To use health care effectively, respect for the principles is necessary. Because of the clear bidirectional causal relationship between malnutrition and active tuberculosis, nutritional screening, assessment, and management are integral components of tuberculosis treatment and care.
Scope and purpose
There is no evidence that nutritional management of acute malnutrition in patients with active TB should be different from that in those without active TB. Closer nutritional monitoring and earlier initiation of nutritional support (before the first 2 months of TB treatment is completed) should be considered if the nutritional indicator approaches the threshold for a diagnosis of severe malnutrition.
Background
Because malnutrition increases the risk of progression from TB infection to active TB disease, food insecurity and poor overall nutritional status in the population are important contributors to the global burden of TB disease. Initiating tuberculosis treatment earlier in pregnancy is generally associated with better maternal and infant outcomes (37, 39).
Guideline development process
The guideline development group discussed the relevance of the questions and modified them as necessary. WHO technical staff, together with method experts from the guideline group, prepared evidence summaries according to the Grading of Recommendations Assessment, Development and Evaluation (64) (GRADE) approach to assess the overall quality of the evidence (65). At least two-thirds of the guideline development group had to be present for the initial discussion of the evidence and the proposed recommendations and comments.
The WHO Secretariat collected the forms and disclosed the summary of results to the guideline development group. If there was not complete agreement, a two-thirds vote of the guideline development group would have been required. A draft of the revised principles and recommendations was circulated for external peer review in February 2012.
All guideline group members and guideline development meeting participants submitted a declaration of interest form along with their curriculum vitae prior to each meeting.
Summary of the evidence
Providing free food or high-energy nutritional products may produce a modest increase in weight gain during treatment for active TB (moderate-quality evidence). A literature review was conducted to investigate whether family contacts with poor nutritional status were at higher risk of contracting or developing active TB disease. Six studies were identified on the risk to children in contact with people with active TB.
Two of the studies found that malnutrition and younger age individually increased the risk of household contacts developing active TB. Although malnutrition is a risk factor for progression from TB infection to active TB disease, it is not known whether and by how much macro- or micronutrient supplementation reduces the risk of progression. Among young children who have recently had contact with a case of active TB, it is not known whether nutritional supplementation in combination with treatment of latent TB infection reduces the risk of progression to active TB more than treatment for latent TB infection alone.
Risk of micronutrient deficiency in people with active TB compared to people without TB.
Key principles
When malnutrition is identified at the time of tuberculosis diagnosis, tuberculosis should be considered as an important causative factor that needs to be addressed. As an integral part of tuberculosis care and control, health care should recognize and help address common malnutrition, food insecurity and other socio-economic determinants and consequences of tuberculosis. Such interventions can also help alleviate some of the financial and social consequences of tuberculosis.
While food and nutrition are essential to the health and well-being of all individuals, food assistance may not be the best or most appropriate factor for access to and adherence to TB treatment, nor the best way to mitigate the catastrophic economic and social costs of TB. . The increasing prevalence of diabetes in low- and middle-income countries contributes to the persistently high incidence of tuberculosis. Diabetes mellitus triples the risk of developing tuberculosis and can worsen the clinical course of tuberculosis.
Diet is an important component of the management of diabetes mellitus and should be part of nutritional counseling of TB patients.
Recommendations
A multi-micronutrient supplement should be provided daily at a recommended nutrient intake in situations where fortified or complementary foods should have been provided in accordance with standard treatment of moderate malnutrition (2, 4) but are not available (conditional recommendation, very low quality evidence). ). All lactating women with active tuberculosis should be provided with iron and folic acid and other vitamins and minerals, according to the United Nations Multiple Micronutrient Preparation (5), to supplement their mothers' micronutrient needs (conditional recommendation, evidence of very low quality). If malnutrition is identified, it should be treated according to WHO recommendations (2-4) (conditional recommendation, very low quality evidence).
There is no evidence to recommend that nutritional management of severe acute malnutrition should be different in patients with active tuberculosis than in those without active tuberculosis. There is no evidence to recommend that nutritional management of severe acute malnutrition in children with active tuberculosis should be different from that in those without active tuberculosis. There is no evidence to recommend that nutritional management of moderate malnutrition should be different for children (<5 years) with active tuberculosis than for those without.
There is insufficient evidence to recommend that antenatal supplementation of calcium, iron and folic acid should be different for pregnant women with active TB than for those without TB.
