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À la Carte -- 5. Managing the Effects of HIV and Meds on the Body

Part of A Practical Guide to Nutrition for People Living With HIV

October 2007

Food-Drug Interactions

Following the food guidelines for your meds will reduce the chance of resistant virus. Check with your doctor or pharmacist about food requirements.

The interactions between you, HIV, medications and nutrition are complex. Nutrients and substances in foods can interact with drugs -- both your anti-HIV meds and other meds -- either enhancing or diminishing the effect of the medication. In addition, some foods can change the absorption of drugs. This is why following food requirements for certain drugs is so important. By not following recommendations, the level of the drug in your blood may decrease to the point where it is like missing a dose. This can lead to viral resistance and the need to change therapy.

Generally, having something to eat when taking medications, as long as this is allowed, can improve tolerance and reduce side effects.

Balancing Food and Meds

  • Be sure to know the food requirements for all your medications. Following food guidelines is part of succeeding with your therapy.
  • Unless meds must be taken without food, try to eat something with each dose. This will make the meds easier to tolerate, especially with the morning dose.
  • Talk to your healthcare team about how to deal with side effects. See Chapter 6 for ideas on how food can help.

Lipodystrophy

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Lipodystrophy syndrome (lipo for short) is the name for a group of separate, but related, conditions that are associated with HAART. The term lipodystrophy actually refers to several distinct problems, including abnormal fat loss or gain and metabolic complications. These may occur separately or together. CATIE's Practical Guide to HIV Drug Side Effects also addresses lipodystrophy. Find it at www.catie.ca. Or call 1-800-263-1638 to speak with a treatment information educator.

Abnormal Fat Distribution

Fat Loss -- Lipoatrophy means a loss of subcutaneous fat (the fat just below the skin) in the face, arms, legs, buttocks and sometimes the trunk. Lipoatrophy (loss of fat) is distinct from muscle wasting (loss of lean body mass). While it can be disturbing to lose body fat, muscle wasting is a much more serious medical condition (see "Weight loss and wasting," Chapter 6). If you notice a thinning of the limbs or buttocks, rather than assume this is purely due to fat loss it is important to assess whether any muscle loss is also happening. Talk with your doctor about this.

Lipodystrophy can be difficult to treat. Talk with your doctor.

Lipoatrophy is difficult to reverse, and nutrition therapy is not an effective treatment. It is important to realize that any weight loss will worsen fat loss, especially in the face, and that fat may not come back even if the weight is regained. Talk with your doctor about ways to manage lipoatrophy.

Fat gain -- In another aspect of lipodystrophy, fat can accumulate in different parts of the body, including in the abdominal cavity around the organs, in the breasts, as a pad of fat between the shoulder blades or on the back of the neck (sometimes called "buffalo hump"), and sometimes as subcutaneous fat on the back, particularly in women.

This accumulation of fat is not the same as normal weight gain. Although it can be difficult to treat, some people have been able to reduce stomach fat accumulation with diet and exercise. Talk with your doctor about ways to manage fat gain.

Metabolic Complications

There are many risk factors for developing heart disease, which remains the number one cause of death in the developed world. Some of these can't be changed, like age, gender, ethnicity and family history. Other risk factors can be modified, including having abnormal blood cholesterol or triglyceride levels, diabetes or insulin resistance, high blood pressure, being obese or having a big waist circumference, smoking and not exercising. Some anti-HIV drugs may increase these risk factors by altering blood fat levels, causing insulin resistance and increasing abdominal fat.

Dyslipidemia and heart disease -- Dyslipidemia is the term used to describe abnormal levels of fats (called lipids) in the blood. The different types of lipids in the blood that are routinely measured include HDL cholesterol, LDL cholesterol, triglycerides, and total cholesterol. HDL (high-density lipoprotein) cholesterol is the "good" cholesterol -- it removes fats from the blood. LDL (low-density lipoprotein) cholesterol and triglycerides and are the so-called "bad" fats. Total cholesterol is a measure of both types of cholesterol (HDL and LDL) in the blood together. There is a range of values that is considered healthy for each lipid. If your lipid levels fall outside the normal range, you may be at increased risk of problems.

