Factors influencing food preferences and eating behaviour among the Forcibly Displaced Myanmar Nationals (FDMN) adolescents in Cox’s Bazar, Bangladesh: a cross-sectional survey

Introduction

The Forcibly Displaced Myanmar Nationals (FDMN), previously known as Rohingya, are an ethnic group in Myanmar that has been denied citizenship in Myanmar, making them the world’s biggest stateless population.1 Around one million FDMN refugees live in Cox’s Bazar, Bangladesh, making it the world’s largest refugee camp.2 Research showed that about 884 000 FDMN were forced to leave Myanmar and are currently living in 34 camps in the subdistricts of Ukhiya and Teknaf in the Cox’s Bazar District of Bangladesh.3 Approximately 54% of the FDMN are under the age of 18 years.4 An estimated 400 000 adolescent FDMN live in Cox’s Bazar, accounting for approximately 40% of the total FDMN population in the camps.5

Adolescence is a transitional period between childhood and adulthood, characterised by rapid physical, psychological and social growth and development.6 Despite being considered a healthy stage of the human lifecycle, adolescence is also marked by a high rate of illness and injury.7 Adolescents who do not consume the recommended amount of nutrients, skip meals or engage in poor eating behaviours are thought to be affected by many health issues later in life.8 9 Moreover, during adolescence, individuals develop behavioural patterns related to diet and exercise that can safeguard their health and the health of those around them.7

Adolescents’ long-term health and well-being may be significantly impacted by their eating habits.10 Many adolescents experience a growth spurt and an increase in appetite and need healthy foods to meet their growth needs.11 Healthy eating is crucial to meet adolescents’ nutritional and dietary needs.11 Consuming a diet high in fruits, vegetables, whole grains and lean proteins while limiting the intake of processed foods can help adolescents meet their nutritional needs and reduce their risk of chronic diseases such as obesity, type 2 diabetes and cardiovascular disease.11 12 The period of adolescence plays a critical role in determining an individual’s future health and even the well-being of their future offspring, highlighting how essential a proper diet is in the developmental origins of health and disease.13

In the context of the FDMN camp in Cox’s Bazar, the sustenance of the burgeoning adolescent population assumes pivotal significance. The World Food Programme (WFP) is the primary provider of food assistance in the FDMN camps in Cox’s Bazar.14 WFP provides a monthly general food assistance ration to all households in the camps, which includes rice, wheat flour, lentils, oil, salt and sugar.14 15 Additionally, select outlets offer Fresh Food Corners (FFCs) with access to fresh produce and live poultry and fish.14 15 Vulnerable households receive an extra US$3 per person per month for purchasing nutritious, protein-rich foods at FFCs.14

Food choice is a complex process deeply rooted in culture and affected by many personal, emotional, social and economic factors.16 17 During adolescence, food choices are essential because what you eat at this age affects your health now and in the future.18 However, globalisation is eroding traditional foods and increasing their availability and options, which could impact adolescents’ food preferences.19 Adolescents’ food preferences are shaped by various factors, such as individual taste preferences, family food culture, peer influence, media exposure and socioeconomic status.20 These factors can influence not only what adolescents eat but also their overall dietary patterns and food-related behaviours.21

Research revealed that adolescents’ eating behaviours and dietary patterns are constantly changing.17 Nowadays, adolescents are becoming more independent and making many food decisions independently,11 and sometimes they are also influenced by their peers.22 Previous research has shown that the impact of peers on the dietary habits of adolescents is frequently observed to be unfavourable, leading to greater consumption of calorie-dense and nutritionally deficient foods.23–25 Nonetheless, there are instances where this influence can yield positive results.26 It is crucial to explore strategies that harness this influence to promote healthy eating behaviours among young individuals.25 The eating habits and food preferences formed during adolescence tend to last into adulthood.27 28 Moreover, poor dietary habits during adolescence can lead to nutritional deficiencies, which can affect their growth and development, immune system, cognitive function and mental health.29

