
==== Front
J Family Med Prim Care
J Family Med Prim Care
JFMPC
J Family Med Prim Care
Journal of Family Medicine and Primary Care
2249-4863
2278-7135
Wolters Kluwer - Medknow India

JFMPC-13-2946
10.4103/jfmpc.jfmpc_1805_23
Original Article
Nutritional status, food security and other correlates among adult tuberculosis patients in a block of Murshidabad district, West Bengal
Roy Avik K.
Adhikary Mrinmoy
Bandyopadhyay Prithwish
Ghosh Ritu
Das Dilip K.
Department of Community Medicine, Murshidabad Medical College, Berhampore, West Bengal, India
Address for correspondence: Dr. Ritu Ghosh, 170, Bishnupur Road, Berhampore, Murshidabad - 742 102, West Bengal, India. E-mail: ritughoshchowdhury@gmail.com
8 2024
26 7 2024
13 8 29462951
09 11 2023
13 12 2023
16 1 2024
Copyright: © 2024 Journal of Family Medicine and Primary Care
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
ABSTRACT

Background:

Tuberculosis (TB) and malnutrition are epidemiologically interrelated two major public health problems in India. Food security also influences nutritional status. This aspect needs evaluation in diverse geographical areas. This study aimed to assess the level of food security, nutritional status and correlates among adult TB patients in a block of Murshidabad, West Bengal.

Methods:

This cross-sectional study was undertaken in the Nabagram block of Murshidabad district during April–July 2023. All adult (≥18 years) patients registered under the Tuberculosis Unit of the block during a reference period of 6 months (October 2022–March 2023) were considered study subjects. Eighty such eligible participants recruited randomly were interviewed with a pre-designed schedule for socio-demographic and programmatic characteristics. Household food security was measured using a validated U.S. Household Food Security Survey Module. Anthropometric measurements were taken, and nutritional status was determined based on body mass index. Statistical Package for the Social Sciences (SPSS) version 26 was used for analysis.

Results:

Among 80 TB patients, 51% were underweight and 20% were severely underweight. The majority (90%) of them had high or marginal food security, and 10% had low or very low food security. On multivariable logistic regression, Hindu religion (adjusted odds ratio (AOR): 6.74, 95% confidence interval (CI): 2.12–29.39), presence of any chronic morbidity (AOR: 11.61, 95%CI: 2.71–49.78) and receipt of dietary counselling by a health worker (AOR: 7.25, 95%CI: 1.22–43.13) appeared as predictors of underweight.

Conclusions:

Underweight among TB patients is quite prevalent in the area, and few programmatic interventions are influencing factors. This underscores the importance of nutritional counselling services and the universal provision of Poshan benefits.

Household food security
nutritional status
tuberculosis
West Bengal
==== Body
pmcIntroduction

Tuberculosis (TB) and under-nutrition are both major public health problems in India. India is a major contributor to the global TB burden in terms of new cases (27% of the global total) and mortality among human immunodeficiency virus (HIV)-negative individuals (35% of the global total), as reported in 2019.[1] In 2021, a total of 1933381 incident TB cases (new and relapse) were notified in India, with an alarmingly high incidence rate of 210 per 100,000 population.[2] The state of West Bengal in the country bears a high burden of TB with a reported total of 101,034 cases through the Nikshay Portal in 2022.[3]

TB and under-nutrition are closely interrelated. Under-nutrition is a predisposing factor for the conversion of TB infection into a full-fledged clinical disease. The outcome of TB also greatly depends on the nutritional status of the patient.[4] The World Health Organization (WHO) has estimated that 0.6 million TB cases in India are attributable to under-nutrition.[1]

WHO guidelines recommend that all active TB cases should be assessed for their nutritional status and receive necessary dietary counselling at diagnosis and throughout treatment.[5] In historical context, before the initiation of modern antitubercular chemotherapy, diet and environmental factors were heavily emphasised in the treatment of TB. However, with the advent of modern therapy, this aspect of TB management has been significantly neglected. Nutritional support for a TB patient improves weight gain, therapy adherence, muscle strength and quality of life and reduces mortality. It also leads to a shorter sputum conversion time and a higher sustained microbiological cure rate, thus decreasing the likelihood of TB relapse.[6]

