Nutrition and health are inextricably linked, so the multi-factorial influences on nutrition ultimately affect health. Malnutrition is characterised by dietary inadequacy sufficient to compromise resistance to disease, and is commonly associated with complex emergencies. It normally, but not exclusively, presents as under nutrition, and is a leading cause of mortality. It may be “primary,” due to lack of food, or “secondary,” associated with diseases that affect ability to eat, digest, and absorb food, and to metabolise nutrients (Golden, 1996).

The disease/nutrition cycle, which affects infants and young children in particular, is discussed by Bellamy (1997). Poor nutritional status leads to lowered immunity and thus to increased morbidity from infectious diseases such as measles, malaria, or tuberculosis. If further deterioration in nutritional status, through inability to eat and/or malabsorption, is not treated by nutritional intervention and medical care, this cycle continues ultimately leading to death. In complex emergencies an immediate concern is to ascertain the level of malnutrition in the population. As nutritional status in children under 5 years responds rapidly to acute food shortages, high levels of malnutrition in this age group usually indicate acute malnutrition in the overall population.

Affected children present with marasmus (severe wasting), kwashiorkor (where oedema is a key feature), or a combination (marasmic kwashiorkor). As well as “protein energy malnutrition” (PEM), there may be micronutrient deficiencies in the population. These are associated with increased morbidity and mortality, but can usually be treated easily. Vitamin A deficiency is associated with night blindness, ocular damage, and lowered immunity, especially to measles. Iron deficiency anaemia can lead to cognitive impairment in children and, in pregnant women, risk of delivering low birth weight infants. In many developing countries lack of iodine in the soil leads to goitre, stillbirth, miscarriage, and brain damage in children. The body requires adequate stores of micronutrients to prevent deficiency in times of crises such as food shortages or trauma. This is best achieved by providing foods that are rich in nutrients or fortified food. Deficiencies can be also treated using supplements of the micronutrient in the appropriate amount (WHO, 2000).

Guidelines for the identification and management of malnutrition have been published by various international and non-governmental organisations. These include Médicins Sans Frontières (1995), the World Health Organization (WHO, 1999 and WHO, 2000), and UNHCR/UNICEF/WFP/WHO (2003). In addition, food security, nutrition, and food aid are included in the minimum standards set by The Sphere Project (The Sphere Project, 2004). Some of these guidelines are described below as this section addresses the identification of food insecurity and malnutrition, nutritional interventions, community-based therapeutic care, and food security.

Identification of Food Insecurity and Malnutrition

Identification of food insecurity and malnutrition normally commences with a rapid assessment of the general situation (MSF, 1997). Interviews and focus group discussions are carried out with members of the general population, as well as community leaders. This should be followed up by observations, for example of food items people are purchasing or collecting from food relief centres. Together with other local information, such as estimated population size, possible increases in illness and death, and information about water, sanitation, and food crops, it may be possible to gauge if there needs to be a further investigation of the nutritional situation.

Overall nutritional status of a population is normally estimated by surveying (using cluster sampling) children aged 6 to 59 months. Anthropometric measurements and demographic information are obtained. Oedema, especially around the ankles, is an important clinical indicator. The index “weight for height” (WFH) is most commonly used to detect acute malnutrition (wasting) in surveys. It compares weight with the median weight of a sample of children of the same height. To date, United States National Centre for Health Statistics/Centers for Disease Control and Prevention reference tables adopted by the World Health Organization (WHO, 1987) have been used, but recently launched WHO Child Growth Standards provide a new international standard (WHO, 2006). Where large numbers of children have to be screened, mid-upper arm circumference (MUAC) can be used to identify wasting. MUAC measurements <11.0 cm are indicative of severe acute malnutrition and are of value in predicting mortality (The Sphere Project, 2004). WFH less than 70% of the median and/or oedema indicates severe acute malnutrition.

Alternatively Z scores may be used, where the WFH is expressed as the number of standard deviations below the median. Thus a Z score of < -3 and/or oedema indicates severe acute malnutrition (Young, Borrel, Holland, & Salama, 2004). Moderate acute malnutrition is indicated if the WFH is between 70% and 80% of the median, or between -3 and -2 Z scores. The term “global acute malnutrition” (GAM) refers to the total number of children with severe acute malnutrition plus those with moderate acute malnutrition, that is all those with WFH < 80% of median, or < -2 Z scores. WHO has set emergency thresholds, above which nutritional intervention is indicated for the population. A critical situation is reached when over 15% of the children surveyed have global acute malnutrition.

Trends in mortality are important in the interpretation of nutrition data. Crude mortality rate (CMR) is the number of deaths in the population, for example per 1,000 per month, or per 10,000 per day. A doubling of CMR above the baseline indicate a public health emergency (The Sphere Project, 2004).

Delayed growth in both height and weight, “stunting,” can be found in situations of chronic malnutrition. In this case, weight for age (WFA) may be a preferred indicator. MUAC has also been used to identify malnourished adolescents, and adults including pregnant women, in need of admission to feeding programmes. A MUAC of <20.7cm indicates severe risk (The Sphere Project, 2004).

