THE AMERICAN JOURNAl, OF CLiNICAL NUTRITION

Vol. 21, No. 8, August, 1968, PP. 875-881

Printed in U.S.A.

International Nutrition

Health Survey of Nepal

Diet and Nutritional Status of the Nepalese People1’2

MYRTLE L. BROWN, PH.D.,3 ROBERT M. WORTH, M.D.,4

AND NARAYAN K. SHAH, M.D.5

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DURING 1965-1966 a team jointly re- as determined by dietary data and clinical
cruiteti by tile Ministry of Health of examination.

the Kingt!om of Nepal, tile School of Public

DESCRIPTION OF SAMPLE
Health, University of Hawaii, and the
Thomas A. Dooley Foundation conducted According to census data of 1961, tile OI1-

a survey to determine the ilealth status of lation of Nepal is estimated at about 10 million
people. A sampling ratio of about one person
the Nepalese people. Tile purpose of tile
survey was to suppiy base-line data to assist per 1,500 was selected as a reasonable goal. On
the basis that tile average village site corn-
the Ministry in evahuating tile progress of
prises about 270 people, the survey goal was
llealthl work in Nepal anti in planning
set at a total of 24 villages, or roughly 6,480
future programs. With tile exception of a people.
survey of three hligh altitut!e Bhotia vil- A small-square numbered grid was placed
lages (1) ant! reports of the Nepal malaria over a large scale map of Nepal and a random
eradication program, few quantitative data saniple of 24 grid squares was selected by hot;
were available from winch the general the village nearest tile center of each square
state of the puibhic health could be assessed. selected was designated as the sampling site.

The plan of the survey required that the Due to illness of team members anti constant
team spend about 2 weeks in each village transportation difficulties, the survey was ter-
minated after 18 villages and one urban site had
surveyed to gather demographic, nutri-
been visited. In all, 957 households comprising
tional, ant! sanitation data from each
6,321 people were included in the sample. Of
ilousehold, and to attempt to examine
this group, 5,011 or 79% were examined by a
every person in tile village to assess health
physician for clinical symptoms of deficiency
status anti prevalence of dhsease. Tile pres- and other diseases.
ent report is concerned only with the nu- The final cohort comprised a good geo-
tritional status of tile Nepalese population grapilic sampling of Nepal and included each
major area: western, central, and eastern moun-
From the School of Public Health, University
taiiis ranging ill altitude from 1,100 to 7,600 ft
of Hawaii, Honolulu, Hawaii.
2 Supported by the Thomas A. Dooley Founda- and tile eastern, midwest, and fan west Tanai,
low areas of 350-575 ft. One urban area, a
tion.
Associate Professor of Public Health. Pro- section of Katmandu, was includeti in the

fessor of Public Health. Assistant Director of sample for comparative purposes (see Fig. 1).
Communicable Diseases and Epidemiology, Minis- The distribution of tile sample according to
try of Health, Government of Nepal. villages is shown in Tablei.

875
876 Brown et al.

The Nepalese population is largely Hindu

of various castes, with a smaller number of
Buddhists and Muslims. The major occupation
is subsistence-type farming; a minority of those
surveyed were wage earners and small shop
keepers. In one village of the far eastern Tarai
and in the urban area, however, wage earners
and shop keepers predominated.

COLLECTION AND ANALYSIS OF DIETARY DATA

Ftc. 1. (0) Lamatar, (1) Pardidhan, (2) Kathauti-
Dietary data were obtained by a team of two
Annapurna, (3) Godar, (4) Debatar, (5) Dulari, (6)
interviewers, one American and one Nepalese.
Jhapa Bazar, (7) Sakkejung, (8) Ramnagar, (9) Kath-
ariea Tola, (10) Piutar, (11) Phulpaw, (12) Brahmin Respondents were asked to recall all food pre-
Dada, (13) Bhawanipur, (14) Kailali, (15) Bajura, pared and eaten by the entire household on the
(16) Dandagau, (17) Talichaur, (18) Inbaha. previous day, and further information was ob-
tamed on usual dietary habits by asking the

