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Wang Y, Yang Z, Li J, Wu Z, Liu X, Wang H, Chen Y, Wang Z, Tong Z, Li X, Ren F, Jin M, Mao G. The risk of dyslipidemia on PLHIV associated with different antiretroviral regimens in Huzhou. PLoS One 2024; 19:e0305461. [PMID: 39302927 DOI: 10.1371/journal.pone.0305461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/30/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND Dyslipidemia is increasingly common in people living with HIV (PLHIV), thereby increasing the risk of cardiovascular events and diminishing the quality of life for these individuals. The study of blood lipid metabolism of PLHIV has great clinical significance in predicting the risk of cardiovascular disease. Therefore, this study aims to examine the blood lipid metabolism status of HIV-infected patients in Huzhou before and after receiving highly active antiretroviral therapy (HAART) and to explore the impact of different HAART regimens on dyslipidemia. METHOD PLHIV confirmed in Huzhou from June 2010 to June 2022 was included. The baseline characteristics and clinical data during the follow-up period were collected, including some blood lipid indicators (total cholesterol and triglycerides) and HAART regimens. A multivariate logistic regression model and the generalized estimating equation model were used to analyze the independent effects of treatment regimens on the risk of dyslipidemia. RESULT The overall prevalence of dyslipidemia among PLHIV after HAART was 70.11%. PLHIV receiving lamivudine (3TC) + efavirenz (EFV) + zidovudine (AZT) had a higher prevalence of dyslipidemia compared to those receiving 3TC+EFV+tenofovir disoproxil fumarate (TDF). In a logistic analysis adjusted for important covariates such as BMI, age, diabetes status, etc., we found that the risks of dyslipidemia were higher with 3TC+EFV+AZT (dyslipidemia: odds ratio [OR] = 2.09, 95% confidence interval [Cl]: 1.28-3.41; TG ≥1.7: OR = 2.40, 95%Cl:1.50-3.84) than with 3TC+EFV+TDF. Furthermore, on PLHIV that was matched 1:1 by the HAART regimens, the results of the generalized estimation equation again showed that 3TC+EFV+AZT (TG ≥1.7: OR = 1.84, 95%Cl: 1.10-3.07) is higher for the risk of marginal elevations of TG than 3TC+EFV+TDF. CONCLUSION The prevalence of dyslipidemia varies according to different antiretroviral regimens. Using both horizontal and longitudinal data, we have repeatedly demonstrated that AZT has a more adverse effect on blood lipids than TDF from two perspectives. Therefore, we recommend caution in using the 3TC+EFV+AZT regimen for people at clinical risk of co-occurring cardiovascular disease.
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Affiliation(s)
- Yanan Wang
- Huzhou Center for Disease Control and Prevention, Huzhou, Zhejiang, China
- Division of Epidemiology and Health Statistics, Department of Preventive Medicine, School of Public Health & Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
- Center on Evidence-Based Medicine & Clinical Epidemiological Research, School of Public Health & Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhongrong Yang
- Huzhou Center for Disease Control and Prevention, Huzhou, Zhejiang, China
| | - Jing Li
- Huzhou Center for Disease Control and Prevention, Huzhou, Zhejiang, China
| | - Zhenqian Wu
- Huzhou Center for Disease Control and Prevention, Huzhou, Zhejiang, China
| | - Xiaoqi Liu
- Huzhou Center for Disease Control and Prevention, Huzhou, Zhejiang, China
| | - Hui Wang
- Division of Epidemiology and Health Statistics, Department of Preventive Medicine, School of Public Health & Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
- Center on Evidence-Based Medicine & Clinical Epidemiological Research, School of Public Health & Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yuxin Chen
- Division of Epidemiology and Health Statistics, Department of Preventive Medicine, School of Public Health & Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
- Center on Evidence-Based Medicine & Clinical Epidemiological Research, School of Public Health & Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ziyi Wang
- Division of Epidemiology and Health Statistics, Department of Preventive Medicine, School of Public Health & Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
- Center on Evidence-Based Medicine & Clinical Epidemiological Research, School of Public Health & Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhaowei Tong
- Department of Infectious Diseases, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Xiaofeng Li
- Department of Infectious Diseases, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Feilin Ren
- Huzhou Center for Disease Control and Prevention, Huzhou, Zhejiang, China
| | - Meihua Jin
- Huzhou Center for Disease Control and Prevention, Huzhou, Zhejiang, China
| | - Guangyun Mao
- Division of Epidemiology and Health Statistics, Department of Preventive Medicine, School of Public Health & Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
- Center on Evidence-Based Medicine & Clinical Epidemiological Research, School of Public Health & Management, Wenzhou Medical University, Wenzhou, Zhejiang, China
