Lactation-associated postpartum weight changes among HIV-infected women in Zambia

Postpartum obesity and weight gain among human immunodeficiency virus-infected and human immunodeficiency virus-uninfected women in South Africa

In South Africa, up to 40% of pregnant women are living with human immunodeficiency virus (HIV), and 30-45% are obese. However, little is known about the dual burden of HIV and obesity in the postpartum period. In a cohort of HIV-uninfected and HIV-infected pregnant women initiating antiretroviral therapy in Cape Town, South Africa, we examined maternal anthropometry (weight and body mass index [BMI]) from 6 weeks through 12 months postpartum. Using multinomial logistic regression, we estimated associations between baseline sociodemographic, clinical, behavioural, and HIV factors and being overweight-obese I (BMI 25 to <35), or obese II-III (BMI >35), compared with being underweight or normal weight (BMI <25), at 12 months postpartum. Among 877 women, we estimated that 43% of HIV-infected women and 51% of HIV-uninfected women were obese I-III at enrollment into antenatal care, and 51% of women were obese I-III by 12 months postpartum. On average, both HIV-infected and HIV-uninfected women gained, rather than lost, weight between 6 weeks and 12 months postpartum, but HIV-uninfected women gained more weight (3.3 kg vs. 1.7 kg). Women who were obese I-III pre-pregnancy were more likely to gain weight postpartum. In multivariable analyses, HIV-infection status, being married/cohabitating, higher gravidity, and high blood pressure were independently associated with being obese II-III at 12 months postpartum. Obesity during pregnancy is a growing public health concern in low- and middle-income countries, including South Africa. Additional research to understand how obesity and HIV infection affect maternal and child health outcomes is urgently needed.

HIV-1 disease progression in immune-competent HIV-1-infected and breastfeeding mothers participating in the ANRS 12174 clinical trial in Burkina Faso, South Africa, Uganda and Zambia: a cohort study

OBJECTIVE

We have assessed HIV-1 disease progression among HIV-1-positive mothers in relation to duration of any or exclusive breast feeding in the context of ANRS 12174 trial.

METHODS

The analysis was completed on 203, 212, 272 and 529 HIV-1-positive and lactating mothers with CD4 count >350 cells/µL from Burkina Faso, South Africa, Uganda and Zambia, respectively. The trial compared lamivudine and lopinavir/ritonavir as a peri-exposure prophylaxis during a 50-week follow-up time. A multiple logistic regression model was run with the mothers' weight, CD4 count and HIV-1 viral load as separate dependent variables, then combined into a dependent composite endpoint called HIV-1 disease progression where HIV-1 viral load was replaced by the HIV-1 clinical stage. Exclusive or predominant breast feeding (EPBF) and any breastfeeding duration were the key explanatory variables.

RESULTS

In the adjusted model, the associations between EPBF duration and weight change, CD4 cell count and the HIV-1 viral load were consistently insignificant. The CD4 cell count was associated with a significantly higher mothers' body mass index (BMI; a mean increase of 4.9 (95% CI 2.1 to 7.7) CD4 cells/µL per each additional kilogram per square metre of BMI) and haemoglobin concentration (19.4 (95% CI 11.4 to 27.4) CD4 cells/µL per each additional gram per decilitre of haemoglobin concentration). There was no significant association between EPBF duration and HIV-1 disease progression. A higher education level was a factor associated with a slower HIV-1 disease progression.

CONCLUSION

Breast feeding was not a risk factor for a faster progression of HIV-1 disease in mothers of this cohort with a baseline CD4 cell count >350 cells/µL.

TRIAL REGISTRATION NUMBER

NCT0064026; Post-results.

Changes in body mass index and hemoglobin concentration in breastfeeding women living with HIV with a CD4 count over 350: Results from 4 African countries (The ANRS 12174 trial)

INTRODUCTION

Breastfeeding is recommended for infants born to HIV-infected women in low-income settings. Both breastfeeding and HIV-infection are energy demanding. Our objective was to explore how exclusive and predominant breastfeeding changes body mass index (BMI) among breastfeeding HIV1-positive women participating in the ANRS12174 trial (clinical trial no NCT0064026).

METHODS

HIV-positive women (n = 1 267) with CD4 count >350, intending to breastfeed HIV-negative infants were enrolled from Burkina Faso, South Africa, Uganda and Zambia and counselled on breastfeeding. N = 1 216 were included in the analysis. The trial compared Lamivudine and Lopinavir/Ritonavir as a peri-exposure prophylaxis. We ran a linear mixed-effect model with BMI as the dependent variable and exclusive or predominant breastfeeding duration as the key explanatory variable.

