What Should You Eat If You're Dealing With HIV and Lipodystrophy?
That's a simple-sounding question without one simple answer. Lipodystrophy is a complicated syndrome, including high blood fats, insulin resistance, and fat redistribution. Because the causes of lipodystrophy are not fully understood, optimal treatment strategies -- including dietary strategies -- are not yet established. Can food choices prevent or reverse lipodystrophy? Nutrition may not be the one "magic bullet" for treating lipodystrophy, but combined with medical treatment, nutrition is a vital component of your treatment arsenal.
Early in the epidemic, HIV nutrition education materials focused on preventing and reversing weight loss and wasting. Butter, cream, rich cheese dishes and the like were often suggested to get in more calories. While wasting and weight loss are still problems in HIV today, we emphasize foods that are high in calories and protein, but that are also heart-healthy. Unlike the early years of HIV disease, now as people are living longer with HIV, we are contending with all those long-term health problems like heart disease, stroke, and diabetes.
What We Know So Far ...
Cholesterol and triglycerides (TG) are types of lipids (fats) that travel in the bloodstream. High levels of cholesterol and TG don't cause physical symptoms. (The one exception is really high TG, which can cause pancreatitis.) But while you won't "feel" high blood fats, the increased risk for cardiovascular problems is very real. Elevated low-density lipoprotein (LDL) cholesterol (the "bad" cholesterol), elevated TG, and decreased high-density lipoprotein (HDL) cholesterol (the "good" one) all put you at risk for cardiovascular disease.
If your cholesterol and TG are normal and then jump after starting highly active antiretroviral therapy (HAART), changes in eating habits likely won't bring your levels all the way back to normal. But, diet changes likely will yield some improvement. Switching HIV medications helps bring down blood fats in some cases, but changing meds often isn't clinically appropriate. Lipid-lowering medications are an option, but that doesn't mean that nutrition changes are fruitless. Because of drug-drug interactions, the number of lipid-lowering medications is limited for people on HAART. So, it's critical to do as much as possible to bring down blood fats through eating habits and exercise.
Simply stated, diet and exercise can improve blood fats in people with HIV. And for those who need a lipid-lowering medication, lifestyle changes will improve lipids more than the medication alone.
The role of food in insulin resistance is still under investigation. Insulin resistance is a condition that often develops into diabetes. Blood sugar levels are often normal in insulin resistance, so the condition is not as easy to spot. The goal of treating insulin resistance is to improve insulin sensitivity and prevent diabetes.
Most of what is known about food and insulin resistance comes from studies of people without HIV. Among HIV negative people with insulin resistance, insulin sensitivity improves by achieving and maintaining a healthy weight, exercising, and eating a fiber-rich diet that is low in fat, processed foods and sugars, and alcohol. Whether these findings apply to people with HIV is not known, but it's a hot area of research. One study that evaluated past dietary habits of people with HIV (both with and without fat redistribution) found no connection between dietary fats and blood levels of fats, sugar, or insulin (Batterham et al.). Another recent study analyzed eating patterns of people with HIV and fat redistribution and found that those with lower fiber intakes and higher intakes of polyunsaturated fats and alcohol were more likely to have high lipids and insulin resistance (Hadigan et al.). However, this study didn't try to show if increasing fiber, reducing alcohol, and moderating polyunsaturated fats would actually prevent or reverse lipodystrophy. More studies are needed.
Insulin resistance often occurs along with fat redistribution, particularly abdominal fat accumulation. This increased visceral fat is not only uncomfortable and distressing, but it also increases cardiovascular disease risk. Which specific dietary factors might affect this fat accumulation are not fully understood, but a few reports have found improvement through strict adherence to a low-fat, high-fiber diet combined with exercise (Roubenoff et al. 1999, Roubenoff et al. 2002, Yarasheski et al. 2001). A case report published earlier this year found that a combination of diet and exercise reduced abdominal fat in a man with HIV (Roubenoff et al. 2002). The diet was high in fiber (more than 25 g per day) and low glycemic index foods (see "Limit Highly Processed Foods and Sugars" below), and low in saturated fat. To date there are no nutrition guidelines specifically targeting lipoatrophy.
So, you may be asking, what am I supposed to eat?
