title: Association between anthropometry-based nutritional status and malaria: a systematic review of observational studies.
abstract: BACKGROUND
  Multiple studies in various parts of the world have analysed the association of nutritional status on malaria using anthropometric measures, but results differ due to the heterogeneity of the study population, species of the parasite, and other factors involved in the host and parasite relationship. The aim of this study was to perform a systematic review on the inter-relationship of nutritional status based on anthropometry and malarial infection.
  
  
  METHODS
  Two independent reviewers accessed the MEDLINE and LILACS databases using the same search terms related to malaria and anthropometry. Prospective studies associating anthropometry and malaria (incidence or severity) were selected. References from the included studies and reviews were used to increase the review sensitivity. Data were extracted using a standardized form and the quality of the prospective studies was assessed. Selected articles were grouped based on exposures and outcomes.
  
  
  RESULTS
  The search identified a total of 1688 studies: 1629 from MEDLINE and 59 from LILACS. A total of 23 met the inclusion criteria. Five additional studies were detected by reading the references of the 23 included studies and reviews, totaling 28 studies included. The mean sample size was 662.1 people, ranging from 57 to 5620. The mean follow-up was 365.8 days, ranging from 14 days to 1 year and 9 months, and nine studies did not report the follow-up period. Prospective studies assessing the relationship between malaria and malnutrition were mostly carried out in Africa. Of the 20 studies with malarial outcomes, fifteen had high and five had average quality, with an average score of 80.5 %. Most anthropometric parameters had no association with malaria incidence (47/52; 90.4 %) or parasite density (20/25; 80 %). However, the impact of malnutrition was noted in malaria mortality and severity (7/17; 41.2 %). Regarding the effects of malaria on malnutrition, malaria was associated with very few anthropometric parameters (8/39; 20.6 %).
  
  
  CONCLUSIONS
  This systematic review found that most of the evidence associating malaria and malnutrition comes from P. falciparum endemic areas, with a significant heterogeneity in studies' design. Apparently malnutrition has not a great impact on malaria morbidity, but could have a negative impact on malaria mortality and severity. Most studies show no association between malaria and subsequent malnutrition in P. falciparum areas. In Plasmodium vivax endemic areas, malaria was associated with malnutrition in children. A discussion among experts in the field is needed to standardize future studies to increase external validity and accuracy.
authors.affiliation: Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil. efremdavila@gmail.com.|Universidade do Estado do Amazonas, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil. efremdavila@gmail.com.
authors.forename: Efrem d'Avila
authors.initials: Ed
authors.lastname: Ferreira
authors.affiliation: Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil. marcialexandre@gmail.com.|Universidade do Estado do Amazonas, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil. marcialexandre@gmail.com.
authors.forename: Márcia A
authors.initials: MA
authors.lastname: Alexandre
authors.affiliation: Division of Infectious Diseases, Department of Medicine, School of Medicine, Emory University, 49 Jesse Hill Jr Drive, Atlanta, GA, 30303, USA. jlsalinas@emory.edu.
authors.forename: Jorge L
authors.initials: JL
authors.lastname: Salinas
authors.affiliation: Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil. amsiqueira@gmail.com.|Universidade do Estado do Amazonas, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil. amsiqueira@gmail.com.|Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Av. Brasil, 4365, Manguinhos, Rio de Janeiro, RJ, 21040-360, Brazil. amsiqueira@gmail.com.
authors.forename: André M
authors.initials: AM
authors.lastname: de Siqueira
authors.affiliation: Universidade do Estado do Amazonas, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil. silvana_benzecry@hotmail.com.
authors.forename: Silvana G
authors.initials: SG
authors.lastname: Benzecry
authors.affiliation: Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil. marcuslacerda.br@gmail.com.|Universidade do Estado do Amazonas, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil. marcuslacerda.br@gmail.com.|Instituto de Pesquisas Leônidas and Maria Deane, Fundação Oswaldo Cruz, Rua Terezina, 476, Adrianópolis, Manaus, AM, 69057-070, Brazil. marcuslacerda.br@gmail.com.
authors.forename: Marcus V G
authors.initials: MV
authors.lastname: de Lacerda
authors.affiliation: Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil. wueltonmm@gmail.com.|Universidade do Estado do Amazonas, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil. wueltonmm@gmail.com.
authors.forename: Wuelton M
authors.initials: WM
authors.lastname: Monteiro
mesh_terms: D000293:Adolescent; D000328:Adult; D000886:Anthropometry; D002648:Child; D002675:Child, Preschool; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016778:Malaria, Falciparum / Q000453:epidemiology* / Q000503:physiopathology*; D016780:Malaria, Vivax / Q000453:epidemiology* / Q000503:physiopathology*; D009752:Nutritional Status / Q000502:physiology*; D064887:Observational Studies as Topic; D010963:Plasmodium falciparum; D010966:Plasmodium vivax; D055815:Young Adult