HIV-Associated HIV-Associated Lipodystrophy: Lipodystrophy: Modifiable Risk Modifiable Risk Factors in Croatian Factors in Croatian Patients Patients Christine M. Stanley, B.A. Christine M. Stanley, B.A. † Drago Tur Drago Tur č č inov, M.D.* inov, M.D.* George Rutherford, M.D. George Rutherford, M.D. † Thomas E. Novotny, M.D. Thomas E. Novotny, M.D. † Josip Begovac, M.D.* Josip Begovac, M.D.* † University of California San Francisco *University Hospital of Infectious Diseases, Zagreb, Croatia
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HIV-Associated Lipodystrophy: Modifiable Risk Factors in Croatian Patients Christine M. Stanley, B.A. Christine M. Stanley, B.A. Drago Turčinov, M.D.*
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Lipodystrophy and HIV/AIDSLipodystrophy and HIV/AIDS
Lipoatrophy:Lipoatrophy: loss of fat from loss of fat from cheeks, arms, thighs, cheeks, arms, thighs, buttocks, shoulders buttocks, shoulders
Anti-retroviral (ARV) related lipodystrophyAnti-retroviral (ARV) related lipodystrophy: :
5-30% of people on protease inhibitors5-30% of people on protease inhibitors
Also non-nucleoside reverse transcriptase Also non-nucleoside reverse transcriptase inhibitors (NNRTI)inhibitors (NNRTI)
Risk Factors for Lipodystrophy Risk Factors for Lipodystrophy (LD)(LD)
Non-modifiableNon-modifiable Increasing ageIncreasing age Female genderFemale gender Greater duration of ARVGreater duration of ARV Greater body weight before ARVGreater body weight before ARV
ModifiableModifiable SmokingSmoking Diet: Smaller intake of total protein Diet: Smaller intake of total protein
and total dietary fiber while taking and total dietary fiber while taking ARVARV
Study Question: Could diet Study Question: Could diet decrease the risk of LD in decrease the risk of LD in HIV/AIDS patients on ARVs?HIV/AIDS patients on ARVs?
Mediterranean Diet:Mediterranean Diet: high intake of legumes, fruits, vegetables, high intake of legumes, fruits, vegetables,
nuts, cereals and olive oilnuts, cereals and olive oil moderate intake of fishmoderate intake of fish low to moderate intake of dairy productslow to moderate intake of dairy products low intake of meat and poultrylow intake of meat and poultry moderate intake of alcoholmoderate intake of alcohol
Population-based Greek study found Population-based Greek study found Mediterranean diet protective against Mediterranean diet protective against death due to coronary heart disease and death due to coronary heart disease and cancer.cancer.
Hypothesis:Hypothesis: HIV/AIDS patients HIV/AIDS patients adherent to adherent to Mediterranean diet Mediterranean diet will have lower LD will have lower LD risk;risk;
Setting:Setting: One clinic in One clinic in Zagreb treats all HIV Zagreb treats all HIV patients in Croatia;patients in Croatia;
Target group:Target group: Patients from Patients from diverse diverse geographical areas geographical areas with differing dietswith differing diets
Croatia: Croatia: A Mediterranean and A Mediterranean and Central European CountryCentral European Country
136 patients from HIV clinic of Fran 136 patients from HIV clinic of Fran Mihalavic Infectious Disease Hospital in Mihalavic Infectious Disease Hospital in Zagreb, treated with ARV for at least Zagreb, treated with ARV for at least one year;one year;
LD assessed using patient self-report LD assessed using patient self-report and confirmation by physical exam;and confirmation by physical exam;
Metabolic data and body Metabolic data and body measurements obtained on all measurements obtained on all patients.patients.
Moderate alcohol consumption Moderate alcohol consumption considered beneficialconsidered beneficial
A ten-point adherence scale dichotomized A ten-point adherence scale dichotomized into:into: < 4 points = low adherence< 4 points = low adherence 4 points = medium and high adherence4 points = medium and high adherence
ResultsResults
41% of participants had moderate to 41% of participants had moderate to severe lipoatrophy; severe lipoatrophy;
32% of participants had moderate to 32% of participants had moderate to severe lipohypertrophy;severe lipohypertrophy;
Mediterranean diet score of Mediterranean diet score of 4 was 4 was independently associated with a lower independently associated with a lower risk of lipohypertrophy.risk of lipohypertrophy.
Risk Factors for LDRisk Factors for LD
OR 95%CI P Lipoatrophy
Gender Male Female
0.33 1.00
0.13-0.86
0.023
Stavudine use Yes No
3.99 1.00
1.72-9.28
0.001
Duration of HAART (per 12 months)
1.47 1.17-1.85 0.001
Lipohypertrophy
Mediterranean diet score <4 ?4
1.00 0.31
0.12-0.77
0.012 Gender Male Female
0.09 1.00
0.03-0.26
<0.001
Known duration of HIV infection before start of HAART (per 12 months)
1.17
1.05-1.31
0.005
Duration of HAART < 25 months ? 25 months
1.00 5.49
1.42-21.31
0.014
LD and Food CategoriesLD and Food Categories
Men without LD Men without LD (n=108) consumed (n=108) consumed more fish more fish (p=0.026), less (p=0.026), less meat (p=0.028) meat (p=0.028) and less vegetable and less vegetable oils (p=0.024). oils (p=0.024). 77% of men 77% of men without LD vs 47% without LD vs 47% with LD frequently with LD frequently consumed olive oil consumed olive oil (p=0.002).(p=0.002).
0
20
40
60
80
100
120
140
Med
ian
food
con
sum
ptio
n (g
/day
)
Lipodystrophy No Lipodystrophy
Meat Fish Vegetable Oils
Dietary intake from 108 men in relation to lipodystrophy
LD is common, progressive syndrome LD is common, progressive syndrome in HIV/AIDS patients taking ARV;in HIV/AIDS patients taking ARV;
Changes in fat distribution persist Changes in fat distribution persist after discontinuation of ARV;after discontinuation of ARV;
LD may be disfiguring and LD may be disfiguring and stigmatizing;stigmatizing;
Because of cost and availability, Because of cost and availability, patients may not have option to patients may not have option to change treatment.change treatment.
DietDiet Adherence to Mediterranean diet Adherence to Mediterranean diet
associated with decreased LD risk;associated with decreased LD risk; Consuming more fish, less meat, and less Consuming more fish, less meat, and less
vegetable oil associated with lower LD risk;vegetable oil associated with lower LD risk; Consuming olive oil associated with lower Consuming olive oil associated with lower
LD risk.LD risk.
SmokingSmoking Former or current smokers had higher risk of Former or current smokers had higher risk of
lipoatrophy (p=0.042)lipoatrophy (p=0.042)
ConclusionsConclusions
Cross-sectional designCross-sectional design Prospective randomization not possibleProspective randomization not possible Difficult to infer causality due to multiple confoundersDifficult to infer causality due to multiple confounders
Study LimitationsStudy Limitations
Results specific to this patient group and may Results specific to this patient group and may not be generalizable;not be generalizable;
Questionable accuracy of retrospective dietary Questionable accuracy of retrospective dietary information; information;
LD determined by self-report and physical exam.LD determined by self-report and physical exam.
Dr. Josip Begovac, Christine Stanley, Sarah Gertler, Nancy Gertler