What is nutritional emergency Vulnerability and triggers Management and challenges

1. Nutritional emergencies
Presenter: Dr. Suhasini Kanyadi
PG Dept. of Community Medicine
J.N.M.C, Belagavi
April 30, 2015

2. Heading
• Introduction 5min
• Vulnerability and triggers 5min
• Types of nutritional emergencies 15min
• Management of nutritional emergencies 15min
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3. Introduction
• Basic right to adequate food and nutrition – emergency
response
• Poor decisions in short-term - long-term negative
impacts
• Failure to meet nutritional needs - resist and fight
infectious diseases.
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4. Introduction
• Emergency: Any situation where there is an exceptional
and widespread threat to life, health and basic
subsistence, which is beyond the coping capacity of
individuals and the community” (Oxfam Humanitarian
Policy, 2003.)
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5. What is Nutritional emergency?
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Classification Level
Mortality and
malnutrition indicators
UN SCN thresholds 1995
Alert
CMR 1/10,000/day
U5MR 2/10,000/day
Wasting 5–8%
Severe
CMR 2/10,000/day
U5MR 4/10,000/day
Wasting >10%

6. What is Nutritional emergency?
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FSNAU/FAO
integrated
food security
phase
classification
(IPC), 2007
Generally food secure CMR < 0.5/10,000 /day
Wasting < 3%
Stunting < 20%
Moderately/Borderline Food
Insecure
CMR < 0.5/10,000/day
U5MR <1/10,000/day
Wasting > 3% but <10%
Stunting 20-40%
Acute food and livelihood
crisis
CMR 0.5-1 /10,000/day
U5MR 1-2/10,000/day
Wasting* 10-15%
Humanitarian emergency CMR <1-5 / 10,000/day
U5MR >2-10/10,000/day
Wasting > 15%
Famine/Humanitarian
catastrophe
CMR >2/10,000/day
U5MR >10/10000/day
Wasting >30%

7. What is Nutritional emergency?
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Benchmarks of mortality indicators

8. Vulnerability to Nutrition Emergencies
• Existing health and nutrition situation
• HIV and AIDS
• Poverty and urban pressure
• Climate change
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9. Who are vulnerable?
• Physiological vulnerability
• Geographical vulnerability
• Political vulnerability
• Internal displacement and refugee status
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10. Triggers for Nutrition Emergencies
• Natural disasters
• Conflict
• Political crises and economic shocks
• Global food prices fluctuations
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11. Types of major deficiency diseases in
emergencies
• Protein energy malnutrition.
-Nutritional marasmus
-Kwashiorkor
-Marasmic kwashiorkor.
• Micronutrient & vitamin deficiencies
-Nutritional anemia
-Iodine deficiency
-Vitamin-A deficiency.
-Other vitamin and mineral deficiency
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12. Protein energy malnutrition
• Major health & nutritional problem
• Results from lack of food or infections
• Important cause of childhood mortality & morbidity
• Different forms
• Different theories
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13. Marasmus
• Marasmos - Greek- wasting
• Wasting of muscles & fat –thin “old man “ face & baggy
pants
• Low weight for height
• Child is alert
• Ribs prominent
• No oedema
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14. • Appetite-good & voracious
• No hair changes
• Biochemical features:
Hydroxyproline/creatinine ratio - low
Serum albumin - Normal/decreased
plasma/amino acid ratio - Normal
urinary urea/gm creatinine - Normal/decreased
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15. Kwashiorkor
• Described as “sickness of weaning” in Ga language in
Ghana.
• Red haired
• Affects 1 – 4 yr children.
• Signs- oedema – moon face
-hair changes - flag sign
-skin changes - flaky paint appearance.
-loss of appetite , irritable & miserable
-hepatomegaly
• Plasma/amino acid ratio- elevated
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16. Complication of PEM
• Immediate
Hypoglycemia
Hypothermia
Septicemia
Electrolyte imbalance
• Late
Intellectual sub normality
Growth retardation
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17. Cont…
Acute Malnutrition level Nutrition classification
<5% Situation is acceptable
5 - 9% Situation is of concern
10 – 14% Situation is serious
≥ 15% Situation is critical
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Classification of public health significance of malnutrition
in a population

