paulo farinatti physical activity and hiv-aids: the experience of the project vida+ university of...

PAULO FARINATTI

Physical Activity and HIV-AIDS: The Experience of the Project

Vida+

University of Rio de Janeiro State, Brasil

Physical Activity and Sport for

Health and Development in Africa

25-29 March, Maputo, Mozambique

Laboratory of Physical Activity and Health Promotion

Methodological aspects of exercise

prescription

Physical activity for

special populations

(elderly, HIV-AIDS, obese, cardiovascular

disease, athletes)

Acute and chronic cardio-

respiratory responses to

exercise

RESEARCH LINES

Describe some effects of HIV-infection and HAART treatment upon risk factors for chronic diseases;

Discuss the effects of regular exercise on the immune function in HIV-infected patients;

Present results from the “Project Vida+”, developed at the University of Rio de Janeiro State

Structure of Presentation

Mutimura E et al. J Cardiometab Syndr. 2008;3:106–110.

Merson HM. N Eng J Med 2006;354(23):2414-2417

Okie S. N Eng J Med 2006(11 May); 354(19):1977-1981

HIV PATIENTS UNDER HIGHLY ACTIVE ANTIRETROVIRAL THERAPY (HAART)

AND RISK OF CHRONIC DISEASES

Somarriba G. HIV/AIDS - Research and Palliative Care 2010:2 191–201

The study investigated the arterial stiffness and skin microvascular function of HIV-infected patients through photoplethysmography and laser Doppler perfusion monitoring (LDPM).

It has been hypothesized that vascular reactivity would be reduced in HIV patients in comparison with healthy subjects.

Borges J et al. HIV Clin Trials 2011;12(4):215–221

Lower endothelial-dependent and independent vasodilation in HIV patients

HIV-infection independent factor even considering age effect on vasodilation


The macrovascular reactivity (measured by SIDVP) indicated that HIV-infected patients had an increased arterial stiffness compared to younger HIV-negative.


The study compared the autonomic control of the heart by means of HRV in HIV-infected patients under HAART and healthy subjects during and following a bout of continuous physical exercise.

It was hypothesized that the HIV patients would exhibit altered autonomic balance, with higher sympathetic and lower parasympathetic activity compared to healthy subjects.

Borges J et al. Int J Sports Med 2011; 32: 1–5

Time domain analysis at rest showed a decrease in SDNN, pNN50 and rMSSD in the HIV group.

Int J Sports Med 2011; 32: 1–5

Frequency domain analysis at rest revealed a decrease in the combined parasympathetic and sympathetic modulation of the heart, since LF, HF and total power were lower in the HIV group.

HIV patients showed no impairment in the expected vagal withdrawal and sympathetic activation during the continuous exercise; however it happened in a narrow range of modulation and reduced variability.

Int J Sports Med 2011; 32: 1–5

• HIV-infected patients under HAART may have increased risk to develop chronic diseases.

• Regular exercise may counteract risk factors for several chronic diseases, related to lipodysthrophia, wasting syndrome, and autonomic imbalance.

• Exercise-related outcomes may have important clinical implications in HIV-patients under HAART.

TAKE HOME MESSAGE

Characteristics of the Disease

Caused by the human immunodeficiency virus: HIV-1 and HIV-2

Cells of the immune system: Helper T cells (CD4+)

Cytotoxic and Supressor T cells (CD8+) Natural Killer Cells Monocytes

Balance Immunity x Exercise

Immunity

Exercise

Epithelial BarrierPhagocytes

NK CellsComplement - ptns

Lymphocytes B

Lymphocytes T

Antibodies

Hours Days

0 6 12 1 3 5

Inate Immunity Acquired Immunity

Time after infection

• Immune function in humans (innate and acquired systems) is affected by genetic and environmental factors;

• Environmental factors include age, exercise, gender, nutritional status, previous exposure to pathogens and stress.

