Feeding Program in Emergency

  

Feeding Program

in Emergency Widya Rahmawati

Feeding Program Strategy

  Type of Feeding

  Program Selective

  General food Micronutrient feeding distribution intervention program

  Supplementary Therapeutic feeding feeding program (SFP) program (TFP)

  Blanket SFP Targeted SFP Mathys et al, 2000

  General Food

Distribution

General Food Ditribution

  Provides a standard general ration to affected population the immediate aim to cover food & nutrient needs to all population with constrained access to normal source of food Involves: distribution of a basket of food commodities to emergency-affected populations

  Commodities  Energy : 1900, 2100 or 2400 kcal/person/day  Sufficient energy, protein, fat  Usually include:

   energy rich foods (a staple, cereal, rice,),

   oils, fats, and

   protein rich foods (pulses: beans, ground nuts, lentils).

  8 Selective Feeding Program

Type of Selective Feeding Program

  The Decision making framework to implement selective feeding programs

  Selective Feeding Program 1) Supplementary Feeding Program Selective Feeding Program: Supplementary Feeding Program (SFPs)

• Provides nutritious food
• In addition to the general food
• The aim: to rehabilitate malnourished person
• Or to prevent a deterioration of nutritional status of the most at- risk
• By the meeting their additional needs, focusing particularly on young children, pregnant women & nursing mother

  Selective Feeding Program: Supplementary Feeding Program (SFPs)

• The aim: to prevent the moderately malnourished becoming severely malnourished & to rehabilitate them
• Food supplement to general food rations to: mild-moderately malnutrition, pregnant women & nursing mother
• The aim: to prevent widespread malnutrition & reduce excess mortality among those at risk
• By providing a food/micronutrient supplement for all member of the group (children under 5/under 3, pregnant women, nursing mother)

  Targeted SFPs  wasting 10-14,9%, atau 5-9% dg aggravating factors (SERIOUS)

Blanket SFPs 

  

wasting > 15%, atau 10-14,9% dg agravating

factors (CRITICAL) Targeted SFPs, Objectives: Rehabilitate moderately malnourished children, adolescents, adults and elderly persons. Prevent the moderately malnourished from becoming severely malnourished. Reduce mortality and morbidity risk in children under 5 years.

  When to start When to close, when all of these are satisfied Prevalence of 10-14% acute malnutrition among children.

  Provide a food supplement to selected pregnant and nursing mothers and other individuals at-risk Provide follow-up to referrals from Therapeutic Feeding Programmes Targeted SFPs, when to start & when to close?

  General food distribution is adequate Prevalence of acute malnutrition is below 10% without aggravating factors Control measures for infectious

disease are effective

  Prevalence of 5-9% acute malnutrition in presence of aggravating factors:

• inadequate general food rations,
• CMR > 1/10.000/hr,
• epidemic measles or pertusis,
• high prevalence of ARI or diarrhea

shown sign of improvement after 2 wks of wet SFPs, or after 1 mo of dry SFPs  should be assessed to find out the cause  referral for

medical/community care

Selected pregnant women and nursing mothers (≤ 6 mos after delivery)

  Aimed primarily to prevent a deterioration in nutritional status of population, And to reduce the prevalence of acute malnutrition of CU5  reducing morbidity & mortality risk Provide a food/micronutrient supplement for all member of groups at high risk of becoming malnourished

  Targeted SFPs, Criteria for admission & discharge: Admission criteria Discharge criteria Moderately malnourished children under 5

• WfH between -3 & -2 z score
• WfH between 70-80% of median Children who have maintained at least 85% median WfH or -1,5 WfH z Malnourished older children, adolescence, adults, elderly (BMI/MUAC), medical referrals Individuals older than 5 y who have attained a stable & satisfactory nutritional status & free from disease Referrals from TFPs Children & adults who have not

Blanket SFPs, Objectives:

  Blanket SFPs, When to start & when to close? Should be set up when one/ Will be closed when all of these combination of these condition are met

