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A Beginner’s Guide to Malnutrition

Acute malnutrition affects 60 million
children under five and contributes to
5 million deaths each year worldwide.
Understanding nutritional crises andfamines is no easy task. Nutritional
crises usually result from a number offactors interacting in complex ways.
Hunger and famine are extremely
emotive and politically sensitive
subjects. Even the definition of what afamine is varies between different
international organizations.
This guide aims to explore different
aspects of nutritional crises and to
explain MSF’s role in trying to deal
with malnutrition. The first section
looks at how malnutrition physically affects the individual. The second looks at
different stages of nutritional crises and what causes them. The final part
explains the role NGOs, governments and international organizations play intrying to address malnutrition, and looks specifically at what MSF does in thefield.

What Is Malnutrition?
On average, the human body needs more than
2,100 kilocalories per day to lead a normal, healthy
life. Adequate nutrition is essential for the physicaldevelopment and maintenance of the body as well
as resistance to disease, ability to learn and energy
to work.
Malnutrition is defined as an imbalance between the
body’s supply of nutrients and the body’s demand for
growth, maintenance and specific activities. When aperson cannot take in sufficient nutrients to meettheir needs, the body begins to waste away. First
they
lose
fat,
and
then
muscle.
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Malnutrition is not measured by how much food is eaten, but by physicalmeasurements such as weight and height. Malnutrition in children is often
measured by comparing their weight measurement with what would be expected
for someone their height. Once a child has fallen below 80% of the weight that isaverage for their height they are defined as “acutely malnourished”. Swellings on
both feet, known as ‘bilateral oedema’, are also a sure symptom of
malnourishment in children.
If children are under-nourished over a long period of time, their growth may be
stunted. This is known as chronic malnutrition. If they experience rapid weightloss – or ‘wasting’ – over a short period of time, they are described as sufferingfrom acute malnutrition.
Even if people have sufficient quantities of food to eat, they can become
malnourished if their food does not provide the right amount macro-nutrients(proteins, fats and sugars) and micro-nutrients (vitamins and minerals). In otherwords, malnourishment is to do with the quality as well as the quantity of food.
Malnutrition and disease can interact
in a vicious cycle. Inadequate foodintake results in the body being
increasingly sensitive to infections.
Infections often lead to poor appetite
and nausea - resulting in reduced foodintake - and can also impair the body’s
ability to absorb nutrients. In turn,malnutrition weakens the immune
system and increases the incidence,
severity and duration of infections.
This dangerous cycle can ultimately
lead to death.
Young children are more vulnerable tomalnutrition than adults, for several
reasons. Children are growing, so theirrelative needs for nutrients are
greater. Because they are not able toingest large bulky meals, they needsmall frequent feeds, which mothers
may not be able to provide during
emergency situations. Children are especially susceptible to malnutrition when
they are weaned from their mother’s breast milk to a diet deficient in protein andother nutrients. Pregnant and breastfeeding women are also particularly
vulnerable to malnutrition since extra energy is needed during pregnancy andlactation.

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Types of malnutrition
Macro-nutrient deficiency

The most common form of malnutrition, called marasmus,
occurs when an individual is unable to take in a sufficientquantity of food in general. Children with marasmus areseverely wasted, with no fat and very little muscle tissue left
on their body. They often appear old and shrivelled andhave prominent ribs and limb joints. They are left withalmost no subcutaneous fat and their internal organs,including the heart and the blood, are weakened. With noreserves to fight infection, illnesses such as pneumonia,
diarrhea, and measles can be fatal.

The second common type of malnutrition in children is
kwashiorkor, which is specifically caused by a lack ofprotein-energy and certain micro-nutrients in the diet.
Symptoms of kwashiorkor include a swollen abdomen,
severe anemia and ‘oedema’ – swellings of the feet, legs
and arms which can make up 30% of a child’s body weight.
Another distinctive symptom is hair turning red and fallingout. Like marasmus, kwashiorkor kills by lowering resistanceto infection. However, it can also be fatal in its own right,
because it disturbs levels of salts and minerals in the body.

Micro-nutrient deficiency
Other forms of malnutrition result from vitamin and mineral deficiencies.
Micronutrients are necessary in small quantities to ensure proper metabolic
functioning.
Vitamin A deficiency weakens the immune systems of a large
proportion of under-fives in poor countries, increasing theirvulnerability to diseases such as diarrhea, measles and malaria.
Lack of vitamin A can also lead to eye diseases and eventually
blindness.

