A

REPORT

ON

DIET AND NUTRITION IN TUBERCULOSIS

Submitted By: Guided By:

Prasann Patel (13BCH040) Dr. Bhoomika Patel
Vishal Patel (13BCH045) Dr. Jigna Shah
Huma Pathan (13BCH046) Dr. Shraddha Bhadada

Prerak Shah (13BCH048)

CHEMICAL ENGINEERING DEPARTMENT

INSTITUTE OF TECHNOLOGY
 NIRMA UNIVERSITY
INDEX
Chapter No. Title Page No.

1. Introduction 1-2
2. Types of Tuberculosis 3-6
3. Tuberculosis and Nutrition 7-15
3. Nutritional Factors That Increase Your Risk For Tuberculosis 7
1
3. Nutritional Response To Infection 8
2
3. Effects Of Tuberculosis On Nutritional Status 9
3
3. Nutritional Treatment Of Tuberculosis 9
4
3. Nutritional Needs Of Children With Tuberculosis 15
5
4. SOURCES OF NUTRITION 16
5. PREVENTION 18
6. References 19
 LIST OF TABLES
Table No. Table Name Page No.

Table 1 Drugs for TB with Guidelines and Side-effects 15

Table 2 Food allowances for High Calorie, High Protein Diet 17

Table 3 Sample Menu Foods Included in 80-100g Protein Diet 17

 1. INTRODUCTION

Tuberculosis (TB) is an infectious disease caused by the bacterium Mycobacterium

tuberculosis (MTB). Tuberculosis generally affects the lungs, but can also affect other parts of the body. Most
infections do not have symptoms, known as latent tuberculosis. About 10% of latent infections progress to
active disease which, if left untreated, kills about half of those infected. The classic symptoms of active TB are a
chronic cough with blood-containing sputum, fever, night sweats, and weight loss. The historical term
"consumption" came about due to the weight loss. Infection of other organs can cause a wide range of
symptoms.

Tuberculosis is spread through the air when people who have active TB in their lungs cough, spit, speak, or
sneeze. People with latent TB do not spread the disease. Active infection occurs more often in people
with HIV/AIDS and in those who smoke. Diagnosis of active TB is based on chest X-rays, as well
as microscopic examination and culture of body fluids. Diagnosis of latent TB relies on the tuberculin skin
test (TST) or blood tests.

Prevention of TB involves screening those at high risk, early detection and treatment of cases,
and vaccination with the bacillus Calmette-Gurin vaccine. Those at high risk include household, workplace,
and social contacts of people with active TB. Treatment requires the use of multiple antibiotics over a long
period of time. Antibiotic resistance is a growing problem with increasing rates of multiple drug-resistant
tuberculosis (MDR-TB).

One-third of the world's population is thought to be infected with TB. New infections occur in about 1% of
the population each year. In 2014, there were 9.6 million cases of active TB which resulted in 1.5 million
deaths. More than 95% of deaths occurred in developing countries. The number of new cases each year has
decreased since 2000. About 80% of people in many Asian and African countries test positive while 510% of
people in the United States population tests positive by the tuberculin test. Tuberculosis has been present in
humans since ancient times.

The disease is called by some, "The Mother of Diseases" and is as much a social disease as an infectious
disease. TB is associated with poverty, overcrowding, alcoholism, stress, drug addiction and malnutrition and is
by far the most common disease in South Africa. The disease spreads easily in overcrowded, badly ventilated
places and among people who are undernourished. This has lead to TB being known as a disease of poverty.

