Desirable Dietary Pattern for Bangladesh PI: Quamrun Nahar, PhD

Co-InvestigatorsProf Subhagata Choudhury, BIRDEMDr M Omar Faruque, BIRDEMSyeda Saliha Saliheen Sultana, HECDr MA Siddiquee, BRRI

Introduction

Food production has tripled since 1971.

Rice production has increased from 9.77 mil MT in 1971 to 33.5mil MT in 2010

Food consumption at individual levels has also increased

However diets remain monotonous, imbalanced and dominated by a high intake of cereals which is 70%

Disproportionate consumption of cereals and non cereals foods is one of the factors leading to the double burden of malnutrition

Indicator Prevalence (%)LBW 22*Stunting (U5) 41Wasting (U5) 16Under weight (U5) 36Zinc deficiency 44Anaemia 33.1

Current Nutrition situation in Bangladesh

*World Health Statistics; BDHS 2011

Indicators Prevalence (%)

Anaemia 26

Zinc deficiency 57.3

Iodine deficiency 42.1

Prevalence of selected micronutrient deficiencies among non pregnant non lactating women

National Micronutrient Survey 2011-12

Indicators Prevalence (%)

DM 7.9a

BMI > 25 18

HTN >140/90 14.8

Central obesity 21.7

Current Prevalence* of NCD

*National NCD survey 2010; aInternational Diabetes Federation (IDF)

Objectives

• Estimate energy requirements by age, gender and physical activity levels namely sedentary, moderate and heavy work in rural and urban areas in Bangladesh

• Compile nutrient requirements disaggregated by gender, age and physiological status (pregnancy, lactation) and physical activity levels

• 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.

Basal metabolic rate (BMR)Physical activity level (PAL)

Calculation of energy requirement

18-29.9 yrs 30-59.9 yrs >60 yrsMale Female Male Female Male Female

BW BMR BW BMR BW BMR BW BMR BW BMR BW BMR

50 29 45 26 50 29 45 27 50 23 45 2455 28 50 25 55 27 50 25 55 22 50 2260 27 55 24 60 26 55 24 60 22 55 2165 26 60 23 65 25 60 22 65 21 60 2070 25 65 22 70 24 65 21 70 20 65 1975 24 70 22 75 23 70 20 75 20 70 1880 24 75 21 80 22 75 19 80 19 75 1885 23 80 21 85 22 80 19 85 19 80 1790 23 85 21 90 21 85 18 90 18 85 17

BMR (kcal/kg/d) in male and females adapted from FAO/WHO, 2004

BW, Body weight in Kg; BMR, Basal metabolic rate, kcal/kg/day

Activity PALSleep 1

Brick breaking 4Brick field worker 3Cutting trees 4.8Chopping wood 4.3Clearing ground 3.8Cooking 1.8

PAL (Physical activity level) of selected occupations

Physical activity levels of females (sedentary occupation)

Example: PAL calculation of a female banker

Per day activity (hr/day) hrs PAL Total PALWorking 8 1.3 10.4Sleeping 7 1 7Personal care 1 2.3 2.3

Eating, Cooking and Sitting 3 1.7 5.1

House hold working 2 1.95 3.9

Watching TV and chatting 3 1.4 4.2

Total time 24 32.9Average PAL 1.37

Category PAL value

Sedentary or light activity 1.40-1.69

Active or moderately active 1.70-1.99

Vigorous or vigorously active >2.0

Classification of lifestyles in relation to physical activity, or PAL (FAO 2004)

UrbanMild, PAL (1.5)

Occupation PALOffice worker 1.41Private Driver 1.59Doctor 1.44Shopkeeper 1.36Banker 1.37

Moderate PAL (1.85)Occupation PALTailoring 1.88Laundry worker 1.85Shoe maker 1.78

Heavy, PAL(2.32)Rickshaw puller 2.84Day laboring 2.65Brick field worker 2Gardener 2.21Electrical worker 2.04

PAL of different occupations

Gender

Urban (18-29 yrs) Rural (18-29 yrs)Mild Moderate Heavy Mild Moderate Heavy

Male 2430 2997 3758 2430 3046 3985

Female 1980 2442 3062 1980 2482 3247

1st trimester

2nd trimester

3rd trimester      

Pregnancy 85 285 475      

Lactation + 675 460      

Calculated Energy Requirements for Bangladeshi Population

Energy Requirements = BMR X PAL X BW

Energy requirement for adult Bangladeshi populationDistribution of Sedentary, moderate and heavy activity occupation in the Bangladeshi

population

Physical Activity level (PAL)

Sedentary Moderate Heavy

Male (%) 31 7 8

Female (%) 45 8 1

Average Energy Requirements= 2430 kcal

Recommended nutrient intakes of micronutrients

11 vitamins6 minerals

Vitamin C, Calcium and Iron (in mg) recommendations

19-50yrs Old(1992) Current (FAO-2004)

