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For decades, tuberculosis control strategies have emphasised prompt diagnosis, effective antibiotic regimens and adherence support. But increasingly, health experts have recognised that drugs alone are not enough. Malnutrition weakens immunity, slows recovery, increases relapse risk, and fuels transmission in vulnerable communities. Against this backdrop, a recent breakthrough from researchers in India has catalysed a paradigm shift in global tuberculosis (TB) policy. In October 2025, the World Health Organization (WHO) published its latest consolidated guidelines on tuberculosis and undernutrition, introducing for the first time a recommendation for food assistance to household contacts of people with TB in food-insecure settings. This addition reflects robust evidence from the (Reducing Activation of Tuberculosis by Improvement of Nutritional Status) trial, a multicentre field study led by a doctor couple based in Mangaluru, which demonstrated that nutritional support can drastically reduce TB activation among close contacts. Earlier guidelines had separately recommended nutritional counselling and supplementation, but stopping short of formal food aid in contact tracing. With this , WHO is acknowledging the deep interplay between disease and poverty, and signalling that ending TB requires tackling social and nutritional vulnerabilities alongside medical treatment. The new guidance invites national TB programs to rethink their approach: from patient-centric to household-centric, integrating nutrition, social protection and clinical care in unison. The WHO's New Position On TB And Nutrition The updated WHO guidelines emphasize several strengthened elements in the intersection of TB care and undernutrition:

• Universal nutrition screening and counselling for all people diagnosed with TB and their household contacts.
• Nutritional interventions (supplementation, food support) for TB patients with undernutrition, regardless of age or drug-resistance status.
• Food assistance to household contacts in food-insecure settings, which is a bold new addition aimed at TB prevention in exposed individuals.

The WHO's rationale behind these changes is based on the fact that undernutrition is not just a co-factor, but a major driver of TB disease, compromising immunity and exacerbating transmission cycles. To implement these recommendations, WHO is also preparing an operational handbook to help countries translate policy into practice. The Indian Study That Turned Heads At the heart of this policy update is the RATIONS trial, published in , which tested whether supplying monthly food baskets and micronutrient supplementation to household contacts could reduce TB activation. The study was driven by a research team including doctors from Mangaluru, Dr Anurag Bhargava and Dr Madhavi Bhargava, in collaboration with national and international partners. Key findings from the trial included:

• A 48% reduction in new pulmonary TB cases among household contacts who received nutritional support.
• Among TB patients themselves, improved survival and treatment outcomes were associated with better nutritional status.
• The food basket scheme in the trial provided staples (rice, lentils) and multivitamins, a modest but consistent intervention.

Because the trial was field-based, conducted across multiple districts and in real-world conditions, its findings resonated powerfully with guideline developers. The evidence was strong enough to push WHO to incorporate a novel recommendation on food aid in contact management, a step that few global pharmacological-oriented guidelines had previously taken. Challenges And Implementation Considerations While the new guidelines are ambitious, translating them into action will not be seamless:

• Resource constraints and coordination: TB programs may lack the budget or mechanisms to provide food assistance. Integrating food aid demands collaboration with nutrition, social welfare, and food security departments at national and subnational levels.
• Targeting and ensuring equity: Identifying which contacts live in food-insecure settings, and thus are eligible, will require granular data and surveillance. Mis-targeting risks waste or exclusion of needy households.
• Sustainability and reliance: Reliance on food assistance could create expectations and dependency; programs must link with existing social protection schemes. WHO's operational handbook aims to help with such integration.
• Measuring impact and accountability: New monitoring indicators will be needed (e.g. uptake of food support, nutritional status changes, contact TB incidence) to evaluate the policy's success.

Implications For India And High-Burden Countries For India, which carries among the highest TB burdens globally, these changes are particularly pertinent. The Indian government already runs the Nikshay Poshan Yojana, which provides cash assistance to TB patients to aid nutrition (recently increased to INR 1,000 monthly). This domestic scheme could form the foundation upon which more formal food assistance to contacts is layered. Incorporating nutrition into TB care may also help India meet goals under its National TB Elimination Program (NTEP), which aims to eliminate TB by 2025 (now extended). Similarly, other high-burden nations in Africa, Southeast Asia and Latin America may benefit from adopting household-level interventions, especially in settings of chronic food insecurity. At a broader level, the shift signals that tackling social determinants like poverty, hunger, malnutrition must be seen as integral, not ancillary, to disease control. It also underlines how high-quality, local research (even from regional institutions) can reshape global policy when rigorously designed and applied. The WHO's new consolidated guidelines on TB and undernutrition mark a significant inflection point in the global fight against TB. For high-burden countries like India, this development offers both opportunity and challenge. Leveraging existing nutrition and social welfare platforms, bolstering interdepartmental coordination, and ensuring equitable implementation will be essential. If executed well, this integrated model holds promise not just for reducing TB incidence and improving outcomes - but for advancing health equity in populations long marginalized by poverty and hunger.