Non-insulin dependent diabetes mellitus which occurs The prevalence of maturity-onset diabetes or NIDDM decreased by 68% in the treatment group. …

Prospects for Improving the Nutrition Situation in Eastern Europe and
Central Asia

Table of Contents

Acknowledgments i

Executive Summary ii

Chapter 1 Introduction 4
Chapter 2 The Causes and Consequences of Malnutrition Worldwide 6
21 Undernutrition 6
22 Micronutrient Deficiencies 9
23 Overweight and Obesity 11

Chapter 3 Prevalence Rates of
Malnutrition in the ECA Region
13
31 Undernutrition and Growth Failure
13
2 Maternal Nutrition and Low Birthweight LBW 14
3 Infant Mortality Rates 15
34 Micronutrient Deficiencies
17
35 Overweight and Obesity 19

Chapter 4 Causes of Malnutrition in the ECA Region
21
41 Behaviors Affecting Nutritional Status
21
42 Disease, Access to Health Services and
Water and Sanitation 23
43 Problems With Access to Food 24
431 Rising Food Prices 24
432 Removal and Reduction of Food Subsidies
25
433 Changes in Real Wages, Food Shares
and Unemployment 26
434 Changes in the Availability of Food in
the General Population
26

Chapter 5: The Effects of the Economic
Crisis on Nutritional Status
29
51 Coping Mechanisms 29
52 Malnutrition in Vulnerable Groups
30
53 Overconsumption 32
54 A Closer Look at the Central Asian Republics
33

Chapter 6: The Policy Environment and Existing Programs
35 61 The Policy Environment
35
62 Existing Programs 35

Chapter 7: Recommendations and Conclusions 38
71 General Recommendations
38
72 Central Asian Republics and Caucasus
40
73 Southern and Eastern Europe and West Former Soviet Union
40
74 Conclusions 41

Bibliography 42-47

Annex: Detailed Information Sheets for Selected Countries Albania,
Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyz Republic,
Lithuania,
Moldova, Romania, Russian Federation, Tajikistan,
Turkey,
Uzbekistan 48-
103

Tables:
Table 1: Eastern and Central European Country Divisions
5
Table 2: The Causes and Consequences of Iron, Iodine and Vitamin A
Deficiencies 10
Table 3: Wasting and Stunting Prevalence of Public Health Concern in the
ECA Region 14
Table 4: Available Prevalence of Low Birthweight in the ECA Region
15
Table 5: Available Prevalence Rates of Anemia in the ECA Region
17
Table 6: Available Overweight and Obesity Prevalence Data in the ECA
Region 20
Table 7: Coverage for Immunization and Prevalence of Diarrhea in Selected
Countries 23
Table 8: Percentage Change in Real Wages and Food Share From 1989-1995

by Sub- Region 26
Table 9: Percentage Change in Food Availability Indicators from 1988-1995

by Sub-Region 27
Table 10: The Status of IDD Control Programs in the ECA Region
37

Figures:
Figure 1: Relative Causes of Child Mortality
6
Figure 2: Proportion of Deaths of Children Due to Severe and Mild/Moderate
Malnutrition on Infectious Diseases
7
Figure 3: The
Multi-Sectoral Causes of Malnutrition
8
Figure 4: The Relationship Between Stunting and GNP/c in the ECA Region
13
Figure 5: Changes in Infant Mortality Rates 1980-1997 deaths per 1,000
live births 16
Figure 6: Share of Pregnant Women, At Term, With Anemia in Russia and
Ukraine
1990-1995 per 100 life births 18
Figure 7: Wasting, Stunting in Children 6-59 months and GDP Trends in
Tajikistan 31

Boxes:
Box 1: Economic Costs of Undernutrition to Society
9
Box 2: New Research on Meeting Requirements for Micronutrients
11
Box 3: Body Mass Index BMI and Related Health Risks
12
Box 4: The Economic Costs of Overweight and Obesity
12
Box 5: Poor Feeding Practices Induce Growth Faltering in Young Children
22
Box 6: Food Consumption Changes in Bulgaria 32
Box 7: Decline in Availability of Iodized Salt
35

Acknowledgments

The authors would like to thank the many World Bank staff who supported the
writing of this report We would first like to thank Ms Maureen Lewis,
Sector Manager, Human Development Economics, the Europe and Central Asia
ECA
Region Her comments and insights on the initial and subsequent
drafts were essential to guiding the authors and completing this document
This report would not have been possible if it had not been for Ms Sabrina
Huffman, formerly from ECA and now in the Human Development Network Ms
Huffman was an important member of the team in providing the authors with
key information and contacting many agencies in the region to help identify
nutrition-related programs She also gave valuable comments on the final
draft of this document Ms Dena Ringold, ECSHD, also was helpful in
identifying some helpful documents in the beginning of the research process
which is very much appreciated

The authors are also grateful to the peer reviewers for this document for
their thoughtful and cogent comments: Mr Harold Alderman, Food Policy
Advisor, RDD; Ms Christine Jones, Principal Economist, ECAVP; Ms Judith
McGuire, Senior Nutritionist, LCSHH; and Ms Milla McLachlan, Nutrition
Advisor, HDNHE Also important to the quality of this document were the
information and comments received from Mr Jan Bultman, ECSHD; Mr Philip
Goldman, ECSHD; Mr Dominic Haazen, ECSHD; Mr Timothy Heleniak, DECDG; Mr
Besim Nuri,
ECSHD; Mr Ross Pavis, ECSHD; Ms Helen Saxenian, HDNHE; and
Mr Tjaart Schillhorn van Veen, ECSSD

In addition to Bank staff, the authors also extend their appreciation to
the following people who generously and willingly provided useful
information and documents on the region: Mr Abe Parvanta, CDC; Ms Sonja
Rabeneck, ACC/SCN; Ms Aileen Robertson, WHO/EURO; and Mr Robert
Steinglass, The BASICS Project
Executive Summary

This report provides an overview of critical nutrition issues and problems
in Eastern Europe and Central Asian ECA countries The ECA region is
large in terms of the number of countries it covers and diverse in terms of
its economic, political and social structures As expected, nutrition
problems are also diverse in the region, from countries where
undernutrition in children is highly prevalent to countries where
overweight and obesity are significant public health problems
Paradoxically, there also are countries where both overweight and obesity
exist simultaneously with undernutrition in children

Undernutrition, as measured by wasting and stunting, in young children is a
public health problem in the Central Asian Republics,
Azerbaijan, Turkey
and Albania In these countries rates of stunting range from 20 to 30
percent and wasting from 7-12 percent In Tajikistan rates of stunting in
children under five years of age have steadily increased over the last few
years to a high of 55 percent

Rates of undernutrition in women do not appear to be a problem in the ECA
region Direct measures of undernutrition in women in Kazakhstan, Kyrgyz
Republic and Uzbekistan show that less than 10 percent fall below the
cutoff for being undernourished body mass index 185 However, rates of
iron deficiency anemia have increased in the region and women, because of
their high requirements for iron, are particularly affected, as are young
children Where information is available, anemia prevalence is high, with
25-60 percent of women and over 50 percent of children under 3 years of age
with anemia Iodine deficiency disorders are on the increase in the
region Although salt was iodized and distributed during the Soviet years,
the Newly Independent States have had difficulty maintaining the
infrastructure and systems to produce and distribute iodized salt
Consequently, goiter prevalence is increasing throughout the
region,
reportedly affecting over 80 percent of the population in some oblasts of
Tajikistan and Kyrgyz Republic While little is known about actual
prevalence of vitamin A deficiency, it is known that the intake of fruits
and vegetables, some of which have good vitamin A activity, are limited in
the region High intake of animal products is preferred over more diverse
diets that would include fruits and vegetables and which are lower in fat
Consequently, rates of overweight and obesity are high in most countries in
the region, with a quarter to one-third of the entire adult population
either overweight or obese This has contributed to increased rates of
cardiovascular disease, maturity onset diabetes and other morbidities
associated with being overweight

Lack of knowledge is the most important determinant of malnutrition in the
ECA region This lack of knowledge has led to low rates of exclusive
breastfeeding and inadequate amounts of complementary foods for young
children, particularly those living in Central Asia and the Caucasus Poor
knowledge about healthy food choices has resulted high intake of fat and
low intake of fruits and vegetables, making rates of overweight and
obesity
one of the highest worldwide

There has been some effect on food intake and nutritional status as a
result of the economic transition of the 1990s, particularly among certain
vulnerable groups A decline in real wages and an increase in unemployment
rates have increased the proportion of the family budget spent on food A
decline in the consumption of meat, milk and fruits and vegetables from 5-
56 across the region has meant that the composition of the family diet has
changed However, because meat and milk intake were excessive prior to
economic transition, it appears that this has not compromised the amount of
food available to meet the requirements on a per capita basis In
addition, many families were able to produce food at home to compensate for
their reduced earning capacity and ability to purchase foods

However, there are vulnerable groups that have suffered because of the
crisis World Bank poverty reports identify the following groups as those
at risk for poverty: families with children, young children, the elderly
without pensions, and those without land In addition, certain ethnic
groups and displaced persons are more at risk for poverty and
undernutrition in
the region Those living in poverty, as seen from one
example in Bulgaria, have a much lower intake of food commodities, and the
ratio between those living in the wealthiest and poorest deciles increased
dramatically due to the economic crisis It is not known how or if rates
of malnutrition increased in the region as a result of the economic crisis
of the 1990s There is only one country for which there are data on the
changing nutritional status of children: in Tajikistan rates of stunting
increased from 41 in 1994 to 55 in 1996

Iron deficiency anemia and iodine deficiency disorders IDD have increased
dramatically in the region For anemia, this may be due to a decrease in
meat intake for certain groups, but more important is the lack of
commitment to addressing and preventing this deficiency For iodine
deficiency, the availability of iodized salt declined after the breakup of
the Soviet Union Only a few countries have continued to iodize salt in
spite of the fact that the populations of the entire region is at high risk
for IDD

To address the nutrition situation in the ECA region, recommendations
include immediately addressing anemia through fortification of flour with
iron
and iodine deficiency disorders by iodizing all salt Since much of
the malnutrition in the region is due to lack of knowledge, it is
imperative to develop communications for behavior change strategies This
means educating policymakers and health providers to develop and deliver
correct nutrition messages Countries in Central Asia and the Caucasus
need special attention to address undernutrition in young children and
micronutrient deficiencies For the entire region, emphasis needs to be
put on improving the quality of food intake Fruit and vegetable intake is
extremely low in the entire ECA region and current information on the
importance of these foods for adult morbidity and mortality should be
disseminated to consumers throughout the region These messages need to be
combined with those for changing lifestyles with regard to high intake of
fat and alcohol
1 Introduction

During the past ten years, there have been massive changes in the political
and economic structures in Eastern European and Central Asian countries
These changes were marked by declines in real wages and food availability,
reduced access to health services, and other determinants of malnutrition
A
legitimate concern has been raised that the nutrition situation has
deteriorated in the ECA region, particularly for the vulnerable groups

As a result of the break-up of the Soviet Union, the entire region suffered
from economic deterioration in the 1990s Some countries were better able
to cope with declines in real income and increasing unemployment rates than
others which experienced dramatic increases in rates of poverty Recovery
has been dependent on adherence to sound economic policies and adjustments
that not all countries complied with

The ECA region is large in terms of the number of countries and diverse in
terms of its economic, political and social structures As expected,
nutrition problems in the region also are diverse In some countries rates
of undernutrition in young children are similar to those found in Sub-
Saharan Africa and South Asia In other countries rates of undernutrition
in young children are low and on par with those in Europe and North
America Similar to the West, other forms of malnutrition are prevalent in
some countries: high rates of obesity and poor intake of micronutrients
have resulted in increased incidence of cardiovascular disease,
diabetes,
and other diseases associated with lifestyle choices In yet another group
of countries, there exists the paradox of undernutrition in young children
and obesity in adults simultaneously

This report provides an overview of the critical nutrition issues and
problems in Eastern European and Central Asian countries The diversity in
the ECA region makes it difficult to draw broad conclusions about the
nutrition situation, and thus to make far-reaching policy and program
recommendations In addition, data particularly trend data on the
nutrition situation is very limited, sometimes of poor quality and in many
cases not nationally representative However, some conclusions can be made
by sub-region, based on comparable socio-economic and child welfare
indicators The report has been structured around such a division Table
1 Examples are presented from certain countries to emphasize points
regarding the causes of undernutrition and micronutrient malnutrition which
the authors think are relevant to the region However, these examples may
in fact only be relevant to the country or the within-country group to
which these data apply

Table 1:Eastern and
Central European Country Divisions

Division based on World Bank regions

Chapter 2 of this report reviews what is known about the causes and
consequences of malnutrition worldwide The prevalence or change in
prevalence of malnutrition in the region are discussed in
Chapter 3 An
overview of the probable causes of malnutrition is presented in Chapter 4
The effects of the economic crisis on nutritional status are discussed in
Chapter 5 A brief section on the policy environment and the state of
current programs to address malnutrition in Chapter 6 is followed by
conclusions and recommendations to improve nutrition through policy and
program support Given the diversity of the region and in order to
maximize information for selected countries, detailed information sheets
with prevalence statistics and program facts relevant to nutrition are
included in the Annex

2 The Causes and Consequences of Malnutrition Worldwide

While malnutrition is typically thought of as undernutrition, it should be
defined as undernutrition, micronutrient deficiencies, and
overweight/obesity, usually accompanied by high fat intake

21 Undernutrition

Undernutrition is an outcome of insufficient food intake in both quality
and quantity and disease In fact, there is a cyclic relationship between
malnutrition and infections Many of the children in developing countries
dying from childhood diseases would not die if they were well-malnourished
It is estimated that
malnutrition is an underlying cause of death in 49
percent of under-five child deaths Figure 1[2]

Figure 1: Relative Causes of Child Mortality

Source: WHO 1998

While it is accepted that concurrent severe malnutrition and disease
increase the risk of premature death in young children, a recent analysis
shows that mild to moderate malnutrition also contributes significantly to
mortality In fact, mild to moderate malnutrition makes up a greater
proportion of child deaths caused by malnutrition about four-fifths in
developing countries compared to severe malnutrition about one-fifth
Figure 2[3]

Figure 2: Proportion of Deaths of Children Due to Severe and Mild/Moderate
Malnutrition on Infectious Diseases

Source: Pelletier 1995

At the same time, nutritional status is compromised by childhood diseases
such as diarrhea, acute respiratory infections and measles Requirements
for nutrients are higher during illness and children become anorexic during
episodes of infection, resulting in reduced food intakes One study found
that vitamin A and protein levels deteriorated even in well-nourished
children when they contracted measles[4] Factors affecting food intake
and disease are
multi-faceted in nature Underlying factors include lack
of knowledge and education, poor maternal and child care practices, family
food insecurity and poor intra-family food distribution Poor access to
health, water and sanitation services at the household level and societal
causes such as lack of human, economic and organizational resources are
among the structural causes of malnutrition Figure 3 shows this multi-
sectoral model for the causes of malnutrition

Figure 3: The Multi-Sectoral Causes of Malnutrition

Source: UNICEF 1990

Besides being the cause of premature death in young children, malnutrition,
as measured by stunting, has a wide range of health, economic and social
consequences for children and adults Poor educational achievement and
reduced capacity to work are known consequences[5] In addition, recent
research shows that fetal malnutrition not only has important immediate and
long-term consequences for survival, growth and development in childhood
and productivity throughout life, but also affects adult health and
survival[6] Unfortunately, stunting in children under two years of age,
when most stunting occurs, is not reversible later in childhood or
in
adulthood, resulting in adults of short stature[7] From data in the
Philippines, it has been estimated that with every 1 percent decrease in
height there is an associated 14 percent decrease in productivity[8] The
effects of malnutrition on development and learning in children and adult
productivity are particularly relevant and important to areas where infant
mortality rates are not high, such as in the ECA region The economic
costs of undernutrition are shown in Box 1