TAKE HOME MESSAGE

“Open window theory”Immune alterations

PhysiologicalStress

Immune Stimulation

ImmuneSupresstion

-2.5

-1.5

-0.5

0.5

1.5

2.5

3.5

open window

Prolonged (2-3h) or intense exercise Moderate exercise (30-45 min)

Beginningof exercise

0.50 1 1.5 2. 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 10

Hours

Nieman, DC and Bishop, NC. J Sports Sci 2006;24(7):763-772

Exercise x Immune System

ACUTE EXERCISE AND INNATE IMMUNE FUNCTION

Effect of exercise intensity and duration on the circulating leukocytes (neutrophil and lymphocyte counts). Mean ± SEM, n = 18. * Significant difference from pre-exercise (P<0.05); # Significant difference compared with 80% VO2max trial.

Robson et al. Int J Sports Med 1999; 20:128-135

Changes in natural killer cell activity (expressed as lytic units per litre of blood) after 45 minutes of running at 80% VO2max. * Siginificant difference (P<0.05) from pre-exercise.

Nieman DC et al. Med Sci Sports Exerc 1993; 25:1126-1134

ACUTE EXERCISE AND ACQUIRED IMMUNE

FUNCTION

Absolute (A) and adjusted per T cell (B) changes in mitogen-stimulated lymphocyte proliferative responses to a 45-minute treadmill run at 80% VO2max (high) and 50% VO2max (moderate). * Indicates a significant difference from pre-exercise values, P<0.05,**P<0.01.

Nieman DC et al. Int J Sports Med 1994; 15:199-206

Changes in the absolute (A) and relative (B) circulating concentrations of CD4+ and CD8+ T cells in response to a 45-minute treadmill run at 80% VO2max

Nieman DC et al. Int J Sports Med 1994; 15:199-206

CHRONIC IMMUNE RESPONSES TO PHYSICAL

TRAINING

Number of days with symptoms of URTI in a group of mildly obese, young women randomly assigned to either 15 wks of moderate exercise training (walking training for 45 min, 5 days/wk at 60% HRR) or no exercise.

From Nieman DC et al. Int J Sports Med 1990;11:467-473

The J-shaped model of the relationship between risk of upper respiratory tract infection (URTI) and exercise volume.

From Nieman DC. Int J Sports Med 1994;15:S131-S141

Effects of an acute increase in the training load on some immune variables in elite athletes.

(A) Robson PJ et al. J Physiol 1999; 515:84-85 and (B) Verde T et al. Br J Sports Med 1992;26:167-175

• Acute bouts of exercise may cause a temporary depression in immune function that lasts ~3–24 hours after exercise, depending on the intensity and duration of the exercise bout (Gleeson & Bishop 1999).

• Periods of intensified training lasting 7 days or more result in chronically depressed immune function, and previous surveys indicate that sore throats and flu-like symptoms are more common in endurance athletes than in the general population (Bishop, 2006).

SUMMARIZING…

• The participation in regular moderate exercise is associated with a lower risk of infections compared with that of a sedentary individual.

• Performing acute bouts of prolonged, intense exercise or heavy volumes of training is associated with an above-average risk of infections.

• In brief, when exercise is too intense and/or repeated frequently there may not be sufficient time for the immune system to recover fully.

TAKE HOME MESSAGE

“Open Window”

Infection

ModerateExercise

Intense or ProlongedExercise

BalanceImmunity x Exercise

Imunidade

Exercício

Imunidade Exercício

IntensityDuration

Nutritional Status

What is the Vida+

• Intervention program including aerobic, resistive, and flexibility exercises for HIV-infected patients, with the aim of improving markers of immunological function, physical fitness and well-being.

GENERAL PURPOSES

- To provide free access to HIV-patients to a supervised program of physical activities;

- To contribute with the formation of human resources to work with exercise prescription and evaluation of this specific population.

The Project Vida+

Target Population

The project currently serves 59 subjects with a mean age of 45 years

Training Program

• 3 times/ week, 90 min;

• Moderate intensity – imunodepression;

• Confort – avoid lower adherence;

• Medical, nutritional, and psychological assistance.

