no diet secrets

No Diet Secrets

INFORMATION FOR MEDICAL PRACTITIONERS

This publication is sponsored by the

S O U T H A F R I C A N S U G A R A S S O C I A T I O N

NO DIET SECRETS

Contributors

Editor

Professor Frederick J. Veldman, PhD

Associate Professor

Head of Discipline: Dietetics and Human Nutrition

School of Agricultural Sciences and Agribusiness

University of KwaZulu Natal (Pietermaritzburg Campus)

Weight Loss/ Weight Management

Professor Marjanne Senekal, PhD

Associate Professor

Head: Division of Human Nutrition

Department of Human Biology

Faculty of Health Sciences

University of Cape Town

Cardiovascular Disease

Professor Marius Smuts, PhD

Professor in Nutrition

School for Physiology, Nutrition and Consumer Sciences

Centre of Excellence in Nutrition

North-West University (Potchefstroom Campus)

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Diabetes Mellitus

Professor Renée Blaauw, PhD

Associate Professor in Therapeutic Nutrition

Acting Head: Division of Human Nutrition

Faculty of Health Sciences

Stellenbosch University

Oral Health

Dr Jennifer MacKeown, MSc Dentistry, PhD

Private Practising Dietitian

Special interest in General Nutrition

HIV/AIDS

Professor Corinna Walsh, PhD

Associate Professor

Department of Nutrition and Dietetics

University of the Free State

Drug-Nutrient Interactions in the Management of Tuberculosis and Hypertension

Professor Frederick J. Veldman, PhD

Associate Professor

Head of Discipline: Dietetics and Human Nutrition

School of Agricultural Sciences and Agribusiness

University of KwaZulu Natal (Pietermaritzburg Campus)


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Contents

Foreword Professor Frederick J. Veldman, PhD

Weight Loss/Weight Management Professor Marjanne Senekal, PhD

Cardiovascular Disease Professor Marius Smuts, PhD

Diabetes Mellitus

Professor Renée Blaauw, PhD

Oral HealthDr Jennifer MacKeown, MSc Dentistry, PhD

HIV/AIDS

Professor Corinna Walsh, PhD

Drug-Nutrient Interactions in the Management of Tuberculosis and Hypertension Professor Frederick J. Veldman, PhD

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Foreword

Recent events in the South African health scene have to some extent stigma-tised the role of nutrition in health and disease. The only way to address this is by ensuring that health professionals are aware of how nutrition can promote and sustain good health, based on sound scientific evidence. It is extremely important to realise that within the context of correct medical care, nutrition should never be perceived as a cure, but that its importance as a complement and link to support effective treatment outcome should never be underesti-mated.

The relationship between specific nutrient deficiencies and ill health is well documented. Yet, in recent years it has also been shown how existing nutrient deficiencies in the pres-ence of other non-related pathological conditions, such as infection with the HIV, can exacerbate the clinical manifestations generally associated with its disease progression, whether it be the rate at which clinical symptoms develop and even re-occur, or the se-verity with which they manifest. It has been shown over and again that individuals with a healthy nutritional status have a better prognosis, when compared to those diagnosed with some form of malnutrition. It is important to acknowledge that in South Africa, mal-nutrition is not only represented by under-nutrition, but also includes the rapidly rising prevalence of over-nutrition in a sector of the population that were once protected against it by their prudent lifestyle. Now, in South Africa, we see a rapid increase in the prevalence of those pathological conditions that we generally associate with overnutrition, includ-ing insulin resistance, hypertension, hypercholesterolaemia, hypertriglyceridaemia etc. The most recent studies show that these pathological conditions also target children. It is estimated that the overall burden of cardiovascular disease alone is predicted to rise by approximately 150% in the developing world within the next 20 years. In the presence of infectious diseases associated with under-development, poverty and under-nutrition, chronic diseases associated with over-nutrition and western lifestyle, HIV/AIDS and other injury-related deaths, over- and under-nutrition that co-exist in one single population makes our task as health professionals so much more difficult.

Diet is one of the few controllable risk factors that, if approached wisely, could, togeth-er with other medical interventions, such as surgery or even pharmaceuticals, not only benefit the patient directly, but also support treatment outcome, such as in the case of


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antiretroviral therapy. Improved nutritional status contributes towards the general well-being of any individual, including on a psychological level. Yet, in order to provide the cor-rect basic guidance to the patient, it is important to ensure that as a health practitioner you understand exactly the role of nutrition intervention in specific disease conditions.This is especially relevant for the patient diagnosed in the early stage of the disease – before the development of any serious long-term pathological complications that require surgical or pharmaceutical intervention. It has been shown that early dietary intervention in many instances delays the need for medical intervention, such as the use of drugs, which not only reduces the risk of developing additional long-term side-effects, but in most instances, also reduces the financial burden on the patient.

It is therefore with this booklet that we promote nutrition as a support to improved health, looking at it from a local point of view, based on sound scientific evidence. It is en-visaged that the information in this document equip the health practitioner with the basic knowledge to guide patients at risk of developing any of the given conditions, towards optimal nutritional health, especially as a tool for prevention. The issue of diet is a volatile one. An individual's eating habits are integral to that person’s way of being, and as such, are often difficult to change, even if one desires to do so. The medical practitioner plays an integral role in this process and should at all times be aware of this.

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Weight Loss / Weight Management

Overweight and obesity and central adiposity (a high waist circumference) have recently been reported to be on the increase among the general South African population, with an estimated 21% of all males being overweight and 8% of them obese, while 27.5% of all females are overweight and a total of 27.4% obese. Obesity is also rapidly on the rise in young children, with the subsequent emergence of more “affluent” disease states. The resultant overall burden of cardiovascular disease is predicted to rise by approximately 150% in the developing world within the next 20 years. Excess body weight is a major health risk in South Africans and is now the cause of 7% of all deaths in the country, and an estimated 10% of healthy life years lost. The burden of disease attributable to obesity is 87% for type 2 diabetes, 68% for hypertensive disease, 61% for endometrial cancer, 45% for ischaemic stroke, 38% for ischaemic heart disease, 31% for kidney cancer, 24% for osteoarthritis, 17% for colon cancer and 13% for postmenopausal breast cancer. For any specific BMI, a larger waist circumference is associated with greater risk of morbidity, when compared to a smaller waist circumference.

Weight gain only occurs when energy intake exceeds the amount of energy expended (positive energy balance). Many genetic and environmental factors affect this energy bal-ance. Major advances in the understanding of the genetic basis of obesity have been made in recent years. Estimates of the relative contribution of genetics versus environ-ment in the development of obesity vary from 25 % to 75%. It is now generally accepted that “obesity is most likely to occur when a genetically susceptible individual encounters an environment conducive to obesity”. Such an environment will include inactivity, thus decreased energy expenditure, as well as the consumption of excessive energy, usually in the form of an energy dense (especially high-fat, but also high-sugar) diet. Guidelines to ensure optimal weight management (prevention of weight gain, weight loss if neces-sary and weight maintenance after weight loss) should thus focus on increased physical activity and decreased energy intake, bearing in mind that genetic predisposition may result in considerable variability in the response of individuals to intervention strategies/programmes.



ASSESSMENT OF WEIgHT STATuS AND ASSOCIATED HEALTH RISK AS WELL AS IDENTIFICATION OF WEIgHT MANAgEMENT gOALS

The most commonly used indicator of weight status for adults is the Body Mass Index (BMI), calculated from: weight (kg) divided by height (m2). The BMI needs to be combined with waist circumference assessments for health risk diagnosis (see Table 1).

Table 1. Weight categories, associated health risk and weight management goalsa

BMI range (kg/m2)

Risk category

Weight management goals Additional risksb to consider for weight management goals(all risk categories)

18.5 - 24.9 Low-to-average

Promote prevention of weight gain; If high waist circumference (WC) , emphasize physical activity and healthy eating

Body fat distributionWC > 102cm for males; > 88cm for females

Weight historyObese/overweight as child/adolescentRepeated failed weight loss attemptsFamily history of obesity Co-morbidities

Biochemical indicatorsElevated blood pressureElevated blood glucoseImpaired glucose toleranceElevated blood lipids(Triglycerides, LDL- cholesterol)

Lifestyle indicatorsSedentary lifestyle:<150 min moderate - vigorous activity/weekHigh total energy and fat intakeSmokingHigh alcohol intake

Co-morbiditiesd

Type 2 diabetesGallbladder diseaseCoronary heart diseaseOsteoarthritis

25.0 - 29.9 Increased Sustained weight loss of 5-10% of starting weight (see comprehensive weight loss programme Table 2); Manage any co-morbidities

30 - 40 without co-morbidities

Moderate-to-severe

Sustained weight loss of 5-10% of starting weight (see Table 2)

≥ 30 withco-morbidities

Severe Treat co-morbidities. Sustained weight loss of 5-10% of starting weight (see Table 2); VLEDc can be consideredPharmacological intervention can be considered

≥ 40 Very severe

Treat co-morbidities. Sustained weight loss of 10% (see Table 2); VLEDc can be considered Pharmacological intervention can be considered Consider surgical options if appropriate

a Adapted from SASSO4

b The more additional risks identified, the more important weight loss becomes for healthc VLED = Very Low Energy Diet (840 to 2560kJ); no evidence for better long-term weight loss d High-to-moderate risk, not all co-morbidities indicated


Components of a comprehensive programme for weight management through life-style modification

It is currently recommended that the focus of overweight/obesity treatment should not be so much on weight loss per se, but rather weight management, thus attaining the best weight possible in the context of overall health. The components of such a comprehen-sive weight management programme are summarized in Table 2.

