Food Consumption Patterns and Nutritional Status in Pakistan

By

Hina Nazli

Asma Shahzad

Amina Mehmood

October 2, 2014

Availability

Energy

Calories

Nutritional Status

Food Intake

Macro Nutrients

ProteinCarbohydrates

Fats

Micro Nutrients

VitaminsMineral

Production Imports

Accessibility Sustainability

Price Income

Food Intake (consumption patterns)

Accessibility Sustainability

Price Income

Nutritional Status

Energy

Calories

Macro Nutrients

ProteinCarbohydrates

Fats

Micro Nutrients

VitaminsMineral

Food Consumption and Nutrition: Plan of Presentation

• Inadequate maternal health or child care practices

• Inadequate access to health care services, safe water and sanitation

Motivation• PSSP (IFPRI) USAID funded set up to assist in building policy research capacity in Pakistan

• Agriculture, Rural Development, Poverty Reduction, Food Security and Nutrition are IFPRI areas of core competence globally and in Pakistan (1980s-90s)

• Analysis of existing data

• Generating own data

• Pakistan’s draft Agriculture and Food Security Policy aims to address the food and nutrition insecurities

• Pakistan Integrated Nutrition Strategy (PINS) aims to address the underlying causes of malnutrition (food diversification, WASH, school feeding, etc)

• Scaling Up Nutrition (SUN) program aims to identify the hurdles in access to food

• Issue of food security needs further research

• Little or no understanding in policy making of the determinants of food security and the relationship between food security, consumption behavior and nutritional outcomes

• Limited understanding and detailed analysis of nutritional status of the vulnerable and its variationacross gender and other demographic variables and other factors such as income and regional location etc

Data available to Examine Malnutrition in Pakistan• Conducted by GOP

• Micro-nutrient Survey 1976-77 (Nutrition Cell, Planning and Development Division)

• National Nutrition Surveys (1985-87, 1991-94, 2000-01, 2010-11) (Aga Khan University’s Division of Women and Child Health, Pakistan’s Ministry of Health and UNICEF)

• Demographic and health survey (1990-91, 2006-07, 2012-13) (National Institute of Population Studies)

• Household Integrated Economic Survey (PBS)

• Conducted by research institutions• IFPRI Panel Survey Years (1986-1991)

• World Bank/PIDE Pakistan Panel Household Survey (2001, 2004, 2010)

• PSSP (IFPRI) Rural Household Panel Survey (2012-2014)

Availability of Average Calories per capita per day based on Official Data

Source: GOP (2014), Economic Survey

1500

1700

1900

2100

2300

2500

2700

49-50 79-80 89-90 99-00 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12

Cal

ori

es/c

apit

a/d

ay

Calories per day Minimum

Available and Consumed Calories (per capita per day) From Official Sources

0

500

1000

1500

2000

2500

3000

2001-02 2004-05 2005-06 2007-08 2010-11

Cal

ori

es p

er c

apit

a p

er d

ay

Available Consumed

Source: GOP (2011)

Calorie Consumption Differs across Rural Urban Areas (based on Official Data)

1,950

2,000

2,050

2,100

2,150

2,200

2,250

2,300

2,350

2,400

Urban Rural Pakistan

CA

LOR

IES/

AE/

DA

Y

Source: HIES 2010-11

Low calorie consumption and high levels of poverty

Malik and Whitney (2014)

0

5

10

15

20

25

30

35

40

45

2001-02 2004-05 2005-06 2007-08 2010-11

PO

VER

TY H

EAD

CO

UN

T (%

)

Urban Rural Pakistan

Calorie Consumption Differs across Poverty Status (based on Official Data)

Source: HIES 2010-11

0

500

1,000

1,500

2,000

2,500

3,000

Poor Nonpoor

CA

LOR

IES/

AE/

DA

Y

Urban Rural Pakistan

70% of food expenditure is spent on energy dense food based on Official Data (2010-11)

0

5

10

15

20

25

30

Dairy Wheat Oils Sugars Meats

SHA

RE

OF

FOO

D E

XP

END

ITU

RE

(%)

Pakistan

Overall Non-poor Poor

0

5

10

15

20

25

30

Dairy Wheat Oils Sugars Meats

SHA

RE

OF

FOO

D E

XP

END

ITU

RE

(%)

Urban areas

Overall Non-poor Poor

0

5

10

15

20

25

30

Dairy Wheat Oils Sugars Meats

SHA

RE

OF

FOO

D E

XP

END

ITU

RE

(%)

Rural areas

Overall Non-poor Poor

Source: HIES 2010-11

Dietary Diversity in Rural Pakistan 2014 from PSSP Data:(% households reporting type of food items consumed in last 24 hours)

0 20 40 60 80 100

Wheat flour

Rice

Other cereals

Dairy products

Ghee/butter/oil

Sugar

Pulses

Dark green leafy vegetables

Vitamin A-rich vegetables

Tomato, onion, egg plant etc.

