Document Sample


                Sarajevo, 2002.
Institute of Public Health of Federation of Bosnia and Herzegovina
 Titova 9, 71000 Sarajevo Tel: + 387 33 663 940, Tel/Fax: + 387 33, 220 548
             Mostar, Vukovarska b.b., Tel/Fax: + 387 36 324 687
                          Bosnia and Herzegovina

                 Aida Filipović Hadžiomeragić M.D.
                   Fatima Jusupović, M.D., D. Sc.
                       Nijaz Uzunović, M.D.
                       Vildana Doder, D.D.M.

              Mervana Hadžimurtezić, B. Sc. Agr.
          Prof. Esma Čemerlić - Zečević, M.D., D. Sc.
              Prof. Husref Tahirović, M. D., D.Sc.
                  Prim. Mira Ademović, M.D.
                   Haris Hajrulahović, M. Sc.
                     Slobodan Lučić M.Sc.
                     Slađana Orlović, B.Sc.
      Expert Council of Instutute of Public Health of FB&H

                              Muris Krupić

                           Publishing editor:
                             GIK “OKO"

 I. INTRODUCTION ................................................................................7

 II. SITUATION ANALYSIS...................................................................9
   1. NUTRITION ..........................................................................................9
     1.1. Nutritional status..........................................................................9
        1.1.1. Undernutrition ....................................................................9 Children...............................................................................9
   1.2. MICRONUTRIENT DEFICIENCIES ......................................................14
     1.2.1. Iodine.......................................................................................14
        1.2.2. Iron.......................................................................................16
        1.2.3. Vitamins...............................................................................17
 Deficiencies of vitamin A and D ...................................18
     1.3. Breastfeeding..............................................................................19
     1.4. Dietary habits and food intake ..................................................20
     1.5. Obesity and related diseases ......................................................24
   2. FOOD SAFETY.....................................................................................27
     2.1. Foodborne diseases....................................................................27
     2.2. Supervision .................................................................................29
     2.3. Laboratory control .....................................................................29
     2.4. Legislation..................................................................................30
   3. SUSTAINABLE FOOD SUPPLY ..............................................................30
   1. GOAL ...............................................................................................33
   2. OBJECTIVES .......................................................................................33
   3. STRATEGY .........................................................................................34
   4. ACTIVITIES ........................................................................................35

Access to safe and healthy food is fundamental human right but also one of
the biggest public health challenges. Need for promotion of nutritious and safe
food, reduction of diseases, promotion of health, reduction of environmental
risks and stimulation of economic development is permanently present. Those
are also objectives of the policy that this document presents. Policy is
developed on the base of number of political commitments that our country
together with other member states made in last ten years.
In wider context we are mentioning Agenda 21 from 1992 adopted at United
Nations Conference on Environment and Development as well as WHO/FAO
International Conference on Nutrition (ICN) from 1992 where World
Declaration and Food and Nutrition Action Plan has been launched.
In the context of health sector policy objectives that include promotion of
health through well balanced nutrition, prevention of deficiency disorders
and control of foodborne diseases, we are recalling health policy for
European region, Health 21, adopted in 1998 by member states, and
number of subsequent World Health Assembly resolutions on food
safety, noncommunicable diseases, infant feeding (International Codex
on Marketing of Breastmilk Substitutes and relevant resolutions) and
prevention and control of iodine deficiency disorders.
Main task of health sector related to food and nutrition in intersectoral
context is to place health and activities that can influence health in center
of all policies. In that sense role of health sector is to collect and
disseminate scientific evidences and information on relation between
nutrition and health, assess impact and economic consequences of food
and nutrition policies on health and to promote partnership with relevant
organizations and sectors.
This document addresses problems and activities from several points of
view, elaborating three aspects of food and nutrition: nutrition, food
safety and sustainable food supply. This approach has also been
recommended by the First Action Plan for Food and Nutrition Policy for
WHO European Region.
Ministry of Health of Federation of Bosnia and Herzegovina established
a working group with a task to develop this document. Group members
were representatives from the Ministry of Health and Ministry of
Agriculture, Water Supply and Forestry, experts in the field of nutrition,
food safety, control and supervision and other experts in the field of
public health and relevant medical disciplines. Work has been

coordinated by the Institute of Public Health of Federation of Bosnia and
Herzegovina (FB&H PHI).
Before addressing situation in Federation of Bosnia and Herzegovina, as
an introduction, we will shortly present arguments relevant for our
country in wider context that are given in the First Action Plan for Food
and Nutrition Policy for WHO European Region. European Action Plan
has been developed on the request of WHO member states as a support to
development of national food and nutrition action plans.
In 1995 it was estimated that each year around 130 millions of Europeans
are affected by episodes of foodborne diseases. Diarrhea, which is the
major cause of death and growth retardation in infants and young
children, is the most common symptom of foodborne illness. It causes
great problems in elderly population as well.
New types of pathogens considered to be a cause of bovine spongioform
encephalopathy well known as a mad cow disease are now considered to
cause Jacob Creutzfeldt - Jakob disease in humans.
Use of antibiotics in animal husbandry and possible transfer of antibiotic
resistance to human pathogens are major public health concern.
WHO estimates that decrease in breastfeeding practice – specially
noticed in some parts of Europe is cause of about 1.5 million of infant
deaths a year.
Iodine deficiency disorders affect around 16% of the European population and
are a major cause of mental retardation. Second deficiency disorder that also
affects millions of people in Europe is iron deficiency anaemia.
It is estimated that one third of cardiovascular diseases is related to
unbalanced nutrition and that in WHO European Region chronic
noncommunicable diseases endanger lives of more than 4 million people
and kill half of them.
Obesity is estimated to costs some health services around 7% of their
total health care budget.
Within the Region, around 2 million people dies of cancer every year and
30-40% of those cancers could be prevented through a better diet.
Preliminary analysis from the Institute of Public Health in Sweden
suggests that 4.5 % of DALYs are lost in EU countries due to poor
nutrition and additional 3.7% and 1.4% due to obesity and physical
inactivity. The total percentage of DALYs lost related to poor nutrition
and physical inactivity is therefore 9.6% compared with 9% due to
smoking. Further analysis, initiated by the Regional Office, is under way
to asses total burden of food related ill health in the Region.


