Micronutrient Survey 2019-20

FINAL REPORT (DRAFT VERSION)
DATE OF SUBMISSION: 31.10.2021
National Micronutrient Survey in

Bangladesh 2019-2020
Principal Investigator: Dr. Aliya Naheed
Scientist & Health Systems Specialist

Head, Initiative for Noncommunicable Diseases
Health System and Population Studies Division
Survey organization: icddr,b
Funding
Global Alliance for Improved Nutrition (GAIN), Bangladesh
Nutrition International, Bangladesh
Institute of Public Health Nutrition,

National Nutrition Services, Mohakhali, Dhaka
Directorate General of Health Services
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Contents
Executive Summary ........................................................................................................................ 8
Chapter 1 ....................................................................................................................................... 10
Introduction ................................................................................................................................... 10
1.1 Background and rational ..................................................................................................... 10
1.2 Micronutrient deficiency in Bangladesh ............................................................................. 10
1.3 Consequences of MDs ........................................................................................................ 11
1.4 Current national programs to address micronutrient deficiencies in Bangladesh............... 15
1.5 Knowledge gap ................................................................................................................... 18
1.6 Objectives ........................................................................................................................... 20
1.6.1. Primary Objective ....................................................................................................... 20
1.7 Outcome parameters ........................................................................................................... 20
Chapter 2 ....................................................................................................................................... 21
Methodology ............................................................................................................................. 21
2.1 Research Design and Methods ............................................................................................ 21
2.1.1. Study design ................................................................................................................ 21
2.1.2. Study settings .............................................................................................................. 21
2.1.3. Study population ......................................................................................................... 21
2.1.4. Inclusion criteria ......................................................................................................... 22
2.1.5 Sample size calculation ................................................................................................ 23
2.1.6 Estimation of the numbers of households and PSUs required for the national survey 25
2.1.7 Sampling Weight ......................................................................................................... 26
2.1. 8. Sampling procedures .................................................................................................. 29
2.1.9 Selection of the study participants ............................................................................... 31
2.2 Study period .................................................................................................................... 31
2.3 Staff Training ...................................................................................................................... 33
2.4 Field set up .......................................................................................................................... 33
2.5 Data collection procedures .................................................................................................. 34
2.6 Biological sample collection, preparation, transport and storage .................................. 36
2.8 Processing of blood and urine samples in laboratory ......................................................... 37
2.10 Quality assurance .............................................................................................................. 42
2.11 Data Management and Data Analysis ............................................................................... 43
2.12 Ethical Assurance for Protection of Human rights ........................................................... 44
2.13 Technical Advisory Group ................................................................................................ 45
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3.5 Field survey......................................................................................................................... 48
Chapter 4 ....................................................................................................................................... 53
Results ....................................................................................................................................... 53
3.1.3 Household characteristics ................................................................................................ 55
3.1.4 Multidimensional Poverty Index (MPI) ........................................................................... 55
Food insecurity.......................................................................................................................... 57
4.3 Micronutrient deficiencies .................................................................................................. 58
Chapter 5 ....................................................................................................................................... 80
Multiple micronutrient deficiencies .......................................................................................... 80
Chapter 6 ....................................................................................................................................... 82
Dietary diversity........................................................................................................................ 82
Chapter 7 ....................................................................................................................................... 86
Vitamin and mineral supplementation coverage....................................................................... 86
Chapter 8 ....................................................................................................................................... 87
Food fortification ...................................................................................................................... 87
1.2 Household coverage of food vehicles ..................................................................... 88
Chapter 9 ....................................................................................................................................... 92
Challenges and barriers ............................................................................................................. 92
Chapter 10 ..................................................................................................................................... 94
Discussion ................................................................................................................................. 94
Public health importance............................................................................................................. 100
Conclusion .................................................................................................................................. 100
Recommendation ........................................................................................................................ 101
Chapter 10 ................................................................................................................................... 102
Reference .................................................................................................................................... 102
List of Tables
Table 1: Sample size for the children (6-59 months), adult NPNL women (15-49 years)
(Details procedures) .................................................................................................................... 24
Table2: Timeline of the activities............................................................................................... 32
Table 3. Blood Tests for micronutrient deficiency at the different population groups ................ 39
Table 4.Cut off point for micronutrient deficiency assessment ................................................... 40
Table 5: List of Technical Advisory Group (TAG) members ..................................................... 46
Table 6.Recruitment of the study participants. ............................................................................ 53
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List of Figures
Figure 1. Sampling procedure flowchart

Figure 1- Prevalence of vitamin A deficiency in children age 6-59 month by place of
residence
Figure 2: Distribution of vitamin A deficiency by divisions
Figure 3: Prevalence of Vitamin A deficiency among NPNL women (15-49 years) by area of
residence
Figure 4: Distribution of Vitamin A deficiency among NPNL women (15-49 years) by
divisions
Figure 5: Prevalence Vitamin D deficiency in children age 6-59 month by place of residence
Figure 6: Distribution of Vitamin D deficiency in children age 6-59 month by divisions
Figure 7.1 Prevalence of vitamin D deficiency among NPNL women by place of residence
Figure 7.2- Prevalence of vitamin D deficiency in NPNL women by classifying insufficient
and deficieny
Figure 8- Prevalence of vitamin D deficiency in NPNL women by division
Figure 9: Prevalence of iron deficiency of children aged 6-59 months by place of residence
Figure 10: Distribution of iron deficiency of children aged 6-59 months by place of residence
Figure 11: Iron deficiency of NPNL women by division
Figure 12: Distribution of Iron deficiency in Women (15-49 years) by divisions
Figure 13. Prevalence of Zinc deficiency among children age 6-59 months
Figure 14. Distribution of zinc deficiency status in children aged 6-59 month by division
Figure 15 Zinc deficiency of NPNL women aged 15-49 years by area division
Figure16. Distribution of Zinc deficiency among non-pregnant and non-lactating women by
division
Figure 17: Prevalence of Anaemia in children age 6-59 month by place of residence
Figure 17.a Prevalence of mild to severe anaemia by place of residence
Figure 18: Distribution of Anaemia in children age 6-59 month by place of residence
Figure 19.1. Overall prevalence of anaemia among NPNL women
Figure 19 Prevalence of mild to severe anaemia in NPNL women by division
Figure 20: Distribution of Anaemia in NPNL women by divisions
Figure 21 Prevalence of Iodine deficiency in children age 6-59 month by area place of
residence
Figure 22- Distribution of Iodine deficiency in children age 6-59 month divisions
Figure 23- Prevalence of Iodine deficiency in NPNL (15-49 years) women by place of
residence
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Figure 24- Distribution of Iodine deficiency in NPNL women by divisions
Figure 25: Prevalence of Vitamin B12 deficiency in Women (15-49 years) by place of
residence
Figure 26: Distribution of Vitamin B12 deficiency in Women (15-49 years) by divisions
Figure 27- Prevalence of Folate deficiency in NPNL women by division
Figure 1.Sampling procedure flowchart....................................................................................... 30
Acronyms and Abbreviations
BBS Bangladesh Bureau of Statistics
BMI Body Mass Index
CAP College of American Pathologists
EA Enumeration area
ERC Ethical Review Committee
FACT Fortification assessment coverage toolkit
FR Fortified Rice
GOB Government of Bangladesh
HNPSP Health, Nutrition and Population Sector Programme
HPLC high performance liquid chromatography
IDD Iodine Deficiency Disorder
IFA Iron-folic acid
INFS Institute of nutrition and food science
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IPHN Institute of public health nutrition
IYCF Infant and Young Child Feeding
LDL low-density lipoprotein
MD Micronutrient deficiencies
MDD Minimum dietary diversity
MICS Multiple indicator cluster survey
MMQAP Micronutrient Measurement Quality Assurance Program
MNP Micronutrient power
MOHFW Ministry of Health and Family Welfare
NBL Nutritional Biochemistry Laboratory
NFP National food policy
NIST National Institute of Standards and Technology
NNS National Nutrition Service
NPNL Non-pregnant and Non-lactating
NVAC+ National Vitamin A plus Campaign
PPS Probability proportional to size
PSU Primary sampling unit
RP-HPLC Reverse-phase high-pressure liquid chromatography
RRC Research Review Committee
SOP Standard operating procedures
SUZY Scaling up Zinc for young children
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VGF Vulnerable Group Feeding
VGD Vulnerable Group Development
VITAL-EQA Vitamin A Laboratory – External Quality Assurance
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Executive Summary
The primary objective of National Micronuteient Survey in Bangladesh, 2019-2020was to estimate
the status of vitamin A, Vitamin D, Zinc, Ferritin, Urinary Iodine and anaemia among under-5
children and Non-pregnant and non-lactating (NPNL) women of reproductive age (15-49 years).
Additionally, to assess Vitamin B12 and Folate in NPNL women.
The secondary objectives of the study were to, (i) estimate the prevalence of micronutrient
deficiency across different sociodemographic factors; (ii) assess dietary diversity and food
frequency at the households, (iii) estimate the coverage of national supplementation programmes
and fortifiable food vehicles (salt, oil and rice) at the household level; (iv) estimate the daily
consumption of fortifiable oil, salt and rice by under-5 children and NPNL women and (v) measure
knowledge of vitamin, minerals and fortification among NPNL women.
For this survey,250 clusters (8 households/ cluster) were randomly selected from the primary
sampling unit of each district of eight divisions developed by Bangladesh Bureau of Statistics
using the list of the Multiple Indicator Cluster Survey (MICS) conducted in 2018 nationwide.
These 250 clusters are expected to cover 6,558 households to include 1,000 NPNL women (15-49
years) and 1,000 under-5 children (6-59 months). A team of 20 staff led by a Team Lead includes
9 data collectors, three phlebotomist and 3 field assistants are conducting the survey.
Biological samples were being obtained at the household level from the study participants
following a written voluntary consent. From NPNL women, 7 ml blood and from under-5 children
5 ml blood is being collected to assess all biomarkers. From the blood collected in the field setting,
2 ml of whole blood is separated in EDTA containing tube in to two aliquots. The first aliquot with
0.5 ml blood is being used for Hb% analysis and the other aliqoutwas being stored for future PCR
based Thalassemia diagnostic tests, which will be done following availability of funding
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requested to WHO. The remaining blood (5 mL for NPNL women and 3 mL for under-5 children
respectively) is centrifuged and aliquoted in trace element free cryovials (pre-labelled). Three
aliquots are being separated from the serum following centrifugation; one aliquot of ~250μl has
been used for analysis of Zinc, one aliquot of 800μl is being used for analysis of micronutrients
including Vitamin A, vitamin B12, Ferritin, Folate, Vitamin D, and one aliquot was being stored
for future analysis of cardiometabolic risk factors, infection markers and genomic studies for
which we will have to apply different funders for obtaining support.
Urine samples were being collected from all the participants and stored in a separate cryovial for
urinary Iodine assessment. Collected samples are being temporarily stored in - 20°C freezer at the
sub-center in field setting. All samples are being processed and stored in Nutritional Biochemistry
Lab in icddr,b, Dhaka following the standard laboratory guidelines (followed by icddr, b as
described below). Lab assays are being performed in batches by the lab team.
The National Micronutrient Survey, 2019-2020 was planned for initiation in March 2020. Due to
the emergence of COVID-19 pandemic the full operation was put on to hold till September 2020.
Following approval of resumption to field activities from icddr,b in October 2020, we started the
survey in one out of 8 divisions. Between 10th October and 4th April ,2020 the survey team
completed data collection from 6 divisions including Sylhet, Rajshahi, Rangpur Chattagram,
Khulna and Barisal division. Due to surge of COVID-19 cases and movement restriction
declaration by the Government the field team had to stop their field activities. The survey has
started in 7th division (Mymensingh) after relaxation of movement restriction on 30th May and
expected to be completed by 12th June We have obtained data and samples from 676 under-5
children and 676NPNL from 6 divisions. and laboratory assessment of samples are ongoing in the
Nutrition Biochemistry Lab of icddr, b.
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Chapter 1
Introduction
1.1 Background and rational
Vitamin and mineral deficiencies adversely affect a third of the world’s people of all ages (1).
Micronutrient deficiencies (MD) are one of the greatest public health and socioeconomic concern
that affect more than 2 billion people worldwide (2-4). People of low and middle-income countries
suffer more due to limited food diversity, poor bioavailability and limited micronutrient content
and poor hygiene(4, 5). Approximately one million children die due to micronutrient deficiencies
especially from vitamin A and zinc deficiency whereas iron deficiency causes 115 000 maternal
deaths per year(6). MD is high among children, pregnant and lactating women in India, Pakistan,
Sri Lanka, and Nepal (7-9). In 2011, a cross-sectional survey conducted in India reported that the
prevalence of vitamin D deficiency is 84% in pregnant women, and a community-based study
conducted in Sri Lanka in 2012 reported that 26% of male children havevitamin D deficiency (10,
11). MDs have been observed in obese individuals in many parts of the world, which may attribute
to impaired immune systems and increase the risk of co-morbidities (12-14).
1.2 Micronutrient deficiency in Bangladesh