Vitamin C 30 45

Calcium 450 1000

Iron

Male 9

Bioavailability

15% 9.112% 11.410% 13.75% 27.4

Female 28

15% 19.612% 24.5

10% 29.4

5% 58.8

Analysis of Food Consumption, Household Income Expenditure Survey, 2010

Rice

Nn-leafy

vege

tables

Potatoes

Fishes

Fruits

WheatSp

ices

Leafy

vege

tables

Milk OIls Salt

Pulses

Poultry

Suga

r/molas

sesMeat Eg

g0

50

100

150

200

250

300

350

400

450 416

131

7050.3 45 40 40 36 32 20.4 15 14.7 11.5 9 7.3 5.72

Average food consumption (g) per capita per day

Shoal/Gajar/T

aki

Rhui/Katla

/Mrig

el/Kalbaush

Pangash/B

oal/Air

Hilsa

Sea Fish

Puti/Big puti/T

elapia/Nilo

tica

Other F

ishes(S

pecify)

Shrimp

Driede Fi

sh

Baila/T

apashi

Mala/Dhela/C

hapila/B

atashi

Tangra/Eelfish Koi

Silver c

arp/G

rass ca

rp/ M

iror c

arp

Magur/Shinghi/K

halisha

56789

1011

Diversity of Fish intake in Bangladeshi population g/capita/d

Diversity of vegetable intake in Bangladeshi population (g/capita/d)

Leafy ve

getab

le

Brinjal

White go

urd/Pumpkin

Caulifl

ower/Cab

bage

Water g

ourd

Perbol(pata

l)

Bean/Lo

beyArum

Green banan

a/ pap

aya

Snake

gourd

/Ribbed go

urd

Tomato

Radish

Balsam

apple

Ladies' fi

nger

10

15

20

25

30

35

4036.1

21.1

12 11.4 10.9 10.3

Macro and Micronutrient consumption

Energy (kcal) Protein, g CHO g Fat, g

2190±521 57.2±15.6 413± 106 29.3±14

Per capita per day macronutrient intake of Bangladeshi populations (weighted value), HIES, 2010

Requirement, 2430 kcal

Macronutriments Ranges of intake % Population

Carbohydrate

<55% 16.355 – 75% 43.3>75% 40.3

Protein

<10% 4010 – 15% 50>15% 10

Fat

<15% 5315 – 30% 44>30% 3

Distribution of population nutrient intake

VitaminsIntake (HIES 2010)

% of RNI,Male

% of RNI, Female

RNI

Male Female

Vitamin-A, retinol Eq (µg/day)

388±291 65 78 600 500

Vitamin-C mg/day 84.8±64.2 188 188 45 45

Thiamine (mg/day) 1.0±0.60 83 91 1.2 1.1

Riboflavin (mg/day) 0.80±0.35 62 73 1.3 1.1

Niacin(mg NEq/day) 17.8±10.2 111 127 16 14

Folic acid (µ/day) 197±81 49 49 400 400

Calcium (mg/day) 439±227 44 44 1000 1000

Current Intake and RNI of different Vitamins for adult Bangladeshi Population (can you show as% of RNI??)

MineralsIntake (HIES 2010)

% of RNI,Male

% of RNI,

Female

Bio-availabili

ty

RDA

Male Female

Zinc (mg/day)

10.03±2.62

71.6 102.3

High 4.2 3.0

Moderate 7.0 4.9

Low 14.0 9.8

Iron (mg/day)

10.96±3.82

40.0 18.6

15% 9.1 19.6

12% 11.4 24.5

10% 13.7 29.4

5 % 27.4 58.8

Zinc and Iron intake and RDA in adult Bangladeshi population

Household dietary diversity score (HDDS) analysis

HDDS considered is a measures of access to food at the house hold level

D 1 D2 D3 D4 D5 D6 D7 D8 D9 d10 D11 d12 D13 D146.4

6.456.5

6.556.6

6.656.7

6.756.8 6.77

6.65 6.656.61 6.59

6.57 6.586.61

6.57 6.56 6.55 6.546.58

6.63

Dietary Diversity Score (DDS): 6.6±1.4 out of 12 food groups

HDDS of 14 different days

Food Groups (FANTA/FAO, 2011)Cereal, white tuber and roots , Vegetables, Fruits, Meat, Eggs, Fish, Legumes and Nuts, Milk and milk products, Fats and oils, Sweets, Spices

<3 (0.2%)

3-5.99 (35%)

≥6 (64.8%)

Population distribution by HDDS

HDDS, out of 12 food groups IDDS, out of 9 food groups

HDDS (Dhaka city, Khagrachari and Rangamati) and IDDS (Students and slum people)

