MACEDONIA NATIONAL N U T R I T I O N S U R V E Y

Transcription

1 Macedonia National Nutrition Survey 2011 Among women of reproductive age and children 6-59 months of age MACEDONIA NATIONAL N U T R I T I O N S U R V E Y 2011 Among women of reproductive age and children 6-59 months of age 1

2 Contents List of Tables 3 List of Figures 5 Acknowledgements 6 Executive Summary 7 Recommendations 12 Introduction 16 Policies and Programmes Directed at Nutrition in Macedonia 18 Methods 20 Objectives of the Nutrition Survey 20 Study population 20 Variable Definitions 21 Anaemia 21 Malnutrition (Undernutrition and Overnutrition) in Children 6-59 Months of Age 22 Chronic Energy Deficiency and Overnutrition in Non-Pregnant Women of Reproductive Age 23 Birth Weight 23 Perinatal Mortality and Stillbirths 24 Dietary Diversity 24 Income 24 Sampling Strategy 25 Sample Size 25 Enrolment and Recruitment Procedures 27 Households, children, and non-pregnant women 27 Data Collection 28 Team composition 28 Training 28 Ethical aspects 29 Fieldwork and data collection 29 2

3 Data entry, editing, and management 29 Quality control 29 Data analysis 29 Results 30 Households Description of Sample 30 Households Bread Consumption 34 Women Description of Sample 42 Women Dietary Diversity 47 Women Nutritional Status 50 Women Micronutrient Status 52 Children Description of Sample 54 Children Feeding Practices 59 Children Nutritional Status 64 Underweight 64 Stunting 64 Wasting and overweight 65 Children Micronutrient Status 70 Conclusions 73 References 75 Annex 1-Sample Size Calculation For Macedonia 78 Annex 2-Consent Form For Macedonia National Nutrition Survey Annex 3-Questionnaires 83 List of Tables Table 1: Data of nutrition indicators available in Macedonia Table 2: Target groups, main outcomes, and source of sample 20 Table 3: Definition of anaemia by haemoglobin concentration, for various age-specific and sex-specific groups 21 Table 4: Definition of anaemia public health significance 21 Table 5: Adjustments in cut-off defining anaemia, by smoking status 22 Table 6: Categories of chronic energy deficiency defined by Body Mass Index (BMI) 23 Table 7: Number of households and individuals from whom data are needed, for different target groups and main outcome 26 3

4 Table 8: Distribution of demographic variables for sample households 31 Table 9: Distribution of household composition for sample households 32 Table 10: Distribution of socio-economic variables 33 Table 11: Distribution (number, weighted %) of income (MKD) by region, residence and ethnicity 34 Table 12: Weighted mean average of bread consumed per household per day (in grams), 95% confidence intervals (CI) 36 Table 13: Types of bread consumed, number (weighted %) 37 Table 14: Place of bread purchased, number (weighted %) 38 Table 15: Type of flour used (purchased or self-milled) in self-baking, number (weighted %) 39 Table 16: Perceptions of fortified flour, number (weighted %) 40 Table 17: Reasons against fortified flour, number (weighted %) 41 Table 18: Description of demographic variables, non-pregnant women years of age 43 Table 19: Description of other variables, non-pregnant women years of age 44 Table 20: Description of reproductive and breastfeeding variables, nonpregnant women years of age 45 Table 21: Description of disease history and knowledge and behavioural variables, non-pregnant women years of age 46 Table 22: Description of dietary diversity, non-pregnant women years of age 47 Table 23: Weighted mean of dietary diversity score by demography, nonpregnant women years of age 49 Table 24: Number (weighted %) of malnutrition (underweight and overweight/obesity), non-pregnant women years of age 51 Table 25: Distribution of adjusted* haemoglobin (Hb) concentrations, nonpregnant women years of age 52 Table 26: Number (weighted (95% CI)) with any anaemia (after adjustment of haemoglobin concentration for smoking), non-pregnant women years 53 of age Table 27: Description of demographic variables, children 6-59 months of age 55 Table 28: Distribution of disease history and treatment variables, children 6-59 months of age 56 Table 29: Number (weighted %) with low birth weight, children 6-59 months of age 58 Table 30: Number (weighted %) ever breastfed and exclusively breastfed until 6 months of age, children 6-59 months of age 60 Table 31: Number (weighted %) breastfeeding duration, children 6-59 months of age 61 4

5 Table 32: Description of dietary diversity, children 6-59 months of age 61 Table 33: Weighted mean of dietary diversity score by demography, children 6-59 months of age 63 Table 34: Number (weighted %, CI) of malnutrition (based on WHO growth standards (16)), children 6-59 months of age 67 Table 35: Number (weighted %) of severe & moderate stunting, children 6-59 months of age 68 Table 36: Number (weighted %) of overweight & obese, children 6-59 months of age 69 Table 37: Number of children 6-59 months of age with anaemia (weighted %) 71 Table 38: Weighted distribution, 95% CI, odds ratio and P-value of any anaemia, children 6-59 months of age 72 List of Figures Figure 1: Recruitment procedures for the household survey, Macedonia Figure 2: Distribution (weighted %) of socio-economic variables by region and total 33 Figure 3: Distribution (weighted %) of dietary diversity, non-pregnant women years of age 48 Figure 4: Distribution (weighted %) of BMI, non-pregnant women years of age 50 Figure 5: Distribution (weighted %) of birth weight, children 6-59 months of age 57 Figure 6: Distribution (weighted %) of dietary diversity, children 6-59 months of age 62 Figure 7: Distribution of weight-for-age z-scores by sex, children 6-59 months of age 64 Figure 8: Distribution of height-for-age z-scores by sex, children 6-59 months of age 65 Figure 9: Distribution of weight-for-height z-scores by sex, children 6-59 months of age 66 Figure 10: Weighted distribution of haemoglobin concentrations, children 6-59 months of age 70 5

