Tuberculosis (TB) remains a global health challenge, particularly in regions grappling with poverty and undernutrition. While antibiotics are crucial for treatment, a comprehensive approach that includes proper nutrition is essential for preventing the disease’s spread, improving treatment outcomes, and enhancing the overall quality of life for those affected. This article explores the intricate relationship between TB and diet, providing evidence-based recommendations for nutritional care and support.
The Intertwined Relationship of TB and Nutrition
Tuberculosis has long been recognized as a social malady, meaning that factors such as well-ventilated housing, good sanitation, and proper nutrition are important to preventing the disease’s spread. Undernutrition is both an important risk factor for, and a common consequence of, TB. It is therefore a common comorbid condition for people with active TB and is associated with increased risk of mortality and poor treatment outcomes. The association between TB and undernutrition has long been known. TB makes undernutrition worse, and undernutrition weakens immunity, thereby increasing the likelihood that latent TB will develop into active disease.
Historical Context
A century ago, tuberculosis largely disappeared from industrialized nations because of improved living conditions, including a decline in food insecurity. With the advent of effective antibiotics, global efforts to eradicate tuberculosis shifted to treatment, rather than prevention.
The RATIONS Trial: Evidence of Nutrition's Impact
The Reducing Activation of Tuberculosis by Improvement of Nutritional Status (RATIONS) trial demonstrated the powerful impact of nutritional interventions. In this trial, patients who gained weight in the first two months of treatment cut their mortality risk by 60 percent. Households receiving additional food baskets developed 40 percent fewer new cases of tuberculosis than the control group.
Global Implications
Studies from multiple countries have shown undernutrition is a leading risk factor for tuberculosis. India is estimated to have the highest number of underweight people in the world; it also bears the world’s highest tuberculosis burden, with 27 percent of cases and 25 percent of tuberculosis deaths globally. While HIV is the leading risk factor for developing tuberculosis in South Africa, the number of undernourished people in India means undernutrition is clearly the leading cause.
Read also: The Hoxsey Diet
Nutritional Needs of TB Patients
Patients with tuberculosis (TB) need to eat a healthy, balanced diet to support their immune system and aid in the recovery process. Addressing comorbid conditions has value for improving access and response to TB treatment and it should be considered as part of the standard of care for people with TB. The aim of comprehensive care should be to improve general health and quality of life. The role of food and nutritional care is integral to successful health promotion and disease prevention.
Macronutrient Requirements
Active TB, like other infectious diseases, is likely to increase energy requirement, and data on the actual level of increase in energy requirements caused by HIV infection may be used as a guide. Studies show that subjects who receive food supplements during TB treatment tend to gain more weight compared with those not receiving food supplements, but the increase in weight gain has not been associated with improvement of TB treatment outcomes.
There is currently no evidence to suggest that the proportion of dietary energy from macronutrients (e.g. protein, carbohydrate and fat), otherwise known as macronutrient distribution, is different for people with active TB than for those without TB. It is generally recommended that all people consume approximately 15-30% of energy as protein, 25-35% as fat and 45-65% as carbohydrate.
Micronutrient Requirements
Low circulating concentrations of micronutrients, such as vitamins A, E and D, and the minerals iron, zinc and selenium have been reported from cohorts of patients beginning treatment for active TB. These usually return to normal after 2 months of appropriate TB treatment. Since studies have not been done on dietary intake near the time of diagnosis, it is unclear whether the low concentrations are related to low dietary intake, to metabolic processes or to the disease itself. It is unknown whether the observed return to normal concentrations is dependent on the quality of dietary intake.
Dietary Recommendations for TB Patients
A well-planned tuberculosis diet chart that includes a sufficient amount of daily nutrients in addition to drugs to combat a tuberculosis infection is essential. Here's what to include in your food diet for tuberculosis patients:
Read also: Walnut Keto Guide
Balanced Diet
Patients with TB should consume a balanced diet that includes plenty of fruits, vegetables, whole grains, lean protein sources, and healthy fats. A balanced diet can help the body fight the Mycobacterium tuberculosis infection and promote faster healing.
Increased Protein Intake
Protein is essential for building and repairing muscles and tissues, and patients with TB may require more protein than usual to help repair the damage caused by the infection. Good sources of protein include lean meat, fish, poultry, eggs, beans, lentils, and dairy products. Protein is crucial for the growth, repair and maintenance of tissues in the body, and TB patients require more protein to aid recovery. Protein-rich foods like eggs, lean meat, poultry, fish, beans, lentils and nuts are excellent sources of protein.
Frequent, Small Meals
Eating small, frequent meals throughout the day can help patients maintain their weight and energy levels, as tuberculosis can cause loss of appetite and weight loss.
Hydration
Drinking plenty of fluids, such as water, herbal teas, and fresh fruit juices can help patients stay hydrated and support their immune systems.