(Vitamin A, Vitamin B12, Vitamin D, Vitamin E, Zinc, Folate an iron deficiency anaemia)
According to the national micronutrient survey conducted in 2011-2012, the overall prevalence of
vitamin A deficiency in rural areas was 19.4% and 21.2% in the urban areas. The prevalence of
vitamin A deficiency was 20% among children less than 5 years of age and adolescents, and 5.4%
amongNon-pregnant and Non-lactating (NPNL) women (15).Another study among Bangladeshi
children reported that nearly 50% of children and adolescents had vitamin D deficiency (16). One
studyconducted in female garments workers reported that 86% of the female garmentworkershad
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a Vitamin D level lower than the recommended cut off or hypovitaminosis D (serum levels below
50 nmol/L) and 16% were vitamin D deficient (serum levels below 25 nmol/L(17).
The overall prevalence of vitamin B12 is 21.5% in rural areas and 23.5% in urban areas
inBangladesh (3). A population-based study in rural area in Bangladesh revealed that near about
46% of pregnant women has vitamin B12 deficiency (3, 18) and another community-based study
reported that 31% of infants suffer from vitamin B12 deficiency (3, 19). However, the national
micronutrient survey conductedin 2011-2012 showed that 22% of the women suffered from
vitamin B12 deficiency (20). The prevalence of zinc deficiency in the urban areas 29.5% and 48.6%
in the rural areas. The prevalence of zinc deficiency(serum zinc < 9.9 mmol/Lin preschool children
and < 10.1 mmol/L in NPNL women) was 44.6% among preschool children and 57% among non-
pregnant women of reproductive age group(21).
The overall prevalence of iron deficiency was 10.7% among the preschool children and 7.1%
among NPNL. Anaemia is one of the biggest public health issues of this country; the prevalence
is around 33.1% in case of preschool children, 26% of NPNL women and 17.0% school going
children (12-14 years). On the other hand, around 7.2% preschool children and 4.8% NPNL
women had iron deficiency anaemia. A study conducted in the rural settings of Bangladesh
revealed that around 27% of the pregnant women had iron deficiency (serum Ferritin level <15.0
ng/ml in NPNL women and <12.0 ng/ml in preschool children, WHO 2012) and 13.4% of them
are suffering from iron deficiency anaemia (22).
1.3 Consequences of MDs
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Vitamin A is defined by low serum retinol (<0.7 mmol/l), an essential micronutrient which is
required for vision, eye health and immune function and highly prevalent in egg yolk; fish liver,
green leafy vegetables, yellow fruits, red palm oil etc. (23). Several studies showed that vitamin A
deficiency causes night blindness in children, adolescent, adults and pregnant women(24-26).
A systematic review has reported that vitamin A deficiencies plays an important role in regulating
body weight and low concentration of serum retinol in overweight and obese people (12, 29, 30).
A case-control study among overweight and obese adult population in Thailand reported a negative
correlation between serum retinol concentration and BMI (31). However poor household expenses,
lack of knowledge, low bioavailability and food insecurity are some of the risk factors of vitamin
A deficiency(32). National micronutrient survey 2011-2012 revealed that slum population had
higher prevalence of vitamin A deficiency than the non-slum urban residents (15).
Vitamin D deficiency is defined as 25-hydroxyvitamin D level of less than 50 nmol per litre which
is equal to 20 ng/ml(16, 29).The major source of vitamin D is sunlight exposure(33-37) but it may
also be found in some food such as milk, fish (salmon, mackerel, and herring) and oils from fish,
including cod liver oil etc. (37). Poor dietary intake of vitamin D rich food, urbanisation, covered
clothing, limited outdoor exposure, modern life style, lack of knowledge etc are the main risk
factors of vitamin D deficiency (32, 38). A hospital-based study among pregnant Bangladeshi
women reported a positive correlation between vitamin D deficiency and preeclampsia and
eclampsia (39).
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Vitamin D deficiency causes rickets in children and in adults. Some other impact of vitamin D
deficiency includes secondary hyperthyroidism, decreased calcium absorption and bone
abnormalities(37, 38). A study conducted among American children and adolescents reported that
individuals with lower circulating 25(OH)D levels had higher risks of recent upper respiratory
tract infection symptoms(40). A high prevalence of hypovitaminosis D and vitamin D deficiency
have been reported among obese or overweight children and adolescents(41). Obesity is
considered to be the most important factor in the development of metabolic diseases, and both of
low and high BMI in childhood impact on overweight, obesity and chronic diseases in adulthood
(42).
A systematic review of prospective cohort studies reported that vitamin D deficiency have impact
on development of cardiometabolic risk factors such as obesity, hypertension, cardiovascular
disease, diabetes mellitus, metabolic syndrome, and cancer(43-45). A meta-analysis of cohort and
case-control studies reported that low concentrations of 25-hydroxyvitamin D [25(OH)D] are
robustly associated with increased risk of type 2 diabetes irrespective of population level of
adjustment, or study design(46). Vitamin D plays a pivotal role in calcium metabolism, and
deficiencyof vitamin Dmay be associated with a range of serious diseases, including cancer,
cardiovascular disease, and type 2 diabetes(47).
Vitamin B12 also known as cobalaminis rich in meat, egg, milk related food, and plays an important
role in cellular growth, development and normal functioning of brain and nervous systems (48,
49).Poor dietary intake, food insecurity, low socio-economic status etc. are some of the factors
causing vitamin B12 deficiency(32).Several studies have reported that vitamin B12 deficiency is
13
related to anaemia, dementia and cognitive dysfunction(50, 51). Vitamin B12deficiency during
pregnancy is considered to be a risk factor of neural tube defect(52, 53). It has a positive
association with infertility, preeclampsia and early pregnancy loss (54-56). A study in South India
reported that high intake of vitamin B12 during pregnancy is associated with low gestational age in
new born(57).
A systematic review reported that the major outcomes of zinc deficiency are growth retardation,
cognitive impairment, low birth weight, pregnancy induced hypertension, postpartum
haemorrhage, prolonged labour and increased risk of abortion and stillbirths(59,60).Community
based supplementation trial reported that zinc supplementation produced highly significant,
positive responses in height and weight increments(61). A meta-analysis reported that the effects
of zinc supplementation in patients with diabetes has beneficial effects on glycemic control and
promotes healthy lipid parameters(62). Zinc supplementation has favourable effects on plasma
lipid parameters and it also significantly reduces total cholesterol, low-density lipoprotein (LDL)
cholesterol and triglycerides(63).
Iron deficiency anaemia during pregnancy harmfully affects maternal health, and is correlated with
increased morbidity and foetal death, while mothers with iron deficiency frequently experience
breathing difficulties, fainting, tiredness, palpitations, and sleep difficulties (64). A systematic
review reported that iron deficiency during the first trimester has a more negative impact on foetal
growth than anaemia developing later in pregnancy(65).
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1.4 Current national programs to address micronutrient deficiencies in Bangladesh
The Government of Bangladesh (GoB) has developed a national strategic plan 2015-2025 to
address micronutrient deficiencies as an important agenda of the VISION 2021. Since 2001, the
National Vitamin A plus Campaign (NVAC+) has been implemented among children6 to 59
months of age(28). Infant and Young Child Feeding (IYCF) Strategy 2007 aims to improve
breastfeeding status from birth to six months of age (IPHN 2007). In 1995, the GoB started
postpartum supplementation policy to provide single dose of vitamin A to all post-partum women
within two weeks of delivery.
The government has implemented iron-folic acid (IFA) supplementation programme for pregnant
women as a part of the antenatal care services (68). According to this policy, all pregnant women
are to be provided with IFA supplements with a daily dose of 60 mg of elemental iron and 400µg
folic acid throughout pregnancy and until 90 days after delivery. Currently, there is no intervention
program for IFA supplementation for NPNL women. However, the current National Nutrition
Service (NNS) programme does recommend weekly IFA supplementation for adolescent girls,
with a dose of two tablets, each having 60 mg elemental iron and 400 μg folic acid.It was also
observed that IFA supplementation could avert over 15,000 deaths and 30,000 cases of preterm
birth annually in Bangladesh assuming 100% coverage and adherence. The estimated the cost per
death averted has been US$175–185 in Bangladesh (70).
The Ministry of Health and Family Welfare (MOHFW) has developed and approved the National
Strategy for Prevention and Control of Anaemia in 2007. The government has initiated anaemia
control programme for children aged 6 to 59 months of age. To combat anaemia, the government
has recommended the use of micronutrient power (MNP) for children 6 to 23 months of
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age(IPHN,2015)(69). This programme does not provide any interventions to prevent and control
anaemia among children less than five years of age, and adolescent girls and NPNL women are
not included in nationwide efforts (69). The Institute of Public Health Nutrition (IPHN) under the
MOHFW is implementing nutritional programmes including Behavior Change Communication
(BCC), Control of Vitamin-A deficiency disorder by Vitamin A supplementation, Control &
prevention of Anaemia by Iron folate supplementation, Control of Iodine deficiency
Disorder Control of Iodine Deficiency Disorder (IDD) and Salt Iodization Program, Zinc
Supplementation during Treatment of Diarrhea, Vitamin D, Calcium Supplementation among
vulnerable groups of children in hard-to-reach areas in 36 sub-districts of nine low performing
districts in Bangladesh (67).
In 2006, the government of Bangladesh has developed a policy for a zinc therapy programme
during diarrhoea for young children. The MOHFW implemented a programme for scaling up Zinc
for young children (SUZY) as the first national effort to expand zinc treatment coverage for
childhood diarrhoea. The NNS have already adopted the zinc supplementation program and is
delivering health facilities in rural and urban settings. The government is implementing area-based
programme for zinc supplementation through micronutrient powder (MNP) and rice fortifications
among children aged 6 to 23 months. Fortified rice is distributed to the poorest of the poor
segments of the population through Vulnerable Group Feeding (VGF) and Vulnerable Group
Development (VGD) card. The micronutrient fortificants used to fortify the rice includes Vitamin
A, Vitamin B1, Vitamin B12, folic acid, iron, and zinc. Fortified Rice (FR) reduced anaemia and
zinc deficiency prevalence. Replacement of regular rice with FR in the VGD programme is
recommended to reduce anaemia among vulnerable groups (71). Addressing Iodine Deficiency
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Disorder (IDD) is a national priority, the government of Bangladesh adopted the Universal Salt
Iodization Strategy in 1989 and endorsed the Salt Iodization Act in1989s. However, there are gaps
and challenges, making it mandatory for edible salt to be iodized in the existing strategies to
prevent and control IDD in Bangladesh, although poor quality of iodization of salt is reported.
Beside last National micronutrient survey reported.
The IPHN has developed national guidelines for food fortification, dietary improvement in
preschool children and school-aged children. The national food fortification program currently
mandates fortification of oil and salt. Fortification of oil with vitamin A has been launched in 2001
to reduce the subclinical Vitamin A deficiency (66). Universal salt iodization began in 1989 to
reduce iodine deficiency and its related outcomes (72). Albeit high prevalence of iodine deficiency
has been reported among children (40%) and adult women (42%). Efforts have been made in
Bangladesh to increase zinc in grain using technologies like agronomic fortification through
spraying zinc sulphate on plants, putting zinc fertiliser in soil, adding zinc oxide to clean rice, and
above all enriching rice grain with zinc through breeding process (73).
The national food policy (NFP) has developed a framework in the three main approaches for
people of different stages of the life cycle: (1) dietary diversification, including nutrition education,
food fortification and supplementation; (2) awareness campaigns; and (3) using multiple inclusions
of poor targeted and market-based interventions. Currently, three government programs, the
Health, Nutrition and Population Sector Programme (HNPSP) 2011-16, NNS-Operational Plan
2011-2016, the National Strategy for Anaemia Prevention and Control in Bangladesh 2007, and
the Infant and Young Child Feeding Strategy 2007 are combinedly working for the control and
prevention of Vitamin A, iron and iodine.
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1.5 Knowledge gap
The 1st micronutrient survey conducted in 2011-2012 for the first time provided estimates of the
burden of Vitamin A and D among children under-5 years, children 6-14 years, and non-pregnant
and non-lactating (NPNL) women in urban and rural areas. Information for Vitamin
B12wasavailable for NPNL women, while estimates for iron and zinc deficiencies were available
for children under 5 years and NPNL women. However, the data of micronutrient deficiency is
being old for more than 7 years and up-to-date information at the national level would be crucial
for giving policy directions and achieving the strategic goals of micronutrient deficiency 2015-
2024. While food fortification could play a significant role to mitigate the burden of micronutrient
deficiencies, regional variations in micronutrient deficiencies across different geographic locations
within the countries by various age groups and population at risk have not been establishedin
Bangladesh. in Bangladesh. Currently, there is scanty information on national and region level
food fortification coverage of salt, oil and rice. The last survey for iodine coverage was done in
2001 and no coverage data exist for oil. There is a critical need to assess the household coverage
of fortified oil and salt well.
We proposed to conduct a survey to establish the evidence of the micronutrient status of selected
micronutrients among children 6-59 month of age and non-pregnant and non-lactating (NPNL)
women of reproductive age(15-49 years) in eight administrative divisions in Bangladesh.
However, due to funding constrains, we later proposed a pilot survey in selected communities in
Dhaka division in order to generate an evidence of potential need of a nationwide micronutrient
surveys in Bangladesh. We conducted a pilot survey in selected communities in Dhaka division
as the 1st phase of the national micronutrient survey in Bangladesh and generated preliminary
evidence of the micronutrient situation, which helped to generate an evidence for designing a
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nationwide survey for obtaining the national prevalence of micronutrient deficiencies in the target
population.
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1.6 Objectives
1.6.1. Primary Objective
To estimate status of selected micronutrients in eight division of Bangladesh to achieve the primary
objectives-
1. To estimate the prevalence of Vitamin A, Vitamin D, Zinc, Iron and Iodine deficiencies among
children (6-59 months) at the national level
2. To estimate the prevalence of Vitamin A, Vitamin D, Vitamin B12, Folate, Zinc, Iron and Iodine
among NPNL women (15-49 years) at the national level
3. To estimate the prevalence of anemia among children (6-59 months) and NPNLW (15-49
years) at the national level
4. To estimate the regional distribution of micronutrient deficiencies of children and NPNL

women.
5. To estimate the nutritional statuses among children and adults in eight divisions in
Bangladesh.
6. To assess the coverage of micronutrient supplementation in eight divisions in Bangladesh.
1.7 Outcome parameters
1. National prevalence of Vitamin A, Vitamin D, Vitamin E, Zinc, Iron and Iodine deficiency
will be known among children (6-59 months) in Bangladesh
2. National prevalence of Vitamin A, Vitamin D, Vitamin B12, Folate, Zinc, Iron and Iodine will
be known among NPNL women (15-49 years) in Bangladesh
3. Urban and rural distribution of micronutrient deficiencies will be known for children (6-59
month) and NPNL women(15-49 years)
4. Regional variations of the status of micronutrient deficiencies will be known for children(6-59
month) and NPNL women(15-49 years)
5. Distribution of wasting, stunting, underweight will be estimated for the children age 6-59
month in urban and rural settings of eight administrative division in Bangladesh
6. Distribution of underweight, overweight and obesity will be known among non-pregnant and
non-lactating (NPNL) woman 15-49 years in urban and rural settings of eight administrative
division in Bangladesh.
7. The correlations between micronutrient deficiencies and nutritional indicators will be known
across all the age groups in urban and rural settings of eight administrative division in
Bangladesh.
8. National coverage of micronutrient supplementation will be known in eight divisions including
urban and rural areas in Bangladesh.
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Chapter 2
Methodology
2.1 Research Design and Methods
To achieve primary objective
Following method was developed for obtaining a national level estimate for the targeted
micronutrients among the children aged 6-59 month and NPNL women aged 15-49 years in each
division and adopted a sampling frame for recruiting study participants in each of the eight
divisions.
2.1.1. Study design
A cross-sectional study was conducted using multi-stage cluster sampling methods to produce
estimate for key micronutrient indicators for eight administrative divisions in Bangladesh(urban
and rural areas separately).
2.1.2. Study settings
This study was designed to conduct survey from urban and rural areas of eight administrative
divisions (Dhaka, Maynmansngh, Bariasal, Khulna, Sylhet, Rajshahi, Rangpur and Chattogram
division) of Bangladesh. This study has been implemented in four divisions (Sylhet, Rajshahi,
Rangpur and Chittagong) of Bangladesh till 31st December, 2020.
2.1.3. Study population
This study included the children 6-59 months of age and NPNL women of reproductive age group
(15-49 years). Household members who lived in a selected cluster for more than six months at the
time the survey was considered permanent residents and study population. The clusters created
with the household in villages for the rural settings and mahallas or wards for the urban settings in
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Bangladesh. The participants who gave written informed consent or assent as appropriate were
eligible to participate in the survey. Blood samples collected only from those participants who
gave voluntary written informed consent.
2.1.4. Inclusion criteria
Inclusion Criteria for the household of NPNL women (15-49 years)
1. A household having at least one NPNL of reproductive age (15-49 years).
2. In the case of more than one NPNL women (15-49 years) in a household one
participant was randomly selected.
3. Household members were permanent resident in a selected PSU for last 6 months
Inclusion Criteria for the household of under -5 children (6-59 months)
1. A household having at least one under-5 children (6-59 months).
2. In case of more than one under-5 children in a single household, one participant was
randomly selected
3. Household members were permanent resident in a selected PSU for last 6 months
4. Mother/caregiver of the children aged of 6-59 months gave consent for child’s
participation in the study
22
2.1.5 Sample size calculation
Sample Size:
To estimate the prevalence of Micronutrient deficiencies, the maximum sample size calculated in
order to obtain a specified precision, that is, a confidence interval of a specified width around a
single point estimate in the survey for each target group and outcome. The formula used for these
calculations was:
Z  P(1 − P)
2
n= x design effect
d2
P = the current prevalence
Z = 1.96 at  =0.05
d = the half confidence interval
and the design effect = 2
Multi-stage cluster sampling technique was used in this study. The required sample size was
estimated according to the random sampling technique and then multiplied with design effect. In
this study,the design effect was used according to the estimate of the National Micronutrient
Survey in Bangladesh, 2011-2012.
The sample size was calculated based on prior estimates of the parameters (e.g. Vitamin A,
Vitamin B12, Vitamin D, Zinc, Iron, Folate, Iodine and Anaemia). For each target group, design
effect assumed 2.0 and 15% non-response rates at the household. The estimated sample size for
23
the children aged 6-59 months was approximately 1000 and 1000 samples for NPNL women. The
grand total of the age adjusted sample size was2000. (Table 1).
The sample size that calculated for primary objective also covers the purpose of secondary
objectives. Therefore, the estimated sample size for the primary objectives also covered the
secondary objectives.
To estimate the total number of household, this study considered national household size 4.4, and
the age distribution of each populations groups, which gives overall 6558 households to list up for
the survey and 820 households per division. However, the household was stratified according to
the proportional allocations to the urban and rural settings of each division. To recruit the total
number of household, this study randomly selected estimated cluster per divisions according to the
proportional allocations to size of EAs from the urban and rural settings of each division.
According to the demographic distribution of reproductive age group women, 5% women were
recruited for the pair assessment of micronutrient indicators for both of NPNL mothers (15-49y)
and children (6-59m).
Table 1: Sample size for the children (6-59 months), adult NPNL women (15-49 years) (Details
procedures)
Indicators Estimate Precisions Estimated Considering non- Sample size

