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Chester Myers' Nutrition Series

Information relating to HIV & Nutrition: HIV & Diet revisited

If you are HIV+, then it is extremely important for you to learn about diet and nutrition. The information in these pages is about eating and certain deficiencies of some of the nutrients. Many of the symptoms of HIV are the same as those from nutritional deficiencies - you must make sure you are not deficient in these nutrients.

Good nutrition is extremely important for PHAs, i.e., people who are HIV+ or who have AIDS. The information here deals with only one aspect of good nutrition.

NOTE: Pertinent references, some noted within the text of this document, are included in References for HIV & Nutrition, part of this series INFORMation relating to HIV & Nutrition, or in a database owned by the author.

Malnutrition is a major and early problem in HIV infection. While some people may be undernourished before becoming HIV+, in other cases HIV results in undernourishment (Beach, Baum and co-workers). In addition to malabsorption problems, nutrients such as zinc, selenium and vitamins B6, B12, E and folic acid are likely used faster than others. Deterioration of the small intestine lining may be the earliest result of HIV infection and it often becomes a dominant feature in advanced HIV disease (Batman et al, 1989; Ehrenpreis, 1992; Gazzard, 1992; Grunfeld, Kotler & coworkers; La Brooy, 1993; Laine et al, 1993; Lim et al, 1993; Ott et al, 1993; Schwarz & Greene, 1992; Smith & Mai, 1992; Ullrich et al, 1989; Zangerle et al, 1993). Even if proper digestion has begun in your mouth and stomach, nutrients still may not be fully absorbed from the intestines. Thus diet needs to be adjusted accordingly.

A good multivitamin should be considered. A minimum of 25 mg of vitamin B6, 50 mcg each of selenium and chromium, and no more than 10,000 i.u. of vitamin A could be a rule of thumb in choosing this multivitamin with minerals. In addition, another 50-75 mg of zinc, 400-800 i.u. of vitamin E from a natural source, vitamin B12 by a non-stomach route, and 600-1500 mg of N-acetyl cysteine (NAC) may be useful. [While many studies have documented zinc deficiencies to be common in HIV disease, re-establishment of serum levels can be difficult (Shambaugh, 1989). Several studies with zinc supplementation indicate significant benefit (Gordon, 1992; Libanore et al, 1987; Mocchegiani et al, 1995). One study (Tang et al, 1993) which found a possible association between disease progression and increased levels of zinc intake seems to be an anomaly.]

A preventive approach is better than a treatment approach; i.e., establish and keep adequate nourishment in the earliest stage of HIV infection as possible. Wasting, an internal deterioration of body chemistries that ultimately results in a persistent weight loss that occurs even in the absence of opportunistic infection, seems to result from problems in the body's metabolism. While protein, fat and carbohydrate in your food provide building blocks and fuel for your body, vitamins and minerals are tools that are necessary for your body to use those building blocks. Making sure you are not deficient in these tools should help your body use the building blocks better, and give better resilience if you get an opportunistic infection.

Food - What's in it?
Food supplies energy for physical activity, and for the building blocks of our bodies. The major components are proteins, carbohydrates and fats.

a. Proteins
Proteins are large molecules made from about 20 different amino acids which are small molecules needed by all living things. Several of these, lysine, methionine and cysteine, are easily destroyed in your food by heat and by oxidation during processing and storage. At least methionine and cysteine tend to become low in the body with HIV infection; we don't know yet about lysine. Glutamine is important for gut integrity, and one report indicates it may help maintain glutathione, an especially important antioxidant for the body (Robinson et al, 1992). Eggs are a good source of glutamine and the branched chain amino acids which are important for muscle maintenance.

Our muscles, hair and skin are made of "structural" proteins. Some other proteins are the enzymes that help us digest our food; still others are parts of our immune system. Of special importance is that the immune system needs protein for energy. Without lysine, methionine and cysteine, these proteins cannot be made. When body protein stores decrease, the immune system loses its ability to fight infection.

Sources of protein are red meats, fish, poultry, eggs, nuts, beans, peas, grains and other seeds. Red meat is the only really good source of carnitine, an important tool that your body needs in order to get its energy from fats and some amino acids. Red meat is also a good source of the antioxidant CoEnzyme Q-10. Meats and eggs are good sources of methionine and cysteine.

