Original research article
Dietary intake and nutritional status of HIV-1-infected children and adolescents in Floriano´polis, Brazil
International Journal of STD & AIDS 2014, Vol. 25(6) 439–447 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462413512808 std.sagepub.com
Elaine Hillesheim1, Luiz RA Lima2, Rosane CR Silva2 and Erasmo BSM Trindade1
Abstract This cross-sectional study aimed to investigate the nutritional status and dietary intake of HIV-infected children and adolescents and the relationship between nutritional status and dietary intake and CD4þ T-cell count and viral load. The sample was composed of 49 subjects aged 7–17 years and living in Floriano´polis, Brazil. Nutritional status was assessed by height-for-age and body mass index-for-age. Dietary intake was assessed by a food frequency questionnaire. Spearman correlations and multiple linear regressions were used to determine the relationship between energy, nutrient intake and body mass index-for-age and CD4þ T-cell count and viral load. The mean body mass index-for-age and heightfor-age values were –0.26 0.86 and 0.56 0.92, respectively. The energy intake was 50.8% above the estimated energy requirement and inadequate intake of polyunsaturated fat, cholesterol, fibre, calcium and vitamin C was present in 100%, 57.1%, 40.8%, 61.2% and 26.5% of the sample, respectively. Multiple linear regression analyses revealed that energy intake was correlated with CD4þ T-cell count (r ¼ 0.33; p ¼ 0.028) and viral load (r ¼ 0.35; p ¼ 0.019). These data showed low body mass index-for-age and height-for-age z-scores, high energy intake and inadequate intake of important nutrients for immune function, growth and control of chronic diseases. A lower energy intake was correlated with viral suppression and immune preservation.
Keywords HIV, AIDS, malnutrition, diet, nutritional status, child, adolescent Date received: 2 July 2013; accepted: 1 October 2013
Introduction For many years, malnutrition was commonly observed in HIV-infected children and adolescents around the world, with a significant decrease in body fat and lean and bone mass compared to the healthy population.1,2 After highly active antiretroviral therapy (HAART) introduction, there was significant improvement in nutritional status, but adverse effects such as body fat redistribution, insulin resistance and hyperlipidaemia were observed.3 Growth and physical development delay have been reported as intrinsic to infection4,5; these delays may be influenced by changes in dietary intake and nutrient absorption.6 The synergistic interaction between nutritional status, progression of HIV infection and the immune system is well documented. HIV infection affects nutritional status, as the infection produces functional changes in the gastrointestinal tract which decrease dietary intake and nutrient absorption.6 Additionally,
there is an increase in the basal metabolic rate in response to inflammation, opportunistic infections and viral replication, which triggers increased release of pro-oxidants, cytokines and reactive oxygen species resulting in higher use of vitamins and minerals.7 On the other hand, the nutritional status of patients affects the infection due to the possibility of immune modulation and changes in the general clinical status.6 In this two-way relationship, HIV infection establishes the risk 1 Department of Nutrition, Federal University of Santa Catarina, Floriano´polis, Brazil 2 Department of Physical Education, Federal University of Santa Catarina, Floriano´polis, Brazil
Corresponding author: Erasmo Benicio Santos de Moraes Trindade, Universidade Federal de Santa Catarina – UFSC, Departamento de Nutric¸a˜o, Bairro Trindade, Floriano´polis, SC, Brasil, CEP 88040-900. Email: [email protected]
Downloaded from std.sagepub.com at Mount Royal University on June 9, 2015
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International Journal of STD & AIDS 25(6)
of poor nutritional status, although its severity varies according to both macronutrient and micronutrient intake. Knowledge of habitual dietary intake and nutritional status of HIV-infected children and adolescents and their relationship with immunological markers of infection may contribute to the establishment of early and effective nutritional interventions for maintaining and recovering growth and immune function. In contrast to adults,8–10 there are few reports on dietary intake of HIV-infected youth related to immunological markers of infection. Thus, the aim of the present study was two-fold: to evaluate the dietary intake and nutritional status of a group of HIV-infected children and adolescents living in Floriano´polis, Brazil, and to determine their associations with CD4þ T-cell count and viral load.
measurement errors were 0.51 kg and 0.19 cm for weight and height, respectively. Nutritional status was assessed by z-score from the anthropometric indicators height-for-age (H/A) and body mass index-for-age (BMI/A).12
Clinical measurements Immunological data, including CD4þ T-cell count, CD8þ T-cell count and viral load, were obtained from medical records and used to categorize immunosuppression.13 Viral load was considered undetectable if HIV RNA was under 50 copies/ml. The HIV RNA viral load and CD4þ and CD8þ T-cells counts were determined by the branched DNA (b-DNA) method and flow cytometry, respectively.
