Aerobic capacity and health-related quality of life in adults HIV-infected patients with and without lipodystrophy

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The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Original

article

Aerobic

capacity

and

health-related

quality

of

life

in

adults

HIV-infected

patients

with

and

without

lipodystrophy

Mansueto

Gomes

Neto

,

Cristiano

Sena

Conceic¸ão

,

Cecília

Ogalha

,

Carlos

Brites

a_{DepartamentodeBiofunc¸ão,CursodeFisioterapia,UniversidadeFederaldaBahia(UFBA),Salvador,BA,Brazil} b_{ProgramadePós-graduac¸ãoemMedicinaeSaúdedaUniversidadeFederaldaBahia(UFBA),Salvador,BA,Brazil}

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Articlehistory:

Received15June2015 Accepted2November2015 Availableonline18December2015

Keywords: Antiretroviraltherapy HIVinfection Qualityoflife Disability

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Introduction:HIVinfectionanditstherapywhichcanaffecttheiraerobiccapacityand health-relatedqualityoflifeofpatients.

Objective:We conducted a cross-sectional study to determine if aerobic capacity and healthrelatedqualityoflifewasdecreasedinHIV-infectedpatientsreceivinghighlyactive antiretroviraltherapyandcomparingpatientswithandwithoutlipodystrophy.

Researchdesignandmethods: HIV-infectedpatientsolderthan18years,andincurrentuse ofhighlyactiveantiretroviraltherapydrugs,wereevaluatedforbloodcount,fastingtotal cholesterol,highdensitylipoprotein,triglycerides,glucose,HIVviralloadandCD4/CD8 counts,bodycomposition,peakoxygenconsumption(peakVO2)andmetabolic

equiva-lent.HealthrelatedqualityoflifewasassessedbyusingShortForm-36(SF-36).Statistical analysiswascarriedoutusingSPSSversion20.0.

Results:Atotalof63patientswithmeanageof43.1±6.4yearswereevaluated,ofthese34 (54%)hadlipodystrophy.TheaveragepeakVO2(31.4±7.6mLkg−1min−1)wassignificantly

lower(p<0.01)thanexpectedvalues(37.9±5.6mLkg−1_min−1_{)accordingtothe}

character-isticsofthepatients.Thelipodystrophygrouppresentedwithasignificantdifferencein musclemass,bodyfat,peak VO2 and metabolicequivalent and infunctionalcapacity

domainsofSF-36.

Conclusion:Aerobiccapacityvalues werereduced inHIV-infected patientsunderhighly activeantiretroviraltherapywhencomparedtopredictedvalues.Lipodystrophywas asso-ciatedwithreducedaerobiccapacityandhigherfrequencyofmetabolicsyndrome.Lifestyle modificationshouldbeapriorityinthemanagementofchronicHIVdisease.

©2015ElsevierEditoraLtda.Allrightsreserved.

∗ _{Correspondingauthorat:DepartamentodeBiofuncão,CursodeFisioterapia–UniversidadeFederaldaBahia–UFBA,InstitutodeCiências}

daSaúde,Av.ReitorMiguelCalmon,s/n–ValedoCanela,CEP40.110-100,Salvador,BA,Brazil. E-mailaddress:mansueto.neto@ufba.br(M.GomesNeto).

http://dx.doi.org/10.1016/j.bjid.2015.11.001

Introduction

HIV-infectedindividualsarelivinglongerintheeraofhighly activeantiretroviraltherapy(HAART).However,recentreports suggest increased rates of cardiovascular risk,1,2 _{body fat} changes(lipodystrophy),3_{andlong-termadverseeffectssuch} aschangesin physicalfunctioning,disabilities and health-relatedqualityoflife(HRQOL)are commonfindingsinthis population.4

Functional impairment is common among HIV-infected persons. HIV-related disability has been associated with decreaseinexercisecapacityandpatient’sdailyactivities.5,6 Reduced aerobic capacity or cardiovascular fitness may contributetofurtherphysicalimpairmentand activity lim-itations, placing HIV-infected patients at risk for poor healthoutcomes.7–9_{Somestudieshaveshownanassociation} between cardiovascular fitness and cardiovascular mortal-ity,aswellasall-causemortalityinmenandwomenofall ages.10,11

