A cross-sectional observational study to assess socio-demographic factors in newly diagnosed TB DM comorbidity

Introduction

Diabetes mellitus (DM) has become more common as a result of urbanisation, as well as social and economic development. People who have a weakened immune system, such as those who have diabetes, are more likely to proceed from latent to active disease.¹ When compared to individuals without DM, people with DM have a two to three times higher risk of tuberculosis (TB).² DM is associated with about 10% of all TB cases worldwide.¹ A high percentage of individuals living with DM and TB go undiagnosed or are diagnosed too late. As a result, early discovery can aid in improving the care and control of both disorders.³

If a four-drug intensive phase regimen is changed to a two-drug regimen after two months in the presence of culture-positive time, DM can lengthen the time it takes for sputum culture conversion, resulting in the development of drug resistance.⁴ People with DM and TB have a higher risk of death during therapy and of TB relapse once treatment is completed. The presence of infectious illnesses, such as TB, complicates DM.⁵ Glycaemic management has also been shown to improve treatment outcomes in TB patients. According to recent studies, DM accounts for 20% of smear-positive TB cases,² and that an increase in DM prevalence in India has posed a significant barrier to TB reduction.⁶

There is a lack of literature regarding this comorbidity in Vijayapura Taluk. Therefore, this study was conducted to determine the percentage of DM among TB patients in Vijayapura Taluk, to study the socio-demographic profile of TB patients with DM and to identify potential risk factors.

Methods

Results

Table 1¹² shows that out of 215 study participants, the majority (27%) of them belonged to the age group of 26–35 years old followed by 46–55 (21.9%) and 36–45 (20.9%) years old. In our study, men constituted 64.2% (138) of participants and women constituted 35.8% (77). A total of 88% of the TB patients were from rural backgrounds. Furthermore, 89.8% of the study participants were married, while only 7.9% were unmarried and there were about 2.3% widowed participants in the study. A total of 87.9% of study participants belonged to Hindu religion and the rest of them i.e., 12.1% belonged to the Muslim community. More than half (54.4%) of the study participants studied up to primary school followed by secondary school (23.7%), while 14.9% were illiterate in the study. In this study, 87% (187) of the participants belonged to a nuclear family, while 13% (28) were from a joint family. In our study, 48.8% of the participants belonged to the lower class according to modified BG Prasad classification,¹³ followed by 25.6% in the middle class and 20% in the lower middle class.

Out of 215 study participants, 74% (159) were in the continuation phase (CP) of the TB treatment and 26% (56) were in the intensive phase (IP).

Table 2 details the prevalence of anti-TB treatment adherence. It was found that nearly 10.6% of the study participants were non-adherent to the treatment course.

Out of 215 study participants the percentage of DM was 23.7% (51) (Figure 1).

Figure 1. Distribution of the prevalence of diabetes mellitus (DM) among tuberculosis (TB) patients.

When looking at the food habits of the study participants, 49% were vegetarians and 51% used to consume both vegetarian and non-vegetarian food items. A total of 43.1% of the study participants were current smokers and 51% were ex-smokers, while 5.9% were non-smokers. A majority (70.6%) of the study participants did not consume alcohol and about 29.4% consumed alcohol. Most (90.2%) of the study participants were engaged in moderate physical activity, while 3.9% described themselves as sedentary and 5.9% engaged in heavy physical activity (Table 3).

Univariate regression analysis was applied to ascertain the percentage of DM and its associated risk factors (Table 4). It was found that participants in the age group of 56–65 years old, who were educated until the 7^th standard, who were ex-smokers, those who consumed alcohol and who lead a sedentary lifestyle were the highest risk factors associated with the occurrence of DM, when compared to their counter variables. All these values were statistically significant.

Discussion

Our study showed that majority of the TB patients were in the age group of 26-35 years old (27%). Similar results were found in a study done by Damtew et al.,¹⁴ in Addis Ababa Ethiopia where the majority of patients were 25–44 years of age. A study done by Balakrishnan et al.,¹⁵ in Kerala revealed that most of the patients were 45–54 years of age. Other studies done by Kishan et al.,¹⁶ in Patiala Punjab and Dutt et al.,¹⁷ in Ahemdabad reported that the 40–60 years old age group was the most commonly involved. These differences in age groups may be due to the different location of the study and study design setting. The mean age was found to be 52.1 years old among diabetics and 37.1 years old among non-diabetics, which was similar to a study done by Natarajaboopathy et al.,¹⁸ in Tamil Nadu where the mean age of the DM TB patients was 52.92 years old and was statistically significant. Padmalatha et al.,³ in Andhra Pradesh showed that the mean age was 46.5±10.3 years old among diabetics and 35.8±11.7 years old among non-diabetics.