Food security at the household level is always a determinant of nutritional status. Food security is defined as ‘all people at all times have both physical and economic access to sufficient food to meet their dietary needs for a productive and healthy life’ (USAID, 1992).[7] Poverty and food insecurity both affect complications, severity and outcome of TB. The level of food security is a reliable indicator of the dietary intake at both family and individual levels, influencing the nutritional status.

Socio-demographic factors, such as gender, occupation and environment, also have a major impact on the nutritional status of a population. Chronic morbidities and risk behaviours, such as diabetes, HIV, tobacco smoking and alcoholism, weaken the immune system and increase an individual’s likelihood of progressing from TB infection to TB disease in a shorter time, significantly impacting treatment outcomes. Thus, towards achieving the goal of TB elimination in the country, besides other interventions, the provision of incentives for nutrition and nutritional counselling has been duly emphasised under the National Tuberculosis Elimination Programme (NTEP). Nikshay Poshan Yojana aims to render nutritional support to all TB patients through the provision of a cash incentive of 500 rupees per month throughout the duration of treatment, preferably through the Aadhaar-enabled bank account of the beneficiary.[8]

However, nutritional status, food security and interplay of the other associated factors among TB patients have been less studied in the programmatic context. Particularly in West Bengal, studies in this aspect are very limited. In this background, this study aimed to assess the nutritional status, the level of household food security and other associated factors among adult TB patients in a community development block in Murshidabad District, West Bengal.

Subjects and Methods

Study design, area and study subjects

This descriptive cross-sectional study was conducted from April to July 2023 at Nabagram community development block in Murshidabad district. Nabagram block, being a rural field practice area of the Department of Community Medicine, Murshidabad Medical College, was selected purposively. All adult (≥18 years) TB patients, registered under the Tuberculosis Unit (TU) of the block during a reference period of 6 months (October 2022–March 2023) and permanently residing for at least 1 year in that area, were considered study subjects. TB patients being critically ill, pregnant and lactating women and with physical deformities were excluded.

Sampling

Considering the prevalence of underweight among TB patients as 79.5% based on a previous study,[9] 95% confidence interval and absolute precision of 5%, the required calculated sample size was 250, but, as per the TB register of TU, a total of 95 patients have been registered during the reference period. Thus, applying finite population correction and with a 15% non-response rate, the final estimated sample size was 80. From the sampling frame of registered and eligible TB patients, a sample of 80 subjects was selected by the simple random sampling technique.

Study tools, techniques and data collection

Participants were interviewed using a pre-designed, pretested and linguistically validated schedule for socio-demographic, programmatic characteristics and household food security. Socio-economic status was assessed according to the Modified BG Prasad Scale on May 22.[10] Chronic morbidity meant diseases that were present for at least 1 year. Anthropometric measurements of height and weight were taken following standard guidelines. Body mass index (BMI) was determined, and nutritional status was classified based on the WHO BMI criteria for Asian adults.[11] The receipt of cash benefits under Nikshay Poshan was recorded through review of the relevant register at the TU. The receipt of dietary counselling meant receiving the same from either the Senior Treatment Supervisor (STS) or auxiliary nurse and midwife (ANM) at the subcentre level during the treatment. Resistant under resistance status included any type of resistance to antitubercular drugs—monodrug resistance, polydrug resistance, multidrug resistance (MDR) and extended drug resistance (XDR).

