THESIS 10 Sep

Enhanced Ration Scale Effects on Non Communicable
Diseases in Pakistan Army Troops-
A Critical Study
ARMED FORCES POST GRADUATE MEDICAL INSTITUTE

RAWALPINDI
PA NO 103940 LT COL IMRAN SAMEE WARAICH
MSc-38, Session 2018-20
Roll No. 29
SUPERVISOR
LT GEN ASIF MUMTAZ SUKHERA (RETD), HI (M)

i
ASRB APPROVAL
ii
DECLARATION
I, PA-103940 Lieutenant Colonel Imran Samee Waraich of MSc-38

session 2018-20, hereby declare that I have presented my original research
work in this thesis. Consulted HEC’s Little Book on Plagiarism and duly referred
all material taken from any source.
Dated: _____ July 2020

Lieutenant Colonel
Imran Samee Waraich
Roll No-29, MSc-38
iii
ACKNOWLEDGEMENT
I would like to acknowledge the blessings of Almighty Allah which enabled

me to complete this dissertation. I am extremely grateful to my worthy
supervisor, Lieutenant General Asif Mumtaz Sukhera (Retd), HI (M), for his
utmost guidance and support. My special thanks to Brigadier Irfan Khan
Commandant Combined Military Hospital Hyderabad, Colonel Muhammad
Naeem Classified Medical Specialist Combined Military Hospital Hyderabad,
Major Muhammad Rizwan Graded Anesthetist 73 Medical Battalion and all
those who contributed to complete this thesis. I am also thankful to the
Department of Research and Development at Armed Forces Post Graduate
Medical Institute for their support during the project work.
Imran Samee Waraich

iv
DEDICATION
My thesis is dedicated to,
Allah (SWT) for all His blessings despite my shortcomings

and
My family (Sofia, Muhammad, Eiman & Areej) for their unconditional support
during all those days and nights of consistent hard work
v
ABSTRACT
BACKGROUND
1. Pakistan Army troops are being provided with increased ration scales
over last 12 years. Coupled with sedentary jobs, social pressures and use of
electronic gadgets; the enhanced caloric intake may lead to rise of NCDs.
AIM
2. To improve health of troops in Pakistan Army.
OBJECTIVES
3. The objectives of the study are as under:-
a. To study the current and old ration scales in terms of quantity and
caloric counts.
b. To study the trends of hypertension, diabetes, and heart diseases

in Army personnel before and after implementation of enhanced
ration scales.
c. To compare the results with national and international studies.
d. To proffer recommendations accordingly for the introduction of a

healthy ration scale.
4. METHODS. This cross-sectional study, comprising of 400 serving army

personnel, was done in Hyderabad from August 2019 to July 2020. Relevant
Information was gathered through a questionnaire. Blood pressure, blood
glucose and cholesterol were checked. The tri services health reports were
extensively researched.
5. RESULTS. The new ration scales (4961 Kcal) have high caloric value
as compared to old ration scales (4001 Kcal). This figure is higher even from
regional and global standards. Significant difference in trends of Diabetes
Mellitus cases were observed after implementation of new scales. The research
yielded higher prevalence rates of NCDs (Diabetes Mellitus 1.5%, Hypertension
1.75% and Heart Diseases 0.75%) in study population as compared to data
published in Army Health Reports. The plausible and robust association
vi
between higher caloric intake and NCDs could not be established due to study
limitations.
6. CONCLUSION. Balanced diet can help to navigate the complexities
of the NCDs. It is high time to rationalize caloric intake for betterment of army
personnel.
7. KEYWORDS . Non Communicable Diseases, Hypertension, Diabetes
Mellitus, Heart Diseases
vii
TABLE OF CONTENTS
Serial Content Page No
Introduction 1
Rationale 5
Chapter 1
Aim 5
Objective 5
Chapter 2 Review of Literature 6
Chapter 3 Methods 9
Results/Findings 12
Objective 1 12
Chapter 4 Objective 2 20
Objective 3 54
Objective 4 67
Discussion 71
Chapter 5 Recommendations 74
Conclusion 76
References 77
Annexures 88
viii
LIST OF TABLES
Table 1: Comparison of Old and New Ration Scales 13
Table 2: Ration Scales of Tri Services 16
Table 3: Ration Scales of Contemporary Armies 16
Table 4: Ration Scales of Pak and Indian Army 17
Table 5: Diabetes Mellitus Cases in Pak Army Troops 20
Table 6: Paired Samples Statistics 24
Table 7: Paired Samples Correlations 24
Table 8: Paired Samples Test 24
Table 9: Hypertension Cases in Pak Army Troops 25
Table 13: Heart Disease Cases (1997-2018) in Pak Army Troops 29
Table 17: Function of Food 37
Table 18: Quality of Ration 37
Table 19: Quantity of Ration 38
Table 20: Meals Consumption 38
Table 21: Hospital Admission 39
Table 22: Reason for Hospital Admissions 39
Table 23: Family History 40
Table 24: Blood Pressure Measurements 40
Table 25: Blood Glucose Measurement 41
Table 26: Blood Cholesterol Measurement 41
Table 27: Smoking History 42
Table 28: Personal History of NCDs 42
Table 29: Knowledge about NCDs 43
Table 30: Weight Profile 43
Table 31: Medicine Use 44
ix
Table 32: Sports Activities 44

Table 33: Sports Activity Days 45
Table 34: Fruit Consumption 45
Table 35: Vegetable Consumption 46
Table 36: Meat Consumption 46
Table 37: Chicken Consumption 47
Table 38: Favorite Food 47
Table 39: Disliked Food 48
Table 40: Salt addition 48
Table 41: Comments about Ration 49
Table 42: Tri –Services Data Vis a Vis Study Results 53
Table 43: NCDs Analysis 53
Table 44: Obesity Study 55
Table 45: Diabetes Study 56
Table 46: Disease Prevalence Data 58
Table 47: Indian Study 59
Table 48: Chinese Study 61
Table 49: Middle East Diabetes Prevalence Study 62
Table 50: Variety of Recommended Dhal 69
Table 51 : Proposed Ration Scales 75
x
LIST OF FIGURES
Figure 1: Diabetes Mellitus Cases (1997-2007) in Pak Army Troops 21
Figure 2: Diabetes Mellitus Cases (2008-18) in Pak Army Troops 21
Figure 3: Box-plot of Diabetes Mellitus Cases 23
Figure 4: Hypertension Cases(1997-2007) in Pak Army Troops 26
Figure 5: Hypertension Cases (2008-2018) in Pak Army Troops 26
Figure 6: Box-plot of Hypertension Cases 27
Figure 7: Heart Disease Cases(1997-2007) in Pak Army Troops 30
Figure 8: Heart Disease Cases (2008-18) in Pak Army Troops 30
Figure 9: Box-plot of Heart Disease Cases 31
Figure 10: Study Population 35
Figure 11: Age Groups 35
Figure 12: Service Years 36
Figure 13: NCD Cases in Study Population 50
Figure 14: Study Age Groups 50
Figure 15: NCD Cases-Service in Years 51
Figure 16: NCD Cases-Educational Status 51
Figure 17: NCD Cases-Family History 52
Figure 18: NCD Cases-Body Mass Index 52

xi
LIST OF ABBREVIATIONS
Abbreviation Full Words

ACC American College of Cardiology
AHA American Heart Association
BLM Base Line Menu
BMI Body Mass Index
CI Confidence Interval
DBP Diastolic Blood Pressure
DM Diabetes Mellitus
FBG Fasting Blood Glucose
HTN Hypertension
ISO International Organization for Standardization
JCO Junior Commissioned Officer
JNC Joint National Committee
MRE Meal Ready To Eat
NCD Non Communicable Diseases
NCO Non Commissioned Officer
OR Odds Ratio
PAF Pakistan Air Force
PAK Pakistan
PN Pakistan Navy
SBP Systolic Blood Pressure
SD Standard Deviation
SEM Standard Error of Mean
WHO World Health Organization
1
CHAPTER 1
INTRODUCTION
1. Napoleon is famous for his great remarks 1, “An army marches on its
stomach.” It is an established fact throughout human history that food
supplies for the troops were a major contributing factor to the outcome of
battles. 1 The food is a critical factor to determine the vigor and vitality which
drives a soldier to perform tough military duties in hostile conditions. The
motivation and enthusiasm of a modern day soldier is decided to a reasonable
extent by the food intake.2 The capacity of human body to fight against different
diseases and disabilities is dependent on immunity, which is influenced by
dietary habits. Hence, optimum nutrition is paramount to keep a soldier fit and
fine. Since ancient times, military troops have relied heavily on food as a source
of energy. At the same time, military food has not enjoyed good reputation due
to many factors notably failing to meet the basic needs of soldiers like energy
requirements, taste and flavor. 3 The armies of ancient Egypt were fed with a
ration that was blamed being insufficient and tasteless while the soldiers of the
Spartan army were forced to survive on diet mainly comprising of meat and
potatoes.4 Many times, the soldiers were left at their own, resorting to hunting,
stealing, purchasing or plundering food. The first account of the organized
ration distribution to soldiers, dates back to Legionnaire Roman Empire, who
were considered the first professional army that thrived on extensive logistics
set up. The soldiers were issued an allowance of two pounds of dough each
day along with olive oil, meat and wine. The primitive soldiers were given a
ration mainly comprised of salted fish, bread, thick stew and beer. In the era of
the Byzantine Empire, the infantry soldiers were required to carry rations that
could be consumed within twenty days. 4 The army often resorted to
requisitioning raw materials from local populations during operations and
military campaigns. Sometimes soldiers even bought food to add variety to
issued food items.
2. The situation was worse for the Navy. 5 An account of the ‘Napoleonic
Wars’ reveals that the British Navy implemented the ‘four for six’ rationing
system, meaning there were four servings for every six men. The staple food
was hard bread; in the form of a sweetened dry biscuit made with flour, sugar,
2
and sometimes crushed bones. The salted meat was also provided to the
sailors, but it was less popular. Water, a rare and precious perishable
commodity, was logically replaced by the popular alcoholic drinks, mostly in the
form of beer, wine or rum. The alcoholic drinks were safer in terms of storage. 5
3. During the ‘Revolutionary Wars’ in the United States, the rations for
troops underwent many changes, both in quantity and composition. 6 Initially,
the ration comprised of salted beef and hard bread. The first known legislation
related to ration dates back to 1775 when the Second Continental Congress
authorized Army about the provision of individual ration. According to the ration
scales, soldiers were provided every week with one pound of salty beef, one
and half pounds of pork or fish, three pounds of peas or beans, a half-pint of
cornmeal or rice and hard bread (commonly called hardtack in the United States
of America). In addition, a pint of milk, four ounces of rum and a pound of flour
was also provided on daily basis. The United States Congress realized the
importance of ration for soldiers and after recommendations by a team of
doctors, added a regular allowance of cider, beer, fresh vegetables and fruits
to combat scurvy; which was commonly reported in soldiers at that time. During
the war of 1812, the importance of ration and its effects on the morale of troops
were acknowledged by the United States Army high command who strongly
encouraged the plantation of gardens at military garrisons in an effort to make
more food available for additional troops. During the American Civil War, troops
relied on a similar type of diet; though some changes in the form of addition of
dehydrated vegetables and fruits won the admiration of soldiers. In another
effort, coffee replaced the daily allotment of rum. The invention of the tin can by
Peter Durand in 1810 revolutionized military rations. In a major and potentially
significant change, preserved food was introduced to rations during the
American-Spanish War in 1898. This experiment initially failed due to
indecorous preservation techniques and airtight cans leading to the risk of
health issues like food poisoning, so it was rejected. 6
4. Scientific research and efforts to preserve food continued and when

