Prospective analysis of patterns of weight change in stage IV human immunodeficiency virus infection

Undernutrition and associated factors among HIV-positive adult patients enrolled in antiretroviral therapy (ART) clinics in the Arba Minch area, southern Ethiopia

Background: Undernutrition constitutes an important threat to the success of HIV programs in sub-Saharan Africa, and failure to effectively address it may jeopardize the benefits gained so far in the fight against HIV. The aim of the study was to assess undernutrition and associated factors among HIV-positive adult patients enrolled in antiretroviral therapy (ART) clinics in Arba Minch area, south Ethiopia. Methods: A facility-based cross-sectional study was conducted in 2017. There were 351 adult individual study participants who were enrolled in ART clinics in Arba Minch area public health facilities. Variables with P-value less than 0.25 on binary logistic regression analysis were entered into a multivariate logistic regression model to outline the independent predictors of undernutrition. CI of 95% was used to assess precision of the study. Results: Out of all the participants, 18.23% (95% CI: 14.52-22.65) were undernourished. The prevalence of undernutrition was significantly lower among those consuming food from five or more food groups per day (AOR: 0.33; 95% CI: 0.16-0.71) and undergoing ART for more than a year (AOR: 0.24; 95% CI: 0.08-0.73). On the contrary, the prevalence was significantly higher among those who were currently smoking tobacco (AOR: 6.67; 95% CI: 1.45-30.76). In addition, those with WHO clinical stage 3 had a significantly higher prevalence of undernutrition compared to those with WHO clinical stage 1 (AOR: 311; 95% CI: 1.47-6.60). Conclusion: The prevalence of undernutrition was high among adults with HIV/AIDS enrolled in ART clinics in the study area. The prevalence of undernutrition was lower among those who consumed diverse food groups and had been receiving ART for longer (more than a year). On the contrary, the prevalence of undernutrition was higher among those who consumed tobacco and with higher WHO clinical stage. Therefore, efforts should be made to enhance the dietary diversity of these individuals.

Blood Pressure, HIV, and Cocaine Use Among Ethnically and Racially Diverse Individuals

OBJECTIVES

Racial minorities are at greater risk of cardiovascular disease (CVD), and CVD is the primary cause of mortality among human immunodeficiency virus (HIV)-infected individuals. Cocaine use also has been associated with hypertension. This study examined the contribution of lifestyle factors to systolic, diastolic, and mean arterial pressure (MAP) among people living with HIV and cocaine users from racially and ethnically diverse backgrounds.

METHODS

Participants (N = 401: 213 men, 188 women) aged 18 to 50 years with no history of CVD were recruited from South Florida. A total of 200 participants were HIV-cocaine-infected, 100 were HIV-infected individuals with no history of cocaine use, and 101 were HIV-uninfected individuals with cocaine abuse or dependence. Carotid intima-media thickness and plaque, blood pressure (BP), and lifestyle risk were assessed.

RESULTS

Mean age was 36 years (standard deviation 9.33); the majority (62%) were African American. Carotid plaques were identified in 23% of participants; 42% were obese, 68% engaged in ≥150 minutes of weekly exercise, and 68% were smokers. Sex, body mass index (BMI), and diet were associated with systolic BP. Age, BMI, cannabis use, and diet were associated with diastolic BP and MAP.

CONCLUSIONS

Age, BMI, cannabis use, and diet were associated with increased diastolic BP and MAP. Cocaine did not emerge as a significant predictor of CVD after controlling for cannabis dependence. Cocaine and HIV lacked significant association with CVD, possibly because the majority of the sample was younger than age 40. Lifestyle modifications and substance abuse counseling may be important in preventing CVD among those without a history of CVD.

BIOIMPEDANCE MARKERS AND TUBERCULOSIS OUTCOME AMONG HIV-INFECTED PATIENTS

Background

The changes in body composition markers (weight, fat mass, lean mass, and BMI) over time can be associated with TB treatment outcome among HIV-infected patients. The aim of this study was to investigate whether changes in fat mass and lean mass were associated with the treatment response among patients with HIV infection and pulmonary tuberculosis.

Materials and Methods

This was a prospective cohort study. Data from HIV-infected patients commencing TB therapy were analyzed. This included body weight measurement using bioimpedance equipment at baseline, one month, and two months after starting TB treatment.

Results

The study was conducted in 125 patients, 17 patients (13.6%) died during treatment, of which 5 died during the first month of treatment, 4 during the second month and 8 after the second month. The group of patients with good response, increased their weight by 1.3 kg (p <0.001) at the end of the first month of TB treatment and 2.6 kg in the second month (p <0.001), and body fat increase was 1.2 Kg (p <0.001) and 2.3 kg (p <0.001), the first and second month respectively. The group of patients who died had lost 2.1 kg fat mass after the first month (p <0.001) and 3.7 kg in the second month (p <0.001).

Conclusions

Our results show that the weight change during TB treatment (increased fat mass) helps us predict therapeutic response. Weight loss during the first month of starting therapy should be evaluated thoroughly to identify the probable cause of treatment failure.

Comparison of body composition changes between atazanavir/ritonavir and lopinavir/ritonavir each in combination with tenofovir/emtricitabine in antiretroviral-naïve patients with HIV-1 infection

BACKGROUND AND OBJECTIVE

Antiretroviral drug regimen choice may influence changes in body composition. The objective of this study was to compare changes in body composition between ritonavir-boosted atazanavir (ATV/r) and ritonavir-boosted lopinavir (LPV/r) over 96 weeks using data from a substudy of CASTLE, which compared once-daily ATV/r with twice-daily LPV/r, both in combination with tenofovir disoproxil fumarate/emtricitabine in treatment-naïve patients with HIV-1 infection.

METHODS

We examined 224 patients (125 on ATV/r; 99 on LPV/r) at baseline, 48 and 96 weeks using dual-energy X-ray absorptiometry and computerised tomography.

RESULTS

In the lowest baseline body mass index (BMI) group, there were significantly greater gains at week 96 for ATV/r than for LPV/r in subcutaneous adipose tissue and in visceral adipose tissue (VAT). By week 96, patients with lowest baseline CD4 cell counts on ATV/r had 28 % increases in VAT versus 14 % reductions for patients receiving LPV/r. Those with the lowest baseline BMI on ATV/r had 19 % increases in VAT versus reductions of 5 % for patients on LPV/r. In the highest baseline BMI group, the mean increase in triglycerides was 6 and 70 % in the ATV/r and LPV/r arms, respectively. Compared with baseline, an increase in proportion of patients with high waist circumference (WC)/high triglycerides at 96 weeks was noted in both treatment arms, but this increase was numerically greater with LVP/r (18 %) than with ATV/r (11 %).

CONCLUSION

Truncal fat gains on ATV/r primarily led to increases in WC, which may reflect return to health, while on LPV/r increases in WC and triglycerides occurred. Changes in body composition with antiretroviral therapy are influenced by treatment choice and baseline characteristics.

