COMMISSION STAFF WORKING DOCUMENT Addressing Undernutrition in Emergencies Accompanying the document COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT AND THE COUNCIL Enhancing maternal and child nutrition in external assistance: an EU policy framework
Date: 2013-03-12
Institutions: European Commission
Subjects: care of mothers and infants, food safety, humanitarian aid, hunger, least-developed country, malnutrition, undernourishment

EUROPEAN 
COMMISSION 

Brussels, 12.3.2013  
SWD(2013) 72 final 

COMMISSION STAFF WORKING DOCUMENT 

Addressing Undernutrition in Emergencies 

Accompanying the document 

COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN 
PARLIAMENT AND THE COUNCIL 

Enhancing maternal and child nutrition in external assistance: an EU policy framework

{COM(2013) 141 final} 

EN 

   EN 

 
 
 
 
  
 
TABLE OF CONTENTS  

I. 

INTRODUCTION...........................................................................................................................3 

II.  SUMMARY .....................................................................................................................................5 

1 

Background .................................................................................................................................7 
1.1 The scaleof the problem ............................................................................................................................. 7 
1.2 Undernutrition as an increasing global priority ........................................................................................ 8 
1.3 Undernutrition in crises ............................................................................................................................. 9 
2 Scope of Nutrition in Emergencies ................................................................................................10 
2.1 The conceptual framework of undernutrition........................................................................................... 10 
2.2. Recent advances in the management of undernutrition in crises ............................................................ 13 
2.3 Key Challenges in Addressing Undernutrition in Emergencies ............................................................... 14 
3 Objectives, Priorities and Principles of The European  Commission's Assistance to Nutrition 
in Emergencies ...................................................................................................................................16 
3.1 Principal objective ................................................................................................................................... 16 
3.2 Specific objectives .................................................................................................................................... 16 
3.3 Strategic priorities ................................................................................................................................... 16 
3.4 Principles that guide the European Commission's assistance to nutrition in emergencies...................... 17 
4 Operational Scope of Assistance ....................................................................................................19 
4.1 Entry and Exit Criteria............................................................................................................................. 19 
4.2 Additional aspects necessary to achieve the European Commission's Objectives ................................... 20 
5 Programmatic Responses ...............................................................................................................24 
5.1 Health and Nutrition ................................................................................................................................ 24 
5.2 Humanitarian Food Assistance and Nutrition ......................................................................................... 29 
5.3 Water, Sanitation and Hygiene (WASH) and Nutrition............................................................................ 32 
6 Humanitarian and Development Actors' Shared Concerns........................................................34 
6.1 Chronic undernutrition (stunting) in emergencies ................................................................................... 34 
6.2 HIV/AIDS ................................................................................................................................................. 34 
The link between HIV/AIDS and nutrition .....................................................................................35 
6.3 Coherence, Coordination and Complementarity ..................................................................................... 36 

ANNEXES ..............................................................................................................................................39 

List of Abbreviations ............................................................................................................39 
A.1 
A.2 Note on Technical Terms............................................................................................................39 
A.3 Policies and Guidelines in Support of this Staff Working Document ....................................42 

 
 
I. 

INTRODUCTION 

In accordance with the orientation of the Humanitarian Aid Consensus and to promote best practice in 

the  provision  of  humanitarian  assistance  for  nutrition  in  emergencies,  this  Staff  Working  Document 

(SWD)  is  intended  to  complement  Commission  Communication  on  'Enhancing  maternal  and  child 

nutrition  in  external  assistance:  an  EU  Policy  Framework'XXX  to  increase  the  effectiveness  and 

efficiency of humanitarian assistance . In particular, this document seeks to: 

•  Clarify  the  objectives,  priorities  and  principles  of  the  Commission's  humanitarian 

assistance for nutrition with regard to populations facing humanitarian crises;  

• 

Identify  issues  and  approaches  that  enhance  the  effectiveness  of  humanitarian 

assistance  for  nutrition  in  humanitarian  crises  whilst  highlighting  the  necessary 

linkages with longer-term support; 

•  Contribute  to  the  elaboration  of  an  EU  strategic  framework  on  undernutrition  in 

developing countries. 

The  scope  of  this  document  covers  the  support  already  provided  by  the  Commission  to  improve  the 

nutrition  outcomes  of  its  humanitarian  assistance.  It  therefore  embraces  the  multiple  sectors  that 

collectively help avoid a negative nutrition impact in situations of humanitarian crises, including health, 

humanitarian food assistance, and water, sanitation and hygiene responses.  

This  SWD  marks  an  important  step  in  the  process  of  developing  guidelines  for  the  Commission’s 

humanitarian assistance in the area of nutrition. It is also a further step towards elaborating a common 

perspective on principles and priorities that support the integration of nutrition objectives across all the 

sectors of humanitarian assistance. To this end, this SWD explores: The issues and trends that need to 

be  considered  (Section  One);  the  conceptual  framework  and  key  challenges  (Section  Two);  the 

objectives,  priorities  and  principles  driving  humanitarian  assistance  for  nutrition  (Section  Three);  the 

operational  scope  of  assistance,  with  a  focus  on  criteria  for  entry  and  exit  (Section  Four);  the 

programmatic  responses  (Section  Five);  and  shared  concerns  (Section  Six).  The  SWD  also  draws  on 

relevant  experiences  from  the  rapidly  evolving  field  of  humanitarian  assistance  for  nutrition.  Such 

experiences are presented as operational case studies throughout the paper, in order to offer the reader 

valuable technical insights into issues of programming, implementation and coordination. 

3

 
 
 
 
 
Note on Terminology 

A humanitarian crisis is an event or series of events which represents a critical threat to the health, 

safety, security or wellbeing of a community or other large group of people. A humanitarian crisis can 

have  natural  or  manmade  causes,  can  have  a  rapid  or  slow  onset  and  can  be  of  short  or  protracted 

duration.  

The  term  undernutrition  covers  short-term  (acute)  or  long-term  (chronic)  situations,  and  includes 

several  physiological  conditions  which  frequently  co-exist:  i)  wasting  (low  weight  for  height)  and 

nutritional  oedema  (a  form  of  severe  acute  undernutrition);  ii)  stunting  (low  height  for  age,  an 

indicator  of  chronic  undernutrition);  iii)  intrauterine  growth  restriction  which  leads  to  low  birth 

weight; and iv) deficiencies of essential micronutrients. The causes of undernutrition are multiple and 

context-specific.  

The term malnutrition, in its exact meaning, refers to any form of physiological impairment caused 

by the body’s use of nutrients, i.e. overnutrition as well as undernutrition. However, in the past, it has 

been  used  synonymously  with  undernutrition.  It  is  for  this  reason  that  certain  acronyms  denote 

‘malnutrition’ rather than the more correct term ‘undernutrition’ – such as CMAM, GAM, MAM and 

SAM  (community-based  management  of  acute  malnutrition;  global  acute  malnutrition,  moderate 

acute malnutrition; and severe acute malnutrition, respectively).  

(In Annex A, the Glossary provides a fuller description of all technical terms used in this document.) 

4

 
 
 
 
 
 
 
 
II. 

SUMMARY 

More  than  a  third  of  deaths  in  children  under  five  years  old  worldwide  are  attributable  to 
undernutrition. 

An estimated 52 million (8%) children under five years old are wasted. 70% of them lived in 
Asia1.  

Undernutrition  in  childhood  makes  children  more  susceptible  to  diseases  and  prevents  proper 
brain development. Irreversible damages caused by undernutrition of individuals have indirect 
repercussions in terms of loss of national productivity and economic growth.  

Undernutrition  is  an  increasing  global  priority.  In  2008,  the  Lancet  series  on  maternal  and  child 
undernutrition played a crucial role in raising international awareness on undernutrition in developing 
countries. Each year, the European Commission allocates well over EUR 100 million to humanitarian 
assistance  actions  that  are  explicitly  associated  with  specific  nutrition  objectives.  The  allocation  to 
nutrition  interventions  in  the  Commission  Humanitarian  assistance  has  doubled  between  2008  and 
2011. 

Undernutrition and deaths related to undernutrition are largely preventable. Key high impact nutrition 
interventions have been clearly identified. However the commitment, the capacities and the resources to 
scale up the interventions to address undernutrition still lack. Wasting has decreased only by 11% since 
19902.  

Undernutrition is the result of multiple immediate, underlying and structural causes, yielded in various 
sectors:  food  security,  health,  water  and  sanitation,  care  and  their  enabling  environment.  Addressing 
undernutrition requires a multi-sectoral approach and a joint humanitarian and development framework.  

The  present  document  reaffirms  the  Commission's  commitment  to  address  undernutrition  in 
humanitarian crises and sets the framework for these interventions. 

The  Commission's  objective  is  to  reduce  or  avoid  excess3  mortality  and  morbidity  due  to 
undernutrition  in  humanitarian  situations.  EU  humanitarian  policy  is  also  concerned  with 
addressing the immediate and underlying causes of undernutrition.   

In  addition  to  the  humanitarian  principles  of  neutrality,  independence,  impartiality  and  humanity,  the 
Commission  upholds  a  set  of  more  specific  principles  already  outlined  in  its  Communication  on 
Humanitarian Food Assistance4.  

Nutrition interventions need to:  

(cid:131)  Respond to the needs of the individuals the most vulnerable to undernutrition : mothers 

and children under 5; 

(cid:131)  Use  methods  and  tools  which  have  demonstrated  their  efficiency  and  cost-

effectiveness; 

1 2 UNICEF-WHO-WB joint child malnutrition estimates - 2012 

3 "Excess" is considered to combine absolute measures in relation to establish emergency thresholds as defined by 
the SPHERE handbook, UNICEF, and the UN Standing Committee on Nutrition (SCN), and relative measures 
in relation to context-specific baselines, see Communication on Humanitarian Food Assistance 

4  Communication  from  the  Commission  to  the  Council  and  the  European  Parliament  on  Humanitarian  Food 

Assistance COM (2010) 126 

5

 
 
 
 
 
 
 
 
 
 
 
                                                 
 
(cid:131)  Respond to well-defined humanitarian risks as well as immediate emergency needs;  
(cid:131)  Promote  a  multi-sector  approach,  which  is  essential  to  tackle  the  causes  of 

undernutrition; 

(cid:131)  Promote a joint humanitarian and development approach to help build resilience.  

Specifically, in emergency situations Commission interventions strives to:  

(cid:131)  Reduce  levels  of  moderate  and  severe  acute  undernutrition,  and  micronutrient 
deficiencies,  to  below-emergency  rates,  through  timely,  efficient  and  effective 
humanitarian response; 

(cid:131)  Prevent  significant  and  life-threatening  deterioration  of  nutritional  status  by  ensuring 
access  by  crises-affected  populations  to  adequate,  safe  and  nutritious  food,  through 
food and non-food responses depending on the context; 

(cid:131)  Reduce  the  specific  vulnerability  of  infants  and  young  children  in  crises  through  the 
promotion of appropriate child care, with special emphasis on infant and young child 
feeding practices; 

(cid:131)  Reduce  specific  vulnerability  of  pregnant  and  lactating  women  in  crises  through 

appropriate support of maternal nutrition; 

(cid:131)  Address  the  threats  to  the  nutritional  status  of  people  affected  by  crises  from  an 
inadequate  public  health  environment,  by  securing  access  to  appropriate  health  care, 
safe water, sanitation facilities and hygiene inputs. 

Other  areas  of  possible  support  have  been  identified  as  key  to  reach  the  above  objectives,  namely 
information systems, quality programming, capacity building, research and advocacy. However, these 
are neither entry points nor stand-alone activities. 

6

 
 
  
 
 
 
 
 
 
 
1 

Background  

1.1 The scale5of the problem 

The following information illustrates the extent to which undernutrition constitutes a massive crisis in 
its own right – one that is global and persistent in nature. Undernutrition kills thousands of people on a 
daily basis all over the world, including in many countries that are widely considered to be stable and 
on a positive development trajectory.  

•  Although undernutrition is largely preventable, it is the underlying cause of over a third of the 
deaths  of  children  under  five  years  of  age  worldwide,  taking  the  lives  of  an  estimated  three 
million small children and over 100,000 women every year.  

•  Around 52 million (8%) of the world’s children under the age of five are wasted. 70% of them 

are in Asia. Around 165 million (26%) of children suffer from stunting globally.6  

•  Stunting, severe wasting, and intrauterine growth restriction are estimated to be responsible for 
21% of disability-adjusted life years lost. In an analysis that accounted for co-exposure of these 
nutrition-related factors, together they were found to be responsible for about 11% of the global 
disease burden. 

•  Undernutrition also causes sub-optimal physical and cognitive development, lower resistance to 
infections  and  hinders  the  productivity  of  adults,  thereby  lowering  the  economic  potential  of 
societies and perpetuating poverty.  

•  Micronutrient deficiencies, essential for the growth and development of individuals, affect 

almost two billion people worldwide, also in developed countries.  

•  Suboptimum breastfeeding, especially non-exclusive breastfeeding in the first 6 months of life, 
results in 1.4 million deaths and represents 10% of the disease burden among children under the 
age of five. 

•  Progress in the achievement of the relevant Millennium Development Goals (MDG) (1,4 and 5) 

is still slow: 

(cid:190)  MDG 1 ‘Eradicate extreme poverty and hunger’ has shown some progress as extreme 
poverty decreased in every region, even if some regions have seen more progress than 
others.  Hunger  remains  a  global  challenge.  The  most  recent  FAO  estimates  of 
undernourishment  set  the  mark  at  850  million  living  in  hunger  in  the  world  in  the 
2006/2008  period  -  15.5%  of  the  world  population.  This  continuing  high  level  of 
undernourishment  reflects  a  lack  of  progress  on  hunger  reduction  in  several  regions, 
even where income poverty has decreased. 

(cid:190)  Although MDG 4 ‘Reduce Child Mortality’ has gained momentum, progress is still too 
slow  to  meet  the  target:  Sub-Saharan  Africa  and  Oceania  have  experienced  child-
mortality  reductions  of  only  around  30%,  less  than  half  of  what  is  required  by  the 
MDG. Southern Asia is also lagging behind with a 44% decline in the child mortality 
rate between 1990 and 2010 - insufficient to achieve a two-third reduction by 2015.  
(cid:190)  MDG 5 ‘Improve maternal health’ has shown progress as maternal mortality has nearly 
halved since 1990. Nonetheless, current maternal mortality levels are still far from the 
target set for 2015. An estimated 287,000 maternal deaths occurred in 2010 worldwide, 
indicating  a  47%decline  from  1990  levels.  Sub-Saharan  Africa  (with  56  percent  of 

5 Unless otherwise stated, figures presented in this section are from the first paper in the Lancet series: Black R.E. 
et al. (2008): Maternal and Child Undernutrition: Global and regional exposures and health consequences. Lancet 
371, 243-260. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61690-0/fulltext. 
6UNICEF-WHO-The World Bank joint child malnutrition estimates (2012) 

7

 
 
 
 
 
                                                 
these  deaths)  and  South  Asia  (29  percent)  together  accounted  for  85%    of  the  global 
burden in 2010, with a joint total of 245,000 maternal deaths.7 

1.2 Undernutrition as an increasing global priority 

In  recent  years,  and  with  the  growing  realisation  of  its  significance  in  terms  of  MDG  progress, 
considerable advancement has been made in re-energizing the fight against undernutrition. As a result, 
new  strategies  and  initiatives  for  tackling  undernutrition  in  developing  countries  are  underway  in 
several EU member states.8 

Due attention should also be devoted to recent publications9 presenting evidence on the most effective 
interventions to address undernutrition. In particular, a landmark publication in The Lancet in January 
2008  (five  papers,  referred  to  as  the  Lancet  Series,  cited  above),  gave  new  momentum  to  the  fight 
against  undernutrition.  Much  of  this  momentum  is  embodied  in  the  Scaling  up  Nutrition  movement 
(SUN).10  This  initiative  aims  to  build  a  multi-stakeholder  and  multi-sectoral  alignment  to  support 
national-level strategies and efforts to address undernutrition. 