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Glutathione is an important antioxidant made up of three amino acids including cysteine. It is important for fighting disease and stress. Glutathione is known to be low in PHAs, and low cysteine is the main culprit; supplementing our diet with cysteine in the form of N-acetylcysteine (NAC) has been shown to increase cysteine (de Quay et al, 1992) and improve the performance of other treatments (Feregrino-Goyos et al, 1994). Glutamine may also be important for our glutathione status; it seems that, for now, supplementation at least with NAC is a good route. CAUTION: excess cysteine can be toxic to the central nervous system so it's not wise to take cysteine directly as an individual supplement.

Strict vegetarians need a variety of different cereals and vegetables to avoid deficiencies of lysine, methionine and cysteine. Combinations are better than any one; oats and rice and peas and beans provide reasonable quantities of protein. It's important for strict vegetarians who are HIV-positive to consider supplementation with carnitine.
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b. Carbohydrates
Carbohydrates are large molecules that are built from individual sugars of which glucose is the most common. You need these for energy.

Dietary fibres are types of carbohydrates. For practical purposes, we can consider two types of fibre:
  1. Insoluble fibre is mostly not digested. Some if it provides roughage, controls stool movement, cleanses the intestinal walls, and provides food for the gut bacteria (the "gut flora"). Bran types of insoluble fibre can make diarrhea worse, so should be reduced or avoided when you have diarrhea.
  2. Soluble fibre is often digested, but can also help control stool movement, and it provides a source of food to keep your gut flora happy and growing. Controlling the bile acids in the intestine is an important function of soluble fibre. These acids help you to digest fats.
Good sources of insoluble fibre are grains (that still have the bran part), celery and cooked lentils. Good sources of soluble fibre are apples, bananas, broccoli, Brussels sprouts, citrus fruits, carrots, oats, blackberries, blueberries, loganberries and boysenberries. Beans, peas and flax are good sources of both soluble and insoluble fibre. The fibres in bananas, oats and flax help control both constipation and diarrhea. Berries, and unrefined/unbleached fibre also contain important antioxidants, some even more potent than vitamin C.

Starchy foods such as potatoes, rice and pasta may be the best source of calories for PHAs. Starch is converted in a controlled manner to glucose without causing the immunesuppression that is associated with eating high amounts of sugars such as sucrose or glucose directly (Sanchez et al, 1973). As noted below, obtaining high levels of calories from fats may not be advisable for PHAs.

c. Fats
Fats, or oils, are made up of molecules that are generally simpler and smaller than either the proteins or carbohydrates. Fats are high in calories (energy). They are needed for the many membranes you have in your body.

When serum triglycerides are high, it is likely best to avoid major amounts of fats other than coconut fat. Coconut fat is about 65% medium chain triglycerides (MCTs) which should not contribute to serum triglyceride elevation. MCTs should provide energy even when carnitine is deficient.

Fish, beef, and vegetables all supply fats. There are different ways of naming these fats; one method calls them by the name "omega" (A) and a number. The A-3 fats are found in fish oils, A-6 in vegetable oils, and A-9 in both animal fats and vegetable oils.

Although we must have a low-to-moderate amount of plant polyunsaturated fatty acids, high levels, particularly of the polyunsaturated type in corn and soy oils, are immunosuppressive. Fish and flax oils and coconut fat, on the other hand, have been associated with immune enhancement (Beisel, 1982; Kinsella et al, 1990). High levels of soy, corn, safflower and regular sunflower oils should be avoided since these are immunosuppressive (Bendich, 1990; Chandra, 1991; Hummel, 1993; Kinsella et al, 1990; Stites & Terr, 1991). In the absence of severe diarrhea and high levels of serum triglycerides, fish oils may be an okay type of polyunsaturated fat. Fish oil, because it is polyunsaturated, increases the body's requirements for vitamin E. Of the vegetable oils, olive oil is good and contains oleic acid which has antifungal properties. Also, butter is better than margarine (except for varieties made from olive or canola oils, or margarine made from coconut butter such as in Pacific/Asian countries ). Except in cases of severe diarrhea, coconut fat should be okay for PHAs since it is not immunosuppressive, it should contribute to energy even when the metabolism of other fats becomes defective (likely because of carnitine deficiency), and may even have antiviral activity (Thormar et al, 1987).