• At the onset of emergency when -General food distribution is general food distribution system are adequate & meeting requirement not adequate
• % of acute malnutrition <
• Problem in delivering/distributing without aggravating factors the general distribution rations
• % of acute malnutrition < 10% in the presence of aggravating factors % of acute malnutrition≥15%
• % of acute malnutrition 10-14,9% in -Disease control are effective the present of aggravating factors
• Anticipated increase in the rate of malnutrition due to seasonally induced epidemics
• Micronutrients outbreaks, to provide micronutrient-rich foods

  Blanket SFPs, criteria for admission All

• All CU5 or CU3 using height as cut off point (5 y = 110 cm, 3 y = 90

  primary cm) target

• Pregnant women from the time of confirmed pregnancy, and nursing

  groups for mothers until 6 months after delivery blanket

• Other at risk groups: sick, elderly

  SFPs are: Food commodities for SFPs  The size & the type of daily food supplement depend on the adequacy of the general food distribution, the malnutrition & mortality rate, & feeding program modalities

   Must be energy dense & rich in micronutrients, cultural appropriate, easily digestible & palatable, usually blended food (composed of pre-cooked cereals & legumes/soybean, fortified with vitamin & minerals)

  Food commodities for SFPs  Energy-dense SF must contain at least 100 kkal/100 grams, with at least 30% energy from fat. 

  Unimix/Famix/CSB (corn soya blend) have 6% fat content  should added 10 g oil/100 g blended food during preparation

   It is not recommended to use milk (fresh/milk powder) in a take-home rations  avoid discouraging effect on BF, bacterial contamination. Milk powder can be distributed in dry form only when mixed with other commodities Distribution of SFPs

  On-site feeding program, or wet rations

• The daily distribution of cooked food/meals at feeding centers
• The number of meals provided can vary in specific situation, but minimum of two/three meals should be provided everyday

  Take-home feeding program, or dry rations

• The regular (weekly/bi-weekly) distribution of food in dry form to be prepared at home
• It may be necessary to increase the amount of food to compensate for intra-household sharing

  Composition of SFPs

• 500-700 kcals energy/person/day
• 15-25 g protein
• Could include blended food, oil, sugar, cereal, high energy biscuit, pulses

  On-site feeding program, or wet rations

  Take-home feeding program, or dry rations

• 1000-1200 kcal/person/day
• 35-45 g protein
• Include blended food, oil & sugar

Take-home vs on-site feeding program Take-home On-site, justified when:

• Fewer resources • Food supply is limited, take- home ration will be shared
• Less risk of cross-infection with other family member among large number of malnourished & sick chil>Difficult to prepare meals in the household, firewood &
• less time consuming cooking utensil in short
• Keeps responsibility for supply feeding within the fa>The security is poor,
• Appropriate for dispersed beneficiaries are at risk when population returning home carrying food supplies

Cooking Porridge using _{Fact sheet 4} UNIMIX or CSB _{2. UNIMIX is a supplementary food that is meant to be eaten in addition to the normal 1. UNIMIX (or CSB) is a special food for children 6 months to 5 years and others with can be added. the energy density and taste, oil, seasonal fruits and vegetables and or any local nuts family food to improve the diet of children and other vulnerable groups. To increase special nutritional needs such as pregnant women and breast-feeding mothers. 4. Before starting to cook, please ensure that the water which is used is safe before}

  3. UNIMIX is pre-cooked but is not an instant product. It should be cooked for 10 _{mixing into porridge and wash your hands thoroughly before preparing the porridge. minutes, but not longer.}

  Ingredients Method _{1 cup of UNIMIX} •Mix UNIMIX or CSB with some cold water to make a paste _{4 cups of water} •Add the rest of the water

• Bring to boil for 10 minutes (no more – no less!) _{Energy-380 Kcal Fat -6g . Carbohydrates-60g Vitamin A Nutrition value of 100g of CSB /UNIMIX}
• Serve _{Protein-18g, Vitamin D}
• – 1700 I.U, Riboflavin – 0.5mg, Pantothenic acid --3mg Phosphorous – 600mg, Sodium – 300mg, _{acid – 40mg Iron – 18mg Iodine – 50mcg Thiamin -0.7mg Vitamin B12- 4mcg Calcium – 800mg Zinc – 3mg}
• – 200, Niacin – 8mg Folacin – 0.2mg Magnesium- 100mg Potassium -700mg Vitamin E -8 I.U Vitamin B6 – 0.7mg Ascorbic
₂₉ Nutritional products used by WFP

  (www.wfp.org)

  micronutrient powder high energy biscuits (sprinkles

  Supplementary Plumpy DozTM

  PlumpyTM the key date-bars components of the WFP food basket.