Each year, the Commission allocates well over EUR100 million to humanitarian assistance actions that 
are explicitly associated with specific nutrition objectives. This funding supports nutrition interventions 
in  emergency  contexts  implemented  by  United  Nations  Agencies,  the  Red  Cross/Red  Crescent 
Movement  and  International  Non-Governmental  Organisations.  Furthermore,  the  promotion  of  more 
effective nutrition outcomes in all response sectors is increasingly recognised as a core priority. 

The  Commission  has  adopted  a  Communication  on  Humanitarian  Food  Assistance2  which  addresses 
undernutrition  concerns  associated  with  inadequate  food  consumption.  The  Commission  has  also 
adopted  two  other  Communications11  (one  on  health  and  one  on  food  security)  that  call  for  more 
comprehensive strategies to tackle undernutrition and for a strengthened link between health and food 
security (both transitory and chronic) to bring about more effective responses. 
Furthermore,  a  Commission  Reference  Document  on  Addressing  Undernutrition  in  External 
Assistance12 was adopted, providing practical guidance on how nutrition objectives can be incorporated 
into different sectors, thematic areas and funding modalities. 

7 http://mdgs.un.org/unsd/mdg/Resources/Static/Products/Progress2012/English2012.pdf 

8For instance: ‘The neglected crisis of undernutrition: DFID’s Strategy’ 

(http://collections.europarchive.org/tna/20100423085705/http://dfid.gov.uk/Documents/publications/nutrition
-strategy.pdf); the French government strategy: ‘Nutrition dans les Pays en Développement — Document 
d’Orientation Stratégique’ (www.diplomatie.gouv.fr/fr/ministere_817/publications_827/enjeux-planetaires-
cooperation-internationale_3030/documents-strategie-sectorielle_20004/les-pays-developpement-nutrition_12 
87987.html); Ireland’s Hunger Envoy Report 2010 
(http://www.irishaid.gov.ie/uploads/Hunger_Envoy_Report.pdf); and Germany’s strategy Rural Development 
and its Contribution to Food Security, 2011 
(http://www.bmz.de/en/publications/type_of_publication/strategies/Strategiepapier302_01_2011.pdf)  

9  For  example:  World  Bank  2010:  Scaling  up  Nutrition.  What  will  it  Cost?  By  S.  Horton  et  al.  and  Save  the 
Children 2009: Hungry for Change. An eight-step, costed plan of action to tackle global child hunger. 
10http://www.scalingupnutrition.org/  

11The EU Role in Global Health (COM(2010)128) and An EU policy framework to assist developing countries in 
addressing food security challenges (COM(2010)127)  
12 Reference document n°13 "Addressing undernutrition in external assistance" 

http://capacity4dev.ec.europa.eu/topic/fighting-hunger 

8

 
 
 
                                                 
In  addition,  the  recently  renegotiated  Food  Assistance  Convention13  reflects  the  nutritional  aspects  of 
food assistance and effectively integrates nutrition in its principles and objectives. 

1.3 Undernutrition in crises  

Crisis situations, whether acute or protracted, impact on a range of factors that can increase the risk of 
undernutrition, morbidity and mortality. They may involve: the large-scale destruction of property and 
infrastructure; the erosion of livelihood strategies and purchasing power; a breakdown of and reduced 
access to essential services including health services, water supply and sanitation; and displacement of 
large numbers of people. Emergencies  can also disrupt social systems and the quality of care/feeding 
practices.  Household  access  to  food  may  be  negatively  affected  and  people  may  find  themselves  in 
over-crowded settlements with their families being divided. As a result, at the individual level, there is 
often an increased risk of deteriorating health and nutritional status, resulting in a greater likelihood of 
death (see Figure 1: Conceptual framework).  

Young children and pregnant and lactating women are particularly vulnerable to undernutrition from a 
physiological point of view, due to their increased nutrient requirements for growth and development. 
Young children are also exposed to a higher risk (compared to other population groups) of contracting 
infections, which can further increase  nutrient requirements, impede nutrient use and reduce appetite. 
For this reason, young children often demonstrate the fastest nutritional deterioration in crisis contexts, 
as well as the highest rates of disease and undernutrition-related mortality. Young children are therefore 
considered  a  primary  target  group  for  assistance.  Furthermore,  older  and  disabled  people,  as  well  as 
people  living  with  chronic  illness  such  as  HIV  and  AIDS  may  also  suffer  from  reduced  appetite, 
difficulties in chewing and difficulties in accessing food, which increase their nutritional vulnerability.  

Gender  also  plays  an  important  role  in  determining  individual  vulnerability  to  undernutrition. 
Women/girls and men/boys face different risks in relation to the deterioration of their nutritional status 
during crises as a consequence of both their different nutritional requirements and a variety of socio-
cultural factors related to gender:  

•  Undernutrition has particularly serious consequences for women, as stunted women face higher 
risks  of  complications  during  childbirth;  Anaemia  (the  most  widespread  nutritional  problem 
affecting girls and women in developing countries) is responsible for a significant proportion of 
maternal mortality. 

•  Maternal acute undernutrition is associated with intrauterine growth restriction and constitutes a 

risk factor for poor neonatal health. 

•  Undernutrition has an intergenerational cycle, as undernourished adolescent and adult mothers 
are  more  likely  to  give  birth  to  low  birth-weight  babies.  This  in  turn,  increases  the  risk  of 
undernutrition in early childhood. 

Gender and nutrition vulnerability during crises  

•  When  food  is  in  short  supply,  women  and  girls  are  more  likely  to  reduce  (voluntarily  or  as  a 
result  of  external  pressure)  their  intake  in  favour  of  other  household  members,  thus  worsening 
their own nutritional status. 

•  Women may face constraints in accessing essential humanitarian services as a result of insecurity, 

cultural discrimination and limited mobility. 

•  Pregnant  and  lactating  women  are  particularly  exposed  to  undernutrition  due  to  their  increased 

13 Document “Food Assistance Convention – 25 April 2012” 

9

 
 
 
 
                                                 
physiological requirements. 

•  While  remaining  the  primary  caregivers  of  children  and  other  dependents,  women  undertake 
additional  activities  during  crises,  particularly  where  male  heads  of  households are  absent.  This 
often leads to the disruption of infant and young child feeding practices and care. 

•  Men  who  are  single  heads  of  households  may  be  removed  from  their  normal  support  structures 
during  crises  and  if  they  do  not  know  how  to  cook  or  care  for  young  children,  this  results  in  a 
greater risk of acute under-nutrition for themselves and their children. 

2 Scope of Nutrition in Emergencies  

2.1 The conceptual framework of undernutrition 

There are numerous possible causes of undernutrition, many of which impact on both acute and chronic 
undernutrition.  These  causes  are  usually  analysed  at  three  levels:  immediate,  underlying  and  basic. 
These three levels are based on the conceptual framework developed by UNICEF in the 1990s, which is 
still regarded as a valuable guideline today (see Figure 1). 

The humanitarian assistance for nutrition provided by the Commission is primarily aimed at preventing 
and  alleviating  the  short-term  consequences  of  maternal  and  child  undernutrition  by  addressing  their 
immediate and underlying causes at the individual and household levels. 

• 

Immediate  causes  are  to  be  found  at  the  individual  level  and  have  two  dimensions:  dietary 
intake  and  the  presence  of  diseases.  This  distinction  emphasises  the  limitation  of  the  term 
‘hunger’  in  denoting  undernutrition,  as  hunger  may  or  may  not  be  a  cause  of  undernutrition. 
The  Commission's  humanitarian  interventions  address  immediate  causes  of  undernutrition  by 
providing  immediate  access  to  food,  in  order  to  improve  food  intake,  and  free  access  to  life-
saving healthcare. 

•  Underlying  causes  operate  at  the  household  and  community  levels.  They  comprise  three 
categories:  (i)  household  food  security,  (ii)  care  for  children  and  women  and  (iii)  health 
environment  and  health  services.  Income  poverty  affects  all  three.  Household  food  insecurity 
can  be  alleviated  through  measures  aimed  at  durably  increasing  household  food  availability, 
accessibility  (e.g.  purchasing  power)  and  utilisation  (e.g.  cooking).  Inadequate  care  practices 
can  be  addressed  through  measures  aimed  at  ensuring  maternal  nutrition  and  appropriate  and 
regular  feeding  of  infants  and  young  children,  as  well  as  providing  safe  feeding  spaces. 
Unhealthy  environments  can  be  addressed  through  water,  sanitation  and  hygiene  measures  as 
well as through the provision of accessible health services  and disease  control  measures (e.g. 
long-lasting insecticide-treated mosquito nets, environmental interventions). 

•  Basic causes include a range of factors operating at the sub-national, national and international 
levels, ranging from the availability of natural resources, to social and economic environments, 
to  political  contexts.14  Basic  causes  that  are  linked  to  political,  cultural,  religious,  economic, 
educational,  demographic,  and  social  systems  can  only  be  addressed  through  long-term 
development strategies. 

Undernutrition  therefore  has  to  be  understood  as  a  multi-sectoral  challenge,  requiring  a  sound 
understanding of the specificities of each context of intervention.  

14 Source: Reference Document n° 13 "Addressing undernutrition in external assistance" 

10

 
 
 
 
 
                                                 
Figure  1:  Conceptual  Framework  of  Malnutrition  showing  the  relationship  between  poverty, 
food insecurity, and other causes of maternal and child undernutrition  

Child malnutrition, 
death and disability 

Manifestations  
of the problem

Inadequate dietary 
intake

Disease 

Immediate causes 
at individual level 

Insufficient 
access 
to food 

Inadequate 
 maternal and 
child-care 

Poor water/ 
sanitation and 
inadequate health 
services

Underlying causes 
at household / 
community level 

Inadequate and/or 
inappropriate knowledge and 
discriminatory attitudes limit 
household access to actual 
resources 

Quantity and quality of actual resources — 
human, economic and organisational — and 
the way they are controlled 

Basic & structural 
causes at community 
/ national / 
international levels  

Potential resources: environment, 
technology, human resources 

Political, cultural, religious, economic 
and social systems, including women’s 
status, limit the utilisation of potential 
resources 

Source: The State of the World's Children, UNICEF 1998 

Figure  2:  The  underlying  causes  of  undernutrition  (adapted  from  the  Communication  on 
Humanitarian Food Assistance) 

Household Food Insecurity 
Lack of safe access to adequate 
and safe food throughout the 
year through: 

•  Food production 
•  Purchase/barter 
•  Gifts, other sources 
•  Food safety and quality 
•  Cash transfers 

Inadequate Care 

•  Maternal nutrition 
•  Maternal Care (workload, 
gender imbalance etc.) 

•  Child care 
•  Infant and young child 

feeding 

•  Eating habits 
•  Food preparation 
•  Intra-household food 

distribution 

•  Capacity to care for 

dependent individuals 

Unhealthy Household 
environment and lack of health 
services 

•  Water quality and quantity 
•  Hygiene and sanitation 
•  (Free) access to and use 

of health services 

11

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2.2. Recent advances in the management of undernutrition in crises 

The following important developments in recent years have taken place: 

(i)     The  publication  of  new  WHO  growth  standards  (2006),  based  on  the  growth  of  children 
under  conditions  of  optimal  nutrition  and  health  from  a  variety  of  countries,  provides  a 
better tool for diagnosing undernutrition, and defining and identifying nutritional risk and 
nutritional needs. 

(ii)     The  emergence  and  expansion  of  Community-based  Management  of  Acute  Malnutrition 
(CMAM).  Extensive  evidence  is  now  available  on  the  heightened  efficiency  and 
effectiveness of such approach compared to models that only offer inpatient treatment. This 
is  linked  to  an  improvement  in  the  identification  of  cases  and  in  the  mobilization  of 
communities around situations of undernutrition, as well as to a reduction in the barriers to 
accessing treatment as a result of better resourced and managed programmes.  
This  approach  uses  a  new  classification  of  severe  acute  malnutrition  (SAM),  which 
categorises  children  either  as  suffering  from  SAM  with  complications  or  without 
complications,  based  on  clinical  symptoms.  The  latter  can  be  treated  as  outpatients  with 
ready-to-use  therapeutic  foods  (RUTF),  while  children  with  medical  complications  are 
treated  following  specialised  medical  protocols  through  the  administration  of  therapeutic 
milk in inpatient facilities. 

(iii)    An  increasing  focus  on  the  quality  of  food  inevitably  contributes  to  nutritional 
improvements.  The  adaptation  of  therapeutic  milk  into  RUTF,  and  the  development  of 
improved formulae of fortified blended foods and specialized ready-to-use supplementary 
foods (RUSF) are playing a key role in this sense. Use of these products has been extended 
into other areas such as the treatment of moderate acute undernutrition, the prevention of 
undernutrition,  the  nutritional  rehabilitation  of  acutely  ill  patients,  etc.  Such  advances 
provide an opportunity for the development and adaptation of new intervention strategies. 

(iv)    The  recognition  that  children  under  five  years  of  age  constitute  the  most  vulnerable  age 
group  in  terms  of  acute  malnutrition.  Although  in  humanitarian  settings  the  provision  of 
assistance  should  be  guaranteed  to  all  nutritionally-vulnerable  age  groups,  particular 
emphasis should be given to children under five years of age.  

(v)       The  understanding  that  the  period  between  conception  and  2  years  of  age  is  crucial  in 
defining  the  future  nutrition  and  health  status  of  the  individual.  This  period  provides  a 
critical  window  of  opportunity  in  which  the  impact  of  interventions  to  improve  maternal 
and child undernutrition - including measures to improve micronutrient intake in the under 
twos (U2s) - on the survival, growth and development of young children is maximised 15.  

(vi)    A  focus  on  population-based  strategies  to  prevent  moderate  undernutrition  is  combined 
with  more  common  interventions  targeting  individuals.  These  range  from  blanket 
distributions  of  (fortified)  supplementary  foods  to  social  protection  schemes  such  as  cash 
transfers.  For  example,  there  is  increasing  evidence  of  the  value  of  integrating  household 
and  community  food  security  and  livelihood  support  with  nutrition  rehabilitation 
interventions. At the same time, access to free medical services has also proved to have a 
great impact on nutrition, as nutrition security is not exclusively linked to food security. 