Dependenceon assistancewith activitiesof dailyliving and/orreduced recreational activities participation may be associatedwithalowerHRQOLandhigherriskofmortality.12 However,conflictingresultshavebeenreportedinregardto aerobiccapacity.Someauthorshavereportedreducedaerobic capacityinHIVpatientsinHAARTuse,5,6,12,13_{whereasothers} havedetectednoadverselong-termeffect.14,15

Themeasureofpeakoxygenconsumption(peakVO2)has

beenutilizedtoassessaerobiccapacityaswellasforthe pre-scriptionofexerciseprogramsinthispopulation.16_HRQOLis oneofthemostutilizedsubjectiveaspectsinevaluatingthe impactofchronicdiseasesandbothitsdefinitionand assess-mentarecontentious.17,18_{Thecombinationofnegativeeffects} onphysicalandmentalfunctioninHIV-infectedpatientswith lipodystrophymayhaveafurtheradverseimpactonHRQOL, butitsimpactonaerobiccapacityandqualityoflifehasnot beenproperlystudied.Theobjectiveofthisstudywasto deter-mineifaerobiccapacityandqualityoflifewasdiminishedin HIV-infectedpatientsreceiving HAARTandiflipodystrophy wasrelatedtotheseoutcomes.

Methods

Patients and settings.The study was conductedatthe AIDS ClinicsofFederalUniversityofBahiaHospital(HUPES),a pub-licHIVreferral service inSalvador, Brazil.Theprojectwas approvedbytheInstitutionalEthicsResearchCommittee.

Study design: We conducted an observational cross-sectionalstudy.Patientswereconsecutivelyinvitedtoenter the protocol following the signature of an informed con-sent.Theinclusioncriteriawere:currentuseofARVdrugs, ageequalorhigherthan18years,andavailabilitytoattend the study activities. Exclusion criteria included pregnancy, activeopportunisticinfectionsandhistoryofregular exercis-ingbeforeenteringthestudy.

Measures

Laboratorymeasurementsconsistedoftotalcholesterol,HDL, triglycerides, glucose, HIV viral load and CD4/CD8 counts.

MetabolicsyndromewasdefinedfollowingNational Choles-terolEducationProgramAdultTreatmentPanelIIIdefinition.19 Basedonthatdefinition,threeormoreofthefollowing crite-rianeedtobemetfordefiningmetabolicsyndrome:(1)fasting serumtriglycerides≥150mg/dL;(2)abnormalwaist circumfer-ence:waistperimeter≥102cminman,or≥88cminwomen; (3)fastingbloodglucose≥100mg/dL;(4)hypertension:systolic blood pressure ≥130mmHg and/ordiastolicblood pressure ≥85mmHg, and/or use of an antihypertensive drug; (5) low HDL-cholesterol: ≤40mg/dL for men, or ≤50mg/dL for women.

Wemeasuredweight,height,bodymassindex(BMI)and skinfold.Bodyweightwasmeasuredusingabalanceaccurate to 100g.Height was measured byastadiometer with sub-jects barefoot. BMIwascalculated bydividingbody weight (kg) byheight squared(m2_{).We usedthe digital caliperto}

evaluate the percentage oflean body mass, fat mass, and musclemass.ThecalculationwasbasedonFaulkner’s skin-foldprotocol.20_{Inaddition,wemeasuredthecircumference} of chest, waist, waist-hip ratio, abdomen, hips, forearms, arms, thighs and calves (0 and 6 months). The measure-ment was performed with the patient standing upright, usingaflexibletapemeasureandextendabletoonedecimal place.21,22

Lipodystrophywasdefinedclinicallybyphysical examina-tion and bypatientreport offatwasting intheface, arms orlegswithorwithoutcentralobesity.Patientswereinitially askedageneralquestionaboutanychangesinbody appear-ance, followed by questions with specific reference to the regionsmentionedabove,timeofonsetofchangesineach region,andwhetherthechangeshadresolved.Patientswith weightchangebutwithoutperipheralfatlosswerenotdefined ashavinglipodystrophy.23

