Vous êtes sur la page 1sur 64

NUTRITION

A Guide to Data Collection, Analysis, Interpretation and Use

April 2005

Food Security Analysis Unit


FSAU is managed by FAO for Somalia

i
First published 2003
Second edition 2005
Food Security Analysis Unit for Somalia (FSAU)
The contents of this manual may be copied, reproduced or stored without permission, with FSAU acknowledged as
the source.
This guide is published by the
Food Security Analysis Unit for Somalia (FSAU)
P.O. Box 1230, Village Market, Nairobi
Tel: +254 (020) 3741299
Fax: +254 (020) 3740598
Email: fsauinfo@fsau.or.ke
Website: www.fsausomalia.org
Design and layout by Jacaranda Designs Ltd.
Printed in Nairobi, Kenya

ii
Acknowledgements
The original version of this manual was developed in November 2003 by the Nutrition Project
Team within the Food Security Analysis Unit (FSAU). Valuable contributions have been made
by Bernard Owadi, Nurah Gureh, Sicily Matu Nyamai, Mohamoud Hersi, James Kingori,
Mohammed Moalim, Susan Kilobia, Osman Warsame, Ahono Busili, Khalif Nuur and the entire
food security analysis unit. The development of the manual was supported by Margaret Wagah
and the initiative supervised by Noreen Prendiville.

The current revision has been undertaken following the use of the manual during numerous
training workshops throughout Somalia. Valuable comments have been made by Nurah Gureh,
Sicily Matu Nyamai, Mohamoud Hersi, James Kingori, Mohammed Moalim, Osman Warsame,
Ahono Busili, Khalif Nouh, Abukar Nur, Mohammed Haji, Mohammed Hassan, Abdikarim
Dualle, Abdikarim Aden, Fuad Hassan Mohammed, Abdirahaman Hersi, Ibrahim Mohamoud
and partners involved in the workshops

A revision by FSAUs team has been found necessary to expound on evolving issues such as
dietary assessments, sentinel sites surveillance and micro-nutrient deficiencies.

The team wishes to thank our partners in Somalia and in the Nutrition Working Group for their
valuable comments on the original version, which have now been incorporated into this
revision. Their input in the piloting of the manual during three training workshops in Hargeisa,
Garowe and Huddur was very valuable.

Finally, the team is grateful for the input of FAO Rome, ESNA and ESNP.

iii
Foreword
Nutrition is about people and the measurement of the nutritional status of a population is one of
the most useful indicators of a populations overall welfare. Nowhere is this more important
than in countries prone to crises and emergencies like Somalia. In the absence of other basic
sources of data in Somalia, the demand for good quality nutrition information has increased.
Both governmental and non-governmental bodies collect, understand and use information. The
continued high levels of malnutrition among Somali populations (including areas in
neighbouring Ethiopia and Kenya) calls for a greater analysis of the causative factors.

As part of its commitment to improve the nutritional status of the Somali people, the United
Nations Food and Agriculture Organization (FAO) supports the Food Security Analysis Unit
(FSAU) in the implementation of food security and nutrition analysis. FSAU works with partners
to strengthen the quality of nutrition-related information in Somalia. These partnerships have
strengthened over the past four years. FSAU now acts as the focal point for the collection,
analysis, storage and dissemination of this information. As a result of these partnerships, there
has been strong collaboration across sectors, in particular food security and health.

In response to demands from partners for specific information on nutrition data management, a
wide range of materials have evolved over the past four years. Methodologies have been
standardized and guidelines have been developed through a process of consultations and field
testing. During the past two years, these materials have been compiled and used during training
sessions for mid-level management. The training sessions were held in various locations
throughout Somalia, Somaliland and Puntland, and the materials developed formed the basis
for the production of this manual.

This manual targets mid-level managers in all sectors who would like to better understand
nutrition information and its use. In addition, certain sections have been adapted and translated
for use by survey enumerators, health facility workers and other field workers. Additional
materials have also been prepared to support the use of the manual during training.

Noreen Prendiville
Project Manager
FSAU

iv
Table of Contents
Acknowledgements ........................................................................................................... iii
Foreword ........................................................................................................................... iv
1 Introduction to nutrition information............................................................................ 1
1.1 Background ........................................................................................................... 1
1.2 Use of nutrition-related information ....................................................................... 1
1.2.1 Nutrition information in early warning ........................................................ 2
1.2.2 Nutrition information in program management ........................................... 2
2 Understanding nutritional vulnerability ........................................................................ 5
2.1 Overall concepts related to nutrition ..................................................................... 5
2.2 Nutritional vulnerability ........................................................................................ 5
2.3 Conceptual framework for understanding possible causes of
poor nutritional status ............................................................................................ 6
2.3.1 Socio economic and political environment ................................................. 7
2.3.2 Food security ............................................................................................... 8
2.3.3 Health, water and sanitation ...................................................................... 10
2.3.4 Care practices ........................................................................................... 11
2.3.5 Food consumption .................................................................................... 12
2.3.6 Food utilization in the body ...................................................................... 12
2.3.7 Nutritional status ....................................................................................... 12
2.4 Summary of the framework .................................................................................. 12
3 Measuring nutritional status ........................................................................................ 13
3.1 Anthropometric assessment ................................................................................. 13
3.2 Biochemical methods .......................................................................................... 14
3.3 Clinical assessment .............................................................................................. 15
3.3.1 Detection of malnutrition during clinical assessment ................................. 15
3.4 Dietary methods .................................................................................................. 17
4 Methods of nutritional assessment and analysis .......................................................... 19
4.1 Current sources of information on nutrition ......................................................... 19
4.2 Data collection methodologies ............................................................................ 19
4.2.1 Nutrition survey ........................................................................................ 20
4.2.2 Rapid assessment ...................................................................................... 24
4.2.3 Health facility data .................................................................................... 25
4.2.4 Sentinel sites surveillance .......................................................................... 26
4.2.5 Dietary assessments ................................................................................... 26
4.3 Qualitative data ................................................................................................... 26
5 Analysis and intepretation of the nutrition situation ................................................... 29
Steps in data analysis and interpretation ...................................................................... 29
Case study ................................................................................................................. 33
Bibliography ................................................................................................................. 35
Appendices ................................................................................................................. 37
Appendix 1 ................................................................................................................. 37
Appendix 2 ................................................................................................................. 39
Appendix 3 ................................................................................................................. 40
Appendix 4 ................................................................................................................. 41
Appendix 5 ................................................................................................................. 43
Appendix 6 ................................................................................................................. 45
Appendix 7 ................................................................................................................. 45
Appendix 8 ................................................................................................................. 46
Figures
Figure 1 Nutritional status conceptual framework ......................................................... 8
Figure 2 Somalia: Current nutrition situation, January 2005 ........................................ 48
Figure 3 Somalia: Nutrition surveys (1999 - 2004) ...................................................... 49
Figure 4 Somalia: Nutrition surveillance locations (health facilities) ............................ 50
Figure 5 Somalia: Nutrition status trends (1999 - January 2005) .................................. 51

v
vi
1 Introduction to nutrition information
1.1 Background
Measurement of nutritional status is one of the
key indicators for:
monitoring the overall welfare of a
population and
measuring the impact of change in factors
that affect the welfare of a population.
Negative change in the nutritional status of a
population indicates a problem. The effects of
increasing malnutrition are felt in a society both
in the short term and long term. In much of sub-
Saharan Africa, measurement (anthropometry) of
children under the age of five is the most
commonly used method for estimating the
nutritional status of the population as a whole,
although strictly speaking, one cannot imply that
because children are malnourished, that the
whole population is malnourished.
Knowing what people eat is critical for nutritional analysis
The availability of good data provides a strong (photo by FSAU)
foundation for the more important next step -
the analysis of the information. Malnutrition
rates are meaningless without explanations for screening tool to identify malnourished
the levels and trends. Frameworks help in the individuals needing special assistance, (iii)
analysis of information and facilitate a better to evaluate the progress of growth amongst
understanding of the factors that interact to the nutritionally vulnerable groups and (iv)
influence nutrition at both the individual and to monitor effects of nutrition interventions
population level. among vulnerable groups.
Is invaluable for program management
A better understanding of causes of malnutrition (planning, implementation, monitoring
provides a sound basis for the design and and evaluation) in many sectors including
implementation of interventions across the food security (agriculture and livestock),
sectors. Understanding the roles of different health, water and sanitation, education
actors leads to more effective strategies and and environment.
efficient use of limited resources. Nutrition information can contribute to
designing of food, health and other
1.2 Use of nutrition-related development policies.
information Facilitates analysis of socio-economic
factors, demographics, food security and
Using information on nutrition and other cultural aspects of a population.
background information supports analysis and Can be used in crisis mitigation especially
decisions on interventions and programs for as an early-warning indicator. This speeds
both short and long-term projects. More up response to threats like droughts or
specifically, nutrition information: disease outbreaks.
Serves as a vital indicator of the overall
health and welfare of populations The principal users of nutrition information are:
especially where regular demographic and Government authorities and Non
health surveys are lacking. Governmental Organizations (NGOs) that
Is critical during crises and emergencies support food security, health and nutrition-
for (i) the identification of most vulnerable related programs
or affected individuals or groups, (ii) as a Donors

1
Communities involved in the design, Nutrition-related information provides an
planning and management of nutrition- authoritative basis for the formulation of an
related programs appropriate response. Once data is available,
Health workers who produce the data appropriate emergency preparedness and
Food aid agencies like WFP and CARE response can be undertaken well in advance.
However, for nutritional surveillance to be
1.2.1 Nutrition information in early warning used as an effective tool for early warning, it
Populations respond to changes in their must incorporate both quantitative and
environment in many ways and these responses qualitative aspects of data collection, analysis
can ultimately be reflected in changes in food and interpretation.
consumption and health status. These
population responses vary from one situation 1.2.2 Nutrition information in program
to another with some populations changing management
their nutrition related behaviour, manifesting as
increasing malnutrition quite early in a crisis Planning and Implementation
and before any apparent deterioration in food Planning involves assessing, analyzing
security. On the other hand, other populations problems and opportunities, setting objectives
will use all means available to avoid any and designing appropriate interventions that
reduction in the quality or quantity of food, can achieve objectives. Nutrition-related
often sacrificing livelihoods in the process. information is used to analyze the situation in
Therefore, a deterioration in nutritional status relation to factors across the sectors in
can be an early indicator of impending hardship particular health, food security, care practices,
if interpreted together with disease and food livelihoods and other underlying factors. The
security patterns. Continuous analysis of the causes of malnutrition may not be obvious. It
nutrition situation combined with reliable is important to differentiate the immediate life-
measurement of outcomes can help to identify threatening problems from the underlying
the stages of a drought process and the response causes and to develop appropriate
of the population to events around them. interventions.
In both emergency and development,
analysis of nutrition information
helps to identify
individuals at risk and
where they are
located. It

FSAU staff sharing information with health facility staff (photo by FSAU)

2
facilitates the design of appropriate conducted accordingly. Project monitoring is
interventions based on the causes and effects. continuous and focuses mainly on short-term
The analysis helps to formulate goals, activities and results. Evaluation on the other
objectives, strategies and activities that the hand is periodic and focuses on the
project/program intends to address. The severity achievement of the project objectives and the
of malnutrition, its nature and the related health impact of the project.
risks determine the choice of response from the Monitoring can therefore be defined as the
problem analysis. Where lives are threatened, continuous process of collecting information
quick action is necessary. and presenting data, through out the project
cycle, in order to assess the impact and lead to
Monitoring and evaluation improvements in the effectiveness of the
Nutrition information is useful for monitoring program.
and evaluation in both emergency and
Evaluation focuses on:
development interventions. Nutrition-related
Relevance
information is used during project
Appropriateness
implementation for monitoring purposes. It is
Effectiveness and efficiency
also used at the evaluation stage to assess the
Timeliness and management of the project
extent and impact of the project.
Achievement of the project overall goal
Monitoring and evaluation assesses the Lessons learned for future planning
nutritional performance against set objectives.
Nutrition provides us with both a tool and a
It ensures that the planned activities are
forum to monitor and evaluate interventions.