1. Nutrition
Nutrition studies problem of food and all food related factors that can
influence development and health status as well as functional and vital
abilities of humans. Following is insight in situation in Federation of
Bosnia and Herzegovina related to nutritional status, food intake and food
habits and review of leading diseases related to poor nutrition.

1.1. Nutritional status

Nutritional status of population is direct indicator of health. Even before
war, there was no systematic monitoring of population’s nutritional status
within health services in FB&H. Existing prewar data were collected
through specific surveys.

During the war, due to emergency situation, nutritional and household
food security surveys have been intensively conduced both by local and
international organizations and institutions.

Since 1995 there were no extended surveys of population’s nutritional
status. Unfortunately, conditions for systematic gathering of those data
are not fulfilled as jet. However, number of different surveys that
included nutritional status indicators have been conducted and some of
those findings will be presented further in text.

1.1.1. Undernutrition
Although Former Yugoslavia was considered a developing country
before the war, existing agriculture and industry could provide sufficient
food for population and undernutrition has not been present in significant
percentage. Children
Nutritional status of children is reflection of their overall health. When
they have access to sufficient quantities of nutritious and safe food, when
they are well taken care of and not exposed to repeated illnesses, they
reach their growth potential and are considered well nourished.

Starvation among children in war, thanks to extraordinary care, has been
avoided and they were spared of undernutrition 1 and its consequences.

Survey on women and children in FB&H – Multiple Cluster Indicator
Survey (MICS) conducted in 2000 by the Federal Ministry of Health and
Institute of Public Health of FB&H and supported by UNICEF included
assessment of nutritional status of children aged 0-5 years. It included
calculation of nutritional status indices where Z score (standard
deviations below the mean of the reference population) has been
calculated. It has been found that 5% of children aged 0-5 years were
undernourished (weight for age) and percentage of stunted children
(weight for height) was 8% (expected percentage in population of
developed countries was 5% 2 ). There were 13% of thin children (height
for age).

Figure 1. Percentage undernourished or severely undernourished children
                     0-5 years, FB&H, MICS 2000




                           Underweight        Severely underweight
             Series 1        4,80%                   0,70%

  WHO: Winter Nutrition Monitoring (1994 - 95), Nutrition Unit, Office for Bosnia and
  Gregory J, Foster K, Tyler H & Wiseman M (1990): The Dietary and Nutritional
Survey of British Adults. Office of Population Census and Surveys. London: HMSO.
Figure 1. Percentage of stunted or severely stunted children 0-5 years,
                         FB&H, MICS 2000



                      Stunted           Severely stunted
        Series 1        10%                   3,20%

Figure 1. Percentage of wasted or severely wasted children 0-5 years,
                        FB&H, MICS 2000



                      Wasted           Severely wasted
       Series 1        6,10%                  1,90%

  Figure 1. Percentage of children 0-5 years retarded in growth, FB&H,
                               MICS 2000

                  13          12,9                      13,8
                                                                     11,3       11,9
      10                      10,4
                                         8,6                         8,6        9,3
                  7,4                                                           6,9
                  6,2         6,4        6,5
       5                                                4,2
                                                        3,5          3,9

           < 6 months 6-11 months     12-23      24-35          36-47       48-59
                                     months      months         months      months

                    underweight               stunted                 wasted Adults
Survey on nutritional status of healthy working population of Sarajevo,
done before the war (1990-91) by the Medical Faculty Institute of
Hygiene, University of Sarajevo, showed that only 4.3% of participants
were undernourished (BMI – body mass index = weight/height2,
underweight = BMI <18.5). In population of developed countries
expected percentage of undernutrition rates from 4 – 7%2.
According to WHO survey conducted at the territory of FB&H during the
war (1994 - 95)1, even during the hardest food shortage undernutrition
did not reach alarming levels.

   Table 1. Percentage of undernutrition (BMI < 18.5) among adult and
        elderly population in three cities on the territory of FB&H
                             (December 1994)

                         Adults (18-59 yrs.)                     Elderly (60+yrs.)
                        No.      % BMI<18.5                    No.       % BMI<18.5
SARAJEVO                302             5.0                    284             7.0
TUZLA                   360             3.1                    435             7.9
ZENICA                  374             1.9                    252             5.2
 Source: Winter Nutrition Monitoring (1994 - 95), Nutrition Unit, Office for Bosnia and

In 2001, supported by the WHO, Institute of Public Health of FB&H
conducted “CINDI health monitoring” survey. For assessment of
nutritional status of adults self reported weight and height of 1988
participants in Sarajevo canton have been used and BMI has been
calculated. Analysis showed that 60.76% had normal weight, 25.96% of
participants were overweight and obese and 6.39% of participants were
underweight. The biggest number of undernurished adults has been found
in the age group 19-24 years. In regard to sex, representation of males
and females in underweight and normal weight group was equal.

This most recent survey showed that undernutrition is not a big problem
but it also showed that obesity is increasing and can be considered a
serious health risk (see chapter Obesity and related diseases).

  Figure 5. Nutritional status of adult population, FB&H, CINDI 2000

                                         Underwight BMI < 18.5
                                         Normal weight BMI 18.5 - 24.9
                                         Overweight/obese BMI >25
                                         Do not know


1.2. Micronutrient deficiencies
1.2.1. Iodine

Mandatory iodine prophylaxis program where salt has been iodized with
5-15 mg of KJ/kg was introduced in FB&H in 1953. Medical Faculty
Institute of Hygiene conducted first survey on goiter prevalence in B&H
in 1956 and than for the purposes of evaluation of iodine prophylaxis
conducted the same survey in 1962 and 1973. Results showed that goiter
prevalence was in constant decreasing.