Theexercisetestingwasperformedtoevaluatethe clin-ical response, the hemodynamic, electrocardiographic and metabolicstress,andtocustomizedexerciseprescriptionand subsequentevaluationoftherapeuticintervention,underthe supervisionofacardiologist.Weusedtheergometertreadmill. Wechoserampprotocolforthestudy.Subjectswereexercised onamotor-driventreadmillwithaninitialspeedof3kmh−1

anda2%incline.Weusedcontinuousincrementsinspeedand incline, followingaramp protocoladjustedtothe subjects’ predicted functional capacity, to reach volitional fatiguein approximately8–12min.Bloodpressurewasmeasuredevery 3minusingastandardarmsphygmomanometer,while 12-leadECGwascontinuouslymonitored.24,16_{Thevaluesofthe} testperformedwerecomparedwiththepredictedvaluesin accordancewithJonesequationforthetreadmilltest(VO2

pre-dictedformalesubjects=[60.0−(0.55×age)]×1.11;andVO2

predictedforfemalesubjects=[48.0−(0.37age)]×1.11).16 Assessmentofqualityoflifewasperformedbyapplyingthe SF-36 (MedicalOutcomesStudy36-Item Short-Form Health Survey).TheSF-36questionnairecontains36questionsthat aregroupedinto eightdomains:functionalcapacity, limita-tionsrelatedtoemotions,andperceptionsofmentalhealth, whosescoresrangefrom0to100,wherezerocorrespondsto the worstgeneralstateofhealthand 100tothe beststate, meaningthatthehigherthetotalscore,thebetterthe percep-tionofqualityoflife.Thistoolwasalreadyvalidatedforuse inBrazilianpatients.25

Table1–Demographicandclinicscharacteristicsofthe HIVinfectedpatientsincludedinstudy.

Studygroup(n=63) Age(yr) 43.1±6.4 Gender(male:female) 34:29 Ethnicity(white:nonwhite) 27:36 Lyposdistrophy(yes:no) 34:29 Metabolicsyndrome 24:39 Bodyweight(kg) 63.3±11.2 Musclemass 55.2±10.5

Bodymassindex(kgm−2_{) 23.1}±3.45

Hip 95.6±7.1 Waist-to-hipratio 0.8±0.1 Bodyfat(%) 21.3±8.6 CD4+(cellmm−3_{) 539.7±291.8} Triglycerides(mgdL−1_{) 185.6±102.1} Totalcholesterol(mgdL−1_{) 207.3±64.1} HDLcholesterol(mgdL−1_{) 48.9±19.8} Glucose(mgdL−1_{) 90.2±15.3} Hemoglobin(gdL−1_{) 13.4±1.3} PeakVO2(mLkg−1min−1) 31.4±7.6 MET 8.7±2.1 Statisticalanalysis

Dataofcontinuousvariableswereanalyzedbyusingmeasures ofcentraltendencyanddispersion,andexpressedasmean andstandarddeviation.Categoricalordichotomousvariables wereanalyzedbyusingmeasuresoffrequency.Weperformed statisticaltestsShapiro–Wilktoevaluatenormalityforall vari-ables. Student’st test or Mann–Whitney test were used to comparethemeandifferencesofvariablesbetweenthe lipos-dystrophyoccurrences.Chi-squaretestwasusedtocompare proportions.Allpvalueswere2-tailed,andstatistical signif-icancewasset at.05.Allcalculationswere performedwith StatisticalPackageforSocialSciences–SPSSversion20.0.

Results

Atotalof70patientswereinvited,howeversevenpatientsdid notattendtheevaluations.Sixty-threeevaluatedpatientshad meanageof43.1±6.4years.Table1showsthedemographic andclinicscharacteristicsofpatientsinthestudy.

Treadmilltesting resultsshowed amean peak VO2±SD

of 31.4±7.6mLkg−1_min−1_{. The average peak VO} 2

was significantly lower (p<0.01) than expected values (37.9±5.6mLkg−1_min−1_{)accordingtotheJonesequation.}16

PatientswerestratifiedbyelapsedtimesinceHIV diagno-sis(±5 years). Nodifferences were found fordemographic characteristics and age (p>0.05). The time sinceHIV diag-nosiswasalsoafactorthatinfluencedtheaerobiccapacity ofthepatients.Patientswithmorethan 5yearssince diag-nosisofHIV infection showed lower aerobiccapacity than patients with less than 5 years of HIV (30.3±7.5 versus 34.7±7.02mLkg−1_min−1_,p=0.04).

54%ofthepatientshadlipodystrophy.Demographic vari-ables were comparable between groups with and without lipodystrophy.

