1
|
Kamenju P, Madzorera I, Hertzmark E, Urassa W, Fawzi WW. Higher Dietary Intake of Animal Protein Foods in Pregnancy Is Associated with Lower Risk of Adverse Birth Outcomes. J Nutr 2022; 152:2546-2554. [PMID: 36774120 PMCID: PMC9644176 DOI: 10.1093/jn/nxac183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/07/2022] [Accepted: 08/12/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The prevalence of adverse birth outcomes is highest in resource-limited settings such as sub-Saharan Africa. Maternal consumption of diets with adequate nutrients during pregnancy may protect against these adverse outcomes. OBJECTIVES The objective was to determine the association between maternal dietary consumption of animal source foods (ASFs) and the risk of adverse birth outcomes among HIV-negative pregnant women in Tanzania. METHODS Using dietary intake data from 7564 HIV-negative pregnant women, we used Poisson regression with the empirical variance (generalized estimating equation) to estimate the RR of adverse birth outcomes-preterm birth, very preterm birth, small for gestational age (SGA), low birth weight (LBW), stillbirth, and neonatal death-for higher and lower frequency of ASF intake. RESULTS Median daily dietary intake of animal protein was 17 g (IQR: 1-48 g). Higher frequency of ASF protein intake was associated with lower risk of neonatal death (quartile 4 compared with quartile 1; RR: 0.59; 95% CI: 0.38, 0.90; P-trend = 0.01). Higher fish intake was associated with lower risk of very preterm birth (high tertile compared with low; RR: 0.76; 95% CI: 0.58, 0.99; P-trend = 0.02). Any meat intake was protective of preterm birth (RR: 0.73; 95% CI: 0.65, 0.82; P < 0.001), very preterm birth (P < 0.001), LBW (P < 0.001), and neonatal death (P = 0.01) but was associated with increased risk of SGA (RR:1.19; 95% CI: 1.01, 1.36; P = 0.04). Any egg intake was protective of very preterm birth (RR: 0.50; 95% CI: 0.31, 0.83; P = 0.01) as compared with no egg intake. Finally, any dairy intake was associated with lower risk of preterm birth (RR: 0.82; 95% CI: 0.68, 0.98; P = 0.03) and very preterm birth (RR: 0.53; 95% CI: 0.34, 0.84; P = 0.01). CONCLUSIONS Higher frequency of dietary intake of ASF is associated with lower risk of adverse birth outcomes in urban Tanzania. Promoting prenatal dietary intake of ASF may improve birth outcomes in this region and similar resource-limited settings.
Collapse
Affiliation(s)
- Pili Kamenju
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA.
| | - Isabel Madzorera
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Willy Urassa
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA; 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
| |
Collapse
|
2
|
Munseri P, Jassely L, Tumaini B, Hertzmark E. Body mass index, proteinuria and total lymphocyte counts in predicting treatment responses among ART naïve individuals with HIV initiated on antiretroviral treatment in Dar es Salaam, Tanzania, 2019: a cohort study. BMJ Open 2022; 12:e059193. [PMID: 35676009 PMCID: PMC9185589 DOI: 10.1136/bmjopen-2021-059193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES To explore the potential use of body mass index (BMI), proteinuria and total lymphocyte count changes in predicting immunological and virological response in individuals with HIV initiated on antiretroviral treatment (ART). DESIGN Prospective cohort study. SETTING Three urban HIV care and treatment centres in Dar es Salaam. PARTICIPANTS Individuals with HIV initiating ART. OUTCOME MEASURES HIV viral load ≥1000 copies/mL (viral non-suppression) at 6 months after ART initiation. RESULTS Of 215 (out of 220 enrolled) participants who returned for evaluation at 6 months, 147 (66.8%) were women. At 6 months of follow-up, 89.4% (76/85) of participants with sustained weight gain were virally suppressed compared with 31.8% (7/22) with sustained loss, p<0.001. In participants who were lymphopaenic at baseline, an increase to normal total lymphocyte counts at 6 months was associated with an increase in CD4 count compared with participants who remained lymphopaenic, 96.2% (50/52) versus 54.8% (17/31), p<0.001. At baseline, 50.0% (110/220) had proteinuria. In participants without proteinuria from baseline to 6 months, 89.8% (79/88) were virally suppressed compared with participants with proteinuria at baseline and/or 3 months, 85.6% (77/90), those with persistent proteinuria, 30.8% (8/26), and proteinuria at 6 months only, 45.5% (5/11), p<0.001. In modified Poisson regression, the independent predictors other than CD4 cell counts for viral non-suppression at 6 months among individuals with HIV initiating on ART were BMI loss >5% from baseline to 6 months (adjusted RR 2.73, 95% CI (1.36 to 5.47)), lymphopaenia at 6 months (adjusted RR=4.54, 95% CI (2.19 to 9.39)) and proteinuria at 6 months (adjusted RR=2.63, 95% CI (1.25 to 5.54)). CONCLUSIONS Change in BMI, total lymphocyte count and presence of proteinuria can monitor and predict ART response and may be particularly helpful in settings when CD4 counts and viral load monitoring are unavailable.
Collapse
Affiliation(s)
- Patricia Munseri
- Internal Medicine, Muhimbili University of Health and Allied Sciences School of Medicine, Dar es Salaam, Tanzania
| | - Lazaro Jassely
- Internal Medicine, Muhimbili University of Health and Allied Sciences School of Medicine, Dar es Salaam, Tanzania
| | - Basil Tumaini
- Internal Medicine, Muhimbili University of Health and Allied Sciences School of Medicine, Dar es Salaam, Tanzania
| | - Ellen Hertzmark
- Global Health, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
3
|
Ma W, Wang M, Wang K, Cao Y, Hertzmark E, Ogino S, Ng K, Willett WC, Giovannucci EL, Song M, Chan AT. Age at Initiation of Lower Gastrointestinal Endoscopy and Colorectal Cancer Risk Among US Women. JAMA Oncol 2022; 8:986-993. [PMID: 35511155 PMCID: PMC9073662 DOI: 10.1001/jamaoncol.2022.0883] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance In the past 4 years, the American Cancer Society and the US Preventive Services Task Force updated recommendations to initiate colorectal cancer (CRC) screening at 45 years of age to address the increasing incidence of CRC among adults younger than 50 years. However, empirical evidence evaluating the potential benefits of screening in younger populations is scant. Objective To examine the association between endoscopy initiation at different ages and risk of CRC among US women. Design, Setting, and Participants This prospective cohort study used data from the Nurses' Health Study II, which included US female health professionals followed up from 1991 through 2017. Data analysis was performed from August 2020 to June 2021. Exposure Age at initiation of sigmoidoscopy or colonoscopy for screening (routine screening or because of family history) or symptoms. Main Outcomes and Measures Incident CRC, confirmed by medical records, pathology reports, and the National Death Index. Cumulative incidence of CRC in each group was estimated with age as the time scale, and the absolute risk reduction associated with endoscopy initiation at different ages through 60 years was calculated. Cox proportional hazards regression was used to calculate hazard ratios (HRs) and 95% CIs, stratified by age and calendar year of questionnaire cycle and adjusted for CRC risk factors in the multivariable models. Results Among 111 801 women aged 26 to 46 years (median, 36 years) at enrollment, 519 incident CRC cases were documented over 26 years, encompassing 2 509 358 person-years of follow-up. In the multivariable analysis, compared with no endoscopy, undergoing endoscopy was associated with a significantly lower risk of incident CRC for age at initiation before 45 years (HR, 0.37; 95% CI, 0.26-0.53), 45 to 49 years (HR, 0.43; 95% CI, 0.29-0.62), 50 to 54 years (HR, 0.47; 95% CI, 0.35-0.62), and 55 years or older (HR, 0.46; 95% CI, 0.30-0.69). The absolute reduction in the estimated cumulative incidence of CRC through 60 years of age was 72 per 100 000 persons for initiation of endoscopy at 45 to 49 years of age vs 50 to 54 years of age. Compared with no endoscopy, initiation of endoscopy before 50 years of age was also associated with a reduced risk of CRC diagnosed before 55 years of age (<45 years: HR, 0.45 [95% CI, 0.29-0.70]; 45-49 years: HR, 0.43 [95% CI, 0.24-0.76]). Conclusions and Relevance In this cohort study, compared with no endoscopy, initiation of endoscopy before 50 years of age was associated with a reduced risk of CRC, including CRC diagnosed before 55 years of age. Screening before 50 years of age was associated with greater absolute reduction in CRC risk compared with initiation of CRC screening at 50 years of age or later.
Collapse
Affiliation(s)
- Wenjie Ma
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston.,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Molin Wang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Kai Wang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Yin Cao
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri.,Division of Gastroenterology, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri.,Alvin J. Siteman Cancer Center, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Shuji Ogino
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Program in Molecular Pathological Epidemiology, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Cancer Immunology and Cancer Epidemiology Programs, Dana-Farber Harvard Cancer Center, Boston, Massachusetts.,Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Kimmie Ng
- Gastrointestinal Cancer Center, Dana-Farber Harvard Cancer Center, Boston, Massachusetts
| | - Walter C Willett
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Edward L Giovannucci
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mingyang Song
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston.,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Andrew T Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston.,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston.,Gastrointestinal Cancer Center, Dana-Farber Harvard Cancer Center, Boston, Massachusetts.,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Cancer Epidemiology Program, Massachusetts General Cancer Center, Boston
| |
Collapse
|
4
|
Hu J, Hu Y, Hertzmark E, Yuan C, Liu G, Stampfer MJ, Rimm EB, Hu FB, Wang M, Sun Q. Weight Change, Lifestyle, and Mortality in Patients With Type 2 Diabetes. J Clin Endocrinol Metab 2022; 107:627-637. [PMID: 34741524 PMCID: PMC9006974 DOI: 10.1210/clinem/dgab800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT The association between weight change and mortality among participants with incident type 2 diabetes (T2D) was unclear. OBJECTIVE To examine above association and evaluate the impact of lifestyle on it. METHODS This prospective analysis included 11 262 incident T2D patients from Nurses' Health Study and Health Professionals Follow-up Study. We assessed weight change bracketing T2D diagnosis in relation to mortality. We also examined potential effect modification by a healthy lifestyle consisting of high-quality diet, regular physical activity, nonsmoking status, and moderate alcohol consumption. RESULTS On average, T2D patients lost 2.3 kg during a 2-year time window spanning the T2D diagnosis, and body weight increased afterwards following a trajectory similar to that of nondiabetics. Compared with patients with a stable weight, T2D patients who lost ≥10% body weight had a 21% (95% CI, 9%-35%) increased all-cause mortality. Lifestyle significantly modified these associations: the hazard ratios (95% CIs) of all-cause mortality comparing ≥10% weight loss with stable weight were 1.63 (1.26-2.09) among participants with a deteriorated lifestyle, 1.27 (1.11-1.46) for a stable lifestyle, and 1.02 (0.81-1.27) for an improved lifestyle (Pinteraction < 0.001). Major weight loss was associated with increased cause-specific mortality and similar effect modifications by lifestyle were also observed. CONCLUSION Significant weight loss upon T2D incidence was associated with increased mortality, although improved lifestyle quality abolished these associations. These results highlight the role of adopting a healthy lifestyle for newly diagnosed T2D patients, especially among those who might lose weight unintentionally, and improving long-term survival.
Collapse
Affiliation(s)
| | | | - Ellen Hertzmark
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Chen Yuan
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Gang Liu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Meir J Stampfer
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Eric B Rimm
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Frank B Hu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Molin Wang
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Qi Sun
- Correspondence: Qi Sun, MD, ScD, Department of Nutrition, Harvard T.H. Chan School of Public Health, 665 Huntington Ave., Boston, MA 02115, USA.
| |
Collapse
|
5
|
Lweno O, Hertzmark E, Darling AM, Noor R, Bakari L, Sudfeld C, Manji K, Fawzi W. The High Burden and Predictors of Anemia Among Infants Aged 6 to 12 Months in Dar es Salaam, Tanzania. Food Nutr Bull 2021; 43:68-83. [PMID: 34615387 DOI: 10.1177/03795721211007009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite several interventions, the prevalence of anemia and related complications remains high among infants in Tanzania. OBJECTIVE We sought to determine the predictors of iron-deficiency anemia (IDA) among infants of HIV-negative women in Dar es Salaam, Tanzania. METHODS Cross-sectional analysis of 2826 mother-infant pairs who participated in a trial of vitamins and perinatal outcomes in Dar es Salaam, Tanzania. Hemoglobin and mean corpuscular volume were used to determine the prevalence of anemia among infants at 6 and 12 months. Multiple logistic regression was used to determine the maternal and infant risk factors for anemia during infancy. RESULTS We found high prevalence of anemia (90%) and IDA (44.2%) among infants. Higher maternal education (odds ratio [OR] = 0.52), maternal normal hemoglobin at enrollment (OR = 0.68) and during the early postpartum period reduced the odds of IDA at 6 months (OR = 0.56). The odds of IDA at 6 months were higher among males (OR = 1.65), wealth score below median (OR = 1.35), low birth weight (LBW; OR = 1.75), and small for gestational age (SGA) infants below the third centile (OR = 1.95) or third to less than fifth centile (OR = 2.29). Higher maternal education lowered the odds of IDA at 12 months (OR = 0.25). Wealth score below median (OR = 1.44), preterm delivery (OR = 1.94), SGA (less than third centile; OR = 2.40), and LBW (OR = 2.89) increased the odds of IDA during infancy in the study population. Dietary diversity was low for infants and women in the study sample. CONCLUSION Interventions to reduce the risk of infant IDA should address women's education, improvement of wealth status, and optimal care for premature, SGA, and LBW infants.
Collapse
Affiliation(s)
- Omar Lweno
- Ifakara Health Institute, Bagamoyo Research and Training Center, Bagamoyo, Tanzania
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Anne Marie Darling
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ramadhani Noor
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Leguma Bakari
- Ifakara Health Institute, Bagamoyo Research and Training Center, Bagamoyo, Tanzania
| | - Christopher Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Karim Manji
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Wafaie Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
6
|
Wang D, Natchu UCM, Darling AM, Noor RA, Hertzmark E, Urassa W, Fawzi WW. Effects of prenatal and postnatal maternal multiple micronutrient supplementation on child growth and morbidity in Tanzania: a double-blind, randomized-controlled trial. Int J Epidemiol 2021; 51:1761-1774. [PMID: 34151973 PMCID: PMC9749718 DOI: 10.1093/ije/dyab117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 05/20/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Maternal micronutrient status is critical for child growth and nutrition. It is unclear whether maternal multiple micronutrient supplementation (MMS) during pregnancy and lactation improves child growth and prevents child morbidity. METHODS This study aimed to determine the effects of prenatal and postnatal maternal MMS on child growth and morbidity. In this double-blind, randomized-controlled trial, 8428 HIV-negative pregnant women were enrolled from Dar es Salaam, Tanzania, between 2001 and 2004. From pregnancy (12-27 weeks of gestation) through to 6 weeks postpartum, participants were randomized to receive daily oral MMS or placebo. All women received daily iron and folic acid during pregnancy. From 6 weeks postpartum through to 18 months postpartum, 3100 women were re-randomized to MMS or placebo. Child-growth measures, haemoglobin concentrations and infectious morbidities were assessed longitudinally from birth to ≤18 months. RESULTS Prenatal MMS led to modest increases in weight-for-age z-scores (mean difference: 0.050; 95% confidence interval: 0.002, 0.099; p = 0.04) and length-for-age z-score (mean difference: 0.062; 95% confidence interval: 0.013, 0.111; p = 0.01) during the first 6 months of life but not thereafter. Prenatal or postnatal MMS did not have benefits for other child outcomes. CONCLUSIONS Whereas maternal MMS is a proven strategy to prevent adverse birth outcomes, other approaches may also need to be considered to curb the high burdens of child morbidity and growth faltering.