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The Colored population in the Western Cape seems to be at greatest risk with incidence rates in excess of 700
per 100 000 being reported in 1994. The WHO has declared TB to be a global emergency and has called for
urgent and extraordinary action. TB has infected approximately a third of the worlds population and there were
an estimated 8.8 million new TB cases in 2005, with the concentration of cases being in poor countries. A total
of 1.6 million people died of TB, including 195 000 patients infected with HIV.
South Africa was classified as a high-TB burden country and was ranked 7th by the WHO, [according to
rank based on estimated number of incident cases (all forms)] in 2005. The combined burden and effect of TB
and HIV/AIDS co-infection is immense. The global burden of TB is increasing, largely due to the spread of
HIV/AIDS. HIV-infected persons are far more susceptible to TB, are more difficult to diagnose, and in addition,
are also more difficult to treat. HIV-infected people have a much higher mortality in the period following TB
treatment, with 30% dying within a year of diagnosis and treatment. With the HIV epidemic continuing to
spread at startling rates in South Africa and globally, it is highly probable that this will contribute to the
increasing numbers of TB cases. Effective treatment of TB is available, but even though clear guidelines and
standardized drug formulations exist in South Africa, cure rates remain unacceptably low.
In the year 2000, not a single South African province has reached the 85% cure target set by the WHO.
Inconsistent treatment protocols, behavioral patterns, increased incidence of side effects and mal absorption of
drugs due to associated diarrhea may contribute to the development of multidrug-resistant (MDR) TB. The rate
of MDR TB is estimated to be at 1.7% in South Africa (6.6% of treatment cases), with over 6000 cases per
annum. Due to South Africas large TB caseload, this translates into the highest absolute number of MDR TB
cases in the world. With the HIV epidemic continuing to spread at startling rates both nationally and globally, it
is highly probable that this will contribute to the increasing numbers of TB cases and the combined burden and
effect of HIV/AIDS and TB co-infection is immense. The WHO estimates that infected adults lose an average
of 3-4 months of work while recuperating from TB disease and an average of 15 years of economic activity is
lost from each adult TB death.

Who is at risk ?
People with compromised immune systems are most at risk of developing active tuberculosis.HIV
suppresses the immune system, making it harder for the body to control TB bacteria. People who are infected
with both HIV and TB are around 20-30% more likely to develop active TB than those who do not have HIV.
Tobacco use has also been found to increase the risk of developing active TB. Over 20% of TB cases worldwide
are related to smoking. Alarming spread of drug-resistant TB threatens global health.

2
2. Types of Tuberculosis

The bacteria that cause TB is spread through the air from person to person. The TB bacteria are put into
the air when a person with TB disease coughs, sneezes, speaks, or sings. People nearby may breathe in these
bacteria and become infected. There are two types of TB conditions: latent TB infection and active TB
disease.

TB bacteria can live in the body without making you sick. This is called latent TB infection. In most
people who breathe in TB bacteria and become infected, the body is able to fight the bacteria to stop them from
growing. People with latent TB infection do not feel sick, do not have any symptoms, and cannot spread TB
bacteria to others.

If TB bacteria become active in the body and multiply, the person will go from having latent TB
infection to being sick with TB disease.

People with TB disease usually have symptoms and may spread TB bacteria to others.

What Is the Difference Between Latent TB Infection and Active TB Disease?

Latent TB Infection Active TB Disease

TB germs are dormant (asleep) in your body. This TB germs are reproducing and spreading in your
phase can last for a very long time - even decades. body, causing tissue damage.
You usually feel sick. Typical symptoms include:
You don't look or feel sick. Your chest x-ray usually is cough lasting >3 weeks, weight loss, night sweats, and
normal. fever. A chest x-ray and other tests are needed to
diagnose TB disease.

3

You can't spread TB to other people.
Usually treated by taking one medicine for 9 months.
If the TB germs are in your lungs or voice box, you
may spread TB to other people by coughing, sneezing,
talking, or singing.
Treated by taking three or four medicines for at least 6
months.

ACTIVE TB
In the case of the OPEN OR PULMONARY-POSITIVE TUBERCULOSIS an inflammation
developed inside the lungs that the immune system is not able to isolate, i.e., bring under control. This
enables TB bacteria to be released through the respiratory tract (e.g., through coughing) and means that
this type of tuberculosis infection is contagious.

In the case of CLOSED OR PULMONARY-NEGATIVE TUBERCULOSIS, the opposite is the case,

and there is no risk of infection as the inflammation is on the lungs periphery and not inside.

Organs are affected by the bacteria most commonly the lymph nodes, but also the bones and joints,
spine, intestines, kidneys or brain in what is described as EXTRA-PULMONARY (EP)
TUBERCULOSIS. As with the closed tuberculosis, EP tuberculosis is not contagious.

Symptoms of active TB :
TB bacteria most commonly grow in the lungs, and can cause symptoms such as:

A bad cough that lasts 3 weeks or longer

Pain in the chest

Coughing up blood or sputum (mucus from deep inside the lungs)

Other symptoms of TB disease may include:

Weakness or fatigue

Weight loss

No appetite

4
 Chills

Fever

Sweating at night

Symptoms of Pulmonary TB

Pulmonary TB is TB in the lungs. The specific symptoms of pulmonary TB are having a bad cough that lasts
longer than three weeks, having pain in the chest, and coughing up blood or phlegm from deep inside the lungs.