Compressed Food - a ready-to-eat cereal- legume based nutritious

  

food with milk,

vegetable fat and sugar.

  1 pack (30 g) will provide 16% and 8% of the RDA

• - light, compact,

  for protein and energy for

   convenient to handle

  4-6 yr old children

   and store, and easy to distribute - can be prepared into porridge by just adding hot water Corazon V Barba, 2007

Instant Cream Soups - made from combination of vegetables and legumes with spices

  1 cup (30 g in 250 ml

   and flavors

  water) will provide 28% and 7% of the RDA for

• - delicious, nutritious,

  protein and energy for 4-6 yr old children

   and convenient to prepare - comes in Squash and Mongo flavors Corazon V Barba, 2007

  

Rice Crispy Bars

• - made from combinations of expanded cereals, flour from legumes, and oilseeds

  25 g portion of tropical

• - ready-to-eat, appealing,

  fruits flavored FNRI Food Bar will provide 4% and

   and nutritious

  5% RDA for protein and energy of 4-6 yr old

• - light, easy to handle

  children

   and transport

• - comes in chocolate-

  coated, peanut flavored, and tropical fruits variants

  Corazon V Barba, 2007 Monitoring of SFPs

   To analyze the efficiency & effectiveness of SFPs

  

Selective Feeding

Program

Therapeutics Feeding Program

Therapeutics Feeding Program (TFPs)

• To rehabilitate severely malnourished person
• The aim: to reduce excess mortality
• TFP may be established for severe malnourished children, adolescence & adults
• Entails treatment of severe malnutrition with nutrition & energy-dense foods, combined with medical intervention
Therapeutics Feeding Programs, Objectives: To provide treatment to severely malnourished individuals to reduce the risk of excess mortality & morbidity

  It consists of intensive nutritional & medical treatment

Therapeutics Feeding Programs, when to starts & when to close

  The number of severely malnourished individuals cannot be treated adequately in other facilities Prerequisite: availability of trained health staff

  The number of patients is decreasing (< 20) Adequate medical & nutritional treatment in either clinics/hospital is available

  The establishment Justifiable to not continue Therapeutics Feeding Programs, criteria for admission & discharge Criteria for admission Criteria for discharge & refer to a

targeted SFPs

  Nutritional Rehabilitation should include intensive Nutritional + Medical Care

  CU5 (or <110 cm) who are severely malnourished (WfH < -3 z or < 70 median)

• - Maintain a WfH

  ≥ -2,5 z, or WfH ≥ median for 2 wks consecutive
• shows a good appetite and free of illness
• The duration to stay in TFPs should not > 6 wks. If the child doesn’t gain weight  feeding regime should be reviewed, or there may be other underlying causes: TB, lack of care Severely malnourished children > 5 yrs, adolescence and adults (WfH and/or oedema) LBW babies Orphans < 1 years (when traditionally care practices are inadequate) Mothers of children < 1 yr with BF failure (where relactation through counseling & traditional feeding have failed)

  Phase I: acute phase (intensive care) Phase II:

  Rehabilitation phase

   reducing mortality risk Electrolyte balance is restored & nutritional treatment is initiated Therapeutic milks: F100 (10-12x) to prevent death from hypoglycemia & hypothermia Should not > 1 wk

  Phase I: Acute phase (intensive care) First 24-h: medical treatment control infection & dehydration

  

 limited energy content of

the diet

Phase II: Rehabilitation phase

• Started by providing at least 6 meals/day to regain most of weight loss
• Psychological & medical care, the mother should involve throughout the process: preparation for discharge the child to targeted SFPs
• Should not > 5 wks
Commodities of TFPs  In the acute phase: only milk-based diet

   Therapeutic milk (TM)  High Energy Milk (HEM): dried skim milk (DSM), oil, sugar, mixed & fortified with minerals & vitamin

   In rehabilitation phase: cereal based porridge, made of blended food (fortified), oil & sugar, given in additional TM. Other foods: biscuit.