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Iodine is necessary for the thyroid to function normally and fordevelopment of the nervous system during the first trimester ofpregnancy. Iodine deficiency results in goitre and ‘cretinism’,associated with severe mental retardation and physical stunting.

Vitamin B1 deficiency can lead to beriberi. There are several
different types of the disease, which can affect the nervous
system and heart and cause gastrointestinal problems. It often
occurs when white rice is the staple food in a population’s diet.

Lack of vitamin C can lead to scurvy. It mainly occurs whenpeople have little access to fresh fruit and vegetables.

Vitamin B3 deficiency leads to pellagra, which is indicated bydiarrhea, dementia and skin lesions (often around the neck).

Causes of Nutrition Crises
Poverty
We are used to seeing images of malnutritionin the context of high-profile crises such as
droughts and wars. In fact, the vast majority ofthe estimated 800 million hungry people in theworld are not the victims of sudden, abnormal
incidents, but rather endure long term, chronicmalnutrition as a result of poverty.

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The poverty-stricken do not have enough money to buy or produce enough foodfor themselves and their families. Poor farmers cannot afford to buy land, seeds,
equipment or water. Craftsmen lack the means to pay for the tools to ply theirtrade. Poor regions of the world lack key agricultural infrastructure such as
irrigation equipment, storage facilities and roads and vehicles to transport food.

The Hunger Gap
In many places, malnourishment occurs in regular cycles, according to theseasons and the harvesting time of year. Populations experience seasonal foodshortages or “hunger gaps”. For farmers, this usually occurs before a harvest
season when food stocks from previous harvests have been exhausted andmarket prices are high. For pastoral populations, it often occurs at the end of adry season, when grazing areas are scarce and epidemics in livestock areprevalent.

Food Distribution Mechanisms
Famine and food crises do not necessarily
occur because of an absolute lack of food in aparticular region. Inequalities built intomechanisms for distributing food and theeconomic incentives that drive food markets
can create severe food shortages. If it is more
profitable for farmers to sell their produce toother regions or abroad rather than to the
local market, the poor in the region may haveno access to food, even if lots is being produced locally. Local producers may
also stockpile food until the hunger gap period in order to sell it at inflated prices
when people are most desperate.
Food crises can also be the deliberate or unintentional result of government
policy. Repressive governments can manipulate food availability in certain
regions in order to suppress their opponents and the populations that support
them. In other cases, food crises are the consequence of a lack of governance,
when civil disorder causes food distribution mechanisms to break down
completely. As the Nobel prize winning economist Amartya Sen famously notedin the 1980s, no functioning democracy has ever suffered from a famine.

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War
There are many ways in which war can leadto a nutritional crisis. Combatants frequently
loot or destroy the food supplies of theirenemies and systematically wreck local
markets. Fields and water wells are mined
and contaminated, land is requisitioned formilitary purposes, and stocks are stolen to
feed militias or armies. People are forced toabandon their land because of the threat ofviolence and find it impossible to return to sow and harvest because of insecurity.

Natural disasters
Drought due to failure of the rains is a common
cause of large scale food crises. Drought canlead to failure of crops and death of livestock.
Problems are often exacerbated by poor
agricultural practices such as over-farming andover-grazing of land. Environmental problems
such as soil erosion, desertification anddeforestation also threaten fertile farmland.
Tropical storms, earthquakes and floods candestroy crops and food stocks and damage the infrastructure and equipment
needed to produce and transport food.
Cultural Practices
Cultural practices can play a significant role in determining the nutritional statusof sectors of a population. In some societies, men are traditionally given priority
in food allocation. This can lead to a greater risk of women becoming
malnourished, particularly those of reproductive age who lose iron during theirmonthly periods and require more energy, protein and micronutrients during
pregnancy and breastfeeding.
Breastfeeding and weaning practices can also
have a crucial influence in child nutrition. For
example, traditional weaning foods in West Africa
such as maize and cereal ‘pap’ are of low
nutritional value in terms of protein and energy. In
some areas, the early introduction of solid foods

7and unhygienic feeding practices result in malnutrition, growth retardation andinfection. Some communities also believe that depriving children of food can curethem of diseases such as measles.

