Effect of the “ rebirth to seven wonders ” powder supplement for nutritional management in HIV-infected subjects on antiretroviral therapy

The rebirth to seven wonders (R7M) powder supplement was used for nutritional management of HIVinfected patients. The powder is a multipurpose powder used as a food supplement in human foods because of its nutritional qualities. It has many uses such as in the fight against malnutrition in Côte d’Ivoire because of its nutritional qualities. The purpose of this study was to evaluate the effect of supplementation of the “R7M” powder consumption on the clinical evolution and the laboratory findings in people living with HIV/AIDS and on antiretroviral treatment. The present work is focused on biochemical analysis and monitoring of some anthropometric and laboratory parameters. The biochemical analysis of the powder showed that 100 g of powder contains 54.02 g of carbohydrate, 7.6 g of fat and 31.25 g of proteins. The same amount of powder contains minerals such as magnesium (149.25 mg), calcium (77.5 mg), zinc (3.25 mg) and iron (47.5 mg). After six months of using the “R7M” powder among both groups, anthropometric parameter (weigh) and biological parameters (creatine, hemoglobin and CD4 count) were measured. Nutritional recovery with the “R7M” powder showed an improvement in the main follow-up criteria, that is, weight, hemoglobin, creatine and CD4 count in both groups. This improvement was significantly increased in HIV group with antiretroviral (ARV) treatment. This study confirms the nutritional properties of the “R7M” powder which can be used as food supplement in the fight against protein-energy malnutrition and micronutrient deficiencies.


INTRODUCTION
Côte d"Ivoire is one of Africa"s sub-Saharan countries most affected by HIV infection with a seroprevalence of about 3.9% according to national plan of AIDS fighting (UNAIDS, 2014).Despite a remarkable commitment of political and civil society in the care (medical, psychological and social) of people living with HIV, nutritional support is still limited.However, the nutritional care of PVVIH by adequate food could bring more improvement of the health status of these patients (Chlebouski, 1985).HIV infection coexists with *Corresponding author.E-mail: aninatchibri@yahoo.fr.
Author(s) agree that this article remain permanently open access under the terms of the Creative Commons Attribution License 4.0 International License malnutrition.Indeed, HIV progressively weakens the immune system and malnutrition itself can also increase susceptibility to infections.The energy deficit in patients with HIV/AIDS results from direct effects of HIV, opportunistic infections, reduced food rations, poor intestinal absorption and increased energy expenditure.The presence of the infection and other opportunistic diseases increase the needs of the organism with nutrients while decreasing the rate of absorption.Many infections reduce appetite.
Therefore, malnutrition can damage the function of an organ, regardless of weaken immune function, compromising the effectiveness of drugs and reduce the quality of life of the patient (Anabwani et al., 2005).It has been widely demonstrated that an infection of HIV is associated with lower serum levels of nutrients.However, immune function is highly dependent on nutritional status.Macronutrients play an important role during the HIV infection.
Protein-energy deficiency can cause malfunctions of cellular immunity.Micronutrients such as vitamins and minerals are important indicators for measuring the nutritional status of man and also have a direct effect on immune functions.The deficit of these micronutrients is associated with a reduction in the number of immune cells that can cause a disorder of the immune function (Gomo et al., 2003).
However, a separate administration of each macronutrient and micronutrient to a patient is tedious given the large number of nutrients used as supplements in the treatment of PVVIH.The use of the rebirth to seven (7) wonders (R7M) powder can be more simple and convenient as it combines minerals, macro and micronutrients.Powder R7M has various important biological and nutritional activities due to the high concentration of natural nutrients.The ""R7M""powder is made with local cereals and leguminous plants which is used in infants with malnutrition.It enables the stimulation of immune system in HIV patients (Lipipun et al., 2003).It can also be produced in an artisanal way and at an affordable cost.The benefit of supplementation of the "R7M" powder lies in the potential health and economic benefits to restore the nutrition gap.
The goal of this study was to assess some biochemical characteristics and the effect of consumption of the "R7M" powder as food supplement by HIV-infected persons who were under ARV treatment at the Military Hospital of Abidjan (HMA) in Côte d"Ivoire.The nutritional quality of this "R7M" powder was specifically evaluated by determination of its biochemical constituents and measuring the anthropometric parameter (weight) and the biological parameters (creatine, hemoglobin and CD4 count).

