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Feeding Program in Emergency Widya Rahmawati

Feeding Program Strategy

Type of Feeding Program

General food distribution

Selective feeding program

Supplementary feeding

program (SFP)

Blanket SFP Targeted SFP

Therapeutic feeding

program (TFP)

Micronutrient intervention

Mathys et al, 2000

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General Food Distribution

General Food Ditribution Provides a standard general ration to affected population

the immediate aim to cover food & nutrient needs to all population with constrained access to normal source of food

Involves: distribution of a basket of food commodities to emergency-affected populations

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Commodities

Energy : 1900, 2100 or 2400 kcal/person/day

Sufficient energy, protein, fat

Usually include:

energy rich foods (a staple, cereal, rice,),

oils, fats, and

protein rich foods (pulses: beans, ground nuts, lentils).

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Selective Feeding Program

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Type of Selective Feeding Program

The Decision making framework to implement selective feeding programs

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Selective Feeding Program 1) Supplementary Feeding Program

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Selective Feeding Program: Supplementary Feeding Program (SFPs)

• Provides nutritious food

• In addition to the general food

• The aim: to rehabilitate malnourished person

• Or to prevent a deterioration of nutritional status of the most at-risk

• By the meeting their additional needs, focusing particularly on young children, pregnant women & nursing mother

Selective Feeding Program: Supplementary Feeding Program (SFPs)

• The aim: to prevent the moderately malnourished becoming severely malnourished & to rehabilitate them

• Food supplement to general food rations to: mild-moderately malnutrition, pregnant women & nursing mother

Targeted SFPs wasting 10-14,9%, atau 5-9% dg aggravating factors (SERIOUS)

• The aim: to prevent widespread malnutrition & reduce excess mortality among those at risk

• By providing a food/micronutrient supplement for all member of the group (children under 5/under 3, pregnant women, nursing mother)

Blanket SFPs wasting > 15%, atau 10-14,9% dg agravating factors (CRITICAL)

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Targeted SFPs, Objectives:

Rehabilitate moderately malnourished children, adolescents, adults and elderly persons.

Prevent the moderately malnourished from becoming severely malnourished.

Reduce mortality and morbidity risk in children under 5 years.

Provide a food supplement to selected pregnant and nursing mothers and other individuals at-risk

Provide follow-up to referrals from Therapeutic Feeding Programmes

Targeted SFPs, when to start & when to close? When to start When to close, when all of these are

satisfied

Prevalence of 10-14% acute malnutrition among children.

General food distribution is adequate Prevalence of acute malnutrition is below 10% without aggravating factors Control measures for infectious disease are effective

Prevalence of 5-9% acute malnutrition in presence of aggravating factors: -inadequate general food rations, -CMR > 1/10.000/hr, -epidemic measles or pertusis, -high prevalence of ARI or diarrhea

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Targeted SFPs, Criteria for admission & discharge:

Admission criteria Discharge criteria

Moderately malnourished children under 5 - WfH between -3 & -2 z score - WfH between 70-80% of median

Children who have maintained at least 85% median WfH or -1,5 WfH z

Malnourished older children, adolescence, adults, elderly (BMI/MUAC), medical referrals

Individuals older than 5 y who have attained a stable & satisfactory nutritional status & free from disease

Referrals from TFPs Children & adults who have not shown sign of improvement after 2 wks of wet SFPs, or after 1 mo of dry SFPs should be assessed to find out the cause referral for medical/community care

Selected pregnant women and nursing mothers (≤ 6 mos after delivery)

Blanket SFPs, Objectives:

Aimed primarily to prevent a deterioration in nutritional status of population,

And to reduce the prevalence of acute malnutrition of CU5 reducing morbidity & mortality risk

Provide a food/micronutrient supplement for all member of groups at high risk of becoming malnourished

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Blanket SFPs, When to start & when to close?