Table 2. Essential weight loss programme components

Component Description/guidelines

Identification of a reasonable weight goal

Weight goals should be individualised, realistic, and maintainable and contribute to general well-being. Factors to consider: current BMI, health risk (see Table 1); family history of obesity; personal weight history from childhood, dieting history, cultural and social perspectives. Aim to lose maximum 5-10% of starting weight and maintain this weight for 6 months before attempting further weight loss.

Rate of weight loss Suggested rate of weight loss: 0.5 to 1kg per week, which could result in weight loss of 5 to 10% (± 12.5 to 25kg) of starting weight in 12 to 25 weeks.

Energy allowance An energy deficit of between 2200-4200kJ could theoretically result in a weight loss of 0.5 to 1kg/week. The minimum safe energy allowance for healthy weight loss is 4200kJ or more. Energy allowance for weight loss needs to be individualized.

Healthful eating Healthful eating should be based on the South African Food Based Dietary Guidelines. Meal plans for weight loss need to be individualized bearing in mind usual eating pattern, socio-economic and cultural factors.

Physical activity To ensure health, 30 minutes of moderate-to-vigorous activity should be done each day (5x) of the week. For weight loss 45-60 minutes of moderate-to-vigorous activity should be done on most (5) days a week. Accumulating 10 minutes here and there is acceptable, including activity of daily living e.g. house work, garden work, walking stairs and walking in general.

Behavioural and psychological strategies

Focus on long-term life-style changes; self-concept, body image, stress management; cognitive behavioural skills and self-monitoring to bring about change. Consider readiness to manage weight. Behaviour and psychological strategies should be individualized.

Weight maintenance Plan the weight maintenance phase to ensure the following: Appropriate energy intake and eating behaviour; continued physical activity; continued self-monitoring and therapist contact/support.


Pharmacological intervention Pharmacological therapy can be considered as adjuvant to diet therapy if there is clear evidence that the above components have been implemented effectively, but have not resulted in the expected weight loss.

Weight loss supplements/products and fad diets

Meal replacements may be considered for those who experience continued problems with stimulus control. Most products/fad diets are not recommended due to lack of scientific evidence regarding effectiveness as well as possible side-effects.

POINTS FOR DISCuSSION

Point 1. Overweight/obesity and associated health risks: Refer to the background in-formation and Table 1 for details on this point and decide which of them are relevant.

Point 2. Reasonable weight goal: Measure weight, height and waist circumference. Calculate BMI and assess the health risk and weight loss goal using the crite-ria stated in Table 1. Check appropriateness bearing in mind the factors men-tioned in the section on ‘Identification of a reasonable weight goal’ in Table 2.

Point 3. Readiness to embark on a weight management programme. Ask yourself the following questions:

Question Yes No

Have you tried to lose weight often in the past?

Were you mostly unsuccessful, meaning that you either did not lose much weight or you did lose weight but regained it at a later stage?

Are you inclined to binge often without being able to stop?

Do you have a problem with compulsive eating, meaning eating all the time, any time?

Do you feel that you have an obsession with eating, meaning that you never stop thinking about food and what you are going to eat next.

Do you suffer from any serious psychological or emotional problems?

If you answers Yes to the first two questions and/or yes to two or more of the other ques-tions, it may be better to focus on preventing any further weight gain at this stage (see Table 1 for specific goals for prevention of weight gain) and work on addressing problems areas, for which you answered YES. Once you have been able to control these issues for a period of at least 6 months or more, weight loss can be attempted again.

Point 4. The suggested rate of weight loss: The suggested rate of weight loss (0.5 to 1kg per week) is much slower than the expectations most dieters have in this


regard. Fast weight loss results in more muscle breakdown and water losses compared to slow weight loss. Fast weight loss sets you up for failure, because as soon as energy intake increases, lost muscle and water are replaced, result-ing in quick weight regain.

Point 5. Importance of the comprehensive approach to weight management: You need to understand that there is no quick fix for overweight and that weight man-agement is a lifelong process, involving most components indicated in Table 2.

Point 6. General weight management guidelines to start off with: the following key ac-tions can be taken to initiate weight management and can pave the way to a more in depth consultation with a registered dietitian:

• Reduce the amount of fat you eat drastically (any type of fat);

• Reduce/exclude the intake of foods rich in refined carbohydrates such as white bread, cake, biscuits, tarts, sweets, chocolates, sweetened cold drinks, milk drinks, yoghurts and desserts, ice-cream and sugar in tea and coffee;

• Increase the intake of high fibre foods such as brown and whole wheat bread, high fibre cereals, oats, legumes, fruits and vegetables (minimum of five fruits and vegetables in total);

• Reduce or avoid alcohol intake;

• Increase your physical activity by walking instead of driving, extra walking for relaxation, taking the stairs instead of the lift and/or joining a gym or starting a sport.

Point 7. Unhealthy/extreme/fad weight loss methods: the following characteristics of such diets include:

• An energy recommendation of less than 4200kJ per day;

• The promise of fast, easy and huge weight losses in a short period of time;

• Guarentees of success without any effort, hardships or self-discipline on your side; especially if the need for increased physical activity and de-creased food intake is negated;

• Emphasis on increasing, decreasing or leaving out specific foods or food groups or emphasis on avoidance of certain nutrient combinations such as carbohydrates and proteins. The motivation given is usually that the foods or combinations of nutrients are either bad/toxic or have ‘magical’ quali-ties to help you lose weight;

• Claims that certain food components, supplements, hormones, pills and potions help to melt fat away.


REFERENCES

1. Bowerman S, Bellman M, Saltsman P, Garvey D, Pimstone K, Skootsky S, Wang H-J, Elashoff R & Heber D. Implementation of a primary care physician network obesity management program. Obes Res 2001; 9:321S-325S

2. Department of Health. South Africa Demographic and Health Survey 2003. Full report: Department of Health, Medical Research Council, ORC Macro. 2007. Pretoria: Department of Health

3. Joubert J, Norman R, Bradshaw D, Goedecke JH, Steyn NP, Puoane T & the South African Comparative Risk Assessment Collaborating Group. Estimating the burden of disease at-tributable to obesity in South Africa in 2000. S Afr Med J 2007; 97:683-690

4. Puoane T, Fourie JM, Shapiro M, Rosling L, Tshaka NC & Oelofse A. ‘Big is beautiful’ – an exploration with urban black community health workers in a South African township. S Afr J Clin Nutr 2005; 18: 6-15

5. Saelens BE, Sallis JF, Wilfley DE, Patrick K, Cella JA & Buchta R. Behavioural weight control for overweight adolescents initiated in primary care. Obes Res 2002; 10:22-23

6. SASSO (Southern African Society for the Study of Obesity). Guidelines for the management of overweight and obesity in South Africa. 2003; Johannesburg, SASSO

7. Senekal M, Booely S & Mckiza Z. Nutrition for Adults. In: Steyn NP & Temple N eds. Com-munity Textbook for South Africa. 2008; Rome, FAO & MRC

8. Senekal M. Love My Body Love Myself. A Weight Management Manual for Women. 2005. Stellenbosch, Senekal

9. Stipanuk MH. Disturbances of energy balance. In: MH Stipanuk, ed. Biochemical, Physi-ological, Molecular Aspects of Human Nutrition. 2006. Missouri, Saunders 2nd ed.


