Nutrition in HIV and Aging

  • The Cretan-Mediterranean and D.A.S.H. diets have the best data on supporting healthy aging and reducing risk of heart disease, diabetes and cancer.
  • HIV infection is a chronic inflammatory condition, further stressing the already weakening antioxidant capacity that accompanies aging. Dietary protein, trace minerals, and antioxidant nutrients act to slow the rate of aging, and can help prevent frailty.
  • Even in the HAART era, nutrient deficits for zinc, selenium, vitamin D, and others affect morbidity and mortality.

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Chronic infection burdens repair and immune functions that are already slowing as a result of aging. Particularly important is the age-related shift in glutathione status, leaving a more pro-oxidant state in cells [1]. The slower protein assembly of aging plays out as impaired muscle, organ, and bone repair. Impaired protein assembly yields “immune senescence”—an inability to activate naïve T cells and generate memory T cells. Immune cell activity is sensitive to nutrition deficits; HIV infection alters gut cell structure, impeding all nutrient absorption, even in the HAART era [2].

A Guide to Groceries for Routine Cuisine

Nutrition is about providing materials for the formation, operation, and repair of cells. The Mediterranean Diet, or Cretan-Mediterranean Diet, is the food plan with the best data on both immune (anticancer) and cardiac benefits [3]. The D.A.S.H. Diet preserves cardiac health, and reduces the risk of developing diabetes [4].

Plant-based vegetarian diets seem to reduce disease risks, but this is epidemiological data that does not incorporate HIV disease elements such as fibrosed intestinal mucosa, altered gut-associated lymphoid tissue (GALT) status, and the redox burden of chronic infection as operative factors in assessing outcomes.

In directing people toward a Cretan-Mediterranean diet, one must consider some key elements. The diet has more fish and seafood, and less meat than other diets. There are liberal amounts of fruit and vegetables, including many wild greens. Whole grains are eaten as cereals and sourdough bread, not as pasta. Legumes, rich in magnesium, are eaten almost daily. Fat sources are nuts, olives, and olive oil. Dairy is more cheese than milk, especially goat and sheep milk cheeses. Chemically, the diet contains more selenium and glutathione, plus a healthier balance of omega-6 to omega-3 fats. It is very high in fiber and rich in antioxidants like vitamins C and E, plus resveratrol from red grapes/wine, and the anti-inflammatory oleuropein from olive oil. One research article reported that people on the island of Crete seem to consume 245 kilograms of plant material per year, (compared to the 150 kg in Italy and France, and 90 in Finland)[5].

Advice for Assembling a Healthy Diet in HIV and Aging

Assemble the Daily Diet in a Series of Five Steps.

Step 1. Determine desirable protein foods, and eat them three times a day—generally breakfast, lunch, and dinner. Research is showing that aging people need more protein, up to double the RDA [6].  Loss of muscle in aging, known as sarcopenia, is a much bigger problem than in the general population and medical and needs to be appreciated [7].

The American Heart Association stresses two 4-ounce servings per week of oily fish. As approximately 50% of Americans consume no fish each week, a daily fish-oil pill supplement should be considered. An average fish-oil pill will usually have 180 mg of DHA, the amount needed to replicate the 50% reduction in risk of senile dementia reported in Framingham studies. Up to 6 grams a day of fish oils have lowered triglyceride levels by almost 40% in an HIV population [8].

As a matter of practicality, whey protein powder is a convenient and inexpensive additive to a meal, often added to breakfast cereal or protein-fruit smoothies. Trials of whey protein use in HIV populations have shown that it can sometimes raise CD4 counts [9] and frequently reverses glutathione (antioxidant enzyme) deficiency [10].  Whey can also improve osteoblast activity in bones [11]. Consumed dairy products should be fat-free or low-fat.

Step 2. Urge the eating of vegetables at both lunch and dinner. Three cups a day would be just a minimum amount to eat for the sake of obtaining Cretan-diet levels of minerals and phytochemicals. HIV-infected people consuming a dietary pattern that included higher intake of vegetables, fruits, and low-fat dairy foods, have significantly higher CD4 counts [12].