- National Clinical Research Center for Ocular Diseases, Wenzhou, Zhejiang, China
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Long H, He Q, Bi Y, Ke Y, Xie X, Zhao X, Tan S, Luo Y, Chen Z, Yu X, Li L. Efficacy and effect on lipid profiles of Ainuovirine-based regimen versus Efavirenz-based regimen in treatment-naïve people with HIV-1 at week 24: A real-world, retrospective, multi-center cohort study. Biosci Trends 2024; 18:176-186. [PMID: 38684402 DOI: 10.5582/bst.2024.01070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
This study aimed to compare the efficacy and effect on lipid profiles of Ainuovirine (ANV)- and efavirenz (EFV) -based regimens in treatment-naïve people living with HIV-1 (PLWH) at week 24. The proportion of PLWH achieving HIV-1 RNA < the limit of quantification in the ANV group was significantly higher than that in the EFV group (89.18% vs. 76.04%, P = 0.002). The mean change of log10 HIV-1 RNA from baseline was greater (-4.34 vs. -4.18, P < 0.001), the median change from baseline in CD4+ T cell count increased more (106.00 cells/μL vs. 92.00 cells/μL, P = 0.007) in the ANV group, while the CD4+/CD8+ ratio was similar (0.15 vs. 0.20, P = 0.167) between the two groups. The mean changes from baseline in total cholesterol (-0.02 for ANV vs. 0.25 mmol/L for EFV, P < 0.001), triglyceride (-0.14 for ANV vs. 0.11 mmol/L for EFV, P = 0.024), and low-density lipoprotein cholesterol (-0.07 for ANV vs. 0.15 mmol/L for EFV, P < 0.001) was significantly different between the two groups. The percentage of patients with improved lipid profiles was significantly higher in the ANV group (37.44 %) than in the EFV group (29.55%, P = 0.0495). The incidence of any adverse events in the ANV group was significantly lower than that in the EFV group at week 12 (6.2% vs. 30.7%, P < 0.001) and was comparable at week 24 (3.6% vs. 5.5%, P = 0.28). The ANV-based regimen was well tolerated and lipid-friendly in treatment-naïve PLWH.
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Affiliation(s)
- Hai Long
- Department of Infectious Disease, GuiYang Public Health Clinical Center, Guiyang, Guizhou, China
| | - Quanying He
- Department of Outpatient, Yunnan Provincial Infectious Disease Hospital, Kunming, Yunnan, China
| | - Yanmei Bi
- Department of Dermatology, Shandong Public Health Clinical Center, Shandong University, Jinan, Shandong, China
| | - Yingchun Ke
- Infectious Disease Center, Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Xiaoxin Xie
- Department of Infectious Disease, GuiYang Public Health Clinical Center, Guiyang, Guizhou, China
| | - Xiuhong Zhao
- Department of Dermatology, Shandong Public Health Clinical Center, Shandong University, Jinan, Shandong, China
| | - Si Tan
- Department of Infection and Immunology, The First Hospital of Changsha City, Xiangya School of Medicine of Central South University, Changsha, Hunan, China
| | - Yanhe Luo
- Department of Infection and Immunology with Chinese Integrative Medicine, Wuhan Jinyintan Hospital, Tongji Medical College of Huazhong University of Science and Technology, Hubei Clinical Research Center for Infectious Diseases, Wuhan Research Center for Communicable Disease Diagnosis and Treatment, Chinese Academy of Medical Sciences, Joint Laboratory of Infectious Diseases and Health, Wuhan Institute of Virology and Wuhan Jinyintan Hospital, Chinese Academy of Sciences, Wuhan, China
| | - Zhong Chen
- Department of Infection and Immunology, The First Hospital of Changsha City, Xiangya School of Medicine of Central South University, Changsha, Hunan, China
| | - Xiaoli Yu
- Department of Infection and Immunology with Chinese Integrative Medicine, Wuhan Jinyintan Hospital, Tongji Medical College of Huazhong University of Science and Technology, Hubei Clinical Research Center for Infectious Diseases, Wuhan Research Center for Communicable Disease Diagnosis and Treatment, Chinese Academy of Medical Sciences, Joint Laboratory of Infectious Diseases and Health, Wuhan Institute of Virology and Wuhan Jinyintan Hospital, Chinese Academy of Sciences, Wuhan, China
| | - Linghua Li
- Infectious Disease Center, Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
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Miao X, Ye H, Cui X, Guo X, Su F. Resveratrol attenuates efavirenz-induced hepatic steatosis and hypercholesterolemia in mice by inhibiting pregnane X receptor activation and decreasing inflammation. Nutr Res 2023; 119:119-131. [PMID: 37826994 DOI: 10.1016/j.nutres.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 09/14/2023] [Accepted: 09/14/2023] [Indexed: 10/14/2023]
Abstract