Because what you recently ate affects the levels of lipids in your bloodstream, it is important to have your lipids tested while you are fasting (no food or drink for at least 8 to 12 hours before the test, and no alcohol for a couple of days before).


Normal Lipid Levels for Adults

Total cholesterol

3.0-5.5 mmol/L

Triglycerides

0.4-2.0 mmol/L

LDL

2.4-4.0 mmol/L

HDL men

0.7-1.9 mmol/L

HDL women

0.9-2.4 mmol/L

Cholesterol/HDL ratio

< 5.0

Good nutrition can help protect your heart.

Nutrition and lifestyle factors are always the first line of treatment for abnormal blood lipids. Even if lipid-lowering medications like statins or fibrates are needed, it is still important to work on diet and exercise. Keep in mind that some people with dyslipidemia are underweight and some of the following nutritional strategies promote weight loss. If unwanted weight loss occurs, talk with your doctor and seek personalized advice from a qualified dietitian or nutritionist.

Taking Care of Your Heart

  • Limit fat intake because dietary fat directly affects both the type and amount of fat in the blood. Choose lower-fat products; avoid greasy, fried and fatty foods; and limit the amount of fat added to foods. Prepared snacks and fast foods tend to be very high in fat.
  • Choose better fats like olive oil, canola oil, avocado and nuts. Choose low-fat dairy products and lean meats. Avoid trans fats, found in hydrogenated oils, some margarines, snack and packaged foods. Become good at reading labels.
  • Almonds and walnuts may have cholesterol-lowering properties and are a good source of calories (and protein).
  • Eat less sugar because when the body receives large amounts of sugar it processes them into triglycerides. Concentrated sugar is found in fruit juice (even pure), soft drinks, candy and sweets.
  • Increase omega-3 fatty acids, which are found in fish, flax seeds and walnuts. Eating fatty fish (e.g. salmon, mackerel, trout, herring, sardines) twice a week has been shown to benefit heart health. Omega-3 supplements, usually salmon oil or a blend of fish oils (not liver oil), at a dose of 6 grams or more a day may decrease triglycerides. This amount can aggravate diarrhea or cause indigestion and may need to be decreased. Flax seeds or flax oil provide a vegetarian source of omega-3 fatty acids but don't seem to be as effective at lowering triglycerides. Be sure to tell your doctor if you are taking concentrated sources of omega-3 fatty acids, such as fish oil pills, because at high doses they can thin your blood.
  • Increase fibre, especially soluble fibre like psyllium, oats and legumes (dried peas and beans), to reduce cholesterol absorption and provide alternatives to sugars and meats.
  • Eat more soy products, such as soy milk, tofu and soy beans. They are high in compounds called phytoestrogens, which reduce the risk of cardiovascular disease if you get enough. You need about 25 grams of soy protein a day, which is about 4 glasses of soy milk or 8 ounces of tofu.
  • Limit alcohol to a couple of drinks per week because it directly increases triglycerides. Alcohol is also hard on the liver.
  • Quit or cut back smoking because it is one of the most powerful risk factors for heart disease and lung and other cancers.
  • Cocaine has been shown to increase progression of heart disease and may increase the risk of having a heart attack.
  • Exercise, especially aerobic/cardio exercise, helps reduce triglycerides in the blood, increase HDL cholesterol and improve cardiovascular fitness.
  • Flavenoids, which are found primarily in fruits and vegetables, have a wide range of health benefits, including protection against heart disease. It is best to get them from colourful foods rather than supplements in order to get the wide range of beneficial nutrients found in the food.
  • B12, B6 and folate lower homocysteine levels in the blood. High levels of homocysteine have been associated with an increased risk of heart disease.
  • In some people, niacin is effective at reducing triglycerides and LDL cholesterol and increasing HDL cholesterol, but it can cause itching and skin flushing, as well liver toxicity and insulin resistance. Talk with your doctor about niacin before trying it on your own.
    Read "Have a Heart" in the Fall/Winter 2003 issue of CATIE's The Positive Side, available at www.positiveside.ca.

