Food, Nutrition and Livelihoods

in Humanitarian Emergencies

Micronutrient deficiencies (MNDs)

in Displaced Populations
Rolf D.W.Klemm, DrPH
rklemm@jhsph.edu
April 23,2014

Today..
1. Basic but underappreciated nutrition facts
2. Why are risks for micronutrient deficiencies (MNDs)
high during humanitarian emergencies?
3. How might Food Aid Response contribute to MNDs?
4. Why do MNDs often go unaddressed in Humanitarian
Emergencies?
5. What are the causes, dietary sources, clinical symptoms
& solutions to specific MNDs in humanitarian
emergencies?
6. What are the options for improving fortification of food
rations?
7. Why is there a lack of convergence for approaches
addressing acute and chronic undernutrition?

MND=Micronutrient Deficiency
HE=Humanitarian Emergency

Why is the Farm Bill relevant to Food

Aid and Response to Humanitarian
Emergencies?

Why are global food prices

relevant to US Food Aid and
response to Hes?

High Food Prices Add Millions to the Hungry &

Correspond with Food Riots & Arab Spring
Food prices

New England Complex Systems Institute

Not surprisingly Food Security jumped to the

top of the G8 and G20 to do list

We also announced a new

alliance on food security with
African leaders and the private
sector as part of an effort to lift
50 million people out of poverty
over the next decade
Kenya slums, Time 2008

Pres Obama, Closing Remarks,

G8 Summit, 2012

Rank the following risk factors from highest to lowest by

which is responsible for causing the greatest burden of
human death, disease and disability each year?
a)
b)
c)
d)
e)

Unsafe sex (HIV-AIDs, etc.)

Unsafe water, sanitation, hygiene
Alcohol use
Childhood underweight
High blood pressure

11% of global DALYs

WHO, Global health risks: mortality and burden of disease attributable to

selected major risk factors, 2009

What proportion of maternal and child deaths can be

attributable to (1) severe wasting & (2) undernutrition as
an underlying cause?
Severe Wasting
a) 1%
b) 3%
c) 7%
d) 11%
e) 15%

Undernutrition
a) 15%
b) 20%
c) 30%
d) 45%
e) 57%

Undernutri/on causes 45% of child deaths

resul/ng in 3.1 million deaths annually
Propor/on of total
A@ributable
deaths of children
deaths with UN
younger than 5
prevalences*
years

Nutri/onal Disorders
Fetal growth restric/on (<1 month)
Stun/ng (1-59 months)

817,000

11.8%

1,017,000*

14.7%

Underweight (1-59 months)

999,000*

14.4%

Was/ng (1-59 months)

Severe Was/ng (1-59 months)

875,000*
516,000*

12.6%
7.4%

Zinc deciency (12-59 months)

116,000

1.7%

Vitamin A deciency (6-59 months)

157,000

2.3%

Subop/mum breasReeding (0-23 months)

804,000

11.6%

1,348,000

19.4%

3,097,000

44.7%

Joint eects of fetal growth restric/on and subop/mum

breasReeding in neonates
Joint eects of fetal growth restric/on, subop/mum breasReeding,
stun/ng, was/ng, and vitamin A and zinc deciencies (<5 years)

Data are to the nearest thousand. *Prevalence esTmates from the UN.

Black R et al, Lancet, 2013

11

WHO, Global health risks: mortality and burden of disease attributable to

selected major risk factors, 2009

Basic but underappreciated

Nutrition Facts

First concern-ensure adequate energy requirements

Kwashiorkor

Marasmus

Health Problems among undernourished

are exacerbated during humanitarian emergencies
Nutritional
Deficiencies

Child and Maternal

Health Problems
Infant or Child
Infection (diarrhea, ARI)
Poor growth
Impaired mental, motor
and behavioral
development
Death
Mother
Obstetric morbidity
Infection/sepsis
Anemia
Death

