Report
of the 2009 Georgia National Nutrition Survey
Report
of the 2009 Georgia National Nutrition Survey
June 2010
Bradley A. Woodruff, MD MPH Consultant, UNICEF-Georgia
Levan Baramidze, MD MPH PhD First Deputy Director General, NCDC&PH Full Professor, Tbilisi State
Medical University
Manana Beruchashvili, MD Deputy Director General, NCDC&PH
Marina Shakhnazarova, MS Head of Division of Data Analysis, NCDC&PH
Konstantine Gvetadze, MD Head, Imereti Zonal Branch, NCDC&PH
Vilma Qahoush Tyler, MS, MPH Nutrition Specialist, UNICEF Regional Office CEE/CIS
Tako Ugulava, MD, PhD Health Officer, UNICEF-Georgia
Nino Lortkipanidze, MD Nutrition Officer, UNICEF-Georgia
The Georgia National Nutrition Survey 2009 Steering Committee:
Mamuka Nadareishvili, Statistitian, Full Professor, Chavchavadze State University
Neli Chakvetadze, MD, PhD Academic Secretary, NCDC&PH
Konstantin Kazanjan, MS, Head of DB Department, NCDC&PH
Rusudan Kvanchakhadze, MD PhD Lead Specialist, NCDC&PH
Lela Sturua, MD MPH PhD Head of NCD Epidemiology and HP Department, NCDC&PH
Manana Tsintsadze, PhD Head of Medical Statistics Service, NCDC&PH
Consultants:
Paata Imnadze, MD PhD, Full Professor Tbilisi State University, General Director of NCDC&PH
Akaki Gamkrelidze, MD PhD, Full Professor Tbilisi State Medical University Deputy General Director of
NCDC&PH
Special thanks to:
First Lady of Georgia Mrs Sandra Elisabeth Roelofs and the members of the Reproductive Health National
Council under the Georgian Ministry of Health and Social Affairs:
Maka Mshvildadze, MD, Neonatologist, Technical Consultant in Pediatrics/Neonatology
Eugenia Tavadze, MD, MSc, PhD Technical Consultant in Safe Motherhood and Cancer Screening
Giovanna Barberis, Representative, UNICEF Senegal
Roeland Monasch, Representative, UNICEF Georgia
Benjamin Perks, Deputy Representative, UNICEF Georgia
David Brown, DSc, MScPH, MSc, UNICEF NY
George Gedevanishvili, Head of Office, and Asmat Beshidze, Medical Coordinator, United Methodists
Committee on Relief (UMCOR) Georgia
James P. Wirth, Senior Associate, Performance Measurement and Research, Global Alliance for
Improved Nutrition (GAIN)
TABLE OF CONTENTS
TABLE OF CONTENTS..................................................................................................... 3
LIST OF TABLES............................................................................................................. 6
List of figures...........................................................................................................10
LIST OF ABBREVIATIONS...............................................................................................11
executive summary..................................................................................................12
Introduction...........................................................................................................12
Results.................................................................................................................12
Conclusions, Discussion, and Recommendations........................................................14
Anemia and iron deficiency.............................................................................14
Folate deficiency............................................................................................16
Bread fortification..........................................................................................17
Salt iodization, storage, and consumption.........................................................18
Acute protein-energy malnutrition....................................................................18
Overweight and obesity..................................................................................18
Chronic protein-energy malnutrition..................................................................19
Underweight.................................................................................................19
Breastfeeding................................................................................................20
INTRODUCTION AND BACKGROUND...............................................................................23
goals and objectives..............................................................................................25
METHODS ...................................................................................................................26
Study population....................................................................................................26
Case definitions and measurement methods of outcomes............................................27
Adequately iodized salt in households...............................................................27
Iron fortification of bread................................................................................27
Birthweight...................................................................................................27
Breastfeeding................................................................................................28
Protein-energy malnutrition in children less than 5 years of age............................29
Overnutrition in children less than 5 years of age...............................................29
Chronic energy deficiency and overnutrition in non-pregnant women
15-49 years of age........................................................................................29
Anemia.........................................................................................................30
Iron deficiency...............................................................................................31
Folate deficiency............................................................................................32
Sampling scheme...................................................................................................32
Georgia National Nutrition Survey 2009
3
Households, children, and non-pregnant women................................................32
Pregnant women............................................................................................33
Sample size calculation...........................................................................................33
Households, children, and non-pregnant women................................................33
Pregnant women............................................................................................34
Enrollment and recruitment procedures.....................................................................35
Households, children, and non-pregnant women................................................35
Pregnant women............................................................................................36
Data collection.......................................................................................................36
Team composition..........................................................................................36
Household procedures....................................................................................37
Data collection instruments.....................................................................................38
Training for study personnel....................................................................................38
Data analysis.........................................................................................................39
Data entry, editing, and management.......................................................................39
Quality control.......................................................................................................39
RESULTS......................................................................................................................40
Households – Description of sample.........................................................................40
Households – Salt storage, usage, and iodization.......................................................43
Households – Bread consumption and iron content.....................................................46
Children – Description of sample..............................................................................56
Children – Birthweight............................................................................................57
Children – Breastfeeding.........................................................................................59
Children – Other dietary intake................................................................................71
Children – Protein-energy nutritional status...............................................................73
Acute protein-energy malnutrition (wasting) and overweight................................73
Chronic protein-energy malnutrition (stunting)....................................................76
Underweight.................................................................................................80
Children – Micronutrient status................................................................................81
Anemia.........................................................................................................81
Iron deficiency...............................................................................................84
Non-pregnant women – Description of sample...........................................................85
Non-pregnant women – Protein-energy nutritional status.............................................88
Non-pregnant women – Micronutrient status.............................................................90
Anemia.........................................................................................................90
Iron deficiency...............................................................................................92
Folate...........................................................................................................94
Pregnant women – Description of sample..................................................................94
4
Georgia National Nutrition Survey 2009
Pregnant women – Protein-energy nutritional status...................................................97
Pregnant women – Micronutrient status....................................................................98
Anemia.........................................................................................................98
ANNEX 1 – Sampling methodology........................................................................100
First stage sampling.............................................................................................100
Households, children, and non-pregnant women..............................................100
Pregnant women..........................................................................................100
Second stage sampling.........................................................................................101
Households, children and non-pregnant women...............................................101
Pregnant women..........................................................................................101
Stratified sampling...............................................................................................101
Children and non-pregnant women.................................................................101
Pregnant women..........................................................................................102
Basic sample size (for regional stratification)............................................................102
Households.................................................................................................104
Children and non-pregnant women.................................................................104
Supplemental sample size (for ethnic stratification)...................................................107
Children and non-pregnant women.................................................................107
Pregnant women..........................................................................................110
ANNEX 2 – DATA COLLECTION FORMS.........................................................................111
ANNEX 3 – QUALITY ASSURANCE DURING and after DATA COLLECTION...................126
Interview............................................................................................................126
Anthropometric measurements..............................................................................126
Physical examination............................................................................................126
Biologic specimen collection..................................................................................126
Laboratory measurements.....................................................................................127
Ferritin and CRP...........................................................................................127
Salt iodine...................................................................................................127
REFERENCES...............................................................................................................129
Georgia National Nutrition Survey 2009
5
LIST OF TABLES
Table 1. Summary results for major indicators, GNNS 2009.............................................. 12
Table 2. Prevalence rates of anemia in children less than 5 years of age, non-pregnant
women, and pregnant women, in Georgia and selected other countries.................. 14
Table 3. Prevalence rates and mean serum folate level, non-pregnant women 15-49 years
of age, in Georgia and selected other countries before implementation of flour
fortification with folate.................................................................................... 16
Table 4. Prevalence rates of stunting in children less than 5 years of age, in Georgia
and selected other countries............................................................................. 20
Table 5. Breastfeeding indicators in two prior MICS and GNNS 2009................................. 21
Table 6. Results of measurement of nutrition indicators included in nationwide
surveys done since independence, Georgia 1999-2009........................................ 24
Table 7. Target groups, outcomes, and source of sample, GNNS 2009.............................. 26
Table 8. Inclusion criteria, by target group, Georgia National Nutrition Survey 2009............. 26
Table 9. Categories of protein-energy nutrition, by value of BMI, GNNS 2009..................... 30
Table 10.Definition of anemia by hemoglobin concentration for various age- and
sex-specific groups, GNNS 2009...................................................................... 30
Table 11.Adjustments in cut-off defining anemia, by altitude of residence, GNNS 2009........ 31
Table 12.Adjustments in cut-off defining anemia, by smoking status, GNNS 2009............... 31
Table 13.Number of households and individuals from whom data are needed,
for different target groups and outcomes, GNNS 2009........................................ 33
Table 14.Summary of biologic specimens to be taken, by target group, GNNS 2009............. 37
Table 15.Distribution of various demographic variables for sample households, GNNS 2009.. 41
Table 16.Distribution of household composition and ethnicity variables for sample
households, GNNS 2009.................................................................................. 42
Table 17.Distribution of socio-economic variables for sample households, GNNS 2009......... 43
Table 18.Number (weighted %) and 95% confidence intervals (CI) for variables
concerning salt storage and use, sample households, GNNS 2009........................ 44
Table 19. Weighted mean average and 95% confidence intervals (CI) for iodine content
in parts per million in household salt specimens, sample households, GNNS 2009... 45
Table 20.Number (weighted %) with salt iodine of various concentrations (in parts
per million), sample households, GNNS 2009..................................................... 46
Table 21.Weighted mean average of bread eaten per person per day (in grams)
and 95% confidence intervals (CI), sample households, GNNS 2009..................... 48
Table 22.Number (weighted %) most often consuming various types of bread,
sample households, GNNS 2009....................................................................... 49
6
Georgia National Nutrition Survey 2009
Table 23.Number (weighted %) purchasing most commonly eaten type of bread
from various sources, sample households, GNNS 2009........................................ 50
Table 24.For most commonly used bread which is purchased in supermarkets, number
(weighted %) with various brand names, sample households, GNNS 2009............. 51
Table 25.Number (weighted %) using various types of flour when baking bread at home,
sample households in which bread is baked at home, GNNS 2009........................ 52
Table 26.Number (weighted %) of bread specimens for which packaging was
marked as fortified with iron or not (does not include homemade bread),
sample households, GNNS 2009....................................................................... 53
Table 27.Weighted mean average and 95% confidence intervals for iron content
in parts per million, household bread specimens, GNNS 2009............................... 54
Table 28.Number (weighted %) and 95% confidence intervals (CI) of household bread
specimens containing >30 parts per million iron, GNNS 2009.............................. 55
Table 29.Description of sample children less than 5 years of age, GNNS 2009.................... 56
Table 30.Point or period prevalence of various forms of morbidity,
children less than 5 years of age, GNNS 2009.................................................... 57
Table 31.Number (weighted %) with various birth weights,
children less than 5 years of age, GNNS 2009.................................................... 58
Table 32.Number (weighted %) with various times of breastfeeding initiation after birth,
children < 24 months of age, GNNS 2009 (WHO/UNICEF recommendations Indicator #1 Early initiation of breastfeeding)...................................................... 61
Table 33.Number (weighted %) and 95% CI of children exclusively breastfed the day
before the interview, children < 6 months of age, GNNS 2009 (WHO/UNICEF
recommendations - Indicator #2 Exclusive breastfeeding under 6 months).............. 62
Table 34.Number (weighted %) and 95% CI of children breastfed the day
before the interview, children 12-15 months of age, GNNS 2009 (WHO/UNICEF
recommendations - Indicator #3 Continued breastfeeding at 1 year)...................... 63
Table 35.Number (weighted %) and 95% CI of children eating complementary food the
day before the interview, children 6-8 months of age, GNNS 2009 (WHO/UNICEF
recommendations - Indicator #4 Introduction of solid, semi-solid or soft foods)....... 64
Table 36.Number (weighted %) with minimum dietary diversity
the day before the interview, children 6-23 months of age, GNNS 2009
(WHO/UNICEF recommendations - Indicator #5 Minimum dietary diversity)............. 65
Table 37.Number (weighted %) with minimum meal frequency
the day before the interview, children 6-23 months of age, GNNS 2009
(WHO/UNICEF recommendations - Indicator #6 Minimum meal frequency)............. 66
Table 38.Number (weighted %) with minimum acceptable diet the day
before the interview, children 6-23 months of age, GNNS 2009
(WHO/UNICEF recommendations - Indicator #7 Minimum acceptable diet).............. 67
Table 39.Number (weighted %) and 95% CI of children ever
breastfed, children < 24 months of age, GNNS 2009
(WHO/UNICEF recommendations - Indicator #9 Children ever breastfed)............... 68
Georgia National Nutrition Survey 2009
7
Table 40.Number (weighted %) and 95% CI of children breastfed the day
before the interview, children 20-23 months of age, GNNS 2009 (WHO/UNICEF
recommendations - Indicator #10 Continued breastfeeding at 2 years)................... 69
Table 41.Number (weighted %) and 95% CI of children with age-appropriate
breastfeeding the day before the interview, children < 24 months of age,
GNNS 2009 (WHO/UNICEF recommendations - Indicator #11 Age-appropriate
breastfeeding)................................................................................................ 70
Table 42.Number (weighted %) and 95% CI of children eating various foods the day
before the interview, by age group, children < 5 years of age, GNNS 2009........... 72
Table 43.Number (weighted %) of children eating various foods the week before the
interview with various frequencies, by age group, children < 24 months of age,
GNNS 2009................................................................................................... 72
Table 44.Number (weighted %) of children eating various foods the week before the
interview with various frequencies, by age group, children 24-59 months of age,
GNNS 2009................................................................................................... 73
Table 45.Number (weighted %) with various levels of acute protein-energy malnutrition
or wasting, overweight, or obesity (defined by weight-for-height z-score
calculated using WHO Child Growth Standard), children less than 5 years of age,
GNNS 2009................................................................................................... 75
Table 46.Number (weighted %) with overweight or obesity (defined by weightfor-height z-score calculated using WHO Child Growth Standard),
children less than 5 years of age, GNNS 2009.................................................... 76
Table 47.Number (weighted %) with various levels of chronic protein-energy malnutrition
(defined by height-for-age z-score calculated using WHO Child Growth Standard),
children less than 5 years of age, GNNS 2009.................................................... 78
Table 48.Number (weighted %) with any chronic protein-energy malnutrition (defined
by height-for-age z-score calculated using WHO Child Growth Standard),
children less than 5 years of age, GNNS 2009.................................................... 79
Table 49.Number (weighted %) with various levels of underweight
(defined by height-for-age z-score calculated using WHO Child Growth Standard),
children less than 5 years of age, GNNS 2009.................................................... 80
Table 50.Number (weighted %) with various degrees of anemia,
children 12-59 months of age, GNNS 2009........................................................ 82
Table 51.Number (weighted %) with any anemia, children 12-59 months of age,
GNNS 2009................................................................................................... 83
Table 52.Number (weighted %) and 95% confidence intervals (CI) with iron deficiency,
children less than 5 years of age, GNNS 2009.................................................... 84
Table 53.Description of demographic variables, non-pregnant women 15-49 years of age,
GNNS 2009................................................................................................... 85
Table 54.Description of reproductive and breastfeeding variables,
non-pregnant women 15-49 years of age, GNNS 2009........................................ 87
Table 55.Description of behavioral variables, non-pregnant women 15-49 years of age,
GNNS 2009................................................................................................... 87
8
Georgia National Nutrition Survey 2009
Table 56.Number (weighted %) with various levels of malnutrition (defined by BMI),
non-pregnant women 15-49 years of age, GNNS 2009........................................ 89
Table 57.Number (weighted %) with overweight or obesity (defined by BMI),
non-pregnant women 15-49 years of age, GNNS 2009........................................ 90
Table 58.Distribution of levels of adjusted hemoglobin concentrations,
non-pregnant women 15-49 years of age, GNNS 2009........................................ 91
Table 59.Number (weighted %) and 95% confidence intervals (CI) with any anemia
(after adjustment of hemoglobin concentration for smoking status and altitude of
residence), non-pregnant women 15-49 years of age, GNNS 2009........................ 92
Table 60.Number (weighted %) and 95% confidence intervals (CI) with iron deficiency,
non-pregnant women 15-49 years of age, GNNS 2009........................................ 93
Table 61.Number (weighted %) with anemia, by iron deficiency status,
non-pregnant women 15-49 years of age, GNNS 2009........................................ 93
Table 62.Description of demographic variables, pregnant women, GNNS 2009.................... 94
Table 63.Description of reproductive history, pregnant women, GNNS 2009....................... 96
Table 64.Description of behavioral variables, pregnant women, GNNS 2009........................ 96
Table 65.Number (weighted %) and 95% confidence intervals (CI) with low MUAC,
pregnant women, GNNS 2009.......................................................................... 97
Table 66.Distribution of levels of hemoglobin concentrations, pregnant women,
GNNS 2009................................................................................................... 98
Table 67.Number (weighted %) and 95% confidence intervals (CI) with any anemia,
pregnant women, GNNS 2009.......................................................................... 99
Table 68. Comparison of CRP testing results from Georgian laboratory and
German laboratory, GNNS 2009..................................................................... 127
Table 69. Comparison of ferritin testing results from Georgian laboratory and German
laboratory, GNNS 2009................................................................................. 127
Georgia National Nutrition Survey 2009
9
List of figures
Figure 1.
Recruitment procedures for household survey, GNNS 2009.................................35
Figure 2.
Weighted distribution of iodine concentrations in household salt specimens,
GNNS 2009..................................................................................................45
Figure 3.
Weighted distribution of households with various per capita daily
bread consumption, GNNS 2009.....................................................................48
Figure 4.
Weighted distribution of iron concentrations in household bread specimens,
GNNS 2009..................................................................................................54
Figure 5.
Weighted distribution of birthweights of children less than 5 years of age,
GNNS 2009..................................................................................................57
Figure 6.
Weighted distribution of birthweights of children less than 5 years of age,
GNNS 2009..................................................................................................58
Figure 7.
Weighted 3-month moving average percent of children breastfed the day
before the interview, by age, children < 36 months of age, GNNS 2009
(WHO/UNICEF recommendations22 - Indicator #13 Duration of breastfeeding)........71
Figure 8.
Weighted distribution of weight-for-height z-scores in children
less than 5 years of age, GNNS 2009..............................................................74
Figure 9.
Weighted distribution of height-for-height z-scores in children
less than 5 years of age, GNNS 2009..............................................................77
Figure 10. Weighted distribution of hemoglobin concentrations in children
less than 5 years of age, GNNS 2009..............................................................81
Figure 11. Distribution of BMI values for non-pregnant women 15-49 years of age,
GNNS 2009..................................................................................................88
Figure 12. Weighted distribution of hemoglobin concentrations
in non-pregnant women 15-49 years of age, GNNS 2009...................................91
Figure 13. Weighted distribution of MUAC measurements, pregnant women,
GNNS 2009..................................................................................................97
Figure 14. Weighted distribution of hemoglobin concentrations in pregnant women,
GNNS 2009..................................................................................................98
Figure 15. Scatterplot showing correlation between Georgian and
Ukrainian laboratories’ results in testing household salt, GNNS 2009..................128
10
Georgia National Nutrition Survey 2009
LIST OF ABBREVIATIONS
BMI
Body mass index
CI
Confidence intervals
CRP
C-reactive protein
ELISA
Enzyme-linked immunosorbant assay
GNNS 2009
Georgia National Nutrition Survey 2009
ICC
Intracluster correlation co-efficient
MICS
Multiple Indicator Cluster Survey
MUAC
Mid-upper arm circumference
NCDCPH
Georgia National Center for Disease Control and Public Health
ppm
Parts per million
RR
Relative risk
UN
United Nations
UNHCR
United Nations High Commissioner for Refugees
WFP
World Food Programme
WHO
World Health Organization
Georgia National Nutrition Survey 2009
11
executive summary
Introduction
Over the past five years the government of Georgia has taken active steps to improve the nutritional status of the population of Georgia. In 2005 the Parliament of Georgia has adopted a Law
called “Prevention of iodine, other microelement and vitamin deficiencies”. The law bans import
and sale of non-iodized salt and puts in place the mechanisms for food fortification policy in the
country. In addition, since 2006 Georgia has been implementing a program to fortify wheat flour
with iron and folic acid. However, these positive developments may have not fully reversed the
adverse impact on nutritional status of the difficult political situation and socio-economic changes.
This report analyses the results of the Georgia National Nutrition Survey 2009 (GNNS 2009), a
cross-sectional, nationwide survey assessment of nutritional status in several target groups in
Georgia. This survey randomly selected households from which children less than 5 years of age
and non-pregnant women 15-49 years of age were recruited. A separate sample of pregnant
women was consecutively recruited from a random selection of facilities providing ante-natal care
in Georgia. The results of this survey can be generalized to the overall population of Georgia, and
many estimates can be generalized to regions or combinations of regions.
This Executive Summary presents a summary of the estimates for major indicators in table form
(see Table 1 below) and includes the Conclusions, Discussion, and Recommendations section
which compares the results of this survey to prior assessments and compares Georgian results
with those from neighboring and other countries. This section also gives recommendations for
programmatic interventions. The Methods section then describes how the survey was carried
out. The Results section presents a detailed analysis of the survey data. The annexes contain a
more information on the sampling scheme, copies of the data collection forms in English which
were used in this survey, and a description of the quality control strategies used during data collection.
Results
Table 1.
Summary results for major indicators, GNNS 2009
Target group
Anemia and iron deficiency
Children < 5 years
of age
Non-pregnant women
12
Indicator*
Anemia
Severe anemia
Moderate anemia
Mild anemia
Iron deficiency
Anemia
Severe anemia
Moderate anemia
Mild anemia
Elevated hemoglobin
Mild elevation
Moderate elevation
Iron deficiency
Georgia National Nutrition Survey 2009
Value
22.8 %
0.6
9.4
12.8
0.1 %
24.1 %
0.4
9.1
14.6
4.9 %
2.5
2.4
1.6 %
Table**
Table 51
%
%
%
Table 52
Table 59
%
%
%
%
%
Table 60
Target group
Indicator*
Pregnant women
Anemia
Severe anemia
Moderate anemia
Mild anemia
25.6 %
0.7 %
7.7 %
17.1 %
Folate deficiency
Mean serum folate level
36.6 %
7.2 ng/ml
Folate deficiency
Non-pregnant women
Value
Table**
Table 67
Bread fortification
Households
Average per capita daily
bread consumption
Most common type of bread
eaten at home
Source of most common
bread
Type of flour used at home
Average iron content of
bread
Bread iron >30 ppm
Salt iodization
Households
Mean iodine content in salt
Salt iodine >15 ppm
Salt iodine <15 ppm
Salt iodine 15.1-40 ppm
Salt iodine 40+ ppm
414 grams
Varies by
region
Varies by
region
Varies by
region
23.8 ppm
24.9 %
36.8 ppm
>99.9 %
<0.1 %
73.4%
26.5 %
Table 21
Table 22
Table 23
Table 25
Table 27
Table 28
Table 19
Table 20
Protein-energy nutritional status
Children <5 years
Non-pregnant women
Pregnant women
Infant and young child feeding
Children <5 years
Children <24 months
Children <6 months
Children 12-15 months
Children 6-8 months
Children 6-23 months
Any wasting
(low weight-for-height)
Overweight or obesity
Any stunting
(low height-for-age)
Severe stunting
Moderate stunting
Any underweight
(low weight-for-age)
Any low BMI
Severe low BMI
Moderate low BMI
At risk
Any high BMI
Overweight
Obese
Low MUAC
Low birthweight
Breastfeeding begun within 1
hour of birth
Exclusive breastfeeding
Continued breastfeeding at
1 year
Complementary food
introduced
Minimum dietary diversity
1.6 %
Table 45
19.9 %
Table 46
11.3 %
Table 48
4.5 %
6.8 %
1.1 %
5.3 %
0.3
1.1
3.9
42.1 %
24.1
18.0
4.8 %
Table 47
Table 49
Table 56
%
%
%
Table 57
%
%
Table 65
4.9 %
Table 31
66.3 %
Table 32
54.8 %
Table 33
36.5 %
Table 34
84.5 %
Table 35
47.7 %
Table 36
Georgia National Nutrition Survey 2009
13
Target group
Indicator*
Minimum meal frequency
Minimum acceptable diet
Ever breastfed
Continued breastfeeding at
2 years
Age-appropriate
breastfeeding
Median duration of
breastfeeding
Children <24 months
Children 20-23 months
Children <24 months
Children <36 months
*
**
Value
Table**
85.3%
42.3 %
87.2 %
Table 37
Table 38
Table 39
16.6 %
Table 40
37.7 %
Table 41
9-10 months
of age
Figure 7
See text of Methods section for definitions
See table indicated for more detailed analysis of outcome, including group-specific results by age, regional
stratum, rural/urban residence, and ethnicity
Conclusions, Discussion, and Recommendations
Anemia and iron deficiency
Anemia is a common health problem in children less than 5 years of age, non-pregnant women
15-49 years of age, and pregnant women in Georgia. Although severe anemia is relatively rare
in these risk groups, moderate and mild anemia can still have deleterious effects on health. According to WHO recommendations, anemia in all three target groups in Georgia is a “moderate”
public health problem (prevalence 20-39%).1 As seen in Table 2, although the prevalence rates
of anemia in young children and women in Georgia are generally lower than those of its neighboring countries, they are substantially elevated when compared to developed countries in Europe
and North America. Table 2 also demonstrates that, unlike Georgia, some advanced industrialized
countries do not have precise measurements of the prevalence of anemia in these target groups.
Table 2.Prevalence rates of anemia in children less than 5 years of age, non-pregnant women,
and pregnant women, in Georgia and selected other countries.
Prevalence of anemia
Children < 5 years
(year of survey)
Country
Non-pregnant women
(year of survey)
Georgia
22.8 % (2009)
24.1 % (2009)
25.6 % (2009)
Azerbaijan
31.8 % (2001)
40.2
(2001)
38.4 % (2001)
Armenia
36.5 % (2005)
24.2 % (2005)
38.6 % (2005)
Turkey
32.6 % *
26.3 % *
40.2 % *
Sweden
8.6 % *
13.3 % *
12.9 % *
Germany
7.8 % *
12.3 % *
12.3 % *
USA
3.1 % (2002)
6.9 % (2002)
*
Pregnant women
(year of survey)
WHO estimate which is not based on national survey
14
Georgia National Nutrition Survey 2009
5.7 % (2002)
Within Georgia, the prevalence of anemia in all three target groups differs substantially between
regional strata, and anemia is generally most common in Azerbaijani children and women (see
Table 51, Table 59, and Table 67).
In children less than 5 years of age and non-pregnant women 15-49 years of age, iron deficiency
is rare, and therefore cannot be a major cause of anemia in these population subgroups. In nonpregnant women, only a very small proportion of women who had anemia also had iron deficiency. These findings are unexpected given the importance of iron deficiency as a cause of anemia
worldwide, including in other developed countries.
These findings are different from some previous assessments of anemia in children and women
in Georgia and are similar to others. One prior survey2 found that 34.8% of 150 children were
anemic; however, these 150 children were a convenience sample selected in hospitals and clinics. Such children may be more likely to be ill than children in the general population, and may,
therefore, have a substantially higher prevalence of anemia than the general population of Georgian children. This survey also included hemoglobin measurements on a convenience sample of
256 women and found a prevalence of anemia of 16.8%. Two nationwide surveys found anemia
prevalence rates in non-pregnant women of 27.8% and 27.0%, more similar to the results of
GNNS 2009.3, 4 In one of these surveys,4 83% of anemia was mild; however, this survey used
a non-standard broader definition of “mild” anemia in non-pregnant women (10.0 – 11.9 g/dL)
which included a greater proportion of survey subjects than the definition used for the GNNS
2009. The other survey3 found a prevalence of iron deficiency in non-pregnant women of 41.3%;
however, the women included in this survey were a convenience sample of teachers, mothers,
and female household members of selected children. These women may not be representative
of all Georgian women. No prior population-based survey measured the prevalence of anemia in
Georgian pregnant women.
Assuming the accuracy of the CRP and ferritin testing results (see Annex 3 for validation results),
the lack of iron deficiency precludes many specific causes of anemia, such as insufficient dietary
intake of iron, poor bioavailability of dietary iron, excessive loss of blood, etc. What then can
be the major causes of anemia in children and women in Georgia? Answering this question goes
beyond the scope of the current survey and requires additional investigation.
Recommendations
1. The causes of anemia, such as hemoglobinopathies, other vitamin or mineral deficiencies, or chronic disease or inflammation, in young children and non-pregnant women in
Georgia should be investigated further. These investigations may also include a more
definitive investigation of iron status to confirm the rather surprising finding of very little
iron deficiency in women and children. Such investigation may include: a) measurement
of hemoglobin in adult men and b) measurement of other markers of iron status, such as
transferrin receptor concentration, erythrocyte protoporphyrin, etc, and c) presence of
hemoglobinopathies, such as alpha, beta, and delta thalessemias
2. Implementation of new programs to enhance dietary iron should be delayed until the importance of iron deficiency and the role of iron deficiency in producing anemia in women
and children is definitively answered by the additional investigations recommended above.
Nonetheless, existing program targeting iron deficiency should not be terminated before
the results of the further investigation are known.
3. The role of iron deficiency in producing anemia in pregnant women should also be investigated to determine whether or not to routinely offer iron supplements during ante-natal
care, as is already done in many countries which have lower prevalence rates of anemia
in pregnancy.
Georgia National Nutrition Survey 2009
15
Folate deficiency
The prevalence of folate deficiency in non-pregnant women 15-49 years of age is quite high
compared to other countries in which folate deficiency has been assessed in national surveys, as
shown in Table 3. On the other hand, the mean serum folate level from GNNS 2009 is somewhat higher than that found in other countries. Note that in order to compare GNNS 2009 folate
results, which used an updated definition of folate deficiency, to the results of older surveys
in other countries, the GNNS 2009 data were re-analyzed using 3.0 ng/mL as the cut-off point
which defines low serum folate. The data analysis presented in the Results section uses the
newer cut-off point of 4.0 ng/mL.
The prevalence of folate deficiency in non-pregnant women from the GNNS 2009 is almost identical to that found in the United States before mandatory wheat flour fortification with folic acid
was introduced in that country in 1995. Moreover, both the prevalence of deficiency and the
mean serum folate in non-pregnant women in Georgia are higher than those found in Costa Rica
just before that country implemented folate fortification of flour.
