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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
  • 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

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
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