Just as high blood fats, insulin resistance, and fat redistribution in HIV seem to be interrelated, the nutrition advice for all is similar. In general: Maintain a healthy weight, exercise regularly, cut back on dietary fats (and choose healthy fats), eat more fiber, and cut back on processed foods, sugar, and alcohol. What exactly does this mean as you walk down the aisle of the grocery store or scrutinize a restaurant menu?
Choose Your Fats Wisely (and Cut Back on Fats Overall)
There are several types of fats in food, some healthy and some not-so-healthy. Limiting your intake of the not-so-healthy ones (saturated and trans fats) or replacing them with more healthy fats (unsaturated fats) helps bring down LDL (bad cholesterol) and TG, and may help improve insulin sensitivity.
Saturated fats are mostly found in animal fats, such as fatty cuts of meat, skin on poultry, whole-milk, cheese, cream, butter and lard. Cut back on these.
... Reducing the Amount of Fat You Eat Overall Seems to Help Reduce Abdominal Fat
Unsaturated fats, which are found mostly in plant-based foods, don't raise blood fats, and if used in place of saturated fats may help bring LDL and TG down without decreasing the HDL (good) cholesterol. Unsaturated fats are further classified as monounsaturated or polyunsaturated. The monounsaturated fats seem to be the most healthy. These include: olive oil, canola oil, most nuts and nut butters, seeds, seed pastes, avacado and olives. Although polyunsaturated fats (found in corn oil, soybean oil, walnuts, oily fish) probably don't increase your blood fats like saturated fats, there is controversy over whether excessive amounts of polyunsaturated fats should be avoided. Avoiding polyunsaturated fats altogether is not necessarily a good idea. Foods rich in a particular type of polyunsaturated fat -- omega-3 fatty acids -- seem to help bring down TG and may have other unique cardiovascular protective effects. Omega-3s are found in fatty fish (salmon, mackeral, sardines, herring, trout, tuna), flax seed, and breads and cereals fortified with flax.
Another type of fat in food is trans fats. Like saturated fats, trans fats seem to raise blood fats. Trans fats are created through a process called "hydrogenation." Hydrogenation is how vegetable fats are transformed to be solid at room temperature (such as margarine or shortening.) Foods made with hydrogenated fats have a longer shelf-life, so you'll find them in many packaged and processed foods. There is no requirement for listing trans fats on food labels, so the best way to know if a food has trans fats is to look for the words "partially hydrogenated oil" in the ingredient list.
A common question: which is better, butter or margarine? My answer: use less of either. Butter has more saturated fat, but margarine has a lot of trans fat, so neither is particularly healthy. Your best bet is to look for an alternative spread: for people who use butter or margarine every day, switching to a spread with plant stanols (Benecol, Take Control, etc.) may actually help bring down your LDL. Or, look for reduced-fat spreads or spreads made with part low-fat yogurt.
For a person who needs about 2,000 calories a day, the recommended breakdown of fat in the diet looks something like this: 35 g of monounsaturated fat, 16 g of polyunsaturated fat, and less than 16 g of saturated and trans fat combined.
Remember that even healthy fats should be used in moderation -- reducing the amount of fat you eat overall seems to help reduce abdominal fat. And remember that all fats are high in calories, and excess calories leads to excess weight. Being overweight in and of itself increases the risk of elevated blood fats and insulin resistance.
Eat Less Dietary Cholesterol
The cholesterol in food does not increase blood cholesterol as much as saturated and trans fats, but it's a good idea to avoid excessive amounts. Egg yolks are high in cholesterol, so you should limit yourself to the equivalent of one yolk per day. Other foods that are high in cholesterol (such as shrimp, shellfish, and organ meats) should probably only be eaten once or twice a week.
Eat More Fiber
To help bring down blood fats and improve insulin sensitivity, eat 25 to 35 g of fiber per day or more. On average, the typical American eats only about 12 g, or half the recommended level. Fiber is found primarily in vegetables, fruits, beans/legumes, and whole grains. If your current fiber intake is low, increase your intake gradually and drink more fluids -- a quick jump in fiber intake without added fluids may cause digestive distress.
Excessive amounts of sugar and refined carbohydrate foods may raise TG and decrease insulin sensitivity. Limiting these foods and eating smaller portion sizes may help. Carbohydrate foods are not "fattening" per se, since they often have minimal fat in them. But in our "supersize" society, portion sizes are often large and those excess calories have to go somewhere!
