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close this bookHandbook for Emergencies - Second Edition (UNHCR, 1999, 414 p.)
close this folder15. Food and Nutrition
View the document(introduction...)
View the documentOverview
View the documentIntroduction
View the documentOrganization of Food Support
View the documentNutritional Assessments
View the documentGeneral Feeding Programme
View the documentSelective Feeding Programmes
View the documentInfant Feeding and use of Milk Products
View the documentKey References
View the documentAnnexes

Annexes

Annex 1 - Basic Facts About Food and Nutrition

All foods are made up of five basic types of nutrient in addition to variable amounts of water.

Carbohydrates, the main source of energy, provide 4 kcal/g. They are mostly starches and sugars of vegetable origin, and are a major component of cereals and tubers.

Fats and oils provide the most concentrated source of energy, and have more than twice the energy content per weight of carbohydrates and proteins (9/kcal/g).

Proteins are body-building substances required for growth and tissue repair. Protein is found in foods of animal origin and in cereals and legumes and provide 4 kcal/g.

Vitamins and minerals are needed in small quantities for the adequate functioning of the body and protection against disease. Fresh vegetables and fruits are a good source of vitamins. Water soluble vitamins are fragile and cannot be stored (Vitamins Bs and C), whereas fat soluble vitamins can be stored in the body (Vitamin A and D). Important minerals are iron, sodium, iodine, zinc, magnesium, potassium, etc. Individual vitamins and minerals or combinations are found in all foods in very variable amounts.

Energy and Protein Intakes

If the energy intake is inadequate, some protein will be burnt to provide energy. That is, it will be used in the same ways as carbohydrate or fat. More than 20% of the energy requirement should be supplied from fats and oils which greatly enhance the palatability of the diet and increase energy density (important for younger children). Energy requirements vary widely even in normal individuals. They are also increased by physical activity. Much higher energy and protein intakes are required for the treatment of malnutrition, when the aim is rehabilitation rather than maintenance.

Food and Diets

Most diets in most countries contain adequate amounts of all the nutrients required for good health if enough of the diet is taken to satisfy the individual's energy requirements. Even a growing child, if healthy, requires no more than 10% of total calories to be supplied from protein sources.


Figure

Annex 1 (cont.) - Nutritional Value Of Food Commodities

COMMODITY

Nutritional Value/100 g



Energy
Kcal

Protein
(g)

Fat
(g)

Price per MT
in US$

Cereals


Wheat

330

12.3

1.5

165

Rice

360

7.0

0.5

280

Sorghum/Millet

335

11.0

3.0

200

Maize

350

10.0

4.0

170

Processed Cereals

Maize meal

360

9.0

3.5

225

Wheat flour

350

11.5

1.5

240

Bulgur wheat

350

11.0

1.5

220

Blended Food

Corn Soya Blend

380

18.0

6.0

320

Wheat Soya Blend

370

20.0

6.0

390

Soya-fortified bulgur wheat

350

17.0

1.5

240

Soya-fortified maize meal

390

13.0

1.5

270

Soya-fortified wheat flour

360

16.0

1.3

240

Soya-fortified sorghum grits

360

16.0

1.0

190

Dairy Products

Dried Skim Milk (enriched)

360

36.0

1.0

1,900

Dried Skim Milk (plain)

360

36.0

1.0

1,800

Dried Whole Milk

500

25.0

27.0

2,200

Canned cheese

355

22.5

28.0

1,850

Therapeutic milk

540

14.7

31.5

2,200

Meat and Fish

Canned meat

220

21.0

15.0

1,950

Dried salted fish

270

47.0

7.5

1,500

Canned fish

305

22.0

24.0

2,000

Oils and Fats

Vegetable oil

885

-

100.0

750

Butter oil

860

-

98.0

2,300

Edible fat

900

-

100.0

950

Pulses

Beans

335

20.0

1.2

440

Peas

335

22.0

1.4

375

Lentils

340

20.0

0.6

500

Miscellaneous

Sugar

400

-

-

350

High Energy Biscuits

450

12.0

15.0

1,250

Tea (black)

-

-

1,235

Iodized salt

-

-

-

150

Dates

245

2.0

0.5

1,900

Dried fruit

270

4.0

0.5

1,200

Note: The prices quoted are free-on-board (FOB) and therefore do not include transportation costs. The prices shown are as of 1998 and will vary over time. This information is regularly updated and published by WFP and is available from WFP HQ's or from their offices in the field.

Annex 1 (cont.) - Characteristics of Common Foods

Food type

Vitamins and minerals

Comments

1.

Cereal grains (rice, corn, sorghum, oats, etc.)

Contain vitamin B and iron.
However these are reduced
by milling, i.e. the whiter the
flour the greater the loss of
vitamins.

The main source of both
energy and protein in most
diets.

2.

Legumes/oilseeds (beans, peas, soya, groundnuts, etc.)

B complex vitamins. Most
contain significant quantities
of iron and calcium.

