Increased lipid levels, which may lead to heart disease, are occurring more often among people with HIV.
Powerful HIV medications may be the driving force behind this rise. Reports of how many people have high lipid levels vary from 11 percent of individuals who are protease inhibitor naive to as high as 58 percent of those on a protease inhibitor.
Far fewer people who developed high blood lipid levels were taking nucleoside reverse transcriptase inhibitors (NRTI) or non-nucleoside reverse transcriptase inhibitors (NNRTI) than were taking a drug combination that included protease inhibitors.
All that is known about heart disease in people without HIV infection seems to apply to those with HIV infection. The likelihood -- or risk -- of coronary artery disease is usually not because of just one factor.
Some risk factors, like gender and family medical history, cannot be controlled. Men, post-menopausal women and people whose families have a history of premature coronary heart disease are more likely to develop heart disease. Obesity, smoking, physical inactivity, abnormal lipid levels, diabetes and high blood pressure are risk factors that can be controlled. (See tables accompanying this article.)
Try Something Else
If your lipid levels rise, the first thing your doctor may want you to do is take another medication.
Usually, non-drug therapies should be tried first. The Second Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults recognizes that dietary therapy and exercise are the first steps. According to the report, "drug therapy should be added to dietary therapy, and not substituted for it."
The usual drugs, statins and fibrates, and even niacin, all have a downside.
Shelley is a 40-year-old HIV-infected woman diagnosed with both HIV and AIDS in 1997, after years of experiencing gynecological problems. Since October 1997, she has been on Norvir, Invirase, Zerit and Epivir. She has been contending with side effects of diarrhea, heartburn, poor appetite, fatigue, and dental problems.
This past winter, Shelley learned that her lipid levels were elevated. On Feb. 15, her blood was drawn when she was in a fasted state, that is, she did not have any food or drink with calories for about 12 to 14 hours prior to the test. Fasting blood tests are helpful in making the diagnosis for numerous conditions.
According to her lab report, Shelley's cholesterol was 321 (desirable is less than 200), triglycerides were 861 (desirable is less than 150), and her blood sugar was 91 (normal is 65 to 115 mg/dl). Her fasting blood sugar seemed to be holding steady.
Shelley has never been a smoker, and her blood pressure has always been normal (below 140/90). Shelley also had elevated liver enzymes, and her physician was concerned that she was developing a fatty liver. Although Shelley's labs indicated she was at an increased risk for heart disease (see table), she was not in an emergency state needing drugs immediately. She and her doctor were ready to try diet and exercise first.
Shelley's doctor said the triglycerides were getting to a point that she needed to look at her diet. He said if diet didn't work, then she should use medications to reduce triglycerides. Shelley, who has never liked taking pills in the first place, would rather solve the problem naturally and not rely on more drugs with more potential for interactions and side effects.
Steps That Were Taken
Shelley's doctor suggested she reduce fat intake and not worry about sugars at this time. Shelley asked him about going to a dietitian for guidance, a course of action that he supported. Because Shelley had already established good working relationships with the dietitians in AIDS Project Los Angeles' Nutrition and HIV Program, that is where she decided to go for assistance.
Within a week of receiving her lab report, Shelley came to my office. We talked, and I gave her written information about reducing total and saturated fats, as well as the difference between mono-unsaturated fats and poly-unsaturated fats. I pointed out the differences between foods with varying levels of cholesterol and fats. I gave her daily diet intake forms for her to write out everything she was eating and drinking. We talked about types of exercise she could do on a more routine basis.
Shelley documented her dietary pattern for five days, well enough to recognize her behavioral patterns and take steps to modify them. She circled all the foods she liked in the daily food guide, compared them to the heart-healthy list, and identified which of her usual foods to reduce or eliminate. She posted her work of art on her kitchen refrigerator and explained it all to her husband, Dan, who does the cooking in their household.
All of the small changes in Shelley's eating habits and substitutions in her diet seemed to make a difference. Instead of choosing her same old routine, Shelley developed a list of new things to do. "It really gives me a sense of accomplishment about what I am doing," she said. "I want to wean myself off the dependency of others fixing things for me so I can do it myself."
Shelley acknowledged that she usually purchases and eats cream cheese and butter. She realized that they should now be avoided and she developed ideas for other foods to use as substitutions (see chart).