(%) (%) sample size response rate# for field
survey
Children(6-59 month)
Vitamin A 20.5 (±5.0) 614 798 1000
Vitamin D 39.6 (±6.0) 511 664
Iron 10.7 (±4.0) 559 727
Zinc 44.6 (±5.0) 760 988
Urinary Iodine 31.3 (±5.0) 661 859
Anemia 33.10 (±5.0) 681 798
NPNL women (15-49 years)
Vitamin A 5.4 (±2.5) 628 816 1000
24
Vitamin D 71.5 (±6.0) 520 676
Iron 7.1 (±3.0) 563 978
Zinc 57.3 (±5.0) 752 974
Urinary Iodine 42.1 (±7.0) 749 770
Anemia 26.0 (±5.0) 592 715
Folate 9.1 (±3.4) 550 709
Vitamin B12 23.0 (±5.0) 545 816
Estimated total 2000
sample size
Estimated 6558
Household size
*The largest sample size considered for the specified age group
#:
20% non-response for the participant level and 10% non-response for the household level
recruitment
2.1.6 Estimation of the numbers of households and PSUs required for the national survey
The number of households estimated using the following formula [76].
𝑛
𝑛𝐻𝐻 =
𝐻𝐻 ∗ 𝑝
Where, nHH was the total number of households for survey in the study. N was the estimated
sample size for target population; HH was the average household size for each administrative
division that already available from the census, 2011 of Bangladesh and p was the proportion of
population in the target age group that was also available from census, 2011 of Bangladesh. The
population distribution of under-5 children (6-59 months) was minimum than the others target
age group in this study. Therefore, we considered the distribution of under-5 children (6-59
months) of each division that provided the maximum number of households. According to the
above-mentioned formula, the total number of 10,176 households would be required to obtain
national estimates across eight divisions, including 8,171 households from rural and 2,004 from
25
urban areas in order to obtain the prevalence of micronutrients deficiency of all targeted
micronutrients under the national survey.
2.1.7 Sampling Weight
The population size was different across different divisions (stratum). Therefore, sampling weight
required for estimating a representative data at the national level, as well as at the division level.
As the study was conducted according to two stage cluster sampling methods, data from population
and housing census 2011 of BBS was used to estimate the population size in each stratum. Thus,
sampling weight was calculated for each sampling stage according to the following formula:
At the first stage, sampling probabilities of each PSU under each stratum calculated by applying
the following formula-
𝑁𝑢𝑚𝑏𝑒𝑟𝑜𝑓𝑠𝑒𝑙𝑒𝑐𝑡𝑒𝑑𝑃𝑆𝑈𝑖𝑛𝑒𝑎𝑐ℎ𝑠𝑡𝑟𝑎𝑟𝑢𝑚 × 𝑁𝑢𝑚𝑏𝑒𝑟𝑜𝑓𝐻𝐻𝑖𝑛𝑒𝑎𝑐ℎ𝑃𝑆𝑈𝑜𝑓𝑒𝑎𝑐ℎ𝑠𝑡𝑟𝑎𝑡𝑢𝑚
𝑃1 =
𝑁𝑢𝑚𝑏𝑒𝑟𝑜𝑓𝐻𝐻𝑖𝑛𝑡ℎ𝑒𝑠𝑒𝑙𝑒𝑐𝑡𝑒𝑑𝑃𝑆𝑈
×
𝑇𝑜𝑡𝑎𝑙𝑛𝑢𝑚𝑏𝑒𝑟𝑜𝑓𝐻𝐻𝑖𝑛𝑒𝑎𝑐ℎ𝑃𝑆𝑈𝑜𝑓𝑒𝑎𝑐ℎ𝑠𝑡𝑟𝑎𝑡𝑢𝑚
At the second stage, the sampling probability within each cluster will be calculated by
𝑁𝑢𝑚𝑏𝑒𝑟𝑜𝑓𝐻𝐻𝑡𝑜𝑏𝑒𝑠𝑎𝑚𝑝𝑙𝑒𝑑𝑖𝑛𝑒𝑎𝑐ℎ𝑐𝑙𝑢𝑠𝑡𝑒𝑟
𝑃2 =
𝑁𝑢𝑚𝑏𝑒𝑟𝑜𝑓ℎ𝑜𝑢𝑠𝑒ℎ𝑜𝑙𝑑𝑙𝑖𝑠𝑡𝑒𝑑𝑖𝑛𝑒𝑎𝑐ℎ𝑐𝑙𝑢𝑠𝑡𝑒𝑟𝑜𝑓𝑒𝑎𝑐ℎ𝑠𝑡𝑟𝑎𝑡𝑢𝑚
The overall selection probability of each household in each cluster of the stratums was the
multiplication of the two stage selection probabilities, P= P1X P2
The design weight for each household in each cluster of the stratums was the inverse of the overall
selection probability, W= 1/P.
26
The sampling weight estimated after correcting with the non-response rate at the household and
individuals’ levels. Since non-response at the cluster level increased the standard error, household
selection from each PSU got equal probability of selection. The individuals within the household
were selected with equal probability and design weight was similar for each individuals of the
household. Therefore, the adjustment of unit non-response was similar for the entire cluster and
household level. The sampling weight calculated by the following procedures –
For the simplicity, The PSU level response will be calculated by
𝑁𝑢𝑚𝑏𝑒𝑟𝑜𝑓𝑐𝑙𝑢𝑠𝑡𝑒𝑟𝑤𝑖𝑙𝑙𝑏𝑒𝑖𝑛𝑡𝑒𝑟𝑣𝑖𝑒𝑤𝑒𝑑𝑖𝑛𝑒𝑎𝑐ℎ𝑠𝑡𝑟𝑎𝑡𝑢𝑚
𝑅1 =
𝑁𝑢𝑚𝑏𝑒𝑟𝑜𝑓𝑐𝑙𝑢𝑠𝑡𝑒𝑟𝑠𝑒𝑙𝑒𝑐𝑡𝑒𝑑𝑖𝑛𝑒𝑎𝑐ℎ𝑠𝑡𝑟𝑎𝑡𝑢𝑚
The household level response rate is –
∑ 𝐴∗ 𝑥𝐵
𝑅2 =
∑ 𝑊𝑥𝐴
Where,
A*= Number of HH found in the selected cluster of each stratum
A= Number of HH interviewed in the cluster
W= Design weight of each cluster of the stratums
The individual response rate will be calculated using the following procedures-
∑ 𝑊 × 𝐿∗
𝑅3 =
𝐿
Where,
W= Design weight of each cluster of the stratums
L*= Number of individuals interviewed in each cluster of each stratum
27
L= Number of eligible individuals found in the cluster of each stratum
This sampling weigh procedure developed from Demographic and Health Survey (DHS) sampling
procedure [78].
𝑊
𝑅4 =
𝑅1 × 𝑅2
The individual sampling weight calculated for each cluster in the stratums by the following
procedures-
𝑅4
𝑊1 =
𝑅3
The household standard weight calculated for each cluster in the stratums by
∑ ∑ 𝐴∗
𝐻𝑊 =
∑ ∑ 𝐴∗ 𝑊
A*= Number of HH found in the selected cluster of each stratum
B= the weighted sum of household interviewed
The household standard weight will be calculated by –
Household weight= W x HW
The individual standard weight calculated for each cluster in the stratums by
∑ ∑ 𝐿∗
𝐼𝑊 =
∑ ∑ 𝐿∗ 𝑊
L*= Number of individuals interviewed in each cluster of each stratum
28
B= the weighted sum of household interviewed
The individual standard weight will be calculated by –
Individuals weight= W x IW
2.1. 8. Sampling procedures
We applied the sampling frame of Multiple Indicator Cluster Survey 2018(MICS), conducted by
UNICEF that followed the 2011 census frame for the selection of Primary Sampling Unit(PSU)
and the frame was developed by the Bangladesh Bureau of Statistics (BBS). The census
Enumeration area (EAs) defined as primary sampling unit (PSU)and every PSU will be considered
as a single cluster. There were 15,000 PSU in the MICS from all over Bangladesh. In our study,
the PSUs were selected from each of the sampling stratum (rural and urban setting of each division)
using a probability proportional to size (PPS) sampling procedure, based on the number of
households in each EAs derived from the population and housing census 2011. We needed 250
clusters to reach 6558 HH, and from those HH we needed to recruit 2000 participants among
under-5 children (6-59months) and NPNL women (15-49 years) to obtain a nationwide estimate.
BBS has identified the required number of PSU from each division including urban and rural
settings. The definitions of urban and rural PSUs used in Multiple Indicator Cluster Survey
(MICS)2018-19 followed by the Bangladesh Bureau of Statistics in the national Population and
Housing Census 2011. The urban PSUs defined by mohollas which is subdivision of a ward in an
upazila under a district. For metropolitan areas, urban PSUs are defined by a moholla under a ward.
A rural area in an upazila is divided into union parishads (UPs) and, within UPs, into mouzas.
These divisions allow the country as a whole to be separated into rural and urban areas. We
randomly selected the estimated number of PSU from the list of urban PSUs and the rural PSU for
29
each division according to the probability proportion to EAs size. The distribution of estimated
PSUs per division under the urban and rural areas was described in the Figure 1. .
Figure 1.Sampling procedure flowchart
The number of clusters has been estimated based on the total households required for meeting the
desired sample size under each division. According to the Bangladesh Bureau of Statistics (BBS),
one PSU is comprised of 120 to 200 household and 15-30 households recommended recruiting per
PSU for a cluster sampling method [77] and for our study 8 households were selected for each
PSU following the systematic random sampling method. One participant enrolled from a single
household including either child aged 6-59 months or NPNL woman (15-49 years).Approximately,
20% of NPNL women recruited from the mother of under-5 children (6-59 months) to maintain
population distribution. If there were more than one NPNL women or child in a single household
the survey team randomly selected one child or a woman from that household. In case of non-
availability of eligible person in a selected household at the time of survey, the adjacent household
was selected to enrol the eligible person.
30
2.1.9 Selection of the study participants
The research team used the list of households of a PSU provided by BBS and updated the
information of the current residents living in the households already included in the map following
a door to door visit of all the households which were already listed under each PSU. Once the list
was updated the research team used the updated household list as a sampling frame and
systematically followed the list to recruit an eligible participant as per the chronological order of
the households. From each PSU 4 children aged 6-59 months were recruited from 4 households
and 4 NPNL women were recruited from another 4 households following a written consent. If
there were more than one NPNL women or child in a single household, we randomly selected one
child or a woman from that household.
2.2 Study period
The duration of the study was between February, 2020 and July, 2021. Initially, data collection
was planned to start from March 2020. Due to emergence COVID-19 pandemic and declaration
of general holiday by government of Bangladesh from 26th March 2020, the data collection halted
for 6 months. After that data collection was resumed from 10th October 2020. Up to 31st
December’2020, the team completed survey of four divisions including Sylhet, Rajshahi and
Rangpur and Chittagong Division. The tentative target to complete the field survey of Khulna,
Barishal, Mymensigh and Dhaka division within February’2020. If necessary, data collection
period may extend for a few more weeksand complete the field activities according to the plan of
the study.
31
Table2: Timeline of the activities
2020 (Feb-Dec) 2021 (Jan-Jul) 2021 (Aug-Dec)

Completed activities Projected timeline Will be applied for NCE
Activities Feb Mar Apr Ma Ju Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Protocol
revision
(Amendment)
Fieldwork
preparation
Survey data Halt Halt Halt Halt Halt Halt
collection*
Data entry Halt Halt Halt Halt Halt Halt
and data
cleaning*
Data Halt Halt Halt Halt Halt Halt
analysis*
TAG Halt
meeting##
Report
writing &
dissemination
*Activities ongoing; #Field related activities halted from April- August, 2020 due to emergence of COVID-19 Pandemic; Color code:
Completed/ongoing activities:
32
2.3 Staff Training
We conducted training on the consenting process ensuring voluntary participation of the study
population and obtaining data using a pre structured survey tool. There were two separate teams
for the field site, (1) data collection team and (2) sample collection team. The data collection team
comprised of 9female Field Research Assistants (FRA). The FRAs had received 20 days long
training on the survey questionnaire. The Principal Investigator provided training on obtaining
consent from the participants, the technique of household listing, data collection, anthropometric
measurement and managing the field sites. For the practical session, the FRAs collected the data
from a particular area out of the sampling frame of the current study. The pilot field experience
was applied for the development and modifications of the questionnaires. The sample collection
team comprised of 3 Field Assistants and3Phlebotomists. The phlebotomists were trained by the
laboratory investigator for standardizing the process of collection of appropriate biological
samples and transportation to the lab. The Principal Investigator and two experts from the
laboratory science division of icddr’b have provided training on blood and urine sample
collections, sample allocation in the tube, processing samples in the selected PSU. The sample
collection team received a practical training in the field prior to initiating the survey. One field
supervisor accompanied the team, who had decision making authority if any problems arise at the
field site and also had administrative responsibility for the sampling procedures.
2.4 Field set up
The PI and other senior members of the research team visited local officer of the National Nutrition
Service, Bangladesh Bureau of Statistics, administrative officers at upazila level, ward
33
commissioner and local law enforcing agency to brief about the survey and obtaining local support
for conducting the survey by the research team.
The research investigator visited the office of Upazila Nirbahi Office (UNO) and submitted a
letter of support to get necessary cooperation from the Chairman of the corresponding Union
Parishad for rural study sites and ward counsellor for the urban study sites. For the field survey of
city corporation areas, approval was obtained from the mayor/ panel mayor of the city
corporations. Govt. signed letters were also submitted to the Upazila Health and Family Planning
officer of each Upazila selected for the survey. For the field survey in the hill tract areas, Govt.
signed letters were submitted to the Chattogram Hill Tracts Development Board, Bangladesh
Army, Bangladesh Polish. A number of meeting were conducted with the local representative of
tribal communities (e.g. Marma, Chakma) for getting necessary cooperation.
2.5 Data collection procedures
Following training we deployed teams in the field for field testing. The field team collected data
from the participants using a pre-structured survey questionnaire. Trained phlebotomists collected
blood samples from the all participants (Children aged 6-59 months and NPNL women aged 15-
49 years). Data collection and blood sample collection were conducted following two standard
operating procedures (SOPs) developed by the investigators.
Questionnaire and data collection
Following consent, data collected using pre-coded structured questionnaires by trained research
assistants separately for different age groups (children aged 6- 59 months and NPNL women of
15-49 years) at household level. We collected the data on the following domains -
34
1. Household questionnaire: The household questionnaire included the questions regarding the
dwelling unit, source of drinking water, type of toilet facilities, types of fuel materials used,
materials used to construct the floor and walls, and ownership of various consumer goods,
Food security status, hand washing practices and Socio-demographic variables including age,
sex, education, occupations.
2. Personal medical history, family medical history and duration of illness collected from the
study participants and co-morbidity status (e.g. fever, diarrhea) before the two weeks of survey
collected of the children of under-5 years.
3. Dietary questionnaire: To measure the food frequency status of household, 24 hours recall
dietary pattern among children and adults has been applied. Infant and Young Child Feeding
(IYCF) questionnaire used for the children aged 6-59 months.
4. Food insecurity, salt intake, food hygiene in the household related data were collected.
5. Physical measurement: Height, weight and mid upper cum circumference (MUAC), Waist and
Hip circumferencemeasured for all age groups.
6. Global positioning system (GPS) data collection from the locations of each household
7. Blood samplescollected by trained phlebotomists following aseptic precautions from
household
8. FACT survey questionnaire on oil, salt and rice fortified food coverage data collection from
the household level
35
2.6 Biological sample collection, preparation, transport and storage
Biological samples were obtained at the households of the children and NPNL recruited in the
survey following consent. Blood samples were obtainedfrom both NPNL women and under- 5
children (6-59 months) to assess Vitamin A, Vitamin D, Zinc, ferritin and Hb%from blood and
urine sample to assess urinary Iodine. In addition to that, Vitamin B12 and Folate were also
assessed in NPNL women through blood collection. Threephlebotomists collected 7 ml blood from
NPNL women, and 5ml blood from the under-5 children. From the collected blood 2 ml of whole
blood separated in EDTA containing tube for Hb% and rest of the 5 /3 mL (NPNL women and
under-5 children respectively) blood transferred into an anti-coagulant coated blood collection tube
(trace element free) and then centrifuged for 10 minutes and aliquoted in trace element free
cryovial (pre-labelled). From the 2 ml whole blood, two aliquotshad been separated. The first
aliquot with 0.5 ml blood used for Hb% analysis and rest of the 1.5 ml stored for future PCR based
Thalassemia diagnostic test which will be done according to the funding availability.
Three aliquot separated from the serum. One aliquot of approximately 250μl was used for analysis
of Zinc. The second aliquot of 800 μlhas used for analysis of micronutrients including Vitamin A,
vitamin B12, ferritin, Folate, Vitamin D. One aliquot is being stored for future analysis.All the
samples were temporarily stored in - 20°C freezer at the sub-center in field setting. All these stored
specimens were transported to the Nutritional Biochemistry Lab in icddr,b, Dhaka on a weekly
basis and stored in frozen condition for long-term storage in -80 freezer or liquid nitrogen tank (-
190°C).A sample record/handover form filled up indicating name of the participants, ID number,
sample ID number, and type of analyses to be done.All samples in the laboratory processed
36
following the standard laboratory guidelines followed by icddr, b as described below. Lab assays
were performed in batches by the lab teams.
2.8 Processing of blood and urine samples in laboratory
Vitamin A
Serum vitamin A measured by high performance liquid chromatography (HPLC). Serum retinol
measured by reverse-phase high-pressure liquid chromatography (RP-HPLC) with photodiode
array detection (Shimadzu Corporation, Kyoto 604-8511, Japan). A small volume of serum mixed
with an equal volume of methanol containing retinyl acetate (Sigma Chemical Co. St. Louis, USA)
as internal standard and then extract twice into hexane. The combined hexane extracts are
evaporated to dryness under nitrogen stream. The dried extract is re-dissolved in mobile phase. An
aliquot of that is injected onto a µ Bondapak C18 column (Waters, USA) and it is then isocratically
eluted with a mobile phase. The chromatograms of retinol and retinyl acetate were monitored by
a PDA (photodiode array detector) at 325 nm and recorded using a computer data system (LC
Solution). The quantification was performed with the pooled serum. The concentration of retinol
in sample was calculated by the “internal standard method” via integration of the peak areas.
The pooled serum sample calibrated against standard reference material (fat-soluble vitamins,
carotenoids and cholesterol in human serum, 968e; National Institute of Standards and
Technology, Gaithersburg, MD, USA). This pooled stored in aliquots at −80 °C and use as a
calibrator and QC in each run/day. Ensuring the quality of results for vitamin A, we participate in
Micronutrient Measurement Quality Assurance Program (MMQAP) organized by NIST and The
37
Vitamin A Laboratory – External Quality Assurance (VITAL-EQA) program organized by
CDC(70).
Vitamin B12, Vitamin D, Ferritin and Folate
Vitamin B12, Vitamin D, Ferritin and Folate in serum measured by electrochemiluminescence
immunoassay (ECLIA) with Roche automated immunoassay analyzersCobas e601 using
commercial kit (Roche Diagnostics, GmbH, 68305 Mannheim, Germany) according to the
manufacturer’s instruction. The method for vitamin D has been standardized against LC-MS/MS
which in turn has been standardized to the NIST standard. Commercial control material
PreciControlVaria from Roche diagnostics are used as internal quality control. We run these
control materials each day to check both accuracy and precision.
To ensure the quality of resultsfor vitamin B12, vitamin D, Folate and ferritin, we participate in the
Vitamin A Laboratory – External Quality Assurance (VITAL-EQA) program organized by CDC.
We also participate in College of American Pathologists (CAP) for vitamin B12 and ferritin tests.
Zinc
Serum zinc measured using flame atomic absorption spectrophotometry (Shimadzu AA-6501S,
Kyoto, Japan). A four-point calibration curve was prepared in every lot from the commercial zinc
standard solution (Cica-Reagent, Kanto Chemical Co. INC), in concentrations of 0.1, 0.2, 0.3 and
0.4 mg/L. With the optimized spectroscopic conditions, standard solutions and diluted serum were
aspirate into the flame of an atomic absorption spectrophotometer. Readings were then recorded
by measuring the absorbance at 213.9 nm using a zinc hollow-cathode lamp and an air-acetylene
38
flame. Calculate the concentration of the serum zinc based on the standard curve which was
prepared by the above known standards.
For internal quality control we use Bi-Level trace elements serum toxicology control, Normal
range and High range (UTAK Laboratories Inc, CA 91355, USA). We run these control materials
each day to check both accuracy and precision. For ensuring the quality of results we participate
in College of American Pathologists (CAP), (External Quality assurance programs).
Iodine
Urinary iodine measured by microplate method based on the Sandell-Kolthoff reaction. In this
method, urine was digested in a microplate using a specially designed sealing cassette. The
digestion mixture is then transferred to another transparent microplate and the Sandell–Kolthoff
reaction is performed. Absorbance was then measured at 405 nm with a microplate reader. The
intensity of the colour is inversely proportional to the iodine concentration.
A standard curve prepared by plotting the logarithmic mean absorbance for each standard on the
y-axis against the standard iodine concentration on the x-axis. The equation obtained from the
linear trend line of the graph is used to calculate the urinary iodine concentrations of each
specimen.
Table 3. Blood Tests for micronutrient deficiency at the different population groups
Children (6-59 NPNL women

