Dietary Practices Among Young Children in Nepal’s Karnali Mountains: A Community-Based Study on Meal Frequency, Diversity, and Fruit or Vegetable Intake

Abstract

Background

Malnutrition is a significant public health challenge in low- and middle-income countries, especially in food-insecure areas including those in Nepal. Despite global efforts to improve infant and young child feeding (IYCF) practices, significant gaps remain in dietary diversity, meal frequency, and fruit or vegetable consumption. However, there is a lack of data from the highly food-insecure mountains of Nepal. This study examines the prevalence of key IYCF practices: minimum meal frequency (MMF), minimum dietary diversity (MDD), and fruit or vegetable consumption in the remote mountains of Karnali region of Nepal.

Methods

A community-based cross-sectional study was conducted among 423 randomly selected mothers of children aged 6–23 months in Kalikot district. Face-to-face interviews were conducted using structured questionnaire. The prevalence of the three IYCF practices were assessed using frequency distribution and their association with socio-demographic factors were examined using chi-square tests (χ²) and multiple logistic regression.

Results

The study found that 78.5% of children met the MMF criteria, but only 24.1% achieved MDD, and 33.1% received any fruit or vegetable in the 24-hr preceding the survey. Father’s education was positively associated with all three indicators: MDD (adjusted odds ratio (AOR): 3.60; 95% confidence interval (CI):1.30, 9.95), MMF (AOR: 2.12; 95% CI: 1.06, 4.24) and fruits or vegetable consumption (AOR: 2.51; 95% CI: 1.25, 5.01). Mother’s education (AOR: 4.27; 95% CI: 1.61, 11.36) and recent child illness (AOR: 2.39; 95% CI: 1.42, 4.02) were also associated with MMF, while family type (AOR: 1.60; 95% CI: 1.05, 2.45) was associated with fruits or vegetable consumption.

Conclusion

This study highlights significant gaps in IYCF practices, particularly low dietary diversity and inadequate fruit or vegetable intake. Addressing these challenges requires locally tailored interventions, including parental education programs that actively engage fathers, improved community-based nutrition initiatives, and strengthening maternal support systems to improve feeding during child illness. Given the region’s longstanding under-resourcing and food insecurity, future strategies should focus on strengthening local food systems to improve availability and consumption.

Introduction

The first few years of life are crucial for children’s growth and development. Optimum nutrition during this period supports their full potential, while malnutrition can cause lasting harm and is linked to nearly half of global under-five deaths [1]. The World Health Organization (WHO) and UNICEF (United Nations Children’s Fund) advocate for beginning breastfeeding within the first hour of birth, maintaining exclusive breastfeeding for the first six months, and introducing safe, nutritious solid foods at six months, alongside continued breastfeeding up to two years or beyond [2].

Optimum Infant and Young Child Feeding (IYCF) practices are crucial for providing essential nutrients for infant and young children; preventing growth faltering and nutrient deficiencies; and infections during the critical 6–23 month period [3]. Inadequate feeding practices contribute to 35% of child deaths from diseases such as diarrhea and pneumonia, leading to growth failure, weakened immunity, and long-term developmental challenges [4].

In 2020, 149 million under five children were stunted and 49 million wasted [5]. Low- and middle-income countries (LMICs) face a double burden of malnutrition, struggling with both undernutrition and diet-related non-communicable diseases, affecting over one-third of the population [6]. Poor nutrition in early life period causes wasting and stunting, and can lead to chronic health outcomes such as cardiovascular disease, type 2 diabetes, and strokes in later life [7]. Under nutrition in infancy increases disease risk due to higher energy needs and poor nutrient absorption. It also harms cognitive development, academic performance, work productivity, and overall economic growth [8]. A diverse diet and regular meal consumption are linked to better energy and micronutrient intake, promoting better growth and development [9, 10]. The WHO and UNICEF IYCF guidelines recommend assessing minimum meal frequency (MMF), minimum dietary diversity (MDD), and zero fruit or vegetable consumption to monitor and improve feeding practices [9].

It is only in the recent guideline 2021 that the WHO and UNICEF included zero vegetable or fruit consumption as a new indicator to ensure that the consumption of fruits or vegetables is monitored well. Zero fruit or vegetable consumption indicates the percentage of children who did not consume any fruits or vegetables in the previous day [9]. A diet rich in vegetables and fruits is crucial for children’s growth, preventing non-communicable diseases, and promoting lifelong healthy habits [11]. Low fruit and vegetable intake contributes to 85% of the global disease burden, including 31% of ischemic heart disease, 15% of cancers, and 11% of strokes [12]. A study showed that more than 80% of people aged 15 and older in 28 LMICs consumed less fruits or vegetables than recommended [13]. People in LMICs typically consume only 3.61 portions of fruits or vegetables per day, which is significantly below the WHO-recommended five portions [14].

