Higher Dose of This Antibiotic Can Help In Tuberculosis Recovery: Study
A higher dose of rifampicin -- a bactericidal antibiotic used primarily to treat tuberculosis (TB) -- may be safe, and its use can potentially lead to recurrence-free survival in patients with pulmonary TB, according to a recent study by the Indian Council of Medical Research (ICMR).
TB is curable but still remains the most common cause of death due to infectious diseases, with an estimated 1.3 million deaths globally in 2022. Rifamycins are a crucial drug group in the anti-TB regimen, which sterilise the lesions and aid in recurrence-free cure.
Currently, rifampicin is administered at 10 mg/kg for six months to all patients with pulmonary TB.
The team reviewed the available evidence from published clinical trials to determine whether higher doses of rifampicin (more than 15 mg/kg) are more efficacious and safer.
"Compared to standard dose, higher doses of rifampicin were found to lead to early sputum conversion in eight weeks and thus faster TB bacteria clearance," said corresponding author Dr Leeberk Raja Inbaraj, Department of Clinical Research, ICMR- National Institute for Research in Tuberculosis, Chennai.
Early sputum conversion is a valuable tool widely used as a surrogate marker for treatment response and those who are at risk for relapse in pulmonary TB.
"The ability of high-dose rifampicin to achieve early sputum conversion and eliminate the persistent bacteria that cause relapse could potentially lead to recurrence-free survival. Early bacterial clearance is also of public health importance as this could potentially reduce disease transmission in the community," the researchers said.
Notably, the study showed 20-30mg/kg rifampicin as the best balance.
"This dose range showed better sputum conversion without a significant increase in serious side effects and may be considered in TB treatment," revealed the study, published in the Indian Journal of Medical Research (IJMR).
On the other hand, doses above 30 mg/kg, although beneficial, came with severe side effects such as serious liver damage (hepatotoxicity) and adverse drug reactions (ADR), leading to treatment discontinuation.
The study showed no reduction in death or treatment failure in people with more than 15 mg/kg doses of rifampicin.
"High doses did not reduce mortality or treatment failure at 6 months compared to standard treatment," the team said.
"This dose could be administered with close monitoring of adverse events and hepatotoxicity. There is an urgent need for adequately powered trials that assess long-term treatment outcomes, including recurrence," they added.
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Indian Express
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In one of Hindi cinema's most iconic scenes, Kalia in Sholay swears by a pinch of salt — 'Sardaar, maine aapka namak khaaya hai' — as he pledges his loyalty to Gabbar. The ubiquitous grainy white condiment failed to save his life and in the 50 years since, a shift in consumption patterns and lifestyles has seen salt slowly eating away at Indians' health. While the permissible amount of salt consumption, as prescribed by the World Health Organisation, is 5 gm a day per person (2,000 mg of sodium or about a teaspoon of salt), several studies have pointed to how Indians consume more than double the amount, posing risks of hypertension, stroke and heart diseases. According to the Indian Council of Medical Research-National Institute of Nutrition's (ICMR-NIN) 2024 Dietary Guidelines for Indians, existing evidence reveals a 'deleterious impact of high salt intake on blood vessels and blood pressure', which in turn can cause heart attack, stroke and/or kidney problems. High amounts of salt in the body results in water retention, which further increases the pressure on the heart to pump larger volumes of fluid, causing hypertension. The primary culprit, experts agree, is ultra-processed food. According to the NIN's Dietary Guidelines, processed foods such as 'snacks, savouries, soups, sauces, ketchup, salted butter, cheese, canned foods, papads, and salted dry fish, salted nuts/dry fruits contribute to higher intake of salt. Preserved meats/vegetables and ready-to-eat foods contain a lot of sodium'. Prompted by the 'alarming' salt consumption patterns, earlier this month, ICMR-NIE (the National Institute of Epidemiology) launched Project Namak, a three-year-long community-led programme that focuses on salt reduction in individuals with hypertension. Sharan Murali, senior scientist at ICMR-NIE and the principal investigator of Project Namak, says, 'Our research team evaluated the hypertension component of the NP-NCD (National Programme for Control and Prevention of Non-Communicable Diseases) programme in 21 districts in the country and understood that 78 per cent of the individuals with hypertension who come for follow-up receive some counselling for behavioural change in the OPD. This opportunity may be used to counsel the individuals with hypertension on dietary salt reduction as an add-on along with the medications.' Over the last two decades, there have been several such studies, including those published in the Journal of Hypertension, Journal of the American Heart Association and Nutrients, among others, that point to high salt intake among Indians. According to India Salt Market Report and Forecast 2025-2034 by Claight Corporation published this year, the India salt market reached around USD 2.32 billion in 2024. The market is projected to grow at a compounded annual growth rate of 6.20% between 2025 and 2034, reaching almost USD 4.23 billion by 2034. With experts also warning against too little salt — Dr Vivekanand Jha of the George Institute of Global Health says 'physiologically, at least 500 mg of sodium is compatible with good health' — how does one strike a balance with something as ubiquitous as salt? Historians say that the earliest evidence of salt production in India can be traced to the Indus Valley Civilization, although consumption would date even further back, 'particularly 11,000 years ago or a little later when they realised that they need to add salt to their diet,' notes Kurush Dalal, archaeologist and culinary anthropologist. 