Nutritional Needs Among HIV positive people in Nepal

Dilip Upreti (PhD Student)(MA, MSc)

Supervisors

Prof. Geraldine McNeillDr. Janet Kyle

Dr. Janine ThoulassDr. Padam Simkhada

Presentation overview

HIV/AIDS and Nutrition in Nepal

Diet and People Living with HIV/AIDS (PLHA) in Nepal

main study Objectives

Validation and pilot study

Field work

Results

Summary of finding and future work

Key facts about Nepal

• Demographic Population: 30 million Life expectancy: 67 years

• HIV/AIDS First HIV case documented in 1988 Estimated by UNAIDS: 63,528 PLHA Prevalence rate 0.39% (15-49 yrs) Government records: 18237 (M:11787& F: 6450)

• Diet Global Hunger Index for Nepal is 21 and ranks 57th out of 88 countries 25 % women have low BMI (cut off ≤ 18.5) with high prevalence in terai (40%) 29 % children were under weight

Source: NCASC, 2011; NDHS 2011 ; UNAIDS 2011; MoH/UNICEF/WHO/MI/New Era (1998); FAO/WFP 2007, based on NLSS (2003/04)

% of undernourishment in Nepal

DER<1810 kcal/d/p DER<1910 kcal/d/p DER<2124 kcal/d/p

21 29 41

HIV/AIDS and Nutrition

• Poor Nutrition• (Weight Loss, muscle

wasting, weakness, micronutrient

deficiency)

• Increased Risk of Infection• (E.g. gut infections, diarrhea for

long time and TB leading too faster progression to AIDS)

• HIV/AIDS

• Impaired Immune System

• (Poor ability to fight HIV• and other infection)

• Increased Nutritional Needs

• (Due to malabsorption & • decreased intake)

Source: Edwards (2006); NDD (2004); Semba and Tang (1999)

Vicious cycle of HIV/AIDS and Nutrition

HIV/AIDS and Nutrition

Increased energy requirements

10% during asymptomatic stages

20-30% if contract secondary infections

50-100% for children / pregnant women

Study objectives

• Investigating diet of People Living with HIV/AIDS in Nepal

Assess dietary and nutrient intakeMeasure anthropometric statusRecord knowledge and practice towards the good diet Collect socio-economic and demographic characteristics.Identify factors influencing dietary intake. Assess associations between dietary intake, nutritional and

anthropometric status and demographic characteristics

• To make recommendations for future nutritional intervention programmes for PLHA in Nepal

Development of questionnaire and Nutrient databases

Development of PLHA Nepal questionnaire and FFQ

Validation and pilot study

Finalise Nepal questionnaire, FFQ and nutrient database for

main study

Data entry and analysis of validation and pilot study

Compile new nutrient composition database

for Nepal

Nepal questionnaire

Food frequency questionnaire

Food frequency questionnaire

Anthropometric measurement

Validation (n=73; M 43 and F 30)

Nutrients FFQ

Energy(kcal) /day 2030 ± 504

Fat(g) /day 28.97 ± 13.04 Fat % of energy/day 12.69 ± 4.24Protein(g) /day 59.97 ± 15.81Protein % of energy/day 11.86 ± 1.53Carbohydrate(g) /day 385.5 ± 96.53Carbohydrate % of energy/day

76.12 ± 5.42

Iron(mg) /day 18.02 ± 5.31Carotene(µg) /day 2219 ± 661Vitamin A/day b 370 ± 110

Vitamin C(mg) /day 48.79 ± 15.1

a Difference in mean, upper and lower values at 95% of CI(± 2SD); b(retinol equivalents = carotene/6)

Dietary intake (mean ± SD)

Validation (n=73; M 43 and F 30)

Nutrients FFQ 24-h recall

Energy(kcal) /day 2030 ± 504 2046 ± 469

Fat(g) /day 28.97 ± 13.04 36.2 ± 18.3Fat % of energy/day 12.69 ± 4.24 15.6 ±7.08Protein(g) /day 59.97 ± 15.81 60.67 ± 16.1Protein % of energy/day 11.86 ± 1.53 11.84 ± 2.11Carbohydrate(g) /day 385.5 ± 96.53 383.2 ± 86.5Carbohydrate % of energy/day

76.12 ± 5.42 75.52 ± 8.02

Iron(mg) /day 18.02 ± 5.31 16.6 ± 8.9Carotene(µg) /day 2219 ± 661 2082 ± 1160Vitamin A/day b 370 ± 110 347 ± 193

Vitamin C(mg) /day 48.79 ± 15.1 49.34 ± 20.14

a Difference in mean, upper and lower values at 95% of CI(± 2SD); b(retinol equivalents = carotene/6)

Dietary intake (mean ± SD)

Validation (n=73; M 43 and F 30)

Nutrients FFQ 24-h recall Sig diff (P) Bland-Altman a

Energy(kcal) /day 2030 ± 504 2046 ± 469 0.745 - 16.8 (860.7; - 894.3)

