Pregnancy is one of the most critical periods for iodine deficiency. The aim of the present study was to assess the iodine status and dietary intake of pregnant women in a population changing from high to lower consumption of milk and fish.

Cross-sectional observational study. Urine samples were collected for measuring urinary iodine concentration (UIC) and creatinine, and blood samples for measuring serum thyroid-stimulating hormone (TSH). Frequency of consumption of selected food and beverages was obtained through a semi-quantitative validated FFQ. The difference in the distribution of UIC, ratio of iodine to creatinine (I:Cr) and TSH between groups following recommendations on fish and dairy product intake or not (fish ≥2 times/week as a main meal, diary products ≥2 portions/d) was assessed.

Primary Health Care of the Capital Area, Reykjavik, Iceland.

Randomly selected pregnant women (19–43 years old, n 162).

The median UIC was 180 μg/l, I:Cr 173 μg/g and TSH 1·5 mmol/l. Women who did not consume fish ≥2 times/week and also did not consume dairy products in line with the recommended intake level of ≥2 portions/d had median UIC of 160 μg/l (I:Cr 149 μg/g) compared with 220 μg/l (I:Cr 190 μg/g) in the group following both the recommendations for fish and those for dairy products. Use of dietary supplements in the two groups was similar.

Iodine status in the population studied was within the optimal range (150–249 μg/d) defined by the WHO.

To investigate the longitudinal relationship between the intake of dietary antioxidants and periodontal disease in community-dwelling older Japanese.

A retrospective cohort study, with a follow-up of 2 years (2003–2005). Intakes of dietary antioxidants (vitamin C, vitamin E, α-carotene and β-carotene) were assessed with a validated FFQ. Participants were classified by tertile of antioxidant intake. Full-mouth periodontal status, measured as the clinical attachment level, was recorded at baseline and follow-up examinations. Periodontal disease progression was considered as loss of attachment of 3 mm or greater over the study period at the interproximal site for each tooth. Finally, the number of teeth with periodontal disease progression per person was calculated and was used as the outcome. Poisson regression analysis was conducted, with dietary antioxidants as the main exposure, to estimate their influence on the number of teeth with periodontal disease progression.

Niigata City (Japan).

Dentate individuals aged 75 years in 2003, for whom data were available, were included in the analyses (n 264).

A higher intake of dietary antioxidants was inversely associated with the number of teeth with periodontal disease progression, controlling for other variables. The multivariate-adjusted incidence rate ratios in the first, second and third tertiles were 1·00, 0·76 (95 % CI 0·60, 0·97) and 0·72 (95 % CI 0·56, 0·93) for vitamin C; 1·00, 0·79 (95 % CI 0·62, 0·99) and 0·55 (95 % CI 0·42, 0·72), for vitamin E; and 1·00, 1·02 (95 % CI 0·81, 1·29) and 0·73 (95 % CI 0·56, 0·95) for β-carotene.

The study results suggest that higher intake of antioxidants may mitigate periodontal disease in community-dwelling older Japanese.

The aim of the present study was to investigate vitamin D status among female out-patients in Saudi Arabia during the summer and winter seasons.

Data were retrospectively collected using medical record abstraction.

A multidisciplinary hospital in Riyadh between January and December 2009.

Saudi females (age ≥19 years; n 1556) attending out-patient clinics for various complaints comprised the studied population. The population was subdivided into two groups depending on the date of their visit where blood samples were collected: summer (n 659) and winter groups (n 897). The summer group was further subdivided into premenopausal (age 19–49 years; n 425) and postmenopausal subgroups (age ≥50 years; n 234). Similarly, the winter group was subdivided into premenopausal (n 543) and postmenopausal subgroups (n 354). Serum levels of 25-hydroxyvitamin D (25(OH)D) were measured using HPLC.

