Vitamin D, Calcium Serum Levels and Biomolecular Parameters in

Active Tuberculosis Patients in North Sumatera, Indonesia

Dina Keumala Sari

, Ridha Dharmajaya

, Mutiara Indah Sari

, Dewi Masyithah

Sunna Vyatra Hutagalung

Nutrition Department, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia

Neurosurgery Department, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia

Biochemistry Department, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia

Parasitology Department, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia

Faculty of Tropical Medicine, Mahidol University, Thailand

Keywords: Vitamin D, Calsium, Biomolecular Parameters, Tuberculosis.

Abstract: Background: Inflammation in tuberculosis affecting nutrition status in tuberculosis patient. Malnutrition is an

important risk factor for tuberculosis (TB) because of high protein as the optimal cell immunity activity in the

cell. Objective: We determine to find vitamin D, calcium serum level, and biomolecular such albumin and hs-

CRP in active tuberculosis patients. Design: We conducted a cross-sectional study of 25 man and women

aged 18-60 years with active tuberculosis in North Sumatera, Indonesia. Parameters were 25(OH)D and

calcium serum level, body mass index, fat mass, and biomolecular parameters such as albumin and hs-CRP

also assessed. The data reported as numerical and categorical data using statistical program. Results: the mean

of study subject age were 35.3±5.9 years old and BMI were 20.8±5.4 kg/m

. There were 88% subjects

categorized into vitamin D deficiency-insufficiency and 12% categorized into vitamin D sufficiency. There

were 92% subjects categorized into normal calcium level, and 8% were hypocalcemia. Based on biomolecular

analysis, there was 90% in normal range level of albumin and most of them had higher hs-CRP (96%).

Conclusions: based on this result, although there was higher vitamin D deficiency, yet found calcium and

albumin in normal level, but there higher hs-CRP showed inflammation status reflecting tuberculosis

progression.

INTRODUCTION

Malnutrition in tuberculosis have reported in many

research, related to immunity activity in the cell that

would affect inflammation process. There are three

risk in tuberculosis (TB) progression caused of

malnutrition: the risk of becoming infected with

Mycobcterium tuberculosis, infection progressing to

active disease, and lower nutrition status. it could

described it as viscious cycle between malnutrition

and inflammation process (Sotgiu et al., 2015;

Subotic et al., 2016).

Both TB and malnutrition are linked to poverty, it

is very important to analize the socio-economic

problem in North Sumatera, Indonesia areas. Higher

point prevalence of infection in malnutrition patients

or community dwellers; would results worse and

more frequent complications of infection in

underweight patients, higher mortality in

undernourished populations; and higher rates of

infectious diseasess (Sotgiu et al., 2015).

Malnutrition such as vitamin D deficiency also

affect TB progression, previous research showed

higher vitamin D deficiency in North Sumatera areas

(Sari, 2017a, 2017b, 2017c). The malnutrition host-

pathogen interaction and involvement of vitamin D-

calcium (Ca) signaling in tuberculosis infection is

crucial and plays a significant role in tuberculosis

pathogenesis [rosen, sharma]. Vitamin D has a

potential role in the prevention and treatment of

infection, supports induction of pleiotropic

antimicrobial responses and immunomodulatory

effects (Gill, 2006). Vitamin D is an essential factor

for the intestinal absorption of dietary calcium and

skeletal mineralization (Gill, 2006; Sharma & Meena,

2017).

Biomolecular parameter such as albumin that

reflects protein status and hs-CRP that reflects

Sari, D., Dharmajaya, R., Sar i, M., Masyithah, D. and Hutagalung, S.

Vitamin D, Calcium Serum Levels and Biomolecular Parameters in Active Tuberculosis Patients in North Sumatera, Indonesia.

DOI: 10.5220/0010085707210725

In Proceedings of the International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches (ICOSTEERR 2018) - Research in Industry 4.0, pages

721-725

ISBN: 978-989-758-449-7

721

inflammation process, can be part of tuberculosis

progression. This inflammatory response is tightly

regulated by both the host and the bacterium during

different stages of infection.

The aims of this study were to find vitamin D,

calcium serum level, and biomolecular such albumin

and hs-CRP in active tuberculosis patientst to our

knowledge, this is would be the based to increased the

quality of tuberculosis patient’s nutrition status in

Medan, North Sumatera, Indonesia. Based on this

study, we could also find the nutrition problem and

support it until tuberculosis eradicated in these areas.

