Nutrients of concern for older infants and young children in packaged food products available in Nepali retail stores

Summary

Background

Nepali older infants and young children (IYC) are increasingly consuming packaged foods. However, energy and nutrients of concern in these products (total sugar, added sugar, total fat, saturated fat, sodium, and non-sugar sweeteners) have not been assessed. This cross-sectional study aimed to assess energy and nutrients of concern in packaged foods available to older IYC in retail stores in Nepal using thresholds from the WHO Southeast Asia Region Nutrient Profile Model (SEAR NPM).

Methods

Nutrition labels on packaged food products for sale in a cross-section of 4 large stores (2 supermarkets, 2 departmental stores) and 22 small (corner) stores were photographed by three trained researchers. Ingredients, energy and nutrients of concern were extracted from the labels. Products were categorised into 14 food groups using the SEAR NPM with the primary outcome being the proportion of products exceeding thresholds for one or more nutrients of concern.

Findings

We found 2001 unique packaged food products, of which 1525 (76.0%) contained all requisite and readable nutrition information on the labels. Of 1525 products, 1323 products (86.8%) exceeded one or more SEAR NPM thresholds for energy and nutrients of concern and/or contained NSS. Most products exceeded the threshold for total energy (94.9%), followed by 79.7%, 72.5%, 71.4%, 55.3%, and 55.1% of products exceeding the threshold for total sugar, total fat, saturated fat, added sugar, and sodium respectively. By food category, almost all bakery products (99.7%), confectionery (99.6%), savoury snacks (99.2%), and water-based flavoured drinks (98.3%), most frozen dairy based desserts and edible ices (88.4%), approximately three-quarters of instant noodles and soups (75.6%), half of the cereals (54.0%), juices (50.0%), and milk and dairy-based drinks (46.0%) exceeded one or more of the SEAR NPM thresholds for energy and nutrients of concern and/or contained NSS.

Interpretation

Our findings suggest that regulatory measures are needed to limit exposure to and consumption of packaged foods by older IYC given the number of products exceeding thresholds for energy and one or more of the nutrients of concern.

Funding

NS was supported by Deakin University Postgraduate Research Scholarship and CR was supported by a Deakin University Post-Doctoral Fellowship.

Research in context.

Evidence before this study

We searched for evidence on the nutritional quality of foods available in Nepal using the search terms “unhealthy food” OR “processed food” OR “packaged food” OR “junk food” OR “nutrient profile” OR “nutrient information” or “nutrient composition” or “nutrient content” AND “Nepal” OR “Nepali” OR “Nepalese” in Global Health, PubMed and ProQuest Medline from January 2010 to August 2024. The search revealed 44 articles. Of these, Pries et al. assessed snack foods and beverages consumed by young children in the last 24 h, profiled 239 products, both home-cooked and commercially produced, and reported 75.3% of them as unhealthy based on UK Food Standard Agency Nutrient Profile Model. Another study assessed advertisements of foods during children's programs on national television and reported that 70.0% of the advertisements were of foods high in sugar, sodium and saturated fat. Four studies reported consumption of unhealthy foods, like biscuits, chocolates/candy, chips, common among school-aged children. While NPMs have been extensively used in other countries to evaluate nutritional quality of food products and guide policy decisions to limit exposure and consumption of unhealthy foods among children, they have not been used in Nepal. Consequently, there is a lack of evidence on the nutritional quality of packaged foods in Nepal.

Added value of this study

To our knowledge, this is the first study to describe energy and nutrients of concern in packaged food products available in retail stores in Nepal. We collected product information using a photographic method, which is useful where databases or product registries are not available, and product purchase is not feasible due to resource constraints. We found 2001 packaged food products, of which 1525 (76.0%) had sufficient and readable nutrient information on the labels to assess nutritional quality. We found that 86.8% of products exceeded one or more of the Southeast Asia Region (SEAR) NPM thresholds for energy and nutrients of concern and/or contained NSS. Products commonly consumed by older IYC, such as, confectionery, bakery, and savoury snacks, were most likely to exceed the nutrients of concern.

Implications of all the available evidence

Along with evidence reporting increased consumption of unhealthy foods by older IYC in Nepal, our study findings highlight the need for policy initiatives to limit exposure to and consumption of packaged foods high in energy and nutrients of concern among older IYC. The lack of nutrient information on many labels also highlights a need for regulations requiring manufacturers to provide this information. Future research should explore exposure to unhealthy foods in other age groups and readiness among policymaker and other stakeholders in Nepal to introduce policy initiatives.