'Salt is indispensable to all mammals. As a rule, hunter gatherers used to get all the salt they needed from the food they ate. They didn't need to add anything at all. It's only when we became farmers that we started adding salt,' he says. 'On every continent', notes Mark Kurlansky in his book Salt: A World History, 'once human beings began cultivating crops, they began to look for salt to add to their diet. How they learned of this need is a mystery… however, most people choose to eat far more salt than they need, and perhaps this urge — the simple fact that we like the taste of salt — is a natural defense.' With that, salt became one of the most valuable commodities of trade. Kurlansky notes, 'Where people ate a diet consisting largely of grains and vegetables, supplemented by the meat of slaughtered domestic farm animals, procuring salt became a necessity of life, giving it great symbolic importance and economic value. Salt was one of the first international commodities of trade; its production was one of the first industries and, inevitably, the first state monopoly.' In India, salt holds a deeply symbolic value given how Mahatma Gandhi shook an empire with a fistful of salt with his Salt Satyagraha. While the origins of salt consumption are global, Indians took to salt more organically. In the absence of any recorded evidence, SubbaRao M Gavaravarapu, scientist and Head of Nutrition Information, Communication and Health Education at NIN, cites 'traditional knowledge' to explain Indians' tendency to consume higher amounts of salt. 'We are a tropical nation and many of our people would work outdoors and perhaps to compensate for the sodium loss through sweat, sodium was incorporated through food,' he says. To understand the detrimental effect of this condiment, however, it is important to know that salt (NaCl, with sodium and chloride ions in a 1:1 ratio) is only as harmful as its sodium content. And that, given our shifting eating patterns, sodium comes from more than just the salt we consume. While, as the NIN guidelines say, 'a major amount of sodium does come from the visible addition of salt', there are also innocuous ways sodium makes its way into our bloodstream. For instance, there is sodium bicarbonate or baking soda, the indispensable ingredient in bakery products. There's also monosodium glutamate or MSG which gives food its umami or savoury flavour and is commonly present in canned food. Then there's sodium nitrite, which is commonly used by commercial meat processing units to preserve meat, and sodium benzoate, which gives acidic foods and beverages such as colas, soft drinks, pickles, salad dressings and jams and preserves their shelf life. And for those into carbonated drinks such as diet soda, there's sodium saccharin to reckon with — all of which add to our sodium intake without any real addition of salt itself or table salt as we know it. Food critic and historian Pushpesh Pant reiterates the need for broadening the understanding of salt to manage one's sodium consumption. 'In Sanskrit, the word for salt is lavana, which does not necessarily mean sodium chloride, which we know as table salt. It could mean potassium chloride, sodium bicarbonate. It could be anything which is alkali,' he says. Khar, the alkali ash that is commonly used in food in the Northeast, is sodium carbonate, he explains. Experts broadly agree that among the easiest ways to combat this excessive supply of sodium to our bodies is to consume less table salt — and achieve a better balance of flavours. In his seminal 1998 work, A Historical Dictionary of Indian Food, the late food historian K T Achaya notes that there are six 'pure' tastes: madhura (sweet), amla (sour), lavana (salty), katu (pungent), tikta (bitter) and kasaya (astringent). 'Every meal was expected to include all the six tastes, and in the order just listed, according to Sushrutha (ancient Indian physician and doctor),' the book says. Traditionally, the use of salt in cooking has been in tandem with the other five tastes, Pant explains, while saying that different regional cuisines in India have their own equation with salt. 'If you are a coastal person, most of your salt would come from sea water fish. The pungency of mustard oil, which is used generously in Bengali cuisine, ensures a limited requirement of salt…Now, if you are a Maratha living away from the coast line, and you are eating millets, which are not very palatable on their own, you will increase the levels of salt and chillies. Or if you are having preserved foods like papad or bari, salt content is higher,' Pant says. Concerns of excessive salt intake and its detrimental effects on public health have prompted a host of studies and small-scale interventions to produce 'low-sodium' salt. This involves replacing a part of the sodium in sodium chloride with other additives, primarily potassium. But so far, these experiments haven't achieved the required scale in India. 