Increased resting energy expenditure, fat oxidation, and food intake in patients with highly active antiretroviral therapy-associated lipodystrophy

Patients living with HIV have quantitatively inadequate food consumption

Objective

The objective of the current study was to estimate energy expenditure and compare it with the usual food consumption of PLWH, and to determine whether duration of high-potency antiretroviral therapy (HAART) influenced nutritional intake and adequacy.

Materials and methods

Anthropometric measurements and bioelectrical impedance analysis (BIA) provided data for estimating resting energy expenditure (REE) using Melchior's equations. Dietary Reference Intakes (DRIs) and 24-Hour Recall were used to verify if reported food intake aligned with energy, macro and micronutrient recommendations.

Results

Sixty one patients with a mean age of 52 ± 9.4 years and who had a high frequency of diabetes mellitus (24.5%), hypertension (54%), and dyslipidemia (90.1%) were evaluated. Estimated REE of female and male patients with less than 10 years of HAART was 1791 (1717.5; 1887.2) and 1941 (1808; 2335.6), and their estimated energy intake was 900.5 (847;1221.9) and 2095.4 (1297.5; 2496.4), respectively. The estimated REE for female and male patients with more than 10 years of HAART was 1796.20 (1598.9;1820.7) and 2105 (1913.4; 2308), and their estimated energy intake was 1566 (1353.1; 1764.3) and 1999.7 (1706.5; 2508.1), respectively. Being on HAART for more than 10 years was associated with increased energy intake (533 (95% CI 3; 1063) kcals), but not with meeting energy requirements.

Conclusion

Patients had an atherogenic metabolic profile, inadequate dietary pattern, and a similar REE, regardless of HAART duration, contributing even more to the increased risk of cardiovascular diseases.

Nutritional aberration and related morphological disorders among patients with human immunodeficiency virus infection on combination antiretroviral therapy (cART) in Ghana: A retrospective study

Background

Metabolic and nutritional abnormalities among people living with human immunodeficiency virus (PLHIV) have been reported due to either their HIV infection, primary malnutrition caused by insufficient intake or consequences of the ART regimen provided. This study investigated the prevalence and patterns of nutritional abnormalities including morphological changes among HIV patients under combination Antiretroviral Therapy (cART) in the Bia-West District of the Western North Region.

Methods

We employed a hospital-based retrospective longitudinal design. Records of 180 patients with HIV infection before and after antiretroviral therapy (ART) initiation were extracted at the Essam Government Hospital. Eligibility criteria included being on treatment without change in regimen for at least one year and without defaulting in scheduled visits. Data extracted included patients' demography, nutritional parameters and medication history. We assessed patients’ nutritional characteristics with the subjective global assessment (SGA) tool which includes five components of medical history (weight change, dietary intake, gastrointestinal symptoms, functional capacity & metabolic stress) and two components of physical examination (signs of fat loss and muscle wasting, alterations in fluid balance).

Results

Malnutrition, lipodystrophy and body wasting among HIV patients were 48.3% (36.5–62.4), 43.9% (32.6–57.7) and 33.3% (23.6–46.0) respectively. Incremental percentage trends of malnutrition (stage I- 7.4%, stage II -22.4%, stage III-24.7%) and lipodystrophy (Stage I - 22.2%, Stage II - 48.7%, Stage III - 51.9%) were significantly associated with worsening disease status. Patients on AZT+3TC + NVP combined regimen presented with the highest malnutrition [52.9% (28.5–76.1)], lipodystrophy [64.7% (38.6–84.7)] and loss of muscle mass [47.1% (23.9–71.5)]. Long-term ART use was significantly associated with high malnutrition rate (p= 0.02620) and increasing muscle mass loss (p = 0.0040).

Conclusion

High malnutrition, lipodystrophy and muscle wasting exist in PLHIV on cART in the Bia-West District. These adverse nutritional effects may be modulated by disease severity, ARV medication and duration.

Resting energy expenditure in HIV/AIDS patients: Development and validation of a predictive equation

BACKGROUND

Accurate measurements of resting energy expenditure (REE) are important for determining nutritional needs in HIV patients. Indirect calorimetry (IC) is a noninvasive method that reflects REE but can be costly and is frequently calculated with predictive equations. Research suggests that REE obtained by predictive equations in people living with HIV/AIDS (PLWH) is inaccurate. The aim of the study is to develop and validate a new predictive equation of REE based on a population of PLWH.

METHODS

Cross-sectional study including 164 PLWH (82 to develop and 82 to validate the equation). Multiple linear regression was used to determine the relationship between variables and to develop the new predictive equation. Intraclass correlation coefficient (ICC) and Bland-Altman methods were used to evaluate agreement between the new predictive equation and indirect calorimetry.

RESULTS

A new predictive equation with an accuracy of 67% when compared with IC was developed. This equation included as covariates: fat free mass, antiretroviral therapy status and age.

CONCLUSION

A new equation to predict energy expenditure in PLWH was developed and validated. This formula can be used to estimate REE if IC is not available.

