Background
Up to 50% of people living with HIV (PLWH) manifest some degree of neurocognitive impairment, even with effective antiretroviral therapy (ART) [
1]. HIV-associated neurocognitive disorders (HAND) may consist of deficits in executive function, attention, and memory, and are implicated in impairments in everyday functioning and poorer quality of life among PLWH [
2‐
4]. Thus, HAND represents a significant public health concern [
1], for which there is currently no evidence-based interventions. Among existing lifestyle modification interventions in the general population, promotion of a healthy diet and physical activity (PA) may benefit neurocognitive outcomes among PLWH.
In the natural course of untreated HIV, progressive weight and muscle loss were common; however, with use of effective ART, many PLWH experienced improvements in nutritional status and weight gain [
5]. Long-term ART, particularly use of protease inhibitors, may contribute to abnormal fat redistribution, known as lipodystrophy [
6]. Body composition changes (e.g., intra-abdominal fat accumulation [
7]) are relevant to the pathogenesis of HAND given the association between abdominal obesity and neurocognitive impairment [
8]. Both healthy diet and PA can influence body composition alterations among PLWH [
5], but the effectiveness of diet and PA interventions to improve neurocognitive outcomes is limited.
Diet and nutrient deficiencies have been extensively documented for PLWH in low-income countries [
9]; however, there is limited research characterizing diet quality among adults living with HIV in the United States (US). One US cohort study of adult PLWH with chronic diarrhea reported that mean intake of fat, saturated fat, and cholesterol was higher than recommended levels set by the National Cholesterol Education Program, whereas mean intake of monounsaturated fat, polyunsaturated fat, and fiber fell below recommended levels [
10]. While more nutritional data is needed to better characterize diet among PLWH in the US, the limited evidence suggests diet may be a relevant modifiable lifestyle factor to target in interventions that promote better health outcomes.
Adherence to a Mediterranean-style diet (MedDiet) is positively associated with better global neurocognition [
11], as well as a lower risk for Alzheimer’s disease, decreased inflammation, and reduced brain atrophy [
12,
13]. Despite this body of evidence supporting the MedDiet as a strategy for promoting better neurocognitive outcomes, few studies have investigated the effectiveness of a MedDiet for HAND. Similarly, observational studies indicate a positive association between PA engagement and neurocognitive function, but PA intervention studies among PLWH have yielded inconsistent effects on neurocognitive outcomes [
14]. Thus, an approach that targets both PA and diet may be optimal for addressing neurocognitive deficits observed among PLWH.
iSTEP is a novel and personalized text messaging intervention that is currently being evaluated in terms of its effectiveness at promoting moderate PA and reducing sedentary behavior (SB) in PLWH, which in turn, is hypothesized to benefit neurocognitive outcomes. The conceptualization of iSTEP was informed by previous mobile health interventions that show positive effects on behavior change outcomes, such as promotion of PA engagement [
15]. As part of the development of iSTEP, focus groups were conducted to elicit feedback from PLWH regarding strategies to increase PA [
16]. During these focus groups, the sample of PLWH expressed a myriad of preferences regarding Short Message Service/Multimedia Message Service (SMS/MMS) delivery and content, indicating the need to adopt a personalized intervention approach (e.g., personalized PA text messages, setting individualized PA goals). Preliminary data from the iSTEP study supports high text message response rates and positive participant feedback [
17].
The aim of the parent project is to expand the iSTEP intervention to include adherence to a MedDiet, including walnut consumption, thereby improving neurocognitive outcomes among PLWH with HAND. The purpose of this qualitative study was: 1) to characterize diet habits among PLWH, including barriers and facilitators of a healthy diet, and 2) to inform the development of a mobile health intervention (iSTEP) that addresses the preferences of PLWH. The qualitative analysis of focus group content provides a foundation for interventions aimed at behavioral modification as treatment for HAND.