Collapse
Affiliation(s)
- Dongqing Wang
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | | | - Anne Marie Darling
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Ramadhani A Noor
- United Nations Children's Fund Tanzania, Dar es Salaam, Tanzania
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Willy Urassa
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Wafaie W Fawzi
- Corresponding author. Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Building 1, Room 1102, Boston, MA 02115, USA. E-mail:
| |
Collapse
|
7
|
Wang D, Natchu UCM, Darling AM, Noor R, Hertzmark E, Urassa W, Fawzi W. Effects of Prenatal and Postnatal Maternal Multiple Micronutrient Supplementation on Child Growth and Morbidity in Tanzania: A Double-Blind, Randomized Controlled Trial. Curr Dev Nutr 2021. [DOI: 10.1093/cdn/nzab046_125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objectives
Maternal micronutrient status is critical for child growth and nutrition. It is unclear whether maternal multiple micronutrient supplementation (MMS) during pregnancy and lactation improves child growth and prevents child morbidity. The aim of this study was to determine the effects of prenatal and postnatal maternal MMS on child growth and morbidity in Tanzania.
Methods
In this double-blind, randomized controlled trial, 8,379 HIV-negative pregnant women were enrolled from Dar es Salaam, Tanzania, between 2001 and 2004. From pregnancy (12 to 27 weeks of gestation) through 6 weeks postpartum, participants were randomized to receive daily oral MMS or placebo. All women received daily iron and folic acid during pregnancy. From 6 weeks postpartum through 18 months postpartum, 3,100 women were re-randomized to MMS or placebo. Child growth measures, hemoglobin concentrations, and infectious morbidities were assessed longitudinally from birth to up to 18 months. Linear mixed-effects models were used to estimate the effects of prenatal and postnatal MMS on child growth z-scores and hemoglobin concentrations. Cox proportional hazards models were used to estimate the effects on undernutrition. Generalized estimating equations were used to estimate the effects on anemia and infectious morbidities.
Results
Prenatal MMS led to modest increases in weight-for-age z-score (mean difference: 0.050; 95% CI: 0.002, 0.099; p = 0.04) and length-for-age z-score (mean difference: 0.062; 95% CI: 0.013, 0.111; p = 0.01) during the first six months of life but not thereafter. Prenatal MMS did not have significant benefits for anemia, morbidity, or other child growth outcomes. Postnatal MMS did not have significant benefits for any child outcomes.
Conclusions
While maternal MMS is a proven strategy to prevent adverse birth outcomes, other approaches may also need to be considered to curb the high burdens of child morbidity and growth faltering.
Funding Sources
This work was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health.
Collapse
Affiliation(s)
| | | | | | | | | | - Willy Urassa
- Muhimbili University of Health and Allied Sciences
| | | |
Collapse
|
8
|
Madzorera I, Ghosh S, Wang M, Fawzi W, Isanaka S, Hertzmark E, Namirembe G, Bashaasha B, Agaba E, Turyashemererwa F, Webb P, Duggan C. Prenatal dietary diversity may influence underweight in infants in a Ugandan birth-cohort. Matern Child Nutr 2021; 17:e13127. [PMID: 33595899 PMCID: PMC8189249 DOI: 10.1111/mcn.13127] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 11/06/2020] [Accepted: 12/02/2020] [Indexed: 12/18/2022]
Abstract
Growth faltering in early childhood is prevalent in many low resource countries. Poor maternal dietary diversity during pregnancy has been linked with increased risk of fetal growth failure and adverse birth outcomes but may also influence subsequent infant growth. Our aim is to assess the role of prenatal maternal dietary diversity in infant growth in rural Uganda. Data from 3291 women and infant pairs enrolled in a birth cohort from 2014 to 2016 were analysed (NCT04233944). Maternal diets were assessed using dietary recall in the second or third trimesters of pregnancy. Maternal dietary diversity scores (DDS) were calculated using the FAO Minimum Dietary Diversity for Women (MDD‐W). Cox regression models were used to evaluate associations of the DDS with the incidence of underweight, stunting and wasting in infants from 3 to 12 months, adjusting for confounding factors. The median DDS for women was low, at 3.0 (interquartile range 3.0–4.0), relative to the threshold of consuming five or more food groups daily. Infants of women in highest quartile of DDS (diverse diets) were less likely to be underweight (adjusted hazard ratio: 0.70, 95% confidence interval: 0.61, 0.80) compared with infants of women in Quartile 1 (p for trend <0.001) in models controlling for maternal factors. There was no significant association between DDS and stunting or wasting. Our findings suggest a relationship between higher maternal dietary diversity and lower risk of underweight in infancy. These findings suggest that programmes to improve infant growth could additionally consider strengthening prenatal dietary diversity to improve child outcomes globally.
Collapse
Affiliation(s)
- Isabel Madzorera
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Shibani Ghosh
- Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, USA.,USAID Feed the Future Innovation Lab for Nutrition, Tufts University, Boston, Massachusetts, USA
| | - Molin Wang
- Departments of Epidemiology and Biostatistics, Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Wafaie Fawzi
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA.,Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Sheila Isanaka
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA.,Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Grace Namirembe
- Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, USA
| | - Bernard Bashaasha
- Department of Agribusiness and Natural Resource Economics, College of Agricultural and Environmental Sciences, Makerere University, Kampala, Uganda
| | - Edgar Agaba
- USAID Feed the Future Innovation Lab for Nutrition, Tufts University, Boston, Massachusetts, USA
| | - Florence Turyashemererwa
- Department of Agribusiness and Natural Resource Economics, College of Agricultural and Environmental Sciences, Makerere University, Kampala, Uganda
| | - Patrick Webb
- Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, USA.,USAID Feed the Future Innovation Lab for Nutrition, Tufts University, Boston, Massachusetts, USA
| | - Christopher Duggan
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA.,Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
9
|
Kalinjuma AV, Darling AM, Mugusi FM, Abioye AI, Okumu FO, Aboud S, Masanja H, Hamer DH, Hertzmark E, Fawzi WW. Factors associated with sub-microscopic placental malaria and its association with adverse pregnancy outcomes among HIV-negative women in Dar es Salaam, Tanzania: a cohort study. BMC Infect Dis 2020; 20:796. [PMID: 33109111 PMCID: PMC7590608 DOI: 10.1186/s12879-020-05521-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 10/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malaria infection during pregnancy has negative health consequences for both mothers and offspring. Sub-microscopic malaria infection during pregnancy is common in most African countries. We sought to identify factors associated with sub-microscopic placental malaria, and its association with adverse pregnancy outcomes among HIV-negative pregnant women in Dar es Salaam, Tanzania. METHODS We recruited a cohort of pregnant women during their first trimester and assessed for the occurrence of placental malaria and pregnancy outcomes. The follow-up was done monthly from recruitment until delivery. Histopathology placental malaria positive results were defined as the presence of malaria pigment or parasitized erythrocytes on the slide (histology-positive (HP)), and the sub-microscopic placental infection was defined as positive Plasmodium falciparum DNA by polymerase chain reaction (DNA PCR) amplification in a negative histopathology test. Adverse pregnancy outcomes investigated included low birth weight (birth weight below 2.5 kg), prematurity (live birth below 37 weeks), and small-for-gestational-age (SGA) (live born with a birth weight below 10th percentile for gestational age and sex). Weighted baseline category logit, log-binomial, and log-Poisson models were used to assess factors associated with placental malaria, and its association with adverse pregnancy outcomes. RESULTS Among 1115 women who had histopathology and DNA PCR performed, 93 (8%) had HP placental infection, and 136 (12%) had the sub-microscopic placental infection. The risk of sub-microscopic placental malaria was greater in women who did not use mosquito prevention methods such as bed nets, fumigation, or mosquito coils (odds ratio (OR) = 1.75; 95% confidence interval (CI): 1.05-2.92; P = 0.03) and in women who were anemic (OR = 1.59; 95% CI: 1.20-2.11; P = 0.001). Women who were underweight had reduced odds of sub-microscopic placental malaria infection (OR = 0.33; 95% CI: 0.17-0.62; P = 0.001). Women who were overweight/obese had 1.48 times higher the odds of HP placental malaria compared to normal weight (OR = 1.48; 95% CI: 1.03-2.11; P = 0.03). HP placental malaria infection was associated with an increased risk of SGA births (RR = 1.30, 95% CI: 0.98-1.72, P = 0.07). In contrast, the sub-microscopic infection was associated with a reduced risk of SGA births (RR = 0.61, 95% CI: 0.43-0.88, P = 0.01). Placental malaria was not associated with low birth weight or prematurity. CONCLUSION Malaria prevention methods and maternal nutrition status during early pregnancy were important predictors of sub-microscopic placental malaria. More research is needed to understand sub-microscopic placental malaria and the possible mechanisms mediating the association between placental malaria and SGA.
Collapse
Affiliation(s)
- Aneth Vedastus Kalinjuma
- Department of Intervention and Clinical Trials, Ifakara Health Institute, P.O. Box 53, Ifakara, Morogoro, Tanzania.
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Anne Marie Darling
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ferdinand M Mugusi
- Departments of Internal Medicine; and Microbiology and Immunology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Ajibola Ibraheem Abioye
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Fredros O Okumu
- Department of Intervention and Clinical Trials, Ifakara Health Institute, P.O. Box 53, Ifakara, Morogoro, Tanzania
| | - Said Aboud
- Departments of Internal Medicine; and Microbiology and Immunology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Honorati Masanja
- Department of Intervention and Clinical Trials, Ifakara Health Institute, P.O. Box 53, Ifakara, Morogoro, Tanzania
| | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
10
|
Madzorera I, Isanaka S, Wang M, Msamanga GI, Urassa W, Hertzmark E, Duggan C, Fawzi WW. Maternal dietary diversity and dietary quality scores in relation to adverse birth outcomes in Tanzanian women. Am J Clin Nutr 2020; 112:695-706. [PMID: 32651998 PMCID: PMC7458779 DOI: 10.1093/ajcn/nqaa172] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 06/11/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Preterm birth (PTB), small for gestational age (SGA), and low birth weight (LBW) are risk factors for morbidity and mortality among infants. High-quality maternal diets during pregnancy may protect against these adverse birth outcomes. OBJECTIVES The aim of this study was to prospectively examine the association of maternal dietary diversity and quality during pregnancy with birth outcomes among women in Dar es Salaam, Tanzania. METHODS We analyzed data from 7553 HIV-negative pregnant women enrolled in a multivitamin trial at 12-27 weeks of gestation. Dietary intake was assessed using 24-h dietary recalls. Dietary diversity scores (DDS; range: 0-10) were computed as the number of food groups consumed by women, using FAO's Minimum Dietary Diversity for Women index. The Prime Diet Quality Score (PDQS; range: 0-42) assessed maternal diet quality based on consumption of 21 healthy and unhealthy food groups. Log binomial regression methods were used to assess associations of DDS and PDQS with PTB, SGA, LBW, and fetal loss. RESULTS In the previous 24 h, 99.9% of all women had consumed cereal and staples, 57.9% meats, 4.7% eggs, and 0.5% nuts and seeds. Median DDS was 3.0 (IQR: 2.5-3.5). For the PDQS, all women consumed ≥4 servings/wk of green leafy vegetables and refined grains. Higher DDS was associated with lower risk of SGA (RR highest compared with lowest quintile: 0.74; 95% CI: 0.62, 0.89). Higher PDQS was associated with lower risk of PTB (RR highest compared with lowest quintile: 0.55; 95% CI: 0.46, 0.66), LBW (RR: 0.53; 95% CI: 0.40, 0.70), and fetal loss (RR: 0.53; 95% CI, 0.34, 0.82). CONCLUSIONS PDQS was inversely associated with PTB, LBW, and fetal loss, and DDS was inversely associated with SGA. These findings suggest that in addition to dietary diversity, diet quality should be considered as important in understanding dietary risk factors for poor birth outcomes.This trial was registered at clinicaltrials.gov as NCT00197548.
Collapse
Affiliation(s)
- Isabel Madzorera
- Department of Nutrition, 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
| | - Sheila Isanaka
- Department of Nutrition, 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
| | - Molin Wang
- Departments of Epidemiology and Biostatistics, Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Gernard I Msamanga
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Willy Urassa
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Christopher Duggan
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA.,Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Wafaie W Fawzi
- Department of Nutrition, 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
| |
Collapse
|
11
|
Mlacha YP, Wang D, Chaki PP, Gavana T, Zhou Z, Michael MG, Khatib R, Chila G, Msuya HM, Chaki E, Makungu C, Lin K, Tambo E, Rumisha SF, Mkude S, Mahende MK, Chacky F, Vounatsou P, Tanner M, Masanja H, Aregawi M, Hertzmark E, Xiao N, Abdulla S, Zhou XN. Effectiveness of the innovative 1,7-malaria reactive community-based testing and response (1, 7-mRCTR) approach on malaria burden reduction in Southeastern Tanzania. Malar J 2020; 19:292. [PMID: 32799857 PMCID: PMC7429894 DOI: 10.1186/s12936-020-03363-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 08/05/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In 2015, a China-UK-Tanzania tripartite pilot project was implemented in southeastern Tanzania to explore a new model for reducing malaria burden and possibly scaling-out the approach into other malaria-endemic countries. The 1,7-malaria Reactive Community-based Testing and Response (1,7-mRCTR) which is a locally-tailored approach for reporting febrile malaria cases in endemic villages was developed to stop transmission and Plasmodium life-cycle. The (1,7-mRCTR) utilizes existing health facility data and locally trained community health workers to conduct community-level testing and treatment. METHODS The pilot project was implemented from September 2015 to June 2018 in Rufiji District, southern Tanzania. The study took place in four wards, two with low incidence and two with a higher incidence. One ward of each type was selected for each of the control and intervention arms. The control wards implemented the existing Ministry of Health programmes. The 1,7-mRCTR activities implemented in the intervention arm included community testing and treatment of malaria infection. Malaria case-to-suspect ratios at health facilities (HF) were aggregated by villages, weekly to identify the village with the highest ratio. Community-based mobile test stations (cMTS) were used for conducting mass testing and treatment. Baseline (pre) and endline (post) household surveys were done in the control and intervention wards to assess the change in malaria prevalence measured by the interaction term of 'time' (post vs pre) and arm in a logistic model. A secondary analysis also studied the malaria incidence reported at the HFs during the intervention. RESULTS Overall the 85 rounds of 1,7-mRCTR conducted in the intervention wards significantly reduced the odds of malaria infection by 66% (adjusted OR 0.34, 95% CI 0.26,0.44, p < 0001) beyond the effect of the standard programmes. Malaria prevalence in the intervention wards declined by 81% (from 26% (95% CI 23.7, 7.8), at baseline to 4.9% (95% CI 4.0, 5.9) at endline). In villages receiving the 1,7-mRCTR, the short-term case ratio decreased by over 15.7% (95% CI - 33, 6) compared to baseline. CONCLUSION The 1,7-mRCTR approach significantly reduced the malaria burden in the areas of high transmission in rural southern Tanzania. This locally tailored approach could accelerate malaria control and elimination efforts. The results provide the impetus for further evaluation of the effectiveness and scaling up of this approach in other high malaria burden countries in Africa, including Tanzania.
