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Nutrition Module Session 5

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					The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response: Nutrition Training
Modules. 2004


                       Nutrition Module: Session 3
          General nutrition support: All groups & At Risk groups

General nutrition support standard 1: all groups (page 137)
“The nutritional needs of the population are met”

General nutrition support standard 2: at-risk groups (page 140)
“The nutritional and support needs of identified at-risk groups are met”

Overall Objective
 To gain a familiarity with and understanding of the standard, key indicators and guidance
   notes.

Specific Objectives:
 To review nutritional requirements that must be met by the “range of foods” in the diet.
 To understand the factors which affect access to foods by emergency-affected
   populations.
 To determine the support required for infants and pregnant and lactating women.

Main messages:
 An adequate food basket is usually comprised of a range of foods from at least four main
   food groups including: carbohydrates, proteins, fats and micronutrient-rich foods.
 To meet the nutritional needs of the population, the quality of the diet must meet certain
   requirements in addition to energy; including percentage energy from protein and fat, and
   adequate availability of micronutrients.
 Populations reliant on emergency food rations are at risk of consuming insufficient
   quantities of micronutrient-rich foods.
 Emergencies impact in many different ways on people‟s access to food.
 Emergency-affected populations are frequently forced to adopt coping strategies which
   become increasingly damaging.
 There are exceptional cases where an infant cannot be breast-fed. In such cases,
   international guidelines must be followed.

Reading:
 WFP Food and Nutrition Handbook. Chapter 2. Food Group and Food Aid Commodities
 Emergency Nutrition Network (1998) Infant Feeding in Emergencies: Policy, Strategy
   and Practice. Dublin.

Handouts:
 Handout 1a: Calculation of percentage energy of protein and fat in the diet
 Handout 1b: Nutritional values of selected food aid commodities
 Handout 1c: Answers to calculations (to be handed out at end of the session).

Resources required for Session 3:
 Flipchart, pens, calculators
 Handouts and reference reading

Timeframe
                    Slides and discussion          Exercises
Objective 1         20 mins                        Ex 1: 15 mins
Objective 2         15 mins                        Optional Ex 2: 15 mins
Objective 3         5 mins                         Ex 3: 30 mins



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The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response: Nutrition Training
Modules. 2004


 Objective 1: To review the nutritional requirements that must be met by the “range of
 foods” in the diet.

Slide 1

For all slides in this document, please refer to corresponding Power Point Files –„S3 General
                                 nutrition support Visuals.ppt‟

    This session covers the General Nutritional Support standards 1 and 2: All Groups and
     At-risk groups.

Slide 2


    Ask a participant to read out the standards
    Ask participants to take a minute to read through the key indicators
    Recommend to the participants to number the key indicators so that reference can be
     easily made to them.

Slide 3


    Introduce objectives of the session.

Slide 4


    Inform the participants that the majority of the indicators in standard 1 refer to
     micronutrient needs. Hence these will be addressed in the MDD session. The first key
     indicator in standard 1 will be the primary focus in this session. A case study at the end of
     the session will be used as an exercise to address the key indicators referring to the
     nutritional and support needs of infants and their mothers in standard 2.

Slide 5


    Firstly, what do we mean by a range? “A range of foods” usually refers to four main
     broad food groups: (i) carbohydrate foods such as cereals, tubers and sugar (ii) protein-
     rich foods including pulses or animal products (iii) foods rich in fats such as oils (iv)
     micronutrient-rich foods.
    Let‟s explore these further, particularly with respect to emergency food rations.

    Ask participants to name examples of foods for each food group and the importance of
     each for maintaining good nutritional status.
    Carbohydrates: Cereals such as maize, rice or wheat form the bulk of the diet. While
     tubers or roots such as cassava, yams etc. are not provided in the ration, these may be
     found locally. These foods are important energy-giving foods. In food aid in
     emergencies, it is extremely important that the staple food is culturally acceptable and
     familiar to the population since this food forms the bulk of the diet. Sugar is also a
     carbohydrate food but is usually eaten in smaller quantities compared to cereals.

    Ask participants to identify other related standards in SPHERE on the concept of
     ‘cultural acceptability’ of food.


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The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response: Nutrition Training
Modules. 2004


    Answer: Food aid planning standard 2: appropriateness and acceptability: The food
     items provided are appropriate and acceptable to recipients and can be used efficiently
     at the household level.(see page 158).

