NUTRITION COUNTRY PROFILE REPUBLIC OF

FOOD AND AGRICULTURE ORGANIZATION OF THE UNITED NATIONS

Acknowledgments

This profile was prepared by Adrian Berisha, PhD, Senior Lecturer in Nutrition and Food Chemistry, Agrofood Department, Agricultural University of , Albania, in collaboration with Estelle Bader and Chiara Deligia, Consultants, and Marie Claude Dop, Nutrition Officer, Nutrition Planning, Assessment and Evaluation Service, Food and Nutrition Division, Food and Agriculture Organization of the United Nations.

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 2 Summary

Albania is a country of Eastern Europe with a relatively young and predominantly rural population. Agriculture accounts for an important share of the gross domestic product (GDP), but the level of mechanization is low and the size of farms is small. Agricultural exports are limited and production is mostly for subsistence. After the end of the communist regime in 1991, Albania experienced a difficult economic transition and suffered two economic shocks due to the financial collapse of the so-called “pyramid schemes” in 1997 and to the crisis in 1999.

While the GDP has been growing substantially, poverty still affects a large proportion of the population, particularly in rural areas and among the newly urbanized, and causes problems of access to food and health services. Another consequence of poverty is the increase in child labour and a subsequent decrease in school enrolment in rural areas during the last decade. Health services remain underdeveloped and of poor quality. However, infant, child and maternal mortality rates have progressively decreased and immunization coverage is good.

Since the 1990s, the supply of many food groups has increased, particularly for dairy products and eggs, and fruit and vegetables. Consequently the diet has become more diversified, especially in urban areas. Presently, at national level, the dietary energy supply is largely sufficient to meet the population’s energy requirements. Overall the prevalence of undernourishment is low. However, Albania is increasingly dependent on imports of cereals.

Infant and young child feeding practices are inadequate. Although a very large majority of infants are breastfed, initiation of breastfeeding after birth is late and exclusive breastfeeding is rarely practiced. These inadequate practices, together with poverty and lack of access to health services of quality are reflected in the poor nutritional status of preschool children, which appears to have worsened in the last few years. In 2000, about a third of children under five years were stunted and one out of ten was wasted. At the same time, the population is undergoing a nutrition transition and the prevalence of overweight and obesity is high among adults in the capital Tirana.

Iodine deficiency disorders are common among children, particularly in mountainous areas which represent a large part of the country. Less than half of rural households consume adequately iodized salt. Although data on vitamin A deficiency are not available, it seems unlikely that this deficiency is widespread because of the high dietary supply of dairy products and eggs. Limited data on iron deficiency suggest that it is an important public health problem affecting a large proportion of children under 2 years of age. Supplementation with iron has been conducted in some areas but is not generalized.

Major improvements in health care and efforts in nutrition education are needed to reduce the high prevalence of undernutrition, while preventing the transition to obesity and chronic diseases. In particular promotion of better infant and young child feeding practices, promotion of diets rich in fruit and vegetables for all, and programmes to alleviate rural and urban poverty to ensure better access to nutritious foods, are the main actions that could improve the nutrition situation.

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 3 Summary Table Basic Indicators Year Population Total population 3.062 million 2000 Rural population 58 % 2000 Population under 15 years of age 30 % 2000 Annual population growth rate 0.44 % 2000/05 Life expectancy at birth 74 years 2000/05 Agriculture Agricultural area 42 % 2002 Arable and permanent cropland per agricultural inhabitant 0.5 Ha 2002 Level of development Human development and poverty Human development index 0.781 [0-1] 2002 Proportion of population living with less than 1$ a day (PPP) MDG1 17 % 2002 Population living below the national poverty line MDG1 25 % 2002 Education Net primary enrolment ratio MDG2 97 % 2000 Youth literacy (15-24 years) MDG2 99 % 2002 Ratio of girls to boys in primary education MDG3 1.0 girl per 1 boy 2001/02 Health Infant mortality rate MDG4 18 ‰ 2003 Under-five mortality rate MDG4 21 ‰ 2003 Maternal mortality ratio (adjusted) MDG5 55 per 100 000 live births 2000 Tuberculosis prevalence MDG6 33 per 100 000 people 2003 Environment Sustainable access to an improved water source in rural area MDG7 95 % of population 2002 Nutrition indicators Year Energy requirements Population energy requirements 2 275 kcal per capita/day 2001 Food supply Dietary Energy Supply (DES) 2 880 kcal per capita/day 2001 Prevalence of undernourishment MDG1 6 % 2000/02 Share of protein in DES 14 % 2000/02 Share of lipids in DES 26 % 2000/02 Food diversification index 53 % 2000/02 Food consumption Average energy intake (per capita or per adult) n.a. Percent of energy from protein n.a. Percent of energy from lipids n.a. Infant and young child feeding Age Exclusive breastfeeding rate <6 months 7 % 2000 Timely complementary feeding rate 6-9 months 24 % 2000 Bottle-feeding rate 0-11 months n.a. Continued breastfeeding rate at 2 years of age 6 % 2000 Nutritional anthropometry Stunting in children under 5 years 32 % 2000 Wasting in children under 5 years 11 % 2000 Underweight in children under 5 years MDG1 14 % 2000 Women with BMI<18.5 kg/m² n.a. Micronutrient deficiencies Prevalence of goitre in school-age children n.a. Percentage of households consuming adequately iodized salt 57 % 2000 Prevalence of vitamin A deficiency in preschool children n.a. Prevalence of vitamin A supplementation in preschool children 7 % 2000 Prevalence of vitamin A supplementation in mothers 3 % 2000 Prevalence of anemia in women n.a. Prevalence of iron supplementation in mothers n.a. MDG: Millennium Development Goal; n.a.: not available

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 4 TABLE OF CONTENTS

Acknowledgments...... 2 Summary ...... 3 Summary Table...... 4 List of tables and figures ...... 6 Acronyms ...... 7 Part I: Overview and basic indicators ...... 8 I.1 Context...... 8 I.2 Population...... 8 Population indicators ...... 8 Population pyramid for 2001...... 9 I.3 Agriculture ...... 9 Land use and irrigation statistics ...... 9 Main crops, agricultural calendar, seasonal food shortage ...... 10 Livestock production and fishery ...... 10 I.4 Economy ...... 10 I.5 Social indicators ...... 11 Health indicators ...... 11 Water and sanitation...... 12 Access to health services ...... 13 Education ...... 13 Level of development, poverty...... 13 Other social indicators ...... 14 Part II: Food and nutrition situation ...... 15 II.1 Qualitative aspects of the diet and food security...... 15 Food consumption patterns ...... 15 Food security situation...... 15 II.2 National food supply data ...... 16 Supply of major food groups...... 16 Dietary energy supply, distribution by macronutrient and diversity of the food supply...... 17 Vegetable/animal origin of macronutrients ...... 18 Dietary energy supply by food group...... 18 Food imports and exports expressed as percentage of DES...... 19 Food aid ...... 20 II.3 Food consumption...... 20 National level surveys...... 20 II.4 Infant and young child feeding practices ...... 21 II.5 Nutritional anthropometry...... 22 Anthropometry of preschool children...... 22 Anthropometry of school-age children and adolescents ...... 25 Anthropometry of adult women...... 25 Anthropometry of adult men ...... 25 II.6 Micronutrient deficiencies...... 26 Iodine deficiency disorders (IDD)...... 26 Prevalence of goitre and urinary iodine level ...... 26 Iodization of salt at household level ...... 27 Vitamin A deficiency (VAD)...... 28 Prevalence of sub-clinical and clinical vitamin A deficiency...... 28 Vitamin A supplementation...... 28 Iron deficiency anemia (IDA) ...... 28 Prevalence of IDA...... 28 Interventions to combat IDA ...... 29 II.7 Policies and programmes aiming to improve nutrition and food security ...... 29 Reference list ...... 30

