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.
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