Dissemination, adaptation and implementation Dissemination
More careful nutritional monitoring and earlier initiation of nutritional support (before the first two months of tuberculosis treatment are completed) should be considered if the nutritional indicator approaches the cut-off value for a diagnosis of severe acute malnutrition. Efforts should be made, within sound principles of nutritional assessment, advice and support, to ensure that TB patients receive the recommended micronutrient intake, preferably through food or fortified foods. The scientific basis supporting the revised principles and recommendations will be published and made available on CD-ROM.
As it is a global guideline, it needs to be adapted to the context of the Member States. Ideally, these recommendations should be implemented as part of an integrated program of TB care and support. EVIPNet fosters country-level partnerships between policy makers, researchers and civil society to facilitate policy development and implementation using the best available evidence.
The impact of this guideline can be assessed within countries (i.e. monitoring and evaluation of programs implemented at the national or regional scale) and between countries (i.e. adoption and adaptation of the guideline globally).
Plans for updating the guideline
Before implementing these principles and recommendations, a public health program must have well-defined goals that take into account available resources, existing policies, appropriate delivery platforms and suppliers, communication channels, and potential stakeholders. To ensure that WHO global guidelines and other evidence-based recommendations for dietary interventions are better implemented in low- and middle-income countries, the Ministry of Food for Health and Development is working with the WHO Evidence-Informed Policy Network (EVIPNet) (81) . ). For global evaluation, the WHO Division of Nutrition for Health and Development has developed a centralized platform to share information on nutrition interventions in public health practice implemented worldwide.
Technical note: Complementary food for the management of moderate acute malnutrition in infants and children 6-59 months of age. Formulation of a multi-micronutrient supplement to be used in pilot programs among pregnant women in developing countries: report of a United Nations Children's Fund (UNICEF), World Health Organization (WHO), United Nations University (UNU) workshop. Moderate to severe malnutrition in patients with tuberculosis is a risk factor associated with early death.
Washington DC: Agency for International Development; 2008 (http://pdf.usaid.gov/pdf_docs/PNADL992.pdf, accessed September 3, 2013).
GRADE summary of findings tables
High quality: We are very confident that the true effect is close to the effect estimate. The true effect is likely to be close to the effect estimate, but there is a possibility that it is significantly different. The true effect is likely to be significantly different from the effect estimate.
The basis for the assumed risk (eg, the average risk of the control group across studies) is given in the footnotes. Mean BMI at baseline was 16.7 in the supplement group and 17.9 in the control group. 14 A study in the United Republic of Tanzania randomized 865 adults with TB plus HIV infection to receive six high-energy protein biscuits or one.
Summary of the Dietary Guidelines Advisory Group's considerations in determining the strength of the recommendation.
Summary of the Nutrition Guidance Advisory Group’s considerations for determining the strength of the recommendation
Resource implications: The resource implications of this recommendation for TB programs are considered moderate to high and may not be achievable in some settings. Resource implications: The resource implications of this recommendation for TB programs are considered moderate to high and. Resource Implications: The resource implications of this provision for TB programs are considered high and may not be achievable in some settings.
Treatment of children with moderate malnutrition and active tuberculosis. Quality of evidence: Very low. Treatment of pregnant women with moderate malnutrition and active tuberculosis. Quality of evidence: Very low. Resource implications: The resource implications of this recommendation for TB programs are considered low, and this could ideally be implemented through antenatal care.
Resource Implications: The resource implications of this provision for TB screening programs are considered low.
Questions in population, intervention, control, outcomes (PICO) format
Department of Food and Nutrition California Polytechnic State University San Luis Obispo, United States Research, Nutrition and HIV/TB. National Institutes of Health Bethesda, United States Program Management, Policy, Research, Nutrition and HIV. Gillings School of Global Public Health University of North Carolina Chapel Hill United States Nutrition Epidemiology and Molecular Epidemiology of Tuberculosis and HIV Pediatric HIV Care Mathematical Modeling of Infectious Disease Dr Christine Wanke.
Tufts University School of Medicine Boston, United States of America Women and gender, HIV and nutrition. Coordinator of the Maternal and Perinatal Health and Prevention of Unsafe Abortion Team, Reproductive Health and Research Department. Food and Nutrition Technical Working Group U.S. Agency for International Development, Office of HIV/AIDS.
Dr. Renuka Jayatissa Department of Nutrition Medical Research Institute Colombo, Sri Lanka Dr. Awal Khan.
