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See Bangladesh case study – a nutrition oriented livelihoods project and Mali case study on linking relief, rehabilitation and development, in separate file.

Further Reading

Aid Delivery methods: Volume 1. Project Cycle Management Guidelines. EuropeAid, March 2004.


Indicators for development projects will depend on the context, the sector chosen and the time frame, and could therefore be drawn from a very wide range of options. For this reason none are highlighted here. Please see the sector-specific indicators listed in Chapter 2 and Annex 3.

4.2.2 Guidance for addressing nutrition through humanitarian projects

In contrast to most development situations, emergency responses often have a very strong emphasis on undernutrition. The challenge therefore is not to integrate nutrition but to manage the responses, act on results and demonstrate the impact more consistently (see Box 16). Furthermore, nutrition concerns in emergencies are often superimposed on pre-existing undernutrition, in particular stunting, which is rarely prioritised. In this way emergencies offer an opportunity to start tackling underlying causes with a view to long-term outcomes (See the Myanmar case study on re-lactation in emergencies and, again, the Zimbabwe one on breastfeeding promotion in separate file).

Box 16: Key issues concerning nutrition in humanitarian response74

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 definition of an emergency is based on a combination of absolute thresholds (such as from Sphere or WHO) plus relative indicators set against a contextual norm. A crisis is triggered by a hazard that may be natural or man-made, rapid or slow-onset, and of short or protracted duration.

There is no agreed definition of a ‘nutrition emergency’, although attempts have been made to classify the severity of an emergency using acute malnutrition as one indicator. While acute malnutrition is a major concern during emergencies, chronic malnutrition and micronutrient deficiencies also arise triggering negative effects.

The key challenges in addressing undernutrition in emergencies are:

    • Responding to early warning indicators;

    • Promoting quality management of undernutrition in emergencies through evidence-based decision-making and implementation;

    • Building an evidence base in research priorities, including field-appropriate methods to assess the impact of action;

    • Ensuring a holistic and meaningful impact on undernutrition;

    • Measuring impact in relation to nutrition and mortality in emergencies;

    • Strengthen national capacity;

    • Ensuring more sustained support from development actors for tackling undernutrition.

While the table overleaf in 4.3.1 could also be applied for emergency projects, Table 6 below presents the most important steps to follow when dealing with nutrition in emergencies.

Table 6: Steps to incorporate nutrition in emergency projects


Actions to be taken

Guiding questions

1. Analysis and Scoping


Rapid assessment: Direct observations of population and environment, interviews with key informants, focus group discussions, review of relevant data available (e.g. health facilities), rapid surveys

Surveys: cluster sample surveys of under-fives (possibly including older children and/or women)

Nutrition surveillance: Repeated surveys, sentinel site surveillance, food security information system

Is there an existing, or a threat of a, nutritional emergency?

What is the estimated number affected by undernutrition?

What is the prevalence of undernutrition?

What are the immediate needs?

What are local available resources and external resources needed?

Are micronutrient deficiencies (likely to be a problem)?

How has the nutritional status changed over time? What could happen in the immediate future?

2. Design (Formulation)

Determine the most appropriate response to the emergency:

moderate and/or severe acute malnutrition: support for community-based management (CMAM) with facility-based management for cases with complications; supplementary feeding;

micronutrient deficiencies: provision of vitamin A, iron etc.;

disease-related undernutrition: de-worming, prevention and early treatment of diarrhoeal diseases, measles vaccination and malaria prevention/control;

safe water, sanitation and hygiene: Improve access to safe water, hand washing and basic hygiene measures (e.g. soap);

access to adequate, safe and nutritious food: cash transfers or vouchers; general food distribution; blanket feeding of at-risk groups;

nutrition information systems (early warning);

national capacity building.

Is nutrition information regularly collected (including anthropometric data)? If not, should it be built into the project design?

Are there capacity gaps (local/national) that need to be filled in order to manage the undernutrition situation?

