Nutritional intakes and associated factors among tuberculosis patients: a community-based cross-sectional study in China

doi:10.21203/rs.2.9261/v2

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Nutritional intakes and associated factors among tuberculosis patients: a community-based cross-sectional study in China

https://doi.org/10.21203/rs.2.9261/v2

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published 29 Oct, 2019

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Background: This study evaluated nutrient intakes of tuberculosis (TB) patients and examine their associated factors. Methods: In this cross-sectional study, 300 adult TB patients were enrolled in two impoverished counties in China. Nutrient intakes were evaluated through two consecutive 24-h dietary recalls and compared with the Chinese Dietary Reference Intakes (DRIs) 2013. Corresponding information for local general population was derived from 2015 China Health and Nutrition Survey. Results: The mean daily energy (1655.0 kcal in males, 1360.3 kcal in females) and protein (44.6 g in males, 35.9 g in females) intakes of TB patients were below Recommend Nutrient Intake (RNI) and Adequate Intake (AI) in both genders, and intakes of many micronutrients, except for vitamin E and sodium, were insufficient. Compared with those for local general population, TB patients’ intakes of all the macronutrients and micronutrients were lower (p<0.05) except total fat. In addition, Proportions of people with macronutrient or micronutrient intakes lower than RNI/AI were higher in TB patients than in general population except for Vitamin E intake. Being unemployed was a risk factor for low energy intake (p<0.05) and out-home-eating was a protective factor for low protein intake (p<0.01). Conclusions: In impoverished areas in China, intakes of macronutrients and most micronutrients in TB patients were less than those in general population. They were also inadequate compared with DRIs, especially in unemployed patients and patients eating at home. These findings suggested that the public health actions are needed to promote education on TB patients about significance of nutritional support, and, further interventions in TB patients’ nutritional intakes are also required.

Internal Medicine Specialties

Tuberculosis patients

Nutrient intake

Associated factors

Tuberculosis (TB) is an airborne disease caused by Mycobacterium tuberculosis and is the first leading cause of death from single infectious agents. According to World Health Organization (WHO), there were estimated 10.0 million people developed TB disease and 1.6 million people died from TB in 2017. China is in 2^nd place among 30 TB high burden countries, with a reported incidence of 63 per 100,000 persons per year in 2017[ 1].

The interactions between tuberculosis and malnutrition are well appreciated. TB will result in malnutrition and malnutrition can predispose to TB. TB increases the basal metabolic rate (BMR)[ 2], thus requiring more energy to maintain body function, leading to weight loss. However, due to reduction in appetite and gastrointestinal disorder[ 3], food intake will decrease in TB patients, resulting in undernutrition. Malnutrition will in turn lead to impaired immune function[ 4, 5], as nutritional deficiency alters the interaction between macrophages and T-lymphocytes[ 6], thus increasing the risk of getting infected firstly. Moreover, although most people who get infected will not manifest symptoms as their immune system manages to control the bacteria, malnourished person are more likely to develop active TB because the infection is no longer constrained by their immune systems[ 7].

Three studies in China[ 8-10]reported previously that protein and caloric intakes in TB patients were inadequate as well as some micronutrients. Insufficient protein and caloric intakes will hinder the functions of some generalized host defense mechanisms that are essential for combating TB[ 11]. Besides, both vitamins and minerals play important roles in immunity[ 12], deficiency of one or more of these nutrients will impair person’s resistance to any infection[ 13].

Assessment of nutrient intakes is critical in nutritional management of patients with TB. Until now, only one research group conducted studies on nutrient intakes in TB patients in China, however, they did not examine associated factors about nutrient intakes. Moreover, to our knowledge, until now there are no studies conducted to evaluate the nutritional status of TB patients with reference to the latest Chinese Dietary Reference Intakes (DRIs) 2013[ 14]. We carried out this community-based study to evaluate nutrient intake levels of TB patients by comparing them with both current dietary recommendations in China and local general population, and to examine associated factors of nutrient intakes among TB patients.

Study Context

This cross-sectional study was undertaken as part of the project “Investigation of nutrition and diet of patients with pulmonary tuberculosis in poor areas in China” supported by the WHO Regional Office in the Western Pacific. It was conducted from November 2015 to April 2017 in two counties, that is, Lingyun county located in Guangxi province and Lin county located in Shanxi Province. These two counties were national impoverished counties and behaved well in their routine work. TB case notification rates in 2016 were 63.16 per 100,000 in Lin county and 106.97 per 100,000 in Lingyun county, respectively.

