The benefit of supplementary feeding for wasted Malawian adults initiating ART
ABSTRACT Food insecurity is considered to be an important contributor to HIV associated wasting in sub-Saharan Africa. Low body mass index (BMI) is a strong risk factor for early mortality during antiretroviral therapy (ART). Nutritional supplementation has become standard of care in wasted patients starting ART in many countries in the region, but there is no unequivocal evidence base for this intervention. Against this background, we performed a retrospective study to compare food supplementation versus no nutritional intervention in wasted adults starting ART in Blantyre, Malawi. All patients received free nevirapine, lamivudine, and stavudine. Participants in an effectiveness trial of two food supplements received either corn-soy blend (CSB) or ready-to-use food spread (RUFS) during the first 14 weeks of ART. Results were compared with a historical control group receiving no food supplement that was part of an observational cohort study of outcomes of the same ART regimen. Characteristics on initiation of ART were similar in the three groups, except the use of cotrimoxazole prophylaxis which was more frequent in the food-supplemented groups. Linear regression analysis showed that increase in BMI was greatest in the RUFS group and better in the CSB group than in those receiving no food supplementation at 14 weeks. These differences were no longer significant at 26 weeks. Lower BMI, CD4 count and hemoglobin, WHO clinical stage IV, male gender, and not receiving cotrimoxazole prophylaxis were independent risk factors for mortality at 14 and 26 weeks in the logistic regression analysis. Supplementary food use was not directly associated with improved survival.
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ABSTRACT: Wasting and food insecurity are commonly seen in patients receiving antiretroviral treatment (ART) programs in sub-Saharan Africa and south Asia, and supplementary feeding is often offered in conjunction with ART. Evidence for the effectiveness of such supplementary feeding is scant. A randomised, investigator-blinded, controlled clinical trial of two types of supplementary food, corn/soy blended flour and a ready-to-use peanut butter-based lipid paste, in wasted adults in Blantyre, Malawi is described and the results summarised. A historical control group who did not receive supplementary food is described as well. Provision of about half of the daily energy requirement as a supplementary food for 14 weeks resulted in more rapid restoration of a normal BMI; and the energy-dense, ready-to-use paste was associated with more rapid weight gain than the blended flour. Survival was similar among the 3 groups. The strong association between lower BMI and survival indirectly suggests that there may well be clinical benefit from supplementary feeding in this population. No differences were seen in ART adherence or quality of life with more rapid restoration of BMI. Further research is urgently needed concerning the widespread practice of supplementary feeding in HIV/AIDS care to most effectively utilize this intervention.Malawi medical journal: the journal of Medical Association of Malawi 06/2010; 22(2):46-8. DOI:10.4314/mmj.v22i2.58792 · 0.19 Impact Factor
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ABSTRACT: Inappropriate prescribing of primarily renally cleared medications in older patients with kidney disease can lead to adverse outcomes. To estimate the prevalence of potentially inappropriate prescribing of 21 primarily renally cleared medications based on 2 separate estimates of renal function and to identify factors associated with this form of suboptimal prescribing in older VA nursing home (NH) patients. Longitudinal study Participants were 1304 patients, aged 65 years or older, admitted between January 1, 2004, and June 30, 2005, for 90 days or more to 1 of 133 VA NHs. Potentially inappropriate prescribing of primarily renally cleared medications determined by estimating creatinine clearance using the Cockcroft Gault (CG) and Modification of Diet in Renal Disease (MDRD) equations and applying explicit guidelines for contraindicated medications and dosing. The median estimated creatinine clearance via CG was 67 mL/min, whereas it was 80 mL/min/1.73m(2) with the MDRD. Overall, 11.89% patients via CG and only 5.98% via MDRD had evidence of potentially inappropriate prescribing of at least 1 renally cleared medication. The most commonly involved medications were ranitidine, glyburide, gabapentin, and nitrofurantoin. Factors associated with potentially inappropriate prescribing as per the CG were age older than 85 (adjusted odds ratio [AOR] 4.24, 95% confidence interval [CI] 2.42-7.43), obesity (AOR 0.26, 95% CI 0.14-0.50) and having multiple comorbidities (AOR 1.09 for each unit increase in the Charlson comorbidity index, 95% CI 1.01-1.19). Potentially inappropriate prescribing of renally cleared medications is common in older VA NH patients. Intervention studies to improve the prescribing of primarily renally cleared medications in nursing homes are needed.Journal of the American Medical Directors Association 10/2010; 12(5):377-83. DOI:10.1016/j.jamda.2010.04.008 · 4.78 Impact Factor
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ABSTRACT: The article systematically reviews theory and existing empirical evidence on the health and welfare effects of integrating AIDS treatment with food assistance. While theoretical predictions point to possible improvements in health, consumption and ambiguous effects on labor supply, there are few empirical studies that used robust designs. Five empirical studies are reviewed and in two of them, food assistance improves nutritional status, especially when provided in the form of ready to use therapeutic feeding. However because of methodological concerns, the positive effects of food assistance on weight gain warrant cautious interpretation. One study found a positive association between food assistance and adherence. While no quantitative study evaluated welfare effects, respondents in a qualitative study self-reported the resumption of labor activities, increased dietary diversity and food consumption. There is still limited evidence on the role of duration of AIDS treatment and programmatic aspects like targeting, composition and duration of food assistance. The major conclusion of the paper is that there is still need for further research based on robust designs which investigates both health and household welfare effects.Social Science [?] Medicine 07/2011; 73(5):685-92. DOI:10.1016/j.socscimed.2011.06.056 · 2.56 Impact Factor