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This article was originally published in the Russian language in Health and Illness (!"#$#%&' ( )#*'+,&) 2013, No 5 (113). It was translated and edited in Almaty, Kazakhstan and is published with permission of the authors and original publisher: Sharmanov T. Sh., President of the Kazakh Academy of Nutrition. The full Russian text is available at http://kankaz.org/states/5_2013.pdf
Sh. S. TAZHIBAEV, A.A. ERGALIEVA, O.V. DOLMATOVA, A.P. SARSEMBAYEVA, O.K. MUKASHEVA !

Kazakh Academy of Nutrition, Almaty!

!
ASSESSMENT OF AWARENESS, FOOD HABITS AND BEHAVIOR OF THE POPULATION OF KAZAKHSTAN IN THE FIELD OF HEALTHY NUTRITION!

Abstract:! This material is intended to establish the formation of an evaluation database of knowledge and a means of providing information about healthy eating, food habits and eating behavior of the population of Kazakhstan.! ! The prevalence of non-communicable diseases and food infections, resistance to adverse

environmental factors and psychological stress, the level of development of competitive economic forces, socio-economic status of the State, and the national security of the country are fundamental indicators of the development of a country and it is known that they can be linked to the nutritional status of the population. According to the World Health Organization, more than 60% of all causes of mortality are directly linked to preventable nutritional disorders that contribute to the development of non-communicable diseases [1-4]; in particular, cardiovascular pathology [5], cancer [6], obesity [7] osteoporosis [8], diabetes II! [9] and micronutrient

deficiencies [10]. Implementation of a set of measures to raise awareness and knowledge about healthy eating plays an important role in the prevention of these diseases.!

Keywords: healthy diet, micronutrients, awareness, prevention of non-communicable diseases.! ! Purpose and Objectives:! The purpose of this study is to develop a database of knowledge and identify ways of providing information about healthy eating, food habits and behavioral skills of the population of Kazakhstan. ! Material and methods study:! The subjects of the study were persons aged 15 years and over living in households in a nationally representative sample. The sample consisted of 2100 households: 70 sample clusters of 30 households per cluster. A cluster represents a census control plot (KUPN) created for the 2009 census with the average size of a KUPN being 1200 residents. A questionnaire surveyed various population groups to ascertain their knowledge and skills for healthy nutrition and the role of nutrition in prevention of most types of noncommunicable diseases and micronutrient deficiencies. The questionnaire also included questions on preferred forms, channels and time information on healthy eating. Field research on the collection of data was carried out in October and November 2012. All of the people were interviewed in either the Kazakh or Russian language as they preferred.! ! Research results:! 1. Awareness of healthy eating and sources of information:! ! An average of 57% of

all surveyed had received some information about healthy eating in the month preceding the

survey. The sources of information came mainly from health workers (55%) and TV (54%). Men were more likely to receive information from TV, and women from health professionals. Different sources of information were reported by only 0.8 to 13% of the respondents. ! For information about healthy eating, health care workers influenced most people (72%) and to a lesser extent TV (36%). Other sources of information showed a low level of influence from 1.2 to 6.6%.! The most effective time to reach respondents for presenting information about healthy eating on TV is the evening from 18.00 to 21.00 and for 22% from 21.00 and later. ! This is the preferred time as well for the dissemination of information by radio, on average for every third respondent. Other times of the day which were preferred on TV and on the radio were from 13.00 to 17.00 by 9 to 11% of the respondents.! The national TV channels and articles in national newspapers and magazines are preferred by the largest number of respondents, 38.5% and 49.3 respectively. More than 90% of respondents want to receive additional information about healthy eating. More than 95% consider it necessary to introduce a program of healthy eating and to keep the population informed of current knowledge in the field of healthy nutrition. More than 97% consider it important to receive information on healthy food programs needed to be implemented in schools.! ! 2. The Nutritional Status of the Population Studied: Based on the frequency of

consumption of basic food groups during the week preceding the survey milk, kefir, yoghurt, cottage cheese, cheese, and Brinza cheese are consumed several times per day by 59%; once a day by 26%, and less from 4.7 to 8.2% of respondents. These data may indicate that, on average,

every fourth person consumes these products in insufficient amounts which may contribute to the development of calcium deficiency and osteoporosis. Cream, sour cream, butter, margarine, and lard are consumed several times per day by 41%, once a day 39%, and less from 2.2 to 12.3%. Thus, about half the population consumes sources of animal fats in excess of which can contribute to the development of weight problems, obesity, and atherosclerosis and other cardiovascular diseases. ! Meat, poultry, sausages, liver and other offal are consumed several times per day by 39%, once a day 15%, and less frequently by 3.5 to 15 per cent of the respondents. Based on these data, it may be assumed that approximately 40% of the population consumes an insufficient amount of sources of high-grade animal protein, zinc and iron with good sources of hemoglobin that can contribute to the development of zinc and iron deficiency and iron deficiency anemia.! Fish and fish products are consumed several times per day by 4.4%, once a day 5.7%, 3 times per week 24%, and less by 62% of respondents. This indicates a lack of consumption of these products by more than half the population, which may contribute to the development of atherosclerosis and other cardiovascular diseases.! Eggs are consumed several times a day by 4.2%, once a day 16%, only 1-3 times a week by 39%, and less by 35% of the respondents. Apparently, only about 20% of the population consumes eggs in excess that can contribute to the development of atherosclerosis and other cardiovascular diseases.! Legumes (beans, peas, soybeans, corn, lentils) and nuts are consumed several times per day 5%; every day 9%; 1-3 times per week 32%, and less frequently 42% per cent of the respondents. Thus, about half the population consumes these sources of dietary fiber and proteins

