A non-profit 501
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Anabolic Steroids, Optimum Nutrition and Exercise Therapy for
HIV-related
Wasting and Lipodystrophy
A Summary
Excerpt
from the book “Built to Survive”
By Michael Mooney and Nelson Vergel
email: powertx@aol.com, mmooney@medibolics.com, web
site - http://www.medibolics.com
Program For Wellness Restoration Guidelines
Anabolic steroids are rapidly
becoming a common therapy in HIV disease to prevent and reverse the loss of
Lean Body Mass (LBM). These compounds have been used since the mid-1980’s by
progressive doctors in
Men’s
Versatile Guidelines Chart (Email PoWeR for women’s and pediatrics guidelines.)
In the table below, options are given for use of
nandrolone decanoate (Deca Durabolin) at lower and higher doses. The PoWeR
cycle is the combination of nandrolone and testosterone in an escalating and
de-escalating pattern. Men require that testosterone be included with
nandrolone (or any other anabolic) so that they have normal libido, since all
anabolic steroids reduce the body's production of testosterone. This sustains
optimum quality of life with less potential for side effects associated with
high-dose testosterone use.
N:Nandrolone
Decanoate (Deca Durabolin) T:
Testosterone enanthate or cypionate
|
Cycle |
One |
Two |
Three |
|
Week |
Moderate Dose Nandrolone |
Higher Dose Nandrolone |
PoWeR Cycle* - Testosterone And Nandrolone
|
|
1 |
100 mg N/100 mg T |
100 mg. N/100 mg T |
100 mg T |
|
2 |
100 mg. N/100 mg T |
100 mg. N/100 mg T |
200 mg T + 100 mg N |
|
3 |
200 mg. N/100 mg T |
200 mg. N/100 mg T |
300 mg T + 200 mg N |
|
4 |
200 mg. N/100 mg T |
300 mg. N/100 mg T |
300 mg T + 200 mg N |
|
5,6,7 |
200 mg N/100 mg T |
400 mg. N/100 mg T |
400 mg T + 300 mg N |
|
8 |
200 mg N/100 mg T |
300 mg. N/100 mg T |
300 mg T + 300 mg N |
|
9 |
100 mg. N/100 mg T |
200 mg. N/100 mg T |
200 mg T + 200 mg N |
|
10 |
100 mg. N/100 mg T |
100 mg. N/100 mg T |
100 mg T + 200 mg N |
|
11 |
100 mg. N/100 mg T |
100 mg. N/100 mg T |
100 mg N |
|
12 |
100 mg. N/100 mg T |
100 mg. N/100 mg T |
100 mg. N |
|
13 |
|
|
|
|
14 |
HCG - 2000 IU every other day for 5 injs. or 5000
IU once/week for 4 weeks. Arimidex at 1 mg/day for 8 weeks. After HCG ends
begin Clomid at 50 mg twice/day for 4 weeks. |
HCG - 2000 IU every other day for 5 injs. or 5000
IU once/week for 4 weeks. Arimidex at 1 mg/day for 8 weeks. After HCG ends
begin Clomid at 50 mg twice/day for 4 weeks. |
|
|
|
Low and
moderate doses cycles. Good basic cycles to follow after patient reaches desired LBM. For
some, one of these cycles alone is effective enough to reach goal LBM. Others
need the higher dose cycles, then use one of these combinations. 16+ week
break after cycle. |
Reversal
Cycle. For
those who don’t respond to moderate or higher dose cycle, or who’ve lost over
10% of normal weight, or whose stamina is very low. After cycle, take 16 week
break, monitoring biweekly for LBM loss. Loss of over 20% of LBM gained
during cycle, means a maintenance cycle should be instituted until the next cycle. |
|
Once
the physician is familiar with anabolic steroid therapy, he/she may want to
consider using the PoWeR cycle as their first cycle to bring patients up to
optimal LBM levels and quality of life. Nelson Vergel, the founder of PoWeR,
and many of PoWeR’s clients, began their anabolic steroid therapy with a PoWeR
cycle, and have gained over 20 pounds of LBM within 12 weeks, while
considerably reducing fat mass (potentially reducing lipodystrophy). As a
result they are experiencing better productivity and health. Anabolic steroid
therapy is most effective when a enhanced protein, moderately hypercaloric diet
is maintained consistently, along with resistance weight-training (45 – 60
minutes, three to four times a week) and optimal micronutrients. We recommend a
protein rich diet of whole foods, fresh fruits and vegetables which may be
supplemented with a protein powder supplement taken 1-2 times daily, and SuperNutrition’s Opti-Pack or Super Blend
daily vitamins to insure adequate levels of macro and micronutrient intake.
PoWeR’s recommended guidelines for daily protein intake are 0.8 to 1 gram of
protein per pound of ideal body weight. Optimal fluid intake (8 - 10 glasses of
water per day) is also important.
What To Do Before You Start The PoWeR Program
1. Information:
Get the BUILT TO SURVIVE book by
calling 1-800-350-2392 . It contains details about the program (nutrition,
supplementation, exercise, anabolic steroid information and lots of scientific
references to show your doctor). You may want to also subscribe to PoWeR’s
newsletter “Medibolics” by sending a
check or money order for $20 to: Medibolics.
2.
Body composition and nutritional counseling: Get a baseline biolectrical impedance analysis (BIA)
done to determine your body composition at baseline. If in Houston, call the
Body Positive Wellness Center (713-524-2374) to set up an appointment free of
charge. Get BIA done again every 3 months after that. If not in Houston, call
your largest HIV/AIDS agency or clinic (or Statscript Pharmacy) to find out who
provides BIA and nutritional counseling in your location, or visit
www.medibolics.com. Tell your doctor that he/she should consider providing
these important services which would be covered by insurance. Also, call RJL Systems, makers of one of the most
popular BIA machines, at 1-810-790-0200 to ask them who may be using their BIA
machine in your city.
3. Micronutrients
and protein: Call the Houston
Buyer’s Club (800-350-2392 or 713-520-5288) to order a vitamin (Opti-Pak or Super Blend) and protein
supplement. Follow the nutritional instructions in Built To Survive. Both
supplements will cost around $60 a month (total). Other HIV buyer’s clubs which
carry these products are: Wholesale Health (Florida) - (888) 666-6743, DAAIR
(New York) - (212) 725-6994, and Boston (800) 435-5586. Remember to maximize
protein, complex carbohydrates (fruits, vegetables, legumes, greens), water,
and minimize sugars and processed grain starches.
