Dietary Guidelinesfor Bangladesh

Bangladesh Institute of Researchand Rehabilitation in Diabetes, Endocrine

and Metabolic Disorders (BIRDEM)

With the support of

NFPCSPNational Food Policy Capacity Strengthening Programme

USAIDFROM THE AMERICAN PEOPLE

Dietary Guidelines for Bangladesh

Quamrun Nahar, PhDSenior Research Officer, BIRDEM

Subhagata Choudhury, MBBS, MPhil, FCPSDirector and Professor, Laboratory Services, BIRDEM

Md. Omar Faruque, PhDSenior Research Officer, BIRDEM

Syeda Saliha Saliheen Sultana, MScAssoc Prof. Home Economics College, Dhaka

Muhammad Ali Siddiquee, PhDHead, Grain Quality & Nutrition Division, BRRI

Technical Contributions

Mohammad Abdul Mannan, PhDNational Food Utilization & Nutrition Advisor

National Food Policy Capacity Strengthening Programme, FAO

Lalita Bhattacharjee, PhDNutritionist

National Food Policy Capacity Strengthening Programme, FAO

This study was financed under the Research Grants Scheme(RGS) of the National Food Policy Capacity StrengtheningProgramme (NFPCSP) Phase II. The purpose of the RGS is tosupport studies that directly address the policy research needsidentified by the Food Planning and Monitoring Unit of the Ministryof Food. The NFPCSP is being implemented by the Food andAgriculture Organization of the United Nations (FAO) and the FoodPlanning and Monitoring Unit (FPMU), Ministry of Food with thefinancial support of EU and USAID.

The designation and presentation of material in this publication donot imply the expression of any opinion whatsoever on the part ofFAO nor of the NFPCSP, Government of Bangladesh, EU orUSAID and reflects the sole opinions and views of the authors whoare fully responsible for the contents, findings andrecommendations of this report.

ISBN: 978-984-33-7492-9

Ill I II II II H 'IIBIRDEM, DHAKA, June-2013

ii

1111 1 I Ill1 I 1 1

Contents

Abbreviations ivPreface

Introduction 1

Policies and strategies 2Current nutrition situation 2

Goals of dietary guidelines 3

Population nutrient intake goals 4

Dietary guidelines for the Bangladeshi population 5Description of dietary guidelines 6

Guideline 1: Eat a well-balanced diet with a variety of foods ateach meal 7

Guideline 2: Consume moderate amount of oils and fats 13

Guideline 3: Limit salt intake and condiments and use onlyiodized salt 16

Guideline 4: Take less sugar, sweets or sweetened drinks 18

Guideline 5: Drink plenty of water daily 20

Guideline 6: Consume safe and clean foods and beverages 21

Guideline 7: Maintain desired body weight through balanced foodintake and regular physical activity 22

Guideline 8: Practise healthy life style with right cooking andhealthy eating 25

Guideline 9: Eat additional food during pregnancy and lactation 27

Guideline 10: Practise exclusive breastfeeding for six months and

start appropriate complementary foods in time 28

Food guide pyramid for Bangladeshi population 29

Physical activity pyramid 31

Self evaluation of food based dietary guidelines 32

Standardization of weights and measures for foods 33

Food exchange list 34

Desirable diet for Bangladesh 35

Menu planning 36

Nutrient requirements 38

Glossary 42

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Abbreviations

Al Adequate intakeBBS Bangladesh Bureau of StatisticsBDHS Bangladesh Demographic and Health SurveyBMI Body Mass IndexBNNC Bangladesh National Nutrition CouncilBIRDEM Bangladesh Institute of Research and Rehabilitation in

Diabetes, Endocrine and Metabolic DisordersBRRI Bangladesh Rice Research InstituteCHD Coronary Heart DiseaseCVD Cardiovascular DiseaseDDP Desirable Dietary PatternFAO Food and Agriculture OrganizationFPMU Food Planning and Monitoring UnitHDL High Density LipoproteinHIES Household Income and Expenditure SurveyIDF International Diabetes FederationINFS Institute of Nutrition and Food ScienceIPHN Institute of Public Health and NutritionLDL Low Density LipoprotcinMg MagnesiumMoHFW Ministry of Health and Family WelfareNCD Non Communicable DiseaseNFPCSP National Food Policy Capacity Strengthening ProgrammeNPNL Non Pregnant Non Lactating

Pg MicrogramPhosphorus

PAL Physical Activity LevelPEM Protein Energy MalnutritionPUFA Polyunsaturated Fatty AcidsRDI Recommended Dietary IntakeRE Retinol EquivalentsRI Recommended IntakeTEE Total Energy ExpenditureTFA Trans Fatty AcidUSA1D United States Agency for International DevelopmentWHO World Health Organization

iv

Preface

A balanced diet provides energy and nutrients for optimalgrowth, development and body maintenance. To achieve abalanced diet, you must eat a variety of foods from each ofthe food groups. This requires an understanding of how toimprove dietary diversity and quality as well as wise foodselection in planning meals. The most important step is toeducate yourself about what your body needs and followdietary guidelines which convert the scientific knowledge ofnutrient requirements and food composition into practicalmessages so as to facilitate proper meal planning andconsumption for nutritional well being.

Given the prevalence of under nutrition in the largersegments of the population and emerging problems of noncommunicable diseases in Bangladesh, the preparation ofthese guidelines is timely. This guide is an attempt todevelop food based dietary guidelines for the general publicand propose practical suggestions for better nutrition andhealth.

