A MATCHED CASE CONTROL STUDY OF THE NUTRITIONAL STATUS OF

NEWLY DIAGNOSED TUBERCULOSIS PATIENTS AND TUBERCULOSIS

FREE CONTACTS IN DELFT, WESTERN CAPE

Candice Clarissa Lombardo

A mini-thesis in partial fulfilment of the requirements for the degree of Magister

Scientiae in the Faculty of Community and Health Sciences, University of the Western

Cape

SUPERVISORS: Professor Rina Swart

Ms Marianne Visser

February 2011

KEYWORDS: Tuberculosis, tuberculosis free contact, malnutrition, C-reactive protein,

micronutrients, acute phase response

 

 

 

 

ABSTRACT

Background: Malnutrition is a risk factor for the development of pulmonary tuberculosis (TB)

and may be responsible for the premature deaths of patients with active disease. An adequate

nutritional status may therefore be protective in delaying the onset from latent infection to active

disease. In South Africa, very little data is available on the nutritional status of adults who

present with tuberculosis. This study therefore aims to compare the nutritional status of newly

diagnosed pulmonary tuberculosis patients with TB-free controls.

Study population & Design: This is a community based case-control study. Forty-three newly

diagnosed pulmonary tuberculosis patients were recruited as cases and matched according to age,

gender and race to 43 TB-free close contacts. HIV positive subjects were excluded from the

study.

Methods: Each participant was interviewed and completed a structured questionnaire to obtain

demographic information. Weight was measured to the nearest 0.1kg and height to the nearest

1mm. A 24-hr dietary recall method was used to obtain dietary information. Biochemical

analysis was carried out to measure concentrations of transferrin, albumin, CRP, ferritin, zinc,

copper, vitamin A and E.

Results: The median Body Mass Index (BMI) for cases was 18.80kg/m² (IQR 14.35, 32.11) and

TB-free contacts 21.17 kg/m² (IQR 16.75, 34.98) with a significant difference between the

groups of p=0.001. There was significant difference in weight (p=0.002) and MUAC (p=0.000)

between groups. No significant difference in dietary intake of energy (KJ) (p=0.695), protein

(p=0.804), CHO (p=0.801) and fat ( p=0.796) was found between groups. There was a

statistically significant increase in ferritin (p=0.000) and C-reactive protein (CRP) (p=0.000) in

TB patients, while albumin (p=0.000), serum zinc (p=0.000) and serum vitamin A (p=0.000)

were statistically significantly lower among cases.

Conclusion: There was no significant difference in the macronutrient intake of TB cases

and TB-free contacts, although a significant difference was seen in BMI, MUAC and

weight between groups, with all these parameters being lower in TB patients. Ferritin and

CRP levels were markedly increased in TB cases while serum zinc, vitamin A and

albumin are all significantly lower in TB patients than TB free contacts.

 

 

 

 

CONTENT PAGE Page Number

CHAPTER 1: BACKGROUND AND INTRODUCTION

1.1 INTRODUCTION 1

1.2 PURPOSE / RATIONALE 2

1.3 AIM 2

1.4 OBJECTIVES 2

CHAPTER 2: LITERATURE REVIEW

2.1 TUBERCULOSIS 3

2.2 MALNUTRITION AND TUBERCULOSIS 3 – 5

2.3 MICRONUTRIENTS AND TUBERCULOSIS 5-10

2.3.1 Vitamin A 6-7

2.3.2 Zinc 7-8

2.3.3 Vitamin E 9

2.3.4 Copper 9-10

CHAPTER 3: METHODOLOGY

3.1 Study design 11

3.2 Study Population 11

 

 

 

 

3.3 Selection of subjects 11-13

3.4 Sample size 13

3.5 Data collection

3.5.1 Socio-demographic data 13

3.5.2 Dietary and anthropometric data 13-14

3.5.3 Blood Sampling 14

3.5.4 Sputum samples 14-15

3.6 Statistical Analysis 15

3.7 Validity and reliability 15

3.8 Ethics and Institutional approval 15-16

CHAPTER 4: RESULTS

4.1 Participant characteristics 17

4.2 Demographic information 17 – 19

4.3 Dietary intake 19 - 20

4.4 Anthropometric status 20

4.5 Serum micronutrient levels 20-21

4.6 Biochemical measurements 21-23

4.7 Summary 23

 

 

 

 

CHAPTER 5: DISCUSSION

5.1 Overview 24

5.2 Nutrient intake 24

5.3 Nutritional status 24-25

5.4 Role of the Acute phase response 25-26

5.5 Vitamin A 26-27

5.6 Zinc 27-28

5.7 Copper, vitamin E and transferrin 28-29

CHAPTER 6:

6.1 Conclusions 30

6.2 Limitations & recommendations 30

BIBLIOGRAPHY 31-36

APPENDIX 1: Structured questionnaire 37-55

APPENDIX 2: Informed consent form 56-58

APPENDIX 3: Information Sheet 59-63

 

 

 

 

DECLARATION

I declare that the Matched case control study of the nutritional status of newly diagnosed

tuberculosis patients and tuberculosis free contacts in Delft, Western Cape is my own

work, that it has not been submitted for any degree or examination in any other

university, and that all the sources I have used or quoted have been indicated and

acknowledged by complete references.

Candice Clarissa Lombardo

February 2011

Signed: ____________________________

 

 

 

 

ACKNOWLEDGEMENTS

I would like to thank the following people for their guidance, advice and input during the

process of writing up this min-thesis:

Professor Rina Swart

Ms Marianne Visser

The Delft Community Health Centre staff who assisted me in recruiting and

gathering data

Ms Ronel Stuurman

Sr. A Sampson

Rosemary Cassels

Angela Menezes

 

 

 

 

DEFINITION OF TERMS

Albumin: It is a plasma protein synthesized in the liver and

plays a role in maintaining oncotic pressure. It

decreases in periods of stress / inflammation

(Litchford, 2008).

Anthropometry: Is the measurement of body size, weight and its proportions

and include measuring weight, height, and mid-upper arm

circumference as well as skinfolds measurements to

determine body fat percentage (Lee & Nieman, 2000)

C-reactive protein: It is an acute phase protein which rises rapidly in

response to acute inflammation and is useful in

detecting acute infection (Mayne, 1994)

Ferritin: An iron-apoferritin complex that is a major storage form of

iron in the liver and other tissues. Levels may increase

during inflammation (Stopler, 2008)

Malnutrition: The term malnutrition is classified based on body weight,

body fat, protein stores and laboratory values. It refers to

under-nutrition caused by inadequate intake, ingestion and

absorption related to infection and illness (Mahan & Escott-

Stump, 2008)

Micronutrient malnutrition: Refers to the clinical deficiency of micronutrients due to

inadequate intake, digestion and absorption which is related

to infection and illness.

 

 

 

 

Pulmonary tuberculosis: Is an airborne infectious disease caused by Mycobacterium

tuberculosis which thrives in oxygen and blood rich areas

such as the apices of the lungs (Mueller, 2008)

Tuberculosis free contact: Refers to an individual who does not present with active

pulmonary tuberculosis but who is in contact as a friend,

family member or neighbour of someone who presents with

active disease.

 

 

 

 

LIST OF FIGURES page no.

Figure 1: Graphical presentation of serum micronutrients 21

Figure 2: Graphical presentation of transferrin and albumin levels 22

Figure 3: Graphical presentation of CRP and ferritin levels 23

 

 

 

 

LIST OF TABLES page no.

