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Nutritional Needs Among HIV positive people in Nepal Dilip Upreti (PhD Student) (MA, MSc) Supervisors Prof. Geraldine McNeill Dr. Janet Kyle Dr. Janine.

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Presentation on theme: "Nutritional Needs Among HIV positive people in Nepal Dilip Upreti (PhD Student) (MA, MSc) Supervisors Prof. Geraldine McNeill Dr. Janet Kyle Dr. Janine."— Presentation transcript:

1 Nutritional Needs Among HIV positive people in Nepal Dilip Upreti (PhD Student) (MA, MSc) Supervisors Prof. Geraldine McNeill Dr. Janet Kyle Dr. Janine Thoulass Dr. Padam Simkhada

2 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

3 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: (M:11787& F: 6450) Diet Global Hunger Index for Nepal is 21 and ranks 57 th 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/pDER<1910 kcal/d/pDER<2124 kcal/d/p

4 HIV/AIDS and Nutrition 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

5 HIV/AIDS and Nutrition HIV/AIDS and Nutrition Increased energy requirements 10% during asymptomatic stages 20-30% if contract secondary infections % for children / pregnant women

6 Study objectives Investigating diet of People Living with HIV/AIDS in Nepal Assess dietary and nutrient intake Measure anthropometric status Record 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

7 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

8 Nepal questionnaire

9 Food frequency questionnaire

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11 Anthropometric measurement

12 Validation (n=73; M 43 and F 30) NutrientsFFQ Energy(kcal) /day2030 ± 504 Fat(g) /day28.97 ± Fat % of energy/day12.69 ± 4.24 Protein(g) /day59.97 ± Protein % of energy/day11.86 ± 1.53 Carbohydrate(g) /day385.5 ± Carbohydrate % of energy/day ± 5.42 Iron(mg) /day18.02 ± 5.31 Carotene(µg) /day2219 ± 661 Vitamin A/day b 370 ± 110 Vitamin C(mg) /day48.79 ± 15.1 a Difference in mean, upper and lower values at 95% of CI(± 2SD); b (retinol equivalents = carotene/6) Dietary intake (mean ± SD)

13 Validation (n=73; M 43 and F 30) NutrientsFFQ24-h recall Energy(kcal) /day2030 ± ± 469 Fat(g) /day28.97 ± ± 18.3 Fat % of energy/day12.69 ± ±7.08 Protein(g) /day59.97 ± ± 16.1 Protein % of energy/day11.86 ± ± 2.11 Carbohydrate(g) /day385.5 ± ± 86.5 Carbohydrate % of energy/day ± ± 8.02 Iron(mg) /day18.02 ± ± 8.9 Carotene(µg) /day2219 ± ± 1160 Vitamin A/day b 370 ± ± 193 Vitamin C(mg) /day48.79 ± ± a Difference in mean, upper and lower values at 95% of CI(± 2SD); b (retinol equivalents = carotene/6) Dietary intake (mean ± SD)

14 Validation (n=73; M 43 and F 30) NutrientsFFQ24-h recallSig diff (P)Bland-Altman a Energy(kcal) /day2030 ± ± (860.7; ) Fat(g) /day28.97 ± ± 18.3< (26.23; ) Fat % of energy/day12.69 ± ±7.08<0.001 Protein(g) /day59.97 ± ± (30.58; ) Protein % of energy/day11.86 ± ± Carbohydrate(g) /day385.5 ± ± (178.1; ) Carbohydrate % of energy/day ± ± Iron(mg) /day18.02 ± ± (21.01; ) Carotene(µg) /day2219 ± ± (2571; ) Vitamin A/day b 370 ± ± (428.6; -383) Vitamin C(mg) /day48.79 ± ± (42.32; ) a Difference in mean, upper and lower values at 95% of CI(± 2SD); b (retinol equivalents = carotene/6) Dietary intake (mean ± SD)

15 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

16 Basic demographic characteristics (%) VariablesAllMaleFemale National data Participants (52)287(48)(M:46 & F: 54) Age (Mean ± 2SD)33.81 ± ± ± (M:20.7 & F: 22.5 ) (17-27) yrs (28-38) yrs (39-49) yrs Total literate (M: 63 & F:35) Place of residence Rural Urban Source: Nepal Living Standards Survey 2011 and CBS 2001

17 Economic characteristics Economic characteristics (%) VariablesAll (601)Male (314)Female (287) Main source of income Daily labor Agriculture Business Services Occupation Manual Non-manual Unemployed 352 Sufficient annual income for food Yes No Food to be borrowed in a year (n=278) < 3 months > 4 months

18 Living with HIV & receiving Anti Retroviral Therapy <4yrs (31%) ART non-users 31%

19 What PLHA think as a good diet? 92 % (n=554) reported that they have knowledge on good diet

20 Why PLHA change their diet? 82 % (n=492) reported they need different diet than other people 43 % (n=260) change their dietary intake habit Reasons for dietary change

21 BMI according to gender and place of residence Variables Total Total BMI (Median and IQR) Total (18.22;22.27) Male314 (52) (18.18;21.94) Female287 (48) (18.27;22.71) Rural303 (50) (17.70;21.38) Urban298 (50) (18.80; 22.93)

22 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 (18.22;22.27) Male314 (52) (18.18;21.94) Female287 (48) (18.27;22.71) Rural303 (50) (17.70;21.38) Urban298 (50) (18.80; 22.93)

23 Dietary intake (mean ±SD) Nutrients All Gender WHO/FAO recommendation a Male (314)Female (287)MaleFemale Energy (kcal)/day 1922 ± ± ± Fat % energy ± ± ± Protein % energy ± ± ± Carbohydrate % energy ± ± ± Iron (mg)/day ± ± ± Carotene (µg)/day 1764 ± ± ± Vitamin A (µg)/day V 294 ± ± ± Vitamin C (mg)/day ± ± ± a Age (19-50) year; *p<0.05; **p<0.01;***p<0.001, V (retinol equivalents = carotene/6)

24 Assessment of association: diet & lifestyle No association with energy or nutrient intake and: ART and Non-ART group Place of residence Region of residence BMI 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)

25 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

26 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

27 Any questions THANK YOU VERY MUCH

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29 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): )

30 Validation (n=20; M 12 and F 8) NutrientsMean from 1 st recall Mean from 2 nd recall Sig diff (P)Bland-Altman a Energy(kcal) /day 1947 ± ± (750; ) Fat(g) /day ± ± (44.86; ) Fat % of energy/day ± ± (21.58; ) Protein(g) /day ± ± (44.56; -38.4) Protein % of energy/day ± ± (7.34; -5.1) Carbohydrate(g) /day ± ± (134.6; ) Carbohydrate % of energy/day ± ± (15.44; -20.4) Iron(mg) /day ± ± (16.84; ) Carotene(µg) /day 1965 ± ± (2653; -2959) Vitamin A/day b ± ± (442.3; 493.4) Vitamin C(mg) /day ± ± (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

31 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)

32 Details of ART

33 Calibration


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