The guidelines have been developed based on an analysis ofthe dietary and nutrient adequacy of the food consumptionof households using data from the 2010 Household IncomeExpenditure Survey. Many different sources of diet relatedinformation as well as regional guidelines have beenreviewed and considered. The dietary guidelines have alsobeen followed up from the guidelines published in 2000 bythe Bangladesh National Nutrition Council, Ministry ofHealth and Family Welfare. The previous qualitativemessages have been updated and quantitative messageshave been included incorporating latest scientific evidencebased information while at the same time, keeping themessages simple and easy to read.

The dietary guidelines developed by BIRDEM and otherstakeholders will serve as an educational tool to express

nutrition principles in terms of foods and dietary practicesthat promote health and lower the risk for diet relateddiseases. In addition, they will contribute to theimprovement of nutrition behavior in the population andserve as a tool to guide health, agriculture and food policies.

P . Apag141,WaharDirector General, BIRDEM

vi

At the heart of good nutrition are dietary guidelines

IntroductionAlthough Bangladesh has made considerable progress infood (cereal) production, household and individual dietarydiversity, child and maternal nutritional status continue topose as challenges. The consumption of an ill balanced dietis known to play a key role in malnutrition and as a riskfactor in chronic disease. Chronic diseases are largelypreventable. Although, more research is needed on someaspects of the mechanisms that link diet to health, availableevidence provides a basis to justify taking preventive action.

Dietary guidelines promote the concept of nutritionallyadequate diets and healthy life style from conception to oldage. This has been highlighted at many national andinternational levels and there was a general consensus that allcountries should adopt food based dietary guidelines suitablefor the country.

The dietary guidelines published by Bangladesh NationalNutrition Council (BNNC) and other regional guidelineshave been reviewed in the preparation of these guidelines. In2000 BNNC, MoHFW in collaboration with multiplestakeholders formulated a set of qualitative dietaryguidelines. The present dietary guidelines have beendeveloped after extensive analysis of the HIES 2010 data,the food and nutrient intake pattern as well as the nutritionsituation of Bangladesh.

In this document, food based approaches, using qualitativeand quantitative messages have been incorporated. Emphasisis on positive recommendations which can maximizeprotective effects through the use of a variety of foods intune with traditional habits. The goals set with respect tofood items such as pulses, meat, fish, milk andvegetables/fruits are intended to encourage appropriatepolicy decisions. Suitable messages for each of the food

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1

groups have been highlighted. A variety of foods, which areavailable and within the reach of the common people, can beselected to plan nutritionally adequate diets. Attempts aremade to give portion sizes and food exchanges. Food baseddietary guidelines emphasize the adequacy of intake of foodsfrom all food groups for maintenance of optimal health.Large scale behavioral change campaigns should belaunched to encourage people to follow dietaryguidelines. Such efforts should be integrated with existingnational nutrition, agriculture and health programs.

Policies and Strategies

Development and promotion of dietary guidelines were amongthe key activities outlined in the National Food and NutritionPolicy and National Plan of Action for Nutrition of Bangladesh1997. This was further outlined in the National Food Policy2006 and the ensuing National Food Policy Plan of Action2008 -2015. It was proposed as one of the priorityinterventions in Programme 11 of the Country Investment Planin Agriculture, Food Security and Nutrition (2011-2015). It isalso outlined as one of the key activities in the OperationalPlan of the National Nutrition Services (2011-2016).

Current nutrition situationAmong the Bangladeshi population, 22% children are bornwith low birth weight (LBW), over a third of children sufferfrom protein energy malnutrition: stunting 41%; wasting16% and underweight 36%. Just over a fourth of womenhave chronic energy deficiency and half of them are deficientin zinc and iodine. About 8.4 million people are reportedlysuffering from diabetes mellitus. The nutrition situation ofBangladeshi population has been summarized in table 1.

Ill

Table 1: Current Nutritional Status

aWHO, bBangladesh Demographic and IfeaIth Survey,eNational Micronutrient Survey, dinternational Diabetes FederationeNCD Risk Factor Survey, Bangladesh

Goals of dietary guidelines

Improve nutritional status of the Bangladeshipopulation and prevent nutritional deficiencydiseases.Ensure adequate nutritional status of pregnant andlactating women.Prevent and control chronic diet-related disorders.Maintain health of the elderly and increase lifeexpectancy.

Indicators % YearLB W 22 2012a

Stunting 412011b

(height-for-age)Child nutritionalstatus-under 5

Wasting(weight-for-height)

16 2011b

Underweight 36 2011b(weight-for-age)

Anaemia NPNL women 26 2011cAnaemia Under 5 33.1 2011e

Zinc deficiency Under 5 44 2011c

Zinc deficiency (NPNL women) 57.3 2011cIodine deficiency (NPNL women) 42.1 2011e

Diabetes Mellitus Adult 7.9 2011d

Obesity: BMI > 25 Adult 17.9 2010c

Population nutrient intake goalsThe population nutrient intake goals represent the populationaverage intake that is consistent with the maintenance ofhealth in a population. The population nutrient intake goalsconsidered by national and regional bodies establishingdietary recommendations for the prevention of diet relatedchronic disorders are given in Table 2:

Table 2: Ranges of population nutrient intake goals'