More than half (54.4%; 117) of the TB patients studied up to primary schooling, 23.7% (51) of patients completed high school education and 14.9% (32) of patients were illiterate, where it was observed that most of the TB patients had received less schooling, which was consistent with other studies. A study done by Sarker et al.,¹⁹ in Bangladesh reported that 25.1% of the participants had primary schooling, 19.8% had secondary schooling and 40.7% were illiterate. Another study by Tahir et al.,²⁰ in Pakistan showed that 51.6% of participants were illiterate, 34.7% had primary schooling and 10.7% had secondary schooling.

In our study, 4.7% of participants were current smokers and 69.3% were non-smokers, which was in line with a study done by Damtew E et al.,¹⁴ in Ethiopia, which revealed that 15% of subjects were smokers and 85% were non-smokers. However, another study done by Ekeke et al.,²¹ in Nigeria showed that 4.8% of participants were non-smokers and 95.2% were current smokers. This variation may be due to different social scenarios.

We found that the majority (84.2%) of the TB patients did not consume alcohol and about 15.8% used to consume alcohol, which was similar to a study by Viswanathan et al.,²² in Tamil Nadu in which 38.9% did not consume alcohol and 1.6% consumed alcohol. While another study by Damtew E et al.,¹⁴ in Ethiopia determined that there wasn’t much difference in alcohol consumption i.e., 51.7% did not consume alcohol and 48.3% consumed alcohol, which may be due to different socio-cultural factors.

The percentage of DM among TB patients in our study was 23.7%, which is consistent with the reports of other studies²³ done in Karnataka State in 2011 where the prevalence was 32%, in Kerala State, 44% (2012) in Tamil Nadu State, and 25% in India (2012). Other studies like an institutional based cross-sectional study done by Padmalatha et al.,³ in Andhra Pradesh showed the prevalence of DM as 30.6%. A facility based cross-sectional study done by Raghuraman et al.,²⁴ in Puducherry (2017) reported the DM prevalence to be 29%. The rise of diabetes in India could potentially affect the prevalence and percentage of tuberculosis (TB) in several ways like, Increased susceptibility:- Diabetes weakens the immune system, making individuals more susceptible to infections, including TB. People with diabetes are at a higher risk of developing active TB if they are exposed to the bacteria that cause it and Higher TB transmission:- Individuals with diabetes who develop active TB may be more likely to transmit the infection to others due to factors such as delayed diagnosis, prolonged infectiousness, and poorer treatment outcomes.

In contrast to the aforementioned findings, another study done in Nigeria by Olayinka et al.,²⁵ found the prevalence to be 5.7%, which could be attributed to differences in demographic characteristics. We employed the American Diabetic Association (ADA) criteria to assess the percentage of DM and studied TB patients registered under the Revised National TB Control Programme (RNTCP).

Some of the variables analysed were based on the information obtained by the study participants hence an element of recall bias and masking of data could be present. TB patients registered under RNTCP were included in the study, thus patients being treated in private hospitals may have missed. Among all the TB patients, only new sputum positive pulmonary TB patients were included, which may be a limitation. In the present study, only a few risk factors of DM were studied. Other risk factors could not be studied due to a lack of resources. Co-morbidity like HIV testing could not be assessed, particularly in remote or resource-constrained areas where TB prevalence is high. Lack of access to testing facilities and trained personnel hindered the assessment of HIV status in TB patients.

The percentage of DM among TB patients was 23.7%, which is quite high so screening of all TB patients should be done just like HIV screening in order to aid in early diagnosis and proper management of the disease. For DMTB patients, regular blood glucose estimation and treatment should be given in DOTS centres along with anti-TB drugs. Primordial prevention can play an important role in preventing the occurrence of DM. Health education regarding the risk factors and symptoms of DM should be given to high-risk groups.

Although the findings were found to be consistent with previously reported studies, direct comparisons are not valid for the reasons stated above, as well as the fact that researchers used different criteria to diagnose the conditions over time, the non-representativeness of patients studied in terms of number and selection criteria, and the different settings of the research. A well-designed large-scale observational study or meta-analysis could resolve the problem.

Conclusions

Routine screening for DM in TB patients should be mandatory due to increases in the prevalence of DM, which would not only help in early diagnosis, but also reduces complications by proper management and in turn will help in the successful outcome of TB treatment.

Data availability