Table 1: Dietary sources of vitamin A 6

Table 2: Dietary sources of Zinc 8

Table 3: Dietary sources of vitamin E 9

Table 4: Dietary sources of copper 9-10

Table 5: Demographic information 18-19

Table 6: Dietary intakes including energy, carbohydrate, protein, fat, vitamin A &

zinc 20

Table 7: Anthropometric measurements including weight, BMI, MUAC & % body

Fat 20

Table 8: Serum micronutrient levels of zinc, copper, vitamin A and E 21

Table 9: Biochemical measurements including transferrin, albumin, CRP &

Ferritin 22

 

 

 

 

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CHAPTER 1: BACKGROUND AND INTRODUCTION

1.1 INTRODUCTION

Tuberculosis (TB) is an infectious disease caused by the Mycobaterium tuberculosis and

pulmonary tuberculosis is the most common form in adults. According to the World

Health Organization(WHO) report on global TB control, 9.4 million new cases of TB

were reported in 2008. Although there is a slight decrease of <1% per year in incident

rates, tuberculosis remains a major public health problem in most developing countries.

In 2008, South Africa was ranked 3rd in the world in terms of total numbers of cases

(WHO, 2009).

In 2008, the Western Cape diagnosed 50 000 new TB cases which is an incidence rate of

892 per 100000. Tuberculosis therefore remains a major public health concern, especially

in developing countries (Western Cape, Department of Health, 2010). Malnutrition has

long been associated with tuberculosis and may play a role in the development of the

disease or vice versa (Gupta et al, 2009). Kennedy et al (1996) conducted a cross-

sectional study in Tanzania amongst tuberculosis patients and reported that malnutrition

was evident before and after tuberculosis treatment. In a similar study conducted in

Malawi, patients who presented with pulmonary tuberculosis and with a body mass index

(BMI) < 17kg/m² had an increased risk of early death (Zachariah et al, 2002).

The nutritional data for both healthy South African adults and those infected with

tuberculosis is limited. A recent national survey of women aged 19-35 indicated a 20%

prevalence of iron deficiency and 25% prevalence of vitamin A deficiency (Labadarios

ed. 2007). No data on the micronutrient status of men is available apart from a small

localized study in 1990 indicating at least 16% iron deficiency (Vorster et al, 1997). No

information on the zinc status of adult South Africans is currently available.

 

 

 

 

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1.2 PURPOSE / RATIONALE

Since the data available in South Africa is limited regarding the nutritional status of

tuberculosis patients is limited, this study aims to investigate the nutritional status of TB

patients in comparison to tuberculosis free controls. This may be of importance when

developing intervention strategies to overcome the detrimental effects of the disease,

especially since the goal of the World Health Organization (WHO) is to reduce TB

prevalence and death by 50% by 2015 (WHO, 2010).

1.3 AIM

This study therefore aims to investigate the nutritional status of newly diagnosed, HIV

negative tuberculosis patients (aged 18-65) in comparison with tuberculosis free contacts

matched for age, race and gender in Delft in the Western Cape.

1.4 OBJECTIVES

The objectives of this study were to measure and compare the following indicators of

nutritional status in both cases and controls:

Anthropometrical status including BMI, arm muscle area and percentage body fat

Serum levels of micronutrients most commonly linked to immunity i.e. retinol

and zinc

Serum levels of micronutrients that are affected by acute infections and which

might impact on the levels of vitamin A and zinc i.e. copper

Dietary intake of macronutrients and micronutrients

 

 

 

 

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CHAPTER 2: LITERATURE REVIEW

2.1 TUBERCULOSIS

Pulmonary tuberculosis is caused by the Mycobacterium tuberculosis which

usually affects the apices of the lungs. It is currently estimated that 1/3 of the

worlds population is latently infected with the bacillus (Flynn & Chan, 2001;

Mueller, 2008). Infection with the bacillus does not necessarily lead to active

disease as the immune response of most individuals can successfully contain but

not eliminate the disease. A decline in the immune response caused by HIV,

aging, alcohol or drug abuse and poor nutritional status may lead to active

infection (Flynn & Chan, 2001). Cytokines, including tumor necrosis factor,

interleukin- 4 and interleukin- 1β, are responsible for the high fever, weight loss

and acute phase response seen in patients with active TB and may lead to

malnutrition and nutrient deficiencies (Karayadi et al, 2007). Alternatively,

malnutrition, including micronutrient deficiencies may affect immunity leading to

increased susceptibly of active infection.

2.2 MALNUTRITION AND TUBERCULOSIS (TB)

Malnutrition may predispose individuals who have latent infection to active disease as

malnutrition affects cell-mediated immunity which decreases the body’s defence to TB

and increases the risk of infection (Cegielski & McMurray, 2004). For this reason

malnutrition and tuberculosis have a long history of being associated with each other

(Gupta et al, 2009). Numerous studies have detailed the poor nutritional status of

tuberculosis cases in terms of body mass index (BMI), mid-upper arm circumference, as

well as skinfold thickness measurements in patients who present with TB. A cross-

sectional study conducted by Kennedy et al (1996) used BMI to assess the nutritional

status of 148 patients who presented with active TB in Tanzania. They found that

malnutrition was evident before (77% males and 58% females had BMI <18.5kg/m²) and

after (32% males and 19% females had BMI <18.5kg/m²) treatment for tuberculosis.

Patients co-infected with HIV had an even lower BMI than those without. Malnutrition

seen in these patients may therefore have been attributable to HIV and not TB alone. The

 

 

 

 

4

patients who had a more favourable nutritional status after treatment had a longer stay in

hospital and therefore increased access to nutritional supplementation and this may have

caused a bias in their results. Zachariah et al (2002), conducted a similar study in Malawi

where they looked at the prevalence of malnutrition on admission (57% of participants

had a BMI<18.5kg/m² on admission) and if there were any associations between

malnutrition and early death. One thousand one hundred and eighteen subjects were

included in the study and they found that patients who had a lower BMI had an increased

risk of early death (10.9% of 414 patients who had moderate to severe malnutrition died

within the first four weeks). A large percentage of these cases however also presented

with HIV which increases the risk of premature death and the authors therefore cannot

conclusively state that TB alone can be the cause of premature death in malnourished

individuals. While Zachariah et al (2002) noted that low BMI is a risk factor for early

death in tuberculosis cases, many confounding factors that may affect validity such as

side-effects of medication, CD4 cell count and staging of HIV, were not controlled for in

this study.

In 2005, Metcalfe conducted a case-control study on malnutrition and tuberculosis

in Sri Lanka. He found that cases had a lower nutritional status (BMI and MUAC)

than controls and this was not gender specific. He found that cases had a

significantly lower BMI (16.2kg/m²) and arm circumference (20.7cm) when

compared to controls (24.0 kg/m² and 28.4cm, respectively). The cases and

controls were not matched for age, race or income groups. The control subjects

were all members of the Sri Lankan Air force base, which means that they had

access to money, food and exercise routines that the cases did not have. The

results of this study may therefore not be considered valid due to these

confounding factors. The author does however mention this and states that a

matched case-control study may yield improved results (Metcalfe, 2005). In 2008,

Dodor, conducted an investigation in Ghana to determine the prevalence of

malnutrition among TB patients before and after treatment initiation. A total of

570 newly diagnosed pulmonary tuberculosis patients were included in the study.

He found the mean BMI to be 18.7kg/m² with 51% classified as malnourished

prior to treatment. The mean BMI increased to 19.5kg/m² two months after

 

 

 

 

5

starting treatment with 40% classified as malnourished. Dodor (2008) suggests

that nutritional supplementation among TB patients in Ghana may be beneficial.