Participants

Adult patients (age≥18 years) with active TB registered in Tuberculosis management information system from Nov 1^st, 2015 through May11^th, 2017 and signed consent form were recruited. Patients with extrapulmonary tuberculosis, and those aged 18 years and below or with severe complications were not eligible for the study. Pregnant or breast-feeding women, and those who refused to sign the consent form were also excluded. China Health and Nutrition Survey (CHNS) was conducted in 2015 among the general population (The sample size was 620 in Lin county and 662 in Lingyun county respectively) in these two countries with the same component for nutrition assessment. The findings of the CHNS was taken as a comparison group for our study. Detailed information about CHNS 2015 was available on website https://www.cpc.unc.edu/projects/china/about/design/sample.

Sample Size

As BMI is commonly used in nutrition assessment, we applied the prevalence of BMI<18.5 which is also defined as malnutrition[ 15] ^],[in the calculation of sample size. We assumed that the prevalence of malnutrition in the general population in poor areas and TB patients would be 6.7% [ 16]and 25.0%[ 2], respectively, and the required sample size was calculated to detect difference in the two proportions. The probability of a type I error was set at 0.05, the power of the study was estimated at 90% and the design effect was set at 1, determining a sample size of TB patients was 77 per study site. Considering participants’ refusal, we expanded the sample size to 150 per study site, and the final sample size of TB patients was 300 totally.

As for general population, after exclusion of subjects with missing data, the sample size was 231 in Lin county and 265 in Lingyun county, thus 496 in total. A multistage, random cluster process was used to draw the sample of general population in CHNS 2015.

Socio-demographic and behavioral factors

Data for associated factors were taken from a questionnaire on personal information, including socio-demographic data (age, gender, education level, marital status, occupation and household income level) and behavioral data (alcohol consumption, smoking status and eating out-of-home). Age was categorized into 3 groups, 18-49 years, 50-64 years, 65 years and above, based on Chinese Dietary Reference Intakes (DRIs) 2013[ 14]. Education level was categorized into 2 groups[ 17], that is, primary school and below, junior middle school and above. Household income level was evaluated by annual household income and was categorized into 3 groups, <20,000 yuan, 20,000-40,000 yuan, and ≥40,000 yuan[ 17]. Alcohol consumption was defined as drinking wine, beer and Chinese spirit now or ever. A smoker was defined as smoking now or smoking previously but have stopped smoking in the evaluation period . Eating out-of-home was defined as eating at least one meal away from one’s own home or their residents’ home during the survey[ 18]. Severity of TB was grouped into two categories based on the result of chest x-ray. If the lesion is confined to two lung fields then it is defined as mild. If the lesion covers more than two lung fields or there’re cavities, it is defined as severe[ 19].

Assessment of Nutrient intake

Trained staff performed face-to-face interviews on each participant to obtain dietary intake data through a 2-day 24-hour dietary recall (24hdr) questionnaire, which was adapted from the method of 3-day 24hdr[ 20]. Participants were instructed to record all food intake at home and away from home in the previous 2 days (one weekday and one weekend day). Consumptions of condiments were also recorded through a questionnaire. All investigations were completed after the patient registering in Tuberculosis management information system and before anti-tuberculosis treatment. Data for dietary intake of general population was obtained from a 3-day 24hdr questionnaire (two weekdays and one weekend day).

Total energy, four kinds of macronutrients and sixteen kinds of micronutrients were evaluated. Nutrient intakes of each patient were calculated based on Chinese Food Composition Tables (CFCT) 2004[ 21].

We also evaluated TB patients’ nutritional intake by applying Chinese dietary reference intakes (DRIs) 2013, with mean daily nutrient intakes compared with Recommended Nutrient Intakes (RNIs) and Adequate Intakes (AIs).

Statistical analysis

A Chi-square test and a Wilcoxon rank sum test were used to compare the characteristics of TB patients and the general population. Data of daily nutrient intakes were presented as means ± standard deviation (SD). A Wilcoxon rank sum test was conducted to compare differences in daily energy and nutrient intakes of TB patients and general population. As dietary recommendations are different for men and women, we compared TB patients’ and general populations’ daily nutrient intakes with DRIs by gender. Comparisons in proportion of participants whose nutrient intakes were below RNI/AI were analyzed with a Chi-square test and Fisher exact test. Since protein-calorie malnutrition (PCM) is the most common form of undernutrition in TB patients[ 11], we only examine factors related to insufficient energy and protein intakes. Univariate logistic regression analysis was used to identify potential risk factors associated with inadequate energy and protein intakes in 300 TB patients. Age, gender, county and severity of TB were considered to be possible confounders in the multiple logistic regression model with stepwise selection. Patients were classified into two groups: below RNI/AI and above RNI/AI. A P-value of less than 0.05 was considered statistically significant. All analyses were performed using SAS 9.4 (SAS Institute Inc, Cary, NC, USA).

