Treatment for lipid changes usually starts with non-drug options: diet and exercise.

Reducing the amount of fat you eat, and particularly saturated fats, is normal

advice for someone with high lipid levels and a risk of heart disease. However, it’s not so simple for many people taking anti-HIV treatment.

When thinking about diet changes, bear in mind that protease inhibitors (apart from amprenavir and indinavir) need to be taken with some fatty food in order to be absorbed properly. You may also be underweight because of past illnesses, or because your treatment is failing to control viral load, or because of lipodystrophy.

Instead, it may be best to focus on making changes to the kinds of fat you eat. Saturated fats are the ones that cause most problems for the heart and your blood vessels. They are:

• Animal fats (the fat on or within meat or poultry, lard in pastry, food fried in lard).

• Coconut milk and coconut cream (used in African, Caribbean, Thai and other Asian food).

• Ghee (used to make curries).

• Palm oil (used a lot in African & Caribbean food and in some margarines).

• Dairy fats – butter, cheese, cream, ice cream, full fat milk, cakes.

• Cocoa fat (chocolate, cakes, biscuits).

If you have high lipid levels, try to cut down the amount of these fats you eat and save them for special occasions.

Omega-3 fatty acids

These are special polyunsaturated fats found in oily fish and certain seeds. They help reduce lipid levels, thin the blood to help reduce the risk of thrombosis, and also improve the flexibility of blood vessels. There is strong evidence that eating more oily fish prevents further development of heart disease.

Fruits and vegetables

Fruits and vegetables are a good source of antioxidant vitamins such as Vitamin A and Vitamin C. Eating more fruits and vegetables will help prevent the cholesterol in the blood from oxidising, and furring up the arteries. Taking megadoses of some vitamins has not been shown to reduce the risk of heart disease.

Foods which are claimed to lower cholesterol

Margarines claimed to lower cholesterol may have a modest effect by blocking the absorption of dietary cholesterol. They tend to be very expensive, however.

Eating tips

• You should eat fish such as salmon, fresh tuna, pilchards, red snapper, swordfish, sardines, kippers and mackerel three times each week. Those who don't eat fish can get Omega-3 oils from linseeds and from flaxseeds.

• Replace red meats, sausages and burgers with, for example, lean chicken, turkey, tofu, Quorn and other meat substitutes.

• Cut down on full-fat dairy products, but make sure you are still getting enough fat to absorb protease inhibitors. Try lower fat cheeses, and low fat yoghurt instead of cream.

• Try to eat five portions of fruit or vegetables each day - this will provide anti-oxidant vitamins, along with other helpful chemicals found in plants (but not in vitamin supplements).

• You get the maximum benefit when you eat lots of different coloured fruits and vegetables – you don’t just need to eat greens!

If you are trying to gain weight:

• Eat frequently - have 3 snacks and 3 meals each day.

• Eat starchy foods such as potatoes, pasta, bread, oatmeal porridge, rice, maize porridge.

• Eat more monounsaturates and polyunsaturates:

• Olive oil, olive oil spreads

• Vegetable oil (especially those made out of rapeseed oil)

• Peanut butter

• Avocados

• Groundnut oil

• Sunflower oil

• Soya oil

Remember: always consult a dietitian for personalised dietary advice.

Alcohol

Anything you eat or drink that provides energy in the form of sugar will be converted into triglycerides. Reducing the amount of sugar and alcohol you eat and drink will help reduce triglyceride levels.

A glass or two of wine or beer each day can increase your levels of good HDL cholesterol.

On the negative side, larger amounts of alcohol will damage the heart muscles, increase blood pressure and add to weight gain if you drink more than one to two units per day. All of these effects further increase the risk of heart disease in people with high lipid levels. A high intake of alcohol will increase the risk of high triglyceride levels.

Exercise

See pages 15 to 20 for information about aerobic exercise, which is recommended as a way of reducing the risk of heart disease.

The contraceptive pill

There is some evidence that the contraceptive pill increases risk of heart disease in women with high lipid levels. If you are currently using the pill, you should talk to your HIV consultant about your contraceptive needs, and ask whether using the pill will increase your risk of heart disease.

Switching treatment

Lipid levels may be improved by switching from a protease inhibitor to an NNRTI or abacavir-containing regimen. This may be an important reason for switching treatment if you have very high lipid levels and/or a high risk of heart disease due to other factors such as age, weight, prior heart condition or family history, and particularly if you have both. However, switching treatment may not be enough to reduce lipids to normal levels if you have very high levels. This strategy may only be suitable for people with plenty of treatment options, such as those on first-line therapy.