Welcome to a pill adventure of the nutritional kind. As it turns out, there's quite a lot going on in the HIV/AIDS nutrition research department -- you'd almost think science had actually acknowledged its importance! Please Note: This article is about over-the-counter vitamins, minerals, and amino acid supplements as they relate to HIV and AIDS. This information is specific to people living with HIV and not intended for the general, healthy public.

When it comes to supplements and HIV/AIDS, the only thing nutritionists and dietitians agree about is that there is disagreement in general, and the issue of supplementation tops the list. The disagreements we usually have are on the specifics, i.e., what ones to take and how much we should take. And that disagreement is valid; you are seriously advised to gather information from more than one source.

I am admittedly aggressive in suggesting doses for the various supplements; but numbers that will not cause harm, and which are within the therapeutic level of safety and benefit. Another thing to keep in mind is that new information, and new drug therapies for HIV/AIDS may tend to cause changes in our suggested limits. And finally, new and more sophisticated research studies may alter previously-held tenets. It’s always a good idea to get updated information, from dietitians and nutritionists who work closely with people living with HIV/AIDS, at least twice yearly. We read medical reports, attend professional meetings (like the AIDS Conference in Vancouver), and witness peoples’ actions and reactions around supplemental regimens.

A few more things to keep in mind: First, qualifications: In most states, nutritionists are not "licensed" as are nurses, doctors, and hairdressers. So, if someone has a phone and an office -- even people who know nothing about nutrition -- they can legally practice nutrition (but not hairdressing!). If you live where there is licensure of nutritionists, you’re lucky. If you happen to live in a state that does not issue licenses, your qualification job is a little bit different. Here, we look for credentials and a professional nutrition healthcare history of working with people who are living with HIV.

The only nationally known group of nutritionists, Registered Dietitians (RDs), belong to the American Dietetic Association (ADA) which has long maintained that routine supplementation is not necessary if we eat correctly. My statement about supplements, then, may place me somewhat at odds with ADA guidelines, but I can support what I recommend. If I couldn’t, I wouldn’t write about it for the Positive Public at circulation numbers such as those in the issue you are reading. Also, when surveyed, over half of all dietitians, like myself, admit to taking supplements. I "came out" on this issue years ago.

Now, let's drop in on Norman Rockwell’s "Middle America" to see how the "walking well" are doing. Food consumption surveys report that the American public is routinely deficient in vitamin E at a level of 73-75%. Also, the meager 60 mg RDA for vitamin C isn't met daily by 38-41% (6 oz. of orange juice more than does this). Vitamin A turns up deficient in 51% of us, and vitamins B1, B2, B3, and B6 run at deficiency rates from 35-48%. So even when enjoying apparent good health, without HIV, an "RDA-level" supplement would be harmless, easy to afford, and good insurance that "95% of normal, healthy Americans will obtain nutrient sufficiency to prevent deficiency diseases." And, a choice made by a majority of nutrition professionals. Note the word healthy: If you are living with HIV you are, unfortunately, out of this classification.

HIV/AIDS creates a whole new set of circumstances and can get us into deficiency big time -- if we let it! For many years I have recommended supplements as an essential component of a wholistic nutritional approach to HIV Disease. I have studied the medical literature with respect to nutrients' effects on immune health and requirements during abnormally demanding circumstances. There's no getting around it -- either take supplements or live probably less well and less long, with easily avoidable nutrient deficiencies.

A word of caution: Curiously, the symptoms of a vitamin overdose are strikingly similar to those of deficiency. For example, night blindness will result from too much vitamin A just as it will from too little of the vitamin. In other words, self-prescribing doses should not be done at home -- get professional advice.

Since we hear about (and practice?) so much "early intervention" when it comes to medical care; it would be totally neglectful not to do early intervention with Nutrition Power as well. This is where we get into the "hit-hard/hit-early" model for nutrition healthcare. For advanced, therapeutic levels of supplementation, read on --

As it happens, when newly-diagnosed, nearly everyone who is HIV-positive -- if they get tested for it, which is all too rarely -- is found to have deficiencies in many vitamins and minerals. So, take it from me, time is of the essence if you are living with HIV/AIDS and not yet taking supplements. And, if you are given guidelines based on Recommended Daily Allowances (RDAs), my best advice to you is to get a "second opinion." What a concept!

