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

Modules. 2004

Nutrition Module: Session 4

Moderate Malnutrition

Correction of malnutrition Standard 1: Moderate Malnutrition (page 145)

“Moderate malnutrition is addressed”

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

Specific Objectives:
• To review the types of programmes to address moderate malnutrition
• To determine the recipients of supplementary feeding programmes (SFPs).
• To outline factors which influence the coverage of supplementary feeding programmes.
• To determine the exit criteria for supplementary feeding programmes.

Main messages:
• Moderate malnutrition can be addressed by a variety of programmes – including food
security, health and hygiene programmes, as well as supplementary feeding programmes.
• There are two types of targeted SFPs: dry take-home rations and on-site feeding.
• Coverage is important in order to ensure that the standard is met as well as the key
indicators.
• Coverage is affected by security, acceptability of the programme, location of distribution
points, service quality, home visiting and the extent of waiting times.
• The proportion of exits from targeted SFPs who have died should be < 3%, recovered >
75% and defaulted < 15%.
• Members of the community must be included in all decision-making regarding
programme implementation.

Reading:
• WFP. 2000. Food and Nutrition Handbook.
• ACF 2002. Assessment and Treatment of Malnutrition in Emergency Situations
• MSF 2001. Nutrition Guidelines.

Handouts:
• Handout 1a: Table for determining entry into an SFP
• Handout 1b: W/H tables
• Handout 2: Consultation and participation of affected community in determining the
need, type and recipients of a SFP.

Resources Required for Session 4

• Flip chart and a variety of coloured marker pens
• Handouts for all participants and reference reading.

Timeframe
Slides and discussion Exercises
Objective 1 15 mins Ex 1: 15 mins
Objective 2 5 mins Optional Ex 2: 15 mins
Objective 3 10 mins Ex 3: 35 mins

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

Objective 4 10 mins
Slide 1

For all slides in this document, please refer to corresponding Power Point Files – S4
Moderate Malnutrition.ppt’

Slide 2

• This session covers Moderate Malnutrition Standard 1: Moderate Malnutrition.

• Ask a participant to read out the standard
• Recommend to the participants to number the key indicators so that reference can be
easily made to them.

Slide 3

• Introduce the objectives of the session.

 Exercise 1 15 mins
TO FIND THE RELEVANT KEY INDICATORS AND GUIDANCE NOTES FOR EACH
OBJECTIVE

Divide the participants into four groups

Give each group one of the objectives.
Group 1: types of programmes
Group 2: recipients for SFPs
Group 3: factors affecting coverage
Group 4: exit criteria
Ask each group to find points that are relevant to that objective within the Key Indicators and Guidance
Notes (Note – in a few cases, it may be necessary to refer to the appendices).
The participants must keep their notes, and the facilitator will call upon them at the appropriate moment in
the training session.

Objective 1: To review the types of programmes to address malnutrition

Slide 4

• Ask the participants in Group 1 to inform the other groups what is said in the
Sphere handbook about the types of programmes which are required to address
moderate malnutrition
• Answer: In the preamble of correction of malnutrition page 145: it is noted that:
access to health care, improving food security, improvement of the general food

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

ration and improving access to potable water. Although the rest of the session
concentrates on SFPs, it is essential to remember these other approaches.
Slide 5

• The participants may have highlighted points in slide 5, more than the alternative
ways shown in slide 4.

• The participants may also have noted that in GN 1 it is noted that targeted
supplementary feeding programmes should be implemented:
o only when anthropometric surveys have been conducted / planned
o if underlying causes of moderate malnutrition are simultaneously addressed

• Ask the participants why a blanket supplementary feeding is not mentioned within
this standard?
• Answer: this standard addresses moderate malnutrition, and hence KI 5 notes that
‘admission of individuals is based on assessment against internationally accepted
anthropometric criteria’. However, in the pre-amble (paragraph 2) it is noted ‘In
some instances, rates of malnutrition may be so high that it may be inefficient to
target the moderately malnourished and all individuals meeting certain at-risk
criteria (eg those aged 6-59 mths) may be eligible. This is known as blanket
supplementary feeding’.

• Ask the participants for any other arguments for blanket supplementary feeding.
• Answer: If the general ration is inadequate (eg during the early stages of an
emergency, when at the same time lobbying for an appropriate general ration); if
seasonal malnutrition is anticipated or to get micronutrients to deficient populations.
N.B. This should only act as a temporary measure to minimise loss of life – until the
general ration has started / improved.

• Within targeted supplementary feeding programmes, there are two types of

programmes – those that provide dry take-home rations, and those that provide on-
site feeding.

• Turn to the flip chart. Write up an empty chart of

Advantages Disadvantages
Dry take-home rations
On-site feeding

• Ask one participant to field points from the rest of the group and to fill them in the
boxes.

Slide 6

• Slide 6 shows some of the points which may have been given by the participants.

Slide 7

• Slide 7 shows a dry-take home ration supplementary feeding programme in E Africa.

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

Objective 2: To determine the recipients of supplementary feeding programmes

• Ask the participants in Group 2 to inform the other groups what is said in the
Sphere handbook about the types of recipients of supplementary feeding

Slide 8

• Ask the participants if they remember any point in General nutrition support
standard 2: at risk groups which addressed other persons who could be included in
a supplementary feeding programme:
• Answer: in GN 4, under ‘pregnant and breastfeeding women: it is stated ‘when the
general ration is inadequate, supplementary feeding to prevent nutritional
deterioration may be necessary’.

 Optional Exercise 2 15 mins

TO DETERMINE ENTRY CRITERIA INTO A SFP

Give out Handout 1a and 1b to each participant.