In South Africa, very little data is available regarding the nutritional status of those who

present with tuberculosis. Roberts et al, (2005) conducted a pilot study in the Western

Cape amongst hospitalized tuberculosis patients and found 48% of males and 29% of

females presented with low BMI (<18.5kg/m²). Karyadi et al (2000) conducted a case-

control study in Indonesia where 41 patients were matched for age and gender, and

compared to 41‘healthy’ controls from the same area. They reported that patients had a

significantly lower BMI (18.5kg/m² for males and 17.8kg/m² for females), MUAC (24cm

for males and 22.3cm for females) and skinfold measurements when compared to

controls (BMI 21.9kg/m² for both females and males and MUAC of 28.4cm for males

and 26.6cm for females). It was also noted that patients had varying degrees of

malnutrition and those who were more malnourished had increased deficiency of

micronutrients as well. The reason for the malnutrition evident in patients who present

with tuberculosis can be attributed to the increase in energy expenditure due to acute

phase response, reduced nutrient intake and in severe infections, fatigue and shortness of

breath may make it difficult to prepare and ingest food (Mueller, 2008). Conversely,

malnutrition itself may increase the risk of developing the disease as lung function,

structure and elasticity are all negatively affected thereby increasing the risk of infection

(Mueller, 2008). Most of the studies conducted to determine the micronutrient status

among TB patients were cross-sectional in nature and very few, if any, looked at the

nutritional status of study participants prior to TB infection (longitudinal study). With

such a high prevalence of TB and lack of nutritional guidelines among TB patients, it

may be beneficial to determine if malnutrition precedes disease or if the disease

precipitates malnutrition.

2.3 MICRONUTRIENTS AND TB

Many micronutrients, due to their role in immune response, also play a role in the

development and treatment outcomes of tuberculosis. An inadequate

 

 

 

 

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micronutrient status may lead to decreased immunity as micronutrients are

involved in a host of processes that include being free radical scavengers as well

as strengthening epithelial barriers. It is for this reason that a micronutrient

deficiency may increase susceptibility to disease by suppressing immunity

(Maggini et al, 2007). Micronutrients that may play a role in the development and

treatment of tuberculosis are vitamin A, zinc, vitamin E and copper.

2.3.1 Vitamin A

Vitamin A is a fat soluble vitamin which is bound to retinol binding protein for transport

in blood and 70% is stored in the liver. The recommended daily allowance (RDA) for

women is 700ug/day while men require 900ug/day (Gallagher, 2008). Vitamin A plays a

role in strengthening the mucosal epithelial barriers in the eye, respiratory and

gastrointestinal tracts (Maggini, et al, 2007). A deficiency may therefore results in Bitot’s

spots, night blindness, upper respiratory tract infections and diarrhoea, especially in

children (Van Lettow et al, 2003), and an increase of bacterial adherence to epithelial

cells (Gupta et al, 2009). Good dietary sources of vitamin A include carrots, liver,

spinach, sweet potatoes and broccoli (Gallagher, 2008).

Table 1: Dietary sources of vitamin A

Food item and amount Vitamin A (ug)

Fried beef liver 30g 3,042

Baked sweet potato, 1 797

Carrot, 1 cup raw 774

Cooked squash, 1 cup 200

Cooked spinach, 1 cup 368

Cooked broccoli, 1 cup 87

Source: Gallagher (2008)

T- lymphocytes and macrophages are also affected by a deficiency of vitamin A (van

Lettow et al, 2003) which is evident by a decrease in macrophage activity and natural

 

 

 

 

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killer cells with an increase in the inflammatory response due to tumour necrosis factor

alpha (TNF-α) (Maggini et al, 2007 & Gupta et al, 2009).

Karayadi et al (2000) conducted a case-control study to compare the vitamin A status of

tuberculosis cases to ‘healthy’ controls. They found that 33% of cases had plasma retinol

concentrations <0.70µmol/L compared to 13% among controls. Mugusi et al (2003)

found that serum vitamin A (measured in µg /dl) was decreased in patients who presented

with pulmonary tuberculosis (15.0ug/dl) and that this deficiency was more severe in

patients co-infected with HIV (13.1 µg /dl). It was also reported however that after 2

months of anti-tuberculosis treatment, plasma vitamin A levels began to increase in HIV

negative patients but remained low in HIV positive group. This may once again be

attributable to the negative effect HIV has on nutritional status. Karayadi et al (2002)

conducted a double blind placebo controlled trial to look at the effects of vitamin A and

zinc supplementation on the treatment response of patients who presented with

pulmonary tuberculosis. They found that patients who were supplemented with vitamin A

had an improved sputum conversion and therefore improved treatment outcome after two

months of anti-tuberculosis therapy. Mathur (2007) however states that while vitamin A

levels are low in patients with active tuberculosis disease, levels return to normal after

treatment without provision of supplementation and the outcome in Karaydi’s results may

be attributable to the co-supplementation of zinc (Karyadi et al, 2002).

2.3.2 Zinc

Zinc is a trace element found in all cells in living tissue. It promotes cell growth and

plays a role in immunity (Walker & Black, 2004). The RDA for zinc is 11mg/day for

males and 8mg/day for females and it is considered an essential nutrient as it cannot be

stored. It therefore needs to supplemented or consumed regularly through food intake

(Gallagher, 2008 & Walker & Black, 2004). Good sources of zinc include oysters, crab,

beef, pork, liver and legumes as well as nuts and beans form plant sources.

 

 

 

 

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Table 2: Dietary sources of zinc

Food item and amount Zinc (mg)

Sirloin steak 30g 7.4

Baked beans, with pork, ½ cup 6.93

Lamp chop 30g 5.2

Fried liver 30g 3.1

Cooked black-eyed peas, 1 cup 2.2

Source: Wardlaw, (1999) & Gallagher (2008)

Zinc deficiency has been shown to have an effect on Th1 lymphocyte response by

decreasing phagocytosis of macrophages, decreasing amount of natural killer cells and

decreasing interleukin-2 production (Gallagher, 2008; Maggini et al, 2007; Metz et al,

2007). Mucosal membrane integrity may also be compromised in zinc deficient states

(Maggini et al, 2007). Zinc deficiency may lead to a decrease in plasma retinol because

of impaired retinal binding protein, and therefore supplementation of zinc may improve

vitamin A metabolism (Gupta et al, 2009).

In the randomized controlled trial conducted by Karyadi et al (2002) tuberculosis patients

who received 15mg of supplemental zinc and 1500 retinol equivalents as vitamin A

showed faster sputum conversion after two months of anti-tuberculosis therapy when

compared to the placebo group. Ghulum et al (2009) found similar results in their study

conducted in India, where patients who presented with active tuberculosis showed

improved sputum conversion after two months of therapy when supplemented with zinc.

This may be due to the fact that zinc seems to play a role in the Th1 response, responsible

to promote immunity, suggesting that a zinc deficiency may increase susceptibility to

infection (Metz et al, 2007). They further suggest that zinc supplementation may increase

natural killer cell activity and improve T cell response, thereby producing an appropriate

immune response.

 

 

 

 

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2.3.3 Vitamin E

Vitamin E or α-tocopherol is a powerful antioxidant or free radical scavenger. It plays a

role in epithelial tissue maintenance and may prevent vitamin A from being oxidized in

the intestine (Mahann & Escott-Stump, 2004). The recommended daily allowance (RDA)

for vitamin E is 15 mg/day for both males and females.

Table 3: Dietary sources of vitamin E

Food item and amount Vitamin E (mg)

Raisin bran, 1 cup 13.50

Sunflower oil, 1tbsp 5.59

Almonds 30g 7.33

Wheat germ, ¼ cup 5

Peanut butter, 2 tbsp 3

Avocado,1 2.7

Source: Wardlaw, (1999) & Gallagher, (2008)

According to a review conducted by Maggini et al (2007), vitamin E enhances a Th1

response by increasing production of interleukin-2, natural killer cells and phagocytosis

by macrophages thereby increasing immunity. Vitamin E levels have also been shown to

be lower in patients with tuberculosis than healthy controls (Gupta et al, 2009). Hemila &

Kapiro (2008) however, found no association between vitamin E supplementation and

decreased tuberculosis risk. They do however suggest that vitamin E supplementation in

patients who were heavy smokers and have a high vitamin C intake may have increased

risk of developing tuberculosis.

2.3.4 Copper

Copper is an essential trace element found in high concentrations in the liver, brain, heart

and kidneys and is transported in blood bound to albumin (Gallagher, 2008). The RDA

for adults is 0.9mg/day or 900µg/day.

