Eradicating hunger and malnutrition among Syrian refugees
Ms. Joana Abou-Rizk and Ms. Theresa Jeremias, Ph.D. candidates and nutritionists, won the “BCFN YES! 2017” Research Grant Competition of the Barilla Center for Food & Nutrition (BCFN) Foundation for their project entitled “Maternal and Child Nutrition among Refugees and Host Communities in Greater Beirut, Lebanon: A Focus on Anemia”.
Your project “Maternal and Child Nutrition among Refugees and Host Communities in Greater Beirut, Lebanon: A Focus on Anaemia” won the 2017 BCFN YES! Competition. Can you tell us about your project?
Our research project focuses on the nutritional status and dietary intake of children under 5 years of age and their mothers from Syrian and Lebanese host communities accessing Primary Health Care Centers (PHCCs) in most vulnerable areas of Greater Beirut, Lebanon. The most recent data on anaemia among women of reproductive age in Lebanon was measured decades ago, in 1998 and 2003 prior to the crisis situation. According to the Global Nutrition Report 2017, over a third of all women of reproductive age are suffering from anaemia worldwide. The figures for children under 5 are even more striking as nearly half of all children worldwide are affected. With the onset of the Syrian crisis in 2011, about 1.5 million people fled to Lebanon for refuge. Due to their social and economic situation many settled in poorer areas of the capital city, Beirut. Our assumption is that Syrian and Lebanese women and their children accessing free health care in most vulnerable localities are more prone to being food and nutritionally insecure. Seven years into the crisis, according to recent assessments of the status of the Syrian refugees, the food and nutrition security of women of reproductive age and children under five is at increased risk of deterioration.
Therefore, we are not only interested in understanding the determinants of anaemia among those vulnerable groups, but also in finding and testing culturally appropriate, food-based solutions for its prevention. Our research project consists of two phases as follows: Phase I is a cross-sectional study with the main objective to assess the prevalence of anaemia among children (0-59 months) and their mothers, women of reproductive age (15-49 years) of Syrian refugees and Lebanese host communities in Greater Beirut, Lebanon, and to examine its determinants such as poor dietary intake, food insecurity and the mental health status of the mothers. Phase II is comprised of an intervention study. Its aim is to assess the effectiveness of a nutrition education and counselling intervention on improving dietary intake of foods rich in hematinic nutrients and in raising hemoglobin levels of respective mildly and moderate anaemia mothers and children (6-59 months). Further, we assess perceived barriers to improving infant and young child feeding practices and challenges faced to accessing a diverse, healthy diet. Both phases use a mixed method approach. This research project is a collaboration project between the University of Hohenheim, Germany, (UHOH) and the American University of Beirut (AUB), supported by BCFN YES! 2017, DAAD, and the Fiat Panis Foundation through the Food Security Center of UHOH.
What inspired you to address maternal and child nutrition among Syrian refugees and host communities in Lebanon?
Having witnessed the Arab Spring firsthand, the impact of conflicts on the nations of the Middle East has been enormous. The Syrian humanitarian crisis is now the worst of our time resulting in the largest refugee population in the world, exceeding 5 million people. Lebanon hosts about 1.5 million refugees reaching the world’s highest per capita concentration of refugees, of which the majority is made up of women and children. With a fragile political, social and economic situation, the nutritional status of vulnerable groups, such as children under-five and women of reproductive age, is increasingly compromised by the protracted crisis. This is not only the case for Syrian refugees, but also for deprived Lebanese. Recent data showed that the vast majority of Syrian refugees in Lebanon are food insecure consuming a more and more monotonous diet, especially the children under 2 years of which only 9 percent reach the threshold of a minimum dietary diversity as defined by WHO (4 out of 7 food groups). There is also a great need of mental health support as people affected by conflict are more likely to suffer from post-traumatic stress disorders and depression. There is emerging evidence that the maternal mental health status is negatively associated with breastfeeding practices. Among the Lebanese community micronutrients deficiencies and inadequate infant feeding practices were already widespread before the crisis.
Can you tell us a bit about the importance of early childhood nutrition and its implications for refugees and host communities in Lebanon, as well as for rebuilding post-crisis Syria?