Anthropometric cutoff points to identify lipodystrophy characteristics in people living with HIV/AIDS: an observational study

Introduction

Introduction: currently, there is no consensus regarding accurate and low-cost methods for diagnosing lipodystrophy in people living with HIV/AIDS (PLWHA). The aim of this study was to propose anthropometric cutoff points for the diagnosis of lipodystrophy among PLWHA. Methods: we included 106 PLWHA (men = 65, women = 41) who are under antiretroviral therapy and have been clinically classified into either a "lipodystrophy" or "non-lipodystrophy" group. Anthropometric measurements included 19 regions of body perimeters and 6 skinfold thickness measures. The Youden index was used to establish anthropometric cutoff points for the diagnosis of lipodystrophy, using the mean values of the anthropometric data (referred to as "original") along with the "Z index" (ZI) values, which were adjusted by the "Phantom Strategy." The cutoff points were proposed when "original" anthropometric measurements and ZI values had a statistical significance of p < 0.01 and an area under the curve (AUC) higher than 70%. The size effect was assessed to verify the influence of lipodystrophy on each anthropometric measure. Results: our data analysis proposes sex-specific cutoff points for the diagnosis of lipodystrophy in PLWHA - 17 points using the "original" anthropometric measurements, and 20 using the ZI values (average effect size between 1.0 and 1.1, and AUC = 76.7% and 78%). Conclusions: our study proposes accurate cutoff points for the diagnosis of lipodystrophy using "original" anthropometric measurements and ZI values adjusted by the "Phantom Strategy." Our findings support the use of anthropometric measurements as a simplified method for diagnosing lipodystrophy and monitoring body composition alterations in people living with HIV/AIDS.

Lipodystrophy diagnosis in people living with HIV/AIDS: prediction and validation of sex-specific anthropometric models

BACKGROUND

Body composition alterations, or lipodystrophy, can lead to serious health problems in people living with HIV/AIDS (PLWHA). The objectives of this study are to predict and validate sex-specific anthropometric predictive models for the diagnosis of lipodystrophy in PLWHA.

METHODS

A cross-sectional design was employed to recruit 106 PLWHA (men = 65 and women = 41) in Brazil during 2013-2014. They were evaluated using dual-energy X-ray absorptiometry, and 19 regions of body perimeters and 6 skinfold thicknesses were taken. Sex-specific predictive models for lipodystrophy diagnosis were developed through stepwise linear regression analysis. Cross-validations using predicted residual error sum of squares was performed to validate each predictive model.

RESULTS

Results support the use of anthropometry for the diagnosis of lipodystrophy in men and women living with HIV/AIDS. A high power of determination with a small degree of error was observed for lipodystrophy diagnosis for men in model six (r² = 0.77, SEE = 0.14, r²_PRESS = 0.73, SEE _PRESS = 0.15), that included ratio of skinfold thickness of subscapular to medial calf, skinfold thickness of thigh, body circumference of waist, formal education _years, time of diagnosis to HIV _months, and type of combined antiretroviral therapy (cART) (with protease inhibitor "WI/PI = 1" or without protease inhibitor "WO/PI = 0"); and model five for women (r² = 0.78, SEE = 0.11, r²_PRESS = 0.71, SEE _PRESS = 0.12), that included skinfold thickness of thigh, skinfold thickness of subscapular, time of exposure to cART _months, body circumference of chest, and race _(Asian) ("Yes" for Asian race = 1; "No" = 0).

CONCLUSIONS

The proposed anthropometric models advance the field of public health by facilitating early diagnosis and better management of lipodystrophy, a serious adverse health effect experienced by PLWHA.

Nrf2 prevents Notch-induced insulin resistance and tumorigenesis in mice

Insulin resistance is associated with increased incidence and enhanced progression of cancers. However, little is known about strategies that can effectively ameliorate insulin resistance and consequently halt cancer progression. Herein, we propose that the transcription factor Nrf2 (also known as Nfe2l2) may be such a target, given its central role in disease prevention. To this end, we developed a mouse that overexpresses the Notch intracellular domain in adipocytes (AdNICD), leading to lipodystrophy-induced severe insulin resistance and subsequent development of sarcomas, as a model reflecting that Notch signaling is deregulated in cancers and shows positive associations with insulin resistance and fatty liver disease in humans. Nrf2 pathway activation was achieved by knocking down Keap1, a repressor of Nrf2, in the AdNICD background. Constitutively enhanced Nrf2 signaling in this setting led to prevention of hepatic steatosis, dyslipidemia, and insulin resistance by repressing hepatic lipogenic pathways and restoration of the hepatic fatty acid profile to control levels. This protective effect of Nrf2 against diabetes extended to significant reduction and delay in sarcoma incidence and latency. Our study highlights that the Nrf2 pathway, which has been induced by small molecules in clinical trials, is a potential therapeutic target against insulin resistance and subsequent risk of cancer.

Accuracy of Predictive Equations for Energy Expenditure in Mexicans Living With HIV/AIDS With and Without Antiretroviral Therapy

INTRODUCTION

Determination of the resting energy expenditure (REE) is essential for planning nutrition therapy in patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) to help to improve their nutrition status. We aim to evaluate the agreement and accuracy of prediction equations that estimate the REE in a Mexican population with a diagnosis of HIV/AIDS with and without antiretroviral therapy (ART).

METHODS

A cross-sectional study in Mexican patients with HIV/AIDS with and without ART. Weight, height, and body composition measured with dual-energy x-ray absorptiometry were evaluated. The REE was determined with indirect calorimetry and estimated using the Mifflin-St Jeor (MSJ), Harris-Benedict (HB), Schofield 1 and 2, Cunningham, Melchior 91, Melchior 93, and Batterham equations. The Bland-Altman method assessed agreement between the real and estimated values, and the percent difference between these values was used to assess the prediction accuracy.

