Overwhelming: Vancouver was an experience! In the ‘60s we called this type of event a Happening. What was so Happening about Vancouver? Protease Inhibitors, other new drug developments, and newer and higher expenses. And Activism. Also, it was something of a "Names Project" (no disregard to the Quilt). Each new drug seems to have two or three names, and all of them are a vocabulary-dense experience. Proper, or common names here are in italics.

The more experienced we get, the more important protease inhibitors are becoming. The new in question is "What’s your cocktail?" Actually, some of us are just riding along on the enthusiasm of others as we manage to hold our CD4 cells at ~ 500: A"contact high" — again from the ‘60s. Viral loads are going down as fast as CD4 cells are going up. Some are getting load test results of "non-detectable" HIV in blood samples. So as lives are being saved, let’s make sure that the nutritional requirements surrounding the new drugs and their efficacy are being well explained for maximum benefit. And there really are nutritional concerns. Many of these are included in this article.

As of now, if you’re taking two members of the AZT family (ddI, ddC, d4T or 3TC), or analogs, in a new common triple combo package with a protease inhibitor (PI), there are also potentials for more unexpected side effects and maybe even more nutritional requirements. The mix/match with other anti-HIV therapies can be confusing — but it could become really important.

Depending on your state of analog "naivete," your doctor may start you with a common combo of AZT and 3TC plus the PI of choice. The analogs, and protease inhibitors will soon be joined by many new meds already well along in the pipeline. We don’t know much about how their actions will combine with other cocktail members, but it’s certain that they too will have important nutritional essentialities.

Results from protease trials are exciting, yet many questions remain. The names, actions and expectations are included elsewhere in this newsletter, so you’ll actually need Nutrition Power to help get the maximum performance from your own cocktail. There are dietary guidelines for using our first three protease inhibitors, and there’s no reason to expect it to get any easier with more and more anti-HIV drugs upcoming. Non-nucleoside reverse transcriptase inhibitors (NNRTIs) are standing in line to join the just-approved Neverapine in yet another anti-HIV direction of attack. We will need a working nutritional management and organization system.

The first Protease Inhibitor (PI) to become available, Roche’s Saquinavir, aka Invirase, came on with a major nutritional challenge — to take it with a full meal. Roche said it was practically useless if taken without food. It has a major malabsorption malady: at best they expect around 4%, and that only with help from a with-a-meal dose. Readers need to know exactly how to make things work for the "with" (feasting) and "without" (fasting) food rules.

Beginning with Invirase, Roche noted that almost none of the drug got absorbed into the bloodstream from a clean and clear stomach/intestinal evironment (fasting). With a full stomach (feasting), however, up to 4% absorption was noted. Logic is everything! Without food, the drug just slips on down the intestinal water slide until finally you expel that expensive drug right into the toilet! Knowing this, we need to make the food hang around better. Here’s where Nutrition Power is a true manifestation of the old saying that Knowledge is Power!

Yes. Normally the stomach is supposed to acidify food and manipulate it -- that's called "peristalsis"-- kind of like a washing machine full of stomach acid instead of soap. Then the stomach becomes a food storage compartment, or holding tank, as the mushed up food lines up to get admitted into the intestine. Food, to be taken with the "feasting" drug, will go down the pipeline slowly. Since the feasting-drug will be absorbed better the longer it stays in the gut, it stands to reason that we should eat the food that has the longest transit time. Absorption to the max! Look to dietary fat for this. If you eat a tuna sandwich with avocado and mayonnaise, you have a high-fat meal. And here, a Nutrition Power Bonus: The fat types are also exceptional! This little "tuna trick" just may best-out Roche’s 4% estimates! And this trick can be modified for peanut butter sandwiches, cheese sandwiches, hamburgers, pizzas, pastries, donuts, cookies, cakes, etc. The more fat there is, the longer the stomach will hold onto its contents and give it time to linger at intestinal walls for maximum absorption.

Meds to take "feasted" include Ritonavir (Norvir), Nelfinavir (Viracept) and Invirase. Looking back at this, though, there is another Nutrition Power Trick for Invirase: Take it with grapefruit juice — pink! Grapefruit juice is a happening thing. Pink grapefruit juice is full of Lycopene, a powerful antioxidant; the colorless one is not as effective (and looks a little like a bottle of urine) — whatever makes you happy!. But, as with all good things, this fruity tonic is apt to mess with other medications, depending on individual health profiles: Check with your pharmacist on medications that work badly if taken with grapefruit juice.

In other medication-related rules, an empty stomach is called for. What that probably means is that it wants to be alone while it does its work, and doesn’t want to be messed up with anything else that may get in its way. Indinivir (Crixivan) from Merk is one of these. The way the "rule" is generally given is: "Take either 1 hour before or 2 hours after eating." And this two or three times a day! Also, since Indinivir is a fasting drug, and so is ddI, talk with your doctor about alternatives in the other cocktail members. Fasting-for-two might be something even I couldn’t manage. If you’ll settle for less benefit: Why do it at all?

And Nutrition Power has a helpful hint here, and I do speak from experience: If you need to eat between meals and you’re taking a "fasting-type" drug, enjoy fruits, vegetables and clear liquids like apple or cranberry juice. Since these types leave the stomach almost as fast as you can pack them in, you can still work in some pretty awesome nutrients even while technically you’re still "fasting." My personal favorite is raspberry sorbet -- pureed berries with a little sugar -- I call it "frozen raspberries". Just make sure you don’t eat mixed foods or fatty foods.