Step 3. Encourage eating fruit three times per day to improve glutathione and glutathione peroxidase levels [13]. Eating fruit, including the traditional “apple-a-day,”  provides the water-soluble fiber pectin, supporting beneficial gut flora, which lower cholesterol numbers, C-reactive protein levels, and body percent fat [14, 15].

Step 4. Nuts and seeds contain essential oils that form cell membranes. A target is eating one handful of nuts and one of seeds every day. A trial of a Mediterranean Diet, supplemented with mixed nuts, proved more useful in heart disease prevention than did a low-fat diet [16]. The fatty acid gamma linolenic acid (GLA), prominent in seeds (and spinach), lowers LDL-cholesterol, raises HDL-cholesterol [17] and lowers blood pressure [18]. Low GLA levels seem to be a risk factor for development of type2 diabetes [19]. Dry skin is a sign of low GLA levels. Consuming ¼ cup raw seeds daily, or taking 2 grams evening primrose oil covers GLA needs. People with a GLA deficiency gain fat in the abdomen, see cholesterol and triglyceride counts rise and HDL-cholesterol levels drop [20] precisely the common body shape and blood lipid changes seen in lipodystrophy.

Step 5. Starches (carbohydrates) are the remaining part of fuel and food needs. Legumes, technically a protein-rich starch, are an important component of the Mediterranean diet, providing fiber, plant protein, and magnesium. Higher magnesium intake is inversely related to cardiac and cancer mortality [21]. In both the D.A.S.H. Diet and Mediterranean Diet, higher magnesium intake is correlated with preservation of cognitive function in aging [22]. Select starch portion sizes wisely in aging; oversized servings of starches tend to turn to fat faster than smaller amounts [23]. At least half of grains consumed should be whole grains.

In addition to assembling a diet that focuses on variety, nutrient density, and amounts, the calories from added sugars and saturated fats, along with sodium should be limited [24].

Nutrition for Accentuated Aging with HIV

Insufficient antioxidant activity coupled with mitochondrial damage underlie the faster rates of deterioration occurring in this population.

Common concerns are osteoporosis, vascular disease risk, sarcopenia, loss of cognitive function, fatigue/frailty, and immune senescence.

Subtle nutrient deficiencies play a role in all of these problems. Using comprehensive nutrition therapy to treat degenerative processes offers the opportunity to avoid increased pharmacologic burden in a population where side effects are especially likely.

In the internet age, many consumers are familiar with nutritional supplements in HIV treatment. Below is a review of conditions and studies that could improve clinicians’ comfort level with the vitamin, mineral, and other supplement interventions their HIV-infected patients are utilizing. Nutrition therapy can help in situations where treatments are nonexistent or have low efficacy.

Heart and Vascular Disease Risk

Cholesterol levels do not account for all cardiac and vascular disease risk. Carotid artery occlusion is associated with longer time on HAART. Subtle B-vitamin deficiencies, seen as higher homocysteine levels, were a cause of carotid artery narrowing in the Framingham study [25]. B–vitamin-dependent enzymatic deficiencies in the elderly cannot be detected in serum B-vitamin-level tests. This speaks to the utility of supplementing with B-complex vitamins in this population.

As stated above, the American Heart Association recommends eating fish twice a week in general, and consuming 1 gram a day of EPA/DHA for people with heart disease. Low HDL is common in this population. This can be reflective of essential fat deficiency, and of lower redox capacity. In HIV-uninfected people, N-acetylcysteine at 1200mg to 3600mg/day range can raise HDL cholesterol by 10 points [26]. Improving HDL level is an important marker for reducing risk from cardiac events even into a patient’s 80s. The amino acid L-Glutamine, along with EPA/DHA fatty acids, improves exercise capacity in patients with heart failure [27].


Chronic inflammation along with some HAART initiates systemic bone loss. Vitamin D and calcium supplements are generally not enough to reverse thinning bones. Newer research, using an algae-derived calcium, with strontium, boron, magnesium, plus vitamins D and K2 supplements, is reversing osteoporosis in just 6 to 12 months in older people [28]. Safety measures to reduce falls at home and increased fitness activity can lower fracture rates [29].

