text:
Hi Rob I was diagnosed with HIV January 2009, my CD4 count is 238. I was told it is not low enough to start treatment and should take care of myself to try and boost it. Im currently taking vit C and vit B complex, is there any other supplement you'd suggest I take, besides wat i'm currently getting from the Clinic.
If you have any other advise on how to live a healthier lifestyle, feel free to let me know.
Among other things ,a healthier lifestyle would include getting adequate sleep/rest, optimizing your diet/nutrition, not smoking or using recreational drugs, using alcohol only in moderation, decreasing stress and participating in a regular exercise program that involves resistance weight training, aerobics (and maybe yoga!). Check out the wealth of information on this site for additional tips. Begin with the information in the section titled "HIV Basics" that can be easily accessed on The Body's homepage. There you will find a chapter entitled "Just Diagnosed" among others devoted to basic information topics. Also, review the information in the archives of the expert forums and related links. I'll reprint below some information about HIV and nutrition from the archives.
I'm concerned that you were told that a CD4 count of 238 was "not low enough to start treatment." I do not agree, nor do all the published treatment guidelines! Are you seeing an HIV specialist physician? If not, you should consult one. If you are seeing an HIV specialist, consider getting a second opinion. I would very strongly recommend you begin combination antiretroviral therapy without delay. I'll also post below some information from the archives concerning when to start treatment.
Good luck. Be well.
Dr. Bob
fatigue (NUTRITION) Nov 2, 2006
How much of a role can diet play in preventing fatigue or counter-acting the side effects of meds?
Response from Dr. Frascino
Many folks, poz as well as neggies, fail to eat properly. This is often associated with inadequate rest and/or exercise as well. In our crisis-crowded world, with its long "to do" lists, getting adequate amounts of rest, sleep and exercise and eating well-balanced nutritious meals are often difficult. Many people with HIV push themselves to work too hard, despite feelings of exhaustion. In turn, working (or playing) too hard is often accompanied by poor nutrition and insufficient rest and exercise. An HIV-knowledgeable nutritionist can check and help optimize your diet, which can reboot your energy supply. Check out the information below and related links that provide HIV-specific nutrition information some trad, some rad!
Bon Appétit!
Dr. Bob
February 21, 2006
Why Is Nutrition Important? Nutrition Guidelines for People With HIV
Good nutrition means getting enough macronutrients and micronutrients. Macronutrients contain calories (energy): proteins, carbohydrates, and fats. They help you maintain your body weight. Micronutrients include vitamins and minerals. They keep your cells working properly, but will not prevent weight loss. Good nutrition can be a problem for many people with HIV. When your body fights any infection, it uses more energy and you need to eat more than normal. But when you feel sick, you eat less than normal.
Some medications can upset your stomach, and some opportunistic infections can affect the mouth or throat. This makes it difficult to eat. Also, some medications and infections cause diarrhea. If you have diarrhea, your body actually uses less of what you eat.
When you lose weight, you might be losing fat, or you might be losing lean body weight like muscle. If you lose too much lean weight, your body chemistry changes. This condition is called wasting syndrome or cachexia. Wasting can kill you. If you lose more than 5% of your body weight, it could be a sign of wasting. Talk to your doctor.
Nutrition Guidelines for People With HIV
First, eat more. Extra muscle weight will help you fight HIV. This is very important. Many people want to lose weight, but for people with HIV, it can be dangerous. Make sure you eat plenty of protein and starches, with moderate amounts of fat.
Protein helps build and maintain your muscles. Meats, fish, beans, nuts, and seeds are good sources.
Carbohydrates give you energy. Complex carbohydrates come from grains, cereals, vegetables, and fruits. They are a "time release" energy source and are a good source of fiber and nutrients. Simple carbohydrates, or sugars give you quick energy. You can get sugars in fresh or dried fruit, honey, jam, or syrups.
Fat gives you extra energy. You need some -- but not too much. The "monounsaturated" fats in nuts, seeds, canola and olive oils, and fish are considered "good" fats. The "saturated" fats in butter and animal products are "bad" fats. A moderate exercise program will help your body turn your food into muscle. Take it easy, and work exercise into your daily activities.
Drinking enough liquids is very important when you have HIV. Extra water can reduce the side effects of medications. It can help you avoid a dry mouth and constipation. Remember that drinking tea, coffee, colas, chocolate, or alcohol can actually make you lose body liquid.
Practice Food Safety
It's very important to protect yourself against infections that can be carried by food or water. Be sure to wash your hands before preparing food, and keep all of your kitchen tools and work areas clean. Wash all fruits and vegetables carefully. Don't eat raw or undercooked eggs or meat, and clean up juices from raw meat quickly. Keep leftovers refrigerated and eat them within three days. Check the expiration date on foods. Don't buy them or eat them if they're outdated.
Some germs are spread through tap water. If your public water supply isn't totally pure, drink bottled water.
What About Supplements?
Some people find it difficult to go shopping and prepare meals all the time. Supplements can help you maintain your body weight and get the vitamins and minerals you need. Don't use a product designed to help you lose weight, even if it says it contains everything needed for good nutrition! Your health care provider can help you choose a supplement that's right for you. Vitamin and mineral supplements can be very helpful.
The Bottom Line
Good nutrition is very important for people with HIV. When you are HIV-positive, you will need to increase the amount of food you eat and maintain your lean body weight. Be sure to eat a balanced diet, including plenty of protein and whole grain foods, with some sugar and fat. An exercise program will help build and maintain muscle.
Drink plenty of liquids to help your body deal with any medications you are taking.
Practice food safety. Keep your kitchen clean, wash foods, and be careful about food preparation and storage. If your tap water isn't pure, drink bottled water.
If you feel you need to use nutritional supplements, be sure to get some expert advice from your health care provider.
For More Information
You can get more information on nutrition and HIV from the following:
A Clinician's Guide To Nutrition In HIV and AIDS, by Cade Fields-Gardner and others, published by the American Dietetic Association, $26 plus $5 shipping and handling: The American Dietetic Association, P.O. Box 97215, Chicago IL 60678-7215; or 800-877-1600, ext. 5000.
Eat Up! Nutrition Advice and Food Ideas for People Living with HIV and AIDS by Charlie Smigelski, RD, $10.00, www.eatupbooks.com/hivbooks.html
Nutrition and HIV: A New Model for Treatment by Mary Romeyn, MD, $18.95, published by Jossey-Bass, Inc, telephone 415 433 1740.
Nutrition and HIV
Good nutrition is key to a healthy lifestyle, regardless of whether one is living with HIV/AIDS. Optimal nutrition can help boost immune function, maximize the effectiveness of antiretroviral therapy, reduce the risk of chronic illnesses such as diabetes and cardiovascular disease, and contribute to a better overall quality of life.
In the early years of the AIDS epidemic, many people with HIV were dealing with wasting and opportunistic infections (OIs) linked to unsafe food or water. While these problems are less common today in developed countries with widespread access to highly active antiretroviral therapy (HAART), many HIV positive people have traded these concerns for worries about body shape changes, elevated blood lipids, and other metabolic complications associated with antiretroviral therapy.
Fortunately, maintaining a healthy diet can help address these problems. As HIV positive people live longer thanks to effective treatment, good nutrition can also help prevent problems (such as bone loss) associated with normal aging. But there is no single, optimal eating regimen appropriate for every person living with HIV/AIDS. Instead, HIV positive people should adopt a sensible balanced diet and consult an experienced nutrition specialist for individualized recommendations.
Food for Life
Food is essential for life, providing the fuel the body needs to function and the building blocks that make up cells, tissues, and organs. The energy provided by food is expressed in terms of calories. The body requires a certain number of calories simply to carry out its basic metabolic functions such as respiration and maintenance of body temperature. Additional calories are needed to support physical activity, fight infection, and rebuild damaged tissues.
If a person does not take in enough calories, fat is broken down to provide fuel. Once the fat is consumed -- or if an individual's metabolism is disrupted due to illness -- lean body mass (muscles and organs) is then used for fuel and raw materials. Conversely, if a person takes in more calories than needed, the extra energy will be stored as fat. The average person needs about 10-20 calories per pound (depending on physical activity level and other factors) to maintain a stable body weight; this requirement is likely to be higher for people with HIV, especially those with advanced disease.
But all food is not equal. While all contain calories, different foods vary widely in the nutrients they provide. A balanced diet is comprised of the following components.
Protein: Protein provides the building blocks of lean body mass. When a protein-rich food is consumed, it is broken down into amino acids, which are reassembled to create enzymes, hormones, and bodily tissues. Most nutrition experts recommend that protein should contribute about 15-20% of the total calories in a person's diet. Good sources include meat, poultry, fish, eggs, dairy products, tofu, nuts, and legumes (e.g., dried beans, lentils).
Carbohydrates: Carbohydrates, which are converted to glucose in the body, are a primary source of energy. Carbohydrates are classified as simple or complex; complex carbohydrates take more time to break down, and thus provide fuel over a longer period of time. Despite the recent popularity of "low carb" diets, most nutrition experts recommend that carbohydrates -- primarily complex ones -- should make up at least 50% of one's total daily calorie intake. Simple carbohydrates are found in processed sugar, honey, fruit and juice, and lactose (milk sugar). Complex carbohydrates are found in grain products such as bread, pasta, and rice; legumes; and starchy foods such as corn, potatoes, winter squash, and root vegetables.
Fats: Fat in food is a source of energy and has a high concentration of calories. Excess energy from any source -- not just fatty food -- is converted to fat in the body and stored for later use. Cholesterol (found in animal products like meat and eggs) and triglycerides are present in food, but are also produced when the body metabolizes sugar and saturated fat. Everyone needs some dietary fat, but getting too little is rarely a problem. More important is the type of fat. Saturated fats promote elevated blood levels of low-density lipoprotein (LDL) "bad" cholesterol, which can clog arteries and increase the risk of cardiovascular disease. Saturated fat is found in meat, butter, tropical oils (e.g., coconut, palm), and "trans" fats or hydrogenated oils (which are chemically altered to make them solid at room temperature). Polyunsaturated fats (found in safflower, sunflower, corn, and soybean oils) are generally considered more healthful, and monounsaturated fats (found in olive and canola oils, nuts, seeds, and avocados) can help raise levels of high-density lipoprotein (HDL) "good" cholesterol, which protects against heart disease. A balanced diet also contains essentially fatty acids, including omega-3 (found in flax and cold-water fish). Most experts say fats should make up no more than 25-30% of total calorie intake, with less than 10% being saturated fat.
