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Sarhad J. Agric. Vol.28, No.2, 2012

EFFECT OF DIETARY COUNSELLING ON THE NUTRITIONAL

STATUS OF TUBERCULOSIS PATIENTS

SALEEM KHAN*, PARVEZ IQBAL PARACHA *, FOUZIA HABIB**,

IMRAN KHAN*, ROHEENA ANJUM* and SAREER BADSHAH***

* Department of Human Nutrition, Agricultural University, Peshawar Pakistan.

** Department of Forensic Medicine, Khyber Medical College, Peshawar Pakistan.

*** Islamia College University, Peshawar Pakistan.

ABSTRACT

This study was conducted from August to November, 2008 to investigate the impact of dietary

counselling on the nutritional status of tuberculosis patients. A total of 20 patients of both sexes were selected

for the study at the Emergency Satellites Hospital, Nahaqi, Peshawar, Pakistan. Energy and nutrient intake of

patients before and after dietary counselling were determined by the 24-hour dietary recall method. The weight

and height of patients were measured for the determination of BMI. Serum protein concentrations of the patients

before and after two months of counselling were determined by the biuret method. Before counselling the

patients were consuming energy (75%), protein (55%), fat (78%) and carbohydrate (75%) of the recommended

dietary intake and after counselling, the intakes of these nutrients increased to 88%, 78%, 90% and 86%,

respectively. Before counselling 30% of patients were normally nourished but 40% were mildly, 25%

moderately, and 5% severely malnourished, as compared to 45%, 45%, 10% and 0%, respectively after

counselling. At the start of the study, 55% of patients had normal and 45% of patients had below normal serum

protein levels compared to 85% normal and 15% below normal serum protein concentrations at the end of thestudy. The results of the study indicated that dietary counselling is a simple and effective mean of stabilizing

nutritional status in tuberculosis patients.

Key Words: Tuberculosis, Dietary Counselling, Nutritional Status of TB Patients.

Citation: Khan, S., P.I. Paracha, F. Habib, I. Khan, R. Anjum and S. Badshah. 2012. Effect of dietary

counselling on the nutritional status of tuberculosis patients. Sarhad J. Agric. 28(2):303-307

INTRODUCTION

Tuberculosis is an infectious disease caused by mycobacterium tuberculosis. It can infect various vital

organs of human body i.e. lung (pulmonary tuberculosis), central nervous, the lymphatic, circulatory,

genitourinary systems, bones, joints and skin (Kumar et al.,2007). The typical symptoms of tuberculosis are

chronic cough with blood tinged sputum, fever, night sweating, weight loss and chest pain (Hopewell, 1994)

Mortality and morbidity data on tuberculosis indicated 14.6 million chronically active cases, 8.9 million new

cases and 1.6 million deaths occurred mostly in developing countries. Among the developing countries twenty-two are considered as high burden countries. Pakistan ranks sixth among the twenty-two high burden

tuberculosis countries worldwide (WHO, 2006).

The energy and protein needs of tuberculosis patients are increased during the disease and an energy

intake of 3540 kcal kg-1

of ideal body weight is recommended. The protein intake of the diet is important to

prevent the wasting of body stores (for example muscle tissues) and an intake of 1.21.5 g protein kg-1

of body

weight or approximately 75100 g protein/day is considered sufficient.

The nutritional status of tuberculosis patients (macro- and micro-nutrient levels) decreases during the

disease which severely affects their muscle and immune response (Onwubalili,1988; Dallman 1987). They need

urgent dietary support in the hospital along with the recommended treatment. Dietary counselling is one of the

effective tools to control malnutrition/wasting associated with tuberculosis. In Pakistan there are no proper

dietary protocols for tuberculosis patients and they often have poor nutritional status. Therefore this study was

designed to assess whether dietary counselling would increase nutrient intake and improve nutritional status in

patients with tuberculosis.

MATERIALS AND METHODS

Study Location

The study was conducted in the Emergency Satellite Hospital, Nahaqi, Peshawar, Pakistan which

provides treatment to tuberculosis and diarrhoeal patients.

