Undernutrition before TB, after treatment initiation associated with adverse outcomes
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Undernutrition, both before tuberculosis onset and at treatment initiation, as well as a lack of body mass index increase after intensive therapy, are associated with unfavorable TB outcomes, according to a recent study.
“Undernutrition is the leading risk factor for TB that most people are not aware of. Undernutrition can blunt immune function needed to control TB infections and prevent progression to TB disease,” Pranay Sinha, MD, assistant professor of infectious diseases at the Boston University School of Medicine, told Healio, adding that more than 2.1 million of the 10.6 million TB cases worldwide are attributable to undernutrition — more than twice the cases attributable to HIV/AIDS.
“In this paper, we set out to understand the impact of undernutrition on TB treatment outcomes,” Sinha said. “While previous studies have tried to address this question, they’ve had a slew of limitations. Chief among these limitations is the fact that most studies have looked at the association between weight at treatment initiation and treatment outcomes.”
He added that although this is an important predictor to consider, it is also “a confounded one.”
Sinha and colleagues conducted a prospective cohort analysis of adults with drug-sensitive pulmonary TB at five sites in the Regional Prospective Observational Research on Tuberculosis (RePORT) India consortium between 2015 and 2019.
According to the study, they used a multivariable Poisson regression to assess independent associations between unfavorable outcomes and nutritional status based on BMI nutritional status at treatment initiation, BMI before TB disease, stunting and stagnant or declining BMI after 2 months of TB treatment.
Overall, the study showed that severe undernutrition (BMI less than 16 kg/m2) at treatment initiation and severe undernutrition before the onset of TB were both associated with unfavorable outcomes (adjusted incidence rate ratio (IRR) = 2.05; 95% CI, 1.42-2.91 and aIRR = 2.20; 95% CI, 1.16-3.94, respectively).
The study also demonstrated that a lack of BMI increase after treatment initiation was associated with increased unfavorable outcomes (aIRR = 1.81; 95% CI, 1.27-2.61). Both severe undernutrition at treatment initiation and lack of BMI increase during treatment were associated high rates of death — a four- and fivefold higher rate, respectively.
Based on these findings, Sinha said that clinicians should systematically assess the nutritional status of people with TB using anthropometry at treatment initiation to gauge the risk of poor outcomes and consider screening for reversible causes of undernutrition like intestinal parasitic infections.
“The increased unfavorable outcomes among those without BMI increase at 2 months may have been due to suboptimal TB therapy or poor nutritional intake,” he added. “Given its prognostic value, anthropometry at 2 months should also be standard practice for TB follow-up.”
Sinha added that people with TB with “stagnant or reduced BMI” should be assessed for causes of treatment failure such as nonadherence or drug resistance and that those who are severely undernourished at treatment initiation or fail to gain weight during therapy should also be offered nutritional counseling and support.
“Our study makes a strong case for integrating nutritional screening and treatment into standard TB therapy just as is the case for HIV today,” Sinha concluded.
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