A lack of nutritious food (often the case in developing countries), loss of appetite, decreased absorption of nutrients due to gastrointestinal complications, and an increased resting energy expenditure (REE) all play an integral role in HIV-associated weight loss and wasting. Poor nutrient status in HIV-infected individuals worsens their immune status, rendering them vulnerable to infections and further deterioration in nutrient status (Scrimshaw 1997; Anabwani 2005). In HIV-infected children, the clinical picture is further complicated by the metabolic demands of growth and development. Dietary therapy is regarded as an important adjunct in the clinical care of patients infected with HIV. It is believed that achieving and maintaining optimal nutrition will improve the individual's immune function, reduce the incidence of complications associated with HIV infection, attenuate the progression of HIV infection, improve the quality of life, and ultimately reduce mortality associated with the disease (Hsu 2005).
HIV-associated weight loss and wasting are independent contributing factors to poor clinical outcomes in people living with HIV/AIDS (Wheeler 1998). A 10% or greater loss of body weight over a year is common in HIV-infected people, although there is a high degree of variability in the extent of weight loss and wasting. In most cases, acute weight-loss episodes are associated with secondary infections (Macallan 1993). Once the secondary infections are successfully treated and energy intake is increased sufficiently, patients are able to regain weight and remain weight-stable (Macallan 1998). Instances of chronic weight loss are normally associated with secondary gastrointestinal infections and subsequent malabsorption (Macallan 1993).
In uncomplicated starvation, the body slows down its metabolic processes, minimising both resting energy expenditure (REE) and total energy expenditure (TEE), and conserving the body's protein stores at the expense of the fat stores. By contrast, in HIV infection, REE is increased in asymptomatic persons, and even more so in symptomatic persons, (Macallan 1995a; Grinspoon 1998; Batterham 2005), with both fat and protein stores being oxidised to fuel the body's energy requirements. Whole-body protein turnover is up to 25% higher in untreated HIV-infected individuals than in HIV-negative controls (Macallan 1995b). The increased protein turnover is positively correlated with REE (Melchior 1997). Furthermore, even in the face of adequate nutrition, fat stores are replenished more readily than protein stores (Kotler 1999). The resultant loss of body protein could further compromise the immune system of the HIV-infected individual.
In this review, the concept of a "balanced diet" refers to the regular intake of meals that contain all the essential nutrients that cannot be synthesised in adequate quantities by the body. A balanced diet will provide the necessary nutrients and energy required for the maintenance of body cells, tissues, and organs, and for normal growth and development. A balanced diet should generally consist of approximately 50% carbohydrates (e.g. fruit, vegetables, breads, cereals, rice, and pasta), 20% protein (e.g. meat, beans and peas, nuts and seeds) and 30% fat (e.g. oil, butter, cheese) and should provide between 5000-7000 kJ/day. These nutrient and energy requirements will vary depending on age, gender, level of physical activity, pregnancy and lactation needs, and general health status. In order to prevent weight loss and wasting, HIV-infected individuals should ensure that, at the very least, these basic nutrient and energy requirements are met.
Various nutritional interventions, including food-based interventions (high energy, protein, or fat diets), oral supplements with specific nutrients, enteral and total parenteral therapy, appetite stimulants and anabolic hormones (growth hormone), have been tested in HIV-infected individuals. An existing Cochrane review has summarised the effects of micronutrient supplementation in people with HIV/AIDS (Irlam 2005). We decided to synthesise the existing research on the effectiveness of macronutrients for improving outcomes in persons with HIV infection, particularly for those living in developing countries. This evidence should further assist professionals in managing malnutrition associated with the disease.
The objective of this review was to evaluate the effectiveness of various macronutrient interventions, such as a balanced diet or a high protein, high carbohydrate, or high fat diet, given orally, in reducing morbidity and mortality in adults and children living with HIV infection.