'The concern in salt is the sodium. To reduce sodium, other kinds of salts are added. Mostly, it is replaced with potassium but there are issues with low-sodium salts — it is expensive and its supply is short,' says NIN's Gavaravarapu. The practice of adding potassium to packaged common salt, however, is yet to take off on a mass scale in the country given the lack of India-specific studies and with little clarity around its potential benefits or perceived risks. Dr K Srinath Reddy, founder president of the Public Health Foundation of India (PHFI) who formerly headed the Department of Cardiology at AIIMS, says that following initial trials across the world, where part of the sodium in salt was replaced with either potassium or magnesium, there were concerns over whether it could 'cause harm to people with reduced renal and kidney function'. 'Potassium is a bit corrosive, so we would have to use it in concentrations that won't damage the lining of the stomach and intestines. There were also concerns over whether low-sodium salt would cause hyperkalemia (excess potassium levels in the blood) in the elderly with renal function though there were successful trials in the US that said it was safe for them. But the findings weren't accepted because the trials were small,' Reddy says, while pointing to a study conducted in China by the George Institute for Global Health. With a 'fairly large' sample size of over 20,000 participants from 600 rural villages in five provinces in the country, the China Salt Substitute and Stroke Study (SSaSS), published in 2023 and conducted over five years, found that 'replacing salt with a reduced-sodium added-potassium 'salt substitute' significantly lowers the risk of stroke, heart disease, and death'. The institute has submitted a funding request to ICMR to conduct a similar study in India, said Dr Vivekananda Jha, Executive Director at The George Institute for Global Health, India. 'The study in China proves the point that lower than usual levels of dietary sodium can be tolerated without ill-effects, and a certain amount of potassium is required to balance the sodium. But whether that's going to become public policy in India, whether people are going to accept the altered tastes, we will have to see,' says Dr Reddy, emphasising that 'ideally', potassium, which negates the effects of sodium, should be consumed in the form of fruits and vegetables rich in the mineral. 'One can consume bananas and coconut water. But everybody may not be able to take all of it all through the year. So introducing a salt substitute like in the China trial is something we should maybe consider… Do some pilots to see what the response is, what the safety is, and what the popular acceptance is,' he adds. The last time a population-level health intervention in salt was carried out was in 1962, when common salt was fortified with iodine under the National Goitre Control Programme. Presently, all packaged salt sold in India, from common salt to rock salt, is iodised. NIN's Gavaravarapu flags another, largely behavioural, concern regarding low-sodium substitutes not being 'salty enough'. 'People think that because it is low-sodium, they can have more of it. Ideally, you should use it even less than usual so that the benefit of replacing it with potassium is passed on,' he says. While we wait for more research and consensus on reducing the sodium component in common salt, experts advocate the need to create awareness among consumers. Dr Reddy and NIN's Gavaravarapu reveal that the Food Safety and Standards Authority of India (FSSAI), a statutory body under the Ministry of Health and Family Welfare, is looking at the feasibility of 'front of the package labeling' that would explicitly warn customers of high levels of sugar, salt and trans fat, among others. 'If a package notes that it has so many grams per cent of fat or carbohydrate or trans fats, unless I have studied nutrition, I wouldn't understand any of it. That's why you require warning labels that communicate clearly and help people recognise there's a problem with the salt or sugar in the product,' says Dr Reddy. The UK and Ireland, for instance, follow a 'traffic light packaging' model, where red, amber and green colours are used to indicate the levels of fat, saturated fat, sugar, and salt in food products. Public health scientist and epidemiologist Dr Monika Arora says the country needs a behavioural change in terms of salt consumption. 'Salt can be reduced in the food served in schools, hospitals and government canteens, which are regulated places. The tongue and palate get adjusted to a gradual reduction. Midday meal is an excellent way of going about it. Another way is to tax high-salt products, making it an incentive for the industry to start reformulating their products,' she says. Celebrity chef and entrepreneur Sanjeev Kapoor says he realised the dangers of excess salt much before it became a talking point. 'When I dived deeper into healthier food options, I realised that it is not only sugar that is the culprit, but also salt,' he says. He also joined hands with the government to raise awareness about healthy food habits through FSSAI's 'Eat Right Movement' that focussed on 'reduction of high fat, sugar and salt foods in the diet'. 'We have to understand that taste is something that you get used to. Your palate gets trained. Salt is a flavour enhancer. If there is low salt in a dish, other flavours may also seem muted. But it also hides flavours. Which means if you add too much salt in a dish, the top note is of salt and you never experience the real flavour of other ingredients. If you want to use less salt, you can start by enhancing the flavour with other ingredients. Lemon works really well as do herbs like mint, coriander, basil and tulsi,' he says. While cutting down on salt may seem like hard work, Kapoor's new catchphrase may hold the key — around 20 years ago, while he started with 'Namak Swad Anusar (salt as per taste)', he now swears by 'Namak Sehat Anusar (salt as per health)'.
