Treatments for Lipodystrophy
Suggestions to Improve Insulin Sensitivity
by Michael Mooney
version of this article titled Protease Inhibitors and Potbellies was published
2, Number 2, Nov. 1997. I
update parts of it as I learn more. The protein nutrition section of this version
was updated June 19, 1999. Minor changes were made in the section on growth
hormone on August 4, 1999. A recommendation regarding the Atkins diet was added
August 20, 1999. Changes in the dietary fat section were added January 14, 2000.)
While the protease
inhibitor (PI) cocktails can bring viral loads down to undetectable levels and
have given many people with AIDS (PWAs) 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 or 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 patients 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 resistance1-3 and is primarily composed of enlarged fat deposits
surrounding the visceral organs, like the stomach, and kidneys, under the abdominal
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 patients on protease inhibitor therapy.
insulin resistance include hyperglycemia (high blood sugar), diabetes, and cardiovascular
disease, and the FDA has recently 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
people who are using protease inhibitors are being found to have accelerated
cardiovascular disease, which is also a common outcome of progressive insulin
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 some
aspects of this problem until medical science gains enough of an understanding
to solve it.
Crixivan Lower Testosterone?
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-positive 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-positive 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-positive 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 this 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-positive 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-positive men12
Studies show that
HIV-positive 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. Some HIV-positive 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 best to apply it two times per day,
while the injections are best given once per week, as studies show that testosterone
enanthate maintains useful blood levels for under 10 days.14
I note that I have
had several women tell me that while they experience little benefit from a testosterone
cream, testosterone injections give them immediate improvements in muscle tone,
libido, energy, and feelings of well-being. Others do well on the creams. The
typical dose of testosterone in creams for women is in the range of 2 to 5 mg
two times per day. Call Women's
for their information packet on hormone creams.
It is also important
to note that the women are much more sensitive to side effects from testosterone,
so the physician should monitor a female patient 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.
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-positive can mean that the "normal" range for testosterone measurements
does not necessarily apply to men. In her study with HIV-positive hypogonadal
men, Dr. Rabkin found that the dose of testosterone enanthate needed to be above
200 mg every two weeks to improve 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-positive men. Sometimes "normal" is just a fairy
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. However, published studies suggest that the need
for higher testosterone doses is most likely caused by elevated sex-hormone
binding globulins and lowered free testosterone, which is common in HIV.39
42 When this
is the case, total testosterone measurements do not adequately reflect the person's
state of health.
to bring free testosterone levels in the body into an optimal range 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 in ways that reduce the potential for cardiovascular
disease in men who are deficient.50
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,
made by compounding pharmacies like Women's International Pharmacy (1-800-279-5708),
might work better as the dose of testosterone can be much greater in a cream
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.
Steroids Improve Insulin Sensitivity & Glucose Disposal
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 this injectable
beta esterified anabolic steroid may have a beneficial effect on insulin sensitivity
another study found that it appears to enhance noninsulin-mediated glucose disposal.80
This study and other
studies state that oral 17-alpha alkylated anabolic steroids, such as oxymetholone
(Anadrol-50), oxandrolone (Oxandrin) and stanozolol (Winstrol) promote insulin
resistance because of their effect on liver metabolism.44
This raises questions about using oral steroids when lipodystrophy is present.
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-positive
males. Indeed, data from a retrospective study of 700 patients recently released
by Dr. Douglas Dieterich gave inferential indication that the use of oral anabolic
steroids, like Oxandrin (and injectable steroids like testosterone and nandrolone)
may be highly effective in decreasing the potential for lipodystrophy-associated
body habitus changes to occur.60
(Other oral steroids like Winstrol and Anadrol also have this potential benefit.)
More study needs to be done to confirm this trend, though.
Growth Hormone (Serostim)
While human growth
hormone does not appear to have an anabolic effect on the part of lean body
mass that is muscle for many HIV(+) people (see the
new data by Kotler) (see also Serostim
Growth Hormone: How Much Muscle Does It Really Build?)
and its relative weakness as an agent to increase total lean body mass is detailed
in the article Cost
Comparison of Anabolic Agents, growth hormone does appear to have a
role in reducing lipodystrophy because of its metabolic effects, including an
increase in lipid oxidation (fat burning), as was asserted by a poster presentation
from Dr. Gabe 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 or total reduction
of fat redistribution on 5 and 6 mg doses of growth hormone, which I assert
are overdoses for most people, four of the subjects (80%) suffered from either
elevated glucose, elevated pancreatic enzymes, or carpal tunnel syndrome, so
growth hormone 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
I suggest that if
growth hormone is implemented, it should be considered that Serono's full vial
dose is an overdose for many HIV(+) people and this may be why 5 and 6 mg dose
caused these side effects. It is advisable to adjust the dose down for each
individual in an attempt to gain the possible benefit without promoting 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
may 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 problems.
