’ Review

Cachexia in tuberculosis in South-East Asian and

African regions: knowledge gaps and untapped
opportunities
Dhruv Mistry, MBBSa, Prashant Patil, MBBS, MDb, Shreya Singh Beniwalc, Raghav Penugonda, MBBSd,
Sushmitha Paila, MBBSe, Dharani Swarna Deiveegan, MBBSf, Charu Tibrewal, MBBSg,
Kamal Yousef Ghazal, MBBS, MD (IM)h, Anveshaki, Suraj Sai Nikhil Padakanti, MBBSj, Jugalkishor Chauhan, MBBSk,
Likhitha Reddy Al, Kareema R. Sofia Cummings, MBBSm, Surya Simha Reddy Molakala, MBBSn,
Pulkit Saini, MBBSo, Mohamed Abdullahi Omar, MBChBp, Mansi Vandaraq, Saakshi A. Ijantkarr,*

Abstract
Tuberculosis (TB) and cachexia are clinical entities that have a defined relationship, making them often found together. TB can
lead to cachexia, while cachexia is a risk factor for TB. This article reviews cachexia in Tuberculosis patients in Southeast Asian
and African regions by conducting a comprehensive literature search across electronic databases such as PubMed, Google
Scholar, and Research Gate between 2013 and 2024 using keywords including ‘Africa’, ‘cachexia’, ‘prevalence’, ‘implica-
tions’, ‘tuberculosis’, and ‘Southeast Asia. This article utilized only studies that satisfied the inclusion criteria, revealing
knowledge gaps and untapped opportunities for cachexia in TB across Southeast Asian and African regions. Many Southeast
Asian and Western Pacific patients initially receive a tuberculosis diagnosis. Sub-Saharan African countries are among the
30 high TB burden nations, according to the WHO. Food inadequacy and heightened energy expenditure can impair the
immune system, leading to latent TB and subsequently, active infection. Symptoms needing attention: shortness of breath,
productive cough, hyponatremia at 131 mmol/l, hypoalbuminemia at 2.1 g/dl, elevated aspartate transaminase at 75 U/l,
increased lactate dehydrogenase at 654, and normocytic anemia. Comorbidities, such as kidney disease, cardiovascular
disease, and asthma, can influence the nutritional status of individuals with TB. While efforts like screening, contact tracing,
and utilizing gene Xpert to detect TB cases were implemented, only a few proved effective. It is essential to conduct further
studies, including RCTs, in Southeast Asia and Africa to evaluate and manage cachexia in TB patients.
Keywords: Africa, cachexia, implications, prevalence, Southeast Asia, tuberculosis

a
Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, bGMERS Medical College, Valsad, Gujarat, cLady Hardinge Medical College, Connaught Place, New
Delhi, dGSL Medical College & General Hospital, Rajamahendravaram, Jagannadhapuram Agraharam, eAll India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh,
f
KAP Viswanatham Government Medical College, Periyamilaguparai, Tiruchirappalli, Tamil Nadu, gRajasthan Hospital (The Gujarat Research & Medical Institute), Shahibaug,
Ahmedabad, Gujarat, hKing Fahad Medical City, Riyadh, Saudi Arabia, iHassan Institute of Medical Sciences, Sri Chamarajendra Hospital Campus, Krishnaraja Pura, Hassan,
Karnataka, jRamaiah Medical College Hospital, Kodihalli, HAL 2nd Stage, Bangalore, Karnataka, kDr. N D Desai Faculty of Medical Science and Research, Nadiad, Gujarat,
l
Madras Medical College, Chennai, Tamil Nadu, India, mCollege of Medical Sciences, University of Guyana, Turkeyen Campus, Greater Georgetown, Guyana, nKamineni
Academy of Medical Sciences and Research Center, L.B. Nagar, Hyderabad, Telangana, oSri Devaraj Urs Medical College, Tamaka, Kolar, Karnataka, India, pFaculty of Health
Sciences, University of Nairobi, Nairobi, Kenya, qBJ Medical College, Ahmedabad, Gujarat, India and rDanylo Halytsky Lviv National Medical University, L’viv, L’vivs’ka Oblast,
Ukraine
D.M. and P.P are joint first author.
S.S.B. and R.P. are joint second author.
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
*Corresponding author. Address: Danylo Halytsky Lviv National Medical University, Pekarska St, 69, L’viv, L’vivs’ka Oblast, 79010, Ukraine. Tel.: + 380 636 968 372.
E-mail: saakshi843@gmail.com (S.A. Ijantkar).
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the terms of the Creative Commons Attribution-Non
Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used
commercially without permission from the journal.
Annals of Medicine & Surgery (2024) 86:5922–5929
Received 14 March 2024; Accepted 30 July 2024
Published online 14 August 2024
http://dx.doi.org/10.1097/MS9.0000000000002446

