- Increases in blood fat levels are now known to
occur during treatment with Protease inhibitors. In addition, in some
people, their face, arms, buttocks and legs becomes thinner while their
abdomen/stomach gets bigger. Its mechanism is still unknown. Dieting and
physical exercising often help improve the situation.
-
- Thanks to their efficacy, protease inhibitors have radically changed
the outlook for people with HIV infection. Nevertheless, this new side-effect
has been recognised as they have been used by more people for a longer
period than the initial studies. It is characterized not only by changes
in the blood fat levels mentioned above, but sometimes sugars blood levels,
and, in up to 30% of people, by changes in their physical appearance.
This issue was raised during the recent Geneva conference. It is also the
topic of a chapter in the new French guidelines on the treatment of HIV.
-
- Some people are getting a paunch
- In some people receiving these drugs, the fatty tissues of the face,
shoulders, arms, buttocks and legs slim down to the point where veins
can be seen through the skin. At the same time, more fat develops under
the abdominal muscles. In women, breast size can also increase. More rarely,
fat can accumulate in the lower part of the back of the neck (this is what
Americans call the "buffalo hemp"). Some of all of these symptoms
are collectively called lipodystrophy, meaning abnormal distribution of
body fat. According to some researchers, lipodystrophy could affect 30%
of treated persons. It can affect people in different ways and does not
always correlate with an increase in your body weight. In some people,
the additional waist fat can compensate the weight of the fat lost from
the face and limbs. Other people just lose fat from the face, limbs and
buttocks without gaining any weight aound their waist.
-
- Higher blood fat levels
- Abnormally high fat levels (cholesterol and triglycerides) over several
years can lead to obstruction of your arteries and to cardio-vascular diseases.
This risk is increased when several factors exist (e.g. smoking, cardio-vascular
problems in the family). However, it is too early to assess the impact
of current treatments on possible heart-related problems. Finally, in some
rare cases, very high triglycerides levels can expose to a risk of pancreatitis
(severe inflammation of the pancreas, a digestive system gland).
-
- Sugar and insulin
- After a meal, carbohydrates (sugars) contained in food get into the
bloodstream. Then, through the effect of insulin, a hormone produced by
the pancreas, sugar gets into some specific cells (muscles, liver, fat
cells) where it is used as an energy store. In some patients, protease
inhibitors seem to alter the entry of sugar into cells. To compensate this,
the pancreas produces more insulin. Sugar is then stocked in fatty cells.
In summary, the risk is to loose muscle mass and to gain fat. To limit
these effects, it is recommended to make a few changes to your diet (see
later paragraph). These abnormalities can be detected by a taking a small
sample of your blood and testing insulin and sugar levels after swallowing
a sugar drink.
-
- Why is this happening?
- No-one can yet fully explain these recent findings. HIV infection is
known to cause various body disturbances anyway, including increased energy
expenditure - where you burn up more calories than an HIV- person doing
the same activity (this is why it is usually recommended to HIV-positive
persons to eat more). Starting an anti-HIV treatment radically changes
the body's energy needs, and probably leads to various disturbances. However,
recent studies indicate that protease inhibitors (PI) probably play a major
role in lipodystrophy, as these problems are seen more in patients taking
these drugs. They have been seen with all PI's (Norvir, Crixivan, Invirase,
and Viracept) but it is not yet proven whether some drugs are more to blame
than others. Could PI's also alter some of the body cells functions ? Several
investigators are looking into this.
-
- All right. So, what can you do?
- Making changes to your diet together with exercise can perhaps help
with some of PI-related problems (insulin or blood fat blood glucose abnormalities,
increased weight around your waist). However, this requires a regular and
sustained program.
-
- Changing your diet
- It is a good idea to cut down on quickly-absorbed sugars (sweet deserts,
sodas, candies) and to completely avoid them between meals. Try eating
more fruit and vegetables which are rich in slowly-absorbed sugars (such
as lentils, fava beans, peas, beans, etc.) and with cereals (bread, pasta,
rice, etc.). This is because, the quicker sugars are assimilated, the higher
the amount of insulin produced by the body and the higher the chances of
sugar being stored as fat. The other advantages of slowly-absorbed sugars
are that they reduce or even suppress the feeling of hunger and, and therefore,
the need to snack between meals. Quickly-absorbed sugars on the other hand
lead to a sharp rise,
- followed by a sharp drop in blood sugar levels, leading to a wanting
to eat sugars again. It is a good idea to cut down on fat, particularly
from dairy food (butter, cream, etc.), while keeping a balanced diet.
