Exercise: The Best Therapy for Managing Side Effects

Exercise: The Best Therapy for Managing Side Effects

How to Stay Active and Energetic

By Michael Mooney and Nelson Vergel

September/October 2009

There are many benefits of exercise in HIV disease. Besides the evident improved self-image, energy level, and mental outlook, several research studies performed with HIV-positive people have found the following clinical benefits in body composition and metabolism.

Exercise produces improved muscle function, increased body dimensions and mass, and strength when used alone.^1,2

It may reduce trunk (belly) fat mass in patients with HIV lipodystrophy.³

It increases muscle mass and decreases LDL (bad cholesterol) when combined with testosterone in eugonadal men (men with normal testosterone) with wasting.⁴

It increases build-up of lean tissue and strength gain when combined with oxandrolone (Oxandrin, an oral anabolic) in eugonadal men with wasting.⁵

Muscle hypertrophy (enlargement), induced by resistance training, may decrease triglyceride levels in the blood of hypertriglyceridemic (those with high triglycerides), HIV-positive men being treated with antiviral therapy.⁶

Acute exercise does not have a deleterious effect on HIV replication in adults with high viral loads.⁷

Moderate physical activity may slow HIV disease progression.⁸

Exercise is associated with significant improvement in mood and overall distress, as well as a significant increase in body cell and lean body mass.⁹

Exercise can increase bone density in men and women.¹⁰

Testosterone and resistance exercise promote gains in body weight, muscle mass, muscle strength, and lean body mass in HIV-positive men experiencing weight loss and low testosterone levels.¹¹

Exercise training resulted in a substantial improvement in aerobic function while immune indices were essentially unchanged. Quality of life markers improved significantly with exercise.¹²

Getting Started

Before you start an exercise program, there are some things to consider. First, get your blood pressure, heart rate, weight, body dimensions, fasting cholesterol, triglycerides, and blood sugar measured. Your doctor should be able to advise you if you are capable of exercising without health if you can.

If you feel tired and weak, start walking every day to your best ability. Walking can help increase energy levels to enable you to start a more intensive exercise program later on when you're feeling better. Using a cheap pedometer to measure your daily steps is useful. Try to reach 10,000 steps a day since that has been associated with good cardiovascular health and fat loss.

There are two types of exercise: resistance (or weight) training and cardiovascular (or aerobic) exercise. Resistance training uses weights to induce muscle growth. Cardiovascular exercise improves the way your body uses oxygen and increases metabolism so that you can burn fat and lower bad cholesterol and blood sugar.

Do low-impact aerobic exercise three to four times a week. Exercising for 20-40 minutes by walking fast, bike riding, going up the stairs, using a stationary bike, elliptical trainer, or treadmill will increase your aerobic capacity, help to burn fat, and decrease cholesterol, triglycerides, and blood sugar. Jogging should only be an option if you have very strong joints and no problems with neuropathy. Do not do aerobic exercise if you are losing weight involuntarily or if you are tired or recovering from illness. Some people worry that cardiovascular (aerobic) exercise can increase fat wasting (lipoatrophy), but this fear is unfounded, in our opinion.

Recommendations

Train with weights and machines three times a week for one hour. Starting with machines is the safest way until you get familiar with the exercises. As you feel more confident and strong, bring in free weight exercise (hopefully with the help of a workout buddy). As you get stronger, increase your weights in every exercise. Exercise one body part per week, and do three exercises per body part. One light warm-up set and two heavier sets of eight to ten repetitions (to momentary muscular failure, meaning until you can not do another rep) are enough for each exercise. If you do not have access to a gym, do push ups on the floor and squats holding books or large bottles full of water at home. As long as you are "resisting" your own body weight, you are doing resistance exercise. You can also get an exercise ball and follow this great home-based workout: www.myfit.ca/exercisedatabase/search.asp?muscle=Home&equipment=yes.

For examples of other exercises you can do at home, visit http://weboflife.nasa.gov/exerciseandaging/chapter4_strength.html.

For great resistance exercises at the gym, visit: www.myfit.ca/exercisedatabase/weight_lifting_exercises.asp.

