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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. Objectives Assessment Interventions Nutrient Deficiencies Surveillance & Monitoring.

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Food & Nutrition in Refugees Situations

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  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 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

  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 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

  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 • 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

  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 • 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)

  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: 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

  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 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).

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

  23. 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 • UNHCR & WFP • Banned distribution dried milk powder (except in TFP) • bottle- feeding to be avoided • Culturally Acceptable & Familiar food

  24. 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

  25. 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

  26. Problems • 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. Selective Feeding Programsexit criteria

  33. 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

  34. 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)

  35. 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

  36. 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

  37. 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

  38. 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

  39. 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

  40. SURVEILLANCE & MONITORINGEmergency 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

  41. 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

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

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