1. Food & Nutrition in Refugees Situations
Ramona Sunderwirth, MD
Global Health Fellowship
Lecture Series
St Lukes/Roosevelt Hospital Center

2. Emergency Food & Nutrition in Refugee Situations
Objectives
Assessment
Interventions
Nutrient Deficiencies
Surveillance & Monitoring

3. Refugee Crises Emergency Phase Top 10 Priorities
6- Health Care in EM phase
7- Control of communicable diseases & epidemics
8- Public health surveillance
9- Human resources & training
10- Coordination
1- Initial Assessment
2- Measles Immunization
3- Water & Sanitation
4- Food & Nutrition
5- Shelter & Site Planning

4. 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 .

5. REFUGEE SITUATION Food & nutritional security threatened
Malnutrition, disease & death
Refugees need partial/full food support (acute phase), +/- nutritional rehabilitation

6. Complex Causes of Malnutrition

7. OBJECTIVES 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

8. Organization of Food Support World 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

9. 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

10. 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

11. Assessment: Other Important Information
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
Health status & services
Environmental health risks
Community structure
Food distribution systems
Social-economic status
Logistics constraints
Security constraints

12. 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

13. 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

14. Key Nutritional Indicators
U Moderate Severe
W/H % of median value % < 70%
W/H in Z scores to -2 Z < -3 Z (edema)
MUAC <125 mm < 115 mm (edema)
Adults
BMI (wt in kg)/(ht in m) < 16
MUAC (pregnant women)

15. 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

16. 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

17. Planning quantity of food
Based on demographic information & prevalence of malnutrition from nutritional survey
If presumption of major nutritional emergency, assume:
U5: % of total pop
Pregnant: % 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

18. Selective feeding programmes

19. 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

20. 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

21. Responding To Crisis Simplified Decision Tool
Finding
Action required
Food availability at household level
< 2100 kcal/person/day
Improve general rations until local food availability and access can be made adequate
Malnutrition rate (GAM) under 10 % with no aggravating factors
- Attention to malnourished individuals through regular community services[2].
Malnutrition rate (GAM) 10 – 14 % or 5 – 9 % plus aggravating factors
- Supplementary feeding targeted to individuals identified as malnourished in vulnerable groups
- Therapeutic feeding for SAM individuals
Malnutrition rate (GAM) ≥ 15 % or 10 – 14 % with aggravating factors[1]
- General rations; plus
- Supplementary feeding for all members of vulnerable groups.
[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).

22. Responsibilities & Coordination
WFP
UNHCR
UNICEF
Food aid agencies
Health agencies

23. Quality of GFR 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
UNHCR & WFP
Banned distribution dried milk powder (except in TFP)
bottle- feeding to be avoided
Culturally Acceptable & Familiar food
Minimum 2,100Kcal/per/d
10-12% protein energy, % fat energy
Classic food basket: 6 ingredients
Cereal
Pulse
Oil/fat
Fortified cereal blend
Sugar & salt
Sometime fish/meat
Grinding facilities if whole grain

25. 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)
plumpynut

26. Implementation of GFR distribution Main 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

27. Problems Gaps in food supply/delivery Food losses
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

28. 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

29. 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

30. 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

31. Supplementary (selective) Programs
Wet rations
Kcal
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

32. 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

33. Selective Feeding Programs exit criteria

35. NUTRIENT DEFICIENCIES predictable & preventable
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
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

36. Prevention 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)

37. 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

38. Vit Bs: water soluble avoid 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

39. 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

41. Minerals: Iron deficiency Anemia
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

42. 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

43. 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

44. Surveillance & Monitoring Post 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

46. Bibliography
Refugee Health, an approach to emergency situations Medecins sans Frontieres 1997
UNHCR Handbook for emergencies, 2nd ed. 2000, 3rd ed. 2007