Oral supplements as adjunctive treatment to nutritional counseling in malnourished HIV-infected patients: randomized controlled trial

Nutrition counselling and clinical outcomes in HIV: A systematic review and meta-analysis

BACKGROUND

People living with the HIV (PLHIV) are at an increased risk of various diseases due to a weakened immune system, particularly if they are naïve or poorly adherent to antiretroviral therapy (ART). Nutrients play a critical role in improving immune health, especially among this population. We systematically reviewed the evidence concerning the impact of nutritional counselling on the occurrence of important clinical outcomes among PLHIV.

METHODS

Medical literature databases (PubMed, EMBASE and Web of Science) were searched from inception to October 2022 for relevant published studies (n = 12) of nutritional counselling and HIV-related outcomes in adults on ART. Random-effects meta-analyses were conducted when the exposure-outcome relationships were similar in three or more studies.

RESULTS

Although the methodologies of nutritional intervention varied across all studies, overall, the evidence from the meta-analysis indicates a nsignificant positive association between nutrition counselling and improvements in CD4 cell count, body mass index and low-density lipoprotein concentration. However, the existing literature does not provide enough evidence to establish a significant impact of nutrition counselling on other immune, anthropometric, and metabolic outcomes including viral load, weight, and lean mass due to the differences in the study designs.

CONCLUSION

Well-powered randomized controlled trials are needed that explore the effect of evidence-based, individualized nutrition counselling on HIV-related clinical outcomes.

Lipid-based nutrient supplement at initiation of antiretroviral therapy does not substitute energy from habitual diet among HIV patients – a secondary analysis of data from a randomised controlled trial in Ethiopia

Introduction: Malnutrition is common among people with HIV in sub-Saharan Africa. Nutritional supplementation at initiation of antiretroviral treatment (ART) has shown beneficial effects, but it is not known if supplementation replaces or supplements the habitual energy intake in a context of food insecurity. Methods: As part of a randomised controlled trial among people with HIV initiating ART in Ethiopia, we assessed whether the provision of a lipid-based nutrient supplement (LNS) affected energy intake from the habitual diet. People with HIV aged ≥18 years with a body mass index (BMI) >17 were randomly allocated 2:1 to receive either early (month 1–3 after ART initiation) or delayed (month 4–6 after ART initiation) supplementation with LNS (≈4,600 kJ/day). Participants with BMI 16–17 were all allocated to early supplementation. The daily energy intake from the habitual diet (besides the energy contribution from LNS) was assessed using a 24-h food recall interview at baseline and at monthly follow-up visits. Linear mixed models were used to compare habitual energy intake in (1) early versus delayed supplementation groups and (2) supplemented versus unsupplemented time periods within groups. Results: Of 301 participants included, 67% of the participants were women, mean (±standard deviation [SD]) age was 32.9 (±8.9) years and 68% were living in moderately or severely food insecure households. Mean (±SD) reported habitual energy intake at baseline was 5,357 kJ/day (±2,246) for women and 7,977 kJ/day(±3,557) for men. Among all participants, there were no differences in mean habitual energy intake between supplemented and unsupplemented groups in neither the first 3 (P = 0.72) nor the following 3 months (P = 0.56). Furthermore, habitual energy intake did not differ within groups when comparing periods with or without supplementation (P = 0.15 and P = 0.20). The severity of food insecurity did not modify the effect of supplementation in habitual energy intake (P = 0.55). Findings were similar when participants with BMI 16–17 were excluded. Conclusion: Our findings indicate that the LNS provided after ART initiation supplement, rather than substitute, habitual energy intake among people with HIV, even among those who are food insecure. This supports the feasibility of introducing nutritional supplementation as part of HIV treatment.

Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults

BACKGROUND

Disease-related malnutrition has been reported in 10% to 55% of people in hospital and the community and is associated with significant health and social-care costs. Dietary advice (DA) encouraging consumption of energy- and nutrient-rich foods rather than oral nutritional supplements (ONS) may be an initial treatment.

OBJECTIVES

To examine evidence that DA with/without ONS in adults with disease-related malnutrition improves survival, weight, anthropometry and quality of life (QoL).

SEARCH METHODS

We identified relevant publications from comprehensive electronic database searches and handsearching. Last search: 01 March 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of DA with/without ONS in adults with disease-related malnutrition in any healthcare setting compared with no advice, ONS or DA alone.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility, risk of bias, extracted data and graded evidence.

MAIN RESULTS

We included 94, mostly parallel, RCTs (102 comparisons; 10,284 adults) across many conditions possibly explaining the high heterogeneity.  Participants were mostly older people in hospital, residential care and the community, with limited reporting on their sex. Studies lasted from one month to 6.5 years.  DA versus no advice - 24 RCTs (3523 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.87 (95% confidence interval (CI) 0.26 to 2.96), or at later time points. We had no three-month data, but advice may make little or no difference to hospitalisations, or days in hospital after four to six months and up to 12 months. A similar effect was seen for complications at up to three months, MD 0.00 (95% CI -0.32 to 0.32) and between four and six months. Advice may improve weight after three months, MD 0.97 kg (95% CI 0.06 to 1.87) continuing at four to six months and up to 12 months; and may result in a greater gain in fat-free mass (FFM) after 12 months, but not earlier. It may also improve global QoL at up to three months, MD 3.30 (95% CI 1.47 to 5.13), but not later. DA versus ONS - 12 RCTs (852 participants) All outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.66 (95% CI 0.34 to 1.26), or at later time points. Either intervention may make little or no difference to hospitalisations at three months, RR 0.36 (95% CI 0.04 to 3.24), but ONS may reduce hospitalisations up to six months. There was little or no difference between groups in weight change at three months, MD -0.14 kg (95% CI -2.01 to 1.74), or between four to six months. Advice (one study) may lead to better global QoL scores but only after 12 months. No study reported days in hospital, complications or FFM. DA versus DA plus ONS - 22 RCTs (1286 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.92 (95% CI 0.47 to 1.80) or at later time points. At three months advice may lead to fewer hospitalisations, RR 1.70 (95% CI 1.04 to 2.77), but not at up to six months. There may be little or no effect on length of hospital stay at up to three months, MD -1.07 (95% CI -4.10 to 1.97). At three months DA plus ONS may lead to fewer complications, RR 0.75 (95% CI o.56 to 0.99); greater weight gain, MD 1.15 kg (95% CI 0.42 to 1.87); and better global QoL scores, MD 0.33 (95% CI 0.09 to 0.57), but this was not seen at other time points. There was no effect on FFM at three months. DA plus ONS if required versus no advice or ONS - 31 RCTs (3308 participants) Evidence was moderate- to low-certainty. There may be little or no effect on mortality at three months, RR 0.82 (95% CI 0.58 to 1.16) or at later time points. Similarly, little or no effect on hospitalisations at three months, RR 0.83 (95% CI 0.59 to 1.15), at four to six months and up to 12 months; on days in hospital at three months, MD -0.12 (95% CI -2.48 to 2.25) or for complications at any time point. At three months, advice plus ONS probably improve weight, MD 1.25 kg (95% CI 0.73 to 1.76) and may improve FFM, 0.82 (95% CI 0.35 to 1.29), but these effects were not seen later. There may be little or no effect of either intervention on global QoL scores at three months, but advice plus ONS may improve scores at up to 12 months. DA plus ONS versus no advice or ONS - 13 RCTs (1315 participants) Evidence was low- to very low-certainty. There may be little or no effect on mortality after three months, RR 0.91 (95% CI 0.55 to 1.52) or at later time points. No study reported hospitalisations and there may be little or no effect on days in hospital after three months, MD -1.81 (95% CI -3.65 to 0.04) or six months. Advice plus ONS may lead to fewer complications up to three months, MD 0.42 (95% CI 0.20 to 0.89) (one study). Interventions may make little or no difference to weight at three months, MD 1.08 kg (95% CI -0.17 to 2.33); however, advice plus ONS may improve weight at four to six months and up to 12 months. Interventions may make little or no difference in FFM or global QoL scores at any time point.