     Figure 6. Decrease of goiter prevalence at endemic localities after 20
                            years of salt iodization

     50                                                                 Srebrenica
     40                                                                 Bratunac
     30                                                                 Doboj
     20                                                                 Fojnica
       1953                                                  1973

Source: Institute of Public Health of FB&H

In the first half of 1999, financially supported by UNICEF and based on
WHO/ICCIDD (International Council for Control of Iodine Deficiency
Disorders) recommendations, Pediatric Clinic of University Clinical
Center Tuzla conducted a prospective study of iodine prophylaxis and
goiter prevalence at the territory of FB&H 3 . Study took place in primary
schools and included 5523 randomly selected children aged 7 to 14 years,
both sexes and with equal distribution of participants in relation to age
and place of living (urban – rural). Goiter prevalence in FB&H was found

    H. Tahirović “Jodni deficit u Bosni i Hercegovini”
to be 27.06% were 24.72% of children had goiter grade I and 2.33% of
children had goiter grade II. Goiter prevalence ranged by cantons, from
12.9% in Zapadna Hercegovina canton to 51.2% in Bosna - Podrinje

  Figure 7. Age and sex distribution of goiter prevalence among school
                           children in FB&H

                      girls          boys

  %       20


                6+7     8      9      10     11    12     13     14
                                   Age (years)

Source: Iodine deficiency disorders survey in FB&H, Pediatric Clinic of University
Clinical Center Tuzla and UNICEF, 1999

Survey also included assessment of iodine content in salt samples and
Table 2 shows results of conducted analyses.

      Table 2. Distribution of salt samples and iodine content (mg/kg)
Iodine content (mg/kg)                                           %
Less than 10 mg/kg                                              23.3
10 – 20 mg/kg                                                   58.7
More than 20 mg/kg                                               18
Source: Iodine deficiency disorders survey in FB&H, Pediatric Clinic of University
Clinical Center Tuzla and UNICEF, 1999
Analyses of iodine content in urine have been done as well and in 34.1%
of urine samples iodine content was lower that 50 µg/l, and in 69.7% of
urine samples iodine content was less that 100 µg/l. According to those
findings it has been concluded that iodine intake per person is still lower
than recommended (150-300 µg/day WHO/UNICEF/ICCIDD

As FB&H was found to be a mild to moderate iodine deficient area and
existing preventive public health measures insufficient, working group
was formed to develop strategy for management of iodine deficiency
disorders (IDD). Results of their work is new Decree on Household Salt
Quality (Official Gazette FB&H no. 46-2001, page 1002) that regulates
salt iodization with 20-30 mg of iodine per kg of salt in the form of NaI,
NaIO3, KI or KIO3.

1.2.2. Iron

Iron deficiency, especially iron deficiency anaemia is one of the most
serious nutritional deficiencies in world. It strikes all age groups. It can
cause retardation in cognitive development of children, damage of
immune mechanisms and is related to increase of morbidity rate. In
pregnancy, iron deficiency is related to increased risk of bleeding, sepsis,
maternal mortality, perinatal mortality and low birth weight. In active
males and females it reduces physical working capability.

Even before the war, according to ambulance and clinical morbidity
reports anaemia was one of the leading causes of diseases in FB&H. For
example, according to FB&H PHI data, in 1991 anaemia was on the sixth
place of ten leading causes of diseases list (morbidity rate 25.0/1000).
Biggest number of cases was found among preschool children and

WHO Survey conducted on general population in May 1994 4 , showed
that 36% of participants were anaemic, and that prevalence was high in
all age and sex groups.

    Anaemia Survey, F BH 1994, WHO Sarajevo Office
Figure 8. Prevalence of anaemia in children less than 5 years old in four






                  Armenia      Former      Bosnia and    United
                              Yugoslav     Herzegovina   Kingdom
                             Republic of

                   severe       moderate      mild       Total

           Source: Anaemia Survey, FB&H 1994, WHO Sarajevo Office

In postwar period no population based study or study on vulnerable
groups that would confirm or deny opinion of health professionals that
anaemia is a significant public health problem in F B&H has been done.
Therefore it is necessary to conduct extended population survey that
would give evidences and serve as a base for implementation of
appropriate public health programs.

1.2.3. Vitamins
Before war, vitamin deficiency disorders were rare in Bosnia and
Herzegovina. Access to food rich in vitamins and production of vitamin
enriched foods resulted in appearance of only sporadic cases of vitamin
deficiencies in adults. Also, preventive program for children that included
administration of vitamin A and D supplements to infants from second
week of life till the end of first year has been implemented. Therefore
rickets were almost eliminated in FB&H.

War brought huge changes in life conditions specially in besieged areas.
A lot of time have been spent in cellars and shelters, access to medical
facilities and adequate medical care was limited, nutrition poor. That was
the reason for WHO Bosnia and Herzegovina Office to conduct the
study “Micronutrient status of the besieged residents of Sarajevo” in May
1993. Laboratory analyses showed that levels of beta carotene, folate and
vitamin D in serum were low, indicating low consumption of green
vegetables and vegetables in general. As vegetables are important source
of vitamin C and riboflavin it is probable that intake of those and other
vitamins (thiamin, pyridoxine, and nicotinic acid) was low as well.
However, nutritional surveys done by WHO (“Winter Nutrition
Monitoring, 1993-95) on general population at whole FB&H territory
that included assessment of clinical signs of vitamin deficiencies as well
did not find any widespread micronutrient deficiencies. We can probably
thank it to undertaken preventive measures. It included iron, calcium and
folic acid fortified flour, powdered milk and fat fortified with vitamin A
and D distributed in humanitarian aid. Powdered vitamin juice specially
rich in vitamin C and vitamin tablets were also sporadically distributed in
humanitarian aid. Nowadays clinically manifested vitamin deficiencies
are rarely reported. Deficiencies of vitamin A and D

Vitamin A deficiency can have negative influence on human immune
functions and should be prevented. Taking into consideration that severe
forms of vitamin A deficiency at the territory of F B&H have not been
recorded for long, preventive prophylactic program has been seized.
Recommendation on vitamin A supplementation stopped earlier but it
was officially announced in 2000 in the Protocol on Infant Feeding
brought by the Ministry of Health of FB&H and Initiative Committee for
Promotion of Natural Nutrition of Children. Instead, Protocol
recommends modifications in diet with special emphasis on improvement
of weaning practices.

