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Guideline Summary
Guideline Title
HIV/AIDS evidence-based nutrition practice guideline.
Bibliographic Source(s)
American Dietetic Association. HIV/AIDS evidence-based nutrition practice guideline. Chicago (IL): American Dietetic Association; 2010 Dec. Various p.
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)

Guideline Category
Assessment of Therapeutic Effectiveness
Counseling
Evaluation
Management
Prevention
Risk Assessment
Screening
Treatment
Clinical Specialty
Family Practice
Gastroenterology
Geriatrics
Infectious Diseases
Internal Medicine
Nursing
Nutrition
Obstetrics and Gynecology
Pediatrics
Preventive Medicine
Intended Users
Advanced Practice Nurses
Dentists
Dietitians
Health Care Providers
Nurses
Occupational Therapists
Pharmacists
Physical Therapists
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Public Health Departments
Respiratory Care Practitioners
Social Workers
Students
Substance Use Disorders Treatment Providers
Guideline Objective(s)

Overall Objectives

  • To help registered dietitians, practitioners, patients, families and consumers make shared decisions about health care choices in specific clinical circumstances
  • To provide medical nutrition therapy (MNT) guidelines for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) to promote and maintain optimal nutrition status and prevent and manage other nutrition-related diseases and comorbidities in people with HIV infection

Specific Objectives

  • To define evidence-based HIV/AIDS nutrition recommendations for registered dietitians (RDs) that are carried out in collaboration with other healthcare providers
  • To guide practice decisions that integrate medical, nutritional, and behavioral strategies
  • To reduce variations in practice among RDs
  • To provide the RD with data to make recommendations to adjust MNT or recommend other therapies to achieve desired outcomes
  • To develop guidelines for interventions that have measurable clinical outcomes
  • To define the highest quality of care within cost constraints of the current healthcare environment
Target Population

Infants (newborns to 23 months), preschool children (2 to 5 years), children (6 to 12 years), adolescents (13 to 18 years), adults (19-44 years), middle age (45 to 64 years), aged (65 to 79 years), advanced age (80 years and over) with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)

Interventions and Practices Considered

Evaluation

  1. Referral to a registered dietitian
  2. Nutrition assessment
    • Client history including medical, social and personal history and history of medications and supplements
    • Biochemical data and relevant laboratory values
    • Anthropometric measurements including height, weight, body mass index (BMI), and weight change rate
    • Nutrition history including food intake, nutrition and health awareness, physical activity and exercise, food availability, psychosocial and economic issues impacting nutrition therapy, and consideration of co-morbid conditions
    • Physical examination

Management/Treatment

  1. Individualized prescription based on:
    • Nutrition intervention such as macronutrient composition based on the Dietary Reference Intakes (DRI); vitamin and mineral supplementation; treatment of diarrhea/malabsorption; education regarding food and water safety, medications, and presence of human immunodeficiency virus (HIV) in breast milk
    • Physical activity interventions
    • Behavioral interventions
    • Pharmacotherapy, when indicated
  2. Coordination of nutrition care
  3. Monitoring of progress
Major Outcomes Considered
  • Body mass index
  • Cardiopulmonary fitness
  • CD4 count
  • Energy intake
  • Morbidity and mortality
  • Quality of life
  • Serum lipid level
  • Weight gain

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

General Methods for Collecting/Selecting the Evidence

The following list provides an overview of the steps which the American Dietetic Association (ADA) evidence analysis team goes through to identify research through database searches.

  1. Plan the search strategy to identify the "current best evidence" relevant to the question. The plan for identification and inclusion of articles and reports should be systematic and reproducible, not haphazard. Write out the original search strategy and document adjustments to the strategy if they occur. Allow for several iterations of searches.
    • List inclusion and exclusion criteria. The work group will define the inclusion and exclusion criteria. These criteria will be used in defining the search strategy and for filtering the identified research reports. ADA uses only peer-reviewed research; that is, articles accepted for evidence analysis must be peer-reviewed and published in a juried publication. Additionally, ADA only uses human subjects in its research and does not include animal studies in its evidence analysis.
    • Identify search words. During the process of considering outcomes, interventions, nutrition diagnoses, and assessments, the work group may have identified a number of specific terms or factors that were important, but were not included in the actual question. These terms can be used as additional search terms to help identify relevant pieces of research. Both text word search and keyword search using Medical Subject Headings (MeSH) definitions may be used.
    • Identify databases to search. PubMed, Medline, CINAHL, EMBASE, Cochrane, Agricola, DARE, TRIP, AHRQ and ERIC are some common databases for clinical nutritional research. Note that search terms can vary depending on the database.
  2. Conduct the search. Depending on the number and type of sources found in the initial search, adjustments might have to be made in the search strategy and to inclusion/exclusion criteria, and additional searches run. Changes to the search plan should be recorded for future reference. Document the number of sources identified in each search.
  3. Review titles and abstracts. At this point, a filtering procedure is used to determine whether a research article matches the inclusion criteria and is relevant to the work group's questions. Typically, the lead analyst, along with a member of the expert workgroup, first reviews the citations and abstracts to filter out reports that are not applicable to the question. If a determination cannot be made based on the citation and abstract, then the full text of the article is obtained for review.
  4. Gather all remaining articles and reports. Obtain paper or electronic copies of research articles that remain on the list following the citation and abstract review. If there are less than six citations, it could mean that the search was too specific to identify relevant research or that research has not been done on this topic. A broadened search should be tried. When there is a long list of citations, ascertain whether it includes articles that are tangential to the question or address the question in only a general way. In this case a more focused search strategy may be necessary.

