2
Nutrient Content and Special Considerations

This chapter presents the rationale for the levels of individual nutrients recommended for the emergency food product (EFP) described in this report, and discusses additional issues to be considered.

The goal of an EFP is to reduce morbidity and mortality among displaced persons by providing a nutritionally complete food that will be adequate as a sole source of nutrients for as long as 15 days from the recognized time of displacement. It should provide nutrition for the period between initial displacement and establishment of a more stable food supply line.

The EFP should be consumed with an ample quantity of water to ensure that the osmotic load provided by the EFP is diluted. This report assumes that emergency relief agencies will provide potable water supplies as a top priority. This assumption is based on assurances provided by the United States Agency for International Development.

There are five characteristics critical to the development of a successful EFP, listed in order of priority: (1) safe, (2) palatable, (3) easy to deliver, (4) easy to use, and (5) nutritionally complete. This order of priority should guide decisions about competing characteristics in developing a prototype EFP.



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High-Energy, Nutrient-Dense Emergency Relief Food Product 2 Nutrient Content and Special Considerations This chapter presents the rationale for the levels of individual nutrients recommended for the emergency food product (EFP) described in this report, and discusses additional issues to be considered. The goal of an EFP is to reduce morbidity and mortality among displaced persons by providing a nutritionally complete food that will be adequate as a sole source of nutrients for as long as 15 days from the recognized time of displacement. It should provide nutrition for the period between initial displacement and establishment of a more stable food supply line. The EFP should be consumed with an ample quantity of water to ensure that the osmotic load provided by the EFP is diluted. This report assumes that emergency relief agencies will provide potable water supplies as a top priority. This assumption is based on assurances provided by the United States Agency for International Development. There are five characteristics critical to the development of a successful EFP, listed in order of priority: (1) safe, (2) palatable, (3) easy to deliver, (4) easy to use, and (5) nutritionally complete. This order of priority should guide decisions about competing characteristics in developing a prototype EFP.

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High-Energy, Nutrient-Dense Emergency Relief Food Product TABLE 2-1 The Population Distribution from Two Reports Providing Demographic Information used to Determine Nutritional Needs for Disaster Responses Sub-Saharan Africaa The Sphere Projectb Age Group (yr) % of Population Age Group (yr) % of Population 0–3 10 0–4 12 4–6 7 5–9 11 7–9 7 10–14 11 10–17 17 15–19 9 18–60 48 20–59 49 > 60 7 60+ 7   Pregnant 2   Lactating 3   Male/female 51/49 a Jamison and Hobbs (1994). b Sphere Project (2001). INTRODUCTION The nutritional advantages of a single EFP as opposed to two or more products are evident. Providing a limited selection of commodity-type foods may increase the risk of malnutrition because nutritional components that are found in only one of the foods (e.g., ascorbic acid) may be absent from the diet if that food is not selected. Under emergency conditions, diets are invariably highly monotonous, and often relief foods quickly become a medium of exchange and are commonly sold or traded for other foods, water, firewood, alcohol, and a variety of other goods and services. If a nutritionally complete food ration is divided among two or more different foods, or if foods are targeted to specific individuals such as children or pregnant women, then certain foods are more likely to be exchanged. This type of exchange can deprive the population of a portion of the profile of nutrients provided by the emergency food ration and increase the risk of malnutrition. Providing a single ration product would reduce this risk. CHARACTERISTICS OF TARGET POPULATIONS Characteristics of potential target populations were considered in determining the nutrient composition of the EFP. As shown in Table 2-1, some target populations may have as much as 23 percent of the population below 10 years of age and 12 to 17 percent below 5 years of age (Jamison and Hobbs, 1994; Sphere Project, 2001). Refugee groups fleeing from military conflicts may have