Protein-energy
malnutrition

Photo: K West

Micronutrient
Deficiencies
Vitamin A,
zinc, iron,
iodine, folate,
others

Early life nutrition

Influence on life-long health

First 1000 days

Food-assisted PM2A

Micronutrient Deficiencies
The Basics
Micro-needed by body in small amounts (mg or
g/day)
Cannot be synthesized by human body
Must be ingested (diet, supplement, fortified
food)
Play essential roles:
Co-factors in production of enzymes &
hormones
Regulation of growth
Development and functioning of immune &
reproductive systems

Micronutrient Deficiencies
The Basics
High requirements during growth
periods (pregnancy, infancy,
childhood)
Water-soluble vitamins (Thiamin-1,
Niacin-B3, Folate,+ 5 other Bcomplex, C)
Fat-soluble vitamins (A, D, E,K)
Essential Minerals (Iron, Iodine, Zinc
+ 12 others)

MNDs
Hidden Hunger
Largely invisible but often devastating
Deficiencies in iron, vitamin A and zinc
each rank among the top 10 leading
contributors to the Global Burden of
Disease (Lancet 2008)

MNDs
Overt clinical signs are rare
Individuals not aware of the deficiencies
Increases susceptibility to infectious
diseases, impairs physical and mental
development, lowers labor productivity,
increases risk of premature death.

10

Micronutrient Deficiencies (MND)

Anemia

Iron

Goiter

Xerophthalmia

Iodine

Vitamin A
.and zinc, folic acid, B-vitamins, vitamin D, etc

MNDs-Whats the fuss?

A Paradigm Shift

Systemic
Effect & nonspecific
effects

He

alt

hR

isk

Classic signs of public health

Significance: Stimulus to act

Altered tissue nutrient

levels & metabolism

Chronic dietary
deficit of micronutrients

Clinical Signs
represent tip
of the ice
berg

11

Iron & Vitamin A Deficiency among

6-59 mo-old children

Prevalence

IronIron-deficiency
Deficiency >60%
in 3 camps
Wasting
VA-deficient
VAC coverage
80

Vitamin A Deficiency >50% in 3 camps

70

Vitamin A Supplementation 3%-67%

60
50
40
30
20
10
0
Kenya

Uganda

Ethiopia-1

Ethiopia-2

Algeria

Refugee Camps
Seal et al., J Nutr 2005

Why are risks for micronutrient

deficiencies (MNDs) high
during humanitarian
emergencies?

12

Why is the risk for MNDs high in

Humanitarian Emergencies?

Decreased total food availability

Decreased variety of foods
Disrupted local markets
Displacement from areas of food production
Growing vegetables & fruit limited by land &
water availability
Loss of livelihood due to drought/conflict
Present, but often not recognized, existing
MNDs prior to crisis

How might Food Aid Response

contribute to MNDs?

13

Oil: 25gm

The daily ration

Legumes: 50 gm

Cereal: 400gm

Typically deficient in a range of nutrientsVit A, Vit C, some B Vit, iron & zinc

How might Food Aid Response

contribute to MNDs?
Focused primarily on provision of foods
adequate in calories and protein
Limited diversity of relief goods (cereal/
grain + legumes)
Limited MN content of relief goods
Dependence on relief goods may reduce
incentive to grow foods locally

14

Supply of micronutrients by foods

NUTRIENTS

Milk

Meat/
Fish/
Poultry

Eggs

Refined
Cereals,
Sugars,
Oils

Fruits
and
vegetables

Beans,
peanuts

Iodine

Zinc

()

Iron

()

Calcium

()

()

Vitamin A

( )

Folate

Vitamin B-12

Vitamin B-2

The issue is not If fortifying but with What? and How?

