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Year : 2017  |  Volume : 10  |  Issue : 5  |  Page : 1210-1214
Malnutrition among patients suffering from HIV/AIDS in Kermanshah, Iran

1 Department of Public Health, School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
2 Nutritional Science Department, School of Nutritional Science and Food Technology, Kermanshah University of Medical Sciences, Kermanshah, Iran
3 Students Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
4 National Health Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
5 School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

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Date of Web Publication6-Nov-2017


Background: Inadequate food intake is one of the causes of malnutrition, which is an important complication of HIV and accelerates the progress of HIV toward acquired immunodeficiency syndrome (AIDS). Objective: The present study aimed to assess nutritional status of people with HIV/AIDS. Materials and Methods: The present cross-sectional study recruited 340 people with HIV/AIDS visiting Behavioral Diseases Counseling Center in Kermanshah Province. Malnutrition was measured by body mass index (BMI). Food Frequency Scale was used to assess food intake, and the amounts of food intake were compared to recommended daily allowance (RDA). The data were analyzed in Stata-11 using Chi-square, Kruskal–Wallis, and ANOVA tests. Results: Mean BMI among men and women was 22.12 ± 3.75 kg/m2 and 25.54 ± 4.66 kg/m2. The prevalence of BMI-based malnutrition was 42.21% (141 people). Of participating patients, 11.08% were underweight, 22.75% overweight, and 8.38% obese. Underweight was reported more prevalent in men than in women and also in singles than in married patients (P = 0.001). Intake of protein, folate, Vitamins A and E, and fiber was less than RDA in a significantly large number of patients. Vitamin A deficiency was more evident in men and folate and calcium deficiencies in women. Conclusion: The present study showed inadequate intake of micro- and macro-nutrients in patients with HIV/AIDS. Malnutrition was observed as varying degrees of underweight and overweight, which requires greater attention to and care for these patients.

Keywords: Body mass index, calorie intake, HIV infection, micronutrients

How to cite this article:
Hamzeh B, Pasdar Y, Darbandi M, Majd SP, Reza Mohajeri SA. Malnutrition among patients suffering from HIV/AIDS in Kermanshah, Iran. Ann Trop Med Public Health 2017;10:1210-4

How to cite this URL:
Hamzeh B, Pasdar Y, Darbandi M, Majd SP, Reza Mohajeri SA. Malnutrition among patients suffering from HIV/AIDS in Kermanshah, Iran. Ann Trop Med Public Health [serial online] 2017 [cited 2020 May 28];10:1210-4. Available from:

   Introduction Top

Acquired immunodeficiency syndrome (AIDS) is caused by HIV infection.[1] AIDS is the most important fatal infectious disease and the fourth leading cause of death in the world. AIDS is the main obstacle to the development of society and affects the majority of active and productive population. The number of people with AIDS was estimated 36.7 million and AIDS-related deaths were reported 1 million people in 2016. The World Health Organization (WHO) has reported the number of AIDS-related deaths in Iran as 6/100,000 people.[2]

People with HIV of all ages are exposed to nutritional deficiencies, and their nutritional status is a strong prognostic factor for the progress of the disease, survival, and functioning levels in the course of disease.[3] The interaction of HIV, immune system, and nutrition is highly complex and interrelated. Like fuel for fire, malnutrition fuels the progression of HIV toward AIDS. Malnutrition may have different causes such as medication side effects, depression, fever, and especially eating disorders.[4] Malnutrition causes immune system dysfunction and increased vulnerability of the host to infections.[5]

Nutritional support has proven crucial for HIV patients. The American Society for Nutrition recommends nutritional support as a component of care provided for HIV-positive patients. Poor nutritional status (including low and high intake of nutrients) can affect immune system function irrespective of HIV infection. HIV infection and its treatment may create unusually complex metabolic malnutrition that can be related to changes in nutritional status such as energy consumption, fat metabolism, and hormonal imbalance which facilitate the incidence of malnutrition. A HIV patient can easily control the disease through proper nutrition.[6]

Studies conducted on HIV patients have provided different results in relation to malnutrition in these patients. A study from China reported the prevalence of body mass index (BMI)-based malnutrition 37.2% and inadequacy of energy intake 59.6%.[7] The prevalence of underweight in patients with AIDS was reported 18.4% in Tanzania.[8] Many studies have also shown inadequate intake of energy and nutrients such as iron and Vitamins A, B, and E in these patients.[9],[10] Few studies in Iran have assessed anthropometric indices in HIV patients and have not provided any statistics for the prevalence of malnutrition among them. Thus, considering that nutritional inadequacy is a major cause of malnutrition and that few studies have assessed nutritional inadequacy and malnutrition among HIV-infected patients in Iran.