Criteria for considering studies for this review
Types of studies
Randomised controlled trials (RCTs) evaluating the effectiveness of various macronutrient interventions in the management of individuals living with HIV/AIDS were considered. Studies were included regardless of the setting in which they were carried out. Studies involving HIV-infected pregnant women, as well as those assessing the effects of total parenteral or enteral nutritional interventions, and comparative studies examining the effect of two or more nutritional interventions, were excluded from this review. Trials evaluating micronutrient supplements in people with HIV infection were also excluded, as they form part of an existing Cochrane review (Irlam 2005).
Types of participants
Adults and children with HIV infection.
Types of interventions
Various forms of macronutrient therapy administered orally (balanced diets or supplements; high fat, carbohydrate, and protein diets or supplements; diets or supplements containing specific nutritional elements, such as amino acids). The duration of the nutritional intervention had to be four weeks or more.
No nutritional therapy or nutritional placebo.
Types of outcome measures
- all-cause mortality
- mortality related to HIV infection and other HIV-related conditions
- morbidity (frequency, types, and duration of episodes of opportunistic infections; incidence of AIDS as defined by each trial; hospital admissions; and other types of illnesses related to HIV infection as reported in each study)
- disease progression according to WHO or CDC staging system as recorded in each study
- indices of viral load
- markers of immune response (absolute CD4+ T-lymphocyte count and CD4+ percent of total lymphocytes)
- nutritional status measurements, such as body weight, body mass index (BMI), energy expenditure, and biochemical markers, such as serum albumin
- dietary intake and appetite
Search methods for identification of studies
See: Collaborative Review Group search strategy.
A comprehensive, unbiased search strategy was developed to ensure that as many relevant studies as possible were screened for inclusion in the review. An attempt was made to identify all relevant studies, regardless of language or publication status (published or unpublished, in press or in progress).
Specific search strategies ( Table 1) were used to identify eligible randomised controlled trials or review articles in the following databases:
CENTRAL (up to March 2006)
MEDLINE (1966 to March 2006)
EMBASE (1988 to march 2006)
LILACS (up to March 2006)
AIDSearch (up to March2006)
Conference abstracts from the International AIDS Conference, reference lists of all relevant articles obtained (including those from previously published reviews), and clinical trial registers (www.clinicaltrials.gov and www.controlled-trials.com) were screened for potentially relevant articles or studies in progress.
Data collection and analysis
Three authors (SM, MV, and LG) independently applied the selection criteria to the results of the search to identify potentially relevant studies. If there was uncertainty about a study's eligibility, the full article was obtained. Any disagreements regarding study eligibility were resolved through discussion with the co-author (JV). Where disagreements could not be resolved, we sought clarification from the original investigators before reaching a decision. All studies not meeting the inclusion criteria were excluded and the reasons for exclusion were stated in the table "Characteristics of Excluded Studies."
Assessment of the methodological quality
Three authors (SM, MV, and LG) independently assessed the methodological quality of the included trials using the following criteria (Jadad 1996).
Generation of allocation sequence
The generation of allocation sequence was considered adequate if a truly random method had been used (computer-generated random numbers, table of random numbers, drawing of lots or envelopes, tossing a coin, shuffling cards, throwing dice, or other methods of allocation that appear to be unbiased and lead to an unpredictable sequence); or unclear if authors stated that the trial was randomised, but the method was not described). Trials using quasi-random methods where the allocation sequence could potentially be related to prognosis (e.g. based on case record number, date of birth, or date of admission) were not considered in this review.
Allocation concealment was considered adequate (a) if participants and the investigators enrolling participants could not foresee assignmenta priori numbered or coded drug containers of identical appearance prepared by an independent pharmacy; central randomisation performed at a site remote from trial location; sequentially numbered, opaque, sealed envelopes; or other descriptions that contained convincing elements of concealment; inadequate (b) if participants and investigators enrolling participants could foresee upcoming assignmentall procedures based on inadequate generation of allocation sequences; an open allocation schedule; unsealed or non-opaque envelopes; or a reported approach that could not be considered adequate; unclear (c) if unclear or the method was not adequately described.