4. Physician:
For those who wish to participate in the use of anabolic steroids, you are
encouraged to enroll your own physician. Present the PoWeR protocol to your
physician that is outlined in Built To Survive. If your physician will not
prescribe the steroids, be aware that there are numerous physicians who will
prescribe anabolic steroids for wasting due to HIV disease. Call (800) 350-2392
e-mail us for a doctor referral. If your doctor needs to speak to another
physician about anabolic steroid use for HIV, have him/her call Dr. Shannon
Schrader (713-520-5537) or Dr. Patricia Salvato (713-961-7100). They have over
100 patients on this program with documented results over the past three years.
There are over 200 physicians now prescribing anabolic steroids in the U.S. to
treat loss of lean body mass and lipodystrophy (fat re-distribution) in HIV
positive people (see article at the end of this document).
5. Prescription:
The prescription for the PoWeR cycle should include nandrolone decanoate (or
Deca-Durabolin) - 12 vials of 200 mg/ml, administered once per week),
Depo-Testosterone (or testosterone cypionate or testosterone enanthate, 10
cc’s, 200 mg/ml, 2 vials, administered once per week), human chorionic
gonadotropin (HCG) - 10,000 USP, 2 vials, as directed in the chart, Arimidex 1
mg per day, and Clomid – 60 tablets at 50 mg each taken twice per day, as
directed in the chart. Vitamin B-12 (30 cc’s, 1000 mcg/ml, 2 vials, 2 - 2 cc
shots a week). Get at least 20 syringes (23 gauge, 1 inch plus 20 additional
needles of 20 gauge to load the steroids into the syringe. You can have your
pharmacist call Watson Pharmaceuticals directly for deca durabolin or you can
order it directly with www.GulfSouthRx.com
6.
Resistance Weight Training: Resistance exercise is key to the success
of your program. Join a gym if you have the means and do not have a membership.
If you have very limited finances and are in Houston, call the Body Positive
Wellness Center (713-524-2374). In other
cities, call your local YMCA and find out if they have a scholarship program
for people on disability or with limited income. Also, find a friend who wants
to work out with you. Follow the exercise recommendations described in Built To
Survive. Keep track of your progress with a work-out log. Also, visit www.hivfitness.org and www.medibolics.com
for more information on exercise and HIV.
Anabolic Steroids For AIDS Therapy: Differences Between Analogs
This table is designed to clear up some of the
misconceptions regarding anabolic steroids as therapeutic agents for
AIDS-related wasting therapy. Specifically, some anabolic steroids are rather
benign compared to other more problematic steroids. This table is a guide to
weighing the relative risks to benefits for some of the common steroid analogs
that are available in the United States and other countries. It merges
anecdotal information from my survey of doctors and athletes over many years
and the published data. Please note, studies show that anabolic steroids may
support cell mediated immune function.1 2 5 6 14 All anabolic
steroids can inhibit the body’s production of its own testosterone, and all can
produce side effects when the dose is high enough.
|
Steroid |
Anabolic |
Androgenic |
Effects/ Side Effects/ Reported Dosages |
|
Nandrolone Decanoate
µµµµµ Trade name is Deca
Durabolin (injections) A best steroid for men Available in the
USA/foreign |
high |
low to medium |
Very good lean
muscle growth. For men, 100-400 mg per week is relatively safe for three
month anabolic cycles. A 12 week NIH-funded men’s HIV study used 600 mg per
week. Can cause some water retention. May decrease libido if used without
testosterone. For women 25 mg per week up to 50 mg for severe wasting only
(chance of virilization). |
|
Methenolone) µµ Trade name is
Primobolan Depot (injections) A best steroid for women. Available
in Europe, Mexico |
Low to Medium |
the lowest |
The “cleanest”,
gentlest anabolic steroid, presents the least chance of virilizing, no water
retention, 100-600 mg/week for men, 25 mg to 100 mg for severe wasting in
women. Primobolan is very weak, though, generally too weak for men. |
|
Methenolone/Primobolan
µ (Oral = tablets)
Availability same as injectable. Good
steroid for women |
low to medium |
lowest |
Same as above,
50-200 mg/day for men, up to 100 mg/day for women. This oral steroid is not
17-alkylated and is safe for the liver. |
|
Stanozolol µµµ Trade name is
Winstrol (injections) This product is not
available in the US. Included here because some PWA’s obtain it from overseas
sources and self-administer. |
medium |
low |
Some growth, no
water retention, very slight chance of virilizing for women, injections need
to be every 2-3 days. Pyrogenic (fever-causing), Although we haven’t seen
liver toxicity at the doses men are using, watch liver GGT, bilirubin
readings as this water-based injectable is 17-alpha alkylated. Men - 50 mg
2-3 x/week. Best used with testosterone, as it does not have enough
androgenic potential for full androgen function in the body. |
|
Stanozolol µµµµ Trade name Is
Winstrol (Oral) Available in the US. Cost effective - 42 cents/ mg |
medium |
low |
Men need 6-28 mg.
per day. No water retention, watch liver enzymes. Best used with
testosterone, as it does not have enough androgenic potential for full
androgen function in the body. |
|
Oxandrolone µµµ (Oxandrin) (Oral) Good steroid for women/children Oxandrin
is available in US pharmacies. Good compassionate use program for those with
limited income and uninsured. Too expensive. $1.50/ mg |
low to med |
very low |
For women, 5-15 mg
per day. For children, 1/10th mg per kg of bodyweight or 2.5 mg per day. Does
not stunt growth in children. For men, 20 mg or more per day added to 100-200
mg per week of testosterone. Possible liver toxicity at doses above 20 mg per
day for adults. May interact with the P450 3A4 enzymes that metabolize
protease inhibitors. Some HIV(+) women report water retention. |
|
Oxymetholone µµµµ Trade name Anadrol
50 (oral) Available in the US.