The prevalence of vitamin D deficiency (25(OH)D <50 nmol/l) was high in both premenopausal and postmenopausal groups (80 % and 68 %, respectively) during the summer, as well as during the winter (85 % and 76 %, respectively).

A high prevalence of vitamin D deficiency among Saudi female out-patients was observed throughout the year despite the routine supplementation with 10–20 μg vitamin D3 for postmenopausal women. Clinicians should seriously consider determining the vitamin D status of Saudi females routinely and prescribing them proper supplementation.

Studies examining the association of dairy consumption with incident CHD have yielded inconsistent results. The current prospective study examined the association between dairy consumption and CHD in a population-based sample of older community-dwelling adults.

Baseline CHD risk factors were assessed and an FFQ was self-administered. Participants were followed for morbidity and mortality with periodic clinic visits and annual mailed questionnaires for an average of 16·2 years, with a 96 % follow-up rate for fatal and non-fatal CHD.

Community.

Participants were 751 men and 1008 women aged 50–93 years who attended a clinic visit in 1984–1987.

At baseline the mean age was 70·6 (sd 9·8) years for men and 70·1 (sd 9·3) years for women. Participants who developed CHD during follow-up were significantly older (P < 0·001), had higher BMI (P = 0·035) and higher total cholesterol (P = 0·050), and were more likely to be male (P < 0·001), diabetic (P = 0·011) and hypertensive (P < 0·001), than those who did not develop CHD. Multivariate regression analyses adjusting for age, BMI, diabetes, hypertension, LDL-cholesterol and oestrogen use (in women) indicated that women who consumed low-fat cheese ‘sometimes/often’ and women who consumed non-fat milk ‘sometimes/often’ had an increased risk of incident CHD (hazard ratio = 2·32; 95 % CI 1·57, 3·41) and CHD (hazard ratio = 1·48; 95 % CI 1·02, 2·16) compared with women who ‘never/rarely’ ate these dairy products.

Woman with higher intake of low-fat cheese and non-fat milk seem to have a higher risk of incident CHD. This needs further investigation considering recent evidence of cardiovascular benefits from certain dairy fat.

To evaluate associations between home environmental factors and BMI of young American-Indian children.

Cross-sectional and prospective study.

School-based obesity prevention trial (Bright Start) on a Northern Plains Indian reservation in South Dakota. Mixed model multivariable analysis was used to examine associations between child BMI categories (normal, overweight and obese) and home food availability, children's dietary intake and physical activity. Analyses were adjusted for age, gender, socio-economic status, parent BMI and school; prospective analyses also adjusted for study condition and baseline predictor and outcome variables.

Kindergarten children (n 424, 51 % male; mean age = 5·8 years, 30 % overweight/obese) and parents/caregivers (89 % female; 86 % overweight/obese) had their height and weight measured and parents/caregivers completed surveys on home environmental factors (baseline and 2 years later).

Higher fast-food intake and parent-perceived barriers to physical activity were marginally associated with higher probabilities of a child being overweight and obese. Vegetable availability was marginally associated with lower probabilities of being overweight and obese. The associations between home environmental factors and child weight status at follow-up were not significant.

Findings indicate that selected aspects of the home environment are associated with weight status of American-Indian children. Obesity interventions with this population should consider helping parents to engage and model healthful behaviours and to increase availability of healthful foods at home.

To identify lessons learned from 30 years of implementing the International Code of Marketing of Breast-milk Substitutes (‘the Code’) and identify lessons learned for the regulation of marketing foods and beverages to children.

Historical analysis of 30 years of implementing the Code.

Latin America and the Caribbean.

None.

Legislation to restrict marketing of breast-milk substitutes is necessary but not sufficient; equally important are the promulgation of implementing regulations, effective enforcement and public monitoring of compliance. A system of funding for regular monitoring of compliance with legislation should be explicitly developed and funded from the beginning. Economic sanctions, while important, are likely to be less effective than reports that affect a company's public image negatively. Non-governmental organizations play a critical role in leveraging public opinion and galvanizing consumer pressure to ensure that governments adopt regulations and companies adhere to them. Continual clinical, epidemiological and policy research showing the link between marketing and health outcomes and between policy and better health is essential.