Environmental Factors
Environmental factors can considerably aggravate nutritional crises. Poor water
quality, a lack of sanitation and inadequate public health services can allcontribute significantly to the deterioration of a community’s nutritional status, byincreasing the prevalence of health problems such as diarrhea and dysentery.

Stages of food crises‘Food security’ means the ability of the household to secure, either from its own
production or through purchases, adequate food for meeting the dietary needs ofall members of the household. Food security is determined by whether food isavailable, accessible and affordable. It is also determined by whether that foodcan actually be utilized, which depends on the availability of firewood, utensils,
tools, water and so on.
Food insecurity is a situation in which a
population does not have sustainable
access to sufficient food to meet dietaryneeds.
Food
insecurity
isusually
temporary: households are generally able
to resume viable livelihoods once the foodsituation has improved.

When food access and/or availability deteriorates, food insecurity can worsen tofamine. The process generally occurs in three stages:
Food insecurity↓
Food crisis↓
FamineFood crises are caused by unexpected severe food shortages. In non-conflictsituations, food crises can be prompted by a gradual deterioration of food accesscaused by prolonged or repeated droughts, flooding, large livestock epidemics,

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economic crisis, etc. In conflict situations, communities may experience sudden
reductions in food availability due to forced population movement, destruction orlooting of crops and livestock, unsafe access to markets etc.
In such circumstances people turn to ‘coping
mechanisms’, for example reducing the number ofmeals they eat per day and eating food which
wouldn’t normally be part of their diet, such asleaves. They may be forced to sell goods essential
to their future livelihood (e.g. cattle). Once thisstage is reached, a return to normal livelihood isdifficult since their future productive capacity has
been compromised.
If the situation worsens, community structurescollapse, skilled and educated people –including
health staff - migrate, and there is a reduction of
support to non-productive members of households
such as the elderly and disabled. Such periods arealso characterised by the increased marginalisationof non-productive people (orphans, beggars etc.)
Famine is an absolute lack of food affecting a large population for a long time
period. There are very few situations today in which a famine can be considereda purely "natural" disaster. Drought, flood and other environmental factors can ofcourse lead to food shortage, but there are almost always human forces at work
as well - such as war, an unstable political and economical environment and theforced displacement of populations.
During a famine, households are destituteand no longer have coping mechanisms tofall back on. People often leave their homes
in search of food - an event known as‘distress migration’. In a famine, insufficient
food and poor health care are the leading
causes of death for severely and moderately
malnourished people. A common indicator ofa famine is that the mortality rate is high for
adults as well as children.
The word "famine" has highly emotive and political connotations and over the past
decades there has been extensive debate among international relief agencies
regarding the precise definition. That debate continues today.

9The table below outlines MSF’s understanding of how food insecurity, food crises
and famine can be differentiated:
Specific characteristics in times of food insecurity, food crisis and famine

Livelihood changes
Food availability
Food accessibility

Food insecurity

Food crisis

FamineTemporary
Normal or slightly
reducedSlightly reduced

Threat to the future
ReducedComplete destitution
Rare or none

ReducedSeverely reduced or
none
Full

Dependence on food Low
aid
Less time
Social breakdown
available for social
support. Care
restricted to directfamily members
Seasonal
Population
migration, mainly
movementmen
Physically
Affected byvulnerable (related
Malnutrition
to disease)
Low or moderate
Global malnutrition(0-10%)
rate
Severe malnutrition Low
(<3%)
rate
Severe malnutrition Low
in adults
Comparable withCrude
an average year.
Mortality
Rate (CMR)*
Less than one
person per 10,000
in the population
dies per day.

Moderate to highDecreased support Social collapse:
for sociallybroken families,
vulnerable such as
traumatised people
the elderly, orphansand disabled people
Migration of families, Distress migration
population
displacement
Socially vulnerable, Everybody, all age(related to poverty,
groups (related toaccess and care)general lack of food)Moderate (10-15%) Highto High (20-40%)(> 40-50%)
Moderate
High(3-5%)
(>5%)
Some
High
Moderate to HighCatastrophic

Between one andtwo people die per
10,000 in the
population per day.

