Niazi Journal of Medical & Dental SciencesXXXX-XXXX2024-12-311354510.58398/0007.000005articleMohammed Khudhair HasanKhadija TariqDepartment of Pharmacy, Ibn Khaldoon Private University College, IraqHussain College of Health Sciences, Lahore, PakistanPhD (Scholar) HND, University of Management and Technology, PakistanTuberculosis (TB) and malnutrition are closely intertwined, yet local data on the nutritional status of TB patients and the factors that shape it remain limited in Pakistan. This cross-sectional study determined the nutritional status of adult TB patients attending public- and private-sector hospitals in Lahore and identified its sociodemographic and health-system determinants while also describing treatment-related and facility-related barriers and their relationships with treatment adherence. A total of 379 adult patients receiving anti-TB treatment were assessed using the 18-item Mini Nutritional Assessment (MNA), and treatment, facility, and patient experiences were recorded through a structured proforma. Nutritional status was classified using standard MNA cut-offs, and determinants of malnutrition and self-reported nonadherence (≥ 2 missed doses in two weeks) were examined using the chi-square test and multivariable logistic regression. The mean MNA score was 15.2 ± 6.1, and malnutrition was highly prevalent: 183 patients (48.3%) were malnourished, and 154 (40.6%) were at risk, leaving only 42 (11.1%) with a normal nutritional status. Female sex (adjusted odds ratio [aOR] 1.59, 95% confidence interval [CI] 1.04–2.44; p = 0.032) and rural residence (aOR 1.74, 95% CI 1.11–2.72; p = 0.015) were independently associated with malnutrition, and a higher patient-barrier score showed a borderline association (aOR 1.25, 95% CI 1.00–1.56; p = 0.048), whereas age and treatment or facility burden were not; household income was associated with malnutrition bivariately but not after adjustment. Self-reported nonadherence, reported by 293 patients (77.3%), was associated with a higher facility-barrier burden (aOR 1.59, 95% CI 1.08–2.34; p = 0.020) but not with nutritional status. The study concluded that malnutrition or its risk affects the overwhelming majority of TB patients in this setting, with women and rural patients at greatest risk, while facility-level barriers—rather than nutritional status—track with missed doses. Nutrition-sensitive TB care that prioritizes women and rural patients, coupled with health-system measures to ease facility barriers, is warranted.