Fiber: Also known as "roughage," fiber is indigestible plant matter such as cellulose. Insoluble fiber plays an important role in digestion, helping food move smoothly through the colon (large intestine); this type of fiber is found in the skin and pulp of many fruits and vegetables, whole grains, popcorn, and seeds. Soluble fiber helps stabilize blood sugar and may reduce LDL cholesterol levels; this type of fiber is found in oatmeal and oat bran, legumes, nuts, and fruits such as apples, oranges, pears, and grapes.
Vitamins and minerals: Along with the "macronutrients" described above, a balanced diet also contains many "micronutrients," organic and inorganic substances necessary for proper biological functioning. Water-soluble vitamins (B and C) are excreted in the urine and must be consumed more often; fat-soluble vitamins (A, D, E, and K) are stored in the liver and can reach toxic levels if taken in large doses. Most vitamins must be obtained from food, although the body manufactures vitamin D when the skin is exposed to sunlight and others are produced by bacteria in the gut. Minerals (including the electrolytes chloride, potassium, and sodium) are inorganic substances found in the environment. The body needs several trace elements in tiny amounts, including boron, chromium, cobalt, copper, iodine, manganese, molybdenum, selenium, and zinc. Cooking and processing can destroy some vitamins and minerals. For information on the function and food sources of specific vitamins and minerals, see the chart below.
Antioxidants: Free radicals are unstable oxygen molecules that contain unpaired electrons. This allows them to set off damaging chain reactions when they bind with and "steal" electrons from other molecules in the body -- a process known as oxidative stress. Antioxidants scavenge and neutralize free radicals. By disrupting the oxidation process, antioxidants help protect cells from damage. Antioxidants include vitamins C and E, beta-carotene, the minerals selenium and zinc, and glutathione.
Phytochemicals: Among the advantages of obtaining nutrients from a balanced diet rather than supplements is that there are substances in whole foods that may offer unrecognized benefits. While most vitamins and minerals were isolated early in the 20th century, plant compound called phytochemicals are just now being discovered. Among these are allyl sulfides (found in garlic and onions), anthocyanins (in blueberries and blackberries), carotenoids (including beta-carotene in orange fruits and vegetables, lycopene in tomatoes, and lutein in dark green leafy vegetables), catechins (the tannins in green and black tea), flavonoids (in dark chocolate, red wine, tea, and many fruits), isothiocyanates (in broccoli and other cruciferous vegetables), limonoids (in citrus fruits), and sulforaphane (also in cruciferous vegetables). Some phytochemicals work as antioxidants, but others appear to have different mechanisms of action.
How HIV Impacts Nutrition ... and Vice Versa
In the early years of the epidemic, healthcare providers soon learned that people with AIDS commonly experienced both overt protein/calorie malnutrition and deficiencies of specific nutrients. But nutrient depletion may also begin to occur earlier in the course of HIV disease, even among individuals with relatively intact immune systems. Several factors can contribute to nutritional problems in people with HIV/AIDS.
Malabsorption: HIV or associated infections can damage the lining of the gastrointestinal tract, which can interfere with absorption of nutrients. Some HIV positive people experience specific problems, such as fat malabsorption, which can impair absorption of fat-soluble vitamins.
Opportunistic infections: Various bacterial, viral, fungal, and parasitic infections can interfere with proper nutrition. Malignancies (cancers) and mycobacterial illnesses such as tuberculosis are often characterized by wasting. Several OIs cause vomiting and diarrhea, which can lead to poor absorption or loss of nutrients. Other infections -- such as thrush (oral candidiasis), gingivitis (gum inflammation), and cytomegalovirus esophagitis (throat inflammation) -- can make eating painful.
Medications: Antiretrovirals, OI drugs, and other medications can contribute to nutrient deficiencies and imbalances, either due to direct drug-nutrient interactions or drug side effects. Vomiting and diarrhea can lead to dehydration and depletion of nutrients. Loss of appetite (anorexia), fatigue, and taste alterations can make it difficult to eat enough. Antibiotics may interfere with nutrition by killing off beneficial bacteria in the gut. Food requirements -- the need to take medications either on a full or an empty stomach or with specific types of food -- can disrupt normal eating patterns. Finally, some antiretroviral medications are associated with metabolic changes such as blood lipid and glucose abnormalities.
Inadequate intake: Ill people often experience anorexia. OI symptoms and medication side effects -- nausea, diarrhea, sore mouth or throat, altered sense of taste or smell -- can further reduce the desire or ability to eat. This may be compounded by lack of money, depression, or feeling too fatigued to shop and prepare food.
Altered nutritional requirements: By altering metabolism (how the body processes and uses nutrients), acute or chronic illness -- including HIV disease and OIs -- and the resulting immune response can increase the body's energy needs. People with HIV/AIDS may require more calories, macronutrients, and specific vitamins and minerals. Chronic illness may also alter hormone and cytokine levels, which may have nutritional implications.
Conversely, nutritional deficiencies can impair immune function, potentially worsening HIV disease progression. Research has shown that depletion of vitamins A, C, and E, the B-complex vitamins, and the minerals selenium and zinc can interfere with cell-mediated immunity (CD4 cell, natural killer cell, and neutrophil proliferation and activation), antibody production, and normal cytokine signaling.
Studies looking at the prevalence of nutritional deficiencies in people with HIV/AIDS have produced conflicting data, but on the whole, depletion of nutrients (e.g., vitamins A and E, and minerals including magnesium, selenium, and zinc) appears to be common, especially among individuals with advanced disease. In particular, having HIV seems to decrease the body's store of antioxidants, as they are needed to offset increased oxidative stress. Researchers have uncovered evidence of subtle nutritional deficiencies among people who appear to be eating an adequate diet and are not suffering from frank protein/calorie malnutrition.
Experts don't yet understand the clinical significance -- if any -- of subtle changes in laboratory values relative to the norms seen in the HIV negative population, nor do they know how much of any given nutrient people with HIV/AIDS need for optimal immune function and overall health. Due to a lack of research on nutritional status in the setting of HIV disease, and because nutritional requirements vary dramatically from person to person, there are few definitive recommendations for nutritional supplementation in the HIV positive population.
Waste Not, Want Not
Wasting -- also known as cachexia -- was a prominent feature of AIDS in the early years of the epidemic; even today, AIDS is referred to as "slim disease" in Africa. Experts define wasting as involuntary or unwanted loss of 10% or more of body weight. As Steven Grinspoon, MD, and Kathleen Mulligan, MD, discuss in an April 2003 special issue of Clinical Infectious Diseases (CID) devoted to nutrition and HIV, "wasting ... has been associated with increased mortality, accelerated disease progression, loss of muscle protein mass, and impairment of strength and functional status." Even a 5% loss has been linked to increased illness and death.
In classic HIV-related wasting, lost weight is in the form of lean body mass rather than fat, especially in men. People with HIV/AIDS (and other chronic illnesses) require more calories simply to maintain their weight, due to increased metabolism, higher energy demands, hormone and cytokine imbalances, inefficient absorption and utilization of nutrients, and/or accelerated tissue breakdown (catabolism).
While effective antiretroviral therapy has dramatically reduced the incidence of severe wasting, moderate weight loss is still a prominent feature of HIV disease. For example, as reported in the September 1, 2005 Journal of Acquired Immune Deficiency Syndromes (JAIDS), Alice Tang, MD, from Tufts University Medical School and colleagues found a steady increase in the rate of 5% or greater loss of body weight between 1995-1997 (pre-HAART) and 1998-2003 (HAART era). In an analysis of 713 HIV positive participants in the Nutrition for Healthy Living cohort, 53% lost at least 5% of their body weight during any six-month period. Weight loss was significantly associated with nausea, diarrhea, thrush, poverty, history of drug use, CD4 cell count below 200 cells/mm3, and HIV viral load above 100,000 copies/mL. The authors were unable to pinpoint the reasons for the increased rate of wasting in the HAART era.
In another study (reported in the October 15, 2005 issue of CID), Adriana Campa, PhD, from Florida International University and colleagues found that 17.6% of 119 HIV positive, mostly homeless drugs users in Miami showed evidence of HIV-related wasting. In this study, wasting was associated with cocaine and heavy alcohol use, "food insecurity" (not eating for one or more days in the past month), and higher HIV viral load. Participants taking HAART were more likely to experiencing wasting than those not receiving anti-HIV treatment (86% vs 67%).
Rather than dramatic whole-body weight loss, today many HIV positive people on HAART experience lipoatrophy, or fat loss in the face, limbs, and buttocks. Paradoxically, this may coincide with fat accumulation in other areas of the body (discussed below). Lipoatrophy is most strongly associated with use of nucleoside reverse transcriptase inhibitors (NRTIs), especially d4T (stavudine or Zerit). For this reason, U.S. government treatment guidelines no longer recommend d4T as part of a first-line regimen for people starting HAART.
Since HIV positive people and their clinicians may not recognize the early signs of wasting, it is important to monitor weight regularly to detect subtle changes. Underlying factors contributing to weight loss -- such as OIs or hormone imbalances -- should be promptly addressed. But, as Grinspoon and Mulligan point out, "no therapeutic guidelines currently exist for the management of weight loss and wasting in HIV-infected patients."
When it comes to weight loss, prevention is often easier than cure. To add calories, focus on proteins and complex carbohydrates rather than "junk food" that contains mostly sugar and fat. Consider eating several small meals and snacks throughout the day rather than two or three large meals. Nutritional supplements such as Ensure or Boost may benefit individuals who find it difficult to eat solid foods. Some cities offer food delivery programs for people with HIV/AIDS who are unable to shop or prepare meals (e.g., Project Open Hand in San Francisco, God's Love We Deliver in New York City, Moveable Feast in Baltimore).
The appetite stimulant megestrol acetate (Megace) tends to promote fat rather than muscle gain and can cause side effects including edema (swelling). Certain antidepressants and other medications may also enhance appetite. Some patients swear by medical cannabis or dronabinol (Marinol), a pill that contains a synthetic version of marijuana's active ingredient, THC.
