2. Some of these slides have been downloaded from
http://clinicaloptions.com/HIV.aspx
And
http://www.hivtrislide.com/
3. Cardiovascular risk
Coping with the side effects of medication
Medications with or without food
Lipodystrophy or middle age spread?
▪ Discussion
Healthy eating for cardiovascular risk reduction
4.
5. Established Additional
Blood Pressure Adiposity
LDL-C Ethnicity
HDL-C Socioeconomic status:
Age • Income
Smoking • health insurance
Gender • education
Family history Geographic region
Physical inactivity
ARV combination
Greenlund KJ et al. Arch Intern Med. 2004;164:181-8.
6. Unmodifiable Modifiable
Diet
Family history Weight and Exercise
Host Genetics Lipids
Age Diabetes
Sex Smoking
Adreno-steroids
Hypertension
Hyperthyroidism
Modified from Dubé. Clin Infect Dis 2000;31:1216.
7. 100
90
80
60
PAR 50
(%)
40 36 33
20
18
20 14 12 10
7
0
Smoking Fruits/ Exercise Alcohol Hyper- Diabetes Abdominal Psycho- Lipids All 9 risk
veg tension obesity social factors
Lifestyle factors
N = 15,152 patients and 14,820 controls in 52 countries
PAR = population attributable risk, adjusted for all risk factors Yusuf S et al. Lancet. 2004;364:937-52.
8. Prevalence in USA General Non HIV Population (2002)
Threshold N (Millions)
Overweight/Obesity BMI ≥25 kg/m2 134.75
High Cholesterol levels Total-Cholesterol ≥5.1mmol/ 106.9
L
Blood Pressure BP ≥140/90 mm Hg 65
Diabetes Fasting Blood Sugar level 13.9 (diagnosed)
≥7mmol/l 5.9 (undiagnosed)
AHA. Heart Disease and Stroke Statistics–2005 Update.
9. Duration of Combination Antiretroviral Therapy Is Associated
With a Small Increase in Incident CVD
10
RR per Year of ART
Incidence of MI per 1000
8 Overall: 1.17
Men: 1.14
Patient-Year
6 Women: 1.38
4
2
0
None <1 1-2 2-3 3-4 4-5 5-6 >6
Exposure to ART (Years)
El-Sadr W, et al. CROI 2005. Abstract 42.
10. Observed Predicted
8
7
MI per 1000 Years
6
5
4
3
2
1
0
0 <1 1-2 2-3 3-4 4+
Duration of HAART (Years)
Law MG, et al. 11th CROI. 2004. Abstract 737.
11. Developed for use in general
population
– Thought to be reasonable
predictor in HIV-infected
population
However, does not include HIV-
specific factors
– Immune status
– Increased inflammatory
markers
– Insulin resistance
14. Dyslipidemia/CHD Lipoatrophy
Liver
Bone density ? Gastrointestinal
Renal
15.
16. Retrospective cohort study of 394 patients from Singapore HIV
observational Cohort Study (SCHOCS)
Impact of malnutrition at time of starting antiretroviral therapy
significantly associated with decreased survival
The higher risk of death was associated with a BMI below 17.5kg/m2
People who were malnourished when they started powerful anti-HIV treatment
were six times more likely to die than people who were well nourished.
Paton et al 2006 HIV Medicine 7(5):323-330
17. ⇓ nutrient intake
70 - 90%
Caus e s o f
We ig ht Lo s s
⇑ metabolic ⇓ absorption/
rate diarrhoea
0 - 10% 10 - 30%
19. Nausea & Vomiting:
• Ginger
• Dry Biscuits/Crackers
• Cold Foods/Fluids
Diarrhoea:
• alter lactose content of diet
• alter fibre content of diet (soluble vs insoluble)
• alter fat content of diet
20. Eat little and often
Enriching meals
Add extra mono/polyunsaturated fats:
e.g. spreading margarine thickly, using extra olive or
rapeseed oil in cooking
Changing behaviour to overcoming barriers to eating
Less time/facilities/motivation re food preparation
e.g. use of snacks easily bought in dairy /corner shop + foods
which don’t require cooking/preparation
21. Vast improvement in dietary restrictions and anti
retroviral medication
Some drugs taken without food
Didanosine (ddI) at least 30 minutes before or 2hr after
eating
Some drugs need to be taken with food
Most protease inhibitors to be taken with food
22. Stocrin (Efavirenz)
food may increase drug levels by up to 50% High fat
meals may also increase absorption, which may lead to
increased side-effects.
“Take on an empty stomach before going to sleep”
Abacavir absorption boosted by alcohol
25. Weight gain is dependent on a
person's energy intake being greater
than energy expenditure.
For a healthy weight, the amount of
energy you eat from food & drink Food & Drink Daily Activities
must equal the amount you use up
with your daily activities.