Quality Control

The study was carried out on the basis of CHNS 2015, from which the investigating method and tool were used in our study. All on-site investigations were carried out by the county-level CDC and interviewers were trained with a standard protocol. Data was checked for completeness and accuracy on the day of investigation and sampled by provincial CDC for verification later. All data was double-entered into a database specially designed for this project.

Characteristics of the subjects

Almost all notified TB patients registered from Nov 1^st, 2015 to May 11^th, 2017 in Lin county were included in our study, while TB patients enrolled in our study accounted for less than 40% of all notified TB patients in Lingyun county during that period. For general population, according to local annals, there were 596.4 thousand resident people in Lin county and 191.7 thousand resident people in Lingyun county in 2015. Thus, the proportion of general population included in our study were 0.038% in Lin county and 0.138% in Lingyun county respectively.

There were significant differences (p<0.05) in both socio-demographic and behavioral characteristics between TB patients and the local general population, except for household income level, as shown in Table 1. Most TB patients in our study aged between 18 and 49, and were males, but the majority of general population was in the 50-64 age group and difference of percentages for different genders was not great. Most TB patients were married, employed and didn’t attend junior middle school, with annual household income less than 20, 000 RMB yuan. More general population tended to have alcohol consumption than TB patients, but the proportion of non-smokers was significantly higher in the general population than in the TB patients. Both TB patients and general population were more likely to eat at home during the survey (Table 1).

Daily energy and nutrient intake

Recommendations for daily energy intake was 2250 kcal in males and 1800 kcal in females, and for daily protein intake was 65 g in males and 55 g in females. Thus, the average daily energy (1655.0 kcal in males, 1360.3 kcal in females) and protein (44.6 g in males and 35.9 g in females) intakes of TB patients were inadequate in both genders (Table 2). As for micronutrients, in male TB patients, the mean daily intake of retinol, niacin, vitamin E, sodium, iron, Manganese, copper and Phosphorus were all higher than RNI/AI, while calcium (216.3 mg) intake was severely less than RNI/AI (800 mg). In female TB patients, the intakes of vitamin E, copper and sodium were higher than RNI/AI. However, the intakes of riboflavin, potassium and calcium were severely inadequate.

Although the mean daily intakes of energy (2069.5 kcal in males, 1741.6 kcal in females) and protein (63.4 g in males, 54.3 g in females) in the general population were higher than those in the TB patients, they were still less than RNI/AI. It was also found that except for total fat, both macronutrient and micronutrient intakes in general population were higher than those in TB patients with significant difference (p<0.05). Proportions of people with macronutrient or micronutrient intakes below RNI/AI were higher in TB patients than in general population except Vitamin E intake.

Factors associated with low energy and low protein intakes in 300 TB patients

As shown in table 4, univariate analysis suggested that being unemployed was associated with inadequate energy intake and annual household income with 40,000 RMB yuan and above was a protective factor. In multivariate analysis (see Table 5), after adjusting for other factors, unemployed participants were more likely to have low energy intake (OR: 3.542; 95%CI:1.471, 8.530)(p<0.01). Meanwhile, lower protein intake was associated with eating at home. The possibility of low protein intake for people eating out-of-home was much lower than those eating at home (OR: 0.328; 95CI%:0.133, 0.809)(p<0.05).

Our study demonstrated that intakes of both macronutrients and selected micronutrients were inadequate in most TB patients. Protein-calorie malnutrition (PCM), characterized by inadequate intakes of both protein and total calories[ 11], was common in TB patients, with both the male and female TB patients taking energy and protein below RNI/AI. This finding was consistent with some published studies[ 8-10] in China. Also, mean daily intakes of many micronutrients were below RNI/AI, especially calcium, in our study, the intake of which was much lower than RNI/AI in all the women and 99.5% of men. A survey conducted in China revealed that TB patients did not take enough fish, shrimp and dairy products[ 22], which are all calcium-rich food. This may explain the insufficient intake of calcium. However, sodium consumption was higher than RNI/AI in TB patients. Researches conducted in other populations[ 23-25] in China also showed that high sodium consumption remained a public health problem. Nevertheless, the quality of diet seemed to improve in some ways, as the daily intake of vitamin E was much higher than RNI/AI in both genders compared with previous studies[ 8-10] ] ^, [9] ^, [.

Compared with the local general population, intake of total fat was a little higher among TB patients. This result was different from another study conducted in TB patients in Shandong Province[ 10], in which general populations’ fat intake was more than TB patients’. The difference may be caused by different dietary patterns in different provinces, thus, further research is needed to confirm this.

Furthermore, we discerned that eating out-of-home was related to higher intake of protein. Relevant studies conducted among other populations in China[ 26-28] also demonstrated that there was an increase in protein intake while eating out-of-home. The reason for this phenomenon may be that people tend to choose food with better tastes and higher nutritional values when they eat away from home^[ ²⁷^]. We also discovered that the inadequate energy intake was significantly higher among unemployed TB patients, being consistent with studies[ 29, 30] ]^, [conducted in other countries. This is most likely because that persons with low socio-demographic status will not be able to afford nutritious food.