Effects on mortality of a nutritional intervention for malnourished HIV-infected adults referred for antiretroviral therapy: a randomised controlled trial

BACKGROUND

Malnourished HIV-infected African adults are at high risk of early mortality after starting antiretroviral therapy (ART). We hypothesized that short-course, high-dose vitamin and mineral supplementation in lipid nutritional supplements would decrease mortality.

METHODS

The study was an individually-randomised phase III trial conducted in ART clinics in Mwanza, Tanzania, and Lusaka, Zambia. Participants were 1,815 ART-naïve non-pregnant adults with body mass index (BMI) <18.5 kg/m² who were referred for ART based on CD4 count <350 cells/μL or WHO stage 3 or 4 disease. The intervention was a lipid-based nutritional supplement either without (LNS) or with additional vitamins and minerals (LNS-VM), beginning prior to ART initiation; supplement amounts were 30 g/day (150 kcal) from recruitment until 2 weeks after starting ART and 250 g/day (1,400 kcal) from weeks 2 to 6 after starting ART. The primary outcome was mortality between recruitment and 12 weeks of ART. Secondary outcomes were serious adverse events (SAEs) and abnormal electrolytes throughout, and BMI and CD4 count at 12 weeks ART.

RESULTS

Follow-up for the primary outcome was 91%. Median adherence was 66%. There were 181 deaths in the LNS group (83.7/100 person-years) and 184 (82.6/100 person-years) in the LNS-VM group (rate ratio (RR), 0.99; 95% CI, 0.80-1.21; P = 0.89). The intervention did not affect SAEs or BMI, but decreased the incidence of low serum phosphate (RR, 0.73; 95% CI, 0.55-0.97; P = 0.03) and increased the incidence of high serum potassium (RR, 1.60; 95% CI, 1.19-2.15; P = 0.002) and phosphate (RR, 1.23; 95% CI, 1.10-1.37; P <0.001). Mean CD4 count at 12 weeks post-ART was 25 cells/μL (95% CI, 4-46) higher in the LNS-VM compared to the LNS arm (P = 0.02).

CONCLUSIONS

High-dose vitamin and mineral supplementation in LNS, compared to LNS alone, did not decrease mortality or clinical SAEs in malnourished African adults initiating ART, but improved CD4 count. The higher frequency of elevated serum potassium and phosphate levels suggests high-level electrolyte supplementation for all patients is inadvisable but the addition of micronutrient supplements to ART may provide clinical benefits in these patients.

TRIAL REGISTRATION

PACTR201106000300631, registered on 1st June 2011.

Nutritional Care of the Child with Human Immunodeficiency Virus Infection in the United States

In well-resourced settings, early infant diagnosis and administration of life-saving antiretrovirals (ARVs) have significantly improved clinical outcomes in pediatric human immunodeficiency virus (HIV) infection. The dramatic increase in survival rates is associated with enhancements in overall quality of life, which reflect a multidisciplinary, holistic approach to care. Current optimism starkly contrasts with the outlook and prognosis two decades ago, when failure to thrive and wasting syndrome from uncontrolled pediatric HIV infection resulted from poor oral intake, malabsorption, chronic diarrhea, and a persistently catabolic state. The tenets of care developed from that era still hold true in that all infants, children, and adolescents with HIV require comprehensive nutritional services in addition to effective combination antiretroviral therapy (cART). This chapter will review the principles of nutrition in the pre- and post-cART eras and discuss the etiologic factors associated with malnutrition, with an emphasis on interventions that have favorably impacted the growth and body composition of infants, children and adolescents with HIV.

Increasing Obesity in Treated Female HIV Patients from Sub-Saharan Africa: Potential Causes and Possible Targets for Intervention

Objectives: To investigate changing nutritional demographics of treated HIV-1-infected patients and explore causes of obesity, particularly in women of African origin.

Methods: We prospectively reviewed nutritional demographics of clinic attenders at an urban European HIV clinic during four one-month periods at three-yearly intervals (2001, 2004, 2007, and 2010) and in two consecutive whole-year reviews (2010–2011 and 2011–2012). Risk-factors for obesity were assessed by multiple linear regression. A sub-study of 50 HIV-positive African female patients investigated body-size/shape perception using numerical, verbal, and pictorial cues.

Results: We found a dramatic rise in the prevalence of obesity (BMI > 30 kg/m²), from 8.5 (2001) to 28% (2011–2012) for all clinic attenders, of whom 86% were on antiretroviral treatment. Women of African origin were most affected, 49% being obese, with a further 32% overweight (BMI 25–30 kg/m²) in 2012. Clinical factors strongly associated with obesity included female gender, black African ethnicity, non-smoking, age, and CD4 count (all P < 0.001); greater duration of cART did not predict obesity. Individual weight-time trends mostly showed slow long-term progressive weight gain. Investigating body-weight perception, we found that weight and adiposity were underestimated by obese subjects, who showed a greater disparity between perceived and actual adiposity (P < 0.001). Obese subjects targeted more obese target “ideal” body shapes (P < 0.01), but were less satisfied with their body shape overall (P = 0.02).

Conclusion: Seropositive African women on antiretroviral treatment are at heightened risk of obesity. Although multifactorial, body-weight perception represents a potential target for intervention.

From wasting to obesity, changes in nutritional concerns in HIV/AIDS

Optimal nutrition is an important part of human immunodeficiency virus (HIV) care; to support the immune system, limit HIV-associated complications as well as maintain better quality of life and survival. The presentation and nature of malnutrition in patients with HIV has changed dramatically over the past 30 years from predominantly a wasting syndrome to lipodystrophy and, now, frailty. Nevertheless, we continue to see all 3 presentations in patient care today. The pathogenesis of poor nutrition in HIV-infected patients depends on caloric intake, intestinal nutrient absorption/translocation, and resting energy expenditure, which are features seen in all chronic diseases.