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Mistry et al. Annals of Medicine & Surgery (2024)

Introduction
HIGHLIGHTS
Tuberculosis (TB) and cachexia are two clinical entities that go • Both the Southeast Asian and African regions share similar
together as there is a defined relationship between them[1,2]. TB is prevalent cases of cachexia due to TB.
a respiratory disease that affects the lungs and airways, caused by • Individuals who are cachexic cachexia and have TB tend to
Mycobacterium tuberculosis (MTB)[3]. Cachexia, on the other experience delayed recovery and higher mortality rates
hand, is a debilitating state caused by prolonged nutritional compared to those with normal nutrition who have TB.
deficiency[1]. There is a clear and consistent relationship between • Common clinical features of cachexia due to TB include;
undernutrition and TB in both developed and underdeveloped persistent productive cough, shortness of breath, and
countries around the world, which has been widely documented weight loss.
and acknowledged[1]. Undernutrition and TB exhibit a com- • Complications such as numerous random nodules scat-
pounding relationship in that undernutrition impairs the immune tered throughout the lung tissue on both sides, central
system in humans, thereby increasing the risk of latent TB pro- cavitation of nodules within the upper lobe, prominent
gressing to an active infection[1]. In other words, TB can lead to lymph nodes in the right hilum and mediastinum, and
cachexia, while cachexia is a risk factor for TB[2]. A global report small, cystic lesions in the liver and spleen are
by the WHO in 2019 showed that the proportion of males to commonly seen.
females experiencing undernutrition was 2:1 among individuals • Efforts to tackle cachexia due to TB in south-Asia and
diagnosed with TB[4]. Although other risk factors for TB aside African regions should be tailored towards multisectoral
from malnutrition, include; poverty, overcrowding, cigarette approaches especially nutritional weight gain, administra-
smoking, TB-HIV co-infection, diabetes mellitus, etc.[5,6]. Over tion of combinational TB nano vaccines, use of travel
the years, extensive research has been done to determine the Africa phenomenon and One Health approach.
relationship between cachexia and TB across the globe[1–3,7].
More than two billion people are infected by M. tuberculosis[8].
Annually, it is estimated that three million deaths occur world- Cachexia in tuberculosis: current scenario,
wide as a result of TB[8]. Although TB is a disease that can be both implications, and efforts
prevented and cured, it claims the lives of approximately 1.5 Prevalence of cachexia in tuberculosis in Southeast Asia and
million individuals annually, making it the most lethal infectious Africa
agent worldwide[9]. Several studies in Southeast Asia and Africa
also indicate a high burden of TB resulting in cachexia in these TB is the most important infectious disease with a resurgence
regions[1–7,10–14]. There are 11 and 54 countries in Southeast Asia globally[22]. In 2014, ~10 million cases of TB were documented
and Africa, respectively[15,16]. Unfortunately, only a few selected worldwide with a death rate of almost 1.5 million[22]. The incidence
countries in these regions have conducted studies on TB and of TB was found to be 20 times greater in individuals residing in
cachexia. This indicates that there is limited data regarding this low-income countries than in high-income countries[23]. According
issue and the possibility of under-reported cases. Despite efforts to global statistics, approximately one-fourth of all new TB cases
to curtail cachexia in TB in these regions, this threat persists as a are estimated to result from undernutrition, and TB is thought to be
significant public health concern in these regions[1,7,17–19]. There one of the prevailing background aetiologies of emaciation. Both
are still many undernourished individuals with TB in Southeast the Southeast Asian and African regions share similar prevalent
Asian and African regions[12,20,21]. For example, a recent study in health issues, including TB[6,19,24,25]. The highest number of newly
Ethiopia showed that over 50% of individuals with TB were diagnosed TB cases occurs in the Southeast Asia and Western
undernourished, with ~51% indicating a high number of old and Pacific regions, accounting for 56% of the total global cases[26].
new cases of nutritional deficiencies in individuals with TB[18]. Research in India, Nepal, Ethiopia, Kenya, and Ghana has indi-
Based on these findings, we speculate that there are knowledge cated that 50–57% of patients with TB suffer from malnutrition.
gaps and untapped opportunities that need to be addressed. This Individuals with malnutrition are twice as likely to perish from
article aims to critically review cachexia in tuberculosis in TB[4,10–13,18,20,27]. In India, the WHO identified nutritional defi-
Southeast Asian and African regions and propose possible solu- ciencies and TB as coexisting health issues that are intricately linked
tions to the problem. This article can be beneficial in developing and constitute interconnected public health challenges[28]. India
tailored strategies aimed at tackling cachexia in people with TB in reported a 55% prevalence of TB that was likely attributed to the
the Southeast Asian and African regions. impact of undernutrition[28]. Between 2013 and 2016, studies
conducted in North Karnataka[29] and West Tripura in India[30]
revealed the prevalence of TB among malnourished individuals was
Methodology 59.1%, with a co-occurrence of 55.8% (30,31). A study in Sri
Lanka found that adult TB patients had significantly lower nutri-
In writing this review, a thorough literature search on the subject tional levels than healthy individuals, and the likelihood of under-
matter was done across electronic databases such as PubMed, nutrition was twice that of contracting active TB[31]. It was revealed
Google Scholar, and ResearchGate between 2013 to 2024 using that cachexia affected 51% of individuals with TB[31]. The first TB
keywords: ‘Africa’, ‘cachexia’, ‘prevalence’, implications’, survey conducted in Vietnam between 2006 and 2007 had the
‘Tuberculosis’, and ‘Southeast Asia’. Only cross-sectional studies, objective of this survey to evaluate the current state of tuberculosis
systemic reviews and meta-analyses, literature reviews, and case in the nation, revealing old and new cases of pulmonary TB with
reports will be considered. On the other hand, studies such as bacterial origin confirmed among 307 people in a population of
editorials, perspectives, and commentaries were not considered. 100 000[32]. New cases of confirmed TB were found to be four