Roots and tubers (potatoes, turnip)

Fresh meat

Poultry

Eggs

Vitamin A-rich fruits

Other fruits

Spices, condiments

Source: RHPS (2014)

Food Frequency last seven days based on PSSP Data

0 1 2 3 4 5 6 7

Wheat flour

Rice

Other cereals

Dairy products

Ghee/butter/oil

Sugar

Pulses

Dark green leafy vegetables

Vitamin A-rich vegetables

Tomato, onion, egg plant etc.

Roots and tubers (potatoes, turnip)

Fresh meat

Poultry

Eggs

Vitamin A-rich fruits

Other fruits

Spices, condiments

Source: RHPS (2014)

Wheat is the major source of energy

0

10

20

30

40

50

60

Wheat Oils Dairy Sugars Meats

% S

HA

RE

IN T

OTA

L C

ALO

RIE

S

Overall Non-Poor Poor

Source: HIES 2010-11

Per Capita Availability and Consumption of Wheat

Source: GOP (2011)

0

20

40

60

80

100

120

140

2001-02 2004-05 2005-06 2006-07 2010-11

KG/c

apit

a/ye

ar

Available Basket Consumption

Sharp Increase in the Price of Wheat since 2007-08

0

5

10

15

20

25

30

35

2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11

Rs/

KG

Source: GOP (2014), Economic Survey 2013-14

The Kilograms of Wheat Flour that one Day’s Wages can Buy

0

5

10

15

20

25

30

35

2006 2007 2008 2009 2010 2011 2012

Kilo

gram

s o

f Fl

ou

r p

er d

aily

wag

e (K

gs)

Skilled Isamabad

Skilled Karachi

Skilled Lahore

Unskilled Islamabad

Unskilled Karachi

Unskilled Lahore

Calories consumed and the cost of calories –PSSP Study

Region or Population Group

Total Calories

(per AE/day)

Food Expenditure

(per AE/day) (Rs)

100 Calories cost Overall

Food (Rs)

Calories from wheat

(per AE/day)

Expenditure on Wheat

(per AE/day) (Rs)

100 Calories cost from

Wheat (Rs)

Rural Poor 1,882 36.8 1.95 1,007 8.2 0.81

Rural Non-Poor 2,664 67.0 2.52 1,208 7.7 0.64

Urban Poor 1,782 40.1 2.25 881 9.2 1.04

Urban Non-Poor 2,289 74.8 3.27 872 7.3 0.83

Pakistan 2,260 57.0 2.52 1,041 7.3 0.70

Source: Malik et al (2014), estimated from HIES (2010-11)

Change in Prices and Income and Demand for Wheat (2010-11): PSSP Study

Budget share on wheat

Expenditure elasticity

Own price uncompensated

elasticity

Own price Compensated

elasticityWheat-rice elasticity

Rural areas 18.6 0.79 -0.32 -0.209 0.006

Poor 22.9 0.84 -0.35 -0.165 -0.005

Non-poor 15.8 0.75 -0.35 -0.227 0.023

Urban areas 15.1 0.74 -0.31 -0.123 0.006

Poor 20.0 0.92 -0.36 -0.155 -0.001

Non-poor 11.8 0.67 -0.20 -0.107 -0.002

Pakistan 17.5 0.77 -0.32 -0.179 0.010

Poor 22.0 0.81 -0.21 -0.163 -0.012

Non-poor 14.5 0.76 -0.39 -0.173 0.021

Source: Malik et al (2014), estimated from HIES (2010-11)

Dietary patterns determine the nutritional status

Malnutrition among Women (BMI) based on official data

0

10

20

30

40

50

60

Underweight (<18.5) Normal (18.5-24.9) Overweight (25-29.9) Obese (>29.9)

% W

OM

EN (

15

-49

YEA

RS)

Pakistan Urban Rural

Source: NNS 2010-11

Micronutrient Deficiency among Women (2001-2011) official data

0

10

20

30

40

50

60

Prevalence of Anemia Vitamin A Deficiency Zinc Deficiency%

WO

MEN

(1

5-4

9 Y

EAR

S)

Pakistan

2001 2011

0

10

20

30

40

50

60

Prevalence of Anemia Vitamin A Deficiency Zinc Deficiency

% W

OM

EN (

15

-49

YEA

RS)

Urban areas

2001 2011

0

10

20

30

40

50

60

Prevalence of Anemia Vitamin A Deficiency Zinc Deficiency%

WO

MEN

(1

5-4

9 Y

EAR

S)

