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Table of Contents
Year : 2023  |  Volume : 20  |  Issue : 1  |  Page : 28-32

Association of tuberculosis with diabetes and anemia: A hospital-based cross-sectional study from central India

1 Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India
2 Department of Pathology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India
3 Department of Community Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India

Date of Submission06-Apr-2022
Date of Acceptance29-May-2022
Date of Web Publication29-Apr-2023

Correspondence Address:
Abhishek Raut
Department of Community Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha 442102, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/MJBL.MJBL_57_22

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Background: According to the World Health Organization, there were 10.4 million cases of tuberculosis (TB) in 2017 and 1.8 million deaths. The highest prevalence is in Asia, where China, India, Bangladesh, Indonesia, and Pakistan collectively make up over 50% of the global burden. India ranks second in the total number of patients who have diabetes. While the national prevalence of diabetes mellitus in India is estimated at 7.3%, it is higher at 11.2% in urban regions. Objectives: The aim is to determine the association of pulmonary TB with diabetes and anemia. Materials and Methods: A hospital-based cross-sectional study was conducted at a tertiary care rural hospital in central India. The study population was recruited from the DOTS center in the hospital. Complete blood count and blood sugar were carried out. Results: Among 162 patients, 31 were TB-positive. Anemic patients were more significantly at higher odds (odds ratio [OR]=15.18, 95% confidence interval [CI]=3.5, 66.2) of having TB than non-anemic patients. Similarly, diabetic individuals had higher odds (OR=2.3, 95% CI=0.64, 8.1) than non-diabetic individuals for TB, but this association was not statistically significant. Conclusion: In this study, we found a significant association between anemia and TB. Also, there is a probable association between diabetes and TB. So, we suggest that every TB patient be screened for anemia and diabetes.

Keywords: Anemia, diabetes, tuberculosis

How to cite this article:
Rathi A, Patil BU, Raut A. Association of tuberculosis with diabetes and anemia: A hospital-based cross-sectional study from central India. Med J Babylon 2023;20:28-32

How to cite this URL:
Rathi A, Patil BU, Raut A. Association of tuberculosis with diabetes and anemia: A hospital-based cross-sectional study from central India. Med J Babylon [serial online] 2023 [cited 2023 Jun 11];20:28-32. Available from: https://www.medjbabylon.org/text.asp?2023/20/1/28/375151

  Introduction Top

In 1882, Robert Koch discovered the infectious agent (Mycobacterium tuberculosis) of tuberculosis (TB) disease. Nowadays, TB continues to be a devastating and widespread public health problem in developing countries.

TB has been recognized as one of the world’s top 10 causes of death.[1] According to the World Health Organization (WHO), there were 10.4 million cases of TB in 2017 and 1.8 million deaths.[1] India accounts for 24% of the global burden of TB and 29% of the fatalities.[2] Many risk factors, including human immunodeficiency virus (HIV/AIDS), diabetes mellitus (DM), smoking, and malnutrition, can be contributed to TB mortality.[3] Malnutrition, categorized as nutrition, leads to 55% of India’s incidence of TB.[3]

In 2016, India had an estimated 61 million cases of DM patients.[4],[5] The prevalence of DM is rising globally, and by 2030 the global prevalence is predicted to be double.[6] While the national prevalence of DM in India is estimated at 7.3%, it is higher at 11.2% in urban regions.[7] Previous studies have shown that the risk of TB in patients with DM is three times greater than in patients without DM.[8] With the prevalence of DM projected to rise by 67% by 2035, India’s co-burden of TB-DM could lead to a significant public health crisis.[9] In India, both the WHO and the Revised National Tuberculosis Program (RNTCP) have recommended routine diabetes testing among TB patients, particularly in high TB settings.[10],[11] During TB infection, the hematopoietic system is severely affected. It affects all myeloid, lymphoid cell lines, and plasma components.[12] Many hematological abnormalities are prevalent in pulmonary TB, which is a necessary diagnostic aid.[13] These abnormalities are valuable markers that indicate the diagnosis, determine the prognosis, and show the complication of the underlying infection and treatment response.[14]

According to the Global Anemia Report 2011 by the WHO, there were 273.2 million cases of anemia.[15] The highest prevalence of anemia exists in the developing world. Its multifactorial causes range from micronutrient deficiencies such as iron, folate, and vitamin B12 to infectious diseases such as malaria and worm infections.

This study aimed to determine the association of pulmonary TB with diabetes and anemia.