 

 

 

 

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Table 4: Dietary sources of copper

Food item Copper (mg)

Fried beef liver 30g 12.4

Oysters, 3 3.63

Brazil nuts, ½ cup 1.2

Brewer’s yeast, 3 tbsp 0.8

Walnuts, ½ cup 0.7

Sunflower seeds, ¼ cup 0.6

Source: Wardlaw, (1999) & Gallagher, (2008)

Due to its function as a component of many enzymatic responses, copper protects against

free radical damage and oxidation as well as promotes synthesis of melanin and

catecholamines (Gallagher, 2008). In a review conducted by Gupta et al (2009) copper

serum levels were said to be significantly higher in patients with tuberculosis while zinc

concentrations were lower. This may be attributed to the increase in copper-binding

ceruloplasmin in the acute phase response which may play a role in immunity (Koyanagi

et al, 2004).

In conclusion, it is evident that malnutrition, including micronutrient deficiencies, may

increase susceptibility to pulmonary TB and vice versa. Therefore, the study aims to

assess the nutritional status of patients who present with active TB in comparison to TB

free contacts.

 

 

 

 

11

CHAPTER 3: METHODOLOGY

3.1 Study Design

A community-based case control study.

3.2 Study population

The study population included adults between the ages of 18-65 years of age residing in

Delft, a low-socio economic, peri-urban settlement in the Western Cape.

3.3 Selection of subjects

In order to successfully determine the nutritional status of patients who present with TB

for the purposes of this study, all cases and controls were matched for age, race, and

gender and subjects who presented with HIV will be excluded. This was determine the

nutritional status of tuberculosis cases outside of HIV infection.

Cases:

Newly diagnosed tuberculosis patients between the ages of 18-65 years receiving

treatment from the Delft Community Health Centre (CHC) were recruited as cases. Cases

were included when 2 sputum specimens tested positive for acid fast bacilli by smear

microscopy or 1 positive sputum specimen plus chest X-ray that indicates active

tuberculosis. Cases were only included after agreeing to undergo HIV testing and

counselling (HCT) for HIV infection. The study provided HCT counsellors who

conducted pre- and post test counselling with all willing participants. Patients who tested

positive for HIV were referred to the Delft CHC for further testing, counselling and

treatment and excluded for the study.

Exclusion criteria included the following:

Re-treatment patients

Patients with extra pulmonary TB

Patients with multi-drug resistant TB

Elevated alanine transaminase levels (>5 fold increase)

Women who were pregnant or wish to become pregnant

 

 

 

 

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Women who had given birth within the last 6 months of study entry

Clinical signs of liver disease, renal failure, congestive heart failure or neoplasm

Use of corticosteroids

Use of supplements containing vitamin A, zinc or iron during previous month

prior to treatment

No consent given for voluntary HIV-test

Subjects who were HIV positive

Controls:

All TB cases recruited were used as a point of contact to recruit controls from other

households (family and neighbours) who were interested in participating in the study. A

sampling frame from the interested households was constructed and included adults

between the ages of 18-65 years who were willing to participate in the study. This

sampling frame was used to select controls who matched cases for age, gender and

population group. A sputum sample was collected from controls to confirm the absence

of active pulmonary tuberculosis. Subjects who had positive sputum samples were

referred to the Delft CHC for counselling and treatment. Controls subjects were only

included if they were willing to undergo VCT for HIV infection. The study provided

VCT counsellors who conducted pre- and post test counselling with all willing

participants. Patients who tested positive for HIV were referred to the Delft CHC for

further testing, counselling and treatment and excluded from the study.

Exclusion criteria included the following:

Subjects who had TB in the past

Elevated alanine transaminase levels (>5 fold increase)

Women who were pregnant or wish to become pregnant

Women who had given birth within the last 6 months of study entry

Clinical signs of liver disease, renal failure, congestive heart failure or neoplasm

Use of corticosteroids

Use of supplements containing vitamin A, zinc or iron during previous month

prior to treatment

 

 

 

 

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No consent given for voluntary HIV-test

Subjects who were HIV positive

3.4 Sample size

At a 95% confidence interval and 90% power, it was calculated that a minimum sample

size of 134 subjects (67 cases and 67 controls) would be required using findings by

Labadarious ed. 2000, the prevalence of vitamin A deficiency in TB patients of 62% and

in control adults of 33%. Only 97 subjects who met criteria at the screening interview

were willing to participate in the study. Of the 97 that agreed to participate, 3 had given

birth in last 6 months, 1 presented with active TB, 2 did not complete the study, 5 had

insufficient blood to complete biochemical analysis and the rest had to be excluded due to

case/control pairs where one was HIV positive. Only 86 subjects who met all inclusion

criteria were therefore included in the study (43 cases and 43 controls).

3.5 Data Collection

All cases and controls were interviewed using a structured questionnaire (Appendix 1)

and the following information obtained.

3.5.1 Socio-demographic data

Socio-demographic characteristics were documented for each subject and included type

of housing, housing density, household income, smoking habits etc. All participants were

asked about the potential misuse of alcohol and performance status was assessed by

means of the Karnofsksy performance scale included in the questionnaire (Appendix 1).

3.5.2 Dietary and anthropometric data

Dietary intake of participants was assessed by means of 24-hr recall method by a

dietician or trained dietetic student using a standardized form. Portion sizes were

determined with the use of food models and examples of household measures such as

cups, bowls etc. Anthropometrical measurements were performed by a dietician or

trained dietetic student. Subjects had to remove shies and all heavy clothing, including

 

 

 

 

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jackets, jerseys, belts before measurements were recorded. Measurements included body

weight to the nearest 0.1kg (A & D Personal Precision Scale, Tokyo, Japan), height on a

portable stadiometer to the nearest 1mm, mid-upper arm circumference measured to the

nearest 1mm on the left arm using a standardized measuring tape and skinfold thickness

measurements on the left arm to the nearest 0.2mm (Skinfold calliper, Scales, 2000,

Durban, South Africa) and included triceps, biceps, sub-scapular and supra-ileac skinfold

measurements. All values were performed 3 times and the average value calculated. Body

density and percentage body fat were calculated with the use of Durnin and Womersley

equations (Durnin & Womersley 1974). Participants who were found to be underweight,

which was classified as a BMI of < 18.5kg/m², were referred to the dietician at the Delft

CHC for counselling or referral to the Nutrition Supplementation Program (NSP).

Participants who were found to be obese, which is classified as a BMI >30kg/m², were

also referred to the dietician at the Delft CHC for further counselling.

3.5.3 Blood Sampling

Venous blood was drawn aseptically from each case and control by the registered study

nurse. The puncture site was cleaned with trace-element free alcohol to avoid

contamination and infection. One 7ml blood sample, SST serum, was collected to

determine ALT level. The samples were analyzed and stored at 37ºC. One 7ml blood

sample was collected in a trace element free tube, and protected from light and stored at

-70ºC after centrifugation. The following biochemical investigations were performed

using High Pressure Liquid Chromotography (HPLC): serum albumin, retinol, zinc,

copper, ferritin, transferrin receptor and C-reactive protein (CRP). One 4.5ml sample was

collected for the purpose of conducting a full blood count (EDTA whole blood, using

Flow Through Technology by Bayer Advia 120).

3.5.4 Sputum Samples

All cases and controls were required to provide the study nurse with a sputum sample

which was collected and transported to Groote Schuur laboratory for analysis. Sputum

smears were examined by means of flourescent microscopy (Auramine stain). Sputum

samples were cultured on liquid (using automated non-radiometric MGIT 960 TB

 

 

 

 

15

system) and solid media (Loewenstein-Jensen (LJ) slopes) to confirm presence of

tuberculosis in cases and absence of disease in controls.

