A twenty minute consultation with a dietician every three months appears to be effective at lowering drug-associated lipid increases following initiation of highly active antiretroviral therapy (HAART), according to a small, randomised trial presented to the 4th IAS Conference in Sydney on Wednesday.
Dietary change is recommended first-line dyslipidaemia intervention
Many individuals who begin HAART see rises in their total cholesterol levels as well as in the more harmful forms of lipids, LDL cholesterol and triglycerides. In some cases, these are high enough to warrant treatment with lipid-lowering drugs in order to reduce the risk of cardiovascular disease.
However, US dyslipidaemia guidelines recommend lifestyle changes, including improving dietary habits, as a first-line intervention for HIV-associated dyslipidaemia, although there is little hard evidence to support this approach in HIV-positive individuals.
The investigators – from Hospital de Clinicas, Universidade Federal de Rio Grande do Sul in Porto Allegre, Brazil – had previously studied aerobic exercise along with a low fat diet in individuals on HAART already presenting with dyslipidaemia and body fat changes. However, this study was of short duration, and although this intervention improved participants’ quality of life no significant changes were observed in plasma lipid levels.
Study design
In order to evaluate the effect of dietary orientation and intervention in blood lipids in treatment-naive individuals starting antiretroviral therapy for the first time, 90 individuals initiating HAART were randomised into two equal-sized groups.
At baseline, both groups received nutritional counselling to reduce consumption of simple carbohydrates as well as saturated and trans fats, and to increase consumption of complex carbohydrates and fibre. Body mass index, waist/hip ratio and lipid profiles were also taken at baseline and at three monthly intervals, and all 90 were asked to recall everything they had eaten in the previous 24 hours at baseline and after six and twelve months.
The 45 individuals in the dietary intervention group also received a brief, twenty-minute consultation with a dietician every three months. The consultation included nutritional counselling based on US Department of Health and Human Service’s National Cholesterol Education Program (NCEP) guidelines, which aimed to help the participants achieve the ideal balance of macronutrients and to reach the NCEP guidelines-recommended target of total cholesterol, HDL and LDL cholesterol and triglycerides.
In order to accurately assess the effect of this intervention on HAART-related lipid changes, the investigators only included in their final analysis those individuals who maintained an undetectable viral load (
A further three individuals had not yet completed the twelve month protocol (two in the control group, and one in the dietary intervention group). Consequently, the analysis included 42 individuals in the dietary intervention group and 38 in the control group. At baseline, there were no significant differences in the gender (60%-63% female), median age (37-38 years), percentage of smokers (26%-29%), body mass index (23-24), waist-to-hip ratio (0.86) or CD4 count (173-181 cells/mm3) between the two groups.
Regular nutritional counselling for everyone initiating HAART recommended
Dr Sprinz noted that, since he and his colleagues had documented the impact of changing dietary intake on plasma lipid levels in this study, “this nutritional intervention was shown to be effective in preventing changes in the lipid profile of HIV-positive individuals who start HAART.”
He added that a one-off “routine nutritional intervention was not enough to control HAART-associated lipidaemia” and that a short, three-monthly nutritional intervention was able to do so.
He concluded that giving this type of advice is safe, effective and should be incorporated into the clinical care of individuals who initiate HAART “and not,” he stressed, “after the development of dyslipidaemia.”
Significant lipid changes observed
Between baseline and 12 months, the individuals in the intervention arm had a significant fall in their total daily average caloric intake (from 2,655 Kcal/day to 2,289 Kcal/day), while those in the control group saw their intake rise from 2,600 Kcal/day a day to 2,814 Kcal/day; difference between groups, p
Similarly, daily intake of fats dropped from 31% of total caloric intake to 21% among those in the intervention group but remained unchanged in the control group (difference between groups, p
Both the average body mass index and waist/hip ratios remained stable in the intervention group but increased in the control group (BMI difference between groups, p
Between baseline and at twelve months, mean total cholesterol and LDL-cholesterol levels were unchanged in the intervention group whereas mean total cholesterol levels increased in the control group from 150mg/dl [3.88mmol/l] to 189mg/dl [4.89mmol/l] while LDL-C levels rose from 85mg/dl [2.20mmol/l] to 106mg/dl [2.74mmol/l]. (p
Triglycerides were actually reduced after twelve months in the dietary intervention group from 134mg/dl [1.51mmol/l] to 101mg/dl [1.14mmol/l]. However, triglycerides increased over twelve months in the control group from 134mg/dl [1.51mmol/l] to 158mg/dl [1.78mmol/l] (difference between groups, p
Lazzerati R et al. Dietary intervention when starting HAART prevents the increase in lipids independently of drug regimen: a randomized trial. Fourth IAS Conference on HIV Pathogenesis, Treatment and Prevention, Sydney. Abstract WEAB303, 2007.