ADB NUTRITION AND DEVELOPMENT SERIES No. 8
Satisfying Hidden Hunger
Addressing Micronutrient Deficiencies in Central Asia
Satisfying Hidden Hunger
Addressing Micronutrient Deficiencies in Central Asia
 Asian Development Bank 2010. All rights reserved. Published 2010. Printed in the Philippines. ISBN 978-92-9092-008-3 Publication Stock No. RPT101339 Cataloging-in-Publication Data Satisfying hidden hunger: Addressing Micronutrient Deciencies in Central Asia. Mandaluyong City, Philippines: Asian Development Bank, 2010. 1. Food. 2. Health. 3. Nutrition. 4. Central Asia. I. Asian Development Bank.
The views expressed in this publication are those of the contributors and do not necessarily reect the views and policies of ADB or its Board of Governors or the governments they represent. ADB does not guarantee the accuracy of data included in this paper and accepts no responsibility for any consequences of their use. By making any designation of or reference to a particular territory or geographic area, or by using the term "country" in this document, ADB does not intend to make any judgments as to the legal or other status of any territory or area. Note: In this report, "$" refers to US dollars.
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THE ADB NUTRITION AND DEVELOPMENT SERIES The ADB Nutrition and Development Series began in 2001 and covers the impact of malnutrition on poverty and depressed human and economic development in Asia and the Pacic. The series stresses three themes: targeting nutrition improvements at poor women and children, with benets to families, communities, and nations throughout the life cycle; reviewing and applying scientic evidence about nutrition impact for policies, programs, and development assistance that will raise the quality of human resources; and creating opportunities for public, private, and civil sector partnerships that can raise the dietary quality of the poor and enhance the learning and future earning capability of poor children. The series is intended for ADB member countries, development partners, and scholars interested in applying science and technology to investment decisions.
Contents
Foreword Xianbin Yao, Director General, Regional Sustainable Development Department, Asian Development Bank Nevin S. Scrimshaw, Institute Professor Emeritus, Massachussetts Institute of Technology; President, International Nutrition Foundation; Visiting Professor, Tufts University Acknowledgments Abbreviations Executive Summary 1. Background Central Asia's Micronutrient Deciencies ADB's Involvement with Food Fortication 2. The Regional Fortication Initiative Objectives and Strategies Scope of the Initiative Alliance Building Implementation Arrangements Achievements of the Initiative Fortication Private Sector Investment Legal and Regulatory Framework Advocacy, Communication, and Mobilization Capacity Development 3. Development Impact Reduced Prevalence of Iodine Deciency and Iron Deciency 4. Development Issues, Lessons Learned, and Conclusion Development Issues Lessons Conclusion Next Steps Appendixes 1. History of Food Fortication in Central Asia and Mongolia before the Initiative 2. Almaty Declaration, 2001 3. Regional Workshops under the Initiative 4. Performance Indicators of the Japan Fund for Poverty Reduction Projects 5. Legislation and Regulations on Food Fortication in Central Asian Countries 6. Declaration of the Third Almaty Forum, 2007
v vii ix xii xiii 1 1 3 5 5 6 8 9 9 9 16 16 18 19 23 23 29 29 32 34 35
37 44 47 48 49 57
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Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
Tables 1.1: 1.2: 2.1: 2.2: 3.1: 3.2: 3.3: Prevalence of Goiter among Children in Central Asia and Mongolia Anemia Prevalence in Central Asia and Mongolia Physical Inputs for Salt Iodization in the First Japan Fund for Poverty Reduction Project, by Country Ingredients of KAP Komplex 1 Estimated Impact of Iodization on Iodine Deciency Disorders Prevention Urinary Iodine Measurements in Children 2–15 Years of Age and Women 15–49 Years of Age, by Country Anemia, Ferritin, and Folic Acid Measurements in Children and Women, by Country 1 2 7 12 23 25 27
A1.1: Summary of National Iodine and Iodine Deciency Disorders Elimination Policy and Program Status, 2000 A1.2: Wheat Production and Flour Consumption in Central Asia and Mongolia
40 42
Figures 2.2: Annual Iodized Salt Production as Percentage of Annual Salt Consumption in Central Asia and Mongolia, 2003–2007 2.3: Percentage of Households Using Iodized Salt in Central Asia and Mongolia in 1995–2006 Compared to World Averages 2.4: Annual Fortied Wheat Flour Production as Percentage of Annual Wheat Flour Consumption in Central Asia and Mongolia, 2003–2007 2.5: Number of Participating Flour Mills in Central Asia and Mongolia, 2003–2007 2.6: Pan American Health Organization Guidelines on Quality Assurance and Control for Food Fortication. 2.7: Share of Grant and Private Industry Costs of Iodized Salt Production in Central Asia and Mongolia in 2001–2007 2.8: Numbers of Salt Engineers and Laboratory Technicians Trained in Central Asia and Mongolia, 2003–2007 2.9: Numbers of Flour Mill Engineers and Laboratory Technicians Trained in Central Asia and Mongolia, 2003–2007 2.10: Numbers of Staff of Control Agencies Trained in Central Asia and Mongolia in 2003–2007 3.1: Number of Newborns Protected Each Year against the Risk of Brain Damage from Iodine Deciency, 2000–2006 Boxes 2.1: 2.2: Kazakhstan's Successful Iodine Deciency Disorders Awareness Campaign Opposition to Mandatory Flour Fortication 19 20
10 10 12 13 14 16 21 21 22 24
Foreword
Malnutrition and micronutrient deciencies are causes and a consequence of poverty. The consequences of chronic malnutrition and micronutrient deciencies, beginning with women and their young children, are intergenerational and account for a large proportion of child and maternal deaths, mental disability, and less productivity of the workforce. The Asian Development Bank (ADB), in partnership with the United Nations Children's Fund (UNICEF) and the International Food Policy Research Institute, conducted a comprehensive assessment of nutrition in Asia in the last decade. It determined that food fortication is one of the most cost-effective strategies that can lift the tremendous human and economic burden of micronutrient deciencies and malnutrition in Asia. The beginning of ADB's active involvement in nutrition in 1999 led to a series of studies and a landmark conference, Strategies to Fortify Essential Foods in Asia and the Pacic (Manila Forum 2000), the reports of which were published by ADB in its Nutrition and Development Series. The studies led to projects in Central Asia and Mongolia, Indonesia, Nepal, and Viet Nam. During 2001–2007, ADB led an initiative in Central Asia and Mongolia, described in this report, to address the growing and urgent problem of disease occurrence due to micronutrient deciencies in the region. The initiative consisted of two sequential projects: the rst, a pilot intervention to fortify two staple foods, salt and wheat our; and the second, a series of activities to broaden and institutionalize mandatory fortication of these foods across the region. Food fortication, as a means to deliver essential nutrients to the poor and vulnerable, also deserves renewed attention as ADB seeks to strengthen its assistance in achieving food security in the region. We hope this monograph on the results of the 7-year-long initiative presents evidence that food fortication indeed works, and that collective efforts by the government, the private sector, and civil society can mitigate debilitating micronutrient deciencies in a relatively short period. The monograph also shares the challenges in and lessons learned from expanding food fortication, in the hope of beneting ongoing and future food fortication projects in whatever small way it can.
Xianbin Yao Director General Regional Sustainable Development Department Asian Development Bank
Foreword
In temperate zones of industrialized countries, soil, water, and food tend to be decient in iodine, and populations are frequently decient in this essential mineral. Iodine deciency during pregnancy lowers the distribution of IQ scores of offspring. Iron deciency is common in low-income populations, mainly because iron is poorly available in the predominantly cereal diet they can afford. Pregnant women and young children are those most vulnerable to iron deciency. Infants of iron-decient mothers have lower iron stores at birth and are at greater risk of developing iron deciency anemia and impaired cognition. Folic acid deciency in early pregnancy increases the occurrence of congenital defects of the spinal cord. In any country, people who do not consume a diet providing sufcient available dietary iron and essential B vitamins suffer serious health consequences from deciencies of these nutrients. Most industrialized and many developing countries rely on salt fortied with iodine, and cereal ours to which thiamine, riboavin, niacin, and iron have been added. The former Soviet Union's centralized health system provided these measures for its citizens, but with its breakup in 1991, these vital measures were discontinued in most of the newly independent countries. When iodization of salt stopped, iodine deciency and goiter returned. Poor economic conditions and deteriorating health services led to an increase in iron deciency anemia and low vitamin intakes in some sectors of the population. This was the situation in the ve countries of Central Asia plus Mongolia in 2001 when Joseph Hunt, then senior health and nutrition economist at the Asian Development Bank (ADB), initiated the ADB project nanced by a grant from the Japanese Fund for Poverty Reduction. Initially planned for the iodization of salt, the project was expanded to include the micronutrient fortication of wheat our. The United Nations Children's Fund (UNICEF) became a partner, and Rie Hiraoka assumed responsibility for the project. She deserves great credit for its success. The strong support and regional inuence of Toregeldy Sharmanov, director of the Kazakhstan Academy of Nutrition in Almaty, was critically important. The project proceeded at different paces in the various countries. Given the obstacles, it could not be expected to achieve its goals in all of them, even when the project was extended from 3 to 7 years, including a follow-on project. However, it did convince governments and industry in the target countries of the health importance of the project, and secured their commitment to it. It did ensure that the necessary laws and regulations were in place in each country, and that the producers understood the technology and standards for the fortication of salt and wheat our. The number of households using iodized salt dramatically increased during the project, and has been maintained. At the end of the project, it was not possible to conduct representative national surveys to determine changes in the iodine, iron, and folic acid status in the populations of each participating country. This information will eventually be obtained as part of future national nutrition surveys. Some quantitative data on the effectiveness of the program were obtained through "sentinel sites," an approach adapted from one used for detecting the spread of infectious diseases. At the beginning of the project, a site was selected in each country where, for logistical reasons, early success would predict whether the program was to be effective nationally. A randomized population sample from each site was studied for nutritional status at the beginning of the project, and twice more. In the third round of surveys of the sentinel populations in 2007, signicant increases were observed in the average levels of blood hemoglobin, serum ferritin, folic acid, and urinary iodine. Corresponding decreases in the prevalence of anemia were found. It could be concluded that salt and wheat our fortication as a result of the project resulted in a signicant improvement in the micronutrient status of sentinel
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Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
households in participating countries. Some of the data and a reference to the published report of the sentinel studies are given in this document. To introduce micronutrient fortication into a country, it is essential to enlist the cooperation of both government and industry from the beginning, and this was done. Depending on a country's circumstances, this process can be rapid or discouragingly slow. Constant technical supervision and periodic meetings of all national personnel and consultants involved in the program were important to the project's success. Shamil Tazhibayev of the Kazakh Academy of Nutrition (KAN) was responsible for the high quality of the laboratory results and was outstanding in his management of the sentinel studies. Mussa Aijanov of KAN made an important contribution to developing the standard our fortication formula and obtaining its acceptance by all the participating countries. Although the ADB project has ended, there is every reason to believe that progress will continue in the countries that participated. Certainly, all the personnel involved in this initiative at both the country and international levels can be proud of what was accomplished.
