Food and Nutrition Handbook

World Food
Programme
Food and Nutrition

Handbook
WFP Food and Nutrition Handbook
Drafted by:
Nutrition Works
Edited by:
Anne Callanan
Reviewed by:
Margot Van Der Velden,
Various chapters reviewed by:
Amir Abdulla, Trudy Bower, Pieter Dijkhuizen, Torben Due, Rasmus Egendal, Haken Falkel, David French, Dieter
Hannusch, Deborah Hines, Maarit Hirvonen, Nicolas Oberlin, Danielle Owen, John Prout, Pablo Recalde, Nicole
Steyer, Jennifer Tatham, Marianne Ward, Philip Ward.
ii
Contents
1 BASIC NUTRITION CONCEPTS ...................................................................................................... 1

Macronutrients .................................................................................................................................................................... 1
Micronutrients ..................................................................................................................................................................... 2
2 FOOD GROUPS AND FOOD AID COMMODITIES .......................................................................... 6

Key Food Groups ................................................................................................................................................................ 6
Emergency Rations / Ready-to-Eat Meals ........................................................................................................................... 9
3 FORTIFICATION OF FOOD AND BLENDED FOODS ................................................................... 13

What is Food Fortification? ............................................................................................................................................... 13
Why fortify foods? ............................................................................................................................................................. 13
Are fortified foods needed in the ration? ............................................................................................................................ 14
Which foods are fortified? ................................................................................................................................................. 14
Fortification of blended food .............................................................................................................................................. 15
Micronutrient Stability, Packaging and Shelf-Life ............................................................................................................... 17
4 MALNUTRITION ............................................................................................................................. 19
What is Malnutrition? ........................................................................................................................................................ 19
Who is Most Vulnerable to Malnutrition? ........................................................................................................................... 22
Causes of Malnutrition ...................................................................................................................................................... 23
Three Underlying Preconditions to Adequate Nutrition ...................................................................................................... 25
Resources and Malnutrition .............................................................................................................................................. 28
Effects of Malnutrition ....................................................................................................................................................... 28
5 MEASURING MALNUTRITION AND NUTRITION SURVEYS ....................................................... 31

Anthropometry .................................................................................................................................................................. 31
Measuring Malnutrition ...................................................................................................................................................... 32
Arm circumference ........................................................................................................................................................... 35
Measuring Malnutrition in Adults and Others ..................................................................................................................... 36
6 FOOD AND NUTRITION ASSESSMENTS ..................................................................................... 43

Meeting Information Needs of Decision-Makers ................................................................................................................ 43
WFP and Vulnerability Assessment and Mapping ............................................................................................................. 44
Assessment Methodologies and Methods ......................................................................................................................... 44
Initial Needs Assessments of Major New Emergency Situations ....................................................................................... 45
Joint FAO/WFP Crop and Food Supply Assessment Missions ......................................................................................... 47
WFP and UNHCR Joint Food Assessment Missions (JFAM) ........................................................................................... 47
In-Depth Food and Nutrition Assessments in Stabilised Emergencies .............................................................................. 48
Assessment of Malnutrition ............................................................................................................................................... 51
Assessment of Micronutrient Deficiency Disorders ........................................................................................................... 51
7 TYPES OF NUTRITION INTERVENTIONS .................................................................................... 54

Nutrition Related Interventions in Emergencies ................................................................................................................. 56
Feeding Programme Strategy ........................................................................................................................................... 56
Nutrition Related Interventions with a Developmental Focus .............................................................................................. 58
Monitoring and Evaluation of Food Aid Interventions ......................................................................................................... 59
8 PLANNING FOOD RATIONS .......................................................................................................... 62

Stages of Planning Rations ............................................................................................................................................... 63
Storage, Quality Control and Specifications ...................................................................................................................... 67
Food Processing and Preparation ..................................................................................................................................... 67
Availability and Substitution of Food Items ........................................................................................................................ 69
The Cost of the Ration and its Resale Value ..................................................................................................................... 70
9 SELECTIVE FEEDING PROGRAMMES ........................................................................................ 72

Types and Objectives of Selective Feeding Programmes .................................................................................................. 72
Criteria for Establishing Selective Feeding Programmes ................................................................................................... 73
Important Principles of Selective Feeding Programmes .................................................................................................... 75
Feeding Regimes and Rations for Different Types of Selective Feeding Programmes ....................................................... 76
iii
Admission and Discharge Criteria for Selective Feeding Programmes .............................................................................. 79

Assessment of Effectiveness ............................................................................................................................................ 80
Closing Selective Feeding Programmes ............................................................................................................................ 80
10 GENERAL FOOD DISTRIBUTION ................................................................................................. 82

Principles of General Food Distribution ............................................................................................................................. 82
Methods of Distribution. To Whom and By Whom? ........................................................................................................... 83
Registration vs. estimation of beneficiary numbers ............................................................................................................ 86
Beneficiary distribution committees ................................................................................................................................... 87
Ration cards or beneficiary lists / beneficiary documents .................................................................................................. 87
Scooping .......................................................................................................................................................................... 87
Distribution cycle .............................................................................................................................................................. 87
Monitoring and Reporting on Distribution ........................................................................................................................... 88
Co-ordination and Management ........................................................................................................................................ 90
11 NUTRITION INFORMATION, EDUCATION AND COMMUNICATION ........................................... 93

Successful Approaches to Nutrition IEC ........................................................................................................................... 94
Important Themes in Nutrition IEC .................................................................................................................................... 94
Identifying the Appropriate IEC Approach ......................................................................................................................... 96
ANNEXES
Annex 1.1 Micronutrient functions, sources and effects of processing ........................................................................... 97

Annex 1.2 Vitamin Requirements (safe levels of intake) .............................................................................................. 102
Annex 1.3 Mineral requirements (safe levels of intake) ................................................................................................ 103
Annex 1.4 Micronutrient deficiencies ........................................................................................................................... 104
Annex 2.1 Specifications and Examples of Blended Foods ......................................................................................... 108
Annex 2.2 Guidelines for the use of milk powder ......................................................................................................... 109
Use of breastmilk substitutes ................................................................................................................... 109
Storage .................................................................................................................................................... 109
Annex 2.3 Policy Statements on Infant Feeding and Infant Formula ........................................................................... 110
Annex 2.4 WFP commodity list and corresponding nutritional value ........................................................................... 112
Annex 3.1 Examples of the Nutrient Content of WFP General Rations ....................................................................... 113
Annex 3.2 WFP fortification specifications for different commodities ........................................................................... 115
Annex 3.3 Examples: Fortified pre-cooked blended foods available in field study sites ................................................ 116
Annex 3.4 Micronutrient Specifications (per 100 gm. dry finished product) ................................................................ 117
Annex 4.1 How to calculate percent of the median and SD scores .............................................................................. 118
Annex 8.1 Energy Requirements for Emergency-Affected Populations,
Developing country profile Kilocalories per day ............................................................................................ 119
Annex 8.2 Mean population energy requirement, and recommended increments of energy (Kcal per day) needed,
taking into account the levels of activity, environmental temperature and food losses during transport ....... 120
Annex 8.3 Fuel-Saving Strategies in Emergencies ...................................................................................................... 121
iv
INTRODUCTION
The World Food Programme is the food aid organisation of the United Nations. Food is the primary input into
programmes it supports, while nutrition is a core outcome. WFP’s mission is to use food aid for three strategic
goals:
• to save the lives of people caught up in humanitarian crises, through Food-For-LIFE;

• to support the most vulnerable people at the most critical times of their lives, through
Food-For-GROWTH; and
• to help the hungry poor become self-reliant and build assets, through Food-For-WORK.
Through all three of these goals, WFP focuses on the most vulnerable: women, children and the elderly.
WFP works closely with a wide range of partners and has signed Memoranda of Understanding (MOUs) and
Letters of Agreement with many United Nations organizations, intergovernmental, non-governmental
organizations and national entities. Two of the most important MOUs which are utilised in a wide range of
emergency food and nutrition programmes, have been signed with UNHCR and UNICEF.
This handbook is aimed at WFP staff at all levels who are involved with the delivery of food assistance to WFP
beneficiaries. It should serve as both a reference and training manual, providing staff with:
• A better understanding of food and nutrition issues as they relate to WFP.

• A practical tool to tackle a number of basic nutrition related tasks, relevant to situations in which they
work.
• The ability to judge when specialised nutrition advice should be sought.
The handbook will enable staff to assess and analyze the nutrition situation in their country or region of
responsibility and help manage the design, implementation, monitoring and evaluation of interventions.
The handbook has been designed as a stand-alone document, referring to other WFP operational guidelines
where relevant. It is not, however, a substitute for expert technical consultation or for other key reference
material on the subject of nutrition (e.g., UNHCR and WHO documents, and the SPHERE Minimum Standards
for Humanitarian Assistance, 1998). Each chapter includes a list of relevant readings.
The handbook is divided in two sections.

Chapters 1-5 are concerned with basic food and nutrition concepts and the process of assessing and analysing
types of nutritional problem and their causes. The second section, Chapters 6-11, covers the practical applications
of nutrition interventions: the range of nutrition related programmes supported by WFP, the tools for planning
an adequate ration, selective feeding modalities , general food distribution, and the core principals of nutrition
information, education and communication as complementary intervention strategies.
Each chapter begins with a statement of purpose, and a summary. A list of learning objectives at the start of
each chapter indicates the knowledge or skills WFP staff might be expected to gain from reading that chapter.
v
vi
WFP 1. BASIC NUTRITION CONCEPTS
1 BASIC NUTRITION CONCEPTS
The purpose of this chapter is to provide a common understanding of basic concepts in nutrition.
1
Summary
This chapter describes the difference between macronutrients and micronutrients and briefly
explains their role and importance in the diet. All foods are made up of five nutrients: protein,
fats, carbohydrate, vitamins and minerals. Water is also essential to life.
Learning objectives
After reading this chapter, WFP staff should be able to:
• Understand the differences between macronutrients and micronutrients, and give examples
of each.
• Identify the main food sources of macronutrients and of key micronutrients, including
vitamin A, iron, iodine, and vitamin C.
Nutrients
All foods are made up of a combination of macronutrients (protein, fat, carbohydrate) and
micronutrients (vitamins and minerals). Together with water, these nutritients are essential for life.
Macronutrients
Macronutrients consist of carbohydrate, protein and fat. These nutrients form the bulk of the diet
and supply all the energy needed by the body.
Carbohydrates are made up of carbon, hydrogen and oxygen. They are burned during metabolism to
produce energy. Carbohydrates in the human diet are mainly in the form of starches and sugars. For
many (poorer) people in the developing world, carbohydrate is the main source of energy, accounting
for as much as 80% of the food they eat.
Fats are also comprised of carbon, hydrogen and oxygen. The term fat encompasses all fats and oils
that are edible and found in human diets. Fats in the body are divided into two groups: storage fat,
which provides a reserve of fuel for the body; and structural fat, which is part of the essential
structure of cells. In developing countries, dietary fat provides a smaller part of total energy (8 to
10%,) than carbohydrates.
Proteins are made up of ‘building blocks’ called amino acids, composed of carbon, hydrogen, oxygen
and nitrogen (amino group). Proteins from different food sources contain different amounts of
amino acids. Proteins from animal origin, such as meat, milk and eggs, contain all essential amino
acids in balanced amounts. Essential amino acids are those that the body cannot make itself and
must therefore be eaten. In contrast, proteins of vegetable origin (e.g., cereals and pulses) contain
on their own insufficient quantities of some of the essential amino acids. By combining different
foods, however (e.g., cereals with beans), adequate levels of all amino acids can be obtained without
requiring protein from animal sources.
Proteins are required to build new tissue, particularly during the rapid growth period of infancy and
early childhood, during pregnancy and nursing, and after infections or injuries. Excess protein is
burned for energy.
1
Energy provided by macronutrients

Energy is needed for the essential body functions (such as breathing), growth (especially during
childhood), and physical activities (working and playing).
1 Macronutrients provide different amounts of energy, expressed as kilocalories (Kcals). Fat provides
approximately twice as much energy (9 kcals/g) as the same weight of protein or carbohydrate (4
kcal/g). As stated above, more carbohydrate than fat is usually eaten in developing countries and,
therefore, most food energy in the diet in these countries is derived from carbohydrate sources.
The relative concentration of protein and fat in the diet is important and is expressed by the percentage
of energy in the diet provided by either fat or protein. For example, if a diet provides 2,000 kcal, of
which 200 kcal is provided by fat, that fat is described as providing 10% of total energy. Chapter 8,
Planning Food Rations, describes the optimal nutritional composition of a ration in terms of energy,
protein and fat.
Energy and protein requirements

The total amount of energy and protein needed by different individuals varies a great deal, depending
primarily on the amount of physical activity but also on age, sex, body size and, to some extent,
climate (see Chapter 8 and Annex 8.1). Extra energy is needed during pregnancy and lactation.
Micronutrients
Micronutrients include all vitamins and minerals. Required in only tiny amounts, they are nonetheless
essential for life and needed for a wide range of body functions and processes. Vitamins are either
water-soluble (e.g., those found in fruits and vegetables such as the B complex vitamins and vitamin
C) and generally not stored by the body for future needs, or fat-soluble (e.g., vitamins A and D),
which can be stored by the body.
Micronutrient deficiencies are widespread and affect large numbers of people in developing countries.
Approximately 2 billion people worldwide suffer from some kind of micronutrient deficiency, causing
a wide array of disorders and increasing the risk of death, disease and disability. For example, between
250,000 and 500,000 children a year become blind because of vitamin A deficiency. One quarter of
the world’s people consume insufficient iodine, causing not only widespread endemic goitre but also
retarding growth and mental development; in its extreme form, this retarded mental development is
known as cretenism. Anaemia, or iron deficiency – characterised by breathlessness and fatigue - is
also prevalent worldwide and, unlike deficiencies in vitamin A and iodine, occurs in both industrialized
and developing countries
Micronutrients are variously distributed in food. Some micronutrients, such as riboflavin, are widely
available in a range of foods and hence deficiencies of these are extremely unusual. Deficiencies are
more common when a particular micronutrient, such as Vitamin A, is found in only a limited range
of foodstuffs. Table 1.1 lists the most important micronutrients, their functions, and sources. Annex
1.1 provides more detail.
An individual’s requirement for different micronutrients depends on age and sex. There are also key
periods when micronutrient requirements increase: pregnancy and lactation, early infant and child
growth, and during certain illnesses. Annex 1.2 and 1.3 contain tables of vitamin and mineral
requirements. There is a risk of toxicity with excessive intakes of some micronutrients; a high intake
of vitamin A, for example, is especially dangerous for pregnant women as damage to the growing
baby can occur.
2
Table 1.1 Major Micronutrients: Functions, Sources
Vitamin A
Function Vitamin A is a fat-soluble vitamin required for the normal functioning of the eyes, the immune system,
growth and development, maintenance of healthy skin, and reproduction.
1
Forms Vitamin A is present in food in two forms:
as preformed vitamin A (retinol) contained in foods of animal origin and easily absorbed;
as carotenoids (largely β-carotene) contained in plant foods, these can be biologically transformed to
vitamin A but are less easily absorbed
Sources Retinol is chiefly found in dairy products, liver and some fatty fish. Carotenoids are found in yellow and
red fruits and vegetables, and in green leafy vegetables, especially the green outer leaves. Vitamin A is
absent in vegetable oils with the exception of red palm oil and fortified vegetable oils or margarine.
Vitamin C
Function Vitamin C is a water soluble vitamin and serves a number of essential metabolic functions. It also assists
in absorption of non-haem iron and is an important anti-oxidant.
Sources Fresh fruit and fruit juices are the richest sources of vitamin C, but amounts vary greatly in different fruits.
Niacin
Function Niacin is water-soluble and plays a central role in the utilization of food energy.
Sources Niacin is widely distributed in plant and animal foods, but only in small amounts. Meat (especially offal),
fish, milk and groundnuts are rich sources of niacin. Dried fruits, nuts and pulses contain smaller amounts.
Thiamin
Function Thiamin is water-soluble and is required mainly for the metabolism of carbohydrate, fat and alcohol. It is
also necessary for the proper function of the nervous system and the heart.
Sources Unrefined cereals, yeast, nuts, legumes, organ meats (e.g., liver and kidney).
Riboflavin
Function Riboflavin is water-soluble and is a component of enzymes, which play a role in the utilization of food
energy.
Sources Riboflavin is plentiful in animal foods, green vegetables, and whole wheat. Poor sources are maize, rice
and highly refined flour.
Iodine
Function Iodine is an essential constituent of hormones produced by the thyroid gland in the neck. In the foetus,
iodine is necessary for the development of the brain and nervous system during the first three months of
gestation.
Sources The level of iodine in the soil determines its content in plants and animals. As most soils contain little
iodine, most foods are poor sources. The only rich source of iodine is seafood.
Iron
Function Most of the iron in the body is present in red blood cells. The main function of iron is the transfer of
oxygen to various sites in the body. Lack of iron eventually results in anaemia.
Sources Meat, fish, eggs, pulses, green leafy vegetables and fortified blended foods are good iron sources. Cereals
contain moderate amounts. Milk is a poorer source.
3
The body’s response to a deficiency of a particular nutrient varies. Chapter 4 describes types of
malnutrition caused by deficiencies in both macro and micronutrients. Annex 1.4 provides more
detail of micronutrient deficiencies.
1 The ability of the body to absorb and utilize certain micronutrients in food depends on four factors:
• The form of the nutrient in food. For example, iron in meat (haem iron) is much more easily
absorbed than iron contained in plant foods (non-haem iron).
• Other items in the diet, which either enhance or inhibit absorption. For example, the absorp-
tion of iron from plant foods is enhanced by eating foods high in vitamin C like oranges or
tomatoes, but inhibited by compounds such as tannin (present in tea) and phytate (present in
cereals).
• Infection. A number of infections adversely affect the body’s ability to absorb nutrients. For
example, persistent diarrhoea prohibits absorption of both macro and micronutrients.
• Food preparation methods. Some methods of food preparation can enhance the availability of
micronutrients. Table 1.2 shows the effects of storage and cooking on the micronutrient con-
tent of food commodities.
Table 1.2 Effects of Storage and Cooking on the Micronutrient Content of Food Commodities
Food commodity Adverse effects/practices Beneficial effects/practices
Cereals Milling reduces folate, iron, niacin, Fermentation increases the availability of
riboflavin and thiamin content plus iron, zinc, calcium and phosphorus and
other trace micronutrients (calcium, increases B-complex vitamin content
phosphorus, pyridoxine, vitamin E and
zinc) Treating whole maize with lime-water
before grinding releases bound niacin
Excessive washing and cooking of rice
reduces B-complex vitamin content Parboiling unhusked rice after preliminary
soaking preserves B-complex vitamin
content
Minimising or consuming water used for

washing and cooking rice reduces losses of
B-complex vitamins
Pulses Cooking reduces folate and niacin Sprouting (germinating) beans increases
content vitamin C content
Oil Vitamin A content in fortified fats and

red palm oil is reduced during frying at
very high temperatures
Storage for more than 6 months reduces

the vitamin A content of fortified fats
and red palm oil
Fortified blended food Storage for more than 6 months reduces

micronutrient content
.
Cooking reduces micronutrient content
4
Key Words
Anaemia Anaemia can be caused by lack of iron, folate or vitamin B12. Though difficult
to diagnose accurately from clinical signs, its symptoms include pallor, fatigue,
headaches, and breathlessness. 1
Carbohydrate Carbohydrates are macronutrients in the human diet, mainly in the form of
starches and sugars.
Fat Macronutrient including all fats and oils that are edible and occur in human
diets.
Macronutrient Including carbohydrate, protein and fat, macronutrients form the bulk of the diet
and provide all energy needs.
Micronutrient Micronutrients include all vitamins and minerals and, in small amounts, are
essential for life.
Nutritional equirements The amount of energy, protein, fat and micronutrients needed for an individual
to sustain a healthy life
Protein Proteins, made up of ‘building blocks’ called amino acids, are required to build
new tissue.
Key Readings
FAO HUMAN NUTRITION in the Developing World. FAO 1997
FAO and WHO. 1995. Trace elements in human nutrition and health. Report of a FAO/WHO consultation. Geneva:
WHO.
WFP and UNHCR. 1997. Joint WFP/UNHCR guidelines for estimating food and nutritional needs in emergencies.
WFP/UNHCR.
WHO. 1974. Handbook of Human Nutritional Requirements. Geneva: WHO.
Paul, A.A. and Southgate, D.A.T. 1978. McCance and Widdowson's the composition of foods, Fourth Ed London:
Elsevier/North-Holland Biomedical Press.
5
2 FOOD GROUPS AND FOOD AID

COMMODITIES
The purpose of this chapter is to describe the food groups and the common food aid commodities
which correspond to them. It also describes less usual commodities sometimes used in emergency
situations.
2
Summary
For convenience, nutritionists divide foods into key food groups: cereal grains, legumes (pulses)
and oilseeds, tubers and roots, vegetables and fruits, animal products oils and fats. Breast milk
is an essential food for small children. A combination of these food groups is required for a
healthy diet. Food aid baskets strive to ensure a proper combination of commodities. Ready-
to-eat- meals are sometimes used in emergency situations.
Learning objectives:
After reading this chapter, WFP staff should be able to :
• Describe the key food groups in the diet and related food aid commodities
• Identify the uses and constraints of Ready to Eat Meals
Key Food Groups

The nutritional value of a diet depends on the individual foods that are included. For practical
purposes nutritionists divide foods up between a number of ‘food groups’, a combination of which
must be consumed on a daily basis to ensure a healthy diet and prevent malnutrition. These key food
groups and the corresponding food aid commodities provided by WFP are shown in Box 2.1.
Cereal grains
Cereal grains - including wheat, rice, sorghum, maize, oats and millet - comprise the bulk of food aid
delivered by WFP. As the staple food in most food aid contexts, cereals provide the largest proportion
of energy in the diet, a large part of the protein, and significant amounts of micronutrients. The
levels of micronutrients present depend on the type of cereal and the extraction rate during milling
or other processing. The higher the extraction rate, the less whole cereal grain remains and, in
general, the lower the level of micronutrients.
Whole grain cereals may be processed commercially to form a variety of food aid commodities:
• A range of flour and meal;
• Parboiled rice;
• Bulgur wheat;
• Soya-fortified cereal grains; soya-fortified bulgur wheat, soya fortified wheat flour (SFWL),
and soya fortified corn meal (CFCM), and soya-fortified sorghum grits (SFSG);
• Blended foods, produced by extrusion, or roasting and milling (see below and also Annex 2.1).
• Pasta.
Processed cereals are usually quicker to cook and, therefore, more fuel efficient than their unprocessed
counterparts. However, processed cereals are much more susceptible than whole grain cereals to
6
WFP 2. FOOD GROUPS AND FOOD AID COMMODITIES
Box 2.1: Key Food Groups in the Diet
Examples
Food Group Description (Common WFP food aid
commodities in italics)
Cereals Cereals are the staple food and main source of energy Wheat, sorghum, maize, rice, cereal
for most cultures. They also contain protein, B flours, processed cereal grains, soya
vitamins and iron.
2
fortified grains.
Legumes and Dried legumes are composed of about 20% protein Beans, peas, lentils, groundnuts, soya
oilseeds and are rich in the B-complex vitamins and iron. The beans, sesame, sunflower seeds,
protein in legumes complements the protein in cereal coconut.
grains. Generally, oilseeds and nuts contain fewer
toxins and more and better quality protein than most
legumes.
Tubers and roots Tubers and roots provide mainly carbohydrates; their Yams, taro, cassava, sweet potato,
protein content, like that of cooked rice, is usually Irish potato.
low.
Vegetables and Fruit and vegetables are an excellent source of Wide range available, green leafy
fruits vitamins A (in the form of carotenes), B, and C, and vegetables, onions, brassicas (e.g.,
iron and calcium. The darker the colour - whether cabbages and broccoli).
green, yellow, or orange - the higher the vitamin A
value.
Animal products Animal products provide high quality protein, but are Meat, eggs, poultry, fish, milk and
usually only eaten in small amounts in most milk products (canned meat, fish and
developing countries. cheese, dried milk).
Oils and fats Oils and fats improve the palatability of the diet and Oil from: groundnut, soya, sunflower,
are a concentrated source of food energy. Fat from rapeseed or a mixture of these.
milk is a rich source of vitamins A and D. Vegetable
oils and fats do not contain these vitamins unless Animal fats, butter oil.
fortified.
Red palm oil.
Breast milk Human milk is the best and safest food for infants. It
satisfies their nutritional requirements up to around 6
months of age. Breastfeeding should be actively
promoted, supported and protected.
The nutritional value and use of these different foods are briefly considered below.
biological and chemical deterioration. Because they are also more susceptible to insect attack, care
must be taken to keep these products clean and uncontaminated. Some processed cereals are fortified
with vitamins and minerals (e.g., bulgur wheat, cornmeal, and soy-fortified cereals are enriched with
B vitamins, vitamin A, iron and calcium).
Legumes and oilseeds

Pulses (peas, beans, and lentils) are rich sources of protein. When complemented with the protein
found in cereals, an adequate level of amino acids can be achieved in a diet. Dried pulses commonly
handled by the WFP include haricot beans, grams, horse beans, butter beans, groundnuts and lentils.
Pulses require careful preparation to make them palatable, safe and digestible. They must be pre-
soaked, hence the need for containers and water. They often require lengthy cooking, which increases
the demand for cooking fuel. Less cooking time is needed for pulse flour and for split peas (particularly
7
pre-cooked yellow-split peas, a commodity sometimes provided by WFP), lentils and grams. The
addition of small amounts of sodium bicarbonate, or traditional soda (ash), during cooking of pulses
greatly reduces cooking time, but the alkaline pH degrades/ destroys thiamin (B-1) and riboflavin
(B-2).
Groundnuts are easier to prepare than many dried beans and are an important source of niacin in
maize-based diets where pellagra may be a risk.
2 Blended foods
Blended foods are a processed mixture of cereals and other ingredients (e.g., pulses, oilseeds, dried
skimmed milk, and possibly sugar and or some kind of vegetable oil) that have been milled, blended,
and pre-cooked by extrusion or roasting. All blended foods were originally designed to provide
protein supplements for weaning infants and younger children or for low-cost weaning foods in
developing countries. The main blended food distributed by WFP is corn-soya blend (CSB) from the
USA, but WFP also purchases locally produced blended foods (e.g., Indiamix, UNIMIX, Unilitho,
Famix, Lukuni Phala). Some of these products are now used in the general ration for adults and
children as a means of providing an additional source of micronutrients. Blended foods are also
used in nutritional rehabilitation programmes.
Blended foods should comply with the ‘’Guidelines on Formulated Supplementary Foods for Older
Infants and Young Children’’ of the Codex Alimentarius. The nutritional value per 100g dry product
should be 400 kcals, 15% protein, 6% fat and a vitamin and mineral complex. The production and
specifications of blended food are covered in chapter 3 and Annex 2.1.
Oils and fats

Oils and fats are essential for improving the palatability of the diet and for increasing its ‘energy
density’ (proportion of calories to weight) as oils provide 9 kcal per gram (in contrast to carbohydrate
and protein which only provide 3.5 and 4.0 kcal respectively per gram). The vegetable oils most
commonly used as food aid are soya bean oil and rapeseed oil. Butter oil has had the protein and
moisture removed, rendering it 100% butterfat (butter is only about 85% fat). Margarine, a butter
substitute, is obtained by processing vegetable oil into hardened fat in which water (20%) is emulsified
to make it spreadable; it may liquefy again in hot climates. Conversely, butter oil may solidify at
temperatures below 20oC.
Cooking oils are susceptible to rancidity; therefore, lightproof and airtight packaging is required.
Metal cans, food grade plastic bottles or jerrycans are the most suitable containers.
Animal products
Canned meat, fish and cheese are expensive and rarely available in sufficient quantities to be used in
general food distribution programmes on a regular basis, unless specific donations have been made
for that purpose. These products are considered ‘commercially sterile’ and hence safe because of
the heat treatment they receive during processing. Cans that are badly rusted, perforated (holed) or
swollen should be discarded. Any canned food which appears defective or in any way spoiled should
not be eaten. Processed cheese should be kept as cool as possible.
There are many types of dried fish used as food aid, usually in small amounts. Those processed in
warm climates will frequently be salted and sun-dried or smoked, whilst stockfish of Scandinavia
and Canada will be unsalted and wind-dried.
8
Milk products
Milk products, including dried milk powders, are a rich source of quality protein, calcium and certain
vitamins. Reconstituted milk is obtained by combined dried skimmed milk (DSM) with butter (or
vegetable) oil. DSM should not be combined with water only; this produces skim milk containing
less fat, and therefore less energy, than whole milk. The two products are not interchangeable. For
emergencies, DSM is used to fortify cereals or porridges. It must be fortified with vitamin A to
ensure it provides similar levels to those found in whole milk. It can also be used for therapeutic
purposes when combined with a suitable oil, sugar and a vitamin/mineral preparation to make a
high-energy mix. Guidelines for the use of milk powder are described in Annex 2.2
2
Infant formula
Infant formula is a product designed and manufactured in accordance with the Codex Alimentarius
standard to substitute for human milk in meeting the normal nutritional requirements of infants
WFP complies with international guidelines on the protection and promotion of breastfeeding. For
this reason, WFP staff must never accept or distribute infant formula. Please see Annex 2.3 for
policy guidelines on infant formulas and breast milk substitutes
Emergency Rations / Ready-to-Eat Meals

Emergency rations are usually nutritionally balanced, ready-to-eat complete foods. They generally
come in two forms: as compressed, vacuum packed bars or tablets made from a range of ingredients
(typically, wheat flour, whole milk, sugar, dried milk products, soya flour, malt extract, fish powder,
vitamins and minerals); or as more complete ready-to-eat meals (Meals Ready-to-Eat, or MREs, are
the most commonly used) with several different items.
These rations are the most expensive food aid commodity distributed by WFP and are usually reserved
for immediate response during the first few days of a sudden disaster or the displacement of large
numbers of people.
Usually these products contain high quality protein, fat and carbohydrate with added vitamins and
minerals. Vacuum packing in foil laminates ensures a shelf life of up to five years. The most commonly
available emergency rations are known by their commercial acronyms (e.g., HEBs, BP5s, HDRs and
MREs). They are discussed below.
Emergency ration biscuits or tablets:

HEBs (high energy biscuits)/ HPBs (high protein biscuits)
HEBs and HPBs are essentially the same products, the difference being that the preferred term
nowadays is “high energy” rather than “high protein” biscuits. The earlier emphasis on the word
protein stems from the time when lack of dietary protein was erroneously thought to be the main
cause of malnutrition.
All HEBs distributed by WFP must meet the following standards: 450 kcal with a minimum of 10
grams and maximum of 12 grams of protein per 100 grams. All HEBs are fortified with essential
vitamins and minerals (50% - 75% maximum of the adult recommended daily requirement).
Biscuits have a limited number of uses. Their main use is for WFP is as emergency rations in the first
days of an acute emergency or as a food to be carried by returnees or other populations during
transit. A secondary use is in therapeutic feeding programmes for night feeds, or for take-home
supplements to encourage appetite.
9
Biscuits are very expensive compared with other ration items and are not an essential part of an
adequate food basket. Apart from the limited uses described above, it is generally culturally and
economically inappropriate to distribute biscuits as a main source of nutrients.
Biscuits for humid areas should be packaged with a moisture barrier to prevent an increase in moisture
content and subsequent deterioration. A sturdy outer package (cardboard carton or tin) is required
to resist breakage. Because of the high fat content of biscuits, lightproof and airtight packaging is
required to avoid rancidity. The packaging and shelf life of biscuits varies. Longer shelf lives (3-5
2 years) are achieved with the tins and the preferred packaging is metal containers (usually10kg), but
they may come in foil wrapped packets of 200-250 grams in cardboard cartons (shelf life of at least
one year and usually two). One ton costs US$1000-1200.
BP-5
BP-5s are compressed tablets, vacumn packed in foil. BP-5s contain, 458 kcal; 15,5 grams of fat and
16,7 grams proteins per hundred grams, they are also vitamin and mineral fortified. Because they are
packed in foil they are moisture proof and resistant to germs, insects and rodents. They are boxed in
500 gram blocks each block containing 9 bars.
The bars are a pale blond colour and because all moisture is removed during processing they are very
dry. They need to be eaten slowly and chewed well. Water must be provided with them. The
manufacturers recommend 100-150 mls of water for each two biscuits consumed. If they are to be
eaten by infants, it is advisable to dissolve them in boiling water and make them into a porridge.
BP-5s are distributed to needy populations in terms of grams rather than ration size. Amounts vary
according to the needs of the population receiving the BP-5s. Six bars of BP-5 biscuits (330 grams,
1,500 kcal) per day provide all the necessary nutrients for short-term maintenance of a healthy body.
One ton of BP5s costs US$3,000.
Ready-to-eat meals:
HDRs (humanitarian daily rations) and MREs (Meals Ready-to-Eat)
HDRs were developed by the United States Department of Defense and are specifically designed to
meet the nutritional needs of civilians in humanitarian crisis. One HDR provides about 1900 - 2000
kcal and an adequate supply of protein, fat and essential micronutrients (vitamins and minerals) –
enough to cover the average daily needs of one civilian individual. They contain no animal products.
Each HDR contains two entrees and five complementary products. To provide variety, 4 different
entrees in 6 different combinations are available. The HDRs come in a toughened, waterproof
plastic bag. They are very difficult to open without a knife or scissors. The food is contained in
individual vacuum-sealed packets.
The major problem with these products is that the food items contained are unfamiliar to many
emergency affected populations and, therefore, some food may be discarded by the beneficiaries.
The plastic packages are also difficult to dispose of. One day’s ration costs US$4.
MREs (Meals Ready-to-Eat):

MREs are army rations that are designed to provide 1 meal 3 times per day (3,600 kcal). Their
packaging, presentation and constraints are similar to HDRs (see above); however, unlike HDRs,
MREs contain fish and meat products. There are over 25 different varieties. A one days MRE
ration costs US$13.
10
Salt, Sugar and Tea

Sugar can play an important role in the diet by improving palatability and, particularly in the case of
a child’s diet, energy density. For take-home supplementary feeding programmes, sugar is often
added to blended foods - together with oil - to produce porridge pre-mix. The importance of sugar
for palatability should not be underestimated: blended foods without sugar are sometimes not
acceptable to children. Though sugar contains no nutrients other than carbohydrate, it is nevertheless
important for increasing the energy of foods for young children. This is particularly relevant for high
energy milk and high energy porridge used in therapeutic feeding programmes. By adding sugar to
milk, additional energy is provided within the same volume of milk.
2
Similarly, salt improves palatability and, when iodized, serves a crucial nutritional function. WFP
policy requires the use of iodized salt (fortified with iodine) in its food rations. For practical purposes
(stability), iodine for salt fortification is used in the form of iodate. Levels between 20 to 40 mg
iodine/kg salt or 20 to 40 mg iodine/ g salt are recommended (WHO/ UNICEF/ ICIDD Consultation,
1997). This level is based on 10 g. or salt per person, per day.
Tea and coffee make virtually no nutritional contribution to the diet, although they may serve as a
vehicle for milk or sugar. In general, WFP does not provide tea and coffee in its rations.
Annex 2.4 shows the WFP commodities list and their corresponding nutritional value.
11
Key Words
Basic food items Basic food items include: cereals, oil, and a protein-rich food such as pulses
(beans/peas etc.) and/or fish/meat in canned or dried form.
Blended food Blended foods are a pre-cooked, fortified mixture of cereals, pulses, oilseeds and other
ingredients (e.g., wheat soy blend, corn soy blend, UNMIX, FAMIX).
2
Infant formula Any food being marketed or otherwise represented as a partial or total replacement for
breast milk, whether or not suitable for that purpose. Infant formula should be
produced in accordance with the Codex Alimentarius standard, though its use is not
sanctioned in WFP projects.
Ready to Eat Meals Emergency rations that are usually nutritionally balanced, ready-to-eat complete foods.
They are often compressed, vacuum packed bars or biscuits made from a range of
ingredients (e.g., whole milk, sugar, dried milk products, soya flour, malt extract, fish
powder, vitamins and minerals)
Extraction rate The extraction rate is the proportion of the whole cereal grain available as final product
(rice, flour) after the milling process. This varies according to the type of cereal and
the milling process and effects the level of micronutrients present in the final product.
Parboiled rice, bulgar The process of parboiling involves soaking, steaming and drying the grain; in the case
wheat of rice, it preserves a higher proportion of nutrients in the grain compared with
polished or highly refined rice; bulgar is gelatinized wheat grits which during cooking
retain their granular consistency; they can be substituted for rice.
Key Readings
FAO HUMAN NUTRITION in the Developing World. FAO 1997
FAO and WHO. 1995. Trace elements in human nutrition and health. Report of a FAO/WHO consultation. Geneva:
WHO.
WFP/UNHCR.
WHO. 1974. Handbook of Human Nutritional Requirements. Geneva: WHO.
WHO. 1995. The Management of Nutritional Emergencies in Large Populations (DRAFT).
Other useful references

Paul, A.A. and Southgate, D.A.T. 1978. McCance and Widdowson’s the composition of foods, Fourth Ed London:
Elsevier/North-Holland Biomedical Press.
WHO/UNICEF/ICIDD Consultation. 1997. Recommended iodine levels in salt and guidelines for monitoring their
adequacy and effectiveness. Based on an expert consultation, World Health Organization, Geneva, July 8 – 9, 1996.
IDD Newsletter.
12
WFP 3. FORTIFICATION OF FOOD AND BLENDED FOODS
3 FORTIFICATION OF FOOD AND

BLENDED FOODS
The purpose of this chapter is to enable WFP staff to understand fortified foods and why their
usefulness in a general ration.
Summary
WFP provides blended foods or other fortified commodities in order to prevent or correct
micronutrient deficiencies and in situations where beneficiaries are totally dependent on
food aid. There are a number of common fortified food aid items, including: iodized salt, 3
vitamin A fortified oil, blended food, and cereals. Issues to consider in relation to utilising
local versus imported fortified foods are reviewed, with particular focus on cereals and
blended food.
Learning objectives
After reading this Chapter WFP staff should be able to:
• Understand the rationale for using fortified foods as a strategy for combating micro-
nutrient deficiency diseases.
• Describe the range of fortified commodities commonly used by WFP in general
rations, and list their main fortificants
• Assess the need for including fortified foods in a general ration
• Understand the advantages and disadvantages of fortifying foods locally
What is Food Fortification?