Cardiovascular Disease

Coronary heart disease (CHD), also known as coronary artery disease (CAD) or ischaemic heart disease (IHD) is the most common cardiovascular disease (CVD). Atherosclerotic CVD is the most common cause of death worldwide. Atherosclerosis, a disease process characterised by arterial fat deposition (rich in cholesterol) that leads to scarring, and sometimes clotting as well, is usually caused by the combined effects of multiple factors but occasionally a single factor may be adequately powerful. CVD is associated with a combination of multiple genetic and modifiable risk factors. The morbidity and mortality asso-ciated with CVD ranks it as a major public health concern. CVD is a disease that has no geographic, gender or socio-economic boundaries. In the developing world, including South Africa, economic transition, urbanisation, industrialisa-tion and globalisation bring about lifestyle changes that promote the develop-ment of heart disease. Atherosclerosis develops over many years and is usually advanced by the time at which clinical symptoms manifest. Since atheroscle-rosis also relates strongly to lifestyle and modifiable physiological factors, risk factor modifications have been unequivocally shown to reduce mortality and morbidity in people with either unrecognised or recognised CVD.

Dietary intake is one of the lifestyle related risk factors for CVD. It is also modifiable. Diet can therefore be used as a strategy to limit the development of CVD, but also plays a cen-tral role in treating those with CVD. Dietary intervention should always be perceived as an integral part of the medical management strategy to reduce the mortality and morbidity from CVD. Such a strategy should encourage those who are following a diet that places them at risk of developing CVD, to change and instead follow a healthy and balanced diet. Patients with an unbalanced diet, especially a diet that increases their risk for developing CVD, should consult a dietitian to advise them on the appropriate dietary interventions.

guIDELINES FOR A HEALTHY LIFESTYLE

• Balance energy intake with energy expenditure

• Balance the amount of food you eat (energy intake) with the level of physical activ-ity (energy expenditure), to achieve and maintain a healthy bodyweight. Patients



with a normal bodyweight should make every effort to maintain it. Overweight in-dividuals should adapt their food intake to consume less energy dense food (food high in fat and sugar) and to exercise regularly in order to increase metabolism and lose weight. It is always advisable to consult with a health professional before fol-lowing any diet.

• Consume a variety of foods, i.e. vegetables, fruit, wholegrain products, legumes, choose fat-free or low-fat dairy products, cook poultry without skin, fish should be consumed at least twice a week, preferably fatty fish; purchase lean red meat. See below – advice on nutrition – for more details in this regard.

• Aim for a desirable lipid profile

• Maintain a normal blood pressure (BP)

• Maintain a normal fasting blood glucose concentration

• Be physically active

• At least half an hour of physical activity most of the days of the week is advisable, but to stay healthy choose enjoyable activities which fits into your daily routine. The duration of exercise should preferably be more or less 30-45 min, 4 to 5 times weekly at 60-75% of the average maximum heart rate

• Avoid use of and exposure to tobacco products

• Those who do not smoke should be advised to never start and all smokers should be professionally encouraged to permanently stop smoking all forms of tobacco

• Avoid the excess use of alcohol

• Epidemiologic evidence indicates that the consumption of small amounts of alcohol (one standard drink for a woman and two for a man) on a regular basis is associated with a decreased risk for the development of CVD. However, increasing amounts of alcohol have adverse effects on body mass, blood pressure, CVD risk and liver function. Until the mechanisms responsible for the apparent benefit of the limited intake of alcohol are clearly understood, it is not necessary to deliberately consume alcoholic beverages based on its apparent health benefit.

ADVICE ON NuTRITION

A positive approach is required to ensure that long-term changes are introduced. The emphasis should be on what can be eaten rather than on what should not be eaten. The main aim with changes in dietary habits is to ensure a healthy body mass, normalise the blood lipid profile, control blood pressure, ensure glucose control and reduce the ten-dency of thrombosis.


• Enjoy a variety of foods

Include vegetables, fruit, whole grain products, low-fat dairy products, lean red meat, poultry without skin and fish in the diet.

• Make starchy foods the basis of most meals

Emphasis should be placed on the consumption of unrefined grain products. Com-pulsory fortification of all bread and maize flour ensures that these foods are im-portant sources of vitamins, such as vitamin A, the B-complex and minerals such as iron and zinc.

• Eat plenty of vegetables and fruit every day

Most vegetables and fruit are rich in vitamins and minerals, low in energy and high in dietary fibre. Diets rich in vegetables and fruit make an important contribution to meet micronutrient, macronutrient, and fibre requirements without causing an increase in the overall energy consumption.

• Include legumes, such as dry beans, peas, lentils and soya as often as possible

Legumes are rich and inexpensive dietary sources of good quality protein, carbo-hydrates, soluble and insoluble dietary fibre, as well as a variety of minerals and vitamins. Dry beans and soybeans are good substitutes for animal protein sources.

• Fish, chicken, meat, milk or eggs can be eaten every day

Fish, especially oily fish, should be consumed twice a week as it provides long-chain omega-3 fatty acids that are known to reduce the risk for CAD. Increasing fish con-sumption should be perceived as an overall strategy to reduce the intake of ani-mal fats (fatty meat and cream in dairy products). The aim is also to improve the quality of fat in the diet. Chicken should be eaten without the skin. White chicken meat contains less fat in comparison with the other parts of the chicken. An egg (preferably boiled) may substitute meats as a source of protein and iron. Eggs are a good source of protein for those who cannot afford other protein rich foods such as meat, poultry and fish. Other sources of protein include liver, kidneys and offal, which are high in cholesterol, but low in total fat. Lean beef and mutton may be consumed as part of a prudent diet. When eating meat one should always take into consideration that the total amount of fats should be low. Ways to comply with such an eating pattern are to choose low-fat or lean meats, including game and ostrich, known for their low fat contents relative to the meat of domesticated animals, and to prepare and cook meat without added fats and oil.

• Eat fats sparingly

Food high in fat is also high in energy. The strategy with the guideline to eat fat spar-ingly is to replace foods with a high fat content, especially high in saturated fat, with foods that contain less fat, but also to ensure that the correct type of fat (unsatu-rated) is consumed. Keep the intake of food high in saturated fat (animal fats and


certain plant fats, e.g. coconut oil and palm kernel oil) low and replace these fats with foods that provide monounsaturated and polyunsaturated fats (e.g. vegetable oils). Yet, oil, margarine, butter or any other cooking fat should be used sparingly in food preparation to lower total fat intake. Bread and crackers should be eaten with bread spreads low in saturated fat (with monounsaturated and polyunsaturated fat instead as the main source of fat).

• Eat salt sparingly

Although the salt-hypertension relationship is a controversial issue, there is enough evidence to show the validity of restricting salt intake as a means of lowering blood pressure. Approaches to comply with salt restriction are to reduce the total amount of salt added during the cooking process, and at the table, as well as to limit the intake of processed foods high in salt.

• Perspective

Lifestyle factors influence the development of atherosclerosis over a lifespan. Im-provement of the diet at any age will protect the individual against the deleterious effects of CVD, hyperlipidaemia (both high cholesterol and/or blood triglycerides), hypertension, as well as diabetes. Lifestyle, though affecting these disorders fa-vourably, will neither cure nor perfectly control these disorders, but considerably improve the livelihood of those that suffer from the consequences of it. Persistently raised fasting glucose (of >7mmol/L) should always be evaluated and followed by a trained medical practitioner. The same applies for a persistently raised blood pres-sure of >140mmHg for systolic or >95mmHg for the diastolic blood pressure. The dietary recommendations provided above are suitable for persons with normal cho-lesterol and triglyceride values, as well as moderately increased values and should be perceived as a prevention strategy. A persistently high cholesterol of >7.5mmol/L or triglyceride level of >5mmol/L requires additional medical intervention, and also consultation with a registered dietitian. Any of these abnormalities, whether inher-ited or not, may require strict dietary control.

For more specific advice on nutrition and lifestyle and related recommendations and guidelines, please contact a registered dietitian.