Lipodystrophygroup presentedwithasignificant differ-enceinmusclemass,bodyfat,peakVO2andMETcompared

Table2–Demographicandclinicscharacteristicsof patientswithlipodystrophycomparedwithno lipodystrophy. Lipodystrophy group n=34 Nolipodystrophy group n=29 Age 44.9±8.9 40.8±9.6 Gender(male:female) 18:15 16:14

Bodymassindex(kgm−2_{) 23.0}±4.5 23.1±2.0

Musclemass 49.2±10.2 55.6±11.8* Bodyfat(%) 27.6±11.8 19.9±7.3* Waist 81.4±11.7 80.9±6.9 Hip 95.82±9.17 95.53±4.74 CD4+(cellmm−3_{) 490.4±25.,6 597.6±320.3} Triglycerides(mgdL−1_{) 197.3±88.1 172.4±118.2} Totalcholesterol(mgdL−1_{) 217.8±79.9 194.6±35.2} HDLcholesterol(mgdL−1_{) 52.4±22.8 44.2±14.6} Glucose(mgdL−1_{) 90.2±18.4 90.3±10.5} Metabolicsyndrome (yes:no) 19:15 8:21* PeakVO2(mLkg−1min−1) 31.4±6.1 30.4±7.6* MET 9.3±1.8 8.7±2.2* ∗ _p<0.05.

withpatientswithoutfatchanges.Thisindicatesthatpatients withlipodystrophyhavelessmusclemassandaerobic capac-ity in addition to ahigher percentage ofbody fat. Table2

displaysdemographiccharacteristicsofpatientsaccordingto theoccurrenceoflipodystrophy.

Inlipodystrophygroup,56%ofpatientshadaprevious diag-nosis ofmetabolicsyndrome (56%)versus only27% in the groupwithoutlipodystrophy(p<0.05).

Table3showstheresultsofHRQOLofpatientsaccording tothepresenceoflipodystrophy.ThedomainsofSF-36that hadlowervalueswerepain,vitality,generalhealthand men-talhealth.ConsideringtheHRQOLamongpatientswithand without lipodystrophyonlythe domainfunctional capacity presented reductionin the group withlipodystrophy com-paredwithnolipodystrophy.

Discussion

Our results demonstratethat aerobiccapacity values were reduced inHIV-infectedpatientsunder HAART when com-paredto predictedvalues. Theprevalenceoflipodystrophy inthisstudywas54%.Patientswithlipodystrophyexhibited asignificantreductioninmusclemassandaerobiccapacity comparedtothosewithoutsuchfatchanges.

InasystematicreviewofBrazilianstudieson lipodystro-phy,theweightedaverageoftheprevalenceoflipodystrophy inpeoplelivingwithHIVwas53.5%26 _{andphysicalactivity} wasconsideredanindependentprotectivefactoragainstthe onsetofHIV-associatedlipodystrophy.

Severalpossiblemechanismsfordeclineinaerobic capac-ity and activity limitation in people with HIV have been reported.Comorbiditiesthatmaybeassociatedwiththeuse ofHAARTsuchascongestiveheartfailure,coronaryartery dis-ease,peripheralvasculardisease,andstrokemayleadtoaloss ofphysicalfunction.27_{Asaresultofassociatedcomorbidities} andrelatedphenomena(suchaslossofleanmusclemassand

Table3–QualityoflifeofHIV-infectedpatientsincludedinstudyandwithlipodystrophycomparedwithno lipodystrophy.

DomainsSF-36 HIV-infectedpatients Lipodystrophygroup Nolipodystrophygroup

Functionalcapacity 71.1±25.4 61.76±24.02* _77.76±24.03 Physicallimitation 81.4±20.8 80.15±33.58 82.76±27.63 Pain 42.3±9.5 43.18±8.58 41.24±10.56 Generalhealth 61.0±20.6 62.35±18.97 59.41±22.64 Vitality 58.0±15.6 58.97±14.86 56.90±16.71 Socialaspects 80.6±21.2 81.31±19.82 79.36±22.72 Emotionallimitation 78.2±33.8 78.04±34.10 78.30±34.07 Mentalhealth 60.2±12.9 62.47±11.22 57.52±14.47

∗ _{p<0.01versusnolipodystrophygroup.}

pain),individualsoftenreducetheirphysicalactivities,which mayfurtherdecreasetolerancetoexerciseandqualityoflife.28 Structuralandinflammatorymuscleabnormalitieswhich mayimpairthemuscle’sabilitytoextractorutilizeoxygen duringexercisealsocanalsobeassociatedwiththephysical limitation.Rasoetal.15_{observedthatpoormusclestrengthis} observedinsomeHIV/AIDSpatients,whichisassociatedwith loweranaerobicpowerandpeakoxygenuptake(peakVO2).