  BF subtitutes for orphan baby

  Monitoring of TFPs  To ensure compliance with therapeutic protocols for provision of nutritional & medical care

  Management Issue 

  If demographic information is not available Management Issue  In the absence of data on prevalence of malnutrition, it can be anticipated in nutritional emergency 15-20% may suffer from moderate malnutrition & about 2-3% severe malnourished

   Using this estimation, requirement for food commodities can be calculated & planned for a period of time

  Preventing and controlling micronutrient deficiency in

emergency area

Widya Rahmawati

   Defisiensi vitamin dan mineral sangat mudah terjadi dan semakin diperparah di daerah emergency

   Ketika terjadi perang atau bencana, hasil pertanian dan ternak hilang, suplai makanan terputus dan penyakit infeksi dan diare mewabah

   Kejadian defisiensi Vitamin and mineral pada daerah emergency:

   Pengungsi Burma di Thailand (2003) 65% anak menderita anemia dieficiency besi.  Selain suplemen vitamin A yang sudah rutin diberikan, suplemen mikronutrient juga harus diberikan sebagai bagian dari program respon darurat.

   Dekade akhir ini, sudahmulai diberikan multiple micronutrient fortification dalam kondisi emergency. ₅₀

   Kamp pengungsi Nangweshi di Zambia (2003), diadakan peralatan penggilingan dan fortifikasi mobile untuk memfortifikasi tepung jagung dengan mikronutrien: vitamin A, folic acid, iron and zinc.

   Penelitian di 2007 menemukan bahwa pemebrian tepung jagung terfortifikasi dapat menurunkan anaemia pada children dan menurunkan defisiensi vitamin pada remaja.

   The UN Standing Committee on Nutrition memberikan rekomendasi bahwa kombinasi beberapa internvensi dapat dilakukan, termasuk meningkatkan akses kepada makanan segar, meningkatkan fortifikasi makanan, distribusi suplemen, dan pemberian sprinkle atau permen terfortifikasi. ₅₁

  52 The most vulnerable group: pregnant women, lactating women and young children a greater risk of dying during childbirth, or of giving birth to an underweight or mentally-impaired baby. determines the health and development of her breast-fed infant, especially during the first 6 months of life. increase the risk of dying due to infectious disease and contribute to impaired physical ₅₃ and mental development

  Strategic to control defciency micronutrient 

  Improvement of food consumption  Supplementation  Fortification (including bio-fortification)  Preventing & treatment to infection  Improvement of environment heath & sanitation

  54 Nurul Muslihah, 2010

   when fortified rations are not being given, children aged 6 to 59 months should be given one dose each day

   when fortified rations are being given, children aged 6 to 59 months should be given two doses each week of the micronutrient supplement shown in table 1 ₅₅ WHO, WFP, Unicef, 2007. schedule in Table 2

  56 WHO, WFP, Unicef, 2007. Address micronutrient deficiencies Essential actions Young, H., A. Borrel, et al. (2004). ⁵⁷ Address micronutrient deficiencies

  Gaps, challenges, and constraints Young, H., A. Borrel, et al. (2004). ⁵⁸

  59 Food & Nutrient Needs in Emergency

Addressing micronutrient (vitamin and mineral) requirements

   The adverse effects of micronutrient deficiencies are profound.  Micronutrient deficiencies may lead to increased risk of death, morbidity and susceptibility to infection, blindness, adverse birth outcomes, growth stunting, low work capacity, decreased cognitive capacity and mental retardation.

