Nutritional Status of Reproductive Ethnic Woman Living in Chittagong Hill Tracts of Bangladesh: Influence of Socio-economic and Nutritional Factors

An ethnic group is a socially defined category of population who recognize with one another based on common ancestral, social, cultural or national experience. They tend to segment themselves with a different origin, cultural heritage, history, language, ideology, religion and ritual ¹. Bangladesh has been culturally enriched by the colourful lifestyle of different ethnic people. Around 44.4 % of ethnic population lived in three hilly districts of Chittagong Hill Tracts (CHTs) with eleven ethnic multi-lingual minorities (e.g. Bawm, Chak, Chakma, Khyang, Khumi, Lushai, Marma, Mro, Pangkhua, Tangchangya, and Tripura). Ethnic minorities or tribal communities possess distinct culture, language, religion, cuisine, dressing style, physical appearance and even landscape from the main land population ^{1, 2}.

In an women`s life reproductive age is identified as those child bearing years between menarche and menopause, roughly from ages 15 to 44 years. The term is imprecise, since some women can become pregnant and bear children at younger or older ages ³. This is one of the most vulnerable group in term of health and nutrition related issues. Blood loss during periods and delivery, extra nutritional requirements during pregnancy and lactation makes this age group a prime concern of any nation. Nutritional status is the current physical status of a person or a group of people in relation to their state of nourishment. Good nutritional status is considered as a reflection of superior standard of living and both social and nutritional awareness, it is not only a determinant but also an outcome of development. Anthropometry is the measurement of body height, weight and proportions of an individual and an efficient indicator of nutritional status ⁴.Previous studies ^{5, 6, 7, 8, 9} on ethnic people of Chittagong Hill Tracts were documented as malnourished, poor, uneducated and underprivileged because of their limited earning and employment opportunities, poverty, unhygienic housing and water sources, limited access to education and other necessary social and health services, most of which are almost two decades earlier. Nutritional status of ethnic reproductive women (15-40 years) in Chittagong Hill Tracts is not properly addressed yet in the context of present uprising economy of Bangladesh. Positive changes in socio-economic status (SES) could influence the nutritional status as well as food security. The aim of this study was to assess the prevalence of nutritional status of lactating (LW) and non-pregnant non-lactating women (NPNLW) of the CHTs and to find out the impact of their present socio-economic condition and different nutritional factors (e.g. food security, dietary calorie intake and nutritional knowledge) on nutritional status of the two groups of reproductive women.

It was a cross sectional study, conducted among the ethnic communities of both the urban and rural areas of Bandarban, khagrachori and Rangamati of the CHTs between the year 2013-2014. A total of 171 participants (85 lactating and 86 Non-pregnant non-lactating) were selected from 156 households as study sample to determine the nutritional status. Verbal permissions and written consent were taken prior the study. Study was approved by the ethical review board of the Biological Science, University of Dhaka. A well semi-structured questionnaire was developed and documented to record data on socio-demographic variables (e.g. age, educational attainments, occupation, marital status and income etc.) and nutritional variables (e.g. food security, dietary calorie intake and nutritional knowledge). ‘Nutritional status’ was assessed by the anthropometric measurements such as height, weight and mid-upper-arm circumference (MUAC) ^{10, 11, 12}. The weight and height were measured by using digital ‘weight scale’ and manual ‘Height Scale’ respectively. Body Max Index (BMI kg/m²) was computed using the standard equation: BMI =Weight (kg) / height (m²) ^{11, 12}. MUAC tapes were used to measure MUAC to the nearest 0.1 cm. MUAC cut off point (22.4 cm) was applied for evaluating nutritional status ^{4, 12}.

‘Food security’ was measured using a set of questions addressing debt situation of the family ¹³. ‘Calorie intake and dietary patterns’ were assessed using a pretested food frequency questionnaire (FFQ) and one day 24-hour dietary recall. A set of standard measuring cups were used to estimate the quantity of food being consumed (serving size in grams). This method is used widely to compare nutrient intakes with specific dietary recommendations. Food conversion factors ¹⁴ were used to convert cooked food weight to raw food weight. Nutrients values were calculated per 100 g of raw food consumed by using the food composition database for Bangladesh ^{15, 16}. Dietary calorie intake was compared with standard RDA value to obtain dietary adequacy ¹⁷. ‘Nutritional knowledge’ score was assessed by another set of questionnaire comprising 45 questions about nutrition (food groups, balanced diet, nutrient rich foods, nutritional diseases, food habit etc.) bearing one point for each right answer and zero for each wrong answer.

