1

Assessing the Impact of a School-Based Nutrition Intervention on Food Security of Refugee

Children in Lebanon: Findings from a Pilot Study

Nahla Hwalla, PhD, RD, FANDProfessor of Human Nutrition & Dean

Faculty of Agricultural and Food SciencesAmerican University of Beirut, Lebanon

1st Exceed Conference -“Forced Migration – environmental and socioeconomic dimensions”October 19 , 2016

648,822 Syrian Refugees ($27 each)

19,575 Palestinian Refugees from Syria

27,208 vulnerable Lebanese (National Poverty Targeting Programme; $27 each)

CBTs: Cash-Based Transfers

e-cards

3

~1 million registered Syrian

Refugees since 2012

~20% of total population

LEBANON: small & densely populated country• Population: 4.4 million

• Area: 10,452 km2

4

� Bekaa (East):

35.2%

� North

Lebanon:

24.4%

Highest

proportion in

� High burden of

diseases

� High proportion

in informal

tented

settlements

(camps)

89% food insecure

(WFP VASyr 2015)

Bekaa

Akkar

2

Syrian Refugee Children in Lebanon

5

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Syrian Refugees

53% Children

53%

of Syrian Refugees CHILDREN

74%

OUT OF SCHOOL

= 403,100 (MEHE, September 2015)

6

Status of Syrian Refugees in Lebanon

Challenges faced by refugees

Food insecurity Limited job opportunities and income

High disease burden

(infectious and chronic

diseases)

Poor living, sanitary, and

health conditions

7

Role of schools

� Interventions reach a large number of children

� Teachers serve as role models and agents of change

� 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

8

3

Purpose of the study

� Develop & pilot-test a nutrition intervention for Syrian refugee children (10-14 years)

� Assess impact of intervention on children’s knowledge, intake, and nutritional status

� Recommend evidence-based strategies to improve food security of children

9

Study Design and Protocol

10

3 non-formal schools in Bekaa, Lebanon

180 Syrian refugee children

1 control school

60 children

Daily snacks (standard)

2 intervention schools 120 children

Weekly nutrition classes

+

Daily nutritious snacks

Teachers trained by nutrition experts

School kitchens refurbished to prepare & distribute safe and nutritious snacks

11

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

12

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

13

Inclusion Criteria Children/Adolescents:

14

Syrian nationality

Children 10-14 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 (2015-2016) Intervention: 6 months (December-May)

Analysis:

• 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)

15

Results

16

5

Socio-demographic characteristics of study

participants (n=173)

17

Average age: 35.9 years

Educational level:24% no schooling37% primary school 35% intermediate school4% high school/technical or university

95% unemployed

Mother

Child

Average age: 11.2 years

Gender :56% females44% males

Father

Educational level :14.5% no schooling39% primary school 37% intermediate school9% high school/technical or university

53% unemployed

Prevalence of household food insecurity among study sample (n=173)

18

2,9% 2,3%

11,6%

83,2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Coping mechanisms by Syrian refugees to deal with food insecurity

� 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

Most

Least

Dietary Adequacy and Nutritional

Status of Study Participants

20

6

Kcal Protein CHO Fat Vit A Vit C Calcium Iron

Composition 357 11 g 61 g 9 g 464 RAE 13 mg 147 mg 3.7 mg

% intake 16 % 33 % 47 % 1.3% 77% 29% 11% 46%

Snacks - intervention schools:

Nutrient composition and % intake from DRIs

IOM - http://www.nationalacademies.org/hmd/Activities/Nutrition/SummaryDRIs/DRI-Tables.aspx

Snack:

• ‘Labneh’ sandwichOR• Cheese sandwichOR• Thyme ‘mankousheh’OR• Spinach pie

1 fruit

RAE: Retinol Activity Equivalents

22

Energy and % Macronutrient Intake from Total Energy

of Syrian Refugee Children (Pre- and Post-Intervention)

in Bekaa, Lebanon (n=116)

1105

1367

Pre-intervention Post-intervention

Total Calories (kcal)

* 51,5

9,9

39,5

6,89,5

51,9

10,6

38,2

6,48,9

0

10

20

30

40

50

60

Carbohydrates Protein Total Fat Saturated Fat Sugar

% t

ota

l k

cal

% Macronutrient intake from total kcal

Pre-intervention Post-intervention

Increase in total kcal & % protein from total kcal post-intervention

*P<0.05

Macronutrient Intake (g) of Syrian Refugee Children

(Pre- and Post-Intervention) in Bekaa, Lebanon (n=116)

