Nutritional Assessment and Counselling in Patients with TB: Challenges for the Health Care System

Introduction

Tuberculosis (TB) is the leading cause of death due to a single infectious agent and remains a major public health problem globally. In 2017, worldwide there were an estimated 10 million new cases of TB and over 1.3 million deaths attributed to TB. [1] In India, there was an estimated 2.8 million new TB cases in the year 2017; contributing roughly 25% to the global incident cases. Also, India is in the list of countries with triple burden of high TB, TB/HIV and MDR-TB.

Challenges in implementation of nutritional guidelines for patients with TB

In India, the launch of ‘Nikshay Poshan Yojana’, is a welcome step towards tackling undernutrition in patients with TB, as nutritional aspect of the patients has been given due importance here. However, the health system may have few challenges. Accredited Social Health activists (ASHA), Auxiliary Nurse Mid Wife, TB health visitor and the medical officers of primary health centers (PHCs) and community health centers (CHCs), who are required to perform nutritional assessment and counselling, need to be trained in principles of nutrition. A recently published study conducted in 37 PHCs in a district of Karnataka state (India), highlighted that medical officers were not calculating BMI for nutritional assessment and nutritional classification was mostly based on the physical appearance of the patient.[10] The study revealed that medical officers had not received any training on nutritional counselling during their career. Hence, it is of utmost importance to train the health care providers and to monitor the implementation of the program with the help of proposed indicators in the nutritional guidance document. Nutritional assessment and counselling need to be given more emphasis in the undergraduate training programs for medical and para medical courses and this should be made as a core competency. Training of health care providers in nutrition will not only help tackling undernutrition in TB patients, but also required for managing the larger epidemic of non-communicable diseases in India.

Another challenge could be due to the impact of 99DOTS on personal interactions with patients. Though 99DOTS could save time and travel costs for the patients, it will reduce the number of patient-provider interactions. Also, behavior change related to nutritional intake may require more interactions and support from the provider. Regular monitoring of weight gain may also get affected due to the reduction in number of patient-provider interactions. Trained grass root level providers like ASHA and ANM can be helpful in overcoming this challenge by home visits at pre-determined time points during the course of treatment.

The third challenge is to tackle food insecurity among poor income households. Undernutrition is largely related to food insecurity in poor income households. There needs to be strong social support system to overcome this food insecurity. Though the DBT through Nikshay Poshan Yojana scheme may partially overcome food insecurity, other measures like linking the TB households for extra ration in public distribution systems and, making food available through funds from Village Health, Sanitation and Nutrition Committee (VHSNC), or non-governmental organizations need to be explored. Health care providers need to be sensitized about the food insecurity and informed about the schemes outside the health care sector for TB patients, so that they can linking TB patients to such schemes.

To conclude, strengthening the primary health care system in nutritional assessment and counselling will help in achieving the End TB strategy milestones. A multisectoral approach with an overall economic and social development will further help to address the issue of undernutrition at the population level.

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