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Nutrition Module Session 1

By Ronald Harris,2014-05-20 16:38
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This graph is based on health and nutrition survey data from Ajiep insuch as therapeutic feeding for the treatment of severe acute malnutrition.

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

    Nutrition Module: Session 1

    Introduction

Overall Objective

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

Specific Objectives

    ? To become familiar with the structure of the chapter on food security, nutrition and food aid in Sphere

    ? To introduce food-related human rights.

    ? To review some basic concepts and definitions

    ? To understand the importance of nutrition in emergencies

Main messages:

    ? There are a number of Human Rights Articles or Conventions which refer to the right to food. This is

    one of the bases on which the Sphere Minimum Standards are written.

    ? The chapter is broadly divided into four sections: (1) Food Assessment and Analysis Standards; (2)

    Food Security Standards; (3) Nutrition Standards and (4) Food Aid Standards.

    ? Each section has associated minimum standards, indicators and guidance notes.

    ? A standard is a universal benchmark that is used to plan programmes.

    ? An indicator measures the impact of the programmes or the process.

    ? The standards and indicators in Sphere are based on agencies‟ experience of providing humanitarian

    assistance.

    ? Malnutrition, and related mortality, can be, and is frequently, the most serious public health problem

    for disaster affected populations.

    ? Malnutrition occurs as a result of inadequate food intake and/or disease (immediate causes) which are

    influenced by a range of factors relating to food, care and health (underlying causes).

    ? Addressing malnutrition frequently requires prioritising between, and combining, a range of different

    response options.

Handouts:

    ? Handout 1: Rights to food

    ? Handout 2: Quiz

Resources Required for Session 1

    ? Flip chart and a variety of coloured marker pens

    ? Marker pens (1 for each participant)

    ? 3 different coloured card paper (for Exercise 1)

    ? Handouts

Timeframe

     Slides and discussion Exercises

    Objective 1 10 mins Ex 1: 15 mins

    Objective 2 15 mins Objective 3 20 mins Ex 2: 20 mins

    Objective 4 10 mins Optional Ex 3: 15 mins

     1

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

Overall Objective: To gain a familiarity with and understanding of the standard, key indicators

    and guidance notes.

Slide 1

    For slides please refer to S1 Intro Visuals.ppt

Slide 2

    For slides please refer to S1 Intro Visuals.ppt

? Introduce the objectives of the session.

Objective 1: To become familiar with the structure of the chapter on food security, nutrition and

    food aid in Sphere

Slide 3

    For slides please refer to S1 Intro Visuals.ppt

? The chapter on food security, nutrition and food aid is divided into four sections.

    ? This is a substantial change from the previous handbook.

     - Food security is a new section

     - Food aid and nutrition have been combined in one chapter

    ? This training is only dealing with the assessment and analysis section (1 page 115) and the nutrition

    section (page 135 onwards).

Slide 4

    For slides please refer to S1 Intro Visuals.ppt

? This slide visually describes the four sections of the chapter (see page 106)

    ? The food aid section covers aspects of both food security and nutrition. ? Ask one participant to give a definition of malnutrition. Then ask all participants to look this up

    on page 108 to compare: ‘malnutrition encompasses a range of conditions, including acute

    malnutrition, chronic malnutrition and micronutrient deficiencies. Acute malnutrition refers to

    wasting (thinness) and/or nutritional oedema, while chronic malnutrition refers to stunting

    (shortness). Stunting and wasting are two forms of growth failure. In this chapter we refer only to

    acute malnutrition and micronutrient deficiency’. 2

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

     Exercise 1 15 mins

     FINDING SOMETHING IN COMMON

     The aim of the exercise is to help participants recognise the differences between standards,

     indicators and guidance notes.