18. Nutritional anaemias
• Iron deficiency, Vit-B12 & folic acid deficiency
• Iron deficiency anaemia: Widespread nutritional
disorder
• Affects-young children , LBW infants , pregnant women
• Sources-red meat, green vegetables, pulses, & tubers
• Enhancers-animal origin foods, vitamin-C, folic acid
• Inhibitors –tea & coffee
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19. Iron deficiency anaemia
Classification of public health significance of anaemia in a
population:
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Category of public health significance Prevalence of anaemia (%)
High >40
Medium 20-39.9
Low 5.0-19.9

20. Iron deficiency anaemia
• Prevention:
1) Dietary improvement
2) Iron fortified food
3) Breast feeding
4) Supplementation
5) Public health measures – hookworm, malaria
• Treatment: severe anaemia
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21. Age Group Daily Dose Duration of treatment
Iron(mg) Folic acid
(micro gram)
Children <2years 25 100 3 months
Children 2-12years 120 400 3 months
Adolescent, adults
and pregnant
women
600 400 3 months
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Treatment of severe anaemia

22. Iodine deficiency
• Essential micronutrient, helps in synthesis of T4 & T3
• Public health problem - worldwide
• Young children and pregnant women
• Preventable- Brain damage
• Iodine deficiency disorders
• 2 principal indicator
1) Total goiter rate
2) Urinary iodine level
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23. Iodine deficiency
• Classification of public health significance of iodine in a
population:
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PREVALENCE INDICATORS
Total Goitre Rate (%) Median Urinary Iodine
level (microgm/L)
Normal <5.0 >/=100
Mild 5.0-19.9 50-99
Moderate 20.0-29.9 20-49
Severe >/=30 <20

24. Iodine deficiency
Prevention :
• Source : sea foods(100ug/100g)
• Daily requirement :150ug
Iodized salt 10g ( iodine conc 20-40mg/kg)
• Alternative : Iodized oil
– Orally 3,6,12 th month (200mg capsule)
– I.M injection every 2 yrs (480mg/ml)
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25. Vitamin deficiencies
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26. Vitamin-A deficiency
• Introduction - reversible, preventable,seen in
malnourished
• Sources- animal, plant
• Requirement- 600microgm(adults)
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27. Vitamin-A deficiency
Classification Lesions of Xeropthalmia
XN Night blindness
X1A Conjunctival xerosis
X1B Bitot’s spot
X2 Corneal xerosis
X3A Corneal ulceration
X3B Keratomalacia
XS Corneal scar
SF Xeropthalmic fundus
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Reversible
Irreversible

28. Vitamin-A deficiency
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Bitot’s spot
Corneal xerosis
Corneal ulcer
Keratomalacia

29. Vitamin-A deficiency
Preventive measures:
• Measles immunization
• High dose vitamin A supplements
• Encouraging breast feeding
• Consumption of vitamin A rich foods
• Relief foods fortified with vitamin A
• Environmental sanitation, personal hygiene
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30. Vitamin-A deficiency
Population group Oral vitamin A dose
Infants <6months 50,000 IU once
Infants 6-12months !,00,000 IU, every 4-6months
Children >1year 2,00,000 I, every 4-6months
Pregnant women Not more than 10,000 IU daily
Lactating women 2,00,000 IU once
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Prevention schedule in emergencies

31. Vitamin A Dosage Schedule for treatment of xeropthalmia
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Timing Oral vitamin A dosage
Immediately on diagnosis
<6 months 50,000 IU
6-12 months 100000 IU
>1 year 2,00,000 IU
Following day Same age specific dose
At least 2 weeks later Same age specific dose

