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Food & Nutrition in Refugees Situations. Ramona Sunderwirth, MD Global Health Fellowship Lecture Series St Lukes/Roosevelt Hospital Center. Emergency Food & Nutrition in Refugee Situations. Objectives Assessment Interventions Nutrient Deficiencies Surveillance & Monitoring.

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Food nutrition in refugees situations

Food & Nutrition in Refugees Situations

Ramona Sunderwirth, MD

Global Health Fellowship

Lecture Series

St Lukes/Roosevelt Hospital Center

Emergency food nutrition in refugee situations

Emergency Food & Nutrition in Refugee Situations

  • Objectives

  • Assessment

  • Interventions

  • Nutrient Deficiencies

  • Surveillance & Monitoring

Refugee crises emergency phase top 10 priorities

Refugee CrisesEmergency Phase Top 10 Priorities

  • 1- Initial Assessment

  • 2- Measles Immunization

  • 3- Water & Sanitation

  • 4- Food & Nutrition

  • 5- Shelter & Site Planning

  • 6- Health Care in EM phase

  • 7- Control of communicable diseases & epidemics

  • 8- Public health surveillance

  • 9- Human resources & training

  • 10- Coordination

Definitions wikipedia

Definitions (Wikipedia)

  • Food security refers to the availability of food & one's access to it. A household is considered food secure when its occupants do not live in hunger or fear of starvation.

  • Hunger is a feeling experienced when one has a desire to eat.

  • Malnutrition is the insufficient, excessive or imbalanced consumption of nutrients .

Refugee situation


  • Food & nutritional security threatened

  • Malnutrition, disease & death

  • Refugees need partial/full food support (acute phase), +/- nutritional rehabilitation

Complex causes of malnutrition

Complex Causes of Malnutrition



  • Objectives of food intervention programmes

    • Ensure adequate nutritional general food ration (GFR)

    • 2,100Kcal/person/day→ Prevent malnutrition/mortality

    • ↓ Prevalence/mortality from malnutrition

  • Role of health agencies: Rx of malnutrition/nutritional deficits

    • Selective feeding programmes

    • Monitor regularity & adequacy of food rations

    • May take charge of general food distribution

Organization of food support world food program un high commissioner for refugees

Organization of Food SupportWorld Food Program & UN High Commissioner for Refugees

  • MOU (WFP & UNHCR) establishes responsibilities & coordination mechanisms for meeting food & nutritional needs of refugees

  • UNHCR food & nutritional coordinator - responsibility for coordination of all aspects of the program

  • Refugees (women) must be involved

  • Nutrition education

  • Aim of food programs:

    • Restoration & maintenance of sound nutritional status

    • Food ration that meets

      • Assessed requirements

      • Nutritionally balanced

      • Palatable & culturally acceptable

Assessment of food nutritional situation part of initial health assessment

ASSESSMENT of Food & Nutritional Situation(part of Initial Health Assessment)

  • Phase I

    • Early, quick evaluation → severity of global picture

      • Need for rapid intervention

      • Facilitate planning necessary resources

      • Based on observation, interviews/discussions key informants

  • Phase II

    • Quantified data gathered on nutritional situation

    • Decides type & size of nutritional programs

    • Prevalence of malnutrition, food available/accessible, factors affecting nutritional status

    • Expensive, time consuming, not always feasible

Assessme n t basic information

Assessment : Basic Information

  • Numbers & demographics

  • Current nutritional status

  • Milling possibilities

  • Food preferences

  • Family capacity to prepare, store, process food

  • Access to fuel, utensils, containers

  • Local food availability

    • Present/over time

    • Local food for purchase

    • Ease of access

  • Groups at risk

    • Who/ how many

  • Self reliance & coping strategies

Assessment other important information

Assessment: Other Important Information

  • Health status & services

  • Environmental health risks

  • Community structure

  • Food distribution systems

  • Social-economic status

  • Logistics constraints

  • Security constraints

  • Availability of human resources

  • Storage capacity & quality

  • Delivery schedule of food & non food commodities

  • Other agencies activities & assistance provided:

    • Quantity, items, frequency

    • Selective feeding programs

Food availability accessibility

Food availability & accessibility

  • Quantity/quality food (usually insufficient w/out distribution)

  • Initial data:

    • Food distribution already taking place

      • Food ration, frequency of distribution, distribution agency, target group

    • Assessment of local market

    • Food basket of individual households (by sample survey)

    • Food sources often diverse: food aid, shared w/ locals, food purchased/bartered for/ gathered

Nutritional status of refugee population prevalence of acute malnutrition in u5 yrs age

Nutritional status of refugee population:prevalence of acute malnutrition in U5 yrs age

  • How to measure malnutrition

    • W/H index most reliable: reflects present situation, most sensitive to rapid change

    • Oedema→ severe malnutrition (Kwashiorkor)