month) (15-49 years)
Assessment of micronutrient biomarkers
Vitamin A √ √
Vitamin B12 √
Vitamin D √ √
Zinc √ √
Ferritin √ √
Folate √
39
Hemoglobin √ √
Iodine √ √
Table 4.Cut off point for micronutrient deficiency assessment
Biochemical Outcomes Test (Cut off point)

assessment
Vitamin A Vitamin A deficiency Serum retinol (<0.7 mmol/L)
(WHO/IVACG)
Vitamin B12 Vitamin B 12 deficiency Serum B12 (<300 pmol/L)
Vitamin D Vitamin D deficiency Serum 25-hydroxy vitamin D
(< 50 nmol/L and <25.0nmol/L or Deficient -
----- <12 ng/ml and Insufficient------ 12-20
ng/ml)
Zinc Zinc deficiency Serum zinc (< 9.9 mmol/Lin preschool
children and < 10.1 mmol/L in NPNL
women) (IZINCG 2004)
Iron Iron deficiency Serum ferritin <15.0 ng/ml in NPNL women
and <12.0 ng/ml in preschool children, WHO
2012)
Folate Folate deficiency Serum folate level <4 ng/mL;
Serum folate level >=4 ng/mL
Urinary Iodine Iodine deficiency Cut-off values of urinary iodine level
<100 µg/L: Iodine deficiency
100-199 µg/L:Optimal
200-299 µg/L:than adequate
>300 µg/L:Possible excess
Hemoglobin Anemia Hemoglobin level < 8.0 gm/ml;
Hemoglobin level: 8.0-10.9mg/ml;
Hemoglobin level 11.0-11.9 mg/ml;
Hemoglobin level ≥12.0 gm/ml
Data collections
We obtained following data from the households to achieve the secondary objectives of the study.
1. Household questionnaire: The household questionnaire included the questions regarding socio-
demographic characteristics, including age, sex, education, occupations of those living in the
household, and household characteristics, including the dwelling unit, source of drinking
40
water, type of toilet facilities, types of fuel materials used, materials used to construct the floor
and walls, and ownership of various consumer goods and food security (using the household
hunger score).
2. Women’s questionnaire: Women’s questionnaire obtained information on dietary diversity and
frequency of 24-hour dietary intake, micronutrient supplement use, knowledge of vitamins,
minerals and fortification, and hand washing practices.
3. Child’s questionnaire: Child’s questionnaire to collect information related to dietary and
frequency of 24-hour dietary intake, micronutrient supplement use, child feeding practices
(using infant and young child feeding indicators, infection etc).
4. FACT survey questionnaire: FACT survey questionnaire to collect information on oil, salt and
rice fortified food coverage data collection from the household level.
Physical measurement for nutritional status
We carried outthe anthropometric assessment according to the WHO stepwise survey on the
under-5 children (6-59 months) and non-pregnant-non-lactating women (15-49 years)(71). A
length board (wooden stadiometer) used to calculate length/height for the children, which was
consist of movable footboard and fixed headboard(72).To measure height of NPNL women, a
portable height/length measuring board, such as from SECAwas used. The following actions were
taken while measuring the height: (1) Separate the pieces of the board (usually 3 pieces) by
unscrewing the knot at the back (2) Assemble the pieces by attaching each one on top of the other
in the correct order (3) Lock the latches in the back and (4) Position the board on a firm surface
against a wall.
41
To measure weight, a portable weighting scale, such as a SECA scale or the Tanita HS301 Solar
Scale was used. The following set up has been taken for the measurement: (1) carpet (2) a sloping
surface and (3) a rough, uneven surface. The following steps below were taken to measure the
weight of a participant: (i) Ask the participant to remove their footwear (shoes, slippers, sandals,
etc) and socks. They should also take off any heavy belts and empty out their pockets of mobiles,
wallets and coins. (ii) Ask the participant to step onto scale with one foot on each side of the scale
(iii) Record the weight in kilograms.The height and weight of eligible participants was taken to
calculate their body mass index (BMI), and therefore to determine the prevalence of underweight,
overweight and obese people in the population.
2.10 Quality assurance
Quality assurance during data collection:
During data collection, the questionnaires and data forms were reviewed by the data collectors to
ensure all relevant information had been captured. After field data collection, the completed
questionnaires were carefully reviewed by the field supervisor for checking any missing data. In
case of any discrepancies identified, the field supervisor contacted the respective data collectors
and resolved any discrepancy before the team left the cluster. For checking the reliability of the
data of the data collector, some part of the questionnaire of the same participants interviewed and
crosscheck with the original survey form.
Activities of quality assurance team:
A quality assurance team was formed including the team leader, a data manager and a Research
Assistant. Quality assurance team checked 25% data forms for inconsistencies and illogical values.
In case of any discrepancies, they communicated with field supervisor and the field supervisor
helped to resolve the discrepancies. Once electronic data entry was done for one division, data
42
manager randomly checked 10% of data (10% of key variables) for each and every individual for
missing or illogical values by comparing between the data collection form and electronic data entry
in order to ensure high quality data. Besides, the quality assurance team sat with the data collection
team once in a month through ‘skype’ or ‘Go to Meeting’ for troubleshooting and re-interviewed
a random sub-sample of 2% from each cluster within a week. The entire field and lab activities of
this team were supervised by the PI of the project through a close monitoring. The PI and other
Investigators visited the field site to observe the interviews, sample collection; and conducted on-
spot checks periodically.
2.11 Data Management and Data Analysis
Data management team
The data management team was responsible for developing a database, entry of the survey form,
cleaning of the dataset and providing a clean dataset for the analysis.
Data management and analyses
Data coding, quality control and data entry were done following established procedures at icddr,b.
Privacy, anonymity and confidentiality of data/information were strictly maintained. A code
number was generated for each participant and this number was used for identification of the
participants. Name or any information that could identify the participants’ identity would not be
published or shared with anyone else. Information collected from field was kept under a locked
cabinet and was password protected.
Pre-coded questionnaires were used. All data forms and questionnaires were checked for errors
and necessary corrections were made before data entry. Data were entered using data entry
43
programme with built-in range and consistency checks. Frequency distributions run to identify
outliers and inconsistency of observations. Basic statistics such as frequency distribution, quartile
applied to summarize the categorical variables, descriptive statistics were applied to summarize
the continuous variables. Frequency distribution applied to summarize the categorical variables
and descriptive statistics to summarize continuous variables. (74).
2.12 Ethical Assurance for Protection of Human rights
The study obtained approval from the Ethical Review Committee (ERC) of icddr,b and Bangladesh
Medical Research Council prior to initiating the study activities in the field. Participation in the
study was completely voluntary and written consent was obtained from all participants prior to
recruitment. The mother or the legal guardian of an under-5 child gave consent for a child 6-59
months of age. Consent of a NPNL was obtained directly from the women. The language of the
consent was Bangla and was written in a simple language, so that the participants with little or no
educational background could understand the consent. The consent form was read out to the
participants and to the guardians/parents of the eligiblechildren if he/she was unable to read.
Signed consent or the left thumb impression (for those who could not sign) obtained from the study
participants or from the parents for participating children in the study.
The questions asked in the study were fairly general and not particularly intrusive or socially
sensitive. Blood samples were collected by a trained and experienced phlebotomist using sterile,
disposable syringes and needles to minimize the risk of getting the infection during blood
collection. Separate standard operating procedure(SOP) were followed by the phlebotomists. The
study was committed to the participants to provide adequate treatment for the condition and bear
all the treatment costs if any problem rose during sample collection.
44
Privacy, anonymity and confidentiality of data were maintained by assigning a unique code
number for each participant. A similar measure was also taken for biospecimen collection. At the
time of analysing information and publication of the results of the study, name or identity of the
study participants would not be used. The participants did not get any monetary benefit from the
study for their time. However, participants were benefitted by getting their biospecimen reportat
free of cost. Participants were informed if he/she hada major micronutrient deficiency or any
illness, and were referred to the nearest health facility.
2.13 Technical Advisory Group
A Technical Advisory Group (TAG) was led by the Additional Secretary, PH&WH, MOH&FW
formed inviting senior officials who represented their organizations. This included the Line
Director and other officials of the National Nutrition Services and representatives of the
development partners, including UNICEF, GAIN Bangladesh, Nutrition International &Institute
of nutrition and food science (INFS), Helen Keller Foundation, Bangladesh, World Health
Organization, Department of statistics, University of Dhaka , Bangladesh Small and Cottage
Industry Corporation, Institute of Child and Mother Health (ICMH),Bangladesh Bureau of
Statistics (BBS),Department of Public Health and Informatics, BSMMU, National Institute of
Population Research and Training (NIPORT),Johns Hopkins Bloomberg School of Public Health,
World Food Program (WFP)(Table 7).The TAG provided guidance regarding the development of
research methodology, development of survey form, data collection at the field level, preparing
the project report, interpretation of the finding. The TAG members met once per month to monitor
the progress of the activity. (Table 5)
45
Table 5: List of Technical Advisory Group (TAG) members
Name Designation
1. Kazi Zebunnessa Begum Additional Secretary, WH, MOH&FW

2. Md Mostafa Kamal Additional Secretary, PH, MOH&FW
3. Md. Helal Uddin Additional Secretary, (Planning Wing), Health Services Division
4. Nilufer Nazneen Joint Secretary (Public Health) Health Services Division, MOH&FW
5. Dr. S M Mustafizur Rahman Deputy Director, DGHS & Line director, National Nutrition Services;
6. Dr.Kazi Matin U Ahmed Professor and Chairman, Department of Geology, University of Dhaka
7. Dr. Sk. Nazrul Islam Professor & Director, Institute of Nutrition and Food Science (INFS)
8. Dr. Mohammad Sharif Director, MCH & Line, Director, MCRAH, DGFP
9. Representative Director, Planning, Research & Development, DGHS
10. Representative Director, CDC
11. Dr. M. Mushtuq Hussain Ex Principal Scientific, Officer & Head, iedcr
12. Engr. Md. Shafiqul Alam Project Director, CIDD Project, BSCIC
13. Dr. Ferdousi Begum Associate Prof. Obs and Gynae, ICMH, Matuail, Bangladesh
14. Md. Alamgir Hossen Deputy Director, Data Management and Focal Ponit Officer, SDG Cell,
Bangladesh Bureau of Statistics (BBS)
15. Dr.FarihaHasneen Associate Professor, Department of Public Health and Informatics,
BSMMU
16. Md. AhsanulAlam Senior Research Specialist, NIPORT
17. Dr. Tahmeed Ahmed Executive Director, icddr’b
18. PiyaliMustaphi Chief, Nutrition Section, UNICEF
19. Pragya Mathema UNICEF
20. Dr. Zeba Mahmud Country Director, Alive & Thrive, Bangladesh
21. Saika Siraj Country Director, Nutrition International
22. Dr. Aliya Naheed Scientist and Health System Specialist, INCD, HSPSD, icddr,b
23. Dr. Md. M. Islam Bulbul Deputy Program Manager, National Nutrition Services; IPHN
24. AminuzzamanTalukder Country Director, HKI
46
Name Designation
25. Keith West Professor and Director, Johns Hopkins Bloomberg School of Public
Health
26. Dr Mostafa Zaman Adviser, Research and Publication, World Health Organization
27. Dr. Faria Shabnam National Professional Officer-Nutrition, World Health Organization
Country Office. Dhaka, Bangladesh
28. Dr. RudabaKhondker Country Director Global Alliance for Improved Nutrition (GAIN)
29. Dr.Ireen Akhter Chowdhury Nutrition Officer , UNICEF
30. Dr.Sabiha Sultana Technical Specialist, Knowledge Leadership, GAIN
31. Malay KantiMridha Associate Professor, JPGSPH, BRAC University
32. Dr. Mohammad Mahbobor Program Officer, WFP
Rahman
47
3.5 Field survey
The filed survey conducted by the nine female data collectors. They collected the data from the
mother of the under-5 children (6-59 months) and non-pregnant and non-lactating women (NPNL)
aged 15-49 years. The data collectors visited the sample households and share general greetings,
purpose of visiting to the survey areas and the purpose of the study. Then they read the consent
paper thoroughly and explained if there was any query from the participants ends.After taking
consent from the participants, the data collectors collected household data in household
questionnaire and children/ NPNL survey form, after completing the survey questionnaire, the
field assistant cooperate the data collector on taking anthropometric measurements. Following that,
the data collectors invited phlebotomist to take blood samples. The phlebotomistshad taken
necessary aseptic preparation for taking blood sample collection.
Photo 1: A Field Research Assistant was Photo 2: A Field Research Assistant

collecting data from a NPNL woman of Marma was collecting signature from a
community at the Manikchari Upazila, Rangamati. NPN|L woman for taking consent.
*Consent taken for publishing photo The site is located at the Dhalar Char
of Bera Upazila, Pabna
*Consent taken for publishing photo
48
Blood sample collection by the phlebotomists
Photo 3: A Phlebotomist was taking Photo 4:A medical technologist is taking

blood sample from a NPNL woman at at blood sample from a NPNL women in the
the Dhalar Char of BeraUpazila, Pabna urban areas of Rangpur city corporation
*Consent taken for publishing photo *Consent taken for publishing photo
Photo-5.A phlebotomist was taking blood Photo-6:Blood sample processing for

sample from a 2 years oldchild storage by a phlebotomist after
ofDighinalaUpazilainKaghrachari collecting the blood in a field site
district. *Consent taken for publishing photo
*Consent taken for publishing photo
49
Field visit of the Government officials
In the Chattagram Division dignitaries from National Nutrition Services including Dr. S M
Mustafizur Rahman, Line Director of NNS visited field activities of Cox’SSadar PSU. The list of
Dignitaries visited in the National Micronutrient Survey is given below:
Table:11: The list of Dignitaries visited in the National Micronutrient Survey
Name of the dignitaries Date of Visit Visit Place
Dr. S M Mustafizur Rahman, Line Director, NNS, 23rd December COX’s Bazar Sadar PSU
IPHN, DGHS 2020
Dr. Maniruzzaman, Program Manager, NNS, 21st December, Patiya, Chattagram
IPHN, DGHS 2020
Dr. M. Islam Bulbul, Deputy Program Manager, 17th December, Begumganj and Senbag ,
NNS, IPHN, DGHS 2020 Noakhali
Eng Nazmul Ahsan, Deputy Program Manager, 17th December, Begumganj and Senbag ,
NNS, IPHN, DGHS 2020 Noakhali
DR. Mahfuza Haque, Deputy Program Manager, 28th December, RangmatiSadarUpozila
NNS, IPHN, DGHS 2020
Dr. S M Mustafizur Rahman, LD, NNS visited the field sites of Cox’s Bazar Sadarupazila.Dr.
Rahman is observing the operation of the field implementation, data collection procedures, sample
collection, storage and socioeconomic conditions of the study participants. Dr. Aliya Naheed
50
(Principal Investigator) was describing the procedures of the field survey and implementation
procedures.
Photo-7: Dr.S M Mustafizur Rahman, LD, NNS visited the field sites of Cox’s Bazar
Sadarupazila.
Dr.Munirruzaman, Program Manager, NNS visited the field sites of PatiyaUpazila of Chittagong
district and observed data collection and field implementation process. Eng. Nazmul Haque (left)
and Dr. M. Islam Bulbul, DPM visited a field site of Begumganj, Noakhali district. The NNS
personnel observed the blood sample collection procedures.
Photo-9: Eng. Nazmul Haque (left) and Dr. Photo-8:Dr.Munirruzaman, Program

