Primary Prevention of NTDs in Turkey by Becky Handforth

Primary Prevention of NTDs in Turkey

Presented by Becky Handforth 24th Annual International Spina Bifida and Hydrocephalus Congress June 2013

Agenda: • Health status of the Turkish population • Folate intake • Neural tube defects • Wheat and flour industry • Flour Fortification activities and stakeholders • Next steps

Turkey Health Profile Births per year-1,345,000 (2009) 4+ Antenatal care visits-74% Births with skilled attendant-96%(urban) 80% (rural) Anemia pregnant women-40% (26% in non-pregnant women) Folate deficiency in women-minimal data NTDs per year- estimated 4250 (~30/10,000 births) Anemia children <5 years-33% Stunting children <5 years-12%

Recommendations for Folate Intake • Women of child-bearing age: 400 µg/day (DFE) • Pregnant women: 600 µg/day (DFE) • Lactating women: 500 µg/day (DFE)

FA Supplement Intake Turkey: 1 Tekkesin and Taser 2012 •Memorial Hospital, Istanbul •Survey of 1076 women in 1st trimester of pregnancy •62.9% were users of folic acid supplements (FA) A. All those who had planned their pregnancies were using FA B. 35% of those who had not planned their pregnancies were using FA •35% of users had started supplementation 3 months prior to conception •Limitation: Women not randomly selected. The women were from middle or high SES households and had sought early prenatal care, thus they may be more health conscious than general population.

FA Supplement Intake Turkey: 2 Baykan et al. 2011 •Family healthcare centers in Central Anatolia •Out of 171 pregnant women, 81% were taking FA at time of study but just 12% starting taking FA at least 1 month prior to conception.

•Out of 912 non-pregnant women, only 31 were taking a vitamin containing folic acid.

•Limitation: Not randomized

Folate Status Öner et al. 2006 •Secondary and high schools in Erdine •704 adolescent girls aged 12-17 years •Serum folate levels-38% adequate, 46% marginal and 16% deficient

Educating Women on Neural Tube Defects for Safe Motherhood and Healthy Generations • • • •

Took place in Izmir (2006) ~4400 participants Brochures, magnets, posters etc.

Prior to campaign 18.5% indicated FA is recommended to prevent congenital anomalies • Pre-intervention questionnaire, provision of information, postintervention questionnaire • Limitation: Behavior change could not be assessed.

Neural Tube Defects in Turkey Macon 1992 •Data from 1981-1990 •Collected from delivery records, State Maternity Hospital in Ankara •Prevalence rate of 32.8 cases of spina bifida per 10,000 births Tuncbilek et al. 1999 •Data from 1993-1994 •Live births and stillbirths at university hospitals throughout Turkey •Prevalence rate of NTDs was 30.1 per 10,000 births

Neural Tube Defects in Turkey Mandýracýoðlu et al. 2004 •Data from 2000 •Multiple types of hospitals in Izmir •36,331 hospital births (live and stillbirths) •93% of total births during timeframe •NTDs occurred in 15 per 10,000 births Onrat, Seyman and Konuk 2009 •Data from 2003-2004 in Afyonkarahisar •Live births, still births and therapeutic abortions included •Prevalence rate of NTDs was 35.9 per 10,000 births

Wheat Production in Turkey heat w 3 1 / s 2012 ’ y t at e s k a r c u e r T “ n is fo 2.3 o i n t c w u o d d o , pr tons n o i l l i from 16.5 m r 12 percent o million ” ar. last ye

Milling Industry • In 2011, there were 682 flour millers. Expected further consolidation in the future.

Turkish Flour Industrialists’ Federation • Founded in 2005 • Compromises 8 flour milling organizations with 388 members • Supportive of fortification and includes relative webpage within its website

Trade of Wheat Flour

Turkey imports a negligible amount of wheat flour Source: http://www.tfyi.gov.tr/en/featured-product/reports-and-resources/wheat-flour-sectoral-analysis Based on 2011 data

Bread Consumption On a daily basis •25,950 tonnes of bread are produced •101 million loaves of bread are prepared to sell •The average individual eats 50% of his/her energy requirement as bread

Annual per capita bread consumption is 155 kg (~62 loaves per year) Turkish “pide”.

Photo by Jason D. Jones

Voluntary Flour Fortification

Fortification at Bakeries

Stakeholders for Flour Fortification • • • • • • • • • •

Ministry of Health Ministry of Food, Agriculture and Livestock Ministry of Economy Food Standards Institute Turkish Flour Industrialists Federation UNICEF Turkey WHO Turkey Turkish Spina Bifida Association Medical associations/Medical professionals Etc.

Action to Date 1994

Salt iodization begins in Turkey

2000

WHO consultants explore collaborations for fortification with millers in Ankara

2001

Turkish Armed Forces trial to fortify bread within their food services

2003-4

Enriched bread product launch by Doruk Milling

2004-6

Turkish Flour Industrialists’ Federation (TFIF) involved in Food Codex Commission subcommittee responsible for developing standards for fortified flour

2006

IAOM Eurasia District inaugural Conference and Exhibition combined with FFI Eurasia Regional Leaders Group meeting successfully held in Istanbul

2007

TFIF organized “Wheat and Flour Fortification Congress” in Antalya and secured support for national fortification from industry

2007

Global Micronutrient Forum held in convergence with TFIF Congress

Action to Date Continued 2008

Secretary General TFIF meets numerous stakeholders.

Decided that fortification should begin with iron.

2008

Key authority in MOA replaced-progress delayed

2010

Delegation from MOA accompanied by Assistant Secretary General of TFIF attend a fortification meeting in Kazakhstan

2010

TFIF Secretary General receives FFI award for work on bringing fortification to Turkey. Incoming Secretary General also supportive of the initiative having previously attending an FFI meeting in France.

2010

National Nutrition Survey conducted

2012

Two consecutive flour fortification workshops held for CEECIS country representatives in Ankara. Ministries in Turkey note the need for folic acid to be included in the Turkish standard and agree to work together to make fortification become a reality.

2012

MOH submits report about importance of fortification to MOA

2013

Results of the National Nutrition Survey remain unpublished.

Next Steps • Continue to inform the general population about the important role of consuming folate prior to and during pregnancy • Connect with public sector stakeholders to encourage dissemination of the NNS results and motivate them to make flour fortification a priority-possible joint advocacy mission • National Food Fortification Alliance

Conclusion • The prevalence of NTDs is very high in Turkey • Preconceptional FA intake needs to be improved • Turkey is a major consumer and exporter of wheat flour and flour-based products • Voluntary fortification will not provide a public health benefit-coverage too low • Stakeholders have engaged in fortification activities but long-term commitment needed

Thank you for your attention!

Questions? bhandforth@gmail.com