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Documents Reviewed by the Committee

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This chapter provides a brief review of the five general nutrition survey-surveillance activities considered by the committee at its 14–15 April 1994 meeting. For each activity, the members reviewed: the purpose of the project, the characteristics of the population(s) examined, the study methods employed, the quality of study methods, and the major findings that derive from the project. Other documents provided to the CIN as background information also are described briefly. These include the U.S. Agency for International Development (USAID) Country Health Profiles for Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan, and trip reports by Centers for Disease Control and Prevention (CDC) personnel.

Table 2-1 summarizes essential aspects of the above five nutrition survey-surveillance activities.

RUSSIAN LONGITUDINAL MONITORING SURVEY

Purpose

The overall goal of this series of extensive community, household, and individual surveys is to assess the effects of the dramatic macroeconomic reforms on household and individual welfare. Household welfare is measured in terms of the effects of economic reforms on income, food security, and health



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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities 2 Documents Reviewed by the Committee ◆ ◆ ◆ ◆ ◆ This chapter provides a brief review of the five general nutrition survey-surveillance activities considered by the committee at its 14–15 April 1994 meeting. For each activity, the members reviewed: the purpose of the project, the characteristics of the population(s) examined, the study methods employed, the quality of study methods, and the major findings that derive from the project. Other documents provided to the CIN as background information also are described briefly. These include the U.S. Agency for International Development (USAID) Country Health Profiles for Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan, and trip reports by Centers for Disease Control and Prevention (CDC) personnel. Table 2-1 summarizes essential aspects of the above five nutrition survey-surveillance activities. RUSSIAN LONGITUDINAL MONITORING SURVEY Purpose The overall goal of this series of extensive community, household, and individual surveys is to assess the effects of the dramatic macroeconomic reforms on household and individual welfare. Household welfare is measured in terms of the effects of economic reforms on income, food security, and health

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities TABLE 2-1 Description of Five General Nutrition Surveys-Surveillance Activities in Russia and the Newly Independent States (NIS) Evaluated by the CIN Study (dates) Purpose Sampling Frame and Size Survey Methods Data Collected Major Findings Comments Russian Longitudinal Monitoring Survey (1992– ) Assess effects of macro-economic reforms on household and individual welfare. 7,200 households containing 17,179 individuals; nationally-representative sample. Each household and individual to be interviewed at 3-month intervals over a 2–3 year period. Household composition, income, food and nonfood expenditures, agricultural production, morbidity patterns, anthropometry, and food intake. In children, levels of malnutrition modest in comparison with developing countries; energy intake not correlated with household income. In adults, overweight more common than underweight; energy intake increased modestly with increasing household income. In all, food expenditure patterns differed between urban and rural areas, significant proportion of population at or below poverty line. Interview schedules inconsistent; past problems with quality control now being corrected; these factors, plus lack of data analysis and information on sample sizes, complicate interpretation of study data. Only 1992 data available. CARE Pensioner Surveys (1992–1993) Identify 1) high-risk groups of pensioners and risk factors associated with pensioner malnutrition; 2) support systems and coping strategies used Approximately 2,350 pensioners, ages 70–78 years from primarily urban areas in Russia, Kazakhstan, Uzbekistan, and Armenia. Approximately Individuals interviewed at home; single contact except for Armenian sample, where a repeat study was conducted; unavailable individuals were Self-reported food intake, height, weight, weight-loss, and perceived food security. Pensioners appeared to have more problems with availability of certain foods than with income; reported adequacy of diet appeared to be declining and quality of diets for most pensioners was poor; extended family support had a positive effect; pensioners in Sampling frame focused on urban dwellers; thus, findings not generalizable to those living in rural areas; self-reported data on weight, height, food consumption, and changes in food consumption difficult to interpret; potential bias

