What is Malnutrition?
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1 HIV & Obesity Gail Shor-Posner, PhD Director, Division of Disease Prevention Department of Epidemiology & Public Health University of Miami Miller School of Medicine
2 What is Malnutrition? Under-nutrition Over-nutrition
3 Malnutrition Wasting
4 HIV & Disease Progression
5 Benefits of Obesity in HIV Patients Shor-Posner, et al. (2000) When Obesity is Desirable: A Longitudinal Study of the Miami HIV-1-Infected Drug Abusers (MIDAS) Cohort. JAIDS
6 HIV Obesity & Disease Progression Shor-Posner, et al. (2000) When Obesity is Desirable: A Longitudinal Study of the Miami HIV-1-Infected Drug Abusers (MIDAS) Cohort. JAIDS
7 Obesity among patients with HIV: The latest epidemic Studies show that 6 out of 10 HIV+ people are overweight/obese More than 70% of the patients were on HAART at the time of the study. Neither duration of HAART nor the type of regimen influenced BMI values. (Amorosa, 2005) Crum et al. (2008) Obesity among patients with HIV: The latest epidemic. AIDS patient care and STDs. Amorosa V et al. (2005) A tale of two epidemics. The intersection between obesity and HIV infection in Philadelphia. J Acquir Immune Defic Syndr
8 HIV Obesity trends are mirroring Global Obesity
9 Malnutrition Obesity MODERN HUMANS
10
11 Obesity in Latin America Rueda-Clausen a, Silva a and López-Jaramillo (March 2008) Epidemic of overweight and obesity in Latin America and the Caribbean, International Journal of Cardiology.
12 Obesity in Colombia Obesity in Colombia approx 40%???
13 Causes of Global Obesity Environmental Influences Portion distortion Less physical activity Greater reliance on technology Pawloski, L. 26 February Department of Global Health & Community Health
14 From Ancient to Modern Diet Lin Khor, G. (2006). 33 rd Session of the SCN, Universiti Putra Malaysia, Geneva.
15 From Ancient to Modern Transportation Lin Khor, G. (2006). 33 rd Session of the SCN, Universiti Putra Malaysia, Geneva.
16 Why Worry? Obesity is linked with Increased risk of cardiovascular disease Increased risk of Diabetes Cancer Depression
17 What has happened in HIV? ARV Therapy Living Longer Survival Rates
18 HIGHLY ACTIVE ANTIRETROVIRAL THERAPY (HAART) Benefits Longer survival Improved quality of life Adverse effects Lipodystrophy syndrome DM2 Alterations in glucose and lipid metabolism Insulin resistance Increase in cardiovascular risk IDF Cape Town Report (April 2007)10 th Meeting of the Mediterranean Group for the Study of Diabetes
19 Lipodystrophy Apparent in 20-35% of patients after months of drug therapy, HIV itself Subcutaneous lipoatrophy Face, limbs, buttocks Fat accumulation Visceral Dorsocervicalspine ( buffalo hump ) Lipomata Breast enlargement Heath KV, JAIDS 2002;30:440-7 & Bastard JP, Lancet 2002;359: GrinspoonS, NEJM 2005;352:48-62
20 Facial Lipoatrophy Korthuis, T. (2006). Metabolic Complications of Antiretroviral Therapy. OHSU HIV Program.
21 Dorsocervical Spine Fat Accumulation Korthuis, T. (2006). Metabolic Complications of Antiretroviral Therapy. OHSU HIV Program.
22 Central Fat Accumulation Korthuis, T. (2006). Metabolic Complications of Antiretroviral Therapy. OHSU HIV Program.
23 Limb Lipoatrophy
24 HIV-Related Metabolic Complications Lipid(cholesterol /triglyceride) abnormalities Abnormal blood sugar (glucose) metabolism Mitochondrial toxicity Body fat redistribution Bone One syndrome or several? One etiology or multifactorial?
