Lipid-based nutrient supplement at initiation of antiretroviral therapy does not substitute energy from habitual diet among HIV patients – a secondary analysis of data from a randomised controlled trial in Ethiopia

  • Nanna Buhl Schwartz Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
  • Daniel Yilma Department of Internal Medicine, Jimma University Specialized Hospital, Jimma, Ethiopia
  • Tsinuel Girma Department of Paediatric and Child Health, Jimma University Specialized Hospital, Jimma, Ethiopia
  • Markos Tesfaye Department of Psychiatry, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
  • Christian Mølgaard Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
  • Kim Fleischer Michaelsen Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
  • Pernille Kæstel Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
  • Henrik Friis Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
  • Mette Frahm Olsen Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark; and Department of Infectious Diseases, Rigshospitalet, Denmark
Keywords: Afrika, nutritional supplement, HIV, energy intake, food insecurity


Introduction: Malnutrition is common among people with HIV in sub-Saharan Africa. Nutritional supplementation at initiation of antiretroviral treatment (ART) has shown beneficial effects, but it is not known if supplementation replaces or supplements the habitual energy intake in a context of food insecurity.

Methods: As part of a randomised controlled trial among people with HIV initiating ART in Ethiopia, we assessed whether the provision of a lipid-based nutrient supplement (LNS) affected energy intake from the habitual diet. People with HIV aged ≥18 years with a body mass index (BMI) >17 were randomly allocated 2:1 to receive either early (month 1–3 after ART initiation) or delayed (month 4–6 after ART initiation) supplementation with LNS (≈4,600 kJ/day). Participants with BMI 16–17 were all allocated to early supplementation. The daily energy intake from the habitual diet (besides the energy contribution from LNS) was assessed using a 24-h food recall interview at baseline and at monthly follow-up visits. Linear mixed models were used to compare habitual energy intake in (1) early versus delayed supplementation groups and (2) supplemented versus unsupplemented time periods within groups.

Results: Of 301 participants included, 67% of the participants were women, mean (±standard deviation [SD]) age was 32.9 (±8.9) years and 68% were living in moderately or severely food insecure households. Mean (±SD) reported habitual energy intake at baseline was 5,357 kJ/day (±2,246) for women and 7,977 kJ/day(±3,557) for men. Among all participants, there were no differences in mean habitual energy intake between supplemented and unsupplemented groups in neither the first 3 (P = 0.72) nor the following 3 months (P = 0.56). Furthermore, habitual energy intake did not differ within groups when comparing periods with or without supplementation (P = 0.15 and P = 0.20). The severity of food insecurity did not modify the effect of supplementation in habitual energy intake (P = 0.55). Findings were similar when participants with BMI 16–17 were excluded.

Conclusion: Our findings indicate that the LNS provided after ART initiation supplement, rather than substitute, habitual energy intake among people with HIV, even among those who are food insecure. This supports the feasibility of introducing nutritional supplementation as part of HIV treatment.


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  1. UNAIDS. MILES TO GO – closing gaps, breaking barriers, righting injustices. Geneva, Switzerland: UNAIDS; 2018.

  2. Weiser SD, Young SL, Cohen CR, Kushel MB, Tsai AC, Tien PC, et al. Conceptual framework for understanding the bidirectional links between food insecurity and HIV/AIDS. Am J Clin Nutr 2011; 94: 1729–39. doi: 10.3945/ajcn.111.012070

  3. Aibibula W, Cox J, Hamelin A-M, McLinden T, Klein MB, Brassard P. Association between food insecurity and HIV viral suppression: a systematic review and meta-analysis. AIDS Behav 2017; 21: 754–65. doi: 10.1007/s10461-016-1605-5

  4. Weiser SD, Tsai AC, Gupta R, Frongillo EA, Kawuma A, Senkungu J, et al. Food insecurity is associated with morbidity and patterns of healthcare utilization among HIV-infected individuals in a resource-poor setting. AIDS 2012; 26: 67–75. doi: 10.1097/QAD.0b013e32834cad37

  5. Liu E, Spiegelman D, Semu H, Hawkins C, Chalamilla G, Aveika A, et al. Nutritional status and mortality among HIV-infected patients receiving antiretroviral therapy in Tanzania. J Infect Dis 2011; 204: 282–90. doi: 10.1093/infdis/jir246