Specific Methods for This Guideline

Searches of PubMed and CENTRAL databases and hand searches of other relevant literature were performed on the following topics:

  • Medical nutrition therapy and dietitian intervention
  • Caloric needs
  • Macronutrient composition
  • Vitamin and mineral supplementation
  • Treatment of hyperlipidemia
  • Treatment of diarrhea/malabsorption
  • Education on food and water safety
  • Physical activity

Each evidence analysis topic has a link to supporting evidence in the original guideline, where the Search Plan and Results can be found. Here the reader can view when the search plan was performed, specific inclusion and exclusion criteria, search terms, data bases that were searched, and the excluded articles.

General Exclusion Criteria

As a general rule, studies are excluded if the:

  • Study sample size is less than 10 in each treatment group
  • Drop-out rate was >20%

Inclusion Criteria

  • Study design preferences: clinical trials preferred
  • Limited to articles in English
Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Conclusion Grading Table

Strength of Evidence Elements Grade I
Good/Strong
Grade II
Fair
Grade III
Limited/Weak
Grade IV
Expert Opinion Only
Grade V
Grade Not Assignable
Quality
  • Scientific rigor/validity
  • Considers design and execution
Studies of strong design for question

Free from design flaws, bias and execution problems
Studies of strong design for question with minor methodological concerns

OR

Only studies of weaker study design for question
Studies of weak design for answering the question

OR

Inconclusive findings due to design flaws, bias or execution problems
No studies available

Conclusion based on usual practice, expert consensus, clinical experience, opinion, or extrapolation from basic research
No evidence that pertains to question being addressed
Consistency

Of findings across studies
Findings generally consistent in direction and size of effect or degree of association, and statistical significance with minor exceptions at most Inconsistency among results of studies with strong design

OR

Consistency with minor exceptions across studies of weaker designs
Unexplained inconsistency among results from different studies

OR

Single study unconfirmed by other studies
Conclusion supported solely by statements of informed nutrition or medical commentators NA
Quantity
  • Number of studies
  • Number of subjects in studies
One to several good quality studies

Large number of subjects studied

Studies with negative results having sufficiently large sample size for adequate statistical power
Several studies by independent investigators

Doubts about adequacy of sample size to avoid Type I and Type II error
Limited number of studies

Low number of subjects studied and/or inadequate sample size within studies
Unsubstantiated by published studies Relevant studies have not been done
Clinical Impact
  • Importance of studied outcomes
  • Magnitude of effect
Studied outcome relates directly to the question

Size of effect is clinically meaningful

Significant (statistical) difference is large
Some doubt about the statistical or clinical significance of effect Studied outcome is an intermediate outcome or surrogate for the true outcome of interest

OR

Size of effect is small or lacks statistical and/or clinical significance
Objective data unavailable Indicates area for future research
Generalizability

To population of interest
Studied population, intervention and outcomes are free from serious doubts about generalizability Minor doubts about generalizability Serious doubts about generalizability due to narrow or different study population, intervention or outcomes studied Generalizability limited to scope of experience NA

This grading system was based on the grading system from: Greer N, Mosser G, Logan G, Wagstrom Halaas G. A practical approach to evidence grading. Jt Comm. J Qual Improv. 2000; 26:700-712. In September 2004, The ADA Research Committee modified the grading system to this current version.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Step 1: Formulate the question

Specify a question in a defined area of practice; or state a tentative conclusion or recommendation that is being considered. Include the patient type and special needs of the target population involved, the alternatives under consideration, and the outcomes of interest.

Step 2: Gather and classify evidence reports

Conduct a systematic search of the literature to find evidence related to the question, gather studies and reports, and classify them by type of evidence. Classes differentiate primary reports of new data according to study design, and distinguish them from reports that are a systematic review and synthesis of primary reports.

Step 3: Critically appraise each report

Review each report for relevance to the question and critique for scientific validity. Abstract key information from the report and assign a code to indicate the quality of the study by completing quality criteria checklist.

Step 4: Summarize evidence in a narrative and an overview table

Combine findings from all reports in a table that pulls out the important information from the article worksheets. Write a brief narrative that summarizes and synthesizes the information abstracted from the articles that is related to the question asked.

Step 5: Develop a conclusion statement and grade the strength of evidence supporting the conclusion

Develop a concise conclusion statement (the answer to the question), taking into account the synthesis of all relevant studies and reports, their class and their quality ratings. Assign a grade to indicate the overall strength or weakness of evidence informing the conclusion statement (see "Rating Scheme for the Strength of the Evidence").

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Moving From Analysis to the Evidence-Based Nutrition Practice Guideline

The expert workgroup, which includes practitioners and researchers with a depth of experience in the specific field of interest, develops the disease-specific guideline. The guideline development involves the following steps.

Review the Conclusion Statements

The workgroup meets to review the materials resulting from the evidence analysis, which may include review of the conclusion statements, evidence summaries, and evidence worksheets.

