In the roughly three minutes that it will take you to finish reading this article, three people somewhere in India would have died from tuberculosis (TB). India bears a significant proportion of the global tuberculosis burden, harbouring one fourth of the world's cases. More than two million Indians develop TB every year. We are well aware of the important aspects of TB care and support that deserve attention in India, including better awareness, early diagnosis, improved access to anti-TB medication, detection of drug resistance and treatment completion. Nutrition, however, is an often-ignored but vital aspect of TB care.
Undernutrition is an important risk factor for TB. The disease, in turn, causes pathophysiological changes that can lead to undernutrition.
Medical history is full of anecdotal evidence that highlights the role of nutrition in helping patients recover from TB. Back in the 19th century, TB was a common disease across Europe. There were no anti-TB drugs available so patients were often sent to a sanatorium, where they were put on a strict daily regimen comprising a nutritious diet, plenty of fresh air, rest and limited activity. And many of them were able to recover! With it being National Nutrition Week, it's a good time to revisit the connection between diet and tuberculosis.
The link between TB and undernutrition
Undernutrition is an important risk factor for TB. The disease, in turn, causes pathophysiological changes that can lead to undernutrition. Patients with TB experience loss of appetite, have a higher basal metabolic rate (BMR) and a reduced ability to synthesise proteins in the body, leading to muscle wasting, loss of fat, weight loss and micro- and macronutrient deficiencies. Undernutrition combined with the long duration of TB treatment and medicines leads to poor treatment outcomes and a higher rate of relapse. Undernutrition at the time of a TB diagnosis is also linked to a higher risk of death from the infection.
The importance of eating well in recovery
An estimated 70% of notified TB cases are seen amongst the most economically productive age group (15 to 54 years), often resulting in loss of work for the patient who may be the sole bread winner of the family. Further, unhygienic living conditions, limited access to health facilities and lack of awareness make families from weaker financial backgrounds more vulnerable and push them into greater financial distress. It is therefore vital to provide need-based nutrition support to patients and their families in order to improve treatment outcomes and reduce TB transmission to other family members.
It is vital, at the time of diagnosis itself, to assess a patient's nutritional status and counsel them about the role of nutrition.
Adequate consumption of calories, proteins, micronutrients and macronutrients during TB recovery can help meet the increased calorie and energy requirements because of the infection, support the immune system and the biochemical reactions involved in the repair and restoration of cells and tissues, and help manage TB symptoms and treatment side-effects. Patients with TB should get 45% to 65% of their daily energy needs from carbohydrates, 25% to 35% from fat and 15% to 30% from protein. Some of the important nutrients for patients are vitamins A, B6, C, D, E, folic acid, copper, iron, selenium and zinc, as they play a key role in cellular and immune functions.
Providing nutritional support to those who need it
The government of Chhattisgarh has been amongst the first to launch an innovative scheme to provide nutrition support to patients with TB. The "Mukhyamantri Kshay Poshan Yojana" provides 30,000 patients with a monthly food basket that includes soya bean oil, groundnuts and milk powder. In other cities such as Visakhapatnam (Andhra Pradesh) and Indore (Madhya Pradesh), need-based nutrition is being given to patients with TB, particularly to those living in tribal areas.
It is vital, at the time of diagnosis itself, to assess a patient's nutritional status and counsel them about the role of nutrition. We must do this without diverting resources from the standard TB regimen and monitoring. Assessment may be done by healthcare professionals or other trained healthcare workers at primary healthcare centres. Multiple parameters such as height, weight, mid-upper arm circumference (in children), medical history, clinical signs of undernutrition (e.g. oedema, wasting), along with dietary evaluation and assessment of comorbid conditions or concurrent treatment can be used to assess if a patient is undernourished. Offering nutritional supplementation can also act as an incentive for patients to motivate them to adhere to and complete their treatment.
India has made significant strides in reducing TB prevalence and mortality in the last 25 years. However, if we are to get rid of the dubious distinction of being the country with the largest global TB burden, then we need to integrate nutritional support into our TB treatment, care and support strategies, particularly for the underprivileged sections of society.