Discussion
Focus group discussion yielded identification of prominent healthy diet barriers and facilitators among PLWH. Barriers to a healthy diet included factors observed among the general population (e.g., time demand of food preparation, depression and other psychiatric issues), as well as factors specific to PLWH (e.g., changes in appetite related to HIV and/or ART). Healthy diet facilitators included environmental factors (e.g., access to medical professionals for diet recommendations, affordable price options) and personal factors (e.g., having a structured food plan, desiring to modify appearance or weight). Additionally, focus group discussion served as an avenue to obtain feedback on intervention components (e.g., text content and preferences regarding Fitbit types) that helped inform the expansion of a novel mobile health intervention to promote adherence to a MedDiet, engagement in PA, and reduction of SB among PLWH with HAND. Importantly, focus group discussion highlighted the importance of patient-centered intervention content to promote acceptability of the iSTEP intervention.
Chronic inflammation is implicated in the pathogenesis of HIV-associated neurocognitive impairment across the age span of PLWH [
8,
18‐
23]. The etiology of metabolic disturbance in HIV is likely multi-factorial and includes diets high in cholesterol, saturated and trans fats [
24,
25]. Current international guidelines for the treatment of HIV-related dyslipidemia recommend dietary intervention as a first-line treatment [
26]. According to one review of dietary interventions in PLWH, administration of omega-3 supplements was successful at lowering triglycerides, but did not have an effect on high-density lipoprotein (HDL) cholesterol, suggesting that a dietary approach that focuses on whole foods might be the most optimal method [
27]. Some nutrition studies have promoted polyunsaturated fatty acids (PUFA) and omega-3 PUFA (n-3 PUFA), which are emphasized in the MedDiet [
28]. PUFA and n-3 PUFA are present in foods such as walnuts and may benefit brain health and function by reducing oxidative stress and inflammation, maintaining neuronal membrane integrity, and attenuating protein aggregation implicated in neurodegenerative diseases and age-related neurocognitive decline [
28]. Adoption of the MedDiet provided reduction in cardiovascular disease events, decreased markers of oxidative stress, and improved neurocognition compared to control or a low-fat diet condition in a large 12-month study [
29‐
34]. Adherence to a MedDiet is associated with improved metabolic function (i.e., lower insulin resistance and higher high-density lipoprotein cholesterol) in PLWH [
35]; however, whether improvement in metabolic profile leads to downstream neurocognitive improvement has not been evaluated. Thus, the aim of the parent intervention study is to examine the effect of a MedDiet, including walnut consumption, on cardiovascular risk and neurocognitive outcomes among PLWH.
Many dietary interventions to date have provided a one-size-fits-all approach that may not adequately target barriers and facilitators of a healthy diet at an individual level [
36]. Thus, for the expansion of the iSTEP intervention, which includes a focus on promoting adherence to a MedDiet, focus groups were conducted to better understand unique experiences related to dietary behaviors. Many of the participant-identified barriers to a healthy diet are consistent with those described previously among the general population [
37‐
40]. For example, in a sample of persons aged 65 years and older, a common barrier to healthy eating was price [
37], which is consistent with a cross-sectional study of middle-aged African American adults who reported that the high price of healthy foods was the biggest barrier to healthy eating [
41]. In a study in which participants were provided with a healthy diet (based on dietary reference values for energy and nutrient requirements) for three consecutive days and were then asked during a semi-structured interview about perceived barriers to continuing eating a healthy diet, the most commonly endorsed barriers were competing demands (e.g., work pattern and social activities), a mismatch between a healthy diet and current diet habits of family or household members, not liking the taste of certain foods, and costs associated with a healthier diet [
39]. A small body of literature focusing on adoption or adherence to a MedDiet in non-Mediterranean areas have identified barriers such as difficulty changing food habits, limited access to certain food items, increase in food costs, and time constraints [
42‐
44]. Although many of the barriers identified in our study have been previously reported (e.g., time demands for food preparation and issues of cost), our study also identified barriers that may be specific or more pronounced for PLWH, such as a gastrointestinal issues, physical disability, and changes in appetite since HIV diagnosis. Together, the results of our qualitative analysis and previous studies identifying factors related to a healthy diet indicate that improvement of diet may need to address both personal and social barriers.
