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Battle of the bulge

Positive Living article • Megan Nicholson • 1 October 2003

Can low-carbohydrate diets help reduce the belly fat accumulation associated with HIV lipodystrophy?

While experts continue to argue about the definition and causes of lipodystrophy, a fat belly remains a major concern for many people with HIV on treatment.

According to new US guidelines, dietary and lifestyle change should be the first step in managing high lipids (blood fatsA type of fat in the blood. Elevated triglyceride levels may be a side effect of some anti-HIV drugs.) in people on antiretroviralA medication or other substance which is active against retroviruses such as HIV. therapy (Dube 2003). Generally these guidelines recommend reducing fat intake, replacing saturated fats with monounsaturated and omega-3 polyunsaturated fats, and doing more exercise.

But will this strategy help you lose your ‘lipo belly’? The traditional low-fat strategy for weight loss has fallen out of favour recently, as mounting evidence shows a low-fat diet produces smaller reductions in weight than other dietary strategies. While high-fat diets have been linked to insulin resistanceA diabetes-like condition in which, while adequate amounts of insulin are produced by the pancreas, the body does not respond normally to the action of insulin. In the wider community, insulin is related to obesity, while in HIV it may be related to lipodystrophy. people with HIV lipodystrophy, and a diet rich in fibre may improve insulin function (Hadigan 2001; Moyle 2001; Barrios 2002), low-fat diets have failed to have any significant impact on lipodystrophy in clinical trials.

This article will explore alternatives to the traditional low-fat diet. Unfortunately, even though it’s been more than six years since HIV lipodystrophy was first described, there are still no reliable studies comparing different dietary strategies in people with HIV. Consequently, this article relies on studies in HIV-negative populations and on community-derived, anecdotal reports. At this stage, there is no clear scientific evidence that any particular dietary strategy will be effective in responding to this condition.

Another important point to bear in mind is that attempts to reduce the ‘lipo belly’ may worsen fat loss in the face and limbs for people who have lipodystrophy. Weight training to build muscles may help to offset this problem.

Low carb — the Atkins diet

One of the approaches that some positive people report having success with is the ‘Atkins diet’, an extremely low carbohydrate diet popularised by Dr Robert Atkins, an American medical practitioner.

The Atkins diet has four phases: a strict two-week ‘induction’ period where carbohydrate (carb) intake is limited to 20 grams each day; an ongoing weight loss phase where you can eat up to 100g of carbsAny of a number of compounds, including sugars and starches, which are important as sources of energy. Along with fat and protein, one of the main constituents of food. daily, and the pre-maintenance and maintenance phases where carb intake remains restricted but you maintain a stable weight. Carbohydrates don’t simply mean bread, rice and potatoes; all food made up of sugar or starch, including fruits and vegetables, contain carbs.

To put the numbers into context, one cup of plain pasta has about 35 grams of carbohydrate.

Two studies published in the reputable New England Journal of Medicine this year found that the low-carb strategy leads to weight loss and improved metabolic parameters.

In the first study, 132 obese people with a high prevalence of diabetes or pre-diabetes were randomisedA method based on chance by which study participants are assigned to a treatment group. Randomization minimizes the differences among groups by equally distributing people with particular characteristics among all the trial arms. The researchers do not know which treatment is better. From what is known at the time, any one of the treatments chosen could be of benefit to the participant to either a low-fat, calorie-restricted diet or a low-carb diet. Average weight loss was 5.8kg in the low-carb group and 1.9kg in the low-fat group — a statistically significant difference. Measures of metabolic function also improved significantly in the low-carb group — triglycerides (a type of blood fatA fat.) fell, irrespective of medication, and insulin sensitivity improved (Samaha 2003).

The second study in 63 non-diabetic, non-obese people compared a low-carb, high-protein, high-fat diet with the traditional low-calorie, high-carb, low-fat diet. Weight loss favoured the low-carb group at six months but subsequent weight gain eroded the benefit in the low-carb group. Triglycerides improved in the low-carb group, as did HDL or ‘good’ cholesterolAn essential component of cell membranes and nerve fibre insulation, cholesterol is important for the metabolism and transport of fatty acids and the production of hormones and Vitamin D. Cholesterol is manufactured by the liver, and is also present in certain foods. High blood cholesterol levels have been linked to heart disease and may be a side effect of some anti-HIV medications. and insulin sensitivity (Foster 2003).

Low carb and lipodystrophy

Positive Living spoke to two HIV-positive people who reported resolution of their lipo bellies on the Atkins diet.