Household-level food security was assessed by the U.S. Household Food Security Survey Module—six-item short form, developed by researchers at the National Center for Health Statistics.[12] The assessment of food security in the scale is based on the last 30 days of recall. A score of ‘1’ was given for affirmative responses and ‘0’ for negative responses. The sum of affirmative responses to the six questions in the module was the household’s raw score on the scale. The higher the score, the lower the level of food security. The raw score of 0–1 denotes high or marginal food security, the raw score of 2–4 denotes low food security and the raw score of 5–6 denotes very low food security. This scale was validated (kappa for each item >0.84) and had good internal consistency (Cronbach’s alpha = 0.82) in West Bengal.[13]

Applying the tools and techniques, data were collected at the household of the participants with prior written informed consent. The necessary permission from the district health authorities was also obtained before data collection.

Analysis

Collected data were checked and cleaned as required and entered into an Excel master sheet. Finally, data were analysed using IBM Corp.’s Statistical Package for the Social Sciences (SPSS) software version 26. Descriptive statistics were measured as mean, standard deviation and proportion according to the nature of the data. Inferential statistics were also applied to find out the correlates. Considering the underweight of TB patients as the outcome variable, multivariable logistic regression was applied to identify predictor variables. Variables with a p-value <0.20 on bi-variate analysis or those biologically relevant were included in the logistic regression model. p-value of ≤ 0.05 was considered significant.

Ethical considerations

Ethical clearance for this study has been obtained from the Institutional Ethics Committee of Murshidabad Medical College, Berhampore [Memo No. MSD/MCH/PR/1478/2023, dated 01/06/2023]. Basic principles of ethical issues have been addressed by maintaining anonymity, data confidentiality, taking informed consent from study participants, conducting no harm, and by random selection of study subjects. During assessment, participants were provided further counselling and services as required.

Results

All 80 selected subjects were studied without any dropout. The socio-demographic characteristics of the participants are presented in Table 1. The mean age of participants was 43.23 years (standard deviation (SD) ±17.64); 70% were male; 42.5% each belonged to other backward classes and were illiterate; and 37.5% belonged to the lower middle socio-economic class. Most of the TB cases were pulmonary (80%) and newly diagnosed (97.2%); 29.7% also had any comorbidity. Among them, 85% received dietary counselling from health personnel and only 15% received cash incentives under Nikshay Poshan [Table 2].

Table 1 Socio-demographic characteristics of the study subjects (n=80)

Characteristics	Categories	Frequency (%)	
Age (in years)	18 to 40	43 (53.8)	
	41 to 60	21 (26.2)	
	≥61	16 (20)	
Gender	Female	24 (30)	
	Male	56 (70)	
Religion	Hindu	40 (50)	
	Muslim	40 (50)	
Caste	General	22 (27.5)	
	Other Backward Caste	34 (42.5)	
	Scheduled Caste	12 (15)	
	Scheduled Tribe	12 (15)	
Education	Illiterate	34 (42.5)	
	Literate	46 (57.5)	
Occupation	Currently working	66 (82.5)	
	Unemployed or at home	14 (17.5)	
Marital status	Currently married	62 (77.5)	
	Unmarried or living alone	18 (22.5)	
Family type	Joint	20 (25)	
	Nuclear	60 (75)	
Socio-economic status*	Lower (<Rs 1272)	15 (18.8)	
	Lower middle (Rs 1272–2456)	30 (37.5)	
	Middle (Rs 2460–4155)	25 (31.2)	
	Upper middle (Rs 4156–8396)	10 (12.5)	
*Modified BG Prasad Scale

Table 2 Programmatic characteristics of the study subjects (n=80)

Characteristics	Categories	Frequency (%)	
Type of TB	Extrapulmonary	16 (20)	
	Pulmonary	64 (80)	
Resistance status†	Resistant	3 (3.8)	
	Sensitive	77 (96.2)	
Any substance use	Yes	38 (47.5)	
	No	42 (52.5)	
Chronic comorbidities	Hypertension	14 (17.5)	
	Diabetes mellitus	6 (7.5)	
	Both hypertension and diabetes	2 (2.5)	
	Hypothyroidism	1 (1.25)	
	Absent	57 (71.25)	
Cash incentive under	Not received	68 (85)	
Nikshay Poshan	Received	12 (15)	
Dietary counselling	Not received	12 (15)	
	Received	68 (85)	
†Any type of resistance to antitubercular drugs—monodrug and polydrug resistance, MDR and XDR

The mean BMI of the participants was 18.84 Kg/m2 (SD ± 3.744); more than half of the participants (51.2%, 41/80) were underweight with 20% being severely underweight. Household-level food security was found to be low or very low among eight (10%) patients; 72 (90%) patients had either high or marginal food security [Table 3].

