Immune System and HIV/AIDS

we're looking at the connection between nutrition infection and the immune system let's start with looking at this undernutrition. generally if we're undernourished what happens? we have impaired immunity and it's usually the cell mediated immunity that gets the most affected but that's not the only immune function that gets impaired we start to see decreased microbial activity of the ____________ we also see a decrease in the activity of the complement system we have a decrease in the secretory antibodies and we even start to see a decreased antibody affinity. now because of this altered immune response we see an increase risk for infection right but also know that infection itself can work to impair our immune response right so think HIV.

phagocytes

A deficiency comprises this first line of defense increasing that our risk of infections like eye infections and GI infections and respiratory infections. now vitamin A deficiency also affects the number of ________ and their ability to do their job so not only do you see reduced numbers of vagocytes but they're not able to do their job very well either. we also see compromises in humoral and cell mediated immunity when vitamin A deficiencies exist so we see that the deficiencies lead to immune-compromised but what does the research say that about supplementation? so research has repeatedly shown that vitamin A supplementation ___________ immunity and has been shown to reduce the infection related morbidity and mortality that's associated with that vitamin A deficiency. so specifically vitamin A has been shown to decrease the severity of diarrheal diseases and has also been shown to decrease the severity but not the incidents of other infections like malaria measles even HIV. so even though vitamin A supplementation is effective there are some adverse effects so supplements should only be used in undernourished individuals or those that have it confirmed vitamin A deficiency.

vagocytes enhances

But really what we have is the fact that malnutrition and HIV from this they form this __________ which ultimately reduces the immunity of the patient even further. now in both HIV and malnutrition you see decreased CD 4 count you see that you know the delayed cutaneous sensitivity and all of those other markers. when it comes to a micronutrient deficiencies there's some evidence that they can impact the replication of the HIV virus but they also induce several ____________ that compromise nutritional status. and this includes things like whole body protein turnover increased urinary nitrogen loss is elevated hepatic protein synthesis and also increased skeletal muscle breakdown the increased muscle breakdown provides for the proliferation of immune cells and for the synthesis of immunoglobulins and acute phase proteins so in HIV patients these alterations often manifest themselves as a fever.

vicious cycle metabolic alterations

now I mentioned energy needs already but energy needs can be ____% higher at least but if there's some malignancy or fever again those needs are going to be higher. so we want to make sure that energy needs are more than adequate to meet the needs. protein needs and recommendations again are based on whatever else is happening with the patient whether or not cachexia is present but generally if you just look at generally what's happening the needs are higher by approximately ____% but keep in mind that while general protein recommendations in HIV or higher right to buffer the catabolism of protein stores that's part of that inflammatory process diets in the US or generally higher in protein rate so there may not be any higher intake that's required somebody may already be meeting the actual protein recommendations now this is very different very different in places like Africa right where protein status is already compromised there the additional protein really goes a long way to improve immune another inflammation mediated responses

10 to 15 50 to 100

The risk of diabetes in HIV positive individuals who are not on these antiretroviral therapy seems to be relatively similar or maybe just slightly higher than the general population. but for those who are undergoing the antiretroviral therapies there's a marked increase in impaired glucose tolerance and type 2 diabetes and there was one study that found that HIV infected men that receiving antiretroviral therapies had a baseline prevalence of diabetes of ___% compared with 5% in the controls and had an approximately fourfold risk of developing diabetes during that follow up so those were pretty significant statistics right

14

babies that are born to HIV positive women generally have about a ____________% risk of contracting the virus through breast milk. a few years ago the American Academy of Pediatrics came out with a statement that individuals born to HIV positive moms should be bottle fed in a lot of developing countries where breastfeeding is still the norm and it's the expected feeding method. breast feeding is still the recommended mode of feeding even if the mom is HIV positive so the American Academy of Pediatrics is saying bottle feed if you have HIV but you know in some of these developing nations that they don't have the luxury or the option of bottle feeding particularly. when you think about these developing countries the recommendation still is to breastfeed even if you have HIV especially initially because with breastfeeding you have all of the other ____________ that is passed through the breast milk especially in the early stages of breastfeeding. so early breastfeeding can be particularly helpful in improving immunity and it is certainly better to feed the baby even if you're HIV positive then not feed the baby if there are no other safe ways available.

20 to 25 immunity

Acquired immunodeficiency syndrome or aids is the final stage of HIV. it's diagnosed first by the HIV infection and then Secondly defined by a CD4 cell count below ____ or less than 14% of lymphocytes present and or the presence of an aids defining illness. so this is the basic criteria to determine that aids diagnosis because at this point when you have a CD 4 count that's so low you have lost the function of your helpers T cells and you can't mount an immune response. so when you do have a foreign invaders such as a virus or bacterial infection it can be fatal. once you're in this in this stage of aids it can be fatal. now this number you know of 200 is not arbitrary what we've seen is that CD 4 cell counts that range between ________ generally provide an adequate immune defense against these opportunistic infections it's when they drop lower that it becomes more critical So what are these aids defining illnesses, so these are things like opportunistic infections opportunistic malignancy's like the kaposi's sarcoma or other conditions like dementia and wasting syndrome or cachexia

200 600 and 1200

the CDC has outlined CD four level categories in clinical categories of HIV infection. category one is defined as CD 4 count of greater than ____ per microliter. category two shows higher risk for some immune deficit related conditions with ______ CD four cells per microliter and then the category three is the criteria of less than ____. now along with those parameters there are clinical categories that describe the potential clinical manifestations of immune dysfunction in adults in adolescents over the age of 13 so this clinical category A includes primary HIV infection apparently asymptomatic HIV infection in a persistent generalized lymph and lymph adenopathy. this clinical category B includes conditions that may be attributable to HIV infection or a deficit in cell mediated immunity other than those that fall into category C of this a few things just to take note of these categories are not a dynamic way to classify a person's current condition and the classification for individuals appears to be progressive. so for example if a person is diagnosed with a diagnosis of aids they will remain categorized with aids diagnosis even if they recover or reverse that condition and have no current aids defining condition and the person who's been diagnosed with the condition listed in category B will remain in that category even if they are apparently _______________ the WHO also has a clinical staging system for international use but here pretty much we use the CDC criteria

500 200 to 499 200 asymptomatic

So what do we know about REE now in this heart treatment era? a lot of studies have shown that our REE per kilogram of fat free mass is indeed ________% higher in asymptomatic HIV infected persons than it is in an HIV negative non obese adult. now why REE is elevated in an asymptomatic patient is a little bit unclear right now keeping in mind that REE in an HIV infected individuals affected by that HIV positive status and other infections and viral load and CD4 but we're not really sure what it is about that asymptomatic patient that also increases their REE. the assumption is that these heart therapies reduce viral load right and that consequently REE should ________ theoretically you should decrease them but the research really has been very inconsistent so I don't think that there is an answer yet but I just want you to know that REE is increased in HIV positive individuals regardless of whether they treat receiving HAART therapy or not. so we don't know if the heart therapy actually reduces REE or not we know the infection itself does

9 to 10 decrease

Nutrition considerations in HIV

Impaired immune function Body composition changes Decreased intake Altered metabolism Malabsorption Malnutrition Dyslipidemia

this cell mediated response is regulated by ____________________ which are really a group of genes that help the immune system recognize those foreign substances. So what that MHC's do is that they display __________ on the surface of the cell which the immune system can then identifies either self or as foreign and these invaders they can be anything really they include bacteria and fungi and parasites, viruses all of these so once these invaders are identified right as non-self that's what triggers the _______________.