Collapse
Affiliation(s)
- Yeromin P Mlacha
- Ifakara Health Institute, P. O. Box 78378, Kiko Avenue, Mikocheni, Dar es Salaam, Tanzania.,Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Duoquan Wang
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, 207 Rui Jin Er Road, Shanghai, 200025, People's Republic of China
| | - Prosper P Chaki
- Ifakara Health Institute, P. O. Box 78378, Kiko Avenue, Mikocheni, Dar es Salaam, Tanzania.
| | - Tegemeo Gavana
- Ifakara Health Institute, P. O. Box 78378, Kiko Avenue, Mikocheni, Dar es Salaam, Tanzania
| | - Zhengbin Zhou
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, 207 Rui Jin Er Road, Shanghai, 200025, People's Republic of China
| | - Mihayo G Michael
- Ifakara Health Institute, P. O. Box 78378, Kiko Avenue, Mikocheni, Dar es Salaam, Tanzania
| | - Rashid Khatib
- Ifakara Health Institute, P. O. Box 78378, Kiko Avenue, Mikocheni, Dar es Salaam, Tanzania
| | - Godlove Chila
- Ifakara Health Institute, P. O. Box 78378, Kiko Avenue, Mikocheni, Dar es Salaam, Tanzania
| | - Hajirani M Msuya
- Ifakara Health Institute, P. O. Box 78378, Kiko Avenue, Mikocheni, Dar es Salaam, Tanzania
| | - Exavery Chaki
- Ifakara Health Institute, P. O. Box 78378, Kiko Avenue, Mikocheni, Dar es Salaam, Tanzania
| | - Christina Makungu
- Ifakara Health Institute, P. O. Box 78378, Kiko Avenue, Mikocheni, Dar es Salaam, Tanzania
| | - Kangming Lin
- Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Ernest Tambo
- Higher Institute of Health Sciences, Université des Montagnes, Bangangté, BP 208, Cameroon
| | - Susan F Rumisha
- National Institute for Medical Research (NIMR), P.O. Box 9653, Dar es Salaam, Tanzania
| | - Sigsbert Mkude
- Ifakara Health Institute, P. O. Box 78378, Kiko Avenue, Mikocheni, Dar es Salaam, Tanzania
| | - Muhidin K Mahende
- Ifakara Health Institute, P. O. Box 78378, Kiko Avenue, Mikocheni, Dar es Salaam, Tanzania
| | - Frank Chacky
- National Malaria Control, Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - Penelope Vounatsou
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Marcel Tanner
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Honorati Masanja
- Ifakara Health Institute, P. O. Box 78378, Kiko Avenue, Mikocheni, Dar es Salaam, Tanzania
| | - Maru Aregawi
- The Global Malaria Programme (GMP), World Health Organization, Geneva, Switzerland
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ning Xiao
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, 207 Rui Jin Er Road, Shanghai, 200025, People's Republic of China
| | - Salim Abdulla
- Ifakara Health Institute, P. O. Box 78378, Kiko Avenue, Mikocheni, Dar es Salaam, Tanzania
| | - Xiao-Nong Zhou
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, 207 Rui Jin Er Road, Shanghai, 200025, People's Republic of China
| |
Collapse
|
12
|
Noor RA, Abioye AI, Hertzmark E, Darling AM, Aboud S, Mugusi FM, Sudfeld CR, Spiegelman D, Fawzi WW. Impaired Hematological Status Increases the Risk of Mortality among HIV-Infected Adults Initiating Antiretroviral Therapy in Tanzania. J Nutr 2020; 150:2375-2382. [PMID: 32621487 PMCID: PMC7540061 DOI: 10.1093/jn/nxaa172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 02/06/2020] [Accepted: 05/26/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hematological status may predict HIV disease progression and mortality among adults initiating highly active antiretroviral therapy (HAART). OBJECTIVES We aimed to examine the relation of anemia and iron status at HAART initiation with survival and morbidity outcomes. METHODS We conducted a case-cohort study of 570 HIV-infected adults initiating HAART who were enrolled in a trial of multivitamins in Tanzania. Hemoglobin, serum ferritin, and hepcidin concentrations were assessed at HAART initiation and participants were followed up monthly. We adjusted serum ferritin for inflammation using a regression correction method to characterize hematological status. Cox proportional hazards models were used to estimate HRs for mortality and incident clinical outcomes. RESULTS We found an 83% prevalence of anemia, 15% prevalence of iron deficiency anemia, and 66% prevalence of anemia of chronic diseases (ACD). The prevalence of elevated iron was 33% and 19% had iron deficiency (ID). After multivariate adjustment, severe anemia (HR: 2.57; 95% CI: 1.49, 4.45) and ACD (HR: 4.71; 95% CI: 2.91, 7.62) were associated with increased risk of mortality as compared with nonanemic participants. In addition, both ID (HR: 2.65; 95% CI: 1.08, 7.78) and elevated iron (HR: 2.83; 95% CI: 2.10, 3.82) were associated with increased risk of mortality as compared with normal iron concentrations. Severe anemia and elevated iron concentrations were associated with incident wasting and >10% weight loss (P values <0.05). CONCLUSIONS Anemia and both ID and elevated iron were associated with increased mortality among HIV-infected adults initiating HAART. Safety and efficacy studies including anemia etiology, timing of HAART initiation, and dose of iron supplementation among HIV patients appear warranted.This trial was registered at clinicaltrials.gov as NCT00383669.
Collapse
Affiliation(s)
| | - Ajibola I Abioye
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Anne M Darling
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Said Aboud
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ferdinand M Mugusi
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher R Sudfeld
- Department of Nutrition, 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
| | - Donna Spiegelman
- Department of Nutrition, 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,Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA,Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA,Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Wafaie W Fawzi
- Department of Nutrition, 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,Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
13
|
Madzorera I, Isanaka S, Wang M, Msamanga G, Urassa W, Hertzmark E, Duggan C, Fawzi W. Maternal Dietary Diversity and Dietary Quality Scores in Relation to Adverse Birth Outcomes in Tanzanian Women. Curr Dev Nutr 2020. [DOI: 10.1093/cdn/nzaa054_103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objectives
Preterm birth, small for gestational age (SGA) and low birth weight (LBW) are risk factors for morbidity and mortality among infants. High-quality maternal diets during pregnancy may protect against these adverse birth outcomes. The objective of this research is to prospectively examine the association of maternal dietary diversity and quality during pregnancy with birth outcomes among women in Dar es Salaam, Tanzania.
Methods
We analyzed data from 7553 HIV-negative pregnant women enrolled in a multivitamin trial at 12–27 weeks gestation. Dietary intake was assessed using 24-hour dietary recalls. Log binomial regression methods were used to assess associations of Minimum Dietary Diversity for Women (MDD-W) and Prime Diet Quality Score (PDQS) with preterm, SGA, LBW, fetal loss, very preterm, severe SGA and very low birth weight (VLBW).
Results
In the previous 24 hours, 99.9% of women reported consuming grains, roots and tubers, 57.9% meats, 4.7% eggs and 0.5% nuts and seeds. Median MDD-W score was 3.0 ± 1.0. For the PDQS, women consumed at least 4 servings/week of green leafy vegetables (100%) and other vegetables (64.7%) and consumption of refined grains was high (99.6%). Higher MDD-W scores were associated with lower risk of SGA (RR highest vs. lowest quintile 0.74, 95% CI: 0.62, 0.89). Higher PDQS scores were associated with lower risk of preterm birth (RR: 0.55, 95% CI: 0.46, 0.67); LBW (RR: 0.53, 95% CI: 0.40, 0.71); fetal loss (RR: 0.53, 95% CI: 0.34,0.82), very preterm (RR: 0.33, 95% CI: 0.17, 0.64) and VLBW (RR: 0.49, 95% CI: 0.26, 0.92) comparing women in highest vs. lowest quintiles.
Conclusions
PDQS was inversely associated with preterm, very preterm, LBW, VLBW and fetal loss, and MDD-W was inversely associated with SGA. These findings suggest that in addition to diet diversity, diet quality should be considered as important in understanding dietary risk factors for poor birth outcomes.
Funding Sources
This work has been supported by the National Institutes of Child Health and Human Development. Co-authors were supported by a grant from the National Institute of Child Health and Human Development and the National Institutes of Health.
Collapse
|
14
|
Abioye AI, Aboud S, Premji Z, Etheredge AJ, Gunaratna NS, Sudfeld CR, Noor RA, Hertzmark E, Spiegelman D, Duggan C, Fawzi W. Hemoglobin and hepcidin have good validity and utility for diagnosing iron deficiency anemia among pregnant women. Eur J Clin Nutr 2020; 74:708-719. [PMID: 31624364 PMCID: PMC7162716 DOI: 10.1038/s41430-019-0512-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 09/24/2019] [Accepted: 09/27/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND/OBJECTIVES Screening and diagnosis of iron deficiency anemia (IDA) is cumbersome as it may require testing for hemoglobin, ferritin, and an inflammatory biomarker. The aim of this study was to compare the diagnostic capacity of hematologic biomarkers to detect IDA among pregnant women in Tanzania. SUBJECTS/METHODS We pooled data from an iron supplementation trial of 1500 iron-replete pregnant woman and a prospective cohort of 600 iron-deficient pregnant women. Receiver operating characteristic curves (ROC) for hematologic biomarkers were used to assess the sensitivity, specificity, and area under the curve (AUC) for iron deficiency (ID) and iron deficiency anemia (IDA), crude, or corrected for inflammation. Regression models assessed the relationship of baseline biomarker categories (gestational age <27 weeks) and IDA at delivery. RESULTS Hemoglobin had the largest AUC for crude ID (0.96), while hepcidin had the largest AUC for corrected ID (0.80). The optimal hepcidin cutoff for the diagnosis of corrected IDA based on maximal sensitivity and specificity was ≤1.6 µg/L. An hepcidin cutoff of <4.3 µg/L had a sensitivity of 95% for regression-corrected ID. Among iron-replete women who did not receive iron, the association of baseline hemoglobin >110 g/L with IDA at delivery (RR = 0.73; 95% CI: 0.47, 1.13) was attenuated. Baseline hepcidin >1.6 µg/L was associated with reduced risk of anemia at delivery by 49% (95% CI: 27%, 45%). CONCLUSIONS Ascertaining hemoglobin and hepcidin levels may improve the targeting of iron supplementation programs in resource-limited countries, though hepcidin's high costs may limit its use.
Collapse
Affiliation(s)
- Ajibola I Abioye
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Said Aboud
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Zulfiqarali Premji
- Department of Parasitology/Medical Entomology, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Analee J Etheredge
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ramadhani A Noor
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Donna Spiegelman
- Center on Methods for Implementation and Prevention Science, Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Christopher Duggan
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Wafaie Fawzi
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
15
|
Lweno ON, Sudfeld CR, Hertzmark E, Manji KP, Aboud S, Noor RA, Masanja H, Salim N, Shahab-Ferdows S, Allen LH, Fawzi WW. Vitamin B12 is Low in Milk of Early Postpartum Women in Urban Tanzania, and was not Significantly Increased by High dose Supplementation. Nutrients 2020; 12:E963. [PMID: 32244279 PMCID: PMC7230874 DOI: 10.3390/nu12040963] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/23/2020] [Accepted: 03/28/2020] [Indexed: 01/21/2023] Open
Abstract
The effect of maternal multivitamin supplementation on breast milk vitamin B12 concentrations has not been examined in Tanzania, where the prevalence of maternal plasma B12 insufficiency is 25.6%. Multivitamins (containing 50 µg vitamin B12) or placebo were provided during pregnancy and in the postpartum period. Breast milk samples were collected at or around six weeks postpartum from 491 participants in a trial of multivitamins (NCT00197548). Linear and logistic regression models were used to examine the effect of supplements on vitamin B12 concentration in milk and its associations with other variables including potential confounders. Median vitamin B12 concentration in breast milk was 206 pmol/L and 70% of women had levels indicating inadequacy (<310 pmol/L). Multivitamin supplements did not significantly reduce the odds of inadequate vitamin B12 in breast milk, suggesting suboptimal absorption. A single unit increase in maternal hemoglobin at six weeks was associated with 18% lower odds of inadequate vitamin B12 in breast milk. Participants with higher BMI at baseline had double the odds of having inadequate vitamin B12 than the reference group (<22 kg/m2). Trials to determine the optimal dose, route, and duration of supplementation to improve maternal B12 status in Sub-Saharan Africa are of utmost importance.
Collapse
Affiliation(s)
- Omar N. Lweno
- Ifakara Health Institute, Bagamoyo Research and Training Center, P.O. Box 74 Bagamoyo, Tanzania;
| | - Christopher R. Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA; (C.R.S.); (E.H.); (R.A.N.); (W.W.F.)
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA; (C.R.S.); (E.H.); (R.A.N.); (W.W.F.)
| | - Karim P. Manji
- Muhimbili University of Health and Allied Sciences, P.O. Box 65001 Dar-es-Salaam, Tanzania; (K.P.M.); (S.A.); (N.S.)
| | - Said Aboud
- Muhimbili University of Health and Allied Sciences, P.O. Box 65001 Dar-es-Salaam, Tanzania; (K.P.M.); (S.A.); (N.S.)
| | - Ramadhani A. Noor
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA; (C.R.S.); (E.H.); (R.A.N.); (W.W.F.)
| | - Honorati Masanja
- Ifakara Health Institute, Bagamoyo Research and Training Center, P.O. Box 74 Bagamoyo, Tanzania;
| | - Nahya Salim
- Muhimbili University of Health and Allied Sciences, P.O. Box 65001 Dar-es-Salaam, Tanzania; (K.P.M.); (S.A.); (N.S.)
| | - Setareh Shahab-Ferdows
- USDA ARS Western Human Nutrition Research Centre, University of California Davis, CA 95616, USA;
| | - Lindsay H. Allen
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, CA 95616, USA;
| | - Wafaie W. Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA; (C.R.S.); (E.H.); (R.A.N.); (W.W.F.)
| |
Collapse
|
16
|
Lweno ON, Sudfeld CR, Hertzmark E, Manji KP, Darling AM, Fawzi WW. Breast milk vitamin B12 concentration and incidence of diarrhea and respiratory infections among infants in urban Tanzania: a prospective cohort study. BMC Res Notes 2020; 13:165. [PMID: 32188495 PMCID: PMC7081683 DOI: 10.1186/s13104-020-05003-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 03/10/2020] [Indexed: 11/16/2022] Open
Abstract
Objective A recent trial of vitamin B12 supplementation among Indian children 6–30 months found no effect on the incidence of diarrhea and respiratory infections. These results differ with studies in adults that showed improvement of the immune response following treatment with vitamin B12. We sought to determine how the adequacy of vitamin B12 concentrations in breast milk could act as immune modulator and protect against the incidence of diarrhea and respiratory infections of children up to 18 months in urban Tanzania. Results A prospective cohort study was undertaken to determine the association of breast milk vitamin B12 concentration with the incidence of acute respiratory infection and diarrhea among infants in urban Tanzania. A random sample of 491 women enrolled in a trial of multivitamins provided milk for B12 analysis at or around 6 weeks postpartum. Of 491 women, 345 had breast milk vitamin B12 inadequacy (< 310 pmol/L). Using generalized estimating equations, we found no overall association of milk vitamin B12 concentration with incident diarrhea and acute respiratory infections in infants. Studies measuring longitudinal changes of breast milk B12 concentration over time are needed to clarify the role of breast milk vitamin B12 in childhood infections.
