Cover Image
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

Nutritional Assessments

· The nutrition assessment should be carried out as soon as possible by an experienced nutritionist;

· Nutritional assessment should include anthropometric surveys as well as food security information;

· Regular assessment is necessary both to monitor the nutritional status of the community as a whole and identify individuals and groups who need special care and food assistance;

· Information must be gathered on mortality and morbidity in addition to malnutrition rates, in order to understand the underlying causes of malnutrition and to identify people who are most affected.


23. An initial assessment of the nutritional status of the refugees should be made as soon as possible and should be carried out by an experienced nutritionist. The extent of malnutrition has important implications for what form the emergency response will take, and will enable early decisions to be taken on the components of the rations and on the requirement for any additional selective feeding programmes.

24. The nutritional assessment should be followed by regular nutrition surveys under specialist supervision to monitor the condition of the population as a whole.

25. Where conditions and/or results of the initial assessment or later surveys indicate a need for selective feeding programmes, individuals will need to be identified and registered for these programmes. Their individual progress should then be monitored through periodic measurements at the feeding centres.

26. The initial nutrition assessment and the periodic nutrition surveys of the population as a whole should be done by measuring the weight and height of a random sample of the child population (as explained below). Initially such surveys should be carried out every two to three months. When conditions have stabilized, once every six to twelve months is sufficient. Any change or trend in nutritional status can thus be detected and appropriate adjustments made in the assistance programmes.

There is a serious nutritional emergency where the malnutrition rate is either over 15%, or over 10% with aggravating factors (e.g. an epidemic). Such a situation requires I urgent action.

Recognizing and Measuring Malnutrition

27. Malnutrition can be recognized by clinical signs (such as oedema and micronutrient deficiencies) and by anthropometry (body measurements). Measurements such as weight-for-height are used as an objective assessment of nutritional status, which quantifies the nutritional situation at one point in time, and allows comparisons over time.

28. Mortality and morbidity information will assist in understanding the underlying causes of malnutrition and identify people who are most affected. Child mortality rates are particularly important.

In an emergency a high child mortality rate is very often associated with high levels of malnutrition.

Death rates among children who are severely malnourished can be about six to ten times greater than those who are healthy and well nourished in the same population.

29. Weight-for-height in children, is the best indicator to assess and monitor nutritional status of populations. The actual weight of a child is calculated as a percentage of the standard weight for a normal child of that height, or as a Z score. It is the most sensitive indicator of acute malnutrition and is preferred for nutrition surveys and for measuring individual progress in feeding programmes. It is usually young children aged between 6 and 59 months who are measured in nutrition surveys, because young children are the first to show signs of malnutrition in times of food shortage and are the most severely affected. When the ages of children are not known, 65 cm and 110 cm height are used as the cut off points instead of 6 and 59 months.

30. Body mass index (BMI) (Weight in kg)/ (Height in m)2, is used for assessing the nutritional status of adults by assessing the degree of thinness (see table 1).

31. Oedema is an essential nutrition indicator and indicates kwashiorkor (see Annex 3). Oedema is characterized by swelling in both feet due to an abnormal accumulation of fluid in intercellular spaces of the body.

32. Mid-upper-arm-circumference

The mid upper arm circumference (MUAC) is measured on the left arm, at the mid-point between elbow and shoulder. MUAC should only be used as part of a two-step screening exercise. In the first step the MUAC of children is measured. Those falling below a certain cut-off circumference are then channelled to weight-for-height measurement to determine their nutritional status and whether they should be included in selective feeding programmes.

33. Weight-for-age and height-for-age are not such useful assessment indicators in emergencies as age is often difficult to determine. This can be used for growth monitoring of individual children, and in assessing long-term (chronic) malnutrition.

Moderate and Severe Malnutrition

34. The standard cut-off points to describe malnutrition, are between 70% and 80% weight-for-height (or between -3 and -2 Z scores) for moderately malnourished and less than 70% weight-for-height (or < -3 Z scores) for severely malnourished.

Children with oedema are always classified as severely malnourished.

Table 1 summarizes the key malnutrition indicators.

Table 1: Key Nutritional Indicators*


Children under 5 years

Adults BMI

height (W/H)%
of median value4

height (W/H) in
Z scores or SD’s5



70% to 79%

-3 to -2 Z

110mm to <125mm



less than 70%

less than -3 Z or oedema

< 110mm, oedema

less than 16

* Results expressed by different methods are not directly comparable

4 Percentage below the median "reference" weight-for-height values.

5 Standard deviations (SDs, or Z score) below the median "reference" weight-for-height values.