Reprinted from Living + Magazine, Sep/Oct 2000
A publication of the BC Persons With AIDS Society, www.bcpwa.org
Metabolic changes among HIV-positive individuals are increasingly common. PWAs are seeking answers and alternatives to medications to treat such changes in blood lipid levels as hypercholesteremia (high blood cholesterol levels), hypertriglyceridemia (high blood levels of triglycerides, a type of fat), and both conditions together, called hyperlipidemia (high fat levels in the blood). Hardening of arteries caused by fat deposits or fat plaques (atherosclerosis) is a related concern. All of these conditions are risk factors for cardiovascular disease, heart attacks, and development of diabetes.
What causes these metabolic changes is still open to debate. Protease inhibitors have been fingered since they are known to alter levels of blood lipids and change glucose and insulin metabolism, and also because these conditions began to be widely discussed during the HAART (highly active antiretroviral therapy) era. However, it is likely that HIV itself plays a role in these metabolic changes. Early in HIV infection, metabolism begins to alter. Lipid abnormalities in HIV-positive individuals were evident before protease inhibitors were used. A 1989 study of wasting revealed that people living with HIV/AIDS had higher triglycerides than HIV-negative individuals. Before HAART, many PWAs also showed decreased HDL (good) cholesterol and were thought to be at increased risk of atherosclerosis. Thus, some say that HIV is a partial cause of high blood lipid levels and lipodystrophy.
Nevertheless, there is considerable evidence to suggest that antiretroviral medications are contributing to metabolic changes.
Mitochondria are the "power plants" of human cells -- they help produce energy and process fat. Nucleoside analogue reverse transcriptase inhibitors (NRTIs
) may cause damage to mitochondria by interfering with an enzyme called mitochondrial DNA polymerase gamma. Mitochondria need this enzyme to reproduce and its inhibition can result in damaged and fewer mitochondria available to do the work. Associated with this condition are a host of problems, including "fatty liver" (hepatic steatosis), which is a build-up of fat in liver cells that can affect the way the liver functions.
Protease inhibitors, too, could possibly be interfering with two proteins involved in fat metabolism that are structurally similar to the HIV protease enzyme. Malfunctioning of these proteins could lead to hyperlipidemia and insulin resistance.
There are probably numerous interrelated causes of changes in blood lipid levels, and it will likely be a long time before the causes are determined and definitive treatment guidelines are established. What we do know is that lifestyle choices that have proven effective for treating heart disease and diabetes can help prevent and manage these metabolic changes. Diet and exercise are effective and should be the first priority. Ask your doctor about cholesterol-lowering drugs called statins.
If you are looking for something extra, the herbs and supplements described below are used in a variety of complementary treatment systems and may be helpful. However, no clinical trials proving their effectiveness have been completed. Nor are there specific tests for HIV-positive individuals whose metabolic changes may be caused by antiretroviral medications.
While you want to avoid fat, PWAs' greater need for protein means that instead of going on an extremely restricted diet, you should consider switching from hamburger to a tuna sandwich (hold the mayo).
The following diet suggestions were developed especially with PWAs in mind by Diana Peabody, R.D., nutritionist at the Oak Tree Clinic in Vancouver:
- Get more omega-3 fatty acids from fish or flaxseed. If fresh fish is too expensive, get canned tuna or salmon in water. If you take fish oil, make sure it is from the body of the fish, as opposed to cod liver or halibut liver oil.
- Substitute animal protein with soy protein such as tofu.
- Choose monosaturated fats, such as olive oil, canola oil, and flax oil.
- Increase your fiber intake with brown rice, quinoa, barley, whole grain bread, and cereal.
- Eat lots of vegetables and more legumes like dried beans, peas, and lentils.
- Limit simple carbohydrates like sugar, candy, sweet foods, pop, Boost/Ensure, and, perhaps surprisingly, fruit juice!
- Avoid greasy and fried foods, such as chips and fast food restaurant items.
- Use less saturated fat (hard fat like butter, lard, dairy fat, and meat fat).
- Avoid "hydrogenated" oil.
Exercising for only fifteen minutes once or twice a day helps! Aerobic exercises such as walking, swimming, and biking, are particularly good. If these are too strenuous, try yoga, tai chi, or qigong. Always try to do some physical activity after a large meal.
A controlled study (Stroke, March 2000;31), suggested transcendental meditation, independent of diet and exercise, reduced atherosclerosis. In this study, the thickness of the artery walls was reduced among meditators compared to those in the control group. The researchers estimated that the amount of reduction would make the meditators 11% less likely to have a heart attack and 7-15% less likely to have a stroke. Other studies have demonstrated that meditation lowers average walking (ambulatory) blood pressure among men with normal blood pressure and increases exercise tolerance among men with heart disease.
Cut Down on Alcohol and Cigarettes
Alcohol raises the triglyceride levels in your blood and weakens the immune system. Smoking is a major risk factor for heart disease. Smoking also increases oxidative stress, which may increase viral replication and further weaken the immune system. Oxidative stress is also a risk factor for atherosclerosis. Recently, Ohio researchers found that HIV-positive smokers were nearly eight times more likely to develop lung damage than smokers without HIV.
While quitting smoking is a desirable health choice, it is a difficult one. Your doctor should provide suggestions and support to help you quit.
- The Patch or nicotine gum can help ease withdrawal.
- In clinical trials, acupressure and acupuncture have helped patients successfully quit smoking.
- Hypnosis, behavioral interventions, and special vitamin regimes can also help.
- Cut down on caffeine, as it increases symptoms of tobacco withdrawal in the first few days.
- Drink lots of water.
Vitamins and Supplements
- Studies show that Vitamin C may reduce blood lipid levels. Vitamin E may help prevent the oxidizing or hardening of fat in the arteries.
- Lycopene, found in tomatoes, is an antioxidant. Researchers at the University of Toronto have suggested two glasses of tomato juice a day. The darker the fresh tomato, the more lycopene.
- Carnitine assists in transporting fat into the mitochondria.
- Niacin (Vitamin B3) reduces cholesterol. The major side effects are burning, flushing, and itching.
Herbs and Foods
For high blood fat levels, cayenne, seaweeds, garlic, onions, mushrooms (shitaake, maitake, and reishi), psyllium, guggilipid, fenugreek, oats, green tea, safflower, crataegus fruit, lecithin, and ginger may be helpful.
Guggilipid is a standardized extract from the myrrh tree that is used in India to lower high cholesterol and high triglycerides. It is said to work by increasing liver metabolism of LDL cholesterol and stopping blood platelets from sticking to each other, thereby lowering the risk for coronary artery disease. Taking guggul (the unpurified form) has caused diarrhea, mild nausea, and restlessness. People with inflammatory bowel syndrome, diarrhea, or liver problems should avoid guggilipid.
- Traditional Chinese medicine suggests drinking tea with meals helps disperse fat and aids digestion.
- Safflower is believed to promote circulation, reduce blood lipids, and break up blood clots.
- Crataegus fruits (shanza or Chinese hawthorn) are thought to eliminate accumulations, promote energy flow, and disperse coagulations. Crataegus is said to activate the blood, bring down blood pressure, aid digestion, treat "fatty liver," and reduce lipid levels in the blood. Do not take it with digoxin.
- Lecithin granules may help protect liver cells and move fat from the liver and decrease cholesterol. Take one teaspoon three times a day.
- Ginger may be good for getting rid of bad fat as well as for treating nausea. A recent experiment with mice showed that dietary consumption of ginger resulted in reductions in plasma triglycerides and LDL (bad cholesterol).
Back to the GMHC Treatment Issues February/March 2001 contents page.