In four countries which had implemented mandatory folate fortification of flour before 2008, the
mean serum folate levels substantially increased in all population groups and the rate of neural
tube defects in newborns fell after fortification.5 Several studies have shown that the higher the
intake of folate and the higher the concentration of serum folate in women when they become
pregnant, the lower the rate of neural tube defects.6
Table 3.Prevalence rates and mean serum folate level, non-pregnant women 15-49 years
of age, in Georgia and selected other countries before implementation of flour
fortification with folate.
Country and
reference
% with folate deficiency
(year of survey)
Mean or median serum folate in ng/mL
(year of survey)
Georgia
24.6* %
(2009)
7.2 (2009)
USA5
24.5% (1988)
5.7 (1988)
Newfoundland,
Canada7
6.4 (1997)
Chile8
4.3 (1999)
19%† urban (1996)
31.4%† rural
Costa Rica9
Germany5
1 %
(1998)
United Kingdom5
0 %
(2000)
10.1 urban
9.6 rural
(1996)
*
GNNS 2009 data re-analyzed using 3.0 ng/mL as cut-off to enhance comparability with older surveys in other
countries
†
Analysis used 6.0 ng/mL as cut-off defining low serum folate
Recommendations
1. Given the overwhelming evidence of the effectiveness of folate fortification in preventing neural tube defects in newborns, extra folate intake should be provided to both nonpregnant and pregnant women in Georgia according to international recommendations.10-12
As discussed below, the current coverage of fortified wheat flour in Georgia is quite poor.
16
Georgia National Nutrition Survey 2009
If full implementation of wheat flour fortification with folic acid cannot be achieved within
the next few years, folic acid supplementation for both pregnant and non-pregnant women, as recommended by WHO,10 should be implemented as rapidly as possible
2. A system of monitoring folate status of women should be implemented. Such a system
could include periodic population assessments of serum folate in non-pregnant women,
market monitoring of fortified foods, and surveillance for neural tube defects. A more
detailed description of such monitoring systems can be found in various publications.11, 13
Bread fortification
Bread consumption in Georgia is more than sufficient to justify using wheat flour as a vehicle
for fortification. Unfortunately, the survey shows that the majority of bread in Georgia is made
from wheat flour which does not meet national standards for iron content. This survey’s results
indicate that homemade bread was most often made using first quality wheat flour, or 70-78%
extraction rate flour for which national fortification standards exist. Notably, GNNS 2009 results
indicate that the iron content of homemade bread was higher than that of commercially baked
bread, indicating that commercial bakeries are either using non-fortified first quality flour, or using
best quality flour (10-25% extraction rate flour for which national fortification standards do not
exist).
Overall the survey found that only 24.9% of bread samples were adequately fortified, which
would not be sufficient for reductions in micronutrient deficiencies at a population level. These
bread sample results are supported by GAIN’s estimates of the market share of fortified wheat
flour (based on total production of fortified flour and production of all flour) of 21.2%. Thus, to
the extent that factories are currently equipped to fortify, the data suggests that these factories
are adequately fortifying.
Regardless, most of the wheat flour used to make bread both in commercial bakeries and at home
was not fortified with iron or fortified with insufficient iron. This lack of fortification is seen in all
regional strata. In addition, because iron is often used as a marker for the presence and adequate
coverage of fortification with other micronutrients, we can conclude that because Georgian bread
is inadequately fortified with iron, it is probably inadequately fortified with other micronutrients,
such as folic acid (see discussion above).
Recommendations
1. The current fortification efforts must continue and should be expanded. Though additional
investigations have been recommended to better understand the etiology of iron deficiency, the current prevalence of folate deficiency must be addressed, and there is little risk of
exposing the population to iron overload as the iron compound used in Georgia’s fortification program, electrolytic iron, has low bioavailability. The expansion of the fortification
program and implementation of additional research should be conducted concurrently;
thus enabling the fortification program to address folate deficiency while the etiology of
anemia is investigated.
2. If the results of future investigation contradict the GNNS 2009 findings, and iron deficiency is indeed found to be an important health problem in Georgia, the necessary policy
and regulatory steps should be taken to ensure that flour milled in Georgia or imported into
Georgia is adequately fortified with iron and other micronutrients according to Georgian
regulations and international recommendations.14 In this case, because bread consumed
in Georgian households is both purchased from stores and made at home, all types of flour
for human consumption should be adequately fortified, including flour sold at the retail
level directly to consumers and flour used by large- and small-scale commercial bakeries.
Georgia National Nutrition Survey 2009
17
3. If flour fortification with iron is expanded, a quality assurance and monitoring system
should be established to ensure that wheat flour milled in Georgia or imported into Georgia meets the requirements of Georgian regulations and international recommendations.
Several sets of recommendations exist to assist in the implementation of such monitoring
systems.11, 13
Salt iodization, storage, and consumption
Salt consumed by Georgian household members is currently well iodized. All specimens collected
had added iodine, and very few specimens had inadequate levels of iodine. This demonstrates
some improvement when compared to the results of the 2005 survey15 in which school-aged children brought household salt to school. In that survey, 90.6% of household salt specimens were
adequately iodized. Nonetheless, only about one-half of households respondents reported that
their salt was iodized, and more than one-third did not know.
Salt storage practices in many households expose salt to humid ambient air which may result in
dampening of the salt and seepage of iodine to the bottom of the container. Nonetheless, the
results of iodine testing of household salt demonstrate that, if this occurs, it has little effect on
the iodine content of household salt.
A large proportion of both non-pregnant and pregnant women add salt to their food before eating it, and many add salt before tasting their food. Hence, salt consumption is common in these
target groups. However, this survey did not measure the quantity of salt added to food nor contained in other foods.
Recommendations
1. Maintain and enhance current monitoring and evaluation practices of salt iodization. Such
practices should follow international recommendations.16 Food fortification programs,
even when functioning as well as salt iodization in Georgia, need frequent monitoring to
ensure that proper fortification is performed, good coverage is maintained, and the desired
outcomes are continuously achieved.
2. Given the advantages of salt consumption in maintaining iodine intake and the strong disadvantages of salt consumption in enhancing the risk for hypertension and cardiovascular
disease, a much more detailed measure of total salt intake should be carried out in the
Georgian population.
Acute protein-energy malnutrition
Overall, acute protein-energy malnutrition is not a significant problem in children less than 5
years of age, non-pregnant women, or pregnant women. Although prior data for adult women
are largely unavailable, the prevalence of acute protein-energy malnutrition has been stable in the
past 10 years, as indicated by comparing GNNS 2009 results to those of prior Multiple Indicator
Cluster Surveys (MICS): 1999 MICS, 2.3%; 2005 MICS, 2.1%, and GNNS 2009, 1.6%.
Overweight and obesity
Overweight and obesity, found in 19.9% of young children and 42.1% of non-pregnant women,
is a much greater problem. Overweight in pregnant women could not be assessed in the GNNS
2009 because there is no standard cut-off for mid-upper arm circumference (MUAC) in pregnant
18
Georgia National Nutrition Survey 2009
women which defines overweight and obesity. However, given the high prevalence in non-pregnant women, it may be safe to assume that overweight and obesity also exist in pregnant women.
In children less than 5 years of age, the decline in the prevalence of overweight and obesity with
age may indicate a change in feeding or exercise habits as young children grow older. Similarly,
the lower prevalence of overweight and obesity in Armenian children imply some difference in
these factors between Armenian populations and the other ethnicities in Georgia.
Although the MICS done in 199917 did not analyze the prevalence of overweight and obesity, the
2005 MICS4 showed that 15.2% of children less than 5 years of age had overweight or obesity.
Unfortunately, the report from the 2005 MICS does not present a measure of the precision for
this estimate, so we cannot determine if the increase from 15.2% in 2005 to 19.9% in 2009 is
statistically significant. Moreover, the 2005 MICS used the NCHS:CDC:WHO reference population, whereas the GNNS 2009 used the WHO Growth Standard as a reference.
Recommendations
1. Factors leading to overweight and obesity in young children and adult women should be
further investigated in order to design specific interventions appropriate for the Georgian
population. Such investigation could include describing methods of infant and young
child feeding, especially changes in feeding practices during early childhood. Of course,
because overweight and obesity are largely dependent on complex combinations of behaviors, their investigation requires specific expertise and long-term commitment.
2. An analysis of the morbidity and mortality associated with childhood and adult overweight
and obesity should be done to help marshal resources for long-term interventions.
3. Additional data should be collected to quantify the severity and prevalence of overweight
and obesity in pregnant women. Indicators could include pregnancy weight gain which
must be collected in special prospective follow-up investigations of pregnant women.
Chronic protein-energy malnutrition
The prevalence of chronic protein-energy malnutrition (or stunting) in children less than 5 years of
age is statistically significantly elevated above the level seen in the WHO Child Growth Standard
(2.3%). According to the suggested classification from WHO, the current prevalence of stunting
of 11.3% in Georgia is considered “low.”18 As shown in Table 4, stunting is substantially less
common in Georgian children than in the children of the neighboring countries of Azerbaijan, Armenia, and Turkey, but more common than in Germany or the United States.
The prevalence of stunting has remained stable in the past 10 years: 1999 MICS, 11.7%; 2005
MICS, 10.4%, and GNNS 2009, 11.3%. Although measures of precision are not available for the
two MICS, these estimates are most likely not statistically significant.
Nonetheless, this does not mean that stunting is without public health importance in Georgia.
Any degree of stunting over and above that found in the WHO Child Growth Standard is cause
for concern and should be addressed by nutrition and health programming.
Underweight
Underweight is not a public health problem in Georgia. The prevalence of underweight in Georgian children less than 5 years of age was not elevated. Given the lack of wasting and the high
prevalence of overweight, this is not surprising.
Georgia National Nutrition Survey 2009
19
Table 4.Prevalence rates of stunting in children less than 5 years of age, in Georgia and
selected other countries.
% stunted
(year of survey)
Country
Georgia
11.3 % (2009)
Azerbaijan
34.4 % (2000)
Armenia
21.4 % (1998)
Turkey
32.9 % (1993)
Sweden
Germany
1.5 % (2003)
USA
3.9 % (2001)
No data
Breastfeeding
Low birthweight is not common in Georgia. The majority of newborns in Georgia are breastfed
at some time in their lives. Breastfeeding is initiated promptly after delivery in most children;
however, breastfeeding does not last long. Only about one-half of children less than 6 months
of age are exclusively breastfed, and on average children are weaned at the age of 9-10 months.
Continued breastfeeding at 12-14 months and 20-23 months of age is found in only a small proportion of children. WHO recommends that exclusive breastfeeding should be practiced until age
6 months and extended breastfeeding should be encouraged until age 2 years.19
Complementary feeding is introduced sufficiently early in most children; however, as indicated
above by the low prevalence of exclusive breastfeeding, probably too early in many children.
Moreover, complementary feeding has inadequate diversity in one-half of children. Although
complementary feeding is given with sufficient daily frequency, a minimum acceptable diet is
eaten by fewer than one-half of children 6-23 months of age. An age-appropriate combination
of breastfeeding and complementary feeding is only practiced by slightly more than one-third of
children less than 24 months of age.
As shown in Table 5, the proportion of children a) initiating breastfeeding early after delivery, b)
exclusively breastfeeding, and c) having timely introduction and adequate frequency of complementary feeding all improved substantially compared to MICS surveys done in 1999 and 2005.
There may be several possible reasons for the sharp rise since 2005 in the prevalence of exclusive
breastfeeding in children under 6 months of age.
First, this increase may be a result of an inaccurate estimate which does not accurately reflect a
true change in infant feeding habits in the Georgian population. This may have resulted, at least
in part, from differences between the questions asked of mothers in the MICS 2005 and GNNS
2009. The standard MICS3 questionnaire used in the Georgia MICS 2005 asked separate questions about several specific liquids which mothers often do not consider to be food and which
they may not consider when asked about exclusive breastfeeding. These liquids include water;
sweetened, flavoured water or fruit juice or tea or infusion; oral rehydration solution; infant formula; and tinned, powdered, or fresh milk; as well as “any other liquids.” On the other hand,
the GNNS 2009 mentioned such liquids in a list contained in the single question “Yesterday, did
[name] eat anything other than breastmilk? This includes water, baby formula, juice, or any solid
foods as well as regular food.” Although this difference in questions may seem small, because
maternal recall of the introduction of non-breastmilk food is poor,20 the extra memory stimulation
20
Georgia National Nutrition Survey 2009
provided by the MICS questions may lead to a somewhat lower estimate of exclusive breastfeeding because mothers more accurately recall giving their children non-breastmilk food and liquids.
Second, there may be inaccuracy in the results from the MICS 2005 leading to a low estimate
of exclusive breastfeeding; however, this is less likely because MICS procedures, including data
analyses, are quite standardized. All MICS surveys use the same questionnaire and most, if not
all, use a standard data analysis program. One would expect an erroneous question or analysis
procedure to be discovered in at least one of the other 50 MICS survey done every 5 years.
Third, there may have been a real change in the population in infant feeding habits. The MICS
2005 results show that a large proportion of young infants were not considered exclusively
breastfed because they ate other types of milk or infant formula. If in the intervening years, because of economic or other considerations, mothers were less able or willing to purchase milk and
infant formula, the exclusive breastfeeding prevalence may have sharply increased. Moreover,
a true increase in the exclusive breastfeeding prevalence is consistent with the improvement in
other breastfeeding indicators seen between MICS 1999, MICS 2005, and GNNS 2009.
Nonetheless, the proportion of children with extended breastfeeding at 12-14 months of age and
20-23 months of age has not changed since 2005 and is still too low, as mentioned above.
Table 5.
Breastfeeding indicators (see reference
GNNS 2009.
Indicator (age group)
21
for definitions) in two prior MICS and
MICS 1999
Breastfeeding initiated with 1
hour after deliver
(<24 months of age)
MICS 2005
GNNS 2009
Not available
36.6 %
66.3 %
Exclusive breastfeeding
(0-5 months of age)
18 %**
10.9 % †
54.8 % †
Continued breastfeeding
(12-15 months of age)
30.3 %
40.5 %
36.5 %
Continued breastfeeding
(20-23 months of age)
12.0 %
19.6 %
16.6 %
Timely introduction of
complementary feeding
(6-9 months of age)
*
12.2 %
34.8 %
43.1 %
Adequate frequency of
complementary feeding
(6-11 months of age)
*
Not available
28.1 %
40.2 %
Not available
19.8 %
47.3 %
Adequately fed infants
(0-11 months of age)
*
This MICS indicator differs from any of the indicators listed in the WHO/UNICEF recommendations.22 As a result,
this MICS indicator is not further considered or discussed in this report.
**
MICS 1999 age group includes only children 0-3 months of age
†
See discussion in text above of possible reasons for large difference between MICS 2005 and GNNS 2009.
*
Georgia National Nutrition Survey 2009
21
Recommendations
1. Ensure that all delivery facilities in Georgia properly encourage and facilitate early initiation
of breastfeeding by mothers delivering in their facilities. Facilities in Achara and Guria and
Samegrelo and those located in rural areas should be targeted first if resources are limited.
UNICEF and WHO have published recommendations for appropriate hospital policy and
practice.23
2. Ensure that all providers of preventive and curative health care for pregnant women, infants, and young children understand the benefits of breastfeeding and the current breastfeeding recommendations of the Ministry of Labor, Health, and Social Affairs. Ensure that
all such providers encourage and support pregnant women and new mothers to breastfeed
according to international recommendations.19 As above, Achara and Guria, Samegrelo,
and rural areas in general should be especially targeted.
3. The difference between the MICS 2005 and GNNS 2009 results for exclusive breastfeeding is striking and warrants additional investigation. An independent estimate should
be done of the exclusive breastfeeding prevalence in infants less than 6 months of age.
Moreover, there should be a review of the MICS 2005 data and data analysis procedures
to determine if the estimate of 10.9% exclusive breastfeeding is accurate.
4. Because there is evidence that children who are not breastfed are more likely to become
overweight24, enhancing breastfeeding should be seen as a strategy to prevent childhood
obesity, which, as seen above, is common in children less than 5 years of age in Georgia.
Efforts should be made to educate pregnant women and new mothers in proper feeding of infants
and young children. As mentioned above for breastfeeding, practitioners who care for pregnant
women and young mothers should be familiar with existing Georgian and international recommendations for infant and toddler feeding and should educate their patients to adhere to these recommendations. Measures of the diversity and frequency of complementary feeding were somewhat
lower in Achara and Guria, Kakheti, and Samagrelo; programs to improve complementary feeding
could be preferentially targeted to these areas first.
22
Georgia National Nutrition Survey 2009
INTRODUCTION AND BACKGROUND
Georgia has suffered repeated economic crises, war, and political instability since independence
from the Soviet Union in 1991. As a result, social, economic, and health conditions have often
been worse than those in other countries which were part of the Soviet Union. These conditions
have had unknown effects on the nutritional status of the population. Past nutrition assessments
have been small local surveys which measured only a small number of indicators. These have
indicated the possible presence of elevated levels of stunting, overweight, and anemia in young
children; overweight, anemia, iron deficiency, and resurgent iodine deficiency in non-pregnant
women; iodine deficiency in pregnant women; and a decline in the coverage of adequately iodized salt in households. In contrast, there have also been three nationwide nutrition assessment
surveys since independence, as shown in Table 6 below. Clearly the coverage of salt iodization
has increased since the 1999 Multiple Indicator Cluster Survey (MICS). Wasting in young children has not been a substantial problem in the past; however, there has been some stunting and
overweight. School children had adequate urinary iodine in 2007, indicating good coverage with
satisfactorily iodized salt. Anemia was a problem in non-pregnant women 15-49 years of age.
Comprehensive data are still lacking on the prevalence of anemia and iron deficiency in young
children and pregnant women, the predominant causes of anemia in any population group, the
prevalence of iron and folate deficiency in women, the prevalence of chronic energy deficiency
and overweight in adult men and women, as well as other nutritional conditions. Although there
are no data on vitamin A deficiency in young children or women, there are no indications of a
problem in Georgia at present.
The Georgia National Nutrition Survey (GNNS 2009) provides estimates for many of those nutrition indicators which have not been adequately measured in past surveys, thus providing to the
Government of Georgia, UNICEF, other United Nations (UN) agencies, donors, and partners the
comprehensive information on nutritional status needed to formulate nationwide, data-driven
policy and evaluate ongoing nutrition programs. For example, flour fortification with iron and
folic acid was begun in 2006. To date, no data are available to monitor the coverage of fortified
flour products or the population effect of this program. Moreover, data on the iodine status of
the population is needed to monitor the enforcement of the national Law on the Prevention of
Disorders Caused by Iodine, Micronutrients and Vitamins. In addition, regional estimates, generated by using a stratified sample, can be used by local authorities to target programs to areas and
subgroups at greatest risk of various types of malnutrition.
Georgia National Nutrition Survey 2009
23
Table 6.
Results of measurement of nutrition indicators included in nationwide surveys done
since independence, Georgia 1999-2009
Indicator
MICS
199917
MICS
200525
School
200515
Households
Salt adequately iodized
8.1%
87.2%
Wasted
2.3%
Stunted
11.7%
10.4%
-
15.2%
90.6%
Children less than 5 years of age
Overweight
2.1 %
School-age children
Low urinary I2
4.4%
Median urinary I2
320.7
Goiter
32.4%
Non-pregnant women 15-49 years of age
Anemia TOTAL
27.8%
Mild
23.1%
Moderate
4.4%
Severe
0.3%
24
Post-partum vitamin A supplementation
Georgia National Nutrition Survey 2009
8.6%
15.8%
goals and objectives
The objectives of the GNNS 2009 included the following:
In the current population of Georgia, excepting those areas outside the control of the government
of Georgia,
1) Estimate the current coverage of adequately iodized salt in households.
2) Estimate the current coverage of iron fortification in bread in households.
3) Estimate the current prevalence of acute malnutrition (wasting) and chronic malnutrition
(stunting) in children less than 5 years of age.
4) Estimate the current prevalence of chronic energy deficiency and overweight in non-pregnant
women 15-49 years of age.
5) Estimate the current prevalence of undernutrition among pregnant women.
6) Estimate the current prevalence and severity of anemia and of iron deficiency in children 1259 months of age and non-pregnant women 15-49 years of age.
7) Estimate the current prevalence and severity of anemia in pregnant women.
8) Estimate the current prevalence of folate deficiency in non-pregnant women 15-49 years of
age.
Additional variables which may influence various types of malnutrition or play a causative role
were also assessed; however, their measurement was not the first priority. Such additional variables included assessment of socio-economic status, individual food consumption patterns, infant
feeding and breastfeeding practices, and other factors. The results of some of these variables
may not be presented in this report. In addition, the survey collected data to assist in the evaluation of fortification programs, including collection of bread specimens for laboratory testing, as
described below in greater detail.
Georgia National Nutrition Survey 2009
25
METHODS
Study population
The sampling universe for the GNNS 2009 included the entire country of Georgia with the exception of areas outside the Georgian Government’s control. The target groups about whom data
were collected included the following:
Table 7.Target groups, outcomes, and source of sample, GNNS 2009
Target group
Outcome measured
Source of sample
Households
•Coverage and adequacy of salt iodization
•Coverage and adequacy of iron fortification of
bread
Household sample of
population
Children less than 5
years of age
•Prevalence of acute protein-energy malnutrition
(wasting)
•Prevalence of chronic protein-energy malnutrition
(stunting)
•Prevalence of overweight and obesity
•Prevalence of anemia (only in children 12-59
months of age)
•Prevalence of iron deficiency (only in children
12-59 months of age)
Household sample of
population
Non-pregnant
women 15-49 years
of age
•Prevalence
•Prevalence
•Prevalence
•Prevalence
•Prevalence
Household sample of
population
Pregnant women
•Prevalence of undernutrition
•Prevalence of anemia
of
of
of
of
of
chronic energy deficiency
overweight and obesity
anemia
iron deficiency
folate deficiency
Ante-natal clinic
attendees
Table 8 shows the inclusion criteria used when recruiting individuals in the various target groups
for data collection.
Table 8.
Inclusion criteria, by target group, Georgia National Nutrition Survey2009
Target group
Inclusion criteria
Households
•An adult household member who gives written consent for survey
data collection
•Household members reside in Georgia at the time of data collection
Children less than 5
years of age
•Age 0-59 months at the time of survey data collection (that is, child
has not yet reached 5th birthday)
•Parent or guardian gives written consent for survey data collection
•Currently resides in Georgia and is considered a usual household
member by adults living in the household
26
Georgia National Nutrition Survey 2009
Non-pregnant
women 15-49 years
of age
•Age 15-49 years at the time of survey data collection
•Gives written consent for survey data collection
•Resides in Georgia and is considered a usual household member by
other adults living in the household at the time of data collection
Pregnant women
•Appears at one of the selected ante-natal care facilities for ante-care
visit during survey data collection days
•Is pregnant by self report at the time of data collection
•Gives written consent for survey data collection
•Resides in Georgia at the time of data collection
Case definitions and measurement methods of outcomes
Adequately iodized salt in households
Household salt specimens were tested using the titration method16 in the NCDCPH Imereti Zonal
Branch Diagnostic Laboratory. Salt was considered adequately iodized if the iodine concentration
was greater than 15 parts per million (ppm) and less than 40 ppm.16 This testing method was in
accordance with the State Standard of Georgia #19-98 (salt iodine common food), titration method, testing methodologies: a) sample collection and preparation- ,,GOST* 13685” and ,,GOST
26929”, b) testing methodologies - ,,GOST 26927, 26930, 26931, 26932, 26933 and 26934”.
The results of re-testing a subsample of salt specimens in a reference laboratory in the Ukraine
(V. P. Komissarenko Institute of Endocrinology and Metabolism) showed excellent agreement between the Georgian and Ukrainian laboratories. See Annex 3 “Quality assurance during and after
data collection” for a more complete description of these results.
Iron fortification of bread
The iron concentration of household bread was measured using atomic absorption spectrophotometry26 performed in the Central Laboratory of the Institute of Horticulture, Viticulture, and Oenology. The total iron content of the bread specimens cannot precisely distinguish which bread
specimens are fortified and which are not because the innate concentration of iron in Georgian
wheat flour and bread is largely unknown. However, one set of recommendations states that if
the per capita consumption of bread is 200 grams or more, 30 mg/kg of iron should be added to
wheat flour.14 In addition, Georgian regulations state that bakery products should contain 30-60
ppm of iron.27 Therefore, the proportion of bread specimens which had 30 ppm or greater iron
concentration was calculated to determine what proportion of bread specimens may have been
made from flour complying with Georgian regulations.
Birthweight
Low birthweight is defined by the World Health Organization (WHO) as a birthweight less than
2500 grams. High birthweight is defined as greater than or equal to 4500 grams.28
* GOST refers to a set of technical standards maintained by the EuroAsian Interstate Council for Standardization,
Metrology and Certification (EASC), a regional standards organization operating under the auspices of the
Commonwealth of Independent States.
Georgia National Nutrition Survey 2009
27
Breastfeeding
The breastfeeding indicators measured in the GNNS 2009 were taken directly from a set of recommendations from WHO and UNICEF.22 Because these indicators are calculated on a subset of
children less than 5 years of age, some subgroup analyses have relatively little precision around
group-specific estimates. For this reason, these analyses do not include the “Other” ethnic
group. Estimates of breastfeeding indicators for this group, which included only 12 children <
24 months of age, would be too imprecise to draw any meaingful conclusions.
Although this reference gives detailed descriptions of each indicator, these definitions will be
summarized below.
• Early initiation of breastfeeding: The proportion of children less than 24 months of age who
were put to the breast within 1 hour of birth.
• Exclusive breastfeeding under 6 months: The proportion of infants less than 6 months of
age who are fed only breastmilk and no other liquids or solids, with the exception of medication and oral rehydration.
• Continued breastfeeding at 1 year: The proption of chldren 12-15 months of age who ate
breastmilk the day before the interview.
• Introduction of solid, semi-solid, or soft foods as complementary foods: The proportion of
infants 6-8 months of age who ate solid, semi-solid, or soft foods the day before the interview.
• Minimum dietary diversity: The proportion of children 6-23 months of age who ate foods
from four or more of the seven food groups the day before the interview. These food
groups include grains, roots and tubers; legumes and nuts; dairy products (milk, yogurt,
cheese); flesh foods (meat, fish, poultry, liver/organ meats); eggs; vitamin-A rich fruits and
vegetables; and other fruits and vegetables.
• Minimum meal frequency: The proportion of children 6-23 months of age who ate solid,
semi-solid, or soft foods the minimum number of times the day before the interview. The
minimum number of times depends on age and breastfeeding status:
o For breastfeeding children 6-8 months of age: 2 times
o For breastfeeding children 9-23 months of age: 3 times
o For non-breastfeeding children 6-23 months of age: 4 times
• Minimum acceptable diet: The proportion of children 6-23 months of age who eat a minimally acceptable diet, defined as eating food with minimal dietary diversity with minimum
meal frequency, as defined above. This definition differs somewhat from that given in the
recommendations.22 In these recommendations, a minimum acceptable diet in non-breastfed children requires at least two milk feeds per day and does not count milk feeds when
defining minimum dietary diversity. However, because the GNNS 2009 questionnaire did
not distinguish milk feeds from other non-breastmilk foods, the definition used for minimum
acceptable diet uses only the definitions given above for minimum dietary diversity and
minimum meal frequency.
• Children ever breastfed: The proportion of children less than 24 months of age who were
ever breastfed at any time in their lives.
• Continued breastfeeding at 2 years: The proportion of children 20-23 months of age who
ate breastmilk the day before the interview.
• Age-appropriate breastfeeding: The proportion of children 0–23 months of age who are appropriately breastfed, defined as follows:
28
Georgia National Nutrition Survey 2009
o For infants less than 6 months of age: exclusive breastfeeding, as defined above, the
day before the interview
o For children 6-23 months of age: ate both breastmilk and solid, semi-solid, or soft foods
the day before the interview
• Duration of breastfeeding: The median duration of breastfeeding among children less than
36 months of age. This is determined by calculating the one month age-specific proportions of children who ate breastmilk the day before the interview and determining the age at
which 50% of children ate breastmilk the day before the interview. In this report, a chart of
the 3-month moving averages of one-month age-specific proportions of children breastfeeding was produced and the median read from this chart.
Several indicators listed in the recommendations were not measured in the GNNS 2009.
These included consumption of iron-rich or iron-fortified foods, predominant breastfeeding under 6 months, bottle feeding, and milk feeding frequency for non-breastfed children.
Protein-energy malnutrition in children less than 5 years of age
Undernutrition (including wasting, stunting, and underweight) and overnutrition in children less
than 5 years of age were defined using the WHO Child Growth Standard.29 Children with z-scores
below -2.0 for weight-for-height, height-for-age, and weight-for-age were defined as wasted,
stunted, or underweight, respectively. Moderate wasting, stunting, and underweight were defined as a z-score less than -2.0 but equal to or greater than -3.0. Z-scores less than -3.0 defined
severe wasting, stunting, and underweight. Children with bilateral pitting edema in the feet or
lower legs were automatically considered as having severe wasting, regardless of their weightfor-height z-score. All z-scores were calculated using computer program WHO Anthro v. 3.0.1.30
Overnutrition in children less than 5 years of age
Overnutrition in children was also defined using z-scores calculated using the WHO Child Growth
Standard. Any overnutrition was defined as a weight-for-height z-score greater than +2.0.
Overweight was a weight-for-height z-score of greater than +2.0 but less than or equal to +3.0.
Obesity was defined as a weight-for-height z-score greater than +3.0.
Before analysis of the prevalence of both under- and over-nutrition, outlying z-score values were
excluded according to the criteria recommended by WHO.18 For the calculation of the prevalence
of acute protein-energy malnutrition, overweight, and obesity, children with weight-for-height
z-scores less than -5.0 or greater than +5.0 were excluded. For the calculation of the prevalence of stunting, children with height-for-age z-scores less than -5.0 or greater than +3.0 were
excluded. For the calculation of the prevalence of underweight, children with weight-for-age zscores less than -4.0 or greater than +5.0 were excluded from the analysis.
