Body fat redistribution syndrome

Overview

Body fat redistribution syndrome (BFRS), also known as lipodystrophy syndrome, is a metabolic condition characterized by abnormal changes in the distribution of body fat. It is most commonly observed in individuals undergoing long-term antiretroviral therapy (ART) for HIV/AIDS. BFRS may present as either lipoatrophy (loss of subcutaneous fat) or lipohypertrophy (accumulation of fat), or a combination of both. These changes can be physically disfiguring and psychologically distressing, and they are often associated with metabolic complications such as insulin resistance and dyslipidemia.

Causes

The primary cause of body fat redistribution syndrome is the long-term use of certain antiretroviral medications, especially older-generation drugs such as:

• Protease inhibitors (PIs) – associated with fat accumulation (lipohypertrophy)

• Nucleoside reverse transcriptase inhibitors (NRTIs) – particularly stavudine and zidovudine, associated with fat loss (lipoatrophy)

Other contributing factors include:

• HIV infection itself – chronic inflammation and immune activation may play a role

• Genetic predisposition

• Age and duration of HIV therapy

• Metabolic factors – such as insulin resistance and elevated triglycerides

Symptoms

Symptoms of body fat redistribution syndrome vary based on whether the individual experiences fat loss, fat accumulation, or both. Common manifestations include:

• Lipoatrophy (fat loss):

  • Sunken cheeks

  • Loss of fat in arms, legs, or buttocks

  • Prominent veins in limbs due to loss of subcutaneous tissue

• Lipohypertrophy (fat accumulation):

  • Fat buildup in the abdomen (central obesity)

  • Buffalo hump – fat accumulation on the back of the neck

  • Breast enlargement (in both men and women)

  • Lipomas – benign fatty tumors under the skin

• Metabolic symptoms:

  • Elevated blood sugar levels (insulin resistance or diabetes)

  • High cholesterol and triglycerides

  • Increased risk of cardiovascular disease

Diagnosis

Diagnosis of BFRS is largely clinical, based on physical examination and patient history, particularly in those receiving antiretroviral therapy. Diagnostic steps include:

• Medical history – including duration and type of ART used

• Physical examination – to assess fat loss and accumulation

• Body composition analysis – using tools like DEXA (dual-energy X-ray absorptiometry) or CT/MRI to quantify fat distribution

• Laboratory tests – to evaluate glucose levels, lipid profile, and insulin sensitivity

There is no universal diagnostic test, and diagnosis often relies on observing characteristic changes over time.

Treatment

Treatment of body fat redistribution syndrome involves a combination of lifestyle changes, medication adjustments, and sometimes surgical or cosmetic procedures. Options include:

• Modification of antiretroviral therapy – switching from older drugs like stavudine or zidovudine to newer, less lipodystrophy-associated medications

• Exercise and diet – regular physical activity and a balanced diet to manage fat distribution and metabolic issues

• Medications – to manage associated metabolic complications (e.g., statins for cholesterol, insulin sensitizers for glucose control)

• Reconstructive procedures – such as facial fillers or fat grafting for lipoatrophy

• Liposuction or surgical removal – in severe cases of lipohypertrophy, particularly for buffalo hump or large lipomas

Prognosis

The prognosis of BFRS depends on the severity of symptoms, the underlying cause, and how early the condition is recognized and managed. While fat redistribution may not completely reverse, switching ART and addressing metabolic issues can significantly improve health and appearance. With newer HIV medications, the incidence of BFRS has decreased. However, for those already affected, long-term management is often necessary to maintain metabolic health and psychological well-being.