Up to date studies on vitamin D deficiencies are not available and real
causes of appearance of rickets on the territory of FB&H are not known.
However, prophylactic program of vitamin D supplementation is still in
progress. Protocol on Infant Feeding recommends administration of 400
– 800 units/day of vitamin D for breastfeeding infants and 400units/day
for not breastfed infants as well as everyday exposure of infants to

1.3. Breastfeeding

Poor nutritional status can be put in direct correlation with inappropriate
dietary habits that start to develop already in infancy and childhood.

Breastfeeding provides ideal food for growth and development of child
and health and economic benefits of breastfeeding are well known.

Prewar health statistics did not include breastfeeding indicators.
Breastfeeding surveys conducted during the war with support of UNICEF
and WHO, showed that breastfeeding practice in FB&H was strongly

 Table 3. Breastfeeding practice in babies up to 16 weeks of age during

                    Exclusive       Breastmilk/   Infant          Not
                    breastfeeding   sweetened     formula/wheat   breastfed
                                    water/tea     cows milk
          Number    %               %             %               %
Bosnia 288          5               42            28              25
 Source: UNICEF/WHO Nutrition and Immunization Survey of Bosnian Women and
                           Children During 1993

In 1993 our country become a signatory of Innocenti Declaration on
Protection, Promotion and Support of Breastfeeding and since than
breastfeeding promotion program coordinated by the Federal Ministry of
Health and Breastfeeding Committee has been conducted.

In order to evaluate the program, in 1999 with the support of UNICEF,
Institute of Public Health of FB&H conducted breastfeeding survey.
WHO/UNICEF guidelines and methodology that ensured validity of data
have been used.

Results were following: exclusive breastfeeding rate up to four months of
age was 8.1%, exclusive breastfeeding rate up to six months of age was
5.5%, predominant breastfeeding rate up to six months of age was 77.3%,
early introduction of solid foods (before six months) rate was 81.3% and
continuing breastfeeding up to one year rate was 40.7%.

   Figure 9. Feeding practice of infants 0-6 months of age by cantons,
                              FB&H 1999



                                                                                                                              Kanton Sarajevo







          Exclusive breastfeeding                         Predominant breastfeeding                                   Arteficial feeding

 Source: Survey “Breastfeeding in F B&H”, Institute of Public Health of F B&H and
                                   UNICEF 1999

Results showed that breastfeeding rates are still lower than expected and
that weaning has been early introduced and inadequate.
Part of breastfeeding promotion program is implementation of Baby
Friendly Hospital Initiative. So far five hospitals in FB&H have been
certified Baby Friendly and three more hospitals await assessment. Goal
of this initiative is for all hospitals in FB&H to become Baby Friendly by
the end of 2004.
Unfortunately, International Code on Marketing of Breastmilk substitutes
neither has been incorporated partly or in whole in some of existing laws
nor it has been adopted as separate law.

1.4. Dietary habits and food intake

In addition to neglected breastfeeding practice other data as well offer
arguments for conclusion that our population have inadequate food intake
and inappropriate dietary habits. Recent surveys showed that as much as
11% of children aged 0-5 years were found to be overweight and 5%

obese (MICS, 2000). Also, CINDI Health Monitoring Survey done in
2001 found 25.96% of overweight and obese adults.

Prewar surveys indicated that diet was mostly abundant and characterized
by intake of huge quantities of meat, fatty food and alcohol and combined
with low level of physical activity 5 .

    Table 4. Reported food intake among non-manual workers in Sarajevo
      before war compared with Former Yugoslavia recommended daily

                           Reported food             Recommended daily allowances
                              intake                     in Former Yugoslavia
Kcal                              3100                                  2700
Protein                            110                                    46
Fat                                 94                                    70
Carbohydrate                       450                                   350
      Source: Nutrition in Prewar Sarajevo, European Journal of Clinical Nutrition Volume 49,
                                   Supplement 2, October 1995

There are no valid data on annual food intake for population. However,
available data on average daily consumption of fruit and vegetables per
person can serve for rough estimate. Unfortunately, it is clear (source:
Statistical Institute of FB&H) figure of 22gr of fruit and vegetables
consumed per person per day is not valid6 . System of data collection is
insufficient as it collects data only from official public markets and does
not include data from private groceries, illegal markets, supermarkets and
food stores that present bigger part of market. But, even if we multiply
this existing figure by ten and get fruit and vegetable consumption of
200gr per person per day it is still much less than recommended by WHO

  Nutrition in Prewar Sarajevo, European Journal of Clinical Nutrition Volume 49,
Supplement 2, October 1995
  Statistički podaci o privrednim/gospodarskim i drugim kretanjima, Broj 2, Sarajevo,
Februar 2001 ISSN 1512-5017

CINDI Health Monitoring collected most recent data on dietary habits
and weekly consumption of foodstuffs in 2001.

Only 48.1% of adults consume fresh fruit every day and 38.3% of adults
consume fresh vegetables every day. As much as 38.5% of participants
consume red meat 3-5 times a week and 45% of participants do not
consume cereals at all. The ones that do eat cereals belong to younger age
groups but they also consume fizzy drinks more frequently. That can be
explained with only recent availability of cereals on market in our
country and strong soft drinks advertising campaigns targeted of youth,
as they are the ones that visit bars where those drinks are served most

         Figure 10. Weekly frequency of consumption of foods, FB&H,
                                 CINDI 2000








           Boiled potato

                           Fried potato

                                                                                                                                                   Fresh fruit/berries

                                                                                                                                                                         Other fruit/berries

                                                                                                             Fresh vegetables

                                                                                                                                Other vegetables
                                                                                             Meat products

                                                                                                                                                                                                                        Non alchocolic

                                                                                                                                                                                               Sweet peistry



                                                       Never                   1-2 times                     3-5 times                                                   6-7times

Habit of drinking coffee is strongly present in population of adults.
47.2% of adults drink 3-5 cups of coffee a day, and 21% drink as much as
5-10 cups of coffee a day. Tradition of tea consumption among adults is
week and almost 95% of participants reported to drink only 1-2 cups of
tea a day.