of vegetable origin with a good amino acid composition in insufficient amounts which may contribute to the development of atherosclerosis and other cardiovascular diseases.! Vegetables and fruits are consumed several times per day by 79%, once a day 12 per cent, and less from 2 to 6% of respondents. About 20% of the population, when they are ill, often consumes these sources of dietary fiber, several B vitamins (Ascorbic acid and folic acid, betacarotene), organic acids, and biologically active compounds that can prevent the development of non-communicable diseases.! Grain products (bread, pasta, flour, rice, buckwheat, barley, and other cereals) are consumed a few times a day by 41%, once a day 39%, and less from 2.2 to 12.3%. These data may indicate adequate consumption of these products, by a large majority of the population. It is also possible that some portion of the population consumes these products in excess which can contribute to the development of weight problems and obesity.! Potatoes, beetroot and other root vegetables and tubers are consumed several times a day 32 percent, once a day 44%, and less by 4 to 20 per cent of the respondents. About 20% of the population does not consume these products often enough which can contribute to the development of deficiency of certain vitamins (Ascorbic acid) and trace elements.! Sugar, candy, cakes, chocolates and other sweets are consumed several times per day by 59%, once a day by 18%, and less by 8 to 11 per cent of the respondents. Therefore, about 60% of the population consumes these simple sugars too often and these sources can contribute to the development of weight problems and obesity, diabetes and other non-communicable diseases.! Tea or coffee is consumed several times per day 91%, once a day 6%, less often 1 to 2%. The majority of the population consumed tea and coffee while eating (49%) or

immediately after eating (42%), which can contribute to the development of iron deficiency and iron deficiency anemia.! Frequency of consumption of basic food groups! Several times per ! day (%)! Milk, kefir, yoghurt, cottage cheese, cheese "#! Cream, sour cream, butter, margarine, and &+!
lard Meat, poultry, sausages, liver Fish and fish products Eggs! Legumes (beans, peas, soybeans, corn, lentils) and nuts Vegetables and fruits Grain products Potatoes, beetroot and other root vegetables! Sugar, candy, cakes, chocolates and other sweets! Tea or coffee!

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3. The consumption of healthy food:!

It was found that healthy foods fortified with

vitamins and minerals; rich in or enriched with fiber; and low in calories, salt, sugar and animal fat were not consumed in the 24 hours prior to the survey by the vast majority of the respondents: from 82% to 93%. This may contribute to the development of micronutrient and dietary fiber deficiencies, weight problems and obesity, diabetes, atherosclerosis and other cardiovascular diseases.! Three quarters of the population is not interested in or aware of the calories, vitamins, micronutrients, sugar, salt and fiber in the foods they buy. This is indicative of a lack of public awareness about healthy foods and their consumption, and of the importance of implementation of a set of activities to raise awareness about healthy eating.! Among respondents who are interested in the content of calories, vitamins, minerals, sugars, salt and dietary fiber in the food products that they buy, 93% prefer such products when

shopping. These data indicate the possibility of success for an informational program to increase consumption of healthy food by increasing public awareness of such products.!

4. Awareness and knowledge of the population about micronutrients and the prevention of micronutrient deficits are characterized by the following basic indicators: Only from 4 to

10% of the respondents had taken nutritional supplements (iron with folic acid, vitamins A, C and D, multivitamins and vitamin-mineral complexes, and iodine) in the 24 hours preceding the poll. This reflects a lack of awareness of the need of micronutrients. At the same time this low level of consumption of vitamin/mineral supplements can contribute to the development of micronutrient deficiencies. Among respondents who had taken micronutrients, 74% of cases were on the advice of medical personnel and 16% on their own initiative which should be considered when implementing informational programs for the prevention of micronutrient deficiencies.! From 20% (about the benefits of zinc) to 86% (about the benefits of iodine) of the respondents had heard about the use of different micronutrients (iron, zinc, iodine, vitamins A, D, and folic acid), which varied among people depending on the type of micro-nutrients.! Respondents also strongly differed in their knowledge of the benefits of different micronutrients and signs of deficiencies. Greater awareness was revealed on the usefulness of iodine and iron, as well as signs of deficiency of micronutrients, and a lower level of awareness concerning use of zinc and signs of its deficiency. These differences relate to the more intensive informative programs for the prevention of iodine and iron deficiencies and the practical absence of such works to prevent zinc deficiency.!

