NUTRITIONAL STATUS OF PATIENTS WITH

TUBERCULOSIS AND TB/HIV CO-INFECTION AT

STANDERTON TB SPECIALISED HOSPITAL,
MPUMALANGA

Janke Wessels

Submitted in fulfilment of the requirements of the degree

Magister in Dietetics

in the

Faculty of Health Sciences

Department of Nutrition and Dietetics

University of the Free State

Bloemfontein

South Africa

June 2017

SUPERVISOR: Prof CM Walsh, Ph D

 DECLARATION

I, Janke Wessels, identity number 9004220023082 and student number 2008007022, hereby declare that
master’s research dissertation that I herewith submit at the University of the Free State, is my independent
work and that I have not previously submitted it for a qualification at another institution of higher
education.

I, Janke Wessels, hereby declare that I am aware that the copyright is vested in the University of the Free
State.

I, Janke Wessels, hereby declare that all royalties as regards intellectual property that was developed during
the course of and/or in connection with the study at the University of the Free State, will accrue to the
University.

Janke Wessels
January 2017

i
ACKNOWLEDGEMENTS

 My Heavenly Father, without Him this study would not have been possible;
 My family for their prayers and moral support, especially my husband and mother who always
encouraged me;
 Prof Corinna Walsh, of the Department of Nutrition and Dietetics, University of the Free State, my
supervisor, for all her support, inspiration and efficient feedback;
 Miss. Riette Nel, of the Department of Biostatistics, University of the Free State, for her efficient
assistance with the statistical analysis of the data;
 The respondents for taking part in the study.

≈≈≈≈≈≈≈≈≈

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LIST OF ABBREVIATIONS

AIDS - acquired immune deficiency syndrome

ART - antiretroviral therapy

ASSAf - Academy of Science in South Africa

BCG - bacille Calmette–Guérin

BMI - Body Mass Index

CCHIP - Community Childhood Hunger Identification Project

CEO - Corporate Executive Officer

CI - confidence intervals

cm - centimetre

CRP - C-reactive protein

DOTS - Directly Observed Therapy, Short-course

E - Ethambutol

ECUFS - Ethics Committee of the Faculty of Health Sciences, University of the Free State

EPTB - extra-pulmonary tuberculosis

g/dl - gram per decilitre

g/kg - gram per kilogram

g/l - gram per litre

H - Isoniazid

HBCs - high burden countries

HIV - Human Immunodeficiency Virus

IUATLD - International Union against Tuberculosis and Lung Disease

kcal/kg - kilocalorie per kilogram

kg - kilogram

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kg/m² - kilogram per metre square

MCT - medium-chain triglycerides

MCV - mean corpuscular volume

MDR TB - multi-drug resistance tuberculosis

mm - millimetre

mm³ - cubic millimetre

mg/l - milligram per litre

ml/kg - millilitre per kilogram

M. tb - Mycobacterium tuberculosis

MUAC - Mid-upper arm circumference

MUST - Malnutrition Universal Screening Tool

NFCS - National Food Consumption Survey

NHNES - National Health and Nutrition Examination Survey

OR - odd ratio

PHREC - Provincial Health and Research Ethics Committee

PLHIV - people living with HIV/AIDS

ppr - person per room

R - Rifampicin

REE - resting energy expenditure

S - Streptomycin

SADoH - South African Department of Health

SANHANES - South African National Health and Nutrition Examination Survey

SANTA - South African National Tuberculosis Association

TB - Tuberculosis

iv
TST - tubercle skin test

UDHR - Universal Declaration of Human Rights

UFS - University of the Free State

vs. - versus

WFP - World Food Programme

WHO - World Health Organization

XDR TB - extremely-drug resistance tuberculosis

Z - Pyrazinamide

% - percentage

> - greater than

< - less than

> - equal to or greater than

< - equal to or less than

v
LIST OF TABLES Page

Table 2.1:
Estimated TB burden in South Africa during 2014 10
Table 2.2:
Estimated TB/HIV co-infection burden in South Africa during 2014 10
Table 2.3:
Vulnerability factors related to progression to TB disease 27
Table 2.4:
Recommended daily dosages of the individual drugs for adults and children >8yrs/ >30kg 27
Table 2.5:
Fixed dose combination tablets available for adults and children >8yrs/ >30kg 28
Table 2.6:
Standard treatment regimen for adults and children >8yrs/ >30kg 28
Table 2.7:
Medications used for the management of TB 29
Table 2.8:
Energy and Nutrient requirements for PLHIV and/or TB 33
Table 3.1:
Weight classifications by Body Mass Index 41
Table 3.2:
Cut-off points for classification of adult- malnutrition by mid-upper arm circumference 41

Table 3.3:
Triceps skinfolds in millimetres for females 20 years of age and older 42

Table 3.4:
Triceps skinfolds in millimetres for males 20 years of age and older 42

Table 4.l:
Socio-demographic information 55

Table 4.2:
Vegetable gardens 56

Table 4.3:
Responses to Community Childhood Hunger Identification Project questionnaire 57

vi
Table 4.4:
Household food security 58

Table 5.1:
Triceps skinfolds in millimetres for females 20 years of age and older 71

Table 5.2:
Triceps skinfolds in millimetres for males 20 years of age and older 71

Table 5.3:
Food related side effects according to HIV status 75

Table 5.4:
Number of food related side effects experienced 76
Table 5.5:
Overall risk of malnutrition 77

Table 5.6:
Unplanned weight loss; comparing TB with and without HIV co-infection 78

Table 5.7:
BMI, MUAC and triceps skinfold (median), comparing genders by means of 95% CI 79

Table 5.8:
BMI, MUAC and triceps skinfold (categories) 80

Table 5.9:
Biochemical Parameters (median); according to gender 81

Table 5.10:
Biochemical Parameters (categories); according to gender 82

Table 6.1:
Median smoking habits of former and current smokers 99

Table 6.2:
Smoking habits 99

Table 6.3:
Level of education, BMI categories and associations with smoking habits 100

vii
Table 6.4:
Alcohol use 101

Table 6.5:
Level of education, BMI categories and associations with alcohol use 102

Table 6.6:
Combined smoking habits and alcohol use 103

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LIST OF FIGURES Page

Figure 2.1
Estimated new TB cases globally during 2010 9

Figure 2.2:
Pathogenesis of TB 13

Figure 2.3:
TB Transmission 14

Figure 2.4
The vicious cycle involving HIV infection and malnutrition 15

Figure 2.5:
Steps required for the diagnosis of TB 17

Figure 2.6:
Relationship between TB and nutrition 23

Figure 2.7:
Factors affecting the impact of food support interventions on malnutrition and disease outcome 25

Figure 3.1:
The Malnutrition Universal Screening Tool 43

ix
LIST OF ADDENDUMS Page

Addendum A:
Guidelines for food safety 128

Addendum B:
Dietary Management of HIV and TB Related Illness 129

Addendum C:
General nutritional recommendations for people with TB and/or HIV 132

Addendum D:
Letter for the PHREC of Mpumalanga Department of Health 133

Addendum E:
Approval letter from the PHREC of Mpumalanga Department of Healt 134

Addendum F:
Approval letter from the Health Research Ethics Committee at the UFS 135

Addendum G:
Letter to ask Permission to Conduct the Study at the Hospital 136

Addendum H:
Approval letter from the CEO at Standerton TB Specialised Hospital 137

Addendum I:
Informed Consent (English and IsiZulu) 138

Addendum J:
Information Document 140

Addendum K:
Questionnaire (English and IsiZulu) 142

x
SUMMARY

Tuberculosis (TB) is a leading cause of morbidity and mortality, especially in middle- and low-income
countries. Globally, an estimated 2 billion people are infected with TB, of which 1 billion are malnourished.
TB is strongly influenced by nutritional status, with nutrition interventions being likely to impact on
prevalence of active disease, response to drug therapy and quality of life.

The aim of this study was to determine the nutritional status of patients with TB and TB/HIV co-infection. A
convenience sample of a 100 hospitalised patients in Standerton TB Specialised Hospital, Mpumalanga, were
included (60 men and 40 women). Socio-economic status, nutritional status (focusing on eating related side
effects, food security, anthropometric measurements, overall risk of malnutrition and biochemical
parameters), and lifestyle behaviours (smoking habits and alcohol use), as well as associations between the
above were determined.

Food security was determined by means of the Community Childhood Hunger Identification Project (CCHIP)
tool (that includes questions related to food insecurity, food shortages, perceived food insufficienty or altered
food intake due to constraints on resources). Weight and height were obtained to calculate body mass index
(BMI), while mid-upper arm circumference (MUAC) and triceps skinfold were taken to determine
malnutrition and muscle wasting. The overall risk of malnutrition was determined by means of the
Malnutrition Universal Screening Tool (MUST) (which calculates the overall risk of malnutrition by making
use of a BMI score, a weight loss score and an acute disease score). Biochemical parameters were recorded
from patient files. Socio-economic status included gender, age, marital status, education level, employment
status, household income and housing density. Lifestyle factors included smoking habits and alcohol use.
These variables were determined by means of a questionnaire completed by the researcher in a structured
interview with each participant.

The majority of participants (91%) did not complete matric and two thirds (66%) were unemployed. More
than one out of ten participants (12%) indicated that they had no monthly income and in 64% of households,
only one person contributed to the monthly income. Room density of more than 2.5 persons per room
(crowded) was present in 29% of households. Only 26% of participants reported having a household
vegetable garden. As far as household food security was concerned, only 3% were classified as food secure
with 27% of households being at risk of hunger and 70% being food insecure (hungry).

The food related side effects reported most commonly included loss of appetite (59%) followed by dry mouth
(48%). According to the MUST, the overall risk for malnutrition was as follows: 70% had a high risk, 22%
had a medium risk and 8% had a low risk. Actual unplanned weight loss and percentage of unplanned weight
loss were significantly higher in patients with TB and HIV co-infection than in patients with TB only (95%
xi
CI [1.5%; 38.2%] and [5.3%; 51.0%] respectively). Median BMI was in the underweight category at 18.3
kg/m². Half of participants (51%) had a MUAC in the low category, while half (49.9%) had triceps skinfold
measurements below the 15th percentile, indicating malnutrition. The majority of participants had albumin
and haemoglobin values below the normal ranges (79% and 92% respectively).

Almost six out of ten participants (58%) indicated that they were former (44%) or current (14%) smokers.
The average cigarettes, pipes or cigars smoked by the former and current smokers were 4 with a maximum
of 20 per day. The average amount of years that the former or current smokers smoked was 9 years with a
minimum of 1 year and a maximum of 30 years. Nearly half of participants (49%) reported that they did use
alcohol with 25% drinking alcohol more than three times per week. Statistically significantly more females
than males were non-smokers and more men drank alcohol three times or more per week than females.
Participants that indicated that they were either former or current smokers had significantly lower levels of
education than participants who were non-smokers (95% CI [-26.7%; -2.6%] and [-39.9%; -1.0%]
respectively). There were no statistically significant differences in terms of BMI in smokers versus non-
smokers.

In the present study, the nutritional status of patients with TB and TB/HIV co-infection was found to be poor.
They were characterised by poor socio-economic status, high levels of food insecurity, malnutrition
(underweight, anaemia and hypoalbuminaemia) and poor lifestyle habits (smoking and alcohol use).

Recommendations to address the poor nutritional status of patients with TB and TB/HIV co-infection should
include relief of poverty in communities, a focus on relevant and culturally acceptable nutrition education
and the establishment of sustainable support networks.

xii
OPSOMMING

Tuberkulose (TB) is ‘n hoofoorsaak van siekte en sterftes, veral in middel en lae inkomste lande. Wêreldwyd
het ongeveer 2 biljoen mense TB, waarvan 1 biljoen wangevoed is. TB word sterk beïnvloed deur
voedingstatus, dus speel voedingsintervensies heel moontlik ‘n belangrike rol in die voorkoms van aktiewe
TB, die reaksie op medikasie en lewenskwaliteit.

Die doel van hierdie studie was om die voedingstatus van pasiënte met TB en TB/MIV ko-infeksie te bepaal.
‘n Gerieflikheidsteekproef van 100 gehospitaliseerde pasiënte by Standerton TB Hospitaal is ingesluit (60
mans en 40 vroue). Sosio-ekonomiese status, voedingsstatus (met fokus op newe effekte wat verband hou
met voedselinname, voedselsekuriteit, antropometriese inligting, risiko vir wanvoeding en biochemiese
merkers), en leefstyl veranderlikes (rookgewoontes en alkoholinname), asook verbande tussen veranderlikes
is bepaal.

Voedselsekuriteit was bepaal deur middel van die Community Childhood Hunger Identification Project
(CCHIP) (wat vrae insluit oor voedselsekuriteit, voedseltekorte, siening oor voedseltekort en verlaagde
voedselinname as gevolg van beperkte voedselbronne). Massa en lengte was gemeet om liggaams-massa
indeks (LMI) te bepaal en bo-arm omtrek en trisepsvelvou was geneem om wanvoeding en spierwegkwyning
te bepaal. Die risiko vir wanvoeding was deur middel van die Malnutrition Universal Screening Tool (MUST)
bepaal (bereken die totale risiko vir wanvoeding deur te kyk na die LMI, massaverlies en akute siekte).
Biochemiese merkers was geneem vanuit die leêrs van pasiënte. Sosio-ekonomiese status het geslag,
ouderdom, huweliksstatus, vlak van opvoeding, werkstatuss, huishouding se inkomste en kamerdigtheid
ingesluit. Leefstylfaktore het rookgewoontes en alkoholinname ingesluit. Hierdie veranderlikes is bepaal
deur middel van ‘n vraelys wat deur die navorser voltooi is in ‘n gestruktureerde onderhoud met elke
deelnemer.

Die meerderheid van deelnemers (91%) het nie matriek voltooi nie en twee derdes (66%) was werkloos. Meer
as een uit tien deelnemers (12%) het aangedui dat hulle geen maandelikse inkomste het nie en in 64% van
huishoudings, dra slegs een persoon tot die maandelikse inkomste by. Kamerdigtheid van meer as 2.5 persone
per kamer (oorbevolking) was teenwoordig in 29% van huishoudings. Slegs 26% van deelnemers het
aangedui dat hulle ‘n groentetuin by die huis het. Met betrekking tot voedselsekuriteit, was slegs 3% van
huishoudings geklassifiseer in die katogorie van voldoende voedselsekuriteit, 27% het ‘n risiko gehad vir
swak voedselsekuritiet en 70% het geen voedselsekuriteit gehad nie (honger).

Die newe effekte wat veband hou met voedseliname wat die meeste gerapporteer was, was ‘n verlies aan
aptyt (59%) gevolg deur ‘n droë mond (48%). Volgens die MUST, was die risiko vir wanvoeding soos volg:
70% het ‘n hoë risiko gehad, 22% ‘n medium risiko en 8% het ‘n lae risiko gehad. Onbeplande massaverlies
xiii
sowel as die persentasie van opbeplande massaverlies was betekenisvol hoër in pasiënte met TB en MIV ko-
infeksie as wat dit in pasiënte met slegs TB was (95% VI [1.5%; 38.2%] en [5.3%; 51.0%] onderskeidelik).
Mediaan LMI was in die ondergewig kategorie van 18.3 kg/m². Die helfte van deelnemers (51%) het lae bo-
arm omterk afmeetings gehad terwyl die helfte (49.9%) trisepsvelvou-afmeetings van onder die 15de
persentiel gehad, wat wanvoeding aandui. Die meerderheid van deelnemers het albumien en hemoglobien
waardes onder die normale waardes gehad (79% en 92% onderskeidelik).

Naastenby ses uit elke tien deelnemers (58%) het aangedui dat hulle vorige (44%) of huidige (14%) rokers
was. Die gemiddelde aantal sigarette of pype wat per dag deur die vorige of huidige rokers gerook was, was
4 met ‘n maksimum van 20. Die gemiddelde aantal jare wat die vorige of huidige rokers gerook het was 9
jaar met ‘n minimum van 1 jaar en’n maksimum van 30 jaar. Bykans die helfte van deelnemers (49%) het
aangedui dat hulle alkohol inneem, met 25% wat alkohol meer as drie keer per week inneem. Statisties
betekenisvol meer vroue as mans het nie gerook nie en meer mans het alkohol drie of meer keer per week
ingeneem as vroue. Deelnemers wat aangedui het dat hulle vorige of huidige rokers was, het betekenisvolle
laer vlakke van opvoeding gehad as deelnemers wat aangedui het dat hulle nie rook nie (95% VI [-26.7%; -
2.6%] en [-39.9%; -1.0%] onderskeidelik). Daar was geen statistiese betekenisvolle verskil in terme van LMI
tussen rokers en nie-rokers nie.

Die voedingstatus van pasiënte met TB en TB/MIV ko-infeksie in hierdie studie was oor die algemeen swak.
Hulle was gekenmerk deur swak sosio-ekonomiese status, hoë vlakke van swak voedselsekuriteit,
wanvoeding (ondermassa, anemie, hipoalbumienemie) en swak leefstylgewoontes (rookgewoontes en
alkoholinname).

Aanbevelings om die swak voedsingstatus van pasiënte met TB en TB/MIV ko-infeksie aan te spreek sluit
verligting van armoede in gemeenskappe, fokus op toepaslike en kulturele aanvaarbaarde voedingsonderrig
en die stig van volhoubare ondersteuningsnetwerke in.

xiv
KEYWORDS

Tuberculosis

Nutritional status

Poverty

Food security

Malnutrition

Lifestyle habits

xv
 i. DECLARATION
ii. ACKNOWLEDGEMENTS
iii. LIST OF ABBREVIATIONS
iv. LIST OF TABLES
v. LIST OF FIGURES
vi. LIST OF APPENDICES
vii. SUMMARY
viii. OPSOMMING
ix. KEYWORDS

xvi
Contents
CHAPTER 1 INTRODUCTION .................................................................................................................................. 1
1.1 BACKGROUND ..........................................................................................................................................................................1
1.2 PREVALENCE OF TB ..........................................................................................................................................................3
1.2.1 TB: A global perspective ..................................................................................................................................................3
1.2.2 TB in Africa ......................................................................................................................................................................3
1.3 FACTORS THAT IMPACT ON TB ..........................................................................................................................................4
1.3.1 Socio-economic status ......................................................................................................................................................4
1.3.2 Nutritional status ..............................................................................................................................................................4
1.3.3 Lifestyle behaviours ..........................................................................................................................................................6
1.4 PROBLEM STATEMENT .......................................................................................................................................................6
1.5 AIMS AND OBJECTIVES ..............................................................................................................................................................6
1.5.1 Aims ..................................................................................................................................................................................6
1.5.2 Objectives .........................................................................................................................................................................6
1.6 OUTLINE OF THESIS ...........................................................................................................................................................7
CHAPTER 2 TB AND TB/HIV CO-INFECTION ..................................................................................................... 8
2.1 INTRODUCTION .........................................................................................................................................................................8
2.2 EPIDEMIOLOGY OF TB AND TB/HIV CO-INFECTION .................................................................................................................8
2.3 AETIOLOGY AND PATHOPHYSIOLOGY OF TB ..........................................................................................................................10
2.4 HIV-ASSOCIATED TB .............................................................................................................................................................14
2.5 SCREENING AND DIAGNOSIS....................................................................................................................................................16
2.6 ASSESSMENT OF NUTRITIONAL STATUS...................................................................................................................................17
2.6.1 Anthropometry ................................................................................................................................................................18
2.6.2 Biochemistry ...................................................................................................................................................................18
2.6.3 Clinical signs and symptoms ..........................................................................................................................................19
2.6.4 Dietary intake .................................................................................................................................................................20
2.6.5 Exercise or physical activity and other lifestyle factors .................................................................................................20
2.6.6 Family/household situation ............................................................................................................................................21
2.8 TB AND MALNUTRITION .........................................................................................................................................................22
2.9 FOOD SECURITY AND FOOD SUPPORT ......................................................................................................................................23
2.10 FOOD SAFETY........................................................................................................................................................................25
2.11 MANAGEMENT OF TB ...........................................................................................................................................................25
2.11.1 Medical treatment of TB ...............................................................................................................................................25
2.11.1.1 DOTS ........................................................................................................................................................................................ 26
2.11.1.2 Vulnerability ............................................................................................................................................................................. 26
2.11.1.3 Standard regimens ..................................................................................................................................................................... 27
2.11.1.4 Drug-nutrient interactions and food related side effects ............................................................................................................ 28
2.11.1.5 Place where TB patients are treated .......................................................................................................................................... 29
2.11.1.6 The “End TB Strategy” ............................................................................................................................................................. 30
2.11.1.7 Drug resistance ......................................................................................................................................................................... 30
2.11.2 NUTRITION THERAPY FOR TB AND TB/HIV CO-INFECTION ...............................................................................................31
2.11.2.1 Macronutrients ..........................................................................................................................................................31
2.11.2.2 Micronutrients ........................................................................................................................................................................... 35
2.11.2.3 Micronutrient supplementation ................................................................................................................................................. 37
2.12 PREVENTION PROGRAMMES..................................................................................................................................................37
2.13 CONCLUSION ........................................................................................................................................................................38
CHAPTER 3 METHODOLOGY ............................................................................................................................... 39
3.1 INTRODUCTION ................................................................................................................................................................39
3.2 ETHICAL CONSIDERATIONS ..............................................................................................................................................39
3.3 SAMPLE SELECTION ................................................................................................................................................................39

xvii
 3.3.1 Population and sample selection ....................................................................................................................................39
3.3.2 Sample ............................................................................................................................................................................39
3.3.2.1 Inclusion criteria ......................................................................................................................................................................... 40
3.3.2.2 Exclusion criteria ........................................................................................................................................................................ 40
3.4 OPERATIONAL DEFINITIONS ....................................................................................................................................................40
3.4.1 Room density ..................................................................................................................................................................40
3.4.2 Eating related side effects and food security ..................................................................................................................40
3.4.3 Anthropometric measurements .......................................................................................................................................41
3.4.3.1 Body mass index (BMI) ...................................................................................................................................................... 41
3.4.3.2 Mid-upper arm circumference (MUAC) .............................................................................................................................. 41
3.4.3.3 Triceps skinfold ................................................................................................................................................................... 42
3.4.4 Overall risk of malnutrition ............................................................................................................................................42
3.4.5 Biochemical parameters .................................................................................................................................................43
3.4.6 Lifestyle behaviours ........................................................................................................................................................44
3.4.6.1 Smoking habits .................................................................................................................................................................... 44
3.4.6.2 Alcohol consumption........................................................................................................................................................... 44
3.5 PILOT STUDY...........................................................................................................................................................................44
3.6 DATA COLLECTION PROCESS ...................................................................................................................................................44
3.7 TECHNIQUES ...........................................................................................................................................................................45
3.7.1 Questionnaire .................................................................................................................................................................46
3.7.2 Anthropometric measurements .......................................................................................................................................46
3.7.2.1 Weight ........................................................................................................................................................................................ 46
3.7.2.2 Height ......................................................................................................................................................................................... 46
3.7.2.3 Mid-upper arm circumference..................................................................................................................................................... 46
3.7.2.4 Triceps skinfold .......................................................................................................................................................................... 47
3.7.3 Biochemical parameters .................................................................................................................................................47
3.8 STATISTICAL ANALYSIS ..........................................................................................................................................................47
3.9 MEASUREMENT AND METHODOLOGY ERRORS AND LIMITATIONS ...........................................................................................47
3.10 VALIDITY AND RELIABILITY .................................................................................................................................................48
3.10.1 Questionnaire ...............................................................................................................................................................48
3.10.1.1 Validity ..................................................................................................................................................................................... 48
3.10.1.2 Reliability ................................................................................................................................................................................. 48
3.10.2 Anthropometric measurements .....................................................................................................................................48
3.10.2.1 Validity ..................................................................................................................................................................................... 48
3.10.2.2 Reliability ................................................................................................................................................................................. 48
3.10.3 Biochemical parameters ...............................................................................................................................................48
3.10.3.1 Validity ..................................................................................................................................................................................... 48
3.10.3.2 Reliability ................................................................................................................................................................................. 49

CHAPTER 4 SOCIO-DEMOGRAPHIC PROFILE AND HOUSEHOLD FOOD SECURITY OF PATIENTS

WITH TB, AND TB/HIV CO-INFECTION AT STANDERTON TB SPECIALISED HOSPITAL,
MPUMALANGA ......................................................................................................................................................... 50
CHAPTER 5 NUTRITIONAL STATUS OF PATIENTS WITH TB, AND TB/HIV CO-INFECTION AT
STANDERTON TB SPECIALISED HOSPITAL, MPUMALANGA .................................................................... 68
CHAPTER 6 SMOKING HABITS AND ALCOHOL USE OF PATIENTS WITH TB, AND TB/HIV CO-
INFECTION AT STANDERTON TB SPECIALISED HOSPITAL, MPUMALANGA ...................................... 94
CHAPTER 7 CONCLUSIONS AND RECOMMENDATIONS ........................................................................... 109
7.1 INTRODUCTION ...............................................................................................................................................................109
7.2 CONCLUSIONS ..................................................................................................................................................................109
7.2.1 Socio-demographic characteristics and household food security ................................................................................109
7.2.2 Nutritional status ..........................................................................................................................................................109
7.2.3 Lifestyle behaviours ......................................................................................................................................................110
7.3 RECOMMENDATIONS .....................................................................................................................................................110
xviii
7.3.1 Recommendations to address TB ..................................................................................................................................110
7.3.1.1 Poverty relief............................................................................................................................................................................. 110
7.3.1.2 Nutrition education ................................................................................................................................................................... 111
7.3.1.3 Support networks ...................................................................................................................................................................... 111
7.3.2 Recommendations for further research ........................................................................................................................112

xix
 CHAPTER 1
INTRODUCTION
1.1 Background
“Interventions and innovations, scientific discoveries, incredible advances in technology – even with all this,
there are still more than 2 billion people infected with TB in the world, 9 million new TB cases every year
and 1.3 million die every year. Sadly, 3 million are missed by health systems and they do not have access to
proper diagnosis, treatment, follow up and the care that they deserve and need”. This statement was made
by Dr. Lucica Ditiu, Executive Secretary of the Stop TB Partnership in 2014. It is almost impossible to
comprehend that a disease that has existed for more than 2000 years is still a major health challenge in 2016.

Tuberculosis (TB) is an infectious disease by when the Mycobacterium tuberculosis (M. tb) organism entering
the lungs. TB can also spread through the bloodstream manifesting as extra-pulmonary TB that affects almost
any organ, including: the genitourinary tract, lymph nodes, bones, brain etc. (Lombardo et al., 2012: 132;
Escott-Stump, 2008: 303; Spencer, 2005: 107).

The World Health Organization (WHO) estimates that globally 33% of people are infected with M. tb.
However, only 10% of those infected with M. tb will develop active TB disease (WHO, 2013a). Certain risk
factors can increase an individual’s chances of developing active TB. These factors include poor nutritional
status, diabetes, smoking, alcohol abuse, human immunodeficiency virus (HIV) infection, cancer or renal
disease (Lombardo et al., 2012: 180; Mueller, 2012: 782; Frieden et al., 2003: 887).

Symptomatic patients most commonly present with fever, a productive cough in the case of pulmonary TB
(lasting longer than two weeks), and night sweats. Other symptoms may include chest pain, haemoptysis,
enlargement of the lymph nodes, chills, shortness of breath, exhaustion, loss of appetite, anorexia, pallor and
weakness. Weight loss is common and is most likely caused by a combination of a reduction in appetite and
increased energy expenditure as part of the inflammatory and immune response (Escott-Stump, 2008: 304;
Oldewage-Theron & Fuller, 2008: 659; Hopewell et al., 2006: 710; Williams, 2006: 51; Spencer, 2005: 109;
Frieden et al., 2003: 888).

Anti-tuberculosis medications (Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol) were introduced in the
1940’s and 1950’s (Marra et al., 2004: 58). However, despite the availability of treatment, WHO declared
TB as a “global health emergency” in 1993 (MacPherson et al., 2014: 126; McConnell & Hargreaves, 2013:
285). In 2000 Karyadi et al. (2000: 720) stated that TB is on the increase throughout the world. In the year
2000 there were an estimated 8-9 million new cases of TB and in 2002 the figure was 8.8 million (Villamor
et al., 2006: 163). Two decades later, TB is still a major challenge and is ranked as the second leading cause
1
of death from an infectious disease after HIV infection, killing approximately two million people per year. In
2011, the WHO estimated that there were 8.7 million new cases of TB and 1.4 million deaths due to TB
disease (Frediani et al., 2013: 1024; Miyata et al., 2013; Gill et al., 2013: 984; Frieden et al., 2003: 889;
Karyadi et al., 2000: 2954). In 2013, the WHO estimated that there were 9 million new cases of TB and 1.5
million deaths due to TB disease (WHO, 2013). Frieden et al. (2003: 889) stated that unless TB is controlled
throughout the world, it will continue to be a major cause of death in developing countries and it will remain
a threat in developed countries.

The impact of TB cannot be isolated from the HIV epidemic, since the two diseases fuel each other (Bloem
& Saadeh, 2010). The incidence of TB in Africa has increased mostly as a result of HIV infection (Frieden
et al., 2003: 888; Semba et al., 2010). The WHO estimates that 66% of people with TB disease in South
Africa are co-infected with HIV (SANTA, 2014; WHO, 2013). Nelson Mandela’s words on July 15, 2004
were: “We cannot win the battle against AIDS if we do not also fight TB. TB is too often a death sentence for
people with AIDS. It does not have to be this way. We have known how to cure TB for more than 50 years.
What we have lacked is the will and the resources to quickly diagnose people with TB and get them the
treatment they need.”

TB and HIV are both diseases causing wasting amongst the infected and co-infection has severe negative
consequences on the nutritional status (Friis, 2006: 1849; Paton et al., 2003: 321). In certain developing
countries like South Africa, Botswana, Zambia and Zimbabwe, the prevalence of TB and TB/HIV co-
infection exceeds 60%. TB is also the most frequent opportunistic infection in patients with HIV living in
developing countries (Escott-Stump, 2008; Marra et al., 2004:58; Paton et al., 2003: 322). Co-infection with
TB and HIV has had a significant impact on global health as well as on, social, political and economic
outcomes (ADA, 2010).

The consequences of TB on the individual level and on the public health sector cannot be ignored. Against
the background of malnutrition, TB could contribute to serious public health setbacks. These setbacks can
have a tremendous impact on individual, community and national well-being (Wallis et al., 2013: 366; Escott-
stump, 2008; Naude et al., 2008). The necessity for governments of countries experiencing a high TB burden
to increase financial, political and social commitment is greater than ever (Mwaba et al., 2011: 824). In
addition to the many research gaps in the field of TB, the need for nutritional research is becoming more
evident by the day (Cegielski & McMurray, 2004: 297; Van Lettow et al., 2004: 61; Van Lettow et al., 2003:
87; Karyadi et al., 2000: 2926).

