Weighty Matters

Just a few years ago, dietitians and doctors told people living with HIV/AIDS that they could eat anything they wanted and that it was OK to drink whole milk, to eat steak, eggs, and fries, and to add fat whenever possible. This is no longer true.

Today, people living with HIV/AIDS need to take extra care to eat right. Many people living with HIV/AIDS are now entering their middle age. With middle age comes a whole bunch of "middle-age problems" that people need to be aware of. Unfortunately, a middle-aged body is not as forgiving as a body in its early 20s and 30s. You no longer can get away with eating bacon and eggs for breakfast, burgers and fries for lunch, and a pizza for dinner without getting a big gut and high cholesterol, both of which put you at higher risk for getting a heart attack or stroke.

With the advent of protease inhibitor (PI) therapy and other powerful new medications to fight HIV, these middle-age problems are starting to occur in much younger people in their 20s and 30s. More young and middle-aged people on PI therapy are starting to see their cholesterol and triglyceride levels skyrocket. To make things worse, one of the protease inhibitors, called Fortovase, requires you to take it with a meal containing fat.

High cholesterol: what can you do?

Cholesterol and triglycerides are fats that float around in the blood. Having too much fat in the blood can damage your arteries and heart and cause heart attacks or strokes. There have been several reports of young people living with HIV/AIDS and taking PI therapy suffering heart attacks or strokes as a result of high cholesterol and triglyceride levels. The rise in cholesterol and triglycerides may be a result of using PI therapy and as a result of aging. PI therapy seems to interfere with the body's ability to break down blood fat. This may be due to the fact that the liver is over-taxed by the medications and does not efficiently rid the blood of fat.

If you have not had your cholesterol and triglyceride levels checked at the doctor's office, you should insist that they be done every 6 months.

Normal Cholesterol Levels:

• Total Cholesterol
  120-200 mg/dL

• HDL Cholesterol (also called good cholesterol)
  women: 35-85 mg/d; men: 35-70 mg/dL

• LDL Cholesterol (also called bad cholesterol)
  less than 130 mg/dL for men and women

• Triglycerides
  women: 35-135mg/dL; men: 40-160 mg/dL

No crash diets please

One thing to keep in mind if you have high cholesterol or triglycerides (be it a result of your middle age or protease therapy) is that you should not go on an extremely low fat diet or skip meals. The best strategy is to change the type of fat you eat, avoid very high fat items (such as fries, pizza, burgers, steak), eat more fruit and vegetables, and exercise. Do not skip meals since you need to help your body burn food slowly throughout the day. Also, try not to eat after 8 p.m. since after that time your body will not have time to process it before you go to bed.

Strategies to help reduce cholesterol and triglyceride levels:

1. Reduce your intake of high fat foods such as fried food, red meat, regular salad dressings, ice cream, whole milk products, cheese, butter, margarine, and oil.

2. Avoid high sugar foods such as colas, candy, sweets, and ice cream.

3. Use olive oil or canola oil instead of other oils, butter, or margarine.

4. Eat at least 3 fruits and 2 vegetables per day. 1 serving = 1 fruit or ½ cup cooked or raw vegetable.

5. Eat throughout the day -- have breakfast, lunch, and dinner. Do not eat the biggest meal at the end of the day.

6. Exercise at least 3 times a week.

7. Take vitamin E (400 IU per day) as a strong antioxidant to help protect your arteries.

8. Be sure your doctor checks your cholesterol and triglyceride levels every 6 months.

9. If your cholesterol and triglycerides continue to be high 3 months after changing your diet, you may need to go on medication (such as lopide) to lower the fats in your blood, or you may need to change your medication.

10. There are herbs and vitamins -- such as vitamin C, niacin, garlic and L-carnitine -- that can help lower cholesterol.

    (for more ways, see "Fighting Fat Naturally").

What do you do if you have high cholesterol and still need fat in your diet to take your meds?

If you are taking Fortovase and need to reduce your cholesterol or triglyceride level, be sure to continue to take your medication with a meal that has at least some fats, such as 2 tablespoons of peanut butter or 2 tablespoons of olive or canola oil. You can lower your fat intake at other times of the day. Use "healthier" fats such as canola oil and olive oil in foods instead of butter, mayonnaise, and lard.

What can you do if you need to lower your cholesterol/triglyceride levels but need to gain weight?

Many people living with HIV/AIDS have experienced weight loss. It is very possible that your blood fat will remain high despite weight loss. This makes everything more difficult since the diet to follow to lower your blood fat will also lower your calorie level by reducing fatty foods in your diet (which can lead to more weight loss). Often, a low weight will be accompanied by low appetite, early feeling of fullness and taste changes, all things that make eating any food difficult.

If this is a problem for you, you should contact a dietitian to work out a plan specifically designed for you. Also, talk to your doctor about getting medication to help lower your blood fat, and about getting an appetite stimulant such as Marinol or Megace. You may want to discuss options available with steroid therapy to help regain lean body mass. Add calories to your diet with lean cuts of meat, use olive oil and canola oil, and avoid butter and other saturated fats. But most importantly, eat food as often and as much as you can and get on a medication to lower the blood fats. Be sure to have your testosterone level checked as well, since it may be low and need to be supplemented.

The other middle-age problems: pot belly or protease paunch?

Its often difficult to figure out whether your new pot belly is due to aging or your new medications. Often a belly due to aging will also put weight on your face, arms, and legs. Some men, however, can naturally form a big gut but still have trim arms and legs. If you are experiencing the protease paunch, fat will accumulate around the gut while fat is lost on the arms, legs, and face. Researchers still do not know why this occurs or what you can do to stop it. Some people never get it at all. If you do notice weight gain around your middle, talk to your doctor right a way and follow these steps:

Reducing or avoiding the Protease Paunch or Natural Pot Belly:

1. Have your testosterone level checked, supplement if low.

2. If you are taking Megace, an appetite stimulant, switch to Marinol.

3. Exercise for a minimum of 3 times each week for 30 minutes each session to build muscle mass.

4. Eat fewer fatty foods. Cut down on the number of servings of fatty foods and eat foods with less fat.

5. Eat at least 3 meals a day. Do not starve your self or skip meals as this will lower your metabolism and make you gain fat faster.

6. Eat less sugary foods such as cakes, cookies, pop, candy, and ice cream.

7. Limit alcohol to no more than 5 drinks a week.

8. Record your weight and waist size each month. If you see a change, talk to your doctor.

9. Have a bioelectrical impedance analysis (muscle mass measurement) done every 6 months to help monitor your muscle and fat gain or loss. Call your doctor or dietitian if you need this test done. These tests are given free at Specialized Prescription Pharmacy in Seattle. Call 1-800-800-5470 or 206-217-0993 to schedule an appointment.

Call Sabina if you have any questions at 206-320-0213.

Sabina Beesley, MS, RD is Dietitian for Chicken Soup Brigade and Joanne Maurice, MS, RD is Dietitian for Madison Clinic.