Table 3 Nutritional status and household food security of the study subjects (n=80)

Nutritional status and food security	Frequency (%)	
Nutritional status		
 Mild underweight	12 (15.0)	
 Moderate underweight	13 (16.3)	
 Severe underweight	16 (20.0)	
 Normal	29 (36.3)	
Overweight or obese	10 (12.4)	
Mean (SD) BMI kg/m2	18.84 (±3.744)	
Household food security		
 High or marginal	72 (90)	
 Low	6 (7.5)	
 Very low	2 (2.5)	

Table 4 depicts the bi-variate and multivariable logistic regression analysis for correlates and predictors of nutritional status. Analysis revealed that Hindu religion (p = 0.001), the presence of any chronic morbidity (p = 0.001) and receipt of dietary counselling by a health worker (p = 0.023) were predictors of underweight among TB patients [Table 4].

Table 4 Correlates and predictors for underweight among TB patients (n=80)

Variables	Underweight n (%)	Not underweight n (%)	COR (95% CI)	AOR (95% CI)	p-value	
Religion						
 Hindu (n=40)	28 (70.0)	12 (30.0)	4.85 (1.88–12.48)	6.741 (2.12–21.39)	0.001	
 Muslim (n=40)	13 (32.5)	27 (67.5)	1 (Ref)	1 (Ref)		
Caste						
 General (n=22)	33 (56.9)	25 (43.1)	2.31 (0.83–6.35)	1.293 (0.39–4.39)	0.678	
 Others (n=58)	08 (36.4)	14 (63.6)	1 (Ref)	1 (Ref)		
Socio-economic status						
 ≥Middle class (n=35)	26 (57.8)	19 (42.2)	1.83 (0.77–4.46)	2.012 (0.62–6.51)	0.243	
 <Middle class (n=45)	15 (42.9)	20 (57.1)	1 (Ref)	1 (Ref)		
Any chronic morbidity						
 Present (n=23)	35 (61.4)	22 (38.6)	4.50 (1.54–13.17)	11.61 (2.71–49.77)	<0.001	
 Absent (n=57)	17 (73.9)	6 (26.1)	1 (Ref)	1 (Ref)		
Received cash incentive						
 No (n=12)	37 (54.4)	31 (45.6)	2.39 (0.66–8.69)	4.39 (0.87–22.21)	0.0.073	
 Yes (n=68)	4 (33.3)	8 (66.7)	1 (Ref)	1 (Ref)		
Dietary counselling						
 Not received (n=12)	7 (58.3)	5 (41.7)	1.40 (0.40–4.85)	7.25 (1.22–43.13)	0.029	
 Received (n=68)	34 (50)	34 (50)	1 (Ref)	1 (Ref)		
Household food security						
 Low or very low (n=8)	5 (62.5)	3 (37.5)	1.67 (0.37–7.50)	1.22 (0.18–8.20)	0.837	
 High or marginal (n=72)	36 (50)	36 (50)	1 (Ref)	1 (Ref)		
Multivariable model statistics=Hosmer-Lemeshow test value=9.142; P=0.243. Nagelkerke R2=0.42. Note: COR=crude odds ratio, AOR=adjusted odds ratio

Discussion

The present cross-sectional studies in a rural area of Murshidabad revealed a high proportion of adult TB patients were underweight. Some of the factors were also found to be significant correlates of TB patients being underweight, which are related to the socio-economic characteristics of the patients and programmatic interventions.