Current Reality-Only a small

fraction of emergency food aid is
fortified
Fortified Foods as a Share of
WFPs Total Food Aid, 2002

Pulses
7%

Misc
1%
Fortified Oil
3%

Cereals
73%

Fortified Flours
10%

~20%

Fortified Blended
Foods
6%

Food and Nutrition Bulletin, 2006

15

MN Content (% RDA) of Rations

with & without fortified blended food
Vit A

Niacin

Vit C

Iron

Cereal (400 g)

45%

44%

Oil (30 g)

Beans (40 g)

6%

9%

Total

32%

53%

89%

49%

Plus Fortified CSB (60 g)

59%

Total

59%

83%

89%

102%

Actual ration received by

Rwandan refugees, 1994

20%

76%

34%

90%

Mason J Nutr 2002

Why do MNDs often go

unaddressed in Humanitarian
Emergencies?

16

Why do MNDs often go unaddressed in

Humanitarian Emergencies?
Surveillance systems not always in place to
identify MND
Simple case definitions not available for all
MNDs
Biochemical tests under emergency conditions
limited
Clinical manifestations reflect late stage of
deficiency & cannot be used to predict MND
problem
Inadequate international attention to low-visibility
crises

What are the causes, dietary sources,

clinical symptoms & solutions to specific
MNDs in humanitarian emergencies?

17

Vitamin A Deficiency
(VAD)

Functions of Vitamin A
Visionrod cell visual cycle
Cell differentiation
Immune response
Hemopoiesis
Growth

18

Dietary Sources

Night blind not children

an not see in dim light

Night blindness

Impaired rod photoreceptor cell function

leads to night blindness

19

Bilateral corneal scars (XS):

VAD Disorders Reflect a Gradient of

Health Consequences
Corneal Blindness

Mo
rta
lity
R

isk

Xerophthalmia
Systemic
Effects

Metaplasia, Impaired immunity,

Morbidity, Anemia, Poor growth

Tissue and plasma

depletion

Chronic dietary
deficit

20

Vitamin A Supplementation Can Reduce

Child Mortality by ~30%, Saving 1-2.5 m Lives/ Yr

Sommer & West, 1996

Photo: K West, Jr.

21

Target Groups and Vitamin A

Prophylaxis Guidelines
Group

Dosage (IU)

Frequency

Children
< 6 mo

50,000

6, 10, 14 wk

6-12mo

100,000

Every 4-6 mo

12 mo

200,000

Every 4-6 mo

Mothers

400,000

6-8 wks
postpartum
(IVACG, J Nutr 2002)

Solutions
Fortification
Diet
Supplements
Deficient
Population

22

Where feasible, in emergency

settings.
Give VA capsules to preschool children upon
screening & every 4-6 months
Close supervision is needed to avoid overdosing
Maternal post-partum dosing (within 6 weeks of
child birth recommended) BUT Do not give high
dose (200,000 IU) vitamin A to pregnant women
Treatment of night blindness in women using
lower dose vitamin A (10,000 IU/daily or 25,000
IU weekly as per WHO recommendation).

Iron deficiency Anemia

(IDA)
Nutritional Anemia

23

Anemia
Defined as Hemoglobin
(Hb) concentration <2
standard deviations of the
age- and sex specific normal
reference
Hb binds to oxygen and
carries it to tissues
Red blood cells (RBCs)
consist mostly of Hb.
Commonly used indicator
to screen for iron deficiency
in population-based surveys
but not specific for iron
deficiency

Normal RBCs

Anemic RBCs

Not all anemia is caused by iron

deficiency.
But iron deficiency is a major cause of
Hookworm
anemia
in many developing countries.

HIV/AIDS
Anemia of
Inflammatory
Conditions

Iron
Deficiency
Anemia

Iron
deficiency

Malaria

Anemia

Other vitamin
deficiencies

Hemoglobinopathies

24

Overlapping causes of Anemia

Malaria

Anemia

Hookworm

Severe: 40%

Moderate: 20-39%

Anemia is one the most widespread disorders

in the world!

