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Addressing Nutritional Risk Among European Migrant Populations

Executive Summary
Each day, thousands of Syrians leave their country to seek refuge for
the safety of their families. The majority of this population makes its way to
Syrias neighbor, Turkey. There are approximately 22 refugee camps in Turkey
that currently take in Syrian migrants. A significant health problem faced by
these migrants and refugees is protein-energy malnutrition, often caused by
pathogenic illnesses and poor gastrointestinal function. This can lead to
wasting of lean body mass and other complications such as kwashiorkor if left
untreated.
In order to prevent and treat protein-energy malnutrition in this
population, we will target Syrian migrant children entering a UNICEF camp in
Turkey that have illnesses involving diarrhea. The mothers or fathers of each
member of this target group will receive tools and education on sanitary
practices to prevent the spread of illness. The parents will also receive
nutrition education and counseling during their stay at the camps on proper
infant and child feeding practices and information on nutrition therapy for
diarrhea, including education and counseling on good sources of animal and
plant-based protein that can be acquired to replenish protein lost after
sickness and even after leaving the refugee camp. Lastly, the target
population will be given electrolytes and protein supplements during their
stay at the refugee camps until they get better. Our staff has specific plans to
establish a lasting relationship with the UNICEF staff throughout the
intervention to collaborate on sustainable, continuing nutrition education. Our
project requires $18,486,500.00 from your agency.
Description of the Entire Plan
Our target population includes Syrian Migrant children aged 2-8
infected with diarrhea in one Turkish UNICEF camp. A generous estimation of
4% of 175,000 individuals having diarrhea in the camp provides us with 7,000
individuals in our target group.
The harsh conditions faced by families migrating on foot and in
crowded spaces present significant nutritional problems. Not only is food very
insecure, but also people fall ill due to the easy spread of pathogenic
bacteria, causing many individuals to have diarrhea. One of the main causes
for malnutrition in ill individuals is diarrhea. Our goal is to prevent proteinenergy malnutrition, which is very serious for children who have higher needs
than other physiologic states due to their rapid growth and development. This
is why we chose to target children who have diarrhea. The reason we will
work with parents within this group is because the spread of pathogens can
be more effectively contained with education and sanitation training, and
children have yet to learn and understand healthy practices due to their level
of cognitive development. By 2018, the prevalence of protein-energy
malnutrition among Syrian migrant children aged 2 to 8 infected with
diarrhea will be reduced by 15%. By April 2018, 90% of all Syrian migrant
families with children that have diarrhea where our program is stationed in
Turkey will have received the nutrition intervention outlined in this plan. By

the end of April 2018 our target group will demonstrate practice of proper
sanitation and personal hygiene and be able to continue the practice
throughout their migration to decrease further infections.
Proposed Intervention
Migrant children aged 2 to 8 experiencing diarrheal diseases will be
assessed through UNICEF health screenings and referred to our program for
treatment. We will have three tents: one for a clinical assessment, one for
education on sanitation and nutrition, and lastly, one for supplementation.
The clinical assessment tent will allow our team to collect anthropometric
data including height, weight, and body fat percentage. WHO growth charts
will be used to help determine proper growth and detect any wasting and
possible malnourishment in our target population. These anthropometric
measures will also help to determine nutritional and general health status.
Additionally, we will be able to determine body composition and lean body
mass by using predictive equations. This may be helpful in determining
protein composition in our target population and maintaining this value in
addition to preventing protein-energy malnutrition. These measures will help
to determine an individuals weight-for-age, weight-for-length, height-for-age
and BMI for age, which will be important in screening for wasting and undernutrition, which are strongly associated with increased risk of mortality and
infectious disease. Lastly, urine samples provided by children will provide us
with urinary nitrogen levels, and information on the childrens electrolyte
balance.
The educational tent will provide sanitation and general nutrition
education and will hold 50 parents per session. We will focus on educating
parents of infected children, since they may be better able to assist children
in preventing the spread of infection to other migrant children. We will
educate parents on proper sanitation and hygiene through proper handwashing techniques, in addition to providing sanitation wipes and education
on when they should be used. Parents will also be educated about the
importance of adequate fluid intake of clean water provided by UNICEF, in
addition to the pedialyte our program will provide for the infected children.
The pedialyte should function as an oral rehydration therapy, and will help in
treating the diarrhea and restoring proper electrolyte balance in the infected
individuals. 24-hour bowel rest will be encouraged for infected children, and
parents will be educated on why this is important. Bowel rest is necessary for
the integrity of the GI tract to heal, and will help in increasing absorption of
nutrients, which is important in preventing protein-energy malnutrition. It is
important to first treat the diarrhea, since the infection is causing a lot of
irritation in the infected child, which is ultimately contributing to decreased
dietary intake, including protein. The infection is also contributing to a higher
inflammatory response, which increases the catabolic rate in the body. This
means that diseased children are breaking down protein and losing lean body
mass, which can lead to protein-energy malnutrition over time. The childrens
inadequate intake of protein and decreased absorption then, exacerbate the
situation further. It is important for parents to understand the importance of
proper protein intake for their children, and obtain the proper
supplementation needed to maintain and prevent further loss of lean body

