Macronutrient supplementation and food prices in HIV treatment

Whole-protein enteral nutrition formula supplementation reduces Escherichia and improves intestinal barrier function in HIV-infected immunological nonresponders

People living with human immunodeficiency virus (PLWH) have persistent malnutrition, intestinal barrier dysfunction, and gut microbial imbalance. The interplay between gut microbiota and nutrients is involved in the immune reconstitution of PLWH. To evaluate the effects of whole-protein enteral nutrition formula supplementation on T-cell levels, intestinal barrier function, nutritional status, and gut microbiota composition in human immunodeficiency virus (HIV)-infected immunological nonresponders (INRs) who failed to normalize CD4+ T-cell counts, with a number <350 cells/µL, a pilot study was carried out in 13 HIV-infected INRs undergoing antiretroviral therapy who received a 3-month phase supplementation of 200 mL/200 kcal/45 g whole-protein enteral nutrition formula once daily. Our primary endpoint was increased CD4+ T-cell counts. Secondary outcome parameters were changes in intestinal barrier function, nutritional status, and gut microbiota composition. We showed that CD4+ T-cell counts of HIV-infected INRs increased significantly after the 3-month supplementation. Dietary supplementation for 3 months improved the intestinal barrier function and nutritional status of HIV-infected INRs. Furthermore, the enteral nutrition formula significantly decreased the relative abundance of Escherichia at the genus level and increased the alpha diversity of gut microbiota in HIV-infected INRs. The findings demonstrated that the whole-protein enteral nutrition formula aids in reducing Escherichia and improving intestinal barrier function in HIV-infected INRs. This study provides insight into the role of nutrients in the improvement of immune reconstitution in HIV-infected INRs. This study is registered in the Chinese Clinical Trial Registry (Document No. ChiCTR2000037839; http://www.chictr.org.cn/index.aspx).

Magnitude and Predictors of Dietary Diversity among HIV-Infected Adults on Antiretroviral Therapy: The Case of North-Western, Ghana

Introduction

Though people living with HIV/AIDS require a good combination of antiretroviral therapy and healthy dietary habits for a quality life and positive medical outcomes, little is, however, known regarding the dietary practices of HIV-positive patients who receive antiretroviral therapy (ART) in the Lawra Municipality.

Objective

This study assessed the magnitude and factors associated with dietary diversity among HIV-positive patients on antiretroviral therapy (ART).

Methods

This study was a facility-based cross-sectional study of 269 study participants recruited using a systematic random sampling technique. Bivariate and multivariable logistic regression analyses were performed to identify factors associated with their dietary diversity.

Results

This study shows that only 36 (13.4%) of the sample consumed a diversified diet with a mean dietary diversity score of 3.7 ± 0.99. Starchy staple foods (96.7%) and flesh food (92.9%) were the most consumed foods. Being a nonfarmer employee (AOR = 10.76, 95% CI = 1.03-112.35), not taking cotrimoxazole prophylaxis (AOR = 3.76, 95% CI = 1.02-14.37) and adults of age 18-27 years (AOR = 5.95, 95% CI = 1.18-30.07) were significant predictors of high dietary diversity.

Conclusion

This study revealed that dietary diversity was a significant nutritional problem among HIV-positive adults in Lawra Municipal Hospital. Starchy staple foods and flesh food were the most consumed foods, while organ meats, dairy products, and eggs were eaten less. Having a secured salary paid job, not taking cotrimoxazole prophylaxis, and being a young adult were strong predictors of a high dietary diversity score. Therefore, efforts should be made to strengthen and improve the economic status and to educate these vulnerable groups on the need to adhere to cotrimoxazole prophylaxis uptake.

Exploring feasibility and acceptability of an integrated urban gardens and peer nutritional counselling intervention for people with HIV in the Dominican Republic

OBJECTIVE

Food security interventions with people living with HIV (PLHIV) are needed to improve HIV outcomes. This process evaluation of a pilot intervention involving urban gardening and peer nutritional counselling with PLHIV assesses feasibility, acceptability and implementation challenges to inform scale-up.

DESIGN

Mixed methods were used, including quantitative data on intervention participation and feasibility and acceptability among participants (n 45) and qualitative data from a purposive sample of participants (n 21). Audio-recorded interviews were transcribed and coded using a codebook developed iteratively.

SETTING

An HIV clinic in the northwest-central part of the Dominican Republic.

RESULTS

The intervention was feasible for most participants: 84 % attended a garden workshop and 71 % established an urban garden; 91 % received all three core nutritional counselling sessions; and 73 % attended the cooking workshop. The intervention was also highly acceptable: nearly, all participants (93-96 %) rated the gardening as 'helpful' or 'very helpful' for taking HIV medications, their mental/emotional well-being and staying healthy; similarly, high percentages (89-97 %) rated the nutrition counselling 'helpful' or 'very helpful' for following a healthy diet, reducing unhealthy foods and increasing fruit/vegetable intake. Garden barriers included lack of space and animals/pests. Transportation barriers impeded nutritional counselling. Harvested veggies were consumed by participants' households, shared with neighbours and family, and sold in the community. Many emphasised that comradery with other PLHIV helped them cope with HIV-related marginalisation.

CONCLUSION

An urban gardens and peer nutritional counselling intervention with PLHIV was feasible and acceptable; however, addressing issues of transportation, pests and space is necessary for equitable participation and benefit.

Nutritional status and the associated factors among people living with HIV: an evidence from cross-sectional survey in hospital based antiretroviral therapy site in Kathmandu, Nepal

BACKGROUND

Nutritional status is the key concern among the people living with HIV but this issue has been failed to be prioritized in HIV strategic plan of Nepal. This study aims to assess the nutritional status among people living with HIV and determine their associated factors.