More than five people
die per 10,000 in the
population per day.
The mortality rate isthen more than ten
times the ‘normal’ rate.

*The CMR expresses the number of people of any age who die on an average day, out of a
population of 10,000. The ‘normal’ CMR is considered to be 0.510Addressing food insecurity, food crises and famine
There is no universal, standard approach to nutritional problems. Response
strategies vary according to the context of a food crisis, its development, andpractical constraints. There are usually many different organisations involved inaddressing food crises, from local community based groups, to national
governments, international NGOs and the United Nations.
MSF’s role is generally to give emergency medicalcare to the most vulnerable and provide nutritional
support to those most in need, such as children,
pregnant and lactating women and people withchronic or acute illnesses. MSF also advocates forincreased food assistance for a population when
the organization is concerned about a worsening
crisis. It makes no sense to provide medical
treatment for malnutrition if no food is available topatients once they are fit to leave the programme.
Although MSF does sometimes organize targeted
distributionoffood(knownas‘blanket
distributions’) it is rare for the organization to be
involved in massive scale ‘general food
distributions’, since that is generally the
responsibility of one of the United Nations
agencies, usually the World Food Programme (WFP). However, if MSF saw anurgent need for a General Food Distribution and other organizations failed to
implement it, MSF would step in. MSF does not run long term food security
programmes, unlike development NGOs such as Oxfam.
Before deciding whether to start a nutritional programme in a particular region,
MSF tries to gather as much information as possible about the situation there.
This is done both through rapid assessment visits and through sharing
information with the government, local authorities and other NGOs.

How MSF Assesses Nutritional Crises and Measures
Malnutrition
It is critical to carefully assess malnutrition levels in a population before andduring a nutritional intervention. This is to determine the severity and magnitudeof a situation. Nutritional surveys help MSF to measure and monitor theprevalence of acute malnutrition in a population; identify vulnerable groups; planand design the appropriate nutritional programmes and establish a baseline fromwhich to follow the evolution of the nutritional status of a population over time.
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Nutritional surveys compare ‘anthropometric’measures such as weight, height, age and midupper arm circumference. They are carried out
among children aged from 6 months to 5 years,
largely because children under five are particularly
sensitive to changes in food availability andchanges in their nutritional status are considered
to reflect food stresses in an entire population.
Standardized reference tables are available forthis age group. This allows the results of a study to be interpreted according to auniversally agreed reference population, which is extremely important because
meaningful comparisons can then be made. Internationally recognized reference
values for teenage and adult populations currently do not exist – a subject ofongoing debate amongst nutrition specialists.

Carrying out a nutritional survey
A good nutritional survey requires sophisticated statistic analysis. If the
population under study is very small (up to about 5000 people), it may bepossible to carry out an ‘exhaustive survey’, in which every single person in thegroup is visited and assessed.
However, because nutritional crises usuallyaffect larger populations, surveys are generally
carried out on a sample of the population. As
with all sampling, its crucial to make sure thatthe sample chosen is as representative as
possible. A population under stress have aninterest in trying to direct NGO staff towards themost needy cases in their community in order
to try and secure their help and foodassistance. However, in order to get a reallyaccurate picture of the nutritional status of thewhole community, it is important to be as
rigorous as possible about surveying a sample
selected as randomly as possible.
The two principle methods used by MSF for doing so are “Systematic Sampling”
and “Cluster Sampling”.
Systematic sampling is a method based on the geographical organisation of anarea. Because every household should have the same chance of being
surveyed, it can only be used if households are arranged in an ordered way, for12instance in a grid layout. Since this is quite a rare occurrence, the technique ismainly used in well-organized refugee camps where shelters are arranged inblocks and rows.
Cluster sampling is used when no detailed register of the population is available,
and the geographical organisation is not compatible with systematic sampling.
With this method, the smallest sector for which the population size can be
estimated is chosen as the sampling base (city block, village etc).
In the first stage of sampling, 30 ‘clusters’of this sector are randomly selected. In thesecond stage, the survey team go to thecentre of the section within which thecluster is located and spin a pen on the
ground in order to randomly choose which
direction to go in. They then walk in that
direction, numbering the houses theyencounter along the way. Next they draw a
random number to select which of thehouses to visit first. They survey any
children under 110 cm tall in thathousehold, and then proceed from house to house by proximity (for example thenext house immediately on the right or on the left; this must be determined inadvance). They continue sampling until they have covered 30 children in 30
clusters – a total of 900 children. Statistical analysis shows that this large sample
size is necessary to provide sufficient precision.
At
eachhouseholdvisitedtheytakeanthropometric measurements of all children aged
6 months to five years – usually their weight,
height, sex, age and record the presence orabsence of bilateral oedema. In many places,parents don’t know the real age of their children,
so the age group has to be approximated bychoosing children between 65 and 110 cm tall.
They also take ‘MUAC’ – mid-upper arm
circumference – measurements (see box). The
team may also gather extra information such aswhether the child has been immunized against
measles and whether the family has access to cooking equipment and fuel.
The team often simultaneously carry out what is known as a ‘retrospective
mortality study’ in order to get an idea of the number of deaths that haveoccurred over a past given period. They choose a date which is memorable tothe community – often a religious or local festival – and ask if any family
members have died since that date.

