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All vitamins and minerals are termed as micronutrients because they are needed in very small or micro amounts. They cannot adequately be made by the body and must be obtained from diet and/or through supplements. Micronutrients do not provide energy but perform vital functions that regulate the many activities and chemical reactions that take place inside the body especially on cellular levels. Without sufficient intake of these micronutrients, symptoms of a deficiency can develop. If not treated, some deficiencies can cause sickness and death.
The US FDA has taken measures such that recommended dietary intake levels have been developed for each vitamin and mineral to give guidance as to how much should be taken every day to prevent deficiency. These are usually described as the RDA (recommended daily allowance). For many micronutrients, experts have also set an Upper Tolerable Limit (UL), which is the maximum daily amount a person should consume. Remember that these recommendations are set for the general population and do not take into consideration any disease state, like HIV. In this article we try to provide guidance about your specific needs as a person living with HIV.
An individual with HIV might be deficient in a micronutrient for any number of reasons: side effects make it hard to eat, nutrients from food are not absorbed, or the body needs more nutrients to fight the virus. Several studies have shown that people with HIV are at increased risk of developing micronutrient deficiencies.
In turn, these deficiencies can increase the rate of HIV disease progression to AIDS and can increase the risk of dying. For this reason it is believed that the micronutrient requirements for people with HIV are higher than the RDAs
Antioxidants are molecules are made by the body or found in some foods and supplements, Antioxidants protect the body by neutralizing other, unstable molecules, called free radicals, that are produced during normal cell functioning.
Long-term infections such as HIV can upset this balance by causing the body to produce more free radicals than usual. In turn, this can lead to a condition known as oxidative stress, in which the body cannot deal with all the free radicals it produces. Oxidative stress can cause a lot of damage to cells. Two ways to lessen the effects of oxidative stress are to increase antioxidant intake and to decrease exposure to things that increase oxidative stress, such as pollution and cigarette smoke.
Antioxidants can be boosted by dietary intakes of colourful fruits and vegetables, black and green tea. Antioxidant supplements include Vitamins C and E, the minerals zinc and selenium as well as coenzyme Q10, alpha lipoic acid and N-acetyl cysteine.
Please refer to table at the end of this article which lists the RDA (recommended daily allowance), UL (upper tolerable limit) and experimental high dose, toxicity, function and food sources.
Several studies have shown that vitamin and mineral supplements can have many benefits in people living with HIV. Taking a multivitamin every day is an important part of a nutritional health plan.
may help slow disease progression in people with HIV. They are also important for healthy mitochondria, the power-producing structures in cells, and may help decrease the impact of mitochondrial toxicity. B vitamins are depleted quickly in times of stress, fever or infection, as well as with high consumption of alcohol. Keep in mind that the RDA is very low and taking a total of 50 mg of B1, B2 and B3 will more than cover B-vitamin needs. Check the multivitamin you take; if it has 30 to 50 mg of these vitamins, you don’t have to take a B-complex supplement in addition to the multivitamin.
levels in the blood may be low in people with HIV. It can also be low in people over the age of 50 years. B12 deficiency is associated with an increased risk of peripheral neuropathy, decreased ability to think clearly, and a form of anemia. People with low B12 levels usually feel extremely tired and have low energy. This deficiency is also linked with HIV disease progression and death. Always get blood tests done at your hospital to check your blood levels. If they’re low, ask about B12 injections to get them back into the ideal range.
If you get B12 injections and your vision is getting worse, mention it to your doctor, especially if you are a smoker. Some forms of injectable B12 can damage your eyes if you have a rare genetic condition called Lerber’s hereditary optic atrophy.
is one of the most important antioxidants. It is very effective at cleaning up molecules that damage cells and tissues. Vitamin C has been studied for cancer prevention and for effects on immunity, heart disease, cataracts and a range of other conditions. Although vitamin C cannot cure the common cold, supplements of 1,000 mg per day have been found to decrease the duration and severity of symptoms.
In people with HIV, there is some evidence that vitamin C can inhibit replication of the virus in test-tube experiments, but it is unclear what this means in the human body. The most important benefit for people with HIV is the widespread antioxidant action of vitamin C. The daily experimental high dose is between 500 mg and 2,000 mg, the upper tolerable limit.
is emerging as a very important nutrient, with more diverse functions than just its traditional role in calcium metabolism. New evidence suggests that 1,000 IU per day should be the recommended daily intake.
