By Courtney George
A hot topic in global nutrition is the coexistence of overnutrition (eating too much of something) and undernutrition (not eating enough of something), called the dual burden of malnutrition (see textbox below). This is also occurring alongside the well-documented dual burden of disease, which is when an individual or community has both infectious (ex. malaria) and noninfectious (ex. heart disease) diseases. Communities and individuals are experiencing non-infectious and infectious diseases simultaneously with overnutrition and undernutrition (in essence, a very tough life). Countries, especially of lower incomes (LMIC), are scrambling to find the resources to deal with the impacts of these multiple burdens of disease and mortality on their populations.
Traditionally, overnutrition has been associated with chronic non-infectious disease (ex. obesity and Type 2 diabetes) while undernutrition was associated with infectious diseases (partially because lower protein intake weakens the immune system and makes it harder to fight off infections). Research is now showing that there is much more complexity to this relationship, and malnutrition has multiple forms which contribute to both infectious and chronic diseases. One situation which is particularly nefarious and not well-understood is the syndemic of malnutrition, obesity, nutrition-related chronic diseases (NRCDs), and HIV.
What is a Syndemic?
The word syndemic is a relatively new term in global public health. It describes the interactions of epidemics that occur in similar times and places, share common underlying societal drivers, and produce heightened effects when they co-occur. A common syndemic in the HIV world is between HIV and tuberculosis, because infection with one greatly increases the risk of contracting the other. Obesity and NRCDs also tend to form syndemics with one another, something commonly taught to nutrition professionals and medical practitioners. However, there is another syndemic that is not often discussed- NRCDs in people living with HIV (PLHIV).
PLHIV taking antiretroviral therapy (ART) for long periods of time are at much higher risks for many NRCDs, specifically cancer, Type 2 diabetes, and cardiovascular disease. Researchers are unsure of the cause of this relationship, and they don’t know how much ART drugs contribute to it. No one in their right mind would tell PLHIV to stop taking their life-saving and life-prolonging ART, so researchers will need to find new solutions and interventions. The nutrition and health communities are paramount to finding these solutions, but in order to do so, we must attempt to understand why this syndemic is occurring in the first place.
Why is this happening?
Southern Africa has the highest number of PLHIV, and a large portion of its population is experiencing this syndemic between HIV and nutrition-related chronic diseases. Southern Africa is also an area of rapidly-growing population density, obesity, and novel NRCD prevalence, especially in women. My research is centered around developing a model and describing the nutrition-related contributing factors which would have the highest probability of generating the greatest benefits to communities and individual’s health, if adequate solutions are developed. These are by no means the only factors; they are simply the most deleterious, pervasive, and misunderstood. The factors are as follows:
- Chronic inflammation: Both HIV and nutrition-related chronic diseases are characterized by inflammation, and this inflammation can cause further disease and death.
- Weight gain: Most ARTs lead to weight gain, but newer ARTs leads to excessive weight gain and metabolic syndrome, especially in women of color, who make up the largest proportion of PLHIV.
- Breastfeeding: Until 2010, most PLHIV were told not to breastfeed in order to prevent mother-to-child transmission. The downstream effects of this are myriad, one being an increased risk of obesity and NRCDs for mother and child in the long-term.
- Gut microbiota: Nascent research is attempting to understand the significance of disruption of the gut microbiota, which is very common in PLHIV and many NRCDs.
- Body Image Standards: Many people, especially women in LMIC, intentionally work to achieve higher BMIs in order to fit a societal ideal body image of beauty, health, and wealth, namely to avert HIV stigma, which is culturally associated with very low BMI.
- Lower-class status: People who identify as women, people of color, sex workers, the LGBTQ+ community, and others tend to have lower-class status. This increases their social and political vulnerability in society, leading to increased risk for food insecurity, gender-based violence, and poverty, all factors which increase the risk of entering into this syndemic.
What is the Takeaway?
Most research in HIV is investigating long-term drugs and cures for HIV. Although research into HIV’s connections to nutrition isn’t as common, it may be just as important. While investigating long-term drugs and cures for HIV are very important, they may not address all of the side effects experienced by PLHIV, and they will also do little to address the complex social situations such as poverty and violence against women that underpin global HIV transmission.
All providers, family members, friends, and other professionals who interact with PLHIV need to be made aware of these connections. While a cure is something to hope for, it does not necessarily mean that effects from this syndemic will be completely eliminated due to the irreversible damage done by the development of NRCDs. Furthermore, these cure regimes might impart their own unique, unknown side effects, requiring further care and research in this population.
Many questions remain about this syndemic, but they are not asked often enough. I urge all those who are reading this article from nutrition or other health backgrounds to appreciate the interconnectivity of nutrition and the immune system with all other systems in the body, as well as continuing to ponder this complex web of factors when interacting and counseling PLHIV.
Want to learn more about HIV and chronic diseases at UNC? Check out the NIH-funded MACS/WIHS study which will be hosting a cohort at UNC-Chapel Hill
Peer-edited by Kaylee Helfrich and Laetitia Meyrueix