Formulate Recommendations for the Guideline Integrating Conclusions from Evidence Analysis

The workgroup uses an expert consensus method to formulate the guideline recommendations and complete the various sections on the recommendation page. These include:

  • Recommendation(s): This is a course of action for the practitioner. The recommendation is written using two brief and separate statements. The first statement is "what" the dietitian should do or not do? The second statement describes the "why" of the recommendation. More than one recommendation may be formulated depending on a particular topic and the supporting conclusion statements.
  • Rating: The rating for the recommendation is based on the strength of the supporting evidence. The grade of the supporting conclusion statement(s) will be help determining this rating (see "Rating Scheme for the Strength of the Recommendation").
  • Label of Conditional or Imperative: Each recommendation will have a label of "conditional" or "imperative". Conditional statements clearly define a specific situation, while imperative statements are broadly applicable to the target population without restraints on their pertinence.
  • Risks and Harms of Implementing the Recommendation: Includes any potential risks, anticipated harms or adverse consequences associated with applying the recommendation(s) to the target population.
  • Conditions of Application: Includes any organizational barriers or changes that would need to be made within an organization to apply the recommendation in daily practice. Also includes any conditions which may limit the application of the recommendation(s). For instance, application may be limited to only people in an inpatient setting, or not applicable for pregnant women. Conditional recommendations will always have conditions specified. Imperative recommendations may have some general conditions for application.
  • Potential Costs Associated with Application: Includes any costs that may be associated with the application of this recommendation such as specialized staff, new equipment or treatments.
  • Recommendation Narrative: Provides a brief description of the evidence that supports this recommendation.
  • Recommendation Strength Rationale: Provides a brief list of the evidence strength and methodological issues that determined the recommendation strength.
  • Minority Opinions: If the expert workgroup cannot reach consensus on the recommendation, the minority opinions may be listed here.
  • Supporting Evidence: Provides links to the conclusions statements, evidence summaries and worksheets related to the formulation of this recommendation(s).
  • References Not Graded in the American Dietetic Association's (ADA) Evidence Analysis Process: Recommendations will be based on the summarized evidence from the analysis. Sources that were not analyzed during the evidence analysis process may be used to support and formulate the recommendation or to support information under other categories on the recommendation page, if the workgroup deems necessary. References must be credible resources (e.g., consensus reports, other guidelines, position papers, standards of practice, articles from peer-reviewed journals, nationally recognized documents or websites). If recommendations are based solely on these types of references, they will be rated as "consensus."

    Occasionally recommendations will include references that were not reviewed during the evidence analysis process but are relevant to the recommendation, risks and harms of implementing the recommendation, conditions of application, or potential costs associated with application. These references will be listed on the recommendation page under "References Not Graded in ADA's Evidence Analysis Process."

Develop a Clinical Algorithm for the Guideline

The workgroup develops a clinical algorithm based on ADA's Nutrition Care Process, to display how each recommendation can be used within the treatment process and how they relate to the Nutrition Assessment, Diagnosis, Intervention and Monitoring and Evaluation.

Complete the Writing of the Guideline

Each disease-specific guideline has a similar format which incorporates the Introduction (includes: Scope of the Guideline, Statement of Intent, Guideline Methods, Specific Methods, Implementation, Benefits and Risks/Harms of Implementation), Background Information, and any necessary Appendices. The workgroup develops these features.

Criteria Used in Guideline Development

The criteria used in determining the format and process for development of ADA's guidelines is based on the following tools and criteria for evidence-based guidelines:

  • Guideline Elements Model (GEM), which has been incorporated by the American Society for Testing and Materials (ASTM) as a Standard Specification for clinical practice guidelines
  • AGREE (Appraisal for Guidelines Research and Evaluation) Instrument
  • National Guideline Clearinghouse (www.guideline.gov External Web Site Policy)
Rating Scheme for the Strength of the Recommendations

Criteria for Recommendation Rating

Statement Rating Definition Implication for Practice
Strong A Strong recommendation means that the workgroup believes that the benefits of the recommended approach clearly exceed the harms (or that the harms clearly exceed the benefits in the case of a strong negative recommendation), and that the quality of the supporting evidence is excellent/good (grade I or II)*. In some clearly identified circumstances, strong recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.
Fair A Fair recommendation means that the workgroup believes that the benefits exceed the harms (or that the harms clearly exceed the benefits in the case of a negative recommendation), but the quality of evidence is not as strong (grade II or III)*. In some clearly identified circumstances, recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits outweigh the harms. Practitioners should generally follow a Fair recommendation but remain alert to new information and be sensitive to patient preferences.
Weak A Weak recommendation means that the quality of evidence that exists is suspect or that well-done studies (grade I, II, or III)* show little clear advantage to one approach versus another. Practitioners should be cautious in deciding whether to follow a recommendation classified as Weak, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role.
Consensus A Consensus recommendation means that Expert opinion (grade IV)* supports the guideline recommendation even though the available scientific evidence did not present consistent results, or controlled trials were lacking. Practitioners should be flexible in deciding whether to follow a recommendation classified Consensus, although they may set boundaries on alternatives. Patient preference should have a substantial influencing role
Insufficient Evidence An Insufficient Evidence recommendation means that there is both a lack of pertinent evidence (grade V)* and/or an unclear balance between benefits and harms. Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as Insufficient Evidence and should exercise judgment and be alert to emerging publications that report evidence that clarifies the balance of benefit versus harm. Patient preference should have a substantial influencing role.

*Conclusion statements are assigned a grade based on the strength of the evidence. Grade I is good; grade II, fair; grade III, limited; grade IV signifies expert opinion only and grade V indicates that a grade is not assignable because there is no evidence to support or refute the conclusion. The evidence and these grades are considered when assigning a rating (Strong, Fair, Weak, Consensus, Insufficient Evidence - see chart above) to a recommendation.