The present study aimed to determine anthropometric indices, the prevalence of malnutrition, and food intake in patients with HIV/AIDS in Kermanshah Province.

   Materials and Methods Top

The present cross-sectional study was conducted in 2015 on a population of HIV/AIDS patients in Kermanshah Province, in which a sample size of 340 patients was calculated with 95% confidence and accuracy of 5%. Samples were selected from patients visiting Behavioral Disorders Counseling Center in Kermanshah according to simple random sampling. Participants' informed consents were obtained before collection of data. The study inclusion criteria included being diagnosed with HIV infection or AIDS.

The evaluation of food habits

Food intake was assessed by food frequency questionnaire (FFQ) whose validity and reliability have been confirmed in Iran.[11] FFQ includes a list of 161 foods and their standard amount. FFQ consists of food groups including bread and grains, fruits, vegetables, meat and bean, milk and dairy products, miscellaneous, foods, and salads. Nutritional information obtained through FFQ was analyzed in a specific software program. The software was programmed by visual basic 6.0. Standard values for energy, folate, Vitamin A, Vitamin E, and calcium were considered based on recommended dietary allowances for different age groups. The recommended value for protein intake is 0.8 g/kg bw and the recommended fiber was considered 25 g daily.[12] Energy was calculated considering each gram of protein, carbohydrate, and fat provides 4, 4, and 9 kcal of energy, respectively, and the total energy was obtained from the total energy produced by proteins, carbohydrates, and fats. The participants were classified into age groups of 19–30, 31–50, and 51–70 years.

Patients were weighed using a calibrated mechanical Seca scale, and their heights were measured in standing position facing forward with the heels touching the wall using a tape measure (precision of 0.1 cm). Malnutrition was assessed and classified according to BMI, calculated by division of weight (kg) by square of height (m). According to the WHO, BMI <18.5 is classified as underweight, 18.5 [13]

Finally, all data and codes were analyzed in Stata-11 using descriptive statistics (mean, standard deviation, and percentage), and analytical tests (Chi-square, Kruskal–Wallis, and ANOVA) at significance level of P < 0.05. Stata is a general-purpose statistical software package created in 1985 by statacorp.

   Results Top

Participants included 330 patients, of whom 123 (36.5%) were female and 214 (63.5%) were male, with age range of 18–70 years, and mean age of 38.53 ± 8.86 years. In terms of marital status, 180 (53.57%) were single, and in terms of education, 99 (8.5%) were illiterate, 230 (68.05%) were high school dropouts, 67 (19.82%) had high school diploma, and the rest had university education. The majority of participants (251 patients, 74.48%) lived in the provincial center and only 7.4% lived in rural areas. Mean household size was 3.22 ± 1.22 people.

Mean weight of participating men and women was 67.67 ± 11.9 kg and 66.03 ± 12.77 kg, respectively, and their mean BMI was 22.12 ± 3.75 kg/m 2 and 25.54 ± 4.66 kg/m 2, respectively, which increased with aging but not significantly (P = 0.63) [Table 1].
Table 1: The mean and standard deviation of anthropometric parameters in patients with HIV/acquired immunodeficiency syndrome

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Of participating patients, 37 (11.08%) were underweight, 76 (22.75%) were overweight, and 28 (8.38%) were obese. The prevalence of BMI-based malnutrition was 42.21% (141 patients). Underweight was more prevalent in 51–70-year-old group compared to other age groups but not significantly. The prevalence of malnutrition was higher in men than in women and in singles than in married people (P = 0.001) [Table 2].
Table 2: Body mass index classification according to age group, gender, and marital status in HIV/acquired immunodeficiency syndrome patients

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Of the total daily calorie (energy) intake by patients, 48.08 ± 4.8% was provided by carbohydrates, 36.55 ± 4.11% by fat, and 14.68 ± 2.19% by protein.

Mean daily calorie intake from protein and fat was significantly different in men and women, with men consuming both more than women (P < 0.05). Calorie provided by carbohydrates was also higher in men but not significantly (P = 0.08). Compared to nonsmokers, smokers received fewer calories from fat and more from carbohydrates (P < 0.001).