Immune Reconstitution

Many older people come late to care, with very low CD4 counts. Adequate glutathione levels are necessary for generating T cells. Supplementing N-acetylcysteine at 1 to 2 grams per day, or L-glutamine at 5 to 10 grams per day, is helpful for this. A B-complex 25 with vitamin C pill improves T-cell numbers in HIV disease [30] Use of protease inhibitor therapy puts people at risk for low vitamin B12 levels [31] as does taking proton pump inhibitors [32]. A multivitamin improves T-cell and NK-cell counts and reduces sick days in the elderly.[33,34] Vitamin E at 200 units improves immune responses to vaccines.[35] Co-enzyme Q10 reverses lymphadenopathy and improves immune function [36]. It protects endothelium in people with diabetes [37].


From a nutrition perspective, frailty is simply failure to achieve adequate repair of many cell and organ systems. L-glutamine plus antioxidant vitamin supplementation reverses HIV wasting [38]. Glutamine alone raises both glutathione and mood levels [39].  L-carnitine supplements reverse both neuropathy symptoms [40] and lipodystrophy problems [41]. At 2 grams per day it has improved muscle action in heart failure trials [42]. Coenzyme Q10 can increase ejection fractions in seniors, improving constitutional energy levels [43].

The Bottom Line

  • Patients need to be reminded to emphasize lifestyle factors such as food, nutrition, and fitness to maintain their health and improve their quality of life while aging with HIV.
  • Food and fitness education can reduce all-cause mortality in an at-risk dyslipidemic population by 75% over two decades [44]
  • Being infected with HIV acts both separately and synergistically with usual brain aging to cause neuronal changes [45] The Mediterranean Diet, coupled with routine exercise, lowers risk of Alzheimer’s more than either diet or exercise alone [46,47]
  • Multivitamin supplements can positively affect immune cell behaviors and telomere length.

Updated on February, 2016 by Charlie Smigelski, B.A., B.S., R.D., Infectious Disease Program, Lynn Community Health Center, Lynn, MA.