Adapted by the American Dietetic Association from the American Academy of Pediatrics, Classifying Recommendations for Clinical Practice Guideline, Pediatrics. 2004;114;874-877.

Cost Analysis

Potential costs associated with application of each recommendation were considered. The following potential costs were identified:

  • Costs of medical nutrition therapy (MNT) sessions and reimbursement vary; however, MNT sessions are essential for improved outcomes.
  • Assessment of body composition may be costly depending on the time required and methodology.
  • Monitoring and evaluation of body composition may be costly depending on the time required and methodology.
  • Medium-chain triglycerides may be costly.
  • In previously sedentary individuals, a graded exercise test with electrocardiogram (ECG) monitoring is recommended before undertaking aerobic physical activity with intensity exceeding the demands of everyday living (more intense than brisk walking), and this is a potential cost.
  • Staff and volunteers, such as food providers, may also need to be trained on food and water safety.
Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Each guideline is reviewed internally and externally using the AGREE (Appraisal of Guidelines for Research and Evaluation) instrument as the evaluation tool. The external reviewers consist of a multidisciplinary group of individuals (may include dietitians, doctors, psychologists, pharmacists, nurses, etc.). The review is done electronically. The guideline is adjusted by consensus of the expert panel and approved by American Dietetic Association's Evidence-Based Practice Committee prior to publication on the Evidence Analysis Library (EAL).

Recommendations

Major Recommendations

Ratings for the strength of the recommendations (Strong, Fair, Weak, Consensus, Insufficient Evidence), conclusion grades (I-V), and statement labels (Conditional versus Imperative) are defined at the end of the "Major Recommendations" field.

Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) Screening and Referral for Medical Nutrition Therapy (MNT)

HIV/AIDS: Screening for People with HIV Infection

The registered dietitian (RD) should collaborate with other health care professionals, administrators and public policy decision-makers to ensure that all people with HIV infection are screened for nutrition-related problems, based on referral criteria regardless of setting, at every visit. People with HIV infection are at nutritional risk at any time-point during the course of their illness.

Consensus, Imperative

HIV/AIDS: Referral for MNT

The RD should collaborate with other health care professionals, administrators and public policy decision-makers to ensure that all people with HIV infection are referred for MNT based on nutritional risk. The timeline for referral of patients categorized by nutritional risk is as follows: High risk, to be seen by an RD within one week; moderate risk, to be seen by an RD within one month; low risk, to be seen by an RD at least annually.

Consensus, Conditional

Recommendation Strength Rationale

  • The American Dietetic Association (ADA) HIV/AIDS Work Group concurs with the references cited.

HIV/AIDS Medical Nutrition Therapy (MNT)

HIV/AIDS: MNT

MNT provided by an RD is recommended for individuals with HIV infection. Four studies regarding MNT (with or without oral nutritional supplementation) report improved outcomes related to energy intake, symptoms and cardiovascular risk indices. Two studies regarding nutritional counseling (non-MNT) also report improved outcomes related to weight gain, CD4 count and quality of life.

Strong, Imperative

HIV/AIDS: Frequency of MNT

The RD should provide at least one to two MNT encounters per year for people with HIV infection (asymptomatic) and at least two to six (or more) MNT encounters per year for people with HIV infection (symptomatic but stable, acute or palliative), based on the following:

  • Appropriate disease classifications
  • Nutritional status
  • Comorbidities
  • Opportunistic infections
  • Physical changes
  • Weight or growth concerns
  • Oral or gastrointestinal symptoms
  • Metabolic complications
  • Barriers to nutrition
  • Living environment
  • Functional status
  • Behavioral concerns or unusual eating behaviors

Studies regarding MNT (with or without oral nutritional supplementation) report improved outcomes related to energy intake, symptoms, and cardiovascular risk indices, especially with increased frequency of visits.

Consensus, Imperative

Recommendation Strength Rationale

  • Conclusion Statement was Grade I

HIV/AIDS Nutrition Assessment

HIV/AIDS: Nutrition Assessment

The RD should assess the following for people with HIV infection:

  • Food/nutrition-related history, such as knowledge, beliefs and attitudes and factors affecting access to food and food/nutrition-related supplies (see also the Assess Food/Nutrition-Related History recommendation)
  • Anthropometrics (see also the Anthropometric Assessment recommendation)
  • Biochemical data, medical tests and procedures such as lipid profile, fasting blood glucose, electrolytes, complete blood count and bone density measurements
  • Nutrition-focused physical findings
  • Client history
    • Patient, client and family medical/health history
    • Social history
  • Comparative standards

Assessment of nutritional and medical status is crucial to quality nutrition care for every person living with HIV infection.

Consensus, Imperative

Recommendation Strength Rationale

  • The ADA HIV/AIDS Work Group concurs with the references cited.

HIV/AIDS Assess Food/Nutrition-Related History

HIV/AIDS: Assess Food/Nutrition-Related History

The RD should assess the food and nutrition-related history of people with HIV infection, including but not limited to:

  • Food and nutrient intake, focusing on energy, protein, fat, fiber, sodium, calcium and vitamin D
  • Medications, herbal supplements and their potential negative interactions
  • Knowledge, beliefs and attitudes
  • Behavior
  • Factors affecting access to food and food and nutrition-related supplies
  • Physical activity and function
  • Nutrition-related patient and client-centered measures

Several studies report variations in energy and nutrient intake in people with HIV infection, some were under- and over-estimated requirements. A clear understanding of food and nutrient intake will form the basis for the nutrition diagnosis, prescription and intervention.