Nevin S. Scrimshaw, PhD, MD, MPH Institute Professor Emeritus, Massachusetts Institute of Technology President, International Nutrition Foundation Visiting Professor, Tufts University
Acknowledgments
The initiative is heavily indebted to a wide range of people and organizations. First, dedicated country project and regional coordination team members; government ofcials, especially ofcials of health ministries; food producers and nongovernment organizations of the project countries; professors of the Kazakh Academy of Nutrition; international advisors Nevin Scrimshaw, Peter Ranum, Frits van der Haar, and Gary Gleason; and colleagues of other development agencies, especially the United Nations Children's Fund (UNICEF). Second, many ADB staff members contributed to the projects. The project would not have been born without Joseph Hunt, former Asian Development Bank (ADB) project ofcer, who managed to persuade ADB management and decision makers in the six countries to implement food fortication in the region. The project would not have stayed on the agenda of governments without the support of country directors and national ofcers of ADB resident missions in Central Asia and Mongolia, and sector directors. Project implementation beneted greatly from the tireless project analysts who simultaneously dealt with the requests coming from six country ofces. Rustam Muzafarov, the regional coordinator based in Almaty, monitored implementation in six countries, and coordinated the efforts of a large number of food producers, development agencies, and suppliers. We would like to list the names of other key people to be especially acknowledged, although hundreds of people in the participating countries contributed to the projects. Regional Coordination and Administration Ofce Maksat Kystaubaev, nancial analyst Natalya Mainster, ofce manager Azerbaijan Azerbaijan Research Institute of State Standards Committee (and Rauf Ismailov, director) Krystal Salt Company (and Humbat Kerimov, director) Babaturk Company (and Toc Aliev, chair of the board) Kazakhstan Nailya Karsybekova, country project coordinator Kazakh Academy of Nutrition (and Toregeldy Sharmanov, president; Shamil Tazhibayev,vice-president; and Igor Tsoi, vice-president) League of Grain Processors and Bakers of Kazakhstan (and Evgeny Gahn, chair) National Commission on Family Affairs and Gender Issues (and Aitkul Samakova, chair) Confederation of the Non-Governmental Organizations of Kazakhstan (and Valentina Sivryukova, president)
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Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
Kyrgyz Republic Artur Buiuklyanov, country project coordinator Association of Fortied Foods and Bakery of the Kyrgyz Republic (and Alexander Shefner, president) Kyrgyz Association of Salt Producers (and Sarpek Eshaliev, president) Swiss Red Cross Mongolia Begi Byambatogtokh, country project coordinator Grain Processing Association of Mongolia (and Batmend Rentsen, president) Salt Producers Association of Mongolia (and Ts. Bat-Erdene, president) National Federation of Mongolian Consumers' Association (and D. Togtokhbayar, executive director) Mongolian Women's Federation (and J. Erdenchimeg, president) Tajikistan Abdusalom Vokhidov, country project coordinator Association of Flour Millers and Salt Producers of Tajikistan (and Urunboi Issokov, president) National Committee on Women Affairs NGO Social Partnership for Development (and Ziyoda Davlyatbekova, chair) Uzbekistan Amankul Baikulov, country project coordinator National Joint Stock Company Uzdonmakhsulot (and Alisher Ishmetov, vice-president) Don Mahsulotlari (Scientic Production Center) (and Dilorom Gafurova, director) National Youth Organization Kamalot (and Tuhtasin Arslanov, director of youth programs) National Research Institute of Endocrinology (and Said Ismailov, director) National Institute of Hematology (and Dilorom Suleimanova, head, Laboratory for Anemia Diseases) During almost 7 years of project design and implementation, ADB country directors and social sector directors, and national ofcers and supporting staff both in resident missions and sector divisions, extended support through advocacy with the governments and helping the country project ofces. We are sure that the participating countries will join us in thanking the Government of Japan for nancing the projects through the Japan Fund for Poverty Reduction (JFPR). The JFPR project for Improving Nutrition of Poor Mothers and Children in Asian Countries in Transition was close to $7 million in size, which was not only more than the norm for JFPR projects in size but project implementation was also more complex. Approval for the JFPR project was gained with the help of Mr. Narita, then coordinator for JFPR funds in ADB; and approval for the JFPR project for Sustainable Food Fortication owed much to the support of the ofce of the Japanese executive director, and Mr. Araki, then JFPR coordinator. This report acknowledges and draws heavily on the documents below from the food fortication initiative, and cannot fully reect the richness of each report. Thus, we encourage interested readers to visit these documents for detailed accounts of each aspect of the initiative. Other sources are cited in the text. ADB. 2001. Proposed Grant Assistance to Asian Countries in Transition for Improving Nutrition for Poor Mothers and Children. Manila (March). ———. 2004. Proposed Grant Assistance to Kazakhstan, Kyrgyz Republic, Mongolia, Tajikistan, and Uzbekistan for Sustainable Food Fortication. Manila (May).
Acknowledgments
xi
———. 2008. Asian Countries in Transition for Improving Nutrition for Poor Mothers and Children. Implementation Completion Memorandum. Manila (October). Gary Gleason. 2004. Issues Paper on Communication Activities: Beyond Creation of Consumer Demand for Iodized Salt and Flour Fortication in Central Asia. Manila: ADB (August). Fritz van der Haar. 2009. Promoting Universal Salt Iodization in Central Asia and Mongolia, 2001–2007. Experiences of Japan Fund for Poverty Reduction (JFPR) 9005 and JFPR9052. Manila: ADB. Available: www. adb.org/Documents/Reports/Consultant/37721-REG/37721-01-REG-TACR.pdf Rustan R. Muzafarov. 2008. Implementation Completion Report: Sustainable Food Fortication in Central Asia and Mongolia. Manila: ADB (technical assistance consultant's report). Available: www.adb.org/Documents/ Reports/Consultant/37721-REG/37721-03-REG-TACR.pdf Peter Ranum. 2009. Promoting Wheat Flour Fortication in Central Asia and Mongolia, 2001–2007. Experiences of Japan Fund for Poverty Reduction (JFPR) JFPR9005 and JFPR9052. Manila: ADB. Available: www.adb.org/Documents/Reports/Consultant/37721-REG/37721-REG-TACR.pdf S. Tazhibayev, et al. 2008. Evaluation of the Potential Effectiveness of Wheat Flour and Salt Fortication Programs in Five Central Asian Countries and Mongolia, 2002–2007. UN Food and Nutrition Bulletin. 29 (4). pp. 255–265.
Abbreviations
ADB APC CPO IDA IDD JFPR KAN MICS NGO ppm QAC SES UNICEF USI USSR WHO
– – – – – – – – – – – – – – – –
Asian Development Bank anemia prevention and control country project ofce iron deciency anemia iodine deciency disorders Japan Fund for Poverty Reduction Kazakh Academy of Nutrition multiple indicator cluster survey nongovernment organization parts per million quality assurance and control sanitary epidemiological service United Nations Children's Fund universal salt iodization Union of Soviet Socialist Republics World Health Organization
Executive Summary
Background
During the 1990s, the newly emerging countries of Central Asia, as well as neighboring Mongolia, faced a growing and urgent problem of disease caused by micronutrient deciencies. In response, the Asian Development Bank (ADB) decided to mount a regional food fortication initiative to reverse this spreading public health problem that was particularly affecting poor women and children and was costing the countries about 1% of their gross domestic product. The major micronutrient deciencies were iodine deciency disorder and iron deciency anemia (IDA). Iodine deciency is the single most important cause of irreversible mental retardation in the world, and also causes cretinism-associated problems, including goiter. The prevalence of goiter ranged from 23% to 73% in children in Central Asia at the time the initiative began—well above the 5% cutoff used to signal a public health problem. IDA, which impairs the cognitive development of young children, reduces the work productivity of manual laborers, and is a major cause of maternal mortality, is the most prevalent nutrient deciency in the world. This deciency was present in 38% of children under 5-years old and more than half of all pregnant women in Central Asia and Mongolia; again, well above the cutoff and indicating IDA was a serious public health problem. ADB's involvement is rooted in its Policy for the Health Sector. The policy notes that improvements in health support economic growth through (i) increased worker productivity, (ii) increased returns to investments in education, (iii) increased returns to other factors of production, and (iv) freeing up nancial resources by preventing disease. Investments in health also help to reduce poverty because the poor suffer from worse health status and face more serious economic and nancial consequences when they become ill. These observations apply equally well to the specic problem of micronutrient deciencies. However, ADB also recognizes that the solution to eliminating deciencies in iodine, iron, and other micronutrients is not only a challenge for health policy in a narrow sense but is also a challenge for industrial policy. The private sector has played a major role in improving the quality of foods people regularly consume in industrialized countries. Food fortication has helped reduce public health problems in many countries. This initiative in Central Asia, however, was unique in its regional approach and was the rst major initiative using public– private partnership to address public health problems in the region. It faced several major unknown regional development factors: Would public–private partnership toward sustainable food fortication work in countries newly emerging from centralized economies Could fortied staple foods be made affordable for the poor in Central Asian countries and Mongolia Would target countries gain added value through a regional approach to food fortication In particular: I Could regional developing-country standards in food fortication, and the policy and regulatory environment to enforce them, be created, and implemented I Could region-wide demand and supply for fortication to improve health be created
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Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
The Regional Fortication Initiative
ADB's food fortication initiative in Central Asia and Mongolia was conducted through two regionwide projects supported by the Japan Fund for Poverty Reduction. ADB approached the governments of Azerbaijan, Kazakhstan, the Kyrgyz Republic, Mongolia, Tajikistan, and Uzbekistan1 and obtained their agreement to participate in the initiative, with the United Nations Children's Fund (UNICEF) as the main partner. From the beginning of the initiative, the Kazakh Academy of Nutrition (KAN) provided technical guidance and took part in monitoring and evaluation. The rst project, Improving Nutrition for Poor Mothers and Children in Asian Countries in Transition, aimed to improve the nutritional status and physical and mental capacity of the poor, particularly targeting poor women of reproductive age and children, by establishing an umbrella regional program to deliver micronutrient-fortied salt and wheat our. The second project, Sustainable Food Fortication in Central Asia and Mongolia, aimed to reinforce and sustain the reduction of iron deciency disorder and IDA among poor women and children in Central Asia. There were ve major components of the initiative: Roundtable conferences and regional and national workshops. Three roundtable conferences brought together stakeholders from the countries and aid agencies to discuss strategies and targets, resolve major issues, and review progress. Eight regional workshops sought to build capacity among the project countries to deal with pressing issues as they arose. National workshops covered issues that needed agreement and coordination among the various stakeholders. Fortication of salt and our. Iodization of salt, already being done to some extent in the region, and fortication of our with iron and several vitamins that were also decient in the region—which had not been attempted in the region and required development of a special "premix"—were the approaches followed. Salt producers, our millers, and bakers were assisted in upgrading processing and marketing technology. A 1-year supply of forticants was also provided. Capacity development. The initiative provided capacity development in appropriate areas to salt industry and our mill personnel, government ofcers, and regulatory authorities. Social marketing and mobilization. A communication strategy was developed to strengthen activities in policy and regulatory advocacy, provide organizational motivation and training, create new alliances, and provide community communication to generate demand for fortied foods. Monitoring and evaluation. Monitoring included project supervision, technical workshops, midterm review, annual auditing, and a rigorous efcacy study on the impact of fortied food.

1
Azerbaijan joined after the project was approved for the other ve countries, and a separate supplementary agreement was prepared.
Executive Summary
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Achievements
By the end of the initiative in 2007, the participating countries were well on the way toward universal salt iodization, and at least three countries had established sustainable wheat our fortication. Production of iodized salt through the initiative increased signicantly and even exceeded regional demand, and the proportion of households using quality iodized salt increased in all countries during the initiative, reaching 90% in Kazakhstan. By the end of the initiative, all countries had enacted legislation making iodization mandatory. Initiative results indicate that almost 24 million new consumers of iodized salt were added in the region during the rst Japan Fund for Poverty Reduction project, and an additional 500,000 newborns were protected against brain damage resulting from iodine deciency. The annual economic costs avoided by the correction of iodine deciency across the region through the initiative are estimated at up to $300 million. A new premix for wheat our was developed for the initiative at KAN, based on recommended dietary intakes, nutritional requirements and deciencies in the region, and cost. Over the duration of the initiative, the numbers of millers fortifying their our and moves by governments toward making our fortication mandatory increased. Wheat our fortication signicantly improved the micronutrient status of children and women living in households where fortied our was expected to be available. Overall anemia rates dropped from 42% to 34% in women and from 35% to 22% in children. Ferritin levels increased in both children and women, showing improvement in iron status, and levels of folate, one of the vitamins added to our, increased in both women and children. The overall level of severe folic acid deciency dropped from 39% to 2% in children and from 13% to 2% in women. Under the umbrella of the initiative, all the participating countries agreed on a set of fortication standards and made regulations and laws accordingly. Adoption of common standards took place in the remarkably short time of about 2 years. Much of the credit for the success of the initiative is because of awareness, communication, and marketing activities, through which the participating countries were able to obtain the support of decision makers and other stakeholders down to community members. Coordination of each tier of communication activities from policy level to that of the community was important to ensure that the right messages were available at the right time. In particular, motivating all the key players in fortication was a major task and key factor.
Development Issues
The three development issues that ADB addressed in the initiative were all answered positively. Public– private partnership in these mainly newly emerging market economies proved successful and vital. Collaboration during the initiative helped establish good working relations and strong partnership between the government and the salt industry and our millers in all the countries, and the salt industry and our millers gradually developed a sense of ownership of the fortication program. Formation of industry associations and collaboration of government and nongovernment organizations in workshops, etc., further helped sustain the fortication programs. The question of affordability to the poor was initially a concern. Salt and wheat our are the most basic staples in the region and are very sensitive to price change. When the initiative started, the price of iodized salt was higher than that of noniodized salt, while the cost of our fortication, a new concept for the region, was an unknown factor. However, by the time the initiative ended, the price differentials were insignicant. This was due in part to increasing ownership and investment by the producers due to the
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Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
mandatory nature of fortication in the region. Also, growing demand allowed for economies of scale in production. Finally, the regional approach was vindicated, despite the competitiveness of the Central Asian countries and their many pressing development problems and priorities. The regional approach enabled establishment of common standards for fortied salt and our, achieved economies of scale, took advantage of cross-learning, and enriched interregional cooperation. ADB support on a country-by-country basis would not have had these advantages and would have been unable to address regional issues, such as trade and its regulation.