‘Marco’ told PL that he developed severe lipodystrophy with abdominal fat accumulation and fat loss as a result of long-term antiretroviral therapy. As well as going on the Atkins diet, Marco attended gym regularly and commenced a cholesterol-controlling medication. The first fortnight of the diet was, he said, “a complete nightmare.” Marco wasn’t hungry but finding or preparing no-carb meals was difficult. However, the benefits of the diet were apparent to Marco almost immediately. “I saw enormous changes in those two weeks and my belly went down to almost flat,” he said. He also felt less bloated and more comfortable although his energy levels fluctuated during the induction phase.

In the long-term, Marco’s diet has altered significantly — he rarely eats white bread or pasta, and his consumption of fibre has increased.

David has been on the Atkins diet for 14 weeks, losing 12 kg. He described the induction period as vile, and relied on low-carb vegies and chicken soup to get him through. David continues to avoid bread, rice, cereals and pasta and spends up to three hours a day at the gym. Like Marco, David reported a dramatic reduction of abdominal fat during the induction phase of Atkins.

The risks of Atkins in people with HIV

Despite these encouraging case studies, the Atkins diet may have serious health consequences for HIV-positive people in the short and long term.

Two specialist HIV dietitians, Pip Greenop from the Royal Prince Alfred Hospital and Simon Sadler from the Albion Street Clinic in Sydney, warn that Atkins is an unbalanced diet which is not sustainable or safe in the long term.

For people with HIV, Greenop and Sadler argue that the Atkins diet raises many specific concerns:

  • The body needs glucose. When glucose consumption is dramatically restricted, the body accesses its glycogen stores — glucose stored in the muscles and the liverA large organ, located in the upper right abdomen, which assists in digestion by metabolising carbohydrates, fats and proteins, stores vitamins and minerals, produces amino acids, bile and cholesterol, and removes toxins from the blood.. If glycogen stores are not replenished through dietary glucose, fatigue may occur and contribute to muscle wasting. Maintaining muscle is known to preserve immune function and slow disease progression in people with HIV.
  • Low consumption of fibre may have negative effects. In people with HIV, treatment soluble fibre is often recommended to help control cholesterol, relieve treatment-associated diarrhoea, and maximise gut health.
  • Low consumption of carbs may alter calcium metabolism, causing kidney stones or reducing bone mineral density.
  • A high-protein diet may be difficult for people with kidney damage to tolerate.
  • A low-carb diet may be high in saturated fats, and thus contribute to elevated cholesterol and the long-term risk of arterya blood vessel which carries oxygenated blood away from the heart. disease.
  • A low-carb diet may remove many B group vitamins and antioxidant nutrients from the diet. Low vitamin and mineral consumption may compound deficiencies in HIV-positive people.

Greenop and Sadler also question the nature of the weight loss in people on Atkins. They argue that much of the initial effect comes from fluid loss, as the body raids its stores of glycogen. This concern is supported by a study conducted at the University of Sydney. Dietitian and researcher Jennie Brand Miller told PL that a randomised study comparing four diets has shown that people on a low glycemic index (GI) diet lose more fat than people on a high protein diet, even though overall weight loss is comparable.


Aside from the health risks, is the misery of Atkins necessary? Who really wants to give up potatoes, pasta and bread, even for two weeks?

Two other diets which aim at reducing blood glucose and insulin levels and promoting weight loss are the low GI diet and the Zone diet.

Low GI diet

The glycemic index (GI) is a way of comparing foods in terms of how quickly blood sugar rises after consuming carbohydrate-containing foods. Some foods such as potatoes, white rice and white bread are processed quickly, producing a rapid and dramatic peak in blood sugar levels. These foods are called high GI foods. Other foods are turned into blood sugars more slowly, and produce a less dramatic and more enduring rise in blood sugar. These are low GI foods. Examples include pasta, lentils, apples and porridge.

A detailed list of GIs for over 750 types of food can be found free on the internet (Foster-Powell 2002). Alternatively, The GI Factor by Jennie Brand Miller contains a list of GIs.

A low GI diet involves eating fewer refined foods, less potato and rice, and more fibre and unsaturated fats. Simple changes such as replacing white bread with wholemeal bread will help reduce blood sugar levels after eating.

GI influences hunger and weight loss. The rapid peak in blood sugar associated with high GI foods is followed by a drop in blood sugar, producing hunger. In contrast, low GI foods delay the return of hunger. By controlling hunger, low GI foods can contribute to weight loss.

Key elements of the low GI strategy have been incorporated into the management and prevention of diabetes and pre-diabetes. By eating a low GI diet, you limit blood sugar levels, improve control of blood sugars and reduce insulin levels.

Low GI and lipodystrophy

A case study published last year reported successful treatment of lipodystrophy and metabolic improvements using a high-fibre, low GI diet plus regular aerobic exercise and weight training. The man’s diet was made up of 15 percent protein, 30 percent fat and 55 percent carbs including at least 25 grams of dietary fibre daily.

