Undernutrition in Armenia: A Matter of National Security

An estimated 171 million children under the age of 5 are stunted in the world, according to the World Health Organization (WHO). Of those 171 million, 115 million suffer from wasting; 20 million from acute malnutrition; and almost 4 million die each year from health problems related to undernutrition. In other words, over 10,000 children die each day from an easily preventable condition.

Undernutrition affects children all over the world, from industrialized countries like the U.S., where 49 million people are at risk of hunger, to impoverished regions like Somalia, where 42 percent of children under 5 suffer from stunting. In Armenia, stunting affects roughly one in five children, according to the 2010 Armenian Health and Demographic Survey (ADHS), released in April 2012.

Stunting, which is the result of long-term undernutrition, can be observed in the below-normal height of a child. Undernutrition reflects chronic or acute malnutrition. The consequences stretch beyond what meets the eye—beyond the missing inches in height: It can be detrimental to the health of a child, increasing susceptibility to illness and disease. It can also have a devastating impact on a child’s emotional and social behavior, and cognitive (learning) functions, and can even cause death. Stunting “is often impossible to correct” according to UNICEF. Wasting, in turn, is a sign of acute malnutrition. It “describes a recent severe process that has produced substantial weight loss, usually as a consequence of acute shortage of food, severe disease, or both,” notes the ADHS report.

Malnutrition is not just a tragedy on the individual level, but a national disaster in the eyes of Kim Hekimian and Richard Deckelbaum, lecturers at the Institute of Human Nutrition at Columbia University. “Imagine if almost 20 percent of Armenia’s already diminished population cannot reach their full potential as a result of chronic malnutrition. The implications are disastrous… Developing long-term strategies for improving childhood nutrition is an investment in Armenia’s future and critical to its survival,” they stated in a project proposal aimed at improving the nutritional status of children in Armenia.

The quality and variety of food, more than the quantity, lie at the core of the problem in the country. Children in Armenia are not receiving proper nutrition as a result of “poverty, food prices, competition for household resources caused by globalization, and greater access to over-processed foods via supermarket expansion,” Hekimian, who is also a visiting professor at the American University of Armenia (AUA), told the Armenian Weekly.

Hekimian and Deckelbaum recommend developing educational initiatives geared towards healthcare professionals, policy makers, pregnant women, and mothers; agricultural programs to ensure the availability of nutritional food products; the administration of medical tests that determine treatable causes of malnutrition (i.e., celiac disease, enteric parasites, and cow’s milk allergy); and the distribution of micronutrient supplements, if necessary.

The successful eradication of the problem hinges on awareness-raising and education on the one hand, and intervention on the other. “We want to measure the knowledge of caregivers—mothers and grandmothers—because they probably don’t know about the importance of iron and protein for little ones, thinking that bread and potatoes are filling, nutritious, and relatively cheap,” said Hekimian. “Evidence suggests that both poor and wealthy families have stunted kids.”

“The reason we don’t have stunted growth in the U.S. is not because of our GDP but because of the fortified foods we give our babies,” she explained. “The pediatrician recommends that at six months you give rice cereal, which is fortified, as are our pastas and breads.”

According to Armenia’s Ministry of Health, the rate of folic acid deficiency is about four times higher in Armenia than it was in the U.S. before the country began flour fortification. The effects of folic acid deficiency can be seen in the high rate of neural tube defects in babies in Armenia. Children can be anemic, but not have low iron stores. There is only one national data set on anemia in Armenia, conducted by the ADHS in 2005, and it shows a high level of anemia in children. Hekimian’s team at Columbia would like to further research blood iron levels in children, as the ADHS survey only looked at overall hematocrit and hemoglobin levels.

Over the past 10 years, the ADHS report, which is conducted by Armenia’s National Statistical Service (NSS) and the Ministry of Health, has been the only ongoing and nation-wide survey in the country. Hekimian and Deckelbaum hope to conduct further research on the causes of undernutrition in Armenia because a solid set of data is the first stepping stone. They plan to evaluate and monitor the nutritional status of 1,500 children and their mothers during their proposed five-year project. The team will explore the factors that contribute to stunting—including medical, socio-economic, and behavioral conditions. Children will be tested for anemia, celiac disease, and parasites. Treatments will be administered and educational programs will be set up.

