxatives (medicines that soften the stools and stimulate bowel movements). Generally, however, it is best to avoid laxatives, as they cause loss of water and essential salts.

Diarrhoea

Several different factors can cause diarrhoea, including medications, infections, food poisoning, emotional stress and food intolerance. Sometimes the cause is unknown. Diarrhoea can cause dehydration (loss of water and essential salts) and reduces the gut's ability to absorb nutrients. Repeated episodes of diarrhoea can lead to protein-calorie malnutrition, which may itself cause diarrhoea. Thus it's very important to keep up your fluid and nutrient intake when you have diarrhoea, as follows:

    Replace fluids and salts:

    • Drink at least eight cups of fluid per day, between rather than with meals. In addition to water, include drinks such as soup, fruit juice (especially apple, pear, peach, apricot and grape) and sports drinks.
    • Eat mineral-rich foods to replace lost salts such as sodium and potassium. Potassium-rich foods include fruit (such as bananas, grapefruit, potatoes, oranges, melons, tomatoes, grapes, pineapples, apricots and peaches), as well as meat and milk products.
    • Consider taking a vitamin-mineral supplement.
  • Avoid caffeine (in coffee, tea, chocolate and sodas), which over-stimulates the gut.
  • Avoid alcohol, which causes water loss through increased urination.
  • Limit foods high in insoluble fibre (see Constipation), which can irritate the gut.
  • Choose foods that are high in soluble fibre and easily digested, including: oatmeal; stewed or pureed fruits and vegetables without peels or seeds (pears, apples, peaches, apricots, mangoes, paw-paws); ripe bananas; fruit segments with the membranes removed (orange, grapefruit); mashed potatoes; white bread, rice and pasta; cream of wheat; ready-to-eat cereals; cooked porridge or pap.
  • Reduce fat intake: high-fat foods can irritate the gut. (See tips onreducing dietary fat under Problems with Fat Digestion). Remember, however, that fat is a good energy source, and you shouldn't banish it from your diet completely unless absolutely necessary.
  • Lactose intolerance can cause diarrhoea, so avoiding milk products could improve symptoms.
  • Six to eight small meals are easier to digest than three large ones.

If diarrhoea persists longer than a few days, seek medical advice: you might have an infection. Your doctor may think it is necessary to prescribe anti-diarrhoeal medication.

Gas and bloating
Causes of gas and bloating include physical changes in the gut, emotional stress, and certain foods and medications. To help manage gas and bloating:

  • Eat smaller meals more regularly.
  • Avoid gas-forming foods such as beans, cabbage, broccoli, cauliflower, onion and fizzy drinks.
  • Avoid spicy foods such as curry.
  • Avoid fried or greasy food.
  • Wait a couple of hours after a meal before lying down.
  • Avoid alcohol, coffee, peppermint and chocolate.
  • Don't smoke.
  • Try to relax, especially during meals. Eating and drinking while stressed may cause you to swallow air and may interfere with digestion.
  • Eat slowly and chew well.
  • Sip drinks slowly - don't gulp - especially when swallowing pills with water.
  • Avoid chewing-gum, which may cause you to swallow air. Sugar-free gum containing sorbitol can cause diarrhoea and gas.
  • You may be lactose intolerant, a condition which can cause gas and bloating. If you are, reducing your intake of milk products may relieve symptoms.

Lactose intolerance
Some people with HIV infection are partially or totally lactose intolerant i.e. the gut has difficulty digesting lactose, the sugar in milk. This is because of a deficiency in the enzyme lactase, which is needed to break down lactose. Symptoms include diarrhoea, gas and bloating.

If you're not sure whether or not you are lactose intolerant, try cutting out milk products (including low-fat dairy products; milk powder; ice-cream; and drinks, soups or desserts containing milk) from your diet to see if symptoms improve.