2
1.2 Prevalence of TB
1.2.1 TB: A global perspective
The WHO estimates that over 4 000 people die of TB every day and 3 million TB cases are missed by health
care systems (WHO, 2015). The TB burden is most significant in developing countries, with developed
countries having the lowest TB prevalence. The incidence of TB in Australia and Northern Italy, which are
both developed countries, is among the lowest in the world, with respective rates of 6 and 7.6 cases per 100
000 of the population (Facinni et al., 2013: 486; Gill et al., 2013: 985).

TB is one of the top killers of women, with 300 000 global deaths among HIV-negative women and 200 000
deaths among HIV-positive women in 2011 (Miyata et al., 2013). TB is a major challenge in poor developing
countries, contributing to as many as 95% of all deaths (WHO, 2013). India, Indonesia, Pakistan, China and
Bangladesh together account for more than half of the global TB burden. According to a Household Health
Survey that was undertaken in Indonesia in 1995, TB ranked second among the leading causes of death. India
had an incidence of 185 cases per 100 000 of the population in 2010 (Bhargava et al., 2013). Globally there
has been a 45% decrease in TB deaths since 1990. However, even with that progress, 1.3 million people died
of TB and 8.6 million people were diagnosed with TB in 2012 (WHO, 2013). In 2014, even higher rates were
reported with an estimated 9.6 million people diagnosed with TB and 1.5 million TB deaths (WHO, 2015).

1.2.2 TB in Africa
The African Region is the only region which is not on track with the WHO Millennium Development Goal
that has set a target to reduce the incidence of death caused by TB by half between 1990 and 2015
(MacPherson et al., 2014: 128). In 2012 27% of all TB cases were diagnosed in Africa (WHO, 2013). Sub-
Saharan Africa has the highest incidence of TB with a 290 per 100 000 infection rate (Frieden et al., 2003:
891; Karyadi et al., 2002: 724). According to the WHO (2013) and the South African National Tuberculosis
Association (SANTA) (2014), South Africa is one of the countries with the highest TB burden in the world.
South Africa has the third highest incidence of TB with only India and China having higher figures (WHO,
2013). In 2004, South Africa had the highest incidence of TB in Africa with an estimated rate of 718 cases
per 100 000 of the population. In 2009 the incidence rate increased to 971 cases per 100 000 of the population
(Lombardo et al., 2012: 185). The figure increased to over a 1 000 cases per 100 000 of the populating in
poor communities in the Western Cape of South Africa. Since 2010 there has been a slight reduction in the
TB incidence per 100 000 people with 948 in 2010, 922 in 2011, 892 in 2012, and 860 in 2013.

In South Africa, the TB epidemic is also fuelled by the HIV pandemic, with almost 7 million people infected
by HIV. Individuals infected with HIV have an increased risk of becoming infected with TB and an estimated
60% of patients with TB in South Africa are HIV-positive. In 2014 89 000 TB deaths were reported in South

3
Africa, of which 64 000 were HIV co-infected. South Africa also had a fourfold increase in TB case numbers
over the last twenty years, mainly driven by the fast spread of HIV (Nieburg & Angelo, 2015: 5-6; Louwagie
et al., 2014: 501).

Independent of the HIV burden in South Africa, the TB and TB/HIV co-infection situation is even more
complex than that in most other lower- and middle-income countries. South Africa faces many other
challenges including poverty, the stagnating economic situation, stigma and discrimination against people
with TB disease, and the two class health system (state and private) that cannot adequately address the basic
health needs of the larger more vulnerable population (Nieburg & Angelo, 2015).

1.3 Factors that impact on TB

1.3.1 Socio-economic status
Socioeconomic factors impact heavily on the rate of TB infection in a country. These include poverty, over
crowding, unemployment, malnutrition, and inadequate health facilities. These factors do not only increase
the incidence of TB, but also increase the chances of treatment failure. According to the SANTA, the
incidence of TB is especially high amongst males, miners, migrants, prisoners, the elderly, refugees and
internally displaced persons, substance users, homeless persons, the poor and the very young groups in South
Africa (SANTA, 2014; Chee et al., 2013: 205; Songpol et al., 2005: 221).

Food insecurity is a socio-economic factor that plays an important role in the progression of TB infection to
active TB disease (Bloem & Saadeh, 2010). Rudolph et al. (2013) have reported that 96.5% of adult males
and females with TB disease in South Africa experience food insecurity (defined according to Bloem &
Saadeh (2010) as difficulties with food utilisation, availability or access). In an attempt to optimise nutritional
status and health care for the community and the individual, food and nutritional security are essential factors
to consider (ADA, 2010).

1.3.2 Nutritional status

Proper nutrition plays a vital role in supporting the health and quality of life of people with HIV and TB
disease (ADA, 2010). The immune function and nutritional status are closely related (Macallan, 1999: 743).
According to Rudolph et al. (2013) malnutrition is a serious global health problem that is often least addressed
by public health programmes. Neither current WHO guidelines for treatment of TB, nor the 17 International
Standards of Tuberculosis Care, address the importance of under-nutrition or nutritional support during
treatment (Bhargava et al., 2013; Hopewell et al., 2006: 710-725).

According to the WHO, a low body mass index (BMI) (< 18.5 kg/m²) is the best predictor of weight-related
morbidity. The relationship between TB and BMI has been studied by several researchers (Bhargava et al.,
2013; Rudolph et al., 2013; Lombardo et al., 2012: 183; Lönnroth et al., 2010: 181; Semba et al., 2010;
4
Villamor et al., 2006: 168; Cegielski & McMurray, 2004: 288; van Lettow et al., 2003: 84; Karyadi et al.,
2000: 725; Kennedy et al., 1996). A BMI below the lower cut off point (<18.5 kg/m²) is an established
indicator for energy deficiency (Lönnroth et al., 2010). Systematic reviews by Lönnroth et al. (2010:181) and
Cegielski & McMurray (2004: 288) have reported that malnutrition (defined using BMI) is an important risk
factor for the progression of underlying TB infection to active TB disease. Rudolph et al. (2013) reported that
the average BMI in adult South African males and females with TB is 19.2kg/m² (normal) and 23.3kg/m²
(normal), respectively. Despite the fact that the BMI of South African females are within the normal range it
is still lower than that of the general population, who are often overweight or obese. Villamor et al. (2006:
168) performed a cross-sectional study in adults with pulmonary TB co-infected with HIV and found that the
lean body mass was low. Kennedy et al. (1996) used BMI to assess the nutritional status of 148 patients in
Tanzania who presented with active TB. They found that malnutrition manifested before and after treatment
for TB. Several cross-sectional studies have confirmed a lower BMI in adults with TB disease together with
an increased risk for mortality and micronutrient deficiencies (Lombardo et al., 2012: 183; Semba et al.,
2010; van Lettow et al., 2003: 84; Karyadi et al., 2000: 725).

In addition to BMI, mid-upper arm circumference (MUAC) is commonly used to determine the nutritional
status of adults (Tang et al., 2013). Singla et al. (2010) and Karyadi et al. (2000: 725) found significantly
higher proportions of patients with very low MUAC (<20cm) among TB-treated patients from India and
Indonesia. A case control study that was conducted in Indonesia also reported that patients with TB had
significantly lower skin fold measurements, which is an indication of malnutrition (Karyadi et al., 2000: 725).

The Academy of Science of Southern Africa (ASSAf) refers to malnutrition and TB as the so-called “chicken
vs egg conundrum”. This is because malnutrition may predispose to TB and TB also causes malnutrition. The
ASSAf has identified the top three epidemics in 2007 as being HIV infection, TB infection and malnutrition
and called it the “three concurrent epidemics”. HIV and TB are caused by disease organisms, namely the
human immunodeficiency virus and the Mycobacterium tuberculosis bacteria respectively. The third
epidemic, malnutrition, is a consequence of these two disease states (ASSAf, 2007). Thus HIV, TB and
malnutrition result in a vicious cycle, with the one epidemic exacerbating the other. Van Lettow et al. (2003:
81) refer to HIV, TB and malnutrition as “triple trouble”.

Malnutrition has been described in patients with TB by several researchers (Bhargava et al., 2013 ; Frediani
et al., 2013: 1026; Villamor et al., 2006: 169; van Lettow et al., 2004: 61; Frieden et al., 2003: 895; Karyadi
et al., 2000). Both malnutrition and HIV infection are associated with an increased risk of progression from
latent TB infection to active TB disease, because of the negative impact that dietary deficiencies have on cell-
mediated immune response (Lönnroth et al., 2010: 152; Semba et al., 2010; Cegielski & McMurray, 2004:

5
296). TB very often results in poor dietary intake, nutrient deficiencies, malnutrition and wasting (Cegielski
& McMurray, 2004: 296; van Lettow et al., 2004: 61; Paton et al., 2003: 322).

1.3.3 Lifestyle behaviours

Lifestyle factors that are strongly associated with the development of TB infection and progression to TB
disease, include the use of tobacco and alcohol. Smoking is associated with underweight in the general
population (Wack & Rodin, 1982). PrayGod et al. (2013) found that patients with TB that smoke, weighed
less and had more fat mass than fat-free mass compared to those that did not smoke. Cigarette smoking is
also associated with an increased lifetime risk for TB infection (Saad & Tirkey, 2013). Peltzer (2014) found
that factors such as male gender, a high incidence of poverty and lower level of education, were strongly
associated with tobacco and alcohol use among patients with TB. Coetzee et al. (1988: 353) found that
households reported problematic alcohol consumption were more likely to develop TB.

1.4 Problem statement

South Africa is one of the countries in Africa with the highest burden of TB and HIV co-infection. It is a
well-known fact that TB infection is associated with wasting and micronutrient deficiencies, however,
information about the impact of nutritional status on increase TB risk and manifestation of the disease is still
limited. Treating hospitalised TB patients may be challenging due to the increased rates of MDR TB, which
may also be part of the disease-malnutrition viscious cycle. For this reason, the current study will aim to
evaluate the nutritional status of patients with TB at Standerton TB Specialised Hospital, Mpumalanga, South
Africa. Information gathered from this study will contribute to the identification of specific areas that need
to be focused on in nutrition interventions. This might ultimately play a vital role in improving the outcome,
quality of life and prognosis of patients with TB.

1.5 Aims and objectives

1.5.1 Aims
The main aim of the study was to determine the nutritional status of adult patients with TB and TB/HIV co-
infection at Standerton TB Specialised Hospital, Mpumalanga.

1.5.2 Objectives
In order to achieve the aim, the following objectives were determined:

1. Socio-economic status (gender, age, marital status, education level, employment status, household
income and housing density)
2. Nutritional status:
2.1 Eating related side effects and food security

6
 2.2 Anthropometric measurements (body mass index (BMI), mid-upper arm circumference
(MUAC), Triceps skinfold)
2.3 Overall risk of malnutrition
2.4 Biochemical parameters (total protein, albumin, C-reactive protein (CRP), CD 4 cell count,
mean corpuscular volume (MCV), haemoglobin)
3 Lifestyle behaviours (smoking habits and alcohol use).
4 Associations among variables listed in sub-aims 1- 3.

1.6 Outline of thesis

Chapter 1: Introduction. Chapter 2: TB and TB/HIV co-infection. Chapter 3: Methodology. Chapter 4: Socio-
demographic profile and household food security of patients with TB, and TB/HIV co-infection at Standerton
TB Specialised Hospital, Mpumalanga. Chapter 5: Nutritional status of patients with TB, and TB/HIV co-
infection at Standerton TB Specialised Hospital, Mpumalanga. Chapter 6: Smoking habits and alcohol use of
patients with TB, and TB/HIV co-infection at Standerton TB Specialised Hospital, Mpumalanga. Chapter 7:
Conclusions and Recommendations.

7
 CHAPTER 2
TB AND TB/HIV CO-INFECTION
2.1 Introduction
TB affects many people globally, impacting on health, nutrition, food security and socioeconomic
development. Even though TB is a curable disease, in 2014 alone there were 1.5 million TB related deaths
worldwide (WHO, 2015). Chapter two highlights current literature on the aetiology, pathophysiology, clinical
presentation, diagnosis, management (medical and nutritional) and prevention of TB and TB/HIV co-
infection.

2.2 Epidemiology of TB and TB/HIV co-infection

Mycobacterium tuberculosis (M. tb) was first discovered in 1882 by Dr. Robert Koch. At that time, TB was
responsible for the death of every one out of seven persons living in Europe and the United States. A century
later, in 1982, the first World TB Day was announced and sponsored by the WHO and the International Union
against Tuberculosis and Lung Disease (IUATLD) (GBTI, 2015).

Globally, TB is the leading cause of death and the second leading cause of death from infections after HIV
(UNAIDS, 2014). Approximately one-third of the world population, an estimation of more than 2 billion
people, are infected with M. tb. TB prevalence and mortality rates have dropped with 40% and 47%
respectively since 1990 (WHO, 2015). The global incidence of TB was the highest in 2003 with a mortality
rate that peaked at 1.8 million people (Horsburgh et al., 2012; Frieden et al., 2003: 887). An estimated 1.6
million deaths occurred from TB disease in 2005 (USAID, 2008). In 2014, an estimated 9.6 million people
worldwide were diagnosed with TB disease, but only two-thirds (63%) were reported to the WHO (WHO,
2015). Mortality rates due to active TB disease are expected to increase to five million by the year 2050. The
main reasons for this increase include increasing poverty, the spread of HIV/acquired immune deficiency
syndrome (AIDS), population growth, poor health care systems and TB management, socioeconomic factors,
TB drug resistance and unreliable funding of TB prevention and treatment programmes (USAID, 2008;
ASSAf, 2007).

The epidemiology of TB differs greatly around the world. The highest rates of TB (100 per 100 000
population or higher) occur in sub-Saharan Africa, India, China, and the islands of Southeast Asia and
Micronesia. It is estimated that fifty percent of adults in sub-Saharan African and South and South-East Asia
are infected with TB. Moderate rates of TB (26 to 100 cases per 100 000 population) occur in Central and
South America, Eastern Europe, and northern Africa. Low rates (less than 25 cases per 100 000 population)
occur in the United States, Western Europe, Canada, Japan, and Australia (USAID, 2014; Horsburgh et al.,
2012). Figure 2.1 illustrates the estimated new cases of TB per 100 000 population globally. This figure
clearly indicates that Africa and more specifically South-Africa has a high burden of TB.
8
Figure 2.1 Estimated new TB cases globally during 2010 (WHO, 2011)

An estimated 70% of persons with TB disease are co-infected with HIV (Amollo, 2009). Worldwide, an
estimated 12% of new adult TB cases in 2014 were infected with HIV. Sub-Saharan Africa has the highest
incidence rate of 290 cases per 100 000 population. An estimated 8% of new TB cases occur in 22 high-
burden countries (HBCs) (WHO, 2015; Frieden et al., 2003: 887).

The estimated TB burden in South Africa during 2014 is shown in Table 2.1, while the TB/HIV co-infection
statistics are shown in Table 2.2. Among the HBCs, South Africa has the third highest reported incidence and
fifth highest estimated prevalence (undiagnosed) TB cases. When adjusting for population size, South Africa
does not only have the highest number of HIV-associated TB cases but also the highest incidence and
prevalence of TB among the HBCs (Churchyard et al., 2014: 244).

9
Table 2.1: Estimated TB burden in South Africa during 2014 (WHO, 2015)

Number (thousands) Rate (per 100, 000 population)

Mortality (excludes HIV+TB) 24 (22-26) 44 (41-48)
Mortality (HIV+TB only) 72 (58-89) 134 (107-164)
Prevalence (includes HIV+TB) 380 (210-590) 696 (390-1088)
Incidence (includes HIV+TB) 450 (400-510) 834 (737-936)
Incidence (HIV+TB only) 270 (240-310) 509 (439-584)
Case detection, all forms (%) 68 (61-77)

Table 2.2: Estimated TB/HIV co-infection burden in South Africa during 2014 (WHO, 2015)

Number Percentage
TB patients with known HIV status 295 136 93
HIV-positive TB patient 179 756 61
HIV-positive people screened for TB 1148 477

Drug resistance is also a major contributor to the growing TB epidemic. In 2014 there were a total of 480 000
MDR-TB cases, but only 123 000 were detected and reported. Globally 20% of previously treated TB cases
and 3.3% of new TB cases had MDR TB. In 2014 alone, 190 000 people died from MDR TB and 14% more
patients started on MDR-TB treatment than in 2013. Globally only 50% of MDR TB patients were
successfully treated in 2014 (WHO, 2015). In many parts of the world, multi-drug resistant TB (MDR TB) is
increasing, especially in Asia and Africa. MDR TB is difficult to treat and the cure rate for MDR TB patients
is less than 50% (Evian, 2003: 257). According to Nieburg & Angelo (2015), South Africa is at risk of
becoming a country in which the TB pandemic becomes dominated by MDR TB.

2.3 Aetiology and pathophysiology of TB

Risk factors for becoming infected with TB disease may be divided into an impaired immune status and
increased exposure to infection (Horsburgh et al., 2012). The risk of acquiring TB in poor developing
countries, such as South Africa, is often high due to socio-economic factors such as poverty and food
insecurity (ASSAf, 2007), while the most commonly reported risk factor in developed countries, such as the
United States, is substance abuse (Horsburgh et al., 2012).

The genetic factors that make some people more susceptible to M. tb are poorly understood. A receptor on
human dendritic cells, called DC-SIGN, has common polymorphisms that are less common in African than

10
in Eurasian populations. This receptor seems to be associated with significant protection against the
development of active TB disease (ASSAf, 2007). Even though associations between TB susceptibility and
genetic polymorphisms differ vastly according to ethnic origin, the extent to which genetic polymorphisms
contribute to the global TB burden is unclear because of the difficulty of separating genetics from
environmental influences (Frieden et al., 2003: 889).

M. tb belongs to the genus Mycobacterium that includes more than 50 other species. TB is defined as a disease
caused by members of the M. tb complex. One unique feature of this organism is the presence of the cell
envelope, which differs from the gram negative bacteria. Mycobacterium has no true outer membrane, but is
composed of a core of three macromolecules linked to each other and a lypopolysaccharide, which is thought
to be attached to the plasma membrane (Riley et al., 2012).

The easiest way for TB to enter the body is through inhalation of a very small number of droplet nuclei
containing virulent tubercle bacilli. As mycobacteria require an environment high in oxygen, the lungs and
kidneys are good examples of target organs. In healthy individuals, the bacilli are inhaled, but the organism
may be inactivated before an immune response is induced. The immune response controls the replication of
the bacilli and the individuals remain disease free until some immunosuppressive event (e.g. HIV) later in
life induces the reactivation of TB (ASSAf, 2007: 98). Thus, disease progression depends on a person’s health
status, immune system and the number of infected bacilli. The larger the number of infected bacilli and the
weaker the immune system, the more likely it is that a person will develop active TB (Shi & Sugawara, 2013:
128).

Four stages of clinical manifestation can be identified, including; latency, primary disease, primary
progressive disease, and extrapulmonary disease (Shi & Sugawara, 2013: 128; Frieden et al., 2003: 888).
Sites apart from the lungs that can also be infected include the lymph nodes, pleural cavities, pericardium,
peritoneum, meninges, vertebral bodies and synovial tissue of other joints. Multi-organ involvement
including the liver, spleen, lungs and bone marrow may also occur (Churchyard & Corbet, 2008: 438).

Extra-pulmonary TB (EPTB) occurs in more than twenty percent of patients. Lymphatic TB is the most
common EPTB (Leeds et al., 2012). The most serious location for EPTB is the central nervous system, where
infection may result in meningitis which is often fatal. Mycobacterial infection of the blood stream may also
be fatal (Shi & Sugawara, 2013:129). TB can affect any joint or bone. The spine is the most common bony
structure involved, with the thoracic location in the spine most often affected (Frieden et al., 2003: 889).
Patients with lower CD₄ cell counts (<100 cells/µl) are more likely to develop EPTB than pulmonary TB.
Sutariya et al. (2015: 75) found that peripheral lymph node TB was more common in females than in males,
and the mortality rate among individuals with EPTB was higher than in individuals with pulmonary TB.
11
The tubercle bacilli begin to multiply in the alveolus and are attacked and ingested by alveolar macrophages
at the same time. This is known as the initial phase of primary infection. Although some tubercle bacilli will
be destroyed, the macrophages are non-specifically activated and some tubercle bacilli will survive and
replicate within the macrophages. Usually, the infection is later brought under control by activated
macrophages and T-lymphocytes (Pratt, 2003: 128). Phagocytosis of M. tb can occur through alveolar
macrophages, epithelial cells, dendritic cells and neutrophils (Shi & Sugawara, 2013: 129). Cytokines are
responsible for the high fever, weight loss and acute phase response that are commonly seen in patients with
active TB disease. Malnutrition and nutrient deficiencies may affect immunity, leading to increased
susceptibility to active infection (Frieden et al., 2003: 888).

Latent infection with M. tb is defined by the presence of an M. tb specific immune response in the absence of
active TB (Chee et al., 2013: 205). Active TB develops in only 5-10% of individuals exposed to the M. tb
(Shi & Sugawara, 2013: 129). Several factors can trigger the development of active TB infection to reactive
TB disease. While HIV is the greatest single risk factor, other medical conditions may also compromise the
immune system and predispose to development of active disease. These include poorly controlled diabetes
mellitus, renal failure, underlying malignant disease, chemotherapy, extensive corticosteroid therapy,
malnutrition and vitamin D or A deficiency. When individuals with active TB cough, sneeze, sing, or speak
they can generate infectious droplets that transmit the TB infection (Nunes-Alves et al., 2014; Shi &
Sugawara, 2013; ASSAf, 2007: 97; Frieden et al., 2003: 888). Figure 2.2 illustrates the pathogenesis of TB.

12
Figure 2.2: Pathogenesis of TB (Nunes-Alves et al., 2014)

Within three to eight months of the primary infection, primary TB may develop. Post-primary TB or
reactivation may develop when the tubercle bacilli remain inactive for years and then start to multiply. Active
TB can be caused by re-infection and HIV positive individuals are pre-disposed because of their immune-
deficiency. It is difficult to differentiate between latent infection and re-infection; a general guideline is that
more people develop active TB due to re-infection (Pratt, 2003: 133).

The transmission of TB is illustrated in Figure 2.3. Macrophages are crucial components in the killing of
either mycobacterial or in the prevention of bacterial multiplication. Dendritic cells circulate to the lymph
nodes and T cells, and return to the lungs to control the infection. The antibacterial activity of macrophages

13
is enhanced by the T cells that release cytokines. The infection is then cleared by the macrophages. Most
individuals develop a T-cell response in the absence of any clinical symptoms, which is defined as a latent
infection. The moment that the T cells response is insufficient to control the initial infection, clinical
symptoms start to develop (Shi & Sugawara, 2013; Young et al., 2008; ASSAf, 2007). These clinical
symptoms are discussed in a later section.

Figure 2.3: TB Transmission (Young et al., 2008)

2.4 HIV-associated TB
As mentioned previously, healthy individuals have a 10% lifetime risk of developing TB compared to HIV-
infected patients that have a 10% annual risk (Shi & Sugawara, 2013:129; ASSAf, 2007). The risk of
contracting TB is estimated to be 26 to 31 times greater in HIV positive individuals than in uninfected people
(Sutariya et al., 2015: 75). Approximately one third of all HIV-infected Africans die in hospitals because of
TB, and only half of them are diagnosed with TB during their lifetime (Churchyard & Corbet, 2008: 438).
People with HIV-related TB are four times more likely to die than those who are infected with TB and are
HIV-negative. In 2015, one third of all HIV deaths were due to TB (WHO, 2016). According to Semba et al.
(2010: S353) HIV co-infection seems to be a much stronger risk factor for mortality in adults with TB than
is malnutrition alone.

TB with HIV/AIDS co-infection has a major impact on the infected person (Pratt, 2003: 134). Though there
is little evidence suggesting that HIV infection predisposes an individual to primary infection, it clearly
increases the risk of progression from infection to disease. The effects of HIV on CD₄ cell counts (which are
essential in the control of mycobacterial growth) are the most likely reason for this. HIV-infected patients

14
with TB also have a worse prognosis than HIV-infected persons who remain free of TB disease (ASSAf,
2007: 100).

TB can occur at any level or stage of HIV infection, but the weaker the immune system, the more likely it is
that an HIV-infected person will develop TB (Churchyard & Corbet, 2008: 439). Thus, nutrition is important
during all stages of HIV and TB infection. Figure 2.4 illustrates the vicious cycle of malnutrition and HIV,
which also applies to TB.

Increased
nutritional needs Poor nutrition
•due to increased •weight loss, muscle
resting energy wasting, weakness,
metabolism, micronutrients
malabsorption and deficiency
decreased intake

HIV
Increased risk of Impaired
infections immune system
•gut infections, TB,
•poor ability to fight
flu and therefore
HIV and other
faster progression to
infections
AIDS

Figure 2.4 The vicious cycle involving HIV infection and malnutrition (Adapted from Regional Centre
for Quality and Healthcare, 2003)

The extent of immunosuppression also changes the features of TB. TB that develops at an early stage of HIV-
infection resembles HIV-negative TB, which involves pulmonary disease in the upper zones and cavities as
well as smear-positive disease. HIV-infected individuals with advanced immunosuppression are more likely
to present with hilar adenopathy and smear-negative disease. Extrapulmonary TB may also occur more
commonly in the highly immunosuppressed patients (Churchyard & Corbet, 2008: 439).

It is difficult to diagnose TB in HIV infected patients and currently there is no rapid accurate diagnostic test
for this. The clinical presentation is not very specific and the sensitivity towards microscopy is poor. The
immunological recovery after the initiation of antiretroviral therapy (ART) increases the inflammatory
response against the high mycobacterial organism load that is present in HIV infected patients with TB,

15
unmasking the TB infection and increasing the risk of death due to the strong inflammatory reaction (Alvarez-
Uria et al., 2013: 123).

The burden of TB is growing globally, largely due to the spread of HIV/AIDS (Churchyard & Corbet, 2008:
434). HIV-infected people are more difficult to diagnose, more susceptible to TB and more difficult to treat.
Furthermore, HIV-infected persons have a higher mortality following TB treatment. Thirty per cent of all
HIV-infected persons with diagnosed TB die within a year of diagnosis and treatment (ASSAf, 2007: 34).
Thus all persons with TB should be tested for HIV and all persons living with HIV should be screened for
TB (Amollo, 2009). A better understanding on how TB and HIV interact is critical (Bloem & Saadeh, 2010:
S289).

2.5 Screening and diagnosis

Symptoms of TB disease include fever, involuntary weight loss, night sweats, persistent cough (lasting two
weeks or longer), chest pain, shortness of breath, haemoptysis, fatigue, loss of appetite, and localised pain or
swelling. The WHO recommends four-symptoms for TB screening in HIV infected patients namely: the
presence of fever, weight loss, night sweats or cough of any duration. This four-symptoms screening is not,
however, specific or optimally sensitive (Williams, 2006: 50; Frieden et al., 2003: 889). Recently the WHO
has recommended the implementation of the GeneXpert MTB/RIF assay in developing countries for national
TB programmes. When comparing the smear microscopy, the GeneXpert MTB/RIF assay increases the
diagnosis of TB by 13-38%, but it is a much more expensive test. Since, it is crucial to exclude TB in all
patients who become eligible for HIV treatment before the initiation of ART, this expensive test may be
warranted (Alvarez-Uria et al., 2013: 123; Churchyard & Corbet, 2008: 438).

There are several steps required before the final diagnosis of TB disease can be made. Figure 2.5 summarises
the process of TB diagnosis (SADoH, 2014).

16
 Started on
TB
treatment • A functional health care system is needed to
ensure that all persons with positive TB
Test positive for investigations are started on TB
TB

•TB tests with excellent sensitivity and

Investigated for TB, test specificity are required to ensure that
negative persons with TB are accurately
identified
•Finding persons with TB requires
screening of all persons presenting at
Present to PHC, TB not suspected health care facilities and investigating
those with TB symptoms
•Finding persons with TB
depends on self-presentation to
TB disease - untreated, in community health care facilities, or active
outreach by health care workers

Figure 2.5: Steps required for the diagnosis of TB (SADoH, 2014)

The criteria for the diagnosis of active TB vary according to the setting. All patients that present with a
persistent cough should be assessed for TB. Any patient that experiences three or more of these symptoms
for three or more weeks should be screened for TB. Ideally, the diagnosis and treatment must occur as quickly
as possible to minimise the damage that occurs in the infected tissues (Williams, 2006: 50). Diagnostic tests
for TB vary in sensitivity, specificity, speed, and cost (Frieden et al., 2003: 890).

The tubercle skin test (TST) identifies previous TB-infection but does not distinguish between active TB and
latent TB infection (Churchyard & Corbet, 2008: 441). The TST test is of little clinical value in the South-
African setting because it is non-specific to latent and active TB. Immunosuppression, HIV and malnutrition
may also lead to a decreased sensitivity of TST (Chee et al., 2013: 207; Ndjeka et al., 2008). Despite the
questionable validity of the TST, it still remains a good predictor of future TB risk and the response to
preventative therapy in HIV-infected individuals (Churchyard & Corbet, 2008: 441). Preventative
chemotherapy might be a consideration, especially in persons with latent TB infection with an increased risk
for progression to active TB (such as immunosuppressed individuals) (Chee et al., 2013: 209).

2.6 Assessment of nutritional status

The main objectives for nutritional assessment, counselling and support of patients with TB include; assessing
their current nutritional status, identifying all the underlying causes of malnutrition, and improving nutritional

17
intake through any setting specific methods (education, counselling or food assistance) (UNAIDS, 2014;
WHO, 2013).

One method to assess nutritional status is the “ABCDEF” approach, which involves assessment of the
following aspects: anthropometry, biochemistry, clinical signs, dietary intake, exercise or physical activity
and the family/household situation (UNAIDS, 2014). Each of these aspects will be discussed in more detail
in the following section.

2.6.1 Anthropometry
Anthropometry includes measurements of body composition, weight, height, change in weight (involuntary
weight loss), body mass index (BMI), mid-upper arm circumference (MUAC), and hand grip strength
(UNAIDS, 2014).

Involuntary weight loss, wasting and cachexia are common findings in patients with TB. All of the above
processes are most likely the result of a combination of factors, including increased nutrient losses, altered
metabolism, and decreased appetite and food intake, which are all directly linked to a poor prognosis (Kirenga
et al., 2015; Chang et al., 2013; Nezhad et al., 2012; USAID, 2010).

According to the WHO, a low BMI (< 18.5 kg/m²) is the best predictor of weight-related morbidity. BMI is
the indicator that is most commonly used to estimate the degree of fatness or thinness in adults over the age
of 18 years (WHO, 2013). Several cross-sectional studies have confirmed a lower BMI in adults with TB
(Lombardo et al., 2012: 183; Semba et al., 2010; Van Lettow et al., 2003: 84; Karyadi et al., 2000: 725).
According to Hanrahan et al. (2010: 1507) BMI may be a useful surrogate marker of TB risk or mortality
among HIV-positive individuals.

MUAC correlates well with BMI in the adult population. MUAC is often used to assess nutritional status and
determine eligibility for nutrition support among adults in resource limited settings (Tang et al., 2013).
Another measurement that is used to determine work capacity (lean body mass) in patients with TB is
handgrip strength (PrayGod et al., 2012: 268).