Food fortification is the process whereby one or more nutrients (vitamins or minerals) are added to
foods during processing. This increases the nutritional value of the food without greatly increasing
the cost or adversely affecting its taste or general acceptability. A food may be fortified to increase
the level of specific nutrient(s) in a food or to restore nutrients lost during food processing (e.g.,
fortification of cereal flour and dried skimmed milk powder).
Why fortify foods?

WFP is committed to providing appropriately fortified food commodities in order to increase the
intake of micronutrients, thereby improving micronutrient status and preventing damage caused by
deficiency (see chapters 1 and 4). For populations entirely dependent on food aid, WFP policy calls
for a basic general ration to provide appropriately fortified food commodities in order to ensure
adequate essential micronutrients. In the past, the absence of fortified commodities has resulted in a
number of epidemics of micronutrient deficiencies amongst food aid dependent populations (e.g.,
niacin in Mozambique and Angola; vitamin C in Somalia; riboflavin in Nepal).
Fortification is one of the least costly and most effective means of combating micronutrient deficiencies.
A good example is the iodization of salt, which has been well established in many developed and
developing countries. Where fortified foods are manufactured locally on a commercial basis,
fortification has often proven to be economically sustainable.
13
Although fortification is well suited to increasing levels of micronutrients in the diet of the poor or
emergency affected populations, it is not advisable to rely on a single food vehicle to eradicate
deficiencies of all micronutrients. A range of food commodities should be fortified with different
types and levels of micronutrients. Furthermore, while fortification represents an important tool to
combat micronutrient deficiencies and improve micronutrient status, other tools are sometimes
required or desirable.
Are fortified foods needed in the ration?

Where people are dependent on a general ration as their only source of food, it is likely to be
deficient in certain micronutrients, particularly if it contains no fresh foods. The type of staple cereal
3 included in the ration greatly influences the types of deficiency disease to which populations may be
at risk.
These risks are likely to vary depending on the different nutritional requirements of the food aid
population – for example, the very young, pregnant and lactating women and adult men all have
different requirements.
Annex 3.1 shows the impact on deficiency risks of adding a range of fortified food to rations based
on different staples.
It is possible, without undertaking a lengthy and detailed analysis, to make certain generalisations
about expected micronutrient shortfalls in micronutrients based on the ration composition (see Table
3.1). But be aware that levels of micronutrients are subject to considerable variation, firstly as a
result of possible lack of uniform mixing during production, and secondly as a result of losses during
transport and storage. Fortified food products will be most effective in combating micronutrient
deficiencies if they are tailored for the needs of particular groups. This includes ensuring foods are
palatable, especially when they are for infants and young children.
Which foods are fortified?

Foods may be fortified with single nutrients (salt with iodine, vegetable oil with vitamin A) or with
several vitamins and minerals (fortified cereal flour, blended food).
Levels of fortification are set on the basis that the vitamin or mineral added will make a significant
contribution to nutritional requirements, but not lead to a micronutrient intake above the safe upper
limit. In addition, fortification must not alter the taste, smell, look, texture, physical structure or
shelf life of the food.
WFP policy calls for the provision of vegetable oil fortified with vitamin A and iodized salt when
these items are included in the food basket. All DSM intended for direct utilisation by beneficiaries
must be fortified with vitamin A; only DSM for dairy projects need not be fortified as this can be
done during the processing. For all international purchases of cereal flours, WFP includes fortification
with B-complex vitamins, folate and iron as a requirement of the tender. Annex 3.2 shows WFP
fortification specifications for all commodities. All blended foods distributed by WFP are fortified
with a pre-mix that provides essential micronutrients. In addition, WFP has recently devised
specifications for the vitamin and mineral fortification of High Energy Biscuits.
Where the population is entirely dependent on food aid or is at risk of micronutrient deficiencies,
blended food should be included in the general ration – except in cases when a suitable fortified
cereal is provided. The use of fortified cereal flour reduces the dependence on blended food in the
general ration, although blended foods are also provided in order to provide a suitable food for small
children.
14
Table 3.1 Risks of Micronutrient Deficiency from General Rations

and the Need for Fortified Foods
Possible food sources to be included in the

Risk
ration; naturally occurring or fortified (f)
All food rations are likely to be deficient in vitamin C Fresh fruits and vegetables, blended food (f);
unless there is access to fresh fruit and vegetables, or 48 mg/100g
fortified foods.
The bioavailability of iron is generally low (of the Blended food (f), green vegetables 0.7 – 2 mg/100g,
order of 5%) in all food rations composed largely of lentils 7 mg/100g, rice 0.4 mg/100g
cereals and legumes. This may be improved if vitamin
C rich foods are eaten simultaneously.
Situations where iodine deficiency disorders are Iodized salt (f)

3
endemic and most households (>90%) do not have
access to iodized salt
All food rations are likely to be deficient in vitamin A Vitamin A fortified oil (f). Blended food (f)
unless fortified foods are included in the ration.
Where the staple is maize or sorghum, additional Groundnuts or pulses, offal, blended food (f), high energy
sources of niacin are required. biscuits (f), dried fish.
Where the staple is polished rice additional sources of Include parboiled rather than polished rice. Pulses, nuts,
thiamine are required. vegetables, eggs etc.
Brewers yeast is a good source, so where cereals are

fermented to make beer this may be a good source
Limited exposure to sunlight increases the risk of Sunlight on the skin. Fatty fish, canned fish, eggs, milk,
vitamin D deficiency (rickets and osteomalacia), e.g. margarine or oil (f),
among women in purdah, or infants and children kept
covered or indoors. Also found to occur among blended food (f)
emergency affected populations previously dependent
on milk as a major food source.
Fortification of blended food

Blended foods are produced in many developing countries for local consumption as a complementary
food for infants and young children. WFP often purchases locally produced blended food (e.g.,
UNILITO in Nepal, Famix in Ethiopia, Likuni Phala in Malawi, UNIMIX in Kenya, INDIAMIX in
India). Blended food should be produced in accordance with the “Guidelines on Formulated
Supplementary Foods for Older Infants and Young Children” of the Codex Alimentarius (see
Readings). Processing instructions and product specifications for precooked fortified blended food
are shown in Annex 2.1.
In practice, blended foods are procured from a range of sources. The nutritional compositions may
vary (see Annex 3.3); however, energy, protein, fat and fortification levels must all meet the minimum
standard. As such, all blended foods are interchangeable. Also, the final concentration of each vitamin
and mineral in the fortified product depends on the naturally occurring level of micronutrients in the
food after processing.
Because of the lack of international guidelines for the enrichment and fortification of food aid
commodities, WFP, UNHCR and UNICEF have jointly agreed on specifications for the micronutrient
levels in UNIMIX and other blended foods supplied by WFP. Annex 3.4 gives the levels of fortification
in various blended foods, including those required by WFP.
15
The quality of locally produced blended foods has sometimes been cause for concern; hence, quality
control measures are vital to ensure optimum product quality and levels of fortification. Quality
problems have included infestation, coarsely milled products and flavour taints. The insistence of
WFP that vitamin mineral premixes are purchased from reputable suppliers is one means of ensuring
adherence to appropriate fortification levels.1
WFP policy requires that its local producers of blended foods and flours purchase the micronutrient
premix from Roche, BASF or other reputable suppliers of vitamin/mineral pre-mixes. Producers
must be able to show receipts or other proof of purchase. This ensures adherence to the WFP-
recommended specification for fortification. Quality control measures to monitor and control the
fortification process must be built in to the production procedures to ensure that fortification levels
are adequate and uniform.
3
Local fortification of cereals
Cereal flour can be either fortified in the country of origin or the whole grain cereal may be transported,
milled and fortified regionally or locally. At present, large-scale well established commercial flour
millers in most developing countries either have the technology and experience to fortify cereal
flours or can easily adapt their equipment for fortification of cereals. When required, WFP either
brings in whole cereal grain to be milled and fortified centrally ( the case in Bolivia) or, alternatively,
fortified flour is purchased from existing regional sources (as from South Africa).
Table 3.2 The Advantages and Disadvantages of the Local Fortification of Cereals
Advantages of local fortification Disadvantages
Cereals may be transported as whole grains to the Additional resources are needed to cover the
local site of fortification, a benefit because: extra storage, transport and handling costs in
country (bagging of bulk cereals at point of
whole grains have a longer shelf life; disembarkation, de-bagging for milling and
fortification, re-bagging for onward transport and
bulk cereals are easier to handle than bagged flour, distribution).
bulk cereals are less expensive to transport.
(Milled flours are expensive to package, transport

and handle, which explains their higher costs
compared with the bulk handling of cereal grains.)
Levels of fortificants may be more easily tailored The fortification technology may need to be
to the needs of the population brought in, which is costly and time consuming.
The closer the point of fortification and milling is The shelf-life of cereal flours with a high
to the site of use, the more easily it may be to extraction rate is limited. Flours are sensitive to
match supply to demand. adequate packaging and storage.
The capacity to mill and fortify locally may be

insufficient to meet WFP’s needs.
The food aid pipeline to the point of fortification

must be assured and reliable
Additional management capacity is required to

ensure logistical efficiency and quality control of
the milling and fortification process.
1 This form of control is necessary as it is prohibitively expensive to analyse the micronutrient composition of foods post-production (it costs approximately
$4,000 to have a full vitamin/mineral analysis). By insisting on a reputable/ known supplier of appropriate micronutrient compounds only the amounts
of a single vitamin or mineral in the blended food need to be tested.
16
The technology to fortify cereals at the point of milling has yet to be developed at the community
level, although research to develop this capacity is underway. In addition, a pilot project is being
prepared by WFP to test milling and fortification of maize - with a mobile self-contained milling/
mixing unit - at distribution points of refugee and emergency operations.
Micronutrient Stability, Packaging and Shelf-Life

The stability of added vitamins in a food depends on, amongst other things: the storage temperature,
the moisture content of the food, and the presence or absence of light. The product’s packaging
determines the last three conditions. To minimize micronutrient losses during storage and
transportation, fortified food must be properly packaged.
Dried products like cereal flour, salt, blended food and milk powder easily become damp when 3
improperly packaged under humid conditions. This causes deterioration. To prevent this, they should
be packed in plastic lined, airtight bags or containers. Conditions of storage – adequate ventilation,
separation from floors and walls, etc. – are probably equally important to maximizing shelf-life.
Packaging such as jute, that allows the product to absorb moisture, partly accounts for the much
shorter shelf-life of milled products in developing countries.
Packaging that excludes oxygen (vacuum packaging, packaging in tins etc.) ensures a longer shelf
life. However, this is very expensive and is usually limited to specialised commodities like therapeutic
milk and long shelf-life biscuits.
Fortification itself may also reduce the expected shelf-life of the product because of the instability
created by added vitamins. Foods fortified with vitamin A - such as oil or blended food - have a
shelf-life of six months after which time the potency of vitamin A decreases. This might mean the
food does not comply with its original specification, although it may still be edible or fit for human
consumption. Added minerals tend to be more stable than vitamins, as they are less sensitive to heat,
light and other kinds of chemical stress.
The limited shelf-life of fortified foods means greater care must be taken to maintain the integrity of
their packaging and to use these foods in a timely way, usually within six months of their production.
17
Key words
Bioavailability Proportion of the ingested nutrient that is absorbed and available for use by the body.
Blended food Blended foods are a pre-cooked, fortified mixture of cereals, pulses, oilseeds and other
ingredients (e.g., wheat soy blend, corn soy blend, UNAMIX, FAMIX).
Enrichment A food item is enriched where those micronutrients lost or removed during processing are
added back or restored in the final product (e.g., wheat flour is enriched with vitamin B1,
niacin and iron).
Food vehicle The food to which fortificants are added.
3 Fortificant The micronutrient compound that is added to a food either singly, or as part of a vitamin
mineral premix.
Fortification Fortification is the addition of micronutrients during or after processing to a food, bringing
the micronutrients to levels over and above the amounts in the original food product.
Key readings
Guidelines on Formulated Supplementary Foods for Older Children and Young Infants CAC/GL 08-1991
Codex Alimentarius ‘Code of Hygienic Practice for Foods for Infants and Children’ and ‘Code of Sound Manufacturing
Practices’
Lotfi, M. Venkatesh Manar M. G. Merx. J. H. M. van den Heuvel P. N. 1996. Micronutrient Fortification of Foods.
Current practices, research, and opportunities, The Micronutrient Initiative, International Agricultural Centre, Ottawa,
Canada
Mears, C., and H. Young. 1998. Acceptability and use of cereal-based foods in refugee camps. Case-studies from
Nepal, Ethiopia and Tanzania., Oxfam, An Oxfam Working Paper.
Nestel, P. 1993. Food fortification in developing countries. United States Agency for International Development
(USAID), WA, USA.
OMNI. Fortification Basics - Choosing a Vehicle , Opportunities for Micronutrient Interventions, in collaboration
with Roche and USAID.
OMNI Fortification Basics - Wheat Flour, Opportunities for Micronutrient Interventions, in collaboration with Roche
and USAID.
WHO/ UNICEF/ ICCIDD Consultation. 1997. Recommended iodine levels in salt and guidelines for monitoring
their adequacy and effectiveness. Based on an expert consultation, World Health Organization, Geneva, July 8-9,
1996. IDD Newsletter.
18
WFP 4. MALNUTRITION
4 MALNUTRITION
The purpose of this chapter is to enable WFP staff to attain a common understanding of types of
malnutrition and their underlying causes.
Summary
This chapter describes Protein Energy Malnutrition (PEM), the most common form of
malnutrition among infants and young children and the most important vitamin and mineral
deficiency disorders. The second part of the chapter presents a conceptual framework for
analysing the causes of malnutrition. The immediate causes of malnutrition relate to food
intake and infectious disease, while the underlying causes include: household food security,
access to health services and the health environment, and factors related to the social and
care environment.
4
Learning objectives
• Describe briefly the two extreme manifestations of protein energy malnutrition, maras-
mus and kwashiorkor, and their main identifying characteristics.
• Identify the three micronutrient deficiency diseases of greatest public health importance
worldwide as well as and three others which have occurred in populations dependent on
food aid.
• Describe the immediate and underlying causes of malnutrition by employing a concep-
tual framework.
What is Malnutrition?
Malnutrition is a broad range of clinical conditions in children and adults that result from deficiencies
in one or a number of nutrients. Malnutrition has been defined as,
... a state in which the physical function of an individual is impaired to the point where he or
she can no longer maintain adequate bodily performance processes such as growth, preg-
nancy, lactation, physical work, and resisting and recovering from disease.
In children, malnutrition is usually indicated by growth failure. Malnourished children are shorter
and lighter than they should be for their age. Though many people still refer to growth failure as
"Protein-Energy Malnutrition", or PEM, it is now recognized that growth may fail as a result of
deficiencies of various micronutrients, not just the macronutrients energy and protein. There are two
types of growth failure associated with malnutrition: wasting (acute malnutrition) and stunting (chronic
malnutrition). These can be measured and classified by anthropometry, or using body measurements
to assess nutritional well-being (see Chapter 5).
Protein-Energy Malnutrition is the most common form of malnutrition occurring among infants and
young children. Mild PEM manifests itself mainly as poor physical growth, whereas individuals with
severe PEM have high case fatality rates.
Marasmus and kwashiorkor are the two forms of protein-energy malnutrition. Both conditions may
be distinguished by their own particular clinical characteristics.
19
Box 4.1: Types of growth failure
Wasting Wasted children are extremely thin.
Wasting is the result of recent rapid weight loss or a failure to gain weight.
Wasting is readily reversible once conditions improve.
Wasting is evidence of acute protein energy malnutrition.
Wasting is measured by the weight-for-height index.
Adults can become severely wasted
Stunting Stunted children are short for their age.
Stunted children may have normal body proportions but look younger than their actual age.
Stunting develops over a long period as a result of inadequate nutrition or repeated infections or
both.
4 Unlike wasting, the development of stunting is a slow cumulative process and it may not be evident
for some years, at which time the child’s nutrition may have improved.
By two years of age, height deficits may be irreversible.
Stunting is measured by the height-for-age index.
The main distinguishing characteristics of kwashiorkor is oedema, or fluid accumulation in the

body as a result of severe nutritional deficiencies. Oedema may be detected by pressing the thumb
just above the ankle for three seconds; this will leave a definite pit. Loss of appetite is another
common feature. Mental changes are also common, resulting in a child who is apathetic and irritable.
WFP photolibrary WFP photolibrary
Malnourished Children
Note the oedema on the childs hands and feet, this is the key sign of kwashiokor a very serious form
of malnutrition.
20
WFP 4. MALNUTRITION
In addition, the child's hair becomes thinner and may change colour from black to light brown or
red. His or her cheeks may seem to be swollen, giving a characteristic moonfaced appearance. Any
child with kwashiokor is considered extremely malnourished and has a high risk of dying.
Marasmus is identifiable by severe weight loss or wasting. The ribs are very prominent, the limbs
emaciated, and the muscles extremely wasted. In contrast, the belly appears protuberant. Marasmic
children often have a good appetite and are quite alert. If treated correctly, a child suffering from
marasmus has a good prognosis.
Some children present a mixed form of both marasmus and kwashiorkor, known as marasmic
kwashiorkor.
Micronutrient malnutrition
Micronutrient deficiencies are widespread in developing countries. The most common deficiencies
in the world are due to lack of iron (anaemia), vitamin A (xerophthalmia) and iodine (goitre and
cretinism). Outbreaks of other types of deficiency disorders, although rare, have occurred, most
notably in emergencies among populations entirely dependent on food aid. These include deficiencies 4
of vitamin C (scurvy), niacin (pellagra) and thiamin (beriberi). Chapter 1 provides an overview of
Table 4.1 Micronutrient Deficiency Disease and Dietary Source from Food Aid Commodities.
Source in food aid

Micronutrient Deficiency disease
commodities
Iron Anaemia can be caused by lack of iron, folate or vitamin B12. Cereals, pulses, fortified
It is difficult to diagnose accurately from clinical signs, which blended food
include pallor, tiredness, headaches and breathlessness.
Vitamin A Night blindness: inability to see well in the dark or in a Fortified vegetable oil,
darkened room. An early sign of vitamin A deficiency. blended food.
Xeropthalmia, including Bitot’s spots and corneal ulceration

and night blindness. Vitamin A deficiency also weakens the
immune system and hence increases the severity, complications
and risk of death from measles, maternal mortality, etc
Iodine Cretinism: severe mental and physical disability which occurs Iodised salt, CSB.
in the offspring of women with severe iodine deficiency in the
first trimester of pregnancy.
Goitre: swelling of the thyroid gland in the neck caused by

iodine deficiency.
Niacin Pellagra is caused by niacin deficiency which affects the skin, Cereals, pulses, nuts, fortified
gastro-intestinal tract and nervous systems and is sometimes blended food
called the 3Ds: dermatitis, diarrhoea and dementia.
1
Thiamine Beriberi is caused by thiamin deficiency. There are many Cereals, pulses, fortified
clinically recognisable syndromes including wet beriberi, dry blended food
beriberi and infantile beriberi.
Vitamin C Scurvy is caused by Vitamin C deficiency. Typical signs Fortified blended food
include painful joints, swollen and bleeding gums, and slow
healing or re-opening of old wounds.
1 Wet Beriberi: the main feature is pitting oedema, which may result in circulatory failure and death; Dry Beriberi: the patient is thin and
wasted and has difficulty walking; untreated, the patient becomes bedridden; Infantile Beriberi occurs in breastfed infants under six months
of age as a result of inadequate thiamine in the breastmilk. In its acute form, the infant dies of cardiac failure.
21
A malnourished man, note the skin lesions

on his arm caused by niacin deficiency.
WFP photolibrary
the main micronutrient deficiencies, while Annex 1.1 and 1.4 includes a more detailed picture of
deficiency signs, indicators, and 'at risk' groups. Micronutrient requirements are given in Annex 1.2
and Annex 1.3. Table 4.1 lists some key micronutrients, the deficiency diseases that can result from
insufficient quantities of these micronutrients, and key sources of the micronutrients in food aid
commodities
Who is Most Vulnerable to Malnutrition?

Malnutrition, or the risk of becoming malnourished, may be transmitted from one generation to
another. Small women give birth to small babies who, in turn, are more likely to become small
children, small adolescents and, ultimately, small adults (Figure 4.1). While smallness may be genetically
inherited, the vast majority of small individuals in most poor countries are small because they have
suffered, or are currently suffering, from malnutrition. When considering approaches to combating
malnutrition, it is important in the long-term to adopt a life-cycle approach.
A low birth weight (LBW) baby is effectively born malnourished and is at higher risk of dying in
early life. By age five, s/he is more likely to be stunted (i.e. low height-for-age), a condition that will
probably persist through adolescence and adulthood. The stunted child is likely to become a stunted
adolescent and, later, a stunted adult. Stunted pregnant women are more likely to give birth to low
birth weight babies. And so the cycle turns (Figure 4.1). This inter-generational cycle of malnutrition,
maintained by poor and malnourished women (often unwittingly or against their will), underlines the
importance of WFP's Commitments For Women which stress the importance of protecting and
fulfilling women's rights to adequate nutrition. These commitments are described in Box 7.2 in
Chapter 7.
22
WFP 4. MALNUTRITION
Figure 4.1: Inter-generational Cycle of Malnutrition
Nutrition throughout the life cycle

Source: Commission on the Nutrition Challenges of the 21st Century (1999). Ending Malnutrition by 2020: An agenda for Change in the Millennium.
Final Report to the ACC/SCN.
A child has food, health and care needs that must all be fulfilled if s/he is to grow well. Most growth
faltering occurs between the ages of 6-24 months, when the child is no longer protected by exclusive
breastfeeding. At this time, the child is more exposed to disease and infection through contaminated
food or water and is dependent on the mother or caregiver for frequent complementary feeding.
Unfortunately, even a child adequately nourished after age 2 is unlikely to recover growth "lost" in
the first two years as a result of malnutrition.
The priority should be to prevent malnutrition from occurring among these 6-24 month old children
because:
• growth failure cannot be significantly corrected later, and
• the consequences of malnutrition are most serious at this age
Causes of Malnutrition
Malnutrition is not synonymous with a lack of food. In an individual, malnutrition is the result of
inadequate dietary intake, or infection, or a combination of both. These in turn derive from a
combination of food, health, and care related causes at the household and community level. Figure
4.2 provides a conceptual framework for analysing malnutrition and its causes at different levels in
society. It is relevant both to a development and an emergency context.
As reflected in Figure 4.2, health and nutrition are closely linked: disease contributes to malnutrition,
and malnutrition makes an individual more susceptible to disease. Severe malnutrition especially
increases the incidence, duration, and severity of infectious disease. The most common types of
disease suffered by young children in both stable and emergency situations are: diarrhoea, acute
respiratory infections, measles, and malaria. All of these conditions may contribute to malnutrition
through loss of appetite, mal-absorption of nutrients, loss of nutrients through diarrhoea or vomiting,
or through altered metabolism (which increases the body's need for nutrients).
23
Figure 4.2 A Conceptual Model of the Causes of Malnutrition
Source: UNICEF, 1997
Adapted from the UNICEF Framework of Underlying Causes of Malnutrition and Mortality
24
WFP 4. MALNUTRITION
Figure 4.3 Malnutrition-infection Complex
BETTER NUTRITION
NORMAL MILD MODERATE SEVERE

WEIGHT UNDERWEIGHT UNDERWEIGHT UNDERWEIGHT
WORSE WORSE SEVERE OR FATAL

INFECTION INFECTION INFECTION INFECTION
TIME
4
Mason (1996)
This vicious cycle, in which disease and malnutrition exacerbate one another, is known as "the
malnutrition-infection complex" (see Figure 4.3, below).
Adequacy of food intake relates to:
• The quantity of food consumed,
• The quality of the overall diet with respect to various macro and micronutrients,
• Its form of the food, including palatability, energy density, bulk, and
• How frequently the food is actually consumed.
Information about the underlying causes of inadequate dietary intake and the prevalence of certain
diseases is essential for planning and prioritising action.
Three Underlying Preconditions to Adequate

Nutrition
The framework in Figure 4.2, a modified version of the framework employed by UNICEF, describes
three main underlying preconditions to adequate nutrition:
Food ......... Health ......... Care
Food.... The food-related underlying cause is inadequate household food security (access to
food).
Health.... The health-related underlying cause refers to household access to adequate health services
and the adequacy of environmental health conditions.
Care.... Care relates to the social and care environment within the household and local community
and its impact upon nutrition, particularly with regard to women and children.
For an individual to be adequately nourished, all three of these preconditions need to coexist. In any
assessment of the causes of malnutrition, the relative roles of food, health and care must be examined.
These three underlying causes are not discrete but instead interact in important ways, as depicted by
the overlapping circles in the framework. Likewise, a successful strategy to treat malnutrition is
25
almost never based solely on a food security intervention. If food based approaches are linked to
interventions aimed at the health and care-related factors, then the overall effectiveness of the
combined actions is likely to be significantly enhanced.
Precondition 1: household food security

In simple terms, food security is concerned with people's access to food. It can be defined as:
Access by all people at all times to the food needed for an active and healthy life.
For a household this means the ability to secure adequate food to meet the dietary needs of all
members, either through their own food production or food purchases. Food production depends on
a wide range of factors, including access to fertile land, availability of labour, appropriate seeds and
tools, and climatic conditions. Factors affecting food purchases include household income and assets
as well as food availability and price in local markets. In emergencies, other factors - such as physical
security and mobility in war-affected regions, the integrity of markets, etc. - may come into play.
4
Precondition 2: health and environment
An individual or household's degree of access to good quality health services, safe water supplies,
adequate sanitation and good housing are preconditions for adequate nutrition. The health environment
influences exposure to, and therefore incidence of, infectious disease,.
Important health issues are: the existing primary health infrastructure, the types of services performed
at these facilities, their accessibility and affordability to vulnerable populations and, of course, the
quality of these services. Inadequate or delayed treatment of disease places a child at increased risk
by prolonging the disease and possibly increasing its severity.
Key environmental issues include the degree of access to adequate quantities of safe drinking water,
adequate sanitation systems, and adequate housing.
Precondition 3: the social and care environment

Malnutrition can occur even when access to food and healthcare is sufficient and the environment is
reasonably healthy. The social context and care environment within the household and local community
can also directly influence nutrition.
Appropriate childcare, which includes sound feeding practices, is an essential element of good nutrition
and health.
The major childcare activities and behaviours that influence nutrition are:
• Feeding behaviours, including breastfeeding and complementary feeding.
• Hygiene behaviours related to food, individuals, and home.
• Psychosocial behaviours, including responsiveness, warmth, involvement and opportunities for
learning.
• Health behaviours, such as service utilisation, oral rehydration therapy and home care.
Cultural factors and resources - like income, time and knowledge - condition caring practices. The
values of the society strongly influence the priority given to the care of children, women and the
elderly. Attitudes to modern health services, water supplies and sanitation also affect caring practices.
Finally, the care of children is particularly linked with the status, roles and responsibilities of women.
26
WFP 4. MALNUTRITION
Among poor households there are likely to be severe constraints on caring behaviours. Some of
these constraints may be the poor health and psychological state of the mother and other family
members, the absence of key family members, or the break-up of the family. Others may be self-
imposed, as when people decide to switch to a cheaper but less nutritious food.
In emergencies, displacement or forced migration is likely to cause severe social disruption and
upheaval which may break links with extended family and wider social networks that would normally
support the family in the care of its children and elderly. New social networks or groups - such as
local NGO's or church relief groups - may then evolve to replace these structures. Another factor
during emergencies which may diminish physical capacity, reduce energy intake and undermine caring
capacity is the extra work demands on caregivers to secure food (e.g., foraging for wild food and
poorly paid income-earning activities).
Critical to the design of programmes is an analysis of the care and social environment that:
• Takes into account the role and position of women in society in order to ensure that their
particular needs are met in the most appropriate manner.
• Identifies the roles of caregivers and the demands placed upon them to ensure supportive
interventions.
4
• Understands local attitudes to the most 'at-risk' groups in order to consider the feasibility of
targeting resources at those most in need.
• Identifies viable leadership structures and community networks in order to ensure community
participation and accountability.
Obviously, the success of a Programme hinges not only on resources given, but also on the ability to
reach those most in need and to give caregivers the support they need to use resources effectively in
the care of their families. It is also important to identify which caring practices are essential to a
meaningful nutritional intervention - particularly in emergencies - and to ensure that appropriate
steps are taken to support these caring practices. For example, the elderly may need assistance in
getting to food distribution sites during an emergency, while staff for therapeutic feeding programmes
may require training in order to provide appropriate psycho-social support for malnourished children.
Feeding practices - Optimal infant and young child feeding

Breastfeeding is the most important nutritional act in ensuring the adequate growth and
development of the newborn child. It simultaneously addresses her/his food, health and care
requirements. Breastfeeding should be exclusive for about the first six months of a child's
life, after which time semi-solids should be progressively introduced to the diet to complement
the continued breastfeeding. If a child less than six months old is not being breastfed, it is
important to understand the reasons - and possible constraints - behind this.
Complementary feeding needs to be initiated at around six months of age in addition to
sustained breastfeeding. By this age, the nutritional needs of the infant cannot be met by
breast milk alone. Complementary foods should no longer be to as "weaning foods" as this
incorrectly implies the cessation of breastfeeding. The quantity, quality and form of
complementary foods are important as well as the frequency of their use. Complementary
food should be safe, palatable, energy-dense, and micronutrient-rich.
The elements of care most critical for women during pregnancy and lactation are: extra quantities
of good-quality food, release from onerous labour, adequate rest, and skilled, sensitive pre- and
post-natal health care from trained practitioners.
27
Resources and Malnutrition