~50% pre-school children

~42% pregnant
~30% non-pregnant

~50% have
IDA

McLean et al. Public Health Nutr, 2008, 12: 444-454

25

Iron Deficiency among 6-59 mo-old

children
Wasting

Iron-deficiency

VA-deficient

VAC coverage

80

Prevalence

70
60
50
40
30
20
10
0
Kenya

Uganda

Ethiopia-1

Ethiopia-2

Algeria

Refugee Camps
Seal et al., J Nutr 2005

Summary of Health Risks of Iron

Deficiency Anemia
Maternal Mortality
Perinatal Mortality
Pregnancy

Childhood

Adults

Low birth weight

Neonatal mortality
Post-neonatal, child mortality
Negative effects on child cognition
and behavior
Productivity and economic gains

26

Iron requirement at different life stages

Iron requirement increases 3 x s due to
expansion of maternal red-cell mass & growth
Increased growth
ofMenstrual
fetal-placental
unit.
losses
needs exhaust
stores
Net
iron requirement
superimposed
with is 1 g (~4 units of blood)
accumulated during
needs
for rapid growth
gestation

Institute of Medicine, 2001

Intervention strategies-Iron Deficiency

Dietary modification?

Iron Supplements?
Screen?

Home
fortification?

Central
fortification?
Delayed cord clamping?

27

Dietary modification--Effective & safe?

Fe-rich animal source foods are expensive and often
unavailable
Dietary diversification, while important for overall
dietary quality, is generally unsuccessful at closing
the Fe gap for young children
Summary: It is unlikely that dietary modification
strategies alone will be sufficient in most lowincome populations

Iron supplementation
Delivery of
medicinal Fe orally
in the form of pills
or liquids, usually
consumed in the
absence of food.

Prentice A et al. NIH Technical Working Group, Presented

At ICN Bangkok, 2009)

28

Routine iron supplementation in

pregnancy prevents anemia at delivery
Consistent
results
showing
reduction of
anemia risk

Reduces
Risk

Increases
Risk

Kulier et al,
Int J Gyn & Obst 1998, 63: 231-246

29

Use of Micronutrient Powders or Sprinkles

In children, highly effective

at reduction Fe deficiency
(RR 0.44 [0.22, 0.86]) &
anemia (RR 0.54 [0.46,
0.64])

Iron Supplementation in Young Children

Benefits and Risks Remain Controversial

Stoltzfus, Micronutrient Forum, 2007

Tielsch J et al, Lancet 2006, Sazawal S et al, Lancet 2006

30

ConclusionsGiving Iron tablets in malaria

endemic context
At this time, the provision of iron via
tablets of liquids requires caution & may
be the least desirable approach in malaria
endemic areas
Fortified foods may be the most viable
alternative intervention. This includes Fe
fortification (central or home) of
complementary foods for infants and
young children & of staple foods or
condiments of women and older children
Prentice A et al. NIH Technical Working Group, Presented
At ICN Bangkok, 2009)

Intervention strategies-Malaria & Hookworm

De-worming for
hookworm

Quality Focused Antenatal

Care (FANC)

Intermittent
Preventive
Treatment (IPT)
Use of insecticide treated
nets (ITN)

31

Iron Deficiency Summary

Provision of adequate dietary sources often not
feasible due to low bioavailability of non-heme
sources
Recommended to give all pregnant & lactating
women iron-folate supplements
Supplementation needs to be accompanied by
intensive nutrition education to enhance
compliance
Inclusion of fortified blended food in general
ration can increase iron content of the food
basket
Also, control of malaria & parasitic infections

Iodine Deficiency

32

Goiter

Iodine Deficiency
Iodine essential component of thyroid
hormone
Iodine deficiency can damage brain &
nervous tissue

33

Spectrum of
Iodine Deficiency
Disorders
Fetus: abortion, stillbirth,
congenital abnormalities,
deaf mutism, increased
mortality
Neonate: goiter
Child & Adolescent: goiter,
hypothyroidism, impaired
mental function, retarded
physical development
Adult: Goiter,
hypothyroidism, impaired
mental function

Iodine Deficiency: Global & Regional

WHO 2004
UN
Region
Africa
Asia

%
Countries

Low I
Intake
(millions)

% of
popn

Goiter
(millions)