Diet and exercise are the first line of treatment for abnormal levels of lipids and blood sugar.

Insulin resistance and diabetes -- Some studies have suggested that people with HIV on HAART have a higher risk of developing diabetes or its precursor, insulin resistance. These are conditions that occur when the body is unable to process blood sugar properly and the level of sugar in the blood remains high for long periods of time. If not treated, this can cause serious damage to the blood vessels.

The kinds of food you eat can have a huge impact on what happens to blood sugar levels, and so nutrition can play a significant role in helping insulin work properly and keeping blood sugar in the ideal range. Carbohydrates, especially simple carbs, affect blood sugar levels quickly. Proteins and fats tend to slow down the digestion and absorption of carbohydrates, and so will slow changes in blood sugar levels.

Anyone who has been diagnosed with diabetes should attend a diabetes education centre to get as much information as possible on the management of this disease.

Helping to Keep Blood Sugar in the Normal Range

  • Carbohydrates are the foods that need to be controlled. Limit simple carbohydrates, such as sugars and starchy foods like potatoes, white rice and pasta. Choose more whole grains and fibre because these don't affect blood sugar as strongly.
  • Take a minute to figure out what a portion size is for a particular food. Canada's Food Guide can help.
  • Try spreading out carbohydrates throughout the day. This will help you avoid having a large portion at any one time.
  • Always have proteins and a small amount of fats with carbohydrates. This will slow digestion.
  • Have regular eating habits with consistent meals and snacks at regular intervals throughout the day.
  • Exercise as many days as possible. Exercise after a meal helps blood sugar come down more quickly.
  • Read "La Dolce Vita -- The sweet lowdown on blood glucose levels" in the Spring/Summer 2005 issue of CATIE's The Positive Side, available at www.positiveside.ca.

Mitochondrial Toxicity

Mitochondria are often called the "power plants" of human cells. All cells contain these microscopic structures, which produce energy for the cell to do its work and stay healthy. Mitochondria convert fats and carbohydrates into a molecule called ATP, the basic fuel for cells. Some cells, like nerve, heart and muscle cells, need a lot of ATP, so they have a lot of mitochondria.

One of the most troublesome toxicities of anti-HIV drugs is that they can damage mitochondria. Some anti-HIV drugs damage the DNA so that the cell can't produce new mitochondria. When cells get low on mitochondria, they can't make enough energy to function properly. This condition is called mitochondrial toxicity. It wreaks havoc throughout the body and is thought to contribute to nerve damage (neuropathy), muscle damage (myopathy), heart muscle damage (cardiomyopathy), fat wasting (lipoatrophy) and other health problems. Two anti-HIV drugs associated with the highest risk of mitochondrial toxicity -- d4T (stavudine, Zerit) and ddI (didanosine) -- are used much less frequently now that we have newer, safer drugs that are less likely to cause this effect.

People experiencing mitochondrial toxicity often have elevated levels of lactate (lactic acid) in the blood. High lactate levels can cause nausea, headaches and fatigue and can make you feel full on a small amount of food (early satiety). Very high lactate levels, called lactic acidosis, can be fatal. If lactic acidosis has occurred or is suspected by your doctor, HAART must be stopped temporarily. Once the acidosis subsides, you may restart HAART with a different combination of anti-HIV drugs.

There are no specific nutrition guidelines for treating mitochondrial toxicity, but some small studies have shown a benefit from B vitamins and L-carnitine supplementation. As well, treatment options for children born with defective mitochondria may provide some guidance. In these children, experts often recommend supplementation with all the cofactors that help the mitochondria function properly (see below). Although there is no scientific evidence that this strategy works for mitochondrial toxicity in HIV, it may offer benefits in terms of feeling better and being able to stay on medications.

