Oral Nutritional Supplementation and Weight Changes During Therapy in Malnourished Patients With Resistant Tuberculosis: A Clinical Trial

Tuberculosis (TB) is linked to poverty, malnutrition, and reduced immunity, with malnutrition both contributing to and resulting from TB.1-3 Active TB increases energy needs, causes protein breakdown, and leads to muscle wasting. Malnutrition, which is common in TB patients, worsens clinical outcomes and increases the risk of death.1 TB treatments can also cause nausea and vomiting, further contributing to malnutrition.4 Thus integrated management is essential for successful treatment.

In India, 68.6% of MDR-TB patients without HIV infection are malnourished, a prevalence comparable to that observed among MDR-TB patients at Persahabatan General Hospital, Jakarta, Indonesia (51.8%).5,6 Malnourished MDR TB patients have worse clinical outcomes, more side effects, and a higher risk of death.7 A BMI under 18.5 kg/m2 and inadequate weight gain during treatment indicate a poor response and increased risk of recurrence.1 Failure to gain weight (≤ 5%) in the first two months of treatment has been demonstrated to be linked to TB recurrence.8 Oral nutritional supplements have demonstrated the potential to improve nutritional status, muscle strength, and immunity, thus potentially facilitating an accelerated treatment process. Studies have also shown that nutritional supplements can improve BMI and gamma interferon levels.9 However, some studies have indicated that despite increased macronutrient intake, MDR TB patients may still experience a decline in body weight.10 This study aims to evaluate whether oral nutritional supplements providing 705 kcal and 30.5 grams of protein daily during the first two months can increase body weight and improve other clinical outcomes of MDR TB patients, including the impact of supplementation on albumin, globulin, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels.

Inclusion criteria

• Who had access to electronic devices (e.g., mobile phones) for adherence monitoring
• individuals newly diagnosed with rifampicin-resistant pulmonary tuberculosis (RR-TB), multidrug-resistant tuberculosis (MDR-TB), or pre-extensively drug-resistant tuberculosis (Pre-XDR-TB) at the drug-resistant tuberculosis outpatient clinic of Persahabatan General Hospital, Jakarta, Indonesia.
• BMI of 13-20 kg/m²
• had received standardized or individualized treatment regimens for seven days
• had no severe drug-induced hepatitis indicated by elevated liver enzymes >5 times the normal upper limit

Exclusion criteria

• individuals with HIV infection,
• end-stage renal failure,
• severe anemia (hemoglobin <8 g/dL),
• severe hypoalbuminemia (albumin <2.5 g/dL),
• acute or chronic liver diseases (including hepatitis, cirrhosis, or jaundice),
• cancer,
• interstitial lung disease (ILD),
• anatomical gastrointestinal disorders (either congenital or post-surgical),
• diabetes mellitus,
• long-term corticosteroid or immunosuppressant therapy
• other acute pulmonary infections such as pneumonia,
• exacerbations of chronic obstructive pulmonary disease (COPD), or asthma