Although the world produces enough food to feed its entire population, almost 1 billion children, men and women suffer from hunger around the globe
Every year, more than six million children die of complications due to malnutrition.
Every day, some 25,000 people, mainly children, die of malnutrition.
Globally, in 2011 some:
• 165 million children under-five years of age were stunted (too short for their age)
• more than 90% of the world’s stunted children live in Africa and Asia
• 101 million children under-five years of age were underweight (low weight in comparison to age)
• 52 million children under-five years of age were wasted (low weight in comparison to height)
• 70% of the world’s wasted children live in Asia
The Red Cross/Red Crescent Movement has been dealing with such a global issue since 1952.
In 1986 the Resolution XVIII adopted by the 25th International Conference, also recalling that malnutrition is often one of the major problems identified during Health assessment following emergencies, set out a “Nutrition and Food Donation Policy in Emergency Operations” which:
1. recommends that all Red Cross and Red Crescent nutritional programmes be integrated into the general health programme adapted specifically to each emergency operation,
2. recommends that any Red Cross and Red Crescent nutritional response, including food distribution, be undertaken within the framework of a clearly established Red Cross and Red Crescent nutritional programme which is effectively planned, monitored and evaluated,
3. urges that all nutritional programmes of the ICRC, the League and National Societies be developed in accordance with the Nutrition and food donation policy in Red Cross and Red Crescent emergency operations and be established under the guidance of nutritionists,
4. recommends that each government participating in food distribution and other nutritional activities through ICRC/League emergency operations, or on a bilateral basis with a National Society, take full account of the Nutrition and food donation policy in Red Cross and Red Crescent emergency operations.
In 1997, with the adoption of its Food Security and Nutrition Policy, Nutrition and Food Security become a major priority for the International Federation and for its network (now made by 187 National Societies) working with millions of volunteers at the community, national and international level.
This policy sets the basis of Red Cross and Red Crescent action in food security.
According to this policy, the International Federation and each National Society shall
Recognise the role of the Red Cross/Red Crescent in protecting life, which includes food security, as complementary to Government and other actors and strive to form partnerships, advocate and raise awareness on food security issues
Strive to build food security upon programming in disasters or in efforts to reduce risk to disasters as well as health including HIV/AIDS Home Care.
Recognise that food insecurity may have a different impact on men and women, on different individuals and groups of people. Programmes should be designed and implemented in a diversity and gender sensitive way to consider biological, social and cultural differences.
Undertake food security assessment and analysis that demonstrates an understanding of how affected populations normally secure food, the risks, the causes and impact of disasters on the immediate and future food security and the most appropriate responses to address both transient (acute) food insecurity and longer term (chronic) food insecurity, through recognising and supporting household coping mechanisms.
Undertake nutrition assessment and analysis that demonstrates an understanding of public health in order to better determine the causes and impact of disasters as well as the effectiveness of interventions.
Support primary production when it is a viable food security strategy by ensuring that people have the means to e.g. undertake agricultural production, fish, or rear livestock, in an economically and environmentally sustainable manner for consumption or exchange.
Support income generation or employment where there has been a demonstrated loss of income generation opportunities or employment or where this is a key coping mechanism of people affected by food insecurity. Remuneration can be in kind or cash and programmes should not interfere with seasonal livelihood activities.
Support asset development, protection or recovery where those assets support livelihood strategies or provide an opportunity for diversification of such strategies.
Support access to markets both as producers and consumers to buy, sell or exchange food and other essential items at reasonable prices and in an efficient manner. This may include advocacy at International, Regional or National or projects such as community village road construction.
Provide food aid when appropriate as either a nutrition input or as an economic input to households. Food aid should be culturally acceptable, free from undesirable long-term consequences and adhere to recipient country specifications for quality and international standards. The impact of food aid on agricultural production and the economy should be considered prior to programming. Food aid programming can take different forms including, free food distributions, food for work, complementary and supplementary feeding.
Not accept or distribute donations of Dried Skimmed Milk (DSM) or other milk powder, e.g. whole milk powder, unless this is done as part of a premix for supplementary feeding or under special circumstances where supervision of preparation and access to sufficient clean water is possible. This recognises the inherent difficulties of ensuring adequate hygiene and appropriate use of milk powder when provided as a separate item for distribution.