Implementation of the Code has not come easily as it places the interests of underfinanced national governments and international and non-governmental organizations promoting breast-feeding against those of multinational corporations that make hundreds of millions of dollars annually marketing infant formulas. Efforts to protect, promote and support breast-feeding have been successful with indicators of breast-feeding practices increasing globally. The lessons learned can inform current efforts to regulate the marketing of foods and beverages to children.

To provide an independent monitoring report examining the ongoing impact of Australian self-regulatory pledges on food and drink advertising to children on commercial television.

Analysis of food advertisements across comparable sample time periods in April/May 2006, 2007, 2009, 2010 and 2011. The main outcome measure comprised change in the mean rate of non-core food advertisements from 2006 to 2011.

Sydney free-to-air television channels.

Televised food advertisements.

In 2011 the rate of non-core food advertisements was not significantly different from that in 2006 or 2010 (3·2/h v. 4·1/h and 3·1/h), although there were variations across the intervening years. The rate of fast-food advertising in 2010 was significantly higher than in 2006 (1·8/h v. 1·1/h, P < 0·001), but the same as that in 2011 (1·5/h).

The frequency of non-core food advertising on Sydney television has remained essentially unchanged between 2006 and 2011, despite the implementation of two industry self-regulatory pledges. The current study illustrates the value of independent monitoring as a basic requirement of any responsive regulatory approach.

To develop and apply a socio-ecological model (SEM) for healthy eating in school students, to better understand the association between factors at different levels of the SEM and pupils’ dietary choices.

Student-level data, collected through anonymised questionnaires, included reported dietary choices and correlates to these; data on school approaches to food were collected through postal surveys. We used multilevel analysis to study the association of each level of the SEM on student dietary choice while controlling for factors found at other levels.

Data were collected from secondary schools in Wales that were a part of the 2005/2006 Health Behaviour in School-aged Children (HBSC) study.

The final sample for analysis included data from 6693 students aged 11–16 years and 289 teachers from sixty-four secondary schools in Wales.

Student interpersonal factors, an individual's social environment, had a greater association with the dietary choices students made for lunch than student intrapersonal characteristics, those that reside within the person, which were found to have a greater association with the dietary choices made outside school. School organisational factors, such as rules and policies, had a greater association with whether students ate unhealthy foods, whereas the community nature of the school had a greater association with the choosing of healthy foods.

Using the SEM and multilevel analysis allowed us to study how factors were associated with the choice of different foods at different times of the day by students. Interventions can use an SEM to target specific correlates and change health outcomes in the school.

To examine the association between breakfast consumption and CVD risk factors in European adolescents.

Cross-sectional. Breakfast consumption was assessed by the statement ‘I often skip breakfast’ and categorized into ‘consumer’, ‘occasional consumer’ and ‘skipper’. Blood pressure, weight, height, waist circumference, skinfold thickness, total cholesterol (TC), HDL cholesterol (HDL-C), LDL cholesterol (LDL-C), TAG, insulin and glucose were measured and BMI, TC:HDL-C, LDL-C:HDL-C and homeostasis model assessment–insulin resistance index (HOMA-IR) were calculated.

The European Union-funded HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence) Study.

European adolescents, aged 12·50–17·49 years, from ten cities within the HELENA study (n 2929, n 925 with blood sample, 53 % females).

In males, significant differences across breakfast consumption category (‘consumer’, ‘occasional consumer’ and ‘skipper’) were seen for age, BMI, skinfold thickness, waist circumference, cardiorespiratory fitness, systolic and diastolic blood pressures, TC:HDL-C, LDL-C:HDL-C, glucose, insulin, HOMA-IR and LDL-C; in females, for cardiorespiratory fitness, skinfold thickness, BMI, insulin and HOMA-IR. In overweight/obese males significant differences were also seen for TC and LDL-C, whereas no differences were observed in non-overweight males or in females regardless of weight status.

