It’s better to die of HIV than be fat?

Whenever you hear news about a presentation made at a meeting or conference, it is best to take it with a grain of salt. Wait until the research is actually published — and its methodology, data and findings are available for scrutiny — before taking it seriously. (You’ll quickly find that few studies presented at meetings are good enough to ever go on to be published in journals.) The media isn’t able to verify the study claims, either. In fact, invariably, the media stories are all identical and come out on exactly the same day, because they came from the same press release embargoed for that date, meaning they’re marketing.

Press releases do not make for sound science, which is why very few studies issued to the media at meetings are reported at Junkfood Science. We’re making an exception today.

An identical story was picked up by media across the country — 150 outlets by noon today, per Google — evidence of effective marketing. It reported on an especially indefensible idea floated at the annual meeting of the Infectious Disease Society of America. A speaker suggested doctors worry that HIV-positive patients are getting fat like everyone else because the disease is being so successfully managed that patients are living longer. The presenter said that doctors should encourage HIV-positive people to diet and exercise to maintain “a healthy, normal weight.”

Not only does this story provide a disturbing example of myths surrounding fat, but it’s a haunting example of how fears of fat can be deadly, especially for those most in need of sound information and our care and compassion.

The Associated Press’ science writer reports:

Obesity a problem in HIV population

...AIDS researchers and advocacy groups say the waistlines of HIV patients are growing right along with the girths of uninfected Americans as the disease shifts from a death sentence to a chronic condition....Doctors say there's a growing need to screen people with the AIDS virus for obesity, which raises the risk of diabetes, high blood pressure and cholesterol problems. “We used to worry that they would lose weight and become wasted," said Dr. Nancy Crum-Cianflone of TriService AIDS Clinical Consortium in San Diego. “Maybe we should redirect our concerns to making sure they are maintaining a healthy, normal weight."...

A turning point in the AIDS crisis came with advances in modern medicine. Powerful drugs that keep the virus at bay also boost the body's immune system. The result is that more HIV patients are living longer than their counterparts two decades ago, and may be prone to poor eating habits and lack of exercise..... When patients gained weight, they tended to put on an average of 13 pounds over a decade. Those who became infected younger, those who had the virus for a longer time, or those who had high blood pressure were more likely to get fat...

“It would be very sad to survive HIV and die of something else that was preventable, said [Dr. John T. Brooks, an epidemiologist at] the CDC....

Few HIV-positive people would view it as tragic that they’re able to live long enough to die of old age-related chronic diseases like everyone else!

People, with and without HIV, eating normally will be a wide range of sizes: some fat and some not. So, what these researchers are actually proposing is that fat people undereat, and eat less than we all need for good nutrition, in order to try and be thinner than their natural genetic makeups. But the real issue here isn’t that promoting weight loss and thinness is based on unsound science, it’s that it ignores the most significant concerns for the welfare of HIV-positive patients:

The evidence unfailingly shows that being fatter and gaining weight and having the best nutritional status is a huge survival benefit for HIV-positive patients, whereas undernutrition or losing weight prior to the onset of AIDS greatly reduces chances of living.

And shouldn’t helping them live be a greater priority than what their figures look like?

Yet, as is typical with press releases and media writers when it comes to 'obesity,' no attempt was made to question these recommendations, to examine the science and present a balanced viewpoint, or to recognize that presenting such claims to the public could put the lives of millions of people in jeopardy.

It appears that the researchers in this paper merely tallied the BMIs of 663 HIV patients being treated at two Naval Medical Centers and flipped out about their sizes. Yet, incredibly, they didn’t report anything about how the BMIs affected the patients’ disease or lifespan. The body of evidence on the survival advantage of body fat for HIV patients is so overwhelming, however, we don’t even need to try hard to find it.

Researchers at the University of Miami School of Medicine, Florida, for example, specifically examined when obesity is desirable. Their study of HIV-1 seropositive patients in the MIDAS cohort, receiving treatment at a community clinic from 1992 to 1996 before highly active antiretroviral therapy, found that obesity was associated with better survival. Over an 18-month period, there was a three-fold increase in survival among the obese patients compared to the nonobese patients. “Measurements of BMI were inversely associated with progression to death, independent of CD4 count <200 cells/mm3 (p<.02),” they concluded.