Fat(g) /day 28.97 ± 13.04 36.2 ± 18.3 <0.001 - 7.21(26.23; - 40.65)Fat % of energy/day 12.69 ± 4.24 15.6 ±7.08 <0.001Protein(g) /day 59.97 ± 15.81 60.67 ± 16.1 0.705 - 0.7 (30.58; - 31.98)Protein % of energy/day 11.86 ± 1.53 11.84 ± 2.11 0.924Carbohydrate(g) /day 385.5 ± 96.53 383.2 ± 86.5 0.827 2.26 (178.1; - 173.6)Carbohydrate % of energy/day

76.12 ± 5.42 75.52 ± 8.02 0.523

Iron(mg) /day 18.02 ± 5.31 16.6 ± 8.9 0.204 1.47 (21.01; - 18.07)Carotene(µg) /day 2219 ± 661 2082 ± 1160 0.341 136.6 (2571; - 2298)Vitamin A/day b 370 ± 110 347 ± 193 0.341 22.76 (428.6; -383)

Vitamin C(mg) /day 48.79 ± 15.1 49.34 ± 20.14 0.829 - 0.54 (42.32; - 43.4)

a Difference in mean, upper and lower values at 95% of CI(± 2SD); b (retinol equivalents = carotene/6)

Dietary intake (mean ± SD)

Dietary surveillance of PLHA in Nepal

• Method Cross-sectional Interviewer administered General information Dietary intake Anthropometrics measurement

• Study population People Living HIV/AIDS (PLHA) in Nepal

• Location 2 regions of Nepal: Kathmandu valley and Terai highway

• Sample size and sampling method 601 (M:314 and F:297) Purposive sampling method was used

• Consent Participants gave written consent Study approved both locally in Nepal & Aberdeen

Basic demographic characteristics (%)

Variables All Male Female National data

Participants 601 314 (52) 287(48) (M:46 & F: 54)

Age (Mean ± 2SD) 33.81 ± 6.42 35 ± 6.05 32 ± 6.52 21.6 (M:20.7 & F: 22.5 )

(17-27) yrs 17 10 24 18.4 (28-38) yrs 60 63 58 18.2 (39-49) yrs 23 27 18 9.2

Total literate 73 89 55 49 (M: 63 & F:35)

Place of residence Rural 51 40 62 85 Urban 49 60 38 15

Source: Nepal Living Standards Survey 2011 and CBS 2001

Economic characteristics (%)

Variables All (601) Male (314) Female (287)Main source of income Daily labor 31 26 37 Agriculture 27 25 28 Business 21 27 14 Services 21 22 21Occupation Manual 69 63 75 Non-manual 28 32 23 Unemployed 3 5 2

Sufficient annual income for food Yes 54 65 41 No 46 35 59

Food to be borrowed in a year (n=278) < 3 months 43 42 43 > 4 months 57 58 57

Living with HIV & receiving Anti Retroviral Therapy

ART users69%

PLHA on ART

<2 yrs49%2-4yrs

30%

>4 yrs21%

Numbers of years taking ART

4 -8 yrs (55%)

> 8 yrs (14%)

Numbers of years living with HIV

<4yrs (31%)

ART non-users

31%

What PLHA think as a good diet?

Honey and sweets

Healthy and fresh food

Ghee, butter and fat

Fortified foods

Egg

Milk and milk product

Dahl+Rice+Curry

Fruits and Fruit juice

Pulses and Legumes

Vegetables

Meat and fish

0 10 20 30 40 50 60 70 80

311

1732

4651

6265

7072

percentage

Nam

e of

food

s

92 % (n=554) reported that they have knowledge on good diet

Why PLHA change their diet?

Prevent from OIs

Increase the effectiveness of ART

Keep strong immunity

Required more energy

Maintain good health

Prolong the life

0 10 20 30 40 50 60 70 80 90

22

33

43

50

65

84

percentage of subjects

Reso

ns fo

r die

tary

cha

nge

82 % (n=492) reported they need different diet than other people43 % (n=260) change their dietary intake habit

Reasons for dietary change

BMI according to gender and place of residence

Variables TotalTotal BMI (Median and IQR)

Total 601 20.15 (18.22;22.27)

Male 314 (52) 20.17 (18.18;21.94)

Female 287 (48) 20.11 (18.27;22.71)

Rural 303 (50) 19.51 (17.70;21.38)

Urban 298 (50) 20.77 (18.80; 22.93)

BMI according to gender and place of residence

Variables Total

Total BMI (Median and IQR)

Stages of BMI (%)

Under weight

Normal weight

Over weight

Total 601 20.15 (18.22;22.27) 29 62 9

Male 314 (52) 20.17 (18.18;21.94) 29 65 6

Female 287 (48) 20.11 (18.27;22.71) 28 59 13

Rural 303 (50) 19.51 (17.70;21.38) 34 61 4

Urban 298 (50) 20.77 (18.80; 22.93) 23 63 14

Dietary intake (mean ±SD)

