2. UNHCR/InterWorks - Emergency Management Training7.2.1. Session 7.2. Assessment 4: Working with Sectoral Indicators: Food & Nutrition WFP Photo

3. UNHCR/InterWorks - Emergency Management Training7.2.2. Objectives After completing this session, participants will be able to:  Highlight the relationship between malnutrition and disease  Describe an adequate basic ration  Review the standards and indicators used for determining nutritional status in the population  Understand the uses of special feeding programs and targeted interventions

4. UNHCR/InterWorks - Emergency Management Training7.2.3. A vicious cycle Measles Diarrhea Pneumonia Malaria LoweredResistance Poor Appetite Infection High energy Utilization MalnutritionMalnutrition

5. UNHCR/InterWorks - Emergency Management Training7.2.4. Malnutrition: when a person can no longer maintain adequate performance in growth, pregnancy, lactation, work, and resisting and recovering from disease

6. UNHCR/InterWorks - Emergency Management Training7.2.5. Death Rate Correlates with Malnutrition Malnutrition Rate in Population DeathsDeaths CMR Crude mortality rate

7. UNHCR/InterWorks - Emergency Management Training7.2.6. Kwashiorkor - an extreme indicator from inadequate protein intake and/or the stress of infection Visible signs:  Edema - swelling  Flaking skin  Thin, light hair  more common among 3-5 year olds

8. UNHCR/InterWorks - Emergency Management Training7.2.7. Energy, Calories, and Nutrients  Short for "Kilocalories”  Food energy

9. UNHCR/InterWorks - Emergency Management Training7.2.8. Required Nutrients  Protein: 4 kcals/gram  Carbohydrates: 4 kcals/gram  Fat: 9 kcals/gram  Micronutrients: Vitamins and Minerals

10. UNHCR/InterWorks - Emergency Management Training7.2.9. Kilocalories per gram of food

11. UNHCR/InterWorks - Emergency Management Training7.2.10. All Guidelines and Standards Highlight the Same Indicator  2,100 Kilocalories Per Person Per Day as a gross planning figure

12. UNHCR/InterWorks - Emergency Management Training7.2.11. Individual Need for Calories varies  Some people need 1,500 kcal/day…..  Some people need 5,000 kcal/day…...  What does the need depend on?

13. UNHCR/InterWorks - Emergency Management Training7.2.12. Who has the greatest daily needs in kilocalories??? 1. Males - especially 15-19 years old 2. Lactating women 3. Pregnant women 4. Heavy physical activity 5. Severe cold weather

14. UNHCR/InterWorks - Emergency Management Training7.2.13. Daily Energy Requirements Age group Males (kcal/day) Females (kcal/day) Average (kcal/day) % of pop. 0-4yr132012501290 12.37% 5-9yrs.198017301860 11.69% 10-14yrs.237020402210 10.53% 15-19yrs.270021202420 9.54% 20-59yrs.246019902230 48.63 60+yrs.201017801890 7.24 Pregnant 285 (extra) 2.4% Lactating 500 (extra) 2.6% AVERAGE DAILY REQUIREMENT: 2100 Kcal/person/day Based on WHO technical Report No. 724 and UN Pop. Data, mid 1995

15. UNHCR/InterWorks - Emergency Management Training7.2.14. Making a Basic Food Ration: What are our goals? 2,100 kilocalories - adjusted for: 17% fat 10-12% protein All micronutrients - Something rich in vitamins and minerals - like blended foods (corn-soy blend)

16. UNHCR/InterWorks - Emergency Management Training7.2.15. Let’s Design a Ration for a Refugee Population  Foods that are available  Foods that are reasonably priced  Foods that won’t spoil quickly  Foods that are acceptable  Foods that achieve nutrition objectives

17. UNHCR/InterWorks - Emergency Management Training7.2.16.  Major food item: Grain (staple) either wheat, maize, rice, sorghum or a flour (4 kcal/gram minus loss)  Food with protein: beans or lentils (4 kcal/gram minus loss)  Source of fat and energy: oil (9 kcal/gram)  Something rich in vitamins and minerals: Blended Food - Corn/Soy blend (3.8 kcal/gram)  Salt for flavor and iodine (no calories)  Sugar for flavor and energy (4 kcal/gm)

18. UNHCR/InterWorks - Emergency Management Training7.2.17. An Example Ration 15Sugar 25 Vegetable Oil 50Corn-Soy-Blend 60 400Rice Grams (/person/day) Commodity Pulses

19. UNHCR/InterWorks - Emergency Management Training7.2.18. Food Aid Management Concerns  Do people have access to fresh foods and alternative foods?  Will they accept the food in their cultures?  What if there is not enough of the needed food? What can be substituted?  What about the food that is lost in grinding and cooking?  Do they have enough water, cooking fuel, grinding facilities and kitchen utensils?  Is the food safe? What about powdered milk?

20. UNHCR/InterWorks - Emergency Management Training7.2.19. Example Difference between two families Family IFamily II 1 Pregnant2 Elderly 1 Lactating1 Adult 2 Teenage1 Child 1 Adult1 Child Needs 2500 Calories1700 Calories With ration of 2100 kcals, Family I will have a ration deficit and Family II a ration surplus.

