Slide 1: Copyright © 2008 by Nelson Vergel Beyond HIV Survival Enhancing Health and Body Shape in the post-HAART era Nelson Vergel Program for Wellness Restoration, powerusa.org


Slide 2:This information (and any accompanying printed material) is not intended to replace the attention or advice of a physician or other health care professional. Anyone who wishes to embark on any dietary, drug, exercise, or other lifestyle change intended to prevent or treat a specific disease or condition should first consult with and seek clearance from a qualified health care professional.


Slide 3:Relax, ask questions, let’s make this fun! Do not stress about writing anything down! Copies of these slides are found for download at POWERUSA.org


Slide 5:COMPREHENSIVE APPROACH TO WELLNESS Medications Exercise Stress Reduction Nutrition


Slide 6:Precontemplation. You have no conscious intention of making a change, whether through lack of awareness or information (“Overweight in my family is genetic; it’s just the way we are”) or because you have failed in the past and feel demoralized (“I’ve tried so many times to lose weight; it’s hopeless”). Contemplation. You are aware that a behavior is a problem and are considering doing something about it, but you still aren’t committed to taking any action. Ambivalence may lead you to weigh and re-weigh the benefits and costs: “If I stop smoking, I’ll lose that hacking cough, but I know I’ll gain weight,” or “I know smoking could give me lung cancer, but it helps me relax; if I quit, stress could kill me, too!” Action. You’ve changed — stopped smoking, for example and you’ve begun to experience the challenges of life without the old behavior. You’ll need to practice the alternatives you identified during the preparation stage. Maintenance. Once you’ve practiced the new behavior change for at least six months, you’re in the maintenance stage. Now you’re working to prevent relapse and integrate the change into your life. Where Are You in Your Wellness?


Slide 7:Metabolic Disorders Protease Inhibitors: Insulin resistance, life style, genetics Zerit AZT ZERIT,AZT Protease Inh.: Insulin Resistance, family history Zerit, DDI ?? Zerit AZT 60% 30-50% 20-40 % 10-15 % 40-60 % < 5 %


Slide 8:Lipohypertrophy Increase in body fat. In HIV-infected persons, body fat accumulations typically occur in the trunk, eg, visceral fat increase or “buffalo hump.” Lipoatrophy Loss of fat under the skin. HIV-infected persons, may experience loss of subcutaneous fat in the periphery, buttocks and face. Lipodystrophy syndrome As used with HIV/AIDS, this term refers to the presence of lipoatrophy and/or lipohypertrophy accompanied by metabolic abnormalities, typically with altered lipid profile and impaired glucose metabolism.


Slide 9:HIV Lipodystrophy Truncal obesity Facial wasting Wasting of arms Wasting of legs Patient also has hyperlipidemia & diabetes Buffalo hump Regimen: Crixivan+Zerit +Epivir 1.5 years CD4=300 VL= <400 Fat and Muscle Fat & Muscle


Interventions for Decreasing Abdominal (Visceral ) Fat :Interventions for Decreasing Abdominal (Visceral ) Fat Diet- Lower carb? Exercise- cardiovascular vs resistance training? Weight Reduction Anti-diabetic drugs: Metformin (Glucophage), Rosiglitazone (Avandia), Pioglitazone (Actos) Testosterone gel Anabolic Steroids- Oxandrin, nandrolone Human Growth Hormone (Serostim) Human Growth Hormone Releasing Hormone- Tesamorelin Modification pr cessation of HAART Surgery


Carruthers Lipoatrophy Severity Scale :Carruthers Lipoatrophy Severity Scale Stage 1 Stage 2 Stage 3 Stage 4 James J et al. Dermatol Surg. 2002;28:979-986.