While recombinant human growth hormone (HGH, Serostim) is FDA-approved for the treatment of HIV-related wasting, it is extremely expensive and can cause side effects including carpal tunnel syndrome, joint pain, and insulin resistance. Anabolic (muscle-building) steroids such as testosterone and oxandrolone (Oxandrin) help some patients gain weight, but can also cause adverse effects. Hormone replacement therapy is most useful for individuals who have low levels; there is little evidence that "supraphysiological" doses (higher than the natural physiological range) are beneficial, and they may be harmful (see "HIV and Hormones" in the Summer 2004 issue of BETA). Research has shown that anabolic steroids work better when combined with resistance exercise; in fact, some studies suggest resistance exercise works better than steroids, without the cost or side effects.
Weights and Measurements
Body weight alone is not the best indicator of body composition. Various other metrics can give a better sense of relative proportions of lean body mass and fat. Each method has its pros and cons; ask your healthcare provider which are most appropriate given your individual situation.
Body mass index (BMI): an equation that relates weight to height (weight in kilograms divided by height in meters squared). BMI below 18.5 indicates that a person is underweight; 18.5-24.9 is normal weight; 25.0-29.9 is overweight; and 30.0 or above is obese.
Waist-to-Hip Ratio: waist measurement (at the narrowest point) divided by hip measurement (at the widest point). Weight carried around the waist (an "apple" shape) is associated with greater cardiovascular risk than weight distributed around the hips and thighs (a "pear" shape). A healthy waist-to-hip ratio is below 0.9 for men or 0.8 for women. This measure may not be appropriate for HIV positive individuals with lipodystrophy.
Bioelectrical impedance analysis (BIA): a technique for determining body composition using a mild electrical current that travels more easily through muscle than fat.
Skinfold thickness: a technique that uses calipers to assess the amount of subcutaneous fat under the skin at multiple sites.
Hydrostatic weighing: a technique for assessing body density in which a person's weight measured when dry is compared to his or her underwater weight, accounting for residual air in the lungs and gastrointestinal tract.
Magnetic resonance imaging (MRI): a noninvasive method for viewing soft tissues of the body using a magnetic field.
Dual-energy X-ray absorptiometry (DEXA): an X-ray technique used to measure body composition, including proportion of fat and bone mineral density.
Computerized tomography (CT or CAT scans): a method of visualizing tissues of the body using X-rays.
Too Much of a Good Thing
For many HIV positive people in the developing world today, severe overall wasting due to protein/calorie malnutrition is not a major concern. In fact, some research suggests obesity may be a bigger problem. For example, Valerianna Amorosa, MD, and colleagues from the University of Philadelphia reported in the August 15, 2005 issue of JAIDS that in a cohort of nearly 1,700 HIV positive individuals, 31% of men and 30% of women were overweight, and 11% and 28%, respectively, were obese (in contrast, just 9% overall experienced wasting). Obesity was not associated with age, income, employment status, education, history of injection drug use, HIV treatment, or viral load, but in women it was more common among African-Americans. In Tang's study discussed above, the proportion of patients categorized as overweight was greater in the HAART era than before the advent of effective antiretroviral therapy (35% vs 30%). And HIV positive people are hardly alone: the National Center for Health Statistics reports that two-thirds of all Americans are overweight and nearly one-third of adults are obese -- double the proportion in 1980.
While "garden variety" obesity remains common, HIV positive people on HAART may also experience accumulation of fat in specific areas of the body including the belly, breasts, and back of the neck ("buffalo hump"). This abdominal or truncal lipohypertrophy is composed of deep visceral fat surrounding the internal organs. Both lipoatrophy (described above) and lipohypertrophy are features of lipodystrophy syndrome; however, as discussed in an article by Denise Jacobson, PhD, and colleagues from Tufts in the June 15, 2005 issue of CID, experts now recognize that these are two distinct processes, not simply redistribution of fat from one area to another.
Lipodystrophy syndrome also includes elevated blood lipid levels and blood glucose abnormalities (see "Insulin Resistance and Diabetes" in the Winter 2004 issue of BETA). While most research indicates that lipodystrophy is associated with antiretroviral therapy -- in particular protease inhibitors (PIs) -- it is likely a multifactorial condition related to long-term HIV infection or immune reconstitution, since some people who develop the syndrome have never taken HAART. In a recent study by Peter Bacchetti, PhD, and colleagues, for example, abdominal fat accumulation was not linked to HAART, and was actually more common among HIV negative than HIV positive men (see "News Briefs," in this issue.)
Obesity, and in particular visceral abdominal fat, has been linked to increased risk of cardiovascular disease in the general population. While it is still uncertain whether HIV positive people on HAART have higher rates of heart attacks and strokes (studies have yielded mixed data), it is likely that traditional cardiovascular risk factors -- advancing age, male sex, cigarette smoking, high LDL cholesterol and triglyceride levels, insulin resistance, elevated blood pressure, and being overweight -- are as important for HIV positive people as for anyone else (see "Cardiovascular Disease in People with HIV" in the Summer/Autumn 2002 issue of BETA).
While early nutritional guidelines for people with AIDS often emphasized packing on the calories -- adding cream, cheese, peanut butter, gravy, and the like to foods -- many HIV positive people today would be better served by adopting a balanced, low-fat diet.
Lifestyle changes, including diet modification, weight loss (if needed), exercise, and smoking cessation, are the first line of defense against cardiovascular disease. In order to lose weight, HIV positive people must follow the same rules as everyone else: burn more calories than one takes in. But reducing the amount of fat and cholesterol in the diet is not always enough to reverse fat accumulation or bring blood lipids within a healthy range, and exercise may not have much effect on visceral fat. When this is the case, lipid-lowering medications (including the statin and fibrate classes) are often used. Altering one's antiretroviral regimen to include drugs less linked to high blood fat -- such as substituting atazanavir (Reyataz) for another PI -- is often effective. Researchers have tried treating lipodystrophy with human growth hormone and anabolic steroids, with mixed results. Although it is not yet clear what are the best interventions to address increased cardiovascular risk among HIV positive people on HAART, experts agree that a healthy diet certainly can't hurt, and is likely to be part of the solution.
Healthy Diet Basics
A healthy diet provides adequate nutrition without a lot of empty calories. "Balanced" means eating a variety of foods from all the important food groups, since no food alone provides all the nutrients the body needs. The traditional Food Guide Pyramind offers guidelines about how much to eat from each food group. (The traditional food pyramid was replaced in 2005 with a new pyramid, an online tool at www.MyPyramid.com. Because the new pyramid is more difficult to interpret, however, many nutrition experts continue to use the traditional version.) It recommends 6-11 servings per day of grain products such as bread, cereal, rice, and pasta; 3-5 servings of vegetables; 2-4 servings of fruit; 2-3 servings of dairy products such as milk, yogurt, and cheese; 2-3 servings of high-protein foods such as meat, poultry, fish, eggs, and legumes; and small amounts of fat, oil, and sugar.
This may seem like a lot, but a "serving" is smaller than many people realize. A "serving" as per the guidelines would be, for example, a 3-ounce portion of cooked meat (about the size of a deck of playing cards), one chicken leg, a 2-inch cube of cheese, an 8-ounce glass of milk, a single tortilla or slice of bread, 5-6 crackers, one-third cup of cooked pasta, one-half cup of cooked vegetables, or one medium-size apple or orange. The amount of food typically served in restaurants, therefore, actually accounts for multiple "servings."
The 2005 revision of the food pyramid focuses less on quantity and more on quality, while also emphasizing the importance of physical activity. At least half of one's daily consumption of bread and cereal products should be comprised of whole grains; as a rule, less processed foods contain more nutrients. Simple carbohydrates tend to make blood glucose spike soon after eating and then fall, while complex carbohydrates tend to promote more stable levels over time. But what really matters is a food's "glycemic index," a measure of how quickly it is broken down in the body. Foods with a high glycemic index are broken down rapidly, causing blood sugar to rise sharply, while low glycemic index foods help the body maintain a steadier glucose level.
Eat vegetables of various colors -- including dark green and deep orange -- since these contain different vitamins, minerals, and phytochemicals. Whole fruit is preferable to juice, which is high in sugar and calories and typically lacks fiber. Since cooking can destroy vitamins, it is usually recommended to eat vegetables raw or lightly steamed. However, this may not be the best advice for people with severely compromised immunity who are at risk of infection with microorganisms that can be killed by cooking.
In the dairy group, select low-fat or non-fat products. People who choose not to consume dairy foods should be sure to obtain enough calcium from other sources. In the protein group, the new pyramid recommends eating more legumes, nuts, seeds, and fish -- which contains heart-healthy omega-3 fatty acids. When eating meat or poultry, remove visible fat and skin. Broiling, baking, and grilling are healthier cooking methods than frying.
In terms of fats, avoid animal-derived fats and chemically altered hydrogenated oils, instead substituting plant-derived monounsaturated and polyunsaturated oils. This is good advice even for people who do not need to lose (or could stand to gain) weight, since animal fats increase the risk of cardiovascular disease. Fortunately, thanks to consumer demand, it is easier than ever to find commercial baked goods, snack foods, salad dressings, and the like that do not contain saturated fats. Another boon for the heart: a low-sodium diet can help keep blood pressure under control.
In addition to eating a balanced diet, it is also important to consume enough fluids. Experts traditionally recommend eight 8-ounce glasses of water per day. Herbal tea, broth, and fruit or vegetable juices can also be good fluid sources. But beverages that contain caffeine or alcohol have a diuretic effect, and can cause loss of water due to increased urination. It is especially important to drink enough fluid to prevent dehydration when suffering prolonged vomiting or diarrhea. People with very low CD4 cell counts concerned about infections such as cryptosporidiosis due to contaminated tap water should use filtered or bottled water.
Facts Versus Fads
The traditional dietary guidelines are not free of controversy. Some critics contend that in putting together the recommendations, the federal government has been unduly influenced by the food industry. They argue, for example, that adults really do not need to consume cow's milk at all. Some believe the pyramid recommends more protein than most people need, while others argue that humans evolved to eat a "hunter-gatherer" diet much lower in carbohydrates.