15

 However, this understanding has served to highlight the opportunities for enhanced synergies with longer-term efforts by 

the Commission to prevent undernutrition, by underscoring the crucial requirement to intervene both to save lives and to avoid 

long-term  adverse  outcomes  for  this  age  group.  This  understanding  has  also  heightened  attention  to  potential  evidence 

regarding specific challenges that can be associated with ensuring access to nutritional assistance for  children under two years 

of age. 

12

 
 
 
                                                 
 
(vii) 

The  standardisation  of  survey  methods  to  assess  the  prevalence  of  undernutrition  in 
emergencies,  in  particular  the  Standardized  Monitoring  and  Assessment  of  Relief  and 
Transition (SMART) methodology, and progress towards new survey techniques to assess 
programme coverage (e.g. SQUEAC). 

(viii)  The recognition of the importance of acute undernutrition in non-emergency contexts such 
as areas with persistently high levels of undernutrition in the long term, or during ‘seasonal 
hunger  gaps’,  and  of  the  need,  therefore,  to  integrate  undernutrition  prevention  and 
treatment  into  national  food  security  and  healthcare  systems,  as  well  as  cross-sectoral 
development planning. 

(ix)      A  consensus  on  the  importance  of  Infant  and  Young  Child  Feeding  practices  in 
Emergencies  (IYCF-E) in  order to save lives and improve health and the development of 
children.  This  includes  measures  that  assess  the  IYCF-E  context;  the  integration  of 
breastfeeding  and  IYCF-E  support  into  other  services  for  mothers,  infants  and  young 
children; and the provision of food that is suitable for infants and young children. Although 
the  promotion  of  breastfeeding  is  a  priority,  in  certain  humanitarian  situations  it  is 
preferable  to  support  formula  feeding.  The  importance  of  preventing  and  avoiding 
donations of breast-milk substitutes, bottles, teats and other milk products in emergencies is 
also recognised.  

(x)     There are several key areas where progress has been made which, despite not being 'new', 
have a bearing on how undernutrition should be managed in crisis contexts. These include: 
a  better  understanding  of  the  multifaceted  causes  of  undernutrition,  the  identification  of 
links between HIV and Tuberculosis and nutrition/undernutrition, the identification of the 
benefits  of  a  holistic  multi-sectoral  approach  and  a  heightened  understanding  of  the 
importance of tackling micronutrient deficiencies in the management of undernutrition and 
in the improvement of health conditions. 

2.3 Key Challenges in Addressing Undernutrition in Emergencies 

The  following  list  presents  the  key  challenges  to  be  faced  when  addressing  undernutrition  in 
emergencies: 

•  Good coordination, which requires effective leadership and the establishment of mechanisms 
to  build  consensus  for  an  appropriate  and  context-specific  strategy.  Such  a  strategy  must  be 
able  to  ensure  multi–sectoral  capacities  and  commitment  to  clearly  identified  nutrition 
objectives.  

•  Accurate analysis of the causes of undernutrition and interpretation of information from 
multiple  sectors  including  gender  and  age  disaggregated  indicators  of  food  and/or  nutrition 
security,  to  feed  into  timely  and  appropriate  responses.  Challenges  include  the  absence  of 
regular  and  reliable  monitoring  mechanisms  for  nutritional  status,  especially  in  areas  where, 
despite  SAM  being  a  persistent  or  recurrent  concern,  it  is  not  adequately  recognised  or 
addressed by concerned governments or development partners. 
skilled 

•  Availability 

resources 

(human 

human 

of 

resources                        

shortage)  and  strengthened  capacity  to  respond  to  nutrition  emergencies  (emergency 
preparedness). 

•  Promotion  and  scaling-up  of  effective  interventions  such  as  community-based  approaches 
for the prevention and management of acute undernutrition, while ensuring adequate attention 
and resources for other crucial sectoral response options. 

•  Promotion of quality management of humanitarian assistance for nutrition through evidence-
based decision-making and implementation. This requires cross-sectoral approaches; collection 
and  analysis  of  gender  and  age  disaggregated  data;  innovations  in  programme  design 

13

 
 
 
(including,  for  example,  adapting  effective  local  practices);  sound  management;  good 
documentation; and investment in research to fill evidence gaps. 

•  Ensuring a gender-sensitive approach to the assessment of needs and nutrition programming, 
particularly  in  the  areas  of  community  consultation  and  participation,  awareness  raising  and 
nutrition education. 

•  Contributing  to  efforts  to  build  an  evidence  base,  in  order  to  assess  the  impact  of 
interventions;  development  and  dissemination  of  new  survey  methods  that  are  easier  to 
undertake  in  difficult  contexts;  diagnostic  tools  to  analyse  micronutrient  deficiencies  without 
requiring  sophisticated  laboratory  analyses;  and  treatment  of  infant  acute  undernutrition  in 
emergencies.  

•  Measuring  impact  in  relation  to  reducing  and  preventing  undernutrition  and  mortality  in 
emergencies  and  drawing  lessons  to  inform  future  responses.  The  absence  of  standardised 
reporting  mechanisms  for  programme  performance  (including  programme  coverage)  is  an 
important constraint on impact monitoring. 

•  Taking advantage of the opportunities and resources that humanitarian assistance can bring to 
strengthen national capacity for the prevention and management of undernutrition – while at 
the  same  time  striving  to  secure  long  term  strategic  planning  and  investment  in  capacity-
strengthening. 

•  Ensuring long-term, sustained support from development actors for tackling undernutrition 

prior to, during and after an emergency.  

•  Developing a holistic and integrated approach to undernutrition 
•  Ensuring  availability  of  appropriate  capacities  for  sectoral  and/or  multi-sectoral 

coordination in addressing both existing and upcoming needs 

In  the  sections  below,  these  challenges  will  be  further  discussed  and  emerging  experience  regarding 
how best to address them will be presented to chart the road ahead. 

14

 
 
 
3 OBJECTIVES, PRIORITIES AND PRINCIPLES OF THE 
COMMISSION'S ASSISTANCE TO NUTRITION IN EMERGENCIES 

Considering  all  these  recent  developments  and  challenges,  and  building  on  existing  policies,  the 
Commission  identifies  the  following  objectives,  priorities  and  principles  for  its  work  on  nutrition  in 
emergencies. 

3.1 Principal objective 

The  principal  objective  is  to  reduce  and  avoid  excess  mortality  and  morbidity  caused  by 
undernutrition in humanitarian situations. 

3.2 Specific objectives 

The principal objective is to be achieved through the following specific objectives: 

•  To  reduce  levels  of  moderate  and  severe  acute  undernutrition  to  below-emergency  rates,  and 
prevent/correct micronutrient deficiencies through timely, efficient and effective humanitarian 
responses. 

•  To  prevent  significant  and  life-threatening  deterioration  of  nutritional  status  by  safeguarding 
the  availability  of,  access  to  and  consumption  of  adequate  safe  and  nutritious  food  while 
protecting livelihoods and promoting conditions for the restoration of self-reliance. 

•  To  reduce  the  threats  to  the  nutritional  status  of  people  affected  by  crises  stemming  from  an 
inadequate public health environment, by securing access to appropriate healthcare, safe water, 
sanitation facilities and hygiene inputs. 

•  To  reduce  the  specific  vulnerability  of  infants  and  young  children  in  crises  through  the 
promotion of appropriate child care, with special emphasis on infant and young child feeding 
practices. 

•  To  reduce  the  specific  nutrition  vulnerability  of  pregnant  and  lactating  women/women  of 

reproductive age.16  

•  To  reduce  the  specific  nutrition  vulnerability  of  most  affected  groups  (such  as  the  elderly, 

disabled, HIV- positive, children over five, and adolescents). 

•  To strengthen the capacities of the international humanitarian aid system to enhance efficiency 

and effectiveness in the delivery of humanitarian assistance for nutrition. 

3.3 Strategic priorities 

In  populations  affected  by  emergencies,  the  priority  focus  is  on  acute  (moderate  and  severe) 
undernutrition, which is associated with a higher risk of mortality and morbidity.  
In  line  with  the  above  objectives,  the  Commission  responds  to  underrnutrition  and  its  causes  in 
emergencies by funding interventions that meet the following strategic priorities:  

i) Interventions to treat MAM and SAM  

ii)  Interventions  through  the  nutrition,  health  and  food  assistance  sectors  that  tackle  the 
immediate causes of undernutrition (inadequate dietary intake and disease);  

16 Note: Throughout this document, where reference is made to pregnant and lactating women and their associated 
physiological  nutrition  vulnerability,  it  is  acknowledged  that  this  overlaps  considerably  with  the  nutrition 
vulnerability  of  ‘women  of  reproductive  age’  and  ‘adolescent  girls’  and  that  such  considerations  can  have 
significant operational implications. 

15

 
 
 
                                                 
iii)  Interventions  through  the  nutrition,  health,  food  assistance  and  WASH  (water,  sanitation 
and  hygiene)  sectors  that  tackle  the  underlying  causes  of  undernutrition  (food  insecurity, 
inadequate care practices and inadequate access to healthcare and environmental health);  

iv)  Integration  of  nutrition  interventions  within  an  overall  resilience  strategy  in  coordination 
with development partners. 

3.4 Principles that guide the Commission's assistance to nutrition in emergencies 

In pursuit of the above-mentioned objectives, the following principles underscore the Commission's 
support to nutrition in humanitarian situations: 

i)  The  nutrition  interventions  aiming  at  treating  and  preventing  undernutrition  are  based  on 
individual needs. The individual nutritional status is assessed using standard methods, measures 
and  threshold.  The  preventive  interventions  and  indirect  interventions  on  the  causes  of 
undernutrition  are  based  on  appropriate  needs  assessment,  using  standard  indicators  such  as 
GAM and SAM prevalence, access to food and access to basic health care.  

ii)  The  choice  of  the  most  appropriate  intervention(s)  and  instrument(s)  must  be  based  on 
evidence:  the  needs  assessment,  the  nutrition  causal  analysis,  the  context  analysis  and  the 
response  analysis.  The  design  of  any  response  should  compare  alternative  activities  and 
modalities on the basis of cost-effectiveness for meeting identified needs. Interventions should 
be regularly reviewed on the basis of local dynamics and situation changes.  

iii)  Nutrition  interventions  respond  to  well  defined  humanitarian  risks.  They  are  targeting 
individuals particularly vulnerable to mortality and morbidity related to undernutrition: children 
under 5, the pregnant and lactating mothers, elderlies and chronically ill.  

iv)  Understanding the causes of undernutrition and enabling environment is crucial to identify the 
appropriate  combination  of  activities  to  address  undernutrition  and  its  causes.  Causes  of 
undernutrition  are  often  multiple.  Adopting  a  multi-sector  approach  and  coordinating 
humanitarian and development actions are thus essential. 

v)  The Commission seeks to incorporate systematically gender perspectives into its humanitarian 
nutrition  assessments.  It  also  considers  the  gender  implications  of  its  emergency  nutrition 
interventions,  recognising  the  importance  of  gender  roles  in  caring  and  feeding  practices, 
livelihoods, the use and allocation of food at household level, and beneficiaries' utilisation of 
food assistance resources. 

vi)  Nutrition assistance upholds the principles of  Linking Relief Rehabilitation and Development 
(LRRD). Where possible and appropriate, the Commission works with its development partners 
to  maximise  the  sustainability  of  interventions  by  promoting  their  integration  into  national 
policy  frameworks  and  plans  (e.g.  in  health  policy,  emergency  response  plans,  national 
protocols for the treatment of undernutrition, etc.).  

vii) The Commission strives to do no harm through its humanitarian assistance for nutrition. This is 
especially important in relation to the safety of innovations and the use of specialized nutrition 
products. The Commission always ensures that all available evidence is considered fully, and 
that the best interests of the beneficiaries remain central.  

viii) The  Commission  promotes  those  practices  that  are  efficient  and  effective  in  managing 
undernutrition.  The  care  given,  quality  of  food  products  used  and  reliability  of  information17 

17 For example, high case-fatality rates of severe acute undernutrition have been attributed to inappropriate case 
management and poor knowledge of medical staff. Wider implementation of the WHO guidelines through in-
service training and incorporation into medical and nursing curricula is the key to substantially decreasing case-
fatality rates of SAM. Collins S. et al. Management of severe acute malnutrition in children. The Lancet, Vol. 368 

16

 
 
 
                                                 
 
that  guides  programme  design  follow  international  standards  –  such  as  Sphere,  WHO,  or 
guidance from the Global Nutrition Cluster. 

(9551), page 1992-2000, 2 December 2006. http://www.thelancet.com/journals/lancet/article/PIIS0140-
6736(06)69443-9/abstract 

17

 
 
                                                                                                                                                          
4 OPERATIONAL SCOPE OF ASSISTANCE 

4.1 Entry and Exit Criteria  

In  line  with  the  Commission’s  Communication  on  Humanitarian  Food  Assistance,  the  Commission 
follows the entry and exit criteria for operations outlined below, always mindful of the commitment to 
supporting appropriate transition through LRRD (Linking Relief, Rehabilitation and Development).  

Entry criteria for operations 

•  The  Commission  may  trigger  nutrition  support  when  emergency  rates  of  mortality  or  acute 
undernutrition  (U5  mortality  rate  >2/10,000/day,  GAM  >15%,  and  GAM  rates  >10%  with 
aggravating  factors)  have  been  reached  or  exceeded,  or  are  anticipated,  on  the  basis  of  firm 
forecasts. Such “anticipation” should be based on early warning indicators that show a critical 
deterioration in the food security and/or health environment, which, unless responded to, will 
become  life-threatening  within  a  timeframe  that  is  consistent  with  the  Commission's 
humanitarian remit. 

•  Recognizing  that  a  food  crisis  sometimes  begins,  calling  for  a  reaction  before  the  nutritional 
status  deteriorates  further,  the  Commission  does  not  necessarily  wait  for  rising  rates  of  acute 
undernutrition  before  providing  humanitarian  food  assistance  and  nutritional  support,  and 
respond to well-defined humanitarian risks that pose a threat to life. The Commission does not 
require a formal disaster declaration in order to respond to an emergency. 

• 

• 

In  considering  whether  and  how  to  respond  to  a  given  crisis,  the  Commission  pays  close 
attention to the comparative advantages and disadvantages of the humanitarian instruments at 
its disposal. This requires: a careful analysis of the existing needs and the causes of the crisis; a 
consideration of the type of response that will address those needs in the most appropriate way 
without causing any harm; and a close review of the alternative assistance mechanisms that are 
available.  