Symptoms of Extra pulmonary TB

Extra pulmonary TB, which is also known as disseminated or miliary TB, refers to all the different types of
TB other than pulmonary TB. Generally it is the types of TB that do not affect the lungs. The main exception to
this is the type of extra pulmonary TB known as Pleural TB. The general symptoms of extra pulmonary TB are
the same as for pulmonary TB, but there can then be specific symptoms relating to the particular site or sites in
the body that are infected.

Symptoms of Lymph node TB

Lymphadenitis is the inflammation and/or enlargement of a lymph node and is a common response to a
variety of infections particularly in children. The only symptoms of TB lymphadenitis may be painless slowly
enlarging lymph nodes, as there are often no general TB symptoms. The swollen lymph nodes are often in the
neck area, although they can be in the groin. TB infection of the lymph nodes in the neck is sometimes referred
to by the name Scrofula, or as TB adenitis.

Symptoms of skeletal (bone and joint) TB

The most common initial symptom of bone TB is pain, but it depends on the bone or joint that is affected.
There may also be curving of the affected bone or joint, as well as loss of movement in the affected bone or
joint. The affected bone may also be weakened and may fracture easily. Spinal TB is also known as TB
Spondylitis or Pott Disease. The symptoms of Pott disease depend on the stage of disease, and the affected site,
but back pain is the earliest and most common symptom.

Symptoms of Meningitis TB

5
 TB meningitis does not start with classic meningitis symptoms. It begins with vague, general symptoms of
aches and pains, a fever, and generally feeling unwell. This lasts for anywhere from about 2 to 8 weeks. Only
then do the more obvious symptoms like vomiting, severe headache, a dislike of lights, neck stiffness and
seizures occur.

Gastrointestinal or Abdominal TB & its symptoms

The symptoms of abdominal TB can be abdominal pain, diarrhea, and bleeding from the anus or rectum. As
with a number of the other types of TB, the symptoms will depend on the exact area that is affected.

Symptoms of TB in children

In a similar way to adults the symptoms of TB in children depend on the type of TB that the child has.
Children usually have pulmonary TB and the symptoms are usually a chronic cough, a fever and failure to
thrive or a weight loss. Children develop extra pulmonary TB (disseminated TB) more often than adults.
Disseminated or Miliary TB, such as TB meningitis particularly occurs in children less than three years old.

6
3. TUBERCULOSIS AND NUTRITION
3.1 Nutritional Factors That Increase Your Risk For Tuberculosis
The risk of complications including death from infections is influenced by the nutritional status of an
individual, but the nutritional status of an individual and utilization of nutrients are also adversely affected
following an infection.
Protein-energy malnutrition

Under nutrition can be considered as one of the risk factors in the development of TB, since under
nutrition is known to adversely affect the immune system. Still there remains a question as to whether
malnutrition predisposes to tuberculosis, or whether it is a consequence of the disease. Irrespective, a vicious
cycle is known to exist between tuberculosis, HIV and malnutrition such that one is promoting the other(s).
Some of the key signs and symptoms of TB, for example wasting, anemia, loss of lean and fat mass, are
also signs of malnutrition. Tuberculosis results in anorexia, cachexia and generalized weakness. Nutritional
deficiencies are generally associated with increased risk for and severity of tuberculosis by adversely affecting
precisely those immunological mechanisms that are crucial for the successful control of mycobacterium, namely
the functions of T-lymphocytes and a variety of phagocytes cells.
There are several ways in which nutritional deficiencies could influence the prevention and management
of TB. A central way in which malnutrition may change the pathogenesis of TB is to increase the risk of
progression from TB infection to primary disease in the short term, or to increase the risk of reactivation of TB
disease in the longer term. Furthermore, nutritional status may also influence the progression from TB infection
to disease by altering the availability of essential nutrients to meet the metabolic needs of the pathogen and the
individual.
Additionally, concomitant malnutrition could diminish the pharmacodynamic effectiveness of anti
mycobacterial drug regimens, which must be taken for several months to cure the patient. Malnutrition-induced
loss of some immune functions is reversed fairly rapidly upon correction of the nutritional deficiencies. Thus,
nutritional intervention in combination with appropriate pharmaceutical therapy, as is the case in HIV infected
patients, could improve the outcome in malnourished TB patients. Malnutrition could also impair the protective
efficacy of Bacillus Calmette-Gurin (BCG) vaccine, thereby increasing the disease burden in vaccinated
populations that are nutritionally vulnerable or deficient.
Micronutrients and immune function

