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Dong R, Lin H, Ding Y, Chen X, Shi R, Yuan S, Li J, Zhu B, Xu X, Shen W, Wang K, Ding D, He N. Effects of Docosahexanoic Acid on Gut Microbiota and Fecal Metabolites in HIV-Infected Patients With Neurocognitive Impairment: A 6-Month Randomized, Double-Blind, Placebo-Controlled Trial. Front Nutr 2022; 8:756720. [PMID: 35127778 PMCID: PMC8814435 DOI: 10.3389/fnut.2021.756720] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 12/16/2021] [Indexed: 11/24/2022] Open
Abstract
Neurocognitive impairment (NCI) and gut microbiota dysbiosis are prevalent in patients with HIV infection. Docosahexanoic acid (DHA) supplementation may alleviate multiple neurocognitive diseases symptoms and plays important role in regulating gut microbiota. However, it is not known whether DHA algae oil supplements can alleviate neurocognitive impairment (NCI) and regulate gut microbiota and fecal metabolites. A randomized, double-blind, placebo-controlled trial was performed on 68 HIV-infected patients with NCI. Participants were randomized to receive a 3.15 g daily DHA algae oil supplement or placebo for 6 months. We collected blood and fecal samples from these patients before and after the trial. Mini mental state examination (MMSE) and neuropsychological tests (NP tests) were administered to assess the cognitive status of participants. The influence of DHA algae oil on the gut microbiota, fecal metabolomics, plasma proinflammatory, and oxidative stress factors was also investigated. There were no significant changes in NCI according to global diagnosis score (GDS) and MMSE score within the two groups, while patients receiving DHA had improvement in several blood lipids, pro-inflammatory and oxidative stress factors. The DHA supplement increased α-diversity indexes, increased abundances of Blautia, Bifidobacterium, Dorea, Lactobacillus, Faecalibacterium, Fusobacterium, and Agathobacter, and decreased abundances of Bacteroides and Prevotella_9. Furthermore, DHA supplement was correlated with improved fecal lipid metabolites as indicated by ceramides, bile acids, glycerophospholipids. In addition, the DHA supplement was associated with altered cholesterol metabolism and purine metabolism pathways. A daily supplement of DHA algae oil for 6 months has been shown to promote favorable transformations in gut microbiota, profiles of fecal metabolomic, and factors responsible for proinflammatory and oxidative stress, which might be beneficial for the prognosis of HIV-infected patients with NCI in the long-term.
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Affiliation(s)
- Ruihua Dong
- Department of Nutrition and Food Hygiene, School of Public Health, Fudan University, Shanghai, China
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
| | - Haijiang Lin
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
- Taizhou City Center for Disease Control and Prevention, Taizhou City, China
| | - Yingying Ding
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
| | - Xiaoxiao Chen
- Taizhou City Center for Disease Control and Prevention, Taizhou City, China
| | - Ruizi Shi
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
| | - Shiying Yuan
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
| | - Jing Li
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
| | - Bowen Zhu
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
| | - Xiaohui Xu
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
| | - Weiwei Shen
- Taizhou City Center for Disease Control and Prevention, Taizhou City, China
| | - Keran Wang
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
| | - Ding Ding
- Institute of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Na He
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
- Shanghai Institute of Infectious Diseases and Biosafety, Fudan University, Shanghai, China
- *Correspondence: Na He
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Vieira ADS, Silveira GRMD. Effectiveness of n-3 fatty acids in the treatment of hypertriglyceridemia in HIV/AIDS patients: a meta-analysis. CIENCIA & SAUDE COLETIVA 2018; 22:2659-2669. [PMID: 28793080 DOI: 10.1590/1413-81232017228.21752015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 01/25/2016] [Indexed: 01/15/2023] Open
Abstract
Hypertriglyceridemia is common in antiretroviral therapy-treated patients and Omega 3 fatty acids are being used as a intervention in reducing serum triglycerides (TG) in these patients. The objective of this study is to evaluate the effectiveness of the use of Omega 3 in the treatment of hypertriglyceridemia in HIV/AIDS patients on antiretroviral therapy. This study is a systematic review with meta-analysis of randomized clinical trials. Electronic databases - PubMed, Cochrane and Lilacs were researched. Fifty one articles were encountered. Nine were added to the meta-analysis. The reduction of triglycerides level was -77.55 mg (IC of -121.85 to -33.25) in Omega 3 groups. The analysis considering trials with more than 1000 mg of EPA/DHA included seven studies and the heterogeneity dropped to 0%.The reduction of combined averages was -101.56mg (IC of -145.76 to -57.37). The analysis considering trials with patients that had more than 200 mg/dL of initial triglycerides included also seven trials and the heterogeneity dropped to 0%. The reduction of combined averages was -114.15 mg (IC of -162.34 to -65.97). EPA/DHA supplementation reduces serum triglycerides levels in patients with HIV/AIDS-associated hypertriglyceridemia in stable use of antiretroviral therapy.
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Affiliation(s)
- Aline Doria Sobral Vieira
- Hospital Gaffrée Guinle, Universidade Federal do Estado do Rio de Janeiro (Unirio). R. Mariz e Barros 775, Tijuca. 20270-004 Rio de Janeiro RJ Brasil.