21. UNHCR/InterWorks - Emergency Management Training7.2.20. Micro-nutrient Deficiencies 1.Vitamin A - Blindness 2.Vitamin B1 - Beri-Beri (Thiamin) - Paralysis/Cardiac Failure/Death 3.Vitamin C - Scurvy - Bleeding/Anemia/Numbness/Death 4.Iron - Anemia, Paleness-Death 5.Niacin - Pellagra - Diarrhea/Dermatitis/Dementia/Death 6. Iodine - Goiter

22. UNHCR/InterWorks - Emergency Management Training7.2.21. Most Micronutrient Deficiency Disease is Hidden Typical Refugee Population No DeficienciesVarious Vitamin, Mineral Deficiencies Observable, Clinically Evident

23. UNHCR/InterWorks - Emergency Management Training7.2.22. Vitamin & Mineral Deficiency Disease Epidemics will occur, predictably, in refugee crises What Indicators can we use to find them?

24. UNHCR/InterWorks - Emergency Management Training7.2.23. Salter Scale Salter Scale Weight

25. UNHCR/InterWorks - Emergency Management Training7.2.24. Height boards

26. UNHCR/InterWorks - Emergency Management Training7.2.25. Mid-upper Arm Circumference or “MUAC”

27. UNHCR/InterWorks - Emergency Management Training7.2.26. MUAC of all children aged 6 - 59 months MUAC > 13.5 cm MUAC < 13.5 cm or oedema Not referred unless at high risk Referred to central WfH assessment NOT admitted to feeding programme Therapeutic Feeding Programme Supplementary feeding Programme WfH > 80%WfH < 70%WfH 70 - 79% QUICK MUAC as QUICK Screening Tool

28. UNHCR/InterWorks - Emergency Management Training7.2.27.  < 80% of the reference value of Weight-for-Height Malnutrition Rates  < 70% of the reference value of Weight-for-Height “Severely” Malnourished: “Moderately” Malnourished:

29. UNHCR/InterWorks - Emergency Management Training7.2.28. Malnutrition Rates / Interventions Serious! Supplementary feeding for all vulnerable. groups Therapeutic feeding for severely malnourished Alert! Suppl. feeding for selected individuals in vulnerable groups Therap. feeding for severely malnourished < 5%Acceptable No need for population-wide programme > 10% or 5-9% plus aggravating factors >20% or 10 - 19% plus aggravating factors

30. UNHCR/InterWorks - Emergency Management Training7.2.29. What is an “aggravating factor?” General food ration of < 2100 kcal/day General food ration of < 2100 kcal/day Crude mortality rate of > 1/10,000/day Crude mortality rate of > 1/10,000/day Measles or whooping cough epidemic Measles or whooping cough epidemic High prevalence of respiratory or diarrheal diseases High prevalence of respiratory or diarrheal diseases

31. UNHCR/InterWorks - Emergency Management Training7.2.30. Our biggest enemy: loss of appetite anorexia loss of appetite shrunken stomach

32. UNHCR/InterWorks - Emergency Management Training7.2.31. What are the most Important Things Given in Supplementary and Therapeutic Feeding?  Regular, hot, sweet, fluid meals (typically in the form of porridge or milk, with crackers)  Personal A t t e n t i o n

33. UNHCR/InterWorks - Emergency Management Training7.2.32. In Extreme cases, Therapeutic Feeding will Focus on oral rehydration and high energy milk

34. UNHCR/InterWorks - Emergency Management Training7.2.33. Oral Rehydration Salt formula (ORS) 1 liter Water (boil first!) 20 grams Glucose sugar 1.5 grams Potassium chloride Banana Banana 2.5 grams Sodium bicarbonate Baking soda Baking soda 3.5 grams Sodium Chloride Salt

35. UNHCR/InterWorks - Emergency Management Training7.2.34. WFP ResponsibilitiesUNHCR NOTE: Under the 2002 MOU, WFP will conduct 12 pilot cases where they disribute food directly to beneficiaries instead of UNHCR

36. UNHCR/InterWorks - Emergency Management Training7.2.35. WFP/UNHCR MOU Responsibilities Basic Commodities (WFP) Complementary Commodities (UNHCR) - Cereals (Wheat, Rice, Maize) -Oils and Fats -Protein-rich Food (Beans/Peas or Nuts) -Canned Fish or Meat* -Dried Fish or Meat* -Salt* -Sugar - Fortified Blended Food - High Energy Biscuits -When recommended by the Joint Assessment Mission, UNHCR will supply: - Fresh Meat or Fish -Vegetables and Fruit -Condiments (Soy Sauce, Tomato Paste, etc.) -Spices -Dried skimmed milk (DSM)

37. UNHCR/InterWorks - Emergency Management Training7.2.36. Joint Responsibilities (in consultation with Host Government)  Defining locations of EDPs  Monitoring overall food aid supply situation (through FASreps)  Constant exchange of information  Consultation for problem resolution UNHCR WFP

38. UNHCR/InterWorks - Emergency Management Training7.2.37. CONCLUSION Avoid serious malnourishment, by quickly establishing a satisfactory basic food rationAvoid serious malnourishment, by quickly establishing a satisfactory basic food ration Treat serious malnutrition that does occur with special supplementary and therapeutic feeding programmes for those in needTreat serious malnutrition that does occur with special supplementary and therapeutic feeding programmes for those in need Use commonly agreed indicators for assessing, designing, and monitoring food and nutrition programmesUse commonly agreed indicators for assessing, designing, and monitoring food and nutrition programmes