 Figure 11. Daily consumption of tea and coffee by age groups, FB&H,
                            CINDI 2000


    80                                                                                      19-24
    60                                                                                      35-44
    40                                                                                      55-65


          Coffee 1-2   Coffee 2-5   Coffee 5-10   Tea 1-2 cups Tea 2-5 cups Tea 5-10 cups
          cups         cups         cups

Highest percentage of population (64.34%) use oil for preparation of food and
12.32% use butter. Highly educated (university degree) adults have the
healthiest diet. 68.40% of them use oil for food preparation and only 0.99%
of them use lard and saturated fats. On contrary, 6.52% of participants with
lower level of education use lard and saturated fats for preparation of food.

  Figure 12. Type of fat used for preparation of food in house, FB&H,
                              CINDI 2000


                                                                        Vegetable oil
                                                                        Butter and butter products

                                                                        Lard, animal fats
                                                                        No fats
                                                       64,34%            Do not know

                                                                        Does not prepare food

So in general it can be concluded that intake of read meat, fat and coffee
is high while intake of fruit, vegetables and cereals is low.

1.5. Obesity and related diseases

Both in developed and developing countries of Europe and world obesity
became increasing public health concern. Obesity was present in Bosnia
and Herzegovina and on the whole territory of Former Yugoslavia even
before war and chronic noncommunicable diseases were major burden
for health services and significant financial burden for country.

Available prewar data related to obesity in FB&H came from survey
conducted by Sarajevo Medical Faculty Institute of Hygiene in 19915.
Assessment of nutritional status, health status, food intake and physical
activity has been done on population of workers of four big companies in
Sarajevo. Results showed that 8% of participants were obese.

There were more obese women (11.6%) than man (5.5%). Survey also
confirmed strong relation between obesity and precipitating factors.

During the war fear of undernutrition and deterioration of population’s
nutritional status diverted attention from obesity. However, in the last
round of WHO survey done in February 19952, obesity was assessed and
high percent was found. Again, there were more obese women than men.

  Table 5. Obesity in adults and elderly in FB&H by sex, February 1995

                                               % BMI >30
                         SARAJEVO           TUZLA    ZENICA       ENGLESKA
Adults      Males              2.0           9.7         9.4            8.0
            Females            9.5           21.5       15.5           12.0
Elderly     Males              5.1           7.4         5.3            7.3
            Females           12.9           16.5       12.4           12.8
  Source: Report of WHO Nutrition Unit in B&H “Winter Nutrition Monitoring 1995”

Survey on women and children MICS 2000, found obesity in children
(12% of children 0-5 years old were overweight and 5% obese) and
CINDI Health Monitoring found as much as 25.96% overweight and
obese adults. Biggest number of obese adults was found in age group 45-
54 and 55-65 years and again there were more obese women than man.

According to statements of participants hypertension was the most
frequent noncommunicable disease (21.01%) followed by muscle and
skeletal diseases (19.52%) and angina pectoris (12.4%).

 Figure 13. Age distribution of self reported diagnosed diseases, FB&H
                              CINDI 2000







                                                                                                                                    Back pain


                                                                   Angina pectoris

                                                                                     Chest pain

                                                    Hart failure

                                            19-24                  25-34                          35-44                     45-54               55-65

Official morbidity statistics data of the FB&H PHI Statistical Service
indicate that chronic noncommunicable diseases are in increase and that
nutrition related diseases continue to be present on ten leading chronic
noncommunicable diseases list.

     Figure 14. Leading chronic noncommunicable diseases in FB&H,
                      1999-2001god., rate at 100000

    Malignant neoplasm     320
          Tyroid gland     385
           malfunction     448
              Diabetes            1.548
 Chronic obstructive                1.797
 pulmonary disorder                 1.758
  Iron deficiency anemia            1.881                                      2000.
 Mental and behavioral               2.100
         disorders                    2.238
   Chronic diseases of                    2.852
   digestive system                                4.153
  Diseases of muscle                                       4.947
  and skeletal system                                  4.286
 Diseases of circulatory                                               8.636
 system                                                            8.066

Source: Report on Health Status of Population of F B&H in 2001, Institute of Public
Health of F B&H

Although secondary and tertiary health care professionals keep warning
on relation between nutrition and some malignant diseases there is no
register of malignant diseases in FB&H that would serve as a base for
further analyses and research.

However there is sufficient evidence on presence of obesity in population
of FB&H and there is a need for development of appropriate strategies
and implementation of specific preventive programs.

2. Food safety
Industrialization and development of technology led to increase of
number of products and improvement of production, transport,
distribution, storage and preparation of food. All this together with
import of food increased the risk of biological contamination of food with
bacteria, parasites, fungi and their toxic metabolites – mycotoxines as
well as risk of chemical contamination with heavy metals, pesticide
residues, antibiotics. In addition, war left deteriorating consequences on
overall food production, circulation, supervision and control system at the
territory of F B&H.

2.1. Foodborne diseases

Microbiological contamination of food and foodborne diseases are
unsolved issues in FB&H, specially after collapse of the state caused by
Data on safety of foodstuff and common use objects are collected within
the mandatory health statistics reporting system. Laboratories for food
control within cantonal institutes of public health are responsible for
collection of data and sending of three months, six months and annual
summary reports to the Institute of Public Health of FB&H. However,
this reporting system is insufficient as it does not include data from other
food safety and quality control laboratories like those within scientific
and research institutions (Veterinary Faculty, Faculty of Natural Sciences
and Mathematics, Faculty of Agriculture, etc.) and like food industry
internal laboratories. Therefore real magnitude of existing overall food
control is not known and it is not known if it fulfills legislative
requirements (analysis of 15 samples per 1000 inhabitants).

