Correcting Malnutrition

Even if the overall food needs of refugees are adequately met, inequities in the distribution system, disease, and various social factors may contribute to a high degree of malnutrition among certain groups. Children younger than 5 years of age, pregnant and lactating women, the chronically ill (e.g., tuberculosis and HIV/AIDS patients), and the elderly are considered vulnerable groups since they have specific nutritional requirements. A special nutrition intervention or selective feeding program targets these nutritionally vulnerable groups through supplementary feeding programs and those in need of nutritional rehabilitation through therapeutic feeding programs. Malnutrition prevalence rates, as well as an assessment of aggravating factors in the environment, are used as guidelines to determine if a nutrition intervention program needs to be initiated. Aggravating factors that influence the nutritional situation include an elevated crude mortality rate; epidemics of communicable diseases such as measles, diarrhoeal diseases, and respiratory infections; and an unstable social, political, or environmental situation.

Nutrition intervention programs are primarily managed by nongovernmental organizations (NGOs) that have specialization in the management of refugee nutrition. Other humanitarian partners have roles to play in the response to refugee situations, including host country authorities, United Nations agencies such as the World Food Programme, UNHCR, and UNICEF; and other multi-sectoral NGOs. There exist memorandums of understanding and partnership agreements among agencies to provide assistance to the affected populations. The need for partnership is essential for management of refugee nutrition and health programs. The Sphere Project was launched in 1997 to develop a set of universal minimum standards in vital sectors of humanitarian assistance. The aim of the project is to improve the quality of assistance provided to affected populations and to enhance the accountability of the humanitarian system in emergency response.

Supplementary Feeding Programs The most common nutrition intervention is supplementary feeding programs (SFPs) to address malnutrition in emergency situations. SFPs provide a high-quality food as a nutritional supplementation to the daily diet of malnourished populations. There are two main types of SFP—targeted and blanket. The goal of targeted supplementary feeding is to prevent people who are moderately malnourished from becoming severely malnourished. Blanket supplementary feeding, which provides all members of a vulnerable group with a food supplement, is intended to prevent the deterioration of nutritional status among a larger population group rather than narrowly defined individuals at specific nutritional risk. Implementation of SFPs can take two forms: prepared meals consumed on site (wet rations) or food rations issued weekly or monthly to take home for preparation (dry rations). Food supplements usually consist of a fortified blended food (FBF) mixed with oil, and sometimes sugar is included. Wet rations should provide 500-700 kcal, whereas the recommended dry ration is doubled to 1000-1200 kcal in order to account for sharing at home.

Therapeutic Feeding Programs Therapeutic feeding programs (TFPs) provide the severely malnourished with their full nutritional requirements in addition to medical care. They are initiated to reduce excess mortality among individuals facing severe malnutrition and have played an important role in reducing malnutrition-related mortality in emergencies. The first phase of a TFP focuses on treatment of infections, management of other medical complications, and metabolic stabilization. This phase has the highest mortality rate of all nutrition interventions due to the poor state of the patients and the intensive treatment required. The second phase of a TFP is a rapid weight gain period designed to rehabilitate the patient's nutritional status.

Recognition of severe acute malnutrition as a complex nutritional condition during the 1990s led to the development of certain foods defined explicitly for therapeutic treatment of malnutrition with the appropriate balance of energy and protein in order to avoid overloading the body's metabolism, which potentially may lead to cardiac shock. These products include F-75, F-100, and BP-100 biscuits and other ready-to-use therapeutic foods (RUTFs) such as 'plumpy nut.' In addition to balanced energy and protein, these products also contain several vitamins and minerals. For the first stage, TFP F-75 therapeutic milk is used, with the amount of milk given calculated according to the patient's age and weight. During the second stage, F-100 therapeutic milk, with a higher protein content required for rapid weight gain, is used. During the final stage of the treatment, a micronutrient-rich porridge is introduced and eventually, if possible, a family-type meal is introduced in order to reaccustom the patient to the kind of food eaten at home. Those who survive therapeutic treatment generally need further support under SFPs in order to reduce the likelihood of relapsing into a severely malnourished state (Figure 4).

General Nutrition Support (General Food Distribution)

Correction of Malnutrition

Supplementary Feeding Programme (SFP)

Therapeutic Feeding Programme (TFP) (for Severely Malnourished Children)

Targeted Supplementary Feeding Programme (for Moderately Malnourished Children)

Blanket Supplementary Feeding Programme (Children under Five, Pregnant and Lactating Women)

Figure 4 Nutrition interventions. (Adapted from Sphere Project (2004) Humanitarian Charter and Minimum Standards in Disaster Response. Sphere Project, Geneva, Switzerland.)

Community Therapeutic Care Community-based care is a recently developed public health approach to dealing with severe malnutrition and aims to treat the majority of people suffering from severe malnutrition in their homes. A community therapeutic care (CTC) programme initially is set up complimentary to traditional TFP components and represents a new approach to managing malnutrition in situations at the community level. A CTC programme has the same initial metabolic stabilization phase, and life-threatening infections are identified and treated just as in a TFP. However, once the patient is stabilized, he or she moves directly to an outpatient therapeutic programme that operates through existing health structures and, with the use of ready to use therapeutic foods (RUTFs), nutritional rehabilitation is initiated. When patients are no longer at risk of severe malnutrition, they are referred to SFPs for recuperation. This phase is followed by greater emphasis on community mobilization to increase the population's involvement and training of mothers who are selected based on their ability to raise well-nourished children even in the face of poverty. After a short training period on nutrition, these mothers team with members from their communities in order to educate them on the fundamentals of successful treatment and prevention of moderate malnutrition and the manufacturing of local RUTFs. At this point, a CTC truly becomes community owned and operated.

CTC is an innovative approach that is still under debate. Proposed benefits of this method are the improved coverage to increase the number of people treated and reduce overall mortality rates. In addition, local production of RUTFs would reduce the cost of treatment, and the shortened length of stay in centres away from the family would have economic and social benefits for the entire family. Finally, the decentralized nature of CTC would allow for earlier detection of

Table 3 Milestones in addressing nutrition in refugees

1960s: Food response based on commodities available (donated)

Limited recognition of relevance of nutritional content of rations

Food provided based on resources rather than nutritional needs 1970s: Focus on protein deficiency (in protein-energy malnutrition)

Food ration comprised mainly cereal, pluses/beans, and oil

Fortified blended foods (FBFs) used only in supplementary feeding 1980s: Major relief agencies raise planning figure from 1500

to 1900kcal/person/day 1990s: Relief agencies raise planning figure for fully food aid-dependent populations from 1900 to 2100 kcal/ person/day

FBF included in most rations for completely dependent populations

Basic six-commodity food basket becoming common: cereal, pulses, oil, salt, sugar, FBF

UNHCR/WFP Memorandum of Understanding signed with clear roles and responsibilities

Development of multi-UN agency and NGO policies and guidelines on common approaches to addressing malnutrition in emergencies

Fortification of oil, salt, and flours, on international market

Development of therapeutic foods for treatment of malnutrition (F100-F75)

Local production of fortified blended foods 2000s: Development of community therapeutic care approaches

Development of capacity in nutrition in humanitarian staff

Pilot testing of on-site milling and fortification in a refugee camp

Adapted from Toole M (1998) An Overview of Nutrition in Emergencies, paper presented to the ACC/SCN Working Group on Nutrition in Emergencies, April 11.

malnutrition, thereby reducing the incidence of severe malnutrition (Table 3).

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