Copyright © 2011 by Nelson Vergel

Beyond Survival-  A Breakthrough in Well-Being

Nelson VergelProgram for Wellness Restoration

This information (and any accompanying

printed material) is not intended to replace the

attention or advice of a physician or other

health care professional.

Anyone who wishes to embark on any dietary,

drug, exercise, or other lifestyle change

intended to prevent or treat a specific disease

or condition should first consult with and seek

clearance from a qualified health care

professional.

These Slides Are Available at

PoWeRUSA.org

AGENDA

• Update on lipodystrophy• How to prevent bone loss• Protecting yourself from anal cancer• Exercise: The best therapy• What you did not know about testosterone• Questions?

Dyslipidaemia

Hepatic steatosis

Abnormalities of body composition

CVD Bone & Kidney disease

The changing pattern of clinical spectrum of HIV: LIPODYSTROPHY and Non-infectious Co-MORBIDITIES depict the HIV specific Ageing phenotypes

HANDBody image alterations

Glucose metabolism impairment

Depression HT Vit D T2D CancerSexual Dysfunction

Background

Interactions among aging, HIV, and HIV drugs increase the risk of comorbidities. (Vance, Am J Nurs 2010)

Pp prevalence was higher in cases than controls in all age strata (all p-values <0.001) Pp prevalence seen cases aged 41-50 was similar to that observed among controls aged 51-60 controls (p=0.282)

Poly-pathology prevalence in cases and controls, stratified by age categories

Pp 3.9% 9.0% 20.0% 46.9% Pp 0.5% 1.9% 6.6% 18.7%

Visceral Fat Reduction

9

Abdominal Obesity and the Cardiometabolic Risk

Intra-abdominal fat is a strong correlate of

Cardiometabolic Risk

Intra-abdominal orVisceral Fat

INSIDE

Intra-abdominal Fat

OUTSIDE

Waist Circumference

10Pouliot et al. Diabetes. 1992;41:826-834.

310

248

186

124

62

0

60

45

30

(mg

/dl)

HDL-cholesterol

(mg

/dl)

Triglycerides

Nonobese NonobeseObese Obese

LowVAT

HighVAT

LowVAT

HighVAT

High visceral fat (VAT) increases cardiovascular risk

DAD Study: Lipodystrophy Incidence 2000-2002 vs 2003-2006

2000-2002

2003-2006

Visceral Fat:Sustiva vs Boosted Reyataz &

Truvada (Viread + Emtriva) vs Epzicom (Ziagen+Epivir)

A5224s

Truvada vs EpzicomSustiva vs Reyataz+Novir

Trunk Fat (Visceral + SubQ) (by DEXA)

Sustiva vs Boosted Reyataz &Truvada vs Epzicom

A5224s

Visceral Fat

Exercise

Low Carb, High Fiber Diet?

Egrifta

Metformin?Changing HIV Meds?Testosterone

Anabolic Steroids?

Supplements?

Weight Loss

Liposuction?

Researched Options to Decrease Visceral Fat

16

Reduction in Abdominal Subcutaneous and Visceral Fat In Response to a 7% Exercise-Induced Weight loss, 6 cm reduction in Waist Circumference

Adapted from Ross et al. Ann Intern Med. 2001; Obesity Research. 2004.

Visceral FatSubcutaneous Fat * p< 0.05 vs control

MEN WOMEN

Red

ucti

on

(%

)

Control Exercise

*

*

Red

ucti

on

(%

)

Control Exercise

*

*

0

10

20

30

0

10

20

30

DIET Study (Dietary Intervention:Effects on Tryglicerides

in HIV Lipodystrophy) Using food records that began from 6 to 24 months

before development of fat deposition the following factors were identified.

When compared to people with HIV who developed fat deposition, patients without fat deposition had:

- greater overall energy intakes from their diet (p = 0.03)- greater intakes of total protein (p = 0.01)- more total dietary fiber (p = 0.01)- more soluble dietary fiber (p = 0.01)- insoluble dietary fiber (p = 0.03)- pectin (P = 0.02)

Those without fat deposition also were currently doing moreresistance training exercise and were less likely to be smoking (only borderline statistical significance (p = 0.05))

Hendricks at al, Am J Clin Nutr, 2003 Oct;78(4):790-5

Newly FDA Approved Product to Decrease Visceral Fat in HIV+ Patients

• 2 mg injections under the skin every day. Effect disappears when stopped

• A patient assistance program for those without insurance and incomes under $60K

• More information on Egrifta.com

Effect of HIV Drugs on Lipids

Cholesterol/Triglycerides

Higher Risk

Stavudine- D4TAZTDidanosine-DDILopinavir/r-KaletraAmprenavir-LexivaDuranavir-PrezistaSustiva (Atripla)

Lower RiskNevirapine- ViramuneTenofovir- VireadAbacavir- ZiagenLamivudine- 3TCEmtricitabine- EmtrivaEnfurvitide-FuzeonSaquinavir- InviraseAtazanavir- ReyatazRaltegravir- Isentress Maraviroc- SelzentryEtravirine-Intelence

DHS/PP

TempleFill

Cheek Augmentati

on

Lipoatrophy Deficits Requiring Correction

HIV Medications and Lipoatropy (Fat Wasting)

Lipoatrophy Fat Wasting

Higher Risk

Stavudine-D4T

AZT

Didanosine-DDI?