Sex, smoking, and socioeconomic status are associated with body composition among tuberculosis patients in a deuterium dilution cross-sectional study in Mwanza, Tanzania

Underweight is common among tuberculosis (TB) patients. However, there is little information on determinants of body composition at TB treatment initiation in high-TB-burdened countries. This study aimed to determine factors associated with body composition at commencement of TB treatment in Mwanza, Tanzania. A cross-sectional study was conducted from 2007 to 2008 among newly diagnosed TB patients. Fat and fat-free mass were determined using a deuterium dilution technique and fat and fat-free mass indices were computed. Correlates were assessed using multiple regression analysis. A total of 201 pulmonary TB patients were recruited; of these, 37.8% (76) were female, 51.7% (104) were HIV infected, 65.3% (126) had sputum-positive TB, and 24.4% (49) were current smokers. In multiple regressions analysis, males had a 2.2-kg/m(2) [(95% CI = 1.6, 2.9); P < 0.0001] lower fat mass index but 1.5 kg/m(2) [(95% CI = 0.9, 2.0); P < 0.0001] higher fat-free mass index compared with females. Sputum-positive TB was associated with a lower fat mass index among HIV-uninfected patients [-1.4 kg (95% CI = -2.5, -0.4); P = 0.006] but not among HIV-infected patients (P-interaction = 0.09). Current smokers had a 0.7-kg/m(2) [(95% CI = 0.02, 1.5); P = 0.045] lower fat mass index, but smoking did not affect fat-free mass. High socioeconomic status (SES) was associated with higher fat as well as fat-free mass. HIV infection, cluster of differentiation 4 count, and antiretroviral therapy were not correlates. Sex, smoking, and SES were associated with body composition of TB patients at treatment commencement. Prospective studies are needed to determine the role of these factors on weight gain, functional recovery, and survival during and after treatment.

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.

Assessing Nutrient Intake and Nutrient Status of HIV Seropositive Patients Attending Clinic at Chulaimbo Sub-District Hospital, Kenya

Background. Nutritional status is an important determinant of HIV outcomes. Objective. To assess the nutrient intake and nutrient status of HIV seropositive patients attending an AIDS outpatient clinic, to improve the nutritional management of HIV-infected patients. Design. Prospective cohort study. Setting. Comprehensive care clinic in Chulaimbo Sub-District Hospital, Kenya. Subjects. 497 HIV sero-positive adults attending the clinic. Main Outcome Measures. Evaluation of nutrient intake using 24-hour recall, food frequency checklist, and nutrient status using biochemical assessment indicators (haemoglobin, creatinine, serum glutamate pyruvate (SGPT) and mean corpuscular volume (MCV)). Results. Among the 497 patients recruited (M : F sex ratio: 1.4, mean age: 39 years ± 10.5 y), Generally there was inadequate nutrient intake reported among the HIV patients, except iron (10.49 ± 3.49 mg). All the biochemical assessment indicators were within normal range except for haemoglobin 11.2 g/dL (11.4 ± 2.60 male and 11.2 ± 4.25 female). Conclusions. Given its high frequency, malnutrition should be prevented, detected, monitored, and treated from the early stages of HIV infection among patients attending AIDS clinics in order to improve survival and quality of life.

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.

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

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

The effect of energy–protein supplementation on weight, body composition and handgrip strength among pulmonary tuberculosis HIV-co-infected patients: randomised controlled trial in Mwanza, Tanzania

Undernutrition is common among smear-positive pulmonary tuberculosis (PTB+) patients. Micronutrient supplementation may improve treatment outcomes, but it is unclear whether additional energy–protein would be beneficial. The present study aimed to assess the effect of energy–protein supplementation on weight, body composition and handgrip strength against a background of high micronutrient intake during tuberculosis (TB) treatment. A total of 377 PTB+ patients co-infected with HIV were randomly allocated one or six biscuits daily for 60 d during TB treatment. Weight, arm fat area, arm muscle area and handgrip strength were assessed at baseline and 2 and 5 months. There were no effects on any outcome at 2 months, but energy–protein supplementation was associated with a 1·3 (95 % CI − 0·1, 2·8) kg marginally significant gain in handgrip strength at 5 months. However, after 2 months, energy–protein supplementation led to a weight gain of 1·9 (95 % CI 0·1, 3·7) kg among patients with cluster of differentiation 4 (CD4) counts ≥ 350 cells/μl, but not among patients with low CD4 counts ( − 0·2 kg; 95 % CI − 1·3, 0·8, Pinteraction = 0·03). Similarly, at 5 months, energy–protein supplementation led to a 2·3 (95 % CI 0·6, 4·1) kg higher handgrip strength gain among patients with CD4 counts < 350 cells/μl, but not in those with high CD4 counts (Pinteraction = 0·04). In conclusion, energy–protein supplementation to PTB+ HIV-co-infected patients had no overall effects on weight and body composition, but was associated with marginally significant gain in handgrip strength. More research is needed to develop an effective supplement, before it is recommended to TB programmes.

Weight, body composition and handgrip strength among pulmonary tuberculosis patients: a matched cross-sectional study in Mwanza, Tanzania

This study aimed to estimate deficits in weight, arm fat area (AFA), arm muscle area (AMA) and handgrip strength among smear-positive pulmonary TB (PTB+) patients starting treatment. We conducted a cross-sectional study among PTB+ patients and age- and sex-matched neighborhood controls. HIV status, anthropometric measurements and handgrip strength were determined. Deficits in weight, AFA, AMA and handgrip strength associated with PTB+ and HIV were estimated using multiple regression analysis. We recruited 355 pairs of PTB+ patients and controls. PTB+ was associated with deficits of 10.0kg (95% CI 7.3; 12.7) in weight and 6.8kg (95% CI 5.2; 8.3) in handgrip strength among females and 9.1kg (95% CI 7.3; 10.9) in weight and 6.8kg (95% CI 5.2; 8.4) in handgrip strength among males. In both sexes, PTB+ was associated with deficits in AFA and AMA. Among females, HIV was associated with deficits in AMA and handgrip strength, but the deficit in handgrip strength was larger among PTB+ patients (3.2kg 95% CI 1.3; 5.2) than controls (-1.6kg 95% CI -4.8; 1.5) (interaction, P=0.009). These findings suggest that deficits in weight and handgrip strength among patients starting TB treatment are severe. Thus, nutritional support may be necessary to ensure reversal of the deficits, and may improve treatment outcomes.

Impact of household food insecurity on the nutritional status and the response to therapeutic feeding of people living with human immunodeficiency virus

BACKGROUND

The role of household food security (HFS) in the occurrence of wasting and the response to food-based intervention in people living with human immunodeficiency virus (PLHIV), especially adults, is still controversial and needs investigation.

METHODS

Face-to-face interviews to collect data for Coping Strategies Index score and Dietary Diversity Score estimation were conducted during a noncontrolled and nonrandomized study assessing the effectiveness of ready-to-use therapeutic food in the treatment of wasting in adults with HIV. Coping Strategies Index score and Dietary Diversity Score were used to determine HFS, and the participants and tertiles of Coping Strategies Index score were used to categorize HFS.

RESULTS

The study showed that most participants were from food insecure households at admission, only 2.7% (5/187) ate food from six different food groups the day before enrolment, and 93% (180/194) were applying forms of coping strategy. Acute malnutrition was rare among <5-year-old children from participants' households, but the average (standard deviation) mid-upper arm circumference of other adults in the same households were 272.7 (42.1) mm, 254.8 (33.8) mm, and 249.8 (31.7) mm for those from the best, middle, and worst tertile of HFS, respectively (P = 0.021). Median weight gain was lower in participants from the worst HFS tertile than in those from the other two tertiles combined during therapeutic feeding phase (0.0 [-2.1 to 2.6] kg versus 1.9 [-1.7 to 6.0] kg; P = 0.052) and after ready-to-use therapeutic food discontinuation (-1.9 [-5.2 to 4.2] kg versus 1.8 [-1.4 to 4.7] kg; P = 0.098). Being on antiretroviral therapy influenced the response to treatment and nutritional status after discontinuation of ready-to-use therapeutic food supplementation.