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Interpreting Anthropometric Indicators
Different systems of classification are used when defining malnutrition in
individuals or in populations:
For individuals: malnutrition is categorised into moderate acute or severe acute.
For populations: malnutrition is categorised into severe acute and global acute.
Global acute malnutrition refers to the total cases of moderate acute and severe
acute malnutrition in a population. The severe acute malnutrition rate is often
referred to as ‘SAM’ and the global acute malnutrition rate is known as ‘GAM’.

Individuals
Putting the various anthropometric measurements against each other andcomparing them with a reference population helps the MSF team to judge
whether individuals are malnourished. The indices are compared with a cut off
point below which an individual is considered to be malnourished.
In emergency situations, comparing
children’s weight for their heightagainst a reference index is the mostcommon way of quantifying acutemalnutrition.
Weightforheightmeasurements are the best indicator of
wasting and reflect recent weight loss or
gain. They therefore are a good
indicator of an abnormal or emergency
situation.
Weightforheightmeasurements are usually recorded interms of statistical expressions known as ‘Z-scores’ and ‘percentage of themedian’ results (see box).
Comparing children’s height for their age is the best indicator of stunting, whichreflects a long term, chronic problem. When nutrition is inadequate over a long
period of time, children grow slowly. Low height for age indicates a slowing inskeletal growth.

14And now for the maths bit… classifying malnutrition using “Percentage of theMedian” and “Z-score” results.
Nutritionists use two types of statistical expressions to classify degrees of malnutrition.
Both involve comparing the weight of a child against standardized reference tables.
These tables indicate the weight that should be expected for children of different
heights, according to a normal distribution curve. The child’s nutritional status is thenclassified according to certain cut-off points shown in the table below.
The “percentage of the median” result expresses the weight of a child as apercentage of the median expected weight for that height group.
For example:
A child is 70 cm tall and weighs 6.3kg. The reference table shows that the medianweight for a child 70cm tall is 8.5kg.
6.3
8.5 x 100 = 74.1%
74.1% is between 70 and 80%, so the child has moderate acute malnutrition.

The Z-score represents the difference between the observed weight and the medianweight of the reference population expressed in standard deviation units.
Weight for Height cut-off points
Percentage of the median
Severeacute Less than 70%
malnutrition
Moderate
acute Between 70% and 80%
malnutrition

Z-scoresZ-score less than -3
Z-score between -2 and -3

MUAC measurements are a fast, approximate measure of acute malnutrition inchildren under the age of five. MUAC stands for “middle upper arm
circumference”. The MUAC measure is a long plastic strip with a series of color
bands:

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The MUAC bracelet is put around the child’s bare upper arm to measure its
circumference. The colour band then indicates the level of malnutrition:
Green: >135mm(normal)Yellow: 125-134mm(risk of malnutrition)
Orange: 110-124mm(moderate malnutrition)
Red: <110mm(severe malnutrition andrisk of death)
MUAC measurements are used for rapid assessment during emergencies andare a good predictor of risk of death. They provide a ‘rough and ready’ estimationof malnutrition and always need to be followed up with further detailed analysis of
the situation.
Bilateral oedema - swelling in the feet, legs or face - is a separate, clinicalindicator of severe malnutrition in children (oedema in adults can be provoked byother pathologies such as renal and cardiac problems).

