Nutrition

Rations

• Each of the rations above provides at least minimum quantities of energy, protein, and fat.
• Ration 2 provides additional quantities of various micronutrients through the inclusion of a fortified blended cereal. When provided in the general ration, fortified cereal blends should be used for the whole family.

The standard requirement of 1,900 kcals is based on the following demographic structure of a population:

• Children less than 5 years of age (20%).
• Children 5-14 years of age (35%).
• Women 15-44 years of age (20%), of whom 40% are pregnant or lactating.
• Males 15-44 years of age (10%).
• Adults greater than 44 years of age (15%).

Guidelines for ration distribution

• Food should be distributed in a community setting. Camps and mass feedings should be avoided if at all possible.
• Ration distribution should complement, not replace, any food that the refugees are able to provide for themselves.
• Distributed food should be familiar and culturally acceptable to the refugees.
• If food is distributed in uncooked form, adequate fuel and cooking utensils should be made available.
• Grains should be provided in ground form, or grinders must be made available.
• Distribution must be done on a regular basis, with no longer period than 10-14 days between distributions.
• If a specified food item in the ration cannot be supplied, the energy and nutrient content of the missing item should be provided by including additional quantities of another available commodity. This type of substitution is appropriate only as a short-term measure.
• Breast-feeding should be encouraged and supported.
• Lactating women should be provided with extra sources of calories and protein. Appropriate weaning foods should be included in the general ration (fats and oils).
• Bottle feeding should be discouraged. Infant bottles and formula should not be distributed.
• Dry skim milk (DSM) and other milk products should not be included in the ration as such, except where milk consumption is part of the traditional diet. Milk products should be mixed with milled grains to form a cereal. Any milk product that is included in the rations should be fortified with vitamin A.
• If fresh fruits and vegetables are not available, fortified blended foods (e.g., corn-soya milk (CSM)), CSB, or similar local products) should be provided to meet micronutrient requirements.
• Refugees should be encouraged to grow vegetables. Seeds, gardening implements, and suitable land should be made available for kitchen gardens. This is critical for the prevention of pellagra and scurvy.
• Refugees should be permitted access to local markets and be allowed to create markets. Trading or selling of ration commodities may be a necessary part of the camp economy. It enables refugees to supplement their diets with foods otherwise unavailable to them and to obtain essential nonfood items.
• It may be advisable to include certain culturally significant items i.e., tea, sugar, and spices in the food basket. Where such items are highly valued, refugees will sell or trade part of their ration to obtain them. This results in a reduction of caloric intake. Providing these items eliminates this overall reduction.

SFPs are designed to help prevent severe malnutrition and to rehabilitate moderately malnourished persons. SFPs are not intended to be used as a method of targeting food during an emergency phase. Similarly, SFPs are inappropriate as a long-term supplement to an inadequate general ration.

Implementation of a SFP is necessary under the following circumstances:

• When the general ration is less than 1,500 kcal/person.
• Where nutritional assessment reveals that greater than 20% of children less than 5 years of age are acutely malnourished, as determined by a Z-score indicator of less than -2.
• When the acute malnutrition prevalence (as determined by a Z-score indicator of less than -2) falls between 10%-20% and the general ration is between 1,500-1,900 kcal.
• Where there is a high incidence of measles or diarrheal disease.

The following groups should be targeted for inclusion in a SFP:

• Acutely undernourished children less than 5 years of age (WFH Z-score less than -2 or less than 80% of reference median).
• Pregnant and lactating women.
• Elderly, chronically ill (e.g., TB patients), or disadvantaged groups.

Caloric requirements. A SFP should provide at least 500 kcal and 15 g protein/day in one or two feedings.

High energy milk (HEM), a calorie-dense milk mixture, may be used in a SFP. One milliliter of HEM provides 1 kcal of energy. The formula below makes 5 L of HEM:
420 g dried skimmed milk,
250 g sugar,
320 g oil, and
4.4 L water

If the general ration is inadequate (less than 1,900 kcal/person/day), the supplementary ration should provide 700-1,000 kcal/person/day in two to three feedings.

Types of SFPs. SFPs fall into two categories, either on-site feeding or take-home rations. Listed below are some of the advantages and disadvantages of each type of SFP (1).

On-site feeding. "Wet" rations are prepared by SFP staff and served to recipients in the feeding center. Listed below are the advantages of wet rations:

• The likelihood that the ration will be shared among family members is reduced.
• SFP staff maintain control over the preparation and consumption of the supplementary meals.
• Additional services can be incorporated into the feeding program.

