December 9, 2015
Obesity prevalence doubled from 1998 to 2010 in adults starting antiretroviral therapy (ART) in the United States and Canada, from 9% to 18%, according to a large study. After one year of ART, 20% of cohort members starting ART with a normal body mass index (BMI) had become overweight and 15% of those overweight had become obese.
More than one-third of U.S. adults are overweight (BMI 25 to 29 kg/m2), and about the same proportion are obese (BMI ≥ 30 kg/m2). Rates are similar in Canada. A recent comparison of two nationally representative U.S. populations found that two in five HIV-positive women and one in five HIV-positive men were obese. HIV-positive women were 20% more likely to be obese than women in the general population, but HIV-positive men were half as likely to be obese than their general-population counterparts.
The 14,000-person NA-ACCORD analysis is the first to assess differences in BMI by sex and race when adults starting ART change weight after one and three years of treatment. The analysis focused on 14,084 adults in 17 NA-ACCORD cohorts who started their first antiretroviral regimen from 1998 to 2010. Because NA-ACCORD does not collect pregnancy data, this analysis excluded women who gained more than 10% in body weight within six months of starting ART.
From 1998-2000 to 2007-2010, the proportion NA-ACCORD members who were obese at ART initiation climbed significantly from 11% to 17% (P < 0.001). From 1998 to 2010, obesity prevalence doubled from 9% to 18%.
An analysis adjusted for baseline age, sex, race and CD4+ count determined that average BMI when ART began rose in a roughly linear fashion from 1998 to 2010. Compared with 2003, mean BMI was 0.55 kg/m2 lower in 1998 and 0.41 kg/m2 lower in 2000, but 0.32 kg/m2 higher in 2005, 0.56 kg/m2 higher in 2007 and 0.83 kg/m2 higher in 2010. In the same analysis, men had significantly lower BMI than women regardless of race, and nonwhites had significantly higher BMI than whites regardless of sex.
One year after ART began, 20% of initially normal-weight NA-ACCORD members had become overweight and 15% of initially overweight people had become obese. Three years after ART began, 22% of initially normal-weight cohort members had become overweight and 18% of initially overweight people had become obese.
NA-ACCORD members had lower BMI when they started ART than people in the general population matched for age, sex and race. But after three years of ART, HIV-positive white men, nonwhite men and nonwhite women "caught up" with their general-population peers in BMI and did not differ from them significantly. After three years of ART white women had surged past age-matched white women in the general population and significantly exceeded them in BMI (30.8 versus 27.9 kg/m2, P = 0.02).
The NA-ACCORD researchers caution that "the pattern of short-term weight gain and increased obesity prevalence after ART initiation we observed in NA-ACCORD may have profound consequences for the future burden of cardiometabolic diseases and other noncommunicable diseases (NCDs) in the HIV-infected population."
The NA-ACCORD team suggests that providers and patients may still equate HIV infection with wasting and conclude that "a 'healthy' (i.e. higher) weight remains desirable, though this view needs to be balanced against the potential health risks of excess adiposity."
Mark Mascolini writes about HIV infection.
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