1. Meaning of malnutrition
   • Undernutrition, micronutrient deficiencies, and overweight
   • Simple community-friendly explanation
2. Why malnutrition happens in Jumla/Karnali
   • Food insecurity and seasonal shortages
   • Poverty, difficult transport, remote geography
   • Low dietary diversity
   • Maternal undernutrition, early marriage and pregnancy
   • Poor infant and young child feeding
   • Diarrhoea, worms, respiratory infections, poor sanitation
   • Gender-related food distribution and workload
3. Who is most at risk
   • Children under 5 years, especially 6-23 months
   • Pregnant and breastfeeding women
   • Adolescent girls
   • Low-birth-weight infants
   • Poor and food-insecure households
4. Types and visible signs
   • Stunting: child is too short for age
   • Wasting: child is too thin for height
   • Underweight: low weight for age
   • Bilateral pitting oedema: swelling of both feet
   • Anaemia and other micronutrient problems
   • Danger signs requiring referral
5. How communities identify and screen children
   • MUAC tape
   • Checking both feet for pitting oedema
   • Growth monitoring and regular weighing
   • When to visit the health post urgently
6. Prevention from pregnancy to age 2 years
   • The first 1,000 days
   • Maternal diet, antenatal care, iron-folic acid and deworming as advised by health workers
   • Early initiation and exclusive breastfeeding for the first 6 months
   • Complementary feeding from 6 months while continuing breastfeeding until 2 years or beyond
   • Safe water, sanitation, vaccination and prompt treatment of illness
7. Locally practical food messages for Jumla
   • Use available foods: cereals, pulses/beans, eggs, milk or curd where available, green leafy vegetables, potatoes, seasonal fruits, oil/ghee in small amounts, and animal-source foods when possible
   • Improve child meals by adding a pulse, vegetable, egg/milk/meat when available, and a little oil/ghee for energy
   • Feed young children more often than adults
8. Treatment and referral
   • What families should do at home for mild nutrition problems
   • What must be managed through the health post, outpatient therapeutic programme, or nutrition rehabilitation services
   • Why families should not wait if a child is severely thin, has swollen feet, is not feeding, is very sleepy, or has repeated vomiting/diarrhoea
9. Community action
   • Mothers' groups, Female Community Health Volunteers, health posts, schools, local agriculture groups, kitchen gardens, hygiene promotion, and household decision-making.

Brief community overview

A child needs frequent, diverse, safe food; continued breastfeeding; clean water and hygiene; vaccination and early treatment when ill.

1. Nepal and Karnali/Jumla situation
2. Causes and risk factors
3. Types, signs, MUAC screening and referral
4. Prevention and infant/young-child feeding
5. Locally available foods and practical meal examples
6. Community-level intervention plan
7. Full combined field-teaching note

Malnutrition in Nepal: Community-Level Field-Teaching Note

1. Learning objectives

1. Explain malnutrition in simple words.
2. Identify children and mothers at high risk.
3. Recognize common signs of undernutrition and danger signs.
4. Describe correct breastfeeding and complementary feeding.
5. Use locally available foods to improve family diets.
6. Know when and where to refer a child to the health post.
7. Participate in household and community actions to prevent malnutrition.

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Part A. Professor-facing content

2. Definition of malnutrition

• Stunting: a child is too short for his or her age due to long-term poor nutrition and repeated infection.
• Wasting: a child is too thin for his or her height due to recent weight loss or failure to gain weight.
• Underweight: low weight for age. It can result from stunting, wasting, or both.
• Micronutrient deficiencies: lack of iron, iodine, vitamin A, zinc, and other vitamins/minerals.
• Severe acute malnutrition (SAM): a life-threatening form of acute undernutrition.

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3. Malnutrition situation in Nepal and Karnali

Key national and provincial facts

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4. Why malnutrition occurs: UNICEF conceptual framework

Malnutrition-infection cycle

Local risk factors to ask about during community diagnosis

• Household food shortage, especially before harvest or during winter
• Diet mainly based on cereal/potato with little pulse, egg, milk, meat, fruit, or vegetables
• Child not breastfed exclusively before 6 months
• Complementary foods started too late, too early, too thin, too little, or too infrequently
• Child receives food last or less than adults
• Mother is undernourished or anaemic
• Early marriage, early pregnancy, short birth interval
• Repeated diarrhoea, pneumonia, fever, worms, skin infections
• Unsafe drinking water, open defecation, poor handwashing
• Incomplete immunisation or missed vitamin A programme contacts
• Poor access to ANC, growth monitoring, health posts, and referral transport
• Heavy physical work by pregnant or breastfeeding mothers
• Alcohol/tobacco use in the household affecting food expenditure and care

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5. Who is most vulnerable?

