Nutrition and food security in Nepal: a narrative review of policies

Abstract

In the past few decades, the Nepali government has endorsed several nutritional policies, strategies, and guidelines. Given the lack of a comprehensive review of such policy documents, this review aims to describe the nutrition and food security policies and understand the existing policy gaps in Nepal. Findings from this study can be used to develop policies and programs to address Nepal's current and future nutritional needs. Policies relevant to nutrition and food security were identified by searching government websites and directly approaching relevant government ministries. Thematic analysis was conducted using framework methods under 8 predetermined themes: nutrition intervention, food security, food system, capacity building of human resources, nutrition education, nutrition governance, research, and monitoring and evaluation. The contents of each document reviewed were manually extracted in a spreadsheet stratified by the themes, and the findings were summarized for the respective themes. A total of 30 policy documents were reviewed. Most policies have focused on undernutrition; only a few have addressed overnutrition and diet-related noncommunicable diseases. Food security through a sustainable food system has been considered a key policy area in Nepal. Other areas in the food and nutrition policy landscape are capacity building for human resources, behavior change practices, nutrition governance, monitoring, and evaluation. Policy gaps have been identified in the quality and sustainability of nutrition programs; access to health care services; competent human resources for nutrition; intersectoral coordination and commitment; and support for monitoring, evaluation, and research activities. Most policies have tried to address a wide range of components of food and nutrition security; however, strategies focused on overnutrition and diet-related noncommunicable diseases are lacking. Several gaps are identified in this policy review; the findings can guide the policymakers to address these gaps via further policy development.

INTRODUCTION

Malnutrition consists of a deficiency, excess, or imbalance of energy and other macro- and micronutrients that changes the body composition and function, resulting in poor clinical outcomes.¹ Malnutrition has a multidimensional impact, from hindering individual capacities to affecting the overall socioeconomic development of a country.^2,3 At the individual level, nutritional deficiency is an impediment to the health, learning ability, immunity, and productivity of people, and these are is linked to countries' economic development.^3,4 Childhood malnutrition, including stunting, wasting, underweight, and overweight, is a major global cause of mortality and morbidity among children younger than 5 years.⁵ Globally, 150.8 million children have stunted growth, 50.5 million have wasting, and 38.3 million children are overweight. At the same time, 2.01 billion adults are overweight and obese.⁶ Malnutrition has contributed to 3.5 to 5 million deaths annually of children younger than 5 years.⁷ Mortality and morbidity associated with malnutrition represent a direct loss in human capital and productivity for the economy.⁸ It is estimated that 22% of income is lost every year by an adult suffering from malnutrition.⁹ An improvement in nutritional status contributes to 2% to 11% growth in the gross domestic product.⁴ Every dollar invested in nutrition will offer 16 dollars returns.^4,10

Given the high prevalence of malnutrition and existing poor economic status, the effects of malnutrition are disproportionately high in low-income countries.¹¹ Nepal is 1 of the low-income countries in the South Asia region that has a high burden of malnutrition. An estimated 2% to 3% of gross domestic product (US$250 million to $375 million) is lost every year in Nepal just due to vitamin and mineral deficiencies.¹² Current evidence shows that Nepal is facing a double burden of malnutrition. For example, the Nepal Demographic and Health Survey Report 2016 stated that the prevalence of stunting, wasting, underweight, and overweight among children younger than 5 years was 35.8%, 11%, 27%, and 1% respectively.¹³ In 2016, the global nutrition report estimated that 17.4% of women and 16% of male adults were underweight, and 22.8% of women and 19.1% of male adults were overweight in Nepal.¹⁴ Approximately 17% of women of reproductive age have chronic energy deficiency (ie, body mass index <18.5) and 22% of reproductive-age women are overweight.¹⁵ In 2017, 69% of children aged 6–23 months and 41% of reproductive-age women were anemic in Nepal.¹⁶ On the other hand, overnutrition has also been a great threat in recent years. Evidence suggests that overweight and obesity among women aged 15–49 years increased from 13% to 21% from 2011 to 2016.¹³ Similarly, current statistics show 17% of men aged 15–49 years are overweight or obese.¹³ Such a growing rate of obesity has substantially contributed to the prevalence of noncommunicable diseases, which accounts for 66% of total deaths in Nepal.¹⁷

The Nepali government has committed to achieving internationally agreed-upon World Health Assembly global nutrition targets by 2025 and goal 2 of the Sustainable Development Goals on zero hunger by the year 2030. In this context, the government of Nepal has set a target of reducing the prevalence of childhood stunting to 24% by 2025 and 15% by 2030, reducing wasting to <5% by 2025 and to 4% by 2030, reducing anemia to 10% by 2030, and increasing the percentage of exclusive breastfeeding to >90% by 2030.^6,11 To achieve these targets, Nepal has implemented a wide range of nutrition-sensitive and nutrition-specific interventions. The nutrition-specific interventions are targeted toward individuals and include micronutrient supplements for children younger than 5 years, adolescents, and women during pregnancy and lactation; micronutrient fortification (ie, salt iodization and flour fortification); awareness raising; and behavior change communication about optimal infant and young child feeding, and management of severe acute malnutrition. The nutrition-sensitive interventions are targeted toward families and communities and include hygiene and sanitation, nutritious food and diets, school feeding programs, and parental education.

The Nepali government formally introduced nutrition as a priority agenda during the 1970s. For the first time, nutrition was included as a development agenda in the fifth 5-year plan (1975–1980). A high-level, national nutrition committee was formed in 1977, followed by the endorsement of a national nutrition strategy in 1978. After participating in the Scaling Up Nutrition movement in 2010,¹⁸ Nepal endorsed a multisector nutrition plan, which has been a main guiding document for nutrition strategies and programs. Before and after the implementation of the multisector nutrition plan, various food and nutritional policies and strategies have been implemented. Recent evidence, however, suggests that policy incoherence across the board is a greater challenge.¹⁹ Such policy incoherence has not been well documented in the current literature. At the same time, the evidence is limited as to what extent the existing food and nutrition policies have addressed current and future nutritional concerns. For example, in the past few decades, the government has endorsed some food- and nutrition-related guidelines and programs to curb obesity and noncommunicable diseases. However, to our knowledge, such policies have not been reviewed in terms of policy sufficiency and policy coherence. Policy review is not only important to explore the gaps in the existing policies, it is also crucial to provide recommendations to the concerned stakeholders. So, in this review, we explored the nutrition areas covered by the existing policies, identified the gaps and incoherence among them, and we provide recommendations for the concerned stakeholders.