• Young children must be accompanied to the center. This may lead to poor attendance rates and create a hardship for many mothers who must also provide for other family members.
• Feeding centers must be located near the homes of the recipients.
• In order to increase motivation and attendance, other services may need to be offered.
• Feeding centers are a drain on health personnel resources.
• Feeding center meals may be substituted for meals at home, resulting in a net food intake deficit.
• On-site feedings are not appropriate for targeting entire families or community groups.
• Children less than 2 years of age are generally underserved by on-site feedings.
• On-site feedings remove the family's responsibility and control over providing for family members.
• The possibility of cross-contamination and infection is increased in mass feedings.

• Daily attendance of the enrollee or other family members is not required.
• Fewer centers are needed, and these may be located at a greater distance from homes.
• The supplementary ration increases the purchasing power of the family.
• The ration is intended to provide supplementation 365 days/year. (No missed days for holidays)
• Dry rations generally achieve higher coverage rates than wet rations.
• There is less disruption of family activities, as daily attendance is not required.
• The family is able to maintain control over feeding practices.

• Dry rations are less effective at targeting person beneficiaries.
• Sharing of the ration among family members is increased.

• Vitamin A should be administered upon admission to the SFP and every 3 months thereafter.
• If vitamin C is not included from the ration, vitamin C supplements should be administered weekly to all persons enrolled in SFPs.
• If iron deficiency anemia is highly prevalent, the provision of iron syrup to children enrolled in SFPs should be considered.
• All enrollees in the SFP should have their measles immunization status checked upon admission, and vaccine administered if needed.
• Mebendazole, an anthelminthic, should be administered along with the vitamin A, if it is available. Each child should be administered two 100 mg tablets to be chewed. Mebendazole should not be administered to infants less than 12 months of age or to pregnant women.
• On-site feeding centers require a regular supply of clean water and cooking fuel.

Therapeutic feeding programs (TFPs) are considered a medical intervention, the purpose of which is to save lives and restore the nutritional health of severely malnourished children. The recommendations listed below are adapted from the procedures for selective feeding (2).

Enrollment criteria. Children should be enrolled in a TFP if they meet one of the following criteria:

• Children less than 5 years of age (or less than 115 cm in height) with WFH Z-score of less than -3 (less than 70% median).
• Children with clinically evident edema.
• Children referred to TFP by medical personnel.

• Children enrolled in a TFP should receive 150 kcal and 3 g of protein for each kg body weight/day.
• Feeding should be done in four to six meals/day. Feeding centers that provide meals on a 24-hour basis are likely to be most effective.
• HEM should be included in the TFP ration.
• All children enrolled in the TFP should receive a full course of vitamin A upon admission.
• Severely malnourished children typically have poor appetites and may require nasogastric feedings for short intervals. Trained and experienced personnel are needed for this procedure.

• The child has maintained 80% WFH (or a Z-score of -2) for a period of 2 weeks.
• Weight gain has occurred without edema.
• The child is active and free from obvious illness.
• The child exhibits a good appetite.

• A register should be maintained with the details of each patient.
• Each patient should be given a personal ration card and an identification bracelet.
• Each patient should be weighed daily at first, and then twice weekly to monitor progress.
• TFPs should aim for a weight gain of 10 g/kg body weight/day.
• All absentees should be followed up at home and encouraged to resume attendance.
• Regular nutrition surveys should be conducted, and malnourished children who are not enrolled in a feeding program should be referred to either the SFP or the TFP. Feeding programs should aim for at least 80% enrollment and 80% daily attendance. In addition, health workers should be involved in active case-finding in the community.

Ideally, the recommended daily allowances for all essential nutrients should be provided in the general rations. However, specific measures may be necessary to provide certain micronutrients.

Vitamin A

Risk factors for vitamin A deficiency. Provide vitamin A supplements whenever any of the following conditions are present:

• The refugee population originates from a geographic area at high risk for vitamin A deficiency.
• There is evidence of severe vitamin A deficiency in the population.
• The general ration provides inadequate quantities of vitamin A (less than 2,000-2,500 IU/person/day).

• Children 12 months 5 years of age should receive 200,000 IU every 3 months.
• Infants less than 12 months of age should receive 400,000 IU total dose in the first year of life, administered as follows:
  • If a dose can be assured every 3 months: 100,000 IU to the infant every 3 months for 1 year.
    • If 3-month dosing is impractical but 6-month dosing is anticipated: 200,000 IU to the infant every 6 months for 1 year.
    • If any subsequent dosing is unlikely: 200,000 IU to the infant when examined.

