Nutritional and dietary diversity status of under-5 children and adolescent girls among forcibly displaced Myanmar nationals living in Bhasan Char relocation camp, Bangladesh: a cross-sectional survey

STRENGTHS AND LIMITATIONS OF THIS STUDY

The study used validated methods to document the dietary diversity and nutritional status of one of the most vulnerable refugee groups, forcibly displaced Myanmar nationals living in Bhasan Char relocation camp of Bangladesh.

Chances of any variability in dietary diversity due to seasonality, political or socioeconomic changes are very low as data collection period was brief (1 week).

As we have measured dietary diversity using the 24-hour dietary recall method, it is possible that we could have missed documenting regular food consumption patterns of some of the participants.

Introduction

Rohingya people are one of the two major populations residing at Rakhine state of Myanmar.1 On 25 August 2017, they had to flee from the state as they were attacked and their villages were ruined by the Myanmar army.2 As a result, a series of humanitarian crises unfolded that led an unprecedented flow of refugees across the border to neighbouring Bangladesh. During the next few weeks, half a million Rohingya refugees entered Bangladesh seeking safety and shelter.2 At present around 890 000 Rohingya refugees are living in refugee camps in Cox’s Bazar. They are now termed as forcibly displaced Myanmar nationals (FDMN) to Bangladesh. Like other forcibly displaced refugees, FDMN also suffer from different forms of malnutrition. The reported prevalence of chronic undernutrition, global acute malnutrition and severe acute malnutrition among Rohingya children aged 6–59 months were 43%, 24% and 7.5%, respectively, in Kutupalong refugee camp of Cox’s Bazar.3 Not surprisingly, only 9.8% of them took minimally diversified diet.3 Leidman et al found that 20% of Rohingya children living in informal settlements in Cox’s Bazar district of Bangladesh were suffering from wasting and 48% of them were anaemic.4 A similar scenario should also be prevailing among adolescent FDMN girls as majority of the Rohingya families living in overcrowded refugee camps of Cox’s Bazar did not have access to good housing, safe drinking water, good sanitation system and blanket food assistance.5 6

Since October 2017, citing the issues of overcrowding, congestion and security in Cox’s Bazar, the Government of Bangladesh has been relocating FDMN to Bhasan Char. The relocation site is situated in Hatiya, an island at the end the Meghna River in the Bay of Bengal. The Bhasan Char relocation camp is hundreds of kilometres away from the current camps at Cox’s Bazar. Until, 17 698 FDMN have been relocated and of them 3997 are under-5 children, about 5000 are adolescent girls and 1016 are pregnant women. While efforts are ongoing to provide shelter and humanitarian supports to the relocated Rohingya population, humanitarian partners are raising concerns about the dietary and nutritional status of the relocated refugee population, especially under-5 children and adolescents. However, there is inadequacy of data regarding nutritional and dietary diversity status of these vulnerable population living at Bhasan Char relocation camp. Such lack of information is limiting the ability to design and adoption of appropriate nutrition programmes for them. We conducted a cross-sectional survey to generate baseline evidence on the nutritional and dietary diversity status of under-5 children and adolescent girls of FDMN community living at Bhasan Char relocation camp of Hatiya, Bangladesh.

MethodsDesign, setting, participants and data collection

The cross-sectional survey was conducted from 7 November 2021 to 12 November 2021. During the survey period, 17 698 FDMN were staying in 18 shelters of Bhasan Char relocation camp. Each shelter had 192 households. Around 5000 adolescent girls and 4000 under-5 children were living in these accommodations. We created a sampling frame that listed all the eligible households where at least one under-5 child or one adolescent girl was living. Participating households were selected randomly using computer generated random numbers. Only one participant from each of the households was interviewed. If any household had participants from both age groups, only one of them were recruited to the study. The response rate was 100%. All the participants we approached agreed to participate in the study. Sociodemographic information, dietary diversity status and anthropometry data (length/height, weight, mid–upper arm circumference (MUAC), head circumference) was collected from randomly selected 248 under-5 children (6–59 months) and 299 adolescent girls (11–17 years).

Trained field research assistants collected data using validated anthropometry tools and pretested survey questioners (online supplemental files 1,2). Age-specific WHO growth standards were used to define undernutrition using relevant anthropometric indices (body mass index (BMI)-for-age z-score, height/length-for-age z-score (HAZ), weight-for-age z-score (WAZ), weight-for-height/length z-score (WHZ) and MUAC. Pretested food frequency questionnaires were used to document the dietary intake status of the participants. Children who consumed at least four out of eight defined food groups during the preceding 24 hours of data collection were classified as having minimum dietary diversity (MDD).7 For adolescents, we followed Food and Agricultural Organisation guideline to calculate Women’s Dietary Diversity Score (WDDS).8 We collected data from the caregivers of the under-5 children. Families/participants who did not consent to take part and adolescent girls who were pregnant or were lactating during the survey period were excluded from the study.

Sample size calculation

We assumed 20% prevalence of global acute malnutrition (WHZ <−2) in children4 and 25% prevalence of underweight (BMI<18.5 kg/m2) in adolescent girls9. Using the above-mentioned proportion as assumed prevalence and using the formula for cross sectional study design (n= Z1-α/22 P (1−P) / d2, where Z1-a/2 = 1.96, precision, d=0.05 and proportion=P), our required minimum sample sizes for children and adolescent girls were 232 and 289, respectively, after adjusting for finite population correction. We collected data from 248 under-5 children and 299 adolescent girls.

Statistical analyses

We summarised the normally distributed variables as mean and standard deviation (SD), whereas median and interquartile range (IQR) were used for the variables with skewed distribution. Binary and categorical variables were presented as counts and percentages. Prevalence of different forms of nutritional and dietary intake status was reported along with 95% confidence interval (95% CI). The WDDS ranging from 0 to 9 was being used for measuring the dietary diversity status of the adolescent girls. We computed values for the dietary diversity variable by summing all nine food groups included in WDDS. As per the recommendation of FAO, we used the mean WDDS score for analysing the dietary intake data of adolescent girls. Descriptive findings of adolescents were split according to early (age group 11–14 years) and late (age group 15–17 years) adolescence. We conducted linear and logistic regression analyses to measure the association between nutritional status and dietary diversity. For under-5 children, the outcome variables were HAZ-score, WAZ-score, WHZ-score, stunting (yes/no), wasting (yes/no) and underweight (yes/no) and the predictor variable was MDD (present/absent) status. In adolescents, the outcome variables were BMI-for-age z-score, HAZ-score and MUAC values and the predictor variable was WDDS score. Statistical analyses were conducted in R (V.4.1.1).

Patient and public involvement

None.

Results

The mean age of the adolescent girls and the children were 13.66±1.73 (mean±SD) years and 28±13.82 (mean±SD) months, respectively. Households where our participants belonged had five to six family members and monthly income of the households ranged between BDT2500 and BDT3000 (US$30–US$35) only. All the participants used improved water (piped water on premises or other improved drinking water sources such as public taps or standpipes, tube wells or boreholes, protected dug wells) and improved sanitation (flush or pour-flush to piped sewer system, septic tank pit latrines, ventilated-improved pit latrines or pit latrines with slab or composting toilets) facilities. Two-thirds of the under-2 children were breastfed. Detailed descriptive characteristics of the participants can be found in table 1.

Table 1

Descriptive statistics of the participants

Table 2 describes the nutritional and dietary intake status of the adolescent participants according to their anthropometric indices and MUAC. When categorised by BMI-for-age z-score, we found that nearly 17% of the surveyed adolescents were suffering from severe (6.69% (95% CI 3.86 to 9.52%)) or moderate thinness (10.03% (95% CI 7.2 to 12.87%)), whereas nearly 5% of them were overweight (4.01% (95% CI 2.79 to 7.76%)) or obese (0.67% (95% CI 0.00 to 3.5%)). When nutritional status was categorised and stratified using MUAC and the respective prevalence was presented according to age groups, we found that severe thinness was more prevalent (2.02% (95% CI 0.84 to 4.77%)) in older adolescents (15–17 years old) than their younger (11–14 years old) counterparts (3.92% (95% CI 0.98 to 14.44%)). Overall, nearly 30% of the adolescents were suffering from either severe or moderate thinness. The prevalence of severe and moderate stunting in adolescents were 14% (95% CI 11.21 to 16.87%) and 29% (95% CI 25.93 to 31.59%), respectively.

Table 2

Nutritional and dietary intake status of the adolescent girls based on anthropometric indices and MUAC

Figure 1 presents the proportion of intake of different food groups by adolescent girls according to their nutritional status. Nearly all the adolescent girls (98% of 299) consumed starchy staples and 79% of them took dark green leafy vegetables. But very few of them took animal protein based diets (organ meat/egg/fish or milk and milk products). Proportion of adolescents who consumed vitamin A or iron rich foods were also low. On average, adolescents consumed 3.10 (1.03) (mean (SD)) groups of food out of 9 food groups during the preceding 24 hours. The distribution of dietary diversity did not show much variance over the nutritional status of the participants.

Figure 1Figure 1Figure 1

Proportion of intake of different food groups in adolescent girls according to the nutritional status. Nutritional status is categorised by BMI-for-age Z-score, height-for-age Z-score (HAZ score) and mid upper arm circumference (MUAC). BMI, body mass index.

Table 3 describes the nutritional and dietary intake status of the surveyed children. Among the surveyed under-5 children, nearly 32% were either severely (8.50% (95% CI 5.60-11.33%)) or moderately stunted (23.08% (95% CI 20.24-25.90%)), 27% were either severely (4.43% (95% CI 1.60-7.27%)) or moderately underweight (22.98% (95% CI 20.15-25.81%)) and 12% of them were suffering from severe wasting (1.21 (95% CI 0.00-4.04%)) or wasting (10.88 (95% CI 8.05-13.72%)). The prevalence of moderate acute malnutrition (MUAC 11.5–12.5 cm) in children was 8% and only two of the surveyed children were suffering from severe acute malnutrition.

Table 3

Nutritional and dietary intake status of the under-5 children (catagorised according to anthropometric indices)

Figure 2 presents the proportion of intake of different food groups by under-5 children according to their nutritional status. The diets of under-5 children were comprised of grains, roots and tubers, flesh foods, pulses, nuts and seeds, eggs and other fruits and vegetables. But the proportion of intake of carbohydrate-based diet was more than the intake of protein-based diets. Only 25% (95% CI 22.9728.64%) of under-5 children took minimum diversified (consumption of four or more food groups from the eight food groups) diet. To summarise, nearly all the children we surveyed consumed diets that were mainly carbohydrate based and poorly diversified, irrespective of their nutritional status.

Figure 2Figure 2Figure 2

Proportions of intake of different food groups in children according to the nutritional status. Nutritional status is categorised by height-for-age Z-score (HAZ score), weight-for-age Z-score (WAZ score), weight-for-height Z-score (WHZ score) and mid upper arm circumference (MUAC).

Figures 3 and 4 present the strength of association of anthropometric indices of adolescent girls and under-5 children to WDDS and the status of MDD, respectively. We found that none of the anthropometric indices were statistically significantly associated (p>0.05) to the predictor variables.

Figure 3Figure 3Figure 3

Regression coefficients (β) and p values of association of anthropometric indices (BMI for age z-score, height-for-age z-score (HAZ score), mid upper arm circumference, MUAC) of adolescent girls to Women’s Dietary Diversity Score. BMI, body mass index.

Figure 4Figure 4Figure 4

Regression coefficients (β) and p values of association of anthropometric indices (height-for-age z-score or HAZ score, weight-for-age z-score (WAZ) score, weight-for-height z-score (WHZ)-score) and nutritional status (stunting, wasting and underweight) of under-5 children to minimum dietary diversity status.

Discussion

We found that adolescent girls and under-5 children of the relocated FDMN community living in Bhasan Char relocation camp of Bangladesh were suffering from different forms of malnutrition. They mostly consumed poorly diversified carbohydrate-based diets.

Adolescence, the transition period from childhood to adulthood, is regarded as the last window of opportunity for building the foundation of healthy adulthood. Adolescent girls are future mothers. Any form of malnutrition during adolescence can give rise to inadequate weight gain, micronutrient deficiency during pregnancy and birth of an undernourished child in future. We found that one-third of the FDMN adolescents were suffering from severe thinness/thinness and nearly half of them were stunted. A recent record review of health status of Rohingya refugees in Bangladesh echoed our findings and reported the nutritional status of the Rohingya adolescent girls as poor.10 The prevalence of different forms of undernutrition among the surveyed Rohingya adolescent girls were higher than the adolescents from Bangladeshi Bengali community. According to Bangladesh Demographic and Health Survey 2017–2018, the prevalence of lower height (<145 cm) and thinness among Bengali adolescent girls were 11% and 25%, respectively.11

We also found that one in every 20 adolescents we surveyed were suffering from overweight/obesity. Presence of double burden of malnutrition is not unique to this refugee adolescent group. A study conducted among the adolescent Afghan refugees living in a refugee camp in Peshawar, Pakistan reported that the participants were suffering from stunting, thinness and overweight and obesity.12 Similar scenerio were found among the adolescents from Syrian refugee families living in Turkey and North Korean refugee families living in South Korea.13 14 Double burden of malnutrition can result in detrimental outcome in any impoverished community by increasing the burden of non-communicable diseases in future. We found that the diet of the adolescents was mostly comprised of carbohydrate-based foods. Inadequate dietary diversity is a cause of nutrient inadequacy and micronutrient deficiency, and intake of poorly diversified monotonous diets can result in double-burden of malnutrition.8 15 16 The presence of inadequate dietary diversity in the surveyed FDMN adolescents was ubiquitous as a large proportion of the adolescents from other communities living in South-Asian and South-East Asian countries also took carbohydrate-based foods.17–20

The prevalence of different forms of undernutrition among under-5 children was higher, at least in case of underweight and wasting, than the national estimate of the host country—Bangladesh. According to Bangladesh Demographic and Health Survey 2017–2018 report, the national prevalence of stunting, underweight and wasting was 31%, 22% and 8%, respectively.11 On the other hand, nearly 32% of the surveyed FDMN children were either severely stunted/stunted, 27% were severely underweight/underweight and 12% of them were suffering from severe wasting or wasting. In this sample of Rohingya children, the prevalence of global acute malnutrition (weight-for-height z-score <−2) exceeded the global emergency threshold of 10%.21 Studies done among other refugee groups echoed our findings. Among 178 Burmese refugee children from the Mae La camp in Thailand, approximately one-third were underweight, one-third were stunted and 8.7% were wasted.22 Another study done among the Syrian refugee children living in Zaatari camp in Jordan reported a higher prevelance of stunting compared to the children living outside the camp in the host community.23 Undernutrition in children, in both acute and chronic forms, is associated with morbidity and mortality, poor neurocognitive development, lower school achievement and reduced earning potential during adulthood. Moreover, intake of food with poor dietary diversity could lead to poor immunity and eventually that results in a morbid cycle of illness and malnutrition.24 Hence, instead of providing short-term nutrition support to the relocated FDMN children and adolescent girls of Bhasan Char, a nutrition-specific approach should be taken by ensuring promptly initiated exclusive breast feeding for newborns, and introduction of nutritious and diverse foods for children and adolescents. In addition, blanket coverage of micronutrient supplementation should be considered.

This is the first survey that documents the nutritional and dietary diversity status of under-5 children and adolescent girls among FDMN who were relocated to Bhasan Char camps from Cox’s Bazar of Bangladesh. We used validated methods to document the dietary diversity and nutritional status of the study participants. Data collection period for this study was very brief (1 week). Hence, chances of any variability in dietary diversity due to seasonality, political or socioeconomic changes are very low. However, as we have measured dietary diversity using the 24-hour dietary recall questionnaire, it is possible that we could have missed documenting regular food consumption patterns of some of the participants.

Conclusion

Different forms of malnutrition were prevalent in different proportions in the under-5 children and adolescent girls of relocated FDMN living in Bhasan Char of Bangladesh. Nearly all the participants we surveyed had carbohydrate-based poorly diversified diets. The results of the survey could help policy makers to design appropriate nutrition programmes for the relocated FDMN. Such nutrition programmes should also consider distributing diversified and micronutrient fortified rations to the FDMN families living in the relocation camps of Bhasan Char of Hatiya, Bangladesh.

Data availability statement

Data are available on reasonable request.

Ethics statementsPatient consent for publicationEthics approval

This study involves human participants and was approved by Institutional review Board, icddr,b (reference no. PR-21130). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

icddr,b acknowledges with gratitude the commitment of sida to its research efforts. icddr,b is also grateful to the Governments of Bangladesh, Canada, Sweden and the UK for providing core/unrestricted support. We thank the forcibly displaced Myanmar national families of Bhasan Char relocation camp of Bangladesh for sharing their information with us.

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