   In emergency situations, the affected population may have suffered endemic micronutrient deficiencies, often exacerbated by a general deterioration in nutritional status, a limited access to fresh foods, a loss of access to traditional foods and a lack of food diversity ₆₀

Addressing micronutrient (vitamin and mineral) requirements

   Determining the micronutrient adequacy of a ration requires a straightforward comparison of the population’s daily micronutrient requirements with the estimated level of micronutrients in the basic ration.

  61 Addressing micronutrient (vitamin and mineral) requirements

  

   Populations that are highly dependent on food assistance are often at risk of micronutrient-deficiency diseases.

   Iron deficiency anaemia, vitamin A deficiency and iodine deficiency are recognized as the three most significant micronutrient- deficiency diseases worldwide.

   Factors that increase the micronutrient-deficiency diseases:  endemic micronutrient deficiencies in the country of origin;  lack of suitable diversification in rations (e.g. only one or two commodities are provided);

   lack of access to fresh foods; ₆₂  rations based on highly refined cereals that may be low in B vitamins, iron, potassium, magnesium and zinc; and  high rates of infection and/ or diarrhoea in children.

Fortification

   The inclusion of a fortified blended food — an effective vehicle for a number of micronutrients

  —is an important part of the basic ration in an emergency situation, particularly for the micronutrient needs of young children, pregnant and lactating women, and the elderly. Blended foods must meet certain criteria in terms of composition and micronutrient fortification (see Annex 7).

   Food fortification is the process whereby one or more nutrients (vitamins or minerals) are added to foods during processing. These micronutrients are essential for human growth, natural immunity and development. Fortification does not greatly increase the cost of food or adversely affect its taste and acceptability.

   A single fortified food commodity is not a practical vehicle for the delivery of all essential micronutrients. Rather different foods should be fortified with the appropriately matched micronutrient(s). For example, the following box shows ₆₃ foods with mandatory fortification Requirements

  64 WFP fortification specifications for vegetable oil, salt, wheat and maize flour, and blended foods follow in Table 4

  65 Type of food used in fortified

  programs

  Ascorbic acid Canned, frozen, and dried fruit drinks, canned and dried milk products, dry cereal products

  Thiamin, riboflavin, niacin Dry cereals, flour, bread, pasta, milk products Vitamin A (or - carotene) Dry cereal products, flour, bread, pasta, milk products, margarine, vegetable oils, sugar, monosodium glutamate

  Vitamin D Milk products, margarine, dry cereal products, vegetable oils, fruit drinks ₆₆ Corazon V Barba, 2007

  Type of food used in fortified programs

  Calcium Cereal products, bread, orange juice, milk Iron Wheat flour, rice, cornmeal, sugar, condiments, milk, infant foods Iodine Salt, bread, water Proteins Cereal products, bread, cassava flour Amino Acids Cereals, bread, meat substitutes

  Corazon V Barba, 2007 ⁶⁷ Lesson Learned from Fortified

  Programs  Consumer education is important  Intake of the nutrient must be well below estimated requirements

   The food fortified must be chosen carefully:  must be a staple of the target population  must retain its desirability after fortification

   fortification must easy and inexpensive based on feasibility studies

   fortification sites must be easily monitored  There should be enough number of well-trained, motivated and honest staff to monitor the fortification

   Producers must receive incentives, e.g. technical assistance for small producers, as well as face sanctions such as swift but not overly punitive punishment of offenders and noncompliant companies

  Corazon V Barba, 2007 ⁶⁸ Lesson Learned from Fortified Programs 

  Soy sauce fortification with Fe in China: improved Hb level, reduced anemia & improved weight & height (Chunming, 2003, Wang et al, 2008)  Sugar fortification with vitamin A in Central Anemia: Positive effect on children having plasma retinol < 20 g/dl

   Sprinkle: Spice like added with micronutrient (Fe, Zn, Vit A, B) sprikled to home made complementary foods for 6-24 months  In Ghana: effective reducing amenia  In Zambia: effective to cure anemia, but it did not improve Zn status  In Indonesia: HKI

