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1.  Food Insufficiency Is Associated with High-Risk Sexual Behavior among Women in Botswana and Swaziland 
PLoS Medicine  2007;4(10):e260.
Background
Both food insufficiency and HIV infection are major public health problems in sub-Saharan Africa, yet the impact of food insufficiency on HIV risk behavior has not been systematically investigated. We tested the hypothesis that food insufficiency is associated with HIV transmission behavior.
Methods and Findings
We studied the association between food insufficiency (not having enough food to eat over the previous 12 months) and inconsistent condom use, sex exchange, and other measures of risky sex in a cross-sectional population-based study of 1,255 adults in Botswana and 796 adults in Swaziland using a stratified two-stage probability design. Associations were examined using multivariable logistic regression analyses, clustered by country and stratified by gender. Food insufficiency was reported by 32% of women and 22% of men over the previous 12 months. Among 1,050 women in both countries, after controlling for respondent characteristics including income and education, HIV knowledge, and alcohol use, food insufficiency was associated with inconsistent condom use with a nonprimary partner (adjusted odds ratio [AOR] 1.73, 95% confidence interval [CI] 1.27–2.36), sex exchange (AOR 1.84, 95% CI 1.74–1.93), intergenerational sexual relationships (AOR 1.46, 95% CI 1.03–2.08), and lack of control in sexual relationships (AOR 1.68, 95% CI 1.24–2.28). Associations between food insufficiency and risky sex were much attenuated among men.
Conclusions
Food insufficiency is an important risk factor for increased sexual risk-taking among women in Botswana and Swaziland. Targeted food assistance and income generation programs in conjunction with efforts to enhance women's legal and social rights may play an important role in decreasing HIV transmission risk for women.
In a cross-sectional study, Sheri Weiser and colleagues found that food insufficiency was an important risk factor for increased sexual risk-taking in women in Botswana and Swaziland.
Editors' Summary
Background.
For people in sub-Saharan Africa, insufficient food for their daily needs and infection with the human immunodeficiency virus (HIV; the cause of acquired immunodeficiency syndrome or AIDS) are inextricably linked and major causes of illness and death. By reducing the number of healthy adults in the region, HIV/AIDS has decreased food production so fewer people have secure access to sufficient food for a healthy life—many are subject to “food insecurity.” Because good nutrition is essential for a strong immune system, food insecurity increases the likelihood that people exposed to HIV become infected with the virus and reduces their ability to remain healthy after infection. Consequently, more people succumb to HIV/AIDS and food insecurity increases. To break this vicious cycle, UNAIDS (the Joint United Nations Programme on HIV/AIDS) and other international bodies have suggested a move towards integrated food security programs and HIV/AIDS prevention and treatment programs wherever possible.
Why Was This Study Done?
Integrated food and HIV/AIDS programs might also be beneficial for another reason. HIV is usually spread through unprotected sex with an infected partner and it is thought that a lack of food increases sexual risk taking, particularly among poor women. These women have little control over food supplies but are expected to feed their children and other members of the household (such as elders). To do this, they may sell sex or become sexually involved with men of a different generation, both of which put them at risk of HIV. In addition, they are rarely able to demand that their partners use condoms or to control when they have sex. In this study, the researchers have examined how food insufficiency affects sexual risk taking among men and women in Swaziland and Botswana. These two countries have the highest HIV infection rates in the world—one in three adults in Swaziland and one in four in Botswana are infected—and in both countries many people are extremely poor.
What Did the Researchers Do and Find?
The researchers interviewed more than 2,000 randomly selected adults from Botswana and Swaziland using a standard questionnaire. This included general questions about the participants (for example, age and marital status) and questions about food insufficiency (defined as not having had enough food to eat over the previous 12 months) and risky sexual behaviors—for example, sex exchange (selling or paying for sex) and inconsistent condom use—over the same period. Nearly one in three women and one in four men reported food insufficiency. After allowing for variables such as education and income, women in both countries who reported food insufficiency were nearly twice as likely to have used condoms inconsistently with a non-regular partner or to have sold sex as women who had had sufficient food. They were also more likely to have had intergenerational sexual relationships and to report a lack of control in sexual relationships. Among men, food insufficiency was weakly associated with inconsistent condom use but not with other risky sexual behaviors.
What Do These Findings Mean?
Food insufficiency is associated with multiple (often interdependent) risky sexual practices among women in Botswana and Swaziland. These results may not hold for other countries and may be limited by the definition of food insufficiency used in the study and by participants failing to remember or report all instances of risky behavior or food insufficiency that occurred during the previous year. Nevertheless, the findings strongly suggest that protecting and promoting access to food may decrease vulnerability of women in sub-Saharan Africa to HIV infection. Improved food security might be achieved through targeted food assistance and by supporting women's subsistence farming and other means of food production. Such programs would also need to enhance women's legal and social rights so that they have more control over food supplies as well as their sexual lives.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040260.
The Food and Agriculture Organization of the United Nations Special Programme for Food Security (in several languages)
HIV InSite, comprehensive and up-to-date information on all aspects of HIV/AIDS from the University of California San Francisco
UNAIDS (Joint United Nations Programme on HIV/AIDS) fact sheet on nutrition, food security, and HIV/AIDS
HIV and AIDS in Swaziland and Botswana, information provided by Avert, an international AIDS charity
The IMAGE Study, an example of a research initiative that is investigating the potential role of poverty alleviation and women's empowerment in reducing HIV incidence in South Africa
doi:10.1371/journal.pmed.0040260
PMCID: PMC2039764  PMID: 17958460
2.  Food Insecurity with Hunger Is Associated with Obesity among HIV-Infected and at Risk Women in Bronx, NY 
PLoS ONE  2014;9(8):e105957.
Background
Food insecurity, insufficient quality and quantity of nutritionally adequate food, affects millions of people in the United States (US) yearly, with over 18 million Americans reporting hunger. Food insecurity is associated with obesity in the general population. Due to the increasing prevalence of obesity and risk factors for cardiovascular disease among HIV-infected women, we sought to determine the relationship between food insecurity and obesity in this cohort of urban, HIV-infected and –uninfected but at risk women.
Methods
Using a cross-sectional design, we collected data on food insecurity, body mass index and demographic and clinical data from 231 HIV-infected and 119 HIV-negative women enrolled in Bronx site of the Women’s Interagency HIV Study (WIHS). We used multivariate logistic regression to identify factors associated with obesity.
Results
Food insecurity was highly prevalent, with almost one third of women (110/350, 31%) reporting food insecurity over the previous six months and over 13% of women reported food insecurity with hunger. Over half the women were obese with a Body Mass Index (BMI) of ≥30. In multivariate analyses, women who were food insecure with hunger had higher odds of obesity (Adjusted odds ratio [aOR] = 2.56, 95% Confidence Interval [CI] = 1.27, 5.20) after adjusting for HIV status, age, race, household status, income, drug and alcohol use.
Conclusion
Food insecurity with hunger was associated with obesity in this population of HIV-infected and –uninfected, urban women. Both food insecurity and obesity are independent markers for increased mortality; further research is needed to understand this relationship and their role in adverse health outcomes.
doi:10.1371/journal.pone.0105957
PMCID: PMC4146558  PMID: 25162598
3.  Poor Nutrition Status and Associated Feeding Practices among HIV-Positive Children in a Food Secure Region in Tanzania: A Call for Tailored Nutrition Training 
PLoS ONE  2014;9(5):e98308.
Undernutrition among HIV-positive children can be ameliorated if they are given adequate foods in the right frequency and diversity. Food insecurity is known to undermine such efforts, but even in food rich areas, people have undernutrition. As yet no study has examined feeding practices and their associations with nutrition status among as HIV-positive children in regions with high food production. We therefore examined the magnitude of undernutrition and its association with feeding practices among HIV-positive children in a high food production region in Tanzania.
