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Nutrition in Disasters Dr. Sergei Koryak WHO EHA Coordinator December 9, 2007 1| 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) 2| 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. 3| 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). 4| 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 5| 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 6| 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 7| 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 8| 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 9| 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 10 | 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 11 | 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 12 | 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 13 | 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..) 14 | 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 15 | 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 16 | 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 17 | 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 18 | 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 19 | 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 20 | 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..) 21 | 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 22 | 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 23 | 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 24 | 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 25 | 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. 26 | 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..) 27 | 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 28 | 9 December 2007