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Effects of docosahexanoic acid supplementation on inflammatory and subcutaneous adipose tissue gene expression in HIV-infected patients on combination antiretroviral therapy (cART). A sub-study of a randomized, double-blind, placebo-controlled study. Cytokine 2018; 105:73-79. [PMID: 29471285 DOI: 10.1016/j.cyto.2018.02.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 02/01/2018] [Accepted: 02/03/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Omega-3 fatty acids have the potential to decrease inflammation and modify gene transcription. Whether docosahexanoic acid (DHA) supplementation can modify systemic inflammatory and subcutaneous adipose tissue (SAT) gene expression in HIV-infected patients is unknown. METHODS A randomized, double-blind, placebo-controlled trial that enrolled 84 antiretroviral-treated patients who had fasting TG levels from 2.26 to 5.65 mmol/l and received DHA or placebo for 48 weeks was performed (ClinicalTrials.gov, NCT02005900). Systemic inflammatory and SAT gene expression was assessed at baseline and at week 48 in 39 patients. RESULTS Patients receiving DHA had a 43.9% median decline in fasting TG levels at week 4 (IQR: -31% to -56%), compared with -2.9% (-18.6% to 16.5%) in the placebo group (P < 0.0001). High sensitivity C reactive protein (hsCRP) and arachidonic acid levels significantly decreased in the DHA group. Adipogenesis-related and mitochondrial-related gene expression did not experience significant changes. Mitochondrial DNA (mtDNA) significantly decreased in the placebo group. SAT inflammation-related gene expression (Tumor necrosis factor alpha [TNF-α], and monocyte chemoattractant protein-1 [MCP-1]) significantly decreased in the DHA group. CONCLUSIONS DHA supplementation down-regulated inflammatory gene expression in SAT. DHA impact on markers of systemic inflammation was restricted to hsCRP and arachidonic acid.
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Domingo P, Fernández I, Gallego-Escuredo JM, Torres F, Gutierrez MDM, Mateo MG, Villarroya J, Giralt M, Vidal F, Villarroya F, Domingo JC. Effects of docosahexanoic acid on metabolic and fat parameters in HIV-infected patients on cART: A randomized, double-blind, placebo-controlled study. Clin Nutr 2017. [PMID: 28648475 DOI: 10.1016/j.clnu.2017.05.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Hypertriglyceridemia is common in HIV-infected patients. Polyunsaturated fatty acids reduce fasting serum triglyceride (TG) levels in HIV-infected patients. It is not known whether docosahexanoic acid (DHA) supplementation can reduce hypertriglyceridemia and modify fat distribution in HIV-infected patients. METHODS We conducted a randomized, double-blind, placebo-controlled trial with 84 antiretroviral-treated patients who had fasting TG levels from 2.26 to 5.65 mmol/l and were randomized to receive DHA or placebo for 48 weeks. TG levels were assessed at baseline, week 4 and every 12 weeks. Body composition was assessed at baseline and at week 48. Registered under ClinicalTrials.gov Identifier no. NCT02005900. RESULTS Patients receiving DHA had a 43.9% median decline in fasting TG levels at week 4 (IQR: -31% to -56%), compared with -2.9% (-18.6% to 16.5%) in the placebo group (P < 0.0001). DHA levels and decrease in TG at week 4 in the DHA arm correlated significantly (r = 0.7110, P < 0.0001). The median reduction in TG levels in the DHA arm was -43.7% (-32.4% to -57.5%), and in the placebo arm +2.9% (-21.3% to +30.1%) at week 12. The difference remained statistically significant at week 48 (P = 0.0253). LDL cholesterol levels significantly increased at week 4 by 7.1% (IQR: -4.8% to +35.3%) in the DHA arm but not in the placebo group. No significant changes were observed in HDL cholesterol, insulin, and HOMA-IR during the study. Limb fat significantly increased in both arms, without statistically significant differences between groups (P = 0.3889). DHA was well tolerated; only 3 patients experienced treatment-limiting toxicity. CONCLUSIONS Supplementation with DHA reduced fasting TG levels in antiretroviral-treated HIV-infected patients with mild hypertriglyceridemia. DHA was well tolerated with minor GI symptoms. Peripheral fat significantly increased in the DHA group but did not increase significantly compared with placebo.
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Affiliation(s)
- Pere Domingo
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Infectious Diseases Department, Hospital Arnau de Vilanova, Universitat de Lleida, Institut de Recerca Biomèdica de LLeida (IRBLleida), Lleida, Spain.
