Desirable Dietary Pattern for Bangladesh

The study conducted by:

Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM)

Principal Investigator: Quamrun Nahar, PhD Senior Research Officer, Dept of Biochemistry & Cell Biology BIRDEM

Co-Investigators: Subhagata Choudhury, MBBS, FCPS, MPhil Director and Professor, Laboratory Services, BIRDEM

Md Omar Faruque, PhD, Senior Research Officer, Dept of Biochemistry & Cell Biology, BIRDEM

Sayeda Saleha Saliheen Sultana, MSc. Assoc. Prof., College of Home Economics, Dhaka

Muhammad Ali Siddiquee, PhD Head, Grain Quality and Nutrition, BRRI

This study was carried out with the support of the

National Food Policy Capacity Strengthening Programme

June 2013 [Type

a quote from the document

This study was financed under the Research Grants Scheme (RGS) of the National Food Policy Capacity Strengthening Programme (NFPCSP) Phase II. The purpose of the RGS is to support studies that directly address the policy research needs identified by the Food Planning and Monitoring Unit of the Ministry of Food. The NFPCSP is being implemented by the Food and Agriculture Organization of the United Nations (FAO) and the Food Planning and Monitoring Unit (FPMU), Ministry of Food with the financial support of EU and USAID. The designation and presentation of material in this publication do not imply the expression of any opinion whatsoever on the part of FAO nor of the NFPCSP, Government of Bangladesh, EU or USAID and reflects the sole opinions and views of the authors who are fully responsible for the contents, findings and recommendations of this report.

Acknowledgements

It is with great pleasure that we acknowledge the Food and Agriculture Organization (FAO) of the UN, Bangladesh for providing technical support to BIRDEM for conducting the study Desirable Dietary Pattern for Bangladesh. This study is a fundamental step towards improving the health and nutritional status of the population of Bangladesh. We are also grateful to the authority of BIRDEM for the permission and support given to us to carry out this work.

We are expressing our indebtedness and gratitude to Dr. Lalita Bhattacharjee, Nutritionist and Dr. Mohammad Abdul Mannan, National Food Utilization and Nutrition Advisor, NFPCSP, FAO of the United Nations for their technical guidance and support given throughout the study period thus leading to its fruitful completion.

We are also grateful to Dr. Ciro Fiorillo, CTA, NFPCSP, FAO of the United Nations for his kind suggestions and overall supervision.

Our special thanks go to Dr. Nur Ahamed Khondaker, Research Grants Administrator of NFPCSP, FAO of the United Nations for his assistance and cooperation on issues related to the research management and logistics.

Special thanks are also due to Mr. Touhidul Islam, Deputy Project Director of Bangladesh Bureau of Statistics (BBS) for his help from time to time on the HIES data management and to Mr. SM Manzoor Ahmed Hanifi and Dr. Nurul Alam of ICDDRB for support on the statistical tools.

We are also grateful to Ms. Jillian Waid of HKI for her help regarding Dietary Diversity Score (DDS) calculation and for review of that section in the study.

We thank Kbd SM Emdadul Hoque, Deputy Director (Fruit and Vegetables), Food Crop Wing, DAE, Khamarbari and Mr. SM Quamruzzaman, Project Director, Integrated Quality Horticulture Development Project, DAE, Khamarbari, Dhaka for their support in adapting the crop calendar and related materials.

We are also thankful to Prof. Ekhlasur Rahman, Director IPHN and Line Director NNS; Prof. SM Keramat Ali of Daffodil University, Prof. Shaheen Ahmed, Former Principal, Home Economics College, Prof. Khursheed Jahan, Prof. Moududur Rahman, Prof. SK Nazrul Islam, Prof. Nazrul Islam Khan, Prof. Nazma Shaheen and Prof. ATA Rahim of INFS for their valuable suggestions.

We would like to express our heartfelt thanks to all the household members who have spent important time to give us information on the 24 hr dietary recall for the DDS calculation.

The working group that was set up for this research work also deserves special thanks for their keen interest and contribution towards the study.

Quamrun Nahar Senior Research Officer, BIRDEM Principal Investigator, DDP

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Table of Contents

Contents Page No

Acronyms viii

Executive Summary xi

1. Introduction 1 1.1.Objectives and key research questions 1

2. Literature review 3 2.1 Dietary pattern 3 2.2 Nutrition situation 4 2.2.1. Energy deficiency 5 2.2.2. Obesity and chronic diseases 6 2.2.3. Micronutrient deficiency 6 2.2.3.1.Iron deficiency 6 2.2.3.2.Vitamin A deficiency 8 2.2.3.3.Iodine deficiency 8 2.2.3.4.Zinc deficiency 9 2.3 Energy requirements and reference body weight 9 2.4 Basal metabolic rate 11 2.5 Physical Activity Level (PAL) 11 2.6 Nutrient requirements 12 2.7 Health and food crop diversity 16 2.8 Dietary Diversity Score 16 3. Methodology 20 3.1. Energy requirements 20 3.2. Nutrient requirements 21 3.3. Food intake patterns in Bangladesh 21 3.4. Household dietary diversity score 21 3.5. Key food identification 22 3.6. Crop calendar 22 3.7. Compilation of Bangladeshi foods 22 3.8. Optimizing nutrition return 22 3.9. Menu planning 22 3.10. Serving size calculation 23 3.11. Food exchange lists 23 3.12. Key stakeholders 23 3.13. Dietary guidelines for Bangladesh 23 3.14. Analysis of datasets 23 4. Results and discussion 24 4.1.Energy requirements for Bangladeshi population 24 4.2.Requirements of macro and micronutrients for Bangladesh 31 4.3.Diet and nutrient consumption patterns in Bangladeshi population 35

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4.4.Dietary diversity score 45 4.4.1 DDS of Khagrachari, Rangamati and Dhaka city populations 47 4.5. Desirable intake for Bangladeshi population 47 4.6. Energy and nutrient gap calculation for Bangladeshi population 48 4.7. Identification of key foods 50 4.8. Exchange lists of foods based on energy values 58 4.9. Optimizing nutrition return 63 4.10. Dietary guidelines for Bangladeshi population 63 4.11. Menu planning 63 4.12. Conclusion 64 4.13. Recommendations 64

5. Bibliography 65 Appendices A1: Physical Activity Level (PAL) calculations in different occupations in 73 Bangladeshi population A2: List of occupations in different PAL group 82 A3: PAL values for different type works 83 A4: Physical Activity Level (PAL) value of different work for females 85 A5: BMR in male and females according to age and body weight (FAO, 2004) 86 A6: Rich source of Energy, Carbohydrate, Protein and Fat 87 A7: Rich sources of Thiamine, -carotene and Vitamin-C 89 A8: Rich sources of Calcium, Iron and Fiber 91 A9: Nutrient Return per 100 taka Spent 94 A10: Vegetable calendar for Bangladesh from January to June 103 A11: Vegetable calendar for Bangladesh from July to December 104 A12: Seasonal fruit calendar from January to June 105 A13: Seasonal fruit calendar from July to December 106 A14: Menu plan 107 A15: Scientific name of all the available Bangladeshi foods 131 A16: Selected photographs of DDP activity 139

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List of Tables Page No Table 2.1: Per capita/day intake of major food items (g) in Bangladeshi population 3

Table 2.2: Prevalence of anaemia among pregnant and non-pregnant rural women 7

Table 2.3 Nutrition situation of Bangladesh 10

Table 2.4 Ranges of population intake goals 13

Table 2.5 Summary of the different terms of reference intake 16

Table 2.6 Measures of DDS at a glance 19

Table 4.1: Energy Requirements of Boys and Girls (up to 17 yrs of age) 25

Table 4.2: Energy Requirements of male and females of urban and rural areas 26

for 18-29.9yrs of age

Table 4.3: Energy Requirements of male and females of urban and rural areas for 27

30-59.9yrs of age

Table 4.4: Energy Requirements (kcal/day) of male and females of urban and rural 28

areas for >60yrs of age

Table 4.5: Energy Requirements of male and females for hilly region (PAL, 2.41) 29

Table 4.6: Energy requirements for pregnant women and lactating mothers 30

Table 4.7: RDA for Macronutrients in different age groups for both male and females 31

Table 4.8: RNI of Vitamins for Bangladeshi population 32

Table 4.9: RNI (Recommended nutrient intake) of Calcium, Phosphorus, Iron, 33

Magnesium and RI (recommended intake) of Sodium and Potassium

Table 4.10: RNI of iodine and zinc for Bangladeshi population 34

Table 4.11: Food intake (g/p/d) of the Bangladeshi population 35

Table 4.12: Mean per capita energy, protein, carbohydrate, fat and fiber intake of

Bangladeshi population (weighted value) 36

Table 4.13: Distribution ranges of population- nutrient intake goals 36

Table 4.14: Adult male equivalent (AME) consumption for household members

in different age groups according to HIES 2010 data 37

Table 4.15: Cereal intake of Bangladeshi population 41

Table 4.16: Comparison of energy, cereal and rice intake, HIES 2005 and 2010 41

Table 4.17: Diversity of pulse intake in Bangladeshi population 41

Table 4.18: Diversity of fish intake of Bangladeshi population 42

Table 4.19: Diversity of poultry and meat intake of Bangladeshi population 42

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Table 4.20: Diversity of vegetables intake for Bangladeshi population 43

Table 4.21: Diversity of fruit intake among the Bangladeshi population 43

Table 4.22: Diversity of Oil and visible Fat intake of Bangladeshi population 44

Table 4.23: Diversity of milk and dairy product intake of Bangladeshi population 44