In a 2003 issue of Clinical Infectious Diseases, research led by Dr. Clara Jones of Tufts University School of Medicine, Boston, examined the effects of weight loss and BMIs on the progression of disease among 871 women HIV-positve patients. The women who had higher BMIs prior to diagnosis had a slower rate of their first CD4 cell counts falling below 200 cells/mm3. Examining changes in BMIs over time, “the underweight and normal women had higher risks of developing AIDS, and underweight women had increased risk of HIVrelated death, compared with obese women... even after controlling for prior values of CD4 cell count, viral load, and treatment. Higher BMI and increases in BMI are associated with a decreased risk of HIV progression.”

Not only is fatness a survival advantage, but suggesting weight loss is especially dangerous for HIV-positive patients. In reviewing the literature, the Tufts researchers concluded it is “likely that the improved outcomes associated with an increased BMI were associated with increased fat mass.” During weight loss, regardless of whether it is intentional or intentional, they noted, not only is overall nutritional status compromised, but leptin levels also fall which compromises the immune system.

The literature universally supports that weight loss is a strong predictor of increased mortality, according to David A. Wheeler, M.D., medical director, Inova HIV Services and clinical assistant professor of medicine, Georgetown University, Washington, DC. “Weight loss is also associated with higher risk of opportunistic infections. A loss of 5% to 10% of body weight augments the risk of individual infections by as much as 61% to 176%. Even a weight loss of less than 5% is associated with a 19% increase in the risk of developing some opportunistic infection.”

Weight loss among HIV patients can, of course, be a result of the disease process. But weight loss even long before the onset of AIDS has been shown to significantly decrease survival. Examining nutritional variables, researchers in France found undernutrition remains a major cause of disease progression and morbidity among HIV-positive patients, independent of CD4 cell counts. The origins of undernutrition are varied and hard to pinpoint, but include dietary reductions, they said, concluding that nutrition and BMI should be a mandatory part of patient management

The suggestion made in today’s news was that since the advent of newer drugs and highly active antiretroviral therapy (HAART), muscle wasting is no longer a concern. That claim, however, is unsupported in the medical research. Dr. Christine Wanke and colleagues at Tufts School of Medicine, for example, tested this very assumption in a longitudinal study of 469 HIV patients enrolled in a study of nutrition and HIV. They found that one-third of HIV patients developed wasting and half was getting HAART and half wasn’t. There was no differences in wasting related to therapy. “These data strongly suggest that weight loss and wasting continue to be common problems for individuals infected with HIV. In addition, these complications continue to occur in patients treated with HAART as well as in those for whom HAART has failed or those who cannot tolerate the HAART regimens.”

These were also the conclusions of the Department of Health and Human Services Working Group on the Prevention and Treatment of Wasting and Weight Loss Identifiers. They also found that inadequate food intake contributes to wasting. Reporting their findings in a recent issue of Clinical Infectious Diseases, they said:

Weight loss and muscle wasting remain significant clinical problems, even in the era of potent antiretroviral therapy. In patients infected with human immunodeficiency virus (HIV), wasting, particularly loss of metabolically active lean tissue, has been associated with increased mortality, accelerated disease progression, loss of muscle protein mass, and impairment of strength and functional status. Factors that may contribute to wasting include inadequate intake, malabsorptive disorders, metabolic alterations, hypogonadism, and excessive cytokine production. Evidence now demonstrates that nutritional counseling and support, appetite stimulants, progressive resistance training, and anabolic hormones can reverse weight loss and increase lean body mass in HIV-infected patients.

Worse, by proposing weight loss, the very successes enjoyed from the latest advances in antiretroviral medications could be reversed. Recent research from Singapore published in HIV Medicine found that undernutrition and low BMIs at the time of starting antiretroviral treatments reduced their effectiveness and significantly decreased survival.

Oh, but they’ll be thin!? What does it say about our culture that a trim figure has become more important than doing what is best for the health, quality of life and welfare of people?

Whether it be HIV, cancer, kidney or heart disease, dementia, or countless other medical conditions, letting kids grow up, or giving birth to a baby; fearing fat can have deadly consequences. We won’t hear that from mainstream media, though. It’s up to us to advocate for ourselves and for each other.

©2007 Sandy Szwarc