Methods
We conducted this mixed-method study among 748 children aged 6 months-14 years attending 9 of a total of 32 care and treatment centers in Tanga region, Tanzania. We collected quantitative data using a standard questionnaire and qualitative data through seven focus group discussions (FGDs).
Results
HIV-positive children had high magnitudes of undernutrition. Stunting, underweight, wasting, and thinness were prevalent among 61.9%, 38.7%, 26.0%, and 21.1% of HIV-positive children, respectively. They also had poor feeding practices: 88.1% were fed at a frequency below the recommendations, and 62.3% had a low level of dietary diversity. Lower feeding frequency was associated with stunting (β = 0.11, p = 0.016); underweight (β = 0.12, p = 0.029); and thinness (β = 0.11, p = 0.026). Lower feeding frequency was associated with low wealth index (β = 0.06, p<0.001), food insecurity (β = −0.05, p<0.001), and caregiver's education. In the FGDs, participants discussed the causal relationships among the key associations; undernutrition was mainly due to low feeding frequency and dietary diversity. Such poor feeding practices resulted from poor nutrition knowledge, food insecurity, low income, and poverty.
Conclusion
Feeding practices and nutrition status were poor among HIV-positive children even in food rich areas. Improving feeding frequency may help to ameliorate undernutrition. To improve it, tailored interventions should target children of poor households, the food insecure, and caregivers who have received only a low level of education.
doi:10.1371/journal.pone.0098308
PMCID: PMC4028312  PMID: 24846016
4.  Food Insecurity, Food Based Coping Strategies and Suboptimal Dietary Practices of Adolescents in Jimma Zone Southwest Ethiopia 
PLoS ONE  2013;8(3):e57643.
Despite the high prevalence of adolescent food insecurity in Ethiopia, there is no study which documented its association with suboptimal dietary practices. The objective of this study is to determine the association between adolescent food insecurity and dietary practices. We used data on 2084 adolescents in the age group of 13–17 years involved in the first round survey of the five year longitudinal family study in Southwest Ethiopia. Adolescents were selected using residence stratified random sampling methods. Food insecurity was measured using scales validated in developing countries. Dietary practices were measured using dietary diversity score, food variety score and frequency of consuming animal source food. Multivariable regression models were used to compare dietary behaviors by food security status after controlling for socio-demographic and economic covariates.
Food insecure adolescents had low dietary diversity score (P<0.001), low mean food variety score (P<0.001) and low frequency of consuming animal source foods (P<0.001). After adjusting for other variables in a multivariable logistic regression model, adolescent food insecurity (P<0.001) and rural residence (P<0.001) were negatively associated with the likelihood of having a diversified diet (P<0.001) and frequency of consuming animal source foods, while a high household income tertile was positively associated. Similarly, multivariable linear regression model showed that adolescent food insecurity was negatively associated with food variety score, while residence in semi-urban areas (P<0.001), in urban areas (P<0.001) and high household income tertile (P = 0.013) were positively associated. Girls were less likely to have diversified diet (P = 0.001) compared with boys.
Our findings suggest that food insecurity has negative consequence on optimal dietary intake of adolescents. Food security interventions should look into ways of targeting adolescents to mitigate these dietary consequences and provide alternative strategies to improve dietary quality of adolescents in Southwest Ethiopia.
doi:10.1371/journal.pone.0057643
PMCID: PMC3595236  PMID: 23554864
5.  Undernutrition among HIV-positive children in Dar es Salaam, Tanzania: antiretroviral therapy alone is not enough 
BMC Public Health  2011;11:869.
Background
The prevalence of HIV/AIDS has exacerbated the impact of childhood undernutrition in many developing countries, including Tanzania. Even with the provision of antiretroviral therapy, undernutrition among HIV-positive children remains a serious problem. Most studies to examine risk factors for undernutrition have been limited to the general population and ART-naive HIV-positive children, making it difficult to generalize findings to ART-treated HIV-positive children. The objectives of this study were thus to compare the proportions of undernutrition among ART-treated HIV-positive and HIV-negative children and to examine factors associated with undernutrition among ART-treated HIV-positive children in Dar es Salaam, Tanzania.
Methods
From September to October 2010, we conducted a cross-sectional survey among 213 ART-treated HIV-positive and 202 HIV-negative children in Dar es Salaam, Tanzania. We measured the children's anthropometrics, socio-demographic factors, food security, dietary habits, diarrhea episodes, economic status, and HIV clinical stage. Data were analyzed using both univariate and multivariate methods.
Results
ART-treated HIV-positive children had higher rates of undernutrition than their HIV-negative counterparts. Among the ART-treated HIV-positive children, 78 (36.6%) were stunted, 47 (22.1%) were underweight, and 29 (13.6%) were wasted. Households of ART-treated HIV-positive children exhibited lower economic status, lower levels of education, and higher percentages of unmarried caregivers with higher unemployment rates. Food insecurity was prevalent in over half of ART-treated HIV-positive children's households. Furthermore, ART-treated HIV-positive children were more likely to be orphaned, to be fed less frequently, and to have lower body weight at birth compared to HIV-negative children.
In the multivariate analysis, child's HIV-positive status was associated with being underweight (AOR = 4.61, 95% CI 1.38-15.36 P = 0.013) and wasting (AOR = 9.62, 95% CI 1.72-54.02, P = 0.010) but not with stunting (AOR = 0.68, 95% CI 0.26-1.77, P = 0.428). Important factors associated with underweight status among ART-treated HIV-positive children included hunger (AOR = 9.90, P = 0.022), feeding frequency (AOR = 0.02, p < 0.001), and low birth weight (AOR = 5.13, P = 0.039). Factors associated with wasting among ART-treated HIV-positive children were diarrhea (AOR = 22.49, P = 0.001) and feeding frequency (AOR = 0.03, p < 0.001).
Conclusion
HIV/AIDS is associated with an increased burden of child underweight status and wasting, even among ART-treated children, in Dar es Salaam, Tanzania. In addition to increasing coverage of ART among HIV-positive children, interventions to ameliorate poor nutrition status may be necessary in this and similar settings. Such interventions should aim at promoting adequate feeding patterns, as well as preventing and treating diarrhea.
doi:10.1186/1471-2458-11-869
PMCID: PMC3226559  PMID: 22087543
6.  Dietary intake and main food sources of vitamin D as a function of age, sex, vitamin D status, body composition, and income in an elderly German cohort 
Food & Nutrition Research  2014;58:10.3402/fnr.v58.23632.
Background
Elderly subjects are at risk of insufficient vitamin D status mainly because of diminished capacity for cutaneous vitamin D synthesis. In cases of insufficient endogenous production, vitamin D status depends on vitamin D intake.
Objective
The purpose of this study is to identify the main food sources of vitamin D in elderly subjects and to analyse whether contributing food sources differ by sex, age, vitamin D status, body mass index (BMI), or household income. In addition, we analysed the factors that influence dietary vitamin D intake in the elderly.
Design and subjects
This is a cross-sectional study in 235 independently living German elderly aged 66–96 years (BMI=27±4 kg/m2). Vitamin D intake was assessed by a 3-day estimated dietary record.
Results
The main sources of dietary vitamin D were fish/fish products followed by eggs, fats/oils, bread/bakery products, and milk/dairy products. Differences in contributing food groups by sex, age, vitamin D status, and BMI were not found. Fish contributed more to vitamin D intake in subjects with a household income of <1,500 €/month compared to subjects with higher income. In multiple regression analysis, fat intake and frequency of fish consumption were positive determinants of dietary vitamin D intake, whereas household income and percentage total body fat negatively affected vitamin D intake. Other parameters, including age, sex, physical activity, smoking, intake of energy, milk, eggs and alcohol, showed no significant association with vitamin D intake.