M. Islam Bulbul, DPM visited a field site of Manager, NNS visited the field sites of
Begumganj, Noakhali district. PatiyaUpazila of Chittagong district
51
Dr. Mahfuza Haque, PHN, from the National Nutrition Service visited filed site of Rangamati
SadarUpazila. Dr. Haque observed the field implementation and data collection procedures in the
visited study site.
Photo-10.Dr.Mahfuza Haque, PHN, from
the National Nutrition Service visited filed
site of Rangamati SadarUpazila.
Field visits of Principal Investigator
Dr. Aliya Naheed, Principal Investigator of the study visited the field sites of Chattagram and
Sylhet Division and observed the whole procedures of the field implementation, data collection
sample processing and quality assurance.
Photo-11.Dr. Aliya Naheed, Principal Investigator of the study visited the field sites of
Khagrachari district.
52
Chapter 4
Results
This study has been implemented in the eight division of Bangladesh. A total of 250 cluster were
survey for the study. This study has been implemented in the urban and rural areas of eight
division. (Table 12)
Table 6.Recruitment of the study participants.
Division PSU Household Household Children Household NPNL

listed visited for U-5 visited for women
children recruited NPNL recruited
women
Sylhet 18 2120 1008 71 360 72
Rajshahi 29 4640 928 116 696 116
Rangpur 30 5340 1440 120 840 120
Chattagram 42 4785 1531 136 1941 136
Khulna 36 4320 2341 144 1979 144
Barisal 24 1920 781 64 1139 64
Dhaka 52 2860 1872 245 988 245
Total 250 9100 4994 1027 4106 1030
3.1 Socio-demographic characteristics of Non-Pregnant Non-Lactating Women (15-49

years)
A total of 921 NPNL women participated in the survey. The average age of the NPNL women was
31 years. More than half of the population (59.8%) completed at least primary education. Among
all of the women 79.2% were married, 3.1% were divorced or widowed, and 17.7 % were
unmarried. The majority (74.6%) of these women were housewives. However, 6.4% of these
women were service holders or 1.6% ran their own business. (Table 9)
53
Table 9. Socio-demographic characteristics of the study NPNL women
Characteristics NPNL Percentage Mother of Percentage (%)

(N=1027) (%) U-5 children
(N=1013)
Age (in years), Median IQR(25th-75th) 31(23-37) 30(26-35)
Education, n (%)
Never went to school 81 8.8 57 6.11
Below primary (1-4 class) 120 13.0 106 11.37
Completed primary (5-10 class) 551 59.8 539 57.83
Completed secondary (11 class and more) 14.2
169 18.3 133
Religion, n (%)
Islam 798 86.6 712 76.39
Others (Hindu, Christen) 123 13.4 126 13.51
Marital status
Unmarried 163 17.7 3
0.32
Married 729 79.2 826 88.62
Others (Divorced/ Separated/ Widowed) 0.64
29 3.1 6
Occupation
Housewife 687 74.6 776 83.26
Service 59 6.4 30 3.21
Business 15 1.6 17 1.82
Unemployed 158 17.2 7 0.75
3.1.2 Children 6-59 months of age

A total of 934 children of 6-59 months age were recruited in this survey. The mean age was 33±16
months and 42.1% were female. Around a quarter of the children (26.3%) were less than two years
of age (6-23 months) and about 2/3rdwere recruited from a rural community (73.7%). (Table 10)
Table 10. Basic characteristics of the children (6-59 months)
Characteristics Total (N)= 1027 Percentage (%)

Place of residence, n (%)
Rural 619 66.3
Urban 315 33.7
Gender, n (%)
Male 62 57.9
Female 45 42.1
54
Characteristics Total (N)= 1027 Percentage (%)
Age (in months), Mean± SD 33±16
Age group, n (%)
6-23m 234 26.3%
Male 116 49.6%
Female 118 50.4%
24-59m 656 73.7%
Male 353 53.8%
Female 303 46.2%
3.1.3 Household characteristics

Table 11 represents the demographic characteristics of the sampled households. The median
household size was 5 people in both rural and urban areas in Bangladesh.
Table 11. Household and demographic characteristics of the survey sample

Variables Overall Urban Rural
(N=2047) (N=655) (N=1392)
Household
Household size, Median (25th -75th quartile) 5 (4,6) 5 (4,6) 5 (4,6)
Mean±SD 4.9±1.7 4.9±1.7 4.8±1.7
Household dependency ratio, median2 0.50 0.50 0.50
(0.33-1.0) (0.33-1.0) (0.29-1.0)
1. All values are mean/percentage (95% confidence interval) or median (25th, 75th percentile) as indicated and are
weighted to correct for unequal probability of selection. The mean was used as the measure of central tendency for
normally distributed variables. The median was used for non-normally distributed variables.
2. Household dependency ratio = number of household members below 15 years of age and above 64 years of age
divided by number of household members between 15 and 64 years of age. aMother of the child
3.1.4 Multidimensional Poverty Index (MPI)

Regarding the living standard components of the households, the survey participants experienced
some issues including unimproved sanitation (77.67%), inadequate cooking fuel source, i.e dung,
wood coal or charcoal (81.68%) and possession of fewer than two key assets (1.5%). Around
81.2% of households in rural area reported to have unimproved sanitation facilities and 91.2% of
households in rural were still dependent on inadequate cooking fuel source (table 12.2).
15.5% of the household reported that at least one child of school age (5-14 years) of the family
was not in school. However, regarding the level of deprivation of education, there was no
55
significant difference between rural (16%) and urban areas (14.5%). On the other hand, about 35.2%
of households in the survey had no members of the family with more than five years of education.
The regional variation was 37.6% in rural and 30.3% in urban areas.
The MUAC measurement showed that around 3% of children were malnourished. According to
the survey report, only 1.07% of households had lost at least one child of under-five years of age
in the last five years (Table 12.2).
Table 12. Multidimensional Poverty Index and its component indicators
Variables Overall Rural Urban P-

(N=2047) % (N % (N=656) % value
=1392) *
Living standard component
No electricity, % 34 1.9% 30 2.6% 4 0.7% .006
Unimproved sanitation, %3 1374 77.67% 887 75.8% 487 81.2% .001
Unsafe drinking water source, %4 126 7.12% 82 7.04% 44 7.37% .736
Inadequate flooring, %5 985 55.7% 778 66.5% 207 34.7% .001
Inadequate cooking fuel source,
1445 81.68% 1066 91.2% 379 63.4% .001
%6
Fewer than two key assets and no
26 1.5% 22 1.9% 4 0.7% .045
car/truck, %7
Education component
At least one child (5-14 years old)
not currently attending school 255 15.5% 177 16% 78 14.5% -
(N=1647)
No member age 10 years or older
P<.00
has completed five years of 2270 35.2% 1610 37.6% 660 30.3%
1
schooling, %(N=6454)
Health and nutrition component
At least one child born in the last 5
19 1.07% 12 1.02% 7 1.16% 0.89
years has died, %
N=932 % N=618 % N=314 %
#Caregiver or child is
28 3% 21 3.39% 7 2.22% 0.363
malnourished, %
1
All values are percentages (95% confidence interval) and weighted to correct for unequal probability of selection. ; 2Households with multi-
dimensional poverty index score ≥ 0.33.;3The household does not have access to an improved sanitation facility (a flush toilet or latrine,
ventilated improved pit, or composting toilet), or the facility is improved but is shared with other households.; 4The household does not have
access to safe drinking water (piped water, public tap, borehole or pump or tube well, protected well, or protected spring), or safe drinking water
is more than a 30-minute round-trip walk from home.;5The household has an earth, sand, or dung floor.;6The household cooks with dung, wood,
coal, or charcoal.;7From among the following assets: radio, television, mobile/nonmobile phone, bicycle, motorcycle, refrigerator, and/or car or
truck.;8Mid-upper-arm circumference is <230 mm for female caregiver, or <125 mm for child six months or older.;[Note to the user: These
56
# The denominator was 186 (missing observation:12) *
categories and footnotes must be adapted to the country-specific MPI module.]; independent chi-square test
done to calculate p- value
Food insecurity
The degree of food insecurity was assessed on the basis of how often a household has the chance
to have preferred and quality food in their meal and whether they had faced any of the three severe
conditions, namely running out of food, going to bed hungry, or going a whole day and night
without eating. Food insecurity was classified into three categories (i.e mild, moderate, severe food
insecurity). To assess household insecurity, this survey collected information from 1769
households.
As shown in Table 13, 32.6 % of households experienced moderate to severe level of food
insecurity in terms of access to food. 28.4% household in rural area reported to have moderate
food insecurity. Contrary to that, 8.0% of households in urban area mentioned to have severe food
insecure access than the rural area.
Table 13.Food insecurity status at the household level
Food insecurity level Overall (N=2047) Rural (N=1353) Urban (N=656)

N % N % N %
Food secure 586 33.1% 372 31.8% 214 35.7%
Mildly food insecure
606 34.3% 407 34.8% 199 33.2%
Moderately food insecure
471 26.6% 332 28.4% 139 23.2%
Severely food insecure
106 6.0% 58 5.0% 48 8.0%
1Food secure households: The households who did not experience any food insecurity conditions and rarely worried about such
conditions.
2Mildly food insecure households: Those who worried about not having enough food sometimes or often, and/or were unable to
eat preferred foods, and/or eat a more monotonous diet than desired and/or some foods considered undesirable but did so only
rarely. They did not however cut back on quantity or experience any of the three most severe conditions, namely running out of
food, going to bed hungry, or going a whole day and night without eating.
3Moderately food insecure households: Those who sacrificed quality more frequently, by eating a monotonous diet or undesirable
foods sometimes or often, and/or have rarely or sometimes started to cut back on quantity by reducing the size of meals or
number of meals, but never experienced any of the three most severe conditions.
57
4
Severely food insecure households: Those who had to cut back on meal size or number of meals often and/or had experienced
any of the three most severe conditions, even if only rarely.
4.3 Micronutrient deficiencies
Vitamin A deficiency
In this survey, the prevalence of Vitamin A deficiency assessed among children 6-59 months of
age and NPNL women (15-49 years of age) with the amount of serum retinol from the blood test
result.
This survey assessed serum retinol in 1023 children from 6-59 months of age (under-5). Among
under-5 children almost half (42.8%) had mild degrees of Vitamin A deficiency (serum retinol 10-
19 µg %), while few children 7.20% had moderate vitamin A deficiency (serum retinol 20-30 µg
%). The prevalence of moderate vitamin A deficiency found almost similar in children in urban
area and rural area (6.4% vs. 7.7%) (See figure 1).
100.00%
90.00%
80.00%
70.00%
60.00%
50.00% 49.90% 50.20%
50.00% 42.80% 42.40% 43.50%
40.00%
30.00%
20.00%
7.20% 7.70% 6.40%
10.00%
0.00%
Overall Rural Urban
Moderate VAD Mild VAD Sufficient Vitamin A
Figure 1- Prevalence of vitamin A deficiency in children age 6-59 month by place of residence
Among eight divisions, the highest proportion of moderate vitamin A deficiency found in Sylhet
(11.0%) followed by Barisal (11.0 %) and Chittagong (8.7%) division. (Figure 1)
58
80.00% 73.20%
70.00% 63.20%
60.00% 50.30% 52.80% 56.00% 54.80%
47.60% 44.40% 47.50%
50.00% 41.30% 41.00% 44.10%
40.00% 36.20% 33.90%
31.90%
30.00% 25.00%
20.00% 11.10%
8.70% 8.50% 11.30%
4.90% 7.80%
10.00% 1.80% 2.80%
0.00%
Moderate VAD Mild VAD Sufficient Vitamin A
Figure 2: Distribution of vitamin A deficiency by divisions

Vitamin A deficiency in NPNL women
1013 women were recruited from 8 divisions including Dhaka, Chattagram, Sylhet, Rajshahi,
Khulna, Barisal, Rangpur and Mymensingh. There were around 9% women had mild Vitamin A
deficiency and 0.9% had moderate Vitamin A deficiency. Among the NPNL women from rural
area (9.50%) experienced to have slightly higher proportion of Vitamin A deficiency than the
urban women (7.6%) (Figure 3).
100.00% 90.30% 89.40% 92.00%
80.00%
60.00%
40.00%
20.00% 8.80% 9.50% 7.60%

0.90% 1.10% 0.30%
0.00% moderate mild sufficient
Total Rural Urban
Figure 3: Prevalence of Vitamin A deficiency among NPNL women (15-49 years) by area of
residence
Among the eight divisions Sylhet Division (21.10%) reported to have highest number of Vitamin
A deficiency compared to other divisions. (Figure 4)
59
moderate mild sufficient
120.00%
98.20% 98.60%
100.00% 89.20% 92.30% 93.10% 92.40%
81.90%
77.60%
80.00%
60.00%
40.00%
21.10%
16.40%
20.00% 9.20% 7.70% 6.20% 5.90%
1.80% 1.40%
0.00%
Figure 4: Distribution of Vitamin A deficiency among NPNL women (15-49 years) by divisions
Vitamin D deficiency
Serum Vitamin D level gives us a picture of Vitamin D level in the body. Vitamin D was assessed
among both under-5 children and NPNL women. There are controversial scientific discussions
exist regarding the cut off level of Vitamin D deficiency level. Most of the guidelines recommend
target serum 25-hydroxyvitamin D (25[OH]D) concentrations of ≥50 nmol/L (20 ng/mL) while
there is minimum consensus in the scientific community is that serum 25(OH)D concentrations
below 25–30 nmol/L (10–12 ng/mL) must be prevented and treated. In the recent survey, we
identified serum vitamin D < 50 nmol/L as insufficiency and < 30 nmol/L as deficiency level.
Vitamin D deficiency of under-5 children
Among 805 under-5 children from eight divisions (Dhaka, Chattagram, Khulna, Rajshahi,
Rangpur, Sylhet, Barisal and Mymensingh) 24.5% of children of this survey were suffering from
Vitamin D deficiency (serum Vitamin D <30 nmol/L). The proportion of Vitamin D deficiency
found higher in urban area than the rural area (28.6% vs. 22.2%) (See figure 5).
60
VItamin D sufficient Vitamin D deficiency
100.00%
90.00%
75.50% 77.80%
80.00% 71.40%
70.00%
60.00%
50.00%
40.00%
24.50% 28.60%
30.00% 22.20%
20.00%
10.00%
0.00%
Total Rural Urban
Figure 5: Prevalence Vitamin D deficiency in children age 6-59 month by place of residence
According to the divisions, Sylhet has the highest proportion of vitamin D deficiency followed by
Chittagong (41.5% and 39.1% respectively). (Figure 6)
VItamin D sufficient Vitamin D deficiency

100.00%
90.00% 85.30% 85.80%
80.60% 81.90%
80.00% 74.60% 76.80%
70.00%
60.90% 58.50%
60.00%
50.00% 41.50%
39.10%
40.00%
30.00% 25.40% 23.20%
19.40% 18.10%
20.00% 14.70% 14.20%
10.00%
0.00%
Barisal Chittagong Dhaka Khulna Mymensingh Rajshahi Rangpur Sylhet
61
Figure 6: Distribution of Vitamin D deficiency in children age 6-59 month by divisions
Vitamin D deficiency in NPNL women
More than half of the NPNL women (56.7%) from 8 divisions (Dhaka, Chattagram, Khulna,
Rajshahi, Rangpur, Sylhet, Mymensing and Barisal) were suffering from any level of Vitamin D
insufficiency (≤ 50 nmol/L) in this survey. Among these women, 16.1% had a severe deficiency
(Vitamin D < 30 nmol/L). However, there were 27.2% of participants reported to have sufficient
levels of Vitamin D in their bodies (Figure 7).
As shown in Figure 7, 59% and 55.2% of the NPNL women were suffering from Vitamin D
insufficiency in urban and rural areas, respectively. On top of that, 23.70% women were suffering
from vitamin D deficiency in urban areas which was double compared to the estimates of rural
areas (11.9%) (Figure 7).
90.0% 83.2%
80.0% 72.8%
70.0% 67.1%
60.0%
50.0%
40.0% 32.9% 32.9%
27.2%
30.0%
20.0%
10.0%
0.0%
Overall Rural Urban
Vitamin D deficiency Vitamin D sufficient
Figure 7.1 Prevalence of vitamin D deficiency among NPNL women by place of residence
62
70.00%
59.60%
60.00% 56.70% 55.20%
50.00%
40.00%
32.90% Deficiency
30.00% 27.20%
23.70% Insufficient
20.00% 16.10% 16.70% Sufficient

11.90%
10.00%
0.00%
Total Rural Urban
Figure 7.2- Prevalence of vitamin D deficiency in NPNL women by classifying insufficient and
deficieny
Among all eight divisions, Dhaka Division reported to have highest proportion of Vitamin D
deficiency (25%). Whereas, Mymensingh division most frequently reported to have vitamin
insufficiency (62.50%) (Figure 8).
Deficiency Insufficient Sufficient