Also note that, incorrect supplementation may do more harm than good, thus, it's wise, easy, and affordable to get that expert guidance. This member of your healthcare team should be thoroughly familiar with HIV medical science, like common HIV-specific symptoms, OIs, medications, treatments, etc. And also someone who has a decent understanding of the individual (supplemental) nutrients.

Vitamin B1 (thiamin), is important for proper carbohydrate use. Thiamin deficiency can result in encephalopathy [Wernike’s] and beriberi. When you work at County Hospital, you can probably see just about everything; I’ve personally witnessed them all -- Beriberi is highly unpleasant and totally avoidable. Thiamin’s best dietary source is Pork -- well cooked, please. Vitamins B2 and B3 (riboflavin and niacin) are necessary for converting calories into energy. Riboflavin's best food source is milk, and niacin is found in meats (especially organ meats), grains and starches. Vitamin B6 (pyridoxine) is vital for protein metabolism and for immune function. Needs for B6 with HIV/AIDS are way above RDA status; and this is HIV-specific. Best food sources of B6 include meats, legumes, and whole grains. Another B-complex member is folic acid, or folate. Food sources can be found by knowing how it got named: For Foliage -- green leafy vegetables. Also it's in lean meats and legumes (beans, lentils).

Since deficiencies of vitamin B12 are commonly diagnosed along with HIV, a close look at B12 will help make my point. Normally, our bodies maintain sufficient tissue stores of vitamin B12 to supply for 3 to 10 years' needs. Essentially, this means that when HIV diagnosis is made, the B12-deficient individual has used up to 10 years' worth of B12!! Logic says that this represents a much higher-than-normal usage rate of B12 due to HIV.

Couple this with about a dozen purely scientific reasons why the HIV-infected digestive tract doesn't function normally enough to adequately process vitamin B12, and you have every reason to assume a deficiency, even if it doesn't show up on a lab report. Recently, Dr. Don Kotler, one of our internationally premier nutrition experts, stated this about vitamin B12: "The test (for sufficiency) is too expensive and complicated; just give the supplement."

Add now, a few soothing facts: vitamin B12, in excess, hasn't been shown to be toxic. Vitamin B12 plays a major role in nerve function (think neuropathy). In fact, B12 has a hand in an amazing array of our bodies' chemical reactions occurring all the time. I recently read a report about vitamin B12 reversing a very painful neuropathy and, in another case, healing an encephalopathy (brain infection) and yet another case reported the remission of PML (a particularly resistant "always fatal" Opportunistic). Yes, vitamin B12 is very important to get enough of for sufficient HIV/AIDS nutrition healthcare.

Because vitamin B12 is so hard to process for Positive People, and the HIV-affected gut has lost (or, is certainly prone to losing) the ability to do it correctly, we should be routinely supplementing with B12. But with the problem of that sensitive HIV gut, it's best given by injection to bypass the damaged digestive tract. For those who hate shots, a sub-lingual B12 -- dissolves under the tongue -- is inexpensive, and a fair alternative. A nasal gel is also available (I, personally, have a bit of an aesthetic problem with this). The scientific name for vitamin B-12 is Cobalamin or Cyanocobalamin.

As promised above, I will give safety ranges for the various vitamins (for the group of healthy Americans. What is safety? My notes offer the minimum toxic dose. Safety cannot be guaranteed above these limits, but I feel confident that since HIV usually causes malabsorption, the upper limit would be somewhat higher for us.

As to levels of the other B-family members, toxicity has wide ranges: B-1 (thiamin) is at an upper limit of 300 mg, Both B-2 and B-3, (riboflavin and niacin) edge in at 1,000 mg, B-6 (pyridoxine) has 2,000 mg, and folic acid hits minimal at 400 mg, biotin gets high at 50 mg, and pantothenic Acid registers at 10,000 mg. As for the B-family, I suggest limits of 75 mg to 150 mg ranges. Given the above, this is a safe range. Below this, a deficiency may be lurking due to decreased food intake, malabsorption, hypermetabolism, and/or altered metabolism. Also, from the financial angle, going above these levels may be costly and inefficient, so stay under 150 mg (that is, so long as some scientific report in the future doesn’t change this information).