Vitamins and Minerals
A balanced diet rich in vitamins A, C, D, and E, zinc, iron, and magnesium, found in foods such as sweet potatoes, citrus fruits, fatty fish, nuts and seeds, lean meats, and leafy greens, can help support the proper functioning of the immune system, promote healing, and improve bone health and wound healing in patients with tuberculosis. Micronutrients are essential nutrients that are required in small amounts for overall health and well-being. These include vitamins and minerals, which play a crucial role in maintaining the immune system, aiding recovery and preventing further complications.
Read also: Weight Loss with Low-FODMAP
Calorie Intake
TB patients often require extra calories to help aid recovery. Consuming high-calorie foods can provide the necessary energy. Some high-calorie foods that can be included in the Tuberculosis diet are avocados, cheese, nuts, peanut butter, whole milk, yoghurt, dried fruits, dark chocolate and granola bars.
Superfoods
Superfoods like turmeric, garlic, ginger and green tea have anti-inflammatory and immune-boosting properties that can aid in the management of TB. Turmeric contains curcumin, which has been found to have antimicrobial and anti-inflammatory effects.
High-Energy Foods
TB patients may experience loss of appetite, nausea and weight loss, which can lead to weakness and fatigue. Consuming high-energy foods like smoothies, soups and stews can provide the necessary nutrients in an easily digestible form.
Good Carbohydrates
Good carbs are an essential part of a healthy diet, especially for TB patients. Good carbs are complex carbohydrates that are rich in fibre and nutrients, such as whole-grain bread, pasta and brown rice.
Healthy Fats
Investing in good fats is important for TB patients as they need healthy sources of energy to aid in recovery. Good fats, such as those found in avocados, nuts, seeds and olive oil, are rich in essential fatty acids that can help improve heart health, brain function and immune system function.
Vegetables
Vegetables are a great source of vitamins and minerals that can help boost the immune system and aid recovery in TB patients. Dark green leafy vegetables, such as spinach and kale, are rich in vitamins A, C and vitamins K, as well as iron and calcium.
B-Complex Vitamins
B-complex vitamins are important for maintaining good health, especially in the context of tuberculosis management. Foods rich in B-complex vitamins include leafy green vegetables, whole grains, nuts and seeds, legumes, dairy products, meat, fish and poultry.
Zinc-Rich Foods
Zinc is an essential mineral that plays a crucial role in maintaining a healthy immune system, wound healing and growth and development. Some foods that are rich in zinc include oysters, beef, pork, chicken, nuts, beans, whole grains and dairy products.
Specific Food Recommendations
- Curd: TB patients can eat curd as it is a good source of protein and beneficial bacteria that can support digestive health. Additionally, curd can help improve the absorption of nutrients from other foods.
- Rice: TB patients can eat rice as it is a good source of carbohydrates and can provide energy to the body. However, it is recommended to choose brown rice over white rice as it is more nutrient-dense and can provide additional fibre.
- Fruits: Fruits such as papaya, oranges, guava, kiwi, and berries are good options for TB patients as they are rich in vitamins, minerals, and antioxidants that can support the immune system.
Foods to Avoid During TB Treatment
Just like healthy and nutritious foods are essential for people with TB, there are a few food items that should be strictly avoided during the course of the medicine.
- Avoid tobacco consumption.
- Avoid alcohol intake as it can interfere with the treatment by reacting with medicines.
- Restrict coffee and caffeinated drinks to a minimum and increase intake of fluids like water and coconut water.
- Avoid deep-fried food, junk food, and refined products, like sugar, flour, etc. as these have no nutritional value.
- Limit consumption of red meat or food items that are not easily digestible as these might worsen TB symptoms, like diarrhoea and abdominal cramps.
Addressing Malnutrition in TB Patients
Malnutrition and tuberculosis are both problems of considerable magnitude in most of the underdeveloped regions of the world. These two problems tend to interact with each other. Tuberculosis mortality rates in different economic groups in a community tend to vary inversely with their economic levels. Similarly, nutritional status is significantly lower in patients with active tuberculosis compared with healthy controls. Malnutrition can lead to secondary immunodeficiency that increases the host's susceptibility to infection. In patients with tuberculosis, it leads to reduction in appetite, nutrient malabsorption, micronutrient malabsorption, and altered metabolism leading to wasting. Both, protein-energy malnutrition and micronutrients deficiencies increase the risk of tuberculosis. It has been found that malnourished tuberculosis patients have delayed recovery and higher mortality rates than well-nourished patients. Nutritional status of patients improves during tuberculosis chemotherapy.
Available Guidance for Treatment of Malnutrition/Undernutrition
BMI is the most commonly used indicator to measure the degree of thinness and fatness in adults over 18 years of age, while BMI-for-age-and-sex Z-score is used in children and adolescents aged 5-19 years. Weight-for-length or weight-for-height Z-score is the recommended indicator for children who are less than 5 years of age, with mid-upper arm circumference being used to identify cases in need of life-saving nutrition management.
Severe Acute Malnutrition
Severe acute malnutrition is a common cause of morbidity and mortality in many settings. Nutritional therapy aims to reduce the risk of death, shorten hospitalization and facilitate rehabilitation and a full recovery.