25 HIV & CARDIAC RISK Vergel, N. Beyond HIV Survival: Enhancing Health & Body Shape in the post-haart era. Powerusa.org.
26 Vergel, N. Beyond HIV Survival: Enhancing Health & Body Shape in the post-haart era. Powerusa.org.
27 DIABETES AND AIDS TWO EPIDEMICS OF XXI CENTURY 0.3% 0.9% 0.1% Diabetes prevalence 0.8% 1.2% 0.2% 0.6% 0.5% 5.9% 0.4% AIDS prevalence
28 Insulin Resistance and HIV Venter - The New HIV Precipe? Metabolic Disorders. Reproductive Health & HIV Research Unit. University of Watersrand
29 MULTICENTER AIDS COHORT STUDY Incidence of DM in HIV+ patients with HAART exposure 4 X greater than HIV-controls 568 HIV + men - HAART 710 HIV - men Adjusted for age, BMI DM in HIV + rate: 4.7 cases per 100 person/yr DM in HIV- rate: 1.4 cases per 100 person/yr Arch Inter Med 2005, 165: 1179 IDF Cape Town Report (April 2007)10 th Meeting of the Mediterranean Group for the Study of Diabetes
30 DISORDERS OF GLUCOSE METABOLISM IN HIV INFECTED PATIENTS ON TREATMENT 61% of patients develop insulin resistance 14% of patients develop Metabolic Syndrome A collection of metabolic risk factors that accelerate the onset of: diabetes, heart disease, stroke, and certain cancers IDF Cape Town Report (April 2007)10 th Meeting of the Mediterranean Group for the Study of Diabetes
31 Metabolic Syndrome Abdominal obesity Elevated TRIG Low HDL Hypertension Hyperglycemia Ackerman, P. Metabolic Syndrome and its Relation to Chronic Disease. UP Diabetes Outreach Network.
32 HIV Patients and risk for metabolic syndrome Metabolic Syndrome is more prevalent in HIVseropositive than HIV-seronegative women due to dyslipidemias. -- Sobieszczyk, et al. (2008). Prevalence and predictors of metabolic syndrome among HIV-infected and HIV-uninfected women in the Women s Interagency HIV Study. JAIDS, 48:, Metabolic Syndrome prevalence in HIVpositive adults was lower than in the general population. Samaras et al. (2007). Prevalence of metabolic syndrome in HIVinfected patients receiving highly active antiretroviral therapy using International Diabetes Foundation and adult treatment panel III criteria. DiabeCare, 30, The prevalence of Metabolic Syndrome among HIV-infected patients is similar to that in uninfected individuals. Jericó, et al. (2005). Metabolic syndrome among HIV-infected patients: Prevalence, characteristics, and related factors. Diab Care, 28,
33 Potential Mechanisms for Metabolic Abnormalities Vessels Increased trygliceride in circulation Increased apolipoprotein E Decreased degradation of Lipoprotein B Liver Decreased mitochondrial fatty acid oxidation Increased lipid accumulation and hepatic steatosis Fat Increased lipolysis Decreased subcutaneous fat Decreased SRBP1-activated PPAR expression Toxic effect on mitochondria Pancreas Increased insulin secondary to resistance Muscle Decreased glucose Transport (GLUT 4) Increased intramyocellular lipid and fatty acid oxidation IDF Cape Town Report (April 2007)10 th Meeting of the Mediterranean Group for the Study of Diabetes
34 What Do We Know? Traditional lifestyle risks are most important in HIV for cardiovascular risks Same in diabetes Venter - The New HIV Precipe? Metabolic Disorders. Reproductive Health & HIV Research Unit. University of Watersrand
35 CONCLUSIONS Obesity is an emerging health problem among HIV+ men and women Metabolic and body-fat abnormalities are common among ARV treated HIV+ adults Preliminary evidence suggests that such patients have an increased risk of cardiovascular disease. Clinicians caring for HIV-infected adults should assess cardiovascular risk factors and target risk reduction, though not at the expense of successful treatment of the underlying HIV disease. Diet, lifestyle modification, and use of lipid-lowering and insulinsensitizing regimens may be useful in specific situations. Role of intentional weight loss in obese HIV will need careful study, as weight loss is a documented predictor of decreased survival.
36 Acknowledgements Victoria Elf
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