HTP-module-23-technical-notes

PART 2: TECHNICAL NOTES
The technical notes are the second of four parts contained in this module. They provide an overview of the nutrition of older
people (50 years and above) in emergencies. The technical notes are intended for people involved in nutrition programme
planningandimplementation.Theyprovidetechnicaldetails,highlightchallengingareasandprovideclearguidanceonaccepted
current practices. Words in italics are defined in the glossary.
Summary
This module discusses nutrition in older people in low to middle income countries affected by emergencies. It explores
the demographics of ageing and how ageing affects nutrition. It then describes techniques for nutrition assessment
and the assessment of functional outcomes of relevance to older people in their daily lives. Finally, it presents the range
of interventions necessary to protect and support the nutritional wellbeing of this important population group in
emergencies.
1
MODULE 23
Nutrition of Older People in Emergencies
These technical notes have five sections. It starts with a discussion on ageing in the developing world and presents
international commitments to older people. This is followed by a section on vulnerability and rights of older people in
emergencies. The next examines the determinants of undernutrition in older people and the complexity of risk factors and
vulnerabilityexperiencedbythispopulationgroup.Thefourthsectiondealswiththeassessmentofundernutritionandnutritional
vulnerability of older people in emergencies, and the fifth section describes the range of interventions which can be put in
place to support and protect older people’s nutritional well-being.
These technical notes draw on the other HTP modules as well as the following references and Sphere standards (see boxes
below):
• Borrel A, 2001. Addressing the nutritional needs of older people in emergency situations in Africa: ideas for action.
HelpAge International, Africa Regional Development Centre. Nairobi. www.helpage.org/download/4c4a1362b392f/
• Collins S, Duffield A and Myatt M, 2000. Assessment of nutritional status in emergency-affected populations.
UN Administrative Committee on Coordination, Sub-Committee on Nutrition (ACC/SCN), Geneva.
(http://www.unscn.org/layout/modules/resources/files/AdultsSup.pdf)
• Emergency Nutrition Network publication, Field Exchange. www.ennonline.net/fex
• HelpAge International Ageways no 76; Food and older people, February 2011.
(http://www.helpage.org/what-we-do/health/ageways-76-food-and-nutrition/)
• HelpAge International and Age UK, 2011. On the Edge: why older people’s needs are not being met in
humanitarian emergencies.
• IASC Guidelines 2008
• Ismail S and Manandhar M, 1999. Better nutrition for older people: assessment and action. HelpAge International and
the London School of Hygiene and Tropical Medicine.
HTP, Version 2, 2011, Module 23, Nutrition of older people in emergencies, Version 1, 2013

TECHNICAL NOTES
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MODULE 23 Nutrition of Older People in Emergencies
Key messages
• Older people (aged 50 and above) make up nearly a quarter of the worldûs population (22%) and their numbers
are growing fastest in low and middle income countries.
• Older people are increasingly affected by natural disasters and conflicts, and have specific vulnerabilities and
needs that are often neglected by humanitarian responses due to an emphasis on other groups, particularly
children under five.
• Older people play important roles in household livelihoods and childcare so it is important to protect their health
and nutritional status as much as possible to maintain their ability to function actively in daily life.
• Functional ability is the best outcome indicator against which to measure nutritional status in older people,
in place of mortality and morbidity (and growth) used with children.
• In line with human rights and UN Principle of Impartiality, humanitarian responses to undernutrition and
vulnerability in older people should be a standard component of planning and programming.
• The causes of undernutrition (either acute malnutrition or stable malnutrition) in older people are complex.
They involve physiological, social, cultural, psychosocial, economic, and medical factors in addition to inadequate
quantity and quality of diet and food intake.
• All these factors need to be considered in nutritional vulnerability assessments through the use of checklists
and questionnaires.
• With no agreed anthropometric indicators and cut-offs for assessing undernutrition in older people, WHO’s 1995
recommendations for assessing physical status in adults should be used.
• The participation of older people in all aspects of planning and programming to prevent and address
undernutrition is essential.
• Mid-Upper Arm Circumference (MUAC) is the best anthropometric measurement to take in emergencies.
• A broad-based approach to interventions for tackling undernutrition in older people is crucial.
• Non-food based interventions relate to shelter, distribution systems, social supports, medical care, psychosocial
supports, and livelihood and cash transfer activities.
• Food interventions for older people will focus on the general ration and selective feeding programmes.
Nutrient-dense and micronutrient-fortified foods are needed to meet nutritional requirements for older people.
• Navarro-Colorado C, 2006. Adult malnutrition in emergencies: an overview of diagnosis and treatment Field Guidelines.
Version 3. Action Contre La Faim. (http://www.actionagainsthunger.org.uk/resource-centre/online-library/detail/media/
adult-malnutrition-in-emergencies-an-overview-of-diagnosis-and-treatment-guidelines-version-3/)
• WHO and Tufts University School of Nutrition and Policy, 2002. Keep fit for life: meeting the nutritional needs of
older persons. Geneva. (http://whqlibdoc.who.int/publications/9241562102.pdf)
• WHO, 2002. Active Ageing: A Policy Framework.
• Wells J, 2005. Protecting and assisting older people in emergencies. HPN Network Paper no 53.
• Hutton D, 2008. Older people in emergencies: considerations for action and policy development. WHO.
• HelpAge International and UNHCR, 2007. Older people in disasters and humanitarian crises: guidelines for best practice.
• UNHCR/WFP, 2011. Guidelines for selective feeding: the management of malnutrition in emergencies.

TECHNICAL NOTES
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MODULE 23Nutrition of Older People in Emergencies
Content
Older people in a changing and challenging world................................................................................................................... 5
Defining“old” ........................................................................................................................................................................................................ 5
Our ageing world: a triumph and a challenge .......................................................................................................................................... 6
Active role in livelihoods ................................................................................................................................................................................... 6
Changing social roles ......................................................................................................................................................................................... 8
Ageing, health and sickness............................................................................................................................................................................. 9
Physical and mental health ............................................................................................................................................................................ 10
International commitments, national responses ................................................................................................................................... 11
Vulnerability and rights................................................................................................................................................................. 13
Rights and the principle of impartiality ..................................................................................................................................................... 14
Participation......................................................................................................................................................................................................... 15
Missing and under-funded: older people in the humanitarian system ......................................................................................... 16
What we know about older people in humanitarian emergencies................................................................................................. 17
Missing from the humanitarian nutrition agenda ................................................................................................................................. 17
Undernutrition in older people .................................................................................................................................................... 19
Defining terms for undernutrition in adults ............................................................................................................................................ 19
Nutritional risk factors for older people .................................................................................................................................................... 20
The focus on children under five ............................................................................................................................................................................................20
Ageing and nutritional status........................................................................................................................................................................ 22
Nutritional requirements for older people ............................................................................................................................................... 24
Macronutrients...................................................................................................................................................................................................................................25
Micronutrients ....................................................................................................................................................................................................................................25
Fluids and other requirements...................................................................................................................................................................... 27
Food intake in its social context ................................................................................................................................................................... 28
Undernutrition in older people in middle and low income countries ........................................................................................... 29
Assessment of nutritional status and vulnerability of older people .................................................................................... 30
Assessing complex vulnerabilities ............................................................................................................................................................... 31
Assessing nutritional status ........................................................................................................................................................................... 34
Dietary intake ......................................................................................................................................................................................................................................35
Clinical assessment..........................................................................................................................................................................................................................35
Anthropometric assessment of nutritional status ................................................................................................................................. 35
Using Mid-Upper Arm Circumference (MUAC) .............................................................................................................................................................35
Using Body Mass Index (BMI) ....................................................................................................................................................................................................38
BMI: body shape and body composition issues (see also HTP Module 6)....................................................................................................40
The relationship between nutrition and functional outcomes......................................................................................................... 44
What to use in emergencies?......................................................................................................................................................................... 45

TECHNICAL NOTES
4
Interventions and responses to address undernutrition in older people ............................................................................ 45
Non-food interventions ...................................................................................................................................................................................48
Income and livelihoods ................................................................................................................................................................................................................48
Shelter (including food distribution and health centres) ........................................................................................................................................49
Psychosocial support interventions......................................................................................................................................................................................49
Health interventions .......................................................................................................................................................................................................................51
Older people living with HIV and AIDS ...............................................................................................................................................................................51
Interventions to improve food security for older people in emergencies .................................................................................... 51
Availability:............................................................................................................................................................................................................................................52
Access ......................................................................................................................................................................................................................................................52
Consumption ......................................................................................................................................................................................................................................52
Utilisation (and acceptability) ...................................................................................................................................................................................................52
Food-based interventions .............................................................................................................................................................................. 53
General Food Distribution ..........................................................................................................................................................................................................54
Supplementary Feeding Programmes (SFP) ............................................................................................................................................ 55
Blanket Supplementary Feeding Programmes (BSFP) ..............................................................................................................................................55
Targeted Supplementary Feeding Programmes (SFP) ..............................................................................................................................................56
Therapeutic Feeding Programmes, CMAM ......................................................................................................................................................................57
Food products used in selective feeding programmes ....................................................................................................................... 58
Monitoring and evaluation........................................................................................................................................................... 60
The Minimum Reporting Package (MRP) (http://www.mrp-sw.com) ............................................................................................. 61
SQUEAC (Semi-Quantitative Evaluation of Access and Coverage). ................................................................................................. 61
Participation, voice and inclusion ................................................................................................................................................................ 62
Existing challenges and areas for research................................................................................................................................ 63
Advocacy, awareness and capacity ............................................................................................................................................................. 63
Assessment .......................................................................................................................................................................................................... 63
Interventions .......................................................................................................................................................................................................64
Monitoring and evaluation ............................................................................................................................................................................ 64
Participation.........................................................................................................................................................................................................64
Annex 1: Key events and documents related to older people in humanitarian situations ............................................. 65
Annex 2: UN General Assembly Resolution no 46/91: 18 General Principles for Older Persons, 1991 ........................ 66
Annex 3: Madrid International Plan of Action on Ageing. Issue 8: Emergency Situations.............................................. 67
Annex 4: Example of an older people’s vulnerability assessment form (used in South Sudan) .................................... 69
Annex 5: Mini-Nutritional Assessment MNA used for nutritional assessment and screening of .................................. 70
older people in high-income countries
Annex 6: Guiding principles for nutrition interventions for older people in emergencies ............................................. 72
Annex 7: Checklist for older people in internally displaced persons camps ...................................................................... 73
Annex 8: Summary of supplementary foods recommended by WFP in an emergency................................................... 74

TECHNICAL NOTES
5
Older peoplein a changing and
challenging world
Defining‘old’
For the purposes of this HTP module, the term ‘older people’
refers to people age 50 and above. This definition differen-
tiates the content from the term‘adult(s)’which refers to both
men and women from 18 to 49 years.
Most high-income ‘westernised’ countries have adopted an
arbitrary, chronological definition of an older adult or older
(often referred to as ‘elderly’) person. This classification of
‘old age’ originated in economically driven government
decisions about a set retirement age. Old age became
inextricably linked to a transition in livelihood, marking a
shift from working to retirement. It most commonly hinges
on age cut offs of 60 or 65 years, although there is variation
between countries.
Sphere standard
As a cross-cutting issue, ageing is mainstreamed in all Sphere standards and they all apply to the specific population of
older people. Older people are specifically mentioned in the following sections:
Outline of the cross-cutting themes: Older people (page 16)
Older men and women are those aged over 60 years, according to the UN, but a definition of ‘older’ can vary in
different contexts. Older people are often among the poorest in developing countries and comprise a large and
growing proportion of the most vulnerable in disaster- or conflict-affected populations (for example, the over-80s are
the fastest-growing age group in the world) and yet they are often neglected in disaster or conflict management.
Isolation and physical weakness are significant factors exacerbating vulnerability in older people in disasters or conflict,
along with disruption to livelihood strategies and to family and community support structures, chronic health and
mobility problems, and declining mental health. Special efforts must be made to identify and reach housebound older
people and households headed by older people. Older people also have key contributions to make in survival and
rehabilitation. They play vital roles as carers of children, resource managers and income generators, have knowledge
and experience of community coping strategies and help to preserve cultural and social identities.
Minimum standards in food security and nutrition, Appendix 3 (page 223)
There is currently no agreed definition of malnutrition in older people and yet this group may be at risk of malnutrition
in emergencies.WHO suggests that the BMI thresholds for adults may be appropriate for older people aged 60-69 years
and above. However, accuracy of measurement is problematic because of spinal curvature (stooping) and compression
of the vertebrae. Arm span or demi-span can be used instead of height, but the multiplication factor to calculate height
varies according to the population.Visual assessment is necessary. MUAC may be a useful tool for measuring malnutrition
in older people but research on appropriate cut-offs is currently still in progress.
Source: The Sphere Project ‘Humanitarian Charter and Minimum Standards in Humanitarian Response; Chapter 3: Minimum Standards in Food Security and Nutrition’,
The Sphere Project, Geneva, 2011.
This concept of old age does not always fit well in many low
and middle income countries, including many that have
experienced humanitarian emergencies in the last few
decades. In non-western cultures, where formal retirement
structures are only newly emerging, old age is more socially
constructed. Age and life stage classifications tend to relate to
changing health, the onset of physical impairments and
disabilities and accompanying changes in social roles. Culture
defines ‘old’as the point when active contribution to house-
hold, agricultural or family livelihood activities is no longer
possible.1,2
In recognition of these multidimensional aspects of defining
‘old’, initiatives, such as the Older Person in Africa for the
Minimum Data Set (MDS) Project (1999-2003)3,4
, have adopted
the lower age of 50 years and above, arguing that this is a
better representation of ageing for African populations as well
as the social construction of old age.5
Taking this age cut-off
for older people also fits better with many relevant data
1
Gorman M, 2000. Development and the rights of older people. In: Randel J et al., eds. The ageing and development report: poverty, independence and the world’s older
people. Earthscan Publications Ltd.; 3-21.
2
Kinsella K and Phillips D, 2005. Global ageing: the challenge of success. Population Bulletin: 60 (1). New York.
3
Ferreira M and Kowal P. See: www.who.int/healthinfo/survey/ageing_mds_pub02.pdf
4
WHO, 2000. Report of a Workshop on creating a Minimum Data Set (MDS) for Research, Policy and Action on Aging and the Aged in Africa. Harare, Zimbabwe. Jan
20-22. Geneva. WHO: Ageing and Health Programme.
5
WHO website on Health Statistics and health information systems: Definition of an older or elderly person.

TECHNICAL NOTES
6
collection and reporting systems, such as that for HIV/AIDS
and other diseases, which include an adult category ‘up to
49 years’, and therefore older people as being 50 years and
older.
Our ageing world: a triumph and a challenge6
All of the world’s countries are ageing as a result of social and
economic progress. For the first time in human history, those
who survive childhood can now expect to live past 50 years
of age.
Twenty two per cent of the world’s population is aged 50 years
and above. About 12.6% is aged over 60 years. By 2050, the
percentage over 60 years old is estimated to increase to 22%
of the world’s population, with absolute numbers passing 2
billion.7
By then, older people will outnumber children under
14. People aged 80 and over are the fastest-growing popu-
lation group, projected to increase almost fourfold by 2050.
High HIV prevalence, low birth rate, conflict or economic
migration means an even higher proportion of older people
in the population.
Ageing is not just an issue for the world’s richer countries. In
low to middle income countries, low life expectancy at birth
often masks the fact that there are millions of older people.
Today 60% of the world’s older people live in low to middle
income countries. By 2050, this will have risen to 80%. The
developing world will see a jump of 225% – to over 1.5 billion
people over 60 years – between 2010 and 2050.8,9
The ratio of
older people to younger people is increasing fastest in low to
middle income countries and disasters disproportionately
affect poorer countries. Virtually all (97%) people killed by
disasters live in low to middle income countries.10
A recent
estimation is that 26 million older people are affected by
natural disasters every year, and many millions more are
affected by conflict.
The Asian continent has the largest numbers of the world’s
older population. Over half of the world’s older people live in
Asia. For example, China is getting old before it is getting rich.11
The sub-Saharan African region is considered to have the
fastestgrowingolderpopulationofanyworldregion,although
the exact demographic picture is unclear due to the absence
of vital registration systems (recording of births and deaths) in
most countries of the region, and the tenuous nature of demo-
graphic projections. As the poorest and least developed major
worldregion,theageingofAfrica’spopulationislargelyunfold-
ing in a context of widespread economic strain, social changes
and, in many places, climate change, environmental degrada-
tion and political instability and conflict.12
Most Africans enter
old age after a lifetime of poverty and deprivation, poor access
to health care and a diet that is often inadequate in quantity
and quality.13,14
This demographic ageing transformation is accompanied by
economic, social and cultural change affecting both rural and
urban settings, changes which will also be played out in
protracted and acute emergencies. Many of them not only
have implications for the nutrition and health of the older
peoplethemselves,butalsoonthenutritionofothermembers
of the household, particularly children, and pregnant and
lactating mothers through the roles and responsibilities that
older people have in their households and communities.
Active role in livelihoods
In low to middle income countries, 80% of older people have
no regular income. Less than 5% receive a pension.15
Many
older people have no choice but to work throughout their
lives.
Older people in low to middle income countries are much
more likely to be economically active than older people in the
developedworld.AccordingtoHelpAge’sresearch,atleasthalf
of the over-60s in low to middle income countries are
economically active, and a significant proportion (a fifth or
more)arestillworkingeverydaywellintotheirlate70s.Overall,
around half of the world’s older people support themselves
through informal labour, such as childcare and trading.16
They
contribute substantially to agricultural labour, animal
husbandry, vegetable farming and household livelihoods and
to the economic life of their communities. In South Africa, for
example, research has shown that the income earned by older
6
WHO, 2002. Active Ageing: a Policy Framework. Geneva.
7
Population Division of the Department of Economic and Social Affairs of the UN Secretariat UNDESA Population Prospects 2010 update, http://esa.un.org/unpp
8
State of the World’s Older People, 2002.
9
HelpAge International/AgeUK, 2011. On the edge: why older people’s needs are not being met in humanitarian emergencies.
10
IFRC, 2007. World Disasters Report.
11
UNFPA, 2011. State of the World’s Population: people and possibilities in a world of 7 billion.
12
Aboderin I, 2010. Understanding and advancing the health of older people in sub-Saharan Africa: policy perspectives and evidence needs. Public Health Reviews:
Vol 32 (no.2); 357-376.
13
Charlton K and Rose D, 2001. Nutrition among older adults in Africa: the situation at the beginning of the Millennium. Journal of Nutrition: 131; 2424S-2428S.
14
HAI Africa 2004.
15
HelpAge International/AgeUK, 2011. On the edge: why older people’s needs are not being met in humanitarian emergencies.
16
Wells J, 2005. Protecting and assisting older people in emergencies. ODI Humanitarian Policy Group Network (HPN) Paper Number 53. December.