2.6.2 Biochemistry
Although nutrient deficiencies can be identified through biochemistry, these tests are usually expensive, and
they are seldom applied in nutritional assessment of persons from resource limited areas. More commonly
measured biochemical assessments include haemoglobin, albumin, triglycerides, total cholesterol, low/high-
density lipoproteins and iron (UNAIDS, 2014).

Serum protein concentrations can be useful in assessing protein status, to evaluate a patient’s response to
nutritional support, and to determine whether a patient is at risk of experiencing medical complications (Lee
18
& Nieman, 2013: 320) on condition that there is no acute phase response present due to metabolic stress that
may affect the reliability of this indicator as a measure of nutritional status.

Serum albumin is an indicator of depleted protein status (Lee & Nieman, 2013: 320). Hypoalbuminaemia is
an important marker of severe malnutrition (Matos & Moreira Lemos, 2006: 1363), but is not a reliable
indicator of nutritional status when an infection is present, since it reacts as a negative phase protein
(Litchford, 2012; Salgado et al., 2001). Low serum albumin levels are strongly associated with an increased
risk of TB. This was confirmed in a study amongst adult patients in the United States (Cegielski et al., 2012:
409), confirming that serum albumin might be a useful diagnostic and prognostic marker for TB in HIV
infected patients (Alvarez-Uria et al., 2013: 127). A study of hospitalised patients with TB in Brazil, found
that the group of patients who died during hospitalisation had statistically significantly lower mean albumin
levels that the group of patients that survived (26 g/l vs. 31 g/l) (Matos & Moreira Lemos, 2006: 1361).
Alvarez-Uria et al. (2013: 127) found that a serum albumin value of >38 g/l was a negative predictor for TB
even in settings with a high prevalence, whereas a serum albumin value of <32 g/l was associated with 85%
TB specificity.

A study conducted in Pakistan amongst 127 patients with TB, reported that the median CRP was 11.21 mg/l
in males and 13.82 mg/l in females respectively. The researchers concluded that a high CRP is noticeably
associated with more severe TB disease (Shaikh et al., 2012: 144).

A number of studies in Gambia, India, the United States, Tanzania and Indonesia have confirmed that anaemia
is particularly common in patients with TB (Minchella et al., 2015: 764; Boloor et al., 2014: 476; Cegielski
et al., 2012: 412; Isanaka et al., 2012: 353; Karyadi et al., 2000: 2957) predominantly due to anaemia of
inflammation (also known as anaemia of chronic disease) (Minchella et al., 2015: 771).

2.6.3 Clinical signs and symptoms

A clinical assessment or examination of a patient is useful to identify signs or symptoms of dehydration,
oedema, malnutrition, ascites, taste changes or swallowing difficulties. The condition of certain body parts
(fingernails, hairs, skin) is also examined (UNAIDS, 2014).

Clinical monitoring of possible side effects in patients with TB is important during treatment (WHO, 2004).
It is unknown whether the food related side effects experienced by patients with TB, and TB/HIV co-infection
are caused by the disease, the treatment or a combination of the two. Several food related side effects (gastro-
intestinal irritation, nausea, vomiting, abdominal pain, constipation, anaemia, jaundice, pancreatitis, altered
taste, anorexia, and fatigue) have been reported to be related to TB medications (Isoniazid and Rifampicin)
(SADoH, 2014; Escott-Stump, 2012; WHO, 2004). Adverse side effects from medication are more common

19
in HIV positive than in HIV negative patients with TB (WHO, 2004). Drug related side effects are discussed
in more detail in a later section.

Involuntary weight loss of more than 1.5 kg per month and wasting are some of the first clinical signs seen
in patients with TB, and are most likely caused by a combination of reduction in appetite and increased energy
expenditure as part of the inflammatory and immune response. Contact with a person with TB increases the
likelihood of TB diagnosis and symptoms such as weight loss thus need to be investigated (SADoH, 2014;
Escott-Stump, 2008: 304). When involuntary weight loss occurs, the risk of malnutrition increases (Bapen,
2003). Malnutrition, which is very common in patients with TB, is discussed in more detail in a later section.

2.6.4 Dietary intake

There are many tools that can be applied to assess dietary intake (24 hour recall, usual food intake, food
frequency questionnaires, food records and diaries). The information gained through these approaches is
aimed at providing data on the intake of particular foods, nutrients, herbal remedies and other supplements.
Intake can either be determined in terms of the number of servings from each food group, or in terms of
nutrient intake using food composition tables or dietary assessment computer programmes (UNAIDS, 2014).

The most frequent tool used to determine dietary intake of patients with TB seems to be the 24 hour recall
method and has been used by several researchers. Karyadi et al. (2000) determined dietary intake of 82
subjects (41 TB patients and 41 controls) in Indonesia and found that intake of energy, protein, carbohydrates,
fat, vitamin A and iron tend to be lower in patients with TB than in the healthy control group. Swaminathan
et al. (2008) reported that energy and protein intake of patients with TB and TB/HIV co-infection were below
the recommended daily allowance in India. More recently, Lombardo et al. (2012) determined dietary intake
of 86 subjects (43 TB patients and 43 controls) in Cape Town and concluded that there were no significant
difference between the two groups in terms of energy, protein, carbohydrate, fat, zinc and vitamin A intake.
Lastly, Mupere et al. (2012) determined the dietary intake among patients with TB in Uganda and found that
the average intake of energy, protein, carbohydrate, fat, calcium, folate and vitamin A were significantly
lower among TB patients with moderate to severe disease compared to TB patients with mild disease. Nutrient
deficiencies that are specific to TB are discussed in a later section.

2.6.5 Exercise or physical activity and other lifestyle factors

An assessment of physical activity and other lifestyle practices includes questions on activities of daily life,
work and planned exercise as well as smoking and alcohol habits. A balance between energy expenditure and
energy intake is required to maintain or reach a healthy weight (UNAIDS, 2014).

When determining the physical activity levels of patients, daily activities such as domestic work and
gardening should be taken into consideration, since it requires energy to complete these tasks (McArdle et
20
al., 2001). Patients with TB and HIV co-infection are usually inactive, despite the beneficial role of exercise
in patients with TB and TB/HIV co-infection (Jones, 2001). Malnutrition increases fatigue which in turn often
leads to physical inactivity in immunocompromised patients (Piwoz & Preble, 2000).

Lifestyle factors that are strongly associated with the development of TB infection to TB disease include the
use of tobacco and alcohol. Alcohol and smoking have been established to be risk factors for acquiring TB
disease, and continued use of alcohol and tobacco products, once a person has contracted TB, decreases the
chances of successful treatment (Louwagie et al., 2014: 501). Smoking is a risk factor for TB, independent
of alcohol use or other socio-economic factors. Both passive and active exposure to tobacco smoke is
associated with an increased risk for TB infection (SADoH, 2014; Saad & Tirkey, 2013). A high alcohol
consumption (>40g alcohol per day) is associated with a threefold increased risk of developing TB (SADoH,
2014).

2.6.6 Family/household situation

During an assessment of nutritional status, it is important to assess poverty, illness or disability in the family,
which may affect the family’s capacity to obtain or prepare food. Nutritional knowledge, psychosocial factors,
and food drug interactions also need to be assessed (UNAIDS, 2014).

Socioeconomic factors are closely related to TB infection. These include poverty, over crowding,
unemployment, malnutrition, and inadequate access to efficient health facilities. These factors do not only
increase the risk for developing TB, but also increase the chances of treatment failure. According to the South
African National Tuberculosis Association (SANTA), the incidence of TB is especially high amongst males,
miners, the poor and the very young in South Africa (SANTA, 2014; Chee et al., 2013: 205; Songpol et al.,
2005: 221). TB is mostly associated with specific population subgroups including immigrants from countries
with high endemicity, ethnic minorities, refugees, and the homeless (Faccini et al., 2013: 485).

The quality of life of TB patients is negatively affected, since TB often leads to social isolation. It is important
to evaluate the quality of life of patients with TB since it has an impact on treatment outcome and prognosis.
Factors that negatively affect the quality of life of patients with TB include disease severity, use of drugs and
the fear of dying (Awan et al., 2012: 330).

Mental health problems, such as anxiety and depression, are common in patients with TB and TB/HIV co-
infected patients, and may be related to the psychological effects of dealing with a life-threatening disease.
Patients who experience more economic hardship are more likely to display depressive symptoms (Louwagie
et al., 2014: 501-508; Awan et al., 2012:330).

21
2.8 TB and Malnutrition
Very often, malnutrition in patients with TB is neither recognised nor addressed. This worsens disease, delays
recovery and increases the length and frequency of hospital visits. Malnutrition affects an individual’s health,
wellbeing and ability to work or perform daily activities (Bapen, 2003).

In settings with limited resources, TB infection and the HIV epidemic are often highest where malnutrition
is already present (UNAIDS, 2014). In 2007, the ASSAf identified the top three epidemics as HIV infection,
TB infection and malnutrition and called it the “three concurrent epidemics”. Although HIV and TB are
caused by disease organisms, the third epidemic, malnutrition, is very often a consequence of these two
disease states (ASSAf, 2007). Thus; HIV, TB and malnutrition result in a vicious cycle, with the one epidemic
exacerbating the other.

Some important signs and symptoms of TB (e.g. wasting, anaemia, loss of lean and fat mass, etc.) are also
signs of malnutrition (ASSAf, 2007:155-156). According to Cegielski & McMurray (2004) malnutrition is
an important risk factor for the development of TB and for progression from latent to active disease. Poverty
is mostly the common denominator, since population groups with an increased risk for poor nutritional status
contribute to an elevated risk for developing TB. Even though there is a clear link between TB and
malnutrition, the risk relative to the specific degrees and types of malnutrition are still unclear (Cegielski &
McMurray, 2004: 294).

The presence of malnutrition has been described in patients with TB by several researchers (Bhargava et al.,
2013; Frediani et al., 2013: 1026; Villamor et al., 2006: 169; van Lettow et al., 2004: 61; Frieden et al., 2003:
895; Karyadi et al., 2000). Both malnutrition and HIV infection are associated with an increased risk of
progression from latent TB infection to active TB disease, because of the negative impact that dietary
deficiencies have on cell-mediated immune response (Lönnroth et al., 2010: 152; Semba et al., 2010;
Cegielski & McMurray, 2004: 296). TB very often results in poor dietary intake, nutrient deficiencies,
malnutrition and wasting (Cegielski & McMurray, 2004: 296; Van Lettow et al., 2004: 61; Paton et al., 2003:
322).

TB may lead to prolonged fatigue, anorexia, nutrient malabsorption, altered metabolism, and weight loss
(Dong & Imai, 2012: 876). The reasons for involuntary weight loss and wasting are multifactorial including
increased energy expenditure, food insufficiency, decreased absorption or increased need for certain nutrients
(Bloem & Saadeh, 2010: S290; ASSAf, 2007). Nutritional deficiencies are known to worsen immunological
mechanisms that are crucial for successful control of mycobacteria, namely the functions of T-lymphocytes
and a variety of phagocytic cells. Thus, nutrition deficiencies are generally associated with increased risk and
severity of TB disease (ASSAf, 2007: 151).

22
The inflammatory state increases resting energy expenditure (REE) and also reduces appetite through effects
on the hypothalamus. Thus, patients develop a negative energy balance, metabolise body stores of muscle
tissue, and are at higher risk of wasting. Reduced food intake, as well as increased utilisation of energy and
micronutrients, leads to weight loss and micronutrient deficiencies (Semba et al., 2010: S352)

The relationship between TB and malnutrition is illustrated in Figure 2.6. Through this illustration it is clear
that nutrition and food security are directly related to the diagnosis, prognosis and mortality of a patient with
TB. Thus, focusing on the nutritional status of people who are at risk of developing TB, may directly decrease
the number of TB infections, improve treatment outcomes and reduce TB associated mortality (WFP, 2016).

Figure 2.6: Relationship between TB and malnutrition (WFP, 2016)

2.9 Food security and food support

According to the National Food Consumption Survey (NFCS) of 1999, 33% of South African household were
at risk of hunger and 52% of households experienced hunger at that time (Labadarios et al., 2005). According
to the NFCS of 2005, similar results were found, with one out of three households at risk of hunger and 51.6%
of households experiencing hunger (Labadarios et al., 2008). More recently, the South African National
Health and Nutrition Examination Survey (SANHANES) of 2012 interviewed 5972 households and
concluded that 39% of households do not have enough money for basic needs, like food (Shisana et al., 2013).

Even though food insecurity together with proper nutrition has long been recognised to play a vital role in
TB infection, the HIV epidemic, and progression of TB infection to active disease, there is still very little
understanding of their exact role (Bloem & Saadeh, 2010).

23
Food security is defined as “access to enough food at all times by all people for an active and healthy life”
(Anderson, 1990; Keenan et al., 2001). According to Bloem & Saadeh (2010), food insecurity is defined as
limited food utilisation, availability, or access. Households experience food insecurity in the most basic form
when they do not have adequate resources to obtain enough food to meet their basic nutritional needs;
resulting in hunger for all household members (Keenan et al., 2001). In an attempt to optimise nutritional
status, food and nutrition security are essential factors to consider (ADA, 2010).

Globally poor household food security is a major concern. According to the global International Food
Security Assessment for 2011 to 2021, the number of food-insecure people and the food gap are estimated to
decline respectively by 16% and 7% during the ten year period. In Sub-Saharan African, however, the
opposite is predicted, with an increase of 17 million in the number of food-insecure people and an increase
of 20% in the food gap between 2011 and 2021 (USDA, 2011).

Between 1999 and 2008 the prevalence of food insecurity in South Africa appears to have been reduced by
half (from 52.3% to 25.9%), but the percentage of people at risk of experiencing food insecurity remained
almost unchanged, due to population growth together with high levels of unemployment (WHO, 2013;
Labadarios et al., 2011). A major concern with regards to household food security, is that a household may
be food secure overall, but a poor understanding of individual needs together with an unequal distribution
among household members, may lead to food and nutrition insecurity for the more vulnerable household
members, like persons infected with TB and/or HIV (Ogundiran et al., 2014; Bloem & Saadeh, 2010: S290).

“The Right to Food” is a basic human right enshrined in the South African constitution. The right to adequate
food as a basic human right was first formally recognised by the United Nations in the Universal Declaration
of Human Rights (UDHR), as a part of the right to a decent living standard (FAO, 2016). During 2009, the
World Food programme (WFP) provided food assistance to 3 million people that were affected and infected
with HIV and TB (Bloem & Saadeh, 2010: S291). As mentioned, food insecurity is a major risk factor for
the development and prognosis of TB disease. According to Amollo (2009) food insecurity also increases the
exposure to HIV in women as they may engage more easily in transactional sex in order to generate an income
to provide food for their families.

Most nutrition support programmes for adults with TB and HIV provide food and nutrition support when
treatment is initiated. Therapeutic food products are often prescribed to treat malnutrition based on strict
anthropometric entry and exit criteria (low BMI and low MUAC). Food support for treatment initiation and
adherence might require specific foods to manage side effects as illustrated in Figure 2.7 (UNAIDS, 2014).
The impact of food and nutrition support on treatment success depends on many factors (Figure 2.7).

24
However, the efficiency of food support programmes remains unclear, especially if some of these factors are
ignored (De Pee & Semba, 2010).

Characteristics of food supplement:

Impact of food
 Content of supplement intervention on
 Nutrients: macro- and micronutrients, protein quality, malnutrition and
essential amino acids, essential fatty acids
disease progression
 Anti-nutrients
 Energy density
 Amount provided per day
 Form of food
 Ingredients
 Packaging
 Setting in which the food is provided

Total food and nutrient intake:

 What information and counselling are provided to the

patient?
 How much of the food supplement does the patient
consume per day?
 For how long does the patient take the supplement?
 What else does the patient consume?

Starting point of patients and context:

 Baseline nutritional status

 Target group
 Food security situation
 Basic diet to which food supplement is added
 HIV status/disease stage

Figure 2.7: Factors affecting the impact of food support interventions on malnutrition and disease
outcome (Adapted from De Pee & Semba, 2010)

2.10 Food safety

Food safety is very important in patients with TB and/or HIV co-infection. Patients with TB and/or HIV co-
infection are more susceptible to foodborne illness due to a compromised immune system. Detailed guidelines
on ensuring food safety are indicated in Addendum A (SADoH, 2007).

2.11 Management of TB
2.11.1 Medical treatment of TB
The primary goals of TB treatment are to eradicate M. tb infection, prevent development of drug resistance,
and prevent relapse or death. In order to achieve these objectives, a combination of TB medicines should be

25
administered. Successful treatment of individual cases includes reducing the risk of transmission of TB to
others in the community (Horsburgh et al., 2012; Frieden et al., 2003: 891). Medical treatment might improve
the nutritional status of patients with TB, but treatment alone is probably not sufficient to ensure an optimal
nutritional status in patients living in food insecure areas (WHO, 2013).

2.11.1.1 DOTS
In 1991 the World Health Assembly resolution recognized TB as a major global health problem and as a
result, the WHO developed the five-element DOTS (Directly Observed Therapy, Short-course) strategy. The
DOTS program is a method recommended by the WHO to improve compliance of patients with TB and thus
to increase the cure rate of TB. The DOTS strategy was later implemented in 184 countries. According to the
WHO (2011), 84% of patients that suffer from TB did not receive any DOTS support during 2010, since there
are several challenges that are common in the implementation of the DOTS strategy.

The DOTS components include:

1. Government commitment to TB control;

2. Case detection among symptomatic patients;
3. Standardised chemotherapy for all sputum smear-positive cases under proper case management
conditions;
4. Regular drug supply; and
5. Monitoring system for program supervision and evaluation (Horsburgh et al., 2012:2; Frieden et al.,
2003: 891).

DOTS is recommended by the WHO and IUATLD. It is very important that treatment adherence and
prevention of drug resistance are facilitated by trained individuals, since family members are usually not
reliable (Frieden et al., 2003: 891). TB treatment is more likely to be successfully completed when there is
a treatment supporter to administer the medication on a daily basis and to observe that the pills are swallowed.
TB treatment outcomes are often poor due to poor compliance, treatment interruption or death. Other
contributing factors such as inadequate healthcare, clinical and socio-economic factors, and substance use
also prevent and interfere with successful completion of treatment (Louwagie et al., 2014: 501).

2.11.1.2 Vulnerability
Beyond medical treatment, factors that affect vulnerability to infection and progression of TB disease also
need to be considered. Table 2.3 summarises individual, household/community, and environmental
vulnerabilities (USAID, 2008)

26
Table 2.3: Vulnerability factors related to progression to TB disease (USAID, 2008)

Individual Household/community Environmental/institution

Age Socio-economic status Geography/physical terrain
Sex Migration Availability of health services
Nutritional status Access to treatment Quality of health care
Immunity Over crowding Availability of appropriate
Genetics treatment
Interactions with other diseases Emergence of drug resistance
(HIV, diabetes) Development of infrastructure/
Behaviour other service
Poverty Public policy
Education
Knowledge
Diet
Livelihood

2.11.1.3 Standard regimens

The South Africa Department of Health (SADoH) have compiled recommendations for daily dosages of
individual and combination drugs for adults and children over the age of 8 years. These recommendations are
summarised in Table 2.4 and Table 2.5.

Table 2.4: Recommended daily dosages of the individual drugs for adults and children >8yrs/ >30kg
(SADoH, 2014: 41)

Essential TB drug Dose mg/kg Dose range mg/kg

Rifampicin (R) 10 8 – 12
Isoniazid (H) 5 4–6
Pyrazinamide (Z) 25 20 – 30
Ethambutol (E) 15 15 – 20
Streptomycin (S) 15 12 – 18

27
Table 2.5: Fixed dose combination tablets available for adults and children >8yrs/ >30kg (SADoH, 2014:
41)

Intensive Phase Continuation Phase

RHZE (150,75,400,275mg) RH (150,75mg)
RH (300,150mg)

The standard treatment regimen for new and previously treated patients in South Africa is summarised in
Table 2.6. For the first two months, treatment is with Rifampicin, Isoniazid, Pyrazinamide and Ethambutol
(RHZE) in fixed dose combinations given every day of the week. If the patient is improving clinically and is
also smear negative at the end of the second month, they are treated with RH in fixed dose combinations
every day of the week for a period of four months (SADoH, 2014: 41).

Table 2.6: Standard treatment regimen for adults and children >8yrs/ >30kg (SADoH, 2014: 41)

Pre-treatment body Intensive Phase Continuation Phase

weight (2 months) (4 months)
RHZE RH RH
(150,75,400,275) (150,75) (300,150)

30 – 37 kg 2 tablets 2 tablets
38 – 54 kg 3 tablets 3 tablets
55 – 70 kg 4 tablets 2 tablets
>70 kg 5 tablets 2 tablets

2.11.1.4 Drug-nutrient interactions and food related side effects

TB is treated with multiple medications and antibiotics, which can all result in a number of food-drug
interactions. Patients with TB require more vitamin B6, vitamin D and mineral intake from supplements
because medication (isoniazid) reduces levels of vitamin B6 and interferes with vitamin D absorption which
in turn can decrease absorption of calcium and phosphorus (Mueller, 2012: 796; Fenton & Silverman, 2009:
918; SADoH, 2007). Isoniazid and Rifampicin should preferably be taken 30 minutes to 1 hour before or 2
hours after a meal, due to reduced absorption when taken with food. TB medication should not be taken
together with alcohol (Mueller, 2012: 796). Table 2.7 indicates the medications commonly used in the
management of TB together with possible food related side effects and/or nutrient interactions that may occur.

28
Table 2.7: Medications used for the management of TB (Escott-Stump, 2012: 305; Singla et al., 2010: 82;
SADoH, 2007)

Medication Interactions/ Side effects

Aminosalicylic Interfere with vitamin B12 and folate absorption
acid Nausea/vomiting
Chemotherapy Increase serum calcium levels
Ethionamide Requires vitamin B6 supplementation
Anorexia; metallic taste; nausea/vomiting; diarrhoea; weight loss and
hypoglycaemia
Ethambutol Gastrointestinal distress; nausea and anorexia
Not to be used for >2 months, due to harmful effects on the eyes
Isoniazid (INH) Depletes vitamin B6 causes neuritis
May decrease absorption of pyridoxine, calcium, and vitamin D.
Increase requirements for pyridoxine, folate, niacin (vitamin B₃) and
magnesium.
May cause hepatitis, constipation, anaemia, and fatigue
Tastes bad
Nausea/vomiting; anorexia; stomach cramps and dry mouth
Hepatotoxic
Better absorbed in an acidic pH
Pyrazinamide Anorexia and nausea/vomiting
Hepatotoxic
Rifampicin May interfere with folate and vitamin B12
Nausea/vomiting; diarrhoea; anorexia; gastrointestinal distress; anaemia;
jaundice; pancreatitis and altered taste
Hepatotoxic
Streptomycin Hearing and balance affected when using for >3 months

Food related illnesses that are likely to occur in patients with TB and/or HIV co-infection together with
specific dietary, prevention and treatment guidelines are listed in Addendum B (Republic of Ghana, 2013).

2.11.1.5 Place where TB patients are treated

There is controversy about whether patients with TB disease should be treated as in- or out-patients. The
WHO suggests that hospitalisation is of no value in the management of patients with TB disease and the
29
British Thoracic Society agrees that most patients with TB disease can be treated as outpatients. The
American Thoracic Society has no clear recommendation regarding this issue (WHO, 2013; Chu et al., 2001:
147).

In a rural setting in Uganda, home-based care and treatment for patients with MDR TB was found to be
preferred by staff and patients over hospital-based care for three main reasons: it was more conductive to
patient recovery; it enabled enhanced psychosocial support; and it allowed more free time for patients and
caretakers for other activities (Horter et al., 2014). This approach (home-based care and treatment), however,
is not realistic for patients with comorbidities or more severe TB disease, who should ideally be hospitalised
(Chu et al., 2001: 148).

2.11.1.6 The “End TB Strategy”

According to the WHO, the most recent global goal is to end the TB epidemic through the implementation of
the “End TB Strategy”. The main objectives of this strategy is: to reduce the number of TB deaths by ninety
percent by 2030, to cut new cases of TB by eighty percent by 2030, and to prevent families from being
burdened with the high costs due to TB disease (WHO, 2015).

New vaccines, diagnostics, and drugs will be needed to achieve the targets set in the “End TB Strategy”
(WHO, 2015). Even though new diagnostic methods have been developed, the main diagnostic methods are
still the sputum smear and culture, both of which are over a hundred years old. No new first-line TB drugs
have been developed since 1950; thus two thirds of people who develop TB disease are not effectively
diagnosed, treated or monitored (Frieden et al., 2003: 896).

Currently, ten vaccines for TB prevention and two immunotherapeutic vaccines are in the process of being
researched. In addition, nine new or repurposed TB drugs are in the late phases of clinical development for
sensitive TB, drug-resistant TB and latent TB infection. There is an urgent need for short, effective and well-
tolerated treatments for latent TB infection, a clear diagnostic test, and an effective post-exposure vaccine to
end the global TB epidemic (WHO, 2016; WHO, 2013).

2.11.1.7 Drug resistance

MDR TB refers to TB which is resistant to one or more first-line anti-TB drugs (Pratt, 2003: 147). Drug
resistance occurs as a result of inadequate treatment for TB, or poor treatment compliance (Evian, 2003: 257).
Institutionally acquired MDR TB has a rapid progression to disease in HIV-infected patients and an extremely
high mortality if not immediately diagnosed and treated with suitable MDR TB treatment. Patients who are
thus suspected to have MDR TB should be kept separate from HIV-infected patients as far as possible
(Churchyard & Corbet, 2008: 441).

30
Two types of drug resistance occur. Primary drug resistance refers to infection with resistant tubercle bacilli
due to the exposure to a person who is drug-resistant. Secondary resistance occurs when an individual has
poor adherence to therapy or inadequate treatment. Alcoholics, drug users, and the homeless often exhibit
poor adherence, as well as those who are socially, economically and educationally deprived. Supervision of
therapy is a key factor in the prevention of MDR and treatment completion and consistent adherence to the
prescribed regimen are critical issues (Pratt, 2003: 148).

The main challenges of TB control in Africa are the unknown burden of drug resistant TB cases (which
increase yearly), the unavailability of second-line drugs, inadequate infection control and poor drug-resistant
TB monitoring and evaluating systems (Ndjeka et al., 2008).

2.11.2 Nutrition therapy for TB and TB/HIV co-infection

Nutrition, immune function and infection interact in complex ways (Cegielski & McMurray, 2004: 288). As
previously mentioned, limited information is available about effective nutritional management for patients
with TB (Rudolph et al., 2013). Nutritional care and management of persons with active TB (with or without
malnutrition) are similar to other persons with moderate malnutrition. It includes assessing nutritional status,
identifying and treating the underlying causes of malnutrition and improving nutrient intake through
counselling, education, and/or food assistance (WHO, 2013).

The importance of proper nutrition in the treatment of TB and TB/HIV co-infection is tremendous, since any
nutrient deficiency may impair resistance to infection (ASSAf, 2007: 117). Nutrients are required to regulate
certain body processes and to build and repair tissues and thereby promote health and prevent illness. In some
settings, macronutrients (carbohydrate, protein, and fat) are generally consumed in sufficient amounts.
Carbohydrates and some fat are used as energy sources, while protein and some fat are used as structural and
functional components in the body. In patients with TB, micronutrients (vitamins, minerals and
phytochemicals) are usually consumed in insufficient amounts. Together, macro- and micronutrients are
essential for metabolic processes, cellular integrity and tissue regeneration (WHO, 2013).

Although the relation between impaired immunity due to malnutrition and risk of acquiring TB has not been
well described, it is generally understood that malnutrition is an important risk factor for TB. A balanced
diet should provide macronutrients, micronutrients and energy required for optimal growth and development
(ASSAf, 2007: 155). General nutrition recommendations for patient with TB and/or HIV are summarised in
Addendum C (FANTA, 2013).

2.11.2.1 Macronutrients
There has been no published randomised, clinical trial to support macronutrient supplementation for people
with TB and HIV co-infection. Thus, there is no specific guideline related to the macronutrient distribution

31
of the diet for patients with TB disease. A general recommendation is that all people consume around 45-
65% of energy as carbohydrates, 15-30% as protein and 25-35% as fat for optimal growth and development
(WHO, 2013). A balanced food or enteral supplement which contains 50-60 % carbohydrates, 15-30 %
protein and 20 – 30 % fat may be beneficial to increase energy and protein intake (ASSAf, 2007: 135).
Providing access to food and oral supplements high in energy and protein is a cost effective and practical
option for patients with TB (Escott-Stump, 2012; Paton et al., 2004). Despite this recommendation, PrayGod
et al. (2012: 270) have reported that energy and protein supplementation in patients with pulmonary TB and
HIV co-infection in Tanzania, with high multi-micronutrient intake, had no direct effect on body composition
or weight.

a. Energy
Maintaining a healthy weight and optimal lean body mass are two of the main objectives of nutrition
management (Escott-Stump, 2012). Patients with TB have increased energy needs and when HIV/AIDS is
present, energy requirements increase by 20-30% to maintain body weight (SAHoH, 2007). The energy and
nutrient requirements for people living with HIV/AIDS (PLHIV) and/or TB, developed in Ghana, are
summarised in Table 2.8.

32
Table 2.8: Energy and Nutrient requirements for PLHIV and/or TB (Republic of Ghana, 2013).

Age group Healthy HIV and/or TB-infection

Asymptomatic Symptomatic Severely acutely malnourished
Children
10% more 20% more 50%-100% more energy
energy energy
6 – 11 months 680 760 830 150 – 200 kcal/kg of body
weight/day
12 – 23 months 900 990 1080 150 – 200 kcal/kg of body
weight/day
2 – 5 years 1260 1390 1510 150 – 200 kcal/kg of body
weight/day
6 – 9 years 1650 1815 1980 75 – 100 kcal/kg of body
weight/day
10 – 14 years 2020 2220 2420 60 - 90 kcal/kg of body
weight/day
Adults
Non- 2000 – 10% more 20% more
pregnant/lactating 2580 energy energy
Pregnant/lactating 2460 – (210 – 258 (420 more
women 2580 more kcal) kcal)

Insufficient research is currently available to ascertain whether routinely providing energy supplements at or
above recommended daily amounts results in better TB treatment outcomes, improved quality of life, or has
any clinical benefits (Sinclair et al., 2011). Surprisingly little data is available in the literature on habitual
macronutrient and micronutrient intake in patients with TB. A recent Cochrane review on the quality of
evidence of trails on nutrient supplementation in TB concluded that there is insufficient evidence to determine
whether an increase in energy intake improves patient outcomes (Frediani et al., 2013: 1024).

When hypermetabolism and fever occur, energy requirements increase by 13% for every degree Celsius of
temperature above normal (Fenton & Silverman, 2008: 1011). If an HIV-infected individual’s REE is found
to be increased, energy requirements increase by 10% above normal requirements. REE is increased

33
dramatically in persons with opportunistic infections and as a result, the appropriate amount and type of food
should be prescribed (ASSAf, 2008: 134).