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 5 List of tables and figures

List of tables Table 1: Population indicators ...... 8 Table 2: Land use and irrigation...... 9 Table 3: Livestock and fishery statistics ...... 10 Table 4: Basic economic indicators...... 11 Table 5: Health indicators...... 12 Table 6: Access to safe water and sanitation...... 12 Table 7: Access to Health Services...... 13 Table 8: Education...... 13 Table 9: Human development and poverty ...... 14 Table 10: Other social indicators...... 14 Table 11: Trends in per capita supply of major foods groups (in g/per day)...... 16 Table 12: Share of the main food groups in the Dietary Energy Supply (DES), trends ...... 19 Table 13: Initiation and duration of breastfeeding ...... 21 Table 14: Type of infant feeding by age...... 21 Table 15: Anthropometry of preschool children ...... 23 Table 16: Anthropometry of adult women ...... 25 Table 17: Anthropometry of adult men ...... 26 Table 18: Prevalence of goitre and level of urinary iodine in school-age children...... 27 Table 19: Iodization of salt at household level ...... 27 Table 20: Vitamin A supplementation of children and mothers...... 28

List of figures  Figure 1: Dietary energy supply (DES), trends and distribution by macronutrient ...... 17  Figure 2: Vegetable/animal origin of energy, protein and lipid supplies...... 18  Figure 3: Dietary energy supply by food group...... 18  Figure 4: Major food exports as percentage of Dietary Energy Supply (DES), trends...... 19  Figure 5: Major food imports as percentage of Dietary Energy Supply (DES), trends...... 20

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 6 Acronyms

BMI Body mass index CWF Committee on Women and Family DES Dietary energy supply DPT3 Diphtheria, pertussis (whooping cough) and tetanus vaccine – three doses FAO Food and Agriculture Organization of the United Nations FAOSTAT FAO Statistical Databases FIVIMS Food Insecurity and Vulnerability Information and Mapping Systems FNAP Food and Nutrition Plan Action FSS Faculty of Social Sciences GDP Gross domestic product GNP Gross national product GOA Government of Albania Hb Hemoglobin HIV/AIDS Human immunodeficiency virus/ acquired immuno deficiency IDA Iron deficiency anemia IDD Iodine deficiency disorders ILO International Labour Organization IPH Institute of Public Health ITU International Telecommunication Union MICS Multiple Indicator Cluster Survey NCHS National Center for Health Statistics NGOs Non Governmental Organizations PPP Purchase power parity SOFI The State of Food Insecurity in the World SuRF Surveillance of chronic disease Risk Factors TGR Total goitre rate UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNESCO United Nations Educational, Scientific and Cultural Organization UNICEF United Nations Children’s Fund UNPD United Nations Population Division UNSTAT United Nations Statistics Division VAD Vitamin A deficiency WB World Bank WHO World Health Organization

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 7 Part I: Overview and basic indicators

I.1 Context

The Republic of Albania is a small, very mountainous country on the western side of the Balkan Peninsula, bordered by the Adriatic Sea to the west, Greece to the south, the former Yugoslav Republic of Macedonia to the east, and and to the north and north east. Its total land area is of 28 750 km2. About 70 % of the territory is above 300 m. The land rises steeply from the coastal plain to elevations of more than 2 400 m. The most rugged mountains are in the north. The mountains become gentler to the south, eventually merging with the Pindus Mountains of northern Greece. The coastal lowlands have a Mediterranean climate with hot, dry, almost cloudless summers with mild, rainy winters. In the mountains, there is more summer rainfall and higher humidity, especially in the north. Temperatures in the mountains have much larger diurnal variation. The average temperatures in August, the hottest month, range from 17°C to 31°C. January, the coldest month, ranges from 2°C to 12°C. December, the wettest month, has an average rainfall of 211 mm while the driest months, July and August, receive only 32 mm. On the coast, annual rainfall averages 1 200 mm, but it may range up to 4 060 mm in the mountains, often occurring as snow (FAO, Forestry Division; FAO, 2004a).

I.2 Population

Population indicators

The Albanian population is relatively young, with 30% of the population under 15 years. It is estimated that about 900 000 people have emigrated in that period, representing about 35% of the work force of the Albanian population. Urbanization has increased rapidly since 1991, together with emigration (IMF, 2000). In 2003, the unemployment rate was about 15% (GOA & UNDP, 2004). Table 1: Population indicators Indicator Estimate Unit Reference Period Source Total population 3 062 thousands 2000 UNPD Annual population growth rate 0.44 % 2000-2005 UNPD Crude birth rate 17.2 ‰ 2000-2005 UNPD Population distribution by age: 2000 UNPD 0-4 years 9 % 5-14 years 21 % 15-24 years 17 % 60 and over 11 % Rural population 58 % 2000 UNPD Agricultural population 48 % 2000 FAOSTAT Population density 107 inhabitants per km2 2000 UNPD Median age 27 years 2000 UNPD Life expectancy at birth 74 years 2000-2005 UNPD males per 100 Population sex ratio 98.9 2000 UNDP female Net migration rate -6.5 ‰ 2000-2005 UNPD Total dependency rate 60 % 2000 UNPD

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 8 Population pyramid for 2001

Source: UNAIDS, 2002

I.3 Agriculture

Agriculture in Albania is still the main activity, employing about half of the labour force. The average agricultural land per capita (less than a hectare) is one of the smallest in Europe, even though agricultural land more than doubled from 1950 to 1990 due to drainage of marshland, terracing and cultivation of forest and pastures, and establishment of new irrigation schemes. has a low level of mechanisation and is considered as subsistence agriculture. Production is dominated by cereals, forage, vegetables, fruits and olive production. Agriculture still provides the income base for most of the population and serves as an employment safety net (FAO, 2004a; INSTAT, 2005).

Land use and irrigation statistics Table 2: Land use and irrigation Type of area Estimate Unit Reference period Source Total Land Area 2 740 1000 Ha 2002 FAO Agricultural Area 42 % 2002 FAO Arable lands & Permanent Crops 26 % 2002 FAO Permanent Crops 4 % 2002 FAO Permanent Pasture 16 % 2002 FAO Forested land areas 36 % 2002 FAO Irrigated agricultural land 12 % 2002 FAO Arable & Permanent cropland in Ha per 0.5 Ha 2002 FAO agricultural inhabitant N.B. Percents are calculated on the total land area.

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 9 Main crops, agricultural calendar, seasonal food shortage The 5 major food and agricultural commodities produced in Albania in 2002 were cow milk, wheat, watermelons, fresh vegetables and maize (FAO, Statistics Division). All these commodities were mainly used for local human consumption (FAO, FAOSTAT Database).

Source: GIEWS/FAO

Based on the seasonality, fresh vegetable shortage might occur from November to May.

