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					    National Institute of Nutrition
                Cairo


    Capacity Building Initiative

           14 - 15 July, 2004
             Cairo - Egypt
1
2
               Overview
1-   Geography
- The State of Kuwait occupies the north
western   corner of the Arabian Gulf.

- The total area is 17,818 sq km

- The weather is       typical     of   the   Sahara
geographic region.
 3
4
2-   Population
The estimated mid-year population in 2002
stood at 2,363,325.
   - 37% Kuwaitis and 63% non- Kuwaitis

According to 1995 census, among Kuwaiti
population
     - 55.2 % < 19 yrs
     - 4.1 % > 60 yrs
     - 56.3 % of expatriate population are
between 25 to 45 years of age.
 5
Health
Kuwait has a well developed health care
system.
     - free to all Kuwaitis
     - Immunization is compulsory and free for
     all

 Infant mortality rate decreased from
     10.9/1000 live births      1998
     9.6/1000 live births        2002

 Maternal mortality decreased;
    No Kuwaiti maternal deaths in 2000 &
    2001.
  6
Trends in Energy Requirements and Food
               Supplies

Food Consumption

-The economic transition over the past half century
   * Increased family income and hence purchasing
   power

       * Increased availability of varied and commercial
      foods

      * Stimulated food advertisements

  7
-Traditional diets has been changed to more diversified
diets

- Canned, frozen, dehydrated foods are imported from
all over the world

- Sweets, chocolates, pastries, and snacks are available
in abundance.

-Food franchises covering a wide range of choices are
widely spread, and eating outside the home has
become an acquired habit

- Fast foods such as hamburgers, pizza, fried chicken
are widely consumed by the younger generation.
  8
As a result
 - Food habits and choices adversely changed

  And in the presence of
 - Sedentary lifestyle prevalent in all walks of life
 - Stress
 - Smoking

the incidence of diet-related non-communicable
diseases    such    as   diabetes, hypertension,
cardiovascular disease and cancer had markedly
increased
    9
According    to   Food    and    Agriculture
Organization Food Balance sheets for Kuwait
1995 versus 1999, the food availability data
showed:

    * General increase in meat and poultry,
    sweeteners, and milk and milk products.

    * An increase of calories by 152 kcal,
    proteins 4.5 grams and total fat   2.7
    grams per day.

Community   based   food   intake   data   not
available
 10
     Micronutrient Deficiency




11
Iron-Deficiency Anemia

- Prevalence increasing among vulnerable
groups

- According to Kuwait nutrition Surveillance,
     23 % of preschool children,
     22 % of adolescent girls, and
     24 % of child bearing women

are anemic


 12
Based on WHO classification, Kuwait falls
in the medium category group of countries
( anemia prevalence 15.0 % to 39.9 % ).
Those at risk are women and children.




  13
                                    Prevalence of Iron Deficiency Anemia 98-2000

                40
                                                                                         34.2
                35
                                                                             30.6
                30

                             24          24.1
                                  22.7
P er cent age




                25
                     21.4
                                                    18.9                                        Males
                20
                                                                                                Females
                                                           14.9
                15                                                    11.9

                10
                                                                                    6
                5

                0
                        <5          6-9                10- 13           14-20           >20
                                                Age Group ( Years )

  14
                        Prev alence of Iron Deficiency Anemia2002

                  35
                              30
                  30   27.9                                                             28.3

                                       23.4
                  25                                                        21.8
                                            18.4
     Percentage




                  20
                                                        16.5             16.6                  Males
                  15                                                                           Females
                                                              10.6
                  10
                                                                                   5
                  5

                  0
                          <5               6-9              10- 13         14-20       >20

                                                   Age Group ( Years )


15
Iron Fortification of Flour
- Legislation passed in 1999
- Implementation in March 2001
- Quality Control Committee for follow up
- March 2004 Monitoring Group established


Iron Supplementation Programs
- Targeted for pregnant ladies at MCHC
- Problem is with compliance!!
- Other high risk groups have to be targeted
e.g. under 5yrs

 16
Vitamin D deficiency

A study on Vitamin D status of the Kuwaiti
mothers and their neonates in two hospitals
showed that 40% of the mothers and 60% of the
neonates are vitamin D deficient on the day of
delivery (Abdul Majid Mulla et al, 2000).

More research is needed.


 17
Iodine deficiency

-No data available on the status of IDD in the
population
-It is now mandatory that all salt for human
consumption to be fortified with Iodine (Kuwaiti
Standards, 2003).




  18
Vitamin A deficiency
- Little data on vitamin A deficiency in Kuwait

-Only one study was conducted on newborns
and their mothers

- Results showed no evidence of deficiency in
these groups.



 19
                      Obesity

Data from previous studies showed;

- Obesity in Kuwait steadily increasing (Moussa
et al., 1999, Surveillance, 2003)

- Probably the highest in Gulf states (Al-Mousa,
1996)

- Independently, a high risk factor for CHD ( Al-
Mousa 1996) and Type 2 DM in Kuwait (Emara et al.,
1989; Alwan & King, 1992; Abdella et al 1995)

   20
Prevalence of obesity

Data from Nutrition Surveillance, 1998-2000,
showed the prevalence of obesity (weight-for-
height >2SD) among preschool children under 5
years to be
     - 6.5% for males
     - 9.2 % in females.