Rural areas2001 2011

Source: NNS 2010-11

Nutritional Intake among Women (24 hours food recall)

official data

0 500 1000 1500 2000 2500

Energy(K.cal)

Protein (gm)

Fats (gm)

Carbohydrate (gm)

Calcium (mg)

Phosphorus (mg)

Iron (mg)

Zn (mg)

Vit.C (mg)

Pakistan

Pakistan Recommended Allowance

0 500 1000 1500 2000 2500

Energy(K.cal)

Protein (gm)

Fats (gm)

Carbohydrate (gm)

Calcium (mg)

Phosphorus (mg)

Iron (mg)

Zn (mg)

Vit.C (mg)

Urban areas

0 500 1000 1500 2000 2500

Energy(K.cal)

Protein (gm)

Fats (gm)

Carbohydrate (gm)

Calcium (mg)

Phosphorus (mg)

Iron (mg)

Zn (mg)

Vit.C (mg)

Rural areas

Source: NNS 2010-11

Undernourished Females and Future Generation (World Bank, 2006)

• A malnourished woman is at higher risk of giving birth to an anemic or an underweight child (less than 2.5 kg)

• Such children have five times the risk of death in the first year and a high risk of growth failure during childhood

• Low birth weight may result in greater chronic diseases as an adult

• Severe iron deficiency anemia causes deaths during pregnancy and childbirth

• Iodine deficiency in pregnancy causes the birth of mentally impaired children

• Human and economic potential can be at risk by malnutrition

Results of Malnutrition

• Child mortality• Low birth-weight babies (31.6% of live births in 2007) rank 3rd in 183 countries• Under five mortality rate (89 per 1000 live births, 2008-2012)• Infant mortality rate (74 per 1000 live births, 2008-2012)• Neonatal mortality rate (55 per 1000 live births, 2008-2012)

• Disability • About 2.65 % population was disabled in 2012 (based on the projections on 1998

Census), 2.54% was in 1998• Of these, 43% are children (1-15 years)• Of total disabled, 8.2% are blind, 7.5% deaf, 14% mentally retarded, 8.3% have

multiple disabilities

• Probability of falling sick, loss in work days and income

Source: PDHS 2012-13Source: UNICEF, State of the World's Children, Childinfo, and Demographic and Health Surveys by ICF International Source: Helping Hands for Relief and Development (2012). Persons with Disabilities (PWDs) Statistics in Pakistan 2012

Protein-Energy Malnutrition among Children official data (< 5 years of age) official data

0

10

20

30

40

50

60

70

1977 1985-87 1990 1990-94 2001 2011

% c

hild

ren

Underweight Stunted Wasted

Source: NNS 2010-11

Micronutrient Deficiency among Children (2001-2011) official data

0

10

20

30

40

50

60

70

Prevalence of Anemia Vitamin A Deficiency Zinc Deficiency%

CH

ILD

REN

Pakistan

2001 2011

0

10

20

30

40

50

60

70

Prevalence of Anemia Vitamin A Deficiency Zinc Deficiency

% C

HIL

DR

EN

Urban areas

2001 2011

0

10

20

30

40

50

60

70

Prevalence of Anemia Vitamin A Deficiency Zinc Deficiency%

CH

ILD

REN

Rural areas

2001 2011

Source: NNS 2010-11

Nutritional Intake among Children 0-23 months(24 hours food recall) official data

0 200 400 600 800 1000 1200

Energy(K.cal)

Protein (gm)

Fats (gm)

Carbohydrate (gm)

Calcium (mg)

Phosphorus (mg)

Iron (mg)

Zn (mg)

Vit.C (mg)

Urban areas

0 200 400 600 800 1000 1200

Energy(K.cal)

Protein (gm)

Fats (gm)

Carbohydrate (gm)

Calcium (mg)

Phosphorus (mg)

Iron (mg)

Zn (mg)

Vit.C (mg)

Pakistan

Pakistan Recommended Allowance

0 200 400 600 800 1000 1200

Energy(K.cal)

Protein (gm)

Fats (gm)

Carbohydrate (gm)

Calcium (mg)

Phosphorus (mg)

Iron (mg)

Zn (mg)

Vit.C (mg)

Rural areas

Source: NNS 2010-11

Mothers’ Knowledge about Child Nutrition (PSSP data)

23.5925.59

14.06

0

5

10

15

20

25

30

Iron deficiency Iodine Rich Food Drinking Water Treatment

Pe

rce

nta

ge

Source: RHPS (2012)

Prevalence of Malnutrition (<–2SD) by Province and Rural Pakistan (2013) (PSSP Study)