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High-Energy, Nutrient-Dense Emergency Relief Food Product TABLE 2-2 Estimated Mean Per Capita Energy Requirement (EMPCER) by Body Size of Adults   Sub-Saharan Africa South and Southeast Asia United States Male height, weight 170 cm, 63.5 kg 165 cm, 60.1 kg 180.4 cm, 78.1 kg Female height, weight 155 cm, 50.0 kg 153 cm, 49.0 kg 163.7 cm, 55.3 kg EMPCER 2,076 2,045 2,194   SOURCE: Institute of Medicine (IOM, 1995b). women and children as a large proportion of the population, with only a small proportion of women pregnant or lactating. Data from the Nutrition Collaborative Research Support Program (CRSP) in Kenya (Calloway et al., 1992; Neumann and Harrison, 1994; Neumann et al., 1991), as well as data from sub-Saharan Africa (Sphere Project, 2001) and South and Southeast Asia (James and Schofield, 1990), indicate that people from these areas have smaller body sizes than those in Western populations (Table 2-2). While the EFP might have nonemergency uses (e.g., as a complementary food for breast-fed children 7 to 12 months of age), it has been designed as a sole food source for periods of 2 to 15 days. It is likely that the recipient population will be in poor nutritional status and may have some wasting, appetite depression, and malabsorption. The goal of this report is to provide recommendations for a product that would meet the needs of diverse populations. General Assumptions Given the goal outlined above, the following assumptions are made regarding the recipient population: The relief food product is the only food consumed. Individuals eat to meet their energy requirement. Individuals in the target population are of smaller stature and body mass than similarly aged groups in the North American population (this is the same premise used in an earlier report from the Food and Nutrition Board, Estimated Mean per Capita Energy Requirements for Planning Emergency Food Aid Rations [IOM, 1995b]). All individuals over the age of 6 months will consume the product.

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High-Energy, Nutrient-Dense Emergency Relief Food Product Estimating Energy Requirements The energy content of the EFP should be determined by the energy needs of the recipient population. However, because the EFP must be manufactured prior to knowing where it will be needed, the population’s energy needs will not be known. Recommended intakes for nutrients from recent reports in the United States and Canada are typically used as the standard for nutrient requirements and thus nutrient content (IOM, 1997a, 1998, 2000, 2001), but, as discussed earlier, energy consumption per individual may be less in the EFP target population than in the United States or Canada due to lower body weights for similar subgroups. Furthermore, because the EFP is a single food meant to support a heterogeneous population, nutrient content must be determined on an energy density basis. Estimating Energy Requirements of the Population A potential basis for calculating the energy requirements for a refugee population is provided in the Institute of Medicine report, Estimated Mean per Capita Energy Requirements for Planning Emergency Food Aid Rations (IOM, 1995b). The goal of this report was to establish an estimated mean per capita energy requirement (EMPCER) when little was known about the characteristics of the population. Energy requirements for 14 age and gender groups, plus pregnant and lactating women, were estimated based on body mass and assumptions about energy needs in pregnancy and lactation obtained in two refugee populations. The estimated energy requirements for adults were calculated based on an estimate of basal metabolic rate (BMR) and a physical activity level (PAL). To estimate BMR, the report used equations developed by the Food and Agriculture Organization/World Health Organization/United Nations University (FAO/ WHO/UNU, 1985). An average height of 170 cm for adult men and 155 cm for adult women was assumed (the average of adult men and women in sub-Saharan Africa; see Table 2-2). These average heights are slightly greater than those of adults in South and Southeast Asia (Table 2-2) and less than those of the U.S. population. The weights used for the estimates of BMR were the median weight for U.S. adult males of 170 cm (63.5 kg) and females of 155 cm (50 kg). The U.S. median weights (NRC, 1989) were used to provide a conservative estimate of the EMPCER for populations in most developing countries (IOM, 1995b). For individuals under 18 years of age, values were based on data from affluent populations. Although the individuals from whom these data were derived were larger (and therefore assumed to have a greater BMR) than many children and adolescents from refugee populations, this “extra” allotment for children in developing countries was deemed appropriate on the basis that the additional food would allow some compensatory growth (IOM, 1995b). Both the adult and child values were recognized as overestimates of energy requirements, but were justified in order to establish a conservative EMPCER.

