Fund for Armenian Relief:

Trend analysis of nutritional status of children.

The survey in 2000:

According to ADHS 2000, nutrition in women and children are assessed through
breastfeeding and supplementary feeding. The results showed that the breastfeeding was
carried out in most of the household. Around 88 percent of the children born before 5 years
from the beginning of the survey were breastfed. The survey also mentions that the frequency
of breastfeeding varies within a region. The breastfeeding practices differ in rural and urban
areas. Urban children are more likely to be breastfed within one hour after birth compared to
the children in rural areas, who were more likely to be fed in more than one hour after birth. 1

In the same survey on exclusive breastfeeding it was shown that, 95% of the children who
were breastfed, only 45% were exclusively breastfed below four months of age. The remaining
children were fed with non-breast milk, water, and solids or mushy food. Data also mentions
that around 34% of children under four months were fed through bottles with nipple.1All this
shows that there was a need to improve breastfeeding practices, as it is essential to exclusively
breastfeed children for six months for optimum nutrition and health. 2

Complementary feeding is advised for children from 6 months of age. It is necessary to

introduce supplementary food to children to assure their nutrient requirements for optimal
growth.2 The survey conducted to analyze supplementary feeding practices showed that higher
percentage of children below six months of age were fed with other forms of food, such as
infant formulas, dairy products, and other liquids. Though these food types were fed
infrequently, it proved that even small amounts of these food have adverse effects on the overall
health of the children.1 Talking about the diversity of food introduced, the number of the
supplementary food varied between breastfed and non-breastfeed children and food primarily
involved bread, cheese, yogurts, vegetables, and fruits.1

Considering Armenia is a mountainous region, it is necessary that the food is adequately

supplemented with iodized salt as the iodine in the soil in these region tend to leach out.
According to the survey, almost 84% of household uses iodized salt to adequate amount but
this varies in regions and in Tavush, it is significantly lower that is around 54% of the
household. Another micronutrient deficiency that has been reported to be a concern is Iron.
Less than 2% of women have reported taking Iron supplements during pregnancy.1 On the
analysis of anemia, 24% of children suffer from anemia and prevalence of anemia varies among
regions and highest being Tavush region (39%). Anemia in women is highest in Syunik region
20%. The rates of anemia are found to be climate dependent according to the survey, where it
was is more prevalent in October to December, before the time of harvest. 1

Stunting rate in 2000:

According to the anthropometric measurements in 2000, it was found that 13% of the
children were stunted and 3% were severely stunted in Armenia, and this is more prevalent in
the Gegharkunik region. (As shown in the chart below, ADHS 2000). The reason for this
difference in the rate can be due to the region, education of a mother and many other factors as
stated by the study. 1

Wasting and underweight survey mentioned that around 2% were wasted and 3% were
underweight in Armenia.1
Maternal health status plays a vital role in the children’s health status.2 For this reason, it is
essential to understand and analyze their nutritional status as well. According to the BMI and
height measurements, over 27% are overweight, and 14% are obese. The survey also highlights
that more than half of the older women (35 years and older) are obese showing that most
women failed to lead a healthy lifestyle as they get older.2

Survey 2005:

This survey showed that the significance of breastfeeding was well recognized in Armenia
compared to 5 years back. The State adopted program on breastfeeding, which apart from being
supported by UNICEF and WHO, was in conjunction with Baby-friendly Hospital Initiative
(BFHI) and this BFHI was expanded to many maternity hospitals.3

There was a substantial increase in breastfeeding practices compared to 2000, from 88% to
97% children were breastfed. Among these children, 28 percent were breastfed within one hour
of birth, and 62 percent were breastfed within 24 hours of birth, but this rate would vary in
different regions.3. Coming to exclusive breastfeeding, one third of children were exclusively
breastfed, showing that there has been an increase in the number of exclusively breastfed
children (30 to 33%). Also there has been an increase in the rate of children receiving breast
milk along with complimentary food by 3%.3 Among 6-8 months children, there has been a
significant change in the percentage of children receiving breast milk and complimentary food
from 2000 to 2005, 56% to 63% accordingly.