Chronic energy deficiency and overnutrition in non-pregnant women 15-49 years of age
Chronic energy deficiency and overnutrition in non-pregnant women 15-49 years of age were assessed using body mass index (BMI), which is calculated by dividing the weight in kilograms by
the square of the standing height in meters. The most common cut-off points for BMI to define
levels of under and over nutrition in non-pregnant adults are shown below.31
Georgia National Nutrition Survey 2009
29
Table 9.
Categories of protein-energy nutrition, by value of BMI, GNNS 2009
BMI
Category of malnutrition
< 16.0
Severe
16.0 - 16.9
Moderate
17.0 - 18.4
18.5 - 24.9
Normal
25.0 - 29.9
Overweight
> 30
Obese
At risk
Because BMI is not valid in pregnant women, mid-upper arm circumference (MUAC) measurements were used in this group to assess protein-energy malnutrition. Although no international
consensus exists, the World Food Programme (WFP) and the United Nations High Commissioner
for Refugees (UNHCR) suggest defining malnutrition in pregnant women as a MUAC less than
22.0 cm.32
Anemia
Hemoglobin concentrations were measured on blood obtained by fingerstick or venipuncture using a portable hemoglobinometer made by Human GmbH of Wiesbaden, Germany. The machine
was operated according to the methods recommended by the manufacturer. The basic cut-off
points for hemoglobin concentration used to define anemia depend on the age and sex of the
person tested,1 as shown below:
Table 10. Definition of anemia by hemoglobin concentration for various age- and sex-specific
groups, GNNS 2009
Age and sex group
Hemoglobin concentration (g/dL)
defining anemia
Children 6 months - 5 years
< 11.0
Children 5-11 years
< 11.5
Children 12-13 years
< 12.0
Non-pregnant girls and women >13
years
< 12.0
Pregnant women >13 years
< 11.0
Boys and men >13 years
< 13.0
The cut-off defining normal hemoglobin concentrations was also adjusted for survey subjects who
live at high altitude.33 The altitude-specific adjustments are shown below.
30
Georgia National Nutrition Survey 2009
Table 11. Adjustments in cut-off defining anemia, by altitude of residence, GNNS 2009
Altitude (in meters) of
residence
Increase in cut-off
point defining anemia (g/dL)
< 1000
No adjustment
1000 – 1249
+ 0.2
1250 – 1749
+ 0.5
1750 – 2249
+ 0.8
2250 – 2749
+ 1.3
2750 – 3249
+ 1.9
3250 – 3749
+ 2.7
3750 – 4249
+ 3.5
4250 – 4749
+ 4.5
4750 – 5249
+ 5.5
5250 +
+ 6.7
The cut-off defining normal hemoglobin concentration in adults was also adjusted for smoking,
as shown below.34
Table 12. Adjustments in cut-off defining anemia, by smoking status, GNNS 2009
Cigarettes smoked per day
< 10 per day
Increase in cut-off
point defining anemia
(g/dL)
No adjustment
10 – 19 per day
+ 0.3
20 – 39 per day
+ 0.5
40 + per day
+ 0.7
Smoker but number of
cigarettes per day unknown
+ 0.3
Iron deficiency
Iron deficiency in survey participants was measured using ferritin concentration in plasma. Ferritin is one of the two biomarkers recommended for use in population-based assessments of iron
deficiency.34 The cut-off points defining iron deficiency are taken from WHO recommendations:
1) in children less than 5 years of age, a serum ferritin concentration below 12 µg/l defines iron
deficiency, and 2) in non-pregnant women 15-49 years of age, a serum ferritin concentration
below 15 µg/l defines iron deficiency.1 Because ferritin is an acute phase reactant which rises
with inflammation, its measurement was accompanied by the measurement of C-reactive protein
(CRP), an indicator of acute inflammation. A concentration of CRP of 5 mg/l or above was considered indicative of acute inflammation in young children and women. Ferritin values in survey
subjects with elevated CRP levels were excluded from the analysis of iron deficiency.
Georgia National Nutrition Survey 2009
31
Both ferritin and CRP were tested in the NCDCPH Imereti Zonal Diagnostic Laboratory using the
photometric turbidimetric method using the “Turbi-Quick” Immuno/ Coagulation Analyzer made
by Vital Diagnostics Srl in Forli, Italy. Reagents for ferritin and CRP testing were supplied by Human GmbH of Wiesbaden, Germany. Test reagents included a memory stick which maintained
the calibration curve needed for the test. An aliquot of a random selection of 400 serum specimens obtained from children and women during GNNS 2009 data collection were sent to the
Human GmbH laboratory in Wiesbasden for validation. The comparison of the results from the
Georgian and the German laboratories can be seen in Annex 3.
Folate deficiency
Folate deficiency was assessed using folate concentration measured in plasma separated from
blood obtained by venipuncture. As recommended by WHO, a plasma folate concentration below 4.0 ng/mL (10 nmol/L) was considered indicative of folate deficiency.12 However, in order
to compare the GNNS 2009 results to prior surveys done in other countries, as shown in the
Conclusions, Discussion, and Recommendations section, re-analysis of the data was carried out
using the older cut-off point of 3.0 ng/mL. Testing was done using in the NCDCPH Imereti Zonal
Branch Diagnostic Laboratory using an enzyme-linked immunosorbant assay (ELISA) method and
a microbiologic test kit (DRG International Inc., USA.). All procedures followed the laboratory kit
manufacturer’s recommendations.35
Sampling scheme
A summary of the sampling scheme and sample size calculation is presented below. For a much
more detailed explanation of these procedures, see Annex 1.
Households, children, and non-pregnant women
Cluster sampling of households was done to obtain a random sample of households, children
less than 5 years of age, and non-pregnant women in the Georgian population. In the first stage
of sampling, census units were selected as primary sampling units using equal probability from
a list of 606 census units which had already been selected probability proportional to size from
all census units in Georgia for use in population-based surveys. In each of eight regional strata,
25 census units were selected. The two largest ethnic minorities, Azerbaijanis and Armenians,
were oversampled in order to generate independent estimates for each minority. This was done
by selecting additional census units in the two regional strata in which a large proportion of the
population consists of one of these minorities. As a result, the total sample of households were
distributed in 236 census units (or clusters).
During a second stage of sampling, the required number of households from the household list
in each selected census unit was selected. Systematic random sampling was used, starting at
a randomly selected starting point. Once households were selected, sampling was complete for
children; all eligible children less than 5 years of age who lived in selected households were recruited for the survey sample. All eligible non-pregnant women 15-49 years of age who lived in
a randomly selected subsample of these households were also eligible for inclusion in the survey
sample. Bread and salt specimens were collected in the same households in which non-pregnant
women were eligible for recruitment. Pregnant women found in selected households were not
included in the survey nor were any data collected from them.
In census units which had an insufficient number of households to select the required number of
households for that cluster, all households were eligible for child recruitment, and the number of
households needed to recruit non-pregnant women and obtain bread and salt specimens were se32
Georgia National Nutrition Survey 2009
lected from this original census unit. The number of households required to complete the desired
number of children were selected randomly from an adjacent census unit.
Pregnant women
Selection of pregnant women began with a random selection with equal probability of 25 facilities
providing ante-natal care in Georgia. Because in each selected facility women were recruited for
the same number of days, and the number of visits per day varies greatly among facilities, the
number of women recruited from each facility (and therefore the number of women in each cluster) were quite different. However, because the facilities were selected with equal probability,
the resulting sample of pregnant women is equally weighted by region. Sampling was stratified
on ethnicity by selecting additional ante-natal care facilities in regions with a substantial number
of minority pregnant women.
Sample size calculation
The required minimum sample size for the GNNS 2009 sample was calculated separately for each
major outcome and target group. All sample size calculations used the following assumptions:
1) The limit of statistical significance (alpha) = 0.05
2) The power (1-beta) = 0.8
3) The population size from which the sample was selected was assumed to be greater than
10,000; hence, the finite population correction factor was not used
Households, children, and non-pregnant women
Table 13 below shows the calculated total minimum number of households and individuals from
whom data had to be collected to achieve the desired precision around the estimate of prevalence
for each target group and for each survey outcome in each regional stratum. Wherever possible,
the assumptions used to calculate desired sample size were based on the results of previous
surveys. However, for variables for which no prior data were available, assumptions were intentionally conservative. For example, in the absence of any prior data, the prevalence of anemia in
children was assumed to be quite high with a high design effect.
Table 13. Number of households and individuals from whom data are needed, for different target groups and outcomes, GNNS 2009
Target group and type of
malnutrition
Assumed
current
prevalence
Precision
required
in each
stratum
(percentage
points)
Design
effect
assumed
Number
needed
with
data in
each
stratum
Minimum
total
number
needed
with data
Households
Iodized salt
90 %
±5
1.8
243
1,944
Iron fortified bread
50 %
±10
2.0
193
1,544
3%
±3
2.0
249
1,992
Children 0-59 months
Wasting (z-score <-2.0)
Georgia National Nutrition Survey 2009
33
Stunting (z-score <-2.0)
12 %
±5
2.0
325
2,600
Overweight (z-score >-2.0)
15 %
±6
2.0
273
2,184
Anemia (< 11.0 g/dl)
35 %
±9
2.5
270
2,160
Iron deficiency
50 %
±10
2.5
241
1,928
Non-pregnant women
Malnutrition (BMI <17.0)
5%
±5
2.0
146
1,168
Overweight (BMI > 25.0)
50 %
±10
2.0
193
1,544
Anemia
28 %
±8
2.0
243
1,944
Iron deficiency
41 %
±10
2.0
186
1,488
Folate deficiency
50 %
±10
2.0
193
193*
Pregnant women**
Low MUAC
50 %
±10
2.0
193
579
Anemia
50 %
±10
2.0
193
579
Sample specimens for folate testing were not stratified because only a single nationwide estimate was to
be calculated
**
Sample sizes for pregnant women are much lower because regional stratification was not done, and ethnicity-specific stratified sampling resulted in only three strata.
*
The outcomes shown in italics are those which required the largest number of individuals in that
target group and, thus, determined the minimum number of that target group for the survey
sample. Because the sample tested for folate deficiency was not stratified, it required a much
smaller sample size than other outcomes. To obtain this much smaller sample size, folate testing
was done on only two women in each cluster.
The number of households to select for the survey was then calculated from 1) the minimum
number of households and individuals from whom data were needed, 2) the estimated individual
non-response rate, 3) the estimated household non-response, and 4) the average number of individuals in each household. For example, to collect hemoglobin data on 2,160 children 12-59
months of age, survey teams had to recruit children from 23,716 households; however, to collect
hemoglobin data on 1,944 non-pregnant women, women had to be recruited from only 3,396
households because there are, on average, many more eligible women than eligible children per
Georgian household. Therefore, it was necessary to select women from only a subsample of the
total sample of 23,716 households. Because response rates and the average number of women
are different for each stratum, the fraction of households from which to recruit women varied by
stratum.
Pregnant women
The sample size for pregnant women, as shown in Table 13 above, is 193 for each of the three
ethnic strata. Assuming 90% response, the total number of pregnant women to be selected in
ante-natal facilities was at least 215 (193 divided by 0.9) in each ethnic group for a total sample
size of 645.
34
Georgia National Nutrition Survey 2009
Enrollment and recruitment procedures
Households, children, and non-pregnant women
In each selected census unit, survey teams traveled to each selected household (and to no other
households) to begin recruitment and collect survey data. Household data were collected from:
1) all households containing an eligible child less than 5 years of age, 2) all households from
which non-pregnant women were eligible to be recruited, and 3) all households from which a salt
or bread specimen was obtained. In those households which were not identified as households
in which non-pregnant women should be recruited and bread and salt specimens collected, if no
eligible child lived in that household, the household was skipped and no data collected. In such
households, because no individuals were enrolled and no specimens collected, no household interview was conducted. Households in which non-pregnant women were eligible for recruitment
and bread and salt specimens requested represent a random sample of all households in each regional stratum and altogether in Georgia. The household data from households in which children
were recruited but in which non-pregnant women were not eligible provide additional information
of interest regarding the households in which children live, but are not a representative sample of
all Georgian households and were not included in analysis of only household variables. Figure 1
below shows a decision algorithm which was used to determine whom to recruit and what specimens to collect in each selected household.
Figure 1.Recruitment procedures for household survey, GNNS 2009
Approach
household
on list
No
No
1. Do not
complete
any forms.
2. Go to next
household.
Is there a
child under
5 years of
age?
Are nonpregnant women
eligible in this
household?
Yes
1. Recruit all
children in
household.
2. Administer
household and
child
questionnaires.
3. Collect
fingerstick
blood from
children 12-59
months of age.
Yes
1. Recruit all children in
household.
2. Recruit all non-pregnant
women 15-49 years of
age in household.
3. Administer household
questionnaire.
4. Administer child and
woman questionnaires,
as needed.
5. Collect blood on all
children and women
recruited (venipuncture
blood on 1st two women
in cluster).
6. Collect salt specimen.
7. Collect bread specimen.
Georgia National Nutrition Survey 2009
35
Upon arrival at a selected household, survey team members explained the survey’s purpose,
methods, and procedures, and requested written consent from a responsible caretaker for eligible
children’s participation and from eligible non-pregnant women in those households from which
women were recruited. For both children and women, all eligible individuals in a household were
recruited for survey participation. If an eligible child or woman was missing at the start of the
survey team’s visit, household members or others in the community were asked to fetch them;
however, the teams could often not wait for potential survey participants who had not arrived
by the time collection of other data has been completed. In such cases, survey team members
made an appointment for a return visit when the eligible individual would be home. If no one in the
household was at home at the time of the survey team’s visit, the team determined from a neighbor when the household members would return home and asked the neighbor to notify the family
of the appointed time for the revisit. Survey teams attempted to make two return visits over
at least 2 days before abandoning data collection for a selected household or individual child or
woman. However, sometimes such return visits might substantially delay departure from a census unit; in such cases, in the interest of efficiency, the survey team left before three visits had
been completed. Survey teams recorded for each selected household or individual whether data
collection was completed, and, if data collection was not completed, why. These data allowed
calculation of response rates and the determination of reasons for non-response. Households or
individuals from which data collection could not be completed were not replaced; the sample size
calculations presented above already account for loss due to non-response.
Pregnant women
During scheduled days, survey teams recruited consecutive pregnant women who visited the
selected ante-natal facility. After an eligible pregnant woman had completed her ante-natal visit
at the clinic, survey team members explained the survey purpose, methods, and procedures, and
requested verbal consent for her participation. After consent was given, data were collected
from the woman. If consent was not given, or for some other reason the woman did not provide
complete data, the reasons were recorded on the data collection form.
Data collection
Team composition
Households, children, and non-pregnant women. Each survey team visiting selected households
consisted of four people: one driver, one interviewer, one anthropometrist, and one laboratorian.
The driver will have no additional duties other than transport. One individual who was not the
driver was designated team supervisor and was responsible for all aspects of household sampling and data collection. The interviewer conducted all interviews of household members to
collect data. The interviewer and anthropometrist were both trained in anthropometry, with the
interviewer acting as the anthropometry assistant. The laboratorian carried out the fingerstick
on eligible children and fingerstick or venipuncture on eligible non-pregnant women. He or she
also measured the hemoglobin concentration and collected and processed blood obtained either
by fingerstick or venipuncture for later testing for iron status indicators and folate concentration.
Pregnant women. Because the survey of pregnant women will, in most ante-natal facilities, require collection of data from few pregnant women each day, a single person easily carried out all
the necessary data collection, including the interview, fingerstick, and measurement of hemoglobin concentration.
36
Georgia National Nutrition Survey 2009
Household procedures
Interviews. Interviews were conducted by appropriate survey team members who had received
instruction in the type of data to be collected by each specific question and the reason these data
are being collected. Interview questions were read verbatim from the interview form. Respondents were allowed to refuse answers to any or all of the questions.
Anthropometric measurements. All anthropometric measurements were taken using standard
methods. For example, for children less than 5 years of age, all measurements were taken using
the procedures outlined in the UNICEF training manual “How to Weight and Measure Children.”36
Children’s height or length was measured using a height board manufactured by Shorr Productions, USA. Weight was measured using a UniScale, a bathroom-type scaled used in nutrition surveys, including UNICEF MICS, for many years. For non-pregnant women, weight was measured
using the same scale as used for children. Height was measured using a portable stadiometer
while the subject stood against a vertical surface.
Physical examination. In all cases where protein-energy malnutrition is assessed in children, the
feet and lower legs were examined for edema by the anthropometrist to rule out edematous malnutrition which invalidates anthropometric indices which include weight. Although theoretically,
adults should also be examined for edema, the many non-nutritional causes of pitting edema
produce too many false positive findings in populations where edematous malnutrition is not
common. Therefore, adults were not be examined for edema. In many children, some measure
of mild restraint is required for certain portions of such examinations. Such restraint is minimized
and carried out only with parents’ permission or by parents themselves.
Collection and processing of laboratory specimens. Table 14 below summarizes the biologic
specimens collected from each target group in the survey.
Table 14. Summary of biologic specimens to be taken, by target group, GNNS 2009.
Target group
Specimen
Methods of
collection
Children 12-59
months of age
Blood
Fingerstick
Non-pregnant
women 15-49
years of age
Blood
Storage matrix
Outcome measured
Immediate testing
for hemoglobin
Anemia
Microtainer
Iron deficiency
Immediate testing
for hemoglobin
Anemia
Microtainer
Iron deficiency
Venipuncture
Blood tube
Folate deficiency
Fingerstick or
venipuncture
Pregnant women
Blood
Fingerstick
Immediate testing
for hemoglobin
Anemia
Household
Salt
Self-collect
Dry, in plastic bag
Iodine level
Bread
Self-collect
Dry, in plastic bag
Iron level
Fingerstick blood was collected by piercing the skin with a new, disposal lancet after cleaning the
skin with alcohol. In children, a pediatric lancet was used which penetrated the skin no deeper
than 1.5 mm, while adult lancets penetrated the skin to a depth of 2.0 mm. As much blood
Georgia National Nutrition Survey 2009
37
as possible, up to 1.0 ml, was collected from the fingerstick site into a microtainer. From this
microtainer, 20 microliters were pipetted using an auto-pipette into the cuvette for use in the HumaMeter® portable hemoglobinometer. The remaining blood remained in the microtainer for later
centrifugation and separation of serum. Centrifugation and separation was done in the evening
of the day the blood specimen was collected. The resulting serum specimens were kept frozen
at -20 or -70 degrees C until analyzed in the laboratory.
In two women per cluster, venipuncture was done instead of fingerstick. Blood was collected
into an appropriate tube using the Vacutainer® system. From this tube, as from the microtainer,
20 microliters were auto-pipetted into the HumaMeter® cuvette for hemoglobin testing in the
household. The remaining blood was kept in cold storage until centrifuged and separated the
same evening. Serum from these specimens was stored in small plastic tubes suitable for freezing at -60 degrees C.
Bread specimens were placed in a small sealable plastic bag. After stirring the salt in the household storage container, approximately 5 g of salt was placed into a clean bag. For bread, only
one specimen consisting of 100 grams was collected per household. If possible, survey teams
collected a specimen of the type of bread eaten most frequently in that household. If, at the time
of data collection, there was no such bread in the household, a specimen of whatever bread was
available in the household was collected.
Data collection instruments
Data collection forms (one for each target group) were written originally in English, then translated into Georgian, Azerbaijani, and Armenian. Experienced translators of Azerbaijani and Armenian
will accompany survey teams in minority regions. A translated copy of the questionnaires was
provided to these translators to read to survey respondents; however, data were recorded on the
Georgian data collection form. See Annex 2 for copies of these data collection forms.
Training for study personnel
Training for survey team members consisted of 5 days of classroom instruction and practice and
2 days of pretesting all survey procedures, including interviews, examination for edema, anthropometric measurement, and biologic specimen collection (except venipuncture). Two survey
workers from each survey team were taught to measure and record height, length, weight, and
MUAC for children and adults in a standardized fashion. Inter-measurer variability, intra-measurer
variability, and difference from an expert measurement was measured and excess variability
corrected. Training for anthropometrists included a description of edema and how to examine
children for its presence.
At least one experienced laboratorian on each survey team was trained to collect the biologic
specimens necessary for this survey. Such training included the use of the HumaMeter® hemoglobinometer to measure hemoglobin concentration. Fingerstick and venipuncture technique were
reviewed and practiced on other survey team members. The processing and storage of specimens was also taught during the training period and closely supervised during the first days of
the survey.
Team leaders were selected and specially trained at the end of the training session.
38
Georgia National Nutrition Survey 2009
Data analysis
Data analysis was done using EpiInfo v. 3.5.1 for Windows. Nationwide prevalence rates were
calculated using weighted analysis to account for the unequal probability of selection between
strata. For individuals selected from the household sample, statistical weights were calculated for
each regional stratum. For pregnant women, statistical weights were calculated for each ethnicspecific stratum. All measures of statistical precision, including confidence limits, were calculated accounting for the complex sampling, including the cluster and stratified sampling. The
statistical significance of apparent differences were judged by comparison of confidence intervals
in one subgroup to point estimates in other subgroups. If the confidence intervals in subgroup A
did not overlap the point estimate in subgroup B and if the confidence intervals in subgroup B did
not overlap the point estimate in subgroup A, the p value for the difference was determined to be
less than 0.05, making the difference statistically significant.
Data entry, editing, and management
Computer data entry was done twice into two separate data sets which were then compared to
detect errors in data entry. The database variable names were added to a copy of the data collection form to create a data key indicating the origin of the data in each field of the database.
Quality control
Extensive training was provided to all survey workers before data collection began. Moreover,
most survey workers had prior experience in nutrition and health assessment surveys, specifically
the 2005 MICS. During data collection at each selected household, survey team leaders supervised all steps of data collection, including the interview, physical examination, anthropometric
measurement, and biologic specimen collection. Upon completion of data collection at each
household, the survey team leader reviewed the entire data collection form to ensure completeness and accuracy. As mentioned above, the two datasets resulting from duplicate data entry
were exhaustively compared to ensure accurate data entry. Specific data analyses were carried
out to assessment data accuracy. For a more complete description of specific measures for quality control, see Annex 3.
Georgia National Nutrition Survey 2009
39
RESULTS
Households – Description of sample
The household sample includes a total of 4,043 households of which 2,426 (60.0%) are households in which non-pregnant women 15-49 years of age were recruited and bread and salt specimens collected. These 2,426 households represent a random sample of households in Georgia.
Because the remaining 1,617 households were only included in the survey sample because they
had children less than 5 years of age, they do not represent a random sample of Georgian households and are not included in the following analysis of household data. Their household data is
included in the analysis of data from children.
The characteristics of these 2,426 households are shown below in Table 15, Table 16, and Table
17 below. Although the actual number of households in each regional stratum does not reflect
the distribution of the Georgian population, the weighted distribution does. About one-half of the
sample households are rural and one-half are urban. This is similar to the rural/urban distribution
of the general population of Georgia. Only a small proportion of households had lived in their
present location for less than 10 years, demonstrating that a minority of survey households had
been recently displaced. The median number of household members was 4 persons, and few
households had more than 6 members. Almost one-third of households had no women 15-49
years of age, and more than two-thirds had no children less than 5 years of age. The majority of households were of Georgian ethnicity and spoke Georgian as their home language. Most
households had at least one person employed outside the home, and in such households, more
than one-third had two or more people employed outside the home.
40
Georgia National Nutrition Survey 2009
Table 15. Distribution of various demographic variables for sample households, GNNS 2009
Survey sample
Characteristic
Actual
number of
households
Weighted
% of
households
Georgia
population*
% population
TOTAL
2426
100.0
100.0
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
292
205
232
365
459
240
346
287
25.1
9.4
17.7
11.6
10.5
9.8
4.5
11.5
25.9
11.9
16.9
9.2
11.2
10.7
4.7
9.5
Rural/Urban
Rural
Urban
1432
994
48.9
51.1
47.3
52.7
Years lived in current location
0-9
10-19
20-29
30-39
40-49
50-59
60-69
70-79
80+
356
363
567
312
288
281
112
65
65
17.4
15.8
23.4
12.8
11.5
9.2
4.6
2.7
2.6
Population estimates for 2009 from National Statistics Office of Georgia (http://www.geostat.ge/index.
php?action=page&p_id=473&lang=eng, accessed 12 March 2010)
*
Georgia National Nutrition Survey 2009
41
Table 16. Distribution of household composition and ethnicity variables for sample households,
GNNS 2009
Characteristic
Number of household members
1
2
3
4
5
6
7
8
9
10+
Number of women 15-49 usually in household
0
1
2
3
4
5
Number of children <5 years usually in household
0
1
2
3
4
Ethnic group of household head
Georgian
Armenian
Azerbaijani
Other
Most common home language
Georgian
Armenian
Azerbaijani
Russian
Other
42
Georgia National Nutrition Survey 2009
Actual number of
households
Weighted % of
households
251
367
323
447
436
325
171
62
24
20
10.6
16.0
14.6
19.2
17.2
11.8
6.3
2.6
0.8
0.9
765
1247
314
89
9
2
32.9
50.0
13.0
3.5
0.5
0.1
1576
599
226
23
2
67.8
23.2
8.1
0.8
0.1
1891
270
192
59
86.9
5.8
4.6
2.7
1921
251
189
34
17
88.1
5.0
4.5
1.8
0.6
Table 17. Distribution of socio-economic variables for sample households, GNNS 2009
Characteristic
Actual number of
households
Weighted % of
households
Household has employed person
Yes
No
1856
559
79.3
20.7
If someone employed, how many
1
2
3
4
5+
1182
529
110
28
7
64.4
28.3
5.9
1.2
0.2
Households – Salt storage, usage, and iodization
In the representative sample of 2,426 households, the distribution of various variables concerning
salt storage and use is shown in Table 18 below. Almost one-third of households stored salt in
the original closed container in which it was purchased, while another 23% stored salt in a different plastic container. Almost 40% of households stored salt in an open container or a clay,
wooden, or cardboard container which presumably left the salt exposed to air. Almost two-thirds
kept this container in a closed cabinet, while almost one-third kept it on an open shelf. Very few
households stored salt near a heat source, such as near a stove or window. The vast majority
of households had salt on the day of data collection and contributed a salt specimen for laboratory testing. Among those respondents who reported having salt in the household, one-half of
respondents said their households salt was iodized, and more than one-third reported that they
did not know.
The weighted distribution of iodine concentrations in household salt specimens is shown in Figure
2 below. In virtually all the specimens, the concentration of iodine was greater than 15 ppm, and
the highest iodine concentration was 50.3 ppm.
The weighted mean iodine content of salt specimens tested in the laboratory is shown in Table 19
below. There is little differences in the iodine concentration of household salt in different regional
strata, between urban and rural households, in different ethnic groups, or by respondents’ report
of salt iodization.
Georgia National Nutrition Survey 2009
43
Table 20 shows the proportion of household salt specimens which were 15 ppm or below, above
15 ppm but below 40 ppm, and 40 ppm or above. The iodine content of about three-quarters of
all specimens fell in the recommended range of 15-40 ppm. About one-quarter were 40 ppm or
above.
Table 18. Number (weighted %) and 95% confidence intervals (CI) for variables concerning salt
storage and use, sample households, GNNS 2009
Characteristic
Number (weighted %)
of households
95% CI
How salt is stored in household
Original plastic container
Original open glass container
Original closed glass container
Clay or wood container
Plastic container
Cardboard box
Other
326(16.2)
232(11.6)
384(16.5)
221 (9.7)
617(23.3)
474(18.2)
112 (4.5)
12.9, 19.5
8.6,14.5
14.0, 19.1
7.9,11.5
20.6, 26.0
15.6, 20.7
3.3,5.7
Where salt is stored in household
In a closed cabinet
On an open shelf
On a counter near the stove
By a window
Other
1495 (64.8)
751(30.4)
65(2.7)
49(1.7)
8(0.4)
61.3,
27.0,
1.6,
1.1,
0.1,
Had salt at time of survey visit
Yes
No
2340 (98.4)
30(1.6)
97.7, 99.2
0.8, 2.3
Salt reported by respondent as iodized
Yes
No
Unknown
1113 (50.9)
385(15.1)
842(34.0)
45.9, 55.9
12.4, 17.8
29.9, 38.1
44
Georgia National Nutrition Survey 2009
68.3
33.9
3.8
2.3
0.7
Figure 2. Weighted distribution of iodine concentrations in household salt specimens, GNNS
2009
Weighted % of salt specimens
14
12
10
8
6
4
2
0
11
13
15
17
19
21
23
25
27
29
31
33
35
37
39
41
43
45
47
49
Iodine concentration in salt (ppm)
Table 19. Weighted mean average and 95% confidence intervals (CI) for iodine content in parts
per million in household salt specimens, sample households, GNNS 2009
Characteristic
Weighted mean
95% CI
TOTAL
36.8
36.4, 37.2
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
37.3
36.7
36.8
36.5
37.1
36.1
36.4
36.5
36.4,38.3
35.6,37.8
35.9,37.8
35.7,37.4
36.5,37.6
35.2,37.1
35.4,37.4
35.6,37.4
Rural/Urban
Rural
Urban
36.7
36.9
36.2,37.2
36.3,37.5
Ethnic group of household head
Georgian
Armenian
Azerbaijani
Other
36.8
37.0
36.9
36.2
36.4,37.2
35.6,38.3
36.0,37.8
34.7,37.7
Reported salt iodized
Yes
No
Unknown
37.1
36.1
36.7
36.5,37.6
35.5,36.8
36.2,37.2
Georgia National Nutrition Survey 2009
45
Table 20. Number (weighted %) with salt iodine of various concentrations (in parts per million),
sample households, GNNS 2009
Characteristic
< 15
TOTAL
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
1(<0.1)
>15 - <40
40+
1400(73.4)
490(26.5)
0
0
1(0.5)
0
0
0
0
0
146(68.2)
139(76.0)
149(73.0)
169(73.8)
275(72.9)
168(78.9)
187(73.9)
167(76.6)
68(31.8)
44(24.0)
54(26.5)
60(26.2)
102(27.1)
45(21.1)
66(26.1)
51(23.4)
Rural/Urban
Rural
Urban
1(0.2)
0
829(74.3)
571(72.4)
278(25.5)
212(27.6)
Ethnic group
Georgian
Armenian
Azerbaijani
Other
1(0.1)
0
0
0
1105(73.4)
132(72.2)
123(74.9)
32(77.2)
380(26.4)
49(27.8)
43(25.1)
14(22.8)
Households – Bread consumption and iron content
The average per capita daily bread consumption was, when averaged among the members of
each household, 414 grams per day. As shown below in Figure 3, most households had a per
capita daily bread consumption above 200-300 grams. As shown in Table 21 below, average
daily per capita bread consumption was statistically significantly lower in households in Tbilisi
than in households in other regional strata. It was also higher in rural households than in urban
households. Consumption was also higher in Azerbaijani households; however, only the difference between Azerbaijani and Armenian households was statistically significant.