Populations

The next step is to determine which proportion of
the population is malnourished, in order to assess
the severity of the situation. The most commonlyused measure is known as the global acutemalnutrition rate. This is found by calculating thepercentage of children under five in a population
who are either moderately or severely
malnourished.

As a general guideline, a global malnutrition rate of 5 – 10% is considered toindicate a precarious situation. A rate of 11 – 20% indicates a severe situation. If
the global acute malnutrition rate is over 20% the situation is very severe.

16However, it is important to understand that a “standard recipe” for interpreting
nutrition survey results does not exist. The results must be analysed in
combination with other information about the context of the crisis and preferably
mortality figures for recent months. For example, it is important to find out the
local market prices of food and livestock and to know whether a General FoodDistribution has been organised. The significance of the figures also depends onwhether the survey was done before or after the harvest. MSF teams always
draw a ‘seasonal calendar’ in order to understand the agricultural cycle in a
specific region and mark out when the hunger gap and harvest periods are.
Figures obtained through a single survey also only provide a snapshot of thenutritional status of the under-five population at the moment of the survey in acertain region. Taken alone, these figures do not give any indication about
whether the nutritional status is improving or deteriorating.

Types of Nutritional Intervention
Once MSF has a picture of the severity and nature of the crisis, the teams decideon the most appropriate type of programme. Broadly speaking, emergency
nutritional programmes are classified into:
General Food Distribution → targets entire population
Blanket Food Distribution → targets entire families
Supplementary Feeding Programme → targets selected individuals
Therapeutic Feeding Programme → targets individuals
MSF is also involved with non-emergency nutritional support programmes.

General Food Distributions (GFD)
A General Food Distribution is considered tobe the key intervention for ensuring the healthand survival of population experiencing foodcrisis and famine. General Food Distributions
target the whole population, or whole regions
or groups. The objective is to cover theimmediate basic food needs of an entire
population group and prevent death and thedeterioration of their nutritional status.
During General Food Distributions, regular rations are given out regularly tohouseholds through local government, traditional leaders, community leaders etc.

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MSF is rarely involved in the distribution process itself (which is usually the
responsibility of the World Food Programme and its partners). However, MSF
may be involved in monitoring food and in advocating for an increase in thefrequency or rations of a General Food Distribution when the teams think it isnecessary.

Blanket Food Distributions (BFD)
Blanket Food Distributions are usually shortterm interventions which aim to increase foodavailability and accessibility rapidly for alimited period. They are often used as‘damage control’ mechanisms to prevent thedeterioration of a population’s nutritional statuswhen a General Food Distribution has been
inadequate, inequitable or ineffective.
MSF uses Blanket Food Distributions if the teams on the ground believe it isnecessary to support the nutrition of families of vulnerable people. The teamfirst calculates the average family size in the population and decides on asuitable standard family ration. They then select one type of family member –often children under five, but sometimes elderly individuals – and distribute
rations to the family of all those people in the community. If the selection is basedon children under 5, and there are two such children in a family, the family would
receive two rations.
Blanket Food Distributions are ‘rough andready’ emergency interventions which cancover large populations and are easier toimplement than General Food Distributions.
However, they are imperfect mechanisms inthe sense that rations are not adapted
according to the size of each family, they don’tallow vulnerable individuals to be carefully
monitored, and families without children underfive often miss out. For these reasons, as soon as an adequate General FoodDistribution system is implemented, the Blanket Food Distribution stops.

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Supplementary Feeding Programmes
Supplementary
feeding
programmes
provideindividual nutritional and medical treatment formoderately malnourished children (younger then five
years) and sometimes pregnant and lactating women.
The aim is to treat moderate malnutrition and prevent
severe malnutrition.
Supplementary feeding programmes can involve
distributing “dry rations” or “wet rations”. Dry rations
are uncooked or partially cooked food items
distributed once a week or fortnight. Wet rations arecooked meals delivered once or twice daily on–site.

