Public nutrition in complex emergencies

doi:10.1016/S0140-6736(04)17447-3

The Lancet

Volume 364, Issue 9448, 20–26 November 2004, Pages 1899-1909

https://doi.org/10.1016/S0140-6736(04)17447-3 Get rights and content

Summary

Public nutrition is a broad-based, problem-solving approach to addressing malnutrition in complex emergencies that combines analysis of nutritional risk and vulnerability with action-oriented strategies, including policies, programmes, and capacity development. This paper focuses on six broad areas: nutritional assessment, distribution of a general food ration, prevention and treatment of moderate malnutrition, treatment of severe malnutrition in children and adults, prevention and treatment of micronutrient deficiency diseases, and nutritional support for at-risk groups, including infants, pregnant and lactating women, elderly people, and people living with HIV. Learning and documenting good practice from previous emergencies, the promotion of good practice in current emergencies, and adherence to international standards and guidelines have contributed to establishing the field of public nutrition. However, many practical challenges reduce the effectiveness of nutritional interventions in complex emergencies, and important research and programmatic questions remain.

Section snippets

Nutritional assessment and surveys

The prevalence of wasting and nutritional oedema among children aged under 5 years is used as a proxy for the prevalence of acute malnutrition. In complex emergencies such data are usually gathered using two-stage 30-cluster surveys that measure the height and weight of children aged between 6 months and 5 years and obtain data on possible underlying causes of malnutrition. This information is used to identify relief needs, to prioritise affected groups or geographical areas, to plan

Meeting food needs through general food distribution

The predominant humanitarian response to acute food insecurity is the provision, for all affected groups, of a general food ration, usually consisting of dry cereals, pulses, vegetable oil and, wherever possible, salt and blended food. In situations of extreme insecurity (eg, eastern Democratic Republic of Congo in 1997, and Somalia in 1992) general rations were distributed cooked.44, 45

The average minimum requirement for energy for a population with a typical developing country demographic

Management of severe acute malnutrition

Therapeutic feeding programmes have a major role in reducing malnutrition-related mortality in complex emergencies. These programmes can be set up in hospitals or other health facilities or in temporary structures. Tried-and-tested guidelines and manuals are available.74, 75

Micronutrient deficiencies

The provision of vitamins and minerals through the general food ration, which often consists of a restricted number of dry foods, is difficult. Rations limited to cereals, oil, and pulses or even a single commodity ration (cereal) are still common,⁴⁵ and deficiencies of vitamin A, iron, and iodine are common in complex emergencies.¹⁵ Rations based on highly refined cereals deficient in zinc, potassium, and magnesium have been associated with high mortality from diarrhoeal disease.⁹²

Food

Nutritional needs of at risk groups

In complex emergencies, sex, age, HIV status, and other characteristics have a role in establishing nutritional risks, which can be exacerbated by changes in social networks and support structures.

The future

In conclusion, major advances in the field of public nutrition in complex emergencies have been made in the past decade, including technical advances in anthropometry, survey methods, fortification, and treatment of severe malnutrition. More generally, conceptual advances have been made in understanding the causes of malnutrition associated with complex emergencies. Further investigation is needed in a number of specific areas (panel).

Finally, institutionalisation of the public nutrition

Search Strategy and Selection Criteria

The paper is based on the personal bibliographic databases of the authors combined with a search of published work using MEDLINE, FirstSearch, Web of Science, JSTOR, ScienceDirect, and Ingenta, and more than 30 keywords, including: “undernutrition”, “severe malnutrition”, “anthropometry”, “interventions”, “nutritional indicators”, “rations”, “supplementary feeding”, “food aid”, “food security”,“micronutrients”.

References (135)

LE Davis
Epidemiology of famine in the Nigerian crisis: rapid evaluation of malnutrition by height and arm circumference in large populations
Am J Clin Nutr
(1971)
R Yip et al.
The burden of malnutrition: a population perspective
J Nutr
(1994)
C Bern et al.
Is mid-upper-arm circumference a useful tool for screening in emergency settings?
Lancet
(1995)
M de Onis et al.
Anthropometric reference data for international use: recommendations from a World Health Organization Expert Committee
Am J Clin Nutr
(1996)
J Mason
Lessons on nutrition of displaced people
J Nutr
(2002)
D Clay et al.
Food aid targeting in Ethiopia: a study of who needs it and who gets it
Food Policy
(1999)
K Hilderbrand et al.
Food rations for refugees
Lancet
(1998)
DL Pelletier et al.
The food-first bias and nutrition policy: lessons from Ethiopia
Food Policy
(1995)
GH Beaton et al.
Supplementary feeding programs for young children in developing countries
Am J Clin Nutr
(1982)
A Ashworth et al.
Latest developments in the treatment of severe malnutrition in children
Nutrition
(1998)

BE Golden et al.