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities   by pensioners to adjust for decreasing food supplies, and 3) most effective means of coordination and delivery of international food and economic aid. 75% female replaced with alternative subjects.   Armenia were much worse off than those in Russia. Reported recent weight loss was substantial. introduced by replacing losts-to-follow-up with alternate subjects. CARE Under-Two-Years-of-Age Survey (1993) Assess current nutritional status of children < 2 years of age and identify groups and geographic areas at risk of malnutrition. Cluster sample of 2,700 (2,141examined) children and mothers drawn from clients of polyclinics in three regions of Russia: Moscow, St. Petersburg, and Ekaterinburg. Interviews of children's parents, anthropometric assessments of the children, and review of medical records for selected data on nutritional status. Household demographics, socioeconomic status, child feeding history, maternal nutrition knowledge, food security, recent changes in household food consumption, anthropometry, and available data on hemoglobin and red blood cell counts on a subsample. More than 96% of children were breast-fed, but median duration was only 4 months; 43% of households, 27% of mothers, and 13% of children perceived themselves to be in food need according to Cornell Food Security Index; 38% of mothers reported worsening food consumption patterns; however, no objective evidence of child undernutrition was found; children's weight-for-height slightly higher than international reference populations. Only 2,141 participants of the 2,700 sampled were interviewed, inconsistent data collection procedures over time, lack of validated analysis of food intake data, and the uncertain quality of the hemoglobin assays diminished confidence in the findings. Mothers highly educated.

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities Anemia Prevalence Survey in Uzbekistan (1993) Determine the prevalence of anemia and identify potential risk factors for low hemoglobin levels. 1,887 persons (1,414 examined) > 6 months of age in the Muynak District of Karakalpakistan. The district was selected because previous surveys had detected high rates of anemia and because of concerns about extensive environmental contamination with substances that may interfere with normal hematopoiesis. Physical exams for all persons; interviews and health histories for women and children < 5 years of age; venous blood samples for 1,250 individuals. Interview data on demographics, socioeconomic status, and dietary habits; height and weight measured; hemoglobin, hematocrit, red blood cell indices, and leukocyte count from blood sample. Moderately high rates of stunting in infants < 1 year (17%), at 1–3 years (32%), and in preschoolers (32%). Rates in older children declined (12%); 64.5% of children and 36.5% of adults were anemic; 52.6% of adult females were anemic versus 20.2% of males. There was little difference in eating patterns between anemic and nonanemic individuals and by age. Only 1,414 of the 1,887 subjects were actually examined and there was no discussion of potential selection biases; anthropometry could not be evaluated because of examiners' failure to control for such details as removal of shoes during exam; dietary questionnaire elicited information only on foods consumed the previous day; not all laboratory results could be linked with survey information on possible risk factors for anemia.

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities Health/Nutrition Early Warning System (1992) Strengthen epidemiologic information systems so there will be timely warning of disease outbreaks. The Russian component was to establish timely nutritional surveillance of infants, preschoolers, and pregnant women. Pilot study. Data were to be collected by clinic personnel. On children 0–15 years, birthweight, infant feeding status, hemoglobin, evidence of rickets, and demographic data; on pregnant women, age, parity, weight, hemoglobin, history of smoking, and prenatal supplement intake. Not provided. CIN could not ascertain what specific data on food and nutrition status would be available on a routine basis apart from infant feeding practices and prevalence of anemia. NOTE: Eleven USAID Country Health Profiles, prepared in 1992, were also reviewed by the CIN. The brief summaries of the food and nutrition situation in each NIS profile was consistent with more recent information from field surveys. See Table 2-2 and narrative in Chapter 2 for more information on the Country Health Profiles.