Vegetal material
The vegetal material used in this study was the "R7M" powder obtained with local cereals and leguminous plants.

Population and sample
The study was carried out from April to September 2014 in HMA.This study sample of 120 HIV-infected subjects of both sexes aged over 18 and were then separated into two equal groups: one with indications for ARV treatment and the other with none.Inclusion criteria were used in this study for all patients seropositive for HIV.Subjects who has been taking this powder supplement based on procedures of the study were at least 18 years of age with documented HIV infection and provided informed consent materialized by signing a form drawn up for this purpose.They have evidence of HIV pain, and they did not have tuberculosis, and have an observing ticket on them six months after the study.Exclusion criteria were patients under 18 years with related conditions (heart disease and cancer) or who have violated the protocol.

Blood sampling
Venous blood samples were drawn after an overnight fast of at least 8 to 10 h, in 5 ml EDTA.Samples were centrifuged at 3000 rpm for 10 min in dry tubes and stored at 4°C for the different analysis.After centrifugation of the blood, the plasma was collected in EDTA tube.

Determination of nutritional value of the "R7M" powder
The moisture and ash content of the powder "R7M" were determined respectively according to BIPEA (1995) and Kim and Lee (2003) methods.The mineral composition (magnesium, zinc, iron and calcium) was determined by Atomic Absorption Spectrophotometer Solaar S2 (Thermo Electron Corporation, Orion, England).
Reducing sugars in turn were extracted and assayed according to the method of Bernfeld (1955) while the total protein was assayed by the Kjeldahl method (AOAC, 1995).The lipid assay was performed by the AOAC method (1995) using a soxhlet apparatus.

Anthropometrics parameters
Body weight was measured to the nearest 100 g with subjects in light clothing and without shoes, per month during six (6) months, using a portable electronic scale of 150 kg capacity (Seca 803 Clara Scale).

Biological parameters
An assay of creatine was measured using jaffé"s kit "creatinina, (ref 100 11 11).Haemoglobin (Hb) was directly measured in the field on a drop of whole blood using HemoCue® (Hemocue HB 201+, Angelholm, Sweden).The counting of the CD4 count was done by using the FACS Count technics and reagent (Becton Dickinson, San Jose, CA).

Statistical analysis
Data were analyzed using XLSTAT 7.5.3.Comparisons between means were performed using Student t test.The level of statistical significance was P value <0.05.

Biochemical composition of "R7M" powder
The powder R7M components are recorded in Table 1.
The analysis of the "R7M" powder revealed 5.73% of water, 31.25 g/dry matter (MS) 100 g of protein, reducing sugars, in 7.6 g lipids/100 g of dry matter (MS) and 1.34 g/100 g of ash.The micronutrients are magnesium, calcium, zinc and iron with respective content of 149 mg/100 g of dry matter (MS); 77.5 mg, 3.25±0.04mg and 47.5±0.08 mg per 100 g of product (Table 1).

Anthropometrics parameters
Data are shown on Figure 1.It was noticed during the recovery period that the weight increased between the two groups of patients.Nevertheless, it was significantly increased in HIV-positive patients with indication of ARV treatment.These histograms indicate that after six (6) months, the average weight of patients without treatment was the lowest, 58.92 ± 10.06 kg while the weight of those receiving ART + flour have the highest average (65.21 ± 9.4).This observed increase is more significant in patients on ARV + flour that than those on only ARV.

Assay of creatine
The result is shown in Figure 2, we denote at the beginning of the treatment with "R7M" flour that the creatinemia mean was 9.4 mg/l in both groups.Six months after the flour supplementation, it was noticed that creatine was decreased in both groups.Moreover, there was a significant decrease in the group of infectedpatient who were under ARV treatment.

