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An Overview Of

Food,Nutrition & Health in

Islamic Republic of Pakistan

Presented By:

Prof.Dr.Perveen Liaqat

COUNTRY PRESENTATION

Intercountry Technical Consultation on National Food based Dietary Guidelines.6th to 9th Dec.2004

WHO-EMRO,Cairo,Egypt

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COUNTRY INTRODUCTION

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Demographic Indicators

Population 130.580 million (PCP 1998) 140 million (Economic Survey03-04) Population Growth Rate 2.2% (Economic Survey 2003-2004) 1.9% (World Development Report 2003)

Economy Agriculture Based

Main Food Crops Wheat,Rice,Sugarcane

Literacy Rate 43.9% (Population census 1998) 54.0% (Economic Survey,estimated 03-04) (66.25 %M & 41.75% F)

Life Expectancy M: 64 years; F:66 years(Pak Dev.House hold survey 1999)

Mortality Rate(Infant) 91 (PCP 1998) 81 (Economic survey 2003-2004)

Mortality Rate(Under Five) 120 (PCP 1998) 105 (Economic survey 2003-2004)

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1. Food Security Situation in Pakistan

Food security according to World Food Summit is defined as “When all people, at all times, have physical and economic access to sufficient, safe and nutritious food and to meet their dietary needs and food preferences for an active and healthy life”.

1. Adequacy of Food

2. Ample Access to Food

3. Reliability of Both Supply and Access

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1.1 Adequacy of Food

1. Food Production

Production of major Food Crops (000 Tonnes)

Source: (Economic Survey of Pakistan 2003)

a) Major Food Crops

Years Sugar Cane Rice Maize Wheat

1999-00 46333 5156 1652 21079

2000-01 43606 (-5.9) 4803 (-6.8) 1643 (-0.5) 19024 (-9.7)

2001-02 48042 (10.2) 3882 (-19.2) 1664 (1.3) 18227 (-4.2)

2002-03 52056 (8.3) 4478 (15.3) 1771 (4.4) 19767 (5.2)

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10000

12000

14000

16000

18000

20000

22000

90

-91

91

-92

92

-93

93

-94

94

-95

95

-96

96

-97

97

-98

98

-99

99

-00

00

-01

20

01

-02

3-F

eb

03

-04

(P)

Wheat Production (000 Tonnes)

Rice Production (000 Tonnes)

2000

2500

3000

3500

4000

4500

5000

5500

Sugarcane Production (000 Tonnes)

30000

35000

40000

45000

50000

55000

60000

Source: Economic Survey 2003

Rice Production (000 Tonnes)

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Source: (Economic Survey of Pakistan 2003)

b) Other Important Foods Commodities

Live Stock:

Accounts for 49.1% of agricultural value added and about 11.4% of the GDP 30-35 million rural population is engaged in livestock raising Live Stock include cattle, buffalos, sheep, goats, camels, horses assess and mules

Poultry:

Good substitute of beef and muttonAccording to Live Stock Wing of Ministry of food, agriculture and livestock, almost every family in rural area and every fifth family in urban area in associated with poultry production

Fisheries:Fisheries contribute substantially to the national income through export earningsDuring July-March 2003-04, 101256 m.tones values at Rs.7.9 billion fish and fishery products were estimated to be exported to Japan, USA, UK, Germany, Middle East, Sri Lanka, China etc.During the same period, the total fish production is estimated at 630,000 m.tonesThe total number of persons engaged in fisheries during 2003-04 is estimated at 395,000

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c) Exports and Imports of Food Products

Exports:

Cumulative Exports by Food Commodities

Commodities July-Aug, 2004in millions

July-Aug, 2003in millions

% ChangeJuly-Aug, 2004

July-Aug, 2003

Rice 5,575.61 5,743.94 -2.93%

Fruits, Vegetables and preparation thereof

1,538.97 1,297.41 +18.62%

Fish and Fish preparation

981.33 1,330.59 -26.25%

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c) Exports and Imports of Food Products

Imports:

Cumulative Imports by Food Commodities

Commodities July-Aug, 2004in millions

July-Aug, 2003in millions

% ChangeJuly-Aug, 2004

July-Aug, 2003

Palm Oil 7,401.00 5,522.43 +34.02%

Tea 2,240.11 1,479.39 +51.42%

Pulses 1,140.71 477.36 +138.96%

Soybean oil 238.39 274.29 -13.09%

Milk and Milk products for infants

194.61 113.13 +72.02%

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Items Units 1997-98 1998-99 1999-2000 2001-2002

Cereals Kg 159.7 171.0 163.5 149.3

Pulses Kg 5.9 6.8 7.2 6.1

Sugar Kg 32.8 31.2 26.4 26.1

Milk ltr 147.3 148.0 148.8 150.8

Eggs Doz 2.2 5.1 25.1 5.2

Edible Oil ltr 11.6 12.3 11.1 11.3

Meat Kg 17.9 18.2 18.7 18.9

Calories (per day)

2,655 2,728 2,625 2,306

Protein(per day) gms

68.37 71.85 70.00 67.00

Source: Planning & Development Division (PES, 2001-2002)

2. Food Consumption

Food availability per Capita

Per capita availability of calories and Protein

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1.2 Ample access to Food

1. Poverty

Year Pakistan Rural Urban

1986-87 26.9 29.4 24.5

1987-88 17.3 29.9 22.7

1990-91 23.3 26.2 18.2

1992-93 20.3 22.5 16.8

1993-94 23.6 26.3 (WFP) 19.4(WFP)

1998-99 32.6 34.8 (WFP) 25.9

2002-2003 62.0

Trends in Food Poverty Incidence

Source: PIDE 1998-99 PSES primary data &Food security analysis 2003

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2. Unemployment

Unemployment 7.8%

Source: (Economic Survey of Pakistan 2003)

3. Lack of Nutrition awareness and Education

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1.3 Reliability of both Supply and Access

40% total farm area 7% landowners

60% total farm area 93% farmers

• Landowners have more access to water for irrigation, fertilizers and other resources

1. Inequity in land holdings

2. Inequity in food supply in different provinces

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2. Nutrition Indicators of Malnutrition

i. Low Birth weight

ii. Childhood Growth

a) Time trend in prevalence of stunting,wasting & underweight

b) Prevalence of Stunting & Wasting among Gender

Source NSWP MNS NNS NHS NNS

Year 1965 1977 1985-7 1990-4 2001-2

Underweight - 53.3 47.9 40.1 37.4

Stunted 49 43.3 41.8 36.3 40

Wasted 11 8.6 10.8 11.8 14.9

Source NHS NNS

Year 1990-4 2001-2

Males Females Males Females

Stunted 36.0 36.3 40.5% 39.5%

Wasted 11.9 11.7 15.4% 14.4%

Underweight 39.8 40.5 37.6% 37.2%

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c) Prevalence of Stunting and Wasting among Rural/Urban children under five.

Source NHS NNS

Year 1990-4 2001-2

Urban Rural Urban Rural

Stunted 32.1 39.0 34.7% 43.1%

Wasted 11.2 11.5 15.5% 14.6%

Underweight 34.5 41.6 34.7% 39.0%

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Underweight Non-pregnant mothers 12.5% (Malnourished with BMI<18.5)

Underweight Lactating Mothers 16.1% (Malnourished with BMI<18.5)

Mothers with normal limits of Nutrition 54%

Lactating Mothers More underweight as compare to less Obese non-pregnant women

Source: NNS 2001-2002

iii. BMI as Nutrition Indicator during Pregnancy & Lactation

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2.1 Prevalence of Micronutrient Deficiencies as Malnutrition Indicators

a) Prevalence of Iron Deficiency Anemia

Moderate Severe

Children 33.0% 2.6%

Mothers 23.7% 1.8%

Iron deficiency Anemia among Children under five & their Mothers

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b) Prevalence of Vitamin A Deficiency

Clinical Deficiency

Bitot spots,night blindness,xerophthalmia

Prevalence of Bitot spots among children under five 1.2%(NNS 2001-2002)