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TABLE I housewife to rate broad groups of food accord-
ing to frequency of consumption. These data
Distribution of survey samples
were obtained to compensate in part for the
according to village
inadequacies of a 24-hr recall for a population
in which seasonal variations in available foods
Number Number Percent -
Region and of Popula- of Per- Lx- could markedly affect food intake.
Villages House- tion sons Ex-
holds amined
amined Interviewers also were responsible for filling

out a household environment check list which

Western mountains yielded information on housing, sanitation,
Bhawanipur 50 287 277 97 food storage, presence of domestic animals,
Bajura 59 310 223 which might serve as food source, and on dis-
Dandagau 36 352 311
86 posal of human and animal excreta, which
Talichaur 40 343 296
might lead to oral contamination.
Central mountains
163 74 Dietary data were expressed in pounds and
Lamatar 34 219
Pardidhan 47 251 191 76 were analyzed by an abbreviated method sim-
Piutar 45 298 274 92 iiar to those described by Leichsenring and
Brahmin Dada 47 343 273 80 Wilson (2) and Clark and Cofer (3). Individual
Eastern mountains nutrient values were used for foods such as rice,
Debatar 32 285 223 78 wheat and corn bread, potatoes, peanuts, soy-
Sakkejung 41 329 255 78 beans, corn, ghee, milk, eggs, and curd. Average
Phulpaw 59 352 262 nutrient values were used for broad groups
Eastern Tarai
such as dal, other beans, yellow-orange vege-
Godar 79 466 366
Dulari 39 307 240 78 tables, green leafy vegetables, other vegetables,
J hapa Bazar 69 408 336 82 citrus fruits, other fruits, muscle meats, poultry,
Ramnagar 63 332 119 j fish, and organ meats. Since the diets consisted
Kathariea Tola 45 267 206 77 primarily of rice, dal, corn, and wheat supple-
Midwest Tarai mented by small amounts of milk and occasion-
Kathauti-Anna- 59 345 297 86 ally vegetables, the abbreviated method of cal-
puma culation appears sufficiently accurate to de-
Far west Tarai scribe grossly the minimum nutrient intake per
Kailali 41 328 263
80 capita.
Urban Katmandu
Nutrient values were calculated from the
Inbaha 72 499 356
1 total consumption of foods by the entire village
and divided by the number of persons included
Total 957 6,321 5,011
in the village diet survey. No information was
See Fig. 1 for location of villages. obtained on individual food consumption al-
 Health Survey of Nepal 877

though data were obtained on weaning prac- it would follow that scurvy would be en-
tices and will be reported separately. Errors in demic in Nepal. However, as will be
nutrient intake are likely to be those of under- pointed out later, clinical examination
estimation. We, therefore, refer to those dietary revealed little evidence of frank deficiency
data as minimum per capita nutrient intake, in
symptoms among the population surveyed.
recognition of the rather high probability of
Energy intakes ranged from 1,923 to
underestimation due to seasonal variations in
3,554 kcal with an average of 2,442 kcal
food intake and to the limitations of tile recall
for the population, a figure somewhat
Illetilod.
higiler than that recently reported by the
CLINICAL EXAMINATION Food and Agriculture Organization (FAO)
(6) for the Far East as a whole. Roughly,
The team physician examined 5,01 1 persons,
76% of total energy consumption was from
79% of those for whom dietary data were ob-
carbohydrates, 11% from protein, largely
tained. The number of persons examined per
village is shown in Table i. The examination of vegetable origin, and 13% from fats.
Approximately 81% of energy was sup-