METHODOLOGY

Study design

A desk review was conducted using a framework method described by Gale et al.²⁰ The framework method is a type of thematic analysis that helps identify the relevant themes and interpret data based on those themes. The content of the study topic was large and multidisciplinary; therefore, this approach helped contextualize data from individual policies within the pool of analyzed policies.

Inclusion and exclusion criteria

All the food- and nutrition-related acts, policies, strategic plans, strategies, and guidelines, hereafter termed “policy documents,” endorsed by the Nepali government were included in this review. The policy documents covered both nutrition-sensitive and nutrition-specific policies that were formulated up to 2021. Because Nepal’s federalism, adopted in 2015, is in fledging stage, only national-level policy documents were included in this review. The nutrition programs and projects were not included in this review, because they were parts of the policy documents.

Data extraction

The policy documents were identified by searching government websites on food and nutrition policies, and strategies, and the documents were downloaded. The websites included that of the National Planning Commission (https://npc.gov.np/en), the Law Commission (https://www.lawcommission.gov.np/en/), the Ministry of Health and Population (https://mohp.gov.np/en), Department of Health Services (https://dohs.gov.np/), Ministry of Agricultural and Livestock Development (https://www.moald.gov.np/), and Department of Food Technology and Quality Control (http://www.dftqc.gov.np/). For comprehensiveness, we conducted a Google search using keywords such as “food and nutrition security,” “policies,” “nutrition strategy,” and “Guidelines” to capture other food and nutrition policies that were not updated on the Nepali government websites. In total, 30 policy documents were extracted, consisting of 9 policies, 5 strategies, 8 acts, 5 strategic plans, and 3 guidelines. Among them, 24 policy documents were downloaded from websites, and 6 were downloaded from the Google search engine.

Data analysis

Thematic synthesis was performed in this review by using the aforementioned framework method. The framework was guided by the interest (deductive), based on the study objectives, and the contents highlighted in the policy documents (inductive). A total of 8 themes were identified:

1. Nutrition intervention: covers the actions adopted by the government, such as food supplementation, food fortification, treatment of deficiency or disorder, and dietary modification

2. Food security: This domain includes 3 components of food security defined by the Food and Agricultural Organization (ie, availability, accessibility, and utilization).

3. Food system: This domain includes the activities involving production, processing, transportation, consumption, and quality control.²¹

4. Training: includes all the activities conducted to improve the nutritional capacity of human resources.

5. Nutrition education: This domain includes information, education, communication, and awareness or counseling that are required for healthy and nutritious behavior adoption.

6. Nutrition governance: assessed in 3 important components of good governance: coordination, institutional capacity building, and commitment.

7. Research: This domain includes research-related activities that support food and nutrition security.

8. Monitoring and evaluation: This domain includes monitoring- and evaluation-related activities that assess policy planning, and implementation including measurement of indicators.

Data on these themes were manually extracted and entered into an Excel spreadsheet. Findings were summarized and interpreted on the basis of these 8 themes.

RESULTS

A total of 30 relevant policy documents: 9 policies, 8 acts, 5 strategies, 5 strategic plans, and 3 guidelines were identified. The list of the documents and their objectives are presented in Table 1.^{11,13,19,22–48} The policy documents are summarized in above mentioned 8 themes.

Table 1.

List of policies, acts, regulations, and plans related to food and nutrition security in Nepal

