United Nations Children's Fund Area Office for Central Asian Republics and Kazakhstan

Progress of Central Asian countries towards food fortification to combat micronutrient deficiencies

(Abstract from the Report of the CARK MCH Forum VI Annual Meeting, Ashgabat, Turkmenistan, 4-6 November 2002)

Fortification of foods with micronutrients is an effective means of long-term prevention and control of many micronutrient deficiencies, and one that has been shown to be cost-effective in many countries. For example, fortification of salt with iodine has effectively eliminated IDD in many countries, both industrialised and non-industrialised. Fortification of wheat flour with iron has also been shown to reduce iron-deficiency anaemia among affected populations. In all CARK countries, measures have been implemented to achieve USI for IDD prevention since the mid-1990s. More recently, countries have begun activities for fortification of wheat flour in an effort to prevent IDA, which is widespread in CARK. This activity has received support from both UNICEF and the ADB /JFPR "Improving Nutrition for Poor Mothers and Children in Asian Countries in Transition" project. UNICEF and ADB are working jointly to assist countries in achieving USI to eliminate IDD and initiate wheat flour fortification to combat IDA.

Status of country progress towards Universal Salt Iodization

Iodine deficiency disorders are widespread in CARK, leading to endemic goitre, cretinism, mental retardation, and impaired physical and intellectual development of entire generations of children. During pregnancy iodine deficiency can also lead to miscarriage, stillbirths, and a variety of congenital abnormalities. Low iodine intake can lead to a loss of an estimated 10-15 points in the intelligence quotient (IQ) distribution of an entire generation of children.
Global experiences have shown fortification of salt with iodine to be both efficacious and cost-effective in combating IDD. Salt is also a food item commonly and frequently consumed by people, regardless of socio-economic status.
Estimates derived from DHS and MICS data from CARK countries suggests that approximately three-quarters of all newborns in the area lack protection from IDD because they are born into households that do not consume adequate amounts of iodine. However, progress towards USI has generally been slow since IDD was recognized as a re-emerging problem throughout CARK in the mid-1990s. A 1994 UNICEF situation analysis revealed that less than 20 per cent of households were consuming iodised salt. Salt iodisation rates in CARK and the CIS have been shown to be the lowest in the world. After considerable effort to increase access to iodised salt, a 2001 situation analysis showed slight improvement. Although CARK countries are at different stages of achieving USI, many trends and constraints are shared among them.
All CARK countries have adopted or are in the process of adopting necessary legal documents mandating the iodisation of salt for human consumption. Although ministerial decrees and documents are a significant step in the right direction, the highest level of legislation is required to emphasise the importance of USI and to ensure proper enforcement. Advocating governments to pass national laws (as in Kazakhstan) or in adjusting laws to accommodate new standards has been difficult. Even with an adequate legal framework, inadequate enforcement by governments can, and often does, render these laws ineffective.
A key constraint to the effective use of salt fortification for IDD prevention is the inability to ensure that adequate amounts of iodine in salt reach the consumer. Improper packaging, transportation and storage methods can all lead to loss of iodine concentration in fortified salt. Raising iodine concentration requirements to at least 40`15 ppm in salt (currently 23`15 ppm in Turkmenistan) is one step being made towards ensuring that sufficient amounts of iodine in salt reach consumers.
Building human and technical capacity to inspect and ensure that this new standard is being applied is another requirement described in presentations. Iodized salt must be tested at all levels: at the production site, at retail outlets, and in households. Countries are beginning or continuing training of relevant staff on proper inspection of the level of iodine concentrations in salt at all levels. Many 2002 activities and those planned for 2003 are related to procurement of necessary equipment and training of staff.
Among consumers, studies have shown increased knowledge and access to iodized salt. However, the need for further efforts to be made by governments and the private sector towards making fortified salt affordable and attractive to consumers, especially in areas where local salt deposits offer cheap supplies of non-iodized salt was emphasized in presentations.
Additional efforts are also required to inform consumers about the need for proper storage of iodized salt and to discourage behaviors such as buying and storing salt in bulk. Awareness of the proper use of salt in cooking to ensure consumption of the maximum amount of iodine through salt is also needed. The survey conducted in Kyrgyzstan also revealed that health workers and television were the most important sources of information for schoolchildren, a finding that may be helpful in the development of communication and awareness-raising campaigns.
The "Agreement on Control and Prevention of IDD" signed by the CIS (which includes the five CARK countries) in 2001 is one step made towards regional co-operation on the issue of trade of non-iodized salt. However, in addition to agreements, information from the presentations made suggest the need for further co-operation between customs, SES and other agencies within and between countries.

