-
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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ii
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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iii
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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iv
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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v
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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vii
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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viii
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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ix
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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x
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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xi
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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2
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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3
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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4
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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5
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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6
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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13
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
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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
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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
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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)
12
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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20
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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21
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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22
(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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23
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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25
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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27
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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28
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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29
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