Effort is example of U.S. Support for Global School Feeding
First I would like to express my gratitude to the Iowa soybean
farmers for sponsoring this
lovely breakfast and the World Initiative for Soy in Human Health
(WISHH) for
affording this opportunity to briefly share thoughts from a medical
community point-ofview on the issue of HIV/AIDS and food and nutrition.
WISHH is a soybean farmerfunded program with the mission to explore
the role of soyfoods in human health and to efficiently meet the
anticipated shortfalls in protein for the world's populations
over the next decades. As such, their mission coincides quite
well with the mission of HIV/AIDS care providers. WISHH has a
table outside which will be manned by the Executive Director,
Jim Hershey. Jim will be happy to talk with any of you more about
WISHH activities and provide you with a "sample pack"
of soyfood products that are being used.
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In many situations we say, "Practice precedes science."
That is, we decide to take action without a clear idea of what
works best and what the impact will be. This is particularly true
in HIV infection, which can be likened to a health earthquake
or monsoon. With the urgent need for action and the time and effort
it takes to establish scientific evidence, more immediate but
careful action seems very appropriate. Closely following these
actions, we need to implement the means to monitor and establish
a research base to yield the evidence needed to invest in the
most effective and feasible plans. In other words, practice and
actions without the development of the evidence to support it
is not likely to last forever and could have us headed down exactly
the wrong road.
In 1987 I worked at the center that was said to "set the
standard" for care in HIV infection, San Francisco General
Hospital. At that time I was told many times in many ways that
the wasting that I saw was a disease issue, a part of the natural
history of AIDS. After spending many pot luck and Domino's Pizza
evenings on the AIDS ward, where the sickest of the group were
admitted, it just didn't ring true. I changed hospitals and was
given free reign to prove my point. We fed people with AIDS. We
got them off of expensive respirators. We extended their lives
for an average of 1 ½ to 2 years beyond
what was considered "long-term survival" which was up
to 18 months after being diagnosed with AIDS. It wasn't until
1989 that the evidence was formally reported in peer-reviewed
scientific publications that the timing of death in HIV infection
is more related to nutritional status, particularly the body's
protein stores (you call them muscles and organs) than to immune
cell counts, the amount of virus in the blood, or opportunistic
infections. So it is nutritional status of the person that determines
when they will die. That was a profound moment for me.
In 1996 guidelines were set and there was a widespread introduction
of anti-HIV drugs in the United States. While I was certainly
ready to pack my bags and sell Mrs. Fields' cookies instead, we
found something else was happening. While many were ignoring the
problem, evidence was presented to show that over the last 7+
years as many as 40% of people with HIV in the United States still
experienced a wasting process. And this problem was related mostly
to a reduction in food intake. Those who were surviving faced
additional nutrition-related problems of accelerated diabetes,
cardiovascular
disease, and osteoporosis. So, I didn't pack up shop.
At this point, I would like to briefly review some of the evidence
that exists.
1. We need to remember to treat the body as well as the bug.
Survival is still most closely related to the maintenance weight
and protein stores. We know that if you lose muscle and organ
tissues because you don't get enough calories and protein, your
body will cease to normally function. Your body won't process
medications as effectively and efficiently as it should. And if
you lose too much, you become debilitated and die.
2. We know that to hang onto muscle and organ tissues with a
chronic infection, like HIV that challenges your body every single
day, you must have enough calories and protein. Recent studies
suggest that high quality protein is related to the ability to
maintain these tissues and that other forms of energy are not
as efficient in that respect.
3. We know that preventing losses is better than regaining ground
after losses exist. In chronic infection the body may not recover
fully to normal levels because of a number of body changes that
happen when you lose this type of weight.
4. We know that the choices for nutrient-dense calories and quality
protein are important to maintain the body. In the United States
and Canada, we have been recommending high protein and high quality
protein diets from the beginning. This is not a difficult task
for our patients here in the US and Canada because we tend to
consume around twice the recommended amount on a daily basis.
We continue to make these recommendations and have added the preference
for soy as a protein source because of its many other potential
health benefits to help in the prevention and treatment of diabetes,
heart disease, and osteoporosis that now plagues our patients.
In resource-limited settings the use of soy as a quality protein
source allows us to implement the high-protein recommendations
in an economically feasible way.
There are a few things that we need to do. We need to think about
the "big picture" in HIV disease. We should not treat
this just as an emergency with no tomorrow to face. With any luck,
the people who receive such care will be "back in our face"
to demand an explanation for such short-term thinking when we
have evidence to keep us from making that kind of mistake. While
it is true that we badly need vaccines, at this time we don't
see one or more close enough on the horizon to stem the tide.
We do know that keeping a nutritionally sound body can extend
survival, a very important factor in settings with
limited resources. We also know that politics, food, and disease
are closely tied. Relieving nutrition insecurity is likely to
reduce the motivations that lead to spread of HIV infection.
As speakers yesterday emphasized, more than talk is needed. In
line with this, at WISHH we have been working collaboratively
with several groups toward problem solving, program development
and implementation, and supporting the process of gathering evidence
to round out the research issues and help the all inclusive "us"
to find our way. WISHH supports efforts for farmers in developing
countries to improve their productivity and hopes to complement
their efforts by addressing the common shortfalls in quality protein.
We are looking at creative ways to enhance the food supply in
resource-limited settings.
The example I would like to share with you is based in Uganda.
USAID has funded an effort to augment feeding for 12,000 people
living with HIV infection and their families totaling 60,000 people
for a period of 5 years. WISHH worked with ACDI/VOCA and its partners
to develop and implement a study to determine the impact of this
program on health, quality of life, living situations, and survival
of a subset of the beneficiaries. This project is a rigorous look
at these criteria that has been reviewed and approved by the Institute
of Public Health at Makerere University and the Uganda National
Centre for Science and Technology.
This one-year project is geared to inform us about the impact
of a feeding program and to determine the strongest indicators
of such impact so that the process can be significantly streamlined
in future work. Research personnel are out in the field as we
speak enrolling participants and taking measures to establish
a baseline on nutritional status and other factors that affect
health and survival. This baseline, a cross-sectional view which
is nearly completed, will allow us to understand the specific
circumstances of living experienced by the beneficiaries and their
families.
Serial measures every three months will take a look at how these
items change. Specific improvements we hope to see include improved
weight and strength, improved growth and catch-up growth in children,
improved quality of life, improved health, and improved living
circumstances. These serial measures of the impact of food intervention
will allow us to determine which aspects of health a food program
can change and improve. We eagerly await the evaluation of the
data gathered and the contribution to evidence about the paths
we are choosing to address the closely tied issues of HIV/AIDS
and nutrition insecurity.
There are several other examples of a variety of the types of
activities that will contribute to our evidence base to improve
practice as well as to help us to abandon less effective activities
for more effective approaches. Working to address the issues of
nutrition in HIV/AIDS to improve survival and health is just one
piece of the puzzle. But it is essential to achieving those things
that have been so inspirationally discussed during this conference.
From left: USDA General Sales Manager
Kirk Miller, World Food Programme Cote dIvoire Country Director
Patricia Kennedy,
World Food Programme Director U.S. Relations Judith Lewis, ASA
Past President Bart Ruth and Archer Daniels Midland Corporate
Vice President Tony DeLio.
Numerous state soybean organizations
support WISHH along with the ASA and the United Soybean Board.
Soybean growers launched the WISHH program in 2000 to help America's
soybean growers build more bridges between America's bounty and
sustainable nutrition programs in countries where rapidly growing
populations of all income levels can benefit from soy in their
diets.
