New Delhi: A new study from rural Chhattisgarh has found high prevalence of under-nutrition in tuberculosis (TB) patients, and a significant association between malnutrition and TB deaths.
“Given the very high prevalence of malnutrition in India, and the already high burden of TB, the synergy between these two is very worrisome. Nutrition is also an important blind spot in current TB control policies and investments in India,” said Dr Madhukar Pai, a co-author and associate professor at McGill University and associate director at McGill International TB Centre.
An estimated 2.3 million new cases of TB occur in India every year. In spite of the expansion of the Revised National TB Control Programme (RNTCP), the disease kills an estimated 320,000 people ever year.
The study published by a team of investigators from Jan Swasthya Sahyog (People’s Health Support Group) in central India, and McGill University in Montreal, Canada, in the journal PLOS ONE, highlights an important issue in the management of TB patients that needs to be taken into consideration by India’s RNTCP.
While it is well known that TB leads to weight loss, many TB patients in India are undernourished even before they develop the disease. The study looked at under-nutrition in patients with tuberculosis of the lungs at the beginning and end of treatment, and its impact on treatment outcomes in 1695 adult patients who were treated at Jan Swasthya Sahyog’s rural hospital over a six-year period. Height and weight were measured at the time of diagnosis; in addition, weight was followed up during the course of treatment and clinical outcome recorded at the conclusion of therapy.
Under-nutrition was found to be highly prevalent, and it hit women harder and more often than men. Nearly a half of the men weighed less than 42 kg, with a body mass index (BMI) below 16; while almost half of the women weighed less than 34 kg, with BMIs below 15. Some patients had BMIs of 13 or less; a level of wasting that is considered to pose an immediate threat to life. Only 2 per cent of the patients had body weights equal to or greater than the reference weights of 60 and 55 kg respectively for men and women, as published by the Indian Council of Medical Research (ICMR).
Such severe under-nutrition at the time of diagnosis was associated with a two to four times higher odds of death in these patients despite effective treatment, even after adjusting for the effects of age, gender, the number of TB bacteria in sputum, and simultaneous HIV infection.
“What is intriguing is that the low body weights persisted even at the end of treatment. Nearly a half of the men and women, who completed treatment successfully, had weights below 48 kg and 39 kg respectively, which was still a far cry from the reference weights of 60 and 55 kg. In fact, the prevalence and severity of under-nutrition in these patients was much worse than that seen in their counterparts in sub-Saharan Africa, where most of them labour under the additional burden of HIV infection,” according to the researchers.
Dr Anurag Bhargava, lead author and associate professor of medicine at Himalayan Institute of Medical Sciences, Dehradun, said, “Our study shows disturbing levels of under-nutrition at the beginning and end of treatment, and highlights its implications for mortality during treatment. Studies in different parts of the world indicate that under-nutrition is associated with more extensive disease, higher risk of adverse effects during treatment and higher risk of relapse after completion of treatment. Severe under-nutrition needs to be considered as a serious co-morbidity in patients with active TB.”
The World Health Organisation (WHO) recommends that adults with BMI less than 16 need nutritional support, regardless of the presence of associated disease. However, current international guidelines for TB care, despite the emphasis on patient-centred care, do not consider under-nutrition an important co-morbidity in TB patients, or suggest nutritional support during treatment.
“With such a high proportion of TB patients suffering from moderate to severe under-nutrition at the time of diagnosis, nutritional support for undernourished TB patients should be considered a priority issue to decrease their greater risk of dying even after being put on treatment with effective drug regimens,” according to the researchers.
Yogesh Jain, a co-author, said, “TB has an adverse effect on entire families, with loss of wages and indebtedness. In such a scenario, nutritional support should be offered to TB patients for the duration of their treatment. It could serve as a powerful incentive for patients to seek care under the Government’s TB programme which currently addresses only half of TB patients in India, while also contributing to the national target of achieving zero TB deaths in India.”