HIV Medications and Lipoatropy (Fat Wasting) :HIV Medications and Lipoatropy (Fat Wasting) Lipoatrophy Fat Wasting Higher Risk Stavudine-D4T AZT Didanosine-DDI? Low Risk Nevirapine- Viramune Tenofovir- Viread/Truvada Abacavir- Ziagen Lamivudine- 3TC Emtricitabine- Emtriva Fuzeon Isentress Celsentry All protease inhibitors


Slide 14:TempleFill Cheek Augmentation Lipoatrophy Deficits Requiring Correction


Commonly Used Options forHIV-related Facial Lipoatrophy (From FacialWasting.org) :Commonly Used Options forHIV-related Facial Lipoatrophy (From FacialWasting.org)


Slide 16:before after For more information visit facialwasting.org


Measuring Body Composition in HIV :Measuring Body Composition in HIV


Dual Energy X-ray Absorptiometry (DEXA) :Dual Energy X-ray Absorptiometry (DEXA)


Slide 19:DEXA SCAN REPORT


Slide 20:SHIELDING AGAINST SIDE EFFECTS


Diarrhea :Diarrhea May be caused by meds (PIs, DDI, antibiotics), HIV, food allergies, parasites Lomotil, Imodium. May mask symptoms L-Glutamine powder: 20 - 40 gm/day (HUFFMAN F. Intl AIDS Society Conference.July 6-11, Buenos Aires) Pancreatic Digestive Enzymes (Ultrace, Absorbaid). May also improve digestion and bloating Acidophilus (good bacteria): 3 times/day (HEISER C. Intl AIDS Society Conference.July 6-11, Buenos Aires) Soluble Fiber: Cilturelle (OTC pills) Calcium/Magnesium Supplements (Sherman DS, Fish DN.Clin Infect Dis. 2000 Jun;30(6):908-14.)


Neuropathy :Neuropathy HIV(+) subjects using ddI, ddC, d4T had reduced acetyl-L-carnitine & had demylinating neuropathies (Famularo, 1997). Mitochondrial toxicity induced Amitriptyline (Elavil) for night time. Nortriptyline (Pamelor) for day time Vitamin B12 injections or nasal (1000-2000 mcg/week) Vitamin B6 – but test level for safety Calcium (1000 mg) and Magnesium (600+mg) Cod liver oil, acupuncture, massage, neuromuscular therapy N-Acetyl Carnitine (ACTG trial) Alpha Lipoic Acid (data in diabetes )


Fatigue :Fatigue Possible causes: infections, low testosterone and/or DHEA, anemia, medications, vitamin deficiencies, depression, sleep problems, viral replication, hypoglycemia, heart problems, lactic acidosis, etc Check your testosterone, thyroid function, and cortisol and have them raised if they are low Procrit (for anemia), or switching from AZT Prevent dehydration! Multivitamins, B-12 shots Antidepressants Exercise, even if it is light and for short periods of time Attention Deficit Drugs (Adderall, Stratera) Better sleep habits. Speep apnea diagnosis. Sleep meds like Ambien and Lunesta Provigil: medication to treat excessive sleepiness caused by narcolepsy, obstructive sleep apnea syndrome , and shift work sleep disorder .


How to Treat Sexual Dysfunction :How to Treat Sexual Dysfunction Testosterone injection/cream /gel/patch Viagra, Levitra, Cialis DHEA - men 50 - 500 mg, women 25 - 100 mg Trimix- Injection of 0.1-0.2 cc in the penis. Less expensive than Caverject. See an Urologist. Visit gotocompoundingshop.com Muse – men, implant - expensive Yohimbe - stimulant, concerns about hypertension (Prescription: Yocon) Blood pressure medication (ACE II inhibitor)- Diovan Counseling may help those with psychologically induced sexual dysfunction Talk to an Urologist!


Depression :Depression Counseling, support groups, get involved Anti-depressants ( Wellbutrin and Remeron have the lowest effect on sexual function.) Be aware of interactions Testosterone Replacement (100-200 mg/week for men) Sustiva and Interferon have been reported to cause depression/anxiety in some patients Life Style Changes Exercise (walking, working out, sports,etc) Improved sleep habits Vitamin supplementation for those who are deficient (B-12, B-6) St. John’s Wort, etc? (careful with interactions)


Appetite Loss/Nausea :Appetite Loss/Nausea Possible Causes: Medications, depression, nausea, infections, loss of taste, vitamin deficiencies, etc Marinol (prescription) Medicinal Marijuana Zofran (prescription) Remeron (antidepressant) Zinc 50-75 mg/day (for loss of taste) Multivitamins Powered ginger root capsules (for nausea) Caution: Megace increases fat mass, blood clots, diabetes, and causes impotence


