Public Nutrition in Complex Emergencies: Learning Objectives To identify the principal forms of malnutrition in emergencies Protein-energy malnutrition (PEM) Micronutrient malnutrition To identify the key indicators of nutritional status for assessment and principles of data interpretation for response planning To understand core principles and protocols for assessing the need for, establishing, maintaining and phasing out of: General food distribution programs Supplementary feeding programs Therapeutic feeding programs To be able to calculate ration composition to meet minimum guidelines To understand, for key micronutrients, the epidemiology of deficiency, assessment techniques, and treatment of deficiency

Nutritional Assessment and Interventions in Emergency Settings Ellen C. Mathys, MPH John B. Mason, PhD Tulane University School of Public Health and Tropical Medicine Photo is from Oxfam food distribution in Ethiopia, c. 2000. Developed in part with support from a grant from CARE International. Photo from Oxfam food distribution in Ethiopia, c. 2000.

Objectives of nutritional programming in emergencies To ensure adequate food supply for entire affected population and thereby prevent malnutrition and other adverse health consequences To provide nutritional rehabilitation for moderately and severely malnourished To prevent nutritional deterioration for ‘vulnerable groups’

Why focus on the whole population first Why focus on the whole population first? Photo of Eritrean refugee camp, July 2000, by Ellen Mathys. Ask students: why focus on the basic needs of the whole population first? The entire population may be living in conditions that challenge health status through altered temperature, exposure to pathogenic elements, overcrowding and stress. Therefore it is essential to implement mechanisms to meet basic needs of the larger population before targeting smaller sub-groups with programs tailored to their needs. Photo of Eritrean refugee camp – Ellen Mathys, July 2000.

Photo of sheeting and laundry in Eritrea – Ellen Mathys, July 2000. Photo of Eritrean refugee camp, July 2000, by Ellen Mathys. Photo of sheeting and laundry in Eritrea – Ellen Mathys, July 2000.

Types of emergency feeding programs Ask students: what types of feeding programs are commonly implemented in emergencies?

Malnutrition in emergencies Protein-energy malnutrition (PEM) Marasmus Kwashiorkor Marasmic kwashiorkor Micronutrient malnutrition Vitamin A deficiency (xerophthalmia) Thiamin (B1) deficiency (beriberi) Niacin (B3) deficiency (pellagra) Vitamin C deficiency (scurvy) Iron deficiency (anemia) Iodine deficiency (goiter, cretinism) Riboflavin (B2) deficiency (ariboflavinosis) PEM will be the focus of this discussion. John Mason will discuss micronutrient malnutrition in greater detail in the second session. Populations affected by conflict and displacement may be at greater risk of micronutrient malnutrition because of decreased access to fresh foods (decreased availability and limited purchasing power) and reliance on a limited general ration which may not include a diversity of foods or blended, fortified foods. Marasmus and Kwashiorkor are two diseases caused by malnutrition. Marasmus:is the result of a child having a low intake of energy and nutrients. It often follows severe illness or a period of frequent infections. It occurs most often during the first 2 years of life, particulary during famines. Symptoms: Extreme low weight. Extreme wasting. An "old person face". A "pot belly" the childs abdomen is swollen. Kwashiorkor: is due to lack of energy and nutrients. It's most common in children age 1-3 years, especially if they are stopped being breastfed in an abrupt way. Symptoms: Oedema on the legs, arms and face. Moon face: the child's face becomes round and swollen. Moderate low weight. Wasted and weak muscles. Misery and apathy, the child looks unhappy. Poor appetite. Pale, thin, peeling skin. Pale sparse hair with weak roots. The symptoms can develop rapidly and the child can get full blown kwashiorkor within a day. This disease has a very high mortality risk.

PEM: Marasmus Main and associated signs: May result from: Severe loss of fat and muscle Thin “old man” face “Baggy pants” Generally alert No nutritional edema Prominent ribs Importance of appetite May result from: Severe food shortage Chronic or recurrent infections with marginally low food intake Marasmus (wasting) is the most common form of PEM in conditions of severe food shortage. The two causes of marasmus – infection and inadequate dietary intake, are in a vicious cycle such that each reinforces the other. Infection may decrease the appetite, and decreased dietary intake makes people at greater risk of infection. One factor which is not an official symptom but is important is appetite – a lack of appetite is a good sign of increased risk of mortality, but a child can have all these symptoms and will probably make it if she still has an appetite.

Marasmus Photo of Somali child by A. Raffaele Ciriello (http://www Somalia child starving, A. Raffaele Ciriello (http://www.ciriello.com).