     2. In a hat, put sets of selected standards, indicators and guidance notes from the nutrition chapter on each individual piece of paper write either a standard, or an indicator or a guidance note. Each standard should have a matching indicator and guidance note. 3. Each participant randomly takes a piece of paper from the hat. 4. Each person finds his/her standard/indicator/guidance note in the Sphere handbook. 5. Then everyone moves to the centre of the room or a place where there is space to move around. 6. Participants are instructed to remain silent, and are told that they can read each other‟s papers and refer to the Sphere handbook, but that they must not speak. 7. Participants from a similar group (e.g. those with a standard, an indicator under that standard and a guidance note which refers to that standard, are defined as one group) must try to find each other. 8. The winners are those who are able to form the first complete group. 9. When the exercise is complete, ask the participants to read out their standard and respective indicator & guidance note.

Slide 5

    For slides please refer to S1 Intro Visuals.ppt

? So as a recap - each section has three common elements: Minimum standards, Indicators and

    Guidance Notes. In addition there are appendices at the end of the chapter.

Slide 6

    For slides please refer to S1 Intro Visuals.ppt

     3 ? Finally, there are a number of issues to highlight about how Sphere was developed.

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

? The chapter does not aim to replace existing guidelines but aims to make reference to existing

    universally accepted protocols and guidelines where these are applicable.

? Ask participants to name examples of specific guidelines that are applicable to the nutrition

    section.

    ? Answer: For example, WHO Management of Severe Malnutrition, MSF Nutrition Guidelines, ACF

    Assessment and Treatment of Malnutrition in Emergency Situations..

    ? Obviously, as the referenced guidelines become outdated and are revised, so Sphere will also aim to

    reflect new knowledge and learning in future revisions of the chapters/handbook, by including more

    recent publications etc.

    ? Sphere does not aim to describe HOW programmes should be undertaken (guidelines are better at

    this). But emphasis is given to “process” e.g. assessment and analysis, resources and capacity,

    participation - relating to the principle of dignity and rights.

    ? Reference to other sector‟s technical standards is made where relevant. This reinforces the fact that

    the nutrition section is closely linked to other sectors i.e. integrated approach endorsed. In fact,

    many of the standards in nutrition can only be achieved if other sectors standards are addressed.

? Ask one participant to read out the examples given on page 109: ‘for example, requirements for

    cooking utensils, fuel and water for food consumption, and for the maintenance of public health, are

    addressed in the standards for Water, Sanitation and Hygiene Promotion, Health Services and

    Shelter, Settlement and Non-Food Items.’

Slide 7

    For slides please refer to S1 Intro Visuals.ppt

? As mentioned before, in this training we are only going to cover the assessment and analysis standard

    2: nutrition and the nutrition section of the chapter.

    ? The training is not a technical training. It is assumed that participants already have some knowledge

    and experience in nutrition programmes. However, some essential technical issues in relation to

    broader concepts that relate to Sphere minimum standards will be included.

? Explain to the participants that it will be impossible to cover the wide array of technical issues that

    Sphere raises. Therefore, some technical questions and discussions may be deferred until the

    breaks.

    ? The training is designed to be participatory and a wide variety of learning approaches will be used.

    These will include quizzes, discussions, case studies, practical exercises, etc.

Objective 2: To introduce food-related human rights

Slide 8

    For slides please refer to S1 Intro Visuals.ppt

     4

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

? Distribute handout 1 to each participant.

    ? Sphere is based on international human rights and humanitarian and refugee law.

    ? This includes the right to food and freedom from hunger.

    ? There are many Declarations and Resolutions, the majority linked to the United Nations that provide

    further adoption of the human right to food, but there are only three that are ratified under

    International Law which explicitly address the right to food. These are:

    o the Universal Declaration of Human Rights

    o the International Convenant on Economic and Social and Cultural Rights

    o the Convention of the Rights of the Child

? Ask one participant to read out the passage taken from the Convention of the Rights of the Child

    (ie: that „State Parties‟ shall take appropriate measures to „combat disease and

    malnutrition….through the provision of adequate nutritious foods, clean drinking water and health

    care‟ and „ensure that all segments of society, in particular parents and children, are informed, have

    access to education and are supported in the use of basic knowledge of child health and nutrition

    [and] the advantages of breastfeeding‟.) Note that this is the only Human Rights convention which

    specifies nutritional needs. All Governments in the world have signed up to this except for USA and

    Somalia!

