Last August, I reported in this newsletter about feasting; eating a lot -- for Saquinivir (Inverase) and fasting; eating very little, -- for Crixivan (Indinavir). It’s a lot easier to be in a "feasting" routine than in one of "fasting." And in a medical nutrition setting, I’ve noticed that clients are appreciative when I give out some of the following "tools" to help with the fasting routine. After all, if perfect is possible, good isn’t enough.

Let’s talk about Crixivan (aka "Crix"). The fasting rule statement usually given is "take this one hour before, or two hours after a meal." Sorry, but that is not explanatory enough. I think "rules" are easier to follow if you know why they exist at all. For a "fasting" recommendation, the reason is that the drug needs to get to, and be "alone" in your small intestine for as long a time as possible. Here are some thoughts for a "normal" work day.

Wake up at 7:00. Take your Crix. Timing couldn’t be better; it’s certainly been at least two hours since your last feeding. After your Crix fix, brush your teeth, do your other morning ablutions, and start making a hearty breakfast. (Your next Crix dose will be around 3:00 pm.) Eat a hearty breakfast at 8:00.

Or, you could choose not to cook. A typical coffee shop breakfast often includes two eggs, hashed browns, bacon, toast, and coffee. Eggs must be hard cooked (Ms. Food Safety never sleeps!) This is the cheapest way to get calories for the day. Are they healthy calories? Well, they could be better, but if you want to gain or maintain weight, keep money in your wallet, and pre-load your daily food intake, this can be a real find!

Actually, that coffee shop breakfast of 2400 calories might be more than a whole day’s worth of calories for many people. And if you are overweight, this breakfast probably isn’t for you. But if you want to gain weight, extra calories are your friends, even though they are about half fat. So use some judgment here.

Those high-fat, high-calorie foods -- if eaten without exercise, may show up as body flab. Then there’s that same old song about building muscles to prevent wasting and death -- that sort of thing. The way I suggest you spend your calories is in a weight-lifting, body-defining exercise routine. That way, you can admire how great you look in the mirror every morning as you ponder your Crix doses for the day.

In the coffee shop’s 2400 total calories, by the way, are 53 grams of protein (about 1/3 of our daily requirement) and 123 grams of fat. This nets the following nutrient profile: 9% of calories as protein, 45% of calories from carbohydrate and 46% of calories from fat. Yes, I know our daily fat content should range from 20-30% of calories -- it's fine if you take it into consideration in subsequent meals. Read on ---

At 10:30 you may have another feeding, but one that’s going to be almost fat free. That coffee shop breakfast won’t be leaving your stomach until 2:30 - 3:00. For now, how’s an English muffin with jelly? Make it a turkey or roast beef sandwich -- dry? Add a piece or two of fruit. Want a burger? Wait until after your next dose has been taken -- about 4:00. Remember, that large breakfast will remain in your stomach for up to five hours. Crixivan prefers that the higher fat meals be an hour or two after your take your dose.

At 12:00-1:00, you may have another feeding but you’ll have to be very careful. This is critical -- this feeding must be small and fat free. Try fat-free yogurt, milk, fruit, cereal, fruit, fruit juices, etc. And don’t eat too much -- your stomach isn’t empty yet and Crix needs for that to happen before its 3:00 appointment.

This "lunch" restriction employs very good strategic logic: the residues of a heavy breakfast, mild mid-morning snack, or a high-fat noonish could remain in your intestines for up to 5 hours, so your 3:00 Crix fix would not be as alone as it should be. Crix’s preferences come first. After all, it’s these "miracle" protease drugs will hopefully keep us alive for a long life-span -- don’t blow it. Your light lunch will prepare your intestines to be "clean" for the 3:00 Crix.

Note that your morning foods were pretty high in fat. You had eggs, meat, greasy potatoes, bread, butter and fruit spread for breakfast, and light, fat-free snacks during the morning. The noontime feeding needs to be much lower in fat to get the best Crix results.