Vitamin D is found in some foods, but these sources generally do not provide enough vitamin D on a daily basis. Also, people who live in northern climates (like Canada) probably do not get enough sun exposure to make adequate vitamin D. And the use of sunscreen, which is highly recommended to prevent skin cancer, blocks the skin’s ability to make vitamin D.
For people with HIV, vitamin D supplements are a sure way to get the recommended daily allowance. Vitamin D is found in multivitamins and calcium supplements as well as individual vitamin D pills. Look for vitamin D3; it is the active form of the vitamin. Be sure to add up all the vitamin D from different supplements to be sure you are not getting too much.
has been used as an antioxidant, typically at doses of 400 IU per day. However, studies have found that people who take more than 200 IU per day may be at higher risk of developing heart disease. Until this is fully studied, it may be a good idea to reduce vitamin E supplements to 200 IU unless your doctor suggests you take more.
Vitamin E deficiency is associated with faster HIV disease progression. People with poor fat absorption or malnutrition are more at risk of being deficient in vitamin E. Use supplements from natural sources and those with “mixed tocopherols” for better effect.
supplements to treat iron-deficiency anemia (low levels of red blood cells) should only be taken if prescribed by your doctor. Iron-deficiency anemia is diagnosed by having a low hemoglobin level in the blood. This can be confusing in someone on HAART because some anti-HIV drugs, especially AZT, can cause low hemoglobin levels. There are other blood tests that can help determine whether there really is an iron deficiency. The important point is to not take high doses of iron unless they are prescribed. Iron is a pro-oxidant (the opposite of an antioxidant), which means it can damage different tissues in the body.
is a critical mineral for the immune system; a deficiency can cause severe immune suppression. People with chronic diarrhea, new immigrants from refugee camps and malnourished people with HIV, especially children, are at high risk of having a deficiency. Be aware that high doses of zinc supplements in people who are not deficient can decrease immune function.
helps regenerate glutathione, the major antioxidant in cells. Studies have shown that low selenium levels in the blood are associated with an increased risk of disease progression and death. Deficiency is associated with low CD4+ cells. One small study found that a daily supplement of 200 micrograms might have a positive effect in some people with HIV. Studies of the general population suggest that selenium supplementation may provide some protection from cancer.
involved in keeping bones strong. Get enough calcium from food plus supplements. For prevention, aim for 1,000 mg of calcium a day. As treatment, aim for 1,500 mg a day.Take calcium supplements with food and spread them over several meals for better absorption. Calcium carbonate is the most common form of supplement and the most concentrated, which means fewer pills to take. However, some people find it constipating and bloating. Calcium citrate may be better absorbed and tolerated.
In recent years, low bone mass and density, called osteopenia or osteoporosis, has become a widespread problem among people with HIV. Osteopenia is an early stage of bone mineral loss in which the bones become less dense and weaker. This condition does not cause pain or limit movement and is usually treated with diet and exercise rather than medications. Osteoporosis, the more advanced form of the disease, results in fragile bones that can fracture easily. The fracture causes pain, limits movement and reduces quality of life. Osteoporosis is sometimes treated with medications as well as diet and exercise. Note that osteoporosis medications may not be suitable for all people, especially women of childbearing age.
It is still not clear whether bone problems are caused by HAART or by the virus itself. However, many other factors are well known to increase the risk of developing osteopenia or osteoporosis. These include genetics (e.g. your mother had osteoporosis); getting older; low physical activity; being underweight; malnutrition; not enough calcium, vitamin D or protein; poor absorption of nutrients; diseases of the liver, gut or kidneys; and low levels of hormones such as estrogen or testosterone.
Some doctors recommend that people with HIV should have their bone density measured every two years by a special X-ray technique called a DEXA scan. The DEXA compares bone density to standards called T-scores. If the T-score is -1.0 to -2.5, it is considered osteopenia; if it’s below -2.5 (for example, -3.2), it is considered osteoporosis.
Nutrition is always the first line of treatment for osteopenia or osteoporosis, and studies have shown that increasing calcium and vitamin D can restore some bone mineralization.
Here we cover some of the other supplements used by people with HIV. In some cases, the benefits of these supplements have been described in small human studies, animal studies and case reports. The therapeutic doses are not really known for HIV disease and recommendations given here are based on doses used for other conditions or in studies.
