At a conference recently, I was having supper with a few of the organizers, who have been living with HIV for over 15 years. I had lectured on nutrition at the meeting, so the conversation drifted to their own concerns. We were talking about having high cholesterol and a "touch of diabetes," problems that ran in the family for one guy. The other guy had 25 pounds of middle-age gut he kept meaning to do something about. Both mentioned wanting to have a little more energy.
These two were typical of many people at this phase of the disease: some side effects, but not as bad as before, and some body shape changes that were maybe caused by HIV or by HAART (highly active anti-retroviral therapy) or by being 40-something. As we talked about diet and nutrition ideas for them, I recognized a familiar pattern: what they didn't know about good nutrition for long-run health mirrors the situation for most people entering or in middle age; what they didn't know about nutrition for chronic infection and for people on HAART was slowly brewing the fatigue, plus heart disease and diabetes risks. I recognized these as exactly the topics in many medical visits for people these days.
I encouraged my dinner companions to spend some time and energy getting in better nutritional and physical shape. Today, as medicines are doing pretty well with managing HIV, it's time to step back and take stock of the whole person -- body, energy, and future metabolic risks. My message for them (and anyone in a similar situation): don't just live with side effects of meds, even though they may be less than before. You might be in okay-enough shape, but imagine having it be even a little better.
What modest changes would it take to feel a little stronger, be in a little better shape, and prevent other complications down the road?
You are what you eat. Think about feeding your body parts just a little better.
Tonight while you sleep, you're repairing brain cells, muscle cells, nerve cells, liver cells, and skin cells. Will your system be sorting through a minefield of groceries to find the right reconstruction materials? Will happy serotonin messages hop through brain cell membranes made of nice slick fish oils, or will the neurotransmitter have to slog through sludgy beef and cheese fat?
Last year, endocrinologist Steve Grinspoon found fatty livers in 50% of people recruited for an HIV metabolism study. A fatty liver is step one in giving people "a touch of diabetes" (especially true for people co-infected with hepatitis C and HIV). Excess weight, antiretrovirals, and oxidative stress of infection play a role in the fat being there, but dietary fats and excess sugar can amplify the problem.
Think about it: what kind of grease was your last serving of French fries cooked in? What kind of semi-plastic shortening was in the muffin or cookies you snacked on yesterday?
The ideal food plan is a caveperson-style diet. It's a chunk of protein for breakfast, and more for lunch and supper. It's careful about fat. For the caveperson, there was only lean protein -- fish, mussels, scallops, birds, and maybe deer or antelope. The only other fat to be found back then came from nuts and seeds. The omega 3 oils in fish, plus the oils in nuts and seeds, are the fat your genes are most comfortable with. Corn and vegetable oils are new creations.
The Grinspoon group that reported on the fatty livers also found that people eating more polyunsaturated fats (found in vegetable oils, like corn and safflower) experienced more lipodystrophy. Remember: nuts, seeds and fish oils know how to travel in your system, keeping your face filled out instead of wasting and your arms and legs from looking too veiny/vascular.
For the caveperson, melons, fruits and berries -- plus a lot of leaves and shoots -- were major fuel sources. Grains hadn't been invented yet, so you would have eaten two bags of spinach leaves to get the 200 calories that Lender stuffs in your bagel. As you can imagine, there is a whole lot more T-cell support in the leaves, blueberries and strawberries than in flour and water, which makes school-kid paste ... and bagels.
When you're looking for some starches for dinner, give peas a chance. Dig some tubers, like potatoes. Put some pintos, black beans or lentils on your plate, daily. Okay, after all this, you get some dark chocolate, or milk and a macaroon, for dessert.
The simple truth is this: a higher protein diet with extra big servings of fruit and vegetables, careful selection of fats, and some attention to limiting junk carbs (those muffins and cookies) goes a long way to preventing or reversing lipodystrophy. It also keeps heart disease away.
What kind of metabolic and physiologic shape are you in?
Perform a self-scan, top to bottom, and see what could get buffed up a bit.
Hormones direct your metabolism. How are yours? Be sure your testosterone levels are okay. It's not just about libido? testosterone matters to bone and muscle strength, sugar and cholesterol metabolism, and better mood. When testosterone runs low, the body experiences this condition as something stressful and releases more of a particular inflammatory signal. This messes up insulin signaling and disrupts fat cell refilling. Know what your total and free testosterone levels are. If they are low, fix them. This goes for both men and women.