100.00%
90.00%
80.00%
70.00% 60.70% 62.50% 61.90%
58.50% 56.90% 57.10%
60.00% 50.90% 53.30%
50.00%
40.00% 32.30% 34.00%
28.40% 29.20% 27.30%
30.00% 25.00% 22.20%
20.70% 21.20%
14.30% 15.30% 16.80% 17.50% 15.60%
20.00%
9.20% 9.00%
10.00%
0.00%
Figure 8- Prevalence of vitamin D deficiency in NPNL women by division
Iron deficiency
Iron deficiency of children
63
Among 805 children, 14.7% of under-5 children had iron deficiency and the proportion of iron
deficiency was about two times higher in urban area compare to rural area (20.60% Vs. 11.40%)
(See figure 9).
Normal range Iron deficiency
100.00% 88.60%
90.00% 85.30%
79.40%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00% 20.60%
20.00% 14.70% 11.40%
10.00%
0.00%
Total Rural Urban
Figure 9: Prevalence of iron deficiency of children aged 6-59 months by place of residence
Figure 10 showed, the highest proportion of vitamin D deficiency was found in Barisal (22.2%)
than the other divisions (Figure 10).
100.00% 91.10% 90.80%
87.00% 87.10% 86.70%
90.00% 81.20% 81.90%
77.80%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00% 22.20% 18.80% 18.10%
20.00% 13.00% 12.90% 13.30%
8.90% 9.20%
10.00%
0.00%
Normal range Iron deficiency
Figure 10: Distribution of iron deficiency of children aged 6-59 months by place of residence
Iron deficiency in NPNL women
64
Figure 11 described that 14.1% NPNL women had iron deficiency and the proportion was higher
in urban area compare to rural area (19% Vs 11.5%).
Normal Iron deficiency
100.00%
85.90% 88.50%
90.00% 81.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
19.00%
20.00% 14.10% 11.50%
10.00%
0.00%
Total Rural Urban
Figure 11: Iron deficiency of NPNL women by division

According to divisions, Iron deficiency was higher in Barisal 30.80% and lower in Rajshahi 6%.
(Figure12).
Normal Iron deficiency
100.00% 94.00% 94.20%

83.40% 86.10% 84.70% 84.60%
90.00% 80.40%
80.00% 69.20%
70.00%
60.00%
50.00%
40.00% 30.80%
30.00% 16.60% 19.60%
13.90% 15.30% 15.40%
20.00%
6.00% 5.80%
10.00%
0.00%
Figure 12: Distribution of Iron deficiency in Women (15-49 years) by divisions
Zinc Deficiency:
65
Zinc plays a vital role in healthy pregnancy, child development and normal immune system
function children with zinc deficiency are more prone to infections such as diarrhea and pneumonia
due to its detrimental impact on immunity. Zinc deficiency caused by inadequate intake of zinc
from the diet, malabsorption, or excess losses of zinc during diarrhea(80). This section of the result
presents prevalence of deficiency among children 6-59 months and among NPNL women of 15-
49 years.
Zinc deficiency was estimated by serum zinc level in the body. Serum zinc concentrations vary by
age group, sex, time of day of the blood collection and fasting status of the individual. Therefore,
cut-offs for zinc deficiency need to be presented separately for each of these categories. According
to that the cut off for Zinc deficiency of under-5 children were determined according to the blood
collection time; for morning non-fasting samples the value is > 0.65 mg/L and for afternoon non-
fasting samples cut off is > 0.57 mg/L. For NPNL women morning, non-fasting cut off is
determined >0.66 mg/L and afternoon, non-fasting value is >0.59 mg/L as Zinc deficiency.
Zinc deficiency of children:

The prevalence of zinc deficiency was 29.3% among the children which was higher in the urban
area compare to the rural areas (31.1% vs. 26.1%) (Figure 13).
66
100.0%
90.0%
80.0% 73.9%
70.7% 68.9%
70.0%
60.0%
50.0%
40.0%
29.3% 31.1%
30.0% 26.1%
20.0%
10.0%
0.0%
Overall Rural Urban
Normal Zinc deficiency
Figure 13. Prevalence of Zinc deficiency among children age 6-59 months
The maximum deficiency was found in the Chittagong division and the lowest deficiency was
found in Sylhet division. (Figure 14)
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0% 24.7%
16.6% 17.9%
20.0% 15.3%
6.8% 7.2% 8.1%
10.0% 3.4%
0.0%
Sylhet Dhaka Mymensingh Barisal Rajshahi Rangpur Khulna Chittagong
Figure 14. Distribution of zinc deficiency status in children aged 6-59 month by division
67
Zinc deficiency of NPNL women:
Zinc deficiency reported across all eight divisions among the NPNL women. The overall
prevalence of Zinc deficiency was 43.9% which was slightly higher in rural area (44.5%) than
urban area (42.9%) (Figure 15).
100.0%
90.0%
80.0%
70.0%
60.0%
50.0% 43.9% 44.5% 42.9%
40.0%
30.0%
20.0%
10.0%
0.0%
Overall Rural Urban
Zinc deficiency Normal
Figure 15 Zinc deficiency of NPNL women aged 15-49 years by area division
The zinc deficiency was maximum in Rajshahi division (20.3%) and minimum in Dhaka division
(5.8%) (Figure 16).
68
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0% 20.3%
20.0% 13.1%
9.7% 11.4% 11.7%
5.8% 8.1%
10.0%
0.0%
Dhaka Sylhet Mymensingh Barisal Rangpur Chittagong Khulna Rajshahi
Figure16. Distribution of Zinc deficiency among non-pregnant and non-lactating women by

division
Anaemia
In this survey we used haemoglobin level in blood for anaemia detection. Anaemia was assessed
using haemoglobin (hb%) level in blood. Anaemia was detected in NPNL women 15-49 years
when hb% level was < 12 gm dl and hb <11 gm/ dl for 6-59 months children.
Anaemia in children age 6-59 month

There were around 21% of children aged 6 to 59 months, suffering from anaemia. Among them,
14% children were suffering from mild anaemia and 6% children were suffering from moderate
anaemia and 0.4% severe anaemia. Prevalence of mild anaemia was higher in rural area
compared to urban areas (19.9%) while, (Figure 17).
69
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0% 23.3%
21.1% 19.9%
20.0%
10.0%
0.0%
Overall Rural Urban
Anaemia Non-anaemia
Figure 17: Prevalence of Anaemia in children age 6-59 month by place of residence
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0% 14.0% 14.1% 13.9%
6.7% 8.7%
10.0% 5.6%
.4% .2% .7%
.0%
Overall Rural Urban
Severe Moderate Mild Non-anaemia
Figure 17.a Prevalence of mild to severe anaemia by place of residence
The prevalence of mild anaemia among under-5 children were reported highest in Chittagong
Division (24.1%), and lowest in Dhaka Division (4.7%). (Figure 18).
70
30.0%
24.1%
25.0%
20.0% 18.8% 18.8%
15.0%
12.4%
10.0%
10.0%
6.5%
4.7% 4.7%
5.0%
0.0%
Dhaka Sylhet Mymensingh Barisal Khulna Rajshahi Rangpur Chittagong
Anaemia Non-Anaemia
Figure 18: Distribution of Anaemia in children age 6-59 month by place of residence
Anaemia of NPNL women (15-49 years)
The overall prevalence of severe anaemia of NPNL women of the survey population was
around 30%, 19% women have mild anaemia and 10.5% women have moderate anaemia.
The proportion of mild anaemia was slightly higher in rural area than the urban area (19.7%
Vs 17.3%). However, moderate anaemia found higher in urban area than the urban area
(19.7% vs. 17.6%) (Figure 19).
71
80.0%
69.9% 70.5% 69.2%
70.0%
60.0%
50.0%
40.0%
30.1% 29.5% 30.8%
30.0%
20.0%
10.0%
0.0%
Overall Rural Urban
Anaemia Non-Anaemia
Figure 19.1. Overall prevalence of anaemia among NPNL women
80.0%
69.9% 70.5% 69.2%
70.0%
60.0%
50.0%
40.0%
30.0%
18.9% 19.7% 17.3%
20.0% 12.1%
10.5% 9.7%
10.0%
.6% .2% 1.4%
0.0%
Total Rural Urban
Non -Anemia Mild Anaemia Moderate Anaemia Severe Anaemia
Figure 19 Prevalence of mild to severe anaemia in NPNL women by division
Among eight divisions, the highest proportion of mild and moderate anaemia was found
in Sylhet 26.9% and 11.5% . (See figure 20).
72
100.0%
90.0%
77.8%
80.0% 75.0%
72.5% 72.4% 70.8%
70.0% 66.9%
64.6%
60.3%
60.0%
50.0%
40.0%
30.0% 26.9%
23.3%
18.5% 19.5% 19.0%
20.0% 16.9% 15.5%
12.4% 12.5% 12.0% 13.9%
10.7% 11.5%
6.9% 8.6%
10.0% 5.8%
0.0% 1.2% 1.8% 0.0% 1.4% 0.0% 0.0% 1.3%
0.0%
Non -Anemia Mild Anaemia Moderate Anaemia Severe Anaemia
Figure 20: Distribution of Anaemia in NPNL women by divisions
Iodine deficiency
According to the World Health Organization (WHO), different degrees of iodine deficiency
depend on median urinary Iodine cut off levels. Median UI below 100 µgm/ L define that a
population has iodine deficiency. WHO also recommended that, the target population of iodine
deficiency survey would be the school based children aged 6-12 years. However, when data for
this age group were not available, data of the next closest age group can be used in the following
order of priority: data from the children closest to school age, adults, the general population,
preschool-age children and other population groups (WHO, 2001). In this survey we collected
report of median urinary iodine concentration of under- 5 children (6-59 months) and the NPNL
women aged 15- 49 years.
73
Iodine deficiency of children (6-59 month)
In our current survey, we found around 23% of the children between 6-59 months age had
iodine deficiency in eight divisions including Dhaka, Rajshahi, Rangpur, Sylhet,
Chattagram, Barisal, Khulna and Mymensingh Division. Overall 11.2% children had mild
iodine deficiency and 6.8% children had moderate iodine deficiency. Mild iodine
deficiency was found higher in rural area compare to urban area (14.1% vs. 5.9%) (See
figure 21).
43.90%
25.80%
Urban
5.90%
2.40%
0.70%
Possible excess
33.80%
More than adequate
24.70% Optimal
Rural
14.10%
9.30% Mild iodine deficiency
0.80% Moderate iodine deficiency
Severe iodine deficiency
37.40%
25.10%
Total
11.20%
6.80%
0.70%
0.00% 10.00% 20.00% 30.00% 40.00% 50.00%
Figure 21 Prevalence of Iodine deficiency in children age 6-59 month by area place of residence
74
Highest proportion of Iodine deficiency reported in Mymensingh (13.9%) and Rajshahi
(13.8%) . on contrary lower proportion of mild iodine deficiency found in Barisal (3.10%)
and Sylhet (3.20%) (Figure 22).
Sylhet
6.20%
1.50%
Rangpur
15.00%
0.80%
Rajshahi
8.60%
0.90%
Possible excess
Mymensingh More than adequate
5.60%
1.40%
Optimal
Khulna Mild iodine deficiency

4.90%
0.70% Moderate iodine deficiency
Severe iodine deficiency
Dhaka
5.40%
0.00%
Chittagong
4.10%
0.60%
Barisal
3.20%
0.00%
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00%
Figure 22- Distribution of Iodine deficiency in children age 6-59 month divisions
Iodine deficiency in NPNL women

The level of Iodine deficiency (UIC < 100 mcg/ L) was 29.3% among NPNL women across eight
divisions including Sylhet, Rajshahi, Dhaka, Chattagram, Khulna, Barisal, Rangpur and
Mymensingh Divisions. Among them, 17.1% women had mild iodine deficiency. 10.3% women
75
had moderate iodine deficiency. According to place of residence, moderate iodine deficiency was
reported higher in rural areas than urban areas (13.4% Vs 4.5%) and mild iodine deficiency was
found slightly higher in rural areas than the urban areas (17.5% vs. 16.3%) (Figure 23).
33.30%
19.80%
25.30%
Urban
16.30%
4.50%
0.70%
25.80% Possible excess

17.20% More than adequate
23.40%
Rural Optimal
17.50%
Mild
13.40%
Moderate
2.60%
Severe
28.50%
18.10%
24.10%
Total
17.10%
10.30%
2.00%
0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00%
Figure 23- Prevalence of Iodine deficiency in NPNL (15-49 years) women by place of residence
Across all eight divisions, highest proportion of iodine deficiency was found in Sylhet
division 53% and lower deficiency found in Barisal division 9%. Among them, mild
iodine deficiency reported in Rangpur Division (28.6%). On contrary, lower proportion
of mild iodine deficiency was found in Barisal division (7.70%) (Figure 24).
76
38.50%
Sylhet 12.80%
5.10%
11.80% Possible excess
Rangpur 28.60%
21.80% More than adequate
22.40%
Optimal
Rajshahi 18.10%
11.20%
Mild
27.80%
Mymensingh 16.70% Moderate
9.70%
28.50% Severe
Khulna 13.90%
8.30%
37.50%
Dhaka 17.90%
5.40%
25.60%
Chittagong 16.70%
10.70%
58.50%
Barisal 7.70%
1.50%
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00%
Figure 24- Distribution of Iodine deficiency in NPNL women by divisions
Vitamin B12 deficiency
Vitamin B 12 deficiency in NPNL women

In this survey, the prevalence of vitamin B 12 deficiency assessed among the NPNL women (15-
49 years of age). The level of vitamin B 12 was assessed with the amount of serum vitamin B12
from the blood test result.
As shown in Figure 25, only 21.30% had Vitamin B12 deficiency (Serum B12 level <203 pg/mL).
Vitamin B12 deficiency found slightly higher in rural area compare to urban area (21.7% Vs
20.1%) (Figure 25).
77
100.00%
78.70% 78.30% 79.90%
80.00%
60.00%
40.00%
21.30% 21.70% 20.10%
20.00%
0.00% Vitamin B12 deficiency Normal

Total Rural Urban
Figure 25: Prevalence of Vitamin B12 deficiency in Women (15-49 years) by place of residence
Among the eight divisions including Sylhet, Rajshahi, Rangpur, Chattagram, Khulna, Barisal and
Mymensingh Divisions, Rajshahi and Mymensing divisions were reported to have equally
highest proportion of vitamin B12 deficiency 29.30% and 29.20% respectively (Figure 26).
90.00% 82.40% 84.70%

79.70% 79.20% 80.50%
80.00% 75.00%
70.80% 70.70%
70.00%
60.00%
50.00%
40.00%
29.20% 29.30%
30.00% 25.00%
20.30% 17.60% 20.80% 19.50%
20.00% 15.30%
10.00%
0.00%
Vitamin B12 deficiency Normal
Figure 26: Distribution of Vitamin B12 deficiency in Women (15-49 years) by divisions
Folate deficiency
Serum folate level was assessed among NPNL women of eight divisions including Dhaka,
Chattagram, Sylhet, Rajshahi, Rangpur and Khluna division in this survey. As shown in Figure 27,
78
30.70% of NPNL women were suffering from folate deficiency (S. Folate <4 ng/mL) and the
highest proportion of Folate deficiency was reported in urban area compare to rural area (36.70%
vs. 27.40%) (Figure 27).
Normal Folate deficiency
80.00% 72.60%
69.30%
70.00% 63.30%
60.00%
50.00%
36.70%
40.00% 30.70%
27.40%
30.00%
20.00%
10.00%
0.00%
Total Rural Urban
Figure 27- Prevalence of Folate deficiency in NPNL women by division
According to the figure 28, highest proportion of folate deficiency was found higher in
Sylhet division 53.30% (Figure 28).
100.00%
90.00% 83.90%
78.10%
80.00% 72.40% 71.70%
69.40%
70.00% 65.50%
60.00% 51.80% 53.30%

50.00% 46.70%
48.20%
40.00% 34.50%
30.60% 28.30%
27.60%
30.00% 21.90%
20.00% 16.10%
10.00%
0.00%
Normal Folate deficiency
Figure 28: Distribution of folate deficiency in Women (15-49 years) by divisions
79
Chapter 5
Multiple micronutrient deficiencies
Multiple micronutrient deficiencies among children (6-59 months)
Results shows that 57% children have two or more micronutrient deficiencies and 30% children
have any one micronutrient deficiencies. The proportion of multiple micronutrient deficiencies
was 53% in female children; 65% children who lived in rural areas; The proportion of multiple
micronutrient deficiency was higher in Rajshahi division (22.3%) and the lowest proportion was
found in Barisal division (7.4%).
Table. Status of multiple micronutrient deficiency in children age 6-59 month
Variables No deficiency 1 (any micronutrient >1 (Multiple micronutrient

deficiency) deficiency)
Overall N=106 13.2% N=242 30.1% N=457 56.8%
Sex
Male 55 56.1 106 48.0 220 52.5
Female 43 43.9 115 52.0 199 47.5
Place of
residence
Rural 65 61.3 155 64.0 298 65.2
Urban 41 38.7 87 36.0 159 34.8
Division
Barisal 15 14.2 14 5.8 34 7.4
Chittagong 24 22.6 43 17.8 102 22.3
Dhaka 7 6.6 25 10.3 24 5.3
Khulna 26 24.5 47 19.4 71 15.5
Mymensingh 9 8.5 22 9.1 41 9.0
Rajshahi 6 5.7 35 14.5 75 16.4
Rangpur 11 10.4 35 14.5 74 16.2
Sylhet 8 7.5 21 8.7 36 7.9
80
Multiple micronutrient deficiencies among NPNL women (15-49 years)
Result shows that 73% NPNL women have two or more micronutrient deficiencies and 22%
NPNL women had any one micronutrient deficiencies. The proportion of multiple micronutrient
deficiencies was55% in 30 to 49 years age group; 70% in rural area and 30% in urban area.. The
proportion of multiple micronutrient deficiencies was higher in Chittagong division (19%) and
the lowest proportion was 7% in Dhaka division.
No deficiency 1 (Any >1 (Multiple

micronutrient micronutrient
deficiency) deficiency)
N=44 5.4% N=178 21.7% N=598 72.9%
Age group 15-29 years 12 3.4 81 22.9 261 73.7
30-49 years 32 6.9 97 20.9 336 72.3
Place of Rural 33 6.2 125 23.6 372 70.2
residence Urban 11 3.8 53 18.3 225 77.9
Division Barisal 4 6.2 11 16.9 50 76.9
Chittagong 12 7.1 44 26.0 113 66.9
Dhaka 1 1.8 14 25.0 41 73.2
Khulna 11 7.6 38 26.4 95 66.0
Mymensingh 3 4.2 11 15.3 58 80.6
Rajshahi 5 4.3 17 14.7 94 81.0