The basic determinants behind insufficient food, health or care are the quantity and quality of resources
available, who controls them, and who uses them. This is true from the household to the national
level. There are three main types of resources:
• human resources - the knowledge, beliefs, skills, physical health and nutritional status, etc. of
the population;
• economic resources - income, assets, food, time etc.; and,
• organizational resources - at a community level these may include alternate caregivers or
community support for care (e.g., crèches); at the national level, the health infrastructure is an
organizational resource; formal and non-formal institutions at all levels are organizational
resources.
Such resources may be combined in the form of projects or programmes aimed at improving nutrition.
4 Political, legal and cultural factors at national and regional levels may either promote or hinder the
efforts of communities, households and individuals to be well-nourished. The basic causes of
malnutrition thus relate to the political economy of nutrition, in other words to the influences on
nutrition of economics, political and social institutions and ideas, and the perceptions, values and
priorities of decision-makers. The political economy determines how nutrition outcomes are perceived,
the degree to which problems trigger remedial action, and the nature and extent of such action.
Culture is also important. For example, malnutrition is likely to be more widespread in societies
where women suffer social and economic discrimination.
Finally, war and insecurity are often characterised by a rapidly changing social and political arena,
leading, for example, to the marginalisation or oppression of particular social or ethnic groups and
an increase in their nutritional vulnerability. In addition, as war disrupts state institutions and civil
society, there is usually a deeply negative impact on health and nutrition.
Effects of Malnutrition
Malnutrition represents a massive drain on human and societal resources. A malnourished child is
more prone to illness and more likely to die than a well-nourished child. Malnutrition adversely
affects cognitive development and thus educational achievement, and it reduces an individual's ability
to work effectively. Finally, recent studies have linked childhood malnutrition with increased chances
for diabetes, heart disease and cancer in an individual's middle-aged years.
28
WFP 4. MALNUTRITION
Key Words
Anaemia Anaemia can be caused by lack of iron, folate or vitamin B12. It is difficult to diagnose
accurately from clinical signs which include pallor, tiredness, headaches and breathlessness.
Artificial feeding Feeding of young infants with breast milk substitute
Beriberi Beriberi is caused by thiamin deficiency. There are many clinically recognisable syndromes
including wet beriberi, dry beriberi and infantile beriberi.
Bitot’s spots Dryness accompanied by foamy accumulations on the conjunctiva that often appears near the
outer edge of the iris, and caused by vitamin A deficiency.
Complementary infant Period during which other foods or liquids are provided along with breast milk
feeding
Cretinism Severe mental and physical disability which occurs in the offspring of women with severe
iodine deficiency in the first trimester of pregnancy.
Goitre Swelling of the thyroid gland in the neck caused by iodine deficiency. 4
Iodine Deficiency IDDs cover a range of abnormalities including goitre and cretinism.
Disorders (IDD)
Kwashiorkor A form of extreme protein-energy malnutrition, characterized by oedema, loss of appetite and
apathy; the child’s hair thins and may change colour from black to light brown or red;
immediate and intense care is required.
Marasmus A form of protein-energy malnutrition identifiable by severe weight loss or wasting; marasmic
children often have a good appetite and are alert; the prognosis for a marasmic child is good if
treated correctly.
Night blindness Inability to see well in the dark or in a darkened room. An early sign of vitamin A deficiency.
Oedema Fluid retention; a distinguishing characteristic of kwashiokor; Oedema results from the
excessive accumulation of extracellular fluid in the body.
Pellagra Pellagra is caused by niacin deficiency which affects the skin, gastro-intestinal tract and
nervous systems and is sometimes called the 3Ds: dermatitis, diarrhoea and dementia.
Protein Energy Growth failure as a result of energy and protein deficiencies; the most common form of
Malnutrition (PEM) malnutrition among infants and young children; it is now recognized that growth failure can
also occur as a result of various micronutrient deficiencies.
Rickets Rickets is caused by Vitamin D deficiency and adversely affects bone development resulting in
pelvis malformation when severe.
Scurvy Scurvy is caused by Vitamin C deficiency. Typical signs include swollen and bleeding gums,
and slow healing or re-opening of old wounds.
Stunting (chronic Growth failure in a child that occurs over a slow cumulative process as a result of inadequate
malnutrition) nutrition and/or repeated infections; stunted children are short for their age and may look
younger than their actual age; measured by the height-for-age index; it is not possible to
reverse stunting.
Wasting (acute Growth failure as a result of recent rapid weight loss or failure to gain weight; wasted children
malnutrition) are extremely thin; wasting is measured by the weight-for-height index; readily reversible once
conditions improve.
Xerophthalmia Xeropthalmia is caused by Vitamin A deficiency and refers to a range of eye signs including
night blindness, Bitot’s spots and corneal ulceration.
29
Key Readings
Golden, M. 1995. Specific deficiencies versus growth failure: type I and type II nutrients. SCN News 12, 10-14.
WFP/UNHCR.
WHO. 1995. The management of nutritional emergencies in large populations (DRAFT).
Toole, M.J. 1994. Preventing micronutrient deficiency diseases. In: Workshop on the improvement of the nutrition of
refugees and displaced people in Africa, Machakos, Kenya, Geneva: ACC/SCN.
FAO Human Nutrition in the Developing World 1997
30
WFP 5. MEASURING MALNUTRITION AND NUTRITION SURVEYS
5 MEASURING MALNUTRITION
AND NUTRITION SURVEYS
The purpose of this chapter is to enable WFP staff to understand how nutritional status is measured,
to judge the of reliability nutrition surveys, and to aid interpretation of the results.
Summary
The chapter describes the use of body measurements to calculate an individual’s nutritional
or anthropometric status. Growth monitoring of children is a principle activity in Mother
Child Health Programmes throughout the world. An assessment of the nutritional status of
a population through nutrition surveys or surveillance should involve analysis of the extent
and severity of acute malnutrition, identification of those most affected, and changes over
time. Practical tips and guidelines exist on how to review and interpret the anthropometric
results of nutrition surveys.
Learning objectives
After reading this chapter WFP staff should be able to: 5
• Understand the process of calculating an individuals nutritional status using the weight
for height index.
• Understand how to classify the nutritional status of an individual according to cut-off
points.
• Understand how to check the reliability of a nutrition survey
Anthropometry
Anthropometry is the use of body measurements (usually weight, height and age) to assess nutritional
well being. In children, anthropometry is usually used to track growth or failure to grow. An individual’s
anthropometric status is sometimes referred to as his/her nutritional status. There are two types of
growth failure associated with malnutrition: wasting (acute malnutrition), and stunting (chronic
malnutrition). Both may be measured and classified by anthropometry (see Box 4.1, Chapter 4).
There are two types of anthropometric assessment:
1. Individual assessment for:

• individual growth monitoring, as part of a Mother Child Health Programme or for monitoring
of progress in supplementary or therapeutic feeding programmes.
• nutritional screening in order to refer individuals for further check-ups or to other services
such as supplementary or therapeutic feeding.
2. Population assessment:
• as part of emergency activities to monitor changes in nutritional status over time (e.g., nutri-
tional surveillance for famine early warning systems).
• as a ‘one-off’, or cross-sectional survey, during an emergency needs assessment in order to
assess the extent and severity of malnutrition, or to estimate numbers of children who might
require supplementary and therapeutic feeding.
31
Measuring Malnutrition
Measuring malnutrition always involves assessment of the anthropometric status of individuals. Usually
the focus is on children from 6 months to five years of age, as they are the most vulnerable to
nutritional deficiency. Adults are also sometimes included in anthropometric surveys in order to
assess the severity and extent of malnutrition throughout the population.
Body measurements and nutritional indices

The recommended body measurements for assessing nutritional status are weight, height and
sometimes mid-upper arm circumference (MUAC). If a child is too young or sick to stand, length
rather than height is measured (usually height is measured for children 85 cm and above and length
for children under 85cm).
The weight and height measurements of children obviously vary according to the children’s age and
sex. In order to take age and sex differences into account, a child’s measurements are transformed
into nutritional indices (e.g., weight-for-height) that describe his/her nutritional or anthropometric
status in relation to the statistical norms of a reference population group.
Guidelines for measuring height, length, weight and arm circumference are found in the forthcoming
WHO Manual on The Management of Nutrition in Major Emergencies. Other measures sometimes
5 used are skinfold thickness, head circumference and low birthweight.
Low Birthweight
The birth weight of a baby is an important anthropometric indicator, reflecting both the duration
of gestation and the rate of foetal growth. It is an indicator of the child’s future health and
nutritional status as well as an indicator of the mother’s nutritional and health status. As such,
birthweight is a pivotal indicator in programmes aimed at pregnant and lactating women and
young children. Children born with weights below 2.5 kg are defined as “low birth weight”.
Reliable birth weight data are often scarce. Data collected at hospitals may be skewed towards
better-nourished mothers who are more likely to give birth in such institutions. Nevertheless,
attempts need to be made in community-based programmes to track birth weights.
Determining nutritional status:

nutritional indices and reference values for children
A nutritional index compares a child’s body measurement with the expected value of a child of the
same height or age from a reference population. Since the reference standards for boys and girls
differ substantially, sex specific references are used where possible.
The World Health Organization recommends the use of a single reference standard based on data
from the US National Center for Health Statistics (NCHS) (WHO, 1986). In this way, any child’s
anthropometric status can be compared against a common international reference to determine his/
her nutritional status.
The international reference standards are available in various forms:
• Complete reference tables showing sex-specific values (WHO, 1997 The Management of
Nutrition in Major Emergencies).
• Plasticized cards for use in field surveys.
32
• The ‘thinness’ wall chart (Nabarro chart) used to classify a child’s nutritional status (weight-
for-height).
• Computer software programmes for processing anthropometric data (e.g., EPI-INFO, available
from WHO).
Despite some technical drawbacks, the NCHS/WHO reference remains the best for worldwide use.
Since the major effect on growth is environmental and not genetic, there is no need for local references;
though some countries (India, for example) have produced their own internal reference values which
may be used.
Different nutritional indices measure different aspects of growth failure (wasting and stunting) and
thus have different uses. Oedema (fluid retention) in children, the key clinical sign of kwashiorkor,
is not measured by a nutritional index. Where oedema is detected, the child is always diagnosed as
severely malnourished and his/her weight need not be recorded. The main nutritional indices, all
found in the NCHS/WHO reference, are shown in Box 5.1
Box 5.1: Nutritional Indices
Nutritional Index Description Use
Weight-for-height or
length (WFH)
WFH reflects recent weight loss or gain and so is WFH is usually the preferred indicator for
the best indicator to determine wasting and an
individual’s recent nutrition.
nutrition surveys in emergencies. 5
WFH is used as the selection criteria for
WFH is also useful when age is unknown. selective feeding programmes
Height-for-age (HFA) HFA reflects skeletal growth. HFA is the best indicator of stunting.
Weight-for-age (WFA) WFA is a composite index as it reflects a WFA growth charts are used to monitor the
combination of both wasting and stunting. It is weight gain of children in Mother and Child
used generally as a measure of ‘underweight’. Health programmes (‘Growth Monitoring’
on ‘Road-to-Health’ cards).
QUAC The QUAC stick is a simple tool for measuring The QUAC stick is particularly favoured
arm circumference and relating it to height. by the International Committee of the Red
Cross for nutrition surveys
Mid-Upper-Arm The World Health Organization recommends MUAC for age or for length/height can be
Circumference-for-age, using reference values to transform arm used as a quick, simple but less accurate
or length/height circumference measurements into MUAC-for- method of initial screening, when scales are
(MUAC-for-age/ or age/ or height. This is now considered preferable not available.
height) to unadjusted arm circumference measurements.
How to convert body measurements into nutritional indices

The two main methods for comparing a child’s measurements with the reference values are by
calculating either their percent of the reference median or by calculating their standard deviation
(SD or Z scores) from expected values.
“Percent of the median” expresses the child’s measurements as a percentage of the expected value
for the reference population.
Standard deviation scores (or SD scores) are a measure of the distance between the child’s value and
the expected value of the reference population. Ninety-five percent of the reference population have
anthropometric SD scores between -2 and +2 – that is, within the normal range. If a child’s SD score
falls outside the normal range, this signals a deviation from the norm in his/her nutritional status.
33
“Percent of the median” is more widely used in the field than SD scores. This is partly practical since
percentages are easier to understand and tables of reference values are readily available. Calculating
SD scores, on the other hand, requires appropriate computer software. Annex 4.1 shows how to
calculate percent of the median and SD scores.
Use of cut-off points to classify nutritional status

Cut-off points on the nutritional index are used for two main purposes:
1. Children are classified as malnourished if their nutritional status falls below an agreed cut-off
point. The cut-off points followed by the Reports on the Nutrition Situation of Refugees and
Displaced Populations (RNIS) and endorsed by the World Health Organization are shown in
Table 5.1.
2. As a guide for action; individual children whose anthropometric status falls below the cut-off
point are referred for treatment or further action (e.g., admission into a supplementary feeding
programme).
Note that a child may display several symptoms of malnutrition simultaneously (e.g., severe wasting
together with oedematous malnutrition, or severe wasting and severe stunting, etc.)
5 Table 5.1: Classification of Malnutrition: Use of Cut-off Points

and or Presence/Absence of Oedema
Well- Mild Moderate Severe malnutrition

nourished Malnutrition malnutrition
Oedema No No No Yes
(Oedematous
malnutrition)
Weight-for-height 90 to 120% 80 to 89% 70 to 79% <70%

(+2 to -1 SD) (-1 to –2 SD) (-2 to -3 SD) (<-3 SD)
(Severe wasting)
Height-for-age 95 to 110% 90 to 94% 85 to 89% <85% (-3SD)

(+2 to-1 SD) (-1 to -2 SD) (-2 to -3 SD) (Severe stunting)
Weight-for-age 60 – 80% <60% (-3 SD)

(-2 to -3 SD) (Severe underweight)
Arm circumference-1 <-3 SD

for age or
height/length
Arm circumference
2
>13.5 cm 12.5 - 13.5 cm 12.0 – 12.5 cm 11.5 - 12.0 cm
Body Mass Index Mild thinness: Moderate Severe thinness: <16

17 - <18.5 thinness:16 - <17
Notes on use of terms:

Total or global malnutrition is the percentage of children with moderate or severe malnutrition i.e.
below < -2 SD’s or <80% Weight For Height + children with Oedema
Wasting = moderate and severe malnutrition = % < -2 SD’S (<80% WFH)
1
Cut-off points for MUAC for age or height/length have yet to be tested in practice.
2
BMI= weight (kg) /height (m)2; these cut-off points apply to adults over 18 years of age.
34
Arm circumference
Measuring mid upper arm circumference (MUAC) is a rapid means of screening large numbers of
children to find the most malnourished. The cut-off points for classifying malnutrition according to
MUAC are shown in Table (5.1).
Rather than using unadjusted MUAC measurements, the World Health Organization now recommends
that MUAC-for height or MUAC-for-age reference values be used to transform MUAC measurements
into nutritional indices. This allows a better comparison of arm circumference across age groups,
but it requires that two measurements be taken, a more time consuming and complicated process.
MUAC does not produce results that are directly comparable with the results of the weight-for-
height index. Using both MUAC and weight-for-height (percent or SD) for nutrition surveys causes
confusion and therefore weight-for-height is the recommended nutritional index to measure wasting
(acute malnutrition) in nutrition surveys.
The QUAC stick is a simple

tool for measuring height,
marked with arm circumfer-
ence cut-offs (-2 SD and –3
SD). In other words, a
child’s height is measured
and that height should cor- 5
respond in a nutritionally
healthy child to a minimum
arm circumference. The
QUAC stick is used for
nutrition surveys by the In-
ternational Committee of
the Red Cross. A difficulty
with this procedure is that
it is only practical to mea-
sure the height of children
2 years and older.
Malnourished boy
Note that adolescents can also
WFP photolibrary become malnourished.
35
Measuring Malnutrition in Adults and Others

Increasing attention is being paid to assessing malnutrition in older children, adults and the elderly.
Women, especially during pregnancy and lactation, have long been considered a nutritionally vulnerable
group (a MUAC measurement of less than 22cm is a simple indicator of malnutrition among pregnant
and nursing mothers). And in some emergencies, high rates of malnutrition among adults and the
elderly have been noted.
The most useful measure of malnutrition in adults is body mass index (BMI), an indicator of weight
deficit in relation to height. BMI is also used to define grades of obesity. The cut-off points for
classifying BMI among adults are shown in Table 5.1. Average BMI in most adult groups in developing
countries falls in the range from 19 to 21 BMI. Two groups who are known to have BMI below
average are the Kenyan Samburu (17.6) and the Dinke from South Sudan (17.6). Both groups are
unusually tall.
Calculation of Body mass index (BMI) = Weight (kg) / Height (m) 2
Adolescents
5 Adolescence, which occurs from around 10 to 18 years of age, is a period of rapid growth. Hence,
the anthropometric indices to assess wasting, which are used for slower growing age groups, are not
applicable. WHO recommends that adolescent wasting be assessed by calculating body mass index
for age (weight/height 2 for age). BMI for age scores are compared to reference data for American
children and a cut-off point below the 5th percentile indicates malnutrition. To assess stunting, height
for age is used in the same way as for younger children; the same cut-off points apply.
The elderly
The elderly are a difficult group to define and a particularly difficult group to assess anthropometrically.
In developing countries, a person may be considered elderly from the age of 45 years onwards,
whereas in developed countries, old age is considered to start at around 60 years.
As the elderly are more likely to be disabled, bedridden, or unable to stand straight, accurately
measuring height and hence BMI is difficult. Furthermore, height decline occurs with age at a rate of
1 – 2 cm per decade and even more rapidly in older age. Research suggests that measures such as
armspan, halfspan, demispan and knee length can be used to estimate height in the elderly. However,
no standard methods of estimating height from these proxy measures has been established. Therefore,
at present, BMI based on actual height can only be assessed accurately in the non-stooping elderly.
Growth Monitoring
Growth monitoring is a principle activity in Mother Child Health Programmes throughout the
developing and developed world. Growth monitoring involves following changes in a child’s physical
development by taking monthly (or at least every three months) measurements of weight and
sometimes length. The child’s weight is plotted on a ‘Road to Health’ growth chart. This card,
usually kept by the mother, also records appointments at the MCH clinic, the child’s and parents
name, date of birth, address, siblings and immunization status.
Target growth rates are based on the WHO/NCHS reference values. A child’s growth is compared
with two reference curves on the weight-for-age chart: an upper curve, which is the median growth
curve for boys; and a lower reference curve for girls. The child’s pattern of growth should fall along
the same curve as age increases. Growth faltering is detected when there is no change or an actual
36
decrease between successive measurements. The growth chart is useful for the early detection of
health and nutrition problems and can be used as a basis to stimulate discussion between health
workers and mothers about child health, nutrition and the possible causes for any noted growth
faltering.
In practice, poor attendance and difficulties understanding growth charts (on the part of both health
workers and mothers) often hobble the effectiveness of growth monitoring programmes. In addition,
interpretation of changes in weight can vary considerably. Finally, the effectiveness of growth
monitoring ultimately depends on the effectiveness of the interventions that it can trigger.
Nutrition Surveys and Surveillance

Nutritional surveys and surveillance provide information for the purposes of policy making, planning
and programme management. Surveillance is a regular activity, whereas surveys may be either ‘cross-
sectional’ (one-off) or longitudinal (continuous monitoring of the same sample). A cross-sectional
survey may be repeated at intervals in order to monitor changes
A survey must have a well-defined purpose and objectives, reflecting how the information is to be
used. A common objective in an emergency nutrition survey is to estimate the prevalence of wasting
(acute malnutrition) among small children (6 to 59 months; or, alternatively, 60 to 115cm in height).
Depending on the survey objectives, some adult groups, particularly women, may be included in the
survey. The survey objectives determine the choice of nutrition indicator, the population to be sampled 5
(age, sex, area etc.), and the sampling method. Anthropometric data is usually just one type of
information collected during the survey or surveillance activities.
Sampling
Anthropometric surveys should be based on a representative sample of the population, meaning that
all members of the population have a known chance of being included in the sample. Procedures for
sampling are outlined in the WHO Manual on the Management of Nutrition in Major Emergencies.
The most common method for selecting a representative sample for a nutrition survey is a two-
stage cluster sample, in which 30 clusters of 30 children are selected. This approach is more convenient
than simple random sampling, as the numbers of sites that must be visited are considerably reduced.
Also, cluster sampling does not require a complete list of all sampling units (children, family’s etc.)
in the population (known as a sampling frame).
Systematic (interval) sampling or simple random sampling are also sometimes used. Where the
population is made up of groups of particular interest, the sample may be stratified (i.e., divided
between those groups).
The malnutrition rate, or prevalence calculated in the sample, is used to estimate the overall rate of
malnutrition among the population. The reliability or ‘precision’ of the estimate is measured by a
statistical term known as the confidence interval (CI). This reflects the error introduced by the
sampling method and the sample size. Confidence intervals are usually associated with a probability
of 95%, meaning there is a one in twenty chance that the population rate falls outside the confidence
interval. The size of the sample influences the size of the confidence interval (the precision of the
estimate).
Analysis of anthropometric data

Statistical analysis of anthropometric data derived from nutritional indices may include:
• Prevalence rate (the percent of children falling into the various categories of malnutrition) and
associated confidence intervals;
37
• Mean3 (or average) nutritional status and associated confidence intervals;

• Frequency distributions: a graph illustrating the spread of measurements around the mean. This
is a visual representation of the results and may be useful in revealing abnormalities in compari-
son with the reference population distribution curve.
Review of survey findings

WFP staff must frequently review anthropometric survey results. Apart from considering the actual
findings, the reliability and trustworthiness of the results should be questioned. A small amount of
error is usually unavoidable, as when the same person carrying out measurements records slightly
different results each time. This is acceptable and accounted for by statistical procedures such as
confidence limits. There are nonetheless certain points that a statistical layperson should review (or
for which he/she should seek the advice of an expert) when determining the reliability of a survey
report (see Table 5.2).
Table 5.2: Reliability Checks for Survey Results
Points to check What you need to know
Were the nutritional indices The recommended indicator of wasting (acute malnutrition) is WFH
5 appropriate for the objectives of the
survey?
If a sample was taken, was an Cluster sampling: how many clusters and how many children in each
appropriate random sampling method cluster? 30 clusters of 30 children is standard.
used?
Simple random sampling & interval sampling: was the coverage of the
sampling frame complete?
Did all children in the population have an equal chance of being

selected?
Was the sample size adequate? For a simple random sample about 450 subjects should be enough. The
size of the confidence interval reflects the sample size. If the confidence
interval is very wide the sample size may have been too small.
How many clusters are enough? For a cluster sample, there should be at least 24 clusters, preferably 30,
and the same number of children should be selected in each cluster.
In what ways might the sample be Systematic measurement error caused by faulty measuring equipment or
biased? faulty techniques.
Incomplete coverage of the population caused by non-compliance, or

absenteeism (migration, working outside the home etc.).
Interviewer bias.
Non-standardisation of methods
What measures were taken to reduce Training, following standard procedures and good practice guidelines
bias?
Were staff employed for the survey Duration & type of training.
already competent or given
appropriate training? Competence of trainers.
3
Body mass index is not normally distributed, in which case it is more appropriate to quote median rather than mean values.
38
Interpretation of anthropometric data

Interpretation of anthropometric results is not as straightforward as it would first appear. Simple
benchmarks and definitions are available to classify the severity of the situation.
The ACC/SCN of the United Nations regularly publishes Reports on the Nutrition Situation of
Refugees and Displaced People (RNIS). The information, obtained from a wide range of collaborating
agencies, both UN and NGO, is mainly about nutrition, health, and survival in refugee and displaced
populations (home based emergency affected populations are not included). The RNIS provides
definitions and benchmarks for a number of indicators, including nutritional indices, as shown in
Box 5.2
Box 5.2: RNIS Definitions and Benchmarks for Interpreting Nutritional Data
Indicator Definition Benchmark for guidance in interpretation
Wasting Less than -2 SD’s, or sometimes 5-10% usual in African populations in non-
80% WFH, usually in children 6- drought periods
59 months.
>20% ‘undoubtedly high and indicating a serious
situation’
5
>40% ‘a severe crisis’
Oedema Clinical sign of kwashiorkor ‘any prevalence detected is cause for concern’
Crude mortality rate The number of deaths per 10,000 1/10,000/day ‘serious situation’
of the population within a specific
time period. >2/10,000/day ‘emergency out of control’
Under five mortality The number of deaths among 2/10,000/day ‘serious situation’
rate children under five years of age
within a specific time period 4/10,000/day ‘emergency out of control’
These benchmarks are useful in stressing the degree of urgency for emergency assistance, but they
do not indicate what actions or interventions might be most appropriate to save lives and prevent
further health and nutritional deterioration in the population.
Nutritional status among adults

Fewer data are available on the nutritional status of adults compared to those available on children.
Data from Congo, Ghana, Mali, Morocco and Tanzania identified a range of between 0.3 and 2.8%
of adults falling below the cut-off of 16 BMI (Bailey and Ferro-Luzzi, 1995). These data sets were
presumably from stable non-emergency populations.
In an emergency context, much higher proportions of malnourished adults are to be expected. In
Somalia in 1992-93, the relief agency Concern found that most adults had a BMI of less than 16.0
and consequently used a cut-off of 13.5 as one of the admission criteria to their adult therapeutic
feeding programmes.
Useful interpretation of nutrition survey results must also consider the determinants or causes of
malnutrition, the mortality risks associated with malnutrition in particular emergency situations, and
the various influences that may bias or confound the results. Ultimately, this interpretation will
determine the choice of programme and affect the number of lives saved. Aspects of the situation
that must be considered when interpreting results of anthropometric surveys are listed in Box 5.3.
39
Box 5.3: Specific Issues Related to the Interpretation of Anthropometric Findings
Issues to consider
when interpreting What to look for
nutrition survey results
Have the results been What secondary sources are quoted – are they reliable? What important sources
corroborated by other have been omitted?
sources of information?
Is there a reasonable Is the information given based on hard or anecdotal evidence?

explanation of the causes of
malnutrition? In particular, Have all three groups of underlying causes of malnutrition been considered:
have food related, health
related and care related Household food security;
causes been considered?
The care and social environment;
Access to health services and the health environment.
What is the age range of the Where possible the survey results should be segregated by age group since
sample? And the age children under five years of age are not a homogenous group and their nutritional
distribution of the results? status is influenced by their age. Infants and younger children are usually more
susceptible to acute malnutrition, although older children and even adults also
become susceptible during a serious nutritional emergency.
5 Have population movements Migration of the population will affect the survey results when the nutrition status
or migration had an impact of those who leave is different to those who remain behind.
on the results?
How has seasonal variation Anthropometric status often fluctuates according to the time of year. For example,
in anthropometric status agricultural communities often suffer a ‘hungry season’ just before the harvest.
affected the results, or how This may coincide with an increase in the prevalence rate of malnutrition due to
would it be expected to temporary food shortages, higher prices, and seasonal increases in diseases such as
affect the results? diarrhoea or malaria associated with the rains. Following the harvest, most
children experience ‘catch-up’ growth.
What are the health risks of Obviously, severely malnourished children are at much greater risk of dying than
wasting (acute their well nourished counterparts. The size of this risk, though, varies, multiplying
malnutrition)? when several risk factors are present (inadequate water and sanitation, poor shelter
leading to exposure or overcrowding, highly malarial areas, limited immunization
etc.). This is why the conditions common in acute emergencies are so hazardous.
40
Key Words
Anthropometry Body measurements used as a measure of an individual's growth and nutritional

(anthropometric) status.
Anthropometric status The growth status of an individual usually in relation to reference values.
Cluster sample A representative sample where the sampling unit, children or adults, are selected in
groups (clusters) rather than individually.
Cut-off points The point on a nutritional index used to classify or screen individuals anthropometric
status.
Famine early warning An information system designed to monitor aspects of the food situation in a region
systems and thereby predict or forewarn of impending food shortages or famine.
Frequency distribution A complete summary of the frequencies of the values of a measurement of a sample.
This may be in the form of a table, histogram or frequency distribution curve.
Total malnutrition The sum of moderate and severe malnutrition, which includes the percent of all children
< -2 SD's (<80%) WFH + oedematous malnutrition
Growth monitoring To assess an individual child’s growth over time and determine if interventions are
required. The results are plotted on the child’s Road to Health chart.
Nutritional index A nutritional index is derived by relating a child’s measurement with the expected 5
value of a child of the same height (or age) from a reference population. Weight-
for-height is the nutritional index commonly used to reflect wasting (acute
malnutrition) in emergency nutritional assessments.
Nutritional screening To identify and select malnourished children in the population
Nutritional status The growth status of an individual, usually based on body measurements in relation to
a reference population.
Nutritional surveillance The regular collection of nutrition information that is used for making decisions about
actions or policies that will affect nutrition
QUAC The QUAC stick is a simple measuring tool used (in particular by the International
Committee of the Red Cross) for adjusting arm circumference measurements for height.
Percentage of the The anthropometric status of an individual expressed as a percentage of the expected
reference median value (or median) for the reference population.
Prevalence rate The percentage of the population with a specific characteristic at a given point in
time.
Reference population The WHO/NCHS/CDC reference values are based on two large surveys of healthy
(reference standards or children, whose measurements represent an international reference for deriving an
values) individual’s anthropometric status.
SD score (Standard This is a measure of the distance between the individual’s measurement and the
deviation or Z score) expected value (or median) of the reference population. The distance is expressed in
multiples of the reference standard deviation.
Stunting (chronic Growth failure in a child that occurs over a slow cumulative process as a result of
malnutrition) inadequate nutrition and/or repeated infections; stunted children are short for their age
and may look younger than their actual age; measured by the height-for-age index; it
is not possible to reverse stunting.
Wasting (acute Growth failure as a result of recent rapid weight loss or failure to gain weight; wasted
malnutrition) children are extremely thin; wasting is measured by the weight-for-height index;
readily reversible once conditions improve
41
Key Readings
Golden, M. 1995. Specific deficiencies versus growth failure: type I and type II nutrients SCN News 12, 10-14.
WHO. 1995. The management of nutritional emergencies in large populations (DRAFT).
42
WFP 6. FOOD AND NUTRITION ASSESSMENTS
6 FOOD AND NUTRITION ASSESSMENTS
This chapter aims to provide WFP staff with an overview of the objectives, methods of data collection,
analysis and interpretation involved in food and nutrition assessments. More detailed information
can be obtained from the “Guidelines in Emergency Needs Assessment” (WFP, September 1999).
Summary
A range of food security and nutritional assessments, including initial needs assessments of
major new emergency situations, and in-depth food and nutrition assessments of more
stabilized emergencies, are relevant to WFP. Assessments of malnutrition, described in the
previous chapter, are usually one important aspect of these wider assessments.
Assessment methodologies consist of a combination of quantitative and qualitative methods
or techniques. Nutritional surveys, for example, are quantitative, while rapid assessments
are qualitative. A key organizing principle of WFP’s approach to assessment and analysis is
vulnerability analysis and mapping. In this context, vulnerability relates to household food
security, in particular to the ability of a household to cope with risks such as drought,
market failure, conflict etc.
The last section in this chapter reviews the assessment of micronutrient deficiency disorders
and considers how WFP staff might assess the risk of micronutrient deficiency disorders
occurring in an emergency context.
6
Learning objectives
• Recognize the importance of ‘sound’ information and analysis as the basis for decision-
making.
• Understand the level of knowledge, skills and experience needed to apply different
methods of assessment.
• Describe a range of qualitative or rapid appraisal techniques, and give examples of
their practical application.
• Assess the risk of micronutrient deficiency disorders occurring among an emergency
affected population
Meeting Information Needs of Decision-Makers

Assessment is the first step towards more informed decision-making and thereby improved practice.
Decisions about the need for food aid and the quantity, type and recipient must be based on sound
information and critical analysis.
WFP undertakes and participates in a range of food security and nutritional assessments, for example:
• Initial needs assessments of major new emergency situations
• In-depth food and nutrition assessments in stabilised emergencies
• Joint UNHCR/WFP Food Assessment Missions (JFAM)
• Joint FAO/WFP Crop and Food Supply Assessment Missions
Assessments are a problem solving process. By figuring out the causes of malnutrition and the
resources available, a team can decide on appropriate action to address nutritional problems. This
43
process of problem assessment and resource analysis, followed by appropriate action, is one which
individuals and communities undertake in their daily lives for many different reasons. It forms the
basis of WFP’s programme or project cycle. And the more participatory the project or programme
cycle, the more likely the choice of action and the outcome will be correct. Finally, monitoring and
evaluation of the active project or programme are simply ongoing re-assessment.
WFP and Vulnerability Assessment and Mapping

Food security and vulnerability to food insecurity are the underlying principles of WFP’s approach
to assessment and analysis, its design of programmes and its targeting strategies. By developing an
understanding of vulnerability and the location of vulnerable groups, an effective response strategy
can be devised. Knowing the needs of the population concerned is just one step towards a full
analysis of the factors shaping their vulnerability.
Vulnerability can be viewed as follows: Vulnerability = exposure to risk + inability to cope
The risks to which households are exposed include, for example, drought, market failure, conflict,
etc. All of these seriously undermine a household’s productive activities, limit access to non-farm
sources of income and disrupt the functioning of markets. When the risk of such an event is high,
vulnerability tends to be greater. Some households may be able to protect themselves from these
risks, or cope to a limited extent with the effects of crisis, through a range of coping strategies. Their
ability to cope, by means of household stocks and assets, transfers from family abroad, local support
networks, government safety net programmes, etc., influences their overall vulnerability.
6 Assessment Methodologies and Methods