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included general appraisal of health status and
specific examination of skin, eyes, mouth, and plied by cereal grains. Rice was the major
extremities for evidence of malnutrition. De- staple but, in a few villages, corn predomi-
tailed examination for disease of other than nated. Consumption of wheat and other
dietary origin will be considered only briefly grains, however, was negligible. Although
here. no definite regional patterns were apparent,
Hematocrit readings were made on blood energy supply of the higher altitude western
obtained from finger pricks collected into
mountain villages and three villages of the
heparinized microhematocrit tubes; readings
eastern Tarai were similar to intakes of
were taken after centrifuging for 3 mm at ap-
the “hligh calorie” areas described by FAO
proximately 12,000 rpm. Over 4,000 readings
(6). Other villages more nearly fit the pat-
were obtained. Red cells were analyzed for
malaria parasites by a method described pre- tern consistent with other countries of
viously (4). Fecal smears were made on a sub- tile Far East.
sample of 347 children ages 4, 8, and 12, stained Protein intakes ranged from 45 g foi the
a lId concentrated by the merthiola tc-iodine- urban area to 98 g for a high calorie village
formahin (MIF) method (5), and examined for of the eastern Tarai. Rice and other grains
parasite contamination. contributed to 70% of total protein con-
sumption and, in the one village of the far
RESULTS AND DISCUSSION
west Tarai, virtually all protein came from
grains. On tile average, only 1 1% of the
Dietary Intake
protein came from beans or peanuts al-
Average minimum per capita daily nu- though in four villages these foods con-
trient intakes for villages are shown in tributed 20-30% of protein intake. Animal
Table ii. Intakes by food groups are shown protein sources, however, were negligible.
in Table iii. There were fairly wide ex- The interviewers observed that farm fam-
tremes in intakes of most nutrients except ilies generally owned two to three cows or
for ascorbic acid values, which were uni- goats and a few chickens, but milk was the
formly low due to low reported intakes only product from the animals consumed
of both fruits and vegetables. These latter by fairly large numbers of the population.
data confirm our hypothesis that nutrient On the basis of responses to usual dietary
intakes calculated from the 24-hr recall of habits, it appears that milk, curd, anti
this population group are minimum levels. muscle meat (except pork and beef) are
If the reported ascorbic acid values were more frequent sources of animal protein
true estimates of average nutrient intake, than poultry, fish, or eggs. The use of
878 Brown Ct al.

TABLE II

Average minimum per capita daily nutrient intake, 19 sampling sites

Car- Ascor-
1 Tb Rb
Protein, Fat, bohy iron, vitamin Niacin, Add,
Region and Villages Calories mii fIaVin,

Western mountains

Bhawanipum 2,042 54.4 37.7 371 366 9.7 2,615 1.7 0.7 10.6 2
Bajuma 3,248 92.7 39.6 620 414 14.5 371 2.5 0.8 28.3 3
Dandagau 3,283 95.4 38.2 631 469 15.5 869 2.6 0.9 28.4 <1
Talichaur 2,834 77.8 29.7 558 371 15.3 839 2.4 0.7 24.4 13
Central mountains
Lamatar 2,403 58.4 26.6 478 328 11.5 2,496 2.1 0.5 26.0 8
Pardidhan 1,957 50.5 27.5 376 258 9.2 2,380 1.6 0.5 12.1 1
Piutar 2,036 52.3 32.7 382 280 9.6 2,406 1.6 0.5 12.0 3
BmahminDada 2,316 74.2 47.8 401 582 15.0 2,950 2.3 1.0 19.6 6

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Eastern mountains
Debatar 2,116 56.1 40.0 383 660 10.0 10,643 1.6 0.8 13.4 15
Sakkejung 2,162 62.5 41.2 383 467 11.6 826 1.9 0.8 22.3 4
Phulpaw 2,479 75.2 30.6 480 317 15.5 3,648 2.4 0.9 15.3 8
Eastern Tarai
Godar 1,923 46.9 23.2 377 201 9.7 295 1.7 0.4 20.2 1
Dulari 2,109 59.3 36.7 306 247 12.2 925 2.1 0.6 22.5 3
JhapaBazar 2,644 77.6 43.0 480 406 14.4 962 2.4 0.8 26.9 4
Ramnagar 2,908 76.7 44.5 549 365 15.0 700 2.6 0.8 28.6 1
KatharieaTola 3,554 98.0 47.9 679 363 19.6 510 3.3 0.9 37.5 1
Midwest Tarai
Kathauti-Annapumna 2,084 61.0 31.8 388 295 12.2 3,247 2.1 0.6 22.8 7
Far west Tarai
Kailali 2,267 45.9 20.4 470 194 9.8 3 1.8 0.3 25.7 1
Urban Katmandu
Inbaha 2,029 45.4 26.0 389 203 9.1 534 1.6 0.4 20.8 7

Average 2,442 66.3 35.0 463 357 l26 1,957 2.1 0.7 22.0 5

See Fig. 1 for location of villages.

