Introduction

CHAPTER-I

INTRODUCTION

1.1 Pulmonary Tuberculosis – Causes, Types Symptoms,

Prevalence and Treatment

1.2 Malnutrition and Pulmonary Tuberculosis Disease

1.3 Socio Economic Status and Pulmonary Tuberculosis Disease

1.4 Importance of Nutrition in Pulmonary Tuberculosis

Patients

1.5 Nutritional Assessment of Pulmonary Tuberculosis Patients

1.6 The Present Study and its Rationale

1.7 Aims and Objectives

1.8 Hypothesis

1.9 Limitations of the Study

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 Introduction

CHAPTER-I

INTRODUCTION

Tuberculosis disease is an old disease. Ancient Hindu texts (300 BP) refer to

Tuberculosis as “Rogaraj”, the king of disease and Rajayakshma, the disease of kings,

but now a day that disease is known as Tuberculosis. Many countries still is, the main

cause of death in human societies due to tuberculosis disease. The second name

stresses that “Tuberculosis” being an infectious disease, strikes indiscriminately and

effects king as well as ordinary people National TB Programme (1997).

Tuberculosis disease is caused by Mycobacterium tuberculosis. First Robert Koch

was discovered on “Mycobacterium tuberculosis” in March 24, 1882. “Robert Koch”

was a German physician and scientist. According to Medilexicon‟s medical

dictionary, Tuberculosis is “A disease caused by infection with Mycobacterium

tuberculosis, the tubercle bacillus can affect any tissue or organs of the body mostly

lungs are highly affected to this disease. Mycobacteria is a pathogenic and non-motile

bacteria. Mycobacterium is a waxy coating bacteria. Waxy coatings are found on cell

surface, which makes the cell impervious to gram staining. Mycobacteria can identify

by Ziehl Neelson Staining method or acid-fast bacillus (AFB) stain. Mycobacterium

tuberculosis are found mainly four types Mycobacterium bovis, Mycobacterium

africanum, Micobacterium canetti and Mycobacterium microti, which causes the

disease is known as tuberculosis. But Mycobacterium tuberculosis is responsible for

human‟s tuberculosis. Mycobacterium bovis is responsible for animal‟s tuberculosis.

Mycobacterium is an aerobic rod shaped bacteria. Mycobacteria are highly oxygen

content bacteria. Their incubation periods are 12 to 18 hours. Mycobacteria are known

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 Introduction

as acid fast bacilli because their solution is acidic solution and their cell wall is made

up of lipid.

These bacteria usually attack the lungs, but sometimes can attack other parts of the

body such as the spine, kidney, skeleton and brain. This germ can cause other kinds of

Tuberculosis but pulmonary Tuberculosis is the most common. If tuberculosis is not

treated properly, it can be fatal National center for HIV/AIDS (2014). Although

tuberculosis is a preventable and treatable disease, through the proper maintenance of

disease during illness we can prevent of the disease. Up to 66 percent of the people

get sick with tuberculosis and after dies causes to disease, if they dies do not get

proper maintenance or medical care during disease period. Tuberculosis spreads

through the air by a person with tuberculosis infectious reveals that Shukla et al. and

Robert Koch (1882).

It is a serious infectious pulmonary disease that attacks the lungs but can also affect

other parts of the body. When the Mycobacteria attack in lungs is known as

Pulmonary Tuberculosis and when Mycobacteria attack the other parts of the body is

known as Extra Pulmonary Tuberculosis. Pulmonary Tuberculosis has become a

global problem. According to the World Health Organization more than 1/4 of the

World population has been affected by Pulmonary Tuberculosis disease.

Four distinct steps in the pathogenesis of tuberculosis can be identified by exposure,

infection, disease and death. Pulmonary tuberculosis spreads through the air. The

sputum of infected people is main causes of tuberculosis. Tuberculosis bacteria are

transmitted by cough, sneeze or saliva of active tuberculosis patients. Those patients

severely infected by this disease they can highly infect other people. One of the first

sign of tuberculosis is unexplained weight loss. As the disease increases, many

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symptoms may occur. Common symptoms include – Tiredness, Loss of weight,

Fatigue, Coughing up blood, Fever and night sweats, cough producing phlegm.

Additional symptoms that may be associated with this disease such as Wheezing,

Sweating excessive, Chest pain and Breathing difficulty reveals that Chandra (1991).

Tuberculosis is a major cause of morbidity and mortality worldwide. Tuberculosis is

one of the top ten causes of illness, death, and disability worldwide and is the leading

cause of death from a curable infectious disease. It is estimated that India accounts for

1/5th of world new tuberculosis cases. As per the World Health Organization

(2008) nearly 2 Billion people have infected with tuberculosis infections.

Approximately 1/3 of the world population infected with Mycobacterium

tuberculosis. Tuberculosis has been declared a global emergency by WHO.