| | - Irene Fernández
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - José Miguel Gallego-Escuredo
- Department of Biochemistry and Molecular Biology, Institute of Biomedicine (IBUB), University of Barcelona, Barcelona, Spain; CIBER Fisiopatologia de la Obesidad y Nutrición, Barcelona, Spain
| | - Ferran Torres
- Biostatistics and Data Management Core Facility, IDIBAPS, Hospital Clinic, Barcelona, Spain; Biostatistics Unit, School of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ma Del Mar Gutierrez
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Ma Gracia Mateo
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Joan Villarroya
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Biochemistry and Molecular Biology, Institute of Biomedicine (IBUB), University of Barcelona, Barcelona, Spain; CIBER Fisiopatologia de la Obesidad y Nutrición, Barcelona, Spain
| | - Marta Giralt
- Department of Biochemistry and Molecular Biology, Institute of Biomedicine (IBUB), University of Barcelona, Barcelona, Spain; CIBER Fisiopatologia de la Obesidad y Nutrición, Barcelona, Spain
| | - Francesc Vidal
- Infectious Diseases Unit, Department of Internal Medicine, Hospital Universitari Joan XXIII, IISPV, Universitat Rovira i Virgili, Tarragona, Spain
| | - Francesc Villarroya
- Department of Biochemistry and Molecular Biology, Institute of Biomedicine (IBUB), University of Barcelona, Barcelona, Spain; CIBER Fisiopatologia de la Obesidad y Nutrición, Barcelona, Spain
| | - Joan Carles Domingo
- Department of Biochemistry and Molecular Biology, Institute of Biomedicine (IBUB), University of Barcelona, Barcelona, Spain; CIBER Fisiopatologia de la Obesidad y Nutrición, Barcelona, Spain
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Ravi S, Khalili H, Abbasian L, Arbabi M, Ghaeli P. Effect of Omega-3 Fatty Acids on Depressive Symptoms in HIV-Positive Individuals: A Randomized, Placebo-Controlled Clinical Trial. Ann Pharmacother 2016; 50:797-807. [PMID: 27323793 DOI: 10.1177/1060028016656017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The antidepressant effect of omega-3 fatty acids has been described in the non-HIV population. The effect of omega-3 fatty acid supplementation on the mood status of HIV-positive patients has not been evaluated yet. OBJECTIVE In this study, the effect of omega-3 fatty acids on depressive symptoms was evaluated in HIV-positive individuals. METHOD A total of 100 HIV-positive patients with Beck Depression Score ≥16, were assigned to receive either omega-3 fatty acids or placebo twice daily for 8 weeks. Depressive symptoms of each participant were evaluated at baseline (month 0) and at the end of months 1 and 2 of the study. Beck Depression Inventory Second Edition, depression subscale of the Hospital Anxiety and Depression Scale, and Patient Health Questionnaire were used for assessment of depressive symptoms. RESULTS Reduction in mean ± SD of all depression scores during the study period was statistically significant within the omega-3 group and when compared with the placebo group (for both comparisons, P < 0.001). Also, the mean differences of all depression scores were decreased significantly during the intervals: months 0, 1, and 2 (P < 0.001 for all comparisons). Among the participants, 7 (7%) and 4 (4%) patients in the omega-3 and the placebo group, respectively, experienced mild gastrointestinal problems, but the incidence of adverse drug reactions related to the interventions was not statistically different between the groups (P = 0.09). CONCLUSION Omega-3 fatty acids improved depressive symptoms in HIV-positive individuals without any significant adverse reaction.
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Affiliation(s)
- Saeedeh Ravi
- Tehran University of Medical Sciences, Tehran, Iran
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Calza L, Colangeli V, Manfredi R, Bon I, Re MC, Viale P. Clinical management of dyslipidaemia associated with combination antiretroviral therapy in HIV-infected patients. J Antimicrob Chemother 2016; 71:1451-65. [PMID: 26846208 DOI: 10.1093/jac/dkv494] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The introduction of potent combination antiretroviral therapy (cART) has had a remarkable impact on the natural history of HIV infection, leading to a dramatic decline in the mortality rate and a considerable increase in the life expectancy of HIV-positive people. However, cART use is frequently associated with several metabolic complications, mostly represented by lipid metabolism alterations, which are reported very frequently among persons treated with antiretroviral agents. In particular, hyperlipidaemia occurs in up to 70%-80% of HIV-positive subjects receiving cART and is mainly associated with specific antiretroviral drugs belonging to three classes of antiretroviral agents: NRTIs, NNRTIs and PIs. The potential long-term consequences of cART-associated dyslipidaemia are not completely understood, but an increased risk of premature coronary heart disease has been reported in HIV-infected patients on cART, so prompt correction of lipid metabolism abnormalities is mandatory in this population. Dietary changes, regular aerobic exercise and switching to a different antiretroviral regimen associated with a more favourable metabolic profile are the first steps in clinical management, but lipid-lowering therapy with fibrates or statins is often required. In this case, the choice of hypolipidaemic drugs should take into account the potential pharmacokinetic interactions with many antiretroviral agents.
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Affiliation(s)
- Leonardo Calza
- Department of Medical and Surgical Sciences, Section of Infectious Diseases, S. Orsola-Malpighi Hospital, University of Bologna, via G. Massarenti n.11, 40138 Bologna, Italy
| | - Vincenzo Colangeli
- Department of Medical and Surgical Sciences, Section of Infectious Diseases, S. Orsola-Malpighi Hospital, University of Bologna, via G. Massarenti n.11, 40138 Bologna, Italy
| | - Roberto Manfredi
- Department of Medical and Surgical Sciences, Section of Infectious Diseases, S. Orsola-Malpighi Hospital, University of Bologna, via G. Massarenti n.11, 40138 Bologna, Italy
| | - Isabella Bon
- Department of Specialized, Diagnostic and Experimental Medicine, Section of Microbiology, S. Orsola-Malpighi Hospital, University of Bologna, via G. Massarenti n.11, 40138 Bologna, Italy
| | - Maria Carla Re
- Department of Specialized, Diagnostic and Experimental Medicine, Section of Microbiology, S. Orsola-Malpighi Hospital, University of Bologna, via G. Massarenti n.11, 40138 Bologna, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Section of Infectious Diseases, S. Orsola-Malpighi Hospital, University of Bologna, via G. Massarenti n.11, 40138 Bologna, Italy
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Abstract
Patients infected with HIV have a high risk of developing dyslipidemia. Effective therapeutic strategies can be challenging due to an increase risk of drug interactions and other comorbidities. Understanding the underlying pathophysiology and the principles of pharmacological and non-pharmacological therapeutic interventions can be of value in the appropriate management of dyslipidemia in the HIV-infected patient.