World War I started, major breakthroughs had been achieved by the United
States Army in making canned food safe and reliable. 7 By 1917, the United
States authorities had more focus on canned foods than ordinary ration due to
3
its operational advantages. Huge amounts of canned foods were transported

to troops across the globe. The canned food mainly comprised of meat and
vegetables, along with crackers. Side by side, fresh meals were also served in
the field wherever considered feasible. Troops were provided with tobacco and
half a pound of candies per week, which was a much popular addition. 7
5. The most important and well-known development in military feeding

practices came in the late 1970s and early 1980s in the form of “Meals Ready
to Eat” (MRE). Thanks to improvements in food processing and storage
techniques, the modern armies notably the United States and the United
Kingdom Military Forces were able to introduce rations that were much lighter,
more flexible and stable in a diversity of harsh environmental conditions. They
also had good flavor and better taste. The important feature was a flat package
of MRE made up of lamination and metal foils that could be easily packed with
different types of food; sealed and stewed for sterilization, to make it shelf -
stable and better taste retaining properties.7
6. The nutrients present in food enable the cells in human bodies to perform
basic functions necessary for sustaining life. 8 In addition, they play an important
role in the growth, development and maintenance of vital body functions.
Essential nutrients regulate different body function and their absence leads to
adverse health outcomes or diseases. Accumulated over a period of time, the
deficiency or surplus of nutrients leads to deranged cell activity and may end
up in adverse health conditions. Nutrients act as ‘messengers’ of vital
instructions or information required for performing body functions. This view
helps us to realize the importance of food that should be included in the diet
rather than focusing on food that should be excluded.8
7. There is reason to believe that chronic NCDs such as obesity, diabetes

mellitus type II, heart disease, stroke, and certain cancers are related to gene
mutation.8 The evidence now attributes these conditions to a plethora of
biological dysfunction secondary to dietary factors. This association warranted
the health experts and nutritionists to explore the possible associations
between food and health conditions. There is a dire need to study the
interaction between nutrients in the diet and human body functions. 8
4
8. The poor dietary patterns have an addictive and cumulative effect and
over a period of time may result in adverse health conditions. The NCDs
subsequent to poor dietary practices are a major concern globally. As per WHO
global directory for the year 2016, 71% of all deaths were attributable to NCDs. 9
The general population is the major victim and the military personnel are not
immune to it. Pakistan is facing a huge challenge in this regard. As per one
estimate, about half of the deaths in Pakistan are due to NCDs. 9 Important
NCDs include hypertension, cardiovascular disease, diabetes and cancers.
The national research data suggests that 77% of age standardized deaths
in Pakistan occur due to NCDs and injuries. The economic cost 10 for dealing
with NCDs is huge for a developing country like Pakistan, where the figure is
estimated to rise from $152 Million in year 2010 to $296 Million in year 2025.
9. The military environment is highly complex and dynamic due to the
plethora of difficulties faced by present-day soldiers. Pakistan Army has
enormous challenges to confront; hence the need for physically and mentally
fit soldiers is paramount to the success of military operations. There is need to
review military nutrition as soldiers are exposed to multiple environmental and
job related stresses. The role of a well-balanced diet that can adequately
maintain the health of troops, decrease chances of disease predisposition, and
enhance the performance of soldiers is crucial. The ration scale for the Indian
Armed Forces were implemented by the British Rulers in 1943. Minor
adjustments were subsequently done in 1945 to cater for varying needs of
soldiers in different areas of deployment. Pakistan Army continued the same
ration scales after independence with few modifications in 1960s and 1970s.
The major breakthrough came in 2008 when ration scales for soldiers in
Pakistan Army were increased to 4961 Kcal/day. 11 Earlier, the soldiers were
provided with 4001 Kcal/day. Consumption of high energy foods over prolonged
periods can lead to adverse health conditions. Dietary salt intake is also an
important factor related to hypertension and cardiovascular risks. The
increased fondness of cooking oil, meat, salt and sweets along with overeating
may predispose soldiers to develop NCDs.
5
Rationale
10. The relationship between diet and human health plays a very important
role. A person's dietary habits can influence growth and increase the risk for
disease. A balance diet may help to achieve a fulfilment of energy needs and
growth. This strongly suggests that food has potential influence on the quality
of health. It is worthwhile to have a realistic analysis of the effects of enhanced
ration scale on the health of soldiers; identify the disease patterns, and create
awareness about the effects of enhanced ration scale. The study is an
endeavor to highlight the significance of food on the health of troops. The
enhanced ration scales were implemented in Pakistan Army on 25 February
2008, and it is high time to study their effects 11. Although, it was a popular
decision among soldiers when the enhanced ration scales were enforced in
Pakistan Army; yet the healthcare experts must be cognizant of the connection
between the diet and disease. This connection warrants the need for health
experts to explore the possible associations between food and NCDs. The
rationale of the study revolves around identifying, assessing and highlighting
the effects of enhanced ration scale effects on NCDs in Pakistan Army troops
through adopting an evidence-based, clear and scientific approach.
Aim
11. To improve health of troops in Pakistan Army.
Objectives
12. The objectives of the study are as under:-
a. To study the current and old ration scales in terms of quantity and
caloric counts.
b. To study the trends of hypertension, diabetes, and heart diseases

in Army personnel before and after implementation of the
enhanced ration scales.
c. To compare the results with national and international studies.
d. To proffer recommendations accordingly for the introduction of a

healthy ration scale.
6
CHAPTER 2
REVIEW OF LITERATURE
13. The research carried out by Teresa T and Fung Eric pointed out that
traditionally in nutritional epidemiology, the focus had largely been to observe
the effects of single nutrients or foods. As a matter of fact, the nutrients and
foods are consumed in various combinations, and the cumulative effects of
various nutrients and foods could be assessed by analyzing complete eating
pattern.14
14. A study conducted by Matthias B Schulze and colleagues focused on

recent knowledge in the associations between dietary plans and coronary heart
disease, stroke, type II diabetes and cancer. The authors suggested possible
areas of association and recommended future research. They observed that
vegetarian nutrition had been linked in prospective cohort studies to lower the
risk of diabetes, heart disease and cancer. 15
15. The researchers Carrie Patnode and Corinne Evans carried out a study
in 2017 to see the effects of ‘Behavioral Counseling’ in promoting a healthy diet
and physical activities in adults. 16 They wanted to establish its efficacy in
cardiovascular disease prevention. The authors found that modest benefits
were accrued by healthy diet. They concluded that extensive dietary
interventions resulted in considerable improvement in blood pressure, low-
density lipoprotein and total cholesterol levels.
16. Najlaa Aljefree and Faruk Ahmed in 2015 carried out a methodical
review of published articles related to dietary association of heart diseases in
African countries. 17 The study concluded that the increased risk of heart
disease and strokes among adults in the Middle Eastern and North African
regions were associated with Western dietary patterns. Conversely, increased
adherence to the Mediterranean diet was associated with a decreased risk of
heart disease and the related risk factors. Therefore, increasing awareness of
the high burden of heart disease and the associated risk factors was very
crucial. There was need for nutrition education programs to improve the
knowledge of the Middle Eastern and North African population regarding
healthy diets and diet related diseases.
7
17. A study conducted by Pasiakos and co-workers in 2013 concluded that

protein supplements and multivitamins were the most frequently consumed
dietary supplements by the United States military personnel. The study
indicated that the prevalence of regular protein supplements use was nearly
20% in study population. The authors also studied the efficacy and safety of
protein supplements for the United States military personnel. The
recommended range for dietary protein intake by warfighter populations
exposed to high metabolic demand was 1.5–2.0 g/kg/day. While inside
garrisons, the warfighters should consume dietary proteins at rate of 0.8–1.5
g/kg/day. 18
18. An important study on the British soldiers in Afghanistan was carried out
in 2014 by Fallowfield et al.19 It determined that understanding the nutritional
burdens on serving military personnel was critical for preparing appropriate
training schedules and dietary endowments. The study population comprised
of 249 active duty British soldiers deployed in Afghanistan. The participants
were observed for body size and body composition. Energy intake was
estimated from food diaries. The results showed a significant decrease in mean
body mass of volunteers. The authors also concluded that daily energy intake
was significantly lower than the estimated daily energy expenditure.
19. To find the effects of dietary patterns on hypertension, a study was
carried out on Iranian army staffers in 2018. It consisted of
405 military personnel between 22 and 51 years of age. The authors
Moghaddam Dabbagh et al studied the effects of Western dietary patterns and
healthy dietary patterns on blood pressure. Food frequency questionnaires
(FFQ) were used to collect data on dietary intake. The authors could not
establish significant relationship between dietary patterns and blood pressure
after adjustment for confounders.20
20. Sami et al in their work done in 2017 mentioned that dietary habits were
the single most important modifiable risk factor related to rapidly rising cases of
Diabetes Mellitus globally. They concluded that solution lied in creating
awareness among masses about dietary knowledge, habits and attitudes. 21
8
21. Praveen et al in 2019 highlighted the fact that there was an

unprecedented rise of NCDs among Indians.22 Prevalence of coronary artery
disease and diabetes was very high, attributable to changing socioeconomic
development. They suggested that the Indians typically developed diabetes
and coronary heart diseases at a younger age and at a lower level of obesity
(BMI) as compared to Europeans.
22. A significant study done by Saleem Khawaja et al in 2011 suggested that

increased incidences of NCDs were related to changing dietary patterns from
the use of plant foods to meat and other animal products among Karachi adults
and children. They concluded that the combination of various modifiable risk
factors like physical inactivity, junk food consumption, smoking and stress were
directly related to etiology of rising epidemic of NCDs.23
23. A milestone study comprising of a unique ‘Framingham-like’ cohort was

carried out by Khan et al during 2010-11 in Karachi.24 Its objective was to
identify the risk factors and the prevalence for diabetes, obesity, hypertension,
and coronary artery disease. A total of 667 households were enrolled for the
study. The researchers concluded that risk factors for NCDs were related to
abdominal obesity in 53% of cases, tobacco use in 45% of cases and
overweight in 20% of cases. The prevalence in cohort was also high for NCDs:
Pre-diabetes (40%), diabetes (8%) and hypertension (18%).
24. An important study published in Lancet in April 2019 by Afshin et al

assessed the health effects of dietary risks in 195 countries. The study involved
scientific evaluation of food consumption in 195 countries. It included
quantifying the effects of food intake on NCDs. The study concluded that global
consumption of sugar sweetened beverages, processed meat, red meat and
sodium were above the optimal levels. These higher levels were leading to rise
of NCDs. 25
9
CHAPTER 3
METHODS
25. The details are given below:-
a. Design. Cross-sectional study.
b. Setting. Hyderabad Cantonment.
c. Duration of Study. Twelve months from the date of synopsis

acceptance by Institutional Review Board (August 2019 - July
2020).
d. Study Population
Serving Junior Commissioned Officers (JCO’s), serving Non-

Commissioned Officers (NCOs), and serving soldiers of Pakistan
Army posted at Hyderabad Cantonment.
e. Sampling Technique
A stratified sampling technique was used for data collection that

was followed by systematic random sampling.
f. Sample Size
(1) Stratified random sampling by including serving JCOs,
NCOs and soldiers having a minimum of 10 years’ service.
(2) WHO calculator was used for sample size calculation at

95% confidence interval and 5% margin of error. 90
(3) The sample size for the study was calculated to be 384.
After allowance for non-response (5%), the sample size
was taken as 400.
g. Sample Selection Criteria (Inclusion Criteria)
(1) Serving JCOs of all ages and ranks having a minimum of

10 years’ service and dining from Army messes.
10
(2) Serving NCOs having a minimum of 10 years’ service

and dining from Army messes.
(3) Serving soldiers having a minimum of 10 years’ service

and dining from Soldiers messes.
h. Exclusion Criteria
(1) Serving JCOs, NCOs and soldiers having less than 10

years’ service.
(2) The JCOs, NCOs and soldiers not dining from messes.
(3) The personnel having known disease history.
i. Data Collection Tools
(1) Modified World Health Organization (WHO) STEPS Self-

Administered Questionnaire.81
(2) Armed Forces Health Reports.
j. Data Collection Procedure
A survey was carried out to determine the effects of ration on the

study population by using the modified WHO Questionnaire. After
informed consent, the validated questionnaire was distributed by
researcher. On average, 10 minutes’ time was required to fill
questionnaire. The researcher collected the responses himself.
k. Plan of Data Analysis
Data was entered in SPSS version 23 for detailed analysis. The

descriptive analysis, before application of any test, was carried
out through calculating frequencies and percentages. ANOVA
test was applied to find out difference between different ages,
ranks, and years of service among soldiers. The paired T-test was
used for comparative analysis of the data before and after the
induction of enhanced ration scales. P-value of less than 0.05 was
taken as significant.
11
l. Ethical Consideration. Ethical approval was obtained from the

Institutional Review Board Armed Forces Post Graduate Medical
Institute. Informed consent was taken from all members of the
survey. The objectives, rationale, and confidentiality policy were
explained to the participants. The anonymity and confidentiality
of participants were maintained.
12
CHAPTER 4
STUDY RESULTS AND FINDINGS
OBJECTIVE 1
26. The study comprised of 4 main objectives. The first objective was to
study the current and old ration scales in terms of quantity and caloric counts.
To achieve this objective, the current and old ration scales, literature, and
related data on ration were collected and studied extensively. A need was felt
in Pakistan Army during the previous decades to provide enhanced ration
scales to troops. A board of officers was detailed and pilot studies were
undertaken from 2005-2007. Inputs from different stakeholders were
incorporated. After a lot of deliberations, enhanced ration scales were
implemented on 25 February 2008.
27. The enhanced ration scales were well received in Pak Army. The
soldiers were happy with increased amounts of ration. No doubt, the morale of
troops had gone up but they have to be made aware of the good and bad effects
of the enhanced ration scales. Over a period of time, it was deemed necessary
to critically analyze the quantity and calorie count of these scales. A
comprehensive comparative analysis of ration scales was undertaken as part
of the study. It is estimated that the energy requirements of a 70 Kg soldier are
claimed to be approximately 2500 Kcal/day for light activities, 3000 Kcal for
moderate activities, and 4000 Kcal during the exceptionally active phase. 13 The
modern armies calculate the daily energy requirement at the rate of 45 Kcal/kg
and it comes out to be 3150 Kcal for a 70 Kg adult. The World Health
Organization also recommends about 3000 Kcal/day for individuals having 70
Kg weight. Pakistan Army earlier authorized about 4001 Kcal/day of ration to
its soldiers whereas the enhanced ration scales provide about 4961 Kcal. 11
These excessive calories coupled with job stress and lifestyle issues, can
influence the health status of soldiers.
13
Table 1: Comparison of Old and New Ration Scales11
Caloric OLD SCALE NEW ENHANCED

Value SCALE
Ser Items Remarks
Per Scale/ Caloric Scale/ Caloric
gm Value Value
Day Day Per day
Per day
1. Atta or 3.6 623 2242 700 2520 30 issues/
Atta and - 170 - 247 - month
Rice (gm) 3.5 453 - 453 -
2. Dhal (gm) 3.34 56 187 85 284 “
3. Ghee (gm) / 9 77 693 100 900 “