AUTHORS' CONCLUSIONS

We found no evidence of an effect of any intervention on mortality. There may be weight gain with DA and with DA plus ONS in the short term, but the benefits of DA when compared with ONS are uncertain. The size and direction of effect and the length of intervention and follow-up required for benefits to emerge were inconsistent for all other outcomes.  There were too few data for many outcomes to allow meaningful conclusions. Studies focusing on both patient-centred and healthcare outcomes are needed to address the questions in this review.

Disorders of nutritional status in sepsis - facts and myths

The problem of diagnosing nutritional status disorders in septic patients remains unresolved. This is associated with the necessity of the introduction of newer and newer methods of assessing nutritional status, often requiring precise and expensive equipment as well as employment of professionals in this field in hospital wards, primarily including intensive care units (ICU). Methods that have been applied thus far for assessing nutritional status, also used in severely ill septic patients, have little impact on improving treatment results. This is due to the high dynamics of changes in nutritional status in these patients, healing process variability in individual patients, and the “mismatch” of methods for assessing nutritional status in relation to the patient’s clinical status. The diagnostic value of the traditional methods of assessing nutritional status, i.e. anthropometric analysis and selected laboratory tests, as markers of nutritional status disorders in septic patients, is still debatable. There is still no precise method that could become the “gold standard” allowing for early identification of malnutrition in these group of patients. Phase angle, bioelectrical impedance vector analysis (BIVA), and the “illness marker”, obtained directly from the resistance, reactance, and impedance, can be used as prognostic or nutritional indices in severely ill septic patients, but the intensity of research on this subject needs to be increased. Detailed assessment of nutritional status should include tests of selected inflammation markers (including TLC, HMGB1, IL-6, IL-10, IL-1ra, sTNFRI).

Nutrition support in hospitalised adults at nutritional risk

BACKGROUND

The prevalence of disease-related malnutrition in Western European hospitals is estimated to be about 30%. There is no consensus whether poor nutritional status causes poorer clinical outcome or if it is merely associated with it. The intention with all forms of nutrition support is to increase uptake of essential nutrients and improve clinical outcome. Previous reviews have shown conflicting results with regard to the effects of nutrition support.

OBJECTIVES

To assess the benefits and harms of nutrition support versus no intervention, treatment as usual, or placebo in hospitalised adults at nutritional risk.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid SP), Embase (Ovid SP), LILACS (BIREME), and Science Citation Index Expanded (Web of Science). We also searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp); ClinicalTrials.gov; Turning Research Into Practice (TRIP); Google Scholar; and BIOSIS, as well as relevant bibliographies of review articles and personal files. All searches are current to February 2016.

SELECTION CRITERIA

We include randomised clinical trials, irrespective of publication type, publication date, and language, comparing nutrition support versus control in hospitalised adults at nutritional risk. We exclude trials assessing non-standard nutrition support.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane and the Cochrane Hepato-Biliary Group. We used trial domains to assess the risks of systematic error (bias). We conducted Trial Sequential Analyses to control for the risks of random errors. We considered a P value of 0.025 or less as statistically significant. We used GRADE methodology. Our primary outcomes were all-cause mortality, serious adverse events, and health-related quality of life.

MAIN RESULTS

We included 244 randomised clinical trials with 28,619 participants that met our inclusion criteria. We considered all trials to be at high risk of bias. Two trials accounted for one-third of all included participants. The included participants were heterogenous with regard to disease (20 different medical specialties). The experimental interventions were parenteral nutrition (86 trials); enteral nutrition (tube-feeding) (80 trials); oral nutrition support (55 trials); mixed experimental intervention (12 trials); general nutrition support (9 trials); and fortified food (2 trials). The control interventions were treatment as usual (122 trials); no intervention (107 trials); and placebo (15 trials). In 204/244 trials, the intervention lasted three days or more.We found no evidence of a difference between nutrition support and control for short-term mortality (end of intervention). The absolute risk was 8.3% across the control groups compared with 7.8% (7.1% to 8.5%) in the intervention groups, based on the risk ratio (RR) of 0.94 (95% confidence interval (CI) 0.86 to 1.03, P = 0.16, 21,758 participants, 114 trials, low quality of evidence). We found no evidence of a difference between nutrition support and control for long-term mortality (maximum follow-up). The absolute risk was 13.2% in the control group compared with 12.2% (11.6% to 13%) following nutritional interventions based on a RR of 0.93 (95% CI 0.88 to 0.99, P = 0.03, 23,170 participants, 127 trials, low quality of evidence). Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.We found no evidence of a difference between nutrition support and control for short-term serious adverse events. The absolute risk was 9.9% in the control groups versus 9.2% (8.5% to 10%), with nutrition based on the RR of 0.93 (95% CI 0.86 to 1.01, P = 0.07, 22,087 participants, 123 trials, low quality of evidence). At long-term follow-up, the reduction in the risk of serious adverse events was 1.5%, from 15.2% in control groups to 13.8% (12.9% to 14.7%) following nutritional support (RR 0.91, 95% CI 0.85 to 0.97, P = 0.004, 23,413 participants, 137 trials, low quality of evidence). However, the Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.Trial Sequential Analysis of enteral nutrition alone showed that enteral nutrition might reduce serious adverse events at maximum follow-up in people with different diseases. We could find no beneficial effect of oral nutrition support or parenteral nutrition support on all-cause mortality and serious adverse events in any subgroup.Only 16 trials assessed health-related quality of life. We performed a meta-analysis of two trials reporting EuroQoL utility score at long-term follow-up and found very low quality of evidence for effects of nutritional support on quality of life (mean difference (MD) -0.01, 95% CI -0.03 to 0.01; 3961 participants, two trials). Trial Sequential Analyses showed that we did not have enough information to confirm or reject clinically relevant intervention effects on quality of life.Nutrition support may increase weight at short-term follow-up (MD 1.32 kg, 95% CI 0.65 to 2.00, 5445 participants, 68 trials, very low quality of evidence).