Some researchers advocate choosing carbohydrate foods according to their "glycemic index." The glycemic index (GI) is a measure of how quickly the sugar from a carbohydrate gets into the bloodstream. The higher the GI the faster the sugar from the carbohydrate is absorbed.
Beans/legumes, most dairy foods, vegetables, and whole grains have a low GI, whereas refined grain products, instant rice, and potatoes have a higher GI. Fruits vary in their GI. Choosing low GI carbohydrates over high GI carbohydrates seems to help diabetics control their blood sugars. Whether following the GI index will help improve insulin sensitivity in HIV, however, is not known. It certainly makes sense, however, to eat a diet rich in beans/legumes, vegetables, and whole grains (all lower GI foods), which are all rich in nutrients and high in fiber.
Eat More Soyfoods
Soy seems to help bring down LDL cholesterol, and since soyfoods are also high in fiber they may also help with TG and insulin resistance. If you're wrinkling your nose at the thought of tasteless tofu, you'll be happy to know that more types of soy foods are emerging. Soy milk, roasted soy nuts, soy beans, edamame (soy beans in the pod), soy-fortified cereals, soy cheese, and soyburgers are just some of the products available at many mainstream grocery stores.
Alcohol raises TG and may reduce insulin sensitivity. Alcohol also has "empty" calories and may impede weight loss efforts. So, when it comes to alcohol, less is probably better.
Other Lifestyle Factors
Exercise is an essential component in treating lipodystrophy. A combination of aerobic exercise, weight training, and flexibility/stretching is ideal, but any exercise program should be specifically designed for the individual and his/her medical condition. You also need to nourish your body adequately to support physical activity. (See "Eating for Exercise.")
While studies of the relationship between smoking and lipodystrophy are lacking, it certainly is advisable to cut back and ultimately quit to cross off a huge risk factor for cardiovascular disease.
Nutritional Strategies to Improve Lipid Profile and Increase Insulin Sensitivity
|Tip||Foods to Choose||Menu Ideas||How it Helps|
|Aim for at least 25-35 g of fiber per day (or more). Focus particularly on soluble fiber.||Dried beans/legumesFruits and vegetables at LEAST five servings per dayOats/oatmeal, whole grain breads, cereals, pasta, rice||Eat more vegetable-based meals (such as beans and rice).Choose bean spreads (such as hummus, black bean dips) instead of sour cream or cheese-based dips and spreads.Choose cereals and bread made with oatmeal.Add fruit to salads, cereal, desserts.Choose fruits for snacks.Add extra vegetables to sandwiches, soups, casseroles.||Reduce LDL (bad) cholesterolReduce triglycerides (TG)Minimize insulin resistance|
|Use less fat, especially saturated fats.|| ||Use nonstick pans or cooking sprays in place of butter, oil, etc.Replace half or more of the fat in baked goods with applesauce or low-fat yogurt.Try broiling, baking or grilling instead of frying food.Try low-fat versions of dairy foods, salad dressings, etc.Trim visible fat from meat.Remove skin from chicken or turkey.||Reduces calorie intake and promotes weight lossReduce LDL and TG|
|Use monounsaturated fats in place of saturated fats or hydrogenated (trans) fats.||Olive oilCanola oil||Use oils in place of butter.Use oil/vinegar salad dressings.Use oils in place of butter in baked goods.||Reduce LDLReduce TGMay minimize insulin resistance|
|Choose "healthy" fats.||Peanuts, nutsNut buttersSeedsOlivesAvocado||Snack on nuts, sunflower seeds.Use olives and avacado in salads and sandwiches.Try different nut butters (cashew butter, almond butter, etc.) for a new sandwich flavor.Add sunflower seeds or sesame seeds to salads.||Decrease LDLDecrease TGMay increase HDL (particularly if healthy fats are replacing unhealthy fats)|
