Food insecurity, but not HIV-infection status, is associated with adverse changes in body composition during lactation in Ugandan women of mixed HIV status

Background: Body composition is an important indicator of nutritional status and health. How body composition changes during 12 mo of breastfeeding in HIV-infected women receiving antiretroviral therapy (ART) is unknown. Objective: We assessed whether HIVor food insecurity was associated with adverse postpartum body-composition changes in Ugandan women. Design: A cohort of 246 women [36.5% of whom were HIV positive (HIV+) and were receiving ART] were followed to 12 mo postpartum. Repeated measures included weight, fat mass, fat-free mass, midupper arm circumference, triceps skinfold thickness [which allowed for the derivation of arm muscle area (AMA) and arm fat area (AFA)], breastfeeding, and individual food insecurity. Longitudinal regression models were constructed to assess associations between HIVand food insecurity and changes in body composition over time. Results: At baseline, HIV+ women compared with HIV-negative women had a higher mean 6 SD food-insecurity score (11.3 ± 5.5 compared with 8.6 ± 5.5, respectively; P < 0.001) and lower AMA (40.6 ± 5.7 compared with 42.9 ± 6.9 cm3, respectively; P = 0.03). Participants were thin at 1 wk postpartum [body mass index (BMI; in kg/m2): 22.9 ± 2.9]. From 1 wk to 12 mo, the weight change was 21.4 ± 4.4 kg. In longitudinal models of body-composition outcomes, HIV was not associated with body composition (all P. 0.05), whereas food insecurity was inversely associated with body weight and BMI at 6, 9, and 12 mo and with AFA at ± and 12 mo (all P < 0.05). At ± mo, every 1-unit increase in the food-insecurity score was associated with a 0.13-kg lower body weight (P < 0.001) and a 0.26-cm3 lower AFA (P < 0.01). Conclusions: Body-composition changes are minimal during lactation. HIV is not associated with body composition; however, food insecurity is associated with changes in body composition during lactation. This trial was registered at clinicaltrials. gov as NCT02922829 and NCT02925429.

