The need to integrate nutrition in TB care

In 2026, India still has the highest number of new cases of Tuberculosis (TB) globally and a decreasing but still unacceptable number of about three lakh deaths due to TB. Almost 10% of successfully treated patients have recurrence within two years. An answer to all these challenges may partly lie in addressing a leading cause and consequence of TB in India, which is undernutrition, closely related to poverty, food insecurity and a predominantly cereal-based diet with deficient protein intake.

On the occasion of World TB Day, evidence from the Reducing Activation of Tuberculosis by Improvement Of Nutritional Status (RATIONS) trial could offer insight into the importance of nutritional interventions. RATIONS was done in Jharkhand with support from the Indian Council of Medical Research and was the first such trial of a food-based intervention. It aimed at reducing new TB cases in TB-affected families, and improving treatment outcomes for patients with TB.

Ramlal, a 19-year-old tribal boy in the trial, weighed only 26 kg and was almost bed-bound at the time of his diagnosis of lung TB. Along with TB drugs, he received a monthly food basket. Over the next few weeks, he started walking and could cycle to work at the end of the treatment, weighing 42 kg. Laxmi, weighing 34 kg, had TB two years ago and had stopped medication after she developed jaundice within two weeks of starting anti-TB drugs. Now, as a result of the trial, she could adhere to the medications and also breastfeed her four-month-old.

Preventing deaths due to TB

Undernutrition, especially severe undernutrition, is common in patients in India. It is a major reversible risk factor for death, drug toxicity, and recurrence after successful treatment. For most patients with TB who are severely underweight, nutritional support is an essential and not optional part of treatment. Poor families are food-insecure and become even more so due to the disease. In the RATIONS trial, a monthly 10 kg food basket of cereals, pulses, milk powder, and oil led to a weight gain of almost 4.5 kg in patients. Even a 5% weight gain in the first two months was protective against death, reducing the risk by more than 60%.

In India, the National TB Elimination Programme’s (NTEP) initiatives in addressing undernutrition in TB care are welcome. For example, the monthly direct benefit transfer under the Ni-Kshay Poshan Yojana increased from ₹500 to ₹1,000 and similarly the Ni-Kshay Mitra Yojana, although not universal, provides in-kind support to patients with TB. However, the plan to introduce energy-dense nutrition supplements for two months to underweight patients with TB needs to be considered with caution, given higher expenses, and the mystification of an adequate balanced diet apart from the risk of monotony and poor acceptability. One in 7 patients with TB in India may have diabetes which also needs to be taken into consideration.

A new avenue

While infection with the TB germ is necessary to develop the disease, it is not sufficient to produce active TB. Almost 90% of those infected, with good immunity, never develop the disease in their lifetime. Undernutrition is the most common cause of poor immunity in India and globally. It contributes to nearly 40% of new cases in India, and improved population-level nutritional status offers an alternative approach to reducing TB incidence.

Diets of the poor in India are particularly deficient in quality protein. TB-affected families experience vulnerabilities of poverty, food insecurity, and undernutrition. The 1.5 kg per month of pulses per family member, along with extra rice, worked like a vaccine in the RATIONS trial, with new TB cases in these families coming down by almost half.

The World Health Organization released new guidelines last year recommending nutritional interventions in settings of poverty and undernutrition, drawing significantly from the evidence of the RATIONS trial.

Improving nutrition security by including pulses in the public distribution system, and expanding the Ni-Kshay Mitra scheme to include TB patients’ households will have long-term benefits in reducing the TB burden in India.

The way ahead

India is a global leader in implementing comprehensive nutrition assessment and support initiatives through the NTEP. Research and evidence from India have influenced global policy. Some of the next positive steps will be to record and report nutritional assessment at diagnosis; at two months; and at the end of treatment. This will help to identify those at risk of death, monitor early weight gain, and assess nutritional recovery. A differentiated TB care model in line with the TN-KET intervention in Tamil Nadu can identify and prioritise severely underweight patients. This will require local contextualisation of food baskets, with due attention given to comorbidities, supported by transport and inpatient care for the sick.

The inverse care law also works in TB and nutrition — the most vulnerable among us such as those in difficult-to-reach areas, the tribals, and the migrant workers, should not be left out.

Dr. Madhavi Bhargava, a public health specialist, teaches at Yenepoya Medical College, Mangalore. Anurag Bhargava, a physician-epidemiologist teaches at the department of Medicine at Kasturba Medical College, Mangalore. Both led the RATIONS trial in Jharkhand. The views expressed are personal.

Published – March 24, 2026 12:26 am IST