Serial number	Policy name	Objectives
1	National Dairy Development policy (2021)22	Improved milk production and productivity through collaboration and partnerships among government, cooperative, and private sectors. To make the country self-sufficient in dairy production and to build a training center
2	Integrated Management of Acute Malnutrition guideline (2020)23	Preventing acute malnutrition through early identification, referral, follow up, and linkage of cases to health and nutrition interventions; and treating acute malnutrition to reduce associated morbidity and mortality
3	National Nutrition Policy (2020)24	Improve nutritional status by increasing access to nutrition-specific (ie, health) and nutrition-sensitive (ie, agriculture; education; women, children, and social welfare; water sanitation and hygiene; agriculture) services for newborns, children, adolescents and women; enhance the quality of nutrition-specific and nutrition-sensitive services and increase the capacity of service providers to provide nutrition services; increase the demand for nutrition-specific and -sensitive services by raising public awareness at the community level, to promote positive behaviors related to nutrition, and to eliminate negative habits and behaviors; increase the scope of nutrition services according to the need of time
4	National Food Safety Policy (2019)25	Adopt risk-based food hygiene and a quality control system to protect consumers from risks in food; make legal and institutional reforms related to food hygiene; food hygiene and quality education to all stakeholders in the food chain, expanding access to information, communication, and dissemination; develop, implement, and promote a quality management system; facilitate effective trade of food goods and services by maintaining reliability of hygiene and quality in food items; develop management systems for prevention of the spread of diseases arising from the consumption of contaminated food and develop systems including food epidemiology surveillance for early warning management of such risks; develop and strengthen competent, robust, effective inspection, monitoring, and laboratory analysis systems for food hygiene and quality on the basis of scientific methods; increase consumer education and public awareness about food hygiene and quality; conduct research on food hygiene and quality enhancement
5	National Health Policy (2019)26	Improve nutrition situation; discourage adulterated and harmful food use and promotion; expand use and access to quality and healthy food
6	Fifteenth Development Plan 2019/2020–2023/202427	Implement the multisector nutrition plan through coordination and partnership
7	Multisector Nutrition Plan (2018–2022)28	Increase the number of service delivery institutions to improve access to and the use of nutrition-specific services; increase access to and the use of nutrition-sensitive services, including improving health-related behavior; improve policies, plans, and multisector coordination at federal, provincial, and local government levels to create an enabling environment to improve nutrition
8	Consumer Protection Act (2018)29	Make amendments to and consolidate the legal provisions relating to consumer protection to protect and promote constitutional rights of consumers to obtain quality goods and services; provide judicial remedy for the enforcement of the rights obtained by consumers; provide compensation for harm and injury likely to be caused to consumers
9	The Right to Food and Food Sovereignty Act (2018)30	Make legal provisions for the implementation of fundamental rights relating to food, food security, and food sovereignty of the citizens; enable appropriate mechanisms to ensure access of the citizens to foods
10	Local Government Operation Act 201731	Formulate, implement, monitor, evaluate, and regulate policy, legislation, standards, and norms related to food and nutrition security
11	Nepal Zero Hunger Challenges National Action Plan 2016–202532	Ensure the right to food by improving food and nutrition security of people to achieve a society free of hunger and malnutrition by 2025
12	Nepal Health Sector Strategy 2016–202133	Emphasizes better implementation of the nutrition-related existing plans, policies, and strategies
13	Food-Based Dietary Guideline 201634	People of every age and group should get all the nutrients from the food that they consume every day, thus leading to a healthy and active life.
14	Sustainable Development Goals 2015–203019	End hunger, achieve food security and improved nutrition, and promote sustainable agriculture
15	Constitution of Nepal 201535	Food as a fundamental human right
16	Strategy for Infant and Young Child Feeding 201436	Improve optimal breastfeeding practices; improve age-appropriate optimal complementary feeding practices; ensure enforcement of national legislation related to infant and young child feeding (eg, marketing of breast milk substitutes and maternity protection); improve the consumption of essential micronutrients (eg, vitamin A, especially among infants aged 6–24 mo; deworming tablet, especially among those aged 12–24 mo)
17	Food and Nutrition Security Plan of Action 201337	Reduce hunger, malnutrition, and poverty among the poorest households by promoting sustainable, agriculture-based livelihoods.
18	Agriculture Development Strategy 2015–203538	Increase food and nutrition security; reduce poverty and competitiveness; ensure higher and more equitable income of rural households; strengthen farmers’ rights
19	Nutrition-Related Legislation on Flour Fortification 201139	Flour processed at large-scale roller mills must contain iron, folic acid, and vitamin A.
20	Agribusiness Promotion Policy 200640	Reduce poverty by encouraging production of market-oriented and competitive agricultural products.
21	School Health and Nutrition Strategy 200641	Improve use of school health and nutrition services by school children; improve healthful school environment Improve health and nutrition behaviors and habits; improve and strengthen community support systems (linkage and networking between ministry of health and population and ministry of education) and policy environment
22	National Policy on Skilled Birth Attendance 200642	Initiating and establishing early and exclusive breastfeeding; educating mother, families, and caretakers about maintaining successful breastfeeding
23	National Nutrition Policy and Strategy 200443	Reduce protein-energy malnutrition, anemia, intestinal worm infestation, and infectious diseases in children; reduce anemia in women; eliminate iodine-deficiency disorders and vitamin A deficiency; reduce low birth weight; improve household food security; promote good dietary habits; control lifestyle-related diseases; improve health and nutritional status of school children; reduce the critical risk of malnutrition and life during exceptionally difficult circumstances; strengthen the system for analyzing, monitoring, and evaluating the nutrition situation
24	National Agriculture Policy 200444	Increase agricultural production and productivity; make agriculture productivity competitive with regional and world markets by developing the bases of commercial and competitive agricultural systems; conserve, promote, and use natural resources, environment, and biodiversity
25	Animal Slaughterhouse and Meat Inspection Act (1999)45	Provide necessary arrangements to establish slaughterhouses and arrange for meat inspection to safeguard the health and welfare of the people in general; control adulteration in meat and meat products; and maintain reasonable standards of meat by protecting the wholesomeness, quality, and adequacy of meat.
26	Iodized Salt (Production, Sale and Distribution) Act, 2055(1998), Amendment Act, 2066 (2010)46	Make provision for the production, import, supply, sale, and distribution of iodized salt in a proper quantity and for mixing iodine with salt to prevent and eradicate extensive and serious effects caused to public health from iodine deficiency
27	National Safe Motherhood Policy 199811	Promotion of breastfeeding through counseling during antenatal care
28	The Mother's Milk Substitution Act and regulation 2049 (1992), 2051 (1994)13	Provide safe and adequate nutrition to infant by protecting and promoting breastfeeding and regulating the mother’s milk substitutes, regulating the sale and distribution of infant foods
29	Black-Marketing and Some Other Social Offenses and Punishment Act, 2032 (1975)47	Control black-marketing, profiteering, adulteration, and some other social offenses to maintain health, convenience, and economic interests of the general public
30	Food Act, Food Rules 2027 (1970), 2052 (1995), fifth amendment 2064 (2007)48	Make legal provisions to maintain proper standard of foodstuffs; prevent any undesirable adulteration in foodstuffs; prevent reducing or extracting any natural quality or utility from foodstuffs

NUTRITION INTERVENTION

Eleven policy documents mentioned nutrition interventions, including nutrition supplementation, fortification, feeding practices, treatment of nutrient deficiencies disease.

Micronutrient supplementation

One policy, 4 strategies, and 1 strategic plan have provisions on micronutrient supplementation for children younger than 5 years and pregnant or postpartum women. The National Nutrition Policy and Strategy (2004),⁴³ National Nutrition Strategy (2020),²⁴ Multisector Nutrition Plan (2018–2022),²⁸ School Health and Nutrition Strategy (2006),⁴¹ National Health Sector Strategy (2016–2021),³³ and Infant and Young Child Feeding Strategy (2014)³⁶ recommend biannual supplementation of 2 lakh (ie, 200 000) IU vitamin A to children younger than 5 years, iron (60 mg), and folic acid (400 µg) supplementation to pregnant women for 180 days and postpartum mothers for 45 days. In addition, the School Health and Nutrition Strategy (2006)⁴¹ has a provision for iron folic acid supplementation for adolescent girls, they receive 2 rounds of weekly iron folic acid supplementation for 13 weeks. Similarly, the Nepali government has been conducting biannual vitamin A supplementation to children younger than 5 years and mass deworming for more than 20 years.

