Magnitude of malnutrition amongst hospitalized TB patients.

Sir,

Malnutrition can predispose to development of variety of infections. Conversely, infections can severely affect the nutritional status and result in malnutrition. Tuberculosis (TB) has been called “pthisis” or “consumption” due to profound wasting associated with the disease. With the rising economy, India is poised to be the market leader in near future but in this journey of development it needs to overcome some of the challenges like poverty, malnutrition, and the huge burden of communicable diseases to name a few. Though India is the second most populous country in the world, India has more new TB cases annually than any other country. In 2008, out of the estimated global annual incidence of 9.4 (21%) million TB cases, 1.98 million were estimated to have occurred in India, of whom 0.87 million were infectious cases, thus catering to a fifth of the global burden of TB.[1]

A prospective cohort study was conducted at LRS Institute of TB and Respiratory Diseases, New Delhi to determine the proportion of hospitalization under revised national tuberculosis control program (RNTCP) and determine status of malnutrition amongst those admitted in the institution. The salient methodology included enumeration of all new “area-patients” registered for treatment under RNTCP at Institute during the reference period [April 1st 2006 to Dec 31st 2006] followed by interview and clinical examination[2] for those patients requiring hospitalization at Institute till the completion of DOTS therapy [upto Dec 31st 2007]. The time period was identified keeping in mind the maximum duration of TB treatment under RNTCP and resource constraint for conduct of study. A single investigator collected the data on a pre-tested semi structured performa after obtaining clearance from ethical committee and consent of the patient. Data were entered into a master excel sheet and analysis carried out using software statistical package [SPSS 10.5]. All operational definitions prescribed under RNTCP were used for the purpose of this study.

It was observed that 2,345 patients were registered for treatment under RNTCP through institute during the reference period, out of which 99 [4.22%] required hospitalization at the Institute. Out of the 99 admitted patients, there were 81.81% Hindu, 13.13% Muslims, and rest observing other religion; 62.62% were males and 37.37% females. The age profile was 5.05%, 75.75%, 11.11%, and 8.08% were less than 15 years; 15-49; 50-60, and 61 years/above respectively; 57.57% were illiterate. 70% patients had more than 5 family members. All the patients belonged to lower socio-economic strata based on Kuppuswamy scale (2002) and resided in slum clusters of South Delhi.

Overall, 68% were having anaemia and 79% patients were found to be malnourished. On further analysis of 79 underweight patients, it was observed out that 10 (12.6%), 18 (22.78%), and 51 (64.5%) were suffering from first degree (BMI: 17-18.4 kg/m2), second degree (BMI 16-16.9 kg/m2), and third degree (BMI: <15.9 kg/m2) chronic energy deficiency (CED). Amongst respective gender category, 47 (75.80%) males and 32 (86.48%) females were underweight [Table 1].

Table 1

Status of admitted patients according to Body Mass Index[2]

In a study conducted in a rural district of Malawi, 673 (57%) out of 1181 new patients registered with TB were found to be malnourished (BMI < 18.5 kg/m2). There were 259 (22%), 168 (14%), and 246 (21%) patients with mild, moderate, and severe degree of malnutrition, respectively.[3] A case (TB patients (n=121) control (n=371) study in Indonesia documented malnutrition in 87% and 33% of cases and controls respectively.[4] A prospective cohort study in Mumbai reported after adjusting for potential confounders, increased mortality in all under-weight categories [relative risk (RR) = 1.94 for BMI < 16.0 kg/m2, 1.38 for BMI 16.0 to <17.0 and 1.24 for BMI 17.0 to <18.5 among women; the corresponding values for men were 2.24, 1.45 and 1.27, respectively] when compared with the rate in the normal weight category (BMI 18.5 to <25.0). Extremely thin (BMI < 16.0) cohort members were at highest risk for death due to tuberculosis (RR = 7.20 and 14.94 in women and men, respectively.[5]

To conclude, study reflects high magnitude of malnutrition amongst admitted TB patients in Delhi that require multi prolonged control strategy including poverty alleviation, improvement of housing, and living standards, etc.