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

Prevalence and associated factors of undernutrition among adult TB patients attending Amhara National Regional State hospitals, Northwest Ethiopia

Background

TB (tuberculosis) is an infectious disease affecting millions of people worldwide; globally, an estimated 10 million people developed TB disease in the past two years; and there were an estimated 1.4 million TB deaths. In Ethiopia, the burden of TB is ranked third and seventh in Africa and the world, respectively. Hence, studies are limited to solving many of the problems related to undernutrition. Therefore this study aimed to assess the prevalence and associated factors of undernutrition among adult TB patients attending Amhara National Regional State hospitals, Northwest Ethiopia.

Methods

A cross-sectional study was conducted in the TB clinics of Amhara Regional State Referral hospitals from March to April 2020. A total of 405 TB patients participated in the study. Proportional allocation and Systematic random sampling were employed to get representative study participants. The outcome variable, undernutrition, was determined by using Body Mass Index (BMI). Interviewer administered structured questionnaire, anthropometric measurements and patients' document review were done. Bivariable and multivariable logistic regressions were done to identify factors associated with undernutrition. Crude odds ratios (COR) and adjusted odds ratios (AOR) with 95% confidence intervals and P-values < 0.05 were employed to declare the significance and strength of association.

Results

The prevalence of under nutrition was 42.2% [95%CI: 32.8, 51.6]. The mean (±SD) BMI was 19.30(±2.83). The odds of undernutrition was higher among TB patients with poor wealth status [AOR = 2.39, 95%CI; 1.19, 4.79], alcohol consumption [AOR = 1.57; 95%CI, 1.01, 2.47], bedridden [AOR = 3.02, 95%CI; 1.21, 7.50] and ambulatory patient [AOR = 2.11, 95%CI; 1.36, 3.26]. Furthermore, being farmer [AOR = 2.59;95%CI,1.08,6.20], housewife [AOR = 2.72;95%CI,1.22,6.06] and unemployed [AOR = 2.46;95%CI,1.18,5.13] were significantly associated with undernutrition.

Conclusion and recommendations

This study illustrated that a considerably high proportion of TB patients were undernourished in Amhara regionals state referral hospitals. Behavioral and socio-economic characteristics were significantly associated with undernutrition. Therefore, nutritional and social support activities are essential for TB patients, particularly those who are socio-economically disadvantaged. Regular nutritional screening and management, as well as behavioral interventions, should be strengthened.

Impact of Moringa oleifera lam. Leaf powder supplementation versus nutritional counseling on the body mass index and immune response of HIV patients on antiretroviral therapy: a single-blind randomized control trial

BACKGROUND

To achieve effective antiretroviral therapy (ART) outcomes, adherence to an antiretroviral regimen and a good immunometabolic response are essential. Food insecurity can act as a real barrier to adherence to both of these factors. Many people living with human immunodeficiency virus (PLHIV) treated with ART in the Democratic Republic of the Congo (DRC) are faced with nutritional challenges. A significant proportion are affected by under nutrition, which frequently leads to therapeutic failure. Some HIV care facilities recommend supplementation with Moringa oleifera (M.O.) Lam. leaf powder to combat marginal and major nutritional deficiencies. This study aims to assess the impact of M.O. Lam. leaf powder supplementation compared to nutritional counseling on the nutritional and immune status of PLHIV treated with ART.

METHODS

A single-blind randomized control trial was carried out from May to September 2013 at an outpatient clinic for HIV-infected patients in Kinshasa (DRC). Sixty adult patients who were at stable HIV/AIDS clinical staging 2, 3 or 4 according to the World Health Organization (WHO), and were undergoing ART were recruited. After random allocation, 30 patients in the Moringa intervention group (MG) received the M.O. Lam. leaf powder daily over 6 months, and 30 in the control group (CG) received nutritional counseling over the same period. Changes in the body mass index (BMI) were measured monthly and biological parameters were measured upon admission and at the end of the study for the patients in both groups.

