How to Decrease HIV related belly fat accumulation

Nelson Vergel

Thread starter #1

Decreasing HIV Related Belly Fat Accumulation

In the mid-90s with the advent of the first antiretroviral (AVR) drug combination therapies, Kaposi’s sarcoma (KS) lesions and lipodystrophy (wasting away of body fat) rapidly faded from public consciousness as signs of HIV infection. Only to be replaced by another symptom that can powerfully impact the health and appearance and health of the HIV population: Belly fat accumulation, also called HIV-related lipohypertrophy.

As disfiguring and embarrassing as the gauntness that once afflicted so many battling this disease once was – many people living with HIV (PLWH) now have to find a way to deal with the unhealthy accumulation of belly fat. Let’s take a look at:

  • What is HIV Lipohypertrophy?
  • The health risks that come with it
  • How to reduce belly fat with diet
  • Reducing belly fat with exercise
  • Supplements that could help
  • Drugs that can be used to reduce belly fat
HIV Lipohypertrophy and Lipoatrophy

PLWH can experience HIV lipohypertrophy: Fat accumulation in their subcutaneous tissues (under the skin), within the abdominal cavity, and on the belly or behind the neck (creating a ‘buffalo hump’ appearance).Women may experience both gynecomastia and breast augmentation.

However, lipohypertrophy can also be accompanied by lipoatrophy (fat loss) in the face, arms, buttocks, and legs. Muscle atrophy and bone loss could also occur. Currently, there isn’t a consensus regarding definitions of the different kinds of lipoatrophy or lipohypertrophy, neither is there a reference test for the diagnosis (1).

Some of these symptoms could be caused by taking HIV medications, and some may be the result of the infection. Lipoatrophy is most frequent with drugs like d4T (Zerit, stavudine) and AZT (zidovudine, ZDV), which aren’t often prescribed in the US (2).

While the accumulation of belly fat is possibly an effect of HIV, it’s also been observed in PLWH who take protease inhibitors like indinavir (Crixivan), which is also rarely prescribed now (3).
Health Risks of Excess Belly Fat

The problem with HIV-related belly fat is that it isn’t limited to just the subcutaneous fat layer (fat located under the skin). Belly fat also includes visceral fat deep inside the abdomen and surrounding the internal organs.

Visceral fat is particularly dangerous because fat around the abdominal organs may not just swell the belly; it can also change the way the body functions (4).

Regardless of body weight, excess visceral fat may increase the risk of:

  • Heart disease or stroke
  • Dementia
  • Type 2 diabetes
  • Colorectal cancer
  • Sleep apnea
  • Early death from all causes
  • Hypertension (high blood pressure)

Fat cells can do much more than store extra calories. Visceral fat tissue, in particular, can behave in an organ-like manner by secreting hormones and inflammatory substances called cytokines; leading to inflammation and interfering with the hormones regulating appetite, brain function, and weight (5).

Decrease HIV Related Belly Fat with Diet

One of the best approaches to dealing with HIV-related belly fat is by making changes to the diet. While calorie restriction alone can reduce belly fat accumulation – it can be hard to stick with long-term (6). Sufficiently reducing food intake to make an impact on body fat levels is typically uncomfortable and may also reduce muscle mass, slowing the resting metabolic rate (6). Calorie restriction may be a way to jump-start fat loss but isn’t optimal to maintain healthy body fat levels.

A better and long-term method of losing belly fat may be by reducing carbohydrate intake with a ketogenic diet.

The body has two sources of fuel; glycogen (sugar) and ketones (fatty acids). When someone consumes a steady supply of starches and sugars, the body does not need to tap into stored fat. A ketogenic diet is intended to deplete the body’s supply of glycogen so that it can begin breaking down the excess fat.

One of the greatest benefits of a ketogenic diet is that it can lead to a reduction in appetite (7). Studies consistently demonstrate that when people reduce carbohydrate intake and consume more protein and fat, they eat fewer total calories. When researchers compared ketogenic to low-fat dieting in recent studies, calories had to be restricted in the low-fat group to achieve comparable results (8).

