Macronutrients

HIV infection increases energy needs due to an increase in REE, as previously stated. This increased REE coupled with HIV-related infections and complications, such as anorexia, place HIV-infected pregnant women at greater nutritional risk than the uninfected woman [23, 24]. Current energy recommendations for HIV-infected pregnant and lactating women are an increase of 10% over baseline energy needs during the asymptomatic phase and an increase of 20-30% over baseline energy needs during the symptomatic phase [25]. Early symptomatic HIV infection is defined as the stage of viral infection caused by HIV when symptoms have begun, but before the development of AIDS. Symptoms may include but are not limited to mouth disorders (oral hairy leukoplakia, oral thrush, gingivitis), prolonged diarrhea, swollen lymph glands, prolonged fever, malaise, weight loss, bacterial pneumonia, joint pain, and recurrent herpes zoster. In addition, the World Health Organization (WHO) recommends an intake of an extra 300 kcal per day during all trimesters of pregnancy [26], while the National Research Council recommends an additional intake of 300 kcal per day during the second and third trimesters of pregnancy [27] (Table 12.2). Energy intakes that fall below established recommendations are likely to result in coinciding low intakes of micronutrients such as calcium, magnesium, zinc, vitamin B-6, and folate [19], which have potential consequences for both the mother and developing child.

Table 12.1

Recommended Weight Gain for Pregnancy Based on Prepregnancy Weight

Table 12.1

Recommended Weight Gain for Pregnancy Based on Prepregnancy Weight

BMI (kg/m2)

Recommended total weight gain (lb)

Underweight

<19.8

28-40 (13-18 kg)

Normal weight

19.8-26

25-35 (11-16 kg)

Overweight

26-29

15-25 (7-11 kg)

Obese

>29

At least 15 (At least 7 kg)

Table 12.2

Adjusted Energy Needs for HIV-Infected Pregnant Women

Additional energy Increase in energy needs Plus for pregnancy HIV-asymptomatic pregnant women 10% above normal needs + 300 kcal/day HIV-symptomatic pregnant women 20-30% above normal needs + 300 kcal/day

Protein requirements are higher during pregnancy to support maternal protein synthesis for expansion of the blood volume, uterus, and breasts and to supply amino acids for synthesis of fetal and placental proteins [27]. The recommended dietary allowance (RDA) for protein for a normal pregnancy and lactation is 71 g per day [28] or approximately 1.1 g/kg/day based on current body weight. This compares to a RDA for protein of 0.8 g/ kg/day for nonpregnant, healthy women [28]. The Institute of Medicine recommends 71 g of protein per day during pregnancy [29]. In the United States and other developed countries, adequate protein intake is not usually a problem. As with nonpregnant individuals, additional protein may be needed under conditions of stress, such as symptomatic HIV infection. However, there is not sufficient data to suggest that HIV infection in and of itself demands a higher protein intake by the infected individual [4].

The Acceptable Macronutrient Distribution Range (AMDR) for fat for normal pregnancy and lactation is 20-35% of kilocalories for all women from 18 to 50 years of age [28]. Structural and functional changes in the gastrointestinal tract in HIV often affect the absorption of fat, leading to fat malabsorption [16]. In this setting, the use of medium chain triglyceride (MCT) oils may be beneficial. MCT are more easily digested than long-chain triglycerides (LCT) and can be absorbed across the small intestinal mucosa in the absence of pancreatic enzymes [30]. MCT oil can be used as a supplement and added to foods. Also, many enteral feeding formulas designed for patients with fat malabsorption contain MCT oil.

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