Is there the capacity to deal with future seasonal peaks of undernutrition?

What preparedness and mitigation steps could help build community/structural resilience to future (recurrent) shocks?

3. Implementation and Monitoring

the programme responds to problems identified; changes in the broader context are continually monitored; feedback from affected groups feeds in to modifications needed.

How will be programme be phased out or handed over to national structures?



assess timeliness, appropriateness, cost effectiveness and impact of emergency interventions.

Is the emergency response in line with the country’s long-term development strategy?

Is the response conducive to long-term gains?

Key lessons on linking relief, rehabilitation and development75

Experience has demonstrated the need to maximise sustainable, inter-sectoral support for undernutrition over the longer term, and not to simply isolate efforts within humanitarian response. See Mali case study on linking relief, rehabilitation and development, and the Nepal one again in separate file.

Lessons on strengthening the coherence and complementarity between humanitarian and development contexts include:

  • encourage robust policy and programme dialogue between emergency and development stakeholders involved in the nutrition field;

  • support cooperation between humanitarian and development actors, (for example through joint assessments, monitoring and evaluation), in order to prevent gaps or duplication in assistance and to promote continuity;

  • develop preparedness measures to link development and humanitarian situations;

  • emphasise training, capacity building, awareness-raising, reliable local early-warning systems and contingency planning;

  • ensure as much flexibility as possible within the instruments to be used in order to promote a smooth transition between prevention, preparedness, emergency response and recovery;

  • promote advocacy to ensure all instruments and actors respond appropriately to nutrition in emergencies.

Niger: cash transfer in the context of a food crisis

Tessaoua, in the Maradi region of Niger, suffered severe food insecurity in the lean season of 2008. This was triggered by the global food price rise and local economic problems in neighbouring northern Nigeria (leading to a rise in prices of staple foods). This placed great pressure on the already low purchasing power of poor households in the area.

A cash transfer pilot project was set up to combat food insecurity and resultant undernutrition. Its specific aims were to offset the seasonal loss of purchasing power, enable households to meet basic needs (including food), protect livelihoods by preventing depletion of productive assets and help prevent undernutrition by addressing the economic causes.

The project targeted very poor households (identified through the ‘Household Economy Approach’ and wealth ranking) in areas declared that the government classed as severely food insecure. About € 90 a month was distributed to 1500 households (approximately one third of the population) over a three-month period. Women were the recipients of the transfer and payments were on condition that the women attended nutrition awareness sessions and participated in community public health activities.

The project wasimplemented by Save the Children UK, in partnership with the Tessaoua sub-regional food crisis management and prevention committee (CSR/ PGCA). It was funded by ECHO. Monitoring was based on a sample of 100 beneficiary households, and included anthropometric measurement of children under the age of five years.


  • Significant improvement in food consumption, both in terms of quantity (energy) and quality (through increased purchase of dairy products, oil and meat, which provide essential protein and micronutrients);

  • Following the first cash distribution, 80 % of households were able to add milk to the millet-based gruel traditionally fed to children (especially during weaning), whereas only half could do so before the project;

  • The nutritional status (measured by weight to height) of children under five years in beneficiary households improved following the first cash transfer. It worsened between the second and third distributions, which coincided with the seasonal increase in malaria and diarrhoea;

  • Despite a substantial improvement in food consumption, households still lacked micronutrients, particularly those found in animal products. These are expensive and, therefore, consumed in small quantities and only infrequently. Other measures are needed to offset the lack of micronutrients: either by increasing the amount of cash transfers, or considering micronutrient supplements, which could be more cost-effective in the short term.

These resultssuggest that cash transfers have the potential to improve diets and reduce acute malnutrition. As such, therefore, they should be considered within a package of measures to address undernutrition, particularly alongside other measures to increase access to micronutrients (e.g. supplementation) and to reduce the nutritional impact of diseases. The potential nutritional benefit of cash transfers is more likely to be realised if nutrition is included as an explicit objective and if other non-economic determinants of undernutrition are also addressed.