RESULTS

The two study groups were similar in terms of long-term nutritional exposure, sociodemographic, socioeconomic, clinical, and biological features. At 6 months follow-up, patients in the MG exhibited a significantly greater increase in BMI and albumin levels than those in the CG. The interaction between the sociodemographic, clinical, and biological characteristics of patients in the two groups was not significant, with the exception of professional activity.

CONCLUSIONS

Under medical supervision, M.O. Lam. leaf powder supplementation may represent a readily available and effective local solution to improve the nutritional intake and nutritional status of PLHIV undergoing ART.

TRIAL REGISTRATION

The study was retrospectively registered in the Pan African Clinical Trial Registry on 15 May 2015, no. PACTR201505001076143.

Body composition of Slovak midlife women with cardiovascular complications

The aim of this study was to analyse differences in body composition of women with and without cardiovascular complications. Bioelectrical parameters were measured with bioimpedance monofrequency analyser (BIA 101) and tissue electric properties were analysed by bioelectric impedance vector analysis (BIVA). The clinical sample (with CVD) consisted of 254 women ranging in age between 39 and 65 years. The sample of women without CVD consisted of 318 women in the same age range and was created from database of our previous studies. Statistical analysis adjusted for age showed significant differences in body composition characteristics of the studied samples. The results of vector analysis showed significantly different tissue electric properties of women in studied groups, what was confirmed by the Hotelling T2- test (p=0.0000). More women with CVD attained risky mean values of obesity indices of BMI and WHR than their “healthy” counterparts. Among women with CVD 80.2% had higher value of the BMI index than optimal one (>24.9 kg/m2) and 74.4% of women had higher value of the WHR index than optimal (>0.80). From the BIA parameters strong correlation coefficient was found between BMI and FM in both groups (r=0.962 for women with CVD; r=0.968 for relatively healthy women). Our data confirmed that cardiovascular disease complications are strongly linked in body composition changes. The cross-sectional nature of our study makes it difficult to draw conclusions regarding causal pathways, though variables of obesity are in line with unhealthy conditions.

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.

Relationship of Acute Phase Reactants and Fat Accumulation during Treatment for Tuberculosis

Background. Tuberculosis causes inflammation and muscle wasting. We investigated how attenuation of inflammation relates to repletion of body composition during treatment in an underserved population. Design. Twenty-four patients (23 to 79 years old) with pulmonary tuberculosis and inflammation (pretreatment albumin = 2.96 ± 0.13 g/dL, C-reactive protein [CRP] = 6.71 ± 1.34 μg/dL, and beta-2-microglobulin = 1.68 ± 0.10 μg/L) were evaluated and had BIA over 24 weeks. Results. Weight increased by 3.02 ± 0.81 kg (5.5%; P = 0.007) at week 4 and by 8.59 ± 0.97 kg (15.6%; P < 0.0001) at week 24. Repletion of body mass was primarily fat, which increased by 2.09 ± 0.52 kg at week 4 and 5.05 ± 0.56 kg at week 24 (P = 0.004 and P < 0.0001 versus baseline). Fat-free mass (FFM), body cell mass (BCM), and phase angle did not increase until study week 8. Albumin rose to 3.65 ± 0.14 g/dL by week 4 (P < 0.001) and slowly increased thereafter. CRP levels declined by ∼50% at each interval visit. Conclusions. During the initial treatment, acute phase reactants returned towards normal. The predominant accrual of fat mass probably reflects ongoing, low levels of inflammation.

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.