MHC or what we call the major histocompatibility complex antigens immune response

General goals of nutrition intervention

Preserve optimal somatic and visceral protein status Prevent nutrient deficiencies or excesses known to compromise immune function Minimize nutrition-related complications that interfere with either intake or absorption of nutrients Support optimal therapeutic drug levels Enhance the quality of life

we know that a significant or severe malnutrition can impair immune function but what happens if someone is suffering from mild or moderate malnutrition? well here the evidence is a little bit less compelling, but it still indicates that there are some changes in the immune response. mainly what we see with this moderate or marginal malnutrition is it reduced number of ______ and even less reactive response to those skin tests with that inflammation. so really what you see with this moderate and marginal malnutrition is a _______ immune response. it's not absent, it is not as dramatic as if somebody has severe malnutrition but it's a blunted response. so how do we know that the number of T cells is decreased? we can do blood work. so we can conduct a ____________ or TLC which is part of the normal CBC. that's pretty standard blood work so we're looking at T cells when we run the standard labs. so keep in mind that human malnutrition consists of multiple nutrient deficiencies so depending on the specific nutrients that may or may not be present in the diet in may be more pronounced in certain individuals.

T cells blunted total lymphocyte count

if we want to look at over nutrition as a type of malnutrition there is a link between overnutrition and immune function as well. so overnutrition and obesity have been shown to alter immunocompetence. obesity is associated with macrophage infiltration of adipose tissue where macrophage accumulation in adipose tissue is directly proportional to the degree of obesity so obesity generally is characterized by that chronic low grade inflammation and inflammation is thought to be an important contributor to the pathogenesis of insulin resistance. so that's one piece of the puzzle now what you'll also hopefully remember is that adipose tissues secrete fatty acids right and hormones and cytokines. ____________ specifically that trigger inflammatory processes and there appears to be a link between adipokine secretion and lowered immunity. now the effects might not be dramatic but there are noteworthy.

adipokines

so then in summary you know as we look at the HIV patient in the function of the immune system what are we what are we looking at what are the issues so the whole problem really is a replication of the virus right and the immune system's inability then to mount a response so with that there's an increased risk for infection and with infection comes an accelerated decline resulting in ____ now these are you know these changes alterations that we see are corresponding with a lot of metabolic issues right so we see the cachexia we see the loss of lean body mass we see some of these hormonal abnormalities as well the metabolic outcomes the metabolic outcomes when we look at wasting one of the things that we're most concerned about right is the risk for those opportunistic infections and then with that comes an increased risk for morbidity and mortality so we need to we need to intervene early enough so we don't see these detrimental metabolic outcomes now when we're thinking about nutrition support questions regarding nutrition support or really just what to feed and how much to feed

aids

So what micronutrients do we know are directly involved in maintaining our immune system? anything that we can classify as an __________ would affect our immune status but which nutrients are those? Again the connection between nutrition and immunity is that completely clear but there are some nutrients that we know that have an effect, so when it comes to specific guidelines in terms of dosage and what the ideal dosages are for nutrients for optimal immune status there really aren't any for immuno-compromised patients. So what we generally say is that for healthy individuals we can use the DRI's but what about those that are immune compromised? them there's some data that suggests that there might be higher requirements in those individuals for things like zinc vitamin A other antioxidants but we don't really know that defense definitively so our recommendations generally tend to be the _____ even in the people who have reduced immunity

anti-oxidant DRI's

so then what happens after that first exposure in a humoral response is that the body is primed to react. so you have that antigen and then that can then combine with the specific _________. so that first exposure primes the body to be ready to attack the second time it gets exposed to that offending pathogen. so humoral immunity can work either by direct attack activation of the complement system or activation of the _____________ system which is something that you might see when food allergies are play. so after that first exposure this humoral response results in the production of chemical mediators by mast cells or it results in direct cellular damage. both the production of chemical mediators and cellular damage are the reason why we see some of those symptoms that we see with an allergic reaction. so just remember in the humoral response the ________ are primarily responsible not by directly killing the pathogen or directly killing the bacteria but for secreting __________ when an antigen is present right so by secreting the antibodies and having that antigen antibody connection they basically are marked for other kinds of other kinds of responses

antibody anaphylactic B cells antibodies

what you also see happening with malnutrition is hypertriglyceridemia which you have already talked about but we also see elevated hepatic fatty acid synthesis we see decreased peripheral Lipoprotein lipase activity we also see hyperglycemia insulin resistance and increase gluconeogenesis so now we have an already compromised system now add to that undernutrition increased REE due to the HIV in now after that an opportunistic infection what happens what do you think happens so during those infections reactive oxygen species and prooxidant cytokines are released and those then cause increased consumption of vitamins like vitamin E&C in beta carotene all of which serve as ___________ so you end up with sort of an antioxidant deficiency.

antioxidants

The mechanism behind altered lipid metabolism and increased incidence of cardiovascular events in HIV patients is not fully elucidated but research has consistently found an increased incidence of cardiovascular events in HIV positive individuals. here is a challenge though with some of the research it's hard to separate this increased risk in incidence from the HIV infection and this ____________ because it appears that both player role right. what we know is that even before antiretroviral therapies there were alterations in lipid profiles so we knew that this was happening because of the infection itself. now early in the course of untreated HIV infection both HDL cholesterol and low density lipoprotein cholesterol or LDL right the levels decrease and triglyceride levels increase but after treatment with these antiretroviral therapies what we usually see is ____________ levels increasing even further and HDL levels typically remain pretty low and LDL levels tend to tend to increase more commonly than not often beyond the baseline level before they had HIV to begin with.

antiretroviral therapy triglyceride

when we talk about body composition changes in HIV most of the changes occur in fat distribution but we also see it decrease in lean body mass as well. now before the ART therapies there was a significant loss of _____________which was quite disproportionate to the amount weight that was lost. now this is very different than the losses that we would see in a typical starvation. the body metabolizes store fat stored fat for energy rate while trying to preserve our muscle mass. now lean body mass is preserved for as long as possible only in the later stages of starvation after all fat stores had been used. in contrast in HIV associated wasting, _________ is preserved and ___________ is a lost. if these patients regain weight they gain fat and not muscle mass so there was a very significant depletion of total body nitrogen. so with art therapy we still see these losses but they aren't as dramatic and as such have you have really impacted positively malnutrition rates in the HIV population

body cell mass body fat lean body mass

still the most common transmission of the HIV virus is through sexual transmission but it can be transmitted through blood and blood products as well and this is just one of the reasons why we're so careful in the hospitals to have those you know barriers in place right to prevent the transmission of the virus through the blood or any body fluids of any kind. so transmission is person to person through infected body fluids so sexual contact needle and syringe sharing contaminated transfusions vertical transmission before having a baby or during the birthing process and even through ____________.