As shown in Table 22 below, the type of bread most commonly eaten in the household varied by
regional stratum and by urban vs. rural location, but not by ethnicity. Factory-produced bread
was the most commonly eaten bread in 85% of Tbilisi households. In contrast, it was the most
commonly eaten bread in only one-half or less of households in the other regional strata. Homemade bread was the most commonly eaten bread in more households outside of Tbilisi, and was
much more often reported as the most commonly eaten bread in rural households than in urban
households. The distribution of bread types was similar in different ethnicities with the exception
of lavash which was more often reported in Georgian households than in Azerbaijani or Armenian
households.
The source of the most commonly eaten household bread is shown in Table 23 below. Bakeries are a source of the most commonly eaten bread for only a small proportion of households in
all regional strata, in both urban and rural households, and in households of all ethnicities. As
shown in Table 24, of bread purchased in supermarkets for which the brand was known, Ipkli
46
Georgia National Nutrition Survey 2009
brand is the most common; however, it was commonly reported only in Tbilisi, Imeretic and
Racha-Leckhumi, and Kvemo Kartli. The brand could not be identified for many bread specimens.
In those households in which bread is baked at home, the most common flour used, as shown in
Table 25 below, is first quality white flour. Although the type of flour does not differ substantially
between urban and rural households or by ethnicity, there are some differences among regional
strata. Respondents in many households did not know what type of flour was used to bake bread
in their household.
For bread purchased from outside the home, Table 26 show the proportion for which the package or label indicated fortification with iron or no fortification. Overall, a small minority of bread
packaging indicated fortification; however, for a relatively large proportion of bread specimens,
the original packaging was unavailable or the survey teams could not inspect the labeling for
some other reason. Packaging indicating fortification was somewhat more common in Tbilisi and
Kvemo Kartli. It was also more common among Azerbaijani households, probably because they
predominantly live in Kvemo Kartli.
Figure 4 below shows the distribution of values for iron content in bread specimens collected from
households.
Table 27 below shows the weighted mean iron content for bread specimens. Lavash had statistically significantly more iron than other types of bread. In addition, the iron content of bread was
higher in some regional strata than in others and higher in specimens from rural households than
specimens from urban households. Iron content did not substantially differ by ethnicity of the
members of the household.
Table 28 below shows the weighted proportion of bread specimens above the minimum iron content for flour (30 mg/kg or 30 ppm) as set by the Ministry of Labor, Health, and Social Affairs27
and international recommendations14. Overall, less than one-quarter of bread specimens met this
criterion. A larger proportion of specimens of lavash contained the minimum 30 ppm of iron.
As expected, bread specimens from the same regional strata which had a higher average iron
content also had a higher proportion of specimens with 30 ppm or greater. The proportion of
bread from Samtckhe-Javakheti with more than 30 ppm iron was statistically significantly higher
than in any other regional stratum. A larger proportion of bread specimens from rural households
than urban households had 30 ppm or greater of iron. A larger proportion of specimens from
Armenian households than households of other ethnicities had 30 ppm or greater of iron, but this
difference may be statistically significant only for the difference between Georgian and Armenian
households.
Georgia National Nutrition Survey 2009
47
Figure 3. Weighted distribution of households with various per capita daily bread consumption,
GNNS 2009
Weighted % of households
25
20
15
10
5
0
0-99
100199
200299
300399
400499
500599
600699
700799
800899
9991000
10001099
1100+
Daily per capita bread consumption (grams)
Table 21. Weighted mean average of bread eaten per person per day (in grams) and 95% confidence intervals (CI), sample households, GNNS 2009
Characteristic
Weighted mean
95% CI
TOTAL
414
393,435
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
323
481
436
492
428
385
401
465
289,356
446,517
377,495
456,527
393,462
347,423
377,425
392,537
Rural/Urban
Rural
Urban
467
363
439,495
341,386
Ethnic group of household head
Georgian
Armenian
Azerbaijani
Other
416
380
457
365
396,436
338,422
397,517
285,445
48
Georgia National Nutrition Survey 2009
Table 22. Number (weighted %) most often consuming various types of bread, sample households, GNNS 2009
Characteristic
TOTAL
Lavash
Factory white
bread
Other factory
bread
Homemade
217 (9.2)
972 (46.8)
94 (4.8)
1073 (38.7)
9 (0.5)
Other
Region
Tbilisi
Achara and Guria
Imereti and RachaLeckhumi
Kakheti
Kvemo Kartli
Samegrelo
SamtckheJavakheti
Shida Kartli and
Mtckheta-Mtianeti
Rural/Urban
Rural
Urban
40
(14.0)
6(3.0)
223 (78.2)
19 (6.7)
1(0.4)
2 (0.7)
86(42.8)
7(3.5)
102 (50.7)
0
2(0.9)
97(42.4)
15 (6.6)
113 (49.3)
2 (0.9)
53(14.8)
13 (3.6)
223 (62.1)
0
70
(19.5)
50
(11.6)
16 (6.7)
213 (49.4)
14 (3.2)
154 (35.7)
0
74(31.1)
14 (5.9)
134 (56.3)
0
7(2.1)
123 (36.1)
8(2.3)
202 (59.2)
1 (0.3)
26 (9.3)
103 (36.7)
4(1.4)
144 (51.2)
4 (1.4)
93 (6.2)
124
(12.1)
320 (21.4)
46 (4.2)
935 (67.7)
4 (0.5)
652 (71.1)
48 (5.3)
138 (10.9)
5 (0.5)
746 (45.5)
81 (4.9)
823 (38.9)
9 (0.6)
90(48.6)
93(50.5)
37(73.8)
9(5.1)
1(2.0)
2(2.8)
151 (43.7)
81(43.3)
14(17.2)
0
0
0
Ethnic group
Georgian
Armenian
Azerbaijani
Other
198
(10.0)
6(2.7)
8(4.2)
4(6.2)
Georgia National Nutrition Survey 2009
49
Table 23. Number (weighted %) purchasing most commonly eaten type of bread from various
sources, sample households, GNNS 2009
Characteristic
Supermarket or
shop
TOTAL
1041 (51.1)
205 (8.8)
1090 (39.3)
26 (0.8)
243 (85.0)
92(45.8)
106 (46.3)
92(25.7)
209 (48.5)
83(34.9)
109 (32.1)
41(14.3)
6(3.0)
8(3.5)
32 (8.9)
51(11.8)
18 (7.6)
25 (7.4)
2(0.7)
101 (50.2)
114 (49.8)
233 (65.1)
157 (36.4)
133 (55.9)
203 (59.7)
0
2(1.0)
1(0.4)
1(0.3)
14 (3.2)
4(1.7)
3(0.9)
107 (38.4)
24 (8.6)
147 (52.7)
1(0.4)
Rural/Urban
Rural
Urban
355 (25.4)
686 (75.6)
67 (4.3)
138 (13.1)
950 (69.0)
140 (11.0)
22 (1.3)
4(0.3)
Ethnic group
Georgian
Armenian
Azerbaijani
Other
828 (50.5)
89(50.8)
79(44.6)
38(78.2)
176 (9.3)
14 (5.5)
9(4.7)
5(4.6)
835 (39.6)
153 (43.5)
84(44.9)
14(17.2)
14 (0.6)
1(0.2)
11 (5.8)
0
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and MtckhetaMtianeti
50
Georgia National Nutrition Survey 2009
Bakery
Bake at home
Other
Georgia National Nutrition Survey 2009
51
21 (7.1)
93(19.2)
93(16.9)
7(10.4)
9(10.7)
5(17.8)
Ethnic group
Georgian
Armenian
Azerbaijani
Other
1(0.2)
0
0
0
0
1(0.2)
0
0
Rural/Urban
Rural
Urban
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and MtckhetaMtianeti
0
0
0
0
0
24(22.6)
1(0.4)
0
1(0.2)
Dika
1(1.1)
22(10.6)
0
0
67(27.6)
0
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
114 (16.3)
Ipkli
TOTAL
Characteristic
2(0.4)
1(3.1)
0
0
0
3(0.7)
0
0
0
0
0
0
3(1.2)
0
3(0.5)
Margi
1(0.2)
1(3.1)
0
1(2.2)
0
3(0.6)
0
0
0
0
0
0
2(0.8)
1(1.1)
3(0.4)
Brand of bread
Mkhneoba
None
554 (59.3)
68(70.5)
35(47.9)
25(60.0)
266 (76.0)
421 (54.3)
87(94.6)
107 (51.4)
53(63.9)
97(89.8)
105 (98.1)
118 (48.6)
79(85.9)
41(38.7)
687 (59.5)
Table 24. For most commonly used bread which is purchased in supermarkets, number (weighted %) with various brand names, sample households, GNNS 2009.
92(13.2)
4(6.8)
10(11.8)
3(9.4)
27 (7.8)
84(14.4)
1(1.1)
24(11.5)
18(21.7)
2(1.9)
2(1.9)
30(12.3)
6(6.5)
28(26.4)
111 (12.8)
Other
84(9.7)
7(6.0)
25(29.6)
4(10.6)
41(9.1)
79(10.6)
3(3.3)
55(26.4)
12(14.5)
9(8.3)
0
22(9.1)
6(6.5)
13(12.3)
120(10.2)
Unknown
Table 25. Number (weighted %) using various types of flour when baking bread at home, sample households in which bread is baked at home, GNNS 2009
Characteristic
TOTAL
Region
Tbilisi
Achara and Guria
Imereti and Racha
Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
SamtckheJavakheti
Shida Kartli and
MtckhetaMtianeti
First quality
white flour
Whole
wheat flour
Both white
and whole
wheat
Other
Unknown
971 (75.1) 113 (6.2) 38 (2.9) 113 (7.4) 136 (8.4)
50(72.5) 3(4.3) 1(1.4) 1(1.4) 14(20.3)
75(57.7) 5(3.8) 4(3.1) 40(30.8) 6(4.6)
133 (93.0) 2(1.4) 4(2.8) 3(2.1) 1(0.7)
223 (80.2) 11 (4.0) 17 (6.1) 2(0.7) 25 (9.0)
152 (77.3) 18 (9.1) 3(1.5) 7(3.6) 17 (8.6)
140 (94.6) 0
0
0
8(5.4)
106 (46.1) 41(17.8) 2(0.9) 34(14.8) 47(20.4)
92(52.3) 33(18.8) 7(4.0) 26(14.8) 18(10.2)
Rural/Urban
Rural
Urban
757 (74.0) 101 (6.9) 29 (3.1) 102 (9.3) 97 (6.8)
214 (78.0) 12 (4.5) 9(2.3) 11 (2.5) 39(12.7)
Ethnic group
Georgian
Armenian
Azerbaijani
Other
768 (75.8)
103 (70.1)
78(68.1)
17(75.4)
52
Georgia National Nutrition Survey 2009
66 (5.3)
26(11.5)
18(15.6)
2(7.6)
35 (3.2)
1(0.4)
2(1.7)
0
108 (8.2)
2(2.0)
1(0.9)
1(2.3)
81 (7.5)
36(15.9)
15(13.7)
3(14.7)
Table 26. Number (weighted %) of bread specimens for which packaging was marked as fortified with iron or not (does not include homemade bread), sample households, GNNS
2009
Characteristic
Marked as
fortified
Not marked as
fortified
Unknown or
original package
unavailable
TOTAL
64(6.5)
890 (77.5)
146 (16.0)
Type of bread
Lavash
Factory white bread
Other factory bread
Other
Unknown
4(3.0)
55(7.1)
5(7.2)
0
0
172 (87.3)
649 (75.4)
61(78.3)
2(100.0)
6(90.8)
16 (9.8)
117 (17.4)
12(14.4)
0
1(9.2)
25(11.1)
2(2.0)
3(2.9)
1(1.0)
25(10.1)
0
5(4.1)
166 (73.5)
87(88.8)
64(61.0)
91(90.1)
209 (84.6)
90(95.7)
99(80.5)
35(15.5)
9(9.2)
38(36.2)
9(8.9)
13 (5.3)
4(4.3)
19(15.4)
3(2.8)
84(79.2)
19(17.9)
Rural/Urban
Rural
Urban
23(4.1)
41(7.3)
339 (87.0)
551 (74.3)
38 (8.9)
108 (18.5)
Ethnic group
Georgian
Armenian
Azerbaijani
Other
46(6.5)
3(1.9)
13(12.4)
2(5.7)
698 (77.0)
77(83.9)
81(82.8)
27(72.2)
119 (16.5)
13(14.1)
5(4.8)
8(22.1)
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and MtckhetaMtianeti
Georgia National Nutrition Survey 2009
53
Figure 4. Weighted distribution of iron concentrations in household bread specimens, GNNS 2009
Weighted % of bread specimens
6
5
4
3
2
1
0
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90+
Iron concentration in bread (ppm)
Table 27. Weighted mean average and 95% confidence intervals for iron content in parts per
million, household bread specimens, GNNS 2009
Characteristic
54
Weighted mean
iron content
95% confidence
interval
TOTAL
23.8
22.9,24.7
Type of bread
Lavash
Factory white bread
Other factory bread
Homemade
Other
28.9
22.2
24.0
24.7
25.2
25.7,32.2
21.0,23.4
20.0,28.1
23.3,26.1
15.7,34.6
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
21.1
22.2
24.2
27.1
23.1
26.7
31.6
22.0
19.4,22.8
19.7,24.7
22.1,26.3
24.0,30.2
21.1,25.2
24.2,29.3
28.5,34.7
19.8,24.2
Rural/Urban
Rural
Urban
24.8
22.8
23.6,26.1
21.6,24.0
Georgia National Nutrition Survey 2009
Characteristic
Ethnic group of household head
Georgian
Armenian
Azerbaijani
Other
Weighted mean
iron content
95% confidence
interval
23.7
25.9
24.4
23.2
22.8,24.6
22.3,29.5
20.7,28.0
18.5,27.8
Table 28. Number (weighted %) and 95% confidence intervals (CI) of household bread specimens containing >30 parts per million iron, GNNS 2009
Characteristic
Number
(weighted %)
of households
TOTAL
543(24.9)
22.5,27.4
Type of bread
Lavash
Factory white bread
Other factory bread
Homemade
77(36.4)
202(21.1)
18(21.8)
233(27.5)
28.9,43.9
17.4,24.7
8.2,35.5
23.5,31.4
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
38(16.7)
37(20.0)
57(28.1)
76(32.2)
93(24.6)
71(33.0)
126(45.5)
45(20.3)
11.8,21.5
12.9,27.1
21.9,34.3
23.8,40.6
19.0,30.2
25.4,40.7
36.4,54.5
14.6,25.9
Rural/Urban
Rural
Urban
333(27.8)
210(22.4)
24.3,31.3
19.0,25.9
Ethnic group of household head
Georgian
Armenian
Azerbaijani
Other
418(24.9)
69(28.8)
44(26.7)
11(20.5)
22.3,27.5
19.7,37.9
16.4,37.0
8.4,32.6
95% CI
Georgia National Nutrition Survey 2009
55
Children – Description of sample
Table 29 shows the characteristics of the 3,069 children included in the survey sample. The
sample contained more boys than girls and more children 48-59 months of age than other ages.
The weighted distribution of children by regional strata is similar to distribution of the Georgian
population. Approximately equal numbers of children lived in rural and urban households, similar
to the distribution of the general population of Georgia.
As shown in Table 30 below, only a small proportion of respondents, usually mothers, reported
that their children had a chronic disease; however, in almost two-thirds of such children, medication was required for management of their chronic illness. A much larger proportion of children
had fever, cough, or diarrhea in the 2 weeks prior to the survey interview.
Table 29. Description of sample children less than 5 years of age, GNNS 2009
Characteristic
Survey sample
Actual number
Weighted %
of children
of children
Georgia census*
% population
TOTAL
3069
100.0
100.0
Sex
Male
Female
1658
1411
54.2
45.8
Age
<12 months
12-23 months
24-35 months
36-47 months
48-59 months
580
643
586
538
722
19.4
21.0
19.2
17.2
23.3
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
370
347
215
308
772
280
509
268
26.4
13.2
13.6
8.1
14.7
9.5
5.5
8.9
25.9
11.9
16.9
9.2
11.2
10.7
4.7
9.5
Rural/Urban
Rural
Urban
1831
1238
49.2
50.8
47.3
52.7
Ethnic group
Georgian
Armenian
Azerbaijani
Other
2253
403
365
44
84.5
7.9
5.9
1.7
Population estimates for 2009 from National Statistics Office of Georgia (http://www.geostat.ge/index.
php?action=page&p_id=473&lang=eng, accessed 12 March 2010)
*
56
Georgia National Nutrition Survey 2009
Table 30.Point or period prevalence of various forms of morbidity, children less than 5 years of
age, GNNS 2009
Actual
number of
children
Morbidity
Weighted %
of children
95% CI
Chronic disease
Takes medication
93
54
3.3
61.4
2.5, 3.9
49.2, 73.5
Fever in past 2 weeks
442
15.6
13.7, 17.5
Cough in past 2 weeks
669
23.1
20.5, 25.7
Diarrhea in past 2 weeks
253
8.1
6.7, 9.6
Children – Birthweight
Figure 5 and Figure 6 below shows the weighted distribution of the reported birthweights of children less than 5 years of age. Overall, less than 5% of children had low birthweight (<2500 g),
and another 1.2% of children had high birthweight (>4500 g). As seen in Table 31 below, the
weighted prevalence of low birthweight did not differ substantially by sex, age, regional stratum,
rural vs. urban households, or ethnic group.
Figure 5.
Weighted distribution of birthweights of children less than 5 years of age, GNNS 2009
10
Weighted % of children
9
8
7
6
5
4
3
2
1
90
11 0-9
00 99
13 119
00 9
15 -13
00 99
17 -15
00 99
19 -17
00 99
21 -19
00 99
23 -21
00 99
25 239
00 9
27 -25
00 99
29 -27
00 99
31 -29
00 99
33 -31
00 99
35 -33
00 99
37 359
00 9
39 -37
00 99
41 -39
00 99
43 -41
00 99
45 -43
00 99
47 -45
00 99
49 479
00 9
51 -49
00 99
53 -51
00 99
55 -53
00 99
-5
59
9
0
Birthweight (grams)
Georgia National Nutrition Survey 2009
57
Figure 6.
Weighted distribution of birthweights of children less than 5 years of age, GNNS 2009
High birthweight
(>4500 g)
1.2%
Very low birthweight (<1500 g)
0.3%
Normal
birthweight (25004500 g)
93.9%
Low birthweight
(1500-2499 g)
4.6%
Table 31. Number (weighted %) with various birth weights, children less than 5 years of age,
GNNS 2009
Birthweight
Low
(1500-2499 g)
Normal
(2500-4500 g)
8(0.3)
132 (4.6)
2886 (93.9)
34 (1.2)
Male
2(0.2)
66 (4.0)
1557 (93.8)
29 (2.0)
Female
6(0.4)
66 (5.3)
1329 (94.1)
5(0.3)
Characteristic
TOTAL
Very low
(<1500 g)
High
(>4500 g)
Sex
Age
<12 months
0
24 (4.9)
551 (94.6)
4(0.5)
12-23 months
4(0.5)
27 (3.5)
597 (94.0)
13 (2.0)
24-35 months
1(0.2)
31 (6.2)
547 (92.9)
4(0.7)
36-47 months
0
20 (3.1)
513 (95.5)
5(0.9)
48-59 months
3(0.5)
30 (5.3)
678 (92.6)
8(1.6)
Region
Tbilisi
1(0.3)
25 (6.8)
339 (91.9)
4(1.1)
Achara and Guria
1(0.3)
14 (4.0)
327 (94.2)
5(1.4)
Imereti and RachaLeckhumi
0
5(2.3)
206 (95.8)
4(1.9)
Kakheti
0
12 (3.9)
292 (95.1)
3(1.0)
3(0.4)
24 (3.1)
737 (95.8)
5(0.7)
Samegrelo
2(0.7)
10 (3.6)
266 (95.0)
2(0.7)
Samtckhe-Javakheti
0
24 (4.7)
477 (94.1)
6(1.2)
18 (6.8)
242 (91.0)
5(1.9)
Kvemo Kartli
Shida Kartli and
Mtckheta-Mtianeti
58
1(0.4)
Georgia National Nutrition Survey 2009
Birthweight
Characteristic
Very low
(<1500 g)
Low
(1500-2499 g)
Normal
(2500-4500 g)
High
(>4500 g)
Rural/Urban
Rural
4(0.3)
70 (3.7)
1731 (94.9)
21 (1.2)
Urban
4(0.3)
62 (5.5)
1155 (93.0)
13 (1.2)
Georgian
6(0.3)
109 (4.8)
2103 (93.6)
29 (1.3)
Armenian
0
9(2.8)
351 (95.8)
5(1.3)
Azerbaijani
2(0.7)
10 (3.1)
388 (96.3)
0
Other
0
4(9.1)
40(90.9)
0
Ethnic group
Children – Breastfeeding
Overall, about two-thirds of children less than 24 months of age were breastfed within 1 hour of
birth, as shown in Table 32. This proportion does not differ substantially by sex or by age. However, some differences exist among regional strata; a smaller proportion of children in Achara and
Guria and Samegrelo were breastfed within 1 hour of birth than children in other regional strata.
Moreover, a small proportion of children living in rural areas were breastfed within 1 hour than
children living in urban areas. A higher proportion of Armenian children were breastfed within 1
hour that than either Georgian or Azerbaijani children.
As shown in Table 33, a little more than one-half of children less than 6 months of age were
exclusively breastfed the day before data collection. The apparent difference between boys and
girls was not statistically significant. On the other hand, some regional strata, such as Shida Kartli and Meckheta-Mtianeti, had substantially higher prevalence rates of exclusive breastfeeding.
The prevalence in Samegrelo was statistally significantly lower than the prevalence in any other
regional stratum. Although the difference was not statistically significant, a somewhat greater
proportion of rural children were exclusively breastfed than urban children. A statistically significantly higher proportion of Azerbaijani children were exclusively breastfed than either Georgian
or Armenian children.
Slightly more than one-third of children 12-15 months of age were still breastfeeding, as shown
in Table 34. Apparent differences between sexes, urban/rural residence, and ethnic group were
not statistically significant. This lack of statistical significance is largely due to the narrow age
range for this indicator and the subsequent small number of children in each subgroup. However,
in spite of this limitation, there were statistically significant differences in this indicator between
regional strata, with Achara and Guria having a particularly low prevalence of continued breastfeeding after 1 year of age.
A large majority of children 6-8 months of age had eaten solid, semi-solid, or soft food the day
before the interview, as shown in Table 35. Because of the small numbers of children in each
subgroup, none of the apparent differences among subgroups (sex, age, urban/rural residence,
regional stratum, or ethnicity) are statistically significant.
As shown in Table 36, less than one-half of children 6-23 months of age achieved minimum
dietary diversity. A larger proportion of girls than boys had minimum dietary diversity, and the
proportion increased with age. As with other breastfeeding indicators, the regional strata showed
some differences, with Achara and Guria and Kakheti showing a smaller proportion of children
Georgia National Nutrition Survey 2009
59
with minimum dietary diversity. Urban children had a higher prevalence of minimum dietary
diversity than rural children, and a larger proportion of Armenian children had minimum dietary
diversity than Georgian or Azerbaijani children; however, only the difference between Armenian
and Georgian children was statistically significant.
Minimum meal frequency was achieved in a large majority of children 6-23 months of age, as
shown in Table 37. The proportion of children meeting this criterion did not differ between sexes,
but it declined with age. Although there were differences between regional stata, the range
was only from 74.3% in Samtckhe-Javakheti to 89.9% in Shida Kartli and Mtckheta-Mtianeti.
In addition, a larger proportion of children in urban areas met the minimum meal frequency than
children in rural areas. Armenian children had the lowest proportion of children with minumum
meal frequency, and the differences between Armenian children and the children of the other two
ethnicities were statistically significant.
As shown in Table 38, fewer than one-half of children 6-23 months had a minimum acceptable
diet (an indicator combining dietary diversity and meal frequency). This proportion was higher in
girls than in boys and higher in children 18-23 months of age than younger children, albeit without
statistical significance in either case. A smaller proportion of children in Achara and Guria and
Kakheti had a minimum acceptable diet than children in other regional strata; however, only some
of the differences were statistically significant. A substantially greater proportion of children in
urban areas had a minimum acceptable diet than children in rural areas, but there was little difference among ethnicities.
The proportion of children < 24 months who had ever been breastfed was very high overall and
in all subgroups, as shown in Table 39. Differences between age groups, regional strata, rural/urban residence, and ethnicities, although occasionally statistically significant, are relatively small.
The proportion of children 20-23 months of age with continued breastfeeding is quite small, as
seen in Table 40. Boys are more commonly still breastfeeding at this age than girls, and a statistically significantly greater proportion of children in Samegrelo are still breastfeeding than in
any other regional stratum. However, this is little difference between children in rural and urban
locations or among children of different ethnicities.
As seen in Table 41, age-appropriate breastfeeding occurred in slightly more than one-third of
children less than 24 months of age. There was little difference between the sexes, between
children with rural or urban residence, or among ethnicities. The proportion of children with ageappropriate breastfeeding declines substantially with age and is somewhat lower in Kakheti than
in other regional strata.
Among children less than 36 months of age, the median duration of breastfeeding is between 9
and 10 months, as shown in Figure 7. By the age of 24 months, very few children are still be
breastfed.