RESULTS

Sixty-five adults without ART and 102 adults with ART were included. The mean REE (kcal/kg) was 24.8 ± 2.4 and 23.8 ± 3.6 in patients without and with ART, respectively. Good agreement and reliability were observed in the HB (intraclass correlation coefficient [ICC], 0.75; P < .05), Batterham (ICC, 0.79; P < .05), Schofield 1 (ICC, 0.74; P < .05), and Schofield 2 (ICC, 0.78; P < .05) results in individuals without ART. In individuals with ART, good agreement and reliability were observed with the HB equation (ICC, 0.76; P < .05). The MSJ equation showed good agreement with poor reliability (ICC, 0.05; P < .05).

CONCLUSION

The equations with the best agreement and accuracy were Schofield 2, Batterham, and HB in individuals without ART and HB and MSJ in the population with ART.

Doubly Labeled Water Method and Accelerometer for the Measurement of Energy Expenditure in Human Immunodeficiency Virus-Infected Patients

BACKGROUND

Several studies have reported increased resting energy expenditure (REE) in human immunodeficiency virus (HIV)-infected patients with HIV-associated lipodystrophy syndrome (HALS). However, limited data exist on the total energy expenditure (TEE). This study was aimed at evaluating the REE and TEE of HIV-infected patients with and without HALS by using the doubly labeled water (DLW) technique and the activity monitor based on accelerometry system (AM), and comparing the results obtained using both methods.

METHODS

Evaluated total of 45 HIV+ men undergoing antiretroviral therapy, including 18 LIPO- (without lipodystrophy) and 27 LIPO+ (with lipodystrophy) individuals were evaluated. Habitual physical activity patterns were measured by using the ActivPAL™ AM system, REE by indirect calorimetry, and TEE by DLW and AM.

RESULTS

No significant differences were found between LIPO- and LIPO+ in REE (1,433 ± 196 vs. 1,510 ± 203 kcal), TEE-DLW (2,691 ± 856 vs. 2,618 ± 415 kcal) and TEE-AM (2,560 ± 458 vs. 2,594 ± 456 kcal), respectively. RQ was a predictor of REE in LIPO+. TEE estimated by the AM had a moderate correlation with DLW, but there was a wide variance in the intra-subject results.

CONCLUSIONS

TEE is not increased in HIV-infected patients with HALS. AM should be used with caution for TEE evaluation during clinical practice.

Relationship Between Adiposity Indices, Lipodystrophy, and Sarcopenia in HIV-Positive Individuals With and Without Lipodystrophy

Metabolism disorders, as well as body shape abnormalities, have been associated with the introduction of antiretroviral therapy. The objective of this study was to compare the diagnostic ability of adiposity indices and to discuss criteria for the classification of lipodystrophy and sarcopenia (SP) in HIV-positive individuals. Anthropometric measurements were determined in 268 individuals of both genders, also submitted to the dual-energy X-ray absorptiometry exam. The adiposity indices calculated were body mass index, body mass index adjusted for fat mass (BMIfat), body adiposity index, body adiposity Index for the Fels Longitudinal Study sample, and The Clínica Universidad de Navarra body adiposity estimator. The presence of lipodystrophy was evaluated using the fat mass ratio (FMR). SP was classified using the appendicular lean mass/height² ratio. The subjects were divided into 3 groups: HIV⁺LIPO⁺ (n = 41), HIV⁺LIPO^- (n = 65), and control (C, HIV-negative individuals; n = 162). Among the adiposity indices assessed, BMIfat showed the strongest correlation with total body fat (in percent) for men (r = 0.87, p < 0.001) and women (r = 0.92, p < 0.001). The frequency of SP was 44.8% and 41.7% in HIV⁺LIPO⁺, 27.8% and 20.7% in HIV⁺LIPO^- and 63.3% and 45.45% in C, for men and women, respectively. The cutoff point suggested for the diagnosis of lipodystrophy according to the FMR was 1.14. The adiposity indices, particularly the BMIfat, have strong correlation with body fat determined by dual-energy X-ray absorptiometry in HIV-positive patients. The implementation of FMR is recommended for more standardized estimates of the frequency of lipodystrophy.

Global physical activity levels among people living with HIV: a systematic review and meta-analysis

PURPOSE

It is unclear how much physical activity people living with HIV (PLWH) engage in. We conducted a meta-analysis to investigate physical activity levels and its predictors in PLWH.

METHODS

PubMed, PsycARTICLES, and CINAHL Plus were searched by two independent reviewers from inception till 1 April 2016 using the keywords: "HIV" OR "AIDS" AND "physical activity" OR "exercise" OR "sports". A random effects meta-analysis was conducted.

RESULTS

Across 24 studies including 34 physical activity levels there were 3780 (2471♂) PLWH (mean age range: 37-58 years). PLWH spent 98.9 (95%CI = 64.8-133.1) minutes per day being physically active which is lower than in most other populations with chronic diseases. 50.7% (95%CI = 39.3-62%) (n = 2052) of PLWH complied with the physical activity guidelines of 150 min moderate intensity physical activity per week. The number of steps walked per day in 252 PLWH was 5899 (95%CI = 5678-6418), which is below the 10,000 steps per day recommendation.

CONCLUSIONS

Our data demonstrate that a considerable proportion of PLWH are insufficiently physically active. Future lifestyle interventions specifically targeting the prevention of physical inactivity in PLWH are warranted. Implications for Rehabilitation Many people living with HIV do not comply with general health recommendations. Physical activity counseling should be key in the rehabilitation of people living with HIV.

