|Year : 2019 | Volume
| Issue : 2 | Page : 134-140
Nutritional status of pulmonary tuberculosis patients: A hospital-based cross-sectional study
Akanksha Shukla1, Shivam Pandey2, S. P. Singh3, Jyoti Sharma4
1 Indian Institute of Public Health Delhi, Public Health Foundation of India, Gurgaon, Haryana, India
2 Department of Biostatistics, Indian Institute of Public Health Delhi, Public Health Foundation of India, Gurgaon, Haryana, India
3 Consultant Chest Physician, TB Hospital, Thakurganj, Lucknow, Uttar Pradesh, India
4 Public Health Nutrition, Indian Institute of Public Health Delhi, Public Health Foundation of India, Gurgaon, Haryana, India
|Date of Submission||16-May-2019|
|Date of Decision||09-Jul-2019|
|Date of Acceptance||09-Sep-2019|
|Date of Web Publication||19-Dec-2019|
Public Health Foundation of India, Indian Institute of Public Health, Plot No 47, Sector 44, Delhi NCR, Gurgaon, Haryana
Source of Support: None, Conflict of Interest: None
Introduction: Undernutrition among tuberculosis (TB) patients is associated with adverse treatment outcomes and increases risk of mortality. The nutritional status of pulmonary TB patients attending Outpatient Department of Combined Hospital, Thakurganj, Lucknow, Uttar Pradesh, India.
Material and Methods: Two hundred recently diagnosed patients and those who were on intensive phase therapy were selected prospectively. A structured questionnaire was used to collect sociodemographic, lifestyle, health, and dietary information of the selected TB patients. Clinical information was collected from medical records. Nutritional status was measured as body mass index (BMI) (weight and height) using standard techniques.
Results: Nutritional status measured as BMI was categorized as underweight (<18.5) and normal (BMI >18.5) was the primary outcome of the study. Ninety-eight (49%) TB patients were very severely undernourished (BMI <16) and 159 (79.5%) patients had BMI <18.5. Only 44.5% patients reported receiving diet counselling during hospital visit. The adjusted analysis showed higher odds of underweight among patients who had breathing difficulty (adjusted odds ratio [AOR] = 2.85; confidence interval [CI] = 1.19–6.85; P= 0.01). Patients with diabetes had significantly lower odds of underweight (AOR = 0.12; CI = 0.02–0.95; P= 0.04). Higher odds of low BMI were also found among patients consumed tobacco (AOR = 2.4; CI = 0.95–6.28; P= 0.05), using open defecation (AOR = 3.77; CI = 0.91–15.64; P= 0.06), but findings were not statistically significant.
Conclusion: This study has demonstrated high proportion of severe undernutrition among pulmonary TB patients. There is an urgent need for the provision of proper nutrition management and counseling of TB hospitals at the hospitals as per the national nutrition guidelines for TB patients.
Keywords: Active-phase tuberculosis, nutritional status, tuberculosis, tuberculosis patients, tuberculosis Uttar Pradesh
|How to cite this article:|
Shukla A, Pandey S, Singh SP, Sharma J. Nutritional status of pulmonary tuberculosis patients: A hospital-based cross-sectional study. Indian J Community Fam Med 2019;5:134-40
|How to cite this URL:|
Shukla A, Pandey S, Singh SP, Sharma J. Nutritional status of pulmonary tuberculosis patients: A hospital-based cross-sectional study. Indian J Community Fam Med [serial online] 2019 [cited 2020 Apr 2];5:134-40. Available from: http://www.ijcfm.org/text.asp?2019/5/2/134/273521
| Introduction|| |
Tuberculosis (TB) is the most common cause of death from infectious diseases that affected humankind for more than 4000 years. Pulmonary TB considered to be most contagious due to its spread through coughing and contaminated air droplets and accounts for about 80% of TB burden.
TB remains a leading cause of morbidity and mortality in developing countries. Six countries accounted for 60% of the New cases of TB: India, Indonesia, China, Nigeria, Pakistan, and South Africa. India as the country with the highest burden of TB disease in the world and accounts for one-fourth of the global TB burden.