METHODS

A hospital based cross-sectional study was conducted where 350 people living with HIV attending the ART clinic were selected using systematic random sampling technique. Nutritional status among people living with HIV was assessed through anthropometry, body mass index; Underweight (body mass index < 18.5 kg/m2) and overweight/obesity (body mass index > 23 kg/m2). HIV related clinical factors such CD4 count, WHO stage, opportunistic infection, antiretroviral therapy regimen etc. were collected from the medical records. Socio-demographic data were collected using pretested structured questionnaire through interview technique. Multiple linear regression method was employed to determine the association between different independent factors and body mass index score.

RESULTS

The prevalence of underweight was found to be 18.3% (95% CI: 14.3-22.6). Most of the study participants were overweight/obese (39.1%). After subjection to multiple linear regression analysis, it was found that age, being male, being married, being in business occupation, smoking, hemoglobin level and antiretroviral therapy duration were significantly associated with body mass index score. Majority of the participants in our study lacked diversified food (62.3%).

CONCLUSION

Overweight/obesity is an emerging problem among people living with HIV. This group of participants should be screened for the presence of non-communicable disease. This study also highlights the importance of nutritional program being an integral part of HIV/AIDS continuum of care. Therefore, an effort should be made to address the burden of malnutrition by addressing the identified determinants.

Determinants of chronic energy deficiency among adults living with HIV in Shebel Berenta District, East Gojjam, Amhara region, North West Ethiopia, 2017: case control study

OBJECTIVE

To assess determinants of chronic energy deficiency in adults living with HIV in Shebel Berenta District Anti-Retroviral Therapy (ART) site health centers, East Gojjam, Amhara region, Ethiopia, 2017. An institutional based unmatched case control study design was employed and simple random sampling was used to select the desired sample size for both cases and controls. Data were entered to Epi-Data 3.1, exported to SPSS version 20 for analysis. Binary logistic regression was used to identify the determinants of chronic energy malnutrition among Human Immune Deficiency Virus positive adult patients.

RESULTS

A total of 473 (118 cases and 355 controls) People Living with Human Immune Deficiency Virus (PLHIV) adult patients were participated. PLHIV who started ART at world health organization (WHO) clinical stage I (AOR: 0.285, CI 0.10, 0.81), rural residents (AOR: 0.38, CI 0.17, 0.83), had family size ≤ 3 (AOR: 0.114, CI 0.03, 0.48) and changed their feeding style (AOR: 0.075, CI 0.038, 0.150) decreased the risk of chronic energy deficiency. However, the baseline CD4 cell < 200/mm3 (AOR: 13.398; CI 4.83, 37.19), monthly family income ≤ 500 Ethiopia Birr (AOR: 6.9, CI 1.07, 44.62) and interrupted treatment (AOR: 2.28, CI 1.02, 5.09) were increasing the risk of chronic energy deficiency. Therefore; the government and partners should focus on the above determinants to improve the nutritional status of the clients.

Food elimination, food substitution, and nutrient supplementation among ARV-exposed HIV-positive persons in southern Ghana

BACKGROUND

Optimal nutrition is a determinant of health in all persons. In persons living with HIV (PLHIV), nutrition is particularly important. Various factors, including dietary practices, play a role in guaranteeing nutritional health.

OBJECTIVES

We investigated multiple non-prescription drugs use among HIV-positive persons receiving antiretroviral therapy (ART) from four treatment centers in southern Ghana. This paper, however, focuses on nutrient supplement use, food elimination, and food substitution practices by the PLHIV.

METHODS

Using quantitative and qualitative methods, we collected data from 540 HIV-positive persons at the health facility level. This paper focuses on only the quantitative data. Individual study participants were selected using a systematic random sampling procedure. Participants were interviewed after informed consent. We used univariate analysis to generate descriptive tabulations for key variables. Multivariable logistic regression modeling identified predictors of three practices (nutrient supplementation, food elimination, and food substitution). P value less than 0.05 or 95% confidence intervals facilitated determination of statistical significance. All analyses were performed using IBM SPSS Statistics for Windows, version 20.0.

RESULTS

The use of nutrient supplements was a popular practice; 72% of the PLHIV used various kinds. The primary motive for the practice was to boost appetite and to gain weight. A little over 20% of the participants reportedly eliminated certain foods and beverages, while 17% introduced new foods since their initial HIV diagnosis. All the three practices were largely driven by the quest for improved health status. We determined predictors of nutrient supplementation to be ART clinic location and having an ART adherence monitor. Having an ART adherence monitor was significantly associated with reduced odds of nutrient supplementation (AOR = 0.34; 95% CI 0.12-0.95). The only predictor for food elimination was education level (AOR = 0.29; 95% CI 0.30-0.92); predictors of food substitution were ART clinic location (AOR = 0.11; 95% CI 0.02-0.69) and anemia (defined as hemoglobin concentration less than 11.0 g/dl) (AOR = 0.21; 95% CI 0.12-0.85).

CONCLUSIONS

The practice of supplementation is popular among this group of PLHIV. Food elimination and substitution are practiced, albeit in moderation. The predictors identified may prove helpful in provider-client encounters as well as local HIV programming.

Oral administration of an aqueous extract from the oyster mushroom Pleurotus ostreatus enhances the immunonutritional recovery of malnourished mice

Mushroom nutriceutical components have lately attracted interest for developing immunonutritional support. However, there is relatively little information pertaining to the use of mushroom preparations for modulating the metabolic and immunological disorders associated to malnutrition. This study was aimed to evaluate the effects of oral administration of an aqueous extract (CW-P) from Pleurotus ostreatus on the recovery of biochemical and immunological functions of malnourished mice. 8-week old female BALB/c mice were starved for 3days and then refed with commercial diet supplemented with or without CW-P (100mg/kg) for 8days. Regardless of the diet used during refeeding, animal body weights and serum protein concentrations did not differ between groups. Oral treatment with CW-P normalized haemoglobin levels, liver arginase and gut mucosal weight. CW-P increased total liver proteins and also DNA and protein contents in gut mucosa. Pleurotus extract provided benefits in terms of macrophages activation as well as in haemopoiesis, as judged by the recovery of bone marrow cells and leukocyte counts. Moreover, CW-P stimulated humoral immunity (T-dependent and T non-dependent antibodies responses) compared to non-supplemented mice. CW-P extract from the oyster mushroom can be used to develop specific food or nutritional supplement formulations with potential clinical applications in the immunotherapy.

