Lipodystrophy is changes in the fat distribution of the body. Some people get this who are HIV negative because of their genes and their eating and exercise habits. Those who eat too much and exercise little are gaining calories and not spending them. Their calorie (bank) account gets larger and we see it as fat. They should withdraw more (exercise) and deposit less (food).

Lipodeposition is the gaining of more fat than is healthy. Usually this happens in the chin and neck, on the back of the upper chest (buffalo hump [joroba en español]), breasts, and around the upper abdomen. They many times have high blood pressure and early or true diabetes. If there is a dark pigmentation in a fold in the back of the neck, this indicates a serious risk for diabetes. I have seen this in many overweight children.

Lipoatrophy is the loss of more fat than is healthy. Usually this is in the face, arms, and legs. You have all seen HIV patients with a loss of fat right in front of the ears, behind the eyes. It is normal to lose fat as we age, but these patients have it at a very early age so they look much older. Men don’t seem to mind the loss of fat in the arms and legs since this makes them look more muscular. But if it happens along with lipodeposition in the center of the body, their body shape is very disproportionate or uneven. Many women who do not lift weights do not appreciate the extra thin arms or legs with prominent veins.

Causes: In lipodeposition we discussed that it is caused by a combination of genes, eating, and lack of exercise but HIV with or without the medications seem to cause it. Lipoatrophy: I have not seen evidence that it happens much in younger HIV negative individuals. I have seen both in HIV patients before starting medications and in others, after starting medications. I have seen them together and apart in patients before or after medications. HIV seems to assist this abnormal fat metabolism and distribution.

Treatment: Of course less food and mostly from plants and very little animal-derived food is the best diet. Artificial sweeteners and processed foods have been implicated in causing fat problems rather than natural, unprocessed foods and whole-grains. Exercises are mainly aerobic (jogging, biking, swimming) or resistance (lifting weights, pushups). Both are important in overall health, but the treatment for lipodeposition, weight gain and diabetes is the aerobic type of exercise. You can tell if you are doing enough aerobic exercise if you are breathing at least a little faster than normal and sweating more. Keep this up for at least 15 minutes, preferably 30—at least 3 times, preferably 5 times a week.
Changing the antivirals is a good idea if the virus is well-controlled, and the medication one is taking, is one of those implicated in these fat abnormalities. Some of the medications are more and others less associated with these lipodystrophies.

Laboratory test abnormalities of the fats: There are two major classes of fats: Triglycerides and the Cholesterols. Both are important to control and dieting helps both, but if medication is needed, then there are different medications for the two classes. Cholesterols are reported as total, good (HDL), and bad (LDL) cholesterols. Of course you want higher good and lower bad. You can try the web calculator, to input your labs, and the upper number of your blood pressure, to find your risk of heart disease in the next 10 years. Of course if you have poorly controlled hypertension or diabetes, then your risk is much higher and these diseases must be tightly controlled.

The causes of these laboratory abnormalities are the same as for lipodeposition and you should take the same strategy in improving these. Switching antivirals sometimes helps, but we can also add on other medications for cholesterol or triglycerides or both. I prefer to keep the number of pills to a minimum, so I like switching the antivirals. But patients who have their virus well-controlled sometimes don’t want to take that tiny risk of losing control and would rather add on the pills to control the fats. The pills do not work well if diet and exercise changes are not being pursued.

Caution: There seems to be a floor effect in losing weight. It may be easier to lose the first group of pounds, but much harder to break through that floor. I am not sure if this is set by your genes or the maximum weight you ever achieved.

OK, keep those questions coming in guys.

Send your e-mails to (attention Dr. Pearce)

By: Doctor Daniel Pearce