The first 1000 days of life from conception to a child’s second birthday have been recognized as a window of opportunity to prevent maternal and child malnutrition. Globally, according to the Global Nutrition Report 2017, 155 million children are stunted, 52 million children are wasted and 41 million children are overweight. In the Eastern Mediterranean region, overweight and obesity are on the rise while undernutrition and micronutrient deficiencies persist. Infant and young child feeding practices (IYCF) are sub-optimal with only about a third of all children under 6 months of age are being exclusively breastfed. According to the updated Lancet Maternal and Child Nutrition Series from 2013, total of deaths in children younger than 5 years can be reduced by 15 percent if populations can access ten evidence-based nutrition interventions at 90 percent coverage. Among those interventions the promotion of breastfeeding and improved complementary feeding through behavior change communication and counseling activities are listed.
Prior to the crisis, the national prevalence of exclusive breastfeeding amongst infants under 6 months was at 43 percent in Syria, which means that mixed feeding was common. The 2013 Joint Nutrition Assessment of the Syrian refugee population in Lebanon found that only a quarter of children under 2 years of age were exclusively breastfed and a third of these children received bottle feedings. 21 percent of Syrian children (6-59 months) were already found anemic in this survey. In 2016, only 42 percent of Syrian children 6-8 months had received complementary food and of those children who had received foods had a poor dietary diversity with insufficient consumption of vitamin A-rich fruits, vegetables, protein-rich food, and fish, in return increasing their risk to anemia and vitamin A deficiency. Only 3 percent of Syrian children aged 6-23 months were fed a minimum acceptable diet according to WHO recommendations, which is an absolute shocking figure.
This is why we are testing the effectiveness of a nutrition education and counseling on improving dietary diversity of the young children (6-59 months) and of their mothers of the vulnerable communities accessing PHCC health services in Greater Beirut. The mother’s diet is closely linked to the child’s dietary intake as women traditionally take up the role of cooking for the whole family and feeding the children. Since women of reproductive age also have high nutritional needs, especially during pregnancy and lactation, and are at high risk of developing anemia and other forms of malnutrition, it is important to improve the mother’s diet at the same time.
Understanding the determinants of anemia of women of reproductive age and young children under 5 of Syrian refugees and host communities in Lebanon is essential to formulate effective nutrition education approaches which should prevent this disease in the first place. The proposed research project will not only fill this knowledge gap, but also will explore the association of the mental health status of the mother and IYCF practices, which has not been looked at before in these vulnerable populations. Hence, we aim to formulate an innovative approach for improving diets and psychosocial wellbeing. The research results should also be relevant for post-crisis Syria as nutritional health and services will have to be rebuilt and new approaches alongside effective traditional nutrition interventions like iron supplementation are vacant, especially for those population groups that are dependent on external assistance.
What are some of the challenges you have encountered with this project and how have they been overcome?
Many challenges are usually faced at all stages of a research project; from early research design to field preparations as well as implementation. The major challenges encountered in our research project so far were of a nature beyond the control of the research team such as lengthy work procedures of external bodies for securing ethical clearance and for the procurement of equipment. One of the strategies to minimize delays was to plan well in advance and run different tasks simultaneously during the field preparation phase. For instance, the survey team was recruited ahead of time and enumerators underwent a rigorous training workshop on data collection methods prior to receiving ethical clearance. In addition, tablets were acquired to allow for real-time data entry on field. As data collection for Phase I started end of June, new challenges were encountered. Despite the fact that the recruitment strategy of study participants was well thought out, the reality of identifying eligible women and their children has been challenging at the primary health care center (PHCC) level. The strategies to overcome these challenges involved establishing a good relationship with the health care centers and its health staff and identifying hours where numerous women with children under 5 are present at the PHCCs; for example, the child vaccination times in the mornings.
A component of your project is on sustainable nutrition education. Can you unpack this concept for us?
Sustainable diets and sustainable food systems are increasingly called for by the international food and nutrition security community which is working on finding urgent solutions to eradicate hunger and malnutrition while working at the other pressing global issues of the agenda of the sustainable development goals like the protection of the environment. The Barilla Center for Food and Nutrition published a double food and environmental pyramid which highlights the links between nutritional value of the food and its environmental impact. Red meat has a high environmental impact and should only be consumed in moderation, whereas other protein and iron-rich foods like legumes have a moderate environmental impact and a good nutritional profile and recommended for frequent consumption.
