An estimated 56 000 people died of TB in South Africa in 2023, according to the most recent WHO figures. (Photo: Shutterstock)News & Features
3rd November 2025 | Biénne Huisman
Evidence has been mounting that poor nutrition impacts both someone’s risk of falling ill with TB and how well they do once ill. But as the World Health Organization (WHO) releases new guidelines on TB and nutrition, it is unclear to what extent the South African government is ready to invest in providing people with nutritional support as part of the fight against TB.
That TB and malnutrition often go hand-in-hand is well established, but it is also one of those connections that is often greeted by a shrug. That is something the WHO is hoping to change.
In September, the WHO released new TB guidelines that arguably pushed the issue of TB and nutrition further than any previous such guidance. Among others, the WHO recommends nutritional assessment and counselling for all people with TB, as well as their household contacts, and nutritional support for all people with TB who need it. Critically, however, the WHO now also recommends “provision of food assistance to prevent TB in household contacts of people with TB in food insecure settings”.
In other words, nutritional support is now recommended both for people with TB and some people at risk of TB. The implications of this for health departments intending to follow the guidelines is substantial, since it could massively increase the number of people eligible for nutritional support.
The change in WHO guidelines follows the publication last year of a landmark study on TB and nutrition in the Lancet medical journal. That large clinical trial, called RATIONS (Reducing Activation of Tuberculosis by Improvement of Nutritional Status), found that providing nutritional support to household contacts of people ill with TB reduced the risk of those household contacts also falling ill with TB by around 40%. The researchers estimated that for every 30 households provided with nutritional support, one case of TB was prevented.
While the RATIONS study was conducted in India, its findings has rippled out around the world, including in South Africa. Like India, South Africa is classified by the WHO as a high TB burden country.
“This study has made the provision of nutrition support more compelling in South Africa,” says Dr Fareed Abdullah, Director of the Office of AIDS and TB Research at the South African Medical Research Council. He says: “government is obliged to provide nutritional support especially where poverty and undernutrition are well documented when a TB diagnosis is made”.
Dr Yogan Pillay, Director for HIV and TB Delivery at the Gates Foundation, agrees that the study “provided evidence for the importance of food and its impact on TB outcomes”. He says: “It has long been known that TB is largely a disease of poverty. People with weakened immune systems – including those that are immunocompromised say from HIV or cancer – are highly susceptible to TB infection.” (Pillay has written about the RATION findings here.)
Two big problems
TB is clearly a serious problem in South Africa. According to the most recent WHO figures, an estimated 56 000 people died of TB in South Africa in 2023. The WHO is set to release new numbers in November.
Only around 10% of people who become infected with TB bacteria end up falling ill with TB since in most cases the body can suppress and kill the bug. Factors like malnutrition and uncontrolled HIV infection weaken the body’s defences, making TB illness more likely. Around 270 000 people are estimated to have fallen ill with TB in South Africa in 2023.
Malnutrition has also been flagged as a major health problem in the country. According to the National Food and Nutrition Security Survey, the proportion of children experiencing both acute and chronic undernutrition has slightly increased over the last decade. It is estimated that more than one in four children under the age of five are stunted.
For people exposed to TB, one of two things happens. Either the body mounts an immune response that contains and may eventually kill the bug, or the bacteria gets past the immune system and causes illness.
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Reflecting on what he describes as a food insecurity crisis in South Africa, Pillay points out that just earlier in October, President Cyril Ramaphosa raised the alarm over malnutrition in the country, referencing the importance of the school nutrition programme and the need for supermarkets to promote nutritious food.
“We know that often poor people purchase foods that are affordable and not always nutritious,” says Pillay. “Many can’t afford more nutritious foods unless they have home or community gardens.”
In India, he says the government provides food parcels and cash to TB patients. “This is done in South Africa through the temporary disability grant. However, it is not clear how many TB patients benefit from it,” he says. In South Africa, some TB patients are eligible for a temporary disability grant for short-term financial support. However, it is an administration-heavy process with inconsistent access.
Government welcomes new guidelines
Responding to questions from Spotlight, the top TB official in the National Department of Health, Dr Norbert Ndjeka, expresses support for the new WHO guidelines.
“We welcome these guidelines,” he says. “We have observed that undernutrition is a risk factor for TB and we have conducted an analysis among our MDR-TB (Multidrug-Resistant Tuberculosis) patients that showed that patients with low body mass index (BMI) are more likely to have poor outcomes compared to MDR-TB patients with normal BMI,” Ndjeka says.
Dr Waasila Jassat, project director for the TB Support Unit at Genesis Analytics, which provides technical support for the health department, concurs.
“The National Department of Health recognises the strong link between undernutrition and TB outcomes and fully supports the WHO’s call for integrated nutritional care across the TB care cascade,” she says.
Jassat adds that “efforts are already underway to strengthen nutritional assessment and support for people affected by TB” and that the department’s TB programme hopes “to standardise nutritional screening at all TB service points and to strengthen data collection on nutritional status and interventions”.
But exactly how far government will go in implementing the new WHO guidelines remains an open question. For example, it is not clear whether household contacts of people with TB will routinely be provided with nutritional support, should they need it.
Working across sector silos
Meanwhile, policy makers point out that food support for TB patients imply “upstream interventions” above and beyond the scope of the health system, noting the need for greater collaboration across sectors in addressing the underlying determinants of TB.
Technical Officer for TB at WHO South Africa, Dr Nkateko Mkhondo, says: “As countries – including South Africa – contextualise these guidelines, there is a need to acknowledge the upstream social determinants of undernutrition, such as food insecurity and poverty, which extend beyond the health sector. Addressing these effectively will require a coordinated, multi-sectoral effort involving health, social development, agriculture, and other key sectors.”
Mkhondo comments that while it has been long known that undernutrition increases the risk of developing TB, and that TB, in turn, exacerbates nutritional deficiencies, the two have often been managed separately.
“The new guidelines present an opportunity to bridge this gap by promoting closer alignment between nutrition and TB programmes,” she says.
Such collaboration is in motion, Jassat says. Speaking on behalf of the health department, she stresses that government is “committed to addressing the social and structural determinants of TB including poverty and undernutrition through a coordinated response”.
She says they are collaborating closely with the Department of Social Development “to develop their TB Plan, which includes measures to improve access to social assistance and nutrition support for people with TB and their households”.
Catastrophic costs for TB patients
As it stands, Abdullah points out that people vulnerable to contracting TB often face “catastrophic costs” and usually cannot afford nutritious food.
“Care and treatment of TB is free,” says Abdullah. “However, the first South African National TB Patient Cost Survey reported that between 56% and 64% of patients with TB was faced with catastrophic costs, largely driven by additional expenses on nutritional supplements and food.”
Furthermore, he says unemployment as a result of a TB diagnosis was found to be common, with more than 90% of households affected by TB experiencing extreme poverty. Abdullah explains: “Costs are considered catastrophic if it exceeds more than 20% of the household’s income. It is thus not just the person with TB who is adversely affected by these catastrophic costs but the entire household.”