Introduction

The nutrition transition in Nepal is marked by a shift in dietary patterns toward increased consumption of an unhealthy diet—energy dense foods and beverages high in sugar and sodium and low in protein, vitamins, minerals, and fibre¹—and increased prevalence of associated non-communicable diseases (NCDs) including type 2 diabetes.² Packaged foods and beverages (hereafter packaged foods), defined as foods and beverages sealed inside packages, contribute to unhealthy diets because they tend to be energy dense and contain high amounts of nutrients of concern such as sugar, sodium and saturated fat.3, 4, 5 High consumption of these nutrients is linked to diet-related NCDs, such as diabetes and heart diseases.⁶

Though packaged foods, such as biscuits, chips, instant noodles, are not specifically marketed to older infants (6–12 months) and young children (13–23 months) (hereafter older IYC), these foods are frequently consumed by them.⁷ As has been observed in other countries,⁷ consumption of packaged foods is common among Nepali older IYC. A 2016 study in urban Nepal found 74.0% of older IYC consumed packaged foods the previous day.⁸ A 2019 study reported unhealthy snack foods, most commonly biscuits, chips, instant noodles, sugar-sweetened beverages (SSBs), contributed a quarter of total energy intake among urban children aged 12–23 months.⁹ A 2022 national survey showed that consumption of unhealthy foods, including packaged foods, was not only high among urban children in Nepal, but nationwide, with 68.0% of older IYC consuming unhealthy foods and 43.3% consuming SSBs in last 24 h.¹⁰ Young children are routinely exposed to these packaged foods marketed in their local settings influencing their caregivers decision to purchase.¹¹ Caregivers, including those from Nepal, are inclined towards packaged foods, because of their availability, affordability and convenience.^11,12 Given that WHO recommends older IYC should not consume foods and beverages high in sugar, sodium and trans-fat,¹³ previous studies describing high unhealthy food and beverage consumption are concerning.

In addition to containing nutrients of concern, packaged foods may displace healthier options containing micronutrients, like fruit and vegetables, further contributing to malnutrition in low-and-middle-income countries (LMIC) like Nepal. A cross-sectional study, utilising the UK Food Standard Agency Nutrient Profile Model to define food consumed by young children as unhealthy, observed lower intake of 11 micronutrients and short length for age for children 12–23 months among high consumers of unhealthy foods compared to their low consuming counterparts.¹⁴ Low diet diversity and inadequate micronutrient intake among high consumers of unhealthy food has also been reported in Mexico and Spain.^15,16 While stunting and underweight respectively affected 25.0% and 19.0% of Nepali children below 5 years of age in 2022,¹⁰ prevalence of overweight and obesity among these children increased from 1.0% in 2016¹⁷ to 2.6% in 2019.¹⁸ With persistent undernutrition and rising overweight and obesity, Nepali older IYC are at a risk of a double burden of malnutrition.

Nutrient profile models (NPMs), as the name suggests, can be used to profile the nutrient content of packaged foods for monitoring and for interventions such as marketing restrictions or similar regulations.¹⁹ The WHO Southeast Asia Region (SEAR) NPM was developed and validated for identifying food products that should not be marketed to children age over 36 months.¹ NPMs can also be used for other purposes including assessing the nutritional quality of packaged food products. There has been limited use of the SEAR NPM in Nepal and consequently, the nutritional quality of packaged foods available in Nepali retail stores has not been assessed. This study aimed to assess energy and nutrients of concern (total sugar, added sugar, total fat, saturated fat, sodium, and non-sugar sweetener) in packaged foods available in large (supermarket, department stores) and small (corner store) retail stores in Nepal against thresholds in the SEAR NPM.

Methods

We used a cross-sectional study design to gather nutrition label information from packaged foods in retail stores in Kathmandu Valley, the largest metropolitan area in Nepal. In the absence of comprehensive database on food products available in Nepal, we used a convenience mixed method sampling to select retail stores, a method previously employed by a study in Nepal.²⁰ We invited 35 stores (5 large and 30 small) to participate from February to April of 2023. Large stores were purposively selected from a store list publicly available on the internet. As a list of small stores was not publicly available, these were sampled systematically from the twenty-two most populous wards in Kathmandu Valley (detailed in Supplementary Table S1). In each ward, the closest store to a pre-school was selected for data collection. We obtained a letter of introduction from Department of Food Technology and Quality Control, Ministry of Agriculture and Livestock Development for data collection at stores that included the study objective and described data collection methods. In addition, verbal consent was obtained from store owners/managers to photograph food products. If verbal consent was not provided, we chose an alternate large store (the next largest in the list); and in the case of small stores, we went to another store within a 50 m radius of the original store. In line with previous research where similar data has been gathered,^5,21 we did not obtain ethics approval as food labels are publicly available information. However, as a courtesy, the store owners/managers were informed of the study and permission requested and obtained.