3
Mother with two children, close in age (photo by FSAU)

4
2 Understanding nutritional vulnerability
2.1 Overall concepts related
to nutrition
Food insecurity and therefore nutritional
vulnerability is complex. It is attributed to a
range of factors that vary in importance across
regions, countries, socio-economic groups and
time. These factors can be grouped into four
areas of potential vulnerability:
1. Socio-economic and political
environment
2. Food security
3. Care practices
4. Health and sanitation
Fragile socio-economic and political of adequate quality and quantity is threatened.
environment, food insecurity, unfavourable This can occur during period of food insecurity,
care practices and health environment lead high incidences of communicable diseases or
to a cycle of malnutrition and further when care is substandard (as a result of
inadequate intake of energy and other destitution, illiteracy, displacement or tradition).
nutrients. The conceptual framework in this In any population or sub group, some
chapter illustrates how key factors interact members are at higher risk of becoming
to influence nutritional status. malnourished, usually with more serious
consequences. They include:
2.2 Nutritional vulnerability Infants and young children (due to their
Nutritional vulnerability occurs when proportionately high demand for
consumption and utilization by the body of food nutritional requirements). Consumption of

Children with their mothers awaiting nutrition screening (photo by FSAU)

5
Pastoral livelihood (photo by FSAU)

inadequate proteins, calories and 2.3 Conceptual framework for


micronutrients retard growth and
understanding possible causes of
development, often irreversibly.
Pregnant and lactating mothers (nutrient poor nutritional status
requirements increasing during pregnancy Food insecurity, poor conditions of health and
due to physiological changes associated sanitation, and inappropriate care and feeding
with the growing foetus). Malnutrition has practices are the major causes of poor
a direct impact on maternal and infant nutritional status.
mortality and morbidity.
The elderly. (Diminished sense of taste and A number of frameworks are in use, each
isolation affect dietary intake) Malnutrition assisting in the development of a better
causes general ill-health and early understanding of the possible causes of
debilitation due to osteoporosis. malnutrition. The most popular of these are the
Those with chronic disease. FIVIMS Framework shown here and the
Socially marginalised groups including UNICEF Framework (Refer to appendix 6). With
displaced and orphans. slight variations in the approach used, both
demonstrate the need to examine a wide range

6
of factors during analysis. Both frameworks Allocation of resources and investment in the
point to the importance of addressing the economy largely depends not on the political
problem of malnutrition using broad multi- will but also on the political condition.
sectoral approaches. As shown in the In Somalia where the political climate has been
framework diagram, the possible causes of low fragile, there are high levels of illiteracy. There
food consumption and poor nutritional status are few institutions and policies in place to
falls under the following headings: address agriculture. Few powerful clan leaders
and businessmen mainly influence money
2.3.1 Socio economic and political supply and inflation. These factors directly affect
environment the food security, health services and general
At the national level, socio-economic and development of the country.
political environmental issues include:
At sub-national or regional level, cultural attitudes
population (movement, characteristics/
towards what to eat, what to own; the social
dynamics),
institutions like clan set-up and relationships,
education (institutions, policies and levels),
livelihood systems (agro-pastoralists, pure
macroeconomic factors (inflation rates,
pastoralists and pure crop producers) and
money supply and employment levels),
household characteristics such as proportion of
natural resource endowment (productive
working adults affect food security.
land, minerals, forests, water bodies like.
rivers for irrigation or sea ports), In Somalia, the main livelihood systems include
market conditions (availability of market pastoralism, riverine, agro-pastoralism and
channels for local produce and operation urban. Riverine are normally more permanent
of such markets) and and prone to heightened food insecurity and
the agricultural sector (livestock condition nutritional vulnerability. This results from
and productivity, crude or mechanised localized seasonal rainfall and crop production
crop farming). failures. Pastoralists who may have the option
of moving to a different locality where water
The political environment determines the
and pasture are available, are less vulnerable
appropriateness of all the above factors.
to food insecurity.

A pastoral household migrating due to stress (photo by FSAU)

7
Figure 1 FIVIMS Nutritional status conceptual framework

CARE PRACTICES
Child care
Feeding practices
Nutrition education
Food preparation
FOOD AVAILABILITY
Eating habits
(trends and levels) Intrahousehold food
Production distribution
SOCIO-ECONOMIC Imports (net)
AND POLITICAL Utilization (food,
ENVIRONMENT non-food) stocks
FOOOD
National level CONSUMPTION
Population STABILITY OF FOOD Energy intake
Education SUPPLIES AND Nutrient intake
Macroeconomy ACCESS (variability)
Policy environment
Natural resource Food production NUTRITIONAL
endowment Incomes STATUS
Agricultural sector Markets
Market conditions Social entitlements
FOOD
Subnational level UTILIZATION
Household BY THE BODY
ACCESS TO FOOD
characteristics
Livelihood systems (trends and levels) Health status
Social institutions Purchasing power
Cultural attitudes Market integration
Access to markets

HEALTH AND
SANITATION
Health care practices
Hygiene
Water quality
Sanitation
Food safety and
quality

2.3.2 Food security access to sufficient amounts of safe and


nutritious food for normal growth and
Food security has been defined as a situation
development and an active and healthy life.
that exists when all people, at all times, have
Food insecurity may be caused by the
physical, social and economic access to
unavailability of food, insufficient purchasing
sufficient, safe and nutritious food that meets
power, inappropriate distribution or inadequate
their dietary needs and preferences for an active
use of food at the household level. It may be
and healthy life. Thus, food insecurity is a
chronic, seasonal or transitory.
situation that exists when people lack secure

8
Sale of livestock products e.g. milk as one of the income sources (photo by FSAU)

Among chronically food insecure people, both urban centres of Somalia the presence of
macro- and micronutrient deficiencies are likely imported food commodities is common.
to be present. Diversification of diets is usually
sufficient to redress these imbalances, but the Food stability
cost is often too high. People may experience Food stability is influenced by both supply and
nutritional imbalances even when obtaining access factors. Seasonal fluctuations in
sufficient dietary energy. production and access are a major feature in
Food security has three basic components Somalia. There are many incidences of
food availability, food stability and food recurrent localized droughts, unpredictable
access although some frameworks also weather changes and seasonal employment
include food utilization. opportunities. These factors affect income
opportunities for the Somalia population. As a
Food availability result, there are variations in food production,
food prices, export prices of food items,
Food availability is a factor of production
movement of food commodities, and changes
capacity, amount of imports and amount that
in production techniques.
is normally used at a given period in time and
of the availability of storage. Food availability During the hunger gap period in southern
is also influenced by the availability of seeds, Somalia (between late May and early July), food
pest infestation/attack, weather conditions, intake is low. Malnutrition and food insecurity
availability of pasture, land acreage under is normally heightened unless the stored stocks
cultivation, labour availability and insecurity from previous harvests were substantial.
issues. The amount of food used by households,
traded or stored, all influence food availability Food access
at the household level.
Many factors affect peoples access to food.
In Somalia, there have been varying weather These include:
conditions characterized by frequent localized Cultural factors. (when women are not
droughts. The droughts have reduced the allowed to eat certain foods)
peoples capacity to produce food (crop and Reduced purchasing power (where
livestock production) in some areas. Infestation households cant afford the food in
of crops by insects and pests like quela quela shops/markets)
has also affected the food production. In the Logistical/geographic obstacles to markets
(rivers becoming impassable)

9
Insecurity (food may be in the market but 2.3.3 Health, water and sanitation
the market may be inaccessible because Practices that promote and maintain good
of fighting) health in the population are influenced by a
In Somalia where a significant proportion of the number of factors including knowledge and
population is considered poor (especially in urban environment. During ill-health, these
centres) accessibility to food is a major problem practices include seeking health services
even when food is available in the markets. For from qualified personnel; access to health
instance, in 2003 there was a significant services; as well as control and treatment of
deterioration of food security and nutritional status communicable diseases.
of the population in Sool plateau of Northern
The poor health of individuals is normally
Somalia. Food items remained largely available
associated with the inability to engage in
in the market. The prices were relatively low but
meaningful productive activities, and higher
the population could not access the food as all
expenditures on treatment at the expense of
their income sources had been depleted by
food items. Poor health increases vulnerability
recurrent droughts.
to food insecurity and therefore nutritional
Household food access is also determined by vulnerability. There is also a synergistic
seasonal patterns. For instance, the main food interaction between malnutrition and poor
crop produced may not be sufficient to meet the health status as one fuels the other.
household needs at all times. Among pastoral
Sanitation issues like disposal of human waste,
communities, milk production varies with rainfall
disposal of garbage and cleanliness of the
and availability of grazing lands. Furthermore,
household environment affect the health of a
opportunities for employment, migration and the
population. Sanitation is especially important in
availability of fish and wild foods are often highly
urban areas where people are relatively
seasonal. Household income and expenditure
congested. Poor sanitation results in disease
may vary according to season hence affecting
outbreaks and also interferes with food
food consumption patterns.
consumption and utilization.
Coping strategies Water availability is also an important indicator
of food security. Access to sufficient quality and
Coping strategies are means adopted by quantity of water is essential to nutritional
populations to survive a change for the worst security. Households require water for chores
in their circumstances. They save the like cooking, cleaning clothes and drinking.
population from deterioration of their well This water must be safe for consumption and
being. In Somalia, this could be in the light of sufficient in quantity. Distance to water points
income sources, food access, movement from determines the amount of time dedicated to
problem areas, as well as other resilience in other productive activities like childcare.
lifestyle. Household members may split, move,
change foods consumed or sell their assets. In Somalia, the main water sources are open
wells, berkards, boreholes and rivers. A
significant proportion of these sources are
unprotected and are prone to contamination.
Consumption of contaminated water
predisposes humans to diarrhoea, diseases that
interfere with food absorption. Furthermore,
drinking water sources are commonly shared
with animals thus increasing the possibility of
contamination. The problem becomes acute
during dry seasons. In wet seasons, there is often
flooding along the riverbanks. The floods not
only destroy crops but are also a breeding place
for mosquitoes.

Water catchment, a common water source in Somalia


(photo by FSAU)

10
A severely malnourished child (photo by FSAU)

2.3.4 Care practices Home health practices. (Promotion of


The environment, tradition and practices within good health, home remedies and
the household and the community influence management of common ailments,
nutritional status. Good care at the household recognizing ill-health, deciding to seek
level ensures that the food and healthcare assistance
resources provided to individual members result Specific care during periods of
in optimal survival, growth and development. vulnerability e.g. childhood, pregnancy,
Care practices vary with age and culture. illness.
Beneficial practices need to be supported and Intra-household food distribution. Ensuring
harmful practices need to be discouraged. In that needs of all household members are
Somalia, care practices like the provision of met, prioritizing the vulnerable members.
inappropriate liquids to infants immediately Eating habits: This dictates the quantity,
after childbirth, delays in starting to breastfeed type of food and frequency of eating. For
and discarding of colostrum impact on a childs instance, pastoralists normally do not eat
nutritional status. vegetables if animal products are available.

Care practices involve: Care resources


Psychosocial care: Responsiveness and
Caregivers need the following resources to
attention to the needs of individual
provide adequate attention and focus on children.
household members
Human resources: Caregivers knowledge,
Food preparation (cooking and
beliefs, education and the ability to put
presentation methods, hygienic storage).
knowledge into practice.
Hygienic practices. (bathing, hand-
Economic resources: Finances and time
washing, food hygiene, hygiene of
required for the provision of adequate care.
clothing, bedding, contact environment).

11
Organizational resources: Alternative 2.3.7 Nutritional status
caregivers and community arrangements to The complex interaction of different factors
facilitate care practices. within the framework is finally reflected in
the welfare or nutritional status of an
2.3.5 Food consumption individual or the population. Good Nutrition
Food availability, stability, accessibility and care is therefore an outcome of the individual or
practices influence the amount (quantity) of population receiving and utilizing the
food consumed, variety (diversity) of the diets, appropriate diet. This diet maintains normal
frequency of consumption, quality of food, functions in processes like growth,
proportion of cereals and of other essential maintenance of tissues, resistance to disease
foods in the diet. and participation in active physical work.
While the intake of energy is important in the Malnutrition on the other hand, is an
diet, other nutrients such as vitamins, proteins, imbalance or deficiency of nutrients in the
and minerals are also required. Nutritional body. It is a condition caused by inadequate
wellbeing is determined by the proportions of intake or inadequate digestion and utilization
essential nutrients in the diet. Micronutrient of nutrients.
deficiencies are common even in areas where
macronutrient intake is adequate and stable. 2.4 Summary of the framework
Hence food diversity in the diet is an important
pointer to nutritional security. The main issues that arise from the framework
are:
2.3.6 Food utilization in the body Poor nutritional status or malnutrition
results from a complex set of elements and
Eating enough food may not necessarily lead not one simple cause.
to nutritional security. The food eaten must be Food, care and health are all necessary
utilized by the body for nourishment. The health conditions, but not sufficient on their own.
status of an individual influences food They must also be linked to the socio-
utilization by the body. Illness often leads to economic and political environment.
increased dietary requirements for body repair The different elements that cause
of tissues damaged by the disease and to cater malnutrition interact with one another.
for increased loss of nutrients caused by the The framework can help to analyze and
disease condition, malabsorption of nutrients, understand the causes of poor nutritional
altered metabolism and loss of appetite. Poor status
health also leads to poor appetite thus reducing Poor nutritional status or malnutrition
intake. Measles, diarrhoea, HIV/AIDS, cannot be overcome by simply
tuberculosis (TB), and respiratory infections improving access to an adequate diet.
have a major influence on an individuals This would only solve one or a part of
nutritional status. Undernourished children are the problem. Diseases and infections,
also likely to be ill more often due to their poor maternal health and childcare
inability to resist or fight infections. practices may be as important a cause
Variety of food in the diet also influences food of malnutrition as inadequate food
utilization in the body. Due to inter-nutrient intake. Solutions are not found on one
interaction, some foods enhance the absorption level only. Different levels need to
of others for instance fruits, vegetables and oil improve at the same moment.
enhance the absorption of some proteins and Understanding the cause of nutritional
cereals. Foods can also interact negatively as vulnerability and malnutrition will enable
in the case of tea inhibiting the absorption of decision makers to address both the
iron, or sugar upsetting the calcium: phosphorus underlying and the direct factors that
balance, leading to increased calcium influence nutrition.
reabsorption from the bone tissue, and resulting
in depleted bone density.

12
3 Measuring nutritional status
Nutritional assessment is the process of Under certain special circumstances
evaluating the nutritional status of an individual. however, it may be essential to measure
Four methods are available that can be referred other age groups.
to as the ABCD of nutritional assessment. Height/Length: Height or length of children
changes over time and is dependent on
1. Anthropometric assessment
their nutrient intake and utilization.
2. Biochemical or laboratory assessment
3. Clinical assessment
Mid Upper Arm Circumference (MUAC):
These are rapid and effective measures that
4. Dietary Assessment
predict risks of death among children aged
12 - 59 months. MUAC is a useful
3.1 Anthropometric assessment screening tool for determining children at
Anthropometry is the measurement of the risk in emergencies.
bodys physical dimensions. The physical Body Mass Index (BMI): Is a useful tool when
dimensions are used to develop an measuring an adults nutritional status.
understanding on an individuals nutritional Weight and height measurements are
status. The following measurements are taken, then used to compute the index.
commonly used. Use of BMI in older people can be
Weight: Changes in weight among young unreliable as accuracy in height may be
children can be a useful indicator of the impeded by age-related factors like spinal
general health and curvature. MUAC is therefore an
wellbeing of appropriate measure since is relatively
the entire independent of aging.
population. Oedema: Abnormal accumulation of fluid
indicating severe malnutrition.

