Caroline Wilkinson

The Double Burden of Obesity and Malnutrition in a Protracted Emergency Setting: A Cross-Sectional Study of Western Sahara Refugees

Surveying women and children from refugee camps in Algeria, Carlos Grijalva-Eternod and colleagues find high rates of obesity among women as well as many undernourished children, and that almost a quarter of households are affected by both undernutrition and obesity.

Program Experience with Micronutrient Powders and Current Evidence

The efficacy of micronutrient powders (MNP) in the treatment of anemia in moderately anemic children aged 6-24 mo has been clearly demonstrated. The evidence of the effectiveness of MNP in large-scale programs, however, is scarce. This article describes the program experience and findings of large-scale MNP distribution in refugee camps and in an emergency context in Bangladesh, Nepal, and Kenya. The MNP contained 15-16 micronutrients as per the WHO/World Food Programme/UNICEF joint statement, whereas the iron content was reduced to 2.5 mg from NaFeEDTA in a malaria-endemic area in Kenya. Hundreds of thousands of children aged 6-59 mo and pregnant and lactating women were targeted to consume MNP either daily or every other day over an extended period of time. Extensive social marketing campaigns were undertaken to promote regular use of the product. A number of studies were embedded in the programs to assess the impact of MNP on the nutritional status of target beneficiaries. Some improvements in anemia prevalence estimates were observed in particular subgroups, but other results did not show significant improvements. A significant decrease in the prevalence of stunting was observed in Nepal and Kenya but not in Bangladesh. Diarrhea episodes decreased significantly among children receiving MNP in Nepal. A key challenge is to ensure high MNP acceptance and adherence among beneficiaries. Investigation of non-nutritional causes of anemia is warranted in settings with high compliance but no improvement in hemoglobin status. Further investigation into the most appropriate manner to use MNP in malaria endemic settings is warranted.

Effects of Multimicronutrient Home Fortification on Anemia and Growth in Bhutanese Refugee Children

Background Anemia remains a significant public health problem in refugee settings. Home fortification with micronutrient powders has been proposed as a feasible option to alleviate micronutrient deficiencies; its efficacy in reducing anemia in children aged 6 to 24 months has been demonstrated in several trials. Objective To evaluate the effectiveness of a large-scale micronutrient powder distribution program in reducing anemia prevalence and promoting growth in refugee children aged 6 to 59 months. Methods Four representative cross-sectional surveys were conducted 13 months before and 7, 14, and 26 months after initiation of the supplementation program. Data collected on children aged 6 to 59 months included hemoglobin concentration, anthropometric indicators, morbidity, feeding practices, and information on the micronutrient distribution program. The study had a pre—post design with no control group. Results The overall prevalence of anemia in children did not change significantly between baseline (43.3%) and endpoint (40.2%). The prevalence of moderate anemia decreased over the same period from 18.9% to 14.4% (p < .05). The levels of severe anemia were negligible (< 1%) in all surveys. The prevalence of stunting decreased significantly from 39.2% at baseline to 23.4% at endpoint (p < .001), a relative decrease of 40%. Reported coverage, use, and acceptance of micronutrient supplements remained consistently high throughout the study. Conclusions In the absence of a control group, changes in key outcomes should be interpreted with caution. The minor effect on hemoglobin status requires further investigation of underlying causes of anemia in this population. The large positive effect on linear growth may be a significant benefit of supplementation if confirmed by future studies.

Child Acute Malnutrition and Mortality in Populations Affected by Displacement in the Horn of Africa, 1997–2009