CONCLUSION

Food insecurity is an important contributing factor to the development of wasting in PLHIV and its impact on therapeutic feeding response outlines the importance of food-based intervention in the management of wasting of PLHIV.

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).

Association between HIV replication and serum leptin levels: an observational study of a cohort of HIV-1-infected South African women

Background

Advanced HIV infection can result in lipoatrophy and wasting, even in the absence of ongoing opportunistic infections, suggesting that HIV may directly affect adipose tissue amount and distribution.

Methods

We assessed the relationship of fat (measured using anthropometry, DEXA, MRI scans) or markers related to glucose and lipid metabolism with viral load in a cross-sectional sample of 83 antiretroviral-naïve HIV-1-infected South African women. A multivariable linear model was fitted to log₁₀VL to assess the combined effect of these variables.

Results

In addition to higher T cell activation, women with viral load greater than the population median had lower waist circumference, body mass index and subcutaneous abdominal fat, as well as lower serum leptin. We demonstrate that leptin serum levels are inversely associated with viral replication, independent of the amount of adipose tissue. This association is maintained after adjusting for multiple variables associated with disease progression (i.e., cellular activation and innate immunity effector levels).

Conclusions

Our results demonstrate that serum leptin levels are inversely associated with viral replication, independent of disease progression: we postulate that leptin may affect viral replication.

Body composition among HIV-seropositive and HIV-seronegative adult patients with pulmonary tuberculosis in Uganda

PURPOSE

We determined whether human immunodeficiency virus (HIV) infection affects body cell mass and fat mass wasting among adults with pulmonary tuberculosis (PTB).

METHODS

We screened 967 Ugandan adults for PTB and HIV infection in a cross-sectional study. We compared anthropometric and bioelectric impedance analysis (BIA) body composition parameters among HIV-seropositive and HIV-seronegative men and women with or without PTB by using a non-parametric test.

RESULTS

We found that poor nutritional status associated with TB differed among men and women. Anthropometric and BIA body composition did not differ between HIV-seropositive and HIV-seronegative patients regardless of gender. Average weight group difference in men consisted of body cell mass and fat mass in equal proportions of 43%. In women, average weight group difference consisted predominantly of fat mass of 73% and body cell mass of 13%. Compared to individuals without TB, patients with TB had lower body mass index, weight, body cell mass, and fat mass regardless of gender and HIV status.

CONCLUSIONS

Gender, but not HIV status, was associated with body composition changes in TB. TB appears to be the dominant factor driving the wasting process among co-infected patients.

HIV/AIDS: nutritional implications and impact on human development

HIV/AIDS is associated with biological and social factors that affect the individual's ability to consume and utilize food and to acquire food. These biological and social factors lead to poor nutritional status and weight loss, which are an important cause of morbidity in individuals infected with HIV, resulting in a poor quality of life; weight loss is an important predictor of death from AIDS. The links between nutrition and HIV/AIDS amplify the negative effects of HIV infection on human development at individual, household, community and national levels. For many developing countries the incidence of HIV/AIDS and malnutrition is impeding progress towards achieving the UN millennium development goals. Aggressive interventions to curb the spread of HIV continue to be needed. Concurrent efforts to improve nutrition for populations living with HIV/AIDS should also be given priority.

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.

Body composition studies in patients with wasting associated with tuberculosis

OBJECTIVE

Wasting is a well-recognized manifestation of tuberculosis (TB), but little is known about the alterations in body composition that occur. Therefore, we measured regional and whole-body composition in patients with TB and wasting.

METHODS

Body composition was measured by dual-energy x-ray absorptiometry in 18 patients with newly diagnosed TB and wasting (10 coinfected with human immunodeficiency virus [HIV]) and 22 controls (10 coinfected with HIV).

RESULTS

Patients with TB and wasting had significantly lower body weight (48.6 versus 62.0 kg), lean body mass (39.6 versus 45.6 kg), and fat mass (6.2 versus 12.6 kg) than did controls. Patients with TB had significantly reduced lean tissue in the limbs (15.2 versus 19.1 kg) and trunk (21.3 versus 23.2 kg) and significantly higher trunk-to-limb lean ratio (1.41 versus 1.22) compared with controls. Patients with TB had significantly reduced fat in the limbs (3.4 versus 6.1 kg) and trunk (2.1 versus 5.7 kg) and significantly lower trunk-to-limb fat ratio (0.52 versus 0.92) compared with controls. Body composition measurements were no different in patients with and without HIV coinfection.

CONCLUSIONS

Wasting in TB is associated with depletion of whole-body lean and fat tissue in approximately equal proportions overall, but lean tissue depletion is greater in the limbs and fat tissue depletion is greater in the trunk. HIV coinfection does not affect the magnitude or distribution of the body composition changes.

Vitamin supplements, socioeconomic status, and morbidity events as predictors of wasting in HIV-infected women from Tanzania

BACKGROUND

Wasting is a strong independent predictor of mortality in HIV-infected persons. Vitamin supplements delay the disease progression, but their effect on wasting is not known. Data are lacking on the risk factors for wasting in African HIV-infected persons.

OBJECTIVES

The objectives were to examine the effect of vitamin supplements on wasting in HIV-infected women and to assess the effects of sociodemographic characteristics, morbidity events, and immunologic progression on the risk of wasting.

DESIGN

HIV-infected women (n = 1078) from Tanzania were randomly assigned to receive 1 of 4 daily oral regimens: multivitamins (B complex, C, and E), vitamin A plus beta-carotene, multivitamins that included vitamin A plus beta-carotene, or placebo. The endpoints of the study included first episodes of a midupper arm circumference <22 cm or a body mass index (BMI; in kg/m2) <18 and the incidence of weight loss episodes during a median 5.3 y of follow-up.

RESULTS

Multivitamins alone significantly reduced the risk of a first episode of a midupper arm circumference <22 cm (relative risk: 0.66; 95% CI: 0.47, 0.94; P = 0.02). In multivariate-adjusted Cox models, the woman's age, education level, and height were inversely related to the incidence of wasting. Episodes of diarrhea, nausea or vomiting, lower respiratory tract infections, oral ulcers, thrush, severe anemia, and low CD4+ cell counts were each significantly related to an increased risk of wasting.

CONCLUSIONS

Vitamins C and E and the vitamin B complex have a protective effect on wasting in HIV-infected women. Prevention of diarrhea, severe respiratory tract infections, and anemia are likely to decrease the burden of wasting.