Strong, Imperative

Recommendation Strength Rationale

  • Conclusion statement was Grade II

HIV/AIDS Anthropometric Assessment

HIV/AIDS: Anthropometric Assessment

The RD should include the following anthropometric measurements in the initial assessment: Weight, height and body mass index; for children, growth pattern indices. In addition, measurements of body compartment estimates should also be included, such as circumference measurements (mid-arm muscle, waist, hip and waist-to-hip ratio) or measurements of body cell mass and body fat (measured with dual energy x-ray absorptiometry [DXA], bioelectrical impedance analysis [BIA], bioimpedance spectroscopy or skinfold thickness measurements). Baseline anthropometric measurements provide information for the nutrition assessment and the majority of research in men, women, children and adolescents reports that fat-free mass and fat mass are altered in people with HIV infection.

Strong, Imperative

Recommendation Strength Rationale

  • Conclusion statements were Grades I and II.

HIV/AIDS Energy Needs

HIV/AIDS: Determining Energy Needs

The RD should use clinical judgment and consider several factors when determining the energy needs of adults and children with HIV infection to maintain a healthy body weight. Factors related to energy needs in people with HIV infection include age, gender, stage of disease, nutritional status, opportunistic infections and comorbidities, inflammation and effects of medications. Although research reports increased resting energy expenditure (as much as 5% to 17%) in people with HIV infection, total energy expenditure may be similar to that of healthy control subjects.

Fair, Imperative

Recommendation Strength Rationale

  • Conclusion statement was Grade II.

Refer to the original guideline document for information about resting metabolic rate and adult and pediatric weight management (PWM).

HIV/AIDS Macronutrient Composition

HIV/AIDS: Macronutrient Composition

  • The RD should prescribe an individualized diet with a macronutrient composition based on the Dietary Reference Intakes (DRI) (20% to 35% of calories from fat, 45% to 65% of calories from carbohydrate, 14g fiber per 1,000 kcal and 10% to 35% of calories from protein)
  • In people with HIV infection, protein needs are highly individualized. Low-fiber/high-fat diets are associated with fat deposition, insulin resistance and obesity. Studies indicate that diets low in saturated and total fat resulted in reduced triglyceride levels, increased HDL-cholesterol levels and a lower risk of lipohypertrophy.

Fair, Imperative

HIV/AIDS: Macronutrient Composition for Hyperlipidemia

  • For people with HIV infection who have hyperlipidemia, the RD should encourage consumption of a cardioprotective dietary pattern tailored to the individual's needs to provide a fat intake of 25% to 35% of calories, less than 7% of calories from saturated fat, less than 1% of calories from trans-fatty acids and under 200 mg of cholesterol per day
  • Research on several lifestyle modification interventions for the treatment of hyperlipidemia in people with HIV infection reports improvements in serum lipid profile. Studies indicate that diets low in saturated and total fat and including omega-3 fatty acids resulted in reduced triglyceride levels, increased HDL-cholesterol levels and a lower risk of lipohypertrophy.

Strong, Conditional

Recommendation Strength Rationale

  • For the recommendation HIV/AIDS: Micronutrient Composition, conclusion statements were Grades II and III
  • For the recommendation HIV/AIDS: Macronutrient Composition for Hyperlipidemia, conclusion statements were Grades I and II.

HIV/AIDS Vitamin and Mineral Supplementation

HIV/AIDS: Vitamin and Mineral Supplementation

If people with HIV infection cannot meet their Recommended Dietary Allowance (RDA) levels for micronutrients through diet, the RD should recommend vitamin and mineral supplements, especially for calcium and vitamin D. Micronutrient deficiencies are common in HIV-infected individuals and studies report increased morbidity and mortality in those not taking vitamin supplementation.

Strong, Conditional

HIV/AIDS Treatment of Diarrhea/Malabsorption

HIV/AIDS: Treatment of Diarrhea/Malabsorption

For people with HIV infection who have diarrhea/malabsorption, the RD should encourage the consumption of soluble fiber, electrolyte-repleting beverages and medium-chain triglycerides (MCT) and decrease the consumption of foods that may exacerbate diarrhea. Studies of fat malabsorption reported that consumption of MCT resulted in fewer stools, decreased stool fat and weight and increased fat absorption.

Fair, Conditional

Recommendation Strength Rationale

  • Conclusion statement was Grade II.

HIV/AIDS Encourage Physical Activity

HIV/AIDS: Encourage Physical Activity

If not contraindicated, the RD should encourage physical activity for people with HIV infection. Studies report that performing constant or interval aerobic exercise, progressive resistance exercise or a combination of both, for at least 20 minutes per session at a frequency of three times per week is generally safe in adults with HIV infection and may lead to significant improvements in strength, endurance, cardiopulmonary fitness and reductions in depressive symptoms.

Strong, Conditional

Recommendation Strength Rationale

  • Conclusion statement was Grade I.

HIV/AIDS Educate on Food and Water Safety

HIV/AIDS: Educate on Food and Water Safety

The RD should educate people with HIV infection, especially those who are severely immunocompromised (having CD4 levels less than 200 cells per mm3) and others involved in their care, about food and water safety. Studies report that people with HIV infection are more susceptible to foodborne illness and also lack knowledge regarding food safety.

Strong, Imperative

Recommendation Strength Rationale

  • Conclusion statement was Grade I.