Social, behavioral, economic, and environmental factors such as undernutrition, indoor air pollution, smoking and alcohol addiction, ignorance, and poverty are associated with TB, out of these, social determinants and undernutrition are the single most important predisposing factor. Undernutrition and TB have a bidirectional relationship, undernutrition, and weak immunity can result in the disease and disease can worsen the nutritional status. Undernutrition among TB patients leads to worse treatment outcomes. Severe undernutrition at diagnosis has been shown to be associated with a two-fold increased risk of death. Therefore, undernutrition needs to be treated concurrently with treatment of the infections. Diabetes, smoking, heavy alcohol use, and undernutrition are individual risk factors, but their combined effect can triple or quadruple the risk of development of recent active TB disease. Anemia is common in patients with pulmonary TB and appears to be more common among TB/HIV-coinfected patients. Expected reasons for this include increased blood loss from hemoptysis (blood in sputum for TB patients), bone marrow involvement (decreased red blood cell production), poor appetite, and food intake resulting in poor micronutrient status.,
According to the WHO global TB report, 2.8 million people developed TB in India in 2015, and among states, Uttar Pradesh accounts for highest number of incidence cases of TB, i.e., 3 lakhs. The state also has a very high burden of undernutrition compared to other states of the country. In the age group, 15–49 years, 26% of population is underweight (body mass index [BMI] <18.5). This high burden of TB and undernutrition, calls for evidence on nutritional status, and management of nutritional issues of TB patients in high caseload facilities. In this background, we conducted a hospital-based study to assess nutritional status and its associated factors among TB patients in a public TB hospital in Lucknow, Uttar Pradesh, India.
| Material and Methods|| |
A hospital-based cross-sectional study was conducted during December 2017–March 2018, at Government Combined Hospital, Thakurganj, Lucknow, Uttar Pradesh.
Government Combined Hospital, Thakurganj, Lucknow, is a secondary-level 200-bedded hospital rendering health services to over 1 million inhabitants in Northwest Lucknow. The hospital provides inpatient and outpatient services to the population in the surrounding area and adjacent regions. The hospital has Directly Observed Treatment Short Course (DOTS) clinic where TB patients are given DOTS. The total caseload of hospital is approximately 90–100 new smear-positive patients per month.
With the anticipated frequency of undernutrition among TB patients to be 85% and 5% precision level, required sample size for the study was 196 TB patients. This number was further rounded off taking into consideration nonresponse and refusal. Final sample consisted 200 pulmonary TB patients.
Newly diagnosed sputum-positive male and female aged 15–49 years at the time of initiation of treatment or patients who were within the first 2 months of treatment (intensive phase therapy) were included in the study. Patients were diagnosed primarily on the basis of sputum smear microscopy according to the RNTCP guidelines.
Patients who were on DOTS continuous phase, drug-resistance TB patients, and defaulter/relapse cases/pregnant women/lactating mother/critically ill patients who could not stand were excluded from the study.
Sociodemographic and lifestyle
A questionnaire was developed to record information on age, gender, residential status sputum smear status, grade of sputum smear, previous history of treatment, history of any illness, or death in a family member diagnosed as TB. Information was also obtained on lifestyle factors conditions such as housing, water and sanitation condition, smoking, and alcohol; all information was corroborated with patient hospital record.
Anthropometric measurements for calculating BMI used to determine the nutritional status of the patients. BMI is calculated by weight for height defined as the weight in kilogram of the individual divided by the square of the height in meter. The standard protocol suggested by the WHO 2006 was followed to conduct and interpret anthropometric assessment.
The weight assessment was conducted using standard weighing scale with patients wearing light cloths. Weighing instruments calibrated (±10 g precision) each morning to ensure validity of the results. Height was measured using standard procedure with a stadiometer. Measurements were recorded to nearest centimeter. All measurements were done by the researcher themselves.
Nutritional status defined as BMI was the principal outcome measure. Outcome was classified into two categories as undernutrition (BMI <18.5 kg/m2) and normal (BMI >18.5 kg/m2).
Guided by existing literature and technical guidelines, a set of potential sociodemographic, diet, lifestyle, and behavioral risk factors that may be associated with BMI among TB patients were used. The variables in the study included sociodemographic factors such as age, sex, level of education, religion, marital status, family size, occupation and income, living conditions, and place of residence. Consumption of alcohol and tobacco, substance abuse, dietary habits, and disease-related factors such as symptoms experience, changes in diet and appetite after initiation of TB treatment, side effects of drugs, and received diet counseling at the hospital or not was also included as covariates.