60
Georgia National Nutrition Survey 2009
Table 32. Number (weighted %) with various times of breastfeeding initiation after birth,
children < 24 months of age, GNNS 2009
(WHO/UNICEF recommendations22- Indicator #1 Early initiation of breastfeeding)
Characteristic
Initiated
breastfeeding
in first hour
Initiated
breastfeeding
1-12 hours
Initiated
breastfeeding
> 12 hours
TOTAL
678 (66.3)
283 (25.3)
101 (8.4)
Sex
Male
Female
362 (64.2)
316 (68.8)
161 (26.2)
122 (24.1)
57 (9.6)
44 (7.1)
Age
<12 months
12-23 months
323 (65.9)
355 (66.6)
140 (26.2)
143 (24.4)
47 (7.9)
54 (9.0)
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
114 (82.6)
51(37.2)
47(78.3)
66(62.3)
193 (65.2)
33(41.8)
99(68.8)
75(73.5)
20(14.5)
69(50.4)
9(15.0)
32(30.2)
68(23.0)
28(35.4)
35(24.3)
22(21.6)
4(2.9)
17(12.4)
4(6.7)
8(7.5)
35(11.8)
18(22.8)
10 (6.9)
5(4.9)
Rural/Urban
Rural
Urban
383 (59.7)
295 (72.5)
185 (30.4)
98(20.5)
59 (9.9)
42 (7.1)
Ethnic group
Georgian
Armenian
Azerbaijani
488 (65.8)
86(81.1)
99(65.1)
211 (25.6)
25(16.7)
42(26.7)
82 (8.7)
3(2.2)
13 (8.2)
Georgia National Nutrition Survey 2009
61
Table 33. Number (weighted %) and 95% CI of children exclusively breastfed* the day before
the interview, children < 6 months of age, GNNS 2009
(WHO/UNICEF recommendations22 - Indicator #2 Exclusive breastfeeding under 6
months)
No. (weighted %) of
children exclusively
breastfed
Characteristic
62
95% CI
TOTAL
161(54.8)
48.5,61.2
Sex
Male
Female
87(57.5)
74(52.2)
48.8,66.0
42.7,61.7
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
15(46.9)
30(62.5)
10(50.0)
11(47.8)
54(65.1)
6(30.0)
19(55.9)
16(76.2)
32.3,61.4
47.0,78.0
29.0,71.0
33.6,62.0
54.2,75.9
12.8,47.2
42.7,69.1
59.0,93.4
Rural/Urban
Rural
Urban
92(59.1)
69(51.1)
50.5,67.7
41.9,60.4
Ethnic group
Georgian
Armenian
Azerbaijani
114(53.4)
17(53.7)
28(69.7)
46.2,60.6
28.5,78.9
55.4,83.9
*
See text for definition of exclusively breastfed
Georgia National Nutrition Survey 2009
Table 34. Number (weighted %) and 95% CI of children breastfed the day before the
interview, children 12-15 months of age, GNNS 2009
(WHO/UNICEF recommendations22 - Indicator #3 Continued breastfeeding at 1 year)
Characteristic
No. (weighted %) of
children breastfed
95% CI
TOTAL
96(36.5)
29.3, 43.8
Sex
Male
Female
56(38.5)
40(34.3)
28.0, 48.9
24.9, 43.8
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
14(35.9)
4(15.4)
7(35.0)
7(29.2)
27(41.5)
15(55.6)
11(35.5)
11(44.0)
20.6, 51.2
0,32.6
14.9, 55.1
10.0, 48.4
29.3, 53.8
32.7, 78.4
20.7, 50.3
22.6, 65.4
Rural/Urban
Rural
Urban
61(40.2)
35(33.3)
29.7, 50.7
23.0, 43.7
Ethnic group
Georgian
Armenian
Azerbaijani
72(36.1)
6(25.7)
17(44.7)
28.1, 44.1
6.9,44.5
26.1, 63.4
Georgia National Nutrition Survey 2009
63
Table 35. Number (weighted %) and 95% CI of children eating complementary food the day
before the interview, children 6-8 months of age, GNNS 2009
(WHO/UNICEF recommendations22 - Indicator #4 Introduction of solid, semi-solid or
soft foods)
Characteristic
64
No. (weighted %) of
children eating solid,
semi-solid, or soft food
95% CI
TOTAL
124(84.5)
77.1, 91.8
Sex
Male
Female
67(82.6)
57(86.7)
73.3, 91.9
77.7, 95.7
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
18(94.7)
15(75.0)
3(75.0)
15(68.2)
32(82.1)
9(90.0)
14(93.3)
18(90.0)
84.3, 100
48.4, 100
44.5, 100
45.9, 90.5
68.1, 96.0
70.9, 100
80.3, 100
76.2, 100
Rural/Urban
Rural
Urban
61(74.6)
63(92.6)
62.0, 87.1
85.0,100
Ethnic group
Georgian
Armenian
Azerbaijani
106(85.3)
8(76.1)
8(68.6)
77.4, 93.1
45.1, 100
37.0, 100
Georgia National Nutrition Survey 2009
Table 36. Number (weighted %) with minimum dietary diversity* the day before the interview,
children 6-23 months of age, GNNS 2009
(WHO/UNICEF recommendations22 - Indicator #5 Minimum dietary diversity)
No. (weighted %)
of children with
minimum dietary
diversity
Characteristic
*
95% CI
TOTAL
426(47.7)
42.2, 53.2
Sex
Male
Female
218(43.6)
208(52.6)
37.2, 50.1
45.4, 59.8
Age
6-11 months
12-17 months
18-23 months
109(41.5)
152(45.1)
165(57.6)
33.2, 49.9
37.6, 52.7
49.9, 65.3
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
73(58.4)
31(28.7)
30(60.0)
29(29.0)
118(48.4)
28(38.9)
77(61.1)
40(45.5)
45.3, 71.5
16.4, 41.0
43.1, 76.9
18.4, 39.6
39.1, 57.6
25.3, 52.4
48.2, 74.0
32.4, 58.5
Rural/Urban
Rural
Urban
233(41.1)
193(53.7)
34.4, 47.9
45.2, 62.2
Ethnic group
Georgian
Armenian
Azerbaijani
307(46.9)
56(60.9)
59(48.2)
40.9, 52.9
47.3, 74.4
33.3, 63.2
See text for definition of minimum dietary diversity
Georgia National Nutrition Survey 2009
65
Table 37. Number (weighted %) with minimum meal frequency* the day before the interview,
children 6-23 months of age, GNNS 2009
(WHO/UNICEF recommendations22 - Indicator #6 Minimum meal frequency)
No. (weighted %)
of children with
minimum meal
frequency
Characteristic
66
*
95% CI
TOTAL
772(85.3)
82.2, 88.4
Sex
Male
Female
413(85.5)
359(85.1)
81.7, 89.3
81.0, 89.2
Age
6-11 months
12-17 months
18-23 months
260(93.0)
283(84.1)
229(78.9)
89.8, 96.1
79.6, 88.7
72.6, 85.1
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
113(89.0)
84(80.0)
42(84.0)
75(78.1)
215(87.0)
62(87.3)
101(74.3)
80(89.9)
82.5, 95.4
70.1, 89.9
73.2, 94.8
68.1, 88.2
82.5, 91.5
78.8, 95.8
63.7, 84.8
83.8, 96.0
Rural/Urban
Rural
Urban
431(82.8)
341(87.5)
78.8, 86.7
82.9, 92.0
Ethnic group
Georgian
Armenian
Azerbaijani
593(86.1)
66(73.0)
105(87.0)
82.7, 89.5
60.2, 85.9
81.2, 92.8
See text for definition of minimum meal frequency
Georgia National Nutrition Survey 2009
Table 38. Number (weighted %) with minimum acceptable diet* the day before the interview,
children 6-23 months of age, GNNS 2009
(WHO/UNICEF recommendations22 - Indicator #7 Minimum acceptable diet)
Characteristic
No. (weighted %) of
children with minimum
acceptable diet
TOTAL
367(42.3)
37.0,47.9
Sex
Male
Female
188(39.4)
179(46.2)
33.1,45.7
39.1,53.3
Age
6-11 months
12-17 months
18-23 months
106(40.9)
131(40.1)
130(47.3)
32.5,49.3
32.8,47.3
39.3,55.3
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
68(54.4)
26(24.1)
28(56.0)
21(21.0)
103(42.4)
25(34.7)
60(47.6)
36(40.9)
41.6,67.2
11.7,36.5
38.6,73.4
9.7,32.3
33.5,51.3
21.5,48.0
34.3,61.0
29.2,52.6
Rural/Urban
Rural
Urban
192(35.0)
175(49.3)
28.3,41.7
40.9,57.6
Ethnic group
Georgian
Armenian
Azerbaijani
274(42.5)
38(43.0)
52(42.4)
36.6,48.5
28.9,57.0
28.5,56.2
*
95% CI
See text for definition of minimum acceptable diet
Georgia National Nutrition Survey 2009
67
Table 39. Number (weighted %) and 95% CI of children ever breastfed, children < 24 months
of age, GNNS 2009
(WHO/UNICEF recommendations22 - Indicator #9 Children ever breastfed)
Characteristic
No. (weighted %)
of children ever
breastfed
95% CI
TOTAL
1068(87.2)
84.6,89.7
Sex
Male
Female
583(88.4)
485(85.7)
85.2,91.7
81.7,89.7
263(92.1)
250(83.8)
294(85.8)
261(87.6)
87.7,96.4
78.6,89.0
81.7,89.9
83.1,92.0
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
138(86.3)
137(87.3)
60(84.5)
106(86.2)
297(87.9)
81(88.0)
145(85.3)
104(92.9)
80.9,91.6
80.6,94.0
73.2,95.8
80.7,91.6
84.0,91.8
80.6,95.5
78.7,92.0
87.6,98.2
Rural/Urban
Rural
Urban
631(89.5)
437(85.1)
86.3,92.7
81.3,88.9
Ethnic group
Georgian
Armenian
Azerbaijani
785(86.6)
114(85.1)
155(92.5)
83.889.4
75.4,94.8
88.3,96.7
Age
68
< 6 months
6-11 months
12-17 months
18-23 months
Georgia National Nutrition Survey 2009
Table 40. Number (weighted %) and 95% CI of children breastfed the day before the
interview, children 20-23 months of age, GNNS 2009
(WHO/UNICEF recommendations22 - Indicator #10 Continued breastfeeding at 2
years)
Characteristic
No. (weighted %) of
children breastfed
95% CI
TOTAL
38(16.6)
11.3,21.9
Sex
Male
Female
24(22.7)
14(10.2)
14.4,31.1
4.5,15.9
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
2(10.0)
3(16.7)
0
1(4.3)
13(22.4)
6(54.5)
7(17.5)
6(24.0)
0,23.1
0,35.4
0,13.0
11.9,32.9
27.0,82.1
4.8,30.2
9.0,39.0
Rural/Urban
Rural
Urban
23(17.5)
15(15.6)
10.6,24.4
6.8,24.4
Ethnic group
Georgian
Armenian
Azerbaijani
24(15.0)
7(19.1)
5(16.3)
9.3,20.7
3.7,34.5
3.4,29.1
Georgia National Nutrition Survey 2009
69
Table 41. Number (weighted %) and 95% CI of children with age-appropriate breastfeeding*
the day before the interview, children < 24 months of age, GNNS 2009
(WHO/UNICEF recommendations22 - Indicator #11 Age-appropriate breastfeeding)
No. (weighted %) of
children with ageappropriate breastfeeding
Characteristic
70
95% CI
TOTAL
463(37.7)
34.6,40.9
Sex
Male
Female
260(39.1)
203(36.2)
35.0,43.1
31.7,40.7
Age
< 6 months
6-11 months
12-17 months
18-23 months
161(54.8)
122(42.5)
113(32.7)
67(21.7)
48.5,61.2
36.5,48.4
26.7,38.7
16.5,27.0
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
57(35.6)
60(38.2)
27(38.0)
34(27.6)
133(39.5)
41(44.6)
62(36.5)
49(43.8)
29.1,42.1
29.8,46.7
26.0,50.0
18.7,36.6
34.3,44.6
33.2,56.0
28.6,44.3
35.2,52.3
Rural/Urban
Rural
Urban
272(39.3)
191(36.3)
35.1,43.5
31.8,40.9
Ethnic group
Georgian
Armenian
Azerbaijani
345(37.3)
48(38.6)
63(38.7)
33.7,40.9
27.1,50.2
31.8,45.7
*
See text for definition of age-appropriate breastfeeding
Georgia National Nutrition Survey 2009
Figure 7. Weighted 3-month moving average percent of children breastfed the day before the
interview, by age, children < 36 months of age, GNNS 2009
(WHO/UNICEF recommendations22 - Indicator #13 Duration of breastfeeding)
Weighted % of children breastfed yesterday
100
90
80
70
60
50
40
30
20
10
0
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
Age (in months)
Children – Other dietary intake
Table 42 below shows the proportion of children less than 5 years of age who ate various foods
the day before the survey interview. Almost one-third of children less than 24 months of age
consumed breast milk substitute. More than two-thirds ate bread or other grain products and
fruits and vegetables. However, relatively few ate protein-rich foods, such as beans or nuts,
meat, fish, chicken, or eggs. Dairy products were consumed by more than one-half; however,
vitamin A rich fruits and vegetables were consumed by fewer than one-quarter. Sweet tea was
commonly drunk in this age group.
As might be expected, children 24-59 months of age consumed breast milk substitute much less
frequently. Although eaten by a larger proportion of older children, the protein sources of beans
or nuts, meat, fish, chicken, and eggs were still eaten by only one-half or fewer of children, although dairy products were consumed by about three-quarters of children. Although most children in this age group at some fruits or vegetables, vitamin A rich fruits and vegetables were only
eaten by slightly more than one-third of children. Fatty foods and sweet tea were consumed by
a large majority of children.
Table 43 and Table 44 show the number of times in the week prior to the survey interview various foods in these categories were eaten. Among children less than 24 months of age, more
than one-third never consumed breast milk substitute. On the other hand, more than one-half
ate bread or grain products at least five times per week. Most young children ate dairy products
at least once per week. Protein-rich foods, such as beans or nuts, meat, fish, chicken, and eggs
were eaten less frequently. About one-half of children ate other fruits and vegetables, fatty
foods, and sweet tea five times per week or more, but more than one-third never ate vitamin A
rich fruits and vegetables.
About 7% of children 24-59 months of age had consumed baby formula during the week prior to
the interview. As with the younger children, bread or other grain products, dairy products, other
Georgia National Nutrition Survey 2009
71
fruits and vegetables, fatty foods, and sweet tea were consumed frequently in this age group.
However, again as with younger children, foods rich in protein, other than dairy products, and
vitamin A rich fruits and vegetables were not eaten so frequently.
Table 42. Number (weighted %) and 95% CI of children eating various foods the day before
the interview, by age group, children < 5 years of age, GNNS 2009
Age < 24 months
Number
95% CI
(weighted %)
Food category
Age 24-59 months
Number
95% CI
(weighted %)
Baby formula
308(30.1)
26.1, 34.2
65(5.1)
2.4, 7.8
Bread or grain products
811(68.5)
65.4, 71.5
1512(82.3)
78.7, 85.9
Beans or nuts
69(5.7)
4.1, 7.3
435(23.5)
20.6, 26.5
Dairy products
716(58.7)
55.2, 62.2
1421(76.8)
73.5, 80.1
Meat, fish, or chicken
352(30.7)
26.3, 35.1
930(54.2)
50.3, 58.2
Eggs
178(16.0)
13.5, 18.5
603(32.4)
29.0, 35.8
Vitamin A rich fruits or
vegetables
259(21.7)
18.1, 25.3
663(36.4)
32.0, 40.8
Other fruits or vegetables
795(67.1)
64.1, 70.0
1579(87.2)
85.0, 89.4
Oily or fatty foods
651(51.9)
47.7, 56.1
1583(85.8)
82.8, 88.8
Sweet tea
690(57.0)
52.7, 61.3
1474(80.2)
77.4, 83.0
Table 43. Number (weighted %) of children eating various foods the week before the interview
with various frequencies, by age group, children < 24 months of age, GNNS 2009
<1
day/week
1-2 days/
week
3-4 days/
week
5-7 days/
week
Food category
Never
Baby formula
898 (69.7)
12 (1.3)
18 (2.0)
21 (2.1)
257 (24.8)
Bread or grain products
300 (24.8)
32 (2.0)
71 (5.7)
109 (9.8)
694 (57.8)
Beans or nuts
716 (60.7)
249 (19.6)
150 (12.6)
67 (5.3)
19 (1.7)
Dairy products
289 (24.4)
56 (4.6)
168 (14.0)
239 (18.9)
454 (38.1)
Meat, fish, or chicken
375 (30.8)
171 (14.2)
335 (25.1)
230 (20.4)
90 (9.6)
Eggs
516 (43.5)
228 (18.9)
313 (25.2)
115 (10.1)
30 (2.2)
Vitamin A rich fruits or
vegetables
479 (40.3)
168 (15.6)
229 (17.1)
190 (15.6)
136 (11.4)
Other fruits or vegetables
286 (23.6)
27 (2.2)
66 (4.9)
192 (16.8)
627 (52.5)
Oily or fatty foods
371 (31.1)
25 (2.4)
74 (7.0)
151 (13.1)
583 (46.4)
Sweet tea
358 (30.5)
19 (2.0)
79 (7.0)
151 (11.6)
601 (48.8)
72
Georgia National Nutrition Survey 2009
Table 44. Number (weighted %) of children eating various foods the week before the interview
with various frequencies, by age group, children 24-59 months of age, GNNS 2009
Food category
Never
<1
day/week
1-2 days/
week
3-4 days/
week
5-7 days/
week
Baby formula
1733
(93.1)
14(0.7)
29(2.2)
25(2.3)
26(1.8)
Bread or grain products
60(3.4)
60(2.9)
194 (10.2)
248 (15.0)
1265(68.5)
Beans or nuts
287 (15.2)
637 (36.5)
615 (31.5)
219 (12.8)
66(4.1)
Dairy products
25(1.4)
84(4.7)
346 (18.9)
571 (29.6)
799 (45.4)
Meat, fish, or chicken
29(1.5)
264 (13.2)
766 (38.2)
528 (30.8)
243 (16.3)
Eggs
91(5.0)
398 (22.6)
828 (45.4)
405 (21.7)
99(5.3)
Vitamin A rich fruits or
vegetables
95(5.6)
363 (22.3)
598 (31.0)
508 (28.7)
250 (12.5)
Other fruits or vegetables
14(0.7)
34(2.0)
119 (7.1)
428 (24.1)
1224(66.1)
Oily or fatty foods
6(0.4)
17(1.1)
112 (5.8)
348 (19.8)
1344(72.9)
Sweet tea
60(3.8)
42(2.5)
111 (6.7)
308 (16.0)
1311(71.0)
Children – Protein-energy nutritional status
Acute protein-energy malnutrition (wasting) and overweight
The weighted distribution of weight-for-height z-scores is shown in Figure 8. The entire distribution is displaced rightward compared to the WHO Child Growth Standard, showing that overall,
Georgian children less than 5 years of age are fatter than children in the standard population.
As shown in Table 45 below, the overall prevalence and the majority of the subgroup-specific
prevalence rates of acute protein-energy malnutrition are at or below the 2.3% prevalence found
in the WHO Growth Standard which is considered normal. Moreover, in those groups in which
the subgroup-specific prevalence is greater than 2.3% (children less than 12 months of age and
children in the Azerbaijani and the “Other” ethnicity category), the difference between the measured prevalence and 2.3% is almost certainly not statistically significant.
On the other hand, overweight and obesity are much more common nutritional problems. Overall, as shown in Table 46, almost one in five children less than 5 years of age are overweight
or obese. Overweight and obesity prevalence rates are not statistically different in boys and
girls, but do decrease in prevalence with age. Although there is an apparent difference between
some regional strata in the prevalence of overweight and obesity, few of these differences are
statistically significant. There is very little difference between children living in rural households
and those in urban households. Children of Armenia ethnicity have statistically significantly less
overweight and obesity than Georgian and Azerbaijani children.
Georgia National Nutrition Survey 2009
73
Figure 8. Weighted distribution of weight-for-height z-scores in children less than 5 years of
age, GNNS 2009
20
Georgia
Weighted % of children
WHO Child Growth Standard
15
Georgia z-scores
Mean = 0.98
SD = 1.29
10
5
0
-4.99 -4.49 -3.99 -3.49 -2.99 -2.49 -1.99 -1.49 -0.99 -0.49 0.01
to
to
to to - to - to - to - to to - to - to 0.5
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
0.51
to
1.0
1.01
to
1.5
Weight-for-height z-score
74
Georgia National Nutrition Survey 2009
1.51
to
2.0
2.01
to
2.5
2.51
to
3.0
3.01
to
3.5
3.51 4.01 4.51
to to 4.5 to 5.0
6.0
Table 45. Number (weighted %) with various levels of acute protein-energy malnutrition or
wasting, overweight, or obesity* (defined by weight-for-height z-score calculated
using WHO Child Growth Standard), children less than 5 years of age, GNNS 2009
Severe
wasting
Characteristic
None
(normal)
Overweight
Obese
TOTAL
19(0.6)
29(1.0)
2352 (78.5)
371(13.1)
180 (6.8)
Sex
Male
Female
13(0.8)
11(0.7)
16(1.0)
13(0.8)
1244 (74.9)
1108 (79.2)
201(13.0)
170(12.6)
147(10.3)
86(6.6)
Age
<12 months
12-23 months
24-35 months
36-47 months
48-59 months
7(0.9)
6(1.0)
3(0.3)
5(1.1)
3(0.5)
15(2.9)
1(0.2)
5(0.6)
3(0.6)
5(0.6)
396(69.0)
471(72.7)
456(80.1)
433(81.3)
596(81.2)
95(17.1)
99(16.2)
61(9.8)
51(10.5)
65(10.4)
3(0.8)
1(0.3)
2(0.5)
4(1.2)
292(80.2)
235(69.5)
35(9.6)
49(14.5)
32(8.8)
49(14.5)
1(0.5)
3(1.4)
140(67.0)
44(21.1)
21(10.0)
3(1.0)
8(1.1)
2(0.7)
4(0.8)
4(1.3)
6(0.8)
1(0.4)
5(1.0)
255(83.9)
590(77.6)
222(80.4)
418(83.9)
31(10.2)
96(12.6)
36(13.0)
49(9.8)
2(0.8)
4(1.5)
200(76.9)
31(11.9)
23(8.8)
Region
Tbilisi
Achara and Guria
Imereti and Racha
Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and
Mtckheta-Mtianeti
*
Moderate
wasting
53(10.1)
61(9.9)
44(9.1)
32(6.5)
43(7.2)
11(3.6)
60(7.9)
15(5.4)
22(4.4)
Rural/Urban
Rural
Urban
16(0.9)
8(0.6)
15(0.9)
14(1.0)
1400 (76.3)
952(77.6)
228(13.6)
143(12.1)
137 (8.3)
96(8.9)
Ethnic group
Georgian
Armenian
Azerbaijani
Other
13(0.5)
2(0.6)
7(1.7)
2(6.7)
22(0.9)
2(0.4)
3(0.7)
2(5.7)
1715 (76.7)
314(86.4)
289(72.5)
30(71.7)
270(12.9)
38(11.0)
59(14.3)
4(11.0)
179 (9.0)
6(1.5)
45(10.8)
3(5.0)
Severe = z-score < -3.0 or edema; Moderate = z-score -3.0 - <-2.0 without edema; None = z-score > -2.0
without edema
Georgia National Nutrition Survey 2009
75
Table 46. Number (weighted %) with overweight or obesity* (defined by weight-for-height
z-score calculated using WHO Child Growth Standard), children less than 5 years of
age, GNNS 2009
No. (weighted %)
Characteristic
with overweight or
95% CI
obesity*
*
TOTAL
551(19.9)
17.5,22.3
Sex
Male
Female
312(21.3)
239(18.3)
18.7,23.9
15.2,21.5
Age
<12 months
12-23 months
24-35 months
36-47 months
48-59 months
134(25.3)
146(24.4)
96(17.6)
78(16.1)
97(16.2)
20.5,30.0
20.3,28.4
13.4,21.9
12.2,20.1
11.3,21.1
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
62(17.3)
82(25.5)
60(29.6)
40(13.2)
142(19.1)
50(18.2)
67(13.6)
48(19.0)
12.8,21.8
16.9,34.0
21.5,37.6
8.9,17.6
14.9,23.3
13.5,22.9
9.8,17.3
12.0,26.1
Rural/Urban
Rural
Urban
329(20.2)
222(19.7)
16.6,23.8
16.5,22.9
Ethnic group
Georgian
Armenian
Azerbaijani
Other
409(20.3)
44(12.6)
92(23.0)
6(14.6)
17.6,23.0
7.4,17.7
17.5,28.6
1.9,27.2
Overweight or obesity = weight-for-height z-score > +2.0
Chronic protein-energy malnutrition (stunting)
In contrast to acute protein-energy malnutrition, there is substantial chronic protein-energy malnutrition, or stunting, in Georgian children less than 5 years of age. Figure 9 shows the weighted
distribution of height-for-age z-scores among children less than 5 years of age in Georgia. The
curve is shifted slightly to the left compared to that of the WHO Child Growth Standard, demonstrating that Georgian children less than 5 years of age are, on average, somewhat shorter than
age-matched children in the standard population. As seen in Table 47, 40% of the stunting in
Georgia is severe. As seen in Table 48, although boys seem to have more stunting than girls,
this difference is not statistically significant. There is little trend in stunting with age. In contrast,
there are substantial differences in the prevalence rates of stunting between regional strata, with
76
Georgia National Nutrition Survey 2009
a range of 6.0% to 19.7%. Many of the differences between strata are statistically significant.
On the other hand, there is no statistically significant difference in stunting between children in
rural households and those in urban households. Stunting prevalence differs substantially by
ethnicity, with the prevalence in Azerbaijani children being almost twice that in other children.
Figure 9. Weighted distribution of height-for-age z-scores in children less than 5 years of age,
GNNS 2009
20
Weighted % of children
Georgia
WHO Child Growth Standard
15
Georgia z-scores
Mean = -0.32
SD = 1.51
10
5
0
-5.99 -5.49 -4.99 -4.49 -3.99 -3.49 -2.99 -2.49 -1.99 -1.49 -0.99 -0.49 0.01 0.51 1.01 1.51 2.01 2.51 3.01 3.51 4.01 4.51 5.01
gto
to
to
to
to
to
to
to
to
to
to
to - to - to - to - to - to - to - to - to - to - to - to
5.5 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 6.0 4.5 5.0 5.5
Height-for-age z-score
Georgia National Nutrition Survey 2009
77
Table 47. Number (weighted %) with various levels of chronic protein-energy malnutrition
(defined by height-for-age z-score calculated using WHO Child Growth Standard*),
children less than 5 years of age, GNNS 2009
Severe
stunting*
Moderate
stunting*
TOTAL
125 (4.5)
223 (6.8)
2579(88.7)
Sex
Male
Female
78(5.3)
47(3.6)
127 (7.0)
96(6.6)
1363(87.7)
1216(89.8)
Age
<12 months
12-23 months
24-35 months
36-47 months
48-59 months
28(4.7)
25(3.8)
26(5.5)
21(4.6)
25(4.2)
38(6.5)
57(8.2)
50(7.6)
36(5.9)
42(6.0)
475(88.8)
532(88.1)
478(87.0)
455(89.5)
639(89.8)
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
13(3.7)
31(9.4)
13(6.3)
6(2.0)
36(4.9)
4(1.5)
15(3.0)
7(2.8)
13(3.7)
34(10.3)
18(8.8)
12(4.0)
77(10.5)
19(7.0)
43(8.7)
7(2.8)
326(92.6)
265(80.3)
174(84.9)
280(94.0)
621(84.6)
247(91.5)
434(88.2)
232(94.3)
Rural/Urban
Rural
Urban
80(5.0)
45(4.0)
141 (7.3)
82(6.4)
1523(87.7)
1056(89.6)
Ethnic group
Georgian
Armenian
Azerbaijani
Other
86(4.4)
7(1.9)
31(8.0)
1(2.6)
137 (6.0)
31(9.7)
51(12.8)
4(9.2)
1917(89.6)
322(88.4)
302(79.2)
34(88.3)
Characteristic
*
78
Severe = z-score < -3.0; Moderate = z-score -3.0 - <-2.0; None = z-score > -2.0
Georgia National Nutrition Survey 2009
None*
(normal)
Table 48. Number (weighted %) with any chronic protein-energy malnutrition (defined by
height-for-age z-score calculated using WHO Child Growth Standard*), children less
than 5 years of age, GNNS 2009
Characteristic
No. (weighted %)
with stunting*
95% CI
TOTAL
348(11.3)
9.1, 13.6
Sex
Male
Female
205(12.3)
143(10.2)
9.6,15.0
7.6,12.9
Age
<12 months
12-23 months
24-35 months
36-47 months
48-59 months
8.1,14.2
9.0,14.9
8.8,17.2
6.9,14.0
5.9,14.5
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
26(7.4)
65(19.7)
31(15.1)
18(6.0)
113(15.4)
23(8.5)
58(11.8)
14(5.7)
3.2,11.5
13.6,25.8
4.4,25.9
3.2,8.9
11.7,19.1
4.8,12.3
7.8,15.8
2.7,8.7
Rural/Urban
Rural
Urban
221(12.3)
127(10.4)
Ethnic group
Georgian
Armenian
Azerbaijani
Other
223(10.4)
38(11.6)
82(20.8)
5(11.7)
7.9,12.9
6.0,17.1
15.8,25.8
0.3,23.1
*
66(11.2)
82(11.9)
76(13.0)
57(10.5)
67(10.2)
8.7,15.9
7.6,13.2
Stunting = height-for-age z-score < -2.0
Georgia National Nutrition Survey 2009
79
Underweight
As shown in Table 49, underweight is uncommon in children less than 5 years of age in Georgia.
Overall, and in all subgroups individually, the prevalence of underweight was less than the 2.3%
prevalence in the WHO Child Growth Standard which is considered normal.
Table 49. Number (weighted %) with various levels of underweight* (defined by height-for-age
z-score calculated using WHO Child Growth Standard*), children less than 5 years of
age, GNNS 2009
Characteristic
Moderate
underweight*
None*
TOTAL
14(0.5)
25(0.6)
2981(98.8)
Sex
Male
Female
7(0.4)
7(0.6)
19(0.9)
6(0.4)
1599(98.7)
1382(99.0)
Age
<12 months
12-23 months
24-35 months
36-47 months
48-59 months
3(0.4)
3(0.7)
1(0.1)
5(1.3)
2(0.2)
7(0.8)
4(0.7)
2(0.3)
4(0.6)
8(0.8)
561(98.7)
627(98.6)
573(99.6)
518(98.1)
702(99.0)
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
3(0.8)
2(0.6)
1(0.5)
2(0.7)
2(0.3)
1(0.4)
3(0.6)
0
1(0.3)
1(0.3)
2(1.0)
1(0.3)
8(1.1)
3(1.1)
8(1.6)
1(0.4)
360(98.9)
337(99.1)
204(98.6)
304(99.0)
751(98.7)
272(98.6)
490(97.8)
263(99.6)
Rural/Urban
Rural
Urban
8(0.5)
6(0.5)
18(0.9)
7(0.4)
1775(98.6)
1206(99.1)
Ethnic group
Georgian
Armenian
Azerbaijani
Other
11(0.5)
1(0.4)
2(0.5)
0
11(0.5)
5(0.9)
8(2.1)
1(2.2)
2188(99.0)
359(98.6)
390(97.4)
40(97.8)
*
80
Severe
underweight*
Severe = z-score < -3.0; Moderate = z-score -3.0 - <-2.0; None = z-score > -2.0
Georgia National Nutrition Survey 2009
Children – Micronutrient status
Anemia
Anemia is quite common in children less than 5 years of age in Georgia. The weighted distribution of hemoglobin concentrations in children less than 5 years of age is shown in Figure 10
below. A substantial proportion of hemoglobin values are below the cut-off defining anemia in
young children (11.0 g/dL). Although anemia is quite common, severe anemia is relatively rare,
as shown in Table 50.
As shown in Table 51, the prevalence of anemia did not differ substantially between boys and
girls. The prevalence of anemia declines with age. The prevalence of anemia is also quite different between regional strata, from 9.2% of children living in Imereti and Racha-Leckhumi to
32.2% of children living in Kvemo Kartli. There was little difference in weighted anemia prevalence between children living in rural households and those living in urban households. Azerbaijani children had a substantially and statistically significantly higher prevalence of anemia than
children of other ethnicities.
The correlation between breastfeeding and anemia could only be analyzed in children 12-23
months of age because children less than 12 months of age did not undergo the fingerstick
necessary to measure hemoglobin. Moreover, among children 24 months of age and older, the
prevalence of breastfeeding was too low. Among the 578 children 12-23 months of age who had
both breastfeeding information and a hemoglobin measurement, children who were breastfed the
day before the interview were 25% more likely to be anemic than children who had not breastfed
(adjusted relative risk [RR] = 1.25, 95% CI: 0.96, 1.63).
