77203 Nutrition at a GLANCE Turkey The Costs of Malnutrition Annually, Turkey loses over US$5.5 billion in GDP • Children who are undernourished between con- ception and age two are at high risk for impaired to vitamin and mineral deficiencies.3,4 Scaling up cognitive development, which adversely affects core micronutrient nutrition interventions would the country’s productivity and growth. cost less than US$36 million per year. • Over one-third of child deaths are due to undernu- (See Technical Notes for more information.) trition, mostly from increased severity of disease.2 • Turkey is anticipated to lose a cumulative US $4.7 Key Actions to Address billion to chronic disease by 2015.5 • The economic costs of undernutrition and over- Malnutrition: weight include direct costs such as the increased Incorporate nutrition-related services into positive burden on the health care system, and indirect incentive payments for family doctors. costs of lost productivity. Include nutrition as an explicit condition in the • Childhood anemia alone is associated with a conditional cash transfer program (CCT). Country Context 2.5% drop in adult wages.6 Target existing micro-nutrient supplementation, salt HDI ranking: 79th out of 182 iodization and fortification programs to reduce regional countries1 Where Does Turkey Stand? disparities. • 1 in 10 of children under the age of five are Life expectancy: 72 years2 stunted.2 Scale up the “Promotion of Breastfeeding and Baby Friendly Hospitals� Program. Lifetime risk of maternal death: • Two-thirds of those aged 15 and above are over- 1 in 8802 weight or obese.7 • 16% infants are born with a low birth weight, Under-five mortality rate: more than double the 7% average of OECD betes and heart disease than children who start out 22 per 1,000 live births2 peers.2,8 well-nourished.11 Global ranking of stunting This “double burden� is the result of various fac- prevalence: 109th highest out of With 10% stunting rates, Turkey has a much tors. There could be further improvements in popu- 136 countries2 higher prevalence of stunting than other European lation health measures to reduce undernutrition; at countries. Within the country, there is wide varia- the same time, the adoption of Western diets high tion across geographic areas and socio-economic in refined carbohydrates, saturated fats and sugars, groups: 22% of children in the lowest wealth quin- as well as a more sedentary lifestyle are commonly Technical Notes tile are stunted compared with 2.1% in the highest cited as the major contributors to the increase in Stunting is low height for age. wealth quintile. Among regions, 21% of children in overweight and chronic diseases.10 the East of the country are stunted compared with Underweight is low weight for age. 4.5% in the Central region.16 Vitamin and Mineral Deficiencies Cause Wasting is low weight for height. Hidden Hunger Current stunting, underweight, and wasting Most of the irreversible damage Although they may not be visible to the naked eye, estimates are based on comparison of the due to malnutrition in Turkey happens vitamin and mineral deficiencies impact well-being most recent survey data with the WHO during gestation and in the first and are prevalent in Turkey, as indicated in Figure 1. Child Growth Standards, released in 2006. 24 months of life. Low birth weight is a birth weight less • Vitamin A: 12% of preschool aged children and than 2500g. 23% of pregnant women are deficient in vitamin Overweight is a body mass index (kg/m2) The Double Burden of Undernutrition and A.13 of ≥ 25; obesity is a BMI of ≥ 30. Overweight • Iron: Turkey began providing free iron supple- Though Turkey is currently on track to meet MDG ments for infants between 4–12 months and iron The methodology for calculating nationwide costs of vitamin and mineral 1c (halving 1990 rates of child underweight by treatment for children between 13–24 months deficiencies, and interventions included in 2015), it has seen a recent increase in adult obesity9. with anemia in 2005 under the “Iron-Like Turkey the cost of scaling up, can be found at: Low-birth weight infants and stunted children may Program.