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Nutrition in Nepal
From: Secretary of Health, Nepal
To: Minister of Finance, Nepal

Executive Summary

The prevalence of malnutrition in childhood and pregnancy remains a major public health

problem in the world, especially among women of reproductive age in the low-income

developing countries. In Nepal, there is 36% of children under age of five being stunned and

27% of children under age of five being underweight.1 Malnutrition can occur due to insufficient

nutrient intake, malabsorption, impaired metabolism, loss of nutrients due to diarrhea, or

increased nutritional needs. Malnutrition is associated with many disorders and circumstances,

including poverty and social deprivation. The risk is also increased at certain periods of life (i.e.,

during infancy, early childhood, adolescence, pregnancy, breastfeeding, and in old age).

Nature and Magnitude of the Problem

The prevalence of malnutrition in South Asia, especially Nepal is among the highest in the

world. Despite the fact, that Nepal has done impressive work in reducing the prevalence of

malnutrition of 21% from 2011 to 20162, the rates of stunning children still represent a major

public health issue. However, those numbers vary by region with 55% in region 6 and 29 % in

region 4. The prevalence of poor nutrition, especially among women of reproductive age in

Nepal has definitely contributed to higher rates of underweight and stunned children. The high

prevalence of dietary supplements in pregnancy, even during one trimester, can improve the

nutritional status of a pregnant woman’s iron showed in a controlled intervention study in

pregnant women from the Nepal area that folic acid alone has no effect on the development of

iron deficiency or anemia in pregnant women3. The best effect in terms of increasing hemoglobin
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levels and reducing anemia by as much as 54% showed a combination of folic acid and iron,

while the combination of folic, zinc and iron led to a 48% reduction and the combination of folic,

zinc, iron and 11 other micronutrients 36% reduction of anemia. The results clearly show that

taking supplements with a combination of more vitamins and minerals does not lead to the best

effect on iron status, and the question of the justification of taking such supplements arises,

especially if it is shown that dietary intervention in pregnant women also improves iron status. is

not drastically higher as in the case of taking dietary supplements, gives continuously better

results and 6 months postpartum4. From all of the above, it is concluded that targeted dietary

supplementation and nutritional intervention could ultimately prove to be more effective in

improving iron status in pregnant women which can later be beneficiary for children’s health.

Affected Populations

Research shows that a woman’s socioeconomic and life characteristics are related to the quality

of nutrition in pregnancy. Thus, they showed that younger women, with lower levels of

education, low income, from rural areas, with more children and higher pre-pregnancy BMI have

poorer quality of nutrition in pregnancy5. The environment affects food availability, which is

reflected in seasonal differences in fruit and vegetable intake. Urban areas are not so exposed to

seasonal variations because groceries are available throughout the year, while in rural areas they

rely heavily on currently available groceries in their daily diet. Infants are not able to keep their

healthy weight because of the lack of knowledge in healthy feeding which contributes to high

prevalence of malnutrition among infants and young children6. Great number of women, 17%

between age of 15 and 49 are underweight themselves, with BMI < 18.5 and one third of them

are teenage girls between 15 and 19 years old6. The reasons for the malnutrition of children are

numerous and that the cause is mostly human, so they can therefore be avoided, and range from
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inefficient economic structures, unequal allocation of resources and / or their unsustainable use,

poor management, excessive reliance on one culture and the practice of planting monoculture,

discrimination against women and children to poor health of the population due to scarce health

systems and shortages education, especially mothers.

