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Fonseca HAR, Bittencourt CR, Monteiro AM, Fonseca FA, Sanches LR, Ferreira CEDS, Neto AMF, Gidlund M, Izar MC. Immunometabolic and Vascular Health Responses among High Endurance Trained Subjects. Int J Sports Med 2024; 45:245-252. [PMID: 37793434 DOI: 10.1055/a-2186-2717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
In this study, we aimed to examine the impact of high endurance training on vascular health parameters and immune-endocrine responses against modified low-density lipoprotein (LDL) particles. This observational, cross-sectional study included high endurance-trained and healthy non-trained subjects. Vascular ultrasound was used to assess vascular health parameters based on carotid intima-media thickness and endothelial function (flow-mediated dilation). Enzyme-linked immunosorbent assays were used to measure interleukin (IL)-8 and IL-10, autoantibody isotypes anti-oxidized LDL (oxLDL) and anti-apolipoprotein B (ApoB-D) peptide. Plasma levels of the corticosterone and 17 α-hydroxyprogesterone hormones were analyzed by mass spectrometry. This study enrolled 96 subjects, of whom 44 were high endurance trained and 52 were healthy non-trained individuals. Smaller carotid intima-media thickness values were observed in the high-endurance trained than in the healthy non-trained males, while no differences were observed between female groups. Flow-mediated dilation measurements did not differ by training or sex. The humoral immune responses to IgG anti-oxLDL and IgM anti-ApoB-D autoantibodies showed an isotype imbalance between the high-endurance trained and the non-trained groups. Immunoendocrine parameters showed inverse correlations between 17 α-hydroxyprogesterone concentrations and carotid intima-media thickness measurements. Direct correlations were found between IL-10 concentrations and flow-mediated dilation measurements. Chronic high-endurance exercise modulates immune-endocrine and vascular health parameters, in a sex-dependent manner.
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Affiliation(s)
- Henrique A R Fonseca
- Cardiology Division, Department of Medicine, Federal University of Sao Paulo, São Paulo, SP, Brazil
- Department of Immunology, Institute Biomedical Science IV, University of Sao Paulo, São Paulo, SP, Brazil
- National Institute of Technology in Complex Fluids, Physics Institute, University of Sao Paulo, São Paulo, SP, Brazil
| | - Celia Regina Bittencourt
- Cardiology Division, Department of Medicine, Federal University of Sao Paulo, São Paulo, SP, Brazil
| | - Andrea Moreira Monteiro
- Department of Immunology, Institute Biomedical Science IV, University of Sao Paulo, São Paulo, SP, Brazil
- National Institute of Technology in Complex Fluids, Physics Institute, University of Sao Paulo, São Paulo, SP, Brazil
| | - Francisco Antonio Fonseca
- Cardiology Division, Department of Medicine, Federal University of Sao Paulo, São Paulo, SP, Brazil
- National Institute of Technology in Complex Fluids, Physics Institute, University of Sao Paulo, São Paulo, SP, Brazil
| | | | | | | | - Magnus Gidlund
- Department of Immunology, Institute Biomedical Science IV, University of Sao Paulo, São Paulo, SP, Brazil
| | - Maria Cristina Izar
- Cardiology Division, Department of Medicine, Federal University of Sao Paulo, São Paulo, SP, Brazil
- National Institute of Technology in Complex Fluids, Physics Institute, University of Sao Paulo, São Paulo, SP, Brazil
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Mabweazara SZ, Leach LL, Ley C, Smith M, Jekauc D, Dave J, Levitt N, Lambert VE. Physical activity behaviours of persons living with HIV of low socioeconomic status: domain, intensity and sociodemographic correlates. AIDS Care 2018; 31:255-259. [PMID: 29962226 DOI: 10.1080/09540121.2018.1493184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Physical activity (PA) is healthy for People Living with HIV and AIDS (PLWHA). This study examined the PA profile of 978 PLWHA based on PA domains and PA intensity. The study also sought to determine whether employment status and level of education can predict PA among PLWHA of low SES. PA and sociodemographic data of 978 PLWHA of mean age 35 (8.77) years were collected using the global physical activity questionnaire and a sociodemographic questionnaire. Results showed that, participants engaged more in work-related PA [160.11 (346.95) min/wk], followed by transport related PA [115.21(SD = 142.04) min/wk], and lastly in leisure related PA [40.84 (SD = 110.37) min/wk]. Participants also engaged more in moderate PA [265.86 (SD = 335.45) min/wk], than in vigorous PA [50.29 (SD = 205.30) min/wk]. Employment was a significant predictor of overall PA controlling for age, CD4 count and education level. The model explained 2.5% of the variance (R2 = 0.025) on overall PA and tested significant at a 0.01 alpha level (p < 0.01). PA interventions for this population should be domain- and intensity-specific. Researchers promoting healthy lifestyle behaviour change can benefit from determining the factors that facilitate domain-specific PA.