If you have HIV infection, there is no reason to restrict fat from your diet in order to lose weight. If blood triglycerides have become higher than normal (for you), then a generally low fat diet may be advisable. Otherwise, a normal-to-low fat intake would seem to be in order (e.g., about 20% of your calories), keeping in mind the above issues so that quality is emphasized. It may help to take extra vitamins C and E and beta (ß) -carotene. These antioxidants help protect you from damage by fat oxidation which tends to be high with HIV infection (Hommes et al, 1991).

Correct fat digestion tends to be poor with HIV. "Futile cycling" of free fatty acids is associated with a tendency for the body to become fatty at the expense of body protein (Grunfeld & Kotler, 1992; Hellerstein, 1992). Several ways to reduce this tendency may be to (i) ensure adequate intake of vitamin C and NAC to encourage the body to make carnitine which you need to burn fat for your energy (instead of your protein stores), (ii) keep red meat, a good source of carnitine, in the diet, (iii) take supplemental carnitine, or (iv) replace some of your fat intake with medium chain length glycerides, usually in the form of purified MCT (medium chain triglycerides from coconut fat) or directly as coconut butter. Your body should be able to use medium chain fatty acids (from the medium chain glycerides) without carnitine.

Our food also contains some materials in small quantities. Most are either vitamins or minerals - very important for your health and necessary for getting energy from proteins, carbohydrates and fats. Vitamins and minerals are also needed by your immune system. While our foods contain vitamins and minerals, it is important to recognize that available data indicate food alone does not supply enough in the presence of HIV, and that supplementation is very important (studies from Miami, Berkeley and Johns Hopkins universities).