mass to ultimately prevent protein-energy malnutrition. Our final tent will


hand out the pedialyte for treating the diarrhea, in addition to the protein
supplementation we are providing. Our program will provide Plumpysup
protein bars to children, which should provide adequate protein in order to
prevent them from becoming protein-energy malnourished.
Expected outcomes

Maintain or increase BW (specifically of lean body mass) of individuals


with diarrhea
Prevent wasting and PEM in individuals with diarrhea through protein
supplementation
Reduction in prevalence and spread of diarrhea in children
Ensuring proper hydration and electrolyte balance in diseased children
Ensure migrants meet protein needs (measure UN, nitrogen balance)

Timeline
Starting in January 2016, we will begin our project. By April 2016 we
will hire Arabic-speaking educators, clinical assessment staff, staff that will
proctor all sanitation measures, and general staff that will aid in the
distribution of supplementation and proctoring of the educational classes that
will be offered. In June- July we will prepare all resources (tents, required
medical equipment, class material) to provide to the refugees. August
through September 2016 all resources and supplies needed for the
intervention will be shipped to Turkey via FedEx and storage arrangements
will be made near the camp. As of April of 2016 a clinical establishments will
locate in a camp in Greece which will gather anthropometric data and
compare these outcomes to WHO growth charts which will aid in determining
if the intervention is effective. The medical staff will measure children on BMI,
triceps, biceps, and waist in order to calculate % body fat and determine
wasting on children. In late september, the classes for the parents of the
intervened children will be administered and the medical staff will start to
administer all supplements for the children at need, suffering from diarrhea.
Throughout the intervention the target group will be regularly monitored for
health and behavioral outcomes. If the program is successful at treating
diarrhea in children,then we will continue the program the following year. If it
is unsuccessful at treating diarrhea in children, we will reevaluate our
methods to determine if the practices in place are efficient and well written.
In June 2017- April 2018, we will continue to gather outcome data on the
intervened children with diarrhea in order to continue getting reliable data
and continue to provide the same intervention for the ill target group. Finally,
by April 2018, end of the study, we will gather, evaluate, analyze and share
relevant data to all staff that participated in the study. We will properly gather
our belongings and leave the area clear. From this point on, analyzation and
evaluation of data will take place.
General Budget and Justification

