Exercise and HIV Wasting: From the Laboratory to the Clinic

Wasting was the topic of a breakfast symposium during the recent amfAR 12th National HIV/AIDS Update Conference in San Francisco. Drs. Fred Sattler, Alison Strawford, and Nicholaos Bellos reported that wasting still exists among a significant portion of people with HIV, and that a treatment approach combining nutrition, exercise, and anabolic medication has proven effective in both the laboratory and the clinical setting.

HIV Wasting Still Common

The CDC defines wasting as the involuntary weight loss of 10 percent or more of body weight. Some experts define wasting as smaller losses over shorter periods of time as well, such as a loss of 3 percent of body weight in one month or 5 percent of body weight in six months.

People diagnosed with HIV-related wasting typically experience loss of energy, increased fatigue, lessened strength and endurance, and other symptoms that can lead to a decreased quality of life. Dr. Fred Sattler of University of Southern California School of Medicine reported that even when HAART has resulted in a lower viral load and an increase in CD4 cell count, unexplained weight loss (weight loss not caused by opportunistic infection, inadequate intake of calories, or poor absorption of nutrients into the bloodstream) can still be seen in people with HIV. In one group studied, 30 percent developed wasting within two years of being on HAART, and 70 percent within six years.

The goal of treatment is to restore not only body weight in general, but lean body mass in particular. Described by Dr. Sattler as "everything that isn't fat," adequate lean body mass is necessary for mobility as well as for basic bodily functions.

Results in the Laboratory

Dr. Alison Strawford and Dr. Marc Hellerstein of the University of California at Berkeley and San Francisco General Hospital conducted a double-blind, placebo-controlled study in laboratory conditions of a "combination therapy" approach to reversing HIV weight loss (first reported at the 12th World AIDS Conference, Geneva, 1998, and published in the Journal of the American Medical Association in April 1999). Study subjects were 22 HIV-positive men who had lost an average of 9 percent of their body weight. The approach employed in the study combined a closely supervised diet, a supervised progressive resistance exercise regimen, and an anabolic medication (oxandrolone).

Though all of the men in the study had normal blood levels of male hormone, they also received a replacement dose of testosterone (100 mg weekly) to equalize hormone levels in all participants. The control group received the diet and exercise regimen but not the anabolic medication.

The results were impressive, with an average gain of 6.9 kg (more than 15 pounds) of lean body mass over an eight-week period in the oxandrolone group, compared with 3.8 kg in the control group. Several strength tests indicated that gains in strength were also significantly higher in the oxandrolone group than in the control group.

This study showed that exercise and proper nutrition combined with a moderate, well-tolerated amount of an anabolic (20 mg per day of oxandrolone) provided better results than other studies have shown with higher doses of less well-tolerated anabolics.

Results in the "Real World"

Dr. Nicholaos Bellos of Methodist Hospital and Southwest Infectious Disease in Dallas, Texas, reported interim data from a new study that replicated the Strawford-Hellerstein approach in the community setting. This study was considerably larger and had no placebo arm (open-label).

In the study headed by Dr. Bellos, 31 clinical practices across the United States enrolled a total of 119 people with HIV (107 men and twelve women) who, on average, were only at 92.5 percent of their normal weight. All participants received 20 mg of oxandrolone daily (in divided doses) for four months, with nutrition and exercise education, and a set of elasticized resistance exercise bands for home use. Participants with low testosterone were given supplemental testosterone.

Most patients gained weight at both two months and four months. Mean weight gain from baseline was 1.8 kg (nearly four pounds) at two months. For patients completing four months of study, the mean weight gain at that time was 2.8 kg (more than six pounds).

Changes in body composition by bioelecrical impedance analysis revealed that the increases in body cell mass compared with baseline, and between months two and four, were significant. Body fat did not significantly change. Quality-of-life assessments showed significant improvement at the second month.

In all, nine patients experienced adverse events probably or possibly related to treatment. All but one were considered mild or minor, and in that patient's case the condition reversed upon discontinuation of therapy. Significantly, no masculinizing effects were reported among the twelve women in the study.

These preliminary results of the ongoing Bellos study show that an HIV wasting treatment proven effective in a controlled research setting can be applied successfully in the real-life clinical setting and give people who have experienced HIV-related weight loss the opportunity to strengthen their bodies and regain their quality of life.

One Community's Exercise Program

Some of the Dallas-based patients in Dr. Bellos's study accomplished the exercise portion of their treatment through the Dallas AIDS Alliance's IMMUNocise program. The program has been run for nine years by Keith Willard and consists of strength training using exercise bands, aerobic training, stretching, and positive imagery. In addition, IMMUNocise has developed a variety of social activities to improve the quality of life for group participants by encouraging the development of supportive friendships.

The 12th National HIV/AIDS Update Conference, sponsored by amfAR, was held in San Francisco on March 15 through 17, 2000. The above summary was provided through an educational grant by BTG Pharmaceuticals and is printed here courtesy The Huff Fund.