Weight loss during pregnancy is associated with adverse pregnancy outcomes among HIV-1 infected women

In a prospective study of 1002 pregnant, HIV-1 infected Tanzanian women, we examined the incidence of fetal death, preterm delivery, low birth weight (LBW), and small for gestational age (SGA) births in relation to maternal anthropometry at the first prenatal visit, weight loss, and low weight gain during pregnancy. Anthropometric measurements were obtained monthly during the 2nd and 3rd trimesters. Low maternal height and weight at the first visit were significantly related to lower mean birth weight and increased risk of SGA, but not to preterm delivery. Maternal stature < 150 cm was significantly related to fetal death. Weight loss during pregnancy, defined as a negative slope of the regression of weight measurements on the week of gestation, occurred in 10% of the women. It was related to increased relative risk (RR) of fetal death (RR = 1.83, 95% CI = 0.93, 3.57), preterm delivery (RR = 1.85, 95% CI = 1.40, 2.44), and LBW (RR = 2.85, 95% CI = 1.69, 4.79) after adjusting for multivitamin supplementation, height, primiparity, baseline weight, malaria, CD4 cell count, HIV disease stage, and intestinal parasitoses. The significant association with fetal death was stronger for weight loss during the 2nd trimester, whereas increased risks of preterm delivery and LBW were higher for weight loss during the 3rd. Similar but weaker associations were found with low weight gain during pregnancy (slope < 25th percentile). We conclude that poor anthropometric status at the first prenatal visit and weight loss during pregnancy among HIV-1 infected women are strong risk factors for adverse pregnancy outcomes.

Growth Hormone Improves Lean Body Mass, Physical Performance, and Quality of Life in Subjects With HIV-Associated Weight Loss or Wasting on Highly Active Antiretroviral Therapy

HIV-associated wasting is defined as > or = 10% involuntary weight loss and includes declines in both lean and fat mass. This large (757 subjects), randomized, double-blind, placebo-controlled trial investigated the efficacy, safety, and tolerability of recombinant human growth hormone (rhGH) in 2 doses-0.1 mg/kg up to a maximum of 6 mg daily (DD) or alternate days (AD)-in the treatment of wasting and weight loss in highly active antiretroviral therapy (HAART)-treated HIV-infected subjects. The evaluable population for ergometry comprised 555 subjects, 87.6% of whom were receiving HAART. At 12 weeks, median maximum work output increased by 2.4 and 2.6 kJ in the AD and DD groups, respectively. The median treatment difference was 2.9 kJ for DD vs. placebo (P < 0.0001). Body weight increased by 2.2 and 2.9 kg in the AD and DD groups, respectively. Corresponding median treatment differences vs. placebo were 1.5 and 2.2 kg (P < 0.0001). Lean body mass (LBM), by bioelectric impedance spectroscopy, increased by 3.3 and 5.2 kg, respectively (P < 0.0001 vs. placebo; P = 0.0173 DD vs. AD), and fat mass, predominately truncal, decreased. Quality of life (QoL) improved significantly in both rhGH groups. Fluid-retention adverse effects and hyperglycemia were more common in the DD than in the AD group. No significant changes in HIV viral load or CD4 cell count occurred. In conclusion, over the 12-week course of therapy, rhGH, 0.1 mg/kg DD, was superior to placebo in improving physical function, body weight, body composition, and QoL and was superior to AD dosing in restoring LBM.

Difficulty Swallowing and Lack of Receipt of Highly Active Antiretroviral Therapy Predict Acute Weight Loss in Human Immunodeficiency Virus Disease

In human immunodeficiency virus (HIV) disease, symptoms of underlying illness may promote weight loss through decreased caloric intake, increased metabolic needs, or nutrient malabsorption. We evaluated disease symptoms as predictors of acute weight loss (i.e., loss of > or =5% of weight). HIV-infected men and women (n=415) were telephoned every 5 weeks to obtain information about weight and recent symptoms. Weight change between each pair of consecutive calls (telephone intervals, 2814) was calculated. Acute weight loss occurred across 4.5% of intervals and among 24% of individuals. Patients reported > or =1 symptom before 58% of telephone intervals. The most common symptoms or symptom complexes before intervals were diarrhea (21% of patients), anorexia (17%), upper respiratory symptoms (16%), skin symptoms (12%), and abdominal pain (12%). Trouble swallowing (6%) and oral symptoms (7%) were less common. Risk of acute weight loss was significantly increased when oral symptoms or trouble swallowing were present, and it was decreased when highly active antiretroviral therapy (HAART) was used or when diarrhea was not present. Even when HAART is being administered, clinicians should remain vigilant regarding weight loss, oral symptoms, and trouble swallowing.

[Isolated dietary counselling program versus supplement and dietary counselling in patients with human immunodeficiency virus infection]

BACKGROUND AND OBJECTIVE

Nutritional intervention is a controversial area. The aim of the study was to compare the influence on nutritional status of nutritional supplementation with a standard polymeric formula as well as nutritional counselling versus isolated nutritional counselling in a group of HIV-infected patients.

PATIENTS AND METHOD

There were 70 patients, 66 of whom were fully evaluated for each study end point after application of prospectively determined evaluability criteria. Of these, 35 were randomized to group I (standard formula) and 35 were randomized to unsupplemented group II. Group I patients received standard enteral formula (3 cans/day, 250 ml per can). Patients were submitted to a prospective serial assessment of their nutrition status (anthropometric and biochemical status) and the nutritional intake was determined by means of 24-hours written food records. Determinations were performed at baseline and at 3 months.

RESULTS

Treatment with oral supplements in group I resulted in a significant and sustained increase in weight (2.75%; p < 0.05) which was mostly due to fat mass (10.8%; p < 0.05). In contrast, no changes were detected in group II patients. The increase in body weight and tricipital skinfold was significant in group I. Total body water and fat free-mass remained without changes. CD4 counts and viral load remained stable in both groups.

CONCLUSIONS

Oral nutritional supplements for a 3-months period resulted in body weight gain in HIV-infected patients, increasing the fat mass. An isolated nutritional counselling did not result in such an increase.

Protein intake is positively associated with body cell mass in weight-stable HIV-infected men

Depletion of body cell mass (BCM) in human immunodeficiency virus (HIV)-infected patients is strongly associated with disease progression and death. Although whole-body protein turnover is increased in HIV infection, it is not known whether protein intake is independently associated with BCM. The purpose of this study was to determine the associations, if any, between protein intake and several body composition variables in 467 weight-stable, HIV-infected men with CD4 <200 cells/mm(3) enrolled in a multicenter nutritional supplementation trial. Baseline BCM, total body fat and extracellular mass as measured by bioelectrical impedance analysis, dietary intake (24 h food recall) and muscle building activity assessed by structured interview were analyzed to determine association(s) between body composition variables and macronutrient intake. Multiple regression analysis showed that BCM was positively associated with body weight (P = 0.001), height (P < 0.001), protein intake (P < 0.001), muscle-building activity (P < 0.001) and African-American ethnicity (P < 0.05) and negatively associated with carbohydrate intake (P < 0.05), age (P < 0.001) and number of prior AIDS-related diagnoses (P < 0.001). We conclude that protein intake is associated with increased BCM, whereas carbohydrate intake is negatively associated with BCM in HIV-infected men, independently of muscle building activity.

