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Candel MJJM, van Breukelen GJP. Best (but oft forgotten) practices: Efficient sample sizes for commonly used trial designs. Am J Clin Nutr 2023; 117:1063-1085. [PMID: 37270287 DOI: 10.1016/j.ajcnut.2023.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 02/08/2023] [Accepted: 02/14/2023] [Indexed: 06/05/2023] Open
Abstract
Designing studies such that they have a high level of power to detect an effect or association of interest is an important tool to improve the quality and reproducibility of findings from such studies. Since resources (research subjects, time, and money) are scarce, it is important to obtain sufficient power with minimum use of such resources. For commonly used randomized trials of the treatment effect on a continuous outcome, designs are presented that minimize the number of subjects or the amount of research budget when aiming for a desired power level. This concerns the optimal allocation of subjects to treatments and, in case of nested designs such as cluster-randomized trials and multicenter trials, also the optimal number of centers versus the number of persons per center. Since such optimal designs require knowledge of parameters of the analysis model that are not known in the design stage, in particular outcome variances, maximin designs are presented. These designs guarantee a prespecified power level for plausible ranges of the unknown parameters and minimize research costs for the worst-case values of these parameters. The focus is on a 2-group parallel design, the AB/BA crossover design, and cluster-randomized and multicenter trials with a continuous outcome. How to calculate sample sizes for maximin designs is illustrated for examples from nutrition. Several computer programs that are helpful in calculating sample sizes for optimal and maximin designs are discussed as well as some results on optimal designs for other types of outcomes.
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Affiliation(s)
- Math J J M Candel
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands.
| | - Gerard J P van Breukelen
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands; Department of Methodology and Statistics, Graduate School of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
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Carpenter CL, Kapur K, Ramakrishna P, Pamujula S, Yadav K, Giovanni JE, Julian O, Ekstrand ML, Sinha S, Nyamathi AM. Lean Mass Improvement from Nutrition Education and Protein Supplementation among Rural Indian Women Living with HIV/AIDS: Results from Cluster Randomized Factorial Trial at 18-Month Follow-Up. Nutrients 2021; 14:179. [PMID: 35011054 PMCID: PMC8746930 DOI: 10.3390/nu14010179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/24/2021] [Accepted: 12/24/2021] [Indexed: 11/17/2022] Open
Abstract
Loss of lean muscle mass impairs immunity and increases mortality risk among individuals with HIV/AIDS. We evaluated the relative contributions of protein supplementation and nutrition education on body composition among 600 women living with HIV/AIDS in rural Andhra Pradesh, India. We conducted a cluster randomized controlled 2 × 2 factorial trial lasting six months with follow up at twelve and eighteen months. Interventions occurred in the Nellore and Prakasam regions of Andhra Pradesh by trained village women, ASHA (Accredited Social Health Activists), and included: (1) the usual supportive care from ASHA (UC); (2) UC plus nutrition education (NE); (3) UC plus nutritional protein supplementation (NS); (4) combined UC plus NE plus NS. A Bioimpedance Analyzer Model 310e measured body composition. SAS 9.4 analyzed all data. Mixed models using repeated measures evaluated lean mass change from baseline as primary and fat weight and total weight as secondary outcomes. Lean mass change was significantly associated with NS (p = 0.0001), NE (p = 0.0001), and combined NS plus NE (p = 0.0001), with similar associations for secondary outcomes. Stronger associations for total weight were observed with greater ART adherence. Nutritional interventions may improve physiologic response to HIV. Significant increases in lean mass resulted from independent and combined protein supplementation and nutrition education.
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Affiliation(s)
| | | | | | - Suresh Pamujula
- People’s Health Society, Nellore 524137, India; (P.R.); (S.P.)
| | - Kartik Yadav
- Sue & Bill Gross School of Nursing, University of California, Irvine, CA 92697, USA; (K.Y.); (A.M.N.)
| | - Jennifer E. Giovanni
- Center for Human Nutrition, University of California, Los Angeles, CA 90024, USA;
| | - Olivia Julian
- College of Medicine, Drexel University, Philadelphia, PA 19129, USA;
| | - Maria L. Ekstrand
- Center for AIDS Prevention, Department of Medicine, University of California, San Francisco, CA 94158, USA;
| | - Sanjeev Sinha
- All India Institute of Medical Sciences (AIIMS), New Delhi 110029, India;
| | - Adeline M. Nyamathi
- Sue & Bill Gross School of Nursing, University of California, Irvine, CA 92697, USA; (K.Y.); (A.M.N.)
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Hodges P, Kelly P, Kayamba V. Helicobacter pylori infection and hypochlorhydria in Zambian adults and children: A secondary data analysis. PLoS One 2021; 16:e0256487. [PMID: 34449790 PMCID: PMC8396721 DOI: 10.1371/journal.pone.0256487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/28/2021] [Indexed: 11/19/2022] Open
Abstract
Background Hypochlorhydria (gastric pH >4) increases susceptibility to diarrhoea, iron deficiency, and gastric cancer. We sought to clarify the prevalence of this condition and its predisposing factors in Zambia by pooling data from previous studies conducted in hospital and community settings. Methods Gastric pH was measured in participants from five separate studies by collecting gastric aspirate from fasted adults and children under 3 years of age undergoing gastroscopy. Gastric pH was correlated with serological testing for Human Immunodeficiency Virus (HIV) and Helicobacter pylori (H. pylori) infections. Results We studied 597 individuals (487 adults and 110 children). Hypochlorhydria was present in 53% of adults and 31% of children. HIV infection was detected in 41% of adults and 11% of children. H. pylori serology was available for 366 individuals: 93% of adults and 6% of children were seropositive. In univariate analysis, hypochlorhydria was significantly associated with HIV seropositivity (OR 1.7; 95% CI 1.2–2.4; p = 0.004) and H. pylori antibody seropositivity (OR 4.9; 95% CI 2.8–8.6; p<0.0001), and with advancing age in HIV negative individuals (p = 0.0001). In multivariable analysis, only H. pylori was associated with hypochlorhydria (OR 4.0; 95% CI 2.2–7.2; p<0.0001) while excluding possible exposure to proton pump inhibitors. Conclusions Hypochlorhydria is common in our population, with H. pylori being the dominant factor. Only young HIV seronegative individuals had a low prevalence of hypochlorhydria. This may have implications for the risk of other health conditions including gastric cancer.
