Micro-nutrient Deficiencies: New Challenges for Central Asia Nune Mangasaryan, UNICEF CARK,

1. 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

2. Current Estimates of Iodine Deficiency in CIS

3. DHS 1995 59 % women 81% children DHS Experience DHS 1997 50 % women 73% children DHS 1999 36 % women 36% children Tadjikistan: Women - > 60% Children - 69% U3) (MOH) DHS 2000 47 % women 36% children DHS 1996 72 % women 81% children

4. Vit. A deficiency in CARK

6. Causes of Death Among Pre-School Children in Non-Industrialised Countries, 2000 Malnutrition 60% Ref.;WHO 2002

7. Causes of Death Among Pre-School Children in Non-Industrialised Countries, 2000 Malnutrition 60% Vitamin A DeficiencyIncreases risk of mortality with 23 % Ref.;WHO 2002

8. Public Health actions Supplementation Dietary diversification Population coverage Food fortification time Strategies to review

9. Programme linkages 1997 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.

10. 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.

11. 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.

12. 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

13. 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.

14. 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

15. 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

16. 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

17. 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

18. Solutions through Partnerships in the country • Government agencies • Associations of producers • NGOs • Consumer organisations • Media • International organisations • Scientific groups

19. 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

20. The economic costs of undernutrition are high: productivity losses

21. Relative Cost Effectiveness of Micronutrient Interventions Source: UNICEF/UNU/WHO/MI, 1999

22. 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.

23. Monitoring and evaluation 1. Production: Quality assurance and quality control 2. Market 3. Households and schools 4. Import: customs

24. 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

25. 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

26. 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

27. 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)

28. 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)

29. 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

30. 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