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Affiliation(s)
- S Z Mabweazara
- a Department of Sport , Recreation and Exercise Science, University of the Western Cape , Cape Town , South Africa.,b School of Public Health , University of the Western Cape , Cape Town , South Africa
| | - L L Leach
- a Department of Sport , Recreation and Exercise Science, University of the Western Cape , Cape Town , South Africa
| | - C Ley
- c Institute of Sport Science , University of Vienna , Vienna , Austria
| | - M Smith
- d Department of Psychology , University of the Western Cape , Cape Town , South Africa
| | - D Jekauc
- e Goethe-Universität Frankfurt am Main , Fachbereich 05 Psychologie und Sportwissenschaften, Institut für Sportwissenschaften, Abteilung für Sportpsychologie , Germany
| | - J Dave
- f Division of Endocrinology and Diabetic Medicine , University of Cape Town , Cape Town , South Africa
| | - N Levitt
- f Division of Endocrinology and Diabetic Medicine , University of Cape Town , Cape Town , South Africa
| | - V E Lambert
- g Division of Exercise and Sports Medicine, Department of Human Biology , University of Cape Town , Cape Town , South Africa
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Born WK, Huang Y, Zeng W, Torres RM, O'Brien RL. A Special Connection between γδ T Cells and Natural Antibodies? Arch Immunol Ther Exp (Warsz) 2016; 64:455-462. [PMID: 27235134 PMCID: PMC5507014 DOI: 10.1007/s00005-016-0403-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 04/04/2016] [Indexed: 12/15/2022]
Abstract
Natural antibodies (NAbs) play an important role in early host defense, autophagy and tissue remodeling, and in immune regulation. They arise spontaneously (without specific immunization), and are already present at birth. NAbs are produced by B1 B cells, MZ B cells and other B cell types. They include all major Ig subclasses but IgM antibodies are prevalent, especially early in development. NAbs may be poly-specific, recognize particular auto-antigens, or detect neo-determinants such as those exposed during apoptosis or generated by oxidation. NAbs do not require cognate T cell help but depend on soluble mediators produced by T cells. Our recent studies suggest that γδ T cells may have a special relationship with NAbs, and play a prominent role in their regulation, in part through the fine-tuning of IL-4 levels. The spontaneously activated state of these cells likely enables their cytokine production and other functions in the absence of external stimulation. Ontogenetically, the earlier arising γδ T cells are better positioned than αβ T cells to shape the developing repertoire of NAbs. Intriguingly, ligand specificities of NAbs and γδ T cell receptors appear to be overlapping, perhaps allowing γδ cognate help for certain NAb specificities. Via NAbs, γδ T cells could exert a regulatory influence on numerous processes in health and disease.
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Affiliation(s)
- Willi K Born
- Department of Biomedical Research, National Jewish Health, 1400 Jackson Str., Denver, CO, 80206, USA.
- Department of Immunology and Microbiology, University of Colorado Health Sciences Center, Aurora, CO, USA.