Helping Your Mitochondria Work Better

  • Mitochondrial toxicity can be very dangerous and requires medical attention. Talk with your doctor before you decide to take any of the following supplements.
  • Try the following supplements: B complex vitamins, coenzyme Q10, alpha lipoic acid, vitamins C and E, zinc.
  • Consider taking L-carnitine (see "Key vitamins and minerals for HIV," Chapter 4).

Bone Health

In recent years, low bone mass and density, called osteopenia or osteoporosis, has become a widespread problem among people with HIV. Osteopenia is an early stage of bone mineral loss in which the bones become less dense and weaker. This condition does not cause pain or limit movement and is usually treated with diet and exercise rather than medications. Osteoporosis, the more advanced form of the disease, results in fragile bones that can fracture easily. The fracture causes pain, limits movement and reduces quality of life. Osteoporosis is sometimes treated with medications as well as diet and exercise. Note that osteoporosis medications may not be suitable for all people, especially women of childbearing age.

It is still not clear whether bone problems are caused by HAART or by the virus itself. However, many other factors are well known to increase the risk of developing osteopenia or osteoporosis. These include genetics (e.g. your mother had osteoporosis); getting older; low physical activity; being underweight; malnutrition; not enough calcium, vitamin D or protein; poor absorption of nutrients; diseases of the liver, gut or kidneys; and low levels of hormones such as estrogen or testosterone.

Getting enough calcium, vitamin D and protein helps to keep your bones healthy.

Some doctors recommend that people with HIV should have their bone density measured every two years by a special X-ray technique called a DEXA scan. The DEXA compares bone density to standards called T-scores. If the T-score is -1.0 to -2.5, it is considered osteopenia; if it's below -2.5 (for example, -3.2), it is considered osteoporosis.

Nutrition is always the first line of treatment for osteopenia or osteoporosis, and studies have shown that increasing calcium and vitamin D can restore some bone mineralization.

Protecting Your Bones

  • Take care of your nutritional needs. There are many vitamins and minerals, as well as protein, involved in keeping bones strong.
  • Maintain a healthy body weight with a BMI between 20 and 25.
  • Get enough calcium from food plus supplements. (See "The big chart of vitamins and minerals," Chapter 4, for food sources.)
    • For prevention, aim for 1,000 mg of calcium a day.
    • During menopause, aim for 1,200 mg a day.
    • As treatment, aim for 1,500 mg a day.
  • Take calcium supplements with food and spread them over several meals for better absorption. Calcium carbonate is the most common form of supplement and the most concentrated, which means fewer pills to take. However, some people find it constipating and bloating. Calcium citrate may be better absorbed and tolerated.
  • Magnesium is a component of bone and interacts with calcium. Whether it needs to be supplemented is not certain. If calcium supplements are constipating, add 350 to 500 mg magnesium per day. If loose stools are a problem, reduce magnesium supplements.
  • Get enough vitamin D. Sunshine is not a reliable source of vitamin D and dietary intake can't be counted on. Current recommendations are for 1,000 IU daily. Calcium supplements and multivitamins contain vitamin D, so be sure to add up the D from all sources.
  • Weight-bearing exercise is critical to maintaining strong bones. This includes activities like walking, running, skipping rope, weight lifting and skating. Even a few minutes of skipping rope a day will stimulate bones to take up minerals.
  • Try to do less of the things that decrease bone health, like smoking, drinking alcohol, consuming caffeine and eating salt.
  • Read "Good to the Bone" in the Fall/Winter 2001 issue of CATIE's The Positive Side, available at www.positiveside.ca.




  
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This article was provided by Canadian AIDS Treatment Information Exchange. Visit CATIE's Web site to find out more about their activities, publications and services.
 
See Also
Side Effect Chart: An Abbreviated, At-a-Glance Guide to HIV Drug Side Effects
More on HIV Medication Side Effects
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