00.5

11.5

22.5

33.5

44.5

54.6

3.7

IDDS

33.5

44.5

55.5

66.5

77.5

8 7.37.7 7.9

HDDS

Identification of key foodsConsidering 75% cumulative % of total nutrient

contribution

Food name Food nameMedium rice Indian Spinach

Wheat (Atta) ChapilaPotato Ripe bananaCoarse rice BeanLiquid milk CauliflowerChicken CabbageRohu RadishGreen gram (boot) PumpkinJack fruit Perbol (patal)Brinjal Dried Fish (chapila)Puti HilsaPangash GuavaLentil(musur) TomatoBeef Bitter gourdMango Shrimp

30 Key foods identified from HIES 2010 using methodology of Haytowitz et al., 2002

% o

f Tot

al P

rote

in

Key foods for protein

Rice

Wheat flour

Chicken

Lentils

PutiBeef

Black F

ish/B

aho

Aire Fi

sh

Silve

r curp

Skim

-milk

(Liquid)

Indian sp

inach0

10

20

30

40

50

6048

5 4 3 3 2 2 2 2 2 1

% o

f Tot

al Ir

on

Key Foods for Iron

Rice

Wheat flour

Turm

eric

Indian sp

inach

Cumin seed

PotatoLe

ntils

Bengal g

ram

Puti fish

Indian riv

er shad

,raw

Onion

Prawal/

potol

Coriander s

eedBeef

Chili(gre

en)0

5

10

15

20

25

3026

11

8 74 3 3 3 2 2 2 2 1 1 1

FoodDesirable (g/P/D) &% Energy (2310 Kcal),

Yusuf et al, 1996

Desirable intake (g/P/D) & % of energy

(2350 kcal) (suggested by the

Expert Committee on 07.08.2007)

Desirable intake (g/P/D) & % of energy (2430 kcal)

(DDP 2012)

Desirable intake % Energy Current

intake % Energy Desirable intake % Energy

Cereal 372 55 375 55 400 56Rice 312 46.6 350 51 350 49

Wheat & other cereals 60 8.4 25 4 50 7Pulses 66 10 60 8.8 50 6.5

Animal Foods 126 5 180 5.46 260 10.5Fish 50 55 2.1 60 3

Poultry & Meat 22 35 1.4 40 2Egg 7 15 0.58 30 2

Milk & milk products 47 75 2.9 130 3.5Fruits 57 2.5 100 4.2 100 3

VegetablesGLV

200100 2

Non leafy Vegetables 132 2.5 3.6 200 2

Potato 130 5 60 2.47 100 4Cooking oil 38 15 40 15.3 30 11

Sugar/ Gur/ Molasses 28 5 18 3.66 20 3Spices 10 20 0.42 20 2

Food taken outside Miscellaneous

Total (g) 959 100 1053 100 1280 100

Des

irab

le D

ieta

ry P

atte

rn

• Physical activity level (PAL)• Gender• Average food price, DAM, 2010 • Per capita money spent on food by household • Serving size • RNI of Micro nutrients• Dietary Diversity Score (DDS)

Factors in Diet planning

Food cost per day, HIES, 2010Food cost / monthrange (Taka)

% HH Food cost (Taka)/person/day

4259-5304 65 35

5927-8247 34 52

>11014 1 82

Balanced food basket providing 2430 Kcal 71 taka/day

Food groups Amount (g)Portion

sizeEnergy (kcal)

% of total Energy Taka

Cereal

Rice parboiled (milled) 240

8 cup 844 338

Rice (flattened) 60 2 cup 213 5 3

Wheat flour (coarse) 60

4 small piece

200 92

Pulse 60 2/3 cup 201 8 4

Meat-fish-poultry 120

1 big piece meat, 1 egg

185

817

Vegetable 320 3 cup 114 5 2

Green leafy vegetables 130

1.25 cup 572

5

Oil 30 3 sp 270 11 5Fruit 300 3 cup 234 10 16Milk 130 1 cup 82 3 8Sugar 10 40 2 1

Total 1460 2440 100 71

Dietary guidelines

GUIDELINE 1: EAT A WELL-BALANCED DIET WITH A VARIETY OF FOODS AT EACH MEAL

• Key messages• Eat rice or wheat or a combination of cereals around 300-420 g

which is equivalent to 10-14 servings daily. • Eat rice or roti with lentils or beans or fish / poultry/ egg every

day for better nutritional quality • Do not discard water from cooked rice as they contain water

soluble vitamins • Try and consume unpolished/brown rice and whole wheat

brown atta for dietary fiber

Consume required amounts of fish, meat, poultry, egg, legumes daily

• Eat 1-4 piece fish, meat, poultry or 1-2 bati pulses and legumes daily

• Combine cereals with legumes in the ratio of 3:1 to improve protein quality

Eat a variety of seasonal fresh fruits and vegetables everyday

• Eat everyday 2 seasonal fruits (100g), one from citrus another from vitamin A sources

