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4593re: TB and Nutrition (reductionist vs integrated evidence)?

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  • Rakesh Biswas
    Nov 1, 2013
    • 0 Attachment
      Cross posting this debate for further inputs by esteemed colleagues:

      From: Manu Mathew <manu56@...>
      Date: Fri, Nov 1, 2013 at 11:57 PM Anna Joseph <annaroopa@...>, Rebecca Mathew <rebeccajoyce7@...>

      Dear All,

      @Dr. Yogesh -
      I understand what you are saying but I can only partially agree with you.

      As people who should ideally be looking towards 'health' in a holistic fashion your reasoning holds strong. Food and nutrition is a basic right of a human being and whatever the evidence we should not come in the way of people obtaining this basic necessity. If anyone asked the question "Does provision of food contribute to overall health of the individual and community", I am sure we wouldn't need evidence to say a definite YES. (But then this is assuming health is synonymous with nutrition and ill health. Isn't health more than that? - but then thats a discussion for another day; the day we are able to provide food for everyone..)

      Unfortunately we don't have the privilege (or the intelligence for that matter) to work that broadly, and we have to tackle one thing at a time, in such a way that there are visible benefits within ones term of administration(5-10years at max). Hence for practical reasons(even though may not be 100% ethical) when working towards eliminating TB our aim is cure and we would invest on the interventions that provide outcomes that lead toward it.

      If we were more intelligent or organized we would fund/provide health in a holistic manner. And not let a Non-HIV pregnant woman with bleeding PV die outside the gates of a hospital, where the only remaining operational unit is that dealing with HIV patients(Funded by the BMgates foundation). Can you imagine that she would have got the care if she was HIV positive?? (This was personal experience recounted by a friend of mine who worked in the HIV AIDS program there).

      The above quoted evidence actually is a relief for policy makers, because they can counter any campaigning on this front and wont have to find funds for food. It would be interesting to think of ideas how we could provide food in the TB in such a way that we could clearly measure a beneficial outcome.. may be adherence to treatment??

      @Dr Priyank - If I understand correctly you reordered the paragraph to show benefits before the no benefits. We tend to order things in such a way that we place the most important things first. I think the review placed more importance in the cure(primary outcome) aspect than the weight gain/QOL aspect(secondary outcome). SR authors are supposed to use such an ordering (primary>>Secondary), based on what they have specified in the protocol, so as not to bias themselves/ readers.

      I hope my arguments make sense.. Would love to hear further thoughts...

      Copying in a few of my colleagues from the SASIANCC. @Anna, you might be interested in writing something up for the TB day or nutrition day based on this discussion.

      Best Wishes


      Dr. Manu E Mathew

      MSc- Public Health
      Lonodon School of Hygiene and Tropical Medicine

      On 1 November 2013 16:52, Yogesh Jain <jethuram@...> wrote:
      Dear Priyank, Rakesh and Manu,

      In research, asking the right questions are as important as finding the right answers.

      I think this question " does providing food supplements in addition to food improve outcomes in tuberculosis " is not a good question. Not good , because it is variably unethical, counterintuitive, and , Non- humanistic . Even though it may be driven by the principles of scientific enquiry. And also be needed by planners and policy makers. I would not like to subject this question to research methodology. If I were a policy maker, I would give supplements to people with tuberculosis. I will not succumb to the demands of the doubters or opponents by agreeing to do such a study.

      I have thought about this whether I am being unscientific or being 'reversely arrogant' by saying this. I don't think I am being that. Yet,  I welcome a debate on my position. 

      There is a second point I want to make . This demand for evidence to draw conclusions and inferences is often a trap that many of us fall into. Not always. Don't we know of so many evidence that are sitting on the shelf and yet have not led to or implememted in form of progressive changes in policy? The road from generating evidence through research to improving human situation in form of reducing injustice or inequity is so long. 


      On Friday, November 1, 2013, Priyank Jain wrote:
      One quick comment

      I would have preferred to see the summary worded thus: 

      Providing free food probably does improve weight gain during treatment, and may improve quality of life. We currently don't know if providing free food to tuberculosis patients, as hot meals or ration parcels, reduces death or improves cure but further research is necessary.

      From: anurag bhargava <anuragb17@...>
      Date: Sat, Nov 2, 2013 at 12:52 AM
      Subject: Re: TB and Nutrition
      To: Rakesh Biswas <rakesh7biswas@...>, Yogesh Jain <jethuram@...>, Manu Mathew <manu56@...>

      I have read this review. The problem with all the literature on nutritional supplements is the tremendous variation in what was given, to whom it was given, and with what outcome in mind. If we talk of a micronutrient (zinc) given to a patient who is not undernourished and with the intent of earlier sputum conversion, then the trial is probably a waste of resources. If the intervention is energy dense food given to a undernourished patient with the intent of earlier sputum conversion / decreased frequency of adverse effects / improved weight gain and better performance status at the end of treatment / decreaed risk of relapse then the trial is worth it. But there are not many trials of this sort. The one major study was the Madras study where some of the results have not been highlighted- 24% of women were bacteriologically positive in the home group vs. 9% in the sanatorium, sputum conversion occurred a month earlier in the sanatorium group and there was a 15% percentage point difference in the rate of sustained microbiologic cure. 

      We have to contextualise the results of this review. When faced with a poor patient with a BMI of 14 kg/m2, should we say that nothing should be done because nothing works? That conclusion would fly in the face of whatever we know about undernutrition and its implications.  How would one do a trial of this situation which may be termed ethical?Absence of evidence should not necessarily be construed as evidence of absence.


      From: Manu Mathew <manu56@...>
      Date: Fri, Nov 1, 2013 at 12:46 AM

      Hello Sir,

      Hope this review would spark some debate..

      The review concludes (End of plain language summary)-

      We currently don't know if providing free food to tuberculosis patients, as hot meals or ration parcels, reduces death or improves cure. Providing free food probably does improve weight gain during treatment, and may improve quality of life but further research is necessary.

      We don't know if vitamins reduce death in HIV-negative people but they probably don't work in HIV-positive people with tuberculosis. No studies have assessed whether vitamins improve tuberculosis cure. Vitamins probably don't improve weight gain, and no studies have assessed their effect on quality of life.

      Read more :http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006086.pub3/abstract ..



      From: Yogesh Jain <jethuram@...>
      Date: Fri, Oct 25, 2013 at 8:02 AM

      This  http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0077979 came out yesterday. Significant message.



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