Adolescents living in Cox’s Bazar faced many challenges, including food insecurity, age-based and gender-based violence, disrupted educational prospects, widespread psychosocial distress and worry, limited health service uptake and inadequate health services for persons with disabilities.30 FDMN adolescents were identified as a particularly marginalised subgroup.31 The FDMN adolescents also experience unusual circumstances, such as a poor living environment in the camp, displacement from the homeland, new peers and culture, and a struggle to adapt to a new environment and eating pattern.1 FDMN depend entirely on humanitarian assistance for protection, food, water, housing and healthcare.31 32

It is conceivable to improve adolescent health by improving food choices and eating behaviour, especially for those living in marginalised conditions like the FDMNs. Today’s adolescents are the future leaders of the FDMN Community. Their proper eating behaviour and food preferences could ensure their health and well-being, which inquest them and the whole community in the future. No study has yet highlighted this vital issue; hence, the study aims to explore the factors influencing adolescents’ food preferences and eating behaviours in FDMN camps in Cox’s Bazar, Bangladesh.

Methods and materials

Data collection procedure

A total of twelve FDMN camps in Cox’s Bazar were randomly selected at the first step (figure 1). Interviews were conducted in Bangla and Rohingya languages depending on the participant’s comfort. The survey was administered via face-to-face interview, following the interview guideline (online supplemental file 1), and the participants’ responses were recorded directly into the ‘KOBo toolbox’ (an open-source platform for field data collection that works both online and offline).33 The anthropometric measurements (height and weight) of adolescents were measured and recorded. The weight was measured to the nearest 100 g with a digital scale, and the size was calculated using a locally built height scale with a 2 mm precision. Following established guidelines, the trained research team performed all nutritional status assessments.34 We designed a semistructured questionnaire (online supplemental file 2) for our research, drawing on previous studies and relevant literature. This questionnaire aimed to gather demographic information from participants, assess dietary behaviours based on established research35 and camp experiences and investigate food preferences by incorporating insights from the literature36 and camp-related experiences. Additionally, we included select questions to gather data on camp rations, considering factors such as availability, accessibility and price, with reference to existing literature,1 37 camp experiences and press releases.38 To assess psychological behaviour, we used the Emotional Eating Scale.35 39 After getting permission from the Refugee Relief and Repatriation Commissioner (RRRC) to conduct research in the FDMN camp, we contacted Majhi (the local camp leader) for assistance in obtaining samples. The crucial assistance offered by the camp leader, a respected member of the Rohingya community, encompassed multifaceted support. Their active involvement included introducing us to the general population, endorsing the research objectives in their own views and fostering an atmosphere of trust and familiarity. This collaborative approach not only bolstered participants’ confidence and belief in the research but also allowed their community to stay informed and engaged with our work, reflecting a harmonious partnership that recognised the research’s sensitivity and significance. The team of data collectors consisted of four well-trained volunteers and one supervisor. The data collection team and the local majhis visited the camp houses to offer research participation. A total of 545 complete interviews were conducted and there was no missing data.

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Figure 1

Map of FDMN camps in Cox’s Bazar, Bangladesh. Landmarks denote the camps from where the samples were collected. FDMN, Forcibly Displaced Myanmar Nationals.

Results

The sociodemographic characteristics of the study participants are shown in table 1. Respondents’ mean (SD) age was 14.38 (±2.52) years, and more than half of the adolescents were aged between 10 and 14 years. The majority of the participants had no formal schooling (67%). Most adolescents (65.7%) had 5–8 family members. Monthly gross household income of less than 10 000 BDT (<100$) per month was observed among 94.3% of respondents.

Figure 2 highlighted the status of BMI-for-age (z-scores), which was generated based on study participant anthropometric (height and weight) measurements and age comparison. In this study, most participants had normal BMI-for-age; male (73.2%) and female (74.0%). Female participants were comparatively more overweight (23.3%) than their male counterparts (5.6%). In addition, 17.8% of males and 1.9% of females belong to the thinness category, respectively.