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Affiliation(s)
- Phoebe Hodges
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine Department of Internal Medicine, Lusaka, Zambia
- Blizard Institute, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Paul Kelly
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine Department of Internal Medicine, Lusaka, Zambia
- Blizard Institute, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Violet Kayamba
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine Department of Internal Medicine, Lusaka, Zambia
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Davis K, Perez-Guzman P, Hoyer A, Brinks R, Gregg E, Althoff KN, Justice AC, Reiss P, Gregson S, Smit M. Association between HIV infection and hypertension: a global systematic review and meta-analysis of cross-sectional studies. BMC Med 2021; 19:105. [PMID: 33980222 PMCID: PMC8117497 DOI: 10.1186/s12916-021-01978-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/31/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Improved access to effective antiretroviral therapy has meant that people living with HIV (PLHIV) are surviving to older ages. However, PLHIV may be ageing differently to HIV-negative individuals, with dissimilar burdens of non-communicable diseases, such as hypertension. While some observational studies have reported a higher risk of prevalent hypertension among PLHIV compared to HIV-negative individuals, others have found a reduced burden. To clarify the relationship between HIV and hypertension, we identified observational studies and pooled their results to assess whether there is a difference in hypertension risk by HIV status. METHODS We performed a global systematic review and meta-analysis of published cross-sectional studies that examined hypertension risk by HIV status among adults aged > 15 (PROSPERO: CRD42019151359). We searched MEDLINE, EMBASE, Global Health and Cochrane CENTRAL to August 23, 2020, and checked reference lists of included articles. Our main outcome was the risk ratio for prevalent hypertension in PLHIV compared to HIV-negative individuals. Summary estimates were pooled with a random effects model and meta-regression explored whether any difference was associated with study-level factors. RESULTS Of 21,527 identified studies, 59 were eligible (11,101,581 participants). Crude global hypertension risk was lower among PLHIV than HIV-negative individuals (risk ratio 0.90, 95% CI 0.85-0.96), although heterogeneity between studies was high (I2 = 97%, p < 0.0001). The relationship varied by continent, with risk higher among PLHIV in North America (1.12, 1.02-1.23) and lower among PLHIV in Africa (0.75, 0.68-0.83) and Asia (0.77, 0.63-0.95). Meta-regression revealed strong evidence of a difference in risk ratios when comparing North American and European studies to African ones (North America 1.45, 1.21-1.74; Europe 1.20, 1.03-1.40). CONCLUSIONS Our findings suggest that the relationship between HIV status and prevalent hypertension differs by region. The results highlight the need to tailor hypertension prevention and care to local contexts and underscore the importance of rapidly optimising integration of services for HIV and hypertension in the worst affected regions. The role of different risk factors for hypertension in driving context-specific trends remains unclear, so development of further cohorts of PLHIV and HIV-negative controls focused on this would also be valuable.
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Affiliation(s)
- Katherine Davis
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, St Mary's Campus, Imperial College London, London, W2 1PG, UK.
| | - Pablo Perez-Guzman
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, St Mary's Campus, Imperial College London, London, W2 1PG, UK
| | - Annika Hoyer
- Department of Statistics, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Ralph Brinks
- Hiller Research Unit of Rheumatology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Edward Gregg
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK
| | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Amy C Justice
- Schools of Medicine and Public Health, Yale University, New Haven, CT, USA
| | - Peter Reiss
- Department of Global Health, Amsterdam University Medical Centers, University of Amsterdam and Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands.,HIV Monitoring Foundation, Amsterdam, Netherlands
| | - Simon Gregson
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, St Mary's Campus, Imperial College London, London, W2 1PG, UK.,Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Mikaela Smit
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, St Mary's Campus, Imperial College London, London, W2 1PG, UK
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The contribution of environmental enteropathy to the global problem of micronutrient deficiency. Proc Nutr Soc 2021; 80:303-310. [PMID: 33663621 DOI: 10.1017/s0029665121000549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Sometimes referred to as hidden hunger, micronutrient deficiencies persist on a global scale. For some micronutrients this appears to be due to inadequate intake, for others intake may not match increased requirements. However, for most micronutrient deficiencies there is uncertainty as to the dominant driver, and the question about the contribution of malabsorption is open. Environmental enteropathy (EE), formerly referred to as tropical enteropathy and also referred to as environmental enteric dysfunction, is an asymptomatic disorder of small intestinal structure and function which is very highly prevalent in many disadvantaged populations. Recent studies of the pathology and microbiology of this disorder suggest that it is driven by very high pathogen burdens in children and adults living in insanitary environments and is characterised by major derangements of the epithelial cells of the intestinal mucosa. Transcriptomic data suggest that it may lead to impaired digestion and absorption of macronutrients. Given the very high prevalence of EE, marginal malabsorption could have large impacts at population scales. However, the relative contributions of inadequate soil and crop micronutrient contents, inadequate intake, malabsorption and increased requirements are unknown. Malabsorption may compromise attempts to improve micronutrient status, but with the exception of zinc there is currently little evidence to confirm that malabsorption contributes to micronutrient deficiency. Much further research is required to understand the role of malabsorption in hidden hunger, especially in very disadvantaged populations where these deficiencies are most prevalent.
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Abioye AI, Andersen CT, Sudfeld CR, Fawzi WW. Anemia, Iron Status, and HIV: A Systematic Review of the Evidence. Adv Nutr 2020; 11:1334-1363. [PMID: 32383731 PMCID: PMC7490171 DOI: 10.1093/advances/nmaa037] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/29/2019] [Indexed: 12/12/2022] Open
Abstract
People living with HIV (PLWHIV) are at high risk of anemia due to inadequate iron intake, HIV and opportunistic infections, and inflammation, and as a side effect of antiretroviral therapy. Though iron supplementation can reduce iron deficiency anemia (IDA) in the general population, its role in anemia and in the health of PLWHIV is unclear due to concerns that iron supplementation may increase HIV replication and risk of opportunistic infections. We systematically reviewed the evidence on indicators of iron status, iron intake, and clinical outcomes among adults and children with HIV. The evidence suggests that anemia is associated with an increased risk of all-cause mortality and incident tuberculosis among HIV-infected individuals, regardless of anemia type, and the magnitude of the risk is greater with more severe anemia. High serum ferritin is associated with adverse clinical outcomes, although it is unclear if this is due to high iron or inflammation from disease progression. One large observational study found an increased risk of all-cause mortality among HIV-infected adults if they received iron supplementation. Published randomized controlled trials of iron supplementation among PLWHIV tend to have small sample sizes and have been inconclusive in terms of effectiveness and safety. Large randomized trials exploring approaches to safely and effectively provide iron supplementation to PLWHIV are warranted.