AUTHORS' CONCLUSIONS

There is low-quality evidence for the effects of nutrition support on mortality and serious adverse events. Based on the results of our review, it does not appear to lead to a risk ratio reduction of approximately 10% or more in either all-cause mortality or serious adverse events at short-term and long-term follow-up.There is very low-quality evidence for an increase in weight with nutrition support at the end of treatment in hospitalised adults determined to be at nutritional risk. The effects of nutrition support on all remaining outcomes are unclear.Despite the clinically heterogenous population and the high risk of bias of all included trials, our analyses showed limited signs of statistical heterogeneity. Further trials may be warranted, assessing enteral nutrition (tube-feeding) for different patient groups. Future trials ought to be conducted with low risks of systematic errors and low risks of random errors, and they also ought to assess health-related quality of life.

Treatment With Nandrolone Decanoate and Megestrol Acetate in HIV-Infected Men

BACKGROUND

Malnutrition, especially loss of lean body mass, is a frequent complication of people living with HIV that may increase their mortality and morbidity.

METHODS

Nine HIV-infected men with unexplained loss of >10% of their usual weight were selected. They received megestrol acetate (MA) (400 mg/day by mouth) and nandrolone decanoate (ND) (100 mg/15 days intermuscular injection) over 16 weeks. Anthropometric evaluations, bioelectrical impedance, grip strength dynamometry, hematologic, biochemical, immunological and hormonal analysis before, during, and after the treatment were performed. Quality of life was evaluated by the Karnofsky index.

RESULTS

In the 7 men that finished the treatment, there were significant increases in weight (11.9 +/- 9.1 kg, p < .05), 4-site skinfold measurements (p < .05), midarm circumference (p < .005), and fat-free mass (FFM) (5.1 +/- 4.1 kg, p < .05). The increase in fat mass was not statistically significant (6.9 +/- 6.4 kg, NS). Muscle strength increased significantly (p < .005). The Karnofsky index values increased from 59% to 73% (p < .05). One patient developed mild hyperglycemia and another one had an increase in aspartate transaminase and gamma-glutamyl transpeptidase that reversed after the treatment. Four patients developed asymptomatic adrenal suppression. Testosterone serum levels decreased significantly during the study (p < .05), and 4 patients had serum values below the normal range at week 16. One patient developed gynecomastia.

CONCLUSIONS

The combined treatment with MA and ND led to a significant increase in body weight and FFM. Muscle strength and quality of life improved during the study. The treatment was well tolerated with mild side effects.

Nutrition education and counselling as strategic interventions to improvehealth outcomes in adult outpatients with HIV: a literature review

Malnutrition poses a significant risk for people living with HIV and accelerates disease progression. This is because adequate nutrition is essential for optimal immune function. This article discusses research on the role and use of nutrition education or counselling as a strategic intervention to improve health outcomes through better health behaviour in adult outpatients with HIV. Ten studies (five quantitative and five qualitative) met the inclusion criteria of the literature review. The findings of the studies related to the following outcomes of nutrition interventions: increases in fat-free and lean body mass; offsetting the adverse effects of HIV infection in patients with a low CD4 cell count; significant improvement in dietary patterns with resultant greater adherence to HIV medications and fewer side effects; and agreement on the importance of addressing the nutrition concerns. The article discusses the five prominent themes that emerged from the literature review: 1) ethical issues in HIV/AIDS research; 2) the role of health and culture in nutrition interventions; 3) HIV stigma and its impact on nutrition interventions; 4) the socioeconomics of HIV and AIDS; and 5) food security and emotional wellbeing among persons with HIV. Although the evidence base is limited and raises questions about key aspects of the quality of the research conducted to date, the overall results show that providing HIV-positive adults with culturally relevant and practical nutrition strategies can improve health outcomes, health behaviour and quality of life. Current and future nutrition interventions for persons with HIV disease should be targeted, sustainable, and rigorously evaluated. There is an urgent need for research on this topic in developing countries, particularly African ones, which are some of the most affected by HIV.

Descriptive characteristics and health outcomes of the food by prescription nutrition supplementation program for adults living with HIV in Nyanza Province, Kenya

BACKGROUND

The clinical effects and potential benefits of nutrition supplementation interventions for persons living with HIV remain largely unreported, despite awareness of the multifaceted relationship between HIV infection and nutrition. We therefore examined descriptive characteristics and nutritional outcomes of the Food by Prescription (FBP) nutrition supplementation program in Nyanza Province, Kenya.

METHODS

Demographic, health, and anthropometric data were gathered from a retrospective cohort of 1,017 non-pregnant adult patients who enrolled into the FBP program at a Family AIDS Care and Education Services (FACES) site in Nyanza Province between July 2009 and July 2011. Our primary outcome was FBP treatment success defined as attainment of BMI>20, and we used Cox proportional hazards to assess socio-demographic and clinical correlates of FBP treatment success.

RESULTS

Mean body mass index was 16.4 upon enrollment into the FBP program. On average, FBP clients gained 2.01 kg in weight and 0.73 kg/m2 in BMI over follow-up (mean 100 days), with the greatest gains among the most severely undernourished (BMI <16) clients (p<0.001). Only 13.1% of clients attained a BMI>20, though 44.5% achieved a BMI increase ≥0.5. Greater BMI at baseline, younger age, male gender, and not requiring highly active antiretroviral therapy (HAART) were associated with a higher rate of attainment of BMI>20.