Two local researchers with food and nutrition backgrounds and experience in data collection were trained by the first author to photograph and record product label information. We created a list of nine food groups (bread and bakery products, cereal and cereal products, confectioneries, instant noodles and soups, dairy products, processed fruits and vegetables, non-alcoholic beverages, snack foods and baby foods) known to be consumed by young children in Nepal, based on a dataset from a 2017 study in Kathmandu Valley.⁹ We did not include food products such as processed meat and fish, sea foods, sauces, dressings, frozen foods, pre-prepared meals (not consumed by young children)⁹; breastmilk substitutes (out of scope of WHO SEAR NPM),¹ processed culinary ingredients (unlikely to make significant contribution to young children's diet); beverages, such as, tea and coffee (discouraged for IYC)¹³ in the list of food groups we created (see Supplementary Table S2). All unique products within the nine food groups available in the stores were photographed. We defined unique food products based on brand, sub-brand, manufacturer, and country manufactured. Each unique product was photographed only once when they were first encountered, with their availability recorded in all subsequent stores. Products with the same nutrient profiles but different package sizes, types or flavours were counted as a single unique product. Photographs were taken of all sides of the package to ensure all required information, including product name, brand, manufacturer detail, nutrition information panel (NIP), and ingredient list were recorded. At the end of each day, photographs were transferred to the first author's computer, stored in a secure drive and reviewed for quality and completeness. A log of products with missing information or unclear photos were kept, and the products were revisited as they were encountered in stores.

A data entry form was created in Qualtrics to facilitate transfer of data from the photographed labels regarding product name, brand, and manufacturer name and country along with a unique photo identification number. Local researchers then categorised each unique product to one of the nine food groups. Where it was unclear which food group a product fitted in (e.g., peanut butter) this was discussed with the first author. The data recorded in Qualtrics was then exported to Microsoft Excel so that information on serving size, ingredient list, energy, and nutrients including total sugar, added sugar, total fat, saturated fat, and sodium could be added for each product. Total energy was recorded in kilocalories (kcal) per 100 g product, and total sugar, added sugar, total fat, and saturated fat in grams (g) per 100 g product. We also recorded presence of non-sugar sweeteners (NSS) in products based on WHO recommendations that NSS should not be consumed by children.¹³ Total sugar is defined as ‘intrinsic sugars incorporated within the structure of the food, plus added sugar, plus sugar naturally present in honey, syrups, and fruit juices’.¹ Added sugar is defined as ‘sugar added to food products during processing or preparation’.¹ NSS are ‘food additives that impart a sweet taste to a food, including artificial non-caloric sweeteners (e.g., saccharin), natural non-caloric sweeteners (e.g., stevia), and caloric sweeteners’.¹

Following export of information to Microsoft Excel, we reviewed the products and excluded: baby food products (e.g., baby cereals) because these are not covered by SEAR NPM; cough candies used for medicinal purposes; celebratory foods which are exempt in the SEAR NPM; and multi product packages containing different products. Approximately 3.0% of the remaining products were reclassified into appropriate groups. We further excluded products: if the NIP was absent; if the specific nutrient information required to assess SEAR NPM was absent; and if the nutrient values were extreme for a particular group of products. When the NIP reported salt instead of sodium, salt content was divided by 2.50 to calculate sodium.¹ Sodium reported in milligrammes (mg) was converted to grams by dividing by 1000. Nutrient information reported per serving was converted to an amount per 100 g. We recorded reconstituted nutrient values for products which needed reconstitution prior to consumption. First author double-entered 5.0% of energy and nutrient information to ensure data accuracy. Agreement was 94.9% for total sugar, 93.6% for energy, total fat, saturated fat, added sugar, and 88.5% for sodium. Disagreement mostly occurred because of rounding errors, and these were resolved by referring back to the product photographs and consistent rounding of the values.

