Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

A narrative review of recent progress in understanding the relationship between tuberculosis and protein energy malnutrition


Protein energy malnutrition (PEM) and tuberculosis (TB) are the major public health issues, particularly in the developing country setting. Malnutrition is an underlying cause of many deaths and when left untreated devastates normal physical and cognitive development. TB continues to gather momentum as a serious infectious killer. They have both rightly been highlighted as important global health issues by their inclusion in the Millennium Development Goals. But what is known of their relationship with one another? It is historically accepted that PEM and TB have a synergistic relationship adversely having an impact on one another. However, researchers have sought to apply this understanding in an examination of the relationship between TB and PEM with often inconclusive results. This narrative review of recently published research and current knowledge may help delineate the association between PEM and TB mortality. Such results will assist future research in this important area of health—an area lacking evidence-based guidance.

This is a preview of subscription content

Access options

Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.


  1. World Health Organisation 2012. (cited 10 October 2012). Fact Sheet: Tuberculosis. Available from <>.

  2. Lawn S, Zumla A . Tuberculosis. Lancet 2011; 378: 57–72.

    Article  PubMed  Google Scholar 

  3. World Health Organisation 2012. (cited 10 October 2012). Fact File: 10 Facts on Nutrition. Available from <>.

  4. Food and Agriculture Organization 2010, FAO of the United Nations (cited 11 October 2012). The State of Food Insecurity in the World 2010. Available from <>.

  5. Rawe K, Jayasinghe D, Mason F, Davis A, Pizzini M, Garde M et al. A Life Free from Hunger: Tackling child malnutrition. Save the Children,. Save the Children UK: London, UK, 2012.

    Google Scholar 

  6. Delisle H . Poverty: the double burden of malnutrition in mothers and the intergenerational impact. Ann N Y Acad Sci 2008; 1136: 172–184.

    Article  PubMed  Google Scholar 

  7. Sinclair D, Abba K, Grobler L, Sudarsanam TD . Nutritional supplements for people being treated for active tuberculosis. Cochrane Database Syst Rev 2011; 11: CD006086.

    Google Scholar 

  8. Greenhalgh T, Robert G, Bate P, Kyriakidou O, Macfarlane F, Peacock R . How to Spread Good Ideas: A systematic review of the literature on diffusion, dissemination and sustainability of innovations in health service delivery and organisation. Report for the National Coordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO): London, UK, 2004.

    Google Scholar 

  9. Mitton C, Adair C, Mckenzie E, Patten S, Perry B . Knowledge transfer and exchange: review and synthesis of the literature. Milbank Q 2007; 85: 729–768.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Jones K . Doing a Literature Review in Health. In: Saks M, Allsop J (eds) Researching health: qualitative, quantitative and mixed methods. SAGE Publications Ltd: London, UK, 2007, pp 32–54.

    Google Scholar 

  11. O'Donnell O, van Doorslaer E, Wagstaff A, Lindelow M The Worldbank; 2007 (cited 10 October 2012). Analyzing health equity using household survey data: a guide to techniques and their implementation: Washington, DC, USA. Available from <>.

  12. World Health Organization. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Consultation, WHO Technical Report Series: Geneva, Switzerland, 1995.

  13. Kennedy N, Ramsay A, Uiso L, Gutmann J, Ngowi FI, Gillespie SH . Nutritional status and weight gain in patients with pulmonary tuberculosis in Tanzania. Trans R Soc Trop Med Hyg 1996; 90: 162–166.

    CAS  Article  PubMed  Google Scholar 

  14. Dodor EA . Evaluation of nutritional status of new tuberculosis patients at the Effia Nkwanta regional hospital. Ghana Med J 2008; 22: 22–28.

    Google Scholar 

  15. Zachariah R, Spielmann MP, Harries AD, Salaniponi FM . Moderate to severe malnutrition in patients with tuberculosis is a risk factor associated with early death. Trans R Soc Trop Med Hyg 2002; 96: 291–294.

    CAS  Article  PubMed  Google Scholar 

  16. Mupere E, Malone L, Zalwango S, Chiunda A, Okwera A, Parraga I et al. Lean tissue mass wasting is associated with increased risk of mortality among women with pulmonary tuberculosis in urban Uganda. Ann Epidemiol 2012; 22: 466–473.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Siddiqui E, Ejaz K, Lone S, Raza SJ . Investment in paediatric tuberculosis prevention in Pakistan: loss or gain? J Pakistan Med Assoc 2010; 60: 897–901.

    Google Scholar 

  18. Podewils LJ, Holtz T, Riekstina V, Skripconoka V, Zarovska E, Kirvelaite G et al. Impact of malnutrition on clinical presentation, clinical course, and mortality in MDR-TB patients. Epidemiol Infect 2011; 139: 113–120.

    CAS  Article  PubMed  Google Scholar 

  19. Villamor E, Saathoff E, Mugusi F, Bosch R, Urassa W, Fawzi W . Wasting and body composition of adults with pulmonary tuberculosis in relation to HIV-1 coinfection, socioeconomic status, and severity of tuberculosis. Eur J Clin Nutr 2006; 60: 163–171.

