Outsmarting HIV with Healthy Nutrition

From: http://www.positivelyaware.com/2012/12_01/hiv_wellness_series.shtml

Living with a chronic illness like HIV can present certain nutritional challenges. Without effective HIV medication treatment, replicating virus can tax the body, destroying lean body mass and impairing immune function and quality of life.¹, ²
While this destruction of lean tissue can be controlled with effective HIV antiretroviral combination therapy, other challenges like fat accumulation and increases in lipids (cholesterol and triglycerides) and/or insulin resistance may arise in some patients after treatment initiation.³ Although limited research has been done on the effects of nutritional approaches on pre- and post-HAART (highly active antiretroviral therapy) metabolic issues, general suggestions can be extracted from studies regarding other conditions like diabetes, cardiovascular disease, and obesity. These suggestions are aimed at helping the body deal with the effects of HIV or its medications on metabolism, body shape, and quality of life as we live longer with HIV.
The components of whole food.
Foods are made up of many different components—some are “micro” or smaller quantity nutrients, like vitamins, and some are “macro” or larger quantity nutrients. The three macro groups that compose the majority of our diets are carbohydrates, proteins, and fats. These three units are the basic materials that fuel our activities and metabolism and maintain body composition. Selecting the best sources and amounts of these three macronutrients may help to minimize metabolic disorders (such as high cholesterol and blood sugar) and prevent loss of lean body mass and accumulation of body fat.⁴, ⁵, ⁶
The best carbohydrates.
Carbohydrates provide our body’s main source of quick energy. After carbohydrates are digested and after some processing by the liver, they are released into the bloodstream as a sugar called glucose to be delivered to the cells.
Throughout the majority of the last million years of our evolution, the human diet consisted of animal carcasses, some seeds, nuts, and fibrous vegetable and fruit carbohydrate sources that are generally nutrient-rich with lots of water, but are not calorie-dense like processed foods of today. The majority of these carbohydrate sources are vegetables, leaves, roots, and fruits (all rich in fiber). Because vegetable fiber tends to slow down digestion, a majority of the carbohydrates in these foods are absorbed relatively slowly, inducing less blood sugar (glucose) and insulin spikes than processed sweets that contain no fiber. Some people call these “slow carbs.”
It was only after the advent of agriculture that human beings were introduced to higher intakes of grains as carbohydrate sources. Higher intakes of grains deliver lots of calories. Additionally, some grains deliver their sugar energy relatively quickly, especially if the grain is milled (which removes the fiber that slows down sugar absorption), as are the grains in breads and pasta. Unless you are very active and exercise enough to metabolize nutrients more rapidly, this quick glucose release into the bloodstream can create a dysfunctional hormonal environment that can ultimately promote obesity, cardiovascular disease, and diabetes. This hormonal shift also has a profound effect on lean body mass and fat metabolism, and possibly immune function.⁷, ⁸, ⁹ The key hormone involved in this problem is called insulin, produced by an organ called the pancreas.
Insulin and insulin resistance.
The hormone insulin is produced by the pancreas to control blood sugar and store it in muscles for later use as glycogen. Insulin’s main job in the body is to promote the delivery of sugar energy as glucose to cells. When a small amount of glucose is delivered into the bloodstream, a small amount of insulin is produced by the pancreas to accompany it. When there is a large amount of glucose, the pancreas works to produce a large amount of insulin to facilitate its delivery so that cells can take in as much glucose as possible. Extra glucose that cannot be taken in by the cells circulates in the bloodstream and can be toxic to brain cells, so under normal circumstances, most of it is soon converted into triglycerides (fat) in the liver to be stored for later use. But we have to be careful with high blood levels of triglycerides, since they are what feed fat cells.
The correct amount of carbohydrate sources will provide enough sugar to give a healthy amount of glucose to the cells, but not too much at once. Thus, levels of glucose and insulin in the bloodstream are not unusually elevated for any long period of time. The pancreas works, but it is not overworked trying to keep up with an unusual demand for insulin.¹⁰ However, in the U.S., much of the diet consists not only of large amounts of high-calorie carbohydrate sources, but also of carbohydrates from sweets and sodas, which are very concentrated sources of sugar. The net effect that intake of these calorie-dense carbohydrate foods creates is a bloodstream that is occasionally flooded with large amounts of glucose, a pancreas that is overworked, and large amounts of insulin and triglycerides circulating in the bloodstream. Note that excess insulin causes increased production of cholesterol.
Over time, these occasional glucose, triglyceride, and insulin floods can cause a decrease in the sensitivity of the cells’ response to insulin, which reduces the cells’ ability to take in glucose. Insensitivity to insulin is called insulin resistance, and it is a serious consideration in HIV because we are now seeing it as one of the core components of lipodystrophy and metabolic problems.¹¹ Some HIV medications can worsen insulin resistance, so we need to be aware of nutritional considerations that can help. Ways to decrease insulin resistance are to exercise, choose more metabolic-friendly HIV medications, and follow a proper diet. For instance, a prominent study from Tufts School of Medicine found that HIV-positive people consuming an overall high-quality diet, rich in fiber and adequate in energy and protein, were less likely to develop fat deposition.¹² This is why it is best to select the majority of your carbohydrate intake from fiber-rich, slow-releasing carbohydrate sources that do not contain an excessive amount of calories. And these good carbs should be accompanied by good sources of protein and fats.