"Low carb" diets (related to the Atkins plan) containing small amounts of carbohydrates and larger amounts of protein and fat have gained considerable popularity in recent years -- so much so that many people have come to believe that carbohydrates per se are "fattening." While such diets may produce temporary weight loss, they are usually short on fiber, can stress the liver and kidneys, and may lead to dangerously elevated blood lipid levels.
More people are also adopting vegetarian or vegan diets, which have been linked to reduced risk of cardiovascular disease and cancer. Most people can obtain adequate nutrition from a diet that contains little or no meat or other animal products, though this may be more challenging for growing children or people with chronic illness who have increased energy needs. The trick is to learn how to combine proteins from different sources (such as grains, legumes, nuts, and soy) to obtain a full complement of essential amino acids; vitamin B12 supplementation may also be needed.
An increasing number of healthcare providers now recommend a "Mediterranean diet" -- including olive oil, tomatoes, garlic, and red wine -- since people from areas that consume such a diet tend to have lower rates of heart disease. A Japanese-style diet that contains lots of fish and soy products is also a healthy option.
Notwithstanding these caveats, the consensus recommendation to eat a range of foods from a variety of categories remains sound. Most experts suggest a breakdown of about 50-60% carbohydrates, 15-20% protein, and no more than 25-30% fat. But because individual nutritional needs vary widely, it is difficult to recommend a specific diet suitable for all people with HIV/AIDS. A trained dietitian who has experience working with HIV positive people can help devise an appropriate individualized eating plan.
Learn how to read the "Nutrition Facts" label, which contains a wealth of information about the nutritional content of packaged foods: www.cfsan.fda.gov/~dms/foodlab.html. What About Supplements? As a rule, it's usually best to obtain nutrients from food. Swallowing handfuls of pills will not make up for a poor diet. But even HIV positive people who eat well can have low levels of various important nutrients -- at a time when their nutritional needs may be increased -- and thus may benefit from supplementation. The U.S. government's Daily Values (formerly known as Recommended Dietary Allowances) for nutrients do not necessarily reflect the amount required for optimal health, just the minimum needed to stave off deficiency symptoms in the average healthy person. It is not yet known whether accepted recommended nutrient levels for the general population are adequate for people with HIV/AIDS.
Dietary supplements are products such as vitamins, minerals, amino acids, herbs, and antioxidants; they are usually taken orally in the form of tablets, capsules, powders, or liquids. Due to the lack of strict quality control and labeling requirements, marketed products can vary widely in contents, strength, and purity. Although regulated by the U.S. Food and Drug Administration (FDA), supplements do not need to undergo rigorous clinical trials of safety and efficacy as required for approval of pharmaceutical drugs. In fact -- because there is little financial incentive to spend money developing products that cannot be patented -- there have been few rigorous, controlled studies on the use of nutritional supplements in people with HIV.
In the mid-1980s, Barbara Abrams, DrPH, and colleagues from the University of California at Berkeley began a large observational study of dietary intake in 296 HIV positive men; results were reported in the August 1993 issue of JAIDS. By one measure, the risk of developing AIDS decreased as consumption of 11 different micronutrients increased -- significantly so for riboflavin, vitamin E, and iron, and approaching significance for thiamin, niacin, and vitamin C. This study was susceptible to selection bias, however, since people who ate healthier diets or took supplements might have had healthier lifestyles overall.
More recently, researchers in Thailand showed that a low-cost multivitamin and mineral supplement improved the survival of HIV positive people who were not taking HAART. As reported in the November 21, 2003 issue of AIDS, Sukhum Jiamton, MD, and colleagues conducted a double-blind, placebo-controlled trial in which nearly 500 HIV positive individuals with CD4 cell counts of 50-550 cells/mm3 were randomly assigned to receive either a placebo or a supplement containing 12 vitamins, eight minerals, and the amino acid cysteine twice daily. After 48 weeks, about twice as many people died in the placebo arm compared with the supplement arm (15 vs 8 deaths); among those with baseline CD4 counts below 200 cells/mm3, the mortality rate was significantly lower in the supplement arm. On the other hand, an earlier study in Zambia found that multivitamin supplementation had no effect on CD4 cell count or mortality.
In the July 1, 2004 New England Journal of Medicine, Wafaie Fawzi, DrPH, from Harvard School of Public Health and colleagues reported on a double-blind, placebo-controlled study in which 1,078 HIV positive pregnant women in Tanzania received either daily supplements of vitamin A; a multivitamin supplement containing vitamins B, C, and E; or both. After a median follow-up of 71 months, 67 out of 271 women (24.7%) who received the multivitamin either died or progressed to advanced HIV disease (stage IV as defined by the World Health Organization), compared with 83 out of 267 women (31.1%) who received the placebo. Women in the multivitamin arm -- but not those receiving vitamin A alone -- also had significantly lower HIV viral load, higher CD4 and CD8 cell counts, and improved birth outcomes.
In a June 10, 2005 AIDS editorial reviewing the current state of knowledge about micronutrient supplementation in people with HIV/AIDS, Tang and colleagues concluded that "a combination of vitamins may afford some benefits to undernourished HIV-infected populations, particularly those with more advanced disease," but conceded that "the role of individual micronutrients ... is less clear." Most healthcare providers agree that HIV positive people can benefit from a daily multivitamin and mineral supplement. (Due to the potential harmful effects of iron, many recommend an iron-free supplement for anyone other than menstruating women and people with iron deficiency). But when it comes to specific nutrients, expert opinion -- and the little relevant research conducted to date -- remains sharply divided.
Higher amounts of various substances have been proposed to improve immune response, ameliorate symptoms and drug side effects, and slow HIV disease progression, on the basis of theoretical understandings about how an agent is expected to behave, laboratory research looking at the effects of a substance in vitro, cross-sectional studies showing specific nutritional deficiencies in a population, or -- less commonly -- controlled trials. Several nutrients that have received the most attention with regard to HIV/AIDS are discussed below.
Vitamin A
Richard Semba, MD, from Johns Hopkins and colleagues reported in 1993 that among a cohort of 179 HIV positive and HIV negative injection drug users in Baltimore, vitamin A deficiency was linked to lower CD4 cell counts and increased risk of mortality. Two years later, he reported that vitamin A deficiency among pregnant HIV positive women in Malawi was associated with increased risk of mother-to-child HIV transmission (32% among deficient women vs 7% among women with normal levels) and higher infant mortality. Similarly, a U.S. study found that vitamin A-deficient women were about five times more likely to transmit HIV to their babies. Some studies have found vitamin A deficiency to be associated with greater vaginal shedding of HIV and higher levels of virus in breast milk -- although Fawzi's study described above actually found a significantly higher rate of mother-to-child transmission via breast-feeding in women given vitamin A supplements.
Several large controlled studies looking at supplementation with vitamin A or beta-carotene (a vitamin A precursor) for HIV positive pregnant women in parts of Africa where frank deficiency is common, however, have failed to detect decreased rates of mother-to-child transmission; results have been mixed concerning reductions in miscarriages, premature births, and infant morbidity and mortality. In Fawzi's Tanzanian study, vitamin A alone did not produce outcomes significantly different from those seen in the placebo arm, and adding vitamin A to the multivitamin seemed to reduce its beneficial effects. Since the benefits are unclear and high doses can cause liver toxicity and other problems, most experts do not recommend vitamin A supplementation -- beyond the amount found in a typical multivitamin pill -- for people with HIV/AIDS.
Vitamin C
In laboratory studies, vitamin C has been shown to inhibit viral replication in vitro; it also plays an important role in tissue repair. Thus, it is not surprising that megadoses of this vitamin have been touted as a cure for everything from the common cold to cancer to HIV/AIDS. Controlled clinical trials comparing vitamin C to placebo for the treatment of colds and flus have yielded mixed results, and the data have been even less promising concerning HIV disease. While vitamin C deficiency does appear to impair various aspects of the immune response, research has not provided evidence that supplementation delays HIV disease progression or improves survival.
Vitamin E
Vitamin E plays a role in metabolism and proper immune function, and laboratory studies suggest it has an antiviral effect. For example, Alonso Heredia, PhD, from the University of Maryland and colleagues reported in the May 20, 2005 issue of AIDS that addition of vitamin E to cell cultures from 10 HIV positive individuals significantly reduced HIV production, as indicated by p24 antigen levels. The authors suggested that supplementation might slow HIV replication enough to inhibit the emergence of drug-resistant virus in resting cells and to delay viral rebound after treatment interruption. But while low (or decreasing) levels of vitamin E have been linked to CD4 cell declines and HIV disease progression, this does not imply causality.
The jury is still out on the benefits and risks of high-dose vitamin E supplementation, but data from recent large studies in the HIV negative population do not look good. In the Women's Health Study (a primary prevention trial that included nearly 40,000 healthy, HIV negative women), subjects randomly assigned to receive 600 IU of vitamin E every other day not only did not have reduced rates of cancer or cardiovascular disease relative to women in the placebo arm, but actually showed a nonsignificant increase in total mortality. Results of a meta-analysis of 19 clinical trials with a total of nearly 136,000 subjects published in the January 4, 2004 Annals of Internal Medicine led authors Edgar Miller, MD, and colleagues to conclude that, "High-dosage [400 IU or more daily] vitamin E supplements may increase all-cause mortality and should be avoided." In the absence of large controlled studies in the HIV positive population, the same advice is sound for people with HIV/AIDS as well.
The trace element selenium -- also known to play a role in proper immune function -- has received considerable attention as a treatment for HIV/AIDS and a variety of other diseases. Some in vitro research indicates that HIV requires selenium in order to replicate. A study of 125 HIV positive injection drug users by Marianna Baum, PhD, and colleagues from the University of Miami (published in 1997) revealed that after adjusting for various factors including CD4 cell count, selenium deficiency was significantly associated with increased mortality. "When all nutrient factors that are associated with survival are considered together," Baum concluded in a later review article, "only selenium deficiency is a significant predictor of mortality." And in a study of 670 HIV positive pregnant women in Tanzania (reported in the June 1, 2005 issue of JAIDS), Roland Kupka, DSc, from Harvard School of Public Health and colleagues found that low plasma selenium levels were associated with increased risk of miscarriage, infant death, and mother-to-child HIV transmission.