The results of a concerted effort are evident in the Talin region, where World Vision Armenia has done work on undernutrition through agricultural, nutritional, and health interventions. Within years, the rate of stunting decreased notably, Hekimian pointed out.

A two-week workshop on nutrition at AUA, with the participation of Columbia University faculty, is also in the plan, geared towards policy makers, parliamentarians, and members of the ministries of health, agriculture, economy, and education. The aim is to encourage a national system-wide structural intervention for greater and long-term impact.

“There is interest among policy makers and national and international stakeholders. I hope that translates into action,” said Hekimian.

For Hekimian, proper nutrition is a matter of national survival. “As an Armenian, and somebody who is worried about the future of Armenia as a whole, I really think that this is a national security issue. There are so many factors that are leading to a diminished population: We have out-migration for economic reasons; we have low, less than replacement rates of fertility; we have increasing rates of premature mortality from chronic illnesses like diabetes; and on top of that, for the small population we have left, we have essentially a situation where one in five children is not going to reach his/her potential.”

Armenia’s Ministry of Health’s Department of Maternal and Child Health, UNICEF, Columbia University’s Institute of Human Nutrition, the Fund for Armenian Relief (FAR), World Vision Armenia, and the American University of Armenia’s College of Health Sciences are ready to collaborate in the implementation of this long-term plan. FAR, for instance, sent Deckelbaum to Armenia in November 2011. Next, the team will have to secure funding for the project—and funding they will need, as the cost of importing lab equipment will be costly.

Breastfeeding in Armenia

Today, Armenia’s Ministry of Health recommends that children up to six months old be exclusively breastfed, because breast milk provides all the nutrients needed by the infant, and limits exposure to illness. However, the ADHS report shows that only 35 percent of children under 6 months are exclusively breastfed, and \ worse, some are also given solid food. “Among breastfeeding children age 6 months and younger, 19 percent received complementary foods, a practice that can be detrimental to the child’s health,” read the report.

In 1993, the dominant opinion did not support exclusive breastfeeding, and the diets of children under the age of four months were supplemented with other foods. “The medical school curriculum in all Soviet countries taught physicians that mothers must complement breastmilk with vegetable and fruit juices. There had not been a legacy of exclusive breastfeeding in Armenia. There had not been in the United States for a long time as well… This is not a Western versus Soviet issue,” noted Hekimian.

In Armenia, breastfeeding children under 4 months increased to 20 percent in 1997. “There was an incredibly successful coordination of strategic intervention for four years in Armenia, paid for by USAID and UNICEF,” she explained. “[It included] a social marketing campaign that involved TV, radio, brochures, and newspapers. They also paid for the in-service retraining of all pediatricians, Ob/Gyns [obstetricians, gynecologists], and most nurses in the field.” They also changed the medical school curriculum on breastfeeding, and related policies at the Ministry of Health. USAID completely halted the distribution of infant formula as humanitarian aid. “After this campaign of four years, infant mortality rate from diarrhea decreased significantly. Now the rate of death of newborns from diarrhea is extremely low in Armenia,” Hekimian said.

The popularity and availability of infant formulas peaked after the 1988 earthquake tore through Armenia. Soon after, the Ministry of Health encouraged donations of infant formulas. Many diasporan and international organizations responded with an influx of baby formulas. At the time, it was not known that the formulas would precipitate a set of different problems.

“People were scared; their country was in economic turmoil; they didn’t have electricity; they didn’t know where their next meal was coming from; and they had the opportunity to get free infant formula and thought it was better for their babies. As soon as they started giving them the formula, their breast milk dried up—because that’s what happens in the supply-demand curve. They didn’t have enough infant formula supply to raise their kids until the age of six months. So they started to give teas, madzoon [yogurt], and cow milk instead, and there were children dying from diarrhea,” explained Hekimian, who in 1993 highlighted the negative impact of infant formula in Armenia while teaching and researching at AUA.