breast milk

we don't know the precise mechanism but regardless it can cause increased visceral fat that can then contribute to the increased risk of ___________ but it can also lead other things right like body image issues which then has been tied very closely with medication noncompliance that although HIV infected individuals with abnormal fat distribution gently maintain a body mass index in the normal or overweight range they often experience cardiometabolic complications that are similar to those seen in frank obesity. there is one study they demonstrated that significantly increased prevalence of dyslipidemia and impaired glucose homeostasis in HIV negative controls were very evident so these changes that we see are not just they're not without metabolic consequences so when we see this lipodystrophy we also see an increase risk for some of these cardiometabolic conditions

cardiovascular disease

malnutrition is a huge concern right based on some of the factors that I've talked about but the GI tract which is a largest lymphoid organ in the body is directly affected by the HIV virus so HIV causes damage to the intestinal cells by _____________ So what happens is that there is malabsorption of fat and carbohydrates if there is fat malabsorption what do we need to be worried about I mean obviously fat but what else do we need to be worried about so start soluble vitamins right particularly vitamin A&E and remember what I talked about you know in or in the earlier part of lecture about vitamin A deficiency in this role on the immune system right so even though antiretroviral therapies they have improved the rates of malabsorption and diarrhea a little bit it hasn't been enough to make a significant difference and the greatest risk for malabsorption seems to be as the CD four counts go lower to less than 200 that's when you start to see high levels of malabsorption by some estimates approximately ______% of asymptomatic patients so these are asymptomatic patients malabsorbed carbohydrates 30% malabsorbed fat and 32% malabsorptive protein and these are no small numbers right that you combine that with reduced intake and increased REE you really have a recipe for malnutrition

causing flattening of the villi and decreased D xylose absorption 30 to 60

we know that if someone is malnourished the compromise that is most often seen in the immune system revolves around the _______________. malnutrition is the most common cause of secondary ___________________. now keep in mind that often when we're looking at research about malnutrition. a lot of early research looked at the link between starvation and immunity but we know that malnutrition rate is not always synonymous with starvation so when we talk about the immunity malnutrition risk in that connection for including those that might be in starvation but also those that have inadequate or imbalanced diet or those that may be suffering from catabolic illnesses like a cancer or even those who might be in a stress state due to injury or surgery or something of that nature. there's significant research that looks at the link between malnutrition and reduced resistance to infection and that opens the door to this sort of cascade of events for infection that leads to _____________ and then further compromises in immune function. so this relationship between malnutrition and infection is an intimate one where the research has consistently shown that nutrient deficiencies can and do alter immunocompetence and increase the risk of infection significantly

cell mediated immunity immunodeficiency inflammation

what's cell mediated immune response?

cell mediated immunity comes from T cells or T lymphocytes which do not produce antibodies, but they do recognize antigen. So what happens is that an antigen is recognized by the T cells as a foreign body and so that prompts the production of cytokines which that help regulate the activities of the B cells which then they go and it destroy the antigens so the helper T cells are essentially helpers for the B cells that plays such an integral role in humoral immunity right

protein energy malnutrition also compromises functions of other lymphoid tissues like the spleen and the lymph nodes. now when we have a protein energy malnutrition humoral immunity is affected to a lesser extent. this antibody affinity and response is generally decreased in protein energy malnutrition is not as dramatic but you do see it affect the humoral immunity as well. it's important to note though that protein energy malnutrition usually occurs with in _____________ with other deficiencies like especially where you see these coexisting together as a protein energy malnutrition plus like a vitamin A deficiency vitamin B6 deficiency folate vitamin E zinc iron copper selenium so it's very often not just protein energy malnutrition in isolation

combination

Now zinc is probably one of the micronutrients that you guys have all heard about in terms of its role in immunity. it is critical for normal development and function of cells that mediate both innate and adaptive immunity. now because zinc is not stored in the body, regular intake of the mineral is important to maintain the integrity of our immune system so when we have inadequate intake it can lead to a zinc deficiency but also a _________________. now with respect to that innate immunity, zinc deficiency impairs the complement system the cytotoxicity of those natural killer T cells the phagocytic activity of the neutrophils and the macrophages and the immune cells ability to generate oxidants that will kill those invading pathogens. so zinc deficiency has quite an impact but also compromises the adaptive immune function response rates including lymphocyte number and function.

compromised immune response

So obviously a hallmark of HIV is a _________________ regardless of the presence of symptoms. so HIV accounts for significant immunosuppression in an infected individual but if the cooperatives of good health are satisfactory then the suppression of immune deficiencies can be mediated or at least mitigated and one of these indices is nutrition. so malnutrition really compromises or taxes an already compromised system and accelerates the progression of HIV to AIDS. malnutrition is a significant contributor to immunodeficiency so malnutrition immune system and infectious diseases are interlocked in this very complex _____________. so malnutrition elicits dysfunctions in the immune system and promotes increased vulnerability of the host to those infection. now couple malnutrition with HIV and it could really cause very detrimental effects so we have HIV which is a chronic inflammatory condition which then increases the risk of a Co-infection so we talked about the link between malnutrition and immune organ function. think about how that cycle right could just be perpetuated again and again further compromising immune function and nutritional status

compromised immune system negative cascade

so HIV is complicated and it really results in a number of different complications so individualized care becomes incredibly important. so every patient will require a different set of dietary and other recommendations based on their nutrition assessment. so when we look at the macronutrient recommendations in distribution those are based on symptom management weight maintenance or restoration and the management of any other ____________ that might be there. so for example if the infection has progressed and someone now has kaposi's sarcoma which is a malignancy then their nutrient needs would be very different then someone who was HIV positive without any other accompanying illness. OK what about fluid recommendations fluid recommendations are based on the needs for hydration maintenance within any limitations or enhanced needs accounted for right so again very individualized so for example if someone has a fever and is sweating or just have the fever itself their needs would be higher.

