WHO Guideline: Nutritional care and support for patients with TB

Undernutrition increases the risk of tuberculosis (TB) and in turn TB can lead to malnutrition. Undernutrition is therefore highly prevalent among people with TB. It has been demonstrated that undernutrition is a risk factor for progression from TB infection to active TB disease and that undernutrition at the time of diagnosis of active TB is a predictor of increased risk of death and TB relapse. However, the evidence concerning the effect of nutritional supplementation on TB prevention and health outcomes among people with TB had not previously been systematically reviewed.

WHO has recently produced a guideline on the principles and recommendations for nutritional care and support of patients with TB as part of their regular TB care. Of note, it does not consider the provision of food as part of a package of enablers to improve TB treatment adherence or as means to mitigate the negative financial consequences of TB.

The primary audience for the guideline is health workers providing care to people with TB. However, the guideline is also intended for a wider audience, including policy-makers, their expert advisers, and technical and programme staff at organisations involved in the design, implementation and scaling-up of nutrition actions for public health.

Three systematic reviews were updated to inform this guideline. The overall evidence base on effects of nutritional supplements for TB prevention and care is limited and the overall quality is low or very low for most outcomes. There is no evidence on improvement of TB treatment outcomes, or prevention of progression from TB infection to active disease, when using nutritional supplementation as an addition to standard care. There is no evidence that nutritional management of acute malnutrition of patients with active TB should be different than for those without active TB.

Principles

Five guiding principles are identified as key for providing nutritional care and support as an integral part of TB care and prevention:

1. All people with active TB should receive TB diagnosis, treatment and care according to WHO guidelines and international standards of care. When malnutrition is identified at the time of TB diagnosis, TB is considered a key causal factor that needs to be addressed. It is essential that nutrition assessment and assistance do not divert resources from optimal TB diagnosis and care. Concerns about weight loss or failure to gain weight during TB treatment should trigger further clinical assess ment (e.g. resistance to TB drugs, poor adherence, comorbid conditions) and nutrition assessment of the causes of undernutrition, in order to determine the most appropriate interventions.
2. An adequate diet, containing all essential macro- and micronutrients, is necessary for the well-being and health of all people, including those with TB infection or TB disease.
3. Because of the clear bidirectional causal link between undernutrition and active TB, nutrition screening, assessment and management are integral components of TB treatment and care.
4. Poverty and food insecurity are both causes and consequences of TB, and those involved in TB care therefore play an important role in recognising and addressing these wider socioeconomic issues.
5. TB is commonly accompanied by comorbidities such as HIV, diabetes mellitus, smoking and alcohol or substance abuse, which have their own nutritional implications, and these should be fully considered during nutrition screening, assessment and counselling.

Recommendations

Patients with TB should be nutritionally assessed and receive the same nutritional care and support as other individuals or populations of similar nutritional status, in agreement with all relevant WHO recommendations.

The WHO guideline recommendations are grouped on four areas related to nutritional care and support – nutrition assessment and counselling, management of SAM, management of MAM, and micronutrient supplementation – to cover especially vulnerable populations, with an additional area for contact investigation.

Closer nutritional monitoring and earlier initiation of nutrition support (before the first two months of TB treatment are completed) should be considered if the nutritional indicator is approaching the cut-off value for a diagnosis of severe undernutrition.

Research priorities

Guideline group members and stakeholders identified several research priorities to improve the body of evid- ence at the basic, clinical, epidemiological and operational levels, on the nutrit- ional care and support for patients with TB.

WHO. Guideline: Nutritional care and support for patients with tuberculosis. Geneva: World Health Organisation; 2013. http://www.who.int/nutrition/publications/en/