Dietary assessment Methods Study design and sample This cross-sectional observational study was carried out between June and November 2010 with HIV-1infected children and adolescents who received treatment at Hospital Infantil Joana de Gusma˜o. The subjects were selected by a non-probabilistic method using the following inclusion criteria: having acquired HIV by mother-to-child transmission, having both clinical and laboratory data in the medical records, being between 7 and 17 years of age, having no signs or symptoms of chronic diseases and no use of medication that altered body composition or nutritional status. Sixty-eight subjects were considered eligible for the study; however, eight subjects did not participate due to lack of time or interest, and 11 did not attend the evaluation after two or more contacts. No subjects withdrew from the evaluation during the study. The final sample was 49 subjects. All procedures were approved by the Institutional Ethics Committee in Human Research under the protocol number 077/2009. Informed consent was obtained from all participants and their guardians.
Dietary intake was assessed by a simplified version of the Food Frequency Questionnaire for Adolescents (FFQA) validated by Slater et al.14 for healthy Brazilian adolescents. This questionnaire is a semiquantitative food frequency questionnaire with 58 foods/preparations. The questionnaire was completed via an interview by a trained dietitian and directed to the guardians when the participant was younger than 14 years old. Total energy intake (TEI) and nutrient intake were calculated using the software Programa de Apoio a` Nutric¸a˜o – NutWin 1.6.0.7 (Federal University of Sa˜o Paulo, Brazil). Dietary reference intakes (DRIs)15–18 were used to analyze the energy, macronutrient, fibre, calcium, iron, vitamins A and C intake. Polyunsaturated fat and cholesterol intake were analyzed according to the First Brazilian Guidelines for the Prevention of Atherosclerosis in Children and Adolescents.19 The estimated energy requirement (EER) was calculated by DRIs15 and adjusted by the WHO recommendation - Nutrient Requirements for People Living with HIV/AIDS.20 In calculating the EER, the daily physical activity level (PAL) was applied to the EER equations.15
Statistical analysis General and anthropometric data Demographic (age, gender, race/ethnicity) and socioeconomic (guardians’ education and monthly income) characteristics were obtained by face-to-face interview. Height was measured to the nearest 0.1 cm with a wall-mounted stadiometer (Tonelli, 120 A, Brazil). Weight was assessed using a calibrated digital scale (Tanita, BF683W, USA) to the nearest 0.1 kg. The measurements were assessed by a trained physical educator applying standardized procedures.11 Technical
All variables were checked for normality by the Shapiro-Wilk test and by graph representation. Nonparametric data were normalized using log10. Descriptive statistical procedures were used for data reporting (central tendency measures, dispersion, relative and absolute frequencies). Inferential statistics applied the t-Student test for independent samples, chi-square test, U-Mann-Whitney test, Spearman correlation and multiple linear regression analysis. Multiple analyses were adjusted for gender and age,
Downloaded from std.sagepub.com at Mount Royal University on June 9, 2015
Hillesheim et al.
441
considering the potential for confounding related to sexual dimorphism, growth and maturation, as well as guardian’s education, which is related to the care of HIV-infected youth. The variables were introduced one at a time into the models by the enter procedure. For all tests, the significance level was also set at 0.05.