Box 1: The Economic Cost of Undernutrition to Society

Undernutrition has serious functional consequences for the affected
individuals, households and nations Undernutrition in children inhibits
their growth, increases their risk of morbidity, affects their cognitive
development and reduces their subsequent school performance and labor
productivity The relationships between malnutrition and mortality,
morbidity, educational performance and work performance have been
documented McGuire, 1996 Stunting in childhood continues into
adulthood, resulting in adults of short stature Ruel et al, 1995 Haddad
and Bouis found a linear relationship between physical stature and
productivity in adult laborers in the
Philippines Haddad Bouis, 1990
and calculated that a 1 percent decrease in height is associated with a 14
percent decrease in productivity

In a population such as in Uzbekistan, a simple calculation can show that
stunting will cause enormous losses in future productivity The number of
pre-school children 0-3 years is 1,892,000, of which 31 percent are
stunted by the age of 3 years Of those stunted, 14 percent are severely
stunted After the age of about 22 months, severely stunted children are
about 10 centimeters shorter than normal children and moderately stunted
children 7 centimeters shorter Stunting during childhood translates to
equal height deficits in adulthood Assuming an average height of 160
meters, 7-10 centimeters corresponds with a 438-625 percent reduction in
height due to impaired growth during childhood, which is estimated to yield
losses in labor productivity of 604 percent for the moderately stunted and
86 percent for the severely stunted Assuming an annual current wage of
US870, the loss of productivity of these children will result in about US
33 million in economic losses

In addition to the economic costs of lost educational attainment
and
productivity, household incomes and national economic growth are negatively
influenced by undernutrition through lower benefits from investments in
education, and higher health care costs

Maternal undernutrition affects the nutritional status of the fetus and is
the main cause of low birthweight 2500 g at birth in developing
countries Low birthweight infants are 40 times more likely to die in the
neonatal period and those who survive infancy have a 50 greater risk of
developmental problems As adults, low birthweight infants are at greater
risk of premature death due to cardiovascular disease, diabetes, and
hypertension[9]

22 Micronutrient Deficiencies

Poor intake of vitamins and minerals, usually referred to as
micronutrients, results in a number of poor health outcomes For example,
compromised growth and immune function is associated with vitamin A
deficiency Reduced mental development, educational achievement, and work
and reproductive capacity have been linked to iron and iodine deficiencies
These three micronutrients, iron, iodine and vitamin A, receive the most
international attention at present because of their life-threatening and
quality of life consequences,
and because programs exist to successfully
address these deficiencies at low cost

Children 6-24 months of age and pregnant women are most at risk for anemia,
followed by all women of reproductive age and older children All
individuals in endemic areas are affected by insufficient intakes of iodine
and are at risk for reduced intellectual capacity and enlargement of the
thyroid ie, goiter However, pregnant women are most at risk because
of the tragic effects of iodine deficiency on the developing fetus ie,
severe mental retardation Vitamin A deficiency has long been associated
with blindness Young children are usually the target group for vitamin A
supplementation not only because they are most at risk for blindness, but
also because of the association between even sub-clinical vitamin A
deficiency and increased mortality Moreover, a recent study in Nepal
found that maternal mortality rates decreased when women took vitamin A
before and during pregnancy[10] The causes and consequences of
deficiencies in these three micronutrients are reviewed in Table 2

Source: Levin, et al 1993

Economic costs of micronutrient malnutrition are high For iron,
productivity losses have been estimated at 17 percent for heavy labor and 5
percent for moderate to mild labor Cognitive losses for iron and iodine
deficiencies range from 4-10 percent[11]

In addition to deficiencies in these three micronutrients, intakes of other
micronutrients are also poor in most developing countries Like iron, the
best sources of zinc are animal products which most people in developing
countries cannot afford Zinc supplementation has recently been found to
reduce the duration of diarrhea and improve growth in young children[12]
In addition, the benefits of consuming foods rich in other micronutrients
and other substances, popularly called phytochemicals, found mainly in
fruits and
vegetables, are coming to light and include reducing risk of
cardiovascular disease, cancer, maturity onset diabetes, cataracts, and
other diseases and health conditions associated with industrial countries
in the West Box 2[13]

23 Overweight and Obesity

Another type of malnutrition is overweight and obesity, caused by excessive
energy intake and a sedentary lifestyle Because overweight and obese
individuals generally have poor diets, they also may be deficient in all or
some of the micronutrients Indicators for overweight and obesity and the
health risks and economic costs for both these conditions are outlined in
Boxes 3 and 4 This type of malnutrition is usually associated with the
wealthy in Western and developing countries, although in many countries
obesity is associated with the poor For example, in Brazil, degenerative
diseases and their risk-factors such as obesity and hypertension, are most
prevalent among the poor[14] and these conditions co-exist in households
where there are undernourished children This is particularly true of
residents of urban areas where activity levels have decreased[15]

In a study in the Baltic Republics, levels of education
and income were
positively associated with the belief that different types of fats put
people at greater risk of cardiovascular disease For example, in Estonia
the odds ratio for this belief in men was 100 at the lowest level of
income and 25 at the highest level of income[16]

3 Prevalence Rates of Malnutrition in the ECA Region

31 Undernutrition and Growth Failure

Undernutrition in children under five years of age is one of the commonest
forms of food deprivation worldwide Acute undernutrition or wasting is
usually caused by a recent reduction in food intake and/or a bout with an
infectious disease or diarrhea The cyclic nature of food intake and
disease also comes into play Most episodes of infection in young children
are accompanied by reduced food intake due to the anorexia that often
accompanies illness and in turn prolongs recovery from disease Reducing
food intake during illness also is exacerbated by erroneous beliefs that
food deprivation aids recovery ie, feed a cold and starve a fever
Chronic undernutrition, or stunting, is the best measure of the overall
nutritional status of the child and is caused by a repeated and long-term
cycle of food
deprivation and/or recurrent infections Stunting also is a
sensitive measure of poverty as rates of stunting decrease when gross
national product GNP per capita increases Figure 4

Figure 4: The Relationship Between Stunting and GNP/c p002 in the ECA
Region

Source: Macro International, Demographic Health Surveys for Kazakhstan
1995, Kyrgyz Republics 1997, and Uzbekistan 1996; Branca, et al
1996WDR 1999-2000

National rates of undernutrition are not widely available in the ECA
region The only countries for which there are figures are listed in Table
3 Shown here are rates that are considered public health concerns

Source: Macro International, Demographic Health Surveys for Kazakhstan
1995, Kyrgyz Republics 1997, and Uzbekistan 1996; Branca, et al
1996

32 Maternal Nutrition and Low Birthweight LBW

There is little documented information on the prevalence of underweight in
women in the ECA region In Uzbekistan, Kazakhstan and Kyrgyz Republic,
where rates of malnutrition in children are high, only 10, 8, and 7 percent
of women, respectively, are underweight[18] Low birthweight prevalence is
a marker
for intra-uterine growth retardation or fetal malnutrition and
prematurity caused by infections High rates of low birthweight in
developing countries are indicative of undernutrition in women In the ECA
region prevalence of LBW is low Table 4 and comparable to rates in West
European countries, confirming that there is little underweight in women
LBW is considered a public health problem if rates are greater than 15-20
percent[19]

Table 4: Available Prevalence of Low Birthweight
in the ECA Region
|Region and Countries | of Live Births |
| |Weighing 2500 g |
|CAR, Turkey, and | |
|Caucasus | |
|Kazakhstan | 9 |
|Kyrgyz Republic |6 |
|Turkey |8 |
|Azerbaijan |6 |
|WFSU | |
|Belarus | 5 |
|Ukraine |8 |
|SEE | |
|Albania | 7 |
|Bulgaria |7 |
|Macedonia |8 |
|Croatia
|8 |
|CE | |
|Czech Republic | 6 |
|Hungary |9 |
|Poland |9 |
|Slovakia |6 |
|Slovenia |6 |
|Baltic States | |
|Latvia | 4 |
|Lithuania |4 |

Source: World Bank 1999

At the same time, there is some evidence that low birthweight rates are
increasing in the region In Armenia, low birthweight rates have increased
since the 1980s[20] and slight increases have been recorded for Albania and
the Ukraine[21] However, these increases probably do not reflect changes
in maternal undernutrition Increasing rates of low birthweight can also
be caused by rising rates of obesity, as is seen in Western Europe, the
United States and Canada It is unknown if rates of above-average
birthweights, often associated with gestational diabetes, have been
increasing in the region

33 Infant Mortality Rates

While malnutrition rates are high in several countries, sub-regional trends
in infant mortality rates IMR show an
overall decrease since the 1980s
and even during and after the economic transition period Figure 5
Further evidence for these low rates can be seen by comparing ECA with
other middle-income countries: only 6 out of 24 middle- income countries
from other regions have IMR below 25 In the ECA region 21 out of 27
countries have infant mortality rates below 25[22][23] Adequate access to
health services may explain why children, although malnourished, are less
likely to die in their first year of life However, access to health
services has declined due to the economic crisis[24], in particular in the
CAR and Caucasus where malnutrition rates are high This may have a
negative impact on infant mortality rates in the near future

While infant mortality rates are not high in ECA compared to similar
regions worldwide, the consequences of undernutrition and micronutrient
malnutrition are still relevant and important to child development,
learning and adult productivity in ECA

Figure 5: Changes in Infant Mortality Rates deaths per 1,000 live births
Source: TransMONEE

34 Micronutrient Deficiencies

Anemia prevalence, both in young children and women of child bearing
age,
is high in the ECA region For countries where there are data, prevalence
rates are shown in Table 5

Sources: Macro International; Tamar Gotzdze, UNICEF, personal
communication, Georgia;
UNICEF 1998

The DHS studies in Kazakhstan, the Kyrgyz Republic and Uzbekistan show that
prevalence of anemia is highest in children 6-23 months of age, when the
most rapid periods of growth are occurring and requirements are highest
In women prevalence is highest in the age group of 30-39 years and is
probably due to frequent, poorly-spaced pregnancies and unsafe abortions

High prevalence rates of anemia are seen not only at different points in
the life cycle but also in special groups in the region For example, a
study in Azerbaijan found that anemia rates were consistently higher in the
internally displaced populations[25] In Kazakhstan there are higher rates
of anemia in the Kazak ethnic group compared to the Russian ethnic
group[26] Regional differences also exist Anemia rates are extremely
high in the Aral Sea region of Kazakhstan and Uzbekistan, where people are
poor
and there are problems with agrochemical pollution, food and water
shortages, and economic stability19

There is evidence that anemia prevalence has increased in many countries
over the last ten years and has dovetailed with economic hardships in the
region For example, in Russia anemia prevalence increased from 12 percent
in 1990 to 34 percent in 1995, and in Ukraine from 7 percent in 1990 to 27
percent in 1995 Figure 6

Figure 6: Share of Pregnant Women, At Term, With Anemia in Russia and
Ukraine, 1990-1995 per 100 life births

Iodine deficiency disorders IDD are prevalent in the ECA region Turkey
has one of the highest rates of goiter[27] in the region, with 36 percent
in school children affected Rates are also high in Central Russia with 15-
25 percent of children and women affected and in other regions of Russia
with up to 40 percent affected[28] In Bosnia-Herzegovina goiter rates of
25 percent have recently been reported[29] In Georgia, goiter rates of 54-
78 percent have been reported Many of the countries in the region are
probably affected more severely in certain areas or pockets of each
country For example in the Khatlon region of Tajikistan, goiter
prevalence is
as high as 80 percent[30] A similar level is reported for
certain oblasts in the Kyrgyz Republic[31] In Ukraine in 1994, it was
estimated that consumption of iodine was two times less than physiological
requirements In 1995 1,340 cases of children with endemic goiter stage
III were reported-an increase from 1994 levels of 928 cases[32] Special
populations may be more vulnerable to IDD For example in Azerbaijan,
goiter prevalence is higher for internally displaced populations 23
percent than the regular population 10 percent Goiter is more common in
women 14 percent than men 6 percent because physiological requirements
are higher for women[33]

Little is known about vitamin A deficiency in the region WHO reports that
in the Aral sea region of Uzbekistan, vitamin A deficiency has been
identified in 40-60 percent of children under five years of age serum
retinol10 ?g/dL[34] Turkey, Romania and Uzbekistan are three countries
where vitamin A deficiency exists but is mild[35] Vitamin A status
appears to vary throughout the ECA region In one study in Armenia only
08 percent of children had low serum retinol values but in Macedonia there
are reportedly clinical cases of vitamin A
deficiency in children with
severe infections[36]

In 1983-91 a large-scale vitamin A survey was conducted for Russia,
Ukraine, Belarus and the Baltic States In general, vitamin A intake was
adequate; however, 6 percent of adults in the Mogiliev and Gomel regions
had mild vitamin A deficiency, and intakes of vitamin A were even lower in
children Deficiencies in carotenoids[37], many of which are precursors to
vitamin A, occurred in 39 percent of adults and 28 percent of children
Pregnant women had the lowest intake of carotenoids[38] It was estimated
that people 18-25 years of age in this region consume only one-fourth of
their requirements for vitamin A and beta-carotene the carotenoid with the
greatest vitamin A-activity

In a comparative analysis of nutrition policies in the region, Albania,
Armenia, Hungary, the Republic of Moldova, Romania, and Turkey identified
vitamin A deficiency as a problem Other micronutrient deficiencies were
also mentioned as problems including vitamin C Hungary, vitamin D
Romania, calcium Czech Republic, Hungary, Poland, Slovak Republic,
Turkey, riboflavin Turkey, Hungary, vitamin B-6 Turkey, thiamin
Hungary and folic acid Poland[39]

35
Overweight and Obesity

The most comprehensive data on global overweight and obesity was collected
between 1983-1986 in the MONICA study[40] In most of the countries
studied, many of which now make up the ECA region, between 50-70 percent of
adults were overweight or obese[41] Lithuania had the highest prevalence
of obesity-22 percent in men and 45 percent in women Current available
data for the ECA region reveal that obesity and overweight are a problem,
with 25-50 percent of the population overweight and between 6-25 percent
obese Table 6 Where children have been examined, there appears to be
low prevalence of overweight and obesity at this time, except in the
Russian Federation, where 21 percent of children under five are overweight
High rates of overweight and obesity in adults have made ischemic heart
disease the most important cause of death throughout the ECA region[42],
and given Eastern and Central Europe the dubious first place in the world
for mortality due to cardiovascular disease According to a recent
report[43], based on the CINDI study, the contribution of cardiovascular
disease to the overall death rate varied from 28 to 32 percent for Russian
men and from
24 to 36 percent for Russian women in areas surveyed In
Kazakhstan, 50 of mortality is attributed to cardiovascular disease[44]
Excessive body mass and hyper-cholesterolemia are leading risk factors for
the development of cardiovascular disease Levels of these risk factors are
extremely high in the CINDI populations in Russia, where hyper-
cholesterolemia is found in 19 of men and 10 of women[45] Excessive
body mass index is found in one-third of men and half of women in the CINDI
population in Russia

Table 6: Available Overweight and Obesity Prevalence Data in the ECA Region

Sources: National surveys and MONICA study

4 Causes of Malnutrition in the ECA Region

As mentioned in Chapter 2, malnutrition includes both undernutrition or
inadequate intake of energy and micronutrients, and excessive intakes of
energy resulting in obesity The causes of malnutrition are driven by any
number or combination of factors as seen in Figure 3 Inadequate dietary
intake and disease are the most significant immediate causes of
undernutrition in most developing
countries The major underlying causes
include poor maternal and child care practices, lack of awareness and
education, family food insecurity and poor intra-family food distribution,
poor access to good quality health and sanitation services, and societal
causes such as lack of human, economic and organizational resources
Another model for the causes of malnutrition is configured around food
availability, access and utilization Because malnutrition in the ECA
region appears to be largely caused by lack of knowledge rather than
inadequate resources, this report will begin with behaviors as the primary
cause of undernutrition, obesity and overweight, and micronutrient
malnutrition Some of the causes of malnutrition presented here have
always existed, such as low rates of exclusive breastfeeding and lack of
awareness about the importance of consuming fruits and vegetables
However, other causes of malnutrition have been triggered by the economic
crisis in the region