1 (WHO/FAO 2003, Diet, Nutrition and the Prevention of Chronic Diseases, WHO Technical Series 916

04

Dietary factor % of total energy

Total fat 15-30%

Saturated fatty acids <10%

Polyunsaturated fatty acids (PUFAs) 6-10%

n-6 Polyunsaturated fatty acids (PUFAs) 5-8%

n-3 Polyunsaturated fatty acids (PUFAs) 1-2%

Trans fatty acids <1%

Total carbohydrate 55-75%

n-6: n-3 5:4

Free sugars <10%

Protein 10-15%

Cholesterol <300 mg per day

Sodium chloride (sodium) <5g per day (<2 g per day)

Fruits and vegetables ?_, 400 g per day

Dietary guidelines for the Bangladeshi population

Dietary guidelines are sets of advisory statements providingprinciples and criteria of good dietary practices to promotenational wellbeing. They are intended for use by individuals.

The following advisory statements indicate what type offoods have to be consumed, the extent to which they have tobe consumed, including the use of spices, condiments andwater. It also suggests the use of healthy preparation andcooking methods for the retention of nutrients and topromote better health.

Eat a well-balanced diet with a variety of foods at eachmeal;

Use in moderation foods high in fat and minimize fats andoils in food preparation;

Limit salt intake and condiments and use only iodized salt;Take less sugar, sweets or sweetened drinks;Drink plenty of water daily;Consume safe and clean foods and beverages;Maintain desired body weight through a balanced foodintake and regular physical activity;Adopt and follow appropriate preparation and cookingpractices and follow healthy eating habits;Eat additional food and take extra care during pregnancyand lactation;Practise exclusive breastfeeding for the first six monthsof life; introduce appropriate complementary foods aftercompletion of 6 months and continue complementaryfeeding along with breastfeeding up to 2 years.

I05

bESCRIPTION OF DIETARYGUIDELINES

06

EAT A WELL-BALANCED DIETWITH A VARIETY OF FOODSAT EACH MEAL

Eat adequate amount of cereals and cereal productsand preferably whole grain cereals daily

Popular cereals in Bangladesh are rice and wheat. Rice is theprincipal source of energy and a good source of B complexvitamins. Rice products such as rice flakes, puffed rice andrice flour are also commonly eaten foods. The next rich sourceof energy is wheat. Wheat is rich in essential minerals likecalcium, magnesium, potassium, menganese, zinc, copper andB complex vitamins. Parboiled, unpolished, unrefined brownrice and whole wheat flour contain higher amount of nutrientsand dietary fibre that are beneficial to health. Whole graincereals also help to reduce the risk of gall stones, heartdisease, colon cancer and many other illnesses. Wholewheat and unrefined cereals have low glycemic index

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(GI) that is good for health. A daily consumption of 9 to 15serving of cereals is recommended of which 8-12 shouldcome from rice and 1-3 can come from wheat.

-Key ivtessages

Eat rice or wheat or a combination of cereals around270-450 g which is equivalent to 9-15 servings daily.Eat rice or roti with legumes or fish / poultry/ eggevery day for better nutritional value.Do not discard water from cooked rice as itcontains water soluble vitamins.Try to consume unpolished/ brown rice and wholewheat atta because it contains nutrients such asprotein, fat, dietary fibre, minerals and vitamins.

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

Fish, meat, poultry, egg, legumes and pulses are goodsources of protein which are needed for growth, bodyfunction and maintenance. Protein is also needed to improve

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immune response and supply of energy. Sea fish has highconcentration of omega 3 fatty acids, vitamin D and B2which are beneficial to health. Small bony fish which can beeaten whole are good sources of calcium for strong bonesand teeth. Meat and poultry are a rich source of vitamins likeniacin and riboflavin and minerals like calcium, zinc andcopper which have protective and regulatory functions in thebody. Eating fish regularly instead of red meat helpsreduce blood cholesterol. Eating lean meat is morebeneficial as a source of protein and it also reduces fataccumulation in blood vessels and the body as a whole.Frequent consumption of meat that has visible fat should beavoided.

Egg is an affordable source of high quality protein. It is apowerhouse of disease-fighting nutrients like protein, lutein,choline, iron and vitamin D.

Pulses and legumes are also a good source of protein. Theycontain a wide range of nutrients, including carbohydrate,dietary fibre, vitamins and minerals, as well as non-nutrients,such as antioxidants and phytoestrogens that are beneficial tohealth. Chickpeas and lentils contain saponins that help tolower blood cholesterol. Pulses include, lentils (mosur dal),peas, chick pea/Bengal gram (chholar dal), black gram(mashkalai dal), mung beans and other legume crops. Pulsesare gluten-free and can be used in diets for celiac disease, agastro-intestinal disorder. Meat/ poultry/ eggs are goodsources of haem iron. Children can eat one egg a day whilenormal adults can take 2 to 3 eggs per week.

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(Key messages

Eat 1 to 4 medium size pieces of fish, meat, poultryand 1/3 to 1/2 cup of pulses daily.Combine cereals with legumes in the ratio of 3:1.