Age as an indicator
Age is used to develop nutritional indicators in
combination with certain anthropometric
measurements like height and weight. For
nutritional assessment in emergencies, children
less than 5 years are commonly measured since
their measurements are more sensitive to factors
that influence nutritional status such as illness
or food shortages.

Anthropometry related indicators


The body measurements of weight, height and
age are converted into nutritional indices. To
generate the indicators, any of the two variables
measured are related. That is, weight, height
and age as follows:
Weight for height
Weight for age
Height for age

Weight for Height/Length (W/H)


- measures wasting or acute malnutrition
Expresses the weight of the child in relation
to the height.

13
In children under 5 years of age, the At population level, the measurement
relationship of weight to height is almost indicates the total proportion of
constant regardless of their sex or race and underweight children.
follows a constant evolution as they grow.
Internationally accepted reference values Oedema
of weight-for-height for under five-year-old It is the abnormal accumulation of large
children are available. amounts of body fluid in the intercellular
Body weight is sensitive to rapid changes tissues.
in food supply or disease, while height It is a key clinical feature of severe
changes very slowly. malnutrition and is associated with high
Low weight for height is characterized mortality rates in children.
by wasting and loss of muscle fat. It is Oedema increases the childs weight. It
an indicator of thinness and identifies therefore tends to hide the true picture of
acute malnutrition. the nutritional status of the child.
This is the most useful index for screening All cases of oedema should be separated
and targeting vulnerable groups in from the rest of the respondents during
emergencies. It is a useful indicator for analysis and treated as severe acute
admissions and discharge in and out of malnutrition.
feeding programs. Oedema should always be used as a major
Alongside oedema, it is the most criteria for admission into therapeutic
appropriate index used to detect existing feeding programs.
malnutrition or recent onset of malnutrition
in the population. Mid Upper Arm Circumference (MUAC)
Height for Age (H/A) MUAC measurements are a good predictor
- measures stunting or chronic of immediate risk of death.
malnutrition It is an initial screening tool in feeding
programs as it is simple and fast to use.
It is a measure of chronic malnutrition.
It is useful when access to population is
That is, long-term and persistent
difficult, resources limited or when WH
malnutrition normally associated with
measurement is not possible.
long-term factors such as poverty and
MUAC results provide indications for
frequent illness.
nutritional status and are less accurate.
A childs height is compared to the median
height (length) of the reference population Taking anthropometrical measurements (see
of the same age and sex to give H/A index. appendix 1)
Children falling below the cut off point of
2 SD from the median of the reference 3.2 Biochemical methods
population are classified as too short for
This is a measure of nutrients in blood, urine
their age or stunted.
and other biological samples. Compared to
other methods, biochemical methods of
Weight for Age (W/A)
nutritional assessment provide the most
- measures underweight
objective and quantitative data on nutritional
It conveys the weight of a child in relation status. The usefulness of biochemical tests is
to the childs age. that they provide indications of nutrient deficits
WH index is a useful index for monitoring long before clinical manifestations and signs
growth and development of children. appear.
When used in growth monitoring at
Biochemical tests are also important in
health facilities, a childs W/A is
validation of data especially where respondents
commonly plotted on the Road to Health
are under-reporting or over-reporting what they
growth chart. This allows for better
eat. These tests are therefore particularly useful
understanding of the childs positive or
in complementing and validating dietary intake
negative growth.
surveys.

14
The major disadvantages of biochemical as a result of an inadequate intake of energy,
methods is that they are complex, expensive protein and other nutrients. The most severe
and require a high level of expertise. clinical forms of acute malnutrition are
marasmus and kwashiorkor. These conditions
3.3 Clinical assessment are characterized by growth failure. Acute
malnutrition has a wide range of manifestations
Clinical signs in the assessment of nutritional that range from weight loss (thinness) to stunting
status result from both lack of nutrients and non- (shortness) or a combination of both.
nutritional causes. Signs and symptoms should
be investigated and combined with Marasmus: This is a very serious form of
anthropometrical, dietary evaluation and acute malnutrition characterized by severe
biochemical tests for accurate analysis and weight loss or wasting. Marasmus is a
interpretation of data. condition commonly associated with low
intake of energy-giving foods. It requires
Clinical assessment involves: immediate treatment.
a) medical history,
b) dietary history and Kwashiorkor: This is a very serious form of acute
c) physical examination by a health malnutrition characterized by oedema, apathy
professional to identify signs and and loss of appetite. It is a condition commonly
symptoms associated with malnutrition. associated with low intake of proteins or
inadequate synthesis of proteins in the body.
The medical history of the respondent is the The condition requires immediate attention.
first step in clinical analysis. This can be
obtained by: Oedema
Finding out the respondents past and
present health status. Many diseases such This is fluid accumulation in the body as a result
as malaria, measles, tuberculosis and HIV/ of severe nutritional deficiency. Bilateral
AIDS can affect the nutritional status. oedema is an indicator of acute malnutrition
Identifying conditions such as diarrhoea and may be detected by pressing the thumb on
and lack of appetite. the feet just above the ankle for three seconds.
Evaluating a childs age, or a womans This will leave a dent.
obstetric history. Bilateral oedema is a manifestation of severe
Analysing socio-economic support and acute malnutrition and requires immediate
access to healthcare. treatment.
Dietary history includes determining the
respondents eating habits. For instance timing Micronutrient deficiency
and frequency of meals, tastes, allergies, ability This is a deficiency that results from the
to access food physically and economically, inadequate intake of nutrients required by the
how food is prepared and how food is body in minute quantities for the normal
distributed at household level. function of the body. The main micronutrient
deficiencies of public health concern are Iron
3.3.1 Detection of malnutrition during Deficiency Anaemia (IDA), Vitamin A
clinical assessment Deficiency (VAD), Iodine Deficiency Disorder
(IDD) and Zinc deficiency. These deficiencies
Acute malnutrition may cause permanent damage to health and
This is a classical form of malnutrition related even death.
to low intake of energy-giving foods and Outbreaks of other types of micronutrient
proteins in the body. Acute malnutrition is the deficiencies occasionally experienced in
most common form of malnutrition. The term emergencies include vitamin C (scurvy), niacin
covers a range of clinical disorders that occur (pellagra) and thiamine (beriberi).

15
Signs and symptoms of malnutrition
Clinical assessment Possible nutritional
deficiency
Hair Dull, dry, brittle, wire-like All associated with
acute malnutrition
Thin, wider gaps between hairs
Lightening of normal hair colour
Can be pulled out easily
Eyes Bitot spots Vitamin A deficiency
Dry greyish yellow or white foamy spots on whites of the eye.
Conjunctival Xerosis. Vitamin A deficiency
Inner lids and white of eyes appear dull dry and pigmented.
Corneal Xerosis Vitamin A deficiency
Cornea (coloured part of the eye) becomes dull, milky,
hazy, opaque.
Teeth Mottled Enamel Excessive fluorine
White or brownish patches in tooth enamel;
pitting of enamel most obvious in front teeth.
Gums Purplish, red, spongy and swollen.
Bleed easily with slight pressure
Glands Enlarged Thyroid. Iodine deficiency
May be visible or felt. More visible with head tipped back
Subcutaneous Oedema Sodium and water
retention
Tissue Bilateral swelling usually of ankles and feet first. associated with
acute malnutrition
Bones Knock-knees - Curve inward at knees Past Vitamin D and
Bowlegs - Legs are bowed outward. Calcium deficiency
Osteomalacia Calcium deficiency

Tender and brittle bones in adults


Joint pain Possible Vitamin C
deficiency
Muscles Muscle wasting Associated with severe
acute malnutrition
Excess folding of skin under buttocks
Skin Dry or Scaly skin; cracking, yellow pigmentation Vitamin A, Zinc, and
Vitamin C deficiencies.
Pellagrous dermatitis Niacin deficiency
Flaky paint dermatitis acute malnutrition
Other Poor wound healing Associated with
Zinc deficiency
Weakness and fatigue Iron and
Vitamin B1 deficiency

16
malnutrition, using regression analysis to
project the level of acute malnutrition in
foreseeable circumstances

Food frequency recall


This is an assessment method commonly used
in nutrition assessments or surveys to determine
dietary intake. It involves establishing the
frequency of which certain types of foods (those
of particular interest in the survey) are
consumed over a specified time-frame normally
a week or two. It is easier to administer than
the 24-hour recall method. The frequency of
consumption could be coded as:
a) Frequently consumed - food item
consumed once a week to many times
a day.
b) Not frequently consumed food item
consumed no more than twice a month
c) Never Consumed food item not
consumed at all.

The 24-hour dietary recall


In this method, the respondent is asked to
remember in detail the type and quantity of
foods consumed during the previous 24 hours.
Asking respondents about their activities during
Children of school going age engaged in herding rather the day can assist in recalling what they ate
than attanding school (photo by FSAU) and provides valuable information in estimating
the level of activity and energy
expenditure. The values of these
3.4 Dietary methods measurements are converted into
grams or millilitres (drinks and
Dietary methods generally involve the beverages). The amounts of various
assessment of food consumption over a period nutrients are then calculated using
of time. In nutrition surveillance, the dietary the food composition tables and/
assessment involves identifying food or nutrition computer packages
availability, accessibility, who consumed and designed for this particular
at what frequency. Data on foods consumed nutritional assessment method.
assist in the identification of nutrient intake. The method is reasonably
Interpretation of dietary intake involves use of quick and inexpensive but
food consumption tables. Nutrient intake in respondents may withhold
dietary methods is used to complement or alter information about
anthropometry, biochemical or clinical data. what they ate due to
Analysis of dietary intake involves: embarrassment or to
grouping of foods according to a influence the research. To
predetermined system (e.g. FAO or USDA) develop an understanding of
to determine diversity seasonality, the assessment
Determining the frequency of should be repeated at
consumption of foods in each food group. intervals throughout the
In some circumstances, based on this year. (see Appendix 3)
baseline and the level of acute

17
An enumerator interviewing a mother during a nutrition survey (photo by FSAU)

18
4 Methods of nutrition surveillance and analysis
4.1 Current sources of information conduct rapid assessments. MUAC is one
of the methods of data collection during
on nutrition
rapid nutrition assessment.
Nutrition surveillance undertaken by FSAU and 4. Sentinel site surveillance: This involves
partners utilizes a diverse range of information surveillance in a limited number of sites
sources on nutrition. These include nutrition or population for the purpose of detecting
surveys, health facility information, rapid trends in the overall well being of the
assessments and sentinel site surveillance (being population. The sites may be specific
developed). Information on the wide range of population groups or villages which
factors affecting nutrition is also collected from cover populations at risk. FSAU usually
partners in other sectors including, health, food undertakes this in highly vulnerable areas
security, water and security. that require close monitoring. Trends are
1. Nutrition surveys: Use weight for height monitored for various indicators
indicator and standard survey including nutritional status, morbidity,
methodologies as per nutrition survey dietary issues, coping strategies and food
guidelines for Somalia. These security. In Somalia, sentinel sites
methodologies are endorsed by the surveillance has been undertaken in parts
Nutrition Working Group of the Somalia of Sool, Sanaag, Nugal and Bari regions.
Aid Coordination Body. 5. Dietary assessments: These are part of
2. Health facilities: Currently there are nutrition surveys and sentinel site
around two hundred health facilities surveillance. The general objective is to
throughout Somalia. Over one hundred obtain information on the overall
of these health facilities collect nutrition adequacy of the diet consumed by
data on a monthly basis through households.
anthropometrical measurements of The 24 hour recall method is used to
children under the age of five. Nutrition determine dietary intake. Depending on
data collected from these facilities serves the objective of the dietary assessment,
as an early-warning indicator in case of actual estimates of amounts of food
a crisis. The health facility data also consumed may be determined through
indicates trends in malnutrition rates over weighing or volume estimates
a period of time. Health facility data are
not representative of the entire population 4.2 Data collection methodologies
given that not all children are brought to
the health centre. Caution should Information on nutrition can be collected using
therefore be exercised when interpreting either quantitative or qualitative research
this data. methodologies. Quantitative approaches
provide actual statistics on nutritional status
Some of the health facilities provide while qualitative research methodologies offer
therapeutic and supplementary feeding explanations into the actual causes of
services to severely and moderately malnutrition. The use of both approaches is
malnourished children, respectively. The required to develop a useful understanding of
trend of admissions and re-admissions the nutrition situation in any population.
may be a pointer to the incidences of
acute malnutrition in the facilitys Qualitative research explores, discovers;
catchment area. asks why, how and under what
3. Rapid assessments: These are mainly circumstances. It involves respondents as
carried out on an ad hoc basis and are active participants rather than subjects. The
useful when nutrition information is investigator is an instrument of research. In
urgently needed or when resources for qualitative research, there is the participant
carrying out a nutrition survey are limited. who contributes the information and the
A combination of methods is used to researcher who guides the research process

19
A survey team member reviewing health facility information (photo by FSAU)

and knowledge generation. These two are Nutrition surveys require a serious
essentially partners and the process towards investment in time - around one month
knowledge generation is based on mutual and in budget.
trust and understanding of a common goal. The survey should never be attempted
without the support of technical expertise
4.2.1 Nutrition survey during planning, implementation and
analysis.
Standard survey methodology is used in all
surveys. Guidelines are available from the
Nutrition Working Group of SACB Main functions of a survey
To establish a baseline
During a survey, anthropometric and other
To measure impact of impending or actual
quantitative data are collected on individual
food insecurity on population
children. Sampling procedures are used to
To measure progress or impact of nutrition
ensure that the children are representative
projects
of the whole population. Qualitative data on
nutrition and related factors are collected to
Steps in conducting a nutrition survey
enable an interpretation of the quantitative
data collected. 1. Plan the survey
2. Administer the survey
Issues of interest in planning a survey
Plan the survey
A nutrition survey is used to determine the
nutritional status of a population when: Successful planning is guided by the following
No major differences are expected principles:
between the various groups in that i. Review existing information related to
population the anticipated survey area. In particular,
Access to all populations in the area of determine the nutritional and health
interest is possible to ensure that random status, socio-economic background,
sampling is undertaken food security, cultural issues, geographic
Remember: location, population and settlement
A nutrition survey will provide one result patterns. Such information is useful in
that is relevant to the whole area surveyed; understanding the actual nutrition
it is not possible to break down the results problem, defining appropriate
by cluster and to draw conclusions for use objectives, selecting relevant resources,
in targeting

