1. 1 |1 | 9 December 2007 Nutrition in Disasters Dr. Sergei Koryak WHO EHA Coordinator December 9, 2007

2. 2 |2 | 9 December 2007 WHO input WHO monograph “The Management of nutritional emergencies in large populations” (1978) The World Declaration and Plan of Action for Nutrition (WHO and FAO, 1992) WHO manual – Rapid Health Assessment protocols for emergencies (1999)

3. 3 |3 | 9 December 2007 Emergencies and nutrition The occurrence of natural and man-made disasters risen dramatically in recent years with a growth in the numbers of refugees, displaced people and vulnerable communities All major emergencies threaten human life and public health resulting in food shortages and impairing the nutritional status of community.

4. 4 |4 | 9 December 2007 Vulnerable populations Among refugees and displaced populations, high rates of malnutrition and micronutrient deficiencies is associated with increased rates of mortality Governments should provide sustainable assistance to vulnerable populations and monitor their nutritional well-being, giving high priority to the control of diseases (World declaration and Plan of Action for Nutrition, Rome, 1992).

5. 5 |5 | 9 December 2007 Developing Plans In response to the World Declaration, many countries have developed, or developing, a national plan of action for nutrition These plans include action for preparedness and capacity building for management of nutrition in emergencies

6. 6 |6 | 9 December 2007 Nutrition interventions It is important that nutrition-related interventions be viewed as an integral part of a comprehensive approach to emergency management in affected areas. Nutrition strategy should be included in overall emergency preparedness

7. 7 |7 | 9 December 2007 Role of health sector Provide education, advocacy and technical expertise to ensure vulnerability reduction and preparedness for appropriate nutrition-related relief, treatment and prevention of malnutrition Promote nutrition in the context of broader health, community rehabilitation and development policy

8. 8 |8 | 9 December 2007 Main functions of a national nutrition program To identify data, indicators and sources for nutritional surveillance and early warning To collect and analyze baseline data To define strategies, programs and technical standards for food surveillance To organize rapid assessments to determine the presence of nutritional emergency To develop continuing surveillance of nutritional status in emergencies

9. 9 |9 | 9 December 2007 Main functions of a national nutrition program To liaise with the emergency coordination cell and other health units and programs, exchanging information and plans To integrate nutrition activities in primary health care To liaise with other Ministries (agriculture, social welfare, community development, commerce, finances etc..) and participate in the activities of national coordination committees

10. 10 | 9 December 2007 Nutritional requirements Basic energy and protein requirements are the primary concern Assessment of nutritional needs of the population is a fundamental management tool Mean daily per capita intake is 2100kcal and 46g of protein

11. 11 | 9 December 2007 Basic principles To cover losses of each nutrient To take account of nutrient interactions in the diet To take account of environmental conditions Maintain physical size, growth, pregnancy, lactation Maintain activity including social activity

12. 12 | 9 December 2007 Most vulnerable Pregnant and lactating women Infants and young children Families or individuals whose needs may not be fully met by a particular ration Elderly, widows and widowers

13. 13 | 9 December 2007 Nutritional needs 2100 kcal for an adult who is: 169 cm (men) and 155 cm (women) Body mass index (BMI) is between 20 and 22 Physical activity is light Safe daily protein intake (cereals, vegetables…) should be 46g

14. 14 | 9 December 2007 Dietary components Fat or oil provide 15% of total energy intake for men, 20% for women of reproductive age and 30-40% for children up to 2 years old It should comprise 17-20% of the ration Should include micronutrients (vitamins, iodine, iron, calcium etc..)

15. 15 | 9 December 2007 Major diseases Protein-energy malnutrition (PEM) Marasmus – severe wasting of fat and muscle, which the body breaks for energy – most common form of PEM Kwashiorkor – characterized by oedema accompanied by skin rash and changes in hair color (reddish) Marasmic kwashiorkor – combination of oedema and severe wasting

16. 16 | 9 December 2007 Major diseases (cont) Micronutrient deficiencies Iron deficiency and anaemia – most prevalent in young children Iodine deficiency – pregnant women and young children – different degrees of mental retardation Vit A deficiency – main cause of blindness Vit D deficiency - rickets

17. 17 | 9 December 2007 Approaches Increasing daily ration and inclusion of fruits and vegetables Varying the composition of the food basket so it contains more micronutrient-rich food (dried beans, nuts, fruits, palm oil) Including micronutrient-fortified foods in the ration (cereals) enriched with Iron and Vit A and B Providing supplementation when there is likely to be a specific deficiency

18. 18 | 9 December 2007 Assessment Communities – to assess the extent and severity of malnutrition including mineral and vitamin deficiencies and to decide whether and what type of feeding programs are needed Individuals – to screen for supplementary or therapeutic feeding and monitor nutritional progress

19. 19 | 9 December 2007 Assessment indicators Weight-for-height the best for assessing and monitoring community nutritional status BMI (kg/m2) – used for assessing the status of adults Mid-upper arm circumference – can be used as an alternative method or initial screening Presence of oedema

20. 20 | 9 December 2007 Reasons for measuring malnutrition in emergencies Not all groups of people are equally affected. Therefore, determination of nutritional status is essential in three contexts: Initial rapid assessment – provides a basis for planning a food relief program Individual screening Nutritional surveillance – monitoring changes

21. 21 | 9 December 2007 Population surveys Information to be collected: Body measurements indicating nutritional status – usually weight for height, possibly arm circumference and presence of oedema Specific location Supplementary information (age, sex, length of time in current location, measles immunization, recent deaths in the household etc..)

22. 22 | 9 December 2007 Organizing screening sessions Community should be informed, at least 24 hours in advance to allow arranging attendance of people. Severely malnourished individuals should be selected first A system of individual identification should be used Results should be recorded

23. 23 | 9 December 2007 General feeding programs Should be organized when the population does not have access to sufficient food to meet its nutritional needs Providing rations that satisfy the full nutritional needs largely avoids the need for additional selective food distribution programs

24. 24 | 9 December 2007 Food distribution Each person should have identification (list of names should be available) Proper arrangements should be done and people should be aware about amount of food they are entitled Food should be ordered in good time – quantity to feed 1000 people for 1 month is approximately 16.4 tonnes To eliminate personal bias, reliable individuals should be recruited from outside the community

25. 25 | 9 December 2007 Outcome indicators The purpose of relief programs in food emergencies is not only to distribute food but also to prevent death and disease and improve nutritional status The only acceptable indicators of program success are data indicating decrease of malnutritio levels and death rates

26. 26 | 9 December 2007 Complementary interventions Infections can contribute to a deterioration in nutritional status Conditions of emergencies (overcrowding, unsafe water supplies, poor sanitation, irregular health services) can contribute to the spread of infections.

27. 27 | 9 December 2007 UN agencies active in the field UN agencies involved in food distribution are WFP – World food program UNHCR – United Nations High Commissariat for Refugees UNICEF – United Nation Children Fund As well as some Non-Governmental organizations (Red Crescent etc..)

28. 28 | 9 December 2007 References “The Management of Nutrition in Major Emergencies” – WHO Geneva 2000 “Management of severe malnutrition: a manual for physicians and other senior health workers” WHO Geneva 1998 “Infant Feeding in Emergencies” Module 1 November 2001