Exercise, too, improves
so people with insulin resistance should consider some kind of regular exercise,
especially weight-training, which builds lean body mass. Aerobic exercise does
not build significant lean body mass. Aerobics can 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,
while accelerating the loss of lean body mass. If you are weight 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 for best effect.
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.
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
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
At the same time,
I recommend an increase in the intake of complex carbohydrates sources that
contain less total calories but lots of fluid and nutrients, like vegetables.
Compared to grains, vegetables 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, insulin resistance and bodyfat accumulation 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
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
While it is also best to reduce any
excessive intake of fats, I generally don't advocate a very low-fat diet, which
might compromise immune function, but a reduction in excess saturated fats,
found in animal fat products like butter and lard, and excess omega-6, an essential
fatty acid that is found in common vegetable oils, like corn, safflower, and
sunflower oils that appear in so many of the most popular foods.
While we need a
small daily intake of omega-6 fat, and data suggests that we probably need a
small amount of saturated fat to be healthy, most Americans get far too much
of these two types of fats, and excess
saturated fats and omega-6 fats can promote insulin resistance.52
At the same time
I recommend purposely getting some regular 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 Americans
typically get about 1/4 as much omega-3 as we need to be healthy.
Omega-3 fats are
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.
also including some daily consumption of monounsaturated fats from sources like
olive oil and avocados. These too can
help to normalize blood fats and reduce
the risk of cardiovascular disease.
Data also suggests that high amounts
of saturated fat in the diet promotes more bodyfat accumulation compared to polyunsaturated
so if you want to be lean, eat clean.
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
It is important
to state that people should experiment with the amount of fat that they take
in. Some people have reported that they have had the most success in reducing
the pot belly or any type of bodyfat accumulation by reducing their fat intake
substantially, so that their total fat intake is only about 10% of total calories.
If you eat a low fat diet it becomes all the more important to be very selective
about the sources of the fats you eat, as your immune system and overall health
depend on getting a certain amount of the essential fatty acids on a daily basis.
If a low fat works
for you, consider using an essential fatty acid supplement, and I recommend
Udo's Choice Ultimate Oil Blend, which is available in natural food stores.
Udo's Choice has a specific balance of omega-3 and omega-6 fats, favoring omega-3,
so that you are getting a consistent source of these two essential fatty acids.
HIV has protein malnutrition as a
common theme; a lack of optimal protein intake contributes to the loss of lean
body mass and makes it hard to maintain it. To
reduce the potential for loss of lean body mass, or to increase lean body mass,
I suggest that your dietary protein intake totals at least 0.8 grams of protein
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 or using
it occasionally for between meal protein snacks, as cottage cheese is a "best"
protein for building muscle; one reason is that it contains a substantial 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, as it can
be hard to eat enough protein to build your body with the burden that HIV creates,
while it is much easier to drink it. Protein types that are contained in common
protein powders include animal source proteins like whey, caseine, and egg,
and vegetable proteins like soy, rice, and pea. Note that the dairy protein
called caseine (seen
on protein powder labels as caseinate and found in great quantity in cottage
cheese) may be somewhat
more effective for improving muscle growth than other proteins, like whey.73
protein appears in products like Next Nutrition Designer Whey Protein. I underline
that the marketing and advertising that most companies, including Next Nutrition,
employ to sell their proteins, that
says that one type of whey protein is superior to another type
is for the most part just hype; none of the various types of whey proteins (ultra-filtered
whey, ion-exchanged whey, etc.) are probably any better or worse than any other
whey proteins for effect on muscle growth. And to reiterate, all whey proteins
are probably slightly inferior on a dose-for-dose basis to caseine proteins
for building muscle. However, it appears that if you have enough protein intake
any differences in effect on muscle growth between various proteins may be insignificant;
the important thing is to get plenty of protein intake, wherever it comes from.
To be clear, medical-grade
whey proteins like Immunocal and Optimune can contain significant amounts of
specific protein fractions, such as glutamyl-cysteine
that support various aspects of healthy immune function, but this is independent
of any potential to support muscle growth. Additionally, lab tests show that
Immunocal and Optimune contain these specific protein fractions in amounts that
are superior to what are contained in any of the proteins sold on the bodybuilding
Consider also that
proteins of animal origin are superior to vegetable proteins for building muscle;
it is hard to increase lean body mass on a strict vegetarian diet because of
the amino acid imbalances in vegetable proteins.
The Zone Diet
Although I do not agree
with some of his more dogmatic concepts, my recommendations for "evolutionary,
hunter-gatherer diet" nutrition have
some similarities to the "zone" diet outlined in the book Mastering the Zone,
by Dr. Barry Sears. While there are many aspects of the zone diet that can be
criticized scientifically, I have had numerous reports that the use of the zone
diet has helped people with lipodystrophy reduce blood glucose, insulin, cholesterol,
triglycerides, the pot belly, and lipodystrophy symptoms in general.