concomitant condition

immunodeficiency disorders prevent the body from adequately fighting infections and or diseases so generally these can be categorized as either ________________ and some might even be a side effect of certain medications or drugs. so it can general or primary disorder is one that you were born with as the name implies acquired or secondary disorders are disorders that you get later in life so that's where HIV comes in and acquired disorders or much more common than these congenital disorders are

congenital or acquired

I'd like to think that we all believe right that there's a link between nutrition and immunity but because the immune system is so complex it can be extremely difficult to assess the direct effect of _____ on our immune system, but we've done a lot of research in this area and research has identified some dietary factors that we can pretty definitively say do actually affect our immune response

diet

so the immune system is obviously also involved in those autoimmune diseases but the difference is that the body __________ the ability to recognize the difference between self and non self when it comes to those autoimmune conditions and so then what we start to see is a destruction of _____________. so using lupus as an example or any of these autoimmune conditions right where the body actually starts to attack its own tissues as a part of this immune as the process of this immune response right lupus type one diabetes rheumatoid arthritis these are just a few examples of these autoimmune conditions

doesn't have our self cells

and this altered protein metabolism has also been seen in children with HIV. why am I mentioning this? what is happening in childhood when it comes to protein synthesis? childhood and adolescence are a time of significant growth so even in periods of growth and an HIV infected child protein catabolism does not appear to be _______________. now add to that the fact that HIV is also inflammatory. now since there is this link between infection, impaired immunity, and inflammation you know we need to think about that about that relationship. So what happens there is that this constant ________________ state leads really to this persistent presence in dysregulation of cytokine mediators of inflammation and immune response. So what this does is lead to hormonal and nutrient abnormalities that increase the risk for other chronic inflammatory conditions like diabetes or cardiovascular disease.

down regulated inflammatory

so in other words as a viral load increases the likelihood of weight loss also increases as you would expect right and as you would also probably expect the weight loss is not usually a consistent weight loss usually what we see are periods of weight loss alternating with periods of weight stability. so the periods of weight loss are usually associated with ____________ of symptoms or with infections and complications so a lot of times if you're following an HIV patient for a while you know a lot of times a lot of clinics will plot their weight on a chart not very similar to a growth chart but in a way that you can visually see and when you see these dips in there wait a lot of times they are correlated with some opportunistic infection or some sort of increase in their symptoms

exacerbations

abnormal fat distribution occurs in more than half of infected HIV patients that are on this antiretroviral therapy and lipid dystrophy is altered fat distribution in the case of HIV is due to the medications the ART meds and even though certain antiretroviral medication seemed to be more highly associated with abnormalities in fat redistribution than others changes in body composition maker to some degree with any of the antiretroviral therapies or strategies. what are some of the common changes that we see in these art treated patients? so patients may experience lipoatrophy in the ____________ and they may have lipohypertrophy of the visceral breast cervical adipose tissue or you might see a combination of lipoatrophy and lipohypertrophy on top of that. in addition to that lipohypertrophy of the existing fat depots that occur that were there to begin with HIV infected individuals also exhibit increased prevalence of __________ distribution in the liver and in the muscles.

face in the limbs ectopic fat

what happens once somebody actually gets infected? so initially with primary HIV infection is usually accompanied by __________ and a reduction in those CD 4 cell counts. now what happens in HIV is that activated CD four cells and several other types of cells like the macrophages are infected and essentially they're rendered dysfunctional by that HIV and CD four cells in particular are targeted by HIV. CD4 cells are made in the bone marrow but then they actually mature in the ________ and once they mature these CD four cells are often called those T helper cells. these helper cells help to mediate those cell recognition events that direct some immune activities to target those antigens but also to promote the differentiation of B cells and the cytotoxic T cells and activate macrophages as well.

flu like symptoms thymus

can't have a conversation about HIV and nutrition without touching on food sanitation which is a huge contributor to decline in nutritional status so compromised immune system really cannot stand up to ________ illness so we have to do a very good and thorough job of educating our patients on food safety it's really important so these are just simple recommendations right so that we should just have in our back pocket and know that we need to talk about when we see a patient with HIV we just have to be very vigilant about this

foodborne

why is this happening? so think back to what I just talked about with lipo dystrophy. both an increase visceral fat and decrease subcutaneous adipose tissue are associated with increased circulating free fatty acid and elevated triglyceride levels so when we have an HIV positive individual rates of basal lipolysis are significantly higher than those who don't have HIV and there's also research that's looked at you know what happens to free fatty acid levels after an oral glucose challenge test and you know those with HIV have higher ___________ levels after that test. it means that there is a reduced ability of insulin to suppress lipolysis which it would do to some degree right under healthy conditions so this hepatic de Novo lipogenesis is also increased in peripheral fatty acid trapping then becomes impaired so when you think about all of these right together these abnormalities then lead to increased circulating free fatty acids very low density lipoprotein cholesterols and triglyceride levels again in terms of etiology some of it appears to be in part due to the HIV infection itself as these changes are also seen in those who are not on antiretroviral therapy so it's not the therapies at least what we think is that we've teased apart and it's the HIV in part the HIV infection itself to blame

free fatty acid

so undernutrition can affect the immune system and increase the risk for infection and infection can also affect the immune system impairing their response even further. now add to that the symptoms that are listed here. so when you were unable to fight infection you have _____________________ via something like vomiting or maybe malabsorption or higher losses in the urine and feces you might also see an increase in catabolic activity due to the higher needs that are often associated with infection. so you have infections that can lead to these symptoms and then you have these symptoms that can lead to undernutrition which then in turn can impair immunity. so you can kind of see where I'm going with this right this is a vicious cycle that is very challenging to stop due to the Inter relationships and those connections. so think about it like this so malnutrition can disrupt the function of various immune system components right weakening the immune defense and ultimately decreasing its effectiveness making it more vulnerable to diseases and infections. In addition the _______________ themselves can also be accompanied by the loss of many nutrients which then aggravates already existing nutrient deficiencies so if nutrition status is not improved what you see happening is a spiral of diseases and infections that can become impossible to control.

higher needs and increased nutrient losses infections or diseases

vitamin E is a lipid soluble vitamin or antioxidant. it protects the integrity of cell membranes from damage that's caused by those free radicals. so in particular if you look at the Alpha tocopherol that form of vitamin E protects against the approximation of those polyunsaturated fatty acids which can potentially cause cellular damage and then can lead to improper immune responses there's a lot of animal studies that have looked at this. human studies too have shown that a vitamin E deficiency impairs both the _____________ aspects of adaptive immunity including the B cells and T cell function. we also know that vitamin E supplementations in excess of current intake recommendations has been shown to enhance immunity and decreases susceptibility to certain infections especially in the elderly.

humoral and cell mediated

so you can see when there is a decreased production of B cells or T cells that there's going to be decreased ability of the _______________ to mount an effective immune response. so cellular immunity is important because it plays a really critical role in resistance to ______________ and other foreign cells so the steps themselves are pretty simple. so first there is this macrophage processing of the specific antigen which again is any substance that can mount an immune response or any substance that comes in and can trigger this immune response is this antigen. then this antigen attracts and activates the __________ and then the third phase of this is this _____________________

humoral and cell mediated immunities viruses to fungi to tumor cells even lymphokines inflammatory response

so you have these non specific general processes that are in place and then we have very organized systems of immunity which are the ____________ and this _______________ these are both important organized processes that play a huge critical role in immune function

humoral immunity cell mediated immunity

the _______________ which involves antibodies and is sometimes referred to as an antibody mediated response. so a humoral response is activated after ____ exposure to the offending allergen. so in this in this case on 1st exposure you're not really going to have any sort of reaction. it's during that subsequent exposure that our reaction occurs and this is because that first exposure simply just triggers the B lymphocytes to produce antigen specific antibodies right or would sometimes what we call these ______________.