6 Acknowledgements The Institute for Public Health extends its gratitude to the UNICEF country office in Skopje for providing technical support in design, analysis and report writing of the Macedonia National Nutrition Survey 2011 for women of reproductive age and children 6 to 59 months of age. In addition, the Institute would like to commend the 10 regional centers for public health for providing field research teams to perform data collection in households. 6

7 Executive Summary The Macedonia National Nutrition Survey 2011 is a nationally representative stratified survey carried out in each of the eight administrative regions of Macedonia (Vardar, East, South West, South East, Pelagoniski, Poloski, North East, Skopje) focusing on the nutritional status of children 6-59 months of age and non-pregnant women of reproductive age (15-49 years). Nutritional status in this survey has been measured in terms of anthropometry (undernutrition and overnutrition) and anaemia status; particularly haemoglobin concentration. The objective of the survey is to give up-to-date information regarding the nutritional status of Macedonian women and children. In particular the report focuses strongly on prevalence of anaemia for the purposes of providing evidence to support efforts for flour fortification programmes in the country. It is hypothesized that Macedonia faces a public health problem due to a high prevalence of iron deficiency anaemia (IDA), one of the most significant public health problems in the world. In addition, for this purpose the report provides information on bread consumption and dietary patterns as well as investigates underlying nutritional problems throughout the country. The fieldwork was carried out over a period of five months during 2010 to Description of sample Nearly two thirds of households sampled were Macedonian and just under one third was Albanian. Minority groups were mainly Turkish, Roma and Serbian. The Roma represented 2.3% of the weighted population, which was very similar to that in the Macedonian population. More than three quarters of the population had lived for more than 10 years in their current households. The median number of household members was five. Unemployment affected nearly a fifth of households, although only 5.7% of households had no income 1. The majority of households had at least one person working and providing income from abroad, and 47.3% had a monthly income over 18,000 Macedonian denar (MKD). Over 50% of households in Skopje and the South West region had incomes in the largest income bracket. Regions in the east of Macedonia make up some of the poorest regions (East, Poloski, North East and South East). Overall, urban residents were better off than rural residents. The poorest ethnic group in the population was Roma, with 23.8% of Roma households having no income. The better off households were of Macedonian ethnicity. The percentage of women with any level of education (primary, secondary, higher) was very high at 95.6%; only 4.3% of women had no education at all. Over 60% of the sample had secondary (44.7%) or higher (16.6%) education. 1 Income groups were delineated as follows: Monthly earnings per family of >18,000 MKD considered non-poor; <18,000 MKD considered poor. The poor group is further broken down into subgroups: <13,000-18,000 MKD, <8,000-13,000 MKD, <5,000-8,000 MKD, <5,000 MKD, and no income. 7

8 Bread consumption Bread consumption in Macedonia differed depending on a number of different factors. Daily bread consumption higher than the national average (633 g) was seen in the East r (704 g) and Skopje (695 g) regions, in rural areas (831 g), and in Roma (909 g) and Albanians (852 g). Bread consumption declined steadily with increasing income, though only in the highest income bracket (>18,000 MKD) was bread consumption (537 g) below the national average. Most households in Macedonia consumed white bread (90.4%), followed by dark bread (6.1%) then wheatmeal (2.9%). The distribution of type of bread consumption was similar across all other variables with a few exceptions. The consumption of white bread over other types of bread was highest in the North East (97.6%) region and rural areas (93.3%). The lowest consumption of white bread was seen in Pelagoniski (85.9%) and Skopje (89.0%) and in Roma (88.3%) and Serbians (88.1%). Bread consumption among different income groups was similar except in the highest income group which consumed much more dark bread (4.9%) and wheatmeal (4.9%) than average consumption among lower income groups ( % for both dark bread and wheatmeal). Nearly three quarters of the population bought bread from a supermarket or shop (although very few from a bakery) while the remaining households baked their own bread at home. Households in the East region, in rural areas, and with ethnicity other than Macedonian were more likely (or just as likely in the case of ethnicity) to bake at home. Buying bread from a shop or supermarket was more common in Skopje, South West and Pelagoniski, respectively, and in Macedonian ethnic households and in higher income groups. The most popular flour used for home baking was white flour, and a small number of households used dark flour. This distribution was similar among urban/rural households and across ethnic groups, although the use of dark flour was slightly higher for Albanian and Roma households. Iron fortification of flour was deemed a [very] good idea in three quarters of the population, and just over 13% did not like the idea of fortified flour. Overall, adverse aesthetic changes (taste/smell) were cited as the main reason for dislike (especially those in the higher income brackets); a smaller number of households were concerned with higher prices (especially those in the lower income brackets). Over a fifth of households who said they did not like the idea of fortified flour were not sure why. This distribution was similar between urban/rural households although rural households were more concerned with price. Among regions the idea of fortified flour was least acceptable in South East, South West and Skopje. Households in the North East, South East and Poloski were more concerned with aesthetic change, and over 20% of households in the North East and East regions were also concerned that the flour would be more expensive. Roma households were more concerned with price and Macedonians more concerned with aesthetics. Turkish households were equally concerned about both aesthetics and price. All Serbian households were unsure why they did not want flour fortification. Reproductive history Over three quarters of women had been pregnant at least once, and a tenth had been pregnant four or more times. The majority of women had been pregnant twice in the past. Few women had had four or more live births in the past. About 1 in 10 women in the sample were breastfeeding at the time of data collection. Most women in the sample had a light to medium menstrual flow with no pre-cycle bleeds. About 10% of women experienced heavy bleeds and 5.2% experienced some pre-cycle bleeds. 8

9 Low birth weight Most children (91.5%) were born with a normal birth weight ( g). Very few children had either a high or very low birth weight (<1500 g). However, 7.5% had a low birth weight ( g), with low birth weight rates in the South West (12.5%) and Pelagoniski (12.5%) regions, well above the national average of 6% determined in 2005 (1). The prevalence of low birth weight decreased with increasing maternal education; the prevalence of low birth weight in women with no education was 9.3%. There was no difference between primary and secondary education level for prevalence of low birth weight. There were no observable patterns by income group for low birth weight. Breastfeeding Most (93.4%) children 6-59 months of age had been breastfed at some point in their lives. This was significantly higher in Vardar (96.1%), and significantly lower in Pelagoniski (87.0%). Significantly more girls (95.2%) than boys (91.5%) were ever breastfed at some point in their lives. Fewer (91.5%) children months of age were ever breastfed. There were no significant differences by urban/rural, ethnicity, mother s education or income group. Exclusive breastfeeding was low at 45%, which was below the national target set at 50% (2). Variation by region was significant: East (21.9%), North East (34.2%) and Pelagoniski (39.6%); Skopje (56.0%) and South West (64.1%). Those in the months age group (52.6%) had significantly higher rates of exclusive breastfeeding after recall. There were no differences between urban/rural or by sex. Women with no education had significantly higher rates of exclusive breastfeeding (60.8%) and breastfed for longer. Among women who had higher education, 54.9% exclusively breastfed their children. The prevalence of exclusive breastfeeding increased with increasing income group. Both exclusive breastfeeding practices and duration of breastfeeding rates are low in Macedonia. The duration of breastfeeding rates are relatively short, with less than half of children in the sample still being given breast milk after 12 months of age. More girls months of age were given breast milk than boys of the same age, but boys tended to have overall longer breastfeeding duration than girls. Roma children had the shortest duration of breastfeeding. Disease history Around 10% of women reported having a chronic disease, and about two fifths were taking medication. A small percentage (1.6%) of women had been diagnosed with anaemia in the previous week, and three quarters of these women were currently taking medication. Less than a third of the population had no idea of the causes or symptoms of anaemia, or awareness of foods rich in iron. Roughly 1 in 5 women took supplements (mainly multivitamins), a third of women smoked, and alcohol consumption was low with only 9% of women drinking any alcohol at all. Only a small proportion of children had a chronic disease and the majority of these children were taking medication. Anaemia diagnosed in the past week was relatively rare (2.3%), and of those diagnosed roughly 80% were currently taking medication for this. Previous anaemia was reported in about 1 in 5 children and about 30% of these children had had anaemia more than once previously, with 11% having had three or more episodes. 9