Table 4.24: Diversity of spices intake of the Bangladeshi population 44

Table 4.25: List of food groups for DDS Calculation 45

Table 4.26: Desirable intake for Bangladeshi population 48

Table 4.27: Current Intake and RNI of different Vitamins for adult Bangladeshi

Population 49

Table 4.28: Intake and RDA of Zinc and Iron for adult Bangladeshi Population 50

Table 4.29: List of key foods with nutrient contributions according to HIES 2010 55

Table 4.29.1: Nutrient values of key foods 56

Table 4.30: Exchange list of fish according to energy contents 58

Table 4.31: Exchange list of lentils according to energy content 59

Table 4.32: Exchange list of leafy vegetables according to energy content 60

Table 4.33: Exchange list of nonleafy vegetables according to energy content 61

Table 4.34: Exchange list of fruits according to energy content 62

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List of figures Page No

Figure 2.1: Trends of anaemia among infants and preschool children in Bangladesh 7

Figure 4.1: Contribution of energy from carbohydrate, protein and fat 38

Figure 4.2: Distribution of carbohydrate intake of Bangladeshi population 39

Figure 4.3: Distribution of protein intake of Bangladeshi population 39

Figure 4.4: Distribution of fat intake of Bangladeshi population 40

Figure 4.5: DDS among Bangladeshi households of 14 different days 46

Figure 4.6: Distribution of DDS among Bangladeshi households 46

Figure 4.6.1: HDDS (Dhaka city, Khagrachari and Rangamati) 47

and IDDS (Students and slum peoples)

Figure 4.7: Key foods for fibre 50

Figure 4.8: Key foods for protein 50

Figure 4.9: Key foods for fat 51

Figure 4.10: Key foods for carbohydrate 51

Figure 4.11: Key foods for calcium 51

Figure 4.12: Key foods for iron 51

Figure 4.13: Key foods for 52

Figure 4.14: Key foods for 52

Figure 4.15: Key foods for vitamin C 52

Figure 4.16: Key foods for Vitamin A 52

Figure 4.17: Key foods for folic acid 53

Figure 4.18: Key foods for zinc 53

Figure 4.19: Key foods for magnesium 53

Figure 4.20: Key foods for sodium 53

Figure 4.21: Key foods for potassium 54

Figure 4.22: Key foods for phosphorus 54

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Acronyms

AED Academy for Educational Development

AI Adequate Intake

AME Adult Male Equivalent

ANR Average Nutrient Requirement

ATP III Adult Treatment Panel III

BARC

BARI

BBS

Bangladesh Agriculture Research Council

Bangladesh Agriculture Research Institute

Bangladesh Bureau of Statistics

BDHS Bangladesh Demographic Health Survey

BDT

BIRDEM

BIRTAN

BMI

BMMS

BMR

BRRI

CBN

CED

DAM

DCI

DDS

DDP

DEI

DRI

DRV

DHS

Bangladesh Taka

Bangladesh Institute of Research and Rehabilitation in Diabetes,

Endocrine and Metabolic Disorders

Bangladesh Institute of Research and Training on Applied Nutrition

Body Mass Index

Bangladesh Maternal Mortality Survey

Basal Metabolic Rate

Bangladesh Rice Research Institute

Cost Basic Need

Chronic Energy Deficiency

Department of Agriculture and Marketing

Direct Calorie Intake

Dietary Diversity Score

Desirable Dietary Pattern

Dietary Energy Intake

Dietary Reference Intake

Dietary Reference Value

Demographic and Health survey

EAR

FANTA

Estimated Average Requirement

Food and Nutrition Technical Assistance

FAO Food and Agriculture Organization

FCS

FCT

Food Consumption Score

Food Composition Table

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FPMU

GOB

Food Planning and Monitoring Unit

Government of Bangladesh

HIES

HKI

Household Income and Expenditure Survey

Helen Keller International

HDDS

HH

Households Dietary Diversity Score

Household

HNPSP

ICDDR'B

Health Nutrition and Population Sector Programme

International Centre for Diarrheal Diseases Research; Bangladesh

ICMR

ID

Indian Council on Medical Research

Iron Deficiency

IDA Iron Deficiency Anemia

IDD Iodine Deficiency Disorder

IDF

IDDS

IOM

INFS

International Diabetes Foundation

Individual Dietary Diversity score

Institute of Medicine

Institute of Nutrition and Food science

IPHN Institute of Public Health and Nutrition

LBW

LRNI

MDG

Low birth Weight

Lower Reference Nutrient Intake

Millennium Development Goals

NIN

NIV

National Institute of Nutrition

Nutrient Intake Value

NPNL Non pregnant non lactating

PAL

PopER

PSU

Physical Activity Level

Population Energy Requirement

Primary Sampling Unit

RDA Recommended Daily Allowance

RDI Reference daily Intake

RNI Recommended Nutrient Intake

SPSS

TDEE

TEE

UNICEF

Statistical Package for Social Science

Total Daily Energy Expenditure

Total Energy Expenditure

United Nations Childrens Fund

UL Upper Limit

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UNL

UNU

VAD

Upper Nutrient Level

United Nation University

Vitamin A Deficiency

WDDS

WHO

WFP

Women Dietary Diversity Score

World Health Organization

World Food Programme

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Executive Summary

Nutrition is a basic human need and prerequisite to a healthy life. A proper diet is essential from the very early stages of life for proper growth, development and to remain active. Food consumption, which to a large extent depends on production, access, distribution and affordability, impacts on the health and nutritional status of the population. Although Bangladesh has made considerable progress in increasing national level food availability, the intake of energy and other essential nutrients is still below the requirements and recommended dietary allowances. Diets are largely imbalanced with the staple food cereals contributing around 70% of total energy intake (HIES, 2010). A desirable dietary pattern therefore needs to be developed based on the current knowledge of nutritional requirements of different age, sex and occupational groups, the countrys food and dietary habits and normative guidelines for a healthy diet. Such recommendations for the desirable dietary pattern are used for formulating dietary guidelines for individuals and groups and for planning national food and agricultural strategies. National guidelines for translating the required energy and nutrients play an important role in supporting long-term planning for balanced food intake, but these are not yet available for Bangladesh. The present study is an attempt to develop a desirable dietary pattern and diet plans for Bangladesh that will help to meet the both macro- and micro-nutrient requirements at affordable costs. Energy requirements for the Bangladeshi population were calculated using the FAO/WHO recommendations. For this purpose, the physical activity levels (PAL) of all the occupations were estimated. PAL values for specific work were adapted from the FAO classification (FAO, 1985; FAO, 2004). After estimating the PAL values, all the occupations were categorized according to physical activity (sedentary, moderate and heavy work) PAL values that varied between 1.4 and 1.69 were considered for the sedentary group, 1.70-1.99 were considered for the moderate activity group and >2.0 were considered for the heavy worker group (FAO, 2004). PAL values for all the occupations were analyzed to calculate the mean PAL values of sedentary, moderate and heavy worker group which are estimated as : sedentary 1.5, moderate 1.88 and heavy 2.46. Moderate and heavy worker groups in the hilly region were considered together because the population doing moderate work are engaged in tasks that involve both up hill and downhill movement. They need to expend more energy, and as such are engaged heavy work with an estimated PAL value for hilly region people at 2.41. The basal metabolic rate (BMR) for different age groups with different body weight have been adapted from the FAO assessment of energy requirements based on energy expenditure estimates expressed as multiples of basal metabolic rates (FAO, 2004). The FAO methodology was used for calculating population energy requirements. Accordingly, the energy (kcal) requirements were for sedentary: urban: male, 2430, female, 1980; rural: male, 2430, female 1980; moderate: Urban: male, 2997, female, 2442; rural: male, 3045, female, 2480; and heavy worker groups: urban: male, 3758, female, 3062; rural: male, 3985, female 3280. This study also documented the comparison of energy requirements and current energy intakes. To estimate the current energy intakes, secondary data from HIES 2010 was analyzed. Weighted per capita/day mean energy consumption according to

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HIES 2010 was 2190 kcal (urban 2094, rural 2223kcal). It appears that the current energy consumption is about 240kcal deficient compared to the requirements of the average adult Bangladeshi population. But in terms of intra-household energy distribution according to adult male consumption equivalents, adult males are consuming adequate energy whereas females are still energy deficient. About 40% of the population take more than 75% of total calorie from carbohydrate which may have a linked with obesity and related diseases. Forty percent of the population take less than 10% of total calorie from protein sources and 53% of the population take less than 15% of total calorie from fat which reflects the scenario of stunting wasting and underweight in the country. Dietary diversity score (DDS) which is a proxy for nutrient adequacy of the diet of individuals, was calculated using the HIES 2010 food consumption data. Fifty percent of the households a dietary diversity score of less than 6 indicating those households at risk for micronutrient deficiency. Weighted per capita/day mean (SD) carbohydrate (g), protein (g) and fat (g) intake for Bangladeshi population were 413106, 57.215.6and 29.314.0 respectively. When protein intake of Bangladeshi population has been analyzed it is found that 66.5% of the population take more than 50g of protein but which are largely from plant sources. Weighted mean intake of vitamin A (g/day), calcium (mg/day), iron (mg/day) and thiamine (mg/day) for Bangladeshi population according to the HIES 2010 data were 388291, 439227, 10.963.82 and 1.00.6. More than 70% of the population are consuming less than the requirements of vitamin a, calcium and iron. Although it appears that the mean intake of vitamin C (85.467.1mg/day) is sufficient, more than 25% of the population are noted to be consuming less than the requirement. Mean pulse intake was 14.68g/person/day and it was mostly from lentil (masur), but interestingly different kinds of pulses were also present in the diet. Mean fish and meat intake were 50.3 and 19 g/person/day respectively. On the other hand mean vegetable (167g) and fruit (45g) intake amounts to about half of the recommended dietary allowances. Mean oil intake was 20.4g/person/day in the Bangladeshi population. This study adapted the RDA of macro- and micro-nutrients (carbohydrate, protein fat, fibre, vitamin A, thiamine, riboflavin, niacin, folic acid, vitamin B12, vitamin C, calcium, magnesium, sodium, potassium, iron, zinc, phosphorus, iodine) from the FAO /WHO recommendations for all the age groups of the Bangladeshi population categorized by gender and physiological status. The present study proposes a total of 400g of cereals as against the current average current intake which is higher and from largely only rice. The present study recommends a combination of cereals (wheat and maize) rather than focus only on rice. For the fulfilment of macro- and micro-nutrient requirements, 50g of pulses, 130g of animal products (fish, meat, eggs), 100 g leafy vegetables, 200 g non leafy vegetables, 100g seasonal fruits and 130ml of milk or milk products have been proposed. Thirty key foods were identified and various menu options have been proposed to meet required nutrients. This study will be helpful to individuals to plan healthy diets and meals for their household and for stakeholders and policy makers for food and agriculture planning as well as for health and nutrition programmes.