Malnutrition will also have an impact on the treatment of TB. Malnutrition will reduce the level of protein in the patient's body, and thus delayed the recovery of lesions. This is probably because sufficient protein, on the one hand, helps the recovery of lesions during the treatment. On the other hand, increases the number of drug carriers in the treatment, therefore, concentration of anti-tuberculosis drugs in the blood will rise, promoting sputum conversion[ 31]. A study in China showed that 56% of patients’ sputum culture were negative after 20 days of treatment in the nutritional support group, which was significantly higher than 28% in the general treatment group[ 32].

Limitations and Strengths

There are some limitations in our study. On the one hand, we used the 24hdr method to evaluate the nutrient intakes, and this method has its own shortcomings. Reliance on the memory of participants and recall bias could result in an underestimation of nutrient intakes[ 33]. And, when measuring the consumption of condiments, we didn’t take the household weighing method commonly used in nutrition survey. On the other hand, we hope to enroll all eligible TB patients in these two counties notified from Nov 1^st, 2015 to May 11^th, 2017. However, almost all notified TB patients in Lin county were included in our study, while TB patients enrolled in our study accounted for less than 40% of all notified TB patients in Lingyun county during that period. Moreover, after consulting local annals for these two counties in 2015, we found that the proportion of general population included in our study were only 0.038% in Lin county and 0.138% in Lingyun county respectively. All of these may result in that our findings could not be generalized to all the local people.

Although limitations existed, our study has outstanding strengths. Firstly, different from previous hospital-based studies, our study is a community-based study initiated in comparing TB patients’ nutrient intakes with the latest DRIs and examining the associated factors in TB patients’ nutrient intake. Moreover, we collected the same information for local general population and make comparisons between these two groups, avoiding the influence of different dietary patterns in various areas.

Our study showed that in poor areas in China, the intakes of macronutrients and most micronutrients in TB patients were less than those in local general population, and were inadequate compared with DRIs, especially for those unemployed and eating at home. These findings suggested that the public health actions are needed to promote education on TB patients about significance of nutritional support, and, further interventions in TB patients’ nutritional intakes are also required.

TB: tuberculosis; DRIs: Dietary Recommended Intakes; RNI: Recommend Nutrient Intake; AI: Adequate Intake; WHO: World Health Organization; BMR: basal metabolic rate; CHNS: China Health and Nutrition Survey; 24hdr: 24-hour dietary recall; CFCT: Chinese Food Composition Tables; SD: standard deviation; PCM: protein-calorie malnutrition; CDC: center for disease control and prevention.

Ethics approval and consent to participate

The present study protocol was approved by the China CDC Institutional Ethics Review Board (NO. 201532) and The Ethic Review Committee of the WHO Regional Office in the Western Pacific (2015.22.CHN.3.STB). All those agreed to participate in the survey had to provide informed consent.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The study was funded by the WHO Regional Office in the Western Pacific.

Authors’ contributions

Zhewen Ren: analyzed the data, completed statistical analysis and wrote the initial draft of the manuscript. Fei Zhao: conceived the research idea, conducted the data collection. Hui Chen and Dongmei Hu: made contributions to data analysis. Wentao Yu and Xiaoli Xu: supervises the data collection and analysis. Dingwen Lin, Fuyi Luo, Yueling Fan and Haijun Wang: participated in the implementation of the study. Jun Chen and Liyun Zhao: designed the study and contributed to the protocol conception. All authors’ read and approved the final manuscript.

Acknowledgement

This study was supported by the WHO Regional Officer for the Western Pacific. We appreciate technical input provided by Dr Nobuyuki Nishikiori throughout the design and implementation of the study. We would like to acknowledge the staff in Shanxi and Guangxi provincial CDCs, and local CDCs in undertaking this survey.

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Due to technical limitations, all Tables are only available as a download in the supplemental files section.

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Editorial decision: Minor revision
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Review #1 received at journal
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You are reading this older preprint version

Read the latest preprint version →

Nutritional intakes and associated factors among tuberculosis patients: a community-based cross-sectional study in China

Status:

Journal Publication

Version 2

Abstract

Background

Methods

Study Context

Participants

Sample Size

Socio-demographic and behavioral factors

Assessment of Nutrient intake

Statistical analysis

Quality Control

Results

Characteristics of the subjects

Daily energy and nutrient intake

Factors associated with low energy and low protein intakes in 300 TB patients

Discussion

Limitations and Strengths

Conclusions

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors’ contributions

Acknowledgement

Reference

Tables

Supplementary Files

Status:

Journal Publication

Version 2