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Multicenter Study
. 2023 Apr 17;76(8):1483-1491.
doi: 10.1093/cid/ciac915.

Impact of Undernutrition on Tuberculosis Treatment Outcomes in India: A Multicenter, Prospective, Cohort Analysis

Pranay Sinha  1 , Chinnaiyan Ponnuraja  2 , Nikhil Gupte  3   4   5 , Senbagavalli Prakash Babu  6 , Samyra R Cox  5 , Sonali Sarkar  6 , Vidya Mave  3   4   5 , Mandar Paradkar  3   4 , Chelsie Cintron  1 , S Govindarajan  6   7 , Aarti Kinikar  8 , Nadesan Priya  9 , Sanjay Gaikwad  8 , Balamugesh Thangakunam  9 , Arutselvi Devarajan  10 , Mythili Dhanasekaran  10 , Jeffrey A Tornheim  5 , Amita Gupta  5 , Padmini Salgame  11 , Devashyam Jesudas Christopher  9 , Hardy Kornfeld  12 , Vijay Viswanathan  10 , Jerrold J Ellner  11 , C Robert Horsburgh  1   13   14   15 , Akshay N Gupte  5 , Chandrasekaran Padmapriyadarsini  2 , Natasha S Hochberg  1   13
Affiliations
Multicenter Study

Impact of Undernutrition on Tuberculosis Treatment Outcomes in India: A Multicenter, Prospective, Cohort Analysis

Pranay Sinha et al. Clin Infect Dis. .

Abstract

Background: Undernutrition is the leading risk factor for tuberculosis (TB) globally. Its impact on treatment outcomes is poorly defined.

Methods: We conducted a prospective cohort analysis of adults with drug-sensitive pulmonary TB at 5 sites from 2015-2019. Using multivariable Poisson regression, we assessed associations between unfavorable outcomes and nutritional status based on body mass index (BMI) nutritional status at treatment initiation, BMI prior to TB disease, stunting, and stagnant or declining BMI after 2 months of TB treatment. Unfavorable outcome was defined as a composite of treatment failure, death, or relapse within 6 months of treatment completion.

Results: Severe undernutrition (BMI <16 kg/m2) at treatment initiation and severe undernutrition before the onset of TB disease were both associated with unfavorable outcomes (adjusted incidence rate ratio [aIRR], 2.05; 95% confidence interval [CI], 1.42-2.91 and aIRR, 2.20; 95% CI, 1.16-3.94, respectively). Additionally, lack of BMI increase after treatment initiation was associated with increased unfavorable outcomes (aIRR, 1.81; 95% CI, 1.27-2.61). Severe stunting (height-for-age z score <-3) was associated with unfavorable outcomes (aIRR, 1.52; 95% CI, 1.00-2.24). Severe undernutrition at treatment initiation and lack of BMI increase during treatment were associated with a 4- and 5-fold higher rate of death, respectively.

Conclusions: Premorbid undernutrition, undernutrition at treatment initiation, lack of BMI increase after intensive therapy, and severe stunting are associated with unfavorable TB treatment outcomes. These data highlight the need to address this widely prevalent TB comorbidity. Nutritional assessment should be integrated into standard TB care.

Keywords: India; malnutrition; outcomes; tuberculosis; undernutrition.

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Conflict of interest statement

Potential conflicts of interest . D. J. C., N. P., and S. P. B. report grants or contracts to institution from the Warren Alpert Foundation. N. S. H. reports a Warren Alpert Foundation grant paid to institution and current employment with the Novartis Institute for Biomedical Research. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

Figures

Figure 1.
Figure 1.
Selection of participants.
Figure 2.
Figure 2.
Survival curves. Survival curves for participants with different BMI distributions at treatment initiation (A), participants with different premorbid BMI distributions (B), participants with increased BMI compared with unchanged or decreased BMI after 2 months of therapy (C), and participants without stunting compared with those with moderate or severe stunting (D). The number of individuals at risk for unfavorable outcomes at different time points is displayed below the survival curves. Abbreviation: BMI, body mass index.
See this image and copyright information in PMC

References

    1. World Health Organization . Global tuberculosis report 2022. Geneva, Switzerland: WHO, 2022.
    1. Sinha P, Davis J, Saag L, et al. . Undernutrition and tuberculosis: public health implications. J Infect Dis 2019; 219:1356–63. - PMC - PubMed
    1. Hochberg NS, Sarkar S, HorsburghCR, Jr., et al. . Comorbidities in pulmonary tuberculosis cases in Puducherry and Tamil Nadu, India: opportunities for intervention. PLoS One 2017; 12: e0183195. - PMC - PubMed
    1. FAO, IFAD, UNICEF, WFP, and WHO . The state of food security and nutrition in the world 2021. Transforming food systems for food security, improved nutrition and affordable healthy diets for all. Rome, Italy: FAO, 2021.
    1. Sinha P, Carwile M, Cintron C, de Perez EC, Hochberg N. Climate change and TB: the soil and seed conceptual framework. Public Health Action 2021; 11:108. - PMC - PubMed

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