To help manage lactose intolerance:

  • Lactase-treated milk, or lactase supplements, can aid milk digestion. Ask your pharmacist, doctor or nutritionist where you can get these products.
  • Sour or fermented milk products such as yoghurt and buttermilk are often better tolerated, since some of the lactose is already broken down in these foods.
  • Hard cheeses such as parmesan may be better tolerated than soft ones.
  • Read labels on foods, supplements and medicines if you are extremely lactose intolerant, to make sure they don't contain milk or lactose.
  • Combining milk with other foods can improve tolerance.

Fatigue
Fatigue can interfere with nutrition in that sometimes you may feel too tired to cook, or even to eat proper meals. To deal with this:

  • Rest as much as possible, and don't tire yourself with food preparation. Ask for help from family and friends to assist with cooking or buying groceries. HIV/Aids support groups can sometimes help with home care and food parcels.
  • Freeze extra portions and leftovers for when you're too tired to cook. Keep stores of canned and frozen foods, which need little preparation.
  • Choose high-energy, easy-to-eat foods that require no preparation, such as bananas, avocados, yoghurt and nuts.
  • Convenience foods, take-aways and food delivery services are fairly expensive, but can be a help during times of fatigue.
  • Tell your doctor if fatigue persists; it may be related to a treatable underlying condition, such as anaemia.

Mouth and throat soreness
Common causes of mouth and throat soreness in people with HIV/Aids include gingivitis (gum inflammation), mouth ulcers and Candida (thrush). Mouth and throat soreness can lead to decreased appetite and food intake, and poor dental hygiene. To help manage this problem:

  • Choose soft, moist foods, such as soup, mashed potato, minced meat, creamed vegetables, pasta, custard, pudding and ice-cream. Mash, mince or liquidise food.
  • Avoid spicy, salty, sticky foods that are difficult to swallow; dry, rough or hard foods like potato chips; fizzy drinks; and sour foods and juices like tomato, pineapple and citrus fruits. These may irritate mouth sores and the mouth and throat lining.
  • Use more herbs and less salt and spices to season food.
  • Soften toast and biscuits by dipping them in milk, tea or soup.
  • Moisten cooked food with gravy, sauce and butter or margarine.
  • Avoid very hot food.
  • Rinse your mouth often with cool water. Avoid commercial mouthwashes that contain alcohol or other irritants.
  • Sip soothing beverages like cold drinks and milk; try using a straw.
  • If brushing your teeth hurts, rinse your mouth with bicarbonate of soda mixed with water.

Dry mouth
Certain medications and treatments decrease saliva production, which results in a dry mouth. This makes eating and swallowing difficult, can cause dental problems, and may dull your sense of taste. To manage a dry mouth:

  • Rinse your mouth with warm, salted water.
  • Moisten your mouth with fluids, frozen yoghurt, pudding or ice.
  • Avoid dry, rough foods.
  • Avoid sweet, sticky foods. Too much sugar can dry out your mouth and damage your teeth.
  • Moisten dry lips with lip balm.
  • Ask your doctor or pharmacist about artificial saliva products.
  • To stimulate saliva production
    • suck sugar-free sweets
    • add lemon to beverages
    • dilute juices and soups
  • Ask your doctor or pharmacist about artificial saliva products.

Problems with fat digestion
People with HIV infection sometimes have problems with fat digestion, most often in the case of severe gut infection in late-stage Aids. To cut down on dietary fat:

  • Avoid fried foods, bacon, sausage, fatty cold meats, butter, margarine, mayonnaise, oil, peanut butter, cream, creamy sauces and cheese.
  • Use low-fat or fat-free milk and milk products
  • Choose lean meat, tuna canned in water, cut visible fat off meat and remove chicken skin.
  • Bake, boil or steam instead of frying.

Decreased fat intake reduces calories, so you may need to eat more of the other food types to maintain your weight.

Taste changes
Medication side-effects, poor nutrition and infections may affect your sense of taste, so that some familiar foods taste strange. To help manage taste changes:

  • If red meat tastes bitter, choose other protein-rich foods such as cheese, eggs, chicken, fish, yoghurt and peanut butter.
  • Try eating high-protein foods cold.
  • Use lemon juice, herbs, spices, onion, garlic, vanilla or cinnamon to add flavour.
  • Brush and floss your teeth regularly.

 
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