Tuberculosis kills approximately 4,700 people every day according to World Health

Organization (2010). The shocking part is that Chhattisgarh is one of the 10th high

risk states across nation in rising cases of tuberculosis especially of Multi Drug

Resistant (MDR) TB in last three years according to facts on tuberculosis cases in

state as published in The Hitavada (2014). An estimated 2.3 million new cases of

Tuberculosis occur in India every year. The Revised National Control Programme

(RNTCP) provides DOTS to patient‟s in spite of this disease kills an approximately

320,000 people every year reveals that Bhargava et al. (2013). When the

Mycobacteria enter in to our body, our immune system stimulates and immune

system fights against these bacteria. Once inhales the bacteria reach to the lungs and

grow slowly over several weeks. Some bacteria live in inactive forms in our body.

This period is called “Latent Stage” In many cases the disease never develops beyond

this stage. But in some cases the disease becomes active in many years reveals that

Lomardo (2012). Sometimes active bacteria again attacks in our immune system and

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 Introduction

destroy our defensive wall. The bacteria enter in to our blood stream and spreads

infections in our body. As soon bacteria enter in blood stream it transmits in our

body. There the germ multiplies rapidly and destroys the tissues of the lungs (or the

other affected organ). In this stage called Active Stage. Active stage is harmful for

us. Active stages generate tuberculosis disease as per the Nutrition information

center (2011).

Over 80% of people‟s immune system kills the bacteria and removes from the body.

In some cases the bacteria is killed by our Immune system but some cannot killed

bacteria, they go in to a dormant condition. The bacteria go to dormant condition this

condition is known as latent condition. In Initial infection bacteria gets into the blood

stream when the defensive barriers are built by the body National Institute for

health and clinical excellence.

There are two general stages of this disease. First is called Latent Tuberculosis and

second is Active Tuberculosis. A person with Latent Tuberculosis has no symptoms

and can‟t make other person sick, but their tuberculosis test have completed.

Tuberculous infection is necessary to develop tuberculosis but overall only 10 percent

of those with the infection ever develop active tuberculosis as per the World Health

Organization (2010). Just because people have been exposed to tuberculosis germs

does not mean they will get sick from tuberculosis yet. This time people do not

infected to bacteria because immune system fights against this infectious bacteria.

About one third of the world population has been infected with the germs that caused

tuberculosis. Active tuberculosis can easily affect to others. About 3% to 5% of

people develop active tuberculosis within a year of receiving positive diagnosis in a

tuberculosis skin test or having evidence of a new infection reveals that Chandra

(1991).

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Many people who are infected with Tuberculosis have few or no symptoms at all at

least in the starting period of tuberculosis. Some people develop symptoms gradually,

over time and pay little attention to them until the disease has reached to the severe

condition When symptoms do appear, they generally include - Fatigue, loss of

appetite, weight loss, cough with purulent and or bloody sputum, Night sweats, low

grade fever that occurred mostly in the afternoon reveals that Academia.edu.copd

about.com (2014). Tuberculosis disease is two types first is pulmonary tuberculosis

and second is extra pulmonary tuberculosis. Pulmonary tuberculosis defines two types

smear-positive pulmonary tuberculosis and smear negative pulmonary tuberculosis.

Tuberculosis in a patient with at least 1 initial sputum smear examinations (direct

smear microscopy) positive for acid fast bacilli that is smear positive tuberculosis.

Tuberculosis in a patient with symptoms suggestive of tuberculosis with at least 2

sputum smear examination negative acid fast bacilli and radiographic abnormalities

consistent with active Pulmonary Tuberculosis as determined by the treating Micro-

organism followed by a decision to treat the patient with a full course of anti-

tuberculosis therapy. Diagnosis based on positive culture but negative acid fast bacilli

sputum smear examinations. Tuberculosis of any organ other than the lungs, such as

the pleura (Tuberculosis Pleurisy), lymph nodes, intestines, skin, joints and bones,

meninges of the brain and genitourinary tract etc. Diagnosis should be based on

culture positive specimen from the extra tuberculosis followed by decision of the

treating micro-organism to treat with a full course of anti-tuberculosis therapy. The

WHO global program on tuberculosis promotes for the use of directly observed

treatment short course (DOTS) for all patients which involves giving Isoniazid,

Rifampicin, Pyrazinamide and Ethambutol for two months then Isoniazid and

Rifampicin also for further four months and the patients is considered cured at six

months.

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Diagnosis Algorithm for Pulmonary Tuberculosis

Adapted from RNTCP at a GLANCE.

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Flow Diagram Shows Diagnosis Algorithm for Pulmonary Tuberculosis

Adapted from RNTCP at a GLANCE.

Flow Diagram Shows Diagnosis Algorithm for Pulmonary Tuberculosis and

Treatment. Adapted from RNTCP at a GLANCE).

