Transcript Managing Obesity in HIV+ Population

Prevalence of Obesity in HIV+
Population
Vickie Remoe Doherty
AIDS Institute/Intern
HIV/AIDS prevalence US
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Center for Disease Control (CDC)
est. that annually there have been
40,000 new cases of HIV
infection since the early 90s.
In 2005, 38,096 cases of HIV/AIDS
in adults, adolescents & children
were diagnosed in 33 states w/
long-term name based HIV
reporting
There are approx between
850,000-1,000,000 HIV-infected
Americans
Obesity & Overweight In US
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National Health and Nutrition
Examination Survey (NHANES),
using measured heights and
weights, indicate that an estimated
66 percent of U.S. adults are either
overweight or obese
Approx 127m adults=overweight,
60m obese & 9m extremely obese
BMI>40
Overweight defined as BMI >/= 25,
Obese defined as BMI>/= 30
Nutrition & HIV Management
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In the pre-HAART era (before 1996)
malnutrition & wasting was common in
HIV infection and was associated with
diminished quality of life. Wasting was
also a predictor of mortality and a sign of
advanced HIV infection.
Nutritional management in the pre-HAART
era consisted of managing wasting &
malnutrition in HIV+ patients.
Nutrition & HIV Management
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Since the availability of highly active antiretroviral therapy (HAART) the incidence of
malnutrition has reduced substantially, and US
deaths due to HIV have decreased from
45,000(1995)-15,000(annually since 1997)
Several studies have identified obesity/weight
gain as important complications in HIV/AIDS
management in the HAART era (esp. for HIV+
women)
Obesity affects health, quality of life, and mental
health
Nutrition & HIV Management
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Overweight & obese persons w/ HIV
infection are at an increased risk of
developing metabolic and body
composition abnormalities such as
lipodystrophy, hyperlipidemia and
insulin resistance associated with
HIV infection and side effects from
HAART medications.
Obesity Increases Risk of Other
Diseases
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Hypertension
Dyslipidemia (for example, high total cholesterol
or high levels of triglycerides)
Type 2 diabetes
Coronary heart disease
Stroke
Gallbladder disease
Osteoarthritis
Sleep apnea and respiratory problems
Some cancers (endometrial, breast, and colon)
Obesity in HIV+ Population
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Cross Sectional study of body shape & composition in
urban cohort…characterizes body changes reported by
women attending an urban US clinic
-163 women attending adult HIV outpatient clinic at
J.Hopkins Baltimore/MD over 2mth Jul-Aug. Women
>18yrs, HIV+…excluded pregnant, new to clinic, no
documented VL/CD4 in past 3mths
-BMI and weight/hip ratio calculated
-based on patient results the following definitions were
created lypodistrophy, weight loss, weight gain
Obesity in HIV pop
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Results
-Data was available for 161/163 women. 42% of women
who visited the clinic over 2mth period were enrolled in
study. 89.4% Af.Am, Mode of trans reported sexual
contact (54%) & IDU (40.4%)…w/77% of all subjects
reporting history of cocaine, heroine & crack use.
12/161 or 7.5% women reported body changes
consistent w/ lipodystrophy, 27/161 or 16.4%
reported weight loss and 85/161 or 52.8%
described overall weight gain
Continued
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Study suggests that obesity is an important issue for
ethnic minority, in urban pops regardless of HIV status.
In accordance w/ other studies that suggest weight loss
as an indicator of poor health.
In this study of HIV+ women, obesity and unhealthy,
unintentional weight loss are greater than lipodystrophy
in terms of prevalence. Most prevalent problem in
cohort was weight gain and measured BMI
confirming obesity
These results suggest that nutritional management
may be most important for these populations as
they are more at risk for obesity related illnesses
such as heart disease and diabetes
Dietary Intake, Obesity in Urban Cohort
SMART/EST Women’s Project
-466 HIV (receive stress management & nutrition education
to test group vs. personalized counseling)
- From Miami=191, NY & NJ= 186
Hypothesis-those who receive high intensity intervention
(personalized w/ behavioral therapist) will have improved
health & health behavior.
Nutrition & Physical Activity Intervention focused on four
components: identification of barriers to healthy eating,
facilitator assisted self assessment of nutritional strengths
and weaknesses, behavioral contracting to address
participants highest priority nutrition/physical activity
issues, monitoring behavioral progress adapting the
behavioral contract as needed
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Continued
All measures collected by trained interviewers at baseline, 3mths
(after completion of phase 1 CBSM+ interverntion),6mths(after
completion of phase 2 health intervention),12mths(6 months
after completion of full intervention) & 24mths (18 mths later).
Used Rapid Eating Assessment and Activity Assessment for
Patients (REAP) modified
Subj in their 30s & 40s, women of color (Af.Am, Latina, Haitian
=91%). Most (88.4%) reported incomes of $10,000 or less per
year.
