Fat is needed for the body to function. It plays an important role in keeping the skin and hair healthy, protecting body organs, and maintaining body temperature. Fats also stores energy.

There are different types of fat found in the body. Visceral fat is located deep in the belly under the muscle. Subcutaneous fat is the layer of fat just under the skin. Lipids are fats or fat-like substances in the blood, such as cholesterol and triglycerides.

Lipodystrophy means abnormal fat changes. It is used to describe a number of unwanted and potentially unhealthy changes in HIV+ people including:

• Body shape changes
  • Lipohypertrophy: Fat gain in the breasts, back of the neck (buffalo hump), visceral fat in the belly, or round lumps that appear under the skin (lipomas)
  • Lipoatrophy: Loss of subcutaneous fat in the arms, legs, butt, or face (sunken cheeks)
• Blood fat and sugar changes (metabolic problems)
  • Increased fats (lipids) in the blood
  • Increased sugar (glucose) in the blood

HIV+ people with lipodystrophy can have both body shape changes and metabolic problems. Some treatments can help with certain lipodystrophy changes, but nothing has been proven to get rid of all them.

This info sheet looks at treatments for fat gain. See also Lipodystrophy Treatments Part II: Treatments for Fat Loss, and Lipodystrophy Treatments Part III: Treatments for Metabolic Changes.

Fat gain, especially visceral fat in the belly, can cause a number of problems. These include feeling bad about how your body looks and feeling depressed, as well as bloating, tiredness, and heart problems. Fat gain not only affects the way people look, it can also be harmful to the health.

No one is really sure what causes fat gain. Sometimes it happens when a person puts on weight because of lack of exercise or getting older. However, fat gain may also be linked to the use of HIV drugs including protease inhibitors. There are several treatments being explored for HIV-related fat gain.

Human growth hormone (hGH) is naturally produced in the human body. Two drugs have been developed based on hGH that have shown the ability to reduce visceral belly fat:

• Serostim: This drug is a man-made version of hgH
• Tesamorelin: This drug is a man-made growth hormone releasing factor, which causes the body to produce more hgH

In HIV studies, Serostim lowered visceral belly fat by 30 percent in six months. Serostim is taken by injection under the skin every day or every-other-day. If the drug is stopped, the visceral fat comes back. The main side effects are joint aches, water retention, diabetes, increased lipoatrophy, and increased blood sugar levels.

Serostim is approved by the Food and Drug Administration (FDA) to treat HIV wasting, but not HIV-related fat lipodystrophy. The FDA said there was not enough safety and efficacy data to approve it to treat lipodystrophy, especially for long-term use.

Since Serostim is not approved for HIV-related fat gain, it will not be covered by insurance for this purpose. It is expensive, costing up to $3,000 a month. There is a patient assistance program for Serostim at http://www.serostim.com/default.aspx?pageid=331.

Tesamorelin has been shown to lower visceral fat by 15 percent in six months in studies. However, like Serostim, people who stopped the drug had their belly fat return.

Tesamorelin also requires daily injections, but it seems to have milder side effects than Serostim. It does not increase blood sugar or cause lipoatrophy, and it may lower triglycerides.

Tesamorelin (brand name Egrifta) will soon be up for FDA approval. It will probably also have a high price tag. Insurance coverage will depend on whether or not it receives approval for lipodystrophy-related fat gain. The company is planning to have a patient assistance program.

Over-the counter nutritional hgH supplements are often advertized. Beware of these – there is no proof that they work.

Leptin is a hormone that is produced by fat cells. High levels of leptin suppress appetite and cause more fat to be used up.

Leptin requires two injections under the skin a day, although other doses may be studied in the future. In a small trial of HIV+ men with lipodystrophy, visceral fat decreased by 32 percent after six months, with no change in subcutaneous fat. Small studies have not shown leptin to have negative effects on blood sugar.

Activists are asking the manufacturer of leptin to do larger studies in HIV+ people.

This diabetes drug showed promise in reducing belly fat in early studies. However later studies have not confirmed this and have even shown that it may worsen lipoatrophy.

These products are not recommended and not proven to be effective in HIV+ people. They usually contain stimulants that decrease appetite and the ability to sleep. They can also increase blood pressure and make heart disease worse.

Man-made testosterone has been studied as a treatment for lipodystrophy. Unfortunately, in a study of testosterone gel (AndroGel), it did not decrease visceral fat. In fact, visceral fat increased and lipoatrophy in the arms and legs increased as well.

Oxandrin is an anabolic steroid that is taken by mouth. In a small study, it decreased visceral fat. But, LDL (“bad”) cholesterol went up and HDL (“good”) cholesterol went down, along with a small drop in subcutaneous fat. No body fat studies have been done with the other commonly-used anabolic steroid, nandrolone decanoate.

Ultrasound-assisted liposuction has been successfully used to remove fat accumulation in the back of the neck (buffalo hump). Liposuction for this purpose has a good track record of insurance coverage when health care providers justify it due to pain or sleep disorders. In some cases, however, the hump may return after a few months. Liposuction should not be used for removing visceral fat in the belly, since this is a difficult and risky procedure.

Studies are lacking in this area. However, in one study, nutrition and lifestyle changes resulted in decreased belly fat in HIV+ people. More research is needed on low-carbohydrate diets, which have been shown to improve blood sugar problems and visceral fat in HIV-negative people.

Cardiovascular (aerobic) exercise and resistance (strength or weight) training decreased triglycerides and visceral fat in a small study of HIV+ people. Another study showed that resistance training decreased fat, while improving cholesterol and triglycerides.

Cardiovascular exercise is any activity that increases your heart rate. Examples include walking at a fast pace, jogging, roller blading, dancing, and climbing stairs. In a gym you can also use treadmills, elliptical machines, and stair climbers.

Resistance training consists of using weights to improve muscle strength and growth. Examples include push-ups, squats, and the use of free weights and machines at the gym.

A regimen of an hour of strength training combined with 20 minutes of aerobic exercise three to four times a week has been shown to work for most people. It is a good idea to check with your doctor if you are going to start an exercise program to make sure you don’t overdo it.

Some body shape changes and metabolic problems have been linked with heart disease and strokes in HIV+ people. To minimize the risk of heart disease and/or stroke:

• Get checked and, if needed, treated for high blood pressure
• Have regular lab tests to check you lipid and glucose levels
• Eat a healthy diet, see a dietician if you need help with this
• Get regular exercise
• Keep your weight down
• Give up smoking

It may also be a good idea to get a BIA (Bioelectrical Impedance Analysis). A BIA is an easy and painless test that can give information about fat and lean body mass. Having BIAs done over time can be helpful in monitoring body shape changes.

If you are experiencing lipodystrophy it is especially important to take care of yourself. Keep all of your medical appointments, get regular lab tests, and tell your health care provider about any changes in the way you feel or in your body shape. Do not make any changes to your medication regimen without your health care provider’s guidance.

See other TWP info sheets on Hyperlipidemia, Diabetes, Lactic acidosis, Bone Disease, Lipodystrophy, Exercise, Nutrition, Caring for your Heart, Smoking, and Understanding Lab Tests I: Complete Blood Count and Blood Chemistry.