Executive Summary

As the world enters a new millennium, natural disasters and international or internal conflicts continue to displace hundreds of thousands of people. The human and physical needs of disaster and other emergency victims—deprived of or uprooted from their homes, on the road or in crowded camps and exposed to harsh elements—are paramount in efforts to provide a significant measure of relief. In response to the plight of refugees, the United States has provided assistance in many ways to victims of such emergencies the world over, most notably via food programs.

To a large extent, the emergency food relief assistance provided by the U.S. government has been channeled through the U.S. Agency for International Development (USAID) and the Department of Defense (DOD). The bulk of medium- and long-term food relief contributed by USAID has traditionally been in the form of commodity foods. However, USAID and DOD also participate in rapid, short-term food relief operations that require special high-energy, self-contained food products not currently manufactured in the United States. Such products constitute the vanguard of food relief and are designed for use over the normally short period of time needed to establish a more permanent, stable, food-based relief pipeline. Because of legislative restrictions on the use of some federal appropriations, only limited purchases of such products can be made by USAID from food manufacturers outside the United States. The availability of science-based technical specifications for use in calls for bids from U.S. food manufacturers, therefore, is of the essence not only to allow procurement of the most appropriate product, but also to do so in the United States.



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High-Energy, Nutrient-Dense Emergency Relief Food Product Executive Summary As the world enters a new millennium, natural disasters and international or internal conflicts continue to displace hundreds of thousands of people. The human and physical needs of disaster and other emergency victims—deprived of or uprooted from their homes, on the road or in crowded camps and exposed to harsh elements—are paramount in efforts to provide a significant measure of relief. In response to the plight of refugees, the United States has provided assistance in many ways to victims of such emergencies the world over, most notably via food programs. To a large extent, the emergency food relief assistance provided by the U.S. government has been channeled through the U.S. Agency for International Development (USAID) and the Department of Defense (DOD). The bulk of medium- and long-term food relief contributed by USAID has traditionally been in the form of commodity foods. However, USAID and DOD also participate in rapid, short-term food relief operations that require special high-energy, self-contained food products not currently manufactured in the United States. Such products constitute the vanguard of food relief and are designed for use over the normally short period of time needed to establish a more permanent, stable, food-based relief pipeline. Because of legislative restrictions on the use of some federal appropriations, only limited purchases of such products can be made by USAID from food manufacturers outside the United States. The availability of science-based technical specifications for use in calls for bids from U.S. food manufacturers, therefore, is of the essence not only to allow procurement of the most appropriate product, but also to do so in the United States.

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High-Energy, Nutrient-Dense Emergency Relief Food Product BACKGROUND AND CHARGE TO THE COMMITTEE The present study was conducted by an ad hoc subcommittee of the Committee on Military Nutrition Research. The Subcommittee on Technical Specifications for a High-Energy Emergency Relief Ration was established by the Food and Nutrition Board of the Institute of Medicine in response to a request from USAID and DOD to develop technical specifications for a product for use in food relief after natural disasters or other emergency situations around the world. The specifications are to be used by both agencies in their calls for bids from U.S. food manufacturers to supply such a product. The charge to the subcommittee was as follows: Based on information on the nutritional requirements of target populations, food/nutrition specifications, product descriptions of similar rations already in use (e.g., emergency biscuits), and recommendations by refugee nutrition experts, what are the committee’s recommendations to these questions: What are the specifications for a cost-effective emergency ration bar for uprooted people in emergency situations that meets all of the following criteria: satisfies all nutrient requirements for a population of all ages over 6 months appropriate for use as the sole source of subsistence for up to 15 days acceptable to people of any ethnic and religious background can be eaten on the move without preparation steps can, without significant cost increase, be prepositioned in harsh environments for at least 3 years can, without significant cost increase, withstand an airdrop without endangering persons on the ground Specifications should include consideration of each of these categories: nutritional composition, including macro- and micronutrient content and water content food properties, including nutrient stability, food consistency, palatability, and organoleptics universal acceptance, especially cultural acceptability to refugees and displaced persons configuration, size, color, and shape packaging for shipping, long-term stability (3 years), stability for airdrop, and ease of use feasibility of manufacture commodity cost within limitations of average relief operations