RESULTS

Any breastfeeding or exclusive/predominant) breastfeeding was initiated by 99.6% and 98.6% of the mothers respectively in the first week after birth. The median (interquartile range: IQR) duration of the group that did any breastfeeding or the group that did exclusive /predominant breastfeeding were 9.5 (7.5; 10.6) and 5.8 (5.6; 5.9)) months, respectively. The median (IQR) age, BMI, CD4 count, and HIV viral load at baseline (day 7) were 27 (23.3; 31) years, 23.7 (21.3; 27.0) kg/m2, 530 (432.5; 668.5) cells/μl and 0.1 (0.8; 13.7)1000 copies/mL, respectively. No major change in mean BMI was seen in this cohort over a 50-week period during lactation. The mean change between 26 and 50 weeks after birth was 0.7 kg/m2. Baseline mean BMI (measured on day 7 postpartum) and CD4 count were positively associated with maternal BMI change, with a mean increase of 1.0 kg/m2 (0.9; 1.0) per each additional baseline-BMI kilogram and 0.3 kg/m2 (0.2; 0.5) for each additional CD4 cell/μl, respectively.

CONCLUSION

Breastfeeding was not negatively correlated with the BMI of HIV-1 infected Sub-Saharan African mothers. However, a higher baseline BMI and a CD4 count >500 cells/μl were associated with maternal BMI during the exclusive/ predominant breastfeeding period. Considering the benefits of breast milk for the infants and the recurrent results from different studies that breastfeeding is not harmful to the HIV-1-infected mothers, this study also supports the WHO 2016 guidelines on infant feeding that mothers living with HIV should breastfeed where formula is not safe for at least 12 months and up to 24 months, given that the right treatment or prophylaxis for the infection is administered. These findings and conclusions cannot be extrapolated to women who are immune-compromised or have AIDS.

Food insecurity, but not HIV-infection status, is associated with adverse changes in body composition during lactation in Ugandan women of mixed HIV status

BACKGROUND

Body composition is an important indicator of nutritional status and health. How body composition changes during 12 mo of breastfeeding in HIV-infected women receiving antiretroviral therapy (ART) is unknown.

OBJECTIVE

We assessed whether HIV or food insecurity was associated with adverse postpartum body-composition changes in Ugandan women.

DESIGN

A cohort of 246 women [36.5% of whom were HIV positive (HIV+) and were receiving ART] were followed to 12 mo postpartum. Repeated measures included weight, fat mass, fat-free mass, midupper arm circumference, triceps skinfold thickness [which allowed for the derivation of arm muscle area (AMA) and arm fat area (AFA)], breastfeeding, and individual food insecurity. Longitudinal regression models were constructed to assess associations between HIV and food insecurity and changes in body composition over time.

RESULTS

At baseline, HIV+ women compared with HIV-negative women had a higher mean ± SD food-insecurity score (11.3 ± 5.5 compared with 8.6 ± 5.5, respectively; P < 0.001) and lower AMA (40.6 ± 5.7 compared with 42.9 ± 6.9 cm³, respectively; P = 0.03). Participants were thin at 1 wk postpartum [body mass index (BMI; in kg/m²): 22.9 ± 2.9]. From 1 wk to 12 mo, the weight change was -1.4 ± 4.4 kg. In longitudinal models of body-composition outcomes, HIV was not associated with body composition (all P > 0.05), whereas food insecurity was inversely associated with body weight and BMI at 6, 9, and 12 mo and with AFA at 6 and 12 mo (all P < 0.05). At 6 mo, every 1-unit increase in the food-insecurity score was associated with a 0.13-kg lower body weight (P < 0.001) and a 0.26-cm³ lower AFA (P < 0.01).

CONCLUSIONS

Body-composition changes are minimal during lactation. HIV is not associated with body composition; however, food insecurity is associated with changes in body composition during lactation. This trial was registered at clinicaltrials.gov as NCT02922829 and NCT02925429.

Breastmilk Output in a Disadvantaged Community with High HIV Prevalence as Determined by the Deuterium Oxide Dose-to-Mother Technique

INTRODUCTION

World Health Organization breastfeeding guidelines for HIV-infected mothers are exclusive breastfeeding for 6 months and then continued breastfeeding for 12 months, provided the mother is receiving antiretroviral prophylaxis. Many African women perceive that breastmilk alone is not sufficient for their infant's nutritional requirements for the first 6 months of life, and mixed feeding is a common practice.

