The Role Of Diabetes Co-Morbidity for Tuberculosis Treatment Outcomes

Daniel Faurholt-Jepsen, Nyagosya Range, George Praygod, Jeremiah Kidola, Maria Faurholt-Jepsen, Martine G, Aabye, John Changalucha, Dirk L. Christensen, Torben Martinussen, Henrik Krarup, Danie R Witte, Ase B Andersen, Henrik Friis (2012:12)

Abstract
Background :

To study association between diabetes & TB

Methods :

Linear mixed-effect model (repeated measurement)

Results :

1,3 kg & 1,0 kg; 0,6 g/dL & 0,5 g/dL

Conclussion :

TB patients with diabetes experience delay recovery of bodymass and hemoglobin

Background
Due to the association between diabetes

and pulmonary TB, diabetes may threaten the control of TB. In a prospective cohort study nested in a nutrition trial, we investigated the role of diabetes on changes in anthropometry, grip strength, and clinical parameters over a five months fol

Methods

Cohort study, 2 large randomized, double blind, controlled nutrition interventional study with all patient diagnosed and treated for TB according to international guidelines. Measurement :

TB patient : use Spot-morning-spot sample Weight & height : barefoot, minimal clothing Waist circumference : lower costa-iliac crest AFA & AMA : use TST & MUAC Grip strength : digital hand dynamometer Diabetes : FBG > 108 mg/dL ; 2 h pp > 198 mg/dL HIV : ELISA CD4 : flow cytometry

Results
Of 1205 TB patients, the mean (standard

deviation) age was 36,6 (13,0) years, 40,5% were females, 48,9% were HIV co-infected, and 16,3% had diabetes. TB patient with diabetes co-morbidity experienced a lower weight gain at two (1,3kg) and five months (1,0kg). Similarly, the increase in the level of hemoglobin was lower among TB with diabetes co-morbidity after two (0,6 g/dL)and five months (0,5 g/dL)of TB treatment, respectively

Background characteristics
Patient w/o diabetes Age (SD) Female sex HIV infection TB status PTBPTB+ Ethnic Group Msukuma tribe Other tribe 459 (45,6) 584 (54,4) 94 (47,7) 103 (52,3) 0,582 * 339 (33,6) 669 (66,4) 83 (32,0) 134 (68,0) 0,65 * 36,3 (12,8) 404 (40,1) 507 (50,3) Patient w/ diabetes 38,0 (13,8) 89 (45,2) 97 (49,2) p 0,083 0,183 0,786

Patient w/o diabetes Marital status Single 249 (24,9)

Patient w/ diabetes 42 (21,5)

0,605

Married
Divorced Occupation Farmer/fisherman Employed Housewife Unemployed

528 (52,8)
223 (22,3) 394 (39,2) 356 (35,4) 120 (11,9) 51 (5,1)

108 (55,4)
45 (23,1) 75 (38,3) 74 (37,8) 23 (11,7) 9 (4,6) 0,974 * * *

Patient w/o diabetes Religion Christian * 741 (73,8)

Patient w/ diabetes * 155 (78,7)

P * 0.191

Muslim
Smoking Never Past smoker Current smoker Take alcohol No Yes

223 (22,1)
* 675 (82,9) 110 (85,9) 216 (84,7) * 533 (82,9) 475 (84,5)

38 (19,3)
* 139 (17,1) 18 (14,1) 39 (15,3) * 110 (17,1) 87 (15,5)

*
* 0.60 * * * *

Patients w/o diabetes Weight, kg Baseline * 51,8

Patients w/ diabetes * 53,3

P * *

2 months
Increase 5 months Increase

54,8
3,0 57,1 5,3

55,1
1,7 * 57,7 4,3 *

*
* 0,001 * * 0,007

Difference 1,3

Difference 1,0

Patient w/o diabetes BMI, kg/m2 Baseline * 18,7

Patient w/ diabetes * 19,3

P * *

2 months
Increase 5 months Increase

19,8
1,1 20,7 1,9

19,9
0,6 * 20,9 1,6 *

*
* 0,001 * * 0,012

Difference 0,5

Difference 0,3

Patients w/o Patients w/ diabetes diabetes Waist circumference, cm * Baseline 72,1 * 73,7

P * *

2 months
Increase Difference 5 months Increase Difference

74,5
2,4 0,3 76,3 4,2 0,1

75,8
2,1 * 77,8 4,1 *

*
* 0,512 * * 0.697

Patients w/o diabetes AMA, mm2 Baseline * 34,6

Patients w/ diabetes * 35,6

P * *

2 months
Increase 5 months Increase

37,2
2,7 40,7 6,2

37,4
1,7 * 41,0 5,4 *

*
* 0,100 * * 0,164

Difference 0,9

Difference 0,8

Patients w/o diabetes AFA, mm2 Baseline * 8,1

Patients w/ diabetes * 8,3

P * *

2 months
Increase Difference 5 months Increase Difference

9,2
1,1 0.4 10,4 2,3 0,2

9,0
0,8 * 10,4 2,1 *

*
* 0,297 * * 0,524

Patients w/o diabetes Grip Strength, kg Baseline 2 months Increase Difference 5 months Increase Difference * 25,8 27,6 1,8 0,2 30,5 4,7 0,3

Patients w/ diabetes * 25,2 26,8 1,6 * 29,6 4,4 *

P * * * * 0,610 * * 0,550

Change in hemoglobin level

Patients w/o diabetes Hemoglobin, g/dL Baseline 2 months Increase Difference 5 months Increase Difference * 10.8 12.3 1.6 0.6 13.0 2.2 0.5 Patients w/ diabetes * 10.7 11.7 1.0 * 12.4 1.7 * P * * * * <0.001 * * 0.004

Patients w/o diabetes Whiteblood cell count Baseline 2 months Increase Difference 5 months Increase Difference * 6.4 4.7 -1.7 0.02 4.3 -2.2 -0.03

Patients w/ diabetes * 6.8 5.0 -1.7 * 4.6 -2.2 *

P * * * * 0.918 * * 0.889

Patients w/o diabetes Neutrophil count Baseline 2 months Increase Difference 5 months Increase Difference * 4.1 2.3 -1.8 0.1 1.8 -2.3 0.1

Patients w/ diabetes * 4.6 2.6 -2.0 * 2.2 -2.3 *

P * * * * 0.493 * * 0.658

Patients w/o diabetes CD4 count Baseline * 425.9

Patients w/ diabetes * 409.2

P * *

2 months
Increase Difference 5 months Increase Difference

477.5
51.7 25.7 436.2 10.3 22.8

435.1
25.9 * 396.6 -12.5 *

*
* 0.362 * * 0.431

Mean weight increase

non diabetes2
diabetes

Mean hemoglobin

non diabetes
diabetes

Discussion
Diabetes co-morbidity was associated with

delayed recovery of weight and hemoglobin level within the first two and 5 months of TB treatment not affected by diabetes

Functional recovery based on grip strength Low level of hemoglobin at baseline are

primarily inflamation-induced anemia from on-going HIV and TB infection, the hemoglobin level is expected to rise during recovery

 The differences did not depend on TB status

On average the participants gained three

and five kg over the two and five months treatment period, but diabetes patient had a one kg weight deficit months) were not effected by diabetes comorbiditiy.

Fluctuations in CD4 level (increase in first two

Conclussion
TB patients initiating TB treatment with

diabetes co-morbidity may experience slower recovery from their TB disease such as anthropometry and hemoglobin
return to work, and thus the delay may not only have beneficial health outcomes, but also economically consequences for low income families burdened by TB

This study focused on general outcomes

A quick functional recovery lead to sooner