REFERENCES

1. Blackhurst DM & Marais AD. Alcohol - foe or friend? S Afr Med J 2005; 95:648-654

2. Carlton KE & Jooste PL. Eat salt sparingly – sprinkle, don’t shake! SA J Clin Nutr 2001; 14: S55-S64

3. De Backer G, Ambrosioni E, Borch-Johnsen K et al. European guidelines on cardiovascu-lar disease prevention in clinical practice: Third joined task force of European and other societies on cardiovascular disease prevention in clinical practice. Eur Heart J 2003; 24: 1601-1610

4. Diekman C, Elmadfa I, Koletzko B, Puska P, Uauy R & Zevenbergen H. Summary statement of the international expert meeting: Health significance of fat quality of the diet. Ann Nutr Met 2009; 54(suppl 1): 39-40

5. Jakobsen MU, O’Reilly EJ, Heitmann BL, Pereira MA, Bälter K, Fraser GE, Goldbourt U, Hall-mans G, Knekt P, Liu S, Pietinen P, Spiegelman D, Stevens J, Virtamo J, Willett WC & Asche-rio A. Major types of dietary fat and risk of coronary heart disease: pooled analysis of 11 cohort studies. Am J Clin Nutr 2009; 89: 1425-1432

6. Joint FAO/WHO Expert Consultation on Fats and Fatty Acids in Human Nutrition. Interim summary of conclusions and dietary recommendations on total fat & fatty acids. Novem-ber 10-14, 2008; WHO HQ, Geneva (Available at: http://www.fao.org/ag/agn/nutrition/docs/Fats and Fatty Acids Summaryfin.pdf. Date accessed: 22 Feb 2011)

7. Joint WHO/FAO Expert Consultation. WHO Technical Report Series 916: Diet, nutrition and the prevention of chronic diseases. 2003. World Health Organisation, Geneva, 2003

8. Lambert EV, Bohlmann I & Kolbe-Alexander T. ‘Be active’ – physical activity for health in South Africa. SA J Clin Nutr 2001; 14: S12-S16

9. Lichtenstein AH, Appel LJ, Brands M et al. Diet and lifestyle recommendations revision 2006: A scientific statement from the American Heart Association Nutrition Committee. Circulation 2006; 114: 82-96

10. Love P & Sayed N. Eat plenty of vegetables and fruits every day. SA J Clin Nutr 2001; 14: S24-S31

11. Maunder EMW, Matji J & Hlatshwayo-Molea T. Enjoy a variety of foods – difficult but nec-essary in developing countries. SA J Clin Nutr 2001; 14: S7-S11

12. Scholtz SC, Vorster (jun) HH, Matshego L & Vorster HH. Foods from animals can be eaten every day – not a conundrum. SA J Clin Nutr 2001; 14: S39-S47

13. Venter CS & Van Eyssen E. More legumes for overall health. SA J Clin Nutr 2001; 14: S32-S38

14. Vorster HH & Nell TA. Make starchy foods the basis of most meals. SA J Clin Nutr 2001; 14: S17-S23

15. Wolmarans P & Oosthuizen W. Eat fats sparingly – implications for health and disease. SA J Clin Nutr 2001; 14: S48-S55

16. Wolmarans P. Background paper on global trends in food production, intake and composi-tion. Ann Nutr Met 2009; 55: 244-272


Diabetes Mellitus

Due to the chronic nature of the disease, it requires continuing medical and nutritional care and effective patient education to manage acute complications (hyper-and hypoglycaemia) and to reduce the development of long-term com-plications. The primary goal of the treatment for DM is control of blood glu-cose. In type 1 DM, insulin therapy is the most important treatment modality, whereas in type 2 DM, the key aspects of treatment include diet, oral medica-tion, and lifestyle modifications. Dietary intervention in the early stages of type 2 DM is an effective first-line defence against disease progression, and together with a proper exercise regimen, could even reverse it. In uncontrolled type 2 DM, insulin therapy can eventually be employed if diet and oral medication fail to successfully control the patient blood glucose concentrations.

It is important to emphasize that the diabetic diet is not a special diet in the true sense of the word, but rather a balanced eating pattern that should be followed by the whole family. Successful nutrition intervention has been proven through clinical trials to result in reduced low-density lipoprotein cholesterol (LDL-C) concentrations and decreases in glycosylated haemoglobin (HbA1c). It is recommended that the HbA1c level should be <7% for optimal outcomes.

KEY POINTS TO REMEMBER

• Follow a low GI diet, including 20-40g fibre per day;

• Routine supplementation of micronutrients and antioxidants is not necessary pro-vided a balanced diet is followed;

• Meals should be eaten more or less at the same time each day, the size and distribu-tion is dependent on the individual patient’s requirements and medication regimen;

• Sucrose can be included in the diet. However, it should form part of a high-carbohy-drate, high-fibre, and low-fat diet;

• Regular activity of 150 minutes/week or 30-45 minutes/day, 3-5 days per week ini-tially, is recommended;



• If hypoglycaemia is present a fast energy release carbohydrate (e.g., sugar, honey, or syrup), as well as a slow energy release carbohydrates (such as whole-wheat biscuit or a sandwich) must be consumed immediately. This should be followed up with a meal to prevent the recurrence of hypoglycaemia.

DIETARY MANAgEMENT

Energy

Achieving weight loss and maintaining a reasonable body weight should be the first goal of the treatment plan.

• Long-term weight loss is seen with programmes that emphasize lifestyle changes, including education, individualized counselling, reduced dietary energy and fat in-take, regular physical activity, and frequent patient contact.

Carbohydrate and Fats

Various contributions of these macronutrients to the total energy (TE) are proposed and these are dependent on the individual patient response to carbohydrate intake and blood glucose and lipid control:

• A fibre intake of 14g/1000 kcal or ± 20-40 g/day should be aimed for. Emphasis should be placed on including sources of soluble fibre, such as the pectins (also fruit, oats, dried beans, and legumes).

Protein

The intake of protein does not affect plasma glucose concentrations directly, but does increase serum-insulin responses.

• The protein intake should consist of 10-20% of TE. Half of the protein should be of high biologic value (i.e., containing all 9 essential amino acids).

Micronutrients

Although certain micronutrients may affect glucose and insulin metabolism, no convinc-ing evidence exists to date documenting the role of micronutrients in the development of diabetes. It is also likely that the response of patients to micronutrient supplementation is determined by their micronutrient status. Only those with micronutrient deficiencies will respond to the supplements favourably.

• Routine supplementation of micronutrients and antioxidants in individuals with dia-betes is not recommended;

• However, in people following an energy-restricted diet, pregnant or lactating wom-en, strict vegetarians, or the elderly, a multivitamin supplement may be required;

• Supplementation should not exceed nutrient intakes in excess of the Dietary Refer-ence Intake (DRI) levels.


• The importance of following a balanced diet that contains all the necessary nutri-ents through natural foods should always be the first priority.

Meal distribution

It is important that diabetic patients should maintain a balance between their food intake and the type or amount of medication at all times, in order to maintain euglycaemia:

• Meals should be eaten more or less at the same time each day;

• There is thus no standard dietary prescription for food distribution over and above that of the three basic daily meals;

• The size of the meals and the intake of snacks must be individualized according to the medication which the patient receives;

• The energy, and specifically carbohydrate distribution, must be taken into account to establish actual meal size and the meal distribution for the day. This must coin-cide with the peak action of the various medications prescribed:

• Rapid insulin [Novorapid (Novo Nordisk); Humalog (Lilly); Apidra (Sanofi-Aventis)] - Duration of about 3 hours and peak after one hour, snacks in-be-tween are therefore unnecessary;

• Short-acting insulin [Humalin R (Lilly); Actrapid (Novo Nordisk)] - Duration of about 3-6 hours and peak time is after 1-3 hours, snacks 2 hours after admin-istration are essential;

• Intermediate acting [Protophane (Novo Nordisk); Humalin N (Lilly)] - Duration of about 18-20 hours and peak after about 90 minutes after administration. A single snack 2 hours after administration is important;

• Long acting [Humalin L (Lilly); Lantus (Sanofi-Aventis); Levemir (Novo Nord-isk)] - Duration of approximately 16-20 hours (might slightly vary from each other). Because there is no peak, no snacks are necessary, unless hypoglycae-mia is present;

• Premix [Humalog Mix 25 (Lilly); Humalog Mix 50 (Lilly); Humalin 30/70 (Lilly); Novomix 30 (Novo Nordisk)] - Duration of approximately 14-18 hours (might slightly vary from each other) and peak 1-8 hours after administration. Snacks approximately 2 hours after administration are imperative to avoid hypogly-caemia.

Sucrose

Randomized controlled trials have found that glycaemic and lipid control are not adverse-ly affected by the intake of a modest amount of sugar.

• Sucrose can be included in the diet, however, it should form part of a high-carbo-hydrate, high-fibre, low-fat diet and should not exceed 50 g/day or should be <10% of TE.


Sweeteners

Several alternative sweeteners are available for use by individuals with DM. They are categorized as nutritive (energy containing – examples are fructose and sugar alcohols i.e. sorbitol, xylitol and mannitol) and non-nutritive (non-energy containing – examples are saccharine, aspartame, acesulphame K, neotame, sucralose). These products are all considered safe provided intake falls within the levels established by the Food and Drug Administration (FDA).

• The use of nutritive sweeteners in diabetic patients should be evaluated on the basis of the individual's blood glucose and lipid control, as well as in the overall context of the diet. Moderation in the consumption of nutritive sweeteners would appear to be prudent as they may be involved in the aetiology of diabetic complica-tions i.e. retinopathy and autonomic neuropathy.