Malnutrition is still a major issue in Nepal. Under 5 stunting rate in the country has dropped significantly, from 57% in 1996 to 25% in 2022 [15]. Similarly, under 5 wasting has decreased from 15% to 8% over the same period, while the prevalence of overweight has remained stable at 1% [15]. Despite national-level improvements, there is a disparity in such improvements within the country. In the Karnali region, 35.8% of children under five are stunted compared to Bagmati (18.5%) and Gandaki province (19.7%) [15]. In the Karnali region, 28% of households face food insecurity, and 7% suffer from severe food shortages [16]. The main drivers of high rate of undernutrition include the region’s challenging terrain, low economic status, poor transportation and supply chains, limited education, minimum meal frequency, and widespread food insecurity [16, 17].

Achieving minimum dietary diversity prevents nutrient deficiencies and supports growth while meeting minimum meal frequency ensures sufficient energy intake for infant and young children [18]. Few studies have assessed these IYCF indicators in Nepal, but they fail to capture the situation in food-scarce areas such as Karnali, where dietary inadequacies are more pronounced. A hospital-based study in Bhaktapur found that 66.2% of children aged 6–23 months met the MDD criteria, while 79.1% achieved MMF [19]. However, it did not assess the factors influencing these feeding practices. Similarly, a study in Syangja district reported that 53.3% of children met MDD and 61.5% met MMF [20]. A further analysis of Nepal Demographic Health Survey(NDHS) 2016 data examined MMF and MDD but did not assess fruit or vegetable consumption [21]. Additionally, a multilevel analysis of the Nepal Multiple Indicator Cluster Survey found that only 39.8% of children met the MDD criteria, while over two-third achieved MMF [22]. However, none of these studies included zero fruit or vegetable consumption as an indicator, and primarily focused on maternal factors, neglecting the influence of paternal factors on child nutrition.

At the national level, the NDHS 2022 data revealed that half of the children (50%) aged 6–23 months in Karnali province fail to meet the MDD criteria, indicating a substantial dietary gap [23]. Despite this, there is a lack of comprehensive research exploring the trends, patterns, and determinants of dietary diversity and meal frequency in this region [24]. The Karnali region faces numerous challenges which include geographical isolation, food insecurity, and restricted access to agricultural and market infrastructure, which exacerbate these nutritional gaps [15, 25, 26]. Existing data primarily focus on undernutrition but lack deeper insights into inadequate nutrient intake, particularly in remote regions where diverse and nutrient-rich food consumption is low [23]. This narrow focus hinders efforts to address the root causes of malnutrition, in areas such as Karnali, where food insecurity is widespread and food choices are limtied [27]. These studies do not comprehensively address regional disparities, particularly in remote and food-insecure districts such as Kalikot in the Karnali province. The literature gap underscores the need for region-specific place-based research to understand dietary patterns, diversity, frequency, and fruit or vegetable consumption.

With this background, this study aimed to investigate the prevalence of and the factors associated with minimum meal frequency, minimum dietary diversity, and fruit or vegetable consumption among children aged 6–23 months in the Kalikot district of Karnali province. This research will provide critical insights into the dietary patterns of young children in the region, and inform targeted interventions to improve nutrition and reduce malnutrition-related health risks.

Methods

Study setting and context

This study was carried out in Kalikot district, situated in the upper western mountainous region of Karnali province, Nepal. The district is 180 m to 7,348 m from the sea level, has higher mountainous terrain, and is mainly rural, comprising eight administrative units— three municipalities and five rural municipalities [28]. The Karnali region is known for its difficult access, mountainous terrain, and food insecurity, and is the least accessible and least developed region in the country. The government of Nepal has implemented critical initiatives such as the Agriculture Development Strategy (ADS), Multi-sector Nutrition Plan (MSNP) II (2018–2022), and the Zero Hunger Challenge National Action Plan (2016–2025) to improve food security and nutrition [29]. Despite these efforts, achieving food security and improving nutrition remains a major challenge in Karnali. Poor road infrastructure, reliance on distant market hubs in the Terai, and high food prices continue to limit access to adequate nutrition [29]. Several implementation-level challenges persist, including disparities in access to nutrition and healthcare services, inadequate data for informed decision-making, and limited emphasis on improving feeding practices despite the presence of multiple nutrition interventions [30, 31]. Furthermore, unequal distribution of agricultural resources and the unpredictability of food supply during emergencies pose significant obstacles to translate policies into effective actions in Nepal [30].