For the children between 6 to 10 years
      - 9.3 % in males and 9.5% in females


  21
                     Kuwait Nutrition Surv eillance System[ 1998-2002 ]
                        Intermediary School Children 10-14 years

              30
                   25.3
                                                                          24.223.7
              25       23.2                        23
                                                                                 20.9
                                            19.4        19.6
              20                                            17.3                       17.2
                                                                                              Overweight M
 Percentage




                           14.6                                                               Overweight F
              15               12.5
                                                                                              Obesity M
              10
                                                                                              Obesity F
              5

              0
                       98-2000                       2001                       2002

Overweight = BMI >= 25 kg/m2/ Age Obesity = BMI >= 30 kg/m2 / Age Ref: BMJ, Vol 320, 2000.



22
                         Kuwait Nutrition Surv eillance System[ 1998-2002 ]
                                    Secondary School Children
             30


                                                                      24.6
                            24                                                              24
             25                                               23
                                                                                                            21.8
                  20.9                                20.9
                                                                                                    19.5
             20
                                                                                     17.7
                                                                                                                            Overweight M
Percentage




                                                                              16.2
                                    14.6                                                                                    Overweight F
             15
                                               12.3
                                                                                                                            Obesity M
             10
                                                                                                                            Obesity F
              5



              0
                         98-2000 14 - 18 yrs                 2001 14-20 yrs                      2002


                             Overweight = BMI >= 25 kg/m2/ Age Obesity = BMI >= 30 kg/m2 / Age             Ref: BMJ, Vol 320, 2000.



 23
                   Kuw ait Nutrition Surveillance System [ 1998-2002 ]
                             Obesity Among Adult Kuw aitis

             60

                                                                                 49. 7
             50




                                                               33. 7     33. 8
             40
Percentage




                                  29. 9                28. 3                             Males
                         27. 5
             30

                                                                                         Females
             20



             10



              0

                            98-2000                         2001             2002
                  Obesity >= 30   Body Mass Index(BMI)     Years



   24
     Chronic Non-Communicable
              Diseases

1- Cardiovascular disease
- Coronary heart disease is the number
  one cause of mortality in Kuwait
- Incidence is 40.6/100,000



25
2- Diabetes
- Type 2 diabetes mellitus a leading chronic non-
communicable disease among the adult Kuwaiti
population.

-Over all, prevalence rate for glucose intolerance
reached as high as 15.8% among Kuwaiti population
below 50 years of age. (Abdella et al., 1999)

- The prevalence rises to >25% if the undiagnosed are
included



 26
-A study on incidence of type 1 DM in Kuwait showed
that Kuwait has the highest incidence in the region,
(Shaltout et al., 1995)

-- The annual incidence of type 1 DM for children aged
0-14 years over the 2 year period was 15.4/100,000

- Male to female ratio is 1.2:1.

-Compared with the previous study by Taha et al.
(1983), there was a nearly 4X increase of type 1 DM in
this age group but mainly in under 5 years


  27
Diabetic subjects presented at a relatively young age,
 prevalence in the age group

       20 –39     was 5.7%
       40 –59     was 18.3 %.




  28
3- Cancer
-Second leading cause of death in Kuwait with an
incidence of
      20.2/100,000      males
      29.2/ 100,000     females

Lung cancer most common cancer among Kuwaiti
males
Breast cancer most common cancer among Kuwaiti
and non-Kuwaiti females.


  29
          Research in Nutrition

- National Nutrition Survey for Kuwait
     We are in the process of finalizing the
     project, a baseline data on the nutritional
     status of the population identifying at risk
     groups, prevalence of non-communicable
     diseases and micronutrient deficiencies.




30
Nutrition Surveillance - room for
improvement

   Data is collected on:
   • Anthropometry
   • Infant feeding practices
   • Fruit/vegetable consumption
   • Smoking
   • Physical Activity


   31
                N u tritio n S u rv e illa n c e s y s te m In fa n t
                 fe e d in g fo r c h ild re n <= 12 m o n th s

               70
                         66
               60                 61.7
                                            57.3    56.23
               50
F e e d in g




                                                                        B reas t
               40
                                            32.4                        B ottle
               30                 28.7              31.31
                         24.3                               26.4        M ix
                     %




               20
                                                            16.6
               10        9.7      9.6       10.3    12.46
                0
                    1998       1999     2000     2001   2002
                                        Ye a r

32
          CONSTRAINTS
• Limited number of
      Health educators
      Dietitians
      Clinical nutritionists
      nutrition research
- Still, no B Sc degree
- Totally dependent on Diploma graduates
- Lack of trainers/specialists for in-hospital
  training
- Limited budget for training, research and
  consultation
- Nutrition not a priority
 33
1-    Nutrition Facilities l Infrastructure Capabilities

Within the Food and Nutrition Administration

- Central out patient clinic, with lab facilities
      Providing Nutrition Counseling

- Continuous Nutrition Education ( CNE )

- Training department- 9 months concentrated training course
  for all new diploma assistant dietitians and B.Ss graduates from
  other specialties.

- Nutrition Education - schools, community and for special
  groups.



     34
- Research department conducts Nutrition Surveillance
  system to monitor
    Growth in children

    Iron deficiency status among the Kuwaiti population

    Prevalence of diabetes and hyperlipidemia among Kuwaiti
     adults.

- Nutrition counseling in some Primary Health Centers,
  and mostly focused in diabetic centers.




  35
 2. Personnel and Expertise, degree of experience
               Personnel              (#) ( %)
     Physicians( Ph. D Nutrition )                  2     1.6

     Physicians                                     4     3.3

     Dietitians with Masters in Nutrition           15    12.5
     ( Non-Kuwaitis )
     Dietitians with Bachelor Degree                33    27.5
     (Mostly Non-Kuwaitis)
     Assistant Dietitians with Diploma              66    55.0
     ( Kuwaitis )
     Total                                          120   100

Experience ranges from new graduate to 25 years for the senior staff.
36
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