Cardiorespiratory fitness levels and moderators in people with HIV: A systematic review and meta-analysis

Cardiorespiratory fitness (CRF) is a modifiable risk factor for cardiovascular disease and premature mortality. CRF levels and moderators among people living with HIV (PLWH) are unknown. The aim of the current meta-analysis was to (1) determine mean CRF in PLWH and compare levels with age- and gender-matched healthy controls (HCs), (2) explore moderators of CRF, (3) and (4) explore moderators of CRF outcomes following physical activity (PA) interventions. Major electronic databases were searched systematically for articles reporting CRF expressed as maximum or peak oxygen uptake (ml/min/kg) in PLWH. A random effects meta-analysis calculating the pooled mean CRF including subgroup- and meta-regression analyses was undertaken. Across 21 eligible studies, the CRF level was 26.4ml/kg/min (95% CI=24.6 to 28.1) (n=1010; mean age=41years). There were insufficient data to compare CRF levels with HCs. A higher body mass index (β=-0.99, 95% CI=-1.93 to -0.06, P=0.04), older age (β=-0.31, 95% CI=-0.58 to -0.04, P=0.02) and the presence of lipodystrophy (β=-4.63, 95% CI=-7.88 to -1.39, P=0.005) were significant moderators of lower CRF levels. Higher CD4+ counts (β=0.004, 95% CI=0.0007 to 0.007, P=0.016), supervised interventions (P<0.001) and interventions with a lower frequency of weekly sessions (2 or 3 versus 4 times) (P<0.001) predicted a better CRF-outcome following PA. CRF levels of PLWH are among the lowest in comparison to other vulnerable populations. More research on the most optimal physical activity intervention characteristics is needed.

Prevalence of metabolic syndrome among HIV-infected patients in Ghana: A cross-sectional study

BACKGROUND

Prevalence of metabolic syndrome (MetS) in HIV-infected patients is very limited in the Ghanaian setting and may vary across the globe by the different study populations and criteria used.

AIM

We investigated the prevalence of MetS among HIV-infected patients receiving highly active antiretroviral therapy (HAART) at the St. Dominic Hospital, Akwatia, Ghana.

PATIENTS AND METHODS

This cross-sectional study recruited 433 HIV-infected patients (294 on HAART and 139 HAART-naïve) from the period of February 2013 to December 2013. Information on the demographic, clinical, anthropometric characteristics were obtained and lipid profile for each patient was assessed. MetS was assessed based on the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III), World Health Organization (WHO) and International Diabetes Federation (IDF) criteria.

RESULTS

The prevalence of MetS was 24.5% according to WHO criteria, 48.3% by NCEP-ATP III criteria, and 42.3% by IDF criteria. In general, participants on HAART were significantly associated with higher prevalence of MetS compared to those without HAART (P < 0.05) irrespective of the criteria used. Prevalence of clustering components of MetS was significantly higher among those on HAART when risk scores of 2 and above were used compared with those not on HAART (P < 0.05).

CONCLUSION

HAART recipient developed MetS as indicated by dyslipidemia, high blood pressure, and abnormal body fat. It is incumbent on health giver to incorporate MetS assessment as a part of treatment and management plan in patients receiving HAART.

Comparing the Ability of Anthropometric Indicators in Identifying Metabolic Syndrome in HIV Patients

BACKGROUND

Highly active antiretroviral therapy (HAART) can cause side effects in HIV patients, as the metabolic syndrome. Early identification of risk for development of cardiovascular diseases using available reliable and practical methods is fundamental. On this basis, the aim of this study was to compare the effectiveness of anthropometric indicators to identify metabolic syndrome in HIV patients on HAART.

METHODS

It is a cross-sectional study. A number of 280 stable HIV patients were studied. It measured weight, height, waist circumference (WC), hip circumference (HP), thigh circumference (TC) and calculated body mass index (BMI), body adiposity index (BAI), waist to hip ratio (WHR) and waist to thigh ratio (WTR). There was also a performance of biochemical tests of lipid profile and fasting glucose. Systemic blood pressure was measured. The criteria proposed by the National Cholesterol Education Program III (NCEP-ATP III) to metabolic syndrome classification was used. Individuals were divided in groups with or without metabolic alterations and their anthropometric indicators were compared. Receiver operating characteristic (ROC) curves were designed for each anthropometric indicator using the metabolic syndrome classification to identify sensitivity and specificity.

RESULTS

WC was a good tool to identify each metabolic disorder separately: total cholesterol (only females, p<0.05), triglycerides (only males, p<0.001), HDL cholesterol (p<0.05), LDL cholesterol (p<005) and fasting glycemic (p<005). WC also showed the best performance to identify metabolic syndrome in both genders (areas under the curve (AUCs): 0.79 and 0.76 for male and female, respectively), while BAI proved to be an inadequate indicator (AUCs: 0.63 and 0.67 for males and females), respectively, in this population.

CONCLUSIONS

The central adiposity measure (WC) had the best performance to identify metabolic syndrome, and it is a convenient, cheap and reliable tool that can be used in clinical practice routinely to prevent cardiovascular complications in HIV patients.