Promote and protect breast-feeding in line with in-country policies on mother to child transmission of HIV through awareness raising and distribution of breast milk substitutes when absolutely necessary. In such cases where breast-milk substitutes are necessary and distributed, adherence to the World Health Organisations “International Code of Marketing of Breast-milk Substitutes” is to be demonstrated by the distributing organisation.
Prevent micronutrient deficiencies through appropriate programming and wherever possible in the most sustainable way through community-based health and nutrition education as well as advocating for national legislation on public health interventions, e.g. iodisation of salt. Micronutrient deficiencies arising from Vitamin A, Iodine, and Iron deficiency are of primary concern.
Ensure that food security programmes are adequately monitored and evaluated in a participatory manner.
According to the IFRC World Disaster Report 2011 on Hunger and Malnutrition, in order to reduce the risks of food and nutrition insecurity among vulnerable populations, rural and urban poor must have access to instruments that not only help them manage risks and respond to shocks in the short term, but also improve their resilience and promote their food security in the long run.
Food security programming can be a key component of programmes in support of chronically ill people including people living with HIV/AIDS, TB and other communicable diseases.
IFRC currently runs nutrition programmes in 33 countries.
The level of programmes differs from one country to another.
For moderate and severe acute malnutrition, programmes range from screening and referral to treatment, although the Red Cross is usually dealing with moderate acute malnutrition and severe acute malnutrition and not really equipped to deal with severe acute malnutrition with complications.
For chronic malnutrition, programmes are usually around food security interventions (home gardening, irrigated gardens) or integrated programmes with water and sanitation projects, education and behaviour change, etc.), but also around growth monitoring, cooking demonstration, hygiene promotion and breastfeeding promotion.
Responding to malnutrition risks and reduce mortality and morbidity rates among children under five and pregnant and lactating women is one specific field in which the Red Cross Red Crescent is actively engaged.
Distribution of food assistance and nutritional screening should run at the same time with measures intended to protecting livelihoods and assets, such as provision of fodder for livestock and more long term oriented interventions such as development of regional food security and early warning policies, investments in diversified and sustainable agricultural practices, women’s groups, and community training and education. These longer term activities should also contain elements of nutritional awareness.
Any approach aimed at tackling under-nutrition should in fact be part of an integrated, sustainable, community-based planning which includes health programs, as well as education and hygiene promotion. It should develop and scale-up approaches that recognize the key role of local partners, build their capacities and are specifically adapted to the needs of vulnerable populations.
Hunger, malnutrition and food insecurity remain ever-present threats to the lives and livelihoods of countless vulnerable people throughout the world. Their causes go beyond access to sufficient nutritious food and include structural factors such as chronic poverty, social unrests, conflicts, lack of investment in agriculture, poor sanitation and access to safe water, climate change, volatile fuel prices, commodity speculation and, last but not least, corruption.
In such an effort an important role is played by the appropriate use of food supplements. According to the European Directive 2002/46/EC of 10 June 2002, food supplements are “alimentary products intended to supplement the normal diet and which are concentrated sources of nutrients, such as vitamins and minerals, or other substances with a nutritional or physiological effect, alone or in combination”.
This Directive is established with the aim to ensure a high level of protection of public health and a free circulation of these products inside the ‘European Union, ensuring that the supplements have adequate and appropriate labeling.
Food supplements are presented in the form of blocks, capsules, tablets, sachets of powder, ampoules of liquids, vials and dispensing bottles, and other similar forms of liquids and powders to provide a default intake of nutrients and / or substances having a physiological effect.
Two elements deserve particular consideration.
Firstly, the definition of integrator, which is, inter alia, based on the following points:
1) dietary supplements are food and therefore subject to the related regulation;
2) the purpose of these products is to integrate the normal diet;
3) food supplements are concentrated sources of nutrients or other substances with nutritional (for example vitamins, minerals etc…) or physiological effect (for example plant extracts), alone or in combination;
4) supplements are marketed in forms pre measured, so that they can be taken in small quantities measurable and measured.
