Putting out the fire

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Post by Neil McKellar-Steward27 Aug 2010

An Australian expert was heard to say recently that AIDS has been cured and HIV should now be thought of as a disease of inflammation. Neil McKellar-Stewart tends to agree.

More and more these days, health issues apart from HIV are taking centrestage in our lives. On top of the list are lifestyle changes that we are being encouraged to make to reduce our risk of contracting other illnesses.

One of the reasons why PLHIV are more susceptible to these diseases is thought to be because of the inflammation that HIV is constantly causing in our bodies – even when it is being successfully suppressed by HAART.

Inflammation is a natural and usually desirable immune response to infection and cancerous cells. Ongoing, low-level (chronic) inflammation, however, has been strongly associated with cardiovascular disease, liver disease and diabetes.

The research story

The results of a major US study on inflammation in PLHIV have just been released. The study1 looked at nearly 1,000 positive people – 90% of whom were on treatment – and measured two blood ‘markers’ of inflammation: fibrogen and C-reactive protein (CRP). Fibrogen and CRP have been associated with a range of diseases in the general community. Higher levels of these inflammatory markers are associated with an increased risk of death, even when other risk factors (such as smoking, high cholesterol levels, hepatitis C infection, waist circumference and increased weight) are accounted for. Earlier research2,3suggested that PLHIV do tend to have elevated levels of fibrogen and CRP when compared to similar people without HIV but this study showed just how common it is. Approximately one-third of the PLHIV in the study had high levels of the two inflammatory markers and this included people whose CD4 counts were well above 500.

These findings confirm comments l read4 recently in the International Journal of Infectious Diseases: ‘As treating clinicians, we may tell patients that their HIV disease can now effectively be considered to be in remission when their viral loads become undetectable and their CD4 cell counts improve, often to a reasonable or even normal range. We may even say that so long as patients do as they are told, they really should be fine. All they need to do is take all their pills; use condoms, sunscreen, and seat belts; quit smoking; eat five servings of fruits and vegetables per day; and exercise.’

Sound familiar? They then go on to say . . . ‘However, there are adverse outcomes associated with inflammation that initially may improve with effective ART but then may fail to normalise or may recur; in addition, other complications may appear later.’

The authors go on to discuss some of these complications of inflammation. They include changes in the way fats are processed (and stored), an increased risk of some cancers, minor losses in brain function (especially thinking and remembering), damage to blood vessel functioning, low levels of ‘good’ (HDL) cholesterol and an increased risk of heart disease.

They summarise research5 which found that younger PLHIV (aged between 33 and 44) who were on effective treatment had markers of inflammation that were 40% higher than those in the study without HIV.

In older PLHIV (those between 45 and 76 years old), inflammation biomarkers were up to 60% higher, markers of blood clotting were 50% higher and markers of reduced kidney function were 21% higher. Raised levels of such ‘biomarkers’ in the general population are linked to heart disease, diabetes and other diseases.

Not very cheery news, I know. And it all may seem very scary. Fortunately, however, through lots of research into a range of diseases, we know that there is a lot we can do to reduce some of the risk.

Fibre, fibre, fibre!  

Recent findings from a major European trial add to the growing body of evidence supporting the significant health benefits of a diet high in fibre.

This particular trial6 looked at the benefits of psyllium husks and concluded that this simple and natural product not only reduces low-density lipoprotein LDL (‘bad’) cholesterol ,triglycerides and blood pressure, but it also reduces some of the unhealthy products of ‘oxidative stress’.Oxidative stress is a condition which occurs when the production of free radicals in the human body exceeds the body's ability to neutralise and eliminate them.

Oxidative stress canresult from a lack of antioxidants or from an over-abundance of free radicals. A free radical is an atom or group of atoms that has at least one unpaired electron and is therefore unstable and highly reactive.

A review7 of the research conducted in this field of nutrition concludes that a high level of fibre intake does have significant health-protective effects and disease-reversal benefits.

Compared to those who have a minimal fibre intake, people who consume generous amounts of dietary fibre are at lower risk for developing heart disease, stroke, hypertension, diabetes ,obesity, and gastrointestinal diseases (including reflux, irritable bowel syndrome, and some inflammatory bowel diseases such as Crohn’s disease). Increasing the intake of high-fibre foods improves cholesterol levels, lowers blood pressure, improves blood glucose control for people with diabetes aids weight loss, and of course improves regularity.

There is also some emerging research showing that consuming certain soluble fibres, such as ‘inulin’, enhances our immune function.