Livestock production and fishery Livestock breeding in Albania is still done on extensive pasture during the summer while livestock is fed forage during the winter. Livestock breeding is dominated by cattle, pigs (especially in the catholic areas such as Lezha, Shkodra, Mirdita region) with approximately 2~5 heads per family. Sheep breeding is concentrated in some mountain areas such as Peshkopi (Luma), Tepelena, Gjirokastra and Vlora area and nomadic breeding is occasional. Poultry production is limited, and is mainly a family type production (INSTAT, 2005). Consumption of fish is increasing with the fisheries’ production, amounting to 4.6 kg per capita per year in 2003 (FAO, 2004b). Table 3: Livestock and fishery statistics Livestock production and Estimate Unit Reference period Source fishery Cattle 700 000 number of heads 2004 FAO Sheep and Goats 2 825 000 number of heads 2004 FAO Poultry Birds 5 355 thousands 2004 FAO Fish catch and aquaculture 700 000 tons 2004 FAO

I.4 Economy

The agricultural sector contributes 29% of GDP. Among the non-agricultural activities, services represent 46% of GDP, industry represents 10%, transport 10% and construction 9% (Luçi, 2004). The transition from a centrally planned economy to a market system, witch started after the collapse of the Union of Soviet Socialist Republics (USSR) in 1991, has been marked by a steady growth, but also by increased poverty, underemployment and gender inequality. The financial disaster and civil unrest triggered by the implosion of the pyramid schemes in 1997 and the inflow of refugees caused

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 10 by the Kosovo crisis in 1999 further aggravated the situation. The progress of the country continues to be largely dependent on external flows of assistance, be it from foreign aid or working abroad (WFP, country brief; Jarvis, 2000; HDPC, 2002). Table 4: Basic economic indicators Indicator Estimate Unit Reference Period Source Gross Domestic Product per capita 4 830 PPP US $ 2002 UNDP GDP annual growth 7.3 % 2000 WB Gross National Income per capita 1 150 $ 2000 WB Industry as % of GDP 19 % 2000 WB Agriculture as % of GDP 29 % 2000 WB Services as % of GDP 52 % 2000 WB Paved roads as % of total roads 39 % 2000 WB per 10 000 Internet users 39 2002 ITU people Total debt service as % of GDP 0.7 % 2000 WB Military Public expenditure 1.2 % of GDP 2000 UNDP

Albania’s main non agricultural imports are manufactured goods, transport machinery and equipment, minerals, fuels, chemical products. Its main non agricultural exports are manufactured goods and crude materials (INSTAT, 2002).

I.5 Social indicators

Health indicators The child mortality rate has been reduced by almost half since 1990, and Albania is making progress in reducing both infant and under-five mortality. However, data are not always available for remote rural areas, and national rates remain high in comparison with the level in European countries (GOA & UNDP, 2004). Maternal mortality rates also remain high for the European level, particularly in rural areas. However, the reduction of illegal abortions and the increase in contraceptive use are trends that should lead to a decrease in maternal mortality in Albania (GOA & UNDP, 2004). Albania has an obligatory vaccination scheme which maintains child immunization rates at a high level against measles, diphtheria, tetanus, pertussis, tuberculosis, poliomyelitis, hepatitis B as well as rubella (GOA & UNDP, 2004). Tuberculosis is perceived as a threat to national health, with a soaring tuberculosis prevalence. Poverty, urban overcrowding and promiscuity, as well as the geographical isolation of a part of the population and an overcrowded prison system all underline the size of the total population at risk and the high potential for a rapid increase of the disease (GOA & UNDP, 2004). The incidence of HIV/AIDS in Albania is very low but is increasing (MOH, 2003), and although data are lacking, Albania is considered as a country at high risk concerning Sexually Transmitted Infections, in part due to the young population, to internal and external migration, and to an increase in prostitution (HDPC, 2002).

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 11 Table 5: Health indicators Reference Indicator Estimate Unit Source Period Mortality Infant mortality 18 ‰ 2003 UNICEF Under-five mortality 21 ‰ 2003 UNICEF Maternal mortality ratio : UNICEF per 100 000 reported 20 1985-2003 UNICEF live births per 100 000 adjusted 55 2000 UNICEF live births Morbidity Prevalence of diarrhoea in the last 2 7 % 2000 UNICEF/MICS weeks in under-fives Oral Rehydration rate among under-fives 51 % 1994-2003 UNICEF/MICS Percentage of under-fives with acute 1 % 1998-2003 UNICEF/MICS respiratory infections in the last 2 weeks per 100 000 Tuberculosis prevalence 33 2003 UNSTAT people HIV/AIDS Prevalence in adults < 0.1 % 2000 UNSTAT Percentage of women (15-24) who know that a person can protect herself from HIV 42 % 2000 UNSTAT infection by consistent condom use Immunization Percent of infants with immunization 95 % 2003 UNICEF/WHO against tuberculosis at 1 year of age Percent of infants with DTP3 97 % 2003 UNICEF/WHO immunization at 1 year of age Percent of infants with immunization 93 % 2003 UNICEF/WHO against measles at 1 year of age Percent of pregnant women immunized 30 % 2000 UNICEF/MICS against tetanus

Water and sanitation Only 66% of Albanians have access to piped water, with lower rates in rural areas. Overall 80% of households have access to improved water sources, when all these sources are considered, and not just piped water. In rural areas water is of poor quality and unsafe. Combined with poor hygiene, it is a major cause of infant morbidity (GOA & UNDP, 2004). In many cities, the availability of water could reach 500~700 litres/capita, but the losses in the distribution systems (up to 60%) are reducing drastically water availability for end-users (Rohde et al, 2004). Concerning sanitation, there is a striking gap between rural and urban areas, with 46% of rural population not having any access to a piped toilet, while 93% of the population in Tirana has at least one toilet in their dwelling (GOA & UNDP, 2004). Table 6: Access to safe water and sanitation Indicator Estimate Unit Reference period Source Sustainable access to an improved water source: Combined urban/rural 80 % of population 2002 GOA & UNDP Access to improved sanitation: Combined urban/rural 89 % of population 2002 UNICEF

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 12 Access to health services

Albanian health services are limited. Budgetary spending on health in Albania is one of the lowest in the region. Currently, 30% of existing health centers are not functioning due to a variety of reasons (IMF, 2000). There is a lack of trained and motivated health personnel, particularly in rural areas. The bad state of health service equipment, limited physical access to health services, poor quality of basic services and widespread poverty contribute to a general low access, in terms of quality as well as quantity, to health services in the country (GOA & UNDP, 2004). Table 7: Access to Health Services Reference Indicator Estimate Unit Source Period per 100 000 Health personnel: number of physicians 137 1990-2003 WHO people Population with sustainable access to low 1999 UNDP affordable essential drugs access* Percent of births attended by skilled 99 % 1995-2002 UNICEF health personnel Public expenditure on Health 2.4 % of GDP 2001 UNESCO * estimated at 50-79% of total population

Education For the 8 years of mandatory , enrolment rates are above 95%. However, overcrowded classes and unfavourable teaching conditions impact negatively on the quality of education. Since 1990, total enrolment in school has been declining. Deep poverty is a major cause of school drop-out, particularly for boys, and in northeastern areas and among households that have migrated to the outskirts of big cities. In primary education, female participation fell from 92% in 1995 to 82% in 2000. Illiteracy is growing especially in younger age groups and in areas where there is large-scale migration of the population (HDPC, 2002; GOA & UNDP, 2004). Recently, a number of private elementary and high schools have flourished, especially in big cities like Tirana, Durres etc. Table 8: Education Reference Indicator Estimate Unit Source Period Adult literacy 99 % 2002 UNESCO Adult literacy rate : females as % of males 99 % 2002 UNESCO Youth literacy (15-24 years) 99 % 2002 UNESCO Net primary enrolment ratio 97 % 2000 UNESCO Grade 5 completion rate n.a. number of girls Ratio of girls to boys in primary education 1.0 2000-2001 UNESCO per 1 boy Public expenditure on education 5.8 % of GDP 1990 UNESCO n.a.: not available

Level of development, poverty In 2002, 25% of the Albanian population was living under the national poverty line, and 5% could not meet their basic food needs. There is a strong regional dimension of poverty in Albania: rates of poverty are 50% higher in rural, remote and mountainous areas of the country than in urban areas. The poverty situation is related to a weak social safety net, poor service infrastructure in health care, education and social security. The average level of poverty in Kukes, Has, Tropoje, Diber, Malesi Madhe, Bulqize, Librazhd, and Gramsh is 46%. About 80% of those receiving aid live in these areas. Numerous households, women- headed households, rural youth and elderly are among the most vulnerable (GOA & UNDP, 2004).