CONCLUSION

This study reports significant gains in weight and BMI among patients enrolled in the FBP program, though only a minority of patients achieved stated programmatic goals of BMI>20. Future research should include well-designed prospective studies that examine retention, exit reasons, mortality outcomes, and long-term sustainability of nutrition supplementation programs for persons living with HIV.

A randomized trial of ready-to-use supplementary food versus corn-soy blend plus as food rations for HIV-infected adults on antiretroviral therapy in rural Haiti

BACKGROUND

The epidemics of food insecurity, malnutrition, and human immunodeficiency virus (HIV) frequently overlap. HIV treatment programs increasingly provide nutrient-dense ready-to-use supplementary foods (RUSFs) to patients living with HIV and food insecurity, but in the absence of wasting, it is not known if RUSF confers benefit above less costly food commodities.

METHODS

We performed a randomized trial in rural Haiti comparing an RUSF with less costly corn-soy blend plus (CSB+) as a monthly supplement to patients with HIV infection who were on antiretroviral therapy (ART) <24 months prior to study start. We compared 6- and 12-month outcomes by ration type in terms of immunologic response, body mass index (BMI), adherence to ART, general health quality of life, household food insecurity, and household wealth.

RESULTS

A cohort of 524 patients with HIV receiving ART was randomized and followed over time. Median CD4 cell count at baseline was 339 cells/µL (interquartile range [IQR], 197-475 cells/µL) for the CSB+ group, and 341 cells/µL (IQR, 213-464/µL) for the RUSF group. Measured outcomes improved from baseline over time, but there were no statistically significant differences in change for BMI, household wealth index, hunger, general health perception score, or adherence to ART by ration type at 6 or 12 months. The RUSF group had higher CD4 count at 12 months, but this was also not statistically significant.

CONCLUSIONS

In 12 months of follow-up, there was no statistically significant difference in outcomes between those receiving RUSF-based compared with CSB+-based rations in a cohort of HIV-infected adults on ART in rural Haiti.

Impact of nutritional supplementation on immune response, body mass index and bioelectrical impedance in HIV-positive patients starting antiretroviral therapy

Background

Challenges to HIV care in resource limited settings (RLS) include malnutrition. Limited evidence supports the benefit of nutritional supplementation when starting antiretroviral therapy (ART) in RLS.

Methods

Randomized controlled pilot study. HIV-positive ART-naive adults with self-reported weight loss were randomized to receive ART plus FutureLife porridge® nutritional supplement (NS) (388 kcal/day) or ART alone (Controls) for 6 months. Patients returned for monthly assessments and blood was drawn at enrolment and 6 months on ART. Differences in body composition, biochemical and laboratory parameters were estimated at 6 months on treatment.

Results

Of the 36 randomized patients, 26 completed the 6 month follow-up (11 NS vs 15 Controls). At enrolment, groups were similar in terms of age, gender, body mass index (BMI) and bioelectrical impedance. NS patients had a lower median CD4 count (60 cells/mm³ [IQR 12–105 vs 107 cells/mm³ [IQR 63–165]; p = 0.149) and hemoglobin (10.3 g/dL [IQR 9.0-11.3] vs 13.1 g/dL [IQR 11.1-14.7]; p = 0.001).

At 6 months, NS patients increased their median CD4 count by 151 cells/mm³ [IQR 120–174) vs 77 cells/mm³ [IQR 33–145] in the Controls. NS patients had higher mean percentage change in body weight (12.7% vs 4.9%; p = 0.047), BMI (7.8% vs 5.5%; p = 0.007), absolute CD4 count (83.0% vs 46.4%, p = 0.002) and hemoglobin (9.5% vs 1.0%; p = 0.026). Patients in the NS arm had a higher mean percentage fat-free mass (16.7% vs −3.5%, p = 0.036), total body water (13.0% vs −1.9%, p = 0.026), intracellular water (16.1% vs −4.1%, p = 0.010) and basal metabolic rate (5.3% vs −0.2%, p = 0.014) compared to Controls. Patients in the NS arm also showed an improvement in physical activity at 6 months post-ART initiation compared to Controls (p = 0.037).

Conclusion

Preliminary results are encouraging and suggest that NS taken concurrently with ART can promote weight gain, improve immune response and improve physical activity in HIV-positive patients that present at ART initiation with weight loss.

Impact of protein supplementation and care and support on body composition and CD4 count among HIV-infected women living in rural India: results from a randomized pilot clinical trial

Body composition in HIV-infected individuals is subject to many influences. We conducted a pilot 6-month randomized trial of 68 women living with AIDS (WLA) from rural India. High protein intervention combined with education and supportive care delivered by HIV-trained village women (activated social health activist [Asha] life [AL]) was compared to standard protein with usual care delivered by village community assistants (usual care [UC]). Measurements included CD4 counts, ART adherence, socio-demographics, disease characteristics (questionnaires); and anthropometry (bioimpedance analyzer). Repeated measures analysis of variance modeled associations. AL significantly gained in BMI, muscle mass, fat mass, ART adherence, and CD4 counts compared to UC, with higher weight and muscle mass gains among ART adherent (≥66%) participants who had healthier immunity (CD4 ≥450). BMI of WLA improved through high protein supplementation combined with education and supportive care. Future research is needed to determine which intervention aspect was most responsible.

Nutritional interventions for reducing morbidity and mortality in people with HIV

BACKGROUND

Adequate nutrition is important for optimal immune and metabolic function. Dietary support may, therefore, improve clinical outcomes in HIV-infected individuals by reducing the incidence of HIV-associated complications and attenuating progression of HIV disease, improving quality of life and ultimately reducing disease-related mortality.

OBJECTIVES

To evaluate the effectiveness of various macronutrient interventions, given orally, in reducing morbidity and mortality in adults and children living with HIV infection.

SEARCH METHODS

We searched CENTRAL (up to August 2011), MEDLINE (1966 to August 2011), EMBASE (1988 to August 2011), LILACS (up to February 2012), and Gateway (March 2006-February 2010). We also scanned reference lists of articles and contacted authors of relevant studies and other researchers.

SELECTION CRITERIA

Randomised controlled trials evaluating the effectiveness of macronutrient interventions compared with no nutritional supplements or placebo in the management of adults and children infected with HIV.

DATA COLLECTION AND ANALYSIS

Three reviewers independently applied study selection criteria, assessed study quality, and extracted data. Effects were assessed using mean difference and 95% confidence intervals. Homogenous studies were combined wherever it was clinically meaningful to do so and a meta-analysis using the random effects model was conducted.

