17/02/2016

Prinsip Food & Nutrition in

Emergency
“Setiap orang memiliki hak yang sama
untuk mendapatkan standart kehidupan yang layak
untuk kesehatan dan kesejahteraannya
untuk dirinya dan keluarganya, termasuk makanan...”
Feeding Program
in Emergency
Widya Rahmawati
“Everyone has the right to a standard of living adequate
for the health & well-being of himself and his family,
including food…”
(Universal Declaration of Human Right/UDHR, article 25-1)

Bantuan Makanan untuk keadaan

emergency
 Dalam keadaan emergency, diharapkan semua orang
tetap memiliki akses terhadap makanan yang cukup
dan aman
 Bantuan makanan, diharapkan dapat:
 Memenuhi seluruh kebutuhan gizi untuk semua populasi
(quantity, quality & safety)
 Memenuhi kebutuhan minimum energy, protein & lemak
untuk bertahan hidup dalam aktivitas ringan
 Gizi seimbang
 Beraneka ragam, diterima cara budaya, sesuai untuk
konsumsi manusia, dan sesuai untuk seluruh sub group
dalam populasi

www.unicef.org

Nutritional support for Emergency

situation
1) General nutrition support: distribution of a basket of food
commodities to crisis-affected populations.

2) Correcting malnutrition: selective feeding interventions for

vulnerable groups
• targeted supplementary feeding - to prevent moderately  severely malnourished, for
vulnerable group
• blanket supplementary feeding - to prevent malnutrition and related mortality, for sub-
populations
• therapeutic feeding - treatment of severe malnutrition with nutrient + medical
intervention.

3) Micronutrient interventions: fortified foods or local fortification to

meet people’s needs or address outbreaks of micronutrient deficiency.

www.unicef.org

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Feeding Program Strategy Hal-hal yang perlu dipertimbangkan

Type of
sebelum melaksanakan program gizi
Feeding
Program
di emergecy
 Prevalensikekurangan gizi (GAM & SAM)
Selective  Adatidaknya aggravating factors (faktor
General food Micronutrient
feeding pemberat)
distribution intervention
program

Supplementary Therapeutic
feeding feeding
program (SFP) program (TFP)

Blanket SFP Targeted SFP

Mathys et al, 2000

WHO decision tree for implementation of Type of Selective Feeding Program

selective feeding program

www.unicef.org

The Decision
making
framework
to
implement
selective
feeding
programs

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Type of
Feeding
Program

Selective
General food Micronutrient
feeding
distribution intervention
program

Supplementary Therapeutic
feeding feeding
program (SFP) program (TFP)

Blanket SFP Targeted SFP

General Food Ditribution

Provides a standard general ration to Commodities
affected population
 Energy : 1900, 2100 or 2400 kcal/person/day
 Sufficientenergy, protein, fat
the immediate aim to cover food & nutrient  Usually include:
needs to all population with constrained  energy rich foods (a staple, cereal, rice,),
access to normal source of food  oils, fats, and
 protein rich foods (pulses: beans, ground nuts,
lentils).
Involves: distribution of a basket of food
commodities to emergency-affected
populations

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www.unicef.org

www.unicef.org

Type of
Feeding
Program

Selective
General food Micronutrient
feeding
distribution intervention
program

Supplementary Therapeutic
feeding feeding
program (SFP) program (TFP)

Blanket SFP Targeted SFP

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Selective Feeding Program:

Selective Feeding Program: Supplementary
Supplementary Feeding Program Feeding Program (SFPs)
(SFPs)
• The aim: to prevent the moderately • The aim: to prevent widespread
• Provides nutritious food malnourished becoming severely malnutrition & reduce excess
• In addition to the general food
malnourished & to rehabilitate mortality among those at risk
them • By providing a food/micronutrient
• Food supplement to general food supplement for all member of the
• The aim: to rehabilitate malnourished person rations to: mild-moderately group (children under 5/under 3,
• Or to prevent a deterioration of nutritional status of the most at- malnutrition, pregnant women & pregnant women, nursing mother)
risk nursing mother

