evidence-based blog of Filippo Dibari

Posts Tagged ‘adults’

They starved so that others be better fed: remembering Ancel Keys and the Minnesota experiment.

In Under-nutrition on June 3, 2014 at 1:51 pm

by Kalm LM, Semba RD.

 J Nutr. 2005 Jun;135(6):1347-52




During World War II, 36 conscientious objectors participated in a study of human starvation conducted by Ancel Keys and his colleagues at the University of Minnesota. The Minnesota Starvation Experiment, as it was later known, was a grueling study meant to gain insight into the physical and psychologic effects of semistarvation and the problem of refeeding civilians who had been starved during the war.


During the experiment, the participants were subjected to semistarvation in which most lost >25% of their weight, and many experienced anemia, fatigue, apathy, extreme weakness, irritability, neurological deficits, and lower extremity edema. In 2003-2004, 18 of the original 36 participants were still alive and were interviewed.


CaptureMany came from the Historic Peace Churches (Mennonite, Brethren, and Quaker), and all expressed strong convictions about nonviolence and wanting to make a meaningful contribution during the war. Despite ethical issues about subjecting healthy humans to starvation, the men interviewed were unanimous in saying that they would do it all over again, even after knowing the suffering that they had experienced.

After the experiment ended, many of the participants went on to rebuilding war-torn Europe, working in the ministries, diplomatic careers, and other activities related to nonviolence.

Use, perceptions, and acceptability of a ready-to-use supplementary food among adult HIV patients initiating antiretroviral treatment: a qualitative study in Ethiopia

In Under-nutrition on March 30, 2014 at 6:38 am
Mette Frahm Olsen, Markos Tesfaye, Pernille Kaestel, Henrik Friis, and Lotte Holm
Patient Preference and Adherence 2013:7 481–488 (download)


Ready-to-use supplementary foods (RUSF) are used increasingly in human immunodeficiency virus (HIV) programs, but little is known about how it is used and viewed by patients. We used qualitative methods to explore the use, perceptions, and acceptability of RUSF among adult HIV patients in Jimma, Ethiopia.


The study obtained data from direct observations and 24 in-depth interviews with HIV patients receiving RUSF.


Participants were generally very motivated to take RUSF and viewed it as beneficial. RUSF was described as a means to fill a nutritional gap, to “rebuild the body,” and protect it from harmful effects of antiretroviral treatment (ART). Many experienced nausea and vomiting when starting the supplement. This caused some to stop supplementation, but the majority adapted to RUSF. The supplement was eaten separately from meal situations and only had a little influence on household food practices. RUSF was described as food with “medicinal qualities,” which meant that many social and religious conventions related to food did not apply to it. The main concerns about RUSF related to the risk of HIV disclosure and its social consequences.


HIV patients view RUSF in a context of competing livelihood needs. RUSF intake was motivated by a strong wish to get well, while the risk of HIV disclosure caused concerns. Despite the motivation for improving health, the preservation of social networks was prioritized, and nondisclosure was often a necessary strategy. Food sharing and religious fasting practices were not barriers to the acceptability of RUSF. This study highlights the importance of ensuring that supplementation strategies, like other HIV services, are compatible with the sociocultural context of patients.

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Adult consequences of growth failure in early childhood

In Under-nutrition on January 27, 2014 at 12:17 pm

by John Hoddinott, Jere R Behrman, John A Maluccio, Paul Melgar, Agnes R Quisumbing, Manuel Ramirez-Zea, Aryeh D Stein,
Kathryn M Yount, and Reynaldo Martorell

Am J Clin Nutr 2013;98:1170–8. Printed in USA

(download the paper here)


Background: Growth failure is associated with adverse consequences, but studies need to control adequately for confounding.

Objective: We related height-for-age z scores (HAZs) and stunting at age 24 mo to adult human capital, marriage, fertility, health, and economic outcomes.

Design: In 2002–2004, we collected data from 1338 Guatemalan adults (aged 25–42 y) who were studied as children in 1969–1977. We used instrumental variable regression to correct for estimation bias and adjusted for potentially confounding factors.

Results: A 1-SD increase in HAZ was associated with more schooling (0.78 grades) and higher test scores for reading and nonverbal cognitive skills (0.28 and 0.25 SDs, respectively), characteristics of marriage partners (1.39 y older, 1.02 grade more schooling, and 1.01 cm taller) and, for women, a higher age at first birth (0.77 y) and fewer number of pregnancies and children (0.63 and 0.43, respectively). A 1-SD increase in HAZ was associated with increased household per capita expenditure (21%) and a lower probability of living in poverty (10 percentage points). Conversely, being stunted at 2 y was associated with less schooling, a lower test performance, a lower household per capita expenditure, and an increased probability of living in poverty. For women, stunting was associated with a lower age at first birth and higher number of pregnancies and children. There was little relation between either HAZ or stunting and adult health.

Conclusion: Growth failure in early life has profound adverse consequences over the life course on human, social, and economic capital.

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Anthropometric predictors of mortality in undernourished adults in the Ajiep Feeding Programme in Southern Sudan

In Under-nutrition on July 8, 2013 at 8:03 pm

In Uncategorized on July 8, 2013 at 8:00 pm

by Abel H Irena, David A Ross, Peter Salama, and Steve Collins

Am J Clin Nutr August 2013


Background: Various nutritional assessment tools are available to assess adult undernutrition, but few are practical in poorly served areas of low-income countries.

Objective: The objective was to assess the relation between midupper arm circumference (MUAC), weight, body mass index (BMI), and clinical assessment for edema in predicting mortality in adults with severe acute undernutrition.

