Tuberculosis (TB) is a global disease, which is responsible for 1.4 million deaths each
year (WHO 2010). Bangladesh is the sixth highest TB-burden country in the world. TB
treatment may be complicated when malnutrition also coexists in patients. TB has
been found to coexist with malnutrition among patients at the beginning of treatment in
both developed and developing countries (Zachariah et al. 2002, Onwubalili JK 1988,
Kennedy et al. 1996, Harries et al. 1988). Nutrition supplementation can play an
important role in improving the disease condition to reduce further morbidity and
mortality. Some TB-burden countries have already started food supplementation
programme for patients’ healthy life (Farmer et al. 1991, Karyadi et al. 2002, Paton et
al. 2004, Aye and Wyss 2009).
There is no nutrition intervention programme for patients in DOTS (Directly
observed treatment, short course) approach to TB treatment under National TB
Control Programme (NTP) of Bangladesh, where malnutrition is prevalent. Even,
Bangladesh does not have much information about the nutritional situation of TB
patients to formulate nutrition intervention. To fill-in this knowledge gap and help in
informed design of a nutrition intervention for TB patients, this study measured the
nutritional status (using Body Mass Index or BMI) of TB patients before, at two
months, and after completion of TB treatment (DOTS) to study the changes during
treatment and its relation with various socioeconomic and demographic factors
including household food availability and consumption.
About 1,110 TB patients were registered at 10 peri-urban DOTS clinics in Dhaka city
from May 2009 to April 2010. Of them, 1,066 were enrolled for the study. We also
included 910 healthy controls selected from non-family neighbours of the patients
based on availability. A healthy control had no TB, diabetes, or any other disease
including mental disorder, and was not currently pregnant or lactating. They were age
and sex–matched with TB patients. The information of patients on age, sex, duration
of symptoms, patient’ types, school education, employment status, religion, marital
status, and family size were collected. The nutrition indicators [weight (kg), height
(cm.), and mid upper arm circumference (MUAC, cm.)] of both the groups were
measured before staring treatment. Later, such information was taken from patients at
two months and after completion of treatment. The BMI was calculated as body weight
(kg) divided by height in meter square (BMI=wt (kg)/height m2). BMI ≤ 18.5 kg/m2 and
MUAC <22.0 cm were taken as cut-off points for malnutrition. In-depth interviews with
40 TB patients were also conducted to explore the socioeconomic barriers that
impeded patients in accessing adequate food during illness. In addition, food
availability at household (food security) and patients’ food consumption were assessed
using a set of questionnaires (quantitative survey with 305 TB patients, sub-sample of
1,066 TB patients).
1. About two-thirds of the TB patients (67%) had low BMI (<18.5 kg/m2) before
starting treatment (DOTS), whereas, it was 23% in healthy control. The low BMI
was more prevalent among those who earned less than Tk. 6,000 (71%), were
illiterate (73%), males (73%), sputum-positive (74%), patients with chronic illness
(> 6 weeks) (75%), and were unmarried (77%). At the end of treatment, half of
the patients (49.9%) had low BMI. Among them, 12% had severe malnutrition
2. The MUAC <22.0 cm was highest among patients before (42%), after two months
(39%), and at the end of treatment (34%) compared to control group (9%, before
3. The TB patients did not have comprehensive knowledge about nutrition and TB.
Poverty and loss of appetite were identified as major barriers in accessing
adequate food. Further, the community had socio-cultural barriers (social
isolation, lack of family support, sudden changes in food prices, etc.) that
impeded accessing adequate food.
4. The majority of TB patients’ households (49%) had occasional to chronic food
deficit all the year round, and 39% of the households had to change both quality
and quantity of food during crisis period (lean period, price hike, etc.)
5. Nearly half of the TB patients did not eat animal protein (45-49%) and
micronutrients source of food such as fruits once a week (49%) and 60% of them
never ate extra food (snacks) in between two meals.
Malnutrition among TB patients during treatment is a serious problem impeding rapid
recovery and should be given due attention. We strongly suggest to include nutrition
education and supplementation component in TB DOTS programme, and thereby,
helping in speedy recovery and reducing the risk of mortality and morbidity among TB
Based upon the findings, we recommend the following:
Nutrition surveillance for patients undergoing DOTS
Nutrition surveillance is required in DOTS to screen out TB patients with MUAC <
22cm and BMI <18.5 cm, and provision of special nutrition care (nutrition education
and food supplementation) must be established until completion of treatment regimen.
A sustained national campaign to build awareness on the necessity of maintaining
good nutrition during TB DOTS treatment is necessary for motivating the community.
Education and motivation is needed so that family gives priority to the TB patient
during household food allocation. Capacity building of the TB healthcare providers on
the importance of nutrition in TB patients is necessary to guide patients properly
regarding food to be taken.
For less severe cases, various community-based options (e.g., community food bank
from left-over food from the rich households, mobilizing the community to give some
food by individual household each day, raising community resources to buy some
protein-rich food, etc.) should be considered for providing some extra energy-dense
food to the patient. The programme can provide cash or food for these malnourished
TB patients from its own resources, if available.