Lifestyle Interventions

Adults who adhere to Guidelines which promote a healthy diet and physical activity have lower rates of cardiovascular morbidity and mortality than those who do not. In adults without overt cardiovascular risk factors counselling interventions result in improvements in health-promoting behaviors and a positive but small benefit in preventing CVD. In adults with cardiovascular risk factors, counselling interventions have a moderate benefit in preventing CVD. Most important among lifestyle interventions is the recommendation of smoking cessation. All adults should be advised to stop smoking; the benefit of smoking cessation is substantial.

This table may be used as an example, but referring to individual national Guidelines would be just as appropriate.

Dietary counselling

  • Dietary intervention should not interfere with the dietary requirements necessary for appropriate absorption of ART drugs (e.g. maintaining sufficient calorie intake for RPV)
  • Keep caloric intake balanced with energy expenditure
  • Limit intake of saturated fat, cholesterol and refined carbohydrates
  • Reduce total fat intake to < 30% and dietary cholesterol to < 300 mg/day
  • Emphasise intake of vegetables, fruit and grain products with fibre
  • Cut back on beverages and foods with added sugar
  • Choose and prepare foods with little or no salt. Adequate intakes of salt in adults have been estimated mostly around 3 g/day
  • Emphasise consumption of fish, poultry (without skin) and lean meat
  • Consider referral to dietician, one-week food and drink diary to discover ‘hidden’ calories
  • Avoid binge eating (‘yo-yo dieting’)
  • In persons with HIV-related wasting and dyslipidaemia, address wasting first and consider referral to dietician
  • Persons who are obviously overweight should be motivated to lose weight. Starvation diets are not recommended (immune defence mechanisms potentially decreased). Malnutrition has to be addressed where observed.
    Normal BMI range: 18.5-24.9;
    Overweight: 25.0-29.9,
    Obesity: > 30.0 kg/m2
  • The following questions are helpful to determine average alcohol intake
    1. How often do you drink alcohol:
      never, ≤ 1/month, 2-4x/month, 2-3x/week, > 4x/week
    2. If you drink alcohol, how much typically at a time:
      1-2, 3-4, 5-6, 7-9, > 10 drinks
    3. How many times do you have 6 or more alcoholic drinks at one occasion:
      never, < 1/month, 1x/month, 1x/week, more or less daily
  • Intake of alcohol should be restricted to no more than one drink per day for women and two drinks per day for men (< 20-40 g/day)
  • In particular, persons with hepatic disease, see NAFLD, adherence problems, inadequate CD4 count increase, tumours, past tuberculosis, diarrhoea and other conditions associated with high alcohol intake should be motivated to decrease or stop alcohol intake

Exercise promotion

  • Promote active lifestyle to prevent and treat obesity, hypertension and diabetes
  • Encourage self-directed moderate level physical activity (take the stairs, walk to work, cycling, swimming, hiking, etc.)
  • Emphasise regular moderate-intensity exercise rather than vigorous exercise
  • Achieve cardiovascular fitness (e.g. 30 minutes brisk walking > 5 days a week)
  • Maintain muscular strength and joint flexibility

Smoking cessation

PLWH who smoke tobacco should be made aware of the substantial health benefits of smoking cessation which include reducing the risk of tobacco-related diseases, slowing the progression of existing tobacco related disease, and improving life expectancy by an average of 10 years. Regularly consider the following algorithm with two major questions:

Adapted from the European Smoking Cessation Guidelines and Calvo-Sanchez M., et al, 2015

  1. Pharmacotherapy: Nicotine replacement therapy: nicotine substitution (patch, chewing gum, spray), varenicline and bupropion are approved by the EMA. Bupropion is contraindicated with epilepsy and varenicline may induce depression. Bupropion may interact with PIs and NNRTIs, see Drug-drug Interactions between ARVs and Non-ARVs
  2. Cognitive-behavioral intervention: Use specific available resources
  3. Motivational strategy: Identify potential health risks of the smoker and to stratify both acute (e.g. exacerbations of COPD) and long-term (e.g. infertility, cancer) risks. Explain the personal benefits of stopping smoking. Identify the barriers or obstacles that might impede the success of a quit attempt. Smoking cessation interventions should be delivered repeatedly, as long as the person is not willing/ready enough to quit smoking

 

At this moment, neither EMA nor FDA approve e-cigarettes as a smoking cessation agent. In PLWH there is no data on long-term outcomes and it is not possible to add any more specific recommendations. EACS follows the statement issued by the CDC in 2018

There is inadequate evidence to determine the effect of e-cigarettes on achievement of smoking cessation as well as the harms of e-cigarettes when used as a smoking cessation tool