 Table 6. Summary review of analyses done in public health laboratories
 for food safety and quality control in three year period at the territory of
                Microbiological                        Chemical
Year        No. of       Incorrect     %      No. of examined     Incorrect    %
          examined                                samples
1998        5864           1307       22.3         2902             508       17.5
1999        6523            906       13.9         3276             753        23
2000        9027            975       10.8         3425             702       20.5
                     Source: Institute of Public Health of FB&H
   Most frequent causes of not meeting microbiological criteria were
   increased total number of microorganisms, increased number of
   Enterobacter, E. Coli, coagulasis positive staphylococci and salmonellas.
   Most frequent causes of not meeting chemical criteria were inappropriate
   content, use of forbidden additives or presence of over quantities of
   allowed additives (synthetic organic colors, preservatives).

   Reporting on alimentary toxic infections and intoxications as well as
   foodborne epidemics is a part of mandatory communicable diseases
   reporting system. Epidemiological services in cantonal public health
   institutes are responsible for data collection and sending of reports to PHI
   FB&H Epidemiological Service that provides summary reports for

   At the territory of FB&H in 2001 alimentary infections morbidity rate
   was 36,62 %000 and it put them at eight place of ten leading
   communicable diseases list. There were 5 epidemics of alimentary toxic
   infections with 108 causes. It is certain that low awareness and low level
   of education on hygiene and principles of handling, preparation and
   storage of food in house highly contribute to appearance of epidemics.

    Table 7. Ten leading communicable diseases at the territory of FB&H in
                           period of 1997-2001 god.
      Disease                  1997.              1998.              1999.              2000.                 2001.





                                   No. of


                                                      No. of


                                                                         No. of


                                                                                            No. of


                                                                                                                  No. of

      Influenza           1       14445       1      16274       1       52145      1      39321        1        35695
        Scabies           2       6908        3      4700        4        3514      5       2229        5        1865
      Varicellae          3       6020        4      4462        3        3930      2       4309        2        4130
    Enterocollitis        4       4555        2      5578        2        4334      3       3703        3        3590
       Morbilli           5       4060        5      2811        -         69       -        34         -         26
   Angina streptocc.      6       2264        6      2483        5        2064      6       1686        6        1719
  Mononucleosis inf.      7       2235        -       247        -        199       -       190         -         269
   TBC Pulmonum           8       1645        7      1706        6        1732      8       1555        7        1581
       Rubeola            9       1092        -       167        -         61       -        75         -         44
      Scarlatina          10       617        9       587        9        422      10       408        10         499
Toxinfectio Alimentaris    -       565        8       959        8        965       9       1072        8         845
  Parotitis epidemica      -       159        -       113        7        1136      4       3512        4        3020
                            Source: Institute of Public Health of FB&H

As it can be seen there is plenty of data on foodborne diseases but insight
in real situation still is not complete due to inaccuracy of reporting,
absence of modern information and networking system and lack of
capacity for identification of causal agent.

2.2. Supervision

Supervision of circulation and production of foodstuffs in FB&H is under
authority of sanitary inspection of the Ministry of Health, veterinary and
phytosanitary inspection that work under the Ministry of Agriculture,
Water Supply and Forestry and market inspection that works under the
Ministry of Trade. Presence of illegal border crossings and unorganized
customs system interfere work of those inspection services.
New organization of customs, border service (with 20 border crossings
and 3 customs stations) and inspection services that is in progress, should
provide complete supervision of food import and overall circulation and
production of food including objects and stuff.

2.3. Laboratory control

Another issue is laboratory control of safety and quality of foodstuffs.
First of all, number of food safety and quality laboratories is insufficient.
Out of ten cantonal public health institutes only five do have laboratories
and one more is in construction. Those laboratories are insufficiently
equipped and therefore many required microbiological, physical and
chemical parameters can not be examined. In most chemical laboratories
only simple instrumental techniques that use spectrophotometric and
titrimetric methods are in use and only basic chemical parameters have
been examined. Use of sophisticated methods like thinlayer
chromatography, liquid chromatography, gas chromatography, gas
spectrometry and flame techniques is limited not only due to inadequate
equipment but due to inadequate education and training of staff as well.
Therefore it is still impossible to do specific analyses of additives,
mycotoxins, antibiotics, hormones, vitamins and some toxic substances
(dioxin) in F B&H. Pesticide analysis include only quantity. Although
atomic absorptive spectrometry is in use in some laboratories whole
palette of heavy metals can not be analyzed in any of them. Also control
of radiological contamination of foodstuffs has been introduced only
recently and can be done only in the Institute of Public Health of FB&H.

Additional training of exisiting stuff for use of new laboratory equipment
is in progress but improvement of work of laboratory would require new
professional stuff as well.

Only recently, Federal agency for standardization has started evaluation
of laboratories for license and accreditation as referral laboratories for
food safety and quality control. Federal Public Health Institute laboratory
has got this license. Process of accreditation needs to be finished as soon
as possible.

2.4. Legislation

Legislation is another important issue in the field of food safety. Existing
laws are outdated and inadequate in many aspects. Those laws are
takenover from Former Yugoslavia and have not been either revised or
harmonised with international standards and norms as jet. That
comlicates work in control and supervision (for example number of new
aditives emerge but laboratory control standards for them do not exist)
enables abuse and creates new health risks. Ministry of Health of F B&H
is authorised for regulation of following laws related to food safety: law
on safety of foodstuffs and common use objects, law on protection of
population from communicable diseases and law on sanitary inspection.
Ministry of health works on revision of those laws.
Initiative for accession to European Union has been introduced in B&H
in 1998. It has been proposed for harmonization of laws related to food
safety to be done according to European Union White Book from 1995.

