Nutrition in Nepal
Today’s Dietitian
By Alison J. Rigby, PhD, MPH, RD
Vol. 6 No. 5 p. 42

A study visit to Nepal enabled dietetics students to transition from the classroom to a much broader learning experience. It was an opportunity for university students to learn about the Nepal National Vitamin A Program (NVAP) and excel in many competencies, including cultural awareness and diversity. The trip was organized through a partnership with San Francisco State University and the Sann Research Institute, a study abroad program based in Kathmandu, the capital city of Nepal, with American headquarters in Boulder, Colo.

The Kingdom of Nepal
Nepal is sandwiched between two large neighbors: China (Tibet) in the north and India in the south. It is a country with varied landscapes, temperature, and elevation. The highest peak on the planet, Mt. Everest, and the lowest gorge make Nepal unique compared with other countries. The result is a variety of climatic zones throughout Nepal, making the agricultural produce quite diverse. Irrigated crops include rice, vegetables, wheat, corn, potatoes, lentils, and flowering mustard.

There are many tales in Nepali culture that attempt to explain the country’s history. One ancient myth tells the story of a monk draining the massive lake that covered the Kathmandu Valley with two slashes of his sword, leaving a rich, fertile watershed. There may be some truth in this story, as approximately 10,000 years ago, the lake ruptured along what is now known as the Chobar Gorge, forming the valley that exists today. The earliest Nepali rulers were the Kiratis in the seventh and eighth century BC. Villages and communities were springing up in the Terai region, and Prince Sidartha Gautam led his followers under his religion of Buddhism.

The Golden Age of Nepal developed with the arrival of the Licchavis from India, who brought their own art and culture with the Hindu caste system. It was at this time that Buddhism was replaced by the Hindu religion. In the ninth century, the Licchavis were overpowered by the Thakuris, leading to a 300-year period known as the “dark ages” of the country. Limited advancements were made during the Thakuri rule. The Malla Kings were the next succession of rulers and became the second golden age, during which Jayashithi Malla, one of the country’s important kings, solidified the caste system, unified the Buddhists with the Hindus, and consolidated the four main states that existed in the Kathmandu Valley.

During the 18th century, Nepal was a collection of 46 independent kingdoms with no commonality. Prithvi Narayan Shah, a king of the Ghorka Kingdom, began the slow conquest of the valley and founded the modern nation of Nepal. This was a long process, as his advance met with resistance from the Malla kings in Kathmandu. The Mallas recruited assistance from the British East India Company, with an attempt to fend off the Ghorka warriors, with success in 1768. Internal conflict escalated through the 19th century, culminating in a violent turning point at the Kot massacre, where 55 top officials were murdered in Durbar Square, Kathmandu, as revenge against the Shah dynasty. Jung Bahadur, the initiator of the coup, named himself prime minister and changed his name to the more prestigious Rana. He removed the power from the throne but preserved the monarchy to appease the people. However, not many Nepalese people were content with the Rana family, and the Nepali Congress Party was formed.

The 1980s were the last decade of real power for the kings; elections in 1991 led to a declaration of democracy. Since 1996, Maoist rebels have been fighting against the monarchial democratic system. Their presence is stronger in the northwestern and western parts of the country; however, the atmosphere of political unrest is noticeable in Kathmandu. Strikes are common occurrences and interrupt all daily activities. We actually arrived in Kathmandu after serious rioting and four deaths due to derogatory comments made in an Indian movie. Most stores, schools, and transportation were shut down for the duration of the strike. Sadly, shortly after our return, in 2001, the Crown Prince Dipendra was reported to have shot almost all of the royal family as a result of not being able to marry a beautiful aristocrat during a get-together in Kathmandu. In January 2003, the Nepali government and the Maoists reached a cease-fire agreement in which they agreed to controlled negotiation to solve their differences.