HIV/AIDS Coordination of Care

HIV/AIDS: Coordination of Care

For people with HIV infection, the RD should implement MNT and coordinate care with an interdisciplinary team and community resources. The interdisciplinary team is composed of health professionals including, but not limited to: RDs, physicians, physician assistants, nurse practitioners, nurses, pharmacists, case managers, substance use disorders treatment providers, respiratory care practitioners, occupational therapists, physical therapists, speech therapists, exercise physiologists, dentists and mental health professionals. Community resources may include, but are not limited to, food assistance programs, support systems and recreational facilities. This approach is necessary to effectively integrate MNT into overall management for people with HIV infection.

Consensus, Imperative

Recommendation Strength Rationale

  • The ADA HIV/AIDS Work Group concurs with the references cited.

HIV/AIDS Educate on Breastfeeding Avoidance

HIV/AIDS: Educate on Breastfeeding Avoidance

The RD should educate women with HIV infection who are pregnant or lactating about the presence of HIV in breast milk. To reduce perinatal HIV transmission, breastfeeding is NOT recommended for HIV-infected women where safe, affordable and feasible alternatives are available and culturally acceptable.

Consensus, Conditional

Recommendation Strength Rationale

  • The ADA HIV/AIDS Work Group concurs with the references cited.
  • Evidence in support of the recommendation was level "A-II evidence"; however, the evidence analysis was not reviewed by the ADA HIV/AIDS Work Group using the ADA evidence analysis methodology, resulting in a strength of Consensus.

HIV/AIDS Educate on Medications

HIV/AIDS: Educate on Medications

For people with HIV infection who are prescribed medications, the RD should provide education regarding food and drug interactions, nutrition-related adverse effects and risk of teratogenicity. Adverse effects of medications, including metabolic complications, gastrointestinal disturbances, and compromised nutrition intake, may lead to non-adherence and/or resistance to the prescribed medication regimen and poor nutrition status.

Consensus, Conditional

Recommendation Strength Rationale

  • The ADA HIV/AIDS Work Group concurs with the references cited.
  • Evidence in support of the recommendation was level A-I, A-II and A-III evidence.

HIV/AIDS Monitor and Evaluate Food- and Nutrition-Related History

HIV/AIDS: Monitor and Evaluate Food- and Nutrition-Related History

The RD should monitor and evaluate the food- and nutrition-related history of people with HIV infection, including but not limited to:

  • Food and nutrient intake, focusing on energy, protein, fat, fiber, sodium, calcium and vitamin D
  • Medications, herbal supplements and their potential negative interactions
  • Knowledge, beliefs and attitudes
  • Behavior
  • Factors affecting access to food and food- and nutrition-related supplies
  • Physical activity and function
  • Nutrition-related patient and client-centered measures

Several studies report variations in energy and nutrient intake in people with HIV infection. Some were under- and over-estimated requirements. A clear understanding of food and nutrient intake will form the basis for the nutrition diagnosis, prescription and intervention.

Strong, Imperative

Recommendation Strength Rationale

  • Conclusion statement was Grade II.

HIV/AIDS Monitor and Evaluate Anthropometric Measurements

HIV/AIDS: Monitor and Evaluate Anthropometric Measurements

Using the same methodology as in the assessment of anthropometric measurements, the RD should monitor and evaluate body weight and height, body mass index, body compartment estimates and for children, growth pattern indices. The majority of research in men, women, children and adolescents reports that fat-free mass and fat mass are altered in people with HIV infection.

Strong, Imperative

Recommendation Strength Rationale

  • Conclusion statements were Grades I and II.

Definitions:

Conditional versus Imperative Recommendations

Recommendations can be worded as conditional or imperative statements. Conditional statements clearly define a specific situation, while imperative statements are broadly applicable to the target population without restraints on their pertinence. More specifically, a conditional recommendation can be stated in if/then terminology (e.g., if an individual does not eat food sources of omega-3 fatty acids, then 1g of EPA and DHA omega-3 fatty acid supplements may be recommended for secondary prevention).

In contrast, imperative recommendations "require," or "must," or "should achieve certain goals," but do not contain conditional text that would limit their applicability to specified circumstances. (e.g., portion control should be included as part of a comprehensive weight management program. Portion control at meals and snacks results in reduced energy intake and weight loss).

Conclusion Grading Table

Strength of Evidence Elements Grade I
Good/Strong
Grade II
Fair
Grade III
Limited/Weak
Grade IV
Expert Opinion Only
Grade V
Grade Not Assignable
Quality
  • Scientific rigor/validity
  • Considers design and execution
Studies of strong design for question

Free from design flaws, bias and execution problems
Studies of strong design for question with minor methodological concerns

OR

Only studies of weaker study design for question
Studies of weak design for answering the question

OR

Inconclusive findings due to design flaws, bias or execution problems
No studies available

Conclusion based on usual practice, expert consensus, clinical experience, opinion, or extrapolation from basic research
No evidence that pertains to question being addressed
Consistency

Of findings across studies
Findings generally consistent in direction and size of effect or degree of association, and statistical significance with minor exceptions at most Inconsistency among results of studies with strong design

OR

Consistency with minor exceptions across studies of weaker designs
Unexplained inconsistency among results from different studies

OR

Single study unconfirmed by other studies
Conclusion supported solely by statements of informed nutrition or medical commentators NA
Quantity
  • Number of studies
  • Number of subjects in studies
One to several good quality studies

Large number of subjects studied

Studies with negative results having sufficiently large sample size for adequate statistical power
Several studies by independent investigators

Doubts about adequacy of sample size to avoid Type I and Type II error
Limited number of studies