soybeans, an excellent vegetable protein were consumed daily by almost all house-
source, is practically nonexistent in Nepal. holds, vitamin A intakes were very low and
Calcium intakes were uniformly low and only in eight villages are intakes near the
were paralleled by low intakes of ribo- estimated minimum requirements (7). In
flavin, a reflection likely of low consump- one village in which vitamin A level was
tion of milk products anti leafy vegetables. estimated at only 3 IU, rice, wheat, bread,
Altilougll the requirement for calcium anti potatoes comprised the major part of
and significance of low intakes remain the tliet for the entire village. It is appar-
controversial, riboflavin intakes clearly are ent from Table IV that fruits and vege-
marginal for the large majority of the pop- tables are consumed in fairly small quan-
ulation (7) but, like ascorbic acid levels, tities in Nepal although undoubtedly at a
are probably underestimated. Unfortu- level higher than apparent from tile 24-hr
nateiy, tile tlegree of underestimation can- recall.
Dot be determined from our data. Thiamine anti niacin intakes are gen-
\Vitil the exception of one village in erahly adequate to high due largely to
which leafy green or yellow vegetables consumption of whole grain cereals in
 Health Survey of Nepal 879

TABLE III
Average minimum per capita food intake, 19 sampling sites (g/day)

Yellow
Beans and Other Milk
Other e,5ht
Region and Villages Rice Grains and Green Vege- Fruits Ghee
Fats Pouity Prod- Wine
Nuts Vege- tables ucts
tables

%\resterfl mountains
Bhawanipur 472 23 2.5 9.4 213 23.8
Bajura 454 445 42 18 9 3.2 13.2 49.9 132
Dandagau 440 481 51 1.1 9.0 54.5 I 77 8.5
Talichaur 381 350 73 104 132 4.1 9.0 95 8.5
Central mountains
35
Lamatar 518 129 27 18 I .5 8.5 53
Pardidhan 50 45 8 I .0 2.5 13.6 I 23 20
Piutar 55 458 1 .8 6.3 27.2 141 20
78 5 14 0.4

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Brahinin Dada 277 200 13.4 22.7 245 3.4
Eastern mountains
Debatar 95 427 5 91 5 12.3 I .8 345
Sakkejung 413 14 68 14 9.9 8.1 59.0 236 10.2
Phulpaw 36 558 91 50 4.6 2.4 73 I .7
Eastern Tarai
Godar 427 28 45 9 1 .5 11.0 5.4 33 17.0
Dulari 445 91 9 18 0.8 14.1 18.2 41 I .7
J hapa Bazar 486 68 91 6 27 4.8 15.0 63.6 145 25.5
Ramnagar 563 104 86 8.8 16.4 18.2 109
Kathariea Tola 740 41 I 32 2 9.4 17.9 45.4 54 5.1
Midwest Tarai
Kathauti-Annapurna 400 21 103 32 45 1.1 13.0 18.2 73
Far west Tarai
Kailali 599 9 14 0.1 8.8
Urban Katmandu
Inbaha 418 81 9 5 104 0.6 12.3 136 27 62.9

See Fig. 1 for location of villages.

Nepal. Almost all rice consumed is un- among children, the infant mortality was
milietl; the grains are coarsely cracked by estimated by several methods to be about
oun1i11g, but the bran remains largely 150/ 1,000 live births, an astonishingly high
figure (8). Moreover, tue annual death rate
intact.
of children, ages one to four, was estimated
Clinical Examination
at 39/1,000 and about 56% of all deaths
Gross clinical evaluation of undernutri- occurred before the age of five. The high
tion and obesity revealed inconsistent pat- mortality rates suggest that some degree of
terns associatet! with individuals within malnutrition exists among Nepalese chil-
certain villages but they were not char- dren, which, along with the severe fecal
acteristic of an entire village. Similarly, contamination of the village environment,
tue number of clinically obese persons in could lead to a high mortality from gastro-
each village was not inversely correlated intestinal or other infections. The fatal
with the number of persons evaluated as interaction between the simultaneous
undernourished. stresses of malnutrition and infection is well
Although no evidence of severe clinical documented (9, 10). From these data there
protein-calorie malnutrition was noted is reason to believe that both infection
880 Brown et ai.