32. Vitamin-B1 (Thiamine) deficiency
• Seen when energy expenditure is high
• Oxidative pthway of glicose
• C/F-wet beri beri(acute cardiac)
-dry beri beri( peripheral neuritis)
-infantile beri beri.
• In older infants- CNS signs seen.
• Prevention -1mg thiamine daily
-whole grains, pulses, cereals, nuts & red meat
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33. Vitamin-B1 (Thiamine) deficiency
Treatment –
• Infants- 25-50mg/IV, F/by10mgIM 1wk , F/B 3-5mg /day
oral for 6wks
• Adults- 50-100mg slow iv
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34. Vitamin B3 deficiency (niacin)
• Tryptophan-precursor
• Not excreted in urine
• Deficiency- pellagra
• 4D’s
• Milk is poor source
• Sources-pulses, nuts, meat, lightly milled cereals,fish,
milk & cheese.
• Prevention -15-20 mg/day
• Treatment-300mg oral for 3-4 wks.
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35. Vitamin B3 deficiency (niacin)
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36. Vitamin – C deficiency
• Helps in absorption of iron
• Water soluble
• Most sensitive to heat
• Deficiency: Scurvy
• Clinical Feature:
• Requirement :40mg of vitamin C daily
• Treatment:1g Ascorbic acid daily for 2-3 wks
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37. Vitamin C deficiency
PREVENTION-
A) Local production of fruits/ vegetable Easy
Local production of fruits/ vegetable immediately available
1) add some fruits vegetable to the ration.
2) encourage barter or purchase -10% extra ration
Local production of fruits/ vegetable not immediately
available
3) Encourage household food production / necessary inputs
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38. B) Local production of fruits/ vegetable not Easy
Provision of commodities fortified with vitamin C:
4) Fortified flour or fortified sugar
5)Fortified cereal/pulse blended foods(120mgvit c per
ration)
6)Other Vitamin C rich foods
7)Provision of b Vitamin C supplements
8)Distribution of vitamin C tablet - weekly
Breast milk- good source
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39. Vitamin D deficiency
• Kidney hormone , metabolically inactive
• Forms –D2(calciferolD2(calciferol) & D3(cholecalciferol)
• Deficiency – rickets , osteomalacia.
• Prevention–exposure to sunlight
(10-15min daily)
-fortification
-periodic dosing
intake-2.5 mcg-adults,
Treatment- Cap 5000 IU oral daily for 4-6 wks,
F/b 1000 IU daily for 6 months
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40. Milk
Dry fig Legumes
Yoghurt
Salmon Broccoli
AlmondsSpinachCheese
Kale
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41. Other communicable diseases
• Measles , meningitis & poliomyelitis
• Diarrhoeal diseases
• Viral hepatitis
• Malaria
• Acute respiratory infections
• Tuberculosis
• Louse-borne typhus
• Typhoid fever
• Scabies
• Worm infections
• HIV & AIDS
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42. Management of nutrition in major
emergencies
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43. Management of nutrition in major
emergencies
Principles
• Knowledge of nutritional requirement
• Essential to identify most vulnerable group
• Meeting energy & protein requirements
• Meeting micronutrient & other specific nutrient
requirement
• Monitoring the adequacy of food access & intake
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44. Management of nutrition in major
emergencies
Daily energy requirement and safe protein intake for
developing countries- FAO/WHO/UNN Expert Consultation
1985
• Energy requirement - 2100 kcal/day
• Protein requirement – 46gm/day
assuming BMI- 20-22, light physical activity
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45. Feeding programme
FEEDING PROGRAMME STRATEGY
1. General Feeding programmes
Provides a standard general ration
Aim- cover food and nutritional needs
2. Selective Feeding Programmes
There are two forms of Selective Feeding Programme
• Supplementary Feeding Programme
• Therapeutic Feeding Programme
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46. Feeding programme
General Food Distribution Selective Feeding Programme
Supplementary Feeding Programme Therapeutic Feeding programme
Targeted Supplementary
Feeding Programme
Blanket Supplementary
Feeding programme
Feeding programme strategy
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47. Supplementary Feeding Programmes
• Provide nutritious food in addition to general ration
• Aim - rehabilitate malnourished persons or
- prevent a deterioration of at risk group
• Short-term measures
• Should not be seen as a means of compensating for an
inadequate general food ration
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48. Supplementary Feeding Programme
1. Targeted SFPs:
• Aim - prevent moderately malnourished becoming
severely malnourished and to rehabilitate them.
• Objectives – reduce prevalence of acute & severe
malnutrition
- reduce excess mortality.
• Features – individual registration ,monitoring of weight,