    Protein rich foods: Pulses (kidney or lima beans, lentils) or legumes such as groundnuts
     are good sources of protein. Dried fish or tinned meat is sometimes, but rarely provided
     in food rations. There are varying quantities of protein in different protein-rich foods.
    Ask participants to refer to the food composition tables and look at the g of protein per
     100g of beans or dried fish in comparison to other foods.

    Proteins are required to build new tissue, particularly during the rapid growth periods
     e.g. early childhood, pregnancy etc. Proteins from animal products contain all the
     essential amino acids (essential amino acids cannot be made by the body). In contrast,
     proteins of plant origin do not contain, on their own, sufficient quantities of essential
     amino acids. By combining different foods, adequate amounts of essential amino acids
     can be obtained without necessarily eating animal proteins.
    Fat rich foods: Fat provides at least 2-3 times more energy in comparison to other foods.
     Fat, usually provided in the form of vegetable oil in rations, is important for the body fat
     stores (which provides a fuel reserve for the body) and for the structure of the cells.
    Micronutrient rich foods: Vegetables and fruits are good sources of micronutrients but
     these are often not available to emergency-affected populations. Therefore, salt and oil
     and sometimes cereals are fortified, and blended food (specifically for population groups
     requiring micronutrient-rich foods such as younger children and older people) should be
     included in the ration. This will be discussed in more detail in a later session.

    Ask participants: What food contains all these food groups.
    Answer: (1) Breastmilk as a food group on its own.
    Refer to key indicator 1 in standard 2 (page 140)….”infants under six months are
     exclusively breastfed or, in exceptional cases, have access to an adequate amount of an
     appropriate breast milk substitute”. This is the only food group for infants less than six
     months! This will be discussed later in the session (in the case study – objective 3).
    Ask participants: What other food groups, in addition to these, could be included?
    (1) Water
    (2) Essential condiments such as salt
    So in summary, a range of foods refers to at least four main food groups. But how do
     we know whether or not the food ration is meeting “nutritional requirements”.

Slide 6


    What do we mean by nutritional requirements? To simplify things, let‟s take an example
     of a situation where a population is reliant on a food ration and examine this closer.
    To be nutritionally adequate, this ration must meet certain minimum requirements.
    Sphere specifies, as does WFP, WHO etc. that a ration must be adequate in minimum
     requirements in terms of (energy), fat, protein and micronutrients.
    Ask participants: What are the requirements are in terms of energy, protein and fat?
    Answer: Energy; 2,100kcal, Fat 17% (40g) and Protein 10-12%
    Where are these referred to in Sphere?
    Answer: GN 1, page 138. Note also in the GN 1 that these „are the requirements for food
     aid provision only if the population is entirely dependent on food aid to meet its
     nutritional requirements‟.




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The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response: Nutrition Training
Modules. 2004




         Exercise 1                                                                            15 mins
                                        RATION CALCULATION

          Read the short case study (handout 1a)
          Working in pairs, carry out the calculations and answer the questions (also need
           handout 1b)
          Go through one example on a flip chart first of all
           o    Eg one person receives 13.8 kg maize /mth  13.8/30 = 460g/d
           o    100g of maize provides 10g protein  460 g of maize provides 10x 4.6 = 46g protein.
           o    100g of maize provides 4g fat  460 g of maize provides 4x 4.6 = 18.4g fat (see handout 1b).

           o    when the totals have been calculated
           o    1g protein provides 4 kcal  62g x 4 = 248 kcal
           o    1g fat provides 9 kcal  44.4g x 9 = 399 kcal
           o    If 2099 kcals provides 100% of the kcals, then 248 kcals provides 248/2099 x 100 = 11.8%
           o    If 2099 kcals provides 100% of the kcals, then 399 kcals provides 399/2099 x 100 = 19%
          Answers (handout 1c) will be handed out at the end of the session.

      The exercise can be simplified in case of time constraints or if participants have difficulties with the
                                             nutrition calculations.



Slide 7


   In the practical exercise you calculated the energy, protein and fat content of a food aid
    ration. But what about the micronutrient content?
   Ask participants: How do you know whether the micronutrient requirements of the
    ration are being met?
   Answer: First one needs to know what the vitamin and mineral requirements are.