Should be set up when one/ combination of these

Will be closed when all of these condition are met

-At the onset of emergency when general food distribution system are not adequate

-Problem in delivering/distributing the general distribution rations

-% of acute malnutrition≥15%

-% of acute malnutrition 10-14,9% in the present of aggravating factors

-Anticipated increase in the rate of malnutrition due to seasonally induced epidemics

-Micronutrients outbreaks, to provide micronutrient-rich foods

-General food distribution is adequate & meeting requirement

-% of acute malnutrition < 15% without aggravating factors

-% of acute malnutrition < 10% in the presence of aggravating factors

-Disease control are effective

Blanket SFPs, criteria for admission

• All CU5 or CU3 using height as cut off point (5 y = 110 cm, 3 y = 90 cm)

• Pregnant women from the time of confirmed pregnancy, and nursing mothers until 6 months after delivery

• Other at risk groups: sick, elderly

All primary target

groups for blanket

SFPs are:

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Food commodities for SFPs

The size & the type of daily food supplement depend on the adequacy of the general food distribution, the malnutrition & mortality rate, & feeding program modalities

Must be energy dense & rich in micronutrients, cultural appropriate, easily digestible & palatable, usually blended food (composed of pre-cooked cereals & legumes/soybean, fortified with vitamin & minerals)

Food commodities for SFPs Energy-dense SF must contain at least 100 kkal/100

grams, with at least 30% energy from fat.

Unimix/Famix/CSB (corn soya blend) have 6% fat content should added 10 g oil/100 g blended food during preparation

It is not recommended to use milk (fresh/milk powder) in a take-home rations avoid discouraging effect on BF, bacterial contamination. Milk powder can be distributed in dry form only when mixed with other commodities

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Distribution of SFPs

• The daily distribution of cooked food/meals at feeding centers

• The number of meals provided can vary in specific situation, but minimum of two/three meals should be provided everyday

On-site feeding

program, or wet rations

• The regular (weekly/bi-weekly) distribution of food in dry form to be prepared at home

• It may be necessary to increase the amount of food to compensate for intra-household sharing

Take-home feeding

program, or dry rations

Composition of SFPs

• 500-700 kcals energy/person/day

• 15-25 g protein

• Could include blended food, oil, sugar, cereal, high energy biscuit, pulses

On-site feeding program, or wet rations

• 1000-1200 kcal/person/day

• 35-45 g protein

• Include blended food, oil & sugar

Take-home feeding

program, or dry rations

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Take-home vs on-site feeding program

Take-home

• Fewer resources

• Less risk of cross-infection among large number of malnourished & sick children

• less time consuming

• Keeps responsibility for feeding within the family

• Appropriate for dispersed population

On-site, justified when:

• Food supply is limited, take-home ration will be shared with other family member

• Difficult to prepare meals in the household, firewood & cooking utensil in short supply

• The security is poor, beneficiaries are at risk when returning home carrying food supplies

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Cooking Porridge using UNIMIX or CSB Fact sheet 4

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1. UNIMIX (or CSB) is a special food for children 6 months to 5 years and others with

special nutritional needs such as pregnant women and breast-feeding mothers.

2. UNIMIX is a supplementary food that is meant to be eaten in addition to the normal

family food to improve the diet of children and other vulnerable groups. To increase

the energy density and taste, oil, seasonal fruits and vegetables and or any local nuts

can be added.

3. UNIMIX is pre-cooked but is not an instant product. It should be cooked for 10

minutes, but not longer.

4. Before starting to cook, please ensure that the water which is used is safe before

mixing into porridge and wash your hands thoroughly before preparing the porridge.

Ingredients

1 cup of UNIMIX

4 cups of water

Nutrition value of 100g of CSB /UNIMIX

Energy-380 Kcal Fat -6g . Carbohydrates-60g Vitamin A – 1700 I.U, Riboflavin – 0.5mg, Pantothenic acid --3mg Phosphorous – 600mg, Sodium – 300mg,

Protein-18g, Vitamin D – 200, Niacin – 8mg Folacin – 0.2mg Magnesium- 100mg Potassium -700mg Vitamin E -8 I.U Vitamin B6 – 0.7mg Ascorbic

acid – 40mg Iron – 18mg Iodine – 50mcg Thiamin -0.7mg Vitamin B12- 4mcg Calcium – 800mg Zinc – 3mg

•Mix UNIMIX or CSB with some cold water to make a

paste

•Add the rest of the water

•Bring to boil for 10 minutes (no more – no less!)

