Missing nutrients in Asian diets

From IRIN, a story on how nutrients missing from diets in Asia could be a silent killer of the area's children.

By the time Fatima Emilova was six months old she had been hospitalized twice for 10 days at a time with debilitating bouts of diarrhoea. The disease, a worldwide killer, is often caused by a lack of zinc, one of several micronutrients dangerously deficient among infants in the impoverished Central Asian nation of Kyrgyzstan.

“After she was born, she was very weak,” said Fatima’s mother, Jazira Seitaliyeva, 34. “But after six months, that stopped. Now she walks, runs, flies around – she’s different from the other children.” Seitaliyeva attributes the changes in the youngest of her six children, now eighteen months old, to a micronutrient powder containing iron, folic acid, vitamins A and C and zinc, given free to infants aged 6-24 months in Talas Province, where the family lives in Ak-Korgon, a dusty village of about 160 homes.

“The little ones who get it cut their teeth faster,” Mahera Uruzbayeva, the local nurse-practitioner in charge of distributing the powder in the neighbouring hamlet of Kok-Kashat, told IRIN. “Their appetite is better and they’re sick less. The year before last, more children had the flu; this year we got a rest.”
The powder - Gulazyk in Kyrgyz and Sprinkles in English - has been distributed in Talas since June 2009 and is part of a larger pilot programme to fight malnutrition and promote early childhood development, implemented since 2008 by Kyrgyzstan’s Health Ministry, the UN Children’s Fund (UNICEF) and the Swiss Red Cross, with support from the US Centres for Disease Control (CDC).

Preliminary results show that the Gulazyk project is working. An initial analysis of the data - to be presented, pending final review, on 23 November in Kyrgyzstan’s capital, Bishkek - suggests it has already cut the rate of iron-deficiency anaemia in Talas Province by 20 percent.

According to the CDC the disease afflicts nearly 40 percent of the country's women and at least half the children, and the hope is to expand the programme nationally.

Hidden hunger

In Kyrgyzstan, as elsewhere, malnutrition is dangerously easy to overlook when children don’t have protruding ribs and distended bellies. Healthy eating means not only getting enough food but getting the right vitamins and minerals, or micronutrients, particularly iron, iodine, Vitamin A, folic acid and zinc. When these are absent in early childhood, the damage can be invisible at first but devastating in the long run.

“Micronutrient deficiency is the main threat to the physical health and intellectual capacity of children under two,” said Dr Tursun Mamyrbaeva, a leading nutritionist at Kyrgyzstan’s Republican Centre for Immunoprophylaxis. “A persistent deficiency, even of a tiny amount of vitamins and minerals, can provoke and exacerbate hundreds of ailments, including malignant tumours and developmental defects, and can ultimately undermine the viability of the nation as a whole.”

UNICEF saw alarming signs of chronic micronutrient deficiency in Kyrgyzstan in 2006, when it found that 13 percent of children under five were growing more slowly than normal; in Talas Province the prevalence of stunted growth was twice the national average. A survey overseen there by the CDC in 2008, before the introduction of Gulazyk, found that two-thirds of babies aged 6-24 months were iron-deficient, and just as many had too little folic acid.

Nationwide, dangerously low levels of folic acid in pregnant women leave 150 babies a year with severe birth defects, mostly of the brain and spinal cord, while 300 newborns die from insufficient Vitamin A, too weak to fight off lethal infections, according to Kyrgyzstan’s Health Ministry.

Iron, the weakest link

Micronutrients are best considered as a group, but nutrition experts in Kyrgyzstan have focused mostly on iron deficiency, which places more than 20,000 children under two – about 10 percent – at risk of mental retardation, according to the Health Ministry.

“Six months to two years is a period of very rapid growth for children. Their regular intake of iron can’t keep up with their needs,” said Elizabeth Lundeen, a health promotion adviser to the Swiss Red Cross, who has been working in Kyrgyzstan for over four years and helped develop the Gulazyk project. “In the West we have tons of fortified complementary foods, but in many developing countries these foods are either unavailable or unaffordable.”

Fatima’s household is a case in point. Like many in Kyrgyzstan, the family spends well over half its income on food, which includes buying about 100 kg of flour a month, but none of the four food shops in Ak-Korgon sells fortified cereals and a 2009 law on fortification has been hard to enforce, particularly in rural areas. Most of the mountainous country’s 3,000 flour mills are tiny private enterprises, with significant amounts of flour imported across porous borders with few controls.

