PSSP Third Annual Conference "Agricultural and Natural Resource Issues and Policy Reform" Islamabad, Pakistan April 14, 2015

1. Food Consumption Patterns and
Nutrition
Sohail J. Malik
Hina Nazli
Asma Shahzad
Amina Mehmood
April 15, 2015

3. Plan of Presentation
• Food security and Consumption Patterns
• Food prices and cost of calories
• Nutritional status and hidden hunger
• women
• children
• Determinants of malnutrition in Children
• Policy implications and Recommendation

4. Food Security and Resilience
FoodSecurity
Availability
Production +
Stocks
Income
Imports-exports
Accessibility
Prices
Poverty
Income
Utilization
Consumption
Water, sanitation and
Hygiene (WASH)
Nutritional status
Nutritional status
Sustainability Variability in availability,
accessibility, utilization Resilience

5. Per capita availability (kg/annum) declining or
stagnant
0
20
40
60
80
100
120
140
160
2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12
Per capita availability (kg/annum) of Wheat
and Milk
Wheat Milk
0
5
10
15
20
25
2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12
Per capita availability (kg/annum) of Other
Food Items
Rice Pulses Edible oil/ghee Meat
Source: GoP (2013). Agriculture Statistics of Pakistan 2011-12

6. Average Supply of Calories per adult equivalent per
day has increased over time and is higher than the
recommended allowance of 2350
Source: GOP (2014), Economic Survey 2013-14
0
500
1000
1500
2000
2500
3000
2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11
Calories/adultequivalent/day
2350

7. Food Accessibility in Pakistan

8. Decreasing ability to access: Kilograms of Wheat
Flour that one Day’s Wages can Buy declining
0
5
10
15
20
25
30
35
2006 2007 2008 2009 2010 2011 2012
KilogramsofFlourperdailywage(Kgs)
Skilled Isamabad
Skilled Karachi
Skilled Lahore
Unskilled Islamabad
Unskilled Karachi
Unskilled Lahore
Source: GOP (2014), Economic Survey 2013-14

9. Calorie consumption is lower than calorie
supply
0
500
1000
1500
2000
2500
3000
2001-02 2004-05 2005-06 2007-08 2010-11
Caloriespercapitaperday
Available Consumed
Government of Pakistan (2011). Change in the cost of Food Basket 2010-11. Nutrition Cell, Planning Commission

10. On Average more than 70% of food expenditure is spent
on Dairy, Wheat, Fats, Sugars, and Meats (2010-11)
Source: HIES 2010-11
0
5
10
15
20
25
30
Dairy Wheat Oils Sugars Meats Pulses Fruits & vegs Other
SHAREOFFOODEXPENDITURE(%)
Overall Non-poor Poor

11. Differences in the Consumption Patterns of Agricultural
and Non-agricultural households (Rural Pakistan 2010-11)
Source: HIES 2010-11
0
2
4
6
8
10
12
Milk Wheat Fruits &
vegetables
Sugar Rice Fats Meat Pulses
kg/capita/month
Agricultural households Non-agricultural households

12. Share of Food expenditure of Poor Households
is High and Food Expenditures are Rising
0
10
20
30
40
50
60
70
2001-02 2004-05 2005-06 2007-08 2010-11
%households
Botton quintile Highest quintile
Source: HIES (various issues)

13. Poor Spend more on wheat and non-poor on Dairy
(2010-11)
0
5
10
15
20
25
30
Dairy Wheat Oils Sugars Meats
SHAREOFFOODEXPENDITURE
(%)
Pakistan
Non-poor Poor
0
5
10
15
20
25
30
Dairy Wheat Oils Sugars Meats
SHAREOFFOODEXPENDITURE
(%)
Urban areas
Non-poor Poor
0
5
10
15
20
25
30
Dairy Wheat Oils Sugars Meats
SHAREOFFOODEXPENDITURE
(%)
Rural areas
Non-poor Poor
Source: HIES 2010-11

14. Limited Dietary Diversity in Rural Pakistan:
(% households reporting type of food items consumed in last 24
hours – PSSP 2014)
Source: RHPS (2014)
0 1 2 3 4 5 6 7
Wheat flour
Spices, condiments
Ghee/butter/oil
Sugar
Dairy products
Tomato, onion, egg plant etc.
Roots and tubers (potatoes, turnip)
Pulses
Vitamin A-rich vegetables
Rice
Vitamin A-rich fruits
Eggs
Poultry
Dark green leafy vegetables
Fresh meat
Other fruits
Other cereals
% households

15. Wheat is the major source of energy
0
10
20
30
40
50
60
Wheat Oils Dairy Sugars Meats
%SHAREINTOTALCALORIES
Overall Non-Poor Poor
Source: HIES 2010-11

16. Trends in the Prices of Food Items
0
20
40
60
80
100
120
140
Wheat flour Basmati rice Moong Sugar Milk
Rs/kg
2000-01 2004-05 2009-10 2013-14
Source: GOP (2014), Economic Survey 2013-14

17. Sharp Increase in the Price of Wheat since
2007-08
0
5
10
15
20
25
30
35
2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11
Rs/KG
Source: GOP (2014), Economic Survey 2013-14

18. Calories consumed and the cost of calories
(2010-11)
Source: HIES 2010-11
0.0
1.0
2.0
3.0
4.0
5.0
6.0
100 Calories cost Overall Food excluding wheat (Rs) 100 Calories cost Wheat (Rs)
Rs/100calories
Rural Poor Rural Non-Poor Urban Poor Urban Non-Poor

19. Econometric Estimates indicate that Increase in Wheat Price has possible
adverse implications for other essential Human Development Indicators
• An increase in the price of wheat may not result in substitution with other
food items (low own and cross price elasticity)
substitution with non-food items is possible
• A substitution with health and education may worsen the already low
human development indicators
adverse effect on already high levels of poverty in the country
• Serious implications especially for current nutritional status and
productivity of future generation
• A further reduction in the purchasing power of the wage earners can
aggravate this situation further
Source: Authors estimates using HIES 2010-11 data and applying LA-AIDS model

20. Dietary patterns impact on
nutritional status

21. Malnutrition among Women (BMI) – Over 47 % are
Malnourished 2010-2011
0
10
20
30
40
50
60
Underweight (<18.5) Normal (18.5-24.9) Overweight (25-29.9) Obese (>29.9)
%WOMEN(15-49YEARS)
Pakistan Urban Rural
Source: NNS 2010-11

22. Hidden Hunger:
Micronutrient Deficiency among Women (2001-2011)
0
10
20
30
40
50
60
Prevalence of Anemia Vitamin A Deficiency Zinc Deficiency
%WOMEN(15-49YEARS)
Pakistan
2001 2011
0
10
20
30
40
50
60
Prevalence of Anemia Vitamin A Deficiency Zinc Deficiency
%WOMEN(15-49YEARS)
Urban areas
2001 2011
0
10
20
30
40
50
60
Prevalence of Anemia Vitamin A Deficiency Zinc Deficiency%WOMEN(15-49YEARS)
Rural areas
2001 2011
Source: NNS (2001; 2010-11)

23. Undernourished Females – Implications for Future
Generation
• A malnourished woman is at higher risk of giving birth to an anemic or
an underweight child (less than 2.5 kg)
• such children have five times the risk of death in the first year and
• high risk of growth failure during childhood
• Low birth weight may result in greater chronic diseases as an adult
• Severe iron deficiency anemia causes deaths during pregnancy and
childbirth
• Iodine deficiency in pregnancy causes the birth of mentally impaired
children
• Human and economic potential can be at risk due to malnutrition
Source: World Bank (2006)

24. Pakistan: Child malnutrition Results in
• Child mortality
• Low birth-weight babies (31.6% of live births in 2007) rank 3rd highest in 183
countries
• Under five mortality rate (86 per 1000 live births, 2008-2012) ranks 26 out of 194
countries
• Infant mortality rate (74 per 1000 live births, 2008-2012)
• Neonatal mortality rate (55 per 1000 live births, 2008-2012)
• Disability
• About 2.65 % population was disabled in 2012 (based on the projections on 1998
Census), 2.54% was in 1998
• Of these, 43% are children (1-15 years)
• Of total disabled, 8.2% are blind, 7.5% deaf, 14% mentally retarded, 8.3% have
multiple disabilities
• Probability of falling sick, loss in work days and income
Source: PDHS 2012-13
Source: UNICEF, State of the World's Children, Childinfo, and Demographic and Health Surveys by ICF International
Source: Helping Hands for Relief and Development (2012). Persons with Disabilities (PWDs) Statistics in Pakistan 2012

25. Malnutrition (PEM) among Children 2010-11
(under 5 years of age)
0
10
20
30
40
50
60
70
1977 1985-87 1990 1990-94 2001 2011
%children
Underweight Stunted Wasted
Source: NNS 2010-11

26. How reliable are the data?
Variations in the estimated malnutrition indicators based on
different national surveys for the same year 2001
0
10
20
30
40
50
60
70
Underweight Stunted Wasted
%children
National Nutrition Survey 2001 Pakistan Socio-Economic Survey 2001 Pakistan Rural Household Survey 2001

27. Hidden Hunger:
Micronutrient Deficiency among Children (2001-2011)
0
10
20
30
40
50
60
70
Prevalence of Anemia Vitamin A Deficiency Zinc Deficiency
%CHILDREN
Pakistan
2001 2011
0
10
20
30
40
50
60
70
Prevalence of Anemia Vitamin A Deficiency Zinc Deficiency
%CHILDREN
Urban areas
2001 2011
0
10
20
30
40
50
60
70
Prevalence of Anemia Vitamin A Deficiency Zinc Deficiency%CHILDREN
Rural areas
2001 2011
Source: NNS (2001; 2010-11)

28. Low Levels of Mothers’ Knowledge about Child
Nutrition
23.59
25.59
14.06
0
5
10
15
20
25
30
Iron deficiency Iodine Rich Food Drinking Water Treatment
Percentage
Source: RHPS (2012)

29. High and Variable Prevalence of Malnutrition (<–2SD)
by Province and Rural Pakistan (2013)
40
46
23
35
41
22
52
59
28
31
38
16
0
10
20
30
40
50
60
70
Underweight Stunting Wasting
%CHILDREN
All Pakistan Punjab Sindh KPK
Source: Authors’ estimates using RHPS, Round 2 (2013)

30. Determinants of Malnutrition: Results of Logistic
Regression
• Mother’s education improves the general state of nutrition among
children under five
• Improving hygienic conditions appear important to reduce long term
malnutrition (toilet facility and safe drinking water)
• Access to health care services plays a significant role in reducing the
short-term nutrition (LHW)
• Incidence of malnutrition among children under five is highest in
Sindh
• The prevalence of malnutrition is high across all income groups
• Poverty and malnutrition are determined by the same variables
• Nutritional status is a more direct measure of household welfare
Source: Authors’ estimates using RHPS, Round 2 (2013)

31. Summing up
• High prevalence of malnutrition in the country:
• Poverty - Lack of resources at the household level to maintain the minimum daily
allowance of essential nutrients;
• limited diversification because cost of non wheat calories significantly higher
• Lack of awareness about balanced diet and maintaining good health
• Focus of previous research on estimating numbers only
• Food Security not fully understood or integrated into policies
• Little work on understanding the linkages between food security, consumption
behavior and nutritional outcomes and variations across socio-economic groups and
regions
• Need re-prioritization and evaluation of any previous policies and
programs

32. Summing up
• The consumption of micronutrient rich foods is very low (vegetables and
fruits)
• Average calorie consumption is lower than the recommended level of
2350 and unbalanced in terms of micro-nutrients
• Wheat is the main source of calories, carbohydrate and fiber
• Food policy to date focused on availability of wheat tonnage through
production and import. Little diversification away from four major crops.
• Lesser focus on accessibility, sustainability and safety.
• Wheat consumption is price inelastic (implications for dietary diversity and
household expenditures on education, health care, etc.)

33. Results Indicate the Need for:
• Massive nutrition awareness campaigns and education
• Provision of safe drinking water
• Improvement in sanitation facilities
• Expansion in health care coverage (e.g., lady health workers)
• Promotion of kitchen gardens
• Food fortification and bio-fortification
• Special attention to the mother’s nutritional status through proper
medical care, adequate food, and iron, folic acid, and multivitamin
supplementation

34. Recent Global Initiatives to address Malnutrition
• Global Alliance for Improved Nutrition (GAIN) (2002)
• United Nation’s Millennium Development Goals
• First goal “eradicate extreme poverty and hunger.” Undernourishment and malnutrition are
amongst the indicators for this goal
• United Nation’s Sustainable Development Goals (2012)
• Replacement of MDGs
• United Nation’s zero hunger challenge (2012)
• Elimination of stunting is the first goal
• United Nation’s Scaling up nutrition (SUN) movement (2009)
• The First 1000 Days Initiative
• The Copenhagen Consensus 2012

35. Recent Nutrition Initiatives in Pakistan
• National Zero Hunger Program, launched in 2012
• Pakistan’s draft Agriculture and Food Security Policy 2013 aims to address
the food and nutrition insecurities
• Pakistan Integrated Nutrition Strategy (PINS), launched in 2013, aims to
address the underlying causes of malnutrition (food diversification, WASH,
school feeding, etc.)
• Scaling Up Nutrition (SUN) program, launched in 2013, aims to identify the
hurdles in access to food and address the issue of malnutrition

36. Needed Steps
• Improve identification of malnourished population based on scientific
method
• Sustained political commitment and government ownership
• Institutional and sectoral coordination and collaboration
• Sufficient resource allocation to strengthen implementation
• Massive awareness campaigns
• Enhancing zero hunger program, PINS, SUN
• Ensuring synergies - no overlaps
• Monitoring and evaluation system to improve real-time program
implementation and effectiveness

37. Thank you so much