humoral pathway one immunoglobulins

so patients with aids will experience greater increases in REE than patients with HIV infection who do not have aids and patients with aids in secondary or opportunistic infections will experience even greater increase. so you can tell that having the infection itself increases REE. remember for now I'm talking about in the untreated HIV patient and then aids ___________ the REE further and then if you have an infection on top of that that increase is your REE even more. because of the varied complications of HIV infection there is an extraordinarily wide range in REE.

increases

Now when we think of the different types of immunity, you might see them refer to as nonspecific or _____________ or specific immunity also known as _______________. so the immune system has many layered defenses to protect us. they start with those most simple like the physical barriers the skin to prevent those pathogens from getting in but now let's say a pathogen breaches that barrier that's when our ______________ systems come into play

innate immunity acquired immunity innate or nonspecific

Sometimes our nutrition interventions are not enough and in those instances then we can use some non nutrient therapies to help improve nutritional status things like anti wasting medications androgens appetite stimulants exercise of course growth hormone and insulin sensitizing agents when it comes to intake the two most common medications for the treatment of anorexia which we talked about a little bit with cancer are mega stroll acetate right and marinal both of these have been shown to be effective in _________ and ultimately and increasing intake oftentimes in HIV when lean muscle mass has been compromised using hormone replacement therapy has been effective in HIV patients to improve muscle stores and then that improves their overall health and their quality of life androgens have been used commonly in men and have had good results in terms of reversing some of the muscle that was lost growth hormones also being used in HIV patients to treat the wasting but also to help with the Lipo dystrophy too and then we have those in insulin sensitizing agents like metformin which i already talked about that are also used in HIV patients to address that HIV associated insulin resistance

increasing appetite

the most compelling evidence that malnutrition is associated with an immunodeficiency comes from the fact that we tend to see these higher __________ rates. but also remember that infections are as much a cause of malnutrition as a consequence. so sometimes there may be errors in describing that cause and effect. also what do we usually think of as a telltale sign of infection? oftentimes it's a ______ but when someone is severely malnourished and you have someone who is suffering from malnutrition for a long time, what do you think happens to that febrile response? oftentimes the fever response is inadequate. So what happens is that the infection might actually be ________. so if you have someone with an impaired immune system you may not see that fever that we often associate with this infection.

infection fever silent

our immune system in that defense mechanism part of that is also an ___________________ so it involves these barriers but it also involves an inflammatory response. and a critical hallmark of a fully functioning immune system is its ________________ that's like the most basic sort of criteria for a functioning immune system. now this is a very basic concept but if our immune system is unable to do that first critical step right we obviously are going to have a lot of problems.

inflammatory response ability to recognize things as self and non-self

these ______________ responses are generalized responses to any pathogen and the reason that they are you know called nonspecific is that they don't target a particular cell type. so when you think of white blood cells plasma proteins these would fall under this umbrella of innate immunity.

innate and nonspecific responses

the fat and carbohydrate recommendations also must be made while keeping in mind the increased risk that we see in HIV patients for __________ so we make those recommendations based on lipid profiles and blood sugar testing right so we want to have data and then provide individualized recommendations now patients are unable to consume it up then we always turn to oral supplements like you know boots or insurers which have shown to have moderate success i wouldn't say they've been incredibly successful

insulin resistance and cardiovascular disease

when we think about immunity our first line of defense comes from what?

it comes from barriers. so barriers like our skin, our tears and saliva mucus you know all of those things those are part of that defense mechanism

So what is immunodeficiency?

it's a state in which the immune system ability to fight infectious disease is compromised or it's entirely absent. so essentially you know these disorders of which HIV is one

what is immunity?

it's our capacity to resist all types of organisms and toxins that might actually damage our tissues or might actually damage our organs. so immunity then if you look at it that way is a protective mechanism right.

now there is research available that has looked at vitamin supplementation in patients with HIV to see if there is improved immunity like an improved CD 4 count or is there a slowing down in the progression of from HIV to aids and they didn't find that large amounts of supplements even the antioxidants really had in effect. now when someone's deficient and you give them an adequate amount certainly that can help and can have a have a benefit but ____________ which have been previously suggested as effective have recently been question

large doses

OK so do we do anything different to ameliorate the cardiometabolic risk that's associated with HIV. I mean not really right we implement ______________ as that first line approach so we'll focus on things like smoking cessation exercise diet all these things that we think of as the first line of defense when it comes to lifestyle modifications formalized exercise programs in individuals with HIV infection have actually shown benefit to reducing cholesterol and triglyceride levels and show decrease in waist circumference but sometimes these lifestyle modifications just aren't enough right so if we're insulin resistance oftentimes you'll see __________ being used and has been shown to significantly improve in some levels and waist circumference and diastolic blood pressure but metformin appears to decrease both visceral and subcutaneous adipose tissue so that it may not actually be appropriate for individuals who have already have severe lipoatrophy.

lifestyle modifications metformin

so when we know malnutrition is present how does it actually manifest itself as an immunodeficiency? a lot of it has to do with the fact that _______ tissues are very vulnerable to malnutrition because many cells of the immune system are known to depend on specific nutrients as cofactors for certain metabolic pathways. So what we see happening is decreased _______________ mainly due to the fact that oftentimes a lymphoid atrophy occurs particularly when we have a protein energy malnutrition so because of that then we started to see decreased production of B cells and T cells and also a decreased function of cytokines the complement system and even phagocytosis.

lymph organ function

when you look at the research that's also shown that several types of dietary lipids can modulate the immune response as well so fatty acids that you know have this role right include the long chain polyunsaturated fatty acids in the omega-3 and Omega 6. when it comes to the intake of specific lipids both excesses and deficiencies can cause immunocompromise so if individuals aren't getting enough essential fatty acids that can lead to ______________ which essentially does what? if we have lymphoid atrophy why is that a problem because it reduces the body's production of immune specific cells and so then consequently we see a decreased antibody response there's also some evidence that an excess of polyunsaturated fatty acids can also suppress immunity partially due to the fact that these lipids can be pro inflammatory and some of these lipids are more inflammatory than others.

lymphoid atrophy

beta carotene specifically increases ____________ and T killer cell activity so both of them vitamin A and beta carotene are directly related to T cells and cell mediated immunity

macrophage cytotoxicity

Now there are gender differences as well. so you'd see a greater loss of body cell mass in _______ initially with minimal fat loss and that's because men have more and the more you have the more you lose generally. typically with women there's more of a progressive and disproportionate decrease in body fat relative to lean body mass and this is really attributed to those ___________ differences between the sexes the decreased testosterone the decreased muscle synthesis and decrease initial body cell mass

men hormonal

research has shown us a few things when it comes to the relationship between malnutrition and immunity. so first alterations in immune responses occur early in the course of ____________ deficiencies. second the extent of immunological impairment depends on a number of factors such as a type of nutrient involved its interactions with other essential nutrients. obviously the severity of the deficiency makes a difference and whether there are any concomitant infections present. also age can play a significant role in the extent of immunological impairment. we also know that immunological abnormalities predict outcomes particularly when it comes to the risk of infection and mortality and we keep talking about malnutrition in terms of undernutrition but again ____________ intakes of certain micronutrients can also be associated with impaired immune responses.