Respondents

Twenty patients (both sexes) clinically diagnosed with tuberculosis, age range 1545 years were

randomly selected. Patients who were not interested or not cooperative with the researcher, of low socio


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Saleem Khan et al. Effect of dietary counseling on the nutritional status of tuberculosis patients 304

economic status, not registered with the TB center, suffering from gastrointestinal diseases or could not afford

the recommended diet were excluded from the study. A preformed questionnaire was given to each patient and a

detailed face-to-face interview was held.

Data Collection and Dietary Counselling

The data collection included height and weight measurements of the patients which were measured

according to standard methods (WHO 1995) with the help of a non-stretchable measuring tape. The weight of

the patients was taken using bathroom scales. The bathroom scales were checked for accuracy to the nearest0.1kg before using. Dietary intake of the patients was determined by a 24-hour dietary recall method (Weiner

and Lourie, 1969.) Biochemical assessment of the patients included serum protein which was determined by the

biuret method (Johnson et al. 1999), the detail of which is given below. Dietary counselling was done by

nutritionist working as an internee at the health care centre and involved the prescription of energy and nutrient

rich diets using regular foods. The prescription identified the type, amount and frequency of feeding, specified

the caloric and protein level to attain and included any restrictions and limited or increased individual dietary

components.

Determination of BMI

Anthropometric data measured, included weight and height measurements which were used to calculate

the body mass index (BMI) of the patients before and after counselling by the following formula

BMI = weight (kg)/ height (m2)

Determination of Energy and Nutrients IntakeThe recommended energy and nutrient intake of patients were calculated using ideal body weight

(IBW) which was determined by measuring the body frame size of the patients with the help of the following

formula:

Body frame size = Height (cm)/wrist circumference (cm).

The values calculated using IBW were used for comparison purposes.

The dietary intake of patients before and after counselling was calculated by the 24-hour dietary recall

method. After counselling dietary intakes were calculated for 3 consecutive days per week for two months. The

time period of 24 hours began at 8:00 am and ended the following day at 8:00 am. Energy and nutrient intake of

the patients before and after counselling were calculated from the dietary intake using Nutrition Survey for

Windows (Erhardt, 2007). The energy and nutrient intake per day after counselling were calculated by taking

the means of energy and nutrient taken over a two month period.

Serum Protein Determination

Before and after two months of counselling, a blood sample was taken from the cephalic vein of each

respondent by the laboratory technician using disposable 5mL plastic syringes Beckton, Dickinson, Karachi).

Blood samples were transferred to sterilized centrifuge tubes and allowed to clot at room temperature for 20

minutes. The blood samples were centrifuged for 10 minutes in a centrifuge (Hermle Z 200A, Hermle-

Labortecnik, Goshe Merster. 56, Type H6 CHSTIUL, Germany) at 4000 rpm.The serum was separated off and

stored at -20C for analysis.The serum total protein level was determined by the biuret method (Johnson et al.

1999) using Spectrophotometer (GENESYS 10, Rochester NY USA) and Dia sys kit( Diagnostic system GmbH,

Germany).

Procedure

The wavelength of the spectrophotometer was adjusted to 540 nmand 1cm light path cuvette was used.

Twenty (20) l of sample and 1000 l of reagent were pipetted into test tubes and mixed. After 5 minutes of

incubation at 37

o

C in a water bath, the absorbance against the reagent blank was recorded.Calculation

A sampleSerum total protein (g /dl) =

A standardx100

A = absorbance


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Sarhad J. Agric. Vol.28, No.2, 2012 305

Statistical Analysis

Microsoft Excel version 2003 was used to calculate the mean nutrient intake and standard deviation

(SD) for each nutrient before and after counselling. BMI and serum protein level before and after counselling

were compared through graphs using Excel (Lena et al., 2002).

RESULTS AND DISCUSSION

Energy and Nutrients Intake of Tuberculosis Patients

Table I shows the energy and nutrient intake of the tuberculosis patients. The recommended intakes

calculated using IBW were used for comparative purposes in this study.

Table I Recommended, before and after, counselling the daily nutrients intake of tuberculosis patients

**Rec. Before AfterNutrients

Mean + SD Mean + SD% of the Rec.

intakeMean + SD

% of the Rec.

intake

Net

Increase %

Energy (kcal) 1827 + 362 1379 + 287 75.49 1608 + 272 88.04 13

Protein (g) 81+18 45 + 11 55.8 63 + 16 78.03 22

Fat (g) 60 + 14 47 + 15 78.29 54 + 14 90.03 12

CHO (g) 242 + 49 182 + 34 75.24 210 + 35 86.76 12

* Values in the columns 2, 3 and 5 are the means of 20 patients.