Since most of the reliable data on the role of micronutrients in immunity to tuberculosis have been
generated on experimental animal models, the relevance for humans of the conclusions drawn from such studies
7
must be interpreted cautiously. It is known that deficiencies of zinc, vitamin D, vitamin A, vitamin C, and iron
can cause profound impairment of immunity (and precisely the cell types that are critical to "fight"
tuberculosis). It is therefore not unreasonable to propose that dietary deficiencies of these micronutrients may be
important determinants of tuberculosis resistance.

3.2 Nutritional Response To Infection

Acute infectious illnesses, such as tuberculosis, are accompanied by a complex variety of nutritional and
metabolic responses within the body. The response to infection is associated with an increase in the energy
expenditure of the patient and various degrees of tissue breakdown. Additionally, in the body's attempt to fight
the infection energy expenditure is increased, thereby increasing energy needs in the TB patient. Patients
characteristically present with loss of appetite and body weight. Complex changes occur in the metabolism of
all the macronutrients, i.e. protein, carbohydrate and fat. An increase in protein breakdown for example, leads to
muscle wasting in these patients. TB patients are also known to have high losses of protein (nitrogen), which
may result in mal absorption due to diarrhea, loss of fluids, electrolytes and other nutritional reserves.
The breakdown of protein and other reserves due to fever may also worsen under nutrition and further
impair resistance against the infection. There is also good evidence that underweight, in itself, is a risk factor for
the development of tuberculosis in infected persons.
The response to infection also includes a profound impact on the micronutrient status of the patient.
Vitamins and minerals are compounds that are essential for normal growth and maintenance of body functions,
playing key roles in many different metabolic processes in both health and disease. The increased energy
expenditure and tissues breakdown associated with infection are thought to increase the requirements of
micronutrients such as vitamin A, E, B6, C, D and folate. It is also known that a decrease in blood levels of
trace elements such as iron, zinc and selenium occur during the infection.
Infectious diseases, such as tuberculosis, are therefore associated with increased requirements of both
the macro- and micronutrients. A causal relationship between nutrition and tuberculosis has not yet been
established, because of the difficulties involved in separating the influence of nutrition from economic,
environmental and genetic factors, which characterize high-risk populations. There remains the question still as
to whether malnutrition predisposes to tuberculosis, or whether it is a consequence of the disease.

8
3.3 Effects Of Tuberculosis On Nutritional Status

Nutritional status is significantly lower in patients with active pulmonary tuberculosis compared with
healthy controls in different studies in Indonesia, England, India, and Japan. Tuberculosis patients have been
found to have lower serum albumin concentration than controls. Tuberculosis is probably associated with more
severe malnutrition than other chronic illnesses; in an Indian study, the nutritional status of patients with
tuberculosis was worse than that of those with leprosy. A study in Uganda demonstrated that poor nutritional
status is common among adults with pulmonary tuberculosis. In yet another Indian study, tuberculosis patients
were respectively 11 and 7 times more likely to have a BMI < 18.5 and mid-arm circumference < 24 cm.

For any infection, there is a complex interaction between the host response and the virulence of the
organisms, which modulates the overall metabolic response and the degree and the pattern of tissue loss. In
patients with tuberculosis, a reduction in appetite, nutrient mal absorption, micronutrient mal absorption, and
altered metabolism leads to wasting.

In a study, Indian patients with pulmonary tuberculosis were compared with malnourished and normally
nourished healthy subjects. Whereas protein synthesis and breakdown in the fasting state were not significantly
different between groups, patients with tuberculosis used a larger proportion of proteins from oral feeding for
oxidation and hence for energy production than did either control group. Such failure to channel food protein
into endogenous protein synthesis has been termed Anabolic block. This anabolic block represents one of the
mechanisms for wasting in tuberculosis and other inflammatory status.

Anorexia is also a contributing factor for wasting in tuberculosis. In an unselected U.S. cohort of
patients diagnosed with tuberculosis, 45% lost weight and 20% had anorexia. Increased production of cytokines
with lipolytic and proteolytic activity cause increased energy expenditure in tuberculosis. Leptin may also play
an important role in wasting. In a study, malnutrition has been associated with atypical presentations of
tuberculosis.