Among the respondents, 37% reported that they had anemia, 20% iodine-deficiency, 19% zinc deficiency, 15% vitamin A, 18% lack of folic acid, and 12% are deficient in vitamin D. These data show a high prevalence of micronutrient deficiency and the need for the implementation of integrated programs for its prevention.! From 84 to 87% of respondents want to have further information on the various micronutrient deficiencies and prevention, which suggests a need to implement a set of measures to raise awareness and knowledge of the role of micronutrients, signs and prevention of their deficits. ! 5. Awareness and knowledge of the population about the fortification of foods and micronutrients:! General awareness of iodized salt (92%), interest in (75%), and a

preference for iodized salt (99%) when shopping for salt were high. In addition, 94% of respondents reported that they usually eat iodized salt at home. These figures illustrate the high level of public awareness about the benefits, availability and consumption of iodized salt. According to the information on the packaging, the salt in 97 per cent of households was iodized. In 89% of cases it was stored in closed containers and in 91% of households was made by Araltuz. ! These results are the result of many years of comprehensive work on salt iodization for prophylaxis of iodine deficiency among the population. Since 2007, the Republic of Kazakhstan has been certified by international organizations as a country that has solved the problem of salt iodization.! Total awareness of the fortification of wheat flour was low (31%), as was interest in fortification (57%) and preference (52%) for fortified flour when buying. Only 10% of

respondents reported that they usually eat fortified flour at home. These indicators describe a low level of knowledge by the population about the fortification, availability and consumption of flour.! According to the packaging information, only 10% of households used fortified flour. In 36% of the households, flour was packed in1-3 kg paper packaging and in 62% packing was in 25-50 kg sacks. 34% used "Tsesna astyk" brand and the share of other brands of wheat flour ranged from 0.03 to 3.7%. These data indicate the need to increase the production and availability of fortified wheat flour and to raise public awareness of fortified flour. 81% of the respondents want to get more information about fortified wheat flour and 84 per cent about iodized salt.! ! 6. Awareness and knowledge of the population about the role of nutrition in the development and prevention of non-communicable diseases: Among respondents, 28%

have had cardiovascular disease, 8% an increase of blood glucose, and 5% and 2.1% osteoporosis or cancer. It is possible that these figures are understated because of the lack of timely diagnosis of these diseases. From 0.5 up to 47 per cent of the respondents knew that the consumption of some foods can promote the development of disease, and from 2 to 37% of the respondents that the consumption of other foods may contribute to the prevention and treatment of non-communicable diseases. The lowest figures were for cancer and osteoporosis, showing a low level of awareness and knowledge of the role of nutrition in the development and prevention of non-communicable diseases, and underscoring the need to improve this knowledge and awareness.!

80 to 86% of the respondents would like more information about the role of nutrition in the development, prevention and treatment of non-communicable diseases.!

Conclusion:!! During this work on a national scale we identified the levels of awareness and behavioral patterns of the population in the area of healthy diet and the role of diet in the prevention of many common non-infectious diseases and micronutrient deficiencies. The research
also indentified preferred, most effective and influential forms, channels, and times for receiving information about healthy eating habits that must be taken into account in the implementation of

communication activities for the formation of healthy nutrition. ! The initial questionnaire survey in the first year of the study was undertaken in order to collect baseline data at the national level. That is, before the implementation of the State program "Salamaty Kazakhstan", an integrated block of communication activities at the national level in the field of healthy nutrition for the reform of health care, The baseline data will be used in the next two years to carry out a comparative analysis of the effectiveness of integrated communication for administrative activities in the field of healthy nutrition.! ! List of References! 1. Manual program CINDY. WHO; 2000; c. 49 ! 2. Preventing Chronic Diseases: A Vital Investment. WHO; 2005; p. 32 3. Preventing Noncommunicable Diseases in the Workplace through Diet and Physical Activity: WHO/World Economic Forum on the joint event; WHO, the World Economic Forum; 2008; c. 47 ! 4. WHO, World Health statistics. Geneva; 2010; p. 177.! 5. Cardiovascular Diseases Fact Sheet. The Who; 2007; p. 3 !

6. Carcinogens and Anticarcinogens in the Human Diet: A Comparison of Naturally Occurring and Synthetic Substances; Committee on Comparative Toxicity of Naturally Occurring Carcinogens, National Research Council; isbn 0-309-55659-7; 1996; p. 436. the pdf is available from the National academies press at: http://www.nap.edu/catalog/5150.html.! 7. The Problem of Obesity in the WHO European Region; Strategy of the WHO; Copenhagen; 2009; p. 408.! 8. Prevention and Management of Osteoporosis. Report of WHO Scientific Group; WHO Technical Report Series; 2003; No 921; p. 201 ! 9. Global Prevalence of Diabetes. Estimates for the Year 2000 and Projections for 2030. Diabetes Care; Vol. 27, no. 5, 2004; p. 1047-53.! 10. Vitamin and Mineral Deficiency. A Global Progress Report. UNICEF, the Micronutrient Initiative; 2007; p. 43! !! !