In  this  regard,  the  Commission's  humanitarian  assistance  does  generally  not  respond  to 
permanently  high  levels  of  undernutrition  (whether  stunting,  wasting  and/or  micronutrient 
deficiencies) except where non-intervention poses an imminent humanitarian risk of significant 
scale and severity and where other more appropriate actors are either unable or unwilling to act, 
and cannot be persuaded to act; and where, in spite of its comparative disadvantages, positive 
impact can be expected within the time limitations of the intervention by the Commission. In 
such  cases,  the  delivery  of  humanitarian  assistance  for  nutrition  is  anticipated  by  advocacy, 
dialogue and appropriate coordination with relevant development actors. 

Exit criteria for operations 

•  The Commission considers phasing out its humanitarian nutrition assistance when indicators of 
acute  undernutrition  and  related  mortality  are  stabilised  below  emergency  levels,  or  are 
expected  to  stabilise  there  in  the  foreseeable  future,  independently  of  the  Commission's 
humanitarian support.  

•  The  Commission  also  considers  phasing  out  or  transitioning  its  humanitarian  support  where 
non-humanitarian  players  (e.g.  State  or  development  actors)  are  able  to  respond  to  the 
nutritional needs of the populations at risk, therefore mitigating the level of humanitarian risk 
associated with withdrawal; or when the humanitarian needs of the population are fully covered 
by other humanitarian donors and actors. 

•  The  Commission,  at  all  times,  evaluates  its  humanitarian  exit  strategies  on  the  basis  of  its 
comparative  advantage  relative  to  other  actors.  The  Commission  seeks  to  avoid  creating 
disincentives to the engagement of other actors  by delaying its own exit. It advocates instead 

18

 
 
 
 
 
for  other,  more  appropriate,  actors  across  the  relief  and  development  spectrum  to  respond, 
according to the specific context and needs. 

•  The Commission also considers exiting from humanitarian nutrition assistance operations when 
its  core  principles  cannot  be  respected,  particularly  if  the  risk  of  doing  harm  outweighs  the 
potential benefits of remaining engaged. 

4.2 Additional aspects necessary to achieve the Commission's Objectives 

The Commission's humanitarian  mandate, its capacity and priorities all give it a specific comparative 
advantage  to  respond  to  the  above-mentioned  undernutrition  challenges  in  crises.  The  Commission 
recognises, however, that in order to achieve the greatest benefits in terms of improved nutrition, it is 
also necessary to address two other persistent challenges in emergencies:  

i) The production of reliable information to guide decisions, with special emphasis on situation and 
response analyses that are sensitive to gender and age-related inequalities; and 

ii) The strengthening of capacities for efficient and effective delivery of humanitarian assistance for 
nutrition. 

These  two  areas  are  therefore  included  here  so  as  to  enable  the  achievement  of  the  Commission's 
objectives. However, they are not included as stand-alone areas or entry points for response.  

4.2.1 Information Systems 
Where  they  exist,  health,  nutrition  and  food  security  information  systems  regularly  collect  nutrition 
information (including anthropometric  data) that can be used in decisions about policies and/or guide 
strategies and monitor interventions 

Such  information  systems  require  long-term  support,  with  national  or  regional  ownership  and  careful 
consideration  of  economic  and  political  perspectives.  It  is  therefore  imperative  that  any  humanitarian 
support in this area is coherent with a longer term strategy by the Commission and/or other donors and 
national systems.  

The  closely  related  activities  of  situation  analysis  (including  nutrition  causal  analysis)  and  response 
analysis are crucial in securing the overall effectiveness of an intervention.  

The  Commission  recognises  the  value  of  applying  a  nutrition  ‘lens’  to  assessments,  problem  and 
response analysis, as well as to the monitoring and evaluation of all multi-sectoral projects. 

The Commission facilitates the integration of nutrition data into other information systems and projects, 
such as the IPC project (Integrated Food Security Phase Classification),18 while continuing its support 
to the Household Economy Approach in relation to the Cost of Diet analysis.19  

Finally, gender analyses should be integrated in any situation and response analysis, and it is crucial to 
ensure that specific capacities are in place to achieve this goal. 

18 http://www.ipcinfo.org/ 
19http://www.savethechildren.org.uk/resources/online-library/the-household-economy-approach-a-guide-for-

programme-planners-and-policy-makers; 
cost-of-the-diet 

http://www.savethechildren.org.uk/resources/online-library/the-

19

 
 
 
 
 
 
                                                 
THE SIGNIFICANCE OF GENDER ANALYSIS IN THE PLANNING OF HUMANITARIAN ASSISTANCE FOR 

NUTRITION 

The  commitment  to  strengthening  a  gender-sensitive  approach  is  enshrined  in  the  European 
Consensus  on  Humanitarian  Aid  which  highlights  the  importance  of:  (i)  integrating  gender 
considerations,  (ii)  incorporating  protection  strategies  against  sexual  and  gender-based  violence, 
and (iii) promoting the active participation of women in humanitarian assistance. 
Rationale: Crisis situations, whatever their cause,  are not gender neutral. Women, girls, boys and 
men face different risks of deterioration in their nutritional status. These different vulnerabilities are 
related  both  to  their  differing  physiological  nutrition  requirements  and  to  socio-cultural  factors 
related to gender.20  
Why  gender  and  age  matter:21  Gender-blind  actions  are  less  effective  because  they  neglect  the 
diversity  of  needs,  capacities  and  coping  mechanisms  of  different  groups  of  beneficiaries.  Good 
nutrition programming must take due account of gender issues at all stages of the project cycle. In 
particular,  there  must  be  attention  to  ensuring  a  gender  perspective  in  situation  and  response 
analysis.  Experience  shows  that  poor  child  feeding  practices,  lack  of  access  to  health  services, 
economic and livelihood insecurity, cultural practices and gender inequality more broadly tend to 
be  inadequately  incorporated  into  national  vulnerability  analyses  and  strategic  programming.  A 
gender analysis is undertaken to better understand the division of roles, responsibilities, constraints 
and access to resources,  mobility, specific vulnerabilities, needs and risks faced by women, girls, 
boys and men, including sexual and gender-based violence. 

To  maximise  the  quality  and  effectiveness  of  nutrition-related  interventions,  the  Commission 
emphasises  the  value  of  utilising  the  full  project  management  cycle:  needs  assessment,  response 
analysis,  planning  (programme  identification),  appraisal,  financing,  implementation,  and  monitoring 
and evaluation.22  

The Commission, especially in crisis-prone countries, pays specific attention to the collection of quality 
nutrition  data,  and  promotes  implementation  of  nutritional  assessments  according  to  standardised 
methodologies.23  Such  assessments  may  include,  other  than  anthropometry,  data  that  will  help  to 
identify  the  likely  causes  of  undernutrition  (most  notably  linked  to  health,  food  security  and  the 
environment).24  

4.2.2 Capacity Building 
In  the  high-pressure  context  of  humanitarian  crises,  the  imperative  to  respond  quickly  and 
professionally  requires  the  presence  of  capacity  to  do  so.  At  the  same  time,  the  nutrition  field  is 
advancing very quickly, creating additional pressure on staff to know the latest evidence that can inform 
the  design  of  humanitarian  responses  for  nutrition.  The  Commission  recognises  the  challenges  and 

20http://oneresponse.info/crosscutting/gender/Gender%20Marker%20Materials/Nutrition%20Gender%20Marker%

20Kit.pdf 

21 http://sites.tufts.edu/feinstein/2011/sex-and-age-matter 

22 DG ECHO (2005) Manual Project Cycle Management. Brussels 

as  SMART 

(Standardized  Monitoring 

23Such 
and  Transitions): 
http://www.smartmethodology.org/index.php?option=com_content&view=article&id=1084&Itemid=298&lang=e
n 
24 See Emergency Nutrition Assessment: Guidelines for field workers. Save the Children, November 2004.  

and  Assessment 

of  Relief 

20

 
 
 
 
 
 
 
                                                 
opportunity costs of such a widening gap between theoretical knowledge and operational capability, and 
will seek to prioritize efforts to bridge this gap.  

In order to maximise the effectiveness of nutrition assistance, the Commission recognises the need to 
invest  in  supporting  institutions  and  developing  the  capacity  of  key  stakeholders  involved  in  the 
management of acute undernutrition in crises. While responding to humanitarian needs, it is possible to 
develop  policies,  systems  and  skills  that  are  compatible  both  with  emergency  and  development 
contexts.  The  Commission's  support  aims  to  enhance  local  and  national  capacities  to  manage 
undernutrition in emergencies  and to face  seasonal  peaks, and to build resilience to face  existing and 
upcoming shocks. 

Where  possible  and  appropriate,  the  Commission  works  within  the  timeframe  of  its  humanitarian 
operations  to  simultaneously  enhance  national  capacities  for:  i)  nutritional  surveillance;  ii)  nutrition 
surveys; iii) health, food security & nutrition data monitoring; iv) cross-sectoral causality studies and 
assessments  and;  v)  enhance  the  capacity  for  the  implementation  of  nutritional  activities.  Such 
investments  should  be  coordinated  with  other  Commission  aid  instruments  to  ensure  continuity  when 
the  humanitarian  intervention  is  concluded  (see  section  6.3  on  Coherence,  Coordination  and 
Complementarity). 

4.2.3 Integration into national systems 
A  central  challenge  facing  humanitarian  assistance  for  nutrition  involves  the  need  for  timely 
engagement and rapid intervention, while ensuring that minimum standards of quality are consistently 
maintained. Experience suggests that, as far as possible, this challenge can be best met through effective 
preparedness measures in the framework of an integrated 'system-strengthening' approach. Despite the 
fact  that  humanitarian  crises  do  not  take  place  in  a  vacuum,  the  humanitarian  imperative  to  provide 
immediate life-saving response frequently leads to a focus on the establishment of new mechanisms for 
delivery,  leading  to  the  neglect  of  pre-existing  local  systems  (not  only  in  the  health  sector,  but  also 
within other relevant local institutions and community structures). 

Where  appropriate,  the  Commission  therefore  encourages  the  inclusion  of  programming  to  address 
nutrition  within  the  broader  context  of  national  systems  (including  provisions  for  the  adaptation  of 
national protocols for surge programming). This in turn highlights the need for a thorough assessment 
of  national  capacities  and  resources  prior  to  intervention,  as  well  as  a  commitment  to  reinforce 
government  ownership  and  capacity  where  this  is  conducive  to  the  achievements  of  the  objectives  of 
humanitarian assistance.  

4.2.4 Advocacy 

The Commission recognises that both acute and chronic undernutrition and micro-nutrient deficiencies 
are  prevalent  and  often  co-existing,  to  varying  degrees,  in  many  stable  contexts.  Given  the 
consequences  of  such  persistently  high  burden  of  undernutrition  on  infant  and  child  mortality,  child 
development,  and  longer-term  economic  growth  prospects,  the  Commission  insists  that  all  forms  of 
undernutrition be firmly placed at the centre of the development agenda.  

Advocacy and public awareness building are essential to secure better policies and the development of 
appropriate  actions  to  respond  to  undernutrition.  Key  targets  in  this  process  are  national  government 
authorities, civil society and development partners. A major focus is placed on initiatives to improve the 
understanding  of  those  measures  that  are  required  in  order  to  achieve  the  MDGs  of  reducing  hunger, 
and child and maternal mortality. 

Although the Commission has a specific remit and a comparative advantage in humanitarian action, as 
opposed  to  some  local  actors,  the  humanitarian  imperative  to  save  lives  and  reduce  rates  of  acute 
undernutrition  should  be  responded  to, whenever  feasible,  in  a  manner  that  does  not  undermine  local 
capacities or neglect national policies. Local capacity for the routine management of persistent burdens 

21

 
 
 
 
 
 
 
of  acute  undernutrition  and  for  the  management  of  future  crises,  should  therefore  be  supported  and 
strengthened whenever possible. 

4.2.5 Research  
With  a  growth  in  awareness  of  the  multi-sectoral  causality  of  undernutrition  and  an  expansion  in  the 
programmatic options to respond to the phenomenon, the collection of robust and up-to-date evidence 
on the efficiency and effectiveness of different forms of assistance becomes today more essential than 
ever before. 

The  Commission  acknowledges  the  need  to  contribute  to  the  evidence  base  on  the  efficiency  and 
effectiveness  of  various  interventions  to  address  undernutrition,  taking  into  account  the  diversity  of 
contexts (urban, pastoral, agricultural, acute/chronic, situations of displacement, etc.) and the needs of 
specific  population  groups  (women/men;  different  age  groups;  persons  with  disabilities;  ethnic  and 
other  socio-cultural  groups;  economically  diverse  groups).  The  Commission  therefore  continues 
supporting operational research on nutrition under the following conditions: 

•  Research  is  not  the  entry  point  for  any  operation  -  operations  should  be  justified  by 

humanitarian needs and not by research 

•  The context should allow for research to be conducted effectively - the research location should 
be  accessible  and  stable  for  the  duration  of  the  research  period  in  order  to  ensure  adequate 
quality outcomes 

•  Partners must be running ongoing quality operations in the proposed project area and have the 

technical expertise that is necessary in order to conduct any proposed research  

•  Partners'  research  should  respect  international  research  standards  including  the  validation  of 
research protocols by an international ethical review board and, if possible, by a national one, 
through the appropriate involvement of local authorities and communities. 

•  Transparent documentation and dissemination of research findings must be ensured at all times. 

22

 
 
 
 
 
 
 
5 PROGRAMMATIC RESPONSES 

The Commission supports comprehensive life-saving nutrition strategies to address emergency levels of 
undernutrition. These include interventions that have been demonstrated to be effective and efficient in 
tackling both moderate and severe acute undernutrition, as well as specific micronutrient deficiencies.  

Other programmes are required to address the immediate and underlying causes of undernutrition (see 
Conceptual  framework),  which  also  help  to  create  the  foundations  and  enabling  environment  that  are 
necessary  in  order  to  sustain  nutritional  gains  over  time.  These  include  interventions  that  have  been 
demonstrated to be effective at  addressing the underlying causes  of undernutrition such as improving 
access  to  safe  water  and  improving  household  food  security  through  agriculture  and  livestock 
interventions.  

Operational Case Study 

Niger: "Cost of Diet" - an analytical tool to inform nutrition interventions 

In May 2011, Save the Children UK (SC UK) conducted a "Cost of the Diet (CoD) assessment" in the 
Zinder Region of southern Niger. The aim was to better understand the underlying economic causes of 
malnutrition. 

The  CoD  analytical  tool,  developed  by  SC  UK  with  support  from  the  Commission,  is  designed  to 
calculate the cost of the cheapest diet that meets the nutritional requirements of families and exclusively 
contains locally available food. The CoD combines data on food prices, consumption, and availability 
with information from interviews with household members about their eating habits and lifestyle. It can 
be used to estimate the proportion of households in a region that are unable to afford a nutritious diet, as 
well as the size of the gap between current income and the amount of money needed to meet the needs 
of a household. 

In  Zinder,  nutritious  food  was  available  in  the  market.  CoD  analysis  found,  however,  that  during  the 
lean  season,  the  minimum  cost  of  this  diet  is  far  beyond  the  income  levels  of  poor  households.  By 
identifying the size of this income gap, SC UK and other partners could tailor programming accordingly 
(for example, through cash and voucher assistance). 

