December 12, 2013
Myles Helfand: Would you say the same is true of vitamin C, which had long been colloquially associated with greater ability for a weakened immune system to fight off infection?
Jül Gerrior-Schofield: I would approach everybody individually. There may be someone who would more likely be a candidate for vitamin C. But I wouldn't be comfortable suggesting everybody with HIV take vitamin C to prevent these problems, because the truth is that there's been debunking evidence for all of these individual supplements.
Individual supplements also can interfere with the delicate balance of absorption of your nutrients. If you take excess C, you may not get your zinc, for example, in another form.
There's a lot of controversy around taking extra individual supplements. Unfortunately, there's just not a lot of good studies. It's not to say that supplements may not be useful; we just haven't had good, randomized, controlled trials to actually support the overarching recommendation of these individual nutrients, even in Africa and other countries.
If we can invest our time talking about where to get vitamin C in food, and try to focus our energy on teaching people the right things to eat, I think we're that much better off.
Myles Helfand: Correct me if I'm wrong, but it's easier, in terms of public assistance, to access food aid than it would be to get supplements paid for, isn't it?
Jül Gerrior-Schofield: Yes. Absolutely.
Myles Helfand: Do ADAPs normally cover vitamins?
Jül Gerrior-Schofield: Multivitamins, in some clinics, have been covered. They're giving away multivitamins, and that's great. I'm not sure about ADAP. I think a lot of it may be Ryan White funded, depending on where you are and what you're offering.
There are some other things: For example, glutamine is a protein powder, an amino acid that's been very useful at improving the gut. That's a very specialized product: If someone comes to us and has really intense, watery diarrhea, I would try some other nutrition things to intervene first, like reducing saturated fat and adding soluble fiber. But then there are these little arsenals of supplements that can be very useful.
Myles Helfand: Another thing you got at a little bit there is that the side effects of some antiretrovirals can involve a lot of gastrointestinal distress. That's where nutrition can also come into play: all the nutritional alterations that can help alleviate diarrhea, gas, or any number of other gastro issues.
Jül Gerrior-Schofield: When I started working in the field in '96, I was tasked with, "OK, Jül, do you want to work with patients who have diarrhea who are HIV positive?" And I'm like, "Absolutely." It was so prevalent. We saw a lot of watery, loose stools. Not only the meds, but HIV itself, was really altering the gut, and causing a lot of problems with malabsorption. Patients were losing weight.
What we did was, we put everybody on this formula called Lipisorb. Lipisorb was made up of these small protein peptides and medium-chain triglycerides - similar to coconut oil, medium-chain fat -- and then simple-to-digest carbohydrates. We put our patients on it and we said, "Don't eat anything else, but drink this formula." This formula reduced stool volume remarkably. It put weight on our patients, and they just felt better. It was purely a nutritional intervention. And it's such a good feeling to see.
It went away for a while: We don't really talk about diarrhea, because it wasn't as common. Nowadays, it's interesting: I'm doing another diarrhea study. Here we are, 2013, and my job comes full circle. We're using what's called a serum bovine immunoglobulin. It's a protein isolate that is supposed to also help nourish the gut and reduce stool volume. I've got many candidates out there that are suffering from medication-induced diarrhea. We're hopeful that this is going to make an impact. This is considered a medical food. It's still in a research phase, so we're not sure how it's going to do in HIV, but it's been studied in things like Crohn's disease.
There's a lot of interesting things that are being done. It's just about getting awareness again, and getting people to understand that nutritional options are available.
Staying on antiretrovirals is huge. What we don't want is for people to be suffering these side effects if we can help manage them. Even lipodystrophy, for example -- people want to come off of d4T [stavudine, Zerit], or whatever they're taking. Or they know Norvir [ritonavir], for example, is causing their diarrhea, so they want to jump off that.
This is where nutrition comes in: to try to help manage these symptoms. If we can get them to control their diarrhea by changing their diet, or doing something like this, these are the tangible things that we can make a difference in.
This is where we're often brought in. Because if a patient doesn't have room to move on their antiretrovirals, we want to be able to help support them in that.
Myles Helfand: Is there anything that you wanted to add in that we haven't already discussed?
Jül Gerrior-Schofield: Again, the big question for physicians, if this is going to be helpful, is to just have the conversation. Start the conversation with access to food: Are your patients getting enough? I think developing a checklist is something that I would like to promote. And if I come up with it, I'll share it with you guys. But I think that's the critical conversation starter, just get the awareness out there.
It's been a great run, working in this field of nutrition and HIV. I really love what I do. I think we've made a good impact in improving the lives of many patients with HIV with our nutrition interventions. So I'm hopeful that this can be translated across the country. If people are enthusiastic about learning about nutrition, it definitely warrants a discussion. And it does start in the doctor's office, for the most part.
We, as nutritionists and dietitians, have very detailed and thorough nutrition assessments geared for people with HIV and other diseases. We can modify this simple tool so that a clinician can use it and we can educate them not to panic -- if they start to actually see problems, not to say, "Oh, no, I don't have time to deal with this." Just make that referral to the dietitian.
Dietitians are everywhere in this field, or in general. They're part of the medical environment, the community. They're there. They just need to be accessed.
It's also very important that the patient has a good experience with a dietitian, to help to create that value. Then they'll come back. What often happens is, they'll have maybe one visit with a dietitian, and then you don't see them again. It's all about trying to get that relationship.
That's true for all problems in all different disciplines; it's not just specific to HIV. But it's hard to get people, in general, thinking about their nutrition, paying attention to their diet, maintaining their weight and staying balanced. It's difficult for a lot of people, not just people who have illnesses. But it makes it that much more complex, when you're dealing with someone who does have a chronic disease, and has a lot of other priorities.
We always say, "We're not the food police. We come in peace." I'm not here to completely inspect your diet. We're very realistic about what's reasonable for somebody, and what their goal is.
We just want them to think about more balance. It's baby steps: You set small, realistic goals to get them to the next place.
Myles Helfand: Very similar to mental health, it's avoiding judgment. It's providing a supportive environment, rather than a harsh environment.
Jül Gerrior-Schofield: Right. Absolutely.
Myles Helfand: Thank you, Jül.
This transcript has been edited for grammar and clarity.
Myles Helfand is the editorial director of TheBody.com and TheBodyPRO.com.
Follow Myles on Twitter: @MylesatTheBody.