Nutrition

Rations

For populations totally dependent upon food aid, a general ration of at least 1,900 kcal/person/day is required. At least 10% of the calories in the general ration should be in the form of fats and at least 12% should be derived from proteins.

The calculation of rations should account for calorie loss during transport and food preparation. Similarly, when the mean daily temperature falls below 20 C, the caloric requirement should be increased accordingly by 1% per degree of temperature below 20 C.

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

The calculation of ration requirements should be adjusted for deviations from the above population structure (age/gender breakdown), the underlying health and nutritional status of the population, and relative activity levels of the community.

Guidelines for ration distribution

Supplementary feeding programs

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:

Inclusion and discharge criteria.

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

Children should be discharged from the SFP after they have maintained greater than 85% of median WFH (or a Z-score greater than -1.5) for a period of 1 month.

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:

These are the disadvantages of wet rations:

Take-home programs. "Dry" rations are provided on a regular basis to supplement the general ration normally received. These are the advantages of dry rations:

These are the disadvantages of dry rations:

Other elements of SFPs

Therapeutic feeding programs

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:

Caloric requirements

Discharge criteria. Discharge from a TFP to a SFP should occur when the following criteria are met:

Monitoring requirements

Provision of micronutrients

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:

Supplemental doses and schedule

In all cases, mothers should be administered 200,000 IU within 2 months of giving birth in order to provide adequate quantities of vitamin A in the breast milk. If it is not possible to provide supplements to the mother at or within 2 months of giving birth, then the mother should receive 100,000 IU during the third trimester of pregnancy.

Full treatment schedule. A full treatment schedule of oral vitamin A should be administered to all persons suffering from severe malnutrition (WFH Z-score less than -3) or exhibiting eye symptoms of vitamin A deficiency (xerosis, Bitot's spots, keratomalacia, or corneal ulceration). The dose schedule is given below:
200,000 IU on day 1,
200,000 IU on day 2, and
200,000 IU 1 to 4 weeks later.
Children less than 12 months of age receive half doses.

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:

The risk of anemia is highest in pregnant and lactating women, and in children ages 9-36 months. If the general ration contains inadequate amounts of absorbable iron, folate, and vitamin C, anemia may be prevented through the daily administration of iron/folate tablets and vitamin C supplements. Supplementary feeding of high-risk groups with CSM will also help to reduce the likelihood of anemia (CSM contains 18 g iron/100 g).

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.

Selected Reading

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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