Myocardial glucose uptake in patients with the m.3243A > G mutation in mitochondrial DNA

Mitochondrial mutations impair glucose oxidation and increase glucose uptake in cell cultures and lead to cardiomyopathy in patients. Here we characterize cardiac glucose uptake in 14 patients with the m.3243A > G mutation in mitochondrial DNA. The 14 patients with m.3243A > G and 13 controls were similar in age, physical activity and body mass index. Ten patients had diabetes. Left ventricular glucose uptake per tissue mass (LVGU) was measured with 2-[(18) F]fluoro-2-deoxyglucose positron emission tomography during euglycemic hyperinsulinemia. Cardiac morphology and function were assessed with magnetic resonance imaging. We found that the LVGU was 25% lower in the patients than that in the controls (P = 0.029). LVGU was inversely correlated with mutation heteroplasmy, glycated haemoglobin and fasting lactate in patients. The seven patients with mutation heteroplasmy ≥ 49% had 44% lower LVGU than the seven patients with heteroplasmy < 49%. This difference remained significant after adjustment for concurrent free fatty acid concentration or glycated haemoglobin or glucose uptake in skeletal muscle or all (p < 0.048 [All]). Patients with m.3243A > G had a lower stroke volume and a higher heart rate than the controls, whereas cardiac output and work were similar. Myocardial glucose uptake is not increased but decreased with a threshold effect pattern in patients with the m.3243A > G mutation. The glucose hypometabolism adds to the impaired cardiac energetics and likely contributes to the progression of the mitochondrial cardiomyopathy.

Improvement in human immunodeficiency virus-1/acquired immune deficiency syndrome patients’ well-being following administration of “Phyto V7”

AIM: To corroborate the capacity of Phyto V7, a complex of phytochemicals, to improve the physical well-being of human immunodeficiency virus-1 (HIV-1) infected and acquired immune deficiency syndrome (AIDS) patients not undergoing antiretroviral treatment.

METHODS: Two hundred and thirty nine HIV-1 seropositive male and female voluntary inmates were recruited through the Uruguay National Program of AIDS. The study participants received for 90 consecutive days every eight hours two tablets (760 mg/each) of Phyto V7, containing a mix of the following phytochemicals: flavonols (Kaempferol, Quercetin), flavones (Apigenin, Luteolin), hydroxy-cinnamic acids (ferrulic acid), carotenoids (Lutein, Lycopene, Beta carotene) and organosulfur compounds, all from vegetal origin. The participants did not receive any antiretroviral treatment during the study. At days 0, 30, 60 and 90 (± 2 d) the participants were evaluated for body mass index (BMI), tolerance to Phyto V7 and Index of Quality of Life based on the Karfnosky scale. ANOVA, Tukey Post-test, χ² test and Wilcoxon Signed Rank test were used to analyze the effect of treatment.

RESULTS: One hundred and nighty nine study participants finished the study. Already after 30 d of Phyto V7 consumption, the weight, BMI and Karnofsky score statistically significantly improved (P < 0.001), and continued to improve until the end of the study. The mean weight gain per participant during the 90 d was of 1.21 kg (approximately 2% of body weight). The overall increase in the mean Karnofsky score after 90 d was 14.08%. The lower the BMI and Karnofsky score of the participants were at the beginning of the study, the more notorious was the improvement over time. For example, the mean increment of Index of Quality of Life, among the participants with an initial Karnofsky score of 5 or below (n = 33) from day 0 to day 90, was of 35.67% (0.476 ± 0.044 vs 0.645 ± 0.09; P < 0.001). The tolerability to Phyto V7 was very good and no adverse reactions were recorded or reported.

CONCLUSION: Administration of the Phyto V7 can be an important tool to improve the well-being of HIV-1 seropositive individuals and AIDS patients, not undergoing antiretroviral treatment.

Proposed ratios and cutoffs for the assessment of lipodystrophy in HIV-seropositive individuals

OBJECTIVES

To propose objective ratios using anthropometry and dual-energy X-ray absorptiometry (DXA) and to suggest cutoff points for them in order to classify lipodystrophy in male patients.

METHODS

It is a cross-sectional study. DXA was applied and anthropometric measurements were performed in 100 men on highly active antiretroviral therapy. Receiver operating characteristic curves were used to propose cutoffs. Individuals were divided in without (lipo-) or with (lipo+) lipodystrophy and their metabolic parameters were compared.

RESULTS

The following ratios were proposed: fat mass ratio by DXA (FMR), waist thigh ratio (WTR), waist calf ratio (WCR), and arm to trunk ratio (ATR). The best cutoffs observed for FMR, WTR and ATR were 1.26, 1.74 and 2.08, respectively. Using the proposed cutoff for FMR, we observed worse metabolic profile, with increased tryglicerides, fasting serum glucose and more hypercholesterolemia in the lipo+ group. WTR and ATR showed a significant correlation with FMR.

CONCLUSIONS

Anthropometric ratios (WTR/ATR) and FMR can be used to aid the diagnosis of lipodystrophy in order to contribute to a more accurate and earlier diagnosis permitting intervention and even preventing metabolic disturbances.

Plasma homocysteine levels in HIV-infected men with and without lipodystrophy

OBJECTIVE

Lipodystrophy syndrome is an unexpected clinical manifestation in patients infected with HIV and might be a clinical marker of increased risk for cardiovascular diseases (CVDs). Because hyperhomocysteinemia has been associated with CVD, the goal of the present study was to investigate homocysteine (Hcy) levels and their association with the factors of lipodystrophy syndrome in men with HIV.

METHODS

Hcy metabolism-related molecules were determined in 13 men infected with HIV with lipodystrophy (HIV+LIP), 10 men with HIV without lipodystrophy (HIV), and 10 healthy controls (C).

RESULTS

Significant (P < 0.05) increased Hcy plasma levels were found in HIV (20.5%) and in HIV+LIP (35.2%) compared with the control group. Plasma levels of vitamin B12 (HIV, 26.5%; HIV+LIP, 28.8%) and folate (HIV, 39.1% and HIV+LIP, 49.4%) were significantly (P < 0.05) lower in the two groups of HIV patients compared with control. HIV+LIP men presented raised plasma total sulfur-containing amino acids (20.1%) and lower total plasma thiol (11.3%) than controls. The same was not observed in the HIV group. Spearman's correlation test revealed significant (P < 0.05) association between plasma Hcy and duration of highly active antiretroviral therapy (HAART) and plasma insulin, as well as plasma adiponectin levels.