•Serve

Method

Nutritional products used by WFP (www.wfp.org)

the key components of the WFP food basket.

micronutrient powder

(sprinkles high energy biscuits

Plumpy DozTM Supplementary PlumpyTM

date-bars

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Compressed Food

- a ready-to-eat cereal-

legume based nutritious

food with milk,

vegetable fat and sugar.

- light, compact,

convenient to handle

and store, and easy to

distribute

- can be prepared into

porridge by just adding

hot water

1 pack (30 g) will provide

16% and 8% of the RDA

for protein and energy for

4-6 yr old children

Corazon V Barba, 2007

Instant Cream Soups

- made from combination

of vegetables and

legumes with spices

and flavors

- delicious, nutritious,

and convenient to

prepare

1 cup (30 g in 250 ml

water) will provide 28%

and 7% of the RDA for

protein and energy for 4-6

yr old children

- comes in Squash

and Mongo flavors

Corazon V Barba, 2007

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Rice Crispy Bars

- made from combinations

of expanded cereals, flour

from legumes, and

oilseeds

- ready-to-eat, appealing,

and nutritious

25 g portion of tropical

fruits flavored FNRI Food

Bar will provide 4% and

5% RDA for protein and

energy of 4-6 yr old

children - light, easy to handle

and transport

- comes in chocolate-

coated, peanut flavored,

and tropical fruits

variants Corazon V Barba, 2007

Monitoring of SFPs

To analyze the efficiency & effectiveness of SFPs

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Selective Feeding Program Therapeutics Feeding Program

Therapeutics Feeding Program (TFPs)

• To rehabilitate severely malnourished person

• The aim: to reduce excess mortality

• TFP may be established for severe malnourished children, adolescence & adults

• Entails treatment of severe malnutrition with nutrition & energy-dense foods, combined with medical intervention

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Therapeutics Feeding Programs, Objectives:

To provide treatment to severely malnourished individuals to reduce

the risk of excess mortality & morbidity

It consists of intensive nutritional & medical treatment

Therapeutics Feeding Programs, when to starts & when to close

The number of severely malnourished individuals cannot be treated adequately in other facilities

Prerequisite: availability of trained health staff

The number of patients is decreasing (< 20)

Adequate medical & nutritional treatment in either clinics/hospital is available

The establishment

Justifiable to not continue

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Therapeutics Feeding Programs, criteria for admission & discharge

Criteria for admission Criteria for discharge & refer to a targeted SFPs

CU5 (or <110 cm) who are severely malnourished (WfH < -3 z or < 70 median)

- Maintain a WfH ≥ -2,5 z, or WfH ≥ median for 2 wks consecutive - shows a good appetite and free of illness -The duration to stay in TFPs should not > 6 wks. If the child doesn’t gain weight feeding regime should be reviewed, or there may be other underlying causes: TB, lack of care

Severely malnourished children > 5 yrs, adolescence and adults (WfH and/or oedema)

LBW babies

Orphans < 1 years (when traditionally care practices are inadequate)

Mothers of children < 1 yr with BF failure (where relactation through counseling & traditional feeding have failed)

Nutritional Rehabilitation

should include intensive Nutritional + Medical Care

Phase I:

acute phase (intensive care)

Phase II:

Rehabilitation phase

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Phase I: Acute phase (intensive care)

First 24-h: medical treatment control infection & dehydration reducing mortality risk

Electrolyte balance is restored & nutritional treatment is initiated

Therapeutic milks: F100 (10-12x) to prevent death from hypoglycemia & hypothermia

Should not > 1 wk limited energy content of the diet

Phase II: Rehabilitation phase

• Started by providing at least 6 meals/day to regain most of weight loss

• Psychological & medical care, the mother should involve throughout the process: preparation for discharge the child to targeted SFPs

• Should not > 5 wks

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Commodities of TFPs

In the acute phase: only milk-based diet

Therapeutic milk (TM)

High Energy Milk (HEM): dried skim milk (DSM), oil, sugar, mixed & fortified with minerals & vitamin

In rehabilitation phase: cereal based porridge, made of blended food (fortified), oil & sugar, given in additional TM. Other foods: biscuit.