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High-Energy, Nutrient-Dense Emergency Relief Food Product Make recommendations on special circumstances when this ration should and should not be used (and any provisions for simple alternatives or supplements), including: severely malnourished groups of refugees or liberated prisoners of war who may have specific micronutrient deficiencies or protein deficiency populations with a high prevalence of disease, such as acquired immune deficiency syndrome or diarrheal diseases individuals in harsh environmental conditions. METHODS The subcommittee met twice during the study. The first meeting was held at the U.S. Army Soldier Systems Center, Natick, Massachusetts, to allow the subcommittee to benefit from the experience of the DOD Combat Feeding Program, Performance Enhancement and Food Safety Team, and thus gather information on processes, ingredients, and packaging systems used by the U.S. Army in developing products similar to the desired emergency food product (EFP). Also at this meeting, USAID representatives described the agency’s worldwide emergency food relief programs, and three USAID consultants discussed two background papers commissioned for this purpose by the agency. Moreover, the consultants contributed invaluable information on field conditions during emergency food relief operations that were taken into consideration by the subcommittee in its deliberations. The second and final subcommittee meeting was held in Washington, D.C. REPORT ORGANIZATION The report contains four chapters. Chapter 1 summarizes the project scope, its rationale, and the background for the need and uses of an EFP. It describes the types of emergencies and populations expected to benefit from such a product, and the special circumstances inherent to food relief operations after natural or man-made disasters, famines, massive displacement of people, and other emergencies that must be considered in defining the nutritional, chemical, and physical characteristics the EFP should have. Chapter 2 describes the basic assumptions underlying the energy level chosen for the EFP, the calculations of macro- and micronutrient levels, and, in some instances, the recommended origin or modality of the nutrients to be used. The daily energy requirement recommended for planning emergency aid rations by a 1995 IOM report (2,100 kcal/day) was adopted by the subcommittee. Fundamental assumptions made by the subcommittee in determining the nutritional content of the EFP are given in Box ES-1. Each macro- and micronutrient specification is discussed individually in Chapter 2. However, the subcommittee’s recommendation for each is presented

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High-Energy, Nutrient-Dense Emergency Relief Food Product BOX ES-1 Assumptions Used in Developing the Nutrition Composition of the EFP Potable water is provided as a top priority and is available with the EFP. Individuals will eat to meet their energy requirements. The product is to be consumed by all age groups, except infants less than 6 months of age; thus the product is not to be used in lieu of breast feeding, which is encouraged to at least 1 year of age with complementary use of the EFP after 6 months of age. It is not to be used as a therapeutic product and is not appropriate for severely malnourished individuals. It may constitute the sole source of food for target recipients for up to 15 days. Recipients are likely to be at least mildly malnourished and/or suffer from mild to moderate diarrhea and other debilitating diseases brought about by unsanitary conditions and exacerbated by stress. The recipient population may have nutrient needs comparable to well-nourished individuals in spite of smaller body weights due to maintaining muscle and visceral mass at the expense of body fat. The product should provide a nutrient density that will meet or exceed the nutrient recommendations as specified by the recommended intakes (IOM, 1997, 1998, 2000, 2001; NRC, 1989) which are designed to meet the needs of almost all individuals in each life stage and gender group (with the exception of infants) without exceeding Tolerable Upper Intake Levels (IOM, 1997, 1998, 2000, 2001). Nutrient needs of pregnant and lactating women are not included in the calculations, but it is assumed they will consume more than the daily ration based on individual needs for additional energy beyond the average of 2,100 kcal/day. in tabular form in Chapter 4 (as Table 4-1) for ease of use by the agencies and potential manufacturers. Chapter 3 discusses the preservation, processing, and packaging techniques that manufacturers should use in preparing the EFP so that it will attain the required stability under the expected conditions of delivery and use. These conditions might include extreme temperatures, rough handling, improvised storage, and the possible need to airdrop the product from low altitude. The recommendations from Chapter 3 are presented in the form of a performance specification for use by the agencies in preparing a call for bids in Chapter 4. The subcommittee views the technical specifications recommended in this report as optimal, but recognizes that the sponsoring agencies may be forced to consider developing EFPs prepared and packaged in less desirable ways if cost becomes the primary consideration.

