barbara scott, mph, rd november 3, 2019€¦ · level, finances, family and culture, health,...

2019 Autumn Update

HIV Nutrition and Chronic Disease Management

HIV, Nutrition and Chronic Disease Prevention and

Management

Barbara Scott, MPH, RD November 3, 2019

Learning Objectives

• Discuss the impact of nutrition intervention onChronic Disease Management • Describe the specific macronutrient and

micronutrient needs of people living with HIV • Recognize the role of a Registered Dietitian on the

medical team

Learning Objective 1:

Discuss the impact of nutrition intervention on chronic disease

management


2019 Autumn Update 1

2019 Autumn Update


Chronic (Non-Communicable) Disease – In General

•“Reaching Epidemic Levels” •Deadly: Accounting for ~70% of all premature deaths

•Prevalent: About half of all Americans have at least one chronic condition, and

1/3rd have two or more conditions

•Expensive: 20% of US GDP, 75% of health care spending and rising

•2015 $3.2 trillion •2018 $3.7 Trillion •2030 estimates as high as $6 trillion

•Includes CVD, Stroke, Diabetes, HTN, Cancer, Respiratory Disease &

their complications (kidney disease, blindness, lost productivity, etc.)

•Most causative/risk factors are potentially preventable or modifiable:tobacco use, obesity, low physical activity, excessive alcohol use, etc.

Chronic Disease in HIV

• Good news: ART has significantly increased survival for HIV+ adults in the US. Average life expectancy = HIV-

•Bad news: •HIV+ persons on ART more likely to develop chronic

disease or experience “early aging” than HIV-individuals.

•One study of Medicaid-enrolled PLWH: 75% of patients had at least 1 chronic condition and 25% had 5 or more conditions.

•In this era of highly effective treatment, HIV is emerging as a “cusp” disease – communicable AND chronic.

Risk Factors for Chronic Disease in HIV

•Traditional Risk Factors are the same: smoking, alcohol or other substance abuse, obesity, poor diet, low activity, etc.

•HIV Specific Risk Factors: • Chronic exposure to medication toxicities

(especially in older patients) • Chronic underlying immune activation/

inflammation, hypercoagulability, frailty phenotype •Questions:

•If there are there distinct aspects of HIV disease that alter the biology of aging in some fundamental manner, will diet or other lifestyle interventions be effective in lowering chronicdisease burden in PLWH?

•Do we need different interventions?



2019 Autumn Update


Evidence is Strong for Dietary Interventions in Chronic Disease in

the General Population

•Effective and Affordable • Prevention • Treatment and management

Many studies show effectiveness of interventions in different populations

• All ages • All ethnicities • Different locations (resource poor/resource rich,

urban/ rural) • Across different chronic diseases (CVD, diabetes, HTN,

etc.)

Many Different Types of Interventions Have Been Shown to Be Effective to Some Extent

• Community Level (Public Health) • School Based • Clinic Based • Individual counseling • Group interactive sessions • Telehealth: telephone, email messaging • Phone Apps



2019 Autumn Update


However….

• Chronic disease is on the rise, costing more each year, affecting more people…. • So in spite of the studies showing effective intervention

models, we obviously have a long way to go. • The general medical care system is still primarily designed

for acute care, but some changes are underway to address (and pay providers for) prevention, team-based care, multiple visits, telehealth, etc.

HIV clinics and care delivery systems may actually be best prepared to address chronic disease for our patients.

Given the lack of evidence for lifestyle and nutrition modification in PLWH, we still can forge ahead and apply evidence-based interventions from other patient populations!!



2019 Autumn Update


g j

Describe the specific macronutrient and

micronutrient needs of people living with HIV

Short Answer:

•Their nutritional needs aren’t any differentfrom HIV- individuals •BECAUSE: •Every person is unique and the HIV+population is heterogeneous



2019 Autumn Update


Goals of Chronic Disease Intervention Are the Same: HIV+ or HIV-

• Effective Self Management • Prevent complications • Increase years of health • Optimize quality of life • Increase patient knowledge (including self

knowledge) • Decrease use of health care system and decrease

costs

However, our patients may have some unique challenges that

help inform & guide interventions:

Many of our patients have…

•Lower educational levels •Lower health literacy

These patients may not benefit fromusual patient education efforts.