This study was conducted in Khadachakra Municipality, one of the district’s administrative centers. Figure 1 presents the study map, highlighting the geographical boundaries and key areas of focus within the study region. Although designated as a municipality, the study area closely resembles remote settings in terms of infrastructure, services, and lifestyle. According to the National Census 2021, Khadachakra has 4,101 households and a total population of 22,274, with 72,245 males and 73,047 females [32]. The current study is part of a larger study conducted in the study area, carried out with the objective to access the coverage of and factors associated with the regular use of Fortified Blended Flour (Supplementary Food) among children aged 6–23 months [33].

Fig. 1.

Geographical representation of the study area

Participants and procedure

This was a community-based cross-sectional study conducted from February to March 2024 [33]. The current study settings have 11 wards, and the participants were selected on the basis of probability proportional to the size of each ward. Initially, a list of eligible children in each ward was compiled from local sources, such as the vitamin A register, supplemented by the local knowledge of health workers and volunteers. Notably, the local council office (ward) has records of all births that have occurred in the region; the vitamin A register includes all children aged 6 months to under five years who receive biannual vitamin A supplementation, the coverage of which is approximately 100%. The local female community health volunteers are the residents of the local communities, actively engaged in maternal and child health programs and other social activities, are likely to know the hard-to-reach communities, and are able to identify 6–23-month-old children in their communities. Therefore, our sampling frame was likely to include all 6 to 23-month-old children. Once the list was prepared, random sampling was employed to select participants from each ward’s list. Our primary preference for respondent was mother of the child. Only in the absence of mother, caretaker of the child was included as a respondent. If any mother or caretaker declined to participate, the next person on the list was chosen. However, no participants declined to participate in the study. The participants who provided consent were included in the interviews. Only the youngest child from each household was included to minimize recall bias, as caregivers are more likely to accurately remember recent practices. Furthermore, if the respondents were unable to answer the questions due to any severe health condition or cultural circumstances, they were excluded. A total of 423 eligible mothers/child pairs were included in this study.

Face-to-face interviews were conducted in Nepali language at participants’ homes using structured questionnaires. The infant feeding variables were adapted from the WHO/UNICEF IYCF guidelines [34] and the NDHS 2022 [15]. Other independent variables were adapted from the NDHS 2022 and former studies from Nepal [15, 35–37]. We also pretested the tool among 10% of a similar population in nearby municipalities and modified the flow and wording of the Nepali version of the questionnaire before use.

Ethics

Ethical approval was granted by the Institutional Review Board of the Institute of Medicine, Maharajgunj, Kathmandu (Dec 22,2023 / 286). Participants were fully informed in local language about the study’s purpose and assured that their participation was voluntary, with the option to withdraw at any time. Written informed consent was obtained before conducting interviews, and mothers provided consent on behalf of themselves and their infants.

Variables

Outcome variables

We included three key IYCF indicators for this study: minimum dietary diversity, minimum meal frequency, and fruit or vegetable consumption using the recent IYCF guidelines [34]. Minimum Dietary Diversity (MDD) measures the percentage of children aged 6–23 months who consumed foods and beverages from at least five of the eight defined food groups in the last 24 h. The eight food groups include breastmilk; grains, roots, and tubers; legumes and nuts; dairy products (milk yogurt, cheese); flesh foods (meat, fish, poultry, and organ meat); eggs; vitamin A-rich fruits and vegetables; and other fruits and vegetables [9, 15]. Similarly, Minimum Meal Frequency (MMF) captures the proportion of children in the same age range who received solid, semi-solid, or soft foods (including milk feeds for non-breastfed children) at least the minimum recommended number of times within the last 24 h. The WHO guidelines suggest that breastfed infants aged 6–8 months should be offered complementary foods 2–3 times a day. For those 9–23 months, the recommendation increases to 3–4 times daily, with nutritious snacks 1–2 times daily. Non-breastfed children are advised to have 4–5 meals each day [9]. Finally, the vegetable or fruit consumption variable reflects the percentage of children aged 6–23 months who consumed fruits or vegetables during the prior day [9].

Independent variables

The study included the independent variables based on an extensive literature review. Several religions are represented in the National Census 2021, including Hinduism, Buddhism, Islam, Kiranti, Christianity, Prakriti, Bon, Jain, Bahai, and Sikhism [32]. Due to the limited number of non-Hindu respondents, the religion variable was simplified into two categories: Hindu and Others [38]. We categorized the caste into three main categories using existing literature: Brahmin/Chhetri; Dalit; and Janajati, and others such (as Shahi and Malla) [20].

To evaluate economic status, a wealth index was constructed using principal component analysis (PCA), incorporating indicators like access to drinking water, sanitation facilities, primary cooking fuel sources, separate kitchens, types of flooring materials, and ownership of various items such as electricity, radios, televisions, mobile phones, sofas, and cupboards [35]. The wealth quintile was then divided into three categories: poor, middle, and rich [35]. The educational attainment of parents was classified into three levels: no formal education, school education, and higher education [36]. Fathers’ occupations were categorized into four groups: employed, semi-employed, engaged in foreign employment, or unemployed. In contrast, mothers’ occupations were classified as employed, semi-employed, or involved in household and agricultural work [36]. Exclusive breastfeeding for this study was defined as exclusively breastfeeding children until six months of age without introducing solid or liquid foods, including water [38].