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities and nutritional status. USAID and the government are also interested in the effects of structural adjustment on agricultural production, employment, and labor markets. The background document for this project indicates that “it is expected that in many sectors, rapid changes in productivity will result in significant improvements in the quality of life.” Thus, there is the explicit assumption that the series of economic reforms will result in productivity gains that will lead to growth in national income, and in many cases, in household income. However, it is also clear from the materials presented that there is an equally explicit assumption that some individuals and households might be negatively affected in the short to medium term. These adverse effects are assumed to be mediated, in large part, by decreasing real income, caused in part by escalating food prices and removal of broad subsidies on energy and housing. Some publicly provided health services have also been curtailed. USAID and the government of Russia wanted a monitoring system that could identify groups and individuals likely to be affected negatively by structural adjustment in order to design effective “safety net ” programs. To this end, an equally important articulated goal of this project is to upgrade efforts of the Russian government to provide a more effective monitoring and surveillance system. The two primary government groups involved in the monitoring effort include the Russian State Statistical Bureau (Goskomstat) and the All-Russian Center for Preventative Medicine. Beginning in the fifth round, there were also plans for the Institute of Nutrition, Russian Academy of Medical Science, to participate in this consortium. Characteristics of the Study Population(s) The Russian Longitudinal Monitoring Survey (RLMS) is the first nationally representative survey in Russia with the first data gathered July to October 1992. A good deal of attention was paid to the sampling frame, although because of time, cost, and infrastructural constraints, it is a clustered sample. The authors point out that many of the census statistics that Western samplers take for granted were inaccessible or nonexistent in Russia. A three-staged sampling approach was used to draw the sample. Primary sampling units were chosen in stage one; 2,335 official regions were stratified according to 10 quality-of-life regions and the percentage of the area defined as urban. The populations of each were weighted and combined to form primary sampling units (PSU). In stage two, voting districts within each PSU were ordered according to size; from this, 10 districts within each PSU were selected to form 200 secondary sampling units (SSU). Finally, a list of all household addresses was compiled in each SSU from which 36 households were chosen. This method resulted in a final sample of 7,200 households containing 17,179 individuals. Worth noting is the fact that of

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities these 17,179 individuals, 24 percent, or 4,148 individuals, were over 55 years of age. Of the total sample of households, 27.8 percent fell below 100 percent of the Russian poverty line, and 53.7 percent fell below 150 percent of the poverty line. Study Methods The primary emphasis in the study is on households and individual members of those households. At the household level, data are collected on household composition, income, food and nonfood expenditures, and agricultural production. For individuals aged 14 years and older, data are collected on time use, employment patterns, migration history, health service and medical service utilization, morbidity patterns, and nutritional status using a variety of anthropometric measures. For women, information is also obtained on fertility patterns and history of abortion. For children under age 14 years, information on child care is collected. A 24-hour recall is used to obtain information on the dietary intake of all household members. Each household and individual was to be interviewed every 3 months over a 2- to 3-year period. This schedule has been modified somewhat given that it has been difficult to maintain this intensive data collection effort. Thus, the timing on some of the rounds has deviated from the original schedule. Other problems identified after the first few rounds caused additional modifications in the study protocol. Tracking individual identification numbers from one survey round to the next proved difficult. Enhanced quality control measures were, therefore, developed. The extensive individual dietary intake data were to be entered directly in the field to expedite processing and ensure rapid analyses. The researchers found this process produced numerous data entry errors, and an appropriate level of quality control was not possible. Procedures for handling the dietary data were modified, and manual editing and coding of all dietary data is now being done. Given the detailed, multilevel information collected and the lack of funding directed to the rapid analysis of information, it may not be surprising that processing and release of the data has been delayed. Only the data collected from Round One of the survey in July to October 1992 were available at the time of this review. Quality of Methods The sheer magnitude of the data collected has created problems for data quality and processing. It was predictably difficult to link an individual's data from one round to the next. This may compromise one objective of the RLMS,

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities which was to document the effects of structural adjustment policies on an individual's health and nutritional status over time. Additionally, data entry and subsequently data processing have been difficult, and data handling procedures in the field have had to be revised. Major Findings The report contains only descriptive tables with no accompanying text for interpretation. Thus, any conclusions presented here are those drawn by the CIN. The data presented are difficult to interpret, not simply because of lack of interpretation by the study investigators but also because of lack of essential information. None of the tables provided any significance testing of data, nor was sample size information provided. Therefore, obvious anomalies in the data could not be resolved. For example, there were large variations in anthropometric data across and within regions. In one region, 50 percent of female children had weight-for-height Z scores <−2.0 while zero percent of male children in this same region fell below −2.0. This finding may simply be an artifact of small sample sizes, but a final resolution of this issue was not possible because of the paucity of information provided. With such preliminary data, the committee was necessarily cautious in interpreting the results. With this caveat in mind, the following six general conclusions emerged: In children, the levels of malnutrition, either short term (as measured by weight-for-height Z score <−2.0) or long term (as measured by height-for-age Z score <−2.0), were modest in comparison to most developing countries. In adults, overweight as measured by body mass index > 25 is more common than underweight (< 18.5). In adults, energy intake increased modestly with increasing household income. However, with the data provided, it is not possible to ascertain whether this trend was statistically significant. In contrast to adults, children's energy intake did not show a strong response to increasing household income. Food expenditure patterns between urban and rural areas differed for a number of key food groups. For example, 23.5 percent of total food expenditures in the rural areas were for foods in the bread, cereals, and grains category compared to 9.6 percent of expenditures for urban households. These differences in food expenditures are important in predicting the household's response to escalating food prices. A significant proportion of the population was below or near the poverty line, and thus there is concern about falling incomes and their potential adverse effects on food security.