  1. Rebrin I, Sohal RS. Pro-oxidant shift in glutathione redox state during aging. Adv Drug Deliv Rev 2008,60:1545-1552.
  2. Knox TA, Spiegelman D, Skinner SC, Gorbach S. Diarrhea and abnormalities of gastrointestinal function in a cohort of men and women with HIV infection. Am J Gastroenterol 2000,95:3482-3489.
  3. de Lorgeril M. Mediterranean diet and cardiovascular disease: historical perspective and latest evidence. Curr Atheroscler Rep 2013,15:370.
  4. Jacobs S, Harmon BE, Boushey CJ, Morimoto Y, Wilkens LR, Le Marchand L, et al. A priori-defined diet quality indexes and risk of type 2 diabetes: the Multiethnic Cohort. Diabetologia 2015,58:98-112.
  5. Simopoulos AP. Evolutionary aspects of diet: the omega-6/omega-3 ratio and the brain. Mol Neurobiol 2011,44:203-215.
  6. Gaffney-Stomberg E, Insogna KL, Rodriguez NR, Kerstetter JE. Increasing dietary protein requirements in elderly people for optimal muscle and bone health. J Am Geriatr Soc 2009,57:1073-1079.
  7. Iannuzzi-Sucich M, Prestwood KM, Kenny AM. Prevalence of sarcopenia and predictors of skeletal muscle mass in healthy, older men and women. J Gerontol A Biol Sci Med Sci 2002,57:M772-777.
  8. Woods MN, Wanke CA, Ling PR, Hendricks KM, Tang AM, Knox TA, et al. Effect of a dietary intervention and n-3 fatty acid supplementation on measures of serum lipid and insulin sensitivity in persons with HIV. Am J Clin Nutr 2009,90:1566-1578.
  9. Sattler FR, Rajicic N, Mulligan K, Yarasheski KE, Koletar SL, Zolopa A, et al. Evaluation of high-protein supplementation in weight-stable HIV-positive subjects with a history of weight loss: a randomized, double-blind, multicenter trial. Am J Clin Nutr 2008,88:1313-1321.
  10. Micke P, Beeh KM, Buhl R. Effects of long-term supplementation with whey proteins on plasma glutathione levels of HIV-infected patients. Eur J Nutr 2002,41:12-18.
  11. Xu R. Effect of whey protein on the proliferation and differentiation of osteoblasts. J Dairy Sci 2009,92:3014-3018.
  12. Hendricks KM, Mwamburi DM, Newby PK, Wanke CA. Dietary patterns and health and nutrition outcomes in men living with HIV infection. Am J Clin Nutr 2008,88:1584-1592.
  13. Gil L, Lewis L, Martinez G, Tarinas A, Gonzalez I, Alvarez A, et al. Effect of increase of dietary micronutrient intake on oxidative stress indicators in HIV/AIDS patients. Int J Vitam Nutr Res 2005,75:19-27.
  14. Davis JN, Hodges VA, Gillham MB. Normal-weight adults consume more fiber and fruit than their age- and height-matched overweight/obese counterparts. J Am Diet Assoc 2006,106:833-840.
  15. Miller TL, Wolin MJ. Pathways of acetate, propionate, and butyrate formation by the human fecal microbial flora. Appl Environ Microbiol 1996,62:1589-1592.
  16. Estruch R, Ros E, Salas-Salvado J, Covas MI, Corella D, Aros F, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013,368:1279-1290.
  17. Levy E, Thibault L, Garofalo C, Messier M, Lepage G, Ronco N, et al. Combined (n-3 and n-6) essential fatty deficiency is a potent modulator of plasma lipids, lipoprotein composition, and lipolytic enzymes. J Lipid Res 1990,31:2009-2017.
  18. Das UN. Essential fatty acids and their metabolites could function as endogenous HMG-CoA reductase and ACE enzyme inhibitors, anti-arrhythmic, anti-hypertensive, anti-atherosclerotic, anti-inflammatory, cytoprotective, and cardioprotective molecules. Lipids Health Dis 2008,7:37.
  19. Kroger J, Schulze MB. Recent insights into the relation of Delta5 desaturase and Delta6 desaturase activity to the development of type 2 diabetes. Curr Opin Lipidol 2012,23:4-10.
  20. Tremblay AJ, Despres JP, Piche ME, Nadeau A, Bergeron J, Almeras N, et al. Associations between the fatty acid content of triglyceride, visceral adipose tissue accumulation, and components of the insulin resistance syndrome. Metabolism 2004,53:310-317.
  21. Guasch-Ferre M, Bullo M, Estruch R, Corella D, Martinez-Gonzalez MA, Ros E, et al. Dietary magnesium intake is inversely associated with mortality in adults at high cardiovascular disease risk. J Nutr 2014,144:55-60.
  22. Wengreen H, Munger RG, Cutler A, Quach A, Bowles A, Corcoran C, et al. Prospective study of Dietary Approaches to Stop Hypertension- and Mediterranean-style dietary patterns and age-related cognitive change: the Cache County Study on Memory, Health and Aging. Am J Clin Nutr 2013,98:1263-1271.
  23. Wolever TM, Mehling C. Long-term effect of varying the source or amount of dietary carbohydrate on postprandial plasma glucose, insulin, triacylglycerol, and free fatty acid concentrations in subjects with impaired glucose tolerance. Am J Clin Nutr 2003,77:612-621
  24. US Dietary Guidelines. 2015.