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1. Introduction

Over the last decades, Bangladesh has made considerable progress in increasing national level food availability and also individual level energy intake. Nevertheless, the intake of energy and other essential nutrients is still far below the nutrient requirements and recommended dietary allowances. Diets are largely imbalanced with the staple food cereals contributing around 70% of total energy intake (HIES 2010). While a declining trend in the consumption of cereals has been noted, the pace of decline needs to be accelerated. A desirable dietary pattern (DDP) should be aimed at, with a proportion of no more than 60% dietary energy intakes (DEI) from cereals. The desirable dietary pattern of nutrients for a countrys population is recommended based on the current knowledge of nutritional requirements of different age and sex groups and the countrys food and dietary habits. Such recommendations for the desirable dietary pattern are used as the basis for dietary guidelines for individuals and groups and for planning national food and agricultural strategies. The Joint FAO/WHO/UNU Expert Consultation on Human Energy Requirements in 2001 led to review and update for energy, nutrient requirements and dietary intakes towards informing and guiding nutrition policy and planning (FAO, 2004). Further the recommended dietary allowances for protein and amino acids in human nutrition were also revised (WHO/FAO/UNU Expert Consultation, 2007). The Expert Consultation also proposed that countries could develop their own guidelines adapting from the FAO/WHO/UNU recommendations. The National Institute of Nutrition (NIN) updated its nutrient requirements and recommended dietary allowances based on the 2004 FAO/WHO/UNU Expert Consultation. Diet plans that identify the quantities of different foods to be consumed to provide the human body with the required energy and nutrients play an important role in supporting long-term planning for balanced food intake, but these are not yet available in Bangladesh.

The present study is an attempt to develop a desirable dietary pattern and diet plans for Bangladesh that will help to meet the macro and micronutrient requirements at affordable costs. Such diets will have adequate dietary diversity; will be sustainable with an emphasis on the consumption of a variety of traditional and seasonal foods for ensuring diet improvement on a long term basis. This is in line with one of the key areas of interventions, namely long term planning for balanced food as outlined in National Food Policy Plan of Action 2008-2015.

1.1 Objectives and key research questions

Objectives A. Compute energy requirements using PAL values for different physical activity categories

segregated by age and gender in rural and urban areas of Bangladesh B. Compile nutrient requirements disaggregated by gender, age and physiological status

(pregnancy, lactation) and physical activity levels

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C. Develop diet plans that identify the types and quantities of foods required to provide energy and essential nutrients for a balanced diet of population disaggregated by gender, age, physiological status and physical activity levels in urban and rural areas with due attention to local food habits, food availability and biodiversity.

Research questions 1. What is the current dietary intake and pattern in Bangladesh?

What are the gaps in meeting the nutrient requirements? How to fill up the gaps given the factors of (a) seasonality; (b) cost; (c) local availability;

and (d) biodiversity 2. What is the energy and nutrient requirements for different age (0-65yrs) categories

disaggregated by gender, physiological status and physical activity levels (sedentary, moderate and heavy workers) in both rural and urban areas of Bangladesh?

3. What are the types and quantities of foods to be identified for a desirable dietary pattern? 4. What is extent of biodiversity that exists for the Bangladesh diet? 5. What time frame should be used to assess the dietary intake? 6. What are the different food baskets that can be proposed? 7. What is the optimum nutrient return per 100 taka spent? 8. Who are the key stakeholders for building consensus on the desirable dietary pattern?

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2. Literature Review Diet, nutrition and health are closely interrelated. Mere availability of foods does not ensure the intake of a well balanced diet; it depends on proper nutritional knowledge, purchasing capacity and also on local food habits. Dietary intake patterns especially related to energy, protein and micronutrient rich foods and the diversity of diets are discussed in this section. 2.1 Dietary pattern

Cereals, largely rice, form the main components of the diet in Bangladesh. The typical diet in Bangladesh is not balanced and remains dominated by a high intake of cereals (Jahan et al 1998; BBS, 2005; BBS, 2010). Household food consumption studies over the last 15

Table 2.1: Per capita/d intake of major food items (g) in Bangladeshi population, HIES

Food items, g

Survey years

1995-96

2000

2005

2010

Poor Non-poor Total

Total 913.8 893.06 947.75 816.22 1084.53 999.99

Rice 464.3 458.54 439.64 406.19 420.52 416.01

Wheat 33.7 17.24 12.08 20.36 28.73 26.09

Potato 49.5 55.45 63.30 63.44 73.78 70.52

Pulses 13.9 15.77 14.19 10.15 16.22 14.30

Vegetables 152.5 140.47 157.02 141.8 177.25 166.08

Edible oil 9.8 12.82 16.45 14.20 23.41 20.51

Onion 11.6 15.41 18.37 15.69 24.74 21.89

Beef 6.6 8.30 7.78 1.55 9.27 6.84

Mutton 1.0 0.49 0.59 0.11 0.83 0.60

Chicken/Duck 4.0 4.50 6.85 4.11 15.09 11.22

Eggs 3.2 5.27 5.15 3.40 9.02 7.25

Fish 43.8 38.45 42.14 31.16 57.81 49.41

Milk & milk products

32.6 29.71 32.40 12.18 43.63 33.72

Fruits 27.6 28.35 32.54 20.46 56.0 44.80

Sugar/Gur 9.2 6.85 8.08 3.32 10.88 8.50

Food taken outside

- - 24.76 17.70 35.41 29.83

Miscellaneous 50.9 55.44 48.38 50.28 81.81 72.41

years have shown the consumption of cereal intake decreases but it still makes up the largest share (70 percent) of the diet, followed by non-leafy vegetables, roots and tubers, which together comprise more than four-fifths of the rural peoples total diet (BBS, 2010). Protein and

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micronutrient-rich foods like fish, meat, eggs, milk, milk products, fats and oils account for less than 10 percent of the rural persons diet, and the consumption of vegetables and fruits are slowly improving over the years. Rural consumption of leafy and non-leafy vegetables has remained more or less the same over the past two decades after increasing over the preceding 30 years. With an average national per capita consumption of 31g of leafy vegetables, 136g of non-leafy vegetables and 45g of fruit, the average Bangladeshi eats a total of 212g of fruit and vegetables daily (HIES 2010). This is far below the amount of 400 g of vegetables and fruit recommended by FAO/WHO in 2003.It is encouraging that the HIES 2010 points towards an increase in vitamin A and iron consumption as compared to HIES 2005 and Bermudez et al, 2012) but it still needs improvements to fulfill the requirements. In addition, cultural norms dictate a better diet for males over females with the male head of the household getting the best meal portions. Persistent poverty, inadequate nutrition information and gender inequity cause pervasive malnutrition among women, especially pregnant women and lactating mothers 2.2. Nutrition situation The nutritional well-being of large part of the population is still being neglected because of insufficient access to sufficient, safe and nutritious food. As a result, children and women in Bangladesh continue to suffer high levels of malnutrition and micronutrient deficiencies, including low birth weight (LBW), under nutrition (underweight, stunting and wasting), vitamin A deficiency, iodine deficiency disorders and iron deficiency anaemia. At the same time, over nutrition, obesity and related health problems are emerging as multiple public health problems. Chronic energy deficiency (CED) is expressed as BMI less than 18.5 kg/m2 and used as a measure of malnutrition and health status in adults. A recent report (WHO, 2011) on non-communicable disease risk factor survey Bangladesh 2010 have been documented that about one fourth of the population are underweight (BMI

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causes of Vitamin A deficiency require further attention and support. Iron deficiency anemia affects one-third of adolescent girls and non-pregnant women and is even higher in pregnant women (51 percent; HKI/IPHN 2002). The latest National Micronutrient survey 2011/12 has shown a significant improvement where the prevalence of anaemia in the non-pregnant non-lactating women was 26% and in the preschool age children (under-5) was 33%. The immediate cause of malnutrition inadequate dietary diversity, as well as high infectious disease burden, household food insecurity and inappropriate household practices in feeding especially adolescent girls, pregnant women, mothers and young children. 2.2.1Energy deficiency Energy deficiency is defined as negative energy balance and includes chronic energy deficiency which is characterized by decreased body mass index i.e., BMI less than 18.5kg/m2. This is also termed as adult under nutrition. Present undernutrition among both sexes in the country is about 25% (WHO, 2011). Maternal undernutrition (body mass index