See also Kenya case study in Chapter 2.

Many of the sector-specific indicators listed in Chapter 2 also apply to emergencies. In addition, The Sphere Handbook (2011 edition) presents a comprehensive set of agreed indicators that span nutrition, food security, health, water/sanitation and shelter that should be incorporated into emergency monitoring systems. Box 17 highlights those that are most relevant to an overall assessment of the situation.

Box 17: Key nutrition indicators in emergencies

  • Prevalence of wasting in children under five

  • Prevalence of low MUAC (children 6 to 59 months)

  • Prevalence of severe acute malnutrition (including oedema) in children under five

  • Prevalence of low BMI in women of reproductive age

  • Exclusive breastfeeding until 6 months

  • Early initiation of breastfeeding

Further Reading

Sphere, 2011: The Humanitarian Charter and Minimum Standards in Humanitarian Response /

WHO, 2009: Child Growth Standards t/childgrowth/publications/technical_report_velocity/en/index.html

WHO, 2000: Manual on the management of nutrition in major emergencies t/publications/2000/9241545208.pdf

ECHO, 2010: Interim Position on Nutrition (internal document)

ECHO, 2009: Food Assistance Policy http://ec.europa.eu/echo/files/policies/sectoral/Food_Assistance_Comm.pdf

The Global Nutrition Cluster: The Harmonised Training Package


WFP, 2003; Food and nutrition needs in emergencies t/nutrition/publications/en/nut_needs_emergencies_text.pdf

Save the Children, emergency health and nutrition toolkit,


Good Humanitarian Donorship Principles, 2003 http://www.goodh/gns/principles-good-practice-ghd/overview.aspx

The Integrated Food Security Phase Classification, IPC. /

Emergency Nutrition Network /


Annex 1: Glossary

Acute malnutrition is characterised by wasting, but also includes kwashiorkor (nutritional oedema). It results from recent rapid weight loss, or a failure to gain weight over a short period of time (important in growing children). Acute malnutrition can be moderate (MAM) or severe (SAM). In combination it is global acute malnutrition (GAM). MAM is defined as wasting < -2 Z-scores of the median weight-for-height of the reference population; SAM is < -3 Z-scores and/or nutritional oedema.

Adult undernutrition: Thinness is assessed using Body Mass Index (BMI) – weight divided by the square of height (kg/m2). BMI <18.5 denotes moderate undernutrition, and <16 severe. Adult chronic undernutrition is important in pregnancy outcomes: height below 145cm in females aged 15-49 years. Mid-upper arm circumference (MUAC) is another indicator of adult undernutrition.

Anaemia may be caused by lack of iron, folate or vitamin B12. It is difficult to diagnose accurately from clinical signs which include pallor, tiredness, headaches and breathlessness. WHO defines anaemia in children under 5 years of age and pregnant women as a haemoglobin concentration < 110 g/l at sea level.

Cut-off values for public health significance76


Prevalence cut-off values for
public health significance


≤ 4.9 No public health problem

5.0–19.9 Mild public health problem

20.0–39.9 Moderate public health problem

≥ 40.0 Severe public health problem

Anthropometric status: Body measurements of an individual in relation to reference values.

Anthropometry is human body measurement. Anthropometric indices can be single measures, such as mid-upper arm circumference, or combinations, such as weight and height. They are taken as proxy indicators of nutritional status.

Artificial feeding refers here to the feeding of infants <6 months with breast milk substitute.

Bitot’s spots are triangular patches of keratin built up on the conjunctiva of the eye. They are an early sign of vitamin A deficiency.

Blanket feeding covers all of an affected population without targeting specific sub-groups.

Blended food is a precooked fortified mixture of cereals and other ingredients such as pulses, dried skimmed milk and vegetable oil. Blended foods are usually intended for young children as they provide essential micronutrients whilst also being energy-dense.

