Food Supplements Are Transforming TB Survival In India

A new study quantifies the impact of malnutrition on the successful treatment of tuberculosis (TB). Malnutrition is a major risk factor for acquiring TB and dying from it.

India had an estimated 3 million new TB cases in 2021, accounting for 27% of the global tuberculosis incidence and 35% of tuberculosis deaths.

The Reducing Activation of Tuberculosis by Improvement of Nutritional Status (RATIONS) trial was just published in The Lancet Global Health. It showed a striking reduction in the death rate and return to function of patients.

Similarly, improving the nutrition of family members of patients with pulmonary (lung) TB, which is highly infectious, cut the rate of contagiousness to other family members by almost half. This was shown in an accompanying paper in the Lancet.

These studies were led by Professor Anurag Bhargava in India and were funded by the Indian Council of Medical Research. They were large, randomized trials with 10,345 household contacts of 2800 patients with pulmonary TB living in rural India.

The study was a large cluster-randomized controlled trial. This means that instead of individual patients being randomized to different treatments, groups of patients living in a region were. This is a way of helping make accurate comparisons between large groups of people.

One thing that was striking is that the studies were conducted in Jharkhand. This is a rural area where almost a quarter of the population are tribal. This region has one of the highest proportions (46%) of people living in “multidimensional poverty”—that is not just money, but also lacking in education and basic infrastructure such as access to clean water, sanitation, and electricity. Being a largely forested and mountainous region means access to care is difficult. The study was conducted early in the Covid pandemic, adding more hurdles. Fortunately, the authors included community workers in the planning phases. (Having tried to run a small TB trial in rural and hilly India myself some years ago, I can assure you that overcoming such logistical issues is not easy. We had to hike into some of the villages looking for patients.)

The degree of malnutrition in this region is mind-boggling to most of us with a Western frame of reference. The mean weight for men at enrollment was 94 pounds (BMI 16) and 80 pounds for women. Ten percent were confined to a bed or chair and could only do self-care; 2% were too weak even for that.

Community health workers delivered food baskets of pulses (beans, lentils, peas), powdered milk, and oil, containing 1200 cal and 52 g protein per day, and a micronutrient pill each month. Household contacts received food baskets providing 750 cal and 23 grams of protein per day per person and the micronutrient pill.

In addition to antibiotics, food deliveries continued for six months for people with drug-susceptible tuberculosis and 12 months for multidrug-resistant tuberculosis.

Findings

Among family members living with a person with active lung TB, improving nutrition resulted in a 40-50% reduction in new TB cases.

Treatment of the underlying TB was successful in 94% of the patients. Nutritional supplements reduced the risk of death by 13% for those patients who had a 1% weight gain and by 61% for those with a 5% weight gain at two months. Overall, nutritional support in patients reduced TB mortality by 35%.

By the end of treatment, 75% of patients were able to work.

Cost:

While some might want to focus on the human toll of TB, others will ask about the cost and affordability of providing nutritional support.

This remarkable improvement in lives saved and a return to productivity for patients cost only US $0.49 per day ($13/month), including delivery costs. For adult household contacts of patients, the cost was $4.75 per month. Food was nearly as effective as newer vaccines against TB. In fact, at the Papworth village settlement for TB in the UK, providing adequate nutrition alone resulted in a six-fold reduction in tuberculosis incidence, even without access to anti-tuberculosis medicines or vaccines.

The cost of treating a case of drug-sensitive TB was $235. In contrast, treating a patient with multidrug-resistant TB (MDR-TB) can run $5,723. The average cost for treating a case of pulmonary XDR-TB (extensively drug-resistant TB) is $8,401.

Co-author Dr. Madhavi Bhargava said, “Nutritional support needs to be an essential and not an optional part of patient-centered care in the Indian context.”

Dr. Soumya Swaminathan is a TB expert and the former Chief Scientist of the WHO. She added, “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.”

This study is an excellent example of a real-world, pragmatic trial. The monthly food baskets and micronutrient supplements reduced new microbiologically confirmed tuberculosis by 48%. It would likely reduce other infections as well. Treating malnutrition is a sound, cost-effective strategy, as well as being the just and humane thing to do.