Patients' characteristics by BMI groups were analyzed using the Pearson Chi-square test or Fisher's exact test. We studied associations between BMI (dependent variable) in two classes (<18.5 kg/m2, [underweight] and ≥18.5 kg/m2) and sociodemographic, disease, lifestyle, and dietary characteristics. All variables associated with the outcome in the literature or that had a P < 0.20 in the bivariate analysis were considered eligible to enter the multivariate model using logistic regression. All data were analyzed using SPSS 24 Statistics (IBM, Madison, WI, USA).
The research proposal was approved by the Institutional Ethics Committee of IIPH Delhi. Formal permission was also obtained from Chief Medical Officer of the Combined Hospital, Thakurganj Lucknow, Uttar Pradesh.
A participant information sheet was developed in the local language (Hindi) to provide information about the study to the respondents. The purpose of the study was explained and written consent was obtained from all the respondents before including them in the study. In case respondent was not able to give write then the consent was taken from a witness on his/her behalf. In case the respondent did not want to answer any question he/she was not forced to reply.
| Results|| |
A total of 159 (79.5%) TB patients were undernourished. Ninety-eight (49%) patients were in the category of severe undernutrition (BMI <16) and very severe undernutrition (BMI <14) was present among 41 (20.5%) patients. Sixty (30%) patients were moderate undernutrition (BMI 16–18.5) and remaining 42 (21%) patients were in the category of normal weight (BMI >18.5). Three patients out of these 42 had BMI >25. Undernutrition was more prevalent (83.3%) among patients who were on intensive phase therapy compared to newly diagnosed patients (76.3%) [Table 1].
[Table 2], [Table 3], [Table 4] represent the percentage distribution background characteristics by BMI status. The profile of the respondent shows that higher proportion of respondents was males (64%) in the age group of 18–25 and 36–59 years. Thirty-three percent respondents were illiterate, 46% were unemployed, and 70.5% of them were earning International Normalized Ratio <5000/month. Majority of respondents (67%) were living in crowded house and almost 31% of them were practicing open defecation. Significant differences were seen in nutritional status in across several socioeconomic characteristics including religion (P = 0.01), marital status (P = 0.02), using open defecation (P = 0.001), and place of residence (P = 0.03).
|Table 2: Percentage distribution of respondents as per body mass index status and sociodemographic characteristics|
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|Table 3: Percentage distribution of respondents as per body mass index status and disease symptoms|
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|Table 4: Percentage distribution of respondents as per body mass index status and lifestyle factors|
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BMI also differ significantly among patients with diabetes and other disease (P = 0.01), had breathing difficulty (P = 0.001), and taking antidiabetic treatment (P = 0.005). Among lifestyle factors, BMI differs significantly among patients who reported consuming alcohol (P = 0.04). BMI did not differ with other lifestyle factors including tobacco use and type of tobacco consumed. Majority (74.5%) of respondents reported that they were consuming 1–2 meals per day and only 43.7% of TB patients reported that they received diet counseling at the facility.
[Table 5] shows the adjusted and unadjusted odds ratio (OR) with 95% confidence interval (CI) estimated from multiple logistic regression. Odds for underweight among TB patients increased if they were using open defecation (adjusted OR [AOR] =3.77; CI = 0.91–15.64; P = 0.06) and consumed tobacco (AOR = 2.4; CI = 0.95–6.28; P = 0.06). Statistically significant increase in odds of having low BMI was found among patients who were facing breathing difficulty (AOR = 2.85; CI = 1.19–6.85; P = 0.01). The findings further showed that patients with diabetes (AOR = 0.04; CI = 0.02–0.95; P = 0.04) were likely to have significantly lower odds of underweight. Odd of having low BMI also found among patients who were using substance (AOR = 0.22; CI = 0.05–1.07; P = 0.05), residing in rural areas (AOR 1.35; CI = 0.42–4.40; P = 0.6), taking 1–2 meals (AOR = 1.15; CI = 0.29–4.54; P = 0.8), and not received diet counseling (AOR = 1.37; CI = 0.59–3.17; P = 0.5), although the association was not statistically significant.
