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
  • 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

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