Results The sample’s demographic, clinical and growth characteristics are described in Table 1. The mean age was 12.6 2.7 years. There was no significant difference in mean age between the genders (p ¼ 0.58), and 53.0% (n ¼ 26) of the sample consisted of children up to 13 years old. More than half the children were in early stages of the disease (61.5% in category N – not
symptomatic or A – mildly symptomatic; 38.5% in category B – moderately symptomatic or C – severely symptomatic). Among adolescents (>13 years old) 52.2% had symptoms consistent with AIDS. The mean percentage of CD4þ T-cells was 30.8 8.7. Viral load was undetectable in 27 subjects (55.1%) and only two showed a value above 10,000 copies/ml of HIV RNA. The age- and gender-BMI cutoffs identified 45 (91.8%) participants as eutrophic, 3 (6.1%) as overweight (z-score >1) and 1 (2.0%) as underweight (z-score
Dietary intake and nutritional status of HIV-1-infected children and adolescents in Floriano´polis, Brazil
International Journal of STD & AIDS 2014, Vol. 25(6) 439–447 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462413512808 std.sagepub.com
Elaine Hillesheim1, Luiz RA Lima2, Rosane CR Silva2 and Erasmo BSM Trindade1
Abstract This cross-sectional study aimed to investigate the nutritional status and dietary intake of HIV-infected children and adolescents and the relationship between nutritional status and dietary intake and CD4þ T-cell count and viral load. The sample was composed of 49 subjects aged 7–17 years and living in Floriano´polis, Brazil. Nutritional status was assessed by height-for-age and body mass index-for-age. Dietary intake was assessed by a food frequency questionnaire. Spearman correlations and multiple linear regressions were used to determine the relationship between energy, nutrient intake and body mass index-for-age and CD4þ T-cell count and viral load. The mean body mass index-for-age and heightfor-age values were –0.26 0.86 and 0.56 0.92, respectively. The energy intake was 50.8% above the estimated energy requirement and inadequate intake of polyunsaturated fat, cholesterol, fibre, calcium and vitamin C was present in 100%, 57.1%, 40.8%, 61.2% and 26.5% of the sample, respectively. Multiple linear regression analyses revealed that energy intake was correlated with CD4þ T-cell count (r ¼ 0.33; p ¼ 0.028) and viral load (r ¼ 0.35; p ¼ 0.019). These data showed low body mass index-for-age and height-for-age z-scores, high energy intake and inadequate intake of important nutrients for immune function, growth and control of chronic diseases. A lower energy intake was correlated with viral suppression and immune preservation.
Keywords HIV, AIDS, malnutrition, diet, nutritional status, child, adolescent Date received: 2 July 2013; accepted: 1 October 2013
Introduction For many years, malnutrition was commonly observed in HIV-infected children and adolescents around the world, with a significant decrease in body fat and lean and bone mass compared to the healthy population.1,2 After highly active antiretroviral therapy (HAART) introduction, there was significant improvement in nutritional status, but adverse effects such as body fat redistribution, insulin resistance and hyperlipidaemia were observed.3 Growth and physical development delay have been reported as intrinsic to infection4,5; these delays may be influenced by changes in dietary intake and nutrient absorption.6 The synergistic interaction between nutritional status, progression of HIV infection and the immune system is well documented. HIV infection affects nutritional status, as the infection produces functional changes in the gastrointestinal tract which decrease dietary intake and nutrient absorption.6 Additionally,
there is an increase in the basal metabolic rate in response to inflammation, opportunistic infections and viral replication, which triggers increased release of pro-oxidants, cytokines and reactive oxygen species resulting in higher use of vitamins and minerals.7 On the other hand, the nutritional status of patients affects the infection due to the possibility of immune modulation and changes in the general clinical status.6 In this two-way relationship, HIV infection establishes the risk 1 Department of Nutrition, Federal University of Santa Catarina, Floriano´polis, Brazil 2 Department of Physical Education, Federal University of Santa Catarina, Floriano´polis, Brazil
Corresponding author: Erasmo Benicio Santos de Moraes Trindade, Universidade Federal de Santa Catarina – UFSC, Departamento de Nutric¸a˜o, Bairro Trindade, Floriano´polis, SC, Brasil, CEP 88040-900. Email: [email protected]
Downloaded from std.sagepub.com at Mount Royal University on June 9, 2015
440
International Journal of STD & AIDS 25(6)
of poor nutritional status, although its severity varies according to both macronutrient and micronutrient intake. Knowledge of habitual dietary intake and nutritional status of HIV-infected children and adolescents and their relationship with immunological markers of infection may contribute to the establishment of early and effective nutritional interventions for maintaining and recovering growth and immune function. In contrast to adults,8–10 there are few reports on dietary intake of HIV-infected youth related to immunological markers of infection. Thus, the aim of the present study was two-fold: to evaluate the dietary intake and nutritional status of a group of HIV-infected children and adolescents living in Floriano´polis, Brazil, and to determine their associations with CD4þ T-cell count and viral load.
measurement errors were 0.51 kg and 0.19 cm for weight and height, respectively. Nutritional status was assessed by z-score from the anthropometric indicators height-for-age (H/A) and body mass index-for-age (BMI/A).12
Clinical measurements Immunological data, including CD4þ T-cell count, CD8þ T-cell count and viral load, were obtained from medical records and used to categorize immunosuppression.13 Viral load was considered undetectable if HIV RNA was under 50 copies/ml. The HIV RNA viral load and CD4þ and CD8þ T-cells counts were determined by the branched DNA (b-DNA) method and flow cytometry, respectively.