micronutrient excessive

so vitamin A and its metabolites play critical roles in both innate and adaptive immunity. so in innate immunity the skin in the mucosal cells of the eye and respiratory system the GI system the genital-urinary tracks even those function as a barrier against infections. so essentially vitamin A helps to maintain the structural and functional integrity of the _________ cells and the mucosal linings which include those of the GI tract and now remember that the GI tract plays a huge role in immunity. Vitamin A also plays a pretty large role in maintaining the normal function of immune cells so those cells like the __________________ that are part of our innate response. Vitamin A also plays a role in adaptive immunity or that specific immunity in that it is important in maintaining proper function of the ____________ and then consequently it's necessary for the generation of antibodies to those specific antigens. we also know that vitamin A is involved in cell replication and the differentiation of lymphocytes the monocytes and even the granulocytes so keeping it in mind its function it is not hard to make the link between vitamin A deficiency and then compromises in the immune system because of its role in maintaining epithelial and mucosal linings.

mucosal macrophages and the neutrophils T cells and B cells

Regardless of the specific cause protein energy malnutrition significantly increases susceptibility to infection by adversely affecting aspects of both the innate immunity and the adaptive immunity with respect to innate immunity protein energy malnutrition has been associated with a reduced production of certain cytokines several complement proteins as well as impaired phagocyte function. So what you will find is that a lot of these deficiencies result in some of the same outcomes when it comes to specific immune markers. the protein energy malnutrition can also compromise the integrity of those ___________ so then what would that do? that will increase vulnerability to infections of the respiratory tract of the GI in the urinary tract as well. now with respect to adaptive immunity protein energy malnutrition primarily affects cell mediated aspects instead of components of the humoral immunity specifically really protein energy malnutrition leads to atrophy of the _______ and that's what we're doing that produces the T cells which reduces the number of circulating T cells and then that decreases the effectiveness of the memory response to antigens.

mucosal barriers thymus

one of the things to think about when you're conducting a thorough nutrition assessment is to determine if someone has good immune function how can we do this?

one way to do this is a skin prick test of cell mediated immunity. So what you do generally is you inject an antigen just below the skin and you would expect after a short period of time that you would have some sort of big red BLOB on your arm because it's a familiar antigen because you want to have the ability to organize a cell mediated response. if you're injecting something under the skin that is a known antigen or a known pathogen and if you've been exposed to it before you should be able to see this cell mediated response skin response.

So malnutrition impacts the progression of the disease but one of the factors that actually leads to malnutrition in an HIV infected person is reduced appetite which is a result of many different factors. so first it could be due to difficulty in adjusting food as a result of specific infections like a lot of times you'll see HIV infected patients with __________ that's caused by candida which is a very common opportunistic infection in HIV infected individuals. you might see other factors like fever the side effects of medicines and even depression can affect intake. so with this decreased intake what we see is that HIV positive individuals tend to have lower intakes of vitamin ____________ and what the research has shown us is that supplementations has been effective particularly when it comes to beta carotene where improvements have been seen in CD four counts and that's really significant and vitamin C is also been shown to increase the number of phagocytes and cell function now when we look at the _____ supplementation has been shown to increase our T cell count and all of these are positive in terms of improved immune function

oral thrush or esophagitis A B6 B12 C & E B12

when we think about T cells keep in mind that a T cell can be a helper but still can also be more cytotoxic in nature of meaning it can be a killer cell as well. so as a helper T cell it's much more of an ___________ so it's really more of an organizing system but they can be cytotoxic so if you're a T cell you're either going to be a helper or going to be a killer

organizer

now because of this cycle a lot of interventions focus on the treatment of the ____________ as the first step to breaking that cycle of infection and malnutrition and immune impairment. energy intake seems to have an important effect on immune activity. undernourished people are at a greater risk from these infections. however while a lot of this may be due to specific nutrients some of this from reduced immunity is directly related to being undernourished from the ________ perspective and when you look at weight loss studies weight loss programs that have people consuming less than 1200 calories per day have been shown to have reduced immune function so just a decreased calorie intake or having an energy deficit regardless of specific nutrients does impair our immune response but by the same token over-nutrition or excessive energy intake has also been linked to a compromised immune system and some of this is due to the connection between obesity and cardiovascular disease which appears to affect immune function

overt infection energy

you also see increased consumption of minerals like zinc copper manganese and selenium so essentially the infection has created a deficiency of antioxidants which causes increased __________ which then leads to apoptosis of T cells and then indirectly compromises the cell mediated immunity and may actually stimulate than HIV replication. in cell cultures HIV replication was shown to be inhibited by various antioxidants and while we don't have enough clinical data that exists right now to show that yes there is this direct link in humans between antioxidant intake and decreased HIV replication it is certainly in the area that's being looked at very carefully in an area future reach research. what's interesting is that maternal micronutrient deficiencies might also have a have an impact on viral load so generally when it comes to supplementations or recommendations for micronutrients it's generally believed that the intake of nutrients at levels that are recommended for the general population do not appear to be adequate for the HIV infected patients the general thought is that an HIV infected patient adult needs _______% more energy per day in approximately ________% more protein and if those needs can be met the micronutrient needs then can also be met

oxidative stress 10 to 15 50-100

So what are some examples of innate processes that we have to keep ourselves healthy?

phagocytosis: where the monocytes literally eat the pathogens, these responses these are immediate but they are nonspecific in nature in the stomach with HCL the hydrochloric acid: we have natural killer cells which are also part of this immune process so it's almost like anything that goes into the stomach that is a pathogen. the permeability of the GI tract is another innate immune mechanism so that the destruction of swallowed organisms by acid secretions of the stomach language sets another example of innate immunity can get destroyed by that hydrochloric acid Resistance of the skin to invasion blood chemicals: that can directly attack or destroy any of these invaders so there are things like the lysosomes or interferon.

