BMI and sociodemographic characteristic among patients with tuberculosis attending a DOTS clinic at a tertiary care hospital in Kathmandu, Nepal

Tuberculosis (TB), an infectious disease caused by Mycobacterium tuberculosis is a serious public health threat in low-and middle-income countries. In tuberculosis, the sociodemographic aspects play a significant role in increasing the susceptibility to infection. The current study aimed to study the BMI and sociodemographic characteristic among patients with tuberculosis attending a DOTS clinic at a tertiary care hospital of Kathmandu. An observational descriptive cross sectional study using census sampling technique was conducted among 170 persons with tuberculosis coming for ATT drugs in Community Medicine OPD of Nepal Medical College Teaching Hospital. The information was obtained using self-constructed structured questionnaire from the study population. The information regarding socioeconomic characteristics, medical and family history, type and clinical presentation of tuberculosis and anthropometric measurement were taken. Out of 170 tuberculosis patient 93 had pulmonary tuberculosis, 71 had extrapulmonary tuberculosis and 6 had both. The different types of tuberculosis showed the association with occupation of respondents, family types, socioeconomic status, family size, BCG scar and social habits before tuberculosis. Weight loss and cough were most common clinical presentation among the participants whereas lymphnode and gastrointestinal tract were most common sites for extrapulmonary tuberculosis. According to BMI, 16.5% of the study population were underweight. Thus, the present study provides valuable information regarding association of sociodemographic factors with tuberculosis and nutritional status of persons with tuberculosis.


INTRODUCTION
Tuberculosis (TB) is a communicable disease that is a major public health problem and one of the leading cause of death worldwide.Until the coronavirus (COVID-19) pandemic, TB was the leading cause of death from a single infectious agent, ranking above HIV/AIDS.A total of 1.5 million people died from TB in 2020 (including 214 000 people with HIV).Worldwide, TB is the 13th leading cause of death and the second leading infectious killer after COVID-19 (above HIV/AIDS).In 2020, an estimated 10 million people fell ill with tuberculosis (TB) worldwide in which 5.6 million were men, 3.3 million were women and 1.1 million were children.The number of people acquiring infection and developing disease (and thus the number of deaths caused by TB) can be reduced through multisectoral action like by addressing TB determinants such as poverty, undernutrition, overcrowding, HIV infection, smoking and diabetes.Some countries have already reduced their burden of TB disease to fewer than 10 cases and less than 1 death per 100 000 population per year. 1 Globally, TB incidence is falling at about 2% per year and between 2015 and 2020 the cumulative reduction was 11%.This was over half way to the End TB Strategy milestone of 20% reduction between 2015 and 2020.An estimated 66 million lives were saved through TB diagnosis and treatment between 2000 and 2020. 2 The tuberculosis (TB) epidemic is strongly influenced by social and economic development and health-related risk factors. 1 TB cases are highest in developing countries and in marginalized areas such as slums in big cities. 3 Persons infected by Mycobacterium tuberculosis may not develop symptoms of TB (latent TB); nonetheless, infected individuals have a 5-15% lifetime risk of becoming sick within 2-5 years of getting the infection.However, individuals who are immunocompromised such as people with HIV, diabetes, malnutrition, and older adults and children have a higher risk of developing symptoms of TB. 4 It has been shown that the areas with the highest TB incidence are also those with high incidence of HIV infection, incarceration, unemployment and immigrants. 5lobally, over 90% of TB patients are in lowand middle-income countries and the cases remain mainly clustered among economically and socially disadvantaged groups. 6 of 2021, Nepal is one of the high TB burden countries, with an increasing prevalence of cases. 7The National TB prevalence survey 2018-19 was the first ever nationally representative TB survey to understand the actual TB disease burden in the general population in Nepal.According to the survey, currently over 117 000 people are living with TB disease in Nepal and its prevalence is 416 per 100000 population.Likewise, 69 000 people developed TB in 2018-19.Its burden (incidence) is 245 per 100000 population which is much higher (1.6 times) than previously estimated and its prevalence is much higher among elderly and in men and also its prevalence was found more in hills and terai as compared with mountain and Kathmandu valley. 8The incidence of tuberculosis (per 100,000 people) in Nepal was 238 in fiscal year 2075/76. 9e aim of our study is to assess the BMI and socio-demographic characteristics of TB patients seeking treatment from tertiary care teaching hospital, Kathmandu, Nepal.

