NUTRITIONAL STATUS OF PATIENTS WITH TUBERCULOSIS AND TB/HIV CO-INFECTION AT STANDERTON TB SPECIALISED HOSPITAL, MPUMALANGA Janke Wessels Submitted in fulfilment of the requirements of the degree Magister in Dietetics in the Faculty of Health Sciences Department of Nutrition and Dietetics University of the Free State Bloemfontein South Africa June 2017 SUPERVISOR: Prof CM Walsh, Ph D DECLARATION I, Janke Wessels, identity number 9004220023082 and student number 2008007022, hereby declare that master’s research dissertation that I herewith submit at the University of the Free State, is my independent work and that I have not previously submitted it for a qualification at another institution of higher education. I, Janke Wessels, hereby declare that I am aware that the copyright is vested in the University of the Free State. I, Janke Wessels, hereby declare that all royalties as regards intellectual property that was developed during the course of and/or in connection with the study at the University of the Free State, will accrue to the University. Janke Wessels January 2017 i ACKNOWLEDGEMENTS  My Heavenly Father, without Him this study would not have been possible;  My family for their prayers and moral support, especially my husband and mother who always encouraged me;  Prof Corinna Walsh, of the Department of Nutrition and Dietetics, University of the Free State, my supervisor, for all her support, inspiration and efficient feedback;  Miss. Riette Nel, of the Department of Biostatistics, University of the Free State, for her efficient assistance with the statistical analysis of the data;  The respondents for taking part in the study. ≈≈≈≈≈≈≈≈≈ ii LIST OF ABBREVIATIONS AIDS - acquired immune deficiency syndrome ART - antiretroviral therapy ASSAf - Academy of Science in South Africa BCG - bacille Calmette–Guérin BMI - Body Mass Index CCHIP - Community Childhood Hunger Identification Project CEO - Corporate Executive Officer CI - confidence intervals cm - centimetre CRP - C-reactive protein DOTS - Directly Observed Therapy, Short-course E - Ethambutol ECUFS - Ethics Committee of the Faculty of Health Sciences, University of the Free State EPTB - extra-pulmonary tuberculosis g/dl - gram per decilitre g/kg - gram per kilogram g/l - gram per litre H - Isoniazid HBCs - high burden countries HIV - Human Immunodeficiency Virus IUATLD - International Union against Tuberculosis and Lung Disease kcal/kg - kilocalorie per kilogram kg - kilogram iii kg/m² - kilogram per metre square MCT - medium-chain triglycerides MCV - mean corpuscular volume MDR TB - multi-drug resistance tuberculosis mm - millimetre mm³ - cubic millimetre mg/l - milligram per litre ml/kg - millilitre per kilogram M. tb - Mycobacterium tuberculosis MUAC - Mid-upper arm circumference MUST - Malnutrition Universal Screening Tool NFCS - National Food Consumption Survey NHNES - National Health and Nutrition Examination Survey OR - odd ratio PHREC - Provincial Health and Research Ethics Committee PLHIV - people living with HIV/AIDS ppr - person per room R - Rifampicin REE - resting energy expenditure S - Streptomycin SADoH - South African Department of Health SANHANES - South African National Health and Nutrition Examination Survey SANTA - South African National Tuberculosis Association TB - Tuberculosis iv TST - tubercle skin test UDHR - Universal Declaration of Human Rights UFS - University of the Free State vs. - versus WFP - World Food Programme WHO - World Health Organization XDR TB - extremely-drug resistance tuberculosis Z - Pyrazinamide % - percentage > - greater than < - less than > - equal to or greater than < - equal to or less than v LIST OF TABLES Page Table 2.1: Estimated TB burden in South Africa during 2014 10 Table 2.2: Estimated TB/HIV co-infection burden in South Africa during 2014 10 Table 2.3: Vulnerability factors related to progression to TB disease 27 Table 2.4: Recommended daily dosages of the individual drugs for adults and children >8yrs/ >30kg 27 Table 2.5: Fixed dose combination tablets available for adults and children >8yrs/ >30kg 28 Table 2.6: Standard treatment regimen for adults and children >8yrs/ >30kg 28 Table 2.7: Medications used for the management of TB 29 Table 2.8: Energy and Nutrient requirements for PLHIV and/or TB 33 Table 3.1: Weight classifications by Body Mass Index 41 Table 3.2: Cut-off points for classification of adult- malnutrition by mid-upper arm circumference 41 Table 3.3: Triceps skinfolds in millimetres for females 20 years of age and older 42 Table 3.4: Triceps skinfolds in millimetres for males 20 years of age and older 42 Table 4.l: Socio-demographic information 55 Table 4.2: Vegetable gardens 56 Table 4.3: Responses to Community Childhood Hunger Identification Project questionnaire 57 vi Table 4.4: Household food security 58 Table 5.1: Triceps skinfolds in millimetres for females 20 years of age and older 71 Table 5.2: Triceps skinfolds in millimetres for males 20 years of age and older 71 Table 5.3: Food related side effects according to HIV status 75 Table 5.4: Number of food related side effects experienced 76 Table 5.5: Overall risk of malnutrition 77 Table 5.6: Unplanned weight loss; comparing TB with and without HIV co-infection 78 Table 5.7: BMI, MUAC and triceps skinfold (median), comparing genders by means of 95% CI 79 Table 5.8: BMI, MUAC and triceps skinfold (categories) 80 Table 5.9: Biochemical Parameters (median); according to gender 81 Table 5.10: Biochemical Parameters (categories); according to gender 82 Table 6.1: Median smoking habits of former and current smokers 99 Table 6.2: Smoking habits 99 Table 6.3: Level of education, BMI categories and associations with smoking habits 100 vii Table 6.4: Alcohol use 101 Table 6.5: Level of education, BMI categories and associations with alcohol use 102 Table 6.6: Combined smoking habits and alcohol use 103 viii