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Oliveira JM, Rondó PH. Omega-3 Fatty Acids and Hypertriglyceridemia in HIV-Infected Subjects on Antiretroviral Therapy: Systematic Review and Meta-analysis. HIV CLINICAL TRIALS 2015; 12:268-74. [DOI: 10.1310/hct1205-268] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Paranandi A, Asztalos BF, Mangili A, Kuvin J, Gerrior J, Sheehan H, Skinner SC, Tang AM, Wanke CA. Short communication: effects of omega-3 fatty acids on triglycerides and high-density lipoprotein subprofiles in HIV-infected persons with hypertriglyceridemia. AIDS Res Hum Retroviruses 2014; 30:800-5. [PMID: 24988179 DOI: 10.1089/aid.2014.0005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Hypertriglyceridemia and low high-density lipoprotein (HDL)-cholesterol (HDL-C) may contribute to a presumed accelerated risk for cardiovascular disease in HIV-infected individuals. We evaluated the effect of omega-3 fatty acid treatment on triglycerides, low-density lipoprotein (LDL)-C, HDL-C, and HDL subpopulations. Forty-one HIV-seropositive subjects with hypertriglyceridemia (≥150 mg/dl) on active antiretroviral therapy were enrolled in this placebo-controlled, double-blind, randomized, crossover trial comparing the effects of omega-3 fatty acid treatment (1.9 g EPA and 1.5 g DHA) on triglycerides, LDL-C, HDL-C, and HDL subpopulations. An independent sample t-test was used to assess the study start to posttreatment change for all components. After omega-3 fatty acid treatment, triglyceride levels decreased 63.2±86.9 mg/dl (p<0.001). No significant changes in total cholesterol, LDL-C, or HDL-C were found. Within HDL subpopulations, significant changes were seen in the most atheroprotective HDL particles, α-1, which increased by 2.5±5.6 mg/dl (p<0.05), and preα-1, which increased by 0.6±1.0 mg/dl (p<0.001). Preα-3, a presumably atherogenic HDL particle, decreased by 0.5±0.9 mg/dl (p<0.01). Omega-3 fatty acid treatment significantly lowered triglyceride levels in HIV-positive patients with moderate hypertriglyceridemia. While no study-wide improvements in LDL-C or HDL-C were detected, the HDL subpopulation profile changed in a beneficial way suggesting more cardioprotection after treatment.
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Affiliation(s)
- Anu Paranandi
- Tufts Medical Center, Division of Geographic Medicine and Infectious Diseases, Boston, Massachusetts
| | - Bela F. Asztalos
- Lipid Metabolism Laboratory, Human Nutrition Research Center on Aging at Tufts University, Boston, Massachusetts
| | - Alexandra Mangili
- Tufts Medical Center, Division of Geographic Medicine and Infectious Diseases, Boston, Massachusetts
- Tufts University School of Medicine, Department of Public Health and Community Medicine, Nutrition/Infection Unit, Boston, Massachusetts
| | - Jefferey Kuvin
- Tufts Medical Center, Division of Cardiology, Boston, Massachusetts
| | - Jul Gerrior
- Tufts University School of Medicine, Department of Public Health and Community Medicine, Nutrition/Infection Unit, Boston, Massachusetts
| | - Heidi Sheehan
- Tufts University School of Medicine, Department of Public Health and Community Medicine, Nutrition/Infection Unit, Boston, Massachusetts
| | - Sally C. Skinner
- Tufts University School of Medicine, Department of Public Health and Community Medicine, Nutrition/Infection Unit, Boston, Massachusetts
| | - Alice M. Tang
- Tufts University School of Medicine, Department of Public Health and Community Medicine, Nutrition/Infection Unit, Boston, Massachusetts
| | - Christine A. Wanke
- Tufts Medical Center, Division of Geographic Medicine and Infectious Diseases, Boston, Massachusetts
- Tufts University School of Medicine, Department of Public Health and Community Medicine, Nutrition/Infection Unit, Boston, Massachusetts
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Comparative effectiveness of fish oil versus fenofibrate, gemfibrozil, and atorvastatin on lowering triglyceride levels among HIV-infected patients in routine clinical care. J Acquir Immune Defic Syndr 2014; 64:254-60. [PMID: 23892238 DOI: 10.1097/qai.0b013e3182a60e82] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The goal of this study was to compare the effectiveness of fish oil, fenofibrate, gemfibrozil, and atorvastatin on reducing triglyceride (TG) levels among a large cohort of HIV-infected patients in clinical care. DESIGN Retrospective observational cohort study. METHODS The primary endpoint was absolute change in TG levels measured using the last TG value pretreatment and the first TG value posttreatment. A pre-post quasi-experimental design was used to estimate the change in TG because of initiating fish oil. Linear regression models examined the comparative effectiveness of treatment with fish oil versus gemfibrozil, fenofibrate, or atorvastatin for TG reduction. Models were adjusted for baseline differences in age, sex, race, CD4⁺ cell count, diabetes, body mass index, protease inhibitor use, and time between TG measures. RESULTS A total of 493 patients (mean age, 46 years; 95% male) were included (46 patients receiving gemfibrozil; 80, fenofibrate; 291, atorvastatin; and 76, fish oil) with a mean baseline TG of 347 mg/dL. New use of fish oil decreased TG [ΔTG, -45 mg/dL; 95% confidence interval (CI): -80 to -11] in the pre-post study. Compared with fish oil (reference), fibrates were more effective (ΔTG, -66; 95% CI: -120 to -12) in reducing TG levels, whereas atorvastatin was not (ΔTG, -39; 95% CI: -86 to 9). CONCLUSIONS In HIV-infected patients in routine clinical care, fish oil is less effective than fibrates (but not atorvastatin) at lowering TG values. Fish oil may still represent an attractive alternative for patients with moderately elevated TGs, particularly among patients who may not want or tolerate fibrates.