Drought and conflict in the Horn of Africa are causing population displacement, increasing risks of child mortality and malnutrition. Humanitarian agencies are trying to mitigate the impact, with limited resources. Data from previous years may help guide decisions. Trends in different populations affected by displacement (1997–2009) were analyzed to investigate: (1) how elevated malnutrition and mortality were among displaced compared to host populations; (2) whether the mortality/malnutrition relation changed through time; and (3) how useful is malnutrition in identifying high mortality situations. Under-five mortality rates (usually from 90-day recall, as deaths/10,000/day: U5MR) and global acute malnutrition (wasting prevalences, < −2SDs of references plus edema: GAM) were extracted from reports of 1,175 surveys carried out between 1997–2009 in the Horn of Africa; these outcome indicators were analyzed by livelihood (pastoral, agricultural) and by displacement status (refugee/internally displaced, local resident/host population, mixed); associations between these indicators were examined, stratifying by status. Patterns of GAM and U5MR plotted over time by country and livelihood clarified trends and showed substantial correspondence. Over the period GAM was steady but U5MR generally fell by nearly half. Average U5MR was similar overall between displaced and local residents. GAM was double on average for pastoralists compared with agriculturalists (17% vs. 8%), but was not different between displaced and local populations. Agricultural populations showed increased U5MR when displaced, in contrast to pastoralist. U5MR rose sharply with increasing GAM, at different GAM thresholds depending on livelihood. Higher GAM cut-points for pastoralists than agriculturalists would better predict elevated U5MR (1/10,000/day) or emergency levels (2/10,000/day) in the Horn of Africa; cut-points of 20–25% GAM in pastoral populations and 10–15% GAM in agriculturalists are suggested. The GAM cut-points in current use do not vary by livelihood, and this needs to be changed, tailoring cut points to livelihood groups, to better identify priorities for intervention. This could help to prioritize limited resources in the current situation of food insecurity and save lives.

Research priorities to improve the management of acute malnutrition in infants aged less than six months (MAMI).

By engaging expert opinion, Marko Kerac and colleagues set research priorities for the management of acute malnutrition in infants.

Assessing the impact of micronutrient intervention programs implemented under special circumstances--meeting report.

Introduction and Objective The World Food Programme and the Office of the United Nations High Commissioner for Refugees organized a meeting of experts to discuss evaluation of micronutrient interventions under special circumstances, such as emergency and refugee situations. Results Multimicronutrient interventions for groups with higher needs may include home fortification products for young children or supplements for pregnant and lactating women. The choice of preparation should be guided by target group needs, evidence of efficacy of a product or its compounds, acceptability, and cost-effectiveness. Different designs can be used to assess whether an intervention has the desired impact. First, program implementation and adherence must be ascertained. Then, impact on micronutrient status can be assessed, but design options are often limited by logistic challenges, available budget, security issues, and ethical and practical issues regarding nonintervention or placebo groups. Under these conditions, a plausibility design using pre- and postintervention cross-sectional surveys, a prospective cohort study, or a step-wedge design, which enrolls groups as they start receiving the intervention, should be considered. Post hoc comparison of groups with different adherence levels may also be useful. Hemoglobin is often selected as an impact indicator because it is easily measured and tends to respond to change in micronutrient status, especially iron. However, it is not a very specific indicator of micronutrient status, because it is also influenced by inflammation, parasitic infestation, physiological status (age, pregnancy), altitude, and disorders such as thalassemia and sickle cell disease. Conclusion Given the constraints described above, replicability of impact in different contexts is key to the validation of micronutrient interventions.

United Nations High Commissioner for Refugees Feeding Program Performance in Kenya and Tanzania: A Retrospective Analysis of Routine Health Information System Data

Background The United Nations High Commissioner for Refugees (UNHCR) Health Information System is a primary source of routine nutrition program data and provides a comprehensive assessment of UNHCR selective feeding programs in more than 90 refugee camps in 18 countries worldwide. Objective To evaluate the coverage and effectiveness of UNHCR supplementary and therapeutic feeding programs for malnourished children under 5 years of age in Kenya and Tanzania refugee camps. Methods Analysis of Kenya and Tanzania refugee camp population, growth monitoring, and nutrition program data from the UNHCR Health Information System. Results UNHCR-supported implementing partners in Kenya and Tanzania admitted nearly 45,000 malnourished refugee children in selective feeding programs between January 2006 and May 2009. Average recovery rates of 77.1% and 84.6% in the therapeutic and supplementary programs, respectively, mortality rates of less than 1%, and average readmission below 5% suggest that feeding programs had a beneficial effect on enrolled children. Conclusions Increasing admission and enrollment in supplementary feeding programs was successful in preventing cases of severe malnutrition in some camps. Further attention to these camps would be likely to yield sizeable benefits in terms of absolute reductions in malnutrition prevalence and mortality rates.

