The recent RATIONS trial conducted by The Lancet provides compelling evidence that enhancing nutrition among individuals in close contact with patients suffering from infectious lung TB can lead to a remarkable 40% reduction in the overall incidence of TB and a nearly 50% reduction in the cases of infectious TB. Notably, the study also underscores that timely weight gain in underweight TB patients can substantially slash their mortality risk by an impressive 60%.
In the case of an 18-year-old tribal individual from Jharkhand who was diagnosed with TB, his situation appeared dire – emaciated at a mere 26 kg, bedridden, and seemingly devoid of hope. Given the family’s struggle to secure even one proper meal a day, his health continued to decline. However, a significant transformation occurred when he was introduced to nutritious food packets. Over a span of six months, his body weight surged by 16 kg. This young man’s experience became a vital component of a trial that yielded compelling results – showcasing that a well-balanced diet and improved nutrition not only played a role in averting new cases of tuberculosis (TB) among vulnerable individuals living with infected patients but also exhibited the ability to mitigate mortality rates within TB patients themselves.
These remarkable findings stem from two separate studies conducted by the Indian Council of Medical Research (ICMR), both of which have been published in renowned scientific journals, The Lancet and The Lancet Global Health. Carried out within the region of Jharkhand, these studies offer a groundbreaking revelation – the provision of additional nutrition can effectively serve as a preventive measure against new instances of TB and also contribute to lowering mortality rates among TB patients within the Indian context.
New evidence from the RATIONS trial reveals the significant impact of improved nutrition on tuberculosis (TB) prevention and patient outcomes. The trial involving 10,345 household contacts of 2,800 TB patients demonstrated a 40% reduction in all forms of TB incidence and nearly 50% reduction in infectious TB cases through enhanced nutrition. Notably, underweight TB patients who gained weight early on saw their mortality risk drop by 60%. Another study tracked 2,800 TB patients over six months, revealing a 13% reduction in immediate mortality risk for a 1% weight gain and a remarkable 61% risk reduction for a 5% weight gain. These findings underscore the vital role of nutrition in TB management and public health.
These significant findings hold particular relevance as the Government strives to meet Prime Minister Narendra Modi’s ambitious target of eliminating TB by 2025. The implications extend to policy implementation, especially in the context of the national TB program. Patients diagnosed with tuberculosis receive monthly nutritional support of Rs 500 through direct benefit transfer for the duration of their treatment, as part of the Ni-Kshay Poshan Yojna introduced in 2018, amounting to $244 million thus far. Additionally, the government launched the Ni-kshay Mitra program in the past year, enabling volunteers to supply monthly nutrition kits to their adopted patients, further enhancing the approach to TB management and care.
In 2021, India witnessed the diagnosis of three million new TB cases, resulting in 4,94,000 fatalities, accounting for 27 per cent of the global TB incidence and 35 per cent of deaths, as highlighted by the WHO Global Tuberculosis Report, 2022.
Experts emphasize the importance of both studies due to the emergence of undernutrition as a prominent global risk factor for TB. The findings underscore the effectiveness of basic dietary interventions in reducing TB incidence. Dr. Anurag Bhargava from the Department of Medicine at Yenepoya Medical College, Mangalore, and Dr. Madhavi Bhargava, the lead authors, note the community-level impact of improved nutrition among family members demonstrated by the trial results.
Dr. Soumya Swaminathan, co-author of the study and Chairperson of the M.S. Swaminathan Research Foundation and former Chief Scientist of the WHO, highlights the groundbreaking nature of the research. The study sought to answer whether nutritional intervention could lead to a reduction in TB incidence. Dr. Swaminathan underscores the significance of evidence emerging from India, which will influence global policy. The study’s outcomes emphasize the importance of providing a substantial nutritional package containing calories, proteins, and micronutrients to household members of TB patients. The results revealed a remarkable 40 per cent reduction in all forms of TB incidence. Additionally, the study indicated that only three per cent of participants were employable at enrollment, but this figure surged to 75 per cent upon completion of treatment.
The study’s implications for implementable schemes are substantial. The research suggests that providing nutritional supplementation to approximately 30 households, consisting of 111 household contacts, could prevent one case of TB. Similarly, offering food support to around 47 patients could prevent the incidence of one case. The cost of a food basket was estimated at Rs 1,100 per patient per month and Rs 325 per contact per month (2019 prices).
Conducted over a span of three years, from August 2019 to August 2022, the study took place in collaboration with the National TB Elimination Programme and the National Institute for Research in Tuberculosis, Chennai. The Indian Council of Medical Research (ICMR) provided support for the study.
Jharkhand was chosen as the trial site due to its high TB burden (with 52,179 cases reported in 2021 and an annual case notification rate of 130 per 100,000 population) and its substantial level of multi-dimensional poverty. Participants in the study received a monthly food basket containing rice, pulses, milk powder, and oil, along with multivitamins for a duration of six months. For family members, the intervention group was provided with 5 kg of rice and 1.5 kg of pulses per person per month (with 50 per cent of these quantities allocated if families had a child under 10 years old). Dr. Anurag Bhargava, one of the lead authors, expressed encouragement at the study’s outcomes, highlighting that the ability of a low-cost food-based nutritional intervention to significantly prevent TB is a promising development.
NUTRITION AND TB: Key Observations
1) Many individuals were reliant on the Public Distribution System (PDS) for accessing rations.
2) A significant proportion of patients (four out of five) exhibited undernutrition, with severe undernutrition observed in nearly half of them (BMI<16 kg/m2).
3) While the prevalence of HIV, diabetes, and MDR-TB was relatively low, there was a high incidence of alcohol and tobacco use.
4) A noteworthy finding was that nearly one percent of patients demonstrated signs of hypotension, hypoxia, or were unable to stand, indicating a need for in-patient care.
5) Among contacts of TB patients, one out of three individuals of all age groups displayed undernutrition at the time of enrolment.