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High-Energy, Nutrient-Dense Emergency Relief Food Product RECOMMENDATIONS There are five characteristics critical to development of a successful EFP. These are listed in order of importance. The EFP must be: Safe Palatable Easy to deliver Easy to use Nutritionally complete. In terms of decisions in the development of a prototype, this order of importance of the EFP should guide decisions about trade-offs between competing characteristics. In addition, it is recognized that the EFP must meet economical considerations; although considered in developing the specifications, it was beyond the scope of this report to weigh technical and nutritional advantages versus cost in a cost–benefit analysis. In addition to the recommended levels of each macro- and micronutrient presented in Table ES-1, the following recommendations are made: Microbiological stability. Preservation techniques that include combinations of low water activity values and some preservative(s) are the best approach to achieve microbiological stability of the EFP. Chemical stability and nutrient retention. A water activity level lower than 0.4 in the EFP is necessary to ensure protection against nutrient degradation. Microencapsulation of selected components and nutrients, particularly vitamin E together with highly unsaturated lipids, ascorbic acid, and iron (as FeNa EDTA), and other minerals is essential to minimize adverse lipid oxidation and nutrient losses. Antioxidants could be used in combination with microencapsulation depending on the ingredients used to prepare the EFP. Flavor and color. Based on anecdotal information, is suggested that only a sweet flavor and natural colors be used. The product, if dispersed in water, must not resemble milk. However, potential manufacturers should be encouraged to propose other flavors for the EFP, but these flavors should be tested for acceptability as described below. Ingredients. The ingredients used to prepare the EFP must provide the nutritional profile and other characteristics defined in the specifications. However, because the product will be distributed among multiple ethnic and cultural groups, alcohol or animal products other than milk may not be used. Use of milk solids must be limited so that lactose levels are not in excess of amounts known to be tolerated by individuals who are lactose maldigestors. Foods containing known allergens, such as peanuts, should be avoided. Some

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High-Energy, Nutrient-Dense Emergency Relief Food Product TABLE ES-1 Nutritional Content of the Emergency Relief Food Product (EFP)a Nutrient Limiting Group Minimum Required Nutrient Density per 1,000 kcala Amount per Single (233 kcal; 50g) EFP Bar Fat N/A   9–12 g Proteinb 51+ yr, men   7.9 g Carbohydrate N/A   23–35 g Sodiumc 2–5 yr, children 1.3 g 300 mg Potassiumc 2–5 yr, children 1.7 g 396 mg Chloridec 2–5 yr, children 2.0 g 466 mg Calcium 9–13 yr, children 768 mg 180 mg Phosphorus 9–13 yr, children 740 mg 172 mg Magnesium 14–18 yr, boys 190 mg 45 mg Chromium — 13 µgd 3 µg Copper 51+ yr, women 560 µgd 131 µg Iodine 1–3 yr, children 105 µg 25 µg Irone 19–50 yr, women 16 mgd 3.8 mg Manganese 1–3 yr, children 1.4 mg 0.33 mg Selenium 14–18 yr, girls 28 µg 6.5 µg Zinc 14–18 yr, boys 10.5 mgd 2.4 mg Vitamin A 14–18 yr, boys 500 µgd 117 µg Vitamin D 51–70 yr, women 5.2 µgd 1.2 µg Vitamin E 14–18 yr, girls 16 mgd 2.2 mg Vitamin K 19–50 yr, men 60 µg 14 µg Vitamin C 51+ yr, men 100 mgd 11.1 mg Thiamin 1–3 yr, children 1.2 mgd 0.28 mg Riboflavin 14–18 yr, boys 1.2 mgd 0.28 mg Niacin 14–18 yr, boys 11.2 mg NEd 2.6 mg NE Vitamin B6 51+ yr, women 1.2 mgd 0.28 mge Folatef 14–18 yr, girls 310 µg DFEd 72 µg DFE Vitamin B12 14–18 yr, girls 12 µgd 2.8 µg Pantothenic acid 14–18 yr, girls 3.9 mgd 0.9 mg Biotin 51+, women 24 µgd 5.6 µg Choline 51+, men 366 mgd 85 mg a Ration set at 2,100 kcal/d (IOM, 1995). b From NRC (1989); based on reference weights from IOM (1997) and estimated energy expenditure from Table 2-3. c Values based on estimated requirements or desirable intakes (NRC, 1989). d Adjusted from baseline nutrient density value; see text for explanation. e Based on 10% iron bioavailability. f If folate is provided as synthetic folate, which is more readily absorbed, these numbers should be divided by 1.6. SOURCE: IOM (1997, 1998, 2000, 2001).