Good compassionate
use program. Very cost effective, 24
cents/ mg |
very high |
very high |
For men, 10-100 mg per day. Most powerful, least
costly oral steroid for building muscle. Unlike other steroids Anadrol
supports libido. Dose-related potential for hair loss, increased blood
pressure, water retention, body hair growth, gynecomastia, etc. Should not be
used with testosterone, as this increases the potential for side effects. Men
typically cut tablets in fourths, and take one quarter 2 – 4 times per day. |
|
Testosterone Cypionate or Enanthate µµµµµ
(Injections) Inexpensive. |
high |
medium to high |
Excellent lean
muscle growth, water retention, potential for balding, acne, gynecomastia,
Men 100-200 mg/week, strong injectable for libido, may virilize women, see
note #3. |
Notes:
Five stars = highest
rating; one star = lowest rating. Some good muscle-building steroids are given
lower ratings because they may have more potential for side effects.
1. Nandrolone
decanoate, a generic drug, should cost about $14.00 (California price) for a
200 mg bottle, whereas Deca Durabolin (trade name by Organon) costs about
$30.00 for the same compound. Buy the generic version, if possible. Question
any pharmacist who says they can’t get nandrolone. They make more money on
Deca. Except for two periods during the last five years, generic nandrolone has
been readily available everywhere in the US. (It was not available at press
time, April, 1999.)
2. Some studies show
that specific anabolic steroids have beneficial effects on specific immune
functions.1 2 5 6 14 Differences in how specific anabolic steroids
affect the immune system in HIV should be studied. Many AIDS doctors prescribe
testosterone and the other anabolic steroids and see improvements in critical
components of the immune system, such as CD8 T cells.14 Studies show
that testosterone can delay the progression of immune diseases, like the
autoimmune disease lupus.7
3. Common
oral/tableted steroids are 17-alpha alkylated. This presents a burden to the
liver that can cause an increase in liver-specific blood tests because they may
be somewhat toxic to the liver in a dose-dependent manner. Injectable steroids,
except injectable stanozolol (not sold in the US), which is 17-alpha alkylated,
do not cause any significant liver burden.3 13 Injectable steroids
are generally preferred over oral steroids for this reason. However, injectable
steroids may appear to cause elevations in multi purpose liver function tests
(SGOT, SGPT, and LDH) during increased muscular stress or other stress in the
body. Steroid-free athletes with high metabolic and muscular stress may show
some elevation of some of these blood tests, too. Numerous other drugs also
elevate these blood tests. Liver test elevations usually reverse with cessation
of the steroids. Anecdotal evidence from competitive bodybuilders who use
steroids in high doses, and published data in the medical literature suggest that
the incidence of liver toxicity from oral steroids is somewhat exaggerated and
rarely creates severe problems in healthy
humans. I suggest that physicians be particularly sensitive to the discrete
liver readings bilirubin, GGT, and the liver isoenzyme of LDH. Data suggests
that these are more consistent indicators than the multi-purpose liver tests,
like SGOT and SGPT, when looking for potential liver problems related to
anabolic steroids.11 12 Of course, it is prudent to respond to all
aberrant liver function tests when pharmacology is complicated with compounds
like the standard AIDS medications.
4. Virilizing means
masculinizing. This can mean increased body hair growth, a deeper voice, etc.
in males and females. Women may find that they start to get oily skin and acne,
grow dark peach fuzz or a mustache or other body hair, have itching of the
clitoris followed by increasing clitoral size, or develop other male
characteristics with continued administration of steroids that are somewhat
androgenic. These problems sometimes reverse if the steroid dose is not too
high and steroid use is stopped immediately when side effects are detected.
5. Anabolic refers to
the growth of muscle and is desirable for wasting therapy. Optimal lean body
mass is highly correlative with survival in AIDS.4 While increased
androgenic potential can mean more potential for side effects and virilizing,
some androgenic potential is necessary for healthy metabolism as natural
androgenic activity is necessary for libido, energy, and healthy brain
chemistry. Generally speaking, the less androgenic a steroid is, the less side
effects there will be. However, all anabolic steroids have some androgenic
potential, and steroids that have very low androgenic potential also usually
have less anabolic potential.
6. The upper dosage listed for women is usually for severe wasting only. Women’s bodies do not tolerate anabolic steroids as well as men in general, so doctors agree that it is best to be conservative in the dosages, except in special circumstances where there is severe wasting. The steroids that are more androgenic, like testosterone, may not be problematic if the dosage is appropriately low. It is wise to consider starting at the lowest dosage possible when women use androgens/steroids.
References:
1. Ooshika, N, et al.
Effect of an anabolic steroid on cellular immunity and postoperative evaluation
of uterine cervical cancer. Jap J of Canc
Chemo (1984) 11(10):2177-2184.
2. Mendenhall, CL, et
al. Anabolic steroid effects on immune function: differences between analogues.
J Ster Biochem Molec Biol (1990)
37(1):71-76.
3. Marquardt, GH, et
al. Failure of non-17-alkylated steroids to produce abnormal liver function
tests. J Clin Endocrinol (1964)
24:1334-1336.
4.) Kotler, DP, et al.
Magnitude of body-cell-mass depletion and the timing of death from wasting in
AIDS. Am J Clin Nutr (1989)
50:444-447.
5.) Calabrese, LH, et
al. The effect of anabolic steroids and strength training on the human immune
system. Med Sci Sports Exerc (1989)
21(4):386-392.
6.) Huys, JV, et al.
Effect of nandrolone decanoate on T-Cell lymphocytes during radiotherapy. Clin Therap (1979) 2(5):352-357.
7.) Ansar, AS, et al.
Sex hormones, immune responses, and autoimmune diseases. Mechanisms of sex
hormone action. Am J Pathol (1985)
121(3):531-551.
8. Ehriches, L.
Testosterone may prevent AIDS wasting.
Fam Pract (1994) Oct. 10:36.
9. Jekot, WF, et al.
Treating HIV/AIDS patients with anabolic steroids. AIDS Patient Care (1993) April; 7(2):11-17.
10. Gilden, D. Weight loss: a role for growth
hormone and anabolic steroids. AIDS
Treatment News (1993) Nov 19; 187:16.