Undernutrition and associated factors among adults living with Human Immune Deficiency Virus in Dembia District, northwest Ethiopia: an institution based cross-sectional study

Background

Appropriate dietary intake determines the disease progression and success of Anti-Retroviral Therapy (ART). Undernutrition unacceptably increases the risk of mortality among adults living with Human Immune Deficiency Virus (HIV). However in resource limited settings including Ethiopia, many of HIV positive clients lack access to sufficient quantities of nutritious food. There is limited evidences showing the magnitude of undernutrition in this segment of the community, particularly in the rural residents. Therefore, this study aimed to assess undernutrition and associated factors among HIV positive adults attending ART clinic in Dembia District.

Methods

An institution based cross-sectional study was conducted in Dembia District from October 1 to 30, 2015. Systematic random sampling technique was used to recruit the study subjects. The anthropometric measurement, Body Mass Index, was computed to determine the nutritional status of the study participants. In order to identify factors associated with undernutrition a multivariable logistic regression analysis was employed. The Adjusted Odds Ratio (AOR) with 95 % Confidence Interval (CI) was calculated to show the strength of association. In multivariable analysis, variables with a P-value of <0.05 were considered as statistically significant.

Results

Of the study participants, about 23.2 % [95 % CI: 19.2, 27.2 %] were undernourished in Dembia District. The result of adjusted analysis revealed that, the odds of undernutrition was higher among adults whose age ranged between 18-29 years [AOR = 2.50, 95 % CI: 1.10, 5.69], who had a Cluster of Differentiation (CD)4 count less than 200 cells/mm³ [AOR = 6.21, 95 % CI: 2.97, 12.98), were widowed [AOR = 2.18, 95 % CI: 1.08,4.40), and anemic [AOR = 3.17, 95 % CI: 1.70, 5.92].

Conclusions

The prevalence of undernutrition among HIV positive adults was higher in the study area. Furthermore, being in the age range of 18-29 years, widowed, anemic, and having a CD4 count of less than 200 cells/mm³ were positively associated with undernutrition. Therefore, efforts should be strengthened to mitigate the higher burden of undernutrition by considering the identified determinants.

Does Food Insecurity Undermine Adherence to Antiretroviral Therapy? A Systematic Review

A growing body of research has identified food insecurity as a barrier to antiretroviral therapy (ART) adherence. We systematically reviewed and summarized the quantitative literature on food insecurity or food assistance and ART adherence. We identified nineteen analyses from eighteen distinct studies examining food insecurity and ART adherence. Of the thirteen studies that presented an adjusted effect estimate for the relationship between food insecurity and ART adherence, nine found a statistically significant association between food insecurity and sub-optimal ART adherence. Four studies examined the association between food assistance and ART adherence, and three found that ART adherence was significantly better among food assistance recipients than non-recipients. Across diverse populations, food insecurity is an important barrier to ART adherence, and food assistance appears to be a promising intervention strategy to improve ART adherence among persons living with HIV. Additional research is needed to determine the effectiveness and cost-effectiveness of food assistance in improving ART adherence and other clinical outcomes among people living with HIV in the era of widespread and long-term treatment.

Shamba Maisha: Pilot agricultural intervention for food security and HIV health outcomes in Kenya: design, methods, baseline results and process evaluation of a cluster-randomized controlled trial

BACKGROUND

Despite advances in treatment of people living with HIV, morbidity and mortality remains unacceptably high in sub-Saharan Africa, largely due to parallel epidemics of poverty and food insecurity.

METHODS/DESIGN

We conducted a pilot cluster randomized controlled trial (RCT) of a multisectoral agricultural and microfinance intervention (entitled Shamba Maisha) designed to improve food security, household wealth, HIV clinical outcomes and women's empowerment. The intervention was carried out at two HIV clinics in Kenya, one randomized to the intervention arm and one to the control arm. HIV-infected patients >18 years, on antiretroviral therapy, with moderate/severe food insecurity and/or body mass index (BMI) <18.5, and access to land and surface water were eligible for enrollment. The intervention included: 1) a microfinance loan (~$150) to purchase the farming commodities, 2) a micro-irrigation pump, seeds, and fertilizer, and 3) trainings in sustainable agricultural practices and financial literacy. Enrollment of 140 participants took four months, and the screening-to-enrollment ratio was similar between arms. We followed participants for 12 months and conducted structured questionnaires. We also conducted a process evaluation with participants and stakeholders 3-5 months after study start and at study end.

DISCUSSION

Baseline results revealed that participants at the two sites were similar in age, gender and marital status. A greater proportion of participants at the intervention site had a low BMI in comparison to participants at the control site (18% vs. 7%, p = 0.054). While median CD4 count was similar between arms, a greater proportion of participants enrolled at the intervention arm had a detectable HIV viral load compared with control participants (49% vs. 28%, respectively, p < 0.010). Process evaluation findings suggested that Shamba Maisha had high acceptability in recruitment, delivered strong agricultural and financial training, and led to labor saving due to use of the water pump. Implementation challenges included participant concerns about repaying loans, agricultural challenges due to weather patterns, and a challenging partnership with the microfinance institution. We expect the results from this pilot study to provide useful data on the impacts of livelihood interventions and will help in the design of a definitive cluster RCT.

TRIAL REGISTRATION

This trial is registered at ClinicalTrials.gov, NCT01548599.