CONCLUSION

Our results demonstrated that HIV+LIP men were more susceptible to disturbances in Hcy metabolism compared with men infected with HIV without lipodystrophy characteristics. Duration of HAART treatment, elevated plasma insulin, and low levels of adiponectin seem to be relevant for the appearance of these Hcy metabolic disorders.

Effects of HIV and antiretroviral therapy on resting energy expenditure in adult HIV-infected women-a matched, prospective, cross-sectional study

BACKGROUND

Several studies have reported increased resting energy expenditure (REE) in people with human immunodeficiency virus (HIV). However, limited data exist on REE in HIV-infected women and the effect of antiretroviral therapy (ART) on REE in this population.

OBJECTIVE

The purpose of this study was to compare REE in healthy controls to adult HIV-infected women classified in three groups: naïve to ART, on ART with virologic suppression, and on ART with an HIV-1 RNA level >5,000 copies/mL.

DESIGN

After a fast, body composition by bioelectrical impedance analysis and REE by indirect calorimetry were determined. Anthropometric measures were also taken.

STATISTICAL ANALYSIS

Distributionally appropriate two-sample tests were used for between-group analyses and analysis of covariance was used for confounding adjustment.

RESULTS

Eighty-seven women were enrolled and the HIV-infected and control women were matched for age and body mass index. Log-transformed REE was significantly higher in HIV-infected women naïve to ART compared to controls (7.26±0.22 vs 7.14±0.19; P=0.04, respectively) and the difference remained significant after adjustment for body cell mass (P=0.008). Log-transformed REE was not different in HIV-infected women on ART compared to HIV-infected women naïve to ART (7.25±0.25 vs 7.26±0.23; P=0.81, respectively). Adjusting for body cell mass did not change the results (P=0.56). Similarly, REE was not different between women naïve to ART and those on ART with undetectable HIV-1 RNA, regardless of adjustment for body cell mass. REE correlated to current and nadir CD4 count and trended toward a negative correlation with HIV-1 RNA levels.

CONCLUSIONS

We showed that REE is elevated in ART-naïve, HIV-infected women and continues to be elevated when on ART, regardless of virologic suppression, compared to age and body mass index-matched healthy women. This suggests an effect of HIV infection itself and not ART on REE in these HIV-infected women, and should be considered during nutrition assessment and counseling of HIV-infected adult women.

Hypermetabolism and altered substrate oxidation in HIV-infected patients with lipodystrophy

OBJECTIVE

Human immunodeficiency virus type 1 (HIV)-associated lipodystrophy syndrome compromises body composition and produces metabolic alterations, such as dyslipidemia and insulin resistance. This study aims to determine whether energy expenditure and substrate oxidation are altered due to human HIV-associated lipodystrophy syndrome.

METHODS

We compared energy expenditure and substrate oxidation in 10 HIV-infected men with lipodystrophy syndrome (HIV+LIPO+), 22 HIV-infected men without lipodystrophy syndrome (HIV+LIPO-), and 12 healthy controls. Energy expenditure and substrate oxidation were assessed by indirect calorimetry, and body composition was assessed by dual-energy X-ray absorptiometry. The substrate oxidation assessments were performed during fasting and 30 min after eucaloric breakfast consumption (300 kcal).

RESULTS

The resting energy expenditure adjusted for lean body mass was significantly higher in the HIV+LIPO+ group than in the healthy controls (P = 0.02). HIV-infected patients had increased carbohydrate oxidation and lower lipid oxidation when compared to the control group (P < 0.05) during fasting conditions. After the consumption of a eucaloric breakfast, there was a significant increase in carbohydrate oxidation only in the HIV+LIPO- and control groups (P < 0.05), but there was no increase in the HIV+LIPO+ group.

CONCLUSION

Hypermetabolism and alteration in substrate oxidation were observed in the HIV+LIPO+ group.

Energy expenditure in HIV infection

Energy intake recommendations for adults should be based preferably on direct measurements of total daily energy expenditure (TDEE) in corresponding populations who are maintaining healthy body weight and satisfactory physical activity levels. During adolescence, pregnancy, and lactation, energy requirements should be based on TDEE plus the additional energy required to advance these physiologic states. With illness, energy expenditure and energy intake change, but nutritional intervention is not necessarily beneficial. This article reviews data on energy expenditure in HIV infection with a focus on adults, adolescents aged ≥14 y, and pregnant and lactating women. Resting energy expenditure (REE) in adults with untreated asymptomatic HIV is ~ 10% higher than in healthy control subjects. In asymptomatic adults receiving antiretroviral therapy, REE may be similarly increased. HIV wasting and secondary infections are also associated with increased REE. In contrast, TDEE is typically normal in asymptomatic HIV and decreased in HIV wasting and secondary infection. No direct measurements of REE or TDEE are available in adolescents or in pregnant or lactating women with HIV. On the basis of current data, energy intake may need to increase by ~ 10% in adults with asymptomatic HIV to maintain body weight. In adolescents and in pregnant and lactating women with asymptomatic HIV, energy requirements should approximate recommendations for their uninfected counterparts until further data are available. In the resource-rich world, the energy expenditure changes associated with HIV are unlikely to contribute to significant weight loss. More data are needed on energy expenditure in HIV-infected populations from developing nations, where concurrent malnutrition and coinfections are common.