Our findings among European adolescents confirm previous data indicating that adolescents who regularly consume breakfast have lower body fat content. The results also show that regular breakfast consumption is associated with higher cardiorespiratory fitness in adolescents, and with a healthier cardiovascular profile, especially in males. Eating breakfast regularly may also negate somewhat the effect of excess adiposity on TC and LDL-C, especially in male adolescents.

To examine changes in energy intake along with markers of dietary quality (animal-source energy and protein intakes) among household members in the presence of supplementary school feeding in rural Kenya.

A 2-year, longitudinal, randomized controlled feeding intervention study.

Kyeni South Division, Embu District, Kenya.

A total of 182 schoolchildren and selected household members.

There was no evidence that schoolchildren who received supplementary snacks at school experienced reduced intakes at home or that intakes by other family members were increased at the expense of the schoolchild's intake.

This analysis highlights a number of factors useful in planning for supplementary feeding interventions in rural Kenya and similar communities.

Financial constraint is the underpinning determinant of household food insecurity; however, there has been little research examining the impact that increasing the ‘money available’ to food-insecure households could have on food purchasing. The main objective of the present study was to examine the effect of additional money (in the form of supermarket vouchers) on food expenditure in food-insecure households with children.

A parallel randomized controlled trial with a 4-week baseline phase followed by a 4-week intervention phase. Households were randomized to either receive vouchers (coupons) for 4 weeks or a control group that did not receive any vouchers.

Dunedin, New Zealand.

Low-income households with children (≤18 years) reporting food insecurity (n 214).

The mean monetary value of the vouchers received by households was $NZ 17·00 per week. The voucher group spent $NZ 15·20 (95 % CI 1·46, 28·94) more per week on food during the intervention phase compared with the control group (P = 0·030). There were no differences in expenditure between the voucher and the control group for the food groups ‘fruit and vegetables’ (mean difference: $NZ 0·46; 95 % CI −1·97, 2·89; P = 0·709), ‘meat and poultry’ (mean difference: $NZ 0·29; 95 % CI −3·07, 3·64; P = 0·866) and ‘dairy’ (mean difference: $NZ 0·82; 95 % CI −0·75, 2·42; P = 0·302).

Providing money via supermarket vouchers to food-insecure households resulted in an increase in overall expenditure on food.

To determine the prevalence of and associated factors for overweight, especially to determine the relationship between the intake of monosodium glutamate (MSG) as a seasoning and overweight in Vietnam.

A cross-sectional survey was conducted of Vietnamese adults aged ≥20 years in 2008. Dietary intake was assessed by the 24 h recall method for 3 d. MSG intake was evaluated by the weighing method on three consecutive days. Physical activity was assessed based on the Global Physical Activity Questionnaire recommended by the WHO. Overweight was defined as BMI ≥ 23·0 kg/m2. Other characteristics such as age and lifelong occupation were determined by a structured questionnaire.

Some rural and urban areas of Hanoi, Thua Thien Hue Province and Ho Chi Minh City, Vietnam.

A total of 1528 adults living in surveyed areas were randomly selected by the multistage cluster sampling method.

The prevalence of overweight was 27·9 %, and 81·0 % of participants were MSG users. Average MSG intake was 2·2 (sd 1·8) g/d. Multiple logistic regression analysis revealed that factors associated with overweight were age, region of residence, lifelong occupation, physical activity and intakes of energy, carbohydrates, saturated fat and animal protein. There was no significant association between MSG intake and overweight.

The study demonstrated that overweight was not associated with MSG intake in Vietnamese adults. Further longitudinal studies should be done in different populations to determine the relationship between MSG and overweight.