| | - Yafei Huang
- Joint Laboratory for Stem Cell Engineering and Technology Transfer, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Wanjiang Zeng
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Raul M Torres
- Department of Immunology and Microbiology, University of Colorado Health Sciences Center, Aurora, CO, USA
| | - Rebecca L O'Brien
- Department of Biomedical Research, National Jewish Health, 1400 Jackson Str., Denver, CO, 80206, USA
- Department of Immunology and Microbiology, University of Colorado Health Sciences Center, Aurora, CO, USA
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Sm M, A K, W G, A B, Ac O, Ba D, I K. Effect of Aerobic Exercise on CD4 Cell Count and Lipid Profile of HIV Infected Persons in North Eastern Nigeria. ACTA ACUST UNITED AC 2015; 6. [PMID: 30918743 PMCID: PMC6433405 DOI: 10.4172/2155-6113.1000508] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background: Literature consistently shows dearth of published data from developing countries on effect of exercise on HIV infected persons. Objective: The study was aimed at determining effect of aerobic exercise on CD4 cell counts and lipid profile of HIV infected persons in Northeastern Nigeria. Methods: Sample of convenience was employed to enroll volunteer and willing 91 HIV infected persons attending antiretroviral clinic at a tertiary hospital in Northeastern Nigeria. Eighty two met the inclusion criteria and participated in the study. Participants were randomly assigned to experimental and control groups. Baseline values of the variables were determined. Experimental group participated in moderate intensity treadmill aerobic exercise for 12 weeks. Control group participated in weekly lectures on nutrition, adherence to therapy among others. At the end, the study recorded 22% attrition rate, leaving 32 participants in each group (64 participants in both). After the 12 weeks, the variables were re-evaluated. Descriptive statistic summarized the socio-demographic characteristics of the participants. Paired and unpaired Student t-tests analyzed the significant difference in mean values of the variables. Results: Mean ages in years of the 64 participants, the control and experimental groups were 39.57 ± 10.13, 39.38 ± 10.03 and 40.84 ± 10.05 respectively. There was significant improvement (p < 0.05) in the variables between pre- and post-tests in the experimental group. In the control group, there was either no significant change (p > 0.05) or significant deterioration (p < 0.05) in lipid profile between pre- and post-tests, while in CD4 cell counts, significant improvement was observed. Significant difference (p < 0.05) existed in the variables at the end of the study between both groups. Conclusion: CD4 cell counts and lipid profile of HIV infected persons who participated in the 12 weeks moderate intensity treadmill aerobic exercise significantly improved. Proper nutrition and adherence to antiretroviral therapy may enhance immune function in HIV population.
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Affiliation(s)
- Maduagwu Sm
- Department of Physiotherapy, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria
| | - Kaidal A
- Department of Physical and Health Education, University of Maiduguri, Maiduguri, Borno State, Nigeria
| | - Gashau W
- College of Medical Sciences, University of Maiduguri, Maiduguri, Borno State, Nigeria
| | - Balami A
- Department of Physical and Health Education, University of Maiduguri, Maiduguri, Borno State, Nigeria
| | - Ojiakor Ac
- Department of Nursing Services, University of Maiduguri Teaching Hospital, Maiduguri, Borno State
| | - Denue Ba
- College of Medical Sciences, University of Maiduguri, Maiduguri, Borno State, Nigeria
| | - Kida I
- College of Medical Sciences, University of Maiduguri, Maiduguri, Borno State, Nigeria
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Derman EW, Whitesman S, Dreyer M, Patel DN, Nossel C, Schwellnus MP. Healthy lifestyle interventions in general practice: Part 9: Lifestyle and HIV/AIDS. S Afr Fam Pract (2004) 2014. [DOI: 10.1080/20786204.2010.10873924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Bachi ALL, Suguri VM, Ramos LR, Mariano M, Vaisberg M, Lopes JD. Increased production of autoantibodies and specific antibodies in response to influenza virus vaccination in physically active older individuals. RESULTS IN IMMUNOLOGY 2013; 3:10-6. [PMID: 24600554 DOI: 10.1016/j.rinim.2013.01.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 01/22/2013] [Accepted: 01/23/2013] [Indexed: 12/26/2022]
Abstract
Immunosenescence is associated to aging and among many changes in immune response is reported a reduced response to vaccination and an increase in the number of cases of autoimmunity, caused by autoantibodies known as natural antibodies whose function, according to reports, would be protection against infection and inflammation. Although immunosenescence is an irreversible process, regular moderate exercise can attenuate some aspects of the decline in the immune system. So, the aim of this study was to investigate the humoral immune response in physically active elderly individuals before and 30 days after vaccination against influenza virus. The results showed that the percentage of individuals positive for antinuclear antibodies and serum immunoglobulin M and G levels after vaccination were higher in the group that exercised regularly than in the sedentary group. We were also able to demonstrate a significant correlation between levels of natural autoantibodies and response to vaccination.