% of
pop n

42
50

324
1,239

43
36

202
505

27
15

West et al, Intl Pub Hlth Nutr, 2005

34

IDD Prevention Strategies

Iodization of Salt
Iodization of other vehicles
Iodized Oil supplementation

Zinc Deficiency

35

Functions of Zinc
Essential mineral
Found in almost EVERY cell
Stimulates >100 enzymes that promote
biochemical reactions
Supports healthy immune system
Helps maintain sense of taste and smell
Needed for DNA synthesis
Supports normal growth & development during
pregnancy, childhood and adolescence

Therapeutic Effects of Zinc on Duration of

Acute Diarrhoea/Time to Recovery
*India, 1988
*Bangladesh, 1999
*India, 2000
*Brazil, 2000
*India, 2001
Indonesia, 1998
India, 1995
Bangladesh, 1997
India, 2001
India, 2001
Nepal, 2001
Bangladesh, 2001
Pooled
0.5

0.75

1.25

*Difference in mean and 95% CI

Relative Hazards and 95% CI

36

WHO/UNICEF
Diarrhea Treatment
Protocol modified
to include the
giving of zinc for
10-14 days.

Major outbreaks of micronutrient

deficiency disorders in emergencies
Disease

Year(s)

Scurvy

Nutrient Location
Deficiency (Group affected)
Vitamin C Somalia
Kenya
Afghanistan

Beri Beri

Thiamin

1974
1999

Mauritania
Nepal (Bhutanese)

A.Stomatitis Riboflavin Nepal (Bhutanese)

Pellagra

Niacin

mid-1990s
1994/95
2001

1998-2000

Malawi (Mozambique)1989-1995
Tanzania
2001
Angola
2002-2005

37

What role can fortification play in

addressing MNDs during
humanitarian emergencies?

Food fortification:
Food fortification is the practice of
deliberately increasing the content
of essential micronutrients in a
food so as to improve the
nutritional quality of the food
supply and to provide a public
health benefit with minimal risk to
health.
WHO/FAO Guidelines on Food Fortification

38

Technical Considerations:
Choice of food vehicle
High proportion of at risk popl consumes food
Regularly consumed in relatively constant
amounts
Minimal between-person variation
Low potential for excess intake
Centrally processed
Minimal regional variation
Low-cost fortification technology available

Comparison of Food Vehicles

Grain

Fortified
Flour

CSB

Vegetable
Oil

Biscuits

Sugar

Expected
population
coverage-actual
consumption

90%+

95%+

30-80%

20-70%

In extreme
circumstances
95%, on longterm basis,
10%

95%

Cost/metric ton

$100$200

$120$220

$350

$1,000

$2,000

$600

--

all

all

Vit A

all

at best,
iodine
and Vit A

moderate

low

low

medium
to high

high

medium

MN carrying
capability
Stability of the
food and MNs

Hansch S, 1999, Enhancing the Nutritional Quality of Relief Diets

39

Technical Considerations
Fortificant
Stability?
Bioavailability?
Segregation?
Interaction with other MN?
Reactivity?-effect on color, taste, other
organoleptic properties of food?
Masking qualities?
Acceptable to consumer?
Technical feasibility of adding to food?

What are the options for

improving fortification of food
rations?

40

Key questions
Is the ration likely to be deficient in a specific MN
(s)? Why?
Was/is there an endemic MN deficiency in the
population? If so, can large-scale preventive
intervention be considered thru the general
ration?
Are food-aid commodities in the ration
appropriately fortified?
Are additional interventions (home gardens, deworming) appropriate and feasible?

