HIV-Associated Lipodystrophy: Modifiable Risk Factors in Croatian Patients

1. HIV-Associated Lipodystrophy: Modifiable Risk Factors in Croatian Patients Christine M. Stanley, B.A. † Drago Turčinov, M.D.* George Rutherford, M.D. † Thomas E. Novotny, M.D. † Josip Begovac, M.D.* †University of California San Francisco *University Hospital of Infectious Diseases, Zagreb, Croatia

2. Lipoatrophy: loss of fat from cheeks, arms, thighs, buttocks, shoulders Lipodystrophy and HIV/AIDS • Anti-retroviral (ARV) related lipodystrophy: • 5-30% of people on protease inhibitors • Also non-nucleoside reverse transcriptase inhibitors (NNRTI) • Lipohypertrophy: dorsocervical fat pad, neck circumference, breast, abdominal fat

3. Risk Factors for Lipodystrophy (LD) • Non-modifiable • Increasing age • Female gender • Greater duration of ARV • Greater body weight before ARV • Modifiable • Smoking • Diet: Smaller intake of total protein and total dietary fiber while taking ARV

4. Study Question: Could diet decrease the risk of LD in HIV/AIDS patients on ARVs? • Mediterranean Diet: • high intake of legumes, fruits, vegetables, nuts, cereals and olive oil • moderate intake of fish • low to moderate intake of dairy products • low intake of meat and poultry • moderate intake of alcohol • Population-based Greek study found Mediterranean diet protective against death due to coronary heart disease and cancer.

5. Croatia: A Mediterranean and Central European Country • Hypothesis: HIV/AIDS patients adherent to Mediterranean diet will have lower LD risk; • Setting: One clinic in Zagreb treats all HIV patients in Croatia; • Target group:Patients from diverse geographical areas with differing diets

6. Methods • 136 patients from HIV clinic of Fran Mihalavic Infectious Disease Hospital in Zagreb, treated with ARV for at least one year; • LD assessed using patient self-report and confirmation by physical exam; • Metabolic data and body measurements obtained on all patients.

7. Measuring Dietary Adherence • Food questionnaire included 150 food and beverage items; • Usual dietary intake during the preceding year was calculated: • 5 Beneficial categories: vegetables, legumes, fruits and nuts, cereals and fish • 3 Detrimental categories: meat, poultry, dairy • Moderate alcohol consumption considered beneficial • A ten-point adherence scale dichotomized into: • < 4 points = low adherence •  4 points = medium and high adherence

8. Results • 41% of participants had moderate to severe lipoatrophy; • 32% of participants had moderate to severe lipohypertrophy; • Mediterranean diet score of  4 was independently associated with a lower risk of lipohypertrophy.

9.   Risk Factors for LD

10. Dietary intake from 108 men in relation to lipodystrophy Meat Fish Vegetable Oils LD and Food Categories • Men without LD (n=108) consumed more fish (p=0.026), less meat (p=0.028) and less vegetable oils (p=0.024). • 77% of men without LD vs 47% with LD frequently consumed olive oil (p=0.002).

11. Discussion: Lipodystrophy • LD is common, progressive syndrome in HIV/AIDS patients taking ARV; • Changes in fat distribution persist after discontinuation of ARV; • LD may be disfiguring and stigmatizing; • Because of cost and availability, patients may not have option to change treatment.

12. Conclusions Diet • Adherence to Mediterranean diet associated with decreased LD risk; • Consuming more fish, less meat, and less vegetable oil associated with lower LD risk; • Consuming olive oil associated with lower LD risk. Smoking • Former or current smokers had higher risk of lipoatrophy (p=0.042)

13. Study Limitations • Cross-sectional design • Prospective randomization not possible • Difficult to infer causality due to multiple confounders • Results specific to this patient group and may not be generalizable; • Questionable accuracy of retrospective dietary information; • LD determined by self-report and physical exam.

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