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Affiliation(s)
- André L L Bachi
- Department of Microbiology and Immunology, Federal University of São Paulo, Brazil
| | - Vinicius M Suguri
- Department of Otorhinolaryngology, Federal University of São Paulo, Brazil
| | - Luiz Roberto Ramos
- Department of Preventive Medicine, Federal University of São Paulo, Brazil
| | - Mario Mariano
- Department of Microbiology and Immunology, Federal University of São Paulo, Brazil
| | - Mauro Vaisberg
- Department of Otorhinolaryngology, Federal University of São Paulo, Brazil
| | - Jose D Lopes
- Department of Microbiology and Immunology, Federal University of São Paulo, Brazil
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Ley C, Barrio MR. A narrative review of research on the effects of physical activity on people living with HIV and opportunities for health promotion in disadvantaged settings. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2012; 11:123-33. [DOI: 10.2989/16085906.2012.698079] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Veljkovic M, Dopsaj V, Dopsaj M, Branch DR, Veljkovic N, Sakarellos-Daitsiotis MM, Veljkovic V, Glisic S, Colombatti A. Physical activity and natural anti-VIP antibodies: potential role in breast and prostate cancer therapy. PLoS One 2011; 6:e28304. [PMID: 22140573 PMCID: PMC3227651 DOI: 10.1371/journal.pone.0028304] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 11/05/2011] [Indexed: 12/14/2022] Open
Abstract
Background There is convincing evidence from numerous clinical and epidemiological studies that physical activity can reduce the risk for breast and prostate cancer. The biological mechanisms underlying this phenomenon remain elusive. Herein we suggest a role for naturally produced antibodies reactive with the vasoactive intestinal peptide (VIP) in the suppression of breast and prostate cancer, which we believe could offer a possible molecular mechanism underlying control of these cancers by physical exercise. Methodology and Results We found that sera from individuals having breast and prostate cancers have decreased titers of VIP natural antibodies as demonstrated by a lower reactivity against peptide NTM1, having similar informational and structural properties as VIP. In contrast, sera collected from elite athletes, exhibited titers of natural NTM1-reactive antibodies that are significantly increased, suggesting that physical activity boosts production of these antibodies. Significance Presented results suggest that physical exercise stimulates production of natural anti-VIP antibodies and likely results in suppression of VIP. This, in turn, may play a protective role against breast and prostate cancers. Physical exercise should be further investigated as a potential tool in the treatment of these diseases.
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Affiliation(s)
| | - Violeta Dopsaj
- Institute of Medical Biochemistry, Clinical Centre of Serbia, Belgrade, Serbia
| | - Milivoj Dopsaj
- Faculty of Sport and Physical Education, University of Belgrade, Belgrade, Serbia
| | | | - Nevena Veljkovic
- Center for Multidisciplinary Research, Institute of Nuclear Sciences VINCA, Belgrade, Serbia
| | | | - Veljko Veljkovic
- Center for Multidisciplinary Research, Institute of Nuclear Sciences VINCA, Belgrade, Serbia
- * E-mail:
| | - Sanja Glisic
- Center for Multidisciplinary Research, Institute of Nuclear Sciences VINCA, Belgrade, Serbia
| | - Alfonso Colombatti
- Divisione di Oncologia Sperimentale, Centro di Riferimento Oncologico CRO-IRCCS, Aviano, Italy
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Veljkovic M, Branch DR, Dopsaj V, Veljkovic V, Veljkovic N, Glisic S, Colombatti A. Can natural antibodies to VIP or VIP-like HIV-1 glycoprotein facilitate prevention and supportive treatment of breast cancer? Med Hypotheses 2011; 77:404-8. [PMID: 21684085 DOI: 10.1016/j.mehy.2011.05.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Revised: 05/23/2011] [Accepted: 05/26/2011] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The incidence of non-AIDS-defining cancer is remarkably higher in HIV-infected than in the general population. In contrast, breast cancer risk is significantly reduced in the HIV-infected population. The molecular mechanisms underlying the phenomenon of suppression of breast cancer in the HIV-infected population may serve as a basis for development of a new platform for prevention and treatment of breast cancer. HYPOTHESIS Various evidences indicate that vasoactive intestinal peptide (VIP) plays an important role in growth, and differentiation of breast cancer. We previously showed (i) that natural antibodies recognizing VIP and the gp120-derived peptide NTM significantly contribute to the control of HIV disease progression by suppression of VIP-like activity of HIV-1 gp120 and (ii) that physical exercise stimulates production of these natural antibodies. These findings suggest that natural anti-VIP/NTM antibodies could contribute to a decrease of breast cancer in the HIV-infected population by suppression of VIP, which may play a pro/oncogenic function. Aerobic exercise which stimulates production of anti-VIP/NTM antibodies could be used as prevention and supportive treatment of breast cancer. IMPACT Immunotherapy based on natural anti-VIP/NTM antibodies could serve as an effective adjunct therapy for the treatment of breast cancer. Similarly, aerobic exercise, which stimulates production of these antibodies, should be considered as an inexpensive and safe preventive and supportive breast cancer therapy. Natural anti-VIP/NTM antibodies also represent promising prognostic marker for breast cancer.