-Many of the participants were overweight/obese-Mean BMI 28.1
What participants reported eating
At the beginning of the study 43% of the participants
reported drinking more than 16ounces of sweetened
beverages a day
30.4% ate sweets more than twice a day
34% ate fried foods more than twice a day
Participants in Miami & NY/NJ differed in REAP-S in 10/13
indv questions
Miami participants ate less frequently in restaurants, ate
more fruit, fewer full fat chips and added less fat at the
table
NY/NJ participants reported more whole grains, vegetables,
milk products and lower consumption of high fat cold cuts,
sweets & sweetened beverages
NY/NJ participants had more central obesity as showed with
higher waist to hip ratio
Which intervention worked?
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No differences in improvement b/n the two geographic
sites- however those who received the initial high
intensity intervention initially improved more than those
with who received low intensity treatment. But at 18
months post intervention there were no differences
between those in the high intervention group versus
those in low intervention.
Benefits of high intensity nutrition intervention without
reinforcement eventually taper off over time.
All groups improved their food group choices by
decreasing fats and sugars but did not increase
vegetables, fruits or whole grains (most likely due to
price, lack of familiarity, taste, and availability in low
income areas)
Results suggest those who provide nutritional
education/counseling should be aware of barriers to
accessing healthy foods
Obesity in HIV+ populations
Cross sectional DEXA Substudy in the Women’s Interagency
HIV study (WIHS)
-271 women in Bronx/Manhattan
-53 women in San Francisco
Participants also asked about #hrs spent exercising, type of
exercise, smoking habits, current & nadir CD4, viral load, coinfection w/ hep C or B and social and medical history
Women were then divided into HIV positive & negative. The
positive group was further divided into (no ART=70),
(HAART/PI n=48), HAART/noPI=53. 12 HIV+ women were
on ART that did not meet HAART criteria and were excluded
from analyses on differences in HIV positive women
88 (HIV negative), 183 HIV+ were enrolled and were
matched in terms of racial distribution…majority of women
identified as ethnic minorities and there was no significant
difference (HIV+/-) for exercise level, education level, #
women trading sex for money or # male or female partners
Results from DEXA WIHS Substudy
Majority in both groups overweight/obese
-HIV- Overweight & obese(75% or 66/88 )
HIV+ overweight & obese (68% or 125/183)
Factors assoc w/ total and regional fat in HIV+ women
exercise (>6hrs/wk) was the only factor assoc w/
lower total, trunk & leg fat. Af. Am had sig. more
leg fat than other ethnic groups
-Study provides evidence of sig lower levels of leg fat in HIV
infected women on HAART when compared with both HIVwomen and HIV+ women currently using ART
Suggests that medication may not be responsible for patient
weight gain and obesity; rather that nutritional
management should be used to help patients decrease
food intake and develop healthier eating habits
Another study in HIV+ youth in US
Extracted from the Reaching for Excellence in Adolescent Care & Health
Study
-cross-sectional study during one visit Jan-Oct 2000
-264 HIV+ youth vs. 127 HIV- aged 13-23, at 14 clinic sites in US
-(75% women, 67% Af-Am 20.5% Hispanic)
-calculated BMI, dietary intake, diet quality, CD4/VL & demographic info,
socioeconomic, health & health behavior
RESULTS
-Avg BMI was 28, 51% of participants were obese/overweight. 6 mth avg
weight gain 1.5. Obese participants gained more weight than non-obese
participants. 49% of HIV infected were obese vs. 54% of HIVprevalence of obesity decreased with lower cd4 (more significant for
obese HIV+ female)
-participants from S&NE 4x more likely to be obese than Chicago or LA.
Race/ethnicity & economic not sig predictors of obesity
-For Healthy Eating Index (HEI) that measured food intake, 68%
had diet that needed improvement, 31% had poor diets. HIV+
had poorer diet than uninfected
Does diet & Exercise work for hiv+ obese?
12 week prospective study longitudinal pilot study weight
reduction intervention with diet management &
aerobic/resistance
 Women >18yrs old, obese w/BMI>30, on art and clinically
stable @ St Luke’s, NY
 Subjects received individual counseling at the beginning
and thru out trial period by participating in weekly
nutrition education classes
 Subj exercised 90 mins w/ trainer 3x week. Asked to
completed food diaries
 Of 45 women screened, 39 were eligible and 18 completed
the intervention
 The avg loss after 12 weeks was 6.7kg(2.2lbs/kg) or 7.3%
of initial weight
-This study suggests that caloric restriction, nutritional
education and exercise are just as effective for weight loss
in hiv+ women
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Conclusions
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Obesity is prevalent in HIV+ pops esp
(urban, women of color, disadvantaged)
Some reasons for obesity high caloric
intake, poor quality diet w/ sugar & high
fat content, not enough exercise, lack of
availability/access to better quality
foods
Being on medication alone does not
explain obesity/weight gain in hiv+
pops though some meds cause
abnormal accumulation of fat in body
Conclusions continued
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Nutritional education, exercise, lower caloric
intake can help reduce weight gain & obesity in
HIV+ patients
Different interventions: group education/
personalized nutritional intervention also
helpful
Obesity also prevalent in HIV+ youth
To improve short and long term health
outcomes we must improve provide optimum
nutritional education & services that can help
change eating habits, decrease obesity &
weight gain and improve overall quality of life