� As a result, anemia prevalence for chil- www.worldbank.org/nutrition/profiles be at greater risk of chronic diseases such as dia- dren between 12–23 months has decreased from Solutions to Primary Causes of Undernutrition Turkey Poor Infant Feeding Practices: High Disease Burden Access to Nutritious Food Progress has been Made but More • Undernourished children have an increased risk of • Achieving food security means ensuring quality and is Needed falling sick and greater severity of disease. continuity of food access, in addition to quantity, for • Undernourished children who fall sick are much all household members. • The proportion of infants under six months who more likely to die from illness than well-nourished • Dietary diversity is essential for food security. are exclusively breastfed doubled from 2003 to children. Solution: Involve multiple sectors including agricul- 2008;2 the Government should continue to pro- • Parasitic infestation diverts nutrients from the body ture, education, transport, gender, the food industry, mote breastfeeding.2,4 and can cause blood loss and anemia. health and other sectors, to ensure that diverse, nutri- • During the important transition period to a mix of breast milk and solid foods between six and nine Solution: While Turkey has made strides to ensure tious diets are available and accessible to all house- months of age, one-third of infants are not fed ap- that 85% of children under the age of five are routinely hold members. Examine food policies and the country propriately with both breast milk and other foods.2 immunized against the major childhood diseases, vac- regulatory system as they relate to overweight and cination against the major childhood diseases within obesity. Solution: Continue to expand the “Promotion of the first twelve months is essential to ensuring the Breastfeeding and Baby Friendly Hospitals� Program well-being of every child.12 Hand-washing, deworm- to support women and their families to practice op- ing, zinc supplements during and after diarrhea, and timal breastfeeding. Breast milk fulfills all nutritional continued feeding during illness are also important. needs of infants up to six months of age, boosts their immunity, and reduces exposure to infections. References 30% to 7.8%.15 Turkey should continue to expand which has a strong focus on improving maternal 1. UNDP. 2009. Human Development Report. coverage of its iron program as well as consider and child health. In addition to supporting the Gov- 2. UNICEF. 2009. State of the World’s Children. 3. UNICEF and the Micronutrient Initiative. 2004. providing multiple micronutrient supplements to ernment’s efforts to strengthen its public health sys- Vitamin and Mineral Deficiency: a Global infants and young children, and fortification of tem to address ongoing and emerging challenges, a Progress Report. staple foods. results-based financing component specifically fo- 4. World Bank. 2009. World Development cuses on incentives for physicians to improve detec- Indicators (Database). Figure 1  High Rates of Vitamin A and Iron Deficiency tion and treatment of non-communicable diseases 5. Abegunde D. et al. 2007. The Burden and Costs of Chronic Diseases in Low-Income and Middle- Contribute to Lost Lives and Diminished Productivity through risk-factor prevention, including that of Income Countries. The Lancet 370: 1929–38 45 obesity/overweight. 6. Horton S. and Ross J. The Economics of Iron The Bank also supported the Government in 40 Deficiency. Food Policy. 003;28:517–5. 7. WHO. 2009. WHO Global InfoBase 35 the implementation of a conditional cash transfer Prevalence (%) (Database). 30 program targeted at the poorest 6% of children, 25 8. OECD. 2009. Society at a Glance 2009: OECD conditional on improved use of basic health, nutri- 20 Health Indicators. tion and education services which has now become 15 9. UNICEF. 2009. Tracking Progress on Child and Maternal Nutrition. 10 a national program of the Government of Turkey 10. Popkin BM. et al. 1996. Stunting is Associated 5 with impact evaluation results showing net positive 0 with Overweight in Children of Four Nations Preschool Children Pregnant Women behavioral changes. that are Undergoing the Nutrition Transition. Vitamin A Deficiency Anemia 11. Victora, CG et al. Maternal and Child Undernutrition: Consequences for Adult Health Source: 1995–2005 data from the WHO Global Database on Child Growth and And Human Capital. The Lancet 2008; 371: Malnutrition 340–57. Addressing undernutrition is cost 12. UNICEF. 2009. Programmes 2006–2010: Early effective: Costs of core micronutrient Childhood Care and Learning. 13. WHO. 2009. Global Prevalence of Vitamin A World Bank Nutrition-Related Activities in interventions are as low as Deficiency in Populations at Risk 1995–2005. Turkey US$0.05–4.86 per person annually. WHO Global Database on Vitamin A Deficiency. 14. Horton S. et al. 2009. Scaling Up Nutrition: The World Bank’s lending program supports the Returns on investment are as high as What will it Cost? Government’s Health Transformation Program, 8–30 times the costs.14 15. Ministry of Health. 2009. Health Transformation Program in Turkey. January. 16. Turkey DHS (2008). THE WORLD BANK Produced with support from the Japan Trust Fund for Scaling Up Nutrition