Food fortification

Two acts, 1 policy, 1 strategy, and 1 strategic plan have mentioned food fortification as a nutrition intervention in Nepal. The National Nutrition Policy and Strategy (2004)⁴³ and National Nutrition Strategy (2020)²⁴ recommend fortifying commercially produced wheat flour with iron and rice with micronutrients. Nutrition-relevant legislation on flour fortification (2011)³⁹ mandates fortifying all flour processed at large-scale roller mills with iron, folic acid, and vitamin A. The Multisector Nutrition Plan (2018–2022)²⁸ recommends fortification of wheat flour and rice with iron, folic acid, and vitamin A, and fortification of child complementary food with micronutrient powder sachets. The Iodized-Salt Act (1992)⁴⁶ mandates fortifying the salt with iodine.

Treatment of nutrient deficiency

One policy, 3 strategies, 1 act, and 1 strategic plan have guided the treatment of nutrient deficiency disorders. The National Nutrition Policy and Strategy (2004)⁴³ recommends the use of low-dose vitamin A for the treatment of night blindness in pregnant women after the first trimester. The National Nutrition Strategy (2020)²⁴ and Multisector Nutrition Plan (2018–2022)²⁸ focus on strengthening inpatient and outpatient treatment centers for the management of severe acute malnutrition and moderate acute malnutrition, and treatment of micronutrient deficiency using ready-to-use therapeutic food. The Nepal Health Sector Strategy (2016–2021)³³ and Infant and Young Child Feeding Strategy (2014)³⁶ focus on integrated management of severe malnutrition and community-based early malnutrition management.

Feeding practices

Three policies, 3 strategies, 1 act, and 1 strategic plan have emphasized appropriate feeding practices to address nutritional problems in Nepal. The National Nutrition Policy and Strategy (2004),⁴³ National Nutrition Strategy (2020),²⁴ Mother’s Milk Substitute Act (1991),¹³ Multisector Nutrition Plan (2018–2022),²⁸ Skill Birth Attendance Policy (2006),⁴² Safe Motherhood Policy (1998),¹¹ Nepal Health Sector Strategy (2016–2021),³³ and Infant and Young Child Feeding Strategy (2014)³⁶ focus on promoting exclusive breastfeeding, timely initiation of breastfeeding, and age-appropriate complementary feeding. The National Nutrition Policy and Strategy (2004)⁴³ and food-based dietary guidelines (2016)³⁴ provide nutritional information for promoting healthy dietary practices to address diet-related noncommunicable diseases.

Food security

Two policies, 2 strategies, 1 act, and 2 strategic plans highlighted different provisions to improve food security (ie, availability and accessibility) in Nepal. The National Nutrition Policy and Strategy (2004)⁴³ set a clear objective to improve household food security to ensure that all people have adequate access, availability, and utilization of food needed for a healthy life. The constitution of Nepal (2015)³⁵ clearly states in article 36 that food is a fundamental right of every citizen. A similar provision is made by the Right to Food and Food Sovereignty Act (2018).³⁰ The Fifteenth Plan (2019–2024)²⁷ and National Nutrition Strategy (2020)²⁴ also focus on increasing the availability, accessibility, and quality of nutritious food to all people. Promoting locally available nutritious food and developing special programs for hard-to-reach people to increase accessibility are the major strategies that are clearly mentioned in the National Nutrition Strategy (2020).²⁴ The Agriculture Development Strategy (2015–2035)³⁸ has specific programs to increase food production, improve farmers' income, improve access to the market, reduce postharvest losses, and improve food safety. Similarly, the Multisector Nutrition Plan (2018–2022),²⁸ National Agriculture Policy (2004),⁴⁴ and Food and Nutrition Security Plan (2013)³⁷ promote food security by making provisions for increasing the availability, accessibility, and consumption of nutritious foods.

FOOD SYSTEM

Production

Three policies, 5 strategies, 2 strategic plans, and 2 acts have focused on sustainable and healthy food production in Nepal. The National Health Policy (2019),²⁶ National Nutrition Policy and Strategy (2004),⁴³ and National Agriculture Policy (2004)⁴⁴ highlight the promotion of nutritious food production. These 3 policies emphasize increasing the volume of food production, home production of vitamin A–rich food, promoting kitchen gardens, and consumption of locally available and culturally acceptable food. The Food Act (1966)⁴⁸ and Right to Food and Food Sovereignty Act (2018)³⁰ mandate a ban on the production, sale, and distribution of inferior, contaminated, or unsafe food items and improve the livelihood of farmers. Likewise, the Agriculture Development Strategy (2015–2035),³⁸ National Nutrition Policy (2020),²⁴ and Food and Nutrition Security Plan (2013)³⁷ explicitly emphasize the need to improve agriculture practices for improving food and nutrition security in Nepal. These 3 policy documents mainly focus on increasing the volume of food production sustainably through the use of natural resources. The Nepal Health Sector Strategy (2016–2021)³³ and Infant and Young Child Feeding Strategy (2014)³⁶ also support the production of fortified or nutrient-dense, locally available, and culturally acceptable food.

Storage, transportation, marketing, and distribution of food

Two policies, 3 acts, and 2 strategies have guided the processing, storage, distribution, and marketing of food products. The National Nutrition Policy and Strategy (2004)⁴³ advocates how to store and preserve food items, improve technical knowledge of food processing and encourage better storage practices to prevent nutrient loss. These policies also outline the provision for creating food-storage facilities for farmers. The National Nutrition Strategy (2020)²⁴ and The Mother’s Milk Substitution Act and Regulation (1992)¹³ discourage the marketing and advertisement of mother’s milk substitutes. The Right to Food and food Sovereignty Act (2018)³⁰ defines the roles and responsibilities of central and provincial governments for the purchase, transportation, and distribution of food products. This act also mentions that the federal, provincial, and local governments shall make arrangements for food distribution through fair-price shops or public food-distribution centers.

