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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities 1 Executive Summary ◆ ◆ ◆ ◆ ◆ Over the past 2 years, there has been growing awareness of the potential value for the U.S. Agency for International Development (USAID) to have a standing capability in the Institute of Medicine (IOM) for a more flexible, less costly response to agency needs in the areas of nutrition, food, and health science policy. With support from USAID, the IOM responded in October 1993 by establishing the Committee on International Nutrition (CIN) under the aegis of the Food and Nutrition Board (FNB) and the Board on International Health (BIH). The CIN's mandate is to answer questions of current interest and concern, evaluate current nutrition activities undertaken by the agency, and make recommendations for future activities based on this review. Topics are chosen through systematic consultation with the Office of Nutrition in USAID's Bureau for Research and Development. COMMITTEE CHARGE AND DOCUMENTS REVIEWED This report derives from the first meeting of the CIN, which was held on 14–15 April 1994. The committee's charge—determined by USAID's Offices of Nutrition and of Democratic Initiatives and Health and Humanitarian Resources (DIHHR)—was to review the findings of five nutrition surveys and related surveillance activities conducted in Russia and the Newly Independent States (NIS) by a variety of organizations, including the U.S. government, universities, and private voluntary organizations (PVOs), in order to answer the following three questions:
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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities Question 1: On the basis of the projects reviewed, what can be said about the nutritional status and identification of potential issues of at-risk populations in Russia, such as pensioners, women, and children? Question 2: What indicators and methodologies would be adequate (minimal safety net) and optimal for conducting nutrition monitoring systems in the NIS? Question 3: How can USAID apply the current findings programmatically? The five nutrition surveys and related surveillance activities reviewed by the committee included the Russian Longitudinal Monitoring Survey (RLMS); the Cooperative for American Relief Everywhere (CARE) Pensioner Surveys; the CARE Under-Two-Years-of-Age Survey conducted in urban and rural Russia; the Anemia Prevalence Survey in Uzbekistan; and the Health/Nutrition Early Warning System conducted in Russia, Kyrgyzstan, Uzbekistan, and Armenia. In addition to these five activities, the committee also reviewed the following background information provided to it by USAID: Centers for Disease Control and Prevention (CDC) trip reports and USAID Country Health Profiles for Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan. The committee encountered several difficulties in conducting its review. First, it was not always evident from the documents provided to the committee why the information was being collected. Information verbally provided to the committee by the USAID representatives attending the meeting sometimes conflicted with the written instructions to the CIN. Second, the studies evaluated were diverse in purpose and populations studied; this fact, plus the inconsistent quality of methods across studies, made interpretation of the overall findings difficult. However, many of the studies examined were not yet completed, and thus could not yet provide information that would have been helpful to the committee. Third, because of the sparse information available, a detailed assessment of the nutrition situation in the NIS and an in-depth review of individual programs and projects was not possible, particularly in light of the enormous geographic, ethnic, sociocultural, economic, and political diversity of the NIS and the difficulties in generalizing findings and recommendations for programmatic change. Fourth, most of the documents provided on the nutrition situation in Russia described the situation as of 1992; no data were available on which to base an assessment of the current situation. As a result of these limitations, the CIN was not able to answer the three questions posed to it by USAID to the degree of specificity that it would have liked.
