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Sarhad J. Agric. Vol.28, No.2, 2012
EFFECT OF DIETARY COUNSELLING ON THE NUTRITIONAL
STATUS OF TUBERCULOSIS PATIENTS
SALEEM KHAN*, PARVEZ IQBAL PARACHA *, FOUZIA HABIB**,
IMRAN KHAN*, ROHEENA ANJUM* and SAREER BADSHAH***
* Department of Human Nutrition, Agricultural University, Peshawar Pakistan.
** Department of Forensic Medicine, Khyber Medical College, Peshawar Pakistan.
*** Islamia College University, Peshawar Pakistan.
ABSTRACT
This study was conducted from August to November, 2008 to investigate the impact of dietary
counselling on the nutritional status of tuberculosis patients. A total of 20 patients of both sexes were selected
for the study at the Emergency Satellites Hospital, Nahaqi, Peshawar, Pakistan. Energy and nutrient intake of
patients before and after dietary counselling were determined by the 24-hour dietary recall method. The weight
and height of patients were measured for the determination of BMI. Serum protein concentrations of the patients
before and after two months of counselling were determined by the biuret method. Before counselling the
patients were consuming energy (75%), protein (55%), fat (78%) and carbohydrate (75%) of the recommended
dietary intake and after counselling, the intakes of these nutrients increased to 88%, 78%, 90% and 86%,
respectively. Before counselling 30% of patients were normally nourished but 40% were mildly, 25%
moderately, and 5% severely malnourished, as compared to 45%, 45%, 10% and 0%, respectively after
counselling. At the start of the study, 55% of patients had normal and 45% of patients had below normal serum
protein levels compared to 85% normal and 15% below normal serum protein concentrations at the end of thestudy. The results of the study indicated that dietary counselling is a simple and effective mean of stabilizing
nutritional status in tuberculosis patients.
Key Words: Tuberculosis, Dietary Counselling, Nutritional Status of TB Patients.
Citation: Khan, S., P.I. Paracha, F. Habib, I. Khan, R. Anjum and S. Badshah. 2012. Effect of dietary
counselling on the nutritional status of tuberculosis patients. Sarhad J. Agric. 28(2):303-307
INTRODUCTION
Tuberculosis is an infectious disease caused by mycobacterium tuberculosis. It can infect various vital
organs of human body i.e. lung (pulmonary tuberculosis), central nervous, the lymphatic, circulatory,
genitourinary systems, bones, joints and skin (Kumar et al.,2007). The typical symptoms of tuberculosis are
chronic cough with blood tinged sputum, fever, night sweating, weight loss and chest pain (Hopewell, 1994)
Mortality and morbidity data on tuberculosis indicated 14.6 million chronically active cases, 8.9 million new
cases and 1.6 million deaths occurred mostly in developing countries. Among the developing countries twenty-two are considered as high burden countries. Pakistan ranks sixth among the twenty-two high burden
tuberculosis countries worldwide (WHO, 2006).
The energy and protein needs of tuberculosis patients are increased during the disease and an energy
intake of 3540 kcal kg-1
of ideal body weight is recommended. The protein intake of the diet is important to
prevent the wasting of body stores (for example muscle tissues) and an intake of 1.21.5 g protein kg-1
of body
weight or approximately 75100 g protein/day is considered sufficient.
The nutritional status of tuberculosis patients (macro- and micro-nutrient levels) decreases during the
disease which severely affects their muscle and immune response (Onwubalili,1988; Dallman 1987). They need
urgent dietary support in the hospital along with the recommended treatment. Dietary counselling is one of the
effective tools to control malnutrition/wasting associated with tuberculosis. In Pakistan there are no proper
dietary protocols for tuberculosis patients and they often have poor nutritional status. Therefore this study was
designed to assess whether dietary counselling would increase nutrient intake and improve nutritional status in
patients with tuberculosis.
MATERIALS AND METHODS
Study Location
The study was conducted in the Emergency Satellite Hospital, Nahaqi, Peshawar, Pakistan which
provides treatment to tuberculosis and diarrhoeal patients.