Low number of subjects studied and/or inadequate sample size within studies
Unsubstantiated by published studies Relevant studies have not been done
Clinical Impact
  • Importance of studied outcomes
  • Magnitude of effect
Studied outcome relates directly to the question

Size of effect is clinically meaningful

Significant (statistical) difference is large
Some doubt about the statistical or clinical significance of effect Studied outcome is an intermediate outcome or surrogate for the true outcome of interest

OR

Size of effect is small or lacks statistical and/or clinical significance
Objective data unavailable Indicates area for future research
Generalizability

To population of interest
Studied population, intervention and outcomes are free from serious doubts about generalizability Minor doubts about generalizability Serious doubts about generalizability due to narrow or different study population, intervention or outcomes studied Generalizability limited to scope of experience NA

This grading system was based on the grading system from: Greer N, Mosser G, Logan G, Wagstrom Halaas G. A practical approach to evidence grading. Jt Comm. J Qual Improv. 2000; 26:700-712. In September 2004, The ADA Research Committee modified the grading system to this current version.

Criteria for Recommendation Rating

Statement Rating Definition Implication for Practice
Strong A Strong recommendation means that the workgroup believes that the benefits of the recommended approach clearly exceed the harms (or that the harms clearly exceed the benefits in the case of a strong negative recommendation), and that the quality of the supporting evidence is excellent/good (grade I or II)*. In some clearly identified circumstances, strong recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.
Fair A Fair recommendation means that the workgroup believes that the benefits exceed the harms (or that the harms clearly exceed the benefits in the case of a negative recommendation), but the quality of evidence is not as strong (grade II or III)*. In some clearly identified circumstances, recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits outweigh the harms. Practitioners should generally follow a Fair recommendation but remain alert to new information and be sensitive to patient preferences.
Weak A Weak recommendation means that the quality of evidence that exists is suspect or that well-done studies (grade I, II, or III)* show little clear advantage to one approach versus another. Practitioners should be cautious in deciding whether to follow a recommendation classified as Weak, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role.
Consensus A Consensus recommendation means that Expert opinion (grade IV)* supports the guideline recommendation even though the available scientific evidence did not present consistent results, or controlled trials were lacking. Practitioners should be flexible in deciding whether to follow a recommendation classified Consensus, although they may set boundaries on alternatives. Patient preference should have a substantial influencing role
Insufficient Evidence An Insufficient Evidence recommendation means that there is both a lack of pertinent evidence (grade V)* and/or an unclear balance between benefits and harms. Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as Insufficient Evidence and should exercise judgment and be alert to emerging publications that report evidence that clarifies the balance of benefit versus harm. Patient preference should have a substantial influencing role.

*Conclusion statements are assigned a grade based on the strength of the evidence. Grade I is good; grade II, fair; grade III, limited; grade IV signifies expert opinion only and grade V indicates that a grade is not assignable because there is no evidence to support or refute the conclusion. The evidence and these grades are considered when assigning a rating (Strong, Fair, Weak, Consensus, Insufficient Evidence - see chart above) to a recommendation.

Adapted by the American Dietetic Association from the American Academy of Pediatrics, Classifying Recommendations for Clinical Practice Guideline, Pediatrics. 2004;114;874-877.

Clinical Algorithm(s)

Algorithms are provided in the original guideline document for:

  • HIV/AIDS Nutrition Guideline
  • HIV/AIDS Nutrition Assessment
  • HIV/AIDS Nutrition Diagnosis
  • HIV/AIDS Nutrition Intervention
  • HIV/AIDS Nutrition Monitoring and Evaluation

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

The guideline contains conclusion statements that are supported by evidence summaries and evidence worksheets. These resources summarize the important studies (randomized controlled trials [RCTs], clinical trials, observational studies, cohort and case-control studies) pertaining to the conclusion statement and provide the study details.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • A primary goal of implementing these recommendations includes improving a person's ability to achieve optimal nutrition through healthful food choices and physically active lifestyle.
  • Although costs of medical nutrition therapy (MNT) sessions and reimbursement vary, MNT is essential for improved outcomes. MNT education can be considered cost effective when considering the benefits of nutrition interventions on the onset and progression of comorbidities versus the cost of the intervention.
Potential Harms

Risk/Harm Considerations

  • Access to registered dietitian who is linguistically and culturally sensitive to a population and to the human immunodeficiency virus (HIV)-infected population, as well as having at least general HIV education, is most desirable.
  • Information about the patient's medical condition is necessary to initiate medical nutrition therapy) MNT.
  • Chronic diarrhea that is unexplained or causes unintended weight loss, abdominal pain, or bloating should be investigated further, through stool examination for ova and parasites, cultures for enteric pathogens, and qualitative or quantitative measurement of fecal fat.
  • Intense physical activity in some overweight and obese individuals may contribute to disability or death; thus, consultation with a physician prior to beginning an exercise program should be recommended.
  • Before beginning a program of physical activity more vigorous than brisk walking, people with HIV infection should be assessed for conditions that might be associated with an increased risk of cardiovascular disease.
  • In previously sedentary individuals whose 10-year risk of a coronary event is likely to be equal to or greater than 10%, a graded exercise test with electrocardiogram (ECG) monitoring is recommended.

Contraindications

Contraindications

Clinical judgment is crucial in the application of these guidelines. Careful consideration should be given to the application of these guidelines for patients with significant medical co-morbidities.