However,thepeakVO2ofphysicallyactiveHIVpatientsdoes

notdifferfromthatobservedincontrolsofsimilarageand withsimilarphysicalactivitypatterns.15

Røge etal.29 _{haveidentified that thesignificantly lower} working capacity and the trend toward reduced peak VO2

inHIV-infectedpatientswithlipodystrophycouldbecaused by mitochondrial dysfunction, but may also be caused by impairedphysicalfitnesscausedbyunderlyingchronic dis-ease.

InstudyperformedforZontaetal.,30_amongthe120 HIV-infectedpatients,85%reportedimpairedphysicalactivity,70% ofthepatientscomplainedaboutvariousdegreesofweakness, 50%statedthattheyperformedalloftheirregularactivities, althoughataslowerpace,withpausesforresting;42% admit-tedthattheyhadproblemsinmakinglargereffortsand8%felt likelyinginbed.Functionalstatusandthedisability evalua-tionswereassociatedwithalterationsinmuscularstrength.

Physiologicaldeconditioningalsomayplayaroleinactivity intoleranceinHIV-infectedpatients,butthisfactalonecould nothavefullyaccountedfortheseverityofthelimitationor thefatigue-mediatedfunctional limitationsassociatedwith HIVinfection.31 _{Cade etal.}32 _{report thatthe musculature’s} abilitytoextractandutilizeoxygenaccountsforpeakaerobic exercisedysfunctioninindividualswithasymptomaticHIV infectionandthatHAART,ratherthandeconditioningalone, appearstolimitpeakaerobiccapacity.

Theassessmentofthequalityoflifeisanessential out-comeinrehabilitationprocess,anditisofutmostimportance tounderstandhowHIV-infectedpatientslive.Itisknownthat HRQOLisrelatedtomentalandphysicalstatus.33_Erlandson etal.34_{evaluatedtheimpactofphysicalfunctionimpairments} on quality of life in 359 HIV-infected patients and it was observedthatthefastergaitspeed,chairrisetime,andgreater physical activity were associated with greater quality of life.34

Blanch et al.35 _{evaluated 84 HIV-infected patients with} lipodystrophy and reported a poorer physical status in

comparisonwiththosewithoutlipodystrophy.However,the lipodystrophyitselfwasnotfoundtoinfluenceoverall qual-ityoflife.Thisresultisinagreementwiththepresentstudy that alsofoundno significantdifference inthedomainsof qualityoflifebetweenpatientswithandwithout lipodystro-phy, withthe exceptionoffunctionalcapacity domainthat wasmostimpactedonlipodystrophygroup.Blanchetal. con-cludethattheimpactofHIV-relatedlipodystrophyonquality oflifedependsoncertainpatientcharacteristics,ratherthan onthepresenceoflipodystrophyitself.35

There areanumber oflimitationstoour data. Unfortu-nately, we were unable to measurethe level ofactivity of ourpatients.Thereductioninthelevelofactivitymaybea factorassociatedwiththereductionofaerobiccapacity. How-ever,sincepatientswereincludediftheywere notengaged in regular exercising before the beginning ofthe research, theysupposedlyhadsimilarlevelofprioractivity.Itshould alsobeemphasizedthatourpatientsamplewasdeliberately selectedintermsofanumberofcriteriaforgoodhealthsuch asbeaware,beindependent,andbeabletowalkto hospi-tal.Weuseddigitalcalipertoevaluatethepercentageoflean body mass, fatmass, and musclemass, which isless pre-cisethanmoresophisticatedmethodslike,dualenergyX-ray absorptiometry.Althoughwedidnotuseimagingresources toquantifyfattissue,clinicalevaluationbyphysical exam-ination is also considered a reliable method to diagnosis lipodystrophy.23,35_{ThelackofacontrolgroupwithHIV} nega-tiveisalsoalimitation,becauseitdoesnotallowustoassess themagnitudeoftheimpactofHIVonqualityoflife.

Conclusion

HIV reducesthe aerobiccapacity. Thepresenceof lipodys-trophywasassociatedwithreducedaerobiccapacity,muscle massandhigherfrequencyofmetabolicsyndrome. Lipodys-trophydoes notseem toinfluenceoverallHRQOL. Lifestyle modificationshouldbecomeagreaterpriorityinthe manage-mentofchronicHIVdisease.

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