TABLE IV Clinical signs of riboflavin deficiency

Distribution of hernatocrit levels of (angular lesions, cheilosis, nasolabial sebor-

children, ages 0-9 rhea) were founti in a few adults in a large

number of villages. However, clinical signs
Ilenatocrit, of ascorbic acid deficiency were observed
Number of Subjects Mean
Region Age of ____________________ Hema- in only 13 of the 5,011 persons examined.
Subjects tocrit
20-29 30-39 40-49 50+ These were children or adolescents and
were encountered in all regions. It appears
\\estern 0-4 82 12 79 9 0 35.1
that although the usual diet of Nepaiese
moun- 5-9 131 5 78 17 0 35.4
tains People is low in vitamin A, riboflavin,
Central 0-4 78 4 82 13 1 38.0 and ascorbic acid, seasonal variations in
moun- 5-9 125 2 76 22 0 39.5 food intake undoubtedly supply enough of
tains these vitamins to prevent clinically de-
Eastern 0-4 52 0 83 17 0 38.3
tectable deficiency of public health sig-
moun- 5-9 114 1 60 38 1 40.0
nificance.

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tains
Eastern 0-4 99 8 87 5 0 35.5 Mean hematocrit levels for the various
Tarai 5-9 172 6 78 17 0 36.5 regions are shown in Table iv and, as
would be expected, are higher among
Midwest and 0-4 42 17 81 2 0 32.7
mountain tiwellers than those of the Tarai.
western 5-9 62 3 95 2 0 35.4
Pathologically low hematocrits (below 30%)
Tarai
Urban Kat- 0-4 14 O 71 29 0 a
were encountered in a small number of
mandu 5-9 37 0 70 30 0 34.1 children anti mean hematocrit levels were
within the ranges described as acceptable
Total 1 ,OlO
or high for children according to the

Too
#{176} few data to average. Interdepartmental Committee on Nutri-
tion for National Defense (1 1). These data
and some degree of malnutrition may be tend to coincide with the calculated die-
implicated iii tile high mortality among tary intake of iron. The few low hemato-
young Nepalese children. crit levels observed do not appear to be
As might be expected from dietary data, due to intestinal parasites. Although para-
no cases of beriberi or peilagra were seen sites were found in 72% of all stools exam-
on clinical examination nor was there any med anti 37% contained hookworm, there
evidence of mild deficiency. However, was no apparent correlation between area
clinical evidence of vitamin A deficiency distribution of hookworm or other intesti-
s’as observed. Bitot spots were virtually nal parasite infestation with hematocrit
absent, but xerophtllalmia was occasionally level. Comparison of low hematocrits
encountered in oltier adults in the Tarai. with malarial parasite rates, however, indi-
Corneal scarring was more widely ob- cated a close correlation, except for a few
served, appearing in small numbers at 17 eastern Tarai villages where no malaria was
of the 19 survey sites. The highest mci- found.
dence was seen in the western Tarai where
SUMMARY
vitamin A intakes appeared to be particu-
larhy low. Blindness in 17 children below A dietary survey of 18 villages anti 1
age nine all occurred in areas of low vita- urban site was carrieti out in Nepal using
mm A intake. However, these cases could the 24-hr recall methoti to obtain house-
not be tliagnoseti as specific vitamin A de- hold foot! consumption. Tile diet of the
ficiency anti may hlave been associated with Nepalese people is clearly superior to many
a somewhat elevated incidence of gonor- other areas of the Far East but is gen-
rhea, also encountered in the same villages. erally lacking in sufficient high quality
 Health Survey of Nepal 881

protein, calcium, vitamin A, riboflavin, as an epidemiologic tool. II. The concentration

and ascorbic acid. Iron, thiamine, and of blood parasites by centrifugation. Am. 1.
Hyg. 80: 70, 1964.
niacin intakes are adequate to high due
5. KUNTZ, R. E. Intestinal protozoa and helminths
to consumption of large amounts of un- ill school children in Dacca, East Pakistan. U. S.
milled rice. Although the clinical nu- Naval Med. Res. Unit no. 2, Rept. no. 5, 1960.
tritional status of the population is gen- 6. Food an(l Agriculture Organization of the
erally satisfactory, the high mortality rate United Nations. Third World Food Survey.
FFHC Basic Study no. 11. Rome: FAO, 1963.
among children under five suggests that
7. Food and Agriculture Organization of the
marginal malnutrition exists, which, United Nations. Requirements of vitamin A,
coupled with constant exposure to a con- thiamine, riboflavin and niacin. Rept. of a Joint
taminated environment, is a major factor FAO/WHO Expert Group. FAO Ser. no. 41,
implicated in child deaths in Nepal. Rome, 1967.
8. VERHOE5TRAETE, L. J., AND R. R. PUFFER. Chal-
lenge of fetal loss, prematurity and infant mor-
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