Background
Methods
Data sources and searching strategies
Inclusion and exclusion criteria
Measurement of outcome variables
Quality appraisal
Data extraction
Data synthesis
Heterogeneity, publication bias, and subgroup analyses
Results
Identification of studies
Description of included studies
Studies included assessing the effect of undernutrition on mortality | |||||||||
No | Author (Publication Year) | Study Design | Study/ follow-up period | Quality score | Sample size | Female N (%) | Mortality N (%) | Adjusted confounders for mortality | |
1. | Ferradini et al., (2006) [24] | Retrospective cohort | 2001–2004 | 5 | 1, 308 | 827 (63.2) | 243 (19) | Age, year of HAART initiation, type of ART regimen, follow-up site, sex, and baseline CD4 count | |
2. | Evans et al., (2012) [29] | Retrospective cohort | 2004–2009 | 8 | 8409 | 5204 (61.9) | 661 (7.9) | Hgb, CD4 count, aspartate transaminase, TB, age, and sex | |
3. | Palombi et al., (2009) [98] | Retrospective cohort | NR | 6 | 3, 749 | 2325 (62) | 393 (10.5) | Sex, age, baseline Hgb, baseline CD4 count, baseline HIV RNA level, WHO staging, ART adherence, and length of ART follow-up. | |
4. | Jerene et al., (2006) [99] | Cohort | 2003–2005 | 6 | 152 | 66 (43.4) | 24 (15.8) | TLC, WHO staging and Hgb | |
5. | Johannessen et al., (2008) [100] | Prospective cohort | 2003–2006 | 7 | 320 | 223 (69.7) | 95 (29.7) | Sex, WHO staging, ART start year, Hgb, TLC, and platelet count | |
6. | Moh et al., (2007) [25] | Cohort | 2002–2004 | 7 | 792 | 606 (76.5) | 18 (2) | WHO staging, Hgb, viral load, baseline CD4 count, follow-up CD4 count and follow-up viral load | |
7. | Brown et al., (2016) [39] | Cohort | 2008–2015 | 8 | 432 | 243 (56.3) | 74 (17.2) | Sex, age at enrolment, CD4 count at enrolment, year of enrolment, and route of HIV testing | |
8. | Tesfamariam et al., (2016) [18] | Retrospective cohort | 2006–2013 | 8 | 489 | 254 (51.9) | 87 (17.8) | Educational status, functional status, WHO staging, CD4 count, Hgb, previous OI, HIV related counselling | |
9. | Bastard et al., (2013) [31] | Cohort | 2004–2010 | 8 | 55,789 | 36,508 (65.4) | 1843 (3.3) | Sex, age, WHO staging, CD4 count, diagnosis of TB, eligibility to ART, and mode of entry to ART | |
10. | Dao et al., (2011) [101] | Prospective cohort | 2005–2007 | 7 | 661 | 661 (100) | 53 (8) | Country, age, WHO staging, diagnosis of TB, CD4 count, viral load, prophylaxis, Hgb, WBC, neutrophils count, platelet counts, potassium, chloride, sodium, hyponatremia, creatinine clearance, AST/ALT, and albumin | |
11. | Kouanda et al., (2012) [30] | Retrospective cohort | 2003–2008 | 8 | 5608 | 3926 (70) | 690 (12.3) | Age, sex, occupation, WHO staging, ART regimen, CD4 count, year of HAART initiation, and intensity of intervention | |
12. | Masiira et al., (2014) [102] | Prospective cohort | 1992–2011 | 8 | 374 | 204 (54.5) | 27 (7.21) | Age, sex, marital status, alcohol consumption, tobacco use, Hgb, CD4 count, WHO staging, viral load, malaria infection during follow-up, diarrhea, and viral load | |
13. | Teshome et al., (2015) [38] | Retrospective cohort | 2011–2012 | 6 | 1173 | 649 (55.3) | 47 (4) | Sex, gap b/n test and treatment, marital status, family size, facility type, CD4 count, age, INH prophylaxis, CPT prophylaxis, side effects, functional status, HIV status disclosure, educational status, TB, and WHO staging | |
