A few weeks ago, six-year-old Kushal Ghale and eight-year-old Kajal Ghale were discharged from a nutrition rehabilitation home in Lalitpur.

The Ghale siblings, who come from a small village of Rorang Rural Municipality in Dhading, were referred to the rehab home after they were diagnosed with moderate acute malnourishment by doctors.

Kushal, who was supposed to be at least 15.2 kg to 16.5 kg as per his age and height, was 13.4 kg and his sister, who was supposed to be weighing 19.9 to 22 kg as per the World Health Organization's protocol, was only 16.8 kg.

"It was too tough for us to feed homemade food to the siblings in our rehab home," Sunita Rimal, coordinator of malnutrition prevention and treatment programme of Nepal Youth Foundation, told the Post. "We discharged them after 20 days, when Kushal weighed 14.7 kg and his sister Kajol weighed 18.7 kg."

According to the World Health Organization, many low- and middle-income countries like Nepal are now facing a "double burden" —under-nutrition as well as a rapid upsurge in obesity-related cases, particularly in the urban areas.

The UN health agency said children in low- and middle-income countries are more vulnerable to prenatal, infant, and young child inadequate nutrition. At the same time, it said that children are being exposed to high-fat, high-sugar, high-salt, energy-dense, and micronutrient-poor foods, which tend to be not only lower in terms of cost, but also in nutrient quality. These dietary patterns, in conjunction with lower levels of physical activity, result in sharp increases in childhood obesity. Meanwhile, the undernutrition issues remain largely unsolved.

According to Rimal, the father of the siblings is employed abroad for the past several years. Their mother runs a small grocery shop. Both father and mother give the children money to spend on food. The mother did not object when her children insisted on processed foods, which made them dependent on unhealthy food items.

“Finally, the children stopped eating food cooked at home, which made them malnourished,” said Rimal. “On the other hand, the number of obese children is rising significantly due to their excessive consumption of unhygienic and junk food.”

The country, which has long been struggling to mitigate malnourishment problems, now has to deal with obesity and junk food problems simultaneously, as the use of junk and processed food has become rampant across the country.

"Children are either malnourished (due to lack of food to eat) or overnourished (obese) due to overeating of unhealthy food," Dr Atul Upadhyay, project coordinator at Helen Keller International told the Post. "People relate obesity to being healthy, which is wrong. These are symptoms of nutrition-related problems."

A recent study carried out by Helen Keller International shows that Nepali children are getting a quarter of their calories from junk food. While over-consumption of junk food is often associated with obesity, the study found links to malnutrition and stunting as well.

Researchers from Helen Keller International did a study on families of 745 children throughout the Valley, testing nutritional effects of snack consumption. Published in the Journal of Nutrition, it found a host of factors strongly associated with stunted growth and malnutrition.

The study found that junk food contributed to nearly half of some youngsters’ diets, and those with higher intake of unhealthy snacks were less nourished than those with lower intakes, and they were more likely to be shorter in terms of height.

Experts blamed easy access of processed foods, their cheaper prices, enhanced taste, rise in the number of working mothers, which prevents them from cooking healthy food at home, for the rise in the number of malnutrition and obesity cases.

Similarly, the behavioural factor—such as excessive consumption of cakes and pastries, not doing physical labour in urban areas—is equally responsible for the rise in obesity-related problems.

"Earlier we used to think that malnutrition problems are associated with poverty, but it is rampant in children of well-off families," said Upadhyay. "People often relate obesity with good health, which is a misconception. Obesity leads to chronic diseases."

Upadhyay said that the government has to relay a strategic message to the public about the excessive consumption of junk food and its consequences. "At the same time, a regulatory authority should be set up to regulate unhealthy food items," he added. "The time to take action has come."

Kedar Prasad Parajuli, chief of the nutrition section at the Family Welfare Division under the Department of Health Services, said the coordination among several government ministries and other stakeholders is needed to deal with the nutritional issues.

"Separate agencies work on the import, production, quality monitoring, marketing and others," said Parajuli. “Without coordination of all stakeholders, we can do nothing. We have been working on the awareness part.”

Malnutrition is brewing into a silent crisis for Nepal. According to the Nepal Demographic Health Survey of 2016, 36 percent of children under the age of five years were suffering from chronic malnutrition, while 10 percent suffered from acute malnutrition. Another 27 percent of the children were underweight and one percent overweight, the study found.