Efavirenz (EFV), a widely prescribed antiviral medication, has been implicated in dyslipidemia and can activate the pregnane X receptor (PXR), leading to hepatic steatosis and hypercholesterolemia in mice. Resveratrol (RES) can ameliorate hepatic steatosis and functions as a partial PXR agonist, capable of mitigating PXR expression induced by other PXR agonists. Therefore, we hypothesized that RES could attenuate EFV-induced hepatic steatosis and hypercholesterolemia by downregulating PXR expression and suppressing inflammatory cytokine production. Here, we conducted an in vivo study involving 6-week-old male mice, which were divided into 4 groups for a 7-day intervention: control (carrier solution), EFV (80 mg/kg), RES (50 mg/kg), and RES + EFV groups. Serum and hepatic tissue samples were collected to assess cholesterol and triglyceride concentrations. Hepatic lipid accumulation was evaluated through hematoxylin-eosin and oil red O staining. Polymerase chain reaction and western blot were performed to quantify hepatic inflammatory factors, lipogenic gene, and PXR expression. Our results indicated that hepatic lipid droplet accumulation was reduced in the RES + EFV group compared with the EFV group. Similarly, the expressions of hepatic inflammatory factors were attenuated in the RES + EFV group relative to the EFV group. Furthermore, RES counteracted the upregulation of hepatic lipid-metabolizing enzymes induced by EFV at both the transcriptional and protein levels. Importantly, PXR expression was downregulated in the RES + EFV group compared with the EFV group. Conclusively, our findings suggest that RES effectively mitigates EFV-induced hepatic steatosis and hypercholesterolemia by inhibiting PXR activation and decreasing inflammation.
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Affiliation(s)
- Xingguo Miao
- Department of Infectious Diseases, Wenzhou Central Hospital, Zhejiang, 325000, China; Department of Infectious Diseases, the Sixth People's Hospital of Wenzhou, Zhejiang, 325000, China; Institute of Translational Medicine, Shanghai University, Shanghai, 200444, China
| | - Hui Ye
- Department of Infectious Diseases, Wenzhou Central Hospital, Zhejiang, 325000, China; Department of Infectious Diseases, the Sixth People's Hospital of Wenzhou, Zhejiang, 325000, China
| | - Xiaoya Cui
- Department of Infectious Diseases, Wenzhou Central Hospital, Zhejiang, 325000, China; Department of Infectious Diseases, the Sixth People's Hospital of Wenzhou, Zhejiang, 325000, China
| | - Xiuxiu Guo
- Department of Infectious Diseases, Wenzhou Central Hospital, Zhejiang, 325000, China; Department of Infectious Diseases, the Sixth People's Hospital of Wenzhou, Zhejiang, 325000, China
| | - Feifei Su
- Department of Infectious Diseases, Wenzhou Central Hospital, Zhejiang, 325000, China; Department of Infectious Diseases, the Sixth People's Hospital of Wenzhou, Zhejiang, 325000, China.
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Derangement of Liver Enzymes, Hyperglycemia, Anemia, and Associated Factors among HIV-Infected Patients Treated with Tenofovir Disoproxil Fumarate-Based Regimen in Ethiopia: A Prospective Cohort Study. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6613519. [PMID: 34222476 PMCID: PMC8221861 DOI: 10.1155/2021/6613519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/03/2021] [Accepted: 05/28/2021] [Indexed: 01/17/2023]
Abstract
Hepatotoxicity was found in different case reports and studies in tenofovir disoproxil fumarate- (TDF-) based regimen. However, there was no data regarding liver enzymes, glucose, and hemoglobin in Ethiopian patients receiving TDF-based regimen. The aim of this study was to determine elevated liver enzymes and its associated factors as well as elevated fasting plasma glucose and anemia. A hospital-based observational prospective cohort study was conducted on conveniently selected 63 patients in Tikur Anbessa Specialized Hospital (TASH) from January to September 2019. Laboratory values were determined at pre-TDF-based regimen baseline and six-month follow-up. The data was analyzed by using SPSS version 21.0, and multivariate logistic regression was used to determine associated factors with elevated liver enzymes. The overall elevated liver enzymes were found in 26 (41.3%) participants. From this, elevated alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase (ALP) comprise 3 (4.8%), 3 (4.8%), and 20 (31.8%), respectively. Elevated fasting plasma glucose (FPG) was found in 9 (14.3%) and 14 (22.2%) of participants at baseline and six-month visit, respectively. At six-month visit, 4 (6.4%) of participants experienced anemia. The mean value of ALP and FPG at six months was significantly higher than their respective baseline mean values (mean difference (MD) = +63.38, 95% CI (39.84, 86.92), p = 0.0001; MD = +6.64, 95% CI (2.63, 10.64), p = 0.002, respectively). The mean value of ALT, AST, and Hg at six months was slightly increased compared to their respective baseline mean values, but the difference was not significant. In multivariate analysis, only female sex was significantly associated with elevated ALP (AOR = 4.5, 95% CI (1.03, 19.6), p = 0.045). Overall mild and moderate hepatotoxicity was found to be high (26, 41.3%) in the present study, and from this, the majority was comprised by elevated ALP (20, 31.8%). The proportion of participants with hyperglycemia was increased at the end of follow-up compared to its baseline value, but anemia was not. Female sex was significantly associated with elevated ALP. This study warrants monitoring of liver enzymes and glucose in TDF-based regimen.