Sensory evaluation of locally-grown fruit purees and inulin fibre on probiotic yogurt in Mwanza, Tanzania and the Microbial Analysis of Probiotic Yogurt Fortified with Moringa oleifera

The purpose of this study was to establish new food products that increase the nutritional value and health benefits of the probiotic yogurt currently used in the Western Heads East (WHE) Project in Mwanza, Tanzania. The probiotic yogurt has established health benefits, and product development through fortification must not adversely affect the acceptability of yogurt or the viability of the probiotics. Both sensory testing and microbial analysis testing were conducted. The products tested were yogurt fortified with locally-grown fruit purees with inulin and Moringa oleifera. The results of the sensory evaluation showed that all yogurts were not rated significantly different from the control, except for appearance. The avocado puree without inulin rated significantly lower in all categories. The microbial analysis showed that Moringa oleifera did not negatively affect the growth of Lactobacillus rhamnosus GR-1 in MRS, milk or yogurt, although a significant decrease was found after 5 weeks of storage at 4 (o)C.

Impact of food support on food security and body weight among HIV antiretroviral therapy recipients in Honduras: a pilot intervention trial

Optimal strategies to improve food security and nutrition for people living with HIV (PLHIV) may differ in settings where overweight and obesity are prevalent and cardiovascular disease risk is a concern. However, no studies among PLHIV have investigated the impact of food support on nutritional outcomes in these settings. We therefore assessed the effect of food support on food insecurity and body weight in a population of PLHIV with high prevalence of overweight and obesity. We implemented a pilot intervention trial in four government-run HIV clinics in Honduras. The trial tested the effect of a monthly household food ration plus nutrition education (n = 203), compared to nutrition education alone (n = 197), over 12 months. Participants were clinic patients receiving antiretroviral therapy (ART). Assessments were obtained at baseline, 6 and 12 months. Primary outcomes for this analysis were food security, using the validated Latin American and Caribbean Food Security Scale and body weight (kg). Thirty-one percent of participants were overweight (22%) or obese (8%) at baseline. At 6 months, the probability of severe food insecurity decreased by 48.3% (p < 0.01) in the food support group, compared to 11.6% in the education-only group (p < 0.01). Among overweight or obese participants, food support led to average weight gain of 1.13 kg (p < 0.01), while nutrition education alone was associated with average weight loss of 0.72 kg (p < 0.10). Nutrition education alone was associated with weight gain among underweight and normal weight participants. Household food support may improve food security but not necessarily nutritional status of ART recipients above and beyond nutrition education. Improving nutritional tailoring of food support and testing the impact of nutrition education should be prioritized for PLHIV in Latin America and similar settings.

Tailored nutrition education and food assistance improve adherence to HIV antiretroviral therapy: evidence from Honduras

Food insecurity and malnutrition negatively affect adherence to antiretroviral therapy (ART) and are associated with poor HIV clinical outcomes. We examined the effect of providing household food assistance and nutrition education on ART adherence. A 12-month prospective clinical trial compared the effect of a monthly household food basket (FB) plus nutrition education (NE) versus NE alone on ART adherence on 400 HIV patients at four clinics in Honduras. Participants had been receiving ART for an average of 3.7 years and were selected because they had suboptimal adherence. Primary outcome measures were missed clinic appointments, delayed prescription refills, and self-reported missed doses of ART. These three adherence measures improved for both groups over 12 months (p < 0.01), mostly within 6 months. On-time prescription refills improved for the FB plus NE group by 19.6 % more than the group receiving NE alone after 6 months (p < 0.01), with no further change at 12 months. Change in missed appointments and self-reported missed ART doses did not significantly differ by intervention group.

Success and challenges of measuring program impacts: an international study of an infant nutrition program for AIDS orphans

The HIV/AIDS epidemic in Zambia threatens maternal survival and jeopardizes the ability for families to care for their children. The Christian Alliance for Children in Zambia (CACZ) operates a program called Milk and Medicine (M&M) that distributes food, formula, and medicine at churches in the compounds. This article reports on a mixed methods study to evaluate the outcomes of the M&M program. On-site interviews with families combined with an analysis of a longitudinal data set were the methods used. The results of the study showed families face continuous hardship including hunger, unemployment, disease, and loss. Families expressed appreciation for the program and its staff and suggested improvements. The longitudinal data review helped researchers to recommend an improved protocol for data management. Improved data will assist researchers in an on-going evaluation to compare the growth rates of children in the study to the Zambian normal growth charts. Lessons learned from this evaluation validated the use of mixed methods design for exploratory research on an emerging program. Lessons were also learned about the difficulty of working in natural settings with political and cultural variations. Future evaluations of the M&M program are expected to shed light on more specific program impacts.

Depression and dietary intake in a cohort of HIV-positive clients in Sydney

This cross-sectional study aimed to compare dietary intake in people living with HIV (PLHIV) experiencing symptoms of depression with those not reporting depression. The Centre for Epidemiologic Studies Depression Scale (CES-D10) was used to classify the risk of depression. Dietary nutrient intake was determined using the diet history and food frequency questionnaire. Depressed ( n = 21) compared with non-depressed ( n = 37) subjects had significantly lower mean intake of fibre (16.1 versus 25.4 g/day), vitamin A (801.5 versus 1524.8 mg/day), magnesium (299.8 versus 380.0 mg/day) and folate (264.8 versus 402.9 μg/day). The proportion of subjects achieving the recommended intake of these nutrients, with the exception of folate was also found to be lower in the depressed group compared with non-depressed group. The study found that depressive symptomatology in PLHIV was associated with poorer dietary nutrient intake. A multidisciplinary model of care that includes a nutrition assessment is recommended for the management of PLHIV with depression to reduce the risk of associated nutritional problems.