MAIN RESULTS

Fourteen trials (including 1725 HIV positive adults and 271 HIV positive children), were included in this review. Neither supplementary food nor daily supplement of Spirulina significantly altered the risk of death compared with no supplement or placebo in malnourished, ART naive adult participants in the two studies which reported on this outcome. A nutritional supplement enhanced with protein did not significantly alter the risk of death compared to standard nutritional care in children with prolonged diarrhoea. Supplementation with macronutrient formulas given to provide protein and/or energy and fortified with micronutrients, in conjunction with nutrition counselling, significantly improved energy intake (3 trials; n=131; MD 393.57 kcal/day; 95% CI: 224.66 to 562.47;p<0.00001) and protein intake (2 trials; n=81; MD 23.5 g/day; 95% CI: 12.68, 34.01; p<0.00001) compared with no nutritional supplementation or nutrition counselling alone in adult participants with weight loss. In general supplementation with specific macronutrients such as amino acids, whey protein concentration or Spirulina did not significantly alter clinical, anthropometric or immunological outcomes compared with placebo in HIV-infected adults and children.

AUTHORS' CONCLUSIONS

Given the current evidence base, which is limited to fourteen relatively small trials all evaluating different macronutrient supplements in different populations at different stages of HIV infection and with varying treatment status, no firm conclusions can be drawn about the effects of macronutrient supplementation on morbidity and mortality in people living with HIV. It is, however, promising to see more studies being conducted in low-income countries, and particularly in children, where macronutrient supplementation both pre-antiretroviral treatment and in conjunction with antiretroviral treatment might prove to be beneficial.

Systematic review and meta-analysis of the effects of high protein oral nutritional supplements

Disease-related malnutrition is common, detrimentally affecting the patient and healthcare economy. Although use of high protein oral nutritional supplements (ONS) has been recommended to counteract the catabolic effects of disease and to facilitate recovery from illness, there is a lack of systematically obtained evidence to support these recommendations. This systematic review involving 36 randomised controlled trials (RCT) (n=3790) (mean age 74 years; 83% of trials in patients >65 years) and a series of meta-analyses of high protein ONS (>20% energy from protein) demonstrated a range of effects across settings and patient groups in favour of the high protein ONS group. These included reduced complications (odds ratio (OR) 0.68 (95%CI 0.55-0.83), p<0.001, 10 RCT, n=1830); reduced readmissions to hospital (OR 0.59 (95%CI 0.41-0.84), p=0.004, 2 RCT, n=546); improved grip strength (1.76 kg (95%CI 0.36-3.17), p<0.014, 4 RCT, n=219); increased intake of protein (p<0.001) and energy (p<0.001) with little reduction in normal food intake and improvements in weight (p<0.001). There was inadequate information to compare standard ONS (<20% energy from protein) with high protein ONS (>20% energy from protein). The systematic review and meta-analysis provides evidence that high protein supplements produce clinical benefits, with economic implications.

Selection and use of US Title II food aid products in programming contexts

BACKGROUND

Food aid provided by the United States has saved lives for almost two centuries. Delivering the right products is important, but of equal concern are the ways in which products are delivered and to whom.

OBJECTIVE

The study addresses how food products are currently used, whether interventions are appropriate to achieve nutrition objectives, and whether nutrition targets could be met more cost-effectively with a different mix of products or programs.

METHODS

The team conducted consultations with a broad range of stakeholders. A survey of Title II implementing partners was conducted, focusing on procurement and logistics, and uses of FBFs and other foods. Input of implementing partners, civil society, and donor organizations was obtained through individual consultations, international and small group meetings. More than 400 individuals accessed the project's website. The project convened a panel of experts in food technology and science, food policy, law, industry, medicine, development and humanitarian work, and the maritime industry, and held regular joint meetings with USDA and USAID. The draft report was widely disseminated and posted on the website.

RESULTS AND CONCLUSIONS

There is wide variation in the quantities of fortified blended foods provided to target populations. Most of these foods are used in health/nutrition programs, but they are also used in general family rations or as an incentive or pay. Clearer programming guidance and improved decision tools are needed to match products to nutrition goals, and programs should consider delivering nutrients across a basket of commodities, not single products. The evidence base for the effectiveness and cost-effectiveness of specific foods and programs needs to be strengthened and should be supported by FFP Research is needed to provide guidance on nutrition support for HIV/AIDS. Additional investments are needed in effective behavior change communication.

Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults

BACKGROUND

Disease-related malnutrition has been reported in 10% to 55% of people in hospital and the community. Dietary advice encouraging the use of energy- and nutrient-rich foods rather than oral nutritional supplements has been suggested as the initial approach for managing disease-related malnutrition.

OBJECTIVES

To examine evidence that dietary advice in adults with disease-related malnutrition improves survival, weight and anthropometry; to estimate the size of any additional effect of nutritional supplements combined with dietary advice and to compare the effects of dietary advice with oral nutritional supplements.

SEARCH STRATEGY

Relevant publications were identified from comprehensive electronic database searches and handsearching.Last search: 14 February 2010.

SELECTION CRITERIA

Randomised controlled trials of dietary advice with or without oral nutritional supplements in people with disease-related malnutrition in any health-care setting compared with no advice, oral nutritional supplements or dietary advice given alone.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility, risk of bias and extracted data.

MAIN RESULTS

Forty-five studies (3186 participants) met the inclusion criteria; (dietary advice compared with: no advice (1053 participants); with oral nutritional supplements (332 participants); with dietary advice and oral nutritional supplements (731 participants); and dietary advice plus oral nutritional supplements compared with no additional intervention (1070 participants). Follow-up ranged from 18 days to 24 months. No comparison showed a significant difference between groups for mortality or morbidity. There was a significant change in weight found between groups when comparing dietary advice to no advice for interventions lasting greater than 12 months, mean difference 3.75 kg (95% confidence interval 0.97 to 6.53), and when all studies were combined, mean difference 1.47 kg (95% confidence interval 0.32 to 2.61) although there was significant heterogeneity in the combined analysis (I(2) = 90%). Similar improvements in weight were found for the comparison of dietary advice with nutritional supplements if required versus no advice, mean difference 2.20 kg (95% confidence interval 1.16 to 3.25). Dietary advice compared with no advice was also associated with significantly improved mid-arm muscle circumference when all studies were combined, but with moderate heterogeneity, mean difference 0.81 mm (95% confidence interval 0.31 to 1.31). Dietary advice given with nutritional supplements compared with dietary advice alone resulted in improvements in: mid-arm muscle circumference, mean difference -0.89 mm (95% confidence interval -1.35 to -0.43); triceps skinfold thickness, mean difference -1.22 mm (95% confidence interval -2.34 to -0.09); and grip strength, mean difference -1.67 kg (95% confidence interval -2.96 to -0.37), although the effects on triceps skinfold thickness and grip strength were heterogeneous. Dietary advice with supplements if required resulted in a significant increase in triceps skinfold thickness compared with no advice, mean difference 0.40 mm (95% confidence interval 0.10 to 0.70), although these results are from a single trial with only 29 participants.

