per adult equivalent rose substantially over the period.<sup>14</sup> The study also finds that the decline in caloric consumption is driven by rural households, and that the decline in calories for rural households is driven by the decline in cereal consumption.

Similar trends of rising real consumption spending and/or incomes and falling average caloric consumption have been observed in other countries, such as India and China. Studies for India have offered alternative explanations for the pattern: for example, an increase in the relative price of food; underreporting of food consumed outside the home; an increase in the relative price of nonfood items, which acts to squeeze out food spending; a decline in caloric needs, due to such factors as a decline in physical exertion or an improved disease environment; a shift in diet toward preferred, but more expensive, foods per calorie; and a shift in spending toward desired nonfood goods—for example, televisions.<sup>15</sup> Some of these explanations may apply to Pakistan as well. However, we did not find any studies for Pakistan that empirically test possible explanations.<sup>16</sup> _Household food consumption and child nutrition status_ : Based on 2010 PPHS data, Tiwari, Skoufias, and Sherpa (2013) examine several indicators of household food consumption, namely, calories per capita, food share of total expenditure, non-staples share of food expenditure, nonstaples share of total calories, and household dietary diversity score. They find that these indicators are, for the most part, not significantly associated with either HAZ or WAZ assessed at the conditional mean, median, and lower quantiles. Interestingly, the authors repeat the same exercise for Bangladesh and Nepal, as well as Uganda and Tanzania, and find that the results for Pakistan are exceptional. Using 1986–87 household survey data from poor four districts across Pakistan, Alderman and Garcia (1994) find that caloric consumption per capita does not appear to be associated with WHZ or HAZ, whereas vitamin A consumption per capita is positively associated with WHZ but not HAZ, and protein consumption per capita is positively associated with both WHZ and HAZ.

Some studies have examined household food insecurity by constructing a food insecurity index, based on data collected using the United States Department of Agriculture Economic Research Service (USDA ERS) household food security survey module which asks questions on the food situation in the previous 12 months for the household, adults, and children.<sup>17</sup> Using 2011 NNS data, Di Cesare et al. (2015) find that household food insecurity, measured by this index, is negatively associated with HAZ, WAZ, and WHZ. Similarly, using 2000 survey data for a sample of squatter households in Karachi, Sindh, Baig-Ansari et al. (2006) find that index-based household food insecurity is negatively associated with stunting status. Also using 2011 NNS data, the World Bank provincial nutrition status notes find that indexed-based household food insecurity

> 14 Friedman, Hong, and Hou (2011) also find a decline in average household caloric consumption using national PSLM survey data from 2005–06 and 2007–08, as do Shabnam et al. (2016) using national HIES data from 2005–06 and 2010–11.

> 15 See Basu and Basole 2015; Eli and Li 2015; Gaiha, Jha, and Kulkarni 2013; Smith 2013; Banerjee and Duflo 2012; Deaton and Dreze 2009; Rao 2000.

> 16 World Bank (2016a) states that the decline in caloric consumption is due to imperfect measurement of food consumption outside the home, with the issue mainly manifesting in the measurement of food consumption of rural men, who increasingly have meals outside as they shift from farm to nonfarm work.

> 17 See <u>https://www.ers.usda.gov/media/8279/ad2012.pdf</u> (Last accessed on April 9, 2017).

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