In the absence of a national nutrient profile model in Nepal, we used the SEAR NPM to determine the proportion of packaged foods that exceeded thresholds for total energy, total sugar, added sugar, total fat, saturated fat, sodium. Though not a part of SEAR NPM, we were also interested in identifying products that contained NSS. We regrouped foods from the eight initial groups (excluding baby foods) into the 14 SEAR NPM food groups so we could apply specific nutrient thresholds. The full list of initial and reclassified SEAR NPM food groups can be found in Supplementary Table S2. The primary outcome was the proportion of packaged products that exceeded thresholds for energy and one or more of the nutrients of concern and/or contained NSS. We were also interested in this proportion by food group. Not all nutrient thresholds apply to all food groups; for instance, the threshold for saturated fat applied only to confectionery, and instant noodles and soups groups (see Table 3). We classified all foods where the manufacturer was not in Nepal as imported. Descriptive statistics were calculated in Stata version 18.0. Median and IQR were reported.

Table 3.

Median values and WHO SEAR threshold for energy, total sugar, added sugar, total fat, saturated fat, and sodium per 100 g in packaged food products by food group.

Food groups (N)	Energy (kcal) per 100 g			Total sugar (g) per 100 g			Added sugar (g) per 100 g
	Na	Median (IQR)	WHO SEAR threshold (kcal)	Na	Median (IQR)	WHO SEAR threshold (g)	Na	Median (IQR)	WHO SEAR threshold (g)
All packaged products (1525)	1510	465.00 (362.00–514.80)		1291	16.00 (3.40–40.00)		662	7.00 (0.00–26.90)
Confectionery (462)	460	490.00 (395.90–538.50)	230.00	408	48.00 (35.20–56.70)	6.00	183	39.20 (19.00–50.00)	–
Bakery products (346)	336	484.70 (462.00–500.00)	230.00	259	21.90 (14.00–28.00)	6.00	123	16.7 (3.00–24.60)	–
Cereal (73)	71	390.00 (381.00–408.00)	–	60	7.10 (1.10–22.30)	9.00	45	0.00 (0.00–9.70)	–
Savoury snacks (potato, cereal or starch based, and animal based) (250)	250	520.20 (476.20–556.00)	230.00	209	3.00 (1.30–6.70)	–	130	0.10 (0.00–3.30)	0.00
Processed nuts (15)	15	610.00 (558.00–638.00)	–	15	4.00 (0.50–6.70)	–	9	0.00 (0.00–0.00)	0.00
Juices (10)	10	48.00 (19.00–55.00)	–	10	6.60 (3.40–11.50)	6.00	3	0.00 (0.00–0.00)	0.00
Milk and dairy based drinks (37)	37	82.00 (58.00–99.00)	–	32	8.70 (5.30–9.60)	–	16	4.50 (2.10–5.40)	0.00
Water-based flavoured drink (60)	60	51.10 (44.00–56.50)	–	57	12.09 (11.00–13.60)	2.00	27	10.80 (7.10–13.10)	–
Cereal, grain, tree nut-based beverages (23)	23	44.90 (38.80–59.00)	–	22	2.90 (1.50–4.20)	6.00	17	0.00 (0.00–0.90)	–
Frozen dairy based desserts and edible ices (42)	42	217.00 (145.00–294.00)	230.00	36	22.00 (14.80–24.40)	12.00	22	17.30 (11.70–22.00)	–
Curded dairy based desserts (11)	10	300.00 (267.50–313.00)	230.00	11	47.30 (40.00–55.00)	6.00	8	45.00 (42.50–46.90)	–
Instant noodles and soups (82)	82	433.00 (28.70–471.30)	–	71	1.20 (0.50–2.70)	9.00	40	0.50 (0.20–1.20)	–
Pasta, noodles and like products (56)	56	356.00 (350.00–360.00)	–	49	2.10 (0.00–3.20)	–	25	0.00 (0.00–0.00)	–
Processed fruits and vegetables (58)	58	270.00 (153.00–325.00)	–	52	63.10 (19.50–66.70)	–	14	17.50 (12.00–23.00)	0.00