11. Haupt, HA, et al. Anabolic steroids: a
review of the literature. Am J Sports Med
(1984) 12(6):469- 484.
14. Bucher, G, et al. A prospective study on the
safety and effect of nandrolone decanoate in HIV-positive patients. XI
International Conference on AIDS, Vancouver (1996) 11(1):26. Abstract No.
Mo.B.423.
This article reports on anabolic steroid use by people with HIV. Consult with your doctor about any use of anabolic steroids. These dosages are somewhat conservative and only provide a reference range, actual patient needs are highly individual. The dosage ranges given in this table have been verified by medical doctors familiar with AIDS therapy to generally cause no significant side effects when used appropriately.8-10 This table was excerpted from our quarterly newsletter called MEDIBOLICS v.1, n.1, Sept. 1995 (out of print)
Complementary
Approaches To Treating Lipodystrophy
by Michael Mooney (original version in Medibolics 2(2), Nov.
1997)
While the protease inhibitor (PI) cocktails can
bring viral loads down to undetectable levels and have given many HIV(+) people
a new lease on life, protease inhibitors are not always benign drugs. As we
approach year three of the triple-combo era, numerous problems have appeared
among people who are on protease inhibitors. One of the most common of these
side effects (and perhaps the least understood) is the protease belly or Crix
belly phenomenon. Crix belly, so named because it was mostly observed among
people being treated with Crixivan, is a condition most notably marked by the
appearance of a large protruding potbelly. (At the same time this is happening
some people report that they feel like they are losing muscle mass and fat,
too, especially in the arms and legs.) Another sometimes concurrent but rare
condition is the so-called buffalo hump, which is a fat pad that grows on the
back of the neck that resembles what is seen in Cushing’s syndrome. Women are
also experiencing an increase in breast size as the breasts seem to gain fat
(called lipoma), and many people are losing fat in their cheeks while one of
all of these other things are happening to them. Lipodystrophy is the medical
term that has been given to this syndrome, but it can also simply be called
bodyfat redistribution.
It now appears that lipodystrophy is not a side
effect entirely specific to Crixivan, but may be seen with the usage of any of
the available protease inhibitors, and has even been seen to a lesser degree in
HIV(+) people before protease inhibitors were available. However, the various
cocktails of powerful drugs being used today to combat the HIV virus seem to
increase the severity of this syndrome over the simpler drug combos of a few
years ago. (And in some cases, the addition of the appetite stimulant Megace to
the protease inhibitors seems to increase the potential for bodyfat
redistribution.) There are several reasons why this might happen. Crix-belly in
many respects resembles the potbelly seen in disease states like Cushing's
syndrome, alcoholic hepatitis, and heart disease. In these diseases the
potbelly is associated with the development of insulin resistance 1-3
and is primarily composed of enlarged fat deposits surrounding the visceral
organs, like the stomach, and kidneys, under the abdominal muscle wall.4 The
potential for liver burden or toxicity induced by many of the common AIDS
medications has been documented and the protease inhibitors are no exception to
this rule. Elevated triglycerides, liver enzymes, and blood glucose and even
diabetes have all been observed in patients on protease inhibitor therapy. All
of these conditions are symptoms of diminished insulin sensitivity, so it is
probable that the protease inhibitors' effects on liver metabolism are inducing
a state of insulin resistance in people who are on protease inhibitor therapy.
Complications of insulin resistance include hyperglycemia (high blood sugar),
diabetes, and cardiovascular disease, and the FDA has documented over 80 cases
of diabetes that appear to be associated with protease inhibitor therapy.
Indeed, from early
1998, numerous studies have documented an association between the use of
protease inhibitors and measurements that indicate insulin resistance is
present including data by Kathleen Mulligan, Ph.D. of San Francisco General
Hospital, confirming that protease inhibitors can cause the blood chemistry
changes that are typical of insulin resistance;61 Dr. Ravi Walli of
Ludwig-Maximilians Universitat Munchen in Germany reporting that peripheral
insulin resistance is common in patients on protease inhibitors;62
and Dr. Andrew Carr of St. Vincent's Hospital of Sydney, Australia, detailing
his hypothesis of the cytoplasmic (cellular) retinoic acid-binding protein type
I (CRABP-1) biochemistry involved in the liver dysfunction that may promote
insulin resistance.63 Additionally, some people who are using
protease inhibitors are being found to have accelerated cardiovascular disease,
which is also a common outcome of progressive insulin resistance. A look at
Harrison's Principles of Internal Medicine shows us that lipodystrophy can be
associated with insulin resistance, and so we see that the components in this
puzzle, lipodystrophy; elevated triglycerides, elevated blood glucose, elevated
insulin levels; diabetes; cardiovascular disease; and insulin resistance are
all appearing.
While this article
does not offer a cure for bodyfat redistribution as protease belly, buffalo
hump, loss of facial fat, or lipoma, it offers tools that are documented to
improve insulin sensitivity that may help people gain some control over this
problem until medical science gains enough of an understanding to solve it.
Does
Crixivan Lower Testosterone?
Several doctors I have
spoken to have told me that they have seen that Crixivan can lower testosterone
production, and low testosterone production is known to correlate with
increased insulin resistance in men.5 In contrast, women exhibit
insulin resistance when testosterone is elevated.6 However, low
testosterone does correlate with increased visceral fat in studies with
HIV-negative women.7 One study showed that about 50 percent of
HIV(+) premenopausal women have low testosterone levels, which was associated
with low body cell mass, and a tendency towards having fat mass that is above
normal.38 It may be that normalizing a testosterone deficiency while
being careful about keeping testosterone blood measurements no higher than
mid-normal would be beneficial to HIV(+) women to improve nutrient partitioning
away from fat tissue while lean tissue increases. This is an area
that needs more investigation, as not enough has been done to study testosterone
and wasting in HIV(+) women. We also know that the antiretrovirals can cause
muscle myopathy,8 so it can be several things (including low
testosterone production) that might add up to a loss of lean body mass, and an
increase in visceral fat.