Combining carbohydrates with protein, fiber, and fat.
Protein, fiber, or fat will slow the absorption into the blood of glucose from carbohydrates, which helps to reduce the rise in blood sugar and insulin spikes. So, mixing carbohydrates with protein, fiber, and good fats is one way to reduce their problematic effect on blood sugar and insulin. Ensure that every meal and snack you consume has a mix of these three macronutrients. But what are the best fats, protein, and high-fiber carbohydrates sources out there?
Fats and oils.
There are a number of different kinds of fats. There is motor oil, there is butter, and there are essential fatty acids. The most important oil to keep a Honda running right is not the kind with essential fatty acids (EFAs), but if you want to help your body stay healthy and your immune system operating at its best, you had better consider getting these EFAs on a daily basis. They are called “essential” because your body cannot manufacture them, and must obtain them from an outside source, like food or supplements. These oils are necessary for every critical function in your metabolism, including building lean body mass and fighting infections.
The main point is that since we need EFAs and other fats for health, we should be getting them in our diets from fresh, high-quality sources. A proper diet reduces the amount of starchy carbohydrates while maintaining a certain amount of healthy fats so that there is a different macronutrient balance than the old high-carbohydrate, high-protein, low-fat diets contained. This means striving to get fatty acids from several sources, the least of which are the saturated fats in butter or animal fat. Understand that saturated fats are not the demons we have been led to believe. When we realize that we evolved getting a certain amount of saturated fat from foods in the wild, it is only logical that they would have a place in a healthy diet. One recent study showed that dietary saturated fat and mono-unsaturated fat were associated with healthy testosterone production in humans, while EFAs had no effect. So it appears that we need a little saturated fat for optimal hormonal health. However, most people get far too much saturated fat, which promotes insulin resistance and metabolic problems, and not enough EFAs, which are needed for healthy cells and immune function.¹³
The other important kind of fat that we should consciously include in our daily diet is mono-unsaturated fat, which we get from foods like olive oil. Recent data have shown that mono-unsaturated fats decrease the risk of certain cancers, and have an anti-inflammatory effect.¹⁴ AIDS is an inflammatory disease, so mono-unsaturated fat intake logically has a place of importance in managing AIDS, too.

