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)
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
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
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
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
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
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
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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