Design: Demographic and anthropometric data that were collected in an observational study of 197 adults were analyzed. Participants were aged 18–59 y and were admitted to a therapeutic feeding center in Ajiep, Southern Sudan, during the height of the 1998 famine. Receiver operating curves were calculated and compared.

Results: The mean (±SD) age of the participants was 40.1 ±10.8 y, and the mean (±SD) MUAC, weight, and BMI (in kg/m2) were 16.4 ± 1.3 cm, 35.1 ± 5.2 kg, and 12.6 ± 1.5, respectively. The area under the receiver operating curve for MUAC (0.71) was higher (P = 0.01) than those of BMI (0.57) and weight (0.51). Mean age, weight, and BMI on admission did not differ between survivors and nonsurvivors (P > 0.17). MUAC and edema were independently associated with mortality. For every 1-cm increase in admission MUAC, the odds of subsequent mortality decreased by 58% (adjusted OR: 0.42; 95% CI: 0.28, 0.63; P < 0.001).

Conclusions: In this study, which was conducted at the height of a major famine among adults with extremely severe grades of undernutrition, MUAC and edema were better indicators of short-term prognosis than was BMI. Further studies are needed to define a critical MUAC threshold for the diagnosis of acute adult undernutrition.

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Six-Month Mortality among HIV-Infected Adults Presenting for Antiretroviral Therapy with Unexplained Weight Loss, Chronic Fever or Chronic Diarrhea in Malawi

In Under-nutrition on November 25, 2012 at 8:14 am

by Monique van Lettow, Ann Åkesson, Alexandra L. C. Martiniuk, Andrew Ramsay, Adrienne K. Chan, Suzanne T. Anderson, Anthony D. Harries, Elizabeth Corbett, Robert S. Heyderman, Rony Zachariah, Richard A. Bedell

from PLOs November 19, 2012

(downlowad the paper)




In sub-Saharan Africa, early mortality is high following initiation of antiretroviral therapy (ART). We investigated 6-month outcomes and factors associated with mortality in HIV-infected adults being assessed for ART initiation and presenting with weight loss, chronic fever or diarrhea, and with negative TB sputum microscopy.


A prospective cohort study was conducted in Malawi, investigating mortality in relation to ART uptake, microbiological findings and treatment of opportunistic infection (OIs), 6 months after meeting ART eligibility criteria.


Of 469 consecutive adults eligible for ART, 74(16%) died within 6 months of enrolment, at a median of 41 days (IQR 20–81). 370(79%) started ART at a median time of 18 days (IQR 7–40) after enrolment. Six-month case-fatality rates were higher in patients with OIs; 25/121(21%) in confirmed/clinical TB and 10/50(20%) with blood stream infection (BSI) compared to 41/308(13%) in patients with no infection identified. Median TB treatment start was 27 days (IQR 17–65) after enrolment and mortality [8 deaths (44%)] was significantly higher among 18 culture-positive patients with delayed TB diagnosis compared to patients diagnosed clinically and treated promptly with subsequent culture confirmation [6/34 (18%);p = 0.04]. Adjusted multivariable analysis, excluding deaths in the first 21 days, showed weight loss >10%, low CD4 count, severe anemia, laboratory-only TB diagnosis, and not initiating ART to be independently associated with increased risk of death.


Mortality remains high among chronically ill patients eligible for ART. Prompt initiation of ART is vital: more than half of deaths were among patients who never started ART. Diagnostic and treatment delay for TB was strongly associated with risk of death. More than half of deaths occurred without identification of a specific infection. ART programmes need access to rapid point-of-care-diagnostic tools for OIs. The role of early empiric OI treatment in this population requires further evaluation in clinical trials.

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Association of BMI Category Change with TB Treatment Mortality in HIV-Positive Smear-Negative and Extrapulmonary TB Patients in Myanmar and Zimbabwe

In Under-nutrition on May 8, 2012 at 11:18 am

Benova L, Fielding K, Greig J, Nyang’wa BT, Casas EC, da Fonseca MS, du Cros P.

PLoS One. 2012;7(4):e35948. Epub 2012 Apr 2

“OBJECTIVE: The HIV epidemic has increased the proportion of patients with smear-negative and extrapulmonary tuberculosis (TB) diagnoses, with related higher rates of poor TB treatment outcomes. Unlike in smear-positive pulmonary TB, no interim markers of TB treatment progress are systematically used to identify individuals most at risk of mortality. The objective of this study was to assess the association of body mass index (BMI) change at 1 month (±15 days) from TB treatment start with mortality among HIV-positive individuals with smear-negative and extrapulmonary TB.

“METHODS AND FINDINGS: A retrospective cohort study of adult HIV-positive new TB patients in Médecins Sans Frontières (MSF) treatment programmes in Myanmar and Zimbabwe was conducted using Cox proportional hazards regression to estimate the association between BMI category change and mortality. A cohort of 1090 TB patients (605 smear-negative and 485 extrapulmonary) was followed during TB treatment with mortality rate of 28.9 per 100 person-years. In multivariable analyses, remaining severely underweight or moving to a lower BMI category increased mortality (adjusted hazard ratio 4.05, 95% confidence interval 2.77-5.91, p<0.001) compared with remaining in the same or moving to a higher BMI category.

“CONCLUSIONS: We found a strong association between BMI category change during the first month of TB treatment and mortality. BMI category change could be used to identify individuals most at risk of mortality during TB treatment among smear-negative and extrapulmonary patients.”

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