• If a patient with DM wishes to use sweeteners, a combination of sweeteners should be ingested, to minimize any potential risks.

Alcohol

The consumption of alcohol can result in hypoglycaemia.

• Alcohol should always be ingested together with a meal and never on an empty stomach;

• Alcohol intake should not exceed 6-10% of TE intake (± 20-30 g alcohol per day). This equates to one drink per day for women and two drinks for men;

• Alcohol consumption is contra-indicated in DM patients with hypertriglyceridae-mia, pregnancy, peripheral neuropathy, liver disease, pancreatitis, or gastritis.

Physical Activity

Physical activity is an important component in the treatment of patients with DM, along with dietary intervention and medication. It has several benefits including improved glycaemic control, prevention/delaying of cardiovascular complications, weight mainte-nance, and psychological benefits. In type 2 DM, physical activity, with resultant weight loss, can significantly reverse insulin resistance.

• Regular activity of 150 minutes per week or 30-45 minutes per day, 3-5 days per week initially, is recommended. The exercise should be gradually increased in dura-tion and frequency to 60-76 minutes of moderate intensity activity (e.g., walking) or 35 minutes of vigorous activity (e.g. jogging) daily.

• Individuals using fixed daily insulin dosages need a consistent intake of carbohy-drates in terms of time and amount, whereas individuals using rapid-acting insulin by injections or insulin pumps can adjust their meal and snack based on the carbo-hydrate content of the meal/snack.


REFERENCES

1. Ali YS, Linton MF & Fazio S. Targeting cardiovascular risk in patients with diabetes: man-agement of dyslipidemia. Curr Opin Endocrinol Diab Obes 2008; 15: 142-6

2. American Diabetes Association. Nutrition recommendations and interventions for diabetes - 2008: a position statement of the American Diabetes Association. Diabetes Care 2008; 31 (suppl 1): S61–S78

3. American Diabetes Association. Standards of medical care in diabetes–2009. Diabetes Care 2009; 32(Suppl 1): S13-61

4. Bastaki S. Diabetes mellitus and its treatment. Int J Diabetes & Metabolism 2005; 13: 111-34

5. Franz MJ. Nutritional management of diabetes mellitus and the dysmetabolic syndrome. Clin Nutr Highlights 2006; 2: 2-7

6. Shakil A, Church RJ & Rao SS. Gastrointestinal Complications of Diabetes. Am Fam Phys 2008; 77: 1697-702

7. Shaw JE, Sicree RA & Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diab Res Clin Pract 2010; 87: 4-14

8. Van Zyl DG. Diagnosis and treatment of diabetic ketoacidosis. SA Fam Prac 2008; 50: 35 – 39

9. Wheeler ML & Pi-Sunyer FX. Carbohydrate issues: type and amount. J Am Diet Assoc 2008; 108: S34–S39


Oral Health

All foods, by virtue of being able to ferment have the potential to induce car-ies formation. Acid production caused by fermentation by plaque bacteria in your oral cavity lowers the plaque and salivary pH leading to demineralisation of tooth enamel and resultant dental caries. “Good versus bad foods” for caries prevention should be replaced with “good versus bad diets.”

Consuming a balanced diet rich in whole grains, fruit and vegetables, moderate use of foods rich in “free sugars” (all added sugars and sugars present in fruit juices, honey and syrups) and practicing good oral hygiene will maximize oral health and reduce the risk of developing caries. Although fermentable carbohydrates (including sugar) are the foods in your diet that most likely increase acid production, oral hygiene remains the single most important aspect of preventing dental caries.

FOOD ISSuES TO CONSIDER INCLuDE

Food form

The form of the fermentable carbohydrate (including sugar) in your diet directly influ-ences the duration of exposure and retention of the food on your teeth. Liquids e.g. fruit juice, pass through the oral cavity quickly with limited contact time or adherence to the tooth surface. Solid food e.g. bread adhere to your tooth surface that exposes them to bacteria, more so than liquid foods.

How often you eat fermentable carbohydrates (including sugar)

Regular spacing between meals will reduce repeated exposure to fermentable carbohy-drates. Eating foods too often does not give the layer of enamel the necessary time to recover from normal demineralisation caused from the mechanical destruction associ-ated with eating. In addition, the frequency of eating is also related to retention time: the longer the foods are retained in the oral cavity the greater the potential of starch to break down into sugars and contribute to additional caries development.

Nutrient composition

Diet and nutrition favour remineralisation of teeth when their contents are high in cal-cium, phosphate and protein, such as cheese and other dairy products. This is due to the



increased salivary flow, which is associated with the inhibition of plaque formation, bacte-rial growth and subsequent reduced acid production.

The potential of the food to stimulate the secretion of saliva

Raw fruit and vegetables require greater mastication and thus increase salivary flow. Low salivary flow rate and inadequate buffering capacity exacerbate the development of den-tal caries.

Combination and sequence of food consumption

Consuming fermentable carbohydrates (including sugar), sweetened and acidic beverages with, instead of between meals, and foods (cheese, ham, nuts) at the end of a meal, will prevent a drop in pH inside the mouth, and also stimulate salivary secretion.

REFERENCES

1. American Dietetic Association. Position paper: nutrition and oral health. J Am Diet Assoc 2003; 5: 615-625

2. Kashket S & De Paola D. Cheese consumption and the development and progression of dental caries. Nutr Rev 2002; 60: 97-103

3. Konig KG & Navia J. Nutritional role of sugars in oral health. Am J Clin Nutr 1995; 62 (suppl): 275S-283S

4. Lingstrom P, Van Houte J & Kashket S. Food starches and dental caries. Crit Rev Oral Biol Med 2000; 11: 366-380

5. Mobley C & Dodds MW. Diet and dental health. Top Nutr 1998; 7: 1-18

6. Moynihan P & Petersen PE. Diet, nutrition and the prevention of dental disease. Public Health Nutrition 2004; 7: 201-226

7. Palacios C, Joshipura KJ & Willet WC. Nutrition and health: guidelines for dental practitio-ners. Oral Diseases 2009; 15: 369-381

8. Touger-Decker R & Van Loveren C. Sugar and dental caries. Am J Clin Nutr 2003; 78(suppl):881S – 892S

9. US Department of Health and Human Services. US Public Health Service. Oral health in America: a report of the surgeon general. 2000. Rockville, MD: National Institute of Health.

10. Van Loveren C & Duggal MS. Expert’s opinion on the role of diet in caries prevention. Caries Res 2004; 38(suppl 1):16-23


HIV/AIDS

South Africa is the country with the highest number of people infected and affected by HIV (UNAIDS, 2008). Despite this, only an estimated one third of South Africans with HIV know their status. People who know that they have the virus can take action to ensure that they remain healthy and enjoy a pro-ductive life.

Although changes to the diet cannot cure HIV or AIDS, it can make a significant contribu-tion towards a healthy immune system, in addition to the benefit of following the correct dietary guidelines in those that take antiretroviral therapy. A balanced diet is suggested to improve the quality of life in those affected by HIV.

One of the most common and serious symptoms of HIV is weight loss. This can occur as a result of:

• The HIV and other opportunistic infections that increase individual energy and specific nutrient needs (as much as 10% in the early phase of infection);

• Eating less as a result of poor appetite, mouth and throat sores, tooth decay, food insecurity and depression;

• Increased losses of nutrients as a result of vomiting, diarrhoea and especially poor absorption of nutrients. The mechanism through which the HIV affects the absorption of specific nutrients is not yet well understood.

Healthy foods provide the necessary energy and essential nutrients needed to prevent sporadic loss of weight and sustain a healthy immune system, especially in the early phase of infection, when antiretroviral treatment is not yet indicated. The benefits of antiretro-viral treatment by far outweigh the potential harm. Also in those individuals who take antiretroviral medication, diet supports treatment outcome. Over and above the specific precautions needed to be taken with each of the different antiretroviral drugs, a proper dietary intervention program can support improved adherence (compliance) to the drugs.

FOOD-BASED DIETARy GUIDElINES FOR PEOPlE lIVING wITH HIV

In order to promote healthy eating, it is suggested that people with HIV follow the Food Based Dietary Guidelines designed specifically for South Africa. In the following section



these guidelines have been adapted to meet the specific needs of people living with HIV:

Drink lots of clean, safe water

Adults need 6-8 cups of clean water a day – some of this can be tea, coffee or juice. Tap water is usually safe, but water from rivers, streams or wells may not be clean. Water can be boiled or filtered to make sure it is clean. People with HIV may have diarrhoea, vomit-ing or night sweats and need to replace fluids by drinking extra fluids. The rehydration drink (1 litre boiled cooled water, 8 teaspoons sugar and half a teaspoon salt) may be used to prevent dehydration – drink half to one cup of this drink every time you have been to the toilet. Drinking water after a meal can help clean the mouth and prevent infections of the mouth and tooth decay.