There are a range of assessment approaches that vary in terms of types of information needed and
methods of data collection and analysis. Assessment methodologies consist of a combination of
methods or techniques for collecting information - quantitative data (numbers and statistics) and/or
qualitative information (descriptions, views, opinions). The methodology may also specify the process
of analysis and interpretation.
There is no single correct assessment method or approach. The choice and selection of methods
depends on:
• The assessment’s aims and objectives; why do the assessment?
• The types of information required; what information is needed?
• Practical constraints that affect the methodology, for example: available resources to undertake
the assessment; time available for field work; access to the area and individuals present; the skills
and experience of assessment team members; availability of trusted translators.
In practice, it is often the practical constraints that determine how an assessment will be carried out.
In the early stages of an emergency, for example, decisions must be made almost immediately with
little time to collect detailed and accurate information.
All assessments use a combination of secondary data, i.e. information that already exists, and new
or primary data, collected through surveys and field assessments.
Secondary sources may be in the form of databases, statistics and reports. The knowledge, views
and opinions of agency representatives, academics, technical experts, journalists, etc. are other
important sources. A desk study of existing information (early warning system reports, government
statistics, maps, project documents, newspapers, journals, other databases and consultations with
experts) is essential for all assessments. Much of the quantitative data or figures quoted in rapid
assessment reports originates from secondary rather than primary sources. All sources of secondary
44
information quoted in an assessment report must be fully referenced in order for the reader to consider
the validity and reliability of the source. The methods, techniques and procedures commonly used in
assessments undertaken or considered by WFP are briefly described in Table 6.1.
The correct application of all these techniques requires specific training and experience.
Table 6.1 Assessment Methods and Techniques
Method Description
Secondary sources of information
Consultation with experts Consultations with technical or regional/local experts.
Desk study or review Published and unpublished statistics, reports, articles, maps, etc.
Primary sources of information
Anthropometric surveys The nutritional (anthropometric) status of a sample of children (or adults) is
(quantitative data) measured in order to calculate their nutritional status and estimate the prevalence
and distribution of malnutrition in the population.
Household surveys A random sample of households is selected and the relevant household member is
(quantitative data) interviewed using a pre-formulated household questionnaire. Interviewers are
trained to undertake interviews in a standardized way. Results are analysed
statistically, at a central point once all interviews have been conducted.
Rapid assessment
procedures
Rapid appraisal procedures form the basis of qualitative methodologies. Information
is collected and analysed as the assessment progresses (iteratively). Information 6
(qualitative information) gathering is decentralised. The focus is frequently on learning about differences
rather than estimating averages. Relative values are more important than absolute
values. Flexibility is a basic principle of rapid appraisal. The data needs and
collection techniques may change as the assessment proceeds.
Direct observation Personal observation of the physical condition of the local surroundings, condition
of crops, livestock, the physical appearance of people and their living conditions, the
interactions between people etc.
Transect walks A walk through the area, specifically seeking out areas of interest: agricultural areas,
water points, schools, the market, health centres or hospitals, areas where new
arrivals are settled, etc.
Semi-structured An informal approach to interviewing key informants who are purposefully selected
Interviewing individuals. A mental or written checklist of key areas or open-ended questions is
prepared in advance as part of the assessment team’s orientation and training. Points
of interest raised in the discussion with the key informant may be followed up.
Focus group discussions Managed discussions with selected small groups of individuals on a particular topic.
In an emergency setting this is often more difficult to organize and manage because
of the vested interests represented within a group.
Initial Needs Assessments of

Major New Emergency Situations
Initial rapid assessments (see Table 6.2) based on rapid appraisal techniques provide a preliminary
understanding of the situation, allowing decisions on short-term responses.
45
Table 6.2 Objectives, information needs, and methods for initial assessments of
emergency situations
Aims / objectives Information needed Methods / techniques
To decide if immediate Estimate beneficiary numbers; the Census and other counting techniques
food assistance is needed number of persons present and the rate
and if so, determine the (daily/weekly/monthly) at which people
number of beneficiaries are arriving, in order to establish a
and the most urgent food planning figure for the number of
needs (quantities to be persons to be assisted.
distributed immediately)
Estimate per capita nutritional Where possible adjust the initial planning
requirements. Use an initial planning figure according to:
figure of 2,100kcal per person per day.
The expected demographic profile in that
Adjust according to the populations country,
actual nutritional requirement.(see
Chapter 8) Health, nutritional and physiological status
(malnutrition, morbidity and mortality)
The climate (ambient temperature)
Expected physical activity levels
A rough estimate of the population’s Consider:

ability to obtain food for themselves
(their access to food) – is it roughly Food availability; food production, market
6 100%, 50%, 25% etc. prices and availability
Access to food; own food production,

waged labour and other sources of income,
trade, loans & gifts, aid or charity.
Also consider: Rapid appraisal procedures

(e.g.,observation at key sites, key informant
Which social or ethnic groups appear interviews, semi-structured interviewing)
worse affected and why?
Local food habits and preferences
Availability and access to a diverse

range of foods
Availability and access to milling

facilities
Extent to which people can prepare

food for themselves and for young
children (availability and access to
cooking fuel and other essential non-
food items)
In an initial assessment, a broad estimate of the need for food aid is acceptable. It may be justified on
the basis of either:
• Evidence of deterioration in nutritional status as a result of a lack of food, bearing in mind what
is expected for the time of year.
• Evidence of an absolute lack of food and deduction that certain groups will not access enough
food for their needs
• Evidence of severely restricted access to food for certain groups in the population.
46
Justification for food aid and estimates of the amounts needed are usually made on the basis of
several assessment techniques. The techniques commonly employed by Joint FAO/WFP Crop and
Food Supply Assessment Missions and WFP/UNHCR Joint Food Assessment Missions are good
examples.
Joint FAO/WFP Crop and

Food Supply Assessment Missions
In the case of crop failure affecting large numbers of people, food and crop assessment missions are
organised jointly by WFP and FAO. The FAO/WFP assessment missions calculate overall food aid
needs, commonly on the basis of a national food balance sheet:
National needs = per capita consumption x population figure
Import needs = national needs – production – carry-over stocks + losses/other uses
Food Aid Needs = import needs – commercial imports
Food aid needs cannot be determined only by a simple arithmetic exercise comparing consumption
needs with production. A number of visible and invisible economic assets also have to be considered
to construct a food balance sheet:
• National production
• Total population
• Post harvest losses, use for seeds, animal feed
• Per capita consumption
• Commercial imports/ exports 6
• Number of people affected by a crisis
• Production shortfall/needs of the affected population.
Since, in many countries, there is often a severe lack of existing or reliable information, only very
arbitrary judgments can be made. For example, substantial quantities of the national production may
flow out of the country unregistered; or, conversely, higher purchasing power in relation to a
neighbouring country may attract formal or non-formal imports.
WFP and UNHCR Joint Food Assessment Missions

(JFAM)
WFP and UNHCR undertake joint food assessment missions for all new refugee operations as well
as periodically for on-going operations. These missions make recommendations on:
• Number of beneficiaries
• Modalities of assistance
• Composition of the food basket
• Ration size
• Duration of assistance
• Logistical arrangements
47
UNHCR will normally provide the JFAM with a nutritionist and, if applicable, other specialist staff
to help assess levels of economic self-reliance. The information and analysis needs on which JFAM
recommendations are based are similar to those sought out during in-depth food and nutrition
assessments.
For more details of these types of assessments please refer to “Guidelines in Emergency Needs
Assessment” WFP September 1999, the Memorandum of Understanding signed between WFP and
UNHCR , WFP and UNICEF and Food Aid in Emergencies, Book B, WFP 1993.
If a response is planned, follow-up investigation should be incorporated as part of the programme
activities (e.g., establishing food or nutrition information monitoring activities or planning more in-
depth assessments).
In-Depth Food and Nutrition Assessments in

Stabilised Emergencies
Once an emergency has stabilised sufficiently, a more in-depth assessment may be undertaken for a
wide range of purposes. Examples of the differing objectives of food and nutrition assessments and
their importance in relation to programming are shown below. The type of information needed to
address these objectives and methods of data collection are also suggested.
In WFP/UNHCR joint operations, UNHCR is responsible for organizing regular nutrition surveys
and maintaining, in consultation with WFP, an effective system for monitoring the nutritional status
of emergency affected refugees, returnees or other persons of interest to the agency.
6 When WFP has agreed to work with UNICEF as partners in emergency and/or rehabilitation activities,
the framework for co-operation is described in a Memorandum of Understanding (Box 10.3). In the
initial assessment, re-assessment and routine monitoring, WFP takes the lead in assessing overall
food needs and logistics. UNICEF takes the lead in assessing prevalence of malnutrition, the special
needs of young children and women (including the need for care and facilities for food preparation),
as well as the needs for water, sanitation, health care, education and other social services.
Examples of objectives, information needs and choice of methods for

food and nutrition assessments
Objective 1 – Estimate or determine the extent, severity and distribution of acute malnutrition
Important in relation to establishing the need for:

• A general ration
• A broader range of strategies to support food security
• Supplementary and therapeutic feeding.
Information needed and analysis

Estimate:
• The prevalence, mean and distribution of wasting (acute malnutrition) among children under five
years old (see Chapters 4 and 5).
• The nutritional status of adults with particular attention to women of reproductive age.
48
Methods/ techniques
Random survey (e.g., two stage cluster survey of anthropometric status);
The weight-for-height/length of children under five years
The body mass index of women, or other adults
Objective 2 – Estimate indicators of morbidity, mortality and public health
Important in relation to determining the priority interventions in terms of reducing excess mortality,
morbidity and malnutrition.

Consider:
• Crude mortality rate & under five mortality rate (the number of total or under five deaths per
10,000 population within a specific period, usually one day)
• Evidence of epidemics of communicable disease, particularly diarrhoeal disease, acute respira-
tory infections, measles and malaria.
• Access to adequate shelter, sufficient blankets and clothing.
• Access to adequate supplies of clean water, and sanitation.
• Access to health services, in particular: measles immunization, oral rehydration therapy for
diarrhoea, access to essential drugs.
Methods/techniques 6
Mortality: grave watching/counting; case fatalities in health/feeding programmes; or household
survey
Morbidity: rapid assessment procedures; household survey
Objective 3 – Investigate local food habits, preferences, and food processing

and preparation practices
Important as it influences the choice and amount of different food items to be included in the food
basket (Chapter 6), including the degree of milling or other types of food processing.

• Select ration items and amounts according to:
• Nutritional considerations: risk of micronutrient deficiencies, vulnerable groups
• People’s food preferences and acceptability of available food commodities
• Ease of use (milling/preparation/ cooking)
• Fuel economy and other non-food requirements
• Security factors (e.g., risk of looting)
• Logistical factors (e.g., storage facilities)
Methods/ techniques
Review existing data/ information
Rapid assessment procedures
49
Objective 4 – Assess the ability of people to meet their own food needs (access to food)
Important in relation to planning rations and planning a broader range of strategies to support
household food security.
Information and analysis

Identify risks, and consider the impact on their livelihoods of, for example:
• Crop failure or loss of livestock
• Loss of jobs, fall in wages
• Collapse in terms of trade, limited availability of goods
• Collapse in social networks, or political oppression, including violence
Consider people’s ability to cope with these risks:

• Types of coping strategies and stage of coping
• Permanence of people’s response (how reversible is the situation - temporary coping strategies
versus permanent adaptive strategies)
• What proportion of people are engaged in marginal activities?
• Also consider: gender differences and relationships; the seasonal effects on access to food
Methods/techniques
6 Secondary sources, particularly early warning systems or food information systems.
Primary sources:
Interviews with key informants; interviews with focus groups; household visits, semi-structured
interviewing with occupants; transect walks/ direct observation; proportional piling; time trends,
mapping; activity profiles
Objective 5 – Assess the actual nutritional requirements of the population
Important in relation to planning rations (Chapter 9).

Adjust the initial planning figure of 2,100 kcal per person/per day (pppd) according to the population’s
actual nutritional requirement, based on:
• The known demographic profile of the population
• Health, nutritional and physiological status (malnutrition, morbidity and mortality)
• The climate (ambient temperature)
• Expected physical activity levels
Methods/techniques
Review existing information: national and local statistics, agency reports, etc.
50
Objective 6 – Assess caring capacity of household members
Important in the design of systems for the distribution and targeting of relief commodities and for
ensuring that the needs of women and children in particular are met.
Information and analysis
• Availability of income, and women’s access to resources
• Maternal time for child care
• Availability of alternative care providers
• Community child care facilities
• Maternity benefits, etc.
• Indicators of care provision may include: coverage of vulnerable groups during emergency gen-
eral feeding, training of therapeutic feeding programme staff in psychosocial stimulation for chil-
dren, etc.
• Proportion of women headed households with limited family or community support.
Methods/ techniques
Review existing data/ information
Rapid assessment procedures
Assessment of Malnutrition
Because malnutrition is one of the most significant outcomes of food related emergencies, under-
development and poverty in general, the assessment of the nature, extent, severity and distribution
6
of malnutrition in populations is of critical importance. Different methods are required for assessing
different types of malnutrition (see Chapter 4, which considers types of malnutrition). Growth failure
is usually measured by means of anthropometric surveys, which are commonly employed to assess
rates of malnutrition. Anthropometric surveys are considered in detail in Chapter 5. The prevalence
of particular micronutrient deficiencies is more difficult to assess accurately (see the following section),
and often all that can be achieved is an assessment of the risk of micronutrient deficiencies.
Assessment of Micronutrient Deficiency Disorders

Micronutrient deficiencies are extremely difficult to identify accurately since clinical signs are frequently
general and apply to a number of other diseases. A high level of skill is required to make an accurate
diagnosis. For example, beriberi was diagnosed in West Africa during 1997 based on the presence of
oedema (swelling). In fact, the swelling was ‘famine oedema’, or adult kwashiorkor, due to protein-
energy malnutrition.
Clinical deficiency signs for each micronutrient are shown in Annex 3.1. These are included for
guidance and it is emphasised that the diagnosis of clinical micronutrient deficiencies should only
be made by highly skilled, experienced professionals.
Micronutrient deficiencies can be assessed using clinical and biochemical indicators. Clinical measures
include visible signs of the deficiency, e.g., Bitot’s spots (vitamin A deficiency) or goitre (iodine
deficiency). Biochemical measures, which can indicate sub-clinical deficiency (i.e. deficiency with
no visible clinical signs), include serum retinol (vitamin A status), haemoglobin (iron status) and
51
urinary iodine. Biochemical assessment requires body fluid samples such as blood or urine. These
samples normally have to be analysed in a laboratory. This may not be feasible or appropriate in field
situations and emergencies. The recognition of clinical signs therefore remains the primary means of
identifying deficiencies.
There is, however, a basic flaw with relying on clinical signs to identify deficiencies: deterioration in
micronutrient status prior to the development of clinical signs will be missed, and with it, the
opportunity to take preventive action. Table 6.3 shows the steps which WFP staff can take to determine
the risk of a particular micronutrient deficiency disease outbreak in a population.
Table 6.3: Assessment of Potential Micronutrient Deficiency
Steps Source of information
Establish which micronutrients are lacking in the ration. WFP nutrition department for analysis
of ration content
Assess the availability and accessibility of local foods which may be Local or international nutrition
consumed to supplement the ration and establish whether they are rich expertise
sources of particular micronutrients (e.g., which fruits and vegetables
are commonly consumed and in which seasons they are available?).
Determine whether items of the ration are being exchanged or sold and WFP food monitors and local or
establish how this will alter the micronutrient content of the diet (e.g., international nutrition expertise
is a fortified food item in the ration like blended food being exchanged
for a food item lacking in particular micronutrients?)
6 Establish what existing micronutrient deficiencies were common in the Local or international nutrition and
beneficiary population before the emergency, the major cause of the health expertise
deficiency (i.e., lack of food source or infection), and which population
groups were most at risk.
Assess whether there are existing fortification or supplementation Local or international health expertise
programmes (e.g., health centres frequently provide iron and folate and programmes of other agencies
tablets to pregnant women and vitamin A and D tablets to young
children, while agencies such as UNICEF may support routine vitamin
A supplementation, or local salt iodization)
52
Key Words
Food aid requirement The estimated amount of food aid needed by an emergency affected population.
Food deficit or shortfall The difference between the mean energy requirement of a population and the
ability of people to obtain food on their own (N.B. not necessarily the same as
the food aid requirement)
Initial planning figure or The World Health Organization has estimated that the average estimated per
initial reference value for capita energy requirement in an emergency is 2,100 kilocalories.
energy requirements
Mean per capita energy This is the mean per capita energy requirement of a population and depends on
requirement of a population the populations demographic profile, their activity levels, the ambient
temperature in which they live, and their health and nutritional status.
Nutritional requirements The amount of energy, protein, fat and micronutrients needed for an individual
to sustain a healthy life
Key Readings
Boudreau, T., 1998. The Food Economy Approach: a framework for understanding rural livelihoods. Relief and
Rehabilitation Network, Overseas Development Institute, London.
FAO. 1996. Guidelines for Crop and Food Supply Assessment Missions, Food and Agriculture Organization of the
United Nations, Rome. 6
Gosling, L., and M. Edwards, Eds. 1995. Toolkits, A Practical Guide to Assessment, Monitoring, Review and
Evaluation. London: Save the Children.
Jaspars, S., and H. Young. 1995. General Food Distribution in Emergencies: from Nutritional Needs to Political
Priorities. Good Practice Review 3. London: Relief and Rehabilitation Network, Overseas Development Institute.
MSF. 1995. Nutrition Guidelines. Paris, France: Medecins Sans Frontieres.
The SPHERE Project, 1998, Humanitarian Charter and Minimum Standards in Disaster Response, Chapter 3, Minimum
Standards in Nutrition. Geneva.
WFP. 1998. Gender Mainstreaming in WFP; an Integrated Assessment. World Food Programme, Rome.
———. 1998. Vulnerability Analysis and Mapping (VAM), Vulnerability Analysis and Mapping Unit, Rome.
WHO (1995) The Management of Nutritional Emergencies in Large Populations (Draft).
Young, H. 1992. Food Scarcity and Famine, Assessment and Response, Oxfam Practical Guide No 7. Oxford: Oxfam.
WFP/UNHCR
53
7 TYPES OF NUTRITION INTERVENTIONS
The purpose of this chapter is to describe the different types of nutrition related interventions WFP
supports, to clarify their objectives, to give examples of different target groups, and to provide an
overview of appropriate monitoring and evaluation activities.
Summary
WFP nutrition related interventions include general food distribution, supplementary and
therapeutic feeding, school feeding and vulnerable group feeding. WFP is also involved in
strategies within wider programmes to prevent micronutrient deficiencies. The objectives
of these programmes are to save lives and support the vulnerable at critical periods in their
lives.
The identification of target groups depends on an assessment and analysis of vulnerability.
Food aid can be targeted at specific geographical areas, population groups, households, or
individuals. The final section of this chapter gives an overview of monitoring and evaluation
of food aid interventions.
Learning objectives
• Describe the main types of WFP’s nutrition related interventions.
• Give examples of the objectives of different types of interventions
• Understand the need for targeting and the basis for identifying different target groups.
• Identify appropriate indicators and methods for monitoring.
7
Two of WFP’s major priorities are:
• to save the lives of people caught up in humanitarian crises, through Food-For-LIFE
• to support the most vulnerable people at the most critical times of their lives, through
Food-For-GROWTH
These goals are achieved by programmes and projects that have a direct impact on the nutrition of
the most vulnerable sectors of society, including women, children and the elderly. These nutrition
related programmes are the focus of this handbook and include:
• General food distribution in emergencies (also see Chapter 8 Planning Food Rations, & Chap-
ter 10 General Food Distribution),
• Supplementary and therapeutic feeding (also see Chapter 9 Selective Feeding Programmes),
• School-feeding,
• Vulnerable group feeding through Mother and Child Health programmes (MCH).
In emergencies, there are two mechanisms through which food may be provided: general food
distribution and selective feeding programmes.1
1 Emergency Operations (EMOPs) are limited to meeting emergency food aid needs for a maximum period up to two years. Protracted Relief and
Recovery Operations (PRROs) include works that are ‘semi-developmental’, and will cover a period up to three years. PRROs aim to provide emergency
relief to the most vulnerable, but also promote longer-term food security, for example, by supporting production and education. The PRRO proposal
should include an ‘exit strategy’ for either the phasing out of relief, or it’s evolution into development projects.
54
WFP 7. TYPES OF NUTRITION INTERVENTIONS
School-feeding and vulnerable group feeding through MCH programmes, on the other hand, usually
fall under the category of Development Projects. These projects are implemented in stable situations
in which population groups remain vulnerable to food insecurity either because of poverty or because
they face regular periods of food stress.
WFP has developed policies on a range of issues affecting its programmes, two of which - Ending
the Inheritance of Hunger (Box 7.1), and WFP’s Commitments to Women (Box 7.2) – are described
below.
Box 7.1 Ending the Inheritance of Hunger
Hunger leaves scars. The visible kind may be born by survivors of famine. Less visible, but all
the more damaging, is the long term effects of hunger that run through families through
succeeding generations. Malnourished women give birth to babies whose start in life is already
compromised by their small size. The nutritional welfare of women and infants is vital to the
food security of entire families. Hunger passed from mother to child represents a ruinous
inheritance. It marks a cycle of hunger that transcends generations, unless the cycle is broken.
Food aid provided at crucial times in the lives of women and infants represents an investment
in future health and productivity.
Box 7.2: WFP’s commitments to women
Commitment Action
1. Provide direct access to - Assess the proportion of female headed households without family support
appropriate and adequate food and the burdens faced by women.
- Distribution to women as heads of households.
7
- Encourage women’s participation in the distribution and monitoring
process.
- Address women’s vulnerability to particular micronutrient deficiencies
2. Take measures to ensure - Create women’s committees, reinforce women’s groups, or increase
women’s equal access to, and women’s representation in community structures.
full participation in, power
structures and decision making.
3. Take positive action to facilitate - In addition to distribution directly to women:

women’s equal access to
resources, employment, Encourage women’s participation in FFW;
markets, and trade.
Improve women’s health through support for MCH;
Improve education through school feeding or food for training (FFT).
- By screening school feeding programmes on gender equality, target 50%

of education resources within a country to girls.
4. Generate and disseminate - Include gender segregated data in monitoring and evaluation systems.
gender data.
- Improve accountability through community advocacy and WFP
institutional mechanisms such as the country office gender task force,
gender focal points, etc.
55
WFP fully recognises the key role of women as household food managers. Hence, the Programme is
committed to giving women direct access to, and control over, food aid. WFP believes that targeting
women is key to ensuring that food reaches them and their families. Women are also encouraged to
take active decision-making roles in designing, implementing, and monitoring food distributions.
This is often difficult to operationalise as in many societies women’s role in decision making outside
the household is limited. WFP’s commitments to women, and the actions required, are summarised
in Box 7.2.
Nutrition Related Interventions in Emergencies

The aim of emergency food aid is to save lives by preventing or alleviating malnutrition . A summary
description of emergency food aid interventions and primary objectives is given in Box 7.3.
Supplementary feeding programmes aim to prevent or alleviate malnutrition in the nutritionally
vulnerable. Therapeutic feeding aims to rehabilitate the severely malnourished by providing special
‘therapeutic’ foods together with medical treatment. Box 7.3 shows the three types of emergency
food aid interventions and objectives.
Box 7.3: Types of food Aid Interventions and Objectives in Emergencies
Intervention Description Objectives
General Free distribution of a combination of food 1. Meet immediate food needs of populations
distribution commodities to the affected population as cut off from their normal sources of food.
a whole. If the population is cut off from
its food supply, or suffers abnormally high 2. Famine prevention or livelihood protection;
rates of malnutrition, food rations should preventing the adoption of damaging
meet nutritional needs coping strategies
7
3. Livelihood recovery; supporting
agricultural activities or livestock recovery.
Supplementary The provision of food aid - additional to 1. Nutritional support for moderately
feeding the general distribution - to nutritionally malnourished to save lives, where exposure
vulnerable groups (e.g., children under 5, to disease is high.
the malnourished, pregnant and lactating
women) and to those excluded from social 2. Prevent severe malnutrition.
networks (e.g., unaccompanied minors) or 3. Prevent malnutrition in those with high
unable to look after themselves (e.g., the requirements.
disabled and elderly).
4. Prevent malnutrition in under fives.
Therapeutic The rehabilitation of severely 1. Medical and nutritional support to save

feeding malnourished children by providing lives.
special foods that meets their entire
nutritional requirements combined with
medical treatment.
Feeding Programme Strategy

General food distributions are justified for populations suffering unusually severe food insecurity
and/or malnutrition. The decision to carry out a general food distribution is also influenced by existing
infrastructure and services, capacity and availability of implementing partners, security and access.
WFP only responds where the government or local authorities are unable or unwilling to respond.
56
The need for supplementary and therapeutic feeding programmes is determined by the prevalence of
acute malnutrition, access to food, the prevalence or exposure to disease, and mortality rates. Proposed
interventions based on these indicators are given in Chapter 8 and 9.
In emergencies, WFP needs to ensure that the risk of micronutrient deficiencies is minimised, bearing
in mind that emergency affected populations are usually extremely resourceful and employ a variety
of strategies to obtain foods to complement the general ration. WFP can assist populations to maximise
their intake of micronutrients by following WFP and UNHCR guidelines (WFP and UNHCR, 1997),
which recommend the following strategies in order of priority:
• Promoting the production of vegetables and fruits. The distribution of seeds, tools and other
agricultural inputs allows populations to grow vegetables and fruits for home consumption or
for sale. Access to land is likely to be a major constraint, particularly in refugee camps or in
areas that are heavily land-mined.
• Providing fresh food items in the general ration. Fresh food items, which are micronutrient
rich, can be purchased locally and distributed as part of the general ration. The difficulties of
transporting and storing fresh foods are, however, a major constraint.
• Adding to the ration a food which is rich in vitamins and minerals (e.g., blended foods).
Where there is a risk of a particular micronutrient deficiency, a micronutrient rich food source
can be added or exchanged for another food commodity in the ration.
• Providing fortified foods. Fortified commodities, such as vitamin A fortified oil and iodised
salt, have long been provided routinely in WFP rations. Fortified blended foods are increasingly
included in general rations. Cereals such as wheat flour can also be fortified with calcium, iron,
thiamine and niacin. (see Chapter 3, Fortification of Food and Blended Foods)
• Distributing micronutrient supplements. Distribution of the following micronutrient supple-

ments is frequently desirable: 7
1. Vitamin A every 6 months to infants and young children in emergency situations.
2. Iron and folate to pregnant women through MCH programmes and, possibly, through
emergency supplementary feeding programmes.
3. Multi-vitamins to severely malnourished individuals in therapeutic feeding programmes.
The distribution of micronutrient supplements other than in the above circumstances is highly
problematic. Apart from the problems of distributing actual pills, it is extremely difficult to ensure
correct compliance, as most vitamin pills need to be consumed on a daily basis. However, in
emergencies where there have been outbreaks of specific deficiency disorders, vitamin C supplements
and also niacin supplements have been distributed as an emergency measure to contain the outbreak.
Economic transfer value of food aid

In general food distribution programmes, the economic transfer value of food aid may, quite correctly,
gain increasing importance over time. Free food aid releases family income that would otherwise be
spent on food. As food aid is often the only humanitarian resource that emergency affected populations
receive, some of it may be sold to buy other essential needs or even more appropriate foods. However,
the observation of large-scale sales by the beneficiaries most likely indicates problems with targeting,
ration size or ration composition.
57
Nutrition Related Interventions with a

Developmental Focus
School feeding and vulnerable group feeding through MCH clinics may appear similar to
supplementary feeding in emergencies, but the aims differ considerably. In stable situations, the aim
is to promote growth and improve nutrition in the longer term and thereby strengthen ‘human
capital’, rather than serve as an immediate life-saving measure. Examples of the possible objectives
of these programmes are summarised in Box 7.4. For more in-depth information on these interventions,
refer to: “Supplementary Feeding for Mothers and Children: Operational Guidelines”, WFP 1998:
“Operational Guidelines for WFP Assistance to Education”, WFP 1999; “School Feeding Handbook”,
WFP/UNESCO/WHO, 1999.
Box 7.4: Description and Objectives of Developmental Programmes
Intervention Description Objectives
School feeding The distribution at school of breakfast, lunch - Contribute to improved scholastic
or snacks, prepared on or off-site. Ration performance
composition is based on the age range of the
target group, their nutrient requirements, as - Reduce short-term hunger and/or
well as acceptability and cost. The percentage micronutrient deficiencies
of requirements to be met depends on the type - Improve attendance and enrolment
of school. Day schools should provide 60-
75% of requirements, and boarding schools - Improve concentration
should provide 100%.
- Income transfer to poor families
Vulnerable group Provision of food aid to nutritionally - Promote growth in children under 5, or
feeding vulnerable groups through, for example, MCH under 3.
7 clinics. Nutritionally vulnerable groups could

include children whose growth falters (or - Prevent malnutrition.
children under 3) and pregnant and lactating - Provide a food supplement to those with
women. The ration is a supplement to higher nutritional requirements.
household food supply. This is most effective
when accompanied by nutrition education, - Improve health by improving MCH
which is why distribution through MCH attendance.
centres is preferred.
- Income support, safety net for poor families.
Who Needs Food? Identifying and Reaching Target Groups

The purpose of targeting is to identify those most in need and ensure they are covered by an
intervention. Other reasons for targeting include maximising the impact of limited resources, reducing
the risk of dependency, and limiting damage to the local economy. Restricting the number of
beneficiaries will reduce the quantity of food needed, but targeting requires more in-depth assessment
and, therefore, higher administrative costs.
Who is targeted largely depends on the objective of the intervention and on who is considered
vulnerable. This, in turn, depends on the type of assessment conducted:
• A nutritional assessment will identify the nutritionally vulnerable.
• A food economy assessment will identify food economy areas and groups that are vulnerable to
food insecurity; usually, within this, the most destitute groups are indicated.
• Famine early warning systems identify areas, and possibly population groups, experiencing
deterioration in food security or nutritional status.
58
Ideally, a combination of information is used to identify who is most vulnerable in terms of nutrition,
food security and risks to particular livelihoods.
Assistance may be targeted at individuals, households, population groups, geographical areas or
administrative divisions. Types of targeting are indicated in Box 7.5 below.
Box 7.5: Types of Targeting
Geographical Food aid targeted within a particular geographical area on the basis of nutritional surveys,
food security assessments (food economy areas) or deterioration in food security indicators.
Population groups Food aid targeted at groups with particularly vulnerable livelihood systems or at defined
population groups who have lost their access to food (e.g., displaced or refugees)
Households Food aid targeted at vulnerable households within a population (e.g., economically or
socially vulnerable, or households with malnourished individuals.
Individuals Food aid targeted at physiologically vulnerable individuals, usually in selective or

vulnerable group feeding programmes.
The nutritionally vulnerable can be identified by measuring anthropometric status and through
nutritional surveys (see Chapters 5). Other nutritionally vulnerable groups may include pregnant and
lactating women, the elderly, and the sick. Criteria for the socially vulnerable also exist but it can be
difficult for outsiders to identify these groups or determine their nutritional status. Socially vulnerable
groups may include female-headed households, unaccompanied minors, and the disabled. It should
be noted, however, that female-headed households are only considered particularly vulnerable if
they cannot access family support.
Targeting poor households within communities is extremely difficult. The identification of the poorest
households is most effectively done by community representatives and therefore depends on WFP’s
ability to locate knowledgeable community representatives who are committed to targeting the poor.
7
Even then, political, social and cultural factors may combine to frustrate efforts to target the most
needy households.
In emergency and development situations, targeting the poor through self-selection is sometimes
achieved with Food for Work programmes, the theory being that only the poorest and most needy
will accept the kind of work offered as well as food in lieu of wages.
Monitoring and Evaluation of Food Aid Interventions

Monitoring and evaluation activities assess the appropriateness, efficiency, effectiveness and impact
of an intervention. Monitoring is a continuous and systematic assessment of the progress of a particular
intervention over time. It is an integral part of day-to-day management and should enable WFP
managers to detect, and act on, problems at any level of food aid programming.
Evaluation is a one-off exercise that may be done when the project is completed or after an extended
period of time in a protracted operation. Evaluations should provide information to improve future
interventions.
In general, programme performance indicators should include measures of the timeliness of the
intervention, the degree to which resources were utilised as planned and the degree to which the
recommended quantities of food aid reached the intended beneficiaries. Performance monitoring
should also include measures of the extent to which beneficiaries (particularly women) are involved
in the programme. How programme implementation is monitored depends on the type of food aid
59
intervention (see monitoring guidelines for general distribution and selective feeding in chapters 9
and 10; monitoring in WFP school feeding and MCH programmes is described in their respective
operational guidelines).
Programme impact monitoring establishes whether the objectives of the intervention are being achieved
and, therefore, depends on clearly defined programme objectives. For each objective, a set of indicators
and the means to collect the necessary information need to be defined.
Monitoring impact on nutrition