Malnutrition: trials and triumphs

Trans R Soc Trop Med Hyg

(2000)

S Collins et al.

Dietary treatment of severe malnutrition in adults

Am J Clin Nutr

(1998)

S Collins

Changing the way we address severe malnutrition during famine

Lancet

(2001)

S Collins et al.

Outpatient care for severely malnourished children in emergency relief programmes: a retrospective cohort study

Lancet

(2002)

KF Michaelsen et al.

Inadequate supplies of potassium and magnesium in relief food - implications and counter-measures

Lancet

(1987)

B Reed et al.

Sales of food as sign of distress, not excess

Lancet

(1998)

M Black

A cause for our times: Oxfam the first 50 years

(1992)

JPW Rivers et al.

Lessons for epidemiology from the Ethiopian Famines

Ann Soc Belg Med Trop

(1976)

J Seaman et al.

The Ethiopian Famine of 1973-74. 1. Wollo Province

Proc Nutr Soc

(1975)

MJ Toole et al.

The association between inadequate rations, undernutrition prevalence and mortality in refugee camps: case studies of refugee populations in eastern Thailand, 1979-1980, and Eastern Sudan, 1984-1985

J Trop Ped

(1988)

C de Ville de Goyet et al.

The management of nutritional emergencies in large populations

(1978)

S Peel

Selective feeding procedures. Oxfam Practical Guide No 1

(1977)

Guide to emergency feeding

(1974)

A guide to food and health relief operations for disasters

(1977)

H Young

Public nutrition in emergencies: an overview of debates, dilemmas and decision-making

Disasters

(1999)

ACC/Sub-Committee on Nutrition of the United Nations. Reports on the nutrition situation of refugees and displaced...

J Macrae et al.

Humanitarian action and the ‘war on terror’: a review of issues, in humanitarian action and the ‘global war on terror’: a review of trends and issues, Humanitarian Policy Group Report 14

(2003)

Z Weise Prinzo et al.

Meeting the challenges of micronutrient deficiencies in emergency affected populations

Proc Nutr Soc

(2002)

Physical status: the use and interpretation of anthropometry. Report of a WHO expert committee. WHO Technical Report Series No. 854

(1995)

Field guide on rapid nutritional assessment in emergencies

(1995)

H Young et al.

Nutritional assessments, food security and famine

Disasters

(1995)

MHN Golden et al.

Population nutritional status during famine Annex 6: proceedings of the Standardized Monitoring and Assessment of Relief and Transitions (SMART) Workshop, July 23–26, 2002

(2002)

A Briend et al.

Use of mid-upper-arm circumference for nutritional screening of refugees

Lancet

(1995)

P Nabeth et al.

Demographic and nutritional consequences of civil war in Liberia

Lancet

(1997)

Z Mei et al.

Development of a research child growth reference and its comparison with the current international growth reference

Arch Pediatr Adolesc Med

(1998)

A Briend et al.

Nutritional status, age and survival: the muscle mass hypothesis

Eur J Clin Nutr

(1989)

S Collins et al.

Assessment of nutritional status in emergency-affected populations

(2000)

P Salama et al.

An ongoing omission; adolescent and adult malnutrition in famine situations

ENN Field Exchange

(2000)

BA Woodruff et al.

Adolescents. Assessment of nutritional status in emergency-affected populations

(2000)

S Collins

Using middle upper arm circumference to assess severe adult malnutrition during famine

JAMA

(1996)

J Appleton et al.

Chapter 5: Nutrition of refugees and displaced populations

(2000)

FANTA

Proceedings of the Standardized Monitoring and Assessment of Relief and Transitions (SMART) Workshop, July 23–26, 2002

(2002)

The management of nutrition in major emergencies

(2000)

Famine-affected, refugee, and displaced populations: Recommendations for public health issues

MMWR Recomm Rep

(1992)

N Binkin et al.

Rapid nutrition surveys: how many clusters are enough?