Nepal has an estimated population of 23.7 million (1998) and annual growth rate of 2.7%. It is estimated that the population of Nepal will reach 30 million by 2010. It is among one of the poorest and least developed countries in the world, with more than one-half of its population living below the poverty line (U.S. gross national product $200). Infant mortality is 96 per 1,000 live births, and average life expectancy is 55 years of age for men and 54 years of age for women. It is interesting that despite the very low life expectancy, this is a country where the men slightly outlive the women. The majority of the population is Hindu, with many Buddhists and Muslims. Food habits and rituals surround these different religions from birth to death.

Food and Culture
The typical dinner plate in Nepal is the “Dal-Bhat-Tarakari.” Staying with host families, this soon become our staple diet during the trip. Dal is a colorful soup of black, green, or yellow lentils; Bhat is a large mound of boiled white rice; and Tarakari is a vegetable curry in a rich, spicy broth. On rare occasions, accompaniments are added to the plate: cooked green vegetables, consisting of spinach or broad-leaved mustard greens; and meat curries, which include buffalo, mutton, chicken, or fish prepared with ample quantities of spices and gravy. Cows and therefore beef are sacred and never eaten.

Achar, which is pickled chutney with a rather piquant taste, made with ground tomatoes, sliced radish, boiled and diced potatoes, and coriander, sometimes accompanies the plate of food. This addition is said to “brighten up the mouth.” Other specialty foods served by the Nepali mother, or Ama, include rice pudding, Moma-Cha (dumplings), and fresh coconut. Tea is delicious—ginger tea with clumps of fresh ginger or mint tea with floating fresh mint leaves on top of the hot cup. The famous chai tea is also served, made with boiled milk, spices, and lots of sugar.

Students were taught how to eat with their hands, bringing the fingertips of their right hand together around mounds of food. Trying to be neat only caused more food to be dropped back onto the plates. The Nepali father, or Baba, encouraged them again by showing how to mix the steamed rice with the soupy curry vegetable mixture.

An interesting cultural event was the “rice feeding” ceremony, in which children are fed their first solid food around 6 months of age. The family gathers to celebrate this occasion with many platters of food, signifying that the baby will always have sufficient food to eat. The grandmother or other matriarchal figure conducts the ceremony by feeding the infant a small amount of rice.

A Public Health Problem
Malnutrition continues to be a major public health problem in Nepal. The nutritional deficiencies include protein energy malnutrition, vitamin A deficiency, iodine deficiency disorders, and iron deficiency anemia. A number of successful programs have been implemented in the last 25 years to reduce the severity of micronutrient malnutrition and improve the nutritional status of the Nepalese population.

The purpose of the independent study and learning on the trip was to focus on the NVAP. More than 250 million of the world’s children suffer from vitamin A deficiency. Nepal is one of the countries in which this deficiency constitutes a major public health problem. Each year in Nepal, vitamin A deficiency is responsible for the deaths of some 9,000 children and the permanent blinding of 2,500 children.

The NVAP was set up in 1993 in eight of the 75 districts of Nepal and successfully grew to cover 32 districts by 1997. The main objective of the NVAP is to reduce child mortality and prevent xerophthalmia (eye disease) through supplementation of children with vitamin A capsules. The goal is to reduce vitamin A deficiency to levels low enough that it is no longer considered a public health problem. Another key objective is to increase vitamin A intake by using nutrition education to encourage behavior change. The NVAP has become a model program for other worldwide programs, and it uses Female Community Health Volunteers (FCHVs) in its initiative to organize, train, and motivate community workers and healthcare providers with regard to vitamin A health.

The distribution of high-dose vitamin A capsules to all children aged 6 months to 5 years occurs during twice-yearly campaigns. Children aged 6 to 12 months receive a vitamin A capsule dose of 100,000 international units twice per year, and children aged 1 to 5 receive a vitamin A capsule dose of 200,000 international units twice per year. Severely malnourished children receive one megadose of vitamin A, and mothers receive special attention from the FCHVs. Females following birth up to six weeks postpartum receive a vitamin A capsule dose of 200,000 international units.