Rangpur 6 5.0 27 22.5 87 72.5
Sylhet 2 2.6 16 20.5 60 76.9
81
Chapter 6
Dietary diversity
NPNL Women’s dietary diversity
Milk or milk Product
Milk and milk products are important sources of high-quality protein, potassium and calcium, as
well as Vitamin B12 (available only from animal-source foods) and other micronutrients. This
group includes almost all liquid and solid dairy products from animal sources. Tinned, powdered,
or ultra-high temperature (UHT) milk, soft and hard milk products such as hard cheeses and
yoghurt etc. are also included in this group. However, butter, cream, and sour cream are excluded
from the group as these food items are good sources of fat and oil content. According to Table 31,
over the last 24 hours only 1/3rd of women from the survey population consumed any kind of milk
and one out of ten women consumed any milk products. Any type of milk consumption was higher
among rural women compared to urban (41.7% vs 29.4%). On the other hand, 21.3% of women
had taken milk products in urban areas compared to 9.5% women of rural areas. (Table 29)
Grains, white roots and tubers, and plantains
This group of foods is sometimes also called “starchy staples”. These foods provide energy and
varying amounts of micronutrients (e.g. certain B vitamins) provided by grains. Common
examples of grain include all types of bread, rice, pasta/noodles, porridge or other foods made
from any grains. Any kind of white roots, tubers such as potatoes, white-fleshed sweet potatoes,
white yams, yucca and plantains are also considered to be part of the “starchy staples” group.
82
Almost all households consumed grain made food as their staple food in a week. Around 81.7%
of the women reported to have any white roots, tuber or plantains in their last day meal which was
higher in urban than rural areas (Table 29)
Fruits and Vegetables
Vegetables and fruits are good sources of vitamins and minerals. Among different types of
vegetables, the “other vegetables” (76.8%) consumption was more than dark green leafy
vegetables (47.6%) and colourful Vitamin A-rich vegetables (17.5 %) in both urban and rural
areas. Examples of other vegetables include tomatoes, okra, eggplant, cucumber, etc. Overall
vegetable consumption was higher in urban areas than in rural areas (Table 29). More than one
third (42.6%) of the households consumed fruits at least 2 days per week.
Protein:
Near half of the population reported consuming at least one type of meat or poultry (50.8%) and
eggs (49.1%) as a source of protein in their last day meal. (Table 29).
83
Table 29. Dietary diversity of NPNL women (15-49 years)
Dietary variables Last 24 hours

Overall Rural Urban
n=2047 n=1392 N=655
Milk or milk product
Tinned, powdered or fresh milk, or any other milk, % 34.5 41.7 29.4
Any milk products10, % 14.2 9.5 21.3
Any foods made from grains13
Any white roots and tubers or plantains1, % 81.7 71.5 97
Vegetables and fruits
Any vegetables or roots that are or that are yellow or orange inside2, % 17.5 13.1 24
Any dark green leafy vegetables3, % 47.6 38.1 61.9
Any other vegetables4, % 76.8 69.1 88.5
Any fruits that are dark yellow or orange inside5, % 42.6 39.9 46.8
Source of protein
Any meat made from animal organs6, % 8.9 7.8 10.5
Any other types of meat or poultry7, % 50.8 50.6 51
Eggs, % 49.1 41.7 60.7
Any fresh or dried fish, shellfish or seafood, % 23.1 18.5 30.2
Beans or peas8, %
69.1 68.5 70
Nuts or seeds9, %
12.0 6.9 19.6
Any oils and fats11, %
86.2 90.9 79.1
Any condiments and seasonings12, %
96.9 96.2 98.0
84
1
such as: white potatoes, white yams, cocoyam, manioc/cassava/yucca, taro, or any other foods made from white-fleshed roots or tubers, or
plantains
2
such as: carrots, squash, pumpkin, sweet potatoes
3
such as: cassava leaves, bean leaves, spinach, kale
4
such as tomatoes, okra, eggplant, cucumber
5
Such as: ripe mango, ripe papaya, ripe passion fruit, peaches, apricot
6
such as: liver, kidney, heart, or other organ meats or blood-based foods, including from wild game
7
Such as: beef, pork, lamb, goat, rabbit, wild game meat, chicken, duck, or other birds
8
such as: mature beans or peas (fresh or dried seed), lentils or bean/pea products, including hummus, tofu, tempeh
9
Such as: any tree nut, groundnut/peanut, certain seeds, nut/seed “butters” or pastes
10
such as: cheese, yoghurt or other milk products, but NOT including butter, ice cream, cream or sour cream
11
Such as: oil, fats or butter added to food or used for cooking, including extracted oils from nuts, fruits and seeds, and all animal fat
12
such as: ingredients used in small quantities for flavor, such as chilies, spices, herbs, fish powder, tomato paste, flavor cubes or seeds
13Such as: porridge, bread, rice, pasta/noodles, or other foods made from grains
Dietary diversity of children (6-59 months)
According to 24-hour dietary recall, children from more than half of the households consumed
milk in any form, any white roots or tubers, “other vegetables”, eggs, beans, and peas in their
previous day’s meals. Nearly 59% cosnumed diery product; only 8.3% cosnumed any root
vegetables 38% consumed green vegetables . Nearly 12% taken protein from animal organ;65%
taken beans or peas; 15% nuts or seeds. (Table 31)
Table 31. Dietary diversity of children age in the last 24 hours (6-59 months)
Dietary Variables In last 24 hours

Overall Rural Urban
n=2047 n=1392 N=655
Milk or milk product

Tinned, powdered or fresh milk, or any other milk,
% 58.6 60.1 56.1
Any milk products10, % 11.9 13.2 9.8
Any foods made from grains13, % 95.7 94.4 97.6
Any white roots and tubers or plantains1, % 66.2 60.1 75.6
Vegetables and fruits
Any vegetables or roots that are or that are yellow
or orange inside2, % 8.3 5.1 13.4
Any dark green leafy vegetables3, % 38.8 33.2 47.6
Any other vegetables4, % 50.2 41.0 64.7
Any fruits that are dark yellow or orange inside5, % 37.8 34.7 42.7
Source of protein
85
Any meat made from animal organs6, % 12.5 10.4 16.0
Any other types of meat or poultry7, % 48.6 46.3 52.2
Eggs, % 63.9 57.3 74.2
Any fresh or dried fish, shellfish or seafood, % 4.8 2.6 8.3
Beans or peas8, % 64.8 57.3 76.6
Nuts or seeds9, % 15.3 16.6 13.2
Any oils and fats11, % 26.7 21.3 35.1
Any condiments and seasonings12, % 92.4 91.6 93.7
1
such as: white potatoes, white yams, cocoyam, manioc/cassava/yucca, taro, or any other foods made from white-fleshed roots or tubers, or
plantains
2
such as: carrots, squash, pumpkin, sweet potatoes
3
such as: cassava leaves, bean leaves, spinach, kale
4
such as tomatoes, okra, eggplant, cucumber
5
Such as: ripe mango, ripe papaya, ripe passion fruit, peaches, apricot
6
such as: liver, kidney, heart, or other organ meats or blood-based foods, including from wild game
7
Such as: beef, pork, lamb, goat, rabbit, wild game meat, chicken, duck, or other birds
8
such as: mature beans or peas (fresh or dried seed), lentils or bean/pea products, including hummus, tofu, tempeh
9
Such as: any tree nut, groundnut/peanut, certain seeds, nut/seed “butters” or pastes
10
such as: cheese, yoghurt or other milk products, but NOT including butter, ice cream, cream or sour cream
11
Such as: oil, fats or butter added to food or used for cooking, including extracted oils from nuts, fruits and seeds, and all animal fat
12
such as: ingredients used in small quantities for flavor, such as chilies, spices, herbs, fish powder, tomato paste, flavor cubes or seeds
13
Such as: porridge, bread, rice, pasta/noodles,or other foods made from grains
Chapter 7
Vitamin and mineral supplementation coverage
Approximately, 93.5% of the children received vitamin A supplementation within last six months
since the date of survey. The proportion of Vitamin A supplementation was higher in rural than
urban areas (89.9% vs. 94.3%). Around36% of children received Anthelmintic tablet in the last six
months. (Table 37)
Table37.Vitamin A and anthelminthic Tablet supplementation of under-5 children (6-59
months)
Overall Rural Urban

n=2047 n=1392 N=655
Vitamin A supplementation1 93.5 89.9 94.3
Antihelmintic2 36.1 42.4 36.1
1 last vitamin A-plus campaign 20th June,2019; 2 Last six month;
86
As shown in Table 38, only 9.7% NPNL women reported to consume multivitamin and multiple
micronutrients. 45.2% of women had knowledge regarding vitamin A rich food.
Table38.Vitamin and Mineral supplementation and knowledge of NPNL Women (15-49
years)
Overall Rural(N=630) Urban(N=1227)

(N=1857)% % %
Consume multivitamin or multiple
micronutrient1 9.7 14.2 4.5
Knowledge about vitamin A in food 45.2 49.9 35.8
Knowledge about vitamin A fortified oil2 25.1 42.1 17.9
Knowledge about iodine fortified salt2 82.6 83.0 84.6
1Last one month; 2available in the market
Chapter 8
Food fortification
5.1 Awareness and knowledge about food fortification
As shown in Table 41, around 24% of households among the survey population were reported
hearing about fortified foods. Compared to urban areas half of the rural households had knowledge
regarding the fortified foods. The figures were 16.1% and 36.4% in rural and urban areas,
respectively. However, more than half of the households reported positive attributes of the fortified
foods (overall 52.4%, in rural area 44.4% and in urban areas 58.3%).
There were 84.3% women reported to know about iodized salt is available in the market. Both
rural and urban population had adequate knowledge about salt fortification with iodine (84.9% and
83.3% respectively).
87
On the other hand, only near about 1/3rd (27.7%) of women of the survey population were aware
about fortified oil with Vitamin A in the market. Urban women were more aware regarding oil
fortification than women living in rural areas (43.3% Vs.18.9%). (Table 41)
Table41.Fortification awareness and knowledge among household
Overall Rural Urban

n=2047 n=1392 N=655
Reported hearing about fortified foods*, % 23.6 16.1 36.4
Reported positive attributes of fortified foods2, % 52.4 44.4 58.3
Reported to hear about availability of vitamin A fortified oil 27.7 18.9 43.3
in the market
Reported to hear about availability of iodine fortified salt in 84.3 84.9 83.3
the market
* 4 observations were missing
1
All values are percentage (95% confidence interval) except as indicated and weighted to correct for unequal
probability of selection.
2
Reported that fortification means “fortified/enriched/added micronutrients”, “good for health,” “better quality,” or
“good for growth and development of children.”
1.2 Household coverage of food vehicles
Consumption of salt, oil/ghee and rice was found to be universal (100%) and consumption in their
fortifiable forms almost universal for salt and oil (99.5% and 98.4% for salt and oil respectively).
However, consumption of rice in its fortifiable form was lower at 73.5%, indicating that about one
quarter of households make rice at home (i.e. small scale or in-home milling). This lower
consumption of fortifiable rice was slightly lower in rural areas, where only 62.1% of households
consumed fortifiable rice compared to 90.9% in urban areas. (Figure 3)
88
Figure 3. Household coverage of salt, oil, and rice by place of residence
A. Salt B.Oil C. Rice fortification
Consume Consume fortifiable Consume Consume fortifiable Consume Consume fortifiable

99.5%
100%
100%
100%
98.7%
100%
100%
100%
98.7%
98.4%
98.3%
100%
100%
100%
73.5%
62.1%
National Rural Urban National Rural Urban National Rural Urban
Note:“Consumes fortifiables” means the food vehicle used by the household was industrially
processed (i.e. not made at home). .
Consumption of salt, oil and rice was found to be universal (100%) among both poor and non-poor
group. Moreover, consumption in their fortifiable form also almost universal among the both poor
and non- poor froup for salt (100% and 98.9%, respectively) and oil (98% and 97.8% respectively).
However, consumption of fortifiable rice was slightly lower in poor group, where only 48.6%
households consumed fortifiable rice in compared to 67.4% of non-poor households. (Figure 4)
89
Figure 5. Household coverage of salt, oil, and rice by food security status
A. Salt B.Oil C. Rice fortification
6. Observation of fortication logo: Salt
Over all 32% of households were observed with salt package containing fortification logo or label
of fortification. This number was higher in rural area in compared to urban area. (23.1% Vs 25.6%,
respectively). Poor households were observed higher percentage with fortification logo in their
salt package (36.9%) compared to non- poor households (25.7%). According to the food security
status, 36.2% of food insecure households had salt packaged with fortification logo compared to
only 25% of food secure households. (Figure 6)
90
Observation of fortification logo: Oil
Over all 29.0% of households were observed with oil package containing fortification logo or
label of fortification. This number was higher in urban area in compared to rural area. (39.0% vs.
23.5%, respectively). Moreover, 41.3% of non-poor households were observed with
fortification logo in their oil package and the number was lower than the poor households
(20%). According to the food security status, 39% of of food secure households had oil
packaged with fortification logo compared to only 21.7% of food insecure households.(Figure
7).
Figure 7. Fortification logo observed of oil at the household level
i. oil
Place of residence Wealth Index Food security status at
households
Note: Consumes fortifiables” means the food vehicle used by the household was industrially processed (i.e. not made at home).
91
Chapter 9
Challenges and barriers