• Eat a citrus fruit after a meal to enhance iron absorption

• Eat at least 100g leafy , 200g non leafy vegetables daily

Consume adequate amounts of milk and milk products

1. Take at least one cup (130 ml) milk/ doi for good source of calcium throughout the life for healthy bones and teeth

2. Eat curd or drink soya milk in case of lactose intolerance

GUIDELINE 2: CONSUME MODERATE AMOUNTS OF OILS AND FATS

• Vegetable oil like mustard oil and soybean oil, should be used in moderation daily instead of ghee, butter, butter oil and palm oil.

• Limit intake of fat rich food, fast food, fat rich baked foods and processed meat that may add to undesirable trans-fats

 Limit salt intake to half to one teaspoon (< 5g) a day.Use only iodized saltReduce consumption of highly salted foods and condiments and avoid extra table salt with meals

GUIDELINE 3: LIMIT SALT INTAKE AND CONDIMENTS AND USE ONLY IODIZED SALT

• Refine sugar is known as a dietary disaster and it is advisable to reduce the intake sugar based food especially sweetmeats and rich desserts.

• Encourage the intake of natural sugars from a variety of seasonal fruits.

GUIDELINE 4: TAKE LESS SUGAR, SWEETS OR SWEETENED DRINKS

Drink 1.5 to 3.5 liter ( 6-14 glasses) clean and pure drinking waterDrink coconut water and fresh fruit juices instead of carbonated water

GUIDELINE 5: DRINK PLENTY OF WATER DAILY 

GUIDELINE 6: CONSUME SAFE AND CLEAN FOODS AND BEVERAGES

• Choose fresh, safe and clean foods and beverages.• Eat vegetables and fruits after thorough washing to avoid

microbes and bacteria• Avoid open street foods

GUIDELINE 7: MAINTAIN DESIRED BODY WEIGHT THROUGH A BALANCED FOOD INTAKE AND REGULAR PHYSICAL ACTIVITY

Key messages• Maintain normal BMI (18.5-23.0, kg/m2) along with Waist

circumference (male: 90 cm, female: 80 cm and waist hip ratio (male : > 0.9; female 0.8)

• Practise minimum thirty minutes of daily aerobic physical activities - walking, running, jogging, cycling, household work

GUIDELINE 8: PRACTISE HEALTHY LIFE STYLE WITH RIGHT COOKING AND HEALTHY EATING

Key messages• Eat food timely and avoid overeating• Avoid reuse of fried oil• Avoid faulty food beliefs, fads and fallacies• Avoid sleeping immediately after major meals• Avoid smoking, alcohol consumption and betel nut

chewing

GUIDELINE 9: EAT ADDITIONAL FOOD DURING PREGNANCY AND LACTATION

Key messages• Eat beef, mutton or poultry or germinated pulses

throughout pregnancy for getting dietary iron source

• Eat seasonal fruits throughout pregnancy especially after meals

• Maintain proper weight gain during pregnancy 12kg during pregnancy)  

GUIDELINE 10: PRACTISE EXCLUSIVE BREAST FEEDING FOR SIX MONTHS AND START APPROPRIATE COMPLEMENTARY FOODS IN TIME

Key messages• Exclusively breast feed for six months for adequate

growth of the child• Introduce appropriate complementary foods after

completion of 6 months and continue complementary feeding along with breast feeding up to 2 years

Conclusions The study provides an update on energy, macro and

micronutrients requirement for all ages considering gender, PAL and physiological conditions adapted to FAO/WHO recommendations.

Average energy requirement is 2430 kcal, current intake is deficient by 240 kcal. More than 50% dietary protein and iron sources are from plant sources.

Micronutrient intake especially vitamin A, calcium, iron, zinc, folic acid are inadequate.

The diet plans and menu options have been formulated considering dietary adequacy and nutrient gaps in Bangladeshi diets.

• The diets proposed can be adapted for use by both poor and non poor

households in urban and rural areas. A variety of foods and food groups

has been used in planning the diets so as to achieve a desirable dietary

pattern with adequate dietary diversity scores.

• The study findings can be considered for agriculture, food and diet planning

where in updates on energy and nutrient requirements are needed.

• The key nutrition messages can be considered for use in policy, programmes

and field interventions across food, agriculture and health sectors.

Recommendations

Acknowledgements

Technical Assistance Team Dr Lalita Bhattacharjee, FAO

Dr Md Abdul Mannan, FAO

Supported by

Prof Nazmun NaharDirector General, BIRDEMJillan Waid, HKIProf Nazma Shaheen, INFS