Figure 10. Weighted distribution of hemoglobin concentrations in children less than 5 years of
age, GNNS 2009
Weighted % of children
25
20
15
10
5
0
5.05.9
6.06.9
7.07.9
8.08.9
9.09.9
10.0- 11.010.9 11.9
12.012.9
13.0- 14.013.9 14.9
15.0- 16.015.9 16.9
17.0- 18.017.9 18.9
19.019.9
Hemoglobin concentration (g/dl)
Georgia National Nutrition Survey 2009
81
Table 50. Number (weighted %) with various degrees of anemia*, children 12-59 months of
age, GNNS 2009
Characteristic
Severe
anemia*
Moderate
anemia*
Mild
anemia*
No anemia*
(normal)
TOTAL
13 (0.6)
232 (9.4)
287(12.8)
1690 (77.2)
Sex
Male
Female
8(0.8)
5(0.4)
138(10.3)
94(8.4)
139(11.5)
148(14.3)
911(77.4)
779(76.9)
Age
<12 months
12-23 months
24-35 months
36-47 months
48-59 months
NA*
6(1.0)
3(0.5)
0
4(0.7)
NA
95(13.6)
48(9.4)
34(6.7)
54(7.6)
NA
117(21.3)
63(11.1)
50(8.7)
57(9.6)
NA
358(64.1)
403(79.0)
386(84.7)
542(82.2)
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
2(0.9)
0
0
0
5(0.9)
4(1.7)
1(0.3)
1(0.5)
22(9.6)
13(5.8)
5(2.9)
16(7.0)
88(16.2)
34(14.7)
33(8.5)
21(10.3)
40(17.5)
29(12.9)
11(6.3)
29(12.8)
89(16.4)
22(9.5)
44(11.3)
23(11.3)
165(72.1)
183(81.3)
158(90.8)
182(80.2)
362(66.5)
171(74.0)
310(79.9)
159(77.9)
Rural/Urban
Rural
Urban
10 (0.7)
3(0.5)
164(11.2)
68(7.4)
158(11.4)
129(14.3)
1049 (76.7)
641(77.8)
Ethnic group
Georgian
Armenian
Azerbaijani
Other
7(0.5)
1(0.2)
5(1.6)
0
142 (8.4)
31(9.8)
56(17.8)
3(12.8)
186(12.0)
46(16.7)
51(16.2)
4(18.4)
1247 (79.0)
219(73.3)
196(64.4)
26(68.8)
Severe = Altitude-adjusted hemoglobin < 7.0 g/dl; Moderate = altitude-adjusted hemoglobin 7.0 – 9.99 g/dl;
Mild = altitude-adjusted hemoglobin 10.0 – 10.99; No anemia = altitude-adjusted hemoglobin > 11.0 g/dl
NA = Not applicable; subgroup not measured
*
82
Georgia National Nutrition Survey 2009
Table 51. Number (weighted %) with any anemia*, children 12-59 months of age, GNNS 2009
Characteristic
No. (weighted %)
with anemia*
95% CI
TOTAL
532(22.8)
19.5, 26.1
Sex
Male
Female
285(22.6)
247(23.1)
19.1, 26.0
18.6, 27.5
Age
<12 months
12-23 months
24-35 months
36-47 months
48-59 months
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
64(27.9)
42(18.7)
16(9.2)
45(19.8)
182(33.5)
60(26.0)
78(20.1)
45(22.1)
18.6, 37.3
11.1, 26.2
4.4,14.0
12.0, 27.6
26.6, 40.3
14.2, 37.7
12.9, 27.3
14.2, 29.9
Rural/Urban
Rural
Urban
332(23.3)
200(22.2)
19.4, 27.3
16.8, 27.6
Ethnic group
Georgian
Armenian
Azerbaijani
Other
335(21.0)
78(26.7)
112(35.6)
7(31.2)
17.6, 24.4
18.1, 35.3
26.4, 44.8
7.3,55.1
Not available
218(35.9)
114(21.0)
84(15.3)
115(17.8)
Not available
30.5, 41.2
15.9, 26.2
11.5, 19.1
13.7, 22.0
Anemia = Altitude-adjusted hemoglobin concentration < 11.0 g/dl
*
Georgia National Nutrition Survey 2009
83
Iron deficiency
Overall, 496 (24.7%) of the 2144 children less than 5 years of age in whom CRP was measured
had an elevated CRP indicating the presence of acute inflammation. After exclusion of these
children, very few children had iron deficiency, as seen in Table 52 below.
Table 52. Number (weighted %) and 95% confidence intervals (CI) with iron deficiency*,
children less than 5 years of age, GNNS 2009
No. (weighted %) with
Characteristic
95% CI
iron deficiency*
TOTAL
3(0.1)
0, 0.3
Sex
Male
Female
1(0.1)
2(0.2)
0, 0.2
0, 0.5
Age (months)
<12 months
12-23 months
24-35 months
36-47 months
48-59 months
Not available
2(0.3)
0
1(0.3)
0
Not available
0,0.7
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
0
0
0
0
2(0.5)
0
0
1(0.7)
Rural/Urban
Rural
Urban
3(0.3)
0
0,0.6
Ethnic group
Georgian
Armenian
Azerbaijani
Other
1(0.1)
1(0.5)
1(0.4)
0
0,0.2
0,1.6
0,1.3
Degree of anemia
Severe (Hb < 7.0 g/dl)
Moderate (Hb 7.0-10.9 g/dl)
None
(Hb > 11.0 g/dl)
0
1(0.3)
2(0.1)
0,1.0
0,1.2
0,2.0
0,0.9
0,0.2
Iron deficient = Serum ferritin < 12.0 µg/l and CRP < 5.0 mg/l. Children with CRP > 5.0 mg/l excluded from analysis.
*
84
Georgia National Nutrition Survey 2009
Non-pregnant women – Description of sample
Table 53 shows demographic characteristics of the 1,846 non-pregnant women 15-49 years of
age recruited from households in the GNNS 2009 survey sample. This table also compares them
to Georgian census data. The weighted age distribution of survey sample non-pregnant women
roughly matches the age distribution of the population of all Georgian women 15-49 years of age.
Similarly the weighted regional and rural/urban distribution of the survey sample of non-pregnant
women matches that of the general population of Georgia quite well. The proportions of survey
sample non-pregnant women who are Georgian ethnicity and who are married are somewhat
greater than the corresponding proportions in the population of Georgian women 15-49 years of
age. Survey sample non-pregnant women were quite well educated, with more than one-half
having some university or vocational school education.
Table 54 shows the reproductive and breastfeeding history of non-pregnant women in the GNNS
2009 sample. Slightly more than one-quarter had never been pregnant, and almost one-third
had been pregnant five or more times. Few women had had four or more live births in the past.
Fewer than one in 10 non-pregnant women in the survey sample were breastfeeding at the time
of data collection.
Table 55 shows the distribution of selected behavioral variables. Only a small minority of women
smoked cigarettes. About one-half added salt to their food; however, a smaller proportion added
salt to their food before testing it.
Table 53. Description of demographic variables, non-pregnant women 15-49 years of age,
GNNS 2009
Characteristic
Survey sample
Actual number
Weighted %
of women
of women
Census*
% population
TOTAL
1846
100.0
100.0
Age
15-19
20-24
25-29
30-34
35-39
40-44
45-49
203
318
289
266
246
225
299
10.9
16.3
14.9
14.8
13.9
12.6
16.5
15.3
14.2
13.7
13.4
14.8
15.3
13.2
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
207
222
171
179
360
207
285
215
23.5
13.4
17.2
7.5
10.9
11.2
4.9
11.4
25.9
11.9
16.9
9.2
11.2
10.7
4.7
9.5
Rural/Urban
Rural
1125
49.0
47.3
Georgia National Nutrition Survey 2009
85
Urban
Survey sample
Actual number
Weighted %
of women
of women
721
51.0
Ethnic group
Georgian
Armenian
Azerbaijani
Other
1479
168
168
31
88.6
4.0
5.4
2.0
Religion
Orthodox
Muslim
Armenian Gregorian
Roman Catholic
None
Other
1407
254
139
27
3
13
86.0
9.3
3.1
0.5
0.2
0.9
Marital status
Married
Widowed
Divorced
Separated
Never married
1355
40
36
14
397
71.2
2.0
2.3
0.9
23.6
258
11.6
682
33.6
394
22.2
512
32.6
Characteristic
Years of formal education
4-9 (Some or completed secondary school)
10-11
(Some or completed high school)
12-14
(Some university or vocational school)
15+
(Completed university or more)
Census*
% population
52.7
84.1
5.7
6.5
3.6
60.8
3.8
4.4
31.1
Data from National Statistics Office of Georgia
For regional and urban/rural distribution: 2009 estimates of general population (http://www.geostat.ge/index.php?action=page&p_id=473&lang=eng, accessed 12 March 2010)
For distribution of age, ethnic group, and marital status: 2002 census data for women 15-49 years of age
(http://www.geostat.ge/, accessed 24 March 2010)
*
86
Georgia National Nutrition Survey 2009
Table 54. Description of reproductive and breastfeeding variables, non-pregnant women 15-49
years of age, GNNS 2009
Characteristic
Actual number
of women
Weighted %
of women
Number of prior pregnancies
0
1
2
3
4
5+
471
200
248
182
167
578
27.5
10.6
12.7
9.6
8.9
30.6
Number of prior live births
0
1
2
3
4
5+
483
326
710
246
58
23
28.3
18.4
36.6
12.5
2.9
1.4
Breastfeeding now (among women with prior live
birth)
Yes
No
120
1248
8.4
91.6
Table 55. Description of behavioral variables, non-pregnant women 15-49 years of age, GNNS
2009
Characteristic
Actual number
of women
Weighted %
of women
Number of cigarettes smoked per day
0 (Does not smoke)
1-9
10-19
20-39
40+
1779
20
25
19
1
94.0
2.1
2.2
1.6
0.1
Usually add salt to food before eating
Yes
No
1011
826
54.6
45.4
Usually add salt to food before tasting
Yes
No
699
1137
38.6
61.4
Georgia National Nutrition Survey 2009
87
Non-pregnant women – Protein-energy nutritional status
The distribution of BMI values for non-pregnant women 15-49 years of age, shown in Figure 11
below, demonstrates that few women have low BMI, but many woman have high BMI. Table 56
shows the overall and group-specific prevalence rates for the various degrees of malnutrition as
measured by BMI. Severe and moderate energy deficiency are quite rare, and only a few percent
of women fall into the category “at risk of energy deficiency.” On the other hand, overweight and
obesity are much more common. As shown in Table 57, the prevalence of overweight or obesity
increases markedly with age. The prevalence also varies by regional stratum, with the lowest
stratum-specific prevalence being 30.2% in Tbilisi and the highest being 53.3% in Imereti and
Racha-Leckhumi. The prevalence is also statistically significantly higher in women living in rural
households; however, the prevalence does not differ substantially among ethnic groups.
Figure 11. Distribution of BMI values for non-pregnant women 15-49 years of age, GNNS 2009
10
Weighted % of women
9
8
7
6
5
4
3
2
1
0
Normal
Overweight
Obese
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50+
BMI
88
Georgia National Nutrition Survey 2009
Table 56. Number (weighted %) with various levels of malnutrition (defined by BMI*), nonpregnant women 15-49 years of age, GNNS 2009
Severe
Moderate
At risk of
Characteristic
energy
energy
energy
Normal*
Overweight*
Obese*
*
*
*
deficiency
deficiency deficiency
TOTAL
3(0.3)
13(1.1)
71
(3.9)
959 (52.7) 468(24.1)
314 (18.0)
Age (years)
15-24
25-34
35-44
45-49
2(0.8)
0
1(0.2)
0
9(2.6)
4(1.2)
0
0
38
20
9
4
(8.6)
(3.2)
(1.5)
(1.0)
383 (72.6)
31 (61.5)
3
171 (39.8)
74(25.0)
65(12.2)
126(21.4)
166(32.1)
111(35.5)
16 (3.2)
69(12.8)
121 (26.3)
108 (38.4)
2(1.0)
6(2.9)
11
(5.4)
124 (60.5) 33(16.1)
29(14.1)
0
1(0.5)
9 (4.1)
119 (53.6) 60(27.0)
33(14.9)
0
1(0.6)
2 (1.2)
74(44.8) 43(26.1)
45(27.3)
0
0
0
1(0.6)
2(0.6)
1(0.5)
12 (6.7)
18 (5.0)
4 (2.0)
100 (55.9) 41(22.9)
83 (50.8) 99(27.5)
1
98(47.8) 54(26.3)
25(14.0)
58(16.1)
48(23.4)
0
0
7 (2.5)
156 (54.7) 81(28.4)
41(14.4)
1(0.5)
1(0.5)
8 (3.9)
105 (50.7) 57(27.5)
35(16.9)
Rural/Urban
Rural
Urban
1(0.1)
2(0.4)
6(0.6)
7(1.5)
41
30
68 (50.3) 302(26.7)
5
391 (55.0) 166(21.6)
91 (18.9)
1
123 (17.2)
Ethnic group
Georgian
Armenian
Azerbaijani
Other
3(0.3)
0
0
0
12(1.2)
0
1(0.6)
0
56 (3.6)
3 (2.2)
10 (5.6)
2(11.1)
759 (52.5)
92(53.7)
88(52.8)
20(59.1)
268 (18.4)
19(16.5)
23(14.5)
4(15.1)
Region
Tbilisi
Achara and
Guria
Imereti
and RachaLeckhumi
Kakheti
Kvemo Kartli
Samegrelo
SamtckheJavakheti
Shida
Kartli and
MtckhetaMtianeti
(3.4)
(4.3)
364(24.0)
53(27.6)
46(26.5)
5(14.7)
Severe = BMI<16.0; Moderate = BMI 16.0-16.9; At risk = BMI 17.0-18.4; Normal = BMI 18.5-24.9; Overweight = BMI 25.0-29.9; Obese = BMI>30.0
*
Georgia National Nutrition Survey 2009
89
Table 57. Number (weighted %) with overweight or obesity* (defined by BMI), non-pregnant
women 15-49 years of age, GNNS 2009
Characteristic
No. (weighted %)
with overweight or
obesity*
TOTAL
782(42.1)
39.2, 45.0
Age (years)
15-24
25-34
35-44
45-49
81(15.4)
195(34.2)
287(58.4)
219(73.9)
11.7, 19.0
29.7, 38.6
52.7, 64.2
67.7, 80.2
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
62(30.2)
93(41.9)
88(53.3)
66(36.9)
157(43.6)
102(49.8)
122(42.8)
92(44.4)
22.6, 37.8
34.5, 49.3
45.6, 61.1
28.6, 45.2
38.0, 49.2
41.6, 58.0
36.6, 49.0
37.6, 51.3
Rural/Urban
Rural
Urban
493(45.5)
289(38.8)
42.1, 49.0
34.1, 43.6
Ethnic group
Georgian
Armenian
Azerbaijani
Other
632(42.4)
72(44.0)
69(41.0)
9(29.8)
39.2, 45.5
34.1, 54.0
33.0, 49.1
13.0, 46.6
95% CI
Overweight = BMI > 25.0
*
Non-pregnant women – Micronutrient status
Anemia
The weighted distribution of hemoglobin concentrations in non-pregnant women 15-49 years of
age is shown in Figure 12. The pink bars in this figure show anemic women and demonstrate that
anemia is quite common in non-pregnant women in Georgia. In addition, the brown bars show
women with excessive hemoglobin concentrations. Although not as common as anemia, excessive hemoglobin may also be a problem in Georgian women.
Although 24.1% of non-pregnant women had any level of anemia, severe anemia is relatively
rare, as shown in Table 58. Table 59 shows that anemia is not strongly related to age. However, the prevalence of anemia in non-pregnant women differs substantially by regional stratum
ranging from 14.5% in Imereti and Racha-Leckhumi to 32.4% in Kakheti. As seen in Table 51
and Table 59, with the exception of Kakheti, those regional strata with higher prevalence rates of
90
Georgia National Nutrition Survey 2009
anemia in children less than 5 years of age are the same as those with higher prevalence rates of
anemia in non-pregnant women 15-49 years of age. Anemia prevalence did not differ substantially between women living in rural households and those living in urban households. Although
Georgian women apparently have a lower prevalence than Armenian or Azerbaijani women, these
differences may not be statistically significant.
Figure 12. Weighted distribution of hemoglobin concentrations in non-pregnant women 15-49
years of age, GNNS 2009
Weighted % of women
25
20
15
10
5
0
6.06.9
7.07.9
8.08.9
9.09.9
10.010.9
11.011.9
12.012.9
13.013.9
14.014.9
15.015.9
16.016.9
17.017.9
18.018.9
19.019.9
Hemoglobin concentration (g/dl)
Table 58. Distribution of levels of adjusted* hemoglobin concentrations, non-pregnant women
15-49 years of age, GNNS 2009
No. (weighted
%) with adjusted
hemoglobin
concentration
Category of adjusted hemoglobin
concentration
95% CI
Severe anemia (Hb < 7.0 g/dl)
7(0.4)
0.1,0.7
Moderate anemia (Hb 7.0-10.9 g/dl)
164(9.1)
7.3,11.0
Mild anemia (Hb 11.0-11.9 g/dl)
251(14.6)
12.3,16.9
Normal (Hb 12.0-15.9 g/dl)
1227(71.0)
67.9,74.0
Mild elevation (Hb 16.0-16.9 g/dl)
42(2.5)
1.4,3.6
Moderate elevation (Hb 17.0+ g/dl)
30(2.4)
0.9,3.9
Adjusted for number of cigarettes smoked per day and altitude of residence
*
Georgia National Nutrition Survey 2009
91
Table 59. Number (weighted %) and 95% confidence intervals (CI) with any anemia* (after adjustment of hemoglobin concentration for smoking status and altitude of residence),
non-pregnant women 15-49 years of age, GNNS 2009
No. (weighted %)
Characteristic
95% CI
with anemia*
TOTAL
422 (24.1)
21.0, 27.2
Age (years)
15-24
25-34
35-44
45-49
108 (22.8)
133 (26.0)
110 (24.6)
71(22.0)
18.1, 27.5
21.1, 31.0
20.0, 29.3
15.3, 28.7
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
49(29.9)
41(19.3)
24(14.5)
56(32.4)
103 (29.6)
52(25.9)
50(18.9)
47(24.4)
21.8, 38.0
11.9, 26.8
6.5,22.4
20.7, 44.1
23.5, 35.7
17.8, 33.9
11.9, 26.0
16.3, 32.4
Rural/Urban
Rural
Urban
252 (23.2)
170 (25.1)
19.2, 27.1
20.3, 29.9
Ethnic group
Georgian
Armenian
Azerbaijani
Other
329 (23.4)
35(27.1)
50(30.9)
8(30.3)
20.1, 26.7
12.9, 41.4
22.5, 39.3
13.3, 47.40
Anemia = Adjusted hemoglobin concentration < 12.0 g/dl; Not anemic = adjusted
hemoglobin concentration 12.0+ g/ dl
*
Iron deficiency
Overall, 472 (29.5%) of the 1,688 non-pregnant women 15-49 years of age in whom CRP was
measured had an elevated CRP indicating the presence of acute inflammation. After exclusion of
these 472 women, very few women had iron deficiency, as seen in Table 60 below. Nonetheless,
iron deficient non-pregnant women were more than twice as likely to be anemic as non-pregnant
women who were not iron deficient (adjusted RR = 2.5, 95% CI: 1.6, 3.9). (Table 61) On the
other hand, because it is so rare, iron deficiency contributes to very little to anemia in Georgia.
Only 9 (weighted % = 3.8%) of the 281 anemic non-pregnant women in whom iron deficiency
was assessed had iron deficiency.
92
Georgia National Nutrition Survey 2009
Table 60. Number (weighted %) and 95% confidence intervals (CI) with iron deficiency,* nonpregnant women 15-49 years of age, GNNS 2009
No. (weighted
Characteristic
%) with iron
95% CI
deficiency*
TOTAL
Age (years)
15-24
25-34
35-44
45-49
19 (1.6)
0.8,2.4
4(1.0)
5(1.7)
8(1.9)
2(2.0)
0,2.1
0.1,3.3
0.5,3.4
0,4.8
Region
Tbilisi
Achara and Guria
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
1(0.9)
3(2.1)
2(1.8)
1(0.8)
4(1.6)
1(0.7)
2(1.1)
5(3.5)
0,2.8
0,4.2
0,4.3
0,2.4
0.1,3.1
0,2.0
0,2.6
0,7.0
Rural/Urban
Rural
Urban
12 (2.1)
7(1.1)
0.7,3.4
0.2,2.1
Ethnic group
Georgian
Armenian
Azerbaijani
Other
15 (1.6)
2(1.2)
2(1.7)
0
0.7,2.6
0,3.0
0,4.0
Iron deficiency = Serum ferritin concentration < 15 µg/l and CRP < 5.0 mg/l. Women
with CRP > 5.0 mg/l excluded from analysis.
*
Table 61. Number (weighted %) with anemia,* by iron deficiency status*, non-pregnant women
15-49 years of age, GNNS 2009
No. (weighted %)
No. (weighted %)
Characteristic
with anemia*
without anemia*
Iron deficient
Not iron deficient
9 (54.1)
10 (45.9)
242 (20.8)
910 (79.2)
*
Anemia = Adjusted hemoglobin concentration < 12.0 g/dl;
Iron deficiency = Serum ferritin concentration < 15 µg/l AND CRP < 5.0 mg/l. Women with CRP > 5.0 mg/l excluded from analysis.
Georgia National Nutrition Survey 2009
93
Folate
More than one-third of the 407 non-pregnant women 15-49 years of age who were tested had
folate deficiency (weighted % = 36.6%; 95% CI: 29.8, 43.3). The mean serum folate level was
7.2 ng/mL (95% confidence intervals: 6.3, 8.2).
Pregnant women – Description of sample
Table 62 shows the demographic characteristics of the 613 pregnant women recruited from antenatal facilities in Georgia for the GNNS 2009. Because women frequently seek ante-natal care in
facilities outside their province of residence, the distribution of sample pregnant women cannot
be compared to the general population of Georgia. It is instead compared to the number of routine
ante-care visits expected to occur in all facilities in each regional stratum during the time of the
survey teams’ data collection in that province. As expected, most pregnant women in the sample
were of Georgian ethnicity and were of Orthodox religion. Almost all the women reported being
married. As with non-pregnant women, pregnant women were quite well educated with almost
one-half having some university or vocational school education.
Table 63 shows the reproductive history of pregnant women. For less than one-half, the current pregnancy is the first. As with non-pregnant women in the household sample, few pregnant
women had had four or more live births in the past. Pregnant women in the survey sample included women in all three trimesters of pregnancy. As expected, a larger proportion of women
were in the second and third trimesters when women are more likely to seek ante-natal care.
Table 64 shows the distribution of selected behavioral variables. Fewer than one-half of pregnant
women had taken vitamins or other nutritional supplements during the current pregnancy. Of
those who did, slightly more than one-third had taken iron supplements. As with non-pregnant
women, about one-half of pregnant women usually add salt to their food before eating, but a
smaller proportion add salt before tasting the food. Smoking is quite rare among pregnant women
in Georgia.
Table 62. Description of demographic variables, pregnant women, GNNS 2009
Characteristic
Survey sample
Actual number
Weighted %
of women
of women
100
TOTAL
613
Age
15-19
20-24
25-29
30-34
35-39
40-44
45-49
105
257
149
67
21
11
3
10.7
39.7
25.7
15.2
4.4
3.0
1.1
Region
Tbilisi
Achara and Guria
115
13
32.4
4.8
94
Georgia National Nutrition Survey 2009
Program data
% routine ANC
visits
10.9
1.7
Imereti and Racha-Leckhumi
Kakheti
Kvemo Kartli
Samegrelo
Samtckhe-Javakheti
Shida Kartli and Mtckheta-Mtianeti
Survey sample
Actual number
Weighted %
of women
of women
10
3.7
2
0.7
241
23.3
15
5.6
215
28.7
2
0.7
Ethnic group
Georgian
Armenian
Azerbaijani
Other
241
184
183
5
89.4
3.5
6.4
0.7
242
201
156
11
3
81.9
14.0
3.3
0.2
0.5
610
1
0
1
0
99.6
0.4
155
12.9
197
19.7
92
21.9
169
45.5
Characteristic
Religion
Orthodox
Muslim
Armenian Gregorian
Roman Catholic
None
Other
Marital status
Married
Widowed
Divorced
Separated
Never married
Years of formal education
4-9 (Some or completed secondary school)
10-11
(Some or completed high school)
12-14
(Some university or vocational school)
15+
(Completed university or more)
Program data
% routine ANC
visits
1.1
0.1
48.7
2.4
34.6
0.5
0.0
Georgia National Nutrition Survey 2009
95
Table 63. Description of reproductive history, pregnant women, GNNS 2009
Characteristic
Actual number
of women
Weighted %
of women
Number of prior pregnancies
0
1
2
3
4
5+
265
160
89
39
27
33
42.3
24.0
14.4
6.3
5.3
7.8
Number of prior live births
0
1
2
3
4
5+
295
212
90
12
1
2
46.9
33.8
16.0
2.4
0.0
0.7
Current pregnancy trimester
1
2
3
99
285
229
20.1
44.2
35.6
Table 64. Description of behavioral variables, pregnant women, GNNS 2009
Characteristic
Actual number
of pregnant
women
Weighted %
of pregnant
women
Taken vitamins or supplements during this pregnancy
Yes
No
253
360
44.2
55.8
Type of vitamin or supplement taken
Iron
Vitamin C
Other
Unknown
44
22
83
17
35.2
10.5
50.4
3.9
Usually add salt to food before eating
Yes
No
345
251
50.0
50.0
Usually add salt to food before tasting
Yes
No
169
441
20.5
79.5
Number of cigarettes smoked per day
Does not smoke
1-9
10-19
20-39
40+
605
6
0
0
0
98.8
1.2
96
Georgia National Nutrition Survey 2009
Pregnant women – Protein-energy nutritional status
Overall, as shown in Figure 13, protein-energy malnutrition is not a common or severe problem in
pregnant women in Georgia. As seen in Table 65, the prevalence of low MUAC was low and did
not differ substantially between subgroups.
Figure 13. Weighted distribution of MUAC measurements, pregnant women, GNNS 2009
Weighted % of pregnant women
18
16
14
12
10
8
6
4
2
0
18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41
MUAC (cm)
Table 65. Number (weighted %) and 95% confidence intervals (CI) with low MUAC* , pregnant
women, GNNS 2009
No. (weighted %)
Characteristic
95% CI
with low MUAC*
TOTAL
24 (4.8)
1.8,7.9
Age in years
15-24
25-34
35-44
45-49
14 (5.5)
9(4.8)
1(0.5)
0
1.3,9.8
0.9,8.8
0,1.4
Ethnic group
Georgian
Armenian
Azerbaijani
Other
12 (5.0)
4(2.2)
8(4.4)
0
1.6,8.4
0,5.4
0.9,7.9
Current pregnancy trimester
1
2
3
3(3.9)
14 (7.1)
7(2.5)
0,9.4
0.7,13.4
0,5.6
Low MUAC = MUAC < 22.0 cm
*
Georgia National Nutrition Survey 2009
97
Pregnant women – Micronutrient status
Anemia
As shown in Figure 14 and Table 66, anemia is common in pregnant women in Georgia; however,
as with non-pregnant women, only a small proportion of the anemia in this group is severe. The
prevalence of anemia in pregnant women does not differ substantially by age of the woman,
as seen in Table 67. There is, however, a higher prevalence of anemia in pregnant Azerbaijani
women than in Georgian or Armenian women, and these differences are statistically significant.
Anemia also becomes more common with pregnancy stage; by the third trimester, almost onethird of pregnant women in Georgia are anemic.
Figure 14. Weighted distribution of hemoglobin concentrations in pregnant women, GNNS 2009
Weighted % of women
25
20
15
10
5
0
5.05.9
6.06.9
7.07.9
8.08.9
9.09.9
10.0- 11.010.9 11.9
12.012.9
13.0- 14.013.9 14.9
15.0- 16.015.9 16.9
17.0- 18.017.9 18.9
19.019.9
Hemoglobin concentration (g/dl)
Table 66. Distribution of levels of hemoglobin concentrations, pregnant women, GNNS 2009
No. (weighted %)
with hemoglobin
concentration
Category of hemoglobin concentration
98
95% CI
Severe anemia (Hb < 7.0 g/dl)
2(0.7)
Moderate anemia (Hb 7.0-10.9 g/dl)
50(7.7)
2.6,12.9
Mild anemia (Hb 11.0-11.9 g/dl)
112(17.1)
10.8,23.6
Normal (Hb 12.0-15.9 g/dl)
448(74.4)
66.0,82.8
Georgia National Nutrition Survey 2009
0,2.1
Table 67. Number (weighted %) and 95% confidence intervals (CI) with any anemia*, pregnant
women, GNNS 2009
No. (weighted %)
Characteristic
95% CI
with anemia*
TOTAL
164 (25.6)
17.2,34.0
Age (years)
15-24
25-34
35-44
45-49
98(26.3)
57(24.4)
9(31.2)
0
18.2,34.5
11.0,37.7
4.8,57.6
Ethnic group
Georgian
Armenian
Azerbaijani
Other
60(24.9)
32(17.4)
70(38.5)
2(40.0)
15.5,34.3
7.6,27.1
28.9,48.0
0,85.2
Current pregnancy trimester
1
2
3
21(15.8)
71(24.7)
72(32.3)
1.3,30.2
16.1,33.3
18.8,45.8
Anemia = Hemoglobin < 11.0 g/dl. No survey subjects required adjustment for smoking status, and altitude adjustment could not be done due to lack of data on altitude of
residence.
*
Georgia National Nutrition Survey 2009
99
ANNEX 1 – Sampling methodology
First stage sampling
Households, children, and non-pregnant women
Cluster sampling of households was done to obtain a random sample of the population of Georgia.
The primary sampling unit was census unit. Census units were selected using equal probability
from a list of 606 census units already selected probability proportional to size from all census
units in Georgia. The State Department of Statistics periodically updates the household lists in
these 606 clusters.
In each of the eight regional strata in the GNNS 2009 sample (see description of stratification
in section “Details of regional stratification” below) 25 primary sampling units were selected;
these 200 clusters were used to achieve independent estimates for each of the eight regional
strata. However, to be able to derive independent estimates for the two minority communities
of Azerbaijanis and Armenians separate from ethnic Georgians, these minorities had to be oversampled. To this end, additional clusters were added in the two regional strata which contain large
proportions of these minorities (see section “Supplemental sample size (for ethnic stratification)”
below). As a result, the total sample of households were distributed in 236 clusters (see section
“Supplemental sample size (for ethnic stratification)” below for explanation of why the number of
clusters added to the sample is 36).
The total number of clusters in each regional stratum were distributed into the districts (or rayons)
in each regional stratum proportional to the population of each district in that regional stratum.
For example, if a district in a given regional stratum has one-fifth of that regional stratum’s population, five of that regional stratum’s 25 census units will be selected from that district. However,
because dividing a regional stratum’s population by a district’s population rarely results in a whole
number, and a census unit cannot be divided into fractions, such assignment will not precisely
result in a self-weighting sample within a given regional stratum. Therefore, the actual number
of households to be selected in a given district will be determined by multiplying the total sample
size for that regional stratum by the fraction of that regional stratum’s population which is located
in the given district. This number of households will then be apportioned to the number of census
units selected in the given district, as described above. As a result, cluster sizes within a regional
stratum will be slightly different. For example, let us say that a given regional stratum with 25
clusters should have a total sample size of 2,277 households. One of the four districts in that
regional stratum has one-third of the total population of the regional stratum. As a result, the
survey sample in that district should have 759 households (1/3 x 2,277 households) distributed
in 8 clusters (1/3 x 25 = 8.33 or 8 clusters). The resulting cluster size in that district will be
95 households (759 households / 8 clusters = 94.875 or 95 households). In another district
which has one-half of that regional stratum’s population, there will be 13 clusters, each with 88
households (½ x 2,277 households = 1138.5 or 1139 households; ½ x 25 clusters = 12.5 or
13 clusters; 1139 households / 13 clusters = 87.6 or 88 households).