Data were collected in the context of the Prenatal Nutrition and Psychosocial Health Outcomes Study (PreNAPS) and the Postnatal Nutrition and Psychosocial Health Outcomes Study (PostNAPS) in Gulu, Uganda. Together, these composed a longitudinal observational cohort that was designed to examine the relations between food security, psychosocial health, and nutritional status during pregnancy and postpartum in postconflict Northern Uganda. Gulu was the epicenter of a protracted 20-y conflict between the Ugandan government and the Lord’s Resistance Army, which ended in 2006. Data were collected between 10 October 2012 and 19 January 2015 at Gulu Regional Referral Hospital (GRRH). All women at GRRH receive antenatal care and medications free of charge, and HIV+ women receive free ART, as is consistent with national policy in Uganda, and sulfamethoxazole trimethoprim (Septrin; Aspen Pharmacare). HIV+ women who were not receiving highly active antiretroviral therapy at the first ANC visit were given the first-line option B+ (tenofovir, lamivudine, and efavirenz; Cipla Quality Chemicals Ltd.). HIV+ women who were receiving highly active antiretroviral therapy were given several options for continuing treatment as follows: 1) Duovir-N (zidovodine, lamivudine, and nevirapine; Cipla Quality Chemical Industries Ltd.), 2) Duomune (lamivudine and tenofovir; Cipla Quality Chemical Industries Ltd.) and nevirapine (Boehringer Ingleheim), or 3) Duomune and efavirenz (Bristol-Myers Squibb) (27). Study procedures have been previously described (26, 28, 29). Briefly, women (n = 403) were invited to participate in PreNAPS if they met the following eligibility criteria: gestational age between 10 and 26 wk (assessed according to the last menstrual period), living ≤30 km of GRRH, and having a known HIV status. HIV+ women were oversampled to obtain a ratio of 2 HIV-uninfected to 1 HIV+ participants, which resulted in a higher HIV prevalence in the cohort than the age-adjusted HIV prevalence (∼10.3%) at antenatal care clinics in Northern Uganda (30). Mothers were enrolled and were followed monthly throughout pregnancy (mean ± SD prenatal visits per woman: 5.0 ± 1.1). The sample size for PreNAPS was designed to provide 80% power to detect a 50-g difference in weight gain between HIV+ and HIV− women at a 5% level of significance and accounting for a 10% loss to follow-up. The postnatal continuation of the study was exploratory; with the use of postpartum values from a South African cohort of HIV+ and HIV− women (15), with a sample size of 246, we had 98% power to detect a difference in the weight change between HIV+ and HIV− women with an α of 0.05. All PreNAPS participants who delivered after 9 May 2013 were invited to participate in PostNAPS after delivery if the pregnancy resulted in a live singleton birth, and all women accepted the invitation (n = 246). Postnatal visits were conducted at 1 wk and 1, 3, 6, 9, and 12 mo postpartum. At enrollment and all follow-up visits, trained research staff obtained physical measures including weight (Seca 874; Seca North America), height (Seca 206; Seca North America), and midupper arm circumference (MUAC) with the use of a nonstretchable, retractable tape measure. Body composition was assessed at postnatal follow-up visits that occurred after 31 July 2013. At these visits, subscapular, triceps, suprailliac, and midthigh skinfold thickness measurements were obtained on the right side of the body with the use of Harpenden calipers (Baty International). Arm muscle area (AMA) and arm fat area (AFA) were calculated from triceps skinfold thickness and MUAC measurements as follows: A bioelectrical impedance analysis (BIA 450; Biodynamics) was used to estimate fat-free mass and fat mass. Bioelectrical impedance analysis testing was completed after subjects drank ∼8 ounces (250 mL) H2O. Other measures included an interviewer-administered, 10-item, individually focused food-insecurity access scale (26), the Center for Epidemiologic Studies Depression Scale (CES-D) (28), and the assessment of maternal dietary diversity from the previous day (31). At the enrollment visit during pregnancy, education, marital status, urban or rural residence, age, and report of previous displacement and living in an internally displaced person camp during the conflict in Gulu (ending in 2006) were obtained. A household-asset index was derived with the use of a principal components analysis from the self-report of household assets on the basis of the Ugandan National Panel Survey 2009/2010 (Supplemental Figure 1), whereby higher scores indicated greater wealth. Breastfeeding status was obtained by maternal report of any breastfeeding (yes or no) and any other dietary intake of the infant at each postpartum visit. At visits that occurred ≥1 mo postpartum, maternal experiences of diarrhea, vomiting, fever, and malaria in the previous month were ascertained. ART regimens were based on self-reports. The Institutional Review Board (IRB) at Cornell University and the IRB at Gulu University approved the study procedures for the PreNAPS. These IRBs and the IRB at Weill Cornell Medical College approved the PostNAPS procedures. Permission to carry out the study in Uganda was granted by the Ugandan National Council for Science and Technology. All mothers provided written informed consent for both the PreNAPS and PostNAPS. These trials were registered at clinicaltrials.gov as {"type":"clinical-trial","attrs":{"text":"NCT02922829","term_id":"NCT02922829"}}NCT02922829 and {"type":"clinical-trial","attrs":{"text":"NCT02925429","term_id":"NCT02925429"}}NCT02925429 Statistical analyses were conducted with the use of Stata 12.0 software (StataCorp LP) with an α of 0.05 for statistical tests and an α of 0.1 for tests of effect modification. Baseline characteristics were compared between included and excluded dyads with the use of parametric tests for continuous, normally distributed variables and with the use of nonparametic tests for variables that were not normally distributed. These tests were also used to compare differences in baseline characteristics and body composition at 1 wk postpartum by HIV status. Multivariable random-effects longitudinal models were used to assess the association between predictors and maternal body-composition changes from 1 wk to 12 mo accounting for the visit time as an indicator variable [1 wk (reference) and 1, 3, 6, 9, and 12 mo]. Models were built for the following body-composition outcomes: weight, BMI (in kg/m2), MUAC, AMA, AFA, fat mass, fat-free mass, and the sum of skinfold thickness. Hunger season was defined as dates inclusive of 1 April to 30 June. The primary covariates of interest were HIV status (yes or no) and time-varying lagged individual food insecurity [continuous score from previous study visit (e.g., the lagged value at 1 mo was assessed at 1 wk), whereby higher scores indicated greater food insecurity]. We chose to examine lagged individual food insecurity to strengthen the plausibility of associations (32). We evaluated whether the pattern of change over time varied by HIV status or food insecurity by including interaction terms between these factors and the visit; nonsignificant interaction terms were not retained in the final models. Other covariates were included in the final model if the HIV or food-insecurity β coefficients appreciably changed (∼10%) in the base model with only these predictors or with strong literature justification. The time-independent covariates examined were as follows: household-asset index (score, continuous), maternal education beyond primary school (yes or no), maternal age (years, continuous), parity (number, continuous), urban residence (yes or no, comparison to rural), rate of pregnancy weight gain (kilograms per week, continuous, across all prenatal visits), and previous displacement (yes or no). Time-varying covariates were as follows: maternal dietary diversity (score, continuous), CES-D (score, continuous), hunger season occurring in previous month (yes or no), and currently exclusively breastfeeding (yes or no). Any breastfeeding was not included in the models because 8% of participants reported the complete cessation of breastfeeding by 12 mo. In a sensitivity analysis, a second set of longitudinal models were fit from 1 to 12 mo postpartum including the time-varying indicator variables for morbidities that were assessed at these visits (specifically, fever or malaria, vomiting, and diarrhea).

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• Dima Health