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High-Energy, Nutrient-Dense Emergency Relief Food Product The resulting EMPCER in the report was 2,100 kcal/day (after rounding). This number is used below as the basis for the total energy content of the EFP. Estimating Energy Requirements for Specific Life Stage and Gender Groups The IOM (1995b) report estimated energy requirements for specific life stage and gender groups, as described above. However, it was determined that using that approach was inappropriate for determining the content of the EFP for three reasons. First, the approach could lead to underestimates of nutrient density needed because the nutrient density is based on an assumed energy intake. If energy intake is less than expected, the nutrient density will be too low to meet the micronutrient requirements. Second, the life stage and gender groups do not correspond to the current groups used in the Dietary Reference Intake (DRI) reports (IOM, 1997a, 1998, 2000, 2001). Third, the FAO/WHO/UNU (1985) equations used for infants and children under age 5 are now recognized as flawed (Butte, 1996; Torun et al., 1996). For the above reasons, estimates of energy requirements for each life stage category were recalculated and are shown in Table 2-3. For individuals 4 years of age and older, estimated energy requirements were obtained by first calculating individual BMRs based on the age, sex, weight, and physiological status of each individual (FAO/WHO/UNU, 1985). Individual energy requirements were then calculated using the same PAL values (women: 1.56, men: 1.55) that were used by IOM (1995b). With the exception of infants aged 7 through 12 months, the BMR and energy requirements were derived using anthropometric data from individuals in the Kenya Nutrition CRSP (Calloway et al., 1992; Neumann and Harrison, 1994; Neumann et al., 1991). Because the Kenya Nutrition CRSP did not collect anthropometry on children aged 6 through 12 months, the value for this age group was the mean weight of rural infants aged 9 months from the Mexico Nutrition CRSP (Allen et al., 1992). The Kenya data set contains anthropometry on 1,717 individuals aged 0 to 65 years. As is common in much of the developing world, most adults and children in this population were smaller than U.S. individuals, the result of early growth stunting (Martorell and Habicht, 1986) (Figure 2-1). Additionally, the rural Kenyan population was subject to periodic food shortages and were relatively thin (Neumann and Harrison, 1994). Estimating Energy Requirements for Infants and Children. Recent research using doubly labeled water to measure energy expenditure suggests that values derived from the FAO/WHO/UNU 1985 equations are inflated for infants and young children (Butte, 1996; Butte et al., 2000; de Bruin et al., 1998; Prentice et al., 1988). Therefore, the energy requirements for infants 9 months of age (representing the 7- through 12-month-old group) and children 2 years of age

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High-Energy, Nutrient-Dense Emergency Relief Food Product TABLE 2-3 Median Weights, Estimated Basal Metabolic Rate (BMR), and Energy Requirements of a Rural Kenyan Populationa Age Gender Weight (kg) BMR (kcal/d) Energy (kcal/d) Estimated Number of Emergency Food Product (EFP) Barsb per day 7–12 moc,d Both 7.0 371 578 1–2e 1–3 yrd Both 10.2 571 855 3–4 4–8 yr Both 19.4 936 1,456 6–7 9–13 yr Both 26.5 1,086 1,693 7–8 14–18 yr Boys 42.0 1,378 2,136 9   Girls 40.9 1,238 1,931 8–9 19–50 yr Men 54.3 1,509 2,339 9–10   Women 51.0 1,264 1,972 8–9 51+ yr Men 56.1 1,451 2,249 9–10   Women 47.0 1,237 1,929 8–9 a Weights from Kenya Nutrition CRSP (Calloway et al., 1992). b Each EFP bar has approximately 233 kcal; 9 bars = 2,100 kcal = one average ration per day. Each can be broken in half to yield 116 kcal. This allows distribution to young children. c Weights from Mexico Nutrition CRSP (Allen et al., 1992). d BMR estimate based on equations of Butte and coworkers (2000). e It is assumed that the EFP would be used as a complementary energy source to human milk and therefore would provide 50 percent of the estimated energy need. (representing the 1- through 3-year-old group) were calculated according to the formula of Butte and coworkers (2000): Energy requirements (MJ/d) = 0.321 + 0.013 × age (mo) - 0.047 × sex + 0.139 × feeding group + 0.277 × weight, where sex is coded as 1 for boys, and 2 for girls, and feeding group is coded as 1 for breast-feeding (nearly all children in the Kenyan and Mexican populations). Values for boys and girls were later averaged. The Butte equations were based on breast-fed children in the United States and yielded values of similar magnitude to those derived for Mexican infants and young children: 638 kcal/day for 0- through 9-month-old infants and 843 kcal/day for 1- through 2-year-old toddlers (Butte et al., 2000). The resulting energy estimates are lower than those used in the IOM (1995b) report (800 and 1,350 kcal/day, respectively), because the IOM values are based on the energy requirements of children derived from the FAO/WHO/UNU (1985) equations and U.S. body weights.

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High-Energy, Nutrient-Dense Emergency Relief Food Product FIGURE 2-1 Reference weights of DRI life stage groups (U.S. population), and weights of rural Kenyans. Estimating Energy Requirements for Pregnancy and Lactation. Although adequate nutrition during pregnancy and lactation are of concern in refugee populations, the EFP is designed to meet energy requirements based on the assumption that pregnant or lactating women as well as others with higher energy needs (i.e., due to physical activity or rapid growth) will consume additional food bars to meet these needs. In 1985, FAO/WHO/UNU recommended an increased energy intake of 285 kcal/day during pregnancy. However, the actual increased energy needs during pregnancy vary widely by trimester (Prentice et al., 1996) and by population (Prentice and Goldberg, 2000). For example, the total additional energy needed during pregnancy in The Gambia has been estimated at about 7,000 kcal, or about 25 kcal/day (Prentice and Goldberg, 2000). Moreover, Prentice and colleagues (1996) have proposed that maternal energy metabolism during pregnancy may be lower as measured by change in BMR in women in developing countries versus those in affluent populations. This is believed to be due to their smaller body size. If true, then pregnant women in some emergency feeding situations may not need to consume 285 kcal beyond their nonpregnant, nonlactating energy requirement (or 1 to 2 additional food bars over the 9-bar ration). This number is near to the estimated daily increment of 229 kcal/day during the