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities CARE PENSIONER SURVEYS Purpose The four objectives of these surveys were to (1) identify high-risk groups of pensioners, (2) identify risk factors associated with pensioner malnutrition, (3) assess main aid support systems and other coping strategies used by pensioners to adjust for decreasing food supplies, and (4) identify the most effective means of coordination and delivery of international food and economic aid.2 Characteristics of the Study Population(s) The approximately 2,350 pensioners examined were primarily from urban areas. The surveys were conducted in five Russian cities (Moscow, Yekaterinburg, St. Petersburg, Irkutsk, and Gagarin) and in Kazakhstan, Uzbekistan, and Armenia. Mean age at the time of first interview ranged from 70 to 78 years across surveys. Approximately three-quarters of those surveyed were female, and a similar percentage of respondents lived in private dwellings. Study Methods The pensioners were surveyed from April 1992 to April 1993. The only repeat study provided to the CIN was that in Armenia (May 1992 and August 1992). Interviews were conducted by survey teams at the home of the pensioner. If, after a certain number of tries (usually three), a pensioner could not be interviewed, another candidate was interviewed in his or her place. Quality of Methods As noted, the sampling frame was limited to pensioners in urban areas; thus, information on pensioners living in rural areas was not available. Another concern with the sampling frame is the potential bias created by replacing people who were lost to follow-up with alternative subjects. Weights and heights, and weight loss, were self-reported. Reported weight loss information may reflect perceived food insecurity, although it is impossible to be certain of this. The self-reported information on food and food changes is difficult to interpret unless one knows whether or not respondents bias their answers to 2   The committee believes this goal was unlikely to be achieved given the nature of the CARE Pensioner Surveys. Also, the means of linking the survey findings to decision making were not made clear to the committee.

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities appear needy. However, some of the data gave insights as to the respondents ' perception about food availability and their household food security. Major Findings Life was getting harder for the pensioners. There appears to have been more problems with market availability of certain foods than with income, and the quality of diet was poor, based on the types of foods reported to be consumed. The adequacy of diet for most pensioners appears to have deteriorated, although this finding is hard to interpret given the concerns about the validity and accuracy of household self-reports. Some regions had enormous amounts of food aid while others did not. It was difficult to assess income and its sources because of the state of the ruble. The official social support system did not appear to work very well because of its failure to adjust salaries and supplies with inflation. There was a coupon system in place in some areas that appeared to work well, but it was overloaded. To remain in this system, pensioners needed to fight for coupons every month. Trade unions may have provided a very good support system, but this finding was difficult to assess because it was not assessed across different areas. However, extended family support did seem to be effective for many. An exception was widows who were Russian-nationals living in other NIS, who live without these supports, and who appear to be a high-risk group. Pensioners in Armenia were considerably worse off than those in Russia. Two problems were identified: the transportation of goods in and out of Armenia and the availability of pension funds. The pensioners in Armenia are more likely to be solitary and living in special homes. CARE UNDER-TWO-YEARS-OF-AGE SURVEY Purpose Studies were carried out from August to October 1993 in three regions of Russia to assess the current nutritional status of children < 2 years of age and identify groups of individuals and geographic areas at particularly high risk of malnutrition. The report, in draft form, was provided to USAID just one month after data collection ended. Characteristics of the Study Population(s) A representative three-stage cluster sample of 2,700 children and mothers was drawn from clients of polyclinics in three regions (oblasts) of the country: Moscow, St. Petersburg, and Ekaterinburg. Two subdomains, the capital city