METHODOLOGY

A stable isotope technique was used to determine breastmilk output volumes and maternal body composition objectively at five different time points in the first year of the infant's life.

RESULTS

Breastmilk output volumes were high for HIV-infected mothers: 831 ± 185 g/day at 6 weeks; 899 ± 188 g/day at 3 months; 871 ± 293 g/day at 6 months; 679 ± 281 g/day at 9 months; and 755 ± 287 g/day at 12 months. These high output volumes had no negative impact on the mother's fat-free mass. The breastmilk output volumes for HIV-uninfected mothers were not significantly different to the outputs for HIV-infected mothers at any of the time points (p > 0.05): 948 ± 223 g/day at 6 weeks; 925 ± 227 g/day at 3 months; 902 ± 286 g/day at 6 months; 746 ± 263 g/day at 9 months; and 713 ± 264 g/day at 12 months.

CONCLUSION

This study using objective methodology shows that breastmilk outputs of HIV-infected mothers were relatively high (and within published reference ranges), and mothers are able to provide sufficient breastmilk for their infants without compromising their own fat-free mass.

Breast-feeding and postpartum weight retention: a systematic review and meta-analysis

OBJECTIVE

Weight gained during pregnancy and postpartum weight retention might contribute to obesity in women of childbearing age. Whether breast-feeding (BF) may decrease postpartum weight retention (PPWR) is still controversial. The purpose of our systematic review and meta-analysis was to investigate the relationship between BF and PPWR.

DESIGN

Three databases were systematically reviewed and the reference lists of relevant articles were checked. Meta-analysis was performed to quantify the pooled standardized mean differences (SMD) of BF on PPWR by using a random-effect model. Heterogeneity was tested using the χ 2 test and I 2 statistics. Publication bias was estimated from Egger's test (linear regression method) or Begg's test (rank correlation method).

RESULTS

Among 349 search hits, eleven studies met the inclusion criteria for the meta-analysis. Seven studies were conducted in the USA, one in Brazil, one in France, one in Georgia and one in Croatia. Compared with formula-feeding, BF for 3 to ≤6 months seemed to have a negative influence on PPWR and if BF continued for >6 months had little or no influence on PPWR. In a subgroup meta-analysis, the results did not change substantially after the analysis had been classified by available confounding factors. There was no indication of a publication bias from the result of either Egger's test or Begg's test.

CONCLUSIONS

Although the available evidence held belief that BF decreases PPWR, more robust studies are needed to reliably assess the impact of patterns and duration of BF on PPWR.

HIV status, breastfeeding modality at 5 months and postpartum maternal weight changes over 24 months in rural South Africa

OBJECTIVE

To determine the effect of infant feeding practices on postpartum weight change among HIV-infected and -uninfected women in South Africa.

METHODS

In a non-randomised intervention cohort study of antiretroviral therapy-naïve women in South Africa, infants were classified as exclusive (EBF), mixed (MF) or non-breastfed (NBF) at each visit. We analysed infant feeding cumulatively from birth to 5 months using 24-hour feeding history (collected weekly for each of the preceding 7 days). Using generalised estimating equation mixed models, allowing for repeated measures, we compared postpartum weight change (kg) from the first maternal postpartum weight within the first 6 weeks (baseline weight) to each subsequent visit through 24 months among 2340 HIV-infected and -uninfected women with live births and at least two postpartum weight measurements.

RESULTS

HIV-infected (-0.2 kg CI: -1.7 to 1.3 kg; P = 0.81) and -uninfected women (-0.5 kg; 95% CI: -2.1 to 1.2 kg; P = 0.58) had marginal non-significant weight loss from baseline to 24 months postpartum. Adjusting for HIV status, socio-demographic, pregnancy-related and infant factors, 5-month feeding modality was not significantly associated with postpartum weight change: weight change by 24 months postpartum, compared to the change in the reference EBF group, was 0.03 kg in NBF (95% CI: -2.5 to +2.5 kg; P = 0.90) and 0.1 kg in MF (95% CI: -3.0 to +3.2 kg; P = 0.78).

CONCLUSION

HIV-infected and -uninfected women experienced similar weight loss over 24 months. Weight change postpartum was not associated with 5-month breastfeeding modality among HIV-infected and -uninfected women.

Postpartum weight change among HIV-infected mothers by antiretroviral prophylaxis and infant feeding modality in a research setting

OBJECTIVE

To assess the relationship between infant feeding, triple-antiretroviral prophylaxis and weight from 2 weeks (baseline) to 6 months postpartum among HIV-infected mothers in a mother-to-child transmission (MTCT) of HIV-prevention trial in five sub-Saharan African sites.