Phase II of our research project consists of a sustainable nutrition education study with the aim to increase hemoglobin levels of mildly and moderately anaemia women and children (6-59 months of age) by increasing dietary intake of hematinic nutrient-rich foods and overall dietary diversity. We are using the term “sustainable” here as firstly the aim is to run an implementable nutrition education and counseling intervention in the context of PHCCs located in vulnerable localities in Greater Beirut, which can be scaled up in similar settings across Lebanon. This means that we will develop an intervention approach which fits into the existing health system and services provided by the doctors and nurses at the PHCC like the antenatal and postnatal care as well as pediatric services. Secondly, we are developing improved recipes for complementary feeding and family meals, which will be adequate for the young child and the mother alike. These recipes will be built on the concept of the Mediterranean diet and will use locally available foods, which have a low ecological foot print and are rich in iron such as chick peas - commonly consumed in the world famous “hummus” dish. Further, new food and nutrition education materials will be developed emphasizing on foods grown and produced in Lebanon.
As nutrition experts, with our project, we aim to demonstrate that nutrition education and the promotion of improved local recipes is a sustainable solution to prevent anaemia among the most vulnerable groups in Lebanon, post-crisis Syria and the region hosting millions of refugees.
You both have experience working in food security and nutrition. How does this project tie in to your previous or current research/work activities?
We both have many years of experience working in food and nutrition security at academia and international development and humanitarian work.
Joana Abou-Rizk: Through my academic background and research experience at the American University of Beirut (AUB), I acquired deep knowledge and insights on the nutrition situation in Lebanon and the Middle East. As a result, I quickly grasped the need of further research to investigate the root causes of anaemia and suboptimal maternal and child nutrition amongst Syrian refugees and Lebanese host community following years into the Syrian humanitarian crisis.
I earned my B.Sc. in Human Nutrition and Dietetics from the Holy Spirit University of Kaslik (USEK) in 2009, my M.Sc. degree in Nutrition in 2013 and my second graduate-level Diploma in Food Security in 2015 from AUB in Lebanon. Following the completion of my first master’s degree, I have worked as a research assistant at the Nutrition and Food Sciences Department at AUB for 3 years, where I got exposed intensively and rigorously to research in the field of maternal and child nutrition as well as non-communicable diseases. My research interest grew towards the theme of food security, which led me to complete my second-graduate diploma in Food Security and pursue my doctoral studies in food and nutrition security. In 2016, I was awarded the Excellence Ph.D. Scholarship (DAAD supported) by the Food Security Center at the University in Hohenheim and my doctoral studies focus on maternal and child nutrition among refugees and host communities in Lebanon, in addition to hidden hunger and food security.
With my high determination and dedication to research, I have a strong driving force guiding me to improve food and nutrition security, an interdisciplinary theme of high value. Our research topic is deemed highly relevant to the current situation in the Middle East as it focuses on maternal and child nutrition amongst Syrian refugees and Lebanese host communities in the urban setting of a humanitarian crisis. As a young woman researcher from the Middle East, I am working towards producing high quality research in order to make an impact and contribute to science and humanity. Hence, I strongly believe in our quote from the BCFN YES! 2017 Competition as follows “A great path to sustainably rebuild post-crisis Syria and improve the nutrition situation in Lebanon is by raising healthy generations from early life.”
Theresa Jeremias: I first got in contact with refugees from Syria, Iraq, Afghanistan and other countries, through my work at CARE International as Coordinator for Food and Nutrition Security. I was requested to improve the food packages given out to the refugees crossing Serbia by foot on the Balkan route to reach refuge and safety in European countries in August 2015. When I first visited the Serbian camps in March 2016, I spoke to many women about how they manage to feed their infants and young children with the meals that we provided for them and I understood the deep meaning and value of food which is more than just a source of energy and nutrients; it is a source of nourishment for their shaken souls. Ever since I have been working on the improvement of meal rations provided to all remaining refugees in the camps and coordinated with UNICEF the IYCF response.
My recent visit to a Northern Iraqi camp for internally displaced people in June 2018, once again showed me that fighting for the improvement of infant and young child feeding is of utmost importance for child health and survival. Many young children who are fed with infant formula are suffering from diarrhea due to unhygienic conditions and a very hot weather conducive for bacteria growth.
Improving food and nutrition security of the most vulnerable people in the world has been my dream early on in my career and already during my studies of nutrition sciences at the University of Hohenheim and epidemiology at the London School of Hygiene and Tropical Medicine.
As Nutrition Officer of the Food and Agriculture Organization of the United Nations I supported a research project attached to food security and nutrition projects in Cambodia and Malawi. I learned about the importance of evidence-based programming and the power of nutritional educational approaches in improving complementary feeding based on locally available foods and I was able to strengthen my knowledge and skills in nutrition research in the first 1000 days window.
I am convinced that we can only sustainably eradicate hunger and malnutrition globally by respecting the world’s resources and by using evidence-based interventions resulting from rigorous participatory research.