Lipoatrophy and Obesity

Lipoatrophy

Prevention

• Avoid d4T and ZDV or pre-emptively switch. No evidence of benefit by switching other antiretrovirals
• Avoid excessive weight loss due to diet and exercise
• In ART-naïve persons, limb fat usually increases with initiation of ART not containing d4T or ZDV, reflecting “return-to-health” type of response

Management

• Modification of ART
• Switch away from d4T or ZDV: 
  • Increase in total limb fat ~400-500 g/year (in the first two years)
  • Risk of toxicity from new drug, see Adverse Effects of ARVs & Drug Classes
• Surgical intervention: Offered for relief of (facial) lipoatrophy only 

See online video lecture CVD, CKD and Endocrinology from the EACS online course Clinical Management of HIV

Obesity

Definition

• Body mass index (BMI) > 30 kg/m²
• Also body fat > 25% (men) or > 33% (women) for persons with low muscle mass
• Waist circumference is an indicator of abdominal fat and a useful predictor of cardiometabolic diseases. Cut-off points indicating higher cardiometabolic risks are > 88 cm for women and > 102 cm for men.Naturally, different ethnicities have different body builds and proportions. Asians have a naturally slimmer, petite frame and therefore the waist circumference cut off for Japanese, Chinese and South Asian people is lower than for Caucasians
• Visceral adipose tissue (VAT) area ≥ 130 cm² is a validated threshold for increased cardiometabolic risk

Consequences

• Not only cosmetic concern
• Worse outcomes with surgery and actute infections (e.g. pneumonia, influenza)
• Increased risk of diabetes mellitus, hypertension, cardiovascular disease, some cancers, obstructive sleep apnea, colelithiasis, erectile dysfunction, non-alcoholic fatty liver disease, ostheoarthritis and depression

Contributing factors

• Older age
• Sedentary lifestyle
• Intake of excess or poor quality calories (e.g. saturated fats, processed sugars)
• Excess alcohol consumption
• Some medications (e.g. psychotropic drugs, steroids, antidiabetic drugs)
• Endocrine disorders (e.g. GH deficiency, hypothyroidism, Cushing’s syndrome, hypogonadism)

Assessment

• Weight, waist circumference and BMI, see Lifestyle Interventions
• Fasting lipids and glucose, see Prevention of Cardiovascular Disease (CVD), Type 2 Diabetes and Dyslipidaemia
• Dyslipidaemia management, see Dyslipidaemia
• Assess NAFLD, see Non-Alcoholic Fatty Liver Disease (NAFLD)
• Prevention of cardiovascular disease, see Prevention of Cardiovascular Disease (CVD)

Aim

• An objective of 5% weight loss from initial weight may have a beneficial impact on obesity-related co-morbidities

Management:

• Structured exercise
• Dietary intervention
• No data on ART switch
• Treat underlying or associated conditions
• There are several drugs approved to treat obesity (e.g. orlistat, phentermine/topiramate, lorcaserin, nalterxone/bupropion, liraglutide) but they should be prescribed by an endocrinologist or obesity expert. All of them may have adverse effects and drug-drug interactions with ART.
• Bariatric surgery may be considered in persons with a BMI ≥ 40 kg/m² or ≥ 35 kg/m² with obesity-related comorbidities refractory to serious attempts at lifestyle changes and should be coordinated through an established, specialist led obesity programme. Consider theraputic drug monitoring and drug dose adjustment post-bariatric surgery
• Surgery can be considered for localised lipomas and dorsocervical fat accumulation for cosmetic purposes only