Vitamin A in the pre-formed state is important for its own merits. Don't count on beta carotene to satisfy all of our vitamin A needs; the pre-formed version is also important for its significant anti-microbial actions. Dietary sources include meats and dairy products. Not commonly known, pre-formed vitamin A is almost never seen except from animal sources. Your supplement program definitely needs pre-formed vitamin A.

Pay a visit to vitamin D. This one can get us in trouble if we don’t get enough. Usually, vitamin D is made when our skin is exposed to sunlight. But, that skin-made vitamin -- it’s made from cholesterol -- which tends to run very low in Positive People Also, milk products are supposed to be fortified with it. Actually, however, an analysis was done on milk from the grocery dairy counter and guess what -- no, or very little vitamin D. What’s its function? To get better absorption from the gut of the mineral Calcium. Smart move for the dairy folks, isn’t it.

Vitamin K is almost never even considered as a supplement because we do make quite a bit of it in our intestines. That is, if the intestines are working correctly -- a big "if!" Any antibiotic treatment or use as prophylaxis may compromise vitamin K sufficiency. Food sources include green leafy vegetables, and for HIV, I’ve always recommended less emphasis on the salad-type greens, but get into some collard greens, mustard and turnip greens. The vitamin is involved in blood clotting factors -- how’s yours? If you’re a bleeder, try some K. It’s cheap, it’s pill form is small, and taking the whole bottle won’t hurt. Works for me!

Minerals are less well-known, but just as important as vitamins. Unlike vitamins, however, taking an excess of one mineral may bring on undesirable results, like relative deficiencies, of other minerals. Also, "normal" balance is altered in HIV/AIDS, so RDA proportions can be used only as rough guidelines.

Selenium: A late-breaking, HIV-specific report: A long (and scientifically grueling) research article in the A-list biochemical Journal of Medicinal Chemistry is really exciting. The "bottom line" was summed up by Dr. Will Taylor, primary study author, saying it suggests that "HIV slowly depletes the body’s store of selenium. The hope, he states: "This can lead to specific ways of using selenium supplements to help AIDS patients keep their virus in check. Many AIDS patients have low selenium levels, and some already take supplements. It had been reported that AIDS patients had trouble absorbing the nutrient from food."

As his summary, "The new theory: HIV produces proteins that avidly consume the body’s supply of selenium. HIV needs selenium to grow. Once the virus exhausts the selenium in an infected cell, it breaks out in search of more, spreading the infection to other cells." It seems that HIV is a selenium hog -- it’ll eat away at cellular stores, but the cell also needs selenium to function. Who wins? HIV -- usually, after it kills the cell from a selenium deficiency. With plentiful selenium, however, the cell can remain healthy and delay its death from actions of HIV!

Dr. Taylor continues: "If this is true, then selenium may be the key to understanding the control of the HIV life cycle -- the length of time it takes to deplete the body’s stores of selenium could explain HIV’s long latency period when it’s contained within our lymphatic systems."

To put this into practice, take extra selenium. Toxicity doesn’t start until we get to 1,000 mcg; the RDA is 70 mcg. Best food source: Brazil nuts -- awesome! Selenium supplements are safe and cheap. Stay under 800 mcg to be on the safe side. If you’re eating Brazil nuts, don’t eat too many, and cut back on your extra selenium supplement that day as well.

One classic mineral in HIV/AIDS is zinc. The subject of attention in a recent study which found that zinc in excess of 40 mg is harmful found us all in shock. After that wore off, we looked at continuation of data and the different mathematical manipulations to which it was subjected and most of us are comfortable with prior recommendations. It’s always nice to point to recommendations of noteworthy people. In this case, internationally renowned nutrition/immunology expert Dr. R.K. Chandra still suggests about 75 mg of zinc daily for HIV/AIDS. I’ll not rock the elite, I’ll just copy their notes and let them take the rap.

Not only is zinc closely associated with the T-cell making thymus gland, it is also necessary for virtually every chemical reaction involving protein, specifically enzymes (which are 100% protein). Zinc out of synch (balance) is risky since it may depress immune function and create a copper deficiency. Be sure to take at least 2-3 mg of copper if you use supplemental zinc. Zinc is plentiful in protein-rich foods; like meat (especially organ meats) and legumes. Between vitamin B6 and zinc, we have a real find: Protein comes along with the nutrients needed for its own digestion! Mother Nature's so clever.

