Fat Gain- what to do?
Sep 5, 2009
Response from Mr. Vergel
I would not use diet pills since they have been associated with increased blood pressure, cardiovascular disease, and anxiety.
This is recent information that I wrote about what we can do about belly fat in general:
How to Decrease Belly (Visceral) Fat in HIV? - What is New?
Many people living with HIV complain of weight and belly fat gain after they start HIV treatments. However, no one has really been able to determine what causes this problem. Some studies have actually disputed this fact and said that HIV+ people do not have more visceral fat than HIV negatives. But the HIV community as a whole has come to accept the fact that body changes are far too common in those of us living with this virus. The problems associated with increased visceral fat are decreased body image and depression, bloating, fatigue, sleep apnea, and possibly cardiovascular problems in the long term. So it is not only a problem that affects the way we look but also could decrease our long term survival as we age with HIV.
Lypodystrophy has been reported by many studies in HIV. It includes one or a combination of these changes: lipoatrophy or decrease in fat under the skin (associated mostly with the use of Zerit or AZT), lipohypertrophy or fat gain in the inner belly area (visceral or surrounding organs), increases in bad cholesterol (LDL or low density lipoprotein) and triglycerides, and decreases in good cholesterol (HDL or high density lipoprotein) with or without increases in blood sugar. Around 40% of people who start HIV treatments do not experience any body changes, but some experience one or more of these metabolic complications.
The latest study that showed how lipohypertrophy is affecting men living with HIV is the Multicenter AIDS Cohort Study (MACS). It showed that HIV+ men in general weigh less than HIV negative men, but their visceral fat is about the same. Most HIV+'s were thinner due to fat loss under the skin in the arms, legs, buttocks and under the skin of the belly, but had as much internal belly fat as the heavier HIV negatives. This study confirms what we have been saying for years.
Fortunately, we have had a lot of advances in lipoatrophy. We now know that it is associated with the use of Zerit (D4T) or AZT, and we also have two approved FDA options for the correction of facial lipoatrophy in the United States (Sculptra and Radiesse.) However, the same cannot be said about lipohypertrophy, which seems to a problem caused by many factors. Researchers have not been able to blame any specific drug or drug class for it. Several studies have shown that visceral fat increases in people starting therapy at about 15% in 96 weeks. We used to think protease inhibitors were the main culprits or belly fat gain, but as we have gained more and more experience, we have found out that visceral fat gain has been associated with immune reconstitution and higher CD4 increases. So those who start HAART at lower baseline CD4 cells may have more viscerat fat ( or visceral adipose tissue- VAT) gain . Fat gain in the visceral area may be related to inflammatory responses that the immune system has while CD4 cells are increasing in number. Recent data shows that protease inhibitors boosted with Norvir may not increase visceral fat in those who start them over 250 CD4 cells and when used in combination with Viread/Epivir. It is too early to tell what happens to those who start with lower CD4 cells. Some studies have shown that those who start protease inhibitors or non-nucleosides with backbones of Zerit, AZT or Zerit+Videx, seem to have more visceral and hump fat gain than those who start them with other nucleoside analogs. So, the bad guys in lipoatrophy may also worsen belly fat gain.
Switching from protease inhibitors to Viramune or Sustiva in combination with Zerit or AZT have shown no improvements in visceral fat. However, no "switch" studies have been done with backbones of Viread or Ziagen, two nucleosides that seem to be more metabolically friendly than Zerit or AZT.
Insulin resistance may also be implicated in fat gain in HIV. Insulin is a hormone produced by the pancreas to control blood sugar (glucose). It captures glucose and pushes it into muscle tissue to store it as glycogen for later use by the body as energy. That transfer process can be blocked or slowed down by medications like protease inhibitors. Also, some people may have a genetic predisposition to have more insulin resistance than others. Crixivan, higher doses of Norvir, Zerit , AZT and other protease inhibitors have been shown in lab studies to impair the action of insulin. This fact may be just a part of the puzzle but not the entire explanation for visceral/hump fat gain.
Human growth hormone, (Serostim is the brand name of the product with HIV data), works at lowering fat in the abdomen in men and women but not without side effects. It is approved to treat HIV wasting (unintentional weight loss of 10% or more of normal weight.) However, Serostim caused side effects that compelled the FDA to decline their application for approval for lipodystrophy. Side effects included joint pain, edema, and increases in blood sugar. High cost and lack of insurance reimbursement are also factors that became barriers for using this product. A growth hormone releasing hormone (Tesamorelin) made by a Canadian company called Theratecnologies is in its last stages of FDA approval. It is a hormone produced by the pituitary gland that makes this gland produce growth hormone. It seems to be milder in side effects but also in efficacy than Serostim. As was the case with Serostim, the FDA may also deny this products approval if no health benefits are seen. Its side effects are mild edema (water retention) and some joint and a hypersensitivity reaction by 10% of patients who experience sweating and rash. But it does not cause increases in blood sugar and it may lower trigltcerides, another problem that many of us have when using certain HIV medications. Community activists are concerned that Tesamorelin's price will be a high one and that many insurance companies and Medicare may not pay for it since it may be perceived as a cosmetic product. Another concern is that Tesamorelin will be sold in the U.S. by Serono, the company that sells Serostim. Serono has had a horrible history not only with activists but it has also been fined over 700 million dollars by Medicare due to fraudulent practices that induced some physicians to prescribe Serostim for HIV wasting.
