Assessing the Impact of a School-Based Nutrition Intervention on Food Security of Refugee Children in Lebanon: Findings from a Pilot Study

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1 Assessing the Impact of a School-Based Nutrition Intervention on Food Security of Refugee Children in Lebanon: Findings from a Pilot Study 648,822 Syrian Refugees ($27 each) Nahla Hwalla, PhD, RD, FAND Professor of Human Nutrition & Dean Faculty of Agricultural and Food Sciences American University of Beirut, Lebanon 1st Exceed Conference - Forced Migration environmental and socioeconomic dimensions October 19, 2016 CBTs: Cash-Based Transfers e-cards 19,575 Palestinian Refugees from Syria 27,208 vulnerable Lebanese (National Poverty Targeting Programme; $27 each) LEBANON: small & densely populated country Population: 4.4 million Area: 10,452 km 2 Akkar ~1 million registered Syrian Refugees since 2012 ~20% of total population Highest proportion in Bekaa(East): 35.2% North Lebanon: 24.4% 89% food insecure (WFP VASyr 2015) High burden of diseases High proportion in informal tented settlements (camps) Bekaa 3 4 1

2 Syrian Refugee Children in Lebanon 100% 53% of Syrian Refugees CHILDREN 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 53% Children Syrian Refugees 74% OUT OF SCHOOL = 403,100 (MEHE, September 2015) 5 Status of Syrian Refugees in Lebanon 6 Challenges faced by refugees Role of schools Interventions reach a large number of children Teachers serve as role models and agents of change Food insecurity Limited job opportunities and income High disease burden (infectious and chronic diseases) Poor living, sanitary, and health conditions Influential in changing nutrition knowledge and dietary intake of children To date, no school- based nutrition interventions have been conducted among Syrian refugee children in Lebanon 7 8 2

3 Purpose of the study Develop & pilot-test a nutrition intervention for Syrian refugee children (10-14 years) Study Design and Protocol 3 non-formal schools in Bekaa, Lebanon 180 Syrian refugee children Assess impact of intervention on children s knowledge, intake, and nutritional status Recommend evidence-based strategies to improve food security of children 1 control school 60children 2 intervention schools 120 children 9 Daily snacks (standard) Weekly nutrition classes + Daily nutritious snacks Teachers trained by nutrition experts School kitchens refurbished to prepare & distribute safe and nutritious snacks 10 Intervention Group: Training of Trainers Intervention Group: Received 13 interactive nutrition education sessions on: Importance of water Benefits of breakfast Healthy snacking Role of vitamins and minerals in children s growth Basic hygienic practices Active playing

4 Measurements Household Food Insecurity Access Scale and Coping Strategies Index Dietary & anthropometric assessments (pre-and post intervention): Tailored questionnaire evaluate dietary knowledge and behavior of children Anthropometric measurements (calibrated equipment) Dietary intake 24 hour recalls Inclusion Criteria Children/Adolescents: Syrian nationality Children years old (grades 4-6) Generally healthy; absence of: Any disease that may impair growth Chronic illness Inborn errors of metabolism Physical malformations that may interfere with eating patterns and body composition Study Duration: 1 academic year ( ) Intervention: 6 months (December-May) Analysis: Results Data: SPSS (version 20.0) 24 hour recalls: nutrition analysis software (Nutritionist-Pro) Paired t-tests: to explore changes in dietary intake (pre- and post-intervention)

5 Socio-demographic characteristics of study participants (n=173) Prevalence of household food insecurity among study sample (n=173) Mother Father 90% 80% 83,2% 70% Average age: 35.9 years Educational level: 24% no schooling 37% primary school 35% intermediate school 4% high school/technical or university 95% unemployed Child Average age: 11.2 years Gender : 56% females 44% males Educational level : 14.5% no schooling 39% primary school 37% intermediate school 9% high school/technical or university 53% unemployed 17 60% 50% 40% 30% 20% 10% 0% 2,9% 2,3% 11,6% 18 Coping mechanisms by Syrian refugees to deal with food insecurity Most Least Restrict consumption by adults in order for small children to eat Reduce number of meals/day Borrow money to buy food Limit portion size at meal times Rely on less preferred and less expensive foods Rely on help from friend or relative to secure food Remove kids from school Small children (6-15 years) involved in income generation Marriage of children <18 years Accept high risk, illegal, socially degrading or exploitative temporary jobs? 19 Dietary Adequacy and Nutritional Status of Study Participants 20 5

