It would seem that optimal nutrition, essential for all biochemical processes to function properly, is an axiom. Naturally, it will then also be an accepted truth that appropriate nutrition will have to be consumed, in order for the body to recuperate and heal even as it is treated by medicines when under assault. Strangely though, nothing can be as far apart in practice, as this axiom and its corollary.
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The nutritional and environmental factors that influence disease and wellness are now part of a solid study of the human body. While conventional medicine treats and advances cure by drugs and/or surgery, the doctor seldom forgets to mention an appropriate diet to be followed. The problem, however, occurs when there’s a piecemeal handling of the condition, with no insight into the patient’s culture or affordability (for food). Which is why studies validating the cruciality of nutrition in the recovery process of the human body are conducted from time to time.
Latest in this trend is the RATIONS trial by Anurag Bhargava et. al., which tries to address nutrition and tuberculosis within a syndemics framework. The researchers studied the effect of improving nutrition with a combination of a food basket and micronutrients on recovery of patients with TB, and preventing TB in close family members of those who are infected. Prof. Bhargava explains: “There is a backstory to this trial. We [my wife Madhavi and I] worked in a non-profit Jan Swasthya Sahyog that we co-founded in the rural Bilaspur district. We ran a TB treatment program where we realised that undernutrition was the blind spot in TB care and prevention. We finally published a study in 2013 on how low weights in Indian patients were a risk factor for TB mortality.” This was followed by a paper in 2014 where we showed that undernutrition was the leading risk factor for TB Incidence in India and addressing it could lead to substantial decline in TB incidence.
“In the current RATIONS trial, conducted with the NTEP in 28 tuberculosis units in 4 districts of Jharkhand, we had two populations of interest, the household members living in contact with a patient with pulmonary tuberculosis, and the patients themselves undergoing treatment.”
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In the study, he adds further, the household members in 14 TB units were randomised into an intervention group that was given a 6.5 kg food basket (5 kg rice + 1.5 kg pulses/per head/month). The control group living in the other 14 TB Units lived on their usual PDS-based diet. Dr. Bhargava says: “The patients were not randomised since it was considered unethical to deprive them of a food basket which was a 10 kg /month combination of rice, milk powder, and oil. All the participants were followed up for two years in this first-of-its-kind trial that was sponsored by the ICMR and led by us at Yenepoya Medical College, with other investigators from National Institute of Research on Tuberculosis -Chennai.”
Prevalence of undernutrition in household members was high and one-third were undernourished, in the study. In patients, he adds: “We had some of the lowest weights documented in the TB literature, with 1 in 2 patients below a BMI less than 16”. Dr. Madhavi and Dr. Bhargava explain that the results found that early weight gain of about 5% of body weight in the first 2 months was associated with a 60% reduction in the hazard of death. The weight gain observed in the RATIONS patients was higher, the mortality lower and only 1% of patients dropped out of treatment. “Most importantly there was a return to work in 75% of patients after treatment in a situation where over 5% were able to work at the start of treatment,” she said.
It is also believed that a sub-optimal diet is also an important risk factor, preventable in good measure, for non-communicable diseases, an epidemic of which seems to be holding India in its grip. A 2017 study that was done by GBD Diet Collaborators and published in Pubmed, estimated that in that year, 11 million deaths and 255 million Disability Adjusted Life Years were attributable to dietary risk factors..
An emerging and compelling body of research points to the potential of food and nutrition playing a prominent role in the prevention, management and treatment, even reversal of the disease. Such interventions in health care system might be associated with improved health outcomes and reduced healthcare usage and costs. Sarah Downer and colleagues record this in an article in the British Medical Journal — of how a global epidemic of diet-related chronic disease has prompted experimentation using food as a formal part of patient care and treatment. One of every five deaths across the globe is attributable to a suboptimal diet, more than any other risk factor including tobacco.
Another area in which the role of nutrition in recovery has been well documented is in the HIV/AIDS sector. HIV infection and poor nutritional status are interlinked, L. M. Houtzager wrote in 2009 in the Benin Journal of Post Graduate Medicine. The impact of HIV infection on nutrition was identified early in the epidemic, with wasting one of the most visible signs of malnutrition in patients who progress to acquired immune deficiency syndrome (AIDS). In a review, Houtzager pointed out that malnutrition impairs immune function and reduces the body’s resistance to infection. HIV and malnutrition have a cumulative effect of damaging the immune system and worsening nutritional status.
It was in response to such averments that the World Food Programme initiated a pilot phase of distribution of nutrition supplements combined with nutrition counselling for People Living with HIV (PLHIV) on Anti-retroviral Therapy (ART), in Tamil Nadu, along with the Tamil Nadu State AIDS Control Society, about 16 years ago recognising the lack of access to nutrition. The programme was initiated in September 2007 in all ART centres in the State covering more than 25000 PLHIV. In a mid-term assessment, researchers found improvements in both BMI level and haemoglobin in the experiment group, versus the control group. Both BMI and HB were considered key indicators for comparative assessment and as impact indicators.
In a welfare state, the task of ensuring adequate nutritional status undoubtedly rests with the government. At any rate, any lapses in doing so must be set right, with a comprehension of the relevant political and social contexts in terms of supporting health care with nutritional supplements, in order to ensure the best chances of recovery are available for patients.
(ramya.kannan@thehindu.co.in)