While it remains to be
proven, one of the things that was presented by Dr. Gorbach from Tufts
University when he reviewed their Nutrition for Life Cohort (600 HIV+ men
during 254 days on protease inhibitor combos) at the Bethesda National
Institutes of Health conference, was that although people tend to put weight
back on with protease inhibitors, his data assert that they regain mostly fat,
not lean tissue. Note: fat weight is not
correlative with survival, but lean tissue is.9 The loss of lean
tissue and reciprocal gaining of fat so that total body weight stays the same,
is typical of early stage wasting.10 11 This increase in fat mass
again suggests an impairment in glucose disposal and insulin sensitivity. For
those who have the potbelly, I would be concerned about any apparent muscle
wasting and have the blood testosterone levels checked, including both free and
total testosterone. If total testosterone is low, or in some cases, even
mid-normal for men, because of the tendency for HIV(+) men to have decreased
free testosterone levels, which correlates with a progressive decrease in CD4 T
cells,39 a doctor should consider beginning testosterone replacement
therapy. We should also note that free testosterone measurements have been
shown to be more correlative with lean body mass than total testosterone in
wasting HIV(+) men12 and women.13
Fat loss on the face
and extremities has been associated with the use of Zerit (D4T). Talk to your
doctor about switching to other nucleosides if you are experiencing fat loss.
For more information on facial wasting and cosmetic procedures, visit
www.medibolics.com
Women and Testosterone
Studies show that
HIV(+) women who are losing lean body mass may also need testosterone,13
but the appropriate dosage of testosterone enanthate injections for women is
usually much lower than the dosage for men, between 2.5 and 20 mg per week.
This is something for a doctor to determine by taking blood tests, usually two
to three days after the fourth weekly injection for a representative average
level. A number of HIV(+) women are using testosterone creams that are
compounded by a pharmacy like Women’s International Pharmacy (1-800-279-5708).
However, testosterone enanthate injections deliver a longer-lasting blood level
of testosterone than the creams, which have a relatively short life span in the
body. If a cream is used, it is usually applied in a dose of between 2 and 5 mg
twice times per day, while the injections are best given once per week, as
studies show that testosterone blood levels generally decline to baseline
within about 10 days after injection.14 As women are much more
sensitive to side effects from testosterone, the physician should monitor a
female closely for any virilizing side effects, which include oily skin, acne,
peach fuzz, hair loss, and clitoral enlargement, and immediately lower the dose
or cease the therapy if these kinds of symptoms start to occur.
Normal Testosterone Levels May Not Be Enough (Men Only)
I should also note
that finding the correct testosterone dose for each individual is not always
easy, as data from studies by researchers like Dr. Judith Rabkin suggest that
being HIV(+) can mean that the normal range for testosterone measurements does
not necessarily apply to men. In her study with HIV(+) hypogonadal men, Dr.
Rabkin found that the dose of testosterone enanthate needed to be above 200 mg
every two weeks, in order for a good quality-of-life. The dosage she found to
be effective was 400 mg every two weeks (which I suggest is best given as 200
mg per week for more consistent blood levels, less peak/trough effect, and
reduced potential for side effects). At 400 mg given every two weeks the men’s
blood testosterone levels averaged about 1100 ng/dL one week after the fourth
injection (on a scale where the normal range is 300 to 990 ng/dL). In private
correspondence Dr. Rabkin said that she is not sure whether 300 mg every two
weeks would yield a satisfactory result or whether the men would respond
satisfactorily if their average levels only reached 800 ng/dL. She said that
some men did receive benefit at about 700 ng/dL though.15 Remember,
the bottom of the normal scale was 300, so the normal scale didn’t seem to
apply well to these HIV(+) men. Sometimes normal is just a fairy tale.
Free Testosterone
I assert that men’s
apparent need for testosterone at higher than the standard replacement dose of
100 mg per week (for HIV-negative hypogonadal men) may be the result of
hormonal resistance to testosterone. Hormonal resistance appears to happen with
several hormones in HIV pathology. Published studies suggest that the need for
higher testosterone doses may be caused by elevated sex-hormone binding
globulins and lowered free testosterone, which is common in HIV.39 42
There may also be other problems with transcription at the DNA level that are
less clear. Supplementing testosterone can be beneficial to hypogonadal men in
general, by improving the partitioning of nutrients more towards lean tissue
and less toward fat tissue, especially visceral fat.16 Significant
data also suggests that appropriate testosterone supplementation can improve
blood lipid chemistry to reduce the potential for cardiovascular disease in men
who are deficient.50
Testosterone Patches or Creams
We have reports that
application of the Testoderm TTS or Androderm testosterone patches directly on
the buffalo hump appears to shrink it. If this works, testosterone creams or
gels might work better as the dose of testosterone can be much greater than in
a patch. While a study of adipocyte (fat cell) chemistry does provide a
rationale as to why application through the skin might work, application of a
cream would not be likely to work to reduce the belly because of the greater
distance from the skin through the stomach muscles to the fat cells inside.
One study showed that
the injectable anabolic steroid nandrolone decanoate (Deca Durabolin) improved
glucose disposal and lowered insulin levels when administered at 300 mg per
week, while it did not have any effect at 100 mg.40 While injectable
beta esterified steroids like nandrolone may have a beneficial effect on
insulin sensitivity, the oral 17-alpha alkylated steroid, oxymetholone
(Anadrol-50) has been shown to promote insulin resistance because of its
effects on liver metabolism.44 Other oral steroids, like oxandrolone
(Oxandrin) and stanozolol (Winstrol), also can promote insulin resistance.58
This raises questions about using oral steroids when lipodystrophy is
present.
The Paradoxical Effects of Oral Steroids
However, oral steroids
decrease triglycerides (fats) because of their effect of increasing
post-heparin hepatic triglyceride lipase, which breaks down triglycerides. 57
59 For this reason oral steroids should help to decrease visceral fat,
although they promote insulin resistance, and I have had reports of each of the
oral steroids stanozolol, oxymetholone and oxandrolone reducing or eliminating
the protease belly in HIV(+) males. Indeed, data from a retrospective study of
700 patients recently released by Dr. Douglas Dieterich gave inferential
indication that the use of oral and injectable anabolic steroids may be highly
effective in decreasing the potential for lipodystrophy-associated body habitus
changes.60 More study needs to be done to confirm this trend,
though.
