Asia Pac J Clin Nutr 2014;23(4):505-513

505

Mini Review

Nutrition and earthquakes: experience andrecommendations
Nobuyo Tsuboyama-Kasaoka PhD, RD1,2, Martalena Br Purba MCN, PhD3,41

Section of the Dietary Reference Intakes, Department of Nutritional Epidemiology, National Institute of
Health and Nutrition, Tokyo, Japan
2
The Japan Dietetic Association, Tokyo, Japan
3
Indonesian Dietetic Association, Jakarta, Indonesia
4
Nutrition Department Dr Sardjito Hospital, Jogjakarta, Indonesia
In order to sustain life during the occurrence of a natural disaster, it is vital to ensure that people’s intake of waterand food is adequate (prioritizing first energy, then protein and water-soluble vitamins). Infants, pregnant women,patients, and the elderly are particularly vulnerable to insufficiencies in food intake, even if they are provided
with the same quantity of food as others, and providing them with dietary and nutritional support becomes a highpriority as their insufficient intake of energy and protein becomes long term. It is necessary to have a system inplace for identifying those who are vulnerable and in need of support and providing them with the items (food)and nutritional care that they require. Eating is equivalent to living, and if the vulnerable themselves recognize
the importance of food and nutrition, this will help improve the nutritional situation of the entire population. It is
recommended that measures be taken in non-emergency periods such as stockpiling food for special dietary uses.

Key Words: insufficient intake, malnutrition, vulnerable people, preparedness, food for special dietary uses

INTRODUCTION
Food and nutrition management during a natural disaster
differ depending on the phase of the disaster. Moreover,because the conditions in the phases differ according to
the natural disaster, it is difficult to present uniform descriptions of and standards for nutritional management.
To manage and support food and nutrition, it is vitally
important to establish a system to secure the necessary
items (food) and to deliver them to the people who needthem (disaster victims), including fundamental activities,
such as managing the stockpile of aid supplies.
Specifically, it is necessary to carry out two approaches
concurrently: a population approach, which consists ofmeasures to secure nutrition to increase group levels; anda high-risk approach, which is comprised of individualcare for people who are high priority. Infants, pregnant
women, patients, and the elderly are said to be particularly
in need of support during a natural disaster (vulnerable)
and are therefore a high priority in terms of the provisionof meals and nutrition support, and it is recommended
that assistance for them be carried out at a comparatively
early stage. Therefore, this paper is particularly centered
upon the acute and sub-acute phases of a disaster, during
which victims live in emergency shelters.
FOOD AND NUTRITION AFTER A NATURALDISASTER
In order to maintain life when there is a natural disasterand also maintain people’s health, there are four key
points that must be considered: (1) that people intake sufficient water, (2) that they intake adequate food (prioritiz-ing energy first, and then protein and water-soluble vitamins), (3) that their intake is safe (sanitary), and (4) thatthey stay physically active as much as possible. In particular, from the period immediately after the natural disaster up to the time when aid supplies are distributed toemergency shelters, securing the minimum necessarylevels of water and energy should be the priority.1,2
One of the concerns after a natural disaster is people’s
reduced intake of water, for reasons such as limitations onwater availability because of the water supply being cutoff, reduced intake of water derived from foods, or thebathroom environment (unsanitary, having to access outdoor facilities some distance away). Furthermore, there
are cases where the elderly reduce their water intake because of their inhibited sensitivity to feelings of having a
dry mouth and also refrain from drinking water to avoid
incontinence problems. Since a lack of water increases
the risk of dehydration, constipation, cardiovascular disease, and deep-vein thrombosis/pulmonary embolism(economy-class syndrome), it is imperative to actively
intake water.
The sphere project, which comprises a wide range ofCorresponding Author: Dr Nobuyo Tsuboyama-Kasaoka,
Section of the Dietary Reference Intakes, Department of Nutritional Epidemiology, National Institute of Health and Nutrition
1-23-1, Toyama, Shinjuku-ku, Tokyo 162-8636, Japan.
Tel: 81-3-3203-5721; Fax: 81-3-3202-3278
Email: ntsubo@nih.go.jp
Manuscript accepted 31 October 2014.
doi: 10.6133/apjcn.2014.23.4.23

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Nutrition and earthquakes

humanitarian agencies, indicated a minimum standard
foruse during a humanitarian response.1 It is indicatedthat 7.5-15 liters of water per day are needed to meet total
basic water needs (2.5-3 liters for water intake [drinking
and food], 2-6 liters for basic hygiene practices, and 3-6
liters for basic cooking needs).
There tends to be a shortage of food immediately after
a natural disaster, following which biases emerge about
the food that is provided. In both the Hanshin-Awaji
Earthquake and the Niigata Chūetsu Earthquake, many of
the sources of energy in the food supplied to the emergency shelters were carbohydrates, such as rice balls,
bread, and cups of noodles, and the supply situation for
fresh foods, including vegetables, meat, fish, and dairy
products, was poor.3-4 Food shortages when there is anatural disaster have an effect on people’s health, and it
has been shown that the lower the frequency of intake ofgreen vegetables at emergency shelters, the greater thenumber of non-specific complaints, such as colds, coughs,
weight loss, gastrointestinal disorders, stress, and becoming short-tempered.5 The number of non-specific complaints also increases when the intake of fish and seafood
declines, which suggests the need to improve the meals
provided at emergency shelters.
In terms of sanitation, it can be difficult to maintainsanitary conditions when the water supply is cut-off;therefore, through providing education for the mealpreparatory staff and other relevant parties, it is necessary
to implement measures to prevent the occurrence of foodpoisoning and the spread of infectious gastroenteritis,such as the norovirus.
Furthermore, the sphere project also indicated the classifications of the public health significance of selected
micronutrient deficiencies, using different indicators, andthe nutritional requirements for planning purposes in theinitial stage of a disaster (Table 1).1