Reduce Belly Fat by Doing HIIT

Getting regular exercise is a healthy habit and comes with many benefits. Unfortunately, reducing belly and visceral fat isn’t one of them. The amount of running, biking or swimming that someone performs to burn enough calories to significantly impact weight loss is extraordinary. To burn about 3500 calories (the amount in one pound of fat) the average person would need to run about 29 miles at a six mile per hour pace.

But, there is a training protocol that has been demonstrated to reduce body fat while building strength and cardiovascular fitness; high-intensity interval training (HIIT) (9).

HIIT is done by exercising in short bursts of all-out effort with brief rest periods between sets. Research has shown that HIIT is a time-efficient way to:

  • Burn calories in a shorter amount of time
  • Boost the metabolism
  • Lose fat without losing muscle
  • Improve cardiovascular health

Research shows that only 15 minutes of HIIT training can burn more calories than one-hour on a treadmill (9). HIIT workouts can also utilize body weight exercises, so a workout that gets your heart rate up fast like sprinting, jumping jacks, and Burpees can be used for a HIIT workout almost anywhere.
Supplements that Help Reduce Abdominal Fat

Weight loss supplements have a (well-deserved) bad reputation. But certain vitamins and other substances found in nature, when taken while eating a healthy diet and following an exercise routine, could help reduce HIV-related belly fat.

Whey protein: Overweight test-subjects who consumed one whey protein drink per day lost more weight than those who had a daily soy protein shake instead, according to a study published in the Journal of Nutrition (10).

Green tea extract: A study in the European Journal of Clinical Nutrition (11) found that at low doses, a phytochemical in green tea called epigallocatechin gallate can increase fat oxidation by approximately 33 percent.

Glutamine: A study in European Journal of Clinical Nutrition (12) concluded that without reducing caloric intake people still lost weight after taking a glutamine supplement for one month.

Vitamin D: A 2009 study from the University of Minnesota (13) found that individuals who begin a diet with healthy vitamin D levels lost more weight than those who dieted with low vitamin D levels.

Drugs that may be Used to Shrink Belly Fat

Metformin (Glucophage): According to one study (14), weight loss from metformin will tend to happen slowly over a couple of years. The amount of weight lost can also vary between individuals. In this study, the average weight loss after two or more years was between four and seven pounds.

Testosterone: Low testosterone levels have been associated with higher levels of body fat. According to one study - long-term testosterone therapy in men with testosterone deficiency produces significant and sustained weight loss and a marked reduction in waist size (15).

Appetite suppressants: Common prescription appetite suppressants like orlistat, Belviq, Contrave, Saxenda, phentermine, and Qsymia may help reduce HIV-related body fat through calorie restriction (16). A patient will typically need to have a body mass index (BMI) over 27 or have a weight-related condition such as diabetes or hypertension before the doctor will provide a prescription (16).

Egrifta: Egrifta is the first drug approved to reduce the accumulation of HIV-related belly fat. It works as a synthetic analog of human growth hormone-releasing hormone and stimulates the production and release of the body’s natural growth hormone to reduce body fat levels (17).

Oxandrolone: Oxandrolone (Anavar, Oxandrin) is a mild anabolic steroid with low androgenic activity that also has low water retention properties. It will promote muscle mass gains while also helping to reduce body fat (18).

N-Acetylcysteine (NAC) and Glycine: Research demonstrates that combining NAC (a powerful antioxidant) with glycine can increase strength while significantly improving body composition in HIV patients. The data suggest that reduced glutathione (GSH) production caused by a deficiency of cysteine and glycine can be quickly corrected by supplementing with NAC and glycine. Increased levels of GSH is associated with lower body fat, reduced waist circumference, and more fat-free muscle mass and strength (19).


1) Baril, Jean-Guy et al. “HIV-Associated Lipodystrophy Syndrome: A Review of Clinical Aspects.” The Canadian Journal of Infectious Diseases & Medical Microbiology 16.4 (2005): 233–243. Print.