AUTHORS' CONCLUSIONS

Evidence of variable quality suggests that dietary advice with or without oral nutritional supplements may improve weight, body composition and grip strength. We found no evidence of benefit of dietary advice or oral nutritional supplements given alone or in combination on survival. Studies addressing the impact of nutritional interventions on nutritional, functional and patient-centred outcomes are needed.

Macronutrient supplementation and food prices in HIV treatment

Infection caused by HIV and malnutrition have a complex interaction and often coexist geographically. Malnutrition has synergistic immune effects and HIV affects nutritional status. HIV care and treatment programs are compelled to confront this dual burden to optimize HIV outcomes. In this article, we review the published literature concerning intervention studies in adults and children and the effect of food prices on HIV treatment programs. While the evidence base is relatively incomplete for specific macronutrient interventions in the context of HIV treatment, it is clear that a new standard of care is needed, guided by experience, rationale, and existing data, in which malnourished patients may easily access nutritional therapies within HIV treatment. From this clinical foundation, we may both treat patients and evaluate novel therapies. Some HIV care and treatment programs provide food-based supplements; however, rising food costs and economic instability may jeopardize the success of these programs. HIV treatment programs may struggle to meet the needs of patients with potential increased rates of malnutrition and food insecurity in the setting of high food prices.

Macronutrient supplementation for malnourished HIV-infected adults: a review of the evidence in resource-adequate and resource-constrained settings

Access to antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection has expanded rapidly throughout sub-Saharan Africa, but malnutrition and food insecurity have emerged as major barriers to the success of ART programs. Protein-calorie malnutrition (a common form of malnutrition in the region) hastens HIV disease progression, and food insecurity is a barrier to medication adherence. Analyses of patient outcomes have identified a low body mass index after the start of ART as an independent predictor of early mortality, but the causes of a low body mass index are multifactorial (eg, normal anthropometric variation, chronic inadequate food intake, and/or wasting associated with HIV infection and other infectious diseases). Although there is much information on population-level humanitarian food assistance, few data exist to measure the effectiveness of macronutrient supplementation or to identify individuals most likely to benefit. In this report, we review the current evidence supporting macronutrient supplementation for HIV-infected adults, we report on clinical trials in resource-adequate and resource-constrained settings, and we highlight priority areas for future research.

Dietary advice for illness-related malnutrition in adults

BACKGROUND

Illness-related malnutrition has been reported in 10% to 55% of ill people in hospital and the community in areas of food sufficiency. Dietary advice encouraging the use of energy- and nutrient-rich foods rather than oral nutritional supplements has been suggested for managing illness-related malnutrition.

OBJECTIVES

To examine evidence that dietary advice to improve nutritional intake in adults with illness-related malnutrition improves survival, weight and anthropometry; to estimate the size of any additional effect of nutritional supplements given in combination with dietary advice.

SEARCH STRATEGY

Relevant publications were identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Additional studies were sought by contacting dietitians, clinicians and the manufacturers of nutritional supplements. Last search: September 2007

SELECTION CRITERIA

Randomised controlled trials of dietary advice in people with illness-related malnutrition compared with:(1) no advice;(2) oral nutritional supplements; and(3) dietary advice plus oral nutritional supplements.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility, methodological quality and extracted data.

MAIN RESULTS

Thirty-six studies (37 comparisons) met the inclusion criteria with 2714 randomised participants. Twelve trials (comparing dietary advice plus supplements if required with no advice) identified during searching are included as a separate comparison. Follow up ranged from 18 days to 24 months. No comparison showed a significant difference in mortality. There are several significant results for change in weight and other nutritional indices favouring nutritional intervention, but the precise contributions of the different strategies have yet to be determined. It is uncertain whether nutritional supplements and dietary advice produce the same effects. There was insufficient evidence to draw conclusions about clinical outcomes and cost. Few data were available for other outcomes.

AUTHORS' CONCLUSIONS

This review highlights the lack of evidence for the provision of dietary advice in managing illness-related malnutrition. Dietary advice plus nutritional supplements may be more effective than dietary advice alone or no advice in enhancing short-term weight gain, but whether this is sustainable, or whether survival and morbidity are improved remains uncertain. A large adequately-powered randomised controlled trial is needed comparing the efficacy of different therapies to increase dietary intake in people with illness-related malnutrition and examining the impact of this on clinical function and survival.

Nutritional interventions for reducing morbidity and mortality in people with HIV

BACKGROUND

Adequate nutrition promotes and maintains optimal immune function. Dietary support may, therefore, improve clinical outcomes in HIV-infected individuals by reducing the incidence of HIV-associated complications and attenuating progression of HIV disease, thereby improving quality of life and ultimately reducing disease-related mortality.

OBJECTIVES

To evaluate the effectiveness of various macronutrient interventions, such as a balanced diet or high protein, high carbohydrate, or high fat diets given orally, in reducing morbidity and mortality in adults and children living with HIV infection.

SEARCH STRATEGY

We searched CENTRAL (up to March 2006), MEDLINE (1966 to March 2006), EMBASE (1988 to March 2006), LILACS (up to March 2006), and AIDSearch (up to March 2006). We also scanned reference lists of articles and contacted authors of relevant studies and other researchers.

SELECTION CRITERIA

Randomised controlled trials evaluating the effectiveness of macronutrient interventions compared with no nutritional supplements or placebo in the management of adults and children infected with HIV.

DATA COLLECTION AND ANALYSIS

Three reviewers independently applied study selection criteria, assessed study quality, and extracted data. Effects were assessed using weighted mean difference and 95% confidence intervals. Meta-analysis employed a fixed-effect model, except when the chi-square test for heterogeneity was significant (p<0.1).