The NVAP is implemented through the existing infrastructure of the Primary Health Care Network of the District Health Offices, which includes the rural Health Posts, Village Health Workers, and FCHVs. At the district health level, the nongovernmental organizations and other organizations are involved as facilitators. Ongoing assessment and evaluation takes place that monitors the risk for xerophthalmia among districts and monitors the actual coverage of the NVAP by capsule distribution and nutrition education. In recent years, some 36,000 FCHVs have distributed vitamin A supplementation to 2.9 million children. The capsules have covered 85% of the population, and it is estimated that more than 20,000 child deaths have been averted.

Future vitamin A activities include the promotion of maternal literacy and the strengthening of the prevention and treatment of vitamin A-related diseases, such as prolonged diarrhea, malnutrition, measles, and xerophthalmia. There is potential for the expansion of vitamin A supplementation to older children (aged 5 to 10) and for the program to include the promotion of food production and preservation activities. The success of this Nepalese NVAP is most definitely credited to the FCHVs, who have gained great respect and social status in this system. The supplement program is successful because of the strong infrastructure, a well-organized community support system with common trust, and a reliable delivery mechanism of capsules with mass mobilization. It is a highly cost-effective program, and the NVAP has an important impact on the reduction of both the incidence and severity of diarrheal disease and measles in the country.

Vitamin A Research
With orientation from Dr. Ram Kumar Shrestha, the director of the Nepal Technical Assistance Group for the NVAP, we were able to conduct a small study within the framework of the NVAP during our trek through the Annapurna mountain region of Nepal. We trekked up and down rice fields, gardens full of greens, shelters piled high with freshly picked corn, and metal scaffolding surrounding rooftops covered with drying spices. Our decision was to examine the Nepali diet for the presence of certain fruits, vegetables, and meats, with a specific goal of looking at vitamin A intake. Our research objective was to check the status of the NVAP throughout our trek north to the Himalayas and en route to the base camp of Annapurna 1. We also aimed to summarize the breast-feeding habits of some of the mothers we met and to measure the levels of iodine in salt found in a random selection of Nepali households.

Using our Sherpa as a translator, we found that most families consumed green or orange fruits or vegetables at least two to three times per week, and many families consumed green vegetables daily. Many of the families were aware of the NVAP and its goals. Pills were distributed twice per year, which was in accordance with the vitamin A program. Thirty-five percent of the mothers we met were currently breast-feeding (n = 15) and the average age their children began eating solids was 7.6 months (n = 29). All salt tested contained greater than 30 parts per million of iodine, which is considered to be a suitable level and important with the severity of iodine deficiency disorders and high rates of goiter in Nepal.

We were able to conclude that the overall nutritional status of women and children of the Annapurna mountain district of Nepal was assessed as adequate for our small sample. Granted, this was a fairly well-trekked tourist area of the country, and one would perhaps expect people in this area to have access to a greater volume and variety of food. We did find that the NVAP was having a successful impact on the health of the women and children in this district.

Changing Our Lives
Upon reflection, the trip to Nepal was a huge success, and it changed the lives of the young women who participated in the study trip. The trip had an impact on our appreciation for important values and certainly made us welcome some of the basic necessities of life, including clean water for drinking and bathing. Likewise, we hope that we impacted the lives of the people we came in contact with in Nepal. We have many fond memories of this incredibly poor country; we saw overall genuine contentment, especially among the children, in a country vibrant with color. We will always remember how children of all ages followed us like the Pied Piper of Hamilton, calling for “sweets” as we climbed every step of the way up the tiered Himalayan villages.

— Alison J. Rigby, PhD, MPH, RD, is a researcher at Stanford University and teaches nutrition/dietetics classes. She led this trip to Nepal in winter 2001 while teaching a food and world culture class at San Francisco State University.

Subscribe to Today's Dietitian Magazine!