Fatty acid recommendations.
EFAs include the omega-3 and omega-6 fatty acids. Most people get an imbalance of these two by consuming too small an amount of omega-3 fats, which have anti-inflammatory properties, and relatively too large an amount of omega-6 fats, which tend to promote inflammation when out of balance.¹⁵ To get more omega-3s, eat more fish, including salmon, tuna, sardines, anchovies, mackerel, rainbow trout, and herring. Omega-6s are contained in common vegetable oils, like sunflower, safflower, and corn oils. Try to reduce your intake of these.
Oils and cooking.
Olive oil is one of the best oils to cook with. You can also cook with high-oleic sunflower oil, avocado, canola, macadamia, or any oil that is high in mono-unsaturated fatty acids.
Avoid cooking with oils made from corn and sesame. These oils contain more omega-6 fats, and less mono-unsaturated fats, so they have a higher potential for spoiling and turning to trans-fats, which are bad for the immune system. Try to avoid any intake of these oils when they are not absolutely fresh.
Also, choose oils that are minimally processed. Most of the clear oils in supermarkets are stripped of some of their natural components to make them more suitable for sitting on store shelves for long periods of time without spoiling. Do not use these stripped oils. When you do cook, do not overheat the oil so that it smokes, which causes the formation of carcinogens and destroys the beneficial fatty acids.
Avoid margarine, hydrogenated fats, or processed oils.
Do your best to avoid processed fats or oils, as they have negative effects on cellular health, overall metabolism, and your immune system. Look out for the words hydrogenated and partially-hydrogenated. These kinds of manipulated fats probably do increase the risk of cancer and heart disease. They also weaken healthy cellular immune metabolism, which means that they might increase HIV progression. Lastly, they are also likely to promote high lipid levels and insulin resistance.
Protein, food for the immune system.
Dairy protein fractions, such as caseine (contained in milk curd) and whey, are at the top of the list of proteins that optimally feed lean body mass growth. In dairy products, the amino acid balances, insulin-raising potential, and overall growth factor content add up to one thing: milk proteins were created to make mammals grow bigger. While there is a lot of hoopla related to which dairy protein fractions are best, there is more misinformation than reality in this area. Those with lactose intolerance should be careful in their selection of milk-based products. Aged cheeses and yogurt may be more tolerable for those who cannot digest lactose.
Egg protein.
Next on the list are egg proteins. The important thing to remember is that whole egg is probably somewhat better than egg white for lean body mass growth and overall health effect, because the yolk is a rich nutrient source, and its protein content complements the protein in the egg white. Together they are a better source of protein.
Meat protein.
While real food like meat often seems to take a back seat to protein powders because of a mindset created by slick advertising, professional athletes know the value of real food related to lean body mass growth. If you do not make real food and meat fundamentals in your diet, you will not grow lean body mass tissue as well. Fish, chicken, turkey, and beef are vitally important foods, not only because of their protein content, but because they contain numerous other nutritional components that are important for a healthy metabolism. The message is: eat real food, then supplement food with protein powder drinks if you need them.
Lean red meat is a superior source for lean body mass growth and blood-building nutrients. These include creatine, carnitine, phenylalanine, conjugated linoleic acid (CLA), and heme- (blood) iron, the most absorbable form of iron. And meat, in general, is less likely to cause allergic reactions than eggs or dairy proteins, like casein and whey. The only caution about red meat is that the high amount of saturated fat most commercial red meat contains could promote metabolic problems. So be moderate about including it in your diet and choose leaner meats if you do.
Important details on meat: cooking kills bacteria in meats. Stewed meat is better for digestion (chicken soup, beef stew). Roasting is okay. Try not to fry or barbecue with charcoal. Charred foods are associated with increased risk of gastrointestinal system cancers. Any cooking of meat or vegetable protein that causes the formation of a hard outer skin renders the protein that becomes the skin to be much less digestible because it cross-links the protein.
Vegetarian diets
It is very difficult to gain lean muscle weight on a vegetarian diet. In fact, it is almost impossible for most people, especially when they are fighting infections that burn lean body mass. While I know a very few HIV-positive people who can do well adhering to a vegetarian regime, I find that the vast majority cannot do it and keep their lean body mass. Additionally, vegetarian diets increase the potential for anemia because of a lack of blood-building components such as highly absorbable heme-iron and vitamin B12.
If you do choose a vegetarian diet, your best protein sources are beans, seeds and nuts. Digestion of nuts and seeds will be improved by soaking them overnight to reduce the enzymes they contain that inhibit digestion of proteins. If you can eat them without digestive problems, many nuts and seeds are ideal foods because they contain protein, healthy fat, and complex carbohydrates in a very good balance for overall health. They also make a great snack between meals. However, the amino acid balances in these proteins do not appear to be optimum for lean body mass growth for humans. Again, vegetarian or vegan diets present a challenge to people with HIV or AIDS who need a full spectrum of amino acids and micronutrients. Unless you are vegetarian for ethical reasons, consider eating eggs and fish.
Caution:
People who are on HIV medications like tenofovir (in Viread, Truvada, Atripla, Complera, and the Quad), which may affect kidney function in some patients, should be careful about increasing their protein intake too high (over 1 gram per pound of body weight per day), as this can increase the potential for kidney problems. Ask your doctor if you are taking kidney burdening medicines, and, if so, only eat a higher protein diet under your doctor’s direction. Those who have liver problems need good protein intake for the repair of liver tissue, but should also be careful about higher protein intake, and should also do so only under a doctor’s supervision.
Calcium and vitamin D—two important micronutrients
Bone loss has been reported in several HIV studies. It seems to be caused by the effect of the virus on the body. Certain medications like tenofovir (Viread) may make this problem worse. We also seem to have a high incidence of vitamin D deficiency due to potential HIV medication effects or metabolism issues. We know that calcium and vitamin D help to strengthen bone. Many of us chose to take calcium plus vitamin D supplements, but there are also foods that are rich in these nutrients. Calcium-rich foods include milk, cheese, spinach, fortified orange juice (be careful with the sugar, though!), fish, eggs, and beans. Vitamin D-rich foods include milk, most fish, and eggs. However, most of us do not consume the 1000 mg and 2000 IU needed per day for calcium and vitamin D, respectively, and need to take over-the-counter supplements. One word of caution: do not take your calcium supplements with your HIV medications since they may interfere with their absorption (at least two hours before or after is okay).
Miscellaneous nutrition tips