Conclusion
Low habitual dietary vitamin D intake does not affect vitamin D status in summer, and fish is the major contributor to vitamin D intake independent of sex, age, vitamin D status, BMI, and the income of subjects.
doi:10.3402/fnr.v58.23632
PMCID: PMC4168313  PMID: 25317118
25-hydroxyvitamin D; diet; food sources; fish consumption; body composition
7.  Feeding practices, nutritional status and associated factors of lactating women in Samre Woreda, South Eastern Zone of Tigray, Ethiopia 
Nutrition Journal  2013;12:28.
Background
Lactating mothers from low-income settings are considered as a nutritionally vulnerable group. Due to the nursing process, mothers are subjected to nutritional stresses. Frequent pregnancies followed by lactation increase the health risk of mothers resulting in a high maternal mortality.
Objective
To assess the feeding practices, nutritional status and associated factors of lactating women from Samre Woreda, South Eastern Tigray, Ethiopia.
Design
Community based cross-sectional survey
Setting
Four kebeles of Samre Woreda (2 urban & 2 rural kebeles)
Methods
Four hundred lactating mothers were recruited from 400 randomly selected households. Data on socio-demographic characteristics, maternal characteristics, feeding practices, frequency of foods eaten and dietary diversity was collected using a pre-tested and structured questionnaire. Anthropometric measurements were taken from each mother using calibrated equipments and standardized techniques. A one-day weighed food record was also collected from randomly selected sub sample (n=60) of mothers. The nutrient and energy content of foods consumed by the mothers was calculated by using ESHA Food Processor and the Ethiopian Food Composition Tables. To investigate the socio-economic and demographic factors affecting the nutritional status of the women, logistic regression was used. ANOVA and t-test were also used to see if there was a mean difference in nutritional status among the lactating mothers.
Results
Majority (71.2%) of the participants did not take additional meals during lactation. The median dietary diversity score of the study participants was 5 out of 14 food groups. The prevalence of underweight, chronic energy deficiency and stunting were 31%, 25% and 2.2% respectively. Using logistic regression model, factors significantly associated with the nutritional status of the study participants (as determined by BMI and MUAC) were size of farm land, length of years of marriage, maize cultivation, frequency of antenatal care visit and age of breastfeeding child.
Conclusions
The feeding practices, dietary intakes and nutritional status of the lactating women were short of the national and international recommendations. Therefore, sustained health and nutrition education is recommended to the women and their families and communities on increased food intake, proper dietary practices and dietary diversification during lactation in order to improve health and nutrition outcomes of lactating women.
doi:10.1186/1475-2891-12-28
PMCID: PMC3599359  PMID: 23452646
South Eastern Tigray; Lactating mothers; Weighed food record; Feeding practices
8.  Dietary intake and body composition in HIV-positive and -negative South African women 
Public health nutrition  2013;17(7):1603-1613.
Objective
This paper examines dietary intake and body composition in ARV-naïve HIV-positive compared to HIV-negative SA women, as well as the impact of disease severity on these variables.
Design
Baseline data from a longitudinal study assessing bone health in HIV-negative and HIV-positive pre-menopausal SA women over 18 years of age were used. Anthropometry and body composition, measured by dual energy X-ray absorptiometry (DXA), were analysed together with dietary intake data assessed using an interviewer based qualitative food frequency questionnaire (FFQ).
Setting
Soweto, Johannesburg, South Africa
Subjects
Black, urban SA women were divided into three groups: HIV-negative (n=98), HIV-positive with preserved CD4 counts (HIV+ non-ARV; n=74) and HIV-positive with low CD4 counts due to start ARV treatment (HIV+ pre-ARV; n=75).
Results
The prevalence of overweight and obesity was high in this population (59%). The HIV+ pre-ARV group was lighter and had a lower BMI than the other two groups (all p<0.001). Pre-ARV subjects also had lower fat and lean masses and % body fat than their HIV-negative and HIV+ non-ARV counterparts. After adjustment, there were no differences in macronutrient intakes across study groups; however, fat and sugar intakes were high and consumption of predominantly refined food items was common overall.
Conclusion
HIV-associated immunosuppression may be a key determinant of body composition in HIV-positive women. However, in populations with high obesity prevalence, these differences become evident only at advanced stages of infection.
doi:10.1017/S1368980013001808
PMCID: PMC4045640  PMID: 23835214
HIV; diet; body composition; obesity
9.  Lower Nutritional Status and Higher Food Insufficiency in Frail Older US Adults 
The British journal of nutrition  2012;110(1):172-178.
Frailty is a state of decreased physical functioning and a significant complication of aging. We examine frailty, energy and macronutrient intake, biomarkers of nutritional status, and food insufficiency in US older adult (age ≥60 years) participants of the Third National Health and Nutrition Examination Survey (n=4731). Frailty was defined as meeting ≥2 and pre-frailty as meeting 1 of the following 4 item criteria: 1) slow walking; 2) muscular weakness; 3) exhaustion, and 4) low physical activity. Intake was assessed by 24-hour dietary recall. Food insufficiency was self-reported as “sometimes” or “often” not having enough food to eat. Analyses adjusted for gender, race, age, smoking, education, income, BMI, other comorbid conditions, and complex survey design. Prevalence of frailty was highest among people who were obese (20.8%), followed by overweight (18.4%), normal weight (16.1%), and lowest among people who were underweight (13.8%). Independent of BMI, daily energy intake was lowest in people who were frail, followed by pre-frail, and highest in people who were not frail (mean kJ ± SE: 6648±130, 6966±79, 7280±84, respectively, p<0.01). Energy adjusted macronutrient intakes were similar in people with and without frailty. Frail (adjusted odds ratio (AOR)= 4.7, 95% CI 1.7-12.7) and pre-frail (AOR=2.1, 95% CI 0.8-5.8) people were more likely to report being food insufficient than not frail people. Serum albumin, carotenoids, and selenium levels were lower in frail adults than not frail adults. Research is needed on targeted interventions to improve nutritional status and food insufficiency among frail older adults, while not necessarily increasing BMI.
doi:10.1017/S000711451200459X
PMCID: PMC4023911  PMID: 23113895
Frailty; nutritional status; food insufficiency
10.  Undernutrition among HIV positive women in Humera hospital, Tigray, Ethiopia, 2013: antiretroviral therapy alone is not enough, cross sectional study 
BMC Public Health  2013;13:943.
Background
In Ethiopia, undernutrition among women on antiretroviral therapy has been a major challenge to achieve the full impact of intervention. Twenty seven percent and 17% of reproductive age Ethiopian women are chronically malnourished and anemic, respectively. Most studies to examine risk factors have been limited to the general population and ART-naive HIV-positive women, making it difficult to generalize findings to ART-treated HIV-positive women. The objectives of this study were thus to assess nutritional status and associated factors among adult women (≥20 years) on antiretroviral therapy.
Methods
From August to September we conducted an Institution based cross-sectional survey among 276 women on antiretroviral therapy in Humera Hospital, Tigray, Ethiopia. Data was collected using structured and standard face to face interview, anthropometric measurements, BD FACS (CD4 count machine) and Sysmex-21 (hemoglobin analyzer). Logistic regression was done using SPSS version 16 to identify factors that are associated with nutritional status.
Results
The prevalence of under nutrition (Body mass index < 18.5 kg/m2) Was 42.3% (95% CI: 37.4% - 47.3%). Severe, moderate and mild under nutrition was detected on 12%, 10% and 20.3% respondents, respectively. The prevalence of wasting (percentage body weight loss >5%) was 75% (95% CI: 70.4% - 79.2%). Severe wasting was accounted for 26.9% of respondents.