The effect of aging, nutrition, and exercise during HIV infection

Medical advances continue to change the face of human immunodeficiency virus- acquired immunodeficiency syndrome (HIV/AIDS). As life expectancy increases, the number of people living with HIV rises, presenting new challenges for the management of a chronic condition. Aging, nutrition, and physical activity can influence outcomes in other chronic conditions, and emerging data show that each of these factors can impact viral replication and the immune system in HIV. HIV infection results in a decline of the immune system through the depletion of CD4+ T cells. From initial infection, viral replication is a continuous phenomenon. Immunosenescence, a hallmark of aging, results in an increased susceptibility to infections secondary to a delayed immune response, and this phenomenon may be increased in HIV-infected patients. Optimal nutrition is an important adjunct in the clinical care of patients with HIV. Nutritional interventions may improve the quality and span of life and symptom management, support the effectiveness of medications, and improve the patient's resistance to infections and other disease complications by altering immunity. Moderate physical activity can improve many immune parameters, reduce the risk of acute infection, and combat metabolic abnormalities. As people with HIV age, alternative therapies such as nutrition and physical activity may complement medical management.

Association between weight gain and clinical outcomes among malnourished adults initiating antiretroviral therapy in Lusaka, Zambia

OBJECTIVE

To describe the association between 6-month weight gain on antiretroviral therapy (ART) and subsequent clinical outcomes.

DESIGN

A retrospective analysis of a large programmatic cohort in Lusaka, Zambia.

METHODS

Using Kaplan-Meier analysis and Cox proportional hazards models, we examined the association between 6-month weight gain and the risk of subsequent death and clinical treatment failure. Because it is a known effect modifier, we stratified our analysis according to body mass index (BMI).

RESULTS

Twenty-seven thousand nine hundred fifteen adults initiating ART were included in the analysis. Patients in the lower BMI categories demonstrated greater weight gain. In the post 6-month analysis, absolute weight loss was strongly associated with mortality across all BMI strata, with the highest risk observed among those with BMI <16 kg/m (adjusted hazard ratio 9.7; 95% CI: 4.7 to 20.0). There seemed to be an inverse relationship between weight gain and mortality among patients with BMI <16 kg/m. Similar trends were observed with clinical treatment failure.

CONCLUSIONS

Weight gain after ART initiation is associated with improved survival and decreased risk for clinical failure, especially in the lower BMI strata. Prospective trials to promote weight gain after ART initiation among malnourished patients in resource-constrained settings are warranted.

Evaluation of high-protein supplementation in weight-stable HIV-positive subjects with a history of weight loss: a randomized, double-blind, multicenter trial

BACKGROUND

HIV patients with wasting are at increased risk of opportunistic complications and fatality.

OBJECTIVE

We hypothesized that augmenting dietary intake with high-biologic-value protein would enhance weight and lean tissue in weight-stable subjects with a prior unintentional weight loss of >3%.

DESIGN

Fifty-nine subjects with HIV RNA concentrations <5000 copies/mL were randomly assigned to receive a 280-kcal supplement containing 40 g whey protein or a matched isocaloric control supplement without added protein twice daily for 12 wk.

RESULTS

Before the study, intake of total energy and protein exceeded estimated requirements (44.3 +/- 12.6 kcal x kg(-1) x d(-1) and 1.69 +/- 0.55 g x kg(-1) x d(-1), respectively). Both supplements failed to increase total energy intake because of decreases in self-selected food intake. Changes in weight (0.8 +/- 2.4 and 0.7 +/- 2.4 kg) and lean body mass (0.3 +/- 1.4 and 0.3 +/- 1.5 kg) did not differ significantly between the whey protein and control groups, respectively. Waist-to-hip ratio improved more with whey protein (-0.02 +/- 0.05) than with the control (0.01 +/- 0.03; P = 0.025) at week 6 but not at week 12. Fasting triacylglycerol increased by 39 +/- 98 mg/dL with the control supplement and decreased by 16 +/- 62 mg/dL with whey protein at week 12 (P = 0.03). CD4 lymphocytes increased by 31 +/- 84 cells/mm(3) with whey protein and decreased by 5 +/- 124 cells/mm(3) with the control supplement at 12 wk (P = 0.03). Gastrointestinal symptoms occurred more often with whey protein.