• If diet, weight loss, and exercise fail to lower your LDL cholesterol and triglycerides, ask your doctor for a prescription for lipid-lowering agents (statins, fibrates, etc.) or to switch your meds to a more lipid-friendly HIV medication combination.
• For your food, shop mostly in the outer part of the grocery store where the fresh produce, meats, and milk products/eggs are. Avoid overly processed canned or packaged foods, except for frozen vegetables. Read the labels and avoid products with many preservatives and additives. Trans-fats and hydrogenated oils, high fructose corn syrup, and high sugar should be on your radar when reading labels. Watch this funny video for more details on healthy eating.
• Try to eat several smaller balanced (protein + good carbs + good fats) meals or snacks instead of two to three large ones. Smaller meals/snacks are more easily digestible, keep blood sugar and insulin more constant through the day, and keep you from binge eating late at night.
• Eat more almonds, walnuts, pecans and pistachios (good cholesterol-lowering fats). Twice a day, snack on such nuts to get your good fats and fiber. If you wish, mix them with some dried fruit. Research has shown that people who eat nuts tend to have lower LDL cholesterol.
• Avoid junk and fast food. The best way to do this is to have enough food at home and to bring lunch to work. Cook a lot of food on weekends and freeze meals in small containers you can heat up later.
• Do not sabotage yourself by bringing sweets and junk into your home. Watch your cravings at night, when most people find it the most difficult to avoid overdrinking alcohol or eating ice cream, cookies, and comfort foods.
• Eat a large breakfast, a moderate lunch, and a small dinner. Skipping breakfast makes you more prone to overcompensate by eating more calories late in the day. Your body has spent several hours without food and is starved for nutrients in the morning. Do not feed it sugar and white flour products at this important time. Eggs, oatmeal (the type that has no added sugar, and you can add whey protein powder to it!), Greek-style yogurt with nuts and fiber supplements, low-fat cottage cheese with fruit, almond butter on multigrain (high-fiber) bread, and fruit are all good choices for breakfast.
• For lunch have some soup and a glass of water first and wait 10 minutes to trick your body into feeling full faster. Grilled chicken with vegetables, tuna salad over greens and nuts, a Greek salad with sliced steak, and any Mediterranean food choices are good.
• For dinner, fill yourself with stir-fried (use olive oil!) vegetables and lean meats. Two hours before bed, you can have half an almond butter sandwich or yogurt with fruit. You will not be hungry and desperate with this diet!
• Eat fruits and vegetables of all colors. Each has a different antioxidant profile. The produce section of the market is basically a fresh vitamin department and a medicine chest. Some foods like garlic, onions, and ginger have genuine therapeutic effects. Eating the widest variety of fresh produce on a daily basis assures you of getting all the ingredients that nature provides that can help keep your body strong enough to handle bacteria and viruses so that you stay healthy.
• Avoid sodas, sweet drinks, and fruit juices (fruit sounds healthy, but juice contains too much sugar and no fiber to slow down its absorption into the blood).¹⁶ Consuming sugar daily can affect your metabolism, create insulin resistance, make you fat, and have all kinds of negative health consequences. The suggested pecking order of carbohydrate food sources that support your health without increasing insulin resistance follows. Best are vegetables in their many forms. Next are beans and peas. These deliver more calories than vegetables, but the carbohydrates release much more slowly than grains. Next are whole grains, which are calorie-dense but contain carbohydrates that, in general, release somewhat slowly. At the bottom, and the most likely to promote body fat problems, are carbohydrates from milled grains, like wheat and corn. Whole grains are marginally better than processed grains, but when they are milled into flour the difference is not that great. The very worst carbohydrate sources are sweets, like candies, which can deliver as many as 2,000 calories per pound. Try to eat from the first group of slow-release carbohydrate sources most of the time, and if you are relatively healthy, you can have small amounts of milled wheat products or sweets once in awhile.
• Drink lots of water. Six to eight glasses a day is a good goal. If you get thirsty, you are already dehydrated!
• Eat a high-protein, complex carbohydrate-rich meal after workouts. Examples: chicken salad with nuts, cottage cheese or yogurt and nuts/fruit, celery sticks and hummus (chickpea butter), etc.
  Manage your intake of caffeine (it reduces appetite but can increase anxiety). Do not have any caffeine after 4 p.m., since it can impair your sleep.
• Minimize hidden sugars like high fructose corn syrup. Read the labels of food you buy. Diet sodas tend to make your brain crave sweets in general, so they are not good substitutes for sugary drinks. Water, water, water!
• If you do not consume at least 20 grams of fiber a day, add to your intake supplements like Citrucell or Benefiber, purchased in any grocery store. Fiber improves insulin sensitivity, makes you feel full longer, keeps your gut healthy (friendly gut bacteria that produce vitamins love fiber), keeps you regular and reduces diarrhea, and can lower the chances of getting colon cancer.¹⁷
• Eating healthy is eating smart, and it does not mean that you should starve yourself. Hopefully, this information has shed some light on healthy food sources and how they can affect health and the body. Now that we are living longer, food choices can determine how well we do as we age with HIV. So, take charge of your health and take care of your body. It is the only one you have.

Healthy Eating Shopping List

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1. Produce

• Spinach and other green leafy vegetables
• Broccoli and cabbage
• Green beans
• Avocados
• Raspberries and all berries. You can buy frozen ones and add to whey protein shakes
• Whole fruits (remember no juices).
• Sweet potatoes, carrots
• Hummus
• Beans and other legumes (you can buy canned or frozen ones)

2. Nuts, Grains, Oil

• Mix of almonds and other nuts
• Peanut, almond, and cashew butters without hydrogenated oil   (the   healthy   nut   butters   show   oil   and   butter separated since the lack of hydrogenated oils prevents emulsification)
• Pumpkin and sunflower seeds
• Wild rice (the darker the rice, the better)
• Whole grain breads and pasta
• High fiber crackers
• Oatmeal (not the little packets; those are loaded with sugars)
• Olive oil

3. Dairy

• Low fat milk, cheese
• Yogurt (Greek style, no sugar added)
• Eggs (free range or Omega 3 enriched if possible)

4. Meat

• Lean meats
• Salmon, sardines and tuna
• Occasional glass of red wine per day (optional)

