Early, targeted nutrition can fight double burden of malnutrition among South Asian women, UNICEF finds

New UNICEF-led reviews highlight wide gaps in preconception nutrition across South Asia, urging tailored, early interventions to tackle malnutrition and improve maternal-child health outcomes, regardless of whether the adolescent or adult wishes to get pregnant.

“Undernutrition among reproductive-age women, low birth weight, small for gestational age, and preterm birth present significant health burdens in South Asia, which interventions in pregnancy alone have not resolved. Effectiveness of preconception nutrition interventions is not well-documented,” reads a review published in The Lancet Regional Health. 

Another article highlights the growing double burden of malnutrition that South Asian women face, where the prevalence of overweight now exceeds underweight. Fifty percent of women and girls of reproductive age (WRA) in the region are anemic, which is more than any region globally.

“Most WRA have at least one form of malnutrition. Regional estimates state that over one in five WRA are underweight (body mass index or BMI  <18.5 kg/m2), which is the highest proportion globally, while rates of overweight have increased, ranging from an estimated 20–52%,” reads the paper.

About 75% of non-pregnant South Asian women and girls lack iron, zinc, or folate, with limited data on other deficiencies. Deficiencies in micronutrients like iron, folate, vitamin B12, and A, are key causes of anemia, in addition to non-nutritional factors such as infections, inflammation, and hemoglobinopathies.

Micronutrient and food supplement interventions 

A separate study suggests that preconception interventions in South Asia combining micronutrient and food supplements may reduce low birth weight, improve newborn size, and bring additional benefits. These interventions were also paired with and without health screening, psychosocial counseling, and water, sanitation, and hygiene (WASH) interventions.

Trials in South Asia have used micronutrient supplementation such as vitamin A/beta carotene, multivitamins, iron, and vitamin B12 along with foods like lipid-based nutrient supplements, a locally manufactured snack containing green leafy vegetables, milk, and/or dried fruit. 

The study notes that preconception micronutrient supplements alone were not successful in improving micronutrient levels in pregnancy and cord blood and did not significantly alter birth size or preterm birth.

However, people taking preconception food supplementation with or without multiple micronutrients and other interventions resulted in improvements in birth size, especially when starting 90 days before conception.

Additionally, the researchers found a 24% reduction in low birthweight when health, nutrition, psychosocial care, and WASH interventions were provided during preconception and pregnancy. Over half of this reduction is thanks to preconception interventions.

Over half of South Asian women of reproductive age face at least one form of malnutrition.The researchers highlight that their study underscores the importance of overlooked preconception interventions as much as during pregnancy.

Role of BMI and epigenetics 

The research adds to growing evidence that mothers taking food supplementation and having higher BMIs had a better impact on newborn size.

“Nutrient metabolism, fetal supply line development, transplacental transportation of nutrients, and fetal growth require energy and other substrates. These may be inadequate in underweight mothers, who may need extra macronutrients to effectively utilize the nutrients provided by supplements or to ensure nutrient partitioning to the fetus,” details the paper.

“Epigenetics studies suggest that preconception supplements may have anti-inflammatory and antioxidant properties that improve the maternal metabolic profile and change fetal DNA methylation, leading to better placental development, enhanced fetal organogenesis, increased birth size, and improved long-term health.”

However, research on preconception interventions in South Asia is limited, with gaps in evidence despite promising findings, researchers flag.

Evidence backing guidelines

The review looked at trials involving ∼35,000 preconception women, ∼11,500 pregnancies, and ∼12,000 birth outcomes, taking five food supplements and a complex intervention. However, the sample sizes of the two micronutrient supplementation trials were each less than 300.

Preconception food and micronutrient interventions can reduce low birthweight by 24%.The researchers believe that there is enough evidence backing the WHO and UNICEF guidance on preconception education on healthy diets, iron folic acid, anemia treatment, and supplementing undernourished women and girls. 

However, they found no evidence of food fortification, promotion of exercise, or screening and management of diabetes, which are included in the recommendations.

Call for targeted interventions

A separate study suggests that nutritional interventions need to start before women are married and when they are adolescents, regardless of whether they intend to get pregnant. It must be “tailored, contextualized, and life-stage specific” and perhaps alleviate poverty to widen accessibility. 

“Interventions may start through school-based education and nutrition support, although interventions need to be tailored for underweight adolescents in highly deprived areas,” suggests the paper. “Establishing healthy habits in adolescence is a key enabler of lifelong healthy behaviors in adulthood, so starting interventions early is crucial.”

Additional interventions need to start during preconception and the paper suggests nutritional status screening with targeted supplementation for those found to be underweight and/or anemic. Dietary and lifestyle advice should be offered to those who are overweight or obese.

The researchers underline that these interventions rely on existing government programs like India’s Integrated Child Development Services and other approaches like Adolescent Health Days.

They also emphasize the importance of integrated social protection strategies, the private sector, women’s self-help groups, and adolescent groups. 

Nutrition programs are most effective when combined with psychosocial care and WASH support.“Until now, there has been insufficient attention to the potential of public-private partnerships and food systems approaches to improve access to nutritious foods, as well as strategies for increasing consumer demand for healthier options,” the paper details. 

“Furthermore, engagement with government systems is critical to ensure the longevity of interventions and ensure supply. Two programs in India, which engaged with government systems, were effective in increasing uptake of services and should be explored further through further research.”

Gender barriers in South Asia 

Previously, Nutrition Insight spoke with UNICEF, which underscored the need for gender-responsive strategies based on the latest research across Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka.

The research identified intergenerational undernourishment, digital gaps, and gender and class disparities worsening nutrition outcomes in South Asia.

We also spoke to researchers from India and Nepal about how women’s groups are proving to be important forces in improving nutrition access by gathering collective strength to overcome economic, social, and institutional barriers.