** Recommended

The mean recommended intake for energy calculated on the basis of IBW was 1827 kcal/day for all 20

patients. Before counselling the mean energy intake was 1379 k. cal/ day which was 75.5% of the recommendedintake. After dietary counselling, the mean energy intake calculated was 1608 kcal/person/day for two months,

which was 88% of the recommended intake, an increase of approximately 13%. For all 20 patients, the mean

recommended intake of protein was 81g/person/day (Table I) but the actual intake was 45g/person/day, which

increased to 63 g/day after counselling. The mean recommended intake of fat was 60 g/ day and at the start of

the study each person was consuming only 47 g/day, which increased to 54g/day for the two month period.

Based on IBW, the mean recommended intake of carbohydrate was calculated to be 242 g/person/day. However,

before counselling the patients were only consuming 182 g/day, which increased to 210 g/person/day

subsequent to counselling, a 12% increase.

Effect of Dietary Counselling on BMI of Tuberculosis Patients

Figure 1 shows the BMI of tuberculosis patients two months after dietary counselling compared with

their BMI at the start of the project. There was an increase in the percent of normally (30 to 45%) and mildly

malnourished (40 to 45%) nourished patients after two months of counselling. In contrast, there was a reduction

in the percent of moderately malnourished patients from 25% to 10% and there were no severely malnourishedpatients after counselling.

Fig. 1. Body mass indices of tuberculosis patients before and after counselling

Effect of Dietary Counselling on the Serum Protein level of Tuberculosis Patients


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Saleem Khan et al. Effect of dietary counseling on the nutritional status of tuberculosis patients 306

Figure 2 shows a significant increase in the serum protein concentrations of tuberculosis patients after

two months of counselling. There were 55% patients with normal serum protein levels before counselling

compared with 85% patients after two months of counselling.

Fig. 2. Serum protein level of tuberculosis patients before and after dietary counselling

Low BMI is a known risk factor for mortality in tuberculosis patients (Van et al.,2003). The results of

the study show that 70% of the tuberculosis patients were malnourished with a low BMI before dietary

counselling, a large proportion having mild to moderate malnutrition. The observed malnutrition among

tuberculosis patients at the time of registration has been reported in other studies in both developing and

developed countries (Zachariah et al.,2002; Onwubalili, 1988; Harries et al.,1988; Metcalfe, 2004). The low

BMI among patients with tuberculosis may be due to poor energy and nutrient intake, anorexia, impaired

absorption of nutrients or increased catabolism (Hopewell, 1994). The present observations are in concurrence

with studies done in India by Ramakrishnan et al.(2007) and in Malawi by Van et al.(2004). In this study, after

dietary counselling a considerable increase was observed in energy and nutrient intake of the tuberculosis

patients, which in turn produced a significant increase in BMI. The increase in BMI, confirming the findings

that patients with tuberculosis can mount a protein anabolic response to increased energy and nutrient intake(Paton et al.,2003; Macallan et al.,1998).

One of the finding of the present study was that, tuberculosis patients were taking less than therecommended amount of protein before counselling. As a result more than half of the patients had serum protein

levels below normal. In a previous study of Karyadi et al.(2000) and Taneja, (1990), the possible causes for the

low serum protein in tuberculosis patients were considered to be nutritional intake, enteropathy and raised acute

phase proteins. The hepatic synthesis of acute phase proteins is induced by cytokines such as interleukin-6 and

tumour necrosis factor-, which inhibit the production of serum albumin and cause dramatic shifts in the plasma

concentration of protein (Xing et al.,1998; Gabay and Kushner, 1999).

An increase in nutrient intake was observed after counselling, which in turn significantly increased

serum protein level in tuberculosis patients. Paton et al. (2004) in a previous study found that dietary

counselling significantly increased nutrient intake in tuberculosis patients, which resulted in increase serum

protein level.

CONCLUSION AND RECOMMENDATIONS

It is concluded that dietary counselling can have a substantial role in providing the recommended

intake of nutrients and improving the nutritional status of tuberculosis patients. The addition of oral nutritionalsupplements to the diet did not appear to be as effective as dietary counselling.

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