Statistical analysis

The proportion of infants receiving MDD, MMF, and fruit or vegetable consumption was reported using frequency distribution. Univariate association between these IYCF practices and their individual association with independent variables were investigated using chi-square tests. The significant factors (at p < 0.05) were further subjected to multiple logistic regression. Adjusted odds ratios (AORs) and their 95% confidence intervals (CIs) were reported. Statistical significance was set at a p-value of 0.05. Data were entered into Epi-data and analysed using the Statistical Package for Social Sciences (SPSS, Version 22).

Results

Participant characteristics

Table 1 presents the characteristics of the 423 participants, which have also been previously reported [33]. The mean age of the children was 15.06 months (SD: 5.46). Regarding education, 59.1% of fathers and 53.4% of mothers had secondary education. One in four (40%) households were in the poor quintile, with only 17.8% in the rich quintile. Dietary decisions were made primarily by mothers (63.1%).

Table 1.

Participant characteristics

Characteristics	Frequency	Percentage
Child’s age (in months)
6–11	127	30
12–17	123	29.1
18–23	173	40.9
Mean age: 15.06 months (SD: 5.69)	Max: 23 months	Min:6 months
Mother’s age (in Years)
15–24	175	41.4
25–34	197	46.6
35 and above	51	12.1
Mean Age:26.6 years (SD: 5.46)	Max: 50 years	Min: 17 years
Gender of child
Male	234	55.3
Female	189	44.7
Religion
Hindu	412	97.4
Others	11	2.6
Caste
Brahmin/Chhetri	159	37.6
Dalit	188	44.4
Janajati and others	76	18
Type of family
Nuclear	196	46.3
Joint/Extended	227	53.7
Father’s education
No formal education	70	16.5
School level	250	59.1
Higher level	103	24.3
Mother’s education
No formal education	103	24.3
School level	226	53.4
Higher level	94	22.2
Father’s occupation
Employed	75	17.7
Semi employed	263	62.2
Foreign employment	36	8.5
Unemployed	49	11.6
Mother’s occupation
Employed	31	7.3
Semi employed (small business, daily wages)	72	17
Household and agricultural work	320	75.7
Wealth quintile
Poor	169	40
Middle	180	42.6
Rich	74	17.5
Number of children in household (Mean no. of children: 2.5)
3 or less than 3 children	338	79.9
More than 3 children	85	20.1
	Min: 1	Max: 8
Birth order of the child
First born	118	27.9
Second to Fourth	278	65.7
Five or more	27	6.4
Decision making on child diet
Father of the child	75	17.7
Mother of the child	267	63.1
Grandmother of the child	81	19.1
Place of childbirth
Health facility (public + private)	403	95.3
Home	20	4.7
Assistance during birth
Skilled health worker	398	94.1
Other	25	5.9
Mode of birth
Vaginal or Forceps/vacuum	408	96.5
Caesarean	15	3.5
Low birth weight
Yes	70	16.5
No	353	83.5
Mother having any health issues hindering breastfeeding
Yes	74	17.5
No	349	82.5
Mother experienced redness or blisters in breast, child experiencing difficulty during breastfeeding
Yes	52	12.3
No	371	87.7
Child unwell in last 15 days
Yes	158	62.6
No	265	37.4
Illness (n=158)
Childhood diarrhoeal diseases (CDD)	53	33.5
Acute respiratory illness (ARI)	64	40.5
Other	41	25.9

Prevalence of minimum meal frequency, minimum meal diversity, and fruit or vegetable consumption

Figure 2 illustrates the prevalence of MDD, MFF, and fruit or vegetable consumption among the children. While 78.5% of the children met the MMF criteria, the proportion achieving MDD was much lower at 24.1%. Similarly, only 33.1% of children consumed fruits or vegetables on the previous day, leaving 66.9% zero fruit or vegetable consumption. Most children were fed a diet centered on the staple meal of rice and pulses, commonly known as ‘Dal-Bhat’ with little to no inclusion of vegetables.

Figure 2.

Infant and young child feeding practices among children aged 6-23 months

Factors associated with minimum meal frequency, minimum meal diversity, and fruit or vegetable consumption

Table 2 reflects the distribution of MDD, MMF, and fruit or vegetable consumption across various participant characteristics using a chi-square test to determine associations. The factors associated with individual IYCF practices were subjected to multiple logistic regression. Table 3 shows the results of the multiple logistic regression to reflect the factors associated with the three IYCF practices.

