Using the Minimum Standards in Nutrition

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Using the Minimum Standards in Nutrition
2.4
Terre des Hommes - Afghanistan photo
2
Food Security, Nutrition, and Food Aid Why One
Chapter?
and
and
NUTRITION
FOOD AID
FOOD SECURITY

• Big Topic overall
• Food logistics and nutrition/health departments
  in NGOs are often separate
• But, the components are so intertwined, they must
  be considered together

3

• See page
• 106

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Food Security and Food Aid is about...

• Markets
• Logistics
• Livelihood/Employment
• Displacement
• Large
• Populations
• Rations
• Dry food
• Warehouses
• Distribution

FAO photo
5
Nutrition is about..

• Therapy
• Children under-fives
• Targeted intra-family
• Wet Foods, special foods
• Focused on immediate recovery, health outcomes
• Micronutrients
• Diseases stemming from nutrient deficiencies

UN photo
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Assessment and analysis standard 2 nutrition
Where people are at risk of malnutrition,
programme decisions are based on a demonstrated
understanding of the causes, type, degree and
extent of malnutrition, and the most appropriate
response.
UNICEF photo
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nutrition (or malnutrition)
AVAILABILITY (FOOD volume, Storage,
irrigation, Climate, rainfall, Seeds,
drought, Harvest manpower)
BIO-UTILIZATON (Caretaker behavior, knowledge,
family structure, hookworms, hygiene, cuisine
patterns, micronutrient synergy or antagonism)
ACCESS (Trade, , Infrastructure, Merchants,
Borders, Government policies, Subsidies,
incentives, War zones, battle lines)
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Formal and non-formal institutions, political and
Ideological superstructure, economic Structure,
potential resources
(? please see page 136 of the 2004 Edition)
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General nutrition support standard 1 all groups
UNHCR eCentre photo
The nutritional needs of the population are met
(? please see page 137 of the 2004 Edition)
10
General nutrition support standard 2 at risk
groups
UNICEF photo
The nutritional and support needs of identified
at risk groups are met
(? please see page 140 of the 2004 Edition)
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Bell curve of population wt/ht (or any
anthropometric measure we use)
Most nutritional assessment deals with this...
An International Yardstick, using U.S. NCHS
growth as standard
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Common Nutritional Assessment Indexes Weight for
Height
WEIGHT
HEIGHT
Salter Scale
Collapsable Measure
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Weight for Height Chart
Weight
Height,..or
Height for Weight Wall Chart
...Length
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For any bell curve, a Z value or score is,
simply, the number of standard deviations away
from the middle (the average or mean)
-3 Z -2Z -1Z 0Z 1Z 2Z 3Z
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Measure Adult Malnutrition using BMI - Body
Mass Index
BMI weight / ht2
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Weight for Height Advantages

• Case Management Wt/Ht allows us to monitor a
  childs improvement from day to day or week to
  week with more visible precision
• Demonstration We want to promote such use of
  growth monitoring as part of MCH programs
  everywhere.

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Remember Anthropometric measures are not
malnutrition...

• UNHCR, WFP, CARE use wt/ht
• ICRC, ACF, Save the Children use MUAC
• Save UK uses the population mean and not
  subpopulations

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What is the definition of malnutrition being
used n this report? Are there other definitions?
From RNIS publication 22, December 1997
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All Guidelines and StandardsConverge on the Same
Guidance.

• 2,100 Kilocalories Per Person Per Day
• 10-12 of total energy from protein
• 17 of total energy from fat
• And adequate micronutrients

(? please see page 138 of the 2004 Edition)
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Individual Need for Calories

• Some people need 1,000 kcal/day?
• Some people need 5,000 kcal/day?
• What does the distribution depend on?
• What does the distribution look like

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Who have the greatest needs per capita per day in
kcals?

• 1. Lactating women
• 2. Pregnant women
• 3. People doing heavy physical activity
• 4. People living in severe cold weather

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Kilocalories per gram of food constituents
ROUGHAGE
0
SALT
0
WATER
0
FAT/OIL
9
PROTEIN
4
Carbohyd
4
0
2
4
6
8
10
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So, What is the major Food Item?

• Grain (staple). Typically
• wheat,
• maize, (corn)
• rice,
• sorghum or
• a flour.

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Okay, Lets design a general ration using...

• Foods that are available to us
• Foods that are reasonably inexpensive
• Foods that wont spoil quickly
• Foods that are moderately acceptable
• Foods that achieve nutrition objectives

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Exercise the foods below will be distributed as
a complete ration, mark on your glasses, how full
each should be of each commodity for one person
for one day.
SUGAR
RICE
LENTILS
CANNED FISH
OIL
SALT
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Here is the textbook answer. The following is
one standard ration meeting all nutritional
requirements..
420g
20g
60g
SUGAR
RICE
LENTILS
30g
30g
5g
CANNED FISH
OIL
SALT
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What is a typical complement to a grain that adds
protein to the overall diet?

• Beans, lentils, pulses, groundnuts
• And what else?

