Nutritional status is a widely prevalent comorbidity and risk factor for tuberculosis (TB) disease and mortality. Impaired nutrition increases the risk of severe disease, death, drug toxicity, and malabsorption and relapse. Undernutrition poses serious implications for TB patients and nutritional support is necessary to address this. Undernourished people with TB in the absence of nutritional care get entangled in a vicious cycle of worsening disease and undernutrition.

People with TB who get nutritional interventions have a reduced death rate, better weight gain and body composition, an early sputum conversion, better absorption of drugs, an improved functional status, and adherence. Nutrition screening, evaluation, and management are thus essential for TB treatment and care.

Individualized nutritional management should be proposed by a multidisciplinary team by thoroughly explaining the benefits and drawbacks of feeding options to the patient, family, and caregiver. Artificial nutrition and hydration (ANH) are an essential component of palliative care and can improve quality of life in certain patients based on the severity of TB disease. Therefore, the goals of nutrition in palliative care and at the end of life aim at improving the quality of life.

The guiding principles for nutritional care and support in TB care are mentioned in detail in the guidance document.

  1. Nutritional evaluation : 

    The patient’s height and weight should be recorded by the treating physician at the beginning of treatment. In case of children, the nutritional status can be ascertained using the Z scores for weight for height. The mid upper arm circumference (MUAC) may be recorded in adults who are unable to stand. The weight for height and Body mass index (BMI) charts can act as the reference for children and adolescents to assess the degree of undernutrition. Vital sign assessments may reveal a patient’s requirement for inpatient care. Patients with exceptionally low BMIs (< 14 kg/m2) will require admission for further management.

1.Every individual with active TB should get diagnosis, treatment, and care.

2.A sufficient diet that includes all necessary macro- and micronutrients is important for all those with TB infection and disease.

3.The causal relationship between undernutrition and active TB warrants nutritional screening, assessment, and management

4.It is crucial to identify and resolve the prevailing socio-economic problems like food insecurity and poverty that are both causes and effects of TB.

5.The associated comorbid conditions like HIV, diabetes mellitus, alcoholism, smoking, and drug addiction should be addressed.

2. Nutritional counseling

    This includes evaluating the patient's current food intake, learning about their dietary preferences, and talking about the right diet in terms of its composition, frequency of meals, and snacking schedule. The patient should receive guidance on how to use foods that are readily available in their area to boost their calorie and nutrient density. It should be emphasized and explained to the family members that the nutritional supplement (milk powder, groundnuts, and pulses) provided is a form of medication for the patient to assure recovery of the lost weight and muscle mass.

    Nutritional support should be prescribed in accordance with the client’s energy and protein needs, disease stage; tolerability and most importantly the wishes and preferences of the patient, family, and caregivers.

3. Provision of nutritional support40

a) Mobilizing the resources through the Local Self-Government initiatives, Corporate Social Responsibility (CSR), NGOs, philanthropists or inter sectoral collaboration (egTribal Affairs)

b) Delivery of enhanced ration through linkage with the public distribution system for the duration of anti-TB treatment along with a supplement food basket (Antyodaya Anna Yojana).

c) Linkage to Nikshay Poshan Yojana and PMTMBA

d) Severe acute malnutrition may be treated at the inpatient facility of a TB hospital, community health centre, district hospital, or medical college.

e) Social protection measures are required as part of patient-centred care to guarantee long term food security to the person affected by TB and their households.

4. Management of moderate to severe undernutrition

    Nutritional support and care are important to improve the health outcomes for people with TB. Food assistance as a component of a service package is expected to enhance treatment adherence and reduce the financial burden of TB. Provision of wholesome food from the government could help to overcome the stigma associated with the disease.

    Food assistance should address the nutrient gap by enhancing the energy and protein intake of the client. In addition, providing a food basket for family members to combat food insecurity, chronic energy deficiency, and risk of developing tuberculosis would also be beneficial.

    The food assistance package recommended would consist of enhanced ration for patient with TB and family through PDS for the entire treatment period. It should also provide food supplements with high quality protein sources including pulses, oilseeds, and dried milk powder). The various food assistance packages suggested are elaborated in the guidance document.

5. Severe acute malnutrition (SAM) in active TB

   Severe undernutrition is linked to a two-four-fold increased risk of death. A comprehensive clinical evaluation of the patient should be done along with the nutritional assessment to look for red flag indications and necessitate hospitalization for treatment. Individuals at risk of unfavorable consequences and death could be admitted to a suitable medical facility in order to stabilize their condition at the initiation of TB treatment.

   The background knowledge of organ and systems dysfunction is crucial for the management of severe malnutrition. The phases of management of people with severe malnutrition include initial treatment (stabilization), rehabilitation and follow up. Hypoglycemia, hypothermia, dehydration, electrolyte imbalance should be corrected and infections should be treated.

   Since individuals with SAM have infections, decreased liver and intestinal function, and electrolyte imbalance, the F-75 formula feed is advised for nutritional therapy in SAM, which has 75 calories per 100 milliliters and lower levels of protein, fat, and sodium. Locally obtainable ingredients such as cow's milk or skim milk, sugar, cereal flour, and oil can be used to produce an F-75 meal for adults. The recommended daily volume of F-75 should be between 70 and 80 ml/kg.

   Food must be provided often and in little amounts to prevent overloading the kidneys, liver, and intestines. The diet should be provided to patients who are able to eat every two, three, or four hours, day or night. In case of vomiting, reducing the amount given at each feeding as well as the time between feedings is advised. Micronutrient deficiencies are widespread in SAM and should be addressed since they affect immunity.

   Nasogastric feeding can be considered in individuals with severe anorexia, stomatitis, glossitis, or frequent vomiting; severe dysphagia or odynophagia from any cause; individuals suffering from tuberculous meningitis with an altered sensorium; and critically ill patients experiencing shock.

  The risk of refeeding syndrome as a consequence of nutritional therapy for patients with severe malnutrition needs to be addressed. To avoid this, it is critical to recognize these imbalances at baseline and treat them with a mineral mix.