Slide 8


   Ask participants: What are important sources of micronutrients in an emergency
    ration?
   Answer: These include the foods shown on the slide.
   These sources are inadequate however, for populations who only have access to the food
    ration – even when blended foods are included in the ration. Therefore, in some
    circumstances it will be necessary to provide fruit or vegetables, supplements etc.
    Sometimes, an effective strategy is to provide additional basic food items in the ration
    which people can exchange for nutrient-rich foods such as vegetables or milk etc.
   HOWEVER, in many situations, populations may increase the range of foods by
    ‘accessing’ foods other than those made available in the general ration (eg through food
    security measures – see GN 2 – page 138). In these situations, the quality of diet may be
    better in comparison to those populations who are entirely reliant on a general ration.
    This will be discussed further in session 6 – micronutrient deficiency diseases.


Let us move on to the second objective:




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The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response: Nutrition Training
Modules. 2004


 Objective 2: To understand the factors which affect access to foods by emergency-
 affected populations

Slide 9


   Ask participants: What ways can people access food directly? And indirectly?
   Answer: see slide 9.


Slide 10


   The result of adverse impact (seen here from natural disasters) is less availability and
    accessibility of food
   Lowered accessibility (rise in food prices, travel distance, means of transport etc.)

Slide 11


   The very tactics of war are often designed to block people's normal ways of accessing
    food (Macrae and Zwi, 1994).
   Omission: failure by authorities to declare an emergency / deny access to victims of war.
   Commission - actions to undermine food production and hinder coping strategies.
   Provision - selective provision of food to government supporters, to those from whom
    support is sought or to lure populations into areas controlled by the military.
   Access to land and inputs may be limited. Families may be separated or the main bread-
    winners in the household may enter the army or be killed or wounded.

Slide 12


   Political/economic events refer both to national policies and international policies
   Damaging policies e.g. China, North Korea
   Food price hikes e.g. Madagascar in mid 1980s
   Sanctions e.g. Iraq
   Mismanagement of grain reserves e.g. Malawi and Zimbabwe

Slide 13



   When access to food in normal times becomes difficult because of an emergency, people
    will resort to coping strategies which allow them to access different sources of food. The
    next few slides illustrate some of these early coping strategies.
   In many places, wild foods are collected and consumed as a normal part of the diet. When
    times get difficult, different types of wild foods may be collected to supplement the diet.
    Sometimes these are potentially poisonous foods which require special treatment to
    prevent them from being poisonous

Slide 14




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The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response: Nutrition Training
Modules. 2004




        During the war in Bosnia, soldiers received their wages in cigarettes. In order to get food,
         they would sell/swap their cigarette wages for food. These soldiers are standing outside
         the market in Sarajevo.
        Ask participants: What other types of early coping strategies could be employed?
        Answer: Increased sale of firewood, increased remittances from abroad, sale of some
         food aid, sale of assets, reduction of number of meals, consuming less costly foods etc.

Slide 15




        Optional Exercise 2                                                                 15 mins
                         OPPORTUNITIES VERSUS CONSTRAINTS

    1.    Draw „a balance‟ on a flip-chart (see example below)
    2.    Split the participants into two groups.
    3.    Consider a situation (refugee camp or other defined target population) that most of the participants
          are familiar with, or alternatively a pre-prepared case-study that one or two of the participants have
          prepared.
    4.    The case-study should be ¾ to 1 page in length. It should describe (i) background to the emergency
          (ii) description of affected population and means of livelihood (iii) description of major relief
          interventions, particularly food aid. For example the case study prepared for Session 2: Analysis
          could be used again.
    5.    Ask one group to brainstorm on the „opportunities‟ that people have for accessing a range of foods
          in this situation
    6.    Ask the other group to identify the „constraints‟.
    7.    These issues should be written on cards and placed on either side of „the balance‟.




OPPORTUNITIES for accessing                                               CONSTRAINTS for accessing a
      a range of foods                                                          range of foods




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The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response: Nutrition Training
Modules. 2004


 Objective 3: To determine the support required for infant‟s and pregnant and lactating
 women.


