Factors Related to the Low

Nutritional Status among Tuberculosis Patients

Abstract
Background: Tuberculosis and malnutrition have become serious problems in the field
of health. Tuberculosis causes malnutrition and leads to weak body resistance. This
condition will increase the possibility of tuberculosis to become an active disease.
Purpose: The purpose of the research was to analyze the factors related to the low
nutritional status among tuberculosis patients in Malang City.
Method: This research applied a quantitative design with a cross-sectional approach.
The subjects involved are tuberculosis patients with BMI<18. The data were analyzed
using Kendall’s Tau, Mann-Whitney, and Spearman’s Rank.
Results: p-value, after analyzed using SPSS software, indicates the variable of age
p=0.180, gender p=0.633, education p=0453, job p=0.016, family knowledge 0.375,
and culture p=0.281. The significant variable among them is job variable with p<0.05.
Conclusion: The relating factor of the low nutritional status among TB patients is the
job variable.
Keywords: tuberculosis, nutritional status, relating factor

Introduction Commented [A1]: Overall, backgorund has ilustrated

what you needs to explained. However, you need to
Pulmonary TB is estimated to cover 80% of the overall incidence of reported about TB infection and also malnutrition in
Indonesia, focused on Malang City.
tuberculosis (Djojodibroto 2009). Research conducted by Bhargava (2013) stated that
nutritional status at the time of diagnosis and completion of TB therapy can be
associated with death. There were 1179 adult patients with pulmonary tuberculosis in
rural India during 2004-2009, specifically BMI and body weight of men and women
were 16 kg/m2 (42.1 kg) and 15 kg/m2 (34.1 kg) respectively. This result showed that
80% of women and 67% of men have moderate to severe malnutrition (BMI <17.0
kg/m2). Fifty-two percent of patients (57% of men and 48% of women) have stunting
that indicating chronic undernutrition. Half of the women and one-third of men remain
at low body weight at the end of treatment. There are 60 deaths occurred in 1179
patients (5%) at the beginning of treatment. Overall, most patients have evidence of
chronic malnutrition at diagnosis, which survived even after successful treatment in a
significant proportion.

The relationship between TB and malnutrition has long been known. TB makes
malnutrition worse and malnutrition weakens the body’s immunity, thereby increasing
the possibility of latent TB that will develop into active disease. Most individuals with
active TB are in a catabolic condition and experience weight loss and some show signs
of vitamin and mineral deficiency at diagnosis. Weight loss among patients with TB
can be caused by several factors, including reduced food intake due to loss of appetite,
nausea, and abdominal pain; loss of nutrition due to vomiting and diarrhea and
metabolic changes due to disease. Low body mass index (BMI) (below 18.5 kg/m2)
and lack of weight gain with TB treatment are associated with an increased risk of death
and relapse of TB and can be indicator of TB severity, poor treatment response and/or
presence other comorbid conditions (WHOa, 2013).

There is numerous factors influence the low level of nutrition. Knowledge or

information about nutrition and its benefits can affect individual consumption patterns.
For example, when an outbreak of bird flu spreads, many people avoid eating chicken
for fear of contracting it. As a result, their animal protein intake is reduced. In fact, if
the chicken is processed properly, the consumption of chicken will not cause bird flu.
The culture and religion make a person to follow the rules that are regulated. Religion
disallows a person to consume any type of food, such as a cow or pig. Thus, protein
intake from these types of food is reduced and must be replaced with other types of
foods that have the same nutrients (Saputra, 2013). Therefore, this study aims at
determining factors related to the low nutritional status of tuberculosis patients.

Method
Design of the Study
This study applies to cross-sectional design and aims at identifying and
measuring the factors related to the low nutritional status of tuberculosis patients. The
data were analyzed using a questionnaire and physical examination.

Population and Sample

The population involved is 63 TB patients in Kedungkandang and Ciptomulyo

health centers. The samples involved are 47 TB patients with low nutritional status
(IMT<18). The participants are selected using nonprobability sampling with purposive
sampling and positive inclusion criteria TB BTA. The study was conducted in June-
July 2018.

Instrument

The data are analyzed using the following instruments:

1. The questionnaire contains the variable of patient’s characteristics, knowledge,

belief, socio-culture, social economy, and family support. Questionnaire about
knowledge consists of ‘right’ and ‘wrong’ questions (right answer = 1 & wrong
answer = 0). Meanwhile, belief, socio-culture, and social economy consist of
‘yes’ and ‘no’ questions (yes = 1 and no = 0). The total score will be categorized
poor = ≤ 55%, sufficient = 56-57%, and good = 76-100%.
2. Body weight scales to measure body weight.
3. Height scales to measure body height. Commented [A2]: Make sure that you are mention about
body weight and height scale that used in Indonesia
commonly.
Data Analysis

The descriptive analysis covers age, gender, education, job, and nutritional
status. The analysis applies to Kendall’s Tau, Mann-Whitney, and Spearman’s Rank.

