The Positive Side

Winter 2013 

Ask the Experts: Managing Lipid Levels

“My doctor said that my lipid levels are cause for concern. Any do’s and don’ts you can share?”
―JB, Brandon, Manitoba

Interviews by Jennifer McPhee


The Lowdown on Lipids

Our bodies contain thousands of different kinds of fat, known as lipids. When you have your “cholesterol checked,” three of these fats are measured:

  • HDL cholesterol (high-density lipoprotein, also known as “good” cholesterol), which removes bad cholesterol from the blood
  • LDL cholesterol (low-density lipoprotein, also known as “bad” cholesterol), which can build up in the arteries and lead to heart disease and other health problems
  • triglycerides, which can also increase your risk for heart disease if levels are too high

Marek Smieja

Infectious Diseases Specialist, McMaster University
Hamilton, Ontario

Most experts agree that HIV infection can cause abnormal lipid levels and heart disease. We’re also fairly certain that the main reasons more people with HIV suffer from heart disease are smoking, high cholesterol and some HIV medications that can affect cholesterol levels.

If someone is a smoker and has abnormal lipid levels, I first try to help them quit smoking, or at least cut back. Next, a dietitian helps them find ways to lower their bad cholesterol and overall risk for heart disease through diet and regular exercise. Keep in mind that cholesterol is just one risk factor of heart disease. Even if these changes don’t improve a person’s cholesterol levels, there are still effective ways to reduce overall risk of heart disease.

The HIV meds known to increase bad cholesterol and triglycerides include some protease inhibitors and some older nukes, such as d4T and probably AZT and ddI. Every person starting HIV treatment should have a blood test to measure their lipid levels. I give my patients the same test six months later. If the latter reveals high bad cholesterol or triglycerides despite healthy lifestyle choices, we may change their HIV meds or start them on cholesterol-lowering drugs. While seeking to lower cholesterol, I recommend frequent testing. Once a person’s level is considered safe, I recommend that they continue to test regularly though less frequently—generally once a year.

Sometimes the body outsmarts our attempts to reduce cholesterol by producing extra bad cholesterol, even when people exercise and are diligent about their diet. When this happens, medications from a class of drugs known as statins can help. Major studies show that these drugs dramatically reduce a person’s risk of heart disease–related death.

Taking both a statin and a protease inhibitor can produce various side effects—some minor and some more serious though rare. In my opinion, too many people stop their statins because of minor side effects. It’s important to remember that suffering a heart attack or stroke is a serious consequence of not taking these drugs. In the same way that millions of people remain alive because of HIV drugs, many people are still around today because of statins.

There’s a lot of interest in natural treatments. Such approaches can be somewhat helpful, but changes in lipid levels generally occur as a result of a combination of lifestyle changes and drug therapy.


James Snowdon

Pharmacist, Snowdon Guardian Pharmacy

Treatment of abnormal lipid levels is integral to improving the heart health of people living with HIV. It should start with a healthy diet, exercise, smoking cessation, managing hypertension and diabetes. These are the cornerstone of any treatment do’s and don’ts.

HIV medication combos frequently include drugs that elevate cholesterol and triglyceride levels. One option for people on HIV treatment is to switch from the presumed offending agent to another antiretroviral medication. The recent introduction of more lipid-friendly drugs within existing classes (such as the protease inhibitor darunavir (Prezista) and the non-nukes etravirine (Intelence) and rilpivirine (Edurant)) broaden the options. In addition, new classes of drugs (integrase inhibitors such as raltegravir (Isentress) and CCR5 inhibitors such as maraviroc (Celsentri)) offer more options for people starting therapy and for those who need to switch drugs.

Lipid-lowering therapies that have been investigated in people with HIV include fish oils (see interview with Cheryl Collier, opposite), statins, fibrates, ezetimide, niacin and combinations of these therapies.

Statins can significantly reduce bad cholesterol and triglycerides. Drug interactions between statins and antiretrovirals are very common. For example, some protease inhibitors can raise the concentration of statins and can lead to statin toxicity. However, atorvastatin (Lipitor) and pravastatin (Pravachol) are less likely to interact. The newer rosuvastatin (Crestor) does not interact with many drugs.

Fibrates are a class of drugs that can reduce triglycerides significantly in people living with HIV. It is unclear if this triglyceride reduction alone is significant enough to alter cardiovascular risk. Fibrates are generally well tolerated; gastrointestinal upset is the most commonly reported side effect.