3. Sustainable food supply

Aim of sustainable food supply is to ensure sufficient quantities of good
quality food, while helping to stimulate rural economies and promote
social cohesion within rural societies.

War caused damage of 15% of agricultural land, 70% of agricultural
production equipment, around 60% of livestock fund, 20% of forests.
Also 27% of best agricultural land is out of use due to presence of

Existing system of food supply at the territory of FB&H is jagged.
Domestic food production makes only 37-40% of total food supply and
only 3% of it have been produced in state owned sector.

        Table 8. Prewar and postwar agricultural production in FB&H

 Husbandry          199-91    1995/     1995/     1997/     1998/    Change     D Ha
raisingsa (ha)                 96        96        98        99c      99/91
Grains              193157    106424    115482    111059    102344     53.0%     -90813
Vegetables           65741     49254     48513     50210     50834     77.3%     -14907
Industrial plants     7987       737       857      1305      1362     17.1%      -6625
Fodder              117811     52398     56074     64851     62898     53.4%     -54913
Total               384696    228813    220926    227425    217438     56.5%    -167258
Cattle fundc          1990      1996      1997      1998      1999      97/90     D No.
Ox total            447371    205390    216731    222895        Np     49.8%    -224476
Cows and                Np    152180    158801    172973        Np        Np         Np
heifers in calf
Other                   Np     53210     57930     49922       Np         Np         Np
Sheep total         651819    236663    263781    290189       Np      44.5%    -361630
Breeding sheep          Np    170497    189246    209577       Np         Np         Np
Other                   Np     66166     74535     80612       Np         Np         Np
Pigs                179288     90765     80865     76853       Np      42.9%    -102435
Sow and first           Np     10797     12928     15272       Np         Np         Np
Other                    Np     79968     67937     61581      Np         Np         Np
Poultry             2782950   1480656   1877488   2848322      Np     102.3%      65372
Horses                46628     17964     18979     19226      Np      41.2%     -27402
Goats                    Np     31672     30313     35621      Np         Np         Np
Source: Institute for Statistics, Sarajevo
  Harvest, bSowed land, con 31st December

Industrial production is represented with only several state owned food
processing and production factories and with number of small private
factories having outdated equipment, uneducated stuff and poor hygiene
In addition, existing domestic food production is burdened with
ecological risks. Minefields, unsolved issue of disposal of liquid and
solid waste, inadequate waste deposits and inadequate liquid waste filters
present direct risk for contamination of land and indirect consequent
contamination of food.
Cultivation of land along highways and air pollution pose a risk for
indirect contamination of food with heavy metals.
Use of pesticides in agricultural production is in increase and it has been
estimated that almost 10% of agricultural land have been contaminated
by pesticides.
Supervision and control of primary and secondary production and
distribution is complicated. Also, work of sectors involved in food
production circulation and control is not coordinated. Responsibilities
and activities of individual sectors are not precisely defined and that
causes overlapping.

Responsibility of food producers and distributors for assurance of safe
food is small so they neglect potential risks and transfer their
accountability to other subjects.
Knowledge of employed staff on hygienic requirements in the process of
food production and distribution is low and rarely refreshed. Particularly
weak is knowledge on principles and implementation of HACCP system
that includes risk assessment, determination of critical points and
continuing control within the production process and than in whole food

World incidents (use of antibiotics in animal husbandry) and consequent
health risks also need to be mentioned as 60% of food supply in FB&H is
imported and capacities of laboratory control are limited.
In addition to import of ready products that contain GMO there is
potential threat of genetically modified organisms as biological pollutants
(i.e. seed for cultivation) as their effects when relieved in environment
have not been sufficiently examined. FB&H does not have capacity
either for evaluation of submitted risk assessment or for process of
reapproval of GMOs prior to import which is prerequisite for joining EU.

Issues of food production and food supply influence health and therefore
are mentioned here but are elaborated in details in document “Strategy of
agricultural development of Federation of Bosnia and Herzegovina” that
Federal Ministry of Agriculture Water Supply and Forestry developed
with support of FAO in 2000. Document proposes models of sustainable
development of food production and food supply that would help
promotion and improvement of health of population.
Document also stresses the need for stronger collaboration of health and
agricultural sector.


Goal of food and nutrition policy is to protect and promote health and
reduce burden of diseases related to food and nutrition while contributing
to social and economic development and sustainable environment. More
specifically, main goal of health sector is promotion of health through
well balanced diet, prevention of nutritional deficiencies and prevention
and control of foodborne diseases. In that context and taking into
consideration our present situation, objectives have been set as well as
strategic approaches and priority activities for achievement of those

• Reduction of obesity and undernutrition rates in population
• Reduction of prevalence of anaemia and iodine deficiency disorders
• Improvement of dietary habits of population
• Improvement of information and education in the field of nutrition

Food safety
• Reduction of incidence of foodborne diseases
• Insurance of safety of food in every process and every section of food
  production circulation and distribution chain from primary producer to
• Raising of public awareness on food safety and sanitation

Sustainable food supply
• Promotion of sustainable (environmentally friendly) food production
   that will ensure enough food of good quality while stimulating rural
   economies and social cohesion within rural societies

For accomplishment of overall goal and specific objectives stated in this
document following strategic approaches are recommended:

• Education of health professionals in the field of nutrition at all levels
• Education and information of public in the field of nutrition
• Monitoring of nutritional status, dietary habits and food intake, as
   well as chronic noncommunicable diseases related to nutrition
• Breastfeeding promotion and promotion of healthy nutrition
• Conducting of specific programs for prevention of obesity and
   noncommunicable diseases
• Conduction of programs for prevention and control of micronutrient
• Conduction of programs aimed for socio-economically and
   nutritionally vulnerable groups

Food safety
• Strengthening of food safety and control system
• Insurance of implementation of HACCP practice in whole food
   processing chain
• Monitoring of food contaminants
• Research aimed to gathering of data on positive and negative
   influence of food on health

Sustainable food supply
• Insurance of sufficient quantities of nutritious and safe food
• Promotion of sustainable food production
• Cooperation with food industry in implementation of specific
   programs (food fortification, production of foodstuffs with reduced
   salt content etc.)

