Menu ENN Search

Improving minimum dietary diversity for children aged 6-23 months when household affordability is a major constraint in northeast Bangladesh.

View this article as a pdf

Lisez cet article en français ici

By Md Masud Rana, Sheikh Shahed Rahman, Md Al-Amin Shovan, Bazlul Kabir Joarder and Mohammad Raisul Haque

Md Masud Rana is a nutrition advisor for Save the Children, with a particular focus on supporting nutrition programmes in South Asia and East Africa region. Masud has worked for over 10 years in the design, delivery and evaluation of nutrition, food security and livelihoods programmes in Asia and Africa.

Dr Sheikh Shahed Rahman is Chief of Party for the Suchana programme, Save the Children International in Bangladesh. He has worked in food security and nutrition programmes in development and emergency settings for more than 15 years. He is a medical graduate and obtained his MPH from Emory University, USA.

Md Al-Amin Shovan is Manager – Monitoring, Evaluation, Accountability and Learning (MEAL) of the Suchana programme. He has over 15 years of experience working as a MEAL Specialist in the development sector in Bangladesh.

Bazlul Kabir Joarder is Technical Manager – Nutrition for Save the Children in Bangladesh in the Suchana programme. He has over 14 years of experience of working in health and nutrition-focused programmes for multiple non-governmental organisations (NGOs) in Bangladesh.

Dr Mohammad Raisul Haque is Senior Advisor – Nutrition for Save the Children in the Suchana programme. He has over two decades of public health service delivery and programme management experience for multiple NGOs and donor agencies. He holds a master’s degree in population and reproductive health research and a PhD in demography.

The authors would like to thank the donors of the Suchana programme, including the European Union (EU) and the UK Department for International Development (DFID). The findings, interpretations and conclusions in this article are those of the authors. They do not necessarily represent the views of Save the Children, EU or DFID and should not be attributed to them.

Location: Bangladesh

What we know: Mutli-dimensional approaches are needed to achieve a minimum acceptable diet for young children to prevent stunting, including increasing household income.

What this article adds: Two studies were carried out to inform the Suchana programme (2015-2022) that aims to reduce stunting prevalence in Sylhet, Bangladesh through social and behaviour-change communication (SBCC), promoting optimal infant and young child feeding (IYCF) and household food production activities to increase household income and food availability. A barrier analysis among 106 mothers from 16 villages was performed to identify barriers to and boosters of minimum dietary diversity (MDD) among children aged 6-23 months. Household income, food price and understanding of an MDD and its benefits were important determinants of MDD. Failure to remember to include diverse foods was a main barrier. Adaptations to the SBCC component were subsequently made to address this. A cost-of-the-diet (CotD) analysis was then performed to estimate the hypothetical minimum amount of money a typical household needs to purchase food to meet recommended nutrient intakes, analysed against current household income, expenditure, production and consumption. Findings show that all major nutrient requirements can be met using local markets and households can potentially afford a diet that meets energy, protein, fat and micronutrient requirements and takes into account typical dietary habits within existing levels of income, but not when non-food expenditures are taken into account. Free food from home food production activities goes some way to filling affordability gaps; however, more needs to be done to increase household income to achieve an MDD and intended programme outcomes.


Bangladesh has made remarkable progress in reducing stunting and wasting in children under five years of age over the last 20 years. However, the rate of decline in the annual stunting rate has slowed in the last decade and an estimated six million children remain chronically undernourished (NIPORT and ICF International, 2016). More than one in three children suffer from impaired linear growth (i.e. stunting) with higher prevalence in rural areas (37.9%, versus 30.8% in urban areas) and among children from the lowest wealth quintile (49.2%, vs 19.4% in the highest wealth quintile). Geographically, Sylhet division in the North-East of the country has the highest burden where around half of all children under five years are moderately to severely stunted (NIPORT and ICF International, 2016). While causal factors are multiple and poorly understood, research has identified several, including severe food insecurity; poor maternal nutrition; poverty; poor sanitation and hygiene practices; and inappropriate complementary feeding (Choudhury et al, 2016; Ahmed et al, 2016).