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2.2.2. Obesity and chronic diseases Along with the problem of under nutrition among children and chronic energy deficiency in adults in many parts of Asia including Bangladesh, the burden of overweight and obesity is becoming increasingly widespread (WHO, 2007). In some countries, this situation exists amidst food shortage and nutrient inadequacies. Over the last decade, there has also been a progressive increase in over nutrition. Reduced physical activity is identified as a major attributable factor. In affluent urban segments, increased energy intake from fats, refined cereals and sugar, combined with simultaneous reductions in physical activity, have contributed to steep increases in over nutrition in all age groups. Recent evidence (WHO, 2011) from the non-communicable disease risk factor survey Bangladesh 2010 has shown that 17.6% of the Bangladeshi population are overweight and obesity and noticed that urban population (25.1%) are more prone than rural population (10.2%). In that report it is also documented that 3.9% of the population are diabetic on the basis of self reporting system, blood sugar was not measured to diagnose diabetes. Thus it may not the real picture because it is generally accepted worldwide that half of the diabetic population are undiagnosed. A study in a rural Bangladeshi population over a 10 year period have shown that the prevalence of diabetes increased from 2.3% in 1999 to 7.9% in 2009 (Bhowmik et al, 2012& 2013). In that study under nutrition, overweight and obesity in 2009 were 14%, 17% and 26% respectively, and the presence of metabolic syndrome (cluster of metabolic risk factors, i.e., insulin resistance, diabetes, obesity indicators, hypertension, hyperlipidemia) according to WHO, IDF (International Diabetes Federation) and ATP (Adult Treatment Panel III) criteria were 9.9%, 23.7% and 29.6%respectively with the prevalence of overweight and obesity, diabetes and other non-communicable diseases also on the rise in Asian regions. 2.2.3. Micronutrient deficiencies Micronutrient-related malnutrition is often termed hidden hunger as the consequences are not always visible. There are four micronutrients that are particularly relevant to public health: vitamin A, iron, iodine, and zinc. The following sections briefly describe the situation of micronutrient deficiencies in Bangladesh. 2.2.3.1. Iron deficiency Anaemia is the most commonly-used indicator to define iron deficiency in population-based studies or in clinical settings. It has been estimated about two billion people in the world are anaemic, mostly in the low income countries of Africa and Asia. In Bangladesh anaemia is common among all age groups and both sexes are affected, especially children and women-both pregnant and non-pregnant. Anaemia in under-5 children, pregnant and non-pregnant women studied by different organizations in different time periods like 1975/76 (Ahmed et al, 1977), 1981/82 (Hasan and Ahmed, 1983), 1995/1996 (Jahan and Hasan 1998), 1999 (HKI, 2000), 2001 (HKI, 2002), 2003 (Salam et al, 2006), 2004 (HKI, 2006), 2010 (Eneroth, 2010) and in 2011/12 (National Micronutrient Status Survey, 2013) are summarized in figure 2.1 and table 2.2.

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Although the prevalence of anaemia decreased in 2001, after that the condition again deteriorated as reported 2003 and 2004 which may be due to gaps and challenges in the implementation of strategies. The recent national micronutrient survey (2013) reported that the prevalence of anaemia in preschool children and non-pregnant non-lactating women has been declining.

Table 2.2: Prevalence of anaemia among pregnant and non-pregnant rural women

Year Prevalence of anaemia (%)

Pregnant women Non-pregnant women

1975/1976 50 70

1981/1982 47 74

1995/1996 60 81

1997/1998 49.2 45

2003 41 34

2004 38.8 46

2011/12 26

Fig 2.1: Trends of anaemia among infants and preschool children in Bangladesh

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Although the 2012 National Micronutrient Survey indicated significant improvements in the anemia situation of both preschool children and non-pregnant women, it continues to remain a public-health problem in Bangladesh. The cause of anaemia among young children and women is multi-factorial, including the low intake of bioavailable iron in the diet and high rates of infection. The intake of iron from complementary foods is critical for the infant from six months as breast milk alone cannot provide for the infants increased need for iron for accelerated growth during that period. A WHO/UNICEF review of complementary foods in developing countries concluded that requirements of iron might be difficult to meet from non-fortified complimentary foods, especially if animal foods are not widely consumed.

2.2.3.2. Vitamin A deficiency In Bangladesh, vitamin A deficiency (VAD) had been identified previously as a major public-health(HKI, 1985). Study of Helen Keller International has been found a dramatic reduction in the prevalence of night blindness among preschool children from the 1980s to 2004, which is attributed to the successful programme of vitamin A supplementation launched in 1973 (HKI, 2005). Keratomalacia, the most severe form of VAD, is now seen occasionally among children hospitalized for SAM. However, a study in rural Bangladesh, sub-clinical VAD (serum retinol

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micronutrient survey 2011/12where it is stated that 40% of the school children and 42% of the non-pregnant non-lactating women are iodine deficient. 2.2.3.4. Zinc deficiency At the population level, the risk of zinc deficiency can be assessed based on two indirect indicators: (a) the prevalence of stunting and (b) the adequacy of absorbable zinc in food supply at the country level (Black et al, 2008). A stunting rate of more than 20% in under-five children is indicative of high risk for zinc deficiency at the country level (Black et al, 2008). With a 41% prevalence of stunting among under-five children, zinc deficiency is a major nutritional disorder in Bangladesh. The recent study has shown that national prevalence of zinc deficiency was 44.0% in the preschool age children and 57.0% in the NPNL women (National Micronutrients Status Survey 2011/12). The nutritional status of the Bangladeshi population was studied by different national and international organizations in different time periods and is summarized in the table 2.3.

2.3. Energy Requirements and Reference Body Weight Dietary energy requirements of a healthy, well-nourished population should allow for maintaining an adequate BMI at the populations usual level of energy expenditure. At the individual level, a normal range of 18.5 to 24.9 kg/m2 BMI is generally accepted (WHO 1995, 2000). At a population level, a median BMI of 21.0 was suggested by the joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases (WHO/FAO, 2003). Age, gender, height, weight and BMI are interlinked to the energy and nutrient requirements of individuals. Anthropometric standards for population groups differ from country to country. Each country has to set up its own reference standards since height and weight of the population are not equal with other country. The purpose of recommending nutrient requirements help in planning norms for attaining anthropometric reference standards. International Organizations WHO, FAO have proposed reference standards applicable for developing countries. The 95th centile values of weights and heights for given age/gender can be taken to be representative of well- nourished normal population and considered as standard reference values for India. For children below age 17, the reference body weight is fixed at the median of the range of weight-for-height given by the BMI reference tables (WHO, 2006 and 2007). For adults and children of age 10 and above, the reference body weight is estimated on the basis of the fifth percentile of the distribution of the BMI (WHO, 1995; 2007).

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Table 2.3:Nutrition situation of Bangladesh

2011 2007 2005 2004 2002 1999-2000 1996-1997

1993-1994

1990 1970

LBW% 36 36

Child nutritional status

Stunting (height-for-age) (%)

41 43 51 66(HKI/IPHN,BDHS)

Wasting (weight-for-height) (%)

16 17 15

Underweight (weight-for-age) (%)

36 41 39.7(Under

5yrs) 43

67(HKI/PHN,BDHS)

Child mortality/1000

Neonatal mortality 32 37 41 42 48 52 Post-neonatal mortality 10 15 24 24 34 35

Infant mortality 43 52 65 52

(2002-2006)

66 82 87 153

Child mortality 11 14 24 30 37 50 Under-five mortality 53 65 88 94 116 133

Maternal mortality Rate /1000 3.51

(BBS) 2.90

(BBS)

3.20 -4.0 (BMMS)

BMI (Woman) (30) (%) 1.7

Anemia %

Preschool child 49(BBS/ UNICEF)

51(HKI /IPHN)

Pregnant woman 47(BBS/ UNICEF)

Non pregnant woman

33(BBS/ UNICEF)

Adolescent 29(BBS/ UNICEF)

Goiter% 18 (1999 HNPSP)

47

(1993) HNPSP

Biochemical iodine deficiency% 43 (1999 HNPSP)

69 (1993 HNPSP)