  6. Marazzi MC, Liotta G, Germano P, Guidotti G, Altan AD, Ceffa S, et al. Excessive early mortality in the first year of treatment in HIV type 1-infected patients initiating antiretroviral therapy in resource-limited settings. AIDS Res Hum Retroviruses 2008; 24: 555–60. doi: 10.1089/aid.2007.0217

  7. Tang AM, Quick T, Chung M, Wanke CA. Nutrition Assessment, Counseling, and Support (NACS) interventions to improve health-related outcomes in people living with HIV/AIDS: a systematic review of the literature. J Acquir Immune Defic Syndr 2015; 68: S340–9. doi: 10.1097/QAI.0000000000000521

  8. Kosmiski L. Energy expenditure in HIV infection. Am J Clin Nutr 2011; 94: 1677S–82S. doi: 10.3945/ajcn.111.012625

  9. Koethe JR, Heimburger DC. Nutritional aspects of HIV-associated wasting in sub-Saharan Africa. Am J Clin Nutr 2010; 91: 1138S–42S. doi: 10.3945/ajcn.2010.28608D

  10. Daniel M, Mazengia F, Birhanu D. Nutritional status and associated factors among adult HIV/AIDS clients in Felege Hiwot Referral Hospital, Bahir Dar, Ethiopia. SJPH 2013; 1: 24–31. doi: 10.11648/j.sjph.20130101.14

  11. Hailemariam S, Bune GT, Ayele HT. Malnutrition: prevalence and its associated factors in People living with HIV/AIDS, in Dilla University Referral Hospital. Arch Public Health 2013; 71: 13. doi: 10.1186/0778-7367-71-13

  12. Hadgu TH, Worku W, Tetemke D, Berhe H. 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. doi: 10.1186/1471-2458-13-943

  13. Gedle D, Gelaw B, Muluye D, Mesele M. Prevalence of malnutrition and its associated factors among adult people living with HIV/AIDS receiving anti-retroviral therapy at Butajira Hospital, southern Ethiopia. BMC Nutr 2015; 1: 5. doi: 10.1186/2055-0928-1-5

  14. World Health Organization. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach. Geneva: World Health Organization; 2021.

  15. Olsen MF, Abdissa A, Kaestel P, Tesfaye M, Yilma D, Girma T, et al. Effects of nutritional supplementation for HIV patients starting antiretroviral treatment: randomised controlled trial in Ethiopia. BMJ 2014; 348: g3187. doi: 10.1136/bmj.g3187

  16. Hong H, Budhathoki C, Farley JE. Effectiveness of macronutrient supplementation on nutritional status and HIV/AIDS progression: a systematic review and meta-analysis. Clin Nutr ESPEN 2018; 27: 66–74. doi: 10.1016/j.clnesp.2018.06.007

  17. Tesfaye M, Kaestel P, Olsen MF, Girma T, Yilma D, Abdissa A, et al. The effect of nutritional supplementation on quality of life in people living with HIV: a randomised controlled trial. Trop Med Int Health 2016; 21: 735–42. doi: 10.1111/tmi.12705

  18. Pichard C, Sudre P, Karsegard V, Yerly S, Slosman DO, Delley V, et al. A randomized double-blind controlled study of 6 months of oral nutritional supplementation with arginine and omega-3 fatty acids in HIV-infected patients. AIDS 1998; 12: 53–63. doi: 10.1097/00002030-199801000-00007

  19. Sattler FR, Rajicic N, Mulligan K, Yarasheski KE, Koletar SL, Zolopa A, et al. Evaluation of high-protein supplementation in weight-stable HIV-positive subjects with a history of weight loss: a randomized, double-blind, multicenter trial. Am J Clin Nutr 2008; 88: 1313–21. doi: 10.3945/ajcn.2006.23583

  20. Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive treatment to nutritional counseling in malnourished HIV-infected patients: randomized controlled trial. Clin Nutr 1999; 18: 371–4. doi: 10.1016/s0261-5614(99)80018-1

  21. Berneis K, Battegay M, Bassetti S, Nuesch R, Leisibach A, Bilz S, et al. Nutritional supplements combined with dietary counselling diminish whole body protein catabolism in HIV-infected patients. Eur J Clin Invest 2000: 30(1): 87–94. doi: 10.1046/j.1365-2362.2000.00591.x

  22. de Luis Román DA, Bachiller P, Izaola O, Romero E, Martin J, Arranz M, et al. Nutritional treatment for acquired immunodeficiency virus infection using an enterotropic peptide-based formula enriched with n-3 fatty acids: a randomized prospective trial. Eur J Clin Nutr 2001; 55: 1048–52. doi: 10.1038/sj.ejcn.1601276

  23. Federal Ministry of Health. National guideline for nutritional care and support for PLHIV. Addis Ababa, Ethiopia: Federal Democratic Republic of Ethiopia Ministry of Health; 2011.