Antibiotics drugs are provided by DOTS centre during disease time. These all

tuberculosis drugs highly dose. DOTS Programme is the method offered by WHO to

increase the cure rate of tuberculosis treatment. Certain patients do not complete

taking the tuberculosis drugs because they feel better after taking the medication for

two on three weeks, but some patients stop taking the tuberculosis medications

because they cannot tolerate the side effects of the drugs. Therefore some patients do

not regularly intake the tuberculosis medicines. Various studies shows intake of good

nutrition is very effective in tuberculosis disease. Tuberculin drugs are highly

effective to well-nourished patient‟s comparison to undernourished patients.

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Tuberculosis is a treatable disease that needs better awareness. Good nutrition is very

important to pulmonary tuberculosis not only weight management but essential for

properly absorbent of drugs during tuberculosis disease.

Figure: Shows Pathogenesis of Pulmonary Tuberculosis Disease.

Adopted from www.google.com.
1.2 MALNUTRITION AND PULMONARY TUBERCULOSIS

DISEASE

During active Tuberculosis, catabolic processes that caused wasting usually begin

before the patient is diagnosed. At the time of diagnosis the metabolic rate or resting

energy expenditure is increased resulting in increased energy needs to meet the basic

demands for body function. At the same time, energy intakes are likely to decline as a

result of illness associated anorexia. This combination of condition results in weight

loss with eventual wasting if energy intakes are not increased or energy expenditures

are decreased. The nutritional status of tuberculosis patients decreases during the

disease which severely affects their muscle and immune response. They need urgent

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

the effective tools to control malnutrition wasting associated with tuberculosis.

In the acute stage of all types of tuberculosis, the fever may be very high but in the

chronic stage the patient‟s temperature may be only slightly higher than the normal,

thereby the rate of metabolism is lower than that in higher fevers. In duration of

tuberculosis disease body temperatures increases in tuberculosis patients. In these

stage patients feel feverish conditions. Weight loss and nitrogen losses may be seen

during pulmonary tuberculosis condition. Hence in these stages patients need high

Calorie and high Protein diet otherwise under nutrition and nutrient deficiencies may

results. Alternatively, malnutrition, including micronutrient deficiencies, may affect

immunity, leading to increase susceptibly to active infection for this reasons,

malnutrition and tuberculosis have a long history of association Gupta et al. (2009).

Many studies have detailed the poor nutritional status of patients with tuberculosis in

terms of Body Mass Index (BMI), Mid Upper Arm Circumference (MUAC) and skin

fold thickness. A study carried out by Kennedy et al. (1996) in Tanzania used Body

Mass Index to assess the nutritional status of 148 patients WHO presented with active

tuberculosis. They found that malnutrition was obtained before and after treatment of

tuberculosis.

Kharyadi et al. (2000) conducted a case control study in Indonesia and found that

patients had significantly lower Body Mass Index, Mid Upper Arm Circumference

and Skin fold measurements than the controls. It was also noted that patients had

varying degrees of malnutrition. Micronutrients deficiency positively related to the

level of malnutrition. Therefore, supplementation in this group may prove to be

beneficial. Malnutrition is a predominate factor of patients, tuberculosis bacteria can

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easily affect to malnourished persons. Epidemiological evidence indicates that

tuberculosis is a disease associated with malnutrition. Under nutrition and clinical

deficiency of specific nutrients important for immune system function leads to

immune deficiency and higher susceptibility to bacterial infections and viral

infections. Immune enhancing nutrients like Vitamin C Vitamin A, Vitamin E and

other antioxidants have shown beneficial effects on various types of infections

including tuberculosis. Antioxidants used in combination with standard tuberculosis

regiments, have been shown to accelerate healing from tuberculosis. Severe under

nutrition at the time of diagnosis is associated with a two to four times higher in death

of tuberculosis patients. With such a high proportion of tuberculosis patients suffering

from moderate to severe under nutrition at the time of diagnosis, nutritional support

for undernourished tuberculosis patients should be considered a priority issue to

decrease risk of dying even after being put on treatment with effective drug regimens

according to the research by Bhargava et al. (2013). Malnutrition leads to decrease

immunity and body needs to be as strong as possible to defend itself against those

tough tuberculosis bacteria. In this stage highly amounts of nutrition required. This

stage rapidly losses of macronutrient and micronutrient. Micronutrients deficiencies

increase the risk of developing active tuberculosis, while tuberculosis leads to

underweight and weight loss. Therefore nutritional education is such a good way on

prevents of malnutrition. Different types of nutrients decreases in tuberculosis patients

during tuberculosis.

Acute infection illness, such as tuberculosis is accompanied by a complex variety of

nutrition and metabolic response within the body. Tuberculosis with infection is

associated with an increase in the energy expenditure of the patients and various

degrees of tissue breakdown additionally in the body‟s attempt to fight the infection

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energy expenditure is increased, thereby increasing energy needs for the tuberculosis

patients. Hence loss of appetite and reduced body weight are seen in tuberculosis

patients. Complex changes seen in the metabolism of all the macronutrient, i.e.

