WHO’s Nutritional Support Guidelines Challenge South Africa’s TB Battle Plan
CAPE TOWN—The relationship between tuberculosis and malnutrition has been documented for decades, yet it remains one of global health’s most persistent paradoxes. How can we treat a disease effectively when patients lack the basic nutritional building blocks to fight it? This question has taken on renewed urgency following the World Health Organization’s groundbreaking new guidelines that position nutritional support as a cornerstone of TB prevention and treatment.
A Paradigm Shift in TB Management
In what public health experts are calling a watershed moment, the WHO released comprehensive new tuberculosis guidelines in September that fundamentally reshape how we approach nutritional interventions. The guidelines don’t merely suggest—they explicitly recommend nutritional assessment and counseling for all TB patients and their household contacts. More significantly, they call for “provision of food assistance to prevent TB in household contacts of people with TB in food insecure settings.”
Dr. Fareed Abdullah, Director of the Office of AIDS and TB Research at the South African Medical Research Council, describes the shift as “compelling.” Speaking from his decades of experience in South Africa’s TB response, he notes that “government is obliged to provide nutritional support especially where poverty and undernutrition are well documented when a TB diagnosis is made.”
The RATIONS Study: Evidence That Changed Everything
The catalyst for this policy transformation emerged from a landmark clinical trial published in the Lancet medical journal last year. The RATIONS study (Reducing Activation of Tuberculosis by Improvement of Nutritional Status), conducted across multiple sites in India, delivered stunning results: providing nutritional support to household contacts of TB patients reduced their risk of developing active tuberculosis by approximately 40%.
“The RATIONS study provided the hard evidence we’ve been lacking for the importance of food and its impact on TB outcomes,” explains Dr. Yogan Pillay, Director for HIV and TB Delivery at the Gates Foundation. “It has long been known that TB is largely a disease of poverty. People with weakened immune systems—including those immunocompromised from HIV or cancer—are highly susceptible to TB infection.”
The numbers tell a compelling story: researchers estimated that for every 30 households provided with nutritional support, one case of TB was prevented. In a country like South Africa, classified by the WHO as a high TB burden country, the implications are staggering.
The Twin Epidemics: TB and Malnutrition in South Africa
South Africa faces a dual crisis that makes the WHO guidelines particularly relevant. According to the most recent WHO figures, an estimated 56,000 people died of TB in South Africa in 2023, while approximately 270,000 people fell ill with the disease. These numbers represent more than statistics—they reflect a public health emergency unfolding in communities across the nation.
Meanwhile, malnutrition persists as a stubborn companion to tuberculosis. The National Food and Nutrition Security Survey reveals troubling trends: the proportion of children experiencing both acute and chronic undernutrition has slightly increased over the last decade. More than one in four children under five are stunted—a physical manifestation of nutritional deprivation that has lifelong consequences.
Dr. Pillay points to what he describes as a “food insecurity crisis” in South Africa, noting that President Cyril Ramaphosa himself raised the alarm over malnutrition in October. “We know that often poor people purchase foods that are affordable and not always nutritious,” Pillay observes. “Many can’t afford more nutritious foods unless they have home or community gardens.”
The Biological Connection: Why Nutrition Matters
The scientific connection between nutrition and tuberculosis susceptibility is both straightforward and complex. Only around 10% of people infected with TB bacteria develop active disease because, in most cases, the human immune system can suppress and eliminate the pathogen. Malnutrition weakens these defenses at multiple levels.
“When someone is malnourished, their immune system simply doesn’t have the resources to mount an effective defense against TB,” explains a tuberculosis specialist who requested anonymity. “It’s like asking soldiers to fight a battle without weapons, ammunition, or even basic sustenance.”
This biological reality creates a vicious cycle: TB infection increases metabolic demands, leading to weight loss and nutritional depletion, which in turn further compromises immune function. Breaking this cycle requires addressing both the infection and the nutritional status simultaneously.
Government Response: Welcome Words, Implementation Questions
The South African government has responded positively to the WHO guidelines—at least in principle. Dr. Norbert Ndjeka, the top TB official in the National Department of Health, expressed unequivocal support when speaking with Spotlight.
“We welcome these guidelines,” Ndjeka stated. “We have observed that undernutrition is a risk factor for TB and we have conducted an analysis among our MDR-TB patients that showed that patients with low body mass index are more likely to have poor outcomes compared to MDR-TB patients with normal BMI.”
Dr. Waasila Jassat, project director for the TB Support Unit at Genesis Analytics, which provides technical support for the health department, echoed this position. “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 affirmed.
Jassat added 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.”
The Implementation Challenge: From Policy to Practice
Despite these encouraging statements, critical questions about implementation remain unanswered. Will household contacts of TB patients routinely receive nutritional support if needed? What specific nutritional interventions will be provided, and through what delivery mechanisms? How will success be measured?
South Africa already has some mechanisms in place that could be leveraged. Some TB patients qualify for temporary disability grants, providing short-term financial support. However, as Dr. Pillay notes, “it is not clear how many TB patients benefit from it.” The grant application process is administration-heavy, and access remains inconsistent across regions and socioeconomic groups.
Dr. Abdullah highlights the financial burden facing TB patients, pointing to the first South African National TB Patient Cost Survey, which found that “between 56% and 64% of patients with TB was faced with catastrophic costs, largely driven by additional expenses on nutritional supplements and food.”
He elaborates: “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.” With more than 90% of households affected by TB experiencing extreme poverty, the economic dimensions of the disease cannot be separated from its medical treatment.
Breaking Down Silos: The Multi-Sectoral Imperative
Perhaps the most significant challenge—and opportunity—presented by the new WHO guidelines lies in their implicit demand for cross-sector collaboration. Nutritional support for TB patients represents what policy makers term “upstream interventions” that extend far beyond the traditional boundaries of healthcare.
Dr. Nkateko Mkhondo, Technical Officer for TB at WHO South Africa, emphasizes this point: “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 notes that while the connection between undernutrition and TB has long been recognized, the two have typically been managed separately. “The new guidelines present an opportunity to bridge this gap by promoting closer alignment between nutrition and TB programmes,” she says.
According to Jassat, such collaboration is already in motion. 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 points specifically to collaboration 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.”
Looking Ahead: From Guidelines to Impact
The path from international guidelines to tangible improvements in TB outcomes is neither straightforward nor short. It requires not just policy changes but budgetary commitments, implementation capacity, monitoring systems, and—perhaps most challenging—a fundamental shift in how we conceptualize tuberculosis treatment.
As South Africa grapples with these questions, the world is watching. The country’s response to the WHO nutritional guidelines could serve as a model for other high-burden nations facing similar challenges. The stakes are high: successful implementation could prevent thousands of TB cases and deaths annually, while failure would mean continuing to fight a battle with one hand tied behind our backs.
Dr. Abdullah captures the moment’s significance: “This study has made the provision of nutrition support more compelling in South Africa.” The question now is whether this compelling evidence will translate into comprehensive action that reaches the households and communities where TB and malnutrition continue to claim lives.
As the South African government works to contextualize and implement these guidelines, the hope among public health experts is that the historical separation between treating disease and addressing its social determinants will finally give way to a more integrated, effective approach—one that recognizes that medicines alone cannot defeat tuberculosis without the foundation of adequate nutrition.
Source: AllAfrica