TECHNICAL NOTES
7
peopleaccountedfor30%ofhouseholds’expenditureonchild
schooling, 20% on household food, and 15% on clothing.17
Many young people start families without a reliable source
of income and heavily rely on their parents and grandparents
for livelihood support.
HelpAge and its associates across the world have documented
the lives of older people in different situations and settings. A
clear finding from research is that older people themselves
consistently cite income as their number one priority. Main-
taining independence as long as possible is crucial to older
people as well as to society. Activities undertaken by older
people that bring income into the household can also
contribute to the nutritional status of household members.
However, some livelihood strategies can also put older people
at risk. For example, venturing outside a camp to gather fire-
wood or wild foods may expose older people, particularly
women, to rape or other violence. Many older people may
take on such tasks explicitly to protect younger members of
the family from these risks.
The world is the most urbanised it has ever been in recorded
history.18
By 2030, 80% of the world’s urban dwellers will be
living in the cities and towns of low to middle income
countries. The world urban population will be over 5 billion,
and many of these new urbanites will be poor. Urbanisation
modifies domestic roles and relations within the family, and
redefines concepts of individual and social responsibility. In
rapidly expanding urban areas in low to middle income
countries, there has been a proliferation of non-traditional
family forms and new types of households. Smaller families
and the dispersion of extended families in contemporary
urbanized societies have, in combination, also reduced the
level of kinship support systems available, especially for older
women. In the context of growing urbanization, life for older
people is increasingly challenging19
especially for those
affected by HIV/AIDS.20
Humanitarian emergencies also occur in rural areas. Older
people in rural areas of many low to middle income countries
are especially vulnerable to the effects of natural disasters or
conflict.21
Approximately 60% of the world’s older people live
in rural areas and this proportion is growing due to increased
life expectancy and the high levels of migration of younger
people to towns and cities in search of work.22
Many older
people choose to stay in the areas where they have always
lived. The impact of humanitarian crises, in particular natural
disasters, tends to be felt most strongly in rural areas, and the
poorest will always suffer the most enduring damage. If older
people are consistently among the poorest and most
vulnerable parts of society, then the older poor living in rural
areas are especially susceptible to the effects of disasters.
Likewise, the migration of the young to the cities means that
fewer people are available to care for, and support, older
family members.
Rural-to-urban and transnational migration and the processes
of urbanisation mean that the extended family is no longer as
common as it once was. Some older people do not have
families, and the people left around them may not have the
resources or ability to help others at a time when they are also
17
18
UNDP 2007. Ageing and urbanisation.
19
Aboderin I, 2004. Declining material family support for older people in urban Ghana. Oxford Institute of Ageing, 6th May.
20
Chepnegenohanga G, 2008. HIV/AIDS and older people living in urban areas: a case of older people in Nairobi city slums. Paper presented at the Oxford Institute of
Ageing Seminar 22 May.
21
Wells J, 2005. Protecting and assisting older people in emergencies. ODI Humanitarian Policy Group Network (HPN) Paper Number 53. December.
22
WHO 2002. Health and ageing Discussion Paper.
At the household level, the impact of the loss of an adult cannot be underestimated. From a social and local economic
point of view, the loss of an adult is more dramatic than that of a child – though both are equally regrettable. Adults are
the main source of income and food for the rest of the group, they are the caretakers of the younger and older members
of the group, and they are often the only means for the family to be represented in social structures. Indeed,
assessments of vulnerability often consider the lack of the“head of the household”among the key criteria to identify
families at particular risk of suffering the effects of the emergency (food shortages, malnutrition, and many others). The
effect of the loss of one (or both) parents for the family and the social group has been demonstrated in the context of
the HIV epidemic in Southern Africa. Avoiding adult deaths reduces the burden of any emergency, for example by
preventing an increase in the numbers of orphans. It can also preserve the health and the lives of the main actors of
post-crisis reconstruction, an invaluable asset.
Box 1: The impact of the loss of an adult
Source: Navarro-Colorado, C. (2006) Adult malnutrition in emergencies: an overview of diagnosis and treatment. Field Guidelines, ACF, version 3.

TECHNICAL NOTES
8
suffering. Given the context of limited access to social services,
high incidence of poverty and low coverage of social security
in many low to middle income countries, the increasing
numbersofolderpeoplewillchallengethecapacityofnational
and local governments, and thus clearly needs to be more
prominentlyontheagendaofdevelopmentandhumanitarian
agencies.
Changing social roles
Throughout the developing world, older people are key
household decision-makers as well as carers for millions of
children, the sick and people with disabilities. These older
people survive through negotiating a complex combination
of risks, vulnerabilities and resilience.
The UNICEF conceptual framework23
for nutrition emphasises
caregiving and feeding practices as critical for child growth
and development. This is based on the premise that the
mother, and to a lesser extent the father, is exclusively respon-
sible for this caregiving. However, little attention has been paid
to the caregiving and feeding practices conducted by older
household members such as grandmothers. In recent years,
research in Asia and Africa has revealed that grandmothers in
particular have considerable influence on matters related to
women and children’s survival, growth and well-being and
on other household members’ attitudes and practices.24,25
However, most emergency or development programmes
neither acknowledge their influence nor involve them in
efforts to strengthen existing family and community survival
strategies.
Similarly, recent research dealing with child nutrition from
numerous socio-cultural settings in Africa, Asia and Latin
America revealed common patterns related to the social
dynamics and decision-making within households and
communities. A major finding was that grandmothers play a
centralroleasadviserstoyoungerwomen.Grandmothersocial
networks exercise collective influence on maternal and child
nutrition-related practices, specifically regarding pregnancy,
feeding and care of infants, young children and sick children.
Another finding was that men play a relatively limited role in
day-to-day childcare and nutrition within family systems.This
indicates the need for nutritional policies and programmes to
expand their focus beyond mother-and-child to include
grandmothers.26
InThe Gambia, longitudinal time-allocation research revealed
the beneficial effects of older women, particularly maternal
grandmothers, on the nutritional status, health, cognition and
sociological well-being of children27
in both rural and urban
settings.28
The reproductive status of the maternal grand-
mother also influences child growth, with young children
beingtallerinthepresenceofpost-menopausalgrandmothers
than grandmothers who are still reproductively active. In
contrast, paternal grandmothers and male kin, including
fathers, had negligible impacts on the nutritional status and
survival of children. Maternal grandmothers provided the
greatest protection from child mortality during the period of
weaning.29
Recent in-depth research from Kenya (seeBox1) confirms that
grandmothers are often frontline caregivers of young children,
and powerful influencers of decisions related to their general
care and feeding. They are the main alternative caregiver in
the mother’s absence.They are central in decision-making on
issues related to food preparation and feeding young children,
health care (recognising signs of illness and advising on the
23
UNICEF Conceptual Framework Reference.
24
Aubel J, 2006. Grandmothers promote maternal and child health: the role of indigenous knowledge systems’managers. IK Notes: World Bank Newsletter; 89.
25
Sharma M and Kanani S, 2008. Grandmother’s influence on child care. Indian Journal of Paediatrics 73 (4); 295-298.
26
Aubel J, 2012. The role and influence of grandmothers on child nutrition: culturally designated advisors and caregivers. Maternal & Child Nutrition. Volume 8, Issue 1,
pages 19-35, January
27
n = 1,691
28
Sear R, Mace R and McGregor I, 2000. Maternal grandmothers improve nutritional status and survival of children in rural Gambia. Proceedings of the Biological Society:
Aug 22: 267 (1453); 1641-7.
29
n = 780; OR 1:00, p <0.01
“They help us a lot, especially when the baby is sick; they get us traditional herbs and if they fail to work, they assist us to go to
the hospital. When we get busy or have somewhere to go, they remain with the children and take care of them until we have
come back. They share with us the food that they cook, especially when it is something that the baby can eat. Those with cows
that are milked provide milk for the baby. When you are not around, they cook for the children. They advise us to prepare the
food in good hygienic conditions. They ensure the baby is kept clean always, and they are also very observant when it comes to
the babyûs health. They can tell when the baby is unwell, even when you as the mother didn’t know.”
Box 2: Mothers speak about grandmothers and childcare, Western Province, Kenya
Source: Thuita F, (2011). Engaging grandmothers and men in infant and young children feeding and maternal nutrition. Report of a formative assessment in Eastern and
Western Kenya. April. The Manoff Group, IYCN/PATH/USAID/Ministry of Health Kenya.

TECHNICAL NOTES
9
course of action when children are sick), family livelihood (food
production), and spiritual nurturing. They provide advisory
support to daughters-in-law on running the household and
on family life in general.
In many countries, as the middle generation dies of medical
complications due to AIDS, or in conflict, or migrates from
home in search of work, a generation of young children and a
generation of older people are left behind. More older people
than ever before in history are assuming the role of caretaker
for their grandchildren and other orphaned children.30
HelpAge estimates that up to half of the world’s children
orphaned by AIDS are cared for by a grandparent. An on-going
study31
in Uganda found that in 34% of households, the care-
givers of HIV/AIDS orphans are people over 50 years of age,
and often much older. Almost all households headed by older
people (98%) had on average three school-going orphaned
children living in the household.The caregiving burden is likely
to be complicated by issues related to poverty. One study
showed that poverty rates in households with older people
areupto29%higherthaninhouseholdswithoutolderpeople.
Research in Zimbabwe found that older people were the main
providers for people living with AIDS and children orphaned
as a result of AIDS in 84% of cases, and 71% of these caregivers
were female.32
It follows then, that maintaining good nutrition as an older
person is likely to have beneficial effects on those cared for.
The most widely used conceptual framework on nutrition33
(see Figure 1 in the section on undernutrition in older people,
p.30) recognises the link between older people’s nutritional
status and the nutrition of young children through older
peoples’ roles as caregivers. It also makes reference to the
important role that older people play in the treatment of
malnutrition and sickness through supervision of adherence,
for example, to feeding regimes. The effectiveness of this role
will vary according to the educational level of caregivers. In
poor countries, older people, particularly women, are more
likely to have low literacy than younger adults. Less than 15%
of women over 60 years in both South Asia and sub-Saharan
Africa are literate.34
Research has revealed positive associations
between child nutrition and grandmothers’education in India
and community-level maternal literacy in Vietnam.
All these findings imply that an individual-level perspective
may fail to capture the entire impact of education on child
nutrition, and support a call for a widening of focus of nutrition
policy and programmes from the mother-child pair towards
the broader context of their family and community.35
We are
beginning to realise just how great a role grandmothers and
older women have on the feeding and care of young children,
eitherdirectly,orindirectlythroughinstructionandsupervision
of younger women as they exert the power of senior status in
households.
Ageing, health and sickness
The ageing process is a change in which the physical, nervous
and mental capacities of the human body gradually break
down. The most obvious physical signs of ageing are bones
that become weak and brittle, and muscles that weaken and
shrink. Stiffening of the rib cage, weakening heart muscle and
changes in the walls of arteries and veins lead to high blood
pressure, breathlessness and general weakness. Stiffness and
pain in the joints and muscles is a common and disabling
problem for many older people. Low nourishment from a poor
diet can be aggravated by loss of teeth and a lack of saliva.
Nerve-endings may weaken and lose their sensitivity, which
affects all the faculties. Poor vision and hearing can damage
balance and reduce mobility. Physical changes in the brain
and nervous system may result in short-term memory loss.
This may lead to confusion and disorientation. The combina-
tion of these physical changes leaves the individual less able
to cope with the activities of daily living. In an emergency
where survival may depend on being able-bodied, the capa-
city of older people to survive can be seriously compromised
by the ageing process.
In developed countries, substantial research programmes into
aspects of ageing, health and nutrition are well advanced. A
number of major studies on ageing, including aspects of
health, nutrition and functional dis/abilities have also been
taking place in low to middle income countries including: the
WHO SAGE (global study of ageing and adult health, www.
who.int/sage); the International Union of Nutritional Sciences
(IUNS)(alongitudinalstudyofageing,foodintakeandnutrition
in the Asia-Pacific region); and the Ibadan study, Nigeria (a
major longitudinal study on ageing with a focus on the deve-
lopment of functional disabilities).
WHO has shown that, as a developing country ages, there is a
corresponding shift in disease patterns, with an increase in
non-communicable diseases (NCDs) that particularly affect
older people. NCD deaths are expected to rise substantially as
the population ages.Thirty-six million of the 57 million global
30
Population Research Bureau, 2007.
31
MRC/URVI/LSHTM.
32
WHA II, HIV/AIDS and older people, March 2002.
33
UNICEF/ACC/SCN, ACF 2011.
34
35
Moestue H and Huttly S, 2008. Adult education and child nutrition: the role of family and community. Journal of Epidemiology and Community Health 2008: 62;
153-159 doi:10.1136/jech.2006.058578

TECHNICAL NOTES
10
deaths each year are due to NCDs, mainly cardiovascular dis-
eases, cancers, chronic respiratory diseases and diabetes.
Nearly 80% of these deaths occur in low and middle income
countries. Mental health issues, including dementia and de-
pression, are also expected to rise.
Of the estimated 40 million people living with HIV, the vast
majority are adults in their prime working years,36
although
relatively limited data exists on the number of older people
who are infected with HIV and AIDS in low to middle income
countries. What is becoming increasingly clear, however, is
that HIV/AIDS is having a wide impact on older people in low
to middle income countries, both in terms of the social and
economic burden they have to contend with through illness
or death of their adult children and taking care of surviving
grandchildren, but also on their own health and survival
prognosis.
The physical demands and emotional strain of caring for the
seriously ill can also adversely affect the health of older people.
Evidence from Thailand indicates that the increase in daily
chores and activities related to caregiving adversely affects
older people’s physical health and well-being during the time
they care for their ill adult children, and take on the care of
grandchildren. In addition, worry and stress are commonly
reported emotional problems as older people suffer anxiety
over the illness and death of loved ones.37
The epidemic of HIV/AIDS is also contributing to changing
perceptions of ageing in many affected low to middle income
countries. For example, in Nigeria, 62% of people affected by
HIV and AIDS in Yoruba society are older people. The percep-
tionofageinghaschangedfrompeacefulretirementtoacrisis-
ridden state of living, and the negative effects of neglect, poor
feeding and poor health status. Loss of respect as repositories
ofexperience,memory,authorityandwisdomleadstopsycho-
logical problems. These are exacerbated by a lack of income
and disintegrating social support systems.38
Together with the childhood bias generally widespread
throughout humanitarian interventions, older people are also
largely neglected in the HIV and AIDS response, as well as in
standard data collection and monitoring systems (see Box 3).
For example, a wide-ranging review of nutrition and food
security approaches in HIV and AIDS programmes in Eastern
and Southern Africa referred only to adults aged 15-49 years,
and did not mention older people.39
Physical and mental health
With immunity weakening with age, older people are vulner-
able to epidemics such as cholera and dysentery. Cholera epi-
demics have occurred in refugee camps in Malawi, Zimbabwe,
Swaziland, Nepal, Bangladesh, Turkey, Afghanistan, Burundi,
and Zaire. Outbreaks of dysentery have been reported since
1991 in Malawi, Nepal, Kenya, Bangladesh, Burundi, Rwanda,
Tanzania, and Zaire with case-fatality rates as high as 10% in
young children as well as in the older people.40,41
While the AIDS epidemic affects older people mainly through their role as caregivers, the elderly are also vulnerable to
HIV infection. Older people do engage in sexual activity, including as a transactional activity to get cash (especially older
women). However, because they are not considered a target group, older people miss out on many of the HIV prevention
messages. Additionally, many of the statistics on HIV/AIDS do not include those over the age of 50. For example, UNAIDS
prevalence data refers to adults between 15 and 49 years, further reinforcing the notion that older people are not at risk
of contracting HIV. None of the 25 core UNGASS indicators includes people 50 years and over. However, data from
national programmes in Africa, Asia and Latin America indicate that people aged 50 and older do make up a proportion
of reported AIDS cases. Additionally, as access to antiretroviral therapy expands and the survival time of those living with
HIV is extended, greater numbers of people with HIV will be living into their older years. As the epidemic progresses,
older people must be counted and educated about the risks of HIV. Supported with appropriate knowledge and tools,
they will also be able to play a greater role in educating and protecting their communities.
Box 3: Older people and HIV/AIDS
Source: adapted from PRB 2007, UNAIDS and WHO 2006, and other sources.
36
UNAIDS and WHO, 2006.
37
Kespichayawattana J and VanLindingham M, 2003. Effects of co-residence and caregiving on health of Thai parents of adult children living with AIDS. Journal of
Nursing Scholarship 35; 3; 217-214.
38
Ajala A, 2006. The changing perception of ageing in Yoruba culture and its implications on the health of the elderly. Anthropologist: 8 (3); 181-188.
39
Panagides D, Graciano R, Atekyereza P, Gerberg L and Chopra M, 2007. A review of nutrition and food security approaches in HIV and AIDS programmes in
Eastern and Southern Africa. Equinet Discussion Paper no 48. Medical Research Council of Africa and Regional Network for Equity in Health in East and
Southern Africa EQUINET.
40
Centre for Disease Control Prevention, 1994. Health status of displaced persons following civil war-Burundi, December 1993-January 1994. MMWR 43:701-3.
41
Toole MJ and Waldman RJ, 1997. The public health aspects of complex emergencies and refugee situations. Annual Reviews of Public Health: 18; 283-312.

TECHNICAL NOTES
11
In addition to acute infections, trauma and fever, the chronic
sicknessburdenofolderpeoplerepresentsanadditionalfactor
to be considered during nutrition emergencies. Two thirds of
olderpeopleinterviewedbyHelpAgeinDarfurinJanuary2005
said that they suffered from chronic illnesses such as arthritis
and gastritis, and a similar proportion of older people inter-
viewed in Sierra Leone in May 2000 reported joint pains and
arthritis.42
For many older people in emergencies, physical
health is their most important asset, and is bound up with the
ability to work and to function independently. A third of older
people surveyed inWest Darfur in January 2005 were disabled
in some way, and a quarter suffered from eye problems or
blindness. Similarly, 47% of older people interviewed in Sierra
Leone in 2000 suffered with poor eyesight.43
This suggests a
need for support to reduce the burden of disability among
older people.
Emotional distress in emergencies is a common experience
for many older people. Older people are at increased risk of
poor emotional and mental health, including post-traumatic
stress and war trauma. Loss of family members, carers and
cultural and community ties can leave older people isolated
and feeling excluded. Many older people live alone, especially
widowed women. For many survivors, the most difficult aspect
of a disaster is coping with day-to-day life afterwards. Some
older people report feeling depressed at losing the status they
once had in their community. For older people, the sense of
status,securityandcomfortthatahomeprovidesisparticularly
important, so losing their home in a disaster or conflict can
have a profound psychological impact, particularly on the
older old (over 80 years old).44
Some of these feelings are
reflected in analysis summarised in Box 4 above.
International commitments, national responses
In the light of these demographic, health and socio-economic
realities, all national governments and international organ-
isations working on development and humanitarian assis-
tance, need to focus on older people as well as under-fives
and mothers.
Compared to other vulnerable groups such as children and
women for whom specific international rights conventions
exist, older people tend to be covered implicitly via the
universalityofhumanrights.Thereislackofadequatecoverage
under international law, with few legal instruments relating
specifically to older people as a distinct category. The most
important international events and documents relating to
older people in humanitarian situations are depicted in
Annex 1.
The first major international milestone for older people came
in1982withtheInternationalPlanofActiononAgeing,agreed
in Vienna at the First World Assembly on Ageing. This called
on each state to çformulate and implement policies on ageing
on the basis of its specific national needs and objectivesé. It
also suggested that each government establish multidis-
ciplinary national commissions on ageing to develop its own
national policy on ageing. In 1991 (16th December), to “add
life to the years that have been added to life”, the UN General
Assembly adopted 18 Principles for Older Persons (see
Annex 2). This called for ensuring the independence, partici-
pation, care, self-fulfilment and dignity of older people. It also
specificallystatesthatolderpeopleshouldhaveaccesstobasic
services, including shelter, adequate food and health care. In
42
Wells J, 2005.
43
HelpAge International, 2000. Assessment of the nutritional status amongst older people of Kenema District, Sierra Leone.
44
HelpAge International, undated. Guidelines on including older people in emergency shelter programmes.
The prolonged conflict in Angola and the consequent forced migration of millions have drastically reduced the level of
interaction between older people and younger people that would have been common in rural areas. The setting up of
community schools, for example, has lessened the role played by the older members of society in the lives of youth, as
they are no longer perceived as the bearers of wisdom and advice. The Nzango, a traditional meeting place where
members of the community, young and old, would tell stories, discuss important matters, settle disputes, pass on skills,
was crucial to community life in Angola. Refugees, however, have no such place to congregate and interactions between
older and younger generations is limited to the nuclear family. Skills that would have been taught to boys are no longer
relevant, negating the role of older male members of the family. NGOs focus on empowering women, adding to the
erosion of the traditional male role. Older men can start to feel worthless and insignificant. Hunting, fishing and farming
as traditional livelihoods in which older men had seniority, status, leadership and decision-making power are no longer
possible and subject to regulations in refugee camps. Members of many ethnic groups are placed together in refugee
camps. In Mayukwayukwa camp in Zambia, for example, Mdundas, Kaluchazis and Lubales live side by side. As youngsters
from all groups mix together, it is impossible for older men of the various groups to pass on customs and values.
Box 4: Changes affecting older people in refugee camps in Angola
Source: Eruseto, (2002) Older people displaced: at the back of the queue? (extract). Forced Migration Review no 14, University of Oxford.
Adapted: http://reliefweb.int/node/414745