Protein, Carbohydrate and Fat during disease. Increases Protein breakdown in disease

time, leads to muscle wasting in these patients according to Nutrition Information

Center (2001). Under nutrition was seen in pulmonary tuberculosis in various studies.

The study was done by Rema Nagarajan et al. (2013) on under nutrition patients

with tuberculosis of the lung at the beginning and end of treatment and its impact on

treatment outcomes in 1695 adult patients who were treated at Jan Swasthya Sahyog's

rural hospital in village Ganiyari, in Bilaspur district of Chhattisgarh over a six-year

period. It was found to be nearly half the men were less than 42kg, with a Body Mass

Index below 16. Almost half the women weighed less than 34kg, with Body Mass

Index below 15kg/m2. Some patients had Body Mass Index of 13 or less. Only 2%

patients had body weights equal to or greater than the reference weight of 60 and

55kg respectively for men and women.

Nutritional status and food intake are critical factors in disease process. Therefore

nutritional care and nutritional support are key factors in patient‟s management during

active phase of pulmonary tuberculosis. Malnutrition is a major problem in pulmonary

tuberculosis patients. Various studies show that most of the patients were seen severe

malnutrition during tuberculosis disease. So control on malnutrition and prevent on

malnutrition is the main purpose, because many studies show tuberculosis drugs are

highly effective to nourished patients comparison to undernourished patients. Hence

in this stage giving dietary education is very important for pulmonary tuberculosis

patients reveals that Chanda (1996). Low Body Mass Index (A measure of weight for

height that is indicative of nutritional status) and some micronutrient deficiencies

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depress cell-mediated immunity, the key host defence against tuberculosis as per the

Cegielski et al. (2004). Being underweight and poorly nourished can also cause

weakness and lack of energy, affect in quality of life and level of physical functioning

reveals that Paton et al. (2004).

Tuberculosis is a major barrier to social and economic development and it is one of

the most important causes of death in developing countries. Tuberculosis patients

have lower Body Mass Index (BMI) muscle mass and subcutaneous stores of Fat than

control groups. A study was done on Malavi. It was found some participants in this

study suffered malnutrition before contracting tuberculosis, but the disease also

increases the demand for energy which contributes to increase weight loss if that

demand cannot be met Van Lettow (2004).

The tuberculosis bacteria to become pathogenic and make a person sick will need a

poor diet and very stressed life style. Good nutrition is an important aspect of

pulmonary tuberculosis treatment as it can help body fight off the bacteria being

underweight or malnourished could cause become more susceptible to a relapse.

Hence it is essential for patients to get the right nutrition. Many nutrients are good for

a speedy recovery in pulmonary tuberculosis. Below diagram shows relationship

between malnutrition and Tuberculosis disease.

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RELATIONSHIP OF MALNUTRITION AND TUBERCULOSIS

Loss of Weight
Appetite Loss

Malnutrition

Tuberculosis

Weakens Immune
Sustem

Increase risk from

LTBI to TB disease

Increased
Susceptibility to
infections

Cycle Shows Relationship of Malnutrition and Tuberculosis

1.3 SOCIO ECONOMIC STATUS AND PULMONARY

TUBERCULOSIS DISEASE

The socio economic status of the family determines their social values and standard of

living in the society. Therefore related information was collected and discussed about

socio economic status. An individual is born in a family, which belongs to a group. In

the group have its own social structure, society and its own way of livelihood. The

cultural, social, economical and educational levels of the community are closely

related with the food practices of the people, the status of nutrition is highly affected

by the socio economic factors. Social data consist of population, family details (types

of family), education which measures knowledge and achievement of an individual

housing conditions (types of house) small or large house, Pakka or Kachcha house,

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own or rented house etc. Atmospheres of living conditions like slum or clean area is

closely related to disease. Therefore socio economic status of the subjects is assessing.

Family details – family details like total number of family, Education, Housing

condition, Occupation and income levels of the subjects are assessing.

Socio economic background is defined as the socio economic position of an

individual, their present occupational or family circumstances. The socio economic

status shows their socio economic climate of their home and represents living

condition of the subjects. The Socio economic status (SES) is an important

determinant of health and nutritional status as well as of morbidity and mortality.

Socio economic status also affects the availability, affordability, actual consumption

of various available health facilities and living condition Aggarawal (2005). Socio

economic factors are important key components in tuberculosis patients.

In India Tuberculosis is mainly the disease of the poor, besides the disease burden.

Tuberculosis also cause enormous socio economic burden to India as it primary

affects people in most productive years of life commonly in the age group of 15-54

years revealed by World Health Organization (2009). Poor living conditions,

malnutrition, shanty housing and overcrowding are the main reasons for the spread of

the disease according to K. Park (2013). Tuberculosis is associated with various

socio economic factors and often occurs in populations suffering from poverty,

economic deprivation, poor housing and these are also major factors predisposing to

poor nutritional status and impaired immune function. Tuberculosis was developed

most often in busy inner city, economically poor, unhygienic environments and

among people with others medical risk factors.