Enjoy a variety of foods

A variety of foods will ensure that a variety of nutrients are included in your diet. You can eat a variety of affordable foods that will suit your taste and culture. Aim to eat at least 3 mixed meals per day in a relaxed atmosphere. Snacks should also consist of nutritious foods.

Make starchy foods the basis of most meals

Starchy foods such as maize, bread, samp, roti, pasta, sweet potatoes, potatoes, porridge and cereals are important sources of energy. These foods are filling staple foods and are not expensive. In South Africa, maize meal, bread flour and bread are fortified with vi-tamins and minerals by law. People who are losing weight should eat larger portions of starchy foods.

Eat plenty of vegetables and fruits everyday

Many people do not eat adequate amounts of fruits and vegetables. The recommended intake is 5 portions per day. One of these should be a yellow, orange, red or dark green vegetable or a yellow fruit (these contain beta carotene). When people with HIV have diarrhoea or sore mouth, vegetables can be mashed and fruit stewed. Planting your own garden will make it more affordable to eat vegetables and fruit.

Eat dry beans, peas, lentils or soya regularly

These foods help maintain normal blood sugar and fat levels. They provide fibre for a healthy digestive system and affordable protein to help repair and build muscle. They can be added to dishes such as stews and samp or eaten as main courses such as curried beans.

Chicken, fish, milk or eggs should be eaten daily

These foods are good sources of protein, minerals and vitamins. It is possible to obtain all the necessary nutrients without eating these foods, but it is difficult to do. In order to eat less fat, one should remove the skin of chicken and trim the fat from the meat. Limit foods with hidden sources of animal fat such as polony and boerewors. One should also try to use low fat or fat free milk, maas or yoghurt (except in children under 2 years).


Use sugars, fats and oils sparingly

Sugars, fats and oils are part of a healthy, balanced eating plan. They provide energy, but are often found in foods that don’t contain many other nutrients, and should be used sparingly. Small amounts of sugar can be added to foods and drinks like porridge or tea. Sweets and cold drinks can be eaten occasionally, but should not replace meals. There is no evidence that the intake of refined carbohydrates such as sugar has a negative ef-fect on the immune system and causes candida or thrush. People with HIV who have increased energy needs may need to eat extra energy dense foods such as sugar, oil and peanut butter.

Fats and oils increase the risk for weight gain and high blood fats. Fried foods and take-aways (or junk food) are not healthy foods. When weight loss is experienced, people with HIV should eat energy dense nutritious foods such as milk, eggs or bananas. In the late stage of disease, fat may worsen diarrhoea. People on antiretroviral medication may gain weight easily and should use sugar, fat and oil sparingly.

Use salt sparingly

A little salt can be added to food during cooking to improve taste. Extra salt should not be added at the table, especially in people with high blood pressure. If people with HIV have diarrhoea and vomiting, they may need to replace salt that is lost using the rehydration drink.

Be active

Physical activity is essential for good health and moderate exercise is associated with a number of benefits. People with HIV lose muscle mass when they lose weight. Physical activity can help to maintain muscle mass. Aerobic exercise can help to improve strength and endurance, reduce stress and improve sleep. Resistance training can help to build muscle and improve strength.

Do not use alcohol

People with HIV should not use any alcohol. Alcohol is harmful to the liver and results in nutrient losses that affect the immune system. Harmful interactions between medication and alcohol can also occur.

One balanced multivitamin and mineral supplement can be taken

Although people living with HIV often have vitamin and mineral deficiencies, it is not wise to use a large number of different supplements, since this can have a negative effect on health. The WHO recommends that one multivitamin and mineral supplement that provides 100% of the Recommended Dietary Allowance (RDA) for micronutrients can be used. Patients should take a supplement as recommended by their medical practitioner or health worker. To ensure patients get in all the nutrients they need, a diet that includes a wide variety of healthy foods is more important.


SOME HERBAL REMEDIES CAN BE HARMFuL

There is no evidence that certain foods (e.g. garlic, lemon and beetroot) or herbal rem-edies have any benefit in people with HIV. Some over-the-counter medicines or remedies have side-effects and can affect the bodies’ ability to absorb food and antiretroviral medi-cation. It is better for you to use the money that you spend on remedies to buy healthy food. There are drinks (powders) that are designed to provide extra energy and nutrients for patients who struggle to eat enough. Although these may be good for you, they may also be harmful. They can be very expensive and should not replace healthy food in your diet. It is necessary to tell your medical practitioner or health worker if you are using any of these products.

EATINg TIPS FOR COMMON SYMPTOMS IN THOSE INDIVIDuALS INFECTED WITH THE HIV

Lack of appetite

Eat favourite foods often and make sure you eat when you are hungry. You can eat snacks or a small meal every 2 to 3 hours and rather drink liquids between meals than with meals. Make sure food looks and tastes good so that you feel like eating it. Drink nutri-tious fluids like maas and yoghurt. Exercise, such as going for a short walk, can improve your appetite.

Nausea and vomiting

Eat small frequent meals and snacks instead of few big meals. In the morning eat crack-ers, dry toast, or dry cereal. Avoid greasy, fried, or very sweet foods such as chips, pas-tries, and ice cream. Sip on water, juice or the rehydration drink to replace fluid that you have lost.

Sore mouth and throat

Eat small meals more frequently and snack in between meals. Drink nutritious drinks like maas and yoghurt and use a straw. Try soft smooth foods, like mashed fruits and vegeta-bles, scrambled eggs, minced meat or chicken and soft porridge. Avoid foods that sting or irritate the mouth, like orange or tomato juice, hot sauces, and salty foods. Cold foods, such as ice cream, or foods at room temperature, are often easier to eat. Remember to rinse your mouth often to keep it clean.

Diarrhoea

Do not stop eating if you have diarrhoea. Make sure you replace the fluids that you have lost by drinking enough water, juice or the rehydration fluids. It may also help to eat foods like porridge, bananas, grated apples and carrots. Sour milk or yoghurt can be used if you find that milk gives you diarrhoea. If you find that fatty foods worsen the diarrhoea, eat less of them.


PROTECT THE quALITY AND SAFETY OF FOOD

People with HIV are more likely to develop food-borne infections. Eating contaminated food may result in diarrhoea, nausea and vomiting which can result in further weight loss. To avoid this, wash hands with hot soapy water before touching or eating foods. Cook meat, poultry, fish, and eggs until they are well done and use only pasteurized milk. Clean the lids of cans and jars before opening them. Eggs and other high-protein foods should be thoroughly heated (70 degrees C or more). To rinse fresh foods use water boiled for 1 minute and then cooled. It is important to wash fresh fruits and vegetables thoroughly before eating them and to only drink boiled or filtered water. Wash dishes and cutting boards in hot soapy water and use leftovers in the refrigerator within 2 days. A microwave oven can be used to defrost foods. Protein-containing foods (e.g., meats, dairy products) should not be defrosted or held at room temperature for more than 1 hour. Hot foods should be kept hot and cold foods should be kept cold. Store leftovers as soon as possible. Shallow containers allow food to cool best in the refrigerator. Label foods with dates. Hot food leftovers stored in the refrigerator should be heated to 70 degrees C when planning to eat it.

TREATINg COMPLICATIONS OF ANTIRETROVIRAL MEDICATIONS

It is important to acknowledge that each of the antiretroviral drugs has additional dietary requirements, and that these requirements should be strictly adhered to. In some in-stances the type of food in the stomach can promote or prevent proper absorption of the drugs, affect their metabolism, excretion and/or distribution of the drug. Some nutrients can also modify the action of medication. In turn, some of the drugs can affect the ab-sorption, metabolism and/or excretion of specific nutrients. In general, nutrition in those taking antiretroviral treatment should be perceived as a support to positive treatment outcome. In addition, some antiretroviral drugs may induce long term (chronic) complica-tions, such as an increased risk of developing insulin resistance (associated with Type 2 DM), raised blood cholesterol and triglycerides. In most cases, people taking antiretroviral drugs put on weight, especially around the stomach. It is therefore important to monitor your weight and be aware of any signs of underweight or overweight. Follow the guide-lines discussed earlier in this section. Limit your portion size and eat the same amount of starchy food at each meal. Eat vegetables and fruits when you feel hungry and use fats, oils and sugars sparingly, unless the specific drugs you take demand otherwise. Eat dry beans, peas, lentils or soya regularly as these foods are high in fibre that keeps you full for longer and helps to keep your blood sugar and fat levels normal. They are also low in fat to prevent you from putting on too much weight. Drink water instead of sugary drinks and make sure you exercise regularly.