Mean calorie intake in 51–70-year-old group was significantly less than that in other age groups (P = 0.005). Fat intake in 19–30-year-old group was 107.54 ± 47.55 g, which was significantly higher than that in other age groups (P = 0.04). Carbohydrate intake was reported 298.54 ± 101.44 g in 19–30 years age group, 265.67 ± 93.34 g in 31–50 age group, and 219.72 ± 92.64 g in 51–70 age group, with significant differences among the groups (P = 0.006) [Table 3].
Table 3: Mean daily food intake in HIV/acquired immunodeficiency syndrome patients

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[Table 4] presents the comparison of patients' daily nutritional intake with recommended daily allowance (RDA) and shows that intake of protein, folate, Vitamins A and E, and calcium is less than RDA in most participants, and that intake of Vitamin A in 63.75% of HIV/AIDS patients was less than RDA, which was significantly higher in men than in women (P = 0.001). Calcium deficiency was higher in women than in men (6.67% vs. 3.39%).
Table 4: Daily nutrition intake in HIV/acquired immunodeficiency syndrome patients compared to recommended daily allowance

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   Discussion Top

Assessment of nutritional intake in HIV/AIDS patients in the city of Kermanshah showed that intake of protein, folate, Vitamins A and E, and calcium was less than RDA in a significant number of patients. Vitamin A deficiency was higher in men than in women, and in contrast, folate and calcium deficiencies were higher in women. The results obtained suggest adequate intake of total energy in these patients, with calorie intake from fat being in excess of RDA and from protein and carbohydrates less than RDA.

Similar studies conducted worldwide have reported different results in this area. A study conducted on HIV patients in Isfahan showed no deficiency among men, but in women, energy and a number of nutrients including folate and Vitamins B12 and E were less than RDA.[14] In a study conducted in England, energy received by HIV patients was less than their basic metabolic and daily activity needs.[9] In HIV-positive patients in India, energy, fat, fiber, and Vitamin C and iron intakes were reported less than RDA.[10] The results of a study conducted in Colombia showed that fat intake in HIV-positive patients was higher than RDA.[15] Like the present study, other similar studies are indicative of unfavorable, but not irreversible, nutritional status among HIV patients, and their nutritional status and health can be improved through nutritional counseling sessions in behavioral centers. Since long-term consumption of high-fat foods predisposes patients to various diseases, they should be trained to consume variety of foods and less fatty foods.

In a study conducted in Africa, through nutritional intervention and dietary supplements including protein and micronutrients, energy, protein, and body weight significantly improved in HIV patients that received intervention compared to other patients.[16]

Generally, HIV patients eat less food due to secondary opportunistic infections that reduce their appetite and result in weight loss.[7] Many studies have focused on the role of nutrition in HIV infection associated with weight loss and reduced lipid body mass,[17] each of which is associated with increased risk of opportunistic infections and death.[18] The present study results showed that the prevalence of BMI-based malnutrition among HIV/AIDS patients in Kermanshah was 42.21%, of whom 11.8% were underweight. A study conducted in China reported the prevalence of malnutrition among HIV patients 37.2%, and another study from Tanzania reported 18.4% AIDS patients as underweight.[7],[8] In their study, Capili reported the prevalence of overweight and obesity 39.7% and 13.3%, respectively.[19] In a study conducted by Karimi et al., HIV-positive men and women had normal weight.[14] As stated, due to immune system suppression, these patients are vulnerable to many opportunistic infections, and malnutrition can accelerate these infections. Thus, nutritional deficiencies and underweight can worsen prognosis in these patients. Since a significant number of participating patients were overweight, encouraging these patients to exercise and use low-fat and low-calorie foods can help their weight balance.

AIDS wasting syndrome is the second clinical manifestation of AIDS. Weight loss and wasting happen due to several causes, of which inadequate nutritional intake, malabsorption, metabolic problems, uncontrolled opportunistic infections, and reduced physical activity are the most important.[20] However, diminishing food intake is considered the key factor for weight loss in these patients, which is controllable. Development and implementation of nutrition education programs can significantly help nutritional status in these patients. Food support for poorer patients through basic food needs baskets can be effective in preventing malnutrition.

   Conclusion Top

The present study showed inadequacy of intake of micro- and macro-nutrients in HIV/AIDS patients. Protein, Vitamins A and E, folate, and calcium intakes were less than RDA, and fat intake was higher than RDA. Malnutrition was observed as varying degrees of underweight and overweight, which requires greater attention to and care for these patients. It is recommended that ongoing and periodical nutritional counseling sessions be held by behavioral centers that provide services for these patients.


We wish to thank the Research Deputy of Kermanshah University of Medical Sciences for approving this project (No: 93117), and personnel of HSR unit of Health deputy, and participants for their cooperation in this study.

Financial support and sponsorship

The study was supported by the Research Deputy of University of Medical Sciences, Kermanshah, Iran.

Conflicts of interest

There are no conflicts of interest.