TECHNICAL NOTES
12
Table 1: Priorities of the Madrid International Plan of Action on Ageing MIPAA (2002)
Priority 1 Older persons and development • Active participation in society and development
• Work and the ageing labour force
• Rural development, migration and urbanization
• Access to knowledge, education and training
• Intergenerational solidarity
• Eradication of poverty
• Income security, social protection/security and poverty
• Emergency situations
Priority 2 Advancing health and well-being • Health promotion and well-being throughout life
into old age • Universal access to health care services
• Older persons and HIV/AIDS
• Training of care providers and health professionals
• Mental health needs of older persons
• Older persons and disabilities
Priority 3 Enabling and supportive • Housing and the living environment
environments • Care and support for caregivers
• Neglect, abuse and violence
• Images of ageing
Implementation and follow up • National and international action
• Research
• Global monitoring, review and updating
45
UN OCHA, 2004. Guiding Principles on Internal Displacement.
46
National Nutrition Policy and Key Strategies 2008-2012, Federal Ministry of Health, Republic of Sudan. June 2008.
1998, the UN Guiding Principles on Internal Displacement45
includedageinprovisionsagainstdiscrimination,andspecified
that older people are entitled to special protection and assis-
tance, and to treatment that takes into account their special
needs.
The SecondWorld Assembly on Ageing was held in Madrid in
2002.This meeting provided a prime opportunity to reinforce
previous commitments and rally UN member states to take
the issue of ageing and the rights of older people seriously.
Specific consideration was paid to older people in human-
itarian crises. The meeting produced the Madrid Inter-
national Plan of Action on Ageing (MIPAA), signed by the
159 governments present. MIPAA is the first international
agreement explicitly committing governments to include
ageing in social and economic development policies. It stated
that: “in emergency situations, older persons are
especially vulnerable and should be identified as such
becausetheymaybeisolatedfromfamilyandfriendsand
less able to find food and shelter” (Objective 2). MIPAA
priorities were identified, as summarised in Table 1.
A number of articles and objectives related to older people in
emergency situations were specified: see Annex3. MIPAA also
calls for an end to ageismandagediscrimination, as defined
in Box 5.
Despite these plans and guiding principles agreed at
international level, national responses often lag behind.
HelpAge’sAsia-PacificOfficeandAgeUKconductedananalysis
of policies relating to older people in countries in the Asia-
Pacific region. This includes several countries affected by
humanitarian emergencies caused by recent natural disasters.
Theanalysisrevealedthat,althoughmostcountrieshavesome
form of Disaster Reduction Strategy, most do not mention
older people specifically. Myanmar is the only country in the
region to include older people in its national action plans.
Similarly, nutrition policies drawn up by national governments
often fail to make specific mention of older people. For exam-
ple, Sudan published a National Nutrition Policy in 2008.46
While stating the policy is aimed at“all citizens”, the conceptual
framework and nutrition activities refer almost exclusively to

TECHNICAL NOTES
13
The word ‘discrimination’ comes from the Latin ‘discriminare’ which means ‘to distinguish between’. Discrimination is
action based on prejudice, resulting in unfair treatment of people. Ageism is becoming at least as important as racism
and sexism. However, policy makers and the public continue to view age discrimination as less pervasive and less
insidious or harmful than race or sex discrimination. The joint effects of combined ageism, sexism and/or racism can be
significant.
Box 5: Ageism and age discrimination
Source: Mooney-Cotter A-M, 2008. Just a number: an international legal analysis on age discrimination. Ashgate Publishing, UK.
children. In the analysis of the basic causes of malnutrition,
there is acknowledgement that these are exacerbated by
differentials in terms of accessing and utilising these resources
across geographic areas, ethnic groups and gender, but age is
not mentioned.
The UN system plays a unique coordination role in the global
humanitariansystem.Itscoordinationsystemhasthepotential
to ensure that older people’s needs are specifically met.
However, there is no dedicated or specialised UN agency to
look after older people. Over the last decade, the UN system
has increasingly recognised older people as a cross-cutting
issue as well as a specific emergency nutrition challenge (see
Table 1). In 1999, the UN declared 1st October the annual
International Day of Older Persons. Important recent deve-
lopments include the UN General Assembly establishment of
an Open-EndedWorking Group on Ageing (OEWG) in October
2010, followed by the 78th Inter-Agency Standing Committee
(IASC) Working Group Meeting in November 2010, another
OEWG.
The IASC is the UN’s primary mechanism for inter-agency co-
ordination of humanitarian assistance, and has been working
with HelpAge since 2008 to mainstream older people into all
areas of humanitarian action. Guidance is available from the
IASC on humanitarian action and older people. However,
recent HelpAge/Age UK research has shown that the human-
itarian coordination system focuses mainly on younger age
groups and fails to ensure the inclusion of older people in the
humanitarian response.
Within WHO, the Ageing and Life Course Department leads
on World Health Days theme of ageing and older people (e.g.
2012 World’s Health Day slogan was“good health adds life to
years”) and hosts a website on ageing (http://www.who.int/
ageing/en/).Whilst WHO’s Nutrition for Growth and Develop-
ment Department has not recently focused on older people,
it commissioned and published the Physical Status anthro-
pometry review in 1985, which covered the nutritional status
assessment of adults for the first time. An update on this is
under consideration.
Very few international non-governmental organisations
(INGOs) are dedicated to older people. HelpAge is the only
INGO solely dedicated to addressing the needs and rights of
older persons and implements activities through regional
centres, country offices, affiliates and civil society consortia.
Age Demands Action (ADA) is a HelpAge advocacy campaign,
which aims to bring about changes for older people by older
people on a sustainable basis through influencing local
policies. For example, during the Pakistan floods, one initiative
was to influence the public transport system to provide older
people with better services and seating. Other key INGO’s
include Global Age Action and the Global Alliance for the
Rights of Older People.
Vulnerability and rights
HelpAge believes that, in its current state: “the humanitarian
system is poorly equipped to ensure an equitable response
for the most vulnerable.Whilst issues specific to children, age,
oldpeople,womenandthosewithdisabilityarewidelywritten
about, there are few mechanisms to deal with them”.
In a disaster, all parts of a population may have been exposed
to the same risks but the vulnerability and resilience of some
households, and/or some specific members of a household
to the impact of a shock on their food security will vary. The
term‘vulnerable group’is widely used throughout the human-
itarian literature, in guidelines and protocols, with frequent
references to‘vulnerable groups’in need of special assistance
and/or targeting, including for undernutrition. However, there
is no universally accepted clear definition of vulnerability,
leaving the term open to interpretation. While the ‘elderly’,
‘older people’, ‘widowed’, ‘disabled’, ‘unaccompanied old’ are
often included under the umbrella group ‘vulnerable’, they
compete with the more readily targeted children and women.
Being mentioned in a long list of the ‘vulnerable’ does not
guarantee inclusion in programmes.
HelpAge favours the following (Handicap International)
definition of vulnerability:
“The conditions determined by physical, social, economic and
environmental factors or processes, which increase the
susceptibility of an individual or community to the impact of
hazards and risks e.g. age, gender, poverty or location”.

TECHNICAL NOTES
14
47
WHO 2011. Statement: Panel discussion on the realization of the right to health of older persons. 18th session of the UN Human Rights Council).
48
FAO 2000.
49
Sphere Project, 2011. Humanitarian Charter and Action Sheet 3.1.
This definition highlights two main aspects of vulnerability:
• Individual/household/community impairment versus
capacities and coping mechanisms.
• External constraints/events/crises versus a stable
situation.
Vulnerability is not necessarily a permanent state because it
combines personal factors (such as physical condition) with
situational factors (such as displacement, or risk of hypother-
mia). To be results orientated, the existing situation should
always be at the forefront of any consideration of vulnerability.
This definition also stresses the various dimensions of
vulnerability. Social and psycho-social vulnerability refers to
thedisruption,orriskoflosing,normalsocialsupportnetworks,
whether kin or non-kin, formal or informal. An additional key
source of social vulnerability for older people is ingrained
stigma, ageism and age discrimination (see Box 5) to which
many people are subjected.47
Biological or physical vulner-
ability refers to risk of partial or complete loss of functional
ability, either permanently or through temporary impairment.
This can result from chronic disease, illness or accident as well
as exposure to cold (older people are more susceptible than
young people to hypothermia) and extreme heat through
dehydration.
In the context of food insecurity, FAO48
has defined vulner-
ability as:
“The full range of factors that place people at risk of becoming
food insecure. The degree of vulnerability of individuals,
households or groups of people is determined by their exposure
to the risk factors and their ability to cope with or withstand
stressful situations”.
In terms of undernutrition, the vulnerability focus should be
on reducing the risk of, and preventing, early deterioration of
nutritional status. There is more discussion of nutritional vul-
nerability in the assessment section of this module.
Rights and the principle of impartiality
Vulnerability assessment and analysis are commonly used in
humanitarian emergencies (see section on assessment for
more detail), including for older people as a vulnerable group
with distinct needs. However, the terminology of needs and
vulnerability may be insufficient to address the determinants
and effects of undernutrition in older people because other
population groups also described as ‘needy’ and ‘vulnerable’,
such as young children and pregnant women, take prece-
dence. Scarcity of funds and resources and lack of agency
capacity and skills to deal with those groups are often cited as
reasons for this. However, it is important to acknowledge that
in any situation, including disasters and conflict, everyone has
the same human rights. Despite the demographic evidence
of population ageing, and increasing advocacy, there is still
little evidence that the rights (rather than the needs) of older
people are being systematically identified within mainstream
humanitarian response or coordination.
The principle of impartiality stems from this equity of rights.
Everyone has a right to humanitarian assistance regardless of
race,nationality,politicalideologyoraffiliation,religion,gender
or age. This is the basic tenet under which almost all human-
itarian actors claim to operate. However, research shows that
the particular needs of older people as a ‘vulnerable’ group
are not usually included in consultations and assessments and
do not receive appropriate humanitarian assistance.
The UN Humanitarian Principles, endorsed in 1991 by the UN
General Assembly, refer to Humanity, Neutrality and Impar-
tiality(OCHA2010),althoughageisnotspecificallymentioned.
The Sphere Project (2011)49
does refer to age as a ground for
non-discriminationundertherighttohumanitarianassistance.
Sphere’s rights-based approaches to humanitarian assistance
asserts that it is time to shift the emphasis away from a needs-
focused humanitarian system to one that is more grounded
in human rights for all and underpinned by the principle of
impartiality. This means challenging the existing ùchildhood
biasû in humanitarian assistance and the provision of more
funding, capacity, resources and monitoring for the realisation
of the rights of older people in humanitarian crises. There is
also a need to facilitate the opportunities for communities to
identify vulnerable groups and households themselves,
according to their own criteria as part of strengthening parti-
cipatory processes.
Although human rights law recognises that all people have
certain fundamental rights, including the right not to be
discriminated against, most legal instruments predate the
problem of ageing in low to middle income countries and age
is not prohibited as a basis for discrimination. Therefore,
HelpAge believes that the development of a specific legal
treaty devoted to upholding and protecting the rights of older
people, should be considered (for example, a Convention on
the Rights of the Older Person).
The ability to feed oneself and one’s family adequately is a
humanright.Therighttoadequatefoodisrealised“whenevery
man, woman and child, alone or in community with others,
have physical and economic access at all times to adequate
food or means for its procurement.”This implies the“availability
of food in a quantity and quality sufficient to satisfy the dietary

TECHNICAL NOTES
15
50
General Comment 12, adopted in 1999 by the Economic, Social and Cultural Rights, the treaty body for the International Covenant on Economic, Social and
Cultural Rights.
51
UN ACC/SCN, 2004.
52
PUCL Bulletin, July 2001. Supreme Court of India, Record of Proceedings. Writ petition (civil) no. 196 of 2001.
needs of individuals, free from adverse substances, and
acceptablewithinagivenculture”,andthe“accessibilityofsuch
food in ways that are sustainable and that do not interfere
with the enjoyment of other rights.”50
All stakeholders in nutrition emergencies need to be aware of
their full responsibilities as duty-bearers to promote the
realisation of the right to food for everyone, including older
people, and to make efforts to ensure that there is equitable
access to healthy and appropriate food for all sections of the
population. This right refers not just to the right to be fed but
also to be supported in their capacities and efforts to achieve
sustainable food security for themselves, their households and
their communities.
The Fifth Report on the World Nutrition Situation51
urged the
practical application of the right to food. It cited the example
of India’s Supreme Court ruling in 2001, which invoked the
right to food, named ‘the aged’ among groups who saw this
right violated through inequitable availability of food, and
called for a Targeted Public Distribution Scheme for below
poverty level families, issuing of cards, and commencement
of distribution of 25kgs of grain per family per month.52
In September 2001, a panel discussion at WHO discussed the
realisation of the right to health of older persons in the
framework of the 18th session of the Human Rights Council,
Geneva. The discussion concluded with the urge to shift the
paradigm from responding to the needs of older persons to
realising the rights of older persons.
Participation
The importance of working with a community is reflected in
the Humanitarian Charter and the Minimum Standards in
Disaster Response produced by the Sphere Project.‘Working
with communities’is one of the pillars that humanitarian work
is based upon. It forms a common standard that all sectors,
including nutrition, should follow.
The right to participate is central to the realisation of other
rights, including the rights to health and the right to food.This
is particularly important for older people.
With the right support, older people can, and do, make signi-
ficant contributions to the development of their communities.
The participation of older people and their involvement in
decision-making are stated priorities of MIPAA (see Table 1).
The importance of older people’s direct involvement in
conducting their own analysis and using their knowledge in
advocacyanddecision-makingisincreasinglyrecognised.Now
developed and adapted by practitioners and researchers all
overtheworld,participatoryresearchmethodsareincreasingly
used with older people in poor communities.
The participatory process goes beyond simply gathering
information and voice, although that is very important. It
extends to engaging older people, especially those who are
poor and marginalised, in service and policy development. By
taking part in planning, carrying out and disseminating
research, older people can open up new opportunities to
communicate their situation directly to practitioners and
• Livelihoods Analysis – in which people analyse and quantify different sources of income and support – is a useful
tool for finding out about sources of cash and non-cash income, expenditure and use of resources. It can help us
understand how older people make resource decisions, their livelihood strategies and how household resources
are acquitted and shared among members.
• Flow diagrams – to show causes, effects and relationships.
• Daily activity diagrams – e.g. life in camp (for facilitating discussion about gender roles).
• Mapping
• Guided transect walk (e.g. how far people have to go to fetch water or fuel, or get to the distribution or health
centre, what that journey is like and observe physical, sensory and mental capacities). While walking we can
notice problems seeing, hearing, walking or sitting for long periods, what they are required to carry and how easy
this is for them.
Box 6: Examples of participatory processes with older people
Source: HelpAge International, 2002. Participatory research with older people: a sourcebook.

TECHNICAL NOTES
16
53
HelpAge International, 1999: Older people in disasters and humanitarian crises: guidelines for best practice, p2.
54
IASC/HelpAge International, 2007. Inter-Agency review of the inclusion of older people in humanitarian action.
55
Salama P and Collins S, 2000. An ongoing omission: adolescent and adult malnutrition in famine situations. Refuge, Vol. 18 (5); 12-15 (January).
56
Pirzada W, Tayyab M and Asfar M, 2010. Impact assessment: overall humanitarian response. HelpAge International Pakistan Programme.
During a national dissemination workshop on community research in Ghana (1999), older people who had been involved
spoke about the issues it had raised for them:
An older woman spoke about livelihoods:
“Bush fires have caused a lot of problems for older people who farm cocoa. The government helped us for the first two years
but now they have stopped. We are not government workers and have no pension. Cocoa is our livelihood, as well as yam
and other crops. But we are not as strong as we were. Older people do many household chores such as looking after children,
training them and keeping a good house.”
A chief’s representative spoke of older people’s knowledge and experience:
“The research showed we took a lot of things for granted. We didn’t realise that older people had so much experience.
In the fishing community, for example, the older people know where to fish and which waters to avoid”.
Box 7: Older people speak out
Source: HelpAge International, 2002. Participatory research with older people: a sourcebook.
decision-makers. Participatory needs assessment and research
has been part of HelpAge’s approach for several decades.
HelpAge believes that full participation of older people in the
economic, social and cultural life of their communities, and in
emergency situations, is both a key to sound and inclusive
development and a matter of basic human rights. Consulta-
tion, inclusion and empowerment through partnership have
now emerged as the primary indicators of best practice.53
Boxes6and7 giveexamplesofmethodsusedinparticipatory
research, assessments and programme planning with the
active inclusion of older people.
Missing and under-funded: older people in the
humanitarian system
In2007,aninter-agencyreviewoftheinclusionofolderpeople
in humanitarian action found continuing neglect of this
vulnerable group.54
Since then, the situation has not improved.
Box 8 summarises recent evidence of the lack of funding for
older people in emergencies.
Having global covenants and national policies in place are
important foundations for ensuring the inclusion of older
people on the agenda. However, the real test lies in whether
these are actually translated into commitments in terms of
financing, implementation and monitoring.The evidence that
programmes and interventions targeting older people in
humanitarian crises are lacking is increasingly systematic and
quantitative,andnotjustfromanecdotalreportsofoperational
NGOs and observers. For example, during the 1998 famine in
southern Sudan, 18 NGOs were running 50 Selective Feeding
Interventions and 21 Therapeutic Feeding Centres, serving
over 47,000 beneficiaries in Bahr el Ghazal. However, not one
of these centres provided services tailored towards adults.
“Although some centres did include small numbers of adults,
particularly if they were categorised as ùvulnerableû (disabled,
elderly, pregnant and lactating women), the inclusion of
adolescents and adults was generally on an ad-hoc basis”.55
More recently, HelpAge Pakistan reviewed the humanitarian
response to the floods of 2010:
“Almost all relief organisations extended relief services in such
a way that the specific needs of older people could not be
addressed.This was due to the shortage of time to respond to
the disaster and also due to low priority, to the quality of
planning and designing phase of relief services. Some organ-
isations incorporated older people into their programmes as
one of the vulnerable groups. However, the majority of organ-
isations did not take age as a vulnerability factor. Other vulner-
abilities such as disability, injury, illness, and income poverty
were used as criteria for relief, older people generally remained
excluded and invisible to the humanitarian response.”56

