HIV-Associated Lipodystrophy

People living with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) are susceptible to metabolic changes and chronic inflammation. Historically, individuals with HIV or AIDS have been identified as being at increased risk for malnutrition relative to unintentional weight loss. However, antiretroviral therapies (ART) and individual lifestyle factors also may contribute to weight gain. It’s estimated that 60 to 70% of individuals with HIV or AIDS have a body mass index (BMI) within the overweight or obese range; however, the rates of sarcopenic obesity, which is associated with increased mortality, have not been determined in this population.

Alterations in adipose tissue may also develop following treatment with highly active antiretroviral therapies (HAART). This syndrome, called HIV-associated lipodystrophy syndrome (HALS), includes body shape changes and metabolic disorders, but its presentation can vary depending on the patient/client.

With HALS, weight will usually remain stable despite changes in body composition. Taking anthropometric measurements is useful in monitoring location of either fat hypertrophy or atrophy. One study in patients with HIV and lipodystrophy found a 17.6% increase in upper-limb fat mass with decreases in truncal and lower limb fat mass.

There are two different forms of lipodystrophy seen in patients living with HIV. Lipoatrophy is a type of fat wasting where there is a loss of the subcutaneous adipose tissue from the face, arms, legs, and buttocks, with visual prominence of extremity blood vessels. It has been reported less often with the use of newer generation ART. Lipohypertrophy is another type of lipodystrophy resulting in fat accumulation in specific parts of the body, such as the abdomen or trunk.

Lipoatrophy and lipohypertrophy may or may not coexist. HIV patients with body fat changes are at increased risk for developing metabolic abnormalities that include elevated levels of serum triglycerides and low-density lipoprotein cholesterol and reduced high-density lipoprotein cholesterol. This dyslipidemia is similar to that seen in the metabolic syndrome, raising concern that using HAART can potentially increase the risk for cardiovascular complications. There has also been an associated increased risk of hypertension, reduced bone density, diabetes, and impaired glucose tolerance.

Currently, nutrition studies in patients with HALS are limited and conflicting. Nutrition education and counseling have been shown to be effective with weight gain and weight maintenance for HIV patients with wasting syndrome and other gastrointestinal problems, though a need for current research exists.

Overall, there is a lack of recent research evaluating the effectiveness of practices that are currently being used in the nutritional management of HIV. Energy and protein needs may be elevated based on earlier research, and nutrition therapy for co-morbidities in HIV-uninfected populations may be applicable to patients with HIV. The use of dietary supplements may be warranted to correct micronutrient deficiencies and to offset bone loss.

General nutritional considerations for the treatment of lipodystrophy include:

• maintain an appropriate weight range;
• increase dietary fiber intake;
• include foods rich in omega-3 fatty acids;
• encourage smoking cessation; and
• incorporate physical activity and resistance training.

Medical nutrition therapy provided by a registered dietitian nutritionist is recommended for all individuals with HIV. The number of encounters will be contingent on whether a patient is symptomatic or asymptomatic and may need to address a variety of nutrition-related issues, including food access and food safety. Twenty-four to greater than 50% of people with HIV and AIDS are estimated to be affected by food insecurity, which can also significantly affect ART adherence.

Nutrition interventions should be individualized and support the client's treatment goals while reducing any negative nutrition-related health impacts of the disease and the medication regimens. RDNs, as part of the health care team, can help individuals with HIV improve their nutritional status and potentially their quality of life.

References:

• Willig A, Wright L, Galvin TA. Practice Paper of the Academy of Nutrition and Dietetics: Nutrition Intervention and Human Immunodeficiency Virus Infection. J Acad Nutr Diet. 2018;118(3):486-498.
• Academy of Nutrition and Dietetics. Nutrition Care Manual®. HIV/AIDS. Nutrition-Focused Physical Findings. Accessed August 4, 2020.
• Mahan LK, Escott-Stump S, Raymond JL. Medical Nutrition Therapy for HIV and AIDS. In: Krause's Food & Nutrition Care Process, 13th edition. Elsevier Saunders; 2012:864-883.
• Grenha I, Oliveira J, Lau E, et al. HIV-Infected Patients With and Without Lipodystrophy Under Combined Antiretroviral Therapy: Evaluation of Body Composition. J Clin Densitom. 2018;21(1):75-82.
• McKinley MJ, Goodman-Block J, Lesser ML, Salbe AD. Improved body weight status as a result of nutrition intervention in adult, HIV-positive outpatients. J Am Diet Assoc. 1994;94(9):1014-1017.