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High-Energy, Nutrient-Dense Emergency Relief Food Product second trimester, when pregnancy energy requirements appear to be intermediate (Prentice et al., 1996). FAO/WHO/UNU (1985) also recommended an additional 500 kcal/day during lactation, which assumed an additional 200 kcal/day obtained from maternal fat stores. Prentice and colleagues (1996), based on an extensive review of the literature, recommended an increment of 480 kcal/day for mothers of infants 1 through 6 months of age with previous weight loss. CHARACTERISTICS OF THE EMERGENCY RELIEF FOOD PRODUCT Given the estimated energy requirements (Table 2-3), the proposed energy density for the EFP is 4 to 5 kcal (17 to 21 kJ)/g. To obtain this energy density, an EFP low in water (see Chapter 3) with 35 to 45 percent fat along with 10 to 15 percent protein is required (see sections below). Palatability of the EFP is a primary concern, and should dictate the final choice of ingredients (see Chapter 3). It is assumed that pregnant and lactating women will consume more than the average requirement of 2,100 kcal as needed to support pregnancy and lactation. Nutrient Content The methodology for determining the appropriate amount of each nutrient to be included in the EFP is summarized in Box 2-1, followed by a more detailed explanation and rationale for the approach adopted for each nutrient. A starting premise for determining the appropriate nutrient content of the EFP is that the upper limit of an individual’s food intake is somewhat constrained by his or her total energy requirement, while the lower limit is set by many factors, including appetite, access to food, trading of food, and an individual’s ability to make his or her own food decisions. When food intake is lower than energy requirements, the nutrient density may need to be adjusted, thus highlighting a need for testing prototype EFPs developed from the specifications presented in this report. The recommended intakes (either recommended dietary allowance [RDA] or adequate intake [AI]) as specified in the recent reports on DRIs (IOM, 1997a, 1998, 2000, 2001) were used. These reports provide recommended intakes for vitamins and minerals for 16 life stage and gender groups, plus pregnancy and lactation. It should be noted that these DRIs were established based on a selected criterion or criteria of adequacy consistent with good health, as opposed to the mere prevention of overt deficiencies. Thus the values obtained may be higher than those previously recommended by WHO. RDAs were calculated from the estimates of average requirements (EAR) using an estimate of the variability among individuals in the requirement. In most cases, the coefficient of variation of nutrient requirements was assumed to be 10 percent. The RDA is set at two

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High-Energy, Nutrient-Dense Emergency Relief Food Product BOX 2-1 Summary of Methodology to Determine the Nutrient Content of the EFP Use the Adequate Intakes (AI), Recommended Dietary Allowances (RDA), and Tolerable Upper Intake Levels (UL) as developed by IOM (1997a, 1998, 2000, 2001) or, for protein, FAO/WHO (2000). Use 2,100 kcal/person as the target for the population, but evaluate the amounts needed based on estimated energy expenditure for different subgroups of the population. Select the life stage and gender group that has the highest nutrient needs relative to estimated energy needs for each nutrient. This group is designated the limiting subgroup. Determine the nutrient density for the limiting subgroup utilizing the AI or RDA by dividing the recommended intake of the nutrient by the energy requirement determined for that subgroup (see Table 2-3). Adjust the nutrient density value of the limiting subgroup based on probable malabsorption, bioavailability assumptions, potential nutrient interactions, and properties related to the plant sources of ingredients utilized in the EFP. Determine for each nutrient if the requirement for the limiting subgroup exceeds the UL for any other age group. Adjust the proposed nutrient level, if necessary, to ensure that the UL is not reached for other age groups. If the rationale used allows some subgroups to exceed the UL, so state. Provide a maximum level for the EFP based on the UL. Recommend food ingredients that would prevent interactions with other nutrients and avoid reaching the maximum value. Describe the assumptions and the scientific rationale underlying the recommended level for each nutrient. standard deviations above the EAR, and should meet the requirements of almost all of the U.S. and Canadian populations for which it is recommended. For some required nutrients, it was not possible to establish an intake at which half of a life stage and gender group would be adequately nourished, while the other half would demonstrate signs of inadequacy. Thus an EAR could not be set. However, data were available that could be used to establish a level of intake that appeared adequate for most, if not all, people consuming that amount. This is called the adequate intake (AI). AIs are available for a number of the nutrients included in the EFP. Given that the data upon which an AI is