   Ask participants: Which Sphere key indicators refer to infant feeding
   Answer: KI 1, 2, 3, 5 in General Nutrition Support Standard 2 (at-risk groups). (page
    140-141) and KI 7 in Correction of Malnutrition standard 2 (severe malnutrition) (page
    149).
   In addition, there are various guidance notes which refer to support for breastfeeding and
    safe use of infant formula. Participants have already read these as part of the pre-reading.
   Infant feeding in emergencies is a „hot‟ issue.
   Ask participants: Can you think of any examples where infant feeding may be a
    controversial issue and why?
   Answer: Areas of high HIV prevalence where there may be many orphans (e.g. countries
    of sub-Saharan Africa). In some cases, artificial feeding may have to be introduced, but
    tight controls must be maintained to ensure that formula is properly distributed and used.
    (GN 1 &2 pg 141-2).
   Areas where bottle feeding is considered the norm and there is a low prevalence of
    breastfeeding (e.g. the Balkans, Iraq). The issue here is to balance the promotion of
    breastfeeding against supplying infant formula to those who desperately need it and
    ensuring that infant formula does not get onto the market thus encouraging bottle feeding
    further.




         Exercise 3                                                                          30 mins
                       DISTRIBUTION OF INFANT FORMULA TO ROMA BABIES


This exercise aims to illustrate how standard 2: at risk groups can be addressed through using the example
of infant feeding among Roma IDPs in Serbia. The idea is not to discuss the advantages/disadvantages of
distributing infant formula but to look at ways in which the Sphere standards can be addressed.


    1. Divide the participants into 3 groups.
     Group 1 represents the British Aid Agency
     Group 2 represents the Roma
     Group 3 represents „Help to Women‟

     2.    Give out Handout 2
     3.    Each group should discuss the questions set.
     4.    One member of the group should present their answers to the whole group.




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The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response: Nutrition Training
Modules. 2004


Discussion:

Group 1: British Aid Agency (Desk Officer responsible for the „Help to Women‟ project)

Qu: Which key indicators could be addressed to support „Help to Women‟ to
improve infant feeding among the Roma IDP population?
Answer: In General nutrition support standard 2: KI 5 is the most important. They could also
refer to KI 1, 2, 3.

Qu: What action would you take to improve the competence of „Help to Women‟ with
respect to infant feeding?
Answer:
     Organise a supervisory visit to „Help to Women‟ by an international staff
      member with technical qualifications (e.g. a nutritionist) and previous
      emergency experience to provide advice (Key indicator 5).
     Fax out the Codex Alimentarius standards and the International Code of
      Marketing of Breastmilk Substitutes as well as relevant World Health
      Assembly resolutions (to be translated into Serbian) (GN1).
     Re-fax latest guidelines on infant feeding in emergencies and the relevant
      sections of the Sphere manual (translated into Serbian (GN 1)).
     Ensure that health staff working with the Roma were properly qualified to
      advise mothers on appropriate infant and young child feeding practices and
      offer training if available/appropriate.
     Ensure that budget lines and resources (eg utensils, fuel, water, specific
      food commodities) are available for households to prepare appropriate
      complementary foods for children under 24 mths.
     Discuss the adequacy of the food rations given – particularly for the
      lactating mothers (KI3, GN 4). Improve if necessary.

Group 2: Roma IDP woman living in the settlement with a new-born baby.

Qu: Which key indicators are particularly relevant to you?
Answer: In General nutrition support standard 2: KI 3 for themselves and KI 1 and 2 for their
children. Re: KI 1, I may wish to have a voluntary and confidential HIV test (GN 2).

Qu: What type of support would you want to help you feed your baby?
Answer: Support with breastfeeding if I was experiencing difficulties (eg to receive a
breastmilk substitute (KI 1), advice on the use of the formula, support with relactation if
needed (GN 1); additional nutritional support for myself in order that I have adequate milk
production (KI 3, GN 4).

Group 3: „Help to Women‟: staff member in „Help to Women‟.

Qu: What actions could be taken to build local capacity within your organisation with respect
to infant feeding?
Answer: To be sent the relevant guidelines on infant feeding during emergencies & the Code
(KI 5, GN1). To receive education and training on infant and child feeding practices (KI 5).

Qu: What actions could be taken to build local capacity outside your organisation with
respect to infant feeding?
Answer: a service providing voluntary and confidential HIV testing and counselling if this
does not already exist (GN 2); community based care (GN 8) promotion of baby friendly
hospitals in Serbia; support to Ministry of Health to develop and adopt a „Breastfeeding
Promotion Plan‟.



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The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response: Nutrition Training
Modules. 2004


Slide 16

        Re-cap on the objectives and check as to whether there are any outstanding
         questions.

                    For handouts refer to accompanying Word document
                       „S3 General nutrition support - Handouts.doc‟




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