After four months, the man had lost a lot of abdominal fat and his weight had fallen by a total of 8 kg. His LDL or ‘bad’ cholesterol had fallen by 30 percent, fasting insulin by 3.5 percent and insulin resistance by 15 percent.

Zone diet

Another alternative is the ‘Zone diet’ — 40 percent carb, 30 percent protein and 30 percent fat with an emphasis on unsaturated fats. Like Atkins and low GI, the Zone diet attempts to produce weight loss by controlling sugar and insulin levels in the blood.

‘Alastair’ adopted the Zone diet plus exercise and steroidA substance which is structurally similar to human sex hormones which is used for therapeutic purposes due to its anti-inflammatory effects. treatment in an attempt to tackle his fat belly and high triglycerides. He told PL: “Dietitians at the time were amused and amazed to see it worked but continued to recommend the high-carb, low-fat diet.”


The trend away from low-fat diets for weight loss and diabetes control may have implications for people with HIV-related lipodystrophy. However, at present the evidence that controlling blood sugar and insulin, either with a low-carb or low GI strategy, can improve lipodystrophy in HIV-positive people is anecdotal.

Many factors can influence an appropriate diet for people with HIV — stage of disease, metabolic measures, lipodystrophy or fat wasting, individual food preferences, and disposable income. As a result, consultation with a specialist HIV dietitian is recommended before embarking on a new dietary strategy.

Health checklist for people with insulin resistance

  • Eat more fibre (e.g. wholegrains, beans, pulses, most fruits and vegetables).
  • Eat fewer refined carbohydrates (e.g. white bread, cakes, pizza)
  • Reduce and replace consumption of saturated fats (e.g. fat on meat, chicken skin, butter, cream, cheese, coconut, coconut milk) and trans fats (e.g. processed cakes and biscuits, snack foods, takeaway food) with monounsaturated fats (e.g. olive oil, avocado, almonds, macadamia nuts) and polyunsaturated fats (nuts and seeds, sunflower oil, safflower oil, soybean oil, and foods rich in omega-3).
  • Eat more omega-3 fatty acids (sardines, mackerel, salmon, tuna, canola oil, linseed oil)
  • Do regular exercise — both exercise which makes you puff and exercise which strengthens your muscles — to promote insulin sensitivity and loss of body fat.
  • Quit smoking.

Megan Nicholson is a Sydney-based journalist and a contributing site editor to


1 Abbasi F et al. High carbohydrate diets, triglycerides-rich lipoproteins, and coronaryA life-threatening emergency in which the blood supply to the heart is suddenly cut off, causing the heart muscle (myocardium) to die from lack of oxygen. heart disease risk. American Journal of Cardiology 85:45-48, 2000.

2 Barrios A et al. Effect of dietary intervention on highly active antiretroviral therapy-related dyslipemia. AIDS 16(15):2079-2081, 2002.

3 Chandalia M et al. Beneficial effects of high dietary fibre intake in patients with type 2 diabetes mellitus[Diabetes mellitus] A disorder in which sugars in the diet cannot be metabolised into energy due to a lack of the enzyme insulin. Late-onset diabetes mellitus may be a long-term side effect of some anti-HIV drugs.. New England Journal of Medicine 342:1392-1328, 2000.

4 Dube MP et al. Guidelines for the evaluation and management of dyslipidemia in human immunodeficiency virusA small infective organism which is incapable of reproducing outside a host cell. (HIV)-infected adults receiving antiretroviral therapy: recommendations of the HIV Medical Association of the Infectious Diseaes Society of American and the Adult AIDS ClinicalPertaining to or founded on observation and treatment of participants, as distinguished from theoretical or basic science. Trial Group. Clinical Infectious Diseases 37:613-627, 2003.

5 Foster GD et al. A randomized trial of a low-carbohydrate diet for obesity. New England Journal of Medicine 348(21): 2082-2090, 2003.

6 Foster-Powell K et al. International table of glycemic index and glycemic load values: 2002. American Journal of Nutrition 76:5-56, 2002.

7 Hadigan C et al. Modified dietary habits and their relation to metabolic abnormalities in men and women with HIV infection and fat redistribution. Clinical Infectious Diseases 33:710-717, 2001.

8 Moyle G et al. Dietary advice with or without pravastatin for the management of hypercholesterolaemia associated with protease inhibitor therapy. AIDS 15(12):1503-1508, 2001.

9 Samaha FF et al. A low-carbohydrate as compared with a low-fat diet in severe obesity. New England Journal of Medicine 348(21):2074-2081, 2003.

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From Positive Living

This article was first published in the October 2003 issue of Positive Living — more than ten years ago.

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