Malnutrition in Iran
By Dr. Abolghasem Jazayeri
Agricultural Economics & Development (Quarterly)
Special issue on food security
Vol. 2, Autumn 1994
Undernourishment, hunger and malnutrition continue to be among the major difficulties confronting many countries of the world. The physical, mental, psychological, economic and social consequences of these problems are plaguing hundreds of millions of human beings, and seriously hindering their physical and economic activities. Moreover, this state of affairs is primarily experienced by women and children. Undernourishment and malnutrition are prevalent among 20% of the population of developing countries; they also are the main reasons of infant mortality in urban and rural areas.
In most cases, hunger and malnutrition are caused by the unavailability of good food in sufficient quantities on one hand and by the inaccessibility of health and treatment services on the other. The insufficient attention to the food requirements of vulnerable groups (namely women and children), increase in the growth rate of the population, famine and draught also further aggravate the situation.
It is to be noted that many factors, either directly or indirectly, affect undernourishment, hunger and malnutrition. These include low productivity, income problems of households, wastage of food materials, low level of literacy, people's lack of awareness, as well as the shortcomings in planning and guidance of food systems.
Malnutrition in Iran
According to studies made, the current nutrition problems in the country are malnutrition, the lack of energy and protein, anemia and health disturbances arising from the shortage of iodine in the diet (goiter). At present, on the average, 30% of children under five years of age are suffering from varying degrees of malnutrition as well as from protein and energy deficiencies. Furthermore, anemia is suffered by 13% to 53% of women and girls, 12% to 30% of children and 8% of men. Twenty percent to 70% of primary school children in various provinces are also stricken with goiter in varying stages of the disease, and on the whole, three million people are afflicted with this ailment. The lack of vitamin A and some other nutrients has also been observed, albeit to a lesser and milder extent.
On the other hand, the high and unbalanced consumption of certain types of food, coupled with harmful lifestyles (i.e inadequate physical activity, tobacco consumption etc.) have led to an upsurge in vascular and coronary ailments, diabetes and cancer. Vascular and coronary diseases (high blood pressure) have been noted recently as being the main causes of mortality. The percentage of death due to these diseases ranged from 26.2% to 37.9% between 1981 to 1990.
Investigations reveal that the principal contributors to malnutrition have been the consumption of insufficient quantities of food and the low quality of food intake (which mainly result from the uneven distribution of food in the society), improper food habits, lack of full utilization of the benefits of mothers' milk, the prevalence of infections and parasitic diseases, poor environmental health, insufficient income, lack of safe water supply, and the high number of children in the family. The accelerating trend of urbanization and the socioeconomic changes accompanying this have led to changes in food consumption patterns and lifestyles that have undesirable nutrition consequences in some segments of society.
Food and Nutrition Programs in Iran Food Security
Via the adoption of a food policy designed to achieve self-sufficiency in the production of staple food items, and the extensive application of new techniques and methods in the agricultural sector, some steps have been taken to ascertain food security, both at the macro stage and at the household levels. On the basis of a food balance sheet prepared by the Ministry of Agriculture, the net calorie existing in food increased from 2,813 to 3,018 calories in the period between 1986 and 1991 (three-quarters of which was due to internal production). During the same time frame, the quantity of per capita protein went up from 73 to 80 grams per day. These quantities of energy and protein however, were more than the necessary levels. The self-sufficiency coefficient (the ratio between internal production to total supply), also rose for many other food materials. Hence, and notwithstanding increments in population, the supply of food materials exceeded the average per capita need during recent years. However, high prices, the uneven distribution of food items and inflation had given rise to inequalities in consumption. At present, 25% to 30% of people (mostly from the low income classes) are threatened by a lack of food security. Moreover, city dwellers, more than villagers, have benefited from foodstuff subsidies.
Conversion industries that process various foodstuffs grew from 6% to 20% during the course of the First Plan. Despite this positive developments however, the number of processing installations are still not enough. And while the country is confronted with many problems and difficulties connected with food technology, no comprehensive plan has been devised to properly identify and solve these issues. Among the reasons behind the squandering and wastage of foodstuffs in the country (which reach about 30%), one could cite the insufficient number of food conversion units and their low productivity.
Control of Malnutrition
Health problems arising from the shortage of iodine (particularly goiter) was first reported in 1969. Serious steps for the control of this disease were taken only in 1989 however, and the main strategy used for its eradication was expansion in the production and consumption of iodized salt. The program, so far, has been successful and currently, more than three-quarters of city dwellers and half of villagers use iodized salt. Four factors contributed to the success of the program: general education, support given by policy makers and planners, extensive intra-sectoral and inter-sectoral cooperation and the delegation of executive powers to provinces.
Another project, initiated in 1988 and which was quite successful, was the promotion of breast-feeding to infants. The number of mothers who breast-fed their babies for one year, increased from 65% to 98% from 1988 to 1994. The reasons for the success of this program were the same as those mentioned in the case of goiter control.
With regards to problems related to anemia, in view of the importance of iron during infancy and pregnancy, iron tablets and drops were distributed by health and treatment networks to pregnant women and children below one year over the past ten years. For example, 37,835,000 tablets and 1,628,880 bottles of iron drops, with an estimated value of 540,000,000 rials, were handed out in 1372 (March 22, 1993 - March 21, 1994). The scheme's affectivity cannot be ascertained yet however, and evaluation is necessary to determine whether anemia control is being achieved and to pinpoint the causes of success or failure, whichever the case may be. The results that will be gathered after the program's appraisal will be of great help in formulating decisions regarding the continuation, modification or interruption of the project.
Primary Health Care System: A Ground for the Implementation of a Nutrition Program
At present, this system, which is implemented within the health treatment networks, covers more than 75% of the population. The integration of health and nutrition programs within this system, has resulted in better, more effective and less costly implementation. The projects consist of measures for the control of goitre, diarrhoea, as well as respiratory diseases and infections. For example, infectious diseases have been brought under control to a large extent. The vaccination coverage of children and women improved, from 74.5% in 1988 to 84.7% in 1991. During the same periods, villagers' access to safe potable water rose from 70% to 84%. An effective primary health care system, particularly if co-ordinated with the promotion system in the agricultural sector, could serve as a good base for the implementation of a malnutrition control program as well as an improvement in the food and nutrition situation. This assertion is supported by the experiences of some countries during the last two decades.
The Islamic Republic of Iran and the International Conference on Nutrition Iran's Participation in the Conference
Iran's representatives from the Ministry of Agriculture, the Ministry of Health, Medical Care and Training, the Plan and Budget Organisation, the State Institute for Nutrition Research and Food Technology, the Faculty of Health and the Institute of Health Researchers affiliated to the Medical Sciences University of Tehran, actively participated in the preliminary regional sessions in Cairo and Bangkok in 1991, and in the pre-conference in Geneva in the summer of 1992, to express the views of the Islamic Republic of Iran. The ministers of agriculture and health and medical training, together with other high-ranking officials from the Ministry of Foreign Affairs, the Iranian ambassador to Italy, the director-general of the Specialised Organisations of the Ministry of Foreign Affairs, some experts from Iran's mission in the Food and Agricultural Organisation (FAO), and the chief of the Institute of Research and Food Technology participated in the final conference held in Rome in December 1992. Meanwhile, Iran was elected as one of 13 members of the committee charged with drawing up the draft of the declaration and the executive nutrition program, which, in fact, was the most sensitive part of the program.
Preparation of the Executive Nutrition Program of the Country
In the 3rd, 29th and 43rd principles outlined in the Islamic Republic's Constitution, stress is laid on the need of meeting the people's basic requirements, eradication of poverty, removal of any kind of deprivation in the matter of food, as well as individual and social welfare. Given these bases, the government has endeavoured to bring about conditions that will enable households to have access to sufficient food, more extensive health and social services and, at the macro level, the establishment of social justice in the rural and urban areas.
In the course of the First Economic, Social and Cultural Plan, in spite the structural bottlenecks and organisational, financial, manpower and a host of other difficulties, a number of successes have been recorded such as increases in food production, food self-sufficiency and security, reduction of diseases and mortality as well as deceleration in the growth rate of the population. Nevertheless, at present, although the quality of food consumed per day is, on the average, enough and acceptable, some sections of the population are still facing under-nourishment malnutrition and the main victims of these phenomena are women and children. On the other hand, some sections of the population consume excessive amounts of food and they suffer from undesirable consequences.
It should be borne in mind that in any effort made to improve the food and nutrition situation, two essential conditions should be fulfilled in order that society as a whole could obtain good nutrition. The conditions are (1) food security, that is, the possibility of access to enough food for a healthy and active life; (2) physical health, which is possible to achieve through the prevention and control of diseases, such as infections and parasitic ailments. Fulfilment of these two conditions requires a comprehensive and co-ordinated plan, in the compilation and implementation of which the public sector, the private sector and the people should actively take part. The Iranian government, which, along with 159 other countries, took part in the international conference on nutrition, formally committed itself to prepare and present, by the end of 1994, an executive nutrition plan designed to bring about a general improvement in the food and nutrition situation, and to put it into effect after due approval from the cabinet. The object of this program is to reduce malnutrition, raise food security at household and macro levels and to improve the capacity for economic production.
Probable Results of the Executive Nutrition Program
It is clear that one cannot accurately ascertain what results can be garnered from the implementation of the nutrition program. Yet, considering the general scenario in the country and taking into the account the experiences of other countries, the following results are expected, provided the program is implemented successfully.
(1) - A considerable decrease in the prevalence and intensity of malnutrition, and the lack of energy and protein items.
(2) - A marked downturn in the occurrence of health disturbances arising from iodine deficiencies (goitre) and a decline in the percentage of the population afflicted with such ailments.
(3) - Regarding anaemia, it does not seem that efforts for its eradication will be effective as anaemia has its own special problems. The main and rich sources of iron are animal food materials, particularly meat, which are expensive. A program for enriching foodstuffs with iron (such as flour) may be instituted but as not many experiences have been gained in this regard, one therefore cannot expect spectacular success in the Second Plan. Moreover, as parasitic contamination greatly contribute to the occurrence of anaemia, the success of projects that are aimed at controlling this disease are also dependent on the success of parasitic control measures.
(4) - Concerning Vitamin A deficiencies, much is not yet known about its prevalence and intensity. When additional information has been made available; promoting an increased consumption of food materials that are rich with this substance (through general promotion activities or training as an integrated part of the system of health-therapeutic services) can yield fruitful results.
(5) - Better and wider utilisation of water and soil potentials, etc., as envisaged in the Second Plan, can lead to a rise in food security.
(6) - In the course of the Second Plan, not much improvement in the number of conversion industries is expected to be achieved, as this area is faced with many problems and their control is difficult and require a longer period of time. On the contrary, the probability of success in the control and security of food materials is high, provided intra-sectoral and inter-sectoral co-operation and co-ordination are extended and financial and manpower resources are properly allocated.
(7) - Finally, it is hoped that the executive nutrition program become a permanent part of future economic social and cultural programs, and a chapter entitled "Food and Nutrition" will be opened in the planning book.