In response to the multi-dimensional challenges of malnutrition, the UK Department for International Development (DFID) and European Union (EU)-funded Suchana1 programme aims to reduce prevalence of stunting in Sylhet Division. Suchana is a six-year (2015-2022), £48 million programme that aims to reach over 220,000 poor households (representing around 1.1 million people) by targeting women of reproductive age and/or adolescent girls. The programme provides a set of nutrition-specific and nutrition-sensitive interventions to improve household-level nutrition and food security and child care practices to break the inter-generational cycle of under-nutrition.2[2] Suchana’s nutrition-specific component includes a comprehensive set of social and behaviour-change communication (SBCC) interventions promoting optimal infant and young child feeding (IYCF) and maternal and child nutrition in the first 1,000 days. The nutrition-sensitive component promotes increases in household income and availability of food through home food production (HFP) interventions.

To ensure both types of interventions address context-specific immediate, underlying and basic causes of undernutrition, Suchana carried out a barrier analysis and cost-of-the-diet (CotD) assessment in Sylhet and Moulvibazar districts within Sylhet Division. This article shares experiences and findings related to improvement of dietary diversity among young children that were used to inform the programme to improve outcomes further.

A barrier analysis: Identifying barriers to achieving minimum dietary diversity (MDD) of children in Sylhet and Moulvibazar districts


In October 2017, Suchana commissioned a barrier analysis to identify barriers to and boosters of minimum dietary diversity (MDD) among children aged 6-23 months in response to multiple programme monitoring assessments identifying MDD as the worst performing IYCF indicator. The baseline study undertaken in mid-2017 found only 14.7% of girls and 15% of boys received a diversified diet containing four or more food groups. The study primarily employed a ‘doer/non-doer analysis’ to identify behavioural determinants (barriers and enablers) among those who consumed a diversified diet (‘doers’) and those who did not (‘non-doers’). It followed the barrier analysis methods specified in the ‘designing for behaviour change framework’ (TOPS, 2017; Kittle, 2013) and employed a cross-sectional survey of 106 mothers of children aged 6-23 months (53 doers and 53 non-doers) from 16 villages in the two districts.


Table 1 shows a summary of the barriers and facilitators constructs generated from the data. Overall, an overwhelming proportion of respondents from both groups (doers and non-doers) identified economic factors (e.g.  household income and food price) as the main facilitator for achieving MDD. As most households were primarily reliant on markets for access to food, distance to the market was also a big predictor. The barrier analysis additionally identified existing misconceptions around consuming a diversified diet (e.g. certain foods can cause indigestion/breathing problems) and a lack of full understanding of the benefits, as well as perceived difficulty of remembering to include foods from different food groups, as other important determinants of MDD. Approval and support of husbands and mothers-in-law were found necessary for practising the behaviours. However, no social, cultural or religious restrictions or taboos against consumption of a diversified diet by women or children were identified.

Table 1: Barriers and boosters of MDD among children aged 6-23 months in Sylhet and Moulvibazar districts in Bangladesh

Follow-up actions: Based on the findings of this analysis, the existing SBCC strategy and activities were revised in early 2018, as follows:

A CotD analysis: When affordability is a major barrier

Rationale and objectives

While the Suchana programme’s regular monitoring data was suggesting a notable increase in household income and increased availability of food from the HFP intervention, the barrier analysis identified affordability of nutritious food as a major barrier to dietary diversity. In response, a CotD analysis was conducted in Sylhet and Moulvibazar districts to investigate the extent of the gap between household income and expenditure. This would inform necessary adjustments in programme implementation to maximise the impact on child nutrition. Specifically, the assessment set out to estimate the minimum cost of a nutritionally adequate and culturally acceptable diet for typical households and estimate the potential effect of income-generating activities (IGAs) and the HFP intervention on a household’s ability to afford a nutritious diet.