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2.4. Basal Metabolic Rate (BMR) BMR constitutes about 45 to 70 percent of total energy expenditure (TEE) in adults, and is determined principally by gender, body size, body composition and age. It can be measured accurately with small intra-individual variation by direct or indirect calorimetry under standard conditions, which include being awake in the supine position, ten to 12 hours after a meal, following eight hours of physical rest and no strenuous exercise in the preceding day, and being in a state of mental relaxation and an ambient environmental temperature that does not evoke shivering or sweating. BMR can be measured only under laboratory conditions and in small groups of representative individuals. There is a need to estimate BMR at the population level when using the factorial approach to estimate TEE from the average BMR and PAL value attributable to that population. Hence, the alternative has been to estimate a groups mean BMR using predictive equations based on measurements that are easier to obtain, such as body weight and/or height (FAO/WHO/UNU 2004). The report from the 1985 FAO/WHO/UNU expert consultation used a set of equations derived mostly from studies in Western Europe and North America (Schofield, 1985). Almost half of the data used to generate the equations for adults were from studies carried out in the late 1930s and early 1940s on Italian men with relatively high BMR values, and questions have been raised about the universal applicability of those equations (Soares and Shetty, 1988; de Boer et al., 1988; Henry and Rees, 1991; Arciero et al., 1993; Piers and Shetty, 1993; Soares, Francis and Shetty, 1993; Hayter and Henry, 1993 and 1994; Valencia et al., 1994; Cruz, da Silva and dos Anjos, 1999; Henry, 2001; Ismail et al., 1998). The use of closed-circuit indirect calorimetry in most studies has also been questioned, as this technique might overestimate oxygen consumption and energy expenditure. FAO (2004) has reviewed extensively the predictive equations derived from a database with broader geographical and ethnic representation and recommended retaining the equations proposed in 1985 by Schofield to pursue a more thorough analysis of existing information, or to promote a prospective study with broad global geographic and ethnic representation. 2.5. Physical Activity Level (PAL) The 1981 FAO/WHO/UNU Expert Consultation estimated the energy requirements of adults as multiples of BMR (WHO 1985). This was later called physical activity level (PAL) as per FAO software used for the calculation of human energy requirements. The average PAL of healthy, well-nourished adults is a major determinant of their total energy requirement. As growth does not contribute to energy needs in adulthood, PAL can be measured or estimated from the average 24-hour TEE and BMR. Multiplying the PAL by the BMR gives the actual energy requirements. Therefore, a person's Physical activity level (PAL) is a numeric method of expressing one's daily energy expenditure. PAL takes into account total daily energy expenditure (TDEE) and basal metabolic rate (BMR). The equation can be written as:

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Classification of physical activity levels: Energy requirements are highly dependent on habitual physical activity. This consultation classified the intensity of a populations habitual physical activity into three categories, as was done by the 1981 FAO/WHO/UNU expert consultation (WHO 1985). However, in contrast with the 1981 consultation, a range of PAL values, rather than a mean PAL value, was established for each category. Furthermore, the same PAL values were used to assign men and women to a PAL category. Classification of lifestyles in relation to physical activity, or PAL (FAO 2004)

Category PAL value

Sedentary or light activity lifestyle 1.40-1.69

Active or moderately active lifestyle 1.70-1.99

Vigorous or vigorously active lifestyle 2.00-2.40*

* PAL values 2.40 are difficult to maintain over a long period of time.

2.6 Nutrient Requirements

Humans need a wide range of nutrients to lead a healthy and active life. Establishing nutrient requirements is a vast and never-ending task, given the large number of essential human nutrients. The nutrients include protein, energy, carbohydrates, fats and lipids, a range of vitamins, and a host of minerals and trace elements. The required nutrients for different physiological groups can only be derived from a well balanced diet.

Components of the diet must be chosen judiciously to provide all the nutrients to meet the human

requirements in proper proportions for the different physiological activities. The establishment of human nutrient requirements is the common foundation for all countries to develop food-based dietary guidelines for their population. WHO and FAO provide technical support worldwide to establish and disseminate information on nutrient requirements which are adopted as part of the national dietary allowances. Others use it as a base for their standards.

The concept of population nutrient intake goals is based on the first priority to ensure national food security and equity of distribution of available food in accordance with individual needs. Recommended nutrient intake (RNI) is the daily intake, which meets the nutrient requirements of almost all (97.5 percent) apparently healthy individuals in an age and sex specific population group. The FAO/WHO Expert Consultations nutrient recommendations are population intake goals, not individual dietary guidelines. Most nutritional guidelines address the estimated needs of individuals and identify the minimum intake to meet the nutritional needs of individuals. However, in recognition of the detrimental effects the excessively high intakes of essential nutrients may have, the concept of a safe range of intakes has evolved. Population nutrient intake goals follow this concept and focus on the maintenance of low population risk rather than low individual risk. The joint WHO/FAO

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Expert Consultation stressed that because population nutrient intake goals refer to substantially greater than intended if they are to be applied to the individuals. The population nutrient intake goals for consideration by national and regional bodies establishing dietary recommendations for the prevention of diet related chronic diseases as recommended by FAO/WHO are expressed in numerical terms below. Table 2.4 Range of population nutrient intake goals (WHO/FAO 2003)

Dietary factor Goal (% of total energy, unless and otherwise specified elsewhere )

Total Fat 15-30%

Saturated fatty acids

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Reference nutrient intake values: The World Health Organization/Food and Agriculture Organization (WHO/FAO) together with the United Nations University (UNU), has published a number of recommendations (reference values) for different groups of nutrients over time. The most recent report on vitamin and mineral standard intake (FAO, 2004) uses the term RNI (recommended nutrient intake). The RNI is the daily intake that meets the nutrient requirements of almost all (97.5%) apparently healthy individuals in an age- and sex-specific population group. In 2004, FAO has published RNIs for 6 minerals and 11vitamins.

Dietary Reference Intake (DRI): DRI (dietary reference intake) was proposed by the Joint Committee of the United States of America and Canada in 1995, in order to solve such problems. This term was charged with establishing reference values for planning and assessing diets of healthy population as well as serving as a basis for nutrition policies. The DRIs refer to the complete set of reference intakes, including the RDA (recommended dietary allowance), AI (adequate intake), UL (tolerable upper intake level), and EAR (estimated average requirement) (Institute of Medicine National Academy Press 1997, 1998, 2002, 2004). DRIs are expressed as intakes per day but are meant to represent average intakes of individuals over time. It is thought that the nutrient intake can vary substantially from day to day without ill effects (Murphy and Vorster 2007; Institute of Medicine National Academy Press 1997). Each DRI expression (RDA, AI, UL, and EAR) has specific uses for planning and assessing diets or for applications to nutrition policy and education. Dietary Reference Intakes for Japanese, 2005 (DRI-J) was published in April, 2005. The DRIs-J were prepared for health individuals and groups and designed to present a reference for intake values of energy and 34 nutrients to maintain and promote health and to prevent lifestyle-related diseases and illness due to excessive consumption of either energy or nutrients. The DRI-J also includes a special chapter for basic knowledge of DRIs.

Recommended Dietary Allowances (RDA): The RDA is the original term introduced by the US Food and Nutrition Board of the National Research Council in the 1940s (National Academy Press, 1989). It was defined as the level of intake of an essential nutrient that, on the basis of scientific knowledge, is judged by the Food and Nutrition Board to be adequate to meet the known nutrient needs of practically all healthy people. The RDA continues to be used as one of the nutrient intake values included in the US/Canadian dietary reference intake (DRIs). The DRIs refer to the complete set of reference intakes, including the RDA, AI adequate intake), UL (tolerable upper intake level) and EAR (estimated average intake). The RDA is set at a level of intake that meets the needs of 97% to 98% of healthy individuals in a particular age-and sex-specific group. It is the value that can be obtained from estimated average requirements (EARs) and an adequate margin of safety. They are calculated by the formula of RDAs=EARs+2SD (standard deviation). In Japan, the Recommended Dietary Allowances (RDA) was first established in 1970, after which a revision was made every five years. In June 1999, the sixth Revision of RDA was announced by the Ministry of Health and Welfare, and already started to use since 2000 effective to the year 2004. In the past years, RDAs had been established and used as the group target values to prevent nutritional deficiency. RDAs had been also used a guideline applicable for an individual only in case where such factors as sex, age, physical activity, physical generally correspond to those of a specific group on the other hand.

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Dietary Reference Value (DRV): Dietary reference values (DRVs) are nutrient-based dietary standards recommended by the United Kingdom in 1991 (Department of Health 1991, Department of Health 1998). The DRVs apply to groups of healthy people and are not appropriate for those with disease or metabolic abnormalities. As for US/Canadian DRIs, the DRVs for a nutrient assume that requirements for energy and all other nutrients are met when deriving a specific reference value. The British DRVs provide three values for most nutrients: the lower reference nutrient intake (LRNI), the estimated average requirement (EAR), and the reference nutrient intake (RNI). For some nutrients, a safe intake is given, and for carbohydrate and fat, individual minimum, maximum, and population averages are specified (Department of Health 1991).

Recommended Nutrient Intake (RNI): FAO and WHO with the United Nations University (UNU) has published a number of recommendations for different groups of nutrients. The most recent report on vitamin and mineral standards, published in 2004, uses the term RNI (recommended nutrient intake). The RNI is the daily intake that meets the nutrient requirements of almost all (97.5%) apparently healthy individuals in an age- and sex-specific population group. The most recent RNIs (for 6 minerals and 11vitamins) are based on nutrient-specific criteria. This term is set at 2 SD of the requirement above the EAR and will meet the needs of 97% to 98% of the population; it is similar to the US/Canadian RDA. The RNI is the daily intake that meets the nutrient requirements of almost all (97.5%) apparently healthy individuals in an age-and sex-specific population group. The most recent RNIs (for 6 minerals and 11 vitamins) are based on nutrient-specific criteria. A statistical distribution of requirements is derived from primary data, and the RNI equals the mean requirement plus 2 SD. It is equivalent, therefore, to the US/Canadian RDA, the British RNI, and the European PRI. Insufficient data were available to establish an RNI for vitamins E and A. An acceptable intake that supports the known function of vitamin E was determined and used as the best estimate of requirements. A recommended safe intake level was specified for vitamin A as the level of intake that prevents clinical signs of deficiency and allows normal growth, but it does not protect vitamin A status during prolonged periods of infection or other stresses.