6 Snacks - intervention schools: Nutrient composition and % intake from DRIs Kcal Protein CHO Fat VitA VitC Calcium Iron Composition g 61 g 9 g 464 RAE 13 mg 147 mg 3.7 mg % intake 16 % 33 % 47 % 1.3% 77% 29% 11% 46% RAE: Retinol Activity Equivalents Snack: Labneh sandwich OR Cheese sandwich OR Thyme mankousheh OR Spinach pie IOM fruit 1105 Energy and % Macronutrient Intake from Total Energy of Syrian Refugee Children (Pre- and Post-Intervention) in Bekaa, Lebanon (n=116) % Macronutrient intake from total kcal Total Calories (kcal) 60 51,5 51, Pre-intervention Post-intervention P<0.05 % total kcal ,9 10,6 39,5 38,2 0 Carbohydrates Protein Total Fat Saturated Fat Sugar 6,8 Pre-intervention Post-intervention Increase in total kcal & % protein from total kcal post-intervention 6,4 9,5 22 8,9 Macronutrient Intake (g) of Syrian Refugee Children (Pre- and Post-Intervention) in Bekaa, Lebanon (n=116) Energy & Macronutrient Intake of Children ,8 35, ,3 8,1 11,4 27,4 25,1 Pre-intervention: Protein intake (9.9%) < recommended levels Total Fat intake (39.5%) > recommended levels Carbohydrates (g) Protein (g) Total Fat (g) Saturated Fat (g) Sugar (g) Pre-intervention Post-intervention P<0.01 Significant in protein, total fat & saturated fat intakes post-intervention Post-intervention: Significant in total kcal, protein, total and saturated fat intakes Control group post-intervention: only significant in protein intake (from 56 to 45 g, P<0.05); no change in intake of other macronutrients

7 Inadequate Micronutrient Intake reported among Syrian Refugee Children (Pre-intervention) Micronutrient Intake of Syrian Refugee Children (Pre- and Post-Intervention) in Bekaa, Lebanon (n=116) 447,3 373,2 Inadequate nutrient intake (<66% RDA) of: Vitamin A Potassium Vitamin D Calcium Vitamin B12 Vitamin C ,3 P<0.01 8,1 Significant in calcium, iron & vitamin A intakes post-intervention o Calcium & vitamin A: inadequate (<66% RDA) o Iron: adequate ( 66% RDA) 11 Control group post-intervention: only significant in iron intake (from 11 to 6.7 mg) but still >66%RDA; no sign. change in intake of other micronutrients 35 34,6 170,9 Calcium (mg) Iron (mg) Vitamin C (mg) Vitamin A (RAE) Pre-intervention Post-intervention Nutritional Status of Mothers (n=173) BMI Status of Children Pre- and Post-intervention (n=116) 50% 45% 45,3% 84,5% 81,9% 40% 37,2% 35% 30% 25% 20% 15% 17,4% 10% 5% 0% 8,6% 8,6% 3,4% 3,4% 3,4% 6,0% Thiness Normal weight Overweight Obese 27 BMI Pre-intervention BMI Post-intervention 7

8 Pre-intervention: Summary of Findings Low protein and high fat intakes Inadequate micronutrient intakes Post-intervention: Significant in total kcal, protein, total and saturated fats, calcium, iron & vitamin A intakes -Inadequate calcium & vitamin A -Adequate iron in % overweight & obesity post-intervention (12-15%) -Could be attributed to high levels of food insecurity and unhealthy diet ( intake of calories, fat and sat. fat) Worth further exploration.. Conclusions High levels of severe food insecurity among Syrian refugees in Bekaaregion of Lebanon High micronutrient inadequacies among Syrian refugee children Risk of hidden hunger (double burden of obesity and micronutrient deficiencies) among children Pilot nutrition intervention showed positive impact on: odietary intake of children oimprovement in nutrition knowledge (data not shown) Recommendations Acknowledgements Include nutrition in school curricula of refugees Complementnutrition education with healthy and nutritious snacks Expandthis pilot intervention to larger scale nutrition programswithin informal schools Ensure rigorous M&E of nutrition programs Address social determinants of health (physical environment, poverty, violence, health illiteracy, inadequate physical and mental health care) policies to reduce food insecurity Primary Investigator: Dr. Lamis Jomaa, Department of Nutrition and Food Sciences, AUB Partners: - Center for Civic Engagement and Community Service (CCECS) - Environment Sustainability and Development Unit (ESDU) - KayanyFoundation - ( Funders: Reach Out to Asia (ROTA) Member of Qatar Foundation