? Note that while the Food Security and Nutrition standards are a practical expression of the right to

    food, the Food Aid standards are more operationally focused (see page 104).

Ask participants: During an emergency, in what ways are these rights likely to be infringed? (ask

    participants to provide specific examples where possible)

Objective 3: To review some basic concepts and definitions

Slide 9

    For slides please refer to S1 Intro Visuals.ppt

     Exercise 2 20 mins

     QUIZ: BASIC CONCEPTS AND DEFINITIONS 1. Ask the participants to do the quiz either alone or in pairs. Each question is either a multiple choice or a TRUE/FALSE question. Take 10 minutes. 2. Go over the answers and relate each question to the Sphere handbook (providing the page numbers for reference)

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

    Answers to Quiz

1. The term „global acute malnutrition‟ (or „total malnutrition‟) includes all the following children:

    ? children whose weight for height z score falls between -2 and 3

    ? children who are < 60% weight for height

    ? children with bilateral oedema.

     TRUE or FALSE Answer: TRUE page 183

2. The World Food Summit Plan (1996) of Action definition for Food Security is defined as (circle

    the correct one):

    (a) sufficient food stocks for the whole household for the year

    (b) when people, at all times, have physical and economic access to sufficient, safe and nutritious

    food for a healthy and active life

    (c) when people‟s livelihoods are not threatened and their food production is sufficient for food

    and non-food needs at all times

    (d) the definition is irrelevant since it is irrelevant to disaster situations.

    Answer: (b) page 108

3. All the underlying causes of malnutrition are (circle the correct one):

     (a) disease, poor water sources and inadequate household food security

     (b) markets, human resources and infrastructure

    (c) inadequate household food security, inadequate maternal and child care and insufficient

    services and unhealthy environment

     (d) independent of the basic causes.

     Answer: (c) - page 136

4. The agreed and tested definition of malnutrition in adolescents is (circle the correct one):

    (a) Defined by weight (in pounds) divided by height squared (in feet)

    (b) Weight for Height < - 2 z-scores

    (c) A measure of stunting.

    (d) There is no tested and agreed definition of malnutrition in adolescents.

    Answer: (d) page 185

5. The average energy requirement referred to in Sphere (i.e. 2,100 Kcal per person per day), should

    be provided to all populations at risk regardless of their environment.

     TRUE OR FALSE Answer: FALSE page 138

6. The four most commonly observed micronutrient deficiency diseases which result from

    inadequate access to micronutrients in food aid-dependent populations and which are usually

    avoidable in a disaster situation are:

    a) Scurvy, pellagra, beri-beri and riboflavin

    b) Goitre, scurvy, pellagra, beri-beri

    c) Xerophthlamia, Goitre, scurvy, pellagra

    Answer: (a) - page 140

7. In an emergency breast milk substitutes should never be delivered whatever the circumstances.

     TRUE or FALSE Answer: FALSE page 141

8. Milled cereal that is distributed in a disaster response (circle the correct one):

    (a) is always fortified

    (b) requires less cooking time and less fuel compared to whole grain 6

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

    (c) has a longer life-span compared to whole grain

    (d) is always cheaper than whole grain.

    Answer: (b) page 164

     9. Individuals who are tested or suspected to be HIV-positive should be excluded from therapeutic

    feeding programmes in emergencies.

     TRUE or FALSE Answer: FALSE page 151

    10. The only acceptable method for the treatment of severe acute malnutrition is through 24-hour in-

    patient care.

     TRUE or FALSE Answer: FALSE page 145

Objective 4: To understand the importance of nutrition in emergencies.

Slide 10

    For slides please refer to S1 Intro Visuals.ppt

? The occurrence of natural and complex emergencies has risen dramatically in recent decades with a

    parallel growth in the numbers of stricken communities, refugees, and internally displaced persons.