CONCLUSIONS

A whey protein supplement did not increase weight or lean body mass in HIV-positive subjects who were eating adequately, but it did increase CD4 cell counts. The control supplement with rapidly assimilable carbohydrate substituted for protein increased cardiovascular disease risk factors. Careful dietary and weight history should be obtained before starting nutritional supplements in subjects with stable weight loss and good viral control.

Dysregulated Energy Expenditure in HIV-Infected Patients: A Mechanistic Review

Metabolic abnormalities are common in patients with human immunodeficiency virus (HIV) infection and range from protein catabolism to lipodystrophy and dyslipidemia associated with the use of highly active antiretroviral therapy. One abnormality is increased resting energy expenditure, which even occurs in clinically stable HIV-infected patients. Increased resting energy expenditure may aggravate the tendency towards weight loss and wasting, which are independent predictors of mortality. Despite much investigation, the factors associated with altered resting energy expenditure remain unclear; viral load, CD4 cell count, use of antiretroviral drugs, body composition, hormones, and proinflammatory cytokines have been imputed. Mechanisms that could explain increased resting energy expenditure include the HIV accessory protein viral protein R, antiretroviral drugs that affect mitochondrial function, and futile cycling within adipocytes. Other components of energy expenditure are also important to overall energy balance and may also be affected. Identifying unifying mechanisms will be an important step to finding effective treatments for HIV-related alterations in energy expenditure and to reversing metabolic risks in patients with HIV infection.

Bioimpedance analysis and HIV-related fatigue

Although various physiological and psychological causes of fatigue in HIV-positive persons have been proposed, it is still not well understood. Bioimpedance analysis has proved to be an easily used, non-invasive measurement of body composition and cellular integrity. This study, looking at whether body composition as measured by bioimpedance analysis is associated with fatigue, is part of a pilot study looking for physiological and psychological biomarkers that could be factors in the fatigue experienced by HIV-positive people. Twenty-nine men and eleven women were measured for height, weight, and bioimpedance analysis. Correlations were examined between fatigue intensity and weight, body mass index, body cell mass, fat-free mass, extracellular mass, and phase angle. Because of the fat redistribution that has occurred with some people taking protease inhibitors, we also examined differences in weight, body mass index, body cell mass, fat-free mass, and fatigue intensity between those taking and those not taking protease inhibitors. There was no association between fatigue intensity and weight, body mass index, body cell mass, fat-free mass, or phase angle, nor were there differences between those taking and those not taking protease inhibitors. However, it was noted that both the phase angle and the ratio of extracellular mass to body cell mass (extracellular mass:body cell mass) were below their respective normal ranges, indicating that the participants were somewhat compromised nutritionally and with regard to cell membrane integrity. Although fatigue was not shown to be related to body composition measurement in this study, further work is needed on the causes of fatigue, because its effects on the lives of HIV-positive people can be devastating.

Position of the American Dietetic Association and Dietitians of Canada: nutrition intervention in the care of persons with human immunodeficiency virus infection

Infection with the human immunodeficiency virus (HIV) and the development of acquired immunodeficiency syndrome (AIDS) have had a significant impact on domestic and global health, social, political, and economic outcomes. Prevention and treatment efforts to control HIV infection are more demanding than in previous decades. Achieving food and nutrition security, and managing nutrition-related complications of HIV infection and the multiple aspects of disease initiated by or surrounding HIV infection, referred to as HIV disease, remain challenges for patients and for those involved with HIV/AIDS prevention, care, and treatment efforts. Confounding clinical issues include medication interactions, coinfection with other infections and diseases, wasting, lipodystrophy, and others. Dietetics professionals, other health care professionals, and people infected with HIV will need to understand and address multiple complex aspects of HIV infection and treatment to improve survival, body functions, and overall quality of life. Individualized nutrition care plans will be an essential feature of the medical management of persons with HIV infection and AIDS.