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities and the surrounding countryside, were examined in each region. The report made available to the committee contained results of 2,141 examinations (79 percent of the sample). It is not clear if the data analyzed represent all regions and subdomains or whether results from selected areas were analyzed preferentially. The group of women studied was highly educated (26 percent completed secondary education or less, 42 percent attended technical college, and 32 percent attended university) and 68 percent were employed, as were 86 percent of their spouses. The mean per capita income was 15,000 rubles, whereas the poverty level was defined as 10,100 rubles as of April 1993. The women had an average of 1.3 pregnancies per woman during the ages 15–19 years and 4.3 pregnancies per woman during ages > 40 years. A total of 49.5 percent of women had at least one abortion (mean + SD = 1.9 ± 1.4 abortions per woman). An estimated child mortality rate of 21 per 1,000 births was reported, but the age of death was not stated. Thus it is uncertain whether this figure represents an infant or child mortality rate. Study Methods The survey consisted of interviews of the children's parents, anthropometric assessments of the children themselves, and a review of their medical records for selected data on nutritional status. The interviews included questions on household demographics (including maternal fertility and estimated infant mortality) and socioeconomic status, child feeding history, maternal nutrition knowledge, and food security and recent changes in household food consumption. The children's body weights were measured, and previously obtained weights and heights were transcribed from clinic records. Finally, results of previous analyses of hemoglobin and red blood cell counts were recorded from a subsample of children for whom these data were available in the polyclinics. Quality of Methods Results of the food frequency questionnaire could not be interpreted because the method of analyzing and expressing the data has not been validated. Likewise, the questions on maternal nutrition knowledge do not seem useful because some definitions of adequate knowledge that were applied do not conform with current scientific consensus. The anthropometric assessments were completed with appropriate standardization procedures, and “acceptable” precision and accuracy were appaently achieved. Interpretable historical records were available for 96 percent of children, with an average of 6.8 records per child. Eighteen percent of the

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities children's data was excluded because of implausible outliers or missing information. Major Findings More than 96 percent of the children had ever been breast-fed, but the median duration of breast-feeding was only 4 months. Other liquids and foods were introduced earlier than is currently recommended in the United States. For example, water was usually given by 1 month, fruit juices by 1–2 months, and eggs and cheese by 3–4 months. Less than 4 percent of infants were still being exclusively breast-fed at 4 months, and 82 percent of infants 0–5 months of age had received bottles of milk or formula. The questions on food security indicated that 43 percent of households, 27 percent of mothers, and 13 percent of children perceived themselves to be in need of food, as indicated by a positive response to two of four items in the Cornell Food Security Index. Thirty-eight percent of the families described their food consumption as worse than the previous year, 47 percent as the same, and 15 percent as better. Those who felt their situation was worse cited less consumption of fruit, vegetables, meat, and milk due to lack of financial resources. Because there are no historical data for comparison with these results, the interpretation of these findings is problematic. The children's current weight-for-age distributions were slightly higher than the international reference population. Retrospective information provided generally similar results, with only a small magnitude of change over time. Nevertheless, because of inconsistent age patterns and concerns about consistency of data collection procedures over time, it is difficult to interpret any possible time trends. The mean ± SD birth weights were 3,316 ± 501 grams, and only 4.8 percent were less than 2,500 grams. The hematologic assays are of uncertain quality and results were available for only 51 percent of children since January 1993. The mean hemoglobin concentration was 124 g/liter, and 12.4 percent of children had a concentration < 110 g/liter. In conclusion, this survey was conducted in a well-educated population with reasonably high rates of employment. Nevertheless, per capita income was marginal in relation to the cutoff used for establishing poverty levels. There was a very high abortion rate, and abortion apparently is used as a major form of contraception. Infant mortality rates were uncertain. Although there were high rates of initiation of breast-feeding, it was of relatively short duration, and there was virtually no exclusive breast-feeding. A sizable proportion of the families studied reported perceived food insecurity and worsening food consumption patterns, apparently because of lack of purchasing power. However, there was no objective evidence of child