During HIV-infection, energy requirements can range from 35 – 45 kcal/kg current body weight depending
on the health status of the individual and the progression of the disease. Improvement and reversal of HIV-
wasting can be attained when prescribing 500 kcal above estimated energy needs, or 40 – 50 kcal/kg body
weight (Fenton & Silverman, 2008:1011). It is important to note than when people are involved in physical
labour, and if meeting normal energy requirements is already difficult, increasing energy intake by 10% is
reasonable advice (UNAIDS, 2014).

b. Protein
Protein requirements for maintaining health in HIV can be estimated at 1.0 – 1.4 g protein per kilogram
current body weight and 1.5 – 2.0 g/kg body weight for repletion. Protein restriction is only advisable in
severe hepatic or renal disease. In order to prevent wasting, sufficient protein should be consumed. The
protein recommendations for these patients are 1.6-1.8g per kg of current weight. Protein requirements can
increase by 10% for every degree Celsius of temperature above normal. High-protein diets may help to
improve a positive nitrogen balance and restore lean body mass, but the ability of a high-protein diet to reverse
HIV-malnutrition remains controversial (Fenton & Silverman, 2008:1011). Body weight and fat-free body
mass can be increased with the supplementation of a whole-protein diet (ASSAf, 2008:135). Furthermore,
when treating malnutrition, it is important that enough essential amino acids are provided through protein
sources, thus a variety of protein should be included in the diet (animal food products, soybeans, dairy)
(UNAIDS, 2014). Experimental animal studies confirm that a protein deficiency can have negative
consequences on vaccine-induced resistance against TB, but this finding has not been confirmed in humans
(Cegielski & McMurray, 2004: 294).

c. Fat
Immune-compromised patients often struggle with diarrhoea and other abdominal symptoms. In the case of
fat malabsorption or diarrhoea, a low-fat diet is advisable. Medium-chain triglyceride (MCT) oil can help to
decrease stool fat and stool nitrogen content, as well as reducing the number of bowel movements and
abdominal symptoms (Fenton & Silverman, 2008: 1011). MCT oil together with fish oil (omega-3 fatty
acids) is less inflammatory than omega-6 fatty acids and may improve immune function. Omega 3 fatty acids
are associated with increased food intake, less weight loss and improved effects on the function and quality
of lean body mass (Escott-Stump, 2012). Unsaturated rather than saturated fats should be consumed
(UNAIDS, 2014).

34
 d. Fluids and electrolytes
Fluid requirements in TB and TB/HIV co-infected individuals are the same as for healthy individuals (30 –
35 ml/kg per day). Electrolytes (sodium, potassium and chloride) that are lost through fever, diarrhoea,
vomiting and night sweats should be replaced (Fenton & Silverman, 2008:1011). However, Mueller (2012:
918) indicates that all patients with TB require increased fluid intake, unless it is contra-indicated, such as in
renal insufficiency.

2.11.2.2 Micronutrients
Micronutrients are essential for optimal functioning of the immune system (ASSAf, 2007). However, the
relationship between TB and micronutrients is considered to be complex (USAID, 2010: 18) and randomised,
placebo-controlled clinical trials of multi-micronutrient supplementation for adults with pulmonary TB and
HIV co-infection have shown conflicting results. A study in Malawi, with a sample size of 829 adult patients
with TB and HIV co-infection, concluded that daily supplementation with a multi-vitamin and mineral
supplement had no significant impact on mortality (Semba et al., 2007: 856). A study in Tanzania also
concluded that there was no significant impact of micronutrient supplementation on mortality, but
supplementation with micronutrient nutrients did reduce the risk of relapse of TB by 63% in patients with
pulmonary TB and HIV co-infection (Villamor et al., 2008: 1504). In contrast to the results of the above
studies, another study in Tanzania, including 213 adult patients with pulmonary TB and HIV co-infection,
found that daily supplementation with a multi-vitamin that included zinc for a period of eight months, reduced
mortality by 71% (Range et al., 2006: 769). A study in Indonesia, with a small sample size of 54 TB patients,
found that supplementation with vitamin A and zinc improved the effectiveness of anti-TB treatment during
the first two months (Karyadi et al., 2002: 726). According to Murpere et al. (2012) micronutrients may
improve the outcome of TB treatment.

Studies undertaken over the last two decades have found that low serum levels of essential micronutrients;
namely vitamins A, E and D and the minerals calcium, iron, zinc and selenium are common in patients with
active TB starting on treatment (Rudolph et al., 2013; Moses et al., 2008; Ramachandran et al., 2004; Madebo
et al., 2003; Mugusi et al., 2003; Karyadi et al., 2000; Coetzee, 1997). Rudolph et al. (2013) reported that
almost 50% of adult patients with TB had levels of vitamin A, vitamin D, iron, zinc, and albumin below the
normal range. Deficiencies of vitamin A, C and D and the minerals zinc and iron can lead to immune
impairment, and thus deficiencies of these micronutrients may be significant determinants of TB disease. The
increased energy expenditure and tissue breakdown associated with infection are thought to increase the
requirements of micronutrients such as vitamin A, E, B6, C, D and folate (ASSAf, 2007; Van Lettow et al.,
2004).

35
 a. Vitamin A and antioxidants
Low levels of vitamin A and certain antioxidants in patients with TB have been reported by several
researchers (Semba et al., 2010: S352; Moses et al., 2008: 211; Karyadi et al., 2002). This could be because
of oxidative stress, high load of free radicals, decreased dietary intake, and impaired absorption, increased
utilisation during infection, lipid peroxidation or abnormal losses in the urine. All of these processes either
destroy the antioxidants or create a high demand for them (Semba et al., 2010: S352; USAIDS, 2008: 18;
Moses et al., 2008: 211). Karyadi et al. (2002: 726) reported that the effectiveness of anti-TB treatment
improved during the first two months of supplementation with vitamin A and zinc.

b. Vitamin D
Adding calcitriol (1,25(OH)2 vitamin D3) to cultured human macrophages enhances the ability of the cells to
control replication of active M. tb (Semba et al., 2010: S352; Cegielski & McMurray, 2004: 293; ASSAf,
2007). Supplementation with vitamin D may be required where sunlight and diets are inadequate, although
further research on the impact of vitamin D supplementation during TB treatment is needed (USAID, 2010:
21). Abnormalities in terms of calcium homeostasis have been reported in patients with TB, but the
correlation of these abnormalities to vitamin D status is still uncertain (Semba et al., 2010: S352).

c. Iron and anaemia

Anaemia is common in patients with pulmonary TB, and it appears to be more common among TB/HIV co-
infected patients. Karyadi et al. (2000) found that patients with TB were more anaemic and had lower plasma
concentrations of zinc and retinol than controls, while low concentrations of haemoglobin, retinol and zinc
were also more common in malnourished TB patients.

Reasons for anaemia may be related to an inadequate intake, increased blood loss from hemoptysis, bone
marrow involvement, or anaemia of chronic inflammation. As with other infections, intake of iron with TB
disease, beyond correcting iron deficiency, may have harmful effects and should be avoided (Karyadi et al.,
2000: 2957). On the other hand, iron overload occurs in about 10% of individuals in rural African populations
due to high dietary iron intake through the consumption of traditional fermented beverages brewed in iron
pots. Iron overload may increase the growth of M. tb by weakening macrophage suppression of invading
microorganisms (USAID, 2008: 22-23).

d. Other trace elements

Zinc and selenium status are affected during infection. Excessive zinc losses may occur through diarrhoea,
which is common in patients with TB, and may lead to loss of gastrointestinal epithelial integrity and
absorptive power. In animal studies, selenium deficiency is associated with reduced immune function
(ASSAf, 2007: 145).

36
2.11.2.3 Micronutrient supplementation
As mentioned, a number of deficiencies can occur in TB/HIV co-infected patients (Coodley & Albertson,
2001: 155). There is convincing evidence suggesting the need for a multivitamin and mineral supplement,
which should provide 100% of the recommended daily allowances (UNAIDS, 2014; Fenton & Silverman,
2008: 1011). Mupere et al. (2012) has recommended that nutrition supplementation, together with
counselling, is required to improve TB treatment outcomes positively.

2.12 Prevention Programmes

As far as prevention is concerned, HIV testing, prevention, and protection programmes should be emphasised
(Labadarios et al., 2008: 132). The high incidence of TB infection in South Africa is mainly due to the high
rate of HIV co-infection (WHO, 2013) and although TB is curable, HIV cannot be cured. Thus, babies at
increased risk for TB should be vaccinated with bacille Calmette–Guérin (BCG) before discharge from
hospital or as soon as possible (at the 6 weeks postnatal checkup). The BCG vaccination and TB testing
should be promoted in eligible groups (Hoppe et al., 2016). The BCG seems to be protective against serious
forms of disease (meningitis) in children, but not so effective against TB in adults. Therefore there is a need
for a more effective vaccine (Frieden, 2003: 896).

Since South Africa is currently facing an economic crisis, health departments need to identify the cheapest
and most effective treatment for TB. Community support groups are one of the cheapest and most effective
ways to manage TB treatment. Communities can play an important contributory role in reducing the burden
of TB and HIV and in alleviating its impact, stigma and discrimination. Despite this, community resources
in most settings are often inadequate and their role remains undefined (Zacharaih et al., 2006). The DOTS
strategy is a good initiative to support the community, and has been shown to lower the indirect costs of TB
to patients and family members. However, the current implementation of the DOTS strategy needs to be
reassessed (Ahlburg, 2000).

Food support has the potential to have a positive impact on the quality of life of patients with TB and family
members affected by TB (WHO, 2013). Food support at the start of treatment, when people are still recovering
from opportunistic infections and malnutrition, is of major importance. Together with food assistance,
household members should be informed of the different nutritional needs in the family and that more
vulnerable individuals might have increased requirements. Intervention strategies cannot be generalised, but
should be implemented according to what is most appropriate in the specific context (Bloem & Saadeh, 2010:
S290-S291).

Nutrition education has the potential to play an important role in improving nutritional status and ensuring
food security (Keenan et al., 2001). Poverty, however, makes TB education difficult, due to lower levels of
literacy in poverty stricken communities and limited access to mass media and health education services,
37
especially in rural areas. Furthermore, people struggling with daily survival are less inclined to worry about
the long-term implications of illness and therefore are less likely to take preventative measures (FAO, 2003).

2.13 Conclusion
TB is closely associated with poverty and has not received the attention that it deserves in terms of the
development of diagnostics, drugs, treatment and vaccines. It is considered to be a “neglected disease”,
together with HIV/AIDS, malaria and other diseases in developing countries.

Some people refer to TB as “The Mother of Diseases” and there is a saying that goes “TB anywhere is TB
everywhere”. Annually nearly 3 million lives are claimed by the curable TB disease. In South Africa, TB
affects 4 to 5 out of every 1 000 people and thus the TB problem in South Africa is one of the worst in the
world. TB costs about 10 000 lives a year in South Africa and is the most deadly single infectious disease in
this country (ASSAf, 2007).

A better understanding of latent TB infection can assist in focusing on preventative and protective
mechanisms. TB is as much a social disease as an infectious disease, as poverty, stress, drug addiction,
alcoholism, overcrowding and malnutrition are associated with TB. Successfully addressing TB requires
increasing awareness of TB to ensure earlier and better detection, by addressing the fears and preconceptions
that people will feel free to admit having the illness, by giving support to those who are taking treatment to
complete the long course, and by removing unnecessary barriers to treatment.

Proper nutritional status is vital during all lifestyle stages. A person affected by TB disease, directly or
indirectly, requires even more special attention in terms of nutrition. Nevertheless, this group of people are
usually the most neglected and malnourished. In order to obtain an adequate nutritional profile of patients
with TB and TB/HIV co-infection, more research in this field is of tremendous importance.

38
 CHAPTER 3
METHODOLOGY
3.1 Introduction
A cross sectional study was conducted to achieve the main aim of the study, which was to determine the
nutritional status of patients with TB, and TB/HIV co-infection at Standerton TB Specialised Hospital,
Mpumalanga.

To achieve the above mentioned aim, information related to socio-economic status, nutritional status, overall
risk of malnutrition, biochemical parameters and lifestyle behaviours was collected as part of the objectives.
Associations between various parameters were also established.

3.2 Ethical considerations

Ethics approval was obtained from all relevant parties, including the Provincial Health and Research Ethics
Committee (PHREC) of Mpumalanga Department of Health (PHREC MP_2015RP38_556) (Addendum D
& E) and the Health Sciences Research Ethics Committee of the Faculty of Health Sciences, University of
the Free State (ECUFS 56/2015) (Addendum F). Prior to data collection, approval to undertake the study was
obtained from Standerton TB Specialised Hospital (Addendum G & H). All participants completed informed
consent (Addendum I) and an information document (Addendum J) was given to each patient. The
information document explained procedures that would be followed during the study, as well as risks,
benefits, voluntary participation and guaranteed confidentiality.

3.3 Sample selection

3.3.1 Population and sample selection
The study population included all patients with TB, and TB/HIV co-infection at Standerton TB Specialised
Hospital, Mpumalanga. There were a total of five wards in the hospital, of which three wards had patients
with MDR TB. For the purpose of this study, patients with MDR TB were excluded (due to different
medication regimens); thus only two of the five wards were included. The patients with drug sensitive TB
(patients that are not resistant to any of the TB medications) in ward one and two were included.

3.3.2 Sample
A convenience sample of consecutive patients was included. The sample included 100 patients with TB and
TB/HIV co-infection that met the inclusion criteria and were present over a period of one month (21/07/2015
– 17/08/2015). Inclusion and exclusion criteria were applied to select patients who were eligible to participate
in the study.

39
3.3.2.1 Inclusion criteria
The following participants were included in the study:

 For the period of the study, all patients with TB and, TB/HIV co-infection admitted to wards 1 and 2
at Standerton TB Specialised Hospital
 Patients between 20 and 69 years (as this is within the age references of the anthropometric cut-off
points for the Triceps skinfold measurement)
3.3.2.2 Exclusion criteria
The following participants were excluded from the study:

 Patients with additional diagnoses other than TB or TB/HIV co-infection

 Pregnant or lactating patients (anthropometric and biochemical cut-off points differ)
 Patients that were mentally disabled (unable to report accurate information)
 Patients that were physically disabled (anthropometric measures are affected)
3.4 Operational definitions
For the purpose of the study the following definitions were compiled and applied to achieve the objectives of
the study.

3.4.1 Room density

For the purpose of this study, a room density of more than 2.5 persons per room (ppr), was an indication of
crowding (Coetzee et al., 1988: 354).

3.4.2 Eating related side effects and food security

For the purpose of this study, eating related side effects referred to: loss of appetite, sore mouth, dry mouth,
nausea, vomiting, constipation, diarrhoea and night sweats. Food security was assessed by means of the
Community Childhood Hunger Identification Project (CCHIP) tool that included questions related to the
availability of money in the household for food purchases (Wehler et al., 1992). The CCHIP hunger index is
a scale composed of eight questions that investigates whether adults and/or children in the household are
affected by food insecurity, food shortages, perceived food insufficiency or altered food intake due to
constraints on resources (FRAC, 1991).

Food insecurity was categorised as follows (FRAC, 1991):

 A score of five or more positive responses (Yes answers) out of a maximum possible of eight indicated
that the family is “hungry”.
 A score of one to four positive responses (Yes answers) indicated that the family is at “risk of hunger”.
 A negative response (No answer) assumed that the household is “food secure”.
40
3.4.3 Anthropometric measurements
For the purpose of this study anthropometric indicators of nutritional status included height, weight, MUAC
and Triceps skinfold.

3.4.3.1 Body mass index (BMI)

BMI was calculated by dividing weight in kilograms (kg) by height in m2. BMI was interpreted according to
the World Health Organisation (WHO) categories of BMI as indicated in Table 1.

Table 3.1: Weight classifications by Body Mass Index (WHO, 2006)

BMI (kg/m²) WHO classification

< 18.5 Underweight

18.5 – 24.9 Normal weight

25 – 29.9 Overweight / Pre-obese

30.0 – 34.9 Obese Class I

35 – 39.9 Obese Class II

> 40 Obese Class III

3.4.3.2 Mid-upper arm circumference (MUAC)

For the purpose of this study a MUAC of <22cm for females and <23cm for males indicated malnutrition as
indicated by Table 2 (Tang et al., 2013).

Table 3.2: Cut-off points for classification of adult- malnutrition by mid-upper arm circumference

Circumference (cm) Classification

Females > 22 Normal

< 22 Malnourished
Males > 23 Normal

< 23 Malnourished

41
3.4.3.3 Triceps skinfold
For the purpose of this study a Triceps skinfold measurement was interpreted according to the Triceps
skinfold norms from NHANES 2003 – 2006 as indicated by Table 3.3 for females and Table 3.4 for males
(Lee & Nieman, 2013:459-460).

Table 3.3: Triceps skinfolds in millimetres for females 20 years of age and older

Race, ethnicity and age Percentile (mm)

All race and ethnicity groups 5th 10th 15th 25th 50th 75th 85th 90th 95th
20-29 years 10.4 11.9 13.2 15.5 21.1 27.3 30.3 32.4 34.7
30-39 years 12.1 14.7 15.8 18.2 23.9 30.2 32.9 35.3 37.4
40-49 years 12.1 14.1 15.9 19.5 25.6 30.9 33.6 35.2 36.9
50-59 years 13.3 16.1 17.5 20.5 25.9 31.0 33.2 34.9 36.5
60-69 years 13.4 16.6 18.1 20.3 25.4 30.2 32.8 34.2 36.0

Table 3.4: Triceps skinfolds in millimetres for males 20 years of age and older

Race, ethnicity and age Percentile (mm)

All race and ethnicity groups 5th 10th 15th 25th 50th 75th 85th 90th 95th
20-29 years 5.0 6.2 7.1 8.8 12.7 18.9 21.7 25.4 29.4
30-39 years 5.8 7.1 8.2 10.0 13.6 18.3 21.4 23.4 27.0
40-49 years 6.6 7.6 8.7 10.4 13.9 19.2 22.3 24.1 27.9
50-59 years 6.2 7.4 8.9 10.8 14.1 18.5 21.5 23.2 26.7
60-69 years 7.3 8.3 9.4 11.2 14.9 19.7 22.5 25.2 30.3

3.4.4 Overall risk of malnutrition

For the purpose of this study the overall risk of malnutrition was determined by making use of the
Malnutrition Universal Screening Tool (MUST) (Bapen, 2003).

The four-step MUST screening tool to identify adults, who are malnourished or at risk of malnutrition is
illustrated in Figure 3.1:

42
Figure 3.1: The Malnutrition Universal Screening Tool (Bapen, 2003)

3.4.5 Biochemical parameters

The following biochemical markers were measured. Normal values (ranges or cut-off points) for biochemical
parameters are indicated below (Du Buisson et al., 2010):

 Total protein 60 – 78g/l

 Albumin 35 – 52g/l
 C-reactive protein (CRP) 0.0 – 4.9mg/l

43
 CD₄ cell count 500 – 2000mm3
 Mean corpuscular volume (MCV) 79.1 – 89.0f/l
 Haemoglobin Male: 14.3 – 18.3g/dl ; Female: 12.1 – 16.3g/dl

3.4.6 Lifestyle behaviours

3.4.6.1 Smoking habits
Smoking habits were categorised as follows (Peltzer, 2014; Saad & Tirkey, 2013):

 Non-smoker: Patient who had never smoked;

 Former smoker: Patient who had smoked before, but who had stopped smoking for at least 3 months
before entering the study.
 Current smoker: Patient that smoked at least one cigarette, pipe, or cigar per day for at least 6 months
prior to entering the study.
Patients who were former or current smokers were asked how many times a day and for how many years they
were/are smoking.

3.4.6.2 Alcohol consumption

For the purpose of this study, alcohol consumption was categorised according to whether or not the
participants formerly drank alcohol more than 3 times per week (Peltzer, 2014; Saad & Tirkey, 2013). An
alcohol consumption of less than 3 times per week was considered low, while consumption of alcohol 3 or
more times a week was considered high (Saad & Tirkey, 2013).

3.5 Pilot study

A small-scale trial run was conducted to prepare for the main study. The pilot study’s function was to
determine the feasibility of the study (Smith & Harrison, 2009: 35), to ensure that the respondents understood
the questions and to determine how long it would take to complete the necessary interviews with the
respondents. The pilot study was conducted by the researcher herself on the first five patients from Standerton
TB Specialised Hospital. No changes were made after the pilot study, thus these five patients were included
in the main study.

3.6 Data collection process

Step 1

 Approval was obtained from the Research Evaluation Committee of the School of Allied Health
Professionals of the University of the Free State.

44
  Approval was obtained from the Provincial Health and Research Ethics Committee (PHREC) of
Mpumalanga Department of Health (Addendum D & E).
 Approval was obtained from the Health Sciences Research Ethics Committee of the University of the
Free State (Addendum F).
 Approval was obtained from the Corporate Executive Officer (CEO) at Standerton TB Specialised
Hospital (Addendum G & H).
 Informed consent (Addendum I) was obtained from the participating patients. The information
document (Addendum J) was discussed with each patient and informed consent was provided by
patients before taking part in the study.
 The pilot study was undertaken at Standerton TB Specialised Hospital.
Step 2

 Patients at Standerton TB Specialised Hospital completed the consent forms with the help of the
researcher and a translator (if needed). Lay counsellors at the Hospital assisted with translating and
explaining the procedure of the study to patients in their own language. The information document
was given to patients to provide them with more information regarding the study.
 Questionnaires (including; socio-economic status, eating related side effects, food security, overall
risk of malnutrition, smoking habits and alcohol use) were completed with each patient in a structured
interview with the researcher. The interviews took place in a private room.
 The researcher conducted anthropometric measurements (weight, height, MUAC and Triceps
skinfold) on all the patients.
 Biochemical data (total protein, albumin, CRP, CD₄ cell count, MCV and haemoglobin) were taken
from the patients files and recorded on the questionnaire by the researcher.

Step 3

 A feedback report will be given to the hospital to highlight the results of the study and help the hospital
to improve in areas that warrant nutrition intervention strategies.

3.7 Techniques
The techniques that were used to obtain information from the participants included a questionnaire,
anthropometric measurements and biochemical assessments.

45
3.7.1 Questionnaire
For the purpose of this study, a questionnaire was designed by the researcher to obtain information related to
the nutritional status of patients with TB and TB/HIV co-infection at Standerton TB Specialised Hospital
(Addendum K). The questionnaire included questions related to socio-demographic status, eating related side
effects and food security (CCHIP questionnaire), overall risk of malnutrition (MUST tool) and lifestyle
habits. The questionnaire was administered by the researcher, a registered dietician, via a structured interview
with each patient.

3.7.2 Anthropometric measurements

3.7.2.1 Weight

Weight was measured with a platform electronic scale (TCS-200-RT). As recommended by Lee & Nieman
(2013:168), the participants were wearing minimal clothing (removed jacket, shoes and jewellery), standing
still in the middle of the scale’s platform without touching anything and with the body weight equally
distributed on both feet. The weight was recorded to the nearest 0.1 kg.

3.7.2.2 Height
Height for adults was measured by means of a stadiometer (TCS-200-RT) with a vertical scale of 2 meters
and a sliding head-piece, to the nearest 0.5cm. Participants were measured without shoes. The participants
stood with their heels together, arms to the side, legs straight, shoulders relaxed and head in the Frankfort
horizontal plane (looking straight ahead). Heels, buttocks, scapulae (shoulder blades), and the back of the
head were against the vertical surface of the stadiometer. Just before the measurement was taken, the
participant inhaled deeply, held the breath and maintained an erect position while the sliding-headpiece was
lowered to the highest point of the head with enough pressure to compress the hair (Lee & Nieman, 2013:167).

3.7.2.3 Mid-upper arm circumference

MUAC was measured using a non-stretch flexible tape-measure. The participants stood erect and sideways
to the measurer, with the head in the Frankfurt plane, legs apart, and arms relaxed. Sleeved garments were
rolled up or removed. The measurement was taken at the midpoint of the upper arm, between the acromion
process and the tip of the olecranon. After locating the midpoint, the arm was extended so that it is hanging
loosely by the side, with the palm facing inward. The tape was then wrapped gently but firmly around the
midpoint of the arm (Lee & Nieman, 2013: 228; Gibson, 2005: 290). The MUAC measurement was taken
three times on each participant and an average was calculated by the researcher to the nearest 1mm.

46
3.7.2.4 Triceps skinfold
The measurement of the triceps skin fold was performed at the midpoint of the upper right arm, between the
acromion process and the tip of the olecranon, with the arm hanging relaxed. To obtain the midpoint, the right
arm had to be bent at 90º at the elbow, and the forearm had to be placed palm down across the body. The tip
of the acromion process of the shoulder at the outermost edge of the shoulder blade and the tip of the olecranon
process of the ulna was located and marked. The distance between these two points was then measured using
a non-stretchable tape, and the midpoint was then marked with a soft pen. The right arm was then extended
so that it was hanging loosely by the side. The examiner grasped a vertical fold of the skin plus the underlying
fat, 2cm above the marked midpoint, using both the thumb and the forefinger. The skinfold was held between
the fingers while the measurement was taken to the nearest mm (Lee & Nieman, 2013: 190; Gibson, 2005:
275-276). The triceps skin fold measurement was taken three times on each participant and the average was
noted to the nearest 2mm.

3.7.3 Biochemical parameters

Blood of patients are drawn as part of standard procedures in the hospital by a professional nurse. Biochemical
parameters (total protein, albumin, CRP, CD₄ cell counts, MCV, and haemoglobin) were analysed in an
accredited laboratory using standard laboratory techniques.

3.8 Statistical analysis

Descriptive statistics, namely frequencies and percentages for categorical data, medians and percentiles for
continuous data was calculated. Associations between variables were calculated and described by means of
95% confidence intervals (CI) for differences in percentages. All analyses were completed by the Department
of Biostatistics at the University of the Free State.

3.9 Measurement and methodology errors and limitations

Illiteracy and language limitations may have been a challenge during the interviews. To overcome this barrier,
a translator was present during the structured interviews. In order to ensure that questions were not
misinterpreted by the translators, the questionnaire was translated into isZulu and the exact wording was used
by the translator.

In order to ensure that weight measurements were accurate, the weight recorded by the scale was compared
with a known weight after weighing every 20 participants (Myer & Karim, 2014).

This study only included hospitalised patients, thus the chance that more ill, malnourished patients were
included was high, indicating that results may not be representative of patients in the community setting.

47
3.10 Validity and reliability

Validity is defined as a test that measures what it’s supposed to measure. To determine if an instrument is
valid, one need to know what the instrument is meant to measure and to ensure that this is what is indeed
being measured. Reliability refers to a consistent and stable result (Kimberlin & Winterstein, 2008: 2277-
2278; Delport, 2008: 162; Sherry et al., 2003: 113).
3.10.1 Questionnaire
3.10.1.1 Validity
All issues addressed by the questionnaire were directly related to the aim and objectives of the study. The
CCHIP index is internationally used and validated, has excellent sensitivity and good specificity, is one of
the first scales developed to measure hunger in families and is strongly associated with socio demographic
variables (Keenen et al., 2001; Wehler et al., 1992). The MUST tool is internationally validated and regarded
as an accurate tool to evaluate the risk of malnutrition in adult patients (Gibson et al., 2012: 313; Bapen,
2003; Stratton et al., 2004: 807). The content of the lifestyle questionnaire has been selected in accordance
with recommended measurements for factors related to lifestyle which have been suggested in the literature
(Peltzer, 2014; Saad & Tirkey, 2013).

3.10.1.2 Reliability
Only one person, namely the trained researcher, completed the questionnaire in a personal interview with
each participant.

3.10.2 Anthropometric measurements

3.10.2.1 Validity
The scale was moved to the zero point before each measurement. The weight recorded by the scale was
regularly compared with a known weight to ensure that an accurate measurement was taken.

3.10.2.2 Reliability
In order to ensure reliability of the results, weight, height, MUAC, and Triceps skin fold were measured by
the same trained researcher (a registered dietitian) according to standard procedures, as recommended by Lee
& Nieman (2013).

3.10.3 Biochemical parameters

3.10.3.1 Validity
The biochemical variables that were determined included routine tests that are performed on patients in the
hospital.

48
3.10.3.2 Reliability
The results of the blood tests were considered reliable, because they are determined in an accredited
laboratory by trained personnel using standard controls

49
 CHAPTER 4
SOCIO-DEMOGRAPHIC PROFILE AND HOUSEHOLD FOOD SECURITY OF
PATIENTS WITH TB, AND TB/HIV CO-INFECTION AT STANDERTON TB
SPECIALISED HOSPITAL, MPUMALANGA

ABSTRACT

Objective: To determine the socio-demographic profile and level of household food security of patients with
TB, and TB/HIV co-infection.
Design: A cross sectional study was undertaken.
Settings and subjects: The study was conducted at Standerton TB Specialised Hospital, Mpumalanga. One
hundred hospitalised patients with TB, and TB/HIV co-infection were included.
Outcome measures: A structured interview was conducted by the researcher with each patient to obtain
socio-demographic information and the level of food security in the household, using the Community
Childhood Hunger Identification Project (CCHIP) tool.
Results: The majority of participants (91%) did not complete matric and two thirds (66%) were unemployed.
More than one out of ten participants (12%) indicated that they had no monthly income and in 64% of
households, only one person contributed to the monthly income. Room density of more than 2.5 persons per
room (crowded) was present in 29% of households. Only 26% of participants reported having a household
vegetable garden. As far as household food security was concerned, only 3% were classified as food secure
with 27% of households being at risk of hunger and 70% being food insecure (hungry).
Conclusion: The socio-demographic profile of patients with TB and TB/HIV co-infection reflected high rates
of poverty, unemployment and household food insecurity. These factors are known to increase the risk of
developing TB disease and progression of latent TB infection to TB disease. Interventions aimed at
addressing TB need to address unfavourable socio-demographic conditions.
INTRODUCTION

Tuberculosis (TB) is an infectious disease caused when the Mycobacterium tuberculosis (M. tb) organism
enters the lungs (Shi & Sugawara, 2013: 127). According to The World Health Organisation (WHO), 9.6
million new TB cases were diagnosed in 2014, with an estimated 1.2 million that were human
immunodeficiency virus (HIV) co-infected. The African Region accounts for 28% of TB cases and 74% of
TB and HIV co-infected cases worldwide. This amounts to 281 cases per 100 000 population, which is more
than double the global average of 133 cases per 100 000 population (WHO, 2015).

Socioeconomic factors are closely related to TB infection. These include poverty, crowding, unemployment,
malnutrition, and poor access to efficient health facilities. These factors do not only increase the risk for
developing TB, but also increase the chances of treatment failure. According to the South African National
Tuberculosis Association (SANTA), the incidence of TB is especially high amongst males, miners, the poor

50
and the very young in South Africa (SANTA, 2014; Chee et al., 2013: 205; Songpol et al., 2005: 221). TB is
mostly associated with specific population subgroups including immigrants from countries with high
endemicity, ethnic minorities, refugees, and the homeless (Faccini et al., 2013: 485). According to Villamor
et al. (2006: 170), poor socioeconomic status is an important predictor of malnutrition in patients with TB
disease, independent of HIV infection.