Pregnant women
Selection of pregnant women began with a random selection of 25 facilities providing ante-natal
care in Georgia; therefore, the primary sampling unit is ante-natal care facility. Ante-natal care
facilities were selected with equal probability, not probability proportional to size. Because in
each selected facility women will be recruited for the same number of days, and the number of
100
Georgia National Nutrition Survey 2009
visits per day varies greatly among facilities, the number of women recruited from each facility
(and therefore the number of women in each cluster) will be quite different. However, because
the facilities were selected with equal probability, the resulting sample of pregnant women will
be equally weighted.
Second stage sampling
Households, children and non-pregnant women
The second stage of sampling selected the required number of households from the household
list in each selected census unit. Systematic random sampling was used, starting at a randomly
selected starting point. Once households were selected, sampling was complete for children;
all eligible children less than 5 years of age who live in selected households were recruited for
the survey sample. All eligible non-pregnant women 15-49 years of age who lived in a randomly
selected subsample of selected households were also eligible for inclusion in the survey sample.
Pregnant women found in selected households were not included in the survey nor were any data
collected from them.
Some selected census units did not have a sufficient number of households to select the required
number of households for that cluster. In these census units, all households were eligible for
child recruitment, and the number of households needed to recruit non-pregnant women and
obtain bread and salt specimens were selected from this original census unit. Then an adjacent
census unit, not necessarily from the 606 pre-selected census units, was selected. The number
of households required to complete the cluster were randomly selected from this adjacent census
unit in order to recruit a sufficient number of children into the survey sample. No non-pregnant
women were recruited nor any bread or salt specimens obtained from this adjacent census unit.
Pregnant women
In each selected ante-natal care facility, consecutive women coming to selected facilities for routine ante-natal care visits were recruited for the GNNS 2009 for a specified number of days. In
order to determine how many days such recruitment should occur, the estimated total number
of routine ante-natal visits per day in all selected facilities together was determined or calculated
from routine service data. The total sample size of pregnant women needed was divided by this
total number of visits per day to determine the number of days data must be collected in each
facility.
Stratified sampling
Children and non-pregnant women
Because local and national government authorities and other organizations wish to have regionspecific estimates for many of the outcomes measured by the GNNS 2009 in children and nonpregnant women, stratified sampling of households was carried out by region. Regions with very
small populations were combined to make up a stratum. Strata have quite different populations
but similar samples sizes; therefore, because the sampling fraction differs by stratum, a weighted
data analysis is required when calculating nationwide estimates for nutritional outcomes. Table
A1.1. below shows some basic information on the Georgian population and the 606 pre-selected
census units in each stratum.
Georgia National Nutrition Survey 2009
101
Table A1.1. List of sampling strata and regions contained in each, GNNS 2009
% of total population
Region(s) in stratum
Number of
pre-selected
census units
Total
population
Number of
households
in smallest
census unit
Armenian
Azerbaijani
Tbilisi
1,106,700
150
46
-
-
Achara and
Guria
519,000
78
58
-
-
Imereti and
Racha-Leckhumi
742,400
102
42
-
-
Kakheti
401,900
54
85
-
Kvemo Kartli
503,900
66
47
Samegrelo
469,600
48
40
-
-
Samtckhe-Javakheti
207,700
36
46
62.3%
-
Shida Qartli and
Mtckheta-Mtianeti
430,900
72
74
-
-
Total
4,382,100
606
5.1%
9.8%
48.0%
Pregnant women
For pregnant women, only ethnicity-specific estimates, not region-specific estimates, were desired. As a result, sampling of pregnant women was stratified only by ethnicity. Pregnant
women were selected in three strata based on ethnicity: Georgian, Azerbaijani, and Armenian.
“Georgian” ethnicity included other smaller minorities, such as Russians, Ukrainians, Greeks, etc.
who reside in Georgia. The procedure used to ensure sufficient sample sizes of Azerbaijani and
Armenian women is described below in the section “Supplemental sample size (for ethnic stratification).”
Basic sample size (for regional stratification)
The required minimum sample size for the basic GNNS 2009 sample was calculated separately
for each outcome and target group. All sample size calculations used the following assumptions:
1) The limit of statistical significance (alpha) = 0.05
2) The power (beta) = 0.8
3) The population size from which the sample was selected was assumed to be greater than
10,000; hence, the finite population correction factor was not used
102
Georgia National Nutrition Survey 2009
Table A1. 2 below shows the calculated total minimum number of households and individuals
from whom data must be collected to achieve the desired precision around the estimate of prevalence for each target group and for each survey outcome for each regional stratum. Wherever
possible, the assumptions used to calculate desired sample size were based on the results of previous surveys. For example, the MICS 2005 survey demonstrated that the prevalence of anemia
was 27.7% in non-pregnant women 15-49 years of age.21 In this MICS survey, the design effect
for the weighted, nationwide prevalence of underweight in children under 5 years of age was
1.339. Given the average cluster size of 4.3 children in the MICS survey, the intracluster correlation co-efficient (ICC or roh) for this variable was 0.103. Because the GNNS 2009 will have a
larger overall sample size of young children and women divided into fewer clusters, the average
cluster size is larger, thus increasing the design effect somewhat. Given these assumptions, we
assumed a design effect of 2.0 for all anthropometric indices in young children.
However, for most variables there are no data available to assist in formulating the assumptions
necessary to calculate sample size. For these variables, because of the wide variation in climate,
altitude, diet, and culture in Georgia, we have estimated design effects somewhat larger than
those seen in other populations. Although stratified sampling tends to decrease design effects,
the extent of any such decrease was entirely unknown when the sample sizes were calculated;
therefore, this effect was not taken into account. However, when calculating precision from the
survey data during data analysis, this stratification benefit was certainly included.
Table A1. 2. Number of units of analysis on whom data are needed, for different target groups
and outcomes, GNNS 2009
Target group and type of
malnutrition
Assumed
current
prevalence
Precision
required
in each
stratum
(percentage
points)
Design
effect
assumed
Number
needed
with
data in
each
stratum
Minimum
total
number
needed with
data
Households
Iodized salt
90 %
±5
1.8
243
1,944
Iron fortified bread
50 %
±10
2.0
193
1,544
Children 0-59 months
Wasting (z-score <-2.0)
3%
±3
2.0
249
1,992
Stunting (z-score <-2.0)
12 %
±5
2.0
325
2,600
Overweight (z-score >-2.0)
15 %
±6
2.0
273
2,184
Anemia (< 11.0 g/dl)
35 %
±9
2.5
270
2,160
Iron deficiency
50 %
±10
2.5
241
1,928
Non-pregnant women
Malnutrition (BMI <17.0)
5%
±5
2.0
146
1,168
Overweight (BMI > 25.0)
50 %
±10
2.0
193
1,544
Anemia
28 %
±8
2.0
243
1,944
Iron deficiency
41 %
±10
2.0
186
1,488
Folate deficiency
50 %
±10
2.0
193
193*
Georgia National Nutrition Survey 2009
103
Pregnant women**
Low MUAC
50 %
±10
2.0
193
579
Anemia
50 %
±10
2.0
193
579
Sample specimens for folate testing were not stratified because only a single nationwide estimate was to
be calculated
**
Sample sizes for pregnant women are much lower because regional stratification was not done, and ethnicity-specific stratified sampling resulted in only three strata.
*
The outcomes shown in italics are those which required the largest number of individuals in that
target group. For households, testing iodized salt requires the largest sample size. For non-pregnant women 15-49 years of age and pregnant women, the outcome anemia required the largest
sample size of individuals. For children less than 5 years of age, anemia did not require the largest number of individuals with data; however, because hemoglobin was to be measured only in
children 12-59 months of age, a larger number of households had to be selected in order to find
the required number of children in this age group. For this reason, anemia was used in the next
step of sample size calculation for all target groups.
Households
The survey needed salt testing results from a total of 1,944 households and bread testing results
from a total of 1,544 households. As described below, the desired sample sizes for non-pregnant
women, salt testing, and bread testing are similar. In order to simplify field procedures, the same
subsample of households was used to recruit non-pregnant women and request salt and bread
specimens.
Children and non-pregnant women
Because the sample tested for folate deficiency was not stratified, it required a much smaller
sample size than other outcomes. To obtain this much smaller sample size, folate testing was
done on only two women in each cluster, resulting in the collection of 472 specimens for testing
(see explanation below for the number of clusters). Because bread specimens were collected in
households in which non-pregnant women were eligible to be enrolled, many women contributing specimens for folate testing will live in households in which bread was collected for testing,
permitting the analysis of the correlation between the household presence of fortified bread and
folate levels in non-pregnant women.
Because children and non-pregnant women were selected from a random sample of households,
the sample size for these target groups had to be adjusted for two additional factors: 1) household non-response, that is, the proportion of selected households which are entirely unavailable
or refuse participation in the survey; and 2) the average number of individuals in each household.
Data from Georgian Welfare Monitoring Survey (GWMS 2009) and Household Integrated Survey
(HIS 2009) were used to estimate household response rates, individual response rates for nonpregnant women, and number of non-pregnant women in each household. These estimates were
made for each stratum separately. These data are given in Table A1.3 and Table A1.4 below.
104
Georgia National Nutrition Survey 2009
Table A1.4. Household non-response and individual non-response for non-pregnant women, by
stratum, Georgian Welfare Monitoring Survey, June 2009
Stratum
No
residential
building at
address
No one
living at
address
Total
HH nonresponse
Respondent
not at home
Respondent
refused to
answer
Total
individual
nonresponse
Total nonresponse*
Kakheti
0.5%
1.9%
2.4%
10.4%
1.0%
11.4%
13.8%
Tbilisi
3.2%
2.5%
5.7%
23.0%
16.9%
39.9%
45.6%
Shida
Kartli and
MtckhetaMtianeti
2.2%
5.0%
7.2%
11.0%
1.8%
12.8%
20.0%
Kvemo Kartli
3.4%
4.6%
8.0%
3.6%
1.3%
4.9%
12.9%
SamtckheJavakheti
3.7%
3.7%
7.4%
5.3%
2.4%
7.7%
15.1%
Achara and
Guria
1.6%
3.2%
4.8%
0.5%
0.3%
0.8%
5.6%
Samegrelo
4.5%
3.5%
8.0%
20.5%
0.8%
21.3%
29.3%
Imereti
and RachaLeckhumi
1.5%
1.3%
2.8%
4.0%
1.1%
5.1%
7.9%
Total
2.5%
3.0%
5.5%
11.2%
4.6%
15.8%
21.3%
Total non-response is total household non-response plus total individual non-response because in the Georgian
Welfare Monitoring Survey, non-response was categorized as one or the other. Thus, the total non-response
is additive.
*
Table A1.4. Average number of women* 15-49 years of age per household, by stratum, Household Integrated Survey 2009
Stratum
Kakheti
Average number of women 15-49 years per HH
0.74
Tbilisi
0.99
Shida Qartli and Mtckheta-Mtianeti
0.77
Kvemo Kartli
0.95
Samtckhe-Javakheti
0.85
Achara and Guria
0.97
Samegrelo
0.81
Imereti and Racha-Leckhumi
0.75
Georgia
0.86
Because fertility is so low in Georgia, the point prevalence of pregnancy is very low. Therefore,
we assume that the average number of all women 15-49 years of age approximates the average
number of non-pregnant women 15-49 years of age
*
Georgia National Nutrition Survey 2009
105
The non-response rate for children and the average number of children per household used in the
adjustment of sample size were derived from the MICS 2005. The MICS found that Georgian
households contained, on average, 0.183 children less than 5 years of age. To calculate the
number of households to select to obtain the minimum number of hemoglobin measurements on
children 12-59 months of age, we assumed that children 12-59 months of age group represented
about 80% of all children less than 5 years of age. As a result, households should contain on
average 0.146 children 12-59 months of age (80% of 0.183). Because consent for children’s
participation usually comes from mothers, the non-response rate for children is often similar to
that of their mothers. However, mothers may be less willing to consent to a fingerstick for their
young children. Also, when collecting blood from a fingerstick, an additional source of nonresponse results from the failure to obtain enough blood for testing. Therefore, the non-response
rate of women was increased by five percentage points to estimate the non-response rate for
young children.
Table A1.5 and Table A1.6 below show the number of households to select per stratum and in the
total GNNS 2009 survey sample to obtain the minimum number for hemoglobin measurements
in non-pregnant women 15-49 years of age and children 12-59 months of age. To calculate
this number of households in each stratum, the required number of hemoglobin measurements
(column 2 in the tables below) was divided by the household response rate plus the individual
response rate (response rate is the complement of the non-response rate, or 100 – (column 3 plus
column 4) in the tables below). This result was then divided by the average number of individuals
per household (column 5 in the tables below) to obtain the number of households which must be
randomly selected.
Table A1.5. Number of households to select to get the minimum number of hemoglobin measurements in children 12-59 months of age, GNNS 2009
1
2
3
4
5
6
Stratum
Minimum
number of
hemoglobin
measurements
in children
Household nonresponse
rate
Individual
nonresponse
rate
Average
number of
children
12-59
months per
household*
Number
households to
select in one
stratum
Kakheti
270
2.4%
16.4%
0.146
2,277
Tbilisi
270
5.7%
44.9%
0.146
3,744
Shida Kartli and
Mtckheta-Mtianeti
270
7.2%
17.8%
0.146
2,466
Kvemo Kartli
270
8.0%
9.9%
0.146
2,253
Samtckhe-Javakheti
270
7.4%
12.7%
0.146
2,315
Achara and Guria
270
4.8%
5.8%
0.146
2,069
Samegrelo
270
8.0%
26.3%
0.146
2,815
Imereti and RachaLeckhumi
270
2.8%
10.1%
0.146
2,123
Total in all strata
2160
Based on the 2005 UNICEF MICS
*
106
Georgia National Nutrition Survey 2009
20062
Table A1.6. Number of households to select to get minimum number of hemoglobin measurements in non-pregnant women, GNNS 2009
1
2
3
4
5
6
Stratum
Minimum
number of
hemoglobin
measurements in
women
Household nonresponse
rate*
Individual
nonresponse
rate*
Average
number of
women 1549 years per
household*
Number
households to
select in one
stratum
Kakheti
243
2.4%
11.4%
0.74
381
Tbilisi
243
5.7%
39.9%
0.99
451
Shida Kartli and
Mtckheta-Mtianeti
243
7.2%
12.8%
0.77
394
Kvemo Kartli
243
8.0%
4.9%
0.95
294
Samtckhe-Javakheti
243
7.4%
7.7%
0.85
337
Achara and Guria
243
4.8%
0.8%
0.97
265
Samegrelo
243
8.0%
21.3%
0.81
424
Imereti and RachaLeckhumi
243
2.8%
5.1%
0.75
352
Total in all strata
1944
2898
Based on the Georgian Welfare Monitoring Survey (GWMS 2009) and Household Integrated Survey (HIS 2009)
*
Therefore, to collect hemoglobin data on 2,160 children 12-59 months of age, survey teams had
to recruit children from 20,060 households for the basic sample. To collect hemoglobin data on
1,944 non-pregnant women, women had to be recruited from 2,899 households for the basic
sample. Therefore, it was necessary to select women from only a subsample of the total sample
of 20,062 households. Because response rates and the average number of women are different
for each stratum, the fraction of households from which to recruit women varied by stratum (see
below).
Supplemental sample size (for ethnic stratification)
In order to obtain estimates for the two ethnic minorities of Azerbaijanis and Armenians, the
number of households in these minorities from whom data are collected must be the same as the
number calculated for each stratum. Therefore, the sample size and sampling scheme must be
further adjusted by selecting a supplemental sample of minority households and pregnant women.
Children and non-pregnant women
An alternative sampling strategy was used in those two regional strata with substantial populations of ethnic minorities, as shown in Table A1.1 above. In order to ensure an adequate sample
size for these two minorities, the total sample sizes in these two strata were increased by selecting a supplemental sample of census units. The population of Kvemo Kartli is approximately
50% Azerbaijani. To be sure that the household sample in Kvemo Kartli contained at least the
Georgia National Nutrition Survey 2009
107
2,253 Azerbaijani households necessary to make independent estimates for Azerbaijani children
and women, the total sample size for this stratum was doubled by selecting 50 clusters in this
stratum. As with the basic sample, 84 households were selected in each of the additional 25
clusters.
The population of Samtchke-Javakheti is 62.3% Armenian. To ensure an adequate sample of
Armenian households, the sample size in Samtckhe-Javakheti was increased by 1401 households
to ensure selection of at least 2,315 Armenian households. However, Samtckhe-Javakheti has
only 36 pre-selected clusters, too few to add 1401 households and maintain the same cluster
size. As a result, all 36 of these clusters were selected during the first stage of sampling, and the
cluster size was increased to ensure the needed sample size. The final household sample sizes
and the proportion of households in which all non-pregnant women 15-49 years of age were to
be recruited is shown in Table A1.7 below.
108
Georgia National Nutrition Survey 2009
Georgia National Nutrition Survey 2009
109
2,315 +1,401
2,069
2,815
2,123
23,716
SamtckheJavakheti
Achara and
Guria
Samegrelo
Imereti and
Racha-Leckhumi
Total
**
2,253 + 2,253
Kvemo Kartli
From Table A1.6 above
From Table A1.5 above
294 + 294
2,466
Shida Kartli
and MtckhetaMtianeti
*
394
3,744
Tbilisi
3,396
352
424
265
337 + 204
451
381
2,277
Kakheti
Number of
households
to select for
women
(Basic** +
supplemental)
Number of
households to
select for children
(Basic* +
supplemental)
Stratum
236
25
25
1/6
1/7
1/8
1/7
25 + 11 = 36
25
1/8
1/6
1/8
1/6
Fraction of
households
from which to
recruit women
25 + 25 = 50
25
25
25
Number of
clusters
(Basic +
supplemental)
85
113
83
103
90
99
75
91
Number of
households to
select for each
cluster
2334
243
243
243
390
486
243
243
243
Number of
children with
fingerstick
2593
270
270
270
433
540
270
270
270
Number of
women with
fingerstick or
venipuncture
Table A1.7. Final sample size (including basic sample plus supplemental sample) for children and non-pregnant women and distribution of
clusters, GNNS 2009.
Pregnant women
The sample size for pregnant women, as shown in Table 13 above, is 193 for each of the three
ethnic strata. Each of these women underwent anthropometric measurements, a fingerstick
blood specimen for hemoglobin measurement, and collection of a urine specimen for iodine testing. Assuming 90% response, the total number of pregnant women to be selected in ante-natal
facilities was at least 215 (193 divided by 0.9) in each ethnic group for a total sample size of 645.
The number of ante-natal visits per day by Georgian pregnant women was calculated by adding
together the number of visits per day for ante-natal care facilities in those regions which do not
have substantial minority populations. Then, for each of the two regional strata which have a
large minority population, the number of visits by Georgian women was calculated by multiplying
the total number of visits in each region by the proportion of the population in that region which
is of Georgian ethnicity. These numbers of daily visits were then added to the total number of
visits in regions which do not have substantial minority populations to derive the total number of
daily visits in all of Georgia by Georgian pregnant women. As a result, it was calculated that to
achieve 193 hemoglobin measurements in pregnant women, Georgian women were recruited for
one day in the sample of 25 ante-natal care facilities.
In addition to these 25 facilities, all remaining facilities in Samtckhe-Javakheti and Kvemo Kartli
were included in the sample. In those facilities not included in the random sample of 25 facilities, Georgian women will not be recruited. The number of days of data collection for Azerbaijani
and Armenian women in the original sample of facilities and in the additional facilities will differ
depending on the location of the facilities. For the minority regions, using the data contained
in Table A1.1, the average number of visits per day for Armenian women was calculated by
multiplying the number of visits per day in Samtckhe-Javakheti by 0.623, the proportion of the
region’s population which is Armenian. The average number of visits per day for Azerbaijani
women was calculated by multiplying the number of visits per day in Kvemo Kartli by 0.48, the
proportion of the population which is Azerbaijani. For simplicity’s sake, the 5.1% of Kvemo Kartli’s population which is Armenian is not included in these calculations. The final number of days
of data collection for each minority ethnicity is shown below in Table A1.8.
Table A1.8. Number of days of data collection in ante-natal clinics, by ethnicity, GNNS 2009.
Average number of
visits per day
Number of pregnant
women needed
Number of days of
data collection
Georgian
610
215
0.35
(round to 1)
Azerbaijani
35.2
215
6
Armenian
20.5
215
11
Ethnicity
Although for Georgian women, data collection need only be done for one-third of a day, it was
difficult for survey teams to determine a standard method of measuring a data collection period of
less than 1 day. As a result, in those facilities in the original sample of 25 facilities which provide
care to more than one ethnicity, Georgian women were recruited for only 1 day, after which they
will no longer be eligible for recruitment. However, in these facilities and in all other facilities in
the region, Azerbaijani women were recruited for another 6 days and Armenian women were recruited for another 11 days after this first day of data collection in all facilities in their respective
regional strata.
110
Georgia National Nutrition Survey 2009
ANNEX 2 – DATA COLLECTION FORMS
GEORGIA NATIONAL NUTRITION SURVEY 2009
HOUSEHOLD QUESTIONNAIRE
1. Data entry clerk ................................
2. Household Questionnaire ID ......
3. District: ______________________________
4. Village/Place__________________________________
5. Region Tbilisi ................................................1
Achara and Guria..............................................2
Imereti and Racha-Leckhumi ..........................3
Kakheti 4
Kvemo Kartli ...................................................5
Samegrelo ........................................................6
Samtckhe-Javakheti .........................................7
Shida Qartli and Mtckheta-Mtianeti ................8
6.
Urban .......................................................................... 1
Rural ........................................................................... 2
7. Cluster number .........................
8. Cluster control form household number .
9. Team number ..................................
10. Interviewer number .......................................
11. Name of head of household
_____________________________________
12. Date of interview ..........
Day
/
/
Month
Year
13. Interviewer/supervisor notes: Use this space to record notes about the interview with this household, such as
call-back times, incomplete individual interview forms, number of attempts to re-visit, etc
WE ARE FROM THE NATIONAL CENTER FOR DISEASE CONTROL AND PUBLIC HEALTH (MOLHSA)
AND UNICEF. WE ARE WORKING ON A PROJECT CONCERNED WITH NUTRITION AND HEALTH. I
WOULD LIKE TO TALK TO YOU ABOUT THIS. THE INTERVIEW WILL TAKE ABOUT 20-30 MINUTES. ALL
THE INFORMATION WE OBTAIN WILL REMAIN STRICTLY CONFIDENTIAL AND YOUR ANSWERS WILL
NEVER BE IDENTIFIED. AFTER THESE QUESTIONS TO YOU, I WILL SPEAK WITH SOME OF THE WOMEN
IN YOUR HOUSEHOLD AND THE WOMEN WHO TAKE CARE OF THE CHILDREN 0-59 MONTHS.
14. Time data collection began ........................................................................................
:
FIRST, I WOULD LIKE TO ASK YOU SOME GENERAL QUESTIONS ABOUT THE PEOPLE WHO LIVE IN THIS
HOUSEHOLD.
15. How many years have you lived in this house or apartment? ......................
16. How many people usually live in this household? .........................................
17. How many women between the ages 15 and 49 years old usually ................
live in this household?
Unk = 99
Unk = 99
-> If 0, go Q19
Georgia National Nutrition Survey 2009
111
18. For each of these women, please tell me her first name and age
List women in order from the oldest to the youngest
No.
*
First and family name
01
02
03
04
05
06
Age
(in years)
Result *
Result Codes: 1 = completed; 2 = partly completed; 3 = refused; 4 = incompetent; 5 = revisit
19. How many children less than 5 years of age usually live in this household?
20. For each of these children, please tell me the first name and age.
No.
*
First and family name
11
12
13
14
15
16
Age
(in months)
-> If 0, skip to
Q21
Result *
Result Codes: 1 = completed; 2 = partly completed; 3 = refused; 4 = incompetent; 5 = revisit
21. What is the ethnicity of the head of the household? Georgian ................................ 1
Circle only one.
Armenian ................................. 2
Azeri ....................................... 3
Other ........................................ 8
(Specify) _______________
U n kn ow n . . .. . . .. . .. . . .. . . .. . . .. . . .. . . .. . . 9
22. What language does your family speak most often
at home?
Circle only one.
Georgian .................................. 1
Armenian ................................. 2
Azeri ....................................... 3
Russian .................................... 4
Other ....................................... 8
(Specify) _______________
U n kn o wn . . . .. . . .. . .. . . .. . . .. . . .. . .. . . .. . 9
23. Are any of household members employed or earning income? Yes ......................... 1
N o . . .. . . .. . . .. . . .. . . .. . .. . . 2
24. How many household members are employed or earning income? ..............
IF THE HOUSEHOLD IS NOT SELECTED FOR BREAD AND SALT SELECTION, SKIP TO Q 48.
IF IT IS SELECTED, CONTINUE.
112
Georgia National Nutrition Survey 2009
-> Next Q
-> Skip to Q25
NOW I WOULD LIKE TO ASK YOU SOME QUESTIONS ABOUT THE SALT MOST COMMONLY USED IN THIS
HOUSEHOLD.
25. How do you usually store salt in the house?
Circle only one.
Original plastic container............... 1
Original glass container (open) .... 2
Original glass container (closed) . 3
Clay or wooden container ............ 4
Plastic container ........................... 5
Cardboard box ............................. 6
Other ............................................. 8
(Specify) ____________________
U n kn ow n . . . .. . .. . . .. . . .. . . .. . .. . . .. . . .. . . .. . . . 9
26. Where do you usually keep the salt container?
Circle all applicable answers.
In a closed cabinet ....................... 1
On an open shelf .......................... 2
On the counter near the stove ...... 3
By the window ............................. 4
Other ............................................ 8
(Specify) ____________________
Unknown ...................................... 9
27. Do you have salt in your house now?
Yes ........................ 1
No ........................... 2
U n kn o wn . . .. . . .. . . .. . . 9
28. Is it iodized?
Yes ........................ 1
No ......................... 2
Unknown .............. 9
29. May I have a small sample of the salt?
Yes ........................ 1
No ......................... 2
-> Next Q
-> Skip to Q30
-> Collect salt
NOW I WOULD LIKE TO ASK YOU SOME QUESTIONS ABOUT THE BREAD EATEN IN THIS HOUSEHOLD.
30. On average, how many kilograms of bread does your family eat per day?
.
If unknown,
enter 9.9
31. What type of bread do you eat most often in this household?
Lavash ......................... 1
Circle only one.
Factory white bread ..... 2
Other bread from factory 3
Home made .................. 4
Other ............................ 8
(Specify) ____________
Unknown ..................... 9
32. Where do you most often purchase this bread? From the supermarket or shop ..... 1
Circle only one.
From the bakery ........................... 2
Usually bake bread at home .......... 3
Other ............................................. 8
(specify) __________________
Un kn o wn . .. . .. . . .. . . .. . . .. . . .. . . .. . .. . . .. . . .. . . 9
-> Next Q
-> Skip to Q34
-> Skip to Q34
-> Skip to Q34
-> Skip to Q34
Georgia National Nutrition Survey 2009
113
33. What is the brand name of the supermarket bread you buy? Ipkli ...................... 1
Dika ...................... 2
Ask to see package if respondent does not know
Margi .................... 3
Mkhneoba ............. 4
No brand name ..... 5
Other ..................... 8
(Specify) ________
Unknown .............. 9
34. When you bake bread at home,
what type of flour do you use?
Circle only one.
White flour first quality ...................... 1
Whole wheat ....................................... 2
Both white and whole wheat .............. 3
None, do not bake bread at home ....... 4
Other ................................................... 8
(specify) _____________________
U n kn ow n . .. . .. . . .. . . .. . . .. . . .. . .. . . .. . . .. . . .. . . .. . .. . 9
35. Do you have a sample of the bread you most commonly
eat in the household now?
Ask to see package of bread.
36. Is the bread labeled as fortified?
Yes ........................ 1
No ......................... 2
Unknown .............. 9
Yes ........................ 1
No ......................... 2
Unknown (original packaging not available) .. 9
37. May I take a sample of this bread to test in the laboratory?
38. Type of bread from which specimen taken?
Circle only one.
39. Where did you get this bread?
Circle only one.
9
From the supermarket or shop ..
From the bakery ........................
Baked at home ..........................
Unknown ..................................
1
2
3
9
Georgia National Nutrition Survey 2009
-> Next Q
-> Skip to Q40
1
2
3
4
8
Yes ........................ 1
N o . . .. . .. . . .. . . .. . . .. . .. . . . 2
U n kn o wn . . .. . . .. . . .. . . 9
All answers
Skip to Q45
-> Next Q
-> Skip to Q45
-> Skip to Q45
Yes ........................ 1
No ......................... 2
Unknown (original packaging not available) .. 3
42. May I take a sample of this bread to test in the laboratory?
114
Yes ........................ 1
No ......................... 2
Lavash .............................
Factory white bread .........
Other bread from factory .
Home made .....................
Other ...............................
(specify) ____________
Unknown .........................
40. Do you have any other type of bread in the house now?
41. Is the bread labeled as fortified?
-> Next Q
-> Skip to Q40
-> Skip to Q40
Yes ........................ 1
No ......................... 2
Next Q
Skip to Q45
43. Type of bread from which specimen taken?
Circle only one.
44. Where did you get this bread?
Circle only one.
Lavash ......................... 1
Factory white bread ..... 2
Other bread from factory 3
Home made .................. 4
Other ............................ 8
(Specify) ____________
Unknown ..................... 9
From the supermarket or shop .. 1
From the bakery ........................ 2
Baked at home .......................... 3
Unknown ............................... 9
45. Number of interviews completed in the household:
Children ...................
Women ....................