Assay of haemoglobin
Follow-up of hemoglobin"s assays is presented in Figure Atchibri et al. 123 3. Concerning hemoglobin, it was higher in the group that received powder R7M supplement.

Count of lymphocyte CD4
The CD4 count of infected-patients was increased in both groups during the six-month consumption of "R7M" powder supplement.Moreover, the CD4 count was significantly increased in the group that received "R7M powder" and the ARV treatment (Figure 4).

Biochemical analysis
Biochemical analysis has shown that the R7M powder contains 5.73% of water; this quantity of water is due to the type of drying of grains and legumes and the method used during the drying and milling of grains.François in 1988 showed that drying and milling are two steps that strongly affect the powder water content and a small amount of water contribute to conservation of powder during a long time and does not permit micro-organisms proliferation.The high amount of proteins in the R7M powder (31.25 g) is close to that of to the Moringa powder, it used as supplement for HIV-infected patients (Amivi et al., 2012).The amount of protein in the "R7M" powder is very important for HIV-infected because according to FANTA (2004), HIV-infected patients often suffer from protein-energy malnutrition caused by inadequate consumption or food poor in protein and energy (World Bank, 2009).Protein is important because the body cannot synthetize them.They must therefore be introduced through food.Unfortunately, actual data are not sufficient to advise or not to boost protein amount in HIV-infected patients.It is therefore caution to use protein supplement (OMS, 2008).
Results show that the powder contains an amount of carbohydrate (54.02 g); this rate is higher than that of spiruline (12 g) used as supplement for infected HIVpatients (Yamani et al., 2009).This amount would be important to fill the lack of energy of HIV-patients who because of the disease are weak (World Bank, 2009;Banda et al., 2009).Also, note that the reducing sugar content may be due to the milling stage.Indeed, the heat generated during this step is responsible for the hydrolysis of a part of the starch into simple sugars (Francois, 1988).According to François, the quality of reduced sugar in a flour is due to the grinding technique used.Our work has a linked with that François since the grinding technique has been used to obtain the flour R7M.Thus reducing sugars being directly assimilated would be easy for PVVIH to assimilate to benefit from the energy they produce.HIV-infected patients and healthy persons need in fact are same.But a daily supplement is required for patients who are under ARV treatment or underfed (WHO, 2008).The R7M powder content in fat is 7.6 g; it is close to the spirulina (7 g) used as supplement in Bangui (Yamani et al., 2009).It could contribute to energy producing in the body (Banda et al., 2009).This small amount of fat could be necessary for HIV-infected patients under ARV treatment and suffering from metabolic disturbance, because they could need less energy provided from fat (World Bank, 2009).Fat needs of patients with HIV/AIDS in no way differ from those of healthy people (WHO, 2008).PHAs have additional energy requirements due to HIV, opportunistic infections of malabsorption of nutrients.These needs vary between 10 and 30% depending on whether the subject is asymptomatic or not (World Bank, 2009).This amount would be important to fill the lack of energy of HIV-patients who because of the disease are weak (World Bank, 2009;Banda et al., 2009).The deficiency of micronutrients like Mg, Zn, Ca, Fe, P, etc was observed in infected HIV-patients (Kupka, 2002).It is true that many variations were not really known but it known that lack of micronutrients destroy cells ((Banki et al., 1998).The R7M powder contains important minerals such as Zn, Ca and Fe (Banda et al., 2009).The amounts of Fe (47.7 mg) and Zn (3.26 mg) of this powder are higher than that of the Moringa powder, which are respectively of 20 and 2.6 mg.There is no significant difference between the Mg and Ca of the both powders of Moringa and R7M.These different micronutrients are very essentials for HIV-infected persons because the lack of these nutrients on their organism leads quickly to AIDS and death (Piwoz and Preble, 2000).