The most obvious methods for measuring impact on nutrition is through nutritional surveys (Chapter
5) and data collection from supplementary feeding programmes in emergencies. When the aim of the
intervention is to promote growth, growth monitoring data from MCH clinics may be compiled and
analysed. In interpreting the results of nutritional surveys, it must be recognized that improvements
in nutritional status can also be the result of improvements in health.
In some situations, nutritional surveys may not be possible either because of poor road conditions,
widely dispersed populations or - in the case of conflict - because of insecurity or denial of access by
the warring parties. In these cases, information on nutrition has to be obtained indirectly, either
through estimating the impact of overall food aid on alleviating food insecurity or through using a
variety of Participatory Rapid Appraisal (PRA) techniques or “Beneficiary Contact Monitoring”.
PRA techniques to monitor impact include:
• Asking selected groups of beneficiaries to list the main uses of food aid, indicating the relative
importance of each use (proportional piling). This might include consumption, sale of certain
commodities, sharing with others, etc.
• Asking beneficiaries about the main benefits and drawbacks of food aid and asking them to
rank these. The most important benefit, for example, might be improved health, followed by
reduced loss of livestock, followed by providing a cash income, etc.
7
Chapter 6 discusses methods for PRA including household interviews, key informant interviews and
focus groups.
The positive and negative impacts of the intervention must be considered. For example, food aid
may be targeted at those most in need, but its provision may be dividing communities or fuelling
conflict. Distribution sites may increase the risk of attack or facilitate military recruitment. Distribution
at the wrong time of the year may have a disincentive effect on food production.
If programme objectives are not being achieved, this may be because (of):
• Incorrect situation analysis and project design;
• The assumptions underlying the successful achievement of objectives were incorrect;
• The necessary conditions for successful implementation did not exist, or conditions changed
during implementation;
• Problems in implementation (e.g., food did not reach the intended beneficiaries in recom-
mended quantities at the right time).
The appropriateness of the intervention is analysed by assessing how programme objectives and
design relate to the situation analysis. If the situation was incorrectly analysed, or programme objectives
do not follow from the situation analysis, programme objectives are unlikely to be achieved. Every
project proposal should also include a risk assessment, which outlines the key assumptions made
and essential conditions required for the successful achievement of objectives. For example, if the
objective is to improve nutritional status, a key assumption may be that public health will be addressed
by another agency. Essential conditions may include security, access, government support, etc.
60
Key Words
Appropriateness The relevance of programme objectives and design in relation to the situation
analysis.
Blanket supplementary A food/micronutrient supplement for all members of a group (children under 3 or 5,
feeding pregnant and nursing mothers, etc.) in order to prevent widespread malnutrition and
to reduce excess mortality.
Effectiveness The extent to which the intervention reached the intended beneficiaries, according to
assessed needs.
Efficiency Timeliness and appropriate use of resources in programme implementation.
Evaluation One off assessment of the appropriateness, efficiency, effectiveness and impact of an
intervention.
Food for work Food given as payment for work performed (in the context of a supervised public
works programme) to address acute food insecurity and create community capital.
General food Free distribution of a combination of food commodities, usually based on nutritional
distribution needs, to an emergency affected population.
Impact The effect of the intervention.
Monitoring The systematic and continuous assessment of the progress of an intervention over
time.
School feeding Provision of meals or snacks to school children to improve nutrition and promote
education.
Supplementary feeding The provision of food aid to the nutritionally or socially vulnerable (in addition to a
general distribution) to save lives and/or to prevent malnutrition.
Targeting Restricting the coverage of the intervention to those identified as the most vulnerable.
Therapeutic feeding Feeding and medical treatment to rehabilitate severely malnourished children.
Vulnerable group Provision of food to nutritionally vulnerable groups, preferably at MCH clinics, to
feeding promote growth and health.
Key Reading
7
Hallam, A. 1998. Evaluating Humanitarian Assistance Programmes in Complex Emergencies. Good Practice Review
7. Relief and Rehabilitation Network. Overseas Development Institute, London.
WFP. 1996. Working paper. Measuring performance of emergency operations
WFP. 1998. Enhancing capacity to enact change - A strategic action programme.
WFP. 1998. Gender mainstreaming in WFP; an integrated assessment.
WFP. 1998. Supplementary Feeding Guidelines for Mothers and Children: Operational Guidelines. World Food
Programme, Rome.
WFP. 1998. Operational Guidelines for WFP Assistance to Demobilisation and Reintegration Programmes (DRPs)
in Countries Emerging from Conflict Situations, March, 1998.
WFP. 1995. Operational Guidelines for WFP Assistance to Education, SCP 15/INF/3. World Food Programme,
Rome.
WFP. 1997. Assessment guidelines - Role and impact of WFP food aid with respect to national and household food
security.
WFP/UNESCO/WHO 1999. School Feeding Handbook. World Food Programme, Rome.
WFP/UNHCR. 1997. WFP/UNHCR Guidelines for Estimating Food and Nutritional Needs in Emergencies. United
Nations High Commissioner for Refugees, Word Food Programme.
WHO. 1999. Management of Severe Malnutrition, A Manual for Physicians and other Senior Health Workers. World
Health Organization.
61
8 PLANNING FOOD RATIONS
The purpose of this chapter is to enable WFP staff understand the process of planning adequate and
appropriate general food rations in emergencies. Rations for supplementary feeding, school feeding
and vulnerable group feeding can be found in their respective operational guidelines.
Summary
For convenience, the process of planning rations can be broken down into two stages. First,
the population’s nutritional requirements are estimated in terms of average per capita
requirements. In the early stages of an emergency, an initial planning figure of 2,100 kilocalories
per person per day is used for average energy requirements. This figure is later adjusted to
suit local conditions, taking into account the population’s actual nutritional requirements and
its ability to access food. Their requirements for micronutrients are also considered.
The second stage is the selection of the types and quantities of different ration items. This
takes into account factors such as nutritional considerations, food preferences, the acceptability
of available food commodities, ease of use, fuel availability, milling, and the cost and potential
resale value of items. Once the composition of the food basket has been agreed, the total food
aid requirements may be calculated.
Learning objectives
After reading this Chapter WFP staff should:
• Be aware of the two stages of planning a general ration;
• Know the nutritional requirements of an adequate ration in terms of the initial planning
figure for energy and the percent of energy to be provided by fat and protein;
• Be familiar with the range of food aid commodities usually included in a nutritionally
balanced ration; and be familiar with a range of typical rations;
• Understand the basis for adjusting the initial planning figure for energy;
8 • Understand the various considerations (apart from nutritional composition) that must be
taken into account when selecting foods for a ration;
• Be able to give examples of a range of fuel-saving strategies;
• Understand the issues around milling, particularly the need for providing flour in the
early stages of an emergency and the need for adequate milling capacity where whole
grain cereals are provided;
• Be aware of common commodity substitutions, which are necessary when certain items
are unavailable.
It is strongly recommended that readers also consult the WFP/UNHCR Guidelines for
Estimating Food and Nutritional Needs in Emergencies. Also, see Chapter 10 of this manual,
General Food Distribution.
Emergency food aid saves lives and restores or maintains nutritional health. Although its main function
is to feed people, food assistance can also contribute to the process of building up assets and promoting
the self-reliance of poor people and communities. The ration or food basket is the type and amount
of food that is provided daily to each beneficiary through general food distribution programmes
(Chapter 10). The composition of the ration is critical throughout the stages of an emergency and
62
WFP 8. PLANNING FOOD RATIONS
will vary considerably according to the local situation. Consequently, there is no such thing as a
standard WFP ration – each ration must be planned for a specific purpose and context.
Planning the composition of the food basket is an on-going task, beginning at the initial stages of an
emergency and continuing throughout the relief and rehabilitation phases. As a minimum requirement,
the food and nutritional needs of an emergency affected population must be reviewed annually. This
often leads to changes in the ration. Some changes may be temporary. For example, if certain food
aid items fail to arrive, other foods must be substituted if the ration level is not to be reduced.
The food basket or ration usually consists of a variety of basic food items (cereals, oil and pulses)
and, possibly, additional foods known as complementary food items (meat or fish, vegetables and
fruit, fortified cereal blends, sugar, condiments) which enhance nutritional adequacy and palatability.
An adequate ration is described in box 8.1.
Box 8.1: An Adequate Ration
An adequate ration should (be):

• Meet the population’s minimum nutritional requirements for light activity;
• Diversified, including a range of commodities;
• Acceptable and broadly familiar;
• Fit for human consumption (free of contamination, within shelf-life);
• Easily digestible for children and other vulnerable groups;
• Maximise the use of available resources;
• Economic in terms of fuel requirement, preparation time and waste.
Stages of Planning Rations

The two main stages involved in planning rations are:
• Estimating the population’s nutritional requirements.
• Selecting the types and quantities of commodities
8
Each stage involves a number of steps that should be followed either for planning a ration or for
evaluating an existing ration.
Stage 1: Estimating the population’s nutritional requirements
Using an initial planning figure for mean energy requirement

To facilitate planning, rations are based on average energy requirements, also known as the population’s
mean per capita energy requirement. This varies according to:
• The age and sex structure of the population, or its demographic characteristics.
• Health, nutritional and physiological status.
• Physical activity level (PAL).
• Environmental temperature.
This information is rarely available in the early stages of an emergency and so an initial planning
figure of 2,100 kilocalories is used to calculate energy requirements for populations. This reference
value has been estimated by the World Health Organization as the mean per capita energy requirement
in emergency situations globally. It supersedes the previous planning figure of 1,900 kilocalories.
63
This initial planning figure is based on the average energy needs of a “typical” emergency population,
assuming standard population distribution, body size, a warm climate, pre-emergency nutritional
status, and light physical activity. The figure is not specific to any age/sex group and should not be
used to assess requirements of individuals.
Adjusting average energy requirements to suit local circumstances

In time, the energy level of the ration may be adjusted upward or downwards once more is known
about:
• The age and sex structure of the population, or its demographic characteristics. Annex 8.1
gives the energy requirements for emergency situations based on a reference demographic
profile. When the demographic distribution is substantially different from normal (e.g., when
adult males constitute more than 50% of the total) this will influence the average require-
ments1 . For example, a population composed exclusively of women and children requires about
6 percent less energy than a standard population.
• Health, nutritional and physiological status. If, for example, the population is already severely
malnourished, or showing signs of micronutrient deficiency diseases, it is vital that the ration
addresses and compensates for these deficiencies. There is, however, no clear theory or guide-
lines on how the ration should be adjusted in these circumstances. Therefore, in practice, ration
modification often relies on ‘guess-work’ and is influenced by resource availability.
• Physical activity level (PAL). When the workload of adults exceeds light activity, the daily
ration should be increased - by 100 kilocalories for moderate activity, 150 kilocalories for
moderate/heavy activity, and by 250 kilocalories for heavy activity. Differences in workloads by
gender must also be considered.
• Environmental temperature. The reference temperature used to calculate the initial planning
figure of 2,100 kilocalories is 20oC (i.e., a warm climate). For every 5oC drop in temperature
below 20oC, an additional 100 kilocalories energy per day should be provided (or 1% for every
1oC fall). (Annex 8.2)
8 Adjusting the planning figure according to people’s access to food
An understanding of the different ways people are able to obtain food through their own activities
permits a better estimation of the amount of food a population can obtain on its own.
In theory, the ration size may be reduced according to people’s ability to obtain food on their own.
In practice, this must be done with extreme caution. Most estimates of the ability of people to feed
themselves are fairly crude. Even when estimates are reasonably accurate, there are likely to be
certain groups whose food security is well below the average household food security. Reducing the
ration across the board may mean that a significant proportion of the population receives insufficient
food to meet its needs.
In emergencies, people obtain food through a wide range of strategies and mechanisms, such as:
loans or gifts through social networks, credit schemes, illegal means (e.g., theft, prostitution, sale of
illicit goods, and even violence). These illegal strategies are difficult, if not impossible, to assess; and
although they may constitute a significant source of food for some people, their existence should not
automatically influence ration planning one way or the other. In other words, if a strategy is considered
damaging to the individual, family or community, additional rations provision may help discourage
the activity.
1 In practice in emergencies, it is usually better to stick with 2,100 kcal as the initial planning figure, as when there is a significant population displacement
there is almost certainly a shift from the normal age and sex distribution for that country.
64
Requirements for micronutrients

The recommended nutritional requirements for emergency affected populations for nutrients other
than energy are shown in Table 8.1. These figures are the average daily per capita recommended
intakes to cover the needs of a typical (whole) population requiring emergency food aid in a developing
country (WHO, 1995). They are for reference only - they define safe levels of intake for a population
group and are not the recommended intake for a particular individual. In addition, whole population
estimates are only available for a limited number of vitamins and minerals.
Table 8.1: Recommended Mean Daily Per Capita Nutrient Intakes

(for a typical population requiring emergency food aid in a developing country)
Nutrient Recommended daily intake
Protein Between 10 – 12 percent of the energy provided by the ration,

but less than 15% (52 – 63g)
Fat At least 17 percent of the energy provided by the ration (40g)
Vitamin A 500 µg retinol equivalents (1666 IU)
Vitamin D 3.2 - 3.8 µg calciferol
Thiamin (B1)** 0.9 mg (or 0.4 mg per 1,000 kcal intake)
Riboflavin (B2)** 1.4 mg (or 0.6 mg per 1,000 kcal intake)
Niacin equivalents (B3)** 12.0 mg (or 6.6 mg per 1,000 kcal intake)
Folic acid 160 µg
Vitamin B12 0.9 µg
Vitamin C (Ascorbic acid) 28 – 30 mg
Iodine 150 µg
Iron 20.4 mg* 8

* From a diet whose iron is of low bioavailability
** B-vitamin requirements are proportional to energy intake, as shown in brackets.
Stage 2: Selecting the types and quantities of commodities
A range of food commodities must be selected for the food basket. Common food aid commodities
in emergencies are listed in Box 8.2
Box 8.2: Types of Food Aid Commodities
• Cereals (includes whole cereal grains, processed grains and soy-fortified cereals)
• Oil and fats
• Pulses (peas, beans and lentils) and occasionally other protein-rich sources of food (canned meat, fish or
cheese)
• Blended foods (corn soy blend, wheat soy blend, or locally produced blended foods)
• Sugar
• Salt, spices or condiments (in refugee or returnee situations, iodized salt is provided by WFP while
UNHCR is responsible for condiments like pepper, tomato paste, magi cubes)
65
Fresh or dried vegetables and dried fruit (e.g., dried dates) are much less common food aid
commodities handled by WFP. Other agencies may provide them in order to supplement the general
ration.
The selection of foods from the particular groups or types of food depends on a number of
considerations:
• Nutritional and dietary considerations;
• Local food habits, preferences and the acceptability of particular food items;
• Storage, quality control and specifications;
• Ease of use (milling/ preparation/cooking);
• Availability and substitution of food items;
• Need for fortified foods, e.g. blended food (refer to Chapter 3);
• The cost of the ration and its potential resale value.
Nutritional and dietary considerations

Cereals, as the staple food, provide the main source of energy, a large proportion of the protein in
the diet, and a range of micronutrients. Pulses (beans and lentils) are needed to supply additional
protein and micronutrients. A source of fat or vegetable oil is essential to improve palatability and
increase the energy density of the diet. Protein and fat sources should contribute 10-12% and 17%
respectively of the energy content of the ration. The combination of cereals, pulses and oil provides
the major part of people’s nutritional requirements. Other commodities, though, must be added to
make up nutritional shortfalls - particularly in micronutrients - and to improve the palatability of an
otherwise extremely monotonous diet.
In emergency situations where people have no other source of food, the prime concern is often to
provide sufficient food to meet their energy requirements.
When people only have the food basket for survival, they are particularly prone to micronutrient
deficiencies because of the limited variety of foods and the lack of fresh foods. Even where foods
fortified with certain micronutrients are included in the ration - such as blended food, oil and salt -
the rations are often still below the recommended requirements for many micronutrients (see Annex
3.1).
8 Where people are securing some food for themselves and are receiving only partial rations, the foods
included in the partial ration must nutritionally complement the foods people obtain for themselves.
Examples of a range of adequate full rations proposed by WFP and UNHCR are shown in Table 8.2
Note that for rations 1,2,3 & 5, the cereal used for the calculation is maize meal. When this is
substituted by another cereal, the nutritional composition will change; in particular, it is likely the fat
content will drop slightly.
Local food habits and the acceptability of particular food items

Local food habits must be taken into account when deciding on rations. Wherever possible, the
staple food should be the same as the locally preferred staple, or at least familiar to the beneficiaries.
Also, the balance of commodities and relative amounts of each in the food basket should reflect the
population’s preference.
People’s established tastes and preferences are usually based on the wide range of foods that were
available prior to the emergency. These preferences usually persist through an emergency but may
be modified by cost and availability constraints. So, when asking people about their food preferences,
it is important to distinguish between their established preferences and their current preferences. A
variety of foods obviously increases acceptability. But the range available in an emergency ration is
66
Table 8.2 Examples of Adequate Full Rations for a Population Entirely Reliant on
Food Assistance
ITEMS RATIONS
(quantity in g)
Type 1* Type 2* Type 3* Type 4** Type 5*
Cereal flour/rice/bulgur 400 420 350 420 450
Pulses 60 50 100 60 50
Oil (vit. A fortified) 25 25 25 30 25
Canned fish/meat - 20 - 30 -
Fortified blended foods 50 40 50 - -
Sugar 15 - 20 20 20
Iodized salt 5 5 5 5 5
Fresh veg./fruits - - - - 100
Spices - - - - 5
Energy: kilocalories 2 113 2 106 2 087 2 092 2 116
Protein (in g and in % kcal) 58g; 11% 60g; 11% 72g; 14% 45g; 9% 51g; 10%
Fat (in g and in % kcal)* 43g; 18% 47g; 20% 43g; 18% 38g; 16% 41g; 17%
WFP/UNHCR Guidelines for Estimating Food and Nutritional Needs in Emergencies, Dec, 1997, page 5
often restricted as a result of practical constraints (e.g., if food is distributed by air drop or air lift).
A final consideration is that the acceptability of food commodities is directly influenced by its
quality, a factor that can be at least partially controlled by quality control during storage, transport
and handling.
8
Storage, Quality Control and Specifications
The quality of food commodities must be maintained as much as possible throughout transport,
handling, storage and distribution. A system of quality control for all commodities must be implemented
to ensure that food distributed to beneficiaries is of good quality, safe for human consumption and
that it meets the required specification. Specifications for vitamin and mineral fortification of blended
food, based on the Codex Alimentarius, are established by WFP/UNICEF/UNHCR.
Food Processing and Preparation

Food commodities should be easy to prepare with the minimum use of fuel. The ease of preparation
is especially important in the early stages of an acute emergency.
Adequate supplies of essential non-food items must be ensured to allow the proper preparation and
consumption of items in the food basket. Every household should have access to at least one cooking
pot, enough fuel for food preparation, water containers, and soap. Other basic non food needs are
cooking stoves, family cooking sets, emergency shelter, tarpaulin material, plastic sheeting, and
67
blankets. Storage containers, plastic bags etc., may need to be distributed where people receive
milled cereals or blended food, which, once contaminated, cannot be cleaned (unlike whole grain
cereals). The type of food in the ration and the availability of essential non-food items have a
significant impact on the demand for cooking fuels (see Box 8.3 and Annex 8.3). Cooking fuel
should be considered a basic need during an emergency and provided in the emergency phase if not
otherwise available.
Improved (fuel-efficient) stoves

Improved stoves rely on (a) enclosing and insulating the fire and/or (b) controlling the airflow. Simply by
shielding a wood fire from draughts 30 – 40 percent fuel savings can be achieved. Improved stoves are
usually made with mud, metal, clay, ceramic or a combination.
Energy-saving cooking practices:

The use of tightly fitting lids and the correct choice of pot. Removal of excess soot build-up. Cutting foods
up small. Pre-soaking of beans. Putting fires out promptly etc. Grinding of beans and hard grains, such as
maize.
Collective cooking arrangements, in which the numbers served from the same pot are increased to maximise
efficiency.
The use of alternative biomass fuels (alternatives to firewood), for example: peat, charcoal, grass. Typical
consumption levels of firewood range between 1 – 2 kg per person per day.
Use of non-biomass fuels (solar cookers and kerosene stoves). Solar cookers can only be used where
there is high enough exposure to the sun’s rays. Fireless cookers, or haybasket cookers, are usually made
with a basket or box insulated with cloth, newspaper or wood shavings and with a tightly-fitting insulated
lid.
The use of kerosene for cooking in an emergency requires special stoves and fuel storage containers. Fire
risk is considerable at all stages of distribution. People may be unaware how to operate the stoves, which
increases already significant fire risk. For these reasons, the use of these stoves is discouraged at household
level but may be used communally where there is less fire risk and less chance of the sale of fuel and
hardware.
8
Box 8. 3 Fuel-saving Strategies
If unfamiliar food items must be distributed or unfamiliar cooking methods promoted, beneficiaries
should be fully informed about their value and use (see Chapter 11). For example, parboiled rice,
blended food, yellow maize meal and improved stoves have all been well accepted in emergencies
when the benefits were fully understood.
Milling cereals
Cereals are usually milled into flour or meal (coarse flour) prior to cooking. This makes them more
versatile in terms of the dishes that may be prepared, more palatable, and it also reduces the fuel
requirements for cooking.
A needs assessment should determine whether cereals are to be provided in whole grain or as flour
(in the case of refugee and returnee situations, a joint WFP/UNHCR mission carries out the assessment;
see Chapter 6). For practical, nutritional and environmental reasons, WFP and UNHCR are
committed to providing milled grain, rather than whole grain, especially in the early stages of an
emergency. The provision of milled cereals may be difficult to sustain in protracted operations.
68
(Please refer to WFP’s Environment Guidelines)

If whole grain is provided, local milling capacity must be available. As milling by the beneficiaries
reduces the volume of the cereals in the ration by up to 20%, the ration should include compensation
for this loss as well as for milling costs. This compensation is normally 15 percent in East Africa and
20 percent in Francophone Africa. It is usually provided ‘in kind’, not in cash. WFP is responsible
for mobilizing the necessary resources for milling and will provide milling facilities for the beneficiaries
where feasible.
In general, it is easier to store cereals as whole grains for subsequent local milling rather than to mill
prior to dispatch. Flours has much poorer keeping qualities than whole grains.
Availability and Substitution of Food Items

The selection of food items in the food basket and the amounts given may be partly determined by
availability. When certain ration items are unavailable they can be replaced by other available food
items in order to maintain as far as possible the nutritional levels of the food basket. This substitution
should only be temporary and beneficiaries must be fully informed of the change in food basket
composition through the public information system (see Chapter 10). The rate of substitution depends
on the commodities that are being substituted for one another. Some common examples are shown
below:
Blended food and beans 1 to 1

Sugar and oil 2 to 1
Cereal and beans 2 to 1
Cereal for oil (not oil for cereal*) 3 to 1
If, for example, no oil is available for inclusion in the ration, either 100g sugar or 150g cereals could
substitute for 50g oil.
Box 8.4: Examples of food commodity substitutions

8
When there is insufficient food aid available to meet the agreed basket of food items for the whole
population, the following options are available:
• Postpone distribution until a full ration for the total population is available;
• Distribute an equal share of available commodities to all of the population (i.e., reduce rations);
• Give a larger or full ration to vulnerable groups in the population and a smaller (or no) ration
to the general population.
Whichever option is adopted, beneficiaries must be kept fully informed of any changes to the
distribution schedule or amounts and the reason for the change. This information is vital, not least
because beneficiaries must plan their consumption during periods of shortage.
When full distribution of the agreed ration has not been possible, the shortfall in the ration is not
automatically distributed when food aid eventually does arrive (retrospective or retroactive
distribution). In the case of refugees or returnees, the decision on any retroactive distribution is
made jointly by WFP and UNHCR, taking into account:
• The nutritional status of the beneficiaries;
• Measures taken by beneficiaries to make up shortfalls and any liabilities or costs incurred in
coping with the shortfall;
69
• Its economic impact;

• The future availability of resources.
The Cost of the Ration and its Resale Value

As described in the previous sections, the most cost-effective ration is based on a combination of
cereals, pulses and oil. Some food aid commodities (such as canned meat, fish, and biscuits) are
relatively more expensive, so that their routine inclusion in the ration is not cost-effective. Not all
nutritional improvements to the ration are costly. For example, including vegetable oil fortified with
vitamin A or iodized salt incurs marginal additional costs (Chapter 3).
A limited degree of food commodity trading at the household level is acceptable provided there is no
large-scale diversion of assistance or detrimental effects on the health/nutritional status of the
community. Certain commodities may have a potentially high resale value (e.g., sugar and oil). The
resale of these commodities may allow beneficiaries to purchase other essential food items - such as
fruits and vegetables - that are not otherwise available in the diet.
Calculating Food Aid Requirements

Once the size and composition of the ration has been agreed upon, food aid requirements can be
calculated.
Food aid requirements (per month)
Ration item (pppd) x Beneficiaries x Planning period x Transport loss adjustment
Ration item: Individual amount of each ration item per person per day
Pppd Per person per day
Beneficiaries: The projected average number of beneficiaries for the project

8 Planning period: The duration of the feeding operation in days.
Transport loss adjustment Add on percentage for losses during transport, storage and handling:
Country with port +5%; Landlocked country +10%
This formula for the calculation of food aid requirements is misleadingly simple. In practice, the
accuracy of estimates depends on the reliability of the information provided. At each stage of planning
rations, every effort must be made to obtain accurate and reliable data. No figure is more crucial
than the estimation of numbers of beneficiaries, which likewise can change as the emergency situation
unfolds.
70
Key Words
Basic food items Basic food items include: cereals, oil, and a protein-rich food such as pulses
(beans/peas etc.) and/or fish/meat in canned or dried form.
Blended food Blended foods are a pre-cooked fortified mixture of cereals, pulses and other
ingredients (e.g., wheat soy blend, corn soy blend, 'faffa').
Complementary food items Complementary food items include fresh meat/fish, vegetables/fruit,
fortified cereal blends, sugar, condiments, salt and spices.
Extraction rate The extraction rate is the proportion of the whole cereal grain remaining
after the milling process. This varies according to the type of cereal and the
milling process.
Food aid requirement The estimated amount of food aid needed by an emergency affected
population.
Food deficit or shortfall The difference between the mean energy requirement of a population and
the ability of people to obtain food on their own (N.B. not necessarily the
same as the food aid requirement).
Initial planning figure or initial The World Health Organization has estimated that the average estimated per
reference value for energy capita energy requirement in an emergency is 2,100 kilocalories.
requirements
Mean per capita energy Depends on the population’s demographic profile, activity levels, the
requirement of a population ambient temperature, and its health and nutritional status.
Milling To mill whole grain cereals, either by machine or hand grinding, to flour or
meal.
Nutritional requirements The amount of energy, protein, fat, and micronutrients needed for an
individual to sustain a healthy life.
Reference Temperature The reference temperature used to calculate the mean per capita energy
requirement of a population is 20’C. For every 50 C drop in temperature
below the reference, an additional 100 kcal should be added to the
requirement.
Parboiling The process of parboiling involves soaking, steaming and drying the grain 8
(e.g., rice or wheat/bulgar). In the case of rice, for example, it preserves a
higher proportion of nutrients in the grain compared with polished or highly
refined types.
Key Readings
Jaspars, S., and H. Young. 1995. General Food Distribution in Emergencies: from Nutritional Needs to Political
Priorities. Good Practice Review 3. London: Relief and Rehabilitation Network, Overseas Development Institute.
Mears, C., and H. Young. 1998. Acceptability and use of cereal-based foods in refugee camps. Case-studies from
Nepal, Ethiopia and Tanzania., Oxfam, An Oxfam Working Paper.
MSF. 1995. Nutrition Guidelines. Paris, France: Medecins Sans Frontieres.
Schofield, E. C., and J. B. Mason. 1994. Evaluating energy adequacy of rations provided to refugees and displaced
people. Workshop on the Improvement of the Nutrition of Refugees and Displaced People in Africa.
UNHCR. 1998. Environmental Guidelines. Domestic Energy in Refugee Situations, UNHCR, Geneva.
WFP/UNHCR. 1997. WFP/UNHCR Guidelines for Estimating Food and Nutritional Needs in Emergencies. United
Nations High Commissioner for Refugees, Word Food Programme.
71
9 SELECTIVE FEEDING PROGRAMMES
The purpose of this chapter is to help WFP staff make decisions about the need for different types of
selective feeding programmes in emergency situations.
Summary
There are two forms of selective feeding programmes: therapeutic feeding programmes
(TFPs) and supplementary feeding programmes (SFPs). The objective of TFPs is to reduce
mortality in severely malnourished individuals while the objective of SFPs is to prevent
the moderately malnourished becoming severely malnourished. Information is provided in
this chapter on:
target groups for different types of programmes, criteria for establishing programmes,
important principles of programmes, feeding regime and rations for different types of
programme, admission and discharge criteria, assessment of impact.
Learning objectives:
• Assess the need for therapeutic and supplementary feeding programmes
• Understand the objectives of both type of programme
• Understand the basis of establishing selection and discharge criteria and the use of
nutritional index cut-off points in adhering to these criteria
• Understand the relative advantages of ‘wet’ versus ‘dry’ supplementary feeding
programmes
• Describe the stages and components of therapeutic feeding
• Identify key indicators used to monitor and evaluate selective feeding programmes
• Estimate the food requirements of a selective feeding programme
Types and Objectives of Selective Feeding

Programmes
9
There are two forms of selective feeding programmes:
• Therapeutic feeding programmes.
• Supplementary feeding programmes.
Therapeutic feeding programmes

Therapeutic feeding programmes (TFPs) are targeted at the severely malnourished (wasted
individuals). The main aim is to reduce mortality. In most emergency situations, the majority of
those with severe wasting are young children. There have, however, been cases where large numbers
of adolescents, adults and the elderly have become wasted (e.g., Somalia during the height of the
civil war in 1992). In these situations, separate TFP facilities may be established for older age groups.
72
WFP 9. SELECTIVE FEEDING PROGRAMMES
Supplementary feeding programmes (SFPs)

There are two types of SFPs:
·Targeted SFPs: The main aim of targeted supplementary feeding programmes is to prevent the
moderately malnourished becoming severely malnourished. These types of programmes usually
provide a food supplement to the general ration for mild and moderately malnourished individuals
and for selected pregnant and lactating women and other nutritionally vulnerable groups.
·Blanket SFPs: The main aim of a blanket SFP is to prevent widespread malnutrition and related
mortality in nutritionally vulnerable groups by providing a supplementary ration for all members of
the group (e.g., children under five, pregnant and lactating women, etc.).
Target groups for supplementary feeding programmes

As set out in the most recent UNHCR/WFP Guidelines on Selective Feeding Programmes, the
primary target group for targeted SFPs are:
• Mild or moderately malnourished children under five years of age.
Other groups, which may be covered, are:

• Children discharged from TFPs;
• Clinically malnourished individuals over 5 years of age;
• Pregnant and lactating women who are nutritionally vulnerable for medical or social reasons.
The target groups in blanket SFPs are:

• Children under 5 years (or 3 years if resources are scarce);
• Pregnant women from the third month of pregnancy;
• Lactating mothers up to six months;
• Adults showing signs of malnutrition;
• The elderly and sick.
The priority given to these different target groups will depend on several factors, among them:
agency resources, the size of population groups, and how the emergency and resulting interventions
are affecting the food security of different groups.
These target groups are not set in stone and there must be flexibility in defining and prioritising
groups for each situation. Nutritional vulnerability varies between emergencies and among different
population groups. Consequently, there should always be some attempt to identify nutritionally
vulnerable groups in any emergency situation.
9
Criteria for Establishing Selective Feeding

Programmes
Therapeutic Feeding Programmes (TFPs)
The main criteria for establishing TFPs is an excess of severe wasting cases that cannot be adequately
treated by existing health care facilities.
Targeted Supplementary Feeding Programmes (SFPs)
The criteria for establishing targeted SFPs are based on the need to rehabilitate:
• Large numbers of mild or moderately malnourished individuals (prevalence of 10-15% wasting
in the population);
73
• Large numbers of children who will likely become mild or moderately malnourished due to
factors like poor food security, high levels of disease (prevalence of wasting between 5-9% plus
aggravating factors);
• Those children discharged from existing therapeutic feeding programmes.
Blanket Supplementary Feeding Programmes

Blanket SFPs - which are primarily preventive in nature - are normally set up when the general ration
is inadequate. This may occur in the early stages of an emergency programme before a reliable food
pipeline can be established (as was the case in the Ngara refugees camps for Rwandan refugees in
Tanzania in 1994) or if there are problems with the general ration distribution system (as was the
case for IDPs in Rwanda during 1994 when, in some camps, food was distributed via commune
Box 9.1 Decision-making Framework for Implementation of SFPs
UNHCR/WFP Guidelines on Selective Feeding Programme
74
leaders with the result that many beneficiaries did not receive their fair entitlement). Blanket SFPs
may also be established:
• If there are high levels of wasting or if wasting is between 10-19% with aggravating factors;
• If there is an anticipated increase in malnutrition due to seasonal epidemics;
• In order to target micronutrient rich foods to vulnerable group on the basis of evidence of
micronutrient malnutrition.
Box 9.1 shows the decision making framework for the implementation of SFPs
Important Principles of Selective Feeding

Programmes
Targeted SFPs
Targeted SFPs aim to provide a supplement to the general ration. It is therefore assumed that the
general ration provides for all nutritional needs of the population except particular groups. Groups
which might require SFPs are: the malnourished, who have additional nutritional requirements for
catch up growth; the medically ill, who have additional nutritional requirements for tissue repair; and
certain socio-economic groups who have restricted access to the general ration. Therefore, to be
effective, the planned general ration distribution must be fully and efficiently implemented so that the
supplementary ration is additional to, and not a substitute for, the general ration. If this is not the
case, the SFP is unlikely to restore nutritional status in those who have additional nutritional
requirements or prevent nutritional deterioration in those whose access to the general ration is
already restricted.
Nevertheless, in many emergency situations, targeted SFPs are often implemented in the absence of
an adequate general ration. Food aid agencies justify this for a number of reasons:
• SFPs act as a temporary measure to minimize loss of life amongst the most nutritionally vulner-
able, until the general ration can be improved;
• The implementing agency is already present in the emergency location due to some other
activity and staff feel that they must ‘do something’; but, given their small size and limited
access to resources, it only has the capacity to run a small-scale SFP.
When there are such rationales, these should be explicitly stated so that programme performance
can be evaluated on the basis of these modified objectives. It must also be recognised at the outset
that the impact of this type of programme will be limited and that within a short period of time the
programme may be overwhelmed as the numbers of malnourished increase (re-admissions and new
9
cases).
When possible, agency efforts should be expended in improving the general ration provision rather
than in establishing SFPs as a counterbalance to an insufficient general ration.
Every emergency has individual features that lead to situation-specific objectives and approaches for
selective feeding programmes. Guidelines cannot cover the wide range of situations faced by field
staff. There is, therefore, a need to take pragmatic decisions that, at times, may conflict with current
guidelines. Some examples of SFPs with atypical designs or objectives are presented in Box 9.2.
75
Box 9.2: Case-studies
• An on-site supplementary feeding programme for the Rohinga refugees in Myanmar has
been established which provides a full ration for women and children. This unusual type
of programme was justified on the grounds that the general ration was often taken and
sold by men and that this was contributing to the high levels of wasting found in the camp.
• A form of prison supplementary feeding programme was established by a number of agen-
cies in Rwanda during 1997. Many of the detainees in the prisons were awaiting trial and
were dependent on families or friends visiting with food. An objective of these SFPs was
to reduce the demands on these families who were voluntarily assisting the prisoners and
thereby improve their food security
• At the height of the civil war in Liberia, many of those affected by the conflict asked
humanitarian agencies to provide food in the form of a supplementary feeding programme
rather than as a general ration. Their rationale was that a general ration distribution would
place them at too great a security risk as such large quantities of food would probably be
looted. This was less likely to be the case with a supplementary feeding programme. This
programme therefore became a means of getting food out into the general population.
An important rule of thumb is to always seek beneficiary advice about the appropriateness and
design of selective feeding programmes. Women in particular should always be involved in decision-
making.
Feeding Regimes and Rations for Different Types of