Disasters

(1991)

National Nutrition Survey Guidelines

(2002)

P Spiegel et al.

Quality of malnutrition assessment surveys conducted during famine in Ethiopia

JAMA

(2004)

Food and nutrition needs in emergencies

(2002)

S Mardel et al.

Micronutrient status of the besieged residents of Sarajevo: May 1993

Eur J Clin Nutr

(1995)

Cited by (91)

Spatial distribution of various forms of malnutrition among reproductive age women in Nepal: A Bayesian geoadditive quantile regression approach
2021, SSM - Population Health
Addressing both the under-and over-nutritional status of women is an eminent challenge for developing countries like Nepal. This paper examined a critical analysis of factors associated with various forms of malnutrition using Bayesian geoadditive quantile regression approach and assessed spatial variations of malnutrition among Nepalese women using Asian cut-off values. Data drawn from the 2016 Nepal Demographic and Health Survey was utilized to assess the spatial distributions of underweight, overweight and obesity at the provincial level. Spatial and nonlinear components were estimated using Markov random fields and Bayesian P-splines, respectively. The analysis of 4,338 women confirmed that women living in extremely urbanized areas and in Province 1, Province 3, and Province 4 were more likely to be overweight/obese. Similarly, the likelihood of being underweight was prominently high among women residing in rural municipality and women residing in Province 2 and Province 7. Women from the richest and richer quintiles, and with primary education were more likely to be obese. Furthermore, currently-working women and women having access to protected water source were less likely to be obese while improved toilet and access to electricity facility were associated with obesity. Women with access to newspaper and radio were less prone to obesity. Inconsistent distribution of under- and over-nutrition existed in Nepal, given that the high prevalence of overweight/obesity among women living in metropolitan and undernutrition among rural women. Specific intervention measures, addressing location-specific nutrition issues are urgent. Rigorous implementation of strategies incorporated in the national nutrition plan is called for to curb the burden of overweight/obesity. Involving mass media to promote healthier lifestyle and nutritious food could be advantageous at the population level, especially in rural municipalities.
The effects of armed conflict on the health of women and children
2021, The Lancet
Citation Excerpt :
Small-scale cross-sectional household surveys are the main source of data for malnutrition during conflicts. Wasting prevalence in under-5s (weight for height below two standard deviations from the WHO reference population), with the presence of oedema, has become one of the key indicators of the severity of a crisis.34 Large numbers of local surveys using the Standardized Monitoring and Assessment of Relief and Transitions (SMART) methods are conducted to monitor nutritional status.
Women and children bear substantial morbidity and mortality as a result of armed conflicts. This Series paper focuses on the direct (due to violence) and indirect health effects of armed conflict on women and children (including adolescents) worldwide. We estimate that nearly 36 million children and 16 million women were displaced in 2017, on the basis of international databases of refugees and internally displaced populations. From geospatial analyses we estimate that the number of non-displaced women and children living dangerously close to armed conflict (within 50 km) increased from 185 million women and 250 million children in 2000, to 265 million women and 368 million children in 2017. Women's and children's mortality risk from non-violent causes increases substantially in response to nearby conflict, with more intense and more chronic conflicts leading to greater mortality increases. More than 10 million deaths in children younger than 5 years can be attributed to conflict between 1995 and 2015 globally. Women of reproductive ages living near high intensity conflicts have three times higher mortality than do women in peaceful settings. Current research provides fragmentary evidence about how armed conflict indirectly affects the survival chances of women and children through malnutrition, physical injuries, infectious diseases, poor mental health, and poor sexual and reproductive health, but major systematic evidence is sparse, hampering the design and implementation of essential interventions for mitigating the harms of armed conflicts.
One more tool for the food aid toolbox? Experimental evidence on food aid packaging
2019, Food Policy
Citation Excerpt :
Regulating bag manufacturers may be another way to ensure treated bags, though while fortification has been required with firms such as mills and salt producers (Lentz and Barrett, 2013), regulation has not always worked (Barrett 2002). Technical assistance to the bag manufacturers would be a necessary part of any packaging intervention, though working closely with mills and salt producers to fortify foods has not always been possible in complex emergencies (Young et al., 2004). The policy implications of this third test is that as the number of tools grows, opportunity will be identifying points of intervention in supply chains (e.g., bag manufacturers) to arrange tools in complementary ways.