Important Vitamins
It's not possible to describe the differences among the vitamins in a short space. Only a description of why they are important for us and foods that have them in reasonable amounts are given here.
  • ß-carotene is an important fat-soluble antioxidant that provides our vitamin A. Several anti-cancer properties have been reported, and it was one of the first compounds recognized as important for HIV infection. Orange or yellow vegetables such as carrots and green leafy vegetables are generally good sources of this important antioxidant. If taken as a supplement, current information indicates it may be best to use mixed carotenoids from natural sources rather than synthetic ß-carotene.
  • The B vitamins are important during stress, for helping fight disease, and especially for obtaining energy from proteins, fats and carbohydrates. Sex, alcohol, worrying, sun, etc., use up the B vitamins. Both vitamins B6 and B12 are known to decrease with HIV and it is likely that others become low as well. While some of the B vitamins are produced by our gut flora, we also get some from our food. The germ and bran parts of cereals are good sources of B vitamins, as are beans, peas, leafy green vegetables, milk, beef and liver. Vegetarian diets are often poor sources of B vitamins; you should be sceptical of fad diets that recommend you not take B vitamins as dietary supplements. In general, the B vitamins from food alone are insufficient to give benefits in HIV disease. It is very important to get these, for example in a multivitamin with minerals. This has been associated with very significant slowing of disease progression (Tang et al, 1993, 1996).
  • Vitamin C is also known as ascorbic acid or ascorbate. It is the most important of the water soluble antioxidants, and is important for coping with disease and other stress. Vitamin C helps spare other antioxidants such as glutathione and vitamin E, and is required by the immune system. Some cells of the immune system require up to 150 times more ascorbic acid than is required by most other parts of the body. Vitamin C has also been reported to kill HIV in laboratory tests. Fresh fruit, leafy greens, and vegetables are sources; many people who are HIV+ also take vitamin C as a supplement.
  • Vitamin E is another fat soluble anti-oxidant. It is important for lung function, blood circulation, protection against free radical (oxidation) damage, and membrane function. Extra vitamin E is especially important if you take large amounts of polyunsaturated fats. Laboratory studies suggest that vitamin E can improve AZT effectiveness. There are different forms of this vitamin. Natural forms have been shown to be better than synthetic forms. In your food, sources of vitamin E are wheat germ, the oils of grains, leafy greens, various seeds and beans.
Important Minerals
  • Selenium, a metal, is an important antioxidant. It's needed by both vitamin E and an enzyme important for glutathione activity. It's required in only tiny amount. High levels are poisonous. From food sources, you will not get toxic levels. Good food sources depend on their geographic origin. Canadian soils are generally higher than many parts of the world, but lower than in the US. It is likely a good idea to make sure your multivitamin contains 50 micrograms (mcg). Some people take an extra 200-400 mcg.
  • Zinc and copper are metals needed by many enzymes, including those in your stomach, intestines and the immune system. Since body zinc levels tend to decrease with HIV infection, it is often taken as a supplement. Unusually high levels, however, may reduce T-cell levels and impair copper absorption. A total intake of above 150 mg of zinc should not be considered unless symptoms of Crohns disease are present where levels as high as 300 mg per day may be needed (Chandra, 1984). Sources of zinc are seafood, sunflower & pumpkin seeds, mushrooms, spinach and soybeans. Sources of copper are whole grains, leafy greens, cherries, vegetables, nuts, eggs, fish and poultry dark meats. Usually, the food we eat supplies about 15 mg of zinc per day.
  • Magnesium and calcium are needed by the body, for example, for keeping bones healthy. A normal diet that includes dairy products should provide enough calcium without supplementation. Tofu is an alternate source. Magnesium is high in nuts, vegetables, brown rice, parsley, spinach and other leafy greens. There are many reports of magnesium deficiency in HIV disease. Have your doctor test your serum levels of this to decide if you need it in supplemental form.
  • Iron is essential for the body including the blood's ability to exchange oxygen. Sources of iron are spinach, asparagus, Brussels sprouts, fish, eggs, wheat germ, peas, beans and liver. Although excess iron may promote oxidation, higher amounts than are available from food alone may be beneficial (Abrams et al, 1993). Anemia may result from lack of magnesium or the B vitamins, as well as from iron.
Other Important Food Components
  • Garlic contains compounds that are good for your health. These include antifungals, antioxidants, and the mineral germanium. Fresh garlic is good in salads, soups, "stir-fries", scrambled eggs, etc. Eat lots of fresh garlic. Eat lots of cooked garlic. Eat lots of garlic. But if your're not used to it, start with small amounts with any one meal as it can upset your stomach if you're not used to it.
  • Lecithin, particularly the form high in phosphatidylcholine, keeps your membranes working. Soybean oil and cooked egg yolks are good sources of lecithin; however, raw egg yolks may be dangerous since dangerous organisms easily grow in them.
  • CoEnzyme Q-10 (ubiquinone), and germanium, a metal antioxidant, support the immune system. A generally good diet provides both; both are available as supplements.
  • Superoxide dismutase (SOD) is another important antioxidant (enzyme). Although present in many foods, this is a protein and will be broken up in the stomach. Therefore, it must either be synthesized by your body or, if taken as a supplement, it must have a coating so it can get through your stomach without being destroyed.
  • The colours of plants are called pigments and they are strong antioxidants. Some, e.g., PycnogenolTM, are very potent. These pigments are abundant especially in berries that are red or blue-black, e.g., blueberries, blackberries, boysenberries, grapes, etc.
  • Butylated hydroxyanisole (BHA), and butylated hydroxytoluene (BHT), are two fat soluble antioxidants used in food packaging. These were reported to make it difficult for the HIV virus to grow. It is almost certain that this effect was from their antioxidant activities. Neither BHA nor BHT is a natural chemical for the body and BHA is a known carcinogen. Neither is recommended as a dietary supplement. Vitamin E and carotenoids likely do the same job and without bad effects.
  • Your large intestine (bowel) contains a large number of friendly bacteria that you need. You should think of these "bugs" as being your friends. They help protect you against fungal infections, food poisoning, and malabsorption; they also produce some vitamins. The most important of these gut flora are Lactobacillus acidophilus and Bifidobacterium (bifidus), which exist in the lower and upper parts of the large bowel, respectively: they normally stick to the lining of the intestine and grow there if they have enough food such as the dietary fibres. Both are available as supplements.
Several other naturally occurring compounds are also available. These include Astragalus, Codonopsis, Licorice (glycyrrhizin), bee propolis, St. John's wort (hypericin), and others. A good naturopath who is experienced in HIV is recommended for advice about these, and may also be a valuable source of information regarding nutrition.