Selective Feeding Programmes
The two phases of therapeutic feeding programmes (TFP) for children
Phase 1
All newly admitted severely malnourished children start in 24 hour care where they receive (i) medical
treatment to reduce mortality risk and (ii) a carefully introduced sustenance level diet that prevents
nutritional deterioration and allows normalisation of metabolic function.
9 It takes time for the clinical abnormalities of the severely malnourished to be corrected. Until their
condition is stabilised, it is important not to overload their system, particularly with too much salt
(sodium) and protein, as this can cause heart failure and sudden death. For this reason, low sodium,
low protein milk feeds are given. If the child is dehydrated, a modified oral rehydration solution
(ReSoMal) is used in place of the usual WHO formula for ORS. Children normally stay in phase one
for up to one week.
The total amount of food should be given through many small feeds - every 2-3 hours. If frequent
feeds are not possible (e.g., insecurity prevents keeping the TFP open during the night), an absolute
minimum is 6 feeds per day with at least one at night. Therapeutic milk, in the form of WHO F75
starter formula, is considered to be the most effective diet for Phase 1 of treatment. This formula
may be available in pre-prepared sachets or prepared locally from dried skimmed milk (DSM), oil,
sugar and a special salt/mineral solution.
Once medical complications like infection are under control, the child can be transferred to phase 2.
Recovery of appetite and change of attitude/expression are good guides for when this transition has
been made.
76
Phase 2
Children in phase 2 can tolerate much higher intakes of energy and nutrients –necessary to promote
rapid growth and nutritional rehabilitation. The high energy milk formula for Phase 2 is known as
F100 catch-up formula (100 kcal and 2.9g protein/ 100ml). Children should be fed on demand. Milk
feeds can be alternated with porridge feeds, which are based on blended foods. A porridge should
provide 150 kcals per 100 ml; oil and sugar should be added. High Energy biscuits are also sometimes
used as an easy meal or for night feeds. Good weight gains have also been achieved using local diets.
Breast feeding should be promoted and continued during the whole treatment for infants. It should
be stimulated by sufficient feeding and liquid intake of the mother. Artificial formula feeds should
only be used in rare cases when breast feeding is not possible.
TFP for others: treatment of severe wasting and famine oedema in

adolescents and adults
There are four phases of feeding as follows:
Phase 1
Electrolyte (sodium and potassium) imbalances and infection should be corrected. Use the same
formula as for children in phase one.
Phase 2
After a few days, the subject usually develops good appetite. Gradually introduce solid food (usually
cereal-based thick porridge). Appropriate local vegetables/fruits and, if possible, some meat, milk or
fish should be added to regular meals to make these varied and appetising.
Phase 3
A full diet should be given and the patient discharged when oedema free and gaining weight regularly.
The BMI (body mass index, Chapter 5) should also have increased by 2.0 kg/m2 above the BMI
registered at the point when oedema was first observed and weight was at its lowest point. Recovery
to this point usually takes about 3 months.
Phase 4
After discharge, active supervision and regular provision of food supplements should continue for at 9
least 3 months until the home situation is stabilised.
On-site and take-home supplementary feeding programmes

SFPs can be implemented as dry take-home feeding or on-site feeding. Take-home programmes
normally provide a dry ration on a weekly or fortnightly basis while on site feeding takes place each
day. It is generally accepted that take-home feeding should always be considered first as such
programmes are less resource intensive and there is no evidence that either on-site or take home
SFPs are more effective. There are several other advantages of take home feeding (UNHCR/WFP
Selective Feeding Programme Guidelines).
On-site feeding may be justified when:
• There are no other sources of food, so it is certain that the take home ration will be shared with
other family members;
77
• Firewood and cooking utensils are in short supply, so that it is difficult to prepare meals in the
household;
• Insecurity places beneficiaries at risk when returning home carrying weekly supplies of food;
• There are a large number of unaccompanied/orphaned children or young adults.
In some instances, it may be appropriate to offer both on-site and take home feeding and allow
beneficiaries to select the type of programme in which they enroll. This approach is now advocated
by a number of NGOs.
WFP photolibrary
A supplementary feeding programme using a combination of food aid and local foods.
9
The SFP ration
The SFP ration should provide 500 kcals and 15 gm of protein per day for on-site feeding. In order
to account for substitution and sharing with siblings at the center, it is considered appropriate to give
a ration of 500-700 kcals and 15-25 protein; fat should supply 30% of the energy. Two meals are
needed to provide this amount of energy and protein given the small stomach size of children. Food
is also needed for caregivers. A larger ration of 1000-1200 kcals and 35-45 gms of protein is given
for dry take-home rations in order to account for sharing at home; again, fat should supply 30% of
the energy.
Rations for both on-site and take-home feeding are usually based on a pre-mix prepared from blended
food or cereal flour and other ingredients. In general, it is best to avoid distributing separate ingredients
for dry take-home rations, as some may be sold or taken by other family members. Ingredients in the
pre-mix vary but should include a vegetable oil to increase energy density and, if cereal flour is used,
78
a source of additional protein. Sugar is often added to improve taste. This pre-mix is then used to
prepare dishes such as porridge or thick drinks.
Internationally procured blended foods can be very useful to initiate a SFP when appropriate local
foods are lacking. Alternatively, locally produced mixes of cereal flour, high protein sources (ground
beans, lentils or DSM) and high energy sources (e.g., vegetable oil, butter oil and groundnuts) can
be used.
High energy biscuits may be available from donors but their drawback is that they are very popular
with other family members. They are, however, useful for on-site feeding and in situations when
other commodities are not immediately available in the start up phase of an emergency or where
cooking is problematic.
Dry rations can be distributed as either separate ingredients or as a premix. In general, avoid separate
ingredients as some may be sold or taken by other family members. Milk powder can only be distributed
in a premix due to the danger that milk powder may be diluted with un-boiled/contaminated water.
The greatest danger is that the dried milk might be used to feed small babies. Dried milk products
can only be used in on-site feeding situations and only under strictly supervised hygienic conditions.
On-site feeding meals should always be timed so as not to clash with family meals. Women need an
additional 350 kcals/day from the third month of pregnancy and 550 kcals/day for nursing.
Admission and Discharge Criteria for Selective

Feeding Programmes
Children are normally admitted and discharged from selective feeding programmes on the basis of
measurements of their nutritional status. Weight and height measurements are compared against
international growth standards in reference tables (see Chapter 5).
Cut-off points for admission and discharge are associated with different degrees of malnutrition.
However, these cut-off points need to be defined in agreement with national relief policies taking
into consideration capacity and resources of the programme and possibilities. If a malnourished
infant below 6 months is identified, he/she should be admitted as there is a need to rehabilitate the
child through breast feeding. Depending on the situation and resources, malnourished older individuals
may be admitted based on clinical assessment of nutritional status or measurements of BMI.
The quickest way to identify all eligible children in a population is by MUAC (mid-upper-arm
circumference, see Chapter 5) screening using a cut-off point of 13.5cm or 14cm. This is a quick
procedure and although lacking in precision can identify most malnourished children quickly. Once
identified, children can be referred to feeding centers for accurate weight and height measurements. 9
The anthropometric criteria for admission and discharge for therapeutic and supplementary feeding
programmes are as follows: 70% of median of weight for height or -3 Z scores for TFP and 70-80%
for SFP or -3 to -2 Z scores for SFP. If individuals have oedema, no matter what weight they are,
they should be admitted to the TFP. Children are discharged from TFP when they reach 80% weight-
for-height over 2 consecutive weighings (weighings usually take place weekly). If there is no SFP to
which they can be referred, discharge should be delayed until they have reached 85% or 1.5 Z score
(if children live a long way from the feeding centre, discharge should be delayed until they reach
90%). Children are discharged from SFPs if they reach > 85% weight for height during two to four
consecutive weeks.
Where the general ration is grossly inadequate and/or malnutrition prevalence is above 20%, it is
preferable not to discharge from blanket or targeted programmes until food security improves.
79
Assessment of Effectiveness
Effectiveness of selective feeding programmes can be assessed in two ways. First, the impact of the
programme on the nutritional status of the beneficiary population can be monitored by periodic
nutrition surveys. One should not automatically infer that improvements in nutritional status are due
to implementation of the selective feeding programme as other factors may have had a marked
impact (e.g., improvements in overall food security and the health situation). That said, an effectively
implemented SFP should reduce levels of malnutrition. There are also a number of programmatic
indicators that need to be monitored in order to assess effectiveness. Staff at each feeding center
should keep a monthly attendance report to record new admissions, attendance, discharge, death,
default and transfer.
Evaluation indicators should be expressed as a proportion of the total number of children leaving the
programme during the reporting month. Typical evaluation indicators to be monitored are: percentage
of children recovered, percentage of deaths and percentage of defaulters. Attendance rate, programme
coverage, mean length of stay on discharge, average weight gain, and case fatality rates should also
be calculated. Other assessment information, compiled by some agencies, may include cost per meal
and percentage of re-admissions.
Target levels for these indicators have been suggested in a number of recent guidelines (Table 9.1).
However, there needs to be a great deal of flexibility in setting these targets and interpreting the
results as programme performance can depend on many factors and should be assessed in the context
of the whole situation.
While these indicators provide a clear marker of programme performance, they may not allow an
analysis of whether all programme objectives are being met. Given the variation in programme
objectives (See Table 9.1), an important rule of thumb is to clarify objectives at the beginning of
each programme and ensure that appropriate data are collected to allow an assessment of whether
the programme is meeting these objectives.
Table 9.1 Target Levels for Proportions of Exits for Selective Feeding Programmes
Proportion of exits TFP Objectives TFP Alarming SFP Objectives SFP Alarming
Recovered >80% <50% >70% <50%
Deaths <5% >25% <3% >10%
Defaulters <10% >25% <15% >30%
9
Closing Selective Feeding Programmes
Closure criteria should be defined at the start of a programme. It is usual practice to close down a
programme when there are less than 20 patients in TFP and less than 30 patients in SFP. New cases
should then be referred to health centres or hospitals. However, low numbers may not reflect an
improved situation but poor accessibility or acceptability of the programme. Decisions about closure
should therefore be made after a nutrition survey shows an improvement. The survey should
demonstrate levels of wasting under 10%. The following conditions should also be met: the general
ration should be adequate; effective public health and disease control measures should be in place;
no seasonal deterioration in nutritional status should be anticipated; mortality rate should be low;
and the health and nutritional status of the population should be stable.
80
Key Words
Attendance rate Percent of those children enrolled who actually attend.
Case fatality rate This rate expresses the risk of death for a child attending the programme.
Coverage Percent of those children enrolled/ attending out of estimated number of the target group.
Dry rations Distributed (usually weekly) to take home for preparation and consumption.
F75 starter milk A form of high energy milk used in Phase 1 of therapeutic feeding programmes (provides
75 kcal and 0.9g protein per 100ml).
F100 catch-up milk A form of high energy milk used in Phase 2 of therapeutic feeding programmes (provides
100kcal and 2.9g protein per 100ml).
Porridge premix A mixture of ingredients, usually including blended food or cereal flour, oil, and possibly
sugar and milk powder, used for take-home rations or as the basis for porridge for wet
feeding.
Wet rations Prepared/ cooked once or twice daily in the kitchen of a feeding centre and consumed
on-site.
Weight gain Mean weight gain g/kg body wt/ month.
Key Readings
Gillespie, S. 1998. Supplementary Feeding Guidelines for Mothers and Children: Operational Guidelines,
World Food Programme. MSF. 1995. Nutrition Guidelines. Paris, France: Medecins Sans Frontieres.
Shoham, J. 1994, Emergency Supplementary Feeding Programmes, ODI, London: Relief and Rehabilitation Network,
Good Practice Review 2
WHO. 1999. Management of Severe Malnutrition, A Manual for Physicians and other Senior Health Workers. World
Health Organization.
81
10 GENERAL FOOD DISTRIBUTION
The purpose of this chapter is to enable WFP staff to contribute towards the effective design of food
distribution systems in emergency situations.
Summary
All distribution systems should be fair, accountable, transparent and gender sensitive. These
principles and the common methods for applying them are generally accepted. There are
different modalities of distribution, but the question of to whom food should be distributed
should always be considered. Other aspects of designing a distribution system include:
registration, beneficiary committees, ration cards, scooping, distribution interval, number of
distribution points. Finally, varying levels - and different types - of monitoring are required.
Learning objectives
• Understand the key principles of distribution.
• Describe the different modalities of distribution.
• Determine whether to distribute to individuals, households, committees, traditional
leaders, or local government.
• Understand how to monitor distributions.
Principles of General Food Distribution

All food distribution systems should be fair, accountable, transparent, and gender sensitive. These
principles can be defined as:
• Fairness: all emergency affected populations have an equitable right to receive the agreed food
rations, determined by an objective assessment of their needs.
• Accountability: the effectiveness in providing the agreed quantities of food to the intended
beneficiaries in a manner that can be monitored - or verified - by beneficiaries, implementing
agency and donor.
• Transparency: awareness by all key actors of the system of distribution, food supply and
rations, and the ability to witness or observe all aspects of distribution.
• Gender sensitivity: gender relations and roles are taken into account in planning distributions to
10 make sure that food reaches the household (in particular women and children) and that food is
used for its intended purpose.
The methods by which these principles are generally applied are summarised in Box 10.1.
The more transparent the system, the fewer the opportunities for abuse leading to unfair distribution
practices. Informing refugees of their ration entitlements and the timing of distribution require a
regular food pipeline and an efficient food delivery system. It also requires good and regular
communication between WFP and its implementing partners.
Distribution to women is recommended for two main reasons: first, women often have the primary
role in household food management; second, because women are more likely to use food aid for
82
WFP 10. GENERAL FOOD DISTRIBUTION
nutritional purposes (as opposed to sale or exchange for other goods). In polygamous societies,
women should be considered as the head of household to receive food.
Care must be taken that:
• Receipt of food aid is not associated with risk of attack or abuse;
• Special arrangements are made for pregnant women, women with small children, and the
elderly;
• Distribution does not interfere with childcare or other domestic responsibilities;
• Women are able to transport the food home (i.e., short distances to distribution point, quanti-
ties of food that can be carried; or access of women to burden animals).
Box 10.1: Principles of Food Distribution
Principles Method
Fairness - Rations and food allocations are based on an objective assessment of need.
- Monitor the receipt of agreed rations.
- Distribution according to household size.
Accountability to - Distribution system takes account of social, ethnic, political divisions within the affected
beneficiaries population.
- Establishment of beneficiary food committees to elicit their views on distribution and any
complaints.
- Assess and identify the socially and politically vulnerable and ensure they receive their
entitlements.
- Independent monitoring during and post distribution by WFP and/or NGO implementing
partners.
Accountability to - Regular reporting and analysis of quantity of food distributed and number of
donors and beneficiaries.
within WFP
- Presence of WFP/NGO monitors during distribution and/or post-distribution monitoring.
Transparency - Circulate information about food rations, method and timing of distribution.
- Keep population informed of any problems in food supply, changes in rations, delays,
etc.
- Distribution in a public place.
Gender - Women collect food in recognition of their role in household food management.
sensitivity
- Gender representation on food committees.
- Ensure that distribution does not interfere with women’s other domestic responsibilities
and does not put them at unnecessary risk.
10
Methods of Distribution. To Whom and By Whom?
There are three broad modalities of distribution: by WFP directly, through an implementing agency,
or through government. WFP, or it’s implementing partner, may distribute directly to heads of
households or individuals, or to beneficiary representatives or groups. For the majority of distribution
systems, the basic unit for distribution is the family.
In stable situations, with recognised governments, WFP’s first choice is to distribute through existing
government structures. This is generally applied for developmental programmes, such as vulnerable
group feeding through MCH clinics and school feeding. WFP also prefers working through
83
government for emergency interventions in response to natural disasters, unless there is clear evidence
of lack of adequate infrastructure.
In emergency situations associated with conflict, to determine the appropriate distribution system, it
is essential to know the extent of social coherence, as well as the social and political divisions within
the affected population.
If communities are intact, and their leadership is known to be accountable, it may be appropriate to
distribute food through existing leadership. Many emergencies, though, are associated with social
disintegration or collapse.
Military leadership, whose aim might be to control food to further political or military aims, may
replace traditional leadership. In this case, it would be inappropriate to distribute through “community”
representatives or local leaders.
National and international NGOs may implement WFP food distributions. In such cases, formal
agreements are established between WFP, the NGO and the government, defining the method of
distribution to be adopted and the reporting and monitoring requirements. These agreements should
specify:
• The method of distribution to be adopted, including the number of NGO monitors that this will
require; the independence of these monitors should be specified;
• Reporting requirements;
• Requirements for monitoring both process and impact.
Important criteria for selection of an NGO implementing partner include:

• past experience of food distribution;
• past experience - and success - in the geographical area of operation;
• capacity and ability to mobilize qualified and experienced staff quickly;
• their neutrality and impartiality.
If more than one agency or NGO is responsible for distribution implementation, it is essential that
WFP develop a common distribution strategy for all implementing agencies and that resources be
allocated accordingly.
Choosing the type of food distribution system

Choosing a system involves answering two basic questions:
1. Can beneficiary representatives be given the responsibility for distribution to households?
2. How many resources are available to set up and run the system?
Box. 10.2 provides the advantages and disadvantages of each type of distribution system in terms of
10 cost (staff, materials etc.), speed of implementation, knowledge required, and the risk of abuse.
84
Box 10.2 Choosing the Type of Food Distribution System
Recipient Advantage Disadvantage
Local - Quick and efficient if local infra-structure - Government capacity may be limited
government sufficient
- High cost if local infra-structure needs to
- Builds local capacity be re-informed
- Government may have financial or
political motives for controlling food
distribution
Traditional - Social and cultural values of population - Knowledge of social structures and power
leaders respected relations essential
- Easy in initial stages of emergency and for - Only effective in small, intact communities
dispersed populations
- Risk of abuse if social structures have
- Low cost broken down or have been replaced by
military leadership
- Quick
- Difficult to monitor
- No external registration or ration cards
needed
New groups or - Relies on existing, if new, social structures - External registration and ration cards
committees needed in some cases
- Lowers risk of abuse that may be associated
with traditional groups - Appropriate in stable situations
- Some community participation, particularly - Must make sure leaders are elected so they
women’s representation. truly represent communities
- Self-monitoring - Resentment from traditional leadership
- Low cost - Need for extensive information campaigns.
Households - Efficient for large, unstructured populations - High cost (staff, materials, time).
- Initial control over beneficiary numbers - Little beneficiary participation
- Avoids abusive power relations and - Registration and ration cards necessary.
leadership
- Less risk of unequal distribution
- Easy to monitor
Individuals (the - No scope for manipulation or discrimination - Extremely high cost (staff, materials).
provision of
cooked meals) - Self- targeting - Time consuming
- No registration or ration cards needed - Only possible for small groups (1000 per
- Easy monitoring
kitchen).
- No possibility for exchanging rations so all
10
- Overcomes problems of limited fuel, utensils, nutritional needs have to be met.
water.
- Risk creating population concentrations.
- Health risks.
Distribution through government

In stable situations, with recognised governments, the first choice is to distribute through existing
government infrastructure. Where civil administration functions well, governments can draw on
85
networks of information, administration, transport and storage, and is therefore both quicker and
cheaper than establishing a separate distribution network.
Distribution through traditional leaders

Distribution to traditional leaders is only recommended in small communities where social structures
are intact and where existing leadership is known to be accountable to the population they represent.
In some emergencies with social disruption or abusive power relations, this can easily lead to diversion,
unequal distribution, or the control of food distribution to further military or political aims. The
system must be changed as soon as possible to one of those described below.
Distribution through newly created groups or committees

Distribution through newly elected (village) committees has the advantage that it retains community
involvement in distribution. This system is increasingly adopted in refugee distributions once the
situation has stabilised and registration has been done. The latter may involve groups elected on the
basis of family size, or camp section. WFP recommends that women be represented on such
committees1 .
Distribution direct to households or individuals

Distribution direct to households or individuals is entirely agency managed. It may undermine existing
social structures and is therefore only appropriate when these have broken down. Distribution of
cooked food to individuals is increasingly used in conflict situations. It is also appropriate when
beneficiaries do not have access to cooking equipment or fuel, or are too weak to cook for themselves.
Requirements for staff and equipment are large and communal kitchens may create population
concentrations, increasing the risk of disease epidemics or of attack.
Registration vs. estimation of beneficiary numbers

Any food distribution system requires an identification of the intended beneficiaries and an estimate
of their numbers. Registration by communities themselves is appropriate where communities are
small, intact, or if the operation is expected to be of short duration only. In conflict situations, an
external registration should be carried out as soon as this is feasible. External registration needs
careful planning among all interested parties; it is resource intensive in terms of time, staff, materials/
construction.
When a formal registration is not immediately possible, or when registration is thought to be inaccurate,
the minimum requirement is to identify socially excluded or politically marginal groups. In this way,
10 they can be prioritised during distribution, and/or their food receipt monitored.
Registrations need to be regularly updated. In the initial stages of an emergency, particularly in cases
of displacement, beneficiary numbers may change on an almost daily basis. Once a registration has
been done, there needs to be a system in place for periodically updating figures. Even when such a
system is in place, it is likely that a registration exercise will have to be repeated if the operation
becomes protracted. Beneficiary numbers may have become unreliable because of deaths, births, or
population movements.
1 For more information on group distribution, and distribution direct to households, see the UNHCR Commodity Distribution Guidelines (June 1997).
For more information on community bases distribution, see Oxfam. Registration and Distribution. Guide 9, in series on Working in Emergencies;
Practical Guidance from the field.
86
Beneficiary distribution committees

The establishment of beneficiary committees is recommended in all situations, even if they do not
carry out the distribution itself. The role of such committees may vary. Committees can provide a
forum for discussion and a means for disseminating information on the distribution system.
Alternatively, committees may decide who should receive food and how much; and they may carry
out the actual distribution. In all circumstances, beneficiaries should be provided with basic information
on the distribution and their views on distribution should be elicited. The community should elect
such committees, preferably in a meeting at which everyone from the community, including women,
is present.
Ration cards or beneficiary lists / beneficiary

documents
Ration cards are issued to households in situations where an agency distributes directly to heads of
households. The ration card has information on family size, address (village, camp sector), and
usually numbers to indicate for which distribution period food has been received. When distribution
is on a community basis, beneficiary lists may be sufficient and the names of beneficiaries are called
out during distribution. In large camp situations, ration cards are necessary to speed up the distribution.
Scooping
Scooping of rations is the “traditional” way of distributing food in agency-managed distributions to
heads of households. Measures are made for each of the commodities that correspond to the ration
for each individual (or household) for the set distribution period. If beneficiaries are aware of how
many scoops of a particular item they are entitled to, this provides an effective control mechanism on
distribution. However, there is also scope for significant manipulation in distribution through under
or over scooping. Scooping is also time consuming and/or staff intensive. It also assumes that there
will be no changes in ration size over the period of the operation. Increasingly, agencies are moving
away from scooping to bulk distribution to groups (where each household is informed of their
entitlements and they distribute this amongst themselves).
Distribution cycle
Rations are usually distributed weekly, bi-weekly or monthly. The distribution cycle depends on the
type of population served, the context and food resources available. For dispersed or mobile
populations, it is usually most appropriate to distribute food on a monthly basis. When food supply
is uncertain, distribution on a more frequent basis may provide greater flexibility. In refugee situations,
or other easily accessible camp based populations, food is often distributed twice a month. In conflict
situations, the risk associated with carrying or keeping large quantities of food needs to be taken into 10
account - it may be more appropriate to distribute only small quantities of food at each distribution.
The opportunity cost for beneficiaries should also be taken into account. For example, a weekly
distribution would require beneficiaries to spend about 4 days a month queuing for food (if they live
close to the distribution centre).
Once the distribution cycle has been determined, it is crucial to inform beneficiaries and maintain the
schedule in order to keep the confidence of the beneficiary population. If irregularities are anticipated,
the population must be informed so they can plan accordingly.
87
Number of distribution points

In general, distribution points should be located as close to beneficiaries as possible and the number
of beneficiaries attending one distribution point at any one time should be minimised. Particularly if
distributions are on a monthly basis, the rations received may be too heavy to carry over long
distances. Malnourished populations may not be able to move at all and may need food transported
to them. The more distribution points, the greater the cost in terms of staff requirements, transport,
and equipment. UNHCR recommends at least one distribution site per 20,000 refugees. It furthermore
recommends that the distance people have to travel should not be more than 5 to 10 km for dispersed
populations.
Distribution staff
Staff profiles depends on the type of distribution system adopted. Obviously, a community based
distribution system requires less salaried staff than an agency-managed system. The types of staff
required include:
• Distribution monitors;
• Distribution supervisors; field co-ordinators; logistics officers;
• Distributors (in case of agency managed distributions);
• Cooks, cleaners, etc. in the case of cooked distributions;
• Storekeepers, guards.
Monitoring and Reporting on Distribution

The aim of monitoring is to assess on a regular basis whether the objectives of food distribution are
being achieved. This includes the efficiency, effectiveness and timeliness of food delivery to its intended
destination. Monitoring should ensure that food effectively reaches intended beneficiaries in the
agreed quantities and measure its impact on food security and nutrition.
Process or systems monitoring

The aim of process monitoring is to ensure that losses are minimised and accounted for and that food
is distributed to the intended beneficiaries. WFP should be able to identify at what level of the
distribution process problems occur in order to address bottlenecks. Monitoring is not limited to
information collection. The most important aspect of monitoring is analysing and acting on the
information collected. Process monitoring includes monitoring of:
• Food supply and delivery;2
• Food storage and handling;
10 •
•
Quantity of food distributed, and the number of actual vs. planned beneficiaries;
Inequalities in distribution.
Level of monitoring
The level of monitoring required depends on the distribution system adopted, the quantity of food
aid being distributed, the amount of diversion or manipulation of food aid, and donor requirements.
WFP’s implementing partners should carry out all forms of monitoring discussed below. In addition,
some degree of monitoring is required by WFP itself in all situations. If WFP has many implementing
partners operating in the same area, a greater level of WFP monitoring is required to ensure a co-
2 The EDP is the point closest to the beneficiaries, or to the distribution point, to which food is delivered by WFP. It is the point at which WFP hands over
food to UNHCR or it’s implementing partner.
88
ordinated approach. In situations of war or other politically charged situations, international WFP
monitors are required to ensure independent monitoring, in part because NGO monitors are likely to
be under pressure in such circumstances.
Who monitors?
There are arguments to be made for and against the employment of local monitors. Local monitors
have the advantage of knowing the language and culture. Usually they also have freedom to travel.
However, they are subject to a variety of pressures, particularly (but not exclusively) in situations of
conflict. In all situations, monitors should not be from the area where they are monitoring the
distributions. Whether local or international, monitors need:
• Agreed operational principles or ground rules between WFP, NGOs and ruling authorities;
• Encouragement to report on abuses (if necessary confidentially), knowing this will elicit a
response at higher levels.
Distribution reporting
Distribution reports should be completed for each distribution cycle or other agreed period (e.g.,
monthly). The following minimum quantitative information is required: number of actual beneficiaries
for the particular distribution period (checked against the number of registered beneficiaries), opening
balance at the start of the distribution period, quantity of each commodity distributed, losses, damages
and closing balance. This information should be analysed for over or under distributions and to
determine basic information on whether the recommended rations were distributed.
Distribution site monitoring

This includes both the physical presence of food monitors at the distribution site and “food basket
monitoring”. Food basket monitoring involves the selection of a random number of families at the
distribution site; their rations are weighed and the results are then compared with the planned ration
and the family size on the beneficiary document (e.g., ration card). This can provide useful information
on whether beneficiaries are receiving the planned rations. It cannot, however, highlight inequalities
due to inaccuracies in registration. The family size indicated on the beneficiary document may be
smaller or greater than the actual family size, or some families may be not be registered.
Household visits and post distribution (or end-use) monitoring

Household visits are necessary to determine whether there are some households that have been left
out of the distribution altogether or whether some households or groups have been under or over
registered. This could be done on a random sample. But with knowledge of social and political
divisions within the beneficiary population, it should be possible – without a random sample - to 10
identify vulnerable groups that are likely to have been left out of distribution.
Information should be collected on the quantity of food received, the use of food aid, acceptability
and quality, and questions relating to the impact of food aid.
Impact monitoring
Monitoring impact depends on the objectives of the distribution. It is also important to monitor the
social impact of the actual distribution system adopted. Beneficiary views should be elicited on
89
whether the system adopted was actually appropriate. For example, has distribution by an external
agency undermined existing community structures?
If women are intended to be the recipients of food aid, the percentage of women amongst those
coming to collect food should be monitored. If women are not attending the distribution, the reasons
for this should be investigated. Women should be interviewed specifically about their views on the
distribution system, how it impacts on food received in the household, and on their ability to care for
children and perform their other domestic responsibilities.
Co-ordination and Management

Problems in implementing general food distributions often result from inadequate institutional and
logistical capacity, and poor management. Distribution generally involves a range of actors: the
government, UN agencies, NGOs, local partners and the beneficiaries of food aid. Good management
requires:
10
WFP photolibrary
Food distribution
90
Box 10.3 Key Points of the Joint Memorandum of Understanding Signed Between WFP and
UNHCR, and also WFP and UNICEF in Relation to Food and Nutrition
Memorandum of Understanding (MOU) between WFP and UNHCR (March, 1997)

This MOU applies to situations where the number of beneficiaries of concern to UNHCR is more than 5,000
persons (refugees, returnees, displaced persons of concern).
Key points:
• WFP and UNHCR conduct joint needs assessment missions where needed, and jointly assess numbers
eligible for food assistance.
• WFP normally has procedures for assessing the overall food situation in the country.
• WFP handles the procurement and distribution of basic food commodities (includes cereals, edible oils/fats,
pulses and other sources of protein, blended foods, salt, sugar and high energy biscuits) for both general and
selective feeding programmes. Where beneficiaries are totally dependent on food aid, WFP will ensure the
provision of blended foods or other fortified commodities in order to prevent or correct micronutrient
deficiencies.
• UNHCR is responsible for the procurement and distribution of other complementary commodities, including
local fresh foods, spices, tea and dried and therapeutic milks.
• Where micronutrient requirements cannot be met through the ration, UNHCR will assume responsibility for
the provision of the necessary micronutrients until the ration can be adjusted or fortified to meet these needs.
• WFP is responsible for mobilizing the necessary resources for milling and will provide milling facilities to
the beneficiaries where feasible
• If the number of beneficiaries is less than 5,000, UNHCR - rather than WFP - is responsible for the entire
process if it involves refugees/displaced persons/ returnees.
UNICEF/ WFP Memorandum of Understanding in Emergency and Rehabilitation Interventions (1998)

This MOU applies to both emergency and rehabilitation interventions.
Key points:
• WFP and UNICEF will collaborate in assessing the needs of the population affected by the emergency,
identifying ways in which these needs can be best met, and in determining how the resources of the two
organisations can best complement each other.
• Where appropriate, opportunities for the utilisation of WFP food resources in support of UNICEF-assisted
actions in training and rehabilitation activities and in the re-establishment of health services, water supply,
sanitation, education and other social services will be identified by UNICEF.
• UNICEF, in consultation with WFP, will identify requirements for strengthening caring capacity, access to
water, sanitation, health services, education and other social services and resources needed in these areas.
• In the initial assessment, re-assessment and routine monitoring, WFP will take the lead in assessing overall
food needs and logistics. UNICEF will take the lead in assessing prevalence of malnutrition, the special
needs of young children and women including the need for care and facilities for food preparation, and the
needs for water, sanitation, health care, education and other social services.
• When general food distributions are implemented, food baskets will be designed by WFP.
• Both organizations will seek to minimise the need for supplementary feeding by ensuring that the basic food
ration is adequate.
• WFP and UNICEF will work together on advocacy with donor nations in favour of appropriately fortified
foods. They will also work together to increase the capacity for local milling and fortification of donated
cereal products.
• When the assessment indicates a significant risk of micronutrient deficiencies in a population, WFP will seek 10
to address this through the inclusion of a fortified blended food or other fortified commodity in the general
ration. UNICEF will be responsible for covering any unmet micronutrient needs through other measures
(such as supplement distribution, or provision of vitamin/mineral mixes).
• UNICEF will ensure the availability of: therapeutic milk for use in therapeutic feeding of severely
malnourished people, oral rehydration salts, generically labeled breast-milk substitutes and vitamin/ mineral
preparations where the assessment indicates these are necessary.
• Both organizations will, to the extent possible, promote, protect and support breast-feeding in emergencies.
• WFP will be responsible to mobilise and provide all non-food items necessary for the transport, storage and
distribution of all food commodities required for joint operations. UNICEF will be responsible to mobilise
and provide other non-food items, related to food preparation and consumption, for other needs of the
population, for nutrition and health monitoring, and for selective feeding operations.
91
Key Words
Beneficiary Individual that ultimately receives and benefits from food aid.
Beneficiary committees Elected committee to represent beneficiaries in food distribution
Distribution interval The interval between distributions
Distribution point or site The point at which distribution to beneficiaries takes place
Extended delivery point Point closest to distribution point to which WFP is responsible for food delivery
On-site monitoring Monitoring during distribution at the distribution site
Post-distribution monitoring Monitoring after distribution to determine whether planned rations were received
by intended beneficiaries, how they were used, and, possibly, their impact.
Ration card Card which entitles a household to receive food aid, detailing family size,
address, food receipt.
Recipient Person or body to whom food is distributed, in some cases for on-distribution to
beneficiaries.
Registration Method of identifying the beneficiaries for food distribution
Scooping Use of a standard measure to distribute food to households
Key Readings
CARE, 1995. Chapter 12. CARE International, Atlanta.
Jaspars,S., and H. Young. 1995. General food distribution in emergencies; from nutritional needs to political priorities.
Good Practice Review 3. Relief and Rehabilitation Network. Overseas Development Institute, London
The SPHERE Project. 1998. Humanitarian Charter and Minimum Standards in Disaster Response. . The SPHERE
Project, Geneva.
Telford, J. 1997. Counting and Identification of Beneficiary Populations; Registration and Its Alternatives. Good
Practice Review 5. Relief and Rehabilitation Network. Overseas Development Network, London.
UNHCR. 1994. Registration; a practical guide for field staff. UNHCR, Geneva.
UNHCR. 1997. Commodity Distribution; A Practical Guide for Field Staff. UNHCR, Geneva.
10
92
WFP 11. NUTRITION INFORMATION, EDUCATION AND COMMUNICATION
11 NUTRITION INFORMATION, EDUCATION