Lesson  learnt:  There  is  no  "one  size  fits  all"  answer  to  a  specific  situation  of  undernutrition  in  any 
given emergency. Depending on the social and economic situation of a household, the functioning of 
the market, the livelihood assets and the level of resilience, humanitarian interventions for nutrition can 
vary. The CoD tool can be very useful for understanding the difficulties of crisis-affected households in 
accessing nutritious food, and particularly for the promotion of IYCF practices for children older than 6 
months based on appropriate complementary foodstuff that is available at local markets. 

5.1 Health and Nutrition  

5.1.1 Management of moderate and severe acute undernutrition 

Where indicated by an assessment of needs, and where not covered by existing health provision, it can 
be necessary to specifically intervene in the management of moderate and severe acute undernutrition 
for the most vulnerable (generally children under five and pregnant and lactating women). Strategies to 
manage  acute  undernutrition  in  crisis  contexts  must  be  closely  linked  to  efforts  to  promote  the 
nutritional security of the entire emergency-affected population.  

23

 
 
 
 
 
 
 
 
 
The  choice  of  intervention  depends  on  the  prevalence  of  acute  undernutrition  (moderate  and  severe), 
any  aggravating  factors,  the  local  context  and  the  dynamic  of  the  crisis  (particularly  in  terms  of  the 
possibility to gain access to affected groups). The Commission emphasises the relevance of:  

•  Early detection of acute undernutrition at the community level and intensive case finding 

through community mobilisation; 

•  Provision of outpatient treatment for individuals suffering from severe acute undernutrition 
without medical complications. The caseload of SAM without complications is estimated to 
be 80-90% of the total SAM caseload; 

•  Facility-based  treatment  of  individuals  suffering  from  SAM  with  medical  complications 
(estimated  at  10-20%  of  total  SAM  caseload).  This  might  include  therapeutic  feeding 
centres,  hospitals  or  stabilisation  centres;  appropriate 
identification  of  medical 
complications and access to the appropriate (lifesaving) treatment; and appropriate follow-
up  after  referral  and  after  discharge,  particularly  in  the  management  of  severe  acute 
malnutrition (at stabilisation centres and through outpatient programmes); 

•  Supplementary Feeding Programmes treating those with moderate acute undernutrition; 
•  Concomitant access to free healthcare.. 

The Commission welcomes the advances made in recent years through the introduction and scaling up 
of  community  based  approaches  for  CMAM.  The  Commission  particularly  recognises  the  value  of 
ready-to-use therapeutic foods, which have been integral to the success of this approach. CMAM aims 
to  provide  effective  treatment  for  all  children  with  both  severe  and  moderate  acute  undernutrition  by 
decentralising  treatment  nearer  to  those  that  need  it,  removing  the  need  for  long  inpatient  stays  and 
stimulating  understanding  and  engagement  of  the  target  population  around  acute  undernutrition. 
Barriers to accessing treatment are reduced and early diagnosis of the condition occurs more frequently. 
Early diagnosis of acute undernutrition in combination with effective treatment at the community level 
can largely reduce fatality rates and increase coverage of the affected population.  

The burden of undernutrition in emergencies is felt in terms of numbers affected (more children have 
moderate acute undernutrition) and in terms of mortality (the risk is greatest for those with severe acute 
undernutrition).  The  management  of  acute  undernutrition,  therefore,  needs  to  consider  strategies  for 
MAM  alongside  those  for  SAM,  so  that  there  can  be  coherence  and  sustained  progress.  Crucially,  a 
multi-sectoral approach is necessary to address moderate acute malnutrition, e.g. through humanitarian 
food assistance, improved access to healthcare and improved access to sanitation and drinking water.  

Operational Case Study 

Ethiopia: Strengthening of the capacity of the Ministry of Health for more effective humanitarian 
response and improved resilience 

Ethiopia has one of the highest under-five mortality rates in the world and is chronically vulnerable to 
food and nutrition crises. 
In 2003/4, a widespread food and nutrition crisis highlighted the low capacity of existing Therapeutic 
Feeding Centres for the treatment of severe acute malnutrition. This situation prompted the Ministry of 
Health  (MoH)  to  begin  working  with  partners  to  scale-up  services  dealing  with  nutrition  across  the 
country. The international non-governmental organization Concern Worldwide launched a programme 
to  support  the  MoH  in  establishing  adequate  services  to  treat  a  large  number  of  children  with  SAM 
during ‘normal’ times. The intervention included the strengthening of capacities in order to enable these 
services  to  rapidly  scale-up  at  times  of  crisis.  The  project  aimed  to  mitigate  delays  in  setting  up new 
therapeutic programmes in response to crises.  
The  programme  provided  a  package  of  ‘minimal  support’  to  the  MoH,  consisting  of  training,  joint 
supervision, experience-sharing visits, workshops and community mobilisation assistance. In addition, 
support  was  provided  for  the  incorporation  of  CMAM  into  the  National  Nutrition  Strategy  and  its 
guidelines.  
In  2008,  a  dramatic  increase  in  the  prevalence  of  SAM  was  recorded  across  two  regions  in  Ethiopia, 
primarily  due  to  the  effects  of  drought.  In  many  districts  the  magnitude  of  caseloads  overwhelmed 
treatment capacities. The MoH made the decision to decentralise CMAM services to primary healthcare 
posts  through  the  employment  of  health  extension  workers.  This  was  rapidly  achieved  by  mobilising 

24

 
 
 
 
 
support from a number of agencies (UNICEF, WHO, and NGOs). The results have been striking: 

•  Within  4  months,  455  health  posts  (50%  of  the  districts)  in  the  two  affected  regions  were 
managing outpatient therapeutic programmes (OTP), reaching over 27,000 children with SAM. 
The results25 fulfilled Sphere standards. This prompted an acceleration of major efforts to scale-
up CMAM across other regions. 

•  Extensive CMAM scaling-up has enabled increased access to information on SAM admissions 
in a considerable proportion of the country. Programme monitoring data increases the potential 
for humanitarian actors to respond in a timely manner to increases in the prevalence of SAM, 
rather than having to rely on the longer-term completion of nutrition surveys. In March/April 
2011, CMAM reports showed a 90% increase in the number of admissions, which led UNICEF 
and  implementing  partners  to  trigger  a  humanitarian  response  using  contingency/reserve 
funding while discussions for additional support were still under way. 

Lesson Learnt: This case highlights the gains associated with a "system approach" where nutrition 
interventions in emergencies build on existing capacity. This approach is only possible in the presence 
of an appropriate funding mechanism that promotes bridges between humanitarian and development 
interventions. 

Infant and young child feeding in emergencies (IYCF-E)  

In  the  context  of  humanitarian  assistance  for  nutrition,  IYCF  refers  to  a  range  of  nutrition  and  care 
interventions  that  improve  child  survival  and  growth.  These  include  appropriate  and  evidence-based 
support  for  (exclusive)  breastfeeding  and  counselling,  formula  or  emergency  feeding  interventions 
when necessary, nutrient-dense complementary feeding interventions for children > 6 months, support 
for  improved  care  practices,  child  development  and  child  protection.  In  more  general  terms,  IYCF 
covers  maternal  and  child  nutrition,  including  the  management  of  acute  undernutrition  in  infants. 
Special attention should be paid to address any cultural practices surrounding breastfeeding and feeding 
that may discriminate girls. 

The Commission seeks to uphold the provisions of the International Code of Marketing of Breast-milk 
Substitutes  and  subsequent  relevant  WHO  Resolutions  (and  requires  its  partners  to  uphold  the  same 
standards). Inappropriate in-kind donations (such as infant formula, powdered milk or bottles and teats) 
are discouraged by the Commission, in accordance with the Operational Guidance on IYCF-E and the 
International Code on the Marketing of Breast-milk Substitutes. 

In  a  humanitarian  crisis,  other  less  recognised  influences  on  IYCF  practices  must  be  addressed 
including  security,  privacy  and  shelter  for  mothers.  The  psychosocial  components  of  nutrition 
(including the psychological, emotional and social dimensions of a child and mother's health and well-
being) are of crucial importance, as they can have a considerable impact on nutritional status. Nutrition 
has extremely close links with care practices and a child's nutritional status is often determined as much 
by  feeding  practices,  home  environment  and  the  attention  received  from  primary  caretaker  as  by  the 
food  consumed.  Evidence  also  indicates  that  inclusion  of  psychosocial  stimulation  for  mothers  and 
children  in  programmes  for  the  treatment  of  undernutrition  can  improve  long-term  health  and 
development of children.26 

The recent review of the Management of Acute Malnutrition in Infants (MAMI)27 confirms that a high 
prevalence  of  wasting  in  infants  below  6  months  of  age  is  a  public  health  problem  requiring  a 

2577.6% recovery, 0.7% mortality and 4.2% default rates.  

26 Nahar; B., Hamadani, J.D., Ahmed, T., Tofail, F.; Rahman, A.; Huda; S.N.; et al (2008): Effects of psychosocial 
stimulation on growth and development of severely malnourished children in a nutrition unit in Bangladesh. 
European Journal of clinical nutrition; September 2008. 

27 Management of Acute Malnutrition in Infants (MAMI) Project commissioned by the Global Nutrition Cluster; 
Summary Report. ENN; October 2009. 

25

 
 
 
 
 
                                                 
humanitarian  response.  There  is  an  urgent  need  to  increase  our  knowledge  on  how  to  diagnose  acute 
undernutrition  in  this  age  group,  improve  understanding  of  causes  and  consequences,  and  improve 
interventions to treat it. More specifically, there is a need to explore the modalities, costs and impact of 
integrating IYCF support in CMAM programmes, and interventions addressing acute undernutrition in 
infants need to be updated through innovation, research and the considerations of past lessons.  

Operational Case Study 

Myanmar: The experience of a young mother during the 2008 cyclone and subsequent floods  

Jasmine’s mother was nearing the end of her pregnancy when the cyclone hit. She and her four boys 
were  hit  by  the  storm  while  they  were  at  several  days'  walk  from  her  village.  She  sought refuge  in a 
monastery  where  she  met  a  woman  who  had  three boys  of  her  own,  all  over  8 years  old. When  they 
were forcibly evacuated from the monastery, Jasmine’s mother knew she was too close to giving birth 
to make the journey back to her village with her boys. So she stayed with the family she had met at the 
monastery. When Jasmine was born, weighing 2.5kg, her mother decided she could not care for her and 
left her with the family she had been staying with. Six weeks later, Jasmine weighed 2.3kg.  

Breastfeeding counsellors were supporting Jasmine’s foster mother to re-lactate for about 10 days. She 
was instructed to put Jasmine to the breast as often as she could during the day (at least every 2 hours) 
and to allow her unrestricted access to the breast all night (the whole family slept on one mat under the 
only mosquito net in the house). The foster mother was also instructed in the preparation of powdered 
infant formula and cup feeding. She was told to feed Jasmine enough formula to satisfy her (about 6 or 
7  times  a  day)  and  to  drink  any  leftovers  herself  or  give  it  to  one  of  the  boys.  When  Jasmine  was 
observed breastfeeding, it was evident that she was transferring milk from the breast effectively (active 
rooting  followed  by  long  slow  sucks,  big  swallows,  relaxed  expression,  hand  becoming  more  open 
through the feed, and sleepy after the feed). Her bowel movements also indicated that she was getting a 
significant amount of breast-milk. From that point, Jasmine’s foster mother was instructed to reduce the 
number  of  times  she  offered  her  formula  during  the  day.  Under  two  weeks  later,  Jasmine’s  foster 
mother stopped offering formula milk altogether. 

Jasmine is now exclusively breastfed, and has regained and exceeded her birth weight. 

Lesson learnt: this example demonstrates the importance of prioritising IYCF-E. Through expert and 
dedicated  support,  vulnerable  infants  can  be  prevented  from  deteriorating  nutrition  situations  to  the 
extent where therapeutic feeding would be required.   

Acute undernutrition in adolescents and adults 

Although  the  management  of  acute  undernutrition  in  children  under  five  years  of  age  has  improved 
considerably  in  the  last  decade,  there  are  still  gaps  in  evidence  concerning  the  treatment  of  acute 
undernutrition  in  adolescents  and  adults.  Experience  shows  that  the  specific  nutritional  needs  of 
adolescents  and  adults  require  adapted  life-saving  strategies  beyond  food  assistance.  It  is  therefore 
imperative that undernourished adolescents and adults have access to appropriate treatment and support.  

Women  and  adolescent  girls  can  be  particularly  vulnerable  due  to  their  productive,  reproductive  and 
social roles.28 Undernutrition in women contributes to maternal deaths and is directly related to faltering 
nutritional status and growth retardation in children. Maternal undernutrition is also linked to low birth 
weight, which in turn results in higher infant morbidity and mortality as well as long-term disability and 
chronic illness. The Commission therefore encourages systematic attention to interventions that address 

28 Women are the primary carers of children and the main decision-makers with regards to their children's dietary 
consumption.  Women's  education  and  status  in  society  are  directly  linked  to  the  nutritional  status  of  the 
children in their care. 

26

 
 
 
 
                                                 
 
undernutrition  among  women  in  reproductive  age,  particularly  during  pregnancy  and  lactation  in  the 
framework of all humanitarian contexts and closely monitors the quality of the work of those partners 
whose work has a specific impact on this group.  

The  Commission  also  ensures  that  the  special  needs  of  other  specific  groups  within  its  beneficiary 
caseload (e.g. disabled, elderly, chronically ill) are integrated into the design of humanitarian nutrition 
responses. 

5.1.2 Management of micro-nutrient deficiencies (MND)  
The Commission acknowledges the growing international evidence gathered in recent years in relation 
to MND and their specific impact on children’s morbidity, mortality and cognitive development. Over 
10% of deaths among children under five years of age are attributed to deficiencies in Vitamin A, zinc, 
iron and iodine.29 

On the basis of assessed needs, the Commission therefore supports nutrition strategies to both treat and 
prevent MND during emergencies. The combination of response options adopted depends on the level 
and severity of the problem: 

•  Provision of fresh food items that are complementary to a general food ration (e.g. through 

fresh food vouchers); 

•  Provision of fortified food aid commodities30 such as fortified cereal, CSB+/++ (corn soya 
blend),  lipid-based  nutrient  supplement  and  iodized  salt  and/or  powders  or  sprinkles  for 
home fortification in the general ration; 

•  Special attention to the quality of complementary feeding for children under two years of 

age; 

•  Distribution of micronutrient supplements31 either as single micronutrient (e.g. Vitamin A 
for children, iron/folic acid for pregnant women) or population-level supplementation32 in 
the  case  of  widespread  deficiencies  of  specific  micronutrients,  such  as  scurvy  (vitamin  C 
thiamine 
deficiency),  pellagra  (niacin  deficiency)  and  beri-beri  (vitamin  B  and 
deficiencies); 
Integration of micronutrients into the prevention and treatment of certain diseases. Zinc has 
been shown to be effective in the management of diarrhoeal diseases (prevention of future 
episodes as well as reduction in the duration of current episodes), which in turn can have 
serious nutritional consequences; 

• 

•  Provision  of  vitamin  A  alongside,  for  example,  measles  vaccinations,  can  help  to  protect 
children  against  infection.  The  Commission  therefore  supports  interventions  aimed  at 
incorporating  zinc  and  vitamin  A  into  delivery  of  healthcare  services  (e.g.  through  the 
provision of zinc with low-osmolality oral rehydration salts (ORS). 