In the multivariate analysis, Household food insecurity [AOR = 1.85; 95%CI 1.16, 2.86], inadequate dietary diversity [AOR = 1.19; 95%CI 1.08, 1.75], anemia [AOR = 1.67; 95%CI 1.05, 2.65] and absence of nutritional support [AOR = 0.34 95%CI 0.22, 0.54) were found to be independent predictors of under-nutrition.
Conclusion
HIV/AIDS is associated with an increased burden of undernutrition even among ART treated women in Humera Hospital, Tigray, Ethiopia. In addition to ART among HIV positive women interventions to ameliorate poor nutritional status may be necessary in this and similar settings. Such interventions aimed at improving household food security, dietary diversity, micronutrient supplementation, proper use of therapeutic food, as well as treating oral candidiasis.
doi:10.1186/1471-2458-13-943
PMCID: PMC3852443  PMID: 24107008
Undernutrition; HIV/AIDS; Food security; Dietary diversity; Antiretroviral therapy
11.  Health and Treatment Implications of Food Insufficiency among People Living with HIV/AIDS, Atlanta, Georgia 
HIV/AIDS is concentrated among the inner-city poor and poverty may directly interfere with HIV treatment. This study examined food insufficiency in relation to HIV-related health and treatment. A sample of 344 men and women living with HIV/AIDS in Atlanta, Georgia completed measures of food security, health, and HIV disease progression and treatment. HIV treatment adherence was monitored using unannounced pill counts. Results showed that half of people living with HIV/AIDS in this study lacked sufficient food, and food insufficiency was associated with multiple indicators of poor health, including higher HIV viral loads, lower CD4 cell counts, and poorer treatment adherence. Adjusted analyses showed that food insufficiency predicted HIV treatment non-adherence over and above years of education, employment status, income, housing, depression, social support, and non-alcohol substance use. Hunger and food insecurity are prevalent among people living with HIV/AIDS, and food insufficiency is closely related to multiple HIV-related health indicators, particularly medication adherence. Interventions that provide consistent and sustained meals to people living with HIV/AIDS are urgently needed.
doi:10.1007/s11524-010-9446-4
PMCID: PMC2900577  PMID: 20419478
HIV/AIDS treatment; Food security; Food insufficiency; Poverty and health
12.  Dietary behaviors, physical activity and sedentary lifestyle associated with overweight and obesity, and their socio-demographic correlates, among Pakistani primary school children 
Background
There is no data on diet- and activity-related behaviors associated with overweight and obesity among Pakistani school-aged children. The study aimed to explore dietary behaviors, physical activity and sedentary lifestyle associated with overweight and obesity, and their socio-demographic correlates, among Pakistani primary school children.
Methods
A population-based cross-sectional study was conducted with a representative multistage random cluster sample of 1860 children aged five to twelve years in Lahore, Pakistan. Overweight (> +1 SD) and obesity (> +2 SD) were defined using the World Health Organization reference 2007. Chi-square test was used as the test of trend. Linear regression was used to examine the predictive power of independent variables in relation to body mass index (BMI). Logistic regression was used to quantify the independent predictors and adjusted odds ratios (aOR) with 95% confidence intervals (CI) were obtained. Statistical significance was considered at P < 0.05.
Results
Children skipping breakfast (8%), eating fast food and snacks ≥ once a week (43%) and being involved in sedentary lifestyle > one hour a day (49%) were significantly more likely to be overweight and obese while those participating in physical activity > twice a week (53%) were significantly less likely to be overweight and obese (all P < 0.01). Skipping breakfast (P < 0.001), eating fast food and snacks (P = 0.001) and sedentary lifestyle (P < 0.001) showed an independent positive association with BMI while physical activity showed an independent inverse association (P = 0.001). Skipping breakfast (aOR 1.82, 95% CI 1.22-2.71), eating fast food and snacks ≥ once a week (OR 1.41, 95% CI 1.07-1.86), physical activity > twice a week (aOR 0.49, 95% CI 0.34-0.70) and sedentary lifestyle > one hour a day (aOR 1.56, 95% CI 1.19-2.03) were independent predictors of being overweight. Skipping breakfast had independent inverse association with physical activity (aOR 0.63, 95% CI 0.45-0.89) and eating fast food and snacks had independent positive association with sedentary lifestyle (aOR 1.79, 95% CI 1.49-2.16). Female gender was independently associated with skipping breakfast (aOR 1.50, 95% CI 1.04-2.16). Male gender (aOR 1.64, 95% CI 1.33-2.02), urban area with high SES (aOR 5.09, 95% CI 3.02-8.60) and higher parental education (aOR 1.74, 95% CI 1.12-2.68) were significant independent predictors of eating fast food and snacks ≥ once a week. Living in the rural area was independently associated (aOR 2.51, 95% CI 1.71-3.68) with physical activity > twice a week. Male gender (aOR 1.60, 95% CI 1.31-1.95), urban area with low SES (aOR 1.46, 95% CI 1.02-2.09), high-income neighborhoods (aOR 1.52, 95% CI 1.02-2.25), higher parental education (aOR 1.55, 95% CI 1.03-2.34) and fewer siblings (aOR 1.38, 95% CI 1.10-1.73) were independent predictors of sedentary lifestyle > one hour a day.
Conclusions
Dietary behaviors, physical activity and sedentary lifestyle are independent predictors of overweight and higher BMI among Pakistani primary school children, and are significantly affected by the child's socio-demographic characteristics. These findings support the urgent need to develop a National strategy for diet and physical activity and to implement culturally relevant behavioral interventions in the resource-poor developing country settings.
doi:10.1186/1479-5868-8-130
PMCID: PMC3250930  PMID: 22117626
13.  Is Food Insufficiency Associated with Health Status and Health Care Utilization Among Adults with Diabetes? 
OBJECTIVES
Preliminary studies have shown that among adults with diabetes, food insufficiency has adverse health consequences, including hypoglycemic episodes and increased need for health care services. The purpose of this study was to determine the prevalence of food insufficiency and to describe the association of food insufficiency with health status and health care utilization in a national sample of adults with diabetes.
METHODS
We analyzed data from adults with diabetes (n = 1,503) interviewed in the Third National Health and Nutrition Examination Survey. Bivariate and multivariate analyses were used to examine the relationship of food insufficiency to self-reported health status and health care utilization.
RESULTS
Six percent of adults with diabetes reported food insufficiency, representing more than 568,600 persons nationally (95% confidence interval, 368,400 to 768,800). Food insufficiency was more common among those with incomes below the federal poverty level (17% vs 4%, P≤.001). Adults with diabetes who were food insufficient were more likely to report fair or poor health status than those who were not (63% vs 43%; odds ratio, 2.2; P =.05). In a multivariate analysis, fair or poor health status was independently associated with poverty, nonwhite race, low educational achievement, and number of chronic diseases, but not with food insufficiency. Diabetic adults who were food insufficient reported more physician encounters, either in clinic or by phone, than those who were food secure (12 vs 7, P <.05). In a multivariate linear regression, food insufficiency remained independently associated with increased physician utilization among adults with diabetes. There was no association between food insufficiency and hospitalization in bivariate analysis.
CONCLUSIONS
Food insufficiency is relatively common among low-income adults with diabetes and was associated with higher physician utilization.
doi:10.1046/j.1525-1497.2001.016006404.x
PMCID: PMC1495227  PMID: 11422638
food insufficiency; diabetes; health status
14.  Complementary feeding adequacy in relation to nutritional status among early weaned breastfed children who are born to HIV-infected mothers: ANRS 1201/1202 Ditrame Plus, Abidjan, Cote d'Ivoire 
Pediatrics  2006;117(4):e701-e710.