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Abstract
HIV-associated lipodystrophy syndrome (HALS), comprising metabolic and morphological alterations, is a known side effect of highly active antiretroviral therapy (HAART). Evidence for the role of nutrition in the management of the systemic parameters of HALS is currently limited. In the present paper we review the current knowledge base surrounding HALS, focusing particularly on the role of nutrition in mitigating the systemic parameters of the syndrome. Reported prevalence of HALS was found to vary from 9 to 83 % due to lack of a standardised definition, as well as variations in assessment methods and in the study population used. HALS is associated with both morphological (lipoatrophy, lipohypertrophy) and metabolic (dyslipidaemia, glucose intolerance, diabetes, hypertension, endothelial dysfunction and atherosclerosis) alterations, which may occur singly or in combination, and are associated with an increased risk of CVD. HAART-induced adipocyte inflammation, oxidative stress and macrophage infiltration, as well as altered adipocyte function and mitochondrial toxicity, have been shown to be central to the development of HALS. The adipocyte, therefore, represents a plausible target for treatment. Pharmacological and surgical treatment interventions have shown effect. However, their use is associated with numerous adverse effects and complications. Targeted lifestyle interventions may provide a useful alternative for managing HALS owing to their safety and tolerability. A Mediterranean-style diet has been found to be effective in improving the systemic parameters of HALS. Furthermore, the effects of n-3 PUFA supplementation are encouraging and future randomised controlled trials investigating the beneficial effects of n-3 PUFA in HALS are justified.
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Grobler L, Siegfried N, Visser ME, Mahlungulu SSN, Volmink J. Nutritional interventions for reducing morbidity and mortality in people with HIV. Cochrane Database Syst Rev 2013:CD004536. [PMID: 23450554 DOI: 10.1002/14651858.cd004536.pub3] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Adequate nutrition is important for optimal immune and metabolic function. Dietary support may, therefore, improve clinical outcomes in HIV-infected individuals by reducing the incidence of HIV-associated complications and attenuating progression of HIV disease, improving quality of life and ultimately reducing disease-related mortality. OBJECTIVES To evaluate the effectiveness of various macronutrient interventions, given orally, in reducing morbidity and mortality in adults and children living with HIV infection. SEARCH METHODS We searched CENTRAL (up to August 2011), MEDLINE (1966 to August 2011), EMBASE (1988 to August 2011), LILACS (up to February 2012), and Gateway (March 2006-February 2010). We also scanned reference lists of articles and contacted authors of relevant studies and other researchers. SELECTION CRITERIA Randomised controlled trials evaluating the effectiveness of macronutrient interventions compared with no nutritional supplements or placebo in the management of adults and children infected with HIV. DATA COLLECTION AND ANALYSIS Three reviewers independently applied study selection criteria, assessed study quality, and extracted data. Effects were assessed using mean difference and 95% confidence intervals. Homogenous studies were combined wherever it was clinically meaningful to do so and a meta-analysis using the random effects model was conducted. MAIN RESULTS Fourteen trials (including 1725 HIV positive adults and 271 HIV positive children), were included in this review. Neither supplementary food nor daily supplement of Spirulina significantly altered the risk of death compared with no supplement or placebo in malnourished, ART naive adult participants in the two studies which reported on this outcome. A nutritional supplement enhanced with protein did not significantly alter the risk of death compared to standard nutritional care in children with prolonged diarrhoea. Supplementation with macronutrient formulas given to provide protein and/or energy and fortified with micronutrients, in conjunction with nutrition counselling, significantly improved energy intake (3 trials; n=131; MD 393.57 kcal/day; 95% CI: 224.66 to 562.47;p<0.00001) and protein intake (2 trials; n=81; MD 23.5 g/day; 95% CI: 12.68, 34.01; p<0.00001) compared with no nutritional supplementation or nutrition counselling alone in adult participants with weight loss. In general supplementation with specific macronutrients such as amino acids, whey protein concentration or Spirulina did not significantly alter clinical, anthropometric or immunological outcomes compared with placebo in HIV-infected adults and children. AUTHORS' CONCLUSIONS Given the current evidence base, which is limited to fourteen relatively small trials all evaluating different macronutrient supplements in different populations at different stages of HIV infection and with varying treatment status, no firm conclusions can be drawn about the effects of macronutrient supplementation on morbidity and mortality in people living with HIV. It is, however, promising to see more studies being conducted in low-income countries, and particularly in children, where macronutrient supplementation both pre-antiretroviral treatment and in conjunction with antiretroviral treatment might prove to be beneficial.
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Affiliation(s)
- Liesl Grobler
- Centre for Evidence-based Health Care, Stellenbosch University, Cape Town, South Africa.