41 Behaviors Affecting Nutritional Status

One cause of undernutrition, obesity and micronutrient malnutrition is
inadequate intake of food, both in quantity and quality Paradoxically, in
some ECA countries
undernutrition rates in young children are high together
with rates of overweight and obesity in adults, suggesting that nutrition
problems are due to lack of education and proper utilization of food rather
than lack of food Dietary inadequacies may be caused by poor choices in
buying the right food or by mothers having too little time to prepare food
and feed their children Lack of knowledge about healthy nutrition
behaviors and practices is a major cause of poor nutrition in the ECA
region

In the Central Asian Republics and the Caucasus where malnutrition is
highest, inadequate feeding of young children preceded economic hardship
Poor feeding is caused by non-exclusive breastfeeding, the early
introduction of foods other than breastmilk, and inadequate amounts of
complementary foods starting at about six months Most of these are
related to poor child care practices Box 5

Source: Michaelsen, et al 1999; Griffiths and Cheetham 1998

Because resources to buy adequate quantities of high-quality foods have
declined for some families, feeding practices have deteriorated further
Several factors have played a role: food shortages; lack of appropriate
coping mechanisms
such as access to land to produce food for home
consumption; or the caregivers involvement in other activities to make
ends meet rather than caring for their young children

In adults, lack of knowledge, leading to poor food choices, is the cause of
high rates of overweight and obesity in the region As one example, a
study in the Baltics found that most residents did not know that certain
types of fat ie, saturated fats put people more at risk for
cardiovascular disease than other types of fats[46] In the past, beliefs
that high fat and meat intakes are healthy were translated into national
policies to subsidizes these foods

Other poor health behaviors also are associated with malnutrition
Smoking, alcohol and lack of exercise are important determinants of certain
conditions linked with overweight and obesity, and generally poor
nutritional status Smoking and excessive alcohol consumption increase
requirements for certain micronutrients and can displace food so that
intakes do not meet requirements A cross-sectional comparison of
cardiovascular disease risk factors across European populations, including
15 former communist countries, found that cardiovascular disease
mortality
was highly associated with hypertension and smoking in men and hypertension
and overweight in women The study advocated for greater emphasis on
increased consumption of foods containing anti-oxidants, such as fruits and
vegetables, that decrease the risk of cardiovascular disease and certain
types of cancer[47]

42 Disease, Access to Health Services, and Water and Sanitation

Disease, in particular infectious disease, affects dietary intake and
nutrient utilization In most cases, malnutrition is the combined result
of inadequate dietary intake and disease Malnutrition may also result
from a combination of causes, such as the lack or low utilization of health
services, poor quality of health services, including health professionals
who are poorly trained and motivated, inadequate water supplies and
sanitary facilities, poor food hygiene, and inadequate childcare

Because childhood diseases and infections increase the risk of
malnutrition, it is useful to look at immunization coverage rates for the
region As mentioned earlier, immunization coverage, based on available
information, is high in most of the region In the CAR, however, where
rates of malnutrition are
high, coverage rates for immunization, based on
community surveys, need improving in several countries However, diarrhea
is still prevalent in these areas Table 7

Table 7: Coverage for Immunizations and Prevalence of Diarrhea in Selected
Countries
| |Third Dose |Measles |Diarrhea in last |
| |DPT | |two weeks |
|Kazakhstan |512 |719 |157 |
|Kyrgyz |953 |854 |176 |
|Republic | | | |
|Uzbekistan |944 |915 |52 |
|Turkey |771 |778 |248 |

Source: Macro International, Demographic and Health Surveys for these
countries: Kazakhstan 1995, Kyrgyz Republic 1997; Turkey1993; Uzbekistan
1996

Governments typically inherited large and inefficient health care systems,
most of which were plagued by serious problems even prior to the transition
period Since that time, economic growth across the region has generally
been slow or negative and limited public resources have been available for
healthcare The transition period brought about a decline in health care
systems in the region,
both in terms of access and quality Coverage for
immunization can be a useful indicator for deterioration of nutritional
status so it is useful to examine if coverage rates have declined in the
region However, it is unknown if immunization services have deteriorated
since 1991 Immunization rates were over-reported in the former Soviet
Union because children who were not immunized due to contraindications and
over-exaggerated fears of vaccines, weakness of infants and complacency
about immunization were not included in coverage calculations This
problem persists In Armenia, for example, DPT3[48] coverage was reported
to be 82 percent in 1998 but a national immunization coverage survey, in
which all children were accounted for found that only 62 percent of
children had been immunized[49] Similarly, in Azerbaijan, in 1999
coverage for DPT3 was reported to be 87-97 percent, depending on the area,
but a community-based survey that same year found that only 57-70 percent
were in fact immunized In at least one country, Kazakhstan, the incidence
of infectious and parasitic disease did increase by 95 between 1990 and
1994[50], but generalizations cannot be made that the same is
true
elsewhere

The lack of access to water and poor environmental sanitation are important
underlying causes of malnutrition The collapse of the Soviet Union left
the CAR governments with major infrastructural constraints regarding
drinking water and sewage According to one report, less than half of the
rural population of CAR has access to safe water and in many urban
settings, the water is contaminated due to corrosion of pipes and mixing of
sewage and drinking water[51] In 1992 Central Asian sanitary facilities
were in general unsatisfactory with open latrines and untreated sewage
discharge leaking into open waterways

Because of the Aral Sea environmental disaster, about three million Kazaks
and Uzbeks living in the proximity of the Aral Sea are at risk for
consequent health problems as reflected in increases in mortality from
tuberculosis and hepatitis A reduction in the availability of food has
compromised nutritional status in that area The high incidence of
respiratory disease and neurological and congenital disorders is frequently
attributed to chemical pollution Independence and the subsequent decline
in health and nutrition standards and access to basic services
has created
a situation conducive to a rise of infectious and preventable disease
Lack of safe drinking water has resulted in an increase in water-borne
disease such as diarrhea, hepatitis and typhoid[52]

43 Problems with Access to Food

Food security is often defined as access by all people at all times to
sufficient food, in terms of quantity, quality and diversity, for an active
and healthy life Declining food subsidies and increasing poverty rates,
resulting from the transition in the 1980s, have affected the availability
of food for some groups Changes in welfare provision have impacted on the
availability of certain foods given as part of the welfare provision
These changes have affected the health and nutrition situation in
particular for the poor

431 Rising Food Prices

The post-independence era is characterized by sharp increases in food
prices across Eastern Europe and Central Asia Food shortages, high
inflation and price liberalization pushed prices up, while incomes could
not keep up the same pace This is particularly true for the Central Asian
Republics In Kazakhstan for example, the January 1992 price
liberalization increased food prices 5 to 10 times, from
already doubled
food prices in 1991[53] In Uzbekistan, families had to spend almost their
entire family income on food as prices of basic foods increased by 2 to 10
times, despite local production of fruit and vegetables[54]
Unfortunately, these changes in food prices were not accompanied by
nutrition education programs that could have informed people to make
correct food choices with what resources they had

432 Removal and Reduction of Food Subsidies

An important factor that affects access to food is the removal of producer
and consumer subsidies In the former USSR subsidies were intensively used
as instruments of social policy Among other objectives, state subsidies
on food stuffs had an important social function to keep remote rural areas,
as well as farms with lower than average productivity, alive and guaranteed
employment opportunities The average consumer subsidy rate in the USSR in
1988 for meat was 230 percent, for butter 240 percent, and for milk 170
percent Accordingly, high availability and accessibility levels of meat
and milk were seen in that period[55] However, removal of these
subsidies may have improved the nutrition situation for some groups
by
decreasing high intake of certain types of high fat foods

All the countries in transition started their reforms by removing most
state producer and consumer subsidies Removal of subsidies took different
routes, depending on the country but in most cases the poor were most
affected Evidence indicates that the declines in food consumption were
highest for those defined as living in poverty

The price of bread in Poland increased more rapidly than that of meat and
milk due to different pre-reform subsidy levels Hence meat consumption
actually increased in Poland between 1989 and 1991, while bread consumption
remained relatively constant and milk consumption declined For the
poorest in Poland income below 70 percent of ultra poverty line, energy
and protein intakes fell around 20 percent between 1989 and 1992[56] This
is of concern given that both fell below their recommended minimum intake
levels, at 2,101 kcal for energy and 55gm per day for protein Among the
ultra poor energy intake fell by 11 percent and protein by 13 percent, and
were below minimum recommended intake levels These two groups accounted
for about 20 percent of the Polish population by 1992, having been
just 10
percent in 1989

In Hungary the price of milk and bread rose much quicker than that of meat
due to the higher pre-reform subsidies Energy intake of the ultra poor
also fell by 9 percent, and protein by 6 percent resulting in energy
intakes below recommended levels at 2,127 kcal, and protein only marginally
adequate at 66 grams per day Those with inadequate intakes in the
population rose from 6 to 10 percent between 1989 and 1992[57] but it is
not known if these figures have continued to rise

433 Changes in Real Wages, Food Shares and Unemployment

Economic changes were marked in many countries by a decline in real wages,
and an increase in the share of the family budget being spent on food
Table 8

Table 8: Percentage Change in Real Wages and Food Share from 1989-1995 by
Sub-Region
|Sub-region |CAR |Caucasu|W FSU |SEE |CE |Baltic |
|Average change | |s | | | | |
|Real Wage |- 653 |-766 |-588 |-522 |-228 |-486 |
|Food Share | | | | | | |
|Pre-transition | |40-50 |30-40 |40-50 |30-40 |30-40 |
|proportion | |277 |221 |64 |-1
|121 |
| change | | | | | | |

Sources: UNICEF-ICDC 1995; TransMONEE database No data is available for
Turkey and the Balkans

As shown, there was a significant decline in real wages across the entire
ECA region between 1989-1995 Declines were most severe in the CAR and
Caucasus where undernutrition rates are highest Some improvements have
been made in certain countries of the CAR and Caucasus, but recent data[58]
show that real wage levels remain at less than 37 percent of the 1991 level
for Kazakhstan, less than 50 percent of the 1990 level for the Kyrgyz
Republic, and less than 31 percent of the 1993 level for Turkmenistan

Decreasing real wages and other factors have resulted in a greater
proportion of the family budget being spent on food The food budget
share, often used as a measure of poverty, increased in each sub-region
after the transition, except in Central Europe, where real wage changes
were lower than the rest of the region In the Caucasus, families are
spending 50 to 65 percent of their income on food In Albania, Romania,
Lithuania, Belarus, Ukraine, and Azerbaijan families are spending 55
percent of their
incomes on food This proportion of the family budget
spent on food is similar to those seen in sub-Saharan Africa and South
Asia, where malnutrition rates are the highest in the world

Prior to the economic transition, unemployment rates were close to zero
because unemployment was part of the state welfare system Since the
transition, unemployment rates have increased Rates of unemployment are
10 percent in the Central European countries Slovakia, Poland and
Hungary[59] and in Bulgaria, Latvia and Russia[60],[61] Rates are higher
in Central Asia but may be under-reported there because many people do not
feel it worth their while to collect limited benefits

434 Changes in the Availability of Food Among the General Population

Based on food availability data[62], all but the CAR and Caucasus regions
had access to sufficient food, even during economic crisis FAO established
a threshold of 2,300 kcal/per capita per day which ensures sufficient food
availability for a population There was an overall 8-18 percent decrease
in the availability of energy in the region but energy availability did not
fall below needed requirements in the Western Former Soviet Union, South
Eastern
Europe, Central Europe and the Baltic States In these sub-regions
energy availability was high before the crisis For example, daily energy
availability in Albania decreased from 3,049 kcal per capita per day to
2,550 kcal which is still adequate to meet the energy requirements of the
population However, vulnerable groups, in particular poor children and
women, may not have adequate energy intakes both because they are
marginalized within society, a situation which existed prior to the
economic crisis, and because of the economic crisis itself

The two sub-regions where energy intakes were compromised are the Caucasus
and CAR In the Caucasus energy decreased by 28 percent from 2,100 kcal
per capita per day to only 1,860 kcal or below the requirements for the
population In fact, 1990 energy intakes in the Caucasus can be compared
with energy intakes in the poorest countries in Africa ie, Niger, Mali
and Togo and Asia Bangladesh Food availability has changed for many
food items in all regions as shown in Table 9

Table 9: Percentage Change in Food Availability Indicators From 1988-1995
by Sub-Region
|Sub-region |CAR |Cauca|W |SEE |CE |Balti|
|Average
change | |sus |FSU | | |c |
|Average per capita daily meat| | | | | | |
|availability: | | | | | | |
| Change |-23 |-57 |-25 |-5 |-12 |-44 |
|g meat/d 1995 |93 g |79 g |137 g|110 g|189 g|145 g|
|g protein/d |19 g |16 g | | | | |
| | | |27 g |22 g |37 g |29 g |
|Average per capita daily milk| | | | | | |
|and dairy availability: | | | | | | |
| change |-21 |-56 |-31 |-20 |-24 |-31 |
|g milk and dairy/d 1995 |482 |427 |701 |290 | |871 |
|g protein/d 2 oz of cheese |18 |18 |18 |18 |405 |18 |
|g protein/d from milk |14 |11 |20 |7 |18 |25 |
|mg calcium/d 2 oz of cheese|510 |510 |510 |510 |11 |510 |
| |480 |417 |730 |261 |510 |512 |
|mg calcium/d from milk | | | | |392 | |
|Average per capita daily | | | | | | |
|bread and cereal | | | | | | |
|availability:
|NA |-6 |NA |-1 |4 |16 |
| change | |425 g| |430 g|340 g|301 g|
|g/d 1994 | | | | | | |
|Average per capita daily | | | | | | |
|vegetables and melons | | | | | | |
|availability: |-11 |-16 |- 22|NA |NA |NA |
| change |230 g|236 g| | | | |
|g/d 1995 | | |233 g| | | |
|Average per capita daily | | | | | | |
|potato availability: | | | | | | |
| change |-7 |20 |-7 |NA |NA |NA |
|g/d 1995 |121 g|132 g|299 g| | | |

Sources: Heleniak and Dunlop 1991, Moscow Statistical Yearbook 1999;
UNICEF-ICDC 1997

As shown in Table 9, dramatic changes in the availability of meat, milk and
dairy products were experienced in all regions However, because of high
intake before the crisis, the availability of these foods is still adequate
for the populations living in the Western Former Soviet Union, South
Eastern Europe, Central Europe and
the Baltic States Pre-crisis intakes
were excessive due to high meat and milk subsidies, particularly in Western
Former Soviet Union and Central Europe, as mentioned previously

The decrease in energy intake from animal products was not compensated, as
would be expected, by an increase in cereal, bread or potato consumption,
except in the Caucasus where the availability of potatoes increased by 20
percent Increased home production of foods has been used as a coping
mechanism during the crisis, but it is not known what and how much is
produced at home to draw any conclusions about how this food substituted
for food previously purchased

Even though the availability of foods is adequate, this does not
necessarily reflect that all nutrients were adequate A troubling figure
for the region is the low availability of vegetables and melons, a popular
fruit across the region that can be used as a proxy for fruit consumption
In the regions for which there are data, the availability of fruits and
vegetables has decreased by 10-20 percent and most countries, except
Azerbaijan and Moldova, had to import fruits and vegetables to meet their
needs[63] Before the crisis, the average
availability of fruits and
vegetables was never higher than 200 to 300 grams of fruits and vegetables
per day recommended intake are five servings per day or 500-600 grams per
day

Iron intake has been affected in the region causing increased rates of
anemia in certain vulnerable groups For example, in Bulgaria anemia
increased by 19 percent in pregnant women between 1989 and 1992 As stated
previously, in Russia, anemia in pregnant women increased from 12 percent
in 1990 to 34 percent in 1995[64] A reason for the increase in anemia may
be a decrease in meat intake, the best source of absorbable iron, for some
groups In Russia grain products contribute most of the iron to the diet,
but most of this iron is not well absorbed because of the presence of
inhibitors of iron absorption In Ukraine, the daily iron intake for a
family of three is reportedly only 65 mg/day from meat and fish[65], which
represents only 13 percent of the familys requirement for iron Iron
intake is greatly dependent on income, with the lowest decile consuming
less than half the iron of the highest decile Based on the availability
of meat, iron takes are lowest in the CAR and Caucasus where rates of
anemia
are known to be high in women and children 30-50 percent in women
and 50-70 percent in young children-Table 5