The CotD3 method and software were developed by Save the Children in order to estimate the hypothetical minimum amount of money a typical household would need to purchase food to meet recommended intakes of energy, protein, fat and micronutrients, using locally available foods (Deptford et al, 2017). Food price data were collected through a market survey involving 16 urban, peri-urban and rural markets in Sylhet and Moulvibazar. Local food consumption patterns and cultural practices were identified through individual interviews covering 84 individuals and 12 focus group discussions (FGDs). Household income and expenditure, household size and composition, and HFP and consumption data were obtained from the most recent programme survey.

Key findings

Overall, the analysis found that markets in Sylhet and Moulvibazar have a diverse range of food items and can fulfil all major macro- and micro-nutrient requirements for households. However, calcium was found to be most difficult to obtain; i.e. the most significant cost driver, followed by folic acid and vitamin B12.

The cost of four hypothetical diets was estimated using CotD software for a typical household of six individuals (including a 12-23 month-old child and a breastfeeding mother); including: (i) a lowest-cost diet that only meets recommended average energy requirements  (energy only (EO) diet); (ii) a lowest-cost diet that meets the average energy and the recommended protein and fat requirements (macronutrient(MAC) diet); (iii) a lowest-cost diet that meets specifications for energy, protein, fat and micronutrients but does not take into account typical dietary habits (minimum-cost nutritious (NUT) diet); and, (iv) a lowest-cost diet that meets specifications for energy, protein, fat and micronutrients and takes into account typical dietary habits and cultural acceptability (food habit nutritious (FHAB) diet).

The lowest annual cost of an EO, MAC and NUT diet for a six-person household was BDT 40,630.00, BDT 41,523.00 and BDT 64,312.00 respectively (Figure 2). However, the cost of a FHAB diet was 67% higher than the NUT diet, at BDT 107,459 per year. Within the household (Figure 3), the cost of meeting the nutritional requirements of a breastfeeding women was highest (22% of the household cost of diet), followed by the adult male (21%) and 10-11 year old children (20%).

The affordability calculation (Figure 4) shows that households can potentially afford the FHAB diet, but cannot afford to meet both the cost of the diet and additional non-food expenditures (NFE) with their existing level of income. The affordability gap ranges from BDT 193 to BDT 14,181 per year, depending on the beneficiary type and their livelihoods options. However, when the effect of the HFP element of the programme, which provides free food for the household, was also taken into account (Figure 5), the annual cost of an FHAB diet was reduced by between 2.2% and 3.2% (16-24% reduction in the household affordability gap); this demonstrates some gain, albeit not as much as the project team expected.

Figure 1: The percentage of energy and the recommended nutrient intakes for micronutrients met by a FHAB diet for the whole family

Figure 2: Annual cost of the various diet type for a standard household with six members and average annual income 

Figure 3: Individual cost of the diet expressed as a percentage of total cost of the FHAB diet

Figure 4: The affordability of an EO, NUT and FHAB diet by Suchana beneficiary type (IGA intervention type and phase)


The x-axis bars refer to different project beneficiary types. Phase 1 and Phase 2 refer to the beneficiary selection cycle. On/Off-Farm refer to the ‘Income-generating activity (IGA)’ support beneficiaries received from the project. On-Farm IGAs are linked to food production through agriculture, poultry/livestock and aquaculturem; e,g. training, inputs and provision of seeds, fertilisers and pesticides. Off-Farm IGAs are livelihoods options other than farming/food productions, including water fishing, tea stalls, vegetable trading, bamboo crafting and a ferry business.

Figure 5: The potential effect of different HFP activities on the annual cost of an FHAB diet for a household with six members, including a child aged 12-23 months

Discussion and recommendations

It is well known that interventions focused on reducing poverty (i.e. generating income) as part of a multi-sector nutrition programme are not enough to have a positive impact on nutritional outcomes. Household income must go beyond a certain threshold to enable household members to practice recommended child feeding practices. This CotD analysis set a benchmark for the livelihoods component of the Suchana programme, by which increases in household income could be monitored to ensure that they are large enough to meaningfully impact household food security and nutritional status. Results of the analysis indicate that the programme should consider identifying beneficiary households that are below this benchmark and struggling to cross the threshold to prioritise them for linkages with existing government social protection programmes.