    • MUAC: quick, high variability, rapid assessment tool

  • Implementation of nutritional survey

    • Sample of children 6mo-5yrs w/ W/H index

  • How to express malnutrition rates: Z scores

    • Global malnutrition: % children <-2 Z scores and/or oedema

    • Moderate malnutrition: % children < -2 Z scores > 3 Z scores

    • Severe malnutrition: % children < -3 Z scores and /or oedema

Key nutritional indicators

Key Nutritional Indicators

  • U5Moderate Severe

    • W/H % of median value 70-79% < 70%

    • W/H in Z scores -3 to -2 Z < -3 Z (edema)

    • MUAC 115 - <125 mm < 115 mm (edema)

  • Adults

    • BMI (wt in kg)/(ht in m)2 16-17 < 16

    • MUAC (pregnant women)

Other information

Other information

  • Contextual factors

    • Mortality figures

    • Majors disease outbreaks (measles, cholera, diarrhea, etc)

    • Micronutrient deficiencies

    • Housing conditions

    • Water supply & sanitation

    • Climate & geography

    • Customary diet of population

    • Security situation

    • Provisions of local health services

Interpretation of results

Interpretation of results

  • Essential indicators

    • Global acute malnutrition rate : 5% common in Africa/Asia, 5-10% should act as warning, > 10% serious

    • Severe acute malnutrition rate

  • Bias in estimating severity

    • Very hi MR among most vulnerable: under estimates malnutrition

    • Timing & season of the year

  • Distribution of malnutrition in population

    • Age grp, date of arrival, ethnic grp, camp section, etc

    • Helps target programs

  • Three main contextual factors

    • Mortality figures

    • General food rations & food accessibility

    • Major outbreaks of disease

Planning quantity of food

Planning quantity of food

  • Based on demographic information & prevalence of malnutrition from nutritional survey

  • If presumption of major nutritional emergency, assume:

    • U5: 15-20% of total pop

    • Pregnant: 1.5-3% of total pop

    • Lactating: 3-5% of total pop

    • 15-20% moderate malnutrition

    • 2-3% severe malnutrition

      Quantity of Commodity Required=

      Ration/person/day X no. benef. X no. days

Selective feeding programmes

Selective feeding programmes

Class ical emergency food interventions

Classical Emergency Food Interventions

  • General food distribution

    • Ensure adequate food rations for all

  • Selective feeding programs

    • Targeted Supplementary feeding programs (SFP)

      • Moderately malnourished U5, selected pregnant /nursing women, referrals from TFP, other malnourished people & medically referred

    • Blanket SFP

      • Children <3 or 5 yrs age, all pregnant/nursing women, other at risk groups

    • Therapeutic feeding programs (TFP)

      • <5yrs severely malnourished, idem other age grps

      • LBW infants

      • Unaccompanied minors/orphans <1yr age

      • Mothers of <1yr infants w/ breastfeeding failure

How to decide on the intervention

How to decide on the Intervention

  • General food ration available

    • 2,100Kcal/person/day for all refugees

  • Malnutrition rate

    • Indicates level of intervention required

  • Aggravating factors: requiring ↑ level intervention

    • CMR > 1/10,000 day, ↑ level malnutrition

    • Inadequate food ration < 2,100Kcal/person/day

    • Epidemics: measles, cholera, shigella , pertussis, etc

    • Severe cold & inadequate shelter, ↑ level activity/males

    • Unstable situation: new influx of refugees

    • Wastage (grinding, poor storage), losses, ↑ barter for non food items

  • Other considerations

    • Vulnerabilities of specific grps, logistical constraints, agencies capacity, security, food basket unfamiliar to refugees, local nutritional status, etc

Responding to crisis simplified decision tool

Responding To CrisisSimplifiedDecision Tool

[1] Aggravating factors are: i) General food ration below the mean energy requirement (<2100 kcal/kg/person), ii) Crude Death Rate greater than 1/10 000/day and iii) Epidemic of measles or whooping cough.

[2] This may include therapeutic care integrated into primary health system (hospitals and health centres).

Responsibilities coordination

Responsibilities & Coordination

  • WFP



  • Food aid agencies

  • Health agencies

Quality of gfr

Quality of GFR

  • Minimum 2,100Kcal/per/d

    • 10-12% protein energy, 10-17% fat energy

  • Classic food basket: 6 ingredients

    • Cereal

    • Pulse

    • Oil/fat

    • Fortified cereal blend

    • Sugar & salt

    • Sometime fish/meat

    • Grinding facilities if whole grain

  • Complementary food items

    • Fortified blended foods or staple foods to vulnerable grps

    • Essential vitamins & minerals: fresh foods, vegetables, fruits, fortified cereals, blended foods, condiments, tablets


    • Banned distribution dried milk powder (except in TFP)