BMI – see adult undernutrition. The following cut-offs have been agreed:-

BMI < 17.0 indicates moderate and severe thinness

BMI < 18.5 indicates underweight. 3–5 % of a healthy adult population has a BMI < 18.5.

BMI 18.5–24.9 indicates normal weight

BMI ≥ 25.0 indicates overweight

BMI ≥ 30.0 indicates obesity

A BMI < 16.0 is associated with a markedly increased risk of ill health, poor physical performance, lethargy and even death; this cut-off is therefore a valid extreme limit.77

Cut-off values for public health significance:


Prevalence cut-off values for public health significance

Adult BMI < 18.5


5-9 % Low prevalence (warning sign, monitoring required)

10-19 % Medium prevalence (poor situation)

20-39 % High prevalence (serious situation)

≥ 40 % Very high prevalence (critical situation)

Calorie is a measure of energy usually measured in Kilocalorie (Kcal). It can describe energy used up by the body (energy expenditure) or the energy content of food that is eaten (caloric intake).

Cash transfer is a form of social transfer which provides cash to target populations. Conditions may be attached.

Chronic undernutrition: see stunting.

CMAM, or community-based management of acute malnutrition, is a cost-effective and efficient method for treating severe (and moderate) cases of acute malnutrition using ready-to-use foods. In patient care is required for cases with medical complications, otherwise malnourished children (and adults) are supported through community-based systems.

CTC, or Community based Therapeutic Careinvolves treating as many cases as possible of severe acute malnutrition, without clinical symptoms, as outpatients using ready-to-use therapeutic foods (RUTFs).

Complementary feeding: the process starting when breast milk alone or infant formula alone is no longer sufficient to meet the nutritional requirements of an infant, and therefore other foods and liquids are needed along with breast milk or a breast milk substitute. The target range for complementary feeding is generally considered to be 6 - 23 months.

Cretinism is a form of severe iodine deficiency disorder presenting as mental impairment. It is caused by iodine deficiency during critical periods of brain development.

DALY stands for disability-adjusted life year. It is an estimate of the potential years of healthy life (and thereby economic productivity) lost due to ill-health and/or disability.

Diarrhoeal diseases cause diarrhoea (runny stools, with or without blood). The three most deadly diseases are: cholera, bacillary dysentery and typhoid.

DHS or Demographic and Health Surveys are nationally-representative household surveys conducted every 5 years or so.

Early warning system is an information system designed to monitor indicators that may predict or forewarn of impending food shortages or famine.

Emergency or humanitarian crisis is a situation requiring humanitarian assistance. The health, safety, security or well-being of a large group of people are under threat. A crisis stems from natural or man-made causes, is rapid or slow-onset, and of short or protracted duration.

Exclusive breastfeeding describes an infant feeding practice where only breast milk is given - no other liquids or solids. Drops or syrups of micronutrients or medicines may be given.

Food security describes the situation where people have physical and economic access to sufficient, safe, nutritious, and culturally acceptable food to meet their dietary needs at all times.

Fortification of food is the addition of micronutrients to food, during or after processing.

Goitre is an enlargement of the thyroid gland which becomes visible in the neck area. It can indicate iodine deficiency.

Growth monitoring involves the regular individual measurement of a child’s growth (weight for age) and the plotting of results on a ‘Road to Health’ chart. The intention is to then use the visual depiction of a child’s growth as a basis for dialogue with the mother/caregiver (hence the use of the term Growth Monitoring and Promotion (GMP).

Hunger (or undernourishment) is used at population level to describe the situation when dietary intake is below minimum requirements (typically taken as an average of 2 100kcal per person per day). Hunger is an outcome of food insecurity.

Incidence is defined as the number of new cases over a specified period of time.

Infant mortality rate is defined as the number of deaths of infants (aged less than 12 months) per 1000 live births in a given population.

Infant and young child feeding (IYCF) describes the feeding practices for infants (aged less than 12 months) and young children (aged from 12 to 23 months).