SPECIAL CARE FOR THE VULNERABLE
From the results of the survey of emergency shelters, it
was found that the proportion of vulnerable who needed
nutritional care had risen. However, at the affected areas,
priority is given to emergency medical care and severe
disease, and the supports for the vulnerable and thechronically diseases are postponed. The provision ofmeals and nutritional care should be a priority for thevulnerable, for whom an inappropriate diet can have fatal
or long-term effects. In a survey of the intake at emergency shelters following the Athens Earthquake in 1999, boththe elderly and adults consumed less than they were actually provided with, and in particular, their inadequate
intake of energy and protein became long term.6 This indicates the importance of ascertaining the food consumption of the elderly. The factors behind the decline in intake among the elderly are the difficulties in providing
food suitable for them (rather than cold and hard food thatis not easy to swallow, food they are not used to, etc.),that they refrain from eating as they are reserved with theyounger generation, they have no appetite due to anxiety,and the lack of an eating environment where they can eat
in comfort. Moreover, the needs of disaster victims living
at home must not be overlooked, as well. The elderly disaster victims living at home include those with serious
diseases, such as the bedridden. Their needs, including
nutritional needs such as special dietary requirements ortreatment for pressure ulcers, are a high priority. It is important to cooperate with other medical staff and utilize
nutritional assessment sheets2 to identify those elderly
who are in need of support.
It has been reported that people’s blood sugar andblood pressure levels worsen at the time of a natural disaster, but it has also been reported that those who are able
to control their food intake at emergency shelters are able

Table 1. Nutritional requirements and public health significance of micronutrient deficiencies1
Nutrient
EnergyProtein
Fat
Vitamin A
Vitamin D
Vitamin E
Vitamin K
Vitamin B1 (Thiamin)
Vitamin B2 (Riboflavin)
Vitamin B3 (Niacin)
Vitamin B6 (Pyidoxine)
Vitamin B12 (Cobalamin)
FolatePantothenate
Vitamin C
Iron
IodineZinc
CopperSelenium
Calcium
Magnesium

Minimum population requirement
2,100 kcals
53 g (10% of total energy)
40 g (17% of total energy)
550 μg RAE
6.1 μg
8.0 mg alpha-TE
48.2 μg
1.1 mg
1.1 mg13.8 mg NE
1.2 mg2.2 μg363 μg DFE
4.6 mg41.6 mg
32 mg
138 μg12.4 mg
1.1 mg27.6 μg
989 mg
201 mgMicronutrient deficiency

Night blindness, Bitot’s spots , Corneal Xerosis, ulceration, or
keratomalacia, Corneal scars

Beriberi, Wernicke's encephalopathy
Angular cheilitis, Stomatitis, Glossitis, Seborrheic dermatitis
Pellagra
Megaloblastic anemia, Neural tube defects in the fetus
ScurvyAnaemia
Goitre (visible + palpable)

Alpha-TE: alpha-tocopherol equivalents; RAE: retinol activity equivalents; NE: niacin equivalents; DFE: dietary folate equivalents.
Modified from the Sphere hand book, 2011.1

N Tsuboyama-Kasaoka and MB Purba
to suppress a deterioration of their blood sugar control.7
During a natural disaster, many of the provided boxed
meals include deep-fried foods, and food supplies frequently include items like canned food with a high saltcontent, boil-in-the-bag meals, and cups of noodles. Thus,in order to prevent a worsening of chronic conditions, it isimportant that people educate themselves about nutrition
during non-emergency periods and acquire the skills to
put that knowledge into practice at the time of natural
disasters. Also, while food supplies may include foods forpeople with chronic conditions (including kidney diseases,etc.), food allergies, and swallowing difficulties (thickening agents), it can be difficult to find specific items
among the various supplies delivered from warehouses
and then provide them to the people who need them, particularly during the period immediately following thedisaster. It is particularly necessary for the vulnerable tostockpile for themselves the food they need for special
dietary uses, and also for both they and facilities to havecooking utensils and prepared heat sources to warm meals(gas, etc.).
At the time of a natural disaster, a system needs to bein place so that the people who provide assistance canlocate the vulnerable individuals who need said assistanceand provide them with nutritional care. At the same time,
it is particularly important that the vulnerable, such as theelderly, themselves are aware of the fact that when they
are in good spirits, those around will also be in good spirits, and of the need for adequate food and nutrition tomaintain their health, even when priority is given to
emergency medical treatment. It is thus necessary to urge
them to proactively supplement their nutritional intake.
To eat is to live, and it is recommended that measures betaken during non-emergency periods.
JAPANESE EXPERIENCES
Food and nutrition problems after the Great East Japan
Earthquake
The magnitude 9 Great East Japan Earthquake hit on
March 11, 2011, followed by a large tsunami. An estimated 450,000 evacuees were temporarily housed in over
2,400 emergency shelters.
In the Great East Japan Earthquake, even one monthafter its occurrence, the provision of meals at the emergency shelters was biased toward carbohydrates, andthere was a lack of meals that contained a large amount ofprotein as the main dish (meat, fish, egg, beans, etc.) andvegetables as the side dish.8 The reasons for this are considered to be the shortage of stockpiles,9 the difficulties inusing stockpiles, the poor state of supply procurement,10
and the provision of too much of certain types of foodsupplies, such as carbohydrate-based food. In the
Hanshin-Awaji Earthquake emergency shelters, boxed
meals that included a balanced main dish were being distributed to the majority of shelters in the affected area
about one month after the earthquake,4 and compared tonatural disasters in the past, the Great East Japan Earthquake is characterized by a delay in providing victims
with sources of protein.8 The distribution of cooked meals
was also limited, and it was a long time before hot meals
were provided. In fact, the ability to cook and gas availability significantly improved their dietary provision as

