Every two minutes, three people in India die from tuberculosis, a curable and preventable disease. In 2011, this was the equivalent of nearly 3,00,000 men, women and children. Worse, a majority of these individuals were poor and in their most economically productive years of life.
TB preys on the poor as they are often undernourished and, therefore, lack a strong immune system to fight the disease. Unbeknown to them, many individuals carry the infectious bacillus, Mycobacterium tuberculosis, which causes the disease, silently in their body. In fact, about half the adult Indian population has latent or dormant TB infection. An opportunistic bacteria, the bacillus becomes active when immunity is reduced due to under-nutrition, HIV infection, Diabetes mellitus or old age. In the majority of otherwise healthy individuals who have latent TB infection, the body’s immune system is able to keep the infection under control for their lifetime.
Malnutrition is an important risk factor for progression from latent to active TB, especially among children and HIV-positive individuals who already have lower immunity. India has one of the highest percentages of undernutrition in children globally, with almost 40 per cent children, below the age of five years, being undernourished. Adults fare only marginally better. According to India’s third National Family Health Survey, 2005-2006, as high as 36 per cent women and 34 per cent men aged 15-49 were reported to be in an undernourished state.
The sheer number of undernourished children and adults coupled with the burden of TB in our country, is alarming. India’s Revised National Tuberculosis Control Programme has made enormous strides in the treatment and detection of the disease. However, the policies and programmes which sought to address the burden of TB in India have not considered that nutrition should be an integral part of prevention and care.
The relationship between nutrition and tuberculosis is complex and perpetuates a vicious cycle of malnutrition, poverty and disease. It is well-known that nutritional deficiencies can delay recovery by diminishing the effectiveness of the antibiotic drugs which can cure TB. However, what is not so well-known is that the disease itself is a risk factor for malnutrition and may be one of its causes. Patients suffering from TB experience a reduced appetite, their body finds it difficult to absorb nutrients and undergo an altered metabolism. This leads to muscle wasting, anorexia and generalised weakness. Concurrently, such patients will also use more energy to fight the infection, thereby increasing their energy and nutritional needs.
In the National Strategic Plan for the 12th Plan period, the Government is aiming for universal access to free and high quality TB diagnosis and treatment. Achieving this will need attention to some of the social determinants of disease like poor housing, smoking, alcohol dependence and malnutrition. The World Health Organisation is developing guidelines for nutritional care and support of TB patients. The Government has a real opportunity now to integrate food and nutritional support in their response to TB.
A beginning could be made by integrating nutritional indicators (like weight, body mass index) into TB monitoring and evaluation activities. A preliminary study conducted in Tiruvallur district near Chennai showed that almost half of TB patients were either moderately or severely food insecure. lack of quality food could lead not only to a poor response to treatment, but also to non-adherence to treatment, because patients need to get back to work to feed themselves and their families.
The food security Bill would give a much-needed legal entitlement to food and includes a uniform five kg of foodgrains to 75 per cent of the country’s rural and 50 per cent of the urban population. Also needed is a targeted approach to nutrition, TB and other chronic debilitating diseases, where additional food entitlements, rich in calories and protein, can be provided. A study conducted in Singapore showed that energy and protein supplementation of TB patients during the first six weeks of treatment resulted in a gain in lean muscle mass and not just fat.
At the same time, groups with a high propensity for contracting TB should be targeted for intensified case-finding. Malnourished children should be identified and screened for TB and linked to a comprehensive package of treatment through engagement with the Nutritional Rehabilitation Centres. We also need to support research into the efficacy of various nutritional interventions such as higher monthly rations, fresh meals or high-calorie, high-protein supplements, which could form a part of our national policy and practice. Recent evidence has shown that high doses of Vitamin D supplementation can expedite the recovery of a TB patient.
India bears the highest burden of tuberculosis in the world. Proper and appropriate nutritional support is essential in the fight against this ailment.
(The writer is Director, National Institute for Research in Tuberculosis, Chennai)