Table 2.

Distribution of minimum dietary diversity, minimum meal frequency and fruits or vegetables consumption among young children of Karnali regions of Nepal, 2024

Factors	Minimum meal diversity# (criteria met)	Minimum meal frequency## (criteria met)	Fruits or vegetables consumption (yes) ###
Maternal age (in years)	p = 0.493	p = 0.169	p = 0.153
15–24	45 (25.7%)	137 (78.3%)	64 (36.6%)
25–34	47 (23.9%)	161 (81.7%)	56 (28.4%)
35+	9 (17.6%)	34 (66.7%)	20 (39.2%)
Gender of the child	p = 0.160	p = 0.750	p = 0.460
Female	39 (20.6%)	147 (77.8%)	59 (31.2%)
Male	62 (26.5%)	185 (79.1%)	81 (34.6%)
Religion	p = 0.653	p = 0.050	p = 0.677
Hindu	99 (24.0%)	326 (79.1%)	137 (33.3%)
Others	2 (18.2%)	6 (54.5%)	3 (27.3%)
Caste	p = 0.162	p = 0.162	p = 0.432
Brahmin/Chhetri	126 (79.2%)	126 (79.2%)	57 (35.8%)
Dalit	141 (75.0%)	141 (75.0%)	56 (29.8%)
Janajati and others	65 (85.5%)	65 (85.5%)	27 (35.5%)
Father’s education	p = < 0.001	p = < 0.001	p = 0.021
No formal education	9 (12.9%)	40 (57.1%)	16 (22.9%)
School level	49 (19.6%)	212 (84.8%)	80 (32.0%)
Higher level	43 (41.7%)	80 (77.7%)	44 (42.7%)
Mother’s education	p = < 0.001	p = < 0.001	p = 0.245
No formal education	18 (17.5%)	62 (60.2%)	29 (28.2%)
School level	43 (19.0%)	193 (85.4%)	74 (32.7%)
Higher level	40 (42.6%)	77 (81.9%)	37 (39.4%)
Number of children in household	p = 0.221	p = 0.423	p = 0.582
3 or less than 3 children	85 (25.1%)	268 (79.3%)	114 (33.7%)
More than 3 children	16 (18.8%)	64 (75.3%)	26 (30.6%)
Birth order of the child	p = 0.901	p = 0.901	p = 0.087
First born	32 (27.1%)	91 (77.1%)	48 (40.7%)
Second to fourth	64 (23.0%)	220 (79.1%)	82 (29.5%)
Five or more	5 (18.5%)	21 (77.8%)	10 (37.0%)
Type of family	p = 0.066	p = 0.066	p = 0.025
Nuclear	160 (82.5%)	160 (82.5%)	75 (38.7%)
Joint/extended	172 (75.1%)	172 (75.1%)	65 (28.4%)
Father occupation	P = 0.036	P = 0.116	P = 0.224
Employed	16 (21.3%)	60 (80.0%)	29 (38.7%)
Semi employed	74 (28.1%)	198 (75.3%)	79 (30.0%)
Foreign employment	5 (13.9%)	30 (83.3%)	11 (30.6%)
Unemployed	6 (12.2%)	44 (89.8%)	21 (42.9%)
Mother’s occupation	p = 0.356	p = 0.568	p = 0.619
Employed	9 (29.0%)	23 (74.2%)	12 (38.7%)
Semi employed (small business, daily wages)	21 (29.2%)	54 (75.0%)	21 (29.2%)
Household and agricultural work	71 (22.2%)	255 (79.7%)	107 (33.4%)
Wealth quintile	p = 0.037	p = 0.09	p = 0.055
Poor	50 (29.6%)	88 (54.0%)	57 (33.7%)
Middle	40 (22.2%)	81 (46.0%)	67 (37.2%)
Rich	11 (14.9%)	28 (39.4%)	16 (21.6%)
Decision maker on child’s diet	p = 0.394	p = 0.394	p = 0.483
Father of the child	18 (24.0%)	57 (76.0%)	22 (29.3%)
Mother of the child	69 (25.8%)	215 (80.5%)	94 (35.2%)
Grandmother of the child	14 (17.3%)	60 (74.1%)	24 (29.6%)
Child ill in past 15 days	p = 0.520	p = < 0.001	p = 0.483
Yes	35 (22.2%)	180 (68.4%)	48 (30.4%)
No	66 (24.9%)	224 (84.5%)	92 (34.7%)
Exclusive breastfeeding	p = 0.962	p = 0.108	p = 0.824
Yes	213 (81.0%)	213 (81.0%)	86 (32.7%)
No	63 (24.0%)	119 (74.4%)	54 (33.8%)
Currently breastfeeding	p = 0.558	p = 0.006	p = 0.534
Yes	92 (23.5%)	313 (80.1%)	131 (33.5%)
No	9 (28.1%)	19 (59.4%)	9 (28.1%)
Low birthweight	p = 0.027	p = 0.027	p = 0.046
Yes	13 (18.6%)	48 (68.6%)	16 (22.9%)
No	88 (24.9%)	284 (80.5%)	124 (35.1%)
Place of childbirth	P = 0.511	p = 0.468	p = 0.202
Health facility (public + private)	95 (23.6%)	315 (78.2%)	136 (33.7%)
Home	6 (30.0%)	17 (85.0%)	4 (20.0%)
Assistance during birth	p = 0.326	p = 0.233	p = 0.319
Skilled health worker	93 (23.4%)	310 (77.9%)	134 (33.7%)
Other	8 (32.0%)	22 (88.0%)	6 (24.0%)
Mode of birth	P = 0.382	P = 0.885	P = 0.202
Vaginal or Forceps/vacuum	96 (23.5%)	320 (78.4%)	135 (33.1%)
Caesarean	5 (33.3%)	12 (80.0%)	5 (33.3%)
Mother having any health issues hindering breastfeeding	p = 0.616	p = 0.517	p = 0 0.042
Yes	16 (21.6%)	56 (75.7%)	17 (23.0%)
No	85 (24.4%)	276 (79.1%)	123 (35.2%)
Mother experienced redness or blisters in breast	p = 0.213	p = 0.331	p = 0.804
Yes	16 (30.8%)	38 (73.1%)	18 (34.6%)
No	85 (22.9%)	294 (79.2%)	122 (32.9%)
Received nutritional counselling during health facilities visits	p = 0.674	p = 0.007	p = 0.151
Never received	16 (22.2%)	48 (66.7%)	19 (26.4%)
Ever received	83 (24.6%)	274 (81.1%)	119 (35.2%)