507

they were better enabled to serve balanced meals in theemergency shelters.8 Furthermore, the states of food procurement and meal provision were made higher in facilities by cooperation with other facilities.10,11 It is hopedthat in the future, both the national and local governments
will distribute food supplies that are not biased toward
any type of food, perhaps through planned food stockpiling.
Regarding vulnerable people for whom an individualized approach is necessary, a survey conducted in emergency shelters after the Great East Japan Earthquake
found that there were many “people who needed milk orbaby foods” and also many “elderly or people with disabilities who were unable to eat normal meals”, and it was
ascertained that there were many vulnerable who require
support for meals.8 It is necessary to have stockpiles in
the facilities that house these vulnerable people. It wasreported that great improvement were seen in terms of thequantity and quality of stocks in nursery schools after theGreat East Japan Earthquake.12
During the chronic phase, a prudent dietary pattern was
associated with better living conditions among survivors
in temporary housing.13 Therefore, disaster victims are inneed of continuous nutritional supports.
The support activities following the Great East Japan
Earthquake
With the goal of improving food and nutrition conditions
after the Great East Japan Earthquake, The Ministry of
Health, Labour and Welfare aimed to secure the required
number of meals and the necessary quantities of nutrientsfor the emergency shelters from the first through the third
months following the earthquake, and it indicated Nutritional Reference Values for energy (2000 kcal), protein(55 g), and vitamins B1 (1.1 mg), B2 (1.2 mg), and C (100mg) that should actually be provided in the meals(http://www.mhlw.go.jp/stf/houdou/2r9852000001a159img/2r9852000001a29m.pdf, in Japanese). Those nutrients that will become deficient at an early stage because
people have few internal reserves stored within their bodies have been identified, and they are considered a toppriority in a nutritional plan at the time of a natural disaster. Further, a supplementary provision of vitamin B1 isneeded for metabolizing a diet that is high in carbohydrates.14 The National Institute of Health and Nutrition
has presented an example of various food compositions
and a specific menu that satisfies the reference values(Table 2 and Table 3). Additionally, with the objective ofinvestigating whether the provision of meals was sufficient during the three months following the earthquake, it
presented the “Nutritional Reference Values for Dietary
Assessments and Planning for the Provision of Meals to
Emergency Shelter” for energy (1,800-2,200 kcal), protein (55 g), and vitamins B1 (0.9 mg), B2 (1.0 mg), and C(80 mg). (http://www.mhlw.go.jp/stf/houdou/2r98520000
01fjb3-att/2r9852000001fxtu.pdf, in Japanese). Careshould be taken to ensure that people’s intake at emergency shelters does not fall below the “Nutritional Reference Values for Dietary Assessments and planning.” Itseparately lists as special items the quantities of calcium
and vitamin A that are essential during a child’s growth
period. The quantity of sodium is presented primarily

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Nutrition and earthquakes

Table 2. Example of food composition of meals in an
emergency shelter
Food
Cereals
Potatoes and starches
Vegetables
FruitsFish and shellfish
Meats
Eggs
PulsesMilk and dairy products
Fats and oils

Unit: grams
550
60
350
150
80
80
55
60
200
10

This example of the food composition of meals was prepared on
the basis of the findings of the 2009 National Survey of Healthand Nutrition. The weight of cereals is after having been cooked.

from the perspective of lifestyle-related disease prevention.
To provide support at actual sites within the disaster
affected areas, national registered dietitians and generaldietitians were dispatched by local governments and fromthe Japan Dietetic Association (JDA) to conduct activities
there. Three weeks after the earthquake, the JDA dispatched 1,588 volunteer registered and general dietitians
to the affected areas. Their five-month-long tasks were to

support and improve the essential food supply and provide nutrition care to protect the lives of nutritionally vulnerable evacuees. Among their efforts, the activity that
produced particularly remarkable results was the JDA’s
distribution of rice fortified with vitamin B1 and othernutrients to the emergency shelters in the disaster affectedareas and to those disaster victims who were living at
home. According to the results of a survey by Miyagi
Prefecture, the shortfall in vitamin B1 intake had been
recovered by about two months after the earthquake.15 It
is necessary to include the provision of fortified foods,
such as rice fortified with vitamins, in a stockpile plan.
Disaster dietitian
The JDA established the Japan Dietetic AssociationDisaster Assistance Team (JDA-DAT, http://www.dietit
ian.or.jp/english/jda01/jda_dat.html). The JDA-DAT is anutrition support team that received training in the specialty of nutrition care activity in disaster affected areas.
The purpose of this team is to promote and foster registered dietitians equipped with the necessary technicalknowledge and techniques required in order to provide
swift emergency dietary support for the disaster-stricken
region in cooperation with medical, welfare, and government nutrition specialists, etc., when a large-scale natural
disaster, such as a major earthquake or typhoon, strikes