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Yoghurts are another source of gut flora. The form of Lactobacillus in commercial yoghurts is usually L. bulgaricus: this doesn't stay on the intestinal lining so you must eat it every day. Use of bifidus in North American yoghurts has been allowed only recently and is not widely practised: in Europe and Japan there are many claims that bifidus boosts the immune system, prevents certain cancers, produces vitamins, etc. Use of antibiotics, anal douching, generally poor health, etc., all kill these healthy gut bacteria. Most other bacteria that are important for the intestine are not taken as nutritional supplements since they can cause infections in other parts of the body such as in your mouth.
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Lack of rest, excess sunlight, strenuous exercise and euphoric drugs should be avoided; these are forms of stress and use up your antioxidants.

A healthy diet can be obtained in a number of ways. There is a huge variety of foods so you should never be bored. While regular meals are best, in general eat in a way that keeps you the happiest. Whatever, NEVER neglect to eat lots each day, and "get lots of calories". The Canada Food Guide to Healthy Eating is a good starting place. This places an emphasis on grains, vegetables and fruits, then milk products and finally meat & alternatives. For those who cannot tolerate lactose, even by the use of lactase enzyme supplementation, then adjustment is necessary within the Canada Food Guide.
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Eating Well - some Suggestions
A "good attitude" is important to keep you healthy. This means having a positive, informed and focused attitude. When you are 'up', the brain produces chemicals that help the immune system. While most stress is bad, some moderate stress may help; moderate exercise is important. A "determined" attitude is said to be characteristic of those who are healthiest. This "informed attitude" is the opposite of "burying your head in the sand". Early, active and positive intervention is essential; an HIV+ person must actively pursue routes that are known to help prolong life and raise the quality of life. Eating properly and taking supplements are excellent first steps! Just because you are HIV+ doesn't mean you can't have a good time; a high "quality of life" surely means you should enjoy yourself! Be relaxed and "take one day at a time".

Many people who are HIV+ take higher than normal amounts of vitamins and some other compounds (minerals such as zinc and selenium, "immune boosters", etc.). This may give the body a sort of 'store' that provides a sort of 'pressure' to work against infections. Antioxidants may be especially important. Those supplements that are water soluble tend not to store in the body so that these should be taken every day; those that are oil soluble store in your fatty tissue and a reservoir is built up - it's not serious if you sometimes miss a day or two.

Eat a good breakfast in the morning, starting with yoghurt; acidophilus/bifidus supplements help keep your gut "bugs" plentiful (remember they are your friends). Having an apple or banana provides them with food. Some form of oatmeal cereal is also normally an excellent choice. Be particularly careful if fat content is high; use fats that are not likely to do harm. High levels of soluble fibre (e.g., oatmeal, apples) and reasonably high levels of insoluble fibre are good stuff! Remember that fibre "keeps you regular", helping control both diarrhea and constipation. Bran types of fibre, however, may make diarrhea worse. Leafy vegetables, lettuce (Romaine has more vitamin C than iceberg lettuce), celery, tomatoes, carrots, fresh chopped garlic, green peppers, cucumbers, etc. contain antioxidants, vitamins and minerals, and make a good salad that could be eaten several times a week. Always wash fruits and vegetables - dust on them may contain life-threatening bacteria, fungal spores or parasites (if your T-cells are especially low, then special precautions may be necessary, such as using Chlorox or Javex in your wash water). If some cheese, sardines or canned tuna is added for protein, a salad may sometimes be your main course if it is large enough. Foods high in pectins (apples and most fruits, vegetables) are important since these feed the "gut flora". You can make your own salad dressing using vinegar, olive oil and garlic. If it is difficult to maintain weight, remember that salads are not very dense in calories; in this case, it may be necessary to decrease salad intake in favour of extra foods that contain more calories such as eggs, potatoes and supplemental drinks (see HIV and Liquid Food Supplements in this series).