Our multi-year budget is as follows. The cost of the project is based on


217,000 refugees in the camp at any given time. One Plumpysup
supplement per day per infected individual for our two year intervention
comes out to $2,534,560.00. 1/2 L Pedialyte per infected individual per day
for two years comes out to $14,052,500.00. Supplies for the two years will
cost $2,029.00. Shipment and storage of the supplies will cost $724,000.00.
Living costs of the three researchers will cost $49,413.22, and their salary
request is $200,000.00 each for the two years. Wages for the staff and
educators cost approximately $924,000.00. The total budgeted amount for
the 2-year project is approximately $18,486,500.00.
Monitoring and Evaluation Methods
Our main goals for children refugees are to treat diarrhea and prevent
chronic PEM. The techniques we will use monitor the interventions will be by
assigning experience staff in clinical assessment to measure different factors
that relate to PEM caused by diarrhea. Staff will measure urinary urea
nitrogen (UUN) to get a sense of protein malabsorption and breakdown in the
body, and measure electrolyte imbalance through provided urine samples
from the diseased children suffering with diarrhea. In addition, staff will
measure height and weight, and use WHO growth charts for reference to
determine body composition and possible wasting for children suffering from
diarrhea. Lastly, we will measure body fat percentage though the use of
calipers to determine lean body mass in infected children to determine if
children are wasting or malnourished.
After gathering data we will continue to assess our intervention by
providing supplements to the children to treat the diarrhea and prevent PEM.
We will offer supplementation to infected children who are prone to suffer
from PEM with Plumpysup protein bars that contain 12.7g PRO per bar, which
meets the children daily RDA. Even so, we will provide children with
electrolytes and Pedialyte to treat the immediate diarrhea. In addition, staff
will provide education for parents of children with diarrhea on proper
sanitation practices and health importance to decrease the spread of
infection that could cause diarrhea to other refugees. The program will
provide antibacterial wipes after the educational courses for sanitation
purposes.
In conclusion, to determine the effectiveness of the program we will
gather data in Greece in a camp where we will reside that will measure the
effectiveness of supplementation on protein malnutrition and bowel and
bowel movement in children. We will conduct a small survey panel where we
will ask questions to the intervened group to determine the effectiveness of
the intervention on the parents of the diseased children and the diseased
children.
1. What has changed in the health of the diseased children after receiving
supplementation in the camp in Turkey?
2. How has this program made a difference on the lives of the children in
aspects of health education and sanitation practices?
3. How does intervention at an early stage of diarrhea and protein
malnutrition correlate with intake of supplementation to cure diarrhea
and prevent further malnutrition?

Sustainability Plan
Our intervention may continue to help infected children in the camps
even after we are no longer present. We may need to convince UNICEF on the
importance and effectiveness of our program, and allow our staff to properly
train UNICEF staff in order for our services to effectively continue through
them. Towards the end of our program, we will have unicef staff members sitin on our education sessions to allow them to be able to implement our
program basics onto future migrant children affected by diarrheal diseases.
Although they may not have adequate resources to provide proper
rehydration therapy and protein supplementation, education on proper
hygiene to prevent the spread of infection, encouragement of rest and
adequate fluid intake, and knowledge in consuming sufficient protein may be
a feasible and realistic way for UNICEF staff to continue our program. In
addition to the continuing education future migrants will receive, we will
create posters about proper hygiene for preventing the spread of infection.
We will also provide pamphlets about adequate hydration and rest for
individuals explaining the importance for treating infection. Additional
pamphlets including general nutrition knowledge and a list of healthy protein
sources may help migrants choose healthier options when they are available.
Lastly, providing migrants with resources of which foods should be avoided
while experiencing diarrhea may help aid in their recovery.
Long term follow up plan
While the intervention group is in the Turkish camps, they will be
informed that our program is stationed in Greece to do follow up assessments
for the group. Our staff in Greece will survey incoming migrant children,
asking the parents whether the child had been a part of the intervention in
the Turkish camp. Those that participated in the intervention will have
anthropometrics and nitrogen balance measured again. We will survey them
about their diet patterns from the journey from Turkey to Greece to monitor if
the program intervention and education had an impact on their ability to find
appropriate high protein foods. These outcomes are useful to determine
whether our objectives in reducing protein-energy malnutrition in children
have been met.
References
http://www.vox.com/2015/9/27/9394959/syria-refugee-map
http://www.nutriset.fr/en/product-range/moderate-acutemalnutrition/plumpy-sup.html
http://www.businessinsider.com/map-of-europe-refugee-crisis-2015-9
https://www.nlm.nih.gov/medlineplus/ency/article/002350.htm
UC Davis Nutrition 116B Lower Intestinal Tract Lectures

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