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Affiliation(s)
- Ajibola I Abioye
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
| | | | - Christopher R Sudfeld
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Wafaie W Fawzi
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
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Abstract
BACKGROUND Micronutrient deficiencies are common among adults living with HIV disease, particularly in low-income settings where the diet may be low in essential vitamins and minerals. Some micronutrients play critical roles in maintenance of the immune system, and routine supplementation could therefore be beneficial. This is an update of a Cochrane Review previously published in 2010. OBJECTIVES To assess whether micronutrient supplements are effective and safe in reducing mortality and HIV-related morbidity of HIV-positive adults (excluding pregnant women). SEARCH METHODS We performed literature searches from January 2010 to 18 November 2016 for new randomized controlled trials (RCTs) of micronutrient supplements since the previous review included all trials identified from searches prior to 2010. We searched the CENTRAL (the Cochrane Library), Embase, and PubMed databases. Also we checked the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and the ClinicalTrials.gov trials registers. We also checked the reference lists of all new included trials. SELECTION CRITERIA We included RCTs that compared supplements that contained either single, dual, or multiple micronutrients with placebo, no treatment, or other supplements. We excluded studies that were primarily designed to investigate the role of micronutrients for the treatment of HIV-positive participants with metabolic morbidity related to highly active antiretroviral therapy (HAART). Primary outcomes included all-cause mortality, morbidity, and disease progression. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion, and appraised trial quality for risk of bias. Where possible, we presented results as risk ratios (RR) for dichotomous variables, as hazard ratios (HRs) for time-to-event data, and as mean differences (MD) for continuous variables, each with 95% confidence intervals (CIs). Since we were often unable to pool the outcome data, we tabulated it for each comparison. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included 33 trials with 10,325 participants, of which 17 trials were new trials. Ten trials compared a daily multiple micronutrient supplement to placebo in doses up to 20 times the dietary reference intake, and one trial compared a daily standard dose with a high daily dose of multivitamins. Nineteen trials compared supplementation with single or dual micronutrients (such as vitamins A and D, zinc, and selenium) to placebo, and three trials compared different dosages or combinations of micronutrients. Multiple micronutrientsWe conducted analyses across antiretroviral therapy (ART)-naive adults (3 trials, 1448 participants), adults on antiretroviral therapy (ART) (1 trial, 400 participants), and ART-naive adults with concurrent active tuberculosis (3 trials, 1429 participants). Routine multiple micronutrient supplementation may have little or no effect on mortality in adults living with HIV (RR 0.91, 95% CI 0.72 to 1.15; 7 trials, 2897 participants, low certainty evidence).Routine supplementation for up to two years may have little or no effect on the average of mean CD4+ cell count (MD 26.40 cells/mm³, 95% CI -22.91 to 75.70; 6 trials, 1581 participants, low certainty evidence), or the average of mean viral load (MD -0.1 log10viral copies, 95% CI -0.26 to 0.06; 4 trials, 840 participants, moderate certainty evidence). One additional trial in ART-naïve adults did report an increase in the time to reach a CD4+ cell count < 250 cells/mm³ after two years of high dose supplementation in Botswana (HR 0.48, 95% CI 0.26 to 0.88; 1 trial, 439 participants). However, the trial authors reported this effect only in the trial arm that received multiple micronutrients plus selenium (not either supplementation alone), which is inconsistent with the findings of other trials that used similar combinations of micronutrients and selenium.In one additional trial that compared high-dose multiple micronutrient supplementation with standard doses in people on ART, peripheral neuropathy was lower with high dose supplements compared to standard dose (incidence rate ratio (IRR) 0.81, 95% CI 0.7 to 0.94; 1 trial, 3418 participants), but the trial was stopped early due to increased adverse events (elevated alanine transaminase (ALT) levels) in the high dose group. Single or dual micronutrientsNone of the trials of single or dual micronutrient supplements were adequately powered to assess for effects on mortality or morbidity outcomes. No clinically significant changes in CD4 cell count (data not pooled, 14 trials, 2370 participants, very low or low certainty evidence) or viral load (data not pooled, seven studies, 1334 participants, very low or low certainty evidence), were reported. Supplementation probably does increase blood concentrations of vitamin D and zinc (data not pooled, vitamin D: 4 trials, 299 participants, zinc: 4 trials, 484 participants, moderate certainty evidence) and may also increase blood concentrations of vitamin A (data not pooled, 3 trials, 495 participants, low certainty evidence), especially in those who are deficient. AUTHORS' CONCLUSIONS The analyses of the available trials have not revealed consistent clinically important benefits with routine multiple micronutrient supplementation in people living with HIV. Larger trials might reveal small but important effects.These findings should not be interpreted as a reason to deny micronutrient supplements for people living with HIV where specific deficiencies are found or where the person's diet is insufficient to meet the recommended daily allowance of vitamins and minerals.
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Affiliation(s)
| | - Solange Durao
- South African Medical Research CouncilCochrane South AfricaPO Box 19070TygerbergCape TownSouth Africa7505
| | - David Sinclair
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolUKL3 5QA
| | - James H Irlam
- University of Cape TownPrimary Health Care DirectorateE47 OMBGroote Schuur HospitalCape TownWestern CapeSouth Africa7925
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Carter GM, Indyk D, Johnson M, Andreae M, Suslov K, Busani S, Esmaeili A, Sacks HS. Micronutrients in HIV: a Bayesian meta-analysis. PLoS One 2015; 10:e0120113. [PMID: 25830916 PMCID: PMC4382132 DOI: 10.1371/journal.pone.0120113] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 02/04/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Approximately 28.5 million people living with HIV are eligible for treatment (CD4<500), but currently have no access to antiretroviral therapy. Reduced serum level of micronutrients is common in HIV disease. Micronutrient supplementation (MNS) may mitigate disease progression and mortality. OBJECTIVES We synthesized evidence on the effect of micronutrient supplementation on mortality and rate of disease progression in HIV disease. METHODS We searched MEDLINE, EMBASE, the Cochrane Central, AMED and CINAHL databases through December 2014, without language restriction, for studies of greater than 3 micronutrients versus any or no comparator. We built a hierarchical Bayesian random effects model to synthesize results. Inferences are based on the posterior distribution of the population effects; posterior distributions were approximated by Markov chain Monte Carlo in OpenBugs. PRINCIPAL FINDINGS From 2166 initial references, we selected 49 studies for full review and identified eight reporting on disease progression and/or mortality. Bayesian synthesis of data from 2,249 adults in three studies estimated the relative risk of disease progression in subjects on MNS vs. control as 0.62 (95% credible interval, 0.37, 0.96). Median number needed to treat is 8.4 (4.8, 29.9) and the Bayes Factor 53.4. Based on data reporting on 4,095 adults reporting mortality in 7 randomized controlled studies, the RR was 0.84 (0.38, 1.85), NNT is 25 (4.3, ∞). CONCLUSIONS MNS significantly and substantially slows disease progression in HIV+ adults not on ARV, and possibly reduces mortality. Micronutrient supplements are effective in reducing progression with a posterior probability of 97.9%. Considering MNS low cost and lack of adverse effects, MNS should be standard of care for HIV+ adults not yet on ARV.
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Affiliation(s)
- George M. Carter
- Foundation for Integrative AIDS Research, Brooklyn, NY, United States of America
| | - Debbie Indyk
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Matthew Johnson
- Teachers College, Columbia University, New York, NY, United States of America
| | - Michael Andreae
- Department of Anesthesiology, Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Kathryn Suslov
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Sudharani Busani
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Aryan Esmaeili
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Henry S. Sacks
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
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Filteau S, PrayGod G, Kasonka L, Woodd S, Rehman AM, Chisenga M, Siame J, Koethe JR, Changalucha J, Michael D, Kidola J, Manno D, Larke N, Yilma D, Heimburger DC, Friis H, Kelly P. Effects on mortality of a nutritional intervention for malnourished HIV-infected adults referred for antiretroviral therapy: a randomised controlled trial. BMC Med 2015; 13:17. [PMID: 25630368 PMCID: PMC4308881 DOI: 10.1186/s12916-014-0253-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 12/10/2014] [Indexed: 01/24/2023] Open
Abstract
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.
