WHO Updates TB Guidelines to Include Nutrition Support, Inspired by Indian Research

Key Points:

Geneva / Mangaluru, 13 October 2025 — The World Health Organization (WHO) has released new global guidelines on tuberculosis (TB) and undernutrition, marking a major shift in TB care policy. The updated guidance mandates nutritional assessment, counselling, and provision of food assistance as core components of TB treatment and prevention.

The new guidelines reflect the findings of the RATIONS trial (“Reducing Activation of Tuberculosis by Improvement of Nutritional Status”), a field-based study conducted in Jharkhand, India. This trial provided robust evidence that integrating nutritional support with TB therapy can significantly reduce TB incidence and improve patient outcomes. ¹

Key Updates in WHO Guidelines for TB

The guidelines introduce several major recommendations for TB programs worldwide:

• Mandatory nutritional assessment and counselling for all TB patients and their household contacts.

• Provision of nutritional interventions for patients experiencing undernutrition, regardless of age, drug resistance, or pregnancy status.

• Food assistance to household contacts to prevent TB development in high-risk, food-insecure families.

• Operational guidance to help countries implement these recommendations effectively through health, nutrition, and social protection systems.

By elevating nutrition as a central element, WHO acknowledges that tackling TB requires addressing social determinants of health, such as food insecurity and malnutrition.

Evidence from the RATIONS Trial

The RATIONS trial enrolled 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 food rations providing approximately 1,200 kcal and 52 g of protein per day, alongside multivitamins.

• Household contacts in the nutrition arm received rations of about 750 kcal and 23 g of protein per day, plus multivitamins.

• Over two years, new cases of active TB among household contacts decreased by 39–48% compared to controls. ¹

Preliminary programmatic analyses also indicated that weight gain among TB patients was associated with reduced mortality, demonstrating the potential lifesaving impact of integrating nutrition into TB treatment programs. ¹

Indian Contribution and Local Impact

The RATIONS trial was led by Dr. Anurag Bhargava and Dr. Madhavi Bhargava of Yenepoya University, Mangaluru, whose research has been recognized for influencing global TB policy.

The trial has strengthened nutrition-focused initiatives in states such as Jharkhand, where the program has been scaled to provide food baskets to TB-affected families. Several other states are exploring similar interventions based on RATIONS findings and the WHO guidance.

Implications for India and High-Burden Countries

India carries the highest TB burden globally, with approximately 2.8 million new cases and over 320,000 deaths in 2023 (WHO Global TB Report, 2023). Integrating nutrition into TB care could improve treatment outcomes and prevent new infections, particularly in households facing food insecurity.

The RATIONS trial demonstrates that household-centered nutritional support is both feasible and effective. Preliminary modeling suggests that scaling nutrition interventions nationally could lead to substantial reductions in TB cases and deaths, though precise projections depend on program scale and implementation. ¹

Scientific Rationale

Undernutrition is a well-documented risk factor for TB, and it can affect both susceptibility to infection and treatment efficacy. Malnourished individuals often experience altered drug absorption, distribution, metabolism, and elimination, potentially increasing treatment toxicity and reducing effectiveness (Nutrients, 2025). By embedding nutritional support in TB programs, countries can address both disease progression and treatment outcomes more effectively.

Next Steps

WHO plans to release a detailed operational handbook to guide countries in implementing these guidelines (WHO, 2025). Successful adoption will require multisectoral coordination, including health, nutrition, and social protection systems, as well as sustained funding to reach vulnerable populations.

References:

1. Bhargava, Anurag, Bhargava, Madhavi, Nutritional supplementation to prevent tuberculosis incidence in household contacts of patients with pulmonary tuberculosis in India (RATIONS): a field-based, open-label, cluster-randomised, controlled trial, DO - 10.1016/S0140-6736(23)01231-X

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