Brown fat activity is not apparent in subjects with HIV lipodystrophy and increased resting energy expenditure

The HIV lipodystrophy (LD) syndrome is associated with increased resting energy expenditure (REE), but the basis of this hypermetabolism has not been determined. The objective of this pilot study was to determine if brown fat is activated in subjects with HIV LD and increased REE. In this descriptive study of four subjects with HIV LD and marked hypermetabolism, REE was measured by indirect calorimetry and brown fat activity was determined by (18)F-fluorodeoxyglucose (FDG) positron-emission tomography (PET) combined with anatomic computed tomography (CT). Brown fat activity was not apparent in any subject with HIV LD and resting hypermetabolism. Therefore, brown fat activation is unlikely to be the principal cause of the increased REE associated with the HIV LD syndrome. Evidence of adaptive thermogenesis has been demonstrated in this syndrome, but this study suggests that tissues other than brown adipose tissue (BAT) are responsible. Further understanding of the chronic hypermetabolism associated with HIV LD could provide new insights into the regulation of energy balance.

Decreased respiratory quotient in relation to resting energy expenditure in HIV-infected and noninfected subjects

The purpose of this study was to evaluate the relationship of respiratory quotient (RQ), a surrogate marker of substrate oxidation, as well as body composition and dietary intake to resting energy expenditure (REE) among HIV-infected patients in the current era of highly active antiretroviral therapy and among non-HIV-infected control subjects. Resting energy expenditure is increased in HIV-infected patients; but little is known regarding the potential contribution of altered substrate metabolism, body composition, and dietary intake to increased energy expenditure in this population. Respiratory quotient, REE, body composition, and dietary intake parameters were assessed in 283 HIV-infected patients and 146 community-derived HIV-negative controls who were evaluated for metabolic studies between 1998 and 2005. Respiratory quotient was lower (0.83 +/- 0.00 vs 0.85 +/- 0.01, P = .005), whereas REE adjusted for fat-free mass (FFM) was higher (31.8 +/- 0.3 vs 29.8 +/- 0.3 kcal/[d kg], P < or = .0001), in HIV-infected compared with control subjects. In multivariate modeling among HIV-infected patients, including age, sex, and parameters of immune function, FFM (beta = 24.811334, P < .0001), visceral adiposity (beta = .7182746, P = .008), and total body fat (beta = 8.0506839, P = .041) were positively associated with REE, whereas RQ was negatively associated with REE (beta = -528.4808, P = .024). Overall r(2) was equal to 0.705 and P was less than .0001 for the model. In control subjects, by contrast, only visceral adiposity (beta = 1.0612073, P = .004), total body fat (beta = 15.805547, P = .010), and FFM (beta = 22.613005, P < .0001) were significant predictors of REE; and there was no relationship with RQ. Overall r(2) was equal to 0.825 and P was less than .0001 for the model. These data suggest that alterations in substrate metabolism may contribute to increased REE in HIV-infected patients compared with control subjects.

m.3243A>G mutation in mitochondrial DNA leads to decreased insulin sensitivity in skeletal muscle and to progressive beta-cell dysfunction

OBJECTIVE

To study insulin sensitivity and perfusion in skeletal muscle together with the beta-cell function in subjects with the m.3243A>G mutation in mitochondrial DNA, the most common cause of mitochondrial diabetes.

RESEARCH DESIGN AND METHODS

We measured skeletal muscle glucose uptake and perfusion using positron emission tomography and 2-[18F]fluoro-2-deoxyglucose and [15O]H2O during euglycemic hyperinsulinemia in 15 patients with m.3243A>G. These patients included five subjects with no diabetes as defined by the oral glucose tolerance test (OGTT) (group 1), three with GHb <6.1% and newly found diabetes by OGTT (group 2), and seven with a previously diagnosed diabetes (group 3). Control subjects consisted of 13 healthy individuals who were similar to the carriers of m.3243A>G with respect to age and physical activity. Beta-cell function was assessed using the OGTT and subsequent mathematical modeling.

RESULTS

Skeletal muscle glucose uptake was significantly lower in groups 1, 2, and 3 than in the control subjects. The glucose sensitivity of beta-cells in group 1 patients was similar to that of the control subjects, whereas in group 2 and 3 patients, the glucose sensitivity was significantly lower. The insulin secretion parameters correlated strongly with the proportion of m.3243A>G mutation in muscle.

CONCLUSIONS

Our findings show that subjects with m.3243A>G are insulin resistant in skeletal muscle even when beta-cell function is not markedly impaired or glucose control compromised. We suggest that both the skeletal muscle insulin sensitivity and the beta-cell function are affected before the onset of the mitochondrial diabetes caused by the m.3243A>G mutation.

Dietary patterns and health and nutrition outcomes in men living with HIV infection

BACKGROUND

Nutritional status is an important determinant of HIV outcomes.

OBJECTIVE

We assessed the association between dietary patterns identified by cluster analysis and change in body mass index (BMI; in kg/m(2)), CD4 count, and viral load (VL).

DESIGN

HIV-positive adult male subjects (n = 348) with a BMI >or= 20.5 were evaluated by biochemical, body composition, and dietary data. Cluster analysis was performed on 41 designated food groups derived from 3-d food records. Dietary clusters were compared for sociodemographic, nutrient intake, and clinical outcomes. Multivariate linear regression assessed associations between dietary clusters and change in BMI, CD4 count, and VL.