14 | Chen et al., (2008) [103] | Retrospective cohort | 2004–2006 | 7 | 2, 838 | 1716 (60.5) | 376 (13.2) | Sex, age, and WHO staging | |
15. | Sieleunou et al., (2009) [104] | Retrospective cohort | 2001–2006 | 7 | 1, 187 | 660 (55.6) | 338 (28.5) | Sex, WHO staging, CD4 count, and Hgb | |
16. | Liu et al., (2011) [20] | Retrospective cohort | 2004–2009 | 7 | 8271 | 11,927 (65.3) | 1673 (9.2) | Hgb and MUAC | |
17. | Ssebutinde et al., (2018) [35] | Retrospective cohort | 2006–2012 | 7 | 8364 | 5308 (63.5) | 180 (2.1) | Age, sex, WHO staging, CD4 count, and level of education | |
18. | Maskew et al., (2013) | Retrospective cohort | 2004–2010 | 8 | 7354 | 4621 (62.8) | 333 (4.5) | Sex, age, CD4 count, and Hgb | |
19. | Geng et al., (2013) [105] | Retrospective cohort | 2007–2011 | 7 | 2633 | 1563 (59.4) | 42 (1.6) | Age, sex, CD4 count, baseline TB diagnosis, pregnancy at ART initiation, WHO staging, income, employment status, education, and distance from ART clinic | |
20. | Hoffmann et al., (2011) [106] | Retrospective cohort | 2003–2008 | 7 | 15,060 | 5455 (36.2) | 2658 (18) | Sex, age, WHO staging, TB symptoms, Hgb, viral load, and CPT | |
21. | Toure et al., (2008) [27] | Retrospective cohort | 2004–2007 | 6 | 10,211 | 7187 (70.4) | 1140 (11) | Sex, age, CD4 count, WHO staging, ART regimen, Type of HIV, and Hgb | |
22. | Damtew et al., (2015) [21] | Retrospective cohort | 2007–2011 | 6 | 784 | 485 (61.9) | 87 (11.1) | Marital status, educational status, functional status, WHO staging, CD4 count, anaemia, and TB co-infected | |
23. | Ayele et al., (2017) [23] | Retrospective cohort | 2012–2014 | 7 | 280 | 183 (65.4) | NR | Sex, age, educational level, residence, religion, occupation, marital status, alcohol, WHO staging, CD4 count, TB treatment, type of ART regimen, and prophylaxis | |
24. | Maman et al., (2012) [107] | Retrospective cohort | 2001–2010 | 7 | 24, 037 | 16,355 (68) | 568 (2.4) | HIV program, sex, age, WHO staging, initial CD4 count, updated CD4 count, and year of ART initiation | |
25. | Naidoo et al., (2018) [34] | Retrospective cohort | 2008–2010 | 6 | 948 | 547 (57.7) | 56 (5.9) | Age, sex, CD4 count, WHO staging, and TB | |
26. | Stringer et al., (2006) [108] | Cohort | 2004–2005 | 7 | 21,755 | 13,646 (62.7) | 1, 120 (5.1) | Age, ART non-adherence, sex, Hgb, CD4 count, WHO staging, and TB infection | |
27. | Hussen et al.,(2016) [19] | Retrospective cohort | 2006–2011 | 8 | 340 | 200 (58.8) | 42 (12.4) | Age, marital status, CD4 count, WHO staging, occupation, educational level, Fluconazole prophylaxis, and Baseline HAART | |
28. | Pac et al., (2015) [109] | Prospective cohort | 2010–2012 | 7 | 540 | 324 (60) | 39 (7.2) | Age, sex, CD4 count, Hgb, TB infections, and positive serum Cr Ag | |
29. | Tchounga et al., (2016) [110] | Cohort | 2014–2015 | 7 | 1825 | 1102 (60.4) | 221 (12.1) | Sex, age, year of ART initiation, WHO staging, CD4 count, and Hgb | |
30. | Nansera et al., (2012) [37] | Retrospective cohort | 2007–2010. | 6 | 386 | 142 (36.8) | 53 (13.7) | Sex, anaemia, CD4 cell count, and WHO staging | |
31. | Otwombe et al., (2014) [111] | Prospective cohort | 2003–2010 | 8 | 2221 | 1555 (70) | 242 (11) | Sex, time on ART, CD4 count, employment status, ever smoking, and ever TB | |
Prospective cohort | 2003–2010 | 4469 | 3480 (77.9) | 324 (7.2) | |||||