Therapeutic Feeding Programmes

An MSF Therapeutic Feeding Programme
provides intensive medical and nutritional
treatmentforseverelymalnourishedindividuals. Proper medical treatment and followup are crucial to avoid the death of patients.
The treatment is divided into two phases. The firstphase is designed to medically stabilise patients.
Phase One patients are treated in an inpatient
treatment unit, or ITFC, where intensive medical and nutritional care is provided
24 hours a day. The second phase focuses on nutritional rehabilitation.
Depending on the degree of malnutrition and whether they have medical
complications, children either enter as Phase One patients and then progress to
Phase Two, or enter directly as Phase Two patients.
Phase One treatment involves 24-hour intensive care. Medical complications aretreated and therapeutic feeding is started. This comprises eight feeds per day, often ofa therapeutic milk called F75. Treatment is not intended to make the patient gain
weight. In fact, a weight loss is expected in patients with oedema (swelling), as theyshould lose their oedema. All patients must be carefully monitored for signs ofoverfeeding during this initial phase in order to avoid heart failure.
Patients are eligible to enter Phase Two treatment if they have no medical
complications, show appetite and have no oedema. They receive four to six meals per
day of high energy content food and are monitored closely. Constant weight gain is an
important sign of recovery and should be about 10 g/kg/day.
When patients have recovered to reach the appropriate weight for their height, they
are discharged from the therapeutic feeding programme. They are often then referred
to a Supplementary Feeding Programme.
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The set up of a therapeutic feeding programme depends on the specificcircumstances of the population. Conventionally, the two phases of treatment are
combined and patients are treated during both Phase One and Two in a‘therapeutic feeding centre’, or TFC.
However, in recent years there has been a move towards providing
decentralized, community-based therapeutic care in some circumstances. With aconventional TFC, the child’s carer – normally the mother – is required to leave
the family for the full length of the treatment, usually between 30 and 45 days.
This can be problematic, especially if she has other malnourished children athome and needs to acquire and prepare food for them. Centralised TFCs arealso poorly adapted to large-scale nutritional crises since they are resourceintensive and require a lot of skilled staff .
In community-based therapeutic feeding programmes,
Phase Two treatment is carried out on an outreach or‘ambulatory’ basis. Patients are treated in their homes
using ready-to-use therapeutic foods (see box) andmonitored by medical staff once a week.
This type of programme may be more appropriate when
the population is more widely spread out and when it isdifficult for mothers of severely malnourished children to
spend long periods of time away from home. TFCs arestill likely to be used when the population at risk isgathered together in one place, for example in camps for refuges or displaced
people.
Ready-To-Use Therapeutic Food (“RUTF’)
Ready-to-use therapeutic foods were first developed in
the late 1990’s and have marked a minor revolution in
nutrition programmes in recent years. They are
specially designed to provide high protein and energy
content and essential micronutrients, whilst being easy
to use and distribute. MSF commonly uses ready-touse therapeutic foods called BP-100 and ‘Plumpy’nut’
which is a paste based on peanuts. Plumpy’nut comesin individual sachets, each of which contains 500
kilocalories as well as a complex of vitamins andminerals.
Plumpy’nut is especially useful in difficult environments because it doesn’t need to bemixed with water (clean or boiled water can be hard to come by). It comes in individuallywrapped airtight foil sachets which are hygienic and easy to distribute, and it is resistantto bacterial infection. It has a long shelf life, so can be stored, transported and used inhigh temperatures.
Ready-to-use therapeutic foods have to date chiefly been used to treat severe acutemalnutrition in children. However, some nutrition experts believe that there is significant
potential to develop this type of product further and use it more widely, for example formoderately malnourished children, pregnant and lactating mothers, HIV+ individuals 20
inneed of nutritional support and for children of weaning age.

Supportive nutritional programmes
As well as running emergency nutritional programmes in areas where access tofood is limited, MSF sometimes also runs programmes to improve the nutritional
status of people suffering from specific diseases. The amount of nutritional
support offered varies between different contexts, but these programmes usuallytarget patients suffering from tuberculosis, HIV/AIDS, trypanosomiasis,shigellosis and measles.

Further Reading

Famine that kills: Darfur, Sudan Alex de Waal, 2005
Where and why are 10 million children dying every year? Black, Morris andBryce, Lancet Vol 361, 2003
Changing the way we address severe malnutrition during famine, S. Collins,
Lancet vol 358, 2001
Supplemental feeding with ready-to-use therapeutic food in Malawianchildren at risk of malnutrition, Patel, Sandige, Ndekha, Briend, Ashorn andManary, J. Health Popul Nutr, 2005
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