Table 3. Example of a specific menu of meals
Food group
Cereals

Potatoes,
vegetables

Pattern 1 (when cooking with heat is impossible)
No of times
Example meal and standard amountper day*1
per day
3 times•Bread roll, 2•Convenience store rice ball, 2•Fortified rice, 1 bowl

Pattern 2 (when cooking with heat is possible)
No of times
Example meal and standard amountper day*1
per day
3 times•Bread roll, 2•Rice ball, 2•Fortified rice, 1 bowl

3 times

3 times•One from the following list
Vegetable soup with meat, 1
Boiled vegetables with meat (mayuse dried foods, such as edible
seaweed and dried sliced daikon),
1 plateBoil-in-the-bag curry, 1 packBoil-in-the-bag stew, 1 pack
Rice bowl with beef, 1 pack
•Boiled vegetables, 1 pack (100 g)•Fresh vegetables (1 tomato, etc)

3 times•Canned fish, ½ can•Fish-meat sausage, 1•Included in (curry, stew, rice with
beef, potato and vegetable soup,boiled vegetable)•1 egg•Can of beans, ½ can•Boil-in-the-bag beans, 1 bag•Natto, 1 pack

•Boil-in-the-bag sweet potatoes, 3•Dried potatoes, 2•Vegetable juice (200 ml), 1 can•Tomato, 1, and cucumber, 1Fish andshellfish,meats, eggs,
pulses3 times•Canned fish, ½ can•Fish-meat sausage, 1•Ham, 2 slices―•Can of beans, ½ can•Boil-in-the-bag beans, ½ bag•Natto, 1 pack

Milk anddairy products

1 time•Milk (200 ml), 1 carton•Yogurt, 1 pack + processed cheese,
1 slice

1 time•Milk (200 ml), 1 carton•Yogurt, 1 pack + processed cheese,
1 slice

Fruits1 time•100% fruit juice, (200 ml), 1 can•Canned fruit, around 1 cup•Apple, banana, orange, etc 1-2

1 time•100% fruit juice, (200 ml), 1 can•Canned fruit, around 1 cup•Apple, banana, orange, etc 1-2

Care should be taken to actively hydrate (drink water).
*1 Select the “example meal” based on the standard “number of times per day.” For example, if the number of times per day for cereals is
three, select as follows: morning, bread rolls, 2; lunch, convenience store rice ball, 2; dinner; convenience store rice ball, 2.

N Tsuboyama-Kasaoka and MB Purba

anywhere in Japan.
Such systematic and large-scale dietary support after adisaster is rare, even worldwide. Nutritional care of evacuees could be partially improved by being better preparedfor disasters.
CHINESE EXPERIENCES
China has also experienced large earthquakes several
times. After the Wenchuan Earthquake, there were several reports regarding nutritional problems. The prevalenceof malnutrition significantly increased two years after the
Wenchuan earthquake in vulnerable people, such as infants and young children.16 Instances of children who
were underweight, or experienced stunting and wasting,occurred. Furthermore, the prevalence of anemia dramatically increased in infants and young children. Interestingly, the increasing percentage of anemia was more obvious
in girls than boys. Anemic prevalence and iron deficiency
were also high in pregnant, nursing, and child-bearing
women.17 There were vitamin deficiencies, such as vitamins A, D, and B12, in pregnant, nursing, and childbearing women. After the disaster, infants, young children, and these women should be cared for immediately
and improving their nutritional status should be a priority.
INDONESIAN EXPERIENCES
One of the most frightening and destructive phenomenaof nature is a severe earthquake and the terrible after effects. An earthquake is a sudden movement of the Earth,caused by the sudden release of energy that has accumulated over a long period of time. Indonesia sits on the
Pacific "Ring of Fire" where tectonic plates collide, causing frequent seismic and volcanic activity. The volcanoes
in Indonesia are the most active of the Pacific Ring ofFire. They were formed due to the subduction zones ofthree main active tectonic plates, namely the Eurasian
Plate, Pacific Plate, and the Indo-Australian Plate. Earthquakes can kill large numbers of people in one fell swoop,
destroy crops, food reserves, assets, and roads, all ofwhich can adversely impact food security; they destroy
health facilities, water, and sanitation systems, which canlead to a high risk of malnutrition.18
Case studies of earthquake in Indonesia
Many earthquakes that occur throughout the Indonesianarchipelago remain largely under-reported, frequently
because they began a number of years ago, and someevents have become chronic or long-term. One of thelargest earthquakes during this century that hit Indonesia
is remembered as the Aceh Tsunami. On Sunday morning,
December 26, 2004, an earthquake registering 9.0 on the
Richter scale struck off the western coast of North Sumatra, triggering massive waves that devastated coastal regions throughout the Indian Ocean rim. Indonesia’s Aceh
Province suffered the greatest mortality, with widespread
destruction extending along more than 1000 km of coastline. The Indonesian government’s estimation indicated
129,775 deaths, 38,786 missing, and 504,518 tsunamidisplaced in Aceh Province alone.19,20
Another volcanic earthquake was the 2010 eruptions ofMount Merapi in Jogjakarta, Central Java, which began in
mid-September and lasted into late November 2010.