These and other supplements can be quite expensive and should not be seen as a replacement for a healthy diet and lifestyle. Before starting any new supplement, get information from a knowledgeable healthcare professional. And be sure to discuss it with your doctor. Also, it is best to start only one new supplement at time, so you can be more aware of any side effects.
is a powerful antioxidant made by the body that is used to regenerate glutathione (the major antioxidant in cells) as well as the activated form of vitamins C and E. It also plays an important role in energy production in the mitochondria. Lipoic acid is used to treat diabetic neuropathy (a nerve condition associated with diabetes) and liver disorders, and it may also have a role in slowing the hardening of the arteries (arteriosclerosis). The dose recommended for diabetic neuropathy is 100 mg 3 times per day; the dosage for HIV is unknown.
(also known as L-carnitine) is a natural substance found in foods and made by the body. It works with the mitochondria to process fats and produce energy for the cells. It does this mainly by supplying the building blocks needed by the mitochondria to make an energy molecule called ATP, the basic fuel for cells. Most of the research suggests that carnitine has a protective effect on the central and peripheral nervous systems and the heart, probably because of its role in mitochondrial function. It may be helpful in the treatment of peripheral neuropathy (numbness, tingling or burning in the feet and sometimes hands), dementia and mitochondrial toxicity.
Over-the-counter supplements may contain a version of carnitine called acetyl-l-carnitine but beware that some have very little L-carnitine in them; be sure to buy from a reliable source. In Canada, L-carnitine is available by prescription and is called Carnitor.
The therapeutic dose for L-carnitine is somewhere between 500 and 3,000 mg daily. The dosage is not defined because it has not been studied enough or approved for these applications. Some people with HIV who have mitochondrial toxicity and/or peripheral neuropathy appear to benefit from 1,500 mg of acetyl-l-carnitine once or twice daily for many months. Carnitine supplements should be spread out over 3 daily doses to prevent side effects, most commonly diarrhea.
a derivative of the amino acid L-cysteine, is a potent antioxidant that regenerates glutathione in the cell In this role, NAC protects liver cells by decreasing oxidation. Cysteine appears to decline in people with HIV who have low CD4+ cell counts and in those with wasting and weight loss. NAC supplements may be able to replenish low glutathione and improve the antioxidant capacity of cells. Study doses have been as high as 2,000 mg per day, but this is expensive and may not be well tolerated. Side effects include nausea, vomiting, diarrhea and headache. The most beneficial dose is not certain, although a dose of 500 mg per day may offer some benefit with a reduced risk of toxicity.
is an amino acid that is used to provide fuel for intestinal cells, muscle cells and immune cells. It plays an important role in immunity because it helps to maintain the intestinal barrier and is a preferred fuel for various cells of the immune system. Glutamine levels decline during periods of physiological stress like opportunistic infection, surgery, burn and cancer. It may have a therapeutic role in treating intestinal disease and wasting, and some people with HIV have found it to be a good treatment for chronic diarrhea. The dose for treating diarrhea is 10 to 30 grams per day; the maintenance dose is 5 grams per day. It is best absorbed if dissolved in water and taken on an empty stomach.
are live organisms, including the bacteria Lactobacillus and Bifidobacterium species and yeasts. They help build a healthy population of good bacteria (microflora) in the intestines. Microflora keep the gut healthy by preventing the growth of disease-causing bacteria and maintaining the intestinal barrier. Probiotic supplements are helpful after a course of antibiotics because they replace the microflora that were damaged by the antibiotic. Probiotics may also reduce chronic diarrhea and improve symptoms of irritable bowel syndrome. The most common type of probiotic is L. acidophilus but some products now contain mixed organisms. These are found in foods that contain live culture, such as yogurt and kefir. Purchase supplements that are refrigerated and have a long shelf life.
is a substance that plays a role as an antioxidant as well as a cofactor in mitochondrial energy production. It has been used to treat congestive heart failure and gum disease (gingivitis) and may help protect the heart and nerves. Statins, a class of cholesterol-lowering drugs, reduce CoQ10 levels. The usual CoQ10 dosage range is 60 to 240 mg daily.
Many people use herbal remedies to supplement their diet. It is always important to do this with caution and to tell your doctor and/or HIV pharmacist what you are taking. Some supplements can stop anti-HIV drugs working properly.
People with HIV could stand to benefit from adding powdered moringa leaves (Moringa oleifera) to their diet, especially during antiretroviral therapy, as this can improve their nutritional status and boost their immune system, according to research in BMC Complementary and Alternative Medicine.
