Anecdotal evidence has long supported this view and is a crucial aspect of India’s efforts to eradicate tuberculosis

In the roughly three minutes that you may take to finish reading this article, three people somewhere in India will have died from tuberculosis. India bears a significant proportion of the global tuberculosis burden, harbouring one-fourth of the world’s TB cases. About 2.84 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, vital aspect.

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.

Under-nutrition is an important risk factor for TB. The disease, in turn, causes patho-physiological changes that can lead to under-nutrition. 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 macro-nutrient deficiencies. Under-nutrition combined with the long duration of TB treatment and medicines leads to poor treatment outcomes and a higher rate of relapse. Under-nutrition at the time of a TB diagnosis is also linked to a higher risk of death

What recovery entails 

An estimated 70 per cent 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 breadwinner of the family. Further, unhygienic living conditions, limited access to health facilities and lack of awareness make families from weaker financial backgrounds more vulnerable. 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. Adequate consumption of calories, proteins, micro-nutrients and macro-nutrients during TB recovery can help meet the increased calorie and energy requirements; 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 per cent of their daily energy needs from carbohydrate, 25 to 35 per cent from fat and 15 to 30 per cent from protein. Some important nutrients for patients are vitamins A, B6, C, D, E, folic acid, copper, iron, selenium and zinc.

Providing support 

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 Vishakhapatnam and Indore , need-based nutrition is being given to patients, particularly to those in tribal areas.

It is vital at the time of diagnosis itself to assess a patient’s nutritional status and counsel the patient 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 trained workers at primary healthcare centres. Multiple parameters such as height, weight, mid-upper arm circumference (in children), medical history, clinical signs of under-nutrition (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 supplements can also motivate patients 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 carrying the largest global TB burden, we need to integrate nutritional support into treatment, care and support strategies, particularly for the underprivileged.