Inulin is a complex of sugars which is digested in the lower bowel (colon) and stimulates the growth of bacteria in the gut, especially the so-called ‘healthy’ flora such as bifidobacteria. In various amounts, it is found naturally in Jerusalem artichoke, chicory, bananas, leeks, onions, garlic and asparagus. Inulin can also be taken as a food supplement.

Two 2009 reports out of the PREDIMED study (PREvención con DIeta MEDiterránea: a large randomised 5-year clinical trial aimed at assessing the effects of the Mediterranean diet on the prevention of cardiovascular disease in Spain) found that dietary fibre reduces blood vessel damage8 and other risk factors for heart disease. It also lowers bad and raises good (HDL) cholesterol .9

One review10 of seven clinical trials which looked at the influence of dietary fibre found that six of the trials reported significantly lower CRP levels with increased fibre intake.

So, it’s pretty basic: eat lots of fresh fruits and vegetables and consider additional fibre supplementation. One of the easiest (and cost effective) ways of doing this is with unflavoured psyllium husks which can be bought in the health food section of major supermarkets or at health food stores. Psyllium is included in products such as Metamucil, but note that these sorts of products may contain additional ingredients such as sucrose and artificial colours and flavour.

Three heaped teaspoons of psyllium stirred rapidly in a large glass of water and drunk quickly will normally be a sufficient supplement to a diet which includes lightly cooked vegetables, fruits and nuts. Be careful to take with plenty of water as psyllium swells when it co es into contact with liquids and forms a ‘gluggy’ mass which can stick in your throat unless it is diluted well.

Other dietary fibres you might consider are rolled oats or oat bran: there is a sound evidence base11 that they reduce LDL (‘bad’) cholesterol but recent evidence12 suggests that they do not reduce inflammatory markers.

In these spring months, oatmeal porridge may still be part of your breakfast menu. Or you may prefer your oats in low-fat muesli with fresh fruit.

Inulin has received a lot of recent popular attention; it is the major active ingredient in some proprietary products (e.g., Fibersure, which is manufactured from chicory root). The evidence that it plays a role in a number of health issues is growing.1314 Recent clinical trials on a small cohort indicate that supplementation up to 10g/day (2 teaspoons) with inulin derived from chicory root is safe and well tolerated.15 For some people it does cause flatulence and bloating, so if you do use it it might be best to start with a lower amount each day.

Fish oils    

And finally a little word about fish oils. Recent Australian research16 on dietary supplementation with omega-3 oils combined with plant sterols has confirmed their antiinflammatory effects. We all eat plant sterols in fruits, vegetables and oils; they are a group of chemicals which are somewhat like cholesterols in animal-based foods. They are contained in foods like wheat germ, rice bran, flax seeds, peanuts, banana, grapefruit, cucumber, onion, oats, potatoes and soy oil. In a recent Danish study,17 PLHIV who took 3.4g of omega-3 fatty acids (EPA and DHA found in fish oil) had slightly reduced triglycerides and increased anti-inflammatory markers compared to those who didn’t take fish oil.

The take-home story is that fish oil may help reduce some of the elevated blood sugars. To get a therapeutic dose, however, you may need to take 4-5 concentrated fish oil capsules or up to 8-10 normal-strength capsules daily.18 Just be sure to speak with a doctor or nutritionist before taking larger, therapeutic doses of any supplement.

In Australia, all fish oil supplements must be tested for heavy metals and must be below national standards, so mercury contamination should not be a problem. If fish oil helps you to reduce your triglycerides, daily supplementation should not pose any health risk for you; however, it’s probably wise to check with your GP.

Check with your treating doctor, your local AIDS council or PLHIV organisation for information about how you can use diet and functional foods to ensure that you stay well with HIV as an inflammatory disease.