A survey done on Wardha district (Maharastra) is the only sources of survey data

linking tuberculosis in the community to socio economic criteria. The prevalence rates

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in the survey had depends on literacy (lowest in the graduates and highest among the

illiterates) employment held (highest among the professionals) followed by cultivators

and agriculture labor. These were also depending on income, living standard (whose

person living in “Kachcha Houses” had a higher prevalence than living in “Pakka

House” Chakraborty (1997).

1.4 IMPORTANCE OF NUTRITION IN PULMONARY

TUBERCULOSIS PATIENTS
Good Nutrition plays an important role in the prevention and treatment of tuberculosis

disease. Poor diet are main causes of develop complications and severity of

pulmonary tuberculosis disease. The nutritional status of people (whether they get all

the nutrients their bodies need) and utilization of nutrients (how their bodies use these

nutrients) are also adversely affected after they have been tuberculosis infections.

Tuberculosis infections often causes of loss of appetite in tuberculosis patients,

resulting in the tuberculosis patients losing weight. Nutritional status of the patients is

very low during disease time that is proved by various studies. Mostly body

temperature increases during disease, therefore catabolic process increases in

tuberculosis patients. Hence high amount of nutrients, such as energy, Protein,

carbohydrate, Fat and minerals are required for controlling of catabolic process in

tuberculosis patients.

Energy

Adequate energy need for tuberculosis patients. The current recommendations for

tuberculosis patients are based on the nutrient and energy requirements for hyper

catabolic and undernourished patients. In this condition high Calorie diet is required

for undernourished tuberculosis patients. In the case of co-infection, the highest

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recommendation should be implemented, based on the individual‟s needs and other

requirements.

Protein

The Protein intake of the diet is important to prevent the wasting of body stores (for

example muscle tissues) in tuberculosis patients. Proteins are vital for any living

organism. Protein is important components for the tissue and cells of the body.

Protein makes the essential components of muscle and other tissue and vital body

fluids like blood. All the nutrient and drugs are transported in various organs through

the blood. The Protein supplies the body building material for the body. Protein works

for reformation of damaged cells in the body. Protein makes an antibody. Antibodies

helps fight against infections in body Gopalan (1999). Protein deficiency is the

causes of catabolism in body. The main causes of breakdown of tissues in body

during tuberculosis infections by catabolism. Catabolism is the process of breakdown

of various tissues to their simpler components. Decrease in Albumin synthesis is one

of the main reasons of nitrogen losses in the body. Hence high Protein diet is very

essential to this condition. High Protein diet controls loss of nitrogen in patients.

Hence high Protein diet is required for maintained for weight in tuberculosis patients.

In many tuberculosis patients have been seen Protein energy malnutrition. High

Protein diet is preventing Protein Energy Malnutrition and helps regenerate of the

tissues. Immunoglobulins are Proteins produced by lymphocyte and plasma cells.

Protein is the main building block of our bodies. All our cells and tissue are made by

Protein. Protein helps healing of wound. Also an energy provider the body uses

Protein energy only after it has exhausted the energy provided by carbohydrates.

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Zinc

Zinc deficiency causes of weak immunity in host. Hence decreased phagocytosis and

leads to a reduced number of circulating T-cells and reduced tuberculin reactivity

Karyadi et al. (2000) and Mc Murray et al. (1990). Zinc has an essential for

Vitamin A metabolism. Various studies found that Zinc supplementation has

beneficial effect for Vitamin A metabolism which has an important role in

tuberculosis. Zinc is required for growth and development of Protein synthesis and

cell division and they are dependent on it. Zinc helps lymphocyte trans-formation,

and cell-mediated immunity. It is known that deficiencies of zinc can cause profound

impairment of immunity and precisely the cell types that are critical to fight

tuberculosis. Dietary deficiencies of zinc may be important components of

tuberculosis resistance Nutrition information center (2001).

Vitamin A

Various studies shows on Vitamin A has played immune competent role in human

tuberculosis. Mathur (2007) has found Vitamin A deficiencies present in pulmonary

tuberculosis patients. Vitamin A was reported to inhibit multiplication of virulent

bacilli in cultured human macrophages Crowel et al. (1989). In addition, Vitamin A

has a vital role in lymphocyte proliferation and in maintaining the function of

epithelial tissues Chandra (1991). Vitamin A is essential for proper functioning of T

and B lymphocytes, macrophage activity, increased immunity and generation of

antibody response Semba (1998). Vitamin A was found to be lower in tuberculosis

patients in many studies Rwangabwoba et al. (1998), Solon et al. (1978), Fleck et

al. Stephensen et al. (1994), Ramachandran et al. (2004), Chandra (1988),

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Whalen et al. (2001). Hence Vitamin A is essential for tuberculosis disease. All types

of green leafy vegetables provide Vitamin A.