Moderate Undernutrition
The current recommendation for moderate undernutrition in adolescents and adults is to provide supplemental foods in the outpatient setting until BMI is normalized. The approach is that individuals with moderate undernutrition have different nutritional needs than either people without undernutrition or those with severe acute malnutrition. An individualized approach that addresses the various causes of moderate undernutrition is needed, since the appropriate therapy depends on the cause of undernutrition. For most people with active TB, assuming sufficient food is available, effective TB therapy will improve nutritional status by improving appetite and food intake, reducing energy/nutrient demands, and improving metabolic efficiency.
Nutrition care or management of persons with active TB with moderate undernutrition, similarly to other persons with moderate malnutrition, includes assessing their nutritional status, identifying and treating the underlying causes of malnutrition and improving the nutrient intake through education, counselling, food assistance and other activities.
Social Determinants of Malnutrition and TB
Because undernutrition increases the risk of progression from TB infection to active TB disease, food insecurity and poor general nutritional status in the population are important contributors to the global burden of TB disease. Catastrophic health expenditure is a common consequence of TB diagnosis, treatment and care, which can lead to a worsening of food insecurity for TB patients and their families during the course of the disease. At least 75% of all TB cases are among people who are 15-54 years of age and in their prime working years. TB is a major cause of poverty aggravation because people with TB often face the double burden of reduced income and increased expenses: they are often too sick to work and their families have to pay expenses associated with treatment.
TB and Pregnancy
Low birth weight, a predictor of infant morbidity and mortality, is more common in infants borne by women with TB. Infants of mothers with TB have increased risks of premature birth and perinatal death, while the mothers are more likely to have complications during pregnancy, with disorders of hypertension during pregnancy being the more common. Initiation of TB treatment earlier in the pregnancy is generally related to better maternal and infant outcomes.
Adequate weight gain during pregnancy, which is associated with improved birth weight, is a concern in women with TB.
Pregnant women with TB have been noted to be at increased risk of developing pre-eclampsia. Health-care providers should be made aware of this risk and follow the WHO nutrition recommendations for women at risk of developing pre-eclampsia and eclampsia. In populations where calcium intake is low, calcium supplementation as part of antenatal care is recommended for the prevention of pre-eclampsia among pregnant women, particularly among those at higher risk of hypertension.
Regardless of the presence of TB, the maternal requirement for micronutrients during pregnancy tends to be 25-50% higher, depending on the nutrient, than the pre-pregnancy requirements.
A healthy well-nourished woman should gain between 10 kg and 14 kg during pregnancy, to increase the likelihood of delivering a full-term infant weighing at least 3.3 kg.
Underweight pregnant women (BMI less than 19 kg/m2) can eat additional food, in order to achieve a total weight gain between 12.5 kg and 18 kg, with an average weekly weight gain of 510 g and an average monthly gain of 2 kg in the second and third trimesters.
TB and Child Household Contacts
Owing to their proximity and frequency of contact, children with TB are usually infected by someone in their immediate household. When the positive case in the household is detected, screening for TB amongst household members is a means to detect TB early in children and other close contacts. Young children are particularly vulnerable, owing to their relatively immature immune systems. Undernourished children are at particular risk. Undernutrition and younger age individually increase the risk of household contacts of TB patients developing active TB disease.
An additional complication for screening household contacts for TB infection is the fact that children with mild to moderate malnutrition become anergic, meaning that they cannot mount an immunologic response to the TB skin test. This increases the likelihood of missing the TB diagnosis where skin testing is used. These children represent a potentially significant number of future TB cases.
WHO Recommendations on TB and Undernutrition
The World Health Organization (WHO) has released new recommendations on tuberculosis (TB) and undernutrition, as part of the WHO consolidated guidelines on tuberculosis. Module 6: tuberculosis and comorbidities. Undernutrition remains one of the most significant drivers of the TB epidemic globally - contributing to increased vulnerability to TB disease, poorer treatment outcomes, and preventable mortality. Addressing undernutrition and food insecurity among people affected by TB has the potential to improve outcomes and save lives.
Key Recommendations:
- Nutritional assessment and counselling for all people with TB, as well as their household contacts. This recognizes that a significant proportion of people in households with TB may be undernourished.
- Provision of nutritional interventions to optimize clinical outcomes in people with TB who have undernutrition, regardless of age, drug resistance, pregnancy status or severity of undernutrition.
- Provision of food assistance to prevent TB in household contacts of people with TB in food insecure settings.
The updated guidelines will be accompanied by an operational handbook to support implementation at country level. This will provide practical steps for stakeholder engagement and coordination, and on integrating nutritional care and food assistance into TB care and prevention efforts.
The Broader Perspective: Beyond Treatment
Bhargava is hopeful the study will provide the spark for addressing undernutrition in South and Southeast Asia more broadly. “[Nutrition] is not a new drug. It’s not a new vaccine. It’s not a new intervention,” he says.
Pai says that financial support is a good start, but expanding benefits through existing programs, like India’s vast system of ration shops, would go a long way towards tackling food insecurity and preventing new TB cases.
tags: #TB #and #diet #recommendations