To lose weight you must change
eating habits permanently.
26. One pound (0.45 kg) is equal to 14647kj (3,500
calories)excess.
Therefore, a person consuming 2031kj (500cal)
more than he or she expends daily will gain 1 lb a
week.
27. The last 30 Years, a Major Societal Shift
NZ Family life, family structures, family traditions,
decline of home cooking
Work dominating life, commuting, family time
pressured, convenience driven
Leisure-Consumerism, 7 day shopping, gadgets,
technology, subscriber television, spectation
replaces participation
Competition, education, academic qualifications,
decline of physical work, physical activity generally
It’s a very different world from 1970’s in New Zealand
R Bree 2006 Food Industrial Work Group
28.
29.
30. Too many calories, too little activity
When ‘treat’ foods, energy-dense foods, become
the staple diet
When ‘virtual’ world replaces ‘real’ world
When wheels replace legs and feet
When family nutrition, health and wellbeing
come second to taste, pleasure and convenience
It’s no accident that the richest nations are
also the most obese
R Bree 2006 Food Industrial Work Group
31. Lipodystrophy is a side effect of some anti-HIV
drugs. It can mean losing some fat from your
face, legs arms or buttocks and gaining fat on
your belly.
Fat loss and gain can be difficult to live with.
Many people HIV find these changes harder to accept
than other illnesses and side effects.
32.
33. Waist circumference is known to be a significant
cardiac risk factor in non HIV-infected patients
▪ Yusuf S et al Lancet 2005; 366:1640-1649
Central adiposity is associated with significant
metabolic abnormalities
▪ Hadigan C et al Clin Infect Dis 2001; 32:130-139
▪ Dolan SE et al AIDS 2005; 39:44-54
36. Inactivity Loss of fitness Weight gain
Further
Further fat gain Decrease in patient power-
weight ratio
Motivational barrier against Increased difficulty to undertake
physical activity normal activities
37.
38. WHO classification:
45-59 years – Middle aged
60-74 years – Elderly
75-89 years – old
90+ years – Very old
In the UK, normal retirement age (65 years)
generally accepted as elderly.
Population Ageing.
In Europe, 20% of the population is elderly (aged over
60 years). 25% by 2020
39. One of every seven new AIDS cases over age 50
15% of those diagnosed with AIDS in the U.S. today
are over 50 (CDC, 2008). As many as 1 in 5, or even 1
in 4 in specific areas.
– 24% of people with AIDS in N.Y.C. age 50 or older
– This trend is also highlighted when looking at those 40-50
More than 118,000 people age 50 or older living with
HIV in 2005
41. ↓ taste and smell – ↓ vision ↓ LBM, muscle tone &
loss of taste buds mobility
Gastrointestinal
Bone loss - ↑
changes
osteoporosis & Ageing and the
↓digestive
fracture risk body
capacity
Skin thinning
↑ water lost via skin
Thirst mechanism less ↑ risk of pressure sores
Increased risk of kidneys unable to
sensitive - High risk of
disease concentrate urine efficiently
dehydration
42. Cardiovascular disease
Metabolic syndrome/ diabetes mellitus
Body Composition Changes
Bone disease
Renal Dysfunction
Cancer
43.
44. Death certificates of 68,669 Overall deaths
HIV-infected New York City HIV-related deaths
Non-HIV–related deaths
residents examined for causes of
per 10,000 Persons With AIDS
Cardiovascular-related deaths
death
Age-Adjusted Mortality
900 Cancer-related deaths
800 Substance abuse–related deaths
700
Deaths from non-HIV–related causes 600
500
increased from 19.8% to 26.3% 400
between 1999 and 2006 300
200
100
▪ Due to CVD, substance abuse and
non-AIDS–defining cancers 30
20
Among individuals ≥ 55 years, CVD 10
1999 2000 2001 2002 2003 2004
leading cause of death
Sackoff JE, et al. Ann Intern Med. 2006;145:397-406.
45.
46. Kcal requirements and absorption.. ….means that Nutrient requirements
5 main issues re. nutrition for older people:
Fluid balance and renal function
Skeletal changes
Physical fitness and strength
Changes in the immune system
Gastrointestinal changes.
“Good nutrition contributes to the health of elderly
people and to their ability to recover from illness”.
47. Pre vio us Expe rie nc e Curre nt Living S tate o f He alth
Co nditio ns
Budgetary skill Food availability Confusion
Cultural traditions Cooking ability Depression
Education Cooking facilities Medicines
Habit Cooking for self / others Dysphagia
Individual likes/dislikes Cost of food items Loss of senses
Nutrition knowledge Eating alone / others Pain
Previous food experience Living conditions Physical illness
Religious beliefs Tim available to prepare
e Poor dentition
and eat
Willingness to experiment Social networking Polypharmacy
48.