Materials and METHODs
This is an observational descriptive cross sectional study using census sampling technique.The study was conducted among persons with tuberculosis coming for ATT drugs to the DOTS clinic in Community Medicine OPD of Nepal Medical College Teaching Hospital from June 2022 to January 2023.Ethical approval was taken from Institutional Review Committee (IRC) of NMCTH.The study participants included patients of all the age group referred from other departments within the hospital and also outside from other centres who were diagnosed with tuberculosis on the basis of sputum smear, sputum culture, Mantoux test, Chest-radiograph, GeneXpert, cytological and histopathological examination.Patients not willing to participate in the study or not in position to give information (hearing, speech impairments or mental illness) were excluded from the study.The total sample size was 170.The tuberculosis patients of the study period were explained about the purpose of the visit and consent was obtained.Their interview was taken using the self-constructed structured questionnaire.During the interview with the participants the information regarding socioeconomic characteristics, medical and family history, type and clinical presentation of tuberculosis and anthropometric measurement were obtained.After measuring the height by measuring tape and weight by bathroom weighing scale, BMI was calculated as Weight(kg)/Height(m 2 ).BMI is based on weight and height of the individual and measured by weight in kg and height in m 2 . 10e collected data were entered in Microsoft excel sheet and statistical analysis were

DISCUSSION
The study conducted by Sajith et al, 11 showed tuberculosis was found to be more among 25-34 years age group, married, employed, alcoholic and also among female in compare with male.
Similarly in other study conducted by Saber et al, 12 showed that tuberculosis was found more among male, joint family, ≥8 family members, employed and residents of rural area.In the study conducted by Laghari et al, 13 52.8% were females and 47.2% were male.In this study the common age group was 20-30 years, female, married, not working, nuclear family members and with ≤4 family members.In this study it also showed the different types of tuberculosis had association with occupation of respondents, family types, socioeconomic status, family size, BCG scar and social habits before tuberculosis.
In the study conducted by Song et al, 14  In the study conducted by Shrestha et al, 19 study showed that there was positive and significant correlation among BMI and age and the similar result was present of Mungreiphy et al 20 .In this study also there was significant positive correlation of age with BMI.It showed that BMI increased with increase of age.
In conclusion, the study showed that weight loss and cough were most common clinical presentation among the participants.It showed the most common site for extrapulmonary tuberculosis were lymphnode and gastrointestinal tract.The study showed that the different types of tuberculosis was associated with occupation of respondents, family types, socioeconomic status, family numbers, presence of BCG scar and social habits such as smoking and alcohol consumption before tuberculosis.

Table 1
continued... carried out using SPSS 16.Frequency of sociodemographic and clinical characteristics of tuberculosis patients, correlation analysis were performed to see the association between age and BMI, Chi square test were performed to see the association of different variables with tuberculosis and binary logistic regression analysis of tuberculosis with sociodemographic and clinical characteristics.

Table 2 : Association of different variables with tuberculosis Variables Pulmonary and both (n) Extrapulmonary (n) Chi Sq. value P-value Age (Years)
In table 4, there was significant positive correlation of age with BMI.It showed that BMI increased with increase of age.As shown in table 5, weight loss and cough were most common clinical presentation

Table 3 : Binary Logistic regression analysis of tuberculosis with sociodemographic and clinical characteristics
Binary logistic regression analysis: Family types, Family size, Socioeconomic status, BCG scar, Social habits, Occupation of patient.

Table 4 : Correlation between age and BMI Variables Age BMI
**. Correlation is significant at the 0.01 level(2-tailed)

Table 5 : Various clinical presentation among study population
*Multiple response were present