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Yazie TS. Dyslipidemia and Associated Factors in Tenofovir Disoproxil Fumarate-Based Regimen Among Human Immunodeficiency Virus-Infected Ethiopian Patients: A Hospital-Based Observational Prospective Cohort Study. DRUG HEALTHCARE AND PATIENT SAFETY 2020; 12:245-255. [PMID: 33304107 PMCID: PMC7723030 DOI: 10.2147/dhps.s283402] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/14/2020] [Indexed: 12/22/2022]
Abstract
Background Studies showed conflicting results regarding the effect of broadly used tenofovir disoproxil fumarate (TDF)-based regimen on lipid profiles, and in Ethiopia, there is no data regarding the magnitude of dyslipidemia and its associated factors. Objective The aim of this study was to determine the magnitude of dyslipidemia and its associated factors among adult human immunodeficiency virus (HIV)-infected patients in TDF-based regimen in Tikur Anbessa Specialized Hospital (TASH) in Ethiopia. Methods A hospital-based observational prospective cohort study was conducted on conveniently selected 63 patients in TASH from January to September, 2019. The data was analyzed by using SPSS version 21.0, and multivariate logistic regression was used to determine associated factors with dyslipidemia. Results The overall dyslipidemia was 73% and 77.8% at baseline and six months, respectively. The prevalence of total cholesterol (TC) ≥200 mg/d, triglyceride (TG) ≥150 mg/dL, low density lipoprotein cholesterol (LDL-c) ≥130 mg/dL, and high density lipoprotein cholesterol (HDL-c) <40 mg/dL was 38.1% vs 42.9%, 23.8% vs 31.7%, 17.5% vs 22.2%, and 41.3% vs 41.3% at baseline and six month follow-up, respectively. Age ≥50 years old (AOR = 0.6, 95% CI: 0.004-0.71, p = 0.026) and body mass index (BMI) ≥25 kg/m2 (AOR = 6.44, 95% CI: 1.34-30.9, p = 0.02) were significantly associated with TC ≥200 mg/dL. Having cancer (AOR = 0.04, 95% CI: 0.01-0.6, p = 0.019) and education level below diploma (AOR = 9.47, 95% CI: 1.15-77.96, p = 0.037) were significantly associated with overall dyslipidemia. Conclusion In this study, the proportion of patients with dyslipidemia was higher at six month follow-up but there was no significant difference when compared to baseline. The mean LDL-c was significantly higher at six months compared to its baseline mean. The associated factors with dyslipidemia were age, BMI, having cancer and low level of education. Lipid profile monitoring is recommended in patients with a younger age and higher BMI.