Nutritional Interventions

Nutritional Interventions fall into two main categories: general feeding programmes and selective feeding programmes (WHO, 2000). General feeding programmes, designed to meet the needs of the overall population, should adhere to the minimum standards set by The Sphere Project (2004). They should provide for an average daily energy requirement of 2100 kcals, where the ration is the sole food source. More will be required where malnutrition is present, heavy physical work is being carried out, or at low atmospheric temperatures. Supplies are provided preferably as dry food rations, the basic commodities being cereals, pulses, and vegetable oil, to be prepared at home. As a short term measure, rations may be provided as cooked meals. Factors, such as cultural acceptability of the food ration and the choice of suitable foods, must be considered. There are many challenges in ensuring fair distribution of food aid. Food aid targeting should help identify the most vulnerable areas and households. This requires the use of various indicators, such as health status and food security, in addition to nutritional status (Young, Borrel, Holland, & Salama, 2004).

Selective feeding programmes aim to ensure that individuals in specific vulnerable groups receive adequate nourishment. There are two types: supplementary feeding programmes (SFP) and therapeutic feeding programmes (TFP). The former are concerned with groups such as pregnant and lactating mothers, and moderately malnourished infants and children. They are designed as a “safety net” to prevent further deterioration of nutritional status and reduce mortality. As far as infants are concerned the aim is to encourage breast feeding, if possible. For older children and adults, in addition to the general food ration, the SFP supplies an extra 1000-1200 kcal/ person/day (dry rations), or 500-700 kcal/person/day (cooked meal).

Therapeutic feeding programmes target the severely malnourished, particularly infants and young children. These patients are critically ill on admission with high rates of mortality in the first few days. The priority in the acute phase (days 1-2) is treating dehydration, infections, hypoglycaemia, fluid and electrolyte imbalance, and hypothermia. If the infant is being breastfed this should be continued. A starter formula, such as F-75, which is low in protein and sodium and supplying 75 kcal/100ml, should be given in small amounts, initially every 2-3 hours, if necessary through a naso-gastric tube. Once the child’s appetite has returned (usually after 2-7 days), several weeks of rehabilitation follow. F-75 is gradually replaced with F-100 (100 kcal/100 ml) and micronutrient supplements are given, for example vitamin A. The child’s need for social contact, stimulation, and play must not be forgotten. When possible children should be discharged to the care of their own families with weekly monitoring at the feeding centre (WHO, 2000).

Community-Based Therapeutic Care

New methods of therapeutic feeding have led to an increase in community-based therapeutic care (CTC). Ready-to-use therapeutic foods (RUTF), available as energy-dense pastes or biscuits, are resistant to bacterial growth, unlike milk-based liquid products. This has made it easier to care for moderately malnourished children at home (Briend et al., 2005) thus reducing the numbers of children in feeding centres. According to Young, Borrel, Holland, & Salama (2004) this leads to increased access to treatment and possible reduction in cross-infection.

RUTF can also be used in non-emergency situations (Briend et al., 2005). By preventing moderate malnutrition from becoming severe it could play an important role in disaster preparedness. So far most of these foods are imported into the affected area, but there are trials of production of RUTF pastes using locally available grains and legumes, as in Malawi (Collins et al., 2005). Encouraging local initiatives in RUTF production, as well as involving community expertise in CTC implementation, afford opportunities to reduce vulnerability, build community capacity, and increase disaster preparedness.

Addressing Food Security

Nutritional interventions should not result in the community becoming dependent on outside help indefinitely, so rehabilitation is an important component in any programme. Normal food production needs to resume as early as possible. Advice may be required from experts in agriculture and food production, for example with a view to using sustainable methods of food production, or for specific advice to counter soil mineral depletion. The Sphere Project outlines several key indicators designed to ensure that primary food production is protected and supported. It is important that new technologies are only introduced if the “implications for local production systems, cultural practices and environment are understood and accepted by food producers.” In addition, inputs and services introduced must not “exacerbate vulnerability” for example by “increasing competition for scarce natural resources or by damaging existing social networks” (The Sphere Project, 2004, p. 124).

Where it has been essential for the affected population to move to a new location, land and resources (tools and seeds) to re-establish food production, and access to markets are necessary. Any host population already living in the new locality must be informed and involved in decision making, and an increase in numbers living in the area may mean that extra services and facilities have to be provided (WHO, 2000).

Projects involving cash or food in exchange for work can help the community, not only financially and nutritionally, but by increasing self-reliance. They can lead to infrastructure improvements, such as the rebuilding of roads and bridges, improvements in irrigation and drainage, tree planting, and building health posts and schools. Disadvantages may include a possible negative impact on the health of children whose mothers are enrolled in food for work schemes (WHO, 2000).

Although it may fit more readily into the fields of agriculture, food production, and economic or social policy, rather than health care or nursing, addressing food security is still relevant here. It represents ways in which communities can address their own vulnerability and build capacity for nutritional preparedness as they are enabled to mobilise their own resources.

The concepts of vulnerability, capacity, and disaster preparedness will be illustrated in the following section. This will be particularly related to nutrition preparedness and reference will be made to malnutrition and chronic food insecurity in the African country of Kenya