509

More than 350,000 were evacuated from the area within a
10 km radius around the slopes of the volcano. Many remained behind or returned to their homes while the eruptions were continuing. Approximately 353 were killedduring the eruptions, the majority of deaths being fromsevere burns caused by searing gas clouds. Some victims
died in road and other accidents during the panicked exodus from the mountain. Acute respiratory infection, hypertension, and headache were common ailments affecting the Mount Merapi eruption survivors.
The latest volcanic earthquakes were the eruptions ofMount Kelud in East Java and Mount Sinabung in North
Sumatra. On February 13, 2013, Mt Kelud exploded witha powerful eruption (the main ash cloud reached an altitude of nearly 20 km, with sections of the plume reaching
to nearly 30 kilometers). As many as 76,388 people were
evacuated into 293 shelters within the 10 km exclusionzone and three fatalities were caused by the eruption (twoas a result of breathing difficulties caused by the ash andone person in a road accident during evacuation). Meanwhile, Mount Sinabung in North Sumatra has been erupting from September 23, 2013 until present (>1 year) andmore than 20,000 people have been evacuated in a 5 km
radius with 20 fatalities recorded.
Impact of earthquake on access to food
In a disaster, vulnerability will be influenced by the nature, extent, and time-scale of the disaster and the community's capacity to cope with it. That is, it is affected bytheir ability to use available resources and face adverse
consequences. Natural disasters, for example, an earthquake in Indonesia, have a greater devastating impact on
the population’s health status and environment, including
health systems. These disasters usually affect a comparatively large number of people. In general, the people directly affected by disasters were those who were displaced, losing access to their food entitlements. Moreover,persons trapped in disaster zones were cut off from market links and relief food, as well as lost their employment
and income as a result of the resulting economic decline.
21
Disasters such as earthquakes and tsunami not only
have an impact on people’s access to food, but also on thestability of the food supply and access; the impact on
prices and markets exacerbates the effects of natural disasters and weakens institutions.22
Importance of nutrition after an earthquake
It is crucial that careful attention is given to the vulnerability, capacities, and disaster preparedness of people affected by long-term disasters. Vulnerability, capacity, anddisaster preparedness are examined specifically in thecontext of food shortages and malnutrition. Protecting thenutritional status of vulnerable groups affected by emergencies is crucial and a humanitarian right because Individuals who suffer from acute malnutrition are much
more likely to become sick and die. At the same time,sick individuals are more likely to become malnourished.
Emergencies have an impact on a whole range of factorsthat can increase the risk of malnutrition, illness (morbidity), and death (mortality).
It is quite commonly observed after an earthquake thatthe health and nutritional status of infants and young chil-

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Nutrition and earthquakes

dren is affected, particularly if the people have to stay in a
temporary shelter. Poor nutritional status leads to lowered
immunity and increased morbidity from infectious diseases, such as diarrhea, malaria, or tuberculosis. If further
deterioration in nutritional status, from inability to eat
and/or malabsorption, is not treated by nutritional intervention and medical care, this cycle continues, ultimately
leading to death. In disasters, an immediate concern is toascertain the level of malnutrition in the population. As
the nutritional status of children under five years of age
responds rapidly to acute food shortages, high levels of
malnutrition in this age group usually indicate acute malnutrition in the overall population.23
The main nutritional concerns in disasters are acutemalnutrition (wasting), especially in young children, micronutrient deficiencies, and chronic malnutrition (stunting). Of these, the greatest concern is the increased risk ofmoderate and severe acute malnutrition. This is because
acute malnutrition is strongly associated with death. Children under five years of age are particularly vulnerable todeveloping acute malnutrition during emergencies and are
frequently the first group in a community to show signsof malnutrition during times of hardship. For this reason,
weight for height in young children is usually measured
in nutrition assessments and acts as a proxy measurement
for the entire community.24
A nutrition program after an earthquake, therefore, is
one of the crucial elements for ensuring an adequate foodsupply for the entire affected population, as it prevents
malnutrition and other adverse health consequences. In
addition, the program can provide nutritional rehabilitation for moderately and severely malnourished people andprevent nutritional deterioration for vulnerable groups.

children at home or in shelters, thus reducing the numberof children in feeding centers. According to Young et al.,this leads to increased access to treatment and a possible
reduction in cross-infection.30
Research conducted by Almasyhuri et al31 from the Indonesia Center for Nutrition Research & Development
since 2009 has led to the development of ready to eat
foods for during natural disasters.31 The product is basedon the Indonesian Recommended Dietary Allowances for
adults: 2000 kcal & 55 g of protein. They developed two
types of emergency foods (solid biscuits and semi-solid
pasta) based on the following ingredients: cereal as anenergy source, pulses and egg as protein, vegetables toprovide vitamins, minerals and fiber, and vegetable oil asa fat source. Nutrient content of the food per portion is asfollows: biscuit 1 bar (62 g) = 286 kcal and 10.4 g protein,and pasta 1 cup (150 g) = 597 kcal and 19.1 g of protein.
If a person can consume just three cups of pasta and one
bar of biscuits, this would already meet 85–90% of theiradult RDA.
The ready-to-eat food can also be used in nonemergency situations. By preventing moderate malnutrition from becoming severe, it could play an importantrole in disaster preparedness. So far, most of these foods
are imported into the affected areas, but if production ofready-to-eat foods, such as pastas and biscuits, were touse locally available grains and legumes, it would reduce
the probability of malnutrition, even during the critical
period of the disaster. Encouraging local initiatives inready-to-eat food production, as well as involving community expertise in implementation, would afford opportunities to reduce vulnerability, build community capacity,and increase disaster preparedness.32,33