It was noted who (participant, care provider, assessor) was blinded in the trial.
Completeness of follow-up
We recorded the adequacy of follow-up as the % of randomised participants included in the analysis according to the following scale: a=>80%; b=<80%, c=unclear.
The full text of all included studies was obtained. SM, MV, and LG independently extracted data using a standardised and pre-piloted data-extraction form. Data relating to study design, participant characteristics, interventions, and outcomes were collected and entered into RevMan 4.2.8. Discrepancies regarding extracted data were resolved by discussion and, if necessary, referred to an additional reviewer (JV).
The data were analysed using RevMan Analyses (Version 1.0.3). Weighted mean difference was calculated for continuous data, with 95% confidence intervals as the measure of precision of the estimates. We planned to calculate relative risks for dichotomous data; however, at this stage none of the included studies have reported on dichotomous outcomes. We assessed homogeneity in the study results using the Chi-square test for heterogeneity with a 10% level of significance as the cut-off. Meta-analysis employed a fixed-effects model where results were homogeneous; otherwise, we used a random-effects model.
We planned to explore clinical heterogeneity based on participants' age, sex, socioeconomic status, ethnicity, and stage of HIV infection where possible. Furthermore, we planned to conduct a sensitivity analysis to determine the influence of adequacy of allocation concealment on the review results. We also planned to assess publication bias based on the degree of symmetry of the funnel plot. Currently, the available data do not permit any of these analyses.
Description of studies
Eight trials involving 486 participants met our criteria. Twenty-eight studies initially deemed to be eligible for inclusion were subsequently excluded. Reasons for their exclusion are provided in the table "Characteristics of excluded studies."
Four studies were conducted in the USA (Rabeneck 1998; Shabert 1999; Clark 2000; Keithley 2002a), two in Switzerland (Berneis 2000; Karsegard 2004) and one in Germany (Schwenk 1999). It is not clear where the study by de Luis 2003 (de Luis 2003) was conducted, although based on the address of the corresponding author it appears to be Spain.
Male and female participants (mean±SD age: 39 ± 7 years) at different stages of HIV/AIDS were included in the studies. Seventy-three percent of the participants had advanced stage HIV/AIDS (stage C according to Centers for Disease Control and Prevention classification system), with baseline CD4 count below 350 cells/mm3 (mean±SD=299±203) and a viral load of about 3.8±1.2 log10 copies/µl1. Almost all (99%) participants were receiving some form of antiretroviral therapy. The mean body mass index of participants ranged from 19.9 to 26 kg/m2. Upon enrollment into the study, all participants were free of confirmed secondary infections or other signs and symptoms of infection, such as fever, chills, or persistent diarrhoea.
Nutritional interventions and comparison groups
Various types of macronutrient interventions were tested in the studies (for further details, see the table "Characteristics of Included Studies"). In five studies, participants in the experimental group supplemented their normal diet with balanced oral supplements in an attempt to increase energy intake by 600-960 kcal/day (Rabeneck 1998; Schwenk 1999; Berneis 2000; Keithley 2002a; de Luis 2003). All of these macronutrient interventions contained the required daily allowance (RDA) of various vitamins and minerals. This may be a possible confounder in the outcomes of these studies, as one cannot distinguish between the effect of the increased energy supply or that of the vitamins and minerals. Furthermore, control participants in these studies received nutritional counselling alone. There were three comparison groups in Keithley 2002 (Keithley 2002a), two nutritional supplementation arms, and a control arm. In three studies, specific nutritional supplements (amino acid mixture containing arginine, glutamine and ß-hydroxy-ß-methylbutyrate (Clark 2000); monohydrated L-ornithine a-ketoglutarate (Karsegard 2004); L-glutamine and antioxidants (ascorbic acid, a-tocopherol, ß-carotene, selenium and N-acetyl cysteine) (Shabert 1999) were compared with isocaloric (Shabert 1999; Clark 2000) or isonitrogenous nutritional placebos (Karsegard 2004). In Shabert 1999, (Shabert 1999) all participants received the recommended daily allowance of vitamins and minerals. In seven studies, both the experimental and the control group received nutritional counselling in conjunction with either the nutritional intervention or placebo (Rabeneck 1998; Shabert 1999; Schwenk 1999; Berneis 2000; Keithley 2002a; de Luis 2003; Karsegard 2004). Nutritional counselling was not provided to any of the participants in the study by Clark 2000 (Clark 2000). The duration of intervention varied from one year (Keithley 2002a) to 12 weeks (Shabert 1999; Berneis 2000; de Luis 2003; Karsegard 2004) to eight weeks (Schwenk 1999; Clark 2000) to six weeks (Rabeneck 1998).