Human Growth Hormone (Serostim)
While relative
weakness of GH as a muscle-building anabolic hormone is detailed in later
sections, GH does appear to have a powerful role in reducing lipodystrophy
because of its metabolic effects, including an effect on lipolysis (fat
burning), as was asserted by a poster presentation from Dr. Gabriel Torres of
New York, that was presented at the XII International Conference on AIDS in
Geneva.56 It should be noted that Dr. Torres said that while five
patients had partial of total reduction of fat redistribution on 5 and 6 mg
doses of GH, which I assert are overdoses for most people, four of the patients
had either elevated glucose, elevated pancreatic enzymes, or carpal tunnel
syndrome, so GH at these doses increased the potential for serious health
problems. Elevated blood glucose can lead to diabetes and the problems that
result including cardiovascular problems, eye damage, and neuropathy; elevated
pancreatic enzymes can lead to pancreatitis; and carpal tunnel syndrome is
quite painful and may require surgery.
I suggest that if
Serostim GH is implemented, it should be considered that Serono’s full vial
dose is an overdose and this may be why it causes these problems. It is
advisable to adjust the dose down for each individual, in an attempt to gain
the benefit without increasing the problems. At this time I have reports of a
reduction of protease belly and other types of lipodystrophy with doses as low
as 1 mg per day and up to 3 mg per day with no side effects. I assert that
lower daily doses are safer than higher doses administered every few days, and
at a correct dose growth hormone can be an important part of the tools that
address the underlying metabolic problem. While growth hormone will have a less
powerful effect at a lower dose, at the proper individual dose there will still
be a significant effect on fat cell metabolism with significantly less
potential for side effects.
Exercise, too,
improves insulin sensitivity,17 so people with insulin resistance
should consider some kind of regular exercise, especially weight-training,
which also builds lean body mass. Aerobic exercise does not build significant
lean body mass. Aerobics may be useful in an effort to reduce lipodystrophy but
if a person is losing lean body mass it should be avoided at least until the
person has regained any lost weight or stabilized. Aerobics will use energy
that the body would normally use for rebuilding lean body mass, only
accelerating the loss of lean body mass. If your weight is stable and not in
danger of losing weight, to optimally burn fat and reduce lipodystrophy I
suggest doing aerobics three times per week on alternate days to weight
training days, first thing in the morning on an empty stomach.
Nutritional Considerations: Carbohydrates
I would also suggest
altering your diet so that it is balanced somewhat like what might be called an
"evolutionary-type hunter-gatherer diet." This mean getting more
protein and a moderate amount of the healthy types of fats, while eating fewer
high-calorie, starchy complex carbohydrates or high-glycemic, sugary, simple
carbohydrates.
Currently, many
progressive nutritionists are recommending that people with insulin resistance
consider reducing their total calorie intake and intake of high-calorie complex
carbohydrates that can release into the blood stream quickly,18
including wheat breads and most processed wheat products. These kinds of
carbohydrates actually are quite calorie dense and can upset insulin metabolism
as much as sweets.19 20 They are even more problematic when included
in high fat foods. (Think pizza and ice cream.) Also on the list of
carbohydrates to avoid is the sugar called fructose, which is known to promote
insulin resistance, and raise cholesterol.51 Look for it on
ingredient panels as fructose or high-fructose corn syrup. I also underline
that some people will experience a reduction in insulin resistance just by
reducing the total calories in their diet, as many people simply eat too many
calories. However, if you are having a
hard time maintaining weight because of wasting or infection, getting plenty of
healthy calories is essential for keeping and building lean body mass, so be
careful about reducing your intake of food.
At the same time, I recommend an increase in the
intake of complex carbohydrates sources like vegetables, which are more
nutrient dense, and less calorie dense. While some vegetables like potatoes and
carrots have high glycemic indexes, they supply good amounts of nutrients per
calorie, and they do not contain a great amount of calories for their volume
like grains or sweets do, so their effect on insulin production and insulin
resistance is not as great. (Carrots contain only 195 calories per pound,
boiled potatoes contain 450 calories per pound, while breads contain about 1200
to 1500 calories per pound, and sugar and sweets contain about 1700 calories
per pound.) Other good carbohydrate sources are beans, yams and green peas, and
whole fruits like oranges, grapes, apples, pears, and cherries. In other words
try to eat natural food carbohydrate sources that are one step away from
nature. If you do want to include grains in your diet, barley, cream of rye,
oatmeal and brown rice have relatively lower glycemic indexes than most wheat
products, but be careful to moderate the total amount of these high calorie
starch sources. If you include them in your diet, I suggest eating servings
that are about one third as much you'd really like to eat. (Again, try to
moderate your total carbohydrate calories if your goal is to reduce insulin
resistance.)