REFERENCES

1. Academy of Science in South Africa (ASSAf). Scientific inquiry into the nutritional influences on human immunity with special reference to HIV infection and active TB in South Africa. 2007. ASSAf

2. Colecraft E. HIV/AIDS: Nutritional implications and impact on human development. Proc Nut Soc 2008; 67:109-113

3. Coyne-Meyers K & Trombley LE. A review of nutrition in human immunodeficiency virus in-fection in the era of highly active antiretroviral therapy. Nut Clin Prac 2004; 19(4): 340-355

4. Department of Health South Africa. South African National Guidelines on nutrition for peo-ple living with TB, HIV/AIDS and other debilitating conditions. 2005. Department of Health South Africa: Pretoria.

5. Fenton M and Silverman EC. Medical nutrition therapy for human immunodeficiency virus disease. In: Krause’s Food and Nutrition Therapy. Mahan LK & Escott-Stump S eds. 12th edi-tion. 2008. Philadelphia, Pennsylvania: W.B Saunders Company: p.991-1020

6. Fields-Gardener C & Ferquesson P. American Dietetic Association and Dietitians of Canada. Position of the American Dietetic Association and Dietitians of Canada: Nutrition interven-tion in the care of persons with human immunodeficiency virus infection. J Am Diet Ass 2004; 104(9):1425 -1441

7. Grinspoon MD. Metabolic syndrome and cardiovascular disease in patients with human immunodeficiency virus. Am J Med 2005; 118(2):23S-28S

8. Kennedy RD & MacIntyre UE. Development and testing of the South African National Nu-trition Guidelines for people living with HIV/AIDS. SAJCN 2003; 16(1):12-16

9. Piscitelli SC, Burstein, AH, Welden N, Gallicano KD & Falloon J. The effect of garlic supple-ments on the pharmacokinetics of saquinavir. Journal of Clinical Infectious Disease 2001; 35(3):343

10. South African Sugar Association (SASA), Nutrition Department. Dietary Guidelines for Adults who are HIV Positive. Information booklet for Health workers and Counsellors.

11. Spencer DC, Harman C, Naicker T, Gorhe S, Rollins N, Labadarious D, Visser M & The SA HIV Clinician Society Nutrition Focus Group. Nutritional guidelines for HIV-infected adults and children in Southern Africa: Meeting the needs. SA J HIV Med 2007; 3:22-30

12. Tomkins, A. Evidence-based nutrition interventions for the control of HIV/AIDS. SAJCN 2005; 18(2):187-191

13. Venkataramanan R. Milk thistle, a herbal supplement, decreases the activity of CYI and uridine diphoshglucuronosyl transferase in human hepatocyte cultures. Drug Metab 2000; 28(11):1270

14. World Health Organization (WHO). Nutrient requirements for people living with HIV/AIDS. May 2003. Report of a technical consultation, WHO: Geneva


Drug-Nutrient Interactions in the Management of Tuberculosis and Hypertension

In many instances patients disregard the importance of nutrition when making use of commercially available prescription drugs, especially when prescribed by their health practitioner. It is important that the patient realises the extent to which their diet also influences the outcome of prescription drug treatment.

• Food/nutrients can affect medication absorption (e.g. a suggested 77% decrease in the bioavailablity of Crixivan when ingested with a high calorie, high-fat, high-protein meal);

• Food/nutrients can affect medication distribution (decreased blood albumin levels could increase the free fraction of the drug in the systemic circulation, such as war-farin);

• Food nutrients can affect medication metabolism (grapefruit inhibits metabolism of antihyperlipdaemic HMG CoA reductase inhibitors);

• Food/nutrients can affect medication excretion (lithium and sodium compete for tubular reabsorption in the kidney. High sodium intake increases lithium excretion).

The opposite is also true. Some medications could have an effect on nutrient absorption (some antibiotics chelate with Ca, Mg, Fe and Zn), nutrient metabolism (Isoniazid/INH inhibits the conversion of vitamin B6 to the active form), and nutrient excretion (Loop diuretics, such as furosemide, increase excretion of Na, K, Cl, Mg and Ca).

Some food or nutrients have similar effects to those of some drugs, enhancing their ef-fects or the toxicity of the drug (high caffeine intake may increase the adverse effects of theophylline). In some cases the nutrient can also oppose the desired action of the drug (Vitamin K which acts against the action of warfarin) or counteract it (such as a high fat diet which counteracts the effect of antihyperlipidaemic drugs).



Additional effects of medication on food intake and nutritional status include:

• Oral and taste/smell effects

• Gastrointestinal effects (nausea, vomiting, bleeding, ulceration etc.)

• Appetite changes (SSRI antidepressant drugs such as Prozac may induce anorexia and weight loss).

It is therefore important to inform patients about any potential nutritional problems that may arise from the medication use. Patients should be told the name, purpose of the drug, and duration of therapy. It should be clearly stated how and when they should use the drug, expected side-effects, and the potential nutritional problems that may arise from medication use, especially when dietary intake is inadequate. Dietary factors that may alter drug action should be clearly explained, including those food and beverages to avoid. Advice should always include directions on alcohol ingestion. Special diets for a medical condition should always be adhered to. It is important to remind the patient that a personal dietary prescription pertains to that person only. Do not follow dietary sugges-tions prescribed for others. A registered dietitian should be consulted for in-depth nutri-tional information. A pharmacist can also be consulted to address any questions relating to drug action or potential side-effects.

TuBERCuLOSIS

The number of tuberculosis cases in sub-Saharan Africa has increased substantially in the past decade, fuelled by the HIV epidemic, making it difficult for tuberculosis programs to improve outcomes. In South Africa, the national Directly Observed Treatment Short-course (DOTS) treatment success rate has been reported to be only 67%, well below the WHO standard of 85%. Low rates of treatment completion place patients at risk for re-lapse of tuberculosis disease as well as for development of drug resistance. It has become almost standard practice to determine HIV status of all persons diagnosed with active TB disease. HIV co-infection is associated with a higher mortality rate due to tuberculosis when effective treatment is delayed. General side-effects of TB drugs include:

• Thrombocytopaenia;

• Neuropathy;

• Vertigo;

• Hepatitis;

• Rash.

Treatment with Isoniazid (INH):

• Simultaneous ingestion of food decreases absorption of the drug;

• Take 1 hour before or 2 hours after meal;


• Not in conjunction with Aluminum-containing antacids (many patients on antiret-rovirals takes antacids);

• Use 10-15 mg pyridoxine supplementation to prevent peripheral neuropathy;

• INH has Monoamine Oxidase Inhibitor (MAOI)-like activity: avoid tyramine, dopamine, histamine and phenylethylamine-rich foods, including

• Aged cheeses: cheddar, blue;

• Aged meats: dry sausage, salami, biltong;

• Soy products: soy sauce, soybean products etc.;

• Tap beer;

• Yeast extracts: Marmite.

Tyramine is an amino acid which is found in various foods, and is an indirect sympathomi-metic that can cause a hypertensive reaction in patients receiving MAOI therapy. Mono-amine oxidase is found in the gastrointestinal tract and inactivates tyramine; when drugs prevent the catabolism of exogenous tyramine, this amino acid is absorbed and displaces norepinephrine from sympathetic nerve ending and epinephrine from the adrenal glands. If a sufficient amount of pressor amines are released, a patient may experience a se-vere occipital or temporal headache, diaphoresis, mydriasis, nuchal rigidity, palpitations, and the elevation of both diastolic and systolic blood pressure may ensue. On rare occa-sions, cardiac arrhythmias, cardiac failure, and intracerebral hemorrhage have developed in patients receiving MAOI therapy that did not observe dietary restrictions. Therefore, dietary restrictions are required for patients receiving MAOIs. Approximately 10 to 25mg of tyramine is required for a severe reaction compared to 6 to 10 mg for a mild reaction.

