PAULO FARINATTI Physical Activity and HIV-AIDS: The Experience of the Project Vida+ University of...
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Transcript of 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
Borges J et al. HIV Clin Trials 2011;12(4):215–221
The macrovascular reactivity (measured by SIDVP) indicated that HIV-infected patients had an increased arterial stiffness compared to younger HIV-negative.
Borges J et al. HIV Clin Trials 2011;12(4):215–221
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%.
controle experimental
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
controle experimental
1 mês 4 meses52
54
56
58
60
62
64
66
68
70
72
74
Ma
ssa
Co
rpo
ral (
kg)
Farinatti et al. J Sports Med Phys Fitness 2010;50(4):511-8
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
controle experimental
mês 1 mês 48
10
12
14
16
18
20
22
24
26
28
30R
em
ad
a B
aix
a (
kg)
*
Farinatti et al. J Sports Med Phys Fitness 2010;50(4):511-8
* Significant difference vs. control group (p<0,05). Whiskers represent CI 95%.
controle experimental
mês 1 mês 46
8
10
12
14
16
18
20
22
24
26
28
30
Le
g P
ress
(kg
)
*
controle experimental
mês 1 mês 40
5
10
15
20
25
30S
en
tar
e A
lca
nça
r (c
m)
*
Farinatti et al. J Sports Med Phys Fitness 2010;50(4):511-8
* Significant difference vs. control group (p<0,05). Whiskers represent CI 95%.
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%.
*
#
Farinatti et al. J Sports Med Phys Fitness 2010;50(4):511-8
controle experimental
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
)
*
Farinatti et al. J Sports Med Phys Fitness 2010;50(4):511-8
* Significant difference vs. control group (p<0,05). Whiskers represent CI 95%.
IJSM (in review)
1-yr intervention
Psychosocial Aspects
controle experimental
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.
THANK YOU!