Bone Disorders in HIV :Bone Disorders in HIV Treatments for bone loss (HIV negative data) Resistance exercise, preventing wasting syndrome, and avoiding tobacco Calcium (1000- 1500 mg/day) and Vitamin D (400-1000 IU/day MAX). Get some sun! Biophosphonates (Alendronate) Estrogen Replacement Therapy for Women Calcitonin (Intranasal and oral) Teriparatide (Forteo)


Cardiovascular Health in HIV Disease :Cardiovascular Health in HIV Disease


Inconsistent Results: From major studies on CVD risk in HIV-infected and HAART-treated patients :Inconsistent Results: From major studies on CVD risk in HIV-infected and HAART-treated patients 1. Bozzette SA, New Eng J Med. 2003;348:702–10 2. Friis-Møller N, 13th CROI, Denver 2006, #144 3. Klein D,13th CROI, Denver 2006, #737 7. Rickerts V, Eur J Med Res. 2000;5:329–33 8. Lichtenstein K, 13th CROI, Denver 2006, #735 9. El-Sadr W, et al. 13th CROI, Denver 2006, #106LB 4. Currier JS, JAIDS. 2003;33:506–12 5. Mary-Krause M, AIDS. 2003;21:2479–86 6. Moore RD, 10th CROI, Boston 2003, #132


Traditional factors are the biggest contributor to coronary heart disease (CHD) in HIV population :Traditional factors are the biggest contributor to coronary heart disease (CHD) in HIV population ? - - Diabetes *Metabolic syndrome Cigarette smoking Inactivity, diet Orange = Modifiable Green = Non-modifiable


Slide 31:LDL ("bad") cholesterol is like a plasterer, heaping plaques onto the inner lining of arteries. HDL ("good") cholesterol works in the opposite direction, "unloading" cholesterol from arterial plaques.


How To Minimize Heart Disease :How To Minimize Heart Disease Do not smoke! Exercise and low animal fat/sugar diet Lose weight if you are overweight Manage stress. Deep breathing. Relax! Omega 3 fatty acids (cold water fish oils) L-Carnitine (prescription Carnitor) 2-4 grams a day Niacin 300-500 mg 3 x day. Start with lower dose to minimize “flushing” and take an aspirin 20 min before (Niaspan is the prescription grade) Soluble Fiber (oats, etc) Lipid Lowering Agents (statins, fibrates,etc) A Baby Aspirin a Day (81 mg) If HIV + and nothing else works, switch to lipid friendlier drugs: Viramune, Viread, Emtriva, Invirase, Epivir, Reyataz, Ziagen, Fuzeon, Isentress, Selzentry, Intelence, and others


Lipid-Lowering Therapy Overview :Lipid-Lowering Therapy Overview *Low patient acceptance. TG: triglycerides, HDL: high density lipoprotein (good cholesterol), LDL: low density lipoprotein (bad cholesterol)


Testosterone Replacement Therapy :Testosterone Replacement Therapy


Slide 35:Testosterone and Aging


Testosterone Deficiency (Hypogonadism) :Testosterone Deficiency (Hypogonadism) Testosterone deficiency may be present in 38 % of men with HIV (HIV + women may also have this problem) Normal levels in blood: Men... Total test. 300-1100 ng/dL, Free test. 5 - 21 ng/dL Women... Total test. 10-50 ng/dL Free test. 0.10-0.85 ng/dL Symptoms of testosterone deficiency: Fatigue, low or lack of sex drive, poor appetite, loss of muscle mass & strength, depression


Testosterone Therapy Delivery Systems :Testosterone Therapy Delivery Systems Intramuscular injections Transdermal patches (Androderm) Transdermal gel (Androgel or Testim) or cheaper higher concentration compounded gels ( visit gotocompoundingshop.com ) Testopel pellets Special compounded creams for women (by prescription only- go to gotocompoundingshop.com ) Human Chorionic Gonadotropin (HCG) Others: DHEA (women)


Testosterone Supplementation- Potential Side Effects :Testosterone Supplementation- Potential Side Effects Increased blood pressure Increased sex drive Increased skin oil- acne Testicular shrinking Increased in breast tissue (gynecomastia) Increased in hemoglobin and red blood cell volume (polycythemia) Many people have none, some have one or two of these side effects. All are reversible