    CAS  Article  PubMed  Google Scholar 

  20. Schwenk A, Tuberculosis MD . malnutrition and wasting. Curr Opin Clin Nutr Metab Care 2000; 3: 285–291.

    CAS  Article  PubMed  Google Scholar 

  21. Boelaert J, Gordeuk V . Protein energy malnutrition and risk of tuberculosis infection. Lancet 2002; 360: 1102.

    Article  PubMed  Google Scholar 

  22. Schaible U, Kaufmann S . Malnutrition and infection: complex mechanisms and global impacts. PLoS Med 2007; 4: e115.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Pelly T, Santillan C, Gilman R, Cabrera L, Garcia E, Vidal C et al. Tuberculosis skin testing, anergy and protein malnutrition in Peru. Int J Tuberc Lung Dis 2005; 9: 977–984.

    CAS  PubMed  Google Scholar 

  24. Cegielski J, McMurray D . The relationship between malnutrition and tuberculosis: evidence from studies in humans and experimental animals. Int J Tuberc Lung Dis 2004; 8: 286–298.

    CAS  PubMed  Google Scholar 

  25. Cegielski J, McMurray D . Tuberculosis: Nutrition and Susceptibility. In: Caballero B, Allen L, Prentice A (eds) Encyclopedia of Human Nutrition, 2nd edn. Elsevier Ltd: Oxford, UK, 2005, pp 287–294.

    Chapter  Google Scholar 

  26. Macallan D . Malnutrition in tuberculosis. Diagn Microbiol Infect Dis 1999; 34: 153–157.

    CAS  Article  PubMed  Google Scholar 

  27. Kim DK, Kim HJ, Kwon S-Y, Yoon H-I, Lee C-T, Kim YW et al. Nutritional deficit as a negative prognostic factor in patients with miliary tuberculosis. Eur Respir J 2008; 32: 1031–1036.

    CAS  Article  PubMed  Google Scholar 

  28. Cegielski J, Demeshlaira L . Tuberculosis: Nutritional Management. In: Caballero B, Allen L, Prentice A (eds). Encyclopedia of Human Nutrition, 2nd edn. Elsevier Ltd: Oxford, 2005, pp 294–298.

    Chapter  Google Scholar 

  29. Chan J, Tian Y, Tanaka KE, Tsang MS, Yu K, Salgame P et al. Effects of protein calorie malnutrition on tuberculosis in mice. Proc Natl Acad Sci USA 1996; 93: 14857–14861.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  30. Ishikawa LL, França TG, Chiuso-Minicucci F, Zorzella-Pezavento SF, Marra NM, Pereira PC et al. Dietary restriction abrogates antibody production induced by a DNA vaccine encoding the mycobacterial 65kDa heat shock protein. Genetic Vaccines and Therapy 2009; 7 (11).

    Article  PubMed  PubMed Central  Google Scholar 

  31. Compher C . The Impact of Protein-Calorie Malnutrition on Drugs. In: Boullata J, Armenti V (eds) Handbook of Drug—Nutrient Interactions. Humana Press Inc: Totowa, NJ, USA, 2005, pp 83–99.

    Google Scholar 

  32. Sushama Bai S, Lekshmi Devi R . Clinical spectrum of tuberculosis in BCG vaccinated children. Ind Pediatr 2002; 39: 458–462.

    Google Scholar 

  33. Macallan D, McNurlan M, Kurpad A, de Souza G, Shetty P, Calder AG et al. Whole body protein metabolism in human pulmonary tuberculosis and undernutrition: evidence for anabolic block in tuberculosis. Clin Sci 1998; 94: 321–331.

    CAS  Article  Google Scholar 

  34. Van Lettow M, Fawzi W, Semba R . Triple trouble: the role of malnutrition in tuberculosis and human immunodeficiency virus co-infection. Nutr Rev 2003; 61: 81–90.

    Article  PubMed  Google Scholar 

  35. Kim JH, Lee CT, Yoon HI, Song J, Shin WG, Lee JH . Relation of ghrelin, leptin and inflammatory markers to nutritional status in active pulmonary tuberculosis. Clin Nutr 2010; 29: 512–518.

    CAS  Article  PubMed  Google Scholar 

  36. Hoffer JL . Clinical nutrition: 1. Protein–energy malnutrition in the inpatient. CMAJ 2001; 165: 10.

    Google Scholar 

Download references


We acknowledge and express gratitude to Dr Mohammed Ali for his supervisory role and encouraging guidance of the structure and content of this review.

Author information

Authors and Affiliations


Corresponding author

Correspondence to M L H Hood.

Ethics declarations

Competing interests

The author declares no conflict of interest.


Appendix 1

Figure A1
figure 1

The search strategy process for selecting the documents for this review.

Appendix 2

Table a1 Summary table of the items included in this review

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Hood, M. A narrative review of recent progress in understanding the relationship between tuberculosis and protein energy malnutrition. Eur J Clin Nutr 67, 1122–1128 (2013).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • protein energy malnutrition (PEM)
  • protein calorie malnutrition
  • tuberculosis
  • review

Further reading


Quick links