Under-nutrition is said to be both an important risk factor and a common consequence of TB. In our study, more than half of the TB patients (51.2%) were underweight. A similar study in rural central India by Bhargava A et al.[14] reported that 63% of adult TB patients were underweight. Studies on this aspect, specifically among rural TB patients in general, are lacking in the country. However, according to a Government of India document,[15] overall, about 55% of the new TB patients are suffering from under-nutrition at the population level.

Some studies[916] in the urban area also revealed a higher proportion of underweight among adult TB patients; Mollah A. et al.[16] in a municipal area of Burdwan, West Bengal, reported 61.9% and Shukla A et al.[9] in a hospital-based study in Lucknow reported 79.5%.

Even though the studies are not truly comparable in terms of design and setting and also about time frame, but from the findings of our study and also interpreting with the other studies, evidently underweight is quite common among adult Tb patients in the country.

Thus, as a part of comprehensive measures for TB, nutrition aspects have also been emphasised both globally and at the country level in the national programmes. The government of India launched the Nikshay Poshan Yojana, a direct cash benefit transfer scheme, and also recommended nutritional counselling of patients. WHO has also recommended nutritional counselling and support as part of the standard of care for people with TB.[17]

These recommended interventions are already in place in our country as a part of the National Tuberculosis Elimination Programme, but interestingly our present study further revealed a significant association with some of the programmatic components with nutritional status of TB patients. Those patients not receiving nutritional counselling or cash incentives were found to be at a higher risk of being underweight as compared to their counterparts. However, studies assessing these programmatic aspects with the nutritional status of TB patients could not be retrieved for comparing our observations. Some of the socio-demographic factors significantly associated with the nutritional status of TB as revealed in our study were also found by Shukla A et al.[9]

Household food security being generally associated with the nutritional status of people also shares a bidirectional relationship with TB. Food insecurity may both be related to TB causally as an influencing factor and an effect of TB. Empirical evidence on food security or insecurity among TB patients is yet limited in India. Even so, food insecurity in general at the household level is measured in different areas. Few studies in urban slum of Northern India showed the prevalence of food insecurity ranging from 45.5% to 77.2%.[1819] Catastrophic health expenditure as a consequence of treatment, particularly in the case of TB, can lead to worsening of food security during the disease.[20] A cross-sectional study by Ayiraveetil R et al.[20] in South India found that about 34.1% of TB patients have some degree of food insecurity.

In contrast, in this study, we found a high or marginal level of food security among TB patients and about 10% of patients had low or very low food security, indicating prevailing food insecurity, which might also be aggravating factors for nutritional status. Comparatively low levels of food insecurity, especially among households of TB patients, might be due to a reduction in catastrophic health expenditure of TB patients, as the availability of free diagnostic and drug services is being provided under the National Strategic Plan (2017–2025).

TB, being a significant public health problem in many developing countries, similar observations to our study, was also reflected in some other studies in different countries. A systematic review and meta-analysis by Li A et al.[21] revealed high proportion of malnourishment among TB patients; low income and rural residence were significant risk factors for malnutrition in patients with pulmonary TB. Another study by Anbese TA[22] in an urban area of Southern Ethiopia showed that rural residence, age over 45 years and lack of food supplementation were significantly at a higher risk of developing under-nutrition among adult TB patients. Muse AI et al.[23] in East Ethiopia also found that female, educational status and being bedridden were predictors of under-nutrition among adult TB patients.

Despite a few limitations of the present study, with a small sample size in a limited geographical area, possibly restricting the wider generalisability, the present study also highlighted the magnitude of under-nutrition and related correlates of it for appropriate measures in the programmatic context. Chronic comorbidities such as hypertension and type 2 diabetes mellitus and non-receipt of dietary counselling were identified as important predictors of under-nutrition among TB patients. This underscores the role of family care physicians to screen and manage comorbidities such as diabetes and hypertension among TB patients and counsel them for adequate nutritional intake. Besides ensuring food security in general and addressing sociocultural aspects, effective implementation of the Nikshay Poshan Yojana is warranted. Proactive participation of family care physicians in ensuring social support under NTEP can go a long way in combating under-nutrition in TB patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.
==== Refs
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