-
- Exercise
- Regular, light, physical exercise such as cycling, swimming jogging
or rowing uses lots of energy, part of which will reduce stored fat. Regular
exercise increases the number of blood cells in muscle, which increases
their ability to use sugars from the bloodstream: sugars which are "burnt"
this way will not turn into fat.
-
- Stabilize insulin and sugars
- If regular exercise and diet do not bring back insulin and blood sugar
levels to normal, some doctors will offer to use metformin (Glucophage,
LP 850, Stagid, Glucinan), which is usually used to treat some forms of
diabetes. Recent studies have shown that metformin improves the muscles'
ability to use sugars, as does exercise.
-
- Fat-lowering drugs
- Some drugs are used to lower blood fat levels (Zocor, Elisor, Lipanthyl,
Lipanor, etc.). They are used to prevent heart (cardio-vascular) disease.
Their usefulness in lowering blood fat levels related to treatment with
Pis is not yet known. They need to be used with caution because of potential
interactions with PIs. This is why some doctors prefer to use drugs which
are often less effective but which do not carry the same risks : Mediator
decreases triglycerides absorption in the gut and their synthesis in the
liver. Maxepa is made up of fat from some high-fat containing fish species
: salmon, tuna fish, herring, etc. Eskimos who eat large quantities of
these fish have a low incidence of cardio-vascular diseases. Maxepa helps
lowering triglycerides levels and improve the bad/good cholesterol ratio.
It should be taken during meals.
-
- Growth hormone
- Growth hormone increases lean body mass (muscle) at the expense of
body fat. It has been used with some success in the US in some people with
severe lipodystrophy. This very expensive hormone is only available in
France to treat children with growth problems. In spite of many requests
by AIDS activist groups to set up trials in HIV-positive people, no such
trial has been set up so farS
-
- Testosterone
- Testosterone is a male hormone, which is also found in women (in whom
its plays a less important role). People living with HIV often have lower
free testosterone blood levels : total testosterone levels, and not just
free testosterone, need to be assayed. This hormone plays an important
role in the lean body mass/body fat ratio. The opportunity of taking testosterone
supplements can be discussed with your doctor.
-
- What if all this is not enough ?
- Sometimes, physical exercise and a balanced diet are not enough. If
your blood tests (blood fats and sugars) are not improving or if your physical
appearance worries you to the point where you may not be able to continue
to take your anti-HIV treatment, you should talk to your doctor about changing
your treatment. Recent data have shown the efficacy of a new class of drugs
(Sustiva, Viramune, Rescriptor, see page 10 of this issue of Remaides,
and page 26 of Remaides number 28). Some people who have achieved an undetectable
viral load using triple therapy have replaced, with their doctors' approval,
the protease inhibitor in their combination, with one of these new drugs.
After more than 6 months, their viral load remains undetectable. Nevertheless,
little is still known about these drugs and the possibility that they may
have similar long-term side effects. In addition, changing treatment does
not mean that there is no need to keep exercising or watching your diet
!
-
- Conclusion
- These changes in body appearance may have, at first, been seen by doctors
as a mere aesthetic problem, of trivial importance compared with the need
to save lives. However, if this issue is not managed, it could lead to
complications and be an obstacle to treatment adherence. The close link
between quality of life and adherence to treatment can never be overstated.
-
Gilles Pernet
-
- Slow and fast sugars
- Here is a list of food which are high in sugar.
The corresponding numbers indicate how quickly they are absorbed in your
body, compared with that of glucose (pure sugar). During treatment with
a protease inhibitor, slow sugars (those with a low number) should be preferred
to fast sugars (with a high number). For instance, whole-wheat bread (index
number 42) is preferable to white bread (index number 87). Nevertheless,
be cautious with bread from supermarkets which often contain fast sugars
(glucose or saccharose).
-
- Coca-Cola : 124
- Glucose (sugar) : 100
- White bread : 87
- Potatoes : 70
- "Biscottes" (toasted bread) : 70
- Fruit juice : 70
- Oatmeal : 64
- White rice : 53
- Pasta : 50
- Banana : 48
- Whole-wheat bread : 42
- Beans : 40
- Lentils : 35
- Fresh carrots : 32
- Dried peas : 28
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