Food insecurity plays an important role in the progression of TB infection to active TB disease (Bloem &
Saadeh, 2010). Food security is defined as “access to enough food at all times by all people for an active and
healthy life” (Anderson, 1990; Keenan et al., 2001). According to Bloem & Saadeh (2010), food insecurity
is defined as limited food utilisation, availability, or access. Households experience food insecurity in the
most basic form when they do not have adequate resources to obtain enough food to meet their basic
nutritional needs; resulting in hunger for all household members (Keenan et al., 2001). In an attempt to
optimise nutritional status, food and nutrition security are essential factors to consider, especially in the TB
population (ADA, 2010).

Globally household food security is a major concern. According to the global International Food Security
Assessment for 2011 to 2021, the number of food-insecure people and the food gap are estimated to decline
respectively by 16% and 7% during the ten year period. In Sub-Saharan African, however, the opposite is
predicted, with an increase of 17 million in the number of food-insecure people and an increase of 20% in the
food gap between 2011 and 2021 (USDA, 2011).

Between 1999 and 2008 the prevalence of food insecurity in South Africa appears to have been reduced by
half (from 52.3% to 25.9%), but the percentage of people at risk of experiencing food insecurity remained
almost unchanged, due to population growth together with high levels of unemployment (WHO, 2013;
Labadarios et al., 2011). A major concern with regards to household food security is that a household may
be food secure overall, but a poor understanding of individual needs, together with an unequal distribution
among household members, may lead to food and nutrition insecurity for the more vulnerable household
members, such as those infected with TB and/or HIV (Ogundiran et al., 2014; Bloem & Saadeh, 2010: S290).

“The Right to Food” is a basic human right enshrined in the South African constitution. The right to adequate
food as a basic human right was first formally recognised by the United Nations in the Universal Declaration
of Human Rights (UDHR), as a part of the right to a decent living standard (FAO, 2016). During 2009 the
World Food programme (WFP) provided food assistance to 3 million people that were affected and infected
with HIV and TB (Bloem & Saadeh, 2010: S291). As mentioned, food insecurity is a major risk factor for
the development and prognosis of TB disease.

51
In view of the reported negative impact of poor socio-economics conditions on TB, the purpose of this study
was to determine the socio-demographic profile and level of food security of patients with TB and TB/HIV
co-infection at Standerton TB Specialised Hospital, Mpumalanga, where information of this nature has not
previously been collected. This information may contribute to the identification of specific areas that need to
be considered in health and nutrition interventions, which may in turn play a vital role in improving the
outcome, quality of life and prognosis of patients with TB and TB/HIV co-infection.

METHODOLOGY

Study design

A cross sectional study was conducted.

Target population and sampling

The study population included all patients between 20-65 years with TB, and TB/HIV co-infection that gave
informed consent to participate at Standerton TB Specialised Hospital, Mpumalanga in wards 1 and 2 over a
period of one month (21/07/2015 – 17/08/2015). Patients with any additional diagnoses other than TB and
TB/HIV co-infection, pregnant or lactating patients, and mentality or physically disabled patients were
excluded from the study. The sample included 100 patients with TB and TB/HIV co-infection that met the
inclusion criteria.

Pilot study

A pilot study was conducted on the first five patients that met the inclusion criteria and provided onfrormed
consent from Standerton TB Specialised Hospital to determine the feasibility of the methodology. No changes
were made to the questionnaire and data of these participants was thus included in the main study.

Variables and operational definitions

Information related to socio-demographic status included gender, age, marital status, education level,
employment status, household income and housing density.

Food security was assessed by means of the Community Childhood Hunger Identification Project (CCHIP)
tool that includes eight questions that investigate whether adults and/or children in the household are affected
by food insecurity, food shortages, perceived food insufficiency or altered food intake due to constraints on
resources. Food insecurity was categorised as follows (FRAC, 1991):

 A score of five or more positive responses (Yes answers) out of a maximum of eight indicate that the
family is “hungry”.

52
  A score of one to four positive responses (Yes answers) indicate that the family is at “risk of hunger”.
 A negative response (No answer) to all questions indicates that the household is “food secure”.

Techniques

Based on a comprehensive literature review, a questionnaire was designed by the researcher to obtain
information regarding the socio-demographic status of participants. Information related to food security of
patients with TB and TB/HIV co-infection at Standerton TB Specialised Hospital was collected using the
CCHIP questionnaire. The researcher completed a structured interview with each participant.

Validity and reliability

All issues addressed by the questionnaire were directly related to the aim and objectives of the study. The
CCHIP index is an internationally used and validated tool (Wehler et al., 1992). Keenan et al. (2001: S56)
confirmed that the CCHIP huger index has excellent sensitivity and good specificity. Only one person, namely
the trained researcher, completed the questionnaire in a personal interview with each participant.

Ethics

Ethics approval was obtained from the Provincial Health and Research Ethics Committee (PHREC) of
Mpumalanga Department of Health (PHREC MP_2015RP38_556) and the Health Sciences Research Ethics
Committee of the Faculty of Health Sciences, University of the Free State (UFS) (ECUFS 56/2015).

Data collection

All eligible participants signed consent in their language of choice (English/IsiZulu), after the purpose and
procedure of the project had been explained to them by the researcher or a lay counsellor who spoke the
native language. The information document was given to patients to provide them with all the relevant
information regarding the study. Once informed consent had been obtained, participants were interviewed by
the researcher. In addition to information on socio-demographic status and food security, information on
nutritional status, smoking habits and alcohol use were also collected; these are reported elsewhere.

Statistical analysis

Descriptive statistics, namely frequencies and percentages for categorical data, and medians and percentiles
for continuous data were calculated. Associations between variables were calculated and described by means
of 95% confidence intervals (CI) for differences in percentages. All analyses were completed by the
Department of Biostatistics at the UFS.

53
RESULTS

The study sample included 100 participants (60 males and 40 females). The median age of the sample was
39.2 (20.3-63.5) years. More than two thirds of participants (68%) were HIV positive; with HIV co-infection
being slightly higher among women (70%) than among men (66.7%).

Socio-demographic profile

Socio-demographic information is presented in Table 4.1. Half of participants (50%) indicated that they were
unmarried. The majority (91%) did not complete matric, 44% had completed less than grade nine and 8% had
no schooling. Two thirds (66%) were unemployed. Almost one third (32%) of participants indicated that the
total household income per month was R1001-R3000 and 12% indicated that they had no monthly income.
In 13% of participants, no one contributed to the monthly income and more than two thirds (64%) indicated
that only one person contributed to the monthly income

54
Table 4.l: Socio-demographic information

Frequency (n) Percentage (%)

Marital Status (n=100)
Unmarried 50 50.0
Married/Traditional marriage 23 23.0
Divorced/Separated 2 2.0
Widow/Widower 6 6.0
Living together 19 19.0
Level of education (n=100)
No schooling completed 8 8.0
Less than Grade 9 36 36.0
At least Grade 9 47 47.0
Matric completed 7 7.0
Tertiary education 2 2.0
Current employment status (n=100)
Unemployed 66 66.0
Self-employed 1 1.0
Full time wage earner 15 15.0
Part time wage earner 9 9.0
Receives a grant 9 9.0
Total household income per month (n=100)
None 12 12.0
R100 – R500 10 10.0
R501 – R1000 22 22.0
R1001 – R3000 32 32.0
R3001 – R5000 13 13.0
Over R5000 4 4.0
Don’t know 7 7.0
Number of people contributing to the monthly income (n=100)
None 13 13.0
1 Person 64 64.0
2 Persons 20 20.0
3 Persons 3 3.0

55
The median number of people per household was 5 with a maximum of 11 people. A room density of more
than 2.5 persons per room (ppr), indicative of crowding, was present in 29% of households. The median room
density was 2 ppr (0.5-8)

Only 26 of the 100 participants had a vegetable garden. The type of vegetables reportedly grown by
participants with gardens is presented in Table 4.2. Spinach (76.9%) followed by cabbage (42.3%) and
beetroot (34.6%) were the most commonly grown vegetables.

Table 4.2: Vegetable gardens (n=26)

Frequency Percentage
Type of vegetable
Spinach 20 76.9
Cabbage 11 42.3
Beetroot 9 34.6
Pumpkin 8 30.8
Potato 5 19.2
Tomato 4 15.4
Maize ‘Mielies’ 3 11.5
Carrots 3 11.5
Onions 3 11.5
Green beans 1 3.9
Sweet potato 1 3.9
Number of vegetables
1 Type of vegetable 7 26.9
2 Types of vegetables 6 23.1
3 Types of vegetables 7 26.9
4 Types of vegetables 3 11.5
5 Types of vegetables 1 3.9
6 Types of vegetables 2 7.7

Household food security

The responses to the CCHIP questionnaire are presented in Table 4.3. Almost every participant (97%)
indicated that they ran out of money during the month to buy food, and more than nine out of ten (93%) relied

56
on a limited number of foods. More than half (53%) of participants (n=94) reported that their children
sometimes go to bed hungry, because there is not enough money for food.

Table 4.3: Responses to Community Childhood Hunger Identification Project questionnaire

CCHIP Question Yes responses No responses

(%) (%)
Household-level food insecurity (n=100)
Q1: Does your household ever run out of money to buy food? 97 3

Q2: Do you ever rely on a limited number of foods because you are 93 7
running out of money to buy food?
Q3: Do you ever cut the size of meals or skip meals because there 77 23
is not enough money to buy food?
Individual-level food insecurity (n=100)
Q4: Do you ever eat less than you should because there is not 79 21
enough money for food?
Child hunger (n=94)
Q5: Do your children ever eat less than you feel they should 75 19
because there is not enough money for food?
Q6: Do your children ever say they are hungry because there is not 63 31
enough food in the house?
Q7: Do you ever cut the size of your children’s meals or do they 62 32
ever skip meals because there is not enough money to buy food?
Q8: Do any of your children ever go to bed hungry because there 53 41
is not enough money to buy food?

A significantly higher percentage of HIV co-infected than HIV uninfected participants reported relying on a
limited number of foods to feed their children (97.1% compared to 83.9% respectively; 95% CI [-29.8%; -
1.7%]), sometimes cut the size of their meals or skip meals (83.8% and 61.3% respectively; 95 CI [4.2%;
41.3%]), eating less than they wanted to (86.8% and 61.3% respectively; 95% CI [7.4%; 44.0%]) and their
children tend to eat less than they should because there was not enough money available for food purchases
(85.7% and 66.7% respectively; 95% CI [1.4%; 38.1%]).

57
After the scoring of the responses to the CCHIP questions had been applied, categories of household food
security were determined and are presented in Table 4.4. Only 3% of households were classified as food
secure with 27% of households at risk of hunger and 70% being classified as food insecure (hungry). There
was no noticeable difference between males and females in terms of household food insecurity. Although a
lower percentage of participants with TB and HIV co-infection were food insecure (1.5%) compared to
participants that only had TB (6.5%), the difference was not statistically significant (95% CI [-2.3%; 36.3%]).

Table 4.4: Household food security

CCHIP Group Males (n=60) Females (n=40) Total

Food secure (no positive responses) 2 (66.7%) 1 (33.3%) 3
Risk of hunger (1-4 positive responses) 18 (66.7%) 9 (33.3%) 27
Hungry (5 of more positive responses) 40 (57.1%) 30 (42.9%) 70

CCHIP HIV positive (n=68) HIV negative (31) 95% Confidence

Question Yes No Yes No interval for the %
response response response response difference
(%) (%) (%) (%)
Q1 98.5 1.5 93.5 6.5 [-19.3%; 2.9%]
Q2 97.1 2.9 83.9 16.1 [-29.8%; -1.7%]*
Q3 83.8 16.2 61.3 38.7 [4.2%; 41.3%]*
Q4 86.8 13.2 61.3 38.7 [7.4%; 44.0%]*
Q5 85.7 14.3 66.7 33.3 [1.4%; 38.1%]*
Q6 71.4 28.6 56.7 43.3 [-5.3%; 34.7%]
Q7 69.8 30.2 56.7 43.3 [-6.9%; 33.3%]
Q8 58.7 41.3 50.0 50.0 [-12.1%; 29.0%]
Classification (%)
Food secure 1.5 6.5
(n=3)
Risk of 23.5 35.5 [-2.3%; 36.3%]
hunger (n=27)
Hungry 75.0 58.1
(n=69)
* Statistically significant difference

58
DISCUSSION

The median age of participants in the current study was below 40 years (39.2 years) and most (60%) were
men. This is similar to that reported in other studies undertaken in patients with TB where mean age ranged
from 29-46 years (Kirenga et al., 2015; Bhargava et al., 2013; Frediani et al. 2013: 1025; Gill et al., 2013:
985; Matos & Moreira Lemos, 2006: 1361; Marra et al., 2004). When looking at the above studies, the median
age illustrates that TB often affects the working age population in their prime productive years. According to
the WHO (2013a), 75% of all TB cases occur among people between 15-54 years of age.

Sixty percent of participants in the present study were male. Worldwide most TB cases and deaths occur
among men (Bhargava et al., 2013; Frediani et al. 2013: 1025; Miyata et al., 2013; Matos & Moreira Lemos,
2006: 1361; Marra et al., 2004). In women TB disease also remains among the top three killers (WHO,
2013a). Gill et al. (2013: 985) undertook a research study among patients with TB in a low endemic area in
Australia and found that 55% were female. In some studies women have been found to be more likely to
progress from TB infection to active disease than men. In addition, households in which women suffer from
TB are more likely to experience additional losses, since women are most often responsible for food
purchases, cooking, breastfeeding and childcare (Ahlburg, 2000).

An estimated 1.1 million of the 8.6 million people who developed TB in 2012 were HIV-positive and around
75% of these cases were from the African Region (WHO, 2013). Worldwide, 12% of the 9.6 million new
cases of TB in 2014 were HIV positive (WHO, 2015). Globally an estimated 70% of patients with TB are co-
infected with HIV (Amollo, 2009). The results of the current study is similar, with 68% of patients with TB
disease being co-infected with HIV. Louwagie et al. (2014: 503) found a co-infection rate of 85% in male
patients with TB in Tshwane, South Africa, while Villamor et al. (2006: 165) have reported lower rates in
Tanzania (50% among women and 24% among men). In the current study women also had slightly higher
HIV co-infection rates than men (70% among women 66.7% among men).

The South African National Health and Nutrition Examination Survey (SANHANES) was undertaken in a
random sample of South Africans in 2012 and reported that 40% of participants had an education level of
primary school or less and only 20% had completed matric (Shisana et al., 2013). The current study also
found high levels of illiteracy among patients with TB and TB/HIV co-infection (8% with no education and
36% with less than Grade 9). This finding is similar to a study conducted in Pakistan that reported that 65.8%
of patients with active TB had never attended school (Awan et al., 2012: 329). A study that was undertaken
amongst 1005 male patients with TB in the Tshwane Metropolitan Municipality, South Africa, found than
31.1% of patients had an education level of primary school or less and 45.3% had some high school education
(Louwagie et al., 2014: 503).
59
Not only basic education, but TB specific education is very important, since lack of knowledge,
discrimination and stigma are influential social determinants of the disease (Nieburg & Angelo, 2015). In the
words of Dr Thato Mosidi in 2015, a TB activist who previously also suffered from extreme drug resistant
TB (XDR TB): “I believe if we start talking about it and educating people about the disease, we’ll be well on
the way to eradicating it”.

According to the SANHANES, the majority of participants in urban formal, urban informal and rural informal
areas had no formal monthly income. Out of the nine provinces, Mpumalanga (where the current study was
conducted) was the province in which the highest percentage (46%) of respondents reported that they have
no monthly income (Shisana et al., 2013).

The published unemployment rate in South Africa is currently 24.3%, thus one out of four citizens is jobless
(Trading Economics, 2016). An almost three times higher unemployment rate of 66% was noted in the current
study. High rates of unemployment were also reported in an outpatient TB clinic in Tbilisi with an
unemployment rate of 52% (Frediani et al., 2013: 1025). Similarly, Lombardo et al. (2012: 1025) reported
an unemployment rate of 58% in patient with TB in Delft, Cape Town, South Africa. High levels of
unemployment complicate the situation, since it means that limited funds are available for food purchases,
putting families at risk for developing TB disease. The WHO estimates that adults infected with TB disease
lose an average of 3-4 months of potential work time and an adult TB death results in an average of 15 lost
years of economic activity (Ahlburg, 2000).

Results of the current study indicated that the total household income was very low for the majority of
participants. These findings have been confirmed in other studies undertaken amongst large samples of
patients with TB, such as the study undertaken in Tshwane (Louwagie et al., 2014: 5503). It is well known
that population groups at higher risk for poor nutrition are also at high risk for TB, poverty being a strong
denominator (Cegielski & McMurray, 2004: 286). Kirenga et al. (2015) classified the risk factors in patients
with TB in Uganda and found a prevalence of poverty in 39.5% of participants. On the other hand, TB also
increases one’s risk of poverty, since people with TB often face the double burden of reduced income and
increased expenses associated with the treatment program (WHOa, 2013). TB is sometimes referred to as “a
disease of poverty”, because the disease spreads easily in badly ventilated, overcrowded places and among
people with poor nutritional status (Oxlade & Murray, 2012).

Environmental factors such as poor ventilation and crowded living conditions increase the probability of TB
infection (Tornee et al., 2005: 222). Clark et al. (2002: 942) have confirmed that the incidence of TB disease
is higher in communities located in isolated areas, and in communities with a higher average housing density.
Housing density is defined as the average number of ppr. A large percentage of participants in the current
60
study lived in homes with a high room density (>2.5 ppr). Similar findings have been reported in studies
undertaken in Dellft, Cape Town where 53% of patients with TB indicated that five to eight persons were
sharing a room (Lombardo et al., 2012: 1025) as well as in Canada where significant association between
housing density, isolation, income levels, and TB disease were identified (Coetzee et al., 1988: 352-354). A
study undertaken in Uganda, reported that 57.3% of patients with TB were living in overcrowded households
(Kirenga et al., 2015). Overcrowded housing conditions have the potential to increase exposure of susceptible
people to those with infectious respiratory disease, increasing the probability of transmission. This is because
close proximity makes it more likely for these individuals to come into contact with air contaminated with
the bacteria that causes the infection. Furthermore, isolation from health services may increase the likelihood
of developing TB (Tornee et al., 2005: 224; Clark et al., 2002: 940).

Food security

South Africa has recently been classified as the country with the greatest rate of income inequality in the
world according to the GINI Index (a standard economic measurement of inequality looking at the income
distribution among residents in a country) (World Bank, 2016). While South Africa as a country may be food
secure, large numbers of households in the country are food insecure (Altman et al., 2009), as was confirmed
in the current study.

Food insecurity is very difficult to measure. For this reason, there is little certainty about the precise household
food security status of South African households (Altman et al., 2009: 5). According to the National Food
Consumption Survey (NFCS) of 1999, 33% of household were at risk of hunger and 52% of households
experienced hunger (Labadarios et al., 2005). According to the NFCS of 2005, similar results were found
with one out of three households at risk of hunger and 51.6% of households experiencing hunger (Labadarios
et al., 2008). Both of the NFCS’s used the CCHIP hunger index questionnaire to determine the level of
household food security. In contrast, the General Household Survey in 2007 indicated that only 10.6% of
adults and 12.2% of children were sometimes or always hungry. The participants were asked whether they
ever gone hungry because there was not enough food. The participants could responded by indicating never,
seldom, sometimes, often or always (Stats SA, 2007). More recently the SANHANES of 2012 interviewed
5972 households and concluded that 39% of households do not have enough money for basic needs, like food
(Shisana et al., 2013). The results of the current study found even higher occurrence of food insecurity with
27% of households being at risk of hunger and 70% of households experiencing hunger. These findings might
indicate that patients with TB and TB/HIV co-infection are more likely to experience food insecurity than the
general public.

61
Food insecurity is an important contributor to the global burden of TB disease (WHOa, 2013). High levels of
food insecurity were identified in the current study, with the problem of food insecurity at both the household
and individual level being worse in the HIV co-infected participants. A significantly higher percentage of
HIV co-infected respondents reported relying on a limited number of foods to feed their children, sometimes
cut the size of their meals or skip meals, eating less than they wanted and felt like their children eat less than
they should because there was not enough money available for food purchases. After the scoring had been
applied, however, the difference in the percentage of households with patients with TB and HIV co-infection
and patients with TB without HIV co-infection that were food secure, at risk of hunger and hungry did not
reach statistical significance.

Very few participants in the current study reported having a household vegetable garden. The International
Food Security Assessment 2011-2021, food production at household level is an important factor in assuring
food security in sub-Sahara Africa (USDA, 2011). Ogundiran et al. (2014) suggest that home gardening has
the potential to improve food security, health and social interaction of households. Altman et al. (2009: 17)
have concluded that poor households may also engage in gardening as a form of recreation, but that it may
contribute to additional burdens rather than relief in some resource-poor households.

We acknowledge that the results of this single-centre study may not be generalised to all patients with TB
and TB/HIV co-infection.

CONCLUSION AND RECOMMENDATIONS

The present study identified that patients with TB and TB/HIV co-infection are characterised by high levels
of poverty and household food insecurity. The literature confirms that this may have a negative impact on the
development of TB disease in other household members, nutritional status and progression of latent TB
infection to TB disease.

In order to improve outcome, TB control programmes and other interventions should take the socio-
demographic situation of patients into consideration. In view of this, appropriate and relevant preventative
actions need to be planned and implemented through a multi-sectorial approach. Despite the high rate of food
insecurity in households, very few households grew vegetable gardens. Agricultural involvement has the
potential to improve household and individual food security and should thus be encouraged.

Community support groups can play an important role in reducing the burden of TB and HIV through
alleviating its impact, stigma and discrimination. In addition to community intervention programmes, basic
education together with the incorporation of TB education into the school syllabus, may contribute to creating
awareness of the disease.

62
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 CHAPTER 5
NUTRITIONAL STATUS OF PATIENTS WITH TB, AND TB/HIV CO-INFECTION AT
STANDERTON TB SPECIALISED HOSPITAL, MPUMALANGA
ABSTRACT

Objective: To determine the nutritional status of patients with TB, and TB/HIV co-infection.
Design: A cross sectional study was undertaken.
Settings and subjects: The study was conducted at Standerton TB Specialised Hospital, Mpumalanga. One
hundred hospitalised patients with TB, and TB/HIV co-infection were included.
Outcome measures: A structured interview was conducted by the researcher with each patient to obtain
information on food related side effects. The Malnutrition Universal Screening Tool (MUST) was used to
determine risk of malnutrition. Weight, height, mid-upper arm circumference (MUAC) and triceps skinfold
were measured using standard techniques. Biochemical parameters included total protein, albumin, C-
reactive protein (CRP), CD₄ cell counts, mean corpuscular volume (MCV) and haemoglobin. These were
determined in an accredited laboratory using standard laboratory techniques.
Results: The food related side effects mostly reported included loss of appetite (59%) followed by dry mouth
(48%). According to the MUST, the overall risk for malnutrition was as follows: 70% had a high risk, 22%
had a medium risk and 8% had a low risk. Actual unplanned weight loss and percentage of unplanned weight
loss were significantly higher in patients with TB and HIV co-infection than in patients with TB only (95%
CI [1.5%; 38.2%] and [5.3%; 51.0%] respectively). Median body mass index (BMI) was in the underweight
category at 18.3 kg/m². More than half of participants (51%) had low MUAC measurements and nearly half
of participants (49.9%) had triceps skinfold measurements below the 15th percentile, indicating malnutrition.
The majority of participants had albumin and haemoglobin values below the normal ranges (79% and 92%
respectively).
Conclusion: Patients with both TB and TB/HIV co-infection had a compromised nutritional status and an
increased risk of developing malnutrition. Interventions aimed at addressing malnutrition could make a
meaningful contribution to improving drug efficacy and quality of life in these patients.
INTRODUCTION

Tuberculosis (TB) is a leading cause of morbidity and mortality, especially in middle- and low-income
countries. Globally, an estimated 2 billion people are infected with TB of which 1 billion are malnourished.
TB is strongly influenced by nutritional status, with nutrition interventions being likely to impact on
prevalence of active disease, response to drug therapy and quality of life (Cegielski et al., 2012: 409; Moses
et al., 2008: 208). According to Semba et al. (2010: S353) HIV co-infection seems to be a much stronger risk
factor for mortality in adults with TB than is malnutrition alone.

Proper nutrition plays a vital role in supporting the health and quality of life of people with TB and HIV
(ADA, 2010). Immune function and nutritional status are closely related (Lowry & Coyle, 2014: 1261) and
nutrition, immune function and infection interact in complex ways (Cegielski & McMurray, 2004: 288).
According to Rudolph et al. (2013) malnutrition in general is a serious global health problem which is often
68
not adequately addressed in public health programs. Neither current World Health Organisation (WHO)
guidelines for treatment of TB, nor the 17 International Standards of Tuberculosis Care, address the
importance of under-nutrition or nutrition support during treatment (Bhargava et al., 2013; Hopewell et al.,
2006: 710-725).

The Academy of Science of Southern Africa (ASSAf) refers to malnutrition and TB as the so-called “chicken
vs egg conundrum”. This is because malnutrition may predispose to TB and having TB increases one’s risk
of developing malnutrition. In 2007, the ASSAf identified the top three epidemics as HIV infection, TB
infection and malnutrition and called it the “three concurrent epidemics”. The third epidemic, malnutrition,
is very often a consequence of these two disease states (ASSAf, 2007). Thus; HIV, TB and malnutrition result
in a vicious cycle, with the one epidemic exacerbating the other. Van Lettow et al. (2003: 81) refer to HIV,
TB and malnutrition as “triple trouble”.

Malnutrition has been described in patients with TB by several researchers (Bhargava et al., 2013; Frediani
et al., 2013: 1026; Villamor et al., 2006: 169; van Lettow et al., 2004: 61; Frieden et al., 2003: 895; Karyadi
et al., 2000). Both malnutrition and HIV infection are associated with an increased risk of progression from
latent TB infection to active TB disease, because of the negative impact that dietary deficiencies have on cell-
mediated immune response (Lönnroth et al., 2010: 152; Semba et al., 2010; Cegielski & McMurray, 2004:
296). TB (and HIV infection) very often results in poor dietary intake, nutrient deficiencies, malnutrition and
wasting (Cegielski & McMurray, 2004: 296; van Lettow et al., 2004: 61; Paton et al., 2003: 322).

Considering the negative impact of a poor nutritional status on outcome in patients with TB and TB/HIV co-
infection, the purpose of this study was to determine the nutritional profile of patients with TB and TB/HIV
co-infection at Standerton TB Specialised Hospital, Mpumalanga, where information of this nature has not
previously been collected. This information can contribute to the identification of specific areas that need to
be taken into account in nutrition interventions, which may in turn play a vital role in improving the outcome
and prognosis of patients with TB and TB/HIV co-infection.

METHODOLOGY

Study design

A cross sectional study was conducted.

Target population and sampling

The study population included all patients between 20-65 years with TB, and TB/HIV co-infection that gave
informed consent to participate at Standerton TB Specialised Hospital, Mpumalanga in wards 1 and 2 over a

69
period of one month (21/07/2015 – 17/08/2015). Patients with any additional diagnoses other than TB and
TB/HIV co-infection, pregnant or lactating patients, and mentality or physically disabled patients were
excluded from the study. The sample included 100 patients with TB and TB/HIV co-infection that met the
inclusion criteria.

Pilot study

A pilot study was conducted on the first five patients that met the inclusion criteria and provided onfrormed
consent from Standerton TB Specialised Hospital to determine the feasibility of the methodology. No changes
were made to the questionnaire and data of these participants was thus included in the main study.

Variables and operational definitions

Eating related side effects

For the purpose of this study, eating related side effects referred to: loss of appetite, sore mouth, dry mouth,
nauseas, vomiting, constipation, diarrhoea and night sweats that has been experienced during the past 7 days.

Overall risk of malnutrition

For the purpose of this study, the overall risk of malnutrition was determined by making use of the
Malnutrition Universal Screening Tool (MUST) which includes information related to body mass index
(BMI), unplanned weight loss over the past 3-6 months and an acute disease score (Bapen, 2003).

Anthropometric measurements

For the purpose of this study, anthropometric indicators of nutritional status included height, weight, MUAC
and Triceps skinfold.

Body mass index (BMI)

BMI was calculated by dividing weight in kilograms (kg) by height in meter square (m2). BMI was interpreted
according to the World Health Organisation (WHO) categories of BMI, with underweight: <18.5 kg/m 2,
normal weight: 18.5-24.9 kg/m2 and overweight: >25 kg/m2 (WHO, 2006).

Mid-upper arm circumference (MUAC)

For the purpose of this study, a MUAC of <22cm for females and <23cm for males indicated malnutrition
(Tang et al., 2013).

Triceps skinfold

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For the purpose of this study a Triceps skinfold measurement was interpreted according to the Triceps
Skinfold Norms from NHANES 2003 – 2006 and are indicated in Table 5.1 for females and Table 5.2 for
males (Lee & Nieman, 2013: 459-460).

Table 5.1: Triceps skinfolds in millimetres for females 20 years of age and older

Race, ethnicity and age Percentile (mm)

All race and ethnicity groups 5th 10th 15th 25th 50th 75th 85th 90th 95th
20-29 years 10.4 11.9 13.2 15.5 21.1 27.3 30.3 32.4 34.7
30-39 years 12.1 14.7 15.8 18.2 23.9 30.2 32.9 35.3 37.4
40-49 years 12.1 14.1 15.9 19.5 25.6 30.9 33.6 35.2 36.9
50-59 years 13.3 16.1 17.5 20.5 25.9 31.0 33.2 34.9 36.5
60-69 years 13.4 16.6 18.1 20.3 25.4 30.2 32.8 34.2 36.0

Table 5.2: Triceps skinfolds in millimetres for males 20 years of age and older

Race, ethnicity and age Percentile (mm)

All race and ethnicity groups 5th 10th 15th 25th 50th 75th 85th 90th 95th
20-29 years 5.0 6.2 7.1 8.8 12.7 18.9 21.7 25.4 29.4
30-39 years 5.8 7.1 8.2 10.0 13.6 18.3 21.4 23.4 27.0
40-49 years 6.6 7.6 8.7 10.4 13.9 19.2 22.3 24.1 27.9
50-59 years 6.2 7.4 8.9 10.8 14.1 18.5 21.5 23.2 26.7
60-69 years 7.3 8.3 9.4 11.2 14.9 19.7 22.5 25.2 30.3

Biochemical parameters

The following biochemical markers were assessed. Normal value ranges for biochemical parameters are
indicated below (du Buisson et al., 2010):

 Total protein 60 – 78 g/l

 Albumin 35 – 52 g/l
 C-reactive protein (CRP) 0.0 – 4.9 mg/l
 CD₄ cell count 500 – 2000mm3
 Mean corpuscular volume (MCV) 79.1 – 89.0 f/l
 Haemoglobin Male: 14.3 – 18.3 g/dl ; Female: 12.1 – 16.3 g/dl

71
Methods and techniques

Questionnaire

For the purpose of this study, a questionnaire was designed by the researcher to obtain information related to
eating related side effects of participants. Results of the overall risk of malnutrition (MUST tool) were noted
on the same questionnaire.

