New Guidelines by WHO identify the overlooked link between TB and undernutrition

In South Africa, where many TB patients struggle with poverty and food insecurity, something as basic as a regular, nutritious meal can decide whether a patient completes treatment successfully or falls ill again.

However, the new global health guidelines are finally putting nutrition at the centre of the country’s TB response.

In April 2025, the World Health Organization (WHO) released its Consolidated Guidelines on Tuberculosis: Module 4 – Treatment and Care, a comprehensive document merging all previous guidelines into one. These updated guidelines introduce improved treatment regimens for people with multidrug-resistant or rifampicin-resistant TB (MDR/RR-TB), while also placing stronger emphasis on patient-centred care and support services, including nutritional interventions.

Following the release of these guidelines, the TB Think Tank hosted a webinar titled “TB and Nutrition in South Africa: WHO’s Latest Guidance and Why It Matters Now”. The webinar unpacked the urgent need to address the link between undernutrition and TB in the country.

Among the speakers were Dr. Annabel Baddeley, Technical Officer of WHO’s Global TB Programme, who outlined the new recommendations and their global significance. WHO’s TB Technical Officer in South Africa, Nkateko Mkhondo, was also one of the speakers where she presented on the country’s nutritional challenges and TB outcomes.

According to Dr. Baddeley, the updated global guidelines on TB and nutrition are built on new evidence and they mark a significant expansion from previous guidance, introducing several strengthened recommendations aimed at improving patient outcomes and addressing the broader social determinants of health.

“The new guidelines introduce much more expansive recommendations including providing nutritional assessment and counselling to all TB patients at diagnosis and throughout treatment, assessing household TB contacts as part of contact tracing and offering nutritional support to any TB patient with a BMI less than 18.5,” she explained. “They also recommend extending food baskets with multiple micronutrient supplements to all households of people with TB in food-insecure settings.”

Presenting on the 2024 Global TB Report, Mkhondo stressed that undernutrition remains one of the leading drivers of TB. “Globally, undernutrition is actually the leading determinant and while South Africa’s profile is slightly different, it remains a critical risk factor that we need to urgently address.”

In her presentation, Mkhondo further explained how costs have an impact on the nutritional status of TB patients. She references the TB Patient Cost Survey noting that only 6% patients received food parcels, which were not exclusively to only TB patients. Worryingly, many of these patients also faced unemployment rates far above the national average, further exacerbating food insecurity. “By the end of treatment, unemployment among these patients increased from 48% to 68%, worsening their food insecurity,” Mkhondo added.

The survey also showed that 56% of TB patients faced catastrophic costs, spending 20% or more of their annual household income on expenses related to TB. While direct medical costs remain low because treatment services are free in the country, indirect and non-medical costs, including transportation, accommodation, food and nutritional supplements, are significant. Patients spent the most on nutritional supplements, highlighting the inadequate nutritional needs within communities.

Mkhondo stressed that undernutrition and TB form a vicious cycle, with each worsening the other. Malnutrition weakens the immune system, making individuals more susceptible to TB. “When patients have TB, they often lose their appetite or struggle to eat, which further affects their treatment outcomes,” Mkhondo further explained.

Although the country currently has interventions, including nutrition guidelines and policies, Mkhondo points out challenges in implementation. She noted that the gap lies in scaling up these guidelines and nutrition services that are intended to support TB patients and ensuring that they are properly integrated into TB care. She then emphasised the need for strengthened nutrition screening and support in TB programmes so that patients do not continue to fall through the cracks, facing avoidable risks linked to undernutrition and poor treatment outcomes.

Watch the TB Think Tank webinar here: TB Think Tank titled TB and Nutrition in South Africa WHO’s Latest Guidance and Why It Matters Now – YouTube