Drugs to take Fasted: include ddI (Videx), ddC (Hivid) and Crixivan (Indinivir). Also, AZT is better absorbed on an empty stomach.

There isn’t any single drug (not even aspirin) that doesn’t cause side-effects. Combined, we’re often chipping away at side effects, taking one pill to overcome the next pill and not knowing which is doing what. These agents are too new for us to really know long-term results, but here are a couple o’ little tricks for some of the worst.

In general, the side effects of medications include diarrhea, constipation, nausea, vomiting, loss of appetite, malabsorption and other highly unpleasant experiences. Also, gas, cramping, bloating and feeling too full too fast can get tedious. For these, I’ve found that heating pads are very welcome, useful, and effective. Even if they weren’t, the warmth can be a "comfort carrier", since we often associate heat with loving care (not on a hot day, be real). Since bloating (and its kin) is almost always a risk, even without the impetus of medication side-effects, keep a heating pad handy. If crampy bloating is serious, maybe some activated charcoal (a supplement that absorbs gas) and/or acidophilus (a supplement that re-instates normal gut flora) could help.

Now for the worst of the worst: Bowel irregularity: It can be brought on in our crisis management lifestyles regardless of medications. Opportunistic infections, for example. Try balancing soluble with insoluble fibers. Psyllium husk, rice-solid drinks, oat bran and barley are soluble and are a good diarrhea treatment. Wheat bran and whole grains are insoluble and good for constipation. Be careful of the water you drink; never trust tap water — it’s tedious, but worth the effort. For self-defense, carry your own "safe" fluids wherever you go. Always. Prevent diarrhea now, then use nutrition power for higher, more important purposes like absorption-increasing tricks for getting the best advantage from the protease inhibitor you’re using.

Weight loss happens as a side effect and also from actions of HIV itself Losing weight is one thing, but when you lose your appetite to the point that regaining it can be overwhelming -- appetite management skills should be applied. We can lose our appetit for any number of reasons. One is fear of vomiting -- a highly unpleasant thing to have happen. Nausea may happen because of a foul odor — like herb sauces that stink, and it can also cause vomiting episodes. Nausea responds well to dry, salty foods. Crackers, potato chips, chicken broth — whatever it takes. Stay in a well-ventilated area, or get to one before you really have to. There are also medications that are effective for nausea: Call your pharmacist or doctor for a remedy.

Changes in the taste of foods, so-called "altered taste sensation," can interrupt many nutritional pleasures. Know what foods cause this, then avoid them. Replace screwy tasting foods with ones that taste OK-- now. Also, sometimes this taste-change can reverse itself. If your favorite food now tastes yucky, it may taste better in a month or two. If you’re willing to risk the consequences for a favorite food, try it once in awhile -- don’t miss out on something you love just because it once reacted badly.

One side effect, generally not thought of as included under the "nutritional umbrella" is fatigue; practically all HIV drugs can contribute to this problem. But I think fatigue presents serious nutritional concerns: What if you’re too pooped to get a feeding fix? Ah . . . now fatigue is a nutritional side-effect! The way around this includes a standard: "Be prepared." Keep nutritional drinks (Nu-Basics, Sustacal, Instant Breakfast, Ensure, etc.) in good supply as a general precaution. Then when fatigue hits, you won’t have to let your nutrition program down. Just be sure to drink enough for the calories you need. Use whatever you like best. Or use one that is specially recommended by an HIV-sensitive dietitian/nutritionist. Keep it by your bed. When you don’t want to get out of bed to eat, just open and drink! I have also found that getting food can be coupled with bathroom events, so when you’re already "up" you can stop back in the kitchen for a nutraceutical or food feeding. Whatever it takes.

All drugs, foods, nutrients, and assorted alterations of gut flora are happening in our bodies at the same time. Allowing thirst to guide adequate fluid intake is a very bad idea. Instead, plan to drink at least two quarts daily. It doesn’t have to be fancy. Any soda, water, lemonade and other fruit drinks, etc. will do. Play safe with ice cubes -- make 'em with distilled water..

Dehydration is far more dangerous than it sounds! If you or anyone you know is losing fluids, be sure to focus on a double-on-one drinking practice: 2 cups drunk for 1 cup lost. Sweats, hot weather, heavy exercise, and other fun things all count as reason for surprising amounts of "output." Use the two-for-one strategy. Over-estimate if you’re not sure.

They tell us we may have only one chance with PIs. These drugs are very powerful weapons against HIV/AIDS and results are so promising there’s only one way to approach them: With Incredible Attention. Take your pills with serious planning to get the best value. If anyone starts playing with casual attention to best benefit, everyone gets let down; the drug’s effects, the doctor who gave you the drug — and you! The new caveat is "no more drug holidays". The awesome power can be lost simply because of sloppy timing — be really serious about your future health potential, and we’ll all meet up in the old folks’ home!

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As always, first do no harm. If any of the advice here is, or seems to be related to adverse health conditions, contact your doctor or your nutritionist. Or call me.

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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, Positive Threads, and other newsletters.