9 Thank you 33 References Bilukha, O.O., et al., Nutritional Status of Women and Child Refugees from Syria Jordan, April May MMWR MorbMortal Wkly Rep, (29): p Brinkman, H.-J., et al., High food prices and the global financial crisis have reduced access to nutritious food and worsened nutritional status and health. The Journal of nutrition, (1): p. 153S-161S. Coultset al., 2013, International Journal of Health Services ESCWA. Food Security and Conflict in the ESCWA Region, E.A.S.C.F.W.A. (ESCWA), Editor. 2010: New York. Habib-Mourad, C., et al., Promoting healthy eating and physical activity among school children: findings from Health-E-PALS, the first pilot intervention from Lebanon. BMC public health, (1): p IOM - IversLC and C. KA., Food insecurity: special considerations for women.. The American journal of clinical nutrition, (6): p. 1740S-4S. Jamison, D.T., et al., Community Health and Nutrition Programs JjoytiD, FrongilloEA, and J. SJ., Food Insecurity Affects School Children s Academic Performance, Weight Gain, and Social Skills. Journal of Nutrition, : p MEHE, September 2015 Naja, F., et al., Validity and reliability of the Arabic version of the Household Food Insecurity Access Scale in rural Lebanon. Public Health Nutr, 2014: p Pérez-Rodrigo, C. and J. Aranceta, School-based nutrition education: lessons learned and new perspectives. Public Health Nutrition, (1a): p UNICEF warns of silent threat of malnutrition in Syrian refugee children. 2013, unicef. (UNHCR), T.U.R.A., Syria Regional Refugee Response (UNHCR), T.U.R.A., 2015 UNHCR country operations profile - Lebanon WFP, UNICEF, and UNHCR, Vulnerablilityassessment of Syrian refugees (VASyR) in Lebanon Success Lesson plans developed by nutrition experts (in coordination with school teachers) Nutrition and health education classes incorporated into academic curriculum Culturally-sensitive lesson plans Interactive activities Process evaluation showed positive student and teacher feedback High cooperation between school site teachers and the multidisciplinary research team MATERIAL FOR DISCUSSION Challenges Limited involvement of parents and caregivers (reinforcement of nutrition messages at home?) Logistical challenges Severe weather limited few field visits to evaluate progress Drop outs of children (internal displacement and immigration) Changes among teachers during the academic year Implications Provides insight on the nutritional challenges faced by the refugees Sheds light on multiple burdens of poverty, food insecurity, and malnutrition within and among vulnerable communities Expand the health and nutritional educational curriculum Learn challengesfaced by refugees with respect to their food security status and how schools can play an integral role in provision of healthy foods and alleviation of nutrition insecurity

10 Success Lesson plans developed by a team of nutrition experts (in coordination with school teachers) Nutrition and health education classes incorporated into academic curriculum Culturally-sensitive lesson plans Interactive activities Process evaluation showed positive student and teacher feedback High cooperation between school site teachers and multidisciplinary research team Challenges Limited involvement of parents and caregivers (reinforcement of nutrition messages at home?) Logistical challenges Severe weather few field visits to evaluate progress Drop outs of children (internal displacement and immigration) Changes among teachers during academic year Provides an insight on the nutritional challenges faced by refugees Implications Sheds light on multiple burdens of poverty, food insecurity, and malnutrition within and among vulnerable communities Expand health and nutritional educational curriculum Learn challenges faced by refugees with respect to their food security status and how schools can play an integral role in provision of healthy foods and alleviation of nutrition insecurity 39 10

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