Flour fortification in CARK: achievements and challenges

It has been proven that IDA leads to deterioration of the physical and cognitive development of children, reduces the intellectual and physical capacity among adults, and reduces immune system function that, in turn, increases susceptibility to infection and severity of diarrhoeal and respiratory diseases. Iron deficiency anaemia has also been shown to lead to low birthweights and increase infant and maternal mortality.
The proportion of women and children affected by IDA in CARK is enough to classify the widespread IDA prevalence as a public health crisis. Comprehensive APC programmes have been implemented in CARK countries for several years at the pilot level. These programmes have included strategies such as supplementation of vulnerable groups with iron and folate, awareness building among health workers and the general population, and initiation of efforts to fortify wheat flour with iron. However, more time and effort are needed to fully eliminate IDA as a public health problem in CARK. Iron deficiency anaemia is still widespread in CARK, and especially deteriorates the health of young children, and pregnant and breastfeeding women. Thus, in all CARK countries, IDA remains one of the priority public health issues.
Fortification of wheat flour with iron is a key long-term strategy for the prevention and control of IDA that is being pursued in CARK, as in other areas of the world. Wheat flour has been chosen as the preferred vehicle for fortification because it is frequently and consistently consumed by populations across all social strata. Experiences in other countries have demonstrated the stability of flour as a vehicle for delivering adequate amounts of iron to consumers, even after losses in production, storage and cooking are taken into account. Many milestones have been achieved in the process of developing and implementing flour fortification programmes in CARK. In particular, research in the mid-1990s revealed the extent of the problem of IDA affecting CARK populations. In Kyrgyzstan, this awareness led to a pilot project to fortify wheat flour with micronutrients in 1995. A year later, a Nutrition Action Plan for CARK - including plans for USI and WFF - was developed with the support of KAN and international organisations. In 1996, CARK Parliamentarians called for APC programmes including flour fortification. Some WFF activities were initiated as part of the comprehensive national APC programmes developed and implemented throughout CARK in the late 1990s.
Support from UNICEF and ADB/JFPR is helping to initiate, and in the case of Kyrgyzstan, restart, flour fortification programmes in the area. The aim of these efforts is to enable countries to initiate flour fortification and support achievement of USI. A project implementation office, national co-ordination committee, and working group have already been established in the four countries participating in this project: Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan. Although Turkmenistan is not participating in this project, it is working towards WFF with UNICEF support.
Initial steps were already taken towards WFF, including the processing of necessary contracts, procurement/installation of equipment and fortificants, and efforts to create a legislative framework in each of their countries. Workshops have been held to train technical staff on WFF issues and in quality assessment methods. A multi-micronutrient fortificant KAP Complex pre-mix, that includes zinc, thiamine, riboflavin, niacin and folic acid in addition to iron, has been prepared by KAN especially for use in CARK. Many more activities to further develop and adopt the necessary legal and normative documents and to increase both the human and institutional capacity for large-scale WFF are planned for the future.
In discussions during the meeting of the Working Group on Micronutrients that followed the VI CARK MCH Forum, issues related to WFF and other elements of APC programmes were discussed in greater detail. The strategy of using flour fortification to reduce iron deficiency has been shown to be most successful when it is implemented on a large scale, with public and private sector involvement. For example, in countries where a small number of large wheat flour producers are involved in flour fortification, universal WFF is more quickly and easily achieved. The representative from Turkmenistan stated that the centralised system of flour production in the country, dominated by larger state-owned mills, has helped achieve fortification of approximately one-third of all flour produced in that country. Other mills that are not owned by state enterprises are small enough so that they do not compete with state mills. On the other hand, representatives from Tajikistan expressed the difficulty of developing and implementing a large-scale fortification strategy in the country, where most flour is produced in small mills or at home, and at a much smaller scale.
It was also agreed that the sense of national ownership of WFF programmes should be increased. The involvement of local officials and leaders in the entire process can increase public awareness and understanding of the need for these programmes and thus, improve programme implementation. The private sector should be actively involved, and the specific role of flour producers should be clarified to improve their participation. Improving awareness among producers of the benefits of WFF and efforts to reduce the cost of fortification from being passed on to producers and consumers are activities that should be planned for the future.
Advocacy of government should be improved for IDD programmes specifically, and APC programmes in general, in CARK. Representatives from international organizations and country delegations both emphasised that the level of advocacy on anaemia prevention should match the high level of importance attached to IDA. Advocacy should rise from beyond the MoH level to the executive and parliamentary level, as well. To reduce the misperception that IDA is just a medical problem, messages of the importance of IDA prevention to each countryis social, economic and national development should be promoted. Monitoring is needed to understand not only dynamics in IDA, and any changes due to interventions, but also to help analyse behaviours that may affect anaemia prevalence. For example, the high rate of Intra-Uterine Device (IUD) use in Uzbekistan was identified as factor contributing to the high rates of anaemia among women of childbearing age in that country. Representatives from Tajikistan noted the need for national-level data on issues such as IDA prevalence and iron intake to inform APC strategies in that country.

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