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Ration by Kilocalories Consumed
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Lets Design a Ration
Kcal?
TOTALS?
Use the table APPROXIMATE NUTRITIONAL VALUES OF
VARIOUS FOOD COMMODITIES PER 100 GRAMS
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Correction of malnutrition standard 1 moderate
malnutrition
Moderate malnutrition is addressed
Boston University - photo
Q. How is moderate malnutrition defined? How is
it measured?
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Correction of malnutrition standard 2 severe
malnutrition
Severe malnutrition is addressed
Q. How is severe malnutrition defined? How is it
measured?
IFRC photo
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Principle (clinical epidemiology)middle upper
arm circumference (MUAC) predicts mortality
(better than any other measure)
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Arm Circumference and Weight-for-Height are
roughly equivalent in their diagnostic and
prognostic values.
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Children with very low wt/ht
Therapeutic onsite (observed) feeding 8
hours/day
-3Z WfH
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Children with low wt/ht
Supplementary feeding 4-6 hours/day
-2Z WfH
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Criteria for TFP SFP
W/H lt 70 or edema (lt minus 3 Z-scores)
W/H 70-79 (lt minus 2 Z-scores)
Supplementary Feeding Program
Return to TFP
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Total Malnutrition
Moderate Malnutrition
Severe Malnutrition
lt -2 Z scores WFH or 80 median WFH or lt 12.5 cm
MUAC or nutritional oedema
lt -3 Z scores WFH or lt70 median WFH or lt 11.0 cm
MUAC or nutritional oedema
-3 tolt-2Z scores WFH or 70- 80 median
WFH or 11 to lt 12.5 cm MUAC
Children 6.0-59.9 months
-3 tolt-2Z scores WFH or 70- 80 median WFH
lt -2 Z scores WFH or lt80 median
WFH or nutritional oedema
lt -3 Z scores WFH or lt70 median
WFH or nutritional oedema
Children 5-9.9 years
BMI lt 17 or nutritional oedema
16 to lt 17 BMI
Adults 20.0-59.9 years
See critical issues note p. 185
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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

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supplementary feedings- contact with children
allows

• Mebendazole
• De-worms
• Demonstration-effect, (wins parents
  compliance)
• Reduces Malabsorption

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Visualizing some of the indicators
Assessment and analysis Before conducting an
anthropometric survey, information on the
underlying causes of malnutrition is analysed and
reported, highlighting the nature and severity of
the problems, and those groups with the greatest
nutritional and support needs. The opinions of
the community and other stakeholders on the
causes of malnutrition are considered Internati
onal anthropometric survey guidelines, and
national guidelines consistent with these, are
adhered to for determining the type, degree and
extent of malnutrition
(? please see page 115 of the 2004 Edition)
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General nutritional support standard 1 all groups
Some indicators

• There is access to a range of foods -staple
  (cereal or tuber), pulses (or animal products)
  and fat sources that meet nutritional
  requirements.
• There is access to vitamin A, C and iron-rich or
  fortified foods or appropriate supplements
• There is access to iodized salt for the majority
  (gt90) of households
• No cases of scurvy, pellagra, beri-beri or
  riboflavin deficiency

(? please see pages 137 138 of the 2004 Edition)
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Basic indicator - Children suffering from
malnutrition
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General nutrition support standard 2 at-risk
groups
Some indicators

• Infants under 6 months are exclusively breastfed
  or, in exceptional circumstances, have access to
  an adequate amount of an appropriate breast milk
  substitute
• Pregnant and breastfeeding women have access to
  additional nutrients and support
• Community based systems are in place to ensure
  appropriate care of vulnerable individuals

(? please see pages 140 141 of the 2004 Edition)
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The treatment of moderate malnutrition at
supplementary feeding centresA child suffering
from malnutrition is given a food ration of 700 -
1,300 calories, in the form of a cereal broth and
vegetarian foodstuffs enriched with sugar and
oil, well as mineral salts and vitamins, to
supplement the family diet.
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Correction of malnutrition standard 2 severe
malnutrition
Some indicators

• Proportion of exits from a therapeutic feeding
  programme who have died is lt 10, recovered is gt
  75, and defaulted is lt15
• proportion of exits from therapeutic feeding
  programme who have died is lt 10,defaulted lt 15
• Coverage is gt 50 in rural areas, gt 75 in urban
  areas and gt 90 in camp situations
• there is a mean weight gain of ? 8 kg per person
  per day
• Discharge criteria include non-anthropometric
  indices such as good appetite no diarrhea,
  fever, parasitic infestation or other untreated
  illness
• Nutrition worker to patient ratio is at least 110

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Photos USAID
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Correction of malnutrition standard 3
micronutrient malnutrition
Some indicators

• all clinical cases of deficiency diseases are
  treated according to WHO micronutrient
  supplementation protocols
• Procedures are established to respond efficiently
  to micronutrient deficiencies to which the
  population may be at risk
• Health staff are trained in how to identify and
  treat micronutrient deficiencies to which the
  population is most at risk

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Micronutrient deficiency indicator - Bitots
spots, caused by Vitamin A deficiency
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Pellagra
Pellagra is sometimes called the described by the
3 D" disease Dermatitis, Diarrhoea, and finally
Dementia. In extreme cases a fourth can occur -
Death The disease takes 2-3 months to fully
develop symptoms.
Pellagra is caused by Niacin (vitamin B3)
deficiency. The condition can be fatal. Good
sources of Niacin include groundnuts, fish, meat
and pulses.
Photo P. Delchevalerie http//www.ennonline.net/f
ex/10/fa12.html
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http//www.ennonline.net/fex/10/fa12.html
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SUMMARY The 3 Main areas of the Sphere Standards
relating to nutrition are critical -
particularly in emergency nutrition programmes.

• Assessment and Analysis
• General Nutritional Support to the Population
• 3 Nutritional Support to Those Suffering From
  Malnutrition

• Understand
• (common standards)
• 2 Provide enough food for everyone to remain
  healthy
• 3 If that fails, implement programmes to treat
  the malnourished