Other minerals that should be in your supplements include iodine, molybdenum, chromium, manganese, calcium and magnesium, and even boron. Iron at RDA levels is safe, but because of it's strange metabolism in HIV/AIDS, I normally recommend that it be handled by the primary healthcare providers. Also, I'm frequently asked about potassium; any over-the-counter gator-type drink is just fine to replace the electrolytes in fluid losses (sweats, vomiting, diarrhea) for most of us. If you need serious help with re-hydration, your primary medical provider or your (good) nutritionist can help out.

Many readers are probably aware that some recent reports demonstrated no improvement from use of antioxidant nutrients. One found that vitamin E and beta-carotene didn't protect middle-aged male Finnish smokers from lung cancer. That was a seriously flawed study and I have issued comments often. Suffice to say that if you’re a smoker of middle age and a male, taking small doses of (artificial) beta carotene and vitamin E won’t prevent lung cancer. Just as anyone would expect -- Don’t smoke in Finland!

Subsequently another study found that beta carotene didn't prevent colon cancer in patients who already had pre-cancerous colonic polyps. This was a better-designed study, but recently also, at least three genetic markers for colon cancer were identified. The study didn't report if, or how many, study participants may have had genetic markers for colon cancer. But the presence of polyps (again, pre-cancerous lesions) does suggest a tendency of the study participants. And it also used the Finnish study as a reference -- how these do tend to intertwine!

Beta carotene is often (not always) converted to vitamin A, (1/6 of the time, at best!). It is considered to be an antioxidant and has no known daily allowance (RDA) requirement. Also note that Beta carotene is only one of an entire class of phytochemical carotenoids numbering at the 400s to 600s. What we call pigments, Nature calls carotenoids -- they make food colorful. Shopping the produce aisle gathering a rainbow of colors is a seriously inspired botanical selection technique! Go for Color! Unfortunately, the whole rainbow is not pilled and probably won’t be in the near future. Nature and her secrets ---

Before going further, let’s take a science break to describe what antioxidants are and what they do. They can seem confusing, even mysterious, but it's really rather simple, as are all great truths: The name sort of says it all: Antioxidants prevent oxidation. Now, let’s get into oxidation to see what we’re trying to prevent. Another brilliant idea -- understanding !

To truly take science into the kitchen (do try this at home), peel a banana, an avocado or an apple. Leave home for the rest of the day or several hours, noting the appearance of your specimen. Later on, observe the results of your experiment. Brown, rotten fruit. This result is visible evidence of oxidative damage. The black yucky fruit is ugly and decayed, right? One time, at a lecture, I was even asked if eating the "brown" banana would be harmful! Who wants to eat decayed fruit?

You have now witnessed oxidation at its best. Other words for oxidation include rotted, spoiled, eroded, deteriorated and putrefied. In general, this isn’t a good way to serve or eat food. What your kitchen science experience has produced is the result of action of free radicals, a term you’ve probably heard before.

Simply put, all chemical reactions leave a bit of residue behind. Think of two trees breaking at "timber time" colliding -- bam! On the ground, there are probably some leaves that broke off. Think of the leaves that fell as free radicals; just like the chemical "fall-out" that results from the various chemical reactions in our bodies. If the leaves aren’t dealt with, we get a pile of them. These, if unattended, can run a little murky as they harbor both weather elements, fall-outs from other tree-collisions nearby, and animal poop. Antioxidants are like the rakes that get the leaves out of the way, deactivating them: Free radicals gone!

How does this happen? Well, first we need an antioxidant enzyme. This just another careful way to prepare proteins. One specific antioxidant enzymes is Glutathione Peroxidase (GSP). This one uses vitamin E and Selenium for support. The enzyme would be like a "train engine" and the vitamin/mineral mix would be the train cargo.

So, evidently we need to make both a train, and get the cargo. But the weak link of any form enzyme is the least well supplied amino acid. In GSP this weak link is N-Acetyl-L-Cysteine. Otherwise known as NAC, this supplement can be tolerated up to 2,000 or 3,000 mg. And it stinks! It’s a sulphur-containing amino acid -- which makes it special, and is the weakest link on the way to GSP.