At about 3:00, it’s Crix time. So, at 4:00, it’s your next (and possibly only) time for another high fat feeding. Who said you had to have a hearty lunch at noon? The new schedule is better and will net better results. Maybe a taco/enchilada/guacamole combo will do the trick here. Or were you doing Italian with Alfredo sauce or ravioli with cheese. Prefer a tuna sandwich with chips? Like "breakfast," this feeding could be an opportunity to grab a fat fix. But you probably can't do both. Pick one or the other, or tread the middle line both times. If you've got room in your fat budget, a burger and fries -- even with cheese and sides, are OK here. Enjoy a dessert if you want to. This may be your last fat-eating opportunity of the day; use it wisely.

Coming up to about 6:00 or 7:00 in the evening, eat a very light dinner. Your last Crix will be about 10:00-11:00 . If bedtime (i.e., sleep) is not scheduled until 11:00 or so, you may be able to get a little more liberal on amount and fat content for dinner. A dessert should be on the lighter side. Crix needs you to "clean up" between your 3:00 feeding and your dinner at about 6:00-8:00 (You had your opportunity for a "heavier" dessert then; don’t whine.) If your sleep-time is scheduled for 10:00 or earlier, the low fat dinner is a must! If sleep-time is later, say midnight, etc., you may take a little extra fat in the dinner (6:00-8:00) meal.

Again, up to an hour prior to your last Crix dose, you may eat or drink small, nonfat foods (only) like toast with fruit spread, fruit with yogurt, nonfat milk or milk substitute. Butter the toast or fatten the milk or yogurt, and you may destroy the Crix-alone requirements.

Speaking of which, what if you simply cannot do this every day? Do it when you can, and that should be "most-to-all of the time." These drugs are probably going to make our lives change all around -- treat your food habits as closely as you treat your medications; that’s more complicated, but the results, like living better, happier and longer (and in that order), are so spectacular that we must combine diet with medicine for maximal benefit. And, Crix is a little pricey, even if some insurance or other financial agency is paying for you. Breakfast at Denny’s is cheap, but it has a health potential too!

Of course, this is probably not your own schedule -- but it may be mine or someone else’s. Adjust the advice to your own -- since you now know why, hopefully, the general guidelines offered here will help you plan eating events with fasting meds. At the cost and potential for really better HIV-health, do it right and we may all be home free in a couple of years!

Ritonavir (Norvir) seems to have little if any nutritional requirements, but it does have some things that are worrysome. First, it interacts with some other medications you may be taking. Talk to your pharmacist. It also can elevate serum cholesterol. As I noted this with several of my clients, it is worth mentioning here. What to do when you think a drug is causing weird outcomes? Call the manufacturer! So I did, and Abbott Labs were very generous with their time. They did emphasize that if your cholesterol is higher than 200, you may be on the threshold of cardiac problems, just like Average America. If this is the case, ask your doctor. Especially since we’ve seen that the only downside of cholesterol has been when it gets too low, this finding may not be viewed as seriously as it should be. According to Abbott Labs, if your cholesterol gets too high, you may need to make dietary changes, and that coffee shop breakfast is no longer an option. Don’t shoot the messenger; I’m just warning you here!

Since maybe the biggest "down-side" of Crixivan is kidney stones -- rarely. I suggest emphasizing cranberry juice and sauce (jelly-type) -- both of are OK to eat up to one hour before a Crix fix. The Ocean Spray Cranberry company has invested a lot of research to finding "cranberry factor" for no gain. It’s a healthy and reasonable strategy to use cranberry juice, jelly or even dried ones (like raisins). So, we still don’t know if cranberry factor really protects our kidneys, it might, and cranberries are healthy, let them be a big feature in your diet. It doesn’t have to be Thanksgiving to eat cranberries!

Oh, for feasting on Saquinivir, do the opposite. Take your meds with your high fat meals, and balance the extra fat with fat-free snacks throughout the day. And remember that there will be at least one new formulation for Saquinivir that is better absorbed.

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First do no harm: should any of this advice be, or seem to be, associated with adverse consequences, call your nutritionist, doctor, pharmacist, or all three!

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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 Plus, and other newsletters.