Prevalence of Night blindness among mothers (during last pregnancy and current)

7.8% to 9.9% respectively

Sub-clinical Deficiencies

Serum Retinol level <0.74 (mol/l) among pre-school children & their mothers

NHS1998 NNS2001-2002

Children Severe retinol level<0.35 mol/l (%) 3.3% 0.8%

Children Moderate retinol level b/w 0.35-0.7 mol/l (%) 31.8% 11.7%

Mother Moderate retinol level b/w 0.35-0.69 mol/l (%) 5.9 %

rural Urban

6.7% 5.4%

Bio-chemical levels of vitamin A among Mothers

Severe(<0.35(mol/l) 0.5%

Moderate(B/w 0.35-0.69) 5.4 %

Source: NNS 2001-2002

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c) Prevalence of Iodine Deficiency

Clinical Signs

Visible goitre among mothers 12.2%

Palpable goitre among mothers 8.9%

Prevalence of goitre among Mothers by place of Residence

Place of Residence Palpable Visible No Goitre

Urban 7.4% 8.9% 83.8%

Rural 9.8% 14.1% 76.3%

National 8.9% 12.2% 79.1%

Palpable goitre% Visible % No Goitre

Urban 2.1% 1.9% 96.0%

Rural 5.8% 2.6% 91.6%

National 4.4% 2.3% 93.3%

Prevalence of goitre among school-aged children 6-12 years

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Pre school Children 37.1%

(Serum Concentrations< 60 /dl Zinc level)

Pregnant Women 41.4%

(mother of children under five)

d) Prevalence of Zinc Deficiency (NNS 2001-2002)

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Sub Clinical Signs (urinary excretion levels)

a) Thiamine

Adults 0.87%

Children 1.85%

b) Riboflavin

adults 0.25%

children 0.71%

e) Vitamin B Deficiencies

Source: NNS 1985

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2.2 Childhood Morbidity as an indicator

Clinical Signs of Rickets

i. Enlarged Wrist 0.8%

ii. Bowed legs 0.5%

iii. Fontenelle (<2 years) 41.8%

iv. Frontal Bossing(3-5 years) 2.9%

a) Prevalence of vitamin D Deficiency among children upto 59 months

b) Prevalence of Diarrhoea among Children

National level 25%

Urban 20.8%

Rural 27.5%

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0%

20%

40%

60%

80%

100%

Percent urban Male & Female

LOW Middle High

Female

LOW Middle High

Male

2.3 Overweight and Obesity as indicators of Malnutrition

Source: (NHS 1998)

Obese

Overweight

Desirable

Underweight

Severe thin

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2.4 Chronic Diseases Related with Overweight and Obesity

i. Serum Cholestrol level

ii. Blood pressures and Hypertension

iii. Non-insulin dependent diabetes

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2.4.1 Prevalence of elevated cholestrol levels

People with ECL requiring Nutritional/medical advice 7.3 million

12.6% population

Over 15 years of ages

Urban women over 65 years of age 1/every 3

much higher than their male counter parts

ECL: Elevated Cholestrol Levels (random blood cholestrol of at least 200 mg/ml)

Source: NNS 1990-94

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2.4.2 Prevalence of high blood pressure & Hypertension Blood Pressure(systolic>140 mmHg & Diastolic 90mmHg)

Urban 21.5%

Rural 16.2%

Hypertension

Men 5.5 million

Women 5.3 million

Severe Hypertension 4% urban women of high economic status

Systolic pressure > 180 mmHg

Diastolic pressure> 105 mmHg

Obese urban Female Over 45 years of age 65% hypertensive

Obese rural Female Over 45 years of age 48% hypertensive

Overweight Male(age 45+) 58% hypertensive both rural & urban

Source: (NHS 1994)

010203040506070

Obese Overweight Normal Underweight Thin

Percent urbanPercent rural

Female Male MaleFemale

*

*

0

10

20

30

40

50

60

70

Obese Overweight Normal Underweight Thin

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2.4.3 Prevalence of Diabetes among 45-64 years age