Qualifying Statements

Qualifying Statements
  • This nutrition practice guideline is meant to serve as a general framework for handling clients with particular health problems. It may not always be appropriate to use these nutrition practice guidelines to manage clients because individual circumstances may vary. For example, different treatments may be appropriate for clients who are severely ill or who have co-morbid, socioeconomic, or other complicating conditions. The independent skill and judgment of the health care provider must always dictate treatment decisions. These nutrition practice guidelines are provided with the express understanding that they do not establish or specify particular standards of care, whether legal, medical, or other.
  • While the evidence-based nutrition practice guideline represents a statement of promising practice, based on the latest available evidence at the time of publication, the guideline is not intended to overrule professional judgment. Rather, it may be viewed as a relative constraint on the individual clinician's discretion in a particular clinical circumstance.
  • This guideline recognizes the role of patient and family preferences for possible outcomes of care, when the appropriateness of a clinical intervention involves a substantial element of personal choice or values.

Implementation of the Guideline

Description of Implementation Strategy

Description of Implementation Strategy

This publication of this guideline is an integral part of the plans for getting the American Dietetic Association (ADA) Medical Nutrition Therapy (MNT) evidence-based recommendations on human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) to all dietetics practitioners engaged in, teaching about or researching the topic. National implementation workshops at various sites around the country and during the ADA Food Nutrition Conference & Exposition (FNCE) are planned. Additionally, there are recommended dissemination and adoption strategies for local use of the ADA HIV/AIDS Evidence-Based Nutrition Practice Guideline.

The guideline development team recommended multi-faceted strategies to disseminate the guideline and encourage its implementation. Management support and learning through social influence are likely to be effective in implementing guidelines in dietetic practice. However, additional interventions may be needed to achieve real change in practice routines.

Implementation of the guideline will be achieved by announcement at professional events, presentations and training. Some strategies include:

  • National and Local Events – State dietetic association meetings and media coverage will help launch the guideline
  • Local Feedback Adaptation – Presentation by members of the work group at peer review meetings and opportunities for continuing education units (CEUs) for courses completed
  • Education Initiatives – The guideline and supplementary resources will be freely available for use in the education and training of dietetic interns and students in approved Commission on Accreditation of Dietetics Education (CADE) programs
  • Champions – Local champions will be identified and expert members of the guideline team will prepare articles for publications. Resources will be provided that include PowerPoint presentations, full guidelines and pre-prepared case studies.
  • Practical Tools – Some of the tools that will be developed to help implement the guideline include specially designed resources, such as clinical algorithms, slide presentations, training and toolkits.

Specific distribution strategies include:

Publication in full: The guideline is available electronically at the ADA Evidence Analysis Library Web site (www.adaevidencelibrary.com External Web Site Policy) and announced to all ADA Dietetic Practice Groups, Member Interest Groups, and State Affiliates. The ADA Evidence Analysis Library will also provide downloadable supporting information and links to relevant position papers.

Implementation Tools
Clinical Algorithm
Patient Resources
Quick Reference Guides/Physician Guides
Resources
Slide Presentation
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
American Dietetic Association. HIV/AIDS evidence-based nutrition practice guideline. Chicago (IL): American Dietetic Association; 2010 Dec. Various p.
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Dec
Guideline Developer(s)
Academy of Nutrition and Dietetics - Professional Association
Source(s) of Funding

American Dietetic Association

Guideline Committee

Expert Work Group

Composition of Group That Authored the Guideline

Work Group Members: Marcy Fenton, MS, RD, Chair; Saroj Bahl, PhD, RD, LD; Susan Basinger, RD; Janelle L'Heureux, MS, RD; Linda Parker, DSc, RD, LD; Pamela Rothpletz-Puglia, EdD, RD

Financial Disclosures/Conflicts of Interest

In the interest of full disclosure, American Dietetic Association (ADA) has adopted the policy of revealing relationships workgroup members have with companies that sell products or services that are relevant to this topic. Workgroup members are required to disclose potential conflicts of interest by completing the ADA Conflict of Interest Form. It should not be assumed that these financial interests will have an adverse impact on the content, but they are noted here to fully inform readers. Users of the evidence analysis library may assume that only work group members listed below have potential conflicts of interest to disclose.

None of the work group members listed above disclosed potential conflicts of interest.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available to members from the American Dietetic Association Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • American Dietetic Association (ADA) HIV/AIDS evidence-based nutrition practice guideline. Executive summary of recommendations. Chicago (IL): American Dietetic Association. 2010 Dec. Electronic copies: Available from the ADA Web site External Web Site Policy.
  • ADA HIV/AIDS evidence-based nutrition practice guideline presentation. Slide set. 44 p. Electronic copies: Available for purchase from the ADA Web site External Web Site Policy.

In addition, various resources for determining resting metabolic rate (PMR) are available in the appendices of the original guideline document, including practitioner and patient instructions for measuring RMR.

Patient Resources

Patient/client instructions for measuring resting metabolic rate are available in the appendices of the original guideline document.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on March 15, 2011.

Copyright Statement

The American Dietetic Association encourages the free exchange of evidence in nutrition practice guidelines and promotes the adaptation of the guidelines for local conditions. However, please note that guidelines are subject to copyright provisions. To replicate or reproduce this guideline, in part or in full, please obtain agreement from the American Dietetic Association. Please contact Kari Kren at kkren@eatright.org for copyright permission.

When modifying the guidelines for local circumstances, significant departures from these comprehensive guidelines should be fully documented and the reasons for the differences explicitly detailed.

Disclaimer

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