Data from some small studies show that micronutrient intakes are either
borderline or inadequate in a number of countries In Hungary, diets of
adults were found to be low in vitamin E, thiamin, riboflavin, and
pyridoxine vitamin B-6 and deficient in calcium, iron and zinc[66],[67]
School children in Moscow had inadequate intake of calcium, vitamin A,
vitamin C, folic acid, thiamin, niacin and riboflavin[68],[69]
In a few countries in the region, fruit and vegetable consumption has
increased In Poland, for example, consumption of exotic fruits has
increased almost three-fold from 1983 to 1994 with most of those increases
occurring after 1991 Of interest in Poland is that mortality from
cardiovascular disease declined during the same period by 25 in the 20-44
age group and 15 in the 45-64 age group Improvements in the medical
system, health education or a reduction in stress were not significant
enough during this period to have caused this decrease, and declines may
have been due to changes in diet[70]

5 The Effects of the Economic Crisis on Nutritional Status

51
Coping Mechanisms

Households in the ECA region have responded to income and relative food
price changes by increasing subsistence farming where land is available
One reason why increases in rates of malnutrition are not commensurate with
decreases in real income may be because the shift to home production was
rapid From World Bank poverty reports for the region, it is evident that
the poor are characterized by their inability to produce food Those with
access to land have been better able to cope during times of economic
stress[71] Lack of access to land is a key determinant of poverty in both
urban and rural households People in rural areas usually are better able
to make this adjustment and maintain a more diversified diet because they
have access to land, making it likely that deterioration in nutritional
status was more serious in urban areas For example, in Georgia, soup,
bread and tea are standard fare for poor urban families but rural families
have a more varied diet because they have more land to grow food on[72]

In several republics of the USSR, 60 percent of the families possess land
Gardening is especially common in the European part of the former USSR In
Russia,
for example, people living in cities and towns were found to
produce 88 percent of their potatoes, 43 percent of their meat, 39 percent
of their milk, and 28 percent of their eggs on urban household plots[73]
In Kazakhstan, one-third of food is produced at home which might explain
low rates of malnutrition in that country compared to other countries in
Central Asia[74] In Romania the proportion of the family diet produced at
home increased from 21 percent in 1990 to 31 percent in 1992 for families
with at least one family member working, and from 68 to 80 percent for
peasant families Bulgarians rely heavily on the food they produce at home-
40 percent of vegetables, 67 percent of fruit, and 30 percent of meat and
dairy products are produced at home[75] Data from Ukraine show that as
many vegetables are produced as are purchased, and four times as many
fruits are produced as purchased

However, home grown foods do not necessarily ensure food security for
micronutrients For example, Lithuanians produced more food at home than
people in other countries 29 percent compared to 13 and 14 percent for
Latvia and Estonia, respectively but their fruit and vegetable consumption
is lowest
in the Baltic region[76] Throughout the region seasonal
variation may limit the supply of fruits and vegetables and other foods,
either produced at home or purchased A study in Kazakhstan, for example,
found that undernutrition and anemia rates were highest in June and July in
children but not adults[77]

52 Malnutrition in Vulnerable Groups

Looking at food availability for a country or region can be deceiving
because it represents what intake is possible on a population level but
does not reflect what different groups are actually consuming National
food security means adequate food supplies through local production and
imports, but this does not take into account inequitable distribution of
food among households, household members, or even communities and regions
In the ECA region there are some groups that have not been able to cope
during economic crisis and transition

World Bank poverty assessments for countries in the ECA region conclude
that households with more children; young children, in particular
institutionalized and street children; the elderly without pensions, and
ethnic minorities are the poorest groups[78] Families with children have
been enormously
affected by the transition Children represent the group
with the highest probability of being poor, and each extra child in a
family increases the households probability of falling below the poverty
line There is a clear correlation between the number of children and the
probability of living in poverty Households with two children are two
times more likely to be poor, households with three children are four times
more likely to be poor and households with three or more children are six
to seven times more likely to be poor[79] In Russia, 37 percent of
households with two children, 50 percent of households with three children,
and 72 percent of families with four children fell below the poverty line
in 1997 Given this trend it is not surprising that the proportion of
Russian children aged 0-3 years in institutional care increased by almost
70 percent between 1989 and 1997 as parents found it increasingly difficult
to care for all their children There has been a 40 percent increase in
children living in institutions in the Western Former Soviet Union region

Tajikistan is the only country for which there are data on nutrition trends
for the period of economic crisis and
civil war Both wasting and stunting
in Tajikistan increased during that period Figure 7 The deterioration
happened in spite of relief and development activities of the Government
assisted by the Aga Khan Development network

Figure 7: Wasting and Stunting in Children 6-59 months in Gorno-Badakhshan
Autonomous Oblast Tajikistan
Source: Health and Nutrition Surveys, GBAO

Also, the most dramatic declines in meat intake in the region have been
seen in Tajikistan While meat intakes were low in 1988–only 82 grams or
290 oz per capita per day–they declined even further to 38 grams or 134
oz per capita per day, providing only 6 g of protein from meat per capita
per day This decline in the availability of meat, along with a 20 percent
decrease in the consumption of milk products, both of which are energy and
micronutrient-dense foods for young children, may have contributed to
increased undernutrition and iron deficiency in that country and possibly
the rest of the CAR Lack of knowledge about replacing animal products
with other appropriate foods exacerbated the situation

Malnutrition is clearly related to income in the region so that the poor
are more at risk for malnutrition In
Bulgaria, food availability data
show that people living at the poorest decile level have substantially less
access to meat and milk products However, this gap has increased from
1992 to 1997 Box 6

The poorest quintile of the population in Bulgaria obtains 57 percent of
their energy needs from cereals compared to 36 percent for the richest
quintile, and less than 5 percent of their energy from meat compared to the
richest quintile who obtain 10 percent of their energy from meat In
addition to the effects on food intake, an analysis of health problems and
utilization by the poor in the Kyrgyz Republic shows that children living
the poorest quintiles have the most malnutrition, infant and child
mortality rates, and prevalence of diarrhea and acute respiratory infection
when compared to those children living in the richest quintile[80]

53 Overconsumption

As shown previously, while there have been changes in the availability of
food, it is still adequate to meet requirements on a per capita basis in
most countries This is probably because food intake for many countries in
the ECA regions has always been considerably higher than in other
middle-
income countries In fact, the reduction in the availability of meat and
dairy products, and thus in animal fat, may have been positive trend in a
region where obesity and cardiovascular disease, associated with high fat
and energy intake, are prevalent Food balance sheets, although not
indicative of actual intake, show that the average availability per capita
for energy, fat and protein over the period of 1961-1988, exceeded
recommended levels suggested by WHO and FAO[81]

Sedentary lifestyles of many increased in the region High intake of fat
and energy and lack of exercise are believed to be the major contributors
to obesity which increased in adults by 10-40 percent in East and Western
Europe during the period 1987-1997, even though much of this period was
during the economic crisis[82] The ideal diet, as proposed by the American
Heart Association, should contain no more than 30 percent of total energy
from fat, and only one-third of that from animal fat; however, in many of
the W FSU nations over 25 percent of energy in diets is obtained from
animal fat[83]

High consumption of animal products and fat are linked Of the three
Baltic States, Estonia has the lowest
overweight and obesity rates and meat
intake that is 30 percent lower 109 g per capita per day than in Latvia
and Lithuania 164 g of meat per capita per day During the period 1983-
1986, Lithuania had the highest prevalence of obesity found during the
MONICA study with 22 percent of men and 45 percent of women obese[84],[85]
According to the national health and nutrition survey conducted in 1997,
obesity has decreased impressively in that country to 18 percent for women,
but it is unknown if this decline is due to targeted health promotion
campaigns or removal of food subsidies, many of which subsidized high fat
foods such as meat and dairy products

High levels of alcohol consumption are known in the region, and the
additional energy to the diet contributes to overweight and obesity In a
study on behaviors, one-third to one-half of all women and men either did
not know or did not think alcohol was high in energy[86] In spite of
decreases in other foods consumed for countries in the Central Asian
Republics and Caucasus, alcohol consumption did not decrease from 1990-
1994[87]

54 A Closer Look at the Central Asian Republics

The Central Asian Republics were the least developed
and poorest region in
the former Soviet Union Two years before the fall of the Soviet Union,
over 33 percent of the CAR population lived below the poverty line, in
comparison to 5-7 percent in the rest of the region[88] After
independence, the CAR faced enormous challenges largely caused by their
inheritance of the Soviet era

As a welfare state, the Soviet Union ensured the necessary health services
and adequate food for all Soviet citizens, including Central Asians,
through centrally controlled, financed and supplied health care and food
distribution systems Despite its shortcomings, including low quality
services, the Soviet health care system met the basic needs of the Soviet
people However, even before independence, because of broader economic
problems in the Soviet Union, the system started deteriorating and finally
collapsed after independence The food system suffered from economic
problems and lack of hard currency, since it relied heavily on imports
since the 1980s

Before independence the Soviet Union guaranteed full employment, basic
services for all and affordability of food for all its citizens, largely
through cash transfers and substantial subsidies on all
major food
staples Direct food subsidies, according to one publication, exceeded
government expenditure on health and education[89] The depth of
dependence on Moscow is clearly evident in the case of Tajikistan At the
time of independence Tajikistan relied on the Soviet Union for 80 percent
of its fuel and 75 percent of its food[90] Uzbekistan received 195
percent of its GDP in assistance from Moscow in 1991 Understandably, the
independence and subsequent removal or reduction of cash transfers,
subsidies and cuts in many basic services, devastated the already poor
republics Particularly hard hit were the vulnerable groups, low-income
groups, households with a large number of children, working, pregnant,
nursing and single mothers, and children The elderly lost their guarantee
to an adequate standard of living

After independence the CAR suffered rapid, enormous inflation, massive
unemployment, rising prices and food shortages Inflation rates in the
first year of independence ranged from 840 percent in Uzbekistan to 1,760
percent in the Kyrgyz Republic[91] The effect of this worsening situation
was devastating to living standards A general lack of savings and low
pre-
independence salaries drastically decreased purchasing power and made
coping difficult

Unlike for many other former Soviet Republics, foreign donors and
investors, showed little interest in helping the CAR, with the bulk of
foreign assistance going mainly to Eastern Europe[92]

6 The Policy Environment and Existing Programs

61 The Policy Environment

Formal and informal institutions play an important role as the interface
between underlying and basic causes to malnutrition They provide basic
services or promote improved practices regarding food production and child
care The economic stresses of the transition not only affected
households, but it also affected institutions For example, the quality
control and monitoring of iodized salt and the purchase of essential
micronutrients to produce enriched foods declined after the transition Box
7

Source: Gerasimov 1999; UNICEF undated

62 Existing Programs

An exhaustive review of programs in the ECA region was not conducted for
this paper Documentation of known programs and activities in selected
countries can be found in the Country Information Sheets in Annex 1

Most efforts to date to address malnutrition have been
only on a small
scale Although behavior change should be a key component for to programs
address all types of malnutrition undernutrition, obesity or micronutrient
malnutrition, the emphasis on behavior change has varied by program The
World Bank collaborates with WHO on their program called the Integrated
Management of Childhood Illness IMCI which is being implemented in the
Central Asian Republics The program focuses mainly on the training of
general practitioners to introduce a less traditional approach to child
health Nutrition management is part of the IMCI package and currently
child feeding recommendations to be used in the counseling component of
that program are being developed Counseling the mother on exclusive
breastfeeding and appropriate weaning practices is crucial in all countries
of the ECA region, and the IMCI program provides a vehicle for reaching the
mother and child However, counseling on nutrition under IMCI needs to be
closely supervised to ensure the quality

Some work has been conducted in countries to improve specific breastfeeding
practices
Activities have largely centered on making hospitals more supportive of
breastfeeding ie, more Baby Friendly,
and increasing community
support of breastfeeding Some educational and training materials have
been developed to support these activities, but the impact of these efforts
is unknown The program Support for Breastfeeding, part of the Healthy
Nutrition Policy in Russia that was implemented in the Elektrosal region,
was very successful in increasing breastfeeding rates to 90 at three
months and 85 at six months, in comparison to 50 and 30, respectively,
in the control regions No data are available on exclusive breastfeeding
rates

Some policy work is being conducted in the Russian Federation by the
Ministry of Health with the active support of WHO/EURO and UNICEF A
Russian Regional Healthy Nutrition Policy is being developed, research is
being conducted and small scale programs are being tested in several
regions of Russia The support for breastfeeding, mentioned above is one
example of those pilots

As in most areas of the world, there are few programs to address anemia
prevalence While iron supplements are recommended for pregnant women,
only anemic women usually receive iron tablets To adequately reduce high
levels of anemia, a shift in the paradigm from curing anemia to
preventing
it is needed Presently there appears to be little appreciation of the
importance of preventing anemia in the region[93], and the cause of anemia
is usually defined as repeated and excessive blood loss A curative
approach to controlling anemia has led to policies that stress a medical
approach There are no known large-scale programs to fortify foods with
iron, although the President of Turkmenistan has recently asked that all
flour in that country be fortified with iron[94]

A major problem in the region is the lack of access to iodized salt As
mentioned previously Box 7 only Slovakia and the Czech Republic continued
their programs to iodize salt throughout the last decade UNICEF, with the
help of Kiwanis International provided 75 million to support IDD
activities and is working to re-introduce iodization technology to private
salt producers in the region The current status of IDD control programs
in the region is shown in Table 10

Source: UNICEF undated

While Eastern Europe is getting back on track in this area, the iodized
salt situation remains severe in the CAR, the Caucasus, the Baltic States
and selected countries in other sub-regions and needs immediate attention

The Health Promoting Schools project, a partnership between WHO, the
European Union and the European Commission, is active in 40 European
countries including several in Eastern Europe The project seeks to
integrate health into all aspects of life through encouraging school-aged
children and adolescents to adopt life long health behaviors In Eastern
Europe, the project seeks collaboration with the World Bank to expand the
program to the other ECA region countries

70
Recommendations and Conclusions

71 General Recommendations

Several recommendations can be made for improving the nutrition situation
in the ECA region

First, countries in the region should have nutrition policies with a set of
nutrition goals that can guide programs WHO-EURO has assisted countries
since 1997 with the development of national nutrition plans[95] Many
countries have or are in the process of developing their strategies While
national surveys are useful, these data are rarely used at the local level
to identify problems, for planning and to implement programs Instead, a
nutrition monitoring system should be developed for each country so that
child growth and nutritional status are monitored and the information used
in program planning Nutritional status can and should be an indicator of
poverty in the region It is both a sensitive short-term and long-term
indicator of economic change and a means for evaluating program
effectiveness

Second, because much of the undernutrition in children and overweight and
obesity in adults is due to lack of knowledge about what constitutes an
adequate and healthy diet, in both quantity and quality, improving
communications
for behavior change is urgently needed Also important is
behavior change for health professionals so they can deliver correct
nutrition messages An important area of assistance will be in developing
institutional capacity in the medical profession for nutrition In
addition to policy development, upgrades in training programs, refresher
courses in nutrition for all health staff, and building community capacity
are crucial to reducing of malnutrition in young children and adults
Qualitative research is needed to better understand why people select diets
high in fat and low in micronutrients, and to identify who can help
disseminate important messages on these subjects For example, a study in
the Ukraine found that media influenced beliefs less than relatives and
friends Moreover, cost was identified as an influence on healthy food
choices so it was recommended that strategies involving peer education and
focusing on low-cost but healthy foods be designed[96]

Third, nutrition should be integrated into a variety of sectors Since
access to health care and coverage of health services is good, much of the
effort to address nutrition problems can be through the health sector
However,
other sectors such as agriculture and education also may play
important roles and nutrition should be integrated into these activities
where appropriate The private sector also may play a role in improving
nutrition status in the region For example, private sector salt producers
and processors, along with the health sector, need to be part of the
solution for reducing iodine deficiencies in the region