2) Montessori, Valentina et al. “Adverse Effects of Antiretroviral Therapy for HIV Infection.” CMAJ: Canadian Medical Association Journal 170.2 (2004): 229–238. Print.

3) Anuurad, Erdembileg, Andrew Bremer, and Lars Berglund. “HIV Protease Inhibitors and Obesity.” Current opinion in endocrinology, diabetes, and obesity 17.5 (2010): 478–485. PMC. Web. 7 Dec. 2017.

4) Saelens, Brian E et al. “Visceral Abdominal Fat Is Correlated with Whole-Body Fat and Physical Activity among 8-Y-Old Children at Risk of Obesity.” The American journal of clinical nutrition 85.1 (2007): 46–53. Print.

5) Grant, Ryan W., and Vishwa Deep Dixit. “Adipose Tissue as an Immunological Organ.” Obesity (Silver Spring, Md.) 23.3 (2015): 512–518. PMC. Web. 7 Dec. 2017.

6) Tomiyama, A. Janet et al. “Low Calorie Dieting Increases Cortisol.” Psychosomatic medicine 72.4 (2010): 357–364. PMC. Web. 7 Dec. 2017.

7) McClernon, F. J., Yancy, W. S., Eberstein, J. A., Atkins, R. C. and Westman, E. C. (2007), The Effects of a Low-Carbohydrate Ketogenic Diet and a Low-Fat Diet on Mood, Hunger, and Other Self-Reported Symptoms. Obesity, 15: 182. doi:10.1038/oby.2007.516

8) Krebs, Nancy F. et al. “Efficacy and Safety of a High Protein, Low Carbohydrate Diet for Weight Loss in Severely Obese Adolescents.” The Journal of pediatrics 157.2 (2010): 252–258. PMC. Web. 7 Dec. 2017.

9) Boutcher, Stephen H. “High-Intensity Intermittent Exercise and Fat Loss.” Journal of Obesity 2011 (2011): 868305. PMC. Web. 7 Dec. 2017.

10) David J. Baer, Kim S. Stote, David R. Paul, G. Keith Harris, William V. Rumpler, and Beverly A. Clevidence. Whey Protein but Not Soy Protein Supplementation Alters Body Weight and Composition in Free-Living Overweight and Obese Adults. The Journal of Nutrtion. (2011).

11) Stephen Daniells. Green Tea Extract Effective for Weight Loss at Low Doses. (2010).

12) Laviano A, Molfino A, Lacaria MT, Canelli A, De Leo S, Preziosa I, Rossi Fanelli F. Glutamine supplementation favors weight loss in nondieting obese female patients. A pilot study. Eur J Clin Nutr. 2014 Nov;68(11):1264-6. doi: 10.1038/ejcn.2014.184. Epub 2014 Sep 17.

13) Medical News Today Staff. Link Between Successful Weight Loss And Vitamin D Levels. Medical News Today. (2009).

14) The Diabetes Prevention Program Research Group. “Long-Term Safety, Tolerability, and Weight Loss Associated With Metformin in the Diabetes Prevention Program Outcomes Study.” Diabetes Care 35.4 (2012): 731–737. PMC. Web. 7 Dec. 2017.

15) Traish AM. Testosterone and weight loss: the evidence. Curr Opin Endocrinol Diabetes Obes. 2014 Oct;21(5):313-22. doi: 10.1097/MED.0000000000000086.

16) Rodgers, R. John, Matthias H. Tschöp, and John P. H. Wilding. “Anti-Obesity Drugs: Past, Present and Future.” Disease Models & Mechanisms 5.5 (2012): 621–626. PMC. Web. 7 Dec. 2017.

17) Dhillon S. Tesamorelin: a review of its use in the management of HIV-associated lipodystrophy. Drugs. 2011 May 28;71(8):1071-91. doi: 10.2165/11202240-000000000-00000.