Food groups (N)	Total fat (g) per 100 g			Saturated fat (g) per 100 g			Sodium (g) per 100 g
	Na	Median (IQR)	WHO SEAR threshold (g)	Na	Median (IQR)	WHO SEAR threshold (g)	Na	Median (IQR)	WHO SEAR threshold (g)
All packaged products (1525)	1509	18.70 (2.80–27.40)		1239	8.00 (0.60–12.70)		1222	0.20 (0.04–0.48)
Confectionery (462)	461	24.50 (4.00–32.50)	8.00	411	10.30 (1.50–18.30)	6.00	389	0.08 (0.03–0.17)	–
Bakery products (346)	346	20.10 (16.50–24.00)	8.00	229	10.00 (7.80–12.00)	–	219	0.30 (0.20–0.50)	0.25
Cereal (73)	72	5.70 (2.30–8.60)	12.00	61	1.00 (0.60–1.70)	–	57	0.15 (0.00–0.50)	0.35
Savoury snacks (potato, cereal or starch based, and animal based) (250)	248	28.90 (21.00–35.00)	8.00	197	10.90 (7.70–14.20)	–	215	0.70 (0.50–0.90)	0.25
Processed nuts (15)	15	48.00 (38.00–53.30)	–	14	10.00 (5.40–11.70)	–	14	0.40 (0.30–0.50)	0.05
Juices (10)	9	0.00 (0.00–0.00)	–	9	0.00 (0.00–0.00)	–	10	0.02 (0.02–0.03)	–
Milk and dairy based drinks (37)	37	3.10 (1.50–4.00)	7.00	27	1.10 (0.80–2.40)	–	34	0.05 (0.04–0.08)	–
Water-based flavoured drink (60)	49	0.00 (0.00–0.00)	–	47	0.00 (0.00–0.00)	–	42	0.02 (0.01–0.03)	0.30
Cereal, grain, tree nut-based beverages (23)	23	1.40 (0.20–2.90)	–	21	0.30 (0.20–0.30)	–	22	0.04 (0.02–0.05)	0.20
Frozen dairy-based desserts and edible ices (42)	42	10.40 (6.20–16.00)	8.00	33	7.80 (3.90–11.40)	–	25	0.04 (0.02–0.07)	0.10
Curded dairy based desserts (11)	11	4.00 (0.70–6.00)	7.00	11	3.00 (0.40–3.80)	–	11	0.03 (0.01–0.04)	0.10
Instant noodles and soups (82)	82	14.70 (0.70–20.20)	8.00	77	8.10 (0.50–9.60)	3.50	75	0.90 (0.35–1.30)	0.35
Pasta, noodles and like products (56)	56	1.00 (0.90–1.50)	3.00	49	0.30 (0.00–0.50)	–	51	0.00 (0.00–0.02)	0.25
Processed fruits and vegetables (58)	58	0.00 (0.00–0.20)	–	53	0.00 (0.00–0.01)	–	58	0.00 (0.00–0.01)	0.40

N^a includes products for which information on relevant nutrient value is present on the label. Total sugar refers to intrinsic sugars incorporated within the structure of the food plus added sugar plus sugar naturally present in honey, syrups, and fruit juices. Added sugar refers to sugar added to food products during processing or preparation.²²

(−) Denotes no threshold in WHO SEAR Nutrient Profile Model for the food group.

IQR: Inter quartile range; WHO SEAR: World Health Organization Southeast Asia Region.

Ethics

This study did not require ethics application as it collected data from publicly available information. However, as a courtesy, the store owners or managers were informed of the study and permission requested and obtained. In case of refusal, another store was chosen.

Role of the funding source

NS was supported by Deakin University Postgraduate Research Scholarship and CR was supported by a Deakin University Post-doctoral Fellowship. Deakin University had no role in study design, data collection, data analysis, data interpretation, or writing of the manuscript.

Results

We invited 35 retail stores to participate; one large store refused because of company policy restricting taking photos of the products, and eight small stores refused because the primary owners were not present on site at the time of the visit. A total of 2068 unique packaged foods were captured from the remaining 26 stores (4 large and 22 small). We excluded 543 products (see Fig. 1). Of the remaining 1525 products, 50.8% (n = 787) were only available in the four large stores, and 71.0% (n = 1084) were imported, mostly from India (Table 1). A breakdown of the products by food group is reported in Fig. 2.

Fig. 1.

Flow diagram of product included in analysis.

Table 1.

Availability in store type and country of manufacture of packaged food products.

	N = 1525
Availability in store type, n (%)
Small store only (n = 22)	257 (16.8%)
Large store only (n = 4)	787 (50.8%)
Available in both small and large store	510 (32.4%)
Manufactured in, n (%)
Nepal	441 (29.0%)
India	500 (32.8%)
Malaysia	109 (7.2%)
Thailand	73 (5.0%)
Other countries	402 (26.0%)

Fig. 2.

Distribution of food products across WHO SEARO food groups.