25,26

Identification of malnutrition amongst earthquake survivors can be done through a measurement of their nutritional status. Overall nutritional status of a population isnormally estimated by surveying (using cluster sampling)children under five years of age.27,28 Anthropometricmeasurements and demographic information are obtained.
Edema, especially around the ankles, is an important clinical indicator. The index "weight for height" (WFH) is
most commonly used to detect acute malnutrition (wasting) in surveys. Where large numbers of children have tobe screened, mid-upper arm circumference (MUAC) canbe used to identify wasting. MUAC measurements <11.0
cm are indicative of severe acute malnutrition and are ofvalue in predicting mortality. A WFH of less than 70% of
the median and/or edema indicates severe acute malnutrition. Alternatively, z scores may be used, where the WFH
is expressed as the number of standard deviations below
the median. A z score <-3 and /or edema indicates severe
acute malnutrition. Moderate acute malnutrition is indicated if the WFH is between 70% and 80% of the median,or between -3 and -2 z scores.29
Developing ready-to-eat food for an emergency
Ready-to-eat food, particularly during a disaster, is needed to reduce the risk of malnutrition. The foods available
as energy-dense pastes or biscuits are more resistant tobacterial growth, unlike milk-based liquid products. Thishas made it easier to care for moderately malnourished

Disaster preparedness in a hospital setting
By the end of 2014, the Indonesian government targeted aminimum of five government hospitals to be accreditedby the International Joint Commission (JCI) Agency. Dr
Sardjito Hospital in Jogjakarta, Dr Cipto Mangunkusumo
Hospital in Jakarta, and Dr Sanglah Hospital in Denpasar,
Bali have passed the accreditation. Meanwhile Dr Adam
Malik Hospital in Medan, North Sumatra, and Dr Wahidin Sudirohusodo Hospital in Makasar, South Sulawesi
are undergoing the accreditation process. Based on JCI
accreditation, every hospital should have disaster preparedness as part of its Facility and Management Standard.
Health care providers need to direct their efforts at building their capacity and decrease the vulnerability of their
populations, thus enhancing their preparedness for any
future disaster.32,33
Each hospital develops, maintains, and tests an emergency management program to respond to emergencies,
epidemics, and natural or other disasters that have thepotential of occurring within their community. Community emergencies, epidemics, and disasters may directly
involve the hospital, such as damage to patient care areas
as a result of an earthquake that prevents staff from reporting for duty. The development of the program should
begin by identifying the types of disasters that are likely
to occur in the hospital’s region and what the impact ofthese disasters would have on the hospital.
Facility damage or mass casualties, on the other hand,N Tsuboyama-Kasaoka and MB Purba

could potentially occur in any hospital. It is just as important to identify the effects of a disaster as it is to identify the types of disasters. This helps in planning the strategies that are needed in the event of a disaster. For example, what is the likelihood that a natural disaster, such as
an earthquake, will affect water and power? Could anearthquake prevent staff from responding to the disaster,
either because roads are blocked or because they or theirfamily members are also victims of the event? In suchsituations, the staff members’ personal responsibilities
may be in conflict with the hospital’s requirements forresponding to an emergency. In addition, hospitals need
to identify their role within the community. For example,
what resources will the hospital be expected to provide to
the community in the event of a disaster, and what communication methods will be used within the community?
To respond effectively, the hospital develops a program to manage such emergencies. The program provides
processes for:(a) determining the type, likelihood, and consequencesof hazards, threats, and events;(b) determining the hospital’s role in such events;(c) communication strategies for events;(d) the managing of resources during events, including
alternative sources;(e) the managing of clinical activities during an event,including alternative care sites;(f) the identification and assignment of staff roles andresponsibilities during an event;(g) the process to manage emergencies when the personal responsibilities of staff conflict with the hospital’s
responsibility to provide patient care.
The disaster preparedness program of the hospital istested either by an annual test of the full program internally or as part of a community-wide test or testing of
critical elements of the program throughout the year. If
the hospital experiences an actual disaster, activates its
program, and debriefs properly afterward, this situation
represents the equivalent to an annual test.
There are five measurable elements of disaster preparedness according to JCI accreditation.34 First, the hospital
has identified the major internal and external disasters,such as community emergencies, epidemics, and naturalor other disasters, as well as major epidemic events thatpose significant risks of occurring, taking into consideration the hospital’s geographic location. Second, the hospital identifies the probable impact that each type of disaster will have on all aspects of care and services. Third, thehospital establishes and implements a disaster programthat identifies its response to likely disasters. Fourth, theentire program, or at least critical elements of the program, is tested annually. Lastly, at the conclusion of every test, a debriefing about the test is conducted.34
Constraints and recommendations
There are many constraints faced by the nutrition programmer during a disaster, such as insufficientknowledge about emergency nutrition, insufficient humanand natural resources, and sometimes Nutrition & HealthWorker as a survivor/victims. Ideally, on-going nutritional surveillance should be standard practice so that a deteriorating situation can be identified early. This requires