10 10 Dietary diversity Around 50% of women consumed between seven and eight food groups per day, with the average being 7.7. Just over 50% of the children consumed between eight or more food groups per day, with the average being 7.5. Women s dietary diversity was relatively similar for different age groups except the younger women (15-19 years of age) had a significantly lower dietary diversity score than the older women. Dietary diversity was greater in women in the North East and South West regions, rural areas, and among Serbian and Albanian ethnicities. Dietary diversity for children was similar among sexes but increased with age, as expected. Dietary diversity was greater in North East, Serbian children and urban areas, and lower in East, Poloski and Pelagoniski, and in Roma children. Dietary diversity (for both women and children) increased with increasing maternal education and over higher income groups. Anaemia The prevalence of anaemia for all women in the survey was 19.2%, compared to 15.2% in the European Region (3). Three out of eight regions had anaemia prevalence of moderate public health significance (>20%): East (24.0%), Vardar (23.9%) and Poloski (23.2%). Pelagoniski (15.4%) and Skopje (16.4%) had the lowest prevalence of anaemia. The prevalence of anaemia was highest among Albanians, among women years of age and those above 35 years of age, women who had only attended primary level education (although the prevalence of anaemia was lower for women who had had no education), and women in the lowest three income categories. The prevalence of anaemia for all children in the study was 21.8%, compared to 16.7% in the European Region (3). The prevalence of anaemia was significantly higher than the national average for children in the North East and Skopje regions, rural areas, for boys, younger children (6-23 months of age), for Roma, Albanian and Turkish ethnicities, and those with poor maternal education, poor income and poor dietary diversity. Nutritional status Very few women were either underweight or at risk of being underweight. However, the number of women who were either overweight or obese was high, and nearly half of the sample was either overweight or obese, especially in Vardar and Pelagoniski where 1 in 5 women were obese. Severe and moderate chronic energy deficiency was rare, and only a small percentage of women fell into the at risk category of chronic energy deficiency. Overweight and obesity were higher in rural women (50.3%). Roma and Serbian women had significantly higher prevalence of overweight and obesity (60%) than other groups and the national average (46.2%). The weighted prevalence of overweight and obesity increased markedly with age with over 15% of young women years of age being overweight or obese (15.7%). In the oldest age category (45-49 years) nearly 70% were either overweight or obese. Overall, the prevalence of underweight in the sample of children was 2.5%, which is about normal for the population, and is the same as reported in the MICS 2005 report (2.6%) (1). Underweight was significantly higher among boys than girls (3.5% vs. 1.5%), among children months of age, children in the East region and among Roma children (6.4%). Underweight prevalence was highest in the subgroup of children with mothers of no education. There were no observable trends in underweight status by income group, but

11 there was a significantly higher prevalence of underweight children among poor groups (no income - 18,000 MKD monthly) compared to non poor (>18,000 MKD monthly). The overall prevalence of stunting (moderate and severe) was 10.3%, which is similar to the prevalence of stunting (moderate and severe) (11.0%) reported in 2005 (1), though with significant differences between severe (4.9% vs. 2.3%) and moderate stunting (5.4% vs. 8.7%). Stunting was higher for urban children, boys, younger children (less than 35 months of age), children in Poloski, Roma children (24%), followed by Albanian children (12%). Stunting prevalence increased with lower income and lower maternal education. Children with poor dietary diversity were more severely stunted than those with better dietary diversity. The prevalence of wasting within the sample was 6.4% and for overweight was 16.4%. Both of these figures were high for Macedonia which suggests some systematic error in the data collection. Dropping suspected regions (East, South East and Poloski) reduced the overall prevalence of wasting to 3.2% and overweight to 12.2%. The prevalence of wasting determined in MICS 2005 (1) was 3.1% (moderate and severe) and overweight was 10.6%, which are comparable figures. Regardless of this, overweight is a more common problem than wasting in Macedonian children 6-59 months of age. The prevalence of overweight and obesity was not different between boys and girls and there was no observable trend with age. However, 23.7% of children months of age were overweight and this was significantly different from other age groups. Urban children were significantly more overweight and there were differences in overweight between some regional strata. The East (9.0%) and Skopje (9.1%) had the lowest prevalence of children overweight, and Poloski the highest with over 30% of children overweight. The only significant differences for overweight were observed in correlation to maternal education, and no trends were observed under other variables such as income and dietary diversity. 11

12 Recommendations Recommendations for Additional Research Related to This Survey Even though not all anaemia is caused by iron deficiency, the concentration of haemoglobin should be measured in all nutrition surveys. The prevalence of anaemia is an important health indicator, and when it is used with other measurements of iron status, the haemoglobin concentration can provide information about the severity of iron deficiency. Measurements of serum ferritin and transferrin receptor provide the best approach to measuring the iron status of populations (4). Due to limitations within this current study, it is recommended that additional research focus on detecting the direct nutrition-related (micronutrient and dietary) causes of anaemia. For this reason, complementary studies should include: More in-depth analysis to determine dietary causes of anaemia, looking at the type and the quantity of feeding patterns to understand causes and whether simple and noncostly alterations in dietary habits can enhance intake of iron through daily consumption. In addition, the cost of (iron-rich) dietary change should be considered to better understand the financial burden to households; In-depth studies to assess IDA and deficiency of other micronutrients related to anaemia, such as B 12 and folic acid. If performed at the household level (methodologically the most justified approach), such studies require significant human and financial resources, and special consideration should be paid to standardize the laboratory equipment for analysis and the type of blood tests that would be performed. Alternative and much more affordable sources of information could be obtained through health facility-based surveys conducted either through regular or targeted health checkups of (pregnant) women and children under five years of age; Further investigation of reasons for disparities in key mother and child nutrition indicators, such as high prevalence of anaemia in Roma, Albanian and Turkish children, and the high prevalence of anaemia among Albanian women of reproductive age. This should include a combination of the aforementioned studies. Recommendations to Prevent Anaemia and Malnutrition Among Children Under Five Years of Age 12 At community level Improving the quality of infant and young child feeding practices to reduce stunting and iron deficiency anaemia, and ensuring a significant effect on child development. Namely, while only 45% of infants are exclusively breastfed, which is significantly higher than that found in 2005 (16%) (1) and still with significant disparities in geographical regions, it is important to further maintain and increase this percentage to meet the 50% target set by the Food and Nutrition Action Plan (2). Improvement in infant feeding practices beyond six months of age is also required. The percentage of infants who are breastfed

13 beyond six months and up to 12 months of age is very low (29.3%) and remains low (37%) up to 24 months of age. According to WHO standards, exclusive breastfeeding up to six months of age and gradual introduction of healthy and adequate complementary food in combination with continuous breastfeeding up to the age of two years is recommended (5) to help reduce the short-term and long-term burden of diseases. More efforts should be taken to promote best practices of infant and young child feeding, with a focus among the Roma community. Stunting continues to be an issue of high concern: in this survey the prevalence of stunting was 10.3%, as compared to 11% in the MICS 2005 report. Stunting is particularly widespread among the Roma community, which is also a trend previously shown (1). Stunting is an indication of chronic restriction of a child s growth resulting in shortness or low height-for-age compared to a standard population. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period. Specific interventions at community level (in context of previous interventions in the country) should include: Re-establish and scale up of previously existing community-based infant and young child feeding counseling services, (mainly implemented through community non-government organization, including peer mother-to-mother support groups) at the community level, and capacity development of community workers such as community nurses, especially among Roma and other poor communities; Implementation of wider community communication programmes for behavioural and social change with regard to feeding practices, including how to improve the quality and diversity of complementary foods through locally available ingredients, as well as proposing simple alteration of daily feeding practices. Newly available guidelines provided by WHO and UNICEF should be adapted and applied to the local context; Provide nutrition supplements and foods for complementary feeding (when necessary). Promote micronutrient supplementation or fortification at point-of-use (home fortification) in cases where the analysis of available foods shows that while the energy and protein density of foods are adequate (or can be enhanced through better use of locally available foods), the requirements for certain micronutrients cannot be met with locally available foods. It is well documented that if iron supplementation programmes are implemented at 95% geographic coverage, they would avert approximately 12,500 disability adjusted life years (DALY) annually in the European Region where very low rates of adult and child mortality already exist (6). In this respect, iron supplementation programmes are more effective as an intervention than iron fortification programmes, which on the other hand are more cost-effective and require less logistics (6) than iron supplementation programmes. At health system level Establish a national nutrition surveillance system through the National Institute for Public Health in order to define key indicators of infant and young child feeding to be continuously monitored and evaluated, and to understand reasons for certain feeding patterns through conduct analysis of: Quantitative data on infant and young child feeding practices. Primary data includes core indicators of infant and young child feeding (rates of initiation of breastfeeding, exclusive breastfeeding among children less than 6 months of age, continued breastfeeding among children months of age, and data on complementary feeding (timely introduction, frequency, and diversity); 13

14 Qualitative data on infant and young child feeding behaviours and practices, cultural barriers, social norms etc. It is also necessary to gather information on traditional practices related to infant and young child feeding and other data that will affect the design of the communication and education strategy; Secondary data relevant to infant and young child feeding may include household expenditure surveys, living standards measurement surveys, and food and agriculture assessments, which are usually and regularly done through the State Statistical Office, for triangulation purposes. Integrate infant and young child feeding counseling at health service delivery points by: Updating integrated curriculum on infant and young child feeding practices for health providers into pre-service and in-service education; Establishment of counseling on infant and young child feeding practices and other support services at relevant maternal and child health contacts in primary health care facilities (e.g. community nursing system and immunization health providers); Capacity development (continuous medical education programme) in infant and young child feeding and maternal nutrition during pregnancy and lactation for health providers; Institutionalization of the Ten Steps to Successful Breastfeeding in all maternities, in a form of criteria for accreditation of maternity hospitals as baby-friendly hospitals; Ensure full implementation of the Food And Nutrition Action Plan ( ) (2), through enforcement of two specific action points pertinent to optimal nutrition of pregnant women and infant feeding practices. Recommendations to Control and Prevent Anaemia Among Women of Reproductive Age At community level Improve knowledge on symptoms and causes of anaemia as well as foods rich in iron (bioavailable) and dietary inhibitors of iron (phytates and polyphenols). Less than one third of the population was unaware of the causes (28.5%) or symptoms (25.2%) of anaemia, or of foods rich in iron (18.5%). Improve dietary diversity practices with effective and simple alterations in meal patterns to ensure the prevention of overweight or obesity (which affected nearly 50% of all women in the survey), to provide the maximum uptake of iron, along with iron and folate supplementation programmes (see below under health system response). Programmes should especially target teenagers (high school students years of age) who had the lowest score in dietary diversity, and the poorest population groups and geographical regions with the highest prevalence of anaemia. Implement smoking cessation programmes, especially among pregnant women of which almost one third are smokers and of which 70% smoke one to two packs of cigarettes a day as smoking can further aggravate the symptoms of anemia. Encourage appropriate health-seeking practices during antenatal care. On average, pregnant women receive 2.8 mandatory health checkups during antenatal care while 14

15 WHO recommends minimum of four health checkups during the course of pregnancy (7). Content and quality of antenatal care practices should be improved in line with recently endorsed clinical practice protocols on antenatal care (8). Further, utilization rates of antenatal services in the first three months of pregnancy are only 41%. This period is very important for detecting risk factors for anaemia, and consequently providing care for its prevention or treatment (9). This recommendation is in line with the high perinatal mortality rate (16.4 per 1000; 60% of which is due to stillbirths), one of the highest in the European region. At health system level Improve access to quality antenatal practices. The number of community health nurses is unequally distributed throughout the country, leaving rural areas especially underserved (10). Coverage of pregnant women by community nurses is about 50%. Counseling and support on maternal nutrition during pregnancy and lactation, and supplementation should be enhanced through outreach community health work. Agree on national screening standards for anaemia, especially for detecting iron deficiency anaemia, and making sure screening is also mandatory and free of charge for pregnant women. Establish a national nutrition surveillance system. Define basic nutrition indicators and ensure regular follow-up through household surveys, health facility-based surveys and sentinel surveys among groups of interest. Ensure iron and folate supplementation programmes are available free of charge for pregnant women and women of reproductive age. This should be considered as advocacy work with the Health Insurance Fund if the basic benefit package prevents or poses a co-payment policy for the administration of iron and folate supplements to pregnant women. Consider a national food fortification programme. Anaemia is associated with iron deficiency; therefore dietary interventions through supplementation of high-risk groups and fortification of food at the national level (such as fortification of flour and other cereals) are suggested. Wheat flour is the main flour consumed (either as bread or as flour to make bread), which provides an accessible vehicle for iron fortification, especially for older children and women. Perceptions of fortification within the population are fairly positive. 15

16 Introduction Anaemia is one of the most prevailing public health problems in the world, resulting in serious consequences for individual and national development, and has been named as one of the top 10 risk factors contributing to the global burden of disease (11). Iron deficiency anaemia (IDA) represents at least 50% of all anaemias, resulting in poor health, early death and loss of earnings through reduced cognitive and physical productivity. Evidence suggests that worldwide, $50 billion in GDP is lost annually from IDA (11) The prevalence of anaemia in the European Region is as follows: 16.7% among preschool-age children, 18.7% among pregnant women and 15.2% among women of reproductive age (3). Anaemia is defined as a low level of haemoglobin in red blood cells, and manifests with symptoms of paleness and fatigue. The most common cause of anaemia is low absorption of iron from food. While breastfeeding can provide adequate iron for the first six months of life, depending on breastfeeding practices, most foods for complementary feeding are low in iron unless fortified. Other causes for anaemia include helminth infections (hookworm, schistosomiasis), malaria, infections such as HIV/AIDS, tuberculosis and diarrhoea that increase requirements for iron, nutritional deficiencies (other than iron deficiency) such as deficiencies in folic acid and vitamins A and B 12, genetic conditions (e.g. thalassaemia in parts of the Mediterranean; sickle cell anaemia in Africa), and reproductive factors such as high fertility rates, obstetric complications or practices that increase blood loss such as not breastfeeding. Those most at risk of anaemia in a population include infants and young children, teenagers and women. While protected somewhat through breastfeeding, the iron requirement for growth and development is high for infants and young children. The iron that full-term infants have stored in their bodies is used up in the first 4-6 months of life. Premature and low-birth-weight babies are at even greater risk for IDA as they have lower amounts of stored iron. Adequate complementary feeding is therefore necessary to prevent IDA. Teenagers are at risk of IDA if they are underweight, for example from exclusion diets, or have a chronic disease. Women of reproductive age (15-49 years) are at higher risk of IDA due to blood loss from their menstrual cycle. About one in five fertile women have IDA (4). IDA is even more common among pregnant women because of the increased requirement of iron to increase blood volume for the growth of the fetus. IDA can increase a pregnant woman s risk for a premature or low-birth-weight baby. For pregnant women, anaemia contributes to 20% of all maternal deaths (11, 12). Interventions to treat anaemia should aim to address the major defining causes and may involve supplementation with iron tablets, fortification of staple foods, better dietary diversification and dietary practices, deworming and treatment of malaria. Diet is an important factor for IDA, as some eating patterns or habits may result in a higher risk for developing IDA. This includes vegetarian diets (unless particular attention is paid to non-haem iron sources), high fibre diets (fibre can inhibit the absorption of iron), low fat diets (fat is needed for iron absorption), diets where there is high tea and coffee consumption but without vitamin C intake, or a generally poor diet due to health, poverty, social problems, etc. 16

17 Causes of Anaemia in Macedonia Large nationwide nutrition surveys in Macedonia are limited (Table 1) and usually involve Multi-Indicator Cluster Surveys (MICS) which are carried out every five years. There have been two MICS surveys in Macedonia so far, in 1999 and 2005, with the next one planned for While the 2005 MICS survey only reported anthropometric data (1), the 1999 MICS survey had a micronutrient component (13). In Table 1 the results of the MICS 1999 survey showed that children less than five years of age were at the highest risk of anaemia with an estimated prevalence of (mild, moderate and severe) anaemia at 26% (13). Other risk groups for anaemia included pregnant women (18%) and children under 14 years of age (20%). For older women (>65 years) the prevalence of anaemia was 12.6% (14). It was also estimated that 90% of anaemia in Macedonia is due to iron deficiency through poor diet and feeding practices since the occurrence of other causes of anaemia (e.g. helminth infestations and malaria) over the past 50 years has been low (15). This assumption has to be further verified by a targeted study for detecting IDA. The last MICS survey was carried out in 2005 (1). While there was anthropometric data on children 6-59 months of age, there was no data collected on haemoglobin or iron intake or on maternal nutritional status. However, the nutritional status of children 6-59 months of age was measured. The prevalence of underweight and wasting were both similar to the WHO Growth Standards (16). The prevalence of stunting was at 8.7%, although considered low (17), was still above the 2.3% WHO Growth Standard level. A recent study on the anthropometric characteristics of school-age Roma children (18) shows that Roma children compared to their non-roma peers were at higher risk of being underweight and stunted. There were significant differences in weight-for-age, height-for-age and BMI-for-age indexes between Roma and non-roma children attending the first grade of primary school (P <0.05 in the intervals of -2SD and <-1SD; -1SD and the median for all of the three indexes). However, those differences were diminished in 5 th grade children, i.e. Roma children, as they grow and reach the anthropometric parameters of their non-roma peers (18). Overnutrition may be considered an emerging problem in Macedonia, as roughly 1 in 10 children are currently considered to be overweight. Over 60% of women are overweight in Macedonia, and one quarter of them are obese (24.3%) (19). 17

18 Table 1: Data of nutrition indicators available in Macedonia Indicator MICS MICS IPH facility based 1999 (13) 2005 (1) 2004 (20) Children 6-59 months of age Children 4-5yr Underweight (severe, moderate) 6.0% 2.6% 1.0% Wasted (severe, moderate) 3.6% 3.1% 2.4% Stunted (severe, moderate) 6.9% 11% 1.2% Overweight 4.9% 10.6% 7.9% Anaemia in Children - all 25.7% N/A N/A Mild 1.0% N/A N/A Moderate 10.1% N/A N/A Severe 14.6% N/A N/A Low birth weight 6.4% 6.4% N/A Non-pregnant women years of age (BMI) Underweight < % N/A N/A Overweight > % N/A N/A Obese > % N/A N/A Anaemia Women years of age Total 12.2% N/A N/A Mild 10.1% N/A N/A Moderate 2.1% N/A N/A Existing data suggests relatively high levels of anaemia in the Macedonian population and very high levels of overnutrition in women years of age; with 1 in 10 children already overweight by the time they are five. This Macedonian nutrition survey aims to provide up-to-date estimates of a number of indicators of nutrition and feeding practices, some of which have not adequately been measured, especially in different at-risk subgroups. Data on nutritional status is particularly limited in Macedonia, and this survey aimed to provide a source of data for which to measure new and existing indicators in ongoing nutrition programmes as well as help fill the information gap and provide necessary input for stakeholders to make evidence-based policy decisions. Policies and Programmes Directed at Nutrition in Macedonia 18 The Food and Nutrition Action Plan ( ) (2) is an overarching policy document in the country pertinent to nutrition which stipulates the following goals to be accomplished: Reduce the prevalence of food-related non-infectious diseases; Reduce the trend of obesity in children and adolescents; Reduce the prevalence of diseases due to micronutrients deficiencies; Reduce the incidence of food-related diseases. The specific objectives for nutrition, food safety and a safe food supply should be established in order to enable the realization of the established goals. The objectives, which are

19 related to the other determinants for health, such as physical activity, alcohol consumption, safe drinking water etc., are all listed in the above stated strategic document. In order to accomplish these health objectives, the recommendations for basic nutrition need to be harmonized with the following WHO and FAO recommendations (2): Saturated fat must be present with less than 1% of the total daily energy values (DEV); Trans-fatty acids present with less than 1% of the total DEV; Monosaccharide with less than 10% DEV; 500 grams fruits and vegetables daily; Less than 5 grams salt per day; At least 50% of infants should be exclusively breastfed in the first six months of life, and continuously breastfed up to at least 12 months of age. Adequate feeding practices for pregnant women and infants are recognized through the following specific actions: Promotion of optimal nutrition of the fetus by providing proper nutrition to future mothers, counseling about proper nutrition for pregnant women, introducing the support for proper nutrition for groups with low socio-economic status, introduction of micronutrient supplements in the diet; Protection, promotion and support for breastfeeding and gradual introduction of adequate complementary food for infants and small children though renewal of the existing recommendations, harmonization with the overall criteria for baby-friendly hospitals, implementation of the international code for marketing breast milk substitutes. Subsequent promotion of relevant WHO resolutions enabling adequate maternity leave, breaks for breastfeeding and flexibility to support the woman during lactation and early childhood so that exclusive breastfeeding can be enabled during the first six months of life. Taking initiatives to provide adequate complementary food, sufficient use of micronutrients and proper care for the nutrition of infants and small children, especially those who live in specific conditions (e.g. orphans, refugees and displaced children). 19

20 Methods Objectives of the Nutrition Survey 1. To identify levels of anaemia among women of reproductive age (15-49 years) and of children 6-59 months. 2. To evaluate feeding patterns among infants and young children 6 to 59 months of age. 3. To conduct anthropometric measurements among children 6-59 months of age. 4. To evaluate dietary habits among women years of age. Study population The sampling frame for the survey included the whole country. The survey was stratified by region and a separate survey was carried out for each region. The target groups for data collection (main outcomes) are shown in Table 2. Table 2: Target groups, main outcomes, and source of sample Target group Outcome measured Source of sample Households Children 6-59 months of age Non-pregnant women years of age Bread consumption patterns Prevalence of anaemia Prevalence of malnutrition (underweight, stunting, wasting) Prevalence of overweight Prevalence of anaemia Prevalence of chronic energy deficiency Prevalence of overweight and obesity Household sample of population Household sample of population Household sample of population 20

21 Variable Definitions Anaemia Haemoglobin concentrations were measured in blood obtained by finger-stick using a portable haemoglobinometer made by HemoCue Hb301. The basic cut-off points for haemoglobin concentration used to define anaemia were as follows (Table 3): Table 3: Definition of anaemia by haemoglobin concentration, for various age-specific and sex-specific groups Age / sex group Children 6-59 months of age None Mild Moderate Severe Non-pregnant girls and women >13 years of age Haemoglobin concentration (g/dl) 11.0 < <7.0 <12.0 Source: (21) The level of public health significance of anaemia is defined as the following (Table 4): Table 4: Definition of anaemia public health significance Source: (21) Proportion of anaemia in population (%) Severe Moderate Mild Normal Public health significance The cut-off defining normal haemoglobin concentration was also adjusted for smoking (Table 5): 21

22 Table 5: Adjustments in cut-off defining anaemia, by smoking status Cigarettes smoked per day <10 per day No adjustment per day per day per day Smoker but number of cigarettes per day unknown Source: (22) Increase in cut-off point defining anaemia (g/dl) Malnutrition (Undernutrition and Overnutrition) in Children 6-59 Months of Age Undernutrition Undernutrition (stunting, wasting and underweight) in children 6-59 months of age was defined using the WHO Child Growth Standards (16). Chronic malnutrition, also known as stunting, is an indication of chronic restriction of a child s growth resulting in shortness or low height (or length)-for-age compared to a standard population. Stunting reflects the cumulative effects of inadequate food intake and poor health conditions that are associated with endemic poverty. Acute malnutrition, also known as wasting, is often considered an indicator of current or recent food shortage and/or disease occurrence resulting in thinness or low weight-forheight compared to a standard population. Underweight is a composite indicator that reflects both stunting and wasting and is measured as low weight-for-age compared to a standard population. For this reason the term underweight is often difficult to interpret, although it often reflects stunting prevalence in populations where wasting levels are low. Anthropometric indicators were measured in z-scores, which equate to standard deviations from the median of a reference population (16). Children with a weight-for-height z-score less than 2 are termed wasted, those with a height-for-age z-score less than 2 are termed stunted and those with a weight-for-age z-score less than 2 are termed underweight. Children less than 24 months of age were measured lying down to determine length. Moderate stunting was defined as a z-score less than -2.0 but greater than -3.0; severe stunting was defined as z-score less than All z-scores were calculated using the Emergency Nutrition Assessment (ENA) software for Standardized Monitoring and Assessment of Relief and Transitions (SMART) (23) before being imported into the main data set. 22

23 Overnutrition Overnutrition in children was also defined using z-scores calculated using the WHO Child Growth Standards (16) and represents fatness or high weight-for-height compared to a reference population. Any overnutrition was defined as a weight-for-height z-score greater than Overweight was defined as weight-for-height z-score greater than +2.0 but less than Obesity was defined as a weight-for-height z-score greater than Chronic Energy Deficiency and Overnutrition in Non-Pregnant Women of Reproductive Age Chronic energy deficiency and overnutrition in non-pregnant women of reproductive age was assessed using the Body Mass Index (BMI), which is calculated by weight in kilograms divided by height in meters squared (kg/m 2 ). BMI is a simple but objective anthropometric indicator of nutritional status of an adult population, and is closely related to their food consumption levels. Chronic energy deficiency is defined as a steady state where energy intake equals energy expenditure in individuals with already reduced body weight and low body energy stores. The consequences of poor nutritional status and inadequate nutritional intake for women during pregnancy not only directly affect women s health status, but may also have a negative impact on birth weight and early development. A malnourished woman has a higher risk for having a low-birth-weight infant, fetal growth problems, perinatal mortality and other pregnancy complications. Obesity is a risk factor for many chronic illnesses, particularly heart disease and diabetes. Although a variety of factors contribute to obesity, physical activity and dietary practices can help prevent obesity. The most common cut-off points for BMI to define levels of these conditions in non-pregnant women and men are shown in Table 6. Table 6: Categories of chronic energy deficiency defined by Body Mass Index (BMI) BMI (kg/m 2) Category of malnutrition <16.0 Severe Moderate At risk Normal Overweight >30 Obese Source: (24) Birth Weight Low birth weight is a major determinant of mortality, morbidity and disability in infancy and childhood and also has a long-term impact on health outcomes in adult life. Low birth weight is defined as a birth weight of <2500 g. Very low birth weight is defined as being <1500 g, and high birth weight is defined as >4500 g (25). 23