Nutrients AllGender WHO/FAO

recommendation a

Male (314) Female (287) Male Female

Energy (kcal)/day 1922 ± 232.4 1960 ± 195 1880 ± 261.3 2550 1940

Fat % energy 12.09 ± 2.43 12.26 ± 2.29 11.90 ± 2.56 15-30 15-30

Protein % energy 10.82 ± 0.78 10.86 ± 0.76 10.77 ± 0.81 10-15 10-15

Carbohydrate % energy 79.07 ± 2.70 78.94 ± 2.67 79.21 ± 2.74 55-75 55-75

Iron (mg)/day 12.16 ± 2.56 12.12 ± 2.41 12.21 ± 2.72 8.7 14.8

Carotene (µg)/day 1764 ± 351.8 1783 ± 352.9 1744 ± 350.1

Vitamin A (µg)/day V 294 ± 58.63 297.2 ± 58.82 233 ± 58.35 600 500

Vitamin C (mg)/day 48.54 ± 8.78 49.53 ± 8.59 47.46 ± 8.88 30 30

a Age (19-50) year; *p<0.05; **p<0.01;***p<0.001, V (retinol equivalents = carotene/6)

Assessment of association: diet & lifestyle

No association with energy or nutrient intake and:ART and Non-ART groupPlace of residenceRegion of residenceBMI stages

Association with Energy intake and:Literacy (p=0.019)Level of education (p=0.025)Source of income (p<0.001)Occupation (p=0.030)Household income (p= 0.001)Health status (p<0.001)Smoking (p=0.031)Knowledge on good diet (p=0.007)

Qualitative study

Four Focus group discussion

Ten in-depth interview

Data under analysis......

To make recommendations for future nutritional intervention programmes for PLHA in Nepal

Summary and further work

• Summary Newly designed FFQ for assessing dietary intake of PLHA, it has reasonable

agreement with reference method (24h recall). BMI shows that 29% subjects are malnourished (below cutoff point 18.5) No difference in dietary intake between ATR and non-ART group WHO recommendations

Energy , fat, vitamin A intake is lower for men and women iron intake are lower of women

• Further work In-depth analysis of results Qualitative data analysis Write-up Need further research to design the suitable dietary intervention programme

among this group

Any questions

THANK YOU VERY MUCH

Background

• “Taking antiretroviral drugs on an empty stomach is like digesting razor blades” (The Guardian 2009)

• Less chance to benefit from ART in people who are already malnourished (Zachariah et al 2006 and Paton et al 2006)

• Multivitamins are beneficial to reduce HIV replication (Schreck 1991)

• In a double-blinded placebo-controlled trial among ART receivers: CD4 count increased by an average of 65 cells in the micronutrient group but there was a 6-cell decline in placebo group (P = 0.029). (Kaiser et al 2006)

• Adherences to ART was higher among patients in the food group in comparison with controls: 70%Vs 48% (Ronald A et al (2008). JAIDS; 49 (2): 190-195 )

Validation (n=20; M 12 and F 8)

Nutrients Mean from 1st recall

Mean from 2nd recall

Sig diff (P) Bland-Altman a

Energy(kcal) /day1947 ± 336.3 2030 ± 282.3 0.384 -83.06 (750; -961.1)

Fat(g) /day 35.69 ± 18.87 30.77 ± 14.71 0.285 4.92 (44.86; -35.02)Fat % of energy/day 16.52 ± 9.17 13.26 ± 5.23 0.128 3.26 (21.58; -15.06)Protein(g) /day 62.80 ± 16.07 59.71 ± 14.01 0.514 3.08 (44.56; -38.4)Protein % of energy/day 12.87 ± 2.45 11.75 ± 2.29 0.125 1.12 (7.34; -5.1)Carbohydrate(g) /day 361.8 ± 68.97 388.8 ± 50.28 0.151 -27.05 (134.6; -188.7)Carbohydrate % of energy/day 74.44 ± 8.80 76.92 ± 6.13 0.230 -2.48 (15.44; -20.4)Iron(mg) /day 14.87 ± 7.88 19.03 ± 6.76 0.093 -4.16 (16.84; -25.14)Carotene(µg) /day 1965 ± 1001 2118 ± 997.1 0.631 -153.3 (2653; -2959)Vitamin A/day b

327.5 ± 166.8 353 ± 166.2 0.631 -25.55 (442.3; 493.4)Vitamin C(mg) /day

43.89 ± 18.10 48.92 ± 18.30 0.405 -5.03 (47.81; 57.87)

a Difference in mean, upper and lower values at 95% of CI(± 2SD); b (retinol equivalents = carotene/6)

Dietary intake (mean ± SD) from two 24-h recall

Iron and vitamin A

• 66% women and 78% preschool children were affected by anaemia

• 58 % of pre-school children had an inadequate vitamin A intake

• 32% lactating, 41% pregnant and 49% non-pregnant women consumed adequate Vitamin A

FAO/WFP 2007, based on NLSS (2003/04)Source: MoH/UNICEF/WHO/MI/New Era (1998)

Details of ART

Calibration