Eat plenty of fruits and vegetables everyday

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Vegetables and fruits are good sources of vitamins, mineralsand dietary fibre. Dark green leafy vegetables, yellow orangevegetables and fruits are especially good sources of dietaryfibre, folate, and a wide range of carotenoids and vitamin C.Fibre in vegetables and fruits help to remove waste as well aseliminate excess cholesterol and some carcinogeniccompounds. Regular consumption of these foods helps toprevent vitamin A deficiency and anemia. Research hasshown that beta carotene and vitamin C in vegetables andfruits can prevent fat from depositing in blood vessels andalso reduce the risk of some types of cancer. Bangladesh isfortunate in having a wide range of leafy vegetables andlocal seasonal fruits. They should be taken regularly as partof the diet, and especially of children and adolescents to keepthem strong and healthy. It is suggested that everyoneshould eat a variety of vegetables during every meal, takefruits regularly, and especially after meals or as a snack.They should be taken according to seasonal availability.

f Key messagesEat 2 seasonal fruits everyday, one from citrus,another from vitamin A sources.Eat a citrus fruit after a meal to enhance ironabsorption.Eat at least 100g leafy and 200g non-leafy vegetablesdaily.

Consume adequate amounts of milk and milkproducts

Milk is a good source of calcium and phosphorus which areessential for building strong bones and teeth. Milk alsocontains protein, lactose and vitamins (especially vitaminB12) which promotes growth and proper functioning of bodytissues. Consumption of milk is essential for young childrenand adolescents for building maximum peak bone mass.Milk consumption also helps to prevent osteoporosis in laterlife. It is essential in pregnancy and lactation for the skeletaland dental health of both the mother and the baby. In ourcountry cow, goat and buffalo milk is popular.

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Key messages

Take at least one cup (150 ml) milk or one cup(100 ml) milk product such as plain curd or doi as agood source of calcium for healthy bones and teeth.Eat curd or drink soya milk in case there is lactoseintolerance. Curd contains bacteria that are beneficialto the body and can help digest lactose in milk.Fat free or skim milk is recommended for health,especially for older adults.

CONSUME MODERATEAMOUNTS OF OILS

\), AND FATS

Fats and oils are essential foods for health, supplying energy.Oils and fats from plant and animal sources are concentratedsources of energy and provide 9 kcal per gram. In our country,different types vegetable oils like soybean, mustard and ricebran oil are used as cooking oil in food preparation. Ghee andbutter are also used occasionally. Fats in foods provideessential fatty acids and helps absorption of fat solublevitamins A, D, E, and K. Some fats are a source ofantioxidants which are known to reduce the risk of somecancers and chronic heart disease. Apart from these, fatscontribute to texture, flavor and taste, and therefore improvethe palatability of meals. Cholesterol in fat is an essentialcomponent that is needed in small amounts for braindevelopment. Cholesterol is present only in foods of animalorigin such as whole cream milk, butter, ghee, egg, meat andorgan meats, shrimp and prawn and not in plant foods. There aretwo kinds of fat: saturated and unsaturated. Saturated fat comesfrom meat and animal skin, vanaspati, ghee, butter and coconut

AM. Ji1111illIMILIMIE

oil. Consuming too much saturated fat will increasecholesterol levels in blood leading to a greater risk ofcardiovascular disease. To prevent this, saturated fatshould be limited, especially in adults. Fish oil is asource of omega 3 fatty acids that confer nutritional andhealth benefits. Fast foods, bakery products and junk foodcontain unhealthy trans-fat that can raise your LDLcholesterol just like saturated fats. They also increaseinflammation and lower the HDL cholesterol that protectsagainst heart disease. The recommendation for cholesterol isno more than 300mg per day.

Key MessagesVegetable oil, like mustard and soybean oil should beused in moderation daily instead of ghee, butter, andpalm oil.Use only the required amount of cooking oil.Recommended daily intake is 30g per person per dayof visible fat.Limit intake of deep fried foods and oily snacks.Limit intake of high fat bakery products (cake,pastries), fast foods, (hot dog, burger), rich foods(Biriani, Kachhi), processed meat, grilled chicken etc.as they contain trans fats that are bad for health.

Box 1

Recommendations on the type of fat for a healthy dietacross the life span

Total fat should provide between 15-30% of the dailyenergy intake.Saturated fat should provide less than 10% of thedaily energy intake.Poly unsaturated (omega 3 and omega 6) fats shouldcontribute 6-10% of the daily energy intake.Intake of trans fat should be less than 1% of the dailyenergy intake.Remainder of the energy from fat can be provided bymono unsaturated fats.Cholesterol intake should be less than 300mg/ day.Omega 6 to Omega 3 ratio should be 5:4 in the diet.

15

Ç,,,(01 LIMIT SALT INTAKE ANDw CONDIMENTS AND USE

ONLY IODIZED SALT

Sodium is found in most foods as sodium chloride, generallyknown as 'salt'. Sodium is an essential nutrient for normalcellular metabolism. Dietary salt contain 97 to 99% sodiumchloride. One teaspoon of salt provides around 400 mg ofsodium. It is also present in the diet as sodium bicarbonate(baking soda) and as monosodium glutamate in processedfoods, in additives such as sodium phosphate, sodiumcarbonate and sodium benzoate. Too much or too little salt inthe diet can lead to muscle cramps, dizziness, or electrolytedisturbance. A high salt intake is a major risk factor forhypertension or elevated blood pressure. It is estimated thatBangladeshi people consume about 10g salt (2 tea spoons) percapita per day. Foods that are rich sources of sodium includesalted Hilsha, dry fish, cheese, table salt, pickles, fish sauce,ketch up, soya sauce, chips and wafers.

