Micro-nutrient Deficiencies:New Challenges for Central Asia

Nune Mangasaryan, UNICEF CARK, Workshop on Policies on Food Fortification, and Monitoring and Evaluation, 7-9 April 2003, Bishkek, Kyrgyz Republic

Current Estimates of Iodine Deficiency in CIS

Population affected by iodine deficiency

%

Number of people affected

Armenia

DHS 199750 % women73% childrenDHS 199559 % women81% childrenDHS 199672 % women81% childrenDHS 200047 % women36% childrenDHS 199936 % women36% childrenDHS ExperienceTadjikistan:Women - > 60%Children - 69% U3) (MOH)

Anemia in CARK

Vit. A deficiency in CARK

Indicator, Children

< 6 years

Public health concern

Survey result

Serum Retinol < 0.70(mol/L

> 20 %

Kazakhstan

26.9%

Serum Retinol < 0.70(mol/L

> 20 %

Tajikistan

27.6%

(

Chart1

6221

6128.3

8947

7424

5218.9

DHS/MICS/other

STATE

per 1,000 live births

Official and survey estimates of IMR

Sheet1

KAZA 1999 (DHS)KIRA 1997 (DHS)TADA 1993 (MICS)TUKA 2000 (DHS)UZBA 2000 (MICS)

DHS/MICS/other6261897452

STATE2128472419

Sheet1

6221

6128.3

8947

7424

5218.9

DHS/MICS/other

STATE

per 1,000 live births

Official and Survey IMR estimates

Sheet2

Sheet3

Causes of Death Among Pre-School Children in Non-Industrialised Countries, 2000Malnutrition60%Ref.;WHO 2002

Causes of Death Among Pre-School Children in Non-Industrialised Countries, 2000Malnutrition60%Ref.;WHO 2002Vitamin A Deficiency Increases risk of mortality with 23 %

Strategies to review

CARK Anemia Prevention and Control Programme StrategyEducation for dietary changeFlour fortificationWeekly supplementation6-24 monthsAdolescents and childbearing age womenPregnant womenResearch agenda of key studies and monitoring activitiesIMCINut. Act. PlanBFReprod. Health.

There are serious levels of anaemia in all the CARK countries.

These high prevalences will cause developmental problems in children most affected, pregnancy-related outcome problems in women, etc

The experience gained starting 1990s in APC and certain achievements and accomplishments (in all strategic directions) provide a good basis for further expansion and scaling up with significant outcome within 3-4 years. Strategic planning: APC

This is a real opportunity and should be aggressively pursued over the next few years.

The experience of fortification started recently and lessons learned provide a good basis for further expansion and scaling up with significant outcome within 3-4 years. All efforts have to be applied to call for government, partners, donors attention to support the initiative. Like all the approaches this will not be the total answer, but will help elevate the national average intakes of iron (and other micronutrients) and allow resources and attention to be given in a more targeted way to those still deficient. Fortification: Flour fortification

Enforce National Legislation and regulations on flour fortification (including prohibition of export of non fortified flour)

To enforce communication strategy

Develop monitoring system of iron fortification in grain mills. Further support of monitoring system

Main interventions for wheat flour fortification

Initiate mass production of fortified flour at all large mills in countries, thus ensuring access to fortified flour for at least 90% of women and children

Procurement of equipment and consumables to maintain sustainability of fortification process at the pilot mills and to extend experience to the large mills

Technical consultancy and support, including experience exchange from the Countries reaching flour fortification during the first stages of real implementation of flour fortification. Main interventions for wheat flour fortification

Continue Iron supplementation with review of target group, strengthening of all interventions proposed at desk review until fortification is taken to the scaleImprove management and organisation, supply distribution, build capacities, IEC with strong monitoring component at all levelsReview preventive supplementation and treatment guidelinesSupplementation

Conditions Required for an Effective Salt Iodization Programme To reach USI within a year or two and be sustainable:Commitment of the Government and salt industryNeed of partnershipLegislationWorking enforcement mechanismsReliable surveillance system for monitoring quality control and quality Assurance

To have a large population coverage, including the population groups the most at riskMonitoring of household coverageStrengthen Communication component

To correct iodine deficiency by ensuring adequate iodine intakeAssessment of iodine status (UIE) every 3-4 years

Steps to reach USI in CARK To ensure USI:

Support to salt producer: capacities for salt iodisation, marketing, testing, involvement in policy and decision making process

Three-level surveillance system:Reliable surveillance system for monitoring quality control and quality AssuranceMarket monitoring Monitoring of household coverage, with attention to population groups the most at risk

Steps to reach USI in CARK

To be sustainable

Commitment of the Government and salt industryNeed of partnershipLegislation - to adopt and introduce mechanisms for effective enforcement Consumer education

To correct iodine deficiency by ensuring adequate iodine intake

Assessment of iodine status (UIE) every 3-4 years

Government agenciesAssociations of producersNGOsConsumer organisationsMediaInternational organisations Scientific groups

Solutions through Partnerships in the country

National communication plans: to review, enrich, and operationalise Ownership and commitment of government: advocacy has to be reached through advocacy efforts : politicians, media.More tools for decision makers: cost-effectiveness and other economic implications Communications

The economic costs of undernutrition are high: productivity losses

Relative Cost Effectiveness of Micronutrient InterventionsSource: UNICEF/UNU/WHO/MI, 1999

Iron deficiency costs around 0.9% of the GDP

Over $US350 millions to the CARK countries

Kazakhstan $142.2 million; Kyrgyzstan $11.7 million; Uzbekistan $159.3 million; Turkmenistan $28.8 million; Tajikistan $17 million.

1. Production: Quality assurance and quality control2. Market3. Households and schools4. Import: customs Monitoring and evaluation

Government high-level Leadership to play a role of coordination between different agencies: MOH/SES, MoEd, Industry, Agriculture, NGOsNational plans need further development and enrichment to include recommendations for USI, UFF, and successful elimination of VAD The government support, ownership, and investment for the processStrategic planning

Measures to Correct Vitamin A DeficiencyDietary DiversificationPublic Health MeasuresFood Fortification SupplementationAll approaches are complementary and should not be used in isolation

Supplementation: prevention AdvantagesEasy to implementFast improvement of vitamin A status Easy to target vulnerable populations Low-cost (2 cents per capsule)Easy to do - minimal training and equipment required

ConstraintsShort term approach Distribution every 6 monthsRequires heavy logistics

Food FortificationGlobally a growing interest for food fortification Has turned out to be more feasible than expected in non industrialised countries (eg mass fortification in Central America, Morocco, Zambia)

Food FortificationAdvantagesWide coverageEasy to implementNo active participation of populationCheap

ConstraintsEntire population is exposed The target groups - pre school age children and pregnant women - may not be reached Requires centralised food industryRequires effective surveillance system (quality control, biological impact)

Dietary Diversification

AdvantagesLong term approach to control VADRelies onAvailability of vitamin A rich food (fruits, vegetables and animal products)ConstraintsSmall scale projectsLimited population coverage

Complementary Public Health MeasuresIntegrated management to control infections diseases (IMCI)Immunisation (EPI)Safe motherhood interventionsImprove malnutrition and other micronutrient deficiencies Iron deficiencyIodine DeficiencyPromotion of breast feeding Improve water and sanitationPoverty alleviation programmes

Fortunately, public health measures such as food fortification and supplementation are feasible and effective in eliminating this public health burden (from about 10 cents/person/year for iodizing salt to $2/person/year for daily iron supplementation)