Important Things to Remember

• Learn how to do each exercise correctly and concentrate on using strict form to get the most out of exercise and prevent injuries.
• Make sure your muscles are warm before targeting them with more challenging weights. Warm them up with a light, high-repetition exercise set.
• Don't use your body to add momentum; cheating this way takes work away from the targeted muscles. Use a deliberate speed to increase the effectiveness of the movement.
• Use a full range of motion on all exercises. Feel the muscle stretch at the bottom and go for a momentary peak contraction at the top. Don't go too fast!
• Warm up before you work out and stretch afterwards to prevent injury. Briefly stretch the major muscle groups before your training. Th is helps flexibility and muscle recovery. For stretching routines, go tohttp://weboflife.nasa.gov/exerciseandaging/chapter4_stretching.html.
• Feel the muscles working by keeping your head in what you're doing. Focus on your muscles contracting and relaxing. Concentrate on your body exercising, not on thoughts or people around you.
• If the weight's too light (more than 12 repetitions), try using a heavier one with more resistance or do the movement more slowly and really feel the contraction. You should be barely able to finish the tenth rep if your weight is the right one. Of course, as you get stronger with time, increase your weights.
• Keep rest periods to no more than about 20-30 seconds, or shorter, depending on how tired you are from your last set. This will also help to give your heart a mini-workout.

Safety First

Always remember -- safety first! If something you do in an exercise hurts, stop! Ask for help to figure out what you're doing wrong. Maybe it's improper form. If you hurt yourself, you will hinder your progress because you won't want to work out! Learn proper form! Do not exercise if you feel you are coming down with a cold.

Commit Yourself

If you can afford it, join a gym. If you spend the money, you'll be more likely to stay with it, and consistency is the key to success in any exercise program. Also, try to find someone who is enthusiastic to train with, or get a personal trainer (if you can afford one). It's easier to stay motivated when you train with someone else who has a vital interest in your mutual success. It's also safer to have someone to spot you when you lift heavy weight.

Avoid Overtraining

Working out for more than an hour can cause overtraining that can destroy your muscles, decreasing your strength. Overtraining is probably the factor most ignored by exercise enthusiasts. In order to build muscle, the body has to receive a stimulus, a reason, to grow bigger, or hypertrophy. It's really very simple: the body only does what it needs to do, what it is required to do. It isn't going to suddenly expand its muscle mass because it anticipates needing more muscles. But if it is challenged to move weights around, it will respond by growing.

Another way to look at it is, if you take any body builder and put him in bed for weeks at a time, he'll begin to rapidly lose muscle mass because the body will sense that it doesn't need the extra muscle any more. So, one needs to deliver the stimulus to begin muscular hypertrophy (growth) and that's what lifting weights does. However, overdoing exercise stresses out the body and initiates the process of actually breaking down muscle mass as the body begins to burn its own muscles to use for fuel. This is why so many people don't grow at a satisfying rate. Even worse, often times these people will think they aren't training hard enough, and increase their exercise routines, thinking they just need more stimuli! And this is where the biggest error is made -- more is not necessarily better! It seems paradoxical that you could work out less and grow more, but this is very often the case.

Therefore, any exercise beyond that which is the exact amount of stimulus necessary to induce optimal muscle growth is called overtraining.

A Workout Log Is Recommended

The best reason to keep track of your workouts is so you can see graphically what you are accomplishing, and analyze your pattern to see if you're overtraining. You will also be able to see whether you're gaining strength at a reasonable rate. You will find when you log your workouts, that if you are overtraining, you won't be gaining in strength or muscle size. So document your workouts by keeping track of the weight you lift and the amount of reps you lift for each exercise, and then when you go in to train again the next week, you'll know what you are trying to improve upon. If you find out that you're weaker than you were the time before, and everything else like nutrition, etc. is in line, you may be training too often. For downloading workout logs, visit www.exrx.net/WeightTraining/WorkoutLogs.html.

Food and Hydration

Drink at least eight glasses of water a day to keep hydrated. Dehydration can rob you of energy for your workouts. Drink plenty of water while working out and avoid sugary drinks, since they will cause fatigue after an initial burst of energy. Some people like to drink green tea or creatine in juice before a workout to help increase energy levels through a workout.

A light carbohydrate meal (fruits, carbohydrate drinks, etc.) before a workout and a protein-rich one afterwards is advisable. Keep yourself well hydrated with plenty of water throughout the workout. And get plenty of rest aft erwards.

Do not work out after eating a regular meal. Wait at least two hours. If you need a snack, have some fruit and a slice of toast with peanut butter one hour or more before working out. Do not consume protein shakes before working out (leave them for after the workout). Digestion will slow down your workouts and bring your energy down. Within 30-60 minutes after the workout, feed your muscles with a balanced meal containing protein, good fats (olive oil, flaxseed oil), and complex carbohydrates, like fruits and whole grains.

Supplements like glutamine, creatine, and whey protein may be a good thing to consider. A shake containing one heaping tablespoon of glutamine, two tablespoons of flaxseed oil, one or two scoops of whey protein, fruit, and milk (if you are not lactose intolerant, otherwise almond or rice milk, though not soy, since it has been shown to increase estrogen in both men and women), provides a good balanced meal after a workout.