Respondents
Twenty patients (both sexes) clinically diagnosed with tuberculosis, age range 1545 years were
randomly selected. Patients who were not interested or not cooperative with the researcher, of low socio
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Saleem Khan et al. Effect of dietary counseling on the nutritional status of tuberculosis patients 304
economic status, not registered with the TB center, suffering from gastrointestinal diseases or could not afford
the recommended diet were excluded from the study. A preformed questionnaire was given to each patient and a
detailed face-to-face interview was held.
Data Collection and Dietary Counselling
The data collection included height and weight measurements of the patients which were measured
according to standard methods (WHO 1995) with the help of a non-stretchable measuring tape. The weight of
the patients was taken using bathroom scales. The bathroom scales were checked for accuracy to the nearest0.1kg before using. Dietary intake of the patients was determined by a 24-hour dietary recall method (Weiner
and Lourie, 1969.) Biochemical assessment of the patients included serum protein which was determined by the
biuret method (Johnson et al. 1999), the detail of which is given below. Dietary counselling was done by
nutritionist working as an internee at the health care centre and involved the prescription of energy and nutrient
rich diets using regular foods. The prescription identified the type, amount and frequency of feeding, specified
the caloric and protein level to attain and included any restrictions and limited or increased individual dietary
components.
Determination of BMI
Anthropometric data measured, included weight and height measurements which were used to calculate
the body mass index (BMI) of the patients before and after counselling by the following formula
BMI = weight (kg)/ height (m2)
Determination of Energy and Nutrients IntakeThe recommended energy and nutrient intake of patients were calculated using ideal body weight
(IBW) which was determined by measuring the body frame size of the patients with the help of the following
formula:
Body frame size = Height (cm)/wrist circumference (cm).
The values calculated using IBW were used for comparison purposes.
The dietary intake of patients before and after counselling was calculated by the 24-hour dietary recall
method. After counselling dietary intakes were calculated for 3 consecutive days per week for two months. The
time period of 24 hours began at 8:00 am and ended the following day at 8:00 am. Energy and nutrient intake of
the patients before and after counselling were calculated from the dietary intake using Nutrition Survey for
Windows (Erhardt, 2007). The energy and nutrient intake per day after counselling were calculated by taking
the means of energy and nutrient taken over a two month period.
Serum Protein Determination
Before and after two months of counselling, a blood sample was taken from the cephalic vein of each
respondent by the laboratory technician using disposable 5mL plastic syringes Beckton, Dickinson, Karachi).
Blood samples were transferred to sterilized centrifuge tubes and allowed to clot at room temperature for 20
minutes. The blood samples were centrifuged for 10 minutes in a centrifuge (Hermle Z 200A, Hermle-
Labortecnik, Goshe Merster. 56, Type H6 CHSTIUL, Germany) at 4000 rpm.The serum was separated off and
stored at -20C for analysis.The serum total protein level was determined by the biuret method (Johnson et al.
1999) using Spectrophotometer (GENESYS 10, Rochester NY USA) and Dia sys kit( Diagnostic system GmbH,
Germany).
Procedure
The wavelength of the spectrophotometer was adjusted to 540 nmand 1cm light path cuvette was used.
Twenty (20) l of sample and 1000 l of reagent were pipetted into test tubes and mixed. After 5 minutes of
incubation at 37
o
C in a water bath, the absorbance against the reagent blank was recorded.Calculation
A sampleSerum total protein (g /dl) =
A standardx100
A = absorbance
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Sarhad J. Agric. Vol.28, No.2, 2012 305
Statistical Analysis
Microsoft Excel version 2003 was used to calculate the mean nutrient intake and standard deviation
(SD) for each nutrient before and after counselling. BMI and serum protein level before and after counselling
were compared through graphs using Excel (Lena et al., 2002).
RESULTS AND DISCUSSION
Energy and Nutrients Intake of Tuberculosis Patients
Table I shows the energy and nutrient intake of the tuberculosis patients. The recommended intakes
calculated using IBW were used for comparative purposes in this study.
Table I Recommended, before and after, counselling the daily nutrients intake of tuberculosis patients
**Rec. Before AfterNutrients
Mean + SD Mean + SD% of the Rec.
intakeMean + SD
% of the Rec.
intake
Net
Increase %
Energy (kcal) 1827 + 362 1379 + 287 75.49 1608 + 272 88.04 13
Protein (g) 81+18 45 + 11 55.8 63 + 16 78.03 22
Fat (g) 60 + 14 47 + 15 78.29 54 + 14 90.03 12
CHO (g) 242 + 49 182 + 34 75.24 210 + 35 86.76 12
* Values in the columns 2, 3 and 5 are the means of 20 patients.