Quality control

Three acts, 1 policy, 2 strategic plans, and 1 strategy have focused on ensuring the quality control of food products. The Food Act (1966)⁴⁸ states that the government of Nepal may issue quality standards for food products, and if a person intends to produce, sell, distribute, store or process the prescribed foodstuffs, they shall have to obtain a license as prescribed. Similarly, the National Food Safety Policy (2019),²⁵ Multisector Nutrition Plan (2018–2022),²⁸ and Food and Nutrition Security Plan (2013)³⁷ strongly recommend implementing good manufacturing practices, good hygiene practices, Hazard Analysis and Critical Control Points in food safety management systems of food industries. These 3 policy documents also focus on the food import, export, inspection, and certification systems to ensure the import of safe and quality food products. The Black Marketing Act (1975)⁴⁷ and Consumer Protection Act (1997)²⁹ have provisions for protecting consumers from irregularities concerning the quality, quantity, and prices of food. These 2 acts have provisions to prevent unreasonable price hikes of food and price fixing. The Consumer Protection Act (2018)²⁹ states that “the Government of Nepal shall regulate the supplies, price, quality, measurement, label, advertisement of the goods and services regularly as every consumer has the right to access, choose quality goods and services.”

Consumption

One policy, 2 strategic plans, and 4 strategies encourage the consumption of locally available nutritious food. The recently developed National Nutrition Strategy (2020),²⁴ Multisector Nutrition Plan (2018–2022),²⁸ Food and Nutrition Security Plan (2013),³⁷ School Health and Nutrition Strategy (2006),⁴¹ Nepal Health Sector Strategy (2016–2021),³³ and Infant and Young Child Feeding Strategy (2014)³⁶ encourage the consumption of locally available, diversified, and healthy food. The National Nutrition Policy and Strategy (2004)⁴³ gives high priority to promoting the consumption of diversified food by providing food-based dietary guidelines. This policy also promotes the use of appropriate and adequate locally available complementary foods like Jaulo (a semi-solid soup prepared using rice and lentils) and sarbottam pitho (flour prepared using 50% cereal and 50% lentils, with at least 2 types of lentils).

TRAINING

Three strategies, 2 policies, and 1 strategic plan have prioritized the capacity development of human resources for health to improve service delivery at health facilities. The Multisector Nutrition Plan (2018–2022)²⁸ and National Nutrition Policy and Strategies (2004)⁴³ outline comprehensive and systematic approaches to building the capacity of human resources in all relevant sectors. These policies focus on developing information, education, and communication materials and provide different layers of training to health workers for effective counseling, reporting, monitoring, and supervision of nutrition services at the health-facility level. The National Nutrition Policy and Strategies (2004)⁴¹ also has provisions for training the farmers about food safety, food processing, and cooking demonstrations to prepare local nutritious food. The National Food Safety Policy (2019)²⁵ and Agriculture Development Strategy (2015–2035)³⁸ have specific provisions for providing training for food industries to monitor the implementation of good manufacturing practices and good hygienic practices. Similarly, the Strategy for Infant and Young Child Feeding (2014)³⁶ focuses on providing pre- and in-service training for health and non–health workers. This strategy also has a provision to provide practical support to the mothers for adopting optimal feeding practices and solving common clinical breastfeeding problems. The School Health and Nutrition Strategy (2006)⁴¹ has explicitly mentioned the importance of the capacity building of stakeholders and focuses on providing training to all relevant stakeholders for the effective implementation of school health and nutrition services.

NUTRITION EDUCATION

Two policies, 2 strategies, 2 strategic plans, and an act have provisions to improve people’s nutrition-related behavior. The Multisector Nutrition Plan (2018–2022)²⁸ and National Nutrition Strategy (2020)²⁴ recommend the preparation and dissemination of information, education, and communication materials through different channels of communication to improve people’s nutrition-related behavior. Both of these policy documents discourage the dissemination of misinformation related to food. Additionally, the National Nutrition Strategy (2020)²⁴ also focuses on communication strategies to prepare nutritious food through the use of locally available food. The Strategy for Infant and Young Child Feeding (2014)³⁶ and Mother's Milk Substitution Act (1992)¹³ protect breastfeeding practices by restricting the promotion of mother’s-milk substitutes. They also promote breastfeeding practices through regular advertisements on the importance of breastfeeding through electronic media such as radio and television. The Fifteenth Development Plan (2019–2024)²⁷ suggests that the production and dissemination of health-related messages should be made scientific and systematic. These messages should be effective in discouraging and controlling the advertisements of processed food items that are considered harmful to the public’s health. The Strategy for Infant and Young Child Feeding (2014)³⁶ mentions specific strategies to improve counseling services at health facilities and in the community. The key strategies include strengthening community- and institutional-level counseling services by trained counselors, promotion of kitchen gardening, and use of seasonal and locally grown food through public awareness activities. The provision of counseling on breastfeeding during antenatal clinics is also included in the Safe Motherhood Policy (1998).¹¹ Likewise, the National Policy on Skilled Birth Attendants (2006)⁴² prioritizes educating mothers and their family members in the practice and support of successful breastfeeding.

NUTRITION GOVERNANCE

Coordination and collaboration

Three strategic plans, 2 policies, and 3 strategies highlight the importance of coordination in the nutrition sector. The Multisector Nutrition Plan (2018–2022),²⁸ Fifteenth Development Plan (2019–2024),²⁷ National Nutrition Policy and Strategy (2004),⁴³ Food and Nutrition Security Plan (2013),³⁷ Agriculture Development Strategy (2015–2035),³⁸ and National Food Safety Policy (2019)²⁵ emphasize the need for effective coordination between different levels of government (federal, provincial, and local) and other sectors (ie, health; education; agriculture; livestock; women, children, and social welfare; water and hygiene; local government) to address nutrition problems. The National Nutrition Strategy (2020)²⁴ and School Health and Nutrition Strategy (2006)⁴¹ explicitly mention the need to coordinate with the Ministry of Education to improve school health and nutrition services and promote healthy, nutritious behaviors. The Multisector Nutrition Plan (2018–2022),²⁸ Food and Nutrition Security Plan (2013),³⁷ Strategy for Infant and Young Child Feeding (2014),³⁶ and Nepal Health Sector Strategy (2016–2021)³³ integrate nutrition-related services with other national health programs such as safe motherhood and newborn care, immunization, family planning, and reproductive health.