20
planning for adequate equipment and example, is the survey focusing on all
developing the survey schedule. households in the project area or
ii. Identify survey goals and objectives. Set targeted populations only?
objectives for the survey to ensure v. Select survey sample. When dealing
effective outcome of the survey results. with large population groups it is not
All nutrition surveys should be guided possible to survey the entire population
by clearly stated objectives. The survey due to cost and time constraints. For
coordinator needs to know: this reason, a portion of the population
Why is the nutrition survey being is selected. This proportion of the whole
conducted? population is the sample.
What types of nutrition information Four main sampling methods are used
are needed? (See appendix for details)
How will the survey information be 1. Two-Stage Cluster sampling
used? 2. Random sampling
iii. Identify survey indicators. It is 3. Systematic sampling
important to establish a range of 4. Stratified sampling
variables well in advance. The survey vi. Identify types of personnel, equipment
indicators include anthropometric and resources needed for conducting
indicators and mortality data with the the nutrition survey.
possible addition of morbidity vii. Agree on roles and responsibilities of
prevalence, infant feeding, care partners. Ensure that partners in all
practices and household food sectors are involved in the survey.
consumption patterns. viii. Plan a detailed time and activity
iv. Selecting survey methodology. Is schedule to be completed within the set
important to determine the type of the time frame and cost.
survey design during planning. For

A enumerator pre-testing data collection instruments (photo by FSAU)

21
ix. Develop data collection instruments Selecting appropriate data processing
like questionnaires, focus group methods and ensuring quality control
discussion guides, interview schedules procedures
and observation checklists. Analyzing data using appropriate statistical
x. Pre-test the data collection instruments. tools
Interpreting data
Administer the survey Report writing
The plans are translated into actions and Discussing findings and recommendations
include: Sharing the survey findings with partners
Logistical arrangements On completion of the survey, there is need to
Selecting the survey team follow up with stakeholders on how to use
Training research personnel nutrition data generated from survey;
Supervising the survey process Implement nutrition survey recommendations
Data collection activities like continue monitoring and evaluation of the
anthropometric measurements situation.

Weight measurment during a nutrition survey (photo by FSAU)

22
Interpreting nutrition survey data

Cut off points for indicators of malnutrition


Description of Weight for Height Index Oedema MUAC
Nutritional Status
W/H % of Z Score (SD)
the Median
Severe Acute < 70% <-3 Z scores (less than minus 3) Present <11 cm
Malnutrition
Moderate Acute 70% and Less than - 2 Z-scores BUT greater <12.5 cm
Malnutrition < 80% than or equal to -3 Z-score 11 cm
Global / Total < 80% <-2 Z scores Present <12.5 cm
Acute malnutrition
(moderate plus severe)
Normal 80% -2 Z-scores (Greater than or 13.5 cm
equal to -2Z-scores)
At risk <13.5 cm
12.5 cm
means less than or equal to; < means less than; means greater than or equal to
*The presence of oedema always implies severe malnutrition.

Classification of global acute malnutrition using Z- scores


The following classifications for malnutrition have been established by WHO as levels for
interpreting weight for height Z-score in emergencies.

Global Acute Malnutrition W/H Z score Interpretation


< 5% Acceptable level
5 9.9% Poor
10 14.9% Serious
> 15% Critical

Mortality assessment administered to a responsible member of that


household and death statistics are collected
In Somalia, mortality data has been
retrospectively. The recall period commonly used
concurrently collected during standard nutrition
is three months. All households encountered in
surveys (as described above). Mortality data
the sampling process for under-five children
collection uses the same methodology except
should be included until the desired sample size
that while the nutrition data requires thirty
is attained regardless of whether a child below
under-five children in each cluster (which might
the age of five is present or not as a household
be found in twenty households), mortality data
with no children could indicate that a child or
collection will require a minimum of thirty
children had died prior to the survey.
households. The mortality questionnaire is

23
Classification of mortality data

Indicator Definition Interpretation


Crude Mortality Rate (CMR) An estimate of the rate at which members of <1/10,000/day indicates a
the population die during a specified period. situation that is acceptable
This is the number of deaths from all causes 1 to <2/10,000/day
per 10,000 people per day. indicates a situation of alert
2/10,000/day indicates an
emergency situation

CMR=Total number of deaths over a specified time period* 10,000


Total estimated population (current)* specified time period in days

Under Five Mortality The number of deaths among children <2/10,000/day indicates a
Rate (U5MR) between birth and their fifth birthday situation that is acceptable
expressed per 10,000 live births. This is the 2 to 4/10,000/day
number of deaths from all causes per 10,000 indicates a situation of alert
of under five year old children per day. 4/10,000/day indicates an
emergency situation

U5MR= Total number of under 5 deaths over a specified time period* 10,000
Total estimated under 5 population (mid/current)*specified time period in days

Note:
Anthropometric data alone is not sufficient for analysis and interpretation. Contextual information collected during the
survey or from other sources is crucial for an in-depth and broad interpretation of the results. Verification of both qualitative
and quantitative data is important.

4.2.2 Rapid assessment will be required to facilitate triangulation and


verification of all information.
As the name suggests, this is a method used to
gather nutrition information within the shortest
Steps in planning Rapid Nutritional Assessment:
time possible and is particularly useful in
situations where physical access to population Define objectives of the assessment
is limited or when the speed of the assessment Determine target site, area or population
is a major consideration. The results of rapid Develop most appropriate methods of data
assessment provide a basis for planning during collection
an emergency. The purpose of rapid assessment Identify and train personnel to be involved
is to determine the severity and extent of the in the assessment
nutrition situation without embarking on a full Assemble materials and equipment
scale survey. needed during the assessment
In carrying out a rapid nutritional assessment, Develop the time plan and activity
Mid Upper Arm Circumference (MUAC) is the schedules
commonly used screening tool in measuring
malnutrition levels especially in emergencies. Using MUAC in Rapid Nutritional Assessment
MUAC assessments are further complemented Like data collection during nutrition surveys,
by qualitative methods to generate information selection of survey children should be as
on such issues as food security, health, representative as possible. Depending on the
environment, and care practices. size of the population either total population
or a sample may be assessed using MUAC. If a
Rapid assessments need to involve intersectoral
sample is to be used, a 30 by 30 cluster
teams and a variety of data collection methods
methodology will be adopted as used in surveys

24
or in other random sampling procedure. But Direct Observation: Involves observing visible
since MUAC assessment is rapid, an assessment indications of malnutrition and related issues
of all children in selected clusters/villages is that could influence nutritional status like poor
commonly used. All children aged 12-59 environmental health and sanitation.
months in the selected villages are measured. Key Informant Interviews: Involves interviewing
Data for assessing the nutritional status using key persons with specialized information on the
MUAC is taken for all children ages 12-59 subject under study like nutritionists, health
months. MUAC should be taken by the most officers and agriculturalists.
experienced member of the team to ensure Case study: involves an in-depth and focused
accuracy in data collection. study on subjects with similar characteristics
like less than 2-year old children with episodes
Use of MUAC alone is not a sufficient tool for of diarrhoea.
screening during rapid nutritional assessment. Transect Walks: Observations of all aspects of
Qualitative data is used to complement MUAC life in the area of interest during a walk from
using semi-structured interviews with key one edge of the area to the other.
informants and various groups in the Mapping: Supports focus of questions,
community. Direct observation, seasonal identification of resources and understanding
calendars, transect walks, review of documents of livelihoods.
including health facility records are additional
methods used. 4.2.3 Health facility data
*For detailed steps used in Measuring MUAC
Nutrition data is collected at health facilities
(See appendix 1)
and summarized at the end of each month.
Using the methodologies described elsewhere FSAU monitors nutrition data from over 100
in this chapter, information should be collected health facilities. Data from health facilities is
on the issues influencing nutritional status in entered in the Health Information System (HIS)
all sectors. These will include the following, database. This database also contains
among other issues: components on diseases (morbidity) and
Food availability in area under assessment immunization. Health facility personnel are
(Is food readily available? What foods are encouraged to provide explanations for upward
available?) or downward trends in levels of malnutrition
Water sources (type, number and status) among children attending the health facility.
Common diseases in the area
The major limitation of the health facility data
Accessibility to health services (What is the
is that not all children are brought to the health
distance of the health facility from the
centre for growth monitoring. The method is
village?)
therefore not representative of the entire
Any livestock movements (If yes, from
population. Care should be taken when
where to where and what is the reason for
interpreting health facility data.
that movement)
Any population movements (If yes, from FSAU undertakes on-the-job training and
where to where and why) follow-up support at health facility level that
Weaning foods for children aged 6-59 covers the following areas:
months Importance of carrying out nutrition
Feeding pattern (usual number of meals surveillance
per day, current number of meals; usual Methods of carrying out nutrition
and current composition of meals surveillance
Security situation Anthropometric measurement procedures
Other methods of information collection used in terms of accuracy and possible errors
in the analysis of the nutrition data Recording and reporting procedures
through use of standard registers and (HIS)
Focus Group Discussions: Group discussions forms
of 6-12 people that engage in understanding Interpretation of nutrition data using Z
the qualitative aspects of the nutritional status scores
of a given population.

25
Diagnosis of the causes of malnutrition 4.3 Qualitative data
both at individual and population level Qualitative research techniques:
Integrity of the equipment A number of qualitative research techniques are
Flow of information used for nutrition studies. They include:
Growth monitoring process _ Focus group discussions
Supplementary (SFP) and Therapeutic _ In-depth interviews
Feeding Programs (TFP). Data is collected _ Case studies
on new and re-admissions, origin and age _ Observational studies
of the participants. _ Experience survey
4.2.4 Sentinel sites surveillance Focus group discussions
The sentinel sites are purposively selected in
In a focus group discussion, the interviewer acts
highly vulnerable areas following a predefined
as a moderator/facilitator of the group
criterion. Selection of households in each site
discussion process, his/her role involves
is then undertaken in a random manner and a
introducing the topics, probing questions and
household questionnaire administered in each
eliciting responses from the respondents. The
by FSAU staff in collaboration with key partners
moderators role should be passive and should
and community assistants on the ground.
not dominate the discussion.
Qualitative data is collected through focus
group discussions, key informants and Focus groups are composed of people with
observations. Data analysis is further common characteristics such as age, sex, social
undertaken using EPIINFO and Microsoft Excel. or economic background. Interaction is best
Trends observed on the key indicators especially within a small group of participants ranging
nutritional status indicate the sites for from six to twelve persons. Every participant is
continuation in monitoring. encouraged to express views. The type of
response generated from the discussions
4.2.5 Dietary assessments determines the quality and interpretation of
A section of the household survey comprises results.
of a table on dietary intake data collection. The
respondents are required to recall the foods In-depth interviews
consumed in the previous 24 hour. This is an exchange between the interviewer
Key issues like food frequency, types of food and the respondent that allows investigation at
groups consumed and the relationships a greater level of detail. The interview probes
between malnutrition and dietary diversity are for feelings, attitudes, opinions and views. It
investigated. At the analysis stage, diversity of requires the interviewer to be skilled in the
the diet is determined by analysing the range questioning technique so as to elicit the
of food groups consumed during the recall required response.
period.

A team examining existing documents during a nutrition assessment (photo by FSAU)

26
Both the interviewer and the participant work research questions or objectives. The
together in a relaxed setting, a conversation is process begins by reading and fully
created by making participants talk freely on comprehending the field notes. As the
an identified topic. researcher reads and transcribes field
notes, the researcher should watch out for
Observation emerging themes. Such themes can be
It involves watching people and events to see disease prevalence, infant feeding habits,
how something happens rather than how it is commonly consumed foods and foods in
perceived. This is called direct observation. In season.
nutrition studies, one can observe child caring Displaying data and establishing
practices or child feeding practices in a given patterns: The researcher should examine
household over a period of time without data layout more closely. What patterns
interviewing that family. are emerging from the relationships?
Which ideas are related?
Direct observation can be used to confirm Data analysis and interpretation: The
information that respondents may provide on researcher requires analytical skills. These
the same matter. Observations are useful for develop with guidance and experience.
overcoming contradictions provided in Data analysis involves sieving information
interviews by respondents. to establish relationships between
In most observation sites such as the health concepts. For instance, relationships
facility, the researcher should prepare a list of between morbidity and nutritional status
things to observe. What is seen or heard will in a community. Interpretation involves
give meaning and new insights into a nutritional communicating essential ideas of the study
issue being investigated. The observation to identify connections and links with
process should be discreet. major themes. It is processing of findings
to create connections and gaps.
Documentary evidence Triangulation of the qualitative and
quantitative data is done during
This involves analyzing existing material for a interpretation. Triangulation is the
special purpose such as the creation of a integration of two methodologies to give
database. Content analysis can be used to data an in-depth and richer meaning. It is
determine a trends analysis in nutritional status usually after establishing the nutritional
over a period of time, examine food patterns status of a population, that linkage is made
and habits across communities, food and between the prevalence of malnutrition
nutritional policy, cultural beliefs and practices and causal factors in the community.
concerning food consumption. Intervention programme data:
Consideration of the supplementary and
Case study therapeutic feeding data (wherever
The study concentrates on the history and the available) is important to monitor the
story of a specific individual or situation. incidence of malnutrition. Special focus
Factors that contribute to malnutrition of an is made on the new admission and re-
individual child in a refugee camp would admission rates as well as the places of
constitute a case study. The case must be origin of the malnourished cases. Details
understood in its own context. However, by of the age categories to facilitate
undertaking a number of such studies, some establishing the vulnerable population
trends might be identified or further groups are needed.
investigation might be prompted. Report Writing: It is both a descriptive and
narrative account of the nutrition situation.
Basic steps in qualitative data analysis and The report states the problem, significance
interpretation of the study, objectives, methodologies,
findings and consequently,
Data organization: To analyze qualitative
recommendations. Appendix 7 provides a
data, the researcher should first review the
general format for report writing.