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Key messages

Limit salt intake to less than one teaspoon a day.Use only iodized salt.Limit consumption of highly salted / sodium richfoods like chips, biscuit, wafers and condiments.Limit extra table salt with meals.

17

DITAKE LESS SUGAR,

ti, SWEETS OR SWEETENED+ DRINKS,),

Sugar is a concentrated form of energy. Sugar consists ofsimple carbohydrates. Sugar is mainly used to sweeten foodand beverages like tea, coffee and desserts. A high intake ofsugar may also contribute to excess energy intake leading toobesity, which in turn is a risk factor for coronary heartdisease and diabetes mellitus. There is a link between sugarconsumption and dental caries. Children who eat sugaryfoods often have a lower appetite and are prone to toothdecay. Honey and molasses also provide sugar but are betterfor health than refined sugar. Less than 10% of total energyshould be provided from free sugars.

19

r .,Key messages

Consume not more than 25g (5 teaspoons) of sugarper day.Refined sugar is known as a dietary disaster and it isadvisable to reduce the intake of sugar based foodsespecially sweetmeats and rich desserts.Encourage the intake of natural sugars from a varietyof seasonal fruits.Limit consumption of foods rich in hidden sugar andfoods with added sugar e.g. confectionery, biscuits,cakes, jams, jelly, marmalades, chocolates, toffee,candy and sweets.

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%-1 DRINK PLENTY OF

01WATER DAILY

Water is an essential nutrient. All biochemical reactionsoccur within the water components in our body. Water isalso required for digestion, absorption, transportation,dissolving nutrients, elimination of waste products andthermo-regulation. Infants exclusively fed breast milk do notrequire supplemental water. A pregnant woman has slightlyincreased water requirements because of expandingextracellular fluid space, the needs of the fetus and theamniotic fluid. A lactating woman must drink extra water toreplace the fluid lost in breast milk.

(Key messages

Drink 1.5 to 3.5 liters (6-14 glasses) pure drinkingwater daily.Drink coconut water and fresh fruit juices instead ofcarbonated drinks.

20 r. 1111111Wifia.111M 1. 1111.=

CONSUME SAFE AND CLEANw FOODS AN() BEVERAGES

Consumption of unsafe food can cause severe illness andeven death. Aflatoxins of bacteria and moulds spoil the food.Natural enzymes present in food also lead to itsdeterioration. Besides insects and rodents, adulterants, wrongstorage methods and non-permitted food additives make thefood unsafe. Spoilt, stale, poor quality of food is madeattractive by adding harmful chemicals and colors. Streetfood is not considered as safe food especially when preparedand sold in unhygienic condition. Awareness and knowledgeregarding food selection, labelling, food storage, foodhanding and good personal hygiene during food preparationhelp to maintain food safety and good health. Perishablefoods like fish, meat and vegetables need to be refrigeratedand stored properly. Open cuts and wounds and poorpersonal hygiene can be a source of contamination. Dust andflies also contaminate the food, so it should always be keptwell-covered.

Key messages

Buy food items from reliable sources after carefulexamination.Refrigerate perishable food items till consumption.Keep foods well covered from dirt and fliesAvoid eating street foods that are contaminated withpolluted water and dust

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A "EfAIGNHTTTN DIROTHREADBBAOLADNY

WD

,?so, FOOD INTAKE AND REGULARPHYSICAL ACTIVITY

It is recommended that all healthy individuals engage inadequate levels of physical activity throughout their lives toachieve overall physical, mental, social and spiritual health.Many of the diet-related chronic diseases are closely linkedto poor activity patterns. Being physically active from anearly age prevents many diseases and disabilities inadulthood. Exercise improves oxygen utilization, clearsblood glucose and increases working capacity.

22

23i

( ')Key messages

Maintain ideal body weight by balancing foodconsumption with physical activity.Practice minimum 30 to 45 minutes of daily physicalactivity like walking, running, jogging, cycling andhousehold work.Maintain Body Mass Index (BMI, 18.5- 23.0).Avoid risk of obesity-related metabolic complications(waist circumference >90 cm for male and >80 cmfor female is a risk).Maintain healthy waist-hip ratios (male 0.9; female 0.8).After a meal, engage in light activity like household

K chores and walk whenever possible.

BMI is a useful indicator* for the assessment of bodyfatness. The following normogram is proposed asreference:

5250

47

42

39

36

31

6os,

-

WEIGHT(Kg)

,

24

30

25

18.5

Normogram for determining BMISource : NIN, ICMR, 2006

* Recently WHO proposed the upper cut off point of BMI 23.0for Asians.

HEIGHT(cm)

130

140

-150

-160

_ 170

-180

r_

190

I

1

PRACTISE HEALTHY LIFESTYLE WITH RIGHT COOKINGAND HEALTHY EATING

Proper methods of cooking render foods palatable byimproving the appearance, taste, flavor and texture, therebyenhancing acceptability. Cooking makes food soft, destroysgerms and improves digestibility. Foods should be washedwell before preparation to remove contaminants likepesticide residues, parasites and other extraneous material.Vegetables should be cut into large pieces after washing.There are many methods of cooking like boiling, steaming,pressure cooking, frying, roasting and baking. Boiling is themost common method of cooking. Boiling, steaming and stirfrying are healthy methods of cooking. Steamed rice andcooked vegetables without discarded water are healthyfoods. Avoid reuse of fried oils that lead to formation ofperoxides and free radicals which are associated with cancerdevelopment.