|Table 5: Odds ratios with 95% confidence interval estimated from logistic regression predicting the factors associated with underweight (body mass index <18.5)|
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| Discussion|| |
In the present study, the nutritional status was measured as BMI. Overall prevalence of undernutrition was 79% (BMI <18.5) among TB patients. Forty-one (20.5%) patients had BMI (<14), considered as extreme underweight with extremely high risk. The study explored the association of nutritional status of TB patients with sociodemographic, lifestyle, and health-related factors. The results of multivariate analysis showed that patients who had breathing difficulty, consuming tobacco, and other substances were likely to have lower BMI. Patients were diagnosed with diabetes had higher probability of high BMI.
Prevalence of undernutrition (79.5%) in the current study was higher when compared with study conducted in Ghana (51%), Manipur state of India (64.5%). However, the prevalence in the present study was lower than the study conducted in Chhattisgarh state of India (85%). This difference may be due to demographic factors, sociocultural situation, lifestyle, and socioeconomic status of the region. The nutritional status was also found to be significantly associated with age group in bivariate analysis, but in adjusted analysis, age was not independently associated with nutritional status. These findings are in line with the other studies conducted in Ethiopia and Ghana. In contrast to findings from study of Ghana, the present study found no significant association with educational level, income, and immediate family size.
The result from the Sri Lankan study indicated that malnutrition together with sociocultural and economic factors, poor sanitation, and lack of awareness makes people more susceptible to TB. Similarly, open-air defecation was statistically significant with nutritional status in bivariate analysis and showed that patients with no toilet facility had lower BMI as compared to patients with proper toilet facilities.
Diabetes was found to be significantly associated with high BMI among TB patients reflecting a complex interaction between infection, noncommunicable diseases, and nutrition. Smoking and alcohol are important risk factors for TB., However, these did not turn out to be related with nutritional status of TB patients in our study.
In the present study, most of the study participants reported consuming two meals in a day, and this was mainly related to their lower appetite and adaptive mechanisms to food insecurity. Unlike other studies,, meal frequency showed increased risk of having low BMI, but findings were statistically insignificant. Patients who received dietary counseling had better BMI compared to one who did not received. Adjusted analysis showed increased risk of lower BMI among patients who did not receive diet counseling, although the findings were statistically inconclusive and similar results were reported when compared with the findings of other studies.
This is one of the important studies from the high TB burden state reporting primary data on nutritional status of TB patients. However, there are certain limitations that should be kept in mind while interpreting the findings. Because of the location of the study (public hospital) and low-cost services, poor patients and severe cases might have overrepresented in the study. There may be recall bias in self-reported information such as duration of symptoms before diagnosis of TB that could not be verified. However, to reduce recall bias most of the information provided was verified through medical records. Further, small sample size limits generalizability of the findings.
The high prevalence of severe and life-threatening undernutrition among TB patients highlights the need for proper nutritional management of TB patients. Guidance documents on nutrition care and support for TB patients provide systematic information about nutrition management of TB patients; however, implementation of nutrition guidelines yet to be initiated in the facilities. In the hospital where study was conducted, counseling was provided by doctors/nurses in the absence of trained diet/nutrition counselor. Nutrition messages were not uniform and insufficient to address nutritional issues of patients. Therefore, creating diet counseling centers within TB hospitals, and DOTS clinics are vital to promote healthy balanced diet to achieve the desired energy and protein intake for TB patients and clarifying misconceptions regarding diet and supplements. Further, linking benefits of existing food supplement programs and promotion of consumption of locally available food products can help achieving end-TB targets.
| Conclusion|| |
The present study found the high prevalence of severe undernutrition among TB patients receiving treatment at the public sector TB Hospital. Nutrition management of the TB patients was found inadequate and implementation of nutritional guidelines for TB patients yet to be initiated in the facilities. There is an urgent need to focus on provision of nutrition counseling and proper nutrition management of TB patients at TB hospitals.
The study team is grateful to Chief Medical Officer of Government Combined Hospital Thakurganj, Lucknow, Uttar Pradesh, for providing permission to conduct the study. The authors are thankful to staff of the general TB Hospital for extending their support during the study. The authors are grateful to patients and their families without them this study would not have been possible.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]