27
Water is the only food for these teenage girls, during the long hours of herding (photo by FSAU)

28
5 Analysis and intepretation of the nutrition situation
Analysis and interpretation of nutrition data is Steps in data analysis and
carried out in a systematic manner in order to
interpretation
develop an understanding of such questions as:
What is the populations nutritional status? a) Collate relevant data.
Is the current nutritional status acceptable b) Establish links and associations among
or not the various variables and the nutritional
Is the situation improving or deteriorating? status, considering all data collected.
What are the key factors influencing the c) Identify areas requiring interventions.
current nutritional status? d) Prepare study findings/results.
Which interventions are most appropriate e) Discuss findings with study population
in protecting or promoting better nutrition? and partners.
Under the prevailing circumstances how
is the nutritional status expected to evolve A Collate relevant data
over the coming months? Gather the historical data for the area or
What is the likely situation in the population. This includes baseline information
neighbouring areas (i.e. extrapolation) and previous surveys or assessments data. Past
relevant background information including
Notes morbidity data, food security information and
The sources of nutrition information are trends in malnutrition as reported in health
surveys, rapid assessments and health facility facilities. This information helps identify trends
data. Each of these data sets should be and whether the nutrition situation is improving
analyzed in the context of the season in or deteriorating.
which it is collected as this will influence
e.g. food supply, disease patterns and water B Establish links and associations of the
availability. Additionally, reference should be various variables and the nutritional status.
made to past nutrition information for the Analyze and interpret both qualitative and
study area so as to avail a clear indication quantitative data. The causes of malnutrition
on whether the nutrition situation has vary from one population to another hence the
improved or deteriorated over time. need to define the specific factors that
Nutrition surveys provide the most accurate contribute to nutritional status in each
data and the results can be seen as relevant for population. Statistical analysis of nutrition
the population with similar characteristics. survey data can be used to determine the links/
While manual analysis can be used to generate associations while this is not possible for rapid
descriptive statistics, EPIINFO is useful for both assessments and health facility data. Further
descriptive and inferential detailed analysis. links between qualitative data and the resulting
nutritional status can also be established guided
Health facility data is mainly from a self selected by the conceptual framework. (figure1)
group and attendance will be influenced by
many factors e.g. disease outbreaks, quality of Socio-economic and political environment.
service and availability of drugs. Though not
representative, the data is useful in indicating What is the estimated population size and
trends in nutritional status. how is this distributed among the various
livelihood or food economy groups? Is
Rapid assessments data gives an indication of there a particular group that is more
the situation during critical periods and when affected than any other?
surveys are not possible. How do the macroeconomic factors like
No single source of data is used in isolation. inflation rates, money supply and
Triangulation of information is carried out for a employment levels affect food security?
better analysis of the situation. How does the current situation affect trade
and food marketing activities (locally,
The term study is used to refer to the various
sources of data in this chapter.

29
Milk market (photo by FSAU)

nationally, regionally) for instance population that mainly relies on purchases


sanctions, ban on exports, restrictions on to obtain food, determining the prices and
movements of traders? availability of food in the markets is
How do the cultural attitudes influence important. In the case of an agro pastoral
what people eat, own or the social population that mainly relies on its own
institutions. production for food, determining whether
What is the security situation in the area? there was good harvest over the seasons
and if sufficient food stocks were available
Food security situation. at the time of the survey is important.
(Food availability and access) Weather conditions determine if good
Type, quality and quantity of food available. harvests will be realized, if pasture and
The food economy group of the population water supply is good hence influencing
plays a vital role in guiding this process. animal production.
For instance in the case of an urban Interpretation should take into account
availability of food stocks and an
estimation of how long these would last
the families.
Seeds availability and pests, rodents and
disease infestation on crops influence
food availability.

Access to food
Food access is influenced by purchasing
power. Definition of income availability
and the proportion spent on food items is
crucial especially for urban populations.
In the case of agro pastoral and pastoral
populations that also need to purchase

30
certain foodstuffs to supplement their Understanding seasonal trends in disease
production, it is important to establish the contributes to the analysis.
selling prices of their products or their Does the community have access to
terms of trade. quality health services and is the health
Availability of foods in markets at services seeking behaviour positive?
unaffordable prices can limit food access. Immunization is the safest way to protect
Logistical or geographical obstacles to children from immunizable diseases like
markets and insecurity can limit access measles and poliomyelitis. Once
to food immunized, bodies are more able to
If families harvest or obtain food but they fight diseases. If the immunization
sell or use the bulk of it to settle past debts coverage is low, the population is more
there is need to analyse if the balance is vulnerable to outbreaks of
sufficient to meet their needs over a given communicable disease. Understanding
period. the factors that contribute to a high or
Estimating the quantities of food eaten by low immunization coverage rate guides
family members can help define if in defining possible interventions; it is
members are meeting daily food indicative of the level of contact with
requirements or not. In the case of the formal health services, the quality
children, frequency of meals per day is of those health services and ultimately
important and more than three the extent to which the population
nutritionally balanced meals per day are chooses to use the health services.
recommended. Supplementation of certain micronutrients
Coping strategies in times of stress is usually undertaken among certain
contribute to food access in Somalia. The population when deficiency is suspected
normal means of accessing food for a given and when foods rich in these
population may be constrained at a given micronutrients are not readily available.
time but since the people have viable In Somalia, vitamin A supplementation
coping strategies, their access to food may is usually done on a regular basis. High
not be limited. vitamin A supplementation coverage
Establish if there is a change in coping could indicate a low likelihood of
strategies from the normal vitamin A deficiency.
The prevailing food security situation Poor sanitation practices predispose
could guide in predicting future nutritional populations to illnesses like diarrhoea and
status for instance if low malnutrition rates malaria which in turn contribute to
are reported in times of relatively poor food malnutrition. High proportions of the
security, the nutritional status is expected population without access to clean
to deteriorate in the future. sanitary facilities could account for a high
The analysis may coincide with a season diarrhoea incidence.
characterized as a hunger gap and with a If a large proportion is relying on a clean
possibility of improvement if the seasonal source of drinking water, there is need to
variables get better. determine if this is sustainable or not.
Hygiene practices in homes, around
Health and sanitation. water points and when handling foods
Nutritional status and diseases are closely can explain certain disease outbreaks
linked. A high incidence of important like cholera.
childhood illnesses (those that have strong
associations with nutritional status like Care practices for mothers and children.
measles, diarrhoea, ARI and malaria) prior A childs health and nutritional well being
to or around the period of analysis will depends on the type of care that child
influence nutritional status. receives. Poor care practices will
A disease outbreak or high disease contribute to a deterioration in nutritional
incidences in a given area will status. For example a lactating mother who
compromise nutritional status. lacks good care might not have enough

31
milk or even adequate time to breastfeed Food utilization by the body
her child while an expectant mother For certain foods/nutrients to be better
without good care will most likely deliver utilized by the body, they need be
an underweight child. consumed in combination with others. For
Low birth weight and poor childcare instance, for the body to utilize fat-soluble
practices (breastfeeding, weaning, feeding vitamins, fat consumption is important.
frequencies) are likely to contribute to poor Vitamin C helps the body to absorb iron.
nutritional status. Likewise, some foods inhibit the
absorption of other foods. [Consumption
Food consumption of tea (containing tannins) soon after meals
Both quantity and quality of food inhibits iron absorption.]
consumed are important in determining
the well being of an individual. The body Mortality
requires certain amounts of the various
This indicates a crisis. It marks the highest
nutrients on a daily basis for proper
level of deterioration of life and
growth. A limitation in any of these will
livelihoods. A low malnutrition rate while
have negative consequences on an
the under five mortality rate is high does
individuals nutritional status.
not essentially mean that the nutritional
In most cases, people will consume the
status of the population is good. It is
foods that are readily available to them
possible that some of the severely
for instance among the pastoral
malnourished children died prior to the
communities, the quantities of milk
survey hence the low malnutrition rates.
consumed during the good seasons is
high unlike in the lean seasons.

Children recovering from severe malnutrition in a therapeutic feeding centre (photo by FSAU)

32
Livelihood assets: Recommendations on interventions need to
These define the context, options and be guided by the analysis and ideally not by
constraints available to households and the focus of particular organizations.
individuals in their livelihood strategies.
Analysis is undertaken at the zonal and/or D Prepare study findings
household level, with consideration made to Prepare study results highlighting the
privately and public owned assets (or capitals). impor-tant findings.
Physical Capital:This defines the basic
infrastructure and producer goods needed E Discuss study findings with study
to support livelihoods. (e.g. transportation, population
shelter, water supply and communications)
Share the main study findings with the
Financial Capital. This refers to the
study population and partners.
financial resources people use to achieve
This discussion will provide an opening
their livelihood objectives; and flows and
for more comprehensive and longer term
stocks that contribute to consumption and
community based analysis of issues that
production. (e.g. flows of cash income,
can be addressed more efficiently and
livestock holdings, credit)
effectively by the community themselves.
Human Capital: These are the skills,
knowledge, ability to labour and good
health that together enable people to Case study
pursue different livelihood strategies. (e.g. A case study on Bulla Hawa Nutrition Survey
the amount and quality of labour available, in Gedo region undertaken in October 2002 is
skills and health status.) presented to illustrate data analysis and
Social Capital are the social resources from interpretation.
which people draw, in pursuit of their
Gedo is the most chronically food insecure
livelihood objectives. (e.g. networks and
region in Somalia, partially explained by
connectedness, relationships of trust)
recurrent drought and insecurity incidences.
Natural Capital are the natural resource
Consequently, the acute food insecurity and
stock from which resource flows and
human suffering was manifested by the
services useful for livelihoods are derived.
unacceptably high global acute malnutrition
(e.g. land, trees, pasture).
rate of 37% (using <2 Z-score cut-off) in the
December 2001 Belet Hawa nutrition survey
C Identify areas requiring interventions
accompanied by high mortality. These
Interventions that contribute positively to the provoked significant humanitarian responses.
nutritional status include adequate health Both food aid (general and selective feeding)
services; availability of clean and reliable and basic healthcare services in the district
water sources; income generating projects; were supported by CARE and Gedo Health
education facilities; seed distribution Consortium (GHC) amid serious insecurity.
programmes and veterinary services. If Following the relatively good 2002 GU
present, are they accessible to all and season, it was felt that food security and
sustainable? nutritional status might have improved
Are certain factors contributing negatively although the effect of recurrent insecurity and
to the nutritional status for example low the diminished asset levels in households was
knowledge on nutrition-related issues, lack not clear. Implementing organisations and
of sanitation facilities; inadequate health the Humanitarian Response Group of the
services; low immunisation rates, low Somalia Aid Coordination Body (SACB)
vitamin A supplementation coverage and therefore, recommended a repeat survey in
insufficient food. Have these been the district which was undertaken in October
addressed at all? If yes is it sufficiently so? 2002. Some of the survey results are as
Which interventions require immediate or presented on the table.
long term response

33
Indicator No. %
Children under five years screened during the survey 907 100
Global acute malnutrition W/H <-2 Z-score or with oedema 195 21.5 (CI: 18.9%-24.5%)
Severe acute malnutrition W/H <-3 Z-score or with oedema 20 2.2 (CI: 1.4%-3.4%)
Global acute malnutrition W/H in Z-Score (<-2 Z-score) or 71 26.6
presence of oedema in agro-pastoral villages
Global acute malnutrition W/H in Z-Score (<-2 Z-score) or 77 21.0
with oedema in Belet Hawa town including IDP village
% of children with diarrhoea in two weeks prior to the survey 234 25.9
% of children with ARI in two weeks prior to the survey. 186 20.6
% of children with malaria in two weeks prior to the survey 212 23.4
% of children that received Vitamin A within last six months 797 88.1
% of children immunised against Measles 621 72.0
% of children from displaced households 95 10.5

Substantial food aid (that is, both from general still a major problem that calls for continued
distribution by CARE and GHC/UNICEFs support to comprehensive health and nutrition
selective feeding programme), harvests from intervention programmes.
relatively good 2002 Gu rains and
accompanying migration of some livestock, About 27% of the children fed once or twice a
more aggressive/improved health service day. The overwhelming majority of the children
provision (manifested by improved measles (99%) included in the survey were not
immunisation and vitamin supplementation), exclusively breastfed in their first six months
and relatively low incidences of common child while nearly 98% received foods other than
illnesses (compared to 2001) played a key role breast milk in their first three months of life.
in explaining the significant improvement in Mothers reported having to travel increasingly
nutritional status since the December 2001 long distances in search of water (especially
nutrition survey. In addition, the use of bush before the Gu 2002 rains). Some responses to
products increasingly provided a significant limited food access like collecting bush
income source to most households in the products leads long separation from their young
district. The survey reveals that with a children further compromised childcare.
population of about 65,000 residents (WHO
2002) in Belet Hawa, the relief food services Both the survey and other FSAU food security
distributed between December 2001 and information indicate significant shifts in
October 2002 was capable of providing about peoples livelihood patterns in recent years with
70% of the daily food requirements to all many more households now categorised as
individuals assuming minimal losses and use urban and fewer as pastoralist. Purchases
of all the rations within the district. and food aid were the main food sources while
casual work and sale of bush products were
Continued limited food availability and the almost the dominant income sources. Borrowing and
constant insecurity; poor childcare/feeding food aid reliance ranked highly as coping
practices and high disease incidences, all strategies.
contribute to the persistent poor nutritional status
of the population in Belet Hawa District. The Recommendations following the survey include
significant statistical association between the adequate general ration and selective feeding
observed malnutrition and diseases like diarrhoea concurrent with continued support to the
and malaria confirms that disease prevalence is health, livestock and water sectors as immediate

