Boost the TB fight with better undernutrition monitoring

Documenting the different severities of undernutrition so that the benefits of nutrition support reach those most in need is a vital step

Around one-third of tuberculosis (TB) in India is attributable to undernutrition, which, in adults, is defined as having a body mass index (BMI) less than 18.5 kg/m². Adults with BMI 14 kg/m²-15.9 kg/m² (or an MUAC or mid upper arm circumference of 16 cm-18.9 cm) are considered ‘severely’ undernourished and those with BMI less than 14.0 kg/m² (or MUAC less than 16 cm) are ‘very severely’ undernourished. ‘Severely’ undernourished adults who experience an inability to stand without support or bilateral leg swelling or poor appetite are also classified as ‘very severely’ undernourished.

In India, available research suggests the burden of ‘severe’ and ‘very severe’ undernutrition to be very high among adults with TB (90% of all TB is among adults). In high-risk populations, 15% adults with TB have ‘very severe’ undernutrition at diagnosis (unpublished data from a study led by the Indian Council of Medical Research-National Institute of Epidemiology, ICMR-NIE). The Reducing Activation of Tuberculosis by Improvement of Nutritional Status (RATIONS) trial from Jharkhand documented that 32% of adults with pulmonary TB had ‘severe’ undernutrition and 17% had ‘very severe’ undernutrition at TB diagnosis. The trial found that adults with TB who gained 5% of their baseline weight after two months had a 60% lower risk of death.

TB-undernutrition guidance

In 2013, the World Health Organization (WHO) recommended integration of nutritional assessment and care into standard TB treatment. This was reiterated in 2021 by The Union Nutrition-TB Working Group. The India National TB Elimination Programme’s (NTEP) ‘Guidance document–Nutritional care and support for patients with TB in India (2017)’ adapted the WHO recommendation to an Indian context. For ‘severe’ or ‘very severe’ undernutrition, the guidance recommends standard food assistance packages (food baskets) and a doubling of monthly family rations. Additionally, inpatient care and therapeutic nutrition are recommended for those with ‘very severe’ undernutrition (especially if the person’s appetite/performance status/clinical status is poor).

Most adults with ‘very severe’ undernutrition have a poor appetite and cannot tolerate usual solid diets. In fact, during the initial stabilisation phase of therapeutic nutrition, a high protein or energy-dense diet is contraindicated and cautious feeding (orally or through a nasogastric tube) is recommended using a standard WHO recommended liquid formula feed (F75). This can be easily prepared using available ingredients in the kitchens of district headquarters and medical college hospitals. Within a week, patients can tolerate the prescribed daily dose of F75 and are shifted to rehabilitation phase (high protein and energy dense diet). With the lead technical support of the ICMR-NIE, some districts of Tamil Nadu (Tamil Nadu Kasanoi Erappila Thittam, or TN-KET, which means TB death free initiative) and two TB hospitals of Delhi (Delhi Triage and Treat TB Initiative, or D-TAT) have piloted therapeutic nutrition during inpatient care. The results are encouraging.

Nutrition support for people with TB in India

The NTEP provides direct benefit transfer and encourages food baskets by Ni-kshay Mitras for all people notified with TB (public or private). However, the monitoring of nutritional assessment and care is not routinely done under Ni-kshay (Ni means End and Kshay means TB), the web-enabled patient management system for TB control under the NTEP.

A study led by ICMR-NIE highlighted delays (an average of three months in 2022) in the receipt of the first instalment of direct benefit transfer. Given the very high risk of early death among those with ‘severe’ and ‘very severe’ undernutrition, timely credit of benefits is recommended. The recent announcement to double the benefit amount to ₹1,000 a month over the entire duration of TB treatment, and to credit ₹3,000 as first instalment, is a welcome step and opens a window of opportunity to further our efforts to optimise the benefits.

Four indicators for TB-undernutrition

The writers of this article propose a section on TB-undernutrition in the quarterly performance review of the NTEP which will capture four indicators (at least among adults notified with TB from public facilities).

The first point concerns the percentage of ‘severe’ and ‘very severe’ undernutrition at TB diagnosis. The NTEP documents weight and height at diagnosis in Ni-kshay. A field for BMI could be autogenerated.

The second point is on the percentage of ‘severely’ and ‘very severely’ undernourished adults who receive the first instalment of direct benefit transfer and food baskets within a month of diagnosis.

The third is on the percentage of adults with ‘very severe’ undernutrition receiving inpatient care along with provision of therapeutic nutrition.

The fourth is on the percentage of adults with ‘severe’ and ‘very severe’ undernutrition who gain 5% of their baseline weight at two months.

Except the third, all indicators can be autogenerated from existing routinely collected variables in Ni-kshay. Reporting these quarterly will reinforce the implementation of the nutritional support mechanisms. There is a need to sensitise State TB officers, district TB officers, chest physicians, medical superintendents and deans of medical colleges, especially regarding inpatient therapeutic nutrition care for eligible persons with TB.

In summary, while universal implementation of direct benefit transfer and food baskets is encouraged, we cannot evaluate what we do not measure. The inclusion and the monitoring of these four indicators will ensure that the burden of different severities of undernutrition are documented and the benefits of nutrition support reach those most in need, maximising the chances of reducing TB deaths.

Dr. Hemant Deepak Shewade is Scientist E, Division of Health Systems Research, ICMR National Institute of Epidemiology (ICMR-NIE), Chennai. Dr. Kathiresan Jeyashree is Scientist E, Division of ICMR School of Public Health, ICMR National Institute of Epidemiology (ICMR-NIE), Chennai. The views expressed are personal

Published - November 24, 2024 04:00 am IST