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Table 2 describes participants’ food preferences and eating behaviour. Among all the participants, 95.4% consumed carbohydrates such as rice, bread or other cereal-based products daily. Only 10.1% of the study population regularly consumed proteins (meat, fish, eggs or others). When we assessed their vegetable consumption, we found that 82.8% of respondents had not taken fruits and vegetables as recommended. 90.8% of study subjects were unfamiliar with dairy products, while only 9.2% of adolescents occasionally consumed dairy products. When asked if they drank enough water (6–8 full glasses or approximately 1.5–2 litres daily), 58.9% said they did not drink enough water. Around one-third (36.3%) of the respondents did not eat at least three meals daily. A notable amount (55.6%) of study subjects skipped breakfast regularly (4–5 days a week). Eating out was agreed on by 82.4% of our participants. Adolescents’ household food menu plans (98.5%) depend mainly on their parents; 11.2% of adolescents preferred friends’ decisions to take food outside the home; 97.8% responded that media (TV, radio, newspapers and the internet) did not play a role in choosing healthy food.

Table 2 also depicts the status of the camp and rations-related factors. The result found that 99.6% of participants received rations regularly. Furthermore, 63.5% of the sample population believed that rations were inadequate. In comparison, 36.5% of respondents considered they were insufficient and 39.8% had to purchase extra rations. Food price increases in the camp also affected their food accessibility; 76.7% of respondents believed the food price was significantly higher than their ability to purchase it and satisfy their desired food accessibility; 73.2% responded that they had to change their eating habits after migration, whereas 60.2% of study subjects faced difficulties coping with the new food habits.

Factors influencing participants’ food preferences and eating behaviour are displayed in figure 3. Camp and ration-related factors, such as personal, social and psychological factors that influence food preference and eating behaviours, were reported.

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Food availability, sufficiency, buying extra rations and adaptability were all ration-related factors. Their eating habits and food preferences are also influenced by camp-related components like food costs, accessibility and availability. Food preferences, including consumption of carbohydrates, protein, fruits, vegetables and dairy products, are mainly influenced by several factors. Mostly reported factors were whether it is supplied with relief (58.5%) and financial ability to purchase (27.75%). In addition, participants who did not drink enough water claimed lack of safe drinking water (90.66%) was their primary factor in consuming insufficient amounts. Furthermore, eating behaviours, including meal frequency and skipping breakfast, were hastened by financial ability, habit and appetite. Of study respondents who take less than three meals every day and skip breakfast regularly, 83.62% reported financial ability was the main factor.

The facts about the influence of psychological behaviours on eating habits ‘Happy emotions’ encouraged them to overeat; the statement was supported by 31.4%. Conversely, sad states led to less eating; 30.8% agreed with the response. The same 31.6% of adolescents thought their annoying mood caused them to eat less. Moreover, when they were nervous about anything, it led to less eating; this assertion was accepted by 31.9% of participants.

The bivariate analysis of food preferences by explanatory variables is shown in table 3. Significant differences were observed for age groups (protein: p=0.012, fruits & vegetables: p<0.001, dairy product: p=0.012, water: p=0.001) with all the presented dependent variables except carbohydrates. Gender had significant impacts on all of the outcome variables. Protein, dairy products and water consumption significantly differ among educational levels (p=0.019, dairy product=0.001, water=0.010). Water consumption greatly varied with the size of the family. Household income significantly impacted all food groups rather than carbohydrate consumption. Dairy products and water consumption depending on the sufficiency of rations were statistically significant in the bivariate analysis. Other participants’ food consumption significantly differed without carbohydrates due to extra-ration purchasing. Camp food prices and past eating habits significantly impact dairy products and water consumption. Water consumption was also statistically significant due to the adaptability of supplied water (p<0.001). Extra-ration purchasing needs also statistically differed in their consumption of protein (p=0.008), fruits and vegetables (p<0.001), dairy products (p=0.032) and water (p<0.001).

Discussion

This study represents the first comprehensive exploration of the dietary behaviours and food preferences among FDMN adolescents residing in refugee camps in Cox’s Bazar, Bangladesh. The key findings reveal significant sociodemographic disparities, gender-based discrepancies in nutritional status, concerning dietary patterns marked by low intake of essential food groups, challenges in accessing safe drinking water and the pervasive influence of camp-related factors on food preferences. These insights provide a foundational understanding of the unique dietary challenges faced by FDMN adolescents and underscore the urgent need for further initiatives to improve their nutritional well-being within the camp context.