    ? All major emergencies, by definition, threaten human life and public health. They often result in food

    shortages, interrupt or destroy communities‟ capacity to access food, impair or jeopardise the

    nutritional status of a community, and cause excess mortality in all age groups. Malnutrition is

    therefore a key public health concern in disaster-affected populations.

Slide 11

    For slides please refer to S1 Intro Visuals.ppt

? It is well recognised that levels of malnutrition frequently increase during a disaster. The recent crisis

    in Angola is an example of this characteristic trend.

    ? Ask participants: What is the indicator usually used to assess the nutritional status of an

    emergency-affected population?

    ? Answer: The prevalence of wasting (a measure of thinness due to recent, acute problems) among

    children 6-59 months i.e. the latter is a proxy indicator.

? This slide shows the prevalence of acute malnutrition among children under five for two highland

    cities, Mélange and Huambo, in Angola during the 1990s.

    ? The first two points show the prevalence of acute malnutrition during years that the situation in

    Angola was considered to be relatively stable. Nutritional survey findings showed that levels of

    malnutrition were below 5% in both cities.

    ? Political instability, leading to violence and population displacement occurred during late 1998 and

    1999 in Angola. Populations became displaced, moving to the cities where they lost access to food

    production means and became reliant on humanitarian assistance.

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

? Ask participants: What do the findings from subsequent surveys carried out in 1999 tell us?

    ? Answer: The level of acute malnutrition increased dramatically in both Melange and Huambo.

Slide 12

    For slides please refer to S1 Intro Visuals.ppt

? The association between malnutrition and mortality has been well documented. The close relationship

    that is often observed between mortality and malnutrition can be observed from this slide.

    ? This graph is based on health and nutrition survey data from Ajiep in southern Sudan in 1998. The

    graph clearly shows that as levels of acute malnutrition decrease (shown in gold), so does mortality

    (shown in red).

    ? It is important to note however, that the relationship between malnutrition and mortality is not

    constant and will differ in different contexts. In some situations, there is high mortality but the

    prevalence of malnutrition remains relatively low. Mortality may radically change with no major

    changes in the prevalence of malnutrition.

    ? Ask participants if they can come up with any contexts in which they know that this has happened.

Slide 13

    For slides please refer to S1 Intro Visuals.ppt

? Ask participants: Does anyone recognise this framework?

    ? This is the conceptual model of causes of malnutrition. This framework was originally developed by

    UNICEF and has been adopted by Sphere as a framework for analysis (see page 136).

    ? The framework is central to understanding the multi-factoral nature of nutrition.

    ? Malnutrition occurs as a result of immediate causes, which in turn are affected by underlying factors,

    which in turn are influenced by basic causes.

    ? The framework will be explored in greater depth in session 2.

    Optional Exercise: 3 15 mins

     FILLING IN THE CONCEPTUAL FRAMEWORK The aim of this exercise is to show the integral link between the nutrition standards (by using the

     introduction) and the conceptual framework.

     1. Keep the slide of the conceptual framework showing.

    2. Put an empty framework (with no writing on) on a flip chart.

    3. Divide the participants into two groups. 4. Ask one group to refer to the second paragraph on page 135. Ask them to list all the objectives of preventive programming (each one on an individual piece of paper) and then to stick them on the empty flip chart in the correct sections (referring to the powerpoint slide). Only one coloured paper should be used for this. 8 5. Ask the second group to refer to the remaining three paragraphs on page 135-6 and ask them to

    list the programme types (again, each on a separate piece of paper) and stick these on the same

    flip chart. Different coloured paper should be used for this.

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

Slide 14

    For slides please refer to S1 Intro Visuals.ppt

? [If exercise 3 was done: This slide shows some of the points discussed in the previous exercise as

    well as other ones that were not included. N.B. remember that this slide is also not exhaustive by any

    means.]

    ? In relation to the multiplicity of causes of malnutrition, so the breadth and scope of programmes

    addressing and preventing malnutrition are diverse and wide-ranging.