5.1.3 Prevention of disease-related undernutrition  
Undernutrition can be caused and aggravated by diseases, therefore supporting free access to healthcare 
and  promoting  a  healthy  environment  is  an  essential  component  of  the  prevention  and  treatment  of 
acute undernutrition 

The  synergistic  relationship  between  undernutrition,  micronutrient  deficiencies  and  various  infectious 
and  parasitic  diseases  is  well  known  (including  diarrhoeal  diseases,  HIV/AIDS,  tuberculosis, 
infections,  malaria  and  measles). 
infection,  respiratory 
Leishmaniosis, 

intestinal  helminthic 

29 See table 6 in: Black, R.E. et al, for the Maternal and Child Undernutrition Study Group. Lancet 2008; 371: 243 
30  See  WHO/FAO  2006:  http://www.who.int/nutrition/publications/micronutrients/9241594012/en/  and  WHO 
2009: http://www.who.int/nutrition/publications/micronutrients/wheat_maize_fortification/en/ 
31 See WHO (2006): http://www.who.int/making_pregnancy_safer/publications/Standards1.8N.pdf 
32 See WHO/WFP/UNICEF 2007: 
http://www.who.int/nutrition/publications/micronutrients/WHO_WFP_UNICEFstatement.pdf 

27

 
 
 
 
  
                                                 
Undernutrition  and  micronutrient  deficiencies  facilitate  infection,  and  some  infections  may  result, 
directly or indirectly, in the development of undernutrition and micronutrient deficiencies. However, in 
the current programmatic structure of nutritional programmes, the importance of underlying diseases is 
often unaddressed. 

While  tackling  undernutrition  in  emergencies,  the  Commission  seeks  to  provide  adequate  emergency 
healthcare, taking into account the specific needs of children below five years of age and their mothers 
as well as pregnant women. These interventions may include: 

•  De-worming as part of integrated child health programmes, 

•  Prevention and early treatment of diarrhoeal diseases,33  

•  Prevention and early treatment of measles and malaria.34  

Access  to  (basic)  primary  healthcare  should  be  safeguarded  for  those  who  are  most  vulnerable  to 
undernutrition.  According  to  the  Commission's  position  on  user  fees35  in  humanitarian  situations, 
healthcare  should  be  free  at  the  place  of  delivery,  in  order  to  ensure,  as  much  as  it  is  possible,  that 
access to healthcare is guaranteed to all potential beneficiaries.  

The  Commission  seeks  to  ensure  appropriate  procurement  (taking  into  account  product  quality  and 
safety) and storage of the necessary medical and nutritional inputs required to prevent disease-related 
undernutrition.  Regional  prepositioning  of  essential  supplies,  or  support  to  national  emergency 
preparedness stocks can facilitate timely responses, if appropriately managed and supported by reliable 
information systems.  

5.2 Humanitarian Food Assistance and Nutrition 

Response options must be context-driven and could include: 

General Food Assistance: 

- Provision of free cash or vouchers (commodity-based or value-based) distributed on a blanket basis  
- Distribution of free food commodities on a blanket basis (general food distributions) including the provision 
of appropriate fortified food items suitable for young children; 

Targeted Food Assistance: 

Targeted  Food  Assistance  (TFA)  aims  at  reaching  the  most  food  insecure  households  (regardless  of 
whether  General  Food  Distribution  is  under  way).  These  interventions  shall  be  informed  by  a 
Household Economy Analysis (HEA): 

- Provision of targeted free cash or vouchers (commodity-based or value-based) 

- Distribution of free food on a targeted basis (targeted food distributions); 

- Distribution of food, cash or vouchers on a targeted and/or self-targeted basis, in exchange for a beneficiary’s time or 
labour (e.g. cash for work, food for work, food for training, food for assets); 

young 

children 

infants  and 

33 See Joint WHO/UNICEF Statement (2004): http://whqlibdoc.who.int/hq/2004/WHO_FCH_CAH_04.7.pdf 
34 See Conclusions and recommendations of the WHO Consultation on prevention and control of iron deficiency 
in 
revision) 
in  malaria-endemic  areas 
http://www.who.int/nutrition/publications/micronutrients/FNBvol28N4supdec07.pdf 
35 DG ECHO position paper on user fees for Primary Health services in Humanitarian crises, April 2009. "In an 
emergency  context,  DG  ECHO  will  promote  access  to  healthcare  for  all  and  in  particular  for  the  poorest  and 
those  in  greatest  need  and  will  discourage  partners  to  apply  any  user  fee  system.  If  no  alternative  source  of 
income  is  guaranteed  for  payment  of  salaries  or  the  recurrent  costs  or  for  replenishment  of  drugs  or  medical 
supplies, DG ECHO has to make a well informed choice and to consider covering the financial gap. Any choice 
should  be  based  on  considerations  of  the  national  and  political  context  and  the  possible  consequences  of 
abolishing user fees." 

currently  under 

(2006, 

28

 
 
 
 
 
 
                                                 
Blanket  supplementary  feeding  distribution  aims  at  reaching  the  most  nutrition  insecure  individuals  (particularly 
young children, pregnant and lactating women). These interventions shall be informed by sound nutrition surveillance. 
Food security and livelihood interventions are potentially effective36 instruments for the prevention of 
undernutrition (as outlined in the conceptual framework).  

Where response analysis is appropriately performed, existing evidence suggests that cash transfers can 
have  a  positive  impact  on  dietary  intake  and  therefore  should  be  considered  as  a  key  tool  in  the 
management of undernutrition. However, as is also the case with in-kind food aid, assessing the exact 
impact of these transfers on changes in nutritional status remains a challenge37.  

The  Commission  is  committed  to  addressing  this  gap  through:  (i)  the  promotion  of  a  systematic 
inclusion of nutrition-relevant objectives and indicators in the humanitarian food assistance operations 
it supports (including food security information systems); and (ii) consideration of operational research 
that contributes to the collection of evidence on comparative performance between different strategies 
and products. In the case of (i), this can be achieved for instance through anthropometric measurements 
or dietary diversity indices and food consumption scores. 

Where  addressing  undernutrition  is  an  important  objective  of  food  security  interventions,  the 
Commission starts intervening in those areas where the prevalence of acute undernutrition is highest.  

Operational case study 

Niger: The role of cash transfers in reducing undernutrition in extremely poor households 

Save  the  Children  UK  (SC  UK)  piloted  a  cash  transfer  social  safety  net  programme  in  the  Tessaoua 
district of Niger’s Maradi region in 2008. In collaboration with local authorities and with Commission 
funding, SC UK assisted 1500 of the poorest households to close the gap between the cost of food they 
needed to purchase and their income during the lean season. 

Beneficiaries  were  identified  on  the  basis  of  a  Household  Economy  Analysis  (HEA)  and  wealth 
ranking. Special consideration was given to households that included widows, people with disabilities, 
and  mothers  and  caregivers  of  children  under  five.  All  beneficiaries  lived  in  severely  food  insecure 
areas.  One  woman  in  each  of  the  families  received  direct  cash  assistance  in  three  equal  distributions, 
contingent upon their participation in undernutrition and public health awareness sessions.  

SC  UK  monitored  100  households  three  times:  prior  to  the  project,  one  month  after  the  first  cash 
distribution (at the peak of the hunger gap), and one month after the final distribution. Results showed 
that cash transfers allowed the poorest households to meet their minimum food needs while enjoying a 
more diverse diet. The injection of cash into the community stimulated petty trade and increased local 
wage rates as people receiving the transfer worked in their own fields rather than competing for work as 
wage labourers.  

Children  under  five  were  found  to  have  experienced  an  improvement  in  their  nutritional  status.  This 
phenomenon, however, was not sustained throughout time. An explanation could be that cash transfers 
to  families  with young  children  may  be  more  effective  if  accompanied  by  micronutrient  supplements 
and disease prevention measures as cash alone might not address the complexity of nutrition insecurity. 
Nonetheless, families were better able to meet their energy requirements and less likely to take loans or 
mortgage assets during the hunger gap if they received cash transfers. 

Lessons learnt: Cash transfers potentially have a positive impact on the stimulation of local  markets 
and dietary diversity. However, they need to be accompanied by specific nutrition/health interventions 
to address the complexity of nutrition security, with a particular focus on children under five years of 
age. 

36 Bhutta Z. et al 2008: What works? Interventions for maternal and child undernutrition and survival. Maternal 
and Child Undernutrition Study Group. The Lancet 371 (9610) p417–440. 
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61693-6/fulltext 
37 Bailey, S, Hedlun, K. (2012): The impact of cash transfers on nutrition in emergency and transitional contexts, 

http://www.odi.org.uk/resources/docs/7596.pdf  

29

 
 
                                                 
With regard to the management of MAM, the requirement for evidence demonstrating the comparative 
advantage  of  specialised  nutrition  products  (including  RUSF,  and  improved  fortified  blended  food) 
remains  a  priority.  In  general,  however,  supplementary  food  –  as  the  name  indicates  –  is  meant  to 
supplement  an  existing  diet  (when  such  diet  is  deficient  in  quantity  and/or  quality)  and  therefore  a 
thorough  situation  analysis  is  required  to  justify  this  specific  choice  of  response.  The  Commission 
recognises the potential effectiveness that improved fortified and/or nutrient-dense food products could 
have  on  the  treatment  and  prevention  of  acute  undernutrition.  However,  the  Commission  exclusively 
supports  the  use  of  specialised  nutritional  products  where  specific  conditions  are  deemed  to  be 
appropriate and upon close monitoring of their effectiveness and impact.38  

Furthermore, it is recognised that supplementary feeding should under no circumstances compete with 
or compromise breastfeeding (for children 6-23 months even though no longer exclusively breastfed). 
Therefore it is important that supplementary feeding is accompanied by measures aimed at promoting 
and monitoring the continuation of breastfeeding.  

Operational case study 

Somalia: Emergency cash transfer and food vouchers programme  

The  2011  drought  in  the  Horn  of  Africa  had  a  very  serious  impact  on  vulnerable  people  in  Somalia, 
who were already affected by the long-lasting war. On 20 July, for the first time in almost 30 years, the 
United Nations officially declared the presence of a situation of famine in two regions in the southern 
part  of  the  country  (IPC  Phase  5).  Children  in  Somalia  continued  to  be  caught  up  in  chronic  and 
recurrent  malnutrition  crises  with  a  country-wide  median  Global  Acute  Malnutrition  (GAM) 
consistently  and  considerably  above  the  emergency  threshold.  To  respond  to  the  urgent  needs  of  the 
most vulnerable population, UNICEF, with support provided by the Commission, launched its widest 
ever cash/voucher programme in an emergency situation:  

•  The  programme  targeted  360,000  people  (60,000  households)  -  the  direct  beneficiaries  being 
the severely undernourished children under five years of age and drought-affected families in 
Southern Somalia.  

•  The  objective  was  to  reduce  to  (at  least)  below  the  emergency  threshold  excess  mortality 

caused by nutritional deficiencies. 

•  The intervention was based on the provision of nutritional supplies and the distribution of cash 
transfer/vouchers. UNICEF completed 6 rounds of distribution worth a total of 60 million USD, 
each monthly round comprising 58 USD in vouchers and 100 USD in cash given to individual 
households. 

Given the high volume of funds devoted to cash transfer/vouchers and the novelty of cash interventions, 
the expectation in terms of results was very high: 

After three cash distributions, the first signs of resilience recovery could be seen; the improvement of 
the  purchasing  power  of  the  very  poor  households  targeted  caused  an  increase  in  the  purchasing  of 
food, livestock and small business investments. 

The positive nutrition impact of the intervention was evident: the number of  meals per day increased 
(from  1  to  2  for  adults  and  1  to  3  for  children)  and  dietary  diversity  improved  as  well.  Furthermore, 
between October 2011 and February 2012, SAM prevalence decreased from 12% to 8%.  

Lessons learnt: Overall, large-scale cash-based programming can be successful. 

•  Large-scale,  collaborative  monitoring  can  be  done  also  in  complex  conflict-affected 

38 Minimum standardised monitoring (e.g. SPHERE or national protocols); Minimum Reporting Package 
www.mrp-sw.com 

30

 
 
 
 
                                                 
 
environments 

•  Functioning, efficient markets and the Hawala system (local Western Union) were key factors 

that allowed for the rapid impact of the intervention 

•  Common monitoring improved programming and the assessment of the overall impact 

5.3 Water, Sanitation and Hygiene (WASH) and Nutrition 

Environmental factors can be major contributors to the occurrence and severity of undernutrition. Lack 
of safe water, poor sanitation and inadequate hygiene practices all contribute to the spread of infectious 
diseases.  As  such,  they  are  directly  linked  with  faltering  growth,  lowered  immunity  and  increased 
morbidity and  mortality.39 The Commission therefore promotes the incorporation of nutrition-specific 
objectives  into  WASH  humanitarian  responses  in  crisis  contexts  where  undernutrition  is  a  major 
humanitarian concern.40  

In these contexts, the Commission supports those basic sanitation and behavioural change interventions 
that are considered to be essential for the creation of a safe environment.41 These include: 

(cid:131)  Water  supply  interventions  aimed  at  ensuring the  provision of  a  clean  and  safe  water 

supply, in sufficient quantities and in a short timeframe. 

(cid:131)  Sanitation  interventions  focusing  on  immediate  and  safe  excreta  disposal.  Priority  is 
given  to  the  protection  of  drinking  water  sources  from  possible  contamination, 
particularly through human and animal excreta.  

(cid:131)  Hygiene  Promotion  focusing  on  immediate  actions  that  have  the  greatest  potential  to 
reduce the risk and spread of environmental health-related outbreaks (in particular hand 
washing).  

Where  possible,  these  actions  are  designed  and  implemented  in  coordination  with  all  relevant 
stakeholders  including  community  leaders  and/or  representatives  and  in  accord  with  local/national 
authorities.  

Equal  participation  of  men  and  women  in  planning,  decision-making  and  local  management  of 
Emergency WASH operations helps to ensure that the entire population obtains safe and easy access to 
WASH services and that access to these services does not negatively impact on the nutritional status of 
vulnerable  groups,  particularly  women  and  children.  There  are  important  gender  dimensions  related  to 
WASH that would need to be fully considered so as to prevent consequences that could be detrimental to 
women's  (and  children's)  well-being.  Such  gender  and  nutrition-sensitive  design  supports,  for  instance, 
reduced burden and a shorter water collection time for women, as well as improved protection for women 
and  young  girls  to  be  attained  through  an  appropriate  design  of  WASH  facilities  in  refugee  or 
displacement camps. 