5. Supplements

• Whey protein (I like the Isopure brand since it does not give me gut problems and it is very light)
• Vitamin D

NELSON VERGEL, a chemical engineer from Venezuela, has been HIV-positive since 1983, and is a leading treatment advocate on HIV disease. He created the Program for Wellness Restoration (PoWeR) and founded the Body Positive Wellness Center in Houston. Nelson has lectured extensively around the country and overseas, and with his research partner, Michael Mooney, co-authored the book Built to Survive. In 2010, he wrote and published Testosterone: A Man’s Guide—Practical Tips for Boosting Physical, Mental and Sexual Vitality.
He is currently a member of the DHHS Panel on Antiretroviral Guidelines, the AIDS Treatment Activists Coalition, and moderates PozHealth, one of the largest HIV health discussion listservs online.

Read posts from Nelson’s blog, “Surviving HIV”
Read Nelson’s blog, “Outsmarting HIV: A Survivor’s Perspective”

References:

1. Wanke, C. et al. Pathogenesis and Consequences of HIV-Associated Wasting JAIDS Journal of Acquired Immune Deficiency Syndromes.  December 2004 - Volume 37 - Issue - pp S277-S279
2. Brad M. Dworkin, M.D. Dietary Intake in Patients with Acquired Immunodeficiency Syndrome (AIDS), Patients with AIDS-Related Complex, and Serologically Positive Human Immunodeficiency Virus Patients: Correlations with Nutritional Status   JPEN J Parenter Enteral Nutr November 1990 vol. 14 no. 6 605-609
3. Shah, M et al. The role of diet, exercise and smoking in dyslipidaemia in HIV-infected patients with lipodystrophy.  HIV Medicine Volume 6, Issue 4, pages 291–298, July 2005
4. Batterham, M. et al.   Dietary intake, serum lipids, insulin resistance and body composition in the era of highly active antiretroviral therapy 'Diet FRS Study'.  AIDS: 18 August 2000 - Volume 14 - Issue 12 - pp 1839-1843
5. Williams, B. Protein Intake Is Positively Associated with Body Cell Mass in Weight-Stable HIV-Infected Men.
   
   The American Society for Nutritional Sciences J. Nutr. 133:1143-1146, April 2003
6. Mayere, K. et al.   Modifiable Dietary Habits and Their Relation to Metabolic Abnormalities in Men and Women with Human Immunodeficiency Virus Infection and Fat Redistribution. Clin Infect Dis. (2001) 33 (5): 710-717
7. Sanchez A, et al. Role of sugars in human neutrophilic phagocytosis. Am J Clin Nutr 1973; 26: 1180-84
8. Mynarcik, D. et al. Association of Severe Insulin Resistance With Both Loss of Limb Fat and Elevated Serum Tumor Necrosis Factor Receptor Levels in HIV Lipodystrophy. AIDS Journal of Acquired Immune Deficiency Syndromes:1 December 2000 - Volume 25 - Issue 4 - pp 312-321
9. Carr, Andrew. A syndrome of peripheral lipodystrophy, hyperlipidaemia and insulin resistance in patients receiving HIV protease inhibitors.AIDS:7 May 1998 - Volume 12 - Issue 7 - p F51-F58
10. Eizirik, D. et al.  Prolonged exposure of human pancreatic islets to high glucose concentrations in vitro impairs the beta-cell function. J Clin Invest. 1992 October; 90(4): 1263–1268.
11. Carr, Andrew  . A syndrome of peripheral lipodystrophy, hyperlipidaemia and insulin resistance in patients receiving HIV protease inhibitors.AIDS:7 May 1998 - Volume 12 - Issue 7 - p F51-F58
12. Hendricks , K. et al.  High-fiber diet in HIV-positive men is associated with lower risk of developing fat deposition American Journal of Clinical Nutrition, Vol. 78, No. 4, 790-795, October 2003
13. Tishaa, j. Dietary fat intake and relationship to serum lipid levels in HIV-infected patients with metabolic abnormalities in the HAART era. AIDS: 31 July 2007 - Volume 21 - Issue 12 - p 1591-1600
14. O’Keefe, J. et al.  Dietary Strategies for Improving Post-Prandial Glucose, Lipids, Inflammation, and Cardiovascular Health.  J Am Coll Cardiol, 2008; 51:249-255, doi:10.1016/j.jacc.2007.10.016
15. Giuglian, D.  The Effects of Diet on Inflammation: Emphasis on the Metabolic SyndromeJournal of the American College of Cardiology. Volume 48, Issue 4, 15 August 2006, Pages 677-685
16. Bolton, R. et al. The role of di