Lessons
A great many lessons that will prove useful for future work in this eld were learned. The following are some major ones: Mandatory fortication legislation is a prerequisite for ensuring universal access to fortied foods. Political support at the highest level is needed to ensure sustainability of food fortication programs. Public–private partnership was essential in sustaining the momentum of the initiative. Quality control in most of the countries was difcult and needs further strengthening at both industrial and retail levels. Incentives for food producers were essential during program development to prevent their discouragement because of initial losses during fortication start-up. Cost sharing by industry, however, was an important rst step toward sustainability. Donor dependency appeared to be one of the reasons that universal salt iodization had not happened previously. Financial capacity of food producers is a key to sustainable food fortication. For small producers, innovative ways to ensure reliable and reasonably priced forticant supplies are necessary. A strong initial information base is necessary on, for example, prevalence of deciencies and the production and nancial capacity of salt and our producers; if absent, it should be an early priority of fortication programs. A need for awareness building on the advantages of fortied food and its limited availability at local markets was evident in order to increase demand from producers and consumers. Intense awareness campaigns were needed and innovative ways to improve demand are still required. Limited information hampered the initiative from the outset. The initiative lled critical information gaps in food fortication knowledge in the participating countries that will be vital for future fortication activities in the region. Still, any new attempt to fortify food should be preceded by situation analysis of the particular food industry in addition to studying the feasibility of fortication itself. Technology transfer accelerated establishment of food fortication better than using foreign capacity. Domestic capacity development helped the countries to carry out food fortication without external help. Risks of external shocks need to be taken into account. For example, wheat our production, availability, and price vary depending on weather. This had a serious impact on our fortication during the initiative. Political stability is another major factor in program sustainability.

Executive Summary
xvii
Conclusions
In view of the successes of the initiative, the validation of ADB's regional approach to fortication, and in light of the lessons from the initiative, ADB should continue in its role of catalyst in nutrition development efforts in the region, particularly in advocating and promoting fortication of foods that can improve the micronutrient status of the poor. Inclusive growth and regional integration are two of the three strategic agendas of ADB's long-term strategic framework for 2008–2020, Strategy 2020,2 which emphasizes the private sector as a driving force for inclusive growth. Through public–private partnership, ADB should reinvigorate its efforts to promote food fortication so as to deliver much-needed micronutrients to populations in need.
2
ADB. 2008. Strategy 2020: The Long-Term Strategic Framework of the Asian Development Bank 2008–2020. Manila.
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Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
Initiative Participating Countries
Source: ADB.
1. Background
Central Asia's Micronutrient Deciencies
In 2001, the British Broadcasting Corporation produced a television documentary about the rising incidence of cretinism, mental retardation, and associated problems, such as goiter, in children in Central Asia. From Azerbaijan in the west to Mongolia in the east, across Kazakhstan, the Kyrgyz Republic, Tajikistan, Turkmenistan, and Uzbekistan, the story was the same. These conditions, caused by iodine deciency, could be traced to the breakdown of health programs in the former Soviet republics toward the end of the Soviet Union. Initially, the republics were served from a few centralized agencies around the former Soviet Union, depending on need. Iodine was a well-known need, and iodized salt was distributed regularly from Ukraine, reaching most of the populations in iodine-decient areas. By the time the Soviet Union disintegrated in 1991, however, the iodine program had virtually disintegrated. Mongolia took action in the mid-1990s to fortify salt, but by the end of the decade, less than half the population was using iodized salt. The countries in and around Central Asia lie in areas with low soil iodine, leaving sh as the
main source of natural iodine. On the western side of the region, Caspian Sea sh have high iodine content, but elsewhere the harvest is freshwater sh, which have low iodine content. Regardless, most of the region's sheries declined in the decade after independence—by up to 90% in most countries. The countries' economies also were stretched as they grappled with the overnight demise of the Soviet centrally planned economy. The 1990s saw a great increase in poverty in Central Asia, from which individual countries are still recovering as they come to grips, at different speeds, with a market economy. After food subsidies were withdrawn, many residents could not afford adequate nutrition in the decade after independence. Therein lies the core problem: While foods may appear to be adequately nutritious, providing sufcient carbohydrates, fats, and protein, they may lack iodine. Iodine content depends more on the soil level of iodine than on other factors, so what may be an iodine-sufcient diet in one place may be insufcient elsewhere. The consumer has no way of knowing, in the absence of health or food surveys, that a creeping public health problem is unfolding; hence, the problem is called "hidden hunger." Goiter is the physical trait commonly used for identifying iodine deciency disorders (IDD).
Table 1.1: Prevalence of Goiter among Children in Central Asia and Mongolia Item Total goiter prevalence (%) (survey period)
a
Azerbaijana 11.1 (1996)
Kazakhstan 36.7 (2000–2001)
Kyrgyz Republic 49.1 (1994)
Mongolia 23.0 (2001)
Tajikistan 68.7 (1999)
Uzbekistan 73.0 (1998)
Azerbaijan's data are on prevalence in adults. Source: B. de Benoist, et al., eds. 2004. Iodine Status Worldwide. WHO Global Database on Iodine Deciency. Geneva: WHO.
2
Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
At the end of the 1990s, goiter prevalence among school-aged children ranged from 23% to 73% in Central Asia—well above the 5% cutoff used to signal a public health problem (Table 1.1).1 Hidden hunger is not conned to iodine deciency. Iron deciency anemia (IDA) affects more people in the world than any other condition.2 IDA impairs the cognitive development of young children, reduces the work productivity of manual laborers, and is a major cause of maternal mortality. The delay in cognitive development is often irreversible. It is prevalent in wheat-eating populations, such as those in Central Asia and Mongolia, because essential micronutrients are lost during wheat milling. This deciency was present in 38% of children under 5 years old and more than half of all pregnant women in Central Asia and Mongolia—again, well above the 5% cutoff used to signal a public health problem (Table 1.2).3 The developmental importance of folic acid deciency,4 which results in a severe birth defect involving the brain or spinal chord (spina bida),
and zinc deciency,5 which causes suboptimal body functioning, has recently also been recognized. Micronutrient malnutrition is more than a health problem. Estimates from a number of countries suggest that micronutrient malnutrition has cost the national economies in Central Asia about 1% of their gross domestic product.6 The public investment required to eliminate the deciency is low compared to the savings in health care and education costs, improved work ability and productivity, increased economic growth, and local and national development. Indeed, some countries were giving priority to reducing IDD; yet, despite assistance from the World Health Organization (WHO), United Nations Children's Fund (UNICEF), and some bilateral donors, not much more than 20% of households in Central Asia were using iodized salt by the end of the 20th century. Public health programs can provide supplements to certain groups for a short time, but they are
Table 1.2: Anemia Prevalence in Central Asia and Mongolia (%) Country Azerbaijan Kazakhstan Kyrgyz Republic Mongolia Tajikistan Turkmenistan Uzbekistan Preschool Children (<5 years old) 32 36 50 21 38 33 38 Pregnant Women 38 26 34 37 45 30 54 Nonpregnant Women of Reproductive Age 40 36 38 14 41 48 65
Note: WHO category of public health signicance for anemia prevalence: mild 5.0%–19.9%; moderate 20.0%–39.9%; severe 40.0%. Source: B. de Benoist, et al., eds. 2008. Worldwide Prevalence of Anaemia 1993–2005. WHO Global Database on Anaemia. Geneva: WHO.
1
2 3 4
5
6
B. de Benoist, et al., eds. 2004. Iodine Status Worldwide. WHO Global Database on Iodine Deciency. Geneva: World Health Organization (WHO). WHO. 2009. Micronutrient Deciencies. www.who.int/nutrition/topics/ida/en/index.html B. de Benoist, et al. 2008. Worldwide Prevalence of Anaemia 1993–2005. WHO Global Database on Anaemia. Geneva: WHO. There is now general agreement that women need 400 micrograms of folic acid per day, an amount that cannot be provided by normal diets, which indicates the need for fortication or supplementation. N. Wald, et al. 2001. Quantifying the Effect of Folic Acid. Lancet. 358 (9298). p. 2,069. Zinc is required for normal growth and health; deciencies affect about one-third of the world's population. WHO. 2002. World Health Report 2002. Reducing Risks, Promoting Healthy Life. Geneva. ADB. 2005. Special Evaluation Study of Selected ADB Interventions on Nutrition and Food Fortication. Manila.
1. Background
3
neither comprehensive nor sustainable. The most cost-effective solution lies in promoting iodized salt and iron-fortied wheat our (two major staples in the region) to combat IDD and IDA.7 Cost-effective technologies can increase access to iodized salt and iron-fortied wheat by the poor. Fortifying salt with potassium iodate costs an extra $0.05 per person per year, and fortifying wheat our with iron costs an extra $0.09 per person per year.8 Fortifying both salt and our reduces maternal mortality and enhances cognitive development in young children. Also, mass fortication of food staples does not require people to change their eating habits. Resistance to changing eating habits has proven to be a major obstacle in supplementation programs and diet changes. Until 2001, no large-scale fortication efforts were made to address IDA in the region. In 1997, UNICEF began an anemia prevention and control program in the Central Asian countries, using supplements of iron tablets, or iron tablets and folate tablets, and education on the health issues. This program continues, but education alone has limited effect, while distributing free supplements requires continuous funding by donor agencies or the government. UNICEF also started two country projects in Central Asia involving fortifying our with iron. One of these projects, in Turkmenistan, began in 2000 and continues to the present. The Central Asian countries born from the dissolution of the Soviet Union in 1991 suffered pressing micronutrient problems for a decade, with each country making attempts to address the problems internally (Appendix 1). What brought the issues to international attention in 2001 The occasion was a high-level forum in Almaty, Kazakhstan, where a landmark agreement was forged by the Central Asian countries and Mongolia. This Almaty Declaration (Appendix 2) committed them to mitigating micronutrient malnutrition—their hidden hunger—with support from the Asian Development Bank (ADB) and the Japan Fund for Poverty Reduction (JFPR). The countries agreed on
a set of food fortication principles, strategies, and actions involving cooperation and harmonization in food standards and trade regulations across the region. Yet, they still had far to go on the road to economic health. Many visible problems had to be overcome, while hidden hunger remained invisible to both policy makers and the public. The private sector was not being encouraged to fortify food products. Additionally, the countries were only a decade old and inexperienced in working with the private sector. Several attempts by donors to promote regional economic cooperation on water resources and other issues had failed, and the countries had little experience of dealing with multilateral institutions, such as ADB. So, it was a serious question if such a region-wide program would work.
ADB's Involvement with Food Fortication
ADB Policy
Nutrition is a priority in many projects and programs supported or initiated by ADB. ADB has shown clear and strong support for nutrition interventions, such as nutrition education, curbing micronutrient deciencies, basic nutrition for women, food fortication, and early childhood development. Such support for nutrition is either integrated into, or complementary to, support for other areas, such as livelihood and water resources, health (especially public health programs such as maternal and child health), education, and gender-related areas. ADB's involvement is rooted in its Policy for the Health Sector.9 The policy notes that health improvements support economic growth through (i) increased worker productivity; (ii) increased returns on investments in education; (iii) increased returns on other factors of production; and (iv) preventing disease, which frees up nancial resources. Investments in health also help reduce
7
8
9
Despite their limitations, both dietary diversication through a broad-based food policy and supplementation for high-risk groups remain options in an integrated strategy for eliminating micronutrient malnutrition. Although a bit more expensive, an iron-based our premix with minerals is highly cost-effective in reducing nutritional deciencies and improving public heath and the educability of children. ADB. 1999. Policy for the Health Sector. Manila.
4
Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
poverty, because the poor suffer from worse health in general and face more serious nancial consequences when they become ill. So, investments in health contribute to human development and population planning. These general observations apply equally to the specic problem of micronutrient deciencies. However, ADB also recognizes that the solution to eliminating deciencies in iodine, iron, and other micronutrients is not only a challenge for health policy in a narrow sense, but is also for industrial policy. The private sector has played a major role in improving the quality of foods people regularly consume in industrialized countries. As a regional nancial institution, ADB sees fortication as an area where the private food producers, governments, and consumers can collaborate, and is a good example of how human and economic development can mutually reinforce.
As a result of the Manila Forum 2000, ADB and partners mounted a regional initiative to fortify essential foods for the poor. In the Central Asian countries and Mongolia, hidden hunger was gradually depriving the citizens, especially mothers and young children, of nutrition adequate for proper physical and mental development.
Development Questions
Food fortication has helped reduce public health problems in many countries. This initiative in Central Asia, however, was unique in its regional approach and was the rst major initiative using public–private partnership to address public health problems in the region. It faced several major unknown regional development factors: Would public–private partnership toward sustainable food fortication work in countries newly emerging from centralized economies Could fortied staple foods be made affordable for the poor in Central Asian countries and Mongolia Would target countries gain added value through a regional approach to food fortication In particular:
I
Manila Forum 2000—a Turning Point
Recognizing that deciencies in certain vitamins and minerals constitute a serious health problem throughout Asia and the Pacic, ADB combined resources with the Micronutrient Initiative and the International Life Sciences Institute to conduct the Manila Forum 2000: Strategies to Fortify Essential Foods in Asia and the Pacic, a 4-day meeting on using food fortication to address nutrient deciencies. The February 2000 conference, attended by delegations from eight developing countries in Asia and the Pacic, including the Kyrgyz Republic, produced a consensus statement that included: "All salt intended for human consumption should be iodized" and "our fortication with essential vitamins and minerals should be an integral part of all strategies to control and prevent micronutrient deciencies." The meeting also advocated that "centers of excellence" be established around the world to help support food fortication.10
I
Could regional developing-country standards in food fortication, and the policy and regulatory environment to enforce them, be created and implemented Could region-wide demand and supply for fortication to improve health be created
10
ADB. 2000. Manila Forum 2000: Strategies to Fortify Essential Foods in Asia and the Pacic. Manila; Washington, DC: International Life Sciences Institute; Ottawa: Micronutrient Initiative.
