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

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

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

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

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

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

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 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

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 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 U5 Moderate 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 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 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 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

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 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 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).

Responsibilities & Coordination WFP UNHCR UNICEF Food aid agencies Health agencies

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, 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

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

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

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

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 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 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 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 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

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

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)

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 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 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 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) 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 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

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