46. Salt specimen collected?
Yes ........................ 1
No ......................... 2
47. Bread specimen collected?
Most commonly eaten ........... 1
Not most commonly eaten....... 2
No bread specimen collected... 3
48. Time data collection completed: ......................................................
Hour
:
Minutes
49. Other comments about data collection at this household:
The form was reviewed by: _______________________________________ Date: ________________
Supervisor’s signature
Georgia National Nutrition Survey 2009
115
GEORGIA NATIONAL NUTRITION SURVEY 2009
CHILDREN’S QUESTIONNAIRE (HH SAMPLE)
1. Data entry clerk: .....................................
2. Household Questionnaire ID ......
3. Cluster number: ...............................
4. Cluster form household number ........
5. Team number: ...............................................
6. Interviewer number: ..................................
7. Child number (from HH form) ................
1
8. Date of interview:
Day
/
Month
/
Year
9. Interviewer/supervisor notes: Use this space to record notes about the interview with this household, such as
call-back times, incomplete individual interview forms, number of attempts to re-visit, etc
WE ARE FROM THE NATIONAL CENTER FOR DISEASE CONTROL AND PUBLIC HEALTH (MOLHSA)
AND UNICEF. WE ARE WORKING ON A PROJECT CONCERNED WITH NUTRITION AND HEALTH. I
WOULD LIKE TO TALK TO YOU ABOUT THIS. THE INTERVIEW WILL TAKE ABOUT 10 MINUTES. ALL
THE INFORMATION WE OBTAIN WILL REMAIN STRICTLY CONFIDENTIAL AND YOUR ANSWERS WILL
NEVER BE IDENTIFIED. AFTER THESE QUESTIONS TO YOU, I WILL SPEAK WITH SOME OF THE WOMEN
IN YOUR HOUSEHOLD AND THE WOMEN WHO TAKE CARE OF THE CHILDREN 0-59 MONTHS.
:
10. Time interview begun
FIRST, I WOULD LIKE TO ASK YOU SOME GENERAL QUESTIONS ABOUT YOUR CHILD.
11. What is your child’s name and family name? ......... ___________________________
12. What is [name]’s birthdate? ................ ........................
Day
/
Month
/
Unk=99/99/99
Year .
13. What is [name]’s age in completed months? ..................................................
14. What is [name]’s sex?
Male ....................................... 1
Female ................................... 2
15. What is [name]’s ethnicity?
Circle only one.
Georgian ................................ 1
Armenian ................................. 2
Azeri ....................................... 3
Other ........................................ 8
(Specify) _______________
U n kn ow n . . .. . . .. . .. . . .. . . .. . . .. . . .. . . .. . . 9
116
Georgia National Nutrition Survey 2009
Unk = 99
NOW WE WOULD LIKE TO ASK SOME QUESTIONS ABOUT [NAME]’S HEALTH AND DIET.
16. Does [name] have any chronic diseases or conditions,
such as asthma, anemia, heart diseases, rickets, etc.)?
Yes ..................
No ...................
Unknown ........
Refuse .............
1
2
8
9
17. Does [name] take any medicines for this disease or condition?
Yes ..................
No ...................
Unknown ........
Refuse .............
1
2
8
9
18. Has [name] had any fever in the past 14 days?
Yes ..................
No ...................
Unknown ........
Refuse .............
1
2
8
9
19. Has [name] had any cough in the past 14 days?
Yes ..................
No ...................
Unknown ........
Refuse .............
1
2
8
9
20. Has [name] had any diarrhea in the past 14 days?
Yes ..................
No ...................
Unknown ........
Refuse .............
1
2
8
9
Unknown=8888
Refused=9999
21. At birth, how much did [name] weigh? Record answer in grams ...
22. Was [name] ever breastfed?
23. How soon after birth was did his/her
mother start to breastfeed [name]?
Ask for specific response, then mark
mark appropriate answer.
-> Next Q
-> Skip to Q18
-> Skip to Q18
-> Skip to Q18
Yes ................... 1
N o . .. . . .. . . .. . . .. . . .. 2
Unknown ........ 8
Refused ........... 9
-> Next Q
-> Skip to Q24
-> Skip to Q24
-> Skip to Q24
In first the first hour ................................... 1
After the first hour but within 12 hours .... 2
More than 12 hours after birth ................... 3
Unknown ................................................... 8
Refuse ....................................................... 9
24. Now I will ask you questions about what [name] ate yesterday.
Did [name] take any breastmilk yesterday?
Yes ................... 1
No ................... 2
Unknown ........ 8
Refused ........... 9
25. Yesterday, did [name] eat anything other than breastmilk?
This includes water, baby formula, juice, or any solid foods
as well as regular food.
Yes ................... 1
No ................... 2
Unknown ........ 8
Refused ........... 9
26. Yesterday, did [name] eat any solid, semi-solid, or soft foods?
Yes ................... 1
N o . .. . . .. . . .. . . .. . .. . 2
Unknown ........ 8
Refused ........... 9
Georgia National Nutrition Survey 2009
117
Unknown = 88
Refusal = 99
27. Yesterday, how many times did [name] eat solid, semi-solid, ......................
mushy foods or any animal milk or baby formula?
28. Please tell me if [name] ate any of the following foods yesterday. Be sure to think
about all meals and any snacks [name] ate. Read each item and let respondent
answer, then circle the appropriate answer.
Yes
1
Baby formula
1
Bread, porridge, or other grains
1
Beans or nuts
1
Milk, cheese, yogurt, cottage cheese
1
Meat, fish, or chicken
1
Eggs
Vitamin A rich fruits or vegetables (carrots,
1
pumpkins, tomatoes, spinach)
1
Other fruits or vegetables
1
Food made with vegetable oil, butter, or other oil
1
Sweet tea
No
2
2
2
2
2
2
Unknown
8
8
8
8
8
8
2
8
2
2
2
8
8
8
29. Now think about a period of one week. Remember, a week is 7 days, for example,
Monday through Sunday. How frequently on average does [name] usually eat each of the following
foods per week? Read each item and let respondent answer, then circle the appropriate answer.
5-7
3-4
1-2
Unk<1 day
Refused
days a days a days a
Never
nown
a week
week
week
week
1
2
3
4
5
8
9
Baby formula
1
2
3
4
5
8
9
Bread, porridge, or other grains
1
2
3
4
5
8
9
Beans or nuts
1
2
3
4
5
8
9
Milk, cheese, yogurt, cottage cheese
1
2
3
4
5
8
9
Meat, fish, or chicken
1
2
3
4
5
8
9
Eggs
Vitamin A rich fruits or vegetables
1
2
3
4
5
8
9
(carrots, pumpkins, tomatoes,
spinach)
1
2
3
4
5
8
9
Other fruits or vegetables
Food made with vegetable oil,
1
2
3
4
5
8
9
butter, or other oil
1
2
3
4
5
8
9
Sweet tea
NOW WE WOULD LIKE TO MEASURE [NAME]’S HEIGHT AND WEIGHT.
30. Weight (in kilograms) ..............................................................................
31. Child weighed
32. Child weighed wearing
Alone .................. 1
With mother ....... 2
Underwear or no clothes ... 1
Light clothes ...................... 2
Heavy clothes .................... 3
33. Height (in cm) ...................................................................................
118
Georgia National Nutrition Survey 2009
.
.
.
34. MUAC (in cm) ..........................................................................................
35. Edema, bilateral in feet or lower legs
Yes .................. 1
No ................... 2
36. Reason for no weight, height, or MUAC
measurement
Circle all applicable answers.
Disabled, cannot stand on scale ....... 1
Disabled, cannot measure height ..... 2
Uncooperative or uncontrolable ....... 3
Other ................................................ 8
(Specify) ____________________
Refused ............................................ 9
IMPORTANT: Check the child’s age. If child’s age is less than 12 full months, that is, if the
child has not yet reached his/her first birthday, do NOT collect blood. End interview and skip
to Q 41 interviewers comments.
NOW WE WOULD LIKE TO TAKE SOME BLOOD FROM [NAME]’S FINGER FOR TESTING FOR VITAMIN
LEVELS.
IS THIS OK?
37. Consent granted for fingerstick
Yes ......................... 1
N o .. . . .. . . .. . .. . . .. . . .. . . .. 2
.
38. Hemoglobin concentration (g / dl) ..........................................................
39. Approximate volume of blood collected in microtainer (ml) ............................
40. Time data collection completed .......................................................
Hour
-> Next Q
-> Skip to Q40
:
0 .
Minutes
41. Comments about data collection at this household:
The form was reviewed by: _______________________________________ Date: ________________
Supervisor’s signature
Georgia National Nutrition Survey 2009
119
GEORGIA NATIONAL NUTRITION SURVEY 2009
WOMAN’S QUESTIONNAIRE (HH SAMPLE)
1. Data entry clerk ..................................
2. Household Questionnaire ID
3. Cluster number ............................
4. Cluster control form household number
5. Team number .....................................
6 Interviewer number ............................................
7. Woman number (from HH form) .........
0
8. Date of interview .......
Day
/
Month
/
Year .
9. Interviewer/supervisor notes: Use this space to record notes about the interview with this household, such as
call-back times, incomplete individual interview forms, number of attempts to re-visit, etc
WE ARE FROM THE NATIONAL CENTER FOR DISEASE CONTROL AND PUBLIC HEALTH (MOLHSA)
AND UNICEF. WE ARE WORKING ON A PROJECT CONCERNED WITH NUTRITION AND HEALTH. I
WOULD LIKE TO TALK TO YOU ABOUT THIS. THE INTERVIEW WILL TAKE ABOUT 10 MINUTES. ALL
THE INFORMATION WE OBTAIN WILL REMAIN STRICTLY CONFIDENTIAL AND YOUR ANSWERS WILL
NEVER BE IDENTIFIED. AFTER THESE QUESTIONS TO YOU, I WILL SPEAK WITH SOME OF THE WOMEN
IN YOUR HOUSEHOLD AND THE WOMEN WHO TAKE CARE OF THE CHILDREN 0-59 MONTHS.
10. Time interview begun:....................................................................................
:
FIRST, I WOULD LIKE TO ASK YOU SOME GENERAL QUESTIONS ABOUT YOURSELF.
11. Are you currently pregnant?
Yes ......................... 1
No ......................... 2
12. What is your date of birth? ................. ........................
/
Day
Month
/
Unk=99/99/99
Year
13. What is your age in completed years? ............................................................
14. What is your ethnicity?
Circle only one.
120
Georgia National Nutrition Survey 2009
If YES, thank
woman and
END THE
INTERVIEW;
If NO, continue
Georgian ................................ 1
Armenian ................................. 2
Azeri ....................................... 3
Other ........................................ 8
(Specify) _______________
U n kn ow n . . .. . . .. . .. . . .. . . .. . . .. . . .. . . .. . . 9
Unk = 99
15. What is your religion?
Circle only one.
Orthodox ...............................
Muslim ..................................
Armenian Gregorian ..............
Roman Catholic .....................
No religion ............................
Other ......................................
(Specify) _______________
Refused ..................................
1
2
3
4
5
8
Married/lives with partner ....
Widowed ..............................
Divorced ...............................
Separated ..............................
Never married .......................
U nk n ow n . . . .. . . .. . . .. . . .. . .. . . .. . . .. . .
Refused .................................
1
2
3
4
5
8
9
16. What is your marital status?
Circle only one.
9
17. How many years of school did you complete? ...............................................
18. In the past 3 months, including today, have you taken
food supplements or vitamins?
19. What kind of supplements or vitamins?
Circle all applicable answers.
Yes ......................... 1
No ......................... 2
-> Next Q
-> Skip to Q20
Iron .......................................... 1
Vitamin C ............................... 2
Other ........................................ 8
(Specify) _______________
Unknown ................................ 9
If 0, skip to Q24
20. How many times have you been pregnant? ....................................................
21. How many of these pregnancies resulted in a live birth? .............................
22. Are you currently breastfeeding?
Yes ......................... 1
No ......................... 2
Refused ................. 9
-> Next Q
-> Skip to Q24
-> Skip to Q24
23. How many months old is the child you are breastfeeding? ..........................
24. When did you start your last menstrual period? ......
Day
25. Do you smoke cigarettes?
/
Month
/
Year .
Yes ......................... 1
N o . . .. . .. . . .. . . .. . . .. . .. . . . 2
U n kn ow n . .. . . .. . . .. . .. 8
Refused ................. 9
If not applicable,
99/99/99
-> Next Q
->Skip to Q27
->Skip to Q27
->Skip to Q27
26. How many cigarettes per day, on average, do you smoke? ...........................
27. Do you usually add salt to your food just before eating it?
Yes ......................... 1
N o . . .. . .. . . .. . . .. . . .. . .. . . . 2
U n kn ow n . .. . . .. . . .. . .. 8
Refused ................. 9
Georgia National Nutrition Survey 2009
121
28. Do you usually add the salt without first tasting the food?
Yes ......................... 1
No ......................... 2
Unknown .............. 8
Refused ................. 9
NOW WE WOULD LIKE TO MEASURE YOUR HEIGHT AND WEIGHT.
29. Weight (in kilograms) .......................................................................
.
30. Height (in cm) ...................................................................................
.
31. Reason for no height or weight measurement :
Circle all applicable answers.
Disabled, cannot stand on scale .......
Disabled, cannot measure height .....
Other ................................................
(Specify) ____________________
Refused ............................................
1
2
8
9
NOW I WOULD LIKE TO TAKE SOME BLOOD FROM YOUR FINGER / VEIN FOR TESTING.
32. If woman eligible for folate testing, was venipuncture
blood obtained?
Yes ......................... 1
No ......................... 2
32a. Volume of blood in vacutainer (ml)
..................
33. Is blood obtained by fingerstick?
Yes ......................... 1
No ......................... 2
34. If fingerstick done, approximate volume of blood collected in microtainer (ml)
Hour
.
-> Next Q
-> Skip to Q35
.
33a. Hemoglobin concentration (in g / dl) ......................................................
35. Time data collection completed .......................................................
-> Next Q
-> Skip to Q33
:
0 .
Minutes
36. Comments about data collection at this household:
The form was reviewed by: _______________________________________ Date: ________________
Supervisor’s signature
122
Georgia National Nutrition Survey 2009
GEORGIA NATIONAL NUTRITION SURVEY 2009
PREGNANT WOMAN’S QUESTIONNAIRE (ANC SAMPLE)
Pregnant Woman Questionnaire ID
1. Data entry clerk .....................................
3. Region
Tbilisi ......................................................... 1
Achara and Guria ........................................................... 2
Imereti and Racha-Leckhumi ........................................ 3
Kakheti
4
Kvemo Kartli ................................................................ 5
Samegrelo 6
Samtckhe-Javakheti ...................................................... 7
Shida Qartli and Mtckheta-Mtianeti .............................. 8
5. ANC clinic number: ..............................
7. Name of woman ____________________________
2. District: _________________________________
4. ANC clinic name ___________________________
6. Team number: .......................................
8. Date of interview:
Day
/
Month
/
Year
9. Interviewer/supervisor notes: Use this space to record notes about the interview with this household, such as
call-back times, incomplete individual interview forms, number of attempts to re-visit, etc
WE ARE FROM THE NATIONAL CENTER FOR DISEASE CONTROL AND PUBLIC HEALTH (MOLHSA) AND UNICEF.
WE ARE WORKING ON A PROJECT CONCERNED WITH NUTRITION AND HEALTH. I WOULD LIKE TO TALK TO YOU
ABOUT THIS. THE INTERVIEW WILL TAKE ABOUT 10 MINUTES. ALL THE INFORMATION WE OBTAIN WILL REMAIN
STRICTLY CONFIDENTIAL AND YOUR ANSWERS WILL NEVER BE IDENTIFIED . AFTER THESE QUESTIONS TO YOU, I
WILL SPEAK WITH SOME OF THE WOMEN IN YOUR HOUSEHOLD AND THE WOMEN WHO TAKE CARE OF THE
CHILDREN 0-59 MONTHS.
:
10. Time interview begun:
FIRST, I WOULD LIKE TO ASK YOU SOME GENERAL QUESTIONS ABOUT YOURSELF.
11. Are you currently pregnant?
Yes ......................... 1
No ......................... 2
12. What is your date of birth? ................. ........................
Day
/
Month
/
Unk=99/99/99
Year .
13. What is your age in completed years? ............................................................
14. What is your ethnicity?
Circle only one.
If NO, thank
woman and
END
INTERVIEW;
If YES, continue
Unk = 99
Georgian ................................ 1
Armenian ................................. 2
Azeri ....................................... 3
Other ........................................ 8
(Specify) _______________
U n kn ow n . . .. . . .. . .. . . .. . . .. . . .. . . .. . . .. . . 9
Georgia National Nutrition Survey 2009
123
15. What is your religion?
Circle only one.
Orthodox ...............................
Muslim ..................................
Armenian Gregorian ..............
Roman Catholic .....................
No religion ............................
Other ......................................
(Specify) _______________
Refused ..................................
1
2
3
4
5
8
Married/lives with partner ....
Widowed ..............................
Divorced ...............................
Separated ..............................
Never married .......................
U nk n ow n . . . .. . . .. . . .. . . .. . .. . . .. . . .. . .
Refused .................................
1
2
3
4
5
8
9
16. What is your marital status?
Circle only one.
9
17. How many years of school did you complete? ...............................................
18. During this pregnancy, have you taken food supplements
or vitamins?
19. If yes, what kind?
Circle all applicable answers.
Yes ......................... 1
No ......................... 2
Iron .......................................... 1
Vitamin C ............................... 2
Multi-vitamins ....................... 3
Other ........................................ 8
(Specify) _______________
U n kn ow n . . .. . .. . . .. . . .. . . .. . . .. . . .. . .. . . 9
20. How many months have you been pregnant? .......................................................
21. When did you start your last menstrual period? ......
-> Next Q
-> Skip to Q20
Day
/
Month
/
Year .
22. How many times have you been pregnant before this pregnancy?...............
Unknown=99
Unknown enter
99/99/99
If 0, skip to Q24
23. How many of these pregnancies resulted in a live birth? .............................
24. Do you smoke cigarettes now?
Yes ......................... 1
N o . . .. . .. . . .. . . .. . . .. . .. . . . 2
U n kn ow n . .. . . .. . . .. . .. 8
Refused ................. 9
25. How many cigarettes per day, on average? .....................................................
26. Do you usually add salt to your food just before eating it?
Yes ......................... 1
N o . . .. . .. . . .. . . .. . . .. . .. . . . 2
U n kn ow n . .. . . .. . . .. . .. 8
Refused ................. 9
27. Do you usually add the salt without first tasting the food?
Yes ......................... 1
N o . . .. . .. . . .. . . .. . . .. . .. . . . 2
U n kn ow n . .. . . .. . . .. . .. 8
Refused ................. 9
124
Georgia National Nutrition Survey 2009
-> Next Q
-> Skip to Q26
-> Skip to Q26
-> Skip to Q26
NOW WE WOULD LIKE TO MEASURE YOUR ARM.
.
28. MUAC (in cm) .........................................................................................
29. Reason for no MUAC measurement
Circle all applicable answers.
Disabled, cannot measureMUAC .... 1
Other ................................................ 8
(Specify) ____________________
Refused ............................................ 9
NOW I WOULD LIKE TO TAKE SOME BLOOD FROM YOUR FINGER FOR TESTING FOR HEMOGLOBIN
LEVELS. WE WOULD ALSO LIKE TO COLLECT SOME URINE FROM YOU. IS THIS OK?
30. Blood obtained from fingerstick
Yes ......................... 1
No . . .. . . .. . . .. . . .. . .. . . .. . . 2
.
31. Hemoglobin concentration (in g/dl) ........................................................
32. Urine specimen collected
Yes ......................... 1
N o . . .. . .. . . .. . . .. . . .. . .. . . . 2
33. Time data collection completed .......................................................
Hour
:
Minutes
34. Comments about data collection at this household:
The form was reviewed by: ________________________________________ Date: ____________
Supervisor’s signature
Georgia National Nutrition Survey 2009
125
ANNEX 3 – QUALITY ASSURANCE DURING and
after DATA COLLECTION
During data collection at each selected household, survey team leaders supervised all steps of
data collection, including the interview, physical examination, anthropometric measurement, and
biologic specimen collection. Upon completion of data collection at each household, the survey
team leader reviewed the entire data collection form to ensure completeness and accuracy. As
mentioned above, the two datasets resulting from duplicate data entry were exhaustively compared to ensure accurate data entry. Specific measures for the various types of data collected
in the GNNS 2009 are listed below.
Interview
Survey interviewers may influence the answers given by survey participants. To reduce this bias,
interview questions were carefully written and pretested on individuals from a population similar
to that in the survey sample. Careful review of translations ensured that questions collected the
data they are meant to collect. Survey interviewers were carefully trained and supervised to ensure that they read questions verbatim from the data collection form. In addition, most questions
were relatively simple and not require extensive interpretation by respondents.
Anthropometric measurements
As mentioned above, complete training was provided in measurement technique and included a
standardization exercise. The height boards, scales, and tapes used for measurement were carefully constructed and calibrated periodically throughout the data collection period. As mentioned
above, during data analysis, outlying anthropometric indices were excluded from analysis according to the criteria recommended by WHO.18 Additional analysis was done to judge the validity of
anthropometric measurements, including an analysis for digit preference in height measurements,
calculation of the standard deviations of all z-scores, and analysis of the age distribution of children less than 5 years of age by one-month intervals.
Physical examination
Training for survey workers who examined survey participants used photographs of edema; no
example of actual edema were available to demonstrate to survey workers. Team supervisors
confirmed all positive findings during data collection.
Biologic specimen collection
Training for survey workers covered all aspects of specimen collection and any laboratory testing
to be done in the field. For example, training included all the aspects of obtaining fingerstick
blood and operating and calibrating the HumaMeter® hemoglobinometer. Biologic specimens
were processed, stored, and transported according to instructions from the laboratory which did
the testing.
126
Georgia National Nutrition Survey 2009
Laboratory measurements
Ferritin and CRP
The validity of the ferritin and CRP laboratory results from the NCDCPH Imereti Zonal Branch
Diagnostic Laboratory has been confirmed by blinded duplicate testing by Human GmbH in Wiesbaden, Germany. Table 68 and Table 69 below shows the agreement between the two laboratories for the 400 serum specimens from young children and non-pregnant women which were
tested in both laboratories.
Table 68. Comparison of CRP testing results from Georgian laboratory and German laboratory,
GNNS 2009
German laboratory results
Georgian laboratory result
Elevated*
Elevated*
Normal
56
3
2
339
Normal
Elevated = CPR > 5.0 mg/l
Kappa statistic for agreement = 0.95(strength of agreement is almost perfect)
*
Table 69. Comparison of ferritin testing results from Georgian laboratory and German laboratory, GNNS 2009
German laboratory results
Georgian laboratory result
Low*
Normal
Low*
Normal
10
1
5
384
Low = For children < 5 years of age ferritin < 12.0 µg/L; for adult
women ferritin < 15.0 µg/L
Kappa statistic for agreement = 0.76 (strength of agreement is substantial)
*
Salt iodine
A subsample of 30 salt specimens obtained from households during data collection for the GNNS
2009 were re-tested in a salt iodine reference laboratory in Ukraine. Figure 15 below shows the
correlation between the results obtained by the Georgian and Ukrainian laboratories. The correlation coefficient is quite high and the Y-axis intercept of the linear correlation line is very near 0,
demonstrating that the results are very similar.
Georgia National Nutrition Survey 2009
127
Salt testing results from Ukrainian laboratory
(ppm iodine)
Figure 15. Scatterplot showing correlation between Georgian and Ukrainian laboratories’ results
in testing household salt, GNNS 2009
60
50
40
30
y = 1.0237x + 1.3805
R2 = 0.9297
20
10
0
0
10
20
30
40
50
Salt testing results from Georgian laboratory (ppm iodine)
128
Georgia National Nutrition Survey 2009
60
REFERENCES
1. WHO/UNICEF/UNU. Iron deficiency anaemia: assessment, prevention, and control - A guide
for programme managers. Geneva and New York: World Health Organization/United Nations
Childrens Fund/United Nations University; 2001.
2. Esther Wong SA, Lindsay Margoles, Jami Schaffner, and Parmi Suchdev. National Nutrition
Survey of Women and Children - Republic of Georgia 2008: Survey Report. In: UNICEF and
Emory University; 2007.
3. Georgian National Iron Deficiency and Anemia Survey 2007 (Estimation of the prevalence of
iron deficiency and anemia in women of reproductive age (15-49) by measuring serum ferritin
concentration); 2007.
4. Monitoring the situation of children and women: Multiple Indicator Cluster Survey 2005.
Tbilisi: State Department of Statistics of Georgia and National Centre for Disease Control of
Georgia 2005.
5. McLean E, de Benoist B, Allen LH. Review of the magnitrude of folate and vitamin B12 deficiencies worldwide. Food and Nutrition Bulletin 2008;29:S38-S51.
6. Wald NJ, Law MR, Morris JK, Wald DS. Quantifying the effect of folic acid. Lancet
2001;358:2069-73.
7. Ray JG. Efficacy of Canadian folic acid food fortification. Food and Nutrition Bulletin
2008;29:S225-S30.
8. Hertrampf E, Cortes F. Folic acid fortification of wheat flour: Chile. Nutrition Reviews
2004;6:S44-S8.
9. Chen LT, Rivera MA. The Costa Rican experience: Reduction of neural tube defects following
food fortification programs. Nutrition Reviews 2004;6:S40-S3.
10.Weekly iron-folic acid supplementation (WIFS) in women of reproductive age: its role in
promoting optimal maternal and child health: Position statement. World Health Organization, 2009. (Accessed at <http://www.who.int/nutrition/publications/micronutrients/weekly_iron_folicacid.pdf>.)
11. WHO/FAO. Guidelines on food fortification with micronutrients. Geneva: World Health Organization and Food and Agricultural Organization of the United Nations; 2006.
12.Participants in consultation. Conclusions of a WHO Technical Consultation on folate and vitamin B12 deficiencies. Food and Nutrition Bulletin 2008;29:S238-S44.
13. Wesley A, Ranum P, eds. Fortification Handbook: Vitamin and Mineral Fortification of Wheat
Flour and Maize Meal. Ottawa, Canada: The Micronutrient Initiative; 2004.
Georgia National Nutrition Survey 2009
129
14. Wheat Flour Fortification: Current Knowledge and Practical Applications. Summary Report
of an International Technical Workshop. Flour Fortification Initiative. Cuernavaca, Mexico;
2004 December 1-3, 2004.
15. UNICEF/WHO. Eliminating Iodine Deficiency in the Republic of Georgia: Overview of 2005
National Survey. Tbilisi; 2006.
16. WHO/UNICEF/ICCIDD. Assessment of iodine deficiency disorders and monitoring their elimination: A guide for programme managers, 3d ed. Geneva: WHO; 2007.
17.State Department of Statistics, National Center for Disease Control, UNICEF. Republic of
Georgia - Multiple Indicator Cluster Survey, 1999. Tbilisi; 2000.
18.WHO. Physical Status: The Use and Interpretation of Anthropometry: Report of a WHO Expert Committee. WHO Technical Report Series #854. Geneva: World Health Organization;
1995.
19. WHO. The optimal duration of exclusive breastfeeding: Report of an expert consultation. Geneva: World Health Organization; 2002.
20. Li R, Scanlong KS, Serdula MK. The validity and reliability of maternal recall of breastfeeding
practice. Nutrition Reviews 2005;63(4):103-10.
21.Multiple Indicator Cluster Survey Manual 2005: Monitoring the Situation of Children and
Women. Appendix One: Indicators for Global Reporting. New York: Division of Policy and
Planning, UNICEF; 2006.
22. WHO/UNICEF. Indicators for assessing infant and young child feeding practices: conclusions
of a consensus meeting held 6–8 November 2007 in Washington D.C., USA. Washington,
D.C.; 2008.
23. UNICEF/WHO. Baby-Friendly Hospital Initiative: Revised, updated and expanded for integrated care. New York and Geneva: United Nations Childrens Fund and World Health Organization; 2009.
24.Owen CG, Martin RM, Whincup PH, Smith GD, Cook DG. Effect of infant feeding on the
risk of obesity across the life course: A quantitative review of published evidence. Pediatrics
2005;115:1367-77.
25.State Department of Statistics of Georgia and National Centre for Disease Control of Georgia. Monitoring the situation of children and women: Multiple Indicator Cluster Survey 2005.
Tbilisi; 2008 June
26. Nalubola R, Nestel P. Manual For Wheat Flour Fortification with Iron - Part 3 Analytical Methods for Monitoring Wheat Flour Fortification with Iron: Appendix 3.8 Elements by atomic
absorption spectrophotometry, AACC method 40-70. Washington DC: MOST; 2000.
27. Ministry of Labor, Health and Social Affairs Order #300/n, 19.10.2007: Technical Regulation
of Food Fortification. Tbilisi.
130
Georgia National Nutrition Survey 2009
28. WHO International Classification of Diseases 10, version 2007. (Accessed at <http://apps.
who.int/classifications/apps/icd/icd10online/>.)
29. de Onis M, Garza C, Victora CG, Onyango AW, Frongillo EA, Martines J. The WHO Multicentre Growth Reference Study: planning, study design, and methodology. Food and Nutrition
Bulletin 2004;25(1 Suppl):S15-26.
30.WHO Anthro for Personal Computers Manual: Software for assessing growth and development of the world’s children. World Health Organization, 2009. (Accessed at <http://www.
who.int/childgrowth/software/en/index.html>.)
31. Shetty P, James W. Body mass index: a measure of chronic energy deficiency in adults. Food
and Nutrition Paper No. 56. Rome: Food and Agriculture Organization of the United Nations;
1994.
32. UNHCR/WFP. Guidelines for Selective Feeding Programmes in Emergency Situations. Geneva
and Rome: United Nations High Commissioner for Refugees and World Food Programme;
1999.
33. Sullivan KM, Mei Z, Grummer-Strawn L, Parvanta I. Haemoglobin adjustments to define anaemia. Tropical Medicine and International Health 2008;13:1267-71.
34. Assessing the Iron Status of Populations: Report of a Joint World Health Organization/Centers for Disease Control and Prevention Technical Consultation on the Assessment of Iron
Status at the Population Level. Geneva and Atlanta: WHO and CDC; 2004.
35.DRG package insert: DRG® Vitamin Folic Acid (BIO-4886). (Accessed 24 March 2010, at
<http://www.drg-international.com/ifu/bio-4886.pdf>.)
36.How to weigh and measure children: Assessing the nutritional status of young children in
household surveys. New York: United Nations Department of Technical Co-operation for Development and Statistical Office; 1986.
Georgia National Nutrition Survey 2009
131
132
Georgia National Nutrition Survey 2009