Table 3.

Factors associated with minimum dietary diversity, minimum meal frequency and fruits or vegetables consumption

Factors	Minimum meal diversity#	Minimum meal frequency##	Fruits or vegetables consumption ###
Father’s education	p = 0.037	p = 0. 014	p = 0.024
No formal education	1.00	1.00	1.00
School level	1.87 (0.79, 4.39)	2.12 (1.06, 4.24)	1.54 (0.82, 2.90)
Higher level	3.60 (1.30, 9.95)	0.83 (0.32, 2.18)	2.51 (1.25, 5.01)
Low birthweight	p = 0.403	p = 0.404	p = 0.125
Yes	1.00	1.00	1.00
No	1.34 (0.67, 2.68)	1.32 (0.68, 2.58)	1.61 (0.87, 2.97)
Mother’s education	p = 0.115	p = 0.001	not included in the model
No formal education	1.00	1.00
School level	0.88 (0.44, 1.77)	3.09 (1.62, 5.91)
Higher level	1.79 (0.75, 4.25)	4.27 (1.61, 11.36)
Father occupation	p = 0.039	not included in the model	not included in the model
Unemployed	1.00
Employed	1.61 (0.55, 4.72)
Semi employed	2.76 (1.08, 7.05)
Foreign employment	1.11 (0.29, 4.18)
Wealth quintile	p = 0.356
Poor	1.00	not included in the model	not included in the model
Middle	1.10 (0.64, 1.90)
Rich	0.63 (0.29, 1.37)
Child ill in past 15 days	not included in the model	p = 0.001	not included in the model
Yes		1.00
No		2.39 (1.42, 4.02)
Currently breastfeeding	not included in the model	p = 0.171
No		1.00
Yes		1.89 (0.75, 4.75)
Received nutritional counselling during health facilities visits	not included in the model	p = 0.132	not included in the model
Never received		1.00
Ever received		1.61 (0.86, 3.01)
Type of family	not included in the model	not included in the model	p = 0.027
Joint/extended			1.00
Nuclear			1.60 (1.05, 2.45)
Mother having any health issues hindering breastfeeding	not included in the model	not included in the model	p = 0.050
Yes			1.00
No			1.81 (1.00, 3.29)

#variables entered in model: Father’s education, mother’s education, father occupation, wealth quintile, low birth weight

## variables entered in model: Father’s education, mother’s education, child ill in past 15 days, currently breast feeding, low birth weight, receiving nutritional counselling during health facilities visit

