Dear Fiona, Treatment of severely malnourished adults and elderly is a true challenge as in most cases their malnutrition status is caused by secondary reasons which in most cases chronic diseases such as TB, malignancies or HIV related weight loss syndrome , more often especially in Iodine defeciency areas thyroid disease is a major reason , in operational terms those patients tend to suffer from 2 problems: 1) need to stay long time in the program evantually dischrged as non- respondants , some shows very slow response to treatment unless their pridisposing condition treated. 2) their treatment is long lasting or life lasting and in most setting they are not capable to pay the cost of the treatment . you can see the following refrences : 1) Assessment of nutrition status in emergency affected situation ; Steve Collins, Arabella Duffield and Mark Myatt 2) Adult malnutrition in emergency by Carlos Navarro Colorado for Action contre la faim For the other point about HIV + individual i would recommend that you read Malawi Study by ACF December 2007 which have shown that nutrition recovery is acheivable for HIV+ children with malnutrition , now almost it is agreed that HIV+ children with SAM can be treated in inpatient therapeutic care with high importance for the integration between HIV and nutritional services

Dear Fiona and colleagues, I will like to comment briefly on my work on adult malnutrition that was mentioned in a previous reply. Basically, what we found is that nor BMI nor MUAC were identifying patients with acute malnutrition correctly, except for the very very low values (those that Steve Collins had identified for MUAC, for example). A BMI below 16 could be acute malnutrition... or not. The difference could be made by knowing if the patient was actively loosing weight in the last 4 weeks, or if the patient presented objective weakness. When one of these were present, BMI identified acute malnutrition correctly. Weight loss is a basic sing of tissue catabolism and negative energy/nutrient balance, while stable weight denotes equilibrium (what the mechanism is, this is another complex story). Jeejeebhoy documented very well the effect of this on muscular weakness and fatigability. The most important thing is that Stable malnutrition is not associated to an increased risk of death on the short term, as Acute malnutrition is ! We had to invent a name for those patients that presented a low BMI (down to 13 !) but did not feel particularly weak or had not lost weight recently. We decided to call this "Stable malnutrition" to emphasize the fact that IT IS malnutrition, but there is no current weight loss ior catabolic state. We avoided calling it Chronic malnutrition to avoid confusion with stunting in children, since it is a totally different condition. Now, from my point of view, BMI and MUAC are, somehow, like "weight for age" for children: it tells you that there is a problem, but not what is the problem (acute or chronic/stable). The usual patients' complain at the first consultation, indeed, is not "low BMI" or "weight loss", but "weakness". For this reason, we are completing a new study with objective measurements of maximum strength and muscle fatigability in HIV infected malnourished patients from Zambia. Results will be available in the network soon. Now, referring directly to your question. Data on efficacy of programmes for adult malnutrition (HIV or not) is very confusing. Some times they work very well, sometimes they don't work at all. My hypothesis is that this will depend on the type of patients you selected. If the admission criteria was, say, having a BMI below 16, then you will end up with a mix of patients, some with recent weight loss (Acute malnutrition) and those with stable weight and no weakness (what I called Stable malnutrition). Now, the second group will not respond to treatment as well as the first (their mortality rate was already low, and, as happens in children, it is the most acute and severe that improve the most with the same diet)! Therefore, if most patients were actual Acute malnutrition you may end up with a very good efficacy, and if most were Stable malnutrition the programme will look as not effective. In fact, these latter patients would probably need a different type of intervention. To conclude, if your programme is on HIV infected adult patients with malnutrition, it is most likely that majority will be activelly loosing weight, as a consequence of disease and difficulty to feed. So, real Acute malnutrition. However, if the population had important underlying food insecurity and there were important rates of low BMI "before" infection, then you may have a mix of patients. In this case, identifying those with actual Acute malnutrition may be interesting, although feeding them all and taking that mix of patients into consideration on the evaluation of the effectiveness is another acceptable option. For info, the guidelines I wrote for ACF based on this research are available through ACF and on their english web-site (ACH). They need to be simplified and revised to accomodate new information, and ACF and myself will be very happy to be in contact with people having recent experiences with adult malnutrition to improve them. Hope this helps, carlos