Performance of UNHCR nutrition programs in post-emergency refugee camps

BackgroundThe United Nations High Commissioner for Refugees (UNHCR) launched a health information system (HIS) in 2005 to enhance quality and consistency of routine health information available in post-emergency refugee camps. This paper reviews nutrition indicators and examines their application for monitoring and evaluating the performance of UNHCR nutrition programs in more than 90 refugee camps in 18 countries.MethodsThe HIS is a primary source of feeding program data which is collected using standardized case definitions and reporting formats across refugee camps in multiple settings. Data was aggregated across time periods and within and across countries for analysis. Basic descriptive statistics were then compared to UNHCR program performance standards.ResultsCamp populations covered by the HIS ranged from 192,000 to 219,000 between 2007 and mid-2009; 87% of under five children covered by the HIS were in Africa and 13% in Asia. Average moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) rates reported in 74 of 81 camps for the 2007-2009 time periods were 7.0% and 1.6%, respectively. The supplementary feeding program (SFP) admission rate was 151/1000/yr with 93% of SFP admissions occurring in Africa. SFP performance consistently exceeded all UNHCR standards with the exception of length of enrollment. Average length of SFP enrollment was 12 weeks in Africa and 22 weeks in Asia as compared to the UNHCR standard of < 8 weeks. The therapeutic feeding program (TFP) admission was 22/1000/yr with 95% of TFP admissions in Africa. TFP performance met UNHCR standards with the exception of daily weight gain.ConclusionsInclusion of children identified as moderately and severely wasted in the HIS would allow UNHCR to better track and respond to changes in nutrition status. Improved growth monitoring coverage or active malnutrition surveillance would increase UNHCRs ability to identify and treat cases of acute malnutrition. Expansion of nutrition reporting to address the transition to community-based therapeutic care is essential for adequate performance monitoring in the future. In terms of program priorities, a focus on camps and countries with large refugee populations and high feeding program enrollment rates would have the greatest impact in terms of absolute reductions in the incidence and prevalence of malnutrition.

Operational Guidance on the Use of Special Nutritional Products in Refugee Populations

Background Stunting, acute malnutrition, and micronutrient malnutrition are persistent public health problems in refugee populations worldwide. In recent years there has been an increase in the availability and use of special nutritional products in emergency and development contexts to help address inadequate nutrient intakes from low-diversity diets. The availability of new special nutritional products, and the decision by the United Nations High Commissioner for Refugees (UNHCR) to use blanket supplementary feeding programs to prevent stunting and anemia, raised new challenges for designing, monitoring, and evaluating nutritional programs. Objective To develop an Operational Guidance on the use of special nutritional products for the prevention of micronutrient malnutrition, stunting, and acute malnutrition in refugee populations. Methods A literature review and a series of consultations with technical experts, operational organizations, and field staff were performed over a period of 2 years. The Operational Guidance was finalized and released in December 2011. Results The Operational Guidance describes six stages for defining nutritional problems and identifying possible solutions; assessing and managing risks; testing acceptability and adherence, program design and implementation; and monitoring and evaluation. Key performance indicators are defined and a working nomenclature for new special nutritional products is described. Conclusions The UNHCR Operational Guidance has filled an important gap in helping field staff deal with the opportunities and challenges of preventing under-nutrition through the use of new products in blanket supplementary feeding programs. The need for further integration of guidance on selective feeding programs is discussed.

Acute Malnutrition and Anemia Among Rohingya Children in Kutupalong Camp, Bangladesh

Acute Malnutrition and Anemia Among Rohingya Children in Kutupalong Camp, Bangladesh Nearly 700 000 ethnic minority Rohingya people have crossed the border between Myanmar and Bangladesh after violence in Rakhine State, which escalated in August 2017, joining an estimated 200 000 who fled in earlier waves of displacement since the 1990s. The population of 2 preexisting refugee camps and surrounding makeshift settlements have more than doubled with the new influx. Concerns have been raised about the nutritional status of the Rohingya children.