Background
In high HIV-prevalence resource constrained settings, exclusive breastfeeding with early cessation is one of the conceivable interventions aimed at the prevention of HIV through breastmilk. Nevertheless, this intervention has potential adverse effects such as the inappropriateness of complementary feeding taking over breastmilk.
Design
Prospective cohort study in Abidjan, Côte d’Ivoire.
Methods
HIV-infected pregnant women willing to breastfeed who had received a perinatal antiretroviral prophylaxis were offered to practice exclusive breastfeeding and initiate early cessation of breastfeeding from the fourth month to reduce breastmilk HIV transmission. Nature and ages of introductory complementary feeding were described in infants up to their first birthday by longitudinal compilation of 24 hour and seven day recall histories. These recalls were done weekly until six weeks of age, monthly until nine months of age, and then quarterly. We created an index synthesizing the nutritional adequacy of infant feeding practices (in terms of quality of the source of milk, dietary diversity, food and meal frequencies) ranging from 0 to 12. The association of this feeding index with growth outcomes in children was investigated.
Results
Among the 262 breastfed children included, complete cessation of breastfeeding occurred in 77% by their first birthday, with a median duration of four months. Most of the complementary foods were introduced within the seventh month of life, except for baby food and infant formula that were introduced at age four months. The feeding index was relatively low (5/12) at age six months, mainly due to insufficient dietary diversity, but was improved in the next six months (8.5/12 at age 12 months). Inadequate complementary feeding at age six months was associated with impaired growth during the next 12 months, with a 37% increased probability of stunting.
Conclusion
Adequate feeding practices around the weaning period are thus crucial to achieve optimal child growth. HIV-infected women should only turn to early cessation of breastfeeding when they are properly counselled to provide adequate complementary feeding taking over breastmilk. Our child feeding index could contribute to the assessment of the nutritional adequacy of complementary feeding around the weaning period and thus help detecting children at risk of malnutrition.
doi:10.1542/peds.2005-1911
PMCID: PMC2098879  PMID: 16585284
Breast Feeding; Child Development; Cote d'Ivoire; Developing Countries; Disease Transmission, Vertical; prevention & control; Female; Growth; HIV Infections; prevention & control; transmission; Humans; Infant; Infant Food; Infant Formula; Infant Nutrition Physiology; Infant, Newborn; Nutritional Status; Pregnancy; Pregnancy Complications, Infectious; Time Factors; Weaning; Africa; breast feeding; disease transmission, vertical; HIV infections; infant nutrition; nutritional status
15.  Poverty, Food Insufficiency and HIV Infection and Sexual Behaviour among Young Rural Zimbabwean Women 
PLoS ONE  2015;10(1):e0115290.
Background
Despite a recent decline, Zimbabwe still has the fifth highest adult HIV prevalence in the world at 14.7%; 56% of the population are currently living in extreme poverty.
Design
Cross-sectional population-based survey of 18–22 year olds, conducted in 30 communities in south-eastern Zimbabwe in 2007.
Objective
To examine whether the risk of HIV infection among young rural Zimbabwean women is associated with socio-economic position and whether different socio-economic domains, including food sufficiency, might be associated with HIV risk in different ways.
Methods
Eligible participants completed a structured questionnaire and provided a finger-prick blood sample tested for antibodies to HIV and HSV-2. The relationship between poverty and HIV was explored for three socio-economic domains: ability to afford essential items; asset wealth; food sufficiency. Analyses were performed to examine whether these domains were associated with HIV infection or risk factors for infection among young women, and to explore which factors might mediate the relationship between poverty and HIV.
Results
2593 eligible females participated in the survey and were included in the analyses. Overall HIV prevalence among these young females was 7.7% (95% CI: 6.7–8.7); HSV-2 prevalence was 11.2% (95% CI: 9.9–12.4). Lower socio-economic position was associated with lower educational attainment, earlier marriage, increased risk of depression and anxiety disorders and increased reporting of higher risk sexual behaviours such as earlier sexual debut, more and older sexual partners and transactional sex. Young women reporting insufficient food were at increased risk of HIV infection and HSV-2.
Conclusions
This study provides evidence from Zimbabwe that among young poor women, economic need and food insufficiency are associated with the adoption of unsafe behaviours. Targeted structural interventions that aim to tackle social and economic constraints including insufficient food should be developed and evaluated alongside behaviour and biomedical interventions, as a component of HIV prevention programming and policy.
doi:10.1371/journal.pone.0115290
PMCID: PMC4307980  PMID: 25625868
16.  Food insecurity and perceived stress but not HIV infection are independently associated with lower energy intakes among lactating Ghanaian women 
Maternal & child nutrition  2011;7(1):80-91.
HIV seropositive women living in low-income communities may have difficulty meeting the increased energy requirements that are associated with both lactation and HIV infection. Data on household food security and maternal socio-demographic characteristics, perceived stress, anthropometry, reported illness, dietary intakes and preferences, and exposure to nutrition education were collected from 70 lactating women (16 seropositive (HP), 27 seronegative (HN), and 27 who refused to be tested and had unknown HIV status (HU)). Diet was assessed with three 24-hr recalls (one market day, one weekend day, and one non-market weekday). Data were collected at 8.4 (SD=4.7) months postpartum. Most women (74.3%) reported being in good health at the time of study. Three-day mean energy intakes did not differ by HIV status (HP: 12000 kJ (SD=3600), HN: 12600 kJ (SD=5100), and HU: 12300 kJ (SD= 4800); p=0.94). Protein, fat, vitamin A, thiamin, riboflavin, niacin, vitamin C, calcium, iron, and zinc intakes also did not differ by group (p>0.10). There was a higher proportion of women with high stress levels in food insecure households compared to food secure households (55.6% vs. 26.5%; p=0.01). Energy intake was independently negatively associated with food insecurity (high: 11300 kJ (SD=3500) vs. low: 13400 kJ (SD=5400), respectively; p=0.050) and stress (high: 10800 kJ (SD=2800) vs. low: 13400 kJ (SD=5300), p=0.021). These results suggest the need to integrate multi-dimensional interventions that address economic and mental health constraints which may limit some women’s ability to meet their dietary needs.
doi:10.1111/j.1740-8709.2009.00229.x
PMCID: PMC3053124  PMID: 21143587
HIV; human lactation; diet; food security; maternal mental health; low income countries
17.  Dietary intake of vitamin B6, plasma pyridoxal 5′-phosphate and homocysteine in Puerto Rican adults 
Background
Vitamin B6 is an important cofactor in many metabolic processes. However, vitamin B6 intake and plasma status have not been well studied in the Puerto Rican population, a group with documented health disparities.
Objective
To assess dietary intake of vitamin B6, food sources, and plasma status of pyridoxal 5′-phosphate (PLP), and their associations with plasma homocysteine in 1236 Puerto Rican adults, aged 45–75 years, living in the greater Boston area.
Design
Baseline data were analyzed cross-sectionally.
Method
Questionnaire data were collected by home interview. Dietary intake was assessed with a semi-quantitative food frequency questionnaire. Plasma PLP and homocysteine were assayed from blood samples collected in the home.
Results
The mean daily intake of vitamin B6 was 2.90 ± 1.28 mg (mean ± SD) for men and 2.61 ± 1.29 mg for women (P <0.001). Approximately 11% were deficient (PLP <20 nmol/L) and another 17 % insufficient (PLP ≥20 but <30 nmol/L). Household income below the poverty threshold, physical inactivity and current smoking were significantly associated with lower plasma PLP (P <0.05). Food groups contributing most to vitamin B6 intake included ready-to-eat cereals, poultry, rice, potatoes and dried beans. However, only intake of ready-to-eat cereals and use of supplements with vitamin B6 were significantly associated with plasma PLP sufficiency (≥30 vs. <30 nmol/L, P <0.01). Both vitamin B6 intake and PLP were significantly associated with plasma total homocysteine (P < 0.001). The association between PLP and homocysteine remained statistically significant after further adjustment for plasma vitamin B12 and folate (P = 0.028).