Low Risk

Nevirapine- Viramune

Atripla & Complera

Tenofovir- Viread/Truvada

Abacavir- ZiagenLamivudine- 3TC

Emtricitabine- Emtriva

Fuzeon

Isentress

Selzentry

All protease inhibitors

Carruthers Lipoatrophy Severity Scale

Stage 1 Stage 2

Stage 3 Stage 4James J et al. Dermatol Surg. 2002;28:979-986.

FDA Approved Facial Lipoatrophy Products

Off Label Use: Silicone Microdroplet, Artefill

Commonly Used Options for HIV-related Facial Lipoatrophy(From FacialWasting.org)

Product Type/Sessions Approved? Cost

Sculptra(New Fill-

PolyLactic Acid)

Non- permanent

3-7 sessions needed, the 1

touch up a year

FDA approved

Patient Assistance for Product onlyhttp://www.needymeds.org/drug_list.taf?_function=name&name=Sculptra

Labor cost avg. $500 per session. Full price: $1,100 per session for

product.

Radiesse (Calcium

hydroxylapitite (CaHA)

microspheres)

Non- permanent

2-3+ sessions needed, then 1 touch up a year

FDA approvedLimited Patient Assistance

Availablehttp://www.radiesse-fl.com/Physician-section/Patient-access-program/

Full Price: $1,200 per session.

Silikon 1000Microdroplets

Permanent

4-8+ sessions needed

Off label use-FDA approved for

intraocular injections to treat

CMV- related retinal detachment

No Patient Assistance-$700-900 per session

PMMA(Polymethyl-

methacrylate )

Permanent

1-2 sessions needed

Available inMexico, Brazil and

other countries.FDA approved: Artefill but too

expensive

$3,000+ avg. total cost for total reconstruction in Mexico:

http://www.avantiderma.com/

Number of sessions depends on severity of facial lipoatrophy

“Dermal injections for facial lipodystrophy syndrome are only reasonable and necessary using dermal fillers approved by FDA for this purpose, and then only in HIV infected beneficiaries who manifest depression secondary to the physical stigmata of HIV treatment.  All other indications are noncovered.”

Proposed Decision Memo for Dermal injections for the treatment of facial lipodystrophy syndrome (FLS) (Jan 2010)

Pre- and Post-Silikon 100014 treatments over 2 years, 24 cc total

Protecting Your Bones

DEXA

BONE

SCAN

Bone Disorders in HIVTreatments for bone loss

– Resistance exercise, preventing wasting syndrome, and avoiding tobacco

– Calcium (1000- 1500 mg/day) and Vitamin D (400-1000 IU/day ). Get 20 minutes of sun daily

– Biophosphonates (Alendronate- Fosamax)– Calcitonin (Intranasal and oral)– Teriparatide (Forteo)– Testosterone and/or thyroid replacement

therapy

Bone Drugs

IVOnce a year

Subcutaneous, once daily

Once monthy

NNRTIs? Tenofovir?

Vitamin D Terminology

Serum 25-hydroxy vitamin D = 25-OHD

Indicator of vitamin D nutritional “status”

Vitamin D Status 25-OHD serum concentrationng/mL nmol/L

Deficient <12 <30Insufficient 12 to <20 30 to 50Sufficient >20 to 50 >50 to 125Excess >50 >125

http://books.nap.edu/openbook.php?record_id=13050&page=11

Vitamin D Therapy Decreases Parathyroid Hormone (PTH) in Patients Taking Viread

(tenofovir)

• Randomized trial of Vit D 50,000 IU/wk x 12 weeks vs. placebo in patients on (n=118) or not on (n=85) TDF

• Higher baseline PTH levels at baseline in TDF group• Vitamin D had no impact on PTH levels in patients not on TDF

TDF No TDF

Day 0 Change Day

0 Change

Vit D 47 -6 26 -2

PBO 37 +2 25 0

Changes in PTH on study

Havens P, et al. 18th CROI; Boston, MA; February 27-March 2, 2011. Abst. 80.

Mean Baseline PTH by Vitamin D status and Tenofovir Use PTH Differs by Tenofovir use, not Vitamin D status

52

35

43

27

P=0.001 P<0.001

Human Papiloma Virus (HPV) Related Cancers

ClearanceCommon; increases after the age of 40

(as the immune system clears the virus)

Re-infectionAssociated with

persistent risk factors

ReactivationMainly associated

withimmunosuppression

Persistent InfectionAssociated with the development of cancer

Cancers caused by HPV: Cervical, Vagino/vulvar, Penile, Anal, Oropharyngeal, Squamous cellHigher risk with sero-types: 16, 18, 45 and 56

HPV InfectionIncidence of HPV infection

increases with sexual exposure

Levine A, et al. 49th ICAAC; San Francisco, CA; Sept. 12-15, 2009; Abst. 400.