Training Protocol

• Aerobic – 30 min, PWC 150 or 10% lower CPX Anaerobic ThresholdTreadmill or cycloergometer

• Strength– 3 sets of 80% of 12 RM, 8 to 10 exercisesUpper and Lower Body

• Flexibility – Static method, 1 set 30 s, 4 to 6 exercises Upper and Lower Body

Observed Variables

• Absolute and relative (%) CD4 count• Anthropometry (perimeters, skinflids)

and body composition (DEXA)• Muscle function (Isoinertial – RM and

isokinetic – Biodex evaluations)• Flexibility• Cardiorespiratory fitness (VO2 peak and

HR/W and VO2/HR relationships during submaximal effort)

• Body image and perceived well-being

Results

controle experimental

mês 1 mês 410

12

14

16

18

20

22

24

26

28

30

32

CD

4%

Non significant differences (p>0,05). Whiskers represent CI 95%.


mês 1 mês 40

100

200

300

400

500

600

700

800C

D4

(m

m/d

l)

Farinatti et al. J Sports Med Phys Fitness 2010;50(4):511-8

Unpublished data

Body Mass and Composition


1 mês 4 meses52

54

56

58

60

62

64

66

68

70

72

74

Ma

ssa

Co

rpo

ral (

kg)


Non significant differences (p>0,05). Whiskers represent CI 95%.

1-yr intervention

Unpublished data

DXA

DXA

1-yr intervention

Unpublished data

PRE-HAART

Infections and high-grade inflammation

Diarrhoea and intermittent fever

Malabsorption

Catabolism

Wasting Syndrome

POST-HAART

Low-grade inflammation

Neuromuscular inflammation

Mitochondrial dysfunction

Hormonal changes

Lipodistrophy

RISK OF MORTALITY

HIV PATIENTS

CACHEXIA SARCOPENIA

Relationship between muscle mass indexes and muscle functionin HIV-infected patients aged 28-57 years (n=48)

p<0,0001

r=0,835 r=0,637

p=0,0006

Unpublished data

Strength


mês 1 mês 48

10

12

14

16

18

20

22

24

26

28

30R

em

ad

a B

aix

a (

kg)

*


* Significant difference vs. control group (p<0,05). Whiskers represent CI 95%.


mês 1 mês 46

8

10

12

14

16

18

20

22

24

26

28

30

Le

g P

ress

(kg

)

*


mês 1 mês 40

5

10

15

20

25

30S

en

tar

e A

lca

nça

r (c

m)

*



IJSM (in review)

1-yr intervention

IJSM (in review)

Biodex 4 Pro

1-yr intervention

Aerobic Capacity

25 W mês 1

35 W mês 1

45 W mês 1

25 W mês 4

35 W mês 4

45 W mês 4

controle experimental90

100

110

120

130

140

150

160F

reqüência

Card

íaca (

bpm

)

* Diferença significativa para FC a 25 Watts em cicloergômetro (p<0,05). # Diferença significativa para FC a 35 Watts em cicloergômetro (p<0,05). As barras indicam os intervalos de confiança a 95%.

*

#



mês 1 mês 44

5

6

7

8

9

10

11

12

13

14

15Te

mp

o d

e T

est

e n

o C

iclo

erg

ôm

etr

o (

min

)

*



IJSM (in review)

1-yr intervention

Psychosocial Aspects


mes 1 mes 420

22

24

26

28

30

32

34

Índ

ice

de

Sa

tisfa

ção

de

Vid

a (

po

nto

s)

*

Rev Bras Fisioter 2010;14(5):390-5.

* Significant difference vs. baseline (p<0.05). Whiskers represent CI 95%.

Body Image

Concerns the way which the individual realizes and appreciates his/her body. An analysis of body image is

important in situations where there are significant changes in the composition and distribution of lean and fat mass, in order to assess how this affects the

quality of life perception.

KAKESHITA, ALMEIDA, 2006.

The physical deterioration that occurs in AIDS and the fear itself that such deterioration can happen, may

cause various psychological problems, mainly related to body image perception.

As a result, individuals frequently present a distorted perception of their own body.

SONSTROEM apud FECHIO, CORONA, BRANDÃO, 2000.

Body Image

Objective measures

Subjective measures

Objective Measures

• These measures pertain to the assessment of distortions in the appreciation of body posture or body image, in other words, with the precision of body size estimates.

THOMPSON apud FERREIRA, LEITE, 2002

Marsh HW, Roche LA. Res Quar Exerc Sport 1996;67:13-23

Silhouette Matching Task (SMT)

Kakeshita IS, Almeida SS. Rev Saúde Pública 2006;40(3):497-504

Gardner RM, Friedman BN, Jackson NA. Percept Mot Skills 1998;86(2):387-95.