Conclusion
Given the known importance of vitamin B6 to health, the high prevalence of low vitamin B6 status in this Puerto Rican population is of concern. Further work is needed to clarify the potential role that insufficient vitamin B6 may have in relation to the observed health disparities in this population.
doi:10.1016/j.jada.2010.08.006
PMCID: PMC2989853  PMID: 21034879
vitamin B6; pyridoxal 5′-phosphate; homocysteine; Puerto Rican
18.  Assessment of haematological parameters in HIV-infected and uninfected Rwandan women: a cross-sectional study 
BMJ Open  2012;2(6):e001600.
Objectives
Although haematological abnormalities are common manifestations of HIV infection, few studies on haematological parameters in HIV-infected persons have been undertaken in sub-Saharan Africa. The authors assessed factors associated with haematological parameters in HIV-infected antiretroviral-naïve and HIV-uninfected Rwandan women.
Study design
Cross-sectional analysis of a longitudinal cohort.
Setting
Community-based women's associations.
Participants
710 HIV-infected (HIV+) antiretroviral-naïve and 226 HIV-uninfected (HIV−) women from the Rwanda Women's Interassociation Study Assessment. Haematological parameters categorised as (abnormal vs normal) were compared by HIV status and among HIV+ women by CD4 count category using proportions. Multivariate logistic regression models using forward selection were fit.
Results
Prevalence of anaemia (haemoglobin (Hb) <12.0 g/dl) was higher in the HIV+ group (20.5% vs 6.3%; p<0.001), and increased with lower CD4 counts: ≥350 (7.6%), 200–349 (16%) and <200 cells/mm3 (32.2%). Marked anaemia (Hb <10.0 g/dl) was found in 4.2% of HIV+ and none of the HIV− women (p<0.001), and was highest in HIV+ women with CD4 <200 cells/mm3 (8.4%). The HIV+ were more likely than HIV− women (4.2 vs 0.5%, respectively, p=0.002) to have moderate neutropenia with white blood cells <2.0×103 cells/mm3 and 8.4% of HIV+ women with CD4 <200 cells/mm3 had moderate neutropenia. In multivariate logistic regression analysis, BMI (OR 0.87/kg/m2, 95% CI 0.82 to 0.93; p<0.001), CD4 200–350 vs HIV− (OR 3.59, 95% CI 1.89 to 6.83; p<0.001) and CD4 <200 cells/mm3 vs HIV− (OR 8.09, 95% CI 4.37 to 14.97; <0.001) had large independent associations with anaemia. There were large independent associations of CD4 <200 cells/mm3 vs HIV− (OR 7.18, 95% CI 0.78 to 65.82; p=0.081) and co-trimoxazole and/or dapsone use (OR 5.69, 95% CI 0.63 to 51.45; p=0.122) with moderate neutropenia.
Conclusions
Anaemia was more common than neutropenia or thrombocytopenia in the HIV-infected Rwandan women. Future comparisons of haematological parameters in HIV-infected patients before and after antiretroviral therapy initiation are warranted.
doi:10.1136/bmjopen-2012-001600
PMCID: PMC3533001  PMID: 23169875
19.  Is Food Insecurity Associated with HIV Risk? Cross-Sectional Evidence from Sexually Active Women in Brazil 
PLoS Medicine  2012;9(4):e1001203.
Alexander Tsai and colleagues show that in sexually active women in Brazil severe food insecurity with hunger was positively associated with symptoms potentially indicative of sexually transmitted infection and with reduced odds of condom use.
Background
Understanding how food insecurity among women gives rise to differential patterning in HIV risks is critical for policy and programming in resource-limited settings. This is particularly the case in Brazil, which has undergone successive changes in the gender and socio-geographic composition of its complex epidemic over the past three decades. We used data from a national survey of Brazilian women to estimate the relationship between food insecurity and HIV risk.
Methods and Findings
We used data on 12,684 sexually active women from a national survey conducted in Brazil in 2006–2007. Self-reported outcomes were (a) consistent condom use, defined as using a condom at each occasion of sexual intercourse in the previous 12 mo; (b) recent condom use, less stringently defined as using a condom with the most recent sexual partner; and (c) itchy vaginal discharge in the previous 30 d, possibly indicating presence of a sexually transmitted infection. The primary explanatory variable of interest was food insecurity, measured using the culturally adapted and validated Escala Brasiliera de Segurança Alimentar. In multivariable logistic regression models, severe food insecurity with hunger was associated with a reduced odds of consistent condom use in the past 12 mo (adjusted odds ratio [AOR] = 0.67; 95% CI, 0.48–0.92) and condom use at last sexual intercourse (AOR = 0.75; 95% CI, 0.57–0.98). Self-reported itchy vaginal discharge was associated with all categories of food insecurity (with AORs ranging from 1.46 to 1.94). In absolute terms, the effect sizes were large in magnitude across all outcomes. Underweight and/or lack of control in sexual relations did not appear to mediate the observed associations.
Conclusions
Severe food insecurity with hunger was associated with reduced odds of condom use and increased odds of itchy vaginal discharge, which is potentially indicative of sexually transmitted infection, among sexually active women in Brazil. Interventions targeting food insecurity may have beneficial implications for HIV prevention in resource-limited settings.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
At the beginning of the AIDS epidemic, more men than women were infected with HIV, the virus that causes AIDS, but currently half of all HIV-positive adults are women. Most women become infected with HIV through unprotected sexual intercourse with an infected male partner. Biologically, women are twice as likely to become infected through unprotected heterosexual intercourse as men. Moreover, women are often unable to negotiate condom use because of unequal gender relations—men can insist on unprotected sexual intercourse in many relationships. Another factor often related to unequal gender relations that may shape women's risk of exposure to HIV is food insecurity—limited or uncertain access to enough nutritionally adequate and safe food for an active, healthy life. Recent studies done in sub-Saharan Africa suggest that food insecurity can affect women's engagement in risky sexual behaviors such as unprotected sex, transactional sex (sexual relationships that involve the giving of goods or services such as free lodgings), and commercial sex work.
Why Was This Study Done?
Policymakers planning HIV prevention strategies in resource-limited settings need to know whether food insecurity affects sexual risk taking among women. If it increases risk taking, then interventions that target food insecurity should improve the effectiveness of HIV prevention strategies. However, little is known about food insecurity and sexual risk taking outside sub-Saharan Africa. In this cross-sectional study (a study that characterizes a population at a single point in time), the researchers investigate whether food insecurity is associated with risky sexual behavior among sexually active women in Brazil, a country where the number of new heterosexually transmitted HIV infections among women is increasing. Condom promotion is the mainstay of Brazil's HIV prevention strategy, but less than half of the population reports the use of a condom whenever sexual intercourse occurs (consistent condom use) or at last sexual intercourse (recent condom use), and a greater proportion of men than women report condom use, possibly because of unequal power relations between men and women.
What Did the Researchers Do and Find?