Secondly, the official acknowledgement of its “healthy” effect specifically aimed at contributing to the welfare of the organism without goals of care.
In Italy, according to the definition adopted in the European Directive, Legislative Decree May 21, 2004 Article 169.2 defines supplements as “alimentary products aimed at integrating the common diet and which are concentrated sources of nutrients, such as vitamins and minerals, or other substances with a nutritional or physiological effect, in particular, but not limited to, amino acids, essential fatty acids, fibers and extracts of vegetable origin, alone or in combination, in forms pre measured”. In forms pre measured means “forms such as capsules, pastilles, tablets, pills, chewing gums and the like, sachets of powder, ampoules of liquids, drop dispensing bottles, and other similar forms of liquids and powders designed to be taken in small unit quantities”. This means that the consumer has a clear indication of how many tablets, capsules, chewing gum, sachets of powder, and ampoules of liquids to be taken as unit quantities.
According to current regulations, food supplements should ensure:
• safe use, in terms of type and concentration of substances used, as well as for issues related to the hygiene and contaminants
• nutritional and physiological characteristic effect, which must be legitimized by valid scientific assumptions
• effectiveness, supported by an adequate scientific rationale that correlates contained substances with a nutritional or physiological activity to the nutritional or physiological effect attributed to the product
• correspondence between the declared values and those effectively detectable, as regards the content of substances with a nutritional or physiological activity and for the period of preservation of the product
• clarity of the information on the label, in terms of composition, activity and any warnings on the product, in line with the labeling requirements of the DLG 169/2004 and the circulars issued on the subject
These points are considered very important in order to provide consumers with essential appropriate information for guiding choices and encourage correct behavior.
It is useful to point out that the use of food supplements has to take into account the levels of maximum daily intake of nutrients. In this regard, the EU orientation is to assume as general reference levels within safe limits (upper safe level: UL), even taking into account the RDA (recommended dietary allowances). In fact, the intake of vitamins and minerals in excessive amounts can lead to health hazards and for this reason, will be fixed the maximum levels that can be contained in food supplements safely.
Maximum amounts of vitamins and minerals present in food supplements per daily portion of consumption as recommended by the manufacturer shall be established taking into account both the upper safe levels of vitamins and minerals and the contribution of vitamins and minerals from other dietary sources.
Particular attention must be paid to the labeling of food supplements, which have to be clear and transparent.
The above mentioned Legislative Decree and implementing rules (for example, guidelines of the Ministry of Health), in accordance with the EU Regulation 1924/2006, requires clear directions of use and warning about potential adverse reactions to be displayed on the label, in order to allow final consumers’ informed choices.
The regulation focuses on the following objectives:
a) ensuring a higher level of consumers protection by increasing their information
b) promoting a better functioning of the Community market by safeguarding competition
c) promoting and protecting innovation
The new claims cannot be ambiguous or misleading, or cast doubt on the clarity and the nutritional adequacy of other foods; may not encourage or condone excess consumption of a food, or say that a balanced and varied diet is not able to provide adequate amounts of all nutrients. Finally, they cannot refer to changes in bodily functions capable of arousing fear in the consumer.
The overall objective of the Regulation is, in short, to ensure greater transparency and clarity in communication to the consumer.
Case study – Tackling malnutrition in Niger
Situation
In Africa one-third of all children suffer from malnutrition.
In Niger:
Only 9.9 per cent of children under six months are 100 per cent breastfed, and this percentage is lower still for uneducated mothers.
Forty per cent of the country’s population has no access to drinking water.
Eighty per cent of households in Niger do not have their own latrines.
96 per cent of people in the countryside and 57 per cent in cities do not have access to adequate sanitation.
The Red Cross and Red Crescent combat malnutrition in the countries that are worst affected.
The Red Cross is active in 66 Integrated Health Centers and 3 Intensive Nutritional Recovery Centers in district hospitals in the regions of Zinder, Agadez and Niamey.
For the year 2010, in the centers where the Red Cross operates, the cure rate for acute malnourished children is 87 per cent.