MAIN RESULTS

Eight trials (with a total of 486 participants), met the criteria for inclusion in our review. None of the studies reported on mortality, morbidity, or disease progression. Overall, macronutrient supplementation (with or without nutritional counselling) significantly improved energy intake (5 trials; n=254; WMD 367 kcal.day-1; 95% CI: 217 to 516) and protein intake (3 trials; n=128; WMD 17 g.day-1; 95% CI: 8 to 26) compared with no nutritional supplementation or placebo. There was no evidence of an effect on body weight (8 trials; n=423; WMD 0.24 kg; 95% CI: -0.6 to 1.1), fat mass (6 trials; n=305; WMD -0.73 kg; 95% CI: -1.83 to 0.37), fat-free mass (5 trials; n=311; WMD 0 kg; 95% CI: -2.3 to 2.4) or CD4 count (6 trials; n=271; WMD 0.23 cells.mm-3; 95% CI: -40.2 to 40.6).

AUTHORS' CONCLUSIONS

Given the current evidence base, which is limited to a few small trials in high-income countries, no firm conclusions can be drawn about the effects of macronutrient supplementation on morbidity and mortality in people living with HIV.

A randomized clinical trial to evaluate the effect of diet on weight loss and coping of people living with HIV and lipodystrophy

AIM

The purpose of the research study was to evaluate a diet intervention in relation to the perceived weight loss and ways of coping of people living with HIV and lipodystrophy. The objectives were (i) to measure the perceived impact of weight loss upon men with HIV and lipodystrophy following a diet intervention and (ii) to identify strategies used by men to cope with HIV and lipodystrophy following a diet intervention.

BACKGROUND

HIV positive people on antiretroviral treatments are normalizing their lives and are facing a life-long future. Morphological changes occur as a result of antiretroviral therapy causing HIV positive people to hesitate commencing treatment.

DESIGN

An experimental design incorporating pretests and posttests of experimental and control groups was used in the study.

METHODS

The sample consisted of 30 men over 18 years of age, living with HIV and lipodystrophy. All participants were surveyed by questionnaires and their perceived weight loss and ways of coping were measured at baseline and 10 weeks.

RESULTS

Findings indicated a significant improvement for perceived weight loss and although not significant, all coping processes were used more by the participants in the intervention group compared with the control group.

CONCLUSIONS

The diet intervention demonstrated a positive effect particularly upon perceived weight loss on men living with HIV and Lipodystrophy in the study setting.

RELEVANCE TO CLINICAL PRACTICE

Diet is a recommended management option for people who endure severe and distressing symptoms from antiretroviral therapy.

Care and treatment of HIV-infected children in Africa: issues and challenges at the district hospital level

More than 90% of pediatric HIV infection occurs in sub-Saharan Africa and 75% of these children currently die before their fifth birthday. Most HIV-infected children in Africa rely on district hospitals for HIV treatment, but insufficient attention has been paid to improving HIV/AIDS care at this level. Considerable confusion exists about optimal use of combination antiretroviral treatment, prophylaxis for opportunistic infections and other rational healthcare interventions that can greatly improve the quality of life for these children. A simple and inexpensive infant HIV diagnostic assay and alternative laboratory markers of pediatric HIV disease progression would be highly beneficial. Routine anthropometric and neurodevelopmental assessments could help guide initiation and monitoring of antiretroviral therapy. Even in the absence of antiretroviral therapy, interventions such as immunizations, provision of micronutrients and nutrition counseling, prevention and treatment of opportunistic as well as endemic infections (such as helminths and malaria) can substantially reduce pediatric HIV-related morbidity and mortality. The need for pain relief, palliative care, counseling and emotional support is often underestimated. Surmounting the sense of hopelessness by providing district healthcare workers with training in basic pediatric HIV/AIDS care is an urgent priority.

Dietary advice for illness-related malnutrition in adults

BACKGROUND

Illness-related malnutrition has been reported in 10% to 55% of ill people in hospital and the community in areas of food sufficiency. Dietary advice encouraging the use of energy- and nutrient-rich foods rather than oral nutritional supplements has been suggested for managing illness-related malnutrition.

OBJECTIVES

To examine evidence that dietary advice to improve nutritional intake in adults with illness-related malnutrition improves survival, weight and anthropometry; to estimate the size of any additional effect of nutritional supplements given in combination with dietary advice.

SEARCH STRATEGY

Relevant publications were identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Additional studies were sought by contacting dietitians, clinicians and the manufacturers of nutritional supplements. Last search: October 2006

SELECTION CRITERIA

Randomised controlled trials of dietary advice in people with illness-related malnutrition compared with:(1) no advice;(2) oral nutritional supplements; and(3) dietary advice plus oral nutritional supplements.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility, methodological quality and extracted data.

MAIN RESULTS

Thirty-five studies (37 comparisons) met the inclusion criteria with 2648 randomised participants. Twelve trials (comparing dietary advice plus supplements if required with no advice) identified during searching are included as a separate comparison. Follow up ranged from 18 days to 24 months. No comparison showed a significant difference in mortality. Significant improvements in weight at three months were found for groups receiving dietary advice plus nutritional supplements compared with dietary advice alone, WMD 1.68 kg (95% CI 0.14 to 3.21) or no additional advice, WMD 1.97 (95% CI 0.07 to 3.86). There were significant improvements in grip strength and mid-arm muscle circumference in the advice plus supplement groups compared with dietary advice alone. It is uncertain whether nutritional supplements and dietary advice produce the same effects. No significant differences were found between groups for clinical outcomes. Few data were available for other outcomes.

AUTHORS' CONCLUSIONS

This review highlights the lack of evidence for the provision of dietary advice in managing illness-related malnutrition. Dietary advice plus nutritional supplements may be more effective than dietary advice alone or no advice in enhancing short-term weight gain, but whether this is sustainable, or whether survival and morbidity are improved remains uncertain. A large adequately-powered randomised controlled trial is needed comparing the efficacy of different therapies to increase dietary intake in people with illness-related malnutrition and examining the impact of this on clinical function and survival.

The Impact of Nutrition on Physiologic Changes in Persons Who Have HIV

HIV affects almost all bodily systems, which can lead to recurrent opportunistic infections, weight loss, distribution of weight changes, and death. Malnutrition and wasting, two symptoms that interfere with nutrient availability, accessibility, and metabolism, are associated with higher morbidity and mortality. Nausea, vomiting, swallowing or chewing difficulties, or the response of the body to opportunistic infections or medications that are considered vital to the treatment of the disease may affect nutritional status. A positive nutritional balance may help to improve the immune and other body systems, and delay the progression of the disease, This article reviews the effect of the nutritional status on the physiologic changes in the person who is infected with HIV.