TECHNICAL NOTES
17
HelpAge quantified the extent to which older people, and people with disabilities, were specifically targeted through
the UN Consolidated Appeals Process (CAP) for 14 countries and four Flash Appeals between 2010 and 2011, covering
6,003 appeals. The main findings were:
• Out of the US$10.9 billion contributed by official donors to the CAP and Flash Appeals, only $73 million
(0.7% of overall funding) was allocated to projects that included at least one activity targeted at older people
or people with disabilities.
• A total of US$26.6 million went to projects targeted exclusively at older people or people with disabilities (0.3%).
(A similar study analysing CAP and Flash Appeal funds between 2007 and 2010 showed that just 0.2%
was allocated to projects that included an activity specifically targeted at older people)
• Of the 6,003 projects submitted to the CAP and Flash Appeals in 2010 and 2011, only 145 (2.4%) included at least
one activity targeting older people or people with disabilities, and of these 61 (1%) were funded.
• In 21 countries affected by humanitarian crises, there were no projects with activities targeting older people
in any sector in 2010 and 2011. This includes Chad, Central African Republic, the Republic of Southern Sudan,
Yemen, Zimbabwe and 16 countries in West Africa.
• The total amount of projects and funding for older people and for people with disabilities remains extremely low,
highlighting the significant disparity between the needs of these two vulnerable groups and the humanitarian
assistance delivered to meet those needs.
Box 8: The funding gap in the humanitarian response for older people
Source: HelpAge International, 2012. A study of humanitarian financing for older people and people with disabilities, 2010-2011.
Box 9: Older refugees generating income for food in Liberia, 2004
What we know about older people in
humanitarian emergencies
HelpAge and other agencies are reporting that the number
of older people affected by emergencies is growing fast.58
In
internally displaced populations (IDP) and refugee camps, the
numbers, and proportions, of older people can be very high.
For example, in Gulu District of Northern Uganda, 65% of those
remaining in camps in 2009 were over 60 years of age.59
Olderpeoplewillstillattempttofocusongeneratinglivelihood
and caring for others, if at all possible, in an emergency
situation. For example, a study in Rwandan refugee camp in
Tanzania showed that 72% of older people were cultivating
kitchen gardens for sale as well as for household consump-
tion.60
See Boxes 9 to 11.
Micro-credit and other activities that can help older people
earn a living often target younger adults. When communities
returnhome,olderpeopletypicallyfacedifficultiesinaccessing
land and other scarce resources.
Missing from the humanitarian nutrition agenda
As described above, many organisations working in emer-
gency and conflict situations do not generally consider the
special nutrition and food requirements of older people, or
address undernutrition in this population group.
There are many gaps and inconsistencies in the nutrition-
related policies and guidelines of humanitarian agencies in
relation to older people. For example, the WFP’s recent Nutri-
tion Policy (2012) does not mention older people at all, even
57
http://www.globalaging.org/armedconflict/countryreports/Africa/fendall.htm
58
HelpAge International and Age UK, 2011. On the edge: Why older people’s needs are not being met in humanitarian emergencies.
59
HelpAge International, 2010. A study of Humanitarian Financing for Older People.
60
Pieterse S, 1998. The nutritional status of older Rwandan refugees. Public Health Nutrition: 1 (3); 1-6.
How do older refugees support themselves? Those who can still move around, walk for miles in the bush gathering
palm branches to make house brooms that are sold for five Liberian dollars, which is less than 10 US cents. A 98 year old
woman making a broom says: “If I can sell four of these brooms, I will buy one cup of rice and palm oil to eat today”.
Source: Maxi M, 2004. Report on the situation of the elderly at the Fendall and Soul Clinic Internally Displaced People Camps.57

TECHNICAL NOTES
18
Fatima thinks she is over 70 years old. She lives in Krinding camp in Sudan:
“I came to this camp from Kria, a village seven kilometres west of Geneina, nearly eight months ago. I came here by myself
with seven grandchildren, aged 3 to 11. One of their fathers was killed when the fighting started. Another was shot in the
knee and is now in hospital. I don’t know if he will recover. Another son fled to Chad when the fighting started, and the fourth
went to Khartoum to find work because our family needed money. When we came we had nothing. Everything in our village
had gone or been burnt. I made this shelter from wood and twigs, and we were given some plastic sheeting. Neighbours who
have cards for food share what they get with us. We haven’t got a card for food yet, only for plastic sheeting and soap.
My eldest granddaughter collects grass from around the camp to sell at the market. Sometimes she makes some money
to buy food. The four boys go to school and the youngest children stay here with me. It would be good for us to go back
to our village but I am not willing to take the children back unless the UN makes it safe. Seven of my relatives have been killed.
I don’t want to risk these bad things happening again.”
Box 10: Proving sole care for children in Sudan, 2004
Source: Holt K, 2004. Sudan Emergency: Older People’sVoices. HelpAge, November 12, 2004. http://www.globalaging.org/armedconflict/countryreports/africa/voices.htm
Box 11: The experience of a Somali refugee in Dadaab refugee camp, Kenya, 2011
Abdullahi is about 70 years old. He has just been through Hagadera Reception Centre, and as proof of registration, a red
plastic bracelet has been tied around his wrist.This gives him access to a ration for three weeks consisting of food (wheat
flour, oil, cornmeal, sugar, beans, corn-soya blend, salt) a cooking kit, a blanket, a mat, a 10-litre jerry can and soap.
Arriving from Somalia after 15 days of travelling, Adbullahi says:
“I am one of the lucky ones who were transported by truck from the border to Dadaab. I used to live alone and work on
my small piece of land. I have been a widower for seven years. My sons disappeared and my only daughter is married and
looks after her own family. The drought took away my only means of livelihood, and I was forced to leave.”
Now he has to find a place to live before being officially registered by the Kenyan Government’s Directorate of Refugee
Affairs and UNHCR. This registration can take up to two months, and Abdullahi has received food for only three weeks.
Source: Adapted from Fritsch P, 2011: East Africa crisis: older refugees arrive at Dadaab in search of better life. HelpAge International Blog, posted 5 August 2011.
undertheterm‘vulnerablegroup’.Incontrast,FAO’s2005report
“Protecting and promoting good nutrition in crisis and recovery:
Resource Guide” makes numerous references to adults,
including:
• the effects of malnutrition on adults;
• blended foods are designed for children and not well
appreciated by adults;
• the best methods for assessing malnutrition in older
adults are still unclear; and
• a lack of clarity of the use of MUAC/BMI cut-offs for
classification levels of malnutrition.
The report also refers to older persons (elderly) in terms of:
• being a vulnerable group, and thus a priority problem;
• targeting for inclusion in Supplementary Feeding
Programmes (SFP) and Therapeutic Feeding
Programmes (TFP);
• use of anthropometry cut-offs;
• their active roles in the care of children; and
• the importance of their participation in mapping,
gardening, passing on knowledge, and employment for
adherence to Supplementary Feeding Programme.
The current international donor environment is not conducive
to increased efforts on older people, generally and in particular
in humanitarian and nutrition emergencies. There is a broad
tendency (acknowledged by aid workers unofficially) to exert
the bulk of resources, manpower and effort into the children
and women part of the ‘vulnerable groups’ mandate, often
overlooking the fact that older people are also included in that
vulnerable category. This imbalance needs to be addressed.
Added to this, there is a tendency to rely on the specialist
INGOs, mainly HelpAge and its affiliates and partners, to
address the needs of older people.
A decade after MIPAA, Priority 1 relating to emergency situa-
tions for older people is not well implemented, and the
principle of impartiality in access to humanitarian assistance
is being undermined.

TECHNICAL NOTES
19
61
Nhongo TM, 2001. Regional Representative, HelpAge International. Foreword In: Borrel A, 2001. Addressing the nutritional needs of older people in emergency situations
in Africa: ideas for action. HelpAge International Africa Regional Development Centre.
62
James W, Ferro-Luzzi A and Waterlow J, 1988. Definition of chronic energy deficiency in adults. Report of a working part of the International Dietary Energy
Consultative Group. European Journal of Clinical Nutrition, 42 (12); 969-981.
63
Collins S, Duffield A and Myatt M, 2000. Adults: assessment of nutritional status in emergency-affected populations. For ACC/SCN Secretariat, Geneva. July.
64
Navarro-Colorado C, 2006. Adult malnutrition in emergencies: an overview of diagnosis and treatment. Field guidelines. ACF Technical and Research Department.
Version 3, September.
65
http://www.en-net.org.uk/
66
Golden M, 2009. En-Net Forum discussion on MUAC cut-offs for adults. 7 December.
“Perhaps the single most important factor in determining and
addressing the nutritional vulnerability of older people affected
by emergencies is the attitude of humanitarian personnel who
feel that older people ‘have had their day’ or are ‘a waste of
resources’. ”61
Undernutritionin older people
Defining terms for undernutrition in adults
Since the 1980s, two terms have generally been used to des-
cribe undernutrition in adults: Acute Energy Deficiency (AED)
and Chronic Energy Deficiency (CED).62
AED is a state of nega-
tive energy balance (a progressive loss of body energy) leading
to wasting of peripheral tissues. CED is a steady state at which
a person is in energy balance although at a cost, either in terms
ofincreasedrisktotheirhealthorasanimpairmentoffunctions
(see next section on assessment) and health.
However, the use of the term CED for adults has recently been
questioned, for example, by the ACC/SCN report on the assess-
ment of nutrition status in emergency-affected populations
(2000)63
and in an ACF guidelines paper on malnutrition in
adults in emergencies (2006).64
They argue that the CED em-
phasis on energy alone obscures the importance of protein
catabolism and deficiencies of vitamins and minerals. For older
people, the focus needs to be less on energy and more on a
nutrient-dense dietary intake which is propor-tionately richer
in micronutrients, especially Vitamins D, B and iron, than for
younger adults who are not pregnant or lactating, or are ill
(for example, with HIV and AIDS). A discussion on the
Emergency Nutrition Network’s En-Net Forum65
argues that
the use of the term ‘Chronic Energy Deficiency’ is out dated
and should not be used. A low BMI defines degrees of thinness,
but thinness should not be used as a proxy for the deficiency
of any particular nutrient or energy.66
Figure 1: Nutritional risk factors for older people
Source: Borrell 2001, adapted from Ismail and Manandhar, 1999.
DECREASED FOOD INTAKE
(missed meals, lack of access
to nutrient-rich foods, poor
chewing and absorption)
REDUCED ACCESS TO FOOD
(poor acess to means
for obtaining food)
DISABILITY
(poor mobility and eyesight)
HEALTH AND ENVIRONMENTAL
(chronic disease decreased
immunity)
PSYCHOLOGICAL/EMOTIONAL
(confusion, depression)
FUNCTIONAL ABILITY
(poor strength and
coordination)
SOCIO-ECONOMIC
(source of income,
loss of control)
POOR DIET
POOR NUTRITIONAL STATUS

TECHNICAL NOTES
20
* Organ weights taken from Boyd.
+
Metabolic rates for the neonate are estimated by assuming that the metabolic rate of each organ per unit weight is the same as in the adult. The total activities of
the tissues listed are expressed as fractions of the total basal energy expenditure in the adult and the neonate. The total basal metabolic rate in the neonate
approximates to that measured by Benedict and Talbot.
Source: FAO/WHO 1985. Protein energy requirements. Technical report 724. (p 43).
Table 2: Metabolic rates (MR) of organs and tissues in man
Adult Neonate
Organ Weight*kg MR/day % of whole Weight*kg MR/day+
% of whole
kcal body MR kcal body MR
Liver 1.60 482 27 0.140 42 20
Brain 1.40 338 19 0.350 84 44
Heart 0.32 122 7 0.020 8 4
Kidney 0.29 187 10 0.024 15 7
Muscle 30.00 324 18 0.800 9 5
Miscellaneous 20 20
Total 70.00 1,800 100 3.500 197 100
67
See page 12.
68
Andre Briend, personal communication, April 2012.
To address this, the terms undernutrition or stablemalnutrition
have been recommended. ACF recommends the use of the
following terms for describing undernutrition in adults:
• Acute malnutrition: producing metabolic distress and
endangering the life of the patient in the short-term.
This is similar to the use of the term acute malnutrition
in children relating to rapid weight loss due to illness or
an inadequate consumption of food, or both. In
emergencies, most interventions will be dealing with
acute situations.
• Stable malnutrition: simple long-standing thinness,
with relative preservation of metabolic function and not
life threatening in the short-term, but having some
relationship with outcomes of functional importance
in daily living (see later section). The word‘stable’is used
to differentiate it from the term‘chronic malnutrition’
which is used to refer to inhibited growth in height,
or stunting, in children caused by poor nutrition over
a period of time.
Nutritional risk factors for older people
Individuals are malnourished, or suffer from undernutrition if
their diet does not provide them with adequate macronu-
trients (protein, fat, carbohydrates) and micronutrients (mine-
rals and vitamins) in relation to their age- and sex-specific phy-
siological requirements, and/or if they cannot fully utilise the
foodtheyeatduetoillnessorsomeformoffunctionaldisability.
The risk factors for individual older people developing
undernutrition are multifaceted, as depicted in Figure 1.
The risk factors include physiological, psychological, medical
and drug-related, and social changes associated with ageing
which affect food intake and body weight, possibly exacer-
bated by the presence of illness.
The focus on children under five
The conceptual framework of undernutrition most commonly
used in international nutrition policy and programming is the
UNICEF framework, developed in the early 1990s and des-
cribed in HTP Module 1.67
This framework was developed to
‘unpick’ the likely causes of undernutrition in children and
therefore, does not refer to older people.
This child-centred focus rests on a physiological explanation.68
Children have a higher energy requirement per kg of body
weight than adults, their nutritional stores are proportionately
lower and they have a low proportion of muscle in relation to
body mass than adults. Young children are more physiolo-
gically vulnerable than older adults in terms of macronutrient
requirements, and therefore, undernutrition.
This is mainly related to a different body composition between
children and adults, as described in Table 2. Children have a
higherproportionoftheirbodymadeupofenergyconsuming
organs, particularly the growing brain, than adults, but they

TECHNICAL NOTES
21
Older people (and disabled people) who are reliant on others for fulfilling their basic needs such as food, water, medical
support and care, can lose these support systems in an emergency.
For example, the 2010 earthquake in Haiti displaced over 200,000 people over the age of 60, many of whom found
shelter in camps with the help of family, friends and humanitarian workers. Blindness in the elderly population in Haiti is
highly prevalent, limiting mobility to access food, water and medicines. The vulnerability of the elderly to dehydration
and undernutrition is compounded by the fact that ageing reduces the body’s resilience.
Box 12: Physiological vulnerability of older people
Source: HTP Module 1, page 25.
Figure 2: Lifecycle conceptual framework of undernutrition, including older people
69
Marlow M, 1992. Malnutrition in elderly people: challenging the childhood bias. The Health Exchange (December 1992/January 1993); p. 5.
70
WHO, 2008. Report of the Commission on the Social Determinants of Health, WHO.
71
Girerd-Barclay E, 2010. ACF White Paper.
have a low proportion of muscle, with minimum energy con-
sumption (at least in the absence of physical activity).
In addition to this understanding of the physiological vul-
nerability of children to undernutrition, the so called ‘child-
hood bias’69
observed in most humanitarian agencies has, it
has been argued, arisen from a cultural bias of western donors
towards young children.This emphasis on the young child has
recently been invigorated by the influential work of the Com-
mission on the Social Determinants of Health70
which focuses
on reducing inequities in health, and argues that the most-
cost-effectiveandtransformativewindowofopportunityisthe
‘minus 9 months to 2 years’ or ‘1,000 days’ (developing foetus
through to age 2) period. Older people are not mentioned,
although they also have physiological vulnerabilities as
highlighted in Box 12.
Some agencies have recently begun to expand the UNICEF
framework of nutrition to include older people, and to take a
more holistic and inter-generational approach. ACF’s 2010
WhitePaper,71
forexample,includesaflowdiagram(seeFigure
2), showing the impact of hunger and malnutrition through
the life cycle. In this figure, the effect of malnutrition of older
people on the capacity to care for children is depicted, though
this does not depict older people as vulnerable to, and
suffering from the consequences of, undernutrition directly.
A refinement of the original conceptual framework on
nutritionwasmadeinakeypaperonaddressingthenutritional
needs of older people in emergencies in 2001, shown below
in Figure 3.
Source: Girerd-Barclay E, 2010. ACF White Paper.
OLDER PEOPLE
malnourished
WOMEN
malnourished
PREGNANCY
low weight gain
BABY
low birth weight
CHILD
wasted
ADOLESCENT
stunted
CHILD
stunted
Inadequate food,
health and care
Reduced capacity
to care for child
Higher
mortality rate
Higher
maternal
mortality
Inadequate food,
health and care
Inadequate
foetal nutrition
Inadequate
catch-up growth
Impaired mental
development
Increased risk of adult
chronic disease
Untimely/inadequate
weaning
Frequent infections
Inadequate food,
health and care
Inadequate food,
health and care
Reduced
mental capacity
Reduced physcial capacity
and fat-free mass

TECHNICAL NOTES
22
NORMAL RISK FACTORS
FOR OLDER PEOPLE
Figure 3: A conceptual model for the causes of malnutrition in older people
Source: Borrel A, 2001, Addressing the nutritional needs of older people in emergency situations in Africa: ideas for action. HelpAge International, Africa Regional
Development Centre, Nairobi.
MALNUTRITION
IN OLDER PEOPLE
UNDERLYING CHRONIC
ILLNESS
INADEQUATE FOOD
INTAKE
DISEASE
ACCESS TO
LOCAL AND
FAMILAR
FOODS
Likely to encounter
new foods which
older people find
dificult to adapt to.
MEANS TO
ADOPT COPING
STRATEGIES
Limited capacity
to carry out heavy
physcial work or
travel.
CAPACITY OF
FAMILY AND
COMMUNITY
SUPPORT
Loss of family
support, loss of
normal social
status.
PSYCHO-
LOGICAL
STATUS
Death of partner or
family, loss of
home, increased
psychological stress.
PUBLIC
HEALTH
ENVIRONMENT
During epidemic
outbreaks or poor
sanitation, increased
risk of infection for
older persons.
PUBLIC
HEALTH
SERVICES
Services to address
chronic needs of
older people not
a priority.
LOCAL PRIORITES, INFORMAL AND FORMAL
SUPPORT STRUCTURES FOR OLDER PEOPLE
RESOURCES AVAILABLE FOR PROVISION OF SOCIAL
WELFARE SERVICES, PRESENCE OF“SAFETY-NET”
72
Jones J, Duffy M, Coull Y and Wilkinson H, 2009. Older people living in the community: nutritional needs, barriers and interventions: a literature review.
Scottish Government Social Research.
73
Morley J and van Staveren WA, 2009. Undernutrition: diagnosis, causes, consequences and treatment. In Raats M, de Groot L and Van Staveren W (eds).
Food for the ageing population. Ist edition. Woodhead Publishing Limited. Cambridge. pp 153-166.
In old age both the quality and the quantity of the diet are
important to ensure that requirements for macronutrient and
micronutrientintakesaremet.Extensiveresearchindeveloped
countries has shown inadequate nutrient intake leading to a
reduction in body weight to be the predominant cause of
undernutrition in community-living old age, often in combi-
nation with disease. When nutrient intake becomes inade-
quate and declines to levels below requirements, foods which
are nutrient-dense (maintain high nutrients in the presence of
less energy content) become increasingly important,73
particularly when older people continue to have high levels
of physical activity, as is common in many low to middle
income countries.
Ageing and nutritional status
Good nutrition plays a vital role in the well-being and health
of older people, and also helps delay and reduce the risk of
developing diseases.72
Older people are subject to such factors
as nutrition, genetics, physical activity and everyday stress to
influencephysicalandpsychologicalageing.Muchstillremains
to be learned about how nutrition interacts with these other
factors in order to extend healthy life expectancy, indepen-
denceandwell-beinginoldage,andmorewell-designedcon-
trol trials are needed. In the meantime, observational studies
continue to provide clues to healthy ageing. Knowledge about
the nutrient needs and nutritional status of older people has
grown considerably in recent years.