There was a significant decline in the number of children under 4 months, who are exclusively
breastfed (45% to 37 %). The diversity of complementary food received varied in the rates,
where 4 percent of breastfeeding children under six months received infant formula, 21 percent
received other milk, and 68 percent-or two in three children-received cheese, yogurt or another
milk product and 16% ate solid and semi-solid foods. All these indicate that Armenia followed
a poor feeding habits, as feeding these to children can prove to be detrimental. According to
the survey, 84 % children (6-23 months) were fed various foods, and 62% of those children
were fed the minimum number of times required for optimal health. There is 10 % (59 and
49%) difference between urban and rural in term of adhering to the guidelines recommended
for feeding. 3
Anemia rate among children was 37%, and one-half of these children are suffering from
moderate anemia and 1 % from severe anemia. This rate also varies according to the region
and highest prevalence is in the Gegharkunik region. Hence, comparing this from the previous
year we can see a significant increase, almost 50% increase in anemia rates primarily in
Yerevan (13 to 45) and Gegharkunik region (32 to 63%).3 Other micronutrients were also
checked for, where they revealed that 56 % children consumed vegetables and vitamin A rich
fruits, 24 hours before the survey and only 2 % were given deworming medications, because
worms can also lead to anemia and vitamin A deficiency.3

Around 5 % of Armenian women are undernourished, and 27 % are overweight, and 16% are
obese, which is 2% increase from 2000. 25% of the woman is suffering from anemia, which is
also an increase of almost 13% compared to 5 years back (12%) and this is mainly in Yerevan
and Gegharkunik. The survey also shows that only one percent of the women reported taking
iron supplements during the 90 days of pregnancy. 3

Stunting rate in 2005

On surveying children below five years of age, they found there was no change in the
stunting rate from 2000, where the overall stunting rate is 13%, and 3% were severely stunted.
Analysis of this trait in different age groups revealed that stunting increased among children
aged under six months, from 7% to 12 %. But the rate of this trait was higher in the age group
12-17 and 18-23 months. Survey also mentions that rate of trait (stunting) is dependent on the
education of the mother, where the children born to less educated women were more likely to
be stunted compared to the children born to women more educated.

Wasting and Underweight survey revealed that overall around 5% were wasted and 4%
were underweight, showing that there has been an increase in the wasting and underweight rate
from 2000. The graph below shows the rate of stunting, wasting and underweight in different
age groups.
Survey 2010:

According to the data on breastfeeding, overall 97 % of the children were breastfed, where 37
% are breastfed within one hour after birth or within 24 hours after birth. Only one third of
children are exclusively, and other are given liquids other than milk solid and mushy food.
Though not many are exclusively breastfed there has been a slight improvement in the
percentage of children being exclusively breastfed as compared to 2005. However, there has
been a decrease in the percentage of children in the age group (6-8 months) who are breastfed
and started complementary food (from 63% to 45 %). 19 % of the children below six months
receive complimentary food which is detrimental to their health 4

Coming to the diversity in complementary food, 89 percent of breastfed children aged 6-23
months received solid or semi-solid foods. The most common complementary foods were made
from grains (79 percent); roots and tubers (69 percent); cheese, yogurt, or another milk product
(68 percent); and fruits and vegetables other than those rich in vitamin A (58 percent). Iron
supplementation is highest among children 12-17 months and 36-47 months (9 and 8 percent,
respectively). As worming can reduce the micronutrient absorption, deworming medication
can help in reducing them, and only 6% receive it. Micronutrient intake in women, around two
percent of women, reported taking iron supplements for the recommended minimum of 90 days
during the pregnancy.4

Stunting in 2010:
According to the results of the survey, around 19% of the children were stunted with 8 %
severely stunted and this varied with region and the education of the mother. The rate of
stunting was highest in Syunik (37%). The rate of wasting was 4% and 5% are underweight,
15% of the children were overweight. This data shows that overweighting is more than a
concern than underweight. The survey also has been found to be dependent on mother’s
4
education.
Current Scenario: Nutritional Status of Armenia.

According to Armenian Demographic and Health Survey (2015-2016), rates of

stunting was highest among children aged 6-8 months (17 percent), but the rate has been found
to have decreased significantly in the children of age group 24-35 months (5 percent) from the
previous survey in 2010 . Wasting was prevalent primarily in the children under age six months
and age 36-47 months (6 percent) and underweight was found mainly in children under nine
months old. Talking of overweight, 14% of children under the age of 5 are overweight.5 Hence,
looking at these surveys, we can see that overweight is a more of a problem than underweight
and also these health statuses are different for different age groups.