Cooking Oil
4. Milk Fresh 66/ 248 175 248 “
(ml) or 100
ml
Powder
(gm) 4.86 36 50 243
5. Onion 0.24 56 13 56 13 “
Fresh (gm)
6. Potato (gm) 0.64 113 72 113 72 “
7. Vegetable 0.212 170 36 198 42 “
Fresh (gm)
8. Sugar (gm) 3.8 56 224 70 280 “
9. Salt (gm) - 14 - 14 - “
10. Tea (gm) - 5 - 9 - “
11. Condiment 3.0 12 36 12 26 “
(gm)
12. Multi- 1 x Tab/ 1x Tab/ - 4 issues/
vitamin
Man/ Man/ Month
Tablet
(Number) Week Week
14
Ser Items Caloric OLD SCALE NEW ENHANCED Remarks

SCALE
Value
Per gm Scale/day Caloric Scale/day Caloric
Value Value
gm or ml gm or ml Per
Per
day
day
13. Meat 1.64 99 x 8 = 792 x 226 x 8 = 1808 x 8 issues/
Mutton 792 1.64 =
1808 1.64=
1299 2965 month
Beef 127 x 8 = 226 x 8 =
2.1 1016 1016 x
1808 1808 x 8 x issues/
(gm) 2.1 = 2.1=
150 x 6 162 x 6 = month
Chicken 2134 3797
(Dressed) 1.8 =900 972 6 x issues/
900 x 972 x
- 1.8 =120 x 3 = 1.8 = month
360
Chicken 120 x 3= 1620 1750
(Assorted) 360 99 x 5 =
1.5 - - 3 x issues/
495
(gm) 99 x 5 = 360 x 360 x
495 month
Eggs 1.5 = 1.5 =
3.34 540 540
(No)
1808 x 495 x 5 x issues/
3.34 = 3.34 =
month
1653 1653
14. Fruit 0.37 - - - - Daily issue
Fresh in new scale
Citrus
8 x issues/
Non- 0.80 226 x 8 = 1808 x 226 x 30 6780 x
1808 0.8 = = 6780 0.8 = month in old
Citrus
1446 5424 scale
15. Coca 3.1 28 x 4 = 112 x 28 x 4 = 112 x
with 112 3.1 = 112 3.1 =
347 347 4 x issues/
Sugar 28 x 4 = 28 x 4 =
and 4 112 112 x 112 112 x month
66/ 4 = 4 =
Milk 83 x 4 = 83 x 4 =
100 ml 448 448
Fresh 332 ml 332 ml
332 x 332 x
66/100 66/100
= 219 = 219
15
Caloric value per day of items = 9706/30 = Caloric value per day of items =
323 Kcal 17143/30 = 571 kcal
Gross caloric Value of all items = 323 + 3678 Gross caloric value of all items =
= 4001 Kcal 571+4390 = 4961 Kcal
Study Findings
28. As per existing ration scales vis-à-vis their consumption, the following
findings are drawn:-
a. Based on authorized ration scales, the value of calories intake

seems to be on the higher side.
b. Based on authorized ration scales, the value of calories come to

be 4961 calories.11
c. Upon implementation of Base Line Menu, the count will be around

4273 calories.12
d. If 5% of non-entitled individuals are dependent on payment, 4070

calories are consumed by every entitled person.
e. If ration saved on the weekend is sent back to the cookhouse,

then the count is 4161 calories per day. This, however, is not
practiced and ration saved on weekends is disposed of by units
to unit persons at a lower rate as welfare measures. 12
29. Comparison of calorie intake of Pakistan Army with sister services

(taking into account pre-cooking wastages) and contemporary armies is
important to understand the dynamics related to nutritional issues.
16
Table 2: Ration Scales of Tri-Services12
Services Calories Intake Value (Kcal/day)
As per As per BLM Account for

authorized (Army)/Acct for 5% Not
scale wastages (PAF & Entitled
PN 20%) Persons
ARMY 4961 4273 4070
PAF 4030 3942 3754
PN 4173 4075 3881
Table 3: Ration Scales of Contemporary Armies12
Countries/Armies Calories Intake Difference from

Pakistan
(Kcal/day)
Pakistan Army 4961 -
Indian Army 4078 (-) 883
Bangladesh Army 3828 (-) 1133
NATO (Average) 3600 (-) 1361
Australian Army 4656 (-) 305
Study Findings
30. The comparative analysis reveals that calorie intake of Pak Army is on
the higher side as compared to contemporary armies and sister services. The
calorie intake of a soldier of Pak Army is likely to remain higher than that of PAF
& PN as the job of an average soldier of the Army is more strenuous than that
of other service members.
17
Table 4: Ration Scales of Pakistan and Indian Army 87
Serial Items Pak Scales Indian Difference

Scales
1 Atta (gm) 700 613 +87
Or Atta and 247 - -
Rice 453 450 +3
2 Dhal (gm) 85 40 +45
3 Ghee/Cooking Oil 100 80 +20
4 Milk Fresh or 248 ml or 250 -2
Milk Powder whole 50 73 -23
5 Onion Fresh (gm) 56 60 -4
6 Potatoes (gm) 113 110 +3
7 Vegetable Fresh(gm) 198 170 +28
8 Sugar (gm) 70 90 -20
9 Salt Rock (gm) 14 3 +11
10 Tea (gm) 9 9 -
11 Meat Fresh(gm) 226 260 -34
12 Meat on Hoof (gm) 452 640 -188
13 Beef (Dressed) (gm) 226 - -
14 Chicken (Dressed) 162 175 -13

(gm)
15 Chicken (Assorted) 312 350 -38

(gm)
16 Eggs (Numbers) 02 02 -
17 Fruit Fresh - Citrus or 113 110 +3
Or Non Citrus (gm) 226 230 -4

18
Serial Items Pak Scales Indian Difference

Scales
18 Match safety 2 Boxes for - -

(Numbers) fifty men /
week
19 Coca with 28 - -
Sugar (gm) and 28
Milk Fresh (ml) 83
20 Multi Vitamin 1 per man - -

per week
Tablets (Number)
DEDUCTIONS
31. An in-depth analysis of the ration scales of the Pakistan Army and
comparative analysis with other organizations reveals the following important
deductions.
a. The intake of macronutrients in the Army, while being within the

defined margins, is not balanced as fats are on the higher side
(30.5% as against 20-35%) and protein is on the lower side (15%
as against 10-35%) of the defined margins.
b. There is a need to re-define separate calorie intake brackets for

soldiers employed on active duty and those on sedentary roles as
the nature of the duty of individuals employed on sedentary roles
is mostly office-oriented and static.
c. Intake of acidic foods like sugar and oil is on the higher side which
may be curtailed while the intake of alkaline food like vegetables,
fruits, and eggs may be increased.
d. The intake of red meat is also on the higher side along with sweet
dishes which can be decreased to reduce the intake of fats and
carbohydrates.
19
e. As compared to other varieties of Dhal, the supply of Dhal Chana

is more.
f. Non-provision of varieties of vegetables and fruit, as concluded in

the quarterly schedule of contract, resulting in the provision of a
particular variety for a prolonged duration which is an undesired
situation that can be avoided through active involvement.
g. Food processing and mess management models of PAF and PN

are almost the same as that of the Army except for the reason
that cooking standards in PN are much more progressive and
elaborate. Procedure on board the ships are even better wherein
modern techniques are adopted. Procurement of chicken and
meat from certified companies by PN which improves the quality
of meat manifolds.
h. Most of the cooking gadgets are old which causes wastages of

food items and financial losses.
i. There is a definite requirement to improve cooking standards by

training our cooks and managing cook houses more efficiently.
j. WHO recommended daily intake of salt is less than 5 grams/day

while the ration scale is providing 14 grams/day.
k. WHO recommended daily intake of sugar is less than 50

grams/day while the ration scale is providing 70 grams/day.
l. The intake of saturated fats and trans-fats in ration is on higher

side which can be decreased as per WHO guidelines.
20
OBJECTIVE 2
32. The second objective of the study was to study the trends of
hypertension, diabetes, and heart diseases in Army personnel before and
after implementation of enhanced ration scales. To achieve this objective,
data was collected from Army Health Reports. As the enhanced ration scales
were implemented in 2008, NCDs data from 1997 to 2007 were considered for
comparison with data for the period 2008-18. The results of the two periods are
described in the succeeding paragraphs.
Table 5: Diabetes Mellitus Cases in Pak Army Troops*
Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Cases 328 305 381 406 367 455 426 482 462 545 511
Prevalence
0.07 0.07 0.08 0.09 0.08 0.10 0.09 0.11 0.10 0.12 0.11
%
Year 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Cases 504 581 538 622 692 606 616 783 959 979 1218
Prevalence
0.11 0.12 0.10 0.12 0.13 0.11 0.13 0.17 0.20 0.20 0.24
%
* Source: Army Health Reports
Data Analysis
33. Diabetes Mellitus prevalence percentage, from year 1997 to year 2007,
ranged between 0.07 and 0.12 with peak in year 2006. Whereas, from year
2008 to year 2018, it ranged between 0.10 and 0.24. The pattern has been
showing upward trend from year 2013 to 2018.
21
Figure 1: Diabetes Mellitus Cases (1997-2007) in Pak Army Troops*
Cases Prevalence %
545
511
482 462
455
406 426
381 367
328 305
0.07 0.07 0.08 0.09 0.08 0.1 0.09 0.11 0.1 0.12 0.11
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Figure 2: Diabetes Mellitus Cases (2008-18) in Pak Army Troops*
Cases Prevalence %
1218
959 979
783
692
581 622 606 616
504 538
0.11 0.12 0.1 0.12 0.13 0.11 0.13 0.17 0.2 0.2 0.24
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

22
STATISTICAL ANALYSIS
34. A measurement for the number of cases of Diabetes Mellitus

(Prevalence percentage) were taken for two different time periods, that is from
year 1997 to year 2007 (Period ‘A’) and from year 2008 to year 2018 (Period
‘B’) to look for the effects of ration scales administered during different time
periods. A Paired Samples t Test was used to compare two means and test the
statistical difference between the two time periods. Further, correlation analysis
were made for testing the statistical significance of relationship of the reported
disease cases in the target population during the two time periods.
Hypothesis
35. The hypotheses for the study can be expressed as:
H0: µA = µB (The paired population means for the two periods are equal)
H1: µA ≠ µB (The paired population means for the two periods are not
equal)
OR
H0: µA - µB = 0 (There is no difference between the population means
of two time periods)
H1: µA - µB ≠ 0 (There is difference between the population means of
two time periods)
Where,
µA is the population mean of period ‘A’, and
µB is the population mean of period ‘B’.
Statistical Test
36. The paired samples t test is given by the following formula:

𝑥̅ 𝑑 −0
𝑡=
𝑠𝑑/√𝑛
Where, 𝑥̅ 𝑑 = Sample mean of the differences
n = Sample size
23
𝑠𝑑 = Sample Standard Deviation of the differences
𝑠𝑑/√𝑛 = Estimated standard error
37. If the calculated t value is greater than the critical t value, then we reject
the null hypothesis (and conclude that the means are significantly different). It
is evident from the descriptive analysis that variable of Period ‘A’ has a high
value of 545 and a low value of 305 whereas variable of Period ‘B’ has a high
value of 1218 and a low value of 504. The mean value of Period ‘B’ (736.8) is
much higher than the mean value of Period ‘A’ (424.36). Additionally, there are
higher variations in the data of Period ‘B’ as compared to Period ‘A’.
38. The comparative box-plot of these two group variables gives a better
visualization of the prevalence of Diabetes Mellitus for the two groups before
applying the t-test statistic.
Figure 3: Box-plot of Diabetes Mellitus Prevalence
Period ‘B’
Period ‘A’
Prevalence %
39. It is clear from the box-plot that the center of the period ‘B’ data is higher
as compared to that of Period ‘A’, and there is slightly more spread in the Period
‘B’ data as compared to Period ‘A’. Period ‘A’ variables seem to be
symmetrically distributed while Group ‘B’ variable is asymmetrical or positively
24
skewed. It is also evident that the paired samples t test draws a significant
conclusion.
Table 6: Paired Samples Statistics For The Two Periods
Prevalence Mean N Standard Standard Error

Deviation(SD) of Mean(SEM)
Period ‘B’ .1473 11 .04624 .01394
Pair 1
Period ‘A’ .0928 11 .01773 .00535
Table 7: Paired Samples Correlations
Prevalence N Correlation Sig.

Period ‘B’ &
Pair 1 11 .769 .006
Period ‘A’
Table 8: Paired Samples Test
Prevalence Paired Differences t df Sig.