Of the 1525 packaged food products, 86.8% (n = 1323) contained excess amounts of one or more of energy and nutrients of concern and/or contained NSS (Fig. 3). Almost all bakery products (99.7%, n = 345), confectionery (99.6%, n = 460), savoury snacks (99.2%, n = 248), and water-based flavoured drinks (98.3%, n = 59), most frozen dairy based desserts and edible ices (88.4%, n = 37), approximately three-quarters of instant noodles and soups (75.6%, n = 62), more than half of the cereals (54.0%, n = 39), half of the juices (50.0%, n = 5), and nearly half of the milk and dairy-based drinks (46.0%, n = 17) contained one or more of energy and nutrients of concern in quantities above the SEAR NPM threshold and/or contained NSS.

Fig. 3.

Proportion of all packaged food products, by food group that contain excess levels of one or more of the energy and nutrients of concern.

The threshold most commonly exceeded was total energy (94.9%, n = 1042); almost all bakery products, savoury snacks, and nearly all confectionery exceeded this threshold (Table 2). The total sugar threshold was exceeded by 79.7% (n = 721) of all products, particularly confectionery, bakery products, frozen dairy and water-based flavoured drink. The added sugar threshold was exceeded by 55.3% (n = 105) of all relevant products, mostly milk and dairy based drinks and processed fruit and vegetables. The total fat and saturated fat thresholds were exceeded by 72.5% (n = 982) and 71.4% (n = 55) of products respectively. Nearly all bakery products and savoury snacks exceeded the threshold for total fat, followed by majority of confectionery and instant noodles and soups. The sodium threshold was exceeded by 55.1% (n = 434) of products mostly in the savoury snacks, instant noodle and soup and bakery product food groups. NSS was present in 8.9% (n = 135) of all food products, mostly confectionery.

Table 2.

Proportion of packaged food products that exceed thresholds for energy and nutrients of concern.

Food groups (N)	Energy		Total sugar		Added sugar		Total fat		Saturated fat		Sodium		NSS
	Na	n (%)	Na	n (%)	Na	n (%)	Na	n (%)	Na	n (%)	Na	n (%)	Nb	n (%)
All packaged products (1525)	1098	1042 (94.9)	905	721 (79.7)	190	105 (55.3)	1355	982 (72.5)	77	55 (71.4)	789	434 (55.1)	1514	135 (8.9)
Confectionery (462)	460	434 (94.4)	408	390 (95.6)	–	–	461	320 (69.4)	–	–	–	–	458	68 (14.9)
Bakery products (346)	336	335 (99.7)	230	205 (89.0)	–	–	346	341 (98.6)	–	–	219	136 (62.1)	346	33 (9.5)
Cereal (73)	–	–	60	26 (43.3)	–	–	72	5 (7.0)	–	–	57	18 (31.6)	70	0 (0.0)
Savoury snacks (potato, cereal or starch based, and animal based) (250)	250	248 (99.2)	–	–	130	65 (50.0)	248	225 (90.7)	–	–	215	203 (94.4)	249	8 (3.2)
Processed nuts (15)	–	–	–	–	9	2 (22.2)	–	–	–	–	–	–	15	0 (0.0)
Juices (10)	–	–	10	5 (50.0)	3	0 (0.0)	–	–	–	–	–	–
Milk and dairy based drinks (37)	–	–			16	13 (81.2)	37	4 (10.8)	–	–	–	–
Water-based flavoured drink (60)	–	–	57	54 (94.7)	–	–	–	–	–	–	42	0 (0.0)	60	9 (15.0)
Cereal, grain, tree nut-based beverages (23)	–	–	22	1 (4.5)	–	–	–	–	–	–	22	0 (0.0)	23	1 (4.35)
Frozen dairy-based desserts and edible ices (42)	42	17 (40.5)	36	29 (80.6)	–	–	42	29 (69.1)	–	–	25	1 (4.0)	41	2 (4.9)
Curded dairy based desserts (11)	10	8 (80.0)	11	11 (100.0)	–	–	11	1 (9.1)	–	–	11	0 (0.0)	11	0 (0.0)
Instant noodles and soups (82)	–	–	71	0 (0.0)	–	–	82	55 (67.1)	77	55 (71.4)	75	55 (73.3)	82	5 (6.1)
Pasta, noodles and like products (56)	–	–	–	–	–	–	56	2 (3.6)	–	–	51	6 (11.8)	54	0 (0.0)
Processed fruits and vegetables (58)	–	–	–	–	14	11 (78.6)	–	–	–	–	58	1 (1.7)	58	5 (8.6)

N^a: Denominator excludes food products for which either information on relevant nutrient value is not present on the product label or there is no threshold of relevant nutrient for the food category in WHO SEAR Nutrient Profile Model.