34
responses. Income generating activities are also region will also work positively for the Bulla
key to revive the Belet Hawa economy. An Hawa population.
improvement on the security situation in the

Bibliography
Action Against Hunger (2000). Basics of Nutrition and General Food Distributions.
Action Against Hunger (2002). Training Manual on Nutrition Surveillance.
African Medical Research Education Foundation (1994). Community Nutrition For Eastern Africa.
Anne Burgess & others. AMREF. 1994.
Cogill. B, (2001) Anthropometric Indicators Measurement Guide. Food and Nutrition Technical
Assistance. Washington DC.
Emergency Nutrition Coordination Unit (2001)Training Manual on Emergency Nutrition Assessment
in Ethiopia.
Food Agriculture Organization of the United Nations (1993): Food and Nutrition in Management of
Group Feeding Programs. Rome, Italy.
Food and Agriculture Organization of the United Nations (1990). Conducting Small Scale Nutrition
Surveys. A Field Manual. Food and Agriculture Organization of the United Nations. Rome.
Food Security Analysis Unit (2002). Nutrition Surveillance in Somalia.
Food Security Analysis Unit (2002). Nutrition surveillance Training Guide Notes.
Gibson, R.S (1990). Principles of Nutritional assessment.
Young, H. (1992). Food Security and Famine. Assessment and Response. Oxfam Practical Health
Guide No. 7.
Young, H and Susanne, J. (1995). Nutrition Matters. People, Food and Famine. An Intermediate
Technology Group Publication.
Hubbard, M. (1995). Improving Food Security. A Guide for Rural Development Managers. An Inter-
mediate Technology Group Publication.
Lee, RD; Nieman, DC (1995). Nutritional Assessment. 2nd Edition. Morsby.
Lusty, T & Pat, D. (1984). Selective Feeding Programs. Oxfam Practical Health Guide. No. 1. Oxfam
Print Unit. United Kingdom.
Nutrition Working Group (1999). Nutrition Survey : Recommendations for Somalia. February 1999,
Nairobi.
Rosalind S. Gibson: (1990). Principles of Nutrition Assessment. Oxford University Press.
Save the children (2001). The Household Economy Approach. A Resource Manual for Practitioners.
Save the Children, UK.
World Food Program (1998). Food and Nutrition Handbook. Rome, Italy.
World Health Organization (1995). Field Guide On Rapid Nutrition Assessment in Emergencies.
World Health Organization Regional Office for the Eastern Mediterranean. Geneva.
World Health Organization Regional Office for the Eastern Mediterranean. Geneva.
World Health Organization (1999). Management of Severe Malnutrition: A Manual for Physicians and
Other Senior Health Workers. WHO, Geneva.
World Health Organization (2000) Management of Nutrition in major Emergencies. Geneva.

35
A nutrition survey enumerator measuring height of a child (photo by FSAU)

36
Appendices
Appendix 1
Procedure for taking weight, height/length and MUAC measurements
Body measurement Type of equipment
Height/Length Height or length boards (cm); Head block, Foot piece
MUAC MUAC tape
Weight Salter scale (235), plastic pant, rope

Height measurement 2. Lay the child on the measuring board


A child aged 2 years (24 months) and above or with the top of the head pressed firmly
taller than 85 cm should be measured while against the fixed ends .
standing. 3. Make sure the child is lying flat in the
1. Place the measuring board on a smooth centre of the board.
level, flat hard surface preferably against 4. Hold knees straight and bring the
a wall, tree or a doorpost. movable footboard firmly against the
2. Remove shoes, sandals, socks, headgear heels so that the feet are at right angles.
or any other heavy items. 5. Check the childs position.
3. Assist the child stand with its back 6. Read and record the length to the nearest
against the measuring board. Ask the 0.1 cm.
assistant to help keep the child calm and Always note that measurements and reading are
composed taken twice.
4. Position the child with bare feet together.
Weight measurements
Check on the position of the heels,
buttocks, shoulders and back of the head Rope for hanging scales, Measuring sling,
touching the board. Plastic pants
5. Hold the chin so that the child is looking 1. Ensure that the Salter scale is hooked onto
up straight the ceiling or a tree branch and that the
6. Adjust the headpiece so that it is level scale is stable and hanging freely. The
7. Lower the headpiece until it is firm on scale should hung on a strong support.
top of the head. Press gently to ensure 2. Always adjust the scale to zero with
that its in contact with the head. weighing pants hanging on the scale
8. Read the childs height to the nearest before weighing the child.
0.1cm. 3. Request the mother to undress the child.
9. Record the reading immediately. She should remove as many clothes as
10. Remove the headpiece and repeat possible.
the instructions once more. 4. With the mothers assistance, put the
*Note that in weight for height, children child into the weighing pants.
<5years or those whose measurements are 5. Gently lower the child onto the Salter
between 65 and 110cm are considered. scale while the mother holds the baby.
6. Read the childs weight. Ensure that the
Length measurement child is hanging freely and not holding
on to anything.
Children less than two years old or children
7. Read the weight to the nearest 0.1 kg.
whose length is shorter than 85 cm should be
8. Repeat the procedure of reading and
measured lying on their back.
recording the childs weight. Record the
1. Where the child is <2 years old, use
average of the two measurements.
horizontal measuring board.
9. Gently remove the child from the scale.
Do not lift the child by the straps or
weighing pants.

37
A nutrition survey enumerator measuring length of a child (photo by FSAU)

Mid Upper Arm Circumference (MUAC) The tape should be comfortably crossed
measurements over from 0 mark.
In young children, the target group is usually Take the measurement to the nearest 0.1
the age group12 -59 months. cm where the tape crosses at 0.
Request the mother to uncover the childs Record down the data on the data entry
left arm as far as the shoulder. form.
Bend the arm and place the lower arm The entry form should bear the following
across the stomach. details: childs sex, age, presence of
Find the tip of the bone at the back and oedema, and MUAC measurement.
top of the shoulder with your fingertips and
mark it with a pen. To determine a childs age various methods
Mark the second spot at the tip of the could be followed:
elbow. Examining the documentary evidence of
Measure the distance between the two birth date such as Road to Health Card
marked spots while standing behind the from the MCH Centre.
child and divide this measurement by two. Where such evidence is missing, estimate
Using a MUAC tape, wrap the tape around date of birth using parents estimates or
the arm at the midpoint between the local event calendars.
shoulder and the tip of the elbow.

38
Appendix 2
Sources of error in taking anthropometrical measurements
Common errors Solution
1. All measurements
Restless child Postpone measurement. Involve parent in procedure.
Inaccurate reading Training and retraining stressing accuracy.
Recording Record results immediately after taking measurements and
confirm record.
2. Length/Height
Incorrect method for age Use length only when child is <2 years old
Foot wear/headgear Remove
Head not in correct plane, Correct technique with practice and regular retraining.
child not straight, knees bent, Provide adequate assistance. Calm the child.
or feet not flat on floor
Child not straight along Parent or assistant should be present.
board and foot not parallel Dont take measurements while the child is struggling.
with movable board
Sliding board not firmly Settle child. Correct pressure should be practiced.
against heels/head Move head board to compress hair.
3. Weight
Scale not calibrated to zero Recalibrate after every measurement.
Child wearing heavy clothing Remove or make allowances for clothing.
Child moving or anxious Wait until child is calm or remove cause of anxiety.
4. MUAC
Child not standing in Position subject correctly.
correct position
Mid arm point Measure midpoint carefully.
incorrectly marked
Examiner not level with Correct techniques with training, supervision and retraining.
subject, tape around the arm Take into account cultural practices for example. wearing
not at mid point, tape too of armbands.
tight/ too loose

39
Appendix 3
An Example of a 24-hour dietary recall checklist
Name of person interviewed ..........................................
Date ...............................................................................
Date & Day of week .......................................................
Name of interviewee ......................................................
Food Type Breakfast Lunch Supper In-between snacks Amount/portion Which foods
& Beverages eaten and why? foods are not

1.
2.
3.
4.
*Note also that main ingredients in mixed dishes should be identified.

Traditional method of processing cereals before cooking (photo by FSAU)

40
Appendix 4

Basic statistical concepts minimum and the maximum values of all


values to a variable
Variables
Standard Deviation: this is measure of
These are items for which data is sought e.g. dispersion around the mean of values. It
name, level of education, age etc. variables are gives an idea of how the different values
categorized under the following two groups; of a variable disperse from the mean value.
Qualitative variables: these are variables whose It has the unit of values of the variable and
values are descriptive and cannot be quantified the square root of the variance.
e.g. sex of a child (male/female), household 4 Determining Nutritional Status
source of income (remittances, sale of animals, Nutritional indicators are developed
diarrhea in last two weeks (yes/no) etc. These through comparing a childs
values do not compare numerically. measurements to reference measurements.
Quantitative variables: these are variables The reference data has been developed
whose values arise from counts or from the children of the same age, weight
measurements expressed numerically. For and height respectively. Results of
instance weight of a child, age of a child, nutritional status are expressed as,
household size, height of a child etc. Standard deviation scores (Z-Scores)
The percentage of the median or
Steps in Data Analysis: Percentiles
The first step in quantitative data analysis is to
summarize data to make it easier to understand. Standard Deviation Score (Z-Score)
The commonly used tool in summarizing data
is through use of frequency distribution. Are measures of the distance of how far
1 Frequency Distribution: Frequencies are the childs measurement e.g. a childs
counts of different values of a particular weight is from the median weight of the
variable e.g. finding out how many of the child of the same height in the reference
surveyed children are boys and how many data. The distance is expressed in standard
are girls. A set of all frequencies occurring deviation. Its computed as follows:
values is called a frequency distribution. Weight-for-height = Observed reference median
It comprises of counts, percentages and Z-Scores weight weight
cumulative percentages. The frequency Standard Deviation of the
distribution gives a general picture of the reference population
values of the variable. Summaries can
further be made through use of average Z-scores has greater compatibility with the
values (central tendency) and other spread NCHS/WHO reference values and
values (measures of dispersion). suitability for selecting malnourished
children irrespective of height
2 Measures of Central Tendency (Mean, Z-scores are particularly useful for
Mode and Median) determining differentials in malnutrition
Mean: This is the sum of the values of a rates
variable divided by the number of values Z-scores Involve a complex process in
(n). calculation
Median: This is the value that divides the Z-score relies on fitted distribution of
distribution in half when the values are indices across age and height values If
either arranged in ascending or descending a childs SD score falls outside the
order. It therefore becomes the middle normal range (-2 and +2), then this
value in the distribution. signals a deviation from the norm in the
Mode: this is the most frequent value nutritional status
among all values in a variable. Has a greater capacity to determine
3 Measures of Dispersion proportion of malnourished cases.
Range: The difference between the

41
Percentage of the Median recommended by the World Health
Demonstrates the childs anthropometrical Organization.
measurement as a percentage of the expected This reference data is based on basic tenets
value of the reference population. It is the ratio of a normal distribution. For instance, if a
of a childs weight to the median weight of a child falls below 2SD or 80% then that child
child of the same height in the reference data, is considered to have a negative deviant of
expressed as a percentage. For instance, the 5% minority for that height group. If a
assuming that the median weight of the childs weight on the other hand falls below
reference data for a particular height is 10 kg, -3SD or about 70%, then it is a negative
then to say that the child is 80% weight for deviant of the 1% minority for that height
height suggests that the child is 8 kg. group and as a consequence considered as
severely malnourished.
Percentage of the median is calculated as
follows: Confidence Intervals
% of the median = Actual weight of the The nutritional status developed from samples
child being measured X 100 only gives a rough estimate of the situation in
Reference weight of the child the general population. However when the
sample is selected through some random
The usefulness of the percentage of the median
method, then we can use properties of
is that its widely used in the field than SD scores.
distribution to describe the general population.
Besides it is typically used for admissions into
For example, a 95% confidence interval around
feeding centers.
the sample estimate will imply that we are 95%
Also, these calculations are easy to understand, confident that the interval contains a true
calculate and interpret given that tables of population measure. So, a prevalence of 12.5%
reference values are readily available (CI: 10.8% -14.1%) will mean that at least we
can be 95% confident that the true population
Determination of Populations Nutritional prevalence is between 10.8% and 14.1%.
Status
A childs body measurements are compared Inter-relationship Between Anthropometric
with the reference values by calculating either Data and Other Variables
their percent of the reference median or by Further statistical analysis mainly using
calculating their standard deviation scores inferential statistics is normally performed to
In the theoretical perspective of normal relate anthropometric data to other variables
distribution, the mean is normally equal to the collected during survey e.g. sex of the child,
median and also to the mode i.e. age groups of the surveyed children, household
mean=median=mode sources of income, food economy groups,
In such a distribution, about 70% of subjects disease prevalence, breastfeeding and infant
will lie within1SD about the mean, 95% within feeding patterns etc.
2SD and 99% within 3SD about the mean.
When conducting this kind of analysis,
Normal distribution therefore refers to the
statistical tests such as chi square analysis,
distribution where individual measurements are
analysis of variance (ANOVA), regression
symmetrically distributed around the mean (it
analysis and other statistical investigations are
normally takes the bell shaped curve as is
carried out. This is normally an advanced level
shown in the box.)
of analysis and requires assistance by a
Normally, the childs nutritional status is
statistician in order to help determine the type
determined by her/his weight compared to a
of analysis that is suitable for the data collected.
standard child with the same height
Standard median weight for each height Significance tests are performed. These are
measure of children has been developed and facilitated through use of computer packages
used as reference data for determination of as manual packages are time consuming and
nutritional status for by the United States requires even more statistical expertise.
National Centre for Health Statistics (NHCS). Always consult a statistician before embarking
The reference population data has been on this type of analysis.