Mean SD SEM 95% (2-
Confidence tailed)
Interval of the
Difference
Lower Upper
Period
Pair ‘B’ –
.05450 .03453 .01041 .03131 .07770 5.236 10 .000
1 Period
‘A’
The Statistical Results
40. The results indicate that the computed t-value is greater than critical
value and the P-value < 0.001. Therefore, the null hypothesis of no difference
is rejected and it is concluded that the means for the two groups are statistically
highly significant. Furthermore, it is also evident from the results that the data
for two periods are significantly correlated as P-value < 0.01 with correlation
coefficient equal to 0.769 showing positive relationship between the data
collected at two different time periods.
25
Deduction
41. There is significant difference between the two periods (Before and after
induction of new ration scales). There has been an increase in the number of
cases of Diabetes Mellitus in Army persons after implementation of new ration
scales. The period from 2013 to 2018 has been more alarming.
HYPERTENSION
42. Hypertension prevalence percentage from year 1997 to year 2007

ranged between 0.22 and 0.29. Whereas, from year 2008 to 2018, it ranged
between 0.21 (n 1142) and 0.32 (n 1582). The prevalence showed steep
upward trend from year 2011 (0.21, n 1142) to year 2018 (0.32, n 1582).
Table 9: Hypertension Cases in Pak Army Troops*
Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Cases 1098 1046 1330 1202 1107 1117 1044 1194 1091 1144 1329
Prevalence
% 0.24 0.22 0.27 0.25 0.24 0.24 0.23 0.28 0.25 0.25 0.29
Year 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Cases 1331 1437 1308 1142 1156 1209 1064 1088 1317 1349 1582
Prevalence
% 0.28 0.31 0.25 0.21 0.21 0.22 0.23 0.23 0.27 0.27 0.32

26
Figure 4: Hypertension Cases(1997-2007) in Pak Army Troops*
Cases Prevalence %
1330 1329
1202 1194
1107 1117 1144
1098 1091
1046 1044
0.24 0.22 0.27 0.25 0.24 0.24 0.23 0.28 0.25 0.25 0.29
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Figure 5: Hypertension Cases (2008-2018) in Pak Army Troops*
Cases Prevalence %
1582
1437
1331 1308 1317 1349
1156 1209
1142 1088
1064
0.28 0.31 0.25 0.22 0.21 0.22 0.23 0.23 0.27 0.27 0.32
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

27
43. It is obvious from the box-plot that the center of the Period ‘B’ data (2008-
2018) is slightly high as compared to that of Period ‘A’ data (1997-2007). There
is more spread in the Period ‘B’ data as compared to Period ‘A’. Both the
variables are approximately symmetrically distributed, whereas basically very
slightly positively skewed.
Figure 6: Box-plot of Hypertension Prevalence
Period ‘B’
Period ‘A’
Prevalence %
Table 10: Paired Samples Statistics

Deviation of Mean
Period ‘B’ .2544 11 .03669 .01106
Pair 1
Period ‘A’ .2518 11 .02001 .00603

28
Pair 1 Period ‘B’ & Period ‘A’ 11 .099 .773

(2-
Mean Standard Standard 95% tailed)
Deviation Error Confidence
Mean Interval of the
Difference
Lower Upper
Period
Pair ‘B’ -
.00254 .04002 .01207 -.02435 .02943 .210 10 .838
1 Period
‘A’
Results
44. The results are non-significant as p-value > 0.05. There is week positive
correlation between the two periods for hypertension although statistically non-
significant at 95% confidence level.
29
HEART DISEASE CASES
45. The heart disease prevalence from year 1997 to year 2007 fluctuated
between 0.07 (n 310) and 0.31 (n 1414), with peak in year 2007 (0.31, n 1414).
Whereas from year 2008 to 2018, it ranged between 0.12 (n 569) and 0.32 (n
1597).
Table 13: Heart Disease Cases (1997-2018) in Pak Army Troops*
Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Cases 513 545 442 310 679 766 781 754 1206 1210 1414
Prevalence
% 0.11 0.12 0.09 0.07 0.15 0.17 0.17 0.18 0.27 0.26 0.31
Year 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Cases 1447 1524 1216 1167 1597 880 569 810 1319 1126 1086
Prevalence
% 0.31 0.31 0.23 0.22 0.32 0.16 0.12 0.17 0.27 0.23 0.22

30
Figure 7: Heart Disease Cases(1997-2007) in Pak Army Troops *
Cases Prevalence %
1414
1206 1210
766 781 754

679
513 545
442
310
0.11 0.12 0.09 0.07 0.15 0.17 0.17 0.18 0.27 0.26 0.31
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Figure 8: Heart Disease Cases (2008-18) in Pak Army Troops*
Cases Prevalence %
1597
1524
1447
1319
1216 1167 1126 1086
880
810
569
0.31 0.31 0.23 0.22 0.32 0.16 0.12 0.17 0.27 0.23 0.22
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

31
46. It is evident from the box-plot that the center of the Period ‘B’ data (2008-
2018) is higher as compared to that of Period ‘A’(1997-2007), and that there is
slightly more spread in the Period ‘A’ data as compared to Period ‘B’. Both the
variables seem to be approximately symmetrically distributed. It is also quite
likely that the paired samples t test might draw a non-significant conclusion.
Figure 9: Box-plot of Heart Disease Prevalence
Period ‘B’
Period ‘A’
Prevalence %
Table 14: Paired Samples Statistics

Deviation of Mean
Period ‘B’ .2312 11 .06427 .01938

Pair 1
Period ‘A’
.1721 11 .07871 .02373
32
Period ‘B’ &

Pair 1 11 -.163 .632
Period ‘A’

(2-
Mean Standard Standard 95% tailed)
Deviation Error Confidence
Mean Interval of the
Difference
Lower Upper
Period
Pair ‘B’ –
.05910 .10943 .03299 -.01442 .13261 1.791 10 .100
1 Period
‘A’
Results
47. There is non-significant difference between the two periods for heart
disease cases at 95% confidence level as the P-value > 0.05. Furthermore,
there is weak but non-significant correlation between the two periods.
33
STUDY CONDUCTED AT HYDERABAD CANTONMENT
48. The sample size comprised of 400 active duty Pakistan Army personnel
posted at Hyderabad Cantonment having more than 10 years of service and
dining from army unit messes. WHO Calculator was used for sample size
calculation at 95 percent level of confidence and 5 percent margin of error.88
The sample size was calculated to be 384. It was, therefore, decided to register
400 personnel in the study to cater for non-response by some participants. This
study was carried out from August 2019 to July 2020. The study was done in
eight army units. From the list of individuals in each unit, 50 participants were
selected by stratified random sampling. Hence, a total of 5 Junior
Commissioned Officers, 10 Non-Commissioned Officers, and 35 soldiers were
selected from each unit making a total of 400 persons. Personnel having some
disease history were excluded from the study. The study participants were
explained about the questionnaires. The information regarding age, marital
status, educational status, personal habits, exercise profile, and dietary habits
was collected using a pretested questionnaire. Written informed consent was
taken from all the participants. The study protocol was sanctioned by the Armed
Forces Post Graduate Medical Institute (AFPGMI) Ethics Committee before the
start of the study.
49. The major indicators related to NCDs like high blood pressure, raised
blood glucose and raised blood lipids were investigated in this study.
Overweight was defined as BMI 25-29.9 Kg/m2 and hyperlipidemia was
measured by a total cholesterol >240 mg/dl. The raised fasting glucose level
was declared at > 126 mg/dl. Standing height was measured to the nearest 0.1
cm using a stadiometer and body weight was measured to the nearest 0.1 kg
by an automated weight balance. In the morning, blood pressure was measured
twice on the left arm with the use of an automated blood pressure monitor in a
sitting position after 5 minutes of rest in a quiet room. The mean of the two
measurements was taken. ‘Hypertension’ was defined as Systolic Blood
Pressure (SBP) more than 139 mm Hg and Diastolic Blood Pressure (DBP)
more than 89 mm Hg on more than three occasions at six weeks apart. 89
34
Blood was collected after overnight fasting of 10-12 hours for glucose and lipid
profile. Plasma fasting glucose and total cholesterol were measured using
enzymatic kits in laboratories of Combined Military Hospital, Hyderabad.
50. Statistical analyses were carried out by using SPSS version 23. Mean
and Standard Deviation (SD) were calculated as continuous variables and
proportions were calculated for the categorical variables. Presence of
Hypertension, BMI 25-29.9 Kg/m2, total cholesterol >240 mg/dl, fasting glucose
>126 mg/dl were considered as dependent variables to caloric intake.
35
STUDY POPULATION
51. A total of 400 serving Pakistan Army personnel participated in the study,
breakdown of which is shown below:
Study Population
300 280
250
200
150
100 80
40
50
0
JCO NCO Soldiers
Figure 10: Study Population
Demographic Details
52. Demographic details like age, gender, marital status, service years and
education were assessed through a validated questionnaire. The results are
described in succeeding paragraphs.
Age Group
53. The age of the study population ranged between 29 to 46 years. The
population was divided into 3 age groups: < 30 years, 30-40 years, and more
than 40 years. The mean age of the total sample population was 34.5 years.
Age Groups
250
213
200
150
112
100 75
50
0
Under 30 Years 30-40 Years More than 40 Years
Figure 11: Age Groups

36
Service Years
54. The mean experience of the sample population was 14.7 years. The
study population was divided into 3 groups according to the service as shown
in Figure 12.
Service Years
250
204
200
150
113
100 83
50
0
Figure 12: Service Years

37
QUESTIONNAIRE RESULTS
Question 1: What is function of food in your opinion?
Table 17: Function of Food
Response Frequency Percentage
Provision of energy 47 11.75
Hunger satisfaction 20 5
To keep us healthy 9 2.25
All of above 324 81
None of above 0 0
Total 400 100
Deduction. Most of the participants had adequate knowledge of function of

food in human body. Knowledge of troops can be further improved through
education.
Question 2: Are you satisfied with quality of ration served in Army?
Table 18: Quality of Ration
Yes 366 91.5
No 13 3.25
Cannot Say 21 5.25
Total 400 100
Deduction. Most of the participants (91.5%) were satisfied with quality of

ration being served in Army. Efforts are required to further improve the quality
standards.
38
Question 3: Are you satisfied with quantity of ration served in Army?
Table 19 : Quantity of Ration

Satisfied 382 95.5
Not Satisfied 18 4.5
Total 400 100
Deduction. Most of the participants (95.5%) were satisfied with quantity of

ration. Generally, troops are comfortable with ration being supplied.
Question 4: Which of the following meals do you consume daily?
Table 20: Meals Consumption
Meals Frequency Percentage

3 Meals a day plus snacks 370 92.5
3 Meals a day 24 6
2 Meals a day 6 1.5
Total 400 100
Deduction. Majority of the participants (92.5%) were consuming 3 meals a

day in addition to snacks (during tea time).
39
Question 5: How many times have you been admitted in hospital during
service?
Table 21: Hospital Admission

1-5 Times 40 10
6-10 Times 3 0.75
More than 10 Times 1 0.25
Never 356 89
Total 400 100
Deduction. Most of the participants (89%) were never admitted in hospitals

which is a healthy sign. 10% of the study population had history of hospital
admission ranging from 1- 5 times.
Question 6: What was the reason for hospital admission?
Table 22: Reason for Hospital Admissions

Hypertension - -
Diabetes Mellitus - -
Heart Disease - -
Any other disease 44 11
Not Applicable 356 89
Total 400 100%
Deduction. 11% of the study population had history of hospital admission due
to some illness like fever, gastro-enteritis or injury etc.
40
Question 7: Is there history of high Blood Pressure, Diabetes and Heart

Diseases in your family?
Table 23: Family History

Hypertension 13 3.25
Diabetes Mellitus 14 3.51
Heart Disease 6 1.5
No History 367 91.75
Total 400 100%
Deduction. 3.25% of the study population had positive family history of

hypertension while 3.51% had family history of Diabetes Mellitus.1.5% of the
study population had family history of heart diseases.
Question 8: What was the last time you got blood pressure checked and
what was the reading?
Table 24: Blood Pressure Measurements

Normal 382 95.5
Borderline 11 2.75
High 07 1.75
Total 400 100%
Deduction. 95.5% of the study population had normal blood pressure while
2.75% had borderline and 1.75% had high blood pressure.
41
Question 9: What was the last time you got your blood glucose checked and
what was the reading?
Table 25: Blood Glucose Measurement

Normal 386 96.5
Impaired 8 2
High 6 1.5
Total 400 100%
Deduction. The vast majority of the study population (96.5%) had normal
blood glucose while 2% had impaired levels. 1.5% had high blood glucose when
checked for study purpose.
Question 10: What was the last time you got your blood cholesterol checked
and what was the reading?
Table 26: Blood Cholesterol Measurement

Normal 390 97.5
Borderline 7 1.75
High 3 0.75
Total 400 100%
Deduction. The vast majority (97.5%) of the study population had normal
blood cholesterol while 1.75% had borderline values. A total of 0.75% had high
blood cholesterol levels.
42
Question 11: Do you smoke?
Table 27: Smoking History

Yes 25 6.25
No 375 93.75
Total 400 100%
Deduction. 93.75% of the study population were non-smokers which is a

healthy sign while 6.25% were smokers.
Question 12: Have you suffered from any of the following disease?
Table 28: Personal History of NCDs

Hypertension - -
Diabetes - -
Heart Disease - -
Normal 397 99.25
Total 400 100%
Deduction. Majority (99.25%) of the study population did not give any
personal history of NCDs while 0.75% did not reply this answer.
43
Question 13: What are risk factors for developing Non Communicable
Diseases in your opinion?
Table 29: Knowledge about NCDs

Smoking 129 32.25
Physical Inactivity 87 21.75
Stress 51 12.75
Poor Diet and Bad Eating Practice 79 19.75
Family History 54 13.50
Total 400 100%
Deduction. When asked about risk factors for developing NCDs, 32.25%
replied that smoking was the main cause, while 21.75% believed that physical
inactivity was responsible for NCDs. Poor diet and dietary practices were the
causes, as believed by 19.75% of the study population while 13.5% replied that
family history was an important risk factor. There is need to increase awareness
among troops about NCDs.
Question 14: Have you noticed change in your weight since enrolment?
Table 30: Weight Profile

Overweight 51 12.75%
Obese 9 2.25%
Normal 340 85%
Total 400 100%
Deduction. A total of 85% were found to have normal weight while 12.75%
had gained weight and were included in overweight category while 2.25% were
obese. There is need to monitor weight gain trends and employ effective weight
control strategy.
44
Question 15: Do you use any medicine for any disease?
Table 31: Medicine Use