Body weight was reported in all of the studies. Fat-free mass and fat mass were measured using bioelectrical impedance in seven studies (Rabeneck 1998; Shabert 1999; Schwenk 1999; Berneis 2000; Keithley 2002a; de Luis 2003; Karsegard 2004). In Clark 2000 (Clark 2000) fat-free mass and fat mass were measured using skinfold thickness, air displacement plethysmography and computed tomography scan of the thigh musculature. Six studies reported CD4 counts (Shabert 1999; Berneis 2000; Clark 2000; Keithley 2002a ; de Luis 2003; Karsegard 2004) and three studies reported viral loads (Clark 2000; de Luis 2003; Karsegard 2004) although in de Luis 2003 (de Luis 2003) viral load was reported in copies/ml (1). Five studies reported the total energy intake (kcal/day-1 ) (Schwenk 1999; Berneis 2000; Keithley 2002a; de Luis 2003; Karsegard 2004) and three studies reported the daily protein intake (g day-1) (Berneis 2000; de Luis 2003; Karsegard 2004) of the participants. Five studies reported on the adverse events encountered during the study period (Rabeneck 1998; Shabert 1999; Schwenk 1999; Clark 2000; Karsegard 2004).
Risk of bias in included studies
Generation of allocation sequence
The generation of the allocation sequence was adequate in three studies (Berneis 2000; Clark 2000; Keithley 2002a) and unclear in five studies (de Luis 2003; Karsegard 2004; Rabeneck 1998; Schwenk 1999;).
Allocation concealment was adequate in 2 studies (Karsegard 2004; Schwenk 1999) and unclear in 6 studies (Rabeneck 1998; Shabert 1999; Shabert 1999; Berneis 2000; Clark 2000; de Luis 2003; Keithley 2002a).
In one study, participants, care providers, and outcome assessors were all blinded to the treatment being received (Shabert 1999). In another study, participants and providers were blinded, but it is not clear if the outcome assessors were blinded (Karsegard 2004). In a third study, the outcome assessors were blinded, but it is not clear if the participants or providers were blinded (Clark 2000). In the five remaining studies, participants and providers were not blinded and it is not clear if the assessors were blinded (Rabeneck 1998; Schwenk 1999; Berneis 2000; Keithley 2002a; de Luis 2003).
Completeness of follow-up
All of the studies accounted for participants lost to follow-up (withdrawals, dropouts, and protocol deviations) during the course of each trial. In four studies, follow-up rates were greater than 80% (Shabert 1999; Schwenk 1999; Berneis 2000; de Luis 2003) and in the remaining four studies it was less than 80% (Rabeneck 1998; Clark 2000; Keithley 2002a; Karsegard 2004).
Effects of interventions
None of the studies included in this review assessed the effects of macronutrient interventions the on all-cause or HIV-related mortality and/or morbidity we pre-specified as primary outcomes. Proxies of these outcomes, such as body weight, body composition, viral load, CD4 count, energy intake and quality of life were measured.
