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Journalism of Courage
WHEN AN 18-year-old tribal from Jharkhand was diagnosed with tuberculosis, he weighed just 26 kg. With his family barely managing to get one square meal per day, his condition deteriorated. But when given nutritious food packets, he gained 16 kg in six months, and showed improvement.
The teenager was part of two studies — conducted between August 2019 and August 2022 in four districts of Jharkhand — that offer the first evidence of how nutritional support reduces risk of mortality among TB patients.
According to the findings of the Reducing Activation of Tuberculosis by Improvement of Nutritional Status (RATIONS) trial, improved nutrition can reduce the incidence of all forms of TB by up to 40 per cent, and of infectious TB by up to 50 per cent among those in contact with patients suffering from infectious lung TB.
It also found that early weight gain among underweight patients with TB could reduce risk of mortality by up to 60 per cent, as it ensured higher treatment success.
The findings of the studies by the Indian Council of Medical Research (ICMR), in collaboration with the National TB Elimination Programme and National Institute for Research in Tuberculosis, Chennai, have been published in The Lancet and The Lancet Global Health Journals.
As part of the trial, 10,345 “household contacts” of 2,800 TB patients were randomised to receive food parcels. While 5,621 people were given food with additional micronutrients (750 kcal, 23 gm proteins) for a year, the rest got food parcels with no extra nutrients. At the end of the trial, the incidence of TB was 39 per cent less in the former group as compared to the latter.
The second study tracked 2,800 TB patients for six months and found that weight gain following improved nutrition was directly linked to reduced risk of mortality, especially in the first two months when deaths occur. The risk of death was reduced by up to 13 per cent for a one per cent weight gain, and up to 61 per cent for 5 per cent weight gain.
These findings, which come at a time when the Centre is seeking to eliminate TB by 2025, can have implications at the policy implementation level. Under the national programme, TB patients are given monthly nutritional support of Rs 500 through direct benefit transfer for the duration of their treatment. And under the Ni-kshay Mitra programme, volunteers can provide monthly nutrition kits to their “adopted” patients.
“The findings shed light on how we can tackle TB in the future,” said Dr Nivedita Gupta, Head, Epidemiology and Communicable Diseases Division, ICMR.
In India, three million new TB cases and 4,94,000 deaths were reported in 2021, representing 27 per cent of the global TB incidence and 35 per cent of deaths, according to the WHO Global Tuberculosis Report, 2022.
Experts said the studies are significant because under-nutrition has now emerged as the leading risk factor for TB globally and simple dietary interventions have been found to be effective.
“The results of the trial are significant as it shows improved nutrition in family members has worked at the community level,” said lead authors Dr Anurag Bhargava of the Department of Medicine,Yenepoya Medical College, Mangalore, and Dr Madhavi Bhargava.
“The study is the first of its kind in the world and the question was can nutritional intervention reduce TB incidence,” said author, Dr Soumya Swaminathan, Chairperson of the M S Swaminathan Research Foundation and former Chief Scientist of the World Health Organisation (WHO).
“It is wonderful that the evidence is coming from India that will also inform global policy. Essentially, a good nutritional package that provides a substantive amount of calories, proteins and micronutrients should be given to the household members of TB patients,” she said.
According to the study, to prevent a single case of TB, about 30 households (111 household contacts) and about 47 patients would need to be provided nutritional support. The monthly cost of a food basket was Rs 1,100 per patient, and Rs 325 per contact (at 2019 prices).
The TB patients received a monthly 10 kg food basket (rice, pulses, milk powder, oil) and multivitamins for six months. Among family members, the intervention group received 5 kg rice and 1.5 kg pulses per head per month.
Jharkhand was chosen as a trial site because it has a high burden of TB (52,179 cases notified in 2021) and the second highest level of multi-dimensional poverty.
“That a low-cost food-based nutritional intervention could prevent TB to a significant degree is very encouraging,” said Dr Bhargava.