Required Monitoring in Testosterone Replacement :Required Monitoring in Testosterone Replacement Prostatic specific antigen (PSA) blood test and digital rectal exam once a year Hematocrit/hemoglobin (to monitor for polycythemia) Blood pressure Free testosterone levels


Slide 41:Exercise Therapy in HIV Disease


Slide 42:Exercise Benefits: Not a single drug can do this!  total and abdominal fat improves insulin sensitivity improves glucose tolerance increases HDL cholesterol  triglycerides and LDL increases muscle mass improves endurance improves strength improves bone density Improves mood


Lipodystrophy Body Changes: Effect of Exercise :10 men with truncal obesity Intensive 16-week program Significant decrease in total body fat (3.3 Lb, P < 0.01) Greatest decrease was in trunk fat (2.43 Lb, P < 0.03) Significant decrease in triglycerides observed Roubenoff R. et al. AIDS.1999;13:1373-5. Lipodystrophy Body Changes: Effect of Exercise


Benefits of Exercise and Dietary Changes in the Metabolic Syndrome :Benefits of Exercise and Dietary Changes in the Metabolic Syndrome


Exercise ± Oxandrolone in Patients on HAART :Exercise ± Oxandrolone in Patients on HAART


Aerobic (Cardiovascular) Exercise :Aerobic (Cardiovascular) Exercise Start with a brisk walk every day if tired Concentrate in low impact or no impact exercises (e.g. Elliptical Trainers) Do what you enjoy (bicycling, roller skating, etc) Good for burning fat, triglycerides, blood sugar, but it may decrease muscle mass 20 - 30 minutes 3-4 times a week is enough for many people Cardiovascular exercise may increase fat loss under the skin


Progressive Resistance Exercise (PRE) :Progressive Resistance Exercise (PRE) Warm up and stretch before a session Lift maximum weight for muscular failure (exhaustion) at 8-12 repetitions One body part per week One hour sessions 3-4 times a week Three sets per body part If no access to a gym, start with crunches, push ups, and squats at home For more details, visit www.medibolics.com and www.hivfitness.org


PRE Principles :PRE Principles Safety First - Stop if if hurts! High Intensity - Momentary muscular failure to stimulate growth Recovery = Rest, nutrition, and time 2 - 3 warmup, 2- 3 heavy sets per exercise 45 to 60 minutes per session, 3 - 4 sessions per week. DO NOT OVERTRAIN!


PRE Principles (continued) :PRE Principles (continued) Warm up sets: 50 - 60 % of the heavy weight you can lift 6-12 times Heavy sets: Weight you are capable of lifting 6 - 12 times to momentary muscular failure When heavy set strength increases so you can do 12 reps, increase weight 5 – 10 lbs so you can only lift about 6-8 reps to momentary muscular failure


PRE Principles (continued) :PRE Principles (continued) Compound exercises affect the most tissue/mass for quickest growth Full range of motion - recruits/builds the most muscle mass Major muscle group first when energy is highest Secondary/ancillary muscles follow


Best Exercise Sites with videos, etc :Best Exercise Sites with videos, etc www.exrx.net www.MyFit.ca Ipod exercise routine downloads: http://www.menshealth.com/download/


Slide 54:Micro/Macronutrient Supplementation in HIV Disease


Supplements and HIV-Any data? :Supplements and HIV-Any data? Glutamine Powder- 10-30 grams/day Gut and immune system protection, anti-catabolic Whey Protein 20-100 grams/day Popular with bodybuilders. HIV study found compensatory response. People ate less food and no increased LBM was found Creatine 5-15 grams/day Muscle voluminizer, strength enhancer. Caution with diarrhea and kidney overload. Small HIV study found no benefit. Omega 3 oils (fish oils) 3000- 6000 mg/day Decreases cholesterol/triglycerides, anti-inflammatory, mood stabilizer? L-Carnitine 1000-3000 mg/day Helps use fat for energy, cell protection, lowers lipids, anti-catabolic, heart muscle protection, N-Acetyl Carnitine may restore nerve damage in neuropathy B Vitamins (100 mg each/day)- whole body processes, possible prevention of mitochondrial toxicity