So what are the mechanisms behind this? so the lipoatrophy appears to be due to the inhibition of adipocyte differentiation by those ___________ which are part of that art cocktail. now why we see the lipohypertrophy in the accumulation of fat in the liver and muscles seems a little more unclear but what do you think the research is pointing to? it seems like _________ being implicated in a whole host of conditions. so there really is some thought that these inflammatory cytokines play a role although the mechanism isn't really well understood. so another theory is that the hypertrophy, overflow of the storage of surplus energy, particularly triglyceride free fatty acid because they can't be stored in the face or the limbs where the atrophy's occurring but these are just theories.

protease inhibitors cytokines

so obviously when we're looking at supplements what are the considerations? obviously one of them is weight but I want to make sure that we recognize that it isn't always below normal oftentimes we think of HIV and we think of somebody who's underweight they're not always below normal right with body composition we need to recognize that it's very difficult very difficult put muscle back on when somebody is wasting so when you have wasting so you want to prevent the decline in lean body mass at all costs as much as possible most facilities that routinely assess HIV positive patients they do a lot of body composition measurements and they really do this to stay on top of this to prevent the deterioration of muscle because it's so difficult to put back on in the outcomes are so much better when you don't lose that lean muscle mass and of course we know that immune function is going to be a direct outcome of _________ as well as of immune function so some of the options that we have then are these immune enriched formulas which are evidence based upon which I should say which are evidence based upon the additives that are considered conditionally in cachexia so peptide based formulas are recommended if malabsorption is present as well as the elemental and the MCT oils because those can actually enhance absorption and one of the big things though is community feedings in education and _________ I mean that's something that we have to really pay attention to what we're working with HIV population because they tend to be they tend to be a population that does have higher rates of food insecurity we do have to talk about food safety urban food hygiene and educate them well in that area

protein intake food security

Oftentimes when we think about an iron deficiency particularly in children we see a clear link between rates of infection and anemia. what happens is that children are checked for anemia if they seem to be getting sick quite often so sufficient iron is really critical to a lot of different immune functions so these are things include the differentiation and proliferation of this T lymphocytes the generation of these reactive oxygen species that are the ones that killed those pathogens but iron is also required by most infectious agents for _______________. so during an acute inflammatory response serum iron levels start to decrease while our levels of ferritin which is that iris George protein those start to increase. So what does that tell us what does that suggest to us? that suggests that sequestering iron from the pathogens is an important host response to an infection and as we've said before excess can also be problematic. so iron overload can result in impairments right and impairments like deficiencies in phagocytic function in the cytokine production in the complement system activation in the T cell and the B lymphocyte function so a lot of them affect the same parts of the immune system so when you start to think about somebody who might be malnourished overall and deficient in a lot of these nutrients that the link becomes very clear

replication and survival

selenium another antioxidant and what we know is that adequate selenium intake is essential to really mount a proper immune response because it's required for the function of a lot of ___________. so when we have selenium deficiency that impairs the aspects of innate immunity as well as adaptive immunity. so really it has adverse effects on both humoral immunity and the cell mediated immunity. now what the researchers also found is that a selenium deficiency appears enhanced the virulence or the progression of some of these viral infections so we can make it a harsher viral infection. we also know that with supplementations if you have selenium supplementation individuals who are not at least selenium deficient that seems to stimulate the immune response so that you can see that it has a positive impact on the immune response.

selenium dependent enzymes

so let's look at altered metabolism and energy specifically. so it is quite evident that there are definite alterations in energy and macronutrient metabolism in HIV and there has been a ton of research on whether there is an increased REE in HIV patients particularly because HIV related wasting was such a crisis in the 80s in the 90s where many individuals were getting diagnosed with HIV due to this __________. there are some conflicting results on this specific question how much is energy actually altered when somebody has HIV. now we know that total energy expenditure is a function of REE physical activity thermic effect of food and adaptive thermogenesis but because _____ is the largest component comprising about 60 to 65% of TEE that's where we tend to focus when we're looking at energy needs or energy expenditure. so when we look at HIV positive individuals results from the pre HAART treatment era are pretty unclear about whether REE per kilogram of fat free mass was actually elevated in these HIV infected patients but we know now that there is an increased REE in HIV positive patients independent of body cell mass even in asymptomatic HIV patients. So what does this tell us? it tells us that the infection itself is associated with an increased REE but ________ too is correlated with REE per kilogram of fat free mass and CD 4 cell count may also be associated with changes in REE.

severe weight loss REE viral load

now in a skin prick test, generally depending on the ____ of the response it would indicate whether or not the immune response is compromised a little a lot or not at all. so this kind of testing for immune function used to be done more often now we know that there's a lot of other things that can cause a reaction not just your immune response but it's one way to check right if somebody's __________ is functioning optimally so basically when you look at cell mediated immunity it is this organized structure and initiation of the inflammatory response

size immune system

so our barriers they're just trying to keep anything out. so it's not _________. if you think about our skin or if you think about her tears they're not going to keep just specific invaders out but once they've passed those barriers are immune system becomes a little bit more specific so this _____________ response involves a humoral response and a cell mediated response.

specific adaptive

now if let's say, a particularly pesky Organism is able to evade the innate responses that we have right then we have an adaptive or what we would call this _______________ response that comes into play so in a very general sense what happens here is that the immune system adapts that hence the name adapts its response during an infection to improve its recognition of the pathogen. So what happens then is that this improved response is retained in the form of an immunological memory and it allows the adaptive immune system to work ______________ if that same pathogen is encountered again. so these specific responses again are classified as either humoral or cell mediated

specific immune system much more quickly and in a stronger manner

now for those individuals that have dyslipidemia both ____________ therapies have shown a benefit so we've seen a definite benefit with these medications statins may be slightly less effective in HIV infected patients than the general population but they still have a have demonstrated a reduction of approximately 25% in LDL cholesterol levels while fibrates are very effective in HIV positive population for triglyceride production now why we see the statins of a little bit less effective is hard to say like I've looked for this answer a few times I don't have a good mechanism that I can like hang my hat on and safely This is why we're seeing the effect of the drugs work a little bit differently

statins and fibrates

We often talk about HIV is one thing right but in reality there are different __________. so outside of the western region of Africa we see mainly this HIV one and there are several different options in terms of diagnosis. now during the early stages of infection screening tests like the _______ or this enzyme linked immune ascorbic assay which is also known as the rapid test can be used as a screening tool which really can only anticipate the possibility of HIV infection. so the Elisa test needs to then be followed by a more confirmatory test. now when we look at testing the recommendations are to include testing for early infection ______________ so there are some assays to identify early infection within the first 2 weeks of exposure. now as the infection transitions from recent to a more established one there tends to be an increase in the aggressiveness in affinity for HIV antibodies. when we're looking at these confirmatory tests they include things like the western blot the modified western blot the IFA or the indirect immunofluorescent antibody assay and the line immunoassay or sometimes you'll see referred to as Lia

strains Elisa antibody antigen and viral RNA levels

So what happens in HIV is that there are defects in these activities and if that happens what do you think that outcome is? that leaves the body open to a lot of different kinds of infections and even malignancies. with primary infection you see a reduction in CD4 cell counts and as CD four and other cells are damaged and essentially rendered dysfunctional the body just can't defend itself the way it needs to or the way it's designed to do and there's a very strong relationship between CD four counts of viral load and the progression of the disease to aids, so the higher the viral burden the more CD four cells are infected and rendered dysfunctional and destroyed again then increasing the risk for those opportunistic infections. now when we look at CD four counts versus viral load the level of destruction of CD4 cells appears to be more precisely predictive of ____________ than viral load even though we talk about viral load a lot