METHODS

HIV-infected pregnant women with CD4 cell counts of 200-500 cells/μl were counselled to choose breastfeeding to 6 months or replacement feeding from delivery. They were randomized to receive perinatal zidovudine and single-dose nevirapine or triple-antiretroviral MTCT prophylaxis until breastfeeding cessation. Mixed-effect linear models were used to compare maternal weight trajectories over time by infant feeding mode. Antiretroviral prophylaxis and BMI at baseline were examined as potential effect modifiers.

RESULTS

Among 797 mothers, 620 (78%) initiated breastfeeding. Wasting (BMI <18.5) was rare at baseline (2%), whereas overweight/obesity (BMI ≥ 25) was common (40%). In the model including all women, breastfeeding was not associated with weight loss up to 6 months, irrespective of baseline BMI and antiretroviral prophylaxis. Triple-antiretroviral prophylaxis was associated with weight gain among replacement-feeding mothers with baseline BMI at least 25 (+0.54 kg/month; P < 0.0001). In the model including breastfeeding mothers only, triple-antiretroviral prophylaxis was associated with weight gain among mothers with baseline BMI at least 25 who ceased breastfeeding before 3 months postpartum (+0.33 kg/month; P = 0.03).

CONCLUSION

The results suggest that breastfeeding up to 6 months postpartum is not detrimental for postpartum weight among well nourished HIV-infected mothers at intermediate-disease stage. In the absence of breastfeeding or after weaning, triple-antiretroviral prophylaxis is associated with weight gain among women with high BMI, even after cessation of prophylaxis.

Maternal weight loss during exclusive breastfeeding is associated with reduced weight and length gain in daughters of HIV-infected Malawian women

Maternal weight loss during exclusive breastfeeding may influence the growth of exclusively breast-fed infants through impaired quality or quantity of breast milk. This study evaluated how maternal weight loss from 2 to 24 wk postpartum was related to infant weight and length gain in 1309 lactating HIV-infected mothers and their exclusively breast-fed infants. Malawian mother-infant pairs in the Breastfeeding, Antiretrovirals, and Nutrition Study were randomized with a 2 × 3 factorial design to a 2-arm nutritional intervention with a lipid-based nutrient supplement (LNS), meeting nutritional needs of lactation, or no LNS and a 3-arm antiretroviral (ARV) intervention (maternal, infant, or no ARV regimen). Linear regression models were used to relate maternal weight loss (weight loss vs. no weight loss) to infant weight and length gain from birth to 24 mo, stratifying by gender and controlling for maternal BMI at 2 wk (mean ± SD: 23.2 ± 3.0 kg/m(2)) and interacting maternal BMI with weight loss. In adjusted models, compared with daughters of women who did not lose weight, length and weight gain were lower in daughters whose mothers had a lower BMI at 2 wk postpartum coupled with the weight loss. For example, among mothers with an initial BMI of 18 kg/m(2), daughters of those who lost weight gained less weight [β = -0.29 kg (95% CI: -0.53, -0.06)] and length [β = -0.88 cm (95% CI: -1.52, -0.23)] from birth to 24 wk than daughters of those who gained weight. Though effects were only observed in girls, suggesting possible gender differences in suckling and feeding behavior, these findings indicate that maternal weight loss with low energy reserves represents a risk factor for poor infant growth outcomes.

Predictive value of weight loss on mortality of HIV-positive mothers in a prolonged breastfeeding setting

HIV-positive lactating women may be at high risk of weight loss due to increased caloric requirements and postpartum physiological weight loss. Ten percent weight loss is associated with a higher risk of mortality in HIV-positive patients and this alone is a criterion for highly active antiretroviral therapy (HAART) initiation where CD4 counts are not available. However, no study has investigated this association in lactating postpartum women. We investigated whether 10% weight loss predicts death in postpartum HIV-positive women. A total of 9207 HIV-negative and 4495 HIV-positive mothers were recruited at delivery. Women were weighed at 6 weeks, 3 months, and every 3 months thereafter for up to 24 months postpartum and data on mortality up to 2 years were collected. The median duration of breastfeeding was longer than 18 months. Among HIV-positive women, the independent predictors of ≥10% weight loss were CD4 cell count, body mass index, and household income. Mortality was up to 7.12 (95% CI 3.47-14.61) times higher in HIV-positive women with ≥10% weight loss than those without weight loss. Ten percent weight loss in postpartum lactating HIV-positive women was significantly predictive of death. Our findings suggest that 10% weight loss is an appropriate criterion for HAART initiation among postpartum breastfeeding women.