Ethical Consideration

Ethical permission was obtained from the Ethical Review Board (ERB)
committee of University of Muhammadiyah Malang (ERB No.E.5.a/259/KEPK-
UMM/VIII/2018).

Results
Demography Data
Table 1. Demography Data of Participants

Participant
No. Demography Data Number
Frequency Mean
1. Age
 a. Minimum 23 years SD: 11.64 46
b. Maximum 64 years
2. Gender -
a. Men 12 persons 25.5%
b. Women 35 persons 74.5%
3. Education -
a. Not taking formal 1 person 2.1%
education
b. Elementary School 16 persons 34.0%
c. Junior High School 15 persons 31.9%
d. Senior High School 13 persons 27.7%
e. Undergraduate 2 persons 4.3%
4. Job -
a. Working 26 persons 55.3%
b. Not working 21 persons 44.7%
5. Family Knowledge -
a. Good 12 persons 25.5%
b. Sufficient 13 persons 27.7%
c. Poor 22 persons 46.8%
6. Culture -
a. Abstinence 35 persons 62.5%
b. Non- Abstinence 12 persons 37.5%
7. Nutritional Status
Mild Thinness 4 persons 8.5%
Moderate Thinness 24 persons 51.1%
Severe Thinness 19 persons 40.4%
Total (N) 47 persons

Factors that Related to the Low Nutritional Status among Tuberculosis Patients

Table 2. Matrix correlation between independent variables and low nutritional status
among TB patients.
 Independent Variables p
1. Age1 0.180
2. Gender2 0.633
3. Education3 0.453
4. Job3 0.016*
5. Family Knowledge1 0.370
6. Culture2 0.281
Note: 1Kendall’s Tau; (2) = Mann-Whitney; 3Spearman’s Rank
*Correlation is significant at the .05 level (2-tailed)

Discussion

75
Based on the results of the research, age is not associated with low nutritional Commented [A3]: It is better to find finding research
related to age and nutritional status among general
status in patients with tuberculosis. This is not in accordance with Wong (1995) and communicable disease, particularly TB survivors.

Edelman & Manle (1994) in Potter (2005) stated that age can show an individual
learning level, cognitive and behavioral abilities. Djaali’s (2007) also stated that the
more age increases the more capacity and mindset to develop so that the knowledge
gained is getting better. But other research also explains that the older age of a person,
the memory will also decrease (Putri et al., 2016).

The results also showed that gender was not associated with low nutritional
status in patients with tuberculosis. This is supported by research conducted by
Mahanani (2013) in Putri, et al. (2016) which explained that gender is related to life
roles and different behaviors between men and women in society. Another reason is
also mentioned because biological factors, namely women have a greater ability to
adapt to starving (Bharvaga, 2013).
Commented [A4]: I found inconsistent explanation about
gender and low nutritional status in both reference that you
mention. It is better to see other reference talking about
factor related gender and nutritional status among TB
survivors.
It is better to adding some explanation about higher amount
women participant that involve in your study. It would be
related with higher prevalence of women TB survivor in
Malang City or other reason.
109

In addition, education is also not related to the low nutritional status of patients
with tuberculosis. The statement is not in accordance with the research of Widianti
(2007) in Putri, et al. (2016) which stated that through knowledge obtained during
formal education, people with highly educated will have broader knowledge than those
with low education, in this case regarding health knowledge. Nevertheless, education
can also be connected to age and knowledge. According to Wong (1995) in Potter
Commented [A5]: At this point, you needs to find the
spesific reason why education (both formal and informal)
was not related to nutritional status among TB survivors.
You can explain more about theory or other research
finding to find better justification.
(2005), learning, cognitive, and behavioral abilities can be demonstrated through age.
The more mature the level of development of the age, the more learning ability to
perform, cognitive and behavior will increase (Putri et al., 2016). Meanwhile, the
increase in knowledge is the result of interaction with others, it is possible through
these interactions that individual will get new information and understanding (Putri et
al., 2018) Thus, information related to new things is not only obtained through formal
education but also through information obtained in the community. The results of the
research showed that not only low-educated people who experience low nutritional
status but people with higher education level also experience low nutrition status too. Commented [A6]: So, what is other research opinion
about this point? It is better to you to explain other
research that supported you research finding.
Another research stated that family knowledge is not related to low nutritional
Commented [A7]:
status of patients with tuberculosis. As explained above, the knowledge level not only
corresponds with formal education but also age and social interaction. The results of
the research showed that most of the patients have poor knowledge and low nutrition
even they have already graduated from senior high school and undergraduate program.
This condition occurred due to information accessibility is not spread well. By having
good knowledge about nutritional foods, the type and number of food consumed will
be taken into account. However, the spread of information will increase individual
knowledge and understanding regarding disease information (Driscoll et al., 2009 in
Mohammadpour, 2015). Essentially, knowledge also can be influenced by people
interaction. It helps an individual to develop the knowledge and hopefully, an
individual will treat himself well (Mohammadpour, 2015).