Subjective Measures

These measures pertain to the evaluation of affective, attitudinal, and cognitive aspects of the body image, usually by means of questionnaires.

Some scales evaluate the global satisfaction level with the weight, body or appearance, while others measure the satisfaction level with

specific parts of the body.

Subjects

• 29 HIV-positive patients (44±2 anos)

7 lipodystrophic and physically active;

8 no- lipodystrophic and sedentary;

7 no-lipodystrophic and physically active;

7 no-lipodystrophic and sedentary.

Objective analysis - body image

Silhouette Matching Task (SMT), including nine scales of silhouettes/pictures,

corresponding to BMI ranging between 17,5 and 37,5 kg/m2

The degree of insatisfaction with the body was assessed by the difference between the actual silhouette (SA) and the ideal silhouette (SI), as pointed individually.

Subjective analysis - body image

Bruchon-Schweitzer’s Body Image Questionnaire (QIC)

1) Factor I (‘favorable vs. unfavorable body perception’);

2) Factor II (‘exposed vs. hidden body’);

3) Factor III (‘active vs. inactive body’);

4) Factor IV (‘calm vs. nervous body’);

5) ‘social acceptability of the body’ - addition of 'socially desirable responses’ (positive responses)

*diferença significativa em relação demais grupos (p<0,05). diferença significativa em relação as demais variáveis no mesmo grupo (p<0,05).

NS – diferenças não significativas (p>0,05).

IMC SA-test SI-test

Lip-At SLip-At Lip-Sed SLip-Sed14

16

18

20

22

24

26

28

30

32IM

C (

rea

l e

te

óri

co

) (k

g/m

2 )

* *NS

NS

Arch Exerc Health Disease (in press)

Me d ia n a 2 5 % -7 5 % Min -Ma x

L ip -A S L i p o -A L ip o -S S L i p o -S6

8

1 0

1 2

1 4

1 6

1 8

2 0

2 2

corp

o n

erv

oso

x c

orp

o c

alm

o

*

Me d ia n a 2 5 % -7 5 % Mi n -Ma x

L ip -A S L ip o -A L ip o -S S L ip o -S1 0

1 2

1 4

1 6

1 8

2 0

2 2

2 4

2 6

2 8

3 0

3 2

3 4

3 6

corp

o fa

vorá

vel x co

rpo

desfavo

rável

*

* Significant different vs. other groups (p<0,05). Arch Exerc Health Disease (in press)

Mediana 25%-75% Min-Max

L ip-A S Lipo-A Lipo-S S Lipo-S10

12

14

16

18

20

22

24

26

28

corp

o e

xib

ido x

corp

o e

scondid

o

*

Me d i a n a 2 5 % -7 5 % Mi n -Ma x

L i p -A S L i p o -A L i p o -S S L i p o -S1 2

1 4

1 6

1 8

2 0

2 2

2 4

corp

o a

tivo

x c

orp

o p

ass

ivo

Me d ia n a 2 5 % -7 5 % Min -Ma x

L ip -A S L ip o -A L ip o -S S L ip o -S2 0

2 5

3 0

3 5

4 0

4 5

5 0

5 5a

ceit

açã

o s

oci

al

do

co

rpo

*

* diferença significativa do valor mínimo em relação aos demais grupos (p<0,05).

Arch Exerc Health Disease (in press)

Resistance and aerobic exercise are safe and may lead to clinically important improvements in outcomes of weight and body composition for medically stable adults living with HIV/AIDS.

Individual study results suggest potential benefits to cardiopulmonary, strength and psychological outcomes.

Further research is needed to develop recommendations pertaining to the parameters of frequency, intensity, time and type of exercise interventions that might be most beneficial to people living with HIV

Conclusion

HIV-infected patients

+

Moderate intensity/volume exercise

Improvement of fitness, functional, and psychological markers, without

compromising the immune function

+

Support:

Universidade do Estado do Rio de Janeiro Rua São Francisco Xavier, 524, 80 andar, Sala 8121, Bloco F, Maracanã, Cep. 20599-900, Rio de Janeiro, RJ.

[email protected]

[email protected]

THANK YOU!

paulo farinatti physical activity and hiv-aids: the experience of the project vida+ university of...

Documents

infection slide

composition slide

mozambique slide

effects of hiv

hiv group

exercise x immune system

unpublished data slide

home message slide