Iodine deficiency (see also Goitre and Cretinism). A median urinary iodine concentration in a population of < 100 μg/l indicates that the iodine intake is insufficient. A population’s median urinary iodine (UI) concentration should be at least 100 μg/l, with less than 20 % of values < 50 μg/l. For pregnant women, the median urinary iodine should be 150–249 μg/l.78

Cut-off values for public health significance:


Prevalence cut-off values for public health significance

Iodine deficiency

(median UI concentration μg/l)

< 20 μg/l Severe deficiency

20–49 μg/l Moderate

50–99 μg/l Mild deficiency

100–199 μg/l Optimal

200–299 μg/l Risk of iodine-induced hyper-thyroidism

≥ 300 μg/l Risk of adverse health consequences

Reference: WHO, 2008.

Kwashiorkor is a form of severe acute malnutrition, characterised by bilateral pitting oedema. Low weight-for-height may not be observed in cases of kwashiorkor where wasting is masked.

Livelihood comprises the capabilities, assets and activities required for a means of living. Households have different capabilities and assets, and adopt different livelihood strategies and activities to secure their livelihoods.

Malnutrition is a physical condition related to the body’s use of nutrients. There are two forms of malnutrition: undernutrition and overnutrition. This paper focuses on undernutrition.

Maternal mortality ratio is the ratio of the number of maternal deaths per 100 000 live births. It is used as a measure of the quality of a healthcare system. WHO definesmaternal death as the death of a woman whilst pregnant or within 42 days of termination/end of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental causes.

Maternal undernutrition: BMI of less than 18·5 kg/m². Prevalence ranges from 10 % to 19 % in most countries. Above 20 %, maternal undernutrition is serious; 40 % is a critical situation.

MDG1: Eradicate extreme poverty and hunger. The third specific target is to reduce by half the proportion of people who suffer from hunger. The indicators for this are the prevalence of underweight children aged below five years and the proportion of the population below the minimum level of energy consumption.

Micronutrient deficiencies are the form of undernutrition 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 countries. Other deficiencies more specific to emergencies include thiamine, vitamin B, niacin and vitamin C deficiencies.

MICS or Multiple Indicator Cluster Survey is a UNICEF initiative to assist countries in monitoring the situation of children and women – regarding health, education, child protection and HIV/AIDS. Surveys are undertaken in country every five years or so.

MUAC, or mid-upper arm circumference, is an anthropometric measurement used to assess nutritional status in children and adults.

Morbidity is the prevalence or incidence of disease.

Mortality, or death, is usually expressed as a rate in a population, specified for a particular group of people – such as infants, mothers during/after birth or under-five children. Crude mortality rate encompasses an entire population group.

Nutrition is the science of how nutrients and other substances in food act and interact in relation to health and disease. Nutrition is also about the processes by which the body ingests, absorbs, transports, utilises and excretes food substances.79

Nutrition security80 is an outcome of good health, a healthy environment, good caring practices and household-level food security. A family (or country) may be food secure, yet have many individuals who are nutritionally insecure. Food security is therefore often a necessary but not sufficient condition for nutrition security.

Nutritional index is derived by relating an individual’s body measurement with the expected value of an individual of the same height (or age) from a reference population. Weight-for-height is the nutritional index commonly used to reflect acute undernutrition (wasting) in emergency nutritional assessments.

Nutritional status is the physiological condition of an individual that results from the balance between nutrient requirements, intake and the ability of the body to use these nutrients.

Nutrition surveillance involves the regular collection of nutrition information to monitor the situation. Information is used for decisions about actions or policies that will affect nutrition.

Nutrition surveys are carried out to assess the severity and extent of undernutrition in a given geographical area. They can be conducted as occasional exercises or as part of regular monitoring.

Percentile describes the rank position of an individual on a given reference distribution, stated in terms of what percentage of the group the individual equals or exceeds.

Prevalence describes the percentage of a population with a specific characteristic or condition (such as undernutrition) at a particular time.