International food assistance reaches more than 90 million people per year, much of it through in-kind programs that distribute food. Several key aspects of in-kind programs—what food is shipped, when and from where it is sourced—have been changed to improve program effectiveness and efficiency, becoming helpful tools in the modernized in-kind food assistance toolbox. Packaging—in what food is shipped—remains an unstudied and underused tool despite more than 50 million bags per year passing through in-kind supply chains, affecting program effectiveness and efficiency. We conduct an experiment with 46 shipments using different packaging materials and sizes to measure the effect of packaging on shipment quality, cost, and timeliness. Analyzing the data with randomization tests, we find that, relative to the current materials, new materials maintain shipment quality and cost while improving timeliness and in some cases may reduce cost. One promising material that balances cost and effectiveness is a bag with a biopesticide applied, designed to prevent insects from reproducing. We also find that, relative to the current size, larger bags may improve costs at least in the domestic portion of the supply chain. Donors and their partners should consider packaging as one more tool in the modernized food assistance toolbox. As the toolbox continues to fill, the coming opportunity and challenge to identify situations where the various tools work in complementary ways.
Housing, water and sanitation implications on food insecurity and diet diversity in landslide affected communities: A cross-sectional survey of two districts in Uganda
2019, Clinical Nutrition ESPEN
The major landslide of 2010 in Bududa district in Eastern Uganda is the most catastrophic natural disaster in Uganda's recorded history. An estimated 350 people died and some of the affected were resettled in Kiryandongo district. We assessed housing, water and sanitation practises of affected households and controls to establish possible implications on food insecurity and diet diversity.
This cross-sectional study assessed 1078 affected and control households in Bududa and Kiryandongo districts. The head of the households were either affected, selected from landslide disaster-affected communities, or controls from a random sub-county bordering the affected. Structured interviews were used and entries were tested statistically to report crude estimates based on the Pearson x² and ANOVA, while adjusted analysis used multivariate analysis of co-variance (MANCOVA) and Wald's Odds Ratio (OR) of Binary Logistic Regression at the 95% CI.
On adjusting for the disaster and covariates, households who had insufficient access to water scored higher mean (SE) on food insecurity than those who reported sufficient access: 13.1 (0.4) vs. 9.5 (0.3) (P < 0.01). Intriguingly, households who owned a toilet and those who reported always using soap to wash hands scored higher food insecurity than their counterparts: 11.1 (0.3) vs. 9.0 (0.6) (P < 0.01) and 11.3 (0.3) vs. 9.1 (0.5) (P < 0.01), respectively. However, not owning a toilet increased the likelihood of being food insecure (OR 3.43; 95% CI 1.31, 8.97; P = 0.02). In Kiryandongo, affected households scored higher food insecurity than controls: 9.5 (0.5) vs. 5.4 (0.5) (P < 0.01) and higher diet diversity scores (DDS): 6.7 (0.2) vs. 6.2 (0.2) (P = 0.04). Type of housing also predicted food insecurity (P < 0.01) and DDS (P = 0.03). Like Bududa, households with insufficient water access scored higher food insecurity while those owning toilet scored higher DDS. Uniquely, only number of rooms was linked to a high likelihood of being food insecure (OR 1.60; 95% CI 1.19, 2.15; P < 0.05).
Disaster, food security and diet were sensitive to housing, water and sanitation and were integral to an adequate standard of living of victims of this landslide.
“Wasting away”: Diabetes, food insecurity, and medical insecurity in the Somali Region of Ethiopia
2019, Social Science and Medicine
Most research on diabetes has taken place in cities or in high-income countries, even though most diabetes deaths occur in low and middle-income countries, and diabetes disproportionately affects the poor. This research, by contrast, investigates rising concerns about diabetes among Somalis in eastern Ethiopia--in communities where obesity is rare and people face chronic food insecurity, forced displacement, recurrent humanitarian crises, and lack of access to medical care. Findings presented in this article build on ethnographic research with Somalis in eastern Ethiopia since 2007, and include anthropometric and demographic data collection with Somali diabetes patients and select adult siblings of these patients (n = 108) plus in-depth ethnographic interviews with a subset of the diabetes patients, their siblings, and medical providers serving Somali communities (n = 29) in July–August 2018. Most Somali patients we spoke with shared symptoms of progressive weight loss, weakness, and loss of teeth--or what people called “wasting away”--even when complying with prescribed pharmaceutical regimens and/or insulin. Diabetes and “wasting away” were characterized by Somalis as humoral pathologies; but rather than a consequence of obesity or pathological weight gain, these were perceived to be a consequence of stress, trauma, anger, displacement, loss of healthy fatness, and lack of access to fresh and healthy food over their lifetimes. Somalis' simultaneous experiences of progressive nutritional wasting and adult-onset diabetes echo how “tropical diabetes” was defined and experienced for thousands of years prior to the development of effective early diagnostics and biomedical treatments. This analysis therefore suggests heterogeneity and overlaps within and between categories of “type 1” and “type 2 diabetes” in populations with differential exposures to stress, crisis, and poverty. Exposures to food insecurity and medical insecurity, in particular, are pathogenic, and shape diabetes patients' clinical presentations and prognoses, as well as local etiologies and patterns of disease.
Care groups in an integrated nutrition education intervention improved infant growth among South Sudanese refugees in Uganda's West Nile post-emergency settlements: A cluster randomized trial
2024, PLoS ONE