The MUST tool consists of three steps. Step one classifies a patient according to their BMI (>20 kg/m² = 0;
18.5-20 kg/m² = 1; <18.5 kg/m² = 2). Step two evaluates the percentage of unplanned weight loss during the
past 3-6 months (<5% = 0; 5-10% = 1; >10% = 2). Step three evaluates if the patient is acutely ill, and if there
has been most likely no nutritional intake over the past 5 days or more; if so, the patient scores an additional
2 points. The overall risk of malnutrition is then determined by adding step 1, 2 and 3 together. A low risk of
malnutrition equals a total score of 0, a medium risk equals a total score of 1 and a high risk equals a total
score of 2 or more (Bapen, 2003).

Anthropometric measurements

Weight

Weight was measured with a platform electronic scale (TCS-200-RT). As recommended by Lee & Nieman
(2013: 168), the participants were wearing minimal clothing (removed jacket, shoes and jewellery), standing
still in the middle of the scale’s platform without touching anything and with the body weight equally
distributed on both feet. Weight was recorded to the nearest 0.1 kg.

Height

Height was measured by means of a stadiometer (TCS-200-RT) with a vertical scale of 2 meters and a sliding
head-piece, to the nearest 0.5cm. Height of participants was measured without shoes. The participants stood
with their heels together, arms to the side, legs straight, shoulders relaxed and head in the Frankfort horizontal
plane (looking straight ahead). Heals, buttocks, scapulae (shoulder blades), and the back of the head were
against the vertical surface of the stadiometer. Just before the measurement was taken, the participant inhaled
deeply, held the breath and maintained an erect position while the sliding-headpiece was lowered to the
highest point of the head with enough pressure to compress the hair (Lee & Nieman, 2013: 167).

Mid-upper arm circumference

MUAC was measured using a non-stretch flexible tape-measure. Participants stood erect and sideways to the
measurer, with the head in the Frankfurt plane, legs apart, and arms relaxed. Sleeved garments were rolled
72
up or removed. The measurement was taken at the midpoint of the upper arm, between the acromion process
and the tip of the olecranon. After locating the midpoint, the arm was extended so that it is hanging loosely
by the side, with the palm facing inward. The tape was then wrapped gently but firmly around the midpoint
of the arm (Lee & Nieman, 2013: 228; Gibson, 2005: 290). The MUAC measurement was taken three times
on each participant and an average was calculated to the nearest 1mm.

Triceps skinfold

The measurement of the triceps skinfold was performed at the midpoint of the upper right arm, between the
acromion process and the tip of the olecranon, with the arm hanging relaxed. To obtain the midpoint, the right
arm had to be bent at 90º at the elbow, and the forearm had to be placed palm down across the body. The tip
of the acromion process of the shoulder at the outermost edge of the shoulder blade and the tip of the olecranon
process of the ulna was located and marked. The distance between these two points was then measured using
a non-stretchable tape, and the midpoint was then marked with a soft pen. The right arm was then extended
so that it was hanging loosely by the side. The examiner grasped a vertical fold of the skin plus the underlying
fat, 2cm above the marked midpoint, using both the thumb and the forefinger. The skinfold was held between
the fingers while the measurement was taken to the nearest mm (Lee & Nieman, 2013: 190; Gibson, 2005:
275-276). The triceps skinfold measurement was taken three times on each participant and the average was
noted to the nearest 2mm.

Biochemical parameters

Blood of patients are drawn as part of standard procedures in the hospital by a professional nurse. Biochemical
parameters (total protein, albumin, CRP, CD₄ cell counts, MCV, and haemoglobin) were determined in an
accredited laboratory using standard laboratory techniques.

Validity and reliability

Questionnaire

All issues addressed by the questionnaire were directly related to the aim and objectives of the study. The
MUST tool is internationally validated and regarded as an accurate tool to evaluate the risk of malnutrition
in adult patients (Gibson et al., 2012: 313; Stratton et al., 2004: 807; Bapen, 2003). Miyata et al. (2013)
conducted a research study to evaluate the effectiveness of using the MUST to assess the nutritional status of
patients with TB. The conclusion was that the MUST is a reliable tool for nutritional risk assessment and also
a useful indicator of survival in patients with TB.

73
Only one person, namely the trained researcher, completed the questionnaires in a personal interview with
each participant.

Anthropometric measurements

The scale was moved to the zero point before each measurement. The weight recorded by the scale was
compared with a known weight. In order to ensure reliability of the results, weight, height, MUAC, and
Triceps skinfold were measured by the same trained researcher (a registered dietician) according to standard
procedures, as recommended by Lee & Nieman (2013).

Biochemical parameters

The biochemical variables that were determined included routine tests that are performed on patients in the
hospital. The results of the blood tests were considered reliable, because they are determined in an accredited
laboratory by trained personnel using standard controls.

Ethics

Ethics approval was obtained from the Provincial Health and Research Ethics Committee (PHREC) of
Mpumalanga Department of Health (PHREC MP_2015RP38_556) and the Health Sciences Research Ethics
Committee of the Faculty of Health Sciences, University of the Free State (UFS) (ECUFS 56/2015).

Data collection

All eligible participants signed consent in their language of choice (English/IsiZulu), after the purpose and
procedure of the project had been explained to them by the researcher or a lay counsellor who spoke the
native language. The information document was given to patients to provide them with all the relevant
information regarding the study. Once informed consent had been obtained, participants were interviewed by
the researcher. In addition to information on nutritional status, information on socio-demographic status, food
security, smoking habits and alcohol use were also collected; these are reported elsewhere.

Statistical analysis

Descriptive statistics, namely frequencies and percentages for categorical data, and medians and percentiles
for continuous data were calculated. Associations between variables were calculated and described by means
of 95% confidence intervals (CI) for differences in medians or percentages. All analyses were completed by
the Department of Biostatistics at the UFS

RESULTS

74
The study sample included 100 participants (60 males and 40 females). The median age of the sample was
39.2 (20.3-63.5) years. More than two thirds of participants (68%) were HIV positive; with HIV co-infection
being slightly higher among women (70%) than among men (66.7%).

Food related side effects

The food related side effects reported by the participants are summarised in Table 5.3. The majority of patients
experienced a loss of appetite (59%) followed by a dry mouth (48%). Patients with TB and HIV co-infection
experienced more food related side effects than patients without HIV co-infection, but the differences were
not statistically significant.

Table 5.3: Food related side effects according to HIV status

Symptom Total yes TB with HIV co- TB without HIV co- 95% CI for the
responses infection (n=68) infection (n=31) percentage
(n=100) Yes Yes difference
Loss of 59% 40 (58.8%) 18 (58.1%) [-18.8%; 21.2%]
appetite
Sore mouth 23% 15 (22.1%) 8 (25.8%) [-23.0%; 12.7%]

Dry mouth 48% 30 (44.1%) 17 (54.8%) [-30.2%; 10.0%]

Nausea 29% 21 (30.9%) 8 (25.8%) [-14.9%; 21.9%]

Vomiting 23% 17 (25.0%) 6 (19.3%) [-13.4%; 20.9%]

Constipation 30% 18 (26.5%) 12 (38.7%) [-31.9%; 6.7%]

Diarrhoea 7% 7 (10.3%) 0 (0.0%) [-1.9%; 19.8%]

Night sweats 27% 19 (27.9%) 7 (22.6%) [-14.2%; 21.5%]

Table 5.4 illustrates the number of food related side effects that were experienced by the participants. Only
14% of participants reported not experiencing any of the listed food related side effects. A large percentage
of patients (29%) experienced two of the seven symptoms. Almost a quarter (24%) of participants reported
experiencing four to seven of the side effects.

75
Table 5.4: Number of food related side effects experienced (n=100)

Number of symptoms Percentage Cumulative Percentage

experienced
0 14.0 14.0
1 15.0 29.0
2 29.0 58.0
3 18.0 76.0
4 9.0 85.0
5 8.0 93.0
6 6.0 99.0
7 1.0 100.0

The overall risk of malnutrition is summarised in Table 5.5. More than half (51%) of participants had a BMI
of lower than 18.5kg/m² and almost half (48%) of participants had experienced more than 10% weight loss
during the past 3-6 months. Nearly two out of ten (18%) participants were acutely ill and had or were likely
to have no nutritional intake for more than five days. Nearly a third (29%) of participants had a total score of
four, indicating a high risk of malnutrition. More than two thirds (70%) participants had a high risk for
malnutrition (total score of 2 or more). Almost a quarter (22%) had a medium risk for malnutrition (total
score of 1) and only 8% had a low risk for malnutrition (total score of 0).

76
Table 5.5: Overall risk of malnutrition

n=100 Frequency Cumulative Frequency

BMI score
0 (> 20kg/m²) 36 36
1 (18.5-20kg/m²) 13 49
2 (< 18.5kg/m²) 51 100
Weight loss score (unplanned weight loss in the past 3-6 months)
0 (< 5%) 38 38
1 (5-10%) 14 52
2 (>10%) 48 100
Acute disease score (looking at food related side effects)
0 82 82
2 (has been or is likely to be no 18 100
nutritional intake for >5 days)
Total score (BMI score + Weight loss score + Acute disease score)
0 22 22
1 8 30
2 15 45
3 15 60
4 29 89
5 4 93
6 7 100
Overall risk for malnutrition
High (total score of 2 or more) 70 70
Medium (total score of 1) 22 92
Low (total score of 0) 8 100

Anthropometric measurements

The median weight lost during the last 3-6 months was 6kg (2kg-14kg). There was a statistically significant
difference in the unplanned weight loss during the past 3-6 mouths and the percentage of unplanned weight
loss of >10% between patients with TB and patients with TB and HIV co-infection, as presented in Table 5.6.

77
Unplanned weight loss and percentage of unplanned weight loss was statistically significantly higher in
patients with TB and HIV co-infection.

Table 5.6: Unplanned weight loss; comparing TB with and without HIV co-infection

TB with HIV co-infection TB without HIV co-infection 95% CI for the

(n=68) (n=31) percentage
difference

Unplanned 57 20 [1.5%; 38.2%]*

weight loss (83.82%) (64.52%)
during the
past 3-6
months
< 5% 5-10% > 10% < 5% 5-10% > 10% Compared >10%
Percentage 11 6 40 5 7 8 [5.3%; 51.0%]*
of (19.30%) (10.53%) (70.18%) (25.00%) (35.00%) (40.00%)
unplanned
weight loss
* Statistically significant difference

The anthropometric results pertaining to BMI, MUAC and triceps skinfold are presented in Table 5.7 for
median values and Table 5.8 for categorical values. Median BMI was 18.3 kg/m² (men: 18.2 kg/m²; women:
20.6 kg/m²), with more than half (53%) of participants having a BMI of <18.5kg/m². Male participants had a
median BMI in either the underweight or normal range. The BMI of women ranged from underweight to
obese, with 12.5% of women having BMI scores above the normal range. The median MUAC of participants
was 22.6cm (men: 22.5cm; women: 24.2cm). More than half (51%) of participants, fell in the category of
malnourished according to their MUAC measurements. Nearly half of participants (49.9%) had triceps
skinfold measurements below the 15th percentile (40.8% in the 5th percentile and 9.1% in the 10th percentile),
which indicates malnutrition. Men had significantly lower median Triceps skinfold measurements than
women (men: 13.0mm; women: 19.5mm), 95% CI [-10; -2].

78
Table 5.7: BMI, MUAC and triceps skinfold (median), comparing genders by means of 95% CI

Anthropometric Total group Men (n=60) Women (n=40) 95% CI

indication for
median
difference
BMI (kg/m²) 18.3 18.2 20.6 [-4.7; 0]
(11.9-41.7) (13.0-23.9) (12.2-41.7)
MUAC (cm) 22.6 22.5 24.2 [-4.0; 0.4]
(14.1-42,7) (16.4-29.5) (14.1-42.7)
Triceps skinfold (mm) 14.0 13.0 19.5 [-10; -2]*
(5.0-38.0) (5.0-28.0) (5.0-38.0)
* Statistically significant difference

79
Table 5.8: BMI, MUAC and triceps skinfold (categories)

Measurement n=100 Men (n=60) Women (n=40)

BMI (%)

<18.5: Underweight 53.0 65.7 47.5

18.5-24.9: Normal 35.0 43.3 22.5

25.0-29.9: Overweight 7.0 0.0 17.5

>29.9: Obese 5.0 0.0 12.5

MUAC (%)

Malnourished 51.0 41.7 (<23 cm) 60.0 (<22 cm)

Normal 49.0 58.3 (>23 cm) 40.0 (>22 cm)

Triceps skinfold (%)

5th percentile 40.8 8.3 32.5

10th percentile 9.1 6.6 2.5

15th percentile 7.5 5.0 2.5

25th percentile 22.6 10.0 12.5

50th percentile 34.1 21.6 12.5

75th percentile 56.6 36.6 20.0

85th percentile 15.8 8.3 7.5

90th percentile 9.1 1.6 7.5

95th percentile 4.1 1.6 2.5

Biochemical parameters

Biochemical parameters of participants are illustrated in Table 5.9 for median values and Table 5.10 for
categorical values. The majority (61%) of participants had total protein values in the normal range, with 11%
of participants below normal and 28% above normal. The median value for total protein was 71.5g/l, which
80
falls within the normal range of 60-78g/l. Almost eight out of ten (79%) participants had albumin values
below the normal range of 35g/l and the median albumin value was 29.0g/l. Lower albumin levels were
significantly more visible in males than in females. CRP values were only available for 15 participants, of
which everyone had increased values with a median of 81.0mg/l. The median in terms of CD₄ cell count was
179mm³ which is far below the lower normal cut-off value of 500mm³. Almost two thirds (64%) of
participants had a CD₄ cell count below 500mm³ and 57% of participants had a CD₄ cell count below
350mm³. Four out of ten (40%) participants had MCV values within the normal range of 79.1-89.0f/l and
43% had MCV values above the normal range, while 17% of participants had MCV values below the normal
range. The median haemoglobin value was 10.5g/d/l, which is below the lower normal range for males and
females. More than nine out of ten (92%) participants had haemoglobin values below the normal range. Males
also had significantly lower haemoglobin levels than females.

Table 5.9: Biochemical Parameters (median); according to gender

Measurement n Median Men Women 95% CI for

(range) median
difference
Total protein (g/l) 100 73.1 71.5 74.7 [-9; 1]
(46-104) (46.0-104.0) (48.0-96.0)
Albumin (g/l) 100 29.0 29.0 29.0 [-5; 1]
(14-49) (14.0-47.0) (18.0-49.0)
CRP (g/l) 15 8.1 9.0 10.2

CD₄ cell count (mm³) 76 179.0 234.0 174.0 [-116; 59]

(4.0-995.0) (4.0-737.0) (8.0-995.0)
MCV (f/l) 100 88.35 88.4 88.4 [-3.2; 3.5]
(69.8-112.6) (71.6-112.6) (69.8-100.7)
Haemoglobin (g/dl) 100 10.5 10.9 10.2 [-0.4; 1.2]
(6.3-16.0) (6.3-16.0) (8.0-15.6)

81
Table 5.10: Biochemical Parameters (categories); according to gender

Measurement Men Women 95% CI for the

(n=60) (n=40) percentage
difference
Total protein (%) (n=100)
< 60 g/l: Low 11.7 10.0 [-12.7%; 13.8%]
60-78 g/l: Normal 63.3 57.5
>78 g/l: High 25.0 32.5
Albumin (%) (n=100)

<35 g/l: Low 86.7 67.5 [2.7%; 35.9%]*

35-52 g/l: Normal 13.3 32.5
CRP (%) (n=15)
>4.9 mg/l: High 100 100
CD₄ cell count (%) (n=76)
>500 mm³: Low 87.2 79.3 [-8.6%; 26.9%]
500-2000 mm³: Normal 12.8 20.7
MCV (%) (n=100)
<79.1 f/l: Low 16.7 17.5 [-17.0%; 13.5%]
79.1-89.0 f/l: Normal 40.0 40.0
>89.0 f/l: High 43.3 42.5
Haemoglobin (%) (n=100)
Lower than normal range 96.7 85.0 [0.4%; 25.9%]*
(<14.3 g/dl) (<12.1 g/dl)
Between normal range 3.3 15.0
(14.3-18.3 g/dl) (12.1-16.3 g/dl)
* Significant difference

DISCUSSION

Food related side effects

Clinical monitoring of possible side effects in patients with TB is important during treatment (WHO, 2004).
It is unknown whether the food related side effects experienced by patients with TB, and TB/HIV co-infection
are caused by the disease, the treatment or a combination of the two. Several food related side effects (gastro-

82
intestinal irritation, nausea, vomiting, abdominal pain, constipation, anaemia, jaundice, pancreatitis, altered
taste, anorexia, and fatigue) have been reported to be related to the use of TB medications (Isoniazid and
Rifampicin) (SADoH, 2014; Escott-Stump, 2012; WHO, 2004). Adverse side effects from medication are
more common in HIV positive that in HIV negative patients with TB (WHO, 2004). In the current study,
patients with TB and HIV co-infection did experience more food related side effects than those who did not
have HIV, but the difference was not statistically significant.

The most commonly reported food related side effects experienced by patients in the current study included
a loss of appetite followed by a dry mouth. In a study undertaken in patients with TB in the city of
Cochabamba in Bolivia, appetite regulatory hormones were found to be altered. These hormones usually
normalised during treatment after which, appetite was restored and nutritional status improved (Chang et al.,
2013). It is well recognised that a lack of appetite and a low appetite can both exacerbate malnutrition. It is
unclear, however, whether a chronic lack of appetite is due to malnutrition or possibly an unidentified risk
factor for TB (Hernández-Garduño & Pérez-Guzmán, 2007: 870). Common reported side effects in patients
with TB in Uganda, Iran and Pakistan included loss of appetite, loss of weight, dyspnea, fatigue, weakness,
fever, night sweats, chest pain, and hemoptesia (Kirenga et al., 2015; Nezhad et al., 2012; Shaikh et al.,
2012). Nezhad et al. (2012) also concluded that as the number of reported side effects increased the total
recovery time also increased.

Overall risk of malnutrition

Of all the known risk factors for TB, being underweight and malnourished are most likely the least studied
indicators (Hernández-Garduño & Pérez-Guzmán, 2007: 870). Malnutrition may predispose to TB; however,
TB also increases the risk of developing malnutrition. In the current study, the majority of patients presented
with a high risk of malnutrition (according to the MUST). When looking at anthropometric variables (BMI,
MUAC, and Triceps skinfold) the majority of patients were malnourished at the time of the data collection.
Some important signs and symptoms of TB (e.g. wasting, anaemia, loss of lean and fat mass) are also signs
of malnutrition (ASSAf, 2007: 155-156) and this was also seen in the current study.

Although it is well recognised that there is a link between TB and malnutrition, the precise mechanisms that
are involved are unclear (Lombardo et al., 2012: 184; Cegielski & McMurray, 2004: 295). A high prevalence
of malnutrition was also reported in patients with TB in a study conducted by Boloor et al. (2014) in India.
They used the Mini Nutritional Assessment Short-Form (MNA-SF) to determine the level of malnutrition
and concluded that 77% of patients with TB were malnourished and 21% were at risk of malnutrition. These
findings are similar to those of the current study, even though a different tool was used to determine the level
and risk of malnutrition.
83
Anthropometric measurements

Involuntary weight loss, wasting and cachexia are common findings in patients with TB. All of the above
processes are most likely the result of a combination of factors, including increased nutrient losses, altered
metabolism, and decreased appetite and food intake, which are all directly linked to a poor prognosis (Kirenga
et al., 2015; Chang et al., 2013; Nezhad et al., 2012; USAID, 2010). The current study also found involuntary
weight loss to be very common in patients with TB and TB/HIV co-infection. Both unplanned weight loss
and percentage of unplanned weight loss was statistically significantly higher in patients with TB and HIV
co-infection than in patients with just TB. This clearly confirms that patients with TB and HIV infection are
at a higher risk of developing malnutrition.

According to the WHO, low BMI (<18.5kg/m²) is the best predictor of weight-related morbidity. BMI is the
indicator that is most commonly used to measure the degree of fatness or thinness in adults over the age of
18 years (WHO, 2013). Several cross-sectional studies have confirmed a lower BMI in adults with TB
disease, together with an increased risk for mortality and micronutrient deficiencies (Lombardo et al., 2012:
183; Semba et al., 2010; van Lettow et al., 2003: 84; Karyadi et al., 2000: 725). According to Hanrahan et
al. (2010: 1507) BMI may be a useful surrogate marker of TB risk or mortality among HIV-positive
individuals.

Rudolph et al. (2013) reported that the average BMI in adult South African males and females with TB from
Johannesburg, Alexandra was 19.2kg/m² (low) and 23.3kg/m² (normal), respectively. Despite the fact that
the BMI of South African females with TB were within the normal range, it was still lower than that of the
general population (where most women are overweight and obese). The BMI scores in the current study were
even lower than the median BMI reported by Rudolph et al. (2013), with 18.2kg/m² for males and 20.6kg/m²
for females.

The relationship between TB and BMI has been studied by several researchers (Bhargava et al., 2013;
Rudolph et al., 2013; Lombardo et al., 2012: 183; Hanrahan et al., 2012; Lönnroth et al., 2010: 154; Semba
et al., 2010; Villamor et al., 2006: 168; Cegielski & McMurray, 2004: 288; van Lettow et al., 2003: 84;
Karyadi et al., 2000: 725; Kennedy et al., 1996). A BMI below the lower cut off point (<18.5kg/m²) is an
established indicator for energy deficiency and TB incidence has been shown to increase exponentially as
BMI decreased (Lönnroth et al., 2010: 150). The current study confirms that a low BMI is common in patients
with TB and TB/HIV co-infection with a median of 18.3kg/m². Systematic reviews by Lönnroth et al. (2010)
and Cegielski & McMurray (2004) have reported that malnutrition (defined using BMI) is an important risk
factor for the progression of underlying TB infection to active TB disease. Kennedy et al. (1996) used BMI
to assess the nutritional status of 148 patients in Tanzania who presented with active TB. They found that
84
malnutrition manifested before and after treatment for TB. A study in India among adults with pulmonary TB
found under-nutrition in 85% of males and females in rural areas, and more than two thirds of participants
were moderately to severely underweight according to BMI (Bhargava et al., 2013).

In the current study, more than half of participants fell in the low BMI category (<18.5kg/m²). Boloor et al.
(2014: 473) found even higher levels of underweight in hospitalised patients with TB in India, where 79%
had a BMI score of 18kg/m² or less. Persons with an underweight BMI of <18.5kg/m² have an increased risk
for TB (OR: 2.6) (Horsburgh et al., 2012). Cegielski et al. (2012: 414) reported an even higher risk of 5.5 to
12.5 for TB in persons with low a BMI, little subcutaneous fat, or low skeletal muscle than in persons with
normal nutritional status. Promoting adequate nutrition and weight gain in populations that are malnourished
might thus reduce the risk of developing active TB disease (Lönnroth et al, 2010:154).

Individuals infected with HIV with a BMI score in the overweight and obese category have a significantly
reduced risk of both mortality and TB disease. Overweight and obese BMI scores might be protective against
mortality and TB in HIV-infected individuals, even though it raises the risk of developing cardiovascular and
metabolic disease (Hanrahan et al., 2010: 1507). In the current study only a small percentage of women had
BMI scores in the overweight and obese category at 17.5% and 12.5% respectively. More research related to
the relationship between very low and very high BMI levels and TB is needed (Hanrahan et al., 2010: 1502;
Lönnroth et al., 2010: 154).

In addition to BMI, MUAC is commonly used to determine the nutritional status of adults (Tang et al., 2013).
Patients with a low BMI also tend to have a low MUAC (UNAIDS, 2014). Boloor et al. (2014), Singla et al.
(2010) and Karyadi et al. (2000: 725) found significantly higher proportions of patients with very low MUAC
(<20cm) among patients with TB from India and Indonesia compared to the general population. Lombardo
et al. (2012: 183) found that patients newly diagnosed with TB had median BMI and MUAC values at the
lower end of the normal ranges, at 18.8kg/m² and 23.4cm respectively. In the current study, patients with TB
and TB/HIV co-infection had median MUAC values at the lower end of normal (22.6cm) and 51% fell in the
low MUAC category, indicating malnutrition.

Low skinfold measurements are common in patients with TB. Villamor et al. (2006: 168) performed a cross-
sectional study in adults with pulmonary TB co-infected with HIV and found indicators of low lean body
mass. Cegielski et al. (2012: 412) found low skinfold thickness in 32.6% of persons in the United States who
later developed TB with only 4.8% in persons who did not develop TB. In the current study nearly half of
participants had triceps skinfold measurements below the 15th percentile, and statistically significantly more
men had lower triceps skinfold thickness than women. Karyadi et al. (2000: 2955) reported that triceps
skinfold measurements of both males and females in Indonesia were significantly lower in patients with TB
85
than in control groups. In their study, the mean triceps skinfold measurements for males and females with TB
were 7.0mm and 12.1mm respectively. In the current study higher mean triceps skinfold measurements were
found in both males (13.0mm) and females (19.5mm).

Biochemical parameters

Serum protein concentrations can be useful in assessing protein status, to evaluate a patient’s response to
nutritional support, and to determine whether a patient is at risk of experiencing medical complications (Lee
& Nieman, 2013: 320) on condition that there is no acute phase response present due to metabolic stress
(which is unlikely in patients with TB). In the current study the majority of patients had serum protein values
in the normal range, and almost a third of patients had serum protein values above the normal range. Total
protein is often elevated in patients infected with HIV due to a condition termed “polyclonal gammapathy”
(Alexianu & Dan, 2009), which may have been the case in some of the participants in the current study. With
metabolic stress (such as TB and HIV) the albumin decreases, but the globulin fraction increases (high levels
of IgA and IgG); thus, the total protein might increase, decrease or be normal, which further explains the
results of the current study (Shingdang et al., 2016).

In the current study a high percentage of participants had an albumin level below the normal cut-off point
with a median albumin of 29g/l. Men also had statistically significant lower albumin levels than women.
Similar results were confirmed in a study conducted in Singapore amongst patient with TB and HIV co-
infection, where a mean albumin value of 29.6g/dl was reported (Paton et al., 2003: 321). Serum albumin
level is an indicator of depleted protein status and decreased protein intake (Lee & Nieman, 2013: 320).
Hypoalbuminaemia is an important marker of severe malnutrition (Matos & Moreira Lemos, 2006: 1363),
but is not a reliable indication of nutritional status when an infection is present, since it reacts as a negative
phase protein (Litchford, 2012, Salgado et al., 2001). Low serum albumin levels are strongly associated with
an increased risk of TB. This was confirmed in a study amongst adult patients in the United States (Cegielski
et al., 2012: 409). Serum albumin concentrations might be a useful diagnostic and prognostic marker for TB
in HIV infected patients (Alvarez-Uria et al., 2013: 127). Studies in Ethiopia and Malawi both reported that
serum albumin levels were significantly lower in patients with TB than in healthy controls (Madebo et al.,
2003; Mugusi et al., 2003). A study of hospitalised patients with TB in Brazil found that the group of patients
who died during hospitalisation had statistically significantly lower mean albumin levels that the group of
patients that survived (26g/l vs. 31g/l) (Matos & Moreira Lemos, 2006: 1361). Alvarez-Uria et al. (2013:
127) found that a serum albumin value of >38g/l was a negative predictor for TB even in settings with a high
prevalence, whereas a serum albumin value of <32g/l was associated with 85% TB specificity. Thus,

86
correcting a low serum albumin value in the hospital setting through nutrition interventions is very likely to
improve the prognosis of patients with TB.

In the current study a CRP was only available in 15% of participants. In these patients, the median CRP was
above the normal range (median: 8.1mg/l), which indicates that an infection was present in all of them. A
study conducted in Pakistan amongst 127 patients with TB, reported that the median CRP was 11.21mg/l in
males and 13.82mg/l in females respectively. The researchers concluded that a high CRP is noticeably
associated with more severe TB disease (Shaikh et al., 2012: 144).

Low haemoglobin values were present in the majority of participants in the current study and were
significantly more noticeable in men; the reason for this unexpected finding is unknown. A low MVC (an
indication of an iron deficiency) were present in almost a fifth (17%) of participants. It is estimated that one
quarter of the world’s population are affected by anaemia (WHO, 2008). A number of studies in Gambia,
India, the United States, Tanzania and Indonesia have confirmed that anaemia is particularly common in
patients with TB (Minchella et al., 2015: 764; Boloor et al., 2014: 476; Cegielski et al., 2012: 412; Isanaka
et al., 2012: 353; Karyadi et al., 2000: 2957) predominantly due to anaemia of inflammation (also known as
anaemia of chronic disease) (Minchella et al., 2015: 771), which was most probably also the case in the
patients included in the current study. Some studies have reported a lower prevalence of iron deficiency in
patients with TB compared to the control groups (Friis et al., 2006; van Lettow et al., 2005). The incidence
of an iron deficiency in patients with TB is most likely to vary across populations due to contextual factors,
such as dietary intake, and the prevalence of other infections (Isanaka et al., 2012: 353).

We acknowledge that the results of this single-centre study may not be generalised to all patients with TB
and TB/HIV co-infection.

CONCLUSION AND RECOMMENDATIONS

The current study showed that patients with TB and TB/HIV co-infection had poor nutritional status when
considering specific food related side effects, anthropometric measurements and biochemical parameters.
These factors elevate their risk of developing malnutrition, as confirmed by the MUST screening index that
indicated that most were malnourished.

Nutritional interventions cannot replace the medical management of TB, just as medical management of TB
cannot replace adequate nutrition. In order to address the problem of malnutrition, however, nutritional
support should be considered a necessary part of the therapeutic approach when treating a patient with TB.
In addition, provisioning of nutritional support to families and contacts of persons with TB is indicated to
prevent the progression of latent disease to active disease.