Any nutritional supplementation (with or without nutritional counselling) versus no nutritional supplementation or nutritional placebo (with or without nutritional counselling)
There were three comparison groups in Keithley 2002 (Keithley 2002a), two nutritional supplementation arms, and a control arm. In order to include both nutritional supplementation arms in the meta-analysis, the participants in the control arm were divided in two (Ramsay 2003). Overall, nutritional supplementation significantly improved energy intake (Analysis 01.01: five trials; n=254; WMD 367 kcal/day-1; 95% CI: 217 to 516), protein intake (Analysis 01.02: three trials; n=128; WMD 17 g.day-1; 95% CI: 8 to 26) and viral load (Analysis 01.08: two trials; n=88; WMD -0.45 log10 copies/ml-1; 95% CI: -0.87 to -0.04) compared with no nutritional supplementation or placebo. There was no evidence of an effect on body weight (Analysis 01.03: eight trials; n=423; WMD 0.24 kg; 95% CI: -0.6 to 1.1), fat mass (Analysis 01.04: six trials; n=305; WMD -0.73 kg; 95% CI: -1.83 to 0.37), fat-free mass (Analysis 01.05: five trials; n=311; WMD 0 kg; 95% CI: -2.3 to 2.4) or CD4 count (Analysis 01.06: 6 trials; n=271; WMD 0.23 cells/mm
Balanced nutritional supplementation versus no nutritional supplementation or nutritional placebo
Balanced nutritional supplements (consisting of 50-60% carbohydrate, 15-30% protein and 20-30% fat) aimed at improving energy intake by 600-960 kcal/day-1, compared with no nutritional supplements, significantly increased energy (Analysis 01.01: four trials; n=211; WMD 407 kcal.day-1; 95% CI: 250 to 563) and protein intake (Analysis 01.02: two trials; n=85; WMD 23 g.day-1; 95% CI 13 to 34). No differences in body weight (Analysis 01.03: five trials; n=313; WMD -0.2 kg; 95% CI: -1.1 to 0.7), fat mass (Analysis 01.04: four trials; n=234; WMD -1.17 kg; 95% CI: -2.6 to 0.26), fat-free mass (Analysis 01.05: three trials; n=222; WMD -0.38 kg; 95% CI: -2.8 to 2.0) or CD4 count (Analysis 01.06: three trials; n=161; WMD -21.1 cells/mm3; 95% CI: -89.69 to 47.49) was noted between the supplemented and non-supplemented groups. No difference was noted in HIV viral load (copies/ml
Specific nutritional supplementation versus no nutritional supplementation or nutritional placebo
Specific nutritional supplements investigated in these trials included an amino acid mixture containing arginine, glutamine and ß-hydroxy-ß-methylbutyrate (Clark 2000); monohydrated L-ornithine a-ketoglutarate (Karsegard 2004); L-glutamine and antioxidants (ascorbic acid, a-tocopherol, ß-carotene, selenium and N-acetyl cysteine) (Shabert 1999). These specific nutritional supplements were compared with isocaloric (Shabert 1999; Clark 2000) or isonitrogenous nutritional placebos (Karsegard 2004). Nutritional counselling was provided to all participants in Karsegard 2004 (Karsegard 2004) and Shabert 1999 (Shabert 1999) but no participants received nutritional counselling in Clark 2000 (Clark 2000).