1. Pregnant women
2. Lactating mothers
3. Adolescent girls
4. Low-birth-weight or preterm babies
5. Children aged 6-23 months
6. Children under 5 with repeated diarrhoea, pneumonia, fever, or worms
7. Children from poor, food-insecure, remote, or socially excluded households
8. Children whose mothers are thin, anaemic, or have little education

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6. Types of undernutrition

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7. Recognition and community screening

A. Look for visible warning signs

• Child becoming very thin, weak, or less active
• Ribs, shoulder bones, or buttocks very prominent
• Loss of fat from upper arms, thighs, and buttocks
• Poor appetite or refusal to breastfeed/feed
• Weight not increasing over months
• Hair becoming thin, sparse, or changing colour
• Repeated diarrhoea, cough, fever, or mouth sores
• Delayed walking, play, learning, or development
• Swelling of both feet

B. Test for bilateral pitting oedema

1. Press gently with both thumbs on the tops of both feet for about 3 seconds.
2. Remove thumbs.
3. If a pit remains on both feet, suspect nutritional oedema.
4. Refer urgently to the health facility.

C. MUAC screening

Immediate referral danger signs

• Bilateral swelling of feet
• MUAC less than 11.5 cm
• Very thin appearance with visible wasting
• Not able to drink, breastfeed, or eat
• Persistent vomiting
• Convulsion, unconsciousness, unusual sleepiness
• Fever, severe diarrhoea, chest indrawing, or difficult breathing
• Dehydration
• Any child whose caregiver feels the child is becoming rapidly weaker

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Part B. Community teaching content

8. Key messages in simple Nepali

Opening message

कुपोषण भनेको खाना कम खानु मात्र होइन। बच्चा वा आमाले आवश्यक मात्रामा विभिन्न प्रकारका पोषिलो खाना नपाउनु, बारम्बार बिरामी हुनु, सफा पानी र सरसफाइको कमी हुनु पनि कुपोषणका कारण हुन्।

Healthy child = नियमित स्तनपान/पोषिलो खाना + सफा पानी + सरसफाइ + खोप + बिरामी हुँदा छिटो उपचार।

Five messages everyone should remember

1. गर्भवती र सुत्केरी आमाले अरूभन्दा बढी र विविध खाना खानुपर्छ।
2. जन्मेको एक घण्टाभित्र स्तनपान सुरु गरौं।
3. ६ महिनासम्म आमाको दूध मात्र दिऔं। पानी, मह, घुट्टी, जडिबुटी वा अन्य खाना नदिऔं।
4. ६ महिनापछि आमाको दूधसँगै बाक्लो, नरम, विविध र बारम्बार खाना दिऔं।
5. बच्चा धेरै दुब्लो भएमा, दुवै खुट्टा सुन्निएमा, वा खान नसकेमा तुरुन्त स्वास्थ्य संस्था जाऔं।

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9. Nutrition during pregnancy and breastfeeding

Community message

“आमा स्वस्थ भए बच्चा स्वस्थ हुन्छ।”

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10. Infant and young child feeding

A. From birth to 6 months

B. From 6 months onward

“६ महिनापछि बच्चालाई आमाको दूध मात्र होइन, बाक्लो, नरम, पोषिलो र बारम्बार खाना चाहिन्छ।”

Age-appropriate feeding

Principles of good complementary feeding

1. Thick: Thin watery porridge fills the stomach but gives little energy.
2. Frequent: Young children have small stomachs and need small meals many times daily.
3. Diverse: Give foods from several food groups.
4. Responsive: Sit with the child, encourage patiently, do not force or punish.
5. Safe: Wash hands, use clean utensils, cover food, and give freshly prepared food where possible.
6. Continue feeding during illness: Offer breast milk and small frequent meals. Give an extra meal daily for about 2 weeks after recovery.

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11. Locally practical foods for Jumla

Affordable meal examples for 6-23 months

Important practical message

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12. Dietary diversity: simple “family food plate” method

1. Staple food: rice, dhido, roti, potato, maize, millet
2. Body-building food: dal, beans, egg, milk, curd, meat, fish
3. Protective food: green/yellow vegetables and fruit
4. Energy addition: small amount of oil/ghee

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13. Hygiene, infection prevention, and nutrition

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14. Micronutrient deficiencies

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Part C. Community-level action plan

15. What different community members can do

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16. Suggested community diagnosis checklist for your Jumla field visit

Household-level questions

Community-level observations

• Distance, walking time, and transport barriers to health post
• Food market availability and seasonal price changes
• Common local crops, livestock, milk/egg availability
• Water source and sanitation status
• Mothers’ group/FCHV activity
• Seasonal migration and its effect on caregiving and income
• Existing school feeding, child grant, agriculture, or nutrition programmes

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17. A practical 30-minute community teaching session