View all citing articles on Scopus

View full text

SeriesPublic nutrition in complex emergencies

Summary

Section snippets

Nutritional assessment and surveys

Meeting food needs through general food distribution

Management of severe acute malnutrition

Micronutrient deficiencies

Nutritional needs of at risk groups

The future

Search Strategy and Selection Criteria

Am J Clin Nutr

J Nutr

Lancet

Am J Clin Nutr

J Nutr

Food Policy

Lancet

Food Policy

Am J Clin Nutr

Nutrition

Trans R Soc Trop Med Hyg

Am J Clin Nutr

Lancet

Lancet

Lancet

Lancet

A cause for our times: Oxfam the first 50 years

Lessons for epidemiology from the Ethiopian Famines

Ann Soc Belg Med Trop

The Ethiopian Famine of 1973-74. 1. Wollo Province

Proc Nutr Soc

The association between inadequate rations, undernutrition prevalence and mortality in refugee camps: case studies of refugee populations in eastern Thailand, 1979-1980, and Eastern Sudan, 1984-1985

J Trop Ped

The management of nutritional emergencies in large populations

Selective feeding procedures. Oxfam Practical Guide No 1

Guide to emergency feeding

A guide to food and health relief operations for disasters

Public nutrition in emergencies: an overview of debates, dilemmas and decision-making

Disasters

Humanitarian action and the ‘war on terror’: a review of issues, in humanitarian action and the ‘global war on terror’: a review of trends and issues, Humanitarian Policy Group Report 14

Meeting the challenges of micronutrient deficiencies in emergency affected populations

Proc Nutr Soc

Physical status: the use and interpretation of anthropometry. Report of a WHO expert committee. WHO Technical Report Series No. 854

Field guide on rapid nutritional assessment in emergencies

Nutritional assessments, food security and famine

Disasters

Population nutritional status during famine Annex 6: proceedings of the Standardized Monitoring and Assessment of Relief and Transitions (SMART) Workshop, July 23–26, 2002

Use of mid-upper-arm circumference for nutritional screening of refugees

Lancet

Demographic and nutritional consequences of civil war in Liberia

Lancet

Development of a research child growth reference and its comparison with the current international growth reference

Arch Pediatr Adolesc Med

Nutritional status, age and survival: the muscle mass hypothesis

Eur J Clin Nutr

Assessment of nutritional status in emergency-affected populations

An ongoing omission; adolescent and adult malnutrition in famine situations

ENN Field Exchange

Adolescents. Assessment of nutritional status in emergency-affected populations

Using middle upper arm circumference to assess severe adult malnutrition during famine

JAMA

Chapter 5: Nutrition of refugees and displaced populations

Proceedings of the Standardized Monitoring and Assessment of Relief and Transitions (SMART) Workshop, July 23–26, 2002

The management of nutrition in major emergencies

Famine-affected, refugee, and displaced populations: Recommendations for public health issues

MMWR Recomm Rep

Rapid nutrition surveys: how many clusters are enough?

Disasters

National Nutrition Survey Guidelines

Quality of malnutrition assessment surveys conducted during famine in Ethiopia

JAMA

Food and nutrition needs in emergencies

Micronutrient status of the besieged residents of Sarajevo: May 1993

Eur J Clin Nutr

Series
Public nutrition in complex emergencies