Nutritional Supplement and Its Role for Tuberculosis Patients_Dea

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BACKGROUND
in the 21st century, tuberculosis is still the most frequent underlying cause of wasting worldwide;
pathophysiology of wasting in tuberculosis remains poorly understood
high prevalence of human immunodeficiency (HIV) infection in the underdeveloped countries further
aggravates the problem of malnutrition and tuberculosis
risk of tuberculosis was nearly four-fold higher among men who were at least 10% underweight at
baseline than in men who were at least 10% overweight
experimental evidence suggests that malnutrition can lead to secondary immunodeficiency that
increases the host's susceptibility to infection
effects of malnutrition on tuberculosis
1. dietary deficiency causes thymic atrophy and impairs the generation and maturation of Tlymphocytes in animal models of tuberculosis, resulting in reduced number of immunocompetent
T-cells in lymphoid compartments including the blood
2. deficiency of protein and other nutrients impair T-cell functions, including decreased production of
Th1CK IL-2 and IFN- and depressed tuberculin reaction and PPD-induced lymphoproliferation
3. protein malnutrition impairs sequestration or trapping of reactive T-lymphocytes and loss of
tuberculosis resistance following BCG vaccination
4. protein malnutrition potentiates M tuberculosis H37Rv infected monocytes-macrophages to
produce higher level of TGF--a cytokine which has been implicated as a likely mediator of
immunosuppression and immunopathogenesis in tuberculosis
effects of tuberculosis on nutritional status
1. nutritional status is significantly lower in patients with active pulmonary tuberculosis compared
with healthy controls in different studies in Indonesia, England, India, and Japan
2. in patients with tuberculosis, a reduction in appetite, nutrient malabsorption, micronutrient
malabsorption, and altered metabolism leads to wasting
3. increased production of cytokines with lipolytic and proteolytic activity cause increased energy
expenditure in tuberculosis
NUTRITIONAL/DIETARY SUPPLEMENT
as defined by Congress in the Dietary Supplement Health and Education Act, which became law in
1994, a dietary supplement is a product (other than tobacco) that
o is intended to supplement the diet;
o contains one or more dietary ingredients (including vitamins; minerals; herbs or other botanicals;
amino acids; and other substances) or their constituents;
o is intended to be taken by mouth as a pill, capsule, tablet, or liquid; and
o is labeled on the front panel as being a dietary supplement.
nutritional counseling to increase energy intake combined with provision of supplements, when
started during the initial phase of tuberculosis treatment, produced a significant increase in body
weight, total lean mass, and physical function after six weeks
accelerating the recovery of lean tissue might help to restore physical functions more rapidly;
restoration of physical function might help to shorten the convalescent period and facilitate earlier
return to productive work; early restoration of nutrition could also lead to immunologic changes that
could enhance the clearance of mycobacteria and reduce infectiousness of patient
trial showed that vitamins C and E were effective in improving immune responses to tuberculosis
when given as adjuvant to multidrug tuberculosis therapy; supplementation with vitamin A and zinc
improved the effectiveness of the antituberculosis drugs in the first two months
WHO NUTRITION GUIDANCE ADVISORY GROUP KEY PRINCIPLE
1. all people with active TB should receive TB diagnosis, treatment and care according to WHO
guidelines and international standards of care
2. an adequate diet, containing all essential macro- and micronutrients, is necessary for the well-being
and health of all people, including those with TB infection or TB disease
malnutrition increases susceptibility to infection, infection can lead to metabolic stress and weight
loss, further weakening immune function and nutritional status
vitamins A, C, D, E, B6 and folic acid and the minerals zinc, copper, selenium and iron all play key
roles in metabolic pathways, cellular function and immune function; concentration of these
nutrients may have a role in an individuals defence against TB
3. because of the clear bidirectional causal link between undernutrition and active TB, nutrition
screening, assessment and management are integral components of TB treatment and care

Nutritional Supplement and Its Role for Tuberculosis Patients_Dea

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at diagnosis, nutrition screening and assessment should include anthropometric and clinical
measurements; if undernutrition is diagnosed, dietary assessment is also indicated; the following
are required:
1. age-appropriate anthropometric measurements and classification of nutrition status:
height and weight:
o in children who are less than 5 years of age, determination of weight-for-length or weightfor-height Z-score, using the WHO child growth standards
o in children and adolescents aged 519 years, determination of BMI- or-age-and-sex Zscore, using the WHO growth reference data for 519 years
o in adults over 18 years of age, determination of BMI
mid-upper arm circumference:
o in children who are less than 5 years of age and pregnant women
2. history of weight loss and signs of undernutrition, such as visible wasting or oedema
3. clinical assessment for comorbid conditions and concurrent treatments
4. diet assessment if nutritional status indicates malnutrition.
at TB follow-up, assessment should include, at a minimum:
1. anthropometric measures of weight, calculation of BMI and determination of weight and BMI
change since diagnosis or last visit
2. classification of nutrition status.
in patients classified as having moderate undernutrition, or severe acute malnutrition, further risk
factor and dietary assessment will be necessary, such as:
1. poor TB treatment adherence and/or response, resistance to TB drugs
2. clinical assessment for other non-dietary causes of malnutrition, including identification of
important comorbidities like HIV, diabetes mellitus or alcohol or drug abuse
3. biochemical assessment where possible
4. dietary assessment, including assessment of food security.
4. poverty and food insecurity are both causes and consequences of TB, and those involved in TB care
therefore play an important role in recognizing and addressing these wider socioeconomic issues
food insecurity, which is common in TB patients, and concomitant poor nutritional status, can
contribute to poor access and adherence to TB treatment
5. TB is commonly accompanied by comorbidities such as HIV, diabetes mellitus, smoking and alcohol
or substance misuse, which have their own nutritional implications, and these should be fully
considered during nutrition screening, assessment and counselling
immunosuppression associated with HIV has increased the incidence of active TB, especially in
Africa where latent TB is common and HIV prevalence is high
diabetes mellitus triples the risk of developing TB and can worsen the clinical course of TB; TB can
make management of blood glucose more difficult