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Affiliation(s)
| | - Suzanne Filteau
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
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Noncommunicable diseases in HIV infection in low- and middle-income countries: gastrointestinal, hepatic, and nutritional aspects. J Acquir Immune Defic Syndr 2014; 67 Suppl 1:S79-86. [PMID: 25117963 DOI: 10.1097/qai.0000000000000260] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The purpose of this review was to outline the interaction between HIV and noncommunicable diseases affecting the gastrointestinal (GI) tract, liver, and nutritional disorders in low- and middle-income countries (LMICs), and to identify research priorities. Noncommunicable GI tract disorders are only moderately influenced by HIV, and peptic ulceration is actually less common. However, the impact of HIV on GI cancers needs further investigation. HIV interacts strongly with environmental enteropathy, exacerbating malabsorption of nutrients and drugs. HIV has 2 major effects on noncommunicable liver disease: drug-induced liver injury and nonalcoholic fatty liver disease (particularly in persons of African genetic descent). The effect of HIV on nutrition was one of the first markers of the epidemic in the 1980s, and HIV continues to have major nutritional consequences. Childhood malnutrition and HIV frequently coexist in some regions, for example, southern Africa, resulting in powerful negative interactions with poorer responses to standard nutritional rehabilitation. HIV and nutritional care need to be better integrated, but many questions on how best to do this remain unanswered. Across the spectrum of GI, hepatic, and nutritional disorders in HIV infection, there is increasing evidence that the microbiome may play an important role in disease pathogenesis, but work in this area, especially in low- and middle-income countries, is in its infancy.
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Aberman NL, Rawat R, Drimie S, Claros JM, Kadiyala S. Food security and nutrition interventions in response to the AIDS epidemic: assessing global action and evidence. AIDS Behav 2014; 18 Suppl 5:S554-65. [PMID: 24943352 DOI: 10.1007/s10461-014-0822-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The number of people receiving antiretroviral therapy in developing countries has increased dramatically. The last decade has brought an increased understanding of the interconnectedness between HIV/AIDS, food insecurity, and undernutrition and a surge of evidence on how to address the food security and nutrition dimensions of the epidemic. We review this evidence as well as the corresponding evolution of policy support for incorporating food security and nutrition concerns into HIV programming. The available evidence, although varied in scope and methodologies, shows that nutrition supplementation and safety nets in the form of food assistance and livelihood interventions have potential in certain contexts to improve food security and nutrition outcomes in an HIV/AIDS context. In the face of funding uncertainties and competing priorities, we must maintain momentum towards effective and sustainable solutions to the epidemic through continued systematic research to inform policy and through the strengthening of monitoring systems to dynamically inform intervention development.
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Short term micronutrient-antioxidant supplementation has no impact on a serological marker of gastric atrophy in Zambian adults: retrospective analysis of a randomised controlled trial. BMC Gastroenterol 2014; 14:52. [PMID: 24666552 PMCID: PMC3987176 DOI: 10.1186/1471-230x-14-52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 03/18/2014] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Gastric cancer is a major contributor to cancer deaths in Zambia but, as elsewhere, no preventive strategies have been identified. We set out to investigate the possibility of reducing gastric atrophy, a premalignant lesion, using micronutrient-antioxidant supplementation. METHODS We analysed 215 archival samples from a randomised controlled trial of micronutrient-antioxidant supplementation carried out from 2003 to 2006. Participants were randomised to receive either the supplement or placebo and had been taking the allocated intervention for a mean of 18 (range 14-27) months when the samples used in this study were taken. We used low pepsinogen 1 to 2 (PEP1:2) ratio as a surrogate marker of gastric atrophy. A PEP 1:2 ratio of less than three was considered low. HIV serology, age, nutritional status, smoking, alcohol intake and gastric pH were also analysed. Ethical approval was obtained from the University of Zambia Biomedical Research Ethics Committee (011-04-12). The randomized trial was registered (ISRCTN31173864). RESULTS The overall prevalence of low PEP 1:2 ratio was 15/215 (7%) and it did not differ between the placebo (8/103, 7.8%) and micronutrient groups (7/112, 6.3%; HR 1.24; 95% CI 0.47-3.3; P = 0.79). The presence of low PEP 1:2 ratio was not influenced by HIV infection (HR 1.07; 95% CI 0.37-3.2; P =0.89) or nutritional status but it inversely correlated with gastric pH (Spearman's rho = -0.34; P = 0.0001). Age above 40 years was associated with atrophy, but neither alcohol nor smoking had any influence. CONCLUSION Short term micronutrient supplementation does not have any impact on PEP 1:2 ratio, a serological marker of gastric atrophy. PEP 1:2 ratio inversely correlates with gastric pH.
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Louis-Auguste J, Greenwald S, Simuyandi M, Soko R, Banda R, Kelly P. High dose multiple micronutrient supplementation improves villous morphology in environmental enteropathy without HIV enteropathy: results from a double-blind randomised placebo controlled trial in Zambian adults. BMC Gastroenterol 2014; 14:15. [PMID: 24428805 PMCID: PMC3897937 DOI: 10.1186/1471-230x-14-15] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 01/06/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Environmental enteropathy (EE) is an asymptomatic abnormality of small bowel structure and function, which may underlie vaccine inefficacy in the developing world. HIV infection co-exists in many of these populations. There is currently no effective treatment. We conducted a secondary analysis of a randomised controlled trial of high dose multiple micronutrient (MM) supplementation on small bowel architecture in EE in participants with or without HIV infection. METHODS In a double-blind parallel-group trial of the effect of MM on innate immune responses to oral vaccines, consenting Zambian adults were randomised to receive 6 weeks of 24 micronutrients as a daily capsule or placebo. HIV status was established after randomisation. Proximal jejunal biopsies were obtained after the supplementation period. Villous height, crypt depth, villous width, villous perimeter per 100 μm muscularis mucosa (a measure of epithelial surface area), and villous cross sectional area per 100 μm muscularis mucosa (a measure of villous compartment volume) were measured in orientated biopsy sections using semi-automated image analysis. Analysis was by intention to treat. RESULTS 18 patients received MM and 20 placebo. 6/18 MM and 9/20 placebo patients had HIV. In HIV negative patients given MM compared to placebo, mean villous height was 24.0% greater (293.3 v. 236.6 μm; 95% CI of difference 17.7-95.9 μm; P = 0.006), mean villous area was 27.6% greater (27623 v. 21650 μm2/100 μm; 95% CI of difference 818-11130 μm2/100 μm; P = 0.03), and median villous perimeter was 29.7% greater (355.0 v. 273.7 μm/100 μm; 95% CI of difference 16.3-146.2 μm/100 μm; P = 0.003). There was no significant effect on crypt depth or villous width. No effect was observed in HIV positive patients. There were no adverse events attributable to MM. CONCLUSIONS MM improved small bowel villous height and absorptive area, but not crypt depth, in adults with EE without HIV. Nutritional intervention may therefore selectively influence villous compartment remodelling. In this small study, there was a clear difference in response depending on HIV status, suggesting that EE with superimposed HIV enteropathy may be a distinct pathophysiological condition.