Conceptual framework for understanding the bidirectional links between food insecurity and HIV/AIDS

Food insecurity, which affects >1 billion people worldwide, is inextricably linked to the HIV epidemic. We present a conceptual framework of the multiple pathways through which food insecurity and HIV/AIDS may be linked at the community, household, and individual levels. Whereas the mechanisms through which HIV/AIDS can cause food insecurity have been fairly well elucidated, the ways in which food insecurity can lead to HIV are less well understood. We argue that there are nutritional, mental health, and behavioral pathways through which food insecurity leads to HIV acquisition and disease progression. Specifically, food insecurity can lead to macronutrient and micronutrient deficiencies, which can affect both vertical and horizontal transmission of HIV, and can also contribute to immunologic decline and increased morbidity and mortality among those already infected. Food insecurity can have mental health consequences, such as depression and increased drug abuse, which, in turn, contribute to HIV transmission risk and incomplete HIV viral load suppression, increased probability of AIDS-defining illness, and AIDS-related mortality among HIV-infected individuals. As a result of the inability to procure food in socially or personally acceptable ways, food insecurity also contributes to risky sexual practices and enhanced HIV transmission, as well as to antiretroviral therapy nonadherence, treatment interruptions, and missed clinic visits, which are strong determinants of worse HIV health outcomes. More research on the relative importance of each of these pathways is warranted because effective interventions to reduce food insecurity and HIV depend on a rigorous understanding of these multifaceted relationships.

Nutritional screening tools for HIV-infected patients: implications for elderly patients

BACKGROUND

Nutrition is a crucial issue for elderly HIV-infected patients. Screening tools (''DETERMINE your nutrition health checklist'' [NSI], the Mini-Nutritional Assessment [MNA], the Malnutrition Universal Screening Tool [MUST] test, and the modified version of the Subjective Global Assessment [SGA]-HIV) might not detect problems in visceral fat accumulation, visceral protein loss, and lipodystrophy in elderly HIV-positive populations.

METHODS

Literature review of articles in English, French, and Spanish published in Medline and Cochrane databases through January 2010.

RESULTS

New studies question the use of body mass index (BMI) and weight loss as proxies for nutritional problems in HIV-positive patients. In the case of elderly HIV-infected patients, screening tools to deal with the aforementioned issues are currently being investigated.

CONCLUSION

The authors suggest that a unique nutritional screening test that contains measures including BMI, weight loss, waist-to-hip (W/H) ratio, and mid-arm circumference may be able to detect nutritional problems in elderly patients infected with HIV. Further trials combining these 4 anthropometric measures in elderly HIV-infected patients are needed.

Role of Nutrition in HIV Infection: Review of Evidence for more Effective Programming in Resource-Limited Settings

Background

HIV infection and malnutrition negatively reinforce each other.

Objective

For program guidance, to review evidence on the relationship of HIV infection and malnutrition in adults in resource-limited settings.

Results and conclusions

Adequate nutritional status supports immunity and physical performance. Weight loss, caused by low dietary intake (loss of appetite, mouth ulcers, food insecurity), malabsorption, and altered metabolism, is common in HIV infection. Regaining weight, particularly muscle mass, requires antiretroviral therapy (ART), treatment of opportunistic infections, consumption of a balanced diet, physical activity, mitigation of side effects, and perhaps appetite stimulants and growth hormone. Correcting nutritional status becomes more difficult as infection progresses. Studies document widespread micronutrient deficiencies among HIV-infected people. However, supplement composition, patient characteristics, and treatments vary widely across intervention studies. Therefore, the World Health Organization (WHO) recommends ensuring intake of 1 Recommended Nutrient Intake (RNI) of each required micronutrient, which may require taking micronutrient supplements. Few studies have assessed the impact of food supplements. Because the mortality risk in patients receiving ART increases with lower body mass index (BMI), improving the BMI seems important. Whether this requires provision of food supplements depends on the patient's diet and food security. It appears that starting ART improves BMI and that ready-to-use fortified spreads and fortified-blended foods further increase BMI (the effect is somewhat less with fortified-blended foods). The studies are too small to assess effects on mortality. Once ART has been established and malnutrition treated, the nutritional quality of the diet remains important, also because of ART's long-term metabolic effects (dyslipidemia, insulin resistance, obesity). Food insecurity should also be addressed if it prevents adequate energy intake and reduces treatment initiation and adherence (due to the opportunity costs of obtaining treatment and mitigating side effects).

Addressing Tuberculosis in the Context of Malnutrition and HIV Coinfection

Background

Tuberculosis is the second leading cause of infectious disease mortality (1.8 million/year), after HIV/AIDS. There are more than 9 million new cases each year. One-third of the world's population, and 50% of adults in sub-Saharan Africa, South Asia, and South-East Asia, are infected, representing an enormous pool of individuals at risk for developing the disease. The situation is complicated by the HIV/AIDS pandemic, widespread undernutrition, smoking, diabetes, increased mobility, and emergence of multi- and extensively drug-resistant tuberculosis.

Objective

To review the scientific evidence about the interactions among tuberculosis, nutrition, and HIV coinfection.

Results

HIV infection and malnutrition lower immunity, increasing the risk of reactivation tuberculosis and primary progressive disease. Having either tuberculosis or HIV infection causes weight loss. Malnutrition markedly increases mortality among both tuberculosis and HIV/AIDS patients and should be treated concurrently with treatment of the infections. Tuberculosis treatment is a prerequisite for nutritional recovery, in addition to intake of nutrients required for rebuilding tissues, which is constrained in food-insecure households. Additional pharmaceutical treatment to reduce the catabolic impact of inflammation or promote growth may be needed. Specific nutrients can contribute to faster sputum smear clearance, which is important for reducing transmission, as well as faster weight gain when combined with an adequate diet. Adequate nutrition and weight gain in undernourished populations might reduce the incidence of tuberculosis.

Conclusions

The many risk factors for the development of tuberculosis need to be addressed simultaneously, especially HIV/AIDS and food insecurity and undernutrition. For stronger evidence-based guidelines, existing recommendations and clinical applications need to be more widely applied and evaluated.