26

26

/

Key messages

Eat food timely and avoid over eating.Eat food with proper chewing.Steamed food is more nutritious.Wash vegetables and other foods before cutting.Cut vegetable into larger pieces.Do not expose vegetables and fruits in air and waterafter cutting.Cook foods in vessels covered with a lid.Use HTST (high temperature short time) method forcooking vegetables.Avoid reheating food more than once.Avoid reuse of fried oils.Avoid faulty food beliefs, fads and fallacies.Avoid sleeping immediately after a major meal.

Avoid smoking, alcohol consumption and betel nutchewing.

Take sound sleep 6-8 hrs everyday.Take clinical checkup at least once a year.

gle EAT ADDITIONAL FOOD4 DURING PREGNANCY ANDc, LACTATION

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Pregnancy and lactation are the most nutritionallydemanding periods of a woman's life. The body needsenough nutrients every day to support the growth of the babyand the maintenance of the mother's body. All thenourishment the developing baby needs comes from themother, through the foods she eats, the supplements shetakes and the care that she receives. The average weight gainduring pregnancy is about 12 kg (range 10-14 kg) for ahealthy pregnancy.

rKey messages

Eat beef, mutton or poultry or germinated pulsesthroughout pregnancy for best iron sources.Eat seasonal fruits throughout pregnancy, especiallyafter meals.Iron supplements are poorly absorbed when they aretaken with beverages such as coffee or tea orsimultaneously with calcium supplements. Theyshould be taken after a meal, preferably afterbreakfast or after lunch.Maintain proper weight gain during pregnancy.

,

27

1PBRACTISE EXCLUSIVE siE

EA 5T FEEDI NG F0 X0, , MONTHS AND STARTo,

APPROPRIATE COMPLEMENTARYFOODS IN TIME

Breastmilk is the ideal food for infants. The World HealthOrganization recommends exclusive breastfeeding for thefirst six months, when no other food or fluid is required.Breast-milk is the most natural and perfect food for normalgrowth and healthy development of infants. It reduces therisk of infections and prolongs birth interval by fertilitycontrol.

Key messages

Start breast-feeding as soon as the mother recoversfrom delivery, usually, an hourExclusively breast feed for six months for adequategrowth of the child.Ensure active family support, time and rest for themother.Practise exclusive breastfeeding for the first sixmonths of life; introduce appropriate complementaryfoods after completion of 6 months and continuecomplementary feeding along with breastfeeding upto 2 years.Choose home-made complementary foods when thebaby sits up with supportDo not give sweet drinks such as soda, as it can leadto tooth decay.Avoid smoking, tobacco, alcohol and drugs duringbreastfeeding

28

Food Guide Pyramid for BangladeshiPopulationsThe following food guide pyramid includes both qualitativeand quantitative guidelines. The base of the pyramid includescereal based foods which are recommended in maximumportions for consumption. The middle part of the pyramidindicates the required servings from different food groups(vegetables, fruits and meat/fish). The top of the pyramidrecommends that minimum portions should be eaten fromsugar, sugar products and fat foods.

FOOD PYRAMID

Vegetables3 - 6

Servings Daily

Pulses 1 - 2Servings Daily

Fats and oils3 - 6

Servings Daily

EAT SPi KINGLY

Sugar (5 Serving)

11,174.--EAT

MOLA Milk and or Milk Products

EAT MODEFtATELY

1 - 2 Servings Daily

Fish, meat and eggs'.4

Servings Daily

Fruits1 - 3

Servings Daily

Rice, bread,other cereals

9.15Servings

Daily

29

1

15%

53%

Food plate method: Proportion of foods for a healthy diet(Lunch)

ww411vs.

Physical Activity Pyramid

A physical activity pyramid will guide on theduration and type of activities that are

important for a healthy life

2 - 3 times a weekIIIIdc*Watching TV

* Sports - football, *Playing computer/cricket, volleyball video games, workingtennis, etc on computer for hours

* Swimming, weightlifting

* Yoga, gardening

mes a week

* Cycling*Running/ jogging*Dancing, skipping

Aerobics, stair climb

Be active;Engage in household chores;Carry out work manually with minitnum use of machines;Walk everyday for at least 30 minutes;Engage in outdoor games;Take stairs instead of elevators / escalators.

31

Self-evaluation of Food Based DietaryGuidelinesKeeping in mind the 10 rules of dietary guidelines for goodhealth of Bangladeshi people, it is now time to evaluate yourown eating behaviors and related practices.

Place a check mark for your answer in the space provided inaccordance with your past eating behavior.

* Occasionally - 3 days/week; Never - less than 3 days/week

Evaluation score

32

Eating behavior andrelated issues

Frequency of eatingRegular Occasionally never

1. Eat a variety of food from 6-8food groups of food pyramid

2. Eat unpolished rice, wheat3. Eat citrus and vit A rich fruits4. Eat vegetables (leafy & non leafy)5. Eat fish/meat6. Eat pulses7. Eat foods containing fat and oils8. Eat sweetened foods9. Drink milk10. Eat fresh, well prepared foods11. Avoid overeating12. Eat food with proper chewing13. Always wash hands before meals14. Have your body weight

measured weekly15. Perform exercise16. Undertake clinical check-up

at least once a year17. Take enough rest and sleep

Good Moderate Poor15-17 11-14 <10

Standardization of weights and measuresfor foodsThe standard measuring cups, bowls and spoons, used atBIRDEM Hospital, Dhaka have been adapted forstandardizing serving sizes. The approximate energy value(kcal) of each of the servings is also provided.