Another new contender in the search to decrease visceral fat in HIV is leptin. Leptin, a hormone discovered in 1994, is produced by fat cells. In general, leptin levels in the blood are proportional to an individual's level of body fat. At work in the hypothalamus, the part of the brain that controls appetite and other basic functions, high levels of leptin generally suppress the appetite and stimulate fat-burning. When it comes to visceral fat reduction in 6 months, leptin looks as good as Serostim (human growth hormone) and better than Tesamorelin. It was given by injection under the skin at 0.01 mg/kg and 0.03 mg/kg twice daily for successive 3 month periods (which translates to 6.8 mg/day and 20.41 mg/day for a 150 Lb person, respectively.) Visceral fat decreased by 32% with no changes in subutaneousl fat. Bad cholesterol (LDL) decreased by 20% and the good cholesterol increased by 19%, with a dignificant decrease of triglycerides also. Leptin was well tolerated but decreased lean mass. It is not approved by the FDA and this was just a pilot study. Activists are trying to convince its manufacturer to do studies in HIV so that it can get approved for VAT reduction in the future. It is an expensive hormone, however. Unlike Serostim, leptin does not seem to have side effects and no negative effects on blood sugar. It is too soon to tell if leptin is here to stay and if it will be cost-effective. Some people have fallen prey to TV commercials that push fat burners. These products can increase blood pressure and anxiety. Also, growth hormone supplements have been found to be a scam.
A testosterone gel applied to the belly reduced waist size in men but mostly at the expense of subcutaneous fat. No visceral fat decreases were seeing. Testosterone use in HIV is stronger than ever as more people are diagnosed with sexual dysfunction and/or low blood levels of testosterone. Data in women are lacking but small pilot data in the past showed that women with HIV may have higher testosterone levels. Gels, injections, and an emerging subcutaneous pellet delivery system are becoming more commonly accepted by physicians.
A small pilot of Oxandrin (an oral anabolic steroid) yield encouraging results in decreasing visceral fat but LDL increased and HDL increased with also a small decrease in subcutaneous fat. No fat data is available for the other popular anabolic, nandrolone decanoate.
Properly controlled and executed nutritional studies are lacking. A study at Tufts showed a trend towards less lipodystrophy in those who had higher consumption of soluble fiber (fruits and vegetables) and who exercised. We need more research in lower glycemic index (lower simple carbohydrate ) diets who have shown to improve insulin resistance and visceral fat in non HV studies. One observational cohort showed that HIVers eat more saturated fats. Another study showed that counseling for nutritional and life style modifications improved belly fat in HIV+ patients, so it is suggested that physicians and AIDS Service Organizations include nutritional and exercise information for patients.
A small pilot on a combination of cardiovascular exercise and resistance exercise showed decreased in triglycerides and visceral fat. However, exercise research in HIV is at its infancy even after 25 years. Adherence to exercise is a challenge to many people.
Full body DEXA (dual X ray absorptiometry) scan is a gold standard test in lipodystrophy research but hardly used in clinical practice. It is highly useful since it gives information about every body part's fat, muscle mass and bone density. It is not expensive (average price $130) and can be covered by Medicare and insurance. Low bone density has also been associated with HIV so this test can be also useful in detecting early bone changes before fractures happen. DEXA would be useful at baseline when someone tests HIV-positive and then every few years to assess body changes and justify reimbursable therapies.
Thirty to 50% of people with visceral fat may have impaired glucose tolerance (their bodies do not use sugars for energy very well) and may be in a pre-diabetes state. A glucose tolerance test (GTT) may reveal that problem easily. Glucose intolerance has been associated with fat gain, increased triglycerides, and later development of diabetes.
Metformin,( trade name: Glucophage), a generic diabetes drug, has shown to improve glucose tolerance and lower visceral fat. Its effects may be enhanced by exercise. Some are concerned that it may increase lipoatrophy, but no studies have been done in the absence of Zerit and AZT in HIV. In my opinion, it may be an option to consider in patients with higher fat mass, specially in combination with exercise and/or growth hormone. Metformin improves insulin sensitivity, triglycerides, fatty liver, but can cause diarrhea and weight loss. We were concerned about the possibility of lactic acidosis but this has not been observed in HIV. Some people report low blood sugar and dizzy spells on this drug, so have snacks at hand to increase blood sugar if needed.
Ultrasound assisted liposuction seems to be effective in removing fat from the hump but not so for removing visceral fat that surround organs. Breaking the fat fibers with ultrasound seems to loosen them up for easier removal. Some insurance companies and Medicare pay for liposuction when fat gain is associated with pain or sleep disorders.
Enlargement of salivary (parotid) glands on the side of the face can occur in certain patients. We do not know if it is lipid related or caused by immune reconstitution. Low dose electron radiation has worked very effectively but only very few radiologists know how to use it for this purpose
Fat gain can also occur in the upper trunk area , specially in the breasts . Some studies show increases in estradiol (female hormone) in men taking Sustiva that many cause gynecomastia (increased breast size) in few patients. Drugs like Arimidex (an estrogen blocker) may help those who are in early stages of this problem.
I know this is a lot of info, but I tried to summarize where we are when it comes to fat accumulation in HIV. Please ask me any questions after you review this information!
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