Nutrient intake value (NIV): FAO/WHO/UNU concurred (King and Garza, 2007) to use the term NIV (Nutrient Intake Value) to encompass the set of recommendations based on primary data that are analogous to those developed by various regional groups, e.g., dietary reference values (DRVs) by the United Kingdom, nutrient reference values (NRVs) by Australia and New Zealand, reference values for nutrient supply by Germany/Austria/Switzerland, and dietary reference intakes (DRIs) by the United States and Canada. The recommended terminology suggests that the set of values be called nutrient intake values (NIVs) and that the set be composed of three different values. . The group agreed to recommend only two NIVs, the average nutrient requirement (ANR) and the upper nutrient level (UNL). It recognized that groups charged with the development of such recommendations have derived other values, but that these other values usually are derived from estimates of nutrient-specific ANRs or UNLs. ANR reflects the median requirement for a nutrient in a specific population.

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The above discussion about different terms of reference intake with initiating countries or organizations and introducing year are summarizes in the table 2.5.

Expert Committee has suggested to use the uniform term NIV in 2007 for the nutrient recommendations but still the guideline with the value for NIV has not yet published so in this study the latest recommendations of FAO, RNIs are used for 6 mineral and 11 minerals. Table 2.5. Summary of the different terms of reference intake

Name Abbreviation Country/Organization Year

RDA

Recommended dietary allowances

US Food and Nutrition Board of the National Research Council

1940

RDI Reference daily intake USA/Canada 1968

DRV

Dietary reference value United Kingdom 1991

DRI

Dietary reference intake Joint of US Canadian Committee 1995

RNI

Recommended nutrient intake

World Health Organization/ Food and Agriculture Organization and United Nations University

2004

NIV Nutrient intake value FAO/WHO Expert Group 2007

2.7. Health and food crop diversity

There is a crucial link between the maintenance of food crop diversity and effective strategies that ensure optimum nutritional status. Unfortunately, food production strategies to date have resulted in increasing dependence on cereals and other starchy staples, especially in poor communities (Tontisirin et al 2002). This has been linked to poorer nutrition. In this regard, the narrowing of the food base, a global phenomenon, is seen as an important factor affecting dietary diversity. Micronutrient malnutrition remains a problem of public health concern in most developing countries including Bangladesh. Food-based strategies have been recommended as the first priority to meet micronutrient needs (Allen, 2008) and an essential element of food-based approaches involves dietary diversification. 2.8. Dietary Diversity Score (DDS)

Dietary diversity score is defined as the number of individual food items or food groups consumed over a given period of time (Ruel, 2003). It can be measured at the household or individual level through use of a questionnaire. Most often it is measured by counting the number of food groups rather than food items consumed. At the household level, dietary diversity is usually considered as a measure of access to food, (e.g. of households capacity to access costly food groups), while at individual level it reflects dietary quality, mainly

17

micronutrient adequacy of the diet. The reference period can vary, but is most often the previous day or week (FAO & FANTA, 2011; WFP, 2009).

Food and Agriculture Organization (FAO) in 2011 has published operational guidelines for measuring dietary diversity in a standardized way in both individual and household levels, based on a tool originally developed by FANTA (FAO, 2011; Swindale and Bilinsky, 2006). FAO suggested a reference period of the previous 24 hours. Using once 24 hour recall period does not provide an indication of an individuals habitual diet, but it does provide an assessment of the diet at the population level and can be useful to monitor progress or target interventions. There are various other valid time frames for recall, such as the previous 3 or 7 days, and in the case of some foods, the previous month. FAO has been suggested to use 24 hours because it is less subjects to recall error, less cumbersome for the respondents and moreover, DDS based on a 24 hour recall period is easier than with longer recall periods; For the DDS of household levels FAO has been suggested 16 different food groups and intake of foods from each group counts for one score. According to the suggestion of FAO, households who consumed 6 food groups are high DDS.

Different type of DDS: The household dietary diversity score (HDDS) and individual dietary diversity score (IDDS) are calculated differently because the scores are used for different purposes. The HDDS is meant to provide an indication of household economic access to food, thus items that require household resources to obtain, such as condiments, sugar and sugary foods, and beverages are included in the score. The Individual Dietary Diversity Score (IDDS) reflects the nutrient adequacy of the diet and the food groups considered in this score place more emphasis on micronutrient intake rather than economic access to food. For this reason, the IDDS excludes the last two food groups from the 16 food groups which are recommended for HDDS and these two groups are: sweets, and spices, condiments and beverages. These groups may be used for additional analysis and considerations of bioavailability of micronutrients, but do not count as part of the IDDS. So, it is referred as IDDS14. The food groups considered in the score for the women dietary diversity score (WDDS) put more emphasis on micronutrient intake by FAO (2011) than on economic access to foods and a score based on nine food groups has been suggests for WDDS.

Amount of foods in HDDS: The amount of foods to be taken from each food group is an important factor to be considers while ensuring the micronutrient adequacy of diets. To avoid giving credit for consumption of a food group when the amounts reported were small (Kant et al 1993), excluded foods consumed in less than a minimum amount. For the meat, fruit and vegetable groups, the minimum reported amount for inclusion in the diversity score was 30g for all solid foods with a single ingredient and 60g for all liquids and mixed dishes, for the dairy and grain groups, this minimum amount was 15g for all solids and 30g for all liquids and mixed dishes. In the guidelines for measuring household and individual dietary diversity (FAO, 2011) it is recommended not need to set minimum quantities below which foods are not considered, so even small amounts of foods (for example, a very small portion of meat

18

included in mixed dish) needs to be counted. This is because the score is designed to reflect economic access to foods, and therefore even small quantities of food item reflect some ability to purchase that item. For women aged 15-49yrs, DDS were more strongly correlated with micronutrient adequacy of the diet when food quantities of approximately one tablespoon or less (35 as acceptable. Spices and condiments have no score. Correlation of HDDS with micronutrient density: DDS has been found to be positively correlated with adequate micronutrient density of complementary foods for infants and young children (FANTA 2006), and macronutrient and micronutrient adequacy of the diet for non breast-fed children (Hatloy et al, 1998; Ruel et al, 2004; Steyn et al, 2006; Kennedy et al, 2007), adolescents (Mirmiran et al, 2004) and adults (Foote et al, 2004; Arimond et al, 2010).

A number of studies have looked at the association between some measure of dietary diversity and child nutrition outcomes. The Demographic and Health Survey (DHS) from Ethiopia has shown a strong and statistically significant association between food-group diversity measures based either on a 24-hour or seven-day recall and childrens height-for-age Z-scores (HAZ) (Arimond and Ruel 2002). In that study a positive, and generally linear, trend in mean HAZ has been observed as food group diversity in the previous 7 days increases. A difference as large as 1.6 Z-scores has been observed between children who consumed one food group in the previous seven days compared to those who consumed eight food groups with adjusted other potentially confounding factors (Arimond and Ruel 2002).

Over the past decade, three large multi-country validation studies (Hoddinott and Yohannes, 2002; Working Group on Infant and Young Child Feeding Indicators, 2006; Arimond et al, 2010) and many smaller studies have looked at the association between dietary diversity and food security and/or micronutrient adequacy of the diet. Hoddinott and Yohannes (2002) studied the association between household dietary diversity scores and dietary energy availability in ten countries. Increasing household dietary diversity significantly improved energy availability. The results suggest that dietary diversity scores have potential for monitoring changes in dietary energy availability, particularly when resources are lacking for quantitative measurements. A second multi-country study of diets of children 6-23 months from ten sites was undertaken to test the association between dietary diversity and mean micronutrient density adequacy of complementary foods. Significant positive correlations were observed in all age groups and in most of the countries (FANTA/AED, 2006). Recently the association between dietary diversity and micronutrient adequacy of diets of women of

19

reproductive age was assessed in five countries. Dietary diversity was significantly associated with micronutrient adequacy in all sites (Arimond et al, 2010).

Studies carried out in individual countries and across diverse age groups showed correlations of 0.36 to 0.66 between dietary diversity scores and micronutrient adequacy ratios (Kennedy et al., 2007; Mirmiran et al., 2004; Mirmiran, Azadbakht and Azizi, 2006; Steyn et al., 2006; Hatloy, Torheim and Oshaug, 1998). Therefore, dietary diversity scores have been shown to be valid proxy indicators for dietary energy availability at household level and micronutrient adequacy of diets of young children and women of reproductive age.

In a summary of seven studies reviewed by Ruel (2002), five found a positive association between dietary diversity score and nutrient adequacy. Of the studies focusing on young children, a positive correlation was found between DDS and nutrient adequacy in Mali, Kenya and Niger, while inconsistence results or no correlation were found in Guatemala, Ghana and Malawi. Greater dietary diversity has been associated with improved nutrient adequacy in children 4-8yrs of age in Kenya. Analysis of children aged 6-13.9 months from four developing countries concluded that there has been promising evidence for the utility of dietary diversity as an indicator of inadequate nutrient intake (Dewey et al 2005). In Table 2.6measures of DDS (FANTA/FAO) are presented where food groups used at household, individual, women, children and the food consumption score (WFP) are included.

Table 2.6 Measures of dietary diversity

Dietary diversity at household level

Number of foods

Food groups Amount (g)

HDDS (FAO & FANTA 2011)

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Cereals, white tubers and roots, vegetables, fruits, meat, eggs, fish and other seafood, legumes, nuts & seeds, milk & milk products, oils & fats, Sweets, spices, condiments and beverages.