2019 Autumn Update


You have just been diagnosed with type

2 diabetes.

Your doctor advises you to watch your diet, stay under 50 grams of carbohydrate per meal, and read the nifty handout you are given on….

•Diet •Exercise •Medication •Monitoring



2019 Autumn Update


You go home and start reading food labels. You are trying to figure out how much carbohydrate you willget if you eat 2 slices of this bread.

A. 15 grams B. 20 grams C. 30 grams D. 10% E. 20% F. Too much

What skills, strengths, qualities, abilities, resources did you need to be able to answer the question correctly?

Many of our patients have greater needs

• Poorer emotional well being • Limited social support • Lower income and fewer resources • More disability/poorer physical functioning




2019 Autumn Update


ronic disease mana ement c

Many of our patients have more food insecurity

• Less access to safe, nutritionally adequate, affordable foods • PLWH who are food insecure have poorer mental and

physical well-being that pose additional challenges to ART adherence • Being food insecure carries its own stigma in addition to

that of HIV


Ch g an be really complicated, requiring new skills, motivation, support,

practice, changes in long standing habits, additional expenses, etc!

Keys to Success in Chronic Disease

Self-Management • Health Literacy – the ability to obtain, understand and apply medical information

• Numeracy – the ability to effectively usenumbers in everyday life

• Self-efficacy, motivation, empowerment • Social support networks



2019 Autumn Update


Learning Objective 3:

Recognize the role of a Registered Dietitian Nutritionist (RD/RDN) on the medical team

Evidence is strongest

•For RD/RDN delivered dietary interventions •Nutrition education •Medical Nutrition Therapy



2019 Autumn Update


What’s the difference between a dietitian and a

nutritionist?

All registered dietitians are nutritionists, but not all nutritionists are dietitians.

• RD = Registered Dietitian = RDN = Registered Dietitian Nutritionist • LD = (State) Licensed Dietitian (must be an RD) • Other degrees are good but don’t indicate the same scientific

background or level of clinical training (MS, MPH, PhD, etc.) • Many RDs also have other certifications like CDE (diabetes

educator), sports nutrition, nutrition support, etc. • Bottom line: look for RD or RDN



2019 Autumn Update


RDs are trained to help patients in many ways….

Start at the Beginning…

• Help “translate” what the doctor said and explain lab work. E.g. Why is extra weight bad for your heart? What is high cholesterol? • Talk about and clarify understanding of basic

concepts. • Help patients identify success – know what they

are aiming for and what they stand to gain from making changes.

Help Set and Describe Short & Long Term Goals for Success



2019 Autumn Update


Example: Short Term Control your blood glucose

•Hour to hour, day to day: What should the numbers be on your meter? •Focus mainly on Carbohydrate • How much? • What kind? • How often?

Dietary Goals…Long Term Live a Long, Healthy, Full Life

• Month to Month, Year to Year: Control your blood pressure,your weight, your cholesterol…. • Expanded Dietary Focus • Calories and Fat • How much? • What kind?

• Overall dietary quality • Vitamins and minerals • Fiber • Variety and Balance

RD can help assess a patient’s current diet.

How does it compare to the diet that will helpwith preventing or managing disease?



2019 Autumn Update


RD can help with individualizing recommendations for change: .

Considering patient’s readiness to change, food preferences, age, activitylevel, finances, family and culture, health, medicines, nutrition needs.….

RD can help build knowledge and skills…

• Teach dietary information in small, manageable amounts over time. • Start with pointers for achieving short term management goals

first and move to long term goals later. • Demonstrate and recommend tools that patients can use to

become good self-managers over time.

RD can Help Patients Identify Challenges or Barriers to Success

• Are they ready to change? Are they prepared for changes? • Are they in control of what, when, where they eat? • Are they conscious of how they eat now? What they are doing

really well? What improvements are needed? • Can they use nutrition facts panel and list of ingredients when

choosing foods to buy? Do they know where to go for more information? • Can they cook? Do they have experience eating healthy foods?