Body mass index and nutritional status
The measurement of body mass index reflecting the nutritional status at the AIDS stage, weight loss is often associated with malabsorption, anorexia, opportunistic infections and metabolic disorders (Young, 1997).After six months of supplementation of "R7M", nutritional recovery in antiretroviral treatment group was higher than those who took only the anti-retroviral treatment (Figure 1).The most significant weight gain observed in patients administering ARVs and R7M flour could be explained by the fact that for the high-energy and protein in this meal, nutrients is necessary for PLHIV for maintenance of weight gain (Piwoz and Preble, 2000).With administration of 5 g/d, the R7M is a dietary supplement rich in protein and also microelement (zinc and iron) that would provide enormous benefits.
It would allow a renewed appetite and nutritional rehabilitation.Simporé et al. (2005) in Burkina Faso had also observed a nutritional recovery in children under 5 years supplemented with spirulina for 6 weeks with a weight gain of 25 g/day.A comparative nutritional rehabilitation study not only demonstrates the interest of spirulina in treatment of children malnutrition but also its particularity favorable impact on the renutrition of children infected by HIV.R7M used for the rehabilitation of people living with HIV which is plant origin like spirulina.By restoring the metabolism and the physiological disturbances, "R7M" contribute significantly to improving the patient's physical condition.PHAs treated with ARV drugs can increase significant weight loss.Indeed, increased weight shows improved clinical disease.Moreover, some ARV-based treatments such as protease inhibitors are involved in dyslipidemia (World Bank," 2009).This results in a deposit of fat in the body and a body weight gain without effective control of HIV.Optimal viral suppression by antiretroviral therapy, could help restore the immune system and the removal of intestinal malabsorption (Carbonnel et al., 1998).This explains the body weight gain of patients on ARV treatment.As for the weight loss of patients infected with HIV/AIDS, this is frequently associated with an increase in viral load and/or decrease in CD4 lymphocytes.

