Food security and nutrition assessment standard 2: Nutrition
Where people are at increased risk of undernutrition, assessments are conducted using internationally accepted methods to understand the type, degree and extent of undernutrition and identify those most affected, those most at risk and the appropriate response.
Key actions (to be read in conjunction with the guidance notes)
Compile existing information from pre-disaster and initial assessments to highlight the nature and severity of the nutrition situation (see guidance notes 1–5).
Identify groups with the greatest nutritional support needs and the underlying factors that potentially affect nutritional status (see guidance notes 1–2).
Determine if population-level qualitative or quantitative assessments are needed to better measure and understand anthropometric status, micronutrient status, infant and young child feeding, maternal care practices and associated potential determinants of undernutrition (see guidance notes 1–2).
Consider the opinions of the local community and other local stakeholders on the potential determinants of undernutrition (see guidance note 7).
Include an assessment of national and local capacity to lead and/or support response (see guidance notes 1 and 8).
Use nutrition assessment information to determine if the situation is stable or declining (see guidance notes 7–8).
Key indicators (to be read in conjunction with the guidance notes)
Assessment and analysis methodologies including standardised indicators adhering to widely accepted principles are adopted for both anthropometric and non-anthropometric assessments (see guidance notes 3–6).
Assessment findings are presented in an analytical report including clear recommendations of actions targeting the most vulnerable individuals and groups (see guidance notes 3–6).
- Contextual information: Information on the causes of undernutrition can be gathered from primary or secondary sources, including existing health and nutrition profiles, research reports, early warning information, health centre records, food security reports and community groups. Where information is not available for specific areas of assessment or potential intervention, other sources should be consulted such as Demographic Health Surveys, Multi Indicator Cluster Surveys, other national health and nutrition surveys, WHO Nutrition Landscape Information System, WHO Vitamin and Mineral Nutrition Information System, Complex Emergency Database (CE-DAT), Nutrition in Crisis Information System (NICS), national nutrition surveillance systems, and admission rates and coverage in existing programmes for the management of malnutrition. Where representative data are available, it is preferable to look at trends in nutritional status over time rather than the prevalence of malnutrition at a single point in time (see Appendix 3: Nutrition assessment checklist). Nutrition assessment should be considered within broader assessments, especially those focusing on public health and food security. Information on existing nutrition initiatives, their operational capacity and local and national response capacity should be gathered in order to identify gaps and guide response.
- Scope of analysis: In-depth assessment should be conducted following the initial assessment (see Core Standard 3) only where information gaps have been identified and where further information is needed to inform programme decision-making, to measure programme outcomes or for advocacy purposes. In-depth nutrition assessment refers to a number of possible assessment approaches including anthropometric surveys, infant and young child feeding assessments, micronutrient surveys and causal analyses. Nutrition surveillance and monitoring systems may also be used.
- Methodology: Nutrition assessments of any type should have clear objectives, use internationally accepted methods, identify nutritionally vulnerable individuals and create an understanding of factors that may contribute to undernutrition. The assessment and analysis process should be documented and presented in a timely report in a logical and transparent manner. Assessment approaches need to be impartial, representative and well coordinated among agencies and governments so information is complementary, consistent and comparable. Multi-agency assessments may be beneficial in assessing large-scale multi-technical and wide geographical areas.
- Anthropometric surveys are representative cross-sectional surveys based on random sampling or exhaustive screening. Anthropometric surveys provide an estimate of the prevalence of malnutrition (chronic and acute). They should report primarily Weight-for-Height in Z score according to WHO standards (see Appendix 4: Measuring acute malnutrition). Weight-for-Height in Z score according to the National Center for Health Statistics (NCHS) reference may also be reported to allow comparison with past surveys. Wasting and severe wasting measured by mid-upper-arm circumference (MUAC) should be included in anthropometric surveys. Nutrition oedema should be assessed and recorded separately. Confidence intervals for the prevalence of malnutrition should be reported and survey quality assurance demonstrated. This can be done through the use of existing tools (e.g. Standardised Monitoring and Assessment of Relief and Transitions (SMART) methodology manual and tools, or ENA (Emergency Nutrition Assessment) software andEpiInfo software). The most widely accepted practice is to assess malnutrition levels in children aged 6–59 months as a proxy for the population as a whole. However, where other groups may be affected to a greater extent or face greater nutritional risk, assessment should be considered (see Appendix 4: Measuring acute malnutrition).
- Non-anthropometric indicators: Additional information to anthropometry is essential, though should be carefully considered and remain limited when attached to anthropometric surveys so as not to undermine the quality of the survey. Such indicators include immunisation coverage rates (especially for measles), Vitamin A supplementation, micronutrient deficiencies and WHO infant and young child feeding (IYCF) indicators. Crude, infant and under-5 death rates may be measured, where appropriate.
- Micronutrient deficiencies: If the population is known to have been deficient in Vitamin A, iodine or zinc or suffering from iron deficiency anaemia prior to a disaster, this will likely be exacerbated by the disaster. There may be outbreaks of pellagra, beriberi, scurvy or other micronutrient deficiencies which should be considered when planning and analysing assessments. If individuals with any of these deficiencies are present at health centres, it is likely to indicate lack of access to an adequate diet and is probably indicative of a population-wide problem. Assessment of micronutrient deficiencies may be direct or indirect. Indirect assessment involves estimating nutrient intakes at the population level and extrapolating deficiency risk by reviewing available data on food access, availability and utilisation (see Food security and nutrition assessment standard 1, and by assessing food ration adequacy (see Food security– food transfers standard 1. Direct assessment, where feasible, involves measuring clinical or sub-clinical deficiency in individual patients or a population sample, e.g. the measurement of haemoglobin during surveys whereby the prevalence of anaemia may be used as a proxy measure of iron deficiency.
- Interpreting levels of undernutrition: Determining whether levels of undernutrition require intervention requires detailed analysis of the situation in the light of the reference population size and density, and morbidity and mortality rates (see Essential health services standard 1, guidance note 3). It also requires reference to health indicators, seasonal fluctuations, IYCF indicators, pre-disaster levels of undernutrition, levels of micronutrient deficiencies (see Appendix 5: Measures of the public health significance of micronutrient deficiencies), the proportion of severe acute malnutrition in relation to global acute malnutrition and other factors affecting the underlying causes of undernutrition. A combination of complementary information systems may be the most cost-effective way to monitor trends. Wherever possible, local institutions and populations should participate in monitoring activities, interpreting findings and planning any responses. The application of decision-making models and approaches which consider a number of variables including food security, livelihoods, and health and nutrition may be appropriate (see Food security and nutrition assessment standard 1, guidance note 5).
- Decision-making: Assessment findings should inform decisions on responses aimed at managing malnutrition. The decisions to implement general food distribution or other preventative or immediate treatment interventions in the acute phase of a disaster need not await the results of in-depth assessments. Where assessments are conducted, results must inform actions. Decision-making should rely on an understanding of undernutrition as laid out in the conceptual framework, results from nutrition assessments and the existing capacity to respond.