3.6 Statistical analysis

All data was cleaned, coded and entered into SPSS version 17.0 for analysis. A one-

sample Kolmogorov-Smirnov test was used to determine if variables were normally

distributed and appropriate parametric and non-parametric statistics applied. Means

(±SD) were used to describe serum micronutrient levels. Medians (Q1,Q3) were used to

describe the nutrient intake and anthropometric status of patients. Independent t-tests

were used to investigate differences between biochemical micronutrient indicators. Mann

Whitney test was used to investigate differences between the characteristics of the

participants such as nutrient intake and anthropometric status. Chi² used to determine

differences in categorical data

3.7 Validity and reliability

Standardized procedures were followed for the collection and handling of all specimens,

as well as biochemical assays. All anthropometric data was collected by a registered

dietician or trained dietetic student using standardized equipment which was calibrated

regularly. CRP is an acute phase protein that increases in the presence of active infection

and may be useful in interpreting various serum micronutrient levels. CRP levels were

therefore analyzed for each participant.

3.8 Ethics and Institutional approval

Ethics approval for this study was obtained from the UWC Research and Ethics

Committee (reference no. 08/8/2). Written informed consent was obtained from all

participants (Appendix 2). An information sheet (Appendix 3) outlining all aspects of the

study made it clear that the subject could terminate participation in the study at any time

without affecting his/her health care in any way. If any medical treatment was required

by a subject during the study period (such as tuberculosis treatment or any other medical

therapy), such therapy was not denied to any subject participating in this study.

 

 

 

 

16

Confidentiality of all information collected on participating in the study was ensured. All

data entry forms were stored in a locked filing cabinet. The names of participants were

entered into a database containing demographic information; however, access to this

database was restricted to the investigators. All other samples were identifiable by code

only.

Laboratory analysis was performed on all study samples collected. If a participant

indicated that he/she wished to receive the results of his/her

biochemical/dietary/anthropometric analysis, such information was communicated to the

subject as soon as it was available. In the case of biochemical/dietary/anthropometric

findings that would require treatment or counselling, the subject was contacted and

treatment provided and where relevant referral for further medical care made.

 

 

 

 

17

CHAPTER 4: RESULTS

4.1 Participant characteristics:

The study sample consisted of 86 participants, 43 cases and 43 controls. The

mean age of the sample was 28.21 (± 10.36) and included 40 males and 46

females. Ninety four percent of the study population were coloured while the

remaining six percent were classified as black.

4.2 Demographic information:

Table 5 illustrates the associations between the demographic information of cases

and control subjects. The majority of control subjects had a higher education level

that differed significantly from cases (p=0.032). Smoking habits were similar

between groups, with the majority of subjects smoking daily. Both groups

reported a similar intake of alcohol with 18% of cases and 9% of controls stating

that they misused alcohol. Eighty-six percent of cases and 95% of controls

reported that they live in brick houses. This difference was not statistically

significant. The majority of study subjects had access to drinking water, a flush

toilet, electricity and a refrigerator, with no significant differences between

groups. Fifty-eight percent of cases were unemployed compared to 79% of

controls. This difference was however not statistically significant. There appears

to be a significant difference in the total monthly income (p=0.001) and total

money spent on food per month (p=0.002) was found, but this can be attributed

to the large amount of control subjects who did not know what the total household

monthly income was or how much money was spent on food.

 

 

 

 

18

Table 5: Demographic information

Categories Case (n=43)

Controls (n=43)

p-value (Chi-square)

Education level None Primary School High school Tertiary

11 (26%) 28 (65%) 3 (7%) 1 (2%)

0

4 (9%) 28 (65%) 11 (26%)

p=0.032

Smoking Daily Occasionally None

27 (63%) 1 (2%)

15 (35%)

31 (72%)

3 (7%) 9 (21%)

p=0.250

Alcohol misuse Yes No

8 (19%) 35 (81%)

4 (9%)

39 (91%)

p=0.213

Type of dwelling Brick Tin Plank Other

37 (86%) 1 (2%) 3 (7%) 2 (5%)

41 (96%)

1 (2%) 1 (2%)

0

p=0.361

Number of people in house 1-4 5-8 >8

17 (40%) 23 (53%) 3 (7%)

22 (51%) 20 (47%)

1 (2%)

p=0.043

Number of bedrooms 1 2 3 4 >4

10 (23%) 16 (37%) 11 (26%) 2 (5%) 4 (9%)

11 (26%) 23 (53%) 7 (17%) 1 (2%) 1 (2%)

p=0.184

Drinking water Own tap Communal tap Borehole

38 (89%) 4 (9%) 1 (2%)

41 (95%)

2 (5%) 0

p=0.411

Type of toilet Flush Pit Bucket

40 (93%) 2 (5%) 1 (2%)

43 (100%)

0 0

p=0.211

Fuel for cooking Electric Gas Paraffin

41 (96%) 1 (2%) 1 (2%)

40 (93%)

3 (7%) 0

p=0.366

 

 

 

 

19

Refrigerator / freezer Yes No

37 (86%) 6 (14%)

39 (91%)

4 (9%)

p=0.501

Employment status Unemployed Self-employed Wage-earner

25 (58%) 4 (9%)

14 (33%)

34 (79%)

1 (2%) 8 (19%)

p=0.104

Total income per month None R100 – R500 R501 – R 1000 R1001 – R 3001 R3001 – R5000 >R5000 Unknown

3 (7%) 4 (9%)

9 (21%) 19 (44%)

0 0

8 (19%)

2 (5%) 4 (9%)

5 (12%) 13 (30%) 7 (16%) 1 (2%)

11 (26%)

p=0.001

Total money spent on food per month R0 – R100 R101 – R200 R201 – R300 >R300 Unknown

10 (23%) 7 (16%) 11 (26%) 8 (19%) 7 (16%)

6 (14%) 4 (9%)

9 (21%) 7(16%)

17 (40%)

p=0.002

4.3 Dietary intake

The dietary intake of energy, macronutrients, zinc and vitamin A were similar

between groups (table 6). No significant differences between the dietary intake of

energy, protein, CHO, fat, zinc and vitamin A between the case, at the time of

diagnosis and control group were found. The vitamin A intake among both cases

and controls was found to be inadequate (RDA is 700ug which is equivalent to

700RE). The median intake of zinc among cases was inadequate when compared

to RDA (RDA 8 - 11mg). The median intake among cases however fell in the

normal range. Average energy intakes among active, healthy individuals range

between 10 000kj for women and 12000kj for men. The median energy intake

among cases and controls was therefore appears inadequate. Delft is however a

peri-urban community with a high level of unemployment which may affect food

security.

 

 

 

 

20

Table 6: Dietary intake including energy, carbohydrates (CHO), protein, fat, zinc

and vitamin A

Nutrient Case (n=43) Control (n=43) P=value

(Mann-

Whitney U)

Median Min. Max. IQR Median Min. Max. IQR

Energy (kj) 6434.55 3047.9 16475 4909.58 6773.38 2492.5 21016 4446.4 p=0.675

Protein (g) 53.30 53.30 11.90 44.87 53.15 17.97 170.49 42.64 p=0.799

CHO (g) 206.40 63.26 483.31 158.38 182.36 54.80 858 154.48 p=0.739

Fat (g) 59.39 11.47 212.56 47.15 57.38 14.70 188.52 39.82 p=0.746

Zinc (mg) 7.58 2.13 23.04 8.56 9.60 3.01 34.60 7.05 p=0.096

Vit A/RE 425.74 28.02 7701.7 383.73 433.26 18.36 1975.05 623.88 p=0.746

* IQR = Interquartile range

4.4 Anthropometric status

There was a statistically significant difference in the anthropometric

measurements between cases, at the time of diagnosis and controls (table 7).

Weight, BMI and MUAC were all significantly lower in the case group. The

median BMI and MUAC among cases are on the lower end of normal, indicating

suboptimal nutritional status.