BF subtitutes for orphan baby

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Monitoring of TFPs To ensure compliance with therapeutic protocols

for provision of nutritional & medical care

Management Issue

If demographic information is not available

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Management Issue

In the absence of data on prevalence of malnutrition, it can be anticipated in nutritional emergency 15-20% may suffer from moderate malnutrition & about 2-3% severe malnourished

Using this estimation, requirement for food commodities can be calculated & planned for a period of time

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Preventing and controlling micronutrient deficiency in emergency area Widya Rahmawati

Defisiensi vitamin dan mineral sangat mudah terjadi dan semakin diperparah di daerah emergency

Ketika terjadi perang atau bencana, hasil pertanian dan ternak hilang, suplai makanan terputus dan penyakit infeksi dan diare mewabah

Kejadian defisiensi Vitamin and mineral pada daerah emergency: Pengungsi Burma di Thailand (2003) 65% anak menderita anemia

dieficiency besi. Selain suplemen vitamin A yang sudah rutin diberikan, suplemen

mikronutrient juga harus diberikan sebagai bagian dari program respon darurat.

Dekade akhir ini, sudahmulai diberikan multiple micronutrient fortification dalam kondisi emergency.

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Kamp pengungsi Nangweshi di Zambia (2003), diadakan peralatan penggilingan dan fortifikasi mobile untuk memfortifikasi tepung jagung dengan mikronutrien: vitamin A, folic acid, iron and zinc.

Penelitian di 2007 menemukan bahwa pemebrian tepung jagung terfortifikasi dapat menurunkan anaemia pada children dan menurunkan defisiensi vitamin pada remaja.

The UN Standing Committee on Nutrition memberikan rekomendasi bahwa kombinasi beberapa internvensi dapat dilakukan, termasuk meningkatkan akses kepada makanan segar, meningkatkan fortifikasi makanan, distribusi suplemen, dan pemberian sprinkle atau permen terfortifikasi.

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The most vulnerable group: pregnant women, lactating women and young children a greater risk of dying during childbirth, or

of giving birth to an underweight or mentally-impaired baby.

determines the health and development of her breast-fed infant, especially during the first 6 months of life.

increase the risk of dying due to infectious disease and contribute to impaired physical and mental development 53

Strategic to control defciency micronutrient

Improvement of food consumption

Supplementation

Fortification (including bio-fortification)

Preventing & treatment to infection

Improvement of environment heath & sanitation

Nurul Muslihah, 2010

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when fortified rations

are not being given,

children aged 6 to 59

months should be given

one dose each day

when fortified rations

are being given,

children aged 6 to 59

months should be given

two doses each week

of the micronutrient

supplement shown in table 1

WHO, WFP, Unicef, 2007.

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schedule in Table 2

WHO, WFP, Unicef, 2007.

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Address micronutrient deficiencies

Essential actions

Young, H., A. Borrel, et al. (2004). 57

Address micronutrient deficiencies

Gaps, challenges, and constraints

Young, H., A. Borrel, et al. (2004). 58

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Food & Nutrient Needs in Emergency 59

Addressing micronutrient (vitamin and mineral) requirements

The adverse effects of micronutrient deficiencies are profound.

Micronutrient deficiencies may lead to increased risk of death, morbidity and susceptibility to infection, blindness, adverse birth outcomes, growth stunting, low work capacity, decreased cognitive capacity and mental retardation.