Culture does not influence low nutritional status in TB patients. It is related to

abstinence of consuming certain foods. According to Dodor (2008), belief to a certain

food can affect nutritional status in TB patients. Shivalli et al. (2015) revealed that
culture is responsible for the occurrence of the disease. Nutritional treatment of TB can
be solved by identifying and preventing the cause of poor nutrition through education,
counseling, and dietary habit. In a severe case, nutritional treatment aims at reducing
death risk and rehabilitation period (WHOb, 2013). Somehow, several foods should be
avoided due to cough stimulus can distract the respiratory system of TB patients.

However, the results also indicated that job relates to low nutritional status in
TB patients. The percentage stated that working and not working patients are not deeply
different. It is in accordance with Dodor (2008), nutritional status is related to marriage
status, monthly income, and avoiding certain foods. Job surely affects individual
income. Winetsky et al. (2014) explained that low access to nutrition corresponds with
the low economy condition, difficulty in obtaining nutritional food, and a geographical
factor which affect the occurrence of TB. Melizza (2018) showed that instrumental
support of family in term of dietary supplements, treatment cost, and taking the patient
to the hospital can affect nutritional status in TB patients.

Conclusion

According to the previous theory, there are numerous factors that influence
nutritional statuses, such as age, gender, education, job, family knowledge, and culture.
However, the most dominant factor is job. The job is highly related to nutrition intake
and family attention to treat TB patients.

Acknowledgment

The author would like to thank the University of Muhammadiyah Malang –

Indonesia.

References

Bhargava, A, Chatterjee, M, Jain, Y, Chatterjee, B, Kataria, A, Bhargava, M, Kataria,

R, D’Souza, R, Jain, R, Benedetti, A, Pai, M, & Menzies, D 2013, Nutritional
Status of Adult Patients with Pulmonary Tuberculosis in Rural Central India and
Its Association with Mortality, Plos One, vol. 8, no. 10, accessed on September
21, 2017, <http://journals.plos.org/plosone/article?id=
10.1371/journal.pone.0077979>
Djojodibroto, D 2009, Respirologi (Respiratory medicine), EGC, Jakarta.
Dodor, E 2008, Evaluation of nutritional status of new tuberculosis patients at the Effia-
Nwanta Regional Hospital, Ghana Medical Journal, vol. 42, no. 1, page. 22-28,
accessed on September 24, 2017, <https://www.ncbi.nlm.nih.gov/
pmc/articles/PMC2423338/>
Melizza, Nur 2018, Pengaruh Intervensi Supportive Educative System Berbasis
Intergrasi Selfcare dan Family Nursing Model terhadap Peningkatan Stats Gizi
Penderita Tuberkulosis, Thesis, Universitas Airlangga Surabaya.
Mohammadpour, A, Sharghi, NR, Khosravan, S, Alami, A & Akhomd, M 2015, The
effect of a supportive educational intervention developed based on the Orem’s
self-care theory on the self-care ability of patients with myocardial infarction: a
randomised controlled trial, Journal of Clinical Nursing, accessed on November
7, 2017, <https://www.ncbi.nlm.nih.gov/pubmed/ 25880700>
Putri M, Harmayetty, Utomo B 2016, Psychoeducative FamilyTherapy
Mempeengaruhi Pengetahuan, Dukungan Keluarga dan Stigma Kusta, Journal of
Nurse, vol. 11, no. 1, page 88-98
Potter, Perry 2010, Fundamental Of Nursing: Consep, Proses, and Practice Edisi 7
Vol. 3, EGC, Jakarta
Saputra, L 2013, Pengantar Kebutuhan Dasar Manusia, Binarupa Aksara, Pamulang
Shivalli, S, Majra, JP, Akshaya, KM & Qadiri, GJ 2015, Family Centered Approach in
Primary Health Care: Experience from an Urban Area of Mangalore, India,
Scientific World Journal, vol. 2015, accessed on November 7, 2017, <
https://www.hindawi.com/journals/tswj/2015/419192/>
Si, ZL, Kang, LL, Shen, XB, Zhou, YZ 2015, Adjuvant Efficacy of Nutrition Support
During Pulmonary Tuberculosis Treating Course: Systematic Review and Meta-
analysis, Chinese Medical Journal, vol. 128, no. 23, page. 3219-3230, accessed
on September 19, 2017, <https://www.ncbi.nlm.nih.gov /pubmed/26612299>
Winetsky DE, Almukhamedov, O, Pulatov, D, Vezhnina, N, Dooronbekova, A &
Zhussupov 2014, Prevalence, Risk Factors and Social Context of Active
Pulmonary Tuberculosis among Prison Inmates in Tajikistan, Plos One, vol. 9,
issue 1, accessed on October 2, 2017, <journals.plos.org
/plosone/article?id=10.1371/journal.pone.0086046>
World Health Organization 2013a, Global Tuberculosis Report, WHO, Geneva.
World Health Organization 2013b, Guideline: Nutritional Care and Support for
Patients with Tuberculosis, WHO, Geneva.