|Increase omega-3 fatty acids.||Fatty fish (salmon, mackerel, sardines, herring, lake trout, tuna)Flax seed||Aim to eat fish at least twice a week.Spread canned tuna on crackers for a quick and healthy snack.Try flax-fortified cereals and breads.Add ground flax seed to baked goods, cereals, soups, salads.||Reduce TGMay increase HDL|
|Eat more soy foods.||Soybeans, EdamameTofuSoymilkSoy cheeseSoy franks/soy-burgersTempehSoynutsSoy flour||Blend silken tofu into dips.Add tofu or soybeans to casseroles and stirfries.Snack on Edamame or soynuts.Try soymilk on cereal or in place of milk.Grill soy franks/burgers and top with tomatoes, peppers, relish etc.In baked goods, replace one-fourth of the regular flour with soy flour.||Reduce LDL|
|If you use butter or margarine regularly, try plant stanol ester spreads (a "functional food" developed to help improve lipids).||Brand names: Benecol, Take Control, Smart Balance||Use these in place of butter or margarine as a spread on sandwiches, toast etc.Some of these may be used in baking and frying in place of butter, margarine, or shortening (be sure to check the label).||If you typically have used several servings of butter or margarine per day, replacing this with plant stanol spreads may help reduce LDL.|
|Decrease alcohol intake.|| ||For men, drink no more than 2 servings of alcohol per day, and preferably less.For women, drink no more than 1 serving per day (1 serving = 12 oz beer, 5 oz wine, 1 oz liquor).||Reduce TGImprove insulin sensitivity|
|Limit intake of sugar and refined flour.|| ||Avoid excessive intake of sweets/cakes/cookies/ etc.Choose fruit instead for snacks or dessert.Limit intake of soda and sugar-sweetened beverages.Choose whole-grain, high-fiber cereals or oatmeal in place of sugary cereals.Choose whole-grain breads over white breads or rolls.In baking, if a recipe calls for regular flour, replace half with whole-grain flour.||Reduces TGMinimizes insulin resistance|
|Cut Back on ...||... And Replace With|
|75% lean ground beef (this means it's 25% fat)||85% or 90% lean ground beef Ground (skinless) turkey breast|
|Marbled meats (that marbling is fat!)||Leaner cuts: round, loin, sirloin or chuck arm|
|Regular breakfast sausage||Low-fat sausage or turkey sausage|
|Pork bacon||Low-fat bacon, turkey bacon, ham or Canadian bacon|
|Fried chicken||Skinless chicken (Try coating skinless chicken with seasoned breadcrumbs and baking it in the oven for a healthy crispy coating.)|
|Beef or pork frankfurters, Polish sausage, Bratwurst||Low-fat hotdogs, turkey franks, tofu or soy-based franks|
|High-fat pizza toppings, such as pepperoni, sausage, extra cheese||Lower-fat toppings, such as Canadian bacon, low-fat ground beef, vegetables|
|High fat lunch meats, such as bologna, salami, pastrami, corned beef||Lower fat sandwich meats, such as turkey, chicken, boiled ham, lean roast beef|
|Egg yolks||Egg-replacement products; use two egg whites in place of one whole egg|
|Whole milk, 2% milk, Whole chocolate milk||Fat-free milk (also called "skim") or 1% milk, Reduced-fat chocolate milk|
|Whole milk yogurt||Low-fat yogurt|
|Regular cheese||Low-fat cheese|
|Regular cream cheese||Low-fat cream cheese alternative spreads (such as jam or nut butters)|
|Regular sour cream||Low-fat sour cream, low-fat yogurt|
|Butter, margarine, lard, shortening||Plant stanol spreads, canola oil-based spreads (labeled "trans fat free"), yogurt-based spreads (In cooking, use olive oil or canola oil in place of butter, margarine, or lard)|
|Fatback (in cooking)||Skinless chicken or turkey thigh, smoked turkey|
|Cream in cooking||use low-fat milk or yogurt instead|
|Mayonnaise||Low-fat mayo, alternative sandwich spreads such as mustard|
|Cream-based salad dressings||Low-fat salad dressings, vinegar/oil dressings|
|Tartar sauce for fish||Lemon juice|
|Packaged cookies, cakes, crackers (high in trans fatty acids from hydrogenated oils)||Low-fat snacks, homemade baked goods (using healthy fats)|
Shelley Scott is a dietitian at The CORE Center for Prevention, Treatment, and Research of Infectious Disease, for the Cook County Bureau of Health, in Chicago, IL. She can be reached via email at firstname.lastname@example.org. References are available from author upon request.