Vitamin E

In many studies, concentration of Vitamin E was found to be significantly lower in

tuberculosis patients Panasiuk et al. (1991) and Seyedrezazadeh et al. (2006).

Vitamin E possesses anti-oxidant property. Immunomodulatory properties have

present in Vitamin E. Vitamin E is widely distributed in foods. It is present in high

concentration in vegetable oils and in cereals grains.

Vitamin C

Studies have linked Vitamin C deficiency with tuberculosis Panasiuk et al. (1991),

Rwangabwoba et al. (1998). Vitamin C content food provides antioxidant properties.

Vitamin C is essential for pulmonary tuberculosis patients. In presence of Vitamin C

the tuberculosis drugs can do properly function and also can help increase immunity

function in this period. Mainly have been seen immune capacity decreases during

disease. Hence Vitamin C is very important for pulmonary tuberculosis disease.

Selenium

Selenium works an important for maintain the immune processes and thus may have a

critical role in clearance of mycobacteria Shor-Posner et al. (2002).

Iron

Anemia is highly prevalent among adults with pulmonary tuberculosis Kharyadi et

al. (2000). In a study conducted in Ghana, 50% adults with pulmonary tuberculosis

had significantly lower hemoglobin than healthy matched controls. Hastaka et al.

(1992). There are two explanations for the association of low iron status and infection.

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Kharyadi et al. (2000). First is that anemia results from chronic infection and other is

that iron deficiency would increase susceptibility to infection such as tuberculosis.

Iron deficiency or anaemia in pulmonary tuberculosis can cause increase

susceptibility to infection.

1.5 NUTRITIONAL ASSESSMENT OF PULMONARY

TUBERCULOSIS PATIENTS
Nutritional assessment method helps to know about prevalence of malnutrition and

micronutrient deficiencies in persons. Its purpose is to identify the persons who are

malnourished or at nutritional risk. Nutritional assessment method is an easiest

method for measuring nutritional deficiency. Nutritional assessment is quick and

economical method for assess all populations, individual and community. In the field

of nutrition a major challenge is how to identify individual or populations who have

nutritional problems. Nutritional screening is the process of identifying characteristics

known to be associated with malnutrition problems. Nutritional assessment method

helps to know about prevalence in malnutrition and micronutrient deficiencies.

In this study mainly four types of methods were used to assessment of

nutritional status in pulmonary tuberculosis patients. They all method helps to know

about nutritional deficiencies.

1. Clinical assessment.

2. Anthropometric Measurement

3. Dietary : Nutritional History (Current Intake)

4. Biochemical or Laboratory methods.

Clinical examination is the most essential part of all nutritional survey methods.

Through the clinical examination we can identify abnormalities present in external

organs such as hair, tongue, teeth, skin, eyes, and Nails etc. Detection of relevant

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signs helps in establishing the nutritional diagnosis. Clinical assessment method is

economical method. In this method required neither costly equipment nor costly

laboratory reagent.

Anthropometric indices such as weight for age, height for age, weight for height and

measurement such as mid upper arm circumference are especially useful in detecting

a possible chronic imbalance of Protein and energy, to identify moderate and severe

malnutrition no single index of nutritional status provides a definitive diagnosis of all

levels of nutritional deficiencies. To assess the nutritional status of individuals or

populations of combination of biochemical, dietary, clinical and anthropometric

methods are considered the gold standard revealed that Wasantwisut et al. (2011).

Anthropometric assessment is a popular method for measurement of the physical

dimensions. Anthropometry is defined as the study of sizes and proportions of the

human body, and measurement of bone, muscle and adipose (Fat) tissue revealed that

Trowbridge (1979). Anthropometry is one of the most practical field techniques for

quantitative assessment of nutritional status. Patients were assessed by anthropometric

parameters such as height, weight, Body Mass Index and Mid Upper Arm

Circumference. Standard protocol for anthropometric measurement was followed by

the National Center for health statistics. Weight was measured to the nearest 0.1 kg

and height to the nearest 1 mm and Mid Upper Arm Circumference (MUAC) was

measured to the nearest 1 mm according to National Health and Nutrition

Examination Survey (2007). Anthropometric measurements are of prime importance

in public health throughout the world. Anthropometric indices measure growth and

body composition and are used widely in all nutritional measurement procedures,

including nutrition intervention studies Wasantwisut et al. (2011). The

measurements can be performed relatively quickly, easily and reliably using portable

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equipment, provided standardized methods and calibrated equipment‟s are used.

Weight is a measurement of overall nutritional status with age, height and length

required for optimal interpretation. Weight is determined using a weighing machine.

