The World Health Organization (WHO) has unveiled new global guidelines on tuberculosis (TB) and undernutrition, marking a significant policy shift in how TB is treated and prevented. The updated recommendations make nutritional assessment, counselling, and food assistance mandatory components of TB care and prevention programs worldwide.
“Tuberculosis thrives on inequality, with undernutrition as a major driver. To end TB, we must address undernutrition and food insecurity as part of a comprehensive, household-centred response,” said Dr. Tereza Kasaeva, Director of WHO’s TB and HIV Department.
These updated guidelines are informed by findings from the RATIONS trial (Reducing Activation of Tuberculosis by Improvement of Nutritional Status), a landmark field study conducted in Jharkhand, India, which demonstrated that integrating nutritional support into TB therapy can significantly reduce disease incidence and improve treatment outcomes.
Key Updates in the WHO Guidelines
The new guidance introduces several pivotal recommendations for national TB programs:
Mandatory nutritional assessment and counselling for all TB patients and their household contacts.
Nutritional interventions for patients experiencing undernutrition, regardless of age, pregnancy status, or drug resistance profile.
Food assistance for household contacts to prevent TB development in high-risk, food-insecure families.
Operational guidance for countries to effectively implement these strategies through coordinated health, nutrition, and social protection systems.
By embedding nutrition as a core element of TB care, WHO acknowledges that addressing food insecurity and malnutrition is vital to tackling the social determinants of health that drive the global TB epidemic.
Evidence from the RATIONS Trial
The RATIONS trial involved 2,800 microbiologically confirmed pulmonary TB patients and 10,345 household contacts across 28 tuberculosis units in Jharkhand, India (Bhargava et al., 2023).
TB patients in the intervention group received daily food rations providing ~1,200 kcal and 52 g of protein, along with multivitamins.
Household contacts received ~750 kcal and 23 g of protein per day, plus multivitamins.
Over two years, new TB cases among household contacts decreased by 39–48% compared with controls.
Preliminary analyses also revealed that weight gain during treatment was linked to lower mortality, emphasizing the life-saving potential of integrating nutrition into TB programs.
Indian Contribution and Local Impact
The RATIONS trial was spearheaded by Dr. Anurag Bhargava and Dr. Madhavi Bhargava of Yenepoya University, Mangaluru, whose work has directly influenced global TB policy.
Following the trial’s success, Jharkhand has scaled up its program to provide food baskets to TB-affected families, while other Indian states are adopting similar approaches based on RATIONS findings and WHO’s new guidance.
Implications for India and Other High-Burden Countries
India bears the highest global TB burden, accounting for approximately 2.8 million new cases and over 320,000 deaths in 2023 (WHO Global TB Report 2023). Integrating nutritional support into TB treatment could improve outcomes, prevent new infections, and reduce mortality, especially in food-insecure households.
The RATIONS trial highlights that household-centred nutritional support is both feasible and effective. Preliminary modelling suggests that national-scale nutrition programs could substantially cut TB incidence and deaths, though actual impact will depend on the extent and quality of implementation.
Scientific Rationale
Undernutrition remains a key risk factor for TB, influencing both susceptibility and treatment success. Malnourished individuals often exhibit altered drug absorption, metabolism, and distribution, leading to reduced drug efficacy and higher toxicity (Nutrients, 2025).
By formally embedding nutritional support into TB programs, WHO aims to help countries improve treatment outcomes, strengthen patient resilience, and mitigate disease progression through an integrated public health approach.
Next Steps
WHO will release a detailed operational handbook in 2025 to help countries implement these updated recommendations effectively. The organization emphasizes the need for multisectoral collaboration between health, nutrition, and social protection systems, alongside sustained funding and community engagement, to ensure equitable access for vulnerable populations.
This landmark policy underscores a pivotal shift — positioning nutrition not just as supportive care, but as an essential intervention in the global effort to end tuberculosis.
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