Each participant must calculate – using the W/H chart (handout 1b), who is eligible for entry into the
feeding programme.
Go through with the participants at the end of the exercise.

Objective 3: To outline factors which influence the coverage of supplementary feeding

programmes

• Ask the participants in Group 3 to inform the other groups what is said in the
Sphere handbook about the coverage of supplementary feeding

Slide 9

• Ask the participants why coverage is such an important indicator?

• Answers: might include: if all the indicators are reached in a programme – so that
there is a gold standard programme, but with only a very small coverage, this infact

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

would mean that the standard is barely met, because so few people would be
recovering from moderate malnutrition.

• Ask the participants if they have any examples to share where it was not possible to
achieve these key indicators. Why was this the case?
• If there are no examples, ask the participants to consider what might be the
constraints
• Answer: may include:
o if the programme is integrated into the government structures, there may be
a lack of staff and other resources to provide the service, inform
malnourished of its existence or do home visits.

• Ask the participants what factors might play a role in the acceptability of the
programme?
• Answer: may include – the husbands not wanting their wives to travel far out;
rumours that the agency implementing the programme has alternative motives, the
type of food ration that is given may not be popular..

• Ask one participant to read out the last two sentences of GN 2: (page 147)‘Affected
communities should be involved in deciding where to locate distribution centres. The
final decision should be based on wide consultation and on non-discrimination’.

• Ask the participants to turn to page 28. This is a reminder that there is a Common
Standard for participation. This may be of use for the exercise that follows.

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 The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response: Nutrition Training
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 Exercise 3 35 mins
CASE STUDY AND DEBATE
CONSULTATION AND PARTICIPATION OF AFFECTED COMMUNITY IN
DETERMINING THE NEED FOR A SUPPLEMENTARY FEEDING PROGRAMME

Ideally, a case-study based on a region or population with whom the participants are familiar should be
used. This must be prepared by the facilitators or workshop organiser in advance of the workshop. If
possible, the case-study should be prepared by one of the participants in advance of the workshop with
support of the facilitator. The case-study should be short (1/2 to 1 page) and:
contain information on the affected population including local structures and human and material resources
include information the rate of malnutrition and the causes of malnutrition

An example of how the case study can be structured is included as guidance to the facilitator.

The participants are split into four groups. Each of the first three groups represents, and takes the
role of, a specific community group. For example,
Community elders and chiefs
Ministry of Health and Primary health care clinic staff
Women’s group (primarily mothers of malnourished children)

Each of the above groups must prepare a short presentation on the following three categories of
information;
The need for a supplementary feeding programme
Where to have the feeding programme – and what type of programme it should be
The recipients of the feeding programme

Give Handout 2 – one to each of the groups. Inform the participants that they only need to fill in the
relevant row (eg for community elders and chiefs)
It is important to remind the groups that they may include further information beyond that which they
read in the case study if they feel it would add weight to their arguments.

The fourth group takes the role of the agency who is in the process of designing the programme
intervention.
Each of the three ‘community groups’ then has 2-3 minutes to present in a debate-type forum.
The fourth group must decide if, how and why it will involve each group and gives brief feedback to the
community.

The facilitator then leads concluding discussion on the following key points:

On Addressing Moderate malnutrition:

The type of SFP, the distance to travel, who can be admitted, the resources of the MoH in running it, the
impact it may have on the local community, the impact on the mother’s time, security, how it is integrated
with other community services etc…

On Addressing participation
Diverse ways to consult and involve the affected community; difficulties and constraints if there are power-
plays between different community groups; Normal community structures may be distorted following a
disaster and will need to be strengthened; As women usually assume responsibility for the management of
food in the household and have responsibility for the health and welfare of all family members, it is
paramount that women are consulted in all aspects of programme design and monitoring.

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Objective 4: To determine the exit criteria for supplementary feeding programmes

• Ask the participants in Group 4 to inform the other groups what is said in the
Sphere handbook about the exit criteria

Slide 10

• Ask participants: when might defaulter rates be higher?

• Answer: Defaulter rates might be higher in insecure situations when there is the threat of
an attack; harvest time when adult patients may default etc. Also if the community does
not understand the objectives of the programme or does not have confidence in the
feeding programme, if distances are too far for the mothers to travel and they may have
priorities to look after other children at home. Where high default rates do occur, a
community assessment should be conducted to investigate the reasons for the mother’s
defaulting. This also applies for entry into therapeutic feeding programmes (next session)

Slide 11

• Put the following information on a flip chart:

o Month: May
o Total no: of exits from SFP = 175
o Total no: recovered = 142

• Ask a member of group 4 to do the calculation for the % of exits, and to determine
whether this falls within the Sphere criteria.
• Answer: yes (ie it is > 75%).

Slide 12

• Some key points which need to be emphasised in relation to exit criteria are shown on
this slide.

Slide 13

• Ask participants: Using the Sphere handbook and from your knowledge, what other
key aspects of supplementary feeding should be considered?

• Some participants may be aware of the WHO research on the nutritional requirements
for PLWH/A. This includes an increased requirement in total energy intake and some
micronutrients, although this research is not yet finalised.
• Ask participants: how are PLWHA usually identified?

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

• Answer: there are very significant issues around the sensitivity of HIV/AIDS, hence it
is important that PLWHA are not stigmatised. Furthermore, in many contexts there is
poor access to HIV testing resources. Hence often the criteria given is ‘chronically
sick’, with other indicators such as recent deaths in the family, the dependency ratio
amongst household members etc.

Slide 14

• Re-cap on the objectives and check as to whether there are any outstanding
questions

For handouts refer to accompanying Word document

‘S4 Moderate Malnutrition - Handouts.doc

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