Our focus group discussions also focused on facilitators of a healthy diet, given that many PLWH in our sample may already adhere to components of a healthy diet currently or in the past. Focus group members discussed the helpfulness of social and environment factors (e.g., affordable price options for healthy foods, access to medical professionals who provide dietary recommendations), as well as personal factors (e.g., desire to modify appearance or weight and motivation for disease prevention). In a previous study focused on factors related to healthy eating, personal factors were emphasized, such as a desire to stay healthy, prevent disease, and promote a high quality of life [
37]. In another study utilizing latent class cluster analysis to identify clusters of participants with similar influences on health behaviors, participants in the “low barriers” cluster had lower perceived barriers, higher self-efficacy, higher social support, and more resources for healthy diet compared to participants in the “high barriers” cluster [
45]. Thus, interventions aimed at promoting adherence to a healthy diet may identify and provide additional support to participants with fewer personal and social factors supporting healthy dietary behaviors.
The initial aims of iSTEP intervention were to increase moderate PA and improve neurocognition in PLWH with HAND. In the current iteration of iSTEP, the objective is to expand the SMS intervention to also support adherence to a MedDiet. A systematic review and meta-analysis indicated that mobile health interventions promote small decreases in SB and have positive, small-to-moderate effects for PA and walking outcomes [
46]. SMS has been used in studies involving PLWH to assess a variety of health indicators and behaviors, such as medication adherence, food insecurity, and alcohol use [
47]. SMS interventions designed for PLWH have aimed to promote a variety of health behaviors, particularly medication adherence [
48,
49]. In a structured pharmaceutical care intervention (INFAMERICA study), PLWH who were sent periodic text messages about health promotion (e.g., recommendations for improving diet, exercise, and smoking cessation) showed reductions in cardiovascular risk index scores, higher rates of tobacco cessation, and improved medication adherence [
50]. The results of the INFAMERICA study provide initial support of the efficacy of SMS interventions to improve health outcomes among PLWH; however, additional research is needed to establish the efficacy of SMS interventions to simultaneously promote a healthy diet and PA among PLWH.
A review of PA and diet mHealth interventions conducted in developing countries for individuals with non-communicable diseases (diabetes and hypertension) reported that the majority of studies significantly improved eating habits [
51]. Many of these interventions incorporated text messages that included reminders and instructions to follow a diet regimen and information about the benefits of healthy eating. It is worth noting, though, that not all diet mHealth interventions are successful. McCarroll and colleagues observed that approximately half of mHealth RCTs focused specifically on improving diet demonstrated positive outcomes such as increased vegetable consumption or weight loss [
52]. The most successful protocols involved self-monitoring of diet consumption via texts or a cell phone app and feedback that was directly tailored to the self-monitored measures, indicating the importance of integrating these two components.
Similar to the INFAMERICA study, the current iteration of iSTEP aims to intervene on multiple health behaviors (i.e., increase PA, reduce SB, and promote adherence to a MedDiet). Given the multitude of factors impacting engagement in health behaviors, iSTEP is designed to deliver daily personalized and interactive texts in lieu of offering a one-size-fits-all approach. For example, the iSTEP intervention will provide texts with recommendations for healthy food options and recipes based on individual preferences, a strategy endorsed by the focus group participants. iSTEP also provides weekly feedback to the participants on their PA/SB and self-monitored MedDiet adherence, including fruit, vegetable, fish, and legume intake. This intervention is therefore designed to integrate behavioral modification techniques previously shown to be useful, such as adopting a personalized approach with each participant, applying weekly diet self-monitoring, and structuring participant feedback based on changes in their responses over the course of the study. Identifying the relative efficacy of each of these individualized components will be an important step toward improving and refining future patient-centered mobile health interventions.
The current study has several limitations. Our study was a relatively small sample size for qualitative research. Consequently, saturation of categories may not have been reached. All participants had previously participated in other studies at the HNRP, a potential source of sample bias. Although our focus group members were amendable to a mobile health intervention to promote a MedDiet and engagement in PA, the parent prospective clinical trial is needed to determine acceptability of the intervention. Despite these limitations, the perspectives of this sample of PLWH remains important for identifying barriers and facilitators to a healthy diet and obtaining input on a mobile health intervention aimed at promoting adherence to a MedDiet.