Fourth, while economic policies to increase employment and incomes in
families should continue to be a focus, these efforts alone will not
improve the nutritional status of vulnerable groups throughout the region
Continuing efforts to alleviate poverty should be targeted to the groups
identified as the very poor, such as families with children However,
there needs to be some assurance that vulnerable groups will receive and
consume any food or benefit from food subsidies or income transfers
targeted to them Communications for behavior change within the family
would help in this regard and should accompany efforts in this area Care
also should be given to target programs to institutionalized children who
might be in need of special programs to improve their nutritional
status

Fifth, certain areas of the ECA region are particularly vulnerable and
should receive top priority Nutritional status is very poor in
Tajikistan, Uzbekistan, and in the rural areas of Kazakhstan, Azerbaijan
and Turkey It is not recommended to give food to families in these
countries but rather to target the vulnerable through food stamps or income
transfers Efforts should also be made to introduce programs that can
prevent undernutrition through community-based programs such as growth
monitoring and promotion

Sixth, immediate action is required to reduce micronutrient malnutrition in
the region To reduce anemia prevalence in the region, greater attention
needs to be placed on ensuring that all pregnant women and children 6-24
months receive iron supplements This might require a policy change in how
anemia control is viewed As stated previously, reducing anemia prevalence
is only cost-effective when preventive measures are used to make sure all
vulnerable groups are receiving supplements or eating iron fortified foods
The feasibility of fortifying foods with iron should be investigated
throughout the region This will require identifying a food that is
readily
consumed by vulnerable groups Flour is the most likely candidate
in the region for fortifying with iron In the short-term, before
fortification is in place, it may be feasible to give certain groups eg,
school children, adolescents and non-pregnant women a daily or weekly dose
of iron to reduce the high prevalence of iron deficiency in some segments
of the population In a supervised setting, the weekly dose is almost as
effective as the daily dose and can be particularly effective where anemia
is mild to moderately severe However, because of their high requirements,
women need to take a daily dose of iron during pregnancy, even once
fortification programs are in place

For iodine, countries need assistance in developing viable strategies and
implementing them The private salt industry will need help in upgrading
equipment to iodize and package salt Making the commodities needed to
iodize salt affordable is important The major salt producers and
exporters of the former Soviet Union are in Russia, Ukraine and Belarus and
should be targeted to ensure they are iodizing salt for local consumption
and export At present there is a 3-7 price differential for iodized salt
in these
three countries and many consumers find they cannot afford to buy
it Iodized salt should be priced so all consumers can afford to purchase
it

Increasing the intake of all micronutrients is important to the region
Steps to be taken include reserving land for home production of fruits and
vegetables , improving the production of micronutrient-rich foods,
improving the technology in the region so that foods can be fortified, and
educating consumers in order to increase demand for micronutrient
supplements, fortified foods, and fruits and vegetables However, cold
food storage capacity during transport needs to be solved so that fruits
and vegetables can be moved to areas where they are not readily available

Finally, efforts to improve intake for fruits and vegetables should be
linked to campaigns to reduce energy and fat intake in adults across the
region Given the alarming increase in cardiovascular disease, diabetes
and hypertension, immediate attention to the adult diet and adult health
behaviors, including smoking and alcohol consumption, is needed Health
projects should not only work to support curative care for these diseases
and conditions, but work actively to prevent
them in the first place The
challenge lies in educating and convincing governments to invest scarce
resources in prevention

72 Central Asian Republics and Caucasus

As nutrition problems differ greatly among the sub-regions, different
strategies are needed The Central Asian Republics and the Caucasus suffer
from high rates of undernutrition in children and micronutrient
deficiencies in the population at large In fact, it may be that
nutritional status in the CAR is deteriorating even further due to declines
in access to health services, education for women and safe water and
immunization rates Even though economic growth is picking up and
prospects for future economic growth are positive, according to the Country
Assistance Strategies for most of the CAR countries, resource distribution
is unequal and poverty remains a major problem Malnutrition rates are
closely linked to poverty, and nutrition interventions are crucial to stop
further deterioration of the nutritional status To address the nutrition
problems in each country, nutrition should be a significant component to
health and education projects or campaigns Other sectors or programs also
should be involved such as
early childhood development, IMCI and others
Strategies here will include food fortification particularly for iron and
iodine, iron supplementation for pregnant women and young children 6-24
months, possibly vitamin A, education on breastfeeding and complementary
feeding Communications for behavior change are essential to improving
nutritional status in young children and also adults suffering from
cardiovascular disease, diabetes, and hypertension

73 South and Eastern Europe and West Former Soviet Union

Micronutrient deficiencies remain a major problem in most of the countries
in these sub- regions Increased rates of anemia and a breakdown in the
salt iodization industry are symptoms of the deterioration High
deficiency prevalence rates of these two micronutrients iron and iodine
are indeed troubling, yet can easily be rectified in these countries where
the food industry is well developed The capacity to iodize salt needs
improving in most countries, and education programs are needed to introduce
and promote the consumption of fortified foods with iron for vulnerable
groups

In addition, obesity and related health problems are of major concern in
most of the Eastern
European and West Former Soviet Union countries A
cross-sectoral strategy is needed that includes a behavior change strategy
to divert consumption away from high fat/high energy foods to those rich in
micronutrients, as well as agricultural policies that would help diversify
food production and make fruits and vegetables more available and easily
accessible

Although not a concern nationally, there are pockets of undernourished
children in these countries and programs should be targeted to these groups
eg, families at risk of poverty, displaced populations Breastfeeding
rates are extremely low, and efforts should be made to increase the
practice of exclusive breastfeeding for infants under six months Poor
feeding practices need attention and policies regarding feeding should be
improved

74 Conclusions

The nutrition situation, as the economic, political and social situation,
is diverse in the ECA region As shown in this paper, some countries have
undernutrition rates similar to those found in Sub-Saharan Africa, while
others have overweight and obesity problems similar to those found in the
United States and Western Europe In particular, vulnerable groups,
including certain
ethnic groups, women and children, need special
attention

Thanks to relatively high educational levels throughout the region and some
remnants of food industry, it is likely that low levels of investment in
food fortification and collaboration with other donors would yield high
returns in the region Undernutrition and micronutrient malnutrition could
be greatly reduced where needed by strengthening and promoting growth
monitoring and promotion activities and supplementation and fortification
of foods with micronutrients, together with nutrition education programs
By putting in place policies and programs that will reduce rates of
overweight and obesity in the region, cardiovascular disease and diabetes
could be largely prevented

As discussed, many countries in the ECA region have some experience and are
in the process of initiating programs, rehabilitating others such as salt
iodization, and strengthening existing programs Donors can provide
valuable technical assistance to countries in the development and
strengthening of new and existing policies and institutions
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Annex: Detailed Information Sheets in Selected Countries

Introduction

This annex presents detailed nutrition information for selected countries
in the ECA region The purpose is to provide more detailed information on
the nutritional status, existing policies and ongoing programs for each
country, since the diversity of the countries did not allow for this detail
in the paper itself It should be noted that this is not an exhaustive or
complete review of all existing policies and programs, and additional
research at the country level is needed It does, however, only provide a
quick overview on nutrition

The data sources used for the country sheets include: i national
statistics, TransMONEE, DHS and WHO global databases for nutrition and
child mortality indicators and micronutrients; ii national survey data
and UNICEF data for child and maternal practices; iii
national
statistics, DHS and Goldstein, et al 1996, World Bank Technical paper
no 348 for health and sanitation data; iv household budget surveys and
poverty assessments for access to food data; and v World Bank World
Development Indicators for the economic context

The program data are taken from national information made available by the
country offices and WHO/EURO The program data box only mentions existing
programs and committees, but does not provide information regarding their
quality or functioning

The information on ongoing and pipeline portfolio is taken from World Bank
databases Pipeline information is subject to change

List of selected countries:

Albania
Armenia
Azerbaijan
Georgia
Kazakhstan
The Kyrgyz Republic
Lithuania
Moldova
Romania
The Russian Federation
Tajikistan
Turkey
Uzbekistan

Nutrition at a Glance

Albania

A: Basic Data

Data sources: National statistics; WHO Global Malnutrition Database;
TransMONEE; UNICEF Rapid Nutrition Assessment 1997; Human Development
Report, World Bank CAS, 1998, World Bank Technical Paper 384, World Bank
1999

B: Existing Nutrition Programs, Policies and Capacity

Data sources: World Bank CAS 1998 WHO/EURO, 1998 Comparative analysis of
implementation of Innocenti Declaration, 1999 Comparative analysis of
progress in elimination of IDD, 1999

C: Nutrition Priority Problems and Existing Programs

A Rapid Nutrition Assessment was conducted with support from UNICEF on a
sample of Albanian children living in urban, rural and mountains
areas, in
1997 While not nationally representative data, the results of the study
show high levels of stunting, 23, and wasting, 74, both of public health
concern The highest stunting rates were found in the rural and plain
areas, 333 and 285 respectively Acute malnutrition or wasting was
highest in the mountains areas, 104

In addition to undernutrition reflected in stunting and wasting indicators,
micronutrient deficiencies, in particular iron and iodine, are of public
health concern Although the iodine deficiency plan of action was
developed and adopted in 1993 and a national IDD committee has been
established, goiter rates are still reported to be high over 30 of goiter
in some school-aged children, although no national figures exist

In its favor, Albania has the lowest adult mortality rates in the region
which is attributed to its healthy Mediterranean diet, particularly in the
Southern parts of the country Programs to sustain healthy intakes of
fish, olive oil and fruits and vegetables are needed along with campaigns
to improve infant feeding practices Programs that target micronutrient
deficiencies are important Immediate attention should be given to
ensuring that
all salt is iodized in the country Programs to prevent and
reduce the prevalence of iron deficiency anemia also are needed

Nutrition at a Glance

Armenia

A: Basic Data

Data sources: National statistics; Branca, 1998, WHO Global Malnutrition
Database 2000; TransMONEE; Human Development Report, World Bank CAS 1997,
World Bank, 1999

B: Existing Nutrition Programs, Policies and Capacity

Data sources: World Bank CAS, 1997 WHO/EURO, 1998 Comparative analysis
of implementation of Innocenti Declaration, 1999 Comparative analysis of
progress in elimination of IDD, 1999

C: Nutrition Priority Problems and Existing Programs

Poverty is a major problem in Armenia, in particular in the urban areas
where the majority of Armenians live However, poverty is deeper in the
rural areas Lack of access to land and unemployment are strong indicators
of poverty: 70 of the poor do not have access to land and 38 of the
unemployed are food poor Fifty-nine percent of children under five are
poor, 42 of
women and 59 of the elderly

Malnutrition rates are not considered of public health concern according
to WHO standards, but considering high poverty incidence, vulnerable
groups may be at nutritional risk Monitoring of child growth to prevent
malnutrition from increasing is crucial Since Armenia already has good
child health services, with pediatricians visiting children at home up till
one year of age, growth monitoring and counseling during these visits
should be emphasized

Micronutrient deficiencies are of national concern in Armenia UNICEF is
already assisting with the iodization of salt, in particular to strengthen
implementation A recent study[102] found that only 70 of households use
iodized salt so there is much room for improvement Iron deficiency is
equally important and fortification of staple food, such as bread, which is
consumed with every meal, should be considered Despite successful
breastfeeding campaigns[103], only 10 of children are breastfed
exclusively and 20 are not breastfed at all Exclusive breastfeeding up
to six months, breastfeeding up to 24 months, and appropriate weaning
practices should be promoted through training of health staff and
growth
promotion counseling Antenatal care is practiced by most women and
provides a channel for iron supplementation of pregnant women and education
on exclusive breastfeeding and weaning Training and strengthening of
health staff should be considered

Refugees, making up one-sixth of the population in Armenia, form a
particularly vulnerable group A study on the nutrition status of
residents and refugees[104] in Armenia was conducted in May 1998 Large
regional differences were found in stunting rates among children under
five In particular, high rates were found in the rural areas, both among
residents and refugees Private donations of food among friends and
neighbors are common in Armenia, and most of the rural population
including refugees have small garden plots Refugees in general were
found to have less varied diets than residents

Overweight and obesity rates in Armenia are of public health concern
Thirty-six percent of women are overweight and 11 are obese putting them
at higher risk for cardiovascular disease, hypertension and diabetes

In order to reduce high rates of overweight and obesity in Armenia, more
attention is needed on educating adults to make the right
food choices
Improving breastfeeding and weaning practices should be a priority, being
careful to reinforce good practices in the country Educational campaigns
and strengthening of the private sector are needed to reduce micronutrient
deficiencies

Nutrition at a Glance

Azerbaijan

A: Basic Data

Data sources: National statistics; WHO Global Malnutrition Database;
2000; TransMONEE; UNICEF; Human Development Report, World Bank, 1999

B: Existing Nutrition Programs, Policies and Capacity

Data sources: WHO/EURO 1998, World Bank CAS 1999

C: Nutrition Priority Problems and Existing Programs

Azerbaijan has one of the highest chronic malnutrition rates in the region,
in
particular in the rural areas where more than one of every four children
is too small for their age Stunting has a negative impact not only on
overall health status and quality of life but it also reduces learning
capacity and productivity in later life In addition, the high rates of
iron and iodine deficiencies further deprive children under five of
reaching their intellectual capacity and ability to be produced Poor
child care practices, such as low rates of exclusive breastfeeding and
inadequate weaning practices, and insufficient access to food are the main
causes of malnutrition Sixty percent of the population cannot afford to
purchase the minimum food basket, and there is an overall energy supply
deficit of 14 Other important determinants of nutritional status are
more positive For example, access to health services are good with 97 of
children immunized and 99 of all births attended by trained health
personnel

Two programs currently address malnutrition problems: a breastfeeding
program and a salt iodization program, although the latter is not active
The breastfeeding program is, according to available information, only
active in the capital

The internally
displaced persons IDPs form a large group in Azerbaijan
and are among the poorest 25 of the poor are IDPs They also are at the
highest risk of malnutrition In fact, a recent nutrition survey[106]
found a stunting rate of 31 among IDPs, compared to 22 for residents
Another vulnerable group in Azerbaijan are the elderly with 12 percent of
them malnourished

Paradoxically, in addition to Azerbaijans large undernutrition problem,
over consumption of high energy foods is a public health concern, with 30
of adults overweight

Like many other countries in the ECA region, both undernutrition in young
children and overweight in adults exist simultaneously Communications for
behavior change are needed to improve infant feeding in young children,
reducing micronutrient deficiencies, and decrease overweight in adults
Special attention is needed for IDPs and programs need to be tailored for
their situation Immediate attention needs to be given to iodizing salt by
assisting producers and processors to ensure that all salt sold is iodized
Assistance may be needed to monitor the content of salt and ensure that
packaging protects the stability of iodized salt

Nutrition at a glance

Georgia

A: Basic Data

Data sources: National statistics; WHO Global Malnutrition Database 2000
TransMONEE; UNICEF; Human Development Report, World Bank
CAS 1997, World
Bank 1999

B: Existing Nutrition Programs, Policies and Capacity

Data sources: World Bank CAS 1997 WHO/EURO 1998 Comparative analysis of
implementation of Innocenti Declaration, 1999 Comparative analysis of
progress in elimination of IDD, 1999

C: Nutrition Priority Problems and Existing Programs

There are very limited data available on child malnutrition in Georgia, but
small studies that were conducted in 1998 provide some insights The
Institute of Pediatrics evaluated the nutritional status of children under
5 and concluded that there was no malnutrition prevalent The second study
targeted IDPs, and the results show 25 stunting and 3 wasting Although
food supplies have decreased, there is no immediate nutrition or food
crisis This situation, however, might become difficult for the vulnerable
groups, the internally displaced persons and the poor, in particular the
urban unemployed poor without access to land