METHOD

We conducted a cross-sectional study of 25 man and

women aged 18-60 years in North Sumatera,

Indonesia May to July 2018, during the dry season

(dry season in Indonesia is between April and

October, when there was abundant sunlight

exposure). The location of recruitment was in

Sumatera Island (Medan, North Sumatera, Indonesia)

with latitude: 3.57 N and longitude 98.65 E, average

temperature: ±32

C (90

F). The areas are:

Community Health Center ‘Teladan’ and ‘Amplas’,

that located in Medan city. This study was carried out

after ethical approval was obtained from the Health

Research Ethics Committee of Sumatera Utara

University Medical School (No. 96/TGL/KEPK FK

USU-RSUP HAM/2018) and all participants were

given written informed consent to the study

procedures.

Study participants

The subjects of this study consisted tuberculosis

patients in two community health centers with the

higher tuberculosis prevalence in Medan, North

Sumatera, Indonesia, man and women with various

occupations, and taken purposively, there were 25

subjects The inclusion criteria were tuberculosis

patients within the range of 18-60 years old.

Exclusion criteria were subjects with history of

diabetes mellitus, myocardial infarction, renal orliver

dysfunction. In addition to those exclusion criteria,

subjects who were pregnant and lactating were also

excluded.

Anthropometry, status body fat, and blood

pressure

Anthropometry included height (to the nearest 0.5

cm), weight (to the nearest 0.1 kg), waist

ircumference using a standardized measuring tape in

centimetres, systolic and diastolic blood pressure

measurement, and body mass index (calculated as

kg/m

). Categorized BMI was based on Asia Pacific

[6], <18.5 classified as underweight, 18.5-22.9

classified as normoweight, 23-24.9 classified as

overweight/at risk, 25-29.9 classified as obese I, and

>30 classified as obese II. Assessment of body fat

percentage were using Body Composition Monitor

with Scale (HBF-362, KaradaScan-Omron). Body fat

percentage refered to the amount of body fat mass in

regards to the total body weight expressed as a

percentage, the following classified: normal ≤29.9%

and high >30.0% based on Bioelectrical Impedance.

Laboratory analysis

We measured 25(OH) D serum concentration by

chemiluminescent immunoassay (CLIA) technology

(Diasorin, Stillwater, MN), measures were between

4.0 and 150 ng/mL. The lowest value was 4.0 ng/mL

which is based on an inter-assay precision 3.90% CV.

Reference range were <20 ng/mL categorized

deficiency, 20-30ng/mL (insuficiency), 30-100

ng/mL (suficiency) [7]. To convert ng/mL to nmol/L

is multiply with 2.496. Calsium serum was measured

by ADVIA Bayer Assayed Chemistry Controls, with

principle procedure: calcium ions form a violet

complex with o-cresolphthaleincomplexone in an

alkaline medium. The reaction is measured at

545/658 nm, and normal concentration of calcium

was 8.3-10.6mg/dL.

We measured albumin serum using architect

C800 with colorimetry method and to measured hs-

CRP, we also use architect C800 with different

method which are turbidimetry/ immuno-

turbidimetry.

Statistical analysis

This research presented data in two variables which

were continuous and categorical variables.

Continuous variables were expressed as continuous

variables as mean±SD. Categorical variables were

expressed as percentage proportions We used SPSS

program (version 11.5; SPSS Inc, Chicago, IL) to

perform the analysis.

RESULTS AND DISCUSSIONS

The results will be discussed in 4 subsections, they

are characteristic of study participants,

anthropometry and blood pressure, vitamin D and

ICOSTEERR 2018 - International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches

722

calcium, and biomoleculer parameters: albumin and

hs-CRP.

Characteristic of study participants

The aim of this study was to report parameters which

were vitamin D, calcium status and biomolecular

parameters. In Table 1 showed the demographic of

study subject. The mortality, morbidity, and disease

progression of tuberculosis varies between different

age groups. Based on these difference, we had a better

understanding of the immunological mechanisms

underlying disease and protection for cell immunity

of the body.

Table 1. Demographic and clinical characteristics

Variables n(%)

Age (mean±SD)

Age classification

18-30

31-40

41-50

51-60

35.3±5.9

4(16

16(64)

4(16)

1(4)

Gender

Male

Female

20 (80)

5 (20)

Ethnic

Javanese

Bataknese

Minang

Others

6 (24)

8 (32)

3 (12)

Occupation

Student

Employed

Unemployed

Housewife

Smoking history

Yes

5 (20)

8 (32)

4 (16)

20 (80)

5 (20)

Abbreviations:

SD: Standart Deviation

Most of the subject had smoking history, tobacco

smoke increases risk of Mycobaterium tuberculosis

infection by several means: alteration of muco-ciliary

clearance, reduced alveolar macrophage activity;

immune-depression of pulmonary lymphocytes,

reduction of cytotoxic activity of natural killer cells,

alteration of the activity of the pulmonary dendritic

cells. Both active and passive smoking increases the

risk of latent tubercular infection and of pulmonary

and extra-pulmonary tuberculosis (Cegielski &

McMurray, 2004).

Anthropometry and blood pressure

A low body mass index (BMI) was associated with a

3-fold increased risk of tuberculosis when compared

with patients with a normal BMI, and an increased

BMI was associated with a 50% decreased risk of

tuberculosis. In this study, most of the study subjects

were underweight (Casha & Scarci, 2017; Lyons &

Stewart, 2013; Subotic et al., 2016) as presented in

Table 2. In this study, most of the study subjects had

lower fat mass, this was because of malnutrition

condition.

Table 2. Anthropometric characteristics

Parameters Mean±SD and n(%)

Weight (kg) 54.5±12.3

Height (cm) 161.6±8.2

BMI (kg/m

)

Underweight

Normal

Overweight

Obese

20.8±5.4

23(92)

2(8)

Fat mass (%)

Low

Normal

High

Abdominal

circumference (cm)

Normal

High

Blood pressure (mmHg)

Sistole

Diastole

20.2±3.7

19(76)

6(24)

79.3±21.3

25(100)

110.3±24.5

78.5±18.5

Abbreviations:

BMI: body mass indeks

Vitamin D and calcium

Based other previous study, women and man were

susceptible to vitamin D deficiency (Sari et al., 2017a,

2017c), vitamin D affected calcium level also.

Exposure to sunlight is the main source of vitamin D

for human. This exposure induces the conversion of

7-dehydrocholesterol to vitamin D3 via previtamin

D3 in the skin. This form then converted to 25-

hydroxyvitamin D in the liver and is further converted

to the bioactive form of vitamin D, 1.25(OH)

the kidney. Studies have found that it binds to vitamin

D receptor (VDR), activates VDR signaling, and

induces a series of antimicrobial responses such as

induction of autophagy, phagolysosomal fusion,

release, and activation of the antimicrobial peptide

cathelicidin, and killing of intracellular

Mycobacterium tuberculosis (Gibney et al., 2008;

Kim et al., 2014). This study reported that active

tuberculosis patient had deficiency-insufficiency

vitamin D (Table 3).

What caused this? Propably there were many

factors besides low intake of vitamin D food sources,

Vitamin D, Calcium Serum Levels and Biomolecular Parameters in Active Tuberculosis Patients in North Sumatera, Indonesia

723

one of them was lower sunlight exposure. This could

be one of the risk factor of lower 25(OH) D serum

level, in this study found that most of the subjects

were student, employed, and housewife (Table 3).

This could be the reasons that they would avoid the

sunlight. The tuberculosis patient had a job and all of

them had to leave their house to stay at work place.

Previous study also report that higher percentage

women work indoors than outdoors, other factor was

sunscreen application that lower the exposure (Sari et

al., 2017b, 2017c).

Table 3. Serum levels of 25-hydroxyvitamin D and

calcium

Parameters

Mean±SD;

n (%)

25-hydroxyvitamin D serum levels

(ng/mL)

22.8±5.6

Vitamin D status, n (%)

Deficiency-Insufficiency

Sufficiency

Normal in sunny countries

22(88)

3(12)

Serum calcium (mg/dL)

Calcium classification, n(%)

Low

Normal

9.1±0.5

2(8)

23(92)

Continues variable: mean ± SD; categorical variable: n

(%); SD=standard deviation

Calcium serum level maintain ini normal range,

probably because of lower calcium intake, another

reason was calcium food sources that abundant in

slight. Activity vitamin D in tuberculosis as an

immunomodulator, the pathogenesis is when

monocytes, and macrophages exposed to a

lipopolysaccharide or to Mycobacterium

tuberculosis, there is an up-regulate the vitamin D

receptor gene and the 25-hydroxyvitamin D-1α-

hydroxylase gene. This respons resulting an increased

production of 1,25-dihydroxyvitamin D3, increase

the synthesis of cathelicidin, a peptide capable of

destroying M. tuberculosis.

Table 4. Serum levels of albumin dan hs-CRP

Parameters Mean±SD; n (%)

Albumin (g/dL) Low

Normal High

hs-CRP (mg/dL) Low

inflammation

Active inflammation

3.8±0.8

6(24)

19(76)

49.1±15.7

- 25

(

100

)

Abbreviations: Continues variable: mean ± SD;

categorical variable: n (%); SD=standard deviation

A reading above 10 mg/L of hs-CRP may signal

a need for further testing to determine the cause of

such significant inflammation in your body. The

highest hs-CRP showed C-reactive protein (CRP) is

produced by the liver. Its level rises when there is

inflammation in the body. LDL cholesterol not only

coats the walls of the arteries, but it also damages them.

This damage causes inflammation that the body tries to

heal by sending a "response team" of proteins called

"acute phase reactants", one of them was CRP (Yoon,

Davis, & Cattamanchi, 2013). This study showed that

most of the subjects were active TB, and still had

inflammation process, that affect malnutrition based on

BMI and vitamin deficiency.

A suggestion which was nutritional

supplementation in patients with TB is associated

with better cure and treatment completion rates as

well as better performance status. Limitation of this

study that we did not assed parathyroid hormon and

albumin serum that affect vitamin D and calcium

metabolism.

CONCLUSIONS

Higher vitamin D deficiency-insufficiency found in

this study, but not affecting calcium serum level.

Based on biomolecular parameters such as albumin

showed normal level, but there higher hs-CRP

showed inflammation status reflecting tuberculosis

progression.

ACKNOWLEDGMENTS

The authors gratefully acknowledge that the present

research is supported by Ministry of Research and

Technology and Higher Education Republic of

Indonesia, Research and Community Service,

Universitas Sumatera Utara. The support is under the

research grant DRPM of Year 2018 Contract Number

263/UN5.2.3.1/PPM/KP-DRPM/2018.

REFERENCES

Casha, A. R., & Scarci, M. (2017). The link between

tuberculosis and body mass index. Journal of Thoracic

Disease, 9(3), E301.

Cegielski, J. P., & McMurray, D. N. (2004). The

relationship between malnutrition and tuberculosis:

evidence from studies in humans and experimental

animals. The International Journal of Tuberculosis

and Lung Disease, 8(3), 286–298.

ICOSTEERR 2018 - International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches

724

Gibney, K. B., MacGregor, L., Leder, K., Torresi, J.,

Marshall, C., Ebeling, P. R., & Biggs, B.-A. (2008).

Vitamin D deficiency is associated with tuberculosis

and latent tuberculosis infection in immigrants from

sub-Saharan Africa. Clinical Infectious Diseases,

46(3), 443–446.

Gill, T. (2006). Epidemiology and health impact of

obesity: an Asia Pacific perspective. Asia Pac J Clin

Nutr, 15(Suppl), 3–14.

Kim, J. H., Park, J.-S., Cho, Y.-J., Yoon, H.-I.,

Song, J. H., Lee, C.-T., & Lee, J. H. (2014).

Low serum 25-hydroxyvitamin D level: an independent

risk factor for tuberculosis? Clinical Nutrition, 33(6),

1081–1086.

Lyons, J. G., & Stewart, S. (2013). Commentary:

tuberculosis, diabetes and smoking: a burden greater

than the sum of its parts. International Journal of

Epidemiology, 42(1), 230–232.

Sari, D. K., Tala, Z. Z., Lestari, S., Hutagalung, S., &

Ganie, R. A. (2017a). Body mass index but not 25

(OH) D serum is associated with bone mineral density

among Indonesian women in North Sumatera: a cross

sectional study. Asian J Clin Nutr, 9(1), 37.

Sari, D. K., Tala, Z. Z., Lestari, S., Hutagalung, S., &

Ganie, R. A. (2017b). Lifestyle differences in rural and

urban areas affected the level of vitamin D in women

with single nucleotide polymorphism in North

Sumatera. Asian J Clin Nutr, 9(2), 57–63.

Sari, D. K., Tala, Z. Z., Lestari, S., Hutagalung, S., &

Ganie, R. A. (2017c). Vitamin D receptor gene

polymorphism among Indonesian women in North

Sumatera.

Asian J Clin Nutr, 9(1), 44–50.

Sharma, S., & Meena, L. S. (2017). Potential of Ca 2+ in

Mycobacterium tuberculosis H 37 Rv pathogenesis

and survival. Applied Biochemistry and

Biotechnology, 181(2), 762–771.

Sotgiu, G., D’Ambrosio, L., Centis, R., Mura, I.,

Castiglia, P., Spanevello, A., & Migliori, G.

B. (2015). The multidrug-resistant tuberculosis threat: old

problems and new solutions. Journal of Thoracic

Disease, 7(9), E354.

Subotic, D., Yablonskiy, P., Sulis, G., Cordos, I., Petrov,

D., Centis, R., … Migliori, G. B. (2016). Surgery and

pleuro-pulmonary tuberculosis: a scientific literature

review. Journal of Thoracic Disease, 8(7), E474.

Yoon, C., Davis, J. L., & Cattamanchi, A. (2013). C-

reactive protein and tuberculosis screening: a new

trick for an old dog? The International Journal of

Tuberculosis and Lung Disease: The Official Journal

of the International Union against Tuberculosis and

Lung Disease,

17(12), 1656–1656.

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