Holistic approach

The collapse of the Soviet Union and its centralized economy in 1991 ushered in an era of hardship. As newly independent Kyrgyzstan sank into poverty, access to healthcare and education worsened, as did eating habits. Many people began replacing nutritious but increasingly expensive meat and dairy products with cheaper items like bread and tea, which inhibits the body’s uptake of iron.

“In the 1970s, when I visited relatives here, children weren’t allowed to drink tea,” said Jamilya Madalbekova, the UNICEF coordinator in Talas. “My grandmother and her friends would shoo us into the kitchen to drink jarma,” a hearty drink made of crushed grain and water or yogurt. After 1991, “there were about 10 years that were critical for the population - now we’re reaping those fruits.”

UNICEF and the Swiss Red Cross decided on a holistic approach to make up for families' poor access to wholesome food, accurate information and high-quality medical care. The programme began as an educational campaign about healthy eating for pregnant women, best practices for breast-feeding and a balanced diet for infants. The free micronutrient powder was added in 2009, followed by materials for boosting infants’ intellectual development with simple interactions like talking, reading, singing and playing.

“The Gulazyk project is unique in that it addresses both nutrition and early cognitive and social stimulation of young children,” said Farhad Imambakiyev, UNICEF’s communications officer in Kyrgyzstan. “The two are mutually reinforcing - like two wings that allow each child to reach full developmental potential.”

The programme trains local doctors and nurses and groups of volunteers, called village health committees, who spend a few days a month visiting neighbours with health-related information and advice, so as to reach families with small children. Even medical professionals say they have learned from the experience.

“When I was a student there was no emphasis on nutrition - it was more about illness,” said Uruzbayeva, the nurse-practitioner in Kok-Kashat, who likes the colourful charts and pamphlets illustrating the programme’s key points. “The materials make things easier; before, lessons were all oral.”

Obstacles and prospects

The Gulazyk project has not been trouble-free. In the provincial capital of Talas, a city of about 34,000, Dr Damira Baisabayeva, who coordinates distribution of the powder and is second-in-command of healthcare in the province, asked doctors to collect data on usage. They reported that from January to September 2010, 91 percent of eligible families received Gulazyk, but only 59 percent used it as directed.

“In the countryside communities are compact - medical professionals are viewed as authority figures,” Baisabayeva told IRIN. “In the city it’s harder - the population is bigger, there’s lots of migration. People have more doctors to choose from, but doctors have large caseloads and no support from civil society, so there’s less interaction with patients, less time to talk with them.”

Mistrust is as prevalent in the capital as in rural areas. A small number of families refused to participate, saying they were sceptical of the powder’s foreign origins. Others became afraid because Gulazyk, like any iron supplement, changed the colour of children’s stools, or because it was initially introduced in the summer, when children often fell ill with seasonal intestinal infections, and parents attributed these to the powder. Some feared they were being subjected to an experiment.

Gulazyk has proven effective in reducing infant anaemia and the Swiss Red Cross is funding the project for three years in Naryn, one of Kyrgyzstan’s poorest provinces. Charitable foundations backed by financier-philanthropist George Soros have committed US$1.3 million to distribute it in three more of the country’s seven provinces.

In the remaining two, Jalalabad and Osh, which were devastated by ethno-political violence in June, UNICEF and the Health Ministry are distributing the powder to hospitalized children as a part of an emergency response.

Gulazyk’s cost-benefit ratio makes it attractive to donors: one sachet costs less than 2.5 US cents, including shipping and customs clearance. The three-year programmes in Talas and Naryn have price tags of about $300,000 each and a nationwide scale-up would cost under $6 million – a fraction of the estimated $28 million lost by Kyrgyzstan each year “due to the problems of iron and iodine deficiency”, according to statistics cited by the Health Ministry.

The global economic crisis has intensified nutritional needs. Dr Nargiza Kanazarova, a general practitioner in rural Talas, told IRIN: “I’d like to see a programme like Gulazyk for pregnant women ... While they’re pregnant, they’re scared; they want healthy babies. When the babies start growing up, they run, they jump, they seem healthy and mothers get lax.” Many public-health experts and medical professionals would like to see Gulazyk, or comparable supplements, expanded to children older than two.

The World Food Programme concluded in 2008 that one-fifth of Kyrgyzstan’s households were at “high nutritional and health risk because of poor food consumption.”

In 2008 the Copenhagen Consensus, a group of prominent economists rated micronutrient supplements for children as the most cost-effective poverty-fighting measure available. Local production of micronutrient supplements is being considered in Kyrgyzstan.