survival

now even a marginal zinc deficiency which is more common than a severe deep zinc deficiency would be can suppress aspects of immunity so you don't need to be severely deficient to start to see decreases in immunity. so when we look at the relationship between someone who has a zinc deficiency and infections what we find is that zinc deficient individuals have an increased ____________ to a variety of different infectious agents and a lot of this has to do with the fact that zinc deficiencies have specifically been shown to be associated with lymphoid atrophy with decreased continuous hypersensitivity so with those skin tests and decreased thymic hormone activity which are hormones that are released by the thymus because they also have an impact on immune function but excessive amounts of zinc can also have an impact in research has shown that excessive saying can decrease in ____________ so there is that fine line between the deficiency and excess when it comes to immune function

susceptibility neutrophil function and the lymphocyte response

The initial infection with HIV is handled by the body similarly to other infections. the body breaks down protein stores primarily muscle to enhance the amino acid pool and to allow the ___________ of proteins that initiate and maintain immune and healing responses and during the course of HIV we see protein turnover rates in immune system activity elevated. so these catabolic processes are always at play whereas anabolic processes are less regulated or less affected by the disease and appear to be more directly regulated by nutrient substrate availability as opposed to the disease itself. so that really means is that anabolism can occur but it depends largely on ______________. the catabolic processes due to abnormal protein metabolism have a higher activity regardless just because of the nature of the disease

synthesis nutrition status

now one of the primary contributors to impaired glucose homeostasis in that HIV infected population is abnormal fat distribution you know which we've talked about before particularly that visceral adiposity in the lower extremity fat atrophy. there's also a significant amount of evidence that implicates inflammation so _______________ markers you know including things like C reactive protein tumor necrosis factor those are associated with an increased risk of developing diabetes in HIV infection really suggesting a role of chronic inflammation in impaired glucose metabolism the antiretrovirals themselves also appear to contribute to an increased risk of diabetes so that same dad study that I talked about which is data collection on adverse events of anti HIV drugs the incidence of diabetes increased with increasing cumulative exposure to those antiretrovirals even after control for other risk factors but the research also shows is that this risk may be greater in certain drug types so not everybody that's receiving these antiretrovirals is getting the same cocktail of medications which also makes it a little bit more challenging for us to evaluate the results of the research and come to some consensus on some of these on some of these items and processes

systemic inflammatory

where do we see these mechanisms in action these mechanisms that essentially identify a non self-organism from the self-organism

the process of identifying and a non self-organism from a self-organism occurs after an offender passes those protective barriers. so once they have gotten past our skin our tears etc. or we see something that's referred to as an adaptive immune response which is more specific for that invading Organism or intruder right.

when we talk about immunity we talk about the body's ability to resist all types of non-self-organisms, so what are those non self organisms?

they are any type of substance which can induce some kind of antigen antibody response or an immune response right.

so many patients with HIV infection particularly those with associated body composition abnormalities have a dyslipidemia profile of decreased HDL and increase triglyceride increased LDL levels. an increased ____________ level is often the most pronounced lipid abnormality in HIV infected patients and appears to contribute independently to increase cardiovascular risk in this population so one of these studies I can't go so far as to say that is a hallmark study but it was called the DAD study but it was a pretty strong study and one that gets cited a lot what they found was that each two fold increase in triglyceride levels was associated with a ____% increase in the risk of MI and then after control for other traditional risk factors there were there's been a lot of studies that have corroborated these findings but there was another study where it was reported that in a cohort of about 2000 men and women with HIV infection hypertriglyceridemia together with increased ______________ was very highly predictive of metabolic syndrome of insulin resistance and also cardiovascular risk as measured by the Framingham risk score

triglyceride 17 waist circumference

what is HIV? it's a retrovirus that targets the immune cells in turns them essentially into ________________ for HIV reproduction which then results in the loss of immune function and specifically what we see is a loss of ___________ cells which are quantified by looking at those CD four counts. the major concern with HIV is over the intrusion of different infectious agents because of the decreased immunity that's associated with the HIV virus there's a delicate dance between the HIV virus and these other opportunistic infections. it's the progression of these opportunistic infections that leads to the transition from having HIV the virus to ______. so HIV and aids present a wide variety of challenges for the maintenance of nutritional status as some of this is due to the HIV infection itself some of its due to disease complications and co infections and some are due to the actual treatment as many of you guys might already know and be aware of not only are there health implications we need to keep in mind that these interactions with nutritional status also include social and economic and clinical issues so populations already at risk for nutritional compromise because of lack of health care access lifestyle choices smoking alcohol drug abuse food insecurity comorbidities they may find their health status further compromised by HIV in these interactions are pretty complex in their multi factorial

viral factories T1 and T2 aids

And when you keep in mind all the things that we've been talking about that decreased intake that increased REE the altered nutrient metabolism the lipodystrophy in all of that you can see why right HIV and antiretroviral therapy can compromise nutritional status right. so let me just lay the groundwork a little bit what we see is BCM depletion in patients right so depletion in the body cell mass even in those who are symptomatic even in those I should have said even in those that are asymptomatic we see this we also see an elevated REE in patients that are symptomatic right so it's not just the symptoms that that might tell us that this is that I should let me say this is not the severity of the disease based on symptom based on symptoms that leads to malnutrition we see some of these things even in patients that are asymptomatic there appears to be a direct relationship between REE though and HIV symptoms right the more symptomatic you are the higher your REE so we see an increase in those that are asymptomatic but the more symptomatic you are the more increases in REE that we would observe also there seems to be more weight loss associated with the higher _____________.

viral load

so vitamin C is a highly effective anti-oxidant and vitamin C has been shown to enhance the production and function of ____________ particularly the neutrophils phagocytes and the lymphocytes. so _____________ are the cells that will attack foreign bacteria and viruses. they seem to be the primary cell type that is stimulated by vitamin C. the lymphocytes, another phagocyte, are also affected by this deficiency just not to the same degree. there's also a lot of studies that have shown that supplemental vitamin C increases serum levels of antibodies in complement proteins. so that's something that we want and then vitamin C may also protect the integrity of those immune cells neutrophils mononuclear phagocytes lymphocytes they can accumulate vitamin C to pretty high concentrations which then can protect these cell types from oxidative damage.

white blood cells neutrophils

obese individuals exhibit increased susceptibility to various infections as well so when you look at the epidemiological studies as some of those have shown that these patients have a higher incidence of post-operative and other nosocomial infections compared with patients of a normal weight. obesity has also been linked to poor ____________ and increased occurrence of skin infections. we've also seen that a higher weight or BMI may also be associated with increased susceptibility to respiratory gastrointestinal liver and biliary infections. now in obesity the increased vulnerability is severity or complications of certain infections may be related to a lot of different factors right so things like select micronutrient deficiencies or other lifestyle factors that lead to overweight status in the first place or even you know some of those things that we talk about with weight bias and in health care that may just make them more susceptible. Overall though immune responses appear to be compromised in obesity but more research is needed to clarify the relationship between obesity and infection related morbidity and mortality.

wound healing