Weight changes on ART and how to lose weight successfully
Simon Collins, HIV i-Base
Several presentations at the BHIVA/BASHH conference looked at the controversial issue of weight gain.
The opening lecture from Dr Anton Pozniak from the Chelsea and Westminster Hospital provided a comprehensive review of the current evidence about weight gain. 
The talk was based on weight gain being more complicated than just when HIV drugs cause weight gain.
- Average weight increases with age – and studies need to account for this over the 1-2 years for the research.
- Weight gain needs to account for weight gain in the general population (an epidemic of obesity).
- HIV positive people generally put on weight when they first start ART.
- Some HIV drugs can cause weight gain – but this is usually modest – maybe 1-2 kg over the first 1-2 years.
- Some HIV drugs are linked to limiting weight gain – again, just by a modest amount.
- Individual differences might be related to weight before treatment: ie weight gain might be higher in people who are already heavier when then start ART.
- People in research studies – where we get information about new drugs from – are different to wider HIV population. In general, the majority of people research studies are men but 50% of HIV positive people are women. Most studies are also largely white ethnicity.
This was a good talk including a comprehesive review of different studies but the main evidence of integrase inhibitors and TAF causing weight gain comes from the large randomised ADVANCE study in South Africa. This was a study in a Black African population and more than 50% of participants were women.
If both sex (women) and ethnicity (being black) are linked to higher rates of weight increase reported in ADVANCE, this is likely to explain why it is not reported in evidence reviews of largely white male studies.
HIV treatment needs to be managed individually, so care should focus on individual increases and how to manage these. Although changing drugs has not been successful in studies, maybe these studies were not conducted in the right people?
Diet, exercise and how to lose weight successfully
The second of the opening talks for the conference talk was from Maria Halley, a specialist dietician at Imperial College, London. 
This focus on the options for management of weight gain, and a summary of this approach is important enough to outline in bullet points.
The background to unhealthy weight is complex. In additional to global obesity many social issues are involved in an individual relationship with food: loneliness, psychological issues, anxiety and depression. We live a more sedentary life, taking less exercise and relying on cars. Alcohol use is common and can increase weight and the quality of food and nutrients is low in fast food and high fat and high sugar diets.
Approaches to diet
- Set realistic targets – slow and steady – simple small goals are better. Maybe don’t even include weight loss targets. For example make the main emphasis on moving to a healthier lifestyle.
- Waist circumference is better health predictor than weight or BMI.
- Fad diets DONT WORK – low carb/high carb, crash diets etc -are also difficult to sustain.
- Don’t binge diet – skipping meals – starve then binge – generates guilt, poor self esteem.
- Sometimes it is easy to not realise how much we snack. Starvation diets shift the body’s metabolism to store fat – having the opposite effect.
- Generating a fear of fat is especially unhelpful as fats are an essential part of a healthy diet.
- Developing a structured eating pattern – three meals no snacks.
- Aim for a balanced diet for nutrients – Mediterranean-based, nuts, pulses, limited red meat.
- No foods are off-limits or banned, just in moderation. It is really important to still enjoy food.
- Drink more water: 1.5-2 litres a day.
- Switch off the TV more, especially when eating.
- Keep a food and mood diary (to understand your relationship with food).
- Look at other coping mechanisms rather eating – for example, walking and other exercise.
In summary, successful outcomes from dieting should not aim for perfection or extremes but steady change using realistic goals. It is important to get help and support from a dietician who can individualise your approach. Peer support helps – it is difficult to do this alone. And it is difficult to do anyway. Change is rarely easy but it is never too late to start.
Finally, a related poster from the Royal Free reported on outcomes for a pilot project integrating a dietician within HIV services, with twice-weekly diet clinics. This led to 84 referrals (from over 3300 HIV positive people) with roughly half of initial meetings being face-to-face and half virtual. Unfortunately one-third in each group missed this appointment and did not attend. 
Median age of attendees was 54, 60% male, one-third Black African. Most were diagnosed before 2010 (85%), were undetectable (95%) and had CD4 >400 cells/mm3(82%). Most referrals were for help to reduce weight but this also includes diabetes management and IBS. About one-third in each group rescheduled a second appointment. Longer follow-up is not available, and is complicated by short-term funding.
Unless stated otherwise, all references are to the programme and abstracts to the 5th Joint BHIVA BASHH Spring Virtual Conference, 19–21 April, 2021.
- Pozniak A. ART & weight gain; myth or reality?’
- Halley M. Weight considerations for people with HIV – practical tips.
- Yan H et al. P091 Managing metabolic issues: evaluation of a short term comparative implementation project introducing a dietician to an HIV service. Poster abstract P091.