  24. Federal HIV/AIDS Prevention and Control Office. Guidelines for management of opportunistic infections and anti retroviral treatment in adolescents and adults in Ethiopia. Ethiopia: Federal Ministry of Health; 2008.

  25. FAO/WHO. Human vitamin and mineral requirements. Report of a joint FAO/WHO expert consultation. Bangkok, Thailand: Food and Nutrition Division FAO Rome; 2001.

  26. Olsen MF, Tesfaye M, Kaestel P, Friis H, Holm L. Use, perceptions, and acceptability of a ready-to-use supplementary food among adult HIV patients initiating antiretroviral treatment: a qualitative study in Ethiopia. Patient Prefer Adherence 2013; 7: 481–8. doi: 10.2147/PPA.S44413

  27. EHNRI, FAO. Food composition table for use in Ethiopia Part IV. Addis Ababa, Ethiopia: Ethiopian Health and Nutrition Research Institute; 1998.

  28. Ethiopian Nutrition Institute. Ethiopian traditional recipes. Addis Ababa, Ethiopia: Ministry of Health; 1980.

  29. Coates J, Swindale A, Bilinsky P. Household Food Insecurity Access Scale (HFIAS) for Measurement of Food Access: Indicator Guide (v.3). Washington, DC: FHI 360/FANTA; 2007.

  30. Olsen MF, Kæstel P, Tesfaye M, Abdissa A, Yilma D, Girma T, et al. Physical activity and capacity at initiation of antiretroviral treatment in HIV patients in Ethiopia. Epidemiol Infect 2015; 143: 1048–58. doi: 10.1017/S0950268814001502

  31. Henry C. Basal metabolic rate studies in humans: measurement and development of new equations. Public Health Nutr 2005; 8: 1133–52. doi: 10.1079/PHN2005801

  32. World Medical Association. WMA declaration of Helsinki – ethical principles for medical research involving human subjects. n.d. Available from: [cited 19 October 2020].

  33. Gibson RS. Measuring food consumptions of individuals. Principles of Nutritional Assessment. Second Edition. New York, United States: Oxford University Press; 2005.

  34. Popkin BM, Adair LS, Ng SW. Global nutrition transition and the pandemic of obesity in developing countries. Nutr Rev 2012; 70: 3–21. doi: 10.1111/j.1753-4887.2011.00456.x

  35. Anema A, Zhang W, Wu Y, Elul B, Weiser SD, Hogg RS, et al. Availability of nutritional support services in HIV care and treatment sites in sub-Saharan African countries. Public Health Nutr 2012; 15: 938–47. doi: 10.1017/S136898001100125X

  36. Ndekha MJ, van Oosterhout JJG, Zijlstra EE, Manary M, Saloojee H, Manary MJ. Supplementary feeding with either ready-to-use fortified spread or corn-soy blend in wasted adults starting antiretroviral therapy in Malawi: randomised, investigator blinded, controlled trial. BMJ 2009; 338: b1867. doi: 10.1136/bmj.b1867

  37. Black AE, Prentice AM, Goldberg GR, Jebb SA, Bingham SA, Livingstone MB, et al. Measurements of total energy expenditure provide insights into the validity of dietary measurements of energy intake. J Am Diet Assoc 1993; 93: 572–9. doi: 10.1016/0002-8223(93)91820-G

  38. Livingstone MBE, Black AE. Markers of the validity of reported energy intake. J Nutr 2003; 133 Suppl 3: 895S–920S. doi: 10.1093/jn/133.3.895S

  39. Golden MH. Proposed recommended nutrient densities for moderately malnourished children. Food Nutr Bull 2009; 30: S267–341. doi: 10.1177/15648265090303S302

How to Cite
Buhl SchwartzN., YilmaD., GirmaT., TesfayeM., MølgaardC., Fleischer MichaelsenK., KæstelP., Friis H., & Frahm OlsenM. (2022). Lipid-based nutrient supplement at initiation of antiretroviral therapy does not substitute energy from habitual diet among HIV patients – a secondary analysis of data from a randomised controlled trial in Ethiopia. Food & Nutrition Research, 66.
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