    • bottle- feeding to be avoided

  • Culturally Acceptable & Familiar food

Feeding programme foods

Feeding programme foods

  • Fortification

    • Adding micronutrients to foods

      • Iodized salt

      • Fortified blended food

  • Fortified blended foods

    • A flour composed of pre-cooked cereals + a protein source, mostly legumes

    • Fortified with vitamins + minerals

    • E.g.: corn soya blend (CSB)

      wheat soya blend (WSB)


Implementation of gfr distribution main factors for success

Implementation of GFR distributionMain Factors for success

  • Political willingness (donors)

  • Adequate planning & good logistical organization

  • Registration of refugees, ration cards (UNHCR)

  • Distribution system: equity, representative, head of family (natural unit targeted for distribution) registered

  • Good organization: regular distributions, well- planned site (1/20,000-30,000 refugees)

  • Regular monitoring of ration

  • Clear definition of the agreed responsibilities of partners w/ effective coordination



  • Gaps in food supply/delivery

    • Lack of funds, insufficient supplies, poor management

  • Food losses

    • During transport, warehousing, distribution, storage of large amounts food → security problems

  • Inadequate nutrient content of ration (long term programs)

  • Food diversion

    • By households in exchange for non food items/complementary food items: positive effects

    • By powerful grps → inequities in access: security problem, detrimental effects

  • Poor organization of distribution & logistical problems: ↓security

  • Lack of coordination among partners supplying all items regularly

  • Problems w/ food preparation

    • Lack cooking utensils/fuel

    • Lack of knowledge to prepare items distributed

Alternative to general food distribution

Alternative to General Food Distribution

  • Opportunities for refugees to acquire food by themselves

    • Cash distributions

    • Distributions of food items w/ hi economic value & local demand

    • Income-generating programs & support for individual efforts to grow foodstuffs

  • Food-for-work programs

  • Mass preparation of cooked meals

    • Rare situations of great insecurity, temporary solution

    • Heavy logistical requirements, negative psychosocial consequences for population

Supplementary feeding programs

Supplementary Feeding Programs

  • Not a substitute for inadequate general ration

    • Extra ration provided must be additional to, not a substitute for the general ration

  • Based on prevalence of malnutrition & aggravation factors

    • High MR

    • High prevalence of infection

    • General ration below minimum requirements

Identifying those eligible

Identifying those Eligible

  • Active identification and F/U those at risk

    • House to house visits

      • Children U5, elderly, malnourished, ill

    • Mass screening of all children

    • Screening on arrival w/ registration

    • Referrals by community /health services

Supplementary selective programs

Supplementary (selective) Programs

  • Wet rations

    • 500-700Kcal

    • Prepared in feeding centre kitchen, consumed on site twice/day

    • Beneficiary has to come for meals to feeding center, every day

    • May substitute for a regular meal at home

  • Dry rations

    • 1,000-1,200Kcal

    • Hi protein source & hi energy source (oil)

    • Premixed cereal or blended food as base/Plumpynut

    • Take home for preparation & consumption

    • Rations distributed once weekly

    • Preferred

      • Easier to organize, less staff, lower risk transmission infection

      • Less time consuming for mother, family life preserved, food shared

Therapeutic feeding programs

Therapeutic Feeding Programs

  • On site wet feeding (therapeutic milk F75 & F100)

  • Intensive medical care

    • Infection & dehydration

  • Psychological stimulation during rehabilitation phase

  • 150Kcal/kg/day

    • 3-4g protein/kg/d

  • Frequent meals

    • Phase I: 8-10 meals/24h (usually lasts 1 week)

    • Phase II (rehabilitation): 4-6 meals/24h

Selective feeding programs exit criteria

Selective Feeding Programsexit criteria

Nutrient deficiencies predictable preventable

NUTRIENT DEFICIENCIESpredictable & preventable

  • Vit A (xerophthalmia)

    • Low content in GFR

    • Poor health/nutritional status

    • Measles

  • Vit B1 (beriberi - thiamin)

    • Ration based on polished rice

  • Vit B2 (ariboflavinosis)

    • Ration based on cereal flour unfortified w/ B2

  • Vit B3 (pellagra –niacin )

    • Ration based on maize w/ limited amounts of groundnuts /fish/meat

  • Vita C (scurvy)

    • Semi-desert area w/ limited provision of animal products (milk), fresh fruits & vegetables

  • Iron (anemia)

    • Ration limited in meat content

  • Iodine (goitre, cretinism)

    • Pop living in area w/ low iodine soil content & w/ no iodine salt fortification of food



  • Good surveillance system

    • GFR quality monitoring

    • Early detection of cases in refugee pop, clear case definitions

  • Prompt implementation of Rx & preventive measures

  • Ensure food diversification

    • Varied items & fresh food

  • Food fortification

  • Provision of fortified blended food

    • CSB, WSB

  • Vit/mineral supplementation ( Vit A, F, Folate, Iodine)

