Menu ENN Search
Language: English Français

Guidance around post emergency micronutrient supplementation

This question was posted the Micronutrients forum area and has 4 replies. You can also reply via email – be sure to leave the subject unchanged.

» Post a reply

Hatty Barthorp

Global Nut Advisor / GOAL

Normal user

21 Jun 2017, 12:45

Does anyone have any guidance info' or links to documents outlining how population groups should be treated for micronutrient deficiencies with non-clinical manifestations, in lieu of a recent emergency?The context in question are Syrian refugees in Turkey who have recently left their country of origin and are seeking care through dedicated primary health care services in neighbouring Turkey. It is likely that a number of vulnerable groups, including children, PLWs, elderly and/or people with chronic illnesses will have different forms of micronutrient malnutrition to varying degrees, given that many food baskets being provided in Syria are not micronutrient replete, despite providing adequate kcals, frequently lacking adequate calcium, iron, various B Vits, Vit C, D, E & K (based on an average requirement of a adult), not taking into consideration the additional needs of specific high risk groups. As such, I'm trying to find out if there are any guidelines re. how to treat high risk groups curatively, but in the absence of testing or clinical signs. Many thanks,

Alison Fleet

Nutrition Specialist, UNICEF

Normal user

22 Jun 2017, 06:15

Dear Hatty,
you may find this references useful from WHO : http://www.who.int/nutrition/publications/micronutrients/WHO_WFP_UNICEFstatement.pdf?ua=1

Andrew Hall

Nuritionist and parasitologist

Normal user

22 Jun 2017, 07:37

Hello Hatty

You might consider using the new Cost of the Diet software developed by Save the Children to see whether and how a basket of foods meets specifications for energy, protein and micronutrients. Here is a link to a recent paper that describes the method: https://bmcnutr.biomedcentral.com/articles/10.1186/s40795-017-0136-4

The paper gives links to download the practitioners guide, both English and French versions, and register for the software, which is free.

If you provide a basket of foods you will need to find each one in the embedded food tables (there are >3000 listed or new foods can be added) and then enter the same nominal price for each food so that relative price is not an issue in the calculation and all foods have an equal chance of being included. You may want to adjust the number of times food are eaten in a week, to make the frequency of consumption is realistic, or just assume that the basket of foods is the only source of energy and nutrients and see how much has to be consumed to meet specifications, if it's possible. You can select from over 250 individuals to set the specifications for energy and nutrients for the calculations, or apply pre-selected standard families in the software.

The software applies the intake of micronutrients recommened by the WHO and FAO, the RNI, which is set at two standard deviations above the average (not at the average) to minimise the risk of deficiency. This means that the amounts exceed the requirements of 95% of people. The amount of energy however is set at the average, so only meets the needs of 50% of individuals. As the actual requirements for energy and nutrients of any given individual are usually unknown, the approach is based on probability, so I prefer to use the term 'specifications' rather than 'requirements'. The software also takes a probabilistic approach: users can adjust the RNIs in the software between the 1st and 99th percentile (the RNI is set at the 97.725th percentile), as well as many others, to do 'what if' calculations?

If you are concerned that amounts of micronutrients provided by the foods are grossly insufficient, you can add foods to the basket and see what happens. At that point cost may be an issue, so you may need to enter the actual cost per 100g of each food. The software could be a useful tool to help improve the nutritional quality of a food basket, if other foods can be added at low cost. The software, as its name implies, can help you estimate that cost.

Hatty Barthorp

Global Nut Advisor / GOAL

Normal user

22 Jun 2017, 13:17

Thank you both Alison and Andrew for your responses. Alison, I had already looked through the ‘Preventing and controlling micronutrient deficiencies in populations affected by an em’ joint statement, but I’m not sure it would be appropriate to use in our context. My concern with the use of this guide is that it refers to the management of micronutrient deficiencies during emergency contexts, but the population group we may be working with are new refugees in Turkey, living within the host population, accessing food independently and thus their situation wouldn’t be classified as an em’ with a finite timeline. Secondly, it’s only applicable to PLWs and children 6-59, whereas with recent refugees, it’s likely all household members will have been subjected to protracted nutrient deficiencies, during their time in Syria. As such, I am trying to identify whether it would be suitable to provide (through dedicated health services for refugee populations) something like a multiple micronutrient supplement (MMS) i.e. in the form of a powder to be added to family foods, or take home nutrient supplements for adults and children >6m, for a limited period of time (say 2mths), in attempts to build back up nutrient reserves (in the absence of food aid or access to fortified food rations). For the type 1 functional nutrients such as iron, calcium and various vitamins, whereby there are body stores, it is likely that these are depleted and need replenishing. For the type 2 growth nutrients where there are no significant bodily stores, these will obviously need to continue to be provided (in conjunction with type 1 nutrients) through their new diets after the cessation of any supplements.
Andrew, I’m not sure the cost of the diet tool would be appropriate here (although please do correct me if I’m wrong). As the paper you kindly referenced outlines, ‘..it is not a tool to plan a diet nor does it analyse the nutrient content of the foods in a given diet’. As we are not playing a role in food aid provisions in this context, rather looking to provide primary health care with integrated nutrition support, I am basing my assumption on the thinking that recently displaced refugees have been living with nutritionally incomplete diets for some time (in Syria) and thus will likely arrive in Turkey with a number of underlying deficiencies. I would like to try to ensure this is recognised and the issue is treated. Clinical manifestations of type 1 nutrients will not always be evident, less so with type 2 nutrients.

Hatty Barthorp

Global Nut Advisor / GOAL

Normal user

28 Jun 2017, 13:33

Has anyone had experience of treating population groups with assumed micronutrient deficiencies based on indirect assessment of dietary intake?

Back to top

» Post a reply