49. Randomized trial of NCEP 220 Diet Control
diet in adults initiating 200
TC (mg/dL)
ART 180
160
(N = 90) 140
95% on ZDV/3TC 120
75% on EFV 100
15- to 30-minute session 240
0 6 12
with a dietician every 3 220
200
months 180
TG (mg/dL)
160
140
Other outcomes 120
100
Reduced fat, calorie intake 80
60
Reduced BMI 40
Increased dietary fiber intake 0 6 12
Months
Lazzaretti F, et al. IAS 2007. Abstract WEAB303.
50. Most important 1st line non-drug option
▪ 11% decrease in cholesterol, LANCET, 1998
Evidence 1A (Hooper, 2001, systematic review, BMJ)
“Mediterranean Diet”
51. Fruit and
Vegetables
Pulses, Alcohol
Beans,
Legumes
Mediterranean Fish
Diet
Pasta, Low
Bread Saturated
Nuts, Seeds, Fat
Olive Oil
52. • Low in saturated fat
• High in unsaturated fat particularly
monounsaturated fat
• High in fibre particularly soluble fibre
• High in Potassium
• Low in salt
• Good source of omega 3 fatty acids
• Rich in antioxidants
• Rich in B vitamins including folic acid
• Higher levels of Vitamin D
53. 5 portions a day
10-20g/ day - 5% LDL reduction
Bile acid losses
Cup of beans = 6g
3-4 portions fruit = 10g
54.
55.
56. APROCO Cohort (HIV+) MONICA sample (HIV-)
70
60 P < .0001
50 P < .0001
Patients (%)
P = NS
40
30
20 P <.01
P = NS
10
0
Smoking Hypertension Blood Glucose HDL-C LDL-C
126 mg/dL < 40 mg/dL (1.04 > 160 mg/dL
(6.99 mmol/L) mmol/L) (4.14 mmol/L)
223 HIV+ men and women on PI-based regimens vs 527 HIV- male subjects
HIV+ patients had lower HDL and higher TG
No difference in total cholesterol
Predicted risk of CHD > in HIV+ men (RR: 1.2) and women (RR: 1.6); P < .0001
Savès M, et al. Clin Infect Dis. 2003;37:292-298.
57. New England clinics: More than 70% of HIV+ smoke
Niaura R et al. Smoking among HIV-positive persons. Ann Behav Med 1999; 21(Suppl):S116
Swiss HIV Cohort Study
72% are current/former smokers
96% among IDUs
Clifford, GM et al. Cancer risk in the Swiss HIV Cohort Study: Associations with immunodeficiency, smoking and Highly
Active Antiretroviral Therapy. J Natl Cancer Inst 2005;97:425-432
58. 60
% of Cohort With Risk Factor
50
40
30
20
10
0
Family Previous Current BMI HTN DM Hyper- Increased
Hx of CHD Hx of CHD Smoking > 30 mg/m2 cholesterolemia TG
Friis-Moller N, et al. AIDS. 2003;17:1179-1193.
59. Cardiovascular diseases
Cancers
Lung diseases
GI tract
Age-related disorders
….
Single most preventable cause of death
60. Significant changes in mortality and morbidity among
people with HIV
As people with HIV live longer, they are increasingly
becoming ill or dying of non-HIV/AIDS related conditions
Smoking is highly prevalent among PLWHA
Smoking is the single most preventable cause of death
and disease … even for people with HIV
61.
62. Lifestyle Goals
• No smoking
• Saturated Fat: <10% total
Smoking cessation Energy
• Fruits and vegetables:
>400g/day
• Fish: >20g/day
• Oily Fish: >3 times/week
• 30-45 minutes of physical
activity at 60–75% of the
Healthy eating, average maximum heart rate
Increasing on four-five days of the week
Weight
Physical activity
management • Weight reduction ≥ 5%
• Waist <94 cm in men and
<80 cm in women
64. Some of the information used in this talk has been
obtained from the internet
Linsk, N.L., 2008 HIV/AIDS and Aging Inter-
relationships in the Older Fifty Population Midwest
AIDS Training and Education Center [online]
Available at:
http://www.ryanwhite2008.com/PDF/PCC-607-Gallagher
Powderly, W., 2008 Aging and the HIV Patient: A
Video Lecture With William Powderly, MD [online]
Available at:
http://www.medscape.com/viewprogram/8867
65. Metabolic syndrome 3 out of following
Waist circumference >102cm men
>88cm women
Triglyceride levels >1.7mmol/L
HDL cholesterol <1.0mmol/L in men
<1.3mmol/L women
Blood pressure >130/85mmHg
or current antihypertensive treatment
Fasting glucose level >6.0mmol/L
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497.