Methods to Detect Anal Warts, Cancer, and Dysplasia

Anal Cancer in HIV+ Men and WomenDiagnosis and Treatment

Pap-smears and simple anoscopy done in the office. Cytology obtained from pap smears.

Outpatient under anesthesia: after high resolution anoscopy (HRA) with vinegar, any lesions are treated with infrared coagulation (IRC), which involves inserting a light probe into the anal canal under direct visualization, touching the tip of this light probe to the lesion, and delivering a pre-specified amount of energy.

Trained Physicians by UCSF’s anal neoplasia and research group web site :

http://www.analcancerinfo.ucsf.edu/

Signs and Symptoms of Low Testosterone

Loss of muscle mass and strength Loss of libido and erectile dysfunction Depression Lethargy (fatigue, lack of focus) Bone loss Some regression of secondary sexual

characteristics (body hair loss, etc) Low or no sperm count

Tenover JL. Endocrinol Metab Clin North Am. 1998;27:969-987Petak SM, et al. AACE Clinical Practice Guidelines. Available at: http://www.aace.com/clin/guides/hypogonadism.html

Testosterone and Aging

Albumin-bound T38%

Free T2%

Sex Hormone Binding GlobulinSHBG-bound T

60%

T = testosteroneOnly 2% is free testosteroneand 98% is bound

Testosterone Fractions in the Blood

(binds testosterone)

Testosterone Deficiency (Hypogonadism)

• Normal levels in blood: Men... Total test. 300-1100 ng/dL,

Free test. 5 - 21 ng/dL

Women... Total test. 10-50 ng/dL

Free test. 0.10-0.85 ng/dL

• Symptoms of testosterone deficiency:

Fatigue, low or lack of sex drive, poor appetite,

loss of muscle mass & strength, depression

The HPT Hormonal Axis

H

P

T

TestosteroneReplacement Benefits

Sexual function

Mentalfocus

Stamina and Bone Strength

LeanBodyMass

Testosterone Metabolites and Their Functions

Testosterone5-7

mg/day

Androgen

Receptor

Androgen

Receptor

EstrogenReceptor

Dehydro Testosterone(DHT) (by 5α-reductase)

Estradiol (by aromatase)

Direct Effect

LH

Oxidation by LiverElimination by Kidneys

Skin, Prostate

Hair, Brain, Bone

Muscle, Brain

Testosterone Options

Injections

Patch

Pellets

Buccal

Gels

Gels

Potentially Approved in the Next 12-24 Months

Side Effect: Gynecomastia (breast enlargement in men)

Treatment: Estrogen Blocker Medications or surgery (in worst cases)

Side Effect: Increased number of red blood cells (polycythemia)

Watch out for hematocrit over 52 !

Solution: Donate blood or therapeutic phlebotomy (4-5 units every 3-4 months)

Side Effect: Testicular Shrinkage (atrophy)

Treatment: Human Chorionic Gonadotropin(hCG)

Side Effect : Increased prostate size (benign prostatic hypertrophy)

Prevention:Digital Rectal Exam (DRE)Prostatic Specific Antigen (PSA) blood test

For More Information:TestosteroneWisdom.c

om

Exercise, the Best Therapy for Most Health Problems

Low Arm Muscle is associated with highest population-level mortality risk in multivariable analysis

Arm SM Tertile 1

Leg SM Tertile 1

VAT Tertile 30%

5%

10%

15%

20%

15.1%

7.2% 6.5%

Tertile of Skeletal Muscle or Adipose Tissue

Pop

ula

tion

Att

rib

uta

ble

R

isk

Exercise: The Best Medicine

Benefits: total and abdominal fatimproves insulin sensitivityimproves glucose toleranceincreases HDL cholesterol

triglycerides and LDL increases muscle massimproves enduranceimproves strength

improves bone density improves mood decreases frailty

EXERCISE FOR BEST RESULTS

Aerobic (Cardiovascular)

Exercise Start with a brisk walk every day if

tired Concentrate in low impact or no

impact exercises (e.g. Elliptical Trainers)

Do what you enjoy (bicycling, roller skating, etc)

Good for burning fat, triglycerides, blood sugar, but it may decrease muscle mass

20 - 30 minutes 3-4 times a week is enough for many people

Cardiovascular exercise may increase fat loss under the skin

Progressive Resistance Exercise (PRE)

Warm up and stretch before a session Start with compounded exercises Lift maximum weight for muscular failure

(exhaustion) at 8-12 repetitions One body part per week One hour sessions 3-4 times a week One light set and two heavier sets per body

part If no access to a gym, start with crunches,

push ups, and squats at home. Use stairs! For more details, visit www.medibolics.com

Best Exercise Sites with videos, etc

www.exrx.netwww.MyFit.ca

Ipod exercise routine downloads:

http://www.menshealth.com/download/

For More Information More details in “Built To Survive” and ”Testosterone-

A Man’s Guide” (amazon.com or testosteronewisdom.com)

Email:

Nelson Vergel – Nelsonvergel@yahoo.com Websites: www.powerusa.com

www.facialwasting.orgwww.tpan.com

www.TheBody.com

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Questions?