Collapse
Affiliation(s)
- Omar N Lweno
- Ifakara Health Institute, Bagamoyo Research and Training Center, Bagamoyo, Tanzania.
| | - Christopher R Sudfeld
- Departments of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Departments of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ellen Hertzmark
- Departments of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Departments of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Karim P Manji
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Anne Marie Darling
- Departments of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Wafaie W Fawzi
- Departments of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Departments of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
17
|
Noor RA, Abioye AI, Darling AM, Hertzmark E, Aboud S, Premji Z, Mugusi FM, Duggan C, Sudfeld CR, Spiegelman D, Fawzi W. Prenatal Zinc and Vitamin A Reduce the Benefit of Iron on Maternal Hematologic and Micronutrient Status at Delivery in Tanzania. J Nutr 2020; 150:240-248. [PMID: 31618430 PMCID: PMC7373818 DOI: 10.1093/jn/nxz242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/28/2019] [Accepted: 09/11/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Zinc and vitamin A supplementation have both been shown to affect iron status, hemoglobin (Hb) concentration, and anemia in animal and human studies. However, evidence on their combined use in pregnancy, in the context of iron-folic acid (IFA) supplementation, remains limited. OBJECTIVE This study determined the effects of prenatal zinc, vitamin A, and iron supplementation on maternal hematologic and micronutrient status at delivery in Tanzania. METHODS We analyzed 2 large randomized controlled trials, using generalized estimating equations, and examined the effect of daily zinc (25 mg) and vitamin A (2500 IU) supplementation starting in the first trimester of pregnancy compared with placebo (n = 2500), and separately evaluated the safety and efficacy of daily iron (60 mg) supplementation among iron-replete pregnant women (n = 1500). Blood samples from baseline and delivery were tested for Hb, serum ferritin, soluble transferrin receptor, plasma zinc, and zinc protoporphyrin. RESULTS Zinc and vitamin A supplementation were associated with lower Hb concentrations at delivery of -0.26 g/dL (95% CI: -0.50, -0.02 g/dL) and -0.25 g/dL (95% CI: -0.49, -0.01 g/dL), respectively. Vitamin A increased mean ferritin concentrations at delivery (14.3 μg/L, 95% CI: 1.84, 29.11 μg/L), but was associated with increased risk of severe anemia (RR: 1.41; 95% CI: 1.06, 1.88). Among women who were iron replete at baseline, iron supplementation reduced the risk of iron depletion at delivery by 47% (RR: 0.53; 95% CI: 0.43, 0.65). There was no effect of zinc or iron supplements on plasma zinc concentrations. CONCLUSIONS Our findings support existing WHO guidelines on prenatal iron, vitamin A, and zinc supplementation among pregnant women. In this setting, scaling uptake of prenatal iron supplements is warranted, but prenatal zinc and vitamin A supplementation did not benefit maternal hematologic status at delivery. In settings where vitamin A deficiency is endemic, the efficacy and safety of the WHO recommended prenatal vitamin A supplementation require further evaluation.
Collapse
Affiliation(s)
- Ramadhani A Noor
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Ajibola I Abioye
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Anne Marie Darling
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Said Aboud
- Department of Microbiology and Immunology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Zulfiqarali Premji
- Department of Parasitology/Medical Entomology, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ferdinand M Mugusi
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher Duggan
- Department of Nutrition, 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
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Donna Spiegelman
- Department of Nutrition, 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
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Wafaie Fawzi
- Department of Nutrition, 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
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
18
|
Haider BA, Spiegelman D, Hertzmark E, Sando D, Duggan C, Makubi A, Sudfeld C, Aris E, Chalamilla GE, Fawzi WW. Anemia, Iron Deficiency, and Iron Supplementation in Relation to Mortality among HIV-Infected Patients Receiving Highly Active Antiretroviral Therapy in Tanzania. Am J Trop Med Hyg 2020; 100:1512-1520. [PMID: 31017077 DOI: 10.4269/ajtmh.18-0096] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Anemia in HIV-infected patients improves with highly active antiretroviral therapy (HAART); however, it may still be associated with mortality among patients receiving treatment. We examined the associations of anemia severity and iron deficiency anemia (IDA) at HAART initiation and during monthly prospective follow-up with mortality among 40,657 adult HIV-infected patients receiving HAART in Dar es Salaam, Tanzania. Proportional hazards models were used to examine the associations of anemia severity and IDA at HAART initiation and during follow-up with mortality. A total of 6,261 deaths were reported. Anemia severity at HAART initiation and during follow-up was associated with an increasing risk of mortality (trend tests P < 0.001). There was significantly higher mortality risk associated with IDA at HAART initiation and during follow-up versus no anemia or iron deficiency (both P < 0.001). These associations differed significantly by gender, body mass index, and iron supplement use (all interaction test P < 0.001). The magnitude of association was stronger among men. Mortality risk with severe anemia was 13 times greater versus no anemia among obese patients, whereas it was only two times greater among underweight patients. Higher mortality risk was observed among iron supplement users, irrespective of anemia severity. Anemia and IDA were significantly associated with a higher mortality risk in patients receiving HAART. Iron supplementation indicated an increased mortality risk, and its role in HIV infections should be examined in future studies. Given the low cost of assessing anemia, it can be used frequently to identify high-risk patients in resource-limited settings.
Collapse
Affiliation(s)
- Batool A Haider
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts.,Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts
| | - Donna Spiegelman
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts.,Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts.,Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts.,Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts
| | - Ellen Hertzmark
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
| | - David Sando
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Christopher Duggan
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts.,Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts
| | - Abel Makubi
- School of Medicine, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania.,Management and Development for Health, Dar es Salaam, Tanzania
| | - Christopher Sudfeld
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts
| | - Eric Aris
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Guerino E Chalamilla
- Management and Development for Health, Dar es Salaam, Tanzania.,Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts
| | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts.,Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts.,Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
| |
Collapse
|
19
|
Li Y, Schoufour J, Wang DD, Dhana K, Pan A, Liu X, Song M, Liu G, Shin HJ, Sun Q, Al-Shaar L, Wang M, Rimm EB, Hertzmark E, Stampfer MJ, Willett WC, Franco OH, Hu FB. Healthy lifestyle and life expectancy free of cancer, cardiovascular disease, and type 2 diabetes: prospective cohort study. BMJ 2020; 368:l6669. [PMID: 31915124 PMCID: PMC7190036 DOI: 10.1136/bmj.l6669] [Citation(s) in RCA: 228] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To examine how a healthy lifestyle is related to life expectancy that is free from major chronic diseases. DESIGN Prospective cohort study. SETTING AND PARTICIPANTS The Nurses' Health Study (1980-2014; n=73 196) and the Health Professionals Follow-Up Study (1986-2014; n=38 366). MAIN EXPOSURES Five low risk lifestyle factors: never smoking, body mass index 18.5-24.9, moderate to vigorous physical activity (≥30 minutes/day), moderate alcohol intake (women: 5-15 g/day; men 5-30 g/day), and a higher diet quality score (upper 40%). MAIN OUTCOME Life expectancy free of diabetes, cardiovascular diseases, and cancer. RESULTS The life expectancy free of diabetes, cardiovascular diseases, and cancer at age 50 was 23.7 years (95% confidence interval 22.6 to 24.7) for women who adopted no low risk lifestyle factors, in contrast to 34.4 years (33.1 to 35.5) for women who adopted four or five low risk factors. At age 50, the life expectancy free of any of these chronic diseases was 23.5 (22.3 to 24.7) years among men who adopted no low risk lifestyle factors and 31.1 (29.5 to 32.5) years in men who adopted four or five low risk lifestyle factors. For current male smokers who smoked heavily (≥15 cigarettes/day) or obese men and women (body mass index ≥30), their disease-free life expectancies accounted for the lowest proportion (≤75%) of total life expectancy at age 50. CONCLUSION Adherence to a healthy lifestyle at mid-life is associated with a longer life expectancy free of major chronic diseases.
Collapse
Affiliation(s)
- Yanping Li
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Josje Schoufour
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, Netherlands
- Faculty of Sports and Nutrition, ACHIEVE - Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
| | - Dong D Wang
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Klodian Dhana
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - An Pan
- Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoran Liu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mingyang Song
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Gang Liu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, Ministry of Education Key Lab of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hyun Joon Shin
- Division of General Internal Medicine, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Qi Sun
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Laila Al-Shaar
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Molin Wang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Eric B Rimm
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Meir J Stampfer
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Walter C Willett
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Oscar H Franco
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, Netherlands
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Frank B Hu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
20
|
Chaudhury S, Hertzmark E, Muya A, Sando D, Ulenga N, Machumi L, Spiegelman D, Fawzi WW. Equity of child and adolescent treatment, continuity of care and mortality, according to age and gender among enrollees in a large HIV programme in Tanzania. J Int AIDS Soc 2019; 21 Suppl 1. [PMID: 29485735 PMCID: PMC5978660 DOI: 10.1002/jia2.25070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 01/18/2018] [Indexed: 11/30/2022] Open
Abstract
Introduction Global scale up of anti‐retroviral therapy (ART) has led to expansion of HIV treatment and prevention across sub‐Saharan Africa. However, age and gender‐specific disparities persist leading to failures in fulfillment of Sustainability Development Goals, including SDG3 (achieving healthy lives and wellbeing for all, at all ages) and SDG5 (gender equality). We assessed ART initiation and adherence, loss to follow‐up, all‐cause death and early death, according to SDG3 and SDG5 indicators among a cohort of HIV‐infected children and adolescents enrolled in care in Dar‐es‐Salaam, Tanzania Methods SDG3 indicators included young (<5 years) and older paediatric children (5 to <10 years), early adolescent (10 to <15 years) and late adolescent (15 to <20 years) age group divisions and the SDG5 indicator was gender. Associations of age group and gender with ART initiation, loss to follow‐up and all‐cause death, were analysed using Cox proportional hazards regression and with adherence, using generalized estimating equations (GEE) with the Poisson distribution. Associations of age group and gender with early death were analysed, using log‐Poisson regression with empirical variance. Results A total of 18,315 enrollees with at least one clinic visit were included in this cohort study. Of these 7238 (40%) were young paediatric , 4169 (23%) older paediatric, 2922 (16%) early adolescent and 3986 (22%) late adolescent patients at enrolment. Just over half of paediatric and early adolescents and around four fifths of the late adolescents were female. Young paediatric patients were at greater risk of early death, being almost twice as likely to die within 90 days. Males were at greater risk of early death once initiated on ART (HR 1.35, 95% CI 1.09, 1.66)), while females in late adolescence were at greatest risk of late death (HR 2.44 [1.60, 3.74] <0.01). Late adolescents demonstrated greater non‐engagement in care (RR 1.21 (95% CI 1.16, 1.26)). Among both males and females, early paediatric and late adolescent groups experienced significantly greater loss to follow‐up. Conclusion These findings highlight equity concerns critical to the fulfillment of SDG3 and SDG5 within services for children and adolescents living with HIV in sub‐Saharan Africa. Young paediatric and late adolescent age groups were at increased risk of late diagnosis, early death, delayed treatment initiation and loss of continuity of care. Males were more likely to die earlier. Special attention to SDG3 and SDG5 disparities for children and adolescents living with HIV will be critical for fulfillment of the 2030 SDG agenda.
Collapse
Affiliation(s)
- Sumona Chaudhury
- 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
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Aisa Muya
- Management and Development for Health, Dar es Salaam, Tanzania
| | - David Sando
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA.,Management and Development for Health, Dar es Salaam, Tanzania
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Lameck Machumi
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Donna Spiegelman
- 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
| | - Wafaie W Fawzi
- 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
| |
Collapse
|
21
|
Kintu A, Liu E, Hertzmark E, Spiegelman D, Zack RM, Muya A, Sando D, Bärnighausen T, Fawzi W. Incidence and Risk Factors for Overweight and Obesity after Initiation of Antiretroviral Therapy in Dar es Salaam, Tanzania. J Int Assoc Provid AIDS Care 2019. [PMID: 29529909 PMCID: PMC6748468 DOI: 10.1177/2325958218759759] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To describe the incidence of and risk factors for overweight and obesity following antiretroviral therapy (ART) initiation. METHODS We used Cox proportional hazards models to investigate risk factors for incident overweight and obesity in 79 074 individuals aged 15 years or older who initiated ART in Dar es Salaam, Tanzania. RESULTS Twenty-five percent of the patients became overweight and 10% became obese. The incidence rate of obesity was 3.2 per 100 person-years (95% confidence interval [CI]: 3.1-3.3) in patients who were of normal weight before starting ART and 22.6 per 100 person-years (95% CI: 21.9-23.3) in those who were overweight. Lower CD4 count was associated with a higher risk of overweight and obesity ( P value for trend < .0001). CONCLUSION There is a high burden of overweight and obesity after starting ART, leading to proportions of these 2 conditions that are similar to those in the general population.
Collapse
Affiliation(s)
- Alexander Kintu
- 1 Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Enju Liu
- 2 Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ellen Hertzmark
- 2 Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,3 Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,4 Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Donna Spiegelman
- 2 Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,3 Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,4 Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Rachel Margaret Zack
- 3 Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Aisa Muya
- 5 Management and Development for Health, Dar es Salaam, Tanzania
| | - David Sando
- 1 Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,5 Management and Development for Health, Dar es Salaam, Tanzania
| | - Till Bärnighausen
- 1 Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Wafaie Fawzi
- 1 Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,2 Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,3 Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
22
|
Bajaria S, Festo C, Mrema S, Shabani J, Hertzmark E, Abdul R. Assessment of the impact of availability and readiness of malaria services on uptake of intermittent preventive treatment in pregnancy (IPTp) provided during ANC visits in Tanzania. Malar J 2019; 18:229. [PMID: 31288835 PMCID: PMC6617666 DOI: 10.1186/s12936-019-2862-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 07/03/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Intermittent preventive treatment during pregnancy (IPTp) is a highly-recommended intervention to prevent maternal and neonatal complications associated with malaria infection. Despite fairly high antenatal care (ANC) coverage in Tanzania, low IPTp uptake rates represent a gap in efforts to decrease complications attributed to malaria in pregnancy. The objective of this study was to examine if availability, readiness and managing authority are associated with uptake of IPTp during ANC. METHODS Data for this analysis come from a cross-sectional survey, the Tanzania Service Provision Assessment conducted between 2014 and 2015. Principal component analysis was used to create scores for availability of malaria services and readiness for the provision of services. Generalized estimating equation models with logit link and the binomial distribution assessed factors that impact the uptake of IPTp by pregnant women attending ANC. RESULTS Higher fraction of women in their third trimester than second (68% versus 49%, OR = 2.6; 95% CI (2.1-3.3)), had received at least one dose of IPTp. There was a wide variation in the availability and readiness of malaria services provision and diagnostic tools by managing authorities. Public facilities were more likely than private to offer malaria rapid diagnostic test, and more providers at public facilities than private diagnosed and/or treated malaria. Women who attended facilities where direct observation therapy was practiced were more likely to have received at least one dose of IPTp (64% versus 46% who received none; p < 0.001). Women who attended ANC at a facility with a high readiness score were more likely to take IPTp than those attending facilities with low readiness scores (OR = 2.1; 95% CI (1.4-3.3)). Reported stock out on the day of interview was negatively associated with IPTp uptake (OR 0.09; 95% CI 0.07-0.1). CONCLUSION Readiness of health facilities to provide malaria related services, the number of ANC visits and gestational age were associated with uptake of IPTp among women attending ANC. There are disparities in malaria service availability and readiness across geographical location and managing authorities. These findings could be used to assist the malaria programme and policymakers to appropriately decide when planning for malaria service deliveries and interventions.