• If xerophthalmia is observed in older children and adults, include the affected age groups in the standard 200,000 IU preventive vitamin A supplementation program administered to younger children.
• As a general practice, all doses of vitamin A should be documented on the child's growth record chart.

Anemia. The prevalence of anemia can be determined through a rapid anemia survey using a portable Hb photometer (HemoCue system).

The CDC has established the following criteria for defining anemia:

• Children 15 years of age: Hb less than 11.0 g/dL
• Pregnant women: Hb less than 11.0 g/dL
• Nonpregnant women: Hb less than 12 g/dL
• Men: Hb less than 13.5 g/dL

Iron/folic acid. Routine iron/folate supplements should be provided to all pregnant and lactating women through antenatal and postnatal clinics. Female health workers should be employed to seek out pregnant and lactating women and encourage their participation in these programs.

Vitamin C. Fortification of foods with vitamin C is problematic because vitamin C is unstable. Further study is needed on the appropriate vehicle for fortification. The best solution is to provide a variety of fresh foods either by including them in the general ration or by promoting access to local markets. In addition, local cultivation of vitamin C-containing foods should be encouraged. Patients with clinical scurvy should be treated with 250 mg of oral vitamin C two times daily for 3 weeks.

Niacin. Maize-eating populations are at greatest risk for niacin deficiency, which causes pellagra. Recent studies of pellagra outbreaks among refugee populations found groundnut consumption, garden ownership, and home maize milling (as an indicator of higher socioeconomic status) to be protective factors. Niacin-fortified flour should be included in the general ration. The process of fortifying maize flour with niacin is simple and relatively inexpensive.

Clinical cases of pellagra can be treated with nicotinamide. The recommended treatment schedule is 100 mg three times daily for 3 weeks. The total daily dose of nicotinamide should not exceed 600 mg. Where the diet is deficient in niacin, vitamin B complex tablets can be used to prevent pellagra.

Iodine. If the general ration is naturally deficient of iodine, fortification of items such as salt or monosodium glutamate should be considered.

References

1. Peel S, Allegra DT, Knaub C, et al. Nutritional assessment and feeding programs in refugee centers: the Thailand experience. In: Allegra DT, Nieburg P, Grabe M, eds. Emergency refugee health care--a chronicle of the Khmer refugee-assistance operation 1979-1980. Atlanta: CDC, 1983:75-84.
   

2. Godfrey N. Supplementary feeding in refugee populations: comprehensive or selective feeding programmes? Health Policy Plan. 1986;1:283-98.

Brown RE, Berry A. Prevention of malnutrition and supplementary feeding programs. In: Sandler RH, Jones TC, eds. Medical care of refugees. New York: Oxford University Press 1987:124.

CDC. Outbreak of pellagra among Mozambican refugees Malawi, 1990. MMWR 1991;40:209-13.

Desenclos JC, Berry AM, Padt R, Farah B, Segala C, Nabil AM. Epidemiological patterns of scurvy among Ethiopian refugees. Bull WHO 1989;67:309-16.

Nieburg P, Waldman RJ, Leavell R, Sommer A, DeMaeyer EM. Vitamin A supplementation for refugees and famine victims. Bull WHO 1988;66:689-97.

Peel S. Nutritional aspects of refugee assistance. In: Allegra DT, Nieburg P, Grabe M, eds. Emergency refugee health care--a chronicle of the Khmer refugee-assistance operation 1979-1980. Atlanta: CDC, 1983:121-7.

Peel S. Selective feeding procedures. Oxfam Working Paper no.1. Oxford, 1979.

Seaman J, Rivers J. Strategies for the distribution of relief food. J. R. Statist. Soc. 1988;151:464-72.

United Nations Administrative Committee for Coordination, Subcommittee on Nutrition, and the International Nutrition Planners Forum. Nutrition in times of disaster. Presented as a report of an International Conference; September 27-30, 1988; Geneva, Switzerland.

UNHCR/WFP. Guidelines for calculation food rations for refugees. Geneva/Rome. August 1991.

Wallstam E, Nieburg P, Eie E, Lendorff A. Donated foods and their use in refugee-assistance operations. In: Allegra DT, Nieburg P, Grabe M, eds. Emergency refugee health care--a chronicle of the Khmer refugee-assistance operation 1979-1980. Atlanta: CDC, 1983:129-33.

Yip R, Gove S, Farah BH, Mursal HM. Rapid assessment of hematological status of refugees in Somalia: the potential value of hemoglobin distribution curves in assessing iron nutrition status. Presented at the APHA annual meeting, October 20, 1987.

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