2. The Regional Fortication Initiative
Because of Central Asia's regional unknowns, ADB and client countries could not immediately proceed to develop a normal loan project. In this case, the JFPR had just been set up under ADB's administration to nance pilot projects for poverty reduction. ADB seized the opportunity and convinced the Government of Japan to nance a food fortication pilot in the region. ADB's food fortication initiative in Central Asia and Mongolia was conducted through two region-wide projects supported by the JFPR. ADB approached the governments of Azerbaijan, Kazakhstan, the Kyrgyz Republic, Mongolia, Tajikistan, and Uzbekistan11 and obtained their agreement to participate in the initiative (see map on page xviii). UNICEF and the Kazakh Academy of Nutrition (KAN) were the main partners. From the beginning, KAN provided technical guidance and took part in monitoring and evaluation. The rst project—Improving Nutrition for Poor Mothers and Children in Asian Countries in Transition (hereafter called the rst JFPR project)12—began in 2001 and ran for 3.5 years. The project aimed to improve the nutrition status and physical and mental capacity of the poor, particularly targeting poor women of reproductive age and children, by establishing an umbrella regional program to deliver micronutrient-fortied salt and wheat our.
The second project—Sustainable Food Fortication in Central Asia and Mongolia (the second JFPR project)13—began in early 2005 and ended in 2007. It aimed to reinforce and sustain the reduction of IDD and IDA among poor women and children in Central Asia. The rst project received $6.8 million, and the second received $2.0 million, from the JFPR administered by ADB. By the time of the second project, private food producers had become major investors in food fortication.
Objectives and Strategies
The main objective of the rst JFPR project was to expand salt iodization in the region, which had been initiated in Central Asia by UNICEF and other groups but had reached only part of the populations. Flour fortication was included mainly to address the widespread problem of IDA. This project provided technology and equipment for fortication according to best international practices. It sought to reach a signicant proportion of the populations; enable a consensus among the countries on regional standards for food fortication, marketing, and trade; strengthen the food sector's regulatory capability; and increase consumer demand through nongovernment organization (NGO) partnerships.
11 12
13
Azerbaijan joined after the project was approved for the other ve countries, and a separate supplementary agreement was prepared. ADB. 2001. Grant Assistance to Kazakhstan, the Kyrgyz Republic, Mongolia, Tajikistan and Uzbekistan for Improving Nutrition for Poor Mothers and Children in Asian Countries in Transition. Manila. Azerbaijan was added using a supplementary grant in 2001 after the grant was approved. ADB. 2004. Grant Assistance to Kazakhstan, the Kyrgyz Republic, Mongolia, Tajikistan and Uzbekistan for Sustainable Food Fortication. Manila. Azerbaijan was not covered by this project.
6
Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
The objectives of the second JFPR project were to sustain household consumption of iodized salt achieved under the rst project, and to expand our fortication and make it sustainable. The second project also paid parallel attention to supply (production and distribution), demand (public awareness and demand creation), and regulation (quality control, implementation of regulations and legislation, and trade facilitation) but did not nance any forticant or equipment for food producers.
mobilization. (The workshop topics, locations, and dates are given in Appendix 3.)
2. Fortication of Salt and Flour
Iodization of salt, a universally used commodity, was already established worldwide as the preferred way to improve iodine levels in human populations. The rst JFPR project endorsed this approach, using universal salt iodization (USI) standards. For our fortication, the picture was less clear. There had been no previous attempt on a large scale to introduce iron into wheat our in the region,14 and there were other prominent deciencies in the populations that could be reversed through fortication of our with other micronutrients, particularly folic acid (effective in reducing neural tube birth defects) and zinc (required in adequate amounts for normal pregnancy and healthy growth of children). Fortication also provided the opportunity to introduce essential B-complex vitamins. The participating governments worked with selected salt producers, our millers, and bakers to upgrade and retool processing technology for micronutrient-enriched salt and wheat our. The initiative provided a 1-year supply of forticants— potassium iodate for salt and iron-based premix for our—and subsidized two-thirds of the forticant costs. It also advised on the most appropriate ways of iodizing salt, and provided some essential laboratory equipment and diagnostic reagents. Through the initiative, participants made bulk purchases of equipment and forticants, thus achieving both economy of scale and standardization of inputs (Table 2.1). However, the different salt supply situation among the countries required different approaches in order to increase the number of people in each country who regularly consumed iodized salt. In some cases, the availability of imported or freely available noniodized salt complicated the approach.
Scope of the Initiative
The projects comprised ve major components.
1. Roundtable Conferences and Regional and National Workshops
Three roundtable conferences were held in Almaty and became known as the Almaty Forums. Their intent was to bring together stakeholders from the Central Asian countries and development agencies to discuss strategies and targets, resolve major issues, and review progress. Participants included representatives from the participating countries' public health services, the private sector (federations of our millers and salt producers), NGOs that focus on women and children, external assistance agencies, and senior central and local government ofcials. As the initiative progressed and the region became recognized as a business opportunity, international suppliers of equipment and forticants began participating as observers. Regional workshops sought to build capacity, such as communications, regulations and standards, production technologies, and monitoring and evaluation, among the project countries to deal with urgent issues. Regional workshops were also used by private food producers to build networks with international suppliers. Similarly, national workshops were held to cultivate awareness, capacity, and social
14
Two previous our fortication projects in Central Asia—one in the Kyrgyz Republic in 1995 and one in Turkmenistan in 2000, both initiated by UNICEF—involved fortifying our with iron from ferrous sulfate. The Kyrgyz Republic project ran into trouble when some of the fortied our turned rancid and changed color. Turkmenistan continues to fortify our.
2. The Regional Fortification Initiative
7
Table 2.1: Physical Inputs for Salt Iodization in the First Japan Fund for Poverty Reduction Project, by Country Project Support Number of Beneciary Industries 3 2 7 22 3 13 50 Potassium Iodate (tons) 0.30 3.25 1.00 0.20 1.15 3.90 9.80 Iodization Equipment 1 1 3 … 2 12 19 Packaging Equipment and Supplies 3 1 2 4 2 5 17 Packaging Supplies Salt bags Salt bags Salt bags and lm rolls Salt bags Salt bags Salt bags and lm rolls Total Costs* ($) 61,410 76,410 75,406 61,306 90,116 268,651 633,299
Country Azerbaijan Kazakhstan Kyrgyz Republic Mongolia Tajikistan Uzbekistan Total
*
Including installation costs. Source: ADB. 2008 Sustainable Food Fortication in Central Asia and Mongolia Implementation Completion Report. Consultant's report. Manila.
The our fortication initiative focused rst on the larger our mills, with the aim of covering onethird of each country's our consumption.15 As with salt, imports of nonfortied our complicated the work.
3. Capacity Development
The initiative helped salt industries and our mills procure forticants, equipment, and other essential items for food fortication, along with assuring the quality of fortied food. It helped governments develop and strengthen fortication policy and implement food fortication legislation and regulations; improve the quality assurance and control (QAC) systems of both governments and food producers, including border control of trade in salt; and develop regulatory frameworks, standards, and agreements to facilitate trade of fortied food in the region. It also helped regulatory authorities develop food-testing instruments and surveys for
monitoring the enriched food program for mothers and children. The regional workshops helped fortication stakeholders develop capacity in areas of concern across the participating countries. All countries sent qualied delegations to the workshops, which were based on the latest food science and technology and assisted by qualied international consultants. The country delegations were headed by senior government ofcials and included representatives from the private sector and civil society. KAN and UNICEF sent delegations to all roundtable meetings and regional workshops. As the project progressed and received international attention, the Global Alliance for Improving Nutrition (GAIN), the Centers for Disease Control and Prevention (CDC), and interested suppliers also participated at their own cost. Private food producers started nancing their own participation at regional workshops in the second half of the initiative.
15
The original resolution was to fortify our to the maximum extent possible in the region. An early objective was to enable a sufcient number of mills in each country to fortify our so that one-third of wheat our consumed in the country would be fortied. This was later rened to fortifying the premium and rst-grade our, because other types of our were not intended to be fortied. The "onethird" objective was an arbitrary gure used to establish the number of mills to set up for fortifying our and the quantities of premix to order, and to qualify the project's degree of success. That objective proved to be an overly ambitious goal that was unrealistic for some of the participating countries.
8
Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
4. Social Marketing and Mobilization
The public, especially the target groups of poor women and children, had to be informed about fortied food in a structured way that would lead them to select the foods as they came available. The initiative needed to promote public awareness and acceptance of micronutrient-enriched salt and wheat our, and to support innovative activities in communities that would increase the poor's access to these foods. The rst JFPR project developed a communication strategy to strengthen activities in policy and regulatory advocacy, provide organizational motivation and training, create new alliances, and provide community communication to generate demand for fortied foods. Government ofcials and prominent people appeared on television advocating fortied foods. Parliaments conducted hearings. The initiative supported production of audiovisual materials, pamphlets, posters, and publications in newspapers; workshops; and training. It engaged NGOs to conduct social mobilization activities. KAN screened materials before release to ensure that the same message was communicated in each country.
2–15 years of age and 40 women 15–49 years of age) in each country. The rst survey, from December 2002 to April 2003, established a baseline. A second survey followed in May–August 2004, and a third in the latter half of 2007. Each survey interviewed participants, took blood and urine samples, and tested the salt and our that participants used. UNICEF shared the cost of the rst and second surveys. The initiative and UNICEF jointly nanced the rst-ever nutrition survey in Tajikistan in 2003.16
Alliance Building
Before the initiative began, ADB reached an understanding with the nance ministries in the six participating countries that the projects would require some governance reforms. Notes of discussion detailing the responsibilities of ADB, government, private sector, and donor partners were approved by all governments, who promised to apply scal and trade reforms for the duration of the project—and possibly beyond if the reforms worked well. At the rst Almaty Forum, the notes of discussion were converted to country investment plans to reduce micronutrient deciencies. These discussions dened the roles for the different stakeholders, as follows: The central governments of the project countries would establish legal and regulatory frameworks for producing safe fortied foods, provide incentives in the form of tax and tariff exemption for equipment and forticants, and reduce value-added tax for fortied foods. Private food producers (except our mills in Uzbekistan, which were partly owned by the government) would produce iodized salt and fortied our. The public health services in each country would undertake surveillance and monitoring. NGOs in partnership with the governments would carry out social marketing campaigns to stimulate demand.
5. Monitoring and Evaluation
Monitoring the initiative's progress included project supervision, technical workshops, midterm review, annual auditing, and quarterly or annual review of interim indicators including production of fortied salt and wheat our and their quality; also, a sentinel study on the efcacy of fortied food and economic analysis of food fortication to reduce IDD and IDA were also undertaken. A monitoring and evaluation framework that included several performance indicators was agreed upon at one of the regional workshops among country project ofces (CPOs) (Appendix 4). The main objective of the sentinel study was to evaluate the effect of food fortication on people's micronutrient status. The study periodically examined micronutrient status and consumption of fortied foods among the same sample households— 40 households and 120 individuals (80 children

16
Ministry of Health of the Republic of Tajikistan, UNICEF, ADB, and WHO. 2004. Nutrition Status of Mothers and Children in Tajikistan. Dushanbe.
2. The Regional Fortification Initiative
9
The initiative invested time and energy in building alliances among the governments, private food producers, and civil society. Each country established a steering committee comprising representatives of the public and private sectors, and civil society. The steering committees later became national food fortication alliances. Similarly, the initiative worked to build the capacity of associations of food producers and helped the associations network with those in other countries.
Achievements of the Initiative
Despite the unknown factors faced at its beginning, the initiative succeeded on various fronts: The number of households which regulary use iodized salt dramatically increased. Two countries (Kazakhstan and Mongolia) demonstrated sustainable-quality production of fortied wheat our, although the initiative's objective to fortify one-third of wheat our consumed in the participating countries proved difcult, particularly for countries with high our imports and little wheat production. All participating countries moved towards USI and enacted USI laws. All participating countries adopted common standards for iodization and our fortication within 2 years, Iodized salt and fortied our were affordable.