   References Top

Golshah R, Roshandel GH, Rezaei Shirazi R, Roshandel D, Abdollahi N, Jabbari A, et al. Knowledge about AIDS amoung Iranian red crescent volunteers and effect of an AIDS educational program. J Gorgan Univ Med Sci 2008;4:56-60.  Back to cited text no. 1
UNAIDS/WHO Global HIV/AIDS Online Database. Data and statistics. Global summary of the HIV/AIDS epidemic, December 2016. Available from: [Last accessed on 2016].  Back to cited text no. 2
Swaminathan S, Padmapriyadarsini C, Sukumar B, Iliayas S, Kumar SR, Triveni C, et al. Nutritional status of persons with HIV infection, persons with HIV infection and tuberculosis, and HIV-negative individuals from Southern India. Clin Infect Dis 2008;46:946-9.  Back to cited text no. 3
Duggal S, Chugh TD, Duggal AK. HIV and malnutrition: Effects on immune system. Clin Dev Immunol 2012;2012:784740.  Back to cited text no. 4
Enwonwu CO. Complex interactions between malnutrition, infection and immunity: Relevance to HIV/AIDS infection. Niger J Clin Biomed Res 2006;1:6-14.  Back to cited text no. 5
Fields-Gardner C, Campa A, American Dietetics Association. Position of the American dietetic association: Nutrition intervention and human immunodeficiency virus infection. J Am Diet Assoc 2010;110:1105-19.  Back to cited text no. 6
Hu W, Jiang H, Chen W, He SH, Deng B, Wang WY, et al. Malnutrition in hospitalized people living with HIV/AIDS: Evidence from a cross-sectional study from Chengdu, China. Asia Pac J Clin Nutr 2011;20:544-50.  Back to cited text no. 7
Ritte SA, Kessy AT. Social factors and lifestyle attributes associated with nutritional status of people living with HIV/AIDS attending care and treatment clinics in Ilala District, Dar Es Salaam. East Afr J Public Health 2012;9:33-8.  Back to cited text no. 8
Klassen K, Goff LM. Dietary intakes of HIV-infected adults in Urban UK. Eur J Clin Nutr 2013;67:890-3.  Back to cited text no. 9
Wig N, Bhatt SP, Sakhuja A, Srivastava S, Agarwal S. Dietary adequacy in Asian Indians with HIV. AIDS Care 2008;20:370-5.  Back to cited text no. 10
Mirmiran P, Hosseini Esfahani F, Azizi F. Relative validity and reliability of the food frequency questionnaire used to assess nutrient intake: Tehran lipid and glucose study. Irani J Diabetes Lipid Disord 2009;9:185-97.  Back to cited text no. 11
National Center for Education Statistics. Available from: [Last accessed on 2008 Oct 31].  Back to cited text no. 12
Amirifar A, Saberi M. Modern Human Kraus. 1st ed. Tehran: Book Publishing Mir; 2006.  Back to cited text no. 13
Karimi I, Kasaeeian N, Atayi B, Tayeri K, Zare M, Azadbakht L. Anthropometric indices and dietary intake in HIV-infected patients. J Isfahan Med Sch 2010;28:238-47.  Back to cited text no. 14
Giudici KV, Duran AC, Jaime PC. Inadequate food intake among adults living with HIV. Sao Paulo Med J 2013;131:145-52.  Back to cited text no. 15
Grobler L, Siegfried N, Visser ME, Mahlungulu SS, Volmink J. Nutritional interventions for reducing morbidity and mortality in people with HIV. Cochrane Database Syst Rev 2013;28:CD004536.  Back to cited text no. 16
Forrester JE, Spiegelman D, Tchetgen E, Knox TA, Gorbach SL. Weight loss and body-composition changes in men and women infected with HIV. Am J Clin Nutr 2002;76:1428-34.  Back to cited text no. 17
Hendricks KM, Mwamburi DM, Newby PK, Wanke CA. Dietary patterns and health and nutrition outcomes in men living with HIV infection. Am J Clin Nutr 2008;88:1584-92.  Back to cited text no. 18
Capili B, Anastasi JK. Body mass index and nutritional intake in patients with HIV and chronic diarrhea: A secondary analysis. J Am Acad Nurse Pract 2008;20:463-70.  Back to cited text no. 19
Macallan DC, Noble C, Baldwin C, Jebb SA, Prentice AM, Coward WA, et al. Energy expenditure and wasting in human immunodeficiency virus infection. N Engl J Med 1995;333:83-8.  Back to cited text no. 20

Correspondence Address:
Yahya Pasdar
Research Centre for Environmental Determinacies of Health, School of Public Health, Kermanshah University of Medical Sciences, Kermanshah
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ATMPH.ATMPH_315_17

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  [Table 1], [Table 2], [Table 3], [Table 4]


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