42
Appendix 5

Technical Terminology Expandability - Refers to how much extra food


and income can potentially be obtained if the
Household food access is determined by
household needs to increase access to income
seasonality patterns e.g. the main food crop
or food and reduce expenditure by:
produced may not be sufficient to meet the
Expanding existing food and income
household needs at all times. Amongst pastoral
options of households
communities, milk production varies with
Additional food and income generating
rainfall and availability of grazing lands. Further,
options and
opportunities for employment, migration,
Reduction in spending to minimum levels
availability of fish and wild foods are often
highly seasonal. In addition, household income Coping Strategies - are the ways in which
& expenditure may vary according to season households try to make up in some activities
thus affecting food consumption patterns. losses suffered in others.
Household Economy - the sum of ways in Understanding coping strategies helps
which the household produces food and non determine an appropriate response. Coping
food items (assets, livestock, land) for its own strategies change as stress continues. Early
use and also how households obtain non food coping strategies are highly reversible (e.g.
items by exchanging production and labor. short-term dietary change) and require a low
commitment of domestic resources. There are
Vulnerability - the extent to which a household also irreversible coping strategies which involve
is affected by a defined event or risk - whatever a high commitment of domestic resources (such
the risk of that event occurring. For example a as productive asset sales, or out-migration).
household might be regarded as vulnerable to Some examples of coping strategies include:
a defined level of crop failure if this would food reduction, increased labor, consumption
reduce its income by, say, 50%, even if crop of wild food, migration, sale of assets, reduced
failure in that area were rare. Vulnerability can expenditure patterns and splitting household
be reduced by having greater diversity of members amongst relatives.
activities to reduce degree of exposure to any
Cost of Coping - include financial, time,
one risk, and greater range of coping options.
social costs.
Shock or Risk - events with potentially
adverse consequences for the household . Opportunity Cost - the hidden cost of
Shock or risk is unpredictable and out of expanding an activity. For instance, increasing
households control. Can be natural or man- casual labor for other people will imply
made, slow or rapid-onset. neglecting ones own land. This will have long-
term consequences since it will affect food
Effect of a shock (or shocks) on a household in production the following year. Similarly, taking
any location will depend on ; a child out of school might imply receiving
The magnitude of the shock (scale/severity/ additional cash for food in the immediate term
duration) but , it will result in the loss of potentially higher
The normal household economy earnings and social benefits in the future.
Opportunities to compensate for loss of
Distress Strategies - are strategies employed
income
when coping mechanisms fail, e.g. Eating
Choices that the household makes &
budgeted stores, or wild foods that wouldnt
Degree of market dependency
normally be eaten and which may be
Risk Minimization - Strategies employed to detrimental to health. Slaughter/sale of
reduce the anticipated exposure to risk e.g. livestock to unsustainable levels -
storage of crops, pesticide use, splitting herds, jeopardizing future livelihoods. Detrimental
castrating male animals, planting drought- non-economic or social costs for instance
resistant crops and maintaining good women who respond to a shock by becoming
relationships with other people/groups/ commercial sex workers.
populations.

43
Adaptive Strategies - The continuation of a Nutrition - The subject of nutrition is concerned
shock, or series of shocks, forces the household with how people stay alive and well by
to adapt its old way of life into a new one. Thus consumption of food. It includes how people
the economy becomes new or different. e.g. obtain their food, how it is processed, handled,
pastoralists who drop out of pastoralism or prepared, shared, eaten and with what happens
permanent migration to a new location in the body- how it is digested, absorbed and
Health - A state of physical, social, mental and used by the body to contribute to good health.
psychological well-being and not just the Nutrients - Nutrients are small parts of food
absence of disease that the body uses for various body functions.
Morbidity - ill health or disease. Proteins- for building body tissues
Carbohydrates -for producing energy
Immunization - is a process of inoculating vitamins and minerals- for fighting
attenuated or live organisms into the body in infections
order to stimulate production of antibodies
against a particular disease. All children under Nutrients be classified into macronutrients and
five years of age are susceptible to micronutrients for sources see appendix 8.
communicable diseases, many of which can Macronutrients - The foods that we consume
be preventable through vaccination. Somalia comprise of the some major food nutrients,
has developed an Expanded Program for which comprise the bulk of our diets, and they
Immunization (EPI) addressing vaccine are known as macronutrients. Examples of
preventable diseases such as tuberculosis, macronutrients include; proteins, fats and
diphtheria, tetanus, poliomyelitis, and measles, carbohydrates as well as water. Ideally, these
that follow recommendations of WHO. nutrients supply all the energy requirements
Nutrients are the constituents of food or needed by the body. In addition, macronutrients
substances that the body uses for various comprise the bulk of our diets. It is well
functions. They can be either macro- or established that about 80% of our food intake
micro-nutrients. is composed of macronutrients. In order for the
body to discharge its normal functions it needs,
Macronutrients are food nutrients that are proteins, carbohydrates and fats.
required by the body in large quantities. They
comprise the bulk of our diets and include, Micronutrients - These are substances needed
proteins, carbohydrates and fats. proteins are by the body in very small quantities for growth,
used for building body tissues; carbohydrates development and maintenance of different
for producing energy body functions. They comprise of vitamins and
minerals. The important vitamins are vitamin
Micronutrients are substances needed by the body A, the B vitamins, C, D and E while important
in very minute quantities for growth, development minerals include iron, zinc and iodine. Vitamin
and maintenance of a wide variety of bodily A helps the body resist infections and to keep
functions. They include iron, iodine, Vitamin A, all the cells on the surface of the body healthy
Vitamin B Complex, Vitamin C and Zinc.
Malnutrition - Malnutrition may be defined as
Nutrition surveillance - is the process of a state in which the physical function of an
monitoring changes in the nutritional status of individual is impaired to a point where she
a population or subgroup on a regular and or he can no longer maintain adequate
timely basis. Nutrition surveillance involves performance in such processes as growth,
data collection, processing, analysis, pregnancy, lactation, physical work, resisting
interpretation and communication. Nutrition and recovering from disease (Pacey and
surveillance is an important process during Payne, 1985).
normal and emergency situations.
Under Nutrition - Malnutrition should not be
The Food Security Assessment Unit (FSAU) confused with under nutrition, which refers to
supports nutrition surveillance activities in reduced overall food intake in relation to the
Somalia and aims to provide timely and recommended daily dietary nutrition
appropriate information on the nutritional status requirements.
of the population along with possible
explanations for potential or real change.

44
Appendix 6
UNICEFs Conceptual Framework showing the causes of malnutrition

Malnutrition
and
death

Inadequate dietary intake Disease

Inadequate Inadequate Insufficient


household food maternal and services and
security child care healthy
i

Formal and non-formal institutions,


political and ideological superstructure,
Economic structure, potential resources

Appendix 7
Format for Nutrition Assessment Reports
Executive summary
Introduction
Survey/ assessment justification
Background information
Methodology
Results and analysis
Conclusion
Recommendation
Annexes (e.g. of tools and references)

45
Appendix 8 Vitamin A deficiency - Low levels or lack of
vitamin A in the body leads to vitamin A
Micro-Nutrients: Functions and the deficiency (VAD). The main symptoms of
consequences of deficiencies vitamin A deficiency are: eye symptoms (eye
blindness, inflammation of the eye,
Definition of micronutrients - Micronutrients inflammation of the cornea, eye lesions, and
are nutrients that are essential for healthy dry eyes), skin symptoms (rough skin, dry skin),
growth and development but required only in decreased immunity (frequent infections of
small amounts. Micronutrients play very common diseases like diarrhoea and measles)
important roles in the body. They affect adult and loss of appetite as well as growth
productivity, resistance to illness, educational retardation in children.
achievement (cognitive impairment), child
survival and maternal health. Dietary sources of vitamin A - Some of the main
sources include breast milk (especially the
Important micronutrients - Iron, Vitamin A, colostrums), animal products (cheese, butter,
Iodine, Vitamin C and Zinc egg yolk, milk, meat specially liver and kidney,
Iron - Iron helps to make blood, particularly in and oily fish), green vegetables (carrots,
the production of haemoglobin, the protein in pumpkins, parsley, amaranth, spinach, sweet
red blood cells that carries oxygen. Iron also potato and cassava), fruits (mangoes, papayas
helps to make essential enzymes that enable and tomatoes), yellow varieties of sweet potato,
the brain, muscle, and immune systems to yellow maize, red palm oil and fortified foods
function properly. like margarines, vegetable ghee and dried milk.
Iron deficiency - Low levels or lack of iron in Iodine - The body needs iodine for normal
the body leads to iron deficiency. Severe lack mental and physical development. Iodine is
of iron leads to iron deficiency anaemia (IDA). essential for the function of the thyroid gland,
Iron deficiency is the most common nutritional which is responsible for development. Iodine
deficiency. Young children and pregnant is also essential for foetal development.
women suffer high rates of IDA. The main Iodine deficiency - The main symptoms are
symptoms are pallor, fatigue, brittle fingernails, goitre (enlargement of thyroid gland),
sore tongue, and brittle hair, shortness of breath, protruding eyes, hypothyroidism (fatigue,
unusual food cravings, low blood pressure, weight gain, weakness and depression) and
rapid heartbeat, low immunity, headache, hyperthyroidism (weight loss, rapid heartbeat,
decreased appetite, severe menstrual pain and and appetite problems). IDD (Iodine Deficiency
bleeding and disturbed sleep. Disorders) in pregnancy causes dwarfism and
Dietary sources of iron - Some of the sources cretinism (severe mental retardation, stunted
include meat (spleen, kidney and liver physical growth, enlarged head and deafness)
especially), chicken, fish, eggs, dried fruits, to the newborn.
legumes (beans, peas), cocoa and cocoa Dietary sources of iodine - The main sources
products and dark green leafy vegetables. of iodine are sea fish, milk, seaweed, green
Cereals (maize, rice and wheat) contain vegetables grown near the sea (especially
moderate amounts but since they are consumed spinach), iodated salt and fresh water
in large amounts they provide most of the iron. (depending on area).
It is also obtained from iron cooking pots.
Zinc - Zinc promotes normal growth and
Vitamin A - It is essential for vision, growth and development. It promotes wound healing,
skeletal development. Assists in maintaining maintains a healthy immune system and helps
health skin and mucous membranes, protecting prevent diarrhoea in young children.
the bodys major organs, enables proper
function of most body organs, assists Zinc deficiency - Main symptoms of zinc
maintaining health skin and mucous deficiency are slow growth in children, hair
membranes and provides optimum immune loss, various skin lesions, peeling skin, slow
function. healing of wounds, frequent and recurring
infections, severe diarrhoea, poor appetite, loss
of taste and smell, fatigue, and sterility in males.

46
Dietary sources of zinc - Zinc is readily bone strength. Calcium is also used in muscle
available in breast milk for the young children, contraction and blood clotting.
vegetables, seafood, meats (including chicken Calcium deficiency - Main calcium deficiency
and fish), eggs and whole grain cereals and symptoms are weak teeth that easily fall out,
legumes. lack of sleep, premenstrual cramps, high blood
Vitamin C - Vitamin C (also called ascorbic pressure, large forehead, sunken chest,
acid) is essential for healthy teeth, gums and protruding chest, osteoporosis (bones easily
bones. It helps to heal wounds, produce red fracture due to minor falls i.e. bones break
blood cells, build immunity and fight bacterial under their own weight), hump in the back,
infections. Vitamin C helps to form collagen, curvature of the spine, rounded shoulders,
the cement that holds tissues together. Vitamin losing height (becoming shorter) and inability
C enhances the absorption of iron in the body. to hold the body upright.
Vitamin C deficiency leads to a disease known
Dietary sources of calcium - Breast milk for
as scurvy.
the young children, milk and milk products like
Vitamin C deficiency - Main vitamin C cheese and yoghurt, bread (added to white flour
deficiency symptoms includes bruising, swollen by law), finger millet, small saltwater and bones
or painful joints, bleeding gums, nosebleeds, of fresh water fish (e.g. sardines and sprats) and
fatigue and weakness, easily gets colds, hard water. Dark green vegetables and pulses
anaemia, poor digestion, scurvy (skin that (beans and peas) have small amounts of
bruises and bleeds easily, bleeding on fingertips, calcium.
old scars and internal bleeding, nose bleeds,
Vitamin D - The major function of vitamin D is
soft swollen purple gums, bleeding gums, tooth
to maintain normal blood levels of calcium and
decay, hair and tooth loss, bones that easily
phosphorous. Vitamin D helps the body to
fracture, swollen and painful joints, slow
absorb calcium; helping to form and maintain
healing wounds and fractures, loss of appetite,
strong bones.
weakness, fatigue and irritability.
Vitamin D deficiency - Lack of vitamin D can
Dietary sources of vitamin C - The main sources lead to calcium deficiency. Vitamin D prevents
include fruits (like kiwi fruit, oranges, rickets in children (soft bones that bend in
grapefruits, lemons, strawberry), vegetables abnormal way, bowed legs) and osteomalacia
(amaranth, spinach, broccoli, cabbage and in adults (weak bones, bone pain, spinal bone
green pepper) and various leaves (e.g. baobab). pain, pelvic bone pain, muscle pain, muscle
Young maize, sprout cereals and pulses as well weakness, bowing legs and fractures) which are
as plantains and bananas also contain fair skeletal diseases that result in defects that
amounts of vitamin C. weaken bones.
Calcium - Calcium is the most abundant
Dietary sources of vitamin D - Egg yolk,
mineral in the human body. The body requires
fortified foods like margarine, cheese, milk,
calcium in relatively larger amounts than the
butter, fish liver oils, liver are good sources of
other micronutrients. Calcium is used for
vitamin D. Meat and fish contribute vitamin D
building bones and teeth and in maintaining
in small amounts.