Influence of hormonal status and oral intake on phase angle in HIV-infected men

OBJECTIVE

Phase angle alpha can be easily obtained from bioelectrical impedance analysis. In the literature, this angle is the single best predictor of survival in patients with the human immunodeficiency virus (HIV). The aim of our study was to detect nutritional and biochemical parameters that influence the phase angle.

METHODS

One hundred men with HIV were studied. In all patients, anthropometric and biochemical nutritional evaluations were performed. Basal concentrations of testosterone and somatomedin C (insulin-like growth factor-1) were measured. Tetrapolar bioelectrical impedance analysis was used to determine body composition. All patients received instruction on keeping 24-h written food records. Albumin, prealbumin, transferrin, CD4 count, and total lymphocytes were measured.

RESULTS

Patients' mean age was 39.1 +/- 9.9 y, mean body weight was 66.8 +/- 11.2 kg, and mean body mass index was 22.5 +/- 3.5 kg/m2. Patients' average fat-free mass was 58.05 +/- 8.7 kg and average fat mass was 9.17 +/- 4.9 kg. Average phase angle alpha was 8.21 +/- 0.88 degrees. Patients were assigned to one of two groups according to phase angle: those with a phase angle alpha smaller than 8.2 degrees (group 1) and those with a phase angle alpha of at least 8.2 degrees (group 2). Weight, body mass index, transferrin, and somatomedin C were significantly higher in group 2 (P < 0.05 for all). There were significant positive correlations between phase angle alpha and somatomedin C (r = 0.3, P < 0.05) and protein intake (r = 0.2, P < 0.05). In the multivariate analysis (adjusted for number of antiretroviral drugs prescribed, age, disease stage, and energy and protein intakes), only somatomedin C remained in the model (F = 4.5, P < 0.05), with an increase in phase angle alpha of 0.56 degrees (95% confidence interval, 0.04 to 1.08) with each 1-nM/L increase in somatomedin C.

CONCLUSION

Somatomedin C and protein intake influenced phase angle alpha, but only somatomedin C remained as an independent factor in the multivariate analysis.

Hyperphagia contributes to the normal body composition and protein-energy balance in HIV-infected asymptomatic men

Wasting can occur at an early stage of HIV infection. Both reduced energy intake and increased resting energy expenditure (REE) have been considered as factors in wasting with predominant lean body mass loss, suggesting disturbances of protein metabolism. Our aim was to study protein-energy metabolism in relation to body composition and oral energy intake in asymptomatic patients with HIV infection but receiving no active antiretroviral therapy. Stable-weight asymptomatic male patients (n = 8) at stage A of HIV infection with a detectable viral load were compared with 9 healthy control men. Protein metabolism was studied in the postabsorptive state using a primed constant infusion of l-[1-(13)C]leucine and l-[2-(15)N]glutamine. REE was studied by indirect calorimetry, body composition by bioelectrical impedance, and energy intake by dietary records. BMI and lean body mass did not differ between patients and controls. In HIV-infected subjects, energy intake, protein breakdown, protein synthesis, and REE were 57% (P < 0.05), 18% (P < 0.05), 22% (P < 0.05) and 14% (P < 0.05) greater than in controls, respectively. REE and protein breakdown were correlated (r = 0.73, P < 0.05). The hormonal profile was normal in HIV-infected subjects with the exception of low urinary C-peptide and plasma reverse triiodothyronine. Plasma interleukin-6 and tumor necrosis factor-alpha were greater than in controls, but energy intake was 1.53 times the REE in the HIV-infected men. Thus, at the asymptomatic stage of HIV infection, increased protein turnover contributes to the increase in the REE. Moderate hyperphagia, which occurred despite increased levels of cytokines, in conjunction with increased protein synthesis maintains a normal body composition, without significant loss of lean body mass.