Exercise, in addition to dietary changes, is a key component in reducing cholesterol levels.
A physical therapist told Shelley that because she has bad knees, running, jogging or playing tennis were not options for her. Others suggested walking would be a good way to exercise, so Shelley began a walking program.
Shelley and I had already been taking regular walks for a few months. We walk for 20 minutes on quiet side streets near APLA, appreciating seasonal flora and neighborhood life. We cover a mile, do a quick nutrition check-in, get a little perspiration going and come back quite refreshed.
Shelley also began walking with her husband in their own neighborhood and local parks. "Walking is good for you," says Shelley. "I walk at a good pace. It does more for me than just increase my heart rate and move my body. I get to talk about things and think them through.
"Walking with Dan helps our relationship, gives us a calming effect and gives me a sense of accomplishment. It is much different from sitting around feeling depressed, which actually makes it even harder to move, and then that feeds on itself. Walking makes me feel like I am not a slug and that I am doing something good for myself that is more than eating drugs. I feel like I am in better control."
Shelley has been participating in APLA's nutrition classes since 1998. From that time her body cell mass increased a total of 6.7 pounds and her body fat decreased a total of 10.3 pounds over a period of time when she gained 18 then lost 16 pounds for a big total weight increase of 2 pounds. Fluid changes account for the rest of the body composition changes.
Those numbers don't tell the whole story, however. Like many HIV-infected women, Shelley has been experiencing body shape changes. Her face, arms, legs and butt are decidedly thinner, and her waist and breasts are larger.
Four weeks after starting to make concentrated dietary changes to bring down her lipid levels, Shelley had a follow-up lab drawn. The lab reported her triglycerides were 625, a reduction of 236, and cholesterol 332, an increase of 9. Her liver function tests, which earlier were high, went down.
Shelley realizes that she has just started the process of really changing her dietary and activity behaviors. While she is a little disappointed in the rise in her cholesterol, she is looking for trends and the overall picture. She has not been in to discuss these labs with her doctor yet.
Is it hard to maintain high standards in diet and activity? "If I try to make a conscientious food choice every time at every turn," Shelley says, "this gives me room to not be 100-percent perfect and when I really want to eat something I really want to eat, I can do it without guilt and still feel in control."
Lowering Lipid Levels
What to do to reduce cholesterol? Reduce the fat content of your meals, add more foods with fiber -- vegetables, fruits, beans and whole grains -- exercise, and if you smoke, cut it out.
Cut down and/or out any added oils and fats, like butter, hard margarine, vegetable oils, fried foods, added fat-laden salad dressings, sauces and gravies. Choose mono-unsaturated over saturated fatty foods.
Choose leanest cuts of meat, and remove any extra fat or skin. Limit meat, poultry and fish to 6 ounces per day. Eat fish two to three times a week. Avoid high-fat processed meats, such as sausage, salami, bologna and others.
Eat three to five servings of vegetables a day not cooked in butter, cheese or cream sauces.
Eat two to four servings of fruits a day. Choose whole fruits over juice.
Include two servings of non-fat or very low fat dairy products, like non-fat yogurt and non-fat or 1 percent milk. Avoid whole and "low-fat" dairy products.
Eat lots of beans and legumes, whole grains, cereals and starches. Have a couple of servings with each meal and snack.
Watch out for added simple sugars and alcohol, especially if you have high triglycerides.
Develop a routine of regular physical activity and weekly exercising. Walk 40 or more minutes three times a week.
What to do to reduce triglyceride levels?
Reduce all types of dietary fat to less than 20 percent of total calories, or about 50 grams of fat a day.
Restrict excessive calories, especially from refined sugars -- table sugar, soda, candies, cakes and other sweets, too many pieces of bread, tortillas or the like.
Cut down and out alcohol.
Increase Omega-3 fatty acids. Eat fish rich in this special fat (salmon, herring, sardines, anchovy, halibut, mackerel and flaxseed seed or meal) two to three times a week.