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Affiliation(s)
| | - Stephen Greenwald
- Blizard Institute, Barts & The London School of Medicine, London, UK
| | - Michelo Simuyandi
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Rose Soko
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Rose Banda
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Paul Kelly
- Blizard Institute, Barts & The London School of Medicine, London, UK
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
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Baum MK, Campa A, Lai S, Sales Martinez S, Tsalaile L, Burns P, Farahani M, Li Y, van Widenfelt E, Page JB, Bussmann H, Fawzi WW, Moyo S, Makhema J, Thior I, Essex M, Marlink R. Effect of micronutrient supplementation on disease progression in asymptomatic, antiretroviral-naive, HIV-infected adults in Botswana: a randomized clinical trial. JAMA 2013; 310:2154-63. [PMID: 24281460 PMCID: PMC4347896 DOI: 10.1001/jama.2013.280923] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Micronutrient deficiencies occur early in human immunodeficiency virus (HIV) infection, and supplementation with micronutrients may be beneficial; however, its effectiveness has not been investigated early in HIV disease among adults who are antiretroviral therapy (ART) naive. OBJECTIVE To investigate whether long-term micronutrient supplementation is effective and safe in delaying disease progression when implemented early in adults infected with HIV subtype C who are ART-naive. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of supplementation with either daily multivitamins (B vitamins and vitamins C and E), selenium alone, or multivitamins with selenium vs placebo in a factorial design for 24 months. The study was conducted in 878 patients infected with HIV subtype C with a CD4 cell count greater than 350/μL who were not receiving ART at Princess Marina Hospital in Gaborone, Botswana, between December 2004 and July 2009. INTERVENTIONS Daily oral supplements of B vitamins and vitamins C and E, selenium alone, or multivitamins plus selenium, compared with placebo. MAIN OUTCOMES AND MEASURES Reaching a CD4 cell count less than 200/μL until May 2008; after this date, reaching a CD4 cell count of 250/μL or less, consistent with the standard of care in Botswana for initiation of ART at the time of the study. RESULTS There were 878 participants enrolled and randomized into the study. All participants were ART-naive throughout the study. In intent-to-treat analysis, participants receiving the combined supplement of multivitamins plus selenium had a significantly lower risk vs placebo of reaching CD4 cell count 250/μL or less (adjusted hazard ratio [HR], 0.46; 95% CI, 0.25-0.85; P = .01; absolute event rate [AER], 4.79/100 person-years; censoring rate, 0.92; 17 events; placebo AER, 9.22/100 person-years; censoring rate, 0.85; 32 events). Multivitamins plus selenium in a single supplement, vs placebo, also reduced the risk of secondary events of combined outcomes for disease progression (CD4 cell count ≤250/μL, AIDS-defining conditions, or AIDS-related death, whichever occurred earlier [adjusted HR, 0.56; 95% CI, 0.33-0.95; P = .03; AER, 6.48/100 person-years; censoring rate, 0.90; 23 events]). There was no effect of supplementation on HIV viral load. Multivitamins alone and selenium supplementation alone were not statistically different from placebo for any end point. Reported adverse events were adjudicated as unlikely to be related to the intervention, and there were no notable differences in incidence of HIV-related and health-related events among study groups. CONCLUSIONS AND RELEVANCE In ART-naive HIV-infected adults, 24-month supplementation with a single supplement containing multivitamins and selenium was safe and significantly reduced the risk of immune decline and morbidity. Micronutrient supplementation may be effective when started in the early stages of HIV disease.
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Affiliation(s)
- Marianna K Baum
- Florida International University, R. Stempel College of Public Health and Social Work, Miami
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Hong SY, Hendricks KM, Wanke C, Omosa G, Patta S, Mwero B, Mjomba I, Queenan J, Mwamburi M. Development of a nutrient-dense food supplement for HIV-infected women in rural Kenya using qualitative and quantitative research methods. Public Health Nutr 2013; 16:721-9. [PMID: 22974548 PMCID: PMC3984962 DOI: 10.1017/s1368980012004156] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 07/16/2012] [Accepted: 08/01/2012] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Formative research to facilitate the development, packaging and delivery of a culturally acceptable nutrition intervention for HIV-infected women in rural Kenya for an intervention trial. DESIGN Focus group discussion on three areas: (i) ingredients and form of the nutrition intervention, (ii) packaging and delivery and (iii) monitoring of adherence. Two single-blind taste tests with eleven different porridge formulations of various combinations of maize flour, soyabeans, peanuts, sorghum, mung beans, dried fish, raisins and dried whole milk. Follow-up acceptability focus group discussion was also conducted. SETTING Voi, Kenya, community based. SUBJECTS Focus group discussion and two taste tests (twenty-one women aged 16-55 years). Follow-up acceptability focus group discussion (four women enrolled in intervention trial). RESULTS The preferred porridge for taste consisted of maize, soyabeans and peanuts. For animal protein, dried whole milk and dried fish were used. Although the women disliked the taste of dried fish, it was acceptable if added in small undetectable quantities. Sugar over lime was favoured for taste. Women believed they could consume at least two cups of porridge per day without displacing their usual meals. The optimal delivery interval was believed to be every two weeks in individual serving packages. Women who had been consuming porridge for several weeks felt the taste was acceptable for long-term consumption. CONCLUSIONS This formative research resulted in the development, packaging and delivery of a nutrient-dense food supplement using local ingredients to meet the dietary needs of the population and acceptable for daily consumption by women in Kenya for evaluation in an intervention trial.
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Affiliation(s)
- Steven Y Hong
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, USA.
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Forrester JE, Sztam KA. Micronutrients in HIV/AIDS: is there evidence to change the WHO 2003 recommendations? Am J Clin Nutr 2011; 94:1683S-1689S. [PMID: 22089440 PMCID: PMC3226021 DOI: 10.3945/ajcn.111.011999] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
To establish whether there is new evidence to inform changes to WHO 2003 recommendations for micronutrient intake in persons with HIV/AIDS, we conducted a narrative review of the literature published from 2003 to 2010. Although the review focused on new randomized controlled trials of multiple micronutrients in HIV-infected adults, including pregnant and lactating women, we also considered randomized trials of single micronutrients. The review found that there are few published randomized controlled trials of micronutrients in HIV-infected persons and that most trials used high-dose multiple micronutrient supplementation. The trials were heterogeneous with respect to the composition and dose of micronutrients used and the target population studied. Despite this heterogeneity, 5 of 6 trials that used high-dose multiple micronutrients showed benefits in terms of either improved CD4 cell counts or survival. However, many of these trials were small and of short duration, and therefore the long-term risks and benefits of high-dose multiple micronutrients are not established. The current WHO recommendation for an intake of micronutrients at Recommended Dietary Allowance amounts continues to be a reasonable target for persons with clinically stable HIV infection. In light of new data that show adverse effects of high-dose vitamin A, the current recommendation for a single high dose of vitamin A in HIV-infected women within 6 wk of delivery should be reviewed.