When results of this CotD analysis are compared to a previous CotD analysis conducted in the same region in 2013, it appears that the current affordability gap (BDT 193 to BDT 14,181 per year) of very poor beneficiary households is significantly lower than the previous gap of BDT 39,300 per year. This reduction cannot necessarily be attributed to the programme intervention alone; however, there are strong reasons to believe that programme interventions are meaningfully contributing to it. Furthermore, the CotD modelling exercises show that the HFP interventions appear to be improving the availability and consumption of nutritious food at household level.

Nevertheless, gains were not as great as expected and more needs to be done to increase production to eliminate affordability gaps and to improve consumption to meet an MDD. The programme should therefore continue to aim to increase household income and food production and promote equitable intra-household food distribution and consumption through its SBCC activities. The Suchana programme is considering the following recommended actions as a result of the findings presented here:

An independent evaluation is planned for the end of 2019, after which the impact of the Suchana programme on stunting prevalence will be reported.

For more information please contact Masud Rana.


1A Bengali word which means “the beginning of something positive”.

2For further information, see: (i) (ii)

3Further information about the CotD method is available from


Ahmed, T., Hossain, M., Mahfuz, M., Choudhury, N., & Ahmed, S. (2016). Imperatives for reducing child stunting in Bangladesh. Maternal & Child Nutrition12, 242-245. doi: 10.1111/mcn.12284#

Choudhury, N., Raihan, M., Sultana, S., Mahmud, Z., Farzana, F., & Haque, M. et al. (2016). Determinants of age-specific undernutrition in children aged less than 2 years-the Bangladesh context. Maternal & Child Nutrition, 13(3), e12362. doi: 10.1111/mcn.12362

Deptford A., Allieri T., Childs R., Damu C., Ferguson E., Hilton J., Parham P., et al. . (2017). Cost of the Diet: A Method and Software to Calculate the Lowest Cost of Meeting Recommended Intakes of Energy and Nutrients from Local Foods. BMC Nutrition  3 1: 26.

Kittle, B. (2013). A Practical Guide to Conducting a Barrier Analysis. New York, NY: Helen Keller International. Retrieved from


NIPORT, Mitra and Associates, and ICF International. (2016). Bangladesh Demographic and Health Survey 2014. Dhaka, Bangladesh, and Rockville, Maryland, USA: National Institute of Population Research and Training (NIPORT), Mitra and Associates, and ICF International. Retrieved from

TOPS. (2017). Designing for Behavior Change: A Practical Field Guide. Washington, DC: The Technical and Operational Performance Support (TOPS) Program. Retrieved from

More like this

FEX: Affordable and nutritious child feeding in Nigeria: Applying Cost of the Diet modelling

View this article as a pdf Lisez cet article en français ici Md Masud Rana is a Nutrition Advisor at Save the Children, UK Gideon Luper Abako is a Nutrition...

FEX: Affordable and nutritious child feeding in Nigeria: Applying Cost of the Diet modelling

This is a summary of a Field Exchange field article that was included in issue 69. The original article was authored by Md Masud Rana, Gideon Luper Abako, Boluwatito Samuel and...

NEX: Keyhole gardens in Ethiopia: A study of the barriers to scale-up

Yohannes Haile is a public health professional working in Ethiopia with Catholic Relief Services. He has a Master's degree in Public Health from Mekele University in...

FEX: Barrier analysis of infant and young child feeding and maternal nutrition behaviours among IDPs in northern and southern Syria

View this article as a pdf Lisez cet article en français ici By Shiromi Michelle Perera Shiromi Michelle Perera is a Technical Officer with the Technical Unit at...

FEX: Cost of the Diet analysis in Bria, Central African Republic

View this article as a pdf Lisez cet article en français ici By Esther Busquet Esther Busquet is a Nutrition Advisor with International Medical Corps (IMC), currently...