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Hileman CO, Carman TL, Storer NJ, Labbato DE, White CA, McComsey GA. Omega-3 fatty acids do not improve endothelial function in virologically suppressed HIV-infected men: a randomized placebo-controlled trial. AIDS Res Hum Retroviruses 2012; 28:649-55. [PMID: 21870979 DOI: 10.1089/aid.2011.0088] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Omega-3 fatty acids decrease cardiovascular disease (CVD) mortality possibly due to antiinflammatory effect. Inflammation and endothelial dysfunction likely play a role in the heightened CVD risk in HIV. Our goal was to evaluate the effect of omega-3 fatty acids primarily on endothelial function and inflammation in HIV-infected adults with moderate CVD risk on stable antiretroviral therapy. We conducted a 24-week, randomized, double-blind, placebo-controlled study to evaluate the effect of omega-3-acid ethyl esters 1 g twice a day. Flow-mediated dilation (FMD) of the brachial artery, lipoproteins and markers of inflammation, endothelial activation, coagulation, and insulin resistance were measured at entry and week 24. There were no within- or between-group differences in change in FMD over 24 weeks (mean change in FMD -0.13% vs. 1.5% for treatment vs. placebo; p=0.21). There were no between-group differences in changes in lipoprotein levels or biomarkers tested, except soluble tumor necrosis factor receptor-I, which favored omega-3-acid ethyl esters. Omega-3 fatty acids did not improve endothelial function or activation, coagulation, or insulin resistance in virologically suppressed, HIV-infected men with moderate CVD risk; however, inflammation tended to improve. This suggests that omega-3 fatty acids may not be potent enough to counteract the enhanced inflammation and endothelial dysfunction due to HIV and antiretrovirals.
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Affiliation(s)
- Corrilynn O. Hileman
- Department of Medicine, Division of Infectious Diseases, MetroHealth Medical Center, Cleveland, Ohio
- Case Western Reserve University, Cleveland, Ohio
| | - Teresa L. Carman
- Case Western Reserve University, Cleveland, Ohio
- Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Norma J. Storer
- Case Western Reserve University, Cleveland, Ohio
- Departments of Pediatrics and Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Danielle E. Labbato
- Case Western Reserve University, Cleveland, Ohio
- Departments of Pediatrics and Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Cynthia A. White
- Case Western Reserve University, Cleveland, Ohio
- Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Grace A. McComsey
- Case Western Reserve University, Cleveland, Ohio
- Departments of Pediatrics and Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
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Stradling C, Chen YF, Russell T, Connock M, Thomas GN, Taheri S. The effects of dietary intervention on HIV dyslipidaemia: a systematic review and meta-analysis. PLoS One 2012; 7:e38121. [PMID: 22701607 PMCID: PMC3372478 DOI: 10.1371/journal.pone.0038121] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 05/01/2012] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Efficacy of dietary intervention for treatment and prevention of HIV-related lipid disturbances has not been well established. METHODS We conducted a systematic search of electronic databases supplemented with manual searches and conference abstracts, without language restriction. All randomised controlled trials (RCTs) with blood lipid outcomes, involving dietary intervention or supplementation for the treatment or prevention of adult HIV dyslipidaemia, versus no or other intervention were included. Two authors using predefined data fields, including study quality indicators, extracted data independently. RESULTS Eighteen studies (n = 873) met our inclusion criteria. Seven RCTs for omega-3 supplementation (n = 372), and four RCTs for dietary intervention (n = 201) were meta-analysed using random-effects models. Mild statistical heterogeneity was observed. Dietary intervention reduced triglyceride levels by -0·46 mmol/l (95%CI: -0·85 to -0·07 mmol/l) compared to control. Omega-3 supplementation reduced triglyceride levels by -1.12 mmol/l, (95%CI: -1·57 to -0·67 mmol/l) and total cholesterol, -0·36 mmol/l (95%CI: -0·67 to -0·05 mmol/l) compared to placebo/control. CONCLUSIONS Both omega-3 supplementation and dietary intervention reduced triglyceride level, with the latter possibly to a smaller extent. While dietary interventions are beneficial, more stringent dietary approaches may be necessary to fully address lipid disturbances in HIV patients. TRIAL REGISTRATION PROSPERO 2011:CRD42011001329.