Preventing food crises using a food policy approach

A food crisis occurs when rates of hunger and malnutrition rise sharply at local, national, or global levels. This definition distinguishes a food crisis from chronic hunger, although food crises are far more likely among populations already suffering from prolonged hunger and malnutrition. A food crisis is usually set off by a shock to either supply or demand for food and often involves a sudden spike in food prices. It is important to remember that in a market economy, food prices measure the scarcity of food, not its value in any nutritional sense. Except in rare circumstances, the straightforward way to prevent a food crisis is to have rapidly rising labor productivity through economic growth and keep food prices stable while maintaining access by the poor. The formula is easier to state than to implement, especially on a global scale, but it is good to have both the objective, reducing short-run spikes in hunger, and the deep mechanisms, pro-poor economic growth and stable food prices, clearly in mind. A coherent food policy seeks to use these mechanisms, and others, to achieve a sustained reduction in chronic hunger over the long run while preventing spikes in hunger in the short run.

Household dietary diversity and food expenditures are closely linked in rural Bangladesh, increasing the risk of malnutrition due to the financial crisis

In Bangladesh, rice prices are known to be positively associated with the prevalence of child underweight and inversely associated with household nongrain food expenditures, an indicator of dietary quality. The collection of reliable data on household expenditures is relatively time consuming and requires extensive training. Simple dietary diversity scores are increasingly used as measures of food security and as proxies for nutrient adequacy. This study examines associations between a simple dietary diversity score and commonly used indicators of socioeconomic status in Bangladesh. Data representative of rural Bangladesh was collected from 188,835 households over 18 rounds of bi-monthly data collection from 2003-2005. A simple household dietary diversity score was developed by summing the number of days each household consumed an item from each of 7 food groups over a 7-d period. The dietary diversity score was associated with per capita nongrain food expenditures (r = 0.415), total food expenditures (r = 0.327), and total household expenditures (r = 0.332) using Spearman correlations (all P < 0.0001). The frequency of meat and egg consumption showed greater variation across quintiles of total monthly expenditure than other items contributing to the dietary diversity score. After controlling for other measures of socioeconomic status in multiple linear regression models, the dietary diversity score was significantly associated with monthly per capita food and total expenditures. Low dietary diversity during the period prior to major food price increases indicates potential risk for worsening of micronutrient deficiencies and child malnutrition in Bangladesh.

Vitamin A intake and status in populations facing economic stress

Dietary quality and diversity reflect adequacy of vitamin A. Both can deteriorate in response to economic crises. Although the nutritional consequences of the 2008 world food price crisis remain unclear, past studies of diet, status, and socioeconomic standing under usual (deprived) and unusually disruptive times suggest dietary quality and vitamin A status decline in mothers and young children. This is presumably the result of shifting diets to include less preformed vitamin A-rich animal source foods and, to a lesser extent, vegetables and fruits. Cross-sectional assessments of diet, deficiency, and socioeconomic status in a number of countries and surveillance data collected during the Indonesian economic crisis of 1997-8 indicate that the prevalence of vitamin A deficiency, night blindness, and other related disorders (e.g., anemia) may have increased during the 2008 crisis, and that it might not have necessarily recovered once food prices waned later in 2008. Lost employment may be a factor in slow nutritional recovery, despite some easing of food prices. Vitamin A deficiency should still be preventable amid economic instabilities through breast feeding promotion, vitamin A supplementation, fortification of foods targeted to the poor, and homestead food production that can bolster income and diversify the diet.

Castel Gandolfo workshop: an introduction to the impact of climate change, the economic crisis, and the increase in the food prices on malnutrition

The global food supply system is facing serious new challenges from economic and related crises and climate change, which directly affect the nutritional well-being of the poor by reducing their access to nutritious food. To cope, vulnerable populations prioritize consumption of calorie-rich but nutrient-poor food. Consequently, dietary quality and eventually quantity decline, increasing micronutrient malnutrition (or hidden hunger) and exacerbating preexisting vulnerabilities that lead to poorer health, lower incomes, and reduced physical and intellectual capabilities. This article introduces the series of papers in this supplement, which explore the relationships between crises and their cumulative impacts among vulnerable populations, particularly through hidden hunger.

Medium- to long-run implications of high food prices for global nutrition

The combined food, fuel, and financial crises of 2007-2009 had severe and widespread negative impacts around the world. Two key questions challenging governments were: how long would the high prices last and with what effects on food security and nutrition over the longer run? This paper considers the drivers of the crisis and explores if, unlike past shocks, the recent price increases reflect structural changes in food price formation that will have lasting global implications. New cross-commodity relationships allowed prices to spike, although there was no shortage of food at the global level nor indeed a significant downturn in recent yields. Yet recent record levels of farm production were also mirrored by growing numbers of people chronically undernourished and/or micronutrient deficient. The gap between supply and need was underpinned by growing urban demand, consumption of processed and higher-value foods (including meat), biofuel policy, and purchasing power erosion, but also by short-term market-distorting policies implemented by governments responding to perceived shortages of food. Thus, the impact of future food price crises will depend largely on what policymakers chose to do in response to the peaks and what they do not do during the troughs. Appropriate investments are urgently needed not just in smallholder developing country agriculture, but in effective food policies and targeted programming that can reverse the recent negative trends in nutrition and that support access globally to improved diet quality as well as food quantity.

