aResearch Institute for the Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK; and bDepartment of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK.
Received: 8 May 2001; accepted: 24 May 2001.
Exercise/physical activity is increasingly being advocated as a positive addition to the treatment regimen of HIV-positive individuals. We investigated the effects of 10 weeks’ aerobic and resistance training on individuals with HIV-related lipodystrophy. These individuals demonstrated an improvement in exercise tolerance, body composition and blood lipid profiles. Potentially, such changes may contribute to an amelioration of some of the adverse metabolic effects associated with highly active antiretroviral therapy.
Metabolic and body compositional disorders are increasingly apparent in patients prescribed highly active antiretroviral therapy (HAART) for HIV infection . Patients typically present with a combination of hyperlipidaemia, peripheral muscle fat wasting, adipose tissue redistribution, and insulin resistance . Classified under the collective term ‘lipodystrophy’, many of these abnormalities may act as risk factors for coronary artery disease (CAD) . As therapeutic interventions are increasingly prolonging the life expectancy of HIV-infected individuals, a possible increase in the risk of the development of CAD gives cause for considerable concern . Although discontinuation or switching of HAART may be effective in attenuating the features of lipodystrophy, such an approach may not always be clinically feasible. Exercise has been shown to be efficacious in ameliorating hyperlipidaemia, central adiposity, and other co-morbidities associated with CAD in non-HIV-infected populations. In men with AIDS wasting, combined resistance training and testosterone supplementation resulted in positive functional and body compositional adaptations . However, this protocol was associated with a negative impact on HDL concentrations, primarily attributable to testosterone supplementation. Consequently, this regimen may not be suitable for patients with HIV-related lipodystrophy. We hypothesized that in HIV-infected patients with lipodystrophy, exercise training without testosterone supplementation would improve blood lipid profiles while attenuating the adverse body compositional changes.
In order to test this hypothesis, we undertook a prospective 10 week study, combining aerobic and resistance training exercise as an adjunct to HAART. Six HIV-infected individuals with lipodystrophy (five men, one woman, mean age 40.7 ± 13.9 years; height 175.1 ± 6.36 cm; body mass 69.4 ± 17.4 kg, body fat 21%, body mass index 22.4 ± 4.66 kg/m2; CD4 cell count 456 ± 175/mm3) gave informed consent to participate in the study. Lipodystrophy was diagnosed on the basis of a doctor’s confirmation of patient self-report of fat wasting in the face, arms or legs . Inclusion criteria were defined as: (i) no history of exercise during the preceding 12 weeks; (ii) currently following a HAART regimen (four were prescribed a nucleoside reverse transcriptase inhibitor (NRTI)/protease inhibitor regime, one was prescribed a non-NRTI/protease inhibitor combination and the final patient was on a triple NRTI regimen); (iii) not prescribed lipid-lowering medication; and (iv) presenting no contraindications to exercise. Before and upon completion of the exercise regimen, body composition, functional capacity (strength and aerobic), and a 12 h fasting lipid profile (total cholesterol, triglycerides, HDL and LDL) were determined. The patients engaged in three supervised exercise sessions of approximately 90 min each week for 10 weeks, with no other formal activity being performed. Each session consisted of a warm-up and warm-down in addition to approximately 20 min of cycling at 70% of peak heart rate, followed by 60 min of resistance training, incorporating three sets of 10 repetitions of three lower and three upper body exercises. Muscle strength and aerobic function were reassessed each week, and new targets set to maintain a progressive training regimen.
Total cholesterol and triglyceride concentrations decreased by 17.6 and 25.3%, respectively, after completion of the program (Table 1). This reduction contrasts with the progressive increase in cholesterol and triglyceride concentrations that may occur when adhering to HAART [1,2]. HDL demonstrated a small increase, which when combined with reductions in total cholesterol, resulted in a 23% reduction in the total cholesterol : HDL ratio (Table 1). The latter, however, showed a trend towards, but did not attain, significance because of the small numbers in the study. The combined reduction of total cholesterol and triglyceride concentrations, and the trend towards normalization of the total cholesterol : HDL ratio with exercise training has not previously been reported in this population of patients. Previous studies are equivocal, suggesting that exercise is ineffective in reducing cholesterol [4,5], but effective in reducing triglyceride [4,5] and increasing HDL concentrations . We suggest that combined aerobic and resistance training can contribute in modifying blood lipid concentrations. The supervised nature of the study and the high rate of compliance to the exercise regimen (~ 85%, range 80–100%) may explain these positive changes, given the equivocal findings of previous studies [4,5]. A significant increase in body mass, combined with a reduction in body fat (Table 1) may be indicative of positive adaptations in body composition. However, such changes must be viewed in light of the clinical feature of lipodystrophy, i.e. body fat redistribution. Muscular strength increased by approximately 45%, with a significant increase in upper body strength compared with lower body strength being apparent (P < 0.01). The magnitude of these changes exceeds those observed after resistance training in patients with AIDS wasting . These adaptations, when considered in parallel with the increased muscle girths (Table 1), may suggest an attenuation in the loss of muscle function that often accompanies a sedentary lifestyle . Aerobic capacity increased by approximately 17.9%, indicating positive cardiorespiratory adaptations with training. Such improvements are important, given reports of impaired oxygen transport and functional capacity compared with seronegative controls .
A regimen of combined aerobic and resistance training in this cohort of patients with HIV-related lipodystrophy syndrome was effective in enhancing functional capacity (strength and aerobic endurance), reducing subcutaneous body fat, total cholesterol, triglyceride concentrations and increasing body mass. The usefulness of exercise as an adjunct to conventional HAART may rest on its potential to ameliorate the body composition and lipoprotein disturbances associated with adherence to HAART. Further investigations in larger numbers of patients are warranted.
The authors wish to thank the medical staff at the Bolton Centre for Sexual Health and Manchester Royal Infirmary for assistance in data collection. In addition, the exercise facilities provided by Body Positive North West are especially appreciated. Finally, the authors would like to thank the volunteers who contributed their blood, sweat and occasional tears to the project. Finally, the authors would like to thank all those who volunteered for this project.
Simon P. Jonesa
Dominic A. Dorana
Peter B. Leatta
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