32. | Kendi et al., (2013) [95] | Retrospective cohort | 2005–2009 | 6 | 71 | 35 (49.3) | 27 (38) | Age, sex, CD4 count, on ART, and any anti-fungal therapy | |
33 | Zachariah et al., (2006) [112] | Cross-sectional | 2003–2005 | 9 | 1, 507 | 990 (65.7) | 190 (12.6) | Sex, age, WHO staging, CD4 count, and active TB | |
34 | Umanah et al., 2015) [18] | Cross-sectional | 2007–2010 | 8 | 947 | 490 (51.7) | NR | ART regimen, age, sex, site of TB, CPT prophylaxis, CD4 categories, Hgb, infiltrative cavitation change on X-ray, fibrotic change on X-ray, other OIs, comorbidity, and adverse events to medication | |
Studies included assessing the effect of undernutrition on morbidity | |||||||||
No | Author | Study Design | Study/ follow-up period | Sample size | Female N (%) | Morbidity N (%) | Adjusted for confounders for morbidities | ||
35. | Moore et al., (2007) [26] | Prospective cohort | 2003–2005 | 6 | 1042 | 765 (73.4) | 53 (5.1) | Sex, median age, CD4 count, viral load, prior TB treatment, participation in previous safe water/co-trimoxazole study | |
36. | Kufa et al., (2016) [32] | Prospective cohort | 2011–2012 | 7 | 634 | 513 (80.9) | 15 (2.4) | Sex, age, employed, ever smoked, alcohol drinking, duration since HIV test, on ART, current or prior ART use, current CPT use, previous TB treatment, and CD4 count | |
37. | Sabasaba et al., (2019) [96] | Retrospective cohort | 2011–2014 | 8 | 68,378 | 51,486 (75.3) | 3124 (4.6) | Age, sex, marital status, CD4 categories, WHO staging, CPT use, IPT status, ART status, and functional status at enrolment | |
38. | Worodria et al., (2011) [113] | Prospective cohort | NR | 7 | 219 | 157 (71.7) | 6 (3.8) | Age, Sex, TB ski test, C-reactive protein, Hgb, CD4 count, and WHO staging | |
39. | Ahmed et al., (2018) [33] | Retrospective cohort | 2010–2015 | 8 | 451 | 267 (59.2) | 119 (26.4) | Marital status, family size, substance use, previous TB, OIs, bed ridden, length of follow-up, WHO staging, Hgb, CD4 count, and IPT | |
40. | Tiruneh et al., (2019) [36] | Retrospective cohort | 2009–2012 | 8 | 600 | 356 (59.3) | 53 (8.8) | Age, CD4 count, sex, weight, WHO staging, functional status, CPT, previous TB treatment, and OI | |
41 | Nicholas et al., (2011) [114] | Prospective cohort | 2006–2008 | 7 | 28,323 | 18,968 (67.0) | 780 (9) pre 933 (5) pos | Residence, sex, age, history of ART use, TB history, and CD4 count | |
42. | Liu et al., (2015) [115] | Prospective cohort | 2004–2012 | 8 | 67,686 | 50,633 (74.8) | 7602 (11.2) | Age, sex, district, family size, years of enrolment, season of visit, MUAC, anaemia, CD4 count, WHO staging, ALT, CPT, IPT, non-adherence to ART, month on ART, ART regimen, and NNRTI | |
43. | Chang et al., (2015) [116] | Retrospective cohort | 2004–2012 | 8 | 32,611 | 22,106 (67.8) | 2021 (6.2) | Sex, ART at enrolment year, ART regimen, WHO staging, CD4 count, viral load, anaemia, and ART adherence | |
44. | Bjerrum et al., (2016) [117] | Prospective cohort | 2013–2014 | 7 | 473 | 304 (64.3) | 60 (12.7) | Age, sex, CD4 count, cough ≥2 weeks, and fever ≥2 weeks | |
45. | Temesgen et al., (2019) [40] | Retrospective cohort | 2012–2017 | 7 | 492 | 264 (53.7) | 83 (16.9) | Sex, CD4 count, WHO staging, functional status, Hgb, OIs, CPT, and IPT | |
46. | Mupfumi et al., (2018) [118] | Retrospective cohort | 2008–2011 | 7 | 254 | 172 (67.7) | 13 (5) | Sex, age, Hgb, CD4 count, viral load, and hepatitis B infection | |