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities undernutrition by anthropometry. Although there were slightly elevated rates of anemia of undetermined etiology, it is unknown whether this is a chronic problem or a recent phenomenon. More analyses of these findings by specific risk factors, such as urban-rural residence, employment status, and so on, would be useful. ANEMIA PREVALENCE SURVEY IN UZBEKISTAN Purpose To understand the extent and etiology of anemia in the NIS, the USAID Office of Nutrition funded anemia surveys in Uzbekistan, Russia, and Kazakhstan using micronutrient funds designated for the NIS. Preliminary data were available from the Uzbekistan survey, but the surveys in Russia and Kazakhstan are in the preliminary stage. The Uzbekistan survey was conducted in the Muynak District of Karakalpakistan, Uzbekistan, from 17 May through 24 June 1993 to determine the prevalence of anemia and to identify potential risk factors for low hemoglobin concentrations. This district was selected because previous assessments had apparently detected high rates of anemia and because of concerns about extensive environmental contamination with substances that may interfere with normal hematopoiesis. Characteristics of the Study Population(s) A total of 1,887 individuals greater than 6 months of age was selected from the district's household registry of 27,000 residents for inclusion in the study. Of these, 1,414 subjects were actually examined at the Central District Hospital (76.7 percent recruitment rate). No discussion was provided regarding possible selection biases. At the time of preparation of the report that was provided to the committee, laboratory results were available from 1,250 of the subjects. Interviews were conducted on the subjects' demographics, socioeconomic characteristics, and dietary habits. Health histories were recorded for children < 5 years of age and for women, and physical examinations were completed for all study participants. The subjects' weight and height were measured, but the specific measurement procedures were not described in the report. A venous blood sample was obtained for hematologic studies (hemoglobin, hematocrit, red blood cell indices, and leukocyte count by Coulter counter), and samples of blood serum or plasma (it was unspecified as to which were used) were saved for future biochemical analyses. The methods of handling and processing of the samples and the proposed future analyses were not described in the reports presented to the committee.

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities Quality of Methods Concerns were raised by the committee about the quality of the anthropometric data because of the examiners' failure to control such details as removal of shoes and possibly other articles of clothing before the examinations. The questionnaire on dietary habits elicited information on consumption of selected foods on the previous day. The results were expressed as any consumption of a food from individual food groups. Although this information may be a useful indicator of food availability-accessibility, it is of limited value in nutritional terms. Major Findings Information was provided on the children's birth weights, but the source of these data was not indicated. The mean ± SD birth weights were 3,359 ± 498 grams; 2.5 percent males and 7.1 percent females had birth weights < 2,500 grams. The anthropometric data indicated that there were moderately high rates of stunting (defined as height < −2 SD with respect to international reference data) among infants aged < 1 year (17 percent), toddlers aged 1–3 years (32 percent), and preschoolers (32 percent). The rates of stunting declined in older children (12 percent). It is not certain whether these age-related differences reflect temporal trends in the population's nutritional well-being, age-specific differences in nutritional status, or methodological problems. There was no evidence of wasting in any age group. Results of the hematologic survey were presented in terms of prevalence of anemia, but definitions of anemia for each age group and trimester of pregnancy were not provided in the report. Accepting the authors ' unstated definitions, 64.5 percent of children and 36.5 percent of adults were apparently anemic. There were no sex-specific differences in prevalence rates among the children, but the rates in adult females (52.6 percent) were significantly greater than in adult males (20.2 percent). Adult females were not disaggregated by pregnancy or lactation. Because of problems with record identification, not all laboratory results could be linked with survey information pertaining to possible risk factors for anemia. Among the available complete records, there was little difference in the eating patterns of anemic and nonanemic individuals, except perhaps among the elderly. It is notable that a number of high-quality foods, including milk and meat, are being consumed by a large proportion of individuals, although the amounts consumed are unknown. There were few age-related differences in food consumption patterns for children beyond infancy and adults. A high proportion of individuals (85–100 percent) consumed cereal or tuber staples, milk, meat, fats, and sweets on the previous day; relatively few consumed vegetables (40 percent) or fruits (20