Implementation Arrangements
ADB coordinated the projects. The Regional Coordination and Administration Ofce was set up in Almaty to coordinate activities for all participants and be responsible for procuring equipment and forticants. Each participating country had a CPO and a steering committee for project oversight, comprising representatives from the nance, planning and investment, and health ministries; the private food industry; and the NGO community. For the rst project, each country selected special-focus oblasts (provinces) or raions (districts) for intensive project coverage. These were usually among the poorest areas of the countries. Although some activities (such as community mobilization) concentrated in these pilot areas, substantial parts of project activities covered the nation. Food producers were not necessarily selected from the pilot areas. But by the second project, all activities covered the entire countries. The ministries of health of the participating countries were the executing agencies of the national projects through the CPOs. The CPOs were headed by the country project coordinators, who were health specialists supported by nancial analysts. The coordinators worked closely with different government ministries and agencies, the private sector food industries, and NGOs. Each country developed a country investment plan that was agreed upon between each government and ADB. The CPOs submitted nancial, progress, and project completion reports to the Regional Coordination and Administration Ofce, which monitored nancial disbursement and project activities and prepared consolidated project reports and consolidated nancial statements.
Fortication
Iodized Salt Production
At the beginning of the initiative, each country introduced amendments of the iodized salt production standard, specically on iodization level (30–40 parts per million [ppm] in all countries) and the substitution of potassium iodate for potassium iodide. Through the initiative, production of iodized salt increased signicantly and even exceeded regional demand (Figure 2.2), and subsequently the number of households consuming iodized salt dramatically increased (Figure 2.3). While only about 25% of households of the participating countries were using iodized salt at the beginning of the initiative, by the end of the rst project about 66% of the households were using iodized salt, and the rate was maintained through the second project. The multiple indicator cluster surveys (MICSs) have conrmed the outstanding progress made in Kazakhstan, the Kyrgyz Republic, and Mongolia, and the signicant progress made in Tajikistan and Uzbekistan (Figure 2.3). The extent of fortied salt distribution and consumption differed among the participating countries.
10
Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
Figure 2.2: Annual Iodized Salt Production as Percentage of Annual Salt Consumption in Central Asia and Mongolia, 2003–2007
180 160 140 120 100 80 60 40 20 0
Percent
2003
2004
2005
2006
2007
Kazakhstan Kyrgyz Republic
Mongolia Tajikistan
Uzbekistan
Source: ADB. 2008. Sustainable Food Fortication in Central Asia and Mongolia Implementation Completion Report. Consultant's report. Manila. Data source: country project reports.
Figure 2.3: Percentage of Households Using Iodized Salt in Central Asia and Mongolia in 1995–2006 Compared to World Averages
100 90 80 72 70 60 50 40 30 20 10 0 92 69 76 68 46 20 27 20 19 53 83
lia
an
Re pu bl
co un tri
go
an
kh st
ist
M on
za
Ta
Ka
ng
pi
De ve
lo
1995–2000 2003 2004
Ky
rg
yz
2001 2005
2002 2006
Source: ADB. 2008. Sustainable Food Fortication in Central Asia and Mongolia Implementation Completion Report. Consultant's report. Manila. Data source: country project reports, and UNICEF State of the World's Children reports, 2001–2008.
In Kazakhstan, salt production was concentrated in a few large private companies. Two of them were initially involved and a third, new, company later joined. One was given technical assistance under
the initiative, which contributed to the quality of its production. In the Kyrgyz Republic, the number of medium-sized, sustainable salt companies increased
Uz
be k
jik
ist
an
es
ic
2. The Regional Fortification Initiative
11
to 12, which ensured the production of 80%–90% of national demand. The remainder was imported from other Central Asian countries. Mongolia established a reasonable balance between supplying quality iodized salt imported from the People's Republic of China to central areas, and domestically produced iodized salt to remote provinces. The initiative supported the construction of two salt factories at salt deposit sites in remote provinces, which helped improve the quality of the salt produced. In Tajikistan, one company produced almost enough iodized salt to meet national demand. However, illegal noniodized salt still dominated local retail markets.17 Uzbekistan promoted establishment of a few modern salt companies and improved the quality of the iodized salt produced by existing salt factories. By 2007, there were 60 salt producers, of which the 13 participating salt producers provided two-thirds of national production. Most participating countries have developed a national database covering their iodized salt programs. All conduct regular surveys to assess iodized salt coverage with assistance from UNICEF, the CDC, and other international agencies. ADB nanced the Community-Based Early Childhood Development Project in the Kyrgyz Republic, which annually monitored household use of iodized salt in remote districts. Results of salt testing for iodine are often collected as one of the indicators in broader-based health and nutrition surveys, such as demographic and health surveys and MICSs.

Impact: Amounts and sources added must be capable of producing a signicant positive impact. Safety: Amounts and sources added should not cause potential harm. Sensory: There should be no adverse effect on the color, shelf life, baking properties, or consumer acceptance. Cost: Costs to the producer or consumer should be reasonable and acceptable.
Fortied Flour Production
Unlike salt iodization, for which potassium iodate is the standard forticant, for our fortication a premix had to be developed prior to production. The following considerations helped determine what levels and sources of micronutrients to add.
KAN developed a new premix for wheat our, based on recommended dietary intakes, nutritional requirements and deciencies in the region, and cost. The premix contained electrolytic iron, zinc, folic acid (vitamin B9), and three other B vitamins: thiamin (vitamin B1), riboavin (vitamin B2), and niacin (vitamin B3). All the participating countries adopted this our premix, called KAP Komplex 1.18 The amount of each micronutrient to add was calculated to be the amount sufcient to make up for the shortfall between the estimated normal intake of these six micronutrients within the region and their recommended dietary intakes, for an average our consumption of 260 grams per person per day. Minimum standards were developed for use of the our premix, as shown in Table 2.2. These standards were used in regulations in all the participating countries. To achieve the maximum impact in the shortest time, the initiative began fortication at mills with production of more than 200 tons per day. When the rst project was designed, there was almost no data on our mills in the region. Once fortication started, however, project teams in countries, regions, and ADB realized that large-mill production was not necessarily the best option. In the Kyrgyz Republic and Tajikistan, only medium-sized mills were functional. By the end of the rst project, mediumsized mills in the Kyrgyz Republic, Mongolia, and Tajikistan were brought into the project.
17
18
While some of the salt produced in Tajikistan was exported to neighboring countries, this still could not fully explain the gap between the amount of iodized salt produced and the amount apparently consumed in the country. Vitamin A was not included because of its impact on cost and the belief that other foods, such as vegetable oil and margarine, were more appropriate and cost-effective carriers for this vitamin. Vitamins B12 and B6 were not considered at the time because not as much was known about them in regard to our fortication as is known now. Had the fortication been devised today, vitamin B12 may have been included.
12
Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
Table 2.2: Ingredients of KAP Komplex 1 (ppm) Micronutrient Thiamin (vitamin B1) Riboavin (vitamin B2) Niacin (vitamin B3) Folic acid (vitamin B9) Iron (electrolytic) Zinc
a
Addeda 2.0 3.0 10.0 1.5 50.0 22.0
Natural 2.0 0.4 12.0 0.2 14.0 7.0
Total 4.0 3.4 22.0 1.7 64.0 29.0
Standard 3.3 2.8 18.0 1.5 55.0 25.0
ppm = parts per million. By KAP Komplex 1 premix added at 150 grams per ton. Source: ADB. 2009. Promoting Wheat Flour Fortication in Central Asia and Mongolia, 2001–2007. Experiences of Japan Fund for Poverty Reduction (JFPR) JFPR9005 and JFPR9052. Consultant's report. Manila.
Figure 2.4: Annual Fortied Wheat Flour Production as Percentage of Annual Wheat Flour Consumption in Central Asia and Mongolia, 2003–2007
30 25 20 Percent 15 10 5 0 2003 2004 2005 2006 Mongolia Tajikistan 2007
Kazakhstan Kyrgyz Republic
Source: ADB. 2008. Sustainable Food Fortication in Central Asia and Mongolia. Implementation Completion Report. Consultant's Report. Manila. Data source: country project reports.
Fortied wheat our production reached the targeted amount only in Mongolia, although it increased in Kazakhstan and continued in the Kyrgyz Republic and Tajikistan (Figure 2.4). Uzbekistan, which received the support of the Global Alliance
for Improving Nutrition for our fortication, did not receive the second JFPR project's support for our fortication, and, hence, is not included in Figure 2.4. However, Uzbekistan's national wheat our fortication program increased the number of
2. The Regional Fortification Initiative
13
participating mills and used the standard procedures in wheat our fortication, premix formulation, and quality assurance and control (QAC) as developed under the initiative. Although the projects did not achieve their own targets, compared with other areas the participating countries have made remarkable progress. When the initiative began, some Eastern European countries were showing an interest in our fortication but had been unable to get anything started, largely due to a lack of external support. Brazil had been working on a program and began fortifying our in a few mills in 2004, but not to the extent accomplished in Central Asia. Argentina had adopted our fortication standards but had no mills fortifying our. Morocco had not yet started fortifying our, and Egypt had been arguing about fortication for 20 years. South Africa began working on fortication several years before the initiative and is now fortifying
most our, but this is a single country with large, modern our mills. Across the region, the number of participating our mills doubled during 2003–2005 and remained stable (Figure 2.5).
Quality of Fortied Foods
Delivering safe, quality fortied foods to consumers requires an elaborate QAC system. One of the initiative's challenges was to establish such a system in each country, according to a QAC framework recommended by the Pan American Health Organization (Figure 2.6).19 The QAC system needed internal control by the producers and external control by the governments' inspection agencies, and often by consumer groups, at each stage of fortication and delivery, as well as technical capacity at reference laboratories, food producers, and government inspection agencies. Also, the initiative quickly discovered a need to improve
Figure 2.5: Number of Participating Flour Mills in Central Asia and Mongolia, 2003–2007
90 80 70 60 50 40 30 20 10 0 2003 2004 Involved flourmills 2005 2006 Active flourmills 2007 38 32 23 60 45 85 85 73 63 85
Note: Involved mills have ofcially committed to fortifying our; active mills have ofcially committed to and are actually fortifying our. Source: ADB. 2008. Sustainable Food Fortication in Central Asia and Mongolia. Implementation Completion Report. Consultant's report. Manila. Data source: country project reports.
19
Further details on QAC mechanisms for our fortication are available in ADB. 2009. Promoting Wheat Flour Fortication in Central Asia and Mongolia, 2001–2007. Experiences of Japan Fund for Poverty Reduction (JFPR) JFPR9005 and JFPR9052. Consultant's report. Manila. Available: www.adb.org/Documents/Reports/Consultant/37721-REG/37721-REG-TACR.pdf
14
Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
Figure 2.6: Pan American Health Organization Guidelines on Quality Assurance and Control for Food Fortication
Recommended Quality Assurance and Quality Control System for Food Fortification *Imported Food Products
Imported Food
Locally Produced Food Food Vehicle
Nutrient Premix Certification (State)
Quality Control (Factories) Certification of Conformity from Exporting Countries (Customs Authorities) *Fortified Food Products (100%) (Producers' Warehouses) Monitoring (State) "Confidence" Assays (State) *Fortified Food Products (100%) (Large Warehouses) *Fortified Food Products (100%) (Retail Stores) *Fortified Food Products (100%) (Home/Small Industries) Monitoring "Confidence" Assays (State, Provincial, and Local Authorities) Monitoring Acceptance (Consumers, Local Authorities) *Fortified Food Products Inspection "Confidence" Assays
Quality Auditing Rejection or Application of Penalties
Home Surveillance
* = Packed and Labeled () = Responsible Parties
Adapted from: Food and Nutrition Program, Division of Health Promotion and Protection, Pan American Health Organization.
border control of imported salt, as the countries proceeded to ban importing noniodized salt. The initiative provided laboratory equipment and necessary reagents as well as training for laboratory and sanitary epidemiological service (SES) technicians, which are inspecting agencies in the custom ofces of Central Asian countries. Iodized salt in nal product form should contain at least 15 ppm of iodine. The initiative helped governments update salt iodization standards to conform to this standard, and helped the countries in their QAC activities. The QAC for iodized salt was carried out at production sites, retail shops, markets, and households. SESs regularly inspected
salt produced and, in some cases, salt sold at markets. In the Kyrgyz Republic, however, SESs were allowed to inspect food producers only once a year, which is insufcient for enforcing quality standards. More than 42,000 samples from production sites and about 745,000 samples at retail shops and households were tested in 2003–2004 alone, using different test methods—titration, WYD iodine checkers,20 and salt test kits. The results varied depending on the method used. Thus, strict comparisons between 2003 and 2004, or between results at production sites, retail shops, and households, are not possible. In general, the data showed that the majority of samples had adequate iodine level at production sites.
20
Hand-held instruments that measure the salt iodine content.
