H/A: Medical Nutrition Therapy 2010
Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.
HIV/AIDS: Medical Nutrition Therapy (MNT)
Medical nutrition therapy (MNT) provided by a registered dietitian (RD) is recommended for individuals with HIV infection. Four studies regarding MNT (with or without oral nutritional supplementation) report improved outcomes related to energy intake, symptoms and cardiovascular risk indices. Two studies regarding nutritional counseling (non-MNT) also report improved outcomes related to weight gain, CD4 count and quality of life.
HIV/AIDS: Frequency of Medical Nutrition Therapy (MNT)
The Registered Dietitian (RD) should provide at least one to two Medical Nutrition Therapy (MNT) encounters per year for people with HIV infection (asymptomatic) and at least two to six (or more) MNT encounters per year for people with HIV infection (symptomatic but stable, acute or palliative), based on the following:
- Appropriate disease classifications
- Nutritional status
- Opportunistic infections
- Physical changes
- Weight or growth concerns
- Oral or gastrointestinal symptoms
- Metabolic complications
- Barriers to nutrition
- Living environment
- Functional status
- Behavioral concerns or unusual eating behaviors.
Studies regarding MNT (with or without oral nutritional supplementation) report improved outcomes related to energy intake, symptoms, and cardiovascular risk indices, especially with increased frequency of visits.
Risks/Harms of Implementing This Recommendation
- Access to registered dietitian who is linguistically and culturally sensitive to population and sensitive to HIV-infected population and has at least general HIV education, is most desirable and are potential barriers
- Information about the patient’s medical condition is necessary to initiate MNT.
Conditions of Application
- HIV-infected patients may be at nutritional risk at any point in their illness (Nerad et al, CID 2003)
- The CDC classification by CD4 count and clinical signs and clinical signs and symptoms may not be appropriate for nutrition complications or referrals. Rather, defining levels of risk for nutritional compromise as the trigger for nutrition referral and intervention may be more practical, given current resources. Ideally, all patients infected with HIV should have access to a registered dietitian (RD) (Nerad et al, CID 2003).
- There are four underlying assumptions in the design of this scope:
- The assumption that level of experience, skills and proficiency with respect to identified activities varies among individuals
- The assumption that dietetics practitioners may not be competent to practice in all aspects of the field
- The assumption that individual practitioners are expected to practice only in areas in which they are competent
- The assumption that practitioners should pursue additional education and experience to expand the scope of their personal dietetics practice. (American Dietetic Association: Scope of Dietetics Practice Framework).
Potential Costs Associated with Application
Costs of medical nutrition therapy (MNT) sessions and reimbursement vary, however, MNT sessions are essential for improved outcomes.
- Seven studies were evaluated regarding Medical Nutrition Therapy (MNT) or nutrition counseling in people with HIV infection
- One study, completed prior to highly active antiretroviral therapy, stressed that early intervention may prevent progressive weight loss (Chlebowski et al, 1995)
- Four studies regarding MNT (with or without oral nutritional supplementation) report improved outcomes related to energy intake, symptoms and cardiovascular risk indices, especially with increased frequency of visits (Topping et al, 1995; Rabeneck et al, 1998; Schwenk et al, 1999; Fitch et al, 2006)
- Two studies regarding nutritional counseling (non-MNT) also report improved outcomes related to weight gain, CD4 count and quality of life (Kaiser et al, 1996; Tabi and Vogel, 2006).
Recommendation Strength Rationale
Conclusion Statement received Grade I
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
Chlebowski RT, Grosvenor M, Lillington L, Sayre J, Beall G. Dietary intake and counseling, weight maintenance, and the course of HIV infection. J Am Diet Assoc 1995; 95(4): 428-435.
Fitch KV, Anderson EJ, Hubbard JL, Carpenter SJ, Waddell WR, Caliendo AM, Grinspoon SK. Effects of a lifestyle modification program in HIV-infected individuals with the metabolic syndrome. AIDS. 2006; 20: 1843-1850.
Kaiser JD, Donegan E. Complementary therapies in HIV disease. Alternative Therapies in Health and Medicine. 1996; 2(4): 42-46.
Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL, Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial evaluating nutrition counseling with or without oral supplementation in malnourished HIV-infected patients. J Am Diet Assoc. 1998; 98: 434-438.
Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive treatment to nutritional counseling in malnourished HIV-infected patients: randomized controlled trial. Clinical Nutrition. 1999; 18(6): 371-374.
Tabi M, Vogel RL. Nutritional counselling: An intervention for HIV-positive patients. Journal of Advanced Nursing. 2006; 54(6): 676-682.
Topping CM, Humm DC, Fischer RB, Brayer KM. A community-based, interagency approach by dietitians to provide meals, medical nutrition therapy, and education to clients with HIV/AIDS. J Am Diet Assoc. 1995; 95: 683-686.
References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
Hendricks KM, Dong KR, Gerrior JL, eds. Nutrition Management of HIV and AIDS. Chicago, Illinois: American Dietetic Association; 2009.
Los Angeles County Commission on HIV. Standards of Care. Medical Nutrition Therapy. Available at:
Nerad J, Romeyn M, Silverman E, Allen-Reid J, Dieterich D, Merchant J, A Pelletier V, Tinnerello D, Fenton M. General nutrition management in patients infected with human immunodeficiency virus. Clin Infect Dis. 2003 Apr 1; 36 (Suppl 2): S52-S62.
Nutrition in Section 2: Health Maintenance and Disease Prevention; Clinical Management of the HIV-Infected Adult. Available at: http://www.aids-ed.org/aidsetc?page=cm-202_nutrition Manual: http://www.aids-etc.org/aidsetc?page=cm-200-00
PUBLIC LAW 109-415-DEC. 19, 2006 120 STAT. 2767 ‘‘Ryan White HIV/AIDS Treatment Modernization Act of 2006.’’ ftp://ftp.hrsa.gov/hab/reauth06.pdf