Medicine for Hypertension - -
Medicine for Diabetes Mellitus - -
Medicine for Heart Disease - -
Medicine for other diseases 9 2.25%
Do not use any medicine 391 97.75%
Total 400 100%
Deduction. When asked about use of medicine for any disease, 97.75%
replied that they were not using any medicine. Only 2.25% were using medicine
for any occasional ailment like fever, body aches or gastroenteritis etc.
Question 16: How much time do you spend doing sports or fitness
activities on a typical day?
Table 32: Sports Activities

Playing Sports 397 99.25
Do not play any sports 3 0.75
Total 400 100%
Deduction. Majority (99.25%) were playing some sort of sports which is a

very healthy sign while 0.75% did not play sports at all due to some reason.
They should be motivated to start healthy physical activities.
45
Question 17: In a typical week, on how many days do you carry out
sports or fitness activities?
Table 33: Sports Activity Days

Once in a week 0 0
Twice in a week 0 0
Thrice in a week 79 19.75
Four times in a week 186 46.50
Five times in a week 33 8.25
Six times in a week 45 11.25
Daily 57 14.25
Total 400 100%
Deduction. When asked about frequency of sports activities, majority (46.5%)

were playing four times in a week while 19.75% were playing thrice weekly.
Question 18: In a typical week, on how many days do you eat fruits?
Table 34: Fruit Consumption

Once in a week 5 1.25
Twice in a week 27 6.75
Six times in a week - -
Daily - -
Total 400 100%
Deduction. When asked about fruit consumption, 69.75% were eating fruits
thrice in a week while 19.5% were eating fruits four times in a week which is a
healthy sign.
46
Question 19: In a typical week, on how many days do you eat

vegetables?
Table 35: Vegetable Consumption

Once in a week - -
Twice in a week - -
Six times in a week 34 8.5
Daily - -
Total 400 100%
Deduction. When asked about vegetable consumption, 61.25% were

consuming vegetables four times in a week while 18.5% were eating vegetable
thrice in a week.
Question 20: In a typical week, on how many days do you eat red meat?
Table 36: Meat Consumption

Thrice in a week 24 6
Four times in a week - -
Five times in a week - -
Daily - -
Total 400 100%
Deduction. When asked about red meat consumption, 77.75% were

consuming twice weekly while 16.25% were consuming once in a week.
47
Question 21: In a typical week, on how many days do you eat chicken?
Table 37: Chicken Consumption

Four times in a week - -
Five times in a week - -
Daily - -
Total 400 100%
Deduction. When asked about chicken consumption, 68.5% were consuming

chicken twice weekly while 22.25% were consuming once in a week.
Question 22: What is your favorite food item in menu?
Table 38: Favorite Food

Mutton Curry 49 12.25
Chicken Curry 78 19.5
Pulao 142 35.5
Vegetables 56 14
Fruit 34 8.5
Halwa 26 6.5
Paratha 15 3.75
Total 400 100%
Deduction. Pulao (Fried Spiced Rice) was most liked food as 35.5% liked it
while 19.5% preferred chicken curry.
48
Question 23: Which food items you do not like in menu?
Table 39: Disliked Food

Meat dishes 98 24.5
Chicken dishes 77 19.25
Pulao 64 16
Vegetables 98 24.5
Fruit 23 5.75
Halwa 25 6.25
Paratha 15 3.75
Total 400 100%
Deduction. Vegetables and mutton were most disliked food as 24.5% of the
study population voted against each dishes.
Question 24: How often do you add salt to your food as you are eating
it?
Table 40: Salt addition

Almost daily 23 5.75
Rarely 202 50.5
Total 400 100%
Deduction. When asked about salt addition, 19.75% were adding salt twice
in a week to dishes while 12.25% were adding salt thrice in a week. The good
part is that 50.5% were not using extra salt. Troops should be educated to avoid
extra salt.
49
Question 25: Your comments about ration?
Table 41: Comments about Ration

Quality of ration should be improved
121 30.25
Cooking standard needs improvement 88 22
Ration is ok 95 23.75
Training of cooks needs improvement
89 22.25
Instead of ration, money should be given 7 1.75
Total 400 100%
Deduction. Majority of the participants (30.25%) replied that quality of ration

should be improved while 22% said that cooking standard should be further
improved. Cooks can be better trained by refresher courses and constant
supervision.
50
NCD CASES IN STUDY POPULATION
55. Out of total sample population of four hundred (400) Army personnel,
seven (7) were labelled as hypertensive, six (6) were diagnosed as diabetics
and three (3) cases of heart disease were identified.
NCD Cases
8
7
7
6
6
5
4
3
3
2
1
0
Hypertension Diabetes Mellitus Heart Disease
Figure 13: NCD Cases in Study Population
Age Group
56. The NCD cases belonged to following age groups:
Age Groups
4.5
4
4
3.5
3 3
3
2.5
2 2
2
1.5
1 1
1
0.5
0
Hypertension Diabetes Heart Disease
Mellitus
Figure 14: Study Age Group

51
Marital Status
57. All NCD cases diagnosed through our study were married.
Army Service in Years

58. The NCD Cases from study population belonged to following groups as
shown in figure 15.
Service Groups
6
5
5
4
4
3 3
3
2
1
1
0
10-13 Years 14-17 Years More than 17 Years
Figure 15: NCD Cases-Service in Years
Educational Status
59. The educational status of diagnosed NCD cases is shown below:
Educational Status
6
5
5
4
4
3
2 2 2
2
1
1
0
Primary Middle Matriculation Graduate Post-Graduate
Hypertension Diabetes Melitus Coronary Heart Disease
Figure 16: NCD Cases-Educational Status

52
Family History
60. The diagnosed cases of NCDs having positive family history for NCDs is
shown below:
Family History
4.5
4 4
4
3.5
3 3
3
2.5
2
2
1.5
1
0.5
0
Positive Family History No Family History
Figure 17: NCD Cases-Family History
Body Mass Index

61. The weight profile of diagnosed NCD cases is shown below:
BMI
6
5
5
4
4
3
3
2 2
2
0
Hypertension Diabetes Melitus Coronary Heart Disease
Underweight Normal Weight Over Weight
Figure 18: NCD Cases-Body Mass Index

53
STUDY FINDINGS
62. The findings of our study were compared with data of other setups.
Table 42: Tri -Services Data Vis a Vis Study Results*
Pak Study
Category PAF PN
Army Results
Number of Troops 535938 63389 36066 400

Diabetes Mellitus
0.24% 0.19% 0.04% 1.50%
(Prevalence)
Hypertension (Prevalence) 0.32% 0.21% 0.14% 1.75%
Heart Disease (Prevalence) 0.22% 0.18% 0.08% 0.75%

*Source: Pak Army/PAF/PN Health Reports
63. The detailed analysis of NCD cases in our study is tabulated below:
Table 43: NCD Cases Analysis

Diabetes
Category Hypertension Heart Diseases
Mellitus
Total Cases 7 6 3
Sample Size 400 400 400
Positive Family History 57.14% 66.67% 100%
Overweight 28.57% 66.67% 100%
Tobacco Smoking 42.85% 33.34% 33.34%
Older Age(>40 years) 57.14% 50% 66.67%
Service Years(>17 years) 57.14% 83.34% 100%
Physical Inactivity 14.28% - 33.34%
Prefer extra oil 28.57% 16.66% 33.34%
Preferred extra salt 14.28% 33.34% -

54
OBJECTIVE 3
64. The third objective was to carry out comparison of our study results with
national and international studies. To achieve this objective, an extensive
literature research was done. National and international studies were compared
with our study findings to have a comparative analysis of NCDs prevalence in
different setups. The literature related to NCDs prevalence in armed forces is
very limited. Nevertheless, hectic efforts were undertaken to search relevant
data. The important national studies are mentioned in succeeding paragraphs.
Combined Military Hospital Multan Study on NCDs Prevalence
65. Muhammad Hafeez and co-workers carried out an important study in

Combined Military Hospital, Multan during 2016-2017 to find out the prevalence
of Diabetes Mellitus in Army soldiers. The study was published in Pakistan
Armed Forces Medical Journal in 2018. The study design was an observational
cross-sectional study in which seven hundred and seventy-two (772) active
service soldiers were included who were already admitted in Combined Military
Hospital Multan with complaints of polyuria, polydipsia, polyphagia, weight
changes and delayed wound healing. The study participants were inquired in
detail about the symptoms. The study results yielded that 7.12% had Diabetes
Mellitus, 38% had hypertriglyceridemia and 11% had hypertension. The
authors determined that Diabetes Mellitus and related complications were not
uncommon in young active soldiers.26
Meta-Analysis on Hypertension Prevalence
66. Qasim Shah et al carried out a meta- analysis of published literature in

2018 using PubMed, Google and Scopus.27 The work was augmented by a
manual search of retrieved articles for population studies done in Pakistan
providing estimations on the prevalence of hypertension between 1990 and
2017. They defined hypertension for inclusion criteria of the study as the blood
pressure ≥140/90 mm of Hg in adults more than 15 years of age. They selected
a total of 1240 articles for inclusion in the meta-analysis. The study comprised
of total of 42,618 participants.
55
The meta-analysis revealed that the overall prevalence of hypertension was

26.34% in adult Pakistani. The further analysis presented a higher urban
prevalence of hypertension (26.61%) than the rural dwellers (21.03%). An
alarming finding was that the prevalence of the disease was increasing with
time.
Obesity Study in Pakistan Armed Forces

67. Faisal Imran Malik carried out a study in 2018-19 comprising of 450
serving uniform personnel comprising of Pakistan Army, Pakistan Air Force and
Pakistan Navy to determine the prevalence of overweight and obesity. 28 All the
relevant information on demography, lifestyle, family history, and dietary habits
related variables was gathered through a pretested questionnaire distributed
among study population. The results of the study are tabulated below:
Table 44: Obesity Study
Outfit Overweight Obese

Pak Army 14.66% 0.66%
Pak Air Force 18% 1.33%
Pak Navy 28% 2.66%
BLM Study in Rawalpindi Cantonment

68. Nisar Ahmed carried out an extensive study in Rawalpindi Cantonment
from 2017-18 to assess the dietary habits of a soldier’s cohort putting on 10-12
years of service to compare their BMI status. 29 The study objectives also
included determining trends of some nutrition-related diseases like Diabetes,
Hypertension, and Cardiovascular diseases amongst soldiers since the
implementation of Base Line Menu in 2009. Two hundred (200) soldiers of
Pakistan Army having 10-12 years of service, consuming Base Line Menu, and
serving at Rawalpindi Cantonment participated in the study. The author
discovered that 71% of the individuals had a body mass index (BMI) in the
range of 22 – 25 kg/m2. He observed the rising trend of Diabetes Mellitus cases
in the Pakistan Army for the period from 2009 till 2016 which indicated a
negative impact of the existing menu.
56
Diabetes Mellitus Prevalence Study

69. Sultan Ayoub Meo carried out an important study in 2016 to estimate the
current prevalence and future forecast of Type II Diabetes in Pakistan. 30 The
study was published in the Journal of Pakistan Medical Association. The
authors carried out a bibliographic search of scientific databases. They selected
and examined a total of 22 papers published in different journals. They included
all studies reporting the diabetes prevalence in Pakistan. The authors identified
that Diabetes Mellitus is a chronic health problem affecting all age groups, both
genders, involving urban and rural areas in developing and developed countries
globally. They estimated the current prevalence of type II Diabetes Mellitus in
Pakistan as 11.77%. In males, the prevalence was 11.20% and in females, it
came out to be 9.19%. The prevalence was identified to be higher in males than
females and more common in urban areas as compared to the rural areas. The
authors suggested that Diabetes precautionary measures should be included
in educational curriculum and national health policy to halt the burden of
disease.
Table 45: Diabetes Mellitus Study
Diabetes Pakistan Punjab Sindh Khyber Balochistan

Pakhtunkhwa
Prevalence 11.77% 12.14% 16.2% 9.2% 13.3%
in Males
NCDs Policy Study

70. Rukhsana Roshan and colleagues identified in 2018 that large numbers
of deaths in developed and developing countries are attributable to changing
patterns of disease load from communicable to NCDs.31 This problem was more
alarming in low and middle-income countries where major health system
insufficiencies lead to catastrophic disease trends. Pakistan was facing a
similar dilemma where despite the availability of a comprehensive National
Action Plan, no significant improvement was seen due to lack of effective
implementation. The authors recommended that before developing any health
intervention, there was dire need to gauge the severity and dynamics of NCDs
through a comprehensive health system perspective. The authors focused on
57
six building blocks of the World Health Organization (WHO) framework that
were key to identify bottlenecks in health systems.
Hypertension Management Study
71. Mahmud Ahmad Akhtar in his article published in Pakistan Armed

Forces Medical Journal in 2018 identified that management of hypertension
was increasingly becoming difficult in developing countries like Pakistan. 32 The
challenge was quite big even for developed countries but certain factors
peculiar to Pakistan made it more difficult. He identified the factors like lack of
education and limited awareness about hypertension to be key reasons for
mismanagement. The author identified that Pakistanis were in habit of adding
salt to almost every food; might it be bread, curry, pickle, or even fruit. Poor
dietary practices were major contributors to the high prevalence of hypertension
in Pakistan. He mentioned that majority of foods were saturated with Sodium
Chloride leading to precipitation and aggravation of Hypertension. He further
recommended that the Government should take appropriate measures to
restrict the quantity of salt in edibles. He further suggested that labels should
be displayed on food items mentioning the quantity of salt.
58
INTERNATIONAL STUDIES
72. NCD prevalence in different countries is shown below:
Table 46: Disease Prevalence (in Percentages) Data 86
Category Pak India China Saudi USA UK

