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. Fat is also stored 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 potentially unhealthy changes including:

• Body shape changes
  • Lipohypertrophy: Fat gain in the breasts; back of the neck (buffalo hump); visceral fat gain in the belly; 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

People living with HIV (HIV+) who have lipodystrophy can have both body shape changes and metabolic problems. Some treatments can help with certain lipodystrophy changes, but no existing treatment gets rid of all of them.

This info sheet looks at treatments for metabolic complications. See also Lipodystrophy Treatments Part I: Treatments for Fat Gain and Lipodystrophy and Treatments Part II: Treatments for Fat Loss.

Many HIV+ people experience increases in blood fats (lipids) and blood sugar (glucose). There are many possible causes for these metabolic changes, including HIV itself and HIV drugs. Although you cannot see these changes, they can cause serious long-term health problems.

• High lipid levels: High levels of blood fats such as cholesterol and triglycerides can increase your chances of having heart problems.
• High glucose levels: When you eat, your body changes the food into glucose. Glucose is carried through the bloodstream to provide energy to all of your cells. In order for glucose to get into your cells, you need insulin. Insulin is a hormone made by the pancreas. If your body has a problem making or using insulin, glucose cannot get into your cells. As a result, glucose stays in the blood and the cells do not get enough. Some protease inhibitors (PIs) can make it difficult for insulin to get glucose into the cells. This is called insulin resistance. It can lead to pre-diabetes and diabetes. Pre-diabetes and diabetes are serious health conditions. For more information, see TWP’s Diabetes info sheet.

There are some HIV drugs that have less of an impact on cholesterol and triglycerides. These include Viramune (nevirapine), Intelence (etravirine), Edurant (rilpivirine), Isentress (raltegravir), and Selzentry (maraviroc). Reyataz (atazanavir) and Prezista (darunavir) are also less likely to increase lipids, but both are used with Norvir (ritonavir), and Norvir does increase lipids.

If you have high blood sugar levels, your health care provider may recommend that you change your HIV drugs. Some studies have shown that switching to a combination that does not include a PI can help bring these levels under control. Switching is not the best choice for everyone and you should speak to your health care provider before stopping or switching any HIV drugs.

Some people are able to control their glucose levels and lower their lipid levels by keeping their weight down, changing their diet, and increasing their level of physical activity.

While very few studies have looked at the effect of nutrition on lipodystrophy, some small studies have shown benefits. For example, lowering the amount of fats and carbohydrates you eat may help reduce triglyceride levels. More fiber in the diet may help control insulin resistance.

See a registered dietitian or nutritionist to help you make good choices and plan your meals. Many AIDS service organizations have registered dietitians on staff who will see you free of charge.

The health benefits of exercise and physical activity are well known. There are also a couple of small studies in HIV+ people showing that higher levels of physical activity lowered lipid levels. There are two types of exercise: cardiovascular (aerobic) and resistance (strength or weight training). Both can help improve the way your body processes cholesterol and blood sugar.

Cardiovascular exercise is any physical activity that raises your heart rate. Examples include walking at a fast pace, jogging, roller blading, dancing, and climbing stairs. At 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 or resistance 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 health care provider if you are going to start an exercise program to make sure you get off to a good start and do not hurt yourself.

If the triglyceride or “bad” cholesterol levels (LDL) do not go down with diet and physical activity, or if they are very high to start with, your health care provider may prescribe lipid-lowering drugs. Some of these medications interact with HIV drugs, so it is important that your health care provider review all your medications before prescribing anything.

Sometimes, even with a healthy diet and regular exercise, glucose cannot be controlled without the help of medications and/or insulin. There are a number of medications available that lower blood glucose levels. Because the medications work in different ways, they may be used together. Some of the diabetes medications may interact with HIV drugs. To reduce the chance of drug interactions, it is important that your health care provider be aware of all the medications you take.

There are some supplements that may also help with metabolic changes.

• Omega 3 Oils: Oil derived from cold-water fish (e.g., mackerel, tuna, salmon, herring, sardines) has been shown to decrease triglycerides at a dose of 2,000 mg – 3,000 mg a day. It is better to find sources that are free of heavy metals.
• Carnitine: Small studies show decreases in cholesterol and triglycerides in HIV + patients. Typical doses range from 2,000 mg – 3,000 mg a day. It can be purchased over the counter or by prescription (Carnitor).

Again, speak to your health care provider about all the medications you are taking (including over-the-counter drugs, prescription medications, street drugs, herbs, and supplements), even if you only use them occasionally.

Some body shape changes and metabolic problems have been linked with heart disease and strokes in HIV+ people. To lower your 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 or nutritionist if you need help with this
• Get regular exercise
• Stay at a healthy weight
• Stop smoking or cut down on how much you smoke
• For more information, see our info sheet on Caring for Your Heart

It may also be a good idea to get a BIA (Bioelectrical Impedance Analysis). A BIA is an easy and painless test that gives 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.