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities percent). It is unknown whether these consumption patterns have changed or are the same as historical ones. Eighty-five percent of the children less than 42 months of age had ever been breast-fed. The median duration of nursing was approximately 18–23 months. Most infants received water (90 percent), tea (72 percent), milk (17 percent), or fruit juice (8 percent) by 3 months of age. HEALTH/NUTRITION EARLY WARNING SYSTEM The CIN was provided only with brief reports by CDC personnel involved in or planning Emergency Public Health Information Surveillance System (EPHISS) activities. No results were available and thus the following description only summarizes the intent of the activities. Purpose This early warning system was initiated in the NIS as an Interagency Agreement with the CDC's EPHISS to assist health officials in Russia, Kyrgyzstan, and Uzbekistan. The purpose was to strengthen epidemiological information systems so that there will be timely warning of disease outbreaks. In Russia there were plans to include a longitudinal survey on nutritional status, food consumption patterns, and purchasing power. Due to delays and failure of the Russian government to respond, the food surveillance component was not achieved. Nutrition assessments were conducted in Russia and Kyrgyzstan. In 1992, EPHISS activity was started in Armenia, which was the only such activity that had a pediatric and elderly nutrition monitoring component.3 Methods The plan in Russia (and apparently in other NIS) was to implement the nutrition surveillance system in three phases over a 3-year contract period starting in 1993. The purpose was to establish timely nutritional surveillance of infants, preschoolers, and pregnant women in order to enable decision makers to protect the nutritional status of these groups. A pilot project was established in Yekaterinburg with the Nutrition Institute, Ministry of Health, and the Yekaterinburg Sanitary Epidemiological and Surveillance (SES) group. The pilot phase included the development of forms, procedures for data collection, 3   Preliminary results of this survey were published in the Armenian Monthly Public Health Report, 14 November 1993, which was made available to the CIN at the end of its meeting. This survey describes a relatively high prevalence of stunting in infants 12–24 months of age, a gradual loss in BMI in 100 pensioners between June and December 1993, and evidence of sharp increases in food prices.

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities and standard tables for data analysis. In the second phase, pediatric nutrition surveillance was to be instituted in four oblasts. In the third phase, surveillance extended to all oblasts. Infant data were to be collected from polyclinics (pediatric clinics) that serve children 0–15 years of age. These data include birthweight, infant feeding status, sex, date of birth, weight, height, hemoglobin (at 3–4 months, 12 months, then yearly), and evidence of rickets. Data on pregnant women were to be collected after updating the pregnancy nutrition surveillance system, and they focused on age, parity, prepregnancy under- and overweight, hemoglobin, smoking, and prenatal supplement intake. Clinic personnel were trained, and a data entry and dissemination system was developed. Data quality is being assessed systematically. Findings Because data were not presented to the committee, no review could be performed. OTHER DOCUMENTS PROVIDED AS BACKGROUND Country Health Profiles As background, the CIN reviewed 11 USAID Health Profile Desk Studies on the NIS prepared in April 1992. For the most part, the brief summaries of the nutrition and food situation provided in the NIS health profiles were consistent with more recent information provided in the field surveys. In a few cases, they alerted the CIN to issues related to nutrition that did not surface in other documentation. In addition, the basic demographic data (based on U.S. Bureau of the Census analyses) in the health profiles allowed a minimal level of cross-country comparison (Table 2-2). Comments Concerning Nutrition Situation from Country Profiles The following are some of the specific food and nutrition situation assessments obtained from the health profiles that the CIN found to be of particular interest. Kazakhstan Anemia prevalence among pregnant women was reported to be 50–75 percent. The consequences that are noted were not, however, the usual primary concerns related to maternal anemia. The report mentions lactation failure, infection, and cancer as the main consequences. Child malnutrition was not reported to be a problem as of early 1992, although 20–40 percent of children were reported to be anemic.