Arabia
Diabetes 15.8 17.2 9.4 21.4 9.1 7.7
Mellitus
Hypertension 26.34 25.8 19.2 23.3 12.9 15.2
Heart Disease 13.7 .12.8 4.42 7.5 12.1 3.2
Overweight 20.4 19.7 32.3 69.7 31.9 35.7
Obesity 4.8 3.9 6.2 35.4 36.2 27.8
Indian Study
73. An important study was done in India in 2018-19 by Rajeev Gupta et al.
They found that hypertension was the most important Non-Communicable
disease in India which had affected about 200 million persons. The disease
trend was rising especially among the urban dwellers. They declared that
hypertension was more in men (24.5%) than women (20.0%). High
prevalence was found in developed urban communities and better
socioeconomic status individuals. People had generally low awareness
regarding the etiology, treatment, and prevention aspects related to the
disease. There were regional variations in India and disease was targeting the
adults (>40 years) more than other age groups. The alarming aspect was the
frequency of resistant Hypertension.33
Indian Military Study
74. Sougat Ray et al carried out an extensive study in Indian Military

personnel in 2010 to find the prevalence of pre-hypertension.34The authors
identified that approximation of prevalence of prehypertension in a population
and its association with risk features of cardiovascular disease was important
to design preventive programs. The study population comprised of 767 military
59
personnel including 130 military officers. The authors were also interested to
find out the association of pre-hypertension with possible risk factors such as
weight and lipid profiles. They measured blood pressure, serum cholesterol and
triglycerides levels in addition to anthropometric measurements (height, weight
and the waist-hip ratio). Information regarding smoking, alcohol intake, dietary
habits, and physical activity was collected by using pretested questionnaire. For
study purpose, all those having Systolic Blood Pressure in the range of 120-
139 mm Hg and Diastolic Blood Pressure in the range of 80-89 mm Hg were
labelled as Pre-Hypertensive. The results showed alarming 80% of the study
population falling in Pre-hypertension category. The authors suggested
that high prevalence of prehypertension required immediate attention of all
stakeholders. The association of Pre-hypertension with weight and lipid profile
in young warranted targeted interventions to decrease the disease risks. The
study results are summarized below:-
Table 47: Indian Military Study on NCDs
Disease Pre-Hypertension Overweight Hypercholesterolemia
Prevalence 80% 30% 22%
Indian Police Study
75. Rajesh Gupta and co-workers carried out a study in Indian Police to find
occupational stress among police personnel in India. The study was published
in the Indian Journal of Psychiatry & Allied Sciences in 2017. It was a cross
sectional survey done in Calicut district of Kerala. The authors identified that
physical and mental health related issues were very common in Indian police
personnel. Poor service structure, low financial incentives and inadequate living
standards were the leading causes. The results further revealed that stress was
higher among female employees. An alarming 23% of study population was
suffering from hypertension while 4% of them had some sort of mental illness.
Another important finding was related to substance abuse by 29% of
employees.35
60
Iranian Military Study
76. Author Yahya Salimi and co-workers carried out a landmark study in
Iranian Military personnel that was published in the Public Health Journal of
Bio-Med Central in February 2019. The authors identified that obesity and
overweight among military personnel might affect their job performance. They
explored the national lists including Scientific Information Database, MagIran,
Web of Science, Medline via PubMed, and Scopus up to December 2017. A
total of 1431 studies were included in the meta-analysis. A systematic appraisal
was directed to estimate the pool prevalence of overweight and obese persons
among Iranian military personnel. The prevalence of overweight was 41% while
the prevalence of obese persons was 13%. The prevalence of overweight and
obesity was slightly higher in studies done after 2014. For the overweight, the
Iranian Air Forces had the lowermost prevalence (12%) while the Army and
Navy had the maximum prevalence (14%).36
Iranian Army Study
77. Dabbagh Moghaddam et al carried out a study in Iranian Army staff to

find the association between dietary patterns and blood pressure. The authors
identified that Hypertension was one of the most common NCDs in the world.
The study was carried out among 405 military staffs between 22 to 51 years of
age group. Demographic, anthropometric information and Blood Pressure of
participants were evaluated by standard methods. The dietary intake was
collected using a food frequency questionnaire (FFQ). The findings specified
that dietary patterns did not have any significant link with Systolic and Diastolic
Blood Pressures after adjustment for confounders in the healthy military
persons. The authors suggested that to establish dietary patterns association
with Blood Pressure in the healthy military population, stronger design studies
with greater number of participants should be done in the future. 37
Chinese Study
78. Thermite Mara et al carried out a meta-analysis of studies done in China

from 2000-2016 which comprised of 75 articles. The total number of study
participants was 90,758 military officers. The authors identified that chronic
non-communicable diseases caused a tremendous burden on the Chinese
61
Military Medical Setup. The authors studied China National Knowledge

database from 2000 to 2016. They focused on six major chronic diseases:
Diabetes Mellitus, heart diseases, hypertension, hyperlipidemia,
cerebrovascular diseases, and chronic obstructive pulmonary diseases in
Chinese military officers.
Table 48: Chinese NCDs Study

Disease Hypertension Diabetes Heart Hyperlipidemia
Diseases
Prevalence 46.6% 20.7% 48.2% 30.9%
They found that the prevalence rate of Hypertension, Diabetes, Heart disease,
cerebrovascular disease, and chronic obstructive pulmonary disease (COPD)
increased with age in Chinese military officers. Heart diseases and
hypertension increased sharply in retired officers compared with officers in
service. They concluded that the Chronic Non-communicable Diseases
profoundly affected Chinese Military officers especially retired persons. It was
a huge burden on Healthcare finances also. 38
Gulf Study-Hypertension Prevalence
79. Ayman Tailakh et al concluded in 2014 that approximately one billion of

the world’s population had hypertension which led to four million deaths every
year. There were few studies in the Arab world on the prevalence of
Hypertension. Their review comprised of current knowledge regarding
prevalence, responsiveness, and control of hypertension in the Arab countries.
They searched PubMed, Cochrane Library, Scopus, and CINAHL databases to
find the publications on Hypertension among the Arab people from 1980 to
January 2011. They could find 13 studies in literature from 10 Arab countries.
The overall estimated prevalence of hypertension in the Arab world was 29.5%
which indicated a higher prevalence of hypertension among Arabs as compared
to people from the United States America (28%) and Sub-Saharan African
(27.7%). In Arab women, the frequency and prevalence of hypertension were
found to increase with age. 39
62
Middle East Study-Diabetes Prevalence
80. The authors Sultan Ayoub Meo et al carried out a retrospective study in
the male population of the Middle East to find out the prevalence of Diabetes
Mellitus (DM). The study was published in the American Journal of Men Health
in 2019. The authors included seventy-four research articles published from
2008-2018. They identified that Diabetes Mellitus was a serious global health
issue and the world was experiencing the Type II Diabetes epidemic. They
observed regional variations in disease prevalence which were related to
cultural and socioeconomic factors. The disease was rising at a faster pace in
the Middle East than in other regions and the male population was mainly
affected.40
The findings of the study were quite remarkable. Bahrain (33.60%) had the
highest prevalence of Diabetes Mellitus among men followed by Saudi Arabia
(29.10%). The results are summarized below in the table:
Table 49: Middle East Diabetes Study
Country Bahrain KSA UAE Kuwait
Prevalence 33.60% 29.10% 25.83%, 25.40%
Country Israel Iran Egypt Turkey
Prevalence 13.70% 9.90% 12.70% 16.00%
Eastern Mediterranean Region Study
81. Kremlin Wickramasinghe and co-authors mentioned in 2018 that

effective implementation of the WHO-Multi-sectorial Action Plans (MAPs) was
required for the prevention and control of NCDs.41 They undertook a project to
draw on the experiences of four East Mediterranean Region (EMR) countries
that had made good progress in developing and implementing the MAPs. As
part of the study project, four focal EMR countries: Lebanon, Morocco, Sudan,
and Yemen were selected for health experts’ comments and interviews. The
authors recommended the development of multi-sectorial action plans specific
63
to each country to tackle NCDs. The process is no doubt challenging but it is

sustainable to achieve long term results to control NCDs in any society.
European Study (Spain)
82. Gijón-Conde and co-workers analyzed the impact of changes in the 2017
American College of Cardiology/American Heart Association (ACC/AHA)
guidelines that had recommended modification in hypertension definition from
blood pressure (BP) 140/90 to 130/80 mmHg. No data was available on the
comprehensive impact of these guidelines in European countries, where
physicians did not always follow guidelines from their own continent. The
authors assessed the prevalence of hypertension, recommendations for
antihypertensive medication, and cardio-metabolic goals achieved in Spain by
using the European guidelines compared with the American Heart Association
guidelines. They analyzed data from a Spanish national survey on 12074
representative members of the population with a minimum age of 18 years.
They found the hypertension prevalence as 33.1% as per European Guidelines
and 46.9% as per American Guidelines. It precisely represented 5.3 more
million hypertensive patients in a country having a total population of 40 million
adults. Also, 1.4 more million candidates for medication were identified if
American guidelines were used. They concluded that the American College of
Cardiology/American Heart Association (ACC/AHA) guidelines would lead to a
considerable increase in the prevalence of hypertension and the number of
adults who should take medication.42
United States Study
83. Muntner and Carey et al carried out a study in 2017 in the United States
of America to find out the prevalence of Hypertension. As per the guidelines of
American College of Cardiology/American Heart Association (ACC/AHA-2017)
and Joint National Committee (JNC7), the crude prevalence of hypertension
among American adults was 45.3% and 31.8% respectively, while
antihypertensive medication was recommended for 36.2% and 34.3% of United
States adults, respectively. The non-pharmacological intervention was advised
for 9.4% of United States adults. The authors’ concluded that the 2017
64
ACC/AHA guideline caused a considerable rise in the prevalence of

hypertension as compared with the JNC 7 guideline. Along with increased
prevalence, there was also an increase in the percentage of the United State
adults who were advised antihypertensive medication.43
United States Cardiovascular Health Study
84. Alice Shrestha et al did a comparative study in USA to analyze cardio-

vascular health status of army and civilian population. 44 The study was
published in the Journal of American Heart Association in June 2019. The
sample size included 430 Army persons who were compared with a
corresponding set of civilian population. The authors compared four
cardiovascular health parameters including body mass index, smoking, blood
pressure, and diabetic status between army and civilian groups. Ideal blood
pressure was particularly less prevalent in the army (30%) than civilian
participants (55%). Increasing age and senior ranks were more closely related
to Hypertension. Diabetes Mellitus was rare in both groups. They concluded
that Ideal cardiovascular health was less prevalent in the army than the civilian
group. The finding exposed the need for policy changes to promote, preserve,
and progress ideal cardiovascular health.
United States Military Study
85. Brian Smoley and co-workers carried out an extensive study on

prevalence of Hypertension in United States active duty service members. The
study was published in the Journal of the American Board of Family Medicine in
Nov 2008. The authors identified that though Hypertension was a common
ailment, but there was little recognition of its prevalence in the Armed Forces.
They looked over the screening accounts for service fellows who completed
health risk evaluations at Fort Lewis in Tacoma, WA, in 2004. The study
identified that 13% of 15,391 subjects met the study's criteria for hypertension
while 64% met the study definition for prehypertension. The authors proved that
increasing age, male sex, black race/ethnicity, higher body mass index, and
senior rank were mainly related to hypertension. The authors determined that
Hypertension and prehypertension were more prevalent in the United States
Armed Forces than previously testified. They suggested that prehypertension
65
was more common in the United States Armed forces than in the overall
population.45
United States Study on Diet
86. Rebecca Collins and co-workers mentioned in 2020 that ideal dietary
intake is important for the good health and optimum physical performance of
military personnel. A total of 89 studies were included. The authors identified
that single dietary assessment method was used by majority of studies. Food
frequency questionnaire was most frequent methodology employed in studies.
It was followed by 24 hour recalls and food records. Sub-optimal dietary intake
was leading contributor to the increased burden of disease in military
veterans.46
Senegalese Army Study
87. The authors Abdul Aziz Ndiaye et al identified that the NCDs had
become major public health concern.47 They carried out a cross-sectional study
in 2014 in the Senegalese Army comprising of 1224 participants. The study
aimed to assess the prevalence and risk factors of NCDs in the study
population. The study participants were 96.9% men. Their ages ranged from 25
to 60 years with a mean of 39.7 ± 9.2 years. The overall prevalence of high
blood pressure was 26.9% among the study population while 3.3% participants
had diabetes and 44.1% had hypercholesterolemia.
Myanmar Study
88. Marte Kjollesdal and co-workers carried out a study in 2016 in the
Yangon region of Myanmar.48 They intended to establish relations between
consumption of fruits and vegetables with NCDs. Their study design comprised
of two cross-sectional studies in urban and rural areas of the Yangon region of
Myanmar. A total of 1486 men and women in age group from 25–74 years, were
recruited through a multistage cluster sampling method. They excluded
institutionalized people, military personnel, Buddhist monks, and physically and
mentally ill people from study. The authors concluded that a high intake of fruits
and vegetables was associated with lower odds of hypertriglyceridemia among
men and women.
66
Sri Lankan Study
89. Authors Jayaweera et al carried out a descriptive cross-sectional study

in soldiers from three different army camps located in the dry zone of Sri
Lanka.49 The study was published in July 2018 in Bio-Med Central Journal. The
authors took a voluntary group of four hundred and seventeen (417) soldiers
who were screened for NCDs notably essential hypertension, Diabetes
Mellitus, Dyslipidemia (lipid profile), and history of cardiac events leading to
acute coronary symptom in addition to chronic kidney disease. The authors
identified that for the unique nature of military duties and service in hot and
humid conditions, the soldiers were vulnerable to certain health conditions like
dehydration and subsequent development of kidney diseases. The study
participants had mean body mass index of 21.4 ± 2.2 kg/m2. The prevalence of
hypertension was 0.2% while the prevalence of Diabetes Mellitus was 0.1%.
67
OBJECTIVE 4
90. The final objective of study comprised of proffering recommendations for

introduction of a healthy menu in Pakistan Army.
Recommendations
91. Based on our study findings, following recommendations are suggested:
a. To address high carbohydrates intake, the scales of some ration

articles may be reviewed:-
(1) Scale of Sugar
(a) Active BLM. Be reduced by 7% i.e. from 70 to 65

grams.
(b) Sedentary BLM. Be reduced by 25% i.e. from

70 to 52 grams.
(2) Scale of Atta
(a) Active BLM. Be reduced by 7% i.e. from 700 to

650 grams.