FEX: Consumption of iron-rich foods among adolescent girls in Nepal: Identifying behavioural determinants

By Ajay Acharya, Pooja Pandey Rana, Bhim Kumari Pun and Basant Thapa View this article as a pdf Ajay Acharya is a Family Planning Specialist for the USAID-funded Suaahara II...

NEX: Filling the Nutrient Gap in Pakistan: Insights to address malnutrition

Dr Aliahmad Khan is a nutritionist with the World Food Programme Pakistan Country Office in Islamabad. Muhammad Aslam Shaheen is Chief of Nutrition and SUN Focal Point in...

en-net: Consultant Cost of Diet Analysis - Concern Worldwide

Terms of reference External Consultant for Cost of Diet (CoD) Analysis for Concern Worldwide's Irish Aid-funded Liberia WASH Consortium project in Grand Bassa, Sinoe and...

FEX: State of Palestine: Investing in assessment positively impacted programming for complementary feeding

Lisez cet article en français ici Amani Jouda is a Health and Nutrition Officer at UNICEF, State of Palestine. Fairooz Abuwarda is an Early Childhood Development...

FEX: Effectiveness of a community-based infant and young child feeding support group programme among ethnic minorities in Vietnam

By Md Masud Rana, Huan Nguyen Van and Thach Nguyen Ngoc View this article as a pdf Md Masud Rana is a Nutrition Advisor with Save the Children with a particular focus on...

FEX: Cost of the Diet – novel approach to estimate affordability of a nutritious diet

A woman cooking at home in Tanzania By Abigail Perry, Save the Children UK Abigail Perry currently works for Save the Children UK as a nutrition adviser based in London,...

FEX: Transforming food systems to improve diet affordability: Fill the Nutrient Gap analysis in Burkina Faso

View this article as a pdf Research summary1 By Sumra Kureishy, Natalie West, Saidou Magagi and Katrien Ghoos Sumra Kureishy is a Nutrition Officer at the World Food...

FEX: Risk of nutritional deficiencies increases during female adolescence – a comparison of the cost of a nutritious diet across sex and age

View this article as a pdf By Zuzanna Turowska, Janosch Klemm, Nora Hobbs and Saskia de Pee Zuzanna Turowska is a Food Systems Analyst in the Nutrition Division of the World...

Using an in-depth assessment of young children’s diets to develop a Multisectoral Nutrition Communications Strategy in Punjab province, Pakistan

View this article as a pdf Dr Muhammad Nasir is a medical doctor and Programme Manager in the Primary and Secondary Healthcare Departments of the Government of Punjab. Eric...

FEX: Improving nutritional outcomes of rural households through a community-based approach in Ethiopia

This article has been updated since the original version was published in March 2020. View this article as a pdf Lisez cet article en français ici By Haimanot Abebe,...

FEX: Helping homestead gardeners mitigate the impact of soil salinity

By Erica Roy Khetran Erica Roy Khetran is the Country Director for Helen Keller International (HKI) in Bangladesh. She has lived and worked in Asia since 2004 with a focus on...

FEX: Food systems for safe, nutritious and affordable diets in central Sahel

View this article as a pdf Lisez cet article en français ici This article provides the findings and recommendations of a literature review and a series of...

FEX: Preventing teen pregnancies and supporting pregnant teenagers in Ecuador

View this article as a pdf By Sara Bernardini, Geraldine Honton, Laura Irizarry, Jesús Sanz, Estefanía Castillo, Carmen Guevara and Lorena Andrade Sara...

FEX: Higher heights: a greater ambition for maternal and child nutrition in South Asia

Research Summary 1 Poor nutrition in early life threatens the growth and development of children, which has a knock-on effect on the sustainable development of nations. This...


Reference this page

Md Masud Rana, Sheikh Shahed Rahman, Md Al-Amin Shovan, Bazlul Kabir Joarder and Mohammad Raisul Haque (). Improving minimum dietary diversity for children aged 6-23 months when household affordability is a major constraint in northeast Bangladesh.. Field Exchange 61, November 2019. p3.



Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.