There has been a significant change in the Nutritional status of children in Armenia, which
includes a significant decrease in stunting from 18-19% to 9%. 5 The proportion of underweight
children has decreased from 5% to 3%, but the proportion of overweight children has increased
from 11 percent to 15 percent from 2010 to 2015-2016. (Figure 12.2, adapted from ADHS
2015-2016)

Health and nutritional status of a child have been shown to be dependent on the region,
mother’s education, and economic status. This is evident by the higher prevalence of
undernutrition and stunting in a rural setting than in urban, where the children in rural regions
are stunted at a much higher rate (almost twice) compared to children in an urban setting.[5]
Talking about region dependent factor, undernutrition was more prevalent in Shirak (20
percent) compared to Yerevan (4 percent).

Among many health conditions, that can cause nutrient deficiency is diarrhea induced
dehydration. Which, has been shown to be one of the primary cause of death in children and
this condition also varies between different age groups.5 This condition has reduced to a
significant amount in the five years.

Below figures and chart give us the picture of change in different trends in the children under
the age 5 from 2000 to 2016
Conclusion:

On analysis of the data from ADHS (Armenian Demographic and Health Survey), it is
evident that recognition of public health issues such as stunting, wasting and underweight in
2000, it seems like there wasn’t much emphasis given to stunting and to understand the causes
of it. There were improved breastfeeding practices and complementary feeding practices, but
didn't seem to change the stunting. 3 There was also a slight improvement in the underweight
and wasting status .3Though these show that some efforts were made to improve the nutritional
status, the significant problem seemed a bit ignored.

There seems to be a discrepancy in the data collected. The survey in 2005 mentions that the
stunting rate didn’t change from 2000 (13%), but the latest study shows that stunting rate in
2005 was higher than 2000, that is 18%. Stunting remained to be a significant problem. Most
of these contradicting data, where there is improved breastfeeding practices, but stunting keeps
increases shows that the attention must be paid to understand the cause of the problem.

In the 2015 survey, stunting remained to be a significant nutrition public health concern, and it
was increasing, but there was a slight improvement in the wasting rate. During, the last five
years, these conditions seem to have changed drastically. Stunting reduced by almost 10% and
underweight by 2%. Showing that there has been a significant amount of attention and
emphasis given to the stunting. Now overweighting seems to be a problem of concern as it is
increasing every year.

Many of these surveys have mentioned about the mother’s education is a problem1,2,3 and hence
it would be advisable to focus on initiatives educating mothers or family members about
complementary feeding and importance of diverse food. These conditions (stunting and
undernutrition) have also been found to be region dependent according to the survey, mostly
compared with cities and rural areas in the regions. The difference might be due to lack of
access to expert knowledge on best feeding practices, lack of facilities and food (food
insecurity) in rural, as compared to urban. Also, the change in the trend of stunting is the public
concern to overweight being the current concern.

Nutritional status in Armenia.

According to the Armenian Demographic and Health Survey (ADHS) data, stunting
and undernutrition have been a significant public health concern for almost 2 decades now.
This mainly is predominant problem in age group 6-24 months, and the reason for this has been
attributed to many factors. The factors include, inadequate nutritious food, improper
complementary feeding practices and/or also mother’s height6. UNICEF recognizes military
tension to have adverse effect on child’s health and considering this is severe problem in border
region, this can be contributing factor, as this will impact land that must be used for agriculture
and food production 5,6,7

Other determinants of undernutrition is lack of knowledge. In Yerevan city, only 24.1%

people have minimal nutritional knowledge.9 This is because most of them are aware of dietary
recommendation but are not aware of liaison between diet and disease8. Another study
conducted in Yerevan also revealed that the determinants associated with undernutrition status
of children aged 5-17 months in Yerevan were low birth height of the child, low socio-
economic status of the family, lack of diversity in child’s diet and shorter duration of
predominant breastfeeding and father’s low stature was marginally significantly associated
with the outcome9. Among these determinants, the predictors of stunting were also identified
to be children born fourth or later for a mother. That is, the later born child has more chances
to be stunted.10

The study also emphasis on the accuracy of data collected and claims that the accuracy
of the collected data was low.9 There are discrepancies in identification of determinants
stunting in Yerevan and other rural regions, this might because of the difference in the outcome
variable to explain undernutrition.8 Yerevan study used one combined variable to explain all
the three health condition, that is undernutrition, wasting and stunting.11 Whereas study from
Talin, only investigated stunting.