Institutional capacity building

Two policies, 1 act, 1 strategy, and 1 strategic plan have identified institutional capacity building as an important strategy to improve nutrition services in Nepal. To build the institutional capacity, policies focused on the development of health-promoting institutions and infrastructure, formulation of nutrition committees at different levels, the establishment of training centers, and designation of various government bodies to support policy implementation. The National Nutrition Policy and Strategy (2004),⁴³ in particular, states that institutional building is essential to strengthening all nutrition programs. This policy also has provisions for the establishment of separate rooms for breastfeeding in public settings and the development of institutional capacity for regular growth monitoring at health institutions. Similarly, the Multisector Nutrition Plan (2018–2022),²⁸ Right to Food and Food Sovereignty Act (2018),³⁰ and Agriculture Development Strategy (2015–2035)³⁸ include comprehensive institutional development objectives and activities in their overall plan. These policies focus on the formulation of the nutrition steering committee, nutrition coordination committee, food coordination committee, nutrition coordinator, and the focal person at different levels from central to local governments. Similarly, the establishment of a food council and increased investment in physical infrastructure is another major provision made by National Food Safety Policy (2019).²⁵

Commitment

Three strategies and 1 strategic plan have included commitments to address nutritional problems in Nepal. The Multisector Nutrition Plan (2018–2022)²⁸ focuses on developing nutrition programs, especially for hard-to-reach people. This plan also commits to developing nutrition-friendly health services and advocating annual budgets for nutrition from the Ministry of Health and Population and increasing the nutrition budget at all levels. The National Nutrition Strategy (2020)²⁴ has made a strong commitment to maintaining mainstream nutrition in every local-level program. Similarly, the School Health and Nutrition Strategy (2006)⁴¹ has guided policymakers to assign a focal person at all levels from the ministry of health/ministry of education to schools, and formulate and execute School Health and Nutrition Program policy, norms, and guidelines. Furthermore, the National Nutrition Strategy (2020)²⁴ and Strategy for Infant and Young Child Feeding (2014)³⁶ have committed to increasing maternity leave by up to 6 months to promote infant and young child feeding practices.

RESEARCH

Two policies, 1 act, 3 strategies, and 1 strategic plan have prioritized research as an important component to improve food and nutrition security. The National Nutrition Policy and Strategy (2004)⁴³ mentions the need to promote evidence-based nutrition practices through research activities. This policy states the government should take the initiative to develop its own recommended dietary allowance through research activities. Similarly, the National Food Safety Policy (2019)²⁵ has made a strong provision for education and research institutions to conduct research related to the status of food safety at different levels of the food chain. This policy also has provisions for research to develop a proper system for the production of safe and quality indigenous food products in Nepal. The Right to Food and Food Sovereignty Act (2018)³⁰ mentions that central, provincial, and local governments shall make necessary arrangements for the research and development of scientific technology. Similarly, the Agriculture Development Strategy (2015–2035)³⁸ recommends establishing a decentralized research system responsive to farmers and establishing research stations to generate new technologies. The School Health and Nutrition Strategy (2006)⁴¹ gives a high priority to conducting formative research to assess school health nutrition needs and diet diversification. Furthermore, the Fifteenth Development Plan (2019–2024)²⁷ prioritizes research-related activities. This plan states that research work through universities should be incorporated into the national policy-making process and calls for increased investment in scientific studies, research, and invention. The Strategy for Infant and Young Child Feeding (2014)³⁶ has several recommendations, such as conducting qualitative and quantitative research to determine the factors responsible for poor Infant and Young Child Feeding practices, identifying different service users, and exploring cost-effective approaches to improving Infant and Young Child Feeding practices for effective program implementation.

MONITORING AND EVALUATION

Five policies, 5 strategies, 4 acts, and 3 strategic plans have specified monitoring and evaluation as an important part of policy implementation. Five policies have put forward the idea of result-based monitoring and evaluation systems. According to the National Health Policy (2019),²⁶ monitoring and evaluation systems should be updated and well-functioning through the use of electronic systems. This policy has also focused on developing result-based monitoring and evaluation frameworks. The Agribusiness Promotion Policy (2006)⁴⁰ centered on the formulation of separate institutions or monitoring committees and specifying their functions. The School Health and Nutrition Strategy (2006)⁴¹ emphasizes monitoring and evaluation of different nutrition plans and programs that should be in implemented in coordination with other sectors and made more participatory. The National Nutrition Strategy (2020)²⁴ states there should be a mechanism of regular updates and analysis of nutrition-related information and feedback mechanism. The National Nutrition Policy and Strategy (2004)⁴³ has prioritized developing a network for data collection, processing, and setting indicators for reducing malnutrition. The Multisector Nutrition Plan (2018–2022)²⁸ has highlighted the need to strengthen the monitoring and evaluation of nutritional programs. It also advocates for developing and reviewing the monitoring and evaluation framework for all levels and for implementing joint monitoring and evaluation systems by the government of Nepal with external development partners. Similarly, the Fifteenth Plan (2019–2023)²⁷ has also emphasized increasing the use of data in monitoring, assessment, review, policy formulation, and decision-making by making health information systems more systematic, integrated, and technology friendly.

DISCUSSION

This review included 30 nutrition-related Nepali policy documents covering a wide range of nutrition-related topics. Nutrition has historically been a priority agenda in Nepal; however, it gained more attention as a developmental agenda only after the adoption of the Millennium Development Goals in 2000. Although the majority of the policies were congruent with each other, there were some discrepancies, especially when different agencies endorsed the policies. In this section, the findings are discussed in the following 5 sections: nutrition intervention (covering theme 1); food security and food services (covering themes 2 and 3); capacity building of human resources (covering themes 4 and 5); nutrition governance (covering theme 6); and research, monitoring, and evaluation (covering themes 7 and 8).