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 13 Table 9: Human development and poverty Indicator Estimate Unit Reference period Source value Human development index (HDI) 0.781 2002 UNDP between 0-1 Proportion of population living with 17 % HDPC less than 1$ a day (PPP) Population living below the national 25 % 2002 WB poverty line Human poverty index (HPI-1) n.a. n.a.: not available

Other social indicators Whereas there are no significant gender disparities in education, there are on the labour market, particularly in the private sector. Major factors are traditional and conservative views regarding women’s role, limited perspective on employment and career for women and lack of adequate policy framework to support solving of gender-related issues (GOA & UNDP, 2004). In 2000, UNICEF estimated that 31.7% of children ages 5 to 14 years in Albania were working in some capacity. Children, especially from the Roma community, work on the streets as beggars and vendors; other Albanian children work on farms (USDL, 2005). Difficulties experienced by the education system and school drop-outs caused by poverty are factors that could fuel child labour in Albania. Table 10: Other social indicators Reference Indicator Estimate Unit Source period value Gender related development index (GDI) 0.778 2002 UNDP between 0-1 Women’s wage employment in non- agricultural sector as % of total non 41 % 2001 ILO agricultural employees Ratification of ILO Convention 182 on The Ratified 2001 ILO Worst Forms of Child Labour

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 14 Part II: Food and nutrition situation

II.1 Qualitative aspects of the diet and food security

Food consumption patterns As in Mediterranean countries, the staples in Albania are cereals, particularly bread and spaghetti, and starchy roots. Potatoes are widely used baked, fried and boiled, especially in lower income families. The common foods usually complementing the staples are dairy products (milk, butter and cheese), meats (bovine, mutton and goat meat), fats and oils, vegetables (tomatoes, eggplants). The types of dishes are mainly cooked vegetables with meat (cattle and pig meat), oven-baked or cooked potatoes, cooked beans and leeks, and cabbage which is consumed predominantly in winter. Tomato salads with cheese and olive oil, along with fried potatoes, eggplants, peppers and lettuce are eaten in the summer. There is no significant variation among regions or ethnic groups in staples and dishes. The meat consumption is almost at the same level in all Albania. However, there is a higher consumption of pork in the catholic areas (Mirdita, Lezha, Shkodra and Burrel), compared with the rest of Albania and a higher consumption of mutton in the southern part of Albania (Përmet, Tepelena and Vlora). However, there is a difference between the rural and urban diets. In rural areas, because Albanian farms are subsistence farms with low cash revenues, the diet is based on consumption of fresh farm products such as tomatoes, lettuce, eggplants, cabbage, peppers and dairy products (fresh milk, butter and cheese). Being far away from producers, the urban diet in Albania is shifted towards processed fruit and vegetables, and mostly frozen, processed and preserved foods. This can be seen especially during the off season time. Compared with the rural inhabitants, physical activity in cities is far less intense. There is concern that the sedentary life style in urban areas will lead to an increase in prevalence of overweight, high cholesterol, hypertension and atherosclerosis. The differences observed between the urban and rural diets are signs of the nutrition transition in which the country is engaging gradually. The major part of the people consume 3 meals per day (breakfast, lunch and dinner), however, the urbanization of life and the time restriction often cause omission of breakfast.

Food security situation Food security is defined as “A situation that exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life” (FIVIMS). Food insecurity may be caused by the unavailability of food, insufficient purchasing power, inappropriate distribution, or inadequate use of food at the household level. Food insecurity may be chronic, seasonal or transitory. According to the Food Agriculture Organization (FAO) and the World Food Programme (WFP), lack of food security in Albania is a result of the general economic situation of families, especially in rural areas, and not due to a shortage of food supplies. Food production is constrained by the limited area for cultivation. This in turn is influenced by the timing and amount of rainfall, and by other agricultural challenges, such as pests and disease. Before 1990 about 70% of land was irrigated, permitting multiple crops per year. About half of this infrastructure, however, was damaged during the transition period. While some northern communities are dependent upon Government food aid in winter, most farmers survive with small-scale subsistence agriculture. These farmers, however, cannot afford a varied and healthy diet (HDPC, 2002). However, over the past decade, the country has been seeking to develop the framework for a market economy and a more open society. It faced many constraints such as extremely low levels of income and a lack of basic infrastructure, inflation after the shift in regime in 1991, turmoil during the 1997 pyramid crisis, and the social and economic shocks accompanying the 1999 Kosovo crisis (WB & INSTAT, 2004). Poverty causes difficulty in economical access to food. In 2002, about one

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 15 quarter of the Albanian population was poor and 5% could not meet their basic food needs. Food expenditures in Albanian families reach 63% of the family budget (GOA & UNDP, 2004). Difficulties in economic access to food have been decreasing in recent years. The domestic income per capita increases: for the period 1996/2000, the GDP per capita increased from 928 USD to 1934 USD. Remittances from the 10% of population or 35% of the labour force who have migrated contribute to food security (INSTAT, 2005).

II.2 National food supply data

Supply of major food groups Table 11: Trends in per capita supply of major foods groups (in g/per day) Supply for human consumption in g/day Major food groups 1965-67 1972-74 1979-81 1986-88 1993-95 2000-2002 Cereals (excl. Beer) 529 579 611 601 550 457 Starchy roots 38 45 50 39 55 87 Sweeteners 38 44 48 50 80 70 Pulses, nuts, oilcrops 26 22 19 21 21 38 Fruit and vegetables 291 324 339 290 461 679 Vegetable oils 9 14 24 21 22 23 Animal fats 13 9 9 12 10 7 Meat and offals 48 45 50 47 79 103 Fish, seafood 6 10 9 9 5 11 Milk and eggs 273 310 373 363 708 818 Other 20 24 24 30 52 60 Source: FAOSTAT The per capita supply in Albania had exhibited two patterns. Before the 1990s, the per capita supply was mainly constituted of cereals (wheat and maize, predominantly). This was due to the predominance of the traditional agricultural production which was stimulated by the communist policies to achieve staple food sufficiency. The reduction of the daily supply observed for many food groups during the period 1986/88 was due to the extreme centralization of the agricultural production. After the liberalisation of the economy in the early 1990s, the daily supply of many food groups (fruit and vegetables, meat and offals, milk and eggs) increased. The supply is still characterized by the high share of cereals. However, their supply is reduced, giving way to an increase of other food groups, particularly dairy products, fruit and vegetables and meat. The daily supply of starchy roots, fruit and vegetables, milk and eggs and meat more than doubled compared with the 1986/88 period. The increase suggests that diversity of the diet is improving for a major part of the population. On the contrary, cereal consumption was reduced about by one-third during the same period. This was caused by trade liberalization, shifting of the food supply from the traditional domestic production to imported products, together with life style changes. The supply of sweeteners and vegetable oils considerably increased from 1965/67 to 2000/02 and this increase could be a determinant of the nutrition transition emerging in the country.