• By the meeting their additional needs, focusing particularly on

young children, pregnant women & nursing mother Targeted SFPs  Blanket SFPs 
wasting 10-14,9%, atau wasting > 15%, atau
5-9% dg aggravating 10-14,9% dg agravating
factors (SERIOUS) factors (CRITICAL)

Type of
Feeding
Program
Blanket SFPs, Objectives:
Selective
General food Micronutrient Aimed primarily to prevent a deterioration
feeding
distribution intervention in nutritional status of population,
program

And to reduce the prevalence of acute

Supplementary Therapeutic malnutrition of CU5  reducing
feeding feeding morbidity & mortality risk
program (SFP) program (TFP)

Provide a food/micronutrient supplement

for all member of groups at high risk of
becoming malnourished
Blanket SFP Targeted SFP

Blanket SFPs,
When to start & when to close?
Should be set up when one/
combination of these
-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
Will be closed when all of these
condition are met Blanket SFPs, criteria for admission
-General food distribution is
adequate & meeting requirement
-% of acute malnutrition < 15%
All • All CU5 or CU3 using height as cut
without aggravating factors primary off point (5 y = 110 cm, 3 y = 90
cm)
-% of acute malnutrition < 10% in
the presence of aggravating factors target • Pregnant women from the time of
confirmed pregnancy, and nursing
-Disease control are effective groups for mothers until 6 months after
blanket delivery
• Other at risk groups: sick, elderly
SFPs are:

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Type of
Feeding
Program
Targeted SFPs, Objectives:
Selective Rehabilitate moderately malnourished children, adolescents, adults
General food Micronutrient
feeding and elderly persons.
distribution intervention
program
Prevent the moderately malnourished from becoming severely
malnourished.
Supplementary Therapeutic
feeding feeding Reduce mortality and morbidity risk in children under 5 years.
program (SFP) program (TFP)
Provide a food supplement to selected pregnant and nursing mothers
and other individuals at-risk

Blanket SFP Targeted SFP Provide follow-up to referrals from Therapeutic Feeding Programmes

Targeted SFPs, Targeted SFPs,

when to start & when to close?
When to start
Prevalence of 10-14% acute
malnutrition among children.
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
When to close, when all of these are
satisfied
General food distribution is adequate
Prevalence of acute malnutrition is
below 10% without aggravating
factors
Control measures for infectious
disease are effective
Criteria for admission & discharge:
Admission criteria
Moderately malnourished children
under 5
- WfH between -3 & -2 z score
- WfH between 70-80% of median
Malnourished older children,
adolescence, adults, elderly
(BMI/MUAC), medical referrals
Referrals from TFPs
Selected pregnant women and
nursing mothers (≤ 6 mos after
delivery)
Discharge criteria
Children who have maintained at
least 85% median WfH or -1,5 WfH z
Individuals older than 5 y who have
attained a stable & satisfactory
nutritional status & free from disease
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

Food commodities for SFPs 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)
 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 Composition of SFPs

On-site • The daily distribution of cooked food/meals at • 500-700 kcals energy/person/day
feeding feeding centers On-site feeding
• 15-25 g protein
program, • The number of meals provided can vary in program, or • Could include blended food, oil, sugar,
or wet specific situation, but minimum of two/three wet rations
rations meals should be provided everyday cereal, high energy biscuit, pulses

Take-home Take-home
• The regular (weekly/bi-weekly) distribution of • 1000-1200 kcal/person/day
feeding food in dry form to be prepared at home feeding
program, • 35-45 g protein
or dry
• It may be necessary to increase the amount of program, or dry • Include blended food, oil & sugar
food to compensate for intra-household sharing
rations rations

Take-home vs on-site feeding program

Take-home On-site, justified when:

• Fewer resources • Food supply is limited, take-

• 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
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