In socio-demographic profile (table 1), Most (44.4%) of the tribal women were Marma, followed by Chakma (39.8%), Bam (8.2%) and Tripura (5.8%). Mean age of lactating women (LW) and non-pregnant-non- lactating women (NPNLW) was 26 y and 28 y respectively (P=.567) and vast majority of women of both groups were between 18-40 years old. It was also observed that most of LW (76.5%) and NPNLW (66.3%) were literate, married (91.3%), mainly involved in household chores (78.4%). Maximum families (87.0% -89.5%) of the two women groups (P=.530) earned more than 6000 BDT per month, and majority (86%-87%) were reported to be food secured throughout the year. Mean Dietary calorie intake (2631±798) of both groups were up to the mark according to the recommended dietary allowances (RDAs) and vast majority (80.3%-86%) of them also possessed good nutritional knowledge. However, no significant (P>0.05) differences were observed in dietary calorie intake (2731 vs. 2531 kcal) and nutritional knowledge score (33.8 vs. 35.4) between two women groups.

Table 2 compared the anthropometric indices of the two women groups, no significant differences (P>0.05) were observed between mean BMI (22.1 vs. 22.6 Kg/m²) of the two groups. Overall, majority (68.4%) of women were in normal status (BMI 22.3±3.9 Kg/m²), 11.7% found to be underweight (BMI<18.5 Kg/m²) and 19.9% were overweight (BMI ≥25.0 Kg/m²). According to MUAC measurements, 87.2% participants had the MUAC ≥22.4 cm and were considered to have normal weight.

  Table 3 demonstrates the relationship of nutritional status (categories of BMI Kg/m²) of ethnic people with their socio-economic variables, food security, dietary calorie intakes and nutritional knowledge. It was noticed that better nutritional status of lactating and NPNL women were significantly associated with literacy (P<0.05), occupancy in household chores (P<0.05), better income (P<0.05), food security (P<0.05), recommended calorie intake level (P<0.05) and better nutritional knowledge score (P<0.05). Association of nutritional status with age and marital status of LW could not be established as cell values of both ‘15-17 age group’ and ‘unmarried status’ were zero. However, no significant association of Age and marital status with nutritional status of NPNL women was found (P>0.05).

This study postulates that overall 68.4% ethnic reproductive women had normal BMI (18.5-24.99 kg/m²), 11.7% were thin or having Chronic Energy Deficiency (CED) (BMI <18.5 kg/m²) and 19.9% were overweight (BMI ≥ 25 kg/m²). The average dietary calorie intake (2631 kcal) and normal BMI (22.3 ± 3.9 kg/m²) of ethnic LW and NPNLW of this study indicate better socio-economic profile, food security and quality dietary, educational attainment of ethnic participants than previous records ^{6, 7, 8, 9} which collectively upgrade the nutritional status of these women groups. This results are somewhat similar with other studies ^{18, 19}. Study ¹⁸ conducted by Haque and Akhter(2014)among both the male and female members of ethnic communities in CHTs showed better nutritional status of ethnic minorities where prevalence of underweight, normal weight and overweight was 4.7%, 78%, and 17.3% respectively, while previous ‘Nutrition and Health Surveillance in the Chittagong Hill Tracts, 2000’ conducted by Helen Keller International (HKI) ⁵ observed that chronic energy deficiency among Non-pregnant women was 27%. Other dietary factors (data were not shown) those contribute for better nutritional status of these women groups could be their more intake (56.0-63.7%) of green leafy vegetables (GLVs) and non-leafy vegetables (50.3% -59.1%) especially at lunch and milk consumption (17-21.1%) than Bengalese. However, their meat (1.8-8.8%) and fruit (0.6-3.5%) consumption was poor and their rice consumption patterns are similar to Bengalese. Prevalence of common non-communicable diseases was very low in CHTs ethnic community than Bengalese.