    ? Interventions may be: preventive, such as protection of people‟s assets and means to access food or

    the fortification of food, or curative, such as therapeutic feeding for the treatment of severe acute

    malnutrition. General ration programmes and selective feeding depending on the objective, can be

    preventive and curative in nature.

    ? In most situations, it will be most important to prioritise between different response options and

    combining different strategies to prevent malnutrition and reduce mortality.

    ? The type and nature of interventions often required to address and prevent malnutrition, as seen in

    this slide, emphasises the importance of other sector chapters for nutrition.

Slide 15

    For slides please refer to S1 Intro Visuals.ppt

    ? Re-cap on the objectives of the session ? Check if there are any outstanding questions.

     9

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

    Nutrition Module Session 1 Handout 1

    1 copy to each participant

    Rights to food

    The right to adequate food is recognised in several instruments under international law, including the Universal

    Declaration of Human Rights adopted in December 1948 (article 25), and the International Covenant on Economic,

    Social and Cultural Rights adopted by the General Assembly in Dec 1966 and entered into force in Jan 1976.

"Everyone has a right to a standard of living adequate for the health and well-being of himself and of his family,

    including food, clothing, housing and medical care and necessary social services, and the right to security in the

    event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond

    his control" (Article 25 in the Universal Declaration of Human Rights).

"The States Parties ….recognise the right of everyone to an adequate standard of living for himself and his family,

    including adequate food, clothing and housing, and to the continuous improvement in living conditions. The States

    Parties will take adequate steps to ensure the realisation of this right, recognising to this effect the essential

    importance of international cooperation". "The States Parties … recognise the fundamental right of everyone to be

    free from hunger, shall take, individually and through international cooperation, the measures, including specific

    programmes, which are needed” (Article 11 in the International Covenant on Economic, Social & Cultural Rights).

Obligations of States and warring parties to provide humanitarian assistance

    Human rights law and humanitarian law define the legal responsibilities of states or warring parties to provide

    assistance or to allow it to provided, and refrain from behaviour that violates fundamental human rights.

International Covenant on Economic, Social and Cultural Rights:

    "Each party to the present covenant undertakes to take steps, individually and through international assistance and

    cooperation, especially economic and technical, to the maximum of its available resources, with a view to

    progressively achieving the full realisation of the rights recognised in the present covenant by all appropriate means,

    including particularly the adoption of legislative measures" (Article 2). Many states have adopted such legislation,

    however this is not consistent between states.

4th Geneva Convention part 3:

    "To the fullest extent of the means available to it, the Occupying Power has the duty of ensuring food and medical

    supplies of the population; it should in particular, bring in the necessary foodstuffs, medical stores and other

    articles if the resources of the occupied territories are inadequate" (Article 55)

     "If the whole or part of the population of an occupied territory is inadequately supplied, the Occupying Power shall

    agree to relief schemes on behalf of the said population, and shall facilitate them by all the means at its disposal.

    Such schemes, which may be undertaken either by States or by impartial humanitarian organisations such as the

    ICRC, shall consist in particular of the provision of consignments of foodstuffs, medical supplies and clothing"

    (Article 59).

    "The Occupying Power shall in no way whatsoever divert relief consignments from the purpose for which they were

    intended, except in cases of urgent necessity, in the interests of the population of the occupied territory and with the

    consent of the Protecting Power" (Article 60).

Additional Protocols:

    "If the civilian population is suffering undue hardship owing to a lack of supplies essential for its survival, such as

    foodstuffs and medical supplies, relief actions for the civilian population which are of an exclusively humanitarian

    and impartial nature in character and conducted without any adverse distinction shall be undertaken subject to the

    consent of the High Contracting Party concerned" (Additional Protocol 2; Article 18 - referring to non-international

    armed conflict).

Convention of the Rights of the Child 1990

    „State Parties‟ shall take appropriate measures to „combat disease and malnutrition….through the provision of

    adequate nutritious foods, clean drinking water and health care’ and ‘ensure that all segments of society, in

    particular parents and children, are informed, have access to education and are supported in the use of basic

    knowledge of child health and nutrition [and] the advantages of breastfeeding’.

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