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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities CONCLUSIONS The committee's conclusions on the three questions posed follow. It is important to note that the conclusions were based on a relatively small number of studies representing a diverse region (the NIS). Question 1: What can be concluded about the nutritional status and identification of potential issues of at-risk populations in Russia —for example, pensioners, women, and children? Since almost all surveys in Russia evaluated were conducted prior to or during 1992, the committee's conclusions apply only to the situation up to these times. There were no analyses of longitudinal data from Russia that enabled the committee to evaluate changes in food security or nutritional status during the time periods examined. The CIN made the following conclusions regarding Question 1: Due to lack of appropriate qualitative data, it is not certain that the population groups surveyed were those at most risk of food shortage or nutritional problems. Based on the available documentation, and taking into consideration the apparently high average Body Mass Index (BMI) of the adult population of the NIS prior to the recent social and economic changes, there appeared to be little evidence of energy deficiency or widespread malnutrition in Russia in 1992. There was a high prevalence of overweight up to this time; however, this finding does not preclude the possibility that a gradual weight loss due to energy shortage is currently occurring. In the CARE survey of Russian children under 2 years of age conducted from July to October 1993, there was no evidence of low weight-for-age, height-for-age, or weight-for-height in any age group. Thus, the committee concludes that there was no objective evidence of undernutrition among the Russian children less than 2 years of age who were included in the sample. In the RLMS, anthropometric data were aggregated for children 1–17 years of age, which made their interpretation difficult. With this caveat in mind, this group showed little evidence of undernutrition based on weight or height measures. No longitudinal data were available from the two CARE surveys or the RLMS, so that it was not possible to conclude whether the food and nutrition situation was getting worse at that time. There were some indications, however, that the food system was under stress in late 1992. About half of the pensioners in the CARE surveys answered affirmatively to a question about whether they had a 5-kg weight loss in the 6 months prior to being surveyed. Although the
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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities validity of the amount of weight loss is questionable, there is clearly a perceived food security problem among this group. Although average BMI was not low at the time of the CARE surveys, the distribution of BMIs was not provided to the committee. These data possibly may have revealed a certain proportion of individuals with energy deficit, although this is speculative. The Goskomstat survey (Volgarev, 1992) 1 reveals reductions in meat, fish, dairy product, vegetable, and fruit consumption between 1991 and 1992. Some of the populations surveyed showed evidence of chronic micronutrient deficiencies. Anemia is generally perceived to be a common condition in the region, but the only data available in Russia were from pregnant women (Volgarev, 1992). It is possible that a relatively high percentage of anemia in this group has been exacerbated by recent events, including a shortage of iron supplements. Other chronic micronutrient deficiencies reported in the survey populations included iodine and vitamin D (Volgarev, 1992). Iodine deficiency may be endemic in Russia and the NIS, and iodination of salt may be threatened by new trade barriers and lack of funds to repair equipment. Although the prevalence of mild rickets may be overestimated, there are reasons to believe that women and children are at risk of vitamin D deficiency. The relevance to the nutritional situation in Russia of the mortality data presented could not be interpreted, because important potential confounding variables (e.g., availability of medications) were not considered by the researchers. Anecdotal evidence suggested that consumption of alcohol in the Russian populations surveyed was rising, but the relevance of this finding to food security or nutritional status was not clear. Future analyses of the RLMS data may shed light on this situation. Question 2: What indicators and methodologies would be adequate (minimal safety net) and optimal for conducting nutrition monitoring systems in the NIS? The committee's conclusions on this question were restricted to a large extent by a lack of important information. Information that the committee would have found useful in answering the question includes: the extent to which the current food situation is changing in the NIS and the rapidity of this change, the type and size of role that USAID could play in alleviating any acute or chronic food or nutrition problems, and whether there is concern about collecting information or providing assistance that will improve the sustainability of solutions and monitoring. Based on available evidence, the committee concluded the following: 1 M. N. Volgarev, ed. 1992. Nutrition of the Population of Russia. Moscow, Russia: Institute of Nutrition.