### variables entered in model: Father Education, type of family, low birth weight, mother experiencing any health issue

Two factors, i.e., father’s education and maternal education, remained significantly associated with MFF after controlling for other factors in the model. Children whose fathers had a school-level education were twice as likely to receive the minimum meal frequency (AOR: 2.12; 95% CI: 1.06, 4.24). Similarly, children of mothers with higher education were four times more likely to meet the MMF requirement (AOR: 4.27; 95% CI: 1.61, 11.36). The child’s recent illness negatively impacted meal frequency; children without a recent illness were over twice as likely to meet MMF (AOR: 2.39; 95% CI: 1.42, 4.02). Only one factor, father’s education, remained significantly associated with MDD. A higher level of education of fathers increased the likelihood of children receiving diverse diets (AOR: 3.60; 95% CI: 1.30, 9.95), highlighting the crucial role of paternal education in promoting better nutritional practices. Finally, father’s education and family type were associated with fruit or vegetable consumption. Children of fathers with higher education were more than twice as likely to consume fruits or vegetables (AOR: 2.51; 95% CI: 1.25, 5.01). Additionally, children from nuclear families were more likely to receive fruits or vegetables compared to those from extended families (AOR: 1.60; 95% CI: 1.05, 2.45).

Discussion

This study examined the prevalence and the associated factors of the three key IYCF indicators: MDD, MMF, and fruit/vegetable consumption among children aged 6–23 months, along with the factors influencing these practices. The Karnali region, including Kalikot, is a food insecure area in Nepal [26]. To the best of our knowledge, this is the first study in the Karnali province (altitude from sea level: 180 m to 7,348 m [39]), focusing on these indicators in the remote upper western region of Nepal.

Nepal has implemented a number of initiatives to improve infant and child nutrition. Some of these include Growth monitoring and promotion program, Integrated IYCF and Micronutrient Powder community promotion program, Mother and child health and nutrition program, etc. [40]. Specifically, in Karnali Province, targeted efforts such as the Child cash grant Program and the distribution of Fortified Blended Flour aim to improve children’s nutritional status and address regional disparities [41]. Similarly, different plans, such as the Multi-Sector Nutrition Plan (MSNP II), interim plans, and the National Health Sector Programs (NHSP I & II), emphasize improving nutritional outcomes and IYCF practices across the country [40, 42]. Despite multiple interventions, there has been limited focus on sustainable improvements in child feeding practices [30]. This results in poor dietary quality, leaving children vulnerable to malnutrition and its associated health risks. This study found that while more than three-quarters of children received MMF, only a quarter received MDD, indicating a significant gap in dietary variety. These percentages are considerably lower than the NDHS 2022 provincial average of Karnali province, which shows 87% for MMF and 50% for MDD [23], suggesting that the dietary practices in the Kalikot district need considerable improvement compared to the overall trends in the province. The regional disparity in nutritional outcomes is striking, as the neighboring Gandaki province has the highest MDD rate of 57%. This contrast underscores the significant nutritional gaps in Karnali Province [15].

Only 33.1% of children had fruits or vegetables included in their diet, while 66.9% had zero fruit or vegetable consumption. The national average from NDHS 2022 shows that 33% of the children aged 6–23 months did not consume any fruit or vegetable while the provincial average of Karnali is 38% [15, 23]. The finding of this study is similar to that of Ethiopia and India where zero fruit or vegetable consumption is 69.3% and 61% respectively [43, 44]. The food deficiency, poverty, and lack of access to availability of diverse food, among many other social determinants of health, may explain the current low MMF, MDD, and zero fruit or vegetable consumption in the current study setting [15]. Despite relying on food aid since 1996, this temporary and unreliable solution has remained ineffective to address malnutrition [45].

Higher father’s education was found to be positively associated with all three indicators: MDD, MMF, and fruit or vegetable consumption. The study based on NDHS 2011 similarly highlighted the positive impact of a father’s education on both MDD and MMF in infants and young children [46]. Similarly, results from Ethiopia also signify the association of MMF and MDD in children with their father’s education [47]. Further evidence from a study in Kaski district, Nepal, underscores the role of the father’s education in promoting fruit or vegetable consumption among children [48]. Comparable findings have also been reported in Eastern Africa, reinforcing the importance of father’s education in improving child nutrition practices ​ [49].

Mother’s education was found to be associated with MMF, although it was not associated with MDD and fruit or vegetable consumption of the children. A regional analysis in India also supports the finding showing a positive association between MMF and Mother’s education [50]. A longitudinal study of Pakistan contrasts with the findings as it shows a positive association of maternal education with MDD [51]. Findings from Ethiopia and East Africa present contrasting results, showing that maternal education is associated with zero fruit or vegetable consumption [49, 52].

Meal frequency was also associated with a child not having an illness. While there is no other study that has demonstrated a similar association in Nepal, one Ethiopian study had previously reported that a child’s illness was a barrier to an infant’s illness [53]. It is plausible that a sick child will not be eating or drinking as they normally do, and it is also difficult for the mother to continue normal feeding practices when a child is ill. This finding nevertheless highlights the importance of support to a mother or carer to help continue the recommended feeding practices when their children are unwell.