Materials

• MUAC tape
• Growth chart or child health card
• Picture cards/food samples
• One small bowl, spoon, and locally available foods
• Flipchart/poster
• Clean water and soap demonstration if possible

Session flow

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18. Short speaking script for community members

नमस्कार। आज हामी बच्चा, गर्भवती आमा र सुत्केरी आमाको पोषणको बारेमा कुरा गर्नेछौं। कुपोषण भनेको खाना नपाउनु मात्र होइन। बच्चाले पर्याप्त र विभिन्न प्रकारको खाना नपाउनु, बारम्बार झाडापखाला वा निमोनिया हुनु, सफा पानी र सरसफाइको कमी हुनु पनि कुपोषणका कारण हुन्।

बच्चा जन्मेपछि एक घण्टाभित्र स्तनपान सुरु गर्नुपर्छ। पहिलो पहेंलो दूध नफाल्नुहोस्, यही बच्चाको पहिलो खोपजस्तै हो। छ महिनासम्म आमाको दूध मात्र दिनुपर्छ। पानी, मह, घुट्टी र अन्य खाना आवश्यक हुँदैन।

छ महिनापछि आमाको दूधसँगै बाक्लो, नरम र पोषिलो खाना सुरु गर्नुपर्छ। पातलो जाउलो मात्रले बच्चा बढ्दैन। लिटो वा खिचडीमा दाल, सागसब्जी, अण्डा, दूध, वा थोरै तेल/घिउ थप्न सकिन्छ। बच्चालाई दिनमा धेरै पटक सानो-सानो मात्रा खुवाउनुपर्छ।

बच्चा धेरै दुब्लो देखिएमा, खान नसकेमा, वा दुवै खुट्टा सुन्निएमा तुरुन्त स्वास्थ्य चौकी जानुपर्छ। गर्भवती र सुत्केरी आमालाई परिवारले बढी आराम, बढी विविध खाना र स्वास्थ्य जाँचको सहयोग गर्नुपर्छ।

हाम्रो सन्देश: आमाको दूध, बाक्लो पोषिलो खाना, सफा पानी, सरसफाइ र समयमै उपचारले कुपोषण रोक्छ।

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Part D. How to present before your professor

19. Suggested 12-slide presentation structure

1. Title: Malnutrition in Nepal: Community-Level Approach for Jumla, Karnali
2. Learning objectives
3. Definition and types of malnutrition
4. Nepal and Karnali situation: NDHS 2022 data
5. Why focus on Karnali/Jumla? Geography, food insecurity, service access, seasonality
6. Causes: UNICEF framework
7. Stunting, wasting, underweight and SAM
8. Community screening: MUAC, oedema, danger signs
9. First 1,000 days and maternal nutrition
10. IYCF: breastfeeding and complementary feeding
11. Local food-based solutions and WASH
12. Community action plan, referral pathway, conclusion

Strong opening for professor presentation

“Malnutrition in Jumla should not be approached only as a food shortage problem. It is a combined outcome of food insecurity, maternal nutrition, infant feeding, infection, sanitation, poverty, seasonal access, and health-service barriers. Therefore, community diagnosis must identify both children at immediate risk and the household/community determinants that produce malnutrition.”

Strong concluding statement

“For Jumla, the practical priority is to protect the first 1,000 days, identify wasting early with MUAC and oedema screening, improve breastfeeding and complementary feeding with locally feasible foods, prevent infection through WASH and immunisation, and ensure rapid referral of severe cases.”

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20. Likely viva questions and concise answers

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References

1. Ministry of Health and Population, New ERA, and ICF. Nepal Demographic and Health Survey 2022. Kathmandu, Nepal; 2023. The full NDHS report reports national under-5 stunting of 25%, wasting of 8%, underweight of 19%, and Karnali stunting of 36%.
2. UNICEF Nepal. The Nepal nutrition overview describes national nutrition trends, infant feeding gaps, and Nepal’s Multi-Sector Nutrition Plan III, 2023-2030.
3. National Planning Commission, Government of Nepal. The Nepal Nutrition and Food Security Portal describes Nepal’s multisectoral nutrition approach involving health, agriculture, education, WASH, and social protection.
4. Park K. Park’s Textbook of Preventive and Social Medicine. Sections on nutritional assessment, types of undernutrition, and severe acute malnutrition, p. 736.
5. Robbins SL, Cotran RS, Kumar V. Robbins, Cotran & Kumar Pathologic Basis of Disease. Nutritional Diseases and Severe Acute Malnutrition section.
6. Lassi ZS, et al. Community-based child food interventions/supplements for prevention of wasting: systematic review and meta-analysis. Nutrition Reviews. 2025. PMID: 40272950. This recent review supports benefit from certain community food/supplement interventions, but local programmes should follow Nepal health-system guidance rather than using supplements indiscriminately.