87
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 CHAPTER 6
SMOKING HABITS AND ALCOHOL USE OF PATIENTS WITH TB, AND TB/HIV
CO-INFECTION AT STANDERTON TB SPECIALISED HOSPITAL, MPUMALANGA
ABSTRACT

Objective: To determine the smoking habits and alcohol use of patients with TB, and TB/HIV co-infection,
and how it is associated with gender, level of education and body mass index (BMI).
Design: A cross sectional study was undertaken.
Settings and subjects: The study was conducted at Standerton TB Specialised Hospital, Mpumalanga. One
hundred hospitalised patients with TB, and TB/HIV co-infection were included in the study.
Outcome measures: A structured interview was conducted by the researcher with each patient to obtain
information on smoking habits, alcohol use and level of education. Weight and height were measured using
standard techniques.
Results: Almost six out of ten participants (58%) indicated that they were former (44%) or current (14%)
smokers. The average cigarettes, pipes or cigars smoked by the former and current smokers were 4 with a
maximum of 20 per day. The average amount of years that the former or current smokers smoked was 9 years
with a minimum of 1 year and a maximum of 30 years. Nearly half (49%) reported that they did use alcohol
with 25% drinking alcohol more than three times per week. Statistically significantly more females than males
were non-smokers and more men drank alcohol three times or more per week than females. Participants that
indicated that they were either former or current smokers had significantly lower levels of education than
participants who were non-smokers (95% CI [-26.7%; -2.6%] and [-39.9%; -1.0%] respectively). There were
no statistically significant differences in terms of BMI in smokers versus non-smokers.
Conclusion: The results indicated that a high percentage of patients with TB, and TB/HIV co-infection
previously or currently smoked and used alcohol. Smoking and alcohol use are likely to have a negative
impact on nutritional status and may further affect the prognosis of patients with TB. These unhealthy lifestyle
habits should thus be targeted in intervention programmes aimed at improving the outcome of patients with
TB.
INTRODUCTION

Globally, Tuberculosis (TB) affects many people, impacting on health, nutrition, food security and
socioeconomic development. Even though TB is a curable disease, in 2014 alone there were 1.5 million TB
related deaths worldwide. Approximately one-third of the world population, an estimation of more than 2
billion people, are infected with Mycobacterium tuberculosis (M. tb). TB is an infectious disease caused by
the M. tb organism entering the lungs (WHO, 2015). Sites apart from the lungs that can also be infected
include the lymph nodes, pleural cavities, pericardium, peritoneum, meninges, vertebral bodies and synovial
tissue of other joints. Multi-organ involvement including the liver, spleen, lungs and bone marrow may also
occur (Churchyard & Corbet, 2008: 438).

Tobacco smoking has increased significantly over the past three decades, especially in developing countries.
It is expected that smoking will cause about ten million adults deaths in 2030 and most of the increased
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tobacco-related deaths will take place in Africa, Asia and South America (Wang & Shen, 2009). It is estimated
that up to 20% of TB cases globally are attributable to tobacco exposure (Gegia et al., 2015). Patients with
TB who smoked, had an increased risk for mortality of nine times more than patients with TB who had never
smoked. Smoking is accountable for more than one third of TB related deaths in Taiwan (Wen et al., 2010).
In China a study also found that cigarette smoking is strongly associated with TB (Wang & Shen, 2009). The
prevalence of current smokers among patients with TB in Japan, Osaka city was significantly higher than the
national smoking prevalence (Matsumoto et al., 2012: 547). According to the National Health and Nutrition
Examination Survey (NHANES) 1999 – 2000 in the United States, smoking is a strong risk factor for latent
TB infection in countries with a low TB prevalence (Horne et al., 2012). In country such as India were HIV
infection plays a relatively minor role in the TB epidemic, smoking and malnutrition are also considered to
be important risk factors (Bhargava et al., 2013). According to Horne et al. (2012), individuals with higher
prevalence of latent TB infection and an increased risk for progression to active TB disease might be
identified through their smoking status. Thus, all smokers from high-risk populations should be considered
for TB screening.

Cigarette smoking is associated with an increased lifetime risk for TB infection (Saad & Tirkey, 2013). Both
passive and active exposure to tobacco smoke has been shown to be associated with TB infection and
progression to TB disease (Saad & Tirkey, 2013: 340). It is more difficult to identify TB among smokers,
because smokers and patients with TB share a number of clinical symptoms (Wen et al., 2010). In addition
to smoking, alcohol use has also been established to be risk factors for acquiring TB disease, and continued
use of alcohol and tobacco products once a person has contracted TB lowers the chances of successful
treatment (Louwagie et al., 2014: 501).

Peltzer (2014) found a high incidence of combined tobacco and alcohol use among patients with TB in
primary care clinics in South Africa. Furthermore, Coetzee et al. (1988:353) have reported that the prevalence
of TB was higher in households where alcohol use was considered to be a problem. Alcohol is also a relative
risk factor for TB, especially in individuals who consume more than 40g of alcohol per day (SADoH, 2014).

The recent China Health and Nutrition Survey concluded that smoking is associated with an increased risk of
being underweight and a decreased risk of being overweight and obese (Wang, 2015). PrayGod et al. (2013:
738) found that not only do smokers weigh less, but that they were more likely to have lower muscle mass
and higher fat mass than those that don’t smoke. Lower weight among smokers is thought to be due to a
reduction in appetite and food intake as well as increased resting energy expenditure mediated by the effects
of nicotine on body metabolism (PrayGod et al., 2013: 738). Smoking is known to suppress the immune

95
system, and when smoking is combined with HIV infection, the negative impact on TB development and
progression is enormous (Oni et al., 2012; Kolappan & Gopi, 2002: 965-966).

When considering the mentioned negative impacts of smoking and alcohol use on patient with TB, the
purpose of this study was to determine the smoking habits and alcohol use of patients with TB and TB/HIV
co-infection at Standerton TB Specialised Hospital, Mpumalanga and how it is associated with gender, level
of education and BMI. This information may contribute to the identification of lifestyle habits that need to
be taken into account in health and nutrition policies and interventions, which might ultimately play a role in
decreasing the incidence and the impact of TB disease on the individual, the household and the wider
community.

METHODOLOGY

Study design

A cross sectional study was conducted.

Target population and sampling

The study population included all patients between 20-65 years with TB, and TB/HIV co-infection that gave
informed consent to participate at Standerton TB Specialised Hospital, Mpumalanga in wards 1 and 2 over a
period of one month (21/07/2015 – 17/08/2015). Patients with any additional diagnoses other than TB and
TB/HIV co-infection, pregnant or lactating patients, and mentality or physically disabled patients were
excluded from the study. The sample included 100 patients with TB and TB/HIV co-infection that met the
inclusion criteria.

Pilot study

A pilot study was conducted on the first five patients that met the inclusion criteria and provided onfrormed
consent from Standerton TB Specialised Hospital to determine the feasibility of the methodology. No changes
were made to the questionnaire and data of these participants was thus included in the main study.

Variables and operational definitions

Smoking habits
Smoking habits were categorised as follows (Peltzer, 2014; Saad & Tirkey, 2013):

 Non-smoker: Patient who has never smoked;

 Former smoker: Patient who had smoked before, but who has stopped smoking for at least 3 months
before entering the study.

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  Current smoker: Patient that smokes at least one cigarette, pipe, or cigar per day for at least 6 months
prior to entering the study.
Patients who were former or current smokers were asked how many times a day and for how many years they
were/are smoking.

Alcohol use
Alcohol consumption was categorised according to whether or not the participants formerly drank alcohol
more than 3 times per week (Peltzer, 2014; Saad & Tirkey, 2013). An alcohol consumption of less than 3
times per week was considered low, while consumption of alcohol 3 or more times a week was considered
high (Saad & Tirkey, 2013).

Level of education
Information related to socio-demographic status included gender and level of education.
Body mass index (BMI)
BMI was calculated by dividing weight in kilograms (kg) by height in meter square (m2). BMI was
interpreted according to the World Health Organisation (WHO) categories of BMI, with underweight;
<18.5 kg/m2, normal weight; 18.5-24.9 kg/m2 and overweight; >25 kg/m2 (WHO, 2006).

Methods and techniques

Questionnaire
A questionnaire was designed by the researcher to obtain information regarding the smoking habits, alcohol
use and level of education of patients with TB and TB/HIV co-infection at Standerton TB Specialised
Hospital. The researcher completed a structured interview with each participant.

Weight
Weight was measured with a platform electronic scale (TCS-200-RT). As recommended by Lee & Nieman
(2013: 168), the participants were wearing minimal clothing (removed jacket, shoes and jewellery), standing
still in the middle of the scale’s platform without touching anything and with the body weight equally
distributed on both feet. Weight was recorded to the nearest 0.1 kg.

Height
Height was measured by means of a stadiometer (TCS-200-RT) with a vertical scale of 2 meters and a sliding
head-piece, to the nearest 0.5 cm. Height of participants was measured without shoes. The participants stood
with their heels together, arms to the side, legs straight, shoulders relaxed and head in the Frankfort horizontal
plane (looking straight ahead). Heals, buttocks, scapulae (shoulder blades), and the back of the head were

97
against the vertical surface of the stadiometer. Just before the measurement was taken, the participant inhaled
deeply, held the breath and maintained an erect position while the sliding-headpiece was lowered to the
highest point of the head with enough pressure to compress the hair (Lee & Nieman, 2013: 167).

Validity and reliability

Content validity was enhanced by ensuring that all data collected was directly related to the aim and objectives
of the study. Reliability was enhanced by ensuring that all data was collected by a trained researcher, using
standardised techniques.

Data collection

All eligible participants signed consent in their language of choice (English/IsiZulu), after the purpose and
procedure of the project had been explained to them by the researcher or a lay counsellor who spoke the
native language. The information document was given to patients to provide them with all the relevant
information regarding the study. Once informed consent had been obtained, participants were interviewed by
the researcher and anthropometric measurements were taken in a private room. In addition to information on
smoking habits and alcohol use, information on socio-demographic status, food security, and nutrition status
were also collected; these are reported elsewhere.

Ethics

Ethics approval was obtained from the Provincial Health and Research Ethics Committee (PHREC) of
Mpumalanga Department of Health (PHREC MP_2015RP38_556) and the Health Sciences Research Ethics
Committee of the Faculty of Health Sciences, University of the Free State (ECUFS 56/2015).

Statistical analysis

Descriptive statistics, namely frequencies and percentages for categorical data, and medians and percentiles
for continuous data were calculated. Associations between variables were calculated and described by means
of 95% confidence intervals (CI) for differences in percentages. All analyses were completed by the
Department of Biostatistics at the University of the Free State.

RESULTS

The study sample included 100 participants (60 males and 40 females). The mean age of the sample was 39.2
(20.3-63.5) years. More than two thirds of participants (68%) were HIV positive, with HIV co-infection being
slightly higher in women (70%) than in men (66.7%).

Smoking habits

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Table 6.1 illustrates the number of cigarettes, pipes or cigars smoked per day and the number of years that
the former or current smokers had smoked. Table 6.2 presents the smoking habits of male and female
participants. About four out of ten participants (42%) indicated that they were non-smokers, and 58%
indicated they were former (44%) or current (14%) smokers. A significantly higher percentage of females
(60%) than men (30%) were non-smokers (95% CI for the percentage difference [-10.2%; -47.0%]).

Table 6.1: Median smoking habits of former and current smokers (n=58)

Question Median Range (min – max)

Number of cigarettes, pipes or 4 1 - 20
cigars smoked per day
Number of years smoked 9 1 - 30

Table 6.2: Smoking habits (n=100)

Male (n=60) Female (n=40) 95% CI for the

percentage
difference
Non-smoker (n=42) 30.0 60.0 [-47.0%; -10.2%]*
Former smoker (n=44) 48.3 37.5
Current smoker (n=14) 21.7 2.5
* Statistically significant difference

Categories of level of education and BMI and associations with smoking habits are displayed in Table 6.3.
Participants that indicated that they were either former or current smokers had statistically significant lower
levels of education than participants who were non-smokers. Although a higher percentage of participants
that formerly or currently smoked had a BMI in the underweight category than those that had never smoked,
the difference was not statistically significant.

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Table 6.3: Level of education, BMI categories and associations with smoking habits (n=100)

Variables Non- Former smoker Current smoker 95% CI for the

smoker (n=44) (n=14) percentage difference
(n=42)
Level of education (%)
No schooling 0.0 13.6 14.3 Non-Former
[-26.7%; -2.6%]*
Less than Grade 9 33.3 38.6 35.7 Non-Current
[-39.9%; -1.0%]*
At least Grade 9 52.4 43.2 42.9 Former-Current
[-27.3%; 16.0%]
Matric completed 9.5 4.6 7.1

Tertiary education 4.8 0.0 0.0

BMI score (%)
<18.5: Underweight 42.9 59.1 64.3 Non-Former
[-35.3%; 4.7%]
18.5-24.9: Normal 30.9 38.6 35.7 Non-Current
weight [-45.2%; 8.1%]
25.0-29.9: Overweight 14.3 2.3 0.0 Former-Current
[-29.5%; 23.5%]
>29.9: Obese 11.9 0.0 0.0
* Statistically significant difference

Alcohol use

The alcohol use of the male and female participants is presented in Table 6.4. More than half (51%) indicated
that they do not use alcohol. Almost half (49%) indicated that they do use alcohol of which 25% indicated
that they drink alcohol more than three times per week and 24% indicated that they drink alcohol less than
three times per week. Men drank alcohol (three or more times per week) significantly more often than women
(95% CI for the percentage difference [12.6%; 42.7%]).

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Table 6.4: Alcohol use (n=100)

Male (n=60) Female (n=40) 95% CI for the

percentage
difference
Drink alcohol 3 or more 36.7 7.5 [12.6%; 42.7%]*
time per week (n=25)
Drink alcohol less than 3 31.7 12.5
times per week (n=24)
Do not drink alcohol 31.7 80.0
(n=51)
* Statistically significant difference

The associations of alcohol use with level of education and BMI scores are displayed in Table 6.5. There
were no statistically significant differences between participants who did or did not drink alcohol in terms of
level of education or BMI scores.

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Table 6.5: Level of education, BMI categories and associations with alcohol use (n=100)

Variables Used to drink Used to drink Do not drink 95% CI for the
alcohol 3 or alcohol less alcohol (n=51) percentage difference
more times than 3 times
per week per week
(n=25) (n=24)
Level of education (%)
No schooling 4.0 8.3 9.8 >3/week-<3/week
[-22.2%; 12.3%]
Less than Grade 9 52.0 29.2 31.4 >3/week-none
[-17.5%; 10.7%]
At least Grade 9 36.0 54.2 49.0 <3/week-none
[-14.2%; 16.9%]
Matric completed 4.0 8.3 7.8

Tertiary education 4.0 0.0 2.0

BMI score (%)
<18.5: 56.0 62.5 47.1 >3/week-<3/week
Underweight [-31.5%; 19.8%]
18.5-24.9: 40.0 37.5 31.4 >3/week-none
Normal weight [-14.3%; 30.6%]
25.0-29.9: 4.0 0.0 11.8 <3/week-none
Overweight [-8.5%; 36.3%]
>29.9: 0.0 0.0 9.8
Obese
* Statistically significant difference

Combined smoking habits and alcohol use

The combined smoking habits and alcohol use are indicated in Table 6.6. Only 35 participants indicated that
they did not drink alcohol and were non-smokers. Heavy drinking habits (of more than 3 times per day)
together with current smoking were noted in 8 participants.

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Table 6.6: Combined smoking habits and alcohol use (n=100)

% (n) Used to drink Used to drink Do not drink alcohol

alcohol 3 or more alcohol less than 3 (n=51)
times per week times per week
(n=25) (n=24)
Non-smoker (A) 4.8 (2) 11.9 (5) 83.3 (35)
(n=42)
Former smoker 34.1 (15) 34.1 (15) 31.8 (14)
(n=44)
Current smoker 57.1 (8) 28.6 (4) 12.3 (2)
(n=14)

DISCUSSION

The results of the current study indicated that a high percentage of patients with TB, and TB/HIV co-infection
smoked and used alcohol. The smoking habits and alcohol use of patients with TB have been studied by a
number of researchers (Louwagie et al., 2014; Peltzer, 2014; PrayGod et al., 2013; Saad & Tirkey, 2013;
Singh et al., 2013; Awan et al., 2012; Biranvand et al., 2012; Horne et al., 2012; Lombardo et al., 2012;
Matsumoto et al., 2012; Wen et al., 2010; Wang & Shen, 2009; Kolappan & Gopi, 2002; Coetzee et al., 1988;
Feingold, 1976) all of whom found that these unhealthy lifestyle habits were very prevalent in patients with
TB.

A study among patients in Pakistan with TB reported that 42.5% of participants were smoking and 1.7% were
using alcohol at the time that the study was undertaken (Awan et al., 2012: 329). In newly diagnosed TB
patients in Tanzania, 24.4% were current smokers and 54.2% reported that they consumed alcohol (PrayGod
et al., 2013: 737). Among other risk factors for TB, smoking was prevalent in 26.4% and alcohol use in 50.7%
of patients with TB in Uganda (Kirenga et al., 2015). Cegieski et al. (2012: 412) reported that 79% of persons
who were current smokers and 23.5% of persons who consumed more than 7 alcoholic drinks per week
developed TB later in life, thus both smoking and alcohol consumption were listed as risk factors for the
development of TB of persons in the United States. More than 40 years ago, Feingold (1976:1336) conducted
a hospital-based study and found a 49% prevalence of alcoholism in patients newly diagnosed with TB in
Georgia. Nearly three decades ago Coetzee et al. (1988: 354) found that frequent alcohol consumption was a
risk factor for the development of TB disease in households from Mamre, Cape Town.

103
A study of 1005 male patients with TB in Tshwane Metropolitan Municipality, South Africa, reported that
37.6% of participants smoked and 27.3% were alcohol dependant (Louwagie et al., 2014: 503). Similar results
were found in the current study where 58% of participants were either former (44%) or current (14%) smokers
and 49% of participants used alcohol. This study was conducted amongst hospitalised patients, and despite
this, 14% indicated that they were currently smoking. Louwagie et al. (2014: 508) reported even higher levels
of smoking and alcohol use in patients with TB in South Africa, with 79% of participants in their study
currently smoking and 23.5% consuming more than 7 alcoholic drinks per week. Another study undertaken
in South Africa among a large sample of 4900 patients with TB, reported that 10.1% (15.5% males and 3.4%
females) of participants smoked and used alcohol simultaneously (Peltzer, 2014). In the current study similar
results were found with 8% of participants previously drinking alcohol heavily (used alcohol more than three
times per week) together with current smoking.

Smoking and alcohol use is more common in males with TB. The current study also confirmed that
significantly more men smoked and drank alcohol (three or more times per week) than women. This finding
has also been reported by other researchers (Singh et al., 2013; Kolappan & Gopi, 2002). The smoking
prevalence in adult men with TB in India is two to four times higher than in women and a study conducted
by Kolappan & Gopi (2002: 964) found a positive association between tobacco smoking and being an adult
man with pulmonary TB in India (OR=2.48). A study in Iran amongst 183 patients with TB also found that
men were significantly more likely to be smokers than women (OR=12.4) (Biranvand et al., 2012). A study
that included a large national sample of adult patients with a history of TB in Cambodia found that TB
infection was more common in men who smoked manufactured cigarettes and in those that were the heaviest
smokers (more than 1 pack per day, more than 30 packs per year) (Singh et al., 2013). This was also confirmed
in India were both the cumulative smoking years and number of cigarettes smoked were associated with a
significantly increased risk of TB (Saad & Tirkey, 2013: 340).

Some other factors that are strongly related with smoking and alcohol use have been identified by several
researchers. Louwagie et al. (2014: 508) concluded that drug, tobacco and alcohol use were closely related
to poverty in patients with TB in South Africa. Saad & Tirkey (2013: 340) reported that patients with TB who
smoked were more likely to be older adults with lower levels of education and a history of drinking alcohol.
Similarly, male gender, a lower level of education and higher levels of poverty were found to be associated
with simultaneous alcohol and tobacco use, as well as with alcohol or tobacco use among patients with TB
in South Africa (Peltzer, 2014). An analysis of 14 national studies of 14 high-burden TB countries found that
smoking, alcohol consumption and with a BMI <18.5 kg/m² were each independently associated with TB
(PrayGod et al., 2013).

104
In the current study there was a statistically significant difference between the level of education of non-
smokers and smokers (95% CI for the percentage differences [-26.7%; -2.6%] and [-39.9%; -1.0%]
respectively). Smokers had a lower level of education (no schooling completed and less than grade 9) than
non-smokers. Although a high percentage of participants that were underweight (according to their BMI
scores) smoked and used alcohol (42.9% vs. 56%), the difference was not statistically significant.

Smoking and alcohol status were based on the patient’s self-report rather than the detection of nicotine or
alcohol levels. We acknowledge that the results of this single-centre study may not be generalised to all
patients with TB and TB/HIV co-infection. .

CONCLUSION AND RECOMMENDATIONS

A high prevalence of smoking and alcohol use was identified among patients with TB and TB/HIV co-
infection in the current study. This may lead to poorer treatment outcomes, and may also expose more
surrounding people to TB infection due to passive smoking exposure (Matsumoto et al., 2012: 547).

Guidelines on smoking and alcohol use should be incorporated into the National TB control plan and should
also be included in Directly Observed Therapy, Short-course (DOTS) interventions (Wang & Shen, 2009).
Stricter health policies could be implemented on smoking and heavy drinking in populations where TB is a
major problem in order to improve their health and quality of life (PrayGod et al., 2013; Awan et al., 2012:
331).

105
REFERENCES

Awan MS, Waqas M & Aslam MA. 2012. Factors influencing quality of life in patients with active
tuberculosis in Pakistan. World Applied Science Journal, 18(3): 328-331 [Viewed: 21 March 2014].

Bhargava A, Chatterjee M, Jain Y, Chatterjee B, Kataria A, Bhargava M, Kataria R, D’Souza R, Jain R,

Benedetti A, Pai M & Menzies D. 2013. Nutritional status of adult patients with pulmonary tuberculosis in
rural central India and its association with mortality. Plos one, 8(10): e77979 [Viewed: 21 March 2014].

Biranvand E, Abediankenari S, Khalilian A & Biranvand B. 2012. Risk factors for tuberculosis infection: a
brief report. Tehran University Medical Journal, 70(5): 330-333 [Viewed: 16 February 2015].

Churchyard, G. & Corbet, E. 2008. TB and HIV. In: Farham, B. HIV/AIDS in South Africa. New York:
Cambridge University Press: 433 – 454 [Viewed: 26 April 2015].

Ciegieski JP, Arab L & Cornoni-Huntley J. 2012. Nutritional risk factors for tuberculosis among adults in
the United States 1971-1992. American Journal of Epidemiology, 176(5): 409-422 [Viewed: 22 March
2015].

Coetzee N, Yach D & Joubert G. 1988. Crowding and alcohol abuse as risk factors for tuberculosis in the
Mamre population. SAMT, 74: 352-354 [Viewed: 19 March 2015].

Feingold AO. 1976. Association of tuberculosis with alcoholism. South Medical Journal, 69(10): 1336-
1337 [Viewed: 25 November 2015].

Gegia M, Magee MJ, Kempker RR, Kalandadze I, Chakhaia T, Golub JE, Blumberg HM. 2015. Tobacco
smoking and tuberculosis treatment outcome: a prospective cohort study in Georgia. World Health
Organisation, 93: 390–399 [Viewed: 12 September 2016].

Horne DJ, Campo M, Ortiz JR, Oren E, Arentz M, Crothers K & Narita M. 2012. Association between
smoking and latent tuberculosis in the U.S. population: an analysis of the National health and Nutrition
Examination Survey. Plos one, 7(11): e49050 [Viewed: 21 May 2015].

Kirenga BJ, Ssengoba W, Muwonge C, Nakiyingi L, Kyaligonza S, Kasozi S, Mugabe F, Boeree M, Joloba
M & Okwera A. 2015. Tuberculosis risk factors among tuberculosis patients in Kampala, Uganda:
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Kolappan C & Gopi PG. 2002. Tobacco smoking and pulmonary tuberculosis. Thorax, 57: 964-966
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Lombardo CC, Swart R & Visser ME. 2012. The nutritional status of patients with tuberculosis in
comparison with tuberculosis-free contacts in Delft, Western Cape. South African Journal of Clinical
Nutrition, 25(4): 180-185 [Viewed: 20 March 2014].

Louwagie GM, Wouters E & Ayo-Yusuf OA. 2014. Poverty and Substance Use in South African
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Lee RD & DC Nieman. 2013. Nutritional assessment. 6th ed. Singapore: McGraw-Hill International: 166-
196, 224-235, 320, 459-460.

Matsumoto K, Arima K, Komukai J, Danno K, Yoshida H, Hirota S, Koda S, Terakawa K & Shimouchi A.
2012. The association between smoking and sputum smear-positive pulmonary tuberculosis in Osaka city.
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Oni T, Gideon HP, Bangani N, Tsekela R, Seldon R, Wood K, Wilkinson KA, Goliath RT, Ottenhoff THM
& Wilkinson RJ. 2012. Smoking, BCG and Employment and the risk of Tuberculosis Infection in HIV-
Infected Persons in South Africa. PLOS ONE, 7(10): e47072 [Viewed: 16 February 2015].

Peltzer, K. 2014. Conjoint alcohol and tobacco use among tuberculosis patients in public primary healthcare
in South Africa. South African Journal of Psychiatry, 20(1): 21-26 [Viewed: 19 June 2014].

PrayGod G, Range N, Faurholt-Jepsen D, Jeremiah K, Faurholt-Jepsen M, Aabye MG, Mahnussen P,

Changalucha J, Andersen AB, Wells JCK & Friis H. 2013. Sex, smoking, and socioeconomic status are
associated with body composition among tuberculosis patients in a deuterium dilution cross-sectional study
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Saad T & Tirkey SA. 2013. Association between pulmonary tuberculosis and smoking: a case control study.
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Singh PN, Yel D, Kheam T, Hurd G & Job JS. 2013. Cigarette smoking and tuberculosis in Cambodia:
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South African Department of Health (SADoH). 2014. National Tuberculosis Management Guidelines,
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Wang J & Shen H. 2009. Review of cigarette smoking and tuberculosis in China: intervention is needed for
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Wang Q. 2015. Smoking and body weight: evidence from China health and nutrition survey. BMC Public
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Wen CP, Chan TC, Chan HT, Tsai MK, Cheng TY & Tsai SP. 2010. The reduction of tuberculosis risks by
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108
 CHAPTER 7
CONCLUSIONS AND RECOMMENDATIONS
7.1 INTRODUCTION
The objective of this study was to determine the nutritional status of patients with TB, and TB/HIV co-
infection at Standerton TB Specialised Hospital, Mpumalanga.

7.2 CONCLUSIONS
The following conclusions evolved from the study:

7.2.1 Socio-demographic characteristics and household food security

As reported in other studies, high levels of poverty were identified in the patients with TB and TB/HIV co-
infection that were included in the present study. This was evidenced by the high percentage of participants
that were unemployed and the fact that in the majority of households only one person contributed to the
monthly income. A room density of more than 2.5 persons per room (ppr), thus crowding, was present in a
significant number of households.

As far as household food security is concerned, a high percentage of participants were found to be food
insecure. The majority of participants indicated that they ran out of money to buy food during the month and
that they relied on a limited number of foods. A significant percentage of participants indicated that their
children sometimes go to bed hungry, because there is not enough money for food. A higher percentage of
HIV co-infected respondents reported relying on a limited number of food to feed their children, reported
eating less that they wanted to and tended to eat less that they should because there was not enough money
available for food purchases, indicating that poverty was more prevalent amongst this group. Even though
the majority of household indicated that they were food insecure, the minority of participants reported having
a household vegetable garden at home.

7.2.2 Nutritional status

The current study found that patients with TB and TB/HIV co-infection had poor nutritional status when
considering specific food related side effects, anthropometric measurements and biochemical parameters.
These factors increase their risk for developing malnutrition, as confirmed by the MUST screening index that
indicated that most were malnourished.

When considering food related side effects experienced by the participants, a loss of appetite followed by a
dry mouth were the most common reported food related side effects. Patients with HIV co-infection
experienced more food related side effects than patients without HIV co-infections, but the differences were
not statistically significant.

109
As far as anthropometric measurements are concerned, low median values for BMI, MUAC and Triceps
skinfold measurements were reported, confirming the high levels of malnutrition in this sample. Males were
more likely to be malnourished, as evidenced by the significantly lower median Triceps skinfold
measurements than in females. The majority of participants had BMI and MUAC scores in the underweight
and malnourished categories.

Involuntary weight loss was reported by the majority of participants. Significantly more participants with
HIV co-infection had experienced unplanned weight loss (absolute values and percentage) during the past 3-
6 months than participants without HIV co-infection. Similarly, a high percentage of participants were
identified as having a high risk for malnutrition according to the MUST screening index.

As far as biochemistry is concerned, a high percentage of participants had albumin and haemoglobin values
below the normal range, with a significantly higher percentage of males than females affected.

7.2.3 Lifestyle behaviours

A high prevalence of smoking and alcohol use was identified among patients with TB and TB/HIV co-
infection that were included in the present study. As reported in other studies, a significantly higher
percentage of men than women smoked. Participants that indicated that they were either former or current
smokers had significantly lower levels of education than participants who were non-smokers. Significantly
more men drank alcohol (three or more times per week) than women.

7.3 RECOMMENDATIONS
7.3.1 Recommendations to address TB
7.3.1.1 Poverty relief
Poverty in South Africa remains a challenge and a concern. The situation is becoming more and more
problematic as the unemployment rate increases in the midst of income inequality (Trading Economics, 2016;
World Bank, 2016). The fact that poverty is so closely linked to TB points to the urgent need to address
poverty in the fight against TB. The poor are the sector that are least likely to access TB diagnosis and
treatment, emphasising the urgent need to focus and improve TB services in this group (Oxlade & Murray,
2012).

Food security of individuals and households are influenced by various factors, especially those related to their
immediate environment (Labadarios et al., 2011). Poverty is most often responsible for poor household food
security, since most South Africans depend on food purchases to ensure food security. In this context, there
is an urgent need for economic growth to take place and employment opportunities to increase in order to
alleviate poverty and improve household food security. It is thus recommended that communities be taught
skills on how to use available resources effectively and be empowered to become involved in food production

110
(such as household vegetable gardens) and income generating projects that will increase income and address
the issue of food insecurity.

7.3.1.2 Nutrition education

Basic education together with incorporation of TB education in the school syllabus can contribute to creating
awareness of the disease. Furthermore, nutrition education has the potential to play an important role in
improving food security and nutritional status (Keenan et al., 2001) by teaching communities about the
importance of food distribution according to the needs of the individual. Nutrition education also has the
potential to empower communities to eat a healthy diet using the limited resources available to them. A
patient’s immune system can be strengthened by educating patients about optimal nutrition and helping them
to eat a balanced diet using the resources available to them wisely (Suttajit, 2007).

Interventions aimed at improving nutritional status and quality of life in patients with TB and HIV co-
infection should aim at preventing weight loss by focusing on affordable, available and acceptable food
sources. Nutrition interventions cannot replace TB treatment, just as TB treatment cannot replace adequate
nutrition. In order to address the problem of malnutrition, nutrition support and education should be
considered a necessary part of the therapeutic and preventative approach when treating a patient with TB. In
addition, providing nutrition support and education to families and contacts of persons with TB is indicated
to prevent the progression of latent disease to active disease (Cegielski et al., 2012: 418).