Specific  measures  to  strengthen  the  linkage  between  WASH  and  nutrition  interventions  and  improved 
nutrition outcomes include: 

•  The promotion of a Minimum WASH Packages in health facilities (including mobile clinics) to 

improve the health environment; 

39 The Lancet Series includes hand-washing and hygiene interventions among the core measures that reduce the 
risk of diarrhoea. The hygiene and hand washing dimensions of food preparation are an important part of the 
‘childcare’  component  of  nutrition  programmes,  especially  in  areas  where  water  and  sanitation  are  poor. 
Guidelines on hand washing and hygiene are at: http://www.unicef.org/wes/index_43084.html 

40 The Lancet Series include hand-washing and hygiene interventions among the core measures that can reduce 
the risk of diarrhoea. The hygiene and hand-washing dimensions of food preparation are an important part of 
the 'childcare' component of nutrition programmes, especially in areas where water and sanitation are poor. 
Guidelines on hand-washing and hygiene are at: http://www.unicef.org/wes/index_43084.html   

41 WHO/FAO 2006: Guidelines on food fortification with micronutrients. At: 
http://www.who.int/nutrition/publications/guide_food_fortification_micronutrients.pdf 

31

 
 
 
 
 
 
                                                 
•  Ensured access to water for the poorest through the avoidance of user fees or, for example, the 
provision of cash transfers to cover the costs associated to minimum levels of consumption;42 
•  Latrine construction should avoid the risk of contamination by ensuring adequate distance from 
food  preparation,  drinking  water,  storage  of  utensils,  etc.;  Latrines  should  be  properly 
constructed (e.g. concrete slab) to prevent helminthic infections. 

•  The integration of nutrition awareness in hygiene promotion strategies; 
•  Analysis of the significance of water sources for livelihoods and the household economy prior 
to interventions, in order to establish drinking water supply services and avoid tensions between 
the potentially competing priorities of different groups; 

•  Harnessing  humanitarian  WASH  operations  as  an  opportunity  for  conditional  cash  or  food 
transfers,  through  the  engagement  of  beneficiaries  in  the  construction  of  their  own  WASH 
services. 

42 The humanitarian priority is that any user fee must be accompanied by a commitment to ensuring that the needs 

of the most vulnerable are covered and that no one shall be excluded from accessing WASH services. 

32

 
 
 
                                                 
6 HUMANITARIAN AND DEVELOPMENT ACTORS' SHARED 
CONCERNS  

While it is important that pre-existing high levels of chronic undernutrition are taken into account in the 
design  of  any  emergency  response,  this  alone  does not generally  grant  the  triggering of humanitarian 
mechanisms  to  provide  nutrition  assistance.  In  contexts  that  are  characterised  by  either  chronic 
undernutrition (stunting) or persistently high rates of acute undernutrition (wasting), or both, a longer- 
term approach is required in order to ensure predictable funding modalities and close cooperation with 
national government authorities.  

Understanding that such contexts are primarily the outcome of serious structural factors lying outside 
the scope of humanitarian assistance is essential. However, it is also crucial for all actors involved to 
recognise  that  high  levels  of  persistent  undernutrition  imply  an  increased  risk  of  morbidity  and 
mortality and that the burden of undernutrition associated with underdevelopment is far greater than the 
one associated with crises of short duration. 

This section of the paper discusses those aspects of nutrition crises that are best addressed by combining 
interventions of humanitarian and development actors. 

6.1 Chronic undernutrition (stunting) in emergencies 

Although  it  is  recognised  that  high  levels  of  stunting  can  lead  to  an  increased  risk  of  morbidity  and 
mortality, stunting is the effect of sustained nutritional deficit and development failure, and it is not by 
addressing  its  effects  alone  that  the  phenomenon  can  be  halted.  Contrasting  stunting  requires  a  long-
term  approach,  with  predictable  funding  modalities  and  close  cooperation  with  national  government 
authorities.  

Humanitarian  assistance  for  nutrition  offers  no  comparative  advantage  in  this  regard.  Therefore,  the 
Commission,  in  principle,  does  not  resort  to  humanitarian  assistance  in  order  to  address  chronic 
undernutrition, and instead advocates for other instruments/actors to respond. 

Although not justifying an emergency response, pre-existing high levels of chronic undernutrition are 
taken  into  account  in  the  design  of  responses,  as  they  can  indicate  the  vulnerability  of  any  given 
population.  

6.2 HIV/AIDS 

HIV infection can cause nutritional deficiencies in the form of reduced intake, higher metabolic needs, 
and impaired nutrient use. Poor nutritional status may accelerate the progression towards AIDS-related 
illness, undermine the use of and response to antiretroviral therapy, and exacerbate the socioeconomic 
impact of the virus. This in turn may have even broader impacts, as HIV infection reduces economic 
productivity and thus food security.  

The  Commission  recognises  the  positive  impact  that  adequate  food  and  nutrition  can  have  on  the 
management  of  HIV  and  AIDS.43  HIV-infected  children  require  special  attention  to  secure  their 
additional needs for growth and development, in line with the WHO guidelines.44  
In  accordance  with  its  guidelines  on  support  to  people  living  with  HIV/AIDS45  in  humanitarian 
situations,  when  nutrition  or  food  crises  occur  in  areas  with  high  prevalence  of  HIV/AIDS,  the 

43  The  2001  UN  General  Assembly  Special  Session  Declaration  of  Commitment  on  HIV/AIDS  and  the  2006 
Political  Declaration  on  HIV/AIDS,  recognise  that  food  security  and  nutrition  are  interlinked  with  HIV.  In 
particular, Article 28 of the Political Declaration resolves “to integrate food and nutritional support” in responses 
to HIV, “with the goal that all people at all times, will have access to sufficient, safe, and nutritious food to meet 
their  dietary  needs  and  food  preferences  for  an  active  and  healthy  life,  as  part  of  a  comprehensive  response  to 
HIV/AIDS”. 
44  WHO  2009.  Guidelines  for  an  integrated  approach  to  nutritional  care  of  HIV-infected  children  (6  month-14 
years); http://www.who.int/nutrition/publications/hivaids/9789241597524/en/index.html 
45 DG ECHO HIV Guidelines, adopted on 8 October 2008. 

33

 
 
  
                                                 
Commission considers expanding its nutrition support to HIV/AIDS affected persons (through adapted 
nutrition interventions, or through food supplements in conjunction with anti-retroviral treatment). The 
entry point for the humanitarian assistance for nutrition, however, must be the threat or presence of a 
food or nutrition crises, and not the prevalence of chronic illness with nutritional implications. 

The link between HIV/AIDS and nutrition 

HIV  can  exacerbate  the  effects  of  humanitarian  crises.  Likewise,  displacement  from  a  stable 
environment,  food  insecurity  and  poverty  may  increase  vulnerability  to  HIV.  Humanitarian  disasters 
often  occur  in  areas  of  high  HIV  prevalence.  In  emergencies,  there  is  reduced  access  to  basic  food, 
health services, water and sanitation. These factors represent particular problems for people living with 
HIV  who have specific nutrition needs. People living with HIV (even those without symptoms) have 
increased energy requirements, so access to food is of particular importance for them. In emergencies, 
the essential health services and HIV support and treatment services are often disrupted. Antiretroviral 
treatments,  home-based  care  programmes,  nutritional  support  programmes,  and  palliative  care 
programmes  are  therefore  likely  to  be  in  disarray.  The  health  status  of  people  living  with  HIV  can 
deteriorate rapidly under these conditions, causing an additional burden on already strained emergency 
services.  As  gender  inequalities  may  also  be  exacerbated  in  emergencies,  there  is  a  considerable 
probability that such inequalities may result in a disproportionate increase in the vulnerability of women 
to  HIV,  as  opposed  to  the  rest  of  the  population.  Furthermore,  emergencies  often  result  both  in  the 
separation of families and the breakdown of social support systems for individuals outside traditional 
family structures, which can have a particular impact on people suffering from HIV.  

Important activities to be supported 

1.  Integration  of  HIV  into  all  aspects  of  emergency  care:  prevention,  education,  health,  basic 

services, planning and management; 

2.  Targeted food support; 
3.  Maternal and infant health and feeding; 
4.  Treatment and care of HIV; 
5.  Treatment of severe acute malnutrition; 
6.  Support networks, including livelihood support and home-based care; 
7.  Food hygiene, sanitation, water, shelter; 
8.  Protection 

Specific recommendations for maternal and infant health and feeding 

•  Exclusive breastfeeding for the first 6 months should be recommended for all infants regardless 
of HIV exposure (note: minimum requirements for safe formula feeding for babies born from 
HIV-positive mothers are usually not applicable in crisis settings).  

•  HIV  testing  should  be  performed  within  maternal  health  services  to  identify  HIV-positive 
women. HIV-positive women should receive ART (antiretroviral therapy) during pregnancy and 
delivery to reduce the likelihood of transmitting the virus to their children.  

•  HIV-positive women should be encouraged to continue breastfeeding for 12 months along with 
the  introduction  of  complementary  feeds.  When  breastfeeding  women  are  HIV-positive,  both 
mothers  and  infants  should  receive  ART  for  the  duration  of  breastfeeding  and  for  one  more 
week after breastfeeding has stopped.  

•  Because  these  women  and  children  are  at  increased  risk  of  malnutrition,  they  should  be 

regularly screened for growth, nutritional status and illness. 

Adapted from: Global Nutrition Cluster, Harmonized Training Package/Module 18, 2011 

34

 
 
 
 
 
 
 
 
6.3 Coherence, Coordination and Complementarity 

6.3.1 Being more effective in coordinating humanitarian and development aid: steps towards 

Resilience 

In  line  with  the  new  political  framework  on  resilience  and  the  Commission  Communication  on 
Resilience46,  the  Commission  stresses  the  need  to maximise sustainable,  inter-sectoral,  multi-
stakeholder support to undernutrition over the longer term, and to avoid the isolation of efforts within 
humanitarian  response,  with  the  aim  of  strengthening  the  resilience  of  the  most  vulnerable 
communities. 

In  particular,  while  respecting  the  difference  in  principles  and  objectives,  this  should  include  joint 
analysis and planning with development partners, in order to increase synergies.47  

The Commission ensures as far as possible that short term and longer-term nutrition-related needs are 
addressed in an integrated and articulated way to prevent gaps in assistance, avoid duplication, ensure 
continuity  and  maximise  sustainability.  To  do  this,  close  coordination  is  promoted  with  other 
international donors and national actors. For instance, the work that is currently underway in global and 
regional initiatives such as SUN may present significant opportunities for more effective joint planning. 
In  order  for  interventions  to  be  effective,  however,  each  country  situation  should  be  analysed 
individually and interventions should be designed according to needs and the comparative advantages 
of available actors. 

The  Commission  strives  to  operationalize  the  commitments  and  principles  laid  out  in  the  2007 
Consensus  on  EU  Humanitarian  Aid48  and  in  the  Commission  Communication  on  Resilience.  In 
particular,  attention  is  given  to  articulating  the  different  Commission  aid  instruments  and  ensuring 
appropriate  consideration  of  nutrition  issues  in  the  Commission's  development  policies  and  planning, 
with a specific focus on the relevant country strategy papers.  

Pakistan: Joint humanitarian-development programming in a natural disaster situation 

Operational Case Study 

The major floods in Pakistan in 2010 shed light on the serious situation of undernutrition that was 
already prevalent in the country, both at chronic and acute levels. 

In this context, most of the international humanitarian responses were usually concentrated on 
addressing acute undernutrition through food-based responses, with limited attention to those longer-
term investments that are necessary in order to prevent such decline. Support to food security, 
livelihoods and agriculture was not explicitly linked to combating undernutrition.  

DG ECHO and the Delegation of the European Union (DEU) in Pakistan acknowledged the need for 
more explicit attention on programme design in order to better address undernutrition. 

On the "Humanitarian side", the Commission’s interventions in nutrition and food assistance are based 
on a comprehensive mix of activities addressing the likely causes of the undernutrition in flood-affected 
areas of Pakistan. These include: 

46 http://ec.europa.eu/europeaid/what/food-security/documents/20121003-comm_en.pdf 

47 As an example, see the ‘Humanitarian Development Framework – a joint methodology between DG ECHO and 

DEVCO, 2012 

48 EU Humanitarian Consensus, 2007: Section 2.4, Article 22; Section 3.4, Article 53; Section 5; Annex. 

35

 
 
 
 
 
 
 
 
                                                 
- Support to the CMAM programme through UNICEF and NGOs  

- Support to WFP for large-scale food and cash distributions (mostly conditional on work programmes)  

- Flexible food security programmes designed according to the local context through an alliance of 6 
international NGOs 

On the "Development side" the following interventions are supported by the Food Security Thematic 
Programme (FSTP) 

- Conditional cash transfers for flood-affected communities 
- Integrated protection, offering women and their children a safe place where they could take part  in 
nutrition and childcare related discussions  
- Monitoring of child acute undernutrition and women’s diet  

Challenges: this ongoing experience indicates that systematic, informed and structured exchanges 
between humanitarian and development actors are necessary for addressing the immediate, underlying 
and basic causes of undernutrition. 

The  Commission  therefore  strives  to  achieve  better  coherence  and  complementarity  between 
humanitarian  and  development  interventions.  To  this  end,  and  taking  into  consideration  the  holistic 
approach required when tackling acute undernutrition, the Commission encourages, whenever possible, 
the adoption of a robust policy and the promotion of programme dialogue between all emergency and 
development stakeholders who are directly or indirectly involved in the nutrition field. 

Preparedness measures play a vital part in ensuring the connectivity between the fields of development 
and  humanitarian  action.  Efficient  avenues  of  work  should  emphasise  training,  capacity-building, 
awareness-raising, the establishment or improvement of local early-warning systems and contingency-
planning – all of which are highly relevant to nutrition assistance.  

Operational Case Study 

Mali: Joint Humanitarian-Development programming in Nutrition 

The separation between emergency and development can create challenges in the design of appropriate 
responses  to  any  given  context.  In  Mali,  for  example,  a  firm  distinction  between  emergency  and 
development interventions is not always possible for several reasons: 

- Nutrition crises triggered by a shock (e.g. increases in food prices or droughts) are the result of both 
entrenched chronic poverty and vulnerability. The same shock in a less poor/vulnerable context may not 
lead to any crisis (or to crises of a similar magnitude).  

-  Given  their  frequency,  these  crisis  situations  have  become  ‘chronic’  and  a  regular  feature  of  the 
Malian landscape. 

- The ordinary levels of wasting in Mali, outside crisis conditions, tend to be above commonly accepted 
emergency thresholds. 

