India has made significant progress in improving nutrition security over the past decades, overcoming the hurdle of addressing the calorie gap. However, micronutrient deficiencies (MND), commonly referred to as hidden hunger, persist across populations and geographic regions. Addressing micronutrient deficiency (MND) is critical to achieving SDG 2 (zero hunger) and SDG 3 (good health and well-being), and remains a priority under Nutrition 2.0 and the National Nutrition Strategy.
A large proportion of women and adolescent girls have limited awareness about MND and their health impacts. These deficiencies often go undetected due to non-specific symptoms such as fatigue, decreased work capacity, disturbed sleep patterns. It is essential to strengthen regular screening through point-of-care testing and anemia screening under Ayushman Bharat health and wellness centers for early detection and management.
Anemia is one of the most prevalent micronutrient deficiencies in India. According to NFHS-5, more than half (57%) of women of reproductive age (15-49 years) suffer from anemia, indicating a significant public health concern. Anemia during pregnancy is associated with an increased risk of adverse maternal and neonatal outcomes, including complications during delivery. This contributes to increased risk of maternal morbidity and higher risk of postpartum hemorrhage. Maternal anemia also increases the risk of poor health and nutritional outcomes of the newborn, including early childhood anemia. According to NFHS-5 data, 68% of children aged six-59 months suffer from anemia. This results in low birth weight of the newborn and impaired cognitive development. These outcomes contribute to the continuation of intergenerational cycles of malnutrition.
Breaking this inter-generational cycle of malnutrition requires sustained, large-scale and targeted public health interventions. This requires a life-cycle approach to address the broader challenge of anemia and micronutrient deficiencies in children, adolescent girls, women of reproductive age, and pregnant and lactating women. It has been implemented through Anemia Mukt Bharat, a government initiative launched under the National Health Mission to reduce anemia across India with a 6*6*6 strategy (6 beneficiaries, 6 interventions, 6 institutional mechanisms).
The burden of hidden hunger extends beyond mere iron. Gender norms and deeply entrenched domestic hierarchies have made it normal for women to be the last to eat and the least to eat. From childhood to adolescence and pregnancy, their bodies systematically undergo small changes that make them more vulnerable to hidden hunger, not only biologically but also socially. Therefore, meaningful improvements in nutrition outcomes require women-centric strategies that go beyond supplementation. These strategies actively improve dietary diversity, increase awareness of the full spectrum of micronutrient needs, and incorporate a gender perspective into national nutrition policies and planning.
Micronutrient deficiencies extend beyond iron to calcium, folate, iodine, vitamin B12 which are important for women’s health, pregnancy outcomes, child development. A published study, Micronutrient interventions among vulnerable populations over a decade: A systematic review on the Indian perspective (2022)Shows that women and girls under the reproductive age group (15-49 years) across India have inadequate levels of essential nutrients, including calcium, folate, iodine and vitamin B12, which are important for healthy growth, pregnancy and long-term well-being. This is consistent with global findings from a dietary analysis spanning 185 countries: women are more likely than men to have inadequate intakes of iodine, vitamin B12 and iron, underscoring women’s persistent nutritional vulnerability across the lifespan.
In many households, women and girls often have comparatively less access to diverse and nutrient-rich foods due to intra-household food distribution practices, limited decision-making power, increased unpaid care responsibilities, and limited access to health and nutrition services. Adolescent girls, newly married women, pregnant women and lactating mothers are particularly vulnerable due to increased nutritional requirements during these stages.
Therefore, addressing micronutrient deficiencies requires interventions that are not only nutrition-specific but also gender-responsive. Nutrition programs should recognize the distinct nutritional needs of women and girls and address barriers related to access, agency and utilization of services. This includes strengthening women’s access to counselling, antenatal care services, micronutrient supplementation and making informed decisions related to diet and health.
Gender-transformative approaches are important because they address underlying social norms and household power dynamics that influence women’s nutrition, access to services, dietary practices, and health decision-making. Such approaches move beyond recognizing gender differences and seek to improve women’s participation in household food decisions, promote shared responsibility for care and nutrition within families, and engage men and community stakeholders in support of maternal and adolescent nutrition.
These approaches align with globally recognized frameworks such as the gender integration continuum and social norms-based behavior change models, which emphasize moving from gender-sensitive to gender-transformative programming. Within nutrition programs, this may include engaging husbands and mothers-in-law through counseling platforms, integrating gender-responsive counseling within antenatal care services, strengthening women’s participation in community-based groups, and promoting equitable inter-household food allocation practices.
Integrating gender-transformative approaches within reproductive, maternal, and adolescent health programs by addressing harmful gender norms, strengthening community engagement, and promoting shared responsibility for health outcomes. The ‘men as partners’ approach has highlighted the importance of involving men as supportive partners in maternal and reproductive health, including improving care-giving behaviour, supporting maternal nutrition practices and strengthening women’s participation in health decision-making.
There is therefore a need for convergence between nutrition, maternal health, gender, education and social protection interventions to improve nutrition outcomes among women and girls. It will be important to incorporate gender considerations within program planning, implementation, monitoring and behavior change strategies to ensure equitable nutrition outcomes.
While evidence-based interventions are well established, the main challenge lies in strengthening implementation, raising awareness and ensuring sustained multi-sector convergence across government, private sector and communities. Improving dietary practices remains fundamental, as sustainable nutritional outcomes depend on a balanced and varied diet. Food fortification, supported by FSSAI, provides a cost-effective population-level supplement to this goal. Fortified staples can help bridge micronutrient deficiencies; However, it is a complement to a balanced and varied diet, not a substitute for it.
India’s Anemia Free India program distributes free iron and folic acid supplements to adolescent girls, pregnant women, lactating mothers and women of reproductive age (non-pregnant, non-lactating). It is also strengthening service delivery as well as counselling, community engagement and behavior change communication that will be important to improve adherence to regular consumption of these nutritional supplements.
Demand-side barriers, including low awareness and risk perceptions, and misconceptions of MND and anemia require structured communication strategies delivered by frontline health workers, community champions, schools and community platforms. IFA supplementation or a fortified staple that is not consumed is a missed opportunity. FLWs are the cornerstone in last mile delivery and consulting. Access to nutritious food must be coupled with sustained demand generation from the community, reducing hidden hunger requires long-term, gender-responsive action, not just supply.
With a sustained focus on evidence-based interventions, stronger implementation, and better multi-sector convergence, India can accelerate progress in reducing micronutrient deficiencies among women and children. A shift from gender-blindness to gender-sensitive, gender-responsive and ultimately gender transformative is essential to ensure better maternal nutrition outcomes and better newborn health.
(Views expressed are personal)
This article is written by Dr. Ajay Kheda, Country Representative, Engender Health, India.