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 16 Dietary energy supply, distribution by macronutrient and diversity of the food supply • Figure 1: Dietary energy supply (DES), trends and distribution by macronutrient Figure 1: Trends in DES per capita and percentages from protein, lipids & carbohydrates

3000

2500

2000 62 60 y

a 68 68 d

/ 71 l 1500 70 a c k 1000 24 26 20 20 500 18 17 12 12 12 12 14 14 0 1965-67 1972-74 1979-81 1986-88 1993-95 2000-2002

Albania Protein Lipids Carbohydrates Source: FAOSTAT

In 2001, the dietary energy supply (DES) was 2 880 kcal/per capita/day, well above population energy requirements of 2 275 kcal per capita/day1. According to “The State of Food Insecurity in the World” (SOFI), the prevalence of undernourishment was 6% in 2000/02 (FAO, 2004d). For the past 40 years, the per capita DES exhibited a steady increase, from 2 261 kcal/day (1965/67) to 2 861 kcal/day (2000/02). The increase was particularly important in the early 1990s in relation with the political and economical changes in the country. In parallel there was an increase in the share of lipids (from 18 to 26%). The increase in lipids can be related to an increase of the supply of vegetable oils up to 1981 and of meat from 1993/95. The share of lipids is adequate in comparison to recommendations (energy from lipids not exceeding 30%) (WHO, 2003).

1 Energy requirements are for a healthy and active lifestyle, calculated using FAO software (FAO, 2004c). Software default values attribute to 90 % of the urban adult population a light physical activity level (PAL=1.55) and greater than light activity to the remaining 10% (PAL=1.85), and to 50% of the rural adult population a light activity (PAL=1.65) and greater than light physical activity (PAL=1.95) to the other 50%.

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 17 Vegetable/animal origin of macronutrients • Figure 2: Vegetable/animal origin of energy, protein and lipid supplies Figure 2: Origin of energy, protein and lipid supplies, 2000-2002

Vegetable/animal origin 100 (in %) Percentage of animal origin 28 Percentage of vegetable origin 80 47 60 60

40 72 53 20 40

0 Energy Protein Lipid Albania 2000-2002 Source: FAOSTAT

The high proportion of cereals in the food supply results in energy supplies primarily of vegetable origin. Major supplies of milk and eggs and, to a lesser extent, of meat, offals and fish result in a large share of lipid of animal origin.

Dietary energy supply by food group • Figure 3: Dietary energy supply by food group Figure 3: Percentage of energy provided by major food group in 2000-2002

Animal fats 2%

Starchy roots 2% Other 2% Pulses, nuts, oilcrops 3% Meat & offals 7%

Sw eeteners 7% Cereals (excl. beer) 44% Vegetable oils 7%

Fruit & vegetables 7%

Albania Milk & eggs 19% Source: FAOSTAT N.B. Values under 1% (Fish & seafood) are not presented.

Cereals and milk and eggs provide 63% of the total DES. Sweeteners and vegetable oils each have a relatively large contribution to the DES (7%).

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 18 Table 12: Share of the main food groups in the Dietary Energy Supply (DES), trends % of DES Food groups 1965-67 1972-74 1979-81 1986-88 1993-95 2000-2002 Cereals (excl. beer) 65 65 63 63 53 45 Starchy roots 1 1 1 1 1 2 Sweeteners 6 6 6 7 7 7 Pulses, nuts, oilcrops 3 2 2 2 2 3 Fruit and vegetables 5 5 4 4 4 7 Vegetable oils 4 5 8 7 7 7 Animal fats 4 3 3 3 3 2 Meat and offals 4 4 4 4 6 7 Fish, seafood <1 <1 <1 <1 <1 <1 Milk and eggs 8 8 8 8 17 19 Others 1 1 1 1 2 2 The food diversification index remained relatively stable from 1965/67 to 1986/88, at about 35%. After this period an important increase of the diversity was observed and in 2000/02, the index reached 53%. Since 1993/95, the diet is becoming gradually more diverse and diet quality is progressing. This progress can be related to urbanization, trade liberalization and shifts in production which involved the progressive replacement of cereals by other products (predominantly milk and eggs and fruit and vegetables).

Food imports and exports expressed as percentage of DES Food exports are very limited. Currently, food groups exported represent less than 1% of the DES, mainly composed by cereals, vegetables and alcoholic beverages.

• Figure 4: Major food exports as percentage of Dietary Energy Supply (DES), trends Figure 4: Food exports expressed as percentage of DES. Trends from 1965-67 to 2000-2002.

5

4

S 3 E D

f o

% 2

1

Cereals (excl. beer) 0 Vegetables 1965-67 1972-74 1979-81 Alcoholic beverages 1986-88 Albania 1993-95 Source: FAOSTAT 2000-2002 Note that only the 3 most important food groups are shown.

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 19 Before 1979/81, imports of cereals progressively decreased but since then imports exhibited a steady increase. Currently, Albania is very dependant on imports of cereals representing about 40% of the DES particularly of wheat. An increase of the imports of vegetable oils and sweeteners can also be observed.

• Figure 5: Major food imports as percentage of Dietary Energy Supply (DES), trends Figure 5: Food imports expressed as percentage of DES. Trends from 1965-67 to 2000-2002.

50 45

40 Cereals (excl. beer) 35

S 30 E D

f 25 o 20 % 15 10 5 Vegetable oils 0 Sw eeteners 1965-67 1972-74 1979-81 Albania 1986-88 1993-95 Source: FAOSTAT 2000-2002

Note that only the 3 most important food groups are shown.

Food aid In 2003, Albania received a total food aid of 11 812 t, of which 8 697 t of cereals (mainly wheat, and some rice) and 3 115 t of non-cereals (mainly pulses, mixed products, dairy products and oils/fats). This food aid was mainly delivered as emergency food aid (80%) and project food aid (20%). No food aid was delivered as programme food aid 2 (WFP, 2004).

II.3 Food consumption

National level surveys There have been several household income and expenditure surveys, but published data on energy or nutrient intake are not available (INSTAT, 1994; INSTAT, 2000; WB & INSTAT, 2004).

2 Emergency food aid is destined to victims of natural or man-made disasters; Project food aid aims at supporting specific poverty-alleviation and disaster-prevention activities; Programme food aid is usually supplied as a resource transfer for balance of payments or budgetary support activities. Unlike most of the food aid provided for project or emergency purposes, it is not targeted to specific beneficiary groups. It is sold on the open market, and provided either as a grant, or as a loan.

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 20 II.4 Infant and young child feeding practices

Breastfeeding is a very common practice in Albania as 93% of children under 5 years have been breastfed. However, characteristics of infant and young child feeding practices are not so favourable to infant’s health and growth. Early initiation of breastfeeding (within 24 hours of birth) is uncommon. As a result of breastfeeding promotion programmes for health personnel and mothers, early initiation of breastfeeding has become more common in urban areas. Exclusive breastfeeding concerns less than one out of ten children under 4 months. The duration of breastfeeding lasts long, but complementary feeding is not introduced in a timely way and is often of inadequate quality (Islami et al, 2000; NIS et al, 2000).

