Tuberculosis remains a major public health problem in India, with an estimated 3 million new TB cases and 300,000 deaths from TB every year. The recent announcement by the Ministry of Health and Family Welfare to double the direct benefit transfer amount under Nikshay Poshan Yojana (NPY) from Rs 500 to Rs 1,000 per month and start disbursing Rs 3,000 throughout the period of diagnosis is a welcome step. There is also a proposal to provide underweight patients with high-energy nutritional supplements for two months and provide nutritional and social support to their families. India is probably the only country with a high TB burden to launch such a large-scale program that will address the nutritional needs and financial woes of patients.
In terms of its causation and consequences, TB remains a social disease. Social factors associated with poverty, such as overcrowding and malnutrition, increase the risk of TB. Most other risk factors, such as diabetes, smoking and alcohol abuse, are either more prevalent or poorly managed among poor people. Malnutrition is responsible for more than one-third to nearly half of new TB cases in India. Poor access to primary care, poor quality of care and poor compliance create a vicious cycle that puts poor people at risk of serious illness and death. Their plight is dire as they face loss of income, direct and indirect costs of illness and its treatment, food insecurity, and often the inability to return to normal work due to the sequelae of illness.
The Nikshay Poshan Yojana is crucial because severe malnutrition is common among TB patients in India – the average weight of an adult male at the time of diagnosis is 43 kg and that of an adult female is 38 kg. Without nutritional support, such patients have worse outcomes during and after treatment. These patients typically do not experience early weight gain, which carries a high risk of death; even with effective treatment, malnutrition may persist, increasing the risk of TB recurrence. Research also shows widespread food insecurity among households affected by TB. Therefore, nutritional support has good clinical, public health and ethical foundations. It is in line with India’s 2017 adaptation of WHO guidelines on nutritional care and support of TB patients. There is compelling evidence that nutritional support with food baskets can improve treatment compliance and weight gain, allow patients to successfully return to work, and reduce the risk of mortality. In the RATIONS trial, early weight gain was associated with a more than 50% reduction in the risk of death among patients who were provided with a 10-kg food basket each month. Furthermore, a six-month low-cost intervention that provides family members with a basket of grains and legumes and micronutrient pills can reduce new cases by up to 50%, similar to vaccines.
A five-year evaluation of the NPY program by the National Institute of Epidemiology (NIE) in Chennai has important lessons. An important challenge is that TB program staff now involved in other new initiatives feel overburdened by processes that facilitate direct benefit transfers. Another problem is that the most vulnerable communities are unable to access benefits due to lack of proof of identity, residence, bank account or distance. The NIE evaluation showed that not receiving NPY benefits was associated with a four times higher risk of adverse outcomes.
As clinicians and researchers working in this area, there are several clarification and implementation issues that must be addressed. First, dedicated human resources are needed to conduct NPY activities, and these human resources can also be used to assess new measures such as family connections. Second, patients and families need to be provided with locally appropriate counseling materials that emphasize nutrition as an important component of treatment. It should include locally available and culturally acceptable foods to optimize energy and calorie intake. Poor families lack high-quality protein intake. Legumes, soybeans, peanuts, milk and eggs are more cost-effective sources than the supplements they are derived from, and this needs to be highlighted in counseling. Third, given the evidence supporting the food basket, recommendations related to energy-dense supplements should be carefully considered. Commercial nutritional supplements run the risk of higher costs, demystification, lower acceptability and lower long-term sustainability. Given the prevalence of severe malnutrition in our patients, two months of nutritional support may be insufficient.
Fourth, regarding Nikshay Mitra, it does not cover the most vulnerable groups enough and needs to be redesigned. Because of the significant stigma attached to TB, clear advice needs to be given against photographing patients and families receiving food baskets. Finally, nutritional, financial and social support measures work best when integrated with other aspects of care – uninterrupted supply of medications, better management of comorbidities, better assessment of patients’ high-risk characteristics at diagnosis As well as referring patients the patient care done by Tamil Nadu is critical in ensuring better outcomes.
(Anurag Bhargava and Madhavi Bhargava work in the Department of Medicine and Community at Yenepoya Medical College, Mangalore and led the RATIONS trial)
Published – October 19, 2024 at 9:15 pm (IST)