Resources

Two of the best websites for video clips of exercises and an explanation of anatomy are: www.exrx.net/Lists/Directory.html and www.myfit.ca.

Also, several exercise routines are provided on our website, http://medibolics.com/exercise.html.

You can also find most exercise routines explained in videos on youtube.com and menshealth.com.

Be sure to read Michael's and Nelson's book, Built To Survive. For more valuable information, go to powerusa.org.

Nelson Vergel, a native of Venezuela, is a 26-year HIV survivor and advocate for wellness in HIV disease. He is the founding direct or of the Program for Wellness Restoration (PoWeR), the Body Positive Wellness Clinic in Houston, a founding member of the AIDS Treatment Activists Coalition (atac-usa.org), founder/moderator of the largest online HIV health support group (pozhealth at yahoogroups.com), an international speaker, an expert on nutrition and complementary therapies at TheBody.com, and the co-author of the book Built To Survive. Most recently, Nelson was select ed to be a member of the U.S. Department of Health and Human Services HIV Guidelines Panel. For more information about Nelson and his programs, please visit www.powerusa.org.

Michael Mooney is a long-time medical researcher who co-authored "Built To Survive." He was a columnist for Muscle Media for two years, has been interviewed in Sports Illustrated, quoted on ABC's Good Morning America and is Director of Education at SuperNutrition, a best-selling vitamin line. Michael's unique approaches to building bodies will be documented in an exercise video soon. Learn more about Michael's research by visiting his websitewww.michaelmooney.net.

References available online at www.positivelyaware.com.

Got a comment on this article? Write to us at publications@tpan.com.

References

1. Spence DW et al. Arch Phys Med Rehabil. 1990; 71:644-8.
2. Rigsby LW et al. Med Sci Sports Exerc. 1992;24:6-12.
3. Roubenoff R, et al. AIDS. 1999;13:1373-5.
4. Grinspoon S et al. Ann Intern Med. 2000;133:348-55.
5. Strawford A et al. JAMA. 1999;281:1282-90.
6. Yarasheski KE et al. J Appl Physiol. 2001 Jan; 90(1):133-8.
7. Roubenoff et al Appl Physiol. 1999 Apr;86(4):1197-201.
8. Mustafa T et al. Ann Epidemiol. 1999 Feb;9(2):127-31.
9. Rabkin J et al. Med Sci Sports Exerc. 1998 Jun; 30(6):811-7.
10. Tebas P et al. Clinical Infectious Diseases. 2006; 42:108–114
11. Basin S et al. JAMA. 2000;283:763-770.
12. Stringer W et al. Medicine & Science in Sports & Exercise. 30(1):11-16, January 1998.

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The Coming Crisis in HIV Drug Development

Excellent article by Paul Dalton

Project Inform
The Coming Crisis in HIV Drug Development
By Paul Dalton

June 16, 2008

The last few years have seen tremendous progress in treating people with advanced and drug-resistant HIV. Four powerful drugs became available that either overcame drug resistance (Prezista [darunavir, TMC-114], Intelence [etravirine, TMC-125]) or were from entirely new classes [Selzentry (maraviroc), Isentress (raltegravir)].

This marked an important and unique moment in HIV drug development. Never before have so many new and effective drugs come out so close together. People with extensive experience taking HIV drugs have been able to put together powerful regimens with two or more fully active agents -- often for the first time.

Project Inform took pains to highlight both the tremendous promise of these new drugs as well as the importance of using them correctly -- emphasizing that this moment, or anything resembling it, is unlikely to recur. Our message was clear: 'Seize this opportunity, use the new drugs carefully, and don't waste this once-in-a-lifetime chance'.

As good as some of these newer drugs have looked in studies, there are emerging signs of trouble in the real world. Dr. Steven Deeks, a prominent HIV physician and researcher says, "Although the current generation of drugs are generally doing great, many patients are not responding in a durable manner. We are now following about 25 individuals who have failed all six drug classes. The key now is to design regimens to maintain immunologic and clinical stability while we wait for more drugs. I am concerned, however, as it will likely be a few years before we have another shot at getting the virus under control. We desperately need a second generation integrase inhibitor that works against viruses resistant to raltegravir."

Dr. Deeks' experience is far from typical. He follows many of the most treatment experienced people in the San Francisco Bay Area, many of whom have been on therapy since 1987. Although not typical, his experiences have been reported elsewhere, if in smaller numbers.

This suggests a burgeoning problem of people beginning to run out of treatment options, as has happened a couple of times during the epidemic. Project Inform is concerned that the most vulnerable people living with HIV will be left with few or no viable treatment options, possibly for many years.