30g for all solid foods, 60g for all liquids and mixed dishes

Dietary diversity at individual levels (IDDS) (FANTA 2006)

14

Cereals, vitamin A rich vegetables, roots and white tubers, dark green leafy vegetables, other vegetables, vitamin A rich fruits, other fruits, organ meat, flesh meat, eggs, fish, legumes, nuts & seeds, milk and milk products, oils and fats

30g for all solid foods, 60g for all liquids and mixed dishes

Womens dietary diversity (WDDS)

9

Starchy staples, dark green leafy vegetables, other vitamin A rich fruits and vegetables, other fruits & vegetables, organ meat, meat and fish, eggs, legumes, nuts and seeds.

At least 15g

Children (3yrs) Dietary Diversity (Steyn et al, 2006)

10

Cereals and tubers, vitamin A rich fruits & vegetables,other fruits, other vegetables, legumes and nuts, oils and fats, meat/poultry/fish, dairy, eggs, others (sweets,chips,soda,condiments,solid foods and liquid foods).

WFP (2008) 8 Cereals and tubers; pulses; vegetables; fruits; meat, fish, eggs; Milk and milk products; sugar; oil

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3. Methodology

Although the country is producing more food and improving nutritional status but still a large part of the population are facing both under- and over-nutrition related morbidity and mortality which is delaying the national economic cycle. A national desirable dietary guideline is essential for each county following the criteria of International Experts considering habit, PAL, seasonality and availability of foods for healthy life. Most of the developed and developing countries already have developed the dietary guideline but still there is a little information regarding the guidelines for desirable dietary pattern for the Bangladeshi population. The present study focused on the calculation of energy requirements, adaptation of micronutrient requirements using the FAO/WHO recommendations, analysis of the current food and nutrient intake patterns and menu development for the Bangladeshi people, for future healthy generation with the consensus of the key stakeholders of the country. 3.1. Energy requirement: For the calculation of energy requirements of adults we have considered reference body weight, BMR and PAL value according to the suggestions of Expert Consultations (FAO/WHO/UNU, 2004). Reference body weight and BMR for all ages have been adapted from FAO Guidelines 2004 considering gender and physiological condition. In this work energy requirement for 0-17 yrs age have directly adapted from the software named population energy requirement (PopER) which is developed by FAO for both developed and developing countries. In this software physical activity levels of the population in this age group are considered as a common group because they are doing almost similar type of work. Therefore, for a specific age, it is assumed that all the children have similar energy demands.

Average PAL values for different occupations of the Bangladeshi population have been calculated using the PAL values established by FAO/WHO/UNU (2004).In this study we have calculated PAL values of 139 occupations considering 8 hours as occupational work,18 hours for sleeping, and the rest 8 hours for house hold work and personal hygiene and recreation. Out of 139 occupations 17 were urban, 17 were rural and 105 occupations were in both urban and rural areas. These occupations have classified as sedentary, moderate and heavy activities, using the FAO/WHO/UNU classification (sedentary PAL 1.40-1.69, moderate PAL 1.70-1.99 and vigorous PAL 2.00-2.40). Energy requirements for adults were calculated from the factorial estimates of PAL by multiplying with BMR and body weight. The following example to calculate the average energy requirement of a female population aged between 18 29.9 yrs with a moderately active lifestyle and a mean body weight of 55kg is illustrated in the calculation:

Energy requirement = BMR x PAL x Body weight

= 24kcal/kg/d x 1.85 x 55kg

= 2442 kcal/day 1As established by International Labour Organization

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After the estimation of energy requirements for individual age groups of males and females with different physical activity levels for both the urban and rural areas we have calculated the average energy requirements for Bangladeshi adults considering the body weight of males as 60kg and females as 55kg. The proportion of sedentary, moderate and heavy work groups were considered from a previous study (Murshid et al, 2008).

3.2. Nutrient requirement: Reference nutrient requirements have been revised by different organizations as well as different countries over time based on newer scientific knowledge and applications for estimating nutrient requirements and food needs of the population worldwide. The present study has adapted the latest FAO/WHO recommendations for requirements of macro and micro nutrients considering gender and physiological conditions. The recommended dietary allowances (RDA) of carbohydrate and protein were adapted from the recommendations of FAO, 2007 and fat from FAO, 2008. Ranges of population nutrient intake goals were included from the WHO/FAO Expert Consultation 2003. Carbohydrate, protein and fat requirements as a percentage of total energy requirements were recommended as 55 to 75% of total energy from carbohydrate, 10 to 15% energy from protein and 15 to 30 % energy from fat. Micronutrients and fiber requirements were adapted from other sources (Nutrient reference values for Australia & New Zealand, 2005). Recommended nutrient intake (RNI) of Vitamin A, vitamin B like thiamine, riboflavin, niacin, B12, folic acid, and vitamin C were adapted from FAO (Human vitamin and mineral requirements, 2004). Calcium, phosphorus, Iron, magnesium, iodine and zinc were also adapted from FAO (Human vitamin and mineral requirements, 2004). Sodium and potassium requirements were adapted from NIN 2010 that has been based on the FAO/WHO recommendations.

3.3. Food intake pattern in Bangladesh: Current patterns of food and nutrient intake were calculated using secondary data from HIES 2010 considering all the studied households (12240) using the food composition table (FCT) of INFS (Shaheen et al, 2013) for the nutritive value of energy, fat protein, carbohydrate and all the micronutrients (vitamin A, thiamine, riboflavin, vitamin C, calcium, iron, fiber, magnesium, sodium, potassium, phosphorus, iodine, zinc and niacin).

3.4. Household Dietary Diversity Score (HDDS): HDDS of Bangladeshi population were calculated according to the HIES 2010 data using FANTA and FAO, 2011 Guidelines. In this method 24hr dietary recall for 14 different days of 12240 households were analyzed, total foods items have been divided into 12 food groups as in FANTA/FAO guidelines. For consumption of each group food with amounts of at least 30g for solid and 60g for liquid form have been considered for one score. Mean HDDS of 14 different days and as a whole mean HDDS have been calculated. According to the suggestion of FAO, households who consumed 6 food groups are high DDS.

As a cross check for the DDS value of HIES 2010, the present study also collected 24hr household food consumption data of 511 households and 300 individual women from Dhaka city (386 households from Zurain, Mohammadpur, Lalmatia and Mirpur areas, 200 students of graduation level, 100 adults from slum area), Khagrachari (75 households) and Rangamati

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(50 households) districts. HDDS was calculated as above and IDDS for individual students and women from slums were calculated using 9 food groups.

3.5. Key Food Identification: In the identification of key foods for Bangladesh, we have used HIES 2010 food consumption data and applied the methodology established by Haytowitz et al (2002). HIES 2010 data have shown that about 139 types food item were consumed by Bangladeshi population. For the identification of key foods, we have considered amount of food consumption, nutrient content of consumed food and frequency of house hold consumed the food. At first we have calculated per capita average consumption of each food item consumed by the survey respondent. After that we have calculated total consumption of each food item by multiplying average amount of food and the total survey respondents. After that we have calculated total grams consumed for each nutrient from all foods (total quantity of nutrient like carbohydrate, protein, fat, calcium, sodium, potassium, phosphorus, magnesium, zinc, iron, folic acid, vitamin A, thiamine, riboflavin, niacin vitamin C). Finally we have calculated nutrient contribution percent for each individual food by dividing total amount of nutrient consumed from all foods. A cumulative percent up to 75% was considered as key food for individual nutrients. In this way we have selected 5 to 8 food items for each nutrient. About 110 foods have primarily identified as key foods for 17 nutrients. Among the 110 foods we have identified 30 key foods from maximum amount and number of nutrient contributions. The 30 key food lists have arranged on the basis of number of nutrient contribution (Table 4.41).

3.6. Crop Calendar: Staple foods like rice and wheat are available throughout the year, therefore, Bangladeshi fruits and vegetables were documented in the calendar with the help of experts from Bangladesh Agriculture Research Council (BARC) and Agriculture Information Services, Khamar Bari. In this calendar we have included all the available leafy vegetables, non-leafy vegetable and fruits which are grown in Bangladesh. In this study we have included the name of food when it is available in market. Crop calendar is placed in appendix A10 A13.

3.7. Compilation of Bangladeshi Foods: List of all available foods of Bangladesh with local English and scientific names were compiled from reference books and web address and summarized in appendix A14.

3.8. Optimizing Nutrition Return: Money should be spent logically to get the required nutrients. Nutrient return for each hundred taka spent were calculated in this study using updated food composition table and average market prices. Average market prices were determined using the food price from the period of January 2010 to December 2010 of DAM (Department of Agricultural Marketing), Ministry of Agriculture, Bangladesh.

3.9. Menu planning: Different combination of menus with serving size and food exchange lists considering energy content of the menus and diet plans were documented.

Desirable dietary plans for average adults with 60kg weight for male and 55kg weight for female were proposed to meet the energy and essential nutrients for different economic (poor and non-poor) categories giving due attention to local food habits, food availability and

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biodiversity. Photo documentation of different menus, food lists corresponding to calorie requirements have also developed.

3.10. Serving size calculation: Serving size is known as the measuring unit of foods. We have calculated the serving size of Bangladeshi foods especially leafy vegetables, non-leafy vegetables and fruits. Detailed serving size has been discussed in the dietary guidelines.

3.11. Food Exchange list: All available fruits in Bangladesh have been classified into 9 groups according to similarity of calorie contents so as to have an equal exchange of foods/fruits from any group according to need and choice. An exchange list for cereals, leafy vegetables, non-leafy vegetables and fish has been developed.