Among the initiatives taken up to address these nutrition- related problems. A study has
shown that adopting the nutrition program by World Vision, where they implemented 5 types
of interventions in these communities including “(1) seminars for women on child care and
nutrition, (2) establishing Mother Support Groups, (3) distributing public education materials,
(4) promoting locally available healthy food items, and (5) capacity building of primary health
care providers” helped improve the stunting status from 2008 to 2010. 10

Though this public health issue has been acknowledged well in Armenia, the child
undernutrition did not change for over two decades. But in the last five years, this scenario has
been able to see a significant decline. According to ADHS 2015-2016 survey, there has been
10 % decrease in stunting in Armenia. But this information was also accompanied with the
data which showed that there has been an increase in the rate of overweight. 4. A review on
adolescent health in Armenia, mentioned that the physical activity level in children, in Armenia
was low where seventy-three percent of adolescents watched television for 2 hours or more
during weekdays and 76% during weekends.11.

Anemia is quite prevalent in children of Armenia, that is around 16% of children are anemic.
This was because of lack of iron in food.6 In Armenia 10% of the men and 8 % women cannot
identify symptoms of anemia5, implying that most of the them lacked the knowledge regarding
Anemia. Coffee and tea are most consumed beverage in Armenia and drinking too much
coffee, can inhibit non-heme iron absorption, as they contain tannins.13

Undernutrition can affect and exacerbate other health conditions such as respiratory
diseases and diarrhea. Diarrhea is the third leading cause of infant mortality.5 Hence addressing
these issues is not just important for optimum growth but also, to reduce morbidity and
mortality rate in children from diarrhea .11 Lack of diversity in food has been mentioned as the
one of the cause for undernutrition in many studies conducted. 11,7 Hence it is necessary to feed
children with different types of fruits and vegetables and primarily food rich in Vitamin A and
iron, which are important for cognitive development.

Review on undernutrition in other countries and the

interventions implemented.

According to the latest survey conducted by UNICEF in 2016, more than half the death
in children under the age of 5 has been attributed to undernutrition. While this problem occurs
all around the world, it is most prevalent in South Asia and Africa. High rates of undernutrition
can lead to adverse effects in cognitive development, can lead to a reduction in work capacity,
which not only affects an individual productivity and economic development but this can prove
to be a problem at the national level. Children who are undernourished are more susceptible to
infection.1 Studies from the Lancet series on Maternal and child nutrition show that poor
nutrition in childhood and primarily in the first 2 years of life tend to put on weight later on in
life and are also at high risk of chronic disease 15 Poor nutrition in the first 1000 days of child
life can lead to irreversible consequences like stunting1
 The determinants of undernutrition can be many. One of the main reason is poverty. The
income issue affects the food availability and also the food quality. When it comes to low
middle-income countries, the salary a woman receives might be different compared to men,
maybe lower15 and most often women don’t have much freedom in deciding how the income
would be spent and these decisions are usually taken up by the male in the family.

Lack of knowledge can be a cause for undernutrition. Ideally, for optimal health the
infant must exclusively breastfeed for the first 6 months, followed by complementary feeding
after 6 months until 2 years. Most women are not aware of this and end up feeding their kids
earlier thinking breastfeeding is not sufficient to meet their nutritional requirement. It is critical
that the complementary feeding is carried out with food that contains the macro and micro-
nutrients that are essential for optimum growth. It is also necessary to understand that infant’s
digestive system is not as developed as an adult and hence feeding them in a form that is easily
digestible is important and this is not usually communicated or educated about in women in
low middle-income countries.16

The maternal health status plays a significant role in determining the nutritional status of
the infant. Most women in developing countries are usually anemic and are also deficient in
micronutrient, which is vital for optimal growth of their children. According to a study
conducted in India18 they found that stunting and poor linear growth in children were high in
mothers whose height was lesser than 45 cm and primarily those who didn’t have any power
regarding the food. Poor maternal mental health status can also affect the feeding practices, as
the per the same study, children were not fed a minimum number of times and their food lacked
quality. This is a deterioration in the attention towards their infant.18