AND COMMUNICATION
The purpose of this chapter is to enable WFP staff to identify situations when nutrition information,
education and communication (nutrition IEC) will enhance the effectiveness of food aid, and to help
WFP staff and implementing partners to design appropriate approaches to communicate nutrition
information.
Summary
This chapter describes how the effectiveness of both emergency and development food aid
programmes can be improved by linking them with nutrition IEC. Four main themes can be
addressed through IEC approaches: promotion of new foods, enhancement of the diet,
protection of existing beneficial food practices and avoidance of dangerous food practices.
The steps which should be followed to identify key nutrition messages and appropriate
media for communication are: identification of the problem, identification of the target group,
assessment of community views, and assessment of potential channels for communication.
There are benefits and limitations to different channels of communication: face-to-face,
communication, and mass media.
Learning objectives
• Understand the benefits of linking food aid programmes with nutrition IEC
• Identify different kinds of situations where nutrition IEC activities should be imple-
mented
• Describe the steps which should be taken to identify key nutrition messages and appro-
priate media for communication
• Give examples of different modes of communication which can be adopted to relay
nutrition messages
The effectiveness of food aid is greatly increased when combined with the communication of
appropriate nutrition information. Indeed, food aid programmes offer a unique opportunity for WFP
and its implementing partners to communicate nutrition related information. This applies both to
emergency and development programmes. The process is commonly described as nutrition
information, education and communication (nutrition IEC).
Nutrition information refers to new knowledge, such as information about new foods that are being
introduced. Nutrition education refers to training or orientation for a particular purpose (e.g., support
for breastfeeding). Nutrition communication refers to the method by which information is imparted
(i.e., the medium of communication adopted). Nutrition IEC provides people with an informed base
11
for making choices.
Nutrition IEC is not about telling people how to behave or what to eat. Rather it is about empowering
populations to maximise the use of available food and health resources, and to adapt to a changing
environment. This is equally relevant in the context of development and emergencies.
93
Successful Approaches to Nutrition IEC

It is well recognised that IEC approaches that are didactic and which aim to persuade target groups
to change food related behaviours without their involvement or an understanding of the causes of
their problems, are not successful. People remember 20% of what they are told, 40% of what they
are told and read, and 80% of what they find out for themselves. Changing behaviour depends on
many factors and successful IEC approaches often have the following characteristics:
• They take into account the motivations of particular population groups and work with commu-
nities and community leaders;
• They recognise that people have strong and varied beliefs about food and that approaches
should not be based on the assumption that nutrition information or education is being applied
to a ‘clean slate’ on which new ideas can simply be written;
• They are based on a participatory assessment of the nutrition problem, analysis of its causes
and a carefully thought out plan of action which includes evaluation (note that the Triple A
model presented in chapter 6 can also be used in the design of IEC approaches);
• They are based on observed behavioural practices and not on anecdotal evidence ;
• They are targeted at a specific group and communicate a clear message;
• They provide information to allow a reasoned choice.
Important Themes in Nutrition IEC

IEC approaches will vary in different contexts depending on the type of problem faced by the
population and the type of food aid intervention. It is useful to consider four main themes with
regard to food that can be addressed through IEC approaches: promotion, enhancement, protection
and avoidance.
Promotion of new foods

The acceptability of a new food depends on several factors including its quality, status, taste, smell
and similarity to other familiar foods. Information about new food items - those which are not part
of the traditional diet - is essential. The information covered should include requirements for special
processing, cooking and storage. Beneficiary populations receiving pre-cooked blended foods, for
example, should be informed that blended foods are a good source of essential micronutrients and
that over cooking will reduce micronutrient content. Similarly, where rice is introduced, beneficiaries
should understand that over washing will reduce its nutrient value and waste water, whilst saving the
rice water to use in food preparation is nutritionally beneficial.
An example of the acceptance of a new food, which was facilitated through a public information
campaign, is described in Box 11.1.
11 Enhancement of the diet

The full general ration, although meeting 100% of energy needs, fails to meet 100% of micronutrient
requirements (see Chapter 8). It is important, therefore, to promote access to other sources of
micronutrients to help supplement the ration and enhance the diet of all family members. Nutrition
IEC in this case can be used to promote alternative strategies such as the cultivation of fresh fruit
and vegetables, the consumption of micronutrient-fortified foods (see chapter 3) or the purchase of
micronutrient-rich foods from local markets.
94
Box 11.1 Promotion of Parboiled Rice Among Bhutanese Refugees
Bhutanese refugees in Nepal have been supplied with parboiled rice since 1994, although they traditionally
preferred polished rice which they grew themselves. At the time that parboiled rice was introduced, there was
a public information campaign stressing how the rice should be washed to maximise its nutrient value. In
1997, an acceptability study revealed that significant numbers of refugees were saying that not only had they
accepted parboiled rice, but that they now actually preferred it to polished rice. The explanations for this
included the fact that many refugees associated parboiled rice with improved health and nutrition status
particularly with the decline in beriberi which 2-3 years previously had been prevalent in the camps. Acceptance
also seemed to have been helped because of its digestibility and the fact that although there were initial complaints
about its unappetising smell, the problem was resolved through providing information on how to improve
processing and thus the smell. Acceptance was greatly enhanced by the public information campaign.
Promoting the collection and consumption of wild fruits and berries, where these are traditionally
consumed, can also help supplement the diet. There are many examples of these coping strategies.
For example, in Liberia during 1996 certain groups of people were reported to be dependent on wild
foods from the forest as their main food source. In the Democratic People’s Republic of Korea,
where the population traditionally collects wild mushrooms and grasses from the mountains during
the summer, these foods have provided an important source of micronutrients for young children at
kindergarten and nursery schools during food shortages.
Protection of existing beneficial food practices

Food aid beneficiaries often have extensive knowledge about food and nutrition, resulting in positive
practices. These need to be protected and supported, especially in emergency and protracted relief
operations. An important example is breastfeeding. In most developing countries, mothers will strive
to continue to breastfeed their infants. Indeed, breastfeeding is even more important in emergencies
than in normal times to ensure the health of infants by protecting them from the increased risk of
infections and malnutrition. Protection, promotion and support for exclusive breast feeding for the
first 6 months of a child’s life, together with support for the initiation and maintenance of breastfeeding
for newborns and its re-establishment when this has temporarily stopped, is a very important element
of nutrition IEC.
IEC strategies can also be successfully employed to revive breastfeeding in countries where a bottle-
feeding ‘culture’ has eroded traditional practices. The example in box 11.2 illustrates how breastfeeding
was successfully reintroduced during the emergency in Bosnia.
Box 11.2 Protecting Infant Feeding in Bosnia
During the emergency in Bosnia, doctors and nurses, who were not supportive of breastfeeding, attended training
seminars to increase their knowledge and skills about breastfeeding. The training was followed by a breastfeeding
promotion campaign aimed at mothers. The promotional campaign was successful in heightening awareness
about the benefits of breastfeeding and in changing the attitudes and practices of health workers. There was also 11
some evidence that breastfeeding levels increased as a result.
There are, however, some situations where the promotion of breastfeeding is inappropriate. One
such example is illustrated in box 11.3. Where the introduction of breastmilk substitutes is considered
unavoidable, adequate nutrition IEC and strict adherence to the guidelines outlined in the International
Code of Marketing of Breastmilk Substitutes are essential.
95
Box 11.3: Protecting Infant Feeding in Rwanda
In late 1997, escalating civil conflict led to large numbers of Hutu refugees returning from Zaire to Rwanda.
Among these were unaccompanied infants. Because of the high prevalence of HIV, the practice of wet nursing
was unacceptable to mothers, potential wet-nurses, and staff in therapeutic feeding centres. In this situation,
breast milk substitutes had to be introduced under carefully controlled conditions.
Avoidance of dangerous food practices

In certain situations, information about potentially dangerous foods that should either be avoided or
adequately processed to be made safe for consumption is needed. During the civil war in Mozambique,
for example, some people consumed unprocessed cassava containing cyanide which resulted in an
outbreak of paralysis. More recently, it was reported from Rwanda that poisonous tree bark was
being consumed by people foraging in the forest for wild foods. These examples emphasise the
importance of gathering information about previous survival strategies from new arrivals in an
emergency situation.
Identifying the Appropriate IEC Approach

A number of steps should be followed to identify both key nutrition messages and the appropriate
medium for communication. These are shown in box 11.4
Box 11.4: Identification of key nutrition messages and the medium of communication
Steps:
1. Identify the problem. The problem may relate to a particular food related behaviour that places children
at risk of developing malnutrition or a situation where a new food has to be introduced.
2. Identify the target group for IEC. For example, is it the entire population or a sub-group such as women
with young children, fathers or influential leaders? At this stage, it is important to consult with key
members of the community who can play a role in influencing their community. The consultation
process will help in the development of a common approach and will reduce potential misunderstandings
or conflicts.
3. Find out how the community views the problem. This dialogue will help to develop a consensus about
the problem and thereby ensure that the key IEC message is focused on a problem that both the donor
and recipient population have identified.
4. Assess the potential channels for communication (see below) including cost, availability of skilled
manpower and accessibility of the beneficiaries to the proposed medium.
Channels of Communication
11 There are two main methods of communicating nutrition messages: face-to-face or through the
mass media. In many successful IEC approaches, a combination of methods has been applied. The
skills of personnel from a range of sectors (e.g., health, agriculture and community development)
should be harnessed. Special training of local personnel may be necessary (e.g. health staff for
breastfeeding counseling or influential community leaders who can fulfil a peer education role in
promoting certain food related behaviours). The knowledge and skills of local personnel or influential
community members involved in IEC approaches will be a major factor in determining the method
and success of the intervention.
96
Face-to-face or interpersonal communication is an interactive and effective approach not simply to

impart knowledge but to promote behaviour change. The relatively small number of people who can
be reached, however, will limit its impact. It is often more costly then a mass media approach and is
usually adopted in the following settings:
• For targeting individuals with specific nutrition related information (e.g., parents of malnour-
ished children attending health centres or therapeutic feeding centres);
• For targeting specific sub-groups (e.g., school children that are receiving school meals through
a WFP project).
In many WFP supported school feeding programmes, nutrition IEC has been introduced into the
formal school curriculum and through more traditional approaches such as song, dance and theatre.
The Child-to-Child programme, which is a network for mobilising schools for health education is a
widely used approach. School children are involved in a wide range of health and nutrition learning
with the aim of improving their own understanding of how to improve health and through them, the
knowledge of their siblings, parents and communities.
Face-to-face communication can be made more effective through:
• The use of printed materials (e.g., wall charts, flip charts and brochures), although these require
a certain level of literacy among the target group. It is possible to produce picture only materi-
als accompanied by careful explanation.
• Practical demonstrations which do not require a literate audience (e.g., demonstrations of how
to prepare blended foods for complementary feeding, how to process and cook a new food
commodity, or demonstrations of re-lactation methods for nursing mothers).
Mass media communication has the potential advantages of reaching large numbers of people rapidly
without the need for fieldworkers. Well-planned mass media communication has been used successfully
for public information campaigns in emergency situations. It should utilise all available forms of
media, target a single problem or behaviour, and communicate a single message clearly and in a
positive way. Common forms of mass media communication include:
• Radio messages that are listened to by a large number of people. The audience needs frequent
exposure to the message, which should be specific, simple and positive. Radio messages can be
imparted through spot announcements, slogans and jingles, discussions, interviews, mini-
dramas and music.
• Printed messages in newspapers, magazines or posters that ensure longer-term exposure to
messages when widely displayed.
• Messages relayed through popular media such as traditional storytelling, participatory theatre,
puppet theatre, song and dance. These forms of communication combine entertainment with
education.
11
97
Key Words
Nutrition communication The method by which nutrition information is imparted.
Nutrition education Training or orientation for a particular nutritional purpose such as supports for
breastfeeding.
Nutrition information New knowledge such as information about new foods which are being introduced.
Key Reading
Andrien, M. 1994. Social Communication in Nutrition: a methodology for intervention. FAO, Rome.
Pretty, J.N. , I. Gujit, I. Scoones and J.Thompson. 1995. Participatory Learning and Action: A Trainers Guide.
London, International Institute for Environment and Development.
11
98
WFP ANNEX
Annex 1.1 Micronutrient functions,

sources and effects of processing
Vitamin A
Function Vitamin A is a fat-soluble vitamin required for the normal functioning of the visual system, growth and
development, maintenance of epithelial cell integrity, immune function, and reproduction.
Forms Vitamin A is present in food in two forms:

• as preformed vitamin A (retinol) contained in foods of animal origin
• as provitamin A carotenoids (largely β-carotene) contained in plant foods and which can be
biologically transformed to vitamin A but are less easily absorbed
Sources Retinol is chiefly found in dairy products, liver and some fatty fish. Carotenes are found in yellow and
red fruits and vegetables, and in green leafy vegetables, especially the green outer leaves. Vitamin A
is absent in vegetable oils with the exception of red palm oil and fortified margarines.
Sources of retinol: ug retinol per 100 grams

Liver 15,000-20,000
Fatty fish 1,200-2,500
Margarine or oil (fortified) 900
Butter 830
Cheese 320
Milk (dried whole)* 318
Eggs 140
Sources of β-carotene: ug retinol equivalent per 100 grams

Red palm oil 4,000-10,000
Carrots 2,000
Green leafy vegetables 685
Sweet potatoes (red and yellow)** 670
Tomatoes 100
Bananas 30
Yellow maize 30-180
* Dried skimmed milk only contains traces of vitamin A unless fortified.

** Most root crops contain minimal amounts of vitamin A. Red and yellow sweet potatoes are the
exception.
Absorption enhancers Many factors influence the absorption and utilization of provitamin A including:
and inhibitors (of • the amount, type and physical form of the carotenoids in the diet
provitamin A) • intake of fat, vitamin A and fibre
• protein and zinc status
• existence of diseases
• parasitic infections
High intakes/ Vitamin A toxicity can be classified into three categories: acute, chronic and teratogenic:
toxicity • Acute toxicity results from one or several closely spaced very large doses of vitamin A, usually
more than 100 times the safe intake. The signs (vomiting, headaches and hair loss) are usually
transient and disappear after a few days.
• Chronic toxicity occurs with recurrent intakes over a period of months to years of excessive
doses of vitamin A that is usually at least 10 times the safe intake. Most people recover fully from
chronic toxicity.
• Teratogenic toxicity in pregnant women leads to foetal resorption, abortion, birth defects and
permanent learning difficulties in the offspring as well as toxic effects on the mother. It results
from substantial doses (more than 7,500 ug) of vitamin A injected daily, or from larger doses
(more than 30,000 ug ) taken for several days or weeks, or from a single large dose (150,000
ug). The most sensitive period for toxic effects is the first trimester of pregnancy.
Regular intakes of vitamin A should not exceed the following levels:

Population group ug retinol per day
0-12 months 900
1-3 years 1,800
4-6 years 3,000
7-12 years 4,500
Adolescents 6,000
Adult men 9,000
Adult women 7,500
Pregnant women 3,300
A
99
Vitamin C
Function Vitamin C is a water-soluble vitamin and serves a number of essential metabolic functions. It also
assists in absorption of non-haem iron and is an important anti-oxidant.
Sources Fresh fruit and fruit juices are the richest sources of vitamin C, but amounts vary greatly from
species to species.
mg per 100 grams
Guava 242
Papaya 73
Citrus fruits (oranges, grapefruit, lemons) 40-50
Mango 30
Melons and pineapple 25
Green leafy vegetables 15-35
Tomato, lettuce, radish 15-25
Potatoes 9-15
Absorption enhancers Vitamin C is readily and rapidly absorbed. Excess amounts are excreted in the urine.
and inhibitors
High intakes/ The risk of toxicity is low as excess amounts are simply excreted.
toxicity
Effects of storage, Vitamin C is easily destroyed by oxygen (heat or air). That means that as soon as fruit or vegetables
processing and are harvested the vitamin C content begins to be reduced and that cooking reduces the content of
preparation vitamin C. Long storage times decrease vitamin C content.
Vitamin D
Function Vitamin D is fat-soluble and its active form is involved in calcium homeostasis (bone mineralisation).
Forms Vitamin D is found in two forms:

(i) as ergocalciferol (vitamin D2)
(ii) as cholecalciferol (vitamin D3)
Sources Sunlight on the skin is the major source of vitamin D and there are few dietary sources. The only rich
sources are the liver oils of fish, which obtain the vitamin by ingesting plankton living near the
surface of the sea, and so are exposed to sunlight.
ug per 100 grams
Cod liver oil 213
Fatty fish 20-25
Canned fish 6-13
Margarine or oil (fortified) 8
Eggs 2
Absorption enhancers Vitamin D is only absorbed when there is sufficient fat in the diet.
and inhibitors
High intakes/
toxicity Infants are most at risk of developing hypervitaminosis D. Hypercalcaemia may result from doses of
50 ug per day, and mild hypercalcaemia may result from 15 mg doses taken every 3 to 5 months
Effects of storage, Storage, processing and preparation have no adverse effects on vitamin D content.
processing and
preparation
100
WFP ANNEX
Folate
Function Folate is water-soluble and has a number of metabolic functions, an important one of which is the
formation of red blood cells. It also plays a role in the development of the foetus.
Sources Folate is found in a variety of foodstuffs. The richest source is liver.

Liver ug per 100 grams
Peanuts 110-590
Green leafy vegetables 110
Avocado 30-14066
Bread (wholemeal) 54
Orange juice 37
Melon 30
Mung beans 20
Banana 20
Absorption enhancers The availability of folate in food varies and absorption may be affected by other factors in food.
and inhibitors
High intakes/
toxicity High intakes of folate are unlikely to be toxic.
Effects of storage, Food preparation can cause serious losses of folate; in canning, in prolonged heating, when cooking
processing and water is discarded, and from reheating. Reducing agents in food tend to protect folate.
preparation
Niacin
Function Niacin is water-soluble and plays a central role in the utilization of food energy.
Forms Niacin can be synthesized from the amino acid tryptophan. On average 1 mg of niacin is derived
from 60 mg of dietary tryptophan.
Sources Niacin is widely distributed in plant and animal foods, but only in small amounts, except in meat
(especially offal), fish, wholemeal cereals and pulses.
mg per 100 grams
Liver and kidney 7-17
Peanuts 16
Beef, mutton, pork 3-6
Canned meat 1-6
Fish 2-6
Bread 2-4
Rice 2-4.5
Sorghum 2.5-3.5
Pulses 1.5-3
Dried fruit 0.5-5
Absorption enhancers In many cereals, especially maize, niacin is present in a bound, non-absorbable form. It can be
and inhibitors liberated by treatment with alkali such as soaking in limewater.
High intakes/
toxicity Doses of niacin in excess of 200 mg cause vasodilatation and hence flushing. Very high doses (3-6
g per day) cause changes in liver ultra-structure and function, in carbohydrate tolerance and in uric
acid metabolism, which may result in clinical signs of hepatotoxicity.
Effects of storage, Cooking causes little actual destruction of niacin but considerable amounts may be lost in the
processing and cooking water and ‘drippings’ from cooked meat if these are discarded.
preparation
101
Thiamin
Function Thiamin is water-soluble and is required mainly during the metabolism of

carbohydrate, fat and alcohol. It is also necessary for the proper function of the
peripheral nervous system and the heart.
Sources All animal and plant tissues contain thiamin. The only rich sources, however, are plant
seeds and yeast.
mg per 100 grams
Yeast 6-24
Pulses 0.4
Sorghum 0.4
Wheat 0.4
Rice (home pounded) 0.08-0.14
Rice (parboiled and milled) 0.11
Bread 0.2-0.5
Milk (dried skimmed) 0.4
Absorption enhancers
and inhibitors
High intakes/ Chronic intakes in excess of 50 mg per kg or more than 3 g per day are toxic to
Toxicity adults.
Effects of storage, Large losses of thiamin occur during milling or pounding when the outer layer of
processing and cereals is lost. Parboiling rice prior to milling reduces losses as thiamin is driven into
preparation the interior of the grain. As thiamin is water soluble, there are losses when water in
which cereals are cooked is discarded.
Iodine
Function Iodine is an essential constituent of hormones produced by the thyroid gland in the neck. In the
foetus, iodine is necessary for the development of the nervous system during the first three months
of gestation.
Sources The level in the soil determines the iodine content of plants and animals. As most soils contain little
iodine, most foods are poor sources. The only rich source of iodine is seafood.
ug per 100 grams
Sea fish 200-3500
Vegetables, cereals and meat 20-50
Iodised salt Varies depending on estimated daily intake
of salt
Absorption enhancers Absorption Inhibitors (goitrogens):

and inhibitors Goitrogens interfere with iodine uptake by the thyroid. Foods, which have goitrogens, include the
Brassicas (members of the cabbage) family such as cassava.
High intakes/ High iodine intakes can cause toxic modular goitre and hyperthyroidism. Toxicity may arise with
toxicity intakes in excess of 5,000 ug per day.
Effects of storage, Iodine in food is stable.

processing and
preparation
102
WFP ANNEX
Iron
Function Iron has two major roles in the body. Firstly, it is necessary for the synthesis of haemoglobin (Hb),
which carries oxygen to the body’s cells and transports carbon dioxide from the tissues to the lungs.
Secondly, it is a component of myoglobin (a muscle protein) and many enzymes.
Forms Iron is found in two forms:

(i) as haem iron contained in blood
(ii) as non-haem iron contained in vegetables
Sources Meat, cereals, vegetables and fruit all contain iron, but haem iron is much more easily absorbed than
non-haem iron.
Sources of haem iron: mg per 100 grams
Liver 7-21
Red meat 1-3.5
Eggs 2
Milk (dried skimmed) 0.4
Sources of non-haem iron: mg per 100 grams

Millet 3.8-8
Pulses 1.9-14
Dried fruit 1.6-6.8
Bread 1.7-2.5
Green leafy vegetables 0.4-18
Rice 0.5
Absorption enhancers Absorption enhancers:

and inhibitors • organic acids (e.g. foods high in vitamin C)
(of non-haem iron ) • fructose, sorbitol
• alcohol
• amino acids
Absorption inhibitors:
• polyphenols, tannins (e.g. tea)
• phospates, phytates (e.g. in cereals)
• bran, lignin
• proteins (e.g. in eggs and legumes)
• inorganic elements (e.g. Ca, Mn, Cu, Co)
Breast-fed infants absorb approximately 50% of iron in milk. Infants up to the age of 3 months fed on
formulated milks only absorb 10% of iron in milk.
High intkes/ The acute toxic dose in infants is approximately 20 mg per kg body weight and the lethal dose is
toxicity about 200-300 mg per kg. In adults, a 100 g dose of iron is lethal.
Effects of storage, Iron is stable. Iron from pots can be absorbed into food during cooking thereby increasing intakes.
processing and
preparation
103
A
104
WFP
Age/Sex Group Vitamin A Vitamin B12 Vitamin C Vitamin D Folate Niacin Riboflavin Thiamin
ug mg ug calciferol ug mg mg mg
Years ug retinol per day b b b
per day per day per day per day per day per day per day
0 350 0.1 20 10 24 4.2 0.5 0.3

1 400 0.45 20 10 50 6.4 0.8 0.5
2 400 0.53 20 10 50 7.5 0.9 0.55
3 400 0.61 20 10 50 8.2 1.0 0.6
4 400 0.69 20 10 50 8.9 1.1 0.65
0-4 390 0.50 20 10 45 7.1 0.8 0.5

5-9 400 0.82 20 2.5 80 10.3 1.2 0.75
10-14 M 550 1.0 25 2.5 150 13.1 1.6 0.95
10-14 F 550 1.0 25 2.5 130 11.3 1.35 0.8
10-14 M and F 550 1.0 25 2.5 140 12.2 1.5 0.9
15-19 M 600 1.0 30 2.5 200 15.3 1.8 1.1
15-19 F 500 1.0 30 2.5 170 11.9 1.4 0.9
15-19 M and F 550 1.0 30 2.5 185 13.6 1.6 1.0
20-59 M 600 1.0 30 2.5 200 14.5 1.7 1.0
20-59 F 500 1.0 30 2.5 170 11.5 1.4 0.8
20-59 M and F 570 1.0 30 2.5 185 12.9 1.55 0.9
Pregnant +100 +0.4 +20 +7.5 +250 +1.1 +0.1 +0.1
Lactating +350 +0.3 +20 +7.5 +100 +2.7 +0.3 +0.2
Annex 1.2
60+ M 606 1.0 30 3.2 200 11.9 1.4 0.9

60+ F 500 1.0 30 3.2 170 10.3 1.2 0.75
60+ M and F 540 1.0 30 3.2 185 10.9 1.3 0.8
a
Whole 500 0.9 28 3.2-3.8 160 12.0 1.4 0.9
population
a
The higher figure is for developing countries because of the higher proportion of children under 5 years whose requirement is higher.
b
B-complex vitamin requirements are proportional to energy intake and are calculated: Thiamin: 0.4 mg per 1000 kcals ingested; Riboflavin: 0.6 mg per
1000 kcals ingested; Niacin equivalents: 6.6 mg per 1000 kcals ingested;
c
Based on: (WHO, 1995). Sources: (FAO and WHO).
Food and Nutrition Handbook
Vitamin Requirements (safe levels of intake)

1
Iron (bioavailability)
WFP
a
Calcium Very low Low Moderate High Iodine
b c d e
Age/Sex Group (<5%) (5-9%) (10-18%) (>19%)
Years g per day mg per day mg per day mg per day mg per day ug per day
f
0 0.5-0.6 24 13 6 4 50-90
1 0.4-0.5 15 8 4 3 90
2 0.4-0.5 16 8 4 3 90
3 0.4-0.5 17 9 5 3 90
4 0.4-0.5 18 9 5 3 90
0-4 0.4-0.5 18 9 5 3 90
5-9 0.4-0.5 29 16 8 4 110
10-14 M 0.6-0.7 45 24 12 7 140
10-14 F 0.6-0.7 50 27 13 8 140
10-14 M and F 0.6-0.7 47 26 12.5 7.5 140
15-19 M 0.5-0.6 28 15 10 7 150
15-19 F 0.5-0.6 60 32 16 10 150
15-19 M and F 0.5-0.6 44 24 12 8.5 150
20-59 M 0.4-0.5 28 15 8 5 150
20-59 F 0.4-0.5 59 32 16 11 150
Pregnant (latter half) +0.6-0.7 +120-240 +60-120 +30-60 +20-50 +50
Lactating (first 6 mos) +0.6-0.7 33 17 9 6 +50
Menopausal 0.4-0.5 26 15 6 4 150
60+ M and F 0.4-0.5 26 15 7 4.5 150
Whole population 0.45-0.55 41 22 11 7 150

Annex 1.3
a
The lower figure is for developing countries, where (i) body weight is lower and (ii) the population is adapted to lower levels of calcium intake that apparently do not give
rise to disabilities. The higher figure is for industrialized countries (levels of intake to which the population is accustomed).
Basis of calculations of iron requirements:

b
= 4% (diets as in South Asia)
c
= 7.5% (diets as in developing countries)
d
= 15% (diets as in middle-income countries)
e
= 22% (diets as in industrialized countries)
f
The lower figure is for breast-fed babies and the higher for artificially fed babies;
g
Based on (WHO, 1995).
ANNEX
Mineral requirements (safe levels of intake)
Sources: (FAO and WHO, 1988; De Maeyer, 1989; FAO and WHO, 1995).
105
A
Annex 1.4
Micronutrient deficiencies
Vitamin A
Deficiency signs Vitamin A deficiency results in xerophthalmia, which affects the eyes. The signs in order of
presentation are:
• Night blindness
• Dryness accompanied by foamy accumulations on the conjunctiva (inner eyelids), that often
appear near the outer edge of the iris (Bitot's spots)
• Dryness, dullness or clouding (milky appearance) of the cornea (corneal xerosis)
• Softening and ulceration of the cornea (keratomalacia). This is sometimes followed by
perforation of the cornea, which leads to the loss of eye contents and permanent blindness.
Ulceration and perforation may occur alarmingly fast (within a matter of hours).
Population prevalence Criteria: Prevalence (%):

rates to indicate a Night blindness 1.0 and above
serious situation Bitot’s spot 0.5 and above
Corneal xerosis and/or ulceration 0.01 and above
Xerophthalmia-related corneal scars 0.05 and above
At risk groups Vitamin A deficiency occurs widely in developing countries with the highest prevalence rates in the
regions of South East Asia and Africa. Children suffering from measles, diarrhoea, respiratory
infections, chickenpox and other severe infections are at increased risk of vitamin A deficiency.
Vitamin C
Deficiency signs Deficiency of vitamin C results in scurvy. This usually develops gradually with progressive fatigue
and pain in the limbs. Typical signs include:
• Swollen and bleeding gums
• Minute haemorrhages around hair follicles spreading to sheet haemorrhage on limbs
• Brittle hair
• Slow healing of wounds
• Infants tend to be fretful and scream on being handled because of tenderness of the limbs. They
may lie on their backs in a characteristic ‘frog’s legs’ position
Population prevalence There are no international standards to indicate when vitamin C deficiency is a serious situation. A
rates to indicate a single confirmed case of scurvy, especially in an emergency situation, should be investigated and
serious situation stimulate a re-assessment of dietary adequacy.
At risk groups Only populations with no access to fruit or vegetables are at risk of deficiency. These include
emergency affected populations entirely dependent on inadequate rations. The risk of scurvy is
higher in women (especially pregnant women) than men and increases with age.
106
WFP ANNEX
Vitamin D
Deficiency signs Vitamin D deficiency results in rickets. Early signs include:

• General ill ease, sleeplessness, restlessness and nervousness
• Anorexia (loss of appetite)
• Frequent crying
More developed signs include:
• Excessive sweating
• Delayed closure of fontanelles
• Swollen wrists and ankles
• Squared head caused by bossing of frontal bone structure
• Swelling of the ends of the ribs (‘ricketty rosary’)
•
• Decreased muscle tone
• Protuberant abdomen
Severe signs include:
• Spontaneous fractures
• Bowing of legs
• Tetany (twitching in feet and hands) and convulsions
Rachitic children show reduced bone growth, are anaemic, and prone to respiratory infections
Population prevalence There are no international standards to indicate when vitamin D deficiency is a serious situation.
rates to indicate a Rickets is still endemic in parts of the world and has been linked with calcium deficiency. As bowed
serious situation legs (a common sign of rickets) indicates past deficiency, it is not necessarily a reliable indicator of
present deficiency. Concern about rickets is usually only necessary in situations where children have
limited access to sunlight.
At risk groups Rickets is endemic in most Middle Eastern countries in a band going from Morocco to Pakistan and
can occur as far south as Ethiopia. It is also common in parts of eastern Europe. Lack of exposure to
the sun in combination with a diet low in pre-formed vitamin D and high in phytic acid (e.g. bread)
can cause rickets. Populations living in desert areas where atmospheric dust acts as a filter for ultra-
violet light are susceptible, particularly when people stay inside to avoid the heat of the day and
wear extensive clothing. Populations who are forced to remain inside due to shelling or fighting are
also at risk.
Folate
Deficiency signs Folate deficiency can result in megaloblastic anaemia, which shows the same signs as iron-
deficiency anaemia. These are:
• Pale conjunctivae (inner eyelid), nailbeds, gums, tongue, lips and skin
• Tiredness
• Headaches
• Breathlessness
Individual cut-off points Population group: grams per litre

to indicate anaemia 0-5 years < 110
6-15 years < 120
Adult men <130
Adult women <120
Pregnant women <110
Severe anaemia has been defined as <70 g/L and very severe anaemia as < 40 g/L. Cut-off levels
must be shifted upwards for people living at high altitudes and for those who smoke.