While breastfeeding is a common practice, important progress remains to be done in exclusive breastfeeding and timely complementary feeding.

Table 13: Initiation and duration of breastfeeding

Number Among Median Sample Among of children Number duration size Percentage children children everbreastfed, of of Survey (all of children everbreastfed, Background under percentage children breastfeeding name/date children under five percentage characteristics five breastfed under in children (Reference) under years breastfed years within three under three five everbreastfed within one ever 24 hours of years years years) hour of birth breastfed birth¹ (in months)

Total 2 551 93.3 2 381 15.2 51.9 n.a. 14.3 Reproductive Residence Health 1 707 93.1 1 707 17.3 49.6 “ 14.2 Survey in urban Albania rural 844 93.5 844 13.6 53.7 “ 14.6 (2000) Mother's education (Islami et al, no education n.a. n.a. n.a. n.a. n.a. “ n.a. 2000) primary 1 228 93.3 1 143 14.4 54.8 “ 15.0 secondary 1 323 94.2 1 238 16.8 47.7 “ 13.1 or higher ¹ Includes children who started breastfeeding within one hour of birth. n.a.: not available.

Table 14: Type of infant feeding by age Type of feeding in the 24 hours preceding the survey Survey name/date Indicator Percentage Sample size (Reference) by age of children

Exclusive breastfeeding rate Multiple Indicator <4 months 78 9.2 Cluster Survey <6 months 116 6.5 Report Albania (MICS) Timely complementary feeding rate (2000) 6-9 months 66 24.2 (NIS et al, Bottle-feeding rate 2000) 0-11 months n.a. n.a. Continued breastfeeding rate 12-15 months (1 year) 108 65.4 20-23 months (2 years) 95 6.3 Note: For exclusive breastfeeding rate where sample size included less than 100 children per monthly age group, estimates are not shown and a recalculation for all children less than 4 months was done. n.a.: not available.

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 21 A national programme to promote breastfeeding was initiated in 1995 with the support of UNICEF. One of the priorities was to train health personnel in maternal health education including appropriate breastfeeding practices (GOA & UNDP, 2004). The "Baby Friendly Hospital Initiative" is also progressing (Islami et al, 2000).

II.5 Nutritional anthropometry

Low birth weight In 2000, 89% of neonates were weighed. The prevalence of low birth weight (less than 2 500g) was 3% overall and was particularly high in the south (5.4%) in comparison to the northern or central areas (0.8% and 0.7%, respectively). (method: adjusted for relative birth size and heaping at 2 500g; UNICEF, End-decade Databases on Low Birth Weight). The difference observed by region must be interpreted with caution because in the south 96% of neonates were weighed as opposed to only 79% in the north (NIS et al, 2000).

Anthropometry of preschool children Two national surveys document the nutritional status of children under five years. The most recent survey, conducted in 2000, showed that about one-third of children under 5 years were stunted and 17% were severely stunted. These results suggest a state of chronic food insecurity. One out of ten children was wasted and 4% severely wasted. Underweight affected 14% of children (NIS et al, 2000). The nutritional situation was even more concerning in certain population groups. Overall, in rural areas children were more likely to be affected by stunting than in urban areas (37% versus 24%, respectively). In the south, the prevalence of underweight was highest, while the prevalence of stunting was more important in the north, revealing an important state of chronic food insecurity in this region. South and central areas have an important prevalence of wasting (12%) (NIS et al, 2000). The comparison with the previous survey conducted in 1996/98 shows that the nutritional situation has deteriorated considerably regarding stunting, the prevalence of which doubled since the previous survey. Wasting also increased since the previous survey (IPH, 1999). The increase in the prevalence of stunting was particularly striking in the urban sector. Such a rapid and important increase in the prevalence of stunting is unusual. Although it is always difficult to compare surveys carried out by different institutions because differences in methodology cannot be ruled out, it should nevertheless be noted that this deterioration follows two major events that affected the country, the financial collapse of 1997 and the influx of refugees due to the Kosovo crisis in 1999. The 1996/98 survey showed that the prevalence of overweight among children under 5 years was 6% while more recent studies estimated it at 11% (IPH, 1999; Bernd et al, 2004). This increase in overweight among young children could be a sign of the nutrition transition emerging in the country.

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 22 Table 15: Anthropometry of preschool children Prevalence of malnutrition Name/date Percentage of children with of survey Background Age Sample Sex (month/year) characteristics (years) size Stunting Wasting Underweight Overweight (Reference) Height-for-age Weight-for-height Weight-for-age Weight-for-height < -3 Z-scores < -2 Z-scores* < -3 Z-scores < -2 Z-scores* < -3 Z-scores < -2 Z-scores* > +2 Z-scores Total 0-4.99 M/F 1 111 17.3 31.7 3.6 11.1 4.3 14.3 n.a. Multiple Sex Indicator Cluster 19.8 34.1 4.8 11.9 4.8 15.3 Survey Report 0-4.99 M 557 “ Albania 0-4.99 F 553 14.8 29.4 2.4 10.3 3.8 13.3 “ (MICS) Age (June-July 2000) 0-0.49 M/F 88 5.7 19.2 5.4 11.4 2.4 7.3 “ (NIS et al, 0.5-0.99 M/F 80 10.7 27.4 10.1 16.5 4.8 10.7 “ 2000)¹ “ 1-1.99 M/F 202 22.9 36.0 3.5 14.6 9.2 20.1 2-2.99 M/F 232 21.4 37.4 2.0 8.2 6.9 15.5 “ 3-3.99 M/F 310 16.1 30.6 2.5 8.9 1.0 12.0 “ 4-4.99 M/F 199 16.5 29.8 3.6 11.7 2.1 14.8 “ Residence Urban 0-4.99 M/F 423 12.2 23.8 3.7 11.9 4.9 14.1 “ Rural 0-4.99 M/F 688 20.5 36.7 3.5 10.6 4.0 14.4 “ Region Central 0-4.99 M/F 444 14.4 29.2 4.1 12.5 3.2 14.0 “ North 0-4.99 M/F 330 19.0 33.9 2.4 7.9 5.0 10.8 “ South 0-4.99 M/F 336 19.4 33.0 3.9 12.4 5.2 18.1 “ Mother's education no education 0-4.99 M/F 0 primary 0-4.99 M/F 556 19.7 38.3 4.2 12.1 4.6 16.9 “ secondary 0-4.99 M/F 396 15.9 25.4 3.1 10.7 4.2 11.7 “ secondary or “ 0-4.99 M/F 487 14.7 24.2 2.8 10.0 4.0 11.3 higher² * Category <-2 Z-scores includes <-3 Z-scores ¹ Data taken from WHO Database on Child Growth and Malnutrition, except for mother's education (MICS 2000). ² Data are recalculated by a weighted-mean of secondary and higher. n.a.: not available.