While a
high-carbohydrate diet has been recommended by some nutritionists for
conditions of insulin resistance (diabetes), a study by Chen of Stanford
University, showed that a lower-fat, higher-carbohydrate diet led to higher
day-long blood glucose, insulin, and triglycerides, as well as post-prandial
(after a meal) accumulation of triglycerides, and increased VLDLs (very low
density lipoproteins),55 which can increase the risk of
cardiovascular disease. The idea that lower carbohydrates diets are superior is
supported in an article in Nutrition Reviews by dietitian Nancy Sheard, who
said, "Recent studies indicate that
a diet high in monounsaturated fat and low in carbohydrate can produce a more
desirable plasma glucose, lipid, and insulin profile."77 A
study published in the Journal of the American Medical Association further
supported this approach when it showed significantly elevated triglycerides and
LDL cholesterol levels with a high carbohydrate diet, while a
high-monounsaturated fat diet let to a lower-risk lipid profile.78
Fats
While it is also best
to reduce any excessive intake of fats, I don't advocate a very low-fat diet,
but a reduction in excess saturated fats, found in animal fat products like
butter and lard, and excess omega-6 fats, which are found in common vegetable
oils, like corn, safflower, and sunflower oils. Excess saturated fats and
omega-6 fats can promote insulin resistance.52 68-70 At the same
time I recommend a moderate intake of fresh food sources of the essential fatty
acid called omega-3, which can reduce insulin resistance,52 and
reduce the potential for atherosclerosis and heart attacks.65 66
Omega-3 fats are found abundantly in cold water fish like salmon, sardines, tuna,
rainbow trout, anchovies, and herring, and in lesser amounts in flax seed oil,
some nuts and seeds and beans, like walnuts, pumpkin seeds and soy beans, and
in much smaller quantities in dark green leafy vegetables. Consider also
including some daily consumption of monounsaturated fats from sources like
olive oil. These too reduce the risk of cardiovascular disease. Finally, avoid
eating any food that contain artificial fats or processed fats, like
hydrogenated or partially hydrogenated oils. Partially hydrogenated oils are
found in foods like margarine, french fries, potato chips, shortening, many
baked goods, and mayonaise. Harvard researchers have found a very strong link
between these types of unhealthy fats and cardiovascular disease.79
Protein
HIV has protein
malnutrition as a common theme; a lack of optimal protein contributes to the
loss of lean body mass and trouble maintaining it. To reduce the loss of lean
body mass and to increase it, I suggest that your diet include extra protein
that amounts to at least 1/2 gram per pound of body weight per day. If you lift
weights, studies by world-renowned protein scientist Dr. Peter Lemon show that
you probably need at least 0.8 grams of protein per pound of body weight per
day for optimal increases in lean body mass.71 72 If you are not
allergic to dairy protein, consider eating cottage cheese as a "best"
protein for building muscle, as it contains a great amount of the amino acid
L-glutamine, which is discussed below. Also consider supplementing your food
protein with a protein powder drink two or three times per day. Note that the
dairy protein called caseine, seen on labels as calcium caseinate, appears to
have the potential to be somewhat more effective for improving lean body mass
than other proteins, like whey.73
Although I do not
agree with some of his more dogmatic concepts, my recommendations for nutrition
have some similarities to the "zone" diet outlined in the book Mastering the Zone, by Dr. Barry Sears.
I have had numerous reports that the use of the zone diet has helped people
with HIV reduce cholesterol, the potbelly, triglycerides, and lipodystrophy, in
general. (For more discussion on nutrition, see page ***.)
Supplements that have
been shown to improve insulin sensitivity include chromium,21 and I
recommend 200 to 400 micrograms (mcg) of chromium three times per day in the
polynicotinate or picolinate form, as one recent (non-HIV) study showed that
1,000 mcg of chromium per day increased insulin sensitivity by about 40 percent
without toxicity.22 The herb silymarin (milk thistle) as a
standardized extract in a dose of 200 mg three times per day has been shown to
be effective in improving liver function and improving insulin sensitivity.41
But the best supplement for improving
insulin sensitivity and glucose disposal may be the antioxidant called alpha
lipoic acid (ALA), at 100 to 300 mg three times per day.23 ALA
improves insulin dependent and non-insulin dependent glucose uptake, and it has
been shown to effectively lower blood sugar comparable to insulin itself.24
I believe this is one very important reason ALA is a must for anyone taking HIV
medications, especially the protease inhibitors. HIV-nutrition expert Lark
Lands, Ph.D., asserts that ALA is a must for people with HIV because of its
effect on improving glutathione production and recycling.25 Studies
last year at Stanford University showed that glutathione levels directly
correlate with increased survival for people with HIV.26
As noted by Canadian protein chemist Chester
Myers, Ph.D., N-acetyl cysteine (NAC) can be a valuable addition to the
supplements that address lipodystrophy, because of its effect on improving
glutathione, which is necessary for glucose tolerance factor metabolism. I
suggest 500 to 1,000 mg of NAC three times per day. Also carnitine, as the
prescription version called Carnitor, would be beneficial in higher doses,
about 500 to 1,000 mg three times per day, as it helps to lowers triglycerides,27
which are generally elevated when lipodystrophy is present. Also worth
considering is the omega-3 dietary supplement called EPA (fish oil), which has
been shown to reduce insulin resistance,52 and lower triglycerides
somewhat in a study with HIV(+) men.28
And taking a strong
multivitamin, multimineral supplement that includes chromium, vitamins A, D, E
and calcium and magnesium will help improve insulin sensitivity.29-33 67
I recommend taking a supplement that contains doses that are much higher than
the RDAs, though, as numerous studies have shown that higher nutrient levels
are required in HIV disease.53 54 Finally, high dose biotin
supplementation is frequently prescribed by nutritionally-oriented medical
doctors to improve glucose metabolism in diabetes.74 75 High dose
biotin also decreases diabetic neuropathy.76 The dose of biotin that
is commonly used is 1,000 mcg three times per day.
Cardiovascular
Disease
As I mentioned in the
beginning of this article, we are also beginning to see cardiovascular disease
in people on protease inhibitors. When cardiovascular disease is a
consideration, we want to make sure that specific preventive nutrients are
included. While there are many that can be included for this purpose, to keep
it simple I suggest the following: vitamin E at 400 to 800 IU three times per day
to reduce the potential for oxidation of blood fats that can contribute to
atherosclerosis;46 vitamin C at 1,000 to 2,000 mg three times per
day to assist vitamin E in reducing blood fat oxidation;47 folic
acid at 800 mcg three times per day to reduce the potential for elevated
homocysteine, which appears to be another major contributory factor to
cardiovascular disease.43 48 It should also be noted that vitamins
B6 at 50 mg three times per day and
vitamin B12 at 100 to 500 mcg three times per day help to reduce homocysteine.
Of course, all HIV(+) people should consider taking high doses of supplemental
B vitamins.
Glutamine
For any loss of
muscle, Judy Shabert, M.D., M.P.H., R.D., asserts that supplementing with high
doses of the amino acid L-glutamine, will help reduce the catabolic process of
breaking down muscle tissue,34 and a recent study of wasting HIV
patients by Prang showed that this might be true. (See Dr. Shabert's article in
the August 1997 issue of POZ magazine.) For frank wasting, HIV(+) people are
using between 12 and 36 grams per day of L-glutamine. (One tablespoon is 12
grams.) I have friends who have halted their random diarrhea and improved their
lean body mass using these kinds of L-glutamine doses, and in Prang's study
wasting and diarrhea and were checked by using 30 to 40 grams of glutamine per
day. Glutamine too, has been shown to have a powerful effect on improving
glutathione production.35 (See the dietary supplement section in the
chapter on orthomolecular nutrition on page ***.) If you are losing weight I
suggest that you supplement your diet with a tablespoon of L-glutamine added to
each serving of supplemental protein two or three times per day between meals.