This, by the way, is the ONLY amino acid I recommend as a general rule. The "branched-chain" amino acids, are used almost exclusively to make and support muscles. If that’s all you know, you’ll maybe want to get some branched chain amino acids in pill form. But I suggest you eat eggs instead! Cheap, easy, and awesome amino acid potential -- and not another handfuls of pills to take. Eggs must be well cooked (Ms. Food Safety never sleeps!).

Now we need to get back to our falling trees. What’s in your medical cocktail? Anywhere from three to eighteen drugs, more or less? Already we have extra fall-out concerns. What else goes on in your body -- processing those medications, plus our food, power shakes, and supplements, etc. Since we process more stuff, the more damage danger exists from the free radical fall-out event. Hence, we need more antioxidant action. Yes, nutrients are best coming from food. Can we always rely on good feeding habits? Think about it if you ever happen to visit a fine fast-food establishment. The "food" can be amplified with the burst of nutrients from supplements. A brilliant and reassuring Nutrition Power Note!

Realistically, what you'll find in stores are multi-vitamins, multi-minerals, and many single nutrients, and what I call "promotional" supplements. These carry words like "immune booster," "increases energy," and so forth. Just put the word "Stress" on a label and the bottle sells itself!

To simplify that pill jungle, first separate the vitamins from the minerals. There just isn't enough room in a single pill to hold everything. A multiple vitamin should provide vitamins A and D. Also, the B-complex vitamins should be covered. Multivitamins usually contain vitamins C, E, and K, so be sure to look for these. Taking extra C (to 5,000 mg), E (to 800 IU) and to K (1000 mcg) is sufficient. Beta carotene is generally safe, well tolerated and inexpensive. Don’t take so many that your skin turns yellow. And, that yellow skin can be detected in People of Color: The palms of your hands!

Multi-minerals are another chore. Usually, a mineral-multi carries with it the note that you need to take 4, 6, or even 9 pills to get the stated ingredients; most people with that kind of multi take fewer pills than suggested. Read the smallest print! Be sure that the zinc is "covered" by copper, and that the calcium and magnesium are in balance of about 2:1, respectively. You’ll need extra selenium from a single-nutrient supplement.

I don't know anyone who loves taking pills. They sometimes "return" on you (that's science-speak for 'burp-up'), they catch in your throat, they can smell major awful -- but if you want to maximize your health potential, and if you think nutrition is important to meet that goal, then you are well advised to strongly consider supplementation, naturally with the guidance of an HIV-experienced specialist dietitian/nutritionist.

About advice: How to select an advisor. Remember this old consumer warning: Anyone with something to sell cannot be objective. If there's a profit anywhere around your advisor -- find separation. Some pharmacies, buyers clubs and nutritionists do provide supplements at cost. If a nutrition expert advises you about your supplemental needs without a profit motive, you can at least trust that he or she is sincere.

Taking pills with meals is often easier than taking them on an empty stomach. Try taking a pill after every two bites. It'll be more effectively digested, and is less likely to "return" on you. Naturally, if your medications have dietary rules (many protease inhibitors do) you must follow medical directions. Otherwise, the between-the-bite technique can be not only more palatable, but more discrete if dining in public.

The bottom-line on supplements is: Get good advice, take all medications and supplements in the manner directed by your physician and/or nutritionist, and don't pay retail -- we can obtain inexpensive supplements.

Last, but not least: Individuality! No single package of nutritional supplements is THE best for everyone facing HIV/AIDS. That's why only general guidelines can be presented in an article such as this.

Actually, one of the most common characteristics of HIV/AIDS, is individuality. Respect your own individuality, and use carefully combined supplements to improve the nutrient content of the food you eat. You'll probably live better, healthier and longer, and in that order!

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First do no harm: If any of this advice is, or seems to be connected with adverse consequences, contact your primary healthcare provider and/or your nutritionist.

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Nutrition Power is a Registered Trademark of Health and Nutrition Awareness. Copyright 1996, Jennifer Jensen, MS, MBA, RD.. All Rights Reserved.

Other versions of this article have appeared with permission in Being Alive Newsletter, Arts & Understanding Magazine,and other newsletters.