Malnourished children are among the most vulnerable in Niger, one of the world’s poorest countries. Niger came in last, 182nd, in the 2009 ranking of the Human Development Index and had a poverty rate estimated at 59.5 per cent in 2008.
In normal times, stunting rate of children in Niger is over 50 per cent, one of the highest in the world. These children have experienced impaired growth and cognitive development, which is generally considered irreversible.
In June 2010, the rate of acute malnutrition in Niger was 16.7 per cent in children under five, a figure well above the emergency threshold of 15 per cent and the 12.3 per cent estimated for 2009. In some regions, such as Diffa and Maradi, it stood at 22.1 per cent and 19.7 per cent, respectively, as compared with 17 per cent and 13.1 per cent in 2009. Similarly, the rate of severe acute malnutrition, which considerably increases the risk of infant mortality, raised from an average of 2.1 per cent in 2009 to 3.2 per cent in 20103. In November 2010, the overall rate for severe acute malnutrition reached 15.5 per cent, while the rate for overall acute malnutrition remained unchanged.
Malnutrition, the leading cause of infant mortality and morbidity in Niger, is significantly affected by food insecurity. However, other causes are also important, such as illness, poor sanitary conditions and hygiene practices, and poor infant and young child feeding practices. Dietary practices, limited access to health services and the limited access to drinking water are all factors which are underlying causes of illness and an inadequate diet.
When children suffer from malnutrition, their immune system is affected. Common illnesses like malaria or diarrhea may lead to complications, and the risk of death is very high. Yet malnutrition can be treated, and preventive action is possible.
As a result of the meagre farming and stockbreeding season for the year 2009–2010, Niger was hit by a serious food crisis in 2010. The analysis of the current food crisis in households conducted by the government in April 2010 shows that severe food insecurity affected 22.2 per cent of the population or some 3.3 million people, whereas moderate food insecurity hit 25.5 per cent of the population or 3.3 million people. Moderate and severe food insecurity affected 47.7 per cent of the population, or 7.1 million people.
Action
The French Red Cross has been present in Niger since 1998. It has established cooperation ties with the Niger Red Cross to combat malnutrition in the regions of Niamey, Agadez and Zinder, and has set up programmes to fight against malnutrition on a long-term basis.
The Red Cross programmes support capacity-building for health agents who are trained in the national protocols for the treatment of malnutrition. Under these programmes, Integrated Health Centres are equipped with anthropometric material such as scales and height gauges for evaluating children’s nutritional status, as well as medical equipment to ensure a thorough examination of children when they arrive at the IHC. Therapeutic foods are provided for treatment.
The French Red Cross approach focuses of enabling public health centers to treat malnourished children. Integrating programme activities into structures managed by the Ministry of Health is an important approach to ensure sustainable impact of humanitarian action. It supports stronger long-term capacity to address public health and nutrition challenges.
By giving public health centre staff the mandate and training to treat malnourished children, important skills are developed, practiced and institutionalized. Health centers can deal with children’s health from a holistic perspective. Working together with the Ministry of Health helps ensure the long-term viability of projects and closer proximity to the public. These public health centers existed before the Red Cross interventions, and will continue to exist after they are completed.
In conjunction with its project “Community-based nutrition”, the French Red Cross has trained volunteers from the Niger Red Cross to monitor in 85 villages located in the health area of 14 Integrated Health Centers the growth of children aged 0-36 months by means of active screening using middle upper arm circumference, and the seven following essential family practices:
1. 100 per cent breastfeeding
2. washing of hands
3. use of treated bed nets
4. diagnosis and treatment of diarrhea
5. high-quality food supplements
6. use of preventive and curative health services
7. danger signs of the leading illnesses.
The volunteers build community awareness through messages relating to health and child nutrition, monthly growth monitoring of children aged 0-36 months, as well as active screening of children aged 37-59 months for acute malnutrition. Children with a middle upper arm circumference under 125 mm are referred to an Integrated Health Centre, where they are weighed and their height is measured. Their nutritional status is evaluated, and they are treated if they are suffering from moderate or severe acute malnutrition.
