Article Text


Structural determinants of food insufficiency, low dietary diversity and BMI: a cross-sectional study of HIV-infected and HIV-negative Rwandan women
  1. Nicole Sirotin1,
  2. Donald Hoover2,
  3. C J Segal-Isaacson3,
  4. Qiuhu Shi4,
  5. Adebola Adedimeji5,
  6. Eugene Mutimura6,
  7. Mardge Cohen7,
  8. Kathryn Anastos8
  1. 1Department of Medicine, Weill Cornell Medical College, New York, New York, USA
  2. 2Department of Statistics and Biostatistics, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
  3. 3Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
  4. 4Department of Epidemiology and Community Health, New York Medical College, Valhalla, New York, USA
  5. 5Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
  6. 6Women's Equity in Access to Care and Treatment, Kigali, Rwanda
  7. 7Department of Medicine, John Stroger (formerly Cook County) Hospital and Rush University, Chicago, Illinois, USA
  8. 8Departments of Medicine and Epidemiology and Population Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
  1. Correspondence to Nicole Sirotin; nis9066{at}


Objectives In Sub-Saharan Africa, the overlapping epidemics of undernutrition and HIV infection affect over 200 and 23 million people, respectively, and little is known about the combined prevalence and nutritional effects. The authors sought to determine which structural factors are associated with food insufficiency, low dietary diversity and low body mass index (BMI) in HIV-negative and HIV-infected Sub-Saharan women.

Study design Cross-sectional analysis of a longitudinal cohort.

Setting Community-based women's organisations.

Participants 161 HIV-negative and 514 HIV-infected Rwandan women.

Primary and secondary outcome measures Primary outcomes included food insufficiency (reporting ‘usually not’ or ‘never’ to ‘Do you have enough food?’), low household dietary diversity (Household Dietary Diversity Score ≤3) and BMI <18.5 (kg/m2). The authors also measured structural and behavioural factors including: income, household size, literacy and alcohol use.

Results Food insufficiency was prevalent (46%) as was low dietary diversity (43%) and low BMI (15%). Food insufficiency and dietary diversity were associated with low income (adjusted odds ratio (aOR)=2.14 (95% CI 1.30 to 3.52) p<0.01), (aOR=6.51 (95% CI 3.66 to 11.57) p<0.001), respectfully and illiteracy (aOR=2.00 (95% CI 1.31 to 3.04) p<0.01), (aOR=2.10 (95% CI 1.37 to 3.23) p<0.001), respectfully and were not associated with HIV infection. Alcohol use was strongly associated with food insufficiency (aOR=3.23 (95% CI 1.99 to 5.24) p<0.001). Low BMI was inversely associated with HIV infection (aOR≈0.5) and was not correlated with food insufficiency or dietary diversity.

Conclusions Rwandan women experienced high rates of food insufficiency and low dietary diversity. Extreme poverty, illiteracy and alcohol use, not HIV infection alone, may contribute to food insufficiency in Rwandan women. Food insufficiency, dietary diversity and low BMI do not correlate with one another; therefore, low BMI may not be an adequate screening tool for food insufficiency. Further studies are needed to understand the health effects of not having enough food, low food diversity and low weight in both HIV-negative and HIV-infected women.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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  • To cite: Sirotin N, Hoover D, Segal-Isaacson CJ, et al. Structural determinants of food insufficiency, low dietary diversity and BMI: a cross-sectional study of HIV-infected and HIV-negative Rwandan women. BMJ Open 2012;2:e000714. doi:10.1136/bmjopen-2011-000714

  • Contributors KA, EM and CJS-I designed the research. NS, QS, DH, CJS-I and KA analysed the data. NS wrote the paper with input from all authors. NS had primary responsibility for the final content. All authors read and approved the final manuscript.

  • Funding This project has been funded by NIH/NIDA/NIAID/NCI grant 5U01AI035004-16 (KA).

  • Competing interests None.

  • Ethics approval Ethics approval was provided by Rwandan National Ethics Committee and the Institutional Review Board at Montefiore Medical Center.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement There are no additional data available.

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