The role of household food insecurity access, socioeconomic status and dietary diversity as underlying determinants of undernutrition in Pakistani households

Child undernutrition and food security are serious problems facing Pakistan, with almost 42% of children under five years being stunted and almost 50% being anemic. It is estimated that almost three-quarters of the Pakistani population live below the poverty line of ;With household food insecurity as an underlying determinant of undernutrition, our first study's aim was to adapt and validate the global nine-question Household Food Insecurity Access Scale (HFIAS) version 3 for use in Pakistan. We concluded that the HFIAS was reflective of the three domains of food insecurity access (anxiety and uncertainty about the household food supply; inadequate food quality; and insufficient food intake), and could be used by policymakers and researchers to identify and target groups for food insecurity reduction programs.;Even though socioeconomic status (SES) is considered a total measure of the economic and sociological position of a household and its members relative to others in society, there is little consensus in defining SES, especially in developing countries. Researchers collect a plethora of information to account for SES, but few studies efficiently utilize the information collected. As part of a project to demonstrate scaling-up of evidence-based nutrition interventions in Pakistan, we collected baseline data from nearly 47,000 households in a large district. Our study aim was to demonstrate the usefulness of principal component analysis in identifying useful SES indicators to develop a meaningful SES index in rural, periurban and urban areas of Pakistan. Contrary to our assumption, our index did not load heavily on tangible assets and/or the presence of livestock, even in rural areas, as some studies on health inequalities have shown. Instead, we found the largest variance was explained by the frequency of purchasing basic commodities of oil, sugar, tea and wheat, as well as the health-seeking behavior of children under five and pregnant women. Lastly, with strong evidence supporting the association of dietary diversity and improved nutritional status, we used Pakistan's National Nutrition Survey 2001-2002 to characterize dietary factors associated with anemia in young Pakistani children between 6 and 59 months of age. Our results confirmed that irrespective of age group, a majority of Pakistani children were being fed a monotonous diet, with only 22% meeting the recommendation to consume foods from at least four different food groups per day. We found an inverse relationship between the proportion of children consuming iron-rich sources of food and the severity of their anemia. After adjusting for the child's age, mean hemoglobin was significantly higher in children who consumed flesh foods versus those who did not (10.9 vs 10.6 g/dl, p<0.05) as well as for eggs (11.3 vs 10.6 g/dl, p<0.001). We also found a significant trend between severity of anemia and the lack of maternal knowledge regarding dietary sources of iron. In our final multivariate logistic regression model, children reportedly not consuming egg(s) or whose mother was unable to identify dark green leafy vegetables as a source of dietary iron were twice as likely to be anemic, after adjusting for the child's age. Our findings, in combination with the high rate of malnutrition among Pakistani children, should alert policymakers and health care personnel that left to their own means, Pakistani mothers may not be aware of the importance of iron-rich foods as well as which foods are an important source of iron.