The Atkins Diet
The Atkins diet is a very, very
low carbohydrate, high protein, higher fat diet, that can decrease bodyfat significantly
in normally healthy people. I have been hearing reports of people with lipodystrophy
who have adherred to the rather strict Atkins regimen and brought their protruding
belly and their blood glucose, insulin, cholesterol and triglyeride levels down
to normal, so I recommend experimenting with the Atkins diet, being sure to
favor omega-3 fats while reducing omega-6 fats and saturated fats - if you are
capable of the discipline required. This diet may reduce lipodystrophy symptoms
better than the diet I described above, but it is much harder to be consistent
with the Atkins diet. It is also very hard to get enough nutrients from it for
optimal health - taking dietary supplements is a must. If you do try it, please
give me feedback on your results by emailing me at email@example.com.
have been shown to improve insulin sensitivity include:
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 with diabetics
showed that 1,000 mcg. of chromium per day increased insulin sensitivity by
about 40 percent without toxicity.22
2. 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
There has been talk that silymarin
can alter liver function in a way that might affect the metabolism of protease
inhibitors, so it is possible that people who are taking protease inhibitors
should not take silymarin. There is no conclusive data on this yet.
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 help 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., also asserts that ALA is a must for people with HIV because of
its effect on improving glutathione production and recycling.25 I
underline the fact that studies last year at Stanford University showed that
glutathione levels directly correlate with increased survival for people with
worth considering is the dietary supplement called EPA (fish oil), which has
been shown to reduce insulin resistance,52 and lower triglycerides
somewhat in a study with HIV-positive men.28
taking a very high potency complete multivitamin, multimineral, antioxidant
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 for
overall health and immune function in HIV disease.53 54
dose biotin supplementation is frequently prescribed by nutritionally-oriented
medical doctors to improve glucose metabolism in diabetes.74 75 High
dose biotin is also known to improve diabetic neuropathy.76 The dose
of biotin that is commonly used is 1,000 mcg three times per day.
7. 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
8. Also carnitine,
as the prescription version called Carnitor, would be beneficial in higher doses,
about 500 to 1,000 mg three times per day. Carnitine helps to lowers triglycerides,27
which are generally elevated when lipodystrophy is present. Note that the acetyl-L-carnitine
form of carnitine may be more effective than plain carnitine, but it is more
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
48 It should
also be noted that vitamins B6 at 50 mg three times per day and B12 at 200 to
500 mcg three times per day help to reduce homocysteine. Of course, everyone
who is HIV positive should already be taking high doses of supplemental B vitamins,
as studies by Dr. Marianna Baum, of the University of Miami, showed that HIV-positive
people frequently require 6 to 25 times the RDA of these essential nutrients
to stay healthy.53
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, and
see the Prang study by going to L-Glutamine Promotes
Gain In Weight and Body Cell Mass.) For frank wasting, HIV-positive
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 has also been shown to have a powerful effect on improving
and glutamine improves insulin sensitivity.83
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.
most dietary supplements only stay in the blood for a few hours, so it is wise
to take them several times per day.)
Realize that while
taking dietary supplements, especially alpha lipoic acid, may help, it is wise
to investigate the use of the drugs that are prescribed to improve glucose disposal
or 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 more effectively than
Serostim growth hormone while decreasing blood glucose, insulin and lipid levels.60
Serostim can increase blood glucose, insulin and insulin resistance.81
82 This means that Metformin might be found to be superior to Serostim
growth hormone because it not only addresses fat redistribution, but reduces
some of the underlying metabolic problems that growth hormone can promote. An
important consideration is that while Serostim is priced at $6,000 per month,
which makes it inaccessible for a majority of people who have lipodystrophy,
Metformin is available with a doctor's prescription at any pharmacy; if a person
has to pay for it themselves, it only costs about $35 per month.
about the use of Metformin are warranted. Dr. Michael Dube, of the University
of Southern California at Los Angeles says, "Lactic acidosis,
which can be fatal,
is a rare side effect of metformin that is more likely to occur when there is
some impairment of kidney function. Lactic acidosis 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, metformin and NRTI's should therefore only be used
together with great caution. Also, keep in mind that metformin can lower vitamin
I also have numerous reports
of people who are quite satisfied after reconstructive surgery for lipodystrophy.
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.
special thanks go to Jim Brockman, who is 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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This article is provided for educational purposes only, and is in no way a substitute
for the advice of a qualified medical doctor or a recommendation to do other
than your doctor determines is best for you. You should present this information
to your doctor for their analysis because appropriate medical therapy and the
use of pharmaceutical compounds like anabolic steroids should be tailored by
a knowledgeable doctor for the individual as no two individuals are alike. I
do not recommend self-medicating with any pharmaceutical drug as you should
consult with a qualified medical doctor who can determine your individual situation.
If you use the information I present without the approval of your doctor, you
do so strictly at your own risk and no responsibility is implied or intended
on my part.