NUTRITION INTERVENTION

Nutrition interventions have been considered important policy agendas in a majority of policy documents. However, there were incongruences in policy and programs. Most policies emphasized multisector approaches, including both nutrition-sensitive and nutrition-specific interventions. For example, interventions such as vitamin A supplementation and deworming for children aged 6–59 months, iron folate supplementation for pregnant women, and zinc for diarrhea management have been implemented for more than 2 decades. Some nutrition interventions, such as food fortification with micronutrients (eg, iron folic acid and vitamin A in flour, iodine in salt, home fortification of complementary foods with micronutrient powder) were implemented recently. Unfortunately, Nepal lacks long-term, sustainable strategies such as food-based dietary diversification and public health measures, including nutrition behaviour change communication strategies and food safety measures. Recently, the multisector nutrition plan has tried to fill this gap by integrating nutrition-sensitive and nutrition-specific interventions through the network of stakeholders; however, several implementation-level challenges exist,⁴⁹ including disparities in access to adequate nutrition and health care, limited technical capabilities, weak coordination between different levels of government, lack of ownership, inadequate data, insufficient budget, and weak institutional structure.^18,50,51

Most nutritional policies have emphasized the reduction of conditions associated with childhood undernutrition, such as stunting, wasting, underweight, and specific micronutrient deficiency.¹¹ Childhood malnutrition has been reduced significantly over the past decades. For example, childhood stunting, an indicator of chronic undernutrition, has decreased from 57% in 2001 to 36% in 2016⁵²; however, it is still unacceptably high. Child health interventions, such as bi-annual vitamin A supplementation, deworming, iodine fortification, and exclusive breastfeeding for 6 months, have improved maternal and child nutrition in Nepal.⁵³ Although nutrition intervention, such as the vitamin A program, has been considered a successful nutrition intervention in Nepal, it has mainly focused on vitamin A supplementation; less emphasis has been placed on improving feeding practices through home garden demonstration activities to promote nutrition-rich locally available food.

Nutrition policies have placed a low priority on addressing overweight and other diet-related noncommunicable diseases in Nepal. However, the burden of overnutrition and noncommunicable diseases related to poor diet has increased drastically in the past few decades. Over the past 20 years, there has been a more than 10-fold increase in the prevalence of overweight (body mass index ≥ 25) and a 20-fold increase in the prevalence of obesity (body mass index ≥ 30) among adult Nepali women (1.8% in 1996 to 19.7% in 2016 and 0.2% in 1996 to 4.1% in 2016 for overweight and obesity, respectively).⁵⁴ These problems are particularly higher in urban areas compared with rural areas.¹³ This may be due to the nutrition transition toward processed foods with higher energy, fat, and sugar.⁵⁵ The World Health Organization’s STEPwise Approach to Surveillance survey of Nepal in 2019 also reported a high prevalence of dietary risk factors, including low consumption of fruits and vegetables (96.7%).⁵⁶ Approximately 44% of children aged 6 to 23 months are not fed fruits or vegetables and 59% are not fed eggs, dairy, fish, or meat in Nepal.⁵⁷ A study conducted in a western city of Nepal showed that a majority of adolescents (94%) usually eat junk or processed food, and approximately 22% consume it daily.⁵⁸ These findings show a dire need for a shift in the nutritional policy landscape. The nutrition and food security policy also needs to include strategies to address the growing burden of noncommunicable diseases.

FOOD SECURITY AND THE FOOD SYSTEM

Based on the findings of this review, food security and a sustainable food system, including the quality of food, are strong policy agendas in Nepal. For example, the Nepali government has committed to achieving sustainable development goals (specifically, United Nations Sustainable Development Goal 2) by the year 2030. Sustainable Development Goal 2 states, “End hunger, achieve food security and improve nutrition and promote sustainable agriculture.”¹⁹ However, most of the time, food security and the food system have been emphasized by the policy documents from the agriculture sector. In this review, we found that food and nutrition policies in Nepal have fairly focused on nutritional aspects, but missed addressing food systems as a whole. Although a food system includes the path from production to the consumption of food, other dimensions of the policies that could contribute to a sustainable food system were not mentioned, such as land issues, labor migration, farm mechanization, and consumer behavior.⁵⁹ Food security policies have mainly focused on increasing the volume of production, improving household income, and increasing access to and consumption of locally available food.⁶⁰ However, food quality has not been emphasized, which is another important aspect of food security.

Nutrition-sensitive agricultural interventions, such as the farmer field school and nutrition field school; market linkage activities, including the establishment of a “hat bazaar” (ie, a farmer’s market); subsidization of vegetable seeds, crop seeds, and poultry to farmers; establishment of cold storage systems for fruits and vegetable; and provision of grants for small-scale farmers, have contributed to improving food and nutrition security in Nepal.^61–64 Subsidized food through a system of public food-distribution centers has increased access to food by the poorest in Nepal.⁶⁵ However, existing nutritional policies do not adequately address these topics. Specific policies and strategies are needed to address the current widespread availability and accessibility of fast food and junk foods.

Unequal distribution of agricultural resources, such as fertilizer, seed, and other agriculture technology; lack of a transparent marketing system that links farmers to retailers; insufficient extension services; problems of food storage, processing, and conservation facilities; and uncertainty of food distribution due to emergency situations such as the COVID-19 pandemic, are some of the major challenges faced while translating policies into actions in Nepal.^66–68 To overcome these challenges, upcoming policies should incorporate expanding the transparent market system, increasing extension services to the farmer, promoting digital technologies to manage the food supply, and provision of tax subsidies to domestic farmers. The policy should also focus on the adoption and equitable distribution of modern agricultural technology. Additionally, the quality of food production, along with increasing agricultural income and livelihood opportunities, should be addressed effectively by upcoming food and nutrition policies.

CAPACITY BUILDING OF HUMAN RESOURCES

Nutrition policies have covered a wide range of training for health workers, female community-health volunteers, mothers' groups for health, and other community-level groups. However, the components of training are siloed; therefore, the Nepali government has recently introduced a comprehensive, nutrition-specific intervention training for all health workers and female community-health workers. This package merges all the nutrition training into a single package. However, the package lacks practical sessions and post-training evaluation components.