  Materials and Methods Top

This cross-sectional study was conducted after due permission from the Institutional Ethics Committee. A total of 162 cases visited at the DOTS center in the hospital over 4 months from October 2015 to January 2016 and were evaluated prospectively.

Informed written consent was obtained from the willing patients; participants of either gender were included and were subjected to sputum, random and fasting blood glucose, and complete blood count (CBC) test. Patients suffering from HIV-AIDS infection, patients suffering from any other disease and on any drug which affects the blood glucose level, and pregnant mothers were excluded.

As the objective of the study was to find out the association of pulmonary TB with diabetes and anemia, we included suspected patients of TB who were subjected to sputum microscopy for diagnosis purposes; those found positive on sputum microscopy were considered to have the disease (TB) and those found negative on sputum microscopy constituted the comparison group. We assessed the prevalence of diabetes and anemia in both the diseased (TB patients) and comparison groups to study the desired association.

Suspects having cough for more than 15 days were recruited after scrutinizing them through inclusion and exclusion criteria and obtaining written informed consent. We included suspected cases of TB who were subjected to sputum microscopy for the diagnosis of TB.[16] Also, the participants were subjected to biochemical tests such as CBC and blood sugar for the diagnosis of anemia and diabetes, respectively.[17],[18]

Sputum smear microscopy (SSM), a direct microscopic examination of sputum for acid-fast bacilli (AFB), is the recommended first-line investigation for the diagnosis of TB under the National Tuberculosis Elimination Program (NTEP) in India. In alignment with the recommendations under the NTEP, two sputum samples, one “Spot” and one early morning sample, were taken. Even if one sample was positive, the person was considered a case of TB. The same diagnostic criteria were used for the study purpose.[16]

We have used the WHO-specified cut-offs for diagnosing anemia in the present study, i.e., anemia is defined as hemoglobin (Hb) levels <12.0 and <13.0 g/dL in women and men, respectively.[17]

According to the American Diabetes Association, diabetes can be diagnosed using the plasma glucose criteria, such as the fasting plasma glucose (FPG) or 2-hour plasma glucose (2-h PG) values obtained from a 75-g oral glucose tolerance test (OGTT), or A1C criteria. In concordance with this, we have analyzed the fasting and post-prandial samples in the present study. Even if one of these was more than the specified cut-off for fasting (126 mg/dL) or post-prandial (200 mg/dL), the person was considered to have diabetes.[18]

The study involved analysis of de-identified patient data. This being a cross-sectional study, we have used the odds ratio (OR) to measure association in the present study. To study the association, we have applied inferential statistics, both point-estimates (OR) and interval-based estimates (95% confidence interval [CI] of OR). We compared the OR for TB among anemic and non-anemic individuals and diabetic and non-diabetic individuals. If the OR was more than 1, it was considered to increase in odds of causing TB (i.e., positive association). If the 95% CI did not include the null value of 1, it was considered a statistically significant association.

Ethical consideration

The study was conducted in accordance with the ethical principles that have their origin in the Declaration of Helsinki. It was carried out with patients’ verbal and analytical approval before the sample was taken. The study protocol and the subject information and consent form were reviewed and approved by a local Ethics Committee according to the document number IEC/234/2015; MGIMS/IEC/COMMED/76/2015 dated 08/09/2015 to get this approval.

  Results Top

Out of the 162 patients involved in the study, 103 (63%) were males and 59 were females. Among them, 31 were TB-positive, of which the highest proportion (47%) of patients falls in the age group of 30–60 years. This higher proportion of TB patients in the 30–60-year age group and among males could be due to their work-related exposure. This is the group indulging in economically productive work who work outside to earn livelihood for their family, thereby increasing their risk of exposure. Of the total, 22% were addicted to tobacco and 5% to alcohol. Only 2.5% of people (n = 4) had a history of TB.

Of all the presenting symptoms, cough and fever were the most common. Cough was present with a mean of around 68 days and a median of 20 days, whereas fever was there with a mean of approximately 23 days and a median of 15 days.