Researchers at the Université libre de Bruxelles in Belgium compared the effects of daily supplementation with moringa leaf powder against nutritional counseling in HIV patients under retroviral therapy. In particular, the team looked at whether supplementation can improve the nutritional and immune status of the patients during treatment.
The World Health Organization (WHO) defines standard antiretroviral therapy (ART) as “the combination of antiretroviral (ARV) drugs to maximally suppress the HIV virus and stop the progression of HIV disease.” To note, this procedure does not eliminate the virus from the body, but simply prevents it from progressing to more advanced forms such as AIDS. In conventional medicine, most healthcare professionals recommend ART to manage HIV/AIDS.
However, one of the side effects of this type of treatment is the loss of appetite, and metabolic disorders.In some countries like many in the African continent, moringa is used to fight these adverse side effects..
( Reference: CD4 pattern in HIV positive patients on HAART exposed to moringa oleifera leaf powder in south east Nigeria E.N. Ogbuagu1, S. Ufearo2C.N. Ogbuagu3R. Okonkwo1 PlumX Metrics DOI: https://doi.org/10.1016/j.ijid.2016.02.595)
Milk thistle is a common herb used in people to improve liver function and does not interact significantly with antivirals. Keep in mind though that other herbs may interact with conventional HIV treatments.
Medical Marijuana Loss of appetite is common in people with HIV. And some antiviral medications can upset the stomach and make it harder to keep up with scheduled medication doses. Marijuana can help reduce pain, control nausea, and increase appetite. However, medical marijuana is legal only in certain countries. In addition, smoking marijuana is associated with many of the same health risks as the smoking of any substance. A doctor can provide more information.
There’s little evidence to suggest that medical marijuana will interact with modern HIV management medications. Still, people with HIV should consult their healthcare provider before using marijuana to treat their symptoms. The provider will monitor for possible drug interactions or respiratory complications.
The following are some herbal supplements known to interact with Antiretroviral Drugs, Although some fo the newer drugs might not be affected, always consult a doctor first.
Garlic capsules are frequently taken because they are believed to protect the heart. However, they may prevent drugs in the protease inhibitor class from working properly. Garlic capsules were shown to stop saquinavor (Invirase) working properly and it is thought they could have a similar effect on other protease inhibitors and some NNRTIs (non-nucleoside reverse transcriptase inhibitors). Garlic taken in food does not have this effect.
St John’s wort, the herbal antidepressant, was also shown to be inappropriate for people taking protease inhibitors and NNRTIs. The herb was shown to lower levels of the protease inhibitor indinavir (Crixivan) and researchers concluded that it should not be taken with any other protease inhibitors, NNRTIs or maraviroc (Celsentri), as the body processes all of them in the same way.
African Potato and Sutherlandia are two herbal remedies that have been demonstrated in test-tube studies to interfere with the body's ability to process protease inhibitors and NNRTIs.
Echinacea and Ginseng are purported to boost immune function. However, both can interact with certain HIV medications. It may be okay to use these supplements depending on the HIV therapy. A healthcare provider should be consulted.
There is also a theoretical risk of an interaction between anti-HIV drugs and many other herbal preparations, including borage oil, DHEA, ginkgo biloba, liquorice, and valerian. Your HIV pharmacist can give specific advice about potential interactions between your anti-HIV drugs and herbal remedies.
Thailand Medical New will continue to provide more information with regards to various aspects of HIV such as latests drugs, latest research, health tips , drug interactions, secondary diseases associated with HIV etc.
This table lists the RDA (recommended daily allowance), UL (upper tolerable limit) and experimental high dose, toxicity, function and food sources. The RDA usually includes all intake, from both food and supplements, while the UL is from supplements only. Caution should be exercised when taking doses above the UL.