Regarding micronutrient deficiencies, according to the Ministry of Health
reports, 40 of
newborns are iron deficient, reflecting maternal anemia
The routine reporting of incidence of anemia by the MOH shows 30-40 of
pregnant women are anemic In 4 of the cases, anemia contributed to the
complications of delivery more than two-fold increase since 1990 from 19
to 42 in 1998 The Institute of Pediatrics found 52 of children raised
at home and 64 of those attending kindergarten were suffering from
moderate to mild anemia Iodine deficiency remains a problem in Georgia
According to MOH information, the incidence of iodine deficiency recorded
in medical institutions in 1997 affected 58 of children under five A
survey commissioned by UNICEF among school-aged children showed a 64
goiter prevalence

Priority nutrition problems in Georgia are iodine and iron deficiencies
Even though there is a national committee on IDD and a national plan for
control of IDD, iodine deficiency remains a major problem Changes in the
environment, as well as the disruption of iodized salt imports in 1992-
1995, have contributed to the increased prevalence Iron deficiency is
clearly increasing and of public health concern Effective measures to
fortify staple foods, such as wheat flour, with iron
are widely known, and
should be considered together with immediate action to rebuild the salt
iodization system

More information is needed about rates of undernutrition in the country
However, like the rest of the ECA region, attention should be focused on
counseling mothers to improve breastfeeding and weaning practices Growth
monitoring and promotion should be piloted in the country to see if this
type of intervention is effective at putting a focus on improving the
nutritional status of young children

Nutrition at a glance

Kazakhstan

A: Basic Data

Data sources: National statistics; Macro International 1995, WHO Global
Malnutrition Database2000; TransMONEE; UNICEF; Human Development report,
World Bank CAS 1997, World Bank 1999

B: Existing Nutrition Programs, Policies and Capacity

Data sources: World Bank CAS 1997 WHO/EURO, 1998 Comparative analysis of
implementation of Innocenti Declaration, 1999 Comparative analysis of
progress in elimination of IDD 1999

C: Nutrition Priority Problems and Existing Programs

Malnutrition rates in Kazakhstan are high, in particular in the rural areas
and among the poor 314 compared to 158 national average Poverty is
deeper in the rural areas, and especially in households with many children
However, the rural poor have more access to land than the urban poor, and
one third of all food consumed in 1996 was produced at home[111]

In addition to undernutrition and micronutrient deficiencies, overweight
and obesity are major problems in Kazakhstan, and cardiovascular disease is
believed to cause up to 50 of all mortality[112] Recent data from the
Healthy Lifestyle program reports 47 of the women are overweight and 34
of men, with about 15 suffering from obesity Only 8 out of 100 people
exercise regularly, and the common diet includes high fat and high
carbohydrate foods and few fruits and vegetables Although there are no
national data, smoking rates in one Oblast are 62 for men and 9 for
women In 1997
more than 200,000 patients were registered for alcohol
abuse

Priority issues for Kazakhstan include micronutrient supplementation and
fortification of staple foods Improving knowledge of healthy nutrition is
another important area, not only to prevent overweight and obesity, but
also undernutrition due to incorrect beliefs and inadequate knowledge For
example, the Ministry of Health reports that 32 of women suffer from
hypogalactia, a term used when women cannot produce breastmilk It is,
however, well recognized that this not a medical condition but a syndrome
created by uninformed health professionals, strict breastfeeding schedules,
separating mothers from their children and early introduction of weaning
foods Tea is often given to infants at a very early age, reducing iron
absorption Training of health providers on good nutrition practices and
consulting techniques is needed to ensure that breastfeeding and weaning
practices are optimized in the country

Nutrition at a Glance

The Kyrgyz Republic

A: Basic Data

Data sources: National statistics; Macro International 1997, WHO Global
Malnutrition Database 2000; TransMONEE; UNICEF; Human Development report,
World Bank CAS 1998, World Bank 1999

B: Existing Nutrition Programs, Policies and Capacity

Data sources: World Bank CAS 1998 WHO/EURO, 1998 Comparative analysis of
implementation of Innocenti Declaration, 1999 Comparative analysis of
progress in elimination of IDD, 1999

C: Nutrition Priority Problems and Existing Programs

As in most of the CAR, nutrition and health indicators have deteriorated
since independence Malnutrition rates among children 0-6 years
increased by 25 between 1993 and 1996[115] Life expectancy declined in
the early 1990s and
although this has improved since 1995, it has not
reached the pre-1990 levels Mortality from circulatory disease is the
leading cause of death in the Republic[116] Major risk factors for these
high levels are excessive consumption of high-fat foods, tobacco and
alcohol Equally worrying are the trends in communicable diseases WHO
data indicate that the Kyrgyz Republic has the highest level of respiratory
disease in the NIS countries, and infectious and parasitic diseases are
considerably higher in 1998 than in 1990 Mortality and ill health are
greater among the poor A World Bank analysis of 1997 DHS data found that
infant mortality is 18 times greater among the poor than among the richer
quintiles, and malnutrition rates stunting are 24 times as high among
the poor than the rich Anemia rates are very high, both among young
children and women of child bearing age Iodine deficiency is alarmingly
high with some oblasts reporting total goiter rates of 90 percent
Breastfeeding is almost universal, but rates of exclusive breastfeeding are
very low and weaning practices are inadequate

Despite an impressive track record of macro-stabilization and policy
reform, poverty has increased
in the Kyrgyz Republic Real wages and
consumption are about 40 below the former levels In particular
agricultural growth is constrained by land scarcity and low productivity
Even before independence one-third of the Kyrgyz population lived below the
poverty line After independence this increased to half of the population
Rural households are 16 times more likely to be poor than urban
households Households with young household heads or many children are most
likely to be poor

The institutional setting of nutrition is limited and mainly under the
Ministry of Health Public health services are provided through the
Sanitary-Epidemiological Surveillance System SES under this ministry,
including food safety and food handling activities control It does not
have a function in health promotion or disease prevention The MOH,
however, did establish an impressive network of health providers trained in
basic nutrition, but the training is based on obsolete principles[117] For
rural populations, the primary care providers are midwifery posts and rural
physician centers For the urban population, primary care is provided in
polyclinics and outpatient departments

Immediate attention is
needed to address the most pressing nutrition
problems in the country There needs to be a commitment by the government
to iodize all salt and support for the private sector to ensure not only
that salt is iodized but also that the levels of iodine are constantly
monitored in the country Fortification of flour or other staples with
iron should be investigated to reduce high rates of anemia Educational
campaigns should be implemented to address other problems such as poor
infant feeding practices and high fat intakes

Nutrition at a Glance

Lithuania

A: Basic Data

Data sources: National statistics; WHO Global Malnutrition Database
2000;
TransMONEE; UNICEF; Human Development Report, World Bank CAS 1999, World
Bank, 1999

B: Existing Nutrition Programs, Policies and Capacity

Data sources: World Bank CAS 1999 WHO/EURO, 1998 Comparative analysis of
implementation of Innocenti Declaration, 1999 Comparative analysis of
progress in elimination of IDD, 1999

C Nutrition Priority Problems and Existing Programs

The Ministry of Health, jointly with the Ministry of Agriculture, analyzed
the nutrition and health situation in 1996 and identified the following
priority problems:
i low levels of breastfeeding;
ii lack of nutrition and food policies;
iii high fat intake and micronutrient deficiencies; and
iv lack of safe drinking water

According to the MONICA study data and the latest WHO data on overweight,
Lithuanias obesity rates decreased significantly from 40 to 18 during
the period It is
difficult to make a causal link to healthy eating
campaigns, but most probably it has supported improved knowledge on food
and dietary behavior However, much more remains to be done, not only
regarding overweight and obesity, but equally breastfeeding promotion,
weaning practices and micronutrients

Very limited data are available on micronutrient deficiencies However,
one small study in 1994 in 28 secondary schools showed an alarming 53
goiter rate among the school children More data collection and analysis
is recommended However, until that information is available, the country
should ensure that all salt is iodized Instituting of monitoring of
iodine levels in salt is needed Ways should be found to address high
rates of anemia prevalence, particularly in pregnant women and children
under 2 years of age Fortifying flour or other staples with iron should
be considered Improved breastfeeding and weaning practices and healthy
food choices through education campaigns should be designed and
implemented

Nutrition at a Glance

Moldova

A: Basic Data

Data sources: National statistics; WHO Global Malnutrition Database 2000;
TransMONEE; UNICEF; Human Development Report, World Bank CAS 1999, World
Bank 1999

B: Existing Nutrition Programs, Policies and
Capacity

Data sources: World Bank CAS 1999 WHO/EURO, 1998 Comparative analysis of
implementation of Innocenti Declaration, 1999 Comparative analysis of
progress in elimination of IDD, 1999

C: Nutrition Priority Problems and Existing Programs

According to the 1996 report on the situation of the mother and child in
the Republic of Moldova, the nutritional status of mothers and children has
suffered from the economic crisis Low birthweight increased by 26 from
1994 to 1995 Anemia among pregnant women increased from 124 in 1984 to
411 in 1995 Maternal mortality, after falling to 26 per 100,000 live
births by 1994, increased to 41 in 1995 According to the report[122], the
principle causes for this increase are abortions, hemorrhages and
infections, but contributing to that mortality are the
high rates of iron
deficiency in pregnant women, with 50 affected Moldova has seen a sharp
decline in specialized food stores for pregnant women, where future mothers
were offered special food at low prices or for free

Anemia prevalence is high in children, with 28 anemic, and women, with 20
anemic Goiter prevalence was 37, with higher rates in the central and
northern provinces, 39 and 42, respectively At the same time preventive
measures such as salt iodization and iodized bread are not being
implemented There are no data available on vitamin A deficiency at the
time of the report

At the same time alcoholism has become a problem is national concern, also
among women 20 of alcoholics are women and is increasing among youth

Moldova is one of the poorest countries in Europe In 1997 almost 80 of
the population consumed less than Moldovas minimum food basket, valued at
US44 per month Children are the most vulnerable group Larger
households, those with more than five children, are more likely to be poor

Moldova is a country where nutrition activity has been low, both in
gathering information and implementing programs It is clear from
information on anemia prevalence, that
the country would benefit from
fortifying flour with iron Improving the coverage of iodized salt is
essential since only 50 of the population have access to it now Like all
countries in the ECA region, targeting the poor may help in rapidly
reducing national rates of undernutrition, but attention should be paid to
improving breastfeeding and weaning practices in general Reducing
nutrition-related causes of adult mortality such as high consumption of fat
should be a top priority

Nutrition at a Glance

Romania

A: Basic Data

|Child malnutrition, death and | |Average Europe |
|disability | |and Central Asia |
|Stunting chronic malnutrition|8 | |
|Wasting acute malnutrition |25 | |
|Underweight |57 | |
|Overweight and obesity |- |121 adults |
| | |BMI30 |
|Low birthweight |9 | |
|Infant mortality rate IMR |220 |23
|
|Under-five mortality rate |264 | |
|UM5R | | |
|Iron deficiency anemia |- |22 Children 4,|
| | | |
| | |24 pregnant |
| | |women WHO 2000 |
|Iodine deficiency prevalence |20-29 |18 tgr[123] |
|of goiter in school aged | |in population |
|children | |WHO 2000 |
|Vitamin A deficiency |- | |
|Child Practices | | |
|Breastfeeding 1997 |- | |
|Weaning |- | |
|Health and Sanitation | | |
|Immunization rate measles, |- | |
|proxy for access to health | | |
|services | | |
|Access to
safe water |62 | |
|Percentage births attended by |- | |
|trained health personnel | | |
|Percentage Baby Friendly |- | |
|health services | | |
|Incidence of |873 | |
|tuberculosis/100,000 | | |
|Cardiovascular disease |- | |
|prevalence | | |
|Alcohol consumption annual |64 1991 | |
|liters/person | | |
|Non-smokers in population |72 1994 | |
|Access to food | | |
|Daily energy supply per capita |2872 kcal 1994 |2850 |
|Population below income poverty|215 1994 | |
|line | | |
|Land holdings / household plots|- | |
|Economic Context |
| |
|Human Development Index |68 | |
|GNP per capita 1998 |1,390 |2,310 |
|Life expectancy at birth |65-73 |69 |
|male-female | | |
|Adult literacy rate |98 |96 |

Data sources: National statistics; WHO Global Malnutrition Database;
TransMONEE; UNICEF; World Development Report; Human Development report,
World Bank CAS 1997; World Bank 1999

B: Existing Nutrition Programs, Policies and Capacity

Data source: World Bank CAS 1997 WHO/EURO, 1998 Comparative analysis of
implementation of Innocenti Declaration, 1999 Comparative analysis of
progress in elimination of IDD, 1999

C: Nutrition Priority Problems and Existing Programs

Although not immediately visible from the above aggregate data,
malnutrition is expected to be prevalent in
pockets of the population in
Romania due to inaccessibility to food caused by poverty Poverty is deep,
and the number of people living below the poverty line has increased four-
fold from 1 million before the transition to 5 million in 1994 The
average income of the poor is 26 below the poverty line, and two-thirds
live in the rural areas The poverty assessment for Romania estimated a
daily energy intake among the poorest of only 1,500 kcal, 35 percent under
the minimum needs As in most countries, children, the elderly, rural
women, female-headed households and those with more dependents, suffer most
from nutrition problems and have poor health status overall

Child institutionalization is a particular problem in Romania Almost 1 in
every 100 children is institutionalized a 60 increase between 1990 and
1997 Romanias Children, a program launched by the president of
Romania, focuses on children and in particular on those that are
institutionalized The Bank devoted Institutional Development Funds to
strengthen this initiative The Bank, together with the European Union,
WHO and UNICEF, supported the Ministry of Health and the government in the
development of a Health Sector
Strategy This strategy highlights the
importance of behavioral change smoking, alcohol, and diet to improving
health in Romania

Nutrition at a Glance

Russian Federation

A: Basic Data

Data sources: National statistics; WHO Global Malnutrition Database 2000;
TransMONEE; UNICEF; Human Development Report, World Bank CAS 1999

B: Existing Nutrition Programs, Policies and Capacity

Data sources: World Bank CAS 1999 WHO/EURO 1998 Comparative analysis of
implementation of Innocenti Declaration, 1999 Comparative analysis of
progress in elimination of IDD, 1999

C: Nutrition Priority Problems and Existing Programs

Beginning in the 1960s, food and nutrition policies in the FSU promoted a
diet high in meat and dairy products, for which there were
substantial
subsidies The resulting diet was high in fat, particularly saturated fat,
energy and iron The recent social and economic changes have resulted in
declines in food subsidies, increasing meat and dairy prices, with
consequent changes in dietary consumption The proportion of fat in the
diet is still higher than recommended by WHO, but at the same time there is
concern that disadvantaged groups of the population may be undernourished
Recent survey data does not provide evidence of undernutrition, or at least
not on a level to be of public health concern, but the data on overweight
and obesity are of public health concern in the Russian Federation
Overweight and obesity are important risk factors for cardiovascular
disease, one of the leading causes of death Micronutrient deficiencies
are widespread in the Russian Federation Iodine deficiency rates are
moderately high, which is of concern since 20 years ago it was almost
eliminated Anemia prevalence has increased during the economic
transition

Underlying factors contributing to malnutrition in the Russian Federation
have to be reviewed for each of the different malnutrition problems For
undernutrition, likely a
problem among the poorest in the nation, short
duration and non-exclusivity of breastfeeding as well as early introduction
to weaning are likely to play an important role The median duration of
breastfeeding was found to be only three months in 1993, and early
introduction of solids is very high[125] Campaigns to improve
breastfeeding and weaning practices need to be designed and implemented

Poverty has increased during the 1990s in the Russian Federation with 39
of the population and 56 of children under six living under the poverty
line However, the percentage of people living in extreme poverty
decreased from 20 to 17 Rural areas are harder hit, especially those
families with no access to land for household production of food, and those
with more than three children under age six Female-headed households also
are more likely to be poor

Underlying factors to over-consumption are behavioral and traditional
High consumption of meat and dairy, both contributors to a high saturated
fat diet and risk factors to cardiovascular disease, has been promoted in
the Russian Federation Adults over 50, in particular women but more
recently also children under five, are among the
vulnerable groups
Traditional dietary patterns and beliefs play an important role in the
perception of diet A study in the Baltic Republics shows, for example,
that more than half of the population believes that meat is an essential
component of a healthy diet