individual medical treatment.
• Target group- mild and moderately malnourished
individuals (<5 & >5yrs )and for selected pregnant and
nursing mothers and individuals at-risk.
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49. Supplementary Feeding Programmes
When to Start Targeted Supplementary Feeding
Program?
• Malnourished individuals - prevalence of 10-14%
• Large numbers of children predicted to become
malnourished - prevalence of 5-9% acute malnutrition in
presence of aggravating factors
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50. Supplementary Feeding Programmes
Blanket SFPs:
• Objectives – prevent increase in PEM & micronutrient
deficiency rates.
• Features – no individual monitoring or registration.
- selection of children- < 110 cms in length.
- preventive medication – vitamin A , measles
vaccination.
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51. Supplementary Feeding Programmes
When to Start Blanket Supplementary Feeding Program
• At onset of an emergency
• Problem delivering/distributing general ration.
• Prevalence of acute malnutrition =/>15%.
• Prevalence -10-14% acute malnutrition in presence of
aggravating factors.
• Anticipated increase in rates of malnutrition - epidemics.
• In case of micronutrient deficiency outbreak
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52. Supplementary Feeding Programmes
Supplementary food can be distributed in two ways
1) On-site feeding or wet ration: minimum of two or three
meals should be provided per day.
2) Take-home or dry ration: The regular (weekly or bi-
weekly) distribution of food in dry form to be prepared at
home
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53. Therapeutic Feeding Programmes
Objective:
• Provide treatment - severely malnourished individuals .
• Reduce the risk of excess mortality and morbidity
It consists of intensive medical and nutritional treatment
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54. Therapeutic Feeding Programmes
Criteria for Admission in Therapeutic Feeding Program
• Children younger than 5 years - severely malnourished
and/or children with edema.
• Severely malnourished children older than 5 years,
adolescents and adults
• Low birth weight (LBW) babies
• Orphans younger than one year
• Mothers of children younger than one year with
breastfeeding failure
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55. Therapeutic Feeding Programmes
Criteria for Discharge from Therapeutic Feeding
Program:
The common procedure is to refer a child to a targeted
SFP when he/she:
• Maintains a weight-for-height >= 75% of the reference
media or “>= -2.5 Z-score” for two consecutive weeks.
• Shows a good appetite and is free of illness.
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57. Nutritional Rehabilitation
Phase 1: Acute phase (intensive care)
-In 24-hour inpatient intensive care- treatment to control
infection and dehydration
- Electrolyte balance is restored and nutritional
treatment is initiated.
-Very frequent feeds with therapeutic milk (10-12 per
day)
- Phase should not be extended beyond one week
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58. Phase 2: Rehabilitation phase
-Providing at least 6 meals per day in order to regain most
of the weight loss.
-Psychological and medical care is vital
- Phase not expected to last more than five weeks
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59. Programme indicators
• Vulnerability indicators
Structural risk
Process
• Outcome indicators
Prevalence of PEM
Prevalence of micronutrient deficiencies
Mortality
Morbidity/epidemics
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60. Indicators of effectiveness of nutritional relief
General feeding programme:
• Coverage
• Adequacy of ration : Exit survey
Household survey
• Impact
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61. Selective feeding programme:
• Registration
• Attendance
• Impact: Household level
Rehabilitation centres
• Biochemical assessment of micronutrients
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63. References
• Park’s textbook of Preventive And Social Medicine 23rd
edition
• O.P Ghai Text book of Pediatrics- 5th
edition
• The management of nutrition in major emergencies – WHO
• Text book of Preventive & Social Medicine- MC Gupta, BK Mahajan
• Modern nutrition in health & disease 9th edition
• Som Nath Singh.Nutrition in emergencies: Issues involved in
ensuring proper nutrition in post-chemical, biological, radiological,
and nuclear disaster. J Pharm Bioallied Sci. 2010 Jul-Sep; 2(3):
248–252
• Food security and nutrition in emergency – John Hopkins and
International Federation of Red Cross
• A Toolkit for Addressing Nutrition in Emergency Situations, IASC
June 2008.
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64. Next seminar
Cancer – Dr. Ravikiran
National programmes related to cancer – Dr.
Kruthika
April 30, 2015 Nutritional emergencies 64