Supplements- What Works? :Supplements- What Works? Niacin 1000-3000 mg/day Increases good cholesterol (HDL). Caution with “flushing”. Take a baby aspirin 20 min before taking niacin Selenium Glutathione production (anti-oxidant. A study showed people who took 200 mcg/day had better CD4 cells Calcium Carbonate- 500-2000 mg/d Bone protection, diarrhea control Nucleomaxx- Uridine (sugar cane based)- Increases fat under the skin


Get to know the HIV Buyers Clubs :Get to know the HIV Buyers Clubs Houston Buyers Club 1-800-350-2392 “How to Manage Side Effect” booklet DAAIR (NYC) 1-888-951-5433 “ Nutritional Supplements for HIV” booklet AIDS Manasota (FL) 1-941-954-6011 AIDS Treatment Initiatives (Atlanta) 1-888-874-4845


Food as Medicine :Food as Medicine


Nutritional Considerations :Nutritional Considerations Reduce saturated (animal) fats and hydrogenated oils Eat omega-3 fish oils- salmon, tuna, sardines or flax seed oil (alternative) Eat more monounsaturated fats: olive oil Minimize sugar, fructose (sweets, sodas, high fructose corn syrup, etc) Maximize fresh vegetables, fruits, nuts Eat adequate amounts (0.7-1 gm/lb/day) of protein (fish, eggs, cottage cheese, lean meats, chicken, whey, nuts, etc)


More Nutritional Considerations :More Nutritional Considerations Do not skip breakfast (keep an eye on sugar and refined flower products!) Try to eat 4-6 small meals instead of 2-3 large ones Eat more almonds, walnuts, pecans and pistachios (good cholesterol lowering fats) Eat fruits and vegetables of all colors ( varied antioxidant profile) Eat a high protein, complex carbohydrate rich meal after work outs Minimize caffeine (it reduces appetite)


Best Protein Sources :Best Protein Sources Building block of muscle mass and food for the immune system Dairy proteins - best is cottage cheese (casein), whey, etc… made to make mammals grow bigger . Be careful with milk allergies/lactose intolerance Whole eggs are better than egg white Fish - cold water fish like salmon Beef builds blood, too Chicken Soy powders Beans, rice - vegetarian diet requires good knowledge of protein sources


Slide 68:High Carbohydrate Intake May Increase Triglycerides “High carbohydrate load may worsen triglycerides in this (HIV+) population already with a tendency to elevated lipids” K. Mulligan. 4th International Conference on Nutrition and HIV Infection and the 2nd European Workshop on Lipodystrophy April 19 - 21, 2001, Cannes, France


Good Carbohydrates Bad Carbohydrates :Good Carbohydrates Bad Carbohydrates Provide energy and nutrients Bad carbs can worsen insulin resistance and triglycerides Bad: Avoid/reduce high glycemic, high calorie carbs – refined flour, esp. milled grains, sugar, high fructose corn syrup Good: Eat more fiber, nutrient, and fluid-rich, low calorie, low glycemic carbs like vegetables, fruits, roots, greens


Fat is not a Four Letter Word :Fat is not a Four Letter Word Fats are needed for energy, immune function, vitamin absorption, and hormones Good Fats- monounsaturated- Olive Oil Essential Fatty Acids- polyunsaturated Omega 3’s- cold water fish (salmon) Omega 6’s- high oleic sunflower oil, nuts Omega 3’s and 6’s- Flaxseed oil Bad Fats-processed/hydrogenated oils,margarine, artificial creamers, any man-made oil, burned oils, rancid oils, lard


Emotional Support and Stress Reduction :Emotional Support and Stress Reduction Depression and anxiety can decrease immune function and natural killer cell activity. Meditation, Yoga, exercise, gardening, hobbies, “doing nothing”, mindfullness Support groups, volunteer work Surround yourself with people who care, avoid people with negative attitudes Find passion in your life Get professional help if you need it Try to get rid off shame and guilt Turn HIV from a liability to an asset. Reinvent yourself if you have to!


For More Information :For More Information Email: Nelsonvergel@yahoo.com Web Sites: PowerUSA.org (copies of these slides are found here) Medibolics.com SalvageTherapies.org FacialWasting.org