In emergency situations, the affected population may have suffered endemic micronutrient deficiencies, often exacerbated by a general deterioration in nutritional status, a limited access to fresh foods, a loss of access to traditional foods and a lack of food diversity

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Addressing micronutrient (vitamin and mineral) requirements

a. Micronutrient adequacy in a ration

Determining the micronutrient adequacy of a ration requires a straightforward comparison of the population’s daily micronutrient requirements with the estimated level of micronutrients in the basic ration.

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Addressing micronutrient (vitamin and mineral) requirements

b. Micronutrient deficiencies

Populations that are highly dependent on food assistance are often at risk of micronutrient-deficiency diseases.

Iron deficiency anaemia, vitamin A deficiency and iodine deficiency are recognized as the three most significant micronutrient-deficiency diseases worldwide.

Factors that increase the micronutrient-deficiency diseases:

endemic micronutrient deficiencies in the country of origin;

lack of suitable diversification in rations (e.g. only one or two commodities are provided);

lack of access to fresh foods;

rations based on highly refined cereals that may be low in B vitamins, iron, potassium, magnesium and zinc; and

high rates of infection and/ or diarrhoea in children.

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Fortification The inclusion of a fortified blended food— an effective vehicle for a number of

micronutrients—is an important part of the basic ration in an emergency situation, particularly for the micronutrient needs of young children, pregnant and lactating women, and the elderly. Blended foods must meet certain criteria in terms of composition and micronutrient fortification (see Annex 7).

Food fortification is the process whereby one or more nutrients (vitamins or minerals) are added to foods during processing. These micronutrients are essential for human growth, natural immunity and development. Fortification does not greatly increase the cost of food or adversely affect its taste and acceptability.

A single fortified food commodity is not a practical vehicle for the delivery of all essential micronutrients. Rather different foods should be fortified with the appropriately matched micronutrient(s). For example, the following box shows foods with mandatory fortification Requirements

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WFP fortification specifications for vegetable oil, salt, wheat and maize flour, and blended foods follow in Table 4

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Type of food used in fortified programs NUTRIENT FOOD

Ascorbic acid Canned, frozen, and dried fruit

drinks, canned and dried milk

products, dry cereal products

Thiamin, riboflavin, niacin Dry cereals, flour, bread, pasta,

milk products

Vitamin A (or - carotene) Dry cereal products, flour, bread,

pasta, milk products, margarine,

vegetable oils, sugar, monosodium glutamate

Vitamin D Milk products, margarine, dry

cereal products, vegetable oils,

fruit drinks

Corazon V Barba, 2007

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Type of food used in fortified programs NUTRIENT FOOD

Calcium Cereal products, bread, orange

juice, milk

Iron Wheat flour, rice, cornmeal, sugar,

condiments, milk, infant foods

Iodine Salt, bread, water

Proteins Cereal products, bread, cassava

flour

Amino Acids Cereals, bread, meat substitutes

Corazon V Barba, 2007

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Lesson Learned from Fortified Programs Consumer education is important Intake of the nutrient must be well below estimated

requirements The food fortified must be chosen carefully: must be a staple of the target population must retain its desirability after fortification fortification must easy and inexpensive based on feasibility

studies fortification sites must be easily monitored

There should be enough number of well-trained, motivated and honest staff to monitor the fortification

Producers must receive incentives, e.g. technical assistance for small producers, as well as face sanctions such as swift but not overly punitive punishment of offenders and noncompliant companies

Corazon V Barba, 2007

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Lesson Learned from Fortified Programs

Soy sauce fortification with Fe in China: improved Hb level, reduced anemia & improved weight & height (Chunming, 2003, Wang et al, 2008)

Sugar fortification with vitamin A in Central Anemia: Positive effect on children having plasma retinol < 20 g/dl

Sprinkle: Spice like added with micronutrient (Fe, Zn, Vit A, B) sprikled to home made complementary foods for 6-24 months

In Ghana: effective reducing amenia

In Zambia: effective to cure anemia, but it did not improve Zn status

In Indonesia: HKI – reduce anemia

Impact of iron Fortified Soy Sauce in reducing anemia in West Java (in 2003-2004) and in Aceh and North Sumatera (2005-2006) (HKI Indonesia)