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times greater in men than in women and increased with age[32]. The and higher mortality rates compared to those with normal
most old and new cases of TB were identified in developed areas nutrition who have TB[17]. At the molecular level, specific appe-
and the southern region of Vietnam[32]. Old and new cases of TB in tite-regulating hormones are altered in individuals with TB. For
Vietnam were found to be lower compared to other studies con- instance, Peptide YY2, ghrelin, and resistin are elevated, while
ducted in Asian countries with high TB prevalence, particularly in plasma leptin is decreased[41]. After receiving treatment, the
Indonesia in 2014 where the prevalence was 759 per 100 000 normalization of these hormones leads to an improvement in
adults[33], the Philippines with 1159 per 100 000 individuals in appetite and nutritional status, which can explain the low BMI
2016[34], and Myanmar with 468 per 100 000 persons in 2017[35]. and may also explain the poor dietary intake often linked with
Sub-Saharan African countries are among the top 30 globally TB[41,42]. The chief defense mechanism against TB is cell-medi-
with a significant burden of TB[36]. The WHO uncovered that the ated immunity, which makes it a significant risk factor for the
number of senior citizens contracting TB ranges from ~10 000 in emergence of undernutrition[1]. Deterioration in nutritional sta-
Congo to 290 000 in South Africa, according to the latest tus can frequently arise due to the reactivation of latent TB
statistics[36]. Ninety per cent per cent of adults of working age infection, which was previously subclinical[1]. Research con-
with TB are responsible for lost days of work, which in turn ducted in Asian countries has uncovered that cachexia risk fac-
places an economic burden on these countries[36]. A nationwide tors in TB patients often include comorbidities like HIV/AIDS
survey in all 10 provinces of Zambia, covering 49 districts, and diabetes mellitus[29,30]. Studies conducted in African coun-
revealed a prevalence of 319 cases of smear-positive TB per tries have identified significant associations between under-
100 000 adult population, and 568 cases of culture-positive TB nutrition among older persons with TB and factors such as sex,
per 100 000 population. Additionally, the prevalence of bacter- level of education, and functional status[1,20]. Figure 1 shows the
iology has shown a rate of 638 cases of TB per 100 000 aetiopathogenesis of Cachexia in TB.
individuals[18]. Smear, culture, and bacteriology prevalence
confirmed that TB was more prevalent in patients who tested Clinical manifestations
positive for HIV, male patients, patients aged between 35 and 44, Cachexia, a condition commonly observed in TB patients[1,43],
as well as in urban respondents[19]. A study conducted in Zambia has several well-documented clinical manifestations. For exam-
showed that individuals from lower economic backgrounds had a ple, a 47-year-old gay Filipino man with intestinal TB presented
greater burden of TB compared to those from higher wealth with symptoms in the Philippines, such as a persistent productive
status[19]. A 2015 national survey in Ethiopia indicated that two- cough, shortness of breath, and weight loss that had endured for a
thirds of registered elderly individuals typically have a BMI of less year. On examination, the patient exhibited evidence of cachexia,
than 18.5 kg/m²[21]. A study conducted by Muse AI et al.[1] in the as evidenced by temporal wasting[43]. This individual was
Somali region of Ethiopia, found that the ultimate old and new experiencing mild respiratory distress, and a displayed heart rate
cases of nutritional deficiencies in individuals with TB were was 93 beats per minute, while his tachypnoea was 23 per
44.3%, with a 95% CI of o(38.2, 49.7). Two other studies con- minute[43]. Zhenget al.[42] discovered through their case report
ducted in Ethiopia also revealed increased cases of nutritional that there was severe oral thrush but did not observe any palpable
abnormalities in older individuals with the disease compared to lymphadenopathy. Fine crackles were also identified as features
the current study specifically, one study reported a rate of of this medical condition[43]. Although lab results showed a
57.2%[37], while the other reported a rate of 63.2%[38]. The typical white blood cell count, other findings were abnormal:
prevalence was 57% in Zambia and 51% in Malawi, as per there was anemia with normal-sized red blood cells, low sodium
studies conducted in those countries[10,39]. levels at 131 mmol/l, the albumin level was found to be low, at
2.1 g/dl, while the aspartate aminotransferase level was elevated,
Aetiopathogenesis of cachexia in TB at 75 U/l. Similarly, the lactate dehydrogenase level was also
Cachexia is a severe form of malnutrition characterized by a elevated, at 654. However, the lactic acid level was within normal
significant loss of weight and muscle mass due to an inadequate limits[43]. A study in Vietnam uncovered that roughly 58% of TB
intake of nutrients and energy to sustain good health. It is a cases exhibited prolonged cough symptoms for 14 days or
condition that arises when the body does not receive the necessary more[32]. A cross-sectional study conducted in the Somali region
nutrients and energy to function properly[24]. People typically of Ethiopia found that ~34% of respondents had a cough that
become malnourished when their diet fails to deliver sufficient lasted for more than 1 month before a diagnosis of TB was made,
food nutrients necessary for growth and development[25]. Also, while 30% experienced concurrent breathing difficulties[1].
disease conditions can further worsen intestinal absorption of Additionally, ~18% of the participants reported difficulties with
these food nutrients[25]. Due to the intricate relationship between eating, with 12% of respondents experiencing poor appetite, 4%
malnutrition and tuberculosis, insufficient dietary intake and struggling with nausea or vomiting, and less than 1% being
heightened energy expenditure can compromise the immune affected by mouth ulcers[1].
system, consequently leading to latent tuberculosis and sub-
sequent active infection[1]. Due to the intricate relationship Public health implications
between these two factors, tuberculosis exacerbates under- Several public health implications of cachexia in individuals with
nutrition by elevating metabolic demand and diminishing TB have been identified[1,18,44,45]. It emerged that people with
appetite[40]. Pathological features observed in patients with TB catabolic disorders like TB may experience a loss of over 20% of
include reduced appetite, suboptimal nutritional intake, and an their weight and muscle mass within a 3–6-month period, yet still
imbalance of micronutrients resulting from an imbalanced have BMI values within the normal range[46]. A national survey in
metabolic pathway due to the disease process[17]. Individuals who India found that preschool children with low BMI for their age
are cachexia and have TB tend to experience delayed recovery and low weight for height were at a higher risk of infection[47].

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Figure 1. The aetiopathogenesis of cachexia in tuberculosis.

Muse AI et al.[1] in Ethiopia discovered that female respondents sometimes experience bad prognosis health outcomes[45]. Research
with TB were two times more susceptible to undernutrition than in Zambia posited that when the HIV pandemic and poverty
male respondents. Additionally, individuals with no formal edu- coincide in a country, it can increase the number of TB cases[19]. A
cation were four times at risk of suffering from undernutrition study conducted in Nepal revealed that the burden of TB has the
compared to those who were literate[1]. Conversely, individuals potential to cause economic consequences on both the micro and
without formal education are four times more susceptible to macro-economic levels in Nepal[48]. A case study conducted in the
experiencing malnutrition than those with formal education[1]. Philippines highlighted a few complications experienced by a
Individuals who suffer from enuresis and TB were found to suffer cachectic patient with tuberculosis[43]. The complications consist of
from undernutrition four times compared to mobile individuals[1]. numerous random nodules scattered throughout the lung tissue on
People with less education are likely to have a limited under- both sides, radiologic evidence of central cavitation of nodules
standing of dietary diversity and the importance of adhering to anti- within the upper lobe, prominent lymph nodes in the right hilum
TB medications[1]. According to the data, ~12% of respondents and mediastinum, and small, cystic lesions in the liver and
had comorbidities, including kidney-related problems, heart-related spleen[43]. A computed tomography (CT) examination of the
problems, and lung-related problems. For example, asthma could patient’s abdomen was performed, utilizing intravenous adminis-
influence their nutritional needs[1]. A study conducted in Malawi tration of contrast revealing enlarged necrotic lymph nodes in the
indicated that individuals with both TB and low nutrition were two retroperitoneal, pelvic, and inguinal regions[43].
times more susceptible to premature death and long-term respira-
tory disease, and a lack of proper nutrition also raised the like- Efforts to fight cachexia in TB in Southeast Asia and Africa
lihood of contracting TB threefold[44]. A study conducted in Efforts to combat cachexia in conjunction with TB treatment are
Ethiopia demonstrated that the functional capacity of individuals crucial to enhance the treatment outcome, and overall well-being
diagnosed with TB is typically linked to their main health condition, of an individual with TB, and limit the chance of reinfection[1].
including persons who have lower physiological capacity Counseling on nutrition has been demonstrated to ensure

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Figure 2. The efforts to fight cachexia in tuberculosis in Southeast Asia and Africa.

sufficient calorie intake, leading to enhanced and consequently implemented various interventions to alleviate the pressure of TB
crucial improvement in weight, lean body mass, and physical on the population, such as improving routine TB care and ther-
functional state[49]. A systematic review and meta-analysis apy, introducing novel anti-TB drugs, and employing active case
uncovered that the majority of people diagnosed with TB are finding and household contact tracing[56,57]. In 2016, Xpert
typically evaluated for only a single aspect of the malnutrition MTB/Rif was utilized for all screened positive respondents in
construct[6]. BMI is frequently employed as an assessment Vietnam[32] and Indonesia[33]. During the years 2016 and 2017,
method for malnutrition in studies involving individuals with TB, Xpert Ultra was utilized for the screening of TB in the surveys
even though it only partially addresses the domain of conducted in the Philippines and Myanmar, respectively[34,35]. In
malnutrition[6]. The Zambian national survey demonstrated that addition, the Double X Strategy, which involves chest radiograph
implementing a comprehensive TB symptoms screening algo- screening, which is a mobile device, along with an examination of
rithm led to the establishment of more stringent screening criteria, gene Xpert, was implemented in four locations in Vietnam. These
thereby decreasing the likelihood of overlooking TB cases among locations, which consist of Hai Phong, Hoi An, Ca Mau, and Ho
the participants[19]. Unlike a study in Vietnam in 2006, which Chi Minh City, have been developed to provide support for
relied exclusively on cough as a conventional screening method individuals who are considered to be in a vulnerable state[58,59].
for identifying TB among its participants, our approach incor- These groups at risk encompass individuals such as prisoners,
porates various criteria for a more comprehensive and accurate coal miners, and senior citizens[60,61]. One limitation of the
detection process[50]. Unfortunately, multiple investigations have Double X Strategy was that only a small scale was tested with the
demonstrated that symptom-based dynamic TB case finding is method[62]. This procedure proved to be effective in identifying
not effective[51–55]. During the period from 2010 to 2016, inno- new TB cases. The screening awareness program on TB was
vative screening and diagnostic devices were implemented in conducted on an island known as Cu Lao Cham, where 17 recent
Asian regions to identify TB cases[32,56,57]. In 2010, Vietnam cases were identified compared to only 2 ongoing cases before the

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Mistry et al. Annals of Medicine & Surgery (2024)