The researchers obtained data on consistent condom use, recent condom use, and self-reported itchy vaginal discharge in the previous 30 days (used here as an indication that a woman may have a sexually transmitted infection) for 12,684 sexually active women from a national survey conducted in Brazil in 2006–2007. They then used multivariable logistic regression (a statistical method) to investigate the association between these outcomes and food insecurity, which was measured using the Escala Brasiliera de Insegurança Alimentar, an 18-item questionnaire that asks people to recall information about the quantity and quality of food available to them over the previous three months. Severe food insecurity with hunger (the most extreme category of food insecurity) was associated with an adjusted odds ratio (AOR) for consistent condom use of 0.67. That is, women who reported severe food insecurity were two-thirds as likely to use a condom whenever they had sexual intercourse as women who were food secure, after adjustment for other factors that might have affected condom use. The probability of consistent condom use was 15% among women who were food secure but only 10.5% among women who had the worst food security. Severe food insecurity with hunger was also associated with a reduced odds of recent condom use (AOR = 0.75), whereas all categories of food insecurity increased the odds of a recent itchy vaginal discharge.
What Do These Findings Mean?
These findings indicate that severe food insecurity with hunger is associated with reduced condom use and with increased occurrence of symptoms that may indicate sexually transmitted disease among sexually active women in Brazil. Because the study looked at women at only a single time point, these findings do not show that food insecurity causes risky sexual behavior. Moreover, these findings may not be generalizable to other settings, and they do not distinguish between regular condom use with a regular partner and regular condom use with casual partners. Also, although the researchers investigated two hypothesized explanations—lack of control in sexual relations and chronic energy deficiency—neither of these factors could explain why food insecurity is associated with risky sexual behavior. Nevertheless, these findings suggest that interventions that target sexual risk reduction behaviors are unlikely to be optimally effective if food insecurity is not taken into account, and, thus, the researchers conclude, HIV prevention strategies in Brazil should include interventions that target food insecurity.
Additional Information
Please access these web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001203.
Information is available from the US National Institute of Allergy and Infectious Diseases on all aspects of HIV infection and AIDS
NAM/aidsmap provides basic information about HIV/AIDS, and summaries of recent research findings on HIV care and treatment (in several languages)
Information is available from Avert, an international AIDS charity on many aspects of HIV/AIDS, including detailed information on HIV and AIDS prevention, women, HIV, and AIDS, and HIV and AIDS in Brazil (in English and Spanish); personal stories of women living with HIV are available
HIV InSite provides comprehensive and up-to-date information on all aspects of HIV/AIDS from the University of California at San Francisco
Additional patient stories about living with HIV/AIDS are available through the charity website Healthtalkonline
A primer on food security from the Food and Agriculture Organization of the United Nations is available
Information about the 2006–2007 Brazilian national survey on health in women and children is available in Portuguese; a profile of food security in Brazil is also available (some information in English but mainly in Portuguese)
doi:10.1371/journal.pmed.1001203
PMCID: PMC3323512  PMID: 22505852
20.  Persistent household food insecurity, HIV, and maternal stress in Peri-Urban Ghana 
BMC Public Health  2013;13:215.
Background
The mental health of caregivers has been shown to be important for improving HIV prevention and treatment. Household food insecurity affects hundreds of millions of individuals in Sub-Saharan Africa, a region that experiences a disproportionate burden of the HIV pandemic. Both maternal HIV diagnosis and household food insecurity may be linked with maternal stress. This in turn may lead to unhealthy coping behaviors. We examined the independent associations of HIV, persistent household food insecurity and the synergistic effect of both on maternal stress.
Methods
Ghanaian women recruited prenatally from hospitals offering voluntary counseling and testing (VCT) were followed for 12 months after childbirth (N = 232). A locally adapted 7-item version of the US Household Food Security Survey Module was applied at four time points postpartum. We dichotomized participant households as being persistently food insecure (i.e., food insecure at each time point) or not (i.e., food secure at any time point). We dichotomized participant women as not perceiving vs. perceiving stress at 12 months postpartum in reference to the median sample score on the 4-item Cohen’s stress scale. Binary multivariate logistic regression models were used to assess the independent and interactive effects of maternal HIV and persistent household food insecurity on maternal stress.
Results
The proportion of HIV-positive women that lived in severe food insecure households increased over time. By contrast, the HIV-negative group living in severely food insecure households experienced a steady decline across time. HIV-infection (AOR = 2.31, 95% CI 1.29-4.12) and persistent household food insecurity (AOR = 3.55, 95% CI 1.13-11.13) were independently associated with maternal stress in a multivariate model. Being both HIV-positive and persistently food insecure strongly and synergistically increased the risk for maternal perceived stress (AOR = 15.35, 95% CI 1.90-124.14).
Conclusion
In agreement with syndemic theory there is a powerful synergism between maternal HIV diagnosis and household food insecurity on maternal stress. Comprehensive multi-dimensional intervention studies are needed to better understand how to reduce stress among HIV-positive women living in persistently food insecure households and how to reduce the likelihood of food insecurity in HIV-affected households in Sub-Saharan Africa.
doi:10.1186/1471-2458-13-215
PMCID: PMC3608015  PMID: 23497026
Maternal stress; Food Insecurity; HIV/AIDS; Ghana; Syndemic
21.  Vitamin D deficiency in HIV-infected and un-infected women in the US 
Background
Vitamin D deficiency is of increasing concern in HIV-infected persons, because of its reported association with a number of negative health outcomes that are common in HIV. We undertook this study to determine the prevalence and predictors of vitamin D deficiency among a nationally representative cohort of middle-aged, ethnically diverse HIV-infected and uninfected women enrolled in the Women’s Interagency HIV study (WIHS).
Methods
Vitamin D testing was performed by Quest Diagnostics on frozen sera using the liquid chromatography/mass spectroscopy (LC-MS) method. Vitamin D deficiency was defined as 25 (OH) D ≤20 ng/ml. Comparisons of continuous and categorical characteristics among HIV-infected and HIV-uninfected women were made by Wilcoxon tests and Pearson chi-squared tests, respectively.
Results
1778 women (1268 HIV+) were studied. 63% had vitamin D deficiency (60% HIV +vs. 72% HIV−; p<0.001). Multivariable predictors of Vitamin D Deficiency were being African American (AOR 3.02), Hispanic (AOR 1.40), Body mass index (AOR 1.43), Age (AOR 0.84), HIV+ (AOR 0.76), Glomerular filtration rate <90/ml/min (AOR 0.94) and WIHS site; Los Angeles (AOR 0.66), Chicago (AOR 0.63). In the HIV+ women multivariate predictors were; undetectable HIVRNA (AOR 0.69), CD4 50–200 cells/mm3 (AOR 1.60), CD4 <50 cells/mm3 (AOR 1.94) and recent Protease Inhibitor use (AOR 0.67).
Conclusions
In this study of over 1700 women in the US, most women with or without HIV infection had low vitamin D levels and African American women had the highest rates of Vitamin D deficiency. An understanding of the role that vitamin D deficiency plays in non-AIDS related morbidities is planned for investigation in WIHS.
doi:10.1097/QAI.0b013e31821ae418
PMCID: PMC3431159  PMID: 21471818
Vitamin D; Vitamin D Deficiency; HIV infected; HIV uninfected
22.  Very low food security predicts obesity predominantly in California Hispanic men and women 
Public health nutrition  2012;15(12):2228-2236.
Objective
A high prevalence of food insecurity has persisted in the USA for the past two decades. Previous studies suggest that the association between food insecurity and obesity may vary by gender and race/ethnicity. We examined whether food insecurity was associated with BMI and obesity within gender and racial/ethnic groups in a large, diverse sample of low-income adults.
Design
A cross-sectional analysis of a large population-based health survey. We compared the distribution of BMI and obesity by food security levels within gender and racial/ethnic categories.
Setting
Data were derived from the 2003–2009 waves of the California Health Interview Survey.
Subjects
The study sample included 35 747 non-elderly adults with households ≤200% of the federal poverty level.