Control your weight.
|Shelley's Food Substitutions|
|OLD HABITS||RECENTLY DEVELOPED PRACTICES|
|CHEESE! Cheese was eaten on almost anything. Shelley loved cheese in eggs, on crackers, in macaroni, etc.||Uses small amounts of grated Romano or very small amounts of grated cheddar for flavor.|
|Crab Alfredo. Shelley called it "a killer delicious meal" and added a double-baked potato, which she likes. It was a typical meal when she went out to eat.||Shelley remembered that swordfish and salmon were good protein sources, plus they had Omega-3 fatty acids in them. Instead of crab alfredo and double-baked potato, Shelley chose grilled salmon brochette (a kabob-like thing) without extra sauce, a side of steamed vegetables (broccoli, cauliflower, carrots) and rice and sliced tomatoes. Shelley says. "I used the barbecue sauce from the fish to give a little zing to my vegetables."|
|Frying||Shelley uses canola or olive sprays or sometimes water to steam the food. She keeps canola and olive oil on hand, but does not use oil very often.|
|2-percent fat was her choice of milk, and she was a milk drinker||1-percent fat milk was tried and accepted! Milk is used as a beverage and on cereals. The difference is about 30 calories from fat per cup. All that extra fat would really add up cup after cup, day after day.|
|Farmer John sausage||Shelley discovered, tried, and liked Trader Joe's Chicken Sausage (130 calories, total fat 9g sat 2.5g & 12g protein/3 links), and only uses 2 links.|
|Eggs: one egg contains 74 calories with 5g fat, 1.5g saturated fat, 212.5mg cholesterol, and 6g of protein.||Shelley is avoiding regular eggs and buying "Second Nature Eggs," which are egg whites, like "Egg Beaters," just a different brand. One quarter-cup serving is 35 calories, 6 grams of protein with no fat and no cholesterol.|
|Regular mayonnaise||Reduced calorie and reduced fat eggless mayonnaise, which Shelley finds delicious, is good enough that her husband, Dan, uses it too. This mayonnaise has 70-percent less fat and 65-percent less calories, and its ingredients are water, canola oil, vinegar, non-fat dried milk, lemon juice, and spices. 1 tbsp. has 35 calories, 3g fat, and no saturated fat.|
|Salt||Shelley doesn't have high blood pressure, and will "err on the side of salt." For example, on a sandwich of turkey breast and sliced tomatoes to be eaten away from home, Shelley will put plenty of pickles for the "wet" instead of mayonnaise. She could use mustard, but just doesn't like mustard. She will choose whole wheat bread over white bread.|
|Butter||"Smart Balance Butter" has been a helpful substitute for butter. The first ingredient is water, and it has a patented blend to help cholesterol, plus there is no trans-fat or hydrogenated oils or lactose, which is important for anyone lactase deficient. One tablespoon yields 5 grams of fat, which is 1/3 less than regular butter. A usual serving size of butter, though, is 1 teaspoon and 5 grams of fat, so watch out. Don't eat as much fat thinking you are eating less!|
Factors that Increase the Risk for Developing Coronary Heart Disease
Diabetis or insulin resistance
Coronary heart disease in the family
High blood pressure
Other Risk Factors -- Predisposing Risk Factors
Family history of premature coronary heart disease
Conditional risk factors
Elevated serum triglycerides
Small LDL particles
Elevated serum homocysteine
Elevated serum lipoprotein (a)
Prothrombotic factors (e.g., figrinogen)
Inflammatory markers (e.g., C-reactive protein)
A Low-Risk State According to Framingham Study
Serum total cholesterol: 160 to 199 mg/dl
LDL-C: 100 to 129 mg/dl
HDL-C: >45 mg/dl in men and >55 in women
Blood pressure: <120 mm Hg systolic and <80 mm Hg diastolic
No diabetis mellitus
|Relative Risk for Coronary Artery Disease|
|Cholesterol||130-200 mg/dl||200-239 mg/dl||240 mg/dl|
|HDL cholesterol||At or above 35 for men; above 45 for women|
|LDL cholesterol||Below 130 mg/dl||130-159 mg/dl||At or above 160 mg/dl|
APLA's Nutrition & HIV Program offers classes on reducing high cholesterol and high triglyceride levels, managing diabetes and high blood sugar levels, as well as classes on basic nutrition and preserving lean body mass with BIA testing. Call (323) 993-1612 for an appointment.
Marcy Fenton, M.S.., R.D., is AIDS Project Los Angeles' Nutrition advocate. She can be reached by calling (323) 993-1611 or by e-mail at mfenton@APLA.org.
This article has been reprinted at The Body with the permission of AIDS Project Los Angeles (APLA).