*P<0.01

• Significant ↑ in protein, total fat & saturated fat intakes post-intervention

• Control group post-intervention: only significant ↓ in protein intake (from 56 to 45 g, P<0.05); no change in intake of other macronutri ents

143

27,8

48

8,1

27,4

160

35,4

66,3

11,425,1

Carbohydrates (g) Protein (g) Total Fat (g) Saturated Fat (g) Sugar (g)

Pre-intervention Post-intervention

*

*

*

23

Energy & Macronutrient Intake of Children

24

Pre-intervention:Protein intake (9.9%) < recommended levels

Total Fat intake (39.5%) > recommended levels

Post-intervention: Significant ↑ in total kcal, protein, total and

saturated fat intakes

7

Inadequate Micronutrient Intake reported among Syrian Refugee Children (Pre-intervention)

CalciumVitamin A

Vitamin D

Inadequate nutrient intake (<66% RDA) of:

Vitamin C

Vitamin B12

Potassium

25

Micronutrient Intake of Syrian Refugee Children

(Pre- and Post-Intervention) in Bekaa, Lebanon (n=116)

*P<0.01

• Significant ↑ in calcium, iron & vitamin A intakes post-interventiono Calcium & vitamin A: inadequate (<66% RDA)o Iron: adequate (≥66% RDA)

• 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 m icronutrients

254,3

8,135

170,9

447,3

1134,6

373,2

Calcium (mg) Iron (mg) Vitamin C (mg) Vitamin A (RAE)

Pre-intervention Post-intervention

*

*

*

Nutritional Status of Mothers (n=173)

17,4%

37,2%

45,3%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

27

BMI Status of Children Pre- and Post-intervention (n=116)

3,4%

84,5%

8,6%3,4%3,4%

81,9%

8,6% 6,0%

Thiness Normal weight Overweight Obese

BMI Pre-intervention BMI Post-intervention

8

29

Summary of Findings

Pre-intervention:

• 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 Bekaa region 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

o Improvement in nutrition knowledge (data not shown)

30

Recommendations

� Include nutrition in school curricula of refugees

� Complement nutrition education with healthy and nutritious snacks

� Expand this pilot intervention to larger scale nutrition programs within 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

31

Acknowledgements

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)

- Kayany Foundation - (http://www.kayany-foundation.org/)

Funders:

Reach Out to Asia (ROTA) – Member of Qatar Foundation

32

9

Thank you

33

References

• Bilukha, O.O., et al., Nutritional Status of Women and Child Refugees from Syria—Jordan, April–May 2014. MMWR Morb Mortal WklyRep, 2014. 63(29): p. 638-639.

• 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, 2010. 140(1): p. 153S-161S.

• Coults et 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, 2014. 14(1): p. 940.

• IOM - http://www.nationalacademies.org/hmd/Activities/Nutrition/SummaryDRIs/DRI-Tables.aspx

• Ivers LC and C. KA., Food insecurity: special considerations for women. . The American journal of clinical nutrition, 2011. 94(6): p. 1740S-4S.

• Jamison, D.T., et al., Community Health and Nutrition Programs. 2006.

• Jjoyti D, Frongillo EA, and J. SJ., Food Insecurity Affects School Children’s Academic Performance, Weight Gain, and Social Skills. Journal of Nutrition, 2005. 135: p. 2831-2839.

• 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. 1-8.

• Pérez-Rodrigo, C. and J. Aranceta, School-based nutrition education: lessons learned and new perspectives. Public Health Nutrition, 2001. 4(1a): p. 131-139.

• UNICEF warns of silent threat of malnutrition in Syrian refugee children. 2013, unicef.

• (UNHCR), T.U.R.A., Syria Regional Refugee Response 2015.

• (UNHCR), T.U.R.A., 2015 UNHCR country operations profile - Lebanon. 2015.

• WFP, UNICEF, and UNHCR, Vulnerablility assessment of Syrian refugees (VASyR) in Lebanon. 2014.34

MATERIAL FOR DISCUSSION

35 36

•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

Success

• 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

Challenges

• 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 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

Implications

10

37

•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

Success

38

•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

Challenges

39

•Provides an insight on the nutritional challenges faced by refugees

•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

Implications