But the fact that low selenium levels are linked to worse disease progression does not necessarily mean supplementation will improve matters. HIV nutrition expert Mary Romeyn, MD, has reported anecdotal evidence that selenium supplementation leads to clearance of thrush. On the other hand, while low selenium levels were linked to increased likelihood of cervical dysplasia (precancerous cell changes) among HIV positive women in one study, selenium supplements did not reduce the risk.
And, as reported in the December 15, 2004 issue of JAIDS, Scott McClellend, MD, from the University of Washington and colleagues found that in a study of 400 nonpregnant HIV positive women in Kenya, supplementation with a multivitamin plus selenium led to increased vaginal shedding of HIV, which has implications for sexual and perinatal transmission. Among women who started out with normal selenium levels, those who received supplements were more than twice as likely to shed HIV in their vaginal secretions and had higher vaginal HIV viral loads than women who received a placebo; a similar effect was not seen, however, in selenium-deficient women brought up to normal levels. While supplementation resulted in higher CD4 and CD8 cell counts, the authors concluded that, "The potential benefit of micronutrient supplementation in HIV-1-seropositive women should be considered in relation to the potential for increased infectivity."
Zinc deficiency has been linked to impaired immune function and supplementation has been suggested as a treatment for people with HIV/AIDS, but studies to date have produced conflicting results. While some suggest that zinc enhances the body's ability to fight HIV and improves disease symptoms, others have found it has a detrimental effect. In one study of injection drug users, lower zinc levels were associated with reduced CD4 cell counts, but this does not necessarily mean one caused the other. In an early nutritional survey of nearly 300 HIV positive men followed for seven years, high doses of zinc were associated with faster HIV disease progression. Some researchers have hypothesized that this may be related to the fact that HIV requires zinc-containing structures called "zinc fingers" to produce functional viral progeny.
More recently, Raziya Bobat, MD, and colleagues reported in the November 26, 2005 issue of The Lancet that in a randomized, placebo-controlled trial of 96 HIV positive South African children aged six months to five years, zinc supplementation for six months reduced the incidence of diarrhea and pneumonia, and did not appear to promote viral replication. Given the degree of uncertainty, most experts do not recommend zinc supplementation beyond the amount contained in a multivitamin and mineral pill.
Vitamin C, vitamin E, selenium, and zinc act as antioxidants, helping prevent cell damage caused by highly reactive free radicals (oxidative stress). While free radicals play a role in immune defense against invading pathogens, they can also harm surrounding cells. Research has shown that people with HIV and other chronic infections have higher levels of free radicals, which promote viral replication. Conversely, antioxidants appear to reduce oxidative stress, inhibit HIV activity, and possibly slow HIV disease progression. Antioxidants may also reduce liver fibrosis in people with hepatitis B or C and protect the liver from toxicity as it metabolizes drugs.
The body manufactures certain antioxidants as needed, but this process requires adequate amounts of several nutrients. Studies suggest that a major intracellular antioxidant, glutathione, may help reduce the rate of HIV disease progression. Nutrients that help raise glutathione levels include selenium, alpha-lipoic acid, N-acetyl-cysteine (NAC), acetyl-L-carnitine, L-glutamine, and coenzyme Q10. In one small study, high-dose NAC supplementation led to decreased HIV viral load. There have been several case reports and small studies in which supplementation with antioxidants or precursors including NAC, acetyl-L-carnitine, and coenzyme Q10 seemed to counter lactic acidosis (a sign of mitochondrial toxicity) related to antiretroviral therapy. What's more, Andrew Hart, MD, and colleagues from the Royal Free and University College Medical School reported in the July 23, 2004 issue of AIDS that acetyl-L-carnitine supplements helped reverse nerve damage and alleviated the pain of peripheral neuropathy associated with certain NRTI drugs.
But antioxidant supplements may also have deleterious effects. In a small pilot study by Grace McComsey, MD, and colleagues from Case Western Reserve University (reported in the August 15, 2003 issue of JAIDS), while supplementation with vitamin C, vitamin E, and NAC slightly reduced elevated LDL cholesterol levels and abdominal fat accumulation in 10 subjects with HIV-related lipodystrophy, the antioxidants also raised blood glucose levels and worsened insulin resistance. "We should never assume that high doses of vitamins are safe," the authors cautioned. "They are not safe until clinical studies prove them to be safe."
Omega-3 Fatty Acids
Omega-3 fatty acids, found in cold-water fish such as salmon and herring, have been associated with reduced cardiovascular disease risk in the general population; one study of more than 4,700 adults over age 65 showed that eating fish 3-4 times per week was associated with a 30% reduction in congestive heart failure. In the November 15 issue of CID, David Wohl, MD, from the University of North Carolina at Chapel Hill and colleagues reported that omega-3 may also help address one cardiovascular risk factor in people with HIV/AIDS. In this open-label study, 52 HIV positive individuals on HAART with fasting triglyceride levels above 200 mg/dL were randomly assigned to receive either omega-3 fish oil supplements (eicosapentaenoic acid and docosahexaemoic acid) plus nutritional counseling or else nutritional counseling alone. After 16 weeks, subjects receiving fish oil supplements experienced a 19.5% reduction in fasting triglyceride levels, compared with a 5.7% decrease in the counseling-only arm (though seemingly substantial, this difference was not statistically significant). However, LDL cholesterol levels increased by 22.4% in the fish oil arm, while remaining stable in the counseling-only arm; HDL levels did not change in either group. The authors acknowledged that "whether this increase [in LDL] attenuates any benefit in lowering triglyceride levels is unclear."
Special Supplements
Various functional supplements have been developed to augment levels of particular compounds thought to have specific beneficial effects. For example, two small studies presented at the 7th International Workshop on Adverse Drug Reactions and Lipodystrophy in HIV in November 2005 showed that a supplement called NucleomaxX -- a sugar cane extract containing the nucleoside uridine -- helped reverse lipoatrophy in individuals taking NRTIs. Jussi Sutinen, MD, and colleagues from Finland reported than in a study of 20 patients taking d4T or AZT (zidovudine, Retrovir), those taking NucleomaxX three times daily for 10 days gained significantly more arm and leg fat (about 900 grams) than subjects taking placebo; the NucleomaxX group also gained visceral abdominal fat. Likewise, McComsey reported that both patients and their physicians reported significant improvement in lipoatrophy in a study of 14 subjects taking d4T who received NucleomaxX three times daily every other day for 16 weeks. (An open-label Phase II study of NucleomaxX for lipoatrophy is currently enrolling; see "Open Clinical Trials," in this issue).
Good Nutrition is Not a Cure for HIV
While supplementing a range of micronutrients may contribute to improved health, this is not to suggest that nutritional supplements alone can take the place of HAART. A few years ago, South African Health Minister Manto Tshabalala-Msimang raised a furor when she suggested that people with HIV/AIDS should consume garlic, lemon, and olive oil, while her government was resisting efforts to expand access to antiretroviral therapy. This past May, UNAIDS director Peter Piot, MD, blasted vitamin entrepreneur Matthias Rath, who placed ads in South African newspapers promoting vitamins as a treatment for AIDS, claiming that antiretroviral drugs are toxic and cause birth defects. "Vitamins are no cure or treatment for AIDS," stated Piot, "and anybody who claims the contrary is a charlatan."
Nevertheless, according to World Health Organization Director-General Jong-Wook Lee, greater attention must be paid to the nutritional needs of people with HIV/AIDS in the developing world. "We do know that sound nutrition helps maintain the immune system, increases body weight, and boosts energy levels," he said at an April conference in Durban. "Most of the 30 million HIV-infected people in Africa don't even have secure access to the basic nutrients any human being needs to live a healthy life."
More Is Not Always Better
With all this conflicting data, it can be difficult for HIV positive people to make informed decisions about supplements. The bottom line, according to Judith Nerad, Mary Romeyn, and colleagues in the April 2003 CID special issue: "[T]here is little documentation in the literature that supplementation beyond what is recommended has had any impact on clinical outcome." But, "[i]f a patient's vitamin or mineral status is deficient, supplementation is clearly necessary."
People with HIV/AIDS commonly have subtle nutritional deficiencies, and research to date has shown that daily multivitamin use is safe and at least potentially beneficial in this population. Different experts have suggested various supplementation regimens. For example, Romeyn -- in her book Nutrition and HIV: A New Model for Treatment -- suggests a basic regimen that includes:
a multivitamin, without extra iron, twice daily; a trace element supplement once daily; an antioxidant supplement once daily. Others, such as nutritionist Margaret Davis, RD, recommend only the multivitamin, plus increased consumption of fruits and vegetables.
As previously noted, nutritional needs vary widely from person to person, and there is no one diet or supplement regimen appropriate for all people with HIV/AIDS. Further, the presence of a nutrient deficiency does not necessarily mean supplementation is the solution, since poor absorption, underlying infections, metabolic changes, or hormone imbalances could be contributing to the problem.
When using supplements, do not take more than the recommended dose on the label unless advised to do so by a knowledgeable healthcare provider. As some of the studies discussed above illustrate, more is not necessarily better. A recent case underscores this warning. As reported in the September 2005 International Journal of STD and AIDS, an HIV positive man in London developed severe liver inflammation with skyrocketing ALT levels after taking more than a dozen dietary supplements, many at high doses -- as much as 67 times the recommended daily value; fortunately, once he stopped taking the supplements, his liver function returned to normal.
Certain vitamins and minerals (including the fat-soluble vitamins A, D, and E) can be toxic at high doses, and they may cause deleterious effects even at lower doses beyond what is provided in a typical multivitamin pill. Remember that "natural" does not necessarily mean "safe." Beware of any supplement touted as a "cure" for a range of ailments -- if something sounds too good to be true, it probably is. Verify that health claims are supported by reliable research. Some supplements may not be harmful, but simply a waste of money. Seek medical advice before starting a new supplement or beginning any unusual diet. Tell healthcare providers about any use of supplements (as well as over-the-counter medications, recreational drugs, and herbal remedies), since these can potentially interact with antiretroviral drugs.
Eat Right for Life
Nutritional management should be a regular part of HIV/AIDS care. Even if an HIV positive person has no obvious nutritional problems such as wasting, a healthy diet can still help stave off illness and improve quality of life. But, as Tang and colleagues noted in their review, dealing with nutritional issues "may not be part of the traditional care or thought process of the HIV care provider." A registered dietitian (RD) who has experience working with people with HIV/AIDS can be an invaluable resource.