This study has some significant strengths. No prior study has been conducted to highlight the issues of low dietary diversity, inadequate meal frequency, and zero fruit or vegetable consumption in this region, leaving these critical nutrition gaps largely overlooked. This study is the first to bring these issues to light and highlights the urgent need for targeted interventions. We used the 24-hour recall method as recommended by the IYCF guidelines to ensure that the recall was reflected accurately. Our tool was adapted locally from the NDHS tool to ensure that all everyday food items were captured while collecting data. A few limitations need to be accounted for while interpreting the findings of our study. One major limitation of the study is the potential measurement bias introduced by the 24-hour dietary recall method. While this method is widely used and recommended for assessing IYCF practices, it relies on the caregiver’s ability to accurately recall and report the child’s food intake. Another limitation of this study is the seasonal variation in the availability of food items affecting dietary intake data, limiting the applicability of findings to different seasons. As data collection occurred at a single time point, it may not fully capture the seasonal fluctuations in dietary patterns. Future research should adopt a longitudinal approach to assess how seasonal variations impact IYCF practices. A further limitation is the lack of an in-depth exploration of cultural influences on dietary practices. Traditional beliefs and food taboos significantly shape child-feeding behaviors in Nepal, making it challenging to generalize these results to other provinces in Nepal or different sociocultural contexts.

Despite these limitations, this study provides valuable insights into the IYCF challenges in remote Nepal and highlights the urgent need for targeted interventions. The study highlights the need for targeted educational programs that involve both parents. Strengthening nutritional awareness, especially among fathers, could lead to improved dietary practices and better child health outcomes [54]. Efforts should focus on strengthening maternal support systems for feeding during illness by enhancing the role of female community health volunteers and mothers’ groups [55]. Ensuring the sustainability of local food systems is essential to address the longstanding under-resourcing and marginalization of regions like Karnali, while also improving access to and consumption of locally available nutritious foods [45, 56]. Innovative approaches like programs promoting community food banks, home gardening initiatives, and improved food storage facilities should be introduced [57, 58]. Existing initiatives such as the Child Cash Grant Program and food distribution efforts should be linked with behaviour change communication strategies. Conditional cash transfers that require participation in nutrition education sessions can reinforce IYCF knowledge among parents and caregivers [59]. This approach will also contribute to Nepal’s progress towards achieving SDG 2.1, which aims to end hunger and ensure affordable and accessible food for all [60]. To further optimize IYCF practices in the region, future action research should explore and empower local positive cultural practices and food habits. Such research should be built on the areas outlined above, and evaluate the success, failures and scalability of the interventions.

Conclusion

This study provides valuable insights into the infant and young child feeding (IYCF) practices in the remote Kalikot district of Nepal, focusing on three key indicators: minimum meal frequency (MMF), minimum dietary diversity (MDD), and fruit or vegetable consumption. While more than three-quarters of infant and young children received the recommended meal frequency, only one in four received recommended diversity, and two-third of children did not receive any fruits or vegetables. The findings underscore the urgent need for comprehensive interventions that improve food availability and address the socioeconomic determinants that influence feeding behaviors. Education programs that actively involve both fathers and mothers, along with efforts to promote the value of local foods, are essential to address the nutritional challenges of children in this region face. It is crucial to focus on skill-building initiatives that encourage cultivating and consuming locally available nutritious foods instead of relying on band-aid solutions. Strengthening the cultural appreciation of local food production and highlighting its benefits are essential to help improve food security and nutrition in the region.

Abbreviations

ADS

Agriculture Development Strategy

FCHV

Female Community Health Volunteers

IYCF

Infant and Young Child Feeding

LMICs

Low- and Middle-Income Countries

MDD

Minimum Dietary Diversity

MMF

Minimum Meal Frequency

MSNP

Multi-Sector Nutrition Plan

NDHS

Nepal Demographic and Health Survey

NHSP

National Health Sector Programs

PCA

Principal Component Analysis

SDG

Sustainable Development Goals

SPSS

Statistical Package for Social Sciences

UNICEF

United Nations International Children’s Emergency Fund

WHO

World Health Organization

Author contributions

SS designed the study, developed the research protocol, and carried out the fieldwork under supervision of VK. Data analysis was performed by SS, with substantial contributions from VK. SS prepared the initial draft of the manuscript with valuable feedback and assistance from VK. Both authors reviewed the results and interpretations, contributed to revisions, and approved the final version of the manuscript.

Funding

No external funding was received for this study.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This study received ethical approval from the Institutional Review Committee of the Institute of Medicine at Tribhuvan University (Dec 22, 2023/ 286). All the participants provided written informed consent. All methods were carried out in accordance with relevant guidelines and regulations published by the IoM.

Consent for publication

We used deidentified data and have not used any personal account. Therefore, this is not applicable.

Competing interests

The authors declare no competing interests.