AIDS Nelson Vergel, AIDS expert, talks HIV and healthy aging by Kate Sosin, Windy City Times

http://bit.ly/lRCGbu

	AIDS Nelson Vergel, AIDS expert, talks HIV and healthy agingby Kate Sosin, Windy City Times2011-06-08
Nelson Vergel and Jeff Berry from TPAN. Photo by Kate Sosin
Nelson Vergel is not what you think of when you say "AIDS over 50."With hefty round muscles pushing out against a tight blue t-shirt and a lively demeanor, Vergel looks more like Mighty Mouse than a person resistant to nearly every HIV drug on the market. But Vergel is in the business of de-bunking myths about aging with HIV, and while his own HIV is a struggle, he's also the living example of his work. Vergel presented some of the latest findings on HIV and aging at Center on Halsted May 31, during his free talk, "Promising Advances in HIV Cure and Healthy Aging Research." The event was sponsored by Test Positive Aware Network. The Houston-based author and activist focused heavily on the scientific reasons why a cure to HIV/AIDS is both a distant dream and an impending reality. But while Vergel is following progress on possible cures, his own work focuses on informing other HIV-positive people on the changes HIV causes in the body and strategies for living well with the virus. "We're getting older. What is the quality of life going to be?" Vergel asked an audience of about 30 people. According to Vergel, medication is just one of four useful in battling HIV. He also includes stress reduction, exercise, and nutrition. In three years, he said, there will be four once-a-day HIV pills on the market (there is currently just one—Atripla). Still, HIV drug production is slowing because it's less profitable than other drugs. "We're moving into a new world," Vergel said. He expects that some HIV patients will be asked to go off their medications in time so that new possible cures can be tested. That possible cure might include one found four years ago in an American living in Germany. The famous "Berlin Patient" may have been cured of his HIV when he received a bone marrow transplant from a donor whose genetic mutations made him resistant to HIV. Research on that method is ongoing, Vergel said, but it's also still very risky and not enough information is available to make it a viable option yet. In the meantime, Vergel recommends nutrition and exercise. Because people living with HIV are at heightened risk of osteoporosis, HPV, and other illnesses, Vergel said it is especially important to remain vigilant about getting screened for other illnesses, especially HPV. "We're not talking about bottoms or tops or women or men," Vergel said. "[HPV] is affecting everyone." Medicine aside, exercise is the best medicine, said Vergel. "We [HIV-positive people] have an acceleration of the aging process by about 15 years," Vergel said. "Frailty in aging is most related to body strength." Vergel suggests leg squats for preventing frailty. He also said a healthy combination of cardio and muscle resistance can slow the aging process. New research has also shown merits of some vitamins in relieving some HIV symptoms. D vitamins can help maintain bone strength, while B vitamins can help relieve depression. Vergel warned, however, that patients talk to their doctors about vitamins as some can interact with HIV medications. Vergel doesn't stop at health, however. His talk also included strategies for fighting changes in body fat and fat under the skin (also known as lipohypertrophy and lipoatrophy) because Vergel said, "it's not about getting older. It's about getting your healthy look back as you age." Vergel thinks that a lot of doctors are reluctant to offer facial treatments to HIV patients who lose fat under facial skin because they see it as unnecessary, but he said that changes to body weight prevent some people from going on medication at all. However, a number of treatments exist for preventing weight changes while on HIV medication. Finally, Vergel discussed testosterone treatments, which he has covered in his latest book Testosterone: A Man's Guide. Testosterone is often taken by HIV-positive patients to combat fatigue, lack of motivation, poor appetite, and muscle loss. Vergel warns that these should be taken with caution because they can fuel cancer. Before making any decisions, he said, talk to your doctor. But do your own homework, too, he said because not every doctor will cover all the bases on HIV management. "The thing is, we don't have standards," he said. "We don't have guidelines." Information on Vergel's work as well as his complete slideshow presentation is available on his website:www.powerusa.org .

Vitamin D Supplements May Limit Tenofovir Bone Toxicity

Thanks to Jules Levin for sponsoring this article in his web site Natap.org

Vitamin D Supplements May Limit Tenofovir Bone Toxicity
18th Conference on Retroviruses and Opportunistic Infections, February 27-March 2, 2011, Boston

Mark Mascolini

In a randomized trial of 18-to-25-year-olds, vitamin D3 supplementation appeared to offset a negative impact of tenofovir on parathyroid hormone (PTH), which enhances release of calcium from bone [1]. Supplementation lowered PTH levels in people taking tenofovir but had no PTH impact on study participants taking nontenofovir regimens.

Tenofovir promotes renal phosphate wasting, which could contribute to bone abnormalities in people taking this drug. Vitamin D deficiency or insufficiency (a 25(OH) D level below 30 ng/mL) affects more than 80% of HIV-positive youth in the United States. Adolescent Trials Network (ATN) investigators hypothesized that vitamin D supplementation would increase renal tubular reabsorption of phosphate, decrease levels of PTH, and decrease levels of two bone turnover markers, bone alkaline phosphatase (BAP) and C telopeptide (CTX), in young adults taking tenofovir.

Study participants were 18 to 25 years old, had taken the same antiretroviral combination for at least 90 days, and had a viral load below 5000 copies. They could have any vitamin D level. The investigators excluded pregnant or breastfeeding women or people with hypercalcemia or hypercalciuria. The study population consisted of 118 people taking a tenofovir-containing combination and 85 taking a nontenofovir regimen. The ATN team randomized them 1-to-1 to receive directly observed vitamin D3 at a dose of 50,000 IU every 4 weeks for 12 weeks or to placebo.