The American Dietetic Association recommends a baseline nutritional and body composition assessment soon after HIV diagnosis. Follow-up assessments should be conducted at least once annually for asymptomatic individuals with well-controlled HIV disease, and every few months for patients with AIDS or known nutritional problems. Tasmin Knox, MD, from Tufts recommends anthropometric measurements of body composition (see "Weights and Measurements" above for an explanation of various methods); laboratory tests of protein and micronutrient levels in the blood; tests of metabolic parameters such as blood lipids, blood glucose, and liver enzymes; and clinical assessment of eating patterns, supplement use, functional status, physical symptoms, and psychological or socioeconomic issues that may impede adequate nutrient intake. Some experts recommend that people keep a daily diary of everything they eat, along with any dietary problems they encounter.
Once such an assessment is complete, promptly address any underlying problems -- such as infections, hormone imbalances, or metabolic disorders -- that may be interfering with proper nutrition. The next step is to develop an appropriate, individualized nutrition plan. Seniors, growing children, pregnant or breast-feeding women, and people with active OIs are among the many groups that have special nutritional needs. While supplements can offer important benefits, they do not replace a well-balanced diet. When it comes to good nutrition, there is no "quick fix." It's better to develop long-term healthy eating habits, such as cutting back on saturated fat and consuming more fruits, vegetables, and whole grains. But set realistic goals: it's fine to splurge occasionally if one normally adheres to a healthy diet. Fortunately, small changes in eating habits can often make a big difference in terms of health.
Since many people with HIV/AIDS use dietary supplements in addition to HAART, it's crucial to learn more about how nutritional supplementation impacts HIV disease and vice versa. According to Tang and colleagues, areas ripe for further research include the role of micronutrient supplementation in people with well-controlled HIV disease, whether micronutrients can enhance CD4 cell responses, the role of antioxidants in countering increased oxidative stress due to HIV infection or its treatment, whether micronutrient supplementation can help reduce morbidity associated with coinfections such as hepatitis B or C, the role supplements might play in addressing metabolic manifestation such as lipodystrophy and bone loss, and the appropriate doses of supplements for HIV positive people at various stages of disease.
"Attempts to improve dietary quality and micronutrient status may play an overall role in maximizing health for the HIV-infected individual, particularly in undernourished populations," Tang and colleagues concluded, "and may also play a role in the more subtle management of HIV infection in the future."
American Dietetic Association An organization of food and nutrition professionals.
Association of Nutrition Services Agencies An organization promoting nutrition education, advocacy, and community-based nutrition support programs for people with HIV/AIDS.
FoodSafety.gov Food safety information from the U.S. government.
Health Resources and Services Administration, AIDS Education & Training Centers Health Care and HIV: Nutritional Guide for Providers and Clients. June 2002. (Also available in Spanish.)
Clinical Infectious Diseases Special Issue: Integrating Nutrition Therapy Into Medical Management of Human Immunodeficiency Virus. Volume 36, Supplement 2, April 2003. (Full text available free.)
Fields-Gardner, Cade, and others (editors) A Clinician's Guide To Nutrition In HIV and AIDS. American Dietetic Association, 1997.
Romeyn, Mary Nutri


text:
Personalized, one-on-one instruction is the secret to improved skills and increased confidence. CoachUp now makes private volleyball coaching affordable and convenient for athletes of all ages and skill levels.
*Volleyball Coach - PRO Level - Ex professional Volleyball player *Personal - Fitness Trainer *Strength and Conditioning Coach *Corrective Gymnastics Coach *Nutrition Advisor
18.9 Miles away from Inwood, WV
Join CoachUp today to provide athletes with personalized coaching!
With CoachUp you'll get:

subset: commoncrawl


text: Size matters. Even with koi. Are small ones strong enough? Or are the large ones lower maintenance? Is the immune system sufficiently developed in the small ones? Well, both have advantages and disadvantages! In any event it is clear that younger animals sometimes have a less stable immune system and are therefore more vulnerable to disease. It is also more difficult to treat them and the diagnosis is more complicated. The larger animals can have greater problem in adapting to a new environment and may fall more often ill as a result of this. Their period of acclimatisation is much longer than with the small ones!


text:
These large photo prints use state-of-the-art NASA instruments to capture high resolution satellite imagery of Rice Terrace as seen from orbit. If you'll let us get geeky, each satellite picture of earth is captured with 30-cm multi-spectral imagery which means that you are getting a high quality photo print of a view you've likely never seen before.
A professional designer has reviewed this Rice Terrace earth photography print to ensure the highest level of detail and to bring out the natural variety of colour found in this location. Top that off with museum-grade paper and archival, acid-free ink and you can be sure that you'll love having this modern art print hung in your home or office for years to come.
Our selection of hundreds of man-made and natural patterns are perfect for adding some spectacular color and wonder to your walls, so go ahead and treat yourself or give someone a gift of this fine art photography to showcase the stunning beauty of planet Earth.
Paper options for this Rice Terrace Earth Photography - Art Print:
Photographer's Grade Metallic Paper:250 gsm cotton rag, museum quality, archival inks.
Using a new method for cyan dispersion, our metallic paper offers a wider color range. Darks appear deeper and lights more luminous.
Pearlized Luster Paper:180 gsm paper, vibrant color contrast, pearlized semi-gloss finish, archival inks
Our classic paper finish is perfect for framing and offers a smooth and luminous finish with a high color contrast.
Each Rice Terrace Earth Photography - Art Print is made to order and printed just for you! We do this both to help the environment by producing only what we need and to ensure that you receive a brand new, high-quality art print.
We aim to ship orders within 2-3 business days. Please allow an extra day for processing if ordering within two days of a holiday. We ship all orders via standard ground shipping. If you require quicker shipping, please email us and we'll happily arrange that for you.
Shipping is free on all art prints shipping to the United States, Canada and the United Kingdom.
Flat $15 shipping to rest of world.
Delivery times:
US, UK and Canada: 2-5 business days / Rest of world: 10-21 business days
All of our art prints are insured and guaranteed. This means that any order lost, damaged or incorrectly printed will be replaced no questions asked.
Want to take the hassle out of your Rice Terrace Earth Photography - Art Print? Let us frame your prints for you. Upgrade your order to include include our solid wood, black semi gloss frames. Our 12x18" art prints are framed with a 2" border and the frame is 1.25" wide. Our 18x24" and 24x36" art prints are framed with a 3" white border and a 2" wide frame. All three sizes are 1 3/4" deep.
All framed prints include a wire to make hanging a breeze
Framing at this time is sold as a custom order. Please email us at firstname.lastname@example.com with your print size, paper type and shipping address and we'll help you frame your order.
Looking to truly transform your decor? Do it with a custom wallpaper. Ask us for a quote to create a custom wall mural out of our Rice Terrace Earth Photography - Art Print in any color combination. We offer two types of wallpaper to fit your next decorating project's needs. If you need to remove the mural at a later date and leave the original wall residue-free, then our peel-and-stick vinyl is the best option for you. If you are looking for a more permanent mural or will be adding your mural to a commercial or high-traffic area, then we recommend our Permanent Suede option.
Fill our our wallpaper form with your project details and we'll get back to you shortly with a quote.
We offer free shipping on all wall mural orders within North America.
We've been designing art and home decor since 2014. We are the original creators of the City Map Print and have hundreds of cities over the years. We continue to create art inspired by everyday-data that tells the story of your every day.About US
We're all about patterns and highlighting the natural beauty of things that surround us everyday. From the natural patterns of a city's street grid to the colourful rings of a geode rock, we're turning these natural wonders into inspirational art for your home.
Striking images of the Earth's most beautiful landmarks, cities and natural wonders as seen from a state-of-the-art set of satellites. We've captured over 300 places so far.
Capturing the landscapes and buildings of some of our favourite cities using GIS and topographic data, you'll see 3-dimensional representations so detailed you'll feel like you're flying above the city.
Contact our support team using the form and we'll get back to you shortly.
In the meantime, visit our FAQ Page for more information.


text:
You all know that Shah Rukh Khan is now keen to make his "Temptation Reloaded" tour a big hit, after Bachchan camp's "Unforgettable tour" receiving mixed response. So far, it has been ensured that Priyanka Chopra, Arjun Rrampal, Rani Mukherjee and some other undisclosed stars would join Shah Rukh Khan's world tour. King Khan is looking to add more names in the tour and create a big splash around it.
Now, Bollywood's rumor mill keeps churning out rumors suggesting that Shah Rukh Khan has invited Aamir Khan to join the tour. However, Aamir Khan dismissed rumors that he would join Shah Rukh Khan's tour. Known as Mr. Perfectionist, Aamir Khan also denied that he would act in Raj Kumar Santoshi's hit Andaz Apna.
Seeing two Khans together might ensure a big hit as both Khans have a huge fan following. However, Shah Rukh Khan's association with Aamir Khan in a project is less likely to happen as of now.
Related article:khabrein


text:
Wolffe, John
|Google Scholar:
|Look up in Google Scholar
About the book:
This book provides a new and important expansion of the first four volumes. It contains both specially written essays and a related compilation of primary sources drawn from the writings of the day. It explores the wider context of religion in Victorian Britain, in relation to its social and cultural environment at home, and in relation to the development of the Empire and its consequences. The introduction provides an overview of scholarship on Victorian religion in the years since the first four volumes were published in 1988, and subsequent essays examine relationships between religion and gender, trace the development of hymns and church music, and survey the history of Christian overseas missions in the Victorian era. The book also includes two innovative biographical studies, of Bishop John William Colenso and of Friedrich Max Muller, which serve to illustrate wider themes. In the final chapter is a pioneering study of the presence of Islam in Victorian Britain.
|Item Type:
|Book Section
|Copyright Holders:
|1997 The Open University (selection and editorial material)
|0-7190-5184-3, 978-0-7190-5184-5
|Extra Information:
|Published in association with The Open University. Course reader for Open University course AA313 Religion in Victorian Britain (1995-2004).
|Victorian Britain; church history; religion; religious life and customs
|Academic Unit/School:
|Faculty of Arts and Social Sciences (FASS) > Social Sciences and Global Studies > Religious Studies
Faculty of Arts and Social Sciences (FASS) > Social Sciences and Global Studies
Faculty of Arts and Social Sciences (FASS)
|Item ID:
|Depositing User:
|Jean Fone
|Date Deposited:
|29 Jul 2010 14:08
|Last Modified:
|06 Aug 2019 08:33
|Share this page:


text:
When Scott Thompson left Visa to take the CTO role at PayPal in 2005, the Web company's data centre surprised him. "Wait a minute," he recalls saying, "they run a payment system on Linux?"
