1. HIV-Associated Lipodystrophy: Modifiable Risk Factors in Croatian Patients
Christine M. Stanley, B.A. †
Drago Turčinov, M.D.*
George Rutherford, M.D. †
Thomas E. Novotny, M.D. †
Josip Begovac, M.D.*
†University of California San Francisco
*University Hospital of Infectious Diseases, Zagreb, Croatia

2. Lipodystrophy and HIV/AIDS
Anti-retroviral (ARV) related lipodystrophy:
5-30% of people on protease inhibitors
Also non-nucleoside reverse transcriptase inhibitors (NNRTI)
Lipohypertrophy: dorsocervical fat pad, neck circumference, breast, abdominal fat
Lipoatrophy: loss of fat from cheeks, arms, thighs, buttocks, shoulders

3. Risk Factors for Lipodystrophy (LD)
Non-modifiable
Increasing age
Female gender
Greater duration of ARV
Greater body weight before ARV
Modifiable
Smoking
Diet: Smaller intake of total protein and total dietary fiber while taking ARV
Hendricks et al 2003 Am Journal Clinical Nutrition, case control study of 47 cases

4. Study Question: Could diet decrease the risk of LD in HIV/AIDS patients on ARVs?
Mediterranean Diet:
high intake of legumes, fruits, vegetables, nuts, cereals and olive oil
moderate intake of fish
low to moderate intake of dairy products
low intake of meat and poultry
moderate intake of alcohol
Population-based Greek study found Mediterranean diet protective against death due to coronary heart disease and cancer.
Population based (22,043 participants) prospective study of this diet in the Greek population was published in 2003 Found that a higher degree of adherence to the diet was associated with a reduction in total mortality, inverse association between diet adherence and death due to coronary heart disease and death due to cancer

5. Croatia: A Mediterranean and Central European Country
Hypothesis: HIV/AIDS patients adherent to Mediterranean diet will have lower LD risk;
Setting: One clinic in Zagreb treats all HIV patients in Croatia;
Target group: Patients from diverse geographical areas with differing diets
Approximately 450 people identified as having HIV in Croatia

6. Methods
136 patients from HIV clinic of Fran Mihalavic Infectious Disease Hospital in Zagreb, treated with ARV for at least one year;
LD assessed using patient self-report and confirmation by physical exam;
Metabolic data and body measurements obtained on all patients.
Severity and number of signs was used to categorize patients as having lipoatrophy and/or lipohypertrophy
Metabolic characteristics included HDL, LDL and total cholesterol. Body measurements included waist-to-hip ratio, change in BMI, weight prior to HAART

7. Measuring Dietary Adherence
Food questionnaire included 150 food and beverage items;
Usual dietary intake during the preceding year was calculated:
5 Beneficial categories: vegetables, legumes, fruits and nuts, cereals and fish
3 Detrimental categories: meat, poultry, dairy
Moderate alcohol consumption considered beneficial
A ten-point adherence scale dichotomized into:
< 4 points = low adherence
 4 points = medium and high adherence
Sex-specific median cutoffs

8. Results 41% of participants had moderate to severe lipoatrophy;
32% of participants had moderate to severe lipohypertrophy;
Mediterranean diet score of  4 was independently associated with a lower risk of lipohypertrophy.

9. Risk Factors for LD 56 with lipoatrophy, 44 with lipohypertrophy,
56 with lipoatrophy, 44 with lipohypertrophy,
Stavudine is a Nucleotide reverse transcriptase inhibitor

10. LD and Food Categories
Men without LD (n=108) consumed more fish (p=0.026), less meat (p=0.028) and less vegetable oils (p=0.024).
77% of men without LD vs 47% with LD frequently consumed olive oil (p=0.002).
Meat
Fish
Vegetable Oils
Dietary intake from 108 men in relation to lipodystrophy

11. Discussion: Lipodystrophy
LD is common, progressive syndrome in HIV/AIDS patients taking ARV;
Changes in fat distribution persist after discontinuation of ARV;
LD may be disfiguring and stigmatizing;
Because of cost and availability, patients may not have option to change treatment.

12. Conclusions
Diet
Adherence to Mediterranean diet associated with decreased LD risk;
Consuming more fish, less meat, and less vegetable oil associated with lower LD risk;
Consuming olive oil associated with lower LD risk.
Smoking
Former or current smokers had higher risk of lipoatrophy (p=0.042)

13. Study Limitations Cross-sectional design
Prospective randomization not possible
Difficult to infer causality due to multiple confounders
Results specific to this patient group and may not be generalizable;
One time point for assessment of lipodystrophy
Questionable accuracy of retrospective dietary information;
LD determined by self-report and physical exam.

14. Plitvice Lakes National Park , Croatia
Dr. Josip Begovac, Christine Stanley, Sarah Gertler, Nancy Gertler