Collapse
Affiliation(s)
| | - Charles Festo
- Ifakara Health Institute, Box 78373, Dar es Salaam, Tanzania
| | - Sigilbert Mrema
- Ifakara Health Institute, Box 78373, Dar es Salaam, Tanzania
| | | | - Ellen Hertzmark
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Ramadhani Abdul
- Ifakara Health Institute, Box 78373, Dar es Salaam, Tanzania
| |
Collapse
|
23
|
Hawkins C, Hertzmark E, Spiegelman D, Muya A, Ulenga N, Kim S, Khudyakov P, Christian B, Sando D, Aris E, Fawzi W. Switching to second-line ART in relation to mortality in a large Tanzanian HIV cohort. J Antimicrob Chemother 2018; 72:2060-2068. [PMID: 28387836 DOI: 10.1093/jac/dkx098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 03/03/2017] [Indexed: 11/14/2022] Open
Abstract
Objectives In a large cohort of HIV-infected Tanzanians, we assessed: (i) rates of first-line treatment failure and switches to second-line ART; (ii) the effect of switching to second-line ART on death and loss to follow-up; and (iii) treatment outcomes on second-line ART by regimen. Methods HIV-1-infected adults (≥15 years) initiated on first-line ART between November 2004 and September 2012, and who remained on initial therapy for at least 24 weeks before switching, were studied. Survival analyses were conducted to examine the effect of second-line ART on mortality and loss to follow-up in: (i) the whole cohort; (ii) all patients eligible for second-line ART by immunological failure (IF) and/or virological failure (VF) criteria; and (iii) patients eligible by VF criteria. Results In total, 47 296 HIV-infected patients [mean age 37.5 (SD 9.5) years, CD4 175 (SD 158) cells/mm 3 , 71% female] were included in the analyses. Of these, 1760 (3.7%) patients switched to second-line ART (incidence rate = 1.7/100 person-years). Higher rates of mortality were observed in switchers versus non-switchers in all patients and patients with ART failure using IF/VF criteria. Switching only protected against mortality in patients with ART failure defined virologically and with the highest level of adherence [switching versus non-switching; >95% adherence; adjusted HR = 0.50 (95% CI = 0.26-0.93); P = 0.03]. Conclusions Switching patients to second-line ART may only be beneficial in a select group of patients who are virologically monitored and demonstrate good adherence. Our data emphasize the need for routine viral load monitoring and aggressive adherence interventions in HIV programmes in sub-Saharan Africa.
Collapse
Affiliation(s)
- Claudia Hawkins
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Donna Spiegelman
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Aisa Muya
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Sehee Kim
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Polyna Khudyakov
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - David Sando
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Eric Aris
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Wafaie Fawzi
- Departments of Nutrition, Epidemiology and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
24
|
Kawai K, Hawkins CA, Hertzmark E, Francis JM, Sando D, Muya AN, Ulenga N, Fawzi WW. Impact of Antiretroviral Therapy on the Risk of Herpes Zoster among Human Immunodeficiency Virus-Infected Individuals in Tanzania. Am J Trop Med Hyg 2018; 98:396-401. [PMID: 29313475 DOI: 10.4269/ajtmh.17-0568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
We examined the incidence of herpes zoster (HZ) before and after the initiation of antiretroviral therapy (ART), and risk factors for HZ among human immunodeficiency virus (HIV)-infected individuals in Tanzania. A cohort study was conducted among HIV-positive individuals enrolled in HIV care and treatment clinics in Dar es Salaam, Tanzania. A Cox proportional hazard model was used to examine the effect of ART on the risk of HZ after adjusting for sociodemographics and time-varying clinical and nutritional factors. Among 72,670 HIV-positive individuals, 2,312 incident cases of HZ (3.2%) occurred during the median follow-up of 15 months (interquartile range: 3-35). The incidence rate of HZ significantly declined from 48.9 (95% confidence interval [CI] = 46.7-51.0) per 1,000 person-years before ART to 3.7 (95% CI = 3.3-4.1) per 1,000 person-years after the initiation of ART (P < 0.001). The risk of HZ declined with longer duration on ART. Low CD4 cell count, older age, female sex, district of Dar es Salaam, and year of enrollment were independently associated with the risk of HZ in the multivariate analysis. Low body mass index and anemia were not associated with the risk of HZ. The risk of HZ substantially declined after ART initiation in this large cohort of HIV-infected individuals. Earlier initiation of ART could reduce the risk of HZ and other opportunistic infections among HIV-infected individuals in sub-Saharan Africa.
Collapse
Affiliation(s)
- Kosuke Kawai
- Clinical Research Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Claudia A Hawkins
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ellen Hertzmark
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Joel M Francis
- Management and Development for Health, Dar es Salaam, Tanzania.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - David Sando
- Management and Development for Health, Dar es Salaam, Tanzania.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Aisa N Muya
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Nzovu Ulenga
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Management and Development for Health, Dar es Salaam, Tanzania
| | - Wafaie W Fawzi
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| |
Collapse
|
25
|
Kamenju P, Liu E, Hertzmark E, Spiegelman D, Kisenge RR, Kupka R, Aboud S, Manji K, Duggan C, Fawzi WW. Complementary Feeding and Diarrhea and Respiratory Infection Among HIV-Exposed Tanzanian Infants. J Acquir Immune Defic Syndr 2017; 74:265-272. [PMID: 27861238 DOI: 10.1097/qai.0000000000001248] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the association between complementary feeding and risks of diarrhea and acute respiratory infection (ARI) among HIV-exposed infants aged 6-24 months. DESIGN We prospectively used an Infant and Child Feeding Index (ICFI) to measure complementary feeding practices (breastfeeding status, food consistency, dietary diversity, food group frequency, and meal frequency). We determined the association of ICFI and each of its components with the risk of diarrhea and ARI. Generalized estimating equations were used to estimate the relative risks for morbidity episodes. SETTING Dar es Salaam, Tanzania. SUBJECTS A total of 2092 HIV-exposed infants followed from 6 months of age to 24 months of age. RESULTS The ICFI score ranged from 0 to 9; the median score was 6 (interquartile range = 4-7). Low ICFI scores were likely associated with increased risk of dysentery [low vs. high tertile risk ratio (RR): 1.40; 95% confidence interval (CI): 0.93 to 2.10; P for trend = 0.02] and respiratory infection (low vs. high tertile RR: 1.16; 95% CI: 0.96 to 1.41; P for trend = 0.01). Low dietary diversity scores were likely associated with higher risk of dysentery (low vs. high tertile RR: 1.47; 95% CI: 0.92 to 2.35; P for trend = 0.03) and respiratory infection (low vs. high tertile RR: 1.41; 95% CI: 1.13 to 1.76; P for trend = 0.01). Low food consistency scores were associated with higher risk of respiratory infection (RR: 1.77; 95% CI: 1.40 to 2.26; P < 0.01). CONCLUSIONS In this setting, low ICFI, dietary diversity, and food consistency scores were likely associated with increased risk of diarrhea and ARI among HIV-exposed infants.
Collapse
Affiliation(s)
- Pili Kamenju
- Departments of *Global Health and Population; †Epidemiology; ‡Biostatistics; §Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA; ‖Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; ¶Nutrition Section, United Nations Children's Fund (UNICEF), New York, NY; #Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; and **Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Kamenju P, Liu E, Hertzmark E, Spiegelman D, Kisenge R, Kupka R, Aboud S, Manji KP, Duggan C, Fawzi WW. Nutritional status and complementary feeding among HIV-exposed infants: a prospective cohort study. Matern Child Nutr 2016; 13. [PMID: 27686370 DOI: 10.1111/mcn.12358] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 05/24/2016] [Accepted: 06/21/2016] [Indexed: 11/30/2022]
Abstract
Complementary feeding is crucial for improving child survival and promoting growth and development, particularly among HIV-exposed children who have higher risk of morbidity and mortality than their un-exposed peers. This prospective study employed an infant and child feeding index (ICFI) to measure complementary feeding and determine its association with nutritional status among 2092 HIV-exposed infants followed from 6 to 24 months of age in Dar es Salaam, Tanzania. The ICFI measured both quality and quantity of complementary feeding, including current breastfeeding status, food consistency, dietary diversity scores (DDS), food group frequency score, and meal frequency. The ICFI score ranged from 0 to 9; the median score was 6 (Inter-Quartile Range, IQR= 4-7). After adjusting for potential confounders, high ICFI scores were associated with reduced risk of stunting (high vs. low tertile hazard ratio, HR: 0.72; 95% confidence interval, CI: 0.57, 0.91; P< 0.01) and underweight (high vs. low tertile HR: 0.79; 95% CI: 0.61, 1.02; P= 0.07). Low DDS were associated with higher risk of stunting (low vs. high tertile HR: 1.59; 95% CI: 1.23, 2.07; P< 0.01) and underweight (low vs. high tertile HR: 1.48; 95% CI: 1.12, 1.96; P= 0.01). In this setting, high DDS and ICFI scores were protective of stunting and underweight. We recommend for nutrition programs in low-income countries to emphasize educating HIV-exposed children's caregivers on the importance of dietary diversity and optimal complementary feeding to improve nutritional status in this important subpopulation.
Collapse
Affiliation(s)
- Pili Kamenju
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Enju Liu
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ellen Hertzmark
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Donna Spiegelman
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Rodrick Kisenge
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Roland Kupka
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,United Nations Children's Fund, United Nations Children's Fund (UNICEF), New York, New York, USA
| | - Said Aboud
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Karim P Manji
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher Duggan
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Boston Children's Hospital, Boston, Massachusetts, USA
| | - Wafaie W Fawzi
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
27
|
Barnhart D, Hertzmark E, Liu E, Mungure E, Muya AN, Sando D, Chalamilla G, Ulenga N, Bärnighausen T, Fawzi W, Spiegelman D. Intra-Cluster Correlation Estimates for HIV-related Outcomes from Care and Treatment Clinics in Dar es Salaam, Tanzania. Contemp Clin Trials Commun 2016; 4:161-169. [PMID: 27766318 PMCID: PMC5066589 DOI: 10.1016/j.conctc.2016.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction Researchers planning cluster-randomized controlled trials (cRCTs) require estimates of the intra-cluster correlation coefficient (ICC) from previous studies for sample size calculations. This paper fills a persistent gap in the literature by providing estimates of ICCs for many key HIV-related clinical outcomes. Methods Data from HIV-positive patients from 47 HIV care and treatment clinics in Dar es Salaam, Tanzania were used to calculate ICCs by site of enrollment or site of ART initiation for various clinical outcomes using cross-sectional and longitudinal data. ICCs were estimated using linear mixed models where either clinic of enrollment or clinic of ART initiation served as the random effect. Results ICCs ranged from 0 to 0.0706 (95% CI: 0.0447, 0.1098). For most outcomes, the ICCs were large enough to meaningfully affect sample size calculations. For binary outcomes, the ICCs for event prevalence at baseline tended to be larger than the ICCs for later cumulative incidences. For continuous outcomes, the ICCs for baseline values tended to be larger than the ICCs for the change in values from baseline. Conclusion The ICCs for HIV-related outcomes cannot be ignored when calculating sample sizes for future cluster-randomized trials. The differences between ICCs calculated from baseline data alone and ICCs calculated using longitudinal data demonstrate the importance of selecting an ICC that reflects a study's intended design and duration for sample size calculations. While not generalizable to all contexts, these estimates provide guidance for future researchers seeking to design adequately powered cRCTs in Sub-Saharan African HIV treatment and care clinics.
Collapse
Affiliation(s)
- Dale Barnhart
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA
| | - Ellen Hertzmark
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA
| | - Enju Liu
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA
| | - Ester Mungure
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA
| | - Aisa N Muya
- Management and Development of Health, Mwai Kibaki Road, Dar es Salaam, Tanzania
| | - David Sando
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA; Management and Development of Health, Mwai Kibaki Road, Dar es Salaam, Tanzania
| | - Guerino Chalamilla
- Management and Development of Health, Mwai Kibaki Road, Dar es Salaam, Tanzania
| | - Nzovu Ulenga
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA; Management and Development of Health, Mwai Kibaki Road, Dar es Salaam, Tanzania
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA; Wellcome Trust Africa Centre for Population Health, A2074 Road, Mtubatuba, KwaZulu-Natal 3935, South Africa
| | - Wafaie Fawzi
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA; Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA; Department of Nutrition, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA
| | - Donna Spiegelman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA
| |
Collapse
|
28
|
Liu E, McCree R, Mtisi E, Fawzi WW, Aris E, Lema IA, Hertzmark E, Chalamilla G, Li N, Vermund SH, Spiegelman D. Prevalence and risk factors of cervical squamous intraepithelial lesions among HIV-infected women in Dar es Salaam, Tanzania. Int J STD AIDS 2016; 27:219-225. [PMID: 25957324 DOI: 10.1177/0956462415584466] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 03/31/2015] [Indexed: 11/15/2022]
Abstract
To determine the prevalence and predictors of cervical squamous intraepithelial lesions (SIL) among HIV-infected women in Tanzania, a cross-sectional study was conducted among HIV-infected women at HIV care and treatment clinics. A Papanicolaou (Pap) smear was used as a screening tool for detection of cervical SIL. From December 2006 to August 2009, 1365 HIV-infected women received cervical screening. The median age was 35 (interquartile range [IQR]: 30-42) years, and the median CD4 + cell count was 164 (IQR: 80-257) cells/mm(3). The prevalence of cervical SIL was 8.7% (119/1365). In multivariate analysis, older age (≥50 versus 30-<40 years: prevalence ratio [PR], 2.36; 95% confidence interval [CI], 1.45-3.84, p for trend = 0.001), lower CD4 + cell counts (<100 versus ≥200 cells/mm(3): PR, 1.55; 95% CI, 1.01-2.36, p for trend = 0.03) and cervical inflammation (PR, 1.73; 95% CI, 1.16-2.60, p = 0.008) were associated with an increased risk of cervical SIL. Women with advanced WHO HIV disease stage (IV versus I/II: PR, 3.45; 95% CI, 1.35-8.85, p for trend = 0.01) had an increased risk for high-grade SIL. In resource-limited settings where it is not feasible to provide cervical cancer prevention services to all HIV-infected women, greater efforts should focus on scaling-up services among those who are older than 50 years, with lower CD4 cell counts and advanced HIV disease stage.
Collapse
Affiliation(s)
- Enju Liu
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
| | - Renicha McCree
- National Cancer Institute, Center for Global Health, Rockville, MD, USA
| | | | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA Department of Nutrition, Harvard School of Public Health, Boston, MA, USA Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
| | - Eric Aris
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Irene A Lema
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Ellen Hertzmark
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
| | | | - Nan Li
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
| | - Sten H Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, TN, USA
| | - Donna Spiegelman
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA Department of Nutrition, Harvard School of Public Health, Boston, MA, USA Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA Department of Biostatistics, Harvard School of Public Health, Boston, MA, USA
| |
Collapse
|
29
|
Petraro P, Duggan C, Spiegelman D, Hertzmark E, Makubi A, Chalamilla G, Siril H, Sando D, Aboud S, Fawzi WW. Determinants of Anemia Among Human Immunodeficiency Virus-Positive Adults at Care and Treatment Clinics in Dar es Salaam, Tanzania. Am J Trop Med Hyg 2015; 94:384-92. [PMID: 26666698 DOI: 10.4269/ajtmh.15-0587] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/15/2015] [Indexed: 11/07/2022] Open
Abstract
Anemia is often a comorbidity of human immunodeficiency virus (HIV) infection. Many cross-sectional studies have been conducted on anemia and HIV, but few, if any, have addressed incidence of anemia prospectively. A longitudinal analysis was conducted in 48,068 nonpregnant HIV-infected adults in Dar es Salaam, Tanzania, seen at Management and Development for Health-U.S. President's Emergency Plan for AIDS Relief HIV care and treatment programs between 2004 and 2011. Almost 56% (N = 27,184) of study participants had anemia (hemoglobin < 11 g/dL) at the time of enrollment at the clinic. Female gender, low body mass index (BMI), low CD4 T-cell count, high levels of liver enzyme alanine aminotransferase, antiretroviral treatment (ART) regimens, and concurrent tuberculosis treatment were all independently significantly associated with an increased risk of anemia. Low BMI and low CD4 T-cell count were independently significantly associated with an increased risk for iron deficiency anemia (IDA). Higher BMI status and ART use were associated with recovery from anemia. Anemia, including IDA, is a comorbidity that is associated with other adverse consequences (e.g., low BMI and CD4 T-cell count) among individuals with HIV infection, including those on ART. Interventions to prevent anemia and its complications need to be examined in the context of future studies.