Legumes are particularly
useful when eaten with
cereals as the proteins
complement each other.

3.

Whole tubers and roots (yams, taro, cassava, sweet potato, potato, etc.)

Variable but generally low,
except for potatoes which
are rich in vitamin C.

Bulk and low protein content
makes them unsuitable as
staple foods in emergencies.

4.

Vegetables and fruits

Important source of vitamins
and minerals. Variable quantities
of B and C vitamins. Dark green
leaves or yellow/red
pigmentation usually indicates
vitamin A compounds.

5.

Meat, milk and dairy products, eggs, etc.

Good sources of B vitamins.
Whole milk and eggs also good
source of vitamin A.
Milk and eggs provide significant
amounts of calcium.

Usually consumed in very
small quantities in normal
times. They are more readily
used by the body than
proteins of vegetable origin.
Therefore small quantities
useful to improve the quality
and palatability of diet.

6.

Fish, dried

Rich source of calcium and
iron. Contains B Vitamins.

A concentrated source of
protein for those who like it.
Therefore acceptability trials
essential before use.

7.

Fats and oils

Fats derived from milk are
sources of vitamin A and D,
while vegetable fats contain
no vitamin A and D, except
for red palm-oil.

Useful way to increase
energy intake without
increasing bulk of diet.
Improves palatability and
helps in food preparation.

Annex 2 - Examples of Food Rations

Examples of adequate full rations for the affected population entirely reliant on food assistance12

Five types of rations are shown to illustrate differences due to such factors as the food habits of the population and the acceptability and availability of the commodities in the region.

Items

Rations
(quantity in grams per person per day)

Type 1*

Type2*

Type 3*

Type 4**

Type 5*

Cereal flour/rice/bulgur

400

420

350

420

450

Pulses

60

50

100

60

50

Oil (vit. A fortified)

25

25

25

30

25

Canned fish/meat

-

20


30

Fortified blended foods

50

40

50

-

-

Sugar

15

20

20


20

Iodized salt

5

5

5

5

5

Fresh veg./fruits

-

-


100

Spices

-

-

-

-

5

Energy: kilocalories

2113

2106

2087

2092

2116

Protein (in g and in % kcal)

58 g; 11 %

60 g; 11 %

72 g; 14%

45 g; 9%

51 g; 10%

Fat (in g and in % kcal)*

43g; 18%

47 g; 20%

43 g; 18%

38 g; 16%

41 g; 17%

* For rations 1, 2, 3, & 5 the cereal used for the calculation is maize meal

** This ration has rice as a cereal; the low percentage energy for protein is acceptable due to its high quality; the slightly low fat content is in line with food habits in rice-eating countries

Examples of Typical Daily Rations for SFPs (in grammes per person per day)

Take-home
or dry ration

On-site feeding or wet ration

Item

Ration 1

Ration 2

Ration 3

Ration 4

Ration 5

Ration 6

Ration 7

Blended food, fortified

250

200

100


125

100

Cereal


125

High Energy Biscuits (HEB)

12513


Oil, fortified with vitamin A

25

20

15

20


10

10

Pulses


30

30


Sugar

20

15


10

10

Salt, iodized

5


Energy (Kcal)

1250

1000

620

560

700

605

510

Protein (g)

45

36 25


15

20

23

18

Fat % Kcal

30

30

30

30"

28

26

29

12 WFP/UNHCR Guidelines for estimating food and nutritional needs. December, 1997.

13 WFP Specification.

14 High Energy biscuits with 15% fat meet the energy density requirement.

Annex 3 - Main Nutritional Deficiency Disorders in Emergencies"

Protein-energy malnutrition (PEM) is likely to be the most important health problem and a leading cause of death during an emergency. There are several forms:

Marasmus is marked by the severe wasting of fat and muscle, which the body has broken down for energy, leaving "skin and bones". It is the most common form of PEM in nutritional emergencies.

Kwashiorkor is characterized essentially by oedema (swelling which usually starts in the feet and legs), sometimes accompanied by a characteristic skin rash and/or changes in hair colour (reddish). The hair becomes sparse.

In Marasmic kwashiorkor there is a combination of severe wasting and oedema.

Children under 5 years are usually the most affected, but older children and adults are also often at risk or affected. The treatment of severe forms of PEM is presented in the section on selective feeding programmes.

Vitamin and mineral deficiencies can cause long-lasting or permanent disabilities and can be fatal. The deficiencies most likely to occur include:

Iron deficiency (1) causes anaemia. (signs: pallor of skin and eyelids, fatigue, weakness and shortness of breath); (2) increases the risk of haemorrhage, infection and death associated with childbirth; (3) increases rates of low-birth-weight and (4) impairs the cognitive development of infants and children.

Iodine deficiency causes not only goitre but also some impairment of intellectual development of children and of reproductive performance in women. Severe maternal deficiency can cause cretinism in the offspring. Best prevented in emergencies by the use of Iodized salt.