2. The Regional Fortification Initiative
15
Kazakhstan and Mongolia were able to maintain adequate iodine levels from production sites to retailers and households, but in other countries salt tested at retailers and households had less iodine than did salt at production sites. This indicated not only improper packaging and storage (without which iodine content gradually declines), but also the fact that noniodized or poorly iodized salt was still available in the market from illegal sources that were not inspected by the SESs and that some people still used free salt from nearby salt deposits. Flour fortication quality was tested by the iron spot test, which is a simple and semiqualitative procedure used all over the world to check whether a our sample has roughly the right amount of added iron. That, in turn, denotes whether the our is being properly fortied. Most tests were done by laboratories in the our mills. Each country handled external quality control of fortied our differently, with KAN providing product testing for all the countries. Kazakhstan and Mongolia designed and adopted the procedures for monitoring of production, import, and sale of the fortied wheat our, whereas the Kyrgyz Republic, Tajikistan, and Uzbekistan worked from existing sanitary regulations and norms. In general, procedures included control on (i) compliance of the forticants (and/or premix) with the existing standards, (ii) adequacy of the our fortication method, (iii) vitamin and mineral content in the nal product, and (iv) compliance of the packaging and labeling with existing standards. For external monitoring, Uzbekistan used the central Uzdonmakhsulot Milling group in Uzbekistan and SES laboratories; Kazakhstan used the League of Grain Processors and Bakers of Kazakhstan and the SES. The Kyrgyz Republic relied on the Independent Bread Inspection Laboratory, Mongolia relied on Special Governmental Inspection, and Tajikistan relied on a private laboratory that had a contract with the association of food producers in Tajikistan. Only Uzbekistan routinely ran quantitative iron and niacin tests using sophisticated equipment. These were done early in the initiative by the American Ingredients Company (which was a competitively
selected supplier of the premix), KAN, and the SES. Beginning results showed erratic levels of minerals in fortied our samples, consistent with expectations for any new program and the level of milling technology used in Central Asia. Much of the variation came from erratic ow of our through the mill. The problem was mostly underfortication. Occasional spikes of overfortication would not have caused any safety alarm for human intake because the fortication standards were set low enough. The accuracy of both mill dosing and quantitative testing was expected to improve with experience. International experts concluded that, until the matter was resolved, spot tests were the best method of quality testing for emerging our fortication programs, and have modied their advice to other countries accordingly.
Affordability of Fortied Foods
At the beginning of the initiative, many consumers complained that iodized salt was much more expensive than noniodized salt, making it unlikely that the poor would buy iodized salt. Country project ofces (CPOs) regularly checked prices of iodized salt in the market. Observations showed that by the end of the rst JFPR project, the price of iodized salt came down as production increased, and the complaint about the high price disappeared. The problem remained, however, in some pockets around open salt deposits in Mongolia and Tajikistan, from which people took salt freely. Indeed, producers were more worried about costs than consumers. Millers and bakers faced a signicant up-front charge, especially for the our premix. Experience in other countries suggested that the industry might resist our fortication if its cost exceeded $1 per ton of our. Experience had also shown that the premix accounted for about 90% of the cost of fortication, so the project's goal was to keep the fortication cost at around $0.90 per ton. The nal cost to the mill turned out to be $0.97 per ton of our when added at 150 grams per ton, or $0.78 per ton when added at 120 grams per ton as later recommended for rst-grade our. By 2008, the cost of the premix had increased to about $1.10 per ton of our, but the price of our had more than doubled by then, decreasing the proportional cost of fortication.
16
Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
Private Sector Investment
The mandatory nature of salt iodization, prescribed by all participating countries by the end of the initiative, meant that there was a level playing eld for the salt industries. Thus, all producers had to include forticant at the standard rate. This helped them overcome earlier fears about increased production costs, which, in any case, were to be passed on to consumers. In contrast, our fortication, being the rst large-scale trial in the region, needed time to prove its efcacy and remained voluntary in most of the countries. All participating countries started working toward mandatory our fortication in the last 2 years of the initiative. By November 2009, Kazakhstan and the Kyrgyz Republic had mandatory our fortication legislation. As the initiative progressed, the participating producers of both salt and our increased their investments in fortication, not only in the forticant
(which was initially subsidized), processing, and packaging, but also in contributions to strengthening testing laboratories, training personnel, and social marketing. This trend is shown for fortied salt in Figure 2.7. The cost of our fortication was about 0.5% of total processing costs and resulted in a barely noticeable increase in cost to the nal consumers. Since the end of 2007, a private company in Kazakhstan has been producing premix in Kazakhstan. Regional capacity for premix production helps easy procurement by Central Asian countries.
Legal and Regulatory Framework
Common Fortication Standards
The initiative aimed at and, to a large extent, achieved establishing a set of unied (or harmonized) national laws, regulations, and standards to (i) ensure the essential quality of the fortied foods,
Figure 2.7: Share of Grant and Private Industry Costs of Iodized Salt Production in Central Asia and Mongolia in 2001–2007 ($)
800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 2005–2007 2001–2004 2005–2007 2001–2004 2001–2004 2005–2007 2001–2004 2005–2007
Feeders
Potassium Iodate
Internal Laboratory
Training
JFPR funds
UNICEF funds
Private funds
JFPR = Japan Fund for Poverty Reduction, UNICEF = United Nations Children's Fund. Source: ADB. 2008. Sustainable Food Fortication in Central Asia and Mongolia Implementation Completion Report. Consultant's report. Manila. Data source: country project reports.
2. The Regional Fortification Initiative
17
(ii) protect the consumer from fraud, (iii) provide the legal authority an adequate legal framework for the food-control activities, and (iv) strengthen the incentives for food producers and traders for crossborder and countrywide trade of fortied foods. A catalog of laws and regulations adopted during the initiative is shown in Appendix 5. Under the umbrella of the initiative, all the participating countries agreed on a set of standards and made regulations and laws accordingly. Adoption of common standards took place in about 2 years—an impressive achievement. No one had attempted a uniform set of fortication standards for this large region before, except in Central America. A single premix and uniform set of fortied our standards should be used, rather than allowing each country to set up its own standards and premix, and it required all the participating countries to write their regulations and laws accordingly. Common standards simplied procurement of forticants and helped reduce cost. They also helped free trade of fortied salt and our within the region.
Mandatory Flour Fortication Laws
Flour fortication began on a voluntary basis in all the participating countries, and they worked toward making it mandatory. Although some national projects elsewhere began with a mandatory program (e.g., Indonesia, Ghana), this was not possible in Central Asia. An initial voluntary period was needed to allow the milling industry and consuming public to become familiar with fortication of a food staple and then to accept it, and also to demonstrate the efcacy of fortied our. Most aspects of our and bread production were under centralized government control during the Soviet period. Technical standards, procedures, and specications for our production were inherited by the emerging Central Asian countries, which made changing regulations to allow fortication of our and bread a slow and difcult process. The lack of relevant international expertise on fortication meant it was necessary to design new legislation, which delayed enactment of the enabling regulations. The rst task was to set up regulations to allow fortication equipment and premix to be brought into the countries, preferably with reduced or eliminated tariffs and taxes. Most countries were still working toward legislation for mandatory our fortication at the end of the initiative. The President of the Kyrgyz Republic approved legislation on mandatory our fortication in March 2009. In Kazakhstan, wheat our fortication was once mandatory but was changed to voluntary in 2007 in response to political pressure from the ministries of agriculture and trade. Nevertheless, most of the participating our mills (14 of 16) continued fortied-our production, although the amounts remained less than needed. KAN and the League of Grain Processors and Bakers of Kazakhstan started to design provisional company regulations on fortication. Kazakhstan made our fortication mandatory again in September 2009. In contrast to the achievements described above, little progress was made in promoting regional trade in fortied our. Inadequate infrastructure,
Universal Salt Iodization Laws
One of the initiative's biggest achievements was having all participating countries adopt universal salt iodization (USI) laws during its term.21 The initiative helped the countries develop and adopt the laws and regulations required to enforce USI. The laws provide a level playing eld for all producers, while holding them accountable for production of iodized salt and preventing import of noniodized salt. Some countries had laws on salt iodization that were incomplete and allowed import of noniodized salt. These were amended during the project. In Mongolia, 10 food fortication standards, the National Strategy on Prevention of IDA, and the Law on Salt Iodization and Prevention of IDD were approved, and the National Program on Prevention of IDD was revised. Tajikistan's law, however, contained a loophole prohibiting the sale of noniodized salt while allowing production of noniodized salt. This made it difcult to hold producers accountable.
21
Uzbekistan is the only country that did not adopt a USI law during the rst project. Thus, adoption of the law was a condition for Uzbekistan to participate in the second project. Uzbekistan nally approved the law in 2007.
18
Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
resource constraints, and weak institutions remain barriers to realizing greater benets from increased trade in fortied foods. To dramatically improve the availability of fortied our, it would be more efcient and practical for some countries to import fortied our instead of importing wheat from Kazakhstan and trying to fortify it domestically.
Advocacy, Communication, and Mobilization
The countries adopted USI legislation and other important regulations because of extensive advocacy by the initiative. Through marketing activities, the participating countries obtained the support of decision makers and other stakeholders down to community members. Coordinating each tier of communication activities, from policy level to community level, ensured that the right messages were available at the right time. Sometimes the countries' advocacy achievements were diminished by changes made by decision makers, and also by counterattacks from interest groups. The experience taught that advocacy efforts must be continuous in order to maintain political support for food fortication. Television (TV), radio, newspapers, and even technical literature promoted nutrition education and the advantages of fortied food. In Kazakhstan, the Ministry of Culture and Public Information funded regular broadcasting of fortied food advocacy telecasts by national public TV channels. In the Kyrgyz Republic, private TV companies gave free broadcasting time for fortied food advocacy materials. In Mongolia, the initiative supported a documentary on food fortication activities, which was shown at prime viewing time on national TV channels. In Mongolia and Uzbekistan, regular TV lessons were designed with the help of nutritionists and journalists. In the Kyrgyz Republic, Mongolia, and Tajikistan, the popular broadcasting channels transmitted messages on the benets of fortied food. In all, the media coverage of fortication issues totaled 90 telecasts, nearly 150 articles in newspapers and magazines, and about 60 academic publications during the initiative. Motivating the key players in fortication was a major task. Numerous nongovernment organizations
(NGOs), ofcials, and volunteers spent many hours in activities supporting the initiative in communities and sometimes at much higher levels, often with no compensation. It helped to involve the players in producing communication support materials. Mongolia was especially good at involving a wide range of experts and overseeing their professional contributions in developing materials. The most impressive were technical books for physicians, a technical manual on fortication, and manuals on quality assurance. Materials developed within the initiative have been used in orienting other groups, ranging from medical and health staff throughout the country to workers in our and salt production, and pre-service educators. Testing with salt test kits became a powerful social mobilization tool, involving health workers, school children, retailers, consumer associations, and NGOs. The best example was in the Kyrgyz Republic, where the Red Cross started a mass campaign on salt testing in Naryn oblast. Communities tested salt; if it was found to be noniodized, they sent it back to the producers and demanded replacements. The initiative expanded the mass campaign to other oblasts, together with another ADB-nanced project, the Community-Based Early Childhood Development Project. In some cases, salt industries were closed down by government order for producing noniodized salt. The initiative created a "healthy food" logo (shown below), which was adopted by all participating countries as part of the packaging or labeling. The initiative also supported food fortication advocacy based on the logo, which helped marketing efforts of the participating food industries. Logo use by food producers is usually regulated by each country's associations of food producers.
Also, Russian-language and English-language websites were set up to provide reference material and project information to stakeholders.
2. The Regional Fortification Initiative
19
Each country demonstrated good practices in organizational motivation. For example: Retail salt sellers in the Kyrgyz Republic became much more active selling iodized salt after they became involved in testing their salt for iodate content. Technicians at a our mill in Ulaanbaatar, Mongolia, refabricated a broken gear in a feeder to quickly bring fortied our production back on line. One our mill purchased its own microfeeder and others requested technical assistance in locating such equipment. A mill in Astana, Kazakhstan, independently carried out a major marketing effort for fortied our when project social marketing activities were delayed.
Kazakhstan was an early leader in awareness campaigning (Box 2.1). There was also campaigning opposing fortication. Box 2.2 relates how opposition from just one organization or inuential individual can cause setbacks and cripple months or years worth of work.
Capacity Development
Rather than relying on foreign or international expertise, the initiative developed a cadre of trained personnel in both the public and private sectors in the participating countries. This approach partly explains initial delays in project implementation, but it helped forge strong ownership by participating
Box 2.1: Kazakhstan's Successful Iodine Deciency Disorders Awareness Campaign As soon as Kazakhstan's national fortication plan was in place, the Kazakh Academy of Nutrition, along with the Healthy Life-Style Promotion Center and selected public relations rms, produced educational and communications materials about iodine deciency disorders (IDD) and anemia prevention for pretesting in small focus-group interviews with their specic target groups. After adjustment, the materials were tested during the second half of 2003 in pilot areas of South Kazakhstan oblast. The campaign also included TV features, press conferences, presentations, and training seminars for nongovernment organization (NGO) employees, mass media, and salt and our product dealers. The message about the preventive effect of using iodized salt was aimed at large population groups, using the resources of the health care and education sectors, the mass media of the region, and NGOs. The campaign delivered numerous sets of 12 kinds of printed and video products about iodized salt with specic messages to the target audiences: local authorities; salt enterprises and traders; state employees in primary health care and sanitary services; middle schools, colleges, and universities; young school children, teenagers, and pregnant women; mass-media workers; and the general public. Especially in rural areas, these groups were enlightened about the dangers of iodine deciency and the desirability of consuming iodized salt, educated in the principles of iodized salt storage and use during cooking, and informed about the "Healthy Food/Sapaldy Azdyk" general trademark. At the end of 2003, assisted by the initiative and the Kyrgyz Red Cross, monitoring surveys and population interviews were conducted on the quality of iodized salt among 91,000 rural and urban households in South Kazakhstan oblast. The results indicated that awareness of IDD and use of iodized salt among the population had improved from 43% to 61%. Virtually all respondents had heard about iodized salt and knew the advantages of using it. Only 3% of households were still using noniodized salt. These results formed the basis of a comprehensive national campaign during 2003–2004, with a follow-up stage that continued into 2006.
