HIV lipodystrophy with exercise works best
New research shows increase in lean body mass
The most effective treatment for lipodystrophy, which has replaced AIDS wasting as one of the more insidious adverse effects associated with HIV disease, is a combination of steroids, exercise, and dietary changes, an infectious disease expert says.
Research shows that patients following regimens providing that combination approach to combating the problem of fat redistribution will show significant improvements. Interim data from a study headed by Nicholaos Bellos, MD, FACP, president of Bellos Southwest Infectious Disease of Dallas, shows that HIV patients on this regimen had a 10% to 15% increase in lean body mass.
Clinicians should keep in mind that the diagnosis for lipodystrophy is different from that of AIDS wasting, Bellos says. While HIV-infected patients may lose weight in both cases, the two have different causes and different effects on the body.
"Initially in the epidemic, we saw patients with end-stage HIV infection who were very thin and had loose muscle mass, as well as fat mass," Bellos says. "Those were patients who usually did not do very well for very long after their bodies began to waste away."
Fat redistribution more likely
Now that antiretroviral treatment has slowed the progression to AIDS, clinicians are far more likely to see patients with a weight loss that is characterized by fat redistribution, which is generally believed to be caused by the antiretroviral drugs. Those patients might have a low viral load and otherwise appear to be in good health, but their faces might have lost some fat, while fat has begun to grow in their midsections.
AIDS wasting typically results from a patient’s progression to AIDS and opportunistic infections. Such patients have a high basal metabolic rate as their bodies expend more energy fighting various infections, so they’re expending more energy than they can consume, causing an involuntary weight loss of 10% or more of body weight.
The goal in treating lipodystrophy has to be to increase lean body mass, which is more important for the patient’s overall health than it is for the patient to simply gain weight, Bellos says.
"There’s a positive correlation between increasing lean body mass and survival," he explains. "The object isn’t just to put weight on, but to put on good body mass, so therapies are geared toward building lean body mass."
Bellos’ study had no placebo arm but otherwise expanded on a previous study conducted by researchers from the University of California at Berkeley and San Francisco General Hospital.
The earlier study, published in the April 1999 issue of the Journal of the American Medical Association, studied 22 HIV-infected men who had lost an average of 9% of their body weight. The intervention group received a replacement dose of 100 mg of testosterone each week, and they followed a closely supervised diet, a supervised progressive-resistance exercise regimen, and took an anabolic medication called oxyandrolone. The control group received the testosterone and diet and exercise regimen, but not the anabolic medication.
The oxandrolone group gained an average of more than 15 lbs of lean body mass over an eight-week period, compared with a gain of slightly more than half that amount in the control group.
In the more recent study, 119 men and women across the United States with HIV received 20 mg of oxandrolone daily in divided doses for four months. They also received nutritional and exercise education and were given a set of elasticized resistance exercise bands for use at home. The participants were, on average, at 92.5% of their normal weight. Participants with low testosterone also were given supplemental testosterone.
Participants gained an average of about four lbs at two months and more than six lbs at four months. Their body fat didn’t change, which showed that the weight they gained was in lean body mass. Also, a bioelectrical impedance analysis revealed a significant increase in body cell mass compared with baseline and between months two and four.
Nine patients experienced adverse events that could have been related to the treatment. None of the women reported any masculinizing effects from the treatment.
Bellos’ lipodystrophy treatment begins with having a dietitian obtain baseline data from patients. That includes photographing patients when they first visit the clinic. The photographs are reviewed in two to three months to see if the patient’s appearance has changed.
That approach enables clinicians to catch early signs of fat redistribution, such as the loss of fat in the face or increased veining in the arms or legs. Once a patient is suspected of having lipodystrophy, clinicians perform a bioelectrical impedance analysis and compare the results with standards for a patient’s age, height, and weight.
If the results indicate a problem with fat redistribution, the clinic will prescribe steroids, including oxyandrolone and testosterone. Clinicians also explain to patients that they must begin a disciplined exercise regimen that includes resistance exercise, and they recommend a diet containing proper daily nutrition. They also begin to monitor patients for elevated triglycerides and cholesterol. "People come in and say they want the steroids," Bellos says, "but they have to do the exercise in conjunction with the steroids to obtain the best results."
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