rates to indicate a Anaemia 30 and above
serious situation (among high-risk groups young children and
pregnant women)
At risk groups Megaloblastic anaemia occurs commonly in developing countries. It may occur at any age, but adult
women, infants and young children are affected most frequently. It particularly affects pregnant
women.
107
Niacin
Deficiency signs Niacin deficiency results in pellagra, which affects the skin, gastro-intestinal tract and nervous
systems. For this reason, it is sometimes called the 3Ds: dermatitis, diarrhoea and dementia.
Dermatitis is the most distinctive feature and shows the following signs:
• Redness and itching on all areas of the skin exposed to sunlight resembling sunburn
• The redness develops into a distinctive ‘crazy pavement’ pattern
• Where dermatitis affects the neck, it is sometimes termed ‘Casal’s necklace’
Complaints of the digestive system include:
• Nausea and sometimes constipation
Disturbances of the nervous system include:
• Weakness, tremor, anxiety, depression and irritability in mild cases
• Delirium in acute cases
• Dementia in chronic cases
Population prevalence There are no international standards to indicate when niacin deficiency is a serious situation. A
rates to indicate a single confirmed case of pellagra, especially in an emergency situation, should be investigated and
At risk groups Maize eating populations, who do not treat the maize to release niacin, are at risk of developing
pellagra. Where legumes, such as peanuts, have not been provided in emergency rations pellagra
has arisen. Women are at higher risk than men and risk increases with age.
Thiamin
Deficiency signs Thiamin deficiency results in beri-beri. There are 8 clinically recognisable syndromes of beri-beri; 5
in adults and 3 in children. Only four forms commonly due to low intake in developing countries are
described here.
Wet beri-beri:
Early signs include:
• Anorexia (loss of appetite) and ill-defined malaise, associated with heaviness and weakness of
the legs
• Slight oedema (swelling) in the legs
• Slight increase in pulse rate
• Tenderness in the calf muscles on pressure and complaints of ‘pins and needles’
Later signs include:
• Oedema spreading from legs to the face and trunk
• Restlessness and breathlessness
• Rapid pulse rate and palpitations
Dry beri-beri:
The early signs of dry beri-beri are the same as for wet beri-beri. Later signs include:
• Polyneuropathy (general dysfunction of the nervous system) starting with loss of feeling in the
feet and diminished touch sensation
• Muscles become progressively wasted and weak, and walking becomes difficult
Infantile acute cardiac beri-beri:
Peak prevalence occurs in breast-fed babies of 1-3 months of age. Signs include:
• Colic-like symptoms with screaming bouts, restlessness, anorexia and vomiting
• Oedema
• Breathlessness with signs of heart failure
• Increased pulse rate
• Low urine volume occur
• Heart failure eventually leads to death
Aphonic beri-beri:
Peak prevalence is in 4-6 month old children. Signs include:
• Voice changes with a cry that becomes more and more hoarse until no sound at all is produced
• Restlessness and breathlessness
• Oedema
Population prevalence There are no international standards to indicate when thiamin deficiency is a serious situation. A
rates to indicate a single confirmed case of beri-beri, especially in an emergency situation, should be investigated and
A At risk groups Populations who consume non-parboiled polished rice as a staple are at risk, particularly where the
rice is contaminated with moulds.
108
WFP ANNEX
Iodine
Deficiency signs Iodine deficiency causes a range of abnormalities including goitre (swelling of the thyroid gland in
the neck) and cretinism which occurs in the offspring of women with severe deficiency in the first
trimester of pregnancy.
Goitre:
WHO currently recommend a simple three grade classification of goitre:
Grade 0 No palpable (can’t feel) or visibly enlarged thyroid
Grade 1 A palpable but not visibly enlarged thyroid with the neck in a
Normal position
Grade 2 A palpably and visibly enlarged thyroid with the neck in a normal a
Position
Cretinism:
There are 2 types of cretinism;
Neurological cretinism:
• Mental deficiency
• Deaf mutism
• Spasticity
• Ataxia (lack of muscular coordination)
Hypothyroid or myxoedematous cretinism:
• Dwarfism
• Hypothyroidism (small thyroid gland)

rates to indicate a Goitre Above 5
serious situation
At risk groups Goitre is endemic in many mountainous areas of Europe, Asia, the Americas and Africa where there
is limited access to seafoods. The prevalence of goitre increases with age and reaches a peak
during adolescence. Goitre tends to affect girls more than boys and women more than men because
of increased activity of the thyroid gland during pregnancy.
Iron
Deficiency signs Lack of iron eventually results in iron-deficiency anaemia. Typical signs are:
• Pale conjunctivae (inner eyelid), nailbeds, gums, tongue, lips and skin
• Tiredness
• Headaches
• Breathlessness
Field methods of Filter paper method:

assessment A drop of blood is obtained through a prick to the finger, earlobe or heel. A blood spot is placed on filter
paper and the colour compared to a printed set of colour standards, which indicate level of anaemia. The
method is highly subjective and not very accurate. It is cheap, simple, portable and rapid, however.
Haemoglobinometer:
A small sample of blood through a finger prick is collected and placed in a disposable cuvette. The
cuvette is placed in a portable haemaglobinometer (hemoCue) which gives a digital reading of Hb level
within 45 seconds. The method is rapid and accurate but expensive.
Individual cut-off Population group: grams per litre

points to indicate 0-5 years < 110
anaemia 6-15 years < 120
Adult men <130
Adult women <120
Pregnant women <110
Severe anaemia has been defined as <70 g/L and very severe anaemia as < 40 g/L. Cut-off levels must
be shifted upwards for people living at high altitudes and for those who smoke.
Population Criteria: Prevalence (%):

prevalence rates to Anaemia 30 and above
indicate a serious (among high-risk groups young children and
situation pregnant women)
At risk groups At risk groups are:

• Women of child-bearing age (because of blood loss through menstruation);
• Pregnant and breastfeeding women (because of increased iron requirements);
• Babies exclusively breastfed beyond the age of 6 months (because iron in breast milk is inadequate);
• Babies given cow’s milk (because of intestinal blood losses);
A
• Weaning-age children (because of inappropriate weaning diets).
Regions where malaria and intestinal parasitic infestation are prevalent are at risk.
109
Annex 2.1
Specifications and Examples of Blended Foods
Blended foods are a mixture of milled cereals and other ingredients, such as, pulses, dried skimmed
milk, and possibly sugar and or some kind of vegetable oil. Blended foods are produced either by:
• Dry blending of milled ingredients.
• Toasting or roasting, and milling of ingredients.
• Extrusion cooking, which results in a ‘pre-cooked’ product.
The final product is usually milled into powder form, and fortified with a vitamin mineral premix.
A range of ‘blended’ foods is available worldwide for a variety of purposes. Some blended foods
were originally designed to provide protein supplements for weaning infants and younger children
or for low-cost weaning foods in developing countries.
Guidelines on Formulated Supplementary Foods for Older Infants and Young Children have been
developed by the FAO Codex Alimentarius Commission (1991). These guidelines refer to blended
foods suitable for use for infants from six months of age up to the age of three years, for feeding
young children as a supplement to breastmilk or breastmilk substitutes. They are intended to provide
those nutrients, which either are lacking or are present in insufficient quantities in the basic staple
foods.
Several locally produced blended foods have been developed for the commercial market, and only
later used or adapted for emergency relief (e.g. likuni phala in Malawi and faffa in Ethiopia). Some
of these products are now used in the general ration distribution programmes for adults and children
as a means of providing an additional source of micronutrients.
Blended foods have also been designed for use in therapeutic feeding programmes. These products
are more expensive than regular blended foods, partly because of their higher quality ingredients and
higher specification packaging. They also contain a wider range of micronutrients suitable for the
needs of severely malnourished children.
Blended food should be produced in accordance with the ‘Code of Hygienic Practice for Foods for
Infants and Children’ and ‘Code of Sound Manufacturing Practices’ of the Codex Alimentarius.
It is a mixture of the following ingredients:
• Cereal like maize, sorghum, millet, wheat or combination, providing carbohydrates and protein;
• Pulses (chickpeas) or soya beans as an additional source of protein;
• Oilseeds (groundnuts, dehulled sunflower seeds, sesame), soya bean or stabilized vegetable oil as an
additional source of oil;
• Vitamin/mineral supplement;
• If required sugar can be included in the recipe; it replaces an equivalent amount of cereal
It is manufactured according to the following recipe:

• Whole maize: 80% by weight
• Whole soya beans: 20% by weight
• Vitamin/mineral premix (as specified below)
A It should be manufactured by use of extrusion or roasting/milling. It should be fortified to the extent
that to each MT of finished product 1kg vitamin premix and 3kg mineral premix (obtained from La
Rote Ltd. Switzerland, or its local authorized dealer) should be added.
110
WFP ANNEX
Annex 2.2
Guidelines for the use of milk powder
Dried milk powder should not be

distributed to emergency affected populations as part of a general dry ration.
This is because of the danger of it being used as a breast-milk substitute and the risk of high levels
of microbial contamination when prepared with unclean water or in unsanitary conditions. These
risks are greatly increased in an emergency setting.
Milk powder can be used safely:
• As an ingredient in High Energy Milk (or porridge) prepared under strict control and in hy-
gienic conditions in a supervised environment for on-the-spot consumption (well-managed
supplementary and therapeutic feeding).
• As an ingredient in porridge pre-mix, prepared from cereal flour, oil, sugar and DSM. This
should be prepared centrally under strict control and hygienic conditions for distribution in dry
supplementary feeding programmes.
• As an ingredient in the local production of processed foods, for example, blended foods,
noodles, or biscuits. Although the high cost of milk powder may mean this is an inefficient use
of resources.
Use of breastmilk substitutes

If a breast milk substitute (BMS) is considered essential, for example, among an emergency affected
population accustomed to bottle-feeding, they may be provided as long as certain precautionary
measures are followed. BMS should only be available to mothers who have been identified as
needing it (by health workers) through specially designed supervised programmes. BMS should
never be distributed through the general ration programme.
WFP supports the policy of the World Health Organization concerning safe and appropriate infant
and young child feeding, in particular by protecting, promoting and supporting breastfeeding, and
encouraging the timely and correct use of complementary foods.
Storage
Microbial contamination is the major problem in using reconstituted milk powders, so high energy
milk must only be prepared and consumed under strict control and in hygienic conditions.
During storage, as long as the product is kept clean and dry the low moisture content of the product
will not allow microbial growth. Milk powders are packaged in expensive plastic lined bags which
must be handled carefully, so as not to damage the packaging, and stored away from direct sunlight
and kept cool.
Most WFP supplied milk powder can be stored for 6 months to two years, depending on the
temperature:
• In a cold climate (4oC) 24 months A
• In a tropical climate (21oC) 18 months
• In a very warm climate (32oC) 6 months.
111
Annex 2.3
Policy Statements on Infant Feeding
and Infant Formula
Joint Policy Statement on Infant Feeding

In April 1999 a revised Joint Policy Statement on Infant Feeding in the Balkan Region signed by
UNHCR, UNICEF, WFP and WHO was circulated in Macedonia in April 1999. A revised statement
re-circulated in June 1999.
The following is a summary of the key recommendations:
• Exclusive breastfeeding is protected, supported and promoted for all infants until about six
months and continued breastfeeding through the second year of life.
• Donations of infant formula displaying brand names are not accepted.
• In very exceptional circumstances infant formula provided in generic, non-brand formula may
be used.
• If artificial feeding is required as a last resort, cups and not feeding bottles should be use
• Local produce (e.g. fruit and vegetables) and basic food aid commodities (e.g. rice, beans and
lentils) are recommended as complementary infant foods. The use of specialised manufactured
complementary products, which may create a dependency, is discouraged.
• The Joint Statement refers to the distribution of supplementary food commodities such as dried
milk powder and biscuits to children aged 0 - 5 years. It states that dried milk must not be used
to feed infants.
• An education component should be an integral part of every project where supplementary food
commodities (especially infant formula and commercial complementary foods) are distributed.
The International Code (WHO, 1981) and subsequent relevant

resolutions of the World Health Assembly (4, 5)
The Code sets out the responsibilities of national governments, companies, health workers and
concerned organisations in ensuring appropriate practice in the marketing of breastmilk
substitutes, feeding bottles and teats. The Code has the following aim:
to contribute to the provision of safe and adequate nutrition for infants by the protection and
promotion of breastfeeding and by ensuring the proper use of breastmilk substitutes when these are
necessary on the basis of adequate informsation and through appropriate marketing and distribution.
The Code has a series of articles covering a number of possible avenues that
could be used by companies and others to market breastmilk substitutes:
• No donations of free or subsidised supplies of breastmilk substitutes, bottles or teats should be
given to any part of the health care system (WHA 47.5). Donations may be made to institutions
outside the health care system for infants who have to be fed on breastmilk substitutes and
when these are distributed outside the institution supplies should be continued for as long as the
A infants concerned need them (Article 6, The Code).
• No facility of a health care system should be used for the purpose of promoting infant formula
or other products covered by the Code including the display of these products or posters or
112
WFP ANNEX
placards concerning these products.

• Breastmilk substitutes, bottle and teats should only be given if all the following conditions
apply (WHA 47.5):
• Infants have to be fed on substitutes according to agreed criteria
• The supply is continued for as long as the infants concerned need it
• The supply is not used as a sales inducement
• Manufacturers and distributors of infant formula responsible for marketing the products have to
ensure certain labelling requirements are met e.g. that the label is in an appropriate language
and include instructions for appropriate preparation and does not include any picture or text
which idealises the use of infant formula (Article 9, The Code).
The Joint Policy Statement recommends that it is the responsibility of the Ministries of Health and
local authorities to ensure that relief agencies comply with the International Code and subsequent
WHA resolutions. UNICEF is a member of the local authority involved in developing and implementing
the Code in Macedonia. Draft legislation incorporating the Code is before the Macedonian parliament
but not currently not incorporated into the country’s legislation. UNICEF has been involved in the
generation of this draft legislation in close co-operation with the Macedonian Breastfeeding Interest
Group of which UNICEF is a member.
113
Annex 2.4
WFP commodity list and corresponding
nutritional value
Nutritional value/100g
ENERGY PROTEIN FAT
(Kcal) (g) (g)
CEREALS
W heat 330 12.3 1.5
Rice 360 7.0 0.5
Sorghum/Millet 335 11.0 3.0
Maize 350 10.0 4.0
PROCESSED CEREALS
Maize meal 360 9.0 3.5
W heat flour 350 11.5 1.5
Bulgur wheat 350 11.0 1.5
BLENDED FOODS
Corn soya blend (CSB) 380 18.0 6.0
W heat soya blend (W SB) 370 20.0 6.0
Soya-fortified bulgur wheat 350 17.0 1.5
Soya-fortified maize meal 390 13.0 1.5
Soya-fortified wheat flour 360 16.0 1.3
Soya-fortified sorghum grits 360 16.0 1.0
DAIRY PRODUCTS
Dried skim milk (enriched) (DSM) 360 36.0 1.0
Dried skim milk (plain) (DSM) 360 36.0 1.0
Dried whole milk (DW M) 500 25.0 27.0
Canned cheese 355 22.5 28.0
Therapeutic Milk (TM) 540 14.7 31.5
MEAT & FISH

Canned meat 220 21.0 15.0
Dried salted fish 270 47.0 7.5
Stockfish - - -
Canned fish 305 22.0 24.0
OIL & FATS

Vegetable oil 885 - 100.0
Butter oil 860 - 98.0
Edible fat 900 - 100.0
PULSES
Beans 335 20.0 1.2
Peas 335 22.0 1.4
Lentils 340 20.0 0.6
MISCELLANEOUS
Sugar 400 - -
Dried fruit 270 4.0 0.5
Dates 245 2.0 0.5
Tea (black) - - -
Iodized salt - - -
114
WFP ANNEX
Annex 3.1
Examples of the Nutrient Content
of WFP General Rations
The nutrient content of three different rations have been calculated below. These were the actual
rations, which were distributed in three emergencies during 1994 and have been selected because
they were based on different cereals. The Bosnian ration (Ration 2) contains no blended food while
Rations 2 and 3 contained fortified blended food which were included as a method of improving the
micronutrient content of the ration.
Quantity
(grams per day)

Food item
Ration 1 Ration 2 Ration 3
(Tanzania) (Bosnia) (Nepal)

a
Maize flour Wheat flour Parboiled rice
Cereal
350 400 430
b
Oil 20 25 25
c
Pulses 120 40 60
Canned meat 40
d
Blended food 30 40
Sugar 20 20
e
Salt 5 5 7
Yeast 4
f
Fresh vegetables 100
a
Wheat flour fortified with calcium and B vitamins
b
Oil fortified with vitamin A,
c
Types of pulses: Tanzania = red haricot, Bosnia = red haricot, Nepal = red lentils;
d
Types of blended foods: Tanzania = corn soya blend, Nepal = wheat soya blend;
e
Salt fortified with iodine;
f
Fresh vegetables: Nepal = onions
115
Whole population % adequacy for a whole population

b
Requirements
Nutrient per day
a
Ration 1 Ration 2 Ration 3
(Tanzania) (Bosnia) (Nepal)
Energy 2100 kcals 91 89 106

Protein 53 g 124 112 100
Fat 40 g 88 89 81
Vitamin A (retinol) 500 ug 67 45 86
Vitamin B12 0.9 ug 133 89 178
Vitamin C 28 mg 60 6 75
Vitamin D 3.2 ug 563 0 750
Folate 160 ug 135 188 106
Niacin 12 mg 41 75 65
Riboflavin 1.4 mg 47 32 50
Thiamin 0.9 mg 211 177 210
Calcium 500 mg 50 122 76
Iron 22 mg 112 57 83
Iodine 150 ug 113 134 160
Note:
Nutrients are only included for which WHO has established whole population requirements. The
nutrient content of the rations has been estimated from raw foods. The actual nutrient content of the
food after preparation and cooking would be lower than the values shown.
a
Source: (WHO, 1995);
b
Calculated using ACF-NUTCALC programme
All three rations are notably short of vitamin A, vitamin C, niacin and riboflavin. The Bosnian
ration contained virtually no vitamin C at all. Even with the addition of fortified foods, these
rations were dangerously low on certain essential micronutrients. It should be noted that the energy
content of the Tanzanian and Bosnian rations was below the recommended energy requirement of
2100 kcals. This energy requirement was introduced in 1997 (the energy content of the rations did
satisfy the former recommendation of 1890 kcals). Thus, even when general rations, which are
adequate in energy and protein are provided, the micronutrient content is below recommended
requirements and deficiencies will result without other food supplements.
116
WFP ANNEX
Annex 3.2
WFP fortification specifications
for different commodities
Vitamins/Minerals Amount Remarks

Vitamin A 30,000 I.U./kg
Vegetable oil
= 9000 µg RE Vitamin A/kg
Vitamin D 3.000 I.U./kg
= 75 µg Vitamin D/kg
Iodine 20-40mg of Iodine/kg salt or 33- Assumi5ng average
Salt
66mg potassium iodate (KIO3/kg salt intake of
salt) 10g/day;
Assuming 20%
iodine loss from
production site to
household;
Assuming another
20% loss during
cooking
Thiamine (Vitamin B1) 4.4 mg/kg flour Not less than not
Wheat and maize Flour
more than twice the
amount indicated
Riboflavin (Vitamin B2) 2.6 mg/kg flour Not less than not
more than twice the
amount indicated
Niacin 35 mg/kg flour Not less than not
more than twice the
amount indicated
Folic Acid 0.4 mg/ kg flour Not less than not
more than twice the
amount indicated
Iron 29 mg/kg flour (as reduced iron) Not less than not
more than twice the
amount indicated
Blended foods Vitamin A 1664 I.U./100g finished product

(provisional) Thiamine 0.128 mg/100g finished product
Riboflavin 0.448 mg/100g finished product
Niacin 4.8 mg/100g finished product
Folate 60 µg/100g finished product
Vitamin C 48 mg/100g finished product
Vitamin B12 1.2 µg/100g finished product
Iron ++ (as ferrous fumarate) 8 mg/100g finished product
Calcium ++ (as Calcium Carbonate) 100 mg/100g finished product
Zinc ++ (as Zinc Sulphate) 5 mg/100g finished product
High Energy Biscuits Vitamin A 250µg RE/100g biscuit

(provisional) Thiamine 0.5 mg/100g biscuit
Riboflavin 0.7 mg/100g biscuit
Niacin 6 mg/100g biscuit
Folic Acid 80 µg/100g biscuit
Vitamin C 20 mg/100g biscuit
Vitamin B12 0.5 µg/100g biscuit
Iron 11 mg/100g biscuit
Calcium 250 mg/100g biscuit
Magnesium 150 mg/100g biscuit
Iodine 75 µg/100g biscuit
Panthothenic Acid 3 mg/100g biscuit
Vitamin B6
Vitamin B12
1 mg/100g biscuit
0.5 µg/100g biscuit
A
Vitamin D 1.9 µg/100g biscuit
Vitamin E 5 µg/100g biscuit
117
Annex 3.3
Examples: Fortified pre-cooked blended foods
available in field study sites
UNILITO WSB (ex-USA) FAMIX TENAMIX CSB (ex-USA)
Manufacturer Mahalaxmi Foods Protein Grain Faffa factory, HCFM Addis Ababa Protein Grain Products
Biratnagar Products Addis Ababa International
International
Ingredients Wheat pre-cooked wheat pre- Maize pre- maize pre-cooked maize (processed,
Maize pre-cooked cooked cooked soya pre-cooked gelatinized)
Soya pre-cooked soya flour Soya flour full fat chickpea pre-cooked soya flour
vit/min premix salad oil Sugar sugar (defatted,toasted)
vit/min premix Vit/min premix vit/min premix soya oil
vit/min premix
Process Roastiing Extrusion Roasting roasting extrusion
Food values 400 Kcal 360 Kcal 402 Kcal 380 Kcal 380 Kcal
Per 100gm 14 gm protein 20 gm protein 14.7 gm protein 13.3 gm protein 18 gm protein
dry product 6 gm fat 6 gm fat 7 gm fat 7.4 gm fat 6 gm fat
60 gm 70.1gm 65 gm carbohydrate 60 gm carbohydrate
carbohydrate carbohydrate
Preparation None Famix: water Tenamix:water

instructions 2:5 2:5
5 -10 minutes 2 teaspoon oil
boiling Cook for 10 minutes
118
WFP
Unilito Famix Tenamix

WFP Rome WSB CSB
(available in (available in (available in
recommendations ex-USA ex-USA
Nepal) Ethiopia) Tanzania)
Vit. A 1,664.0 i.u. 400.0 microgram 1,658 i.u. 1,300.0 i.u. 1,500.0 i.u. 1,700 i.u.
Vit. B1(thiamine) 0.128 mg 0.1 mg 1.49 mg 0.1 mg 0.3 mg 0.7 mg
Vit. B2(riboflavin) 0.448 mg 1.0 mg 0.59 mg 0.4 mg 0.5 mg 0.5 mg
Vit. B3(niacin) 4.8 mg 5.0 mg 9.1 mg 5.0 mg - 8.0 mg
Folate 60.00 microgram 50.00 microgram 50.00 0.06 mg
Vit. C 48.0 mg 50.0 mg 40.0 mg 30.0 mg 20.0 mg 40.0 mg
Vit. B12 1.2 microgram 5.0 microgram 4.0 microgram 1.0 microgram 0.3 microgram 4.0 microgram
Iron 8.0 mg 15.0 mg 20.8 mg 8.0 mg 12.0 mg 18 mg

(as ferrous fumarate)
Calcium 100.0 mg 100.0 mg 749.0 mg 100.0 mg 200.0 mg 800.0 mg

(as calcium (? not as calcium (? not as calcium
carbonate) carbonate) carbonate)
Annex 3.4
Zinc 5.0 mg 5.0 mg 4.6 mg 5.0 mg 10.0 mg 3.0 mg

(as zinc sulphate)
Vit. B6 - - 0.52 mg - 0.4 mg 0.7 mg
Iodine - - 50 microgram - 0.05 mg 50 microgram
Magnesium - - 202 mg - 20.0 mg 100 mg

Micronutrient Specifications
Selenium - - - - 25.0 mg -
Potassium - - 624 mg - 164.0 mg 700 mg

(per 100 gm. dry finished product)
ANNEX
119
A
Annex 4.1
How to calculate percent
of the median and SD scores
Percent of the median = [Actual weight / Reference child’s weight ] x 100
Actual weight: actual weight of the individual child being measured

Reference weight:the weight of the reference child from the reference tables
SD scores = [ Actual weight – Reference weight ] / Reference standard deviation
Actual weight: actual weight of the individual child being measured

Reference weight: the weight of the reference child from the reference tables
Reference standard Deviation: the value of + or – 1 standard deviation of the reference population
Example of a child:
Length: 82cm
Weight: 9.4kg
Reference weight: 11kg
Reference standard deviation: 0.9kg
Weight-for-length % median = (9.4 / 11) x 100 = 85%
Weight-for-length SD score = (9.4 – 11) / 0.9 = -1.77
120
WFP ANNEX
Annex 8.1
Energy Requirements
for Emergency-Affected Populations,
Developing country profile Kilocalories per day
a a a
Male Female Male & Female
Age/sex
group (years) Energy Energy Energy
% of total % of total % of total
requirement requirement requirement
population population population
per caput per caput per caput
0 1.31 850 1.27 780 2.59 820

b
1 1.26 1250 1.20 1190 2.46 1220
b
2 1.25 1430 1.20 1330 2.45 1380
b
3 1.25 1560 1.19 1440 2.44 1500
b
4 1.24 1690 1.18 1540 2.43 1620
0-4 6.32 1320 6.05 1250 12.37 1290

5-9 6.00 1980 5.69 1730 11.69 1860
10-14 5.39 2370 5.13 2040 10.53 2210
15-19 4.89 2700 4.64 2120 9.54 2420
c
20-59 24.80 2460 23.82 1990 48.63 2230
c
60+ 3.42 2010 3.82 1780 7.24 1890
Pregnant 2.4 285(extra) 2.4
Lactating 2.6 500(extra) 2.6
Whole 50.84 2250 49.16 2010 2070

c
Population
Sources:
(1) Energy requirements derived from WHO Technical Report Series No. 724
(2) Population data (mid-1995): UN Population Division, New York

a
Adult weight: male 60 kg, female 52 kg.
b
Population estimates for years 1, 2, 3 and 4 are not available from UN. Estimates for these years were made by
interpolation between the figures given by UN for 0 year and 5 years.
c
The figures given here apply for ?light? activity level (1.55 x BMR for men, 1.56 x BMR for women).
(The BMR - basal metabolic rate - is the rate of energy expenditure of the body when at complete rest e.g. sleeping.)
Adjustments for moderate and heavy activity: see Annex II.
N.B.
The requirements as expressed above do not take into account the varying fibre content, digestibility and complex-
carbohydrate composition of the diet.
In developing countries, a relatively high proportion of fibre and less-available carbohydrate is usually present. The
carbohydrate content of foods may be expressed in terms of its various components (starches, sugars, fibre, cellulose,
lignins, etc.) or simply as the calculated ?difference? between the total weight and the sum of the other components
(fat, protein, minerals and water). This issue is discussed in WHO Technical Report Series No. 724, section 7.1. If
the Atwater factor (4 Kcals per gramme) is applied to carbohydrate by difference, the real energy available in the
food should be decreased by 5% or the ?requirement? for this type of diet increased by 5%; which, for this Table,
means an increase of +100 Kcals in the energy requirement indicated. A
121
Annex 8.2
Mean population energy requirement, and
recommended increments of energy (Kcal per
day) needed, taking into account the levels of
activity, environmental temperature and food
losses during transport
Developing
country
1. Mean energy requirement 2070
2. Adjustment to requirement for activity-level of adults (18 years+)

Moderate* Males + 360
Females + 100
Whole population + 140
(adults & children)
Heavy* Males + 850

Females + 330
Whole population + 350
3. Adjustment to requirement for mean daily temperature (°C):

20°C -
15°C + 100
10°C + 200
5°C + 300
0°C + 400
_______________________________________________________________________________
4. Adjustment to cover possible food losses in transport:
Country with port + 5%
Landlocked country + 10%
(These figures are not absolute but should be adjusted up or down according to local realities)
122
WFP ANNEX
ANNEX 8.3
Fuel-Saving Strategies in Emergencies
Because emergency situations are not always short-lived, approaches to ensuring an adequate fuel supply must go
hand in hand with strategies to conserve scarce energy resources and to minimise any subsequent environmental
degradation. A range of strategies should be pursued including:
• fuel saving cooking technologies;

• energy saving cooking practices,
• the use of alternative biomass fuels and non biomass fuels.
Fuel-saving cooking technologies

There are various types of improved stoves (fuel efficient) available. They rely on the two principles of (a) enclosing
and insulating the fire and (b) controlling the airflow. Simply by shielding a wood fire from draughts 30 – 40 percent
fuel savings can be achieved. Improved stoves are usually made with metal, clay, ceramic or a combination. Mud
stoves can be constructed using locally available materials. They can vary from simple filling-in of two sides of a 3
stone fire with a mud wall to prevent through-draughts, to designs incorporating a circular fire chamber, arched
doorway for fuel and integral pot rests.
Energy-saving cooking practices

Examples include, the use of tightly fitting lids, the correct choice of pot, removal of excess soot build-up, cutting
foods up small, pre-soaking of beans, putting fires out promptly etc. The grinding of beans and hard grains, such
as maize, reduces cooking time by many hours and energy consumption by up to 80 percent. Collective cooking
arrangements also achieve considerable energy savings. Especially inefficient are cooking groups of one or two
people. Cumulative energy savings begin to decline rapidly above group sizes of seven to eight.
The use of alternative biomass fuels, (alternative to firewood). For example, peat, charcoal, briquettes
(manufactured fuel pellets), carbonized briquettes, grass. The use of these fuels should only occur when sufficient
renewable residues exist which do not compromise future soil fertility. Typical consumption levels of firewood
range between 1 – 2 kg per person per day, although this varies considerably depending on a range of factors.
The use of certain fuels for cooking has health implications through exposure to pollutants released in combustion.
Women, the elderly and very young are likely to be disproportionately affected. Some of the documented health
effects of cooking with biomass fuels in unventilated areas include; acute respiratory infections, chronic obstructive
lung disease, anaemia and eye disorders, conjunctivitis and blindness. Open fires pose the threat of burns and
scalds, especially to young children.
Use of non-biomass fuels, such as solar cookers and kerosene. Solar cookers can only be used where there are high
enough insolation levels (exposure to the sun’s rays). It is possible to cook with an insulated container into which a
pot of partially cooked food can be placed to continue cooking without the use of additional fuel. Fireless cookers
or haybasket cookers, are usually made with a basket or box insulated with cloth, newspaper or wood shavings and
with a tightly-fitting insulated lid.
The use of kerosene for cooking in an emergency requires special stoves and fuel storage containers to be made
available. The fire risk is considerable at all stages of distribution. People may be unaware how to operate the
stoves which increases already significant fire risk. For these reasons it has been opposed at household level, but
may be used communally where there is less chance of sale of fuel and hardware.
Strategies to provide fuel in emergencies should be developed in full consultation with the affected population,
particularly women. Where new or alternative fuels are distributed, people must be kept informed and where
necessary allowed the opportunity to acquire relevant skills.
For guidelines about domestic energy see the UNHCR Environmental Guidelines Domestic energy in Refugee
Situations, UNHCR, May 1998.
A
123
World Food Programme
Nutrition Unit
Strategy and Policy Division
Address:
World Food Programme
Via Cesare Giulio Viola 68/70
00148 Rome, Italy
Telephone:
+39 06 651-31

Food and Nutrition Handbook

Uploaded by

Copyright:

Available Formats

Food and Nutrition Handbook

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Food and Nutrition Handbook

Uploaded by

Copyright:

Available Formats

World Food

Food and Nutrition

Margot Van Der Velden,

Various chapters reviewed by:

1 BASIC NUTRITION CONCEPTS ...................................................................................................... 1

2 FOOD GROUPS AND FOOD AID COMMODITIES .......................................................................... 6

3 FORTIFICATION OF FOOD AND BLENDED FOODS ................................................................... 13

5 MEASURING MALNUTRITION AND NUTRITION SURVEYS ....................................................... 31

6 FOOD AND NUTRITION ASSESSMENTS ..................................................................................... 43

7 TYPES OF NUTRITION INTERVENTIONS .................................................................................... 54

8 PLANNING FOOD RATIONS .......................................................................................................... 62

9 SELECTIVE FEEDING PROGRAMMES ........................................................................................ 72

Admission and Discharge Criteria for Selective Feeding Programmes .............................................................................. 79

10 GENERAL FOOD DISTRIBUTION ................................................................................................. 82

11 NUTRITION INFORMATION, EDUCATION AND COMMUNICATION ........................................... 93

Annex 1.1 Micronutrient functions, sources and effects of processing ........................................................................... 97

• to save the lives of people caught up in humanitarian crises, through Food-For-LIFE;

• A better understanding of food and nutrition issues as they relate to WFP.

The handbook is divided in two sections.

1 BASIC NUTRITION CONCEPTS

Energy provided by macronutrients

Energy and protein requirements

Table 1.1 Major Micronutrients: Functions, Sources

Food commodity Adverse effects/practices Beneficial effects/practices

Minimising or consuming water used for

Oil Vitamin A content in fortified fats and

Storage for more than 6 months reduces

Fortified blended food Storage for more than 6 months reduces

WHO. 1974. Handbook of Human Nutritional Requirements. Geneva: WHO.

2 FOOD GROUPS AND FOOD AID

Key Food Groups

Box 2.1: Key Food Groups in the Diet

Legumes and oilseeds

Oils and fats

Emergency Rations / Ready-to-Eat Meals

Emergency ration biscuits or tablets:

MREs (Meals Ready-to-Eat):

Salt, Sugar and Tea

WHO. 1974. Handbook of Human Nutritional Requirements. Geneva: WHO.

WHO. 1995. The Management of Nutritional Emergencies in Large Populations (DRAFT).

Other useful references

3 FORTIFICATION OF FOOD AND

What is Food Fortification?

Why fortify foods?

Are fortified foods needed in the ration?

Which foods are fortified?

Table 3.1 Risks of Micronutrient Deficiency from General Rations

Possible food sources to be included in the

Situations where iodine deficiency disorders are Iodized salt (f)

Brewers yeast is a good source, so where cereals are

Fortification of blended food

Advantages of local fortification Disadvantages

(Milled flours are expensive to package, transport

The capacity to mill and fortify locally may be

The food aid pipeline to the point of fortification

Additional management capacity is required to

Micronutrient Stability, Packaging and Shelf-Life

Food vehicle The food to which fortificants are added.

Box 4.1: Types of growth failure