In the wake of the 2010 food crisis, the Red Cross introduced active screening in 253 villages in the health areas of 14 Integrated Health Centers in Tanout health district within a 10 km radius from the Integrated Health Centers).
Screening was conducted by five mobile teams each composed of four Niger Red Cross volunteers and a male nurse as head of team, two team supervisors and a screening officer.
In all, 24,268 children aged 6-59 months benefited from active screening based on middle upper arm circumference measurement. All children with a brachial perimeter under 125 mm were weighed and their height was measured by the teams in the villages. Children suffering from moderate or severe malnutrition or severe malnutrition with complications were referred to public health structures for treatment.
A total of 2,356 children were screened and referred to health structures for treatment. Among them, 2,072 were treated, that is 88 per cent (1,534 suffering from moderate acute malnutrition, 517 from severe acute malnutrition and 21 from severe acute malnutrition with complications). The remaining 284 children will be surveyed during the second round of active screening.
This type of screening is essential, because early detection of the pathology boosts a child’s chances for survival. Children are referred to public health structures for evaluation of their nutritional status and quality treatment. Screening is often conducted jointly with UNICEF and other organizations, so as to reach a greater share of the population and estimate the number of children suffering from this pathology. Engaging in awareness-raising in addition to screening is crucial, as this increases the possibility for behavioral change.
The treatment of malnourished children varies depending on the degree of malnutrition. Moderately acute malnourished children are systematically treated with Vitamin A, iron, folic acid and mebendazol; their vaccination status is checked and measles vaccination if need be, the mother is given therapeutic inputs: a corn-soya-bourgou mix, oil and sugar in the form of a premix to prepare as a baby cereal.
In cases of severe acute malnutrition without complications, children are given “plumpy nut”, a ready-to-use therapeutic food. It is administered according to the child’s weight. In the event of severe acute malnutrition with medical complications such as malaria, acute upper respiratory infection and diarrhea, children are referred to a district hospital, where they receive appropriate treatment because the Integrated Health Centers are not authorized to treat cases involving medical complications.
Following the medical consultations, mothers attend awareness-raising sessions organized by Red Cross volunteers, which focus on essential steps to ensure proper child nutrition, an adequate diet and other preventive measures linked to hygiene and health promotion.
Depending on the type of programme (moderate acute malnutrition or severe acute malnutrition without complications), mothers come back either bi-weekly or weekly to have their child’s nutritional status monitored and to receive supplementary food rations or ready-to-use therapeutic food provided by World Food Program and UNICEF. In this way, the Red Cross has reinforced, in terms of skilled human resources, medical equipment, treatment facilities and medicine, existing health structures, which are now capable of treating malnourished children, regardless of the gravity of their state of health.
Food taboos and a lack of knowledge are among the underlying causes of malnutrition and are a real hindrance when it comes to improving children’s health and nutritional status. Awareness-raising must be one of the pillars of the integrated programme approach in order to generate behavioral change in the population in general, and among mothers of children under five in particular.
The Red Cross helps populations change their behavior running awareness-raising campaigns to increase knowledge of malnutrition and to identify acutely malnourished children in the villages and treat them in the Integrated Health Centers.
These awareness-raising campaigns are conducted by Niger Red Cross volunteers, who have been trained in a number of key messages relating to children’s health and nutrition, especially early and exclusive breastfeeding, complementary feeding, use of treated bed nets, and the importance of vaccination.
The volunteers pass these messages on by means of the awareness-building sessions organized at the village level.
What about the long term?
Infant and young child feeding practices, limited access to health services, household dietary diversity, and the limited availability of drinking water are all factors that impact nutrition and health. The causes of malnutrition are multi-dimensional. Awareness-raising, screening and treatment for acute malnutrition must be supplemented by strengthened health and nutrition services which should also address problems of chronic malnutrition (stunting). Moreover, vulnerable populations must have access to drinking water, sanitation, and the means to practice good hygiene behaviors. Improvement in food security is critical for vulnerable populations. It is necessary to strengthen livelihoods, thereby facilitating access to food. An integrated approach is critical to achieve impact over the long-term.