Research finds nutrition intervention can prevent thousands of tuberculosis-related deaths in India

Research has found that providing food baskets to tuberculosis-affected households in India could prevent over 361,000 deaths and 880,700 cases by 2035. Nutrition Insight speaks to the lead researcher, who discusses nutritional interventions and their cost-effectiveness.

The study highlights that undernutrition accounts for 20% of global tuberculosis incidence. 

“Undernutrition compromises the immune system of individuals, which is a key driver of progression to tuberculosis disease and poor health outcomes. Tuberculosis itself also causes weight loss. Some estimates suggest as much as 20% of all tuberculosis is attributable to undernutrition,” says Finn McQuaid, associate professor at the UK’s London School of Hygiene & Tropical Medicine.

The study found that nutritional interventions for 50% of tuberculosis patients and their households could prevent 4.6% of tuberculosis deaths and 2.2% of cases between 2023 and 2035.

The study reveals that interventions would cost ~US$1.35 billion, including US$167 per disability-adjusted life-year saved. It concludes that providing support to 24 households can prevent one tuberculosis death. Ten households would need support to prevent one tuberculosis case.

“Our results show that the intervention is cost-effective, but further analyses are needed to estimate the budget impact — which will affect the coverage that can be achieved,” suggests McQuaid.

Providing food support to TB-affected households in India could prevent over 361,000 deaths and nearly 881,000 cases by 2035.“Further analyses would also be helpful to estimate the cost-effectiveness in different populations, such as those with particularly high burdens of undernutrition and/or tuberculosis.”

Nutrition aids fight against tuberculosis

Published in The Lancet Global Health, the study explains that exposure to Mycobacterium tuberculosis is widespread but is often cleared or contained. However, those with health issues, such as HIV, diabetes, or undernutrition, are at risk of suffering from disease and worse outcomes.

The RATIONS study (Reducing Activation of Tuberculosis by Improvement of Nutritional Status) is a randomized trial in Jharkhand, India, that assessed the impact of providing food support, with macronutrients and micronutrients, to tuberculosis patients and their households. 

The authors of the Lancet Global Health study note that the RATIONS study showed, for the first time, the effects of macronutrient support intervention on lowering tuberculosis incidence in households while improving patient treatment outcomes.

McQuaid says his “understanding is that the RATIONS study’s success was likely due to the inclusion of protein in food baskets as well as the calorie intake.”

Undernutrition and BMI factors

The study cautions against generalizing its findings to other places and states in India since the burden of tuberculosis and undernutrition varies. The model used in the study looked at a nationwide average, not regional differences.

Undernutrition is linked to 20% of global TB cases — and improving BMI is directly tied to better TB outcomes.“We know that there is a roughly inverse log-linear relationship between body mass index (BMI) and tuberculosis incidence. A higher BMI is linked to a lower tuberculosis incidence at a population level, and we do see an association between weight gain and improved treatment outcomes,” reveals McQuaid.

“A recent study in southern Africa also shows the reverse — a decrease in BMI over time in household contacts of tuberculosis-affected individuals was associated with an increased risk of tuberculosis disease.”

Although the study did not consider regional differences in undernutrition and healthcare access affecting intervention success, McQuaid’s team found undernutrition and BMI played a role in lowering tuberculosis.

“High levels of undernutrition might be expected to increase the impact of the intervention through improved treatment outcomes.” 

“Surprisingly, the original trial found a greater protective effect in individuals with a normal BMI, although the mechanisms for this are unclear, suggesting that further research is required. Reduced access to healthcare has the potential to reduce the population-level effect of the intervention,” he says.

Some challenges

The study authors note that the “assumption of instant scale-up is highly optimistic” since success rates depend on healthcare access, resources, and regional variations and costs. 

One tuberculosis death can be prevented by supporting just 24 households with nutritional aid.Nutritional interventions’ effectiveness faces two challenges: The M. tuberculosis transmissions outside households in high-burden areas and the number of undiagnosed tuberculosis deaths.

Further, the study did not factor in model drug-resistant tuberculosis, which has a high prevalence in undernourished individuals. “There is an urgent need for additional data in this area due to a higher prevalence of both undernutrition and poor treatment outcomes for drug-resistant tuberculosis,” underlines the paper.

India in the headlines

In other news, Nutrition Insight spoke to a co-author of a recent study on the world’s largest food assistance program, India’s Public Distribution System, which is bringing transformative impacts on child stunting, boosting household income, and curbing the effects of climate shocks.

We also spoke to UNICEF, which underscores the need for gender-responsive strategies for tackling a high burden of nutrition imbalance across South Asia, with adolescent girls facing greater risks.

Other experts told us about the powerful role of women’s groups in improving nutrition access by gathering collective strength to overcome economic, social, and institutional barriers.