47
Figure 2 Somalia: Current nutrition situation, January 2005

Alula

DJIBOUTI
BOSSASO
"
8 Kandala
Zeylac Gulf of Aden Las Qoray/ Bosaso
Badhan
Lughaye
Awdal
Borama
Baki
Berbera Sanag
W.Galbeed Sheikh El Afwein Erigavo Iskushuban
Gabiley
Odweine
Bari
Hargeisa Caynaba Xudun Gardo
Burco Taleh Bender Beila
Togdheer Sool
Buhodle Garowe
Lasanod
Nugal Eyl
Burtinle

Galkayo Jariban
Goldogob

Mudug
Adado
PIA

Abudwaq Hobyo
HIO
ET

Dusa Mareb

Galgadud
El Bur Haradhere
an
El Barde Belet Weyne
Oce
Bakol Hiran
ian

Rab-Dhuure Hudur
Ind

El Der
Dolo Bulo Burti
Luuq Wajid Tieglo
Belet Hawa Jalalaqsi Aden Yabal

Garbahare Baidoa

Gedo Qansah Dere


Bay Wanle Weyne
Jowhar
M.Shabelle
Adale

El Waq
Bur Hakaba Balad
Bardera Dinsor
Afgoye
Banadir
%[ MOGADISHU
Qoryoley
Kurtun Warrey Marka
Sakow
M. Juba Sablale L.Shabelle LEGEND
KENYA

Buale
Brava NUTRITION STATUS (January 2005)
Jilib Significantly above usual range of malnutrition
Afmadow Above usual range
L. Juba Jamame
Usual range

Kismayo N Regional boundary


District boundary
Badhadhe Major road
0 50 100 150 200 River
Kilometers Coastline

Produced: January, 2005


Food Security Analysis Unit - Somalia
P.O. Box 1230 Village Market, Nairobi, Kenya Email: fsauinfo@fsau.or.ke tel: 254-20-3745734 fax:254-20-3740598
FSAU is managed by FAO, funded by EC and USAID-Somalia FSAU Partners are FEWS, WFP, FAO, UNOCHA SCF-UK, UNICEF, CARE, UNDP
The boundaries and names on these maps do not imply official endorsement or acceptance by the United Nations. The regional &
District boundaries reflect those endorsed by the Government of the Republic of Somalia in 1986.

48
Figure 3 Somalia: Nutrition surveys (1999-2004)

Alula
BOSSASO
DJIBOUTI Zeylac Gulf of Aden Y 08/04
#
Kandala
11/01 Bosaso
Lughaye 10/04
AWDAL # ERIGABO
Y
Baki Berbera Badhan
Borama 05/02 05/02 SANAAG Iskushuban
W. GALBEED Sheikh El Afwein
BORAMA Y
# Hargeisa
Erigabo BARI
Gabiley
05/03 10/03 BURCO 07/04
Y HARGEYSA
# Y
# 10/04
Gardo
Odweine Caynaba Xudun Taleh Bender Beila
06/02 10/04
Burco SOOL
TOGDHEER LAS ANOD
08/03 GAROOWE
Buhodle Y
# Y
# 03/04
Lasanod Garowe
Eyl
Burtinle NUGAAL
03/04

04/04 Galkayo Jariban


Goldogob
04/04 03/02 12/02
GAALKACYO
IA

Y04/04
#
OP

ean
MUDUG
HI
ET

Oc
Adado
Abudwaq 09/04 Hobyo

ian
#DUSA MAREB
Y

Ind
09/04
Dusa Mareb
Belet Weyne GALGADUUD
El Barde BELET WEYNE
04/04 06/02 #
Y El Bur Haradhere
Rab-Dhuure BAKOOL 07/03
02/00 Hudur
09/02 XUDUR Y 09/99
# HIIRAN El Der
Dolo 01/04 09/03 Bulo Burti
Luuq Tieglo 08/01
Wajid
Belet Hawa 10/04 02/00
Baidoa 09/03 Aden Yabal
10/02 GARBAHAAREY Jalalaqsi
Y
# BAYDHABA
Garbahare Y 08/99
# Adale
09/01 Jowhar
GEDO Qansah Dere 10/04 Wanle Weyne JOWHAR M. SHABELLE
08/99 Y
#
El Waq 10/01
Bur Hakaba LEGEND
12/99 BAY Balad
Dinsor Afgoye Global (Total) Acute Malnutrition
Bardera 06/00 Districts/Zones Urban Centers
09/03
Qoryoley
[% Banadir
MOGADISHU
KENYA

MARKA
Sakow Kurtun Warrey Y Marka
# No Data No Data
M. JUBA BU'AALE 0% - 4.9%* 0% - 4.9%*
Sablale
Y 01/01
# L. SHABELLE 5% - 9.9%*
Buale 5% - 9.9%*
Brava
10% - 14.9%* 10% - 14.9%*
Afmadow Jilib
05/04 15% - 19.9%* 15% - 19.9%*
L. JUBA Jamame > 20%* > 20%*
04/01
01/03 Date of Survey (mm/yy)
Kismayo
# KISMAAYO
Y * Weight-for-height <-2 SD compared to the NCHS/WHO
international reference median
05/03
N #
Y Regional Capital
Badhadhe Regional boundary
0 50 100 150 200 District boundary
Kilometers Major road
River
Coastline
Produced: February, 2005
Food Security Analysis Unit - Somalia
P.O. Box 1230 Village Market, Nairobi, Kenya Email: fsauinfo@fsau.or.ke tel: 254-20-3745734 fax:254-20-3740598
FSAU is managed by FAO, funded by EC and USAID-Somalia FSAU Partners are FEWS, WFP, FAO, UNOCHA SCF-UK, UNICEF, CARE, UNDP
The boundaries and names on these maps do not imply official endorsement or acceptance by the United Nations. The regional &
District boundaries reflect those endorsed by the Government of the Republic of Somalia in 1986.

49
Figure 4 Somalia: Nutrition surveillance locations (health facilities)

DJIBOUTI Gulf of Aden Bossaso



AWDAL Lughaye
Ceerigaabo

Bown Berbera

Iskushban

W. GALBEEDHuddisa

SANAAG BARI
Boroma
Gebiley
CadaadleyBurco
Sheikh




Bandar Beyla


Beer Qardho
HARGEYSA
Owdweyne
Yirowe

Balli Gubadle

Salahley TOGDHEER Yagoori
SOOL
Xudun
LIVELIHOOD ZONES
Addun Pastoral: Mixed sheep & goats, camel
Las Caanood Sinujiif
Dan Gorayo
Awdal border & coastal towns: Petty trading, fishing, salt mining
Bay-Bakool Agro-Pastoral High potential sorghum: Cattle, camel


Durukhs
Balleh Dig


Garoowe
Qarhis
Kalabeyd
Central regions Agro-Pastoral: Cowpea, sheep & goats, camel, cattle

Kalabayr
Coastal Deeh: Sheep
Xas Bahale
Eyl

Dawo Pastoral: Shoats, cattle, camel

NUGAL
East Golis Pastoral: Frankinncense
Fishing

Xaarfo

Gagaab Pastoral: Frankincense

Godob Jiraan

Guban Pastoral: Sheep, goats & camel Burtinle
Hawd Pastoral: Camel, sheep & goats

Bacaadweyn
Hiran Agro-Pastoral
Hiran riverine: Sorghum, maize, cattle & shoats
Juba pump irrigation: Tobacco, onions, maize
Kakaar-Dharor Pastoral: Sheep, goats, camel


Balli BusleJariiban

Gallkacyo

L. & M. Shabelle Agro-Pastoral Irrigated: Maize/Sorghum & cattle
L. & M. Shabelle Agro-Pastoral rain-fed: Maize,cowpeas, sesame & cattle
Lower Juba Agro-Pastoral: Maize & cattle



Gellinsoor
North-West Agro-Pastoral: Sorghum, cattle
North-West Valley Agro-Pastoral: Irrigated vegetables, shoats
Nugal Valley Pastoral: Sheep & camel MUDUG
Cadaado

PIA

Potato zone & vegetables


HIO

Shabelle riverine: Maize, fruits & vegetables


Sool-Sanag Plateau Pastoral: Camel, sheep & goats
ET

South-East Pastoral: Cattle, sheep & goats



Southern Agro-Pastoral: Camel, cattle, sorghum
Southern Juba riverine: Maize, sesame, fruits & vegetables Dhusa Marreb

an
Southern coastal pastoral: Goats, cattle

Oce
Southern inland pastoral: Camel, sheep & goats
Togdheer Agro-Pastoral: Sheep, goats & vegetables GALGADUUD

ian
Urban
Dabagale
West Golis Pastoral: Goats, camel, sheep
Ceel
Barde
BAKOOL Maxaas
Belet Weyne
Ceel Buur


Amara
Xarardheere
Ind

HIIRAN Jawle

Luuq Xudur Tayeglow



Rab Dhuure
Dolow


Bulo-Burto Muqakoor
Waneweyn

Belet Xawo

Wajid Biyoley
Dheer

Adan YabaalCeel
Garbaharey


Buur-dhuubo



Berdale Isha

Jalalaqsi
Baydhaba
Burhakaba Kulmis
Buurane Mahaday Weyne
El Wak

GEDO Qansax DheereBay Wanle Weyne

Buulo Shiik
JowharM. SHABELLE
Balcad

Dinsor Afgooye
Gololey
Baar-Dheere

Hawlwadaag


Banadir
Wadajir

Qoryoley


MOGADISHU

Shalaambool
Horseed
M. JUBA Kurtunwarey
Bu'aale L. SHABELLE

KENYA

Gududdei Jilib LEGEND


L. JUBA

NUTRITION SURVEILLANCE SITE

Far Janne
Jamaame
Mogaambo
Regional boundary
District boundary
Buulo Xaaji Kismayo
N Major road
Badhadhe

River

Koday 50 0 50 100 150 200
Coastline

Kilometers
1 cm equals 65 Km
Produced: January, 2005
Food Security Analysis Unit - Somalia
P.O. Box 1230 Village Market, Nairobi, Kenya Email: fsauinfo@fsau.or.ke tel: 254-20-3745734 fax:254-20-3740598
FSAU is managed by FAO, funded by EC and USAID-Somalia FSAU Partners are FEWS, WFP, FAO, UNOCHA SCF-UK, UNICEF, CARE, UNDP
The boundaries and names on these maps do not imply official endorsement or acceptance by the United Nations. The regional &
District boundaries reflect those endorsed by the Government of the Republic of Somalia in 1986.

50
Figure 5 Somalia: Nutrition status trends (1999-January 2005)

Alula
BOSSASO
DJIBOUTI Gulf of Aden
Y
#
Kandala
Zeylac
Las Qoray Bosaso
Lughaye #ERIGABO
Y
Awdal Baki Berbera
Borama Sanag
El Afwein Iskushuban
BORAMA Y
#
W.Galbeed Sheikh Erigabo
Gabiley Bari
BURCO
Y
# HARGEYSA Y
# Gardo
Hargeisa Caynaba Bender Beila
Odweine
Xudun Taleh
Burco Sool
Togdheer LAS ANOD
Buhodle Y
# Y
# GAROWE
Lasanod Garowe
Eyl
Nugal
Burtinle

Goldogob Jariban
Galkayo
GALKAYO
Y
#
Mudug
PIA
HIO

Abudwaq Adado
Hobyo
ET

# DUSA MAREB
Y

an
Dusa Mareb

Oce
BELET WEYNE Galgadud
El Barde Y
# El Bur Haradhere ian
Bakol
Ind
Belet Weyne
Hudur
Rab-Dhuure Y
#
Dolo Luuq
XUDUR Hiran El Der
Bulo Burti
Wajid Tieglo
Belet Hawa Aden Yabal
GARBAHAAREY Baidoa Jalalaqsi
Y
#
Y
# BAIDOA
Garbahare Jowhar Adale
Gedo Qansah Dere
Wanle Weyne
YJOWHAR
#
El Waq Bur hakaba M. Shabelle
Bay Balad LEGEND
Bur Hakaba Afgoye Global (Total) Acute Malnutrition
Bardera Dinsor
Qoryoley [% Banadir Districts/Zones
Mogadishu
Sakow Kurtun Warrey Y
# MARKA < 10% *
Marka
M. Juba L.Shabelle 10% - 14.9% *
BU'AALE Sablale
Y
# 15% - 19.9% *
KENYA

Buale Brava > 20% *


Afmadow Jilib
* Weight-for-height <-2 SD compared to the NCHS/WHO
international reference median
L. Juba Jamame This map reflects range estimates, based on
nutrition surveys and other monitoring data
Kismayo Y
# KISMAAYO %[ Capital
#
Y Regional capital
Badhadhe Major road
N River
Regional boundary
0 50 100 150 200 District boundary
Kilometers
Coastline

Produced: January, 2005


Food Security Analysis Unit - Somalia
P.O. Box 1230 Village Market, Nairobi, Kenya Email: fsauinfo@fsau.or.ke tel: 254-20-3745734 fax:254-20-3740598
FSAU is managed by FAO, funded by EC and USAID-Somalia FSAU Partners are FEWS, WFP, FAO, UNOCHA SCF-UK, UNICEF, CARE, UNDP
The boundaries and names on these maps do not imply official endorsement or acceptance by the United Nations. The regional &
District boundaries reflect those endorsed by the Government of the Republic of Somalia in 1986.

51
52
53
54