** Recommended
The mean recommended intake for energy calculated on the basis of IBW was 1827 kcal/day for all 20
patients. Before counselling the mean energy intake was 1379 k. cal/ day which was 75.5% of the recommendedintake. After dietary counselling, the mean energy intake calculated was 1608 kcal/person/day for two months,
which was 88% of the recommended intake, an increase of approximately 13%. For all 20 patients, the mean
recommended intake of protein was 81g/person/day (Table I) but the actual intake was 45g/person/day, which
increased to 63 g/day after counselling. The mean recommended intake of fat was 60 g/ day and at the start of
the study each person was consuming only 47 g/day, which increased to 54g/day for the two month period.
Based on IBW, the mean recommended intake of carbohydrate was calculated to be 242 g/person/day. However,
before counselling the patients were only consuming 182 g/day, which increased to 210 g/person/day
subsequent to counselling, a 12% increase.
Effect of Dietary Counselling on BMI of Tuberculosis Patients
Figure 1 shows the BMI of tuberculosis patients two months after dietary counselling compared with
their BMI at the start of the project. There was an increase in the percent of normally (30 to 45%) and mildly
malnourished (40 to 45%) nourished patients after two months of counselling. In contrast, there was a reduction
in the percent of moderately malnourished patients from 25% to 10% and there were no severely malnourishedpatients after counselling.
Fig. 1. Body mass indices of tuberculosis patients before and after counselling
Effect of Dietary Counselling on the Serum Protein level of Tuberculosis Patients
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Saleem Khan et al. Effect of dietary counseling on the nutritional status of tuberculosis patients 306
Figure 2 shows a significant increase in the serum protein concentrations of tuberculosis patients after
two months of counselling. There were 55% patients with normal serum protein levels before counselling
compared with 85% patients after two months of counselling.
Fig. 2. Serum protein level of tuberculosis patients before and after dietary counselling
Low BMI is a known risk factor for mortality in tuberculosis patients (Van et al.,2003). The results of
the study show that 70% of the tuberculosis patients were malnourished with a low BMI before dietary
counselling, a large proportion having mild to moderate malnutrition. The observed malnutrition among
tuberculosis patients at the time of registration has been reported in other studies in both developing and
developed countries (Zachariah et al.,2002; Onwubalili, 1988; Harries et al.,1988; Metcalfe, 2004). The low
BMI among patients with tuberculosis may be due to poor energy and nutrient intake, anorexia, impaired
absorption of nutrients or increased catabolism (Hopewell, 1994). The present observations are in concurrence
with studies done in India by Ramakrishnan et al.(2007) and in Malawi by Van et al.(2004). In this study, after
dietary counselling a considerable increase was observed in energy and nutrient intake of the tuberculosis
patients, which in turn produced a significant increase in BMI. The increase in BMI, confirming the findings
that patients with tuberculosis can mount a protein anabolic response to increased energy and nutrient intake(Paton et al.,2003; Macallan et al.,1998).
One of the finding of the present study was that, tuberculosis patients were taking less than therecommended amount of protein before counselling. As a result more than half of the patients had serum protein
levels below normal. In a previous study of Karyadi et al.(2000) and Taneja, (1990), the possible causes for the
low serum protein in tuberculosis patients were considered to be nutritional intake, enteropathy and raised acute
phase proteins. The hepatic synthesis of acute phase proteins is induced by cytokines such as interleukin-6 and
tumour necrosis factor-, which inhibit the production of serum albumin and cause dramatic shifts in the plasma
concentration of protein (Xing et al.,1998; Gabay and Kushner, 1999).
An increase in nutrient intake was observed after counselling, which in turn significantly increased
serum protein level in tuberculosis patients. Paton et al. (2004) in a previous study found that dietary
counselling significantly increased nutrient intake in tuberculosis patients, which resulted in increase serum
protein level.
CONCLUSION AND RECOMMENDATIONS
It is concluded that dietary counselling can have a substantial role in providing the recommended
intake of nutrients and improving the nutritional status of tuberculosis patients. The addition of oral nutritionalsupplements to the diet did not appear to be as effective as dietary counselling.
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