11.3 MNT for HIV/AIDS and for Protein-Energy Malnutrition in Children and Adults
Key Takeaways
WHO estimates that energy needs rise by about 10% in asymptomatic HIV infection and by about 20-30% in symptomatic HIV or AIDS in adults.
Severe acute malnutrition in children 6-59 months is diagnosed by weight-for-height below -3 SD, MUAC below 115 mm, or bilateral pitting edema.
In the stabilization phase of severe acute malnutrition, F-75 provides 75 kcal per 100 mL, and iron is withheld until the rehabilitation phase.
Children with uncomplicated severe acute malnutrition who pass the appetite test can be treated as outpatients with ready-to-use therapeutic food, which provides about 500 kcal per 92 g sachet.
The GLIM criteria diagnose adult malnutrition when at least one phenotypic criterion (weight loss, low BMI, or low muscle mass) and one etiologic criterion (reduced intake or absorption, or inflammation) are present.
The table of specifications lists oncologic conditions, HIV-AIDS, and protein-energy malnutrition under the pathologies examinees must relate to nutrition treatment. Marasmus and kwashiorkor are described in the life-stage assessment section; this section focuses on treatment.
HIV and AIDS
The Philippine HIV and AIDS Policy Act (RA 11166, 2018) sets the national response, including confidentiality and access to treatment. Nutrition care supports immune function, preserves lean mass, and improves tolerance of antiretroviral therapy (ART).
Nutritional problems in HIV:
- Higher energy needs: about 10% more in asymptomatic adults and 20-30% more in symptomatic HIV or AIDS (WHO), with higher needs during opportunistic infections.
- Wasting: involuntary weight loss and muscle loss from poor intake, malabsorption, and inflammation.
- Opportunistic infections: oral and esophageal candidiasis make chewing and swallowing painful; diarrhea and tuberculosis increase losses.
- ART side effects: nausea, taste changes, dyslipidemia, insulin resistance, and changes in fat distribution (lipodystrophy).
- Food safety: immune suppression increases risk from contaminated food and water.
Nutrition management:
| Problem | Intervention |
|---|---|
| Weight loss and wasting | Energy-dense, protein-rich meals and snacks; oral nutrition supplements; treat underlying infections |
| Mouth and throat sores | Soft, moist, bland, non-acidic foods at room temperature; avoid spicy and rough foods |
| Diarrhea | Fluids and ORS, small frequent meals, soluble fiber, temporarily lower lactose and fat if poorly tolerated |
| Nausea | Dry crackers, small meals, cold foods, timing meals around medications |
| Dyslipidemia and insulin resistance | Heart-healthy diet, less saturated fat and refined sugar, physical activity |
| Food safety | Safe water, thorough cooking, hand washing, avoiding raw eggs and unpasteurized milk |
| Drug-food timing | Follow instructions on taking drugs with or without food |
Micronutrient intakes should meet recommended levels through diet, with a standard multivitamin when intake is poor; high-dose single supplements have no proven benefit. WHO recommends that mothers living with HIV who take ART breastfeed exclusively for 6 months and continue breastfeeding with complementary foods.
Severe Acute Malnutrition (SAM) in Children
Diagnosis in children 6-59 months: weight-for-height below -3 SD, mid-upper arm circumference (MUAC) below 115 mm, or bilateral pitting edema. Moderate acute malnutrition (MAM) is weight-for-height between -3 and -2 SD or MUAC from 115 to below 125 mm. The DOH manages acute malnutrition through the Philippine Integrated Management of Acute Malnutrition (PIMAM) protocol, which combines community screening, outpatient care, and inpatient care.
Where to treat:
- Inpatient care for SAM with medical complications (hypoglycemia, hypothermia, severe infection, dehydration), poor appetite (failed appetite test), or age below 6 months.
- Outpatient therapeutic care for uncomplicated SAM with good appetite, using ready-to-use therapeutic food (RUTF), an energy-dense paste of peanuts, milk powder, oil, sugar, vitamins, and minerals providing about 500 kcal per 92 g sachet.
- Supplementary feeding for MAM, using ready-to-use supplementary food or fortified blended foods.
WHO ten steps for inpatient care:
- Treat or prevent hypoglycemia.
- Treat or prevent hypothermia.
- Treat or prevent dehydration using a low-sodium rehydration solution for malnutrition (ReSoMal) given slowly.
- Correct electrolyte imbalance (extra potassium and magnesium; children often have excess body sodium).
- Treat or prevent infection with antibiotics.
- Correct micronutrient deficiencies (vitamin A, zinc, folic acid, copper); withhold iron until the child gains weight in rehabilitation.
- Start cautious feeding with F-75.
- Achieve catch-up growth with F-100 or RUTF.
- Provide sensory stimulation and emotional support.
- Prepare for follow-up after recovery.
| Phase | Formula | Typical target |
|---|---|---|
| Stabilization (about days 1-7) | F-75: 75 kcal and about 0.9 g protein per 100 mL | About 100 kcal/kg/day in frequent small feeds |
| Rehabilitation (weeks 2-6) | F-100 (100 kcal per 100 mL) or RUTF | About 150-220 kcal/kg/day for rapid catch-up growth |
Iron is withheld early because it can worsen infection and oxidative stress before tissue repair begins. Refeeding syndrome is a risk, which is why stabilization feeding is low in protein and sodium and advanced gradually.
Malnutrition in Adults: GLIM Criteria
The Global Leadership Initiative on Malnutrition (GLIM) diagnoses malnutrition in adults when at least one phenotypic and one etiologic criterion are present:
| Phenotypic criteria | Etiologic criteria |
|---|---|
| Unintended weight loss (more than 5% within 6 months, or more than 10% beyond 6 months) | Reduced food intake or assimilation (for example, intake 50% or less of needs for more than 1 week) |
| Low BMI (in Asian adults, below 18.5 if under 70 years, or below 20 if 70 or older) | Inflammation from acute or chronic disease |
| Reduced muscle mass |
Severity is then graded by the degree of weight loss, BMI, or muscle loss. Treatment combines adequate energy and protein, oral nutrition supplements, enteral or parenteral support when needed, and treatment of the underlying disease, with attention to refeeding risk in severely depleted patients.
An adult with HIV has developed tuberculosis and diarrhea and has lost weight. By about how much does WHO estimate energy needs rise in symptomatic HIV?
About 5%
About 50-60%
No increase in energy needs
About 20-30%
A 2-year-old with severe acute malnutrition and pneumonia is admitted. During the stabilization phase, which practice is correct?
Start F-100 at 200 kcal/kg/day right away to promote rapid catch-up weight gain
Give F-75 in small, frequent feeds and withhold iron until rehabilitation
Give ferrous sulfate drops immediately to correct anemia
Rehydrate rapidly with standard intravenous saline
Under the GLIM criteria, which combination confirms malnutrition in a 60-year-old Filipino patient?
BMI of 17.8 and food intake below half of needs for two weeks
BMI of 23 and normal intake, with a family history of diabetes
Weight gain of 3 kg in 6 months and mild inflammation
Normal BMI, normal muscle mass, and no reduction in intake
Sections you finish are checked off in the contents.