Table 1
The key concepts findings and limitations of the most important articles regarding cachexia in TB.
Finding Limitation Reference
Approximately one-fourth of all new TB cases are estimated to result from undernutrition These figures are subjective, recent studies are required for 6,19, 25, 26
validation
Research in India, Nepal, Ethiopia, Kenya, and Ghana has indicated that 50–57% of patients These studies only cover a few countries and need more 10–13, 18, 20, 27
with TB suffer from malnutrition multicentred studies
Nutritional deficiencies and TB as coexisting health issues that are intricately linked and Nutritional deficiencies are not limited to only cachexia 29
constitute interconnected public health challenges
Observed clinical features include; persistent productive cough, shortness of breath, and There are other clinical conditions such as pneumonia and 46
weight loss malignancies with similar presentations
People with less education are likely to have a limited understanding of dietary diversity and This finding depends on the study area and study participants 1
the importance of adhering to anti-TB medications
Children with both TB and low nutrition are two times more susceptible to premature death This is a pediatric study 47
and long-term respiratory disease
The functional lung capacity of individuals diagnosed with TB is typically linked to their main TB can co-exist with HIV, but not necessarily cachexia 48
health condition
mRNA vaccines can also help to fight infectious diseases by discovering the Foreign proteins This study is not specific to TB 70
and responding by producing antibodies

initiation of the program[62]. One of the benefits of the Double X evaluate and manage cachexia in TB in these regions, espe-
Strategy is its capacity to identify overlooked instances of TB[32]. cially in the aspect of the One Health approach, Precision
Figure 2 shows the efforts to fight cachexia in TB in Southeast medicine approaches to harness technological advancements,
Asia and Africa. Numerous studies have indicated specific stra- eco-friendly interventions, and public campaigns[71] (Table 1).
tegies to fight cachexia due to TB[63–66]. For example, normal
weight was identified to prevent TB[63]. Also, there is nutritional
recovery if an individual with chronic TB is given a 20% protein Ethical approval
diet[64]. Additionally, a Cochrane study found that a person
suffering from cachexia due to TB could recover from the six Ethics approval was not required for this review.
protein-energy interventional trials because these trials aid the
completion of treatment and recovery, validate improvements in
physical activities and life quality related to management; and Consent
result to an increase weight gain[65]. TB vaccines such as
Informed consent was not required for this review article.
VPM1002, M72-AS01, MIP, and GamTBVac which work
through the principle of combinational effect, can improve vac-
cine efficacy and protection by inducing a wider immune
Source of funding
response[66] and have been shown to prevent cachexia[67]. mRNA
vaccines can also help to fight infectious diseases by discovering Not applicable.
the foreign proteins and responding by producing antibodies[68].
Another effective way to fight cachexia due to TB is via ChatGPT,
especially in clinical cases[69]. This is evidenced that pathologies Author contribution
can be detected through GPT-powered chatbots[69].
D.M., P.P., and S.S.B.: contributed to the conception and design
of the study, drafting the article, critical revision for important
Conclusion intellectual content, and final approval of the version to be pub-
To effectively manage TB, a comprehensive evaluation of the lished; R.P. and S.P.: participated in the drafting of the article,
patient’s nutritional status is necessary. Such an assessment critical revision for important intellectual content, and final
would enable the identification and management of potential approval of the version to be published; D.S.D., C.T., and K.Y.
complications associated with TB, as well as provide insight G.: participated in drafting the article, critical revision for
into how the patient’s nutritional status may influence the important intellectual content, and final approval of the version
disease’s clinical progression[11]. Health authorities in to be published; A., S.S.N.P., and J.C.: were involved in critical
Southeast Asia and African regions need to devise effective revision for important intellectual content and final approval of
tools and diagnostic tests to evaluate cachexia in TB among the version to be published; L.A., K.R.S.C., and S.S.R.M.: con-
affected populations in these regions, for example, adopting a tributed to the critical revision for important intellectual content
phenomenon called travel Africa, where specific vaccines, and final approval of the version to be published; P.S., M.A.O.,
gathered through ChatGPT, are needed to be recommended by M.V., and S.A.I.: participated in the final approval of the version
healthcare professionals in both south-Asia and African to be published. All authors contributed to writing different parts
regions[70]. Further epidemiological studies and randomized of the manuscript, and all authors have approved the final version
control trials (RCTs) should be conducted by researchers and of the manuscript and agree to be accountable for all aspects of
physicians in Southeast Asia and African regions to properly the work.

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Mistry et al. Annals of Medicine & Surgery (2024) Annals of Medicine & Surgery

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