In  Mali,  it  is  of  paramount  importance  that  a  package  of  measures  be  implemented  to  respond 
comprehensively to the existing situation. Such measures shall include addressing chronic poverty, food 
insecurity  and  vulnerability  alongside  specific  actions  to  prevent  and  treat  undernutrition.  Such  a 
package  has  been  provided  through  the  combination  of  European  Humanitarian  and  Development 
assistance: 

-The  European  Humanitarian  assistance  funds  the  treatment  of  acute  undernutrition;  the  provision  of 
nutrition information and advocacy, calling on the government and development actors to give greater 
priority to nutrition.  
-The European Development assistance funds UNICEF to: 

• 
• 

continue to support nutrition information and the treatment of acute undernutrition; 
enhance  prevention  work  through,  for  instance,  a  government/UNICEF  breastfeeding 

36

 
 
 
 
 
 
 
 
campaign; 
expand  advocacy  work  (e.g.  through  a  series  of  national  and  international  media  events)  to 
increase awareness on the existing nutrition problem and mobilise actors to address it (e.g. at 
central and decentralised government levels, among community networks); and 
strengthen the institutional setup and strategic environment that govern nutrition in the country.  

• 

• 

These practical links between humanitarian and development interventions were made possible through 
the coordination of European development assistance in the health sector and humanitarian assistance 
for nutrition. 

Lesson learnt: Effective coordination of humanitarian and development aid is not limited to technical 
complementarity,  but  requires  a  strong  political  commitment  towards  long-term  strategic  priorities  in 
the field of nutrition.  
To  this  end,  the  Commission  is  actively  involved  in  the  initiative  AGIR  (Alliance  Globale  pour  la 
Résilience) in the Sahel. 

6.3.2 Global Governance and Coordination for Nutrition in Emergencies 
Effective  coordination  is  paramount  for  the  successful  management  of  undernutrition  in  emergencies. 
To this end, the Commission supports the work of the Global Nutrition Cluster49 (with UNICEF as the 
lead agency), the Food Security Cluster and the Health Cluster.  
The Commission advocates for coherence and supports improved coordination for nutrition across all 
relevant sectors and through the engagement of all international actors who are involved in emergency 
nutrition activities.  
In  addition,  coordination  and  cooperation  need  to  go  beyond  operational  contexts,  in  order  to  ensure 
coherence  in  the  scientific  evidence-base  that  informs  policies  and  practice.  For  this  reason,  the 
Commission communicates with other global mechanisms which are concerned with nutrition such as 
the UN Standing Committee on Nutrition (UNSCN), SUN and the WHO’s Nutrition Guidance Expert 
Advisory Group (NUGAG), as well as the Committee on World Food Security (CFS).  

49 http://oneresponse.info/GlobalClusters/Nutrition/Pages/default.aspx 

37

 
 
 
 
 
                                                 
Annexes 

A.1  List of Abbreviations 

AIDS 
ART 
BMI 
CFS 
CFW 
CMAM  
CoD 
CSB (+/++) 

DALYs  
DEU 
DFID 
DG ECHO 
EDF 
EU 
Fe 
FSTP 
GAM 
GFD 
HEA 
HIV 
IASC 
INGO 
IPC 
IYCF(-E) 
LRRD   
MAM 
MAMI   
MDG 
MN 
MND 
MoH 
MUAC  
NGO 
NUGAG 
ORS 
OTP 
RUSF 
RUTF   
SAM 
SC UK   
SQUEAC 
SUN 
TFA 
TB 
USD 
U2s/U5s 
UNICEF 
UNSCN 
WASH  
WFP 
WHO 

Acquired immunodeficiency syndrome 
Anti-retroviral therapy 
Body-Mass Index 
Committee on World Food Security 
Cash for Work 
Community-based Management of acute Malnutrition 
Cost of Diet 
Corn-Soy Blend (+/++ refers to the addition of micronutrient 
mix/micronutrient mix and dried skim milk powder – replacing the basic CSB) 
Disability adjusted life years 
Delegation of the European Union 
Department for International Development – British Aid 
Directorate General for Humanitarian Aid and Civil Protection 
European Development Fund 
European Union 
Ferrous/Ferric - Iron 
Food Security Thematic Programme 
Global Acute Malnutrition 
General Food Distribution 
Household Economy Analysis 
Human immunodeficiency virus infection 
Inter-agency Standing Committee 
International Non-Governmental Organisation 
Integrated Phase Classification 
Infant and Young Child Feeding (in emergencies) 
Linking Relief Rehabilitation and Development 
Moderate Acute Malnutrition 
Management of acute Malnutrition in Infants 
Millennium Development Goals 
Micronutrient 
Micronutrient Deficiency 
Ministry of Health 
Mid-upper arm circumference  
Non-governmental Organisation 
Nutrition Guidance Expert Advisory Group 
Oral Rehydration Salt 
Outpatient Therapeutic Programme 
Ready-to-use supplementary food 
Ready-to-use therapeutic food 
Severe Acute Malnutrition 
Save the Children, United Kingdom 
Semi-Quantitative Evaluation of Access and Coverage 
Scaling up Nutrition (imitative/movement) 
Targeted Food Assistance  
Tuberculosis  
United States Dollar 
Under two(s) (children under two/five years of age) 
United Nations Children's Fund 
United Nation Standing Committee on Nutrition 
Water, Sanitation and Hygiene 
World Food Programme 
World Health Organization 

A.2 Note on Technical Terms 

38

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nutrition  is  the  science  of  how  nutrients  and  other  substances  in  food  act  and  interact  in  relation  to 
health. Nutrition security50 encompasses good health; a healthy environment; good care practices and 
household food security (see Figure 1).  

Food security occurs when people, at all times, have physical and economic access to sufficient, safe 
and nutritious food that meets their dietary needs and food preferences for an active and healthy life.51 
A family (or country) may be food secure, yet include individuals who are nutritionally insecure. Food 
security  is  therefore  a  necessary  but  not  sufficient  condition  for  nutrition  security.  Hunger  is  an 
outcome  of  food  insecurity,  where  dietary  intake,  at  population  level,  falls  below  minimum 
requirements (typically averaged as 2,100 kcal per person per day).  

Nutritional  status  is  the  physiological  condition  of  a  person  resulting  from  the  balance  between 
nutrient  requirements,  intake  and  the  body’s  ability  to  use  these  nutrients.  Anthropometry  is  human 
body measurement used as a proxy for nutritional status (as per nutrition surveys).  

Malnutrition  is  a  physical  condition  related  to  the  body’s  use  of  nutrients.  There  are  two  forms  of 
malnutrition: undernutrition and overnutrition. This document deals only with undernutrition, since it 
is that form of malnutrition that is of specific public-health concern in emergencies.  

An  emergency  or  humanitarian  crisis  is  an  event(s)  which  critically  threatens  the  health,  safety, 
security  or  wellbeing  of  a  large  group  of  people.  The  Commission  defines  an  emergency  based  on  a 
combination  of  absolute  thresholds  (such  as  Sphere  or  WHO)  and  relative  indicators  set  against  a 
contextual norm. A crisis is triggered by a hazard that may be natural or man-made, with rapid or slow-
onset, and of short or protracted duration.  

Undernutrition includes: i) intrauterine growth restriction which leads to low birth weight; ii) stunting; 
iii)  wasting  and  nutritional  oedema;  and  iv)  deficiencies  of  essential  micronutrients.  The  causes  of 
undernutrition are multiple and context-specific.  

Undernutrition  can  be  short-term  (acute)  or  long-term  (chronic).  Acute  undernutrition  in  children 
under  5  years  of  age  is  characterised  by  wasting  (low  weight  compared  to  height)  and/or  nutritional 
oedema.  Wasting  (marasmus)  is  a  condition  resulting  from  rapid  weight  loss,  or  a  failure  to  gain 
weight,  over  a  short  period  of  time.  Acute  undernutrition  can  be  moderate  or  severe.  Together,  these 
constitute the total (or ‘global’) rate of acute malnutrition (GAM). Moderate acute malnutrition (MAM) 
is  defined  as  wasting  >  -3  and  <  -2  Z-scores52  of  the  median  weight-for-height  of  the  reference 
population;  severe  acute  malnutrition  (SAM)  is  <  -3  Z-scores  and/or  nutritional  oedema  (bilateral 
pitting  oedema).  Nutritional  oedema  may  mask  wasting  and  therefore  weight-for-height  may  not  be 
observed. An alternative rapid way to estimate acute undernutrition in children as well as in pregnant 
and lactating women is the measurement of the mid-upper arm circumference (MUAC).  

The  management  of  acute  undernutrition  may  involve  the  use  of  specialised  nutritional  products53 
designed to supplement the diet with  specific  micronutrients, energy/protein or both. These foods are 
usually  intended  for  home  consumption,  and  are  distributed  through  general  rations,  blanket 
distributions (to groups at risk) or programmes targeting acutely undernourished individuals. 

Chronic undernutrition results in stunting i.e. low height compared to age (defined as <-2 Z-scores of 
the  median  height-for-age  according  to  WHO  growth  standards  for  children).  The  longer  time-scale 

50  Gross,  R.  et  al.  (1998)  in  Community  Nutrition:  Definition  and  Approaches.  Encyclopaedia  of  Human 
Nutrition. Ed. by Sadler, M., Strain S. and Caballero B. London. 
51 World Food Summit, 1996 

52 Z-score (or standard deviation score) is the deviation of the value for an individual from the median value of the 
reference population, divided by the standard deviation of the reference.  
53 The terms ready-to-use food (RUF) and ready-to-use therapeutic food (RUTF) are often used.  

39

 
 
 
 
 
 
 
 
 
 
 
                                                 
over  which  height-for-age  is  affected  makes  it  a  better  indicator  for  protracted  nutritional  deficiency. 
The measurement of stunting is more useful for long-term planning than for emergencies.  

Micronutrient  deficiencies  (MND)  are  a  form  of  undernutrition  that  is  related  to  vitamins  and 
minerals.  Deficiencies  of  iron,  iodine,  vitamin  A  and  zinc  are  amongst  the  top-10  leading  causes  of 
death  through  disease  in  developing  countries54.  Other  deficiencies  which  are  more  specific  to 
emergencies include those of thiamine (B1), riboflavin (B2); niacin (B3) and vitamin C. 

Underweight  in  children  is  a  non-specific  indicator  of  undernutrition,  since  it  includes  children  with 
low weight-for-height (wasting) or low height-for-age (stunting). It is defined as < -2 Z-scores of the 
median weight-for-age of WHO growth standards. Growth charts based on weight-for-age, are used for 
growth  monitoring  in  health  centres.  In  emergencies,  weight-for-age  can  be  used  to  indicate  the 
presence of a problem if data on acute undernutrition is not available.  

Adult  undernutrition  is  usually  assessed  using  Body  Mass  Index  (BMI)55  or  Mid  Upper  Arm 
Circumference (MUAC). Undernutrition in pregnant and lactating mothers is identified through MUAC 
and clinical signs (lack of appropriate weight gain during pregnancy). Short stature in women resulting 
from  past  stunting  (height  below  145cm  in  females  aged  15-49  years)  can  result  in  poor  pregnancy 
outcomes. 

Undernutrition and mortality are late indicators of a crisis. It is imperative that information on health, 
food security, water, sanitation and hygiene is used to interpret estimates of undernutrition. The WHO 
definition  of  thresholds56  to  guide  such  interpretation  varies  and  has  to  be  used  with  caution  and 
specificity  to  the  context  (also,  thresholds  for  the  prevalence  of  moderate  and  severe  acute 
undernutrition  in  children  under  five  years  of  age  are  subject  to  adjustments  in  light  of  the  revised 
WHO growth standards from 2006). Trend analysis can reveal a worsening situation even if thresholds 
have  not  been  crossed.  Nevertheless,  the  WHO  definitions  provide  a  reasonable  starting  point  in 
assessing the severity of a crisis. 

54  Black  R.  et  al  (2008):  Maternal  and  Child  Undernutrition:  Global  and  regional  exposures  and  health 
consequences.  Lancet  371,  243-260.  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61690-
0/fulltext 
55 Weight divided by the square of height (kg/m2) 
56 GAM emergency threshold > 15 %; Mortality emergency threshold >2/10,000/day, WHO 

40

 
 
 
  
 
 
                                                 
A.3 Policies and Guidelines in Support of this Staff Working Document 

This document draws on numerous internal and external policies, norms and guidelines. These are listed 
here so that the present document can be read and understood within this context. 

Internal 
The legal basis of EU humanitarian mandate is defined in the Humanitarian Regulation (June 1996)57. 
In line with this, nutrition interventions in crises are provided to meet humanitarian needs, but include 
support to prevent or mitigate disasters and short-term post-emergency recovery.  

The  position  paper  incorporates  the  core  principles,  objectives  and  standards  for  EU  humanitarian 
action which are delineated in the Humanitarian Aid Consensus (2008)58  

The  Commission  Communication  on  Humanitarian  Food  Assistance  Policy  and  its  Staff  Working 
Document59provides  a  framework  for  securing  adequate  food  consumption,  necessary  for  nutrition 
security. 

The  Commission  Communication  on  The  EU  Role  in  Global  Health  and  its  Staff  Working 
Document60 

The  Commission  Communication  on  An  EU  policy  framework  to  assist  developing  countries  in 
addressing food security challenges61  

The  nutritional  needs  of  specific  vulnerable  groups  are  addressed  in  DG  ECHO  HIV  Guidelines 
(October  2008)  and  the  Commission  Staff  Working  Paper  on  Children  in  Emergency  and  Crises 
Situations (2008); and 

The  Commission  Communication  on  Disaster  Risk  Reduction  (2009)  identifies  the  strengthening  of 
capacities in disaster-prone contexts as an appropriate objective during humanitarian response. 

External 

The Sphere Project. Humanitarian Charter and Minimum Standards in Disaster Response. 2011  

International Code of Marketing of Breast-milk Substitutes, WHO 1977 
WHO (2004) Guiding Principles for Feeding Infants and Young Children during Emergencies  

UNHCR/UNICEF/WFP/WHO (2004) Food and Nutrition Needs in Emergencies 

Management of Acute Malnutrition in Infants (MAMI) Project Review. Project commissioned by the 
IASC Global Nutrition Cluster. Summary Report, ENN, October 2009. 

Guidelines on Infant and Young Child Feeding in Emergencies. IFE Core Group, Feb 2007 

Community Based Management of Severe Acute Malnutrition. A Joint Statement by the World Health 
Organisation,  World  Food  Programme,  the  United  Nations  System  Standing  Committee  on  Nutrition 
and the United Nations Children's Fund. May 2007. 

Preventing and controlling micronutrient deficiencies in populations affected by an emergency. Joint 
statement  by  the  World  Health  Organisation,  the  World  Food  Programme  and  the  United  Nations 
Children's Fund. 2007. 

57 Council Regulation (EC) No 1257/96 of 20 June 1996 concerning humanitarian aid  OJ L 163, 
2.7.1996, p. 1–6 (ES, DA, DE, EL, EN, FR, IT, NL, PT, FI, SV)  
58 European Consensus on Humanitarian Aid, 2007 OJ L C25/01, 30.1.2008 

59 COM (2010)126 final, March 2010 

60 COM (2010)128 final, March 2010 

61 COM (2010)127 final, March 2010 

41

 
 
                                                 
WHO  Child  Growth  Standards  and  the  Identification  of  Severe  Acute  Malnutrition  in  Infants  and 
Children. A joint statement by the World Health Organisation, and the United Nations Children's Fund. 
2009. 

42