Vitamin A deficiency causes Xerophthalmia, blindness and death. Eye signs: poor vision in dim light, dryness of conjunctiva or cornea, foamy material on the conjunctiva or clouding of the cornea itself. These signs may appear after several months of an inadequate diet, or following acute or prolonged infections, particularly measles and diarrhoea.

Vitamin B1 (Thiamine) deficiency causes beri-beri. Symptoms and signs: loss of appetite, malaise and severe weakness, especially in the legs; may also lead to paralysis of the limbs or swelling of the body, heart failure and sudden death. Beri-beri occurs when the diet consists almost exclusively of white polished rice or starchy staple such as cassava.

Vitamin C deficiency causes scurvy. Signs: swollen gums which bleed easily, swollen painful joints, easy bruising. This occurs due to a lack of fresh vegetables and fruits.

Niacin deficiency causes pellagra. Signs: skin rash on parts of body exposed to sunlight; diarrhoea; and mental changes leading to dementia. This occurs especially where maize and sorghum are the staples and there is a lack of other foods.

Prevention involves ensuring that people receive or have access to a variety of foods that contain sufficient quantities of essential vitamins and minerals. This also includes fortified food items distributed in food aid, access to local markets, and produce from home gardens.

Treatment consists of administering therapeutic doses of the missing nutrients. The distribution of multi-vitamin tablets to the entire refugee population is a waste of time and money, since they contain insufficient quantities of individual vitamins to correct deficiencies.

15 Adapted from: The Management of Nutritional Emergencies in Large Populations, WHO, Geneva, 1999 (in press).

Annex 4 - Reporting Form: Supplementary Feeding Programme

Country: Location: Agency:




Period:




Total population:
Under (<) 5 population
Moderate malnutrition rate:
Target <5 (moderate malnutrition rate *<5 pop):
Theoretical coverage <5 (new total (J)/Target):


CATEGORIES


< 5 years

³ 5 years

Pregnant

Lactating

TOTAL



M

F

M

F

women

women


Total at end of last
month (A)


New Admissions:


< 80% WFH or
< -2 Z-score


Others


Total New
Admissions (B)


Re-admissions
(C)


Total Admissions
(D=B+C)


Discharged
in this period:

percentage
for <5 yrs
(target):

Discharges (E)


E/I*100%=
(>70%)

Deaths (F)

F/l*100%=
(<3%)

Defaulters (G)

G/l*100%=
(<15%)

Referrals (H)

Total Discharged
(I=E+F+G+H)


New Total at end
of this month
(J=A+D-I)


Average length of stay in the programme

(from all or a sample of 30 recovered children) (target <60 days) =

Total No of days of admission of all (or 30) recovered children

No of recovered children (or 30)

Comments:

Annex 5 - Reporting Form: Therapeutic Feeding Programme

Country:
Location:
Agency:




Period:




Total population:
Under (<) 5 population
Moderate malnutrition rate:
Target <5 (moderate malnutrition rate *<5 pop):
Theoretical coverage <5 (new total (J)/Target):


CATEGORIES

< 5 years

³ 5 years

Adults

TOTAL



M

F

M

F

M

F


Total at end of last
month (A)


New Admissions:


< 70% WFH or
< -3 Z-score









Kwashiorkor




Others


Total New
Admissions (B)


Re-admissions (C)


Total Admissions
(D=B+C)


Discharged
this month:

percentage
for <5 yrs (target):

Discharged (E)








E/l*100%= (>75%)

Deaths (F)

F/l*100%= (<10%)

Defaulters (G)

G/l*100%= (<15%)

Referrals (H)

Total Discharged (I=E+F+G+H)


New Total at end
of this month
(J=A+D-I)


Causes of death:

Average weight gain during last month (from all or a sample of 30 children) (target: >8 g/kg/day) =

weight at end of month (or on exit) - lowest weight recorded during month

lowest weight recorded in last month × No of days between lowest weight recorded and end of month (or on exit)

Average weight gain for marsmus (include only children in phase II) =

Average weight gain for kwashiorkor (include only children in phase II after complete loss of oedema) =

Average length of stay in the programme (from all or a sample of 30 recovered children) (target <30 days) =

Total No of days of admission of all (or 30) recovered children

No of recovered children (or 30)

Annex 6 - Nutrition Survey Reporting Form

Country:
Camp:
Date of reporting:

Population

Male

Female

Total


number

%

number

%

number

total population

under five population

Survey

date:

............/............/............/

method:

random - systematic - cluster

sample size:

under five population

Male

Female

Total

(6-59 month or 65-110 cm)

number

%



number

%



number







Results

weight-for-height
% median

weight-for-height
Z-score

category

number

%

confidence
interval

category

number

%

confidence
interval

<70% and/or
oedema

£ 3 and/or
oedema

>70
and >80%

³3 and ³2

total

total

Other results:

(mean Z-score, mean SD, family size, % children in each category that is attending feeding center)

Comments/Observations:

Action/Intervention: