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Assessment of the effect of nutrition education and micronutrient supplementation on the biochemical and immunological markers and quality of life of pulmonary tuberculosis patients in Bangladesh

Asim (25 years old) from Chittagong, sits in a hospital bed in Dhaka, Bangladesh, where he has been confined with tuberculosis for the last six months. © 2014 Probal Rashid, Courtesy of Photoshare

Research Overview

TRAction is funding research examining the effectiveness of tuberculosis (TB) interventions and services with emphasis placed on improving the nutritional status of TB-positive patients in Bangladesh.  This study examined the difference in quality of life when patients were exposed to nutrition education and/or micronutrient supplementation, specifically zinc and vitamin A. 

Bangladesh is ranked 6thamong 22 countries where TB is considered “high burden,” with a mortality rate of 45/100,000 and an incidence rate of 225/100,000 annually.  The National Tuberculosis Control Program (NTP) is credited with implementing directly observed therapy short course (DOTS) countrywide as of 2006 with an impressive 92% treatment success rate.   While TB contributes significantly to the burden of disease on Bangladesh’s citizenry, malnutrition also remains a significant problem.  By some estimates, 26% of the population is undernourished and among children, 43% of under-5 year olds are stunted.  Malnutrition in childhood often translates into poor nutritional outcomes in adulthood, including impairment of several important mechanisms of immune protection, which can compound hurdles to recovery from TB.

A malnourished adult is more likely to become infected with TB.  Among individuals with latent TB, the occurrence of malnutrition may be an important trigger for active TB development.  Unfortunately, little evidence exists  in regards to micronutrient supplementation effectiveness in improving DOTS treatment of TB.  Given the significant burden that both malnutrition and TB place on the population in Bangladesh, there is an opportunity to improve policy guidance and interventions for better outcomes in TB treatment and control.

Project Location 

Bangladesh: Narayanganj (Rupgonj, Bandar, Sonargoan) Gazipur (Kapasia and Sadar)

Research Objectives

Primary Objective: Understand the value of micronutrients on the TB disease process and its treatment strategy to potentially strengthen the efficacy of the DOTS program.

Secondary objectives:

  1. To assess the impact of interventions to improve nutritional status (weight gain and BMI) among patients with pulmonary TB,
  2. To compare the alteration in biochemical markers (plasma zinc, retinol and plasma leptin) among the patients with pulmonary TB in different study groups,
  3. To compare the changes in quality of life among TB patients in different study groups

Study Approach

Researchers employed a mixed methods, prospective longitudinal design examining an intervention implemented by the USAID TB Care II project.  216 newly diagnosed sputum positive pulmonary TB -positive adults between the age 18-59 were selected into the study from the following sub-districts: Bandar, Rupganj and Sonargoan from Narayanganj district and Kapasia and Sadar upazila from Gazipur district. The study areas were chosen using a convenience sampling approach based on TB case load and active presence of TB Care II. The sites were subsequently randomly selected into one of three groups, with two groups (Groups B & C) receiving different packages of nutrition-related interventions, and one group (Group A) acting as a control. Interventions included nutrition education (Group B and C) and micronutrient supplementation of 20mg zinc and 200,000 IU of Vitamin A (Group C only).   Nutrition education was provided every 2 weeks for the first two months, and then monthly for the next 4 months leading to a total of 6.  To gauge the response to micronutrient supplementation, 6 ml samples of venous blood were drawn at baseline, and follow-up measures were taken at 2 months and 6 months.  A standard questionnaire (SF-36) was used to measure quality of life at baseline and at 6 months.  Sputum specimens were taken using a routine method of 3 morning samples through DOTS.

Key Findings

There was improvement in the overall health status of the study participants. Weight and BMI increased and were the highest among the participants who got DOTS and nutrition education (Group B). Participants who received DOTS, micronutrients (vitamin A + zinc), and nutritional education had higher serum zinc and retinol level after intervention at 6 months compared to the other groups. The time taken for sputum to be AFB-negative was the shortest (9.2 days) in Group B. Serum Leptin level–indicator of fat storage within the body–increased in all groups. Quality of life assessed using Short Form 36 (SF 36) showed improvement in all three groups

Lessons Learned

There were several lessons learned as a result of this research. Training duration and quality were not significant predictors of improvements in nutritional status warranting further research on integration with TB control programs. Improvements in the quality of life assessment across groups illustrated the efficacy of the DOTS program generally and evidence for continued investments to prevent lost-to-follow-up cases. Finally, serum retinol level was raised at 6 months in all groups, but was highest in micronutrient supplementation group illustrating area for further research and potential for interventions.

Research into Action 

The study’s results will be helpful for improving the design of TB control activities, with focus on improving nutritional status through nutritional education and micronutrient supplementation.  Researchers will participate in dissemination activities in order to share the research findings with local stakeholders and ministries of health.

Implemented by

International Centre for Diarrheal Disease Research (icddr,b)

Principle Investigator: Dr. K. Zaman

Project Status

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