3.4 Nutritional Treatment of Tuberculosis

Clinically, it has long been noted that the risk and morbidity of infections are influenced by the
nutritional status of the individual. Likewise, the nutritional status and the intake and utilization of foodstuffs

9
are profoundly altered during the body's response to infection. The association between malnutrition and disease
is well recognized, but the explanation for the association is complex. In the context of TB and HIV/AIDS,
attention should be focused on specific symptoms, such as weight loss, diarrhea, loss of appetite, nausea, and
specific disorders such as micronutrient deficiencies, known to occur commonly among TB and HIV-infected
individuals and to impact adversely in the short- or the longer-term outcomes. Factors that affect food intake,
such as food availability, appetite, eating patterns, medication side effects, traditional food taboos, lifestyles
(smoking, alcohol, physical activity, caffeine intake, use of social drugs), psychological factors (stress and
depression), stigma, and economic factors are also very important to consider.
The South African National Department of Health produced the National guidelines on nutrition for
people living with TB, HIV and AIDS and other chronic debilitating conditions in 2001. These guidelines are
currently being revised.

Nutritional needs in tuberculosis

Energy

Energy needs of TB patients are increased because of the disease itself. The current recommendations
for TB patients are based on the nutrient and energy requirements for hyper catabolic and undernourished
patients. (Approximately 35 - 40 kCal per kilogram of ideal body weight). The WHO technical consultation on
HIV and nutrition stated that energy requirements are likely to increase by 10% to maintain body weight and
physical activity in asymptomatic HIV infected adults and this should then be added to the DRI requirements
for healthy adults. During symptomatic HIV, and AIDS, energy requirements increase by 20-30% to maintain
body weight. In the case of co-infection, the highest recommendation should be implemented, based on the
individuals needs and other requirements.
Protein

The protein intake of the diet is important to prevent the wasting of body stores (for example muscle
tissues). An intake of 1.2 - 1.5 g per kilogram body weight or 15% of energy of total daily intake or
approximately 75 - 100 g per day will be sufficient.
Role of Micronutrients

Because of diverse metabolic characteristics and functions, micronutrients have presently been accepted
as essential for optimum human health. Micronutrients deficiency is considered to be the most frequent cause of
secondary immunodeficiency and infection related morbidity including tuberculosis.

10
Zinc : Zinc deficiency affects the host defenses in a variety of ways. It results in decreased phagocytosis and
leads to a reduced number of circulating T-cells and reduced tuberculin reactivity, at least in animals. In vitro
cellular killing by macrophages was found to be reduced during zinc deficiency and rapidly restored after zinc
supplementation.

Various studies on patients with tuberculosis had shown significantly lower plasma zinc level than those
without tuberculosis, irrespective of their nutritional status. There was significant rise in zinc level at the end of
six- months of anti tuberculosis therapy (ATT). Thus, it may be suggested that plasma zinc status is likely a
marker for monitoring the severity of disease and response to therapy. Zinc deficiency in tuberculosis is likely
due to redistribution of zinc from plasma to other tissues or reduction of the hepatic production of the zinc
carrier protein 2-macroglobulin and to a rise in the production of metallothionein, a protein that transports zinc
to the liver.

Reduction in plasma zinc concentration was shown in tuberculosis patients after two months of
treatment. This phenomenon may be because during the intensive phase of ATT, the anti tuberculosis drugs
were used to kill the population of replicating bacilli and zinc may play important role in the macrophage
contribution to host defences at the site of infection. The other possible mechanisms could be the effect of anti
tuberculosis drugs on zinc absorption. Ethambutol was shown in rats to increase not only zinc absorption but
also urinary zinc losses, resulting in reduced circulating zinc concentration.

Zinc supplementation of patients with pulmonary tuberculosis and bacterial pneumonia was shown to
increase immune function. In a study, it was found that PPD indurations were larger in children receiving zinc
and zinc increases the PPD in duration size in children irrespective of nutritional status.

Zinc has essential role in vitamin A metabolism. Studies in humans and animals have shown that zinc
deficiency impairs the synthesis of retinal binding proteins and reduces plasma retinal concentration. Therefore,
it appears that zinc supplementation has a beneficial effect on vitamin A metabolism which has important role in
tuberculosis. An adequate supply of zinc may also limit free radical membrane damage during inflammation.

Vitamin A : It has been shown that vitamin A has immune competent role in human tuberculosis. Vitamin A
was reported to inhibit multiplication of virulent bacilli in cultured human macrophages. In addition, vitamin A
has a vital role in lymphocyte proliferation and in maintaining the function of epithelial tissues. Vitamin A is
essential for normal functioning of T and B lymphocytes, macrophage activity, and generation of antibody
response.

11
 A study from Rwanda reported vitamin A deficiency among adults with tuberculosis. Concentration of
vitamin A was found to be lower in tuberculosis patients than that in controls in many studies. The low
concentration of retinal in plasma can be due to number of factors including reduced intake or reduced
absorption of fat. Additionally, infection itself can compromise vitamin A status in number of ways. Vitamin A
is excreted in the urine in patients with fever and this has been confirmed in subjects with acute infection
including pneumonia. During the acute phase response, leakage of pro albumin through the vascular
endothelium occurs; and production of retinal binding proteins and pre albumin by liver is reduced. In addition,
requirement of vitamin A during infection is raised by its increased rate of excretion and metabolism.

In an Indian study, the low vitamin A levels observed in tuberculosis patients returned to normal at the
end of ATT without vitamin A supplementation. Vitamin A deficiency increases bacterial adherence to
respiratory epithelial cells.

In the pre chemotherapeutic era, cod liver oil rich in vitamin A and D was used regularly to strengthen
host defense. Supplementation of vitamin A appears to increase survival among chicks infected with M.
tuberculosis and enhances both T-lymphocyte and antibody responses to M. tuberculosis.

Vitamin D : Vitamin D plays a role in the function of macrophages, key factor in host resistance in
tuberculosis. Abnormalities in vitamin D status have been reported in tuberculosis. Genetic variations in the
vitamin D receptor were identified as a major determinant of the risk for tuberculosis in Africans. Vitamin D
deficiency itself was shown to be a risk factor for tuberculosis. Adults with untreated tuberculosis in Indonesia
were shown to have significantly lower 25-hydroxy-vitamin D compared with controls.

Studies have yielded inconsistent findings regarding serum or plasma calcium concentration during
tuberculosis. A study in Africa has related hypocalcemia to moderate to extensive radiographic disease.

Vitamin E : In many studies, concentration of vitamin E was found to be significantly lower in tuberculosis
patients than healthy controls.

Vitamin C : Studies have linked vitamin C deficiency with tuberculosis. In Ethiopians, concentrations of
antioxidant vitamin C, vitamin E, and vitamin A were significantly lower in tuberculosis patients and high
malonaldehyde concentration was associated with clinical severity.

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Selenium : The essential trace element selenium has an important function in maintaining the immune
processes and thus may have a critical role in clearance of mycobacteria. Selenium has been found as significant
factor in the relative risk for developing mycobacterial diseases in HIV positive patients.

A recent Indian study measured concentrations of circulating antioxidants and markers of oxidative
stress in tuberculosis patients. Results showed lower antioxidant potential (lower levels of superoxide
dismutase, catalase, glutathione, and ascorbic acid) and enhanced lipid peroxidation products (malonaldehyde)
in tuberculosis patients. Antioxidant potential increased with treatment.

Iron : Anemia is highly prevalent among adults with pulmonary tuberculosis. In a study conducted in Ghana,
50% adults with pulmonary tuberculosis had significantly lower hemoglobin than healthy matched controls.
Iron deficiency may also be a contributing factor.

In a study, concentration of haemoglobin was lower in tuberculosis patients than that in controls and
those of zinc protoporphyrin (ZPP) were significantly higher than in controls. Elevated concentration of ZPP, a
measure of free erythrocyte porphyrin, is indicative of iron deficient erythropoiesis.

There are two explanations for the association of low iron status and infection. One is that anemia results
from chronic infection and the other is that iron deficiency would increase susceptibility to infection such as
tuberculosis.

Copper : In a recent study, compared with the control group, the concentrations of iron, zinc, and selenium
were significantly lower while that of copper and copper/zinc ratio were significantly higher in the serum of
tuberculosis patients. The serum concentration of zinc increased and serum copper concentration and
copper/zinc ratio decreased significantly after anti tuberculosis chemotherapy.

Polyunsaturated fatty acids : In a study, eicosanoid synthesis was studied in macrophages of guinea pigs fed
with different amounts of omega-6 fatty acids and omega-3 fatty acids. It was concluded that supplementing the
diet with (n-3-) fatty acids can affect resistance to M. tuberculosis, whereas supplementing with (n-6-) fatty
acids does not.

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Cholesterol : Hypocholesterolemia is common among tuberculosis patients and is associated with mortality in
miliary tuberculosis cases. In vitro studies concluded that cholesterol-rich diet accelerated the sterilization rate
of sputum culture in pulmonary tuberculosis patients suggesting that cholesterol should be used as a
complementary measure in ATT.

Despite extensive studies, little is known about the exact vitamin and trace element requirements in
infection and the effects of micronutrient supplementation on TB treatment outcomes, clinical complications,
and mortality are uncertain. A good multivitamin and mineral supplement, therefore providing 50% -150% of
the recommended daily allowance, is advisable since it will be most unlikely that a person with TB will be able
to meet the increased requirements for vitamins and minerals with diet alone (due to a poor appetite).
Recently one study found that supplementation with vitamin E (140 mg alpha-tocopherol) and selenium
(200ug) reduces oxidative stress and enhances total antioxidant status in patients with pulmonary TB treated
with standard chemotherapy.
A link between tuberculosis and vitamin D deficiency has been postulated and fish liver oils and sunlight
were sometimes used to treat tuberculosis before the advent of antimicrobial drug treatment. Low serum vitamin
D levels are associated with higher risk of active tuberculosis and vitamin D deficiency has been postulated. In
addition to its role in mineral and skeletal homeostasis, vitamin D (1, 25 (OH)2D) regulates the growth and
function of a broad spectrum of cells, including cells of the immune system. It is now known that the principle
source of vitamin D is sunlight and that plasma concentrations of vitamin D have striking seasonal variation
with peak levels after summer and the lowest levels in the spring. The occurrence of tuberculosis has been
reported to be related to the seasonal variation in vitamin D status in some, but not all countries. It was also
found that there is a massive local production of active vitamin D (metabolites of vitamin D) in the TB lesions
in the lungs and other affected tissues of people with tuberculosis. There is some uncertainty though as to
whether this is part of the body's protective system against the disease. Recent evidence, however, indicates that
a vitamin D supplement (single oral dose of 2.5 mg vitamin D) corrects hypovitaminosis D at 1 week but not at
8 weeks post-dose in TB patients.
The potential role of vitamin D supplementation in people with tuberculosis should be evaluated,
especially since there is still some uncertainty whether Vitamin D enhances anti mycobacterial immunity and
improves disease outcomes. Emerging evidence however does indicate that a vitamin D supplement (single oral
dose of 2.5 mg vitamin D) enhances antimycobacterial immunity in humans. Such supplements therefore could
be considered in the appropriate settings. The public health implications of these observations remain to be
clarified and vitamin D supplementation is not routinely prescribed to tuberculosis patients as of yet.

14
 Drug -nutrient interactions

Isoniazid is one of the most frequently anti-tuberculosis drugs used in the treatment of the disease. The drug
is an antagonist of vitamin B6 (pyridoxine) and may case peripheral neuropathy (relatively rare) due to a
nutritional deficiency of vitamin B6. It is standard procedure to supplement adults with 25 mg of vitamin B6 per
day (in the form of supplements). Children are not routinely given vitamin B6, but if their blood levels are low
or if they get large (more than 10 mg of isoniazid per day) dosages of isoniazid, they will also need 25 mg of
vitamin B6 in the form of supplementation.
Table 1. Drugs for TB with Guidelines and Side-effects

3.5 Nutritional Needs Of Children With Tuberculosis

The rapid growth periods of infancy and childhood can only be maintained if a child's nutrient intake is
optimal. Insufficient intake can cause impaired growth and result in diseases such as malnutrition. Because of
the previously described link between malnutrition and TB, all children presenting with malnutrition or with
failure to gain adequately in weight must be evaluated for possible TB. Studies of children presenting with
different forms of malnutrition indicate that TB can be found in 12- 30% of cases. When weight gain patterns of
children with TB are studied, it is evident that 66% of cases fail to gain weight or show loss of weight prior to
diagnosis.
The provision of adequate energy and nutrients for a child with TB is very important, since the child has
increased requirements as a result of both growth and TB. In meeting their requirements, it should be born in

15
mind that children have limited stomach capacity and appetites and as such meeting nutrient requirements
presents a difficult challenge. It is therefore necessary to modify and plan the diet carefully to ensure adequate
intake of food. The best way to monitor weight gain and detect malnutrition in children is to use the aid of a
"Road to Health" card (curve that illustrate the growth pattern of a child).