  25. Selhub J, Jacques PF, Bostom AG, D’Agostino RB, Wilson PW, Belanger AJ, et al. Relationship between plasma homocysteine, vitamin status and extracranial carotid-artery stenosis in the Framingham Study population. J Nutr 1996,126:1258S-1265S.
  26. Franceschini G, Werba JP, Safa O, Gikalov I, Sirtori CR. Dose-related increase of HDL-cholesterol levels after N-acetylcysteine in man. Pharmacol Res 1993,28:213-218.
  27. Shahzad K, Chokshi A, Schulze PC. Supplementation of glutamine and omega-3 polyunsaturated fatty acids as a novel therapeutic intervention targeting metabolic dysfunction and exercise intolerance in patients with heart failure. Curr Clin Pharmacol 2011,6:288-294.
  28. Michalek JE, Preuss HG, Croft HA, Keith PL, Keith SC, Dapilmoto M, et al. Changes in total body bone mineral density following a common bone health plan with two versions of a unique bone health supplement: a comparative effectiveness research study. Nutr J 2011,10:32.
  29. Ringe JD, Doherty JG. Absolute risk reduction in osteoporosis: assessing treatment efficacy by number needed to treat. Rheumatol Int 2010,30:863-869.
  30. Fawzi WW, Msamanga GI, Spiegelman D, Urassa EJ, McGrath N, Mwakagile D, et al. Randomised trial of effects of vitamin supplements on pregnancy outcomes and T cell counts in HIV-1-infected women in Tanzania. Lancet 1998,351:1477-1482.
  31. Woods MN, Tang AM, Forrester J, Jones C, Hendricks K, Ding B, et al. Effect of dietary intake and protease inhibitors on serum vitamin B12 levels in a cohort of human immunodeficiency virus-positive patients. Clin Infect Dis 2003,37 Suppl 2:S124-131.
  32. Marcuard SP, Albernaz L, Khazanie PG. Omeprazole therapy causes malabsorption of cyanocobalamin (vitamin B12). Ann Intern Med 1994,120:211-215.
  33. Barringer TA, Kirk JK, Santaniello AC, Foley KL, Michielutte R. Effect of a multivitamin and mineral supplement on infection and quality of life. A randomized, double-blind, placebo-controlled trial. Ann Intern Med 2003,138:365-371.
  34. Chandra RK. Effect of vitamin and trace-element supplementation on immune responses and infection in elderly subjects. Lancet 1992,340:1124-1127.
  35. Meydani SN, Meydani M, Blumberg JB, Leka LS, Siber G, Loszewski R, et al. Vitamin E supplementation and in vivo immune response in healthy elderly subjects. A randomized controlled trial. JAMA 1997,277:1380-1386.
  36. Folkers K, Langsjoen P, Nara Y, Muratsu K, Komorowski J, Richardson PC, et al. Biochemical deficiencies of coenzyme Q10 in HIV-infection and exploratory treatment. Biochem Biophys Res Commun 1988,153:888-896.
  37. Hamilton SJ, Chew GT, Watts GF. Coenzyme Q10 improves endothelial dysfunction in statin-treated type 2 diabetic patients. Diabetes Care 2009,32:810-812.
  38. Shabert JK, Winslow C, Lacey JM, Wilmore DW. Glutamine-antioxidant supplementation increases body cell mass in AIDS patients with weight loss: a randomized, double-blind controlled trial. Nutrition 1999,15:860-864.
  39. Young LS, Bye R, Scheltinga M, Ziegler TR, Jacobs DO, Wilmore DW. Patients receiving glutamine-supplemented intravenous feedings report an improvement in mood. JPEN J Parenter Enteral Nutr 1993,17:422-427.
  40. Youle M, Osio M, Group AS. A double-blind, parallel-group, placebo-controlled, multicentre study of acetyl L-carnitine in the symptomatic treatment of antiretroviral toxic neuropathy in patients with HIV-1 infection. HIV Med 2007,8:241-250.
  41. Benedini S, Perseghin G, Terruzzi I, Scifo P, Invernizzi PL, Del Maschio A, et al. Effect of L-acetylcarnitine on body composition in HIV-related lipodystrophy. Horm Metab Res 2009,41:840-841
  42. Rizos I. Three-year survival of patients with heart failure caused by dilated cardiomyopathy and L-carnitine administration. Am Heart J 2000,139:S120-123.
  43. Langsjoen H, Langsjoen P, Langsjoen P, Willis R, Folkers K. Usefulness of coenzyme Q10 in clinical cardiology: a long-term study. Mol Aspects Med 1994,15 Suppl:s165-175.
  44. Haglin L, Lundstrom S, Kaati G, Backman L, Bygren LO. All-cause mortality of patients with dyslipidemia up to 19 years after a multidisciplinary lifestyle modification programme: a randomized trial. Eur J Cardiovasc Prev Rehabil 2011,18:79-85.
  45. Chang L, Holt JL, Yakupov R, Jiang CS, Ernst T. Lower cognitive reserve in the aging human immunodeficiency virus-infected brain. Neurobiol Aging 2013,34:1240-1253.
  46. Scarmeas N, Luchsinger JA, Schupf N, Brickman AM, Cosentino S, Tang MX, et al. Physical activity, diet, and risk of Alzheimer disease. JAMA 2009,302:627-637.
  47. Harley CB, Liu W, Blasco M, Vera E, Andrews WH, Briggs LA, et al. A natural product telomerase activator as part of a health maintenance program. Rejuvenation Res 2011,14:45-56.

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