Ed. note: There is limited data available regarding HIV-positive women and testosterone, but it is known that low testosterone levels can occur. Some physicians replace testosterone in women using patches or gels/creams, though it can be challenging to find a dose low enough to avoid masculinizing side effects like excess hair and acne -- careful monitoring is required. There have been promising studies on the impact of testosterone replacement in women to treat muscle wasting; research continues on the impact of testosterone on bones, muscles and energy.
Intestine cells struggle. All stretched out, intestines cover an area the size of a tennis court. Gut cells are replaced every three to four days, a huge amount of work for the body. HIV changes their shape and size, reducing their ability to absorb nutrients. Antiviral medicines, like protease inhibitors, often irritate gut cells.
When something is not right in this gut cell system, it's quite a strain on the body. Gut cells will send out distress signals, but these can distort metabolism, again making it hard to keep fat cells filled up in the right places, and making it hard to maintain weight.
View your intestines as an ecosystem. There are about 4 pounds of beneficial bacteria that live in the intestine. They depend on fruit fibers, like the pectin of apples and bananas, for their nutrition -- what they would get from the three to four doses of fruit a day in your caveperson diet. These good bugs make the amino acids and fats that are "repair groceries" for the intestine surface. If they are not doing their job well enough, the back-up amino acid supply for gut repair, L-glutamine, gets pulled from the supply in the muscles. In this way, gut distress and repair problems can affect the muscles all over the body.
In your scan of body systems, think about how your intestines are doing. If you are having diarrhea a few times a week, don't just take anti-diarrhea pills. They only treat the symptom. Behind the scenes, something is not right in the repair process. Use good nutrition as the authentic solution. Eat enough fruit, and then learn about acidophilus/probiotic blends of supplements and L-glutamine to support your gut.
Do you get the diarrhea that happens about one hour after a meal, the "uh-oh, I gotta find a bathroom in about 12 seconds" kind of urge? This is about digestion problems, not about gut cell repair. There is a pH (acidity) problem in your intestines. Protease inhibitors can keep the intestines a little too acidic, so fat digestion is not complete enough. Unabsorbed fat turns to soap, and -- bam! -- you get the hurry call.
There is a pancreatic enzyme called Pancrecarb (available by prescription) that can help with digestion. Unlike other digestive enzyme supplements, it contains bicarbonate, which helps restore the natural conditions necessary for digestion in the upper intestine. I get e-mails from people all over the country who tell me that the combination of one teaspoon of L-glutamine powder once or twice a day plus Pancrecarb, taken with meals, has stopped years of diarrhea within a day or two of taking them.
Know what you personally have to do to be sure your intestinal system is in great shape. Your whole body will be happier for it.
Mitochondria are the power plants of cells -- they convert nutrients into energy. They are not something you can scan, but your blood fats -- triglycerides and cholesterol -- can give you a good idea of mitochondrial functional status.
Okay, let's presume that your diet is reasonable and your health status is alright. You eat good foods most of the time, and desserts are modest. T-cells are stable and above, let's say, 100; viral load is less that 20,000. Let's also say you don't eat over-the-top amounts of grease and sugar and you don't have fevers and wasting, which can also raise blood triglyceride (fat) levels.
You have probably heard the term "mitochondrial toxicity," especially with respect to drugs like d4T and ddI, which have been shown to cause more mitochondrial damage than some other antiretrovirals. When mitochondria are damaged, fat you eat isn't burned up for energy completely enough and it accumulates in cells. Switching to a less toxic drug can reduce the mitochondrial damage, but repair is slow and fat metabolism is sluggish, and so, are you.
Cells clogged with fat are irritated and release a stress signal that messes up sugar metabolism, including insulin activation. A chronic infection like HIV (or HCV) generates many stray electrons ("those darned free radicals," as Dr. Judy Shabert has called them), which means more mitochondrial stress.
For someone with HIV, a blood triglyceride (think: grease) level above 150 suggests mitochondrial energy-processing trouble. Triglycerides travel with a cholesterol coating, so blood cholesterol levels rise, as well. Unfortunately, the level of "good cholesterol," HDL (high density lipoprotein), doesn't rise amid the irritation -- it drops.