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expertise, for example, local fieldworkers to carry out
data collection, and access to logistical, statistical, andnutritional expertise to analyze and interpret findings.
The challenges involved in building capacity in vulnerable communities must not be underestimated. A multidisciplinary approach is needed for effective community
involvement. Just as nutrition itself is multi-factorial, so
knowledge and expertise from several academic and professional disciplines and the local population are needed.
Listening to and respecting the community's knowledge,
experience, views, and expertise, and understanding their
specific cultural, social, psychological, economic, andphysical needs are all critical forces in building capacity
for disaster preparedness in nutrition.
Emergency feeding should not only satisfy hunger but
also consider nutritional needs. Otherwise, malnutrition,with its consequences of morbidity and mortality, willremain uncontrolled. In addition to sustaining life andmaintaining good health, emergency nutrition also provides relief to the condition of casualties, boosts the morale of displaced people, and enables emergency workers
to perform their tasks. Special training on emergency nutrition is needed to manifest this response.
AUTHOR DISCLOSURES
None of the authors had any personal or financial conflict ofinterest to declare.
REFERENCES
1. The Sphere Project. The sphere handbook: Humanitarian
charter and minimum standards in humanitarian response.
Hampshire, United Kingdom: Hobbs the Printers; 2011.
2. National Institute of Health and Nutrition. The Japan Dietetic Association: Manual for nutrition and dietary habits support during a natural disaster. Tokyo: The Japan Dietetic
Association; 2011. (In Japanese)
3. Tsuchida N, Isobe S, Watanabe S, Ishigami K, Yoshita K,
Yoshiike N, Murayama N. Changes in access to food andthe frequency of food consumption before and after the Niigata Chuetsu earthquake: comparison between households
in temporary housing and disaster-stricken housing. J Jpn
Diet Assoc. 2010;53:30-8. (In Japanese)
4. Hyogo Prefecture. Natural disaster dietary habits improvement guidelines. Hyogo: Hyogo Prefecture; 1996. (In Japanese)
5. Okuda T, Hirai K, Masuda T, Yamaguchi H, Tuzukida Y,
Takao F, Miyano M. Survey of health status among victimsof the Great Hanshin-Awaji Earthquake living in evacuation
centers. Jpn J Physiol Anthropol. 1996;1:101-7. (In Japanese)
6. Magkos F, Arvaniti F, Piperkou I, Katsigaraki S, Stamatelopoulos K, Sitara M, Zampelas A. Identifying nutritionallyvulnerable groups in case of emergencies: experience fromthe Athens 1999 earthquake. Int J Food Sci Nutr. 2004;55:
527-36. doi: 10.1080/09637480400029324.
7. Kirizuka K, Nishizaki H, Kohriyama K, Nukata O, Arioka
Y, Motobuchi M et al. Increase in HbA1c following theGreat Hanshin Earthquake in diabetic patients. J Jpn Diab
Soc. 1996; 39:655-8. (In Japanese)
8. Tsuboyama-Kasaoka N, Hoshi Y, Onodera K, Mizuno S,
Sako K. What factors were important for dietary improvement in emergency shelters after the Great East Japan
Earthquake? Asia Pac J Clin Nutr. 2014;23:159-66. doi: 10.
6133/apjcn.2014.23.1.17.
9. Sudo N, Seino F, Yoshiike N. Food assistance and nutri-

512

Nutrition and earthquakes

tional support by local governments after natural disaster.
Jpn J Disast Med. 2007;12:167-77. (In Japanese)
10. Nozue M, Ishikawa-Takata K, Sarukura N, Sako K, Tsuboyama-Kasaoka N. Stockpiles and food availability in feeding facilities after the Great East Japan Earthquake. Asia Pac
J Clin Nutr. 2014;23:321-30. doi: 10.6133/apjcn.2014.23.2.
14.
11. Tsuboyama-Kasaoka N, Hoshi Y, Onodera K, Iwabuchi K,
Izumi A, Saitoh C et al. Factors impacting meal provision in
emergency evacuation centers (shelters) after the Great East
Japan Earthquake. J Jpn Disast Food Soc. 2014;1:35-43. (InJapanese)
12. Amitani Y, Sudo N, Tsuboyama-Kasaoka N, Ishikawa F,
Sako K. Restructuring of the disaster countermeasures about
meal services at nursery schools in a metropolitan area after
the Great East Japan Earthquake. J Jpn Diet Assoc. 2014;57:
192-200. (In Japanese)
13. Nishi N, Yoshimura E, Ishikawa-Takata K, TsuboyamaKasaoka N, Kubota T, Miyachi M et al. Relationship of living circumstances with dietary patterns of Great East Japan
Earthquake victims. J Epidemiol. 2013;23:376-81. doi: 10.
2188/jea.JE20130025.
14. International Life Sciences Institute (ILSI). Present
knowledge in nutrition (10th edition). Iowa: WileyBlackwell: 2012.
15. Miyagi Prefecture. Findings of the third survey on foodconditions in emergency shelters and nutrition-related needs.
Miyagi: Miyagi prefecture; 2011. (In Japanese)
16. Dong C, Ge P, Ren X, Zhao X, Wang J, Fan H, Yin SA.
Growth and anaemia among infants and young children for
two years after the Wenchuan Earthquake. Asia Pac J Clin
Nutr. 2014;23:445-51. doi: 10.6133/apjcn.2014.23.3.03.
17. Dong C, Ge P, Ren X, Zhao X, Fan H, Yin SA, Weiderpass
E. Evaluating the micronutrient status of women of childbearing age living in the rural disaster areas one year after
Wenchuan Earthquake. Asia Pac J Clin Nutr. 2014;23:671677.
18. Natural Disasters in Indonesia. [cited 2014/10/27]; Available from: http://www.indonesiainvestments.com/doing-bus
iness/risks/ natural-disasters/item243.
19. Indonesia - Disaster Statistics. [cited 2014/10/27]; Available
from: http://www.preventionweb.net/english/countries/stati
stics/?c id=80.
20. Shepard D, ed. Survivors of the tsunami: one year later.
New York, NY: United Nations Development Programme;
2005. [cited 2014/10/27]; Available from: http://www.undp.
org/tsunami/UNDP-Tsunamireport-final.pdf.
21. Eastwood M. Principles of Human Nutrition. London:
Blackwell Science Ltd; 2003.