3.12. Key Stakeholders for building consensus: Faculty members of INFS, Dhaka University; and Food and Nutrition Departments of public and private affiliated colleges of Dhaka University, scientist and researchers in the field of Nutrition from ICDDR'B, BRRI, BARI, IPHN, BIRTAN and BARC, Nutritionists working in different hospitals in Dhaka city, policy makers from the Ministries of Agriculture, Food, Disaster Management, and Health and Family Welfare, Representatives from FAO, WHO, UNICEF, WFP (Country Office). A dietary guidelines booklet and a technical report for a desirable dietary pattern for Bangladesh with all necessary information have been developed for use. 3.13. Dietary guidelines for Bangladesh: A desirable dietary guideline for Bangladesh has been developed based on food and nutrient intake analysis of HIES 2010 data along with current nutrient situation of Bangladesh and also consider the suggestions of National and International stakeholders in the field of nutrition. 3.14. Analysis of datasets: Data were analyzed using Statistical Package for Social Sciences (SPSS) for Windows version 17 and database. Mean SD intake of foods, energy and micronutrients were calculated using SPSS. Graphs (bar diagram, pie charts) were prepared using Microsoft Excel 2010. Dietary diversity score for the households were calculated using the same database.

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4. Results and Discussion

4.1. Energy requirements for Bangladeshi population Human energy requirements are estimated from measures of energy expenditure plus the additional energy needs for growth, pregnancy and lactation. Recommendations for dietary energy intake from food must satisfy these requirements for the attainment and maintenance of optimal health, physiological function and well-being. Energy requirements for Bangladeshi population were calculated using the FAO recommendations and methodology (FAO/WHO, 2004). Occupation has a very significant impact on daily energy expenditure, and thus, on per capita energy requirement. This is because individuals engaged in a particular occupation have to remain engaged in a specific activity for one third of the total daily available time, and the type of occupation determines the mean physical activity level (PAL) of a person. Therefore, all the available occupations in the country were tabulated and physical activity level (PAL) of all the occupations were estimated. PAL values for specific works were noted from FAO literatures (FAO 1985, FAO, 2004). For the calculation of energy requirement, the present study considered PAL, BMR, and desired bodyweight following FAO/WHO/UNU (2004) recommendations. PAL values for different occupations in the country were estimated using PAL values of different activities suggested by the Expert Committee (Appendix A1). Bangladeshi occupations were classified into 3 groups: Sedentary having a PAL value between 1.4 and 1.69; Moderate having a PAL value between 1.70-1.99 and heavy worker category with a PAL value >2.0 (FAO 2004). The mean PAL values within the categories were calculated and in the rural occupations, the mean PAL values for sedentary, moderate and heavy workers were calculated as1.5, 1.88 and 2.46 and the values for urban occupations were 1.5, 1.85 and 2.32. Moderate and heavy worker groups in the hilly region were considered together because the moderate need to expend more energy for climbing up hill and downhill activities, the moderate and heavy category of workers are classified into one group. Accordingly estimated PAL values for hilly region people were 2.41. Occupations in sedentary, moderate and heavy work are summarized in Appendix A2 and PAL values of different activities in male and females are tabulated in appendix A3 and A4. The previous study estimated the PAL values for sedentary, moderate and vigorous work groups as 1.46, 1.81 and 2.55 respectively (Murshid et al, 2008) where only 20 occupations were recruited. Basal metabolic rate (BMR) in different age groups with different body weight from FAO literature (FAO/WHO/UNU, 2004) was used to calculate the energy requirements (Appendix A5).

Energy requirements (ER) for children -up to 17 yrs of both boys and girls were adapted from PopER software developed by FAO for the developing countries (table 4.1). For this calculation energy requirement for growth considered with total energy expenditure. In this method PAL values of all the boys for a specific age are considered similar since their activities are mostly similar. Accordingly, PAL values of all the girls for a specific age are similarly considered. For example, energy requirement for 17 year old boys have been

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calculated as 3108kcal/day and for girls as 2377kcal/day. A proportion of urban children are engaged in video games rather than out-door playing, in this situation parents should think about their energy needs and may consults with the proper dieticians otherwise they are going to be overweight and obese. WHO reported in World Health Statistics that about 1.1% of the Bangladeshi children (

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Table 4.2 Energy Requirements of male and females of urban and rural areas, 18-29.9yrs

BW, kg

BMR, kcal/kg/d

Urban Rural

Sedentary, PAL 1.5

Moderate, PAL 1.85

Heavy, PAL 2.32

Sedentary, PAL 1.5

Moderate, PAL 1.88

Heavy, PAL 2.46

Male

45 29 1958 2414 3048 1958 2453 3210

50 29 2175 2683 3364 2175 2726 3567

55 28 2310 2849 3573 2310 2895 3788

60 27 2430 2997 3758 2430 3046 3985

65 26 2535 3127 3921 2535 3177 4157

70 25 2625 3238 4060 2625 3290 4305

75 24 2700 3330 4176 2700 3384 4428

Female

40 26 1560 1924 2413 1560 1955 2558

45 26 1755 2165 2714 1755 2200 2878

50 25 1875 2313 2900 1875 2350 3075

55 24 1980 2442 3062 1980 2482 3247

60 23 2070 2553 3202 2070 2594 3395

65 22 2145 2646 3318 2145 2688 3518

70 22 2310 2849 3573 2310 2895 3788

75 21 2363 2914 3654 2363 2961 3875

BW, Body weight; BMR, Basal metabolic rate

Table 4.3 shows the energy requirements of male and females with 30 to 60 years of age disaggregated by physical activity levels in both urban and rural areas. A male person with 60kg body weight requires 2340, 2886 and 3619 kcal energy for sedentary, moderate and heavy work groups respectively in urban areas whereas 2340, 2933 and 3838 kcal respectively requires for rural areas. Similarly a female person with 55kg body weight requires 1980, 2442 and 3062 kcal energy respectively, in urban areas whereas the energy requirements of rural females with 55kg body weight are 1980, 2482 and 3247 kcal, respectively.

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Table 4.3: Energy Requirements of male and females of urban and rural areas, 30-59.9yrs

BW, Body weight; BMR, Basal metabolic rate Table 4.4 shows the energy requirement for people more than 60 years of age disaggregated by sex and physical activity levels in urban and rural areas. In this age group, male persons with 60kg body weight of sedentary, moderate and heavy work groups in urban areas require 1980, 2442 and 3062 kcal of energy respectively whereas for the rural persons with same body weight requires 180, 2482 and 3247 kcal of energy respectively. Similarly females with 55kg body weight of urban areas require 1733, 2137 and 2680 kcal energy for sedentary, moderate and heavy work group population whereas the same females in rural areas require 1733, 2171 and 2841 kcal of energy, respectively.

Sex BW, kg

BMR, kcal/kg/

d

Urban Rural

Sedentary, PAL 1.5

Moderate, PAL 1.85

Heavy, PAL 2.32

Sedentary, PAL 1.5

Moderate, PAL 1.88

Heavy, PAL 2.46

Male

45 23 1553 1915 2401 1553 1946 2546

50 23 1725 2128 2668 1725 2162 2829

55 22 181 2239 2807 181 2275 2977

60 22 1980 2442 3062 1980 2482 3247

65 21 2048 2525 3167 2048 2566 3358

70 20 2100 2590 3248 2100 2632 3444

75 20 2250 2775 3480 2250 2820 3690

Female

40 24 1440 1776 2227 1440 1805 2362

45 24 1620 1998 2506 1620 2030 2657

50 22 1650 2035 2552 1650 2068 2706

55 21 1733 2137 2680 1733 2171 2841

60 20 1800 2220 2784 1800 2256 2952

65 19 1853 2285 2865 1853 2322 3038

70 18 1890 2331 2923 1890 2369 3100

75 18 2025 2498 3132 2025 2538 3321

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Table 4.4: Energy Requirements (kcal/day) of male and females of urban and rural areas, >60yrs

Sex BW,

kg BMR,

kcal/kg/d Urban Rural

Sedentary, PAL 1.5

Moderate, PAL 1.85

Heavy, PAL 2.32

Sedentary, PAL 1.5

Moderate, PAL 1.88

Heavy, PAL 2.46

Male

45 29 1958 2414 3028 1958 2453 3210

50 29 2175 2683 3364 2175 2726 3567

55 27 2228 2747 3445 2228 2792 3653

60 26 2340 2886 3619 2340 2933 3838

65 25 2438 3006 3770 2438 3055 3998

70 24 2520 3108 3898 2520 3158 4133

75 23 2588 3191 4002 2588 3243 4244

Female

40 27 1620 1998 2506 1620 2030 2657

45 27 1823 2248 2829 1823 2284 2989

50 25 1875 2313 2900 1875 2350 3075

55 24 1980 2442 3062 1980 2482 3247

60 22 1980 2442 3062 1980 2482 3247

65 21 2048 2525 3167 2048 2566 3358

70 20 2100 2590 3248 2100 2632 3444

75 19 2138 2636 3306 2138 2679 3506

BW, Body weight; BMR, Basal metabolic rate The following table (table 4.5) shows energy requirements of the population of hilly region for all the adult age groups in both male and females.

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Table 4.5: Energy Requirements of male and females for hilly region (PAL, 2.41)

Sex

18-29.9 yrs 30-59.9 yrs >60 yrs

BW, kg

BMR, kcal/kg/d

kcal/d BMR, kcal/kg/d

kcal/d BMR, kcal/kg/d

kcal/d

Male

45 29 3145 29 3145 23 2494

50 29 3495 29 3495 23 2772

55 28 3711 27 3711 22 2916

60 27 3904 26 3904 22 3181

65 26 4073 25 4073 21 3290

70 25 4218 24 4218 20 3374

75 24 4338 23 4338 20 3615

Female

40 26 2506