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High-Energy, Nutrient-Dense Emergency Relief Food Product based are less certain, there is more judgment in its derivation. In some cases, the EFP may not provide the AI level due to constraints related to palatability or cost. In this case, the probability that the target population has underlying nutrient deficiencies is assumed, and what is feasible for a product to be used for 10 to 15 days as the sole source of nutrition is determined. There are also nutrients that are deemed essential for inclusion in an EFP, but for which DRIs have not yet been determined. In this case (i.e., macronutrients and electrolytes), other recommendations for these nutrients (FAO/WHO, 2000; NRC, 1989) were considered in determining the amounts appropriate for the EFP. Ideally, the formulation of an EFP requires information on variability in actual consumption of the relief food. Since such information is not available at this developmental stage of the product, a few cautionary flags must be raised in the use of the proposed EFP: The EFP is not designed to meet all the nutrient needs for pregnancy and lactation; however, due to the energy requirements being conservatively estimated based on energy needs for smaller individuals, it should meet the requirements for most nutrients for almost all women. The EFP is not appropriate for severely malnourished individuals who require medical attention. Severe malnutrition is defined in the WHO Sick Child Initiative as quoted by IOM (1995a) as the presence of any one of the following symptoms: visible severe wasting, severe pallor, clouding of the cornea, or edema of both feet. The EFP is not a therapeutic nutritional supplement. (A ration distributed to the general population cannot be formulated as a therapeutic diet, as it would present too many risks of excess intake for individuals who were not severely malnourished. Severely malnourished individuals need special help, including fluid and electrolyte replacement therapy, blood transfusions for severe anemia, and medical supervision. This food product is not meant to be a substitute for this therapy, but a sustaining ration for people who have been uprooted due to war or natural disaster.) The EFP is not a substitute for human milk for infants agers 0 to 6 months. The EFP is not designed to meet the needs of young infants; however, it may be combined with water to produce a gruel suitable as a complementary food for older infants (7 to 12 months of age). Determination of a Minimal Nutrient Density At the population level, there are a number of individual minimal nutrient densities for each nutrient. If a single food must meet the nutrient requirement of most individuals in the population, this food should have a nutrient density that

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High-Energy, Nutrient-Dense Emergency Relief Food Product meets or exceeds the minimal nutrient densities of most individuals in the population. Since food intake is limited by energy requirements, a high nutrient density is necessary to meet the nutrient requirements of an individual with low energy needs. The approach described here to establish the nutrient content for the EFP provides a complete food for individuals consuming on average as little as 855 kcal/day (1- to 3-year-old age group) to those who may require in excess of the average ration of 2,100 kcal/day (adult men); thus the EFP can be used by a diverse population. The approach used to determine nutrient density for the EFP is as follows: for each nutrient, a minimal density value was estimated for the life stage and gender group in the population with the highest nutrient requirement relative to their energy requirement using the data on recommended nutrient intakes (Table 2-4) (IOM, 1997a, 1998, 2000, 2001; NRC, 1989; WHO, 2000), divided by the estimated average energy requirement for that life stage and gender group based on data from Kenyan refugee populations (Table 2-3). Neither pregnant nor lactating women were considered as a limiting group because for some nutrients (e.g., iodine, vitamin A) the minimal nutrient density would provide intakes that would exceed the UL (IOM, 1997a) for other groups in the population. Additional assumptions used in setting the minimal nutrient density include: The relief food is the only food consumed. Individual energy consumption equals energy requirement. The food product should provide a nutrient density that will meet the nutrient requirements of almost all members of each life stage and gender group without exceeding the UL for any group. These assumptions err in the direction of providing more of a nutrient than may be necessary unless energy consumption does not meet energy requirements. In most cases, the RDA values used were calculated from EARs which were originally estimated from only a few individuals with assumed variations in requirements, and then extrapolated to other age and gender groups using conservative approaches. Most of the estimates of AIs were based on mean intakes for healthy population groups that did not demonstrate any indicators of inadequacy of the nutrient, and thus could easily be overestimates of actual requirements for subgroups. Finally, in the case of many nutrients, the minimal nutrient density was subsequently modified upward in order to ensure that possible interactions with other nutrients or storage conditions, poorer bioavailability, or assumed presence of diarrhea or disease in the recipient population were taken into account. Since increased amounts of nutrients will increase the cost and potentially may affect palatability and shelf life of the EFP, and palatability is the major factor that ensures adequate energy consumption, slight reductions in these recommended amounts may be necessary.

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