18) Lovejoy JC, Bray GA, Greeson CS, Klemperer M, Morris J, Partington C, Tulley R. Oral anabolic steroid treatment, but not parenteral androgen treatment, decreases abdominal fat in obese, older men. Int J Obes Relat Metab Disord. 1995 Sep;19(9):614-24.

19) Nguyen, Dan et al. “Effect of Increasing Glutathione With Cysteine and Glycine Supplementation on Mitochondrial Fuel Oxidation, Insulin Sensitivity, and Body Composition in Older HIV-Infected Patients.” The Journal of Clinical Endocrinology and Metabolism 99.1 (2014): 169–177. PMC. Web. 7 Dec. 2017.



Nelson, I have HIV lipodystrophy (mostly accumulation of deep visceral belly fat). I exercise 4 times per week and watch what I eat but my belly does not come down. Any recommendations for me? My viral load is undetectable.

From Nelson:

Here is background information about lipodystrophy and its potential treatments:
HIV Lipodystrophy Options

If you want to lose fat fast follow a modified Atkins diet:

Food plan booklet: dijeta/Dr. Atkins Basic Diet Manual.pdf

There are 3 phases:


If a more moderate diet is preferred, follow these suggestions:

The Science of Healthy Eating

I have a few exercise suggestions here that can accelerate fat loss and lean body mass gain:

Nelson Vergel's Time-Saving Tips to Maximize the Benefits of Exercise

Medications and Blood Tests:

1- Keep your total testosterone over 500 ng/dL (use testosterone replacement therapy if your T is low). Get your total and free testosterone here (No Doctor Visit-US Only)

2- Test your thyroid TSH, free T3, and free T4 to make sure your thyroid is working well. Low thyroid function can make it difficult to lose fat. You can obtain this panel cheaply here (in the US only): Thyroid Panel

2- Metformin at 500 mg twice per day with food may help burn fat. You need a prescription.

Watch my lecture on Metformin here

If you have insurance, get your doctor to prescribe Egrifta (tesamorelin)

The combo of Egrifta plus Metformin plus the diet and exercise may work synergistically but no studies have been performed with this quadruple intervention.

If you do not have insurance, Theratecnologies (makers of Egrifta) has a patient assistance program:

Sign up by calling 1-844-EGRIFTA (1-844-347-4382)

Also, read this article I wrote for suggesting fat loss tips.

If you are using testosterone now, you may want to watch my latest video about the use of HCG with testosterone

Oxandrolone (Old brand names: Oxandrin, Anavar) has been shown to decrease subcutaneous and visceral fat while helping increase lean mass. 20- 40 mg per day is the usual dose.

If your insurance does not want to pay, you can get it by prescription out-of-pocket here (25 mg per day):


I hope this information helps!

Join my HIV discussion group by sending an email to

There are over 3800 long-term survivors there!
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I am seeing my doctor tomorrow and I would like to ask him for an RX for Semorelin. How should he write the Rx (# mg/mL)? I sent a message to the Empower Compounding Pharmacy to get pricing info. My insurance won't pay for Serostim. I am going to try to get my Dr. to prescribe Metformin also. Any more suggestions on obtaining HCG and Metformin?

Nelson Vergel

Thread starter #3
Instructions here:

Oxandrolone at 20 mg per day along with testosterone replacement at 200 mg per week (or daily testosterone gels) may help reduce visceral fat. You may be able to get insurance to pay for it. Sometimes they require doctor pre-authorization. It is expensive at $ 1200 per month. Compounding pharmacies may charge $200-350 per month for the same dosage.

Info on Oxandrolone here:

Oral anabolic steroid treatment, but not parenteral androgen treatment, decreases abdominal fat in obese, older men.
Thanks for all of this information. Having been positive for 16+ years, reduction of lipodystrophy is one of my goals. I'm assuming HCG could have an impact with this since it is in the thread? Dr. Saya recommended it but I just wanted to address my low testosterone first. I'm not really concerned with the size of my testicles. However, I am concerned with the size of my belly as that is where almost all of my body fat is and it is quite embarrassing. I am working out 3-4 times a week using an interval training program. The fat in my neck is going away but I haven't noticed much of a change in my waist. My weight is holding steady at 228#. I've been working out for 10 weeks now and I am on week 2 of TRT. I trust in time, it will improve. I just want to make sure I'm doing everything I should be doing. The suggested supplements are ordered.