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Affiliation(s)
- Janet E Forrester
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA 02111, USA.
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Chandrasekhar A, Gupta A. Nutrition and disease progression pre-highly active antiretroviral therapy (HAART) and post-HAART: can good nutrition delay time to HAART and affect response to HAART? Am J Clin Nutr 2011; 94:1703S-1715S. [PMID: 22089439 PMCID: PMC3226023 DOI: 10.3945/ajcn.111.019018] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Several studies have investigated a variety of nutritional supplementation interventions in adults with HIV. In this narrative review, we summarize the evidence from 31 clinical trials that explore clinical benefits of macronutrient and micronutrient supplementation in this population while attempting to answer the question of whether good nutrition can delay the time to highly active antiretroviral therapy (HAART) initiation and response. We focused on trials published in English between 1990 and 2010 that reported on CD4 count, viral load, and disease progression or survival. Among 9 macronutrient and 22 micronutrient trials, we found that evidence for improved CD4 count and HIV viral load with nutritional supplementation was limited; only 11.1% and 36.8% of macronutrient and micronutrient supplementation trials, respectively, reported improved CD4 count; and 33.3% and 12.5% of macronutrient and micronutrient trials, respectively, reported decreased viral load. Given their utility as surrogate markers of HIV disease progression, this suggests limited evidence for nutritional interventions having an impact on delaying HAART initiation or on improving HAART response. However, there are challenges in evaluating the effects of nutritional supplementation on clinical disease in that comparisons are difficult due to heterogeneity in study design, patient population, nutrient doses and combinations, baseline levels of deficiency, and study endpoints, including lack of clarity in defining and reporting HAART status. Future studies need to adopt a more rigorous standard design with adequate power and follow-up and require a consensus on composition and dose of nutrient interventions to be tested to more specifically answer the question on the impact of nutritional interventions on HIV disease progression and HAART response.
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Thomas T, Eilander A, Muthayya S, McKay S, Thankachan P, Theis W, Gandhe A, Osendarp SJM, Kurpad AV. The effect of a 1-year multiple micronutrient or n-3 fatty acid fortified food intervention on morbidity in Indian school children. Eur J Clin Nutr 2011; 66:452-8. [PMID: 22009072 DOI: 10.1038/ejcn.2011.178] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND/OBJECTIVES Few studies have shown that supplementation with micronutrients (MNs) or n-3 fatty acids may have health benefits such as reduced morbidity in schoolchildren. The effect of a combination of these nutrients has never been investigated. This study aimed to determine the effect of a combination of two different doses of MN and n-3 fatty acids on morbidity in schoolchildren in Bangalore, India. SUBJECTS/METHODS In all 598 children (6-10 years) received foods fortified with either high (100% recommended dietary allowance) or low (15% recommended dietary allowance) MN, combined with either high (900 mg α-linolenic acid (ALA) plus 100 mg docosahexaenoic acid) or low (140 mg ALA) n-3 fatty acids for 1 year. Morbidity was measured by weekly self-reports using a structured questionnaire. Poisson regression analyses of episodes/child/year and duration/episode adjusted for age and sex were performed on clusters of symptoms, including upper and lower respiratory tract infections (URTI and LRTI), gastrointestinal complaints (GI) and general symptoms of illness to observe MN and n-3 fatty acid treatment effects. RESULTS Children consuming high n-3 fatty acids had significantly fewer episodes of URTI/child/year (relative risk (RR)=0.88, 95% confidence interval (CI): 0.79, 0.97) and significantly shorter duration/episode of URTI (RR=0.81, 95% CI: 0.78, 0.85), LRTI (RR=0.91, 95% CI: 0.85, 0.97), GI complaints (RR=0.79, 95% CI: 0.74, 0.85) and general symptoms (RR=0.90, 95% CI: 0.82, 0.98) compared with children who received low n-3 fatty acid intervention. The high MN intervention reduced the duration of general symptoms (RR=0.89, 95% CI: 0.82, 0.98). CONCLUSION Although n-3 fatty acids may be beneficial for reducing illness in Indian schoolchildren, more research is needed to confirm presence of combined effect with MN.
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Affiliation(s)
- T Thomas
- Epidemiology and Biostatistics Unit, St John's Research Institute, St John's National Academy of Health Sciences, Bangalore, India.
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Stojanović D, Marković D, Kocić G. NUTRITION AND PATIENTS WITH HIV/AIDS. ACTA MEDICA MEDIANAE 2011. [DOI: 10.5633/amm.2011.0312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Feasey NA, Healey P, Gordon MA. Review article: the aetiology, investigation and management of diarrhoea in the HIV-positive patient. Aliment Pharmacol Ther 2011; 34:587-603. [PMID: 21777262 DOI: 10.1111/j.1365-2036.2011.04781.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Diarrhoea is a common presentation throughout the course of HIV disease. AIM To review the literature relating to aetiology, investigation and management of diarrhoea in the HIV-infected adult. METHODS The PubMed database was searched using major subject headings 'AIDS' or 'HIV' and 'diarrhoea' or 'intestinal parasite'. The search was limited to adults and to studies with >10 patients. RESULTS Diarrhoea affects 40-80% of HIV-infected adults untreated with antiretroviral therapy (ART). First-line investigation is by stool microbiology. Reported yield varies with geography and methodology. Molecular and immunological methods and special stains have improved diagnostic yield. Endoscopy is diagnostic in 30-70% of cases of pathogen-negative diarrhoea and evidence supports flexible sigmoidoscopy as a first line screening procedure (80-95% sensitive for CMV colitis), followed by colonoscopy and terminal ileoscopy. Radiology is useful to assess severity, distribution, complications and to diagnose HIV-related malignancies. Side effects and compliance with ART are important considerations in assessment. There is a good evidence base for many specific therapies, but optimal treatment of cryptosporidiosis is unclear and only limited data support symptomatic treatments. CONCLUSIONS The immunological response to HIV infection and Antiretroviral therapy remains incompletely understood. Antiretroviral therapy regimens need to be optimised to suppress HIV while minimising side effects. Effective agents for management of cryptosporidiosis are lacking. There is an urgent need for enhanced regional diagnostic facilities in countries with a high prevalence of HIV. The ongoing roll-out of Antiretroviral therapy in low-resource settings will continue to change the aetiology and management of this problem, necessitating ongoing surveillance and study.
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Affiliation(s)
- N A Feasey
- Department of Gastroenterology, University of Liverpool, Liverpool, UK
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de Pee S, Semba RD. Role of Nutrition in HIV Infection: Review of Evidence for more Effective Programming in Resource-Limited Settings. Food Nutr Bull 2010. [DOI: 10.1177/15648265100314s403] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
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).
