Women empowerment is central to addressing the double burden of malnutrition.

Women play a critical role in ensuring that their nutritional needs and those of their children and families are met. Women are also an integral part of delivering nutrition-sensitive interventions, and optimizing food systems to address the double burden of malnutrition characterized by the co-existence of nutritional deficiencies, underweight, and overweight and obesity in low and middle-income countries (LMICs). In this commentary, we highlight how women empowerment affects nutrition with a focus on nutrition-sensitive interventions, and identify research and implementation gaps that warrant greater attention.

Overweight and related non-communicable diseases are increasingly prevalent in all regions of the world, coupled with the unfinished agenda of undernutrition, particularly prevalent in sub-Saharan Africa and south Asia. Underweight, overweight and obesity affect 10 and 40% of women respectively, and micronutrient deficiencies, such as anemia, affect 500 million women globally [1]. Women are vulnerable to nutritional deficiencies given increased requirements for essential nutrients during pregnancy and lactation and to compensate for losses due to menstruation. In spite of their nutritional vulnerability, women's needs are not adequately supported. Investments made in women's nutrition often focus on improving birth and child nutrition outcomes. This needs to change if women and their families’ nutritional status is to improve globally. Double-duty actions to address the double burden of malnutrition are needed, including advancing women empowerment and nutrition-sensitive interventions [2].

Women empowerment addresses gender inequities in access and use of resources which limit women's ability to maximize their potential. Empowerment of women is important for enhancing infant and young child feeding, and maternal and household caloric availability and dietary diversity in LMICs [3,4]. Its importance is further illustrated in smallholder farming, the most prevalent form of farming, especially in low-income settings in Africa and Asia. Women provide close to 50% or higher of the agricultural labor in smallholder farms in these communities, and in many cases this is unpaid [5]. However, women farmers face significant challenges in meeting their aspirations to optimally provide for themselves and their families. They own 5–30% of the agricultural land in LMICs, in smaller landholdings compared to larger shares for men [5]. In Bangladesh, Ghana and Nigeria, male-led households own three times as much livestock as female-headed households and globally only 5% of agriculture extension services are directed at women [5]. Limited access to such resources decreases women's agricultural productivity, income, and ultimately their ability to access nutritious and diverse diets.

Women farmers need empowerment through increased control of production resources including land, improved seeds, technology for planting and harvesting, credit, training and extension services. For example, women's decision-making on credit has been associated with their dietary diversity [3]. Proceeds from farming give women income for purchasing food and other household necessities. However, increasing women's productivity and income alone is insufficient to improve women's nutritional status. Additional actions are required to ensure that women have decision-making power over productive assets and the use of income from agriculture and off-farm employment in order to act on their nutrition knowledge.

It is worth considering unintended consequences of well-intentioned efforts to improve agricultural productivity among women. Agricultural interventions may increase the work burden for women leading to energy deficits with deleterious effects for women's nutrition [6]. They can also affect women's time use, leaving insufficient time for childcare or rest. Another lost opportunity for women occurs when control of income shifts away to men as women enterprises become profitable [6]. Key actions in this area would be for empowerment programs to document, mitigate against, and refine interventions to prevent these negative effects for women.

Achieving the desired shift in women's empowerment will require changing socio-cultural norms in LMICs and reconsidering the role of men as part of the solution. Men are part of the social fabric that dictates a woman's environment; involving them is critical to changing these norms. Roles that men can play include taking on childcare and household responsibilities. Village and community leaders in many LMICs, in many cases men, can change social norms restricting women's access to resources including land, inputs and technology that allow for higher yields. Strategies to ensure effective male engagement are urgently needed to reduce gender inequity and enable women to exercise their roles as integral members of households and communities.

Examples of integrated interventions to improve women empowerment include studies in Burkina Faso and Tanzania where nutrition and gender-sensitive agriculture interventions provided seeds that promoted vegetable production, promoted chicken rearing and higher access to eggs, behavior change communication and land-use agreements for women [7,8]. However, gaps remain in knowledge of which dimensions or combinations of approaches for women empowerment are most effective. A recent review of the evidence did not find associations between women's empowerment and child nutrition and attributed this to poor study designs [9]. Therefore, the development and testing of women empowerment interventions should be pursued using rigorous study designs across varying contexts.

Finally, gaps persist in the tools for measurement of women empowerment. Instruments including the Women's Empowerment in Agriculture Index (WEAI) have been published [3]; nevertheless, the application of existing tools remains limited. Empowerment is multi-dimensional, situational and context-specific, thus its measurement is complex. To be measurable, women empowerment needs clear definitions, and the validity and reproducibility of components across contexts needs to be established. The development of short instruments for administration in existing demographic surveillance systems [10], or national surveys such as MICS and DHS would allow for longitudinal tracking of women empowerment in LMICs. This would also allow for evaluation of the effectiveness of programs that aim to advance gender equity. The pursuit of greater empowerment of women is imperative for them to contribute to advancing universal health within their families and achieving the sustainable development goals.

Declaration of Competing Interest

The authors declare that they have no competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.