Communications for behavior change are needed to address nutrition problems
related to adult health, including unhealthy food choices, leading to high
fat and energy-dense diets

Nutrition at a Glance

Tajikistan

A: Basic Data

Data sources: National statistics; WHO Global Malnutrition Database 2000;
TransMONEE; UNICEF; Human Development Report, World Bank CAS 1998

B: Existing Nutrition Programs, Policies and Capacity

Data sources: Department of Health and Aga Khan Foundation, Gorno-
Badakhshan autonomous Oblast 1998

C: Nutrition Priority Problems and Existing Programs

Both chronic and acute malnutrition rates and micronutrient deficiencies
are high in Tajikistan[128] They are higher than the global average for
developing countries and higher than some of the poorest nations in Sub-
Saharan Africa Three consecutive nutrition surveys have been conducted
over the last six years to monitor the situation Despite relief efforts,
nutritional status continues to deteriorate It appears that child rearing
practices, apart from early introduction of tea, are adequate and are
not
likely contributors to the high rates of malnutrition, as much as in other
countries Breastfeeding rates are reasonably high, but could be improved
to six months exclusive breastfeeding rates could be improved Weaning
practices such as early introduction of tea have negative consequences for
iron levels

A recent study conducted in one Oblast measured risk factors for stunting
and found household not part of MSDSP[129] agriculture program,
household with no electricity, birthweight, vitamin A not received and
less than six months of breastfeeding significant Associated factors with
wasting and not getting enough food that were found include received
vitamins and household with single parent Overall poverty and
inaccessibility of food appear to be the major determining factors for
malnutrition

Poverty is extremely high, with an estimated 80 of the population living
below the poverty line, and about 20 of those in extreme poverty Already
before the dissolution of the FSU, Tajikistan was one of the poorest areas
in Central Asia During the Soviet era, the population of the Oblast Gorno-
Badakhshan received subsidies, fortified food and micronutrients
Tajikistan depended
largely on subsidies The war created a large number
of female-headed households who experience a higher incidence of poverty
Since the collapse they have had to rely on local production and
humanitarian assistance Local production of wheat and potatoes has
increased, and while 52 of households produced food for themselves, it
remains unclear how much this contributes to daily energy intake and what
the quality of the food is Water and sanitation are important constraints
to health Eighty-two percent of households store their drinking water in
buckets, and only 9 have a tap in the house

Reasonably high numbers of people are reported to have received vitamins
and minerals, indicating a reasonably well functioning distribution system
Compliance however, appears to be low, indicating the need for better
counseling and education

Targeting nutrition assistance, either in counseling and income transfers,
to the poor will help improve the nutrition situation in the country
Ensuring that all salt is iodized and that a commonly consumed food staple
is fortified with iron will help address the major micronutrient
deficiencies Overweight and obesity rates are quite low compared to
other
ECA countries Improving beliefs about a healthy diet should be considered
as a strategy to improve health status in general and to prevent high rates
of overweight and obesity that are occurring elsewhere in the region

Nutrition at a Glance

Turkey

A: Basic Data

Data source: National statistics; Macro International, 1993, WHO Global
Malnutrition Database 2000; TransMONEE; UNICEF; Human Development Report,
World Bank CAS, 1997, World Bank 1999

B: Existing Nutrition Programs, Policies and Capacity

Data sources: World Bank CAS 1997 WHO/EURO, 1998 Comparative analysis
of implementation of Innocenti Declaration, 1999 Comparative analysis of
progress in elimination of IDD, 1999

C: Nutrition Priority Problems and Existing Programs

Although Turkeys social development indicators have improved significantly
over the last ten years, they are still well behind those of countries with
comparable economies[132] Education levels are low, especially for girls
Twenty-eight percent of females are illiterate, and the number of years of
schooling for women is half that of men Female school attendance is
heavily influenced by traditional customs Regarding health indicators,
Turkey is doing worse than would be expected from a middle-income country
Infant and maternal mortality are 44/1,000 and 183/100,000 live births
respectively

Malnutrition in Turkey is of public health concern, with 21 of all
children stunted in 1993 Although this information is rather
outdated,
there is no indication that the situation has improved, in particular in
the rural areas However, more research and updated data are needed On
the positive side, breastfeeding practices are almost universal, with 95
of all children breastfed for some period of time However, only 10 are
exclusively breastfed up to three months of age exclusive breastfeeding is
recommended for about 6 months so there is room for improvement Thirty
percent of children under one month of age are already given supplements,
indicating a need for better information on weaning practices

There is a very strong link between the mothers education and the childs
nutritional status 336 of children with mothers that have no education
are stunted, 157 of those with only primary education are stunted, while
43 of those with secondary and higher education are stunted

Improving school enrollment for girls and including nutrition in the
curriculum in schools is essential to reducing malnutrition in Turkey
However, targeted nutrition programs are also needed to improve
breastfeeding and weaning practices and to improve the quality of the
entire diet These programs are particularly needed in rural
areas where
rates of malnutrition are highest Iodizing all salt should be a priority
activity, given high rates of goiter in the country

Nutrition at a Glance

Uzbekistan

A: Basic Data

Data sources: National statistics; DHS 1996, WHO Global Malnutrition
Database; TransMONEE; UNICEF; Human Development Report, World Bank CAS
1998, World Bank 1999

B: Existing Nutrition Programs, Policies and Capacity

Data sources: World Bank CAS 1998 WHO/EURO 1998 Comparative analysis of
implementation of Innocenti Declaration, 1999 Comparative analysis of
progress in elimination of IDD, 1999

C: Nutrition Priority Problems and Existing Programs

Although other human development indicators are good life expectancy of 70
years, adult literacy of 98 and maternal mortality of 17/100,000,
malnutrition rates, both acute and chronic, are high In fact, Uzbekistan
is the only country in the region where acute malnutrition is higher than
10 Levels of 10 are considered high to severe by WHO standards Iron
deficiency is another malnutrition problem of severe public health concern
with 61 of children and 60 of women iron deficient Although
breastfeeding is almost universal, exclusive breastfeeding is very limited
Weaning foods are given very early The extent and nature of
poverty in
Uzbekistan remains incomplete, but a survey conducted in the late 1980s
indicates 44 poor with a strong rural bias
Inadequate care practices, together with the high poverty levels, probably
explain part of the malnutrition problem in Uzbekistan

Much can and should be done to improve the nutrition situation in
Uzbekistan Iodizing all salt should be a top priority as should
addressing high prevalence of anemia by fortifying a commonly consumed
staple with iron However, supplementing vulnerable groups such as
pregnant women and children under 2 years of age with iron is also needed
Breastfeeding and weaning practices should be increased by communications
for behavior change

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———————–
[1] Turkey has been included in the CAR and Caucasus region based on the
rural stunting rates which are comparable to the CAR and Caucasian
countries
[2] WHO 1998 Based on CJL Murray and AD Lopez 1996 The Global
Burden of Disease Harvard University Press, Cambridge USA and DL
Pelletier, EA Frongillo, and JP Habicht, 1993 Epidemiological
evidence of a potentiating effect of malnutrition on child mortality Am
J Pub
Health 83
[3] Pelletier, DL 1994 The relationship between child anthropometry
and mortality in developing countries: implications for policy, programs
and future research J Nutr 12410S: 2106S-2122S
[4] West, CE 2000 Vitamin A and measles Nutrition Reviews 582:S46-
S54
[5] McGuire, J 1996 The Nutrition Pay-Off Paper Population, Health
and Nutrition Division of the World Bank
[6] Barker, DJP 1998 Mothers, Babies and Health in Later Life
Edinburgh: Churchill Livingston
[7] Ruel, MT, J Rivera, and JP Habicht 1995 Length screens better
than weight in stunting populations J of Nut 1255: 1222-8
[8] Pinstrup-Andersen, P , S Burger, J-P Habicht and K Peterson
1993 Protein-energy malnutrition In: DT Jamison, WH Mosley, AR
Measham, and JL Bobadilla, eds, Disease Control Priorities in
Developing Countries Oxford Medical Publications/The World Bank
[9] Barker, DJP 1998 Mothers, Babies and Health in Later Life
Edinburgh: Churchill Livingston
[10] West, KP, J Katz, SK Khatry, SC LeClerq, EK Pradhan, SR
Shrestha, PB Connor, SM Dali, P Christian and RP Pokhrel 1999
Double-blind, cluster randomized trial of low dose supplementation with
vitamin A or beta carotene on mortality related to
pregnancy in Nepal
British Med J 3187183:570-5
[11] Horton, S 1999 The economics of nutritional interventions
Forthcoming in: RD Semba and MW Bloem, eds Nutrition and Health in
Developing Countries
[12] Lira, PIC, A Ashworth and SS Morris 1998 Effect of zinc
supplementation on the morbidity, immune function, and growth of low
birthweight, full-term infants in Northeast Brazil Am J Clin Nutr
68suppl:418S-24S
[13] Gjonca, A and M Bobak 1997 Albanian paradox, another example of
protective effect of Mediterranean lifestyle? Lancet 350 9094:1815-7
[14] Popkin, B 1993 Nutritional patterns and transitions Population
and Development Review 19:1:138-157 and the World Bank 1990 Brazil,
the new challenge of adult health
[15] Doak, CM, LS Adair, C Monteiro and BM Popkin 2000 Overweight
and underweight coexist in Brazil, China and Russia Department of
Nutrition, School of Public Health, University of North Carolina, Chapel
Hill and University of Sao Paulo, Brazil Draft
[16] Pomerleau, J, M McKee, A Robertson, K Kadziauskiene, A
Abaravicius, R Bartkeviciute, S Vaask, I Pudule and D Grinberga
1999 Dietary beliefs in the Baltic Republics WHO report
[17] Stunting and wasting were determined as
the proportion of children
falling below minus two Z-scores of the WHO/NCHS standard
[18] 185 for Body Mass Index DHS surveys for Kazakhstan 1995, Kyrgyz
Republic 1997, and Uzbekistan 1996
[19] ACC/SCN 1997 Third Report on the World Nutrition Situation
Administrative Committee on Coordination/Sub-Committee on Nutrition
[20] Michaelson, KF, L Weaver, F Branco and A Robertson 1999
Guidelines on complementary feeding and control of iron deficiency for 0-3
year olds in the WHO European Region WHO/UNICEF
[21] World Bank 1999 World Development Indicators
[22] Some distortion of the data can be due to the difference in the
definition of live births used by WHO and the former Soviet Union The
latter classified infants born before 28 weeks of gestation age or less
than 1,000 grams as late miscarriage
[23] World Bank 1999 World Development Indicators
[24] Goldstein, E, A Preker, O Adeyi and Chellaraj 1996 Trends in
health status, services and finance World Bank Technical Paper 384
[25] Branca, F, B Burkholder, M Hamel, I Parvanta, and A Robertson
1996 Health and nutrition survey of internally displaced and resident
population of Azerbaijan USAID/ WHO/ UNICEF
[26] Sharmanov, A 1998
Anaemia in Central Asia: Demographic and Health
Survey Experience Food and Nutrition Bulletin 194:307-317
[27] Enlargement of the thyroid gland as a result of iodine deficiency
Grade 0 is no palpable or visible goiter Grade I is palpable enlarged
thyroid, not visible Grade II and III, palpable and visible enlarged
thyroid WHO classification From: Hetzel, B and G Clugston 1999
Iodine In: M Shils, J Olson, M Shike and C Ross, eds Modern
Nutrition in Health and Disease Williams and Wilkins
[28] UNICEF 1998 Salt iodisation: a dramatic problem in Russia today
[29] UNICEF 1998 Progress report to the US National Committee for
UNICEF PBA-SC 98/0289-1
[30] Zarrabi L 1999 Nutritional anthropometry survey Khatlon Oblast,
Tajikistan Action Against Hunger, UK
[31] Hunt, J, Asian Development Bank, personal communication
[32] Government of Ukraine 1997 The health of women and children in the
Ukraine Government of Ukraine, UNICEF, UNDP, WHO and World Bank
[33] Branca, F, B Burkholder, M Hamel, I Parvanta and A Robertson
1996 Health and nutrition survey of internally displaced and resident
population of Azerbaijan USAID/WHO/UNICEF
[34] Michaelson, KF, L Weaver, F Branco and A Robertson
1999
Guidelines on complementary feeding and control of iron deficiency for 0-3
year olds in the WHO European region WHO/UNICEF
[35] WHO 1997 Vitamin A supplements Prepared by a WHO/UNICEF/IVACG Task
Force
[36] Michaelson, KF, L Weaver, F Branco and A Robertson 1999
Guidelines on complementary feeding and control of iron deficiency for 0-3
year olds in the WHO European region WHO/UNICEF
[37] Some of the carotenoids are precursors to vitamin A and as such are
important in the human diet
[38] Spirichev, VB, NV Blazheevich and VA Isaeva 1995 Nutritional
state of vitamin A and carotenoids in adults and children in different
regions of CIS Voprosy Pitaniya 5:3-8
[39] WHO/EURO 1998 Comparative analysis of nutrition policies in WHO
European member states World Health Organization/EURO
[40] The MONICA project is a multicenter international collaborative
project coordinated by the World Health Organization with the objective to
measure trends in cardiovascular mortality and morbidity and to assess the
relation to risk factors, measured at the same time in different countries