Maternal and young child nutrition adversely affected by external shocks such as increasing global food prices

Rising food prices, resulting from the ongoing global economic crisis, fuel price volatility, and climate change, have an adverse impact upon the poor, especially those in food-importing, resource-limited countries. The conventional approach by large organizations has been to advocate for increased staple crop yields of mainly cereals. High food prices are predicted to continue to at least 2015. Past shocks and their known impacts upon nutrition were reviewed. Price instability and increases have long been an existing global problem, which has been exacerbated by recent macroeconomic shocks such as acute emergencies due to war and civil strife, acute climatic events, increase in food prices, fuel price volatility, dysfunction of the global financial systems, long-term climate change, and the emergence of failed states. The FAO estimated that there were 815 million "hungry" people in 2006, with a now additional 75-135 million with increased vulnerability, and currently it is estimated that there are one billion people at risk of food insecurity. The shocks initially compromise maternal and child nutrition, mainly through a reduction in dietary quality and an increase in micronutrient deficiencies and concomitant increases in infectious disease morbidity and mortality. A further reduction in the quantity of diet may follow with greater underweight and wasting. Recent macroeconomic shocks have greatly increased the number of people who are vulnerable to hunger in developing countries. Nutritional surveillance systems need to be strengthened and expanded to inform policy decisions.

Higher household expenditure on animal-source and nongrain foods lowers the risk of stunting among children 0-59 months old in Indonesia: implications of rising food prices

Because the global financial crisis and high food prices affect food consumption, we characterized the relationship between stunting and nongrain food expenditure at the household level among children 0-59 mo old in Indonesia's rural and urban poor population. Expenditure and height-for-age data were obtained from a population-based sample of 446,473 children in rural and 143,807 in urban poor areas in Indonesia. Expenditure on food was grouped into categories: animal, plant, total nongrain, and grain. The prevalence of stunting in rural and urban poor areas was 33.8 and 31.2%, respectively. In rural areas, the odds ratios (OR) (5th vs. first quintile) for stunting were similar for proportion of household expenditure on animal (0.87; 95% CI = 0.85-0.90; P < 0.0001), plant (0.86; 95% CI = 0.84-0.88; P < 0.0001), and total nongrain (0.85; 95% CI = 0.83-0.87; P < 0.0001). In urban poor areas, the relationship between stunting and proportion of household expenditure on animal sources was stronger than in rural areas (OR 0.78; 95% CI = 0.74-0.81; P < 0.0001), whereas the relationship with nongrain was similar to rural areas (OR 0.88; 95% CI = 0.85-0.92; P < 0.0001) and no relationship was observed with plant sources (OR 0.97; 95% CI = 0.93-1.01; P = 0.13). For grain expenditure, OR for stunting in highest vs. lowest quintile was 1.21 (95% CI = 1.18-1.24; P < 0.0001) in rural and 1.09 (95%CI = 1.04-1.13; P < 0.0001) in urban poor areas. Thus, households that spent a greater proportion on nongrain foods, in particular animal source foods, had a lower prevalence of child stunting. This suggests potential increased risk of malnutrition associated with reductions of household expenditure due to the current global crises.

Household rice expenditure and maternal and child nutritional status in Bangladesh

In Bangladesh, poor rural families often deal with high food costs by purchasing primarily rice. Our objective was to characterize the relationship between household expenditure on rice and nonrice foods with maternal and child malnutrition. Food expenditure data and anthropometry were obtained in a population-based sample of 304,856 households in the Bangladesh Nutrition Surveillance Project, 2000-2005. Food expenditures were categorized as rice and nonrice foods and expressed as quintiles of proportional food expenditure. Of children aged 6-11, 12-23, and 24-59 mo, the prevalence of stunting was 33.5, 56.3, and 53.1%, respectively. The prevalence of maternal underweight (BMI < 18.5 kg/m(2)) was 37.3%. Among children aged 6-11, 12-23, and 24-59 mo, rice expenditures were associated with stunting [odds ratio (OR) 1.11, 95% CI 1.02-1.20, P = 0.01; OR 1.09, 95% CI 1.04-1.13, P < 0.0001; OR 1.13, 95% CI 1.08-1.18, P < 0.0001), respectively, among families in the highest compared with the lowest quintile, adjusting for potential confounders, and nonrice food expenditures were associated with stunting (OR 0.87, 95% CI 0.80-0.95, P = 0.002; OR 0.86, 95% CI 0.83-0.90, P < 0.0001; OR 0.89, 95% CI 0.85-0.94, P < 0.0001) among families in the highest compared with the lowest quintile, adjusting for potential confounders. In the highest compared with the lowest quintile, rice expenditures (OR 1.12, 95% CI 1.08-1.15, P < 0.0001) and nonrice food expenditures (OR 0.93, 95% CI 0.90-0.96, P < 0.0001) were associated with maternal underweight. Households that spent a greater proportion on nonrice foods and less on rice had a lower prevalence of maternal and child malnutrition.

The role of expanded coverage of the national vitamin A program in preventing morbidity and mortality among preschool children in India

Higher food prices increase the risk of vitamin A deficiency among preschool children in poor families, because a larger part of the household food budget is spent on grain foods and less on vitamin A-rich foods. Vitamin A supplementation is an important source of vitamin A for children. Our objective was to characterize coverage of the India national vitamin A program for preschool children and identify risk factors for not receiving vitamin A. Anthropometric and demographic data were examined in 23,008 children aged 12-59 mo in the India National Family Health Survey, 2005-2006. Within the last 6 mo, 20.2% of children received vitamin A supplementation. The prevalence of stunting, severe stunting, underweight, and severe underweight was higher among children who did not receive vitamin A compared with those who received vitamin A (P < 0.0001). In families with a child who did and did not receive vitamin A, respectively, the proportion with a history of under-5 child mortality was 8.4 vs. 11.4% (P < 0.0001). By state, vitamin A program coverage was inversely proportional to the under-5 child mortality rate (r = -0.51; P = 0.004). Maternal education of > or =10 y [odds ratio (OR) 2.22; 95% CI 1.69-2.91], 7-9 y (OR 1.99; 95% CI 1.57-2.53), or 1-6 y (OR 1.65; 95% CI 1.28-2.13) compared with no education was an important factor related to receipt of vitamin A. Poor coverage of the vitamin A supplementation program in India has serious implications in the face of rising food prices. Expanded coverage of the vitamin A program in India will help protect children from morbidity, mortality, and blindness.