Age averaged 20.9 (+/- 2.0), 76 enrollees (37%) were women, and 106 (52%) were African American. Entry CD4 counts averaged 587 (+/- 246), and 110 participants (55%) had a 25(OH)D level below 20 ng/mL. The tenofovir group had significantly lower tubular reabsorption of phosphate (92% versus 93%, P = 0.017 adjusted for baseline characteristics) and significantly higher PTH (47.7 versus 31.2 pg/mL, adjusted P < 0.001). PTH was significantly higher in study participants with insufficient vitamin D (45 versus 35 pg/mL, P = 0.024). The tenofovir and nontenofovir groups did not differ significantly in 25(OH)D level (20.8 and 21.7 ng/mL), CTX, or BAP.

PTH concentrations were significantly higher in tenofovir takers than in people on nontenofovir combinations regardless of baseline 25(OH)D level: 52 versus 35 pg/mL (P = 0.001) with 25(OH)D below 20 ng/mL, and 43 versus 27 pg/mL (P< 0.001) with 25(OH)D above 20 ng/mL.

Average 25(OH)D levels rose significantly in study participants receiving supplements, from 21.4 ng/mL when the study began to 35.5 ng/mL at week 12 (P < 0.001). At study entry, 47% of participants randomized to supplementation had a 25(OH)D level above 20 ng/mL, whereas 95% taking supplements had a level that high at week 12 (P < 0.001). Twelve-week 25(OH)D levels did not differ between supplemented people in the tenofovir group and the nontenofovir group, and 25(OH)D concentrations did not change significantly in youth randomized to placebo.

In the 52 people receiving vitamin D supplementation while taking tenofovir, average PTH fell significantly from baseline to week 12 (49 to 42 pg/mL, P = 0.003). In these people PTH dropped regardless of whether pretreatment 25(OH)D was above 20 ng/mL (-6 pg/mL, P = 0.053) or below 20 ng/mL (-8 pg/mL, P = 0.031). PTH did not change at all in tenofovir-treated people randomized to placebo. Tubular reabsorption of phosphate did not change significantly from baseline to week 12 in the supplement group or the placebo group. Among people receiving supplemental vitamin D while taking tenofovir, average BAP fell moderately but significantly (37 to 36 U/L, P = 0.04). Clinical bone or kidney toxicities arose in no study participants, and calcium did not rise above normal levels.

PTH did not change significantly with supplementation or placebo in people not taking tenofovir. Because vitamin D supplementation affected PTH only in people taking tenofovir, the researchers proposed a possible interaction between tenofovir, PTH, and vitamin D. Whether vitamin D supplementation promotes healthier bones via by lowering PTH remains to be determined.

Two other studies reported at this conference assessed the impact of vitamin D supplementation in people with HIV. Twelve weeks of vitamin D supplementation in D-deficient people with HIV did not improve endothelial function in the first placebo-controlled trial of this strategy in HIV-positive adults [2]. Results hinted that efavirenz may limit the impact of vitamin D supplements. A retrospective study found evidence that vitamin D supplementation may lower the risk of type 2 diabetes in adults with HIV [3]. NATAP reviews both of these studies separately at the links noted in the References.

References1. Havens P, Hazra R, Stephensen C, et al.  Vitamin D3 supplementation decreases PTH in HIV-infected youth being treated with TDF-containing combination ART: a randomized, double-blind, placebo-controlled multicenter trial: Adolescent Trials Network Study 063. 18th Conference on Retroviruses and Opportunistic Infections. February 27-March 2, 2011. Boston. Abstract 80.
2. Longenecker C, Hileman C, Carman T, et al. Vitamin D supplementation and endothelial function among vitamin D-deficient HIV-infected persons: a randomized placebo-controlled trial. 18th Conference on Retroviruses and Opportunistic Infections. February 27-March 2, 2011. Boston. Abstract 829. NATAP review online at http://www.natap.org/2011/CROI/croi_16.htm. Study poster online at http://www.retroconference.org/2011/PDFs/829.pdf.
3. Guaraldi G, Zona S, Orlando G, et al.  Vitamin D3 supplementation decreases the risk of diabetes mellitus among patients with HIV infection. 18th Conference on Retroviruses and Opportunistic Infections. February 27-March 2, 2011. Boston. Abstract 827. NATAP review online at http://www.natap.org/2011/CROI/croi_20.htm. Study poster online at http://www.retroconference.org/2011/PDFs/829.pdf.

 

Background:  Tenofovir (TDF) is associated with renal phosphate wasting, elevation in markers of bone turnover, and decrease in bone density. Vitamin D3 (VITD) treatment increases renal tubular phosphate absorption in VITD deficiency. VITD deficiency/insufficiency (serum 25-OH VITD <30 ng/mL) occurs in >80% of HIV⁺ youth in the U.S. We hypothesized that VITD administration would increase tubular reabsorption of phosphate (TRP) and decrease serum parathyroid hormone (PTH), bone alkaline phosphatase (BAP), and C telopeptide (CTX) in HIV⁺ youth treated with TDF.