22. United Nations Information Management Service. Tsunami
recovery status report. New York, NY: United Nations;2005.
23. Australian Agency for International Development, Indonesia
Earthquake: 30 Mar 2005. New York, NY: United Nations
Office for the Coordination of Humanitarian Affairs; March
30, 2005. [cited 2014/10/28]; Available from: http://www.
reliefweb.int/rw/rwb.nsf/db900SID/SODA-6AY5LB?Open
Docu ment&rc=3&cc=idn.
24. World Health Organization. The management of nutrition in
major emergencies. Geneva, Switzerland: World Health Organization; 2000.
25. Rehabilitation and Reconstruction Agency report. Jakarta,
Indonesia: Government of Indonesia; 2005.
26. Widyastuti E, Silaen G, Pricesca A, Handoko A, Blanton C,
Handzel T, Brennan M, Mach O. Assessment of healthrelated needs after tsunami and earthquake - three districts,
Aceh Province, Indonesia, July-August 2005. [cited
2014/10/27]; Available from: http://www.cdc.gov/mmwr/
preview/ mmwrhtml/mm5504a1.htm.
27. UNICEF. UNICEF response to the Indian Ocean emergency.
New York, NY: UNICEF; 2005.
28. World Health Organization. Epidemic-prone disease surveillance after the tsunami in Aceh Province, Indonesia. Wkly
Epidemiol Rec. 2005;80:160-4.
29. Corbett M. Save the children alliance assessment of infant
and young child feeding practices post-earthquake. Jogjakarta, Indonesia; 2006. (Report)
30. Young H, Borrel A, Holland D, Salama P. Public nutritionin complex emergencies. Lancet. 2004;364:1899-909. doi:
10.1016/S0140-6736(04)17447-3.
31. Almasyhuri, Imaningsih N, Yuniati H. Biscuit formulation
as ready to eat food during emergency. Food and Nutrition
Research (Indonesia). 2012;35:42-8.
32. Kuntjoro I, Jamil S. Natural disasters in Indonesia:
Strengthening disaster preparedness. RSIS Centre for NonTraditional Security Studies, Nanyang Technological University. [cited 2014/10/28]; Available from: http://www.
eastasiaforum.org/2010/11/17/natural-disasters-in-indonesia-strengt hening-disaster-preparedness/.
33. Centers for Disease Control and Prevention. Emergency
Preparedness and Response: Keep Food and Water Safe After a Disaster or Emergency. [cited 2014/10/27]; Available
from: http://www. bt.cdc.gov/ disasters/foodwater/facts.asp.
34. Joint Commission International. JCI accredited Organizations. [cited 2014/10/28] Available from: http://www.jointcommissioninternational.org/about-jci/jci-accredited-organi
zations/.

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Mini Review

Nutrition and earthquakes: experience andrecommendations
Nobuyo Tsuboyama-Kasaoka PhD, RD1,2, Martalena Br Purba MCN, PhD3,41

Section of the Dietary Reference Intakes, Department of Nutritional Epidemiology, National Institute of
Health and Nutrition, Tokyo, Japan
2
The Japan Dietetic Association, Tokyo, Japan
3
Indonesian Dietetic Association, Jakarta, Indonesia
4
Nutrition Department Dr Sardjito Hospital, Jogjakarta, Indonesia

營養與地震：經驗及建議
在天然災害發生期間，確保民眾有足夠的水及食物攝取來維持生命，至為重要(優先順序，第一為熱量、再者為蛋白質及水溶性維生素)。嬰兒、孕婦、
病人及老人是易受傷害族群，即便提供他們與他人等量的食物，仍可能受到食物攝取不足的影響。因此，若長期熱量及蛋白質攝取不足為必然時，給予
這個族群飲食及營養的支持，成為優先的措施。需要有個系統就定位，能正
確地鑑定出那些人是易感族群，需要特殊的支持，並提供他們所須的食物及營養照護。吃等同於生活，假如易感族群本身能認知食物及營養的重要性，
將可幫助改善全體族群的營養狀況。建議在非緊急期間採取一些措施，如儲
備特殊飲食使用的食物。
關鍵字：攝取不足、營養不良、易感族群、整備、特殊膳食用食物