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Affiliation(s)
- Clare Stradling
- HIV Metabolic Clinic, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
- Birmingham and Black Country NIHR CLAHRC, University of Birmingham, Birmingham, United Kingdom
| | - Yen-Fu Chen
- Birmingham and Black Country NIHR CLAHRC, University of Birmingham, Birmingham, United Kingdom
| | - Tracy Russell
- Dietetic Department, Western General Hospital, Edinburgh, United Kingdom
| | - Martin Connock
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - G. Neil Thomas
- School of Public Health, Epidemiology and Biostatistics, University of Birmingham, Birmingham, United Kingdom
| | - Shahrad Taheri
- HIV Metabolic Clinic, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
- Birmingham and Black Country NIHR CLAHRC, University of Birmingham, Birmingham, United Kingdom
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, United Kingdom
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Peters BS, Wierzbicki AS, Moyle G, Nair D, Brockmeyer N. The Effect of a 12-Week Course of Omega-3 Polyunsaturated Fatty Acids on Lipid Parameters in Hypertriglyceridemic Adult HIV-infected Patients Undergoing HAART: A Randomized, Placebo-Controlled Pilot Trial. Clin Ther 2012; 34:67-76. [DOI: 10.1016/j.clinthera.2011.12.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 11/21/2011] [Accepted: 12/07/2011] [Indexed: 10/14/2022]
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Sekhar RV, Balasubramanyam A. Treatment of dyslipidemia in HIV-infected patients. Expert Opin Pharmacother 2010; 11:1845-54. [PMID: 20486828 DOI: 10.1517/14656566.2010.487484] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
IMPORTANCE OF THE FIELD Patients infected with HIV are at high risk for dyslipidemia, insulin resistance and cardiovascular disease. Therapies to reverse these risks are complex, sometimes controversial, and not uniformly effective. AREAS COVERED IN THIS REVIEW Pathophysiology of the lipid abnormalities in HIV is discussed, including the causes of alterations in triglycerides, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and insulin resistance. We discuss the therapy of dyslipidemia in HIV using a combination of available clinical evidence and expert opinion based on extensive clinical experience, with discussions of lifestyle intervention and diet, conventional pharmacotherapy with lipid-lowering medications including statins, fibrates, niacin and thiazolidinediones for dyslipidemia, and newer therapeutic approaches including omega fatty acids, acipimox, growth hormone and leptin. WHAT THE READER WILL GAIN A detailed understanding of the pathophysiology and rational or evidence-based approach to therapy of lipid abnormalities in patients infected with HIV. TAKE HOME MESSAGE Treatment of dyslipidemia in patients with HIV is challenging and complicated by the risk of drug interactions. Appropriate therapy requires a sound understanding of pathophysiology and the principles of pharmacological and nonpharmacological therapeutic interventions. An evidence-based approach that combines lifestyle changes and drugs that are both safe and effective, singly and in combination, is described.
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Affiliation(s)
- Rajagopal V Sekhar
- Translational Metabolism Unit, Diabetes and Endocrinology Research Center, Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX 77030-2600, USA
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Sztam KA, Fawzi WW, Duggan C. Macronutrient supplementation and food prices in HIV treatment. J Nutr 2010; 140:213S-23S. [PMID: 19939991 PMCID: PMC3361012 DOI: 10.3945/jn.109.110569] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Infection caused by HIV and malnutrition have a complex interaction and often coexist geographically. Malnutrition has synergistic immune effects and HIV affects nutritional status. HIV care and treatment programs are compelled to confront this dual burden to optimize HIV outcomes. In this article, we review the published literature concerning intervention studies in adults and children and the effect of food prices on HIV treatment programs. While the evidence base is relatively incomplete for specific macronutrient interventions in the context of HIV treatment, it is clear that a new standard of care is needed, guided by experience, rationale, and existing data, in which malnourished patients may easily access nutritional therapies within HIV treatment. From this clinical foundation, we may both treat patients and evaluate novel therapies. Some HIV care and treatment programs provide food-based supplements; however, rising food costs and economic instability may jeopardize the success of these programs. HIV treatment programs may struggle to meet the needs of patients with potential increased rates of malnutrition and food insecurity in the setting of high food prices.
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Affiliation(s)
- Kevin A. Sztam
- Children's Hospital Boston, Division of Pediatric Gastroenterology and Nutrition, Boston, MA 02115 and; Harvard School of Public Health, Department of Nutrition, Boston, MA 02115,To whom correspondence should be addressed. E-mail:
| | - Wafaie W. Fawzi
- Children's Hospital Boston, Division of Pediatric Gastroenterology and Nutrition, Boston, MA 02115 and; Harvard School of Public Health, Department of Nutrition, Boston, MA 02115
| | - Christopher Duggan
- Children's Hospital Boston, Division of Pediatric Gastroenterology and Nutrition, Boston, MA 02115 and; Harvard School of Public Health, Department of Nutrition, Boston, MA 02115
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18
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Woods MN, Wanke CA, Ling PR, Hendricks KM, Tang AM, Knox TA, Andersson CE, Dong KR, Skinner SC, Bistrian BR. Effect of a dietary intervention and n-3 fatty acid supplementation on measures of serum lipid and insulin sensitivity in persons with HIV. Am J Clin Nutr 2009; 90:1566-78. [PMID: 19846544 PMCID: PMC2777468 DOI: 10.3945/ajcn.2009.28137] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Elevated serum triglyceride and low HDL-cholesterol concentrations have been reported in persons with HIV. OBJECTIVE The effect of a dietary intervention plus n-3 (omega-3) fatty acid supplementation on serum triglycerides and markers of insulin sensitivity was investigated. DESIGN Fifty-four persons with HIV and elevated serum triglycerides (>150 mg/dL) and/or abnormal Quantitative Insulin Sensitivity Check Index values (<0.35 but >0.30) were recruited for a dietary intervention in which total fat, type of fat, fiber, and glycemic load were controlled along with supplementation with n-3 fatty acids to achieve an intake of 6 g/d. The subjects were randomly assigned to an intervention or control group, and serum lipids, markers of insulin sensitivity, and serum phospholipid fatty acids were measured in both groups at baseline, 3 wk, and 13 wk. RESULTS Triglycerides in the intervention group decreased from a median of 180 mg/dL (interquartile range: 141, 396) to 114 mg/dL (interquartile range: 84, 169) from baseline to 3 wk, whereas they remained stable in the control group (P = 0.003). Serum phospholipid fatty acids indicated a decrease in de novo lipogenesis and a decrease in arachidonic acid (% nmol; P <or= 0.001) in the intervention group. At 3 wk, the insulin area under the curve decreased but not significantly. CONCLUSIONS Diet and n-3 fatty acid supplementation dramatically reduced serum triglycerides, decreased arachidonic acid in the phospholipids fraction, and appeared to decrease the de novo lipogenesis associated with the metabolic syndrome in the intervention group.