Biological parameters
After six months of R7M supplementation, the decrease in the blood concentration of creatinine in antiretroviral treatment group was more significant than those who took only the anti-retroviral treatment (Figures 2, 3, 4).This shows that the consumption of the R7M power did not induce disturbance of kidney function.The increase of creatinine in the blood is indicative of kidney failure which can be mild or severe, acute, transient or chronic.A cast of muscle associated with severe malnutrition may lead to an increase of creatinina.
Treatment of patients with ARV shows a loss of creatine which would mean the improvement of glomerular filtration with HIV-infected patient which is due to ARV utilization (Nyimi et al., 2001).However, the use of ARV treatment coupled with the "R7M" power, showed a significant decrease of creatine in patients" blood.This could be explained firstly by the fact that the consumption of the R7M power did not cause disturbances in kidney function.The decrease could be explained by the fact that the R7M powder with its high protein content could participate in refeeding patients by increasing their muscle mass (Anwar et al., 2007).The increase of creatinine in the blood is indicative of kidney failure which can be mild or severe, acute and transient or chronic.A cast of muscle associated with severe malnutrition may lead an increase of creatinina.Treatment of patients with ARV shows a loss of creatinemia and that would mean the improvement of glomerular filtration with HIV-infected patient which it due to ARV utilizing (Nyimi et al., 2001).However, the use of ARV treatment coupled with the "R7M" power showed a significant decrease of creatinina in patients" blood.This could be explained firstly by the fact that the consumption of the "R7M" power did not cause disturbances in kidney function.
Regarding the concentration of hemoglobin at the start of the study, it was 32.3% (31/96) of patients taking "R7M" anemic against 34.74% (33/96) taking only ARVs.After six months of supplementation, it could be observed that the percentage of anemic patients on ARVs remained static, 33.72% (29/86) while it increased in the group treated only with ARVs.This increase is more significant in patients treated with ARV and supplemented with R7M flour.The causes of anemia may be due to iron deficiency and/or folic acid deficiency (Grinspoon et al., 1998).
Indeed, these two microelements which are iron and vitamin B12 are key compounds for the synthesis of hemoglobin.The presence of iron in the flour, may participate in the synthesis of the hemoglobin molecule responsible for the delivery of oxygen to all parts of the body (Connor, 2000;Banda et al., 2009).The R7M appear to be a good supplement because it contributes its richness in iron and folic acid to decrease the level of anemia.Alverez et al. (2005) showed that the use of zidovudine in intensive therapy associated with ribavirin for the treatment of HCV in patients infected with HIV reduced hemoglobin.
As for the CD4 cell count, the results showed that the R7M contribute to an increase in CD4 count.Indeed R7M is a good source of b-carotene (which is converted to vitamin A), but also in minerals (zinc magnesium).These micronutrients have a positive effect on cellular immune system.Thus, the significant increase in CD4 cell counts in patients treated with ARV and R7M flour could be explained by ARVs that would allow optimum control of the virus, an increase in CD4 count (Carbonnel et al., 1998) and nutrients as flour could improve the rate of CD4 patients (Muller et al., 2000).Note that HIV destroys the immune system by infecting the CD4 lymphocytes and antigen presenting cells.Thus, the measurement of CD4 lymphocytes is an essential parameter monitoring; a very low rate would indicate an advanced stage of the disease and the immune defense mechanism.Similar findings were reported in Tanzania by Fawzi et al. (1998Fawzi et al. ( , 2004)).The decrease in CD4 count may be due to the increased oxidative stress, apoptosis and syncytia formation (Kotler et al., 1998;Bogden et al., 2000).
A significant improvement of weight was noticed in HIVinfected patients who were under ARV treatment.It showed that there is an improvement in recovery.In fact, the loss of weigh in HIV-infected patients is due to the lowering of the CD4 count in their body.An optimal deletion of HIV virus by the ARV treatment restores the immune system and the deletion of intestinal malabsorption.This explains the increase in weight of infected patients who were under ARV treatment.
The significant improvement of weight in HIV-infected patients under ARV treatment and supplement of "R7M" powder is explained by high amount of energy and proteins of this powder, which necessary nutrient for HIVinfected patients to maintain wellbeing (Piwoz and Preble, 2000).
And secondly, this decrease could be explained by the fact that the R7M flour with its protein content could contribute to a refeeding of patients (Anwar et al., 2007).With regards to the concentration of hemoglobin, there is an increase in both groups of patients, but the increase is more significant with patients with indication of ARV treatment and the "R7M" power.This can be linked on one hand to fatty acids and the other to iron which is present in the flour.This contribution afterwards in the synthesis of the hemoglobin"s molecule is responsible for carrying oxygen in all the parts of the body (Connor, 2000;Banda et al., 2009).
HIV destroys the immune system by infecting CD4 count and cells which have antigen.The CD4 count is an essential parameter.And the significant increase in the number of lymphocytes, CD4 count in patients treated with ARV treatment and the "R7M" flour could be explained by ARV treatment which will cause optimum virus-control destruction, in opposition to an increase in CD4 cells (Carbonnel et al., 1998) and secondly with the flour and its nutrient help in the improvement of CD4 patients" count (Muller et al., 2000).

Conclusion
In this study, it was noted that the biochemical analysis of the "R7M" power has a high content of proteins and carbohydrates, thus containing important minerals such as Zn, Mg, Ca and Fe.These essential components for the immune system, are necessary for the development of non-specific immunity and cell-mediated, especially, CD4.Magnesium is important in protein synthesis; Iron is necessary for all the cells which provide energy and calcium is needed for strong bones and normal functioning of muscles and nervous system.The study on the effect of "R7M" power supplement in recovery of HIVinfected patients after six (6) months showed an improvement in follow-up criteria: weight, creatine, hemoglobin and CD4 count.The significant result is higher among the group with indication for ARV treatment and consumption of the "R7M" power.
All this shows that a meal with "R7M flour" has nutritional and pharmacological qualities in the fight against protein-energy malnutrition and micronutrient deficiency in PV/HIV.Despite the profound metabolic disturbances caused by viral infection, the R7M power helps in nutritional recovery among HIV-infected patients.

Figure 1 .
Figure 1.Evaluation of the average weight of patients.

Figure 2 .
Figure 2. Improvement of creatine assays mean of patients.

Figure 3 .
Figure 3. Improvement of mean hemoglobin in patients.

Table 1 .
Nutritional value of the "R7M" powder g/100 g expressed in g/100 g MS.