Table 7: Anthropometric measurements including Weight, BMI, MUAC and

%body fat

Measurement Case Control P=value

(Mann-

Whitney U)

Median Min. Max. IQR Median Min. Max. IQR

Weight (kg) 49.63 37.38 76.25 11.18 58.20 40.25 84.05 16.02 p=0.002

BMI (kg/m²) 18.80 14.35 32.11 2.41 21.17 16.75 34.98 5.81 p=0.001

MUAC (cm) 23.45 18.4 31.6 2.8 26.00 20.9 34.6 4.2 p=0.000

% body fat 14.90 3.7 35.9 16.9 14.10 4.8 37.5 21.0 p=0.645

4.5 Serum micronutrient levels

The mean zinc status of cases fell just below the lower end of the normal range

(60-110 µg/dl). Serum concentrations of vitamin A among cases were

considerably lower than the reference range (30-85 µg/dl) while the levels vitamin

 

 

 

 

E an

The

all in

Tabl

and

Measuremen

Zinc (µg/dl)

Copper (µg/dl

Vitamin A (µ

Vitamin E (m

Ther

case

diffe

Figu

and

1

1

2

nd copper w

mean serum

n the norma

le 8: Serum

vitamin E

nt

Mea

59.49

l) 173.3

g/dl) 23.55

mg/l) 9.924

re was statis

es while seru

erence betw

ure 1: Graph

controls

0

50

100

150

200

Zinc (p

were in the n

m concentra

al ranges (ta

m micronutrie

C

n (SD)

9 (±10.96)

35(±36.50)

5(±10.08)

4(±3.32)

stically sign

um copper a

ween groups.

hical represe

p=0.000)(

normal range

ations of mic

able 8; figure

ent concentr

Case

CI

56.03 – 62

161.83 – 1

20.37 – 26

8.87 – 10.9

nificant decr

and vitamin

.

entation of s

Copper(p=0.351)

e (5-18mg/l

cronutrients

e 1).

rations inclu

M

.90 77

84.87 16

.73 38

97 9.

rease in seru

E showed n

serum micro

Vit A(p=0.000)

and 70-170

s among the

uding zinc,

Mean (SD)

7.03 (±14.88)

66.61(±28.30)

8.88(±10.93)

69 (±4.92)

um vitamin

no statistica

onutrient co

Vit E(p=0.86

0 µg/dl respe

control gro

copper, vita

Control

CI

72.39 –

157.79

35.47 –

8.16 -1

A and Zinc

ally significa

oncentration

E60)

Case

Control

ectively).

oup were

amin A

– 81.66

9 – 175.43

– 42.28

11.23

levels in

ant

ns in cases

21

P=value

(Independent

t-test)

p=0.000

p=0.351

p=0.000

p=0.860

 

 

 

 

4.6 B

The

rang

grou

rema

Tabl

Measuremen

Transferrin (n

Albumin (g/l)

CRP (mg/l)

Ferritin (ng/l)

A st

foun

Figu

cont

A st

foun

0

1

2

3

4

5

Biochemica

mean album

ge (35-50g/d

up, indicatin

ained within

le 9: Bioche

nt

Mea

ng/ml) 6.73

) 37.65

49.13

) 214.1

tatistically s

nd, with no d

ure 2: Graph

trols

tatistically s

nd among th

0

0

0

0

0

0

Trans(p=0

al measurem

min concent

dl). CRP and

ng the presen

n reference

emical meas

C

n (SD)

(±2.13)

5 (±4.55)

3 (±33.14)

18 (±155.72)

ignificant d

difference s

hical represe

ignificant h

he case grou

sferrin.062)

ments

tration amon

d ferritin lev

nce of inflam

ranges, with

surements o

Case

CI

6.08 – 7.39

36.24 – 39

38.93 – 59

166.26 – 2

difference in

seen in trans

entation of t

higher conce

up compared

Albumin(p=0.000)

ng cases wa

vels were m

mmation. T

h a similar c

of transferrin

M

9 5.

.05 43

.33 2.

62.11 57

n albumin co

sferrin conc

transferrin a

entration of

d to controls

as on the low

markedly inc

Transferrin r

concentratio

n, albumin,

Mean (SD)

85 (±2.21)

3.70 (±2.51)

82 (±2.23)

7.28 (±38.72)

oncentration

entrations.

and albumin

CRP and fe

s (table 8; fi

Case

Control

wer end of th

creased in th

receptor leve

on between g

CRP and fe

Control

CI

5.17 –

42.93 –

2.13 –

45.36 –

ns across gro

n in cases an

erritin levels

igure 3).

he normal

he same

els

groups.

erritin

6.53

– 44.48

3.51

– 69.20

oups was

nd

s was

22

P=value

(Independent

t-test)

p=0.062

p=0.000

p=0.000

p=0.000

 

 

 

 

Figu

4.7 S

No s

zinc

diffe

and

albu

22

ure 3: Graph

Summary

significant d

c between TB

erence is see

CRP levels

umin were a

050

100150200250

CRP

hical represe

difference in

B cases and

en in BMI, M

were mark

all significan

(p=0.000)

entation of C

n the dietary

d TB-free co

MUAC and

edly increas

ntly decreas

) Ferrit(p=0.0

CRP and fer

y intake of m

ontrols was

d weight bet

sed in TB ca

ed within th

tin000)

rritin in case

macronutrie

seen, althou

tween the tw

ases while z

he same grou

Ca

Co

es and contr

nts, vitamin

ugh a signifi

wo groups. F

zinc, vitamin

up.

se

ontrol

rols

n A and

icant

Ferritin

n A and

23

 

 

 

 

24

CHAPTER 5: DISCUSSION

5.1 Overview

The above results demonstrate a significant degree of malnutrition amongst TB

cases which was evident by the lower weight, BMI and MUAC. Micronutrient

malnutrition was also evident among the case group with a significantly lower

serum vitamin A and zinc.

The demographic information reflected in Table 5 indicated no significant

differences in living conditions between groups and therefore confounding factors

such as housing type, number of people in house, money spent on food etc., that

may have affected results, was reduced. The two groups were however not

comparable in terms of education level and housing density with controls being

better off on both indicators. There appeared to be no significant differences in the

nutrient intake of cases and controls.

5.2 Nutrient intake

Table 6 presents the nutrient intakes of cases and controls. Nosignificant

difference between groups were found. The 24hr recall method, however, may not

present an accurate measure of intake as it only reflects one day and is open to

under- or over-reporting. According to a review conducted by Rankin et al

(2010), the 24hr recall method may be simple to use and applicable across

populations but respondents may have difficulty recalling intakes and portion

sizes which may affect accuracy of results. It would not have been useful to repeat

the 24 hr recall method among cases as symptoms generally improve two weeks

after treatment and appetite may increase. Another aspect affecting nutrient intake

would be the socio-economic status of subjects. They reside in an area that has a

high rate of unemployment which may affect food security.

5.3 Nutritional status

Malnutrition amongst tuberculosis patients has been documented in many studies

(Karyadi et al, 2000; Kennedy et al, 1996; van Lettow et al, 2003; Zachariah et

 

 

 

 

25

al, 2002) and is once again reflected in the above results. Karayadi et al (2000)

conducted a case-control study to determine the nutritional status of patients in

Indonesia and demonstrated a significant decrease in BMI, skinfolds, and body fat

percentage amongst TB cases. Serum Vitamin A and zinc were also considerably

lower in PTB cases when compared to controls. Zachariah et al (2002) and

Kennedy et al (1996) conducted cross sectional studies to determine prevalence of

malnutrition in patients presenting with TB. Zachariah et al (2002) found a

significant increase risk of death due to malnutrition in TB cases while Kennedy

et al (1996) found significantly lower BMI’s in patients before and after

tuberculosis treatment. Those patients co-infected with HIV had even lower

BMI’s than those who were not. This study demonstrated a significantly lower

BMI, weight and MUAC among cases (Table 7), which are similar to previous

studies conducted in this population.

It has however been suggested that while malnutrition is common in PTB

patients, whether the disease causes malnutrition or malnutrition predisposes to

the disease still needs to be clarified (Cegielski & McMurray, 2003).

5.4 The role of the Acute Phase Response (APR)

Malnutrition as evident by decreased BMI, weight and body fat percentage may

be attributed to the increase in energy expenditure due to acute phase response,

reduced nutrient intake and in severe infections, fatigue and shortness of breath.