Challenges during project implementation:
The field team has completed survey in 50% of the selected PSUs despite physical and financial
challenges faced due to the emergence of COVID-19 pandemic. The survey was designed and
budgeted before COVID-19 pandemic, and the survey started after 6 months of the start of the
COVID-19 pandemic in Bangladesh. This required us to allocate substantial among of funding for
procuring personal protecting equipment (surgical masks, respiratory masks, gloves, face shield,
goggles, coverall, shoe cover, head cover) and huge volume of hand sanitizers for securing bio
safety of the entire field team, participants, investigators and visitors coming for the movement
and other stakeholder organizations. There was no scope in the budget for allocation for a large
volume of PPE and other supplies to ensure bio safety measures which created financial burden
on the project. Additionally, the local travel costs were inflated due to pandemic and to ensure
proper vehicles for transpiration of the large field team from district to districts for marinating
adequate social distancing and road safety, which had significantly increased the travel cost.
Challenges at field sites
There were number of challenges faced by the research team while implementing the survey at the
field level in four divisions of Bangladesh.
1. A number of study areas were located in the industrial areas of Sylhet division and majority of
the study participants were stone labour. The sample participants were absent in the households
and a number of participants could not manage time for providing information and blood
92
sample in the households. The survey team convinced the participants with the support of local
leader of the laborsto spend some hours for providing survey information.
2. A number of study sites located in the hard-to-reach areas of Sylhet division and roads were
destroyed due to the heavy flood in the region. The survey team reached to that place by boat
and motorcycle
3. Many times the local people created barriers while collecting the blood sample amid COVID-
19 pandemic. The local people assumed that if they provide the blood sample then they will be
affected with the corona virus. The survey team ensured the participants that they were
maintaining proper protection following the standard rules of government before collection of
any blood sample
4. The survey team faced different barriers for collecting the blood sample due to the rumors of
the local people. Some people had spread the rumor to the community that the survey team
were collecting the blood sample for spreading the HIV virus. The survey team contacted with
the community health worker, health assistant and health inspector for getting cooperation and
convening the participants.
5. A number of study sites located in the Char of Padma, Meghna and Jamuna river where a large
number people shifted their residence and migrated to the nearest Mouza. The survey team
conducted the survey from the available households.
6. This study conducted in the hill tracts districts of Chattagram division. The survey team faced
difficulties to reach the study sites and get the entry access in the tribal region. The team
obtained support from the local administration and local leaders of the tribal community for
conducting the survey in such areas
93
Chapter 10
Discussion
Micronutrient Deficiency:
Vitamin A
Vitamin A deficiency (VAD) is a public health problem in South Asia. Severe deficiency can lead
to blindness, increase the risk of severe illnesses and infections, and is associated with higher
morbidity and mortality rates (77). Neaarly one out of ten NPNL women had VAD. There were
no instances of moderate or severe cases. The overall rate depicts an increase in prevalence, as the
2011-12 NMS depicted 8.8% NPNL women experienced VAD. In this 2019 survey, there was a
higher prevalence of VAD in urban than rural women. The highest prevalence of mild VAD across
socioeconomic classes was in the richest class .In the Nepal NMS, 3% of non-pregnant women of
reproductive age (15-49 years) had VAD, with variance across ecological regions and ethnicity
(caste) (76).
Among under-5 children, half of them experienced mild to moderate VAD, and none experienced
severe VAD. Contrasting the NPNL women population, there was a greater prevalence in rural
compared to urban populations.. Compared with the 2011-12 NMS, which found 20.5% of under-
5 children to be experiencing VAD, there was a large increase in prevalence. In the Nepal NMS,
only 4% of children 6-59 months had VAD, though prevalence did vary across geographical
regions and socioeconomic factors (76).
Vitamin B12
94
In this survey, Vitamin B12 deficiency was examined among NPNL women, and one out of four
was found to be deficiency. This demonstrates a similar findings with the 2011-12 NMS, which
found 23% of NPNL women to be Vitamin B12 deficient (79).To date, there is little data
examining the prevalence of Vitamin B12 deficiency among younger populations.
Folate
Among the NPNL women in this survey, one out of three had a folate deficiency. There was a
higher prevalence among urban areas compared to rural. This is an increase from the 2011-12
NMS, in which 9.1% of NPNL women were found to be folate deficient. In the Nepal NMS, 4.5%
of non-pregnant women ages 15-49 had RBC folate deficiency (76)
Vitamin D
Based on a serum Vitamin D level <50 nmol/l, one out of four of preschool- age children (6-59
months) were deficient in Vitamin D in this current survey. On the other hand, the NMS 2011–
2012 indicated that the prevalence of vitamin D deficiency (Serum vitamin D <25 nmol/L) in
preschool-age children was 7.5%. In addition, 12.4· % of preschool- age children were living with
insufficient vitamin D status (i.e. serum vitamin D <50·0 nmol/l), with the highest prevalence
among children living in the urban area. Compared to the previous MNS study, one out of five
preschool children were found from the rural areas than urban areas; one out of three had
insufficient vitamin D level. In 2008, the National Rickets Survey revealed a 1% prevalence of
rickets among children between the ages of 1 and 15 years.
According to the current survey, more than half of the NPNL women (65.4%) were suffering from
vitamin D insufficiency (serum vitamin D <50 nmol/L) and 2 out of ten NPNL women were
suffering from severe vitamin D deficiency (serum vitamin D < 30 nmol/L). In addition to this, the
prevalence of vitamin D deficiency was higher among urban and non-poor women. Compared to
95
the previous NMS survey (2011-12), 21 % of NPNL women were deficient based on a serum
vitamin D level <25·0 nmol/l, and 50 % of them had an insufficient vitamin D status (serum
vitamin D level < 50.0 nmol/L). No corresponding national-level data are available for pregnant
women. (78)
Zinc Deficiency
Zinc is a vital trace element for innumerable cellular function for normal physical growth, immune
system function, healthy pregnancy and neurobehavioral development (80). Because of the dietary
pattern, there is potential for a great magnitude of Zinc deficiency in the South Asian Countries
like Bangladesh. Preschool children and women during their reproductive years and pregnancy are
at greatest risk of zinc deficiency. (82)
In this survey, we observed approximately one-third children of 6-59 months of age were suffering
from Zinc deficiency. The proportion of zinc deficiency among male children was higher
compared to female children. Compared to the previous survey (NMS 2011-12) (79), the national
prevalence of Zinc Deficiency among preschool children was reported to be 44.0%.
The NMS 2011-12 reported that, Zinc deficiency among NPNL women was 57% whereas
according to the current survey around three fourths (3/4th) NPNL women were suffering from
Zinc deficiency with higher prevalence found in rural areas.
Regular and adequate dietary supply of Zinc is required to meet the daily requirement, as there is
no functional reserve of Zinc available in the body. However, only 17% of households reported to
have Zinc rich animal food intake from a 24-hour dietary recall in the current survey. According
96
to Benoist et al, if the prevalence of insufficient zinc intake is >25%, the population of that country
is considered to be at an elevated risk of Zinc deficiency (81).Moreover, high intake of plant-based
diet with a very high content of phytate (an inhibitor of Zn absorption) is one of the major drivers
of Zinc deficiency. (78)
Iodine deficiency
The effects of iodine deficiency pose a public health threat, primarily to children and women (83).
Iodine deficiency disorders include hypothyroidism, impaired growth, goitre, still-birth,
miscarriage, and brain damage (Andersson et al., 2005). In this study, iodine deficiency was
examined in both children and NPNL women on the basis of WHO guidelines.
Among children, this survey found two out of five of the national population to be mild to severe
deficient. This demonstrates a decrease from the 2011 NMS, which found a prevalence of 40.0%
nationally.
There were also decreases in the prevalence of each level of deficiency. Severe cases were reduced
from 5.6% to 5.2%, moderate from 13% to 8.2%, and mild from 21.4% to 17.5% since the 2011-
12 NMS (79). Among the different regions, urban areas had a proportion of 37.3% of children who
were iodine deficient, while the rural areas did not have any children who were iodine deficient.
This result is likely due to a higher proportion of the sample residing in urban rather than rural
areas.
97
Among NPNL women, there was a national prevalence of iodine deficiency of about 22%. This
figure is double to the 2011-12 NMS, which found 42% of NPNL women to be deficient nationally
(79). In this survey, rural populations had a higher prevalence of iodine deficiency than urban.
Anemia
Consistent with the previously conducted National Micronutrient Survey (NMS) in 2011, venous
blood samples were used to measure the concentration of hemoglobin to determine the presence
of anemia. Venous blood samples produce more reliable and consistent results compared to
capillary blood samples, as capillary samples require greater levels of training and care (78).
Based on this survey, there appeared to be a prevalence of anemia of one out of three among NPNL
women. This represents a decrease from the 2011 survey, which revealed a prevalence of 26%
among NPNL women. Compared with Nepal, which is also located in South Asia and possesses
several geographical similarities with Bangladesh, this rate remains slightly higher. The Nepal
National Micronutrient Survey conducted in 2016 identified a 20% prevalence rate of anemia
among non-pregnant women, and a 10% rate of moderate anemia among non-lactating women
(75).
Among the women in this survey, there was a higher prevalence of anemia in the urban (29.7%)
compared to the rural population (24.6%), and the highest prevalence between age groups was
among the NPNL women aged 37-49 years (34.1%).
The prevalence of mild to severe anemia in children 6-59 months in this survey was one querter
of the children. There was a slightly higher prevalence in children of urban areas compared to
98
rural. There was a decrease detected in the overall prevalence, as the 2011 NMS revealed a 33%
rate among under-5 children. However, the Nepal NMS identified a prevalence of 19% among
children aged 6-59 months (76).
Minimum Dietary Diversity for Women of Reproductive Age (MDD-W)
MDD-W provides insight into the consumption habits of women aged 15-49 by indicating whether
a minimum of 5 of ten food groups have been consumed within in the last 24 hours. The overall
dietary diversity score in this survey was a four out of 10. Over half the overall population failed
to meet the minimum dietary diversity score. However, the overall population demonstrated a high
percentage of consumption of animal sources of vitamin A .
Household coverage of fortifiable salt, oil, and rice
Like other South Asian countries in Bangladesh, consumption of salt and oil was found to be
universal and consumption in their fortifiable forms also almost universal for salt and oil
respectively.
Though each study households consume rice, the consumption of rice in its fortifiable form
dropped substantially for reflecting a high proportion of households who make rice at home (i.e.
small scale or in-home milling).
99
Public health importance
Micronutrient deficiencies are substantial in both children under 5 years old and NPNL women of
reproductive age groups in Bangladesh. It is important to note here that Vitamin A supplementation
program is available among children under 5 years old in Bangladesh. Albeit Vitamin A deficiency
is highly prevalent among the children. These findings warrant to generate a national prevalence
of vitamin deficiencies and the coverage of Vitamin A supplementation program. A national
estimate of others micronutrient deficient is urgent for the implementation of micronutrient
supplementation programs for the children and NPNL women.
A high proportion of households were found to be experiencing various components of
multidimensional poverty. The high prevalence of poor IYCF practices and lack of MDD scores
met emphasizes the importance of implementing nationwide awareness campaigns and
government programs. These results are not representative of the whole country given the limited
sample and design. Therefore, to get representative results from which evidence based
programmatic decisions can be made, a nationwide survey would be required.
Conclusion
This study has identified that the micronutrient deficiency was substantial among children and
non-pregnant and non-lactating women. More than two third of women were vitamin D deficiency.
As besides, the burden of iodine deficiency was higher in children. Micronutrient deficiency was
higher in rural than urban areas. The distribution of micronutrient deficiency vary across all the
administrative division. The dietary diversity was lower in both of children and NPNL women.
100
Recommendation
The micronutrient deficiency is substantial among children and women in both urban and rural
areas. A number of recommendations has been given below based on the findings of the study.
1. The coverage of vitamin A and anthelminthic is lower which need to increase

throughout the country
2. The burden of zinc is quite higher in children and women. A separate program
should be considered to mitigate the burden at the population level.
3. The evidence generated from the study suggests that multiple micronutrient
deficiencies are substantial in both children (under -5) and NPNL women of
reproductive age groups
4. Zinc deficiency is increasing in Bangladesh which warrants rethinking of a program
to imporve Zinc status in both children and women
5. Including Vit D supplementation should be considered for strengthening the
micronutrient supplementation programs for the NPNL women
6. The knowledge of food fortification is poor among adult women. A strong policy
is needed to increase knowledge about the food fortification and utilization of
fortified food.
7. The dietary diversity is lower in children and adult women. More knowledge will
be needed to decrease the micronutrient deficiency.
8. The repeated survey is crucial in every two years to monitor the nutritional status
and progress of nutrition program. A small survey is necessary following the
sampling frame of the current study to understand the trends of the malnutrition.
9. The new evidence will gives direction to modify the existing program and to take
a new program for children and NPNL women.
A nationwide study is crucial to understand the geographical variations of micronutrient
deficiencies in children and NPNL women. A nationwide study will generate the evidence of the
coverage of existing supplementation program for children and NPNL women.
101
Chapter 10
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The person involved in the Micronutrient Survey 2019-20 (Phase 1)
National Nutrition Service
Dr. S M Mustafizur Rahman Line Director, National Nutrition Service, Mohakhali, Dhaka-
1212
Dr.Md. Moniruzzaman Programme Manager, National Nutrition Service, Mohakhali,
Dhaka-1212
Mohammad Aman Ullah Deputy Program Manager, National Nutrition Service,

Mohakhali, Dhaka-1212
Dr. Md. M. Islam Bulbul Deputy Programme Manager, National Nutrition Service,
Dr. Md. Abdul Alim Deputy Programme Manager, National Nutrition Service,
Investigators
Dr. Aliya Naheed (Principal Investigator) Scientist and head, Initiative for Non
communicable Diseases, HSPSD, icddr,b
Dr. Sandosh Padmanabhan (Co-I) Institute of Cardiovascular & Medical
Sciences, University of Glasgow, UK
Dr. Rubhana Raqib ( Co- Principal Investigator) Senior scientist and head,
Immunobiology, Nutrition and
Toxicology Laboratory, IDD, icddr,b
Dr. Sohana Safique (Co-I) Deputy Project Coordinator
Health System and Population Studies
Division
Md. Saimul Islam ( Co- Principal Investigator) Initiative for Non communicable
Diseases, HSPSD, icddr,b
Dr. Noshin Farzana (Co- Investigator) Initiative for Non communicable

Diseases, HSPSD, icddr,b
111
Survey team
Mr. Abul Hossain, FRA Field Research Assistant , HSPSD, INCD, icddr,b
Shabnam Sheuly, FRA Field Research Assistant, HSPSD, INCD, icddr,b
Shanaz Pervin Munni, FRA Field Research Assistant, HSPSD, INCD, icddr,b
Marzia Sultana, FRA Field Research Assistant, HSPSD, INCD, icddr,b
Nasima Akter, FRA Field Research Assistant, HSPSD, INCD, icddr,b
Nilufar Yasmin, SFA Field Research Assistant, HSPSD, INCD, icddr,b
MS. Kalpona Rani Mondal, FSA Field Research Assistant, HSPSD, INCD, icddr,b
Ms. Shila Bala, FSA Field Research Assistant, HSPSD, INCD, icddr,b
Ms. Salma Rezuana, FSA Field Research Assistant, HSPSD, INCD, icddr,b
Ms. Xerin Tashnim, FSA Field Research Assistant, HSPSD, INCD, icddr,b
Ms. Nasimal Islam, FSA Field Research Assistant, HSPSD, INCD, icddr,b
Mr. Monirul Islam, SFA
Fahmida, SFA
Sadia Afrin, FA
Mr. Prodip Paul Rozario, FA
Mr. Ratan Chakder, FA
Mr. Md. Arman Habib, FA
Mustafiur Rahman
Prodip Paul Rozario Field Assistant , HSPSD, INCD, icddr,b
Md. Maksudur Rahman Medical technologist, HSPSD, INCD, icddr,b
Sampad Sarker Medical technologist, HSPSD, INCD, icddr,b
Phlebotomist
Md. Elias Hossain Medical technologist, HSPSD, INCD, icddr,b
Zahidul Islam Medical technologist, HSPSD, INCD, icddr,b
Mr. Mamunur Rashid Medical technologist, HSPSD, INCD, icddr,b
Khabirun Nesa Medical technologist, HSPSD, INCD, icddr,b
Kohinur Akter Medical technologist, HSPSD, INCD, icddr,b
Md Yousuf Medical technologist, HSPSD, INCD, icddr,b
112
Md. Maksudur Rahman Medical technologist, HSPSD, INCD, icddr,b
Sampad Sarker Medical technologist, HSPSD, INCD, icddr,b
Data management team
Bilkis Ara Data manager, HSPSD, INCD, icddr,b

AKM Solayman Data management officer, HSPSD, INCD, icddr,b
Md. Shawkat Jahangir Data management officer, HSPSD, INCD, icddr,b
Bishwa Prokash Banerjee Data management assistant, HSPSD, INCD, icddr,b
Laboratory service team
Anjan Kumar Roy Senior Research Investigator, IDD, icddr,b

A.K. Mottashir Ahmed (Coordination manager), IDD, icddr,b
Anjuman Ara Research officer, IDD, icddr,b
Biplob Hosen Research Officer, IDD, icddr,b
Meeting with the Technical Advisory Group (TAG)
1st TAG meetings
113
2nd TAG meeting
3rd TAG meeting
Kazi Zebunnessa Begum, Additional Secretary chaired the session.
114
Group photo with the TAG member
National level dissemination of the micronutrient survey
Dr. S M Mustafizur Rahman (LD, NNS) is delivering speech at the dissemination program
115
Dr Aliya Naheed ( PI, National Micronutrient Survey) is sharing the findings of the study
Participants from government, NGO and international organizations
116

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FINAL REPORT (DRAFT VERSION)

DATE OF SUBMISSION: 31.10.2021

National Micronutrient Survey in

Scientist & Health Systems Specialist

Survey organization: icddr,b

Institute of Public Health Nutrition,

Figure 1. Sampling procedure flowchart

Figure 1.Sampling procedure flowchart....................................................................................... 30

Acronyms and Abbreviations

BBS Bangladesh Bureau of Statistics

BMI Body Mass Index

CAP College of American Pathologists

ERC Ethical Review Committee

FACT Fortification assessment coverage toolkit

GOB Government of Bangladesh

HNPSP Health, Nutrition and Population Sector Programme

HPLC high performance liquid chromatography

IDD Iodine Deficiency Disorder

IFA Iron-folic acid

INFS Institute of nutrition and food science

IYCF Infant and Young Child Feeding

LDL low-density lipoprotein

MDD Minimum dietary diversity

MICS Multiple indicator cluster survey

MMQAP Micronutrient Measurement Quality Assurance Program

MNP Micronutrient power

MOHFW Ministry of Health and Family Welfare

NBL Nutritional Biochemistry Laboratory

NFP National food policy

NIST National Institute of Standards and Technology

NNS National Nutrition Service

NPNL Non-pregnant and Non-lactating

NVAC+ National Vitamin A plus Campaign

PPS Probability proportional to size

PSU Primary sampling unit

RP-HPLC Reverse-phase high-pressure liquid chromatography

RRC Research Review Committee

SOP Standard operating procedures

SUZY Scaling up Zinc for young children

VGD Vulnerable Group Development

VITAL-EQA Vitamin A Laboratory – External Quality Assurance

Additionally, to assess Vitamin B12 and Folate in NPNL women.

knowledge of vitamin, minerals and fortification among NPNL women.

which we will have to apply different funders for obtaining support.

Nutrition Biochemistry Lab of icddr, b.

prevalence of vitamin D deficiency is 84% in pregnant women, and a community-based study

to impaired immune systems and increase the risk of co-morbidities (12-14).

1.2 Micronutrient deficiency in Bangladesh

amongNon-pregnant and Non-lactating (NPNL) women (15).Another study among Bangladeshi

pregnant women of reproductive age group(21).

are suffering from iron deficiency anaemia (22).

1.3 Consequences of MDs

deficiency includes secondary hyperthyroidism, decreased calcium absorption and bone

tract infection symptoms(40). A high prevalence of hypovitaminosis D and vitamin D deficiency

on development of cardiometabolic risk factors such as obesity, hypertension, cardiovascular

case-control studies reported that low concentrations of 25-hydroxyvitamin D [25(OH)D] are

cardiovascular disease, and type 2 diabetes(47).

cognitive impairment, low birth weight, pregnancy induced hypertension, postpartum