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Glennie SJ, Williams NA, Heyderman RS. Mucosal immunity in resource-limited setting: is the battle ground different? Trends Microbiol 2010; 18:487-93. [PMID: 20832319 DOI: 10.1016/j.tim.2010.08.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Revised: 07/29/2010] [Accepted: 08/06/2010] [Indexed: 01/28/2023]
Abstract
In many developing countries, populations are under considerable pressure from high bacterial exposure on mucosal surfaces. Immune dysregulation in this setting is multifactorial and is driven by a range of environmental factors, undernutrition and coinfections such as measles, malaria and HIV. Disruption or subversion of respiratory-tract and intestinal epithelial barriers leads to increased invasion by mucosal pathogens and a high frequency of life-threatening bacterial disease. It is our opinion that a process of epithelial barrier dysfunction and immune dysregulation at these mucosal surfaces leads to the much higher rates of pneumonia, meningitis and severe sepsis seen in resource-limited countries.
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Affiliation(s)
- Sarah J Glennie
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
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Dhaliwal W, Shawa T, Khanam M, Jagatiya P, Simuyandi M, Ndulo N, Bevins CL, Sanderson IR, Kelly P. Intestinal antimicrobial gene expression: impact of micronutrients in malnourished adults during a randomized trial. J Infect Dis 2010; 202:971-8. [PMID: 20695797 DOI: 10.1086/655903] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Because both micronutrients and antimicrobial peptides protect against diarrhea, we looked for an effect on intestinal antimicrobial peptide gene expression during a randomized controlled trial of multiple micronutrient (MM) supplementation. METHODS Consenting adults (n=287) in Lusaka, Zambia, were randomized to receive a daily MM supplement or placebo and were followed up for 3.3 years, with a crossover after 2 years. Intestinal biopsy samples were obtained at annual intervals, and messenger RNA of the intestinal antimicrobial peptides human alpha defensin (HD) 5, HD6, human beta-defensin (hBD) 1, hBD2, and LL-37 were quantified by real-time reverse-transcriptase polymerase chain reaction. Samples were also obtained during diarrhea episodes and after convalescence. RESULTS There was no effect overall of treatment allocation. However, in malnourished adults (body mass index < or =18.5), HD5 mRNA was increased by 0.8 log transcripts/microg total RNA in MM recipients, compared with HD5 mRNA in placebo recipients (P=.007). During diarrhea, HD5 expression was reduced by 0.8 log transcripts in placebo recipients (P=.02) but was not reduced in MM recipients, nor was it reduced after the crossover. Correlations between HD5 and nutritional status were found that were sex-specific but not explained by serum leptin or adiponectin concentrations. CONCLUSIONS Micronutrient supplementation was associated with up-regulation of HD5 only in malnourished adults. Interactions between antimicrobial gene expression and nutritional status may help to explain the increased risk of infection in individuals with malnutrition.
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Affiliation(s)
- Winnie Dhaliwal
- Institute of Cell and Molecular Science, Barts and The London School of Medicine, Queen Mary University of London, United Kingdom
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Kelly P, Shawa T, Mwanamakondo S, Soko R, Smith G, Barclay GR, Sanderson IR. Gastric and intestinal barrier impairment in tropical enteropathy and HIV: limited impact of micronutrient supplementation during a randomised controlled trial. BMC Gastroenterol 2010; 10:72. [PMID: 20604937 PMCID: PMC2910659 DOI: 10.1186/1471-230x-10-72] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Accepted: 07/06/2010] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Although micronutrient supplementation can reduce morbidity and mortality due to diarrhoea, nutritional influences on intestinal host defence are poorly understood. We tested the hypothesis that micronutrient supplementation can enhance barrier function of the gut. METHODS We carried out two sub-studies nested within a randomised, double-blind placebo-controlled trial of daily micronutrient supplementation in an urban community in Lusaka, Zambia. In the first sub-study, gastric pH was measured in 203 participants. In the second sub-study, mucosal permeability, lipopolysaccharide (LPS) and anti-LPS antibodies, and serum soluble tumour necrosis factor receptor p55 (sTNFR55) concentrations were measured in 87 participants. Up to three stool samples were also analysed microbiologically for detection of asymptomatic intestinal infection. Gastric histology was subsequently analysed in a third subset (n = 37) to assist in interpretation of the pH data. Informed consent was obtained from all participants after a three-stage information and consent process. RESULTS Hypochlorhydria (fasting gastric pH > 4.0) was present in 75 (37%) of participants. In multivariate analysis, HIV infection (OR 4.1; 95%CI 2.2-7.8; P < 0.001) was associated with hypochlorhydria, but taking anti-retroviral treatment (OR 0.16; 0.04-0.67; P = 0.01) and allocation to micronutrient supplementation (OR 0.53; 0.28-0.99; P < 0.05) were protective. Hypochlorhydria was associated with increased risk of salmonellosis. Mild (grade 1) gastric atrophy was found in 5 participants, irrespective of Helicobacter pylori or HIV status. Intestinal permeability, LPS concentrations in serum, anti-LPS IgG, and sTNFR55 concentrations did not differ significantly between micronutrient and placebo groups. Anti-LPS IgM was reduced in the micronutrient recipients (P <0.05). CONCLUSIONS We found evidence of a specific effect of HIV on gastric pH which was readily reversed by anti-retroviral therapy and not mediated by gastric atrophy. Micronutrients had a modest impact on gastric pH and one marker of bacterial translocation. TRIAL REGISTRATION Current Controlled Trials ISRCTN31173864.
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Affiliation(s)
- Paul Kelly
- Blizard Institute of Cell and Molecular Science, Barts & The London School of Medicine, Queen Mary University of London, London, UK.
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Ndeezi G, Tylleskär T, Ndugwa CM, Tumwine JK. Effect of multiple micronutrient supplementation on survival of HIV-infected children in Uganda: a randomized, controlled trial. J Int AIDS Soc 2010; 13:18. [PMID: 20525230 PMCID: PMC2894007 DOI: 10.1186/1758-2652-13-18] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2009] [Accepted: 06/03/2010] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Micronutrient deficiencies compromise the survival of HIV-infected children in low-income countries. We assessed the effect of multiple micronutrient supplementation on the mortality of HIV-infected children in Uganda. METHODS In a randomized, controlled trial, 847 children aged one to five years and attending HIV clinics in Uganda were stratified by antiretroviral therapy (ART, n = 85 versus no ART, n = 762). The children were randomized to six months of either: twice the recommended dietary allowance of 14 micronutrients as the intervention arm (vitamins A, B1, B2, niacin, B6, B12, C, D and E, folate, zinc, copper, iodine and selenium); or the standard recommended dietary allowance of six multivitamins (vitamins A, D2, B1, B2, C and niacin) as a comparative "standard-of-care" arm. Mortality was analyzed at 12 months of follow up using Kaplan Meier curves and the log rank test. RESULTS Mortality at 12 months was 25 out of 426 (5.9%) children in the intervention arm and 28 out of 421 (6.7%) in the comparative arms: risk ratio 0.9 (95% CI 0.5 - 1.5). Two out of 85 (2.4%) children in the ART stratum died compared with 51 out of 762 (6.7%) in the non-ART stratum. Of those who died in the non-ART stratum, 25 of 383 (6.5%) were in the intervention arm and 26 of 379 (6.9%) in the comparative arm; risk ratio 1.0 (95% CI 0.6 - 1.6). There was no significant difference in survival at 12 months (p = 0.64, log rank test). In addition, there was no significant difference in mean weight-for-height at 12 months; 0.70 +/- 1.43 (95% CI 0.52 - 0.88) for the intervention versus 0.59 +/- 1.15 (95% CI 0.45 - 0.75) in the comparative arm. The mean CD4 cell count; 1024 +/- 592 (95% CI 942 - 1107) versus 1060 +/- 553 (95% CI 985 - 1136) was also similar between the two groups. CONCLUSIONS Twice the recommended dietary allowance of 14 micronutrients compared with a standard recommended dietary allowance of six multivitamins for six months was well tolerated, but it did not significantly alter mortality, growth or CD4 counts. Future intervention studies should carefully consider: (1) the composition and dosing of the supplements; and (2) the power needed to detect a difference between arms. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00122941.