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Affiliation(s)
- Margo N Woods
- Department of Public Health and Community Medicine, Nutrition/Infection Unit, Tufts University School of Medicine, Boston, MA, USA
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da Silva EFR, Bárbaro G. New options in the treatment of lipid disorders in HIV-infected patients. Open AIDS J 2009; 3:31-7. [PMID: 19639034 PMCID: PMC2714525 DOI: 10.2174/1874613600903010031] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Revised: 05/15/2009] [Accepted: 05/19/2009] [Indexed: 02/06/2023] Open
Abstract
Since the introduction of HAART, there was a remarkably change in the natural history of HIV disease, leading to a notable extension of life expectancy, although prolonged metabolic imbalances could significantly act on the longterm prognosis and outcome of HIV-infected persons, and there is an increasing concern about the cardiovascular risk in this population. Current recommendations suggest that HIV-infected perons undergo evaluation and treatment on the basis of the Third National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (NCEP ATP III) guidelines for dyslipidemia, with particular attention to potential drug interactions with antiretroviral agents and maintenance of virologic control of HIV infection. While a hypolipidemic diet and physical activity may certainly improve dyslipidemia, pharmacological treatment becomes indispensable when serum lipid are excessively high for a long time or the patient has a high cardiovascular risk, since the suspension or change of an effective antiretroviral therapy is not recommended. Moreover, the choice of a hypolipidemic drug is often a reason of concern, since expected drug-drug interactions (especially with antiretroviral agents), toxicity, intolerance, effects on concurrent HIV-related disease and decrease patient adherence to multiple pharmacological regimens must be carefully evaluated. Often the lipid goals of patients in this group are not achieved by the therapy recommended in the current lipid guidelines and in this article we describe other possibilities to treat lipid disorders in HIV-infected persons, like rosuvastatin, ezetimibe and fish oil.
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Abstract
PURPOSE OF REVIEW The recent availability of a concentrated prescription omega-3 fatty acid preparation provides physicians with an additional anti-dyslipidemic agent at a time when limitations of statin therapy in dyslipidemic high-risk patients are recognized. This review examines the evidence supporting the use of omega-3 fatty acid treatment in dyslipidemic states. RECENT FINDINGS There is now considerable evidence that omega-3 fatty acid treatment at the prescription strength of 4 g/day effectively and safely lowers triglyceride levels and increases low-density lipoprotein size, as well as affecting high-density lipoprotein metabolism. Similar effects have been noted in patients treated with statins, and add-on prescription omega-3 fatty acid therapy significantly increases the proportion of statin-treated dyslipidemic patients reaching their non-high-density lipoprotein cholesterol goals. In addition to past studies showing a cardioprotective effect of low-dose omega-3 fatty acid treatment against sudden death, a recent controlled clinical trial showed that 1.8 g of omega-3 fatty acid in statin-treated patients reduced major coronary events by 19% compared with statin plus placebo treatment. SUMMARY Omega-3 fatty acid treatment should be considered in patients with severe hypertriglyceridemia as well as in high-risk patients with an atherogenic lipoprotein phenotype.
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Affiliation(s)
- Ronald B Goldberg
- Division of Endocrinology and Metabolism, University of Miami Miller School of Medicine, Miami, Florida 33136, USA.
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21
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Bennett MT, Johns KW, Bondy GP. Current and future treatments of HIV-associated dyslipidemia. ACTA ACUST UNITED AC 2008. [DOI: 10.2217/17460875.3.2.175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Leyes P, Martínez E, de Talló Forga M. Use of Diet, Nutritional Supplements and Exercise in HIV-Infected Patients Receiving Combination Antiretroviral Therapies: A Systematic Review. Antivir Ther 2008. [DOI: 10.1177/135965350801300208] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The use of combination antiretroviral therapy (cART) has improved the prognosis of HIV infection, but it has also been linked to a spectrum of body composition changes and metabolic alterations known as the lipodystrophy syndrome. Nutritional status could influence body composition changes. Methods We performed a systematic search of published peer-reviewed data on the effects of diet, nutrition support and exercise on body composition and metabolic complications in patients receiving cART. Results Few controlled studies, most of them with small sample size, were found. Oral nutritional support increases protein and energy intake, and results in body weight and fat mass gains. Resistance exercise, with or without an aerobic component, increases lean mass and can improve insulin resistance. Low-fat diets or exercise can result in loss of fat mass, and they should be used with caution in subjects with lipoatrophy. Conclusions Nutritional support and exercise result in small but significant body composition changes and can be used as complementary interventions. There is a need for further research on nutritional interventions in HIV-infected patients receiving cART.
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Affiliation(s)
- Pere Leyes
- Nutritition and Dietetics Unit, Endocrinology Service, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Esteban Martínez
- Infectious Diseases Unit, Hospital Clínic de Barcelona, University of Barcelona, 08036 Barcelona, Spain
| | - Maria de Talló Forga
- Nutritition and Dietetics Unit, Endocrinology Service, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
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