Nelson Vergel

Thread starter #6
Have patience at least with TRT and exercise since it takes a while to see effects on body composition.

Do you know what your triglycerides are? Are you taking any statins or fibrates? How is your blood glucose? The reason I ask is because people with high triglycerides and poor glycemic control are also more prone to having belly fat accumulation.

Please watch the exercise tips video on this link if you can: Options to treat lipodystrophy related fat accumulation
Thank you Nelson.

My total cholesterol is 183, triglycerides are 138, HDL is 54, VLDL is 28 and LDL is 101. I am currently taking Atorvastatin 40mg every night before bed. My fasting blood glucose is always under 100 except this last time it was 107.

When I was on Crixivan is really when the belly developed. After 2 bouts of kidney stones, my doctor switched my regimen to Atripla. That was about 7 years ago and the belly continued to grow. Now that I have finally discovered a doctor to treat my long term low testosterone, I am confident that with a dedicated exercise regimen, the tummy will go away and my body will look more balanced. Restoring my testosterone and losing the belly fat are my main goals at this time. After that I will focus on muscle growth although I figure that will be a pleasant side effect of my main 2 goals.

Nelson Vergel

Thread starter #8

Yes, you fit the clinical phenotype with metabolic disorder. Hopefully after weight loss you can eventually get off the statin.

Do you think your doctor can prescribe metformin and or Egrifta? Is your liver OK (no history of cirrhosis)?
Thank you Nelson. There is no way she'll prescribe either. I'm going to add HCG and I'm looking into metformin. On the advice of my infectious disease physician, I now have a PCP. On my first appointment with him just last week, he said the belly is from the meds. He's young, knowledgeable, and just moved back from Texas so I'm going to see if he'll prescribe Egrifta especially since my insurance covers it. Yes, thankfully my liver is OK with no history of cirrhosis.

Nelson Vergel

Thread starter #10
Good, let us know how it works.

I truly think that 500 mg of Metformin twice per day plus 2 mg Egrifta per day, plus a low glycemic load diet and exercise can be a great combination. Hopefully we can have someone do a study of this combo!

Metformin decreases B vitamin absorption, so make sure you supplement well.
Thanks for all the information. I have been suffering from visceral fat now since the late '90s and really need to lose alot of it. I am on metformin but am not diabetic. My consultant only put me on it to see if it helped with fat loss. To date it hasn't really. I have now purchased all of the supliments you mentioned but before I start any of them can you please explain exactly what is 'modified Atkins diet'? I could not see any difference on the atkins links that would suggest it is modified in any way. I am quite happy to cut out most of the bad carbs and hidden sugars in my diet. Thank you!
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Nelson Vergel

Thread starter #12
The old Atkins diet did not allow for most carbs. The modified version that was listed above has three phases that slowly introduce complex carbs after the initial no carb phase.

Nelson Vergel

Thread starter #15
Oral anabolic steroid treatment, but not parenteral androgen treatment, decreases abdominal fat in obese, older men.

International Journal of Obesity and Related Metabolic Disorders : Journal of the International Association for the Study of Obesity [1995, 19(9):614-624]

OBJECTIVE: To compare the effects of testosterone enanthate (TE), anabolic steroid (AS) or placebo (PL) on regional fat distribution and health risk factors in obese middle-aged men undergoing weight loss by dietary means.

DESIGN: Randomized, double-blind, placebo-controlled clinical trial, carried out for 9 months with primary assessments at 3 month intervals. Due to adverse blood lipid changes, the AS group was switched from oral oxandrolone (ASOX) to parenteral nandrolone decanoate (ASND) after the 3 month assessment point.