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Broccoli is an excellent vegetable - lots of good stuff in it. Peas, beans, squash, carrots, cauliflower, etc., etc. - they are all good, preferably cooked only to a "still crisp" stage so that their minerals are not leached out into the cooking water (okay though in soups). Carrots and leafy greens contain vitamin C, are an excellent source of ß-carotene, and contain both soluble and insoluble fibre. Fruits and berries contain good antioxidants.
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Oatmeal porridge is good - good protein, good fibre, good fat. The carbohydrates are particularly healthy for the walls of the digestive tract (an old remedy for ulcers was to drink gruel made from oatmeal).

Strictly vegetarian diets can cause zinc deficiency, and may be a problem for HIV+ people. Vegetarian diets are high in phytic acid which binds (chelates) zinc into a biologically unavailable form removing it from the body. The bran fractions of cereals contain very high levels of phytic acid. Lack of carnitine may also be a problem with vegetarian diets - supplementation with carnitine is likely very important if you are HIV-positive and vegetarian.

Having a beer or wine stimulates the appetite for some people - then have a beer or glass of wine! (unless there is some medical reason that dictates otherwise). A walk in the fresh air may be adequate and is certainly a good idea in any case. A few drops of Angustura bitters in a tablespoon of water sipped before mealtime may also help some people. Dronabinol (Marinol), a cannabis extract, and thalidomide are available by prescription and may also stimulate appetite. The prescription antihistamine Periactin has also been used for appetitie stimulation. Megace is probably best to avoid unless testosterone is also given to you by your doctor.

It is good to restrict (not necessarily avoid) use of refined sugars (their names end with "ose") since these may encourage you to have yeast and fungal opportunistic infections (e.g., candidiasis or thrush). Excessive amounts are not good for your digestion and overall health (one reason why Ensure, Resource and Boost types of liquid drinks may not be good for you).

Olive oil is a good oil to use for salads, cooking, etc. It is better than many other oils for cholesterol control. It is high in oleic acid which has anti-fungal activity (our elders used warm olive oil treatment for dandruff control).
Main meals - fish and chicken are excellent for protein. Red meats may still be important since they are excellent sources of carnitine and CoEnzyme Q-10. Other proteins from eggs, cheese, yoghurt, chicken/turkey and well-cooked pork provide alternatives to help prevent boredom.

"Excessive" drinking may stress your body - always take plenty of the C and B vitamins for any amount of alcohol consumption. Cigarettes result in high exposure of the lungs to cancer-producing compounds, and generally increase oxidation processes in the body - HIV does this also, so why increase this damage?
Drink coffee in moderation. Tea may be a better stimulant; it contains a number of compounds good for the body - perhaps even anti-HIV, such as from gallic, caffeic and chlorogenic acids.

Chew your food until it is liquid to mix it well with your saliva. Make sure even milk is mixed well with saliva. Remember that digestion starts in your mouth-enzymes to break down both carbohydrates and fats are in saliva.

In this series:
  • HIV & Diet revisited
  • HIV & Dietary Supplements revisited
  • HIV & Nutrients revisited
  • HIV & Cysteine revisited
  • HIV & Copper and Zinc revisited
  • HIV & Vitamin B12
  • HIV & Carnitine
  • HIV & The Gut
  • HIV & Liquid Food Supplements (new to this series)
  • References for HIV & Nutrition
Author, Chester Myers, holds both honours B.Sc. and M.Sc. (1969) degrees in physical chemistry from Dalhousie University, and a Ph.D. (1975) from the University of Toronto (biophysical chemistry) where he investigated the mechanism of action of one of the digestive enzymes. In addition to publishing in the scientific literature and having authored several patents, he has written extensively on topics regarding health and HIV. The latter include articles in The Positive Side, Canadian AIDS News, and monographs available from the AIDS Committee of Toronto (ACT), the Community AIDS Treatment Information Exchange (CATIE), and various other organizations.

The material in this publication is for information purposes only. It does not endorse any particular treatment program nor strategy; neither is it intended as medical advice nor as a replacement for medical advice.

©This document is copyrighted by Chester Myers. All materials may be reprinted and/or distributed without prior permission. However, reprints may not be edited.

February 1997
Last modified on: 09/15/2004

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