Supplementation with specific nutritional supplements significantly increased body weight (Analysis 01.03: three trials; n=110; WMD 1.93 kg; 95% CI: 0.15 to 3.71) and decreased HIV-viral load (Analysis 01.08: two trials; n=88; WMD -0.45 log10 copies/ml-1; 95% CI: -0.87 to -0.04). However, supplementation with specific nutrients did not alter energy intake (Analysis 01.01: one trial; n=43; WMD -66 kcal/day-1; 95% CI: -581 to 449), protein intake (Analysis 01.02: one trial; n=43; WMD -0.7 g.day-1; 95% CI: -19 to 17), fat mass (Analysis 01.04: two trials; n=67; WMD -0.1 kg; 95% CI: -1.8 to 1.6), fat-free mass (Analysis 01.05: two trials; n=89; WMD -0.4 kg; 95% CI: -8.6 to 7.8) or CD4 count (Analysis 01.06: three trials; n=110; WMD 11.57 cells/mm3; 95% CI: -38.43 to 61.57).
Although adverse events were reported in five studies (Rabeneck 1998; Shabert 1999; Schwenk 1999; Clark 2000; Karsegard 2004) only two studies noted any adverse events in any of the participants. In Rabeneck 1998 (Rabeneck 1998), one participant discontinued the supplement (Lipisorb, Mead Johnson, Evansville, Indiana, USA) due to nausea and epigastric burning. In Karsegard 2004 (Karsegard 2004) the frequency of gastrointestinal events was closely monitored in both comparison groups. A higher frequency of gastrointestinal events was noted in the group receiving monohydrated L-ornithine a-ketoglutarate compared with the placebo group (RR: 1.59, 95% CI: 1.06 to 2.39).
HIV/AIDS has many faces. There are major differences between HIV-positive individuals in developed and developing countries with regard to income level, availability of adequate nutrition, and access to basic healthcare or life-prolonging antiretroviral treatment. In addition, patient groups vary in terms of their response to the virus, stage of the disease, susceptibility to secondary infections, nutritional status, and individual response to the various treatments received. These complexities must be taken into account when formulating recommendations and guidelines on nutrient and energy supplementation for HIV-infected individuals.
Our review establishes that experimental evidence on the effects of macronutrient supplementation on important clinical outcomes in HIV-infected individuals is surprisingly limited; despite an exhaustive search, we found only eight small, randomised trials that met our inclusion criteria. Overall, macronutrient interventions, compared with placebo or no nutritional supplementation, increased energy and protein intakes but had no effect on other parameters. When analysed separately, balanced nutritional supplements aimed at improving energy intake by 600-960 kcal/day increased intakes of energy and protein; while supplementation with specific nutritional supplements increased body weight and decreased HIV viral load, leaving other outcomes unchanged.
These findings must be interpreted with caution for several reasons. The studies included in this review are all relatively small (combined sample sizes for the various outcomes range from 128 to 178 participants) and, therefore, the play of chance cannot be ruled out as a possible explanation of the results obtained. There are a number of concerns around key aspects of study quality, which may be, in part, a result of poor reporting. The relatively high degree of loss to follow-up of participants (ranging from 6% to 37%), as well as differences in loss to follow-up of participants between the comparison groups (ranging from 0% to 25%), may also bias the study results.
Variation in the nutritional composition of active supplements and in control interventions across studies, as well as differences in the disease stage of the participants in various studies, (which can significantly affect intake and absorption of food) limits the value of meta-analysis and complicates the interpretation of the findings of this review. Worth noting is that patients with acute opportunistic infectionsthe category most prone to weight losswho are theoretically most likely to experience improvements in nutritional status (such as weight gain), were not assessed in the studies we evaluated. Nonetheless, if the finding of increased energy and protein intake in our review is valid, this would be important, given that decreased energy intake and accelerated protein turnover is common in people with HIV/AIDS. The statistically significant reduction in HIV viral load in patients receiving specific nutritional supplements is encouraging, although this change can be considered to be within the margin of technical or biological variation, and therefore may not be clinically important (Chernoff 2002).