47. | Hanrahan et al., (2010) [29] | Prospective cohort | 2003–2008 | 9 | 3, 456 | 2704 (78.2) | 226 (6.5) | On HAART, CD4 count, CPT use, income, employment status, and smoking ever | |
48. | Melkamu et al., (2013) [119] | Case-Control Study | 2011–2012 | 9 | 357 | 192 (53.8) | NR | Marital status, educational status, having diabetes mellitus, WHO clinical staging, and having separate kitchen | |
49. | Gedle et al., (2017) [120] | Cross-sectional | April–June 2016 | 10 | 323 | 204 (63.2) | 142 (35.9) | Residence, educational status, income, presence of animals, presence of toilet, source of water, WHO staging, and CD4 count | |
50. | Kyeyune et al., (2014) [97] | Cross-sectional | 2010–2012 | 9 | 400 | 277 (69.3) | 260 (65) | Sex, CD4 count, age, HART status, educational status, and employment status | |
51. | Ageru et al., (2019) [121] | Cross-sectional | October–December 2016 | 10 | 411 | 258 (62.8) | 150 (36.5) | Sex, marital status, educational level, HAART status, year live with virus, frequency of eating, CD4 count, and infection with intestinal parasite | |
52. | Chen et al., (2019) [122] | Prospective cohort | 2007–2009 | 8 | 572 | 334 (58.4) | 75 (13.1) | Loss of appetite, handgrip strength, sphygmomanometer test | |
53. | Hussen et al. (2017) [123] | Retrospective cohort | 2006–2011 | 8 | 340 | 200 (58.8) | 83 (24.4) | Educational level, baseline HAART, and INH prophylaxis |
Quality appraisal results
Narrative analysis
The effects of undernutrition on mortality
The effects of undernutrition on tuberculosis
The effects of undernutrition on other morbidities
Meta-analysis of the effects of undernutrition on mortality
Variables | Subgroup | No of studies | Population (N) | AHR (95%CI) | (I2 (%) and Cochrane chi-squared test p-value) |
---|---|---|---|---|---|
Severity of undernutrition | Severe | 6 | 66, 110 | 2.3 (1.9, 2.8) | (45.5, 0.102) |
Moderate | 2 | 42, 308 | 1.8 (1.5, 2.5) | (52.3, 0.145) | |
Mild | 4 | 50, 754 | 1.4 (1.1, 1.8) | (60.9, 0.053) | |
Geographical locations | Eastern Africa | 9 | 14, 601 | 1.8 (1.1, 3.0) | (75.9, < 0.001) |
Western Africa | 3 | 16, 611 | 2.5 (1.9, 3.3) | (23, 0.273) | |
Sothern Africa | 8 | 36, 303 | 2.1 (1.8, 2.3) | (35.3, 0.147) | |
Multicounty | 3 | 58, 275 | 2.4 (1.3, 4.4) | (80, 0.007) | |
Sample size | ≥ 5, 470 | 6 | 103, 441 | 1.8 (1.5, 2.3) | (79.3, < 0.001) |
< 5, 470 | 17 | 22, 349 | 2.3 (1.9, 2.9) | (56.6, 0.002) | |
Publication year | ≤ 2012 | 9 | 45, 657 | 2.3 (1.9, 2.7) | (65.6, 0.003) |
> 2012 | 14 | 80, 133 | 1.9 (1.5, 2.4) | (68.2, < 0.001) | |
Quality score | Good | 13 | 93, 236 | 2.05 (1.7, 2.5) | (73.3, < 0.001) |
Fair/ poor | 10 | 32, 554 | 2.2 (1.7, 2.8) | (51.5, 0.029) |
Subgroup analyses of effects of undernutrition on mortality
Meta-analysis of effects of undernutrition on TB
Subgroup analyses of effects of undernutrition on TB
Variables | Subgroup | No of studies | Population (N) | AHR (95%CI) | (I2 (%) and Cochrane chi-squared test p-value) |
---|---|---|---|---|---|
Geographical locations | Eastern Africa | 6 | 71, 182 | 2.2 (1.6, 2.9) | 51, 0.069 |
Other countries | 4 | 33, 205 | 1.8 (0.9, 3.5) | 84.9, < 0.001 | |
Sample size | ≥ 1, 000 | 4 | 101, 199 | 2.02 (1.4, 2.9) | 87.8, < 0.001 |
< 1, 000 | 6 | 3, 188 | 2.2 (1.3, 3.6) | 56.8, 0.041 | |
Publication year | ≤ 2012 | 5 | 33, 832 | 2.02 (1.2, 3.4) | 80.7, < 0.001 |
> 2012 | 5 | 70, 555 | 2.02 (1.5, 2.8) | 46.8, 0.111 |