Fortification Options
(Not mutually exclusive)
1. Increase levels of certain nutrients in blended
foods
2. Add iron & B vitamins to wheat flour in donor
countries
3. Establish regional pre-distribution fortification
centers near areas prone to emergencies
4. Fortify flour in local mills after food ration is
provided at camp-level
5. Fortify at household level

41

Nutval
http://www.nutval.net/
user friendly software
facilitates a planning process for food aid
rations that ensures that minimum
nutritional standards are met while
minimizing costs

Nutval-- http://www.nutval.net/

42

Option 1: Increase levels of certain

nutrients in blended foods
US blended food limited
to supplementary and
targeted feeding
programs
Primarily used as a
weaning food, mixed with
water as beverage or
gruel
Cost

Corn-Soya Blend

43

Fortification of Blended Foods

Advantages

Disadvantages

May not be acceptable by

Pre-cooked which means
all emergency-affected
minimal losses during
popls
cooking
Need to standardize
appropriate fortification
Main nutrients can be
placed in one food source levels
Phytate content might
Can be stocked for
decrease bioavailability of
emergency
some MNs.

Consumed by family even Increased dependency

if intended for
Short-term strategy
malnourished children
3xs more costly than whole
grains

Option 2. Processing & Fortifying

grains in donor countries
Currently being practiced
Processing & fortifying grains in US adds
~300% to cost of the commodity
Manufacturing standards in US have NOT
been rigorous for PL480 foods until 1999

44

Fortification of Cereals in Donor

Country
Advantages
Convenient way of
preventing deficiency
diseases by providing
food with added MNs
Costs higher if
processed in US
(Cargo Preference
Act)

Disadvantages
Shelf-life reduced
MN losses during
storage, transport and
preparation
Monitoring of quality
control is essential

Option 3. Establish regional pre-distribution

fortification centers near areas prone to
emergencies
Advantages

Disadvantages

High coverage of popl

Even largest millers lack
the technology or
Low Cost
experience to fortify with a
Introduces technology into
premix
poor areas
Minimal milling capacity
Appears practical and
up-country between major
affordable
cities/ports & refugee
Contributes to growth of
camps
regl milling industry
Requires advocacy,
technology transfer, quality
control

45

Option 4. Fortify flour in local mills after

food ration is provided at camp-level
Advantages
Small mills found in
almost all refugee
camps
Low cost
Lower storage &
spoilage
Maximize shelf-life of
grain & minimize MN
losses

Disadvantages
Requires adequate,
affordable &
accessible milling
capacity
Requires quality
assurance
Possible high milling
fees
Need reliable dosing
system for MN

Mobile milling and

fortification unit
(Nangweshi refugee camp,
Zambia)

46

Very small village maize mill in Niger

Pounding of maize in Zambia

Option 5. Home-based fortification

Mixing Sprinkles

47

Micronutrient Powders or
Sprinkles
Tasteless powder containing the
recommended daily intake of 16
vitamins and mineral for one person.
Can be sprinkled onto homeprepared food after cooking just
before eating
Price: $2-3 per 100 sachets

Ready to Use Foods (RUFs)

PlumpyDoz & Supplementary Plumpy
a peanut paste containing
skim milk, sugar, vitamins
and minerals
Micronutrients: vitamin A, E, B1, B2,
Niacin, Pantothenic acid, vitamin C, B6,
B12, Calcium, Magnesium, Selenium,
Zinc, Iron, iodine, Copper, Phoshorus,
Potassium, Manganese, Folic acid
(Supplementary Plumpy also has Vitamin
D, K and Biotin).

http://www.youtube.com/watch?v=b4u-a8TAFSM

48

Nutritional Value (per 100 g

PlumpyDoz/Supplementary Plumpy)
Nutritional Value

Price

Energy 534Kcal /
545Kcal
Protein 12.7g /13.6g
Fat 34.5g / 35.7g
Micronutrients

$0.20 / ration of
Plumpy'Doz
$0.33 / ration of
Supp. Plumpy

Many productsbut guidance & consensus not consistent on

nutrient composiTon, objecTve, use or safety
Rx SAM
Plumpynut

Rx MAM
Plumpydoz or sup

Prevent
malnutriTon
Nutribu]er or Plumpysoy

Prevent MNDs
Micronutrient
Powders

ForTed blended foodsWSB++, CSB++

MND=MicroNutrient
Deciencies
WSB=Wheat Soya Blend
CSB=Corn Soya Blend

49

Dietary Diversification

Dietary Diversification
Advantages
Local fresh foods help IDP
maintain normal diet.
Many fresh fruits and
vegetables provide carotene,
Fe, vitamin C, thiamin.
Lentils & groundnuts provide
Fe, thiamin, niacin
Food sources provide other
nutrients (trace elements,
phyto-nutrients)
Local procurement may
enhance production & provide
economic support

