UNDERNUTRITION IN ARMENIA: A MATTER OF NATIONAL SECURITY
by Nanore Barsoumian
July 19, 2012
An estimated 171 million children under the age of 5 are stunted in
the world, according to the World Health Organization (WHO). Of those
171 million, 115 million suffer from wasting; 20 million from acute
malnutrition; and almost 4 million die each year from health problems
related to undernutrition. In other words, over 10,000 children die
each day from an easily preventable condition.
“Imagine if almost 20 percent of Armenia’s already diminished
population cannot reach their full potential as a result of chronic
malnutrition. The implications are disastrous… Developing long-term
strategies for improving childhood nutrition is an investment in
Armenia’s future and critical to its survival.”
Undernutrition affects children all over the world, from industrialized
countries like the U.S., where 49 million people are at risk of
hunger, to impoverished regions like Somalia, where 42 percent of
children under 5 suffer from stunting. In Armenia, stunting affects
roughly one in five children, according to the 2010 Armenian Health
and Demographic Survey (ADHS), released in April 2012.
Stunting, which is the result of long-term undernutrition, can
be observed in the below-normal height of a child. Undernutrition
reflects chronic or acute malnutrition. The consequences stretch
beyond what meets the eye-beyond the missing inches in height: It can
be detrimental to the health of a child, increasing susceptibility
to illness and disease. It can also have a devastating impact on
a child’s emotional and social behavior, and cognitive (learning)
functions, and can even cause death. Stunting “is often impossible
to correct” according to UNICEF. Wasting, in turn, is a sign of acute
malnutrition. It “describes a recent severe process that has produced
substantial weight loss, usually as a consequence of acute shortage
of food, severe disease, or both,” notes the ADHS report.
Malnutrition is not just a tragedy on the individual level, but a
national disaster in the eyes of Kim Hekimian and Richard Deckelbaum,
lecturers at the Institute of Human Nutrition at Columbia University.
“Imagine if almost 20 percent of Armenia’s already diminished
population cannot reach their full potential as a result of chronic
malnutrition. The implications are disastrous… Developing long-term
strategies for improving childhood nutrition is an investment in
Armenia’s future and critical to its survival,” they stated in a
project proposal aimed at improving the nutritional status of children
in Armenia.
The quality and variety of food, more than the quantity, lie at the
core of the problem in the country. Children in Armenia are not
receiving proper nutrition as a result of “poverty, food prices,
competition for household resources caused by globalization, and
greater access to over-processed foods via supermarket expansion,”
Hekimian, who is also a visiting professor at the American University
of Armenia (AUA), told the Armenian Weekly.
Hekimian and Deckelbaum recommend developing educational initiatives
geared towards healthcare professionals, policy makers, pregnant women,
and mothers; agricultural programs to ensure the availability of
nutritional food products; the administration of medical tests that
determine treatable causes of malnutrition (i.e., celiac disease,
enteric parasites, and cow’s milk allergy); and the distribution of
micronutrient supplements, if necessary.
The successful eradication of the problem hinges on awareness-raising
and education on the one hand, and intervention on the other. “We want
to measure the knowledge of caregivers-mothers and grandmothers-because
they probably don’t know about the importance of iron and protein for
little ones, thinking that bread and potatoes are filling, nutritious,
and relatively cheap,” said Hekimian. “Evidence suggests that both
poor and wealthy families have stunted kids.”
“The reason we don’t have stunted growth in the U.S. is not because
of our GDP but because of the fortified foods we give our babies,”
she explained. “The pediatrician recommends that at six months you
give rice cereal, which is fortified, as are our pastas and breads.”
According to Armenia’s Ministry of Health, the rate of folic acid
deficiency is about four times higher in Armenia than it was in the
U.S. before the country began flour fortification. The effects of
folic acid deficiency can be seen in the high rate of neural tube
defects in babies in Armenia. Children can be anemic, but not have
low iron stores. There is only one national data set on anemia in
Armenia, conducted by the ADHS in 2005, and it shows a high level of
anemia in children. Hekimian’s team at Columbia would like to further
research blood iron levels in children, as the ADHS survey only looked
at overall hematocrit and hemoglobin levels.
Over the past 10 years, the ADHS report, which is conducted by
Armenia’s National Statistical Service (NSS) and the Ministry of
Health, has been the only ongoing and nation-wide survey in the
country. Hekimian and Deckelbaum hope to conduct further research
on the causes of undernutrition in Armenia because a solid set of
data is the first stepping stone. They plan to evaluate and monitor
the nutritional status of 1,500 children and their mothers during
their proposed five-year project. The team will explore the factors
that contribute to stunting-including medical, socio-economic,
and behavioral conditions. Children will be tested for anemia,
celiac disease, and parasites. Treatments will be administered and
educational programs will be set up.
The results of a concerted effort are evident in the Talin region,
where World Vision Armenia has done work on undernutrition through
agricultural, nutritional, and health interventions. Within years,
the rate of stunting decreased notably, Hekimian pointed out.
A two-week workshop on nutrition at AUA, with the participation of
Columbia University faculty, is also in the plan, geared towards policy
makers, parliamentarians, and members of the ministries of health,
agriculture, economy, and education. The aim is to encourage a national
system-wide structural intervention for greater and long-term impact.
“There is interest among policy makers and national and international
stakeholders. I hope that translates into action,” said Hekimian.
For Hekimian, proper nutrition is a matter of national survival. “As
an Armenian, and somebody who is worried about the future of Armenia
as a whole, I really think that this is a national security issue.
There are so many factors that are leading to a diminished population:
We have out-migration for economic reasons; we have low, less than
replacement rates of fertility; we have increasing rates of premature
mortality from chronic illnesses like diabetes; and on top of that,
for the small population we have left, we have essentially a situation
where one in five children is not going to reach his/her potential.”
Armenia’s Ministry of Health’s Department of Maternal and Child
Health, UNICEF, Columbia University’s Institute of Human Nutrition,
the Fund for Armenian Relief (FAR), World Vision Armenia, and the
American University of Armenia’s College of Health Sciences are ready
to collaborate in the implementation of this long-term plan. FAR,
for instance, sent Deckelbaum to Armenia in November 2011. Next,
the team will have to secure funding for the project-and funding they
will need, as the cost of importing lab equipment will be costly.
Breastfeeding in Armenia
Today, Armenia’s Ministry of Health recommends that children up to
six months old be exclusively breastfed, because breast milk provides
all the nutrients needed by the infant, and limits exposure to illness.
However, the ADHS report shows that only 35 percent of children under
6 months are exclusively breastfed, and worse, some are also given
solid food. “Among breastfeeding children age 6 months and younger,
19 percent received complementary foods, a practice that can be
detrimental to the child’s health,” read the report.
In 1993, the dominant opinion did not support exclusive breastfeeding,
and the diets of children under the age of four months were
supplemented with other foods. “The medical school curriculum in
all Soviet countries taught physicians that mothers must complement
breastmilk with vegetable and fruit juices. There had not been a
legacy of exclusive breastfeeding in Armenia. There had not been in
the United States for a long time as well… This is not a Western
versus Soviet issue,” noted Hekimian.
In Armenia, breastfeeding children under 4 months increased to 20
percent in 1997. “There was an incredibly successful coordination of
strategic intervention for four years in Armenia, paid for by USAID and
UNICEF,” she explained. “[It included] a social marketing campaign that
involved TV, radio, brochures, and newspapers. They also paid for the
in-service retraining of all pediatricians, Ob/Gyns [obstetricians,
gynecologists], and most nurses in the field.” They also changed the
medical school curriculum on breastfeeding, and related policies at
the Ministry of Health. USAID completely halted the distribution of
infant formula as humanitarian aid. “After this campaign of four years,
infant mortality rate from diarrhea decreased significantly. Now the
rate of death of newborns from diarrhea is extremely low in Armenia,”
Hekimian said.
The popularity and availability of infant formulas peaked after the
1988 earthquake tore through Armenia. Soon after, the Ministry of
Health encouraged donations of infant formulas. Many diasporan and
international organizations responded with an influx of baby formulas.
At the time, it was not known that the formulas would precipitate a
set of different problems.
“People were scared; their country was in economic turmoil; they
didn’t have electricity; they didn’t know where their next meal was
coming from; and they had the opportunity to get free infant formula
and thought it was better for their babies. As soon as they started
giving them the formula, their breast milk dried up-because that’s
what happens in the supply-demand curve. They didn’t have enough
infant formula supply to raise their kids until the age of six months.
So they started to give teas, madzoon [yogurt], and cow milk instead,
and there were children dying from diarrhea,” explained Hekimian,
who in 1993 highlighted the negative impact of infant formula in
Armenia while teaching and researching at AUA.
Hekimian is proud of how far the country has come in 20 years. “From
1997 until 2010 there have not been national breastfeeding promotion
campaigns, and it still went up from 20 percent to 35 percent. I read
that 35 percent number in a very positive light. Compared to where we
were in 1993, it is a tremendous gain. With each percentage increase in
breastfeeding, you’ll see a corresponding decrease in the percentage
of morbidity and mortality in infants. The number of moms of children
aged 6 months who report giving any breast milk at all is close to
90 percent; in the U.S., I don’t think that’s even at 50 percent. So
what we need to do is to continue the breastfeeding behaviors and
change the supplementing behaviors,” she said, but cautioned that
exclusive breastfeeding for the first six months is not protective
of eventual stunting, as children are still at risk past that age.
During their research in the village of Tsamakapert, where a number
of children are stunted, Hekimian paid special attention to the
children’s diet. “What I realized is that these kids eat potatoes and
bread morning, noon, and night. They’ll have something like jarit,
fried potatoes with bread in the morning, and then they’ll eat some
kind of soup that has potatoes in it in the afternoon, and then puree
[mashed potatoes] at some point, or the blinchig, which is the flour
pancake that is covering the potatoes. It’s delicious food; it’s
calorically high and very filling; and it gives the short spurt of
energy. So the kids are running around and playing soccer the whole day
out on the village road, they come in and have their blinchig, puree,
hats [bread], and may be banir [cheese]-which is fine because banir
has some protein and some calcium in it, but no iron-and he runs back
out. So the mothers are not seeing that the children are malnourished,
because they’re not hungry. This is called chronic undernutrition,
not acute undernutrition.”
Micronutrient deficiencies can be detrimental to children, and may lead
to illness and death. Foods rich in vitamin A and iron are essential
to the health of children. For instance, vitamin A-found in milk,
eggs, fish, butter, carrots, etc.-supports a healthy immune system,
protects children against infections, and helps in the recovery
from illness. Iron too is essential to the development of children;
consuming low levels of it can lead to anemia. The ADHS report
showed that 75 percent of the surveyed children consumed foods rich
in vitamin A during the 24 hours preceding the survey, and 68 percent
consumed iron-rich foods, such as meat, fish, poultry, and eggs.
2010 ADHS survey findings
Over 1,400 children participated in the ADHS survey. The results showed
that 19 percent of children were stunted, and 8 percent severely
stunted. Stunting appears to be more common among children born to
mothers with less education, and is only “slightly” more prevalent in
rural households compared to urban ones. However, there is no clear
correlation between wealth and stunting.
The survey revealed that children 36-47 months old are the most likely
to be stunted (26 percent), followed by those 24-35 months old (21
percent), while 9-11 month-olds are the least likely (13 percent).
Children smaller at birth are more likely to be stunted (26 percent)
compared with larger babies (19 percent). Seven percent of babies
in Armenia are born with low birth weight. According to Hekimian and
Deckelbaum, this means that stunting most often occurs after delivery,
and therefore can be prevented. Out of the 11 regions, stunting is
lowest in Yerevan (11 percent), and highest in Syunik (36 percent),
Aragatsotn (32 percent), and Ararat (29 percent).
Four percent of children under five years old are wasted. Babies up
to 6 months old are more likely to be wasted than children age 6-59
months. Wasting is highest in the Ararat region (12 percent), followed
by Gegharkunik (7 percent), and lowest in Tavush (one percent).
Five percent of children in Armenia are underweight. Children in rural
areas are more likely to be underweight than those living in urban
areas (7 percent and 3 percent, respectively). As with stunting, the
percent of underweight children is higher in low-income households, and
with less-educated mothers. There is a correlation also with the birth
interval, where children born 48 months after a previous birth are
more likely to be underweight (8 percent), compared to children born
24-47 months apart (3 percent). The percent of underweight children
is highest in Ararat (17 percent), and lowest in Kotayk and Yerevan
(2 percent).
http://www.armenianweekly.com/2012/07/19/undernutrition-in-armenia-a-matter-of-national-security/