As dietitians, we spend most of our time with clients talking about what they should eat. What some people might not realize is that dietitians are the first to admit diet alone doesn't cut it (shocking, we know). In the never-ending battle to lengthen life, exercise is essential.
As we age, our bodies' ability to get up and go can sometimes be impaired, leaving us with the question, "What's so 'golden' about the golden years?" If heart disease, osteoporosis, and declining mental status are in some cases inevitable, why are we working so hard? HIV researchers may be wondering the same thing.
Since HIV attacks the immune system, and older adults in general have a greater turnover of CD4 cells, we have to ask how the combination of the two affects immune health. Older adults with HIV have a greater CD4 cell loss than younger people. It remains to be seen if those infected in their youth will experience a greater rate of CD4 cell turnover as they age.
Heart disease (cardiovascular disease) is the number one cause of death for both older men and older women. Its risk increases with age, and our genes are still the most important factor in its development. Smoking, obesity, a poor diet, and inactivity also play a role. These risk factors can be eliminated by making certain lifestyle changes. But are those changes as effective in older adults with HIV?
There is very little known about how HIV treatments will affect the conditions commonly seen in aging. We know that HIV meds increase the risk of body fat complications. In an effort to combat these, doctors recommend behavior changes to improve cardiovascular health. Are these changes, such as exercise, as effective for an HIV-positive 65-year-old? The relationship is complex and the answer is still unclear.
While we are always learning more about treatment approaches for older adults with HIV, we don't have much to work with other than the methods used for HIV-negative older adults. Physical activity is key in the prevention and treatment of chronic illness. Even though we may not have all the answers, it is important to look at the facts and where we stand today in order.
Where Are We Today?
Twenty-seven percent of all people living with AIDS in the U.S. are over 50. In New York City this percentage jumps to over 36% for those over 50 and a whopping 74% over 40. We are currently experiencing a boom in the number HIV-positive older adults as prognosis and treatment of the virus improves.
At least 60% of adults in the U.S. are not regularly active at the level recommended for good health. Only 22% of those over 65 report that they are regularly physically active. Latinos and women are less active than non-Latinos and males. (These groups made up 26% and 17% respectively of the newly diagnosed HIV cases in 2006.) As we age, the time we set aside for leisure also increases. From the age of 55 it is estimated that adults in the U.S. spend up to 33% of their time engaging in leisure activities.
The amount of time dedicated to leisure time physical activity (LTPA) is often influenced by social networks and socioeconomic status. LTPA is defined as exercise, sports, recreation, or hobbies that are not associated with one's regular life duties. What specifically influences LTPA is not completely understood. A study published in Epidemiologic Community Health found that some barriers to activity were a lack of social support, access to exercise facilities or city sidewalks, education, care giving duties, a high-crime environment, lack of scenery, and age. It should also be noted that women, older adults, those of lower socioeconomic status, and people of color are the least active. Infection is highest among minority and lower income populations (nearly one in four African-Americans and one in five Latinos live in poverty).
It is likely that people who are HIV-positive, aging, and of low income are not engaging in regular physical activity as frequently as the U.S. population as a whole. Many AIDS organizations are taking on the changing and more complex needs of older adults, but offering LTPA for this population is a challenge.
The Physical Benefits of Exercise
Older people experience physiological and psychological changes over time, such as loss of lean body mass, poor appetite, and depression. Exercise can help increase muscle mass, improve appetite, and increase the number of "feel-good" neurotransmitters in the brain. Additionally, exercise can combat fatigue by increasing energy and can improve immune function. While there are many physical benefits of exercise, one of the most important for the older people with HIV is the improvement and maintenance of muscle mass.
Muscle wasting is common in HIV, and as the muscles waste they lose their function. Strength training helps maintain muscle function and can increase lean body mass. Examples of strength training include weight lifting, yoga, tai chi, and calisthenics. A review of the effectiveness of resistance training among older adults with HIV was recently featured in Clinical Science. The study found that progressive resistance training increased strength, improved physical fitness, reduced upper and lower limb skin folds, and was associated with an improvement in CD4 counts.
Exercise can also play a vital role in controlling some of the long-term effects of HIV drugs. Metabolic complications such as high cholesterol, triglycerides, and blood sugar are common in people taking these meds. These are also a complication of aging, so people who are over 50 and taking HIV drugs are at greater risk of them. Recommendations to combat these issues generally include a healthy diet and regular exercise, but it remains to be seen how effective that will be in older adults with HIV.
Long-term use of HIV medications can lead to changes in body composition, known as lipodystrophy and lipoatrophy. Lipodystrophy is defined as changes in the body's fat, and is characterized by lipoatrophy (loss of fat from the arms, legs and face) and lipohypertrophy (increased fat in the abdomen or back of the neck). It is psychologically distressing and physiologically dangerous, as it may worsen metabolic complications.