There are many interventions made to combat undernutrition. These interventions used
many strategies including breastfeeding, complementary feeding, food supplements and
micronutrient supplements and general strategy for improving community nutrition and the
most effective among these has been promoting breastfeeding. Complementary feeding is
usually implemented when the region has sufficient food and lacks the knowledge on correct
feeding practices. Ready-to use therapeutic food has been used to combat severe malnutrition
and provision of food supplements in the case of food insecurity. Supplementation usually in
the form of folate supplementation for pregnant women, zinc supplementation, vitamin A
fortification, Calcium supplementation and Iron supplementation. 20
 Intervention were not just on breastfeeding, but also to support exclusive breastfeeding.
The study conducted on the breastfeeding showed that providing support to the breastfeeding
mothers has increased the duration of exclusive breastfeeding. Providing a scheduled support
over one upon request of mothers has been shown to have higher initiation rates. 8 Intervention
made through supplementation includes many strategies, one such is through supplementation
during pregnancy. Iron supplementation did reduce the risk of anemia during the pregnancy
but there wasn’t much effect on infants health9.

Zinc Supplementation for pregnant women showed around 14 % reduction in preterm

birth, as pre-term birth is indication of low nutrition profile of the infant. This strategy has been
proposed for areas of high preterm birth mortality. 24 Iron supplementation in children increased
their hemoglobin levels in their blood10. Zinc supplementation in children increased serum zinc
concentration and the study conducted on zinc supplementation also showed an increase in
linear growth and weight gain in pre-pubertal children.25 Zinc supplementation has also been
used to prevent pneumonia and diarrhea in the children and diarrhea is also been known to be
a cause for children mortality in Armenian.26, 27

Similar Nutritional Intervention program:

Complementary food supplementation was carried out in China, where the food was called
Ying Yang Bao. The calorific value of the supplementary food was 40kCal, 2.0g fat, 2.5
carbohydrates and protein 3.0 g from soybean; vitamin A 250 mg; vitamin D3 200 IU (5 mg);
vitamin B1 0.3 mg; vitamin B2 0.3 mg; iron 5 mg; zinc 5 mg; calcium 250 mg. This was
carried out for a year and the results showed a significant reduction in stunting, underweight
and anemia. 29

Supplementary feeding programme was carried out in the study from Kenya which included
monthly rations of corn/soya blend plus and oil in two counties. Interventions such as vitamin
A supplementation, deworming, immunisation as per the national protocol, and health
education were also included in the blanket supplementary feeding programme. The
intervention lasted for 7 months. The weight-for-height Z score significantly improved in both
the counties. 30

The major nutrition supplementation programs in India are: 1) Integrated Child Development
Services Scheme (ICDS); 2) Mid-day meal Programs (MDM); 3) Special Nutrition Programs
(SNP); 4) Wheat Based Nutrition Programs (WNP); 5) Applied Nutrition Programs (ANP); 6)
Balwadi Nutrition Programs (BNP); 7) National Nutritional Anaemia Prophylaxis Program
(NNAPP); 8) National Program for Prevention of Blindness due to Vitamin A Deficiency; and
9) National Goiter Control Program (NGCP). The ICDS beneficiaries are children below 6
years, pregnant and lactating mothers, and women aged 15-44 years, who are provided the
following: supplementary nutrition; immunization; health check-ups; referral services;
treatment of minor illnesses; pre-school education to children aged 3-6 years.

The MDM program's intended beneficiaries are children attending the primary school.
Children belonging to backward classes, scheduled caste, and scheduled tribe families are
given priority. The SNP is to provide supplementary nutrition and health care services
including supply of vitamin A solution and iron and folic acid tablets to pre-school children,
and pregnant and lactating mothers of poor groups in urban slums and tribal areas. The ANP
strives to make people conscious of their nutritional needs and to provide supplementary
nutrition to children aged between 3-6 years and to pregnant and lactating mothers. The
beneficiaries of the WNP scheme are children of pre-school age and nursing and expectant
mothers in areas with high infant mortality such as urban slums and backward rural areas. 31

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