Nutritional supplementation improves TB treatment's outcome

Two studies have, for the first time, established the link between nutritional support and tuberculosis treatment’s success and mortality.

The results of the Reducing Activation of Tuberculosis by Improvement of Nutritional Status (RATIONS) trial, published in The Lancet on August 9, found that nutritional support was associated with a 39 per cent-48 per cent reduction in tuberculosis incidence among household contacts of microbiologically confirmed pulmonary tuberculosis patients.

RATIONS is a cluster-randomised controlled trial of 10,345 household contacts of 2,800 microbiologically confirmed pulmonary tuberculosis patients. It was embedded within the National Tuberculosis Elimination Programme (NTEP) in four districts of Jharkhand — Saraikela-Kharsawan, West Singhbhum, East Singhbhum, and Ranchi.

The state's population is predominantly rural with a high proportion of people living in poverty, and almost a quarter belong to scheduled tribes.

In the study between August 2019, and August 2022, 5,621 household contacts were placed in the intervention group and 4,724 in the control group.

Tuberculosis patients in both groups received nutritional support amounting to 1,200 kilocalories (kcal), and 52 grams of protein per day with micronutrients for six months. However, only household contacts in the intervention group received monthly food rations and micronutrients amounting to 750 kcal and 23 grams of protein per day.

This led to a reduction of tuberculosis incidence of 39 per cent (all forms) to 48 per cent (microbiologically confirmed pulmonary tuberculosis) in the intervention group, the Lancet paper said.

Led by Anurag Bhargava from the Department of Medicine at the Yenepoya Medical College, Mangaluru, the studies were funded by the Indian Council of Medical Research—India TB Research Consortium.

Another paper published in The Lancet Global Health on the same day found that weight gain decreased the risks of tuberculosis mortality in 2,800 severely malnourished TB patients in Jharkhand.

“More than two-thirds of patients were tribals and were accessing rations from the Public Distribution System. Undernutrition (BMI<18.5 kg/m2) was prevalent in 4 out of 5 patients, with severe undernutrition (BMI<16 kg/m2 ) in nearly half of these. Extremely severe undernutrition (BMI< 14 kg/m2) was present in 1 out of 6 patients,” the researchers said.

For six months, nutritional support was provided to individuals responding to TB drugs, while the duration was 12 months for those with multidrug-resistant tuberculosis. They were given food rations of 1,220 kcal, 52 grams of protein per day as well as micronutrient pills.

However, patients with drug-susceptible tuberculosis could receive an extension of up to six months if their BMI was less than 18·5 kg/m2 at the end of treatment, the researchers said.

An early weight gain in the first two months was associated with a 60 per cent lower risk of TB mortality. The other benefits to patients were higher treatment success, better weight gain, and low rates of weight loss during follow-ups. Only three per cent were able to work at enrolment, but this figure rose to 75 per cent at the end of treatment, a press release said.

The prevalence of HIV, diabetes, and Multi-Drug Resistant-Tuberculosis was low, but alcohol and tobacco use was high. Nearly 10 per cent of patients had hypotension, hypoxia, or were unable to stand, indicating the need for inpatient care, the researchers added.

Soumya Swaminathan, chairperson of the MS Swaminathan Research Foundation and former chief scientist of the World Health Organization said in a media briefing, “Among the risk factors for tuberculosis, undernutrition is the most prevalent one in India, accounting for over 40% of new (incident) cases every year. While other risk factors like diabetes, HIV infection, smoking, and alcohol also need attention, the one risk factor that stands out is undernutrition. Studies conducted by the NIRT, Chennai many years ago showed that TB patients who weighed less than 35 kg had 4 times higher mortality than those who weighed over 45kg.”

Stressing the importance of these findings, Swaminathan said in a statement, “Improving the nutritional status of our population could potentially have a big impact on reducing TB incidence and achieving the ambitious goal of TB elimination in the next few years. As we think about policy actions, we need to explore strategies to expand dietary diversity and provide adequate calories and protein to undernourished people who are at a much higher risk of developing active TB.”

HIV, undernutrition, and diabetes also increase the risk of TB and deaths among TB patients. “Of these, undernutrition, in the population and patients is a most widely prevalent and more correctable risk factor, which is increasing according to estimates by the FAO. Undernutrition increases the risk of TB by 4-fold and around 900,000 cases annually are attributable to its effects. Studies in the past have shown that undernutrition is highly prevalent and severe in patients with TB in India," Bhargava told Down to Earth (DTE).

“Undernutrition in patients, which is worsened by the effect of the disease itself, increases the risk of TB deaths by 3-fold, including deaths early during treatment,” Bhargava told DTE.

“WHO’s End TB strategy aims to reduce the incidence of TB by 90% by 2035. A third of the world’s population is estimated to have latent TB infection. With well-functioning cell-mediated immunity, only 5%-15% of people with latent infection will develop active TB over a lifetime, implying protection of around 90%. To meet the ambitious incidence reduction targets we need to ensure that latent TB infection remains latent by tackling undernutrition and other risk factors for progression to active disease,” Bhargava wrote in an earlier 2016 editorial published in the BMJ journal.

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