N^b: Denominator excludes product with either no ingredient list or the list not legible.

(−) Denotes no threshold in WHO SEAR Nutrient Profile Model for the food group.

With respect to actual nutrient values, savoury snacks, confectionery, and bakery products had median energy values more than double the threshold of 230 kcal/100 g (Table 3). Confectionery had a median total sugar content eight times the recommended threshold of 6.00 g/100 g. Savoury snacks had the highest median total fat content at three times the recommendation of 8.00 g/100 g. Median content of total fat and total sugar in bakery products were more than double the recommendation of 8.00 g and 6.00 g per 100 g respectively. Median sodium content in the instant noodle and soup group was 0.90 g/100 g, three times the recommendation of 0.30 g/100 g and highest among the food groups. Savoury snacks had median sodium content of 0.70 g/100 g, double the recommendation of 0.25 g/100 g. Processed fruits and vegetables, and milk and dairy based drinks had median added sugar contents of 17.50 g/100 g and 4.50 g/100 g respectively, compared to the recommendation of 0 g/100 g.

Discussion

We assessed energy and nutrients of concern in 1525 products available in 26 Nepali retail stores, the majority (71.0%) of which were imported. Of the 1525 packaged foods, 86.8% exceeded one or more SEAR NPM thresholds for energy and nutrients of concern and/or contained NSS. We found almost all bakery, confectionery, savoury snacks and water-based flavoured drinks, and many instant noodles and soups, and frozen dairy-based desserts and edible ice groups exceeded thresholds for one or more of energy and nutrients of concern and/or contained NSS.

Our findings are comparable to studies using similar NPMs. A 2023 study in Germany reported 80.0% of packaged foods ineligible for marketing to children as they exceeded one or more of the WHO EURO NPM thresholds.³ In contrast, a 2021 study in Brazil, using the Pan American Health Organization (PAHO) NPM, reported a lower percentage (62.0%) of packaged foods exceeding amounts of one or more nutrients of concern compared to our study.²³ This may be explained by incorporation of specific energy criteria in the SEAR NPM which are not in the PAHO model. Similarly, a Canadian study reported lower percentages (51.0%) of packaged foods ineligible for marketing to children when using the Food Standards Australia New Zealand-Nutrient Profiling Scoring Criterion (FSANZ-NPSC).²⁴ However, the FSANZ NPSC is not designed to restrict marketing to children,²⁴ its application for restricting marketing may be permissive to products which would have been restricted using the models such as WHO NPM. As such, careful selection of NPMs for specific policy objective should be considered.

Bakery, confectionery, and savoury snacks consistently exceed thresholds for nutrients of concern in the literature,^3,5,21 and our study reports similar findings for Nepal. The median content of sugar and sodium was two to eight times the SEAR threshold in these products. The high sugar and sodium content of these three food groups is particularly concerning because they were reported common in Nepali young children's diet. Biscuits contributed to 10.7% and 20.7% of their daily sugar and sodium intake respectively; chocolate and candy contributed to 8.5% of daily sugar intake; and savoury snacks contributed to 10.3% of daily sodium intake.⁹ We know that the contribution of high sugar and sodium consumption in early childhood is known to increase risk of obesity, hypertension, and morbidity and mortality in later life.^22,25 In addition, foods high in sugar and salt interfere with establishing healthy food preferences among children.²⁶ We also know that early exposure to NSS may result in preference for sweet foods later in life.¹³ In our study, 8.7% of food products contained NSS which was higher than reported in Turkey (5.5%)⁴ and lower than reported in China (21.0%)⁵ and Guatemala (12.6%).²¹ In addition to containing nutrients of concern, many packaged foods, as reported in studies from other countries, are ultra-processed,^5,21 that is, they are manufactured by modification or chemical alteration of whole food and use of additives to enhance appeal and shelf life.²⁷ The low satiety and high palatability properties of ultra-processed foods lead to overconsumption and unbalanced intake of these foods.²⁷ Consequently, these foods may displace healthier options from young children's diet, as evident from different contexts including Nepal.14, 15, 16