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Affiliation(s)
- Grace Ndeezi
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda.
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Hummelen R, Hemsworth J, Reid G. Micronutrients, N-acetyl cysteine, probiotics and prebiotics, a review of effectiveness in reducing HIV progression. Nutrients 2010; 2:626-51. [PMID: 22254046 PMCID: PMC3257666 DOI: 10.3390/nu2060626] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Revised: 05/18/2010] [Accepted: 05/25/2010] [Indexed: 01/24/2023] Open
Abstract
Low serum concentrations of micronutrients, intestinal abnormalities, and an inflammatory state have been associated with HIV progression. These may be ameliorated by micronutrients, N-acetyl cysteine, probiotics, and prebiotics. This review aims to integrate the evidence from clinical trials of these interventions on the progression of HIV. Vitamin B, C, E, and folic acid have been shown to delay the progression of HIV. Supplementation with selenium, N-acetyl cysteine, probiotics, and prebiotics has considerable potential, but the evidence needs to be further substantiated. Vitamin A, iron, and zinc have been associated with adverse effects and caution is warranted for their use.
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Affiliation(s)
- Ruben Hummelen
- Department of Public Health, Erasmus MC University Medical Center Rotterdam P.O. Box 2040, 3000 CA Rotterdam, The Netherlands;
- Canadian Research & Development Centre for Probiotics, Lawson Health Research Institute, 268 Grosvenor Street, N6A 4V2, London, Ontario, Canada
| | - Jaimie Hemsworth
- Division of Food and Nutritional Sciences at Brescia University College, The University of Western Ontario, 1285 Western Road, N6G 1H2, London, Ontario, Canada;
| | - Gregor Reid
- Canadian Research & Development Centre for Probiotics, Lawson Health Research Institute, 268 Grosvenor Street, N6A 4V2, London, Ontario, Canada
- Departments of Microbiology & Immunology and Surgery, The University of Western Ontario, 1151 Richmond Street, N6A 3K7, London, Ontario, Canada
- Author to whom correspondence should be addressed; ; Tel.: 519-646-6100 x65256
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Clark AB, Bachmann MO. Bayesian methods of analysis for cluster randomized trials with count outcome data. Stat Med 2010; 29:199-209. [PMID: 19856321 DOI: 10.1002/sim.3747] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Bayesian approaches to inference in cluster randomized trials have been investigated for normally distributed and binary outcome measures. However, relatively little attention has been paid to outcome measures which are counts of events. We discuss an extension of previously published Bayesian hierarchical models to count data, which usually can be assumed to be distributed according to a Poisson distribution. We develop two models, one based on the traditional rate ratio, and one based on the rate difference which may often be more intuitively interpreted for clinical trials, and is needed for economic evaluation of interventions. We examine the relationship between the intracluster correlation coefficient (ICC) and the between-cluster variance for each of these two models. In practice, this allows one to use the previously published evidence on ICCs to derive an informative prior distribution which can then be used to increase the precision of the posterior distribution of the ICC. We demonstrate our models using a previously published trial assessing the effectiveness of an educational intervention and a prior distribution previously derived. We assess the robustness of the posterior distribution for effectiveness to departures from a normal distribution of the random effects.
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Affiliation(s)
- Allan B Clark
- School of Medicine, Health Policy and Practice, University of East Anglia, U.K.
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Abstract
The interaction between nutrition and infection was the subject of important work by several groups in the 1960s. The explosion of knowledge in immunology, including innate immunity, has led to increased understanding of the impact of nutrition on host defence, but much more work needs to be done in this area. In the last decade an increasing volume of work has opened up the previously obscure world of human endogenous flora. This work suggests that the microbiome, the total genetic pool of the microbiota, contributes to the already complex interaction between nutrition and infectious disease. The established concept that nutritional status, host defence and infection all impact on each other now has to be expanded into a multiple interaction, with the microbiota interacting with all three other elements. There is good evidence that the microbiome programmes host defence and drives a metabolome that impacts on energy balance, and indeed on some micronutrients. In turn, host defence shapes the microbiome, and nutritional status, particularly micronutrient status, helps determine several elements of host defence. While interventions in this area are in their infancy, the understanding of interactions that already have an enormous impact on global health is now at a threshold. The present review explores the evidence for these interactions with a view to putting potential interventions into the context of a conceptual framework.
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Scrimgeour AG, Condlin ML. Zinc and micronutrient combinations to combat gastrointestinal inflammation. Curr Opin Clin Nutr Metab Care 2009; 12:653-60. [PMID: 19684516 DOI: 10.1097/mco.0b013e3283308dd6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW To examine current evidence for dietary supplementation with zinc and other micronutrients for primary prevention of multiple micronutrient deficiencies that are known to result from therapies used in the treatment of gastrointestinal inflammatory disorders. RECENT FINDINGS Epidemiological observations and clinical findings have strengthened the concept that both nutritional deficiencies and nutritional excesses impair the gastrointestinal response(s) and alter susceptibility to inflammation and other diseases. The interaction of micronutrient intake, biochemical indicators of nutritional status, and four specific gastrointestinal inflammation states are reviewed. These conditions include celiac disease and concomitant micronutrient deficiencies resulting from the sustained adherence to a gluten-free diet; micronutrient nutrition as an important determinant of immunity for two major types of inflammatory bowel disease: ulcerative colitis and Crohn's disease; and HIV/AIDS-related diarrhea and concomitant micronutrient deficiencies which may be exacerbated by the initiation of highly active antiretroviral therapy. SUMMARY For each inflammation 'state', enhancement of micronutrient status can improve immunocompetance and minimize therapeutic side-effects. The impact of single-micronutrient deficiencies on immune responses, and the possible impact of uncorrected micronutrient status are discussed.
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Affiliation(s)
- Angus G Scrimgeour
- Military Nutrition Division, U.S. Army Research Institute of Environmental Medicine, Kansas Street, Natick, Massachusetts 01760, USA.
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