"I was pretty familiar with payment systems and global trading systems, but I just scratched my head when I came here," Thompson says. With his history of working on IBM mainframes and large Sun Solaris systems, the PayPal approach to computing seemed alien, especially for a company whose core mission was dealing with money.
PayPal runs thousands of Linux-based, single-rack-unit servers, which host the company's Web-presentation layer, middleware and user interface. Thompson says he quickly saw the economic, operational and development advantages of open source and Linux technology. He now sees no other way to do it.
"When you're buying lots of Big Iron, as I did in other places I've worked, your upgrade path is US$2 million, US$3 million at a clip. You just had to buy big chunks of stuff to scale," he says. "Here at PayPal, our upgrade path is 10 US$1,000 no-name servers, slapped into the midtier of the platform. And we just keep scaling it that way. It's unbelievably cost effective."
This model also leads to a highly reliable site, says Matthew Mengerink, vice president of core technologies for PayPal, who helped build this architecture from scratch.
"Rather than have a monolithic box, or an impenetrable fortress that never breaks, we just have so many [nodes] that the breakages are irrelevant," Mengerink says. Using a proprietary operating system to build out a system with a thousand points of failure would not be an option, he says. "This distributed, highly redundant system we have is predicated on the cost model of Linux and Intel," he adds.
The distributed model also lets the company make massive shifts and resource allocation when needed. The generic Linux Lego-block-style servers that make up the company's Web tier can be easily shifted around for a variety of tasks.
For example, every day at 1 a.m. PST, PayPal runs its batch processing for reconciling payments. Thompson says this kind of work, typically done on mainframes or large symmetric multiprocessing boxes in other payment organizations, is spread across the middle-tier Linux servers in the data centre.
"We don't bring the site down" he says. "We just allocate a higher portion of the [servers] to running batch processes, and we crunch through all that data in three hours every night."
On the back end, these thousands of systems communicate with just a few large Sun Solaris boxes, which run an Oracle database that stores all customer data. A custom-made database connection-management system links Web processes from the Linux-based Web and middleware tiers of the PayPal site to the Sun/Oracle back end.
"The speed with which the processes come and go is blindingly fast," Mengerink says. "So there is a tier that buffers between those Web and database layers. As far as the application is concerned, it just thinks it is making calls out to a database. The application just doesn't care there is this middle layer. Then the database on its side sees a nice, old-fashioned durable connection, and doesn't feel like it's being melted down by a connection storm."
Interested in Open Source? Read how Open Source VoIP is slowly making gains in enterprise adoption; or if Open Source is the answer to ERP.
Join the CIO Australia group on LinkedIn. The group is open to CIOs, IT Directors, COOs, CTOs and senior IT managers.


text:
Stereoboard.com is a Ticket Comparison Service. Prices are set by sellers/promoters & may be above, below or at face value
Hilltop Hoods at Montreal Le Belmont
Hilltop Hoods are an Australian hip-hop group hailing from Adelaide. Formed in 1991 and currently consisting of rappers Suffa and MC Pressure alongside DJ Debris, theyre one of the countrys most popular hip-hop outfits.
Hilltop Hoods will be performing 1 event in Montreal on Wednesday 4th December 2019 at the Le Belmont.
Scroll down to see all ticket options and prices. If you'd like to see a list of Hilltop Hoods events, please CLICK HERE.
Set Your Currency / Country
Stereoboard is a Ticket Comparison Service. Tickets on resale sites are set by sellers and may be above, or below, the original prices set by event organisers - otherwise known as Face Value.
Prices shown do not include any fees or delivery charges, unless stated.
We display the most accurate ticket prices available to us, but Hilltop Hoods ticket prices can change based on demand & availability. Stereoboard takes no responsibility for any difference in prices, or accuracy, displayed here and those on external sites. Our listings are purely for information purposes only and we are unable to verify any accuracy.
Venue Information - Montreal Le Belmont
Sorry, no venue information currently available
Upcoming Events At Montreal Le Belmont
Hilltop Hoods


text:
Diluted Earnings per Share from Continuing Operations of $0.16,
Including Impairment, Pension-related and Restructuring Charges of $1.16
per share On Record Fourth Quarter Sales of $1.54 Billion
Fourth Quarter Highlights
GLENVIEW, Ill.--(BUSINESS WIRE)--Jan. 29, 2013--
Anixter International Inc. (NYSE: AXE) today reported record sales of
$1.54 billion for the quarter ended December 28, 2012, a 3.0 percent
increase compared to the year ago quarter. Organic sales growth, which
excludes the impact of the following items, was flat year-over-year:
Operating income of $38.6 million included pre-tax charges of $46.7
million attributable to:
After adjusting for the charges, operating income was $85.3 million
compared to $91.6 million in the prior year period. Adjusted operating
margin was 5.5 percent compared to 6.1 percent in the prior year period,
driven primarily by a decrease in gross margin.
Adjusted net income from continuing operations was $43.5 million
excluding the impairment, pension-related and restructuring charges of
$38.3 million, net of tax. Adjusted net income was $47.8 million in the
prior year quarter excluding a net tax benefit of $2.0 million.
Adjusted earnings from continuing operations was $1.32 per diluted share
compared to an adjusted $1.43 per diluted share in the year ago quarter.
The current quarter excluded the previously mentioned charges totaling
$1.16 per diluted share while the prior year quarter excluded the
previously mentioned tax benefit equating to $0.06 per diluted share.
The $0.11 year-over-year decline in adjusted earnings per diluted share
was primarily a result of the challenging global economy.
"In light of uneven global growth, we were pleased to achieve record
fourth quarter and full year sales. This strong performance was driven
by record sales in several areas of the business including Security
Solutions, which continued to grow at a double digit rate to exceed $1
billion of sales for the year. Our ongoing focus on cost and balance
sheet management enabled us to deliver solid operating performance and
cash flow," commented President and CEO, Bob Eck. "We continue to have a
strong financial position, with a business model that generates
substantial cash in periods of slower revenue growth, as highlighted by
the current quarter and fiscal year."
Income Statement Detail
Gross margin was 22.2 percent compared to 23.3 percent in the year ago
quarter, primarily caused by a product mix shift within our Electrical
and Electronic Wire and Cable and Enterprise Cabling and Security
Solutions segments. Strong cost management resulted in flat operating
expense year-over-year and a 50 basis point improvement in operating
expense as a percent of sales, excluding the above mentioned charges.
Interest expense in the current quarter of $16.2 million increased by
$4.2 million compared to the prior year quarter as a result of the $4.8
million of incremental expense associated with the second quarter of
2012 bond offering.
Excluding the impact of the impairment, pension-related and
restructuring charges, the tax rate in the current quarter was 35.5
percent. In the first quarter of 2012, the Company recorded a benefit of
$9.7 million related to the reversal of valuation allowances, and
interest and penalties of $1.7 million related to the prior year. In the
third quarter of 2012, the Company recorded an impairment charge and an
inventory adjustment which reduced operating income by $28.4 million, or
$27.4 million net of tax. Excluding all of these charges the full year
tax rate was 36.5 percent. The full year results for the prior year
included net tax benefits of $10.8 million primarily related to the
reversal of deferred income tax valuation allowances, $2.0 million of
which was recorded in the fourth quarter. Excluding this benefit, the
adjusted tax rate in the prior year fourth quarter and full year was
38.0 percent and 37.4 percent, respectively.
Segment Update
In December of 2012, the Company announced a change in reportable
segments without revising or restating historical financial statements
for any period. The new segments are Enterprise Cabling and Security
Solutions, Electrical and Electronic Wire and Cable and OEM Supply.
Enterprise Cabling and Security Solutions ("ECS") sales of $800.0
million declined 1 percent from the prior year period, impacted by the
continuation of the trends we experienced throughout 2012 with companies
delaying commitments to data center investments. Partially offsetting
the decline was a 12 percent increase in security sales, which accounted
for approximately 28 percent of segment sales. Adjusted operating income
was $44.3 million, excluding $12.3 million of pension-related and
restructuring charges, compared to $48.7 million in the year ago
quarter. Adjusted operating margin was 5.5 percent compared to 5.6
percent in the previous quarter and 6.0 percent in the year ago quarter.
Persistent weakness in the European economy and a product mix shift as
security becomes an increasing part of the overall sales mix were the
primary drivers of the margin decline versus the previous periods.
Electrical and Electronic Wire and Cable ("W&C") achieved record
fourth quarter sales of $544.1 million, up 18 percent from the prior
year period, reflecting the acquisition of Jorvex and the continued
strength in our natural resource extraction and power generation
businesses. The strength was geographically broad-based, including
record fourth quarter sales in resource rich regions such as Canada,
Latin America and the Middle East. Adjusted operating income was $43.7
million, excluding $8.5 million of pension-related and restructuring
charges, compared to $39.4 million in the year ago quarter. Adjusted
operating margin was 8.0 percent compared to 8.5 percent in the previous
quarter and 8.6 percent in the year ago quarter. The change in margin
was largely a result of a mix shift from OEM to Industrial products in
North America, and an increase in lower margin project activity outside
of the US.
OEM Supply ("OEM") sales of $200.3 million declined by 12.4
percent from the prior year quarter driven by a year-over-year decline
in heavy truck production levels in North America along with weaker
manufacturing production levels in the European region. Adjusted
operating loss was $2.7 million, excluding $25.9 million of impairment,
pension-related and restructuring charges, compared to an operating
profit of $3.5 million in the year ago quarter. Adjusted operating
margin was negative 1.4 percent compared to 0.2 percent in the previous
quarter and 1.5 percent in the year ago quarter.