Nutrition interventions, guidelines and regulations in Nepal have primarily focused on undernutrition.²⁸ Besides regulating content of trans-fat in food supply²⁹ and nutrient content in cereal-based category of baby foods,³⁰ Nepal does not have other specific guidelines or regulations for the nutritional content of packaged foods targeted to any age group. Increasing availability of energy dense foods high in sugar and sodium for older IYC suggests interventions that target malnutrition in all its forms are needed. Our findings show that many products do not meet SEAR energy and nutrient criteria. In such instances, countries like Chile have successfully introduced nutrient thresholds to restrict marketing of products to children that exceed nutrients of concern,³¹ thereby reducing children's exposure. Also, there is a need for Nepal to alert parents/carers of the excess nutrients of concern in many food products. Food regulations, such as front of pack labelling (FOPL), has been successfully introduced in Chile, Mexico, and Uruguay to warn consumers of the nutritional quality of the food,32, 33, 34 and has been reported by a recent review as likely to improve consumer understanding of the nutritional quality, and the healthfulness of food choices.³⁵ Should Nepal introduce FOPL, it will be important that such regulation is reinforced by media campaigns to provide guidance on how to read food labels and interpret FOPL.³⁶

A national NPM in Nepal is the first step towards measuring nutrients of concern and introducing related food regulations, as has occurred in several countries.³⁷ Key stakeholders in Nepal, including policymakers, food scientists, and public health nutrition experts, will need to make decisions for NPM that limit nutrients of concern and that protect against undernutrition and micronutrient deficiency.³⁸ Regarding thresholds, an important lesson to learn from countries like Chile, Mexico, Argentina, and Venezuela is that they started with the nutrient thresholds which got stricter overtime.³⁷ For instance, Venezuela started with a sodium threshold in its first phase and expanded to sugar and fat in the later phase.³⁷ Such a transition gives manufacturers time to adapt and comply with regulatory measures.

In our study, a NIP was not present on 20.0% of labels and many labels with a NIP did not report all required nutrient information. Information on nutrient content on package food label was not mandated by Nepali regulation prior to data collection in 2023, which likely contributed to the exclusion of some products from our analysis. Enforcing the recent Food Safety and Quality Act 2024, which supersedes the previous Food Act 1967,³⁹ and which mandates nutrient information will facilitate the introduction of a NPM in Nepal. A substantial presence of imported packaged foods in our study points to the need for regional or international cooperation to support national policy efforts to reduce children's exposure to unhealthy food products. Future research should explore international agreements for enforcing the use of NIPs on packaged products and to introduce relevant food regulations. Future research should also explore exposure to unhealthy foods in different age groups, such as school aged children and adolescents, as with increasing age they are likely to be exposed to broader food environments consisting of wider food groups.

This study is the first to compare the energy content and nutrients of concern in foods consumed by older IYC in Nepal with regional nutrient thresholds. Another strength is the inclusion of small stores as these stores are the primary source of foods for many families in Nepal.⁴⁰ There are limitations. First, convenience sampling means we may not have captured all products known to be consumed by young children in Nepal and we do not know what proportion of products we did capture. Development of a national food product database would help overcome this challenge. Second, we only gathered data from urban stores, which may differ from rural stores. However, Kathmandu Valley is Nepal's most populous region,⁴¹ so it is likely that we captured the products available to the majority of the population. Second, the NPM used in this study is not specific to older IYC 6–36 months of age, but children over 36 months of age. However, in the absence of a NPM that has nutrient thresholds for older IYC, SEAR NPM for older children was deemed appropriate. Third, analysis relied on the nutrient information available in the product label and this information was not verified. There is no way to rectify this, other than encouraging manufacturers to comply with Codex legislation. Also, the method has been applied in similar studies.²¹

Many packaged foods available for older IYC in Nepali retail stores contained nutrients of concern above recommended thresholds. Continued exposure to and consumption of these foods could increase the risk of a double burden of malnutrition among Nepalese older IYC and put them at risk of chronic disease later in life. To protect older IYC health and wellbeing, Nepal could consider enforcing mandatory nutrition labelling, adopting a NPM to guide policy decisions and, informing parents/carers about ways to limit consumption of packaged foods containing nutrients of concern.

Contributors

NS designed the study with an input from CB, PLa, PLo, PKP. NS conducted field work. NS led data extraction with support from CR and PKP. NS led the analysis with support from CB and PLa. All authors had access to data. NS wrote the first draft of the manuscript with input from CB. All authors critically reviewed all manuscript versions and had their inputs. All authors read and approved the final manuscript.

Data sharing statement

Data and Stata codes are available upon request to corresponding author after publication.

Declaration of interests

NS is supported by Deakin University Postgraduate Research Scholarship. CR is supported by a Deakin University Post-doctoral fellowship. All authors declare no competing interests.