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities TABLE 2-2 Comparison of Indicators from Country Health Profiles of the Newly Independent States (1992 Report)   Population (millions) Life Expectancy IMR (1990 adjusted MMR (1989) TFR (1990 adjusted) Country   Males Females       Armenia 3.3 69 74.7 35 34.6 2.7 Azerbaijan 7.1 67 74 44 29 2.8 Georgia 5.5 68.1 75.7 33.4 54.9 2.2 Kazakhstan 16.4 63.9 73.1 44 53.1 2.9 Kyrgyzstan 4.4 64.3 72.4 54.2 42.6 3.9 Moldova 4.4 65.5 72.3 33.9 34.1 2.5 Russia 148 64.2 74.5 22.1 49 2.0 Tajikistan 5.3 66.8 71.7 72 38.9 5.2 Turkmenistan 3.6 61.8 68.4 94 55.2 4.4 Ukraine 51.8 66.1 75.2 22.1 32.7 2.0 Uzbekistan 20 66 72.1 64 42 4.1 NOTE: IMR, Infant Mortality Rate; MMR, Maternal Mortality Ratio; TFR, Total Fertility Rate Kyrgyzstan Prior to 1992 childhood malnutrition was reported by feldshers4 to be 10 percent (no specific criteria mentioned). The profile predicted that as early as late 1992, childhood malnutrition rates could increase significantly due to the combined effects of rising food prices, declining purchasing power, and the decline in the number of milk kitchens and school feeding programs. Iron deficiency was reported to be common among infants and pregnant women. Russia Anemia prevalence among pregnant women was reported to be 20–25 percent and as high as 30–35 percent in Siberia and northern Russia. The profile suggested that as of 1992, protein-energy malnutrition had not been seen to any significant extent in Russia, but that micronutrient deficiencies were fairly widespread due to poor dietary patterns. For example, animal products were becoming scarce and expensive, vegetables were scarce, and fruits had never been a big part of the Russian diet. Iodine deficiency disorders were reported to be prevalent in parts of Russia and a number of other NIS. Constraints to iodination of salt were reported to include the use of older, less-stable methods and the use of old, outdated equipment. Tajikistan Micronutrient deficiencies were reported to be a significant problem. Goiter had been noted, particularly in remote, mountainous areas. The 4   According to Webster's Ninth New Collegiate Dictionary, a feldsher is “a medical or surgical practitioner without full professional qualifications or status in some east European countries and esp[ecially] Russia ” (1984, Merriam-Webster, Inc., Springfield, MA, p. 455).

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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities prevalence of anemia among women was officially reported to be 20 –30 percent, although informal estimates were much higher (e.g., 60 –70 percent). Protein-energy malnutrition among children (second-and third-degree malnutrition) was reported to be 10–12 percent, and the median length of breast-feeding was 12 months. Turkmenistan As of 1992, meat, rice, flour, and sugar were rationed. Vegetables were very expensive. Anemia was listed as one of the four major health problems, along with diarrheal diseases, hepatitis, and tuberculosis. Breast-feeding was reported to be declining, but no prevalence levels of nutritional deficiencies were reported. Ukraine It was reported that both health officials and the public were concerned about breast-milk being contaminated due to the Chernobyl accident. As a result considerable effort had gone into development and improvement of infant formula. No breast-feeding data were reported. Food supply in 1992 was said to be better than in other NIS. Intake of cereals, potatoes, meat, dairy products, and sugar was good, but consumption of fruits and vegetables was very low and was reported to have decreased by 20–30 percent between 1990 and 1991. Uzbekistan Food shortages were not yet as severe in 1992 in Uzbekistan as in a number of other NIS because it had a relatively good agricultural base. When it was part of the Soviet Union, Uzbekistan was the main exporter of fruits and vegetables to the rest of the union. Anemia prevalence among pregnant women was reported to be 70 percent on average and higher in rural areas. CDC Trip Reports The committee also reviewed two trip reports by CDC personnel. The first included reports by the Institute of Nutrition in Moscow. Among these was a position paper on Nutrition of the Population of Russia—edited by M. N. Volgarev and published in 1992—containing the following: nutrition data from the previous 4 years; a report on plasma micronutrient values with data from convenience samples of about 25,220 adults in different regions of Russia from 1983–1992, 100 school children in four regions, and 100 infants between 1989–1991 in polyclinics in Volga and northern Siberia; and data from the Russian State Committee on Statistics (Goskomstat) Family Food Consumption Survey that has been continued for 4 decades and now includes 49,000 Russian families. These data include food production and consumption by households and were available through 1991–1992 (Volgarev, 1992). A separate CDC report of a trip to Kyrgyzstan in September 1993 provided a review of more current data on the nutrition situation.