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Vasiljevic N, Veljkovic N, Kosec T, Ma XZ, Glisic S, Prljic J, Vujicic AD, Markovic L, Branch DR. A bioinformatics approach to identify natural autoantibodies from healthy blood donors' sera reactive with the HCV NS5A-derived peptide by immunoassay. Viral Immunol 2011; 24:69-76. [PMID: 21449717 DOI: 10.1089/vim.2010.0107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Natural autoantibodies (NAbs) are continually produced throughout life and have an ability to recognize self and altered self, as well as foreign antigens, by recognizing cellular pattern recognition receptors. Sometimes NAb specificity demonstrates overlap between human and pathologic proteomes. This information can be useful in selecting target sequences for screening purposes. In this study we undertook a multi-step bioinformatics search to predict a virus-derived peptide that can be recognized by NAbs in sera of uninfected individuals. We selected protein hepatitis C virus (HCV) NS5A as a target sequence, motivated by the fact that the HCV proteome is characterized by extensive sequence similarities to the human proteome, and because screening for anti-HCV antibodies, including anti-NS5A, is important clinically, particularly in screening of potential blood donors. The virus-specific peptide P1, and the homologous human peptide derived from enzyme-inducible nitric oxide synthase (iNOS), P2, exhibiting not only simple homology, but also complementarities of physicochemical patterns, were synthesized and 80 HCV-negative and 50 HCV-positive blood donor sera were tested by ELISA. These peptides reacted similarly (p<0.001) with HCV-negative sera, and in several cases the measured reactivity was significantly above the cut-off value of commercial anti-HCV screening assays. In HCV-positive sera, the titers of antibodies reactive with analyzed HCV NS5A peptide were not significantly increased (p<0.001) compared to host peptide, the implications of which are unclear, but may be consistent with these antibodies being "naturally produced." Finally, we extended our bioinformatics analyses to the dataset of human self-binding sequences, and propose a general approach for the selection of specific diagnostic and screening antigens for use in immunoassays.
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Skarlas T, Zevgiti S, Droebner K, Panou-Pomonis E, Planz O, Sakarellos-Daitsiotis M. Influenza virus H5N1 hemagglutinin (HA) T-cell epitope conjugates: design, synthesis and immunogenicity. J Pept Sci 2010; 17:226-32. [DOI: 10.1002/psc.1320] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Revised: 09/17/2010] [Accepted: 09/25/2010] [Indexed: 11/11/2022]
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Somarriba G, Neri D, Schaefer N, Miller TL. The effect of aging, nutrition, and exercise during HIV infection. HIV AIDS (Auckl) 2010; 2:191-201. [PMID: 22096398 PMCID: PMC3218696 DOI: 10.2147/hiv.s9069] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Medical advances continue to change the face of human immunodeficiency virus- acquired immunodeficiency syndrome (HIV/AIDS). As life expectancy increases, the number of people living with HIV rises, presenting new challenges for the management of a chronic condition. Aging, nutrition, and physical activity can influence outcomes in other chronic conditions, and emerging data show that each of these factors can impact viral replication and the immune system in HIV. HIV infection results in a decline of the immune system through the depletion of CD4+ T cells. From initial infection, viral replication is a continuous phenomenon. Immunosenescence, a hallmark of aging, results in an increased susceptibility to infections secondary to a delayed immune response, and this phenomenon may be increased in HIV-infected patients. Optimal nutrition is an important adjunct in the clinical care of patients with HIV. Nutritional interventions may improve the quality and span of life and symptom management, support the effectiveness of medications, and improve the patient's resistance to infections and other disease complications by altering immunity. Moderate physical activity can improve many immune parameters, reduce the risk of acute infection, and combat metabolic abnormalities. As people with HIV age, alternative therapies such as nutrition and physical activity may complement medical management.
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Affiliation(s)
- Gabriel Somarriba
- Division of Pediatric Clinical Research, Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Daniela Neri
- Division of Pediatric Clinical Research, Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Natasha Schaefer
- Division of Pediatric Clinical Research, Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Tracie L Miller
- Division of Pediatric Clinical Research, Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, Florida, USA
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