Double-blind, randomized, placebo-controlled phase III trial of oxymetholone for the treatment of HIV wasting

BACKGROUND

Despite highly active antiretroviral therapy (HAART), chronic involuntary weight loss still remains a serious problem in the care of HIV patients. Various alterations in energy metabolism and endocrine regulation have been found to cause loss of lean body mass (LBM) and body cell mass (BCM). Previous studies in HIV-positive men undergoing androgen replacement therapy or treatment with recombinant growth hormone (rGH) have shown partial restoration of LBM, but these treatments have largely been ineffective in eugonadal individuals.

STUDY DESIGN

Double-blind, randomized, placebo-controlled trial of 89 HIV-positive women and men with wasting assigned to the anabolic steroid oxymetholone [50 mg twice (BID) or three times daily (TID)] or placebo for 16 weeks followed by open-label treatment. STUDY ENDPOINTS: Body weight, bioimpedance measurements, quality of life parameters and appetite.

RESULTS

Oxymetholone led to a significant weight gain of 3.0 +/- 0.5 and 3.5 +/- 0.7 kg in the TID and BID groups, respectively (P < 0.05 for each treatment versus placebo), whereas individuals in the placebo group gained an average of 1.0 +/- 0.7 kg. Body cell mass increased in the oxymetholone BID group (3.8 +/- 0.4 kg; P < 0.0001) and in the oxymetholone TID group (2.1 +/- 0.6 kg; P < 0.005), corresponding to 12.4 and 7.4% of baseline BCM, respectively. Significant improvements were noted in appetite and food intake, increased well-being and reduced weakness by self-examination. The most important adverse event was liver-associated toxicity. Overall, 35% of patients in the TID, 27% of patients in the BID oxymetholone group and no patients in the placebo group had a greater than five times baseline increase for alanine aminotransferase during the double-blind phase of the study.

CONCLUSIONS

Oxymetholone can be considered an effective anabolic steroid in eugonadal male and female patients with AIDS-associated wasting. The BID (100 mg/day) regimen appeared to be equally effective as the TID (150 mg/day) regimen in terms of weight gain, LBM and BCM and was associated with less, but still significant liver toxicity.

The percutaneous endoscopic gastrostomy tube. medical and ethical issues in placement

OBJECTIVE

Offering and recommending PEG tube placement to patients has been a topic of considerable interest in the medical literature. The role of individual health care professionals in the decision making process is poorly defined. PEG tubes are often placed inappropriately because of unrealistic and inaccurate expectations of what they can accomplish in patients unable to tolerate adequate oral intake. We have developed an algorithm for PEG placement for the geriatric, oncology, and neurology patients based on a critical review of current literature.

METHODS

An extensive review of the literature was performed focusing on PEG tube placement in oncology, neurology, and geriatric patients. This algorithm was developed to provide both the primary care provider and the specialist with appropriate indications for PEG placement in these patient populations.

RESULTS

Appropriate indications for PEG placement are 1) Esophageal obstruction (e.g., esophageal cancer), 2) Neurologic etiology of dysphagia without obstruction (e.g., status post cerebrovascular accident, pseudobulbar palsy), 3) Prolonged refusal to swallow without evidence of concomitant terminal illness (e.g., protracted pseudodementia due to severe depression), 4) Supplemental nutrition for patients undergoing chemotherapy or radiation therapy.

CONCLUSIONS

If no physiologic benefit is expected with PEG placement (anorexia-cachexia syndrome), the health care team has no obligation to offer or perform an intervention. This same principle would apply if intervention improves physiologic states but has no effect on quality of life (e.g., permanent vegetative state). Small-bore feeding tubes are cost effective and relatively safe for enteral feedings of up to 6-8 weeks. This is especially pertinent in the population with acute neurological deficits, in which prognostication on extent of impairment is best estimated by communication with neurologist. In the geriatric population there is no proved benefit in weight gain or markers of nutrition (albumin, prealbumin) in patients with malnutrition due to impaired oral intake.

HIV-1 viral load and elevated serum alpha(1)-antichymotrypsin are independent predictors of body composition in pregnant Zimbabwean women

Human immunodeficiency virus (HIV) infection affects body composition, but their relationship has not been studied in pregnant women. We conducted a cross-sectional study among 1669 women receiving antenatal care between 22 and 35 wk of gestation in Harare, Zimbabwe. The role of HIV-1 status and viral load, malaria and elevated serum alpha(1)-antichymotrypsin (ACT, an acute phase protein) in weight, body mass index (BMI), arm circumference (AC), triceps skinfold thickness (TSF), and arm muscle (AMA) and fat (AFA) area were assessed using multiple linear regression analysis. The mean (range) age was 24.4 (14-45) y and gestational age 29 (22-35) wk. HIV infection was present in 31.5% of the women, malaria parasitemia in 0.4% and 11.4% had serum ACT >0.4 g/L. There was no difference in any anthropometric variable between HIV-infected and uninfected women. However, women with viral loads (genome equivalents/mL) between 4 and 5 and >5 log(10) had 1.1 [95% confidence interval (CI): -0.3, 2.3] and 2.5 (95% CI: 0.1, 5.1) kg lower weights compared with uninfected women; this was explained by losses of both AFA and AMA. Malaria parasitemia was associated with 6 cm(2) (95% CI: 0.4; 11.8) or 25% lower AMA. Elevated serum ACT was a negative predictor of all anthropometric variables, i.e., levels between 0.3 and 0.4, 0.4 and 0.5 and >0.5 g/L were associated with 1, 2 and 6 kg lower mean body weights, respectively. Despite the limitations of a cross-sectional design, we conclude that arm fat and muscle areas, reflecting body fat and lean body mass, seem to be unaffected in the majority of HIV-infected pregnant women, but decline with increasing viral loads. The effects of viral load are not explained by elevated serum ACT, which is a strong independent predictor of all anthropometric variables.