Collapse
Affiliation(s)
- Paul Petraro
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts; Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts; Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher Duggan
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts; Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts; Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Donna Spiegelman
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts; Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts; Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ellen Hertzmark
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts; Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts; Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Abel Makubi
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts; Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts; Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Guerino Chalamilla
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts; Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts; Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Helen Siril
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts; Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts; Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - David Sando
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts; Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts; Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Said Aboud
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts; Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts; Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Wafaie W Fawzi
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, Massachusetts; Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts; Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts; Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| |
Collapse
|
30
|
Li N, Sando MM, Spiegelman D, Hertzmark E, Liu E, Sando D, Machumi L, Chalamilla G, Fawzi W. Antiretroviral Therapy in Relation to Birth Outcomes among HIV-infected Women: A Cohort Study. J Infect Dis 2015; 213:1057-64. [PMID: 26265780 DOI: 10.1093/infdis/jiv389] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 06/15/2015] [Indexed: 11/14/2022] Open
Abstract
Although the beneficial effects of antiretroviral (ARV) therapy for preventing mother-to-child transmission are indisputable, studies in developed and developing countries have reported conflicting findings on the association between ARV exposure and adverse birth outcomes. We conducted a prospective observational study at 10 human immunodeficiency virus (HIV) care and treatment centers in Dar es Salaam, Tanzania. Multivariate log-binomial regression was used to investigate the associations between ARV use and adverse birth outcomes among HIV-negative HIV-exposed infants. Our findings demonstrate an increased risk of adverse birth outcomes associated with the use of highly active antiretroviral therapy during pregnancy. Further studies are needed to investigate the underlying mechanisms and identify the safest ARV regimens for use during pregnancy.
Collapse
Affiliation(s)
- Nan Li
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health (HSPH), Boston, Massachusetts
| | | | - Donna Spiegelman
- Departments of Epidemiology, HSPH, Boston, Massachusetts Biostatistics, HSPH, Boston, Massachusetts
| | | | - Enju Liu
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health (HSPH), Boston, Massachusetts
| | - David Sando
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Lameck Machumi
- Management and Development for Health, Dar es Salaam, Tanzania
| | | | - Wafaie Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health (HSPH), Boston, Massachusetts Departments of Epidemiology, HSPH, Boston, Massachusetts Nutrition, HSPH, Boston, Massachusetts
| |
Collapse
|
31
|
Gunaratna NS, Masanja H, Mrema S, Levira F, Spiegelman D, Hertzmark E, Saronga N, Irema K, Shuma M, Elisaria E, Fawzi W. Multivitamin and iron supplementation to prevent periconceptional anemia in rural tanzanian women: a randomized, controlled trial. PLoS One 2015; 10:e0121552. [PMID: 25905863 PMCID: PMC4408096 DOI: 10.1371/journal.pone.0121552] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 02/12/2015] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Women's nutritional status during conception and early pregnancy can influence maternal and infant outcomes. This study examined the efficacy of pre-pregnancy supplementation with iron and multivitamins to reduce the prevalence of anemia during the periconceptional period among rural Tanzanian women and adolescent girls. DESIGN A double-blind, randomized controlled trial was conducted in which participants were individually randomized to receive daily oral supplements of folic acid alone, folic acid and iron, or folic acid, iron, and vitamins A, B-complex, C, and E at approximately single recommended dietary allowance (RDA) doses for six months. SETTING Rural Rufiji District, Tanzania. SUBJECTS Non-pregnant women and adolescent girls aged 15-29 years (n = 802). RESULTS The study arms were comparable in demographic and socioeconomic characteristics, food security, nutritional status, pregnancy history, and compliance with the regimen (p>0.05). In total, 561 participants (70%) completed the study and were included in the intention-to-treat analysis. Hemoglobin levels were not different across treatments (median: 11.1 g/dL, Q1-Q3: 10.0-12.4 g/dL, p = 0.65). However, compared with the folic acid arm (28%), there was a significant reduction in the risk of hypochromic microcytic anemia in the folic acid and iron arm (17%, RR: 0.61, 95% CI: 0.42-0.90, p = 0.01) and the folic acid, iron, and multivitamin arm (19%, RR: 0.66, 95% CI: 0.45-0.96, p = 0.03). Inverse probability of treatment weighting (IPTW) to adjust for potential selection bias due to loss to follow-up did not materially change these results. The effect of the regimens was not modified by frequency of household meat consumption, baseline underweight status, parity, breastfeeding status, or level of compliance (in all cases, p for interaction>0.2). CONCLUSIONS Daily oral supplementation with iron and folic acid among women and adolescents prior to pregnancy reduces risk of anemia. The potential benefits of supplementation on the risk of periconceptional anemia and adverse pregnancy outcomes warrant investigation in larger studies. TRIAL REGISTRATION ClinicalTrials.gov NCT01183572.
Collapse
Affiliation(s)
- Nilupa S. Gunaratna
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | | | | | | | - Donna Spiegelman
- Departments of Epidemiology, Biostatistics, and Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Ellen Hertzmark
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Naomi Saronga
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Kahema Irema
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Mary Shuma
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | - Wafaie Fawzi
- Departments of Global Health and Population, Epidemiology, and Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| |
Collapse
|
32
|
Sando D, Spiegelman D, Machumi L, Mwanyika-Sando M, Aris E, Muya A, Jackson E, Baernighausen T, Hertzmark E, Chalamilla G, Fawzi W. Time trends of baseline demographics and clinical characteristics of HIV infected children enrolled in care and treatment service in Dar es Salaam, Tanzania. BMC Infect Dis 2015; 15:157. [PMID: 25881135 PMCID: PMC4379717 DOI: 10.1186/s12879-015-0875-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 03/10/2015] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Few studies have described time-based trends of clinical and demographic characteristics of children enrolling in HIV and AIDS care and treatment services. We present findings of a study that explored time-based trends of baseline characteristics among children enrolling into 26 public HIV care facilities in Dar es Salaam, Tanzania. METHODS Children enrolled between October 2004 and September 2011 was included in these analyses. The year of enrollment was used as the primary predictor of interest, and log linear and linear regressions model were used to analyze dichotomous and continuous variables respectively. P-values under 0.05 were considered significant. RESULTS Among the 6,579 children enrolled, the proportion with advanced disease at enrollment increased from 35% to 58%, mean age increasing from 5.0 to 6.2 years (p < 0.0001), proportion of children less than 2 years decreased from 35% to 29%. While the median hemoglobin concentration rose from 9.1 g/dl to 10.3 g/dl (P <0.0001), proportion with a history of past TB dropped from 25% to 12.8% (P < 0.0001). Over time, health centers and dispensaries enrolled more children as compared to hospitals (P < 0.0001). Temeke district, which has the lowest socioeconomic status among the three districts in Dar es Salaam, had a significant increase in enrollment from 22% to 25% (P = 0.02). CONCLUSION We found that as time progressed, children were enrolled in care and treatment services at an older age sicker status as evidenced by increase in mean age and more advanced disease stage at first contact with providers. We recommend more efforts be focused on scaling up early HIV infant diagnosis and enrollment to HIV care and treatment.
Collapse
Affiliation(s)
- David Sando
- Management and Development for Health (MDH), P.O. Box 79810, Dar es Salaam, Tanzania.
| | - Donna Spiegelman
- Harvard T.H. Chan School of Public Health (HSPH), P.O. Box 79810, Dar es Salaam, Tanzania.
| | - Lameck Machumi
- Management and Development for Health (MDH), P.O. Box 79810, Dar es Salaam, Tanzania.
| | - Mary Mwanyika-Sando
- Management and Development for Health (MDH), P.O. Box 79810, Dar es Salaam, Tanzania.
| | - Eric Aris
- Management and Development for Health (MDH), P.O. Box 79810, Dar es Salaam, Tanzania.
| | - Aisa Muya
- Management and Development for Health (MDH), P.O. Box 79810, Dar es Salaam, Tanzania.
| | - Elizabeth Jackson
- Harvard T.H. Chan School of Public Health (HSPH), P.O. Box 79810, Dar es Salaam, Tanzania.
| | - Till Baernighausen
- Harvard T.H. Chan School of Public Health (HSPH), P.O. Box 79810, Dar es Salaam, Tanzania.
| | - Ellen Hertzmark
- Harvard T.H. Chan School of Public Health (HSPH), P.O. Box 79810, Dar es Salaam, Tanzania.
| | - Guerino Chalamilla
- Management and Development for Health (MDH), P.O. Box 79810, Dar es Salaam, Tanzania.
| | - Wafaie Fawzi
- Harvard T.H. Chan School of Public Health (HSPH), P.O. Box 79810, Dar es Salaam, Tanzania.
| |
Collapse
|
33
|
Carwile JL, Willett WC, Spiegelman D, Hertzmark E, Rich-Edwards J, Frazier AL, Michels KB. Sugar-sweetened beverage consumption and age at menarche in a prospective study of US girls. Hum Reprod 2015; 30:675-83. [PMID: 25628346 DOI: 10.1093/humrep/deu349] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
STUDY QUESTION Is sugar-sweetened beverage (SSB) consumption associated with age at menarche? SUMMARY ANSWER More frequent SSB consumption was associated with earlier menarche in a population of US girls. WHAT IS KNOWN ALREADY SSB consumption is associated with metabolic changes that could potentially impact menarcheal timing, but direct associations with age at menarche have yet to be investigated. STUDY DESIGN, SIZE, DURATION The Growing up Today Study, a prospective cohort study of 16 875 children of Nurses' Health Study II participants residing in all 50 US states. This analysis followed 5583 girls, aged 9-14 years and premenarcheal at baseline, between 1996 and 2001. During 10 555 person-years of follow-up, 94% (n = 5227) of girls reported their age at menarche, and 3% (n = 159) remained premenarcheal in 2001; 4% (n = 197) of eligible girls were censored, primarily for missing age at menarche. PARTICIPANTS/MATERIALS, SETTING, METHODS Cumulative updated SSB consumption (composed of non-carbonated fruit drinks, sugar-sweetened soda and iced tea) was calculated using annual Youth/Adolescent Food Frequency Questionnaires from 1996 to 1998. Age at menarche was self-reported annually. The association between SSB consumption and age at menarche was assessed using Cox proportional hazards regression. MAIN RESULTS AND THE ROLE OF CHANCE More frequent SSB consumption predicted earlier menarche. At any given age between 9 and 18.5 years, premenarcheal girls who reported consuming >1.5 servings of SSBs per day were, on average, 24% more likely [95% confidence interval (CI): 13, 36%; P-trend: <0.001] to attain menarche in the next month relative to girls consuming ≤2 servings of SSBs weekly, adjusting for potential confounders including height, but not BMI (considered an intermediate). Correspondingly, girls consuming >1.5 SSBs daily had an estimated 2.7-month earlier menarche (95% CI: -4.1, -1.3 months) relative to those consuming ≤2 SSBs weekly. The frequency of non-carbonated fruit drink (P-trend: 0.03) and sugar-sweetened soda (P-trend: 0.001), but not iced tea (P-trend: 0.49), consumption also predicted earlier menarche. The effect of SSB consumption on age at menarche was observed in every tertile of baseline BMI. Diet soda and fruit juice consumption were not associated with age at menarche. LIMITATIONS, REASONS FOR CAUTION Although we adjusted for a variety of suspected confounders, residual confounding is possible. We did not measure SSB consumption during early childhood, which may be an important window of exposure. WIDER IMPLICATIONS OF THE FINDINGS More frequent SSB consumption may predict earlier menarche through mechanisms other than increased BMI. Our findings provide further support for public health efforts to reduce SSB consumption. STUDY FUNDING/COMPETING INTERESTS The Growing up Today Study is supported by grant R03 CA 106238. J.L.C. was supported by the Breast Cancer Research Foundation; Training Grant T32ES007069 in Environmental Epidemiology from the National Institute of Environmental Health Sciences, National Institutes of Health; and Training Grant T32HD060454 in Reproductive, Perinatal and Pediatric Epidemiology from the National Institute of Child Health and Human Development, National Institutes of Health. A.L.F. is supported by the American Cancer Society, Research Scholar Grant in Cancer Control. K.B.M. was supported in part by the National Cancer Institute at the National Institutes of Health (Public Health Service grants R01CA158313 and R03CA170952). There are no conflicts of interest to declare.
Collapse
Affiliation(s)
- J L Carwile
- Department of Epidemiology, Harvard School of Public Health, Boston, MA 02115, USA
| | - W C Willett
- Department of Epidemiology, Harvard School of Public Health, Boston, MA 02115, USA Department of Nutrition, Harvard School of Public Health, Boston, MA 02115, USA Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - D Spiegelman
- Department of Epidemiology, Harvard School of Public Health, Boston, MA 02115, USA Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA Department of Biostatistics, Harvard School of Public Health, Boston, MA 02115, USA
| | - E Hertzmark
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA Department of Biostatistics, Harvard School of Public Health, Boston, MA 02115, USA
| | - J Rich-Edwards
- Department of Epidemiology, Harvard School of Public Health, Boston, MA 02115, USA Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - A L Frazier
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA Department of Pediatric Oncology, Dana-Farber/Children's Hospital Cancer Center, Boston, MA 02115, USA
| | - K B Michels
- Department of Epidemiology, Harvard School of Public Health, Boston, MA 02115, USA Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA Obstetrics and Gynecology Epidemiology Center, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, USA
| |
Collapse
|
34
|
Semu H, Zack RM, Liu E, Hertzmark E, Spiegelman D, Sztam K, Hawkins C, Chalamila G, Muya A, Siril H, Mwiru R, Mtasiwa D, Fawzi W. Prevalence and Risk Factors for Overweight and Obesity among HIV-Infected Adults in Dar es Salaam, Tanzania. J Int Assoc Provid AIDS Care 2014; 15:512-521. [PMID: 25146972 DOI: 10.1177/2325957414542574] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Overweight and obesity are increasingly prevalent among HIV-infected populations. We describe their prevalence and associated risk factors among HIV-infected adults in Dar es Salaam, Tanzania. METHODS A cross-sectional study was conducted to determine the proportion of patients who were overweight or obese at enrollment to care and treatment centres from 2004 to 2011. Multivariate relative risk regression models were fit to identify risk factors. RESULTS A total of 53 825 patients were included in the analysis. In all, 16% of women and 8% of men were overweight, while 7% and 2% were obese, respectively. In multivariate analyses, older age, higher CD4 count, higher hemoglobin levels, female sex, and being married were associated with obesity and overweight. World Health Organization HIV disease stage, tuberculosis history, and previous antiretroviral therapy were inversely associated with obesity and overweight. CONCLUSION Overweight and obesity were highly prevalent among HIV-infected patients. Screening for overweight and obesity and focused interventions should be integrated into HIV care.