Vit a

Vit A

  • Estimate of Vit A content in GFR

  • Food items w/ hi Vit A content in local market

  • Record cases of xerophtalmia, report to health agency

    • Few cases indicate Vit A reserves of most pop depleted

    • Treat all clinical cases immediately

  • Prevention

    • Emergency Phase

      • Supplementation: mass distribution ages 6mo-15 yrs (measles immunization) Breastfeeding best source of Vit A for infants < 6 mos age

    • Post Emergency Phase

      • Mass distribution Vit A (every 4-6 mos if < 50% RDA in ration)

      • Drug supplementation (none for pregnant women, infants < 6 mos age)

      • Food fortification + food diversification (best solution: red palm oil, fresh fruits/vegetables)

      • Care: Vit A quickly destroyed by heat

Vit bs water soluble avoid well refined polished cereal

Vit Bs: water solubleavoid well refined/polished cereal

  • Vit B1 (beriberi): RDA 1.1 mg/per/d

    • Assessment/surveillance of GFR: rice based (milling/polishing)

    • Cases recorded/reported, Rx PO/IM

    • Food diversification (groundnuts/beans) best strategy

    • Food fortification: blended food fortified w/ thiamin (60g/per/d of CSB)

    • Outbreak: weekly mass drug supplements

  • Vit 3 (PP or niacin-pellagra): RDA 15mg/per/d

    • A/S of GFR: maize based

    • Cases definition, record, report, Rx PO Vit B3 + B complex

    • Food fortification(blended cereals, maize flour) best strategy

    • Food diversification (groundnuts, dried fish/meat)

    • Outbreak: weekly mass drug supplementation

  • Vit B2 (ariboflavinosis- neuropathy, glossitis, conjunctivitis, stomatitis)

    • A/S of GFR: refined/unfortified cereal w/ ↑ proportion carb/fat & proteins

    • Rx cases, mass supplementation

Vit c rda 15mg per d

Vit C: RDA > 15mg/per/d

  • Clear case definition for scurvy, routine surveillance

  • Preventive measures

    • Drug supplementation to vulnerable grps

    • Food fortification: (Vit C destroyed by heat) blended foods

    • Food diversification: fresh fruit/vegetables/milk

  • Outbreak

    • Daily mass Vit C drug distribution, weekly/bi-weekly

Minerals iron deficiency anemia

Minerals: Iron deficiencyAnemia

  • Most prevalent nutrient deficiency

  • Associated w/ folate deficiency

  • Malaria & hookworm exacerbate nutritional anemia

  • A/S of GFR if ↑ cases reported to health services

  • Prevention intervention

    • Supplementation (iron + folate) to hi risk grps: pregnant/lactating women, and moderately malnourished

    • Fortification: blended food( CSB, CSM)

    • Diversification: provision of meat to GFR

Minerals iodine idd

Minerals: Iodine (IDD)

  • 30% world’s pop live in I-deficient environments

  • Goitrogens in local diet: thiocyanate in cassava

  • IDD under reported (goitre,↓ psycho-motor development, cretinism)

  • A/S in post emergency phase

    • National control programmes

    • IDD prevalence in pop

      • Goitre by clinical examination of school children (<5%)

      • Urinary I

    • Availability of iodine (seafood/ I salt)

    • Presence of goitrogens in local food basket

  • Intervention

    • Iodized oil administered periodically to vulnerable grps

    • Iodization of salt: safest/cheapest solution

    • Iodine PO to goitres

Surveillance monitoring emergency phase


  • Food availability & accessibility

    • Actual amount & quality that reaches families

    • Data gathered at different levels of food chain

    • Information from distributing agencies, beneficiaries

  • Health & nutritional status

    • Nutritional surveys repeated regularly (q 3mos)

    • Monitor trends malnutrition

    • Morbidity (outbreaks) & mortality (CMR, U5MR)

  • Feeding programs

    • Monitoring feeding centers

      • Proper registration

      • Proportion of recoveries, deaths

      • Attendance rates, coverage of target grp

      • Average Wt gain in TFP

    • Monitoring program effectiveness : Health Status

Surveillance monitoring post emergency phase

Surveillance & MonitoringPost Emergency Phase

  • Food availability & accessibility

    • GF distribution (agencies & at distributions points)

    • Other sources of food (farming, income-generating activities)

      • Market availability & prices

      • Information from refugees

      • Household availability survey

  • Health & nutritional status

    • Nutritional survey (q 6 mos)

    • Malnutrition cases

  • Food & nutritional situation of local population

  • Feeding programs



  • Refugee Health, an approach to emergency situations Medecins sans Frontieres 1997

  • UNHCR Handbook for emergencies, 2nd ed. 2000, 3rd ed. 2007

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