Dietary assessment Methods Study design and sample This cross-sectional observational study was carried out between June and November 2010 with HIV-1infected children and adolescents who received treatment at Hospital Infantil Joana de Gusma˜o. The subjects were selected by a non-probabilistic method using the following inclusion criteria: having acquired HIV by mother-to-child transmission, having both clinical and laboratory data in the medical records, being between 7 and 17 years of age, having no signs or symptoms of chronic diseases and no use of medication that altered body composition or nutritional status. Sixty-eight subjects were considered eligible for the study; however, eight subjects did not participate due to lack of time or interest, and 11 did not attend the evaluation after two or more contacts. No subjects withdrew from the evaluation during the study. The final sample was 49 subjects. All procedures were approved by the Institutional Ethics Committee in Human Research under the protocol number 077/2009. Informed consent was obtained from all participants and their guardians.
Dietary intake was assessed by a simplified version of the Food Frequency Questionnaire for Adolescents (FFQA) validated by Slater et al.14 for healthy Brazilian adolescents. This questionnaire is a semiquantitative food frequency questionnaire with 58 foods/preparations. The questionnaire was completed via an interview by a trained dietitian and directed to the guardians when the participant was younger than 14 years old. Total energy intake (TEI) and nutrient intake were calculated using the software Programa de Apoio a` Nutric¸a˜o – NutWin 1.6.0.7 (Federal University of Sa˜o Paulo, Brazil). Dietary reference intakes (DRIs)15–18 were used to analyze the energy, macronutrient, fibre, calcium, iron, vitamins A and C intake. Polyunsaturated fat and cholesterol intake were analyzed according to the First Brazilian Guidelines for the Prevention of Atherosclerosis in Children and Adolescents.19 The estimated energy requirement (EER) was calculated by DRIs15 and adjusted by the WHO recommendation - Nutrient Requirements for People Living with HIV/AIDS.20 In calculating the EER, the daily physical activity level (PAL) was applied to the EER equations.15
Statistical analysis General and anthropometric data Demographic (age, gender, race/ethnicity) and socioeconomic (guardians’ education and monthly income) characteristics were obtained by face-to-face interview. Height was measured to the nearest 0.1 cm with a wall-mounted stadiometer (Tonelli, 120 A, Brazil). Weight was assessed using a calibrated digital scale (Tanita, BF683W, USA) to the nearest 0.1 kg. The measurements were assessed by a trained physical educator applying standardized procedures.11 Technical
All variables were checked for normality by the Shapiro-Wilk test and by graph representation. Nonparametric data were normalized using log10. Descriptive statistical procedures were used for data reporting (central tendency measures, dispersion, relative and absolute frequencies). Inferential statistics applied the t-Student test for independent samples, chi-square test, U-Mann-Whitney test, Spearman correlation and multiple linear regression analysis. Multiple analyses were adjusted for gender and age,
Downloaded from std.sagepub.com at Mount Royal University on June 9, 2015
Hillesheim et al.
441
considering the potential for confounding related to sexual dimorphism, growth and maturation, as well as guardian’s education, which is related to the care of HIV-infected youth. The variables were introduced one at a time into the models by the enter procedure. For all tests, the significance level was also set at 0.05.
Results The sample’s demographic, clinical and growth characteristics are described in Table 1. The mean age was 12.6 2.7 years. There was no significant difference in mean age between the genders (p ¼ 0.58), and 53.0% (n ¼ 26) of the sample consisted of children up to 13 years old. More than half the children were in early stages of the disease (61.5% in category N – not
symptomatic or A – mildly symptomatic; 38.5% in category B – moderately symptomatic or C – severely symptomatic). Among adolescents (>13 years old) 52.2% had symptoms consistent with AIDS. The mean percentage of CD4þ T-cells was 30.8 8.7. Viral load was undetectable in 27 subjects (55.1%) and only two showed a value above 10,000 copies/ml of HIV RNA. The age- and gender-BMI cutoffs identified 45 (91.8%) participants as eutrophic, 3 (6.1%) as overweight (z-score >1) and 1 (2.0%) as underweight (z-score