700 to 450 grams.
b. To reduce the intake of carbohydrates and fats, following may be

done:-
(1) Sweet dish less day may be observed once a week.
(2) Scale of Oil/Ghee

95 grams.

100 to 82 grams.
68
(c) To add variety and to reduce fried items in Tea time

items, biscuits be added at the scale of 1 x Ticky
pack (3-4 biscuits) twice a week.
c. To reduce the surplus of tea and milk powder, following may be

done:-
(1) Scale of Tea
(a) Active BLM. Be reduced by 22% i.e. from 9 to 7

grams.

9 to 5 grams.
(2) Scale of Milk Powder

45 grams.

50 to 35 grams.
d. To balance out meat related by proteins intake, corresponding

adjustments in red meat may be done as following:-
(1) Beef being red meat be decreased (20%) from 226 to 180
grams per man per issue.
(2) Increase in number of eggs from 4 to 8/ man/ month i.e.

100% increase in both active and sedentary BLM.
e. To capitalize on vegetable nutritional and high fiber value, salad

(onion and cucumber) with its standard substitutes like radish,
tomatoes and carrots are recommended to be further increased
as following:-
(1) Onion. By 10% i.e. from 56 to 62 grams.
(2) Vegetables. By 8% i.e. from 198 to 214 grams.

69
f. Scale of Dhal. To balance out protein intake, dhal is suggested

to be decreased as following:-
(1) Active BLM. Be reduced by 6% i.e. from 85 to 80

grams.
(2) Sedentary BLM. Be reduced by 25% i.e. from 85 to

64 grams.
g. The percentages of Dhal for procurement may be revised as

under for both active and sedentary duties to add more variety
in BLM:-
Table 50: Variety of Recommended Dhal 12
Variety Procurement Issues per month

Percentages
Of Dhal
Old Recommended Old Recommende
d
Dhal Chana 55 45 17 13
Dhal Mash 15 15.5 5 6
Dhal Mong 10 10 4 4
Dhal 5 10 2 4
Masoor
Chana 5 8 Tea Time Tea Time
Kabli Chana 5 4 Tea Time Tea Time
Lobia Red 2.5 5 1 2
Lobia White 2.5 2.5 1 1

70
h. Enrichment in Active and Sedentary BLM. Following dishes may

be added in proposed active and sedentary BLM thereby achieving
more variety and nutritional diet of troops:-
(1) Salad in lunch (daily).
(2) Biscuits in tea break (twice a week).
(3) Eggs Khaqeena (twice a week).
(4) Plain Fried Rice.
(5) Custard in sweet dish.
i. Alternatives in Active and Sedentary BLM. Following items and

their alternatives are recommended in proposed active and sedentary
BLM:-
(1) Fried items in Tea time (Aalu Cutlus and Fried vegetable slice)
may be replaced with biscuits (1 x Ticky Pack).
(2) Addition of salad (cucumber and onion) in lunch meal on daily

basis.
(3) Sweet dish less day may be observed once in a week (Thursday)
(4) Out of 5 Halwas per week, 2 x Halwas per week may be replaced
with custard and sawiyan as part of sweet dish.
(5) Readjustment of Zarda from Sunday to Friday due to duplication

of sweet.
(6) Issue of red meat may be reduced from existing 15 to 14 issues

per month.
(7) Plain boiled rice may be added in place of beef Pallao.
(8) Addition of varieties of dhal as per liking of troops.
(9) Replacement of Paratha with chapatti on daily basis (less Friday).
(10) Unsaturated fats to be incorporated instead of normal ghee.
(11) Quality of milk powder needs definite improvement.

71
CHAPTER 5
DISCUSSION
92. The association between nutrition and good health is intricately

intertwined. The present day soldier has to face many challenges, hence the
need for optimum and balanced diet is paramount. The exact amount of calories
is dependent on various factors like age, activities, assigned tasks, physical
environment and place of duty. While, the deficiency of essential nutrients may
weaken the immune system; the excessive calories also lead to undesirable
effects like obesity. To identify the effects of enhanced ration scales on NCDs
in Pakistan Army, literature research was done but dearth of data was major
impediment. Only few studies on related subjects have been done in Pakistan
Army. The available data indicated that Pakistani troops are being provided with
higher calories as compared to contemporary armies.11 The present study
identified two distinct patterns that linked NCDs to family history and weight
profiles as 68.75% of cases had a positive family history of NCDs while 56.25%
of diagnosed NCD cases were found overweight. The dietary patterns,
identified in study, reflected well-established culturally and geographically
pertinent preferences in the Army where soldiers have a knack of fried items .
Consumers of more salt and liking for fried items coupled with prolonged
sedentary duties may lead to greater odds of NCDs. Greater dietary diversity
including fruit and vegetable consumption may reduce risks of hypertension. 48
There was also evidence of an interaction effect between age, BMI, and dietary
pattern as indicated by the different trajectories of BMI versus age in which the
age group (>35 years) was having a greater number of overweight cases.
Caloric intake was considered to be equal for all participants for study purposes
to gauge the effects of dietary patterns on the NCDs risk factors. It is suggested
that longitudinal data would help establish whether the association between age
and BMI was a life course or cohort effect. Prolonged high caloric intake dietary
form was treated as a likely risk factor for NCDs while adjusting for the potential
confounding factors of age, sex, family history, sedentary job, stress factor,
education level, and rural/urban background.
72
STRENGTHS OF THE STUDY

93. Following are the strengths of the study:-
a. The study was carried out in Hyderabad Cantonment, which
enabled the researcher to interact with the study population.
b. A validated questionnaire was used in the study to reduce the
biases.
c. Informed consent was taken from the participants and anonymity
guaranteed to the sample population.
d. The research to explore association between Ration and NCDs
in Pakistan Armed Forces is a concept of prime importance and
present study can be very helpful in this regard.
e. The scope of our study was quite wide, as it covered three main
components of NCDs and involved three important tiers (JCOs,
NCOs and soldiers) of army.
LIMITATIONS OF THE STUDY
94. The limitations of the study are as under:-
a. Respondents, who agreed to participate in the study may not be
reflective of the majority of Pakistan Army and hence results may
not be generalized.
b. The method to find the prevalence of NCDs by anthropometric
measurements, laboratory tests and questionnaire may lead to
response bias by the participants.
c. The study was geographically limited to only one cantonment with
a small sample size that was available at that time, resultantly the
findings may be interpreted with caution.
d. The respondents in older age groups were less than the
respondents in younger age groups, which may indicate age bias
in the results of the study.
e. The participants belonging to senior service groups were less in
numbers than the individuals in junior service groups, which may
indicate bias in the results.
f. Being a cross sectional study, causal relationship could not be
established.
73
g. Another limitation relates to the reliability of the Food Frequency

Questionnaire data. The answer to some questions were based
on recalls, that might have affected some food items more than
others as even 24 hour recalls are susceptible to misreporting/
under-reporting.
h. Our methods to identify the dietary patterns are based on gross
consumption patterns. The accuracy and significance of food
composition data could be improved through refined analysis of
modern dietary methods using the latest analytical procedures.
i. NCDs risk factors were measured at one point in time only; repeat
measures/follow ups would be preferable.
IMPLICATIONS ON POLICY MAKING

95. The major implications on policy making are as under:-
a. This study can be used for re-evaluation of ration scales in the
Army.
b. The study may also be helpful in introducing screening programs
in Army to trace NCDs.
c. The study may be useful for training the mess staff to promote
better cooking and hygienic practices.
AVENUES FOR FUTURE RESEARCH

96. This study shows following important avenues for further research on the
subject:-
a. The study can be done at different cantonments with a larger
sample size and comparative control group of sample of soldiers
who are not dependent on army messes.
b. Another dimension of future research should be directed towards
identifying the course contents to implement nutrition and dietary
training program.
74
RECOMMENDATIONS
97. Strict surveillance, formation specific guidelines, evidence-based

policies, reinforcement of multi-sectoral coordinated health approach, and
innovative solutions are urgently needed in resource-challenged settings to
curb NCDs risk factors and overall disease burden. Following specific
recommendations related to Pakistan Army ration scales are suggested:-
a. Calories Intake Brackets. Following options are proposed for

segregation of troops into active and sedentary.
(1) Option I. Active BLM be implemented with standard

scales for all troops.
(2) Option II. Sedentary BLM can be implemented on trial

basis in one formation for six months as pilot project. Fresh
input can be received from that formation for subsequent
implementation in whole Army.
b. BLM Gadgetry Items. Procurement of latest BLM gadgetry

items will be very beneficial. It may be issued to all formations/
units on priority to avoid un-necessary pre- cooking wastages
and improve processing of food.
c. Cooks Training/ Incentives. Training facilities of the Army

Cooks Training Institute be optimally utilized to train Army cooks
for implementation of BLM and better management of messes
including preparation of food. Promotion system of cooks to the
rank of JCO be analyzed as an incentive measure.
d. Strict Implementation of Schedule of Varieties. All Army

departments must ensure that approved schedule of varieties of
fruit and vegetables are strictly implemented. An institutionalized
system of checks and balances and a monitoring mechanism
be adopted by respective formations for implementation of the
approved schedule.
75
e. Procurement of Meat. It is recommended that International

Organization for Standardization (ISO) certified firms may be
engaged on experimental basis by one Logistic Area to conclude
contracts of meat items.
f. Savings/Surpluses. All types of savings/ surpluses be

taken on charge and same quantity be less demanded next time.
Government rules pertaining to Certified Receipt Vouchers may
be amended with 60% of deposited amount of money be entitled
to the units as an incentive and remaining 40% as Government
share. The Army will stand benefited as that much quantity of
ration will be less demanded next time.
g. Changes in Caloric Intake of Proposed Scales. Keeping

in view the above mentioned facts, it is recommended that the
ration scales may be revised. The proposed ration scales are
tabulated below:
Table 51: Proposed Ration Scales 12
Category Authorized BLM Actual

Scales (Kcal/day) Intake 5%
Existing 4961 4273 4070

(Authorized
Scale)
Proposed 4481 4161 3962

(Active)
Proposed 3576 3320 3162

(Sedentary)
76
CONCLUSION
98. The comparative study of current and old ration scales yielded higher
caloric counts for new scales. The trends of NCDs, particularly the Diabetes
Mellitus, revealed significant increase in cases after implementation of
enhanced ration scales. The rising trends of NCDs may be associated with
other important factors like job stress, lifestyle issues, inheritance, frequent
medical examinations and improved accessibility to better diagnostic facilities.
There is a dire need to carry out root cause analysis of risk factors linked to
NCDs. The inexorable rising burden of NCDs demands immediate attention of
all stakeholders, as delay in actions to address this challenge may be
catastrophic. Prevention through awareness, physical activities, job incentives,
healthy lifestyle, periodic medical examination and provision of balanced diet
can play a vital role. This will, in turn, provide huge dividends in terms of
improved health status of the military population.
77
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86. World Health Organization. Global Health Observatory. Country Profile.

https://apps.who.int/gho/data/ node. country. Pak-Profile. 2016.
87. Babusa S, Singh K, Shukla, Vasudha S, Som N, Prasad K. Assessment of

ration scales of armed forces personnel in meeting the nutritional needs at
plains and high altitude-I. Defence science journal.2008; 58. 734-744.
10.14429/dsj.58.1701
88. World Health Organization. Shake the Salt Habit. The SHAKE Technical
Package for Salt Reduction. 2016. Geneva: WHO.
https://apps.who.int/iris/bitstream/handle/10665/250135/9789241511346-
eng.pdf?sequence=1, accessed 31 December 2019.
89. World Health Organization. Diagnosis and management of patients with

hypertension. 2017. https://apps.who.int /wproncd.
90. World Health Organization. Sample size calculator. 2017. Retrieved from
https://www.who.int/ncds/surveillance/steps/resources/ sampling/ en/
91. WHO. World Health Organization. 2008-2013 Action Plan for the Global
Strategy for the Prevention and Control of Non-communicable Diseases. 2008-
2013.
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92. Malekzadeh M, Etemadi A, Kamangar H, Khademi L, Golozar G, Islami I, et al.