Source: ADB. 2009. Promoting Universal Salt Iodization in Central Asia and Mongolia, 2001–2007. Experiences of Japan Fund for Poverty Reduction (JFPR) JFPR9005 and JFPR9052. Consultant's report. Manila.
20
Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
Box 2.2: Opposition to Mandatory Flour Fortication Kazakhstan passed mandatory our fortication legislation in October 2004 but rescinded it in 2007, primarily because of trade issues and resistance from some millers. A major aw of the 2004 our fortication law was that it did not have strong involvement or support of the milling industry. The National Fortication Alliance, in particular the Kazakh Academy of Nutrition as a key member of the alliance, used its inuence to get the law passed. One motivation in pushing for rapid passage of the law was the hope of winning a grant from the Global Alliance for Improving Nutrition. When a grant was subsequently declined for the second time, some industry and government support for a mandatory law was lost. There was also strong opposition from the minister of agriculture. However, Kazakhstan made our fortication mandatory again in September 2009.
Source: ADB. 2009. Promoting Wheat Flour Fortication in Central Asia and Mongolia, 2001–2007. Experiences of Japan Fund for Poverty Reduction (JFPR) JFPR9005 and JFPR9052. Consultant's report. Manila.
countries and country project ofces (CPOs), and improved their capacity development. It also promoted centers of excellence, such as the Kazakh Academy of Nutrition (KAN), in these countries, helping to create a solid and broad foundation for sustained food fortication in the region.
Salt and Flour Processors
The initiative helped improve the production systems for fortied salt and our by providing feeders, packaging equipment, and initial supplies of forticants to participating salt industries and our mills. It supported technical assistance among producers by (i) helping form producers' associations, which became active in solving the technical problems of individual producers; (ii) training industry personnel; and (iii) designing and lobbying for legislation, regulations, and standards. By the end of the rst project, some milling consultants started assisting millers in other participating countries. The initiative further ensured adequate training of technical staff through national and regional workshops. These provided practical guidance on the national legislation and regulations, while regional training focused on international best practices in fortication. These training events are summarized in Figures 2.8 and 2.9.
The initiative also worked to strengthen associations of salt producers and our mills. All participating countries had associations, except Uzbekistan where our mills were partly governmentowned joint-stock companies. Associations were provided with quality-monitoring equipment by the project to help their member food producers, and were trained in installing equipment. The associations in the participating countries were relatively weak, and their capacity varied by country. Tajikistan's association has continued to manage a revolving potassium iodate fund for its members even after the initiative's support ended, while the Kyrgyz salt association's work slowed down when it had a change of leader. The League of Grain Processors and Bakers of Kazakhstan is relatively strong and advocated for establishing a regional our mill association towards the end of the initiative, which was generally welcomed by associations in the other countries. Such a regional association would surely contribute to promote our fortication in the region. UNICEF, in cooperation with the CDC, conducted regular training on quality assurance and monitoring of iodized salt in all the countries throughout 2004–2007. Also, UNICEF, in cooperation with the International Association of Operating Millers, the CDC, and the Flour
2. The Regional Fortification Initiative
21
Figure 2.8: Numbers of Salt Engineers and Laboratory Technicians Trained in Central Asia and Mongolia, 2003–2007
80 70 60 50 40 30 20 10 0 2005–2007 2001–2004 2001–2004 2005–2007 2005–2007 2001–2004 2001–2004 2005–2007 2001–2004 2001–2004 2005–2007 2005–2007
Kazakhstan
Kyrgyz Republic
Mongolia
Tajikistan
Uzbekistan
Salt iodization technology
Quality assurance and control
Information meetings
Source: ADB. 2008. Sustainable Food Fortication in Central Asia and Mongolia Implementation Completion Report. Consultant's report. Manila. Data source: country project reports.
Figure 2.9: Numbers of Flour Mill Engineers and Laboratory Technicians Trained in Central Asia and Mongolia, 2003–2007
250 200 150 100 50 0 2005–2007 2005–2007 2005–2007 2001–2004 2001–2004 2001–2004 2001–2004 2005–2007
Kazakhstan
Kyrgyz Republic
Mongolia
Tajikistan
Uzbekistan
Flour fortification technology
Quality assurance and control
Information meetings
Source: ADB. 2008. Sustainable Food Fortication in Central Asia and Mongolia. Implementation Completion Report. Consultant's report. Manila. Data source: country project reports.
22
Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
Fortication Initiative, conducted regular training on quality assurance and monitoring of fortied our in all the participating countries through regional meetings of the International Association of Operating Millers and national workshops.
Regulatory Authorities
The initiative increased the capacity of government control agencies to ensure adequate tests of fortied food samples through procurement of laboratory equipment and reagents. More than 4,000 representatives from the sanitary epidemiological services (SESs), customs services, and other control agencies were trained at national and local workshops. Around 28,000 salt test indicators were distributed among NGOs and retailers to monitor salt iodization in markets and households. In Mongolia, as a result of institutional reform, the Specialized Inspection Agency was established in 2006; in other participating countries, regulatory control is through interaction between the standards agency, the SES, and the customs service. Figure 2.10 provides an overview of the training events and capacity building for the various control agencies.
The regional workshops and training by the CDC and UNICEF constituted a powerful capacity development exercise for the region. These organizations provided the framework for project development in all the countries, set the stage for regional cooperation, and provided necessary skills in project activities.
Nongovernment Organizations
Many NGOs beneted from their active roles in awareness building and social marketing. In Mongolia, for example, organizations such as the Mongolian Women's Federation, Consumer Rights Protection Association, Mongolian Medical Academy, and Family Education Association played leading roles in these activities, along with participating private companies. All were encouraged by the population's reaction to their efforts and believe that their reputation among the communities grew as a result of their involvement in the initiative. At the same time, the experiences made them more capable of sustaining the fortication program in their country.
Figure 2.10: Numbers of Staff of Control Agencies Trained in Central Asia and Mongolia in 2003–2007
140 120 100 80 60 40 20 0 2001–2004 2001–2004 2005–2007 2001–2004 2005–2007 2005–2007 2001–2004 2005–2007 2001–2004 2005–2007
Kazakhstan
Kyrgyz Republic
Mongolia
Tajikistan
Uzbekistan
Ministry of Health
Standard Agency
Customs Committee
Other Government Agencies
Source: ADB. 2008. Sustainable Food Fortication in Central Asia and Mongolia. Implementation Completion Report. Consultant's report. Manila. Data source: country project reports.
3. Development Impact
Reduced Prevalence of Iodine Deciency and Iron Deciency
The adoption of universal salt iodization (USI) by all the participating countries, the rising production of iodized salt, and the growing number of households using iodized salt during the initiative indicate increased protection against IDD. Initiative results show that almost 24 million new consumers of iodized salt were added in the population of Central Asia and Mongolia during the rst Japan Fund for Poverty Reduction (JFPR) project, and an additional 500,000 newborns were protected against brain damage from iodine deciency. A simple scenario calculation by Frits Van Der Haar of Emory University suggests that the annual
savings to the combined national economies as a result of the initiative may have been as high as $300 million. Table 3.1 gives country details of these data, and Figure 3.1 shows progress in the protection of newborns. The iodized salt coverage data were the latest data available as of 2000, 2004, and 2006. They may not be perfectly accurate but are the best data available. The data show that, regionwide, the proportion of newborns protected against iodine-deciencycaused brain damage increased 25% in 2000 to 59% in 2004 and to 63% in 2006. This means that, annually, 500,000 more newborns were protected due to the initiative's efforts than before the initiative began.
Figure 3.1: Number of Newborns Protected Each Year against the Risk of Brain Damage from Iodine Deciency, 2000–2006
350,000 300,000 250,000 200,000 150,000 100,000 50,000 0 Kazakhstan Kyrgyz Republic Mongolia 2006 Tajikistan Uzbekistan
2000
Source: ADB. 2009. Promoting Universal Salt Iodization in Central Asia and Mongolia, 2001–2007. Experiences of Japan Fund for Poverty Reduction (JFPR) JFPR9005 and JFPR9052. Consultant's report. Manila.
24
Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
Table 3.1: Estimated Impact of Iodization on Iodine Deciency Disorders Prevention Population (millions) Percent of HouseProtected holds Using Iodized Salt Against IDD 3.3 4.3 1.3 1.1 1.3 4.7 16.0 % 43 29 27 45 20 19 26 Year 2000 1999 1997 1998 2000 2000 … Annual Births ('000) Per 1,000 Total Numbers Numbers
Country Azerbaijan Kazakhstan Kyrgyz Republic Mongolia Tajikistan Uzbekistan Total
Total 7.7 14.9 4.9 2.5 6.4 24.8 61.2
Population Number Protected Unprotected 15 14 22 20 21 23 … 115 207 109 51 134 570 1,186 49 60 30 23 27 108 297 65 147 79 28 107 462 888
Initiative Countries, end 2000a
Initiative Countries, 2004 Azerbaijanb Kazakhstan Mongolia
c c c b c
8.2 15.4 5.1 2.6 6.2 26.1 63.6
5.7 12.8 3.0 1.9 1.7 14.6 39.7
70 83 59 75 28 56 63
2004 2004 2003 2004 2003 2003 …
14 17 21 23 31 23 …
115 262 108 60 194 600 1,339
80 218 64 45 54 335 796
34 44 44 15 139 265 541
Kyrgyz Republic Tajikistan Total
Uzbekistan
Initiative Countries, 2006 Situationd Kazakhstan Kyrgyz Republic Mongolia Tajikistan Uzbekistan Total 15.3 5.2 2.6 7.0 26.2 56.3 14.1 4.0 1.9 3.2 13.9 37.1 92 76 75 46 53 66 2006 2006 2005 2005 2006 … 18 21 18 30 23 … 275 109 47 210 603 1,244 253 83 35 97 320 788 22 26 12 113 283 456
Note: Numbers may not sum precisely because of rounding. a Data from ADB Salt Situation Assessments; UNICEF; Population size and crude birth rates from UN Population Reference Bureau reports for the respective years. b Data from UNICEF; Population sizes and crude birth rates from the UN Population Reference Bureau reports for the respective years. c Data from Beijing Conference in 2003. d Data from multiple indicator cluster surveys (MICSs) in late 2005 and early 2006. Source: ADB. 2009. Promoting Universal Salt Iodization in Central Asia and Mongolia, 2001–2007. Experiences of Japan Fund for Poverty Reduction (JFPR) JFPR9005 and JFPR9052. Consultant's report. Manila.
3. Development Impact
25
The initiative conducted sentinel studies, coordinated by KAN, on the effects of both salt and our fortication on women and children in each country in pilot areas: a baseline study in 2003 (December 2002–April 2003), a 1-year follow-up study in 2004 (May–August 2004), and a 4-year follow-up study in 2007). The results for the major iodine-related indicators are summarized in Table 3.2, and for the IDA-related and folic-acid-related indicators in Table 3.3. Comparing the 2003 and 2004 data for children shows the immediate effect of the increases in iodized salt supplies on the iodine status of children in all countries except Mongolia (Table 3.2). The values for
children in 2007 indicate that the improvements were sustained, and by then included Mongolia. Results for women were similar. The urinary iodine indicators for 2004 and 2007 show sustained improvements in women's iodine status, accompanied by the salt measurements, which suggest continuing improved access to adequately iodized salt between 2004 and 2007 in the sentinel sites. UNICEF sponsored two national surveys near the end of the initiative—one in Kazakhstan in 2006 and the other in the Kyrgyz Republic in 2007. The surveys assessed the quality and use of iodized salt in households and the iodine nutrition status of a representative sample of the population.