|Nutrient||RDA||UL*||Experimental high dose**||Potential toxic effects||Main function||Best food sources|
|Vitamin A||Men: 3,000 IU
Women: 2,300 IU
|10,000 IU||3,000-10,000 IU||Liver toxicity, dry rough skin and cracked lips, irritability, headache, birth defects||Healthy immune barriers and epithelial tissue, growth, reproduction, bone and red blood cell formation, vision||Foods high in beta carotene, fortified foods, liver|
|Beta carotene (as mixed carotenoids)||ND||ND||5,000-25,000 IU||Possibly increased lung cancer in smokers, harmless orange skin colour||Antioxidant, source of vitamin A, immune booster, possible cancer prevention, vision||Orange, yellow, red and green vegetables and fruits|
|Vitamin D||9-50 years: 200 IU
51-70 years: 400 IU
> 70 years: 600 IU
Osteopenia or osteoporosis: 1,000 IU
|2,000 IU||1,000 IU||Heart/liver/kidney toxicity, hypercalcemia (excess calcium in the blood)||Calcium metabolism, bone mineralization, possible cancer prevention||Fortified milk, fatty fish|
|Vitamin E||22 IU||1,500 IU||200 IU||Possible increase in heart disease, excess bleeding||Antioxidant, anticoagulant, protection from heart disease, possible cancer prevention||Wheat germ, vegetable oils, nuts|
|Vitamin K||M: 120 mcg
W: 90 mcg
|ND||ND||Interaction with blood thinners||Bone mineralization, blood clotting||Green leafy vegetables|
|Vitamin C||M: 90 mg
W: 75 mg
smokers add 35 mg
|2,000 mg||500-2,000 mg||Pro-oxidant, excess iron absorption, diarrhea||Antioxidant, immunity, antiviral in test-tubes, cancer prevention, increases iron absorption||Fruits and vegetables, especially peppers and citrus fruits|
|Thiamine (B1)||M: 1.2 mg
W: 0.9 mg
|ND||30-100 mg||Very high doses may promote tumour growth||Energy metabolism, mood, nervous system||Whole grains, brown rice, fortified foods, legumes, pork, oysters|
|Riboflavin (B2)||M: 1.3 mg
W: 1.1 mg
|ND||30-100 mg||ND||Energy metabolism, antioxidant, possible migraine prevention||Dairy products, leafy greens, oysters|
|Niacin (nicotinic acid)||M: 16 mg
W: 14 mg
|35 mg||500-1,000 mg||Itching, skin flushing,
liver toxicity, insulin resistance
|Energy metabolism, lowers LDL cholesterol and triglycerides, raises HDL cholesterol||Poultry, red meat, fish, legumes, peanut butter, nuts|
|Vitamin B6||M: 1.3-1.7 mg
W: 1.3-1.5 mg
|100 mg||100 mg||Nerve damage (neuropathy)||Protein metabolism, immunity, neurotransmitter synthesis (e.g. serotonin and dopamine), treats peripheral neuropathy and PMS||Meat, fish, poultry, eggs, potatoes, fortified cereals, peanuts, soybeans|
|Folate||0.4 mg||1 mg||0.4 -1.0 mg||High dose can mask B12 deficiency leading to nerve damage||Cell division, prevents neural tube defects and perhaps other birth defects, lowers homocysteine, possible cancer prevention||Leafy greens, legumes, oranges, broccoli, cauliflower|
|Vitamin B12 (cobalamin)||2.4 mcg||ND||1,000 mcg weekly or monthly for deficiency||Rare cases of eye damage||Cell division, amino acid metabolism, nervous system, mental function||Fish, shellfish, meat, fortified soy and rice milk, fermented soy products|
|Calcium||1,000-1,200 mg||2,500 mg (from food and supplements)||1,000-1,500 mg||Calcium deposits in soft tissues||Bone mineralization, muscle contraction||Dairy products, fortified soy and rice milk, fish bones|
|Magnesium||M: 400 mg
W: 320 mg
|350 mg||350 mg||Diarrhea, decreased calcium absorption||Bone mineralization, active in more than 300 chemical reactions in the body||Whole grains, nuts, green vegetables, legumes|
|Iron||M: 8 mg
W: 18 mg
|45 mg||Use only to treat iron-deficiency anemia||Iron overload disorders, heart disease, liver cirrhosis||Makes hemoglobin which carries oxygen, makes energy in the mitochondria||Meat, legumes, tofu, leafy greens, breakfast cereals|
|Zinc||M: 11 mg
W: 8 mg
|40 mg||40 mg||Immune suppression, nausea, metallic taste, copper deficiency||Growth, immunity, wound healing, taste, sperm production, antioxidant, prostate health||Oysters, meat, poultry, fish|
|Selenium||55 mcg||400 mcg||100-400 mcg||Brittle hair and nails, irritability, garlic breath, fatigue, nausea||Antioxidant, immunity, possible cancer prevention, viral infections||Whole grains from selenium-rich soils, poultry, meat, dairy|
|RDA: recommended daily allowance (from all sources); UL: upper tolerable limit (from supplements only); ND: not determined; IU: international unit; mg: milligram; mcg: microgram
* Caution should be exercised when taking doses above the UL.
** There is little to no evidence of efficacy for these doses. Discuss your options with upur doctor