Studies on the experiences of handling nutrition related issues in disaster situations point to the need for developing strategies and operational systems that can:

• Detect vulnerability to nutritional deficiencies and address the problem through development programs
• Prepare contingency plans and monitor early warning indicators
• Promote breast-feeding, and other low cost high nutrition food and ensure that relief efforts facilitate long-term rehabilitation.

Preparedness

During this phase the health workers must be educated about:

• Normal nutritional requirements of infants (Annexure 1) and young children (Annexure 2)
• Foods to be used in disaster situation and their food value (Annexure 3)
• The indicators of malnutrition
• The signs and symptoms related to nutritional deficiencies (Annexure 4)
• How to assess and calculate nutritional needs.
• The identification of vulnerable groups.

Knowledge acquired on all the above topics goes a long way in controlling malnutrition after a disaster has struck.

Normal nutritional requirements of infants and children
Annex1 details age- and sex-specific daily energy and protein requirements, which will help the health worker to calculate nutritional needs.

Foods their nutritional food value
Annex 2 details nutritional values of some of the commonly consumed foods, and the sources of vitamins and micronutrients found in foods.

The indicators of malnutrition

Measurement of weight can be compared with measured length/height and weight for length can be calculated and compared with the standard norms. As length is affected rather late in malnutrition, deficit in weight for height reflects recent (or current) malnutrition. Apart from weight, measurement of mid-arm circumference is also useful in detecting malnutrition. This is a measure of muscle mass, which is reduced in all types of protein-energy-malnutrition. The mid-arm circumference is fairly static (15-16 cm) from 1 to 5 years of age (the common age of malnutrition), and hence can be used for assessment of malnutrition even when the exact age of the child is not known (age-independent nutritional anthropometry). Measurements less than 12.6 cm suggests severe malnutrition. Direct measurement of mid-arm circumference can be replaced by a simple test called the 'Bangle test'. In this test a bangle with an internal diameter of 4.0 cm is used, (circumference and 12.6 cm). If a child's mid-arm circumference is below normal, the bangle can be easily pushed up the arm, and this implies that the child is malnourished. This test is particularly helpful for mass screening of pre-school children, and to select children in need of nutritional supplements.

Mid-arm circumference can be compared with the head circumference (which is not altered in malnutrition) and expressed as an index (Kanawati Index). An index of less than 0.3 can be taken as indicative of malnutrition and that of 0.25 or less as indicative of severe malnutrition. Even body length can be affected in long standing malnutrition.

Signs and Symptoms of Nutritional Deficiencies:

1. Protein-energy malnutrition (PEM)

The condition takes several forms:
Marasmus
Kwashiorkor
Marasmic kwashiorkor
(Details of these conditions are in Annexure 4)
2. Micronutrient deficiencies are among the main causes of long-lasting or permanent disability and most of them are associated with an increased risk of morbidity and mortality. Common deficiencies are that of iron, iodine, and vitamin A and those that are more specifically seen in emergencies, such as thiamine, vitamin B, and vitamin C deficiencies, and must be looked for systematically. The details of these conditions are available in Annexure 4.

Identifying vulnerable groups:
It is also essential to identify the most vulnerable groups in the population, which generally include:

• Pregnant and lactating women
• Infants and young children
• Children with disabilities
• Elderly

The nutritional needs of infants and young children can only be taken care of by promoting breast-feeding as per Annexure 1.

Calculating Nutritional Needs
Factors influencing intake of calories are:

• Age and sex composition of the population
• Mean adult heights and weights (men and women)
• Physical activity levels
• Environmental temperatures
• Malnutrition and ill-health
• Food security

About 100-110 calories/kg body-weight per day are required in the first year of life. By 1 year of age, the child should consume 1000 calories per day. Thereafter, the calorie requirements increase by 100 calories/day/year of age. Thus, a 6-year-old child should ingest 1500 calories per day. Around 10-15 percent of these calories should be obtained from proteins, 35 percent from fats and 55 percent from carbohydrates.

Rescue Phase

In the first 48 hours of the occurrence of a disaster, the community is engrossed and battling with life survival issues. Non-perishable food (like jaggery and "channa") can be stored in situations where the disaster was anticipated like in floods. The help from outside starts coming soon in the "Recovery phase".

Recovery Phase

One of the most urgently needed actions to prevent death and illness caused by malnutrition is to ensure adequate provision and intake of food.

The kind of food provided will make a significant difference in the management of Nutrition related issues of the affected population. It is recommended that fats/oils provide at least 15% of the total energy intake of adults (but 20% for women of reproductive age) and 30 - 40% for children up to 2 years of age. However, saturated fatty acids found in animal fats and some vegetable oils should not provide more than 10%. Fats and oils in human nutrition. Report of a joint FAO/WHO expert consultation. Rome, Food and Agriculture Organization of the United Nations, 1994 (FAO Food and Nutrition Paper, No. 57).

Nutritional emergencies may be characterized not only by protein-energy malnutrition, wasting, and growth failure but also by a variety of micronutrient (mineral and vitamin) deficiencies, some of which lead to blindness, disability, paralysis, and death. Prevention of these deficiencies should be a further consideration in determining the food requirements.

Chronic PEM has many short-term and long-term physical and mental effects, including growth retardation, lowered resistance to infections, and increased mortality rates in young children. In times of nutritional emergency it is primarily the more acute forms of PEM that have to be dealt with. These are characterized by a rapid loss of weight and may affect significantly larger numbers of older children, adolescents, and adults than usual.

For each case of severe PEM there may be 10 cases of moderate PEM and many more of under nutrition. Moderate malnutrition left untreated may rapidly become severe, and case-fatality rates in severe PEM (especially kwashiorkor) can be very high.

Death rates are high among children with untreated PEM, and the risk of dying increases with the severity of the condition. Even after treatment is started it is not uncommon for deaths to result from electrolyte imbalance, hypoglycaemia, hypothermia, or complicating infections.

Management of PEM

Infants and children suffering from severe forms of protein - energy malnutrition must be treated as soon as possible, otherwise they are very likely to die. The treatment should be on the lines described in Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva, World Health Organization, 1999 (Annexure 5).

The most effective way to prevent micronutrient deficiency is to provide a diet that is diversified and includes fresh foods. For practical and logistic reasons, however, emergency food supplies usually consist of three or four basic items that are rarely changed and do not normally include fresh foods. A population that has to depend entirely on such a limited range of food items for more than 2 months runs the risk of developing nutritional deficiencies, especially scurvy (from lack of vitamin C) and pellagra (from lack of niacin).

There are several approaches to preventing onset of micronutrient deficiencies in emergency situations affecting large populations:

• Varying the composition of the food basket, so that it contains more micronutrient-rich foods such as pulses (eg, dried beans), groundnuts, fresh fruits and vegetables. Local production of fruits and vegetables in home gardens should be encouraged wherever agricultural conditions permit.
• Including micronutrient-fortified foods in the ration. The use of low cost high micronutrient food like drum stick leaves should be encouraged.
• Prevention of iodine deficiency is usually achieved through the use of iodized salt.

Rehabilitation Phase

Essential interventions include the following:

• Education and information;
• Provision of necessary material resources;
• Establishment of communications and support networks;
• Coordination with related services;
• Development of special programs for breast-feeding, rehabilitation, orphans.