Methods:  Randomized controlled trial (RCT) of VITD 50,000 IU vs placebo (PL) every 4 weeks for 12 weeks (3 directly observed oral doses) in HIV⁺ youth ages 18 to 24, viral load <5,000 copies/mL, and unchanged cART for ≥90 days. Participants were enrolled based on treatment with cART containing TDF (N = 118) or noTDF (N = 85) and randomized within those groups to VITD (N = 102) or PL (N = 101).

Results:  At baseline, VITD and PL groups were similar in age, race/ethnicity, body mass index, VITD, and calcium (Ca) intake (self-report). Prevalence of VITD insufficiency/deficiency was 84% overall. Participants on no TDF had longer duration of HIV infection and cART, higher viral load, and more advanced Centers for Disease Control and Prevention stage of HIV disease. Those on TDF had lower TRP, higher PTH and CTX; but similar BAP. At week 12, 52% in the VITD group had sufficient VITD, an increase from 17% at baseline, compared to16% at baseline and at week 12 in the PL group (p <0.001 vs VITD). TRP did not change in either group. PTH decreased in the TDF group receiving VITD, but not in the no TDF group receiving VITD or the PL groups. Ca intake affected the strength of the VITD-TDF interaction. CTX and BAP did not change significantly with VITD. There were no clinical bone or renal toxicities or elevations of serum Ca above normal in either group.

PTH (pg/mL) at baseline and change at week 12 by TDF and VITD

	TDF			No TDF
	Baseline	Change	pValue	Baseline	Change	pValue
VITD	47	–6	0.01	26	–2	1.00
PL	37	+2	0.72	25	0	1.00

Data are medians. P values are by Wilcoxon signed rank test, corrected for multiple comparisons by Sidak’s method. Controlled analysis via generalized estimating equations showed similar results.

Conclusions:  Supplementation with VITD3 50,000 IU monthly for 12 weeks in HIV⁺ youth was safe and reduced VITD insufficiency by 46%. VITD was associated with a significant decrease in PTH in those on TDF-containing cART. There was no change in TRP, CTX, or BAP. The effect of VITD on PTH was seen only in those on TDF, suggesting a possible interaction between TDF, PTH, and VITD.

Should I take Vitamin D if I am taking Viread or Truvada?

Vitamin D and Viread. Should I be concerned?
Dec 1, 2008

Dear Nelson:

Thanks for what you do for us

I just read an email that said that a study showed that people on Viread had low vitamin D and may have problems with bone. Should I take Vitamin D with Viread?

I do not want to have broken bones as I age

Tony



Response from Mr. Vergel

Dear Tony

Researchers at Mount Sinai School of Medicine recently presented a very interesting paper at the ICAAC 2008 conference on this issue. As you well know, Tenofovir (Viread) is probably the best nucleoside analog out there with the least problems with lipoatrophy and other side effects. However, it has been associated with kidney issues in some treatment experienced patients and also with loss of bone density in some studies. It seems that the bone effects are greater in those taking tenofovir with boosted protease inhibitors. Unfortunately, most of us do not know we have low bone density until we get a fracture.

Vitamin D is needed by our bodies to metabolize calcium to build up bone. Most of it is made when our skin in exposed to sunlight. Many people do not get enough sun in winter months.

In this study, most patients on tenofovir had low Vitamin D levels in their blood (measured as 25(OH)D). 39% of those with low Vitamin D levels also had high parathyroid hormone levels (PTH)

PTH is produced in the parathyroid glands which are four pea-sized glands located on the thyroid gland in the neck. Though their names are similar, the thyroid and parathyroid glands are entirely different glands, each producing distinct hormones with specific functions. The parathyroid glands secrete PTH, a substance that helps maintain the correct balance of calcium and phosphorus in the body. PTH regulates the level of calcium in the blood, release of calcium from bone, absorption of calcium in the intestine, and excretion of calcium in the urine.

When the level of calcium in the blood falls too low, the parathyroid glands secrete just enough PTH to restore the blood calcium level. High PTH usually means that there may be some bone loss problems. Low Vitamin D is known to cause hyperparathyrodism (high PTH).

The study investigators hypothesize that Viread's effect on bone may be related to this low Vit D/high PTH effect. More studies are needed with a larger number of patients

You may want to ask your doctor to measure 25 (OH) D levels. I am also an activist who is trying to get DEXA bone scans to be part of standard of care for people with HIV. It would be great to get a DEXA bone scan before someone starts HAART and then repeated it every two to three years to see how your bones are doing on therapy.

By the way, HIV infection by itself has also been associated with loss of bone density. But some medications may also add to this problem.

Bone density research in HIV is progressing. I tell people to work out with weights and machines, to get at least 30 minutes of sun a day, and to make sure their thyroid hormones and testosterone are in normal range to prevent bone loss. Some people would also benefit from taking Calcium/Vitamin D supplements and/or precription drugs approved to increase bone density.

Talk to your doctor since this is very new data.

Nelson