To date, few nutritional intervention studies have been conducted in malnourished HIV-infected children. In two quasi-randomised studies conducted in Malawi, ready-to-use-food (an energy-dense liquid paste made from peanut butter, milk powder, oil, sugar, vitamins, and minerals) was significantly more effective than traditional food (a blend of maize and soy flour) in relieving malnutrition in HIV-infected and non-infected children (Sandige 2004; Ndekha 2005). In a randomised study conducted in Zambia, HIV-infected and non-infected children receiving an amino-acid-based elemental feed for four weeks gained more weight than children receiving standard nutritional rehabilitation (Amadi 2005).
Finally, the generalisability of our findings to patients in developing countries must be carefully considered. All of the trials were conducted in either North America or Europe and evaluated males and females between 30 and 50 years old who were reasonably well-nourished in terms of their body mass index, and were receiving antiretrovirals. These observations highlight some challenges in applying the trial findings to people in developing countries, where nutritional status is generally poor and access to antiretroviral therapy is limited.
In sum, there is limited evidence from randomised trials conducted in high-income countries that targeted supplementation of the diet with macronutrients increases energy intake and reduces HIV viral load in HIV-infected patients on antiretroviral therapy. However, the effect of nutritional supplementation on mortality, morbidity, body weight, and immunological parameters remains unclear.
Implications for practice
The evidence base on the effects of macronutrients in people living with HIV is limited to only a few small, randomised trials conducted in high-income countries. These studies have measured intermediate endpoints (such as energy intake) but not important clinical outcomes (such as death and morbidity). There are also substantial variations between studies in the nutritional composition of the experimental and control interventions, the use of dietary counselling, disease stage, and treatment status of the participants. These limitations currently preclude any firm conclusions regarding the effects of macronutrient supplementation on morbidity and mortality in HIV-infected individuals
Implications for research
There is an urgent need for high-quality, adequately powered randomised controlled trials investigating the effectiveness of clearly specified macronutrient interventions in reducing morbidity and mortality in HIV-infected individuals living in developing countries. Interventions should be well-defined and targeted at specific target populations defined by age (adults and children), CD4 cell count, viral load, treatment status (presence and absence of treatment; type of antiretroviral therapy) and baseline nutritional status (under-nourished, adequately nourished or over-nourished).
The authors would like to thank Este Vorster, Ulrich Keller, Douglas Wilmore, Claude Pichard, John Rathmacher, Achim Schwenk, Joyce Keithley, Elizabeth van der Merwe, and Wieland Gevers for methodological input or assistance in the interpretation of data. This review was completed with the guidance and support of the HIV/AIDS mentorship programme coordinated by the South African Cochrane Centre and the HIV/AIDS Review Group. Sarah Mahlungulu received a bursary from the Cochrane Health Promotion and Public Health Field to conduct the review.
Data and analyses
- Top of page
- Authors' conclusions
- Data and analyses
- What's new
- Contributions of authors
- Declarations of interest
- Sources of support
- Index terms
Last assessed as up-to-date: 21 May 2007.
Protocol first published: Issue 4, 2003
Review first published: Issue 3, 2007
Contributions of authors
SM developed the protocol for this review with the help of MVIS and JV. LG assisted SM and MVIS with data extraction and went on to complete the analysis and the write up of the final review. SM, MVIS and JV assisted in editing the final review
Declarations of interest
We declare that we have no affiliation with or involvement in any organisation or entity with a direct financial interest in the subject matter of review (e.g. employment, consultancy, stock ownership, honoraria, or expert testimony).
Sources of support
- UNIVERSITY OF NATAL, DURBAN, South Africa.
- SOUTH AFRICAN COCHRANE CENTER, South Africa.
- COCHRANE HEALTH PROMOTION AND PUBLIC HEALTH FIELD, Australia.
Medical Subject Headings (MeSH)
Diet [*standards]; Dietary Carbohydrates [*administration & dosage]; Dietary Fats [*administration & dosage]; Disease Progression; Energy Intake; HIV Infections [complications; *diet therapy; mortality]
MeSH check words
Adult; Child; Humans
* Indicates the major publication for the study