One of the unintended effects of the recent successes in drug development is that fewer people are available for studies of experimental drugs aimed at treatment experienced folks. We saw this coming and have been counseling drug companies and the Food and Drug Administration (FDA) that the era of 'TORO-like' studies was coming to a close. These studies give volunteers optimized background therapy (the best combination of HIV drugs chosen with resistance test results) with either the experimental drug or a placebo. The design allows regulators, scientists and activists to clearly see the benefit of the new drug. (Some call these studies 'TORO-like' after those that led to the approval of Fuzeon [enfuvirtide, T20]).

This contrasts with how studies of first line treatment are done. When studying HIV drugs as first line, the basic model is head-to-head non-inferiority studies, which are designed to tease out the relative contribution of the entire regimens rather than the individual drugs. (Non-inferiority means that one drug or regimen is equivalent or 'close enough' to another.)

The FDA has allowed non-inferiority studies for drugs being studied as first line, but has insisted on placebo controlled superiority studies for treatment experienced studies. This made a good deal of sense when there were many people signing up for these studies. The situation is now quite different.

While there aren't enough people signing up for these kinds of studies, there's still a sizeable need for studying new HIV drugs. This, combined with the thin drug pipeline and the current difficulty recruiting for studies, may add up to real trouble down the line.

In meetings with many drug companies Project Inform has warned of this impending problem and recommended that they adopt new ways of studying their drugs. The reaction has been mixed. While some companies have been quite open to new ideas, it's fair to say that most would prefer to stick with models that have proven successful.

We have struggled to argue -- to the companies and the FDA -- that ways of studying and developing drugs are both necessary and possible. Gilead Sciences is one of the first to grapple with this. When it came time to do large, pivotal studies of their experimental integrase inhibitor, elvitegravir, there simply were not enough people in the US to enroll a typical study for treatment experienced people. Project Inform had warned Gilead, and others, of this eventuality and argued for studies that would more closely resemble the head-to-head, non-inferiority studies used for studying first-line drugs.

Over time Gilead came to agree that this was the way forward and submitted such a plan to the FDA. The FDA eventually allowed Gilead to move forward with this study design for elvitegravir. This is a great victory for people living with HIV. There is a great need for new treatments to be developed and for the FDA and companies to think and act creatively to ensure this happens.




An Overview of the Current State of HIV Drug Development
The Industry
As a whole, pharma has done a tremendous job developing HIV drugs. However, many visible signs are showing their fading commitment to HIV. Fewer new companies are getting into HIV, and some well established ones are either cutting back or eliminating their drug development plans. The marketplace for HIV drugs is both crowded and competitive. The scientific hurdles for developing new HIV drugs have also grown more difficult, making it a less attractive market for companies.

The FDA
The FDA is responsible for ensuring that drugs are safe and effective before they become available outside clinical studies. Recent media stories that focused on drug safety, particularly on Vioxx and Heparin, have created a somewhat fearful climate inside the FDA where new ideas are met skeptically. Their recent decision to green light elvitegravir's development shows that at least its antiviral division is open to creative drug development plans.

The Current Pipeline
All in all, the pipeline is both thin and unimpressive. There are a few 'me too' drugs (slight changes in existing drugs) which are helpful but not game changing. A few novel compounds may prove promising down the line, but they're struggling right now, due to either study results or in one case the company being bought by a company that doesn't want to work in HIV.

As for those drugs in human studies, the closest to approval is rilpivarine (TMC-278), an NNRTI for first line treatment being studied against Sustiva. Vicriviroc, Schering's CCR5 drug, continues to flounder but is still viable. Bevirimat, a maturation inhibitor from Panacos, has been hamstrung by formulation problems. Other drugs we are following are Pharmasset's racivir, and Avexa's apricitabine.

The Bottom Line
The past two years have been a boon to people with extensive treatment experience. Four successful new drugs, including two new classes, have meant most people can put together powerful, effective and tolerable regimens, even if they've never been able to get to undectable before. However, this period is now over, and we're experiencing a major downturn in the number of promising drugs in the pipeline.

This reinforces the importance of using the current crop of new drugs correctly. Your best chance at getting to and staying undetectable is to start a regimen with at least two and hopefully three fully active drugs. If you're able to do this and get your HIV level to undetectable, good adherence is the best way of keeping it there.

This also points to the need for treatment activists, like Project Inform, to continue to work with the companies, scientists and regulators to ensure that new drugs are developed.
Lastly, this situation points toward the need for a cure. It is only going to become more difficult to keep the companies, their researchers and the general public interested in HIV drugs. There's a growing sense that HIV is not that much of a problem anymore, at least not in wealthy countries.

The only real solution is a cure. While some may discount its possibility, we do not. Many promising approaches are under study, as well as a resurgence in community activism aimed at cure research. A conscientious program mounted by academia, industry, government and community is necessary to reach this goal.