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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 to use for 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 or 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 them all.
This article 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. First, belly fat can make people feel badly about how their bodies look and can lead to depression. Many people living with HIV believe that the fat gain or fat loss of lipodystrophy marks them as HIV+ and increases the stigma they face. Second, additional belly fat can lead to bloating, tiredness, and heart problems. Fat gain can not only affect the way you look, but also be harmful to your health.
No one is really sure what causes fat gain in some people living with HIV. 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 certain HIV drugs, including protease inhibitors. There are several treatments being explored for HIV-related fat gain.
Human Growth Hormone
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 (somatropin): This drug is a synthetic (made in a laboratory) version of HGH
- Egrifta (tesamorelin): This drug is a synthetic growth hormone releasing factor, which causes the body to produce more HGH
Serostim is taken by injecting it 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, excess water held in the body, increased lipoatrophy, and increased blood sugar levels, including diabetes.
Serostim is approved by the US Food and Drug Administration (FDA) to treat HIV wasting (unwanted loss of body mass or size), 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 is not currently covered by insurance for this purpose. It is expensive, costing over $20,000 a month. There is a patient assistance program for Serostim at http://www.serostim.com/treating-hiv-associated-wasting/pharmacy-info-and-assistance.aspx
Egrifta has also been shown to decrease visceral belly fat. Like Serostim, people who stopped Egrifta had their belly fat return. Egrifta requires daily injections, but seems to have milder side effects than Serostim. It does not increase blood sugar or cause lipoatrophy, and it may lower triglycerides.
Egrifta was approved for HIV-related lipodystrophy in 2010. Check with your insurance company to see if it covers Egrifta. If you need assistance paying for this drug, go to http://www.needymeds.org/program_list.taf?_function=name&program_id=1348 for more information.
Over-the-counter nutritional human growth hormone supplements are often advertised. Beware of these – there is neither proof that they work nor proof that they are safe.
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 treatment 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 almost one third after six months, with no change in subcutaneous fat. In February 2014, the FDA approved the use of Myalept (metreleptin, the drug form of the hormone leptin) for lipodystrophy. The most common side effects include headache, low blood sugar, and belly pain. In addition, Myalept can increase people's risk of developing lymphoma, a type of blood cancer.
This diabetes drug showed promise in reducing belly fat in early studies. However, later studies showed conflicting results. Glucophage may also cause a rare but serious, life-threatening condition called lactic acidosis. As a result, it is recommended that women who may be at risk for diabetes discuss the pros and cons of using Glucophage with their health care providers.
These products are not recommended and not proven to be effective in HIV+ people. They usually contain stimulants that decrease appetite and make it more difficult to sleep. They can also increase blood pressure and make heart disease worse.
Synthetic testosterone has been studied as a treatment for lipodystrophy. One study of testosterone gel (Androgel) in HIV+ men showed no decrease in visceral belly 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. Anabolic steroids are synthetic steroid hormones that look and act a lot like testosterone. In a small study, it decreased visceral fat. However, it also made LDL ("bad") cholesterol go up and HDL ("good") cholesterol go down, and was accompanied by 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 the procedure is designed to remove fat under the skin and not deep down around the organs.
Nutrition and Physical Activity
Strong studies are lacking in this area. However, in one study, nutrition and lifestyle changes resulted in decreased belly fat in people living with HIV. 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 physical 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.
The US Department of Health and Human Services (DHHS) recommends at least 30 minutes of moderate intensity aerobic activity five times a week and strength or resistance training twice a week. It is a good idea to check with your health care provider if you are going to start an activity program to make sure you get off to a good start and do not hurt yourself. For more information, see The Well Project's article, Physical Activity, Exercise, and HIV.
Even though the physical changes of lipodystrophy can cause emotional distress, no researcher has suggested that people with lipodystrophy should stop taking their HIV drugs. If you are concerned about your appearance, talk to your health care provider about treatment options. There are many things that you can do to stay healthy and feel good about your body.