Association between nutritional status and dengue infection: a systematic review and meta-analysis

Abstract

Background: Dengue infection has various clinical manifestations, often with unpredictable clinical evolutions and outcomes. Several factors including nutritional status have been studied to find the relationship with dengue severity. However, the nutritional status had conflicting effects on the complication of dengue in some previous studies. Therefore, we conducted a systematic review and performed a meta-analysis to analyze the association between nutritional status and the outcome of dengue infection.

Methods: Eleven electronic databases and manual searching of reference lists were used to identify the relevant studies published before August 2013. At least two authors worked independently in every step to select eligible studies and extract data. Dengue severity in the included studies must be classified into three categories: dengue fever (DF), dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS).

Results: Thirteen articles that met the inclusion criteria came to final analysis. A meta-analysis using fixed- or random-effects models was conducted to calculate pooled odds ratios (OR) with corresponding 95 % confidence intervals. It has shown that there was no statistically significant association between DHF group and DSS group in malnutritional and overweight/obesity patients with OR: 1.17 (95 % CI: 0.99-1.39), 1.31 (0.91-1.88), respectively. A significantly inverse relation between DF and DHF groups of malnutritional patients was revealed (OR = 0.71, 95 % CI: 0.56-0.90). Our meta-analysis also indicated a statistically significant negative correlation between malnourished children with dengue virus infection and healthy children (OR = 0.46, 95 % CI: 0.3-0.70). When analyzing patients with normal nutrition status, we found out that there was a significantly negative relationship between DHF and DSS groups (0.87; 95 % CI: 0.77-0.99). Other comparisons of DSS with DF/DHF groups, DSS/DHF with DF groups, and DHF with DF groups in normal nutritional patients showed no significant correlation. However, the findings should be interpreted cautiously because all significant associations were lost after removing of the largest study.

Conclusions: Results from previous studies failed to show any solid consistency regarding the association between the nutritional status and dengue infection. Consequently, the effects of nutritional status on dengue disease outcome has been controversial. Further studies are recommended to clarify the impact of nutritional status on dengue infection.

Keywords: Dengue; Meta-analysis; Nutritional status; Systematic review.

Fig. 1

Flow diagram of the article screening process from electronic databases

Fig. 2

Association of nutritional factors and the severity of dengue. a Meta-analysis forest plot showing the pooled ORs of malnutrition between DSS and DHF group with 95 % CIs using fixed effect models. b Meta-analysis forest plot showing the pooled ORs of normal nutrition between DSS and DHF group with 95 % CIs using fixed effect models. c Meta-analysis forest plot showing the pooled ORs of obesity/overweight between DSS and DHF group with 95 % CIs using fixed effect models

Fig. 3

Association of malnutrition and the severity of dengue. a Meta-analysis forest plot showing the pooled ORs of malnutrition (weight for age) between DSS and DHF group with 95 % CIs using fixed effect models. b Meta-analysis forest plot showing the pooled ORs of malnutrition between DSS plus DHF group and DF group. c Meta-analysis forest plot showing the pooled ORs of malnutrition between DHF and DF group. d Meta-analysis forest plot showing the pooled ORs of malnutrition (weight for age) between any combined dengue and health control. e Meta-analysis forest plot showing the pooled ORs of malnutrition between DSS and DHF plus DF group

Fig. 4

Association of normal nutrition and the severity of dengue. a Meta-analysis forest plot showing the pooled ORs of normal nutrition between DSS and DHF plus DF group. b Meta-analysis forest plot showing the pooled ORs of normal nutrition between DSS plus DHF group and DF group. c Meta-analysis forest plot showing the pooled ORs of normal nutrition between DHF group and DF group

Fig. 5

Association of obesity/overweight and the severity of dengue. a Meta-analysis forest plot showing the pooled ORs of obesity/overweight (weight for age) between DSS group and DHF group. b Meta-analysis forest plot showing the pooled ORs of obesity/overweight between DSS and DHF plus DF group. c Meta-analysis forest plot showing the pooled ORs of obesity/overweight between DSS plus DHF group and DF group. d Meta-analysis forest plot showing the pooled ORs of obesity/overweight between DHF group and DF group