Results
Among Hispanic men, very low food security was associated with a 1·0 kg/m2 higher BMI (95% CI 0·3, 1·7 kg/m2) and a 36% higher prevalence of obesity (95% CI 17, 58 %) after multivariate adjustment. Among Hispanic women, very low food security was associated with a 1·1 kg/m2 higher BMI (95% CI 0·4, 1·9 kg/m2) and a 22% higher prevalence of obesity (95% CI 8, 38 %). Positive associations were also observed for Asian women and multi-racial men. No significant associations were observed for non-Hispanic whites, African Americans, Asian men or multi-racial women.
Conclusions
Our results suggest that the association of food insecurity and obesity is limited to individuals of certain low-income, minority racial/ethnic groups. Whether targeted interventions to address food insecurity in these individuals may also decrease obesity risk deserves further investigation.
doi:10.1017/S1368980012000857
PMCID: PMC3502688  PMID: 22463949
Food insecurity; Obesity; BMI; Race/ethnicity; Gender
23.  Food selection associated with sense of coherence in adults 
Nutrition Journal  2005;4:9.
Background
Favorable dietary habits promote health, whereas unfavorable habits link to various chronic diseases. An individual's "sense of coherence" (SOC) is reported to correlate with prevalence of some diseases to which dietary habits are linked. However, understanding what determines an individual's dietary preferences and how to change his/her behavior remains limited. The aim of the present study was to evaluate associations between dietary intake and SOC in adults.
Methods
Diet intake was recorded by an 84-item semi-quantitative food frequency questionnaire and SOC was measured by the 13-item Antonovsky questionnaire in 2,446 men and 2,545 women (25–74 years old) from the population based northern Sweden MONICA screening in 1999.
Results
Intakes of energy, total and saturated fat, ascorbic acid, sucrose, and servings of fruits, vegetables, cereals, and sweets correlated with SOC among women, whereas intakes of total and saturated fat, ascorbic acid, fiber, and alcohol, and servings of fruits, vegetables, bread, bread and cereals, fish, and potatoes correlated with SOC among men. With a few exceptions, intakes of these nutrients/foods were significantly explained by SOC quartile scores in linear GLM models. Both women and men classified into the highest SOC quartile had significantly higher age-BMI-education standardized mean intakes of vegetables than those in the lowest quartiles. Women in the highest SOC quartile also had higher intake of fruits but lower intakes of energy, total and saturated fat, sucrose, and sweets.
Projection to latent structures (PLS) multivariate modeling of intakes of the 84 food items and food aggregates simultaneously on SOC scores supported low SOC to coincide with a presumably less health promoting dietary preference, e.g. intake of pizza, soft drinks, candies, sausages for main course, hamburgers, mashed potato, chips and other snacks, potato salad, French fries, whereas men and women with high SOC scores were characterized by e.g. high intake of rye crisp whole meal bread, boiled potato, vegetables, berries, and fruits.
Conclusion
Both men and women in the highest, as compared with the lowest, SOC score quartile reported more "healthy" food choices. Dietary habits for individuals in the lowest SOC quartile therefore may render a higher risk for various endemic diseases.
doi:10.1186/1475-2891-4-9
PMCID: PMC554973  PMID: 15737236
Diet; Sense of coherence; Food frequency questionnaire; Northern Sweden MONICA study
24.  Assessment of Dietary Intake Patterns and Their Correlates among University Students in Lebanon 
Introduction: Unhealthy dietary habits are major risk factors for chronic diseases, particularly if adopted during early years of adulthood. Limited studies have explored the food consumption patterns among young adults in Lebanon. Our study aimed to examine common dietary patterns and their correlates among a large sample of university student population in Lebanon, focusing on correlation with gender and body mass index (BMI).
Methods: A cross-sectional study was carried out on 3384 students, using a proportionate cluster sample of Lebanese students from both public and private universities. A self-administered food frequency questionnaire was used to assess dietary intake of university students. Factor analysis of food items and groups, cluster analysis of dietary patterns, and multivariate regressions were carried out.
Results: Three dietary patterns were identified among university youth namely a vegetarian/low calorie dietary pattern (characterized mainly by consumption of plant-based food while avoiding “western” food, composite dishes, and bread); a mixed dietary pattern (characterized by high consumption of plant-based food, followed by composite dishes, bread, and a low consumption of western type food); and finally, a westernized dietary pattern (characterized by high consumption of white bread and western food, and a strong avoidance of plant food and composite dishes). We observed significant differences between males and females in terms of their reported food intake and dietary patterns. Females were particularly more prone to adopt the vegetarian/low calorie diet than males (ORa = 1.69; p < 0.001), while males were more likely to adopt a westernized diet (ORa = 1.51; p < 0.001), seemingly in private universities (p = 0.053). Students with high income and obese students (BMI ≥ 30 kg/m2) were more likely to consume vegetarian/low calorie diets (p < 0.05).
Conclusion: Male university students reported a higher consumption of the westernized dietary pattern as compared to female university students in Lebanon, while the latter reported a higher adoption of a vegetarian diet. Health promotion programs are needed to address the dietary intakes and lifestyle behaviors of young adults in Lebanon to help prevent obesity and other associated comorbidities.
doi:10.3389/fpubh.2014.00185
PMCID: PMC4204443  PMID: 25374885
dietary pattern; food categories; gender difference; university students
25.  Comparison of Lower Genital Tract Microbiota in HIV-Infected and Uninfected Women from Rwanda and the US 
PLoS ONE  2014;9(5):e96844.
Introduction
Previous studies have shown that alterations of the bacterial microbiota in the lower female genital tract influence susceptibility to HIV infection and shedding. We assessed geographic differences in types of genital microbiota between HIV-infected and uninfected women from Rwanda and the United States.
Methods
Genera of lower genital tract bacterial microbiota were identified by high-throughput pyrosequencing of the 16S rRNA gene from 46 US women (36 HIV-infected, 10 HIV-uninfected) and 40 Rwandan women (18 HIV-infected, 22 HIV-uninfected) with similar proportions of low (0–3) Nugent scores. Species of Lactobacillus were identified by assembling sequences along with reference sequences into phylogenetic trees. Prevalence of genera and Lactobacillus species were compared using Fisher's exact tests.
Results
Overall the seven most prevalent genera were Lactobacillus (74%), Prevotella (56%), Gardnerella (55%), Atopobium (42%), Sneathia (37%), Megasphaera (30%), and Parvimonas (26%), observed at similar prevalences comparing Rwandan to US women, except for Megasphaera (20% vs. 39%, p = 0.06). Additionally, Rwandan women had higher frequencies of Mycoplasma (23% vs. 7%, p = 0.06) and Eggerthella (13% vs. 0%, p = 0.02), and lower frequencies of Lachnobacterium (8% vs. 35%, p<0.01) and Allisonella (5% vs. 30%, p<0.01), compared with US women. The prevalence of Mycoplasma was highest (p<0.05) in HIV-infected Rwandan women (39%), compared to HIV-infected US women (6%), HIV-uninfected Rwandan (9%) and US (10%) women. The most prevalent lactobacillus species in both Rwandan and US women was L. iners (58% vs. 76%, p = 0.11), followed by L. crispatus (28% vs. 30%, p = 0.82), L. jensenii (20% vs. 24%, p = 0.80), L. gasseri (20% vs. 11%, p = 0.37) and L. vaginalis (20% vs. 7%, p = 0.10).
Discussion
We found similar prevalence of most major bacterial genera and Lactobacillus species in Rwandan and US women. Further work will be needed to establish whether observed differences differentially impact lower genital tract health or susceptibility to genital infections.
doi:10.1371/journal.pone.0096844
PMCID: PMC4016010  PMID: 24817204

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