This study showed mean family income was 18,822.2 BDT and majority (86%-87%) were reported to be food secured throughout the year and only 13.5% were food insecure occasionally which are also reflected in Nutrition, Health, Demographic Survey, Bangladesh (2013)¹⁹ where higher mean family income documented for CHTs that exceeded the national average household income and expenditure. This is also indicating a major alleviation of living standards of the ethnic people in the CHTs. However, two decades earlier study ⁶ indicated that 77.25% ethnic households were not food secured and Barakat et al (2009) ⁷ showed monthly family income and expenditure of ethnic people were 5,200 and 4,750 BDT respectively.

Globally a large number of studies ^{20, 21, 22, 23, 24, 25, 26} addressed tribal community, asserted that they are at the lowest stratum of the society due to geographical and cultural isolation, low levels of literacy, multiplicity of the language, high levels of poverty etc. Neighbouring country India where almost half of the world’s tribal population (called scheduled tribe) resided ²⁰ and majority of the studies ^{20, 21, 22, 23, 24, 25, 26} conducted in India reported that the socioeconomic and nutritional status (both anthropometric and dietary) of these ethnic minorities were not up to the mark and worse nutritional situation prevails than ours. Nutritional knowledge of the tribes was reported also unsatisfactory than ours ²⁰.

Over many years, the ethnic people of Chittagong Hill Tracts had suffered from a lot of political (25 years of civil war, which formally ended in 1997 with the signing of a peace accord with Government of Bangladesh), economic and social problems. Post war, area’s remoteness, poor communication and unique socio-economic characteristics, multiplicity of languages have made it difficult to provide basic social services to inhabitants of the CHTs. Thus, CHTs had largely been excluded from mainstream development programmes in Bangladesh. Access to the CHTs was especially challenging for international staff ²⁷. Earlier studies ^{5, 6, 7, 8, 9} on ethnic people of Chittagong Hill Tracts were documented as poor, malnourished, underprivileged, neglected, food unsecured, deprived from basic needs, no health services and job opportunities, and mostly (64%) lived in lower socio economic standards by Jhum cultivation (primitive techniques by burning the trees which made lands infertile and imbalanced the eco-system and created huge environmental damages) followed by agriculture labor (12.5 %).

Previously literacy rate in the CHTs was also lower than that national level and seven out of every ten women in the CHTs were illiterate. Earlier survey ⁷ reported that 54.5% of the ethnic household heads had no formal education and 53.9% of the ethnic people were illiterate. But in the last couple of years this scenario has been changed, which also reflected in this study and showed 71.5% literacy rate, more than half (57.3%) of which completed secondary education. Compared to previous surveys ⁷, an acceleration of literacy rate is seen in another study ¹⁸ among ethnic people of the CHTs that showed 63.3% literacy rate. This increased literacy could be the outcomes of various projects and services like – provision of new schools, mother language based multi lingual pre-primary education and new recruitment and training of teachers provided for ethnic people in the CHTs by local, national and international NGOs.

For many years various development projects ^{27, 28, 29, 30, 31, 32, 33} being run by either government or local or international NGOs to accelerate the lifestyle pattern of ethnic communities in the Chittagong Hill Tracts, which also reflected through their current better nutritional status in present study. Different development programmes were running during data collection and every ethnic household in the CHTs is currently under some kind of development project conducted by either local NGOs or international NGOs. Thus the road of progress was slow and difficult for these ethnic people but gradually these developmental projects and programs had helped ethnic communities of CHTs to upgrade their socio-economic status, offered them an improved living standards (quality education, quota facilities both in higher education and government jobs, various job opportunities, better health care facilities, freedom of expression). The improvement in standard of living of the ethnic people of CHTs is more or less evident and obvious. Thus, comparing previous records, a conclusion can be made that there has been an increasing trend in improving the nutritional status of the ethnic reproductive women of CHTs over the decades.

Ethnic people are in a better nutritional status than reported before. Prevalence of chronic energy deficiency are lower than that of overweight in both groups. Upgraded socio-demographic status in CHTs ensured better nutritional status. Economic stability, high literacy rate, food security, adequate food intakes and proper nutrition knowledge appears to be the important fundamental factors responsible for better nutritional status of the ethnic reproductive women in Chittagong Hill Tracts.

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