Mid Upper Arm Circumference is another anthropometric measurement that has also

been used to evaluate adult nutritional status described by James et al. (1994). Mid

Upper Arm Circumference can be used as a measurement of growth an index of

energy and Protein stores and can provide information on Fat patterning. The

measurement is taken at the mid-point of the upper arm, located middle between the

lateral tip of the acromion and the olecranon when the arm is flexed at a 90 degree

angle. The tap was placed around the arm at the midpoint, with the arm relaxed and

elbow extended and the circumference was recorded to the nearest 0.1cm Callaway

(1988). Mid Upper Arm Circumference was calculated on participants using

measuring Tap. Mid Upper Arm Circumference criteria was 26 to 29 cm normal and

< 26 was showed malnutrition described by www.medical dictionary.com (2005).

Body Mass Index is another method for measurement of weight and height. Body

Mass Index is using more frequently as an assessment tool for malnutrition.

Another important method is dietary history method for assessing the nutritional

assessment. The dietary history gives information on the eating patterns and behaviors

of the family, amount of foods and quality of food consumed by the subjects

www.academia.edu.com (2010). This part of the nutritional assessment on the

number of meals, snacks, and beverages consumed. 24-hour recall method are using

in this study. 24-hour recall method is a most prominent method of assessing nutrient

intake. 24-hour dietary recall method was used to collect the data regarding nutrient

intake of an individual patients. It was based on the foods amount actually consumed

by the patients on three specific days. The patients were asked to recall as much detail

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as possible regarding the food intake for the past 24-hour. This method asked about,

what the patient had eaten in the whole day such as morning time, at lunch time,

during the afternoon, in the evening time and at dinner during the night www.

academia.edu (2010). This method is the easiest dietary assessing methods. Dietary

intake by subjects was evaluated in three days consecutive methods. Nutritional

assessment is useful identified population groups, individuals at risk of becoming

malnourished. The nutrient intake was estimated by dietary survey data, which is

based on the nutrient content of raw foods. Total cooked food consumed by the

subjects was assessed. Nutritive value was calculated of raw foods given nutritive

value by NIN (National Institute of Nutrition). Nutritive value was calculated on total

drinks and all foods consumed by subjects in Three days. Nutritive value was

calculated on all foods cereals, fruits, pulses, vegetables, drinks and oil, except all

spices and condiments. Adequate nutrition plays an important part for good health.

Reasons for malnutrition is not only poverty, it occurs due to imbalanced diet,

ignorance and wrong intake of food also. Nutritional deficiency is usually initiated by

an inadequate intake of one or more nutrients resulting from either a low content in

indigenous food sources or the presence of exogenous factors that interfere with

ingestion absorption and metabolism of the nutrients. This state of nutritional

deficiency usually can be identified by dietary assessment.

Biochemical method is another important component of nutritional assessment.

Biochemical estimation is a quick estimation of any deficiency. Serum Protein and

serum albumin is the main constituent in blood. Blood serum contain about 7 %

Protein, two third of which is the albumin fraction and the other third is in the

globulin fraction. Albumin is a main component in serum Protein component.

Proteins are the important building blocks for all cells and tissues, they are important

23
 Introduction

for body growth and weight management. They form the structural part of most

organs and make up antibodies that regulate body functions. Antibodies help the body

to defend against infection. Decreases of defence agent in pulmonary tuberculosis

patients during disease. Hence whose patient is weak in immunity power they can get

easily infected to tuberculosis infections. Many studies shows low level of serum

Protein is caused of weight loss in pulmonary tuberculosis patients. Decrease in

serum Protein level in pulmonary tuberculosis patients during disease time. High

Protein diet helps to increase the serum Protein level and serum albumin in blood of

pulmonary tuberculosis patients. High Protein diet helps to increase weight in

pulmonary tuberculosis patients. Various studies found that negative nitrogen balance

was present in pulmonary tuberculosis patients during disease. Negative nitrogen

balance is a main cause of weight loss in pulmonary tuberculosis patients. The plasma

Protein especially albumin is the main factor in Protein energy malnutrition.

However, it is generally agreed that the body‟s ability to synthesize serum albumin is

affected relatively late and that causes the primary effect of lack of Protein depletion

of muscle tissue Jelliffe (1966).

Albumin helps in proper absorption of drugs. Protein rich diet can help to increase the

Serum Albumin level in pulmonary tuberculosis patients. Many researches were

found low levels on Serum Protein and Serum Albumin seen in underweight

tuberculosis patients. During tuberculosis disease Serum Protein level is gradually

reduced. Lack of serum Protein in blood of pulmonary tuberculosis is the cause of

malnutrition. Control of malnutrition, Protein rich diet is given to patients. If high

Protein diet is given in malnourished patients, they prevent weight loss to in

pulmonary tuberculosis patients. Albumin is made mainly in the liver. Albumin helps

to carry some medicines and other substances through the blood and is important for

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 Introduction

tissue growth and healing 3.5 g/dl Albumin level is normal range in our blood. Less

level of Albumin causes of malnutrition and weight reduction. When there is an

inadequate Protein intake, the body begins to break down, muscle to obtain enough

amino acid for the synthesis of serum albumin. Low levels of serum albumin are

associated with extra pulmonary organ involvement in patients with pulmonary

tuberculosis Ahmad et al. (2011). Intake of high Protein diet is increased in serum

Protein level in pulmonary tuberculosis patients. Egg is an excellent source of Protein.