Non recorded diabetes 2.7million

Diagnosed diabetes 0.8 million

Urban Male(over 65 yrs age) 15%

Urban Female(45 to 64 yrs) 18%

Rural Male 5%

Rural Female(45 to 64 yrs) 7%

Prevalence of diabetes

among urban female one in every 4th

of 45 years & above

Source: (NHS 1994)

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2.5 Other Health Diseases Common

a) Chronic Bronchitis caused by Tuberculosis & Chronic Obstructive Pulmonary Disease (COPD)

Rural Women(age 65 and above) 14%

Rural Men 6%

Urban(both sexes) 9%

b) Renal Impairment

Chronic Kidney problems *

(Among 40-49 yrs of age group ) 7%

(Among 50-59 yrs of age group) 17%

60+ in both rural and urban areas 13%

* It includes renal insufficiency and creatinine. Renal insufficiency is a clinical condition in which blood urea nitrogen is over 40 mg/dl and creatinine is over 1.2 mg/dl. It is used to monitor kidney function and early screening.

Source: NHS 1990-4

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3. DAILY FOOD INTAKE PATTERN

3.1 Average daily intake of food by Mothers (NNS 2001-02)

3.2 Average Intake of Food by Children-by Food Groups

3.3 Type of Bread Consumed by Regions

3.4 Consumption Frequency of different food items for weak

3.5 Pakistan Food Basket based on 2100 Calories

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3.1 Average Intake of Food by Mothers-by Food Groups

Food Groups Rural Urban National

Total Cereals 357 320 342Wheat 338 297 322Rice 18 23 20

Pulses & Legumes 26 24 25 Fat & Edible Oils 28 28 28Meat 68 78 72 Egg 10 16 13Tubers & Roots (Including Potato) 41 50 45Leafy Vegetables 57 58 57Vegetables 42 48 44Fruits 22 26 24 Milk/Milk Products 98 78 90Sugar 56 52 55

N 379 242 621

grams/person/day

Source:NNS 2001-02

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3.2 Average Intake of Food by Children-by Food Groups

Food Groups Rural Urban National

Total Cereals 235 271 226Wheat 174 156 165Rice 61 61 61

Egg 2.5 1.4 1.9Meat 29 33 31Milk/Milk Products 229 233 231

N 379 242 621

3.3 Types of Wheat Bread Consumed by Regions

Region N Roti Khameeri(Hot Plate)

Roti Pateeri(Hot Plate)

Roti Pateeri(Baked)

Nan(Baked)

NationalUrbanRural

621242379

171218

687165

101010

575

Grams/child/day

Source: NNS 2001-02

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Most frequent Foods used N Once Twice 3-4 times 5-6 times Daily

All MeatUrbanRuralNational

242379621

233027

252022

181214

322

524

ChickenUrbanRuralNational

242379621

353334

191215

989

111

1107

Milk/Milk ProductsUrbanRuralNational

242379621

171314

587

766

222

242424

CarrotsUrbanRuralNational

242379621

354

111

222

011

101

Green Leafy VegetablesUrbanRuralNational

242379621

363133

181919

101614

143

655

Wheat BreadUrbanRuralNational

242379621

724

623

555

151314

828584

3.4 Consumption Frequency of Different Food Items Per WeekPercent

Source: NNS 2001-02

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3.5 Pakistan Food Basket Based on (2100 calories)

Average Caloric Requirement/ Capita/ day (proposed)

(at physiological Level)

Sl. Food Item Quantity (gm)

1. Wheat (Atta) 300

2. Rice 60

3. Other Cereals 15

4. Pulses 30

5. Meat & Products, Poultry & Fish. 40

6. Milk and Milk Products 150

7. Added Fat 30

8. Sugar 50

9. Fruits and Vegetables 100

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4. Food and Nutritional National policies

9th five year programme(2003-08)

Capacity development at all levels to address nutritional problems

Control of nutritional disorders

Universal accessibility to safe and balanced food

Awareness through education for healthy lifestyle and adopting improved nutritional practices

Initiation of community based growth monitoring policy for young child and maternal nutrition.