This may make it difficult to prepare and ingest food (Winkler & Malone, 2008).

In the initial phase of disease, the APR is responsible for the increase in energy

expenditure in these patients, once on treatment however the APR declines and

nutritional status may improve. The APR is also responsible for the often lower

levels of albumin and increases in ferritin seen in patients with active disease.

Albumin is a negative acute phase protein whose production is reduced in periods

of acute stress, trauma or infection due to the APR. The statistically significantly

lower levels of albumin seen among cases can therefore be attributed to the APR

(table 9; figure 2; figure3). The APR generally also results in increases in C-

reactive protein (CRP) which was evident in this study (Koyanagi et al, 2004;

 

 

 

 

26

Mathur, 2007). CRP is increased in infectious states and is used to measure

inflammation which may affect ferritin levels. Ferritin levels rise during acute

inflammation and may therefore not be an accurate measure of iron stores (Beard

et al, 2006). The ferritin levels in the case group were significantly higher than

controls and may be attributed to the APR experienced by these subjects.

5.5 Vitamin A

According to table 8 and figure 1, serum vitamin A and zinc concetrations were

statistically significantly lower amongst cases than controls. These results are

similar to numerous studies and reviews conducted to assess micronutrient status

amongst TB patients. Mugusi et al (2003) conducted a cross-sectional study to

determine the vitamin A status of tuberculosis patients, with and without HIV co-

infection. They found that mean serum vitamin A was lower among patients who

had tuberculosis with HIV co-infection than those who only presented with TB.

HIV free tuberculosis patients reported a significant increase in vitamin A status

after 2 months of treatment. Ramachandran et al (2003) conducted a case control

study to assess vitamin A status among tuberculosis patients and found that

tuberculosis patients had a significantly lower vitamin A status when compared to

household contacts and healthy ‘normals’. These authors similarly found that

vitamin A levels return to normal after anti-tuberculosis therapy (ATT) and

supplementation of vitamin A was not necessary. Mathur (2007) similarly found

that vitamin A concentration where low at baseline but improved after ATT

without supplementation. Karyadi et al (2002) however found that

supplementation with vitamin A improved sputum smear conversion after 2

months of ATT. This may however be attributed to the co-supplementation of

zinc.

Serum Vitamin A may also be affected by the APR as albumin is decreased with a

consequent decrease in retinol binding protein which is responsible for transport

of retinol to various tissues (Karyadi et al, 2000; Mugusi et al, 2003). Urinary

losses of vitamin A associated with fever and infection may also be responsible

 

 

 

 

27

for the low vitamin A levels seen in patients with active disease (Karyadi et al,

2000; Mugusi et al, 2003; Ramachandran et al, 2003).

The case group in this study were newly diagnosed with PTB and not yet on ATT.

They therefore presented with active infection which causes a rise in APR and

CRP, and a subsequent decrease in circulating retinol binding protein (which is

responsible for the transport of vitamin A to various tissues) and an increase in

urinary loss of vitamin A (due to fever).

5.6 Zinc

Serum zinc concentrations were significantly lower amongst cases than controls

which may also have affected the level of vitamin A. Zinc plays an important role

in a host of enzymatic processes including vitamin A metabolism (Christian &

West, 1998; Gupta et al, 2007; Mathur, 2007). A zinc deficiency may cause a

secondary vitamin A deficiency by impairing the production of retinol binding

protein, leading to decrease in vitamin A. Zinc supplementation may therefore

improve vitamin A metabolism, especially among TB patients (Gupta et al, 2007)

and may be responsible for the improved sputum conversion seen in patients after

two months of ATT in Karyadi et al (2002) study in Indonesia. This suggests that

supplementation with vitamin A alone may not confer a benefit.

Zinc deficiency has been shown to have an effect on Th1 lymphocyte response by

decreasing phagocytosis of macrophages, decreasing amount of natural killer cells

and decreasing interleukin-2 production (Gallagher, 2008; Maggini et al, 2007;

Metz et al, 2007) and compromise mucosal membrane integrity (Maggini et al,

2007). In the case-control study conducted by Karyadi et al (2000) in Indonesia,

serum levels of vitamin A and zinc were significantly lower in cases than in

controls which may be attributed to increase in metallothionein, a protein

responsible for transporting zinc to the liver. The increase in metallothionein is

associated with the activation of the APR, which may be the reason for the low

serum zinc levels in this population (Gupta et al, 2007; Koyonagi et al, 2004).

 

 

 

 

28

The results from the Karyadi et al (2000) study on the nutritional status of TB

patients in comparison to TB free controls, led to the development of a double

blind, placebo controlled trial to assess the effect of vitamin A and zinc

supplementation on treatment response (Karyadi et al, 2002). The results from the

study suggested that supplementation of vitamin A and zinc may improve

treatment response in patients after two months of ATT, which is also supported

by Ghulum et al (2009) who suggest that zinc supplementation improves the

effect of ATT after two months of treatment and recommend that zinc

supplementation become mandatory in malnourished individuals receiving ATT.

Range et al (2005) however, conducted a similar randomized controlled trial and

found no significant effects of zinc supplementation on treatment response.

Boloorsaz et al (2007) conducted a cross sectional study among children to assess

the zinc status during ATT. They found that zinc levels were low during the first

month of treatment and returned to normal 4 months after treatment without

supplementation.

Zinc and vitamin A supplementation may therefore be beneficial in improving the

treatment outcomes after two months of therapy among already malnourished

patients. Since levels appear to return to normal after treatment, supplementation

in ‘normal’ nourished individuals may not be necessary.

Copper, vitamin E and transferrin

No significant differences between serum vitamin E, copper and transferrin

between cases and controls. This was not expected as copper tends to increase in

APR due to the increased synthesis and release of copper-binding protein

ceruloplasmin (Gupta et al, 2009; Koyanagi et al, 2004). Serum copper was

however not significantly increased among cases in this study.

In a review conducted by Gupta et al (2009) on tuberculosis and nutrition, it was

stated that vitamin E levels tend to be decreased in patients who present with

active disease. This finding was however not reported by Range et al (2005) nor

 

 

 

 

29

Karyadi et al (2000) and vitamin E levels were not significantly decreased among

cases in this study.

According to Kasvosve et al (2006) transferrin receptor levels tend to be

increased during periods of inflammation independent of iron status. In this study

however, transferring receptor levels amongst cases were not significantly

increased in comparison to controls.

 

 

 

 

30

CHAPTER 6: Conclusions and recommendations

6.1 Conclusion

Malnutrition including, micronutrient malnutrition, especially serum vitamin A

and zinc deficiency was significantly lower in patients who present with active

tuberculosis than TB free contacts. This may be attributed to the APR and

increased metabolism and anorexia seen in these patients. Albumin was also

significantly lower in cases due to the APR while ferritin and CRP were

significantly higher which is can also be attributed to the inflammatory response.

Even though evidence from this study suggest the presence of malnutrition in

active TB cases, it is still unclear whether the disease precipitates malnutrition or

malnutrition leads to disease remains to be seen.

6.2 Limitations and Recommendations

The current sample of the study may be too small and therefore lack the power to

make any significant recommendations regarding nutritional guidelines for

tuberculosis cases. A multi-center study design may be constructed so that

adequate numbers may be recruited for future research into this field.

According to Cegielski and McMurray (2004) case-control studies are not

effective in determining cause and effect of disease as TB causes wasting and

depresses the immune system which resembles malnutrition and therefore the role

of malnutrition in the development of the disease cannot be determined.

A longitudinal study design may be applied in future studies to actually assess the

role of malnutrition in the development of disease.

A 3-day dietary record may prove more reliable to determine nutrient intake.

 

 

 

 

31

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response. American Journal Clinical Nutrition, 84:1498-1505

Boloorsaz M.R., Khalilzadeh S., Milanifar A.R. & Velayati A.A.(2007). Impact

of anti-tuberculosis therapy on plasma zinc status in childhood tuberculosis.