In fact, egg‟s white contains all the amino acids making it a perfect source of Protein.

So the study of nutrition uses the quality of Protein found in egg as a standard to

compare other sources of Protein.

Nutritional assessment is used to growth of abnormalities that point to the presence of

many diseases and also to prevent nutritional disorders and the increased morbidity

and mortality that accompany them. Nutritional support does not mean merely giving

Protein, Calories and Minerals but providing substrates for the biological of healing. It

involves screening all patients on arrival barring those with simple problems for

malnutrition underlying their disease, planning therapy and monitoring progress,

using standard guidelines. Sufficient nutrition is important for maintain the good

nutritional status, correct the nutritional deficiencies, to maintain body‟s ability to

metabolize the nutrients. Hence good nutrition is very effective on maintaining health

during disease time.

1.6 THE PRESENT STUDY AND ITS RATIONALE

Lack of immune system is responsible for pulmonary tuberculosis disease. Under

nutrition is one causes of lack of immune system. Under nutrition increases the risk of

tuberculosis and in turn tuberculosis can lead to malnutrition. Under nutrition is

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 Introduction

therefore highly prevalent among people with tuberculosis. It has been demonstrated

that under nutrition is a risk factor for progression from tuberculosis infection to

active tuberculosis disease and that under nutrition at the time of diagnosis of active

tuberculosis is a predictor of increased risk of death and relapse. Various studies had

been done in relationship of malnutrition and pulmonary tuberculosis disease and also

various studies had been done in importance of dietary counselling in pulmonary

tuberculosis patients and importance of various nutrients in pulmonary tuberculosis

disease. The extensive review of literature reveals that most of the studies were

conducted in western situation. Some studies had been done in India but such studies

have not been done in Chhattisgarh regions. Hence the present study will be done

under Chhattisgarh region. This study will definitely enhance the existing knowledge

and improvement of health status in pulmonary tuberculosis patients in Chhattisgarh.

Good nutrition plays an important role in pulmonary tuberculosis disease. Hence this

study will be done in pulmonary tuberculosis patients. During of disease dietary

counselling will be great help to control of malnutrition in pulmonary tuberculosis.

This study will improve the nutritional status (Weight, Mid Upper Arm

Circumference) which is quite lower in Pulmonary Tuberculosis patients. Nutritional

counselling will also improve the biochemical components like Serum Total Protein

and Serum Albumin which would definitely boost the nutritional status of the

Pulmonary Tuberculosis Patients. This study will be improved in the nutritional status

of the pulmonary Tuberculosis patients. Nutritional counseling can help in

improvement on health status and immunity of pulmonary tuberculosis patients and

improvement of the nutritional knowledge of pulmonary tuberculosis patients. This

study will be improvement weight in undernourished pulmonary tuberculosis patients

and improvement of quality of life and prosperous life.

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 Introduction

Nutritional status and food intake are critical factors in disease process. Therefore

nutritional care and nutritional support are key factors in disease management during

active phase of pulmonary Tuberculosis. Tuberculosis is a treatable disease that needs

better awareness. Good nutrition is very important to pulmonary tuberculosis not only

weight management but properly absorbent of drugs in tuberculosis disease.

Therefore the researcher plans is to study “Effect of Dietary Counselling on the

Nutritional Status of Pulmonary Tuberculosis Patients.”

1.7 OBJECTIVES
The specific objectives of the proposed research are as follows:

1) To study the prevalence of pulmonary tuberculosis in different socio economic

group.

2) To assess the anthropometric measurement of selected subjects.

3) To evaluate the nutrient intake and food habits of the respondents and

compare the pre-test and post-test nutrient intake.

4) To find out the presence of malnutrition in selected subjects.

5) To suggest the dietary guidelines in pulmonary tuberculosis patients.

6) To study the Protein and albumin level in the blood of pulmonary tuberculosis

patients and comparison of standard level.

7) To study the effect of dietary counseling in experimental group and compare it

with control group.

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 Introduction

1.8 HYPOTHESIS

1. There is significant effect of dietary counselling on the anthropometric and

biochemical components of pulmonary tuberculosis patients.

2. There is significant association of pre experimental anthropometric

measurement with selected demographic variables.

3. There is significant association of pre experimental biochemical components

with selected demographic variables.

1.9 LIMITATIONS OF THE STUDY

1. The study area was limited only Raipur district.

2. Only 200 Pulmonary Tuberculosis Patients were selected for the study.

3. The patients within the age group of 30 to 50 years were only considered.

4. Only Hospitalized who came in DOTS Center Patients were involved for the

study.

5. Only Male Pulmonary Tuberculosis Patients was involved in our study.

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