Hekimian is proud of how far the country has come in 20 years. “From 1997 until 2010 there have not been national breastfeeding promotion campaigns, and it still went up from 20 percent to 35 percent. I read that 35 percent number in a very positive light. Compared to where we were in 1993, it is a tremendous gain. With each percentage increase in breastfeeding, you’ll see a corresponding decrease in the percentage of morbidity and mortality in infants. The number of moms of children aged 6 months who report giving any breast milk at all is close to 90 percent; in the U.S., I don’t think that’s even at 50 percent. So what we need to do is to continue the breastfeeding behaviors and change the supplementing behaviors,” she said, but cautioned that exclusive breastfeeding for the first six months is not protective of eventual stunting, as children are still at risk past that age.

During their research in the village of Tsamakapert, where a number of children are stunted, Hekimian paid special attention to the children’s diet. “What I realized is that these kids eat potatoes and bread morning, noon, and night. They’ll have something like jarit, fried potatoes with bread in the morning, and then they’ll eat some kind of soup that has potatoes in it in the afternoon, and then puree [mashed potatoes] at some point, or the blinchig, which is the flour pancake that is covering the potatoes. It’s delicious food; it’s calorically high and very filling; and it gives the short spurt of energy. So the kids are running around and playing soccer the whole day out on the village road, they come in and have their blinchig, puree, hats [bread], and may be banir [cheese]—which is fine because banir has some protein and some calcium in it, but no iron—and he runs back out. So the mothers are not seeing that the children are malnourished, because they’re not hungry. This is called chronic undernutrition, not acute undernutrition.”

Micronutrient deficiencies can be detrimental to children, and may lead to illness and death. Foods rich in vitamin A and iron are essential to the health of children. For instance, vitamin A—found in milk, eggs, fish, butter, carrots, etc.—supports a healthy immune system, protects children against infections, and helps in the recovery from illness. Iron too is essential to the development of children; consuming low levels of it can lead to anemia. The ADHS report showed that 75 percent of the surveyed children consumed foods rich in vitamin A during the 24 hours preceding the survey, and 68 percent consumed iron-rich foods, such as meat, fish, poultry, and eggs.

2010 ADHS survey findings

Over 1,400 children participated in the ADHS survey. The results showed that 19 percent of children were stunted, and 8 percent severely stunted. Stunting appears to be more common among children born to mothers with less education, and is only “slightly” more prevalent in rural households compared to urban ones. However, there is no clear correlation between wealth and stunting.

The survey revealed that children 36-47 months old are the most likely to be stunted (26 percent), followed by those 24-35 months old (21 percent), while 9-11 month-olds are the least likely (13 percent). Children smaller at birth are more likely to be stunted (26 percent) compared with larger babies (19 percent). Seven percent of babies in Armenia are born with low birth weight. According to Hekimian and Deckelbaum, this means that stunting most often occurs after delivery, and therefore can be prevented. Out of the 11 regions, stunting is lowest in Yerevan (11 percent), and highest in Syunik (36 percent), Aragatsotn (32 percent), and Ararat (29 percent).

Four percent of children under five years old are wasted. Babies up to 6 months old are more likely to be wasted than children age 6-59 months. Wasting is highest in the Ararat region (12 percent), followed by Gegharkunik (7 percent), and lowest in Tavush (one percent).

Five percent of children in Armenia are underweight. Children in rural areas are more likely to be underweight than those living in urban areas (7 percent and 3 percent, respectively). As with stunting, the percent of underweight children is higher in low-income households, and with less-educated mothers. There is a correlation also with the birth interval, where children born 48 months after a previous birth are more likely to be underweight (8 percent), compared to children born 24-47 months apart (3 percent). The percent of underweight children is highest in Ararat (17 percent), and lowest in Kotayk and Yerevan (2 percent).

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