Dietary Fe deficiency has a high incidence in Pakistani children and may be associated with increased gastrointestinal absorption of trace metals such as Mn. Therefore, children residing in heavily polluted cities like Karachi may be prone to Mn toxicity. The present study investigated blood Mn concentrations in Karachi children of different Fe statuses.

A prospective observational study was conducted where children were classified into different categories of Fe status – normal Fe, borderline Fe deficiency, Fe deficiency and Fe-deficiency anaemia – using WHO criteria supported by measurements of soluble transferrin receptors. Blood Mn was determined for children in each category using graphite atomic absorption spectroscopy.

Three hospital outpatient departments in Karachi, Pakistan.

A total of 269 children (156 males, 113 females) aged 6–60 months from low-income families of Karachi.

Blood Mn concentrations were significantly higher in children with Fe-deficiency anaemia and Fe deficiency compared with those of normal Fe status (both P < 0·01). Blood concentrations of soluble transferrin receptors were higher in children with Fe-deficiency anaemia compared with those of borderline or normal Fe status (both P < 0·05).

These findings report for the first time high blood Mn concentrations in Fe-deficient children of this age group. There is therefore an urgent need to identify and remove environmental exposure to Mn in combination with health strategies aimed at eradicating childhood Fe deficiency.

To investigate the frequency of vitamin D deficiency in relation to demographics, clinical diagnosis, season of measurement and laboratory parameters in adult out-patients.

Descriptive, retrospective study concerning evaluation of the initial 25-hydroxyvitamin D (25(OH)D) levels determined at admission in relation to demographics, clinical diagnosis, season of measurement and laboratory parameters. 25(OH)D levels <20 ng/ml were classified as deficiency, 20–30 ng/ml as insufficiency and >30 ng/ml as sufficiency.

Out-patient clinics at a tertiary care centre.

A total of 2488 adult patients (mean age: 53·3 (sd 15·2) years; 85·2 % were females) admitted to out-patient clinics at Baskent University Istanbul Hospital were included.

Mean level of 25(OH)D in the overall population was 17·4 (sd 11·5) ng/ml while insufficiency and deficiency were evident in 24 % and 66 % of patients, respectively. Mean 25(OH)D levels in males >45 years old were higher than in their female counterparts (19·4 (sd 11·3) ng/ml v. 17·8 (sd 12·2) ng/ml; P < 0·05). Mean 25(OH)D levels obtained in summer (18·6 (sd 11·1) ng/ml) and autumn (23·3 (sd 13·6) ng/ml) were significantly higher than levels in spring (16·1 (sd 10·3) ng/ml) and winter (14·6 (sd 10·2) ng/ml; P < 0·01). Mean 25(OH)D levels were determined to be significantly lower in obese patients compared with non-obese patients (15·6 (sd 10·4) ng/ml v. 17·6 (sd 11·6) ng/ml; P < 0·05). Levels of 25(OH)D were significantly negatively correlated with serum parathyroid hormone levels (r = −0·194; P < 0·001) while significantly positively correlated with phosphorus (r = 0·059; P < 0·01) and HDL cholesterol (r = 0·070; P < 0·01) levels.

Our findings indicate that vitamin D deficiency is very common among out-patients in Turkey, regardless of gender and age, especially among obese people and during winter and spring.

Formative research to facilitate the development, packaging and delivery of a culturally acceptable nutrition intervention for HIV-infected women in rural Kenya for an intervention trial.

Focus group discussion on three areas: (i) ingredients and form of the nutrition intervention, (ii) packaging and delivery and (iii) monitoring of adherence. Two single-blind taste tests with eleven different porridge formulations of various combinations of maize flour, soyabeans, peanuts, sorghum, mung beans, dried fish, raisins and dried whole milk. Follow-up acceptability focus group discussion was also conducted.

Voi, Kenya, community based.

Focus group discussion and two taste tests (twenty-one women aged 16–55 years). Follow-up acceptability focus group discussion (four women enrolled in intervention trial).