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Affiliation(s)
- Taklo Simeneh Yazie
- Pharmacology Unit and Research Team, Department of Pharmacy, College of Health Sciences, Debre Tabor University, Debre Tabor, Amhara, Ethiopia
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Muche EA, Kiflu M, Ayalew MB. Patient Reported Central Nervous System Adverse Events of Efavirenz-Based Antiretroviral Therapy in People Living with HIV in Northwest Ethiopia. HIV AIDS (Auckl) 2020; 12:601-609. [PMID: 33116922 PMCID: PMC7585818 DOI: 10.2147/hiv.s276111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 09/16/2020] [Indexed: 11/24/2022] Open
Abstract
Background Central nervous system (CNS) toxicities from regimens containing efavirenz are the main reasons for non-adherence, switch and discontinuation of antiretroviral therapy (ART). We aimed to assess prevalence of CNS adverse events and associated factors among HIV patients taking efavirenz-based regimens at the University of Gondar Comprehensive and Specialized Hospital (UoGCSH), Northwest Ethiopia. Methods A hospital-based cross-sectional study was conducted from March 15 to May 15, 2018 on 345 patients living with HIV who were taking efavirenz-based regimens. Information on sociodemographic and clinical characteristics was taken from medical records and patient interview. Binary logistic regression analysis was done to determine association. Statistical significance was declared at P value of ≤ 0.05. Results About 52.8% of participants experienced CNS adverse events. Vivid dreams, confusion, insomnia and somnolence were the most frequently reported adverse events. Most of the CNS adverse events occurred in the first year of treatment initiation and resolved within 1–4 weeks. Age, economic status, CD4 count, disease stage, presence of comorbidities and concurrent use of other medication had a significant association with the occurrence of CNS adverse events. Conclusion More than half of HIV patients taking efavirenz-based regimens at UoGCSH experienced CNS adverse events. Health-care providers should give attention to patients on efavirenz therapy to monitor for CNS adverse events, especially for patients who have low CD4 count, advanced disease, comorbidities, low income and are older in age.
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Affiliation(s)
- Esileman Abdela Muche
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mekdes Kiflu
- Department of Pharmacy, College of Medicine and Health Sciences, Debremarkose University, Debremarkos, Ethiopia
| | - Mohammed Biset Ayalew
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Aparecida Silveira E, Falco MO, Santos ASEADC, Noll M, de Oliveira C. Nutritional Intervention Reduces Dyslipidemia, Fasting Glucose and Blood Pressure in People Living with HIV/AIDS in Antiretroviral Therapy: A Randomized Clinical Trial Comparing Two Nutritional Interventions. Nutrients 2020; 12:E2970. [PMID: 32998416 PMCID: PMC7601880 DOI: 10.3390/nu12102970] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/25/2020] [Accepted: 09/23/2020] [Indexed: 11/16/2022] Open
Abstract
Antiretroviral therapy (ART) increases the risk of cardiometabolic diseases in people living with HIV/AIDS (PLWHA). However, there is a lack of evidence regarding the effectiveness of a nutritional intervention on several cardiometabolic parameters in this population. Therefore, this study aimed to evaluate the effectiveness of two nutritional interventions on several cardiometabolic parameters in PLWHA treated with ART. A parallel randomized clinical trial was performed with PLWHA treated with ART. The participants (n = 88) were divided into two intervention groups: (1) nutritional counseling (n = 44) and (2) individualized dietary prescription (n = 44). The follow-up period was 30 weeks. A reduction in low-density lipoprotein (LDL) was the primary outcome. Secondary outcome variables were reductions in total cholesterol (TC), triglycerides (TG), fasting plasma glucose (FPG), systolic and diastolic blood pressures (SBP and DBP, respectively), waist circumference (WC), body mass index (BMI), and increases in high-density lipoproteins (HDL). A multiple linear regression was used to analyze the effectiveness of the interventions, adjusted for sociodemographic, lifestyle, and clinical characteristics. Sixty-two PLWHA completed the trial (nutritional counseling, n = 32; individualized dietary prescription, n = 30). At follow-up, we observed in the nutritional counseling group significant reductions in SBP (p = 0.036) and DBP (p = 0.001). Significant reductions in FPG (p = 0.008) and DBP (p = 0.023) were found in the individualized dietary prescription group. In the fully adjusted models, significant reductions in LDL, SBP, DBP, and BMI were found in the individualized dietary prescription group. In conclusion, the two investigated nutritional interventions were effective in reducing some cardiometabolic risk factors in PLWHA. However, after adjustments for covariates, the individualized dietary prescription showed significant reductions in the primary outcome and, also, in more cardiometabolic risk factors than the nutritional counseling.
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Affiliation(s)
- Erika Aparecida Silveira
- Department of Epidemiology & Public Health, Institute of Epidemiology & Health Care, University College London, London WC1E 6BT, UK
- Postgraduate Program in Health Sciences, Faculty of Medicine, Federal University of Goiás, Goiânia 74605-050, Brazil; (M.O.F.); (A.S.e.A.d.C.S.)
| | - Marianne Oliveira Falco
- Postgraduate Program in Health Sciences, Faculty of Medicine, Federal University of Goiás, Goiânia 74605-050, Brazil; (M.O.F.); (A.S.e.A.d.C.S.)
| | | | - Matias Noll
- Department of Public Health, Instituto Federal Goiano, Ceres 76300-000, Brazil;
| | - Cesar de Oliveira
- Department of Epidemiology & Public Health, Institute of Epidemiology & Health Care, University College London, London WC1E 6BT, UK
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