Body composition and nutritional parameters in HIV and AIDS patients

Undernutrition is a frequent complication of evolutive and chronic HIV (human immunodeficiency virus) infection characterized by bodyweight loss and changes in body composition. The Centers for Disease Control and Prevention define AIDS wasting as involuntary loss of more than 10% of body weight, plus more than 30 days of either diarrhea, or weakness and fever. Wasting syndrome has been considered as a case definition of the AIDS disease since 1987. Wasting syndrome is clearly linked to disease progression and death. Despite the progress under the era of highly active antiretroviral therapy (HAART), wasting is still a problem for people with AIDS. A small part of the weight lost is fat. More important is the loss of "lean body mass", which is mostly muscle. Body composition changes during HIV infection are different from those observed in food deprivation. Under the era of HAART, a HIV-associated adipose redistribution syndrome (HARS) was described that associates subcutaneous lipoatrophy and abdominal obesity linked to various metabolic disorders. Several factors contribute to wasting syndrome. Not only low food intake and poor nutrient absorption, but mainly altered metabolism (increased resting energy expenditure) and specific disturbances in protein turnover, which is also increased. Nutritional evaluation of HIV-infected patients should include the measurement of body composition and analysis of nutritional parameters, including albumin, transthyretin and C-reactive protein. Transthyretin seems to be particularly useful to follow the recovery period of malnutrition.

Effect of multivitamin and vitamin A supplements on weight gain during pregnancy among HIV-1-infected women

BACKGROUND

The pattern of weight gain during pregnancy among HIV-infected women is largely unknown. Multivitamin supplementation was shown to be effective in preventing adverse pregnancy outcomes among HIV-positive women. These protective effects could be mediated in part by an improvement in the pattern of gestational weight gain.

OBJECTIVE

We examined the effects of multivitamin and vitamin A supplements on weight gain during the second and third trimesters of pregnancy among HIV-infected women.

DESIGN

We enrolled 1075 pregnant, HIV-1-positive women from Dar es Salaam, Tanzania, in a randomized, placebo-controlled trial. Using a 2-by-2 factorial design, we assigned each woman to 1 of 4 regimens: multivitamins (thiamine, riboflavin, niacin, folic acid, and vitamins B-6, B-12, C, and E), vitamin A, multivitamins including vitamin A, or placebo. The women took these oral supplements daily and were weighed monthly until the end of pregnancy.

RESULTS

The mean rate of weight gain was 306 g/wk during the second trimester and 247 g/wk during the third trimester. During the third trimester, average weight gain was significantly greater (by 304 g; 95% CI: 17, 590; P = 0.04) and the risk of low rate of weight gain (<or= 100 g/wk) was significantly lower (relative risk: 0.73; 95% CI: 0.58, 0.93) in women who received multivitamins than in women who did not. Multivitamins including vitamin A were protective against low weight gain during the second trimester compared with multivitamins alone.

CONCLUSION

Multivitamin supplementation during pregnancy improves the pattern of weight gain among HIV-infected women.

Weight loss and survival in HIV-positive patients in the era of highly active antiretroviral therapy

Weight loss and wasting have long been established as strong predictors of mortality in HIV-infected patients. Today, despite the effectiveness of highly active antiretroviral therapy (HAART), there is evidence that HIV-related wasting is still an important comorbidity in many patients. We conducted a study to determine if wasting is still associated with decreased survival in patients receiving HAART and which parameter (weight, fat-free mass [FFM], body cell mass [BCM], or fat mass [FM]) is most strongly associated with mortality. The study population consisted of 678 HIV-positive participants enrolled in the Nutrition for Healthy Living study. Weight, FFM, BCM, and FM were assessed for all participants at 6-month intervals. At each follow-up visit, percent losses of each parameter were calculated from values at baseline and the previous visit. Cox proportional hazards models were used to estimate and compare the relative risks of death for each parameter, adjusting for potential confounders such as HAART use, body mass index, and CD4 cell counts. In analyses examining the parameters separately and together in the same model, weight loss emerged as the strongest independent predictor of mortality. Weight loss of >or=10% from baseline or the previous visit was significantly associated with a four- to sixfold increase in mortality compared with maintenance or gaining of weight. Even one episode of weight loss of >or=3% from baseline or >or=5% from the previous visit was predictive of mortality. In summary, despite the apparent benefits of HAART use on HIV-related survival, weight loss remains an independent predictor of mortality. In addition, FFM or BCM estimated using bioelectrical impedance analysis does not add further prognostic value over weight loss.

Anabolic treatment with GH, IGF-I, or anabolic steroids in patients with HIV-associated wasting

Wasting, and particularly loss of metabolically active lean tissue, contributes to increased mortality, accelerated disease progression, and impairment of strength and functional status in patients with HIV infection. A variety of protein anabolic agents, including growth hormone, insulin-like growth factor-I, testosterone, nandrolone decanoate, oxandrolone, and oxymetholone, have been studied in patients with HIV-associated wasting. Overall, these studies have demonstrated that treatment with protein anabolic agents can increase lean body mass (LBM) and in some cases provide functional benefits and improvements in quality of life. Further research is needed to determine whether such treatment prolongs survival or reduces the overall health care burden of HIV infection. The advances in identification of successful treatments for HIV-associated wasting can provide a model for using these therapies in other catabolic states, including end-stage renal disease, cancer, chronic obstructive pulmonary disease, and cardiac cachexia.

Nutrition and HIV infection

Infection by the human immunodeficiency virus (HIV) is characterized by progressive destruction of the immune system, which leads to recurrent opportunistic infections and malignancies, progressive debilitation and death. Malnutrition is one major complication of HIV infection and is recognized as a significant prognostic factor in advanced disease. Malnutrition is multifactorial and poorly treated during the course of HIV. Even if a standardized approach to the management of active weight loss has not been well established, early nutritional intervention is important in HIV infected patients to maximize gain of lean body mass. From early in the era of highly active antiretroviral therapy (HAART), an initial decreased incidence of malnutrition was noted only in western countries while a variety of changes in the distribution of body fat and associated metabolic abnormalities have been recognized under the banner of lipodystrophy.

The role of exercise in the prevention and treatment of wasting in acquired immune deficiency syndrome

Involuntary weight loss with lean tissue depletion is a serious and AIDS-defining complication of HIV infection. This article explores definitions of AIDS wasting syndrome (AWS), its etiology, methods of assessing body composition, and pharmacological treatments. Recent research literature on the role of exercise in the prevention and treatment of AWS is reviewed. Included are studies of the safety of exercise, the effects of exercise on the immune system, and the effects of exercise on weight gain and body composition as well as studies of exercise in combination with medications and other interventions. Implications for clinical practice are discussed.

Nutritional treatment for acquired immunodeficiency virus infection using an enterotropic peptide-based formula enriched with n-3 fatty acids: a randomized prospective trial

OBJECTIVE

Dietary counseling and intervention based on application of conventional criteria have been ineffective in preventing the progressive weight loss associated with HIV infection. The aim of the study was to compare the progression of clinical and nutritional indicators during nutritional supplementation with or without an enterotropic peptide-based formula enriched with n-3 fatty acids.

DESIGN

Randomized trial.

SETTING

Tertiary care.