The preferred porridge for taste consisted of maize, soyabeans and peanuts. For animal protein, dried whole milk and dried fish were used. Although the women disliked the taste of dried fish, it was acceptable if added in small undetectable quantities. Sugar over lime was favoured for taste. Women believed they could consume at least two cups of porridge per day without displacing their usual meals. The optimal delivery interval was believed to be every two weeks in individual serving packages. Women who had been consuming porridge for several weeks felt the taste was acceptable for long-term consumption.

This formative research resulted in the development, packaging and delivery of a nutrient-dense food supplement using local ingredients to meet the dietary needs of the population and acceptable for daily consumption by women in Kenya for evaluation in an intervention trial.

Eating whole grains (WG) is recommended for health, but multiple conflicting definitions exist for identifying whole grain (WG) products, limiting the ability of consumers and organizations to select such products. We investigated how five recommended WG criteria relate to healthfulness and price of grain products.

We categorized grain products by different WG criteria including: the industry-sponsored Whole Grain stamp (WG-Stamp); WG as the first ingredient (WG-first); WG as the first ingredient without added sugars (WG-first-no-added-sugars); the word ‘whole’ before any grain in the ingredients (‘whole’-anywhere); and a content of total carbohydrate to fibre of ≤10:1 (10:1-ratio). We investigated associations of each criterion with health-related characteristics including fibre, sugars, sodium, energy, trans-fats and price.

Two major grocery store chains.

Five hundred and forty-five grain products.

Each WG criterion identified products with higher fibre than products considered non-WG; the 10:1-ratio exhibited the largest differences (+3·15 g/serving, P < 0·0001). Products achieving the 10:1-ratio also contained lower sugar (−1·28 g/serving, P = 0·01), sodium (−15·4 mg/serving, P = 0·04) and likelihood of trans-fats (OR = 0·14, P < 0·0001), without energy differences. WG-first-no-added-sugars performed similarly, but identified many fewer products as WG and also not a lower likelihood of containing trans-fats. The WG-Stamp, WG-first and ‘whole’-anywhere criteria identified products with a lower likelihood of trans-fats, but also significantly more sugars and energy (P < 0·05 each). Products meeting the WG-Stamp or 10:1-ratio criterion were more expensive than products that did not (+$US 0·04/serving, P = 0·009 and +$US 0·05/serving, P = 0·003, respectively).

Among proposed WG criteria, the 10:1-ratio identified the most healthful WG products. Other criteria performed less well, including the industry-supported WG-Stamp which identified products with higher fibre and lower trans-fats, but also higher sugars and energy. These findings inform efforts by consumers, organizations and policy makers to identify healthful WG products.

The present study explored parents’ requirements for healthy eating support prior to the development of a tailored intervention.

A cross-sectional study of parents attending children's centres.

Children's centres in Cornwall (rural south-west England) and Islington (urban London borough).

A total of 261 parents (94·2 % female) of pre-school children (aged 2–5 years) completed a questionnaire on factors influencing food choice, and preferences for and views on healthy eating support.

Parents reported that health, taste, freshness and quality were the most important factors influencing their food choices for their pre-school children. The importance of individual factors varied according to level of educational attainment. Over a third (38 %) of parents said they wanted more advice on healthy eating for children. Less educated parents showed the greatest interest in learning more about several aspects: what a ‘healthy diet’ means, how to prepare and cook healthy food, how to understand food labels, budgeting for food, examples of healthy food and snacks for children, appropriate portion sizes for children and ways to encourage children to eat well.

There was demand for healthy eating support among parents of pre-school children, especially those who are less educated, in one rural and one urban area of England.

To evaluate if and how the current degree of scientific uncertainty about the safety of fish consumption is incorporated at the media level.