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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities Selection of appropriate indicators and methodologies depends very much on the availability of qualitative information, much of which should be collected locally and in advance of planning. In general, such information should provide a sense of the problems that might exist and their likely causes, whether the problem is likely to be acute or chronic, probable vulnerable groups, options for action, who has need of the information, and how quickly the information is needed. At a minimum, specific qualitative measures should be elicited in advance of any survey and should ideally provide information on such items as recent changes in market food supply, usual sources of income and food and the population groups for whom access to these have changed, rising costs of competing necessities, the functionality of existing food and other safety nets, knowledge about how household food strategies might change under stress, and what kinds of interventions might be possible in a given population in a given region (which requires talking directly with the potential decision makers). It is important to distinguish between the need for data that are vital for revealing undernutrition (e.g., anthropometry) and lack of food security and the data necessary for interpreting outcomes (e.g., economic data). Data collection will be achieved more rapidly and efficiently if restricted to the minimum information necessary to assess the situation and to make comparisons required for decision making. At a minimum, survey measures should include: socioeconomic data, measured weight and height of children (preferably 12–24 months old), BMI of adults, food availability at the household level, and market food security. Optional measures include purchasing power; biochemical analyses including hemoglobin; food intake; prevalence of rickets, goiter, and cretinism; infant feeding practices and availability of appropriate foods for infants and young children; and general indicators of nutritional status and health. The minimum essential data to be collected and the analyses to be performed must be carefully defined before data collection. Dummy tables of results should be prepared from the outset of the survey and likely inferences should be made on which further decisions can be based. Steps should then be taken to ensure that these predefined data get priority at all steps of data collection through analysis, so that results can be quickly returned. Sample sizes in the high hundreds are often sufficient to detect changes in prevalence of outcomes such as BMI and most other anthropometric measures that are important for the kinds of short-term decisions required. Whether a representative regional survey is needed, rather than one focused on specific population groups or regions, will depend on the initial qualitative information concerning likely vulnerable groups, the universality of the food problem, and possible types of action. The need for and timing of repeat surveys depend on the speed with which changes in the situation are likely to evolve.
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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities A surveillance system requires a minimal lag time between data collection and decision implementation, which should be discussed with decision makers. Repeat surveys may benefit from differing sampling frames and changes in the variables collected over time. Decision makers must be identified and involved in the development of any surveillance system for it to achieve effective decisions. Links with existing surveys and activities should be considered both to maximize cost-effectiveness and to assist in interpreting findings. To detect changes in food or nutrition status, a larger sample size is needed for repeated cross-sectional surveys than for longitudinal surveys (where the same household or individuals are monitored continuously). Longitudinal sampling, however, is often more costly and difficult to implement. Criteria must be established to monitor the effectiveness of any surveillance system in terms of information content, timeliness, and usefulness for decision making. Chronic preexisting nutrition problems should be identified and monitored, especially if these are likely to be exacerbated by current crises. Examples include anemia and the need for fortification with iodine, vitamin D, and possibly other micronutrients. Question 3: How can USAID programmatically apply the current findings? The evidence presented to the committee was too out-dated to permit definitive conclusions regarding the current food supply and nutritional status of vulnerable groups or the causes of food-related problems (e.g., a market food shortage versus inadequate purchasing power). There is, however, suggestive evidence of food insecurity, of infrastructural problems that could precipitate a deterioration in conditions, and of preexisting micronutrient deficiencies. The committee makes the following conclusions regarding Question 3: The decision to supply direct food aid should be based on evidence that the national food supply is inadequate. The exception is when direct food aid is carefully targeted to vulnerable groups who consume a relatively small proportion of the total food supply. Assistance with local food distribution and transportation problems may reduce market food insecurity. The nutritional status of the population may be as affected by problems in the delivery of other services as by changes in food supply and purchasing power. These problems might include failures in the social service network; supplies of necessities such as medicines, vaccines, appropriate infant foods, and nutrient supplements; and fortification of food with specific micronutrients.
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Nutrition Surveys and Surveillance Activities in Russia and the Newly Independent States: A Review of USAID-Sponsored Activities Structural changes are needed that may have longer-term impacts on the micronutrient status of the population. These changes include food fortification. There are opportunities for the support of NIS institutions that can take on the task of food and nutrition surveillance. Such support should be achievable at relatively low cost and have a high payoff. The currently high level of interest of bilateral and multilateral agencies concerning the NIS means that there are opportunities for USAID to leverage its food and nutrition monitoring assistance and to increase communication about NIS problems with other organizations.
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