Changes in blood lipid levels occur in any infection, including HIV infection. Typical changes include an increase in triglycerides with a reduced amount of total cholesterol. Many attributes of HIV disease and its treatment predispose to worsening of cardiovascular disease risk factors. The types of changes we now see with the use of anti-HIV therapies include elevation in both triglycerides and total cholesterol.

Medication-induced changes that now concern us greatly, especially those related to the use of protease inhibitors, include a significant increase of LDL-C or "bad" cholesterol with a decrease in HDL or "good" cholesterol.1 The risk for cardiovascular disease appears to be much higher in patients receiving protease inhibitor-based therapy. When cardiovascular disease risk is combined with other risk factors such as family history, insulin resistance, and body shape changes, a multi-disciplinary approach is required.

Diet and exercise are two therapies that are self-driven by the patient. The beneficial effects of diet- and exercise-related interventions on hyperlipidemia remain unclear.2 Regardless of cholesterol levels, healthy diet and adequate exercise can help to improve overall health and reduce risk factors for cardiovascular disease and other conditions now associated with long-term survival.

Diet

A fasting lipid profile should be taken to determine total cholesterol, cholesterol fractions, and triglycerides. Total cholesterol and triglyceride levels should be at or below 200 mg/dL; LDL cholesterol should be maintained at or below 130 mg/dL. HDL cholesterol is protective against heart disease and should be above 35 mg/dL. Dietary goals for hyperlipidemia are described in the National Cholesterol Education Program (NCEP) guidelines and can be summarized as follows:

"     A nutritionally adequate and varied diet

"     A calorie intake adequate to support and maintain body weight

"     A total average fat intake of less than 30% of daily calories

"     A total average saturated fat intake of less than 10% of daily calories

"     A total average dietary cholesterol intake of less than 300 mg/day

To accomplish these goals, emphasizing fruits, vegetables, grains, low or non-fat dairy, and low-fat meat and meat substitute choices are a good start. General recommendations for each of the food groups is shown in Table 1. As always, food safety guidelines should be used in shopping, storing, and preparing foods or dining out.

Exercise

Recent preliminary studies suggest that regular aerobic and progressive resistance training  are beneficial for persons living with HIV and AIDS (PLWHA). Exercise research in HIV and blood lipid control is limited. As a result, much of our knowledge about potential benefits of exercise in HIV-infected populations is based on cardiovascular disease research.2,3,4 Regular aerobic exercise helps to maintain a healthy heart by lowering heart rate and blood pressure and managing an appropriate weight. PLWHA should be encouraged to do regular aerobic activity and progressive resistance training to decrease LDL levels, increase HDL levels, and achieve other health benefits.5,6,7

There are three important components to effective exercise: frequency, intensity, and duration. The anatomy of a proper workout consists of a warm-up, stretching, conditioning, and cool-down phase. The guidelines shown in Table 2 (on page #) have been adapted from the Guidelines for Exercise Testing and Prescription that have been issued by the American College of Sports Medicine.

During high-intensity workouts, you should work at what is called your "maximum heart rate." This term refers to an ideal heart rate which you should not exceed during exercise (it does not mean the highest rate at which your heart can actually beat). To determine this rate, you should subtract your age from 220. Moderate-intensity workouts should be done at 55%-85% of your maximum heart rate. For example: For a 35 year old, the maximum heart rate during exercise would be 185. The target heart rate for moderate-intensity aerobic exercise would be beats per minute. (In practice, this translates into 20-26 beats every 10 seconds)

An exercise program should be individualized for PLWHA according to current fitness levels, risk factors, and goals. Before starting any exercise program, physician advice and consent should be obtained. Cardiovascular health in the age of HAART needs to be a major priority in the primary health care of people living with HIV and AIDS. 

Alan Lee, RD, CDN, CFT works as a consultant for AIDS Service Organizations. He is currently the Chair of Nutritionists in AIDS Care (NIAC), the Alliance Chair of the HIV/AIDS Dietetic Practice Group of the American Dietetic Association, and the President-Elect for the Greater New York Dietetic Association. Alan can be reached at <> or at .

Cade Fields-Gardner, MS, RD, LD, CD is an HIV-specialist dietitian in the Chicago area. Her work includes patient care, program development, training, and education. Cade can be reached at <> or at .

References

     1.   Segarra-Newnham M. Hyperlipidemia in HIV-positive patients receiving antiretrovirals. Ann Pharmacother. 2002;36(4):.

     2.   Geletko SM, ZuWallack AR. Treatment of hyperlipidemia in HIV-infected patients. Am J Health Syst Pharm. 2001;58(7):.

     3.   Fahlman MM, Boardley D, Lambert CP, Flynn MG. Effects of endurance training and resistance training on plasma lipoprotein profiles in elderly women. J Gerontol A Biol Sci Med Sci. 2002;57(2):B54-B60.

     4.   Halbert JA, Silagy CA, Finucane P, Withers RT, Hamdorf PA. Exercise training and blood lipids in hyperlipidemic and normolipidemic adults: a meta-analysis of randomized, controlled trials. Eur J Clin Nutr. 1999;53(7):.

     5.   Kokkinos PF, Fernhall B. Physical activity and high density lipoprotein cholesterol levels: what is the relationship? Sports Med. 1999;28(5):.

     6.   Jones SP, Doran DA, Leatt PB, Maher B, Pirmohamed M. Short-term exercise training improves body composition and hyperlipidaemia in HIV-positive individuals with lipodystrophy. AIDS. 200;15(15):.

     7.   Yarasheski KE, Tebas P, Stanerson B, Claxton S, Marin D, Bae K, Kennedy M, Tantisiriwat W, Powderly WG. Resistance exercise training reduces hypertriglyceridemia in HIV-infected men treated with antiviral therapy. J Appl Physiol. 2001;90(1):.

Internet Resources

Practical advice on nutrition and exercise can be obtained on line at: <http://www.aidsnutrition. org/facts/sheet06.htm> <http://familydoctor. org/handouts/457.html> <http://www.thebody. com/dietnut.html> <http://www.aidsmap. com/publications/factsheets/fs48.pdf>

<http://abcnews.go.com/sections/living/

Healthology/nutrition_hiv.html> <http:// www.hivfitness.org>