[41] Czech Republic, former Eastern Germany, Hungary, former Yugoslavia,
Poland, and the former USSR, including a
population in what is now
Lithuania
[42] Klugman, J and G Schieber 1999 A survey of health reform in
Central Asia In: Implementing Health Sector Reform: Paper from a Health
Policy Seminar held in Ashgabat, Turkmenistan, June, 1996
[43] Monitoring the risk factors of non communicable diseases, death rate
and some indicators of the progress of the CINDI program 1999 Russian
CINDI report The CINDI program monitors risk factors of non-communicable
disease in different countries
[44] Ministry of Education, Culture and Health 1998 Healthy Lifestyle
Program, Almaty, Kazakhstan
[45] Percentages would be much higher if the WHO standard of 200 mg or
more were used instead of the Russian standard of 250 mg or more
[46] Pomerleau, J, M McKee, A Robertson, K Kadziauskiene, A
Abaravicius, R Bartkeviciute, S Vaask, I Pudule and D Grinberga 1999
Dietary beliefs in the Baltic Republics WHO
[47] Ginter, E 1995 Cardiovascular risk factors in the former communist
countries European Journal of Epidemiology 11:199-205
[48] Third dose of diptheria-pertussis-tetanus toxiod
[49] Steinglass, R, The BASICS Project, personal communication
[50] The Economist Intelligence Unit 1998/9 Kazakhstan Country
Profile,
1998-1999 London
[51] The looming crisis and fresh opportunity: health in Kazakhstan,
Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan with emphasis on women
and children 1992 As reported in ACC/SCN 2000
[52] The looming crisis and fresh opportunity: health in Kazakhstan,
Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan with emphasis on women
and children 1992 As reported in ACC/SCN 2000
[53] Center for International Health Information-USAID 1992 Kazakhstan:
USAID Health Profile
[54] Center for International Health Information-USAID 1992 Kazakhstan:
USAID Health Profile
[55] Kuddo, A 1998 Social transition: social and employment policies in
the Former Soviet Union States
[56] Cornia AG 1994 Poverty, Food consumption and nutrition during the
transition to market economy in Eastern Europe AEA Papers and Proceedings
842:297-302
[57] Cornia AG 1994 Poverty, Food consumption and nutrition during
the transition to market economy in Eastern Europe AEA Papers and
Proceedings 842:297-302
[58] UNICEF-ICDC 1999 Women in Transition Regional Monitoring Report
No 6
[59] Men only
[60] Men only
[61] TransMONEE data
[62] Food availability data is not indicative for actual
intake
[63] Zhogoleva, EE 1998 The prospects for integration of agro-
industrial complexes within the commonwealth of independent states Studies
on Russian Economic Development 9:374-380
[64] Goskomstat SSSR 1996 Household income survey, 1994 Goskomstat,
Moscow
[65] The World Bank and Kiev International Institute of Sociology 1995
Household income and Expenditure in Ukraine Technical report
[66] Biro, B, M Antal and G Zajkas 1996 Nutrition survey of the
Hungarian population in a randomized trial between 1992-1994 Eur J Clin
Nutr 504:201-8
[67] Anta, M, A Regoly-Merei, H Varsanyi, L Biro, K Sagi, DV Molnar,
G Zajks, K Nagy, Z Avar and G Biro 1997 Nutritional survey of
pregnant women in Hungary Int J Vitam Nutr Res 672:115-22
[68] Martinchik, AN, AK Baturin, AI Feoktistova, TA Zemlyanskaya,
GA Azizbekyan, VS Baeva, TI Larina, EV Peskova and LS Trofimenko
1997 Monitoring of dietary intake and nutritional state of school
children in Moscow during the 1992-1994 period Voprosy Pitaniya 1:3-9
[69] Istomin, AV and IG Mikhailov 1997 Hygienic evaluation of the
indicators of nutritional status of school children in Monchegorsk
Gigiena i Sanitariya 5:12-14
[70] ZatoDski, W 1996 Evolution of
Health in Poland Since 1988
Maria Sklodowska-Curie Cancer Centre and Institute of Oncology Department
of Epidemiology and Cancer Prevention Warsaw, Poland
[71] World Ban-14
[72] Zato?ski, W 1996 Evolution of Health in Poland Since 1988 Maria
Sklodowska-Curie Cancer Centre and Institute of Oncology Department of
Epidemiology and Cancer Prevention Warsaw, Poland
[73] World Bank Poverty Reports for Albania 1997, Armenia 1996, Belarus
1996, Kazakhstan 1998, Russia 1995 and Ukraine 1996
[74] Robertson, A 1995 Food and Nutrition Assessment, Georgia
WHO/EURO Copenhagen
[75] NRC 1997 Premature death in the newly independent states
National Research Council, National Academy Press, USA As reported in
WHO/EURO 1998
[76] World Bank 1996 Living standards during transition, Kazakhstan
[77] UNICEF-ICDC 1997 Children at risk in Central and Eastern Europe
Perils and promises The Monee Project Regional Monitoring Report No6
UNICEF International Child Development Center
[78] Nutrition and Health Surveys in the Baltic Region, 1999 Forthcoming
[79] Ismail, S and H Hill 1997 Nutritional status in the Kzyl-Orda
area of Kazakhstan In: J Falkingham, J Klugman, S Marnie, and J
Micklewright, eds
Household Welfare in Central Asia MacMillian Press,
Ltd
[80] World Bank poverty reports for Albania 1997, Armenia 1999, Belarus
1996, Kazakhstan 1998 Russia 1995 and Ukraine 1996
[81] Paniccia, R 1997 Impoverishment, food consumption and health in
Central Asia and Eastern Europe during the transition, World Institute for
Development Economics Research WIDER
[82] Gwatkin, DR, S Rutstein, K Johnson, RP Pande, and A Wagstaff
2000 Socio-economic differences in health, nutrition and population
HNP/Poverty Thematic Group of the World Bank
[83] Popkin, B 1993 Nutritional patterns and transitions Population
and Development Review 19 1:138-157
[84] WHO 1997 Obesity: preventing and managing the global epidemic
Report of a WHO consultation on obesity
[85] Popkin, B1993 Nutrition patterns and transitions
[86] Monitoring the risk of non-communicable diseases, death rate and some
indicators in the progress of the CINDI program 1999 Russian CINDI
report The CINDI program monitors risk factors of non-communicable
disease in different countries
[87] WHO 1997 Obesity: preventing and managing the global epidemic
Report of a WHO consultation on obsesity
[88] Pomerleau, J, M McKee, A Robertson, K
Kadziauskiene, A
Abaravicius, R Bartkeviciute, S Vaask, I Pudule and D Grinberga 1999
Dietary beliefs in the Baltic Republics
[89] Falkingham, J, J Klugman, S Marnie and J Micklewright 1997
Household Welfare in Central Asia MacMillan Press, Ltd
[90] Falkingham, J, J Klugman, S Marnie and J Micklewright 1997
Household Welfare in Central Asia MacMillan Press, Ltd
[91] Food and agriculture reform in the former USSR 1999
[92] Aga Khan 1995 Seeds of Change Video produced by the Aga Khan
Foundation
[93] Dannreuther, R 1994 Creating new states in Central Asia Adelphi
Paper 288:3-82
[94] UNRISD 2000 Political factors as basic causes of poor health and
malnutrition in countries in transition Experiences in Central Asia
Forthcoming
[95] Gerasimov, G and A Baturin undated Practices addressing IDA
during the USSR Rollins School of Public Health of Emory University and
Institute of Nutrition, Moscow
[96] Abramov, A UNICEF/Turkmenistan, personal communication
[97] WHO/EURO 1998 Comparative analysis of nutrition policies in the WHO
European member states
[98] Oleg, B and U Virginia undated A pilot study on healthy eating in
Ukraine: attitudes, barriers, and information sources
[99] These
data are from small studies that cover only certain time periods
and districts They are not national data
[100] Total goiter rate
[101] International code on marketing breastmilk substitutes, prohibits the
provision of free samples and publicity on breastmilk substitutes by health
professionals
[102] Total goiter rate
[103] International code on marketing breastmilk substitutes prohibits the
provision of free samples and publicity on breastmilk substitutes by health
professionals
[104] National Institute of Health 1998The health and nutrition status
of children and women in Armenia National Institute for Nutrition Italy
[105] Hekimian K 1993 Infant feeding practices in Armenia
[106] An estimated population of 500,000 total population of Armenia is
33 million
[107] Total goiter rate
[108] Branca et al, 1996 Health and Nutrition Survey of Internally
Displaced People and Residents in Azerbaijan
[109] Total goiter rate
[110] International code on marketing breastmilk substitutes, prohibits the
provision of free samples and publicity on breastmilk substitutes by health
professionals
[111] Total goiter rate
[112] International code on marketing breastmilk substitutes, prohibits
the
provision of free samples and publicity on breastmilk substitutes by health
professionals
[113] Poverty Assessment, 1996
[114] Healthy Lifestyle Program report, 1998
[115] Total goiter rate
[116] International code on marketing breastmilk substitutes, prohibits the
provision of free samples and publicity on breastmilk substitutes by health
professionals
[117] World Bank 1998 Country Assistance Strategy for the Kyrgyz
Republic
[118] Health policy priorities in the Kyrgyz Republic
[119] ADB 2000 Technical Assistance Report Asian Development Bank
[120] Total goiter rate
[121] International code on marketing breastmilk substitutes, prohibits the
provision of free samples and publicity on breastmilk substitutes by health
professionals
[122] Total goiter rate
[123] International code on marketing breastmilk substitutes, prohibits the
provision of free samples and publicity on breastmilk substitutes by health
professionals
[124] The situation of Mother and Child in the Republic of Moldova,
realities and tendencies, 1996, UNICEF and the Government of Moldova
[125] Total goiter rate
[126] Total goiter rate
[127] BF and weaning practices recommendations do not concur with the
latest WHO
recommendations: breastfeed until 10-11 months, exclusive during
the first and main feed during the next 4 to 45 months Complementary
feeding should start very early in life, since the first month, since three
weeks fruits or vegetable water, mashed fruit at 15,2 months, egg yolk at
3 months Breastmilk becomes a complement at 4 months, meat at 7 months
and cows milk at 75 months
[128] Total goiter rate
[129] International code on marketing breastmilk substitutes, prohibits the
provision of free samples and publicity on breastmilk substitutes by health
professionals
[130] Schumacher, B Nutrition, Health and Food Security Survey, 1998,
Deutshce Welthungerhilfe
Health and Nutrition Survey, 1998, USAID
Survey Report, Mission Ost, winter 1997

[131] Total goiter rate
[132] International code on marketing breastmilk substitutes, prohibits the
provision of free samples and publicity on breastmilk substitutes by health
professionals
[133] Table 12 CAS 1997, Turkey compared to Chile, Colombia, Mexico,
Poland, Hungary, Malaysia and Tunisia
[134] Total goiter rate
[135] International code on marketing breastmilk substitutes, prohibits the
provision of free samples and publicity on breastmilk
substitutes by health
professionals

———————–

Box 2: New Research on Meeting Requirements for Micronutrients

The importance of adequate intake of vitamins and minerals is coming to
light with new research about the anti-oxidant effects of many vitamins
vitamin C, vitamin E, folic acid, etc and the benefits of certain types
of fats found in olive oil and fish In addition, the pigments and other
phytochemicals found in fruits and vegetables have been shown to reduce
risk for certain kinds of cancer, cardiovascular disease, cataracts, and
certain birth defects Countries in the Mediterranean that have diets high
in vegetables, fruits, olive oil, and fish have lower adult mortality rates
than other areas of Europe where intake of these foods is lower Albania,
for example, has one of the highest infant mortality rates in the region
but one of the lowest adult mortality rates half the adult mortality rate
of the UK but similar to Italy Adult mortality rates are particularly
low in the southern part of the country where most of the olive oil, fruits
and vegetables are produced and consumed Gjonca and Bobak, 1997

Box 3: Body Mass Index BMI and Related Health
Risks

The relationship between body-mass index BMI and the incidence of several
common conditions caused by excess body fat, such as maturity-onset
diabetes, hypertension, and coronary heart disease CHD for the US, has
recently been shown by Willett 1999 In a woman with a BMI of 26 her
risk of CHD is about twice the risk of a women with a BMI of less than 21
The risk for a man with a BMI of 26 was about 15 times the risk of a man
with a BMI of 21 The risk of diabetes was four times higher in obese men
and eight times higher in obese women, and the risk of hypertension two to
three times higher in obese individuals With a BMI of 29 and higher these
risks are increased It has been estimated that about 64 of male and 77
of female cases of maturity-onset diabetes or NIDDM non-insulin dependent
diabetes mellitus could theoretically be prevented if no person had a BMI
over 25 Severe obesity is associated with a 12-fold increase in mortality
in 25-35-year-olds compared to lean individuals

Box 4: The Economic Costs of Overweight and Obesity

The economic costs of overweight and obesity are important issues for
health care providers and policy-makers alike To date, there have
been
only few attempts to quantify the economic burden of obesity-related
morbidity and mortality Most recent are the Wolf and Colditz estimates
for the US 1998 Economic cost assessments for developing countries
range from 2-7 of total health care costs These are conservative
estimates, but they nevertheless confirm that obesity represents one of the
largest expenditures in national health care budgets Most probably the
cost in developing countries exceeds the estimates for the developed
countries because of the extra burden associated with expensive equipment,
scarce foreign exchange and need for specialized training for staff
Preliminary data also suggest that a large proportion of the economic costs
of obesity can be saved by efficient prevention or intervention strategies
Approximately 63 of the direct cost associated with obesity are from
maturity-onset diabetes or NIDDM Wolf and Colditz, 1998 The authors
conclude that obesity represents a major avoidable contribution to the cost
of illness in the US and probably in the rest of the world
Unfortunately, very little information is available on the economic
benefits of treating obesity, although some extrapolations can be
made from
a large-scale Swedish intervention SOS study The treated groups quality
of life markedly improved and several cardiovascular risk factors
decreased The prevalence of maturity-onset diabetes or NIDDM decreased by
68 in the treatment group In other words, two-thirds of the maturity-
onset diabetes or NIDDM prevalence was cured by the obesity intervention
Segal 1995 attempted to model potential cost-effectiveness of a range of
interventions for the prevention and treatment of maturity-onset diabetes
or NIDDM in Australia The study estimated that the most cost-effective
interventions were a commercial 6-week group session program for men and
the mass-media lifestyle modification program Both interventions were
estimated to result in cost savings from reduced incidence of maturity
onset diabetes or NIDDM, and savings were greater than program costs
Behavior change to reduce cardiovascular disease costs less than US1 per
capita per year in targeted populations Analyses have shown that
prevention is a more cost-effective strategy than treatment once the
disease has been diagnosed WHO, 1997

Box 5: Poor Feeding Practices Induce Growth Faltering in Young Children
Not
only do poverty and food insecurity influence malnutrition rates
Infant and child feeding practices have a strong influence on child
morbidity and mortality There is extensive evidence of the health
advantages of breastfeeding, and more so exclusive breastfeeding for about
6 months, as indicated by lower infant morbidity and mortality than for
bottle-fed infants Only 4 to 17 percent of infants 0-6 months are
exclusively breastfed in the ECA region Early introduction of weaning
foods interferes with the production of breastmilk and can be a source of
contamination resulting in infectious disease Contamination also may be
linked to chemical pollution Early introduction of weaning foods such as
cows milk is associated with potential gastrointestinal blood loss Early
introduction of tea, common in some countries of the region, impairs iron
absorption from meals by 40 percent In consultative research in
Kazakhstan, for example, infants who were not breastfed were given tea
Children are exposed to the highest risk of growth faltering during the
weaning period from the age of 6 to 24 months Data from nutrition surveys
in the Kyrgyz Republic and Tajikistan confirm this-at 24 months,
wasting or
acute malnutrition peaked in the Kyrgyz Republic with 104 percent and in
Tajikistan at 12 months of age Both the Kyrgyz Republic and Tajikistan
have high breastfeeding rates, 96 percent at 6 months; however, exclusive
breastfeeding rates are low, and the introduction of complementary foods is
neither timely nor adequate

Box 6:Food Consumption Changes in Bulgaria
Following price liberalization in 1991 per capita consumption of milk,
yogurt and meat, protein and micronutrient dense food, began to decline
particularly among the poor

Per Capita Consumption of meat, milk, and yogurt in low and high income
groups kgs, 1992 - 1997
| |1992 |1993 |1994 |1995 |1996 |1997 |
|Meat | |
|Poorest decile |190 |169 |140 |126 |120 |74 |
|Wealthiest |555 |547 |444 |454 |456 |368 |
|decile | | | | | | |
|Ratio |29 |32 |32 |36 |38 |50 |
|Milk and Yogurt| |
|Poorest decile |617 |430 |401 |305 |321 |224 |
|Wealthiest |960 |940 |1010 |984 |935
|871 |
|decile | | | | | | |
|Ratio |16 |22 |25 |32 |29 |39 |

Source UNICEF 1999; World Bank 1999

The table above shows that the disparity between rich and poor in the
consumption of protein and micronutrient dense foods has increased markedly
between 1992 and 1997 In 1992 the wealthiest 10 of the population
consumed almost three times more meat than the poorest 10 of the
population By 1997 the wealthiest 10 of the population were consuming
more than five times the quantity consumed by the poorest The change in
milk and yogurt consumption, more relevant for the nutrition of small
children, is even more marked In 1992 the rich consumed just over one and
one-half times more than the poor, but by 1997 were consuming almost four
times as much Yet there are three times more children, on average in the
poorest group that the wealthiest The Bulgarians show a good deal of
reliance on their own production for food: almost 40 of vegetables, two
thirds of fruit consumption, and around 30 of meat and dairy consumption

Box 7: Decline in the Availability of Iodized Salt

The Former Soviet Union began iodizing salt
in the 1950 By 1970 most of
the IDD had been eliminated However, due to poor and relaxed monitoring
and the fact that the newly independent states were less able to purchase
the sodium thiosulphate needed to iodate salt, it started to appear in non-
iodized forms, increasing IDD prevalence in the region For example, cases
of goiter in certain Oblasts in Ukraine increased by 100 between 1980 and
1990, and in Belarus there was a 300 increase in goiter prevalence in some
oblasts after 1986 To exacerbate the situation, the consumption of fish,
a rich source of iodine, declined in the region because people could no
longer afford to eat it regularly coupled with reduced availability due to
the demise of the Soviet fishing fleet Only Slovakia and the Czech
Republic have continued their iodization programs throughout this period,
although Bulgaria re-introduced the program in 1995, and Poland, Armenia,
and Ukraine revived their programs again in 1997 Turkmenistan started
producing iodized salt in 1996 and a monitoring and evaluation system will
be introduced in 1999 with technical assistance from UNICEF

Source:afmrd.org

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