It is common to treat the high lipids with a statin drug like Lipitor, or a fibrate like Tricor, but these are seldom effective enough. Medical groups at the VA and at Baylor University report that 75?80% of their HIV patients with hyperlipidemia fail to reach proper cholesterol and triglyceride lipid levels using standard drug treatments. While statins and fibrates lower blood fats by blocking an enzyme that's needed to make cholesterol, nutrition repairs the basic cellular problems of mitochondrial distress, poor fat-burning, and deranged sugar metabolism.
When it comes to mitochondria, what my recent dinner friends and you need to know is how to help liver and muscle mitochondria restore fat-burning and energy-making ability.
First, taking some extra antioxidants, like 1,000 mg of vitamin C and 600 IU of vitamin E each day, can go a long way to repairing mitochondria. Next, taking 1 to 1.5 grams a day of the amino acid L-carnitine for a month or two can generally lead to a drop in triglyceride levels by at least 25%. Then, taking 3 grams a day of omega 3 fats (fish oils) tells the liver cells to burn off some stray fat in peroxisomes, alternative energy-making units in cells.
The combination of caveperson diet, two to three antioxidant vitamin pills per day, some fish oils, and L-carnitine for a few months offers the prospect of radical improvement in blood fats. One of my patients on Kaletra and Combivir, plus gemfi brozil to lower lipids, had his triglycerides drop from 1800 to 400 in four weeks after he adopted this nutrition regimen. Another patient, on a PI-only regimen of Kaletra and Fortovase and 10 mg of Lipitor, had a cholesterol of 278 and triglycerides of 1,400. Seven weeks into the caveperson diet plus two antioxidant-with-B-complex vitamin pills, 3 grams of fish oil and 1 gram of L-carnitine, he e-mailed me to report his cholesterol was down to 172 and his triglycerides were at 166. He had also gotten back to a walking program of three to four times a week.
The supplement regimen is not forever. Taking some good vitamins to support both CD4 and CD8 T-cells is fundamental. This can cost as little as $12 for a six-month supply (e.g. Trader Joe's Vitamin Crusade antioxidant formula). Buyers clubs (e.g., Boston, Houston and New York Buyers Clubs) have more potent combinations that cost more but include more immune-supportive trace minerals, like selenium and magnesium. (Visit www.bostonbuyersclub.com, www.houstonbuyersclub.com, and www.newyorkbuyersclub.org.)
You might take less of the other supplements. Salmon for lunch and supper a few days a week may replace fish oil pills. A lot of people find the L-carnitine gives them energy, so they keep taking some. Some people take 100 mg of coenzyme Q10 for a few weeks at a time, because they feel it also gives them added energy. These extra supplement items each cost $10-$15 a month, which adds up. Save money; use them when you need them.
Where do you go from here?
Start by getting in touch with the way you eat and live.
The news from HIV research and care centers is that being on HAART increases the risk of heart disease. Fat carried in the gut area contributes to elevated cholesterol and insulin resistance, a contributor to diabetes. High blood fat is part of it; irritations from medicines play a part, too. Lifestyle stuff -- excess weight, cigarette smoking, lack of exercise -- also contributes.
Step back and take a look at how well you are really eating these days. Maybe write down everything you eat for 3 days, including one weekend day, and size it up against the checklist here. The goal is to get as close to this list as possible so your body works as well as possible and you feel good ... or even better.
In making changes in your lifestyle, discover the benefit of some extra focus on diet and nutritional supplements. There are small steps, like my dinner companions and I sharing one dessert as a step toward weight management, and bigger ones, like trying a protein-fruit-nut breakfast for a few weeks. Explore what high quality vitamins or other supplements might do for your energy levels.
The bottom line is that there are many steps you can take to help control the effects of HIV disease, antiretrovirals, and aging. The important thing is to start.
References available at www.tpan.com.
Charlie Smigelski is a Registered Dietitian who has been with Fenway Community Health Center, one of Boston's primary HIV treatment and research centers, for 14 years. His special emphasis is on how diet and supplements can reduce or reverse side effects of HIV and HAART, and helping people live more comfortably with their medical regimens. He is the author of Eat Up! Nutrition Advice and Food Ideas For People With HIV and AIDS.
How Close Is Your Diet to This List Each Day?