Sociodemographic factors play a pivotal role in shaping the dietary preferences and habits of FDMN adolescents. The study revealed that the majority of participants had no formal schooling, indicating a significant educational gap within the camp. This aligns with existing literature highlighting the educational challenges faced by displaced populations, often due to a lack of resources and limited access to schools.41 Moreover, the study’s observation that 94.3% of respondents reported a monthly household income of less than 10 000 BDT underscores the dire economic circumstances of the FDMN population. This financial strain, coupled with large family sizes and high unemployment rates, contributes to the severe financial limitations faced by the camp residents. Similar economic challenges have been documented in other refugee settings.42 43

An alarming finding was the significant gender-based discrepancies in nutritional status among FDMN adolescents, with a higher percentage of females being overweight compared with their male counterparts. This contrasts with existing literature indicating that females in refugee settings are often more susceptible to undernutrition due to gender-specific vulnerabilities.44 These discrepancies raise questions about the underlying factors contributing to overweight status among female adolescents within the camp. Conversely, a considerable proportion of male adolescents fell into the thinness category, suggesting potential undernutrition issues. This aligns with the broader literature on refugee nutrition, which has often reported high rates of undernutrition among displaced populations.45

Food security is not just about getting enough calories; it also means getting healthy food that fits the culture.46 Analysis of dietary patterns revealed several concerning trends among FDMN adolescents. While the consumption of carbohydrates such as rice and bread was widespread, the intake of proteins (meat, fish, eggs or others), fruits, vegetables and dairy products was strikingly low. The majority of respondents failed to meet recommended intake levels for these essential food groups. The unavailability of food, financial problems and high food prices in the camp influenced low consumption. Protein and vegetable prices climbed dramatically compared with similar subdistricts of Cox’s Bazar because of solid demand and limited availability.37 However, at the moment, people in the camps have not received animal protein, and at the same time, they are not allowed to raise those or leave the camps to catch or collect. Some FDMN buy fish, meat and eggs from markets in their centres, but the prices are higher than those outside the camps. This finding aligns with previous reports in the Cox’s Bazar FDMN camp.38 Low intake of proteins and dairy products is of particular concern, as these foods are crucial sources of essential nutrients, including calcium, iron and vitamin B12.47 The inadequate consumption of fruits and vegetables further raises concerns about micronutrient deficiencies among FDMN adolescents, as these foods are rich in vitamins and minerals essential for growth and overall health. These dietary patterns align with existing literature on refugee nutrition, which often highlights the challenges of accessing diverse and nutritious foods within camp settings.48

Local media in the camp area reported rising prices of essential commodities.49 This trend has had a significant impact on FDMN adolescents, particularly regarding their access to fruits and vegetables. Despite the perishable nature and nutritional importance of these items, they have not been included in food aid distributions, leaving adolescents to purchase them at higher costs. Financial constraints often necessitate external assistance. One potential solution could involve expanding arable land within the camps to cultivate these essential foods.37

Inadequate water intake and irregular meal habits were prevalent among FDMN adolescents. More than half of them reported not drinking enough water daily, which is concerning given the importance of proper hydration for overall health. This finding echoes previous research highlighting challenges in accessing safe drinking water within refugee camps.50 Furthermore, the shortage of water makes them vulnerable to drinking unsafe water, increasing the risk of waterborne diseases and related health issues.51

Camp-related factors significantly influenced the dietary behaviours and food preferences of FDMN adolescents. Food accessibility, ration sufficiency and affordability were major concerns, with a substantial portion of participants perceiving rations as inadequate and resorting to purchasing extra rations. The high food prices within the camp further exacerbated food insecurity, affecting the dietary choices of the FDMN adolescents. These findings resonate with existing literature on the challenges of food accessibility and affordability in refugee settings.52 53 The majority of the population reported they struggled to cope up with this meal habit in camp. Difficult to cope with camp food encapsulates a key challenge confronted by Rohingya individuals forcibly displaced from Myanmar to Bangladesh.54 55 This challenge arises from the significant cultural shift in food habits and dietary preferences experienced by these individuals when adapting to the new food culture in the camp setting. This phenomenon highlights the intricate interplay between cultural adjustments and nutritional considerations within this context. Similarly, a previous study conducted among immigrants from Iraq to Sweden discovered that they had trouble adjusting to new foods and habits.56 High food prices and limited income opportunities within camps create barriers to accessing nutritious foods.37 55 Additionally, the need to adapt to new food habits after migration presents challenges for many adolescents, highlighting the intricate interplay between cultural adjustments and nutritional considerations within the camp context.