Eastern Mediterranean Health Journal, 13(5):1078-1084

Cegielski J.P. & McMurray D.N.(2004). The relationship between malnutrition

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Dodor E.A.(2008). Evaluation of the nutritional status of new tuberculosis

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Gallagher M.L.(2008). The Nutrients and their Metabolism. In Mahan L.K. &

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APPENDIX 1: Questionnaire

 

 

 

 

38

 

 

 

 

39

 

 

 

 

40

 

 

 

 

41

 

 

 

 

42

 

 

 

 

43

 

 

 

 

44

 

 

 

 

46

 

 

 

 

47

 

 

 

 

48

 

 

 

 

49

 

 

 

 

50

 

 

 

 

51

 

 

 

 

52

 

 

 

 

53

 

 

 

 

54

 

 

 

 

55

 

 

 

 

56

APPENDIX 2: Informed Consent Form

 

 

 

 

57

Informed Consent The micro-nutrient status of persons with pulmonary tuberculosis (TB) in the Western Cape

Investigators Prof Rina Swart, Me Candice Lombardo, Mrs Marianne Visser, Division Dietetics, University of the Western Cape I, ……………………………………………………… (Name in block capitals), the

undersigned, residing at

…………………………………………………………………………………(Address)

Tel. (if available):………………… have carefully read and understood the Patient

Information Sheet and Informed Consent. All my questions about the procedures and

risks involved in this study, were answered to my complete satisfaction by the study

personnel. I can keep copies of the Patient Information sheet and Informed consent. I

was given enough time to decide on my participation in this study.

By signing this Informed Consent Sheet, I declare that I participate in this study of my

free will, without pressure by any other person. I realise that I may withdraw from this

study at any time without stating my reasons and that my decision will not affect my

medical treatment in any way. The study doctor may also withdraw me from the study at

any time in the interests of my health.

I document my informed consent by signing my name below.

Place: ………………………………….. Date:

…………………………………..

Signature (Patient):……………………………………………

I would like to receive the results from the measurements that will be performed. Yes /

No

 

 

 

 

58

I, …………………………………………….. (Name of trial nurse or project

coordinator), have fully informed the above person of the procedures, aims and risks of

the study, and answered all questions truthfully.

Place:…………………………………… Date:

………………………………….

Signature (Trial nurse or project Coordinator)

………………………………………………

Prof R Swart Me C Lombardo Sr. A. Sampson Tel. 083-482-4113 Tel. 072-2113-109 Tel. 076 5623595 Project coordinator Project nurse

 

 

 

 

59

APPENDIX 3: Information sheet

 

 

 

 

60

Patient Information Sheet The Micronutrient Status of Tuberculosis Patients in the Western Cape (non-tuberculosis control)

Researchers: Prof Rina Swart, Me Candice Lombardo, Mrs Marianne Visser, Department of Dietetics, University of the Western Cape Introduction Vitamins and minerals are necessary in small amounts for health and may be found in many foods. These vitamins and minerals play a role in enhancing your immune system to overcome infectious diseases such as tuberculosis. Aim In this study we would like to find out if there is a difference betwen the micro-nutrient status of people who have Tuberculosis to those who do not. Study Participants You may take part in the study if you are 18 years and older and if

You are willing to undergo counselling and testing for HIV You agree to participate

You may not take part if

You have TB of the lungs You have ever received treatment for TB in the past You have TB affecting other organs You have TB that is resistant to normal TB drugs You are pregnant or wish to become pregnant You have given birth in the last 6 months You have kidney, liver or heart problems You are on corticosteroids You have used any vitamin or mineral capsules containing vitamin A, zinc or iron during the past

month. Procedure of the study and tests that will be performed You will be required to come to the Delt Clinic where the study nurse will draw 2 teaspoons of blood which will be used to determine your levels of vitamins and minerals. The study leaders will take your weight, height, mid-upper arm circumference and skinfold measurements. You will also be asked to recall the foods you ate the day before coming to the clinic. You will be referred for nutrition counselling if you are found to be underweight or obese. You will be counselled before and after your HIV test and if you test positive you will be referred for further testing and treatment. A sputum sample will be collected to confirm that you do not have tuberculosis. Should you be found to have tuberculosis, you will be referred to the clinic for medication. You will receive a small remuneration to cover the transport costs incurred by coming to the clinic. Study Risks All blood samples will be taken by a trained nursing sister following standard procedures to prevent contamination and to limit any risks to you. The risks of drawing blood include temporary discomfort from the needle stick, bruising, bleeding, and rarely, infection.

 

 

 

 

61

Being tested for HIV may cause anxiety regardless of the results. A positive test means that you have been infected with the HIV virus, but nobody can say for certain when, if ever, you will become sick with AIDS or a related condition. Receiving positive results may upset you.

You do not have to take part in this study if you do not want to and you can withdraw at any time, without stating a reason. The results of your tests will be stored in a secure computer database and will be kept private and your name will not be used in any of the biochemical analyses that will be performed or in the final study report. You may request to receive the results from all the biochemical-, dietary-, and anthropometric analyses that will be performed.

Thank you for considering participating in this study. Please contact us immediately if you experience any problems during this study.

Prof R Swart Ms C Lombardo Sr. A. Sampson Tel. 083-482-4113 Tel. 072-2113-109 Tel. 076 5623595 Project co ordinator Project nurse

 

 

 

 

62

Patient Information Sheet The Micronutrient Status of Tuberculosis Patients in the Western Cape (Tuberculosis cases)

Researchers: Prof Rina Swart, Me Candice Lombardo, Mrs Marianne Visser, Department of Dietetics, University of the Western Cape Introduction Vitamins and minerals are necessary in small amounts for health and may be found in many foods. These vitamins and minerals play a role in enhancing your immune system to overcome infectious diseases such as tuberculosis. Aim In this study we would like to find out if there is a difference betwen the micro-nutrient status of people who have Tuberculosis to those who do not. Study Participants You may take part in the study if you 18 years and older and if

You have TB of the lungs You are willing to undergo counselling and testing for HIV You agree to participate

You may no take part if

You have ever received treatment for TB in the past You have TB affecting other organs You have TB that is resitant to normal TB drugs You are pregnant or wish to become pregnant You have given birth in the last 6 months You have kidney, liver or heart problems You are on corticosteroids You have used any vitamin or mineral capsules containing vitamin A, zinc or iron during the last

month.

Procedure of the study and tests that will be performed You will be required to come to the Delt Clinic where the study nurse will draw 2 teaspoons of blood which will be used to determine your levels of vitamins and minerals. The study leaders will take your weight, height, mid-upper arm circumference and skinfold measurements. You will also be asked to recall the foods you ate the day before coming to the clinic. You will be referred for nutrition counselling if you are found to be underweight or obese. You will be counselled before and after your HIV test and if you test positive you will be referred for further testing and treatment. You will receive a small remuneration to cover the transport costs incurred by coming to the clinic. Study Risks All blood samples will be taken by a trained nursing sister following standard procedures to prevent contamination and to limit any risks to you. The risks of drawing blood include temporary discomfort from the needle stick, bruising, bleeding, and rarely, infection.

 

 

 

 

63

Being tested for HIV may cause anxiety regardless of the results. A positive test means that you have been infected with the HIV virus, but nobody can say for certain when, if ever, you will become sick with AIDS or a related condition. Receiving positive results may upset you.

You do not have to take part in this study if you do not want to and you can withdraw at any time, without stating a reason. The results of your tests will be stored in a secure computer database and will be kept private and your name will not be used in any of the biochemical analyses that will be performed or in the final study report. You may request to receive the results from all the biochemical-, dietary-, and anthropometric analyses that will be performed.

Thank you for considering participating in this study. Please contact us immediately if you experience any problems during this study.

Prof R Swart Ms C Lombardo Sr. A. Sampson Tel. 083-482-4113 Tel. 072-2113-109 Tel. 076 5623595 Project co ordinator Project nurse