Disadvantages
Purchase of sufficient
quantities difficult & expensive
Local markets may be
unreliable
Cost is usually high
Logistic problems esp if popl
not easily accessible
Large-scale procurement can
create shortages & price
increases on the local market

50

MN Supplementation

51

Supplementation
Advantages
Very specific for treatment &
prevention
Recommended for treating
outbreaks of deficiency
disease
Storage & transport less

problematic than foodstuffs

Politically-visible

Iron-folate tablets
recommended for preg & lactg
women
Large dose vitamin A capsules
recommended for pre-school
children

Disadvantages
Logistically difficult for
some nutrients (vitamin
C, B complex) that
require daily
supplementation
Procurement of sufficient
amount may be
problematic
Need to monitor iron and
VA supplementation to
avoid potential toxicity

Why is there a lack of

convergence for
approaches addressing
acute and chronic
undernutrition?

52

Emergency

Non-Emergency

Case load

High

Lower

Urgency

High

High

RX/Medical

RX & Prevention

Targeted to affected area

Universal

Duration

Until emergency is
over

Continuous

Delivery
system

Vertical; parallel to MoH

Existing (often
weak)
infrastructure

INGOs, often outside

MoH

MoH

Quality

High?

Wide-ranging

Funds

External

External & internal

Supplies

External

External & internal

Emphasis
Scale

Main actor(s)

Different causes & consequences of acute vs

chronic undernutrition have led to different.

Actor involvement
Screening methods
Foods, supplements, other services
Program models

Bergeron and Castleman, Adv Nutr, 2012

53

Acute Malnutrition

Chronic Malnutrition

Actors

Medical profession thru

treatment & referral
protocols at different levels

Multi-sector actions (thru MN

suppl., fortification, BCC) to
diet, exposure to illness,
care

Screening
methods

MUAC (simple, fieldfriendly)

Weigh-for-length

Length-for-age
(but often weight-for-age)

Foods &
other

F75, F100 for in-patient

RUTF for out-patient (+
antibiotic prophylaxis &
antihelminth treatment)

Complementary supplemental
foods (e.g. CSB, CSB++, WSB+
+, Plumby Doz, MNPs, LNS)

Program
models

Move from CTC to CMAM

Ante-natal Clinics, Child Health

Days, Immunization Contacts,
Growth Monitoring contacts

MOH, NGOs, CHWs

F75=Formula 75; BCC=Behavior Change Communication, CSB=Corn Soya Blend, WSB=Wheat

Soya Blend, MNPs=Micronutrient Powders, LNS=Lipid-based Nutrient Supplements,
CTC=Community Therapeutic Care, CMAM=Community Management of Acute Malnutrition

Bergeron and Castleman, Adv Nutr, 2012

Take Home Messages

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Take Home Messages

MNDs have occurred frequently among refugee
populations dependent on intl food aid
Major MNDs of concern:
Vitamin A Deficiency, Iron Deficiency Anemia, Iodine Deficiency,
Zinc Deficiency, B-vitamins and vitamin C

Fortification of food aid with key MNs is an essential

component of an integrated strategy to prevent MNDs in
humanitarian emergencies
Supplementation, esp. vitamin A for children & iron-folate
for pregnant & lactating women
Where possible, encourage dietary diversification
strategies thru distribution &/or production of fresh fruits
& vegetables.

Multi-pronged Solutions
Fortification

Diet
Supplements
Deficient
Population

55

http://
motherchildnutrition.or
g/resources/pdf/mcniasc-toolkit-nutritionin-emergencysituations.pdf

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