If your weight is stable, L-glutamine may be supplemented at lower doses, such
as one or more teaspoons per day. (Important note: most dietary supplements
only stay in the blood for a few hours, so it is wise to take them several
times per day.)
Metformin
Realize that taking
dietary supplements, especially alpha lipoic acid, may help, it is wise to
investigate the use of the drugs that are prescribed to improve insulin
sensitivity. Ask your doctor about these drugs, which include Metformin.37
New data presented by Saint-Marc at the 6th Retrovirus
Conference, in February, 1999 indicates that Metformin may decrease visceral
fat while decreasing blood glucose, insulin, and lipid levels.60
This suggest that Metformin might be somewhat effective in addressing bodyfat
redistribution, while also reducing some of the underlying metabolic problems
caused by protease inhibitors. Metformin is available with a doctor's
prescription at any pharmacy, and if a person has to pay for it themselves, it
only costs about $35 per month. However, cautions about the use of Metformin
are warranted. Dr. Michael Dube, of the University of Southern California at
Los Angeles says, “Lactic acidosis is a
rare side effect of metformin that is more likely to occur when there is some
impairment of kidney function. Lactic acidosis, which can be fatal, is also a
rare side effect of use of nucleoside analogs. There is no way to know at this
time if using the two together might result in more frequent, or more severe
lactic acidosis problems. In my opinion anyway, metformin and NRTI's therefore
should only be used together with great caution. Also, keep in mind that
metformin can lower vitamin B12 levels.”
I should also note that I know people who have
gotten rid of their potbelly simply by switching from Crixivan to another
protease inhibitor. However, while Crixivan may be a promoter of lipodystrophy,
it appears that any of the other protease inhibitors can also promote it.
My special thanks go to Jim
Brockman, who was the first researcher in AIDS medicine to hypothesize that
insulin resistance was involved in bodyfat redistribution. His guidance sparked
my investigation into this important area.
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DENVER, Nov 14
(Reuters Health) - New York researchers suspect that HIV-infected patients
taking anabolic therapy for AIDS-related wasting, along with antiretroviral
therapy, may experience a reduced incidence of lipodystrophy-associated body
habitus changes.
Dr. Douglas Dieterich of New York University and
colleagues retrospectively reviewed the records of 700 HIV-positive patients,
median age 40 years. In that cohort, 73% were Caucasian, and 91% were men.
Among the 560 patients receiving antiretroviral therapy, 96% were on one or
more protease inhibitors. In addition, 437 of the 700 patients had received
anabolic hormone therapy. Two hundred forty-three patients received testosterone,
101 received oxandrolone, 89 received nandrolone and 4 subjects were on growth
hormone. Relatively few patients (31
subjects) developed "...physically apparent body habitus changes,"
according to a meeting abstract. Dr. Dieterich's group noted changes in body
habitus in 14 patients on nandrolone, 12 patients on testosterone, 4 patients
on oxandrolone, and in 1 patient taking growth hormone.
A report at the AIDS meeting in Geneva this past
summer prompted the current investigation. Researchers there reported a 64%
incidence of lipodystrophy in a study population, Dr. Dieterich told Reuters
Health. "But none of those patients were taking any sort of testosterone
replacement, anabolics or growth hormone to help them gain weight." He noted
that this was much different than in his practice back in New York, where the
lipodystrophy rates were much lower.
The overall implication of the study findings was
that "...if you're using aggressive testosterone replacement, in men or
women, and you're using anabolics to help patients gain weight, your incidence
of lipodystrophy is going to be much lower," Dr. Dieterich said. He
cautioned that this treatment is not going to protect against elevated levels
of triglycerides and cholesterol. "As a matter of fact, testosterone and
the anabolics may actually increase those levels," he said. And use of
growth hormone could increase glucose
levels, possibly leading to diabetes, according to the New York
clinician.
Disclaimer
The
information contained in this publication is for educational purposes only, and
is in no way a substitute for the advice of a qualified medical doctor,
registered dietitian, or certified nutritionist. When you ask any professional
to help you make your decisions about your personal healthcare, we recommend
that you show them the information in this book because they may not be aware
of it and the scientific studies that support our recommendations. Appropriate
medical therapy and the use of pharmaceutical compounds like anabolic steroids
should be tailored for the individual as no two individuals are alike. We do
not recommend self-medicating with any pharmaceutical compound as you should
consult with a qualified medical doctor who can determine your individual
situation. Any use of the information presented in this publication for
personal medical therapy is done strictly at your own risk and no
responsibility is implied or intended on the part of the contributing writers,
or the publisher.
Feel Free To Contact Us Directly At:
Nelson Vergel, Houston,
phone (713) 520-6630, fax (713) 520-6826, email powertx@aol.com
Our Book - Built to
Survive
You can order the book
“Built to Survive” by calling
1-800-350-2392. All proceeds go to fund PoWeR and wellness centers around the
country.
Our Web Site
See selected articles
from Medibolics on the Internet at
http://www.medibolics.com. Also find the PoWeR homepage by going to the Medibolics website and using the
link to PoWeR.
Our Seminars
We provide free exercise seminars and a slide
presentation for patients, physicians and service providers on the program.
Please call Nelson Vergel, Director of PoWeR, at 713-520-6630 if you want to
bring a seminar to your city. Ask any of your HIV/AIDS service organizations if
they are interested to sponsor us. We have provided over 320 seminars in the US
and overseas for many HIV/AIDS organizations.
Wellness Centers
PoWeR helped to create the first-of-its-kind Body
Positive Wellness Clinic in Houston. This non-profit center provides free
resistance weight training with personal trainers, nutritional counseling and
BIA, supplements at cost through the Houston Buyers Club, massage and
neuromuscular therapy, chiropractic therapy, peer support groups, and seminars.
PoWeR serves as a technical consultant to any non-profit organization in the US
and overseas that would like to start a wellness center.
FacialWasting.org
Visit www.facialwasting.org to get all updated
information of all available facial implants for HIV facial lipoatrophy
Lipodystrophy Yahoo Discussion Group
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