Promotion and protection of breastfeeding.

Development of strategic frame work. Consensus building among stakeholders for graphical & practical national nutrition strategic plan

National fond fortification

Research

a) Food Dietary Guidelines

b) Efficiency of single close vitamin A and Serum retinol level in lactating mothers

Micro nutrient supplementation

4.1 Existing

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Tawana Pakistan: School Nutrition Package for girls

National Programme for Family Planning and Primary Health Care/ The Lady Health Workers Programme

Bait-ul-Mal’s Food Support Programme

Pakistan Standards and Quality Control Authority

4.2 Ongoing Nutrition programmes and Projects

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World Health Organization

Micronutrient Initiative (MI) US aid Supported Programme

FAO

British Council

DFID

Save the Children Fund

Unicef

Unesco

4.3 International Organizations (working on Food,Nutrition and Health)

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Department of Preventive Peadiatrics, KEMC, Punjab Faisalabad Agricultural University, Punjab Department of Human Nutrition, NWFP Agriculture University Pakistan Institute of Community Ophthalmology (PICO), NWFP Nuclear Institute of Food and Agriculture (NIFA), NWFP Agha Kahn University, Sindh Department of Pediatrics, Unit 1, Civil Hospital, Karachi Department of Home and Health Sciences, Allama Iqbal Open University

(National Level) Departments of Food & Nutrition at Home Economics Colleges at Provincial level

4.4 EDUCATIONAL INSTITUTES IMPARTING NUTRITION EDUCATION AND RESEARCH

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Society for the Protection of the Rights of Child (SPARC), Islamabad Society for the Advancement of Community, Health, Education and Training

(SACHET), Islamabad Punjab Lok Sujag Jahandad Society for Community Development (JSCD), Punjab Oxfam NGO, Balochistan

4.5 NON-GOVERNMENT ORGANIZATIONS(working on nutrition & health)

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Ministry of Health: Nutrition WingNational Nutrition ProgrammeUSI/ IDD Prevention ProgrammeVitamin A supplementation ProgrammeWorld Food programmeCBNP/ Baby Friendly Hospital Initiative (BFHI) ProgrammeNutrition rehabilitation unit (NRU) programme in NWFPNutrition Support Programme in SindhNational food fortification programme

4.6 GOVERNMENT stake holders (working on Different Nutrition Programmes)

Nutrition Section, Planning and Development Division, Government of PakistanUniversal Salt Iodization ProgrammeIDD WorkshopResearch, Publications, LiteratureMicronutrient fortification in collaboration with MI

National Institute of Health  Applied Research

Laboratory ServicesIDD control Programmes in AJK, NA and Parts of NWFP

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Under Nutrition PEM in Infants and Children

Poverty Illiteracy and lack of nutritional sp. awareness Poor Sanitation Rising Unemployment viza viz price instability

Maternal malnutrition Young girls

Dietary imbalances Early marriages Frequent pregnancies Non-affordability of health food due to poverty Inflation(Low purchasing power) Rural/Urban disparities Cultural Norms

Micronutrient disorders• Anemia• IDD• Vitamin A deficiencies• Zinc

Lack of awareness Excessibility and affordability to nutritional foods(Iodized salt,fortified foods) Non-bioavailability of some important nutrients Dietary Norms Resistance to diet modification

Vitamin D deficiency Lack of awareness

Over weight/Obesity Leading to diet related chronic diseases such as cardiovascular disease, hypertension, diabetes,Renal and dental carries

Excess to extra calories(Fat and simple sugar based) Reduced physical activities Cultural Norms Lack of low cost health clubs Casual attitude on middle and old age Nutritional health

4.7 Summary of Nutritional Problems and Underlying Causes:

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5. Pakistan’s Vision for Food Based Dietary Guide lines

a) Healthy Balanced Diet for average Pakistani

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6. Pakistan’s Vision for Food Based Dietary Guide lines

b) Healthy Balanced Diet for average Pakistani Child