Ezetimide (Ezetrol) appears to have minor cholesterol-lowering effects when taken alone. According to one study, when taken with pravastatin, it lowered levels of bad cholesterol more effectively.

Niacin appears to be well tolerated and reduces triglyceride levels significantly and bad cholesterol to a lesser degree. A concern is the increase in insulin resistance that it can cause.

There is little information available on the efficacy or safety of people with HIV using a combination of therapies, so this should only be done with strict caution.


Cheryl Collier

Clinical Dietitian
BC Women’s Hospital and Health Centre

Your nutrition choices can help reduce your bad cholesterol. This involves cutting back on certain foods and adding heart-healthy foods to your diet. Both saturated and trans fats raise bad cholesterol. Most saturated fat comes from processed foods, fatty cuts of meat, high-fat dairy products and tropical oils, such as coconut and palm. Instead of fatty meat, you can eat leaner meat, skinless poultry, fish, legumes and vegetarian protein, such as peas and beans or soy protein. Select lower-fat dairy products and steer away from highly processed foods. You don’t need to eliminate high-cholesterol foods, but try to eat less of them.

Incorporate more of the following into your diet:

  • Fibre, particularly soluble fibre – it prevents the absorption of bad cholesterol from the food you eat. Good sources include oatmeal and oat bran, barley and psyllium. Increase fibre by including vegetables, fruit and whole grains with meals.
  • Nuts – almonds, walnuts and other tree nuts can help reduce cholesterol. They are a source of healthy fat and are high in calories, so if you’re trying to lose weight, limit your portion to a quarter cup a day.
  • Omega-3 fatty acids – cold-water fish (such as salmon, sardines and trout) are an excellent source and can help lower triglycerides. If you don’t like fish, these oils are available in capsules. Ask your doctor for advice on dosage.

For clients with high cholesterol who are also struggling with unwanted weight loss, I look at what is contributing to the weight loss and help them reach and maintain a healthy body weight. Replacing saturated fats with high-calorie healthy fats from nuts, avocados, and olive and canola oils can help cholesterol levels and boost calorie intake.

It’s more common, however, for people to work on losing extra weight and exercising (both are good for the heart). For people who don’t currently exercise and are finding it hard to start, I suggest participating in an activity they enjoy once or twice a week. Once a consistent routine is achieved, they can start exercising more.

Lifestyle changes take time. Start with one to two key goals and go from there. Diet and exercise can make a difference, even in situations where HIV medication is contributing to high cholesterol or triglycerides, but it’s important to recognize that sustainable change takes time.


Tasleem Kassam

Clinic Director, Effective Health Solutions

Vegetables are not very sexy. We’d all rather eat a corn dog than sit down to a plate of vegetables. But the reality is that the more vegetables you eat, the better. Lots of vegetables and moderate amounts of fruit should be the mainstay of our diets. I tell my clients to think of meat as a condiment. Many people find this shocking, but meat should take up no more than a quarter of the real estate on your plate. Vegetables and whole grains should fill the rest of your plate.

You can also grind up flax seeds and sprinkle them on a salad. Flax seeds help keep the arterial system working well because they’re high in fibre and omega 3-fatty acids.

The less you eat processed food that comes out of a factory, the healthier you’ll be. It can be difficult to do on a limited budget because processed food is often less expensive (plus the food industry has a vested interest in tempting you with factory food, which generates profit).

I also recommend the following supplements:

  • Krill oil – a type of fish oil that contains the antioxidant astaxanthin (a pigment, or carotenoid, responsible for making shrimp and flamingos pink), which can improve lipid levels. Make sure you get a balanced intake of carotenoids (mixed carotenoids); and
  • Vitamin B complex – contains pantothenic acid (B5), useful for correcting lipid metabolism and raising good cholesterol even when medications, diet and exercise have been tried to little avail. Pantothenic acid should not be taken on its own but as part of a B complex. You may want to supplement this with pantethine (a derivative of pantothenic acid) to help manage lipid levels.

Most people with HIV are already taking more medication than the average person. It’s a lot for the liver to process. In my opinion, it’s best to try to manage your cholesterol naturally, if possible, because taking a cholesterol-lowering medication adds to the liver’s workload. Most people who make the right changes to their diets see the payoff in their blood work results.

Jennifer McPhee is a freelance writer who contributes regularly to The Positive Side. Her work has also appeared in numerous publications, including Chatelaine, The Globe and Mail and Childview.