WHO calls food assistance key to fighting TB; What the new guidelines mean for India | Explained  

A recent update from the World Health Organisation (WHO) on tuberculosis (TB) and undernutrition marks a significant shift in global TB policy. For the first time, WHO recommends food assistance for household contacts of people diagnosed with TB in food-insecure settings. This guidance emerges from growing recognition of the strong link between undernutrition and TB activation, a relationship underscored by robust evidence from India’s landmark RATIONS trial.  

According to the WHO, tuberculosis is once again the leading cause of death from a single infectious agent globally, surpassing COVID-19 in recent years. In 2023, an estimated 12.5 lakh people died from TB, while 1.08 crore individuals fell ill with TB worldwide. The burden spans men, women, and children alike, with 60 lakh men, 36 lakh women, and 13 lakh children affected. The disease remains present in every region and age group and continues to pose a major public health challenge due to its infectious nature and its links with undernutrition and poverty. 

In India, the TB burden is particularly heavy. While the country has made significant progress in reducing TB incidence rates, falling from 237 per lakh population in 2015 to 195 per lakh population in 2023, a decline of 17.7 per cent, recent years have seen an uptick in cases. On 18 March 2025, just days before World TB Day, Union Minister of State for Health and Family Welfare Anupriya Patel said that in 2023 and 2024, India reported 25.5 lakh and 26.07 lakh tuberculosis cases, marking the highest number of notified cases ever. According to the government, this increase reflects that they are “missing” fewer cases now due to a more comprehensive screening and detection process, rather than a resurgence of the disease.  

Considering the scale and severity of TB in India, it is important to understand the implications of the new WHO guidelines and explore interventions that address both medical treatment and underlying nutritional vulnerabilities. 

 

Key recommendations in the new guidelines

The updated WHO guidelines emphasise a holistic approach to TB care, integrating clinical treatment with nutrition and social protection. The release of the latest guidelines marks a significant step in addressing social and nutritional determinants as part of people-centred care under WHO’s End TB Strategy. WHO recommends that all people diagnosed with TB, as well as their household contacts, undergo nutritional assessment and counselling, noting that “this recognises that a significant proportion of people in households with TB may be undernourished.”  

The guidelines further advocate for the provision of nutritional interventions to optimise clinical outcomes in people with TB who have undernutrition, stating that these interventions should be applied “regardless of age, drug resistance, pregnancy status or severity of undernutrition.”  

A bold new addition is the recommendation for food assistance to prevent TB in household contacts living in food-insecure settings. WHO highlights that this guidance was informed by the Reducing Activation of Tuberculosis by Improvement of Nutritional Status (RATIONS) trial, which underscores that “provision of food assistance to prevent TB in household contacts of people with TB in food insecure settings” is a critical strategy to reduce disease activation and break the cycle of TB and undernutrition.  

WHO emphasises the social determinants of TB. “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. Integrating nutrition into comprehensive TB care is essential to breaking the cycle of disease and poverty, and constitutes a critical step towards a world free of TB,” said Dr Tereza Kasaeva, Director of the WHO Department for HIV, Tuberculosis, Hepatitis, and Sexually Transmitted Infections.  

India’s pioneering research 

At the centre of this policy shift is the RATIONS, or Reducing Activation of Tuberculosis by Improvement of Nutritional Status, trial, a multi-centre, field-based study led by doctors Anurag Bhargava and Madhavi Bhargava in Mangaluru. The trial tested whether providing monthly food baskets and micronutrient supplementation to household contacts of TB patients could reduce TB activation.  

Conducted under real-world conditions across multiple districts, the trial included 10,345 household contacts, many from indigenous communities such as Santhals, Ho, Munda, Oraon, and Bhumij. Nearly 34 per cent of participants were undernourished. The trial found a 48 per cent reduction in microbiologically confirmed pulmonary TB cases among household contacts receiving nutritional support.  

Among TB patients themselves, improved nutritional status correlated with better treatment outcomes and survival. Statistically, the trial demonstrated that providing food and supplements to roughly 30 households could prevent one new TB case, highlighting the substantial public health impact achievable through nutritional interventions. These findings provided compelling evidence for the WHO to incorporate food assistance into formal TB guidelines.  

Why it matters for India

India bears the brunt of the global TB epidemic, accounting for 26 per cent of cases and a significant proportion of TB-related deaths. India’s government has taken ambitious steps to eliminate TB, with Prime Minister Narendra Modi committing to ending the disease by 2025 during the 2018 “End TB Summit” in New Delhi. This target is five years before the World Health Organization’s (WHO) deadline. While the country has made measurable progress in reducing incidence and deaths, recent years have seen an uptick in cases.  

Calling the new WHO guidelines a “welcoming step,” Dr Harish Chafle, Senior Consultant Chest Physician and Bronchoscopist at Gleneagles Hospitals, Mumbai, said that the renewed emphasis on nutrition brings back an essential but long-overlooked aspect of TB care. “It’s good that WHO has emphasised nutrition, which was definitely lacking all this while,” he noted. 

Dr Chafle explained that historically, treatment for TB before the advent of effective drugs focused on isolation and nourishment. “In the ancient period, the treatment for tuberculosis was basically making the patient go out of the village, which was called sanatorium treatment. Patients were kept away so they didn’t spread the disease and were given enough nutrition to build immunity.” He pointed out that even with limited medicines available in the early 20th century, “those who consumed a high-protein diet and maintained good nutrition often recovered well.” 

According to him, the relationship between nutrition and TB remains as crucial today as it was decades ago. “For any infectious disease, what governs whether you get infected or not is your innate immunity — and your immune status is directly governed by nutrition,” he said, adding that undernourished individuals are more vulnerable to TB and other infections. 

Dr Chafle cited poor dietary habits among young people as a growing concern. “In my practice, I see many college students or schoolchildren who skip breakfast, are undernourished, and then get exposed to infection in crowded settings,” he said, adding that lifestyle trends such as extreme dieting and the “fad of zero figure” have worsened the issue. 

He also highlighted the growing challenge of primary drug-resistant TB, where patients develop resistance despite not being exposed to treatment before. “This is becoming one of the key reasons TB is still not under control,” he said. 

The COVID-19 pandemic, he added, further disrupted India’s progress toward elimination. “During the pandemic, attention was diverted entirely to COVID-19. TB patients could not follow up properly, and ongoing control programmes were affected,” Dr Chafle added.  

He emphasised that India’s goal to eradicate TB will require more than just medical intervention - it needs public awareness, consistent treatment adherence, and a shift in mindset. “Many patients stop treatment once they feel better, which leads to relapse and further spread,” he explained. “Awareness is a major concern; people must understand why they developed the disease and what is needed to recover fully.” 

Social stigma and lack of information, particularly in rural areas, remain major barriers. “People in cities are generally aware, but in villages, social taboos and poor knowledge about TB make it difficult to control,” he said. 

Dr Chafle concluded that the WHO’s focus on nutrition gives a new direction to TB control efforts. “Once a guideline comes, it acts like a prescribed pill - people tend to accept and follow it. Bringing nutrition back to the centre of TB care is a much-needed move,” he said. 

This story is done in collaboration with First Check, which is the health journalism vertical of DataLEADS.

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