Table 3.2: Urinary Iodine Measurements in Children 2–15 Years of Age and Women 15–49 Years of Age, by Country Variable Kyrgyz Azerbaijanb Kazakhstan Republic Mongolia Children 2–15 Years: Comparative Data Urine Iodine/Iodine Deciency (ID) Median (μg/L) 2003 154.7 104.5 78.8 68.8 2004 308.1 246.8 133.4 58.6 2007 323.5 187.9 … 118.6 ID, total (%) 2003 10.0 48.8 67.5 63.8 2004 0.0 7.5 25.0 63.8 2007 1.3c 16.2c … 43.0c Mild 2003 7.5 28.8 37.3 27.5 2004 … 7.5 18.1 20 2007 1.3 12.1 … 31.7 Moderate 2003 1.3 12.5 13.3 26.3 2004 … 2.8 33.8 2007 4.1 … 11.4 Severe 2003 1.3 7.5 16.9 10.0 2004 … 4.2 10.0 2007 … … … Women 15–49 Years: Comparative Data Median, total (μg/L) 2004 315.0 213.7 116.8 72.0 2007 334.3 222.7 … 112.4 ID, total (%) 2004 2.5 15.4 30.8 60.0 2007 2.0 19.4 … 40.0 Mild 2004 2.6 5.1 20.5 27.5 2007 2.0 11.1 … 20.0 Moderate 2004 … 2.6 5.15 25.0 2007 … 8.3 … 17.5 Severe 2004 … 7.7 5.15 7.5 2007 … … … 2.5 Yeara Tajikistan Uzbekistan
29.1 94.2 119.8 88.8 56.2 34.3c 16.3 45.2 31.4 42.5 11.0 2.9 30.0 … … 98.3 130.4 54.5 19.3c 40.9 16.1 4.5 3.2 9.1 …
109.3 246.8 136.8 47.7 28.6 16.3 20.2 14.0 … 8.3 17.4 … … 205.4 134.3 5.0 25.7 5.1 22.8 0.0 2.9 … …
μg/L = micrograms per liter. a Women were not included in baseline data; round 1 in Kazakhstan was carried out in December 2002, and 2002 data for this country are in the 2003 lines. b Round 3 in Azerbaijan was carried out in 2005, and 2005 data for this country are in 2007 lines. c sp < 0.05 in comparison with baseline data (for children) or with round 2 data (for women). (p = probability of rejection of hypothesis.)
26
Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
In Kazakhstan, iodine status reached an optimal level in 2005, and compared to similar data collected in 1999 showed that the outstanding improvement of iodine status in the population was associated with signicant improvements in the use and quality of iodized salt in households—more than 90% of the sampled households were using adequately iodized salt. The Kyrgyz Republic survey conrmed that much progress was achieved in improving the iodized salt supply and iodine nutrition status in the population, but revealed that pregnant women (not sampled in the Kazakhstan survey) were still not consuming enough iodine to satisfy their increased dietary iodine requirements. Wheat our fortication resulted in signicant improvement in the micronutrient status of children and women in households where fortied our was regularly consumed, according to the sentinel studies carried out during 2001–2007 (Table 3.3). While the studies were limited to a small group in each country, the reduction in anemia rates and severe folic acid deciency were good evidence of the efcacy of the our fortication. The detailed results have been published separately.22 In summary: Most of the women in the sample population were aware of fortied our and most said they were using it. By 2007, the iron spot test showed that the our used by most households (83%–100%) in all countries was fortied. Baseline data showed high initial rates of anemia in children and women, similar by country to World Health Organization (WHO) data.

Overall anemia rates dropped from 42% to 34% in women and from 35% to 22% in children. Ferritin levels increased in both children and women, showing improvement in iron store status. The overall incidence of low ferritin levels in women dropped from 42% to 24%. Serum folate levels increased in both women and children. The overall level of severe folic acid deciency dropped from 39% to 2% in children and from 13% to 2% in women.
Production and consumption of fortied wheat our across the participating countries remain low. However, the practice of our fortication has been rmly established in the region. While the amount of fortied our being produced is low in comparison to total our consumption, it is clearly making a valuable nutritional contribution to those people who consume it. Flour fortication would need to be greatly expanded to achieve a measurable effect for the general population. Assessing the effect on IDA would be the hardest task, because this condition is inuenced by a number of dietary factors apart from iron intake. Also, it takes years for improvement to occur and become statistically signicant. A decrease in neural tube birth defects through reduction of folic acid deciency would likely occur the fastest, based on experience in other countries. Overall, the initiative's efforts are helping avert human capital and economic loss as discussed in the introduction.
22
S. Tazhibayev, et al. 2008. Evaluation of the Potential Effectiveness of Wheat Flour and Salt Fortication Programs in Five Central Asian Countries and Mongolia, 2002–2007. UN Food and Nutrition Bulletin. 29 (4). pp. 255–265.
3. Development Impact
27
Table 3.3: Anemia, Ferritin, and Folic Acid Measurements in Children and Women, by Country Kyrgyz Variable Yeara Azerbaijanb Kazakhstan Republicc Mongolia Tajikistan Uzbekistan Children 2–15 Years: Comparative Data Anemia (%) Total 2003 2004 2007 2003 2004 2007 2003 2004 2007 2003 2004 2007 2003 2004 2007 20.9 25.0 6.3* 18.6 23.7 6.3* 2.3 1.3 … … … … 15.2 48.7 16.3 50.0 37.5 32.4* 38.8 33.8 25.7 11.2 3.8 6.8 … … … 43.8 53.8 22.9* 15.0 7.9 7.9 13.8 7.9 … 1.2 … … … … … 4.9 51.2 51.2 12.5 8.8 20.3 12.5 8.8 19.0 … … 1.3 … … … 5.0 52.5 16.4 70.0 24.1 20.3* 40.0 20.3 17.4 27.5 3.8 2.9 2.5 … … 8.7 47.4 12.9 31.4 10.5 16.7* 29.1 10.5 16.7 2.3 … … … … … 8.1 5.1 22.6
Mild
Moderate
Severe
Low ferritin level (%)
Folic acid deciency (%) Total
Mild
Severe
2003 2004 2007 2003 2004 2007 2003 2004 2007
85.0 51.9 16.3* 28.8 29.1 12.5 56.3 22.8 3.8
83.3 83.8 18.9* 20.5 56.3 18.7 62.8 27.5 …
97.6 68.8 68.8 13.4 32.5 32.5 84.2 36.4 36.4
85.0 57.5 41.8* 47.5 27.5 39.3 37.5 30.0 2.5
57.5 69.2 4.4* 21.3 33.3 2.9 36.3 35.9 1.5
16.2 7.7 12.0 10.5 6.4 10.8 5.8 1.3 1.2
continued on next page
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Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
Table 3.3 continued
Variable Anemia (%) Total Mild Moderate Severe Low ferritin level (%) Folic acid deciency (%) Total Mild Severe
Yeara
Kyrgyz Azerbaijanb Kazakhstan Republicc Mongolia Women 15–49 Years: Comparative Data 69.2 50.0 64.1 47.5 5.1 2.5 … 50.0 20.0* 57.5 27.8* 45.0 19.4 10.0 8.3 2.5 47.4 25.0 33.3 … 30.8 … 2.6 … … 47.6 52.6 10.0 25.0 7.5 22.5 2.5 2.5 … 25.0 20.0
Tajikistan
Uzbekistan
2004 2007 2004 2007 2004 2007 2004 2004 2007
33.3 37.1 28.2 37.1 5.1 … … 43.6 22.8*
51.3 27.8 43.6 16.7 7.7 11.1 … 28.2 33.3
2004 2007 2004 2007 2004 2007
12.8 10.0 12.8 10.0 0.0 …
65.0 33.3 42.5 33.3 22.5 …
59.0 … 28.2 … 30.8 …
75.0 37.5* 60.0 32.5 15.0 5.0
30.8 17.2 12.8 14.3 17.9 2.9
33.3 24.1 30.8 24.1 2.6 …
sp 40%.
Salt Industry. Number of salt producers, amount of edible salt produced, imported and exported, packaging
Salt locally produced, mainly by AralTuz (80% of national supply) and PavlodarSol. Imports in west and northeast Kazakhstan from the former Soviet Union. Iodization with iodate has been introduced at both AralTuz and Pavlodar. Industry quality and food control practices not yet settled. Health survey in 1999 showed 29% households using adequately iodized salt.
Major salt deposits developed to production under government administration, packagers in Tashkent. Poor packaging, no labeling.
Salt Iodization. % adequately iodized household salt, level mandated, iodine compound, cost of iodized salt
Interstate USSR standard iodate has been introduced. Local processors are equipped. QA, food control, and enforcement practices are weak. Health survey 1997 showed 27% households using adequately iodized salt.
Interstate USSR standard iodate has been introduced. Industry quality and food control practices not yet settled. Iodized salt supplies reportedly up to 80% of total production. MICS 2000 showed 20% households using adequately iodized salt.
No mandatory level stated by government. Local producers and processors equipped but industry quality and food control practices are unclear. Iodate has been introduced. MICS 2000 showed 19% households using adequately iodized salt.
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Appendix 1: History of Food Fortification in Central Asia and Mongolia before the Initiative
41
Table A1.1 continued
Indicator Legislation and Regulation. Principle act, subsidiary norms and regulations
Kazakhstan Legislation pending. In practice, interstate USSR standards still being followed.
Kyrgyz Republic
Mongolia
Tajikistan Legislation pending.
Uzbekistan Government commitment weak. No effort to prepare for legislation yet. No government experience of partnership building. No effort yet made to promote a coalition. National program not yet being considered.
1994 decree Legislation mandates pending. iodization of all edible salt. Parliamentary law being prepared. No effort yet made to promote a coalition. National Council for IDD Control, multisector, chaired by deputy minister of health. National program launched in 1996, main strategy USI. Local budget with UNICEF and JICA support. National survey completed in 1999. Results pending.
National Coalition. Es- No effort tablishment, composiyet made to tion, meeting frequency promote a coalition.
No effort yet made to promote a coalition.
National Program. Acceptance, major components, nancing, budget support
National program being prepared, main strategy USI but also supplements being considered. Dependence on large national surveys. Kazakh Academy of Nutrition well qualied. Government ofcials and industry staff generally well qualied
National program not yet being considered.
National program not yet being considered.
Progress Monitoring. Arrangement, laboratory capacity, reporting
No national surveys, but donor-driven small-scale studies in project areas. Need for training in industry QA, lab capacity weak. Food inspection training needed. UNICEF
Dependence on large national surveys. Endocrinology Dispensary is qualied. Government ofcials and industry staff weak and need training.
Institute of Endocrinology plays central role but relies on small-scale studies. Government ofcials and industry staff weak and need training.
Human Resources. Institutions, training needs, international links
Strong role by Public Health Institute. Links with Japanese and Chinese scientists.
Donor Involvement
UNICEF
UNICEF, JICA UNICEF, Aga Khan
UNICEF
GBAO = Gorno-Badakhshan Autonomous Province, ID = iodine deciency, IDD = iodine deciency disorders, JICA = Japan International Cooperation Agency, MICS = multiple indicator cluster survey, QA = quality assurance, TSH = thyroid stimulating hormone, UIE = urinary iodine excretion, UNICEF = United Nations Children's Fund, USI = universal salt iodization, USSR = former Union of Soviet Socialist Republics, μg/l = micrograms per liter. Source: ADB. 2009. Promoting Universal Salt Iodization in Central Asia and Mongolia, 2001–2007. Experiences of Japan Fund for Poverty Reduction (JFPR) JFPR9005 and JFPR9052. Consultant's report. Manila.
Central Asia from 1991
Prior to its fortication efforts, UNICEF began an anemia prevention and control (APC) program in 1997 in Central Asian countries. The program was
based on education and provision of supplements of iron tablets alone, or iron tablets with folate tablets. At the same time, advocacy efforts were directed to increase acceptance of our fortication.
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Satisfying Hidden Hunger: Addressing Micronutrient Deficiencies in Central Asia
Table A1.2: Wheat Production and Flour Consumption in Central Asia and Mongolia Flour Consumptionb 2006 Population (millions) 8.5 14.8 5.3 2.7 6.6 27.0 64.9 Wheat Consumed Wheat Supplied by Local Production Wheat Production ('000 tons/year) (%) 1,537 10,703 987 123 640 4,186 18,175 89 494 94 47 72 144 ...
a
Country Azerbaijan Kazakhstan Kyrgyz Republic Mongolia Tajikistan Uzbekistan Total
(grams/ person/ day) 428 294 417 212 302 304 ...
('000 tons/year) 1,299 1,623 785 198 626 2,912 7,442
Note: Wheat production gures are average Food and Agriculture Organization (FAO) values for 2003–2005. a This gure for the Kyrgyz Republic was reported to be 64% in 2008. b Flour consumption includes imports and is estimated from FAO wheat consumption values for 2003–2005 using a our extraction rate of 75%. Source: ADB. 2009. Promoting Wheat Flour Fortication in Central Asia and Mongolia, 2001–2007. Experiences of Japan Fund for Poverty Reduction (JFPR) JFPR9005 and JFPR9052. Consultant's report. Manila.
UNICEF initiated two our fortication projects in Central Asia—one in the Kyrgyz Republic in 1995 and one in Turkmenistan in 2000. Both involved fortifying our with iron from ferrous sulfate. The Kyrgyz Republic project also included adding a small amount of iodine to our as potassium iodate, which was used as a bread improver in the United States but also functions as a nutritional source of iodine. UNICEF supplied the ferrous sulfate and the microfeeders for adding it at the our mills. This project faltered in the Kyrgyz Republic when some of the fortied our was found to turn rancid and change color. This is a well-known problem with the use of ferrous sulfate, occurring when an excessively high level is added or the our is stor