Risk Factors

Risk factors are numerous and include economic and social status, level of knowledge of parents

and their degree of nutrition, body weight at birth, breastfeeding, etc. Children of lower

socioeconomic status are more often exposed to extremes in terms of nutritional status (both

obesity and malnutrition) and overall health. In Nepal, only around 26.88% of the population

lives above the poverty line7. If looking at the maternal education, only 26.9% mothers were

illiterate and 31.2%, 37.1%, and 4,8% of mothers have had primary, secondary, and higher

education. Adolescents are especially exposed during times of intense growth of both sexes. In

girls, it occurs before menarche but continues until the age of 16-17. In boys, intensive growth

begins 2 years later than in girls, and there is an additional need for iron associated with an

increase in hemoglobin at puberty. Infants at the time of birth have sufficient iron stores for 4 - 6

months, which is in line with the fact that infants born at full term do not need iron. The needs of

infants are extremely high (mostly during the life span) and continuous exclusive breastfeeding

leads to the development of anemia within the 1st year of life. The estimated prevalence of

anemia in women of reproductive age is 43% in developing countries, indicating that many

women anemic already at the time of conception8.

Social and Economic Consequences

In addition to the clinical consequences, malnutrition associated with the disease carries with its

significant health care costs. It is stated that the average hospital costs for malnourished patients
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are more than double the costs for those who are not, and the total cost of malnutrition for the

health system is measured in billions of dollars per year9. A special risk for infants is irreversible

reduction of motor functions and mental development, which later in childhood leads to reduced

cognitive and / or behavioral functions, although conclusive evidence for these consequences has

not yet been categorically presented, nor can taking dietary supplements and / or iron therapy

improve outcomes mental system development.

Priority Action Steps

Education programs and the improvement of micronutrient supplementation are needed in order

to improve the malnutrition issue in Nepal. Malnutrition is a major factor after high levels of

morbidity and mortality in children as well represents an obstacle to the full development of the

cognitive and physical level of surviving children. Nutrition Action Plan should focus on

interventions and policies related to women and children, i.e. on good nutrition of pregnant

women until the second year of their child and by prioritizing women, children, girls at puberty,

especially in poor rural areas and among the most vulnerable groups. The importance of

breastfeeding infants should be emphasized as part of special dietary interventions. Action plan

in education is also crucial in order to improve malnutrition of population in Nepal.

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References

1. https://www.usaid.gov/global-health/health-areas/nutrition/countries/nepal-nutrition-
profile

2. MOH et al. 2017; Family Health Division et al. 2002

3. Christian, P., Shrestha, J., LeClerq, S. C., Khatry, S. K., Jiang, T., Wagner, T., Katz, J., West,
K. P. Jr. (2003) Supplementation with micronutrients in addition to iron and folic acid does
not further improve the hematologic status of pregnant women in rural Nepal. J. Nutr. 133,
3492-3498.

4. Black, M. M., Quigg, A. M., Hurley, K. M., Reese Pepper, M. (2011) Iron deficiency and
iron-deficiency anemia in the first two years of life: strategies to prevent loss of
developmental potential. Nutr. Rev. 69(Suppl 1), S64-S70.

5. Rifas-Shiman, S. L., Rich-Edwards, J. W., Kleinman, K. P., Oken, E., Gillman, M. W. (2009)
Dietary Quality during Pregnancy Varies by Maternal Characteristics in Project Viva: A US
Cohort. J. Am. Diet. Assoc. 109(6), 1004-1011.

6. https://www.usaid.gov/sites/default/files/documents/1864/Nepal-Nutrition-Profile-
Mar2018-508.pdf

7. Niraula, Surya & Barnwal, SP & Paudel, Shristey & Mishra, S & Dahal, S & Das, S &
Pradhan, S & Ghimire, Subash & Khanal, Sandesh & Sharma, Shubhangi & Rajput, Shahid
& Bhattarai, Sailesh & Jha, Nemika. (2013). Prevalence and associated risk factors with
malnutrition among under-five Nepalese children of Borbote village, Ilam. Health
Renaissance. 11. 10.3126/hren.v11i2.8217.

8. WHO, World Health Organization, United Nations Children's Fund and United Nations
University (2001) Iron Deficiency Anaemia: Assessment, Prevention, and Control – A guide
for programme managers. WHO/NHD/01.3, 2001. WHO, Geneva

9. Elia M, Stratton R, Russell C, Green C, Pang F. (2005) The cost of disease related
malnutrition in the UK and economic considerations for the use of oral nutritional
supplements (ONS) in adults. BAPEN.