Impact of the economic crisis and increase in food prices on child mortality: exploring nutritional pathways

The current economic crisis and food price increase may have a widespread impact on the nutritional and health status of populations, especially in the developing world. Gains in child survival over the past few decades are likely to be threatened and millennium development goals will be harder to achieve. Beyond starvation, which is one of the causes of death in famine situations, there are numerous nutritional pathways by which childhood mortality can increase. These include increases in childhood wasting and stunting, intrauterine growth restriction, and micronutrient deficiencies such as that of vitamin A, iron, and zinc when faced with a food crisis and decreased food availability. These pathways are elucidated and described. Although estimates of the impact of the current crisis on child mortality are yet to be made, data from previous economic crises provide evidence of an increase in childhood mortality that we review. The current situation also emphasizes that there are vast segments of the world's population living in a situation of chronic food insecurity that are likely to be disproportionately affected by an economic crisis. Nutritional and health surveillance data are urgently needed in such populations to monitor both the impacts of a crisis and of interventions. Addressing the nutritional needs of children and women in response to the present crisis is urgent. But, ensuring that vulnerable populations are also targeted with known nutritional interventions at all times is likely to have a substantial impact on child mortality.

How to ensure nutrition security in the global economic crisis to protect and enhance development of young children and our common future

The global economic crisis, commodity price hikes, and climate change have worsened the position of the poorest and most vulnerable people. These crises are compromising the diet and health of up to 80% of the population in most developing countries and threaten the development of almost an entire generation of children ( approximately 250 million), because the period from conception until 24 mo of age irreversibly shapes people's health and intellectual ability. High food prices reduce diversity and nutritional quality of the diet and for many also reduce food quantity. Poor households are hit hardest, because they already spend 50-80% of expenditures on food, little on medicines, education, transport, or cooking fuel, and cannot afford to pay more. Reduced public spending, declining incomes, increased food and fuel prices, and reduced remittance thus impede and reverse progress made toward Millenium Development Goals 1, 4, and 5. Investments in nutrition are among the most cost-effective development interventions because of very high benefit:cost ratios, for individuals and for sustainable growth of countries, because they protect health, prevent disability, boost economic productivity, and save lives. To bridge the gap between nutrient requirements, particularly for groups with high needs, and the realistic dietary intake under the prevailing circumstances, the use of complementary food supplements to increase a meal's nutrient content is recommended. This can be in the form of, e.g., micronutrient powder or low-dose lipid-based nutrient supplements, which can be provided for free, in return for vouchers, at subsidized, or at commercial prices.

Safety nets can help address the risks to nutrition from increasing climate variability

Models of climate change predict increased variability of weather as well as changes in agro-ecology. The increased variability will pose special challenges for nutrition. This study reviews evidence on climate shocks and nutrition and estimates the economic consequences in terms of reduced schooling and economic productivity stemming from nutritional insults in childhood. Panel data covering up to 20 y indicate that that short-term climate shocks have long-term impacts on children that persist, often into their adult lives. Other studies document the potential for relief programs to offset these shocks providing that the programs can be implemented with flexible financing, rapid identification of those affected by the shock, and timely scale-up. The last of these presumes that programs are already in place with contingency plans drawn up. Arguably, direct food distribution, including that of ready-to-use therapeutic food, may be part of the overall strategy. Even if such programs are too expensive for sustainable widespread use in the prevention of malnutrition, scalable food distribution programs may be cost effective to address the heightened risk of malnutrition following weather-related shocks.

The food, fuel, and financial crises affect the urban and rural poor disproportionately: a review of the evidence

The vulnerability of the urban poor to the recent food and fuel price crisis has been widely acknowledged. The unfolding global financial crisis, which brings higher unemployment and underemployment, is likely to further intensify this vulnerability. This paper reviews the evidence concerning the disproportionate vulnerability of the urban compared with the rural poor to these types of shocks. It reviews some of the unique characteristics of urban life that could make the urban poor particularly susceptible to price and financial shocks and summarizes the evidence regarding the disproportionate vulnerability of the urban poor. The focus is on impacts on poverty, food insecurity, and malnutrition. The review shows that although the urban poor are clearly one of the population groups most affected by the current (and previous) crises, the rural poor, landless, and net buyers are in no better position to confront the crisis without significant suffering. The poorest of the poor are the ones who will be most affected, irrespective of the continent, country, or urban or rural area where they live. The magnitude and severity of their suffering depends on their ability to adapt and on the specific nature, extent, and duration of the coping strategies they adopt. A better understanding of how these coping strategies are used and staggered is critical to help design triggers for action that can prevent households from moving to more desperate measures. Using these early coping strategies as early warning indicators could help prevent dramatic losses in welfare.

High food prices and the global financial crisis have reduced access to nutritious food and worsened nutritional status and health

A global economic and financial crisis is engulfing the developing world, coming on top of high food and fuel prices. This paper assesses the impact of the crises on food consumption, nutrition, and health. Several methods were applied, including risk analysis using the cost of the food basket, assessment surveys, simulations, regression analysis using a food consumption score (FCS), reflecting diet frequency and diversity, and a review of the impact of such dietary changes on nutritional status and health. The cost of the food basket increased in several countries, forcing households to reduce quality and quantity of food consumed. The FCS, which is a measure of diet diversity, is negatively correlated with food prices. Simulations show that energy consumption declined during 2006-2010 in nearly all developing regions, resulting potentially in an additional 457 million people (of 4.5 billion) at risk of being hungry and many more unable to afford the dietary quality required to perform, develop, and grow well. As a result of the crises, large numbers of vulnerable households have reduced the quality and quantity of foods they consume and are at risk of increased malnutrition. Population groups most affected are those with the highest requirements, including young children, pregnant and lactating women, and the chronically ill (particularly people with HIV/AIDS and tuberculosis). Because undernutrition during the first 2 y of life has life-long consequences, even short-term price rises will have long-term effects. Thus, measures to mitigate the impact of the crises are urgently required.