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4. SOURCES OF NUTRITION
A very important factor is nutrition and the appropriate diet that is adequate to supplement our bodies
with all the necessary micro and macro nutrients to prevent tuberculosis from happening.
Following are some sources of nutrition that need to be inculcated in the diet in order to try and prevent
it from happening.

Vitamin E

-sunflower seeds
- almonds
-hazelnuts
- peanuts
-dry cereals
-green vegetables

Selenium

- brazil nuts , tuna

-chicken breast
-sunflower seeds

Vitamin A

-Sweet potato
-Carrots, Leafy greens
-Apricots

Vitamin D

- egg yolks
- cheese, beef liver
- fatty fish, tuna
Zinc

-oysters and beef

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 Iron

-Chick peas
-beef, oysters
Table 2 Food allowances for High Calorie, High Protein Diet

Table 3 Sample Menu Foods Included in 80-100g Protein Diet

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5. PREVENTION
Following are some of the factors which if followed may reduce the risk of having TB
1. Let your surroundings be clean majorly from any sort of pollution that can harm you.

2. Have a balanced diet with all the essential macro and micro nutrients on a regular basis.

3. Refrain from any sort of vices which harm the body in any way .

4. Vaccination for TB is a must .

5. Incase of being diagnosed with Tb , get a proper health checkup done , and get a balanced diet from a
nutritionist with the required medicines so as to keep it in check.

RECOMMENDATIONS
There is no documented evidence that any specific food on its own can alter the course of the disease or
can for that matter be effective in the treatment of malnutrition. TB and HIV/AIDS patients are
encouraged to eat a healthy varied diet.
Pulmonary disease often adversely affects nutritional intake, due to poor appetites, making patients at
risk for malnutrition. Six smaller meals per day are indicated instead of three meals.
The meals should be appetizing in appearance and taste and provide enough energy and protein.
Commercially available high energy and protein drinks (balanced in terms of micro-and macronutrients)
may be used effectively to meet the increased requirements.
Household ingredients, such as sugar, vegetable oil, peanut butter, eggs and non-fat dry milk powder can
be used in porridge, soups, gravies, casseroles or milk based drinks to increase the protein and energy
content without adding to the bulk of the meal.
At least 500 - 750 ml of milk or yogurt should be consumed daily to ensure adequate intakes of vitamin
D and calcium.
At least 5-6 portions of fruit and vegetables should be eaten per day. Pure fruit juice can be used to
decrease the bulk of the diet. Approximately 1/2 a glass of fruit juice is equal to one portion of fruit.
The best dietary sources of vitamin B6 (pyridoxine) are yeast, wheat germ, pork, liver, whole grain
cereals, legumes, potatoes, bananas, and oatmeal.
Alcohol should be avoided.
Adequate fluid intake is important due to increased losses (at least 10-12 glasses per day).

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6. References
[1] Fundamentals of Foods, Nutrition and Diet Therapy
-S.R. Mudambi and M.V. Rajagopal
[2] Amit Kumar, Rakesh Kakkar, S D Kandpal, Girish Sindhwani, Nutritional status in multi-drug resistance-
pulmonary tuberculosis patients, Indian JournaL of Community Health / Vol 26 / Supp 02 / Dec 2014
[3] Krishna Bihari Gupta, Rajesh Gupta, Atulya Atreja, Manish Verma and Suman Vishvkarma, Tuberculosis
and nutrition, Lung India
[4] http://www.mayoclinic.org/diseases-conditions/tuberculosis/symptoms-causes/dxc-20188557
[5] http://www.medicalnewstoday.com/articles/8856.php
[6] http://www.cdc.gov/features/tbsymptoms/
[7] http://tbfacts.org/symptoms-tb/
[8] http://www.who.int/elena/titles/full_recommendations/tb_nutrition/en/
[9] http://www.who.int/nutrition/publications/guidelines/nautcare_support_patients_with_tb/en/
[10] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2813110/
[11]http://www.eatright.org/resource/food/nutrition/vegetarian-and-special-diets/food-sources-of-important-
nutrients-for-vegetarians
[12] https://www.hsph.harvard.edu/nutritionsource/

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