TECHNICAL NOTES
23
Table 3: Summary of selected nutrient concerns in older people
Nutrient Effect of ageing Comment
Energy The body’s need for energy decreases with Physical activity moderates the decline.
loss of muscle mass and physical activity decline.
Protein Needs may stay the same or rise slightly. Fat, and high fibre legumes and grains,
meet protein, and other nutrient, needs.
Iron In women, iron status improves after menopause. Adequate stomach acid is needed for
Deficiencies are linked to chronic blood loss absorption. Antacid or other medications may
(hookworm, schistosomiasis) and low stomach aggravate iron deficiency. Vitamin C increases
acid output. absorption of iron coming from vegetables.
Calcium Intakes may be low. Osteoporosis is common. Stomach discomfort limits milk intakes.
Calcium substitutes or supplements may be
needed, linked with vitamin D supplements.
Yogurt and cheese are good alternatives to milk.
Vitamin B12 Atrophic gastritis common. Deficiency causes neurological damage,
supplements may be needed.
Vitamin D Increased likelihood of inadequate intake, Sunlight exposure only in moderation or
skin synthesis reduces. supplements may be beneficial.
Fibre Likelihood of constipation increases with Inadequate water intakes and lack of physical
low food intakes and changes in the activity, along with some medications,
gastrointestinal tract. compounds problem.
Water Lack of thirst and decreased Total Body Water Mild dehydration is a common cause of
make dehydration likely. confusion. Difficulty obtaining water or getting
to the toilet may compound the problem.
Many changes that accompany ageing impair nutrition status.
A summary of some of the nutrient concerns affected by
ageing is presented in Table 3 below.
The immune system declines with age and it is compromised
by nutrient deficiencies. This combination of age and malnu-
trition makes older people vulnerable to infectious diseases.
Antibiotics are often not effective against infections in people
with compromised immune systems. Consequently, infectious
diseases are a major cause of death in older adults.
In the gastrointestinal (GI) tract, the intestinal wall loses
strength and elasticity with age, and GI hormone secretions
change and diminish appetite. All of these actions lead to
decreased energy intake and weight loss, and slow motility.
Constipation is much more common in older people than in
the young. Atrophic gastritis (a condition that affects almost
one-third of those over 60) is characterised by an inflamed
stomach, bacterial overgrowth and a lack of hydrochloric acid
and intrinsic factor. All of these can impair the digestion, and
absorption of nutrients, notably vitamin B12, but also biotin,
folate, calcium, iron and zinc.
Difficulty in swallowing (medically known asdysphagia) occurs
in all age groups but especially in older people. Being unable
to swallow a mouthful of food can be scary, painful and dan-
gerous. Even swallowing liquids can be a problem for some
people. Consequently, the person may eat less food and drink
fewer beverages, resulting in weight loss, malnutrition and de-
hydration.Tooth loss and gum disease also have serious nutri-
tional consequences, making chewing difficult and painful.
People with tooth loss tend to limit their food selections. This
often leads to a reduction of fruits and vegetables and lower
intake of fibre and vitamins, which exacerbates their dental
and overall health problems.
Sensory loss and other physical problems can also interfere
with an older person’s ability to obtain adequate nourishment.
Failing eyesight can make getting to the store or market
impossible or so difficult that the person avoids the activity.
Carrying bags or baskets becomes an unmanageable task.
Similarly a person with limited mobility may find cooking and
cleaning hard to do. Loss of vision and hearing may contribute
to social isolation, and eating alone may lead to poor appetite.
Not surprisingly, the prevalence of undernutrition is high

TECHNICAL NOTES
24
74
MacIntosh C, Morley J and Chapman I, 2000. The anorexia of aging. Nutrition: 2000; 16; 983-995.
75
Visvanathan R, Newbury J and Chapman I, 2004. Malnutrition in older people: screening and management strategies. Australian Family Physician: 33 (10), 799-805.
Table 4: Macronutrient requirements for older adults
Energy 1.4-1.8 multiples of BMR to maintain body weight at different levels of physical activity (PAL)
• General requirement is 2,100 kcals/day
• For men and women aged 30-59.9 years, and aged 60 or more
• Adjustments will be needed for moderate and heavy activity levels
FAO/WHO/UNU Expert Report (2004) presents reference tables for daily energy requirements according to BMR
factor (or PAL) and body weight.
Fat 30% of total energy intake in sedentary older people
35% of total energy intake in active older people
Protein 0.9-1.1 g/kg per day
Source: FAO/WHO/UNU, 2004. Human Energy Requirements: Report of joint Expert Committee, 17-24 Oct, 2001. Rome.
Note: The requirements as expressed above do not take into account the varying fibre content, digestibility and complex-carbohydrate composition of the diet.
In low to middle income countries, a relatively high proportion of fibre and less-available carbohydrate is usually present. For more discussion, see WHO
Technical Report Series No. 724, Section 7.1. If the Atwater factor (4 kcal per gram) is applied to carbohydrate by difference, the real energy available in the food
should be decreased by 5% or the requirement for this type of diet increased by 5%; which, for this table, means an increase of +100 kcal in the energy
requirement indicated.
among those who are homebound or bedbound, and who
have high levels of sensory impairment. Sensory losses can
also interfere with a person’s willingness to eat and enjoyment
of eating. There is deterioration in taste and smell sensitivities
with increasing age, and this impacts on dietary intake and
nutritional status. The texture and flavour of food may be
particularly important for some older people in order for them
to meet their nutritional requirements.
Although not an inevitable component of ageing, depression
is common among older people. Depressed people, even
those without disabilities, lose their motivation to perform
simple physical tasks (e.g. to cook or even eat). An overwhel-
ming sense of grief or sadness at the death of a spouse, friend
or family member may leave a person feeling powerless to
overcome depression. When a person is suffering the heart-
ache and loneliness of bereavement, cooking meals may not
seem worthwhile. The support and companionship of family
and friends, especially at mealtimes, can help overcome de-
pression and enhance appetite. Older people who live alone
do not necessarily make poor food choices, but they often
consume too little food. Loneliness is directly related to
nutritional inadequacies, especially overall energy intake.
As it ages in adulthood, the human body changes in its com-
position of fat and muscle, influenced by changing hormonal
activity. There is also a progressive loss of muscle stores and
an increase in fat stores. With increasing muscle loss, people
lose their ability to move and maintain balance, making falls
morelikely.Thelimitationsthataccompanylossofmusclemass
and strength play a key part in the diminishing health that
often accompanies ageing. Changes in muscle mass and
quality play a central role in the pathway linking malnutrition,
its biological and molecular consequences, and function.The
functional consequences of this are discussed in the section
on how to assess undernutrition in older people. In a vicious
cycle related to sarcopenia, the prevalence of malnutrition
increases with increasing frailty and physical dependence.74, 75
Nutritional requirements for older people
Settingstandardsforolderpeopleisdifficultbecauseindividual
differences become more pronounced as people grow older.
People start out with different genetic predispositions and
ways of handling nutrients, and the effects of these differences
become magnified with years of unique dietary habits. For
example, one person may tend to avoid most fruits and vege-
tables from his diet, and by the time he is old, he may have a
set of nutrition problems associated with a lack of fibre and
antioxidants. Also as people age they suffer different chronic
diseases and take various medicines – both of which will affect
nutrient needs. For all of these reasons, researchers have diffi-
culty even defining healthy ageing, a prerequisite to deve-
loping recommendations to meet the needs of practically all
healthy people.
It is usually the case that the nutritional needs for older people
are sub-divided into different categories of‘old’. For example,
the FAO/WHO/UNU human energy requirement data tables
refer to women of 51 to 65 years, and those over 65. In the
USA, the Dietary Reference Intakes (DRI) group people over
50 years into two categories: 51 to 70, and 71 and older. Increa-
singly, research is showing that the nutrition needs of people
who are 50-70 years old are different from those over 70.

TECHNICAL NOTES
25
76
FAO/WHO/UNU, 2004. Human energy requirements: Report of joint FAO/WHO/UNU Expert Committee, 17-24 Oct, 2001. Rome.
77
James and Schofield 1990.
78
BMR is the rate of energy expenditure of the body when at complete rest, e.g., sleeping.
79
FAO/WHO/UNU, 2004. Human energy requirements: Report of a joint FAO/WHO/UNU Expert Committee, 17-24 Oct, 2001. Rome.
80
WHO 1995.
81
WHO/CDC, 2008. World prevalence of anaemia 1993-2005. WHO Global Database on anaemia.
82
De Groot L and Van Staveren W, 2010. Nutritional concerns, health and survival in old age. Biogerontology: 11; 597-602.
Macronutrients
Since 1949, the FAO, and, since the early 1950s, WHO have
convened groups of experts to evaluate current scientific
knowledge in order to define the energy requirements of
humans and propose dietary energy recommendations for
populations. The latest recommendations from this group
were published in 2004.76
Energy requirements of adults were
calculated from factorial estimates of habitual total energy
expenditure. With growth no longer an energy-demanding
factor, it is habitually physical activity and body weight which
are the main determinants for the diversity of energy require-
ments of adult populations with different lifestyles.77
Basal
metabolic rate78
(BMR) declines from about 50 years because
lean body mass and thyroid hormones diminish.
Table 4 above presents general requirements for macro-
nutrients for older adults. These requirements are based on
the assumption that, on average, energy needs decline an
estimated 5% per decade, as people usually reduce their
physical activity as they age, although they need not do so. In
fact, this assumption may be inappropriate in the context of
the higher levels of activity of many older people in low to
middle income countries, still involved in livelihood work and
less sedentary than their counterparts in the developed
countries.
Energy requirements for older people can be calculated on
the basis of physical activity levels (PALs) just as they are for
younger adults. Allowances must be made for population
groups who are more or less active at an advanced age, rather
than using age as the single cut-off point to define energy
requirements for the older people.79
Dietary energy intake of
a healthy well-nourished population should allow for
maintaining an adequate BMI at the population’s usual level
of energy expenditure. At the individual level, a normal range
of 18.5 to 24.9 kg/m2
BMI is generally accepted80
(see later in
the Assessment section for classification of undernutrition
using BMI).
Protein is especially important for the elderly to support a
healthyimmunesystem,preventmusclewastingandoptimise
bone mass. Because energy needs decrease, protein must be
obtained from low kilocalorie sources of high-quality protein,
such as lean meats, poultry, fish and eggs, milk products and
legumes. Abundant carbohydrates are needed to protect
protein from being used as an energy source.
As with adults of all ages, fat intake needs to be moderate in
the diets of most older people, enough to enhance flavours
and provide valuable nutrients (but not so much as to raise
the risks of cancer, atherosclerosis and other degenerative
diseases).
Micronutrients
Table 5 summarises current recommended vitamin and
mineral nutrient intakes for older people according to gender.
Note that the age group classifications used are not com-
parable by gender.
Micronutrient deficiencies are widespread in low to middle
income countries with more than two billion people affected
(see HTP Module 4). The main cause of micronutrient
malnutrition is usually an inadequate dietary intake of vitamins
and minerals in relation to the physiological requirements of
an individual, which are sex and age dependent. Micronutrient
deficiencies occur most frequently in individuals on a
monotonous or restricted diet, or in those with infection and
illness such as malaria, diarrhoea and tuberculosis.
Iron deficiency anaemia is a debilitating condition that leads
to fatigue, restricting the individual’s ability to travel around
and do physical work. Although data on anaemia prevalence
among older people are limited, as most national surveys only
collect data on adults up to 49 years old,WHO/CDC estimates
that nearly a quarter of elderly people worldwide are anae-
mic.81
The absorption of iron appears to decrease with age so
that iron deficiency anaemia prevalence may be high among
older people who are reducing their intake of promoters of
non-haem iron absorption such as fruit, beans and vegetables
or haem iron such as animal food (due to cultural/religious
reasons, difficulty chewing).
In displaced camps, people depend on the General Food
Ration (GFR) distributed by WFP. This is usually cereal-
based,pooringreenleafyvegetables,fruitandmeat,and
pooriniron(formoreontheGFR,seeInterventionsection
later in this module).
The European Survey on Nutrition and the Elderly (SENECA)
has noted Vitamin D insufficiency in many European popu-
lations.82
Thisisnotsurprisingconsideringthataboutone-third
of the vitamin D requirements can be obtained by the diet
and the rest by exposure to sunlight where it is synthesised in

TECHNICAL NOTES
26
Table 5: Recommended nutrient intakes by population group: micronutrients
Female 51-65 years* Male 19-65 years Female 65+ Male 65+
Iron µg/day 10.0 10.0 10.0 10.0
Calcium mg/day 1,300.0 1,000.0 1,300.0 1,300.0
Selenium mg/day 26.0 34.0 25.0 33.0
Magnesium mg/day 220.0 260.0 190.0 234.0
Zinc µg/day
High bioavailability 3.0 4.2 3.0 4.2
Moderate bioavailability 4.9 7.0 4.9 7.0
Low bioavailability 9.8 14.0 9.8 14.0
Vitamin C mg/day 45.0 45.0 45.0 45.0
Thiamine mg/day 1.1 1.2 1.1 1.2
Riboflavin mg/day 1.1 1.3 1.1 1.3
Niacin mg/NE/day 14.0 16.0 14.0 16.0
Vitamin B6 mg/day 1.5 1.3 (19-50) 1.5 1.7
1.7 (50+)
Pantothenate mg/day 5.0 5.0 5.0 5.0
Water soluble vitamins
Biotin µg/day 30.0 30.0 30.0 30.0
Folate µg/DFE day 400.0 400.0 400.0 400.0
B12 µg/day 2.4 2.4 2.4 2.4
Fat soluble vitamins
Vitamin A µg/RE day 500.0 600.0 600.0 600.0
Vitamin D µg/day 10.0 5.0 (19-50) 15.0 15.0
10.0 (51-65)
Vitamin E mg alphaTE/day 7.5 10.0 7.5 10.0
Vitamin K µg/day 55.0 65.0 55.0 65.0
* post-menopause
Source: WHO/FAO, 2004. Vitamin and mineral requirements in human nutrition. 2nd Edition. Geneva.
the skin.With calcium,Vitamin D is known for its critical impor-
tance for bone health. Both seem crucial targets for preventive
and treatment measures of osteoporosis. Deficiency in vitamin
D may also affect the broader spectrum of functional
outcomes, involving brain, muscle, vascular and heart health.
Vitamin B12 deficiency is highly prevalent in older people,
particularly where digestive problems, such as atrophic gas-
tritis,reducedtheabsorptionofseveralnutrients.Anestimated
10-30% of older adults over 50 have atrophic gastritis.The bac-
terial overgrowth that accompanies this condition uses up the
vitamin and, without hydrochloric acid and intrinsic factor,
digestion and absorption of Vitamin B12 are inefficient. Poor
cognition, anaemia and neurological damage are negative
effects associated with B12 deficiency, although the effects
appear reversible if treated relatively soon. BothVitamin D and
Vitamin B12 are predominantly derived from animal sources.

TECHNICAL NOTES
27
Table 6: Nutrients that influence the development and activities of the ageing brain
Brain function Depends on an adequate intake of:
Short-term memory Vitamins B12, C, E
Performance problem solving tests Riboflavin, folate, Vitamins B12, C
Mental health Thiamin, niacin, zinc, folate
Cognition Folate, iron, Vitamins B12, B6, E
Vision Essential Fatty Acids, Vitamin A
Neurotransmitter synthesis Tyrosine, tryptophan
Source: Rady Rolfe et al, 2008.
83
Seal A and Prudhon C, 2007. Assessing micronutrient deficiencies in emergencies: current practice and future directions. Journal of Nutrition, Health and Ageing:
vol 12 (8); 599-604.
84
Jones J Duffy M, Coull Y and Wilkinson H, 2009. Older people living in the community – nutritional needs, barriers and interventions: a literature review.
Scottish Government Social Research.
85
WHO, 2002. Keep fit for life: meeting the nutritional needs of older persons. WHO/Tufts University School of Nutrition and Policy.
Some micronutrients are particularly important for the brain,
which responds to genetic and environmental factors that can
enhance or diminish its capacities. Age-related blood supply
decreases the number of neurons (brain nerve cells that
specialize in transmitting information), affecting hearing and
speech, posture and balance. Some of the cognitive loss and
forgetfulness generally attributed to ageing may be in part
environmental, and therefore controllable, including by nu-
trient deficiencies. Table 6 below outlines some of the inter-
actionsbetweenintakesofmicronutrientsandaspectsofbrain
function.
In poor areas of low to middle income countries, and in emer-
gencies, some nutritional deficiency diseases, such as anaemia
andVitamin A deficiency, primarily affect children and women.
Others, such as pellagra, are found more frequently in adults,
men and women. Micronutrient deficiencies have also been
documented in adolescents in African refugee camps. Older
people are rarely, if ever, referred to in studies and reports on
micronutrient malnutrition in emergencies. Certainly, the level
of the challenges in assessing micronutrient problems in
emergencies, and intervening appropriately and with bene-
ficial effect for this population group, is even harder than for
children.83
More attention needs to be paid to this area of the emergency
response. Those micronutrient deficiencies for which older
people can be included as part of ‘whole population’ in
assessments are:
• Beriberi (clinical signs, thiamine level in blood and urine,
dietary intake);
• Pellagra (clinical signs of dermatitis, diarrhoea and
dementia, niacin level in urine, dietary intake of niacin
equivalents); and
• Scurvy (by clinical signs, levels of serum ascorbic acid).
Assessments for Vitamin A deficiency, iodine deficiency and
or iron deficiency do not include older adults or older people
as an appropriate target group for detecting a suspected
micronutrient problem.
Fluids and other requirements
Dehydrationisarealriskformanyolderadults.Totalbodywater
decreases with age so even mild stresses such as fever or hot
weather can precipitate rapid dehydration in older adults. De-
hydrated older adults seem to be more susceptible to urinary
tractinfections,pneumonia,pressureulcers,andconfusionand
disorientation. Despite their physiological needs, many older
people do not seem to feel thirsty or notice mouth dryness.
Many older women who have lost bladder control related to
childbirth or obstetric fistula may be afraid to drink too much
water to avoid the stress and stigma of incontinence. To pre-
vent dehydration, older people need to drink at least 6 glasses
of water a day. Clinical support may be necessary to advise on
quantity, because too much water in undernourished old age
can cause cardiac failure.
Eating high fibre foods and drinking water can alleviate con-
stipation. Sources of complex carbohydrates such as legumes,
vegetables,wholegrainsandfruitsarerichinfibreandessential
vitamins and minerals. Average fibre intakes among older
adults are often lower than recommendations (14gm per
1,000kcal). Physical inactivity and medications also contribute
to the high incidence of constipation.84
Generic guidance on
a healthy diet for older people is provided by a number of
international bodies.85

TECHNICAL NOTES
28
Food intake in its social context
Across human cultures, food is never just food and its signi-
ficance can never be purely nutritional. Humans share food. It
is our central social ritual, it is a focus for social exchange, it
acts as social and intergenerational glue.86
Anthropological
literature provides many examples of how food and meal
ritualsandpracticescontributetofamilyidentityanddomestic
life.So,forolderpeoplewhohavespentsomanyyearsinvolved
in the provision of food for their families, food and eating can
never be removed from its social context.
Even in emergencies, food is intimately bound up with social
relations, including those of power, of inclusion and exclusion,
as well as with cultural ideas about classification, the human
body and the meaning of health.87
While these issues are not
important for young children, they are very important for older
people whose seniority is often tied up with the provision,
choiceandpreparationoffoodforfamilymembers.Inanemer-
gency, this role is frequently undermined, if not completely
disrupted. In addition to the other stresses of the emergency
or conflict, this unfamiliar loss of control over food can have
negative consequences on older people’s emotional and
psychological health, in turn impacting on their appetite, food
intake and choices dependent on food preferences, regardless
of what food is available.
Food is shared and allocated differently within different types
of households depending on demographic composition, who
within the household is sick or has died, has social standing or
economic status and other power factors, many of which are
related to gender and age seniority.88
Intra-household food
distribution, and patterns of self-abstinence, can also be
important causes of undernutrition in older people in low to
middle income countries, both in long-term, development
settings and in emergencies.
The focus on children in most work on undernutrition also
missesthisintra-householdcontextinwhicholderpeoplemay
voluntarily miss meals, or certain nutritious foods, so that other
family members can be fed. HelpAge’s operational program-
mes, and those of many other development agencies, are
frequently reporting examples of many older people going
short of food themselves to feed other family members,
particularly children. For example, in Sri Lanka, where the price
of milk powder almost tripled in February 2009, older people
went without, so that children in their care did not.89
However,
there is little systematic research on this.90
Undernutrition in older people in middle and
low income countries
Inmiddleandlowincomecountries,thereisverylittleresearch
on the nutritional status of older people. The WHO/Tufts
University School of Nutrition and Policy publication “Fit for
Life: meeting the nutritional needs of older persons” (2002)
acknowledged that, despite the rapidly increasing proportion
of older persons in the populations of low to middle income
countries, there is a scarcity of information concerning this
group’s specific nutritional needs. However, we can be sure
that the vast majority of older people in low to middle income
countries enter their later years after decades of poverty and
deprivation,pooraccesstohealthcare,andadietthatisusually
inadequate in quantity and quality.
For Europe’s community-living older people, it was found that
although general undernutrition is not common, they are at
risk for developing poor nutritional status. As described in the
precedingsection,thereasonsforpoornutritionaremultiface-
ted and include the physiological, psychological and social
changes associated with ageing which affect food intake and
body weight, possibly exacerbated by the presence of disease
and illness. Such multifaceted causes will require multifaceted
responses. This will also apply for older people with, or at risk
of, malnutrition in humanitarian situations.
The ACC/SCN 4th World Nutrition Situation Report published
in 2000 was themed ‘nutrition through the life cycle’. For the
first time, a specific section was included relating to adult
malnutrition. However, since then, older people in particular
have not featured in World Nutrition Situation reports.
Duringthe1990s,aresearchprogrammepartnershipbetween
the London School of Hygiene and Tropical Medicine and
HelpAge documented the prevalence of, and risk factors for,
undernutrition among large numbers of older people (aged
50-96 years) in several sites in Africa (rural area near Lilongwe,
Malawi;91
refugee camp for Rwandans in Tanzania92
) and Asia
(urban slums in Mumbai, India93
). The highest prevalence of
86
Quandt S, Arcury T, Bell R, McDonald J and Vitolins M, 2001. The social and nutritional meaning of food sharing among older rural adults. Journal of Aging Studies:
15; 145-162.
87
Caplan 1997. Food, health and identity. Routledge, London.
88
Haddad L, Pena C, Nishida C, Quisumbing A, Slack A, 1996. Food security and nutrition implications of intra-household bias: a review of the literature.
Washington DC; International Food Policy Research Institute.
89
Beales, S, 2011. Ageways. Issue 76. February; p5.
90
Gorman 2011. Why NCD strategies must include older people. Ageing and Development. September; pp 6-7.
91
Manandhar M, 1999. Undernutrition and impaired function amongst elderly slum dwellers in Mumbai, India. PhD thesis. London School of Hygiene and
Tropical Medicine.
92
Pieterse S, Manandhar M, and Ismail S, 1990. The nutritional status of older Rwandan refugees. Public Health Nutrition: 1; 250-264.
93
Chilima D and Ismail S, 1998. Anthropometric characteristics of older people in rural Malawi. European Journal of Clinical Nutrition: 52; 643-649.