Foods to avoid include: Alcoholic beverages - avoid Chianti wine and vermouth. Con-sumption of red, white, and port wine in quantities less than 120ml present little risk. Beer and ale should also be avoided, however other investigators feel major domestic brands of beer is safe in small quantities (½ cup or less than 120ml), but imported beer should not be consumed unless a specific brand is known to be safe. Whiskey and li-queurs such as Drambuie and Chartreuse have caused reactions. Non-alcoholic bever-ages (alcohol-free beer and wines) may contain tyramine and should be avoided. Banana peels - a single case report implicates a banana as the causative agent, which involved the consumption of whole stewed green banana, including the peel. Ripe banana pulp contains 7µg/gram of tyramine compared to a peel which contains 65µg/gram and 700µg of tyramine and dopamine, respectively. Bean curd - fermented bean curd, fermented soya bean, soya bean pastes contain a significant amount of tyramine. Broad (fava) bean pods - these beans contain dopa, not tyramine, which is metabolized to dopamine and may cause a pressor reaction and therefore should not be eaten particularly if overripe. Cheese - tyramine content cannot be predicted based on appearance, flavour, or variety and therefore should be avoided. Cream cheese and cottage cheese have no detectable


level of tyramine. Fish - fresh fish and vacuum-packed pickled fish or caviar contain only small amounts of tyramine and are safe if consumed promptly or refrigerated for short periods; longer storage may be dangerous. Smoked, fermented, pickled (Herring) and otherwise aged fish, meat, or any spoiled food may contain high levels of tyramine and should be avoided. ginseng - some preparations have resulted in a headache, tremulous-ness, and manic-like symptoms. Protein extracts - three brands of meat extract contained 95, 206, and 304 µg/gram of tyramine and therefore meat extracts should be avoided. Avoid liquid and powdered protein dietary supplements. Meat, non-fresh or liver - no detectable levels identified in fresh chicken livers; high tyramine content found in spoiled or unfresh livers. Fresh meat is safe, caution suggested in restaurants. Sausage, bologna, pepperoni and salami contain large amounts of tyramine. No detectable tyramine levels were identified in country cured ham. Sauerkraut - tyramine content has varied from 20 to 95 µg/gram and should be avoided. Shrimp paste - contain a large amount of tyramine. Soups - should be avoided as protein extracts may be present; miso soup is prepared from fermented bean curd and contain tyramine in large amounts and should not be consumed. Yeast, Brewer’s or extracts - yeast extracts (Marmite) which are spread on bread or mixed with water, Brewer’s yeast, or yeast vitamin supplements should not be consumed. Yeast used in baking is safe.

Treatment with Rifampicin

• Take with water 1 hour before or 2 hours after a meal;

• Additional vitamin D supplementation is necessary;

• Side-effects include: oral candidiasis, cramps, diarrhoea, flatulence;

• Caution with diabetics on sulfonylureas. Rifampicin increases the circulating glu-cose concentration, which can become important when treating insulin resistance generally associated with antiretroviral use.

Treatment with Aminosalicylic Acid (Paser Granules)

• This drug should be taken with or after a meal in order to limit the gastric irritation;

• Sprinkle granules on acidic foods, such as apple sauce or yoghurt. May also be mixed with acidic juice, which protects the granules and prevents the formation of hepatotoxins;

• The drug decreases absorption of Vit B12 by 55%. Parenteral Vit B12 supplementa-tion may be required when the drug is used for more than one month;

• Occasional reports of malabsorption of folic acid, iron and some lipids.

Treatment with Rifapentin

• Take with water 1 hour before or 2 hours after a meal;

• Additional vitamin D supplementation is necessary;

• Take Ca or Mg supplements or antacids 1 hr before or 2 hr after the drug;


• Pyridoxine supplementation recommended for malnourished, diabetic, alcoholic or adolescent patients;

• Side-effects include anorexia.

Treatment with Pyrazinamide

• Causes nausea;

• Leads to general loss of appetite.

Treatment with Ethambutol

• May take the drug with food or milk;

• Causes anorexia.

Treatment with capreomycin (Capastat)

• Make sure that the patient takes enough fluid. Caution should be used in lactating women.

Treatment with Ethambutol HCI

• May lead to anorexia;

• Abdominal pain and gastrointestinal distress can also occur;

• May be taken with food to decrease the GI distress.

Treatment with Ethionamide (Trecator SC)

• Pyridoxine supplementation is required (50-100mg/day) to prevent peripheral neu-ritis. The drug causes a metallic taste in the mouth, increased secretion of saliva, stomach pain, nausea and vomiting.

Other drugs used in TB patients:

Ethionamide: Take with or after meals. Avoid alcohol. Supplement Vitamin B6 50-100mg daily. Avoid alcohol.

Amikacin: Increase fluid intake. May be taken with food or on an empty stomach.

Streptomycin: May affect the taste of food. Increase fluid intake.

Capreomycin: May need to increase intake of foods high in potassium, but assure normal renal function first. Increase fluid intake. May be taken on a full or empty stomach.

Cycloserine: Supplement Vitamin B6 as directed. Avoid alcohol.


Linezolid: May be taken with food. Supplement Vit B6 100 mg daily. Avoid food and drinks that contain tyramine. Do not use with drugs that promote release of serotonin or block its uptake (serotonin syndrome).

MALARIA

• Chloroquine (Aralen HCI; Aralen Phosphate): take with meals or milk to decrease GI irritation, causes anorexia and slight decrease in weight, can cause abdominal cramps and diarrhoea. Encourage oral hydration.

• Quinine: should be taken with or after meals in order to decrease gastric irritation. Avoid food or beverages that contain quinine (e.g. tonic water).

HYPERTENSION

Research has shown that following a healthy eating plan can both reduce the risk of devel-oping high blood pressure and lower an already elevated blood pressure. It is estimated that 20-30% of blacks and 15% of whites in the U.S. suffer from hypertension. Hyperten-sion leads to increased organ disease in patients. Essential hypertension is multifactorial, but it is suggested that salt intake may contribute to its worsening, and also that obesity, excessive alcohol intake, tobacco use and a diet low in potassium could exacerbate the symptoms. Secondary hypertension is of an organic cause. Patients at risk of developing hypertension should be given the following advice:

• Reduce sodium intake (replace it with potassium);

• Avoid salt, dairy products, refined foods, fried foods, junk foods and caffeine;

• Eat whole, unrefined and unprocessed foods;

• Calcium intake should be approximately 800-1500mg/day;

• Vitamin C intake should be in the range of 1000mg/day;

• Patients should take supplements that contain Co-enzyme Q10 (50mg 2x/day)

• The patients should include Flaxseed products in the diet.

A high-fibre diet has been shown to be effective in preventing and treating many forms of cardiovascular disease, including hypertension. The type of dietary fibre is important. Of the greatest benefit to hypertension are the water soluble gel-forming fibres such as oat bran, apple pectin, psyllium seeds, and guar gum. These fibres, in addition to be of benefit against hypertension, are also useful to reduce cholesterol levels, promote weight loss, chelate out heavy metals, etc. A key to healthy eating is choosing foods lower in salt and sodium. Before the widespread availability of medication to control high blood pres-sure, people with serious hypertension had only one treatment option, a drastically salt-reduced, low-calorie ‘rice diet.’ Some people can significantly lower their blood pressure by avoiding salt. The following foods should be included in the diet: celery, garlic, onion,


tomato, broccoli, carrot and saffron. Assorted spices that are suggested to benefit indi-viduals with hypertension: fennel, oregano, black pepper, basil and tarragon have active ingredients that are beneficial in hypertension. They can be used in cooking.

REFERENCES

1. Ernst E. Herb-Drug Interactions: Potentially Important But Woefully Under-Researched. Eur J Clin Pharmacol 2000; Volume 56(8):523-524

2. Friedland G, Abdool Karim S, Abdool Karim Q, et al. Utility of tuberculosis directly observed therapy programs as sites for access to and provision of antiretroviral therapy in resource-limited countries. Clin Infect Dis 2004; 38: S421–28

3. Pronsky ZM, Meyer SA & Field-Gardner C. HIV Medications and Food Interactions (And So Much More). 1998. Published by FOOD-MEDICATION INTERACTIONS: Birchrunville, USA

4. Raviglione MC, Harries AD, Msiska R, Wilkinson D & Nunn P. Tuberculosis and HIV: current status in Africa. Aids 1997; 11(suppl B): S115–23

5. Schmidt LE & Dalhoff K. Food-Drug Interactions. Drugs 2002; 62(10):1481-1502

6. Tuberculosis Medication Food and Drug Interactions. (Available at: http://www.heart-landntbc.org/products/tuberculosis_medication_drug_and_food_interactions.pdf. Date accessed: 22 Feb 2011)

7. World Health Organization (WHO). Framework for effective tuberculosis control. 1994. WHO/TB/94.179. World Health Organization: Geneva

8. World Health Organization (WHO). Global tuberculosis control: surveillance, planning, financing. WHO report 2006 (WHO/HTM/TB/2006.362). World Health Organization: Geneva

9. Yamada M & Yasuhara H. Clinical Pharmacology of MAO Inhibitors: Safety and Future. Neurotoxicology 2004; 25(1-2):215-221

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