Main mechanism for implementation of this strategy is intersectoral
coordination and collaboration and involvement of all relevant sectors –
health, education, agriculture, environment protection, industry, media,
non-governmental sector and strengthening of collaboration and
partnership at local, national and international level.

In that context development of food and nutrition policy and action plan
at state level is strongly recommended.

In implementation of food and nutrition policy in next five year period
following activities are considered priority ones:

• Establishment of intersectoral advisory and coordinating body
  such as food and nutrition committee
Actors: Federal Ministry of Health, Federal Ministry of Agriculture,
Water Supply and Forestry, Federal Ministry of Education and Science,
Federal Ministry of Energy, Industry and Mining, Institute of Public
Health of F B&H, B&H Academy of Sciences and Arts

• Using international methodology and protocols to conduct population
   and specific vulnerable groups (i.e. school children) surveys that
   would serve as a base for establishment of systematic monitoring of
   nutritional status and dietary habits of population
• To develop dietary guidelines for health professionals based on
   CINDI dietary guidelines
• To develop dietary guidelines for population
• In the frame of health information system work on establishment of
   cancer register
• To conduct promotional activities and campaigns on healthy diet
   separately and within exiting campaigns and programs (CINDI,
   NEHAP, World Food Day, World Environment Day, Healthy Cities
   and Healthy Schools)
• To conduct specific programs for vulnerable groups
• Within existing breastfeeding promotion program:
   • Conduct assessment of all hospitals and maternity boards for
       Baby Friendly Hospital certification
   • Conduct continuous education of mothers on breastfeeding
   • Develop guidelines on weaning for infants and young children
   • Continuously conduct promotional activities (breastfeeding week)

   •    Work on implementation of International Code on Marketing of
        Breastmilk Substitutes in some of relevant laws (law on safety
        and quality of foodstuffs, law on drags etc.)
    • Establish monitoring of implementation International Code on
        Marketing of Breastmilk Substitutes
• Within existing program for prevention of iodine deficiency
    • Establish committee for iodine deficiency disorders
    • Adopt and implement regulations on import and domestic
        production of salt
    • Train stuff working in inspection on monitoring of iodine content
        in salt
    • Continuously monitor iodine content in salt at all other levels
    • Continuously educate health professionals on iodine deficiency
        disorders prevention
    • Promote use of iodized salt in population’s diet
    • Monitor iodine status in population specially among children
• Establish integrated program for prevention of iron deficiency
• Collaborate and coordinate activities with relevant partners at entity
• Continuously collaborate with international partners in exchange of
    experiences and information, gaining knowledge and providing
Actors: Federal Ministry of Health, Federal Ministry of Education and
Science, Federal Ministry of Agriculture Water Supply and Forestry,
Federal Ministry of Energy Industry and Mining, Federal Ministry of
Physical Planning and Environment, Federal Ministry of Displaced
Persons and Refugees, Federal Ministry of Work and Social Affairs,
relevant ministries at cantonal level, Institute of Public Health of F B&H,
cantonal institutes of pubic health, Institute of Statistics of F B&H,
medical faculties, stomatological faculties, University clinical center,
health centers, relevant non – government organizations (Breastfeeding
Advancement Group), mass media, food industry.

Food safety
• To establish working groups and make plan of action for revision of
   laws related to food safety and supervision and for their
   harmonization with international standards

•   To improve laboratory equipment and educate laboratory stuff for its
    use as a base for establishment of systematic monitoring of food
• To improve existing reporting and surveillance system on foodborne
    diseases morbidity and mortality with laboratory diagnostics data on
    causal agents
• To define referral laboratories for supervision over foodstuffs
    specially imported ones
• To undertake measures for membership and participation in work of
    Codex Alimentarius and its commissions
• To establish registers of sanitary inspectors and data base on available
    equipment and stuff in laboratories for food safety and quality control
• Continuously educate stuff employed in food industry and circulation
   on HACCAP principles and involve chapters on HACCAP principles
   in curricula of relevant undergraduate studies
• Continuously inform public on food hygiene and safe food handling
• Collaborate and coordinate activities with relevant partners at entity
• Continuously collaborate with international partners in exchange of
   experiences and information, gaining knowledge and providing
Actors: Federal Ministry of Health, Federal Ministry of Energy Industry
and Mining, Federal Ministry of Agriculture Water Supply and Forestry,
Federal Ministry of Education and Science, Federal Ministry of Physical
Planning and Environment, relevant ministries at cantonal level, Institute
of Public Health of FB&H, cantonal institutes of pubic health, Institute
for Standards, Norms and Patents of FB&H, medical faculties, veterinary
faculties, food technology faculties, relevant non – government
organizations (Consumer Association), mass media, food industry.

Sustainable food supply
• To establish universal monitoring system that would include entire
  chain of food production with a special emphasis on monitoring of use
  of pesticides antibiotics and biological stimulators in primary
• In secondary production and distribution verify appropriate production
  procedures and supervise it through competent inspection services
• To educate produces in primary and secondary production
• To promote sustainable food production

• To collaborate and coordinate activities with relevant partners at entity
• Continuously collaborate with international partners in exchange of
   experiences and information, gaining knowledge and providing
Actors: Federal Ministry of Agriculture Water Supply and Forestry,
Federal Ministry of Health, Federal Ministry Education and Science,
Federal Ministry of Physical Planning and Environment, Federal Ministry
of Energy Industry and Mining, relevant ministries at cantonal level,
B&H Academy of Sciences and Arts, Institute of Public Health of F
B&H, cantonal institutes of pubic health, Institute of Statistics of F B&H,
relevant non – government organizations (Consumer Association), mass
media, food industry.


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