We used a dedicated software (TalTac®) to investigate the content of 169 news articles related to ‘mercury and fish consumption’ that appeared from 1990 to 2010 in the two Italian broadsheets with the highest circulation figures, in order to identify journalistic frames used in the coverage of benefits v. risks associated with fish consumption. Hypotheses were made on how the public might change fish consumption patterns as a result of media coverage.

Italy.

The two newspapers have different agendas in covering the issue. La Repubblica appears to support the view that, besides health benefits, there may be risks associated with fish consumption, while Corriere della Sera emphasizes health benefits more than possible risks. Depending on the preferred information source, the public could: (i) reduce its fish intake; (ii) increase its fish intake; or (iii) become confused about the problem and sceptical towards the media, as a result of conflicting journalistic frames.

The Italian media, in cooperation with scientists, public health nutritionists and dietitians, should place more emphasis on the existence of a few fish species with high to very high Hg levels and relatively low contents of beneficial n-3 fatty acids (e.g. swordfish and shark). This would enable consumers to make more educated purchasing decisions to maximize the benefits of n-3 intake while reducing possible risks from consuming Hg-contaminated fish.

Several studies have suggested that dairy food may reduce the risk of obesity and metabolic abnormalities but few have been able to conclusively demonstrate that it reduces the risk of diabetes. The aim of the present analysis was to investigate if dairy food intake independently reduces the risk of diabetes.

The Australian Diabetes Obesity and Lifestyle Study (AusDiab) is a national, population-based, prospective survey conducted over 5 years. Baseline measurements included a 121-item FFQ, anthropometrics and an oral glucose tolerance test.

Forty-two randomly selected clusters across Australia.

Adults aged ≥25 years who participated in the baseline survey and returned to follow-up 5 years later.

A total of 5582 participants with complete data were eligible for analysis, 209 of whom had incident diabetes. Compared with men in the first tertile of dairy food intake, men in the third tertile had a significantly reduced risk of developing diabetes after adjustment for age, sex, total energy intake, family history of diabetes, education, physical activity, smoking status, fasting serum TAG and HDL cholesterol, systolic blood pressure, waist circumference and hip circumference (OR = 0·53, 95 % CI 0·29, 0·96; P = 0·033). A similar non-significant association was observed in women.

Dietary patterns that incorporate high intakes of dairy food may reduce the risk of diabetes among men. Further investigation into the relationship between dairy food intake and diabetes needs to be undertaken to fully understand the potential mechanism of this observation.

Low BMI is a major risk factor for early mortality among HIV-infected persons starting antiretrovial therapy (ART) in sub-Saharan Africa and the common patient belief that antiretroviral medications produce distressing levels of hunger is a barrier to treatment adherence. We assessed relationships between appetite, dietary intake and treatment outcome 12 weeks after ART initiation among HIV-infected adults with advanced malnutrition and immunosuppression.

A prospective, observational cohort study. Dietary intake was assessed using a 24 h recall survey. The relationships of appetite, intake and treatment outcome were analysed using time-varying Cox models.

A public-sector HIV clinic in Lusaka, Zambia.

One hundred and forty-two HIV-infected adults starting ART with BMI <16 kg/m2 and/or CD4+ lymphocyte count <50 cells/μl.

Median age, BMI and CD4+ lymphocyte count were 32 years, 16 kg/m2 and 34 cells/μl, respectively. Twenty-five participants (18 %) died before 12 weeks and another thirty-three (23 %) were lost to care. A 500 kJ/d higher energy intake at any time after ART initiation was associated with an approximate 16 % reduction in the hazard of death (adjusted hazard ratio = 0·84; P = 0·01), but the relative contribution of carbohydrate, protein or fat to total energy was not a significant predictor of outcome. Appetite normalized gradually among survivors and hunger was rarely reported.

Poor early ART outcomes were strikingly high in a cohort of HIV-infected adults with advanced malnutrition and mortality was predicted by lower dietary intake. Intervention trials to promote post-ART intake in this population may benefit survival and are warranted.