SUBJECTS

Ninety-one patients were screened for the study. Twenty-three did not meet the inclusion criteria, therefore 74 patients were randomized. Of these, 38 were randomized to group I (standard formula) and 36 were randomized to group II supplementation (enterotropic peptide-based formula enriched with n-3 fatty acids).

INTERVENTIONS

Group I received standard enteral formula and group II received a enterotropic peptide-based enteral formula. The volume was the same (3 cans/day, 236 ml per can). In both groups enteral supplementation were recommended in conjunction with a registered dietitian under a dietary counseling program based on standard nutrition principles. Patients received a prospective serial assessment of nutrition status, nutritional intake with 24 h written food records, GI symptoms, immune function, anthropometric status and intercurrent health events including infections and hospitalization. These determinations were performed at baseline and at 3 months.

RESULTS

Treatment with both supplements resulted in a significant and sustained increase in weight (3.2% in group I and 3.1% in group II); this increase was mostly due to fat mass (12.8% in group I) and (7.5% in group II). Total body water and fat free-mass remained unchanged. CD4 counts remained stable in group I, while a significant increase was detected in group II (576+/-403 vs 642+/-394 cells/mm(3); P<0.05). After the 3 month period CD4 counts remained higher in group II. Hospitalization events (infections) were also followed during the 3 month period. Group II had fewer hospitalizations than group I, but no statistical differences were found.

CONCLUSIONS

Oral nutritional supplements for a 3 month period were well tolerated and resulted in body weight gain in HIV-infected patients. Supplement-enriched formula, with peptides and n-3 fatty acids, increased CD4 count.

Anthropometric indices as predictors of survival in AIDS adults. Aquitaine Cohort, France, 1985-1997. Groupe d'Epidémiologie Clinique du Sida en Aquitaine (GECSA)

The aim of the study was to assess the performance of weight related nutritional markers [reported involuntary weight loss (WL) greater than 10%, measured WL and body mass index (BMI)] in predicting survival at AIDS stage. The three anthropometric indices were used as time dependent variables in Cox models to predict survival at AIDS stage. The studied sample included 630 HIV1-infected individuals of a prospective cohort of those 421 died (median survival at AIDS stage: 19.9 months). After adjustment for usual prognostic factors of survival, the reported WL greater than 10% was a pejorative predictor of survival (hazard ratio (HR) 2.4; 95% confidence interval (CI): 1.9-3.0). For measured WL < 5%, between 5 and 10% and > or = 10% of baseline weight compared with no WL, HR were respectively, 1.9 (CI: 1.4-2.6), 3.3 (CI: 2.4-4.4) and 6.7 (CI: 5.2-8.6). The HR of death were 2.2 (CI: 1.6-3.0) for BMI between 16 and 18.4 kg/m2 and 4.4 (CI: 3.1-6.3) for BMI < 16 compared to normal BMI (> or = 18.5). Even a limited WL measured at a given point in time during follow up increases the risk of death at the AIDS stage. Simple cross-sectional measures of BMI have a good predictive value of survival.

Clinical and diagnostic aspects of intestinal microsporidiosis in HIV-infected patients with chronic diarrhea in Rio de Janeiro, Brazil

The objectives of this study were to determine both the prevalence of microsporidial intestinal infection and the clinical outcome of the disease in a cohort of 40 HIV-infected patients presenting with chronic diarrhea in Rio de Janeiro, Brazil. Each patient, after clinical evaluation, had stools and intestinal fragments examined for viral, bacterial and parasitic pathogens. Microsporidia were found in 11 patients (27.5%) either in stools or in duodenal or ileal biopsies. Microsporidial spores were found more frequently in stools than in biopsy fragments. Samples examined using transmission electron microscopy (n=3) or polymerase chain reaction (n=6) confirmed Enterocytozoon bieneusi as the causative agent. Microsporidia were the only potential enteric pathogens found in 5 of the 11 patients. Other pathogens were also detected in the intestinal tract of 21 patients, but diarrhea remained unexplained in 8. We concluded that microsporidial infection is frequently found in HIV infected persons in Rio de Janeiro, and it seems to be a marker of advanced stage of AIDS.

Nutritional alterations associated with HIV infection

Nutritional alterations are common in HIV infection. Early studies documented weight loss and protein depletion, a finding associated with body cell mass depletion in untreated patients. The application of highly active antiretroviral therapy has led to a decreased incidence of malnutrition, although altered body fat distribution and metabolic alterations, including hyperlipidemia and insulin resistance, are common sequelae. The development of malnutrition is multifactorial and occurs through changes in caloric intake, nutrient absorption, or energy expenditure. Clinically, malnutrition develops as a result of either starvation or cachexia. Other hormonal and endocrinologic alterations include hypercortisolemia and hypogonadism. The rationale for providing nutritional support to AIDS patients is based upon the assumptions that nutrition status can be improved and that such improvements have clinical benefits. The results of hypercaloric feeding studies, including the use of appetite stimulants, indicate that weight gain is possible but that the weight gained is predominantly fat. In contrast, anabolic agents and resistance training exercise have been shown to promote body cell mass repletion and skeletal muscle gain. Cytokine inhibitors also have been evaluated for the treatment of wasting in HIV infection. Development of combination therapies, preventive therapies, and efficient and cost-effective therapies are current tasks in the field.

Phase angle from bioelectrical impedance analysis remains an independent predictive marker in HIV-infected patients in the era of highly active antiretroviral treatment

BACKGROUND

Highly active antiretroviral treatment (HAART) reduces the risk of wasting in HIV infection and may alter the prognostic weight of wasting. The phase angle from bioelectrical impedance analysis (BIA) can be interpreted as a surrogate marker for the catabolic reaction to chronic HIV infection and opportunistic disease.

OBJECTIVE

Our objective was to assess the prognostic ability of the phase angle in HIV-infected patients in the era of HAART.

DESIGN

Two cross-sectional observation studies were conducted in 1996 and 1997 at a German university outpatient HIV clinic. In the 1996 and 1997 cohorts, HAART was prescribed to 17 of 212 and 168 of 257 patients at baseline and to 179 of 212 and 234 of 257 patients during observation, respectively. Whole-body BIA was assessed at 50 KHz. Time to clinical progression and survival were calculated by using Cox proportional hazard models with time-dependent covariates. Median observation times were 1000 and 515 d for the 1996 and 1997 cohorts, respectively.

RESULTS

Higher phase angle was associated with a lower relative mortality risk, adjusted for viral load and CD4(+) cell count, of 0.49 (95% CI: 0.30, 0.81) per degree in 1996 and of 0.33 (95% CI: 0.18, 0.61) in 1997. The influence of phase angle on time to clinical progression, adjusted for viral load and CD4(+) cell count, was not significant in 1996 but the relative risk was 0.58 (0.36, 0.83) in 1997.

CONCLUSION

Despite the favorable effects of HAART on the nutritional status of HIV-infected persons, low phase angle remains an independent adverse prognostic marker of clinical progression and survival.