Photos: ISTOCKPHOTO.COM/ BrianBalster & MA-K

  1. Tien PC et al Inflammation and Mortality in HIV-Infected Adults: Analysis of the FRAM Study Cohort. J Acquir Immune Defic Syndr. 2010 Jun 25. (online). Abstract:http://preview.ncbi.nlm.nih.gov/pubmed/20581689 Aidsmeds.com commentary:http://www.aidsmeds.com/articles/hiv_fibrinogen_crp_1667_18658.shtml
  2. Madden E et al. Association of antiretroviral therapy with fibrinogen levels in HIV-infection. AIDS. 2008 Mar 30; 22(6): 707-15. Abstract:http://preview.ncbi.nlm.nih.gov/pubmed/18356600
  3. Reingold J et al Association of HIV infection and HIV/HCV coinfection with C-reactive protein levels: the FRAM study. J Acquir Immune Defic Syndr. 2008 Jun 1; 48(2): 142-8. Abstract: http://preview.ncbi.nlm.nih.gov/pubmed/20446849
  4. Dubé MP, Sattler FR Inflammation and complications of HIV disease. J Infect Dis 2010 Jun 15; 201(12): 1783-5. Abstract: http://preview.ncbi.nlm.nih.gov/pubmed/20446849
  5. Neuhaus J et al. Markers of inflammation, coagulation, and renal function are elevated in adults with HIV infection. J Infect Dis 2010 Jun 15; 201(12): 1788-95. Abstract:http://preview.ncbi.nlm.nih.gov/pubmed/20446848
  6. Solà R et al. Soluble fibre (Plantago ovata husk) reduces plasma low-density lipoprotein (LDL) cholesterol triglycerides, insulin, oxidised LDL and systolic blood pressure in hypercholesterolaemic patients: A randomised trial. Atherosclerosis. 2010 Mar 17. doi:10.1016/j.atherosclerosis.2010.03.010 Abstract:http://preview.ncbi.nlm.nih.gov/pubmed/20413122
  7. Anderson JW et al. Health benefits of dietary fiber. Nutr Rev. 2009 Apr; 67(4): 188-205. Abstract: http://preview.ncbi.nlm.nih.gov/pubmed/19335713
  8. Buil-Cosiales P et al. Dietary fibre intake is inversely associated with carotid intima-media thickness: a cross-sectional assessment in the PREDIMED study. Eur J Clin Nutr. 2009 Oct; 63(10): 1213-9. Abstract: http://preview.ncbi.nlm.nih.gov/pubmed/19550433
  9. Estruch R et al. Effects of dietary fibre intake on risk factors for cardiovascular disease in subjects at high risk. J Epidemiol Community Health. 2009 Jul; 63(7): 582-8. Abstract:http://preview.ncbi.nlm.nih.gov/pubmed/19289389
  10. North CJ et al. The effects of dietary fibre on C-reactive protein, an inflammation marker predicting cardiovascular disease. Eur J Clin Nutr. 2009 Aug; 63(8): 921-33. Abstract:http://www.ncbi.nlm.nih.gov/pubmed/19223918
  11. Andon MB, Anderson JW State of the Art Reviews: The Oatmeal-Cholesterol Connection: 10 Years Later. Ame J Lifestyle Med. 2008; 2(1): 51-57. Full-text:http://www.goodmorningheart.com/pdf/Oatmeal_cholesterol_connection_10_ye...
  12. Theuwissen E et al. Consumption of oat beta-glucan with or without plant stanols did not influence inflammatory markers in hypercholesterolemic subjects. Mol Nutr Food Res. 2009 Mar; 53(3): 370-6. Abstract:http://preview.ncbi.nlm.nih.gov/pubmed/18979504
  13. Lomax AR et al. Prebiotics, immune function, infection and inflammation: a review of the evidence. Br J Nutr. 2009 Mar; 101(5): 633-58. Abstract:http://preview.ncbi.nlm.nih.gov/pubmed/18814803
  14. Inulin and Oligofructose: Health Benefits and Claims-A Critical Review J. Nutr. 2007 Nov; 137(11 Suppl.): 2489S- 2597S. Full-text of 20 articles in this special supplement, available at: http://jn.nutrition.org/content/vol137/issue11/index.dtl
  15. Bonnema AL et al. Gastrointestinal tolerance of chicory inulin products. J Am Diet Assoc. 2010 Jun; 110(6): 865-8. Abstract:http://preview.ncbi.nlm.nih.gov/pubmed/20497775
  16. Micallef MA et al. Anti-inflammatory and cardioprotective effects of n-3 polyunsaturated fatty acids and plant sterols in hyperlipidemic individuals. Atherosclerosis. 2009 Jun; 204(2): 476-82. Abstract: http://preview.ncbi.nlm.nih.gov/pubmed/18977480
  17. Thusgaard M et al. Effect of fish oil (n-3 polyunsaturated fatty acids) on plasma lipids, lipoproteins and inflammatory markers in HIV-infected patients treated with antiretroviral therapy: a randomized, double-blindplacebo-controlled study. Scand J Infect Dis. 2009; 41(10): 760-6. Abstract: http://preview.ncbi.nlm.nih.gov/pubmed/19685375
  18. www.integrative-medicine.com.au Which Fish Oil Should You Use? [Website content] 2010 February http://www.integrative-medicine.com.au/node/85[Downloaded 25/6/10]