40

46

23

35

41

22

52

59

2831

38

16

0

10

20

30

40

50

60

70

Underweight Stunting Wasting

% C

HIL

DR

EN

All Pakistan Punjab Sindh KPK

Source: Shahzad et al. (2013)

Comparison of malnourished children in NNS 2011 and RHPS 2013 (PSSP Study)

33

46

16

40

46

23

0

5

10

15

20

25

30

35

40

45

50

Underweight Stunted Wasted

% C

HIL

DR

EN

NNS 2011 RHPS 2013

Source: Shahzad et al. (2013)

Logistic Regression Analysis (PSSP Study)

• Dependent variables: HAZ, WAZ, WHZ=1 if malnourished (z-score <-2), 0 otherwise

• Child characteristics: age and gender

• Mother Characteristics: age at child birth, literacy

• Household characteristics: number of siblings, nuclear family, farm household, flush toilet, and poverty status

• Community characteristics: distance from BHU, LHV/LHW

• Location characteristics: Sindh and KPK

Results of Logistic Regression (PSSP Study)

• Incidence of malnutrition among children under five is highest in Sindh

• Improving hygienic conditions appear important to reduce long term malnutrition (toilet facility and safe drinking water)

• Access to health care services plays a significant role in reducing the short-term nutrition (LHW)

• Mother’s education improves the general state of nutrition among children under five

• No significant effect of poverty status on malnutrition

Why is there no significant relationship between malnutrition and poverty? Because Child malnutrition is high across all expenditure quintiles (PSSP Study)

0

10

20

30

40

50

60

Underweight Stunting Wasting

% C

HIL

DR

EN

1st quintile 2nd quintile 3rd quintile 4th quintile 5th quintile

Source: Shahzad et al. (2013)

PSSP Study: Poverty and malnutrition synonymous

• Overall levels of poverty are so high and calorie consumption is so low across the board that children in all expenditure categories are equally affected

• The data of RHPS (2013) shows that the average calories intake of 80 percent households (bottom 4 quintiles) is 2211 that is less than the recommended allowance of 2350 calories

• Poverty and malnutrition are determined by the same variables

• In fact malnutrition indicators are often used as a proxy for poverty in international studies (Reinhard and Wijayaratne, 2002; Setboonsarng, 2005; Heltberg, 2009; Klaver. 2010)

• The United Nation’s Millennium Development Goals conflate hunger and poverty in its first goal to “eradicate extreme poverty and hunger.” Undernourishment and malnutrition are among the indicators for this goal

Summing up• Cereals, fats, sugars, and dairy products are the main sources of calories and

macro-nutrients

• The consumption of micronutrient rich foods (vegetables and fruits) is very low

• Despite calorie-dense diet, average calorie consumption is lower than the recommended amount of 2350 or 2150 and is unbalanced in terms of micro-nutrients

• Wheat is the main source of calories, carbohydrate and fiber

• Little effect on the consumption of wheat with rising prices but at what cost (education, health care, etc.?)

• Focus of policies is on ensuring availability of wheat tonnage through production and import – limited action to other aspects such accessibility, sustainability and safety. That is why very little diversification away from four major crops.

Summing up

• Two main reasons of high prevalence of malnutrition in the country:• Lack of resources at the household level to maintain the minimum daily allowance of

essential nutrients; and

• Lack of awareness about balanced diet and maintaining good health

• Focus of previous research on estimating the numbers

• All the elements of Food Security not fully understood or integrated into policies

• Little work on understanding the linkages between food security, consumption behavior and nutritional outcomes and variations across socio-economic groups and regions

• Vey little prioritization or impact evaluation of any previous programs

Summing up

• Nutritional outcomes represent economic, health, education,

demographic and cultural factors

• Nutritional Status is the most direct measure of the welfare of a

people

• It can be measured directly and in physical terms

• not indirectly and through assumption based analysis such as those for

money-metric measures of poverty which have proved very controversial in

Pakistan

Some Recommendations

• Identification of malnourished population based on scientific method (mapping exercise)• Strong and accessible database for analysis; consistency in measuring indicators

• Moving towards nutrition-sensitive agriculture• Agricultural value chain

• Kitchen gardening

• Better storage facilities/techniques for agricultural products

• Improved infrastructure and well functioning institutions (credit, marketing, etc)

• Fortification and biofortification

• Creating awareness about nutritious diet (in schools, through media)

• Role of local institutions (e.g., LHW)

• Strengthen PINS and SUN through appropriate monitoring and evaluation

There is an urgent need for sound policy research and action

I was hungry,

and you formed a committee to investigate my hunger;

I was homeless,

and you filed a report on my plight;

I was sick,

and you held a seminar on the situation of the under-privileged;

You investigated all aspects of my plight

and yet I am still hungry, homeless and sick.

Thank you so much