In our study, it has been found that the prevalence of anemia among males (65%) is much higher than that among females (44%). We can infer that anemic individuals have higher odds (OR=15.18, 95% CI=3.5, 66.2) than non-anemic individuals of having TB, indicating that the association of hemoglobin level with TB is significant. Males have around two times higher odds than females of getting TB, which might be due to their outdoor nature of work. But, in this study, it is not found to be statistically significant. Similarly, diabetic individuals had higher odds (OR=2.3, 95% CI=0.64, 8.1) than non-diabetic individuals for TB, but this association was not statistically significant [Table 1].
Table 1: Association of tuberculosis with various factors

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TB is positively and significantly associated with decreased mean corpuscular hemoglobin concentration (MCHC) and decreased mean corpuscular volume (MCV). Also, it is positively and significantly associated with increased red blood cell volume distribution width (RDW) [Table 2].
Table 2: Association of tuberculosis with red cell indices

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TB is positively and significantly associated with decreased white blood cell (WBC) count and a decreased lymphocyte count [Table 3].
Table 3: Association of tuberculosis with blood cells

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  Discussion Top

Our findings suggest that a substantial proportion of incident TB in India is attributable to diabetes. DM is attributed to reduced immunity and greater susceptibility to lung infections, with M. tuberculosis being the most common pathogen.[19] The biological basis for the increased susceptibility to TB in DM patients is likely due to their dysfunctional immunity.[20]

In the present study, it has been found that around 33% of the total diabetics are smear-positive, which is following the statewide study done by Balakrishnan et al., which is 44%.[21] Another systematic review of 13 observational studies done by Jeon and Murray[8] in the USA states that DM was associated with an increased TB risk regardless of study design and population. In all these studies, the higher the age group, the higher the chance of getting infected with TB, following ours. Due to rapid urbanization, the prevalence of diabetes is increasing, which has a severe impact on TB control. The study done by Dooley et al. on “Impact of diabetes mellitus on treatment outcomes of patients with active tuberculosis” states that diabetes was a relatively common comorbid condition in patients with active TB, and diabetes was independently associated with an increased risk of death in patients undergoing treatment for TB.[22]

In the present study, around 31% of TB-positive are anemic. Bashir et al.[23] show that approximately 44% of total TB patients were anemic. Our study found that the frequency of anemia among males (65%) is much higher than that among females (44%), similar to the findings by Morris et al.[12]

This may be due to the effect of proinflammatory cytokines, such as interleukin-6 and tumor necrosis factor-a, which decrease the production of erythropoietin, suppress the response of the bone marrow to erythropoietin, and alter the metabolism of iron, which may result in the impairment of erythropoiesis.[24],[25]

According to the National Family Health Survey 2015–16[26], 53% of the women aged 15–49 were anemic, whereas around 22% of the males were anemic. These data differ much from the data we obtained. This variability in the pattern of anemia might be attributed to other factors, viz., food habits, cultural practices, the prevalence of other diseases such as malaria and worm infestation, and so on. These factors need to be further investigated in detail.

Our study found that TB has been positively and significantly associated with decreased MCHC, decreased MCH, and increased RDW. It is also positively and significantly associated with decreased WBC counts. Though many studies have been conducted in which red cell indices have been considered a variable linked with TB, there seems to be no concluding evidence for the same.[12],[27]

Strengths and limitations

This is the first study in central India that attempts to find out the association between TB with diabetes, anemia, and other hematological measurements to the best of our knowledge. The present study cannot comment upon the type of anemia, whether it is anemia of chronic disease, iron deficiency anemia, folic acid deficiency, hemolytic anemia, or any other. Also, it is not in a position to conclude that TB is due to diabetes or vice versa and the mechanism present behind it. Other factors such as housing conditions, nutritional patterns, cultural practices, and family gene pool study need to be investigated further to reach some concrete conclusion.

  Conclusion Top

In this study, we found a definite relationship between anemia and TB. Also, there is probably some relation between diabetes and TB. So, we suggest that every TB patient should be screened to look for both the possible comorbidities.

Institutional Ethics Committee number

Institutional Ethics Committee: IEC/234/2015; MGIMS/IEC/COMMED/76/2015 on dated 08/09/2015.

Financial support and sponsorship

MUHS STRG project—STRG/2015–16/E-1/17.