TECHNICAL NOTES
29
* using MUAC <23cm
Source: HelpAge International Africa Regional Development Centre, 2004. Summary of research findings on the nutritional status and risk factors for vulnerability of
older people in Africa. Nairobi.
Table 7: Prevalence of undernutrition among older people (60+ years) in African countries
BMI <16 BMI <18.5 MUAC ≤24 cm
Country Men Women Men Women Men Women
Benin – – 8.0 11.8 – –
Botswana 4.2 1.6 20.1 14.8 – –
Cameroon – – 7.7 4.2 6.7 1.5
Ethiopia – – 30.1 50* 23.3*
Ghana 30.0 17.1 62.2 44.6 25.3 12.2
Kenya – – 15.3 10.0 – –
Malawi 4.0 4.9 36.1 27.0 23.0 –
Senegal 4.0 3.0 14.5 9.0 18.5 14.0
South Africa 5.8 1.3 19.2 2.2 21.2 4.8
Tanzania 0.8 2.0 7.6 10.8 – –
Uganda 2.9 1.4 13.3 9.4 – 28.5
Emergency situations MUAC
≤22 cm
Kenya – Turkana 15.2 12.5 – – 19.6 17.7
Kenya – Wajir – – – –
Sierra Leone – Kenema 42.0 48.0 – – 86.0 77.0
undernutrition (BMI<18.5kg/m2) and severe undernutrition
(BMI<16kg/m2) was in India where 35% of older people were
undernourished. Figures from Malawi were similar. In contrast,
the vast majority of refugees (97%) came from villages in East
Rwanda where the food situation had been good.The refugee
population was also a specific group, probably representing
the fittest and healthiest people who had managed to reach
the camp.
Thismulti-siteresearchledontothedevelopmentofaresearch
and advocacy programme within HelpAge. From 2000-2003,
there was an intensification of research on older people’s
nutritional situation in Africa, coordinated by HelpAge’s Africa
Regional Development Centre.Table7below summarises the
information obtained from this research, using the recom-
mended cut-offs for BMI and MUAC at the time (for more on
this, see section on assessment below).
As well as highlighting the prevalence of undernutrition in
older people across Africa, this work also contained valuable
lessons relevant to understanding nutritional vulnerability
among older people throughout the developing world,
including in emergency situations. All the risk factors depicted
in Figure 3 above were identified, and the particular
vulnerability of older people to undernutrition in emergencies
was highlighted, including their:
• Ability to queue, fetch fuel and water, prepare food and
cook;
• Mental health and emotional well-being;
• Lack of care and supports;
• Shelter and their vulnerability to hypothermia and/or
dehydration; and
• Physiological state.
In many rural parts of the developing world, the acquisition
of wild foods is still an important activity, particularly for older
people. Older men tend to focus on small game hunting
whereas women tend to forage for berries, mushrooms, roots,
leaves and tubers and other items like caterpillars. Box 13

TECHNICAL NOTES
30
describes how wild foods continue to be an important activity
among the Dinka of southern Sudan. During emergencies, the
acquisition and consumption of wild foods needs to be
investigated.
Assessment of nutritional status and
vulnerability of older people
This section presents the rationale behind, and techniques for,
assessing the nutritional status of older people. It focuses on
social and nutritional vulnerability risk factors to determine the
underlying causes of undernutrition, on clinical signs and
symptoms of physiological vulnerability, and on anthropo-
metry for the assessment of physical nutritional status. This
section also considers the relevance of functional ability in
older people, based on the premise that impaired functional
ability is an important outcome indicator for this population
groupagainstwhichtomeasureindicatorsofnutritionalstatus.
Only assessment methodologies that can be used in
humanitarian settings are presented.
Assessing the nutritional vulnerability and nutritional status
of older people is a requirement for ensuring an impartial
humanitarianresponse.Moreover,givenwhatweknowabout
the crucial role of older people in households and families,
it could be argued that another approach to avoiding
mortality in young children in an emergency would be to
ensure the nutritional status and functional ability of their
older carers.
The assessment of older people is currently not considered a
key indicator for the severity or extent of an emergency or
crisis, nor as a proxy for the situation in the whole community.
However, there are signs that attention is now turning to their
nutritional situation, as population groups in emergencies.
Wild foods are an extremely important food source for the Dinka in southern Sudan, particularly during food shortage
periods. It is generally the older women in these communities who have the skills and knowledge on how to collect,
process and prepare these foods. Older women can recognize the ùgood food typesû and will know where they are
likely to grow. It is generally the younger women and men who are reluctant to make use of wild foods as a result of their
lack of knowledge as well as the stigma associated with eating them. In this context, there is not only the potential for
utilizing the older women’s knowledge and experience but also to promote and support the use of wild foods as a
valuable source of micro-nutrient rich food source for older people.
Box 13: Consumption of wild foods in southern Sudan
Source: quoted in Borrel, 2001, Addressing the nutritional needs of older people in emergency situations in Africa: ideas for action. HelpAge International,
Africa Regional Development Centre, Nairobi (page 46).
In 2001, in recognition of the fact that “what gets measured,
getsnoticed”,94
anexpertgroup(UNAdministrativeCommittee
on Coordination, Sub-Committee on Nutrition – ACC/SCN)
met in Nairobi to discuss the assessment of adult malnutrition
in emergencies. They agreed that it was appropriate to con-
sider assessing malnutrition in adults as well as in children in
specific circumstances, and made recommendations, as pre-
sented in Box 14.
AnothermeetingoftheSCNNutritioninEmergenciesWorking
Group took place in NewYork in 2004.95,96
These developments
represented a pragmatic approach to the issues, and signalled
progress in tackling the historical neglect of this population
group in the field of undernutrition. However, since then, the
focus on older people has not been maintained and efforts to
reinvigorate work on assessment methods and nutritional
vulnerability in older people in emergencies are urgently
needed.
In 2001, HelpAge’s Africa Regional Development Centre
publishedareportonaddressingthenutritionalneedsofolder
people in emergency situations in Africa.97
The rest of this
section and the following section on interventions draw
heavily on this publication, as well as the ACF publication on
adult malnutrition in emergencies.98
Because of the multi-dimensionality of the causes of under-
nutrition in older people as described earlier, it is important to
take a broad approach in any assessment of undernutrition
in older people, taking into account the complexity of vulne-
rability risk factors and the non-food determinants of nutrition
and functional outcomes. As anthropometric measurements
cannot distinguish between acute malnutrition and stable
malnutrition, it is necessary to first look at risk factors for under-
nutrition in order to differentiate between them.
94
Woodruff B, 2004. Postscript on older people, nutrition in emergencies. The Field Exchange. Issue 14 http://fex.ennonline.net/14/scn.aspx
95
Nutrition in emergencies Working Group report, 2004. The Field Exchange. Issue 22. http://fex.ennonline.net/22/scn.aspx
96
Wyness L, 2004. Taking forward research on adult malnutrition. The Field Exchange. Issue 22 (see 101).
97
Borrel A, 2001. Addressing the nutritional needs of older people in emergency situations in Africa: ideas for action. HelpAge International Africa Regional
Development Centre. Nairobi.
98
Navarro-Colorado C, 2006. Adult malnutrition in emergencies: an overview of diagnosis and treatment. Field Guidelines. ACF, version 3.

TECHNICAL NOTES
31
• If the crude mortality rates begin to approximate or surpass the under-five mortality rates, suggesting that the
over-five population is as vulnerable as the under-five population.
• If the prevalence of malnutrition is very high in the under-fives and is not due to a health problem mainly
affecting that age group.
• If there is reasonable doubt that the nutritional status of children does not reflect the adult situation. For example,
in Bosnia and Kosovo, it was suspected that older people were particularly vulnerable to malnutrition.
• If many adults attempt to enrol in selective feeding programmes or present to health posts.
• If anecdotal reports of adult malnutrition are received.
• If there is low coverage of food aid in dependent populations.
• If data is required to act as an advocacy tool to lever resources.
Box 14: ACC/SCN recommendations on when to assess adult malnutrition in emergencies
Source: ACC/SCN 2001. 31st Session: Report of the Working Group on Nutrition in Emergencies.
http://www.unsystem.org/scn/Publications/AnnualMeeting/SCN28/28emergencies.htm
99
Zohoori N, 2001. Nutrition and healthy functioning in the developing world. Journal of Nutrition: 131; 2429S-2432S.
100
Lee and Berthelot, 2010.
101
Ismail S and Manandhar M, 1999. Better nutrition for older people: assessment and action. Joint publication of HelpAge International and the London School of
Hygiene and Tropical Medicine.
Table 8 below summarises the variety of different methods
to assess the nutritional status and nutritional vulnerability of
older people in emergency situations, each of which will be
described in more detail in this section. The choice of all, or
some of these, will depend on context, stage of the crisis,
available resources and technical capacity.
Assessing complex vulnerabilities
In line with the humanitarian principle of fulfilling rights and
acting with impartiality, the nutritional status and vulnerability
assessment of older people in emergencies should be a
standard component of humanitarian programming.
Social and psychological factors assume greater significance
in the nutritional and functional profiles of older people.These
are important in emergency situations when factors such as
loneliness, bereavement and depression become prevalent.
Widowhood (especially later in life) and forced displacement
(due to political conflicts or natural disasters) lead to psycho-
logical insults from which it is difficult to recover, and which
have profound nutritional and health consequences.99
Wars,
famines and disasters can act against older people as a form
of forced triage phenomenon, whereby the old and frail are
either left behind or not cared for, in favour of the younger
and fitter majority.
Even when included in relief efforts, older individuals are less
likely to adapt to new environments and situations and are
more likely to feel the negative consequences of leaving a
familiarhomeenvironment.InpoorareasoftheUSA,thedeath
rates from malnutrition are significantly higher where older
adults were more likely to live alone or be widowed. Being
socially isolated can be harmful because social supports affect
psychosocial well-being and foster healthier behaviours.100
Nutritional vulnerability among older people, as stated above
is influenced by a variety of social, emotional, physical,
economic and community factors. These are captured in
several Vulnerability Risk Factors as shown in Figure 3 above
and Figure 4 below.101
Various tools exist for assessing vulnerability risk factors for
older people, including:
• Disabled, Vulnerable and Frail Persons (DVFP)
Assessment Module
• Mini-Nutritional Assessment (MNA), and shortened
version (MNA-SF)
• Subjective Global Assessment (SGA)
Of these, only the Disabled, Vulnerable and Frail Persons
(DVFP) Assessment Module, developed by Handicap Inter-
national (see Annex 4) is used in emergency situations.
Although it focuses on disability and frailty, it includes infor-
mationrelevanttothevulnerabilityassessmentofolderpeople
in emergencies, including:
• type of vulnerability: fast screening (it includes if the
person is cared for, though not if s/he is a carer);
• causes of vulnerability;
• level of independence and participation, including the
ability to prepare and cook food, and walking short
distances;
• psychosocial issues, including changes in appetite;

TECHNICAL NOTES
32
Table 8: Summary of assessment methods for nutritional status and vulnerability of older people in emergency situations
Assessment method Indicators Tools available
Vulnerability risk factors Functional abilities affecting Activities • Disabled, Vulnerable and Frail
of Daily Living (ADLs) related to People Checklist (DVFP)
collecting food, water and fuel, (Annex 4)
queuing, preparing food, cooking and
chewing (e.g. sight, mobility, dentition) • Risk factors diagram (Figure 4)
Social risk factors Mini-Nutritional Assessment
(MNA) and MNA-short version
(MNA-SF) (Annex 5)
Qualitative (participatory) research
Clinical symptoms, observations Oedema, dehydration, anorexia, Table 9: ACF Flow Diagram,
sarcopenia, infection and disease Figure 6
Anthropometry for: MUAC Table 10: for classification cut-offs
• Identification of acute and/or stable
malnutrition at population and BMI Table 11: for classification cut-offs
individual levels. (using armspan or halfspan if an Figure 6: ACF Flow Diagram
• Entry and exit criteria for interventions accurate measurement of standing
at individual level. height is not possible, e.g. due to Calculation of Cormic Index
kyphosis) and taking into account the
Cormic Index for standing-height:
sitting-height ratio, and famine oedema
See more technical details on BMI
measurements – p.49
Criteria for referral and Admission and discharge criteria into Table 15: Screening of older
intervention selected feeding programmes people for admission into
(CSP, SFP, TFP) targeted SFP
Table 17: Anthropometric, clinical
and social criteria for older
people’s admission into CSP, SFP
and TFP
Dietary intake Nutrient density in GFR Calculate using computer software
http://www.nutricalc.co.uk/home.php programmes (e.g. NutValu, NutCalc)
http://www.nutval.net/
Intake of micronutrients (Vitamins B12, Assess micronutrient intake versus
D, iron etc) requirements (Table 5)
Fluid intake (to avoid dehydration) Clinician referral and advice
Intake of wild foods Qualitative (participatory) research
Intra-household food allocation Qualitative (participatory) research
Participation of older people Level of involvement of older people It is important to take enough time
in nutrition and vulnerability to adapt the environment and
assessments (older people are often methods to maximise the
excluded in research and assessments) participation of older people102
102
HelpAge International, 2002. Participatory research with older people: a sourcebook.

TECHNICAL NOTES
33
Figure 4: Risk factors for nutritional vulnerability in older people
Source: Ismail S and Manandhar M, 1999. Better nutrition for older people: assessment and action. Joint publication of HelpAge International and the London School
of Hygiene and Tropical Medicine.
Functional ability
• needs help with feeding
• poor strength
• poor manual dexterity
• poor coordination
Family life
• living alone
• no regular caregiver
• looking after grandchildren
• adult children far away
Disability
• physical disability
• recent injury
• poor eyesight
• poor mobility
• housebound
• lack of exposure
to sunlight
Poverty
• poverty/low income
• low budget for food
• no control over
household money
• not enough land
to grow food
• debt
• unemployment/
unable to work
Psychological/emotional
• death of loved one
• witnessed traumatic
events
• depression
• in unknown/
new community
• mental illness
• memory loss/confusion
• loneliness
Health
• no health care
• disease
• drug use
• alcoholism
• smoking
Food intake
• unable to acquire/prepare
sufficient food
• poor nutrition knowledge
• lack of fruit and vegetables
• food wastage/rejection
• missed meals, snacks, drinks
• gives food away to other
• given less/worse food than
others
• poor appetite
• prefers other food
• often eat alone
• dental problems or problems
chewing
POOR DIET
POOR NUTRITIONAL
STATUS
• family information;
• level of handicap, such as visual, deformity, pain,
restricted use of body parts such as hands;
• income generating activities and contribution to
household livelihood;
• medical needs and support;
• need for items and equipment, such as to help with
sight and mobility; and
• need for further referral.
The Mini-Nutritional Assessment (MNA)103
is the only nutri-
tional tool that incorporates special consideration of the older
adult (i.e. functionality, mobility, depression and dementia). It
was specifically developed to identify older people at risk of
malnutrition without the need for more invasive tests such as
blood sampling.
103
Guigoz et al, 2002; Abellan Van Kan G and Vellas B, 2011. Is the Mini-Nutritional Assessment an appropriate tool to assess frailty in older adults? Journal of Health,
Nutrition and Ageing: 15 (3); 159.

TECHNICAL NOTES
34
Table 9: Guidelines for recognising basic clinical symptoms associated with severe acute malnutrition in older people
in emergencies
Clinical symptom Observation: through physical examination during patient consultation. A physician or senior
health worker usually carries out a physical examination on patients admitted to a TFP.
Famine oedema • Occurs bilaterally (e.g. in both feet or legs).
accumulation of • On pressing down gently with a thumb for 10 seconds, a pit forms and remains visible for
fluid in tissues a few seconds (‘pitting oedema’).
• On pressing down gently with a thumb for 10 seconds, a pit forms and remains visible for
Oedema following sleep or immobility which disappears after some exercise is usually
a result of poor circulation or heart condition.
Inability to stand/ • Some patients will be too weak to stand/walk, and are usually carried in with stretchers by
immobile family members or out-reach workers.
• This inability to stand may be part of the natural ageing process and general debilitation,
for example where there is kyphosis.
Extreme weakness • Patient does not have the strength to carry out daily tasks and may, in some cases, be too
weak to prepare and eat food by himself.
• Patient will spend long hours sitting or resting.
• Muscle strength is severely depleted and muscle tissue is wasted.
Dehydration • Patient has dry mucosal membranes and dry mouth.
(see p.35 for the • When the skin is gently lifted away from the bone, skin remains upright for a few seconds.
importance of fluids
for older people)
Anorexia • Patient is vomiting and unable to keep food in their stomach.
• Often the patient will refuse to take food.
• Psychological aspect of anorexia, depression.
Source: Borrell A, 2001. Addressing the nutritional needs of older people in emergency situations in Africa: ideas for action. HelpAge International Africa Regional
Development Centre. April.
The MNA consists of a simple, non-invasive, clinician-com-
pleted assessment and screening instrument (Annex 5). This
comprises 18 easily measureable items, classified into four
categories:
1. Anthropometric measurements (four questions on
weight, height and weight loss)
2. Dietary questionnaire (six questions related to number of
meals, food and fluid intake, autonomy of feeding)
3. Global assessment (six questions related to lifestyle,
medication and mobility)
4. Subjective assessment (two questions on self-perception
of health and nutrition)
All answers and measurements are attributed a score, and a
total score summed from all elements is calculated.
A short form (MNA-SF) has also been elaborated to screen
older adults for malnutrition.The MNA-SF takes three minutes
toadministerandincludesmeasurementofheightandweight
for the calculation of BMI.104
Calf circumference has recently
been added, for use when BMI calculation is not possible.
Subjective Global Assessment (SGA)105
is a method com-
monly used for assessing nutritional status in various clinical
situations, particularly in surgical patients and cancer care. First
described in 1982 as a screening tool, it better identifies
established malnutrition than nutritional risk but its sensitivity
is subopti-mal.106
It is not routinely used in emergencies.
Assessing nutritional status
Compared to guidance and methodologies for assessing the
nutritional status of children (see HTP Module 6), there is only
104
Rubenstein et al, 2001.
105
Barbosa-Silva M, Ga C, Barros A, 2006. Indications and limitations of the use of subjective global assessment in clinical practice: an update. Current Opinion in
Clinical Nutrition & Metabolic Care.
106
Makhija S and Baker J, 2008. The Subjective Global Assessment: a review of its use in clinical practice. Nutrition in Clinical Practice.