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 23 Table 15: Anthropometry of preschool children (cont.) Prevalence of malnutrition Name/date Percentage of children with of survey Background Age Sample Sex Stunting Wasting Underweight Overweight (month/year) characteristics (years) size (Reference) Height-for-age Weight-for-height Weight-for-age Weight-for-height < -3 Z-scores < -2 Z-scores* < -3 Z-scores < -2 Z-scores* < -3 Z-scores < -2 Z-scores* > +2 Z-scores Total 0-4.99 M/F 7 642 5.7 15.4 1.5 6.6 1.4 8.1 6.1 National study Sex on nutrition in 5.7 16.1 1.9 6.9 1.5 7.9 Albania 0-4.99 M 3 866 5.8 (1996/98) 0-4.99 F 3 776 5.7 14.6 1.2 6.3 1.4 8.3 6.5 (IPH, 1999)¹ Age 0-0.49 M/F 1 300 2.7 11.1 1.6 5.2 0.6 3.7 10.9 0.5-0.99 M/F 1 342 4.0 13.1 2.0 6.9 1.7 8.7 8.1 1-1.99 M/F 1 559 6.8 19.2 1.7 7.6 1.9 10.3 6.0 2-2.99 M/F 1 356 5.8 14.8 2.4 8.0 1.4 9.7 3.6 3-3.99 M/F 1 030 8.3 17.4 1.3 6.1 1.4 7.8 3.7 4-4.99 M/F 1 055 7.1 16.5 1.0 5.2 1.4 7.8 3.6 Residence Urban 0-4.99 M/F 3 020 2.3 7.3 1.6 7.4 0.8 6.3 5.1 Rural 0-4.99 M/F 4 622 7.9 20.7 1.5 6.1 1.9 9.3 6.8 Region Middle 0-4.99 M/F 3 667 4.9 14.3 1.4 6.0 0.6 5.6 6.7 North 0-4.99 M/F 2 413 8.4 19.8 1.3 6.6 2.2 11.6 6.2 South 0-4.99 M/F 1 995 2.5 8.5 1.8 6.2 1.1 6.8 3.6 * Category <-2 Z-scores includes <-3 Z-scores. ¹ Data taken from WHO Global Database on Child Growth and Malnutrition.

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 24 Anthropometry of school-age children and adolescents No data on anthropometry of school-age children and adolescents are currently available.

Anthropometry of adult women Only local studies are available to document the anthropometric status of women. A cross-sectional study conducted in mid-2001 revealed a high level of overweight and obesity among women aged 25 years and over, with an increasing prevalence after 45 years. Although this study provides the only recent data on overweight and obesity in the largest urbanised part of Albania (including nearly 20% of the Albanian population), its results should not be generalised to the country as a whole. It is likely that both the diet and physical activity levels differ in rural areas (Shapo et al, 2002). National estimates taken from the SuRF report confirm the high prevalence of overnutrition among women. In 2002, the mean Body Mass Index (BMI) among women aged 15 years and above was 25.8 kg/m². Overweight affected more than half of the women (53%) and obesity concerned a quarter of them (WHO, 2005). The representativeness of the data is however not documented. Table 16: Anthropometry of adult women Anthropometry of adult women Body Mass Index¹ (BMI) (kg/m²) Name/date of survey Background Age Percentage of women with BMI (month/year) characteristics (years) (Reference) <18.5 18.5-24.9 25.0-29.9 ≥30.0 Sample Mean size (kg/m²) (chronic energy (normal) (overweight) (obesity) deficiency)

Body weight patterns Total 25-65+ 585 28.6 0.5 21.7 42.2 35.6 in a country in Age transition: a 25-34 50 24.8 4.0 58.0 26.0 12.0 population-based 35-44 115 28.4 0.0 23.5 40.9 35.7 survey in Tirana City, Albania 45-54 157 29 0.0 16.6 44.6 38.9 (mid-2001) 55-64 169 29.2 0.6 19.5 40.2 39.6 (Shapo et al, 2002) ≥65 94 29 0.0 12.7 52.1 35.1

1 excludes pregnant women and women with a birth in the 2 preceding months. Note: the sample represents women. n.a.: not available.

Anthropometry of adult men Adult men are also affected by overweight and obesity. The same cross-sectional study conducted in mid-2001 in Tirana City provides data on anthropometry of adult men. More than half were overweight and 23% were obese. The prevalence of obesity was highest among men aged 35-44 years (31%) (Shapo et al, 2002). Similar results were described in the SuRF report. The mean BMI among men aged 15 years and above was 26.0 kg/m² in 2002. Overweight concerned 57% of men and 19% of them were affected by obesity (WHO, 2005). Representativeness is however not clear.

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 25 Table 17: Anthropometry of adult men Anthropometry of adult men Body Mass Index (kg/m²) (BMI) Name/date of survey Background Age Sample Percentage of men with BMI ≥ (month/year) characteristics (years) size Mean <18.5 18.5-24.9 25.0-29.9 30.0 (Reference) (kg/m²) (chronic energy (normal) (overweight) (obesity) deficiency) Body weight Total 25-65+ 535 27.7 0.4 20.4 56.5 22.8 patterns in a Age country in 25-34 46 26.1 2.2 47.8 41.3 8.7 transition: a 35-44 90 28.3 0.0 15.6 53.3 31.1 population-based survey in Tirana 45-54 132 28.6 0.0 12.1 59.1 28.8 City, Albania 55-64 132 27.9 0.0 20.5 53.8 25.8 (mid-2001) ≥65 135 26.9 0.7 22.2 63.7 13.3 (Shapo et al,

2002)

The lack of previous data precludes the assessment of time trends in prevalence of obesity, but there are reasons to believe that there has been a substantial increase in BMI in both sexes during the past decade. Albania is a country that is experiencing a major transition process. Before 1990s, the levels of physical activity were high, agriculture was not mechanised and highly labour-intensive and the diet was based on what could be produced locally. Albania’s isolation stopped in 1991 and in the following decade the country opened up rapidly to western influences. Consequently, dietary patterns have changed and, for many, physical activity has decreased. These recent increases in urbanisation and socio-economic status reduced physical activity level and dietary changes are likely to have impacted on the prevalence of obesity. A better understanding of the impact of changing lifestyles in both urban and rural areas is thus urgently needed in this society in transition (Shapo et al, 2002).

II.6 Micronutrient deficiencies

Iodine deficiency disorders (IDD)

Prevalence of goitre and urinary iodine level In 1997, a national screening program observed a total goitre rate (TGR) among more than 196 000 school-children of 41% and prevalence appeared to be higher in mountainous regions (Bardhost et al., 1997). The severity of IDD in mountainous areas was confirmed by a recent survey conducted in southeast Albania. This survey was conducted in the city of Korçe (the largest city in southeast Albania) and in villages in the surrounding mountains. Overall in this region, 61% of children aged 5-14 years had goitre, but prevalence was higher among children living in mountainous areas than among children living in the city (93% and 43% respectively). The majority of children (91%) had a low level of urinary iodine but, for this indicator, the difference between the city and the villages was less important (82% in Korçe and 99% in villages) (Zimmermann et al, 2003). As Albania is a mountainous country it is likely that IDD is prevalent in other regions also. The prevalence of cretinism was estimated at 0.1% but no new cases of cretinism in newborns were reported since 1991 (Bardhost et al, 1997).

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 26

Table 18: Prevalence of goitre and level of urinary iodine in school-age children Prevalence of goitre Level of urinary iodine Survey Background Age Percentage with Percentage with name/date Sex Sample Sample Median characteristics (years) goitre urinary iodine (Reference) size size (µ g/L) [Total Goitre] <100µg/L

Total 5-14 M/F 826 60.8 414 30 91.0 Severe iodine Sex deficiency in southern 5-14 M n.a. n.a. n.a. n.a. n.a. Albania 5-14 F n.a. n.a. n.a. n.a. n.a. (2003) Residence (Zimmermann urban 5-14 M/F n.a. n.a. n.a. n.a. n.a. et al, 2003) rural 5-14 M/F n.a. n.a. n.a. n.a. n.a. Region Korçe 5-14 M/F 518 42.5 211 45 82.0 Villages 5-14 M/F 308 92.7 203 17 99.0 Note: Subjects were enrolled from 2 primary schools in the city of Korçe (the largest city in southeast Albania) and 5 primary schools in villages in the surrounding mountains (Lozhan, Qenske, Proptisht, Vanice, Godolisht). n.a.: not available.