Counteracting muscle wasting in HIV-infected individuals

HIV-infected persons often experience a loss of lean tissue mass, which includes decreases in skeletal muscle mass. This HIV-associated wasting is significant because it has been associated with accelerated disease progression and increased morbidity. Signalling related to several circulating molecules, including tumour necrosis factor (TNF)-alpha, growth hormone, insulin-like growth factor (IGF)-1 and testosterone, has been associated with the aetiology of muscle wasting. Additionally, nutritional status related to malnutrition and specific dietary deficiencies may be involved. In an attempt to counter muscle wasting in HIV-infected persons, treatments have been suggested that target these mechanisms. Nutritional supplementation, cytokine reduction, hormone therapy and resistance exercise training are potential treatments for this condition. Resistance exercise training, which is more easily accessible to this population than other treatments, holds promise in counteracting the process of HIV wasting, as it has been successfully used to increase lean tissue mass in healthy and clinical populations. This review will explore the HIV/AIDS muscle-wasting syndrome, its aetiology, and the treatments used to counteract wasting.

ESPEN Guidelines on Enteral Nutrition: Wasting in HIV and other chronic infectious diseases

Undernutrition (wasting) is still frequent in patients infected with the human immunodeficiency virus (HIV), despite recent decreases in the prevalence of undernutrition in western countries (as opposed to developing countries) due to the use of highly active antiretroviral treatment. Undernutrition has been shown to have a negative prognostic effect independently of immunodeficiency and viral load. These guidelines are intended to give evidence-based recommendations for the use of enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) in HIV-infected patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. Nutritional therapy is indicated when significant weight loss (>5% in 3 months) or a significant loss of body cell mass (>5% in 3 months) has occurred, and should be considered when the body mass index (BMI) is <18.5 kg/m(2). If normal food intake including nutritional counselling and optimal use of ONS cannot achieve an adequate nutrient intake, TF with standard formulae is indicated. Due to conflicting results from studies investigating the impact of immune-modulating formulae, these are not generally recommended. The results obtained in HIV patients may be extrapolated to other chronic infectious diseases, in the absence of available data.

Dietary advice and nutritional supplements in the management of illness-related malnutrition: systematic review

BACKGROUND AND AIMS

This review investigated whether dietary advice to improve nutritional intake in adults with illness-related malnutrition improved mortality, morbidity, weight and energy intake, and whether oral nutritional supplements gave additional benefit, when given in combination with dietary advice.

METHODS

Systematic review of randomised controlled trials comparing dietary advice with either (i) no advice, (ii) nutritional supplements or (iii) dietary advice plus nutritional supplements, in people with illness-related malnutrition.

RESULTS

Twenty-four trials (25 comparisons) met the inclusion criteria, including 2135 randomised participants. Duration of follow-up ranged from 16 days to 24 months. There was no significant difference in mortality or morbidity for each comparison. Groups receiving supplements gained significantly more weight (or lost significantly less weight) than those who received dietary advice, weighted mean difference 1.09 kg (0.29-1.90) (4 studies). There were no significant differences in weight and energy intake between groups for the other comparisons. Few data were available for other outcomes.

CONCLUSIONS

Nutritional supplements may have a greater role than dietary advice in the short-term improvement of body weight in illness-related malnutrition. There is a lack of evidence to support dietary advice in the management of illness-related malnutrition, but this is based on few, often poor quality, studies.

L-ornithine α-ketoglutarate in HIV infection: effects on muscle, gastrointestinal, and immune functions

OBJECTIVES

There have been claims that l-ornithine alpha-ketoglutarate (OKG) exerts anticatabolic, anabolic, and immunomodulating properties. This study aimed at quantifying the effects of OKG on muscle force, body composition, and immune function in outpatients infected with the human immunodeficiency virus (HIV) and presenting weight loss.

METHODS

Forty-six HIV(+) patients were included in a double-blind, prospective, randomized, controlled trial for 12 wk (10 g/d of OKG or isonitrogenous placebo and nutritional counseling). Podometry, handgrip strength, step test, triceps skinfold thickness, 50-kHz bioelectrical impedance, 3-d diet record, CD4 cell count, HIV-1 RNA concentration (viral load), and gastrointestinal symptoms were assessed at 0, 4, 8, and 12 wk.

RESULTS

At baseline, patients (OKG, n = 22; placebo, n = 24) has similar CD4 counts (338 +/- 172 and 310 +/- 136 cells/mL), viral load (3.6 +/- 1.3 and 3.5 +/- 1.3 log(10) copies/mL), body mass index (20.0 +/- 2.4 and 20.6 +/- 3.0 kg/m(2)), weight loss (9.0 +/- 3.12 and 9.4 +/- 3.0 kg), and food intake (2509 +/- 962 and 2610 +/- 808 kcal/d). Twenty-nine patients completed the protocol. Both groups increased their body mass index (P = 0.02 versus baseline) and triceps skinfold thickness (P < 0.01 versus baseline). They showed a similar positive correlation between handgrip strength and fat-free mass. Frequency of gastrointestinal symptoms increased in the OKG group (86% versus 54% in the placebo group, P = 0.025). No other differences were observed between groups.

CONCLUSIONS

All patients increased their body mass index and triceps skinfold thickness due to food supplementation and diet counseling. Oral OKG failed to improve nutritional, functional, or immunologic status in these weight-losing HIV(+) patients and had important gastrointestinal side effects.

Practices in relation to nutritional care and support--report from the Council of Europe

Disease-related undernutrition is significant in European hospitals but is seldom treated. In 1999, the Council of Europe decided to collect information regarding Nutrition programmes in hospitals and for this purpose a network consisting of national experts from 12 of the Partial Agreement member states was established. The aim was to review the current practice in Europe regarding hospital food provision, to highlight deficiencies and to issue recommendations in improve the nutritional care and support of hospitalised patients. The data collection regarding the nutritional care providers and their practices of nutritional care and support showed that the use of nutritional risk screening and assessment, and of nutritional support and counselling was sparse and inconsistent, and that the responsibilities in these contexts were unclear. Besides, the educational level with regard to nutritional care and support was limited at all levels. All patients have the right to expect that their nutritional needs will be fulfilled during a hospitalisation. Optimal supply of food is a prerequisite for an optimal effect of the specific treatment offered to patients. Hence, the responsibilities of staff categories and the hospital management with respect to procuring nutritional care and support should be clearly assigned. Also, a general improvement in the educational level of all staff groups is needed.