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High-Energy, Nutrient-Dense Emergency Relief Food Product recommended ingredients are the following in order to provide nutrients as specified (see Table ES-1): cereal base: wheat flour, corn, oat flakes or flour, rice flour protein: soy products, such as concentrates or isolates; milk solids, casein, or derivatives; mixture of cereal base and protein must have a Protein Digestibility-Corrected Amino Acid Score ≥ 1.0 lipid sources: partially hydrogenated soybean or cottonseed oil, flaxseed oil (source of omega-3 fatty acids), canola oil, sunflower oil sugars: sucrose, glucose, high-fructose corn syrup, maltodextrins baking and leavening agents, if needed vitamin and mineral premix as specified in the nutrient profile. Testing prototypes for acceptability. All EFP prototypes should be tested for acceptability under conditions similar to those used by the U.S. Army for General Purpose Survival Packets and Meal Ready-to-Eat, Individual. The suggestion made by the U.S. Army to use its facilities at various overseas locations for testing the EFP among local populations, so that its acceptability by populations having diverse ethnic and cultural backgrounds can be established, is heartily endorsed. Packaging. All packaging components used in the EFP must be capable of withstanding a wide range of temperatures and other physical abuse. Separate or additional packaging may be necessary for EFP airdrop operations. Pulp-based material with a moisture barrier coating should be used for the EFP primary packaging. A pouch constructed of a trilaminate consisting inside out of polyolefin, aluminum foil, and polyester or nylon should be the secondary packaging to keep oxygen at less than 2 percent throughout the 3-year shelf life of the product. Optional presentations of the EFP other than that for airdrop configuration could include a reusable, semi-rigid polyolefin, multi-ration container appropriately designed to allow secondary uses such as storage or water transport. Alternatively, a metal outer package, such as a tinplate box with an easy-to-remove cover, would be of great value to recipients during emergencies. Product configuration. The recommended 2,100-kcal/day energy level should be provided by an EFP weighing approximately 450 g. This ration should be configured as nine equal portions having the shape of bars, each scored across the width of the bar to provide two 116-kcal portions upon breaking it. A daily supply of nine bars should be packaged under a nitrogen flush or vacuum into one trilaminate pouch to provide the barrier against oxygen and moisture needed for extended shelf life. Five daily rations should be packaged into a single bundle so that 5-days worth of food for a single individual or a 1-day feeding of a five-member family may be distributed as a unit. Eight bundles of five EFPs each should be placed into a shipping container of corrugated

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High-Energy, Nutrient-Dense Emergency Relief Food Product construction or constructed of metal, so that they can be recycled for use as storage or water containers. Shippers would be assembled onto a pallet for transport. Production methods. The EFP must be prepared using Good Manufacturing Practices and all sanitary regulations and practices applicable to ready-to-eat food products. Testing for quality assurance and control. Testing of the EFP must be conducted throughout the expected shelf life of the product and under conditions of delivery and storage simulating actual use, to ascertain the initial content and stability of nutrients throughout the expected 3-year shelf life. Standard methodologies for determining vitamin and mineral content of the EFP should be used, and appropriate procedures, such as those used for nutritional labeling, must be applied. REFERENCES IOM (Institute of Medicine). 1995. Estimated Mean per Capita Energy Requirements for Planning Emergency Food Aid Rations. Washington, DC: National Academy Press. IOM. 1997. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, DC: National Academy Press. IOM. 1998. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, DC: National Academy Press. IOM. 2000. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. Washington, DC: National Academy Press. IOM. 2001. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academy Press. NRC (National Research Council). 1989. Recommended Dietary Allowances. 10th ed. Washington, DC: National Academy Press.