• – reduce anemia

   Impact of iron Fortified Soy Sauce in reducing anemia in West Java (in 2003- 2004) and in Aceh and North Sumatera (2005-2006) (HKI Indonesia)

   Sprinkle for reducing micronutrient deficiencies among children in Indonesia, ₆₉ impact and large scale program implementation

  Nurul Muslihah, 2010 Mandatory Fortification in Indonesia

   Salt Iodization  Mandatory by Joint Ministerial Decree (MOH, MOIT,

  M.Interior), 1982; Joint 4 Ministerial (+ Agriculture), 1984, & Presidential Decree No 69/1994  What Fluor Fortification

   Mandatory bu Ministry of Industr7 & Trade’s Decree SNI (Standart Nasional Industri) of Wheat fluor

  : “all wheat fluor produced & marketed in Indonesia has to be fortified with iron, folic acid, zinc, vitamin B1, vitamin B2 ₇₀ Nurul Muslihah, 2010

  Program Strategi yang dapat dilakukan

  Vitamin A Tingkatkan cakupan suplementasi vit A 2x/th (6 bl-5 th) Strategi distribusi dan monev yang terintegrasi

  Ioditusasi Garam Peraturan pemerintah yang mendukung Eduasi dan advokasi melalui fasilitas kesehatan, media, dan sekolah Monev mandiri oleh masyarakat, sehingga membentuk perubahan perilaku dalam jangka panjang Insentif kepada produsen garam beryodium

  Fortifikasi makanan Standar monitoring nasional untuk program fortifikasi, untuk menjamin fortifikasi dapat berjalan dan produsen mendapatkan keuntungan yang sesuai Edukasi masyarakat untuk meningkatkan kesadaran dan permintaan pasar

  Multiple micronutrient supplement for children

  Meningkatkan ketersediaan suplemen dalam rumah tangga pada daerah non-endemik malaria (contoh sprinkle) Penelitian lebih lanjut untuk meningkatkan intake Fe pada daerah endemik malaria ⁷¹ P

  ROGRAM U NTUK M ENGATASI D EFISIENSI

M

  IKRONUTRIENT Program Untuk Mengatasi Defisiensi Mikronutrient Program Strategi yang dapat dilakukan

  Suplemen untuk WUS Meningkatkan intake suplemen Fe & asam folat untuk seluruh WUS, khususnya ibu hamil Edukasi masyarakat, konseling, untuk meningkatkan konsums suplemen Penelitian lebih lanjut tentang suplemen multiple vitamin dan mineral yang ideal untuk WUS

  Suplemen Zinc untuk manajemen diare

  Memasukkan suplement zinc ke dalam program penanggulangan diare nasional Menjamin suplai zinc adequate Identifikasi strategi distribusi Edukasi masyarakat dan kampanye untuk meningkatkan kesadaran

  Food-based approach Memberdayakan program berbasis masyarakat, termasuk edukasi masyarakat dan pelatihan operasional agar bisa dilakukan oleh masyarakat secara mandiri Integrasi ke dalam program kesehatan, gizi dan ketahanan pangan yang sudah ada Adanya bantuan teknis regional untuk menjamin programberjalan dan dan terdistribusi dengan baik ⁷²

  References 

  WFP, 2004. Nutrition in Emergencies: WFP Experiences And Challenge ( ) 

  USAID, 2008. Emergencies In Urban Settings ( ) 

  ENN, 2004. Community-based therapeutic care (CTC) ) 

  ENN, AED, FANTA, USAID, 2008. Integration of Community-based Management of Acute Malnutrition )  SEAMEO-TROPMED RCCN-UI, 2004. Nutrition survey and supplementary/Therapeutic Feeding in Emergency Situation Training

   International code of donation in emergency  Flour Fortification Initiaitove (FFI), The Global Alliance for Improve Nutrition (GAIN), Micronutrient Initiative (MI), UNICEF, USAID, World Bank, WHO, 2009. Investing in the future. A united call to action on vitamin and mineral deficiencies. Global Report 2009. ( )

   WHO, WFP, Unicef, 2007. Preventing and controlling micronutrient deficiencies in populations affected by an emergency (