TECHNICAL NOTES
35
limited literature on assessing the nutritional status of older
people, and on diagnosing and treating malnourished
individuals in the age group above 50 years old.
In line with the HTP Module 6: Measuring Malnutrition, which
states that nutritional status cannot be observed directly in
emergency field conditions, four observable proxy methods
are used to assess an individual’s nutritional status, some
of which are appropriate and feasible for use in emergencies.
These four methods are:
• Dietary intake;
• Biochemical assessment (generally not practical in
emergency situations);
• Clinical assessment, including signs of micronutrient
deficiencies; and
• Anthropometry.
Dietary intake
There are numerous methods for assessing dietary intake,
including diet histories, diet recalls and food-frequency ques-
tionnaires. These rely on locally-appropriate, accurate and
validated food composition tables. Their accuracy is poor in
most community-living populations. The situation is even
moredifficultinanemergencysettingwheretheGeneralFood
Ration (GFR) and feeding programmes are controlled, but
gathering of wild foods, exchange of food for cash or other
goods, and the unknown factor of intra-household food
distribution may complicate the picture.
Clinical assessment
A number of clinical observations can be made to assess older
people in an emergency, as outlined in Table 9. More detail is
also given in HTP Module 3.
All the symptoms of kwashiorkor and marasmus usually
observed in children can also be seen in adults, although they
are less common. These include the presence of: anorexia,
weakness, enlarged (fatty) liver, full moon face (signs of
excessive cortisol); skin lesions and ulcerations; pale sparse hair
andhairloss;discolorationofskinandhair;thinness;associated
infections and other signs of immune depression; amenorrhea
in women and loss of libido.
The current recommended assessment methodologies and
appropriate population groups for the assessment of susp-
ected micronutrient problems in emergencies are presented
in a 2007 SCN publication107
(see HTP Module 4: Micronutrient
Malnutrition).While there is no specific mention of older adults
or older people in the SCN document, this group is captured
in the ùwhole populationû assessment for the indicators of:
• Beriberi108
(through observation of clinical signs, thiamine
levels in the blood and urine, dietary intake);
• Pellagra109
(through observation of clinical signs of
dermatitis, niacin levels in urine, dietary intake of niacin
equivalents); and
• Scurvy110
(by observation of clinical signs, levels of serum
ascorbic acid).
Several other micronutrients that are regarded as particularly
important for older people, particularlyVitamin D andVitamin
B12 need more consideration in the future. Iron deficiency111
is also an important omission, given the increasing evidence
for anaemia among many older women and its potential rela-
tionship with functional outcomes such as handgrip strength.
Anthropometric assessment of nutritional status
In emergency situations, MUAC and BMI are the two anthro-
pometric indicators most commonly used to assess under-
nutrition in older people.112
However, there are no inter-
nationally agreedindicators and related cut-off points to
assess nutritional status in older people, including in
emergency situations.
This section discusses some of the practical issues that need
consideration when making anthropometric measurements
of older people. Illustrations for taking MUAC, weight and
height measurements can be found in HTP Module 6.
Using Mid-Upper Arm Circumference (MUAC)
Mid-upper arm circumference is the circumference of the left
upper arm, measured at the mid-point between the tip of the
shoulder and the tip of the elbow (olecranon process and the
acromium). The use of MUAC for nutritional assessment of
olderpeoplehasmanyadvantages,asitdoesforuseinchildren
(see HTP Module 6).
107
A.Seal, C.Pruhdon,2007.Assessing micronutrient deficiencies in emergencies. Current practice and future directions. NCIS, UNS/SCN.
108
WHO/UNHCR, 1999. Thiamine Deficiency and its prevention and control in major emergencies. Geneva WHO/NHD/99.13.
109
WHO/UNHCR, 2000. Pellagra and its prevention and control in major emergencies. WHO/NHD/00.10 and WHO, 2000. Management of nutrition in major
emergencies (Provisional criteria).
110
WHO/UNHCR, 1999. Scurvy and its prevention and control in major emergencies. WHO/NHD/99.11 (Provisional criteria).
111
WHO, 2000. The management of nutrition in major emergencies.
112
WHO, 1995. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. Technical Report Series No. 854. Available at:
http://whqlibdoc.who.int/trs/WHO_TRS_854_(chp3).pdf

TECHNICAL NOTES
36
Author/ Age Indicator of undernutrition Rationale
source (years) using MUAC in ms based on Comment
Ferro-Luzzi 18-60 SAM MAM Men Women Extrapolated from Criteria“probably
and James, Under <169 <159 more normally inappropriate for
1996113
Normal 170-199 160-189 nourished screening acutely
200-229 190 - 219 populations in undernourished adults”
≥230 ≥ 220 low to middle (Collins, Duffield and
income countries Myatt, 2000).
Ismail and 50-96 Undernutrition <231 MAM 221-230 Cut-offs were Data from multi-site
Manandhar, (in Africans) SAM <221 (in Africans) linked to <16 cross-sectional research
1999114
BMI115
distribution among poor older
HelpAge produced a Shakir strip with as well as actual people in Asia (urban
colour band cut-offs: functional ability slum India) and Africa
Red 0-220 Yellow 220-230 performance test (Rwandan refugee camp
Blue 230-240 Green 240-250 values in Tanzania, rural farmers
in Malawi). Not acute
emergency situations.
Collins, 20-60 Severe undernutrition Admit into Applying these Applies to extreme
Duffield and adult TFC if: MUAC <160 irrespective MUAC cut-offs to situations such as
Myatt (UN/ of clinical signs BMI distribution, famine, and scarcity of
SCN), 2000116
* OR: a MUAC of resources. Deals solely
MUAC 161-185 + one of the following: 185mm with adults in
Based on • bilateral pitting oedema (Beattie corresponded emergencies.
Concern’s grade 3 or worse) to BMI 13 kg/m2
,
CHANCES • unable to stand when applied to These are suggested
model • apparent dehydration data from Ferro- starting points and will
Luzzi and James* require consideration of
Also admit if famine oedema (Beattie additional situation-
grade 3 or worse) alone, by clinician It is considered as specific factors.
assessment severe
undernutrition Recommends
Moderate undernutrition Admit into and is associated development of specific
adult SFC if: MUAC 161-185 and no with risk of cut-off points to account
relevant signs or few social criteria mortality for changing
via screening for: redistribution of fat
• access to food (quantity, quality) during ageing.
• distance from centre
• presence/absence of carers Questions whether there
• dependents is also a need for ethnic
• cooking utensils differences to be
• shelter investigated.
113
Ferro-Luzzi A and James W, 1996. Adult malnutrition: simple assessment techniques for use in emergencies. British Journal of Nutrition 75 (1); 3-10.
114
Ismail I and Manandhar M, 1999. Better nutrition for older people: assessment and action. HelpAge International and the London School of Hygiene and Tropical
Medicine.
115
Using armspan, or another proxy, for height when an accurate height measurement is not possible.
116
Collins S, Duffield A and Myatt M, 2000. Adults: assessment of nutritional status in emergency-affected populations. ACN/SCN.
Table 10: Summary of MUAC classifications used to assess undernutrition in older people
* based on James, Mascie-Taylor, Norgan, Bistriaw, Shetty & Ferro-Luzzi, 1994; Collins, 1996.

TECHNICAL NOTES
37
Author/ Age Indicator of undernutrition Rationale
source (years) using MUAC in ms based on Comment
Borrel, >60 Entry into selective feeding Based on data Formed the basis for
2001117
programmes: No admission: >185 from Nilotic UNHCR/WFP 2011
Normal (unless famine oedema present, populations recommendations,
refer to clinician) see Table 11.
SFC: 160-185 MAM
TFC: <160 SAM
Entry into Community Support
Programme
CSP: >185 High nutritional risk Applies to emergency
If one or more social criteria but no situations and famines.
anthropometric or clinical criteria,
enter into CSP with the purpose of Use in Burundi/Congo
preventing further deterioration in failed to confirm its
nutritional status. usefulness as a
diagnostic tool.118
Not
yet validated in other
populations.
Grellety SAM <200 Figures are Personal
(ACF), 2001119
MAM 200-210 between WHO communication based
1995/Ismail and on experience in
Manandhar 1999/ Rwanda, not
Collins et al 2000 research-based.
Navarro- 20-50 <210 thin, select for further evaluation These are not meant as
Colorado, (weight loss, physical strength and admission criteria or
2006120
clinical signs) criteria for malnutrition.
50+ <180 select for evaluation (weight loss,
physical strength and clinical signs)
Table 10: Summary of MUAC classifications used to assess undernutrition in older people (continued)
117
Borrell A, 2001. Addressing the nutritional needs of older people in emergency situations in Africa: ideas for action. HelpAge International Africa Regional
118
119
Grellety, 2001 personal communication, as quoted in: Tilstone V, 2001. Older people, nutrition and emergencies in Ethiopia. The Field Exchange. Issue 14
http://fex.enonline.net/14/older.aspx
120
121
Collins S, Duffield A and Myatt M, 2000. Adults: assessment of nutritional status in emergency-affected populations. ACN/SCN.
Despite its simplicity and practical advantages (less affected
by oedema than BMI and relatively independent of height),
the use of MUAC to assess, and screen, the nutritional status
of adults and older people in emergencies remains contro-
versial.There is disagreement on the cut-off points to be used,
the efficiency of a two-tiered screening process and poor
reproducibilityinthemeasurements.However,itisincreasingly
being recommended for use in emergencies.121
Table 10 summarises the different cut-offs for MUAC recom-
mendedinthenutritionliterature. Thelatestguidelinesfrom
UNHCR/WFP (January 2011), state that, until new evi-
denceisavailable,thecut-offpointsfromtheWHOExpert
Consultation Report (1995) should be applied for adults
(top line in the table).

TECHNICAL NOTES
38
Table 11: Using BMI (kg/m2) to assess undernutrition in people up to 65 years
Age in years Classification and recommended use Reference
≤65 ≥18.5 (<25) Normal James, Ferro-
and >18 Luzzi and
17.0-18.4 Undernutrition Grade I Waterlow, 1988
16.0-16.9 Undernutrition Grade II WHO 1995
≤15.9 Undernutrition Grade III
<13 Severe wasting Ferro-Luzzi and
<10 Extreme wasting (incompatible with life) James, 1996
≥50* ≥18.5 (<25) Normal Ismail and
17.0-18.4 Undernutrition Grade I Manandhar, 1999
16.0-16.9 Undernutrition Grade II
≤15.9 Undernutrition Grade III
Developed BMI charts in colour coded bands for different
populations to avoid need for calculation
20-60** BMI using James, Ferro-Luzzi and Waterlow (1988) classification is appropriate for Collins, Duffield
assessing the prevalence of undernutrition in a population survey. and Myatt 2000
BMI using James, Ferro-Luzzi and Waterlow (1988) classification is NOT appropriate (based on James,
for individual screening in emergencies because it is affected by oedema and Mascie-Taylor,
body shape, and is also difficult to measure. Norgan, Bistriaw,
Shetty and Ferro-
Luzzi, 1994;
Collins, 1996)
18-50 <17: select thin patients for further evaluation (in a developing country Navarro-
emergency) ; see Fig.6 Colorado, 2006
<16: select for further evaluation; see Fig.6
50+ Admission into TFC should also take into account social factors such as lack of
support, physical or mental disability, difficulty or weakness affecting cooking,
psychologically traumatised.
* When height cannot be measured accurately or easily due to kyphosis, a proxy for height such as halfspan should be used; see below.
** The Cormic Index (sitting height/standing height) should be taken into account, and standardised for, when comparing BMI across different populations.
122
James W, Ferro-Luzzi A and Waterlow J, 1988. Definition of chronic energy deficiency in adults. Report of a working party of the International Dietary Energy
Consultative group. European Journal of Clinical Nutrition 42 (12); 969-981.
123
Ferro-Luzzi A, Sette S, Franklin M and James W, 1992. A simplified approach to assessing adult chronic energy deficiency. European Journal of Clinical Nutrition 46:
173-186.
124
WHO,1995. Physical status: the use and interpretation of anthropometry. Technical Report Series 854, Geneva.
Themainproblemwithclassificationsonundernutrition(acute
and stable) based on MUAC is that we have insufficient data
available that links MUAC with predictive risk of mortality, as
well as with other outcomes of functional relevance to older
people (i.e. those that will affect their strength and mobility,
their ability to care for others, maintain livelihoods and avoid
illnesses).
Using Body Mass Index (BMI)
BMI = mass (kg) / (height (m))2
The most widely used methodology for nutritional assessment
of older people is BMI, using weight and height, or proxy mea-
surements of height. Since its first recommendation in 1988,
BMI has been used for population-level assessments of stable
undernutrition.122
The recognised categories of undernutrition
for adults up to 65 years of age using BMI are shown in Table
11.123,124
Note that there are NO recommended categories
for use in people aged over 65.

TECHNICAL NOTES
39
125
Haboudi N, Hudson P and Pathy M, 1990. Measurement of height in the elderly. Journal of the American Geriatrics Association: 38; 1008-10; Kwok T and Whitelaw M,
1991. The use of armspan in nutritional assessment of the elderly. Journal of the American Geriatrics Association: 39 (5); 492-6.
126
Bassey J, 1986. Demi-span as a measure of skeletal size. Annals of Human Biology: vol 13 (5); 499-502.
127
Bassey J, 1986. Demi-span as a measure of skeletal size. Annals of Human Biology: vol 13 (5); 499-502.
128
Lehmann A, Bassey J, Morgan K and Dallossso H, 1991. Normal values for weight, height, skeletal size and body mass indices in 890 men and women aged over 65
years. Clinical Nutrition: 10; 18-22.
129
Chumlea W, Mukherjee D and Roche , 1987. Nutrition assessment of the elderly through anthropometry. Ohio: Fels Research Institute, Ross Laboratories; Kelly P
and Kroemer K, 1990. Anthropometry of the elderly: status and recommendations. Human Factors: 32; 571-595.
130
Navarro-Colorado C, 2006. Adult malnutrition in emergencies: an overview of diagnosis and treatment. Field Guidelines. ACF, version 3 (see page 64).
Table 12: Alternatives measurements for standing height in older adults/older people
Proxy for height Method Interpretation
Armspan125
Measure between tips of middle fingers This measurement is known to approximate
of both hands across the sternum, with attained height at maturity across human groups
both arms outstretched. before age-related changes begin. The usual
approach is to substitute the arm proxy
measurement directly for a measure of standing
height and then calculate BMI.
Halfspan126
Measure from mid-sternal notch to the This is doubled, and then used as armspan.
tip of middle finger of the hand of one
outstretched arm.
Demispan127
Measure from mid-sternal notch to the Derived indices from arm measurements have
finger root of one hand of one also been suggested (for example, Mindex:
outstretched arm. weight/demispan for women; Demiquet:
weight/demispan2 for men128
) although these are
mainly used in hospital settings.
Knee height129
Measure from the bottom of the heel Requires the application of sex- and
pad and the top of the knee when both race- specific regression equations of height
are flexed at 90 degrees, and measured from knee height derived from data on
in a sitting or recumbent position with population surveys (only available for Caucasians
a sliding calliper. and African-Americans in the USA). Suitable
population-specific correction factors to apply to
proxy measures of height are not usually
available in emergencies.
There are difficulties obtaining an accurate measurement of
weight and height in many older people, described below.
Despitethis,BMIisusedasthemainanthropometrictechnique
forthenutritionalassessmentofolderpeopleinmanysettings.
Weight
The use of weight alone should be limited to monitoring the
progress of patients suffering from long-term morbidity (ill-
ness), recovering from disease or surgery, or during nutritional
rehabilitation within a therapeutic feeding centre. Weight
measurements can be difficult to obtain in emergency situa-
tions. Chair or bed-scales are usually unavailable so older peo-
plemustbeabletostandunsupportedinordertobeweighed.
Many severely undernourished adults requiring admission to
therapeutic feeding centres cannot stand, so BMI cannot be
estimated where this is the case. Older people who are unable
to stand should be weighed using a hanging scale of 50kg
(similar to that used for children, but with a larger range) or
MUAC should be used.130
Height
After reaching skeletal maturity, humans tend to shorten with
age. Evidence from longitudinal studies suggests that a male
of 60-64 years could be 5-6cm shorter than he had been in his
mid-20s, and as much as 7-8cm shorter by age 80.With increa-
sing age, related physical activity and postural changes, the
muscles of the back get weaker and the top of the backbone
becomescurved,causingspinalkyphosis,particularlycommon
in older women. The muscles of the legs also become weak,
so that the legs cannot be fully straightened. Standing height
should not be measured if the person’s back is bent (e.g. due
to kyphosis or scoliosis) and she/he cannot stand up straight,

TECHNICAL NOTES
40
Figure 5: Risk factors for nutritional vulnerability in older people
131
WHO 1995 Physical status.
132
Pieterse S, 1998. The nutritional status of older Rwandan refugees. Public Health Nutrition: 1 (3); 1-6.
133
Collins S, Duffield A, and Myatt M, 2000. Adults: assessment of nutritional status in emergency-affected populations. ACC/SCN. July.
134
Ismail S and Manandhar M, 1999. Better nutrition for older people: assessment and action. HelpAge International and the London School of Hygiene and Tropical
Medicine. Drawings by Tricia Kelly.
135
Steele M and Chenier T, 1987. Armspan, height and age in black and white women. Annals of Human Biology: 17 (6); 533-541.
Source: Ismail S and Manandhar M, 1999. Better nutrition for older people: assessment and action. HelpAge International and the London School of Hygiene and
Tropical Medicine. Drawings by Tricia Kelly.
or if the person cannot straighten his/her legs. A measurement
taken on a person with some curvature of the spine will under-
estimaterealstature,andthereforeoverestimateBMI.131
Astudy
among older Rwandan refugees in Tanzania showed that
individuals with kyphosis had a higher prevalence of under-
nutrition (measured with MUAC and BMI using armspan as a
proxy for height – see below) than those without, illustrating
the importance of including this group in nutritional status
assessments.132
Manyotherstudieshavealsoreportedextreme
weakness, flexor contractions and scoliosis.133
There are a number of alternatives to standing height: (see
Table 12), some of which are highly correlated with height at
maturity and change little, if at all with age (although most
evidence for this comes only from Caucasian populations).
Armspan and halfspan
The recommended proxy measurements for height are arm-
span134
or halfspan, see Figure 5.
Halfspan measurement is advised when a person has difficulty
straightening one arm or whose back is badly bent, or if one
arm or hand is missing, injured or badly affected by arthritis. If
it is not possible to take armspan or halfspan properly, then
MUAC should be measured.
There is considerable individual variation in trunk and limb
proportions and the width of the sternal notch, and errors in
measurement. For example, the standard error of the estimate
of standing height from armspan is reported to be between
2.5cm and 3.8cm,135
and any errors are magnified once the
value is squared for calculation of BMI.
BMI: body shape and body composition issues (see also
HTP Module 6)
While BMI continues to be the nutritional status indicator of
choice for adults across the world, its use and interpretation
inemergenciesisincreasinglyquestioned.Thisismainlyrelated
to issues of oedema, the influence of body shape and changes
in body composition with ageing.