2019 Autumn Update


RD can Assess Patient’s Food Security Status

•There are food pantries in town that provide emergency food bags to families. In the past 6months or so, about how often have your or your family received food from a food pantry? • Never • A few times • Once a month • Once a Week

•People sometime get extra help from friends or relatives to help out with food. In the past 6months or so, about how often have you received help for food from a friend or relative? • Never • A few times • Once a month • Once a Week

•People sometimes run low on food by the end of the month. In the past 6 months or so, about how often have you run low on food? • Never • A few times • Once a month • Once a Week

•People sometimes eat less than they normally would to be sure there is enough food for their children or others in the household. In the past 6 months or so, about how often has this happened for you? • Never • A few times • Once a month • Once a Week

RD can Assess Patient’s Physical Status: Baseline and Change Over

Time • Weight and BMI • Waist Circumference • Body Composition • Hand Grip Strength • Blood Pressure

RDs Provide Practical Nutrition Tips • Focus on what you can eat. Goal is a tasty, healthy diet that you

love! • Self Monitor: • Keep a food or activity record. • Use phone or online apps.

• Increase Knowledge: • Use the nutrition facts panel and list of ingredients when choosing foods

to buy. • Learn portion sizes. • Learn how to decrease calories from obvious sources like goodies, snacks

& beverages. • Learn to separate fact from fiction.



2019 Autumn Update


RDs Provide Practical Nutrition Tips

• Plan Ahead. • Make shopping lists, • Look at restaurant menus ahead of time, • Volunteer to bring something when going to friends for

dinner, etc. • Take control: • Eat at home more often. • Pack lunch & snacks to take to work. • Have healthy foods readily available.

RDs Provide Practical Nutrition Tips

• Cook more…get in the kitchen. •Make cooking a creative activity and a good way to

spend quality time with family and friends. •Practice basic cooking skills. •Learn where to get healthy recipes from Internet,

library, etc. •Try out different solutions…don’t get discouraged.

RDs can provide hands-on teaching and experiences:



2019 Autumn Update


Food as Medicine, Culinary Medicine:Cooking and Tasting

• Healthy Fruits and Veggies: Go for color and variety—dark green, yellow, orange, blue, purple, black and red. • Whole Grains: Try some new ones like brown rice,

quinoa, bulger; Use a rice cooker • Lower Fat options: Steaming vs frying, different

seasonings • Healthy Beverages

Learning to Identify Portions

Going grocery shopping

• How to get the healthiest foods for the lowest cost • Identifying new foods and suggesting ways to

prepare them • Using the unit pricing information • Avoiding temptations



2019 Autumn Update


Recommending Supplements

•Based on … • Dietary restrictions (food allergies/intolerances;

strong food preferences); • Clinical evidence and Lab work • Possibly on food insecurity or other lifestyle risk

factors

Refer for Food Resources

•Food Pantry •Food Stamps/SNAP •Provide low cost shopping lists •Recommend recipes for low cost foods

Looking at Good Informaiton Resources…

•www.choosemyplate.gov

• forecast.diabetes.org/food-recipes •www.diabetes.org

•www.heart.org

•www.fooducate.com

•www.eatright.org

•www.nvdiabetes.org



http://www.choosemyplate.gov/

http://forecast.diabetes.org/food-recipes

http://www.diabetes.org/

http://www.heart.org/

http://www.fooducate.com/

http://www.eatright.org/

http://www.nvdiabetes.org/

https://www.eatright.org

https://www.heart.org

https://www.diabetes.org

2019 Autumn Update


In order to do all these great things, RDs need:

• Respect: equal member of the medical team • Early Referral: don’t wait until things are really bad • Time: at least 45 minutes for initial visit, then 30 minutes for follow

ups • Return visits in phases: bi-weekly, monthly, quarterly • Space: very posh, fancy office (not the broom closet); group room • Resources: for handouts, food, kitchen • Flexibility: to work in the office, at the grocery story, make home

visits • Payment: old models of fee for service vs newer payment for

outcomes or per patient per month more effective for chronicdisease management

Thank You For Your Attention!



barbara scott, mph, rd november 3, 2019€¦ · level, finances, family and culture, health,...

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