7.3.1.3 Support networks

Community based support groups are one of the cheapest and most effective strategies that can be
implemented in the fight against TB. In a country such as South Africa, this can contribute to the effective
management of TB. Communities can play an important role in reducing the burden of TB and HIV and in
alleviating its impact, stigma and discrimination. Therefore a necessary supportive environment should be
created in TB affected areas in order to improve or maintain quality of life of those infected with TB. Despite
this, community resources in most settings are often inadequate and their role remains undefined (Zacharaih
et al., 2006).

The DOTS strategy is an example of an effective initiative to support patients with TB. The DOTS strategy
has been shown to lower the indirect costs of TB to patients and family members, but the current
implementation of the DOTS strategy needs to be reassessed in order to improve its potential (Ahlburg, 2000).

Guidelines on smoking and alcohol use should be incorporated into the National TB plan and should also be
included in the DOTS strategy (Wang & Shen, 2009). Patients who experience higher levels of poverty also
appear to have more depressive symptoms, and alcohol, drug and smoking are closely related with poverty
(Louwagie et al., 2014: 508). Therefore, community support groups might also assist in addressing smoking

111
and alcohol use, which may in turn, improve household food security, and improve the quality of life of the
affected.

7.3.2 Recommendations for further research

According to the Academy of Science of Southern Africa (ASSAf, 2007) “the lack of TB research on the
specific nutrients that are most beneficial and the conditions under which nutrition interventions are
warranted, in terms of cost and effectiveness, is truly astonishing.” In this regard, research to establish the
nutritional status of patients with TB and TB/HIV co-infection on a national scale are necessary in South
Africa. Studies that apply a longitudinal study design have the potential to effectively determine the role of
malnutrition in the development of TB disease on the one hand, while also investigating the impact of TB in
affecting nutritional status on the other (Lombardo et al., 2012; Cegielski & McMurray 2004).

112
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ADDENDUM A
Guidelines for food safety (South African guidelines on Nutrition for people living with TB,
HIV/AIDS and other chronic debilitating conditions) (SADoH, 2007)

Food safety
Wash your hands well with soap and water (preferably warm):
 Before you touch food
 Between touching raw and cooked food
 After touching an animal
 After using the toilet
 After sneezing and blowing your nose
 Before you eat meals

Food safety when shopping

 Food bought should be kept safe e.g. freeze food
 Discounts might contain unsafe and outdate food – do not be tempted.
 Buy ready packed foods, not food that is unwrapped and sitting in a display case
 Wash vegetables and fruit beforehand; look for ‘pasteurized’ milk and dairy products; meat should
not look/smell ‘off’; eggs should never be eaten raw

Kitchen safety
 The room/kitchen should be clean and well aired
 Keep rubbish in a bin with a lid and remove rubbish on a regular basis
 Cloths and sponges should be kept clean and disinfected
 Wash dishes in preferably hot, and soapy water
 Do not use cracked or scratched plastic containers
 Use a special cutting board, not the sink, for cutting raw food

Water safety
 Boil water before drinking it, OR
 Use the bleach method: Add 1 teaspoon of bleach to 25 litres of water. Mix it well and let it stand for
2 hours (overnight is better) before you use it.

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ADDENDUM B
Dietary Management of HIV and TB Related Illness (Republic of Ghana, 2013)

Illness Diet Care and Nutrition Practices

Anorexia  Stimulate appetite by eating favourite  If appetite loss is a result of illness, seek
(appetite loss) foods. medical treatment.
 Eat small amounts of food more often.
 Eat more energy-dense foods.
 Choose foods with pleasant aromas
and that the client likes.
 Eat meals and snacks in pleasant
settings.
Mild  Drink a lot of fluids (soups, diluted Prevention
diarrhoea fruit juices, boiled water, and light  Drink clean boiled water.
herbal teas) to avoid dehydration.  Wash hands with water and soap before
 Avoid citrus fruits (orange, lemon) handling, preparing, serving, or storing
because they irritate the stomach. food.
 Eat foods rich in soluble fibre (millet,  Wash hands with water and soap after
banana, peas, and lentils) to help using a toilet or latrine or cleaning a
retain fluids. child after defecation.
 Eat fermented foods such as porridges Treatment
and yogurt.  Drink more fluids to prevent
 Eat easily digestible foods such as dehydration. Prepare rehydration
rice, bread, millet, cereal porridge, solutions using oral rehydration salt
potato, sweet potato, and crackers. sachets or a homemade solution from
 Eat small amounts of food frequently. cereals.
 Continue to eat frequently after illness  Go to a health facility if symptoms,
to recover weight and nutrient loss. such as severe dehydration (low or no
 Drink non-fat milk if there is no urine output), fainting, dizziness,
problem with lactose. shortness of breath, bloody stools, high
fever, vomiting, severe abdominal pain,
or diarrhoea, persist for more than 2
days.
Severe  Drink a lot of fluids (soups, diluted Prevention
diarrhoea fruit juices, boiled water, and light  Drink clean boiled water.
herbal teas) to avoid dehydration.  Wash hands with water and soap before
 Eat fermented foods such as porridges handling, preparing, serving, or storing
and yogurt. food.
 Eat easily digestible foods such as  Wash hands with water and soap after
rice, bread, millet, cereal porridge, using a toilet or latrine or cleaning a
potato, sweet potato, and crackers. child after defecation.
 Eat small amounts of food frequently. Treatment
 Continue to eat frequently after illness  Drink more fluids to prevent
to recover weight and nutrient loss. dehydration. Prepare rehydration
 Eat soft fruits and vegetables such as solutions using oral rehydration salt
bananas, mashed sweet potato, and sachets or a homemade solution from
mashed carrots. cereals.
 Drink non-fat milk if there is no  Go to a health facility if symptoms,
problem with lactose. such as severe dehydration (low or no
 Boil or steam foods if diarrhoea is urine output), fainting, dizziness,
associated with fat malabsorption. shortness of breath, bloody stools, high
fever, vomiting, severe abdominal pain,

129
  Avoid or reduce intake of dairy or diarrhoea, persist for more than 2
products (milk); caffeine (coffee and days.
teas) and alcohol; fatty foods; fried
foods and extra oil, lard, or butter; and
gas-forming foods such as cabbage,
onions, and carbonated soft drinks.
Fever  Eat soups rich in foods that give  Drink fluids to prevent dehydration,
energy and nutrients, such as cereal, particularly clean boiled water.
potatoes, and carrots.  Bathe in cool water.
 Drink plenty of fluids.  Rest more.
 Drink teas from lemon, guava, and  Take two Paracetamol tablets, if
gum tree. available, with a meal three times a day
 Continue to eat small, frequent meals (morning, afternoon, and evening).
as tolerated.  Go to the health facility if you have
fever that lasts 2 days and is not
relieved with Paracetamol or brief loss
of consciousness, severe body pain,
yellow eyes, severe diarrhoea, or
convulsions and seizures.
Nausea and  Eat small frequent meals.  Avoid an empty stomach; nausea is
vomiting  Eat soups, unsweetened porridge, and worse if nothing is in the stomach.
fruits such as bananas.  Avoid lying down immediately after
 Eat slightly salty and dry foods, such eating—wait at least 20 minutes.
as crackers, to calm the stomach.  Avoid vomiting.
 Drink herbal teas and lemon juice in  Rest between meals.
hot water.
 Avoid spicy and fatty foods.
 Avoid caffeine (coffee and tea) and
alcohol.
 Avoid strong-smelling foods
 Drink liquids such as clean boiled
water.
Thrush  Eat soft, mashed foods such as carrots,  Seek medical treatment.
scrambled eggs, mashed potatoes,  Use a spoon or cup to eat small amounts
bananas, soups, and porridge. of foods.
 Eat cold or room-temperature foods.  Tilt your head back when eating to help
 Avoid spicy, salty, or sticky foods that with swallowing.
may irritate mouth sores.  Rinse your mouth with boiled warm,
 Avoid sugary foods that cause yeast to salty water after eating to reduce
grow. irritation and keep yeast from growing.
 Avoid strong citrus fruits and juices
that may irritate mouth sores.
 Avoid alcohol and drink plenty of
fluids.
Constipation  Eat more high-fibre foods such as  Avoid cleansing practices such as
maize, whole wheat bread, green enemas and medications.
vegetables, and washed fruits with the  Drink plenty of fluids, including clean,
peel. boiled water.
 Drink plenty of liquids.
 Avoid processed or refined foods.

130
Anaemia  Eat more iron-rich foods such as  If available, take one iron tablet once a
animal products (eggs, fish, meat, day with some food.
liver), green leafy vegetables  Take your meals with a source of
(kontomire, spinach), legumes (beans, vitamin C, such as fresh tomatoes,
groundnuts), nuts, oil seeds, and oranges, or guavas, to help with
fortified cereals. absorption of iron from plant-based
 Take iron supplements (if not SAM). foods.
 Avoid drinking tea or coffee within 2  Treat malaria and hookworm if you
hours before or after meals. have symptoms.

Muscle  Eat more and eat more often.  Perform light exercises (such as
wasting  Improve the quality and quantity of walking, climbing stairs), since
foods by eating a variety of foods. exercises help build muscles.
 Eat more foods high in protein.
 Eat more starchy foods (cereals and
other staples).
 Eat small frequent meals.
Bloating or  Eat small, frequent meals.  Eat long enough before sleeping so that
heartburn  Avoid gas forming foods (cabbage, food can digest.
soda).
 Drink plenty of fluids.
TB  Eat foods high in protein, energy, iron,  Seek medical attention immediately.
and vitamins.  Consult medical personnel about taking
food with medications.
 If taking Isoniazid for treatment, take a
vitamin B6 supplement to avoid
deficiency of this micronutrient.
Loss of taste  Use flavour enhancers such as salt,  Eat small frequent meals.
or abnormal herbs, spices, and lemon.  Chew food well and move it around the
taste  Eat dry foods such as crackers. mouth to stimulate receptors.

131
ADDENDUM C
General nutritional recommendations for people with TB and/or HIV (FANTA, 2013)

The following nutrition recommendations are general guidelines for patients with TB:

 Get weighed regularly, and have weight recorded.

 Where possible, eat regular daily meals.
 If weight loss occur, increased energy intake by consuming more meals, snacks and energy dense
foods.
 Eat a variety of foods, and increase the intake of nutritious foods.
 Eat staple foods (rice, wheat, stamp, maize, potato) with every meal.
 Eat legumes every day, if possible.
 Eat foods from an animal source regularly.
 Eat fruit and vegetables daily.
 Increase consumption of micronutrient-rich foods to achieve an intake of one recommended nutrient
intake (RNI) per day. If one cannot afford this, taking a multivitamin/mineral supplement that
provides one RNI may be helpful.
 Drink plenty of clean safe (boiled and treated) water.
 Avoid habits that can lead to poor nutrition and poor health (alcohol intake, smoking, stress, junk food
and lack of sleep).
 Maintain good hygiene and sanitation, and good dental and oral health, to avoid infections that may
affect food intake.
 Get exercise whenever physically possible.

132
ADDENDUM D
Letter for the PHREC of Mpumalanga Department of Health

The Provincial Health and Research Ethics Committee (PHREC) of Mpumalanga Department of Health

I, Janke Wessels (Persal number: 83814078), would like to ask for permission to conduct my research study
for my Masters in Dietetics at Standerton TB Specialised Hospital, Mpumalanga, during 2015.

Title of the research project: Nutritional status of patients with TB and, TB/HIV co-infection at Standerton
TB Specialised Hospital, Mpumalanga

I am registered as a M.Sc. Dietetic student (student number: 2008007022) at the University of the Free State
(UFS), Department of Nutrition and Dietetics. The research study will be conducted after ethics approval is
obtained from the Ethics Committee of the UFS.

I want to determine the nutritional status of patients with tuberculosis (TB) and, TB/HIV co-infection. The
participants will give written consent before they take part in the research study. The information will be
gathered via structured individual interviews. The information that will be recorded on the questionnaire
include socio-economic status, dietary factors (food related side effects and food security, overall risk of
malnutrition and biochemistry), and alcohol and smoking habits. Anthropometric measurements that will be
measured include weight and height to determine body mass index (BMI), mid-upper arm circumference
(MUAC) and Triceps skinfold.

Participants will be interviewed during their free hours in my office. If necessary, lay counsellors, employed
by the hospital, will explain the questions to participants in their language of choice. Questionnaires are
available in the most prevalent languages in the area, namely; English and IsiZulu.
All information will be treated with the utmost confidentiality and participants will not be exposed to any risks. The
results will be made available to the participants upon request.

Please feel free to request any additional information from me.

Regards

JANKE WESSELS
Dietician, Standerton TB Specialised Hospital
Cell: 073 369 7750
Email: [email protected]

133
ADDENDUM E
Approval letter from the PHREC of Mpumalanga department of Health

134
ADDENDUM F
Approval letter from the ethics committee at the UFS

135
ADDENDUM G
Letter to ask Permission to Conduct the Study at the Hospital

Acting CEO: Matron T Masemola

I, Janke Wessels (Persal number: 83814078), would like to ask for permission to conduct my research study for my
Masters in Dietetics at Standerton TB Specialised Hospital during 2015.

Title of the research project: Nutritional status of patients with TB and, TB/HIV co-infection at Standerton TB
Specialised Hospital, Mpumalanga

I am registered as a M.Sc. Dietetic student (student number: 2008007022) at the University of the Free State (UFS),
Department of Nutrition and Dietetics. The research study will be conducted after ethics approval is obtained from the
Ethics Committee of the UFS.

I want to determine the nutritional status of patients with tuberculosis (TB) and, TB/HIV co-infection. The participants
will give written consent before they take part in the research study. The information will be gathered via structured
individual interviews. The information that will be recorded will include socio-economic status, dietary factors (food
related side effects and food security, overall risk of malnutrition and biochemistry), and alcohol and smoking habits.
Anthropometric measurements that will be measured will include weight and height to determine body mass index
(BMI), mid-upper arm circumference (MUAC) and Triceps skinfold).

The ward routine will not be disturbed in any way. Participants will be interviewed during their free hours in my office.
If necessary, lay counsellors, employed by the hospital, will translate the questions to participants in their language of
choice.

All information will be treated with the utmost confidentiality and participants will not be exposed to any risks. The
results will be made available to the participants upon request.

Please feel free to request any additional information from me.

Regards

JANKE WESSELS
Dietician, Standerton TB Specialised Hospital
Cell: 073 369 7750
Email: [email protected]

136
ADDENDUM H
Approval letter from the CEO at Standerton TB Specialised Hospital

137
ADDENDUM I
Informed Consent - English

Title of the project: Nutritional status of patients with TB and, TB/HIV co-infection at Standerton TB
Specialised Hospital, Mpumalanga.
You have been asked to participate in a research study.
You have been informed about the study by ……………………………………..
Your participation will benefit the Department of Health with information on the nutritional status of patients with
tuberculosis and, TB/HIV co-infection. The study will form part of a Master’s degree qualification in the Department
of Nutrition and Dietetics at the University of the Free State.

Should you choose to participate please note that:

 Your participation in this research is entirely voluntary; you are free to choose to participate or not to
participate.
 You will be asked to answer questions regarding your socio-demographic status, food related side effects, food
security and alcohol and smoking habits. Your weight and height and two other measurements (Triceps skin
fold and Mid-upper arm circumference) will also be measured.
 It will take about one hour to complete the questionnaire and to take your measurements.
 All information will be treated with the utmost confidentiality.
 Results will only be reported for the group and your individual information will not be reported. All information
will thus remain confidential.
 You will not be penalised or lose benefits if you refuse to participate or want to withdraw from the study at any
time. It will not cost anything to participate and you will not be paid to participate.
 You may contact the Secretariat of the Ethics Committee of the Faculty of Health Sciences, UFS at telephone
number (051) 401 7794/5 if you have questions about your rights as a research subject.
 You may also contact Prof C Walsh at telephone number (051) 401 2894 if there are any questions related to
the study.
 If you agree to participate, you will be given a signed copy of this document as well as the participant
information sheet, which is a written summary of the research.
 The results of the research study will be available upon your request.

The research study, including the above information has been verbally described to me, I understand what my
involvement in the study means and I voluntarily agree to participate in the research study.

____________________________ __________________________
Signature of participant Date

138
Informed Consent – IsiZulu

Isihloko saleliqembu: Ukudla okunempilo kusiguli esinesifo sofuba Kanye nesandulela ngculaza
esibhedlela esibhekelela isifo sofuba sase Standerton, eMpumalanga.
Uceliwe ukuthi ube yincenye yokucubungulwa kwemfundo.
Wazisiwe ngemfundo ngu ……………………………………..
Ukusebenzisana kwakho kuzonceda umyango wezempilo ngokwazi ngempilo yokudla kweziguli ezinesifo
sofuba/nesandulela ngculaza.

Uma ukhetha ukusebenzisana yazi ukuthi:

 Ukusebenzisana kwakho kulokucubungula kungukuzikhethela ukusebenzisana nokungasebenzisani.
 Uzocelwa ukuthi uphendule imibuza mayelana ne socio-demographic ukudla okusondelene nezifo, ukudla
okuqasheliwe, uphuzo oludakayo Kanye nokubhema njalo. Isisindo sakho, ubude Kanye nokunye okumedwa
okuzokwenziwa.
 Kuzothatha isikhathi esingangehora ukuceda ukuphendula lemibuza Kanye nokulinganisa.
 Konke okuqukethwe lapha kuzoba enkulu imfihlo.
 Imiphumela izothulelwa izigaba kodwa eyakho imiphumela ngeke yethulwe. Yonke imiphumela izogqinwa
iyimfihlo.
 Angeke usolwe uma ungafuni noma ufuna ukuphuma kulesi sifundo nomangabe kunini. Angeke ukhokhe noma
ukhokhelwe ukuze kusetshenziswane kulesifundo.
 Ungaqhumana nobhala imigomo yekomiti lomkhandlu wobuqwepheshe bezempilo, izinombolo zocingo
(051 401 7794/5) uma unemibuzo ngamalungelo akho ungacubungula.
 Ungaqhumana no Profesa C. Walsh ocingweni olungu (051) 401 2894 uma kunemibuzo eqhumana nezifundo.
 Uma unuma ukusebenzisana, uzonikwa iphepha elisayiniwe elinemininingwane Kanye nemiphumela yolwazi,
Kanye nesinciphiso esibhaliwe esiqubunguliwe.
 Imiphumela equbunguliwe izobonakaliswa kuso isicelo sakho.

Ukuqubungulwa kokufunda, Kanye nolwazi kuchazwe ngokuphelele kimi, ngiyazwisisa okungihlanganise

nokuziqeqesha kusho ukuthi ngiyavuma ukuzinikela ekusebenzeni kanye nokuqubungula imfundo.

____________________________ _________________________
Sayina lapha Ubuku

139
ADDENDUM J
Information Document

Study Title: Nutritional status of patients with TB and, TB/HIV co-infection at Standerton TB Specialised
Hospital, Mpumalanga

Thank you for being willing to help with this important research project.

I, Janke Wessels, a master student at the University of the Free State (UFS), am going to do
Research amongst the patients with tuberculosis (TB) and TB/HIV co-infected at Standerton
TB Specialised Hospital.

In this study I would like determine the nutritional status of patients with TB and TB/HIV co-infection.

All information will be gathered via structured individual interviews in language of choice with the
participants, after they have given informed consent.

All questions in the questionnaire will be filled out at Standerton TB Specialised Hospital, in a private room,
by a registered dietician. Respondents will be asked to answer questions regarding the following aspects:

 Socio-demographic status,
 Dietary factors (food related side effects and food security),
 Lifestyle factors (smoking habits and alcohol use).

I will also take measurements such as weight, height, mid-upper arm circumference and Triceps skin fold.

Risk of being involved in the research study: The participants will not be exposed to any risks.

Benefits of being involved in the study: Participants will benefit from the research study in terms of; their
contribution to the body of knowledge for further nutritional treatment of patients with TB, and TB/ HIV co-
infection. It will not cost anything to participate and the participants will also not being paid anything.

Participation is voluntary, and refusal to participate will involve no penalty or loss of benefits to which the
patient is otherwise entitled; the participant may also discontinue participation at any time.

140
Confidentiality: Efforts will be made to keep information confidential by not identifying the participants.
The results will be presented as a group and not as individuals.

Expected outcome of the research: The results of the study will assist in describing the nutritional status of
patients with TB and, TB/HIV co-infection and thus highlight areas that need to be focused on in nutrition
interventions.

You may contact the Secretariat of the Ethics Committee of the Faculty of Health Sciences, UFS at telephone number
(051) 401 7794/5 if you have questions about your rights as a research subject.

Kind regards,

JANKE WESSELS
Contact details 073 369 7750 / 017 714 6045

141
ADDENDUM K
Questionnaire - English

Nutritional status of patients with TB and, TB/HIV co-infection

at Standerton TB Specialised Hospital, Mpumalanga
Instructions FOR OFFICE USE
Mark the appropriate block with a X or write 1-3
your answer on the space provided.

1 Date questionnaires is completed (dd/mm/yy) ……/……/…… 4-9

d d m m y y
2 What is your gender?
Male(1) Female(2) 10

3 What is your birthdate? (dd/mm/yy) ……/……/…… 11-16

d d m m y y
4 What is your marital status?
1 Unmarried 17
2 Married/Traditional marriage
3 Divorced/Separated
4 Widow/Widower
5 Living together

5 What is your level of education? 18

1 No schooling completed
2 Less than Grade 9
3 At least Grade 9
4 Matric completed
5 Tertiary education

6 What is your current employment status? 19

1 Retired by choice
2 Unemployed
3 Self-employed
4 Full time wage earner (receive a salary)
5 Part time wage earner
6 Receives a grant
7 Other, specify (part-ime, piece job etc.)…………………

7 How many people live in your house (yourself included)?

1 Adults (>18 years) 20-21
2 Children (<18 years) 22-23

142
8 How many rooms are in the house (kitchen and bathroom excluded)?
24-25

9 What is the total household income per month? 26

(wages, rent, sales, state grantes etc.)
1 None
2 R100 - R500
3 R501 - R1000
4 R1001 - R3000
5 R3001 - R5000
6 Over R5000
7 Don't know

10 How many people contribute to the total monthly income?

27-28

11 Do you have a vegetable garden at home? 29

1 Yes
2 No

12 If yes, what vegetables do you have in your garden currently?

30-31
32-33
34-35
36-37
38-39
40-41
42-43

143
13 Do you experience any of the following symptoms currently?
13.1 Loss of appetite: 46
1 Yes
2 No

13.2 Sore mouth: 47

1 Yes
2 No

13.3 Dry mouth: 48

1 Yes
2 No

13.4 Nauseas: 49
1 Yes
2 No

13.5 Vomiting: 50
1 Yes
2 No

13.6 Constipation: 51
1 Yes
2 No

13.7 Diarrhoea: 52
1 Yes
2 No

13.8 Night sweats: 53

1 Yes
2 No

144
 The CCHIP tool
14 Does your household ever run out of money to buy food? 54
1 Yes
2 No

15 Do you ever rely on a limited number of foods to feed your children because
you are running out of money to buy food for a meal? 55
1 Yes
2 No

16 Do you ever cut the size of meals or skip meals because there is not enough
money for food? 56
1 Yes
2 No

17 Do you ever eat less than you should because there is not enough money for
food? 57
1 Yes
2 No

18 Do your children ever eat less than you feel they should because there is
not enough money for food? 58
1 Yes
2 No

19 Do your children ever say they are hungry because there is not enough
food in the house? 59
1 Yes
2 No

20 Do you ever cut the size of your children's meals or do they ever skip meals
because there is not enough money to buy food? 60
1 Yes
2 No

21 Do any of your children ever go to bed hungry because there is not enough
money to buy food? 61
1 Yes
2 No

145
22 Weight . (kg) . 62-66

23 Any unplanned weight loss in the past 3-6 months? 67

1 Yes
2 No

24 If yes, how much? 68

1 < 5%
2 5-10 %
3 >10%

25 Height . (cm) . 69-73

26 Body mass index . (kg/m²) . 74-77

27 Mid-upper arm circumference . (cm) . 78-1

. (cm)
. (cm)
Average . (cm)

28 Triceps skin fold (mm) 2-3

(mm)
(mm)
Average (mm)

29 HIV status 4
1 Positive
2 Negative

30 Total protein g/dL 5-6

31 Albumin g/dL 7-8
32 CD4 cell count mm³ 9-12
33 CRP . mg/L . 13-15
34 MCV . f/l . 16-20
35 Haemoglobin . g/dl . 21-24

36 Medication currently on:

25-26
27-28
29-30
31-32
33-34
35-36
37-38
146 39-40
37 Choose one of the following: 41
1 I am a non-smoker (never smoked before)
2 Former smoker (smoked before, but stopped 3 months ago)
3 Current smoker (smokes at least one cigarette, pipe, or cigar per
day for at least 6 months prior to entering the study)

If a former or current smoker:

38 How many times did/do you smoke per day? 42-43

39 For how many years did/do you smoke? 44-45

40 Choose one of the following: 46

1 I used to drink alcohol 3 or more times per week
2 I used to drink alcohol less than 3 times per week
3 I do not drink alcohol

147
Questionnaire – IsiZulu
Ukudla kwesimo sempilo yeziguli ezinesifo sofuba kanye nesandulela ngculaza
esibhedlela esibhekelela isifo sofuba sase Standerton
Imigomo FOR OFFICE USE
Gqwalisa ngalolu phawu X okanye ubhale 1-3
impendulo yakho esikhaleni onikwe sona

1 Usuku ogqwalise ngalo lemibuzo (usuku/inyanga/unyaka) 4-9

……/……/…… d d m m y y
2 Yini ubulili bakho?
Isilisa(1) Isifazane(2) 10

3 Usuku lwakho lokuzalwa (usuku/inyanga/unyaka) 11-16

……/……/…… d d m m y y
4 Izinhlelo zemshado?
1 Awushadile 17
2 Ushadile/Ushade ngokwesintu
3 Ukuhlukana/Isehlukaniso
4 Umfelokazi/Umfelwa
5 Umasihlalisane

5 Izinga lemfundo yakho? 18

1 Qwuyanga esikolweni nhlobo
2 Ngaphansi kwebanga lesishiyagalolunye
3 Ibanga lesishiyagalolunye
4 Umqedile umatikuletsheni
5 Imfundo yebamga eliphakeme

6 Uyasebenza okwamanje? 19
1 Umhlalaphansi ozikhethele wona
2 Awusebenzi
3 Uyazisebenza
4 Yasebenza uhola umholowevike noma wenyanga
5 Usebenza okwesikhashana
6 Thola imau yeqolo
7 Okunye, okubekiwe (okwesikhashana)……………………….

7 Bangakhi abantu ohlala nabo endlini (nawe ngokunjalo)?

1 Abadala (>18 years) 20-21
2 Izingane (<18 years) 22-23

148
8 Unamagumbi amangaki endlini yakho
(ngaphandle kwekhishi kanye nendlu encane)? 24-25

9 Lithini iholo lendlu yakho ngenyanga? 26

(iholo, rent, imali yeqolo)
1 Ayikho
2 R100 - R500
3 R501 - R1000
4 R1001 - R3000
5 R3001 - R5000
6 Angaphezulu kuka R5000
7 Awunasiqiniseko

10 Bangakhi abachasayo eholweni labo lwenyanga ohlala

nabo endlini? 27-28

11 Unayo ingadi yezithelo ekhaya? 29

1 Yebo
2 Cha

12 Uma kungu yebo, unaziphi izithelo engadini yakho?

30-31
32-33
34-35
36-37
38-39
40-41
42-43

149
13 Uyaziqaphela lezizimpawu ezilandelayo kulesikhathi?
13.1 Ukungafuni ukudla kahle: 46
1 Yebo
2 Cha

13.2 Unezilonda emlonyeni: 47

1 Yebo
2 Cha

13.3 Ukoma komlomo: 48

1 Yebo
2 Cha

13.4 Ukuzizwa ngathi ufuna ukuhlanza: 49

1 Yebo
2 Cha

13.5 Ukuhlanza: 50
1 Yebo
2 Cha

13.6 Ukungayi endlini encane: 51

1 Yebo
2 Cha

13.7 Isifo sohudo: 52

1 Yebo
2 Cha

13.8 Ukujuluka: 53
1 Yebo
2 Cha

150
 The CCHIP tool
14 Ekhaya niyaphelelwa imali yokuthenga ukudla? 54
1 Yebo
2 Cha

15 Uke wagqila ekubaleni ukudla okupha izingane ngenxa yakungabi

nemali eyanele ukuthenga ukudla? 55
1 Yebo
2 Cha

16 Uke wadlulisa ukudla wangadla ngenxa yokungabi nemali

yokuthenga ukudla? 56
1 Yebo
2 Cha

17 Ukewadla ngokungenele ngoba kunganamali eyenele

yokudla? 57
1 Yebo
2 Cha

18 Izingane zike zadla ukudla okungenele ngenxa yemali yokudla

okungenele? 58
1 Yebo
2 Cha

19 Izingane zike zathi zilambile ngenxa yokudla okungenele

endlini? 59
1 Yebo
2 Cha

20 Izingane zike zangathola ukudla ngenxa yokungabi nemali

yokuthenga ukudla? 60
1 Yebo
2 Cha

21 Izingane zike zayolala zilambile ngoba kungana mali eyenele

yokuthenga ukudla? 61
1 Yebo
2 Cha

151
22 Isisindo . (kg) . 62-66

23 Ukwehla kwesisindo sakho ungasihlelelanga ezinyangeni

ezintathu ukuya kweziyisithupha? 67
1 Yebo
2 Cha

24 Uma kungu yebo, kangakanani? 68

1 < 5kg
2 5-10 kg
3 >10kg
4 Awunasiqiniseko

25 Ubude . (cm) . 69-73

26 Body mass index . (kg/m²) . 74-77

27 Mid-upper arm circumference . (cm) . 78-1

. (cm)
. (cm)
Okungenani . (cm)

28 Triceps skin fold (mm) 2-3

(mm)
(mm)
Okungenani (mm)

29 Isandulela ngculaza 4
1 Unegciwane
2 Awunalo igciwane

30 Total protein g/dL 5-6

31 Albumin g/dL 7-8
32 CD4 cell count mm³ 9-12
33 CRP . mg/L . 13-15
34 MCV . f/l . 16-20
35 Haemoglobin . g/dl . 21-24

36 Amaphilisi owathathayo okwamanje:

25-26
27-28
29-30
31-32
33-34
35-36
152 37-38
39-40
37 Khetha okukodwa kulokhu okulandelayo: 41
1 Angibhemi (angikaze ngabhema)
2 Ngike ngabhema ngayeka ezinyangeni ezintathe ezindlulile
3 Ngisabhema namanje kanye ngelanga izinyanga eziyisithupha

Umangabe bowubhema okanye usabhema nomanje

38 Ubhema kangaki ngosuku? 42-43

39 Uneminyaka emingakhi ubhema ugwayi? 44-45

40 Khetha okukodwa kulokhu okulandelayo: 46

1 Ngangiphuza utshwala kathathu noma ngokudlulele ngeviki
2 Ngangiphuza utshwala ngaphansi kokuthathu ngeviki
3 Angibuphuzi utshwala

153