TECHNICAL NOTES
41
In order to standardize BMI to take into account changes in SH/S ratio, we recommend using the equations below to
calculate BI standardized to the actual SH/S ratio for the population under study:
Males BMI = 0.78 (SH/S) – 18.43
Females BMI = 1.19 (SH/S) – 40.34
Note: SH/S should be expressed as a percentage
The observed BMIs can then be standardized to a SH/S ratio of 0.52 by adding the differences between the observed
BMI and BMI standardized for the population SH/S ratio to a BMI standardized to 0.52 using the equation below:
BMISstd = BMI0.52 + (BMIob – BMIes),
Where:
BMI = standardized BMI
BMI0.52 = estimated BMI at SH/S of 0.52
BMIob = actual BMI
BMIes = estimated BMI at actual SH/S
Examples:
Male population has a mean BMI of 18.5 kg/m2
and a mean SH/S ratio of 50%.
The BMI0.52 = 0.78*52 – 18.43 = 22.13
The BMIes = 0.78*50 – 18.43 = 20.57
Therefore, the BMIstd = 22.13 + (18.5 – 20.57) = 20.06 kg/m2
Female population has a mean BMI of 17.0 kg/m2
and a mean SH/S ratio of 54%.
The BMI0.52 = 1.19*52 – 40.34 = 23.92
The BMIes = 1.19*54 – 40.34 = 21.54
Therefore, the BMIstd = 21.54 + (17.0 – 23.92) = 14.62 kg/m2
Box 15: Correction of BMI using the Cormic Index (Sitting Height: stature ratio, SH/S)
Source: Collins S, Duffield A, Myatt M, 2000. Adults: assessment of nutritional status in emergency-affected populations. ACC/SCN (page 4).
Oedema
The oedema of malnutrition is an accumulation of fluids in
the interstitial space, producing swelling of the affected area.
Its development is associated with an increase in weight, pro-
ducing an upward bias in BMI. Severe oedema may represent
the accumulation of 10 or more litres of extracellular fluid.136
The frequent co-existence of pitting oedema and ascites
means that oedema fluid can often account for over 10% of
body weight.137
Adult nutritional oedema is common during
famine but the prevalence of diseases that can produce
oedema increases with age, so this needs to be taken into
account when assessing whether a patient has non-nutritional
oedema. Adults presenting with oedema should be referred
to a clinician who is able to make this differentiation. Patients
withseverefamineoedemaandahighBMIoftenhaveapoorer
prognosis than those without oedema but lower BMI.138
Correcting BMI for sitting height (Cormic Index)
BMIisdeterminedbynutritionalstatusbutalsobyotherfactors
of which the most important is the body shape, in particular
the ratio of leg-length to trunk-length, sometimes called the
sitting-height to standing height ratio (SH/S) or the Cormic
Index. It varies widely both between populations and within
populations,139
and can have a considerable influence on BMI,
equivalent, at the extremes of the range, to a variation of over
6kg/m2
. Sitting height can be measured by sitting the person
on a straight-backed chair with a height board strapped to
the back. The measurement is then used to correct BMI by
applying a correction factor (Norgan’s correction) based on a
linear regression model.140
Comparisons of nutritional status using BMI between different
populations can be made by applying a correction factor
136
Navarro-Colorado C, 2006 Adult malnutrition in emergencies: an overview of diagnosis and treatment. Field guidelines. Action Contre la Faim, version 3.
137
138
Collins S, 1995. The limits of human adaptation to starvation. Natural Medicine: 1 (8); 810-814.
139
140
Collins et al, 2000. See Box 1, page 4.

TECHNICAL NOTES
42
• Loss of muscle mass with advancing age (called sarcopenia);
• Increase in body fat, especially internally;
• Redistribution of fat from limbs to trunk;
• Decrease in body water;
• Muscle tissue replaced by intramuscular fat (marbling); and
• Changes in the compressibility and elasticity of skin.
Box 16: Age-related changes in body composition
based upon the mean Cormic Index for each population, see
Box 15. Follow-up surveys for the comparison of within-pop-
ulation data will not require this correction. If BMI is used to
assess an individual’s nutritional status, then the estimation of
the individual’s Cormic Index should also be used as a correc-
tion factor. Without this correction, the sensitivity and speci-
ficity of BMI as a screening indicator may be low.
There is a difference of opinion over whether or not it is appro-
priate or feasible to use sitting height and the Cormic Index
correctionforcalculationofBMIinemergencies.Theargument
against is that, during emergencies, and especially at the peak
of a famine, when there are large numbers of people compe-
ting for relatively scarce resources, there is almost never suffi-
cient time or staff to perform this standardisation, rendering
BMI an inappropriate indicator to use for assessment at either
population, or individual screening, levels in an emergency,
so MUAC is preferred141
(See Table 10 above on MUAC).
However, the 2001 Expert Group meeting on nutrition in older
people in emergencies142
supported the use of sitting-height:
standing-height in emergencies.They argued that, just as there
was initial resistance to the measuring of weight and height
for children and the calculation of Z scores, the resistance to
the complex Cormic Index adjustment of BMI could be
overcome once personnel are fully trained and computerised
techniques become available.
Body composition changes with ageing
Ageing is associated with many changes in body composition,
whichaffectthemeasurementandinterpretationofnutritional
status of older people, as shown in Box 16.
In young adults, BMI, highly correlated with the fat mass of
the body, is a reasonably good index of the body energy stores
as fat and, in some age groups, is highly correlated with fat-
free mass. Low BMI reflects a low body energy store and a low
fat-free mass (FFM) or lean body mass (LBM) for a given stature.
Thus BMI appears to be a plausible choice for the anthro-
pometric assessment of nutritional status in adults for epide-
miologicalstudies.143
However,BMIisalsoinfluencedbydeclin-
ing bone mass and changes in the hydration of the fat-free
body with age.
These changes are still poorly understood but it is acknow-
ledged that they will limit the specificity of BMI with age
among normal individuals compared to those with disease.
Body composition studies have also shown that BMI can
overestimate body fat in older people because of the higher
proportion of internal fat than in younger adults.144
There are
reports of BMI failing to change when weight or FFM fall at
the same time.145
So the use of BMI cut-offs as health indicators
inolderpeoplehasalsobeenquestioned.Acomparativestudy
of low BMI and morbidity among adults in the Philippines146
reported that the threshold at which morbidity begins to rise
is generally not consistent with the accepted cut-off for BMI
at 18.5kg/m2
(see Table 11).
The measurement of BMI is not entirely appropriate on its own
for assessing individual undernourished adults for entry into
feeding programmes: the presence of famine oedema, and
the sitting-height: standing-height ratio for the population in
question, first need to be accounted for.
Figure 6 below is a flow chart for the assessment of, and inter-
ventions for, acute malnutrition and stable malnutrition in
adults without oedema, taken from ACF’sTechnical Guidelines
on Adult Malnutrition.147
Note it is based on BMI cut-offs, and
does not include MUAC.
141
142
SCC/SCN 2001. 31st Session: Report of the Working Group on Nutrition in Emergencies.
143
Shetty P and James W, 1994. Body Mass Index: a measure of chronic energy deficiency in adults. UN FAO, Nutrition Paper 56, Rome.
144
Deurenberg P, van der Kooy K, Hulshof T and Evers P, 1989. Body mass index as a measure of fatness in the elderly. European Journal of Clinical Nutrition 43 (4): 231-6.
145
Chumlea W, Guo S, Vellas B and Guigoz Y, 1997. Assessing body composition and sarcopenia with anthropometry. In: Nutrition personnes agees (Colloque
Internationale) CERIN Symposium, Paris. 6-7 December.
146
Garcia M and Kennedy E, 1994. Nutrition and health of the elderly in five selected baranuays in the Philippines. Nutrition Research 2: 545-60.
147

TECHNICAL NOTES
43
Figure 6: Flow chart for dealing with acute malnutrition and stable malnutrition in adults without oedema
• Do not screen for
malnutrition.
• If sick, refer to medical
structure.
• Keep data in special
register (second visit).
BMI > 17 in adults
BMI >17 in older people
Source: Navarro-Colorado, 2006. Adult malnutrition in emergencies: an overview of diagnosis and treatment. Field guidelines. Action Contre la Faim, version 3 (page 31).
BMI < 17 in adults
BM < 17in older people
Assess for Acute Malnutrition
Weight loss >10 kg in last 3 to 6YES NO
Previous weight not known or
not reliable
Physical strength/weakness
Not
Inability to stand
Severe weakness
Report of recent
loss of strength
Good tonus
Normal strength
No changes
reported
Clinical Evaluation (see text):
• subjective weight change
• important diet changes
• absence of appetite
• mental depression/Patient cannot cooperate
• Important nutrient loss (vomit/diarrdoea/other)
• typical signs of malnutrition (see text)
Majority of YES Majority of NO
ACUTE MALNUTRITION STABLE MALNUTRITION
• Decide on the degree of severity and
the type of treatment necessary
(see following pages):
TFC/Stabilization
OPT (Home treatment)
SEP
• Patient does not need urgent treatment
• Refer to medical structures if other
pathology present
• Keep data in special register (incase
patient returns)
• Refer patient to other programmes, if
necessary (food security, long-term, etc.)

TECHNICAL NOTES
44
The relationship between nutrition and
functional outcomes
The usefulness of any anthropometric indicator for nutritional
status lies in its ability to identify and predict those at risk in
terms of an important functional health outcome, giving it
validity as a screening, assessment and monitoring tool.
Without that prediction ability, the nutrition indicator is just a
number, and any cut-off chosen for it will be a purely arbitrary
choice of no functional relevance.
With infants and young children, the outcome of functional
significance is mortality. However, with older people, the risk
of death becomes increasingly likely with age, and the long-
and short-term causes and effects of disease, diet and lifestyle
are hard to disentangle from the onset of an emergency.Their
nutritional outcomes are complicated by the accumulated
level of their exposure to disease and illness throughout their
life, together with known behavioural indicators that relate to
mortality such as smoking, alcohol and drug use, and physical
activity, as well as initial birth weight.
With older people, there is a complex and confounding
relationship between anthropometric measurements,
nutritional status, body composition and morbidity and
mortality. Adults also tolerate a loss of a higher proportion of
their body mass than do children. So in the absence of growth,
and with mortality and morbidity outcomes overly
confounded by other variables, functional ability is emer-
ging as the most relevant outcome against which to mea-
sure nutritional status in older people, see Box 17.
One of the most important factors limiting independence
in functional ability is muscle weakness. Many of the ADLs
involve mobility and strength, with muscle contractions being
the basis for movement. Ageing is associated with decreases
in muscle mass, muscle strength and muscle power, with mus-
cle strength declining at a higher rate than muscle mass, but
at a lower rate than muscle power. From research in developed
countries,itisthoughtthat,byage70,musclestrengthisabout
35-40% lower than its peak value in youth, although this
decline varies according to activity levels, muscle group and
gender. As limb circumference measurements of MUAC (and
calfcircumference)aresensitiveindicatorsofthelossofmuscle
mass in older people, they are appropriate measurements to
take in nutritional assessment.
A major constraint to our understanding of the relationship
between nutritional status and functional ability as an appro-
priate outcome indicator is that data on both themes for older
people in low to middle income countries are scarce. During
the 1990’s, a research partnership between the London School
of Hygiene andTropical Medicine and HelpAge in various sites
in low to middle income countries explored the relationship
betweenanthropometricmeasurementsandfunctionalability
tests, including handgrip strength among community-living
populations of poor older people (aged 50-96 years). As
expected,MUACwasfoundtobeamorepowerfulpredic-
tor ofimpaired handgrip strength and mobility than BMI.
Other research has also investigated the relationship between
handgrip strength, BMI and arm muscle measurements in
community-living young and older adults in Australia,148
India
(older female labourers)149
and Nigeria.150
However, much has
to be inferred from studies based on adults and older people
living in the developed world.Their relevance in humanitarian
emergency situations is even more problematic.
Functional ability has been defined as“the ability to perform basic activities of daily life (ADLs) without support which
is the key to overall independence and quality of life”. It involves ordinary activities and self-maintenance (transferring
from bed or off the floor, getting dressed, using the toilet, self-bathing and level of continence).
ADL performance has been shown to decline with age, and to be associated with levels of physical disability, mobility,
flexibility, strength and physical activity. If undernutrition compromises functioning to the point that older people cannot
fully care for themselves then the burden on the family and the community as a whole will be substantial. Moreover,
if nutritional status proves to be a correctable source of maintaining and postponing, for as long as possible, functional
ability decline amongst older people, then early nutrition interventions may have considerable beneficial impact for
all concerned.
Box 17: What is functional ability?
Source: Manandhar, MC. (1995). Functional ability and nutritional status of free_living elderly people. Proceedings of the Nutrition Society, 54, 677_691.
148
Massy-Westropp N, Gill T, Taylor A, Bohannon R and Hill C, 2011. Hand Grip Strength: age and gender stratified normative data in a population-based study.
BMC Research Notes 4:127. http://www.biomedcentral.com/1756-0500/4/127
149
Koley S and Kaur N, 2009. A study on handgrip strength and some anthropometric variables in younger and older female labourers of Jalandhar, Punjab, India.
The Internet Journal of Biological Anthropology: 3 (2).
150
Adedoyin R, Ogundapo F, Mbada C et al, 2009. Reference values for handgrip strength among healthy adults in Nigeria. Hong Kong Physiotherapy Journal: 27 (1);
21-29.

TECHNICAL NOTES
45
Agencies have faced many challenges when including older people in targeted SFPs. HelpAge Ethiopia found that BMI
measurements were problematic as different ethnic groups had different sitting:standing height ratios, while MUAC
cut-offs recommended at the time were found to be very low and had to be adjusted.
Oxfam working in Bolosso Sore, Ethiopia, in 2000 enrolled over 200 older people (over 50 years old) in their SFP. The
criteria used for selection was MUAC <18.5cm and >16.0cm. Almost all (98%) of those admitted were female – mostly
widows without access to land. Many had lost their community support networks and had no relatives nearby to support
them. Their nutritional problems were compounded by poor use of food and chronic illness.
Forms of welfare in Ethiopia at the time, such as the employment generation scheme, were not available to them as
many were displaced. In this case, anthropometric indices as well as vulnerability criteria could have been appropriate
to define the target group.
Box 18: Anthropometric and vulnerability criteria used in Ethiopia, 2000
Source: Borrel A (2001). Addressing the needs of older people in emergency situations. Ideas for Action. Field Exchange 12 p.3.
Box 19: Recommendations to agencies for assisting older people in emergencies
What to use in emergencies?
Table8 atthebeginningofthissectionsummarised thebroad
variety of methods available to assess nutritional status and
vulnerabilityamongolderpeople.Guidelinesontheseforolder
people in emergency situations are still scarce, and those few
that do exist151,152
have not been fully evaluated. It is also
unclear to what extent those that refer specifically to older
people153,154
are known and have been applied.
Whilst there are statements above regarding MUAC as a
preferred method to ascertain older nutritional status in
an emergency,itisimportant to point out that thatin the
section of this module related to existing challenges, fur-
therresearchonMUACnormativeguidanceincludingthe
relationshipbetweenMUACcut-offpointsandfunctional
outcomes, is recommended.
Box 18 presents an example of some of the assessment and
contextual issues covered in this section.
Interventions and responses to address
undernutritionin older people
The previous section has discussed assessment methods and
the value of these indicators in their relationship with out-
comes of functional importance for older people.This section
presents the interventions appropriate for humanitarian
responses to undernutrition in older people. It is based largely
on the guidelines produced by HelpAge and by ACF, and also
incorporates material on non-food interventions.
Abroadrangeofinterventionresponseswillbenecessary
to tackle all the different determinants of undernutrition
and vulnerability in this population group: see Table 13.
151
152
153
Borrell A, 2001. Addressing the nutritional needs of older people in emergency situations in Africa: ideas for action. HelpAge International Africa Regional
154
Ismail S and Manandhar M, 1999. Better nutrition for older people: assessment and action. Joint publication of HelpAge International and the London School of
Hygiene and Tropical Medicine.
• Make older people visible in research, planning and implementation of humanitarian and emergency relief
responses, ensuring that they are given equal recognition as a vulnerable group, and that their specific needs
are met.
• Ensure that data collection in times of humanitarian crisis assesses the needs of all vulnerable groups, is
disaggregated by age and sex, and includes older age groups.
• Ensure that programme staff are familiar with the UN IASC Guidelines: Humanitarian Action and Older Persons:
an essential brief for humanitarian actors (2008).
• Make preparations for the growth in the number of older people living in countries that are vulnerable to
Source: HelpAge and Age UK (2011): On the edge. Why older people’s needs are not being met in humanitarian emergencies.

TECHNICAL NOTES
46
Table 13: Key cluster issues for interventions for older people in humanitarian response
Cluster Key humanitarian requirements
Food Security and • Older persons have access to food distribution points and are able to carry rations for
Nutrition long distances.
• Older persons’access to appropriate nutritious foods is guaranteed.
• Older persons’inclusion in nutritional assessments and monitoring is guaranteed.
• Older people are screened and have access to treatment of moderate and severe
acute malnutrition.
• Older people have access to micronutrient malnutrition control and treatment interventions.
• Older women’s role in IYCF practices is emphasized.
Health • Older persons have access to all health services and disability aids they need.
• Medications for chronic diseases are included in emergency health kits.
• Staff attitudes, skills, training on older persons’health issues are ascertained.
• Data disaggregated by age and sex are collected to determine the number and specific
needs of older persons.
Water, Sanitation • Appropriate water carrying containers are provided to older persons (max 10l).
and Hygiene • Latrines designed in such a way that older persons can use them e.g. handrails.
• Older women’s role in hygiene promotion is emphasized.
• Distribution of hygiene kits?
Shelter • Assistance with early warning and evacuation to safe places is provided.
• Particular attention for the ill and disabled is ensured, e.g. provision of mattresses,
warm blankets and clothing.
• Assistance is provided to older persons to construct shelter if they are without family support.
• Consultation of older persons on cultural practices and privacy is guaranteed.
Camp coordination • Identification of housebound, vulnerable older persons is guaranteed as is assistance with
and management replacing or accessing relevant documentation.
• Inclusion of age/sex disaggregated data in camp population figures is ensured.
Early Recovery • Livelihood programmes target older persons, particularly those who are alone or caring
for children.
• Return programmes take into account the needs of older persons.
Protection • All data are disaggregated by sex and age to determine the numbers and kind of
protection needed.
• Older persons’involvement in decision-making, and in humanitarian prevention and
response activities is facilitated.
• The protection of older persons left without caretakers is ensured.
• Older displaced persons are included in tracing and re-unification activities
• Protection strategies include:
° older persons caring for young children/persons with disabilities;
° addressing abuse of older persons and older women as victims of gender-based violence
and sexual abuse; and
° land/property rights for women, in particular for widows.
Source: IASC, 2008. Humanitarian action and older persons: an essential brief for humanitarian actors.

TECHNICAL NOTES
47
155
Toole MJ and Waldman RJ, 1997. The public health aspects of complex emergencies and refugee situations. Anne Rev Public Health: 18; 283-312.
Table 14: Summary of non-food and food interventions for older people in emergencies
Rationale for intervention Type Activity
Prevent undernutrition, Food • General Food Distribution (GFD) and food ration
and/or • Blanket Supplementary Feeding
Prevent deterioration of • Micronutrient interventions (e.g. fortification)
stable malnutrition
Non-food • Income/livelihood supports, e.g. cash transfers
• Social supports to reduce vulnerability and risk
• Health support e.g. clean water and sanitation
• Shelter and equipment
• Community Support Programme (CSP)
Treat moderate and severe Food • Targeted Supplementary Feeding
acute malnutrition • Community Management of Acute Malnutrition (CMAM) with food
(MUAC screening inclusion/ aid commodities (RUTF, RUSF, F75, F-100, fortified biscuits),
discharge criteria -see Table 16) stabilisation centre, outpatient therapeutic care, community
involvement and home visiting.
• Treatment of micronutrient deficiency diseases (using oral
supplement tablet or capsule, new micronutrient powders
approach)
Non-food • Medical check-ups and inpatient care
• Community Support Programme (CSP)
Source: based on HTP Module 1, pages 34-38; UNHCR 2011; and Borell A, 2001. Addressing the nutritional needs of older people in emergency situations in Africa:
ideas for action. HelpAge International Africa Regional Development Centre. Nairobi.
Interventions for infants, young children and mothers in
complex emergencies and refugee situations155
are well
documented(refertoHTPmodules).Howevertherearealmost
no documented experiences of planning, applying and
evaluating nutrition interventions for older people. As stated
in the 4th Report on the World Nutrition Situation, we have
little idea of what works, nor do we even know if their nutri-
tional status can be improved, or if such improvement would
lead to better functional ability. Operational research in these
areas is needed to fulfil the right of older adults to adequate
nutrition.
Box 19 summarises key recommendations made by HelpAge
to agencies to underpin the process of planning and
implementing interventions for older people in emergencies.
They lay important foundations for the implementation of all
non-food and food-based interventions.
Because the causes of undernutrition in older people and the
determinants of their nutritional vulnerability are complex, a
simple ‘one-size-fits all’ approach to interventions will not
suffice. Table 13 below lists some of the key issues faced by
the various clusters for interventions for older people in
emergencies.
Studies by HelpAge have shown that shelter, food, health
and