Public nutrition approach recognises that nutritional status is affected by a complex mix of factors and tends to include multiple avenues of intervention (rather than a single approach).

Reference population is based on surveys of healthy children, whose measurements represent an international reference for interpreting an individual’s anthropometric status.

Selective feeding programmes include supplementary or therapeutic feeding programmes.

Stunting describes chronic undernutrition, characterised by low height compared to age (denoted as <-2 Z-scores of the median height-for-age according to WHO growth standards for children). The longer timescale over which height-for-age is affected makes it more useful for long-term planning and policy development, rather than for emergencies. Severe stunting is defined as a height-for-age index <- 3 Z-scores below the median of the international reference population.

Supplementation is the provision of extra nutrients (micronutrients or energy/protein) in the form of food, tablets, capsules, syrup or powder.

Threshold can refer to either to the nutritional status of an individual or the prevalence of undernutrition in a population group. The threshold below which nutritional status is associated with excess mortality is likely to vary with different environments. The following are established cut-off values:


Prevalence cut-off values

for public health significance


< 10 %: Low prevalence

10-19 %: Medium prevalence

20-29 %: High prevalence

≥ 30 %: Very high prevalence


< 20 %: Low prevalence

20-29 %: Medium prevalence

30-39 %: High prevalence

≥ 40 %: Very high prevalence


< 5 %: Acceptable

5-9 %: Poor

10-14 %: Serious

≥ 15 %: Critical

Reference: WHO, 1995 p. 208 and 212.

Under-five mortality rate (U5MR) is the probability of a child dying before reaching the age of five. U5MR is, strictly speaking, not a rate (i.e. the number of deaths divided by the number of population at risk during a certain period of time) but a probability of death derived from a life table and expressed as rate per 1 000 live births.

Undernutrition includes intrauterine growth restriction which leads to low birth weight, stunting, wasting and deficiencies of essential micronutrients. Undernutrition results from inadequate food consumption, poor absorption and/or impaired biological use of nutrients.

Underweight in children is defined as < -2 Z-scores of the median weight-for-age of WHO growth standards. Severe underweight is < -3 Z-scores. It includes children with low weight-for-height (wasting) or low height-for-age (stunting). Growth charts based on weight-for-age are used for growth monitoring in health programmes. Weight-for-age is less useful in emergencies, but can act as a proxy indicator for undernutrition if data on acute undernutrition are not available.

Vitamin A deficiency (see also Bitot’s spots). The clinical diagnosis of vitamin A deficiency is based on the spectrum of eye conditions known as xerophthalmia, ranging from mild night blindness to corneal necrosis. The sub-clinical diagnosis is based on blood concentrations of retinol (the chemical name for vitamin A) in plasma or serum. A concentration of < 0.70 μmol/l indicates subclinical vitamin A deficiency in children and adults, and < 0.35 μmol/l indicates severe vitamin A deficiency.

Cut-off values for public health significance:


Prevalence cut-off values for public health significance

Serum or plasma retinol
< 0.70 μmol/l in preschool-age children

≥ 2 %-< 10 % Mild

≥ 10 %-< 20 % Moderate

≥ 20 % Severe

Night blindness in pregnant women

≥ 5 % Moderate

Reference: WHO, 2009 p 8.

Vulnerability: The characteristics of a person or group related to their capacity to anticipate, cope with, resist and recover from the impact of a natural or man-made hazard. Vulnerability to undernutrition is conditional on the hazards of loss of access to food, appropriate nutritional care, or an inability to physiologically utilise available food because of infection or other disease.

Wasting (or ‘marasmus’) describes acute undernutrition characterised by low bodyweight compared to height (i.e. < -2 Z-scores of the median weight-for-height81 according to WHO growth standards). Severe wasting is defined as a weight-for-height <- 3 Z-scores of the median of WHO standards. Weight-for-height is recommended for assessments of recent nutrition, and is especially important for assessments of nutrition-related humanitarian emergencies.

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.

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