Furthermore, we found that capacity-building programs were mostly focused on undernutrition. For example, most policies mentioned training on nutrition supplementation and treatment of malnourished children. Although these training programs are important, given the increasing rate of overnutrition and noncommunicable diseases associated with dietary behaviors, there is a need for capacity building of health workers to prevent the overuse of unhealthy and junk foods. Therefore, on the basis of the findings of this review, we suggest training packages that promote health worker competency with respect to both undernutrition and overnutrition. In Nepal, most nutrition-related training is provided to health workers only. Given nutrition is a multisector agenda, we recommend capacity-building activities for key stakeholders, including frontline workers from other sectors such as agriculture and education. Similarly, there is also a need for evaluation of training programs in terms of their impacts at individual and community levels.

NUTRITION GOVERNANCE

Good governance is essential for effective policy development and implementation.^69,70 Coordination with different sectors, commitment to nutrition improvement, and institutional capacity development are essential factors that contribute to effective nutrition governance.^71,72 The majority of policies have considered effective coordination between and within the sectors. For example, the Multisector Nutrition Plan has created a mechanism to enhance coordination across concerned agencies. Similarly, the current national health policy has also emphasized multisector coordination of nutritional activities. Although the recent policy documents have focused on multisector coordination, substantial implementation challenges exist during coordination.^49,73 A study conducted to measure the nutrition governance in Nepal showed that the stakeholder commitments were high but capabilities were weak.⁷¹ Insufficient budget allocations from the local government for nutrition, lack of a specific framework for coordination, weak institutional arrangement for implementing nutrition programs, and poor ownership by the municipal government are the major gaps in Nepal.

RESEARCH, MONITORING, AND EVALUATION

Most food and nutrition policies have emphasized the need for research, including monitoring and evaluation of nutritional programs. They have mentioned that research is necessary for evidence-based planning and implementation, developing evidence-based nutrition practices, identifying new technology, and assessing the factors behind the success and failure of nutrition programs. However, they lack a clear-cut mechanism for those activities. Through this review, we also found inadequate technical and financial support for conducting action research. Policies should provide for appropriate technical and financial support for conducting action research. Furthermore, the research activities should be focused on current and future needs in the food and nutrition sector. For that, a well-structured mechanism should be formulated to conduct research, monitoring, and evaluation of nutrition-related programs. The current evidence suggests that there are problems with timely reporting, poor data quality, inappropriate feedback mechanisms, and lack of a nutrition-specific monitoring system.⁷⁴ Therefore, policies should focus on developing nutrition-specific monitoring and surveillance systems and consistent implementation. Developing and implementing the nutrition policy–specific training package for tertiary-level health workers on monitoring and evaluation of nutrition programs would also facilitate the implementation of the policy.

This review identifies gaps and opportunities in the existing food and nutrition policies in Nepal that can be addressed by future food and nutrition policies and programs. For example, the constitution of Nepal makes special provisions for the right to food and food sovereignty as well as the right to be protected from a state of hunger. Such a constitutional provision creates an enormous opportunity to design and implement programs so that no one will be left behind in achieving food security and nutrition. There is high-level policy support and commitment from the federal to the local governments for nutrition.⁷¹ The government has prioritized food and nutrition security as the development agenda of the nation.⁷⁵ Since 2004, Nepal has been a member of the World Trade Organization. Compliance with the World Trade Organization on food trade and other existing regulations and standards (Codex, Good Agriculture Practices/Good Veterinary Practices, good manufacturing practices, Hazard Analysis and Critical Control Points) also helps to improve food security. Partnerships with international and other nongovernment organizations or private organizations are crucial for the effective implementation of nutrition interventions. There is growing interest from government, private, and international partnerships to invest in nutrition. International bilateral and multilateral organizations, private organizations, civil society, and academic institutions are providing technical and financial support for nutrition policy development and program implementation in Nepal, which could be a great opportunity for improving food and nutrition. Despite these opportunities, some looming threats could hinder the path to food and nutrition security. Natural disasters, the effects of globalization, political instability, donor-driven intervention, and pandemics such as COVID- 19 are serious threats to food and nutrition security.^65,66,76 Because of natural disasters and other emergencies like the COVID-19 pandemic, there has been a decrease in food production and distribution, and there is poor access to food.⁷⁷ Therefore, the government should formulate policies and strategies that will enable stakeholders to tackle the short- and long-term effects emergencies have on food security. More importantly, concerned stakeholders should formulate strategies to enable the food and nutrition system to be resilient enough to handle future crises.

STRENGTHS AND LIMITATIONS

This review has some strengths and limitations that should be considered when interpreting the results. To the extent of our knowledge, this is the first review in the Nepali context that analyzes a wide range of food and nutrition policies formulated by the government of Nepal. The framework method used in this policy analysis has been widely used in health policy research. This method has helped us draw descriptive and explanatory conclusions clustered around themes. However, this review has some limitations. First, this policy analysis was limited to national-level policy documents; this review could not include the policies and strategies that were formulated by the provincial and local governments. Future reviews can explore the variation across the food and nutrition policies at provincial and local levels. Second, although we tried in this review to retrieve all national-level food and nutrition policies of Nepal, some policies or strategies that are not well documented could have been missed.

CONCLUSION

Nepal has implemented a wide range of food- and nutrition-related acts, policies, and strategies in the past few decades. Most policies have addressed undernutrition, improving feeding practices, improving food security, and promoting sustainable food systems, whereas very few have emphasized overnutrition and other diet-related noncommunicable diseases. Although nutritional improvement should cover a wide range of interventions, Nepal has primarily focused on short-term interventions. More importantly, most policies lacked a clear mechanism to effectively implement and monitor progress. Therefore, concerned stakeholders should address these gaps in the existing policy landscape so that Nepal can have sustainable food and nutrition systems to fulfill the current and future needs of Nepali citizens.

Funding

No external funding was received to support this work.

Declaration of interest. The authors have no relevant interests to declare.