Cooking Porridge using Nutritional products used by WFP

UNIMIX or CSB Fact sheet 4
(www.wfp.org)
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
micronutrient
vegetables and or any local nuts can be added. powder high energy biscuits
3. UNIMIX is pre-cooked but is not an instant product. It should be cooked for (sprinkles
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 Method
•Mix UNIMIX or CSB with some cold water to make a paste Plumpy DozTM Supplementary
1 cup of UNIMIX
•Add the rest of the water PlumpyTM
•Bring to boil for 10 minutes (no more – no less!)
4 cups of water •Serve

Nutrition value of 100g of CSB /UNIMIX the key

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
date-bars components of the
acid – 40mg Iron – 18mg Iodine – 50mcg Thiamin -0.7mg Vitamin B12- 4mcg Calcium – 800mg Zinc – 3mg
WFP food basket.

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Compressed Food Instant Cream Soups

1 pack (30 g) will provide
16% and 8% of the RDA
for protein and energy for
4-6 yr old children
- 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
Corazon V Barba, 2007
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
- made from combination
of vegetables and
legumes with spices
and flavors
- delicious, nutritious,
and convenient to
prepare
- comes in Squash
and Mongo flavors
Corazon V Barba, 2007

Rice Crispy Bars

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
- made from combinations
of expanded cereals, flour Monitoring of SFPs
from legumes, and
oilseeds  To analyze the efficiency & effectiveness of SFPs
- ready-to-eat, appealing,
and nutritious
- light, easy to handle
and transport
- comes in chocolate-
coated, peanut flavored,
and tropical fruits
variants
Corazon V Barba, 2007

Type of
Feeding
Program

Selective
General food Micronutrient
feeding
distribution intervention
program

Supplementary Therapeutic
feeding feeding
program (SFP) program (TFP)

Blanket SFP Targeted SFP

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Therapeutics Feeding Program Therapeutics Feeding Programs,

(TFPs) Objectives:
• To rehabilitate severely malnourished person To provide treatment to severely
• The aim: to reduce excess mortality
malnourished individuals to reduce
the risk of excess mortality &
• TFP may be established for severe malnourished children, morbidity
adolescence & adults

• Entails treatment of severe malnutrition with nutrition &

It consists of intensive nutritional &
energy-dense foods, combined with medical intervention medical treatment

Therapeutics Feeding Programs,

Therapeutics Feeding Programs,
when to starts & when to close
The number of severely malnourished
individuals cannot be treated
The adequately in other facilities
establishment Prerequisite: availability of trained
health staff
The number of patients is decreasing
(< 20)
Justifiable to
Adequate medical & nutritional
not continue treatment in either clinics/hospital is
available
criteria for admission & discharge
Criteria for admission
CU5 (or <110 cm) who are severely
malnourished (WfH < -3 z or < 70
median)
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)
Criteria for discharge & refer to a
targeted SFPs
- 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

Nutritional Rehabilitation Phase I: Acute phase (intensive care)

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

should include intensive Nutritional +

Medical Care Electrolyte balance is restored & nutritional
treatment is initiated
Phase I: Phase II:
Therapeutic milks: F100 (10-12x) to prevent
acute phase Rehabilitation death from hypoglycemia & hypothermia

(intensive care) phase

Should not > 1 wk  limited energy content of
the diet

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Phase II: Rehabilitation phase Commodities of TFPs

• Started by providing at least 6 meals/day to regain most of  In the acute phase: only milk-based diet
weight loss
 Therapeutic milk (TM)
 High Energy Milk (HEM): dried skim milk (DSM), oil,
• Psychological & medical care, the mother should involve
throughout the process: preparation for discharge the child to sugar, mixed & fortified with minerals & vitamin
targeted SFPs  In rehabilitation
phase: cereal based porridge,
made of blended food (fortified), oil & sugar, given
• Should not > 5 wks in additional TM. Other foods: biscuit.

BF subtitutes for orphan baby Monitoring of TFPs

 To ensure compliance with therapeutic protocols
for provision of nutritional & medical care

Management Issue Management Issue

 If demographic information is not available  In theabsence 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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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)
 Course Material of Nutrition in Emergency, www.unicef.org

Widya R, 2015, Preventing Micronutrient Deficiency

in Emergency

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