According to the current study, parents, friends and the media influenced food choices. Similarly, few studies revealed associations between food intake with adolescents’ social networks, family decision-making and family meal types.57 58 This study revealed mass media had less impact on eating. Media could be explored more in the camps as it less impacted their eating choice. Mass media and other social platforms barely circulate about nutritious foods and good food habits.59 In camp, language issues are another problem in catching up properly and realising Bangladeshi media programmes which broadcast about foods. Accessibility and availability were other reasons for getting less influenced by media. According to another research, just 37.8% of people use social media and traditional media, such as television, newspapers and radio.60

Psychological factors and their profound influence on the eating habits of FDMN adolescents have been observed in the current research. It revealed that emotions such as happiness, sadness, annoyance and anxiety played a significant role in shaping their food consumption patterns. Psychological health is an aspect that can be overlooked or underestimated in discussions about displaced communities. Numerous studies demonstrate that emotional states, such as happiness, sadness, annoying mood and anxiety, affect eating behaviour.61 62

These findings have significant implications for stakeholders, including camp authorities, non-governmental organisations (NGOs) and humanitarian organisations. First, tailored nutritional education programmes for FDMN adolescents are essential, addressing sociodemographic factors influencing food preferences and emphasising balanced diets. Collaboration between Bangladeshi authorities and humanitarian organisations is crucial to stabilise food prices and ensure a consistent supply of essential items like fruits and vegetables in refugee camps. The rationing system should be reconsidered to better align with the nutritional needs and preferences of the FDMN population, potentially increasing the variety and quantity of items provided. Engaging with the FDMN community, including parents and friends, is vital for promoting healthier eating habits through community-based initiatives and leveraging peer support and family involvement. Psychological factors’ impact on eating behaviour underscores the need for psychosocial support services within camps, addressing emotional well-being and providing coping mechanisms. Ensuring a consistent supply of safe drinking water is also paramount. Lastly, continued research and monitoring of dietary patterns and food preferences among FDMN adolescents are crucial for adapting interventions and policies based on evolving needs and circumstances.

This research boasts several strengths. It represents the pioneering endeavour to investigate food preferences and eating behaviours among the FDMN population, filling a significant gap in our understanding of this community’s dietary practices. Additionally, this research benefits from a large sample size, with participation from over 500 respondents. This enhances the statistical power and reliability of our findings, increasing the confidence in the representativeness of the results for the FDMN adolescent population under study. Current research also employed rigorous data collection and analysis methods, incorporating comprehensive dietary surveys and culturally sensitive approaches to ensure the accuracy and cultural relevance of our findings. This study has a few limitations as well. First, our use of purposive sampling, although aligned with the research objectives, limits the generalisability of our results to the broader adolescent FDMN population. Second, the cross-sectional design limits our ability to establish causal relationships. Moreover, the reliance on self-reported records for assessing eating patterns, food habits, preferences and related factors introduces a potential source of bias and measurement error. Lastly, the COVID-19 pandemic itself introduced unprecedented resource constraints and logistical challenges that influenced the scope of the study, further limiting our ability to conduct direct observations. Moreover, future research opportunities include investigating the effectiveness of food security interventions, culturally tailored nutritional education programmes and psychosocial support services for enhancing dietary behaviours among FDMN adolescents in refugee camps. Researchers can explore long-term health implications and cultural sensitivity in these interventions.

Conclusion

According to our findings, FDMN adolescents’ food preferences were influenced by age, gender, educational level and monthly household income. Ration availability, extra-ration purchasing needs, camp food price and eating habits also influenced food preferences. Protein, fruits and vegetables and dairy products were not adequately consumed. The relief programmes should accommodate FDMN people’s protein, fruits and vegetables, and dairy requirements. Finally, they also need more safe drinking water. Access to safe drinking water and the role of the media in promoting nutritional education should be expanded among the FDMN population.