A study of resistance exercise in adults with HIV was featured in AIDS Care. It found significant increases in weight, lean body mass, and sum of chest, arm, and thigh circumference among those who engaged in aerobic exercise and weight training compared with those who did not. Increasing arm and thigh circumference decreases the severity of lipoatrophy, as muscle is developing in areas where wasting may commonly occur. The study also noted that waist circumference was significantly decreased in those who exercised with weights. Evidently, resistance training combined with aerobic exercise is an effective way to prevent the side effects that can occur with HIV, its treatment, and aging.
The Psychological Benefits of Exercise
Aside from the physical benefits of exercise, research has shown there are significant psychological benefits as well. For one, exercise is an effective way to reduce stress, and chronic stress has been associated with suppression of immune function. Exercise reduces cortisol, which is frequently referred to as the "stress hormone." Chronic stress and elevated cortisol levels may weaken the immune system over time, and can result in impaired inflammatory processes.
Depression is a concern, especially in those with HIV. The psychological demands of HIV medications and the stress of living with HIV can be overwhelming. While exercise is not a cure for depression, it can certainly improve it. Exercise raises the levels of "feel-good" neurotransmitters (such as serotonin), and an increased heart rate boosts the amount of endorphins circulating throughout the body. Exercise should not be substituted for antidepressant medications, but should be considered as an additional treatment.
Exercise is also a healthy coping mechanism. There are many studies linking emotional processes to immune function, showing a direct association between psychological processes and illness. Research shows that poor psychological defenses are associated with a weakened defense against HIV, and may result in greater numbers of opportunistic infections. Lower rates of depression and stress also lead to increased adherence to HIV meds.
The American Heart Association and the American College of Sports Medicine recommend that adults over 65 engage in at least 30 minutes of physical activity five days a week (which can be broken into three 10-minute segments).
But most older adults do not get enough physical activity. Many feel that exercise is for the young. Additionally, they believe that it is costly and often associate exercise with extreme exertion. Their self-efficacy (the belief that they have the ability to achieve certain goals) can be low, and the perceived cost high. Those who do meet exercise recommendations are often well-educated on the benefits of physical exercise, have a high level of self-efficacy, and receive adequate social support.
In a study published in The Journal of Medical Science Sports Exercise, 208 individuals with HIV rated their "stages of change" for exercise: 48% were in the precontemplation stage, 25% in the contemplation stage, 70% in the preparation stage, and 63% in the maintenance stage. Remarkably, no one was in the action stage. The difference between the desire to exercise and actually starting an exercise program is profound. Considering the socioeconomic, ethnic, and psychosocial strains on older people with HIV, there is a risk of a rapid decline in their overall health over the next decade.
Health professionals know that exercise can improve body composition, mood, and immune strength. But we need to continue to educate HIV-positive older adults that moderate physical activity can be achieved at any age. A belief that exercise is possible in spite of barriers and constraints is associated with a greater chance of starting to exercise.
A major barrier to exercise is access to facilities and programs. But physical activity can be done at home, in parks, backyards, or even at the grocery store. Simple enjoyable activities like gardening, walking, or dancing can contribute to activity goals, as long as activities are moderate and last for at least ten minutes. Resistance exercise can be accomplished by lifting cans or other household objects.
Making a list of all the tasks that require physical activity can make remind people that chores like going to the store are part of one's recommended exercise for the day. Activity goals should be small and measurable at first, such as walking or dancing for 10 minutes three times a day. Long-term goals can be ambitious, but make sure that they are realistic and flexible. Having a concrete plan is recommended.
According to the self-efficacy theory, there are four major areas that help older adults believe in their ability to perform specific tasks: accomplishments, learning by watching others, verbal encouragement, and physical and emotional responses. Creating a positive experience and support system for older adults is important. For example, observing other older adults exercise, receiving feedback from family or health care providers, or experiencing the benefits of walking outdoors on a sunny day can help increase the desire to engage in exercise.
Doing a little research to find exercise groups at local senior centers can be helpful. Internet access is not always available, so your community may benefit from having a printed list of centers to give to clients. Encouraging older adults to recruit an exercise buddy can also be a great way to help keep them going. Dietitians, doctors, nurses, social workers, and caregivers can also provide support for clients.
Advances in HIV treatment have made HIV a chronic disease for many, and while this is still a young disease, it is beginning to affect the old. The benefits of exercise for those with HIV are great, especially for those over 50. While the long-term benefits for older adults with HIV may not be known, we do know the benefits today. Exercise results in improved body composition, strength, heart health, mood, and life satisfaction. Adherence to HIV treatment is vital for longevity among this population -- but optimizing health with good nutrition and physical activity is fundamental.
Sarah Robertson and Margaret Swift are HIV Nutrition Specialists at Gay Men's Health Crisis.
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