Collapse
Affiliation(s)
- Helen Semu
- Department of Preventive Services, Ministry of Health and Social Welfare, Dar es Salaam, Tanzania
| | - Rachel M Zack
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
| | - Enju Liu
- Department of Nutrition, Harvard School of Public Health, Boston, MA, USA
| | - Ellen Hertzmark
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA.,Department of Nutrition, Harvard School of Public Health, Boston, MA, USA.,Department of Biostatistics, Harvard School of Public Health, Boston, MA, USA
| | - Donna Spiegelman
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA.,Department of Nutrition, Harvard School of Public Health, Boston, MA, USA.,Department of Biostatistics, Harvard School of Public Health, Boston, MA, USA
| | - Kevin Sztam
- Clinical Nutritional Service, Division of GI/Nutrition, Children's Hospital, Boston, MA, USA
| | - Claudia Hawkins
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | | | - Aisa Muya
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Hellen Siril
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Ramadhani Mwiru
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Deo Mtasiwa
- Prime Ministers' Office, Regional Authority and Local Government, Dar es Salaam, Tanzania
| | - Wafaie Fawzi
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA.,Department of Nutrition, Harvard School of Public Health, Boston, MA, USA.,Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
| |
Collapse
|
35
|
Muya AN, Geldsetzer P, Hertzmark E, Ezeamama AE, Kawawa H, Hawkins C, Sando D, Chalamilla G, Fawzi W, Spiegelman D. Predictors of Nonadherence to Antiretroviral Therapy among HIV-Infected Adults in Dar es Salaam, Tanzania. J Int Assoc Provid AIDS Care 2014; 14:163-71. [PMID: 24966305 DOI: 10.1177/2325957414539193] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Adherence rates of ≥95% to antiretroviral therapy (ART) are necessary to maintain viral suppression in HIV-infected individuals. We identified predictors of nonadherence to scheduled antiretroviral drug pickup appointments in a large HIV care and treatment program in Tanzania. METHODS We performed a prospective cohort study of 44, 204 HIV-infected adults on ART between November 2004 and September 2012. Multivariate generalized estimating equation for repeated binary data was used to estimate the relative risk and 95% confidence intervals of nonadherence. RESULTS Nonadherence was significantly greater among patients with high CD4 counts, high body mass indices, males, younger patients, patients with longer durations on ART, and those with perceived low social support. CONCLUSIONS Targeted interventions should be developed to improve ART adherence among healthier, younger, and more experienced patients who are on ART for longer durations within HIV care and treatment programs. Social support for patients on ART should be emphasized.
Collapse
Affiliation(s)
- Aisa N Muya
- Management and Development for Health, Dar es Salaam, Tanzania
| | | | | | - Amara E Ezeamama
- Department of Epidemiology & Biostatistics, The University of Georgia, Athens, GA, USA
| | - Hawa Kawawa
- Dar es Salaam City Council, Department of Health and Social services, Dar es Salaam, Tanzania
| | | | - David Sando
- Management and Development for Health, Dar es Salaam, Tanzania
| | | | - Wafaie Fawzi
- Harvard School of Public Health, Boston, MA, USA
| | | |
Collapse
|
36
|
Changamire FT, Mwiru RS, Msamanga GI, Spiegelman D, Urassa W, Hertzmark E, Fawzi WW, Peterson KE. Macronutrient and sociodemographic determinants of gestational weight gain among HIV-negative women in Tanzania. Food Nutr Bull 2014; 35:43-50. [PMID: 24791578 DOI: 10.1177/156482651403500106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The effect of dietary macronutrient composition on the rate of gestational weight gain among women in sub-Saharan Africa is unclear. OBJECTIVE To examine the effect of macronutrient intake on the rate of gestational weight gain among HIV-negative women in Tanzania. METHODS The weights of 8,428 women were measured monthly from 12 weeks of gestation to term. Prenatal dietary intake was estimated as the cumulative average of multiple 24-hour dietary recalls. The association between energy intake and percentage of energy from carbohydrate, protein, and total fat and rate of weight gain (grams per month) was estimated from generalized estimating equation models. Macronutrient effects were adjusted for total energy using the nutrient density model and maternal age, maternal height, maternal mid-upper-arm circumference, parity, marital status, maternal occupation, maternal education, household wealth, season, and treatment regimen assignment. Body mass index (BMI) was considered as a confounder and a potential modifier of the effect of macronutrient intake on gestational weight gain. RESULTS A 6 g/month increase in rate of weight gain was associated with every 100-kcal increment in daily total energy intake (95% CI, 1 to 12; p = .03). Analyses substituting 5% of energy from fat by protein showed that weight gain would decrease by 72 g/month (95% CI, 6 to 140; p = .03); substituting 5% of energy from carbohydrate by protein decreased gain by 70 g/month (95% CI, 15 to 124; p = .01). Baseline BMI did not modify these associations. CONCLUSIONS Further research on the effects of macronutrient composition on gestational weight gain is needed to inform the design of supplementation programs for women in developing countries.
Collapse
|
37
|
Machumi LC, Mtisi E, Andrew I, Sando D, Mkali H, Liu E, Hertzmark E, Spiegelman D, Fawzi W, Chalamilla G. Who are they? Identifying risk factors of loss to follow up among HIV+ patients on care and treatment in Dar es Salaam. BMC Infect Dis 2014. [PMCID: PMC4221014 DOI: 10.1186/1471-2334-14-s2-p78] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
38
|
Sania A, Spiegelman D, Rich-Edwards J, Hertzmark E, Mwiru RS, Kisenge R, Fawzi WW. The contribution of preterm birth and intrauterine growth restriction to childhood undernutrition in Tanzania. Matern Child Nutr 2014; 11:618-30. [PMID: 24720471 DOI: 10.1111/mcn.12123] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Objectives were to examine the growth patterns of preterm and growth-restricted infants and to evaluate the associations of prematurity and intrauterine growth restriction (IUGR) with risk of stunting, wasting and underweight. Data from a cohort of HIV-negative pregnant women-infant pairs were collected prospectively in Tanzania. Small for gestational age [SGA, birthweight (BW) <10th percentile] was used as proxy for IUGR. Anthropometry was measured monthly until 18 months. Length-for-age (LAZ), weight-for-length (WLZ), and weight-for-age (WAZ) z-scores were calculated using the 2006 World Health Organization (WHO) Child Growth Standards. Stunting, wasting and underweight were defined as binary outcomes using a cut-off of <-2 SD of the respective z-scores. Multivariate Cox proportional hazard models were used to assess the associations between preterm and SGA to time to stunting, wasting and underweight. The study included 6664 singletons. Preterm and appropriate for gestational age (AGA) infants had slightly better nutritional status than term-SGA infants and despite some catch-up growth, preterm-SGA infants had the poorest nutritional status. The gap in LAZ and WAZ z-scores among the groups remained similar throughout the follow-up. Compared with term-AGA babies, relative risk (RR) of stunting among preterm-AGA babies was 2.13 (95% confidence interval (CI) 1.93-2.36), RR among term-SGA was 2.21 (95% CI 2.02-2.41) and the highest risk was among the babies who were both preterm and SGA (RR = 7.58, 95% CI 5.41-10.64). Similar magnitude of RR of underweight was observed among the three groups. Preterm and SGA infants should be closely monitored for growth failure. Intervention to reduce preterm and SGA birth may lower risk of undernutrition in resource-limited settings.
Collapse
Affiliation(s)
- Ayesha Sania
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Donna Spiegelman
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA.,Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Janet Rich-Edwards
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA.,The Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ellen Hertzmark
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Ramadhani S Mwiru
- Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, USA.,Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA.,Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
39
|
Ezeamama AE, Duggan C, Manji KP, Spiegelman D, Hertzmark E, Bosch RJ, Kupka R, Okuma JO, Kisenge R, Aboud S, Fawzi WW. Clinical malaria diagnosis in pregnancy in relation to early perinatal mother-to-child transmission of HIV: a prospective cohort study. HIV Med 2013; 15:276-85. [PMID: 24215465 DOI: 10.1111/hiv.12111] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We prospectively investigated fever symptoms and maternal diagnosis of malaria in pregnancy (MIP) in relation to child HIV infection among 2368 pregnant HIV-positive women and their infants, followed up from pregnancy until 6 weeks post-delivery in Tanzania. METHODS Doctors clinically diagnosed and treated MIP and fever symptoms during prenatal health care. Child HIV status was determined via DNA polymerase chain reaction (PCR). Multivariable logistic regression models were used to estimate relative risks (RRs) and 95% confidence intervals (CIs) for HIV mother-to-child transmission (MTCT) by the 6th week of life. RESULTS Mean gestational age at enrolment was 22.2 weeks. During follow-up, 16.6% of mothers had at least one MIP diagnosis, 15.9% reported fever symptoms and 8.7% had both fever and MIP diagnosis. Eleven per cent of HIV-exposed infants were HIV-positive by 6 weeks. The RR of HIV MTCT was statistically similar for infants whose mothers were ever vs. never clinically diagnosed with MIP (RR 1.24; 95% CI 0.94-1.64), were diagnosed with one vs. no clinical MIP episodes (RR 1.07; 95% CI 0.77-1.48) and had ever vs. never reported fever symptoms (RR 1.04; 95% CI 0.78-1.38) in pregnancy. However, the HIV MTCT risk increased by 29% (95% CI 4-58%) per MIP episode. Infants of women with at least two vs. no MIP diagnoses were 2.1 times more likely to be HIV infected by 6 weeks old (95% CI 1.31-3.45). CONCLUSIONS Clinical MIP diagnosis, but not fevers, in HIV-positive pregnant women was associated with an elevated risk of early HIV MTCT, suggesting that malaria prevention and treatment in pregnant HIV-positive women may enhance the effectiveness of HIV prevention in MTCT programmes in this setting. Future studies using a laboratory-confirmed diagnosis of malaria are needed to confirm this association.
Collapse
Affiliation(s)
- A E Ezeamama
- Department of Epidemiology & Biostatistics, University of Georgia, Athens, GA, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Mwiru R, Spiegelman D, Hertzmark E, Duggan C, Msamanga G, Aboud S, Fawzi W. Nutritional predictors of acute respiratory infections among children born to HIV-infected women in Tanzania. J Trop Pediatr 2013; 59:203-8. [PMID: 23400399 PMCID: PMC3667589 DOI: 10.1093/tropej/fmt004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
We prospectively determined the association between undernutrition and incidence of acute respiratory infections (ARIs) among 711 children born to HIV-infected women. Overall, underweight was associated with a 58% increased risk of ARI. Similarly, wasting (54%), very low birth weight (88%) and child HIV infection (62%) were significantly associated with increased risk of ARI during the first 2 years. Breastfeeding was associated with 52% reduction in risk of ARI only during the first 12 months of life. Among HIV-exposed, but uninfected, children, underweight, wasting and stunting were associated with 73%, 61% and 33% increased risk of ARI, respectively. Very low birthweight and advanced maternal disease stage were also associated with increased risk of ARI. Similar results were observed among HIV-infected children, except for stunting and very low birth weight. Prevention of child undernutrition could have major impact in reducing child ARI morbidity in settings of high HIV prevalence.
Collapse
Affiliation(s)
- Ramadhani Mwiru
- Department of Nutrition, Harvard School of Public Health, Boston, MA 02115, USA.
| | - Donna Spiegelman
- Department of Biostatistics, Harvard School of Public Health, Boston, MA 02115,Department of Epidemiology, Harvard School of Public Health, Boston, MA 02115
| | - Ellen Hertzmark
- Department of Epidemiology, Harvard School of Public Health, Boston, MA 02115
| | - Christopher Duggan
- Department of Nutrition, Harvard School of Public Health, Boston, MA 02115,Division of GI/Nutrition, Clinical Nutrition Service, Children's Hospital, Boston, MA 02115
| | - Gernard Msamanga
- Department of Community Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, 00255
| | - Said Aboud
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, 00255
| | - Wafaie Fawzi
- Department of Nutrition, Harvard School of Public Health, Boston, MA 02115,Department of Epidemiology, Harvard School of Public Health, Boston, MA 02115,Department of Global Health and Population, Harvard School of Public Health, Boston, MA 02115
| |
Collapse
|
41
|
Lukmanji Z, Hertzmark E, Spiegelman D, Spiegleman D, Fawzi WW. Dietary patterns, nutrient intake, and sociodemographic characteristics in HIV-infected Tanzanian pregnant women. Ecol Food Nutr 2013; 52:34-62. [PMID: 23282190 DOI: 10.1080/03670244.2012.705768] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Routinely collected dietary intakes were available for 925 HIV-infected pregnant women participating in a longitudinal clinical trial of vitamin supplementation in Dar es Salaam, Tanzania. Information on sociodemographic and economic characteristics was recorded. Dietary macronutrient intakes were computed and analyzed using the Tanzania Food Composition Tables. Women's age, parity, education level, and economic independence were positively related to diet intake. Women younger than 25 years were at highest risk of inadequate food and nutrient intake. By World Health Organization recommendations, almost two-thirds of the participants were energy deficient, and nearly half were protein deficient.
Collapse
Affiliation(s)
- Zohra Lukmanji
- Muhimbili University of Health Sciences and Harvard School of Public Health Collaborative Research Project, Dar es Salaam, Tanzania.
| | | | | | | | | |
Collapse
|
42
|
Liu E, Armstrong C, Spiegelman D, Chalamilla G, Njelekela M, Hawkins C, Hertzmark E, Li N, Aris E, Muhihi A, Semu H, Fawzi W. First-line antiretroviral therapy and changes in lipid levels over 3 years among HIV-infected adults in Tanzania. Clin Infect Dis 2013; 56:1820-8. [PMID: 23449270 DOI: 10.1093/cid/cit120] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND With the rapid rollout of antiretroviral therapy (ART) in sub-Saharan Africa (SSA), there has been an increasing concern about cardiovascular risks related to ART. However, data from human immunodeficiency virus (HIV)-infected populations from this region are very limited. METHODS Among 6385 HIV-infected adults in Dar es Salaam, Tanzania, we investigated the nonfasting lipid changes over 3 years following ART initiation and their associations with different first-line ART agents that are commonly used in SSA. RESULTS In the first 6 months of ART, the prevalence of dyslipidemia decreased from 69% to 54%, with triglyceride (TG) decreasing from 127 mg/dL to 113 mg/dL and high-density lipoprotein (HDL) cholesterol increasing from 39 mg/dL to 52 mg/dL. After 6 months, TG returned to its baseline level and increased to 139 mg/dL at 3 years; total cholesterol and low-density lipoprotein cholesterol continued to increase whereas HDL cholesterol leveled off. The prevalence of dyslipidemia increased to 73% after a 3-year follow-up. In multivariate analyses, patients on zidovudine-containing regimens had a greater reduction in TG levels at 6 months (-16.0 vs -6.3 mg/dL), and a lower increase at 3 years compared to patients on stavudine-containing regimens (2.1 vs 11.7 mg/dL, P < .001); patients on nevirapine-based regimens had a higher increase in HDL cholesterol levels at 3 years compared to those on efavirenz-based regimens (13.6 vs 9.5 mg/dL, P = .01). CONCLUSIONS Our findings support the latest World Health Organization guidelines on the substitution of stavudine in first-line ART in resource-limited settings, and provide further evidence for selection of lipid-friendly ART for patients in SSA.