Conflicts of interest


  References Top

World Health Organization. Global Tuberculosis Report 2016. 2016.  Back to cited text no. 1
Huddart S, Nafade V, Pai M Tuberculosis: A persistent health challenge for India. Curr Epidemiol Rep 2018;5:18-23.  Back to cited text no. 2
Government of India. Guidance Document: Nutritional Care and Support for Patients with Tuberculosis in India. 2017.  Back to cited text no. 3
Atlas D International Diabetes Federation. IDF Diabetes Atlas. 7th ed. Brussels, Belgium: International Diabetes Federation; 2015.  Back to cited text no. 4
Global Information and Education on HIV and AIDS. HIV and AIDS in India. 2017.  Back to cited text no. 5
Kottarath MD, Mavila R, Achuthan V, Nair S Prevalence of diabetes mellitus in tuberculosis patients: A hospital based study. Int J Res Med Sci 2017;3:2810-4.  Back to cited text no. 6
Anjana RM, Deepa M, Pradeepa R, Mahanta J, Narain K, Das HK, et al. Prevalence of diabetes and prediabetes in 15 states of India: Results from the ICMR-INDIA B population-based cross-sectional study. Lancet Diabetes Endocrinol 2017;5:585-96.  Back to cited text no. 7
Jeon CY, Murray MB Diabetes mellitus increases the risk of active tuberculosis: A systematic review of 13 observational studies. PLoS Med 2008;5:e152.  Back to cited text no. 8
Whiting DR, Guariguata L, Weil C, Shaw J IDF Diabetes Atlas: Global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract 2011;94:311-21.  Back to cited text no. 9
Lönnroth K, Roglic G, Harries AD Improving tuberculosis prevention and care through addressing the global diabetes epidemic: From evidence to policy and practice. Lancet Diabetes Endocrinol 2014;2:730-9.  Back to cited text no. 10
Revised National Tuberculosis Control Programme (RNTCP). National Framework for Joint TB-Diabetes Collaborative Activities. 2017.  Back to cited text no. 11
Morris CD, Bird AR, Nell H The haematological and biochemical changes in severe pulmonary tuberculosis. QJM: Int J Med 1989;73:1151-9.  Back to cited text no. 12
Bozóky G, Ruby E, Góhér I, Tóth J, Mohos A Hematologic abnormalities in pulmonary tuberculosis. Orv Hetil 1997;138:1053-6.  Back to cited text no. 13
Dikshit B, Wanchu A, Sachdeva RK, Sharma A, Das R Profile of hematological abnormalities of Indian HIV infected individuals. BMC Blood Disord 2009;9:5.  Back to cited text no. 14
World Health Organization. Geneva, Switzerland. The Global Prevalence of Anaemia in 2011.  Back to cited text no. 15
Ministry of Health and Family Welfare, Government of India. Training Modules (1–4) for Programme Managers & Medical Officers. New Delhi, India: National TB Elimination Programme. Central TB Division. 2020.  Back to cited text no. 16
WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. Geneva: World Health Organization; 2011. Available from: http://www.who.int/vmnis/indicators/haemoglobin.pdf.  Back to cited text no. 17
American Diabetes Association; 2. Classification and diagnosis of diabetes: Standards of medical care in diabetes—2020. Diabetes Care 2020;43(Suppl. 1):S14-31.  Back to cited text no. 18
Peleg AY, Weerarathna T, McCarthy JS, Davis TM Common infections in diabetes: Pathogenesis, management and relationship to glycaemic control. Diabetes Metab Res Rev 2007;23:3-13.  Back to cited text no. 19
Gomez DI, Twahirwa M, Schlesinger LS, Restrepo BI Reduced Mycobacterium tuberculosis association with monocytes from diabetes patients that have poor glucose control. Tuberculosis (Edinb) 2013;93:192-7.  Back to cited text no. 20
Balakrishnan S, Vijayan S, Nair S, Subramoniapillai J, Mrithyunjayan S, Wilson N, et al. High diabetes prevalence among tuberculosis cases in Kerala, India. PLoS One 2012;7:e46502.  Back to cited text no. 21
Dooley KE, Tang T, Golub JE, Dorman SE, Cronin W Impact of diabetes mellitus on treatment outcomes of patients with active tuberculosis. Am J Trop Med Hyg 2009;80:634-9.  Back to cited text no. 22
Bashir A, Abdallah SA, Mohamedani AA Anemia among patients with pulmonary tuberculosis in Port Sudan, Eastern Sudan. Int J Recent Sci Res 2015;6:4128-31.  Back to cited text no. 23
Weiss G, Goodnough LT Anemia of chronic disease. N Engl J Med 2005;352:1011-23.  Back to cited text no. 24
Singh PP, Goyal A Interleukin-6: A potent biomarker of mycobacterial infection. SpringerPlus 2013;2:686.  Back to cited text no. 25
National Family Health Survey-4 (2015–16). April 2017 Economic and Political Weekly LII(16). p. 66-70.  Back to cited text no. 26
Tozkoparan E, Deniz O, Ucar E, Bilgic H, Ekiz K Changes in platelet count and indices in pulmonary tuberculosis. Clin Chem Lab Med 2007;45:1009-13.  Back to cited text no. 27


  [Table 1], [Table 2], [Table 3]


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