It’s ancient, yet remains deadly and threatening for the modern world–it's tuberculosis.

Over a decade ago today, a German Physician Robert Koch first discovered Mycobacterium tuberculosis which was later known as the causative agent of tuberculosis (TB). However, thousands of years earlier tubercular decay was detected in some Egyptian mummies from 3000-2400 BC, making this disease one of the oldest diseases in the history of mankind. Today, our modern nomenclature for TB indicates its typical signs and symptoms (a persistent cough lasting more than three weeks, fever, weight loss, night sweats), its locations (pulmonary and extrapulmonary), and its various treatment options. 

Owing to medical technology and knowledge advancement, there have been many global improvements in efforts to eradicate TB. Global and national strategies for eliminating TB have been commenced decades ago and encompass preventive, diagnostic, and curative measures. Nevertheless, TB continues to be the second most significant cause of death worldwide caused by a single infectious agent in 2022 and global targets for TB have either been unmet or even off-track.

The global count of individuals newly diagnosed with TB reached 7.5 million in 2022, marking the highest number recorded since the inception of global TB surveillance by WHO in 1995. It has been the cause of death of 1.3 million globally.

Indonesia holds the position as the second country with the highest TB burden globally, second after India.

The TB incidence rate in Indonesia stands at 354 per 100,000 population, while the TB mortality rate is 52 per 100,000 population. In the modern world where we already have it all, this millennia-old disease remains one of the leading infectious killers in the world. 

While there are various risk factors associated with TB, nutritional status is considered a significant risk factor among them. However, nutritional support appears to be rather normative without clear guidelines on how to incorporate it into the overall global or national TB elimination initiatives. There is certainly no panacea, yet could food play a crucial role in turning the tide against the TB epidemic?

Nutrition and tuberculosis: A critical connection

Tuberculosis has been linked to various forms of malnutrition, undernutrition, micronutrient deficiency, and overweight/obesity. Individuals who suffer from undernutrition are three times more likely to develop TB. The existence of protein-energy malnutrition weakens the body's cell-mediated immunity, which is crucial in defending against TB, making individuals more susceptible to TB infection.

Additionally, undernutrition is often a consequence of TB, resulting in weight loss. This significant weight loss can further increase the risk of treatment-related side effects, such as hepatotoxicity, and eventually lead to poor treatment outcomes. As for micronutrient deficiencies, these conditions are prevalent in populations with TB though the causal relationship has not been definitively established. 

The link between overweight/obesity and tuberculosis, on the other hand, still needs to be investigated. Research indicates that individuals with a high BMI may have an inverse association with the risk of developing TB, but the biological reasons behind this reduced risk among those with high BMI are not yet fully understood. This contradictory relationship also raises questions about the link between obesity and diabetes, as obesity is a significant factor in diabetes development, and diabetes is a known risk factor for tuberculosis.

Tuberculosis and food security: global and Indonesia 

Many social determinants are also drivers in the development of TB, including poor living conditions, inequality of access to healthcare, inability to provide adequate healthy food or food at all, and stigma. It has been long noted that food insecurity–a lack of availability or access to food of sufficient quality and quantity–heightens the risk of developing active TB.

A case-control study of patients with pulmonary TB in Ethiopia reported that household food shortage doubled the risk for active pulmonary tuberculosis. Another study also found that nearly one out of five tuberculosis patients were food insecure and living with concerns, such as not having enough food to eat, and reportedly went to bed hungry.

Furthermore, similar to how food insecurity leads to undernutrition and is linked to an increased risk of TB and negative health outcomes, TB can also exacerbate household food insecurity. This is especially true when the patient cannot contribute to the household finances. On average, 60% of the financial burden of tuberculosis in low- and middle-income countries stems from loss of income. Approximately half of tuberculosis patients and their families experience overwhelming costs (including medical expenses, non-medical costs, and lost income) that exceed 20% of their annual household income, a number that falls short of the WHO End TB Strategy target of zero. Even in countries with free TB care and the provision of food baskets, it is still difficult to deliver enough nutrition due to financial difficulties stemming from unemployment and the expensive nature of healthy food options.

A similar trend has also been observed in Indonesia.

Many TB patients in Indonesia come from low-income households or marginalized communities where food insecurity is prevalent.

Financial strains may hinder their access to nutritious foods regularly.

Discrepancies between rural and urban regions in Indonesia also exist. Tuberculosis patients residing in rural areas may encounter difficulties, particularly in obtaining sufficient healthcare and proper nutrition. Limited knowledge regarding healthy food and the reality of unhealthy food environments in our community perpetuate the existing nutritional problems in tuberculosis patients. 

Addressing the nexus

Addressing TB within the context of food security and nutrition in Indonesia requires multisectoral approaches that integrate healthcare, agriculture, and social welfare policies.

Firstly, collaboration between the health sector, agricultural stakeholders, and government agencies is essential. This can involve initiatives, such as promoting agricultural practices that enhance food diversity and quality combined with thorough nutritional assessment, counseling, and support, which are also needed to be integrated into TB programs, aligned with WHO global recommendations.

In addition, it's crucial for healthcare professionals to keep food security issues in mind when treating TB patients since addressing food security can help reduce the financial and social impacts of TB. While food and nutrition are vital for everyone's health, providing food assistance, as applied in another country, may not always be the best solution for access and adherence to TB treatment or for reducing the economic and social burdens of TB in Indonesia. Each country's context must be taken into consideration. When access and adherence are not optimal, the underlying causes, such as food insecurity, should be identified and addressed with appropriate support. The health sector and national TB programs can collaborate with key actors in the food system and social protection services to ensure that TB patients and their families have access to nutritious food.

Lastly, the collaborative involvement of diverse stakeholders and practitioners is essential in the effort to combat TB. This could entail ensuring the availability of nutritious food, promoting healthy eating patterns, and addressing socioeconomic elements that contribute to both TB and food insecurity. Through collective efforts, we can establish sustainable solutions that address TB and enhance general public health outcomes and well-being.

The 2024 World Tuberculosis Day is a poignant reminder of the persistent challenges posed by tuberculosis, both globally and in Indonesia. By joining forces and fostering collaboration across different sectors, we have the potential to end TB and consign this long-standing ailment to the annals of history.

References:

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