Diet quality predicts HIV progression and death in resource-poor settings

The more diverse and nutrient-rich the diet before starting antiretroviral treatment (ART), the less severe HIV disease progression is, and the less likely death occurs, researchers report in the advance online edition of the Journal of Acquired Immune Deficiency Syndromes. The study involveda cohort of over 800 people living with HIV (PLHIV) in Uganda.

“Our findings demonstrate the importance of diet quality to the health of PLHIV, an important contribution considering the World Food Programme (WFP), the World Health Organization (WHO), UNAIDS and PEPFAR have recommended integration of food assistance into AIDS care and treatment programmes,” the authors comment.

In this secondary analysis of the evaluation of a WFP-supported food-assistance programme for PLHIV, cross-sectional analysis of baseline food consumption showed that each addition of a nutrient-rich food group was linked to a 16% reduction in the likelihood of having a CD4 cell count below or equal to 350 cells/mm³ (adjusted odds ratio [aOR]: 0.84, 95% CI: 0.72-0.97).

Among those with CD4 cell counts over 350 but not among those under 350 at baseline, consumption of nutrient-rich food groups was linked to a lower risk of moderate anaemia (aOR 0.57, 95% CI: 0.34-0.96).

The important role of nutrition in health and disease is well understood.

Food insecurity (limited access for physical, social and/or economic reasons to nutritious food to meet dietary needs for an active and healthy life) is recognised as increasing vulnerability to HIV infection, opportunistic infections, HIV disease progression, increased hospitalisations and death.

Most research, the authors note, has been focussed on one element of food insecurity – food access. Little attention, they add, has been on how nutrient-rich foods and diet quality may be related to HIV disease progression and severity.

For many rural populations in sub-Saharan Africa having a diverse diet adequate to meet basic nutritional needs is a constant challenge.

While the impact of HIV on health in sub-Saharan Africa has been devastating, it has also adversely affected food security and diet quality in households affected by HIV.

So the authors chose to look at diet quality and HIV disease progression, moderate anaemia and death among HIV-infected adults in a resource-poor setting.

The primary (WFP) evaluation comprised adults registered between July 2008 and August 2009 at The AIDS Support Organisation (TASO). A total of 450 participants were each recruited from two districts: Gulu (getting the food assistance intervention) and Siroti (serving as a comparison). Participants were interviewed and followed for an average of 21.6 months.

The authors undertook a cross-sectional analysis of the data from the baseline survey of the evaluation and obtained death data from medical records.

The analysis looked at the association between baseline dietary diversity and immunosuppression (baseline CD4 cell counts under 350 cells/mm³) and moderate anaemia (haemoglobin under 10g/dl). In addition, the authors used a prospective cohort to look at the association between baseline dietary diversity and death. Participant data was collected at the point at which they initiated antiretroviral therapy (at the time this study was conducted treatment was recommended in Uganda when the CD4 cell count fell below 200 cells).

Dietary quality was measured using the Individual Dietary Diversity Score (IDDS range 0 to 20), a proxy measure for the nutritional quality of an individual’s diet.

The IDDS uses the number of different food groups eaten in the 24 hours before the interview from the following 12 groups:

1. cereals

2. roots and tubers

3. pulses, legumes and nuts

4. vegetables

5. fruits

6. meat and poultry

7. eggs

8. fish and seafood

9. milk and milk products

10. oils and fats

11. sugar and sweets

12. condiments and miscellaneous.

In addition to an overall IDDS score, the authors grouped the 12 categories into three sub-groups with a score for each:

1. nutrient rich foods (range 0 to 7)

2. cereals, roots and tubers (range 0 to 2)

3. oils, fats and condiments (range 0 to 3).

The dietary pattern in Uganda comprises starchy staple foods, high consumption of sugars, fats and oil and low consumption of foods rich in proteins and micronutrients. In this context, the authors categorised nutrient-rich foods to include: pulses, legumes and nuts; vegetables; fruits; meat and poultry; eggs; fish and seafood; and milk and milk products.

The mean IDDS score was 6.3 (standard deviation [SD] 1.7) food groups each day, with a mean of 2.7 (SD 1.1) nutrient rich food groups each day. Overall, 197  participants (22%) consumed a high level of nutrient-rich foods at baseline (4 to 7 food groups each day).

During a 22-month follow-up period, it was found that the more diverse and nutrient-rich the diet at baseline, the more protective it was against death. Of the 48 (5.6%) who died, only six (13%) were among those consuming high levels of nutrient-rich foods.

While anaemia has multiple causes, it is acknowledged to be a major consequence of HIV infection and strongly linked to disease progression and death.

Given their observations, the authors suggest “nutritional deficiencies possibly comprise a larger attributable fraction for anemia in individuals with less advanced HIV disease... when anemia is less affected by HIV infection.”

Conversely, when HIV is more advanced, the infection plays a greater role in the development of anaemia, although nutritional deficiencies remain common.

The results, the authors note, highlight the importance of ensuring high-quality diets, especially in resource-poor settings “where the vicious cycle of HIV/AIDS and food insecurity is the most acute”.

Food interventions have the potential to limit the ways in which food insecurity and poor diet compromise the health of HIV-positive people.

Studies have shown the positive effect of food supplementation on adherence and clinical outcomes. 

The WFP provides food and nutrition support to more than 1.4 million food-insecure and malnourished people living with and affected by HIV, the authors write. While the immediate goal is to manage malnutrition, the long-term goal is to help get people back into the workforce and maintain future food security.

Food, vouchers or cash offer critical short-term support, while livelihood interventions and social protection schemes aim to improve food security and diet quality in the long term, the authors note.

While previous findings have shown a link between food security and severity of HIV disease the authors believe this to be the first study showing the link between nutrient-rich food consumption and HIV disease severity and death. The strengths of this study include a large sample size, use of a validated dietary measure and prospective data on death.

The authors conclude: ”our data may help guide the types of food assistance provided and essential elements of nutrition education and counselling that increase the likelihood of improving dietary diversity… highlight the need for future research to determine the most cost-effective approaches to improve diet quality in both the short- and long-terms.”

Rawat R et al. Poor diet quality is associated with low CD4 count and anemia and predicts mortality among antiretroviral therapy naive HIV-positive adults in Uganda. Advance online edition J Acquir Immun Defic Syndr. Doi: 10.1097/QAI.0b013e3182797363, 2012.