Iodine deficiency in Albania is a result of several factors. Crops such as legumes, cereals, fruit and vegetables are planted in iodine poor lands and therefore cannot supply the necessary iodine. Moreover, information regarding the role of iodized products is very limited. Finally, the price of iodized salt imported from Greece is two to four times that of ordinary salt and the poorer and rural population do not buy it (Zimmermann et al, 2003).

Iodization of salt at household level Salt iodization was introduced in 1980, but due to changes after 1991, the iodization of salt ceased. The production of iodized salt in Albania restarted in August 2005 in Vlora Salt Factory. As a result of a prolonged lack of iodized salt production, only 57% of households were consuming adequately iodized salt in 2000 (NIS et al, 2000). Access and promotion of adequately iodized salt is particularly necessary in rural and northern areas. Table 19: Iodization of salt at household level Number of Iodine level of household salt Survey households Percentage of Background name/date where salt was households characteristics Inadequate Adequate (Reference) available for (<15 ppm) ( ≥15 ppm) tested testing Total 4 821 42.8 57.2 97.8 Multiple Indicator Residence Cluster Survey urban 1 928 28.7 71.3 98.2 Report Albania (MICS) rural 2 893 52.3 47.7 97.6 (2000) Region (NIS et al, 2000)¹ North 1 149 58.1 41.9 97.4 Central 1 809 30.3 69.7 99.1 South 1 862 45.8 54.2 96.8 Note: ppm : parts per million. ¹ Data taken from MICS 2000 Tables.

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 27

Vitamin A deficiency (VAD)

Prevalence of sub-clinical and clinical vitamin A deficiency No data are currently available on the prevalence of clinical and sub-clinical vitamin A deficiency in children and pregnant women. In Albania, the supply of animal products (meats and offals, milk and eggs) is important (FAO, FAOSTAT Database). Moreover, the Albanian diet includes vegetables such as spinach, amaranth, yellow pumpkins, squash and carrots, vegetables that are rich in vitamin A. However these observations are not sufficient to exclude vitamin A deficiency in the Albanian population, especially among the poor whose diet may not include large amounts of vitamin A-rich foods, and therefore surveys are needed to assess the vitamin A status of the population.

Vitamin A supplementation Vitamin A supplementation is implemented but its coverage is low among children and women. In 2000, only 7% of children aged 6-59 months had received a high dose vitamin A supplement in the 6 months preceding the survey. Supplementation was lowest in the central areas (4%), followed by the northern regions (7%) and south had the highest coverage (13%) which was still very low (NIS et al, 2000). The discrepancy between the north and the south could be explained by poorer infrastructure and conditions in the north, hindering distribution of supplements. Among mothers, only 3% have received vitamin A supplements within 2 months postpartum, which is a very low coverage rate. In rural areas, only 2% of mothers were supplemented (NIS et al, 2000). Table 20: Vitamin A supplementation of children and mothers Children Mothers

Percent of children who Percent Survey received of mothers who Background Number Number name/date Age vit. A Age received characteristics Sex of of (Reference) (months) supplements in (years) vit. A supplements children mothers¹ the 6 months within 2 months preceding the postpartum survey

Total 6-59 M/F 1 335 7.4 n.a. 260 2.6 Multiple Indicator Sex Cluster Survey 6-59 M 690 8.2 Report Albania (MICS) 6-59 F 646 6.5 (2000) Residence (NIS et al, urban 6-59 M/F 475 7.5 n.a. 103 3.4 2000) rural 6-59 M/F 860 7.3 n.a. 157 2.1 Region² North 6-59 M/F 381 6.5 n.a. n.a. n.a. Central 6-59 M/F 529 3.8 n.a. n.a. n.a. South 6-59 M/F 425 12.6 n.a. n.a. n.a. ¹ Women with a birth in the 12 months preceding the survey. ² Data by region taken from MICS 2000 Tables. n.a.: not available.

Iron deficiency anemia (IDA)

Prevalence of IDA A study conducted in 2000 showed a high prevalence of IDA among preschool children in Lezha District of the northern region. The sample of 112 children aged 6-60 months was recruited during routine vaccinations. Lezha District is considered as representative of the socioeconomic situation of northern Albania because it has a low prevalence of thalassemic diseases, another important cause of

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 28

anemia. The prevalence of anemia, defined as Hb<11g/dL, was 69% and that of iron deficiency anemia 42%. Iron deficiency was defined as serum ferritin level<10mg/dL, and/or mean corpuscular volume (MCV)<70 fL (Buonomo et al, 2005). However, these results cannot be generalized to the country as a whole. In rural areas such as Lezha, IDA in infants could be due in part to bottle-feeding with unfortified cow’s milk (Buonomo et al, 2005). Among 103 mothers of childbearing age, prevalence of IDA (defined as Hb<12.0 g/dL) was 11% (Buonomo et al., 2005). IDA is mainly caused from an insufficient iron intake in the diet. Albanian diets remain probably insufficient in meat and fish, or green leafy vegetables, good sources of iron, although the supply of these products has increased considerably. Furthermore, iron absorption can be inhibited by consumption of whole wheat bread, eggs and dairy products. Thalassemic diseases are also another important cause of anemia in Albania (Buonomo et al., 2005).

Interventions to combat IDA Supplementation primarily targets children under three years of age, pregnant women and women of childbearing age who are particularly at risk of iron deficiency. A supplementation programme is implemented by the Ministry of Health with the support of UNICEF.

II.7 Policies and programmes aiming to improve nutrition and food security

The country has developed a Food and Nutrition Action Plan (FNAP). This current plan is for the period of 2002/07 (HDPC, 2002). Under the framework of the FNAP, different projects aim to improve nutrition and public health conditions. Among others, the Maternal and Child Health Project implemented by the Ministry of Health, with support from UNICEF, is a project for the period of 2001/05 focused on infant feeding and caring practices, iron and folate deficiency as well as other micronutrient deficiencies, especially among young women (WHO, UNICEF & FAO, 2002). Pilot iron and folic acid supplementation is conducted in several districts. Many NGOs conduct food and nutrition programmes, including provision of meals in kindergarten and primary schools and other activities directed to women and children.

Albania Nutrition Profile – Food and Nutrition Division, FAO, 2005 29

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Bernd, R., Nina, S. & Martin, M. 2004. Health in South-eastern Europe: a troubled past, an uncertain future. Bulletin of World Health Organisation. 82: 539-546. World Health Organization. Geneva.

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ILO. C182 Worst Forms of Child Labour Convention, 1999 – list of ratifications. International Labour Organization. Geneva. (available at http://www.ilo.org/ilolex/cgi-lex/ratifce.pl?C182). Accessed in May 2005.

IMF. 2000. Albania Interim Poverty Reduction Strategy Paper. Prepared by the Government of Albania, May 3, 2000. International Monetary Fund. Washington DC. (available at http://www.imf.org/external/NP/prsp/2000/alb/01/INDEX.HTM).

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INSTAT. 1994. Family Budget in Tirana 1993 and 1994. Institute of Statistics. Tirana. (available at http://www.instat.gov.al).

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