Marasmus (Photo from www.nutrition.uu.se)

PEM: Kwashiorkor Relatively uncommon, but high risk of mortality Main and associated signs: Nutritional edema May appear fat because of edema Hair changes: loss of pigmentation, straightening, easy pluckability Skin lesions and depigmentation: dark skin may become lighter in skin folds, outer layers of skin may peel off (esp. legs), ulceration, lesions resembling burns Apathetic, miserable, irritable demeanor, lack of appetite Marasmic kwashiorkor Relatively uncommon, but high risk of mortality May result from: Combination of inadequate diet and infection More common with non-cereal diet (e.g. roots/tubers) Kwashiorkor is much less common than marasmus/wasting in emergencies. (Data on distribution and prevalence) Kwashiorkor is a greater risk with non-cereal based diets. The causality has a complex causality related to a non cereal diet. Although it is often thought to be a protein deficiency, it is not that simple, the role of infection is unclear, and treatment with protein is ineffective where energy deficiency exists, because the protein would just be used for energy. Nutritional edema will likely be found in lower extremities (bipedal) but possibly may be found in hands and face (“moon face”). The most striking manifestations of the disease are a swollen and severely bloated abdomen, resulting from decreased albumin in the blood, and various skin changes resulting in a reddish discoloration of the hair and skin in black African children. Other symptoms include severe diarrhea, enlarged fatty liver, atrophy of muscles and glands, mental apathy, and generally retarded development. Kwashi kids may be thought to be well nourished because they appear fat. Marasmic kwashiorior: refers to marasmic children (<-3 SD wfh) but without other signs of kwashiorkor.

Kwashiorkor (Photo from www.nutrition.uu.se)

Nutritional assessment in emergencies Before data is available: 100:10:1 When should you do a nutritional survey? As an initial assessment of the severity of the problem As a follow-up assessment to monitor trends and impact of interventions When resources are available to act on results When time and conditions allow for survey implementation Before data is available in an emergency, you can assume: 100 normal people, 10 moderately malnourished people, 1 severely malnourished (wasted) person. Use this for preliminary planning purposes. Initial assessments allow you to make critical decisions about the appropriate nutritional response. They also provide baseline data for the monitoring of the impact of humanitarian interventions over time. One should not necessarily wait for nutritional survey results to plan for a general ration; when it is clear that the population will need a general ration, put the processes in place to start these programs and use the survey to modify the programs or implement more targeted programs if warranted.

Nutritional assessment: relevant secondary information History of emergency Household resources (food, non-food) Proximity to markets Development of local market activities Support from local population Numbers of malnourished Food access History of emergency: Look at the duration and nature of displacement, baseline nutritional/health situation Household resources: Food stores, seed, cooking utensils, livelihood tools Proximity to markets: for food purchase, employment Development of local market activities: may allow for trading of distributed items for food, non-food necessities Support from local population: in terms of sharing of resources Numbers of malnourished: there may already be many malnourished in the health system Food access: may be assessed through food basket surveys (aid), previous distribution information (aid) and food economy surveys

Nutritional assessment: sampling and indicators Children 6-59 mos Adolescents, adults Indicators: Acute emergency: wasting, edema Stable emergency: underweight stunting Reporting WFH, edema: Moderate wasting: <-2 to –3 Z scores WFH Severe wasting: <-3 Z scores WFH Moderate+severe wasting (global) plus edema: <-2 Z scores WFH Edema: Nutritional edema, regardless of WFH Sampling: Children 6-59 months are the most common target group because they are in developing countries the most vulnerable group and will show evidence of malnutrition first. Adolescents or adults would only be measured if acute malnutrition appeared to be widespread in these groups. One would look for edema and clinical signs in adolescents; and BMI, MUAC, edema and clinical signs in adults. Show ACC/SCN references. Indicators: In acute emergencies: Wt/ht and edema are key indicators. Wt/ht is important because it is statistically associated with risk of mortality. Edema is important as an indicator of kwashiorkor, which has a high mortality risk. In stable emergencies: One would add ht/age to look for trends in linear growth. It is possible that as wasting levels taper off with the establishment of nutritional programs, stunting levels may increase. MUAC should where possible be followed up with referral for wt/ht measurement. Moderate wasting in and of itself is not a strong indicator of mortality risk. It is more important to report: global malnutrition (moderate plus severe plus edema), and severe wasting, and edema. Wasting is a good short-term indicator of the effectiveness of your interventions in emergencies. Wasting may be measured by WFA or MUAC. As an emergency stabilizes, the wasting rates normalize and then are not particularly predictive of mortality risk. At this point it is more useful to measure underweight (which reflects stunting and wasting) and stunting.

Interpreting anthropometric results for response planning If food availability at hhld level <2100 kilocalories per person per day (kcals pppd): Improve general rations! If global acute malnutrition rate >=15%, OR 10-14% with aggravating factors: Ensure adequate general rations Consider starting a time-limited SFP for vulnerable groups (esp. children, preg/lact women) Therapeutic feeding programs for severely malnourished individuals Take-home points: The first priority is always an adequate general ration. 2100 kcals is only a rule of thumb – the ration may be calculated anywhere between 1700 – 2500 kcals pppd if one changes the temperature, activity level, demographic make up, etc. A SFP should never be started to complement an inadequate general ration, because it will be totally ineffective at achieving this end. SFP should always be time limited, because the general ration should be brought up to levels sufficient to support the nutritional status of the entire affected population. Aggravating factors: General food ration below mean energy requirement CMR more than 1/10,000/day Epidemic of measles or whooping cough (pertussis) High incidence of respiratory or diarrheal diseases

Interpreting anthropometric results for response planning If global acute malnutrition rate is 10-14%, OR 5-9% with aggravating factors: Ensure adequate general rations Targeted SFP for moderately malnourished TFP for severely malnourished If global acute malnutrition rate <10%, OR <5% with aggravating factors: No immediate need for large-scale interventions Surveillance and support to nutritional services in existing health system