RESULTS

We observed 3 dietary patterns: juice and soda; fast food and fruit drinks; and fruit, vegetable, and low-fat dairy. Subjects in the fast food and fruit drinks pattern had the lowest fiber intake, highest VL, and lowest CD4 count and had a lower income than did subjects in the other 2 clusters. Subjects in the fruit, vegetable, and low-fat dairy diet pattern had higher intakes of protein, fiber, and micronutrients and the highest BMI and CD4 count. Subjects in the juice and soda pattern had higher energy intakes and lowest BMI. On average, the fast food and fruit drinks cluster and fruit, vegetable, and low-fat dairy cluster gained 0.33 (P = 0.06) and 0.42 (P = 0.02), respectively, more in BMI than the juice and soda cluster across the study interval in a multivariate model.

CONCLUSIONS

In a cohort of HIV-positive men, we identified 3 distinct dietary patterns; each pattern was associated with specific nutrition, demographic, and HIV-related variables.

Short-term overfeeding increases resting energy expenditure in patients with HIV lipodystrophy

BACKGROUND

HIV lipodystrophy and other lipodystrophy syndromes are characterized by extensive loss of subcutaneous adipose tissue. Lipodystrophy syndromes are also associated with increased resting energy expenditure (REE). This hypermetabolism may be an adaptive response to an inability to store triacylglycerol fuel in a normal manner.

OBJECTIVE

This study was done to determine whether REE increases significantly after short-term overfeeding in patients with HIV lipodystrophy.

DESIGN

REE was measured in HIV-infected patients with lipodystrophy (n = 9) and in HIV-infected (n = 10) and healthy (n = 9) controls after 3 d on a eucaloric diet and again after 3 d on a diet of similar composition but increased in calories by 50%.

RESULTS

After 3 d of eucaloric feeding, REE was significantly higher in patients with HIV lipodystrophy [33.2 +/- 0.27 kcal/kg lean body mass (LBM)] than for both HIV-infected and healthy controls (29.9 +/- 0.26 and 29.6 +/- 0.27 kcal/kg LBM, respectively; P < 0.01). Furthermore, after 3 d of overfeeding, REE increased significantly in patients with HIV lipodystrophy but not in the control groups (33.2 +/- 0.27 vs 34.7 +/- 0.27 kcal/kg LBM; P < 0.01). Finally, postprandial thermogenesis did not differ among the groups after a "normal" test meal but tended to be higher in patients with HIV lipodystrophy than in healthy controls after a large test meal.

CONCLUSIONS

Adaptive thermogenesis in the resting component of total daily energy expenditure and in the postprandial period may be a feature of the HIV lipodystrophy syndrome and may be due to an inability to store triacylglycerol fuel in a normal manner.

Dietary fat intake and relationship to serum lipid levels in HIV-infected patients with metabolic abnormalities in the HAART era

OBJECTIVE

To evaluate dietary intake and its relationship to lipid parameters in HIV-infected patients with metabolic abnormalities.

METHOD

We prospectively determined dietary intake (4-day food records or 24-h recall) in 356 HIV-infected patients and 162 community-derived HIV-negative controls evaluated for metabolic studies between 1998-2005. Differences in dietary intake between HIV-infected patients and non-HIV-infected controls, in relation to the established 2005 USDA (United States Department of Agriculture) Recommended Dietary Guidelines, were determined. The relationship between dietary fat intake and serum lipid levels among HIV-infected individuals was also evaluated.

RESULTS

Assessment of dietary intake in this group of HIV-infected patients demonstrated increased intake of total dietary fat (P < 0.05), saturated fat (P = 0.006), and cholesterol (P = 0.006) as well as a greater percentage of calories from saturated fat (P = 0.002) and from trans fat (P = 0.02), despite similar caloric intake to the control individuals. A significantly higher percentage of HIV-infected patients were above the 2005 USDA Recommended Dietary Guidelines for saturated fat (> 10%/day) (76.0% HIV vs. 60.9% controls, P = 0.003), and cholesterol (> 300 mg/day) (49.7% HIV vs. 37.9% controls, P = 0.04). Saturated fat intake was strongly associated with triglyceride level [triglyceride level increased 8.7 mg/dl (parameter estimate) per gram of increased saturated fat intake, P = 0.005] whereas total fat was inversely associated with triglyceride level [triglyceride level decreased 3.0 mg/dl (parameter estimate) per gram of increased total fat intake, P = 0.02] among HIV-infected individuals.

CONCLUSIONS

Increased intake of saturated fat is seen and contributes to hypertriglyceridemia among HIV-infected patients who have developed metabolic abnormalities. Increased saturated fat intake should be targeted for dietary modification in this population.

Dysregulated Energy Expenditure in HIV-Infected Patients: A Mechanistic Review

Metabolic abnormalities are common in patients with human immunodeficiency virus (HIV) infection and range from protein catabolism to lipodystrophy and dyslipidemia associated with the use of highly active antiretroviral therapy. One abnormality is increased resting energy expenditure, which even occurs in clinically stable HIV-infected patients. Increased resting energy expenditure may aggravate the tendency towards weight loss and wasting, which are independent predictors of mortality. Despite much investigation, the factors associated with altered resting energy expenditure remain unclear; viral load, CD4 cell count, use of antiretroviral drugs, body composition, hormones, and proinflammatory cytokines have been imputed. Mechanisms that could explain increased resting energy expenditure include the HIV accessory protein viral protein R, antiretroviral drugs that affect mitochondrial function, and futile cycling within adipocytes. Other components of energy expenditure are also important to overall energy balance and may also be affected. Identifying unifying mechanisms will be an important step to finding effective treatments for HIV-related alterations in energy expenditure and to reversing metabolic risks in patients with HIV infection.