Tuberculosis and Malnutrition – The Evidence, Challenges, and Way Ahead

India has long faced the challenge of dealing with both tuberculosis (TB) and malnutrition, creating a harmful cycle of poor health outcomes. TB remains a significant public health issue in the country, constituting a substantial part of the global TB burden. Despite initiatives like the National Tuberculosis Elimination Programme (NTEP), the fight against TB is still ongoing. Malnutrition, a hidden epidemic, is worsening the TB crisis. Dr. Soumya Swaminathan, former Chief Scientist of the World Health Organization, highlighted that undernutrition is the predominant risk factor for TB in India, contributing to over 40% of new cases annually.[1] This concerning fact emphasizes the immediate need to address malnutrition as a crucial determinant of TB incidence and mortality. THE REDUCING ACTIVATION OF TUBERCULOSIS BY IMPROVEMENT OF NUTRITIONAL STATUS TRIAL – A GROUNDBREAKING STUDY The Reducing Activation of Tuberculosis by Improvement of Nutritional Status (RATIONS) trial[2] embarked on a pioneering initiative to investigate the influence of nutritional supplementation on both TB treatment and prevention. Conducted in Jharkhand, this groundbreaking study involved 10,345 family members (household contacts) of 2800 TB patients undergoing treatment as part of the NTEP. The outcomes of the trial had significant implications for TB management and the overall public health scenario in India. According to The Lancet editorial that published the trial results, it boldly suggested that “food could be considered the TB vaccine we already have.” This assertion emphasizes the crucial role of nutrition in addressing TB. The trial disclosed that enhancing the nutrition of family members of TB patients resulted in a remarkable reduction in TB incidence. All forms of TB incidence dropped by nearly 40%, and microbiologically confirmed pulmonary tuberculosis witnessed an almost 50% reduction over the 2-year study period. These findings are groundbreaking and underscore the undeniable connection between nutrition and TB. Another noteworthy finding from the RATIONS trial[2] was the potential to lower TB-related mortality through nutritional support. The study revealed that weight gain during treatment, especially at the 2-month mark, was linked to a substantial reduction in mortality risk. A mere 1% increase in body weight at this stage correlated with a 13% decrease in the risk of death during treatment, whereas a 5% weight gain resulted in an impressive 61% reduction in mortality risk. This evidence highlights the lifesaving potential of adequate nutrition for TB patients. One of the most encouraging aspects of the RATIONS trial was the cost-effectiveness of the nutritional intervention. TB patients received a monthly food basket containing essentials such as rice, pulses, milk powder, and oil, along with multivitamins for 6 months. This cost-effective approach demonstrated that a simple, food-based nutritional intervention could significantly contribute to TB prevention. At a monthly cost of Rs. 1100 per patient and Rs. 325 per contact, the intervention is not only feasible but also practical to implement using existing field staff. The RATIONS trial delved deep into the intricate web of social determinants contributing to TB in India. It unveiled that more than two-thirds of trial participants belonged to tribal communities, often relying on rations from the public distribution system (PDS). In addition, a staggering four out of five patients in the trial had a body mass index (BMI) below 18.5, indicating undernutrition. Almost half of the participants were severely undernourished, with a BMI below 16 kg/m2. These findings underscore the social disparities and vulnerabilities that perpetuate the TB-malnutrition link. Furthermore, nutritional supplementation can play a crucial role in aiding TB-HIV-coinfected patients, a significant subgroup with high morbidity and mortality.[3] THE WAY FORWARD: NIKSHAY POSHAN YOJANA AND NIKSHAY MITRAS The success of the RATIONS trial brings a glimmer of hope in the fight against TB, emphasizing the crucial role of effective nutrition interventions. To seize this opportunity and enhance the TB battle, India should adopt a comprehensive strategy. Expansion of the Nikshay Poshan Yojana The Nikshay Poshan Yojana (NPY), designed to offer nutritional support to TB patients, should undergo expansion and improvements to ensure greater accessibility by enhancing its user-friendliness. Vulnerable TB patients, such as the elderly, destitute individuals, orphans, migrants, refugees, and others, often lack essential identity documents or banking mechanisms, hindering their access to the benefits provided by the NPY. Several research studies and field worker reports indicate that a significant number of TB patients still encounter difficulties in receiving timely financial assistance through the NPY during their treatment.[4] The NPY aligns with the insights from the RATIONS trial and holds the potential to be a cornerstone in the fight against TB. Guaranteeing that every TB patient receives adequate nutrition throughout their treatment could be a game-changer in reducing TB mortality. Fortifying public distribution systems The RATIONS trial underscored the reliance of numerous participants on the PDS for their food provisions. Enhancing and streamlining the PDS to deliver nourishing food to vulnerable populations can prove to be an effective strategy in addressing malnutrition and, consequently, TB. Nikshay Mitras Launched in September 2022 by the President of India, the Nikshay Mitra initiative stands as a commendable effort aimed at improving the situation of TB patients.[5] Within the framework of this initiative, individuals, corporations, nongovernmental organizations, and other entities have the opportunity to sponsor TB patients, ensuring their access to sufficient nutrition for a minimum duration of 1 year. This provision not only guarantees a sustained supply of nourishment throughout the treatment period but also extends support beyond the conclusion of the treatment phase, aiming to prevent the recurrence of TB. Promoting awareness about this initiative and encouraging wider participation in adopting TB patients can play a pivotal role in India’s collective endeavor to eradicate TB. Community engagement and education Creating awareness about the correlation between nutrition and TB is crucial. Community-based educational programs can empower individuals and families to make informed dietary choices that promote their health and well-being. TB champions and survivors of TB can serve as invaluable resources for disseminating information and promoting programs such as Nikshay Mitras, as well as engaging in information, education, and communication and advocacy, communication, and social mobilization activities.[6] Research and innovation Continuous research and innovation are vital for refining nutritional interventions and identifying the most effective strategies to prevent TB through improved nutrition. Collaborations between government agencies, research institutions, and international partners can drive progress in this domain. Conducting additional operational research to assess the feasibility of the RATION trial in programmatic settings will help identify and understand the challenges in implementing nutritional support programs for TB patients in India. CONCLUSION The RATIONS trial has unveiled a groundbreaking revelation: nutrition serves as the TB vaccine we already possess! To attain TB elimination in India, addressing the social determinants of TB, particularly malnutrition and hidden hunger, is imperative. By expanding initiatives such as NPY and Nikshay Mitras, India can take significant steps toward a future where TB is no longer a pervasive threat. The battle against TB necessitates a comprehensive approach that acknowledges the intricate interplay between malnutrition and the disease, ultimately fortifying our fight against this long-standing public health challenge. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.