Prevalence, awareness and risk factors of hypertension in a large cohort of
Iranian adult population J Hypertension. 2018; 6-216.5. pp. 1364-1371.
93. Anchala R, Kannuri N, Angelantonio D, Prabhakaran R, et al. Hypertension in

India: a systematic review and meta-analysis of prevalence, awareness, and
control of hypertension J Hypertension.2017;32. pp. 1170-1177.
94. World Health Organization. WHO Delivering for Results Draft Paper. 2017.
https://www.who.int/about/finances-ccountability/budget/20170113_delivering-
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95. Reid C. Nutritional requirements of surgical and critically-ill patients: do we

really know what they need? Proc. Nutr. 2016. Soc. 63, 467–472.
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88
Annexure ‘A’
INFORMED CONSENT
PART I: Information Sheet
Introduction
1. I am Lt Col Dr Imran Samee Waraich, doing a study on enhanced ration

scale effects on Non Communicable Diseases (NCDs) in Pakistan Army troops. I
will be taking information regarding my study topic and invite you to be a part of
this project. You can decide now or take your time for participating in the study.
There may be some questions, which you may not understand, but I will try to
make them simple in the language which you can understand. If you want to ask
any question or need information, you can contact the researcher.
Purpose of the research
2. The main purpose of doing the study is to know about the effects of
enhanced ration scale effects on Non Communicable Diseases (NCDs) in the
Pakistan Army troops to recommend viable measures to improve health of
troops.
Type of Research Intervention
3. The study will require your participation by asking questions, recording

body weight, height, blood pressure and carrying out laboratory tests.
Participant selection
4. Being a soldier you are invited to participate because your input will be
beneficial to uphold the purpose of research.
Voluntary Participation
5. The participation in this study is totally on voluntary basis. You are totally
free to choose whether you want to participate or not. Whether you choose to
participate or not, all the facilities you are getting will continue as before.
89
Protocol
6. Questions will be asked from the structured proforma for quantitative part
of study. In addition, certain body measurements and laboratory investigations
will be carried out.
Duration
7. The study will be conducted from August, 2019 to July, 2020.
Confidentiality
8. The information that will be collected during the study from you, will be
strictly confidential. The information collected about you, will not be shared with
any one and only the examiner will be able to see it. The facts will be used to
analyze the required subject will not be given to anyone for any other purpose.
Sharing the Results
9. The information taken from the study will be shared with you.
Confidential information will not be shared.
Right to Refuse or Withdraw
10. The participation in the study is not mandatory.

90
PART II: Certificate of Consent
I have read the foregoing information or it has been read to me. I had the
opportunity to ask questions about it and any questions that I have asked have
been answered to my satisfaction. I consent voluntarily to participate as a
participant in this research.
Name of Participant__________________
Signature of Participant ___________________
Date ___________________________
I have witnessed the accurate reading of the consent form to the potential
participant, and the individual has had the opportunity to ask questions. I
confirm that the individual has given consent freely.
Name of witness_____________________
Signature of witness ______________________
Date ________________________
Statement by the Researcher/Person taking consent
I have accurately read out the information sheet to the potential participant. I
confirm that the participant was given an opportunity to ask questions about the
study, and all the questions asked by the participant have been answered
correctly and to the best of my ability. I confirm that the individual has not been
coerced into giving consent, and the consent has been given freely and
voluntarily.
Dr Imran Samee Waraich
Signature __________________________
Date ___________________________
91
Annexure ‘B’
QUESTIONNAIRE
Response Guidelines:
 It is survey questionnaire to assess the possible association between

enhanced ration scale effects on Non Communicable Diseases (NCDs) in
Pak Army troops. Your valuable response will remain confidential. Please tick
( √ ) the appropriate boxes where applicable and reply all questions.
1. Name : (Optional)
2. Rank :
3. Education :
a. Primary ☐
b. Middle ☐
c. Matriculation ☐
d. Graduation ☐
e. Post Graduation ☐
4. Date of Birth :
5. Marital Status :
a. Single ☐
b. Married ☐
c. Divorced ☐
6. Date of enrolment in Army :
7. Unit :
8. Location :
92
Serial Questions
1. What is function of food in your opinion?
 To provide energy ☐
 Hunger satisfaction ☐
 To keep us healthy ☐
 All of above ☐
 None of above ☐
2. Are you satisfied with quality of ration served in Army?
 Yes ☐
 No ☐
 Cannot Say ☐
3. Are you satisfied with quantity of ration served in Army?
 Satisfied ☐
 Not satisfied ☐
 It is less than required ☐
 It is more than required ☐

4. Which of the following meals do you consume daily?
 Breakfast ☐
 Lunch ☐
 Dinner ☐
 Tea Break ☐
 All of the above ☐

5. How many times have you been admitted in hospital during service?
 1-5 Times ☐
 5-10 Times ☐
 More than 10 Times ☐
 Never ☐
93
6. What was the reason for hospital admission?

 Hypertension ☐
 Diabetes Mellitus ☐
 Heart Disease ☐
 Any other disease ☐
 Please specify reason or diagnosis :

7. Is there history of High Blood pressure, Diabetes and Heart diseases in
your family?
 Yes ☐
 No ☐
 If Answer is Yes, Please specify disease : ___________________
8. What was the last time, you got your blood pressure checked? And what
was the reading?
 Date :
 Blood Pressure :
 Not checked in last one year :
 Reading of Blood Pressure checked for study purpose :
9. What was the last time you got your blood glucose checked and what was
the reading?
 Date :
 Blood Glucose Level :

 Blood Glucose Level checked for Study Purpose:
94
10. What was the last time you got your blood cholesterol levels checked and
what were the levels?
 Date :
 Cholesterol Levels :
 Blood Cholesterol level checked for study purpose :
11. Do you smoke?

 Yes ☐
 No ☐
If answer is Yes, Please specify no of cigarettes per day
12. Have you suffered from any of the following disease?(Insert √ in box if
applicable)
 Hypertension ☐
 Diabetes Mellitus ☐
 Coronary Heart Disease ☐

13. What are risk factors for developing Non Communicable Diseases in your
opinion?
 Smoking ☐
 Physical Inactivity ☐
 Stress ☐
 Poor diet and bad eating practices ☐
 Family History ☐
95
14. Have you noticed change in your weight since enrolment?

 Increased ☐
 Decreased ☐
 Body weight in Kg checked for study purpose ☐
 Present BMI ☐
15. Do you use any medicine for any disease?
 Yes ☐
 No ☐
 If answer is Yes, Please specify disease and medicine

16. How much time do you spend doing sports or fitness activities on a typical
day?
 Yes ☐
 No ☐
 If answer is Yes, Please specify duration in minutes :

17. In a typical week, on how many days do you carry out sports or fitness
activities? (√ appropriate box)
1 2 3 4 5 6 7
18. In a typical week, on how many days do you eat fruits? (√ appropriate box)
1 2 3 4 5 6 7
19. In a typical week, on how many days do you eat vegetables? (√

appropriate box)
1 2 3 4 5 6 7
20. In a typical week, on how many days do you eat red meat? (√ appropriate
box)
1 2 3 4 5 6 7
96
21. In a typical week, on how many days do you eat chicken? (√ appropriate
box)
1 2 3 4 5 6 7
22. What is your favorite food item in menu?

 Food Item: ____________________
23. Which food item/items you do not like in menu?
 Food Items: ____________________
24. How often do you add salt to your food as you are eating it? (√ appropriate
box)
 Almost daily ☐
 Once in a week ☐
 Twice in a week ☐
 Thrice in a week ☐
 Rarely ☐
25. Your comments about ration?
Comments : _________________________________________________
___________________________________________________________
97
Annexure ‘C’
GANTT CHART
Activities Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
2019 2020
Acceptance
of Synopsis
Refining
Literature
Search
Data
Collection
Data
Analysis
Report
Writing
Printing of
Report
Thesis
Defence
98
Annexure ‘D’
TENTATIVE BUDGET
Budget Head Cost (Rs.) Units Total (Rs.)
Transport 10000 - 10000
Stationary 10000 - 10000
Media/internet/telephone 5000 - 5000
Food and refreshment 2000 - 2000
Miscellaneous 5000 - 5000
Accommodation/stay 5000 - 5000
Total: 37,000 37,000

99
Annexure ‘E’
Participant Number:
INFORMATION SHEET
Study Title: Enhanced Ration Scale Effects on Non-communicable Disease in Pakistan
Army Troops-A Critical Study
Purpose: It has been observed with concern that Non Communicable Diseases are on
the rise in Pakistan Army. The purpose of this study is to find the Enhanced
Ration Scale Effects on Non-communicable Disease in Pakistan Army Troops
Duration: The questionnaire will require 10 minutes of your valuable time.

Procedure: If you agree to participate, you will be asked to complete
questionnaires by placing a tick or encircling the right option.
Risks: There are no major risks from participating in the study but it is
possible that some might find it difficult to answer some questions, or be
uncomfortable expressing their opinions, particularly if they perceive the topic
areas as stigmatized. You are free to withdraw from the evaluation at any time
and there will be no negative consequences withdrawing from the study.
Benefits: There are no direct individual benefits from participating in the
study, but the findings will be used to determine the causes of Non
Communicable Diseases in Pakistan Army with the aim to improve the health
of troops.
Confidentiality: Your identity and views will remain anonymous and will not
be identifiable in any publications from the study.
Voluntary Participation: Your participation in this study is voluntary and you
are free to withdraw from the study at any time without giving any reason. There
will be no penalty or loss of benefits resulting from your refusal to participant.
Further information: Please contact Lt Col Imran Samee Waraich at the
following:
a. Cell: 03458700091
b. email: imransamee75@gmail.com
Thank you for taking the time to read this information sheet.
100
Annexure ‘F’
CONSENT FORM
Study: Enhanced Ration Scale Effects on Non-communicable Diseases

in Pakistan Army Troops-A Critical Study
1. I confirm that I have read the information sheet for the above study and
I had the opportunity to ask questions.
2. I understand that my participation is voluntary and that I am free to

withdraw at any time without giving any reason.
3. I understand that my identity and my views will not be identifiable in any

publications from the study.
4. I voluntarily agree to take part in the above study.
Name : ________________________________
Signature: ________________________________________
Date: ____________________________________________
Researcher:_______________________________________
Signature:_________________________________________
Annexure ‘G’
SUPERVISOR CERTIFICATE
It is certified that the research work contained in the thesis titled

“Enhanced Ration Scale Effects on Non Communicable Diseases in
Pakistan Army Troops- A Critical Study” has been conducted under my
supervision and to my satisfaction by PA 103940 Lieutenant Colonel Imran
Samee Waraich, Roll No-29 MSc-38, and session 2019-2020.
Dated: July 2020 Lieutenant General

Asif Mumtaz Sukhera (Retd), HI (M)

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Enhanced Ration Scale Effects on Non Communicable

Diseases in Pakistan Army Troops-

ARMED FORCES POST GRADUATE MEDICAL INSTITUTE

PA NO 103940 LT COL IMRAN SAMEE WARAICH

MSc-38, Session 2018-20

LT GEN ASIF MUMTAZ SUKHERA (RETD), HI (M)

I, PA-103940 Lieutenant Colonel Imran Samee Waraich of MSc-38

Dated: _____ July 2020

I would like to acknowledge the blessings of Almighty Allah which enabled

Imran Samee Waraich

My thesis is dedicated to,

Allah (SWT) for all His blessings despite my shortcomings

2. To improve health of troops in Pakistan Army.

b. To study the trends of hypertension, diabetes, and heart diseases

c. To compare the results with national and international studies.

d. To proffer recommendations accordingly for the introduction of a

4. METHODS. This cross-sectional study, comprising of 400 serving army

Serial Content Page No

Chapter 2 Review of Literature 6

Table 32: Sports Activities 44

Figure 1: Diabetes Mellitus Cases (1997-2007) in Pak Army Troops 21

Figure 2: Diabetes Mellitus Cases (2008-18) in Pak Army Troops 21

Figure 3: Box-plot of Diabetes Mellitus Cases 23

Figure 4: Hypertension Cases(1997-2007) in Pak Army Troops 26

Figure 5: Hypertension Cases (2008-2018) in Pak Army Troops 26

Figure 6: Box-plot of Hypertension Cases 27

Figure 7: Heart Disease Cases(1997-2007) in Pak Army Troops 30

Figure 8: Heart Disease Cases (2008-18) in Pak Army Troops 30

Figure 9: Box-plot of Heart Disease Cases 31

Figure 10: Study Population 35

Figure 11: Age Groups 35

Figure 12: Service Years 36

Figure 13: NCD Cases in Study Population 50

Figure 14: Study Age Groups 50

Figure 15: NCD Cases-Service in Years 51

Figure 16: NCD Cases-Educational Status 51

Figure 17: NCD Cases-Family History 52

Figure 18: NCD Cases-Body Mass Index 52

Abbreviation Full Words

4. Scientific research and efforts to preserve food continued and when

its operational advantages. Huge amounts of canned foods were transported

5. The most important and well-known development in military feeding

7. There is reason to believe that chronic NCDs such as obesity, diabetes

11. To improve health of troops in Pakistan Army.

12. The objectives of the study are as under:-

b. To study the trends of hypertension, diabetes, and heart diseases

c. To compare the results with national and international studies.

d. To proffer recommendations accordingly for the introduction of a

14. A study conducted by Matthias B Schulze and colleagues focused on

17. A study conducted by Pasiakos and co-workers in 2013 concluded that

21. Praveen et al in 2019 highlighted the fact that there was an

22. A significant study done by Saleem Khawaja et al in 2011 suggested that

23. A milestone study comprising of a unique ‘Framingham-like’ cohort was

24. An important study published in Lancet in April 2019 by Afshin et al

25. The details are given below:-

a. Design. Cross-sectional study.

b. Setting. Hyderabad Cantonment.