Sprinkle for reducing micronutrient deficiencies among children in Indonesia, impact and large scale program implementation

Nurul Muslihah, 2010

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Mandatory Fortification in Indonesia

Salt Iodization Mandatory by Joint Ministerial Decree (MOH, MOIT,

M.Interior), 1982; Joint 4 Ministerial (+ Agriculture), 1984, & Presidential Decree No 69/1994

What Fluor Fortification Mandatory bu Ministry of Industr7 & Trade’s Decree

SNI (Standart Nasional Industri) of Wheat fluor: “all wheat fluor produced & marketed in Indonesia has to be fortified with iron, folic acid, zinc, vitamin B1, vitamin B2

Nurul Muslihah, 2010

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Program Strategi yang dapat dilakukan

Vitamin A Tingkatkan cakupan suplementasi vit A 2x/th (6 bl-5 th) Strategi distribusi dan monev yang terintegrasi

Ioditusasi Garam Peraturan pemerintah yang mendukung Eduasi dan advokasi melalui fasilitas kesehatan, media, dan sekolah Monev mandiri oleh masyarakat, sehingga membentuk perubahan perilaku dalam jangka panjang Insentif kepada produsen garam beryodium

Fortifikasi makanan

Standar monitoring nasional untuk program fortifikasi, untuk menjamin fortifikasi dapat berjalan dan produsen mendapatkan keuntungan yang sesuai Edukasi masyarakat untuk meningkatkan kesadaran dan permintaan pasar

Multiple micronutrient supplement for children

Meningkatkan ketersediaan suplemen dalam rumah tangga pada daerah non-endemik malaria (contoh sprinkle) Penelitian lebih lanjut untuk meningkatkan intake Fe pada daerah endemik malaria

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PROGRAM UNTUK MENGATASI DEFISIENSI MIKRONUTRIENT

Program Untuk Mengatasi Defisiensi Mikronutrient Program Strategi yang dapat dilakukan

Suplemen untuk WUS

Meningkatkan intake suplemen Fe & asam folat untuk seluruh WUS, khususnya ibu hamil Edukasi masyarakat, konseling, untuk meningkatkan konsums suplemen Penelitian lebih lanjut tentang suplemen multiple vitamin dan mineral yang ideal untuk WUS

Suplemen Zinc untuk manajemen diare

Memasukkan suplement zinc ke dalam program penanggulangan diare nasional Menjamin suplai zinc adequate Identifikasi strategi distribusi Edukasi masyarakat dan kampanye untuk meningkatkan kesadaran

Food-based approach

Memberdayakan program berbasis masyarakat, termasuk edukasi masyarakat dan pelatihan operasional agar bisa dilakukan oleh masyarakat secara mandiri Integrasi ke dalam program kesehatan, gizi dan ketahanan pangan yang sudah ada Adanya bantuan teknis regional untuk menjamin programberjalan dan dan terdistribusi dengan baik

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References WFP, 2004. Nutrition in Emergencies: WFP Experiences And Challenge

(www.WFP.org) USAID, 2008. Emergencies In Urban Settings (www.aed.org) ENN, 2004. Community-based therapeutic care (CTC) (www.reliefweb.int) ENN, AED, FANTA, USAID, 2008. Integration of Community-based Management

of Acute Malnutrition (www.reliefweb.int) SEAMEO-TROPMED RCCN-UI, 2004. Nutrition survey and

supplementary/Therapeutic Feeding in Emergency Situation Training International code of donation in emergency Flour Fortification Initiaitove (FFI), The Global Alliance for Improve Nutrition

(GAIN), Micronutrient Initiative (MI), UNICEF, USAID, World Bank, WHO, 2009. Investing in the future. A united call to action on vitamin and mineral deficiencies. Global Report 2009. (www.unitedcalltoaction.org/documents/Investing_in_the_future)

WHO, WFP, Unicef, 2007. Preventing and controlling micronutrient deficiencies in populations affected by an emergency (www.searo.who.int)