Micronutrient Deficiency & Anaemia in Nepal: Iron, Vitamin A, Zinc, Iodine

Micronutrients are the vitamins and minerals the body needs in small amounts, and Nepal has long carried a heavy burden of "hidden hunger" from iron, vitamin A, zinc and iodine deficiencies. The two most authoritative national datasets are the Nepal National Micronutrient Status Survey (NNMSS) 2016, conducted by the Ministry of Health and Population (MoHP) with New ERA, UNICEF, CDC, USAID and the EU, and the Nepal Demographic and Health Survey (NDHS) 2022, which measured anaemia by finger-prick haemoglobin. Together they give the clearest picture of who is deficient and why.

The headline problem is anaemia, a condition of low haemoglobin that most often reflects iron deficiency but can also arise from other micronutrient gaps, infection, inflammation or inherited blood disorders. According to NDHS 2022, about 43% of children aged 6-59 months and 34% of women of reproductive age (15-49 years) were anaemic. These figures place anaemia among Nepal's most widespread nutritional problems, even though rates have fallen over the past two decades.

By contrast, two classic deficiency diseases of the past, xerophthalmia (from vitamin A deficiency) and endemic goitre (from iodine deficiency), have been brought under control through sustained national programmes. This mixed picture, persistent iron and zinc deficiency alongside near-eliminated vitamin A and iodine disorders, is the central story of micronutrient nutrition in Nepal today.

Anaemia is measured in national surveys by testing haemoglobin concentration in the blood. In NDHS 2022, 43% of children aged 6-59 months were anaemic (25% mild, 18% moderate and under 1% severe), and 34% of women aged 15-49 were anaemic (18% mild, 15% moderate, 1% severe). Anaemia in children is defined here as haemoglobin below 11.0 g/dL and in non-pregnant women below 12.0 g/dL, adjusted for altitude.

The long-term trend has been broadly downward but uneven. Anaemia in young children fell from 48% in 2006 to 43% in 2022, though it spiked to 53% in the 2016 NDHS before dropping again. Among women aged 15-49, prevalence rose from 36% in 2006 to 41% in 2016, then declined to 34% by 2022. The earlier NNMSS 2016 (which used a more rigorous venous blood measure) recorded lower anaemia of about 19% in children and 20% in non-pregnant women, and roughly 27% in pregnant women, illustrating how prevalence estimates differ by method and reference.

Anaemia is not spread evenly across the country. NDHS 2022 found the highest burden in the Tarai/Madhesh lowlands, where anaemia among women reached about 45%, compared with roughly 20% in the hills and 23% in the mountains; Madhesh Province recorded over 50% among women. This geographic pattern reflects differences in diet, malaria and parasite exposure, and the higher prevalence of inherited haemoglobin disorders in the southern plains.

Iron deficiency is the single largest contributor to anaemia in Nepal, but it is not the only cause, which is why iron-deficiency anaemia (IDA) is always lower than total anaemia. The NNMSS 2016, which measured serum ferritin and soluble transferrin receptor, found iron deficiency in about 28% of children aged 6-59 months and 14% of non-pregnant women. Iron-deficiency anaemia specifically affected roughly 11% of young children and about 5% of non-pregnant and pregnant women.

The gap between total anaemia and iron-deficiency anaemia is important for programme design. It means that giving iron alone will not eliminate all anaemia, because a substantial share is driven by other factors such as vitamin B12 and folate deficiency, chronic inflammation, malaria, hookworm and soil-transmitted helminth infections, and inherited disorders like thalassaemia and haemoglobin E, which are more common in the Tarai.

Nepal's main response is the maternal iron and folic acid (IFA) supplementation programme, which provides 180 tablets during pregnancy and the postpartum period, alongside deworming. Coverage has improved but remains incomplete; national health data indicate that only around half to two-thirds of pregnant women complete the full 180-day course. Adolescent girls are also targeted through school and community-based weekly iron-folic acid schemes.

Vitamin A deficiency was once a leading cause of childhood blindness and death in Nepal, producing night blindness (difficulty seeing in dim light, known locally as ratauli) and the more severe eye damage of xerophthalmia. Landmark trials in the 1980s and 1990s in Nepal helped prove that high-dose vitamin A supplements sharply reduce child mortality, evidence that shaped global policy.

By the NNMSS 2016, clinical vitamin A deficiency had become uncommon: about 4% of children aged 6-59 months and roughly 3% of non-pregnant women had low serum retinol. Night blindness among children, once widespread, has been nearly eliminated. This transformation is one of Nepal's clearest public-health successes.

The achievement rests on the National Vitamin A Programme, a twice-yearly (biannual) distribution of high-dose vitamin A capsules to children aged 6-59 months, delivered by a large network of Female Community Health Volunteers, usually paired with deworming tablets. The campaigns have sustained coverage above 80% for around 25 years and are credited with saving tens of thousands of young lives since reaching national scale in 2002.

Zinc deficiency is one of Nepal's most prevalent yet least visible micronutrient problems. The NNMSS 2016 found low serum zinc in about 21% of children aged 6-59 months and around 21-24% of non-pregnant women, a level high enough to be classed as a public-health concern. Unlike iodine and vitamin A, zinc has no equivalent national supplementation campaign, so deficiency has remained stubbornly common.

Zinc is essential for growth, immune function and wound healing, and deficiency contributes to stunting, more frequent and severe diarrhoea, and greater susceptibility to infection. This matters in a country where about 25% of children under five were stunted in 2022. The main policy link is the use of zinc supplements alongside oral rehydration solution to treat childhood diarrhoea, rather than routine prevention.

The causes of zinc deficiency overlap heavily with those of iron deficiency: cereal-dominated diets high in phytate (which blocks absorption), limited intake of animal-source foods, and repeated infections. Because plant-based Nepali diets supply both iron and zinc in poorly absorbed forms, dietary diversification and food fortification are seen as key long-term solutions for both minerals.

Nepal historically lay within the "Himalayan goitre belt" and once had one of the world's highest rates of iodine deficiency disorders, including endemic goitre (visible swelling of the thyroid gland in the neck) and, in its most severe form, cretinism with intellectual and physical impairment in children. Iodine deficiency was especially severe in the hills and mountains, where soils and water are iodine-poor.

Universal Salt Iodization (USI), the mandatory iodization of edible salt led with the Salt Trading Corporation, has been the cornerstone of control for around 25 years and has effectively eliminated iodine deficiency as a public-health problem. National surveys report the total goitre rate has fallen to roughly 1% and median urinary iodine levels are now in the adequate range. The two-child-and-spoon ("do bacce") logo on iodized salt is widely recognised across Nepal.

The remaining challenge has, in a sense, reversed: excess iodine intake. The NNMSS 2016 found that a large share of the population, and children in particular, were consuming iodine above recommended levels, with median urinary iodine in school-age children well into the excessive range. This has prompted review of salt iodine content to keep intake within a healthy band rather than swinging from deficiency to overload.

Micronutrient deficiencies in Nepal stem from a mix of dietary, biological and infectious factors. Diets are dominated by rice, maize and other cereals with limited animal-source foods, fruits and vegetables, so intakes of bioavailable iron, zinc and vitamin A are low. High phytate content reduces absorption of iron and zinc, while poverty, food insecurity and food taboos during pregnancy further restrict intake among the most vulnerable.

Infection and inflammation add to the burden. Hookworm and other soil-transmitted helminths cause chronic blood and nutrient loss, malaria persists in parts of the Tarai, and repeated diarrhoea and other infections both deplete micronutrients and blunt their absorption. Inherited haemoglobin disorders such as thalassaemia and haemoglobin E, more common in the southern plains, contribute to the higher anaemia seen there.

The groups at greatest risk are young children aged 6-59 months, adolescent girls, and pregnant and non-pregnant women of reproductive age, whose iron needs are high. People in the Tarai/Madhesh lowlands, poorer and less-educated households, and rural communities with limited dietary diversity carry the heaviest burden. Recognising these at-risk groups helps target supplementation, fortification and deworming where they are needed most.