Micro-nutrient Deficiencies:

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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
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Current Estimates of Iodine Deficiency in CIS
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DHS 1995 59 women 81 children
DHS Experience
DHS 1997 50 women 73 children
DHS 1999 36 women 36 children
Tadjikistan Women - gt 60 Children - 69 U3)
(MOH)
DHS 2000 47 women 36 children
DHS 1996 72 women 81 children
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Vit. A deficiency in CARK
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(No Transcript)
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Causes of Death Among Pre-School Children in
Non-Industrialised Countries, 2000
Malnutrition 60
Ref.WHO 2002
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Causes of Death Among Pre-School Children in
Non-Industrialised Countries, 2000
Malnutrition 60
Vitamin A Deficiency Increases risk of mortality
with 23
Ref.WHO 2002
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Strategies to review
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CARK Anemia Prevention and Control Programme
Strategy
Education for dietary change
Flour fortification
Weekly supplementation 6-24 months Adolescents
and childbearing age women Pregnant women
Research agenda of key studies and monitoring
activities
IMCI
Nut. Act. Plan
BF
Reprod. Health.
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Strategic planning APC

• 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.

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Fortification Flour fortification

• 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.

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Main interventions for wheat 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

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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.

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Supplementation

• Continue Iron supplementation with review of
  target group, strengthening of all interventions
  proposed at desk review until fortification is
  taken to the scale
• Improve management and organisation, supply
  distribution, build capacities, IEC with strong
  monitoring component at all levels
• Review preventive supplementation and treatment
  guidelines

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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 industry
• Need of partnership
• Legislation
• Working enforcement mechanisms
• Reliable surveillance system for monitoring
  quality control and quality Assurance
• To have a large population coverage, including
  the population groups the most at risk
• Monitoring of household coverage
• Strengthen Communication component
• To correct iodine deficiency by ensuring adequate
  iodine intake
• Assessment of iodine status (UIE) every 3-4 years

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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 Assurance
• Market monitoring
• Monitoring of household coverage, with attention
  to population groups the most at risk

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Steps to reach USI in CARK

• To be sustainable
• Commitment of the Government and salt industry
• Need of partnership
• Legislation - 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

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Solutions through Partnerships in the country

• Government agencies
• Associations of producers
• NGOs
• Consumer organisations
• Media
• International organisations
• Scientific groups

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Communications

• 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

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The economic costs of undernutrition are high
productivity losses
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Relative Cost Effectiveness of Micronutrient
Interventions
Source UNICEF/UNU/WHO/MI, 1999
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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.
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Monitoring and evaluation
1. Production Quality assurance and quality
control 2. Market 3. Households and schools 4.
Import customs
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Strategic planning

• Government high-level Leadership to play a role
  of coordination between different agencies
  MOH/SES, MoEd, Industry, Agriculture, NGOs
• National 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 process

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Measures to Correct Vitamin A Deficiency
Supplementation
Dietary Diversification
Food Fortification
Public Health Measures
All approaches are complementary and should not
be used in isolation
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Supplementation prevention

• Advantages
• Easy to implement
• Fast improvement of vitamin A status
• Easy to target vulnerable populations
• Low-cost (2 cents per capsule)
• Easy to do - minimal training and equipment
  required
• Constraints
• Short term approach
• Distribution every 6 months
• Requires heavy logistics

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Food Fortification

• Globally 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)

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Food Fortification

• Advantages
• Wide coverage
• Easy to implement
• No active participation of population
• Cheap
• Constraints
• Entire population is exposed
• The target groups - pre school age children and
  pregnant women - may not be reached
• Requires centralised food industry
• Requires effective surveillance system (quality
  control, biological impact)

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Dietary Diversification

• Advantages
• Long term approach to control VAD
• Relies on
• Availability of vitamin A rich food (fruits,
  vegetables and animal products)
• Constraints
• Small scale projects
• Limited population coverage

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Complementary Public Health Measures

• Integrated management to control infections
  diseases (IMCI)
• Immunisation (EPI)
• Safe motherhood interventions
• Improve malnutrition and other micronutrient
  deficiencies
• Iron deficiency
• Iodine Deficiency
• Promotion of breast feeding
• Improve water and sanitation
• Poverty alleviation programmes