Discussion of Impairment, Pension-related and
Restructuring Charges
In connection with the previously announced change in reportable
segments and in accordance with accounting guidance, the Company was
required to reassign the carrying amount of goodwill to its new
reporting units in the fourth quarter of 2012. This interim assessment
of the recoverability of goodwill and the recoverability of the
Company's long lived assets assigned to the reporting units concluded
that the estimated fair value of the OEM Supply business was lower than
the carrying value of the net assets. This result is primarily due to
the poor global economic conditions that have disproportionately
impacted this segment of our business, resulting in impairment charges
of $21.3 million in the fourth quarter of 2012.
In the fourth quarter of 2012, the Company took two actions related to
its U.S. defined benefit pension plan that will reduce future expenses
and contributions. First, the Company offered a one-time lump sum
payment option to terminated vested participants that resulted in an
additional $34 million pension fund contribution by the Company to fund
these payouts as well as a settlement charge of $15.3 million. These
contributions were made using excess cash from operations, positively
influencing the funded status of the plan. Second, the Company made
changes to its existing U.S. defined benefit plan which are effective
beginning December 31, 2013, that freeze benefits provided to employees
hired on or before June 1, 2004. This change is similar to the change
made in 2004 for any new employees.
Finally, recognizing the ongoing weak global economic conditions, the
Company took further aggressive actions to reduce its cost structure
across all segments and geographies, resulting in a $10.1 million charge
in the fourth quarter of 2012. Most of the costs were severance-related
expenses associated with a reduction in over 200 positions.
The combination of the amendment to the pension plan and the
restructuring actions will drive approximately $20 million in annual
cost savings beginning immediately.
Cash Flow and Leverage
Cash flow generated from operations was $16 million compared to $113
million in the year ago quarter. The lower cash generation in the
quarter was primarily due to a lower rate of working capital improvement
achieved in the current quarter compared to the prior year quarter as
well as the $34 million of additional pension plan contribution. Full
year cash flow was $142 million; however, excluding the additional
pension plan contribution, full year cash flow would have been $176
million, compared to $144 million in the prior year.
"Our disciplined working capital and cash management processes give us
the flexibility needed to manage through an uncertain economic
environment. With a year-end cash balance of $89 million and an
expectation of continuing positive cash flow, we constantly evaluate the
optimal use of our funds," commented Ted Dosch, Executive Vice-President
and CFO. "Going forward, we will utilize future cash flows to invest in
the growth of the business, capitalize on strategic acquisition
opportunities, deleverage our balance sheet, and selectively return
capital to shareholders through share repurchases and special dividends,
as we did in 2012 with our 1 million share repurchase and $4.50 per
share special dividend."
Key capital structure and credit-related statistics for the fourth
Business Outlook
"Our outlook for 2013 includes low to mid-single digit organic sales
growth, which we believe will be weighted to the back half of the year.
While global markets are difficult to predict, we took aggressive
measures in 2012 that position us to continue to expand our leadership
position within each of our segments, further leveraging our global
supply chain platform to better serve our customers," stated Eck. "With
ongoing pressure on companies to reduce costs, our business model, which
is based on helping our customers lower their supply chain costs and
reduce execution risk, is of even greater value. We believe we are well
positioned financially, operationally and strategically to capitalize on
our opportunities."
Financial Results from Continuing
(In millions, except per share amounts)
Fourth Quarter Earnings Call
Anixter will host a conference call to discuss these results beginning
at 9:30 am central time today, Tuesday, January 29, 2013. The call will
be simulcast through Anixter's investor relations website at www.anixter.com/investor.
Additionally, the call may be accessed with the toll-free dial-in number
1 (888) 417-8465 or international toll free number 1 (719) 325-2452.
Please use the pass code 4949555. A supplemental presentation titled
"Fourth Quarter 2012 Highlights and Operating Review" will be posted to
the Company's investor relations website.
A replay of the conference call will be archived on the website and will
also be available for 14 days, beginning at 12:30 pm central time on
January 29, by dialing 888-203-1112 within the U.S. and Canada, or
719-457-0820 outside the U.S. and Canada. Please use the replay code
About Anixter
Anixter International is a leading global distributor of enterprise
cabling and security solutions, electrical and electronic wire & cable,
OEM supply fasteners and other small parts. The Company adds value to
the distribution process by providing its customers access to 1)
innovative inventory management programs, 2) more than 450,000 products
and over $1 billion in inventory, 3) approximately 220 warehouses with 7
million square feet of space, and 4) locations in over 250 cities in
more than 50 countries. Founded in 1957 and headquartered near Chicago,
Anixter trades on the New York Stock Exchange under the symbol AXE.
Safe Harbor Statement
The statements in this news release that use such words as "believe,"
"expect," "intend," "anticipate," "contemplate," "estimate," "plan,"
"project," "should," "may," "will," or similar expressions are
forward-looking statements. They are subject to a number of
factors that could cause the company's actual results to differ
materially from what is indicated here. These factors include
general economic conditions, the level of customer demand particularly
for capital projects in the markets we serve, changes in supplier
sales strategies or financial viability, risks associated with the sale
of nonconforming products and services, political, economic or currency
risks related to foreign operations, inventory obsolescence, copper
price fluctuations, customer viability, risks associated with accounts
receivable, the impact of regulation and regulatory, investigative and
legal proceedings and legal compliance risks, and risks associated with
integration of acquired companies. These uncertainties may cause
our actual results to be materially different than those expressed in
any forward looking statements. We do not undertake to update any
forward looking statements. Please see the company's Securities
and Exchange Commission filings for more information.
Additional information about Anixter is available at anixter.com
Source: Anixter International Inc.
Anixter International Inc.INVESTOR CONTACTSTed DoschEVP
– Finance & Chief Financial Officer(224) 521-4281orLisa
Micou Meers, CFAVP – Investor Relations(224) 521-8895
2301 Patriot Blvd
Glenview, IL 60026
Kevin Burns
SVP Investor Relations & Treasurer
Send Email
Anixter Inc. 2301 Patriot Boulevard, Glenview, Illinois 60026, USA


text: I'm a knitter and would love to order a Swift, but I realized that the thing holding me back is that it doesn't have a shoulder strap. The handles are fine, but I really like to sling my bags over my shoulder (and for some of us on the larger size, there is the question of, will the handles really fit over clothing and perhaps a coat as well). Is there a way a shoulder strap could be clipped onto the Swift as is, or is there a way to customize it so one could be added?


text:
Colorado police looking for a 10-year-old girl who disappeared on her walk to school have found a body in a park, but are not saying whether it is linked to the case and noted Thursday that officers are still searching for her.
The discovery of the body is the latest turn in the disappearance of Jessica Ridgeway that has seen police look for clues in a reported sighting in a car with Colorado plates in Maine and a Wyoming abduction. The FBI said Thursday that abduction was unrelated.
At a pre-dawn news conference, police refused to release any details about the body found late Wednesday at a park in the suburban Denver city of Arvada, about seven miles from where Jessica disappeared Oct. 5. They also declined to say whether the body was that of a child.
Police spokesman Trevor Materasso said investigators were processing evidence from Pattridge Park and that no additional information was available. He left without answering questions.
In tweets, Westminster police said investigators had worked overnight to identify the body. Officers searched more of the park Thursday as well as areas closer to Jessica's home. Police said photo radar vans — normally used to detect and photograph speeding vehicles — were being used to monitor some streets around the girl's house.
Police have ruled out her parents — Sarah Ridgeway, who lives Colorado, and Jeremiah Bryant, who lives in Missouri. Authorities believe Jessica was kidnapped by an "unknown suspect."
Jessica's mother last saw her daughter walking to school. The girl never arrived, setting off a frantic search by hundreds of law enforcement officials and residents.
Aurelio Florez, who has lived in Jessica's neighborhood for six years, said it was shocking that Jessica could have vanished during a two-block walk to a park where she usually met friends before continuing on to school.
"You can see the park from her front door," he said.
Fliers about the fifth-grader were posted on nearly every house in her neighborhood of modest, two-story homes with single-car garages. Purple ribbons, a symbol of hope for her return, were tied around trees.
It was a lively area where children played outdoors, said another neighbor, Luis Pena, but since Jessica disappeared, parents are keeping their children inside and people look at each other with suspicion.
"Nobody trusts anybody anymore," he said.
The only real clue police have revealed in Jessica's disappearance is the discovery over the weekend of a backpack and water bottle that she had with her when she disappeared. Police won't discuss what was found in the bag or test results on it.
The items were found in the town of Superior, some six miles from her home. The spot where the possessions were found is about 7 miles from the park.
Police initially said the public didn't need to fear a kidnapper, then that they were investigating whether the case might be related to that of another girl who was abducted for several hours Monday in Wyoming.
In that case, a man lured the girl into a sport utility vehicle, saying he needed help finding his puppy. The girl was discovered by hunters. The FBI said it does not believe the cases are related. Police are searching for a suspect.
Adding to the mystery was a reported sighting more than 2,000 miles away in Maine — one of hundreds of leads being investigating from at least five states.
Westminster police repeatedly have urged the public to study the details of Jessica's face in a photo — a small, gap-toothed grin, a slight bruise on her nose — and a short home video, hoping someone may have seen something.
Additional police were sent to Jessica's school, said Lynn Setzer, spokeswoman for Jeffco Public Schools. The district has its own security officers at other middle schools and high schools.
Steve Saunders, a spokesman for nearby Adams County schools, said the district is trying to strike a balance between reassuring students and their parents that they are safe, while encouraging them to be vigilant.
Saunders said the district has security officers at all middle schools, but not elementary or high schools. He said the district will seek more help if authorities believe it is warranted.


text:
This year you want to have something more special in your garden, namely, some chickens. However, you also need some appropriate space for them where to sleep and eat. So, in this article, you will find some ideas and projects you can make by yourself at home very easily. Read the entire article and you will see what you have to do.
Page 1 of 6
Next Page


text:
Umpire's Dramatic Strike Three Call Is the Greatest Thing in the History of Great Things
A good umpire blends into the game as much as cleats in the batter's box. This umpire, though, wants to be remembered like a walkoff grand slam in the seventh game of the World Series.
Look at this ump's over-the-top strike three call. The video description says it's better than Leslie Nielsen in 'The Naked Gun.' Is it? Not sure. You can be sure, though, the batters' average and self-esteem take a dip after he punches them out.
Take a look at Nielsen in 'The Naked Gun' and judge which is better for yourself.