SUBJECTS: Thirty healthy, obese men, aged 40-60 years, with serum testosterone (T) levels in the low-normal range (2-5 ng/mL).

MAIN OUTCOME MEASURES: Abdominal fat distribution and thigh muscle volume by CT scan, body composition by dual energy X-ray absorptiometry (DEXA), insulin sensitivity by the Minimal Model method, blood lipids, blood chemistry, blood pressure, thyroid hormones and urological parameters.

RESULTS: After 3 months, there was a significantly greater decrease in subcutaneous (SQ) abdominal fat in the ASOX group compared to the TE and PL groups although body weight changes did not differ by treatment group. There was also a tendency for the ASOX group to exhibit greater losses in visceral fat, and the absolute level of visceral fat in this group was significantly lower at 3 months than in the TE and PL groups. There were significant main effects of treatment at 3 months on serum T and free T (increased in the TE group and decreased in the ASOX group) and on thyroid hormone parameters (T4 and T3 resin uptake significantly decreased in the ASOX group compared with the other two groups). There was a significant decrease in HDL-C, and increase in LDL-C in the ASOX group, which led to their being switched to the parenteral nandrolone decanoate (ASND) after 3 months. ASND had opposite effects on visceral fat from ASOX, producing a significant increase from 3 to 9 months while continuing to decrease SQ abdominal fat. ASND treatment also decreased thigh muscle area, while ASOX treatment increased high muscle. ASND reversed the effects of ASOX on lipoproteins and thyroid hormones. The previously reported effect of T to decrease visceral fat was not observed, in fact, visceral fat in the TE group increased slightly from 3 to 9 months, although SQ fat continued to decrease. Neither TE nor AS treatment resulted in any change in urologic parameters.

CONCLUSIONS: Oral oxandrolone decreased SQ abdominal fat more than TE or weight loss alone and also tended to produce favorable changes in visceral fat. TE and ASND injections given every 2 weeks had similar effects to weight loss alone on regional body fat. Most of the beneficial effects observed on metabolic and cardiovascular risk factors were due to weight loss per se. These results suggest that SQ and visceral abdominal fat can be independently modulated by androgens and that at least some anabolic steroids are capable of influencing abdominal fat.
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Hi Nelson
After purchasing all of the suggested suppliments I did notice on the L-Carnitine bottle it says to take it 1-2 hours BEFORE a meal. I noticed you say to take it with food. What should I do? Cheers!

Nelson Vergel

Thread starter #18
I hope you enjoyed the latest update to this thread. Most of it applies also to people without HIV who want to lose visceral fat.
I just started Egrifta Feb 2018 with full year to 2019 of therapy approved,My Height is 6-3 270 best weight with no belly was 220, In a 2014 post about Egrifta first you suggested NAC, Glycine, Glutathione. Would those supplements be found in this Metformin or is that a product to be taken in addition? I'm walking everywhere I can within reason locally not eating at night (very hard for a guy like me ) and switched to testosterone Androgel packets so can apply to butt, shoulders do not need anymore mass

Nelson Vergel

Thread starter #20
This is what I would suggest (I hope you have a good doctor. Who is he or she?)

Egrifta, two vials before bedtime in a single shot subcutaneously.

Metformin, 500 mg with breakfast and dinner (for a total of 1000 mg per day). Are you taking any integrase inhibitors? They is an interaction with that drug class.

A diet similar to the modified Atkins one I mention above.

Exercise: Weight training for 45 min three times per week followed by 30 min of cardio (treadmill or bicycle with enough resistance/angle to sweat within the first 10 minutes)

One packet of any time during the day with juice (it has glycine and NAC)

If your doctor is cool, 25 mg per day of oxandrolone from (prescription to be faxed)

Since you will be injecting Egrifta (tesamorelin) subcutaneously, I would inject testosterone at 50 mg twice per week also subcutaneously with a 27 gauge 1/2 inch insulin syringe.

I know it seems like a lot of work, but decreasing visceral fat is no easy task!