Collapse
Affiliation(s)
- Enju Liu
- Department of Global Health and Population, Harvard School of Public Health, 1633 Tremont St, Rm 106, Boston, MA 02120, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Finkelstein JL, Manji KP, Duggan C, Hertzmark E, Mehta S, Msamanga GI, Spiegelman D, Fawzi WW. PREDICTORS OF INCIDENT TUBERCULOSIS IN HIV-EXPOSED CHILDREN IN TANZANIA. East Afr Med J 2012; 89:183-92. [PMID: 26856040 PMCID: PMC10864092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To examine the predictors of tuberculosis infection in HIV-exposed children. DESIGN A longitudinal cohort study nested within a randomised controlled trial. SETTING Antenatal clinics in Dar-es-Salaam, Tanzania. SUBJECTS Children born to 875 HIV-infected women in Tanzania. RESULTS A total of 82 children developed tuberculosis during the follow-up period. In multivariate analyses, HIV infection was associated with a six-fold increase in risk of tuberculosis. Breastfeeding duration, child mid-upper arm circumference, and maternal CD4 T-cell counts were inversely related to risk of tuberculosis. In HIV-infected children, greater number of people eating at the same household meal and child CD8 T-cell counts were associated with increased risk of tuberculosis; higher maternal lymphocyte counts, increased duration of breastfeeding, and lower vitamin E levels were associated with reduced risk of tuberculosis. In HIV-uninfected children, breastfeeding duration and increased child mid-upper arm circumference were associated with reduced risk of tuberculosis. CONCLUSION Breastfeeding duration, HIV status, maternal and child nutritional and immunological status were important predictors of child tuberculosis. Appropriate infant feeding and nutritional interventions could represent important adjuncts to prevent tuberculosis in children born to HIV-infected women in sub-Saharan Africa.
Collapse
Affiliation(s)
- J L Finkelstein
- Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | | | | | | | | | | | | | | |
Collapse
|
44
|
Ezeamama AE, Spiegelman D, Hertzmark E, Bosch RJ, Manji KP, Duggan C, Kupka R, Lo MW, Okuma JO, Kisenge R, Aboud S, Fawzi WW. HIV infection and the incidence of malaria among HIV-exposed children from Tanzania. J Infect Dis 2012; 205:1486-94. [PMID: 22457274 DOI: 10.1093/infdis/jis234] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To determine whether human immunodeficiency virus (HIV) infection is associated with increased risk of malaria incidence and recurrence in children. METHODS Newborn infants of HIV-infected mothers were enrolled at 6 weeks and followed for 2 years. HIV status was assessed by enzyme-linked immunosorbant assay and confirmed by HIV DNA polymerase chain reaction. Malaria was defined as (1) physician-diagnosed clinical malaria; (2) probable malaria, in which laboratory testing is requested for parasitemia; and (3) blood smear-confirmed malaria. Cox proportional hazards models estimated hazard ratios (HRs) for development of first and second malaria episodes, and generalized estimating equation models estimated malaria rate differences per 100-child-years in relation to time-updated HIV status. RESULTS Child HIV infection was associated with clinical (HR, 1.34; 95% confidence interval [CI], 1.12-1.61), probable (HR, 1.47; 95% CI, 1.19-1.81), and confirmed (HR, 1.67; 95% CI, 1.18-2.36) malaria episodes. Per 100 child-years, HIV-infected children experienced 88 (95% CI, 65-113), 36 (95% CI, 19-53), and 20 (95% CI, 9-31) more episodes of clinical, probable, and confirmed malaria episodes, respectively, than HIV-uninfected children. Among children with ≥1 malaria episodes, those with HIV infection developed second clinical (HR, 1.28; 95% CI, 1.04-1.57), probable (HR, 1.60; 95% CI, 1.26-2.14), and confirmed (HR, 2.27; 95% CI, 1.06-3.89) malaria sooner than HIV-uninfected children. CONCLUSIONS HIV infection is a risk factor for the development of malaria. Proactive malaria disease prevention and treatment is warranted for all children, particularly those with HIV infection in settings of coendemicity.
Collapse
Affiliation(s)
- Amara E Ezeamama
- Department of Nutrition, Harvard School of Public Health, Boston, MA 02115, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Mehta S, Mugusi FM, Spiegelman D, Villamor E, Finkelstein JL, Hertzmark E, Giovannucci EL, Msamanga GI, Fawzi WW. Vitamin D status and its association with morbidity including wasting and opportunistic illnesses in HIV-infected women in Tanzania. AIDS Patient Care STDS 2011; 25:579-85. [PMID: 21916603 DOI: 10.1089/apc.2011.0182] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Vitamin D has a potential role in preventing HIV-related complications, based on its extensive involvement in immune and metabolic function, including preventing osteoporosis and premature cardiovascular disease. However, this association has not been examined in large studies or in resource-limited settings. Vitamin D levels were assessed in 884 HIV-infected pregnant women at enrollment in a trial of multivitamin supplementation (excluding vitamin D) in Tanzania. Information on HIV related complications was recorded during follow-up (median, 70 months). Proportional hazards models and generalized estimating equations were used to assess the relationship of vitamin D status with these outcomes. Women with low vitamin D status (serum 25-hydroxyvitamin D<32 ng/mL) had 43% higher risk of reaching a body mass index (BMI) less than 18 kg/m(2) during the first 2 years of follow-up, compared to women with adequate vitamin D levels (hazard ratio [HR]: 1.43; 95% confidence intervals: [1.03-1.99]). The relationship between continuous vitamin D levels and risk of BMI less than 18 kg/m(2) during follow-up was inverse and linear (p=0.03). Women with low vitamin D levels had significantly higher incidence of acute upper respiratory infections (HR: 1.27 [1.04-1.54]) and thrush (HR: 2.74 [1.29-5.83]) diagnosed during the first 2 years of follow-up. Low vitamin D status was a significant risk factor for wasting and HIV-related complications such as thrush during follow-up in this prospective cohort in Tanzania. If these protective associations are confirmed in randomized trials, vitamin D supplementation could represent a simple and inexpensive method to improve health and quality of life of HIV-infected patients, particularly in resource-limited settings.
Collapse
Affiliation(s)
- Saurabh Mehta
- Division of Nutritional Sciences, Cornell University, Ithaca, New York
| | - Ferdinand M. Mugusi
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Donna Spiegelman
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Eduardo Villamor
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
- Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts
- Departments of Epidemiology and Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, Michigan
| | | | - Ellen Hertzmark
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
| | - Edward L. Giovannucci
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
- Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts
- Channing Laboratory, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Gernard I. Msamanga
- Department of Community Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Wafaie W. Fawzi
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
- Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts
| |
Collapse
|
46
|
Mehta S, Spiegelman D, Aboud S, Giovannucci EL, Msamanga GI, Hertzmark E, Mugusi FM, Hunter DJ, Fawzi WW. Lipid-soluble vitamins A, D, and E in HIV-infected pregnant women in Tanzania. Eur J Clin Nutr 2010; 64:808-17. [PMID: 20517330 DOI: 10.1038/ejcn.2010.76] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND/OBJECTIVES There is limited published research examining lipid-soluble vitamins in human immunodeficiency virus (HIV)-infected pregnant women, particularly in resource-limited settings. SUBJECTS/METHODS This is an observational analysis of 1078 HIV-infected pregnant women enrolled in a trial of vitamin supplementation in Tanzania. Baseline data on sociodemographic and anthropometric characteristics, clinical signs and symptoms, and laboratory parameters were used to identify correlates of low plasma vitamin A (<0.7 micromol/l), vitamin D (<80 nmol/l) and vitamin E (<9.7 micromol/l) status. Binomial regression was used to estimate risk ratios and 95% confidence intervals. RESULTS Approximately 35, 39 and 51% of the women had low levels of vitamins A, D and E, respectively. Severe anemia (hemoglobin <85 g/l; P<0.01), plasma vitamin E (P=0.02), selenium (P=0.01) and vitamin D (P=0.02) concentrations were significant correlates of low vitamin A status in multivariate models. Erythrocyte Sedimentation Rate (ESR) was independently related to low vitamin A status in a nonlinear manner (P=0.01). The correlates of low vitamin D status were CD8 cell count (P=0.01), high ESR (ESR >81 mm/h; P<0.01), gestational age at enrollment (nonlinear; P=0.03) and plasma vitamins A (P=0.02) and E (P=0.01). For low vitamin E status, the correlates were money spent on food per household per day (P<0.01), plasma vitamin A concentration (nonlinear; P<0.01) and a gestational age <16 weeks at enrollment (P<0.01). CONCLUSIONS Low concentrations of lipid-soluble vitamins are widely prevalent among HIV-infected women in Tanzania and are correlated with other nutritional insufficiencies. Identifying HIV-infected persons at greater risk of poor nutritional status and infections may help inform design and implementation of appropriate interventions.
Collapse
Affiliation(s)
- S Mehta
- Department of Epidemiology, Harvard School of Public Health, Boston, MA 02115, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Mgomella GS, Venkatesh PA, Bosch RJ, Mwakagile D, Urassa W, McIntosh K, Hertzmark E, Msamanga G, Fawzi WW. The use of total lymphocyte count as a surrogate for low CD4+ T lymphocyte cell counts among HIV-1-infected women in Tanzania. East Afr J Public Health 2010; 7:160-164. [PMID: 21413596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Human Immunodeficiency Virus type 1 (HIV-1) infection leads to a progressive decline in CD4+ T-lymphocyte (CD4) cells. Initiation of prophylaxis against Opportunistic infections in adults (CD4% used for children) and antiretroviral therapy is usually based on CD4 cell counts, but CD4 cell counts measurement is not affordable in most African countries. OBJECTIVE To examine whether total lymphocyte counts (TLC) may be used as proxies for low CD4 cell counts. DESIGN Cross-sectional at baseline when women were pregnant and at least six months postpartum. METHODS 1,078 HIV-1-infected pregnant women from Dar es Salaam, Tanzania were enrolled in a randomized clinical trial. A series of receiver operator characteristic (ROC) curves were created at baseline and at least 6 months postpartum and among women in WHO Stage 3 and above. The sensitivity and specificity of TLC and hemoglobin in predicting an absolute CD4 count < 200 cells/mm3 were determined for various clinically relevant cut points. RESULTS TLC was not a good predictor of low CD4 cell counts during pregnancy or at least six months postpartum as exhibited by low ROC Area Under the Curve (AUCs) of .57 and .62 respectively. No other variable had the ability to predict CD4 < 200 cells/mm3. CONCLUSIONS The use of TLC as a proxy for the estimation of low CD4 cell counts in a population of HIV-1-infected adults from sub-Saharan Africa was not substantiated. Inexpensive methods to quantify CD4 cell counts in Africa are needed.
Collapse
Affiliation(s)
- G S Mgomella
- MUHAS-Harvard Informatics Training Project, Project. P.O.Box 65015, Dar es Salaam, Tanzania.
| | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Abstract
PURPOSE Animal and in vitro studies suggest that aspirin may inhibit breast cancer metastasis. We studied whether aspirin use among women with breast cancer decreased their risk of death from breast cancer. METHODS This was a prospective observational study based on responses from 4,164 female registered nurses in the Nurses' Health Study who were diagnosed with stages I, II, or III breast cancer between 1976 and 2002 and were observed until death or June 2006, whichever came first. The main outcome was breast cancer mortality risk according to number of days per week of aspirin use (0, 1, 2 to 5, or 6 to 7 days) first assessed at least 12 months after diagnosis and updated. RESULTS There were 341 breast cancer deaths. Aspirin use was associated with a decreased risk of breast cancer death. The adjusted relative risks (RRs) for 1, 2 to 5, and 6 to 7 days of aspirin use per week compared with no use were 1.07 (95% CI, 0.70 to 1.63), 0.29 (95% CI, 0.16 to 0.52), and 0.36 (95% CI, 0.24 to 0.54), respectively (test for linear trend, P < .001). This association did not differ appreciably by stage, menopausal status, body mass index, or estrogen receptor status. Results were similar for distant recurrence. The adjusted RRs were 0.91 (95% CI, 0.62 to 1.33), 0.40 (95% CI, 0.24 to 0.65), and 0.57 (95% CI, 0.39 to 0.82; test for trend, P = .03) for 1, 2 to 5, and 6 to 7 days of aspirin use, respectively. CONCLUSION Among women living at least 1 year after a breast cancer diagnosis, aspirin use was associated with a decreased risk of distant recurrence and breast cancer death.
Collapse
Affiliation(s)
- Michelle D Holmes
- Channing Laboratory, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
| | | | | | | | | | | |
Collapse
|
49
|
Mehta S, Giovannucci E, Mugusi FM, Spiegelman D, Aboud S, Hertzmark E, Msamanga GI, Hunter D, Fawzi WW. Vitamin D status of HIV-infected women and its association with HIV disease progression, anemia, and mortality. PLoS One 2010; 5:e8770. [PMID: 20098738 PMCID: PMC2808247 DOI: 10.1371/journal.pone.0008770] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2009] [Accepted: 12/28/2009] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Vitamin D has a potential role in slowing HIV disease progression and preventing mortality based on its extensive involvement in the immune system; however, this relationship has not been examined in large studies or in resource-limited settings. METHODOLOGY/PRINCIPAL FINDINGS Vitamin D levels were assessed in 884 HIV-infected pregnant women at enrollment in a trial of multivitamin supplementation (not including vitamin D) in Tanzania. Women were followed up for a median of 69.5 months, and information on hemoglobin levels, HIV disease progression, and mortality was recorded. Proportional hazard models and generalized estimating equations were used to assess the relationship of these outcomes with vitamin D status. CONCLUSIONS/SIGNIFICANCE Low vitamin D status (serum 25-hydroxyvitamin D<32 ng/mL) was significantly associated with progression to WHO HIV disease stage III or greater in multivariate models (incidence rate ratio [RR]: 1.25; 95% confidence intervals [CI]: 1.05, 1.50). No significant relationship was observed between vitamin D status and T-cell counts during follow-up. Women with low vitamin D status had 46% higher risk of developing severe anemia during follow-up, compared to women with adequate vitamin D levels (RR: 1.46; 95% CI: 1.09, 1.96). Women in the highest vitamin D quintile had a 42% lower risk of all-cause mortality, compared to the lowest quintile (RR: 0.58; 95% CI: 0.40, 0.84). Vitamin D status had a protective association with HIV disease progression, all-cause mortality, and development of anemia during follow-up in HIV-infected women. If confirmed in randomized trials, vitamin D supplementation could represent a simple and inexpensive method to prolonging the time to initiation of antiretroviral therapy in HIV-infected patients, particularly in resource-limited settings.
Collapse
Affiliation(s)
- Saurabh Mehta
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, United States of America.
| | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Mehta S, Hunter DJ, Mugusi FM, Spiegelman D, Manji KP, Giovannucci EL, Hertzmark E, Msamanga GI, Fawzi WW. Perinatal outcomes, including mother-to-child transmission of HIV, and child mortality and their association with maternal vitamin D status in Tanzania. J Infect Dis 2009; 200:1022-30. [PMID: 19673647 DOI: 10.1086/605699] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Vitamin D is a strong immunomodulator and may protect against adverse pregnancy outcomes, mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV), and child mortality. METHODS A total of 884 HIV-infected pregnant women who were participating in a vitamin supplementation trial in Tanzania were monitored to assess pregnancy outcomes and child mortality. The association of these outcomes with maternal vitamin D status at enrollment was examined in an observational analysis. RESULTS No association was observed between maternal vitamin D status and adverse pregnancy outcomes, including low birth weight and preterm birth. In multivariate models, a low maternal vitamin D level (<32 ng/mL) was associated with a 50% higher risk (95% confidence interval [CI], 2%-120%) of MTCT of HIV at 6 weeks, a 2-fold higher risk of MTCT of HIV through breast-feeding among children who were HIV uninfected at 6 weeks (95% CI, 1.08-3.82), and a 46% higher overall risk of HIV infection (95% CI, 11%-91%). Children born to women with a low vitamin D level had a 61% higher risk of dying during follow-up (95% CI, 25%-107%). CONCLUSIONS If found to be efficacious in randomized trials, vitamin D supplementation could prove to be an inexpensive method of reducing the burden of HIV infection and death among children, particularly in resource-limited settings.
Collapse
Affiliation(s)
- Saurabh Mehta
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts 02115, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|