200g cooked vegetable 100g banana (1 serving) provides 95 kcal(2 servings) provide100 kcal 50g egg (1 serving) provide 70 kcal

100g cooked rice (1 serving)provides 100 kcal

100m1 thin cooked dal (1 serving)provides 50 kcal 100 kcal

80g cooked fish (1 serving)provides 100 kcal

10m1 oil (2 servings) provide90 kcal

150m1 milk (1 serving) provides

33

Food Exchange List

An exchange list is a grouping of foods based on similarites inenergy content as well as carbohydrate, protein and fat.

Each serving of grains, fish, meat and oil provides 100kcal; fruits and vegetables provide 50 kcal

* Spices includes onion, garlic, ginger, turmeric and chilli.

34

Food Serving size g/ serving Portion size(uncooked)

kcal

,. Rice 8-12 30 1/3 cup 100

Wheat 1-3 30 1/3 cup 100Potato 1-4 50 1 medium 50Lentil 1-2 30 1/3 cup 100Leafyvegetables 1-2 125 1 bunch 50

. Vegetables 2-3 150 1.5 cup 50Fruits 1-3 80 1 50Fish/ meat/ poultry 1-2 80 2 pieces 100

, Egg 1 60 1 100Milk 1-3 150 1 cup 100Sugar 1-5 5(1 tsp) 5 tsp 100Cooking Oil 3-6 5 g 2 tsp 100Spices* 1 20g 4 tsp 50

Desirable diet for BangladeshA desirable dietary intake has been proposed after theevaluation of previous work and current consumptionpatterns of the population.

Table 3: Desirable food intake for Bangladeshipopulation

11

Food

Yusur et al, 1996(2310kcal)

National Experts, 2007(2350 kcal)

DDP, 2013(2430kca )

Desirableintake

(g)

%oftotal

Energy

Desirableintake

(8)

%oftotal

Energy

DesirableIntake

(8)

%oftotal

Energy

56Total Cereal 372 55 375 55 400

Rice 312 46.6 350 51 350 49

Wheat & othercereals

60 8.4 25 4 50 7

Pulses 66 10 60 8.8 50 6.5

Animal foods 126 5 180 7.0 260 10.5

Fish 50 55 2.1 60 3

Poultry & meat 22 35 1.4 40 2

Egg 7 15 0.6 30 2

Milk& milk products

47 75 2.9 130 3.5

Fruits 57 2,5 100 4.2 100 3

Vegetables

Leafy132 2.5 200 3.6

100 2

Non-leafy

200 2

Potato 130 5 60 2,5 100 4

Cooking oil 38 15 40 15.3 30 11

Sugar/Gur/Molasses 28 5 18 3.2 20 3

Spices 10 20 0.4 20 2

Total 959 100 1053 100 1280 100

Menu planning

Meal plans have been developed considering the bodyweight, physical activity level, physiological status, foodcost and dietary diversity scores. The following menu withmoderate cost has been developed for a woman engaged inmoderate activity.

Adult manAge : (19-29 years)Activity level : ModeratePresent energy requirements : 2430 kcal/day.Weight : 60 kg

Determine the quantity (g) of carbohydrate, fat andprotein on the basis of energy requirementsStep 170% of the kcal from carbohydrate.20% of the kcal from fat.10% of the kcal from protein.100%

For 2430 kcal, the division of nutrients translate asfollows:

Carbohydrate:70% X 2430 kcal = 1701 kcal; 1701kcal 4 kcal/g= 425g.(So the man needs 425g carbohydrate).

Fat:20% X 2430 kcal = 486 kcal; 486 kcal 4- 9 kcal/g= 54g.(So the man needs about 54g fat).

Protein:10% X 2430 kcal = 243 kcal; 243 kcal ÷. 4 kcal/g = 61g.(So the man needs about 60g protein)

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Selected glossary

Cholesterol: Cholesterol is a component of cellmembranes and used to produce hormones and bile acids.Cholesterol is present only in animal sources of food (meat,sausages, bacon, eggs, whole milk, cheese, butter, liver etc.).The human body can produce sufficient cholesterol to meetbiological requirements. Excess cholesterol gets depositedinside blood vessels leading to atherosclerosis.

I

Ciird The nnnart nf milk that rnalatec when the milkt- e,-sours or is treated with acid or enzymes. Curd is defined as aproduct obtained by souring boiled or pasteurized milknaturally, by harmless lactic acid bacteria or other bacterialcultures. It may contain a wide variety of lactic acid bacteria,which are not defined qualitatively/quantitatively. In curdand buttermilk, most of the lactose is converted to lacticacid/acetic acid by the enzymes that are found in fermentingbacteria. Hence these products are easier to digest.

Dietary diversity score (DDS): DDS is an indicator thatmeasures access to household food variety. It also reflects inpart the nutrientimicronutrient adequacy of the diets ofhousehold members. For household DDS (HDDS)FANTAJFAO classified foods into 12 groups (cereals, whitetubers and roots, vegetables, fruits, meat, eggs, fish and seafoods, legumes and seeds, milk and milk products, oils andfats, sweets and spices.) Consumption of each foodgroup/day (30g for solid and single ingredient and 60g forliquid and mixed dishes) counts one score. HDDS less than 5is considered as poor, 6-8 as moderate and >9 as good.

Dietary fiber: Dietary fiber is the non-digestible portion offruits, vegetables and grains. There are two forms of fiber:soluble and insoluble. Soluble fiber contains pectin, gums

49

and mucilage which can be found in fruits, beans, fruits, andoats. Soluble fiber dissolves in water, reduces LDL and is goodfor bowel function. Insoluble fiber includes cellulose,hemicellulose and lignin which can be found in whole grainsand vegetables. Insoluble fiber does not dissolve in water andhelps to decrease cholesterol.

Fish oil: These include omega 3 and omega 6 fatty acid. Fishoils play a crucial role in the prevention of atherosclerosis, heartattack, depression and cancer.

Obesity: Obesity is an abnormal accumulation of body fat.Women with over 30% body fat and men with over 25% bodyfat are considered obese. Gynoid (female) obesity is known aslower obesity and pear- shape obesity. Android (male) obesity isknown as abdominal, central, upper and apple- shape obesityand is associated with a greater risk of NCD than gynoidobesity. BMI is one of the indicators used in the assessment ofobesity; BMI over 30 is considered as obesity.

Parboiled rice: Rice that has been partially steamed beforedehulling.

Saturated fat: Saturated fatty acids have no double bondsbetween the individual carbon atoms of the fatty acid chain.Most fats derived from animal sources (meat and meat products,milk and milk products) are saturated fats. Hidden saturated fatsare found in cakes, biscuits, pastries, other bakery products,fried foods and chocolates. Eating foods high in saturated fatscan lead to elevated cholesterol levels in the blood and increasethe risk of atherosclerosis including heart disease.

Skim milk: Milk from which the cream has been removed.Sometimes, only half cream is removed, resulting in semiskimmed milk. Skimmed milk contains 0-0.5% of fat. Skimmilk is recommended for people who are trying to lose weightor maintain a healthy weight.

43

1

Trans-fat: It is a kind of unsaturated fat where carbonatoms around the double bond contain hydrogen atoms intrans position.Although trans-fats are unsaturated fat, theyare considered harmful like saturated fat as they contribute toincreasing LDL-cholesterol in humans and ultimatelyincrease the risk of heart disease. The American HeartAssociation advises limiting trans-fat consumption to lessthan 1% of total energy. Trans fatty acids do not occurnaturally in plant foods but occur in small amounts in animalfoods. Trans fatty acids are formed during the hydrogenationof vegetable oils as in the manufacture of margarine.Cookies, cakes and most deep-fried foods also contain transfatty acids.

Unsaturated fat: Lipids containing fatty acids with doublebonds are known as unsaturated fat and if there are multipledouble bonds then they are called poly unsaturated fattyacids or PUPA, which are good for health throughdecreasing the risk of heart disease and maintaining theblood pressure in normal physiological condition. Linoleic,linolenic and arachidonic acids are the predominant polyunsaturated fatty acids. Linolenic acid is also known asomega-3 fatty acid and linoleic acid as omega-6 fatty acid.Plants and fish oils are the major sources of omega-3 andomega-6 fatty acids.

Waist circumference: An indicator for the assessment ofcentral obesity. A value of over 90 cm for males and over 80cm for females is associated with NCD.

1

44

The authors greatly acknowledge thecontribution of the following stakeholders:

Mr. Naser Farid, Director General, FPMU, Ministry of Food

Prof. Ekhlasur Rahman, Director, IPHN, Mohakhali, Dhaka

Dr. Ciro Fiorillo, Chief Technical Adviser, NFPCSP, FAO

Dr. Nur Ahamed Khondaker, Research Grants Administrator, NFPCSP, FAO

Prof. SM Keramat Ali, Dean, Life Sciences, Daffodil University, Dhaka

Prof. Aminul Hague Bhuyan, Director, INFS, University of Dhaka

Prof. Khursheed Jahan, INFS, University of Dhaka

Prof. Mamunar Rashid, Principal, Ibrahim Medical College, Dhaka

Dr. SK Roy, Chairman, Bangladesh Breastfeeding Foundation

Prof. Khalilur Rahman, Dept of Biochemistry & Molecular Biology, University of Dhaka

Prof. Shaheen Ahmed, Ex Principal, Govt Home Economics College, Dhaka

Prof. Yearul Kabir, Dept of Biochemistry & Molecular Biology, University of Dhaka

Prof. Moududur Rahman, INFS, University of Dhaka

Prof. Sheikh Nazrul Islam, INFS, University of Dhaka

Prof. Nazma Shaheen, INFS, University of Dhaka

Mr. M A Wahed, Consultant, Health, Nutrition and Management, Dhaka

Prof. Md Nazrul Islam Khan, INFS, University of Dhaka

Prof. Abu Torab Abdur Rahim, INFS, University of Dhaka

Mr. Mostafa Faruq Al Banna, Associate Research Director, FPMU, Ministry ofFood

Dr. Monirul Islam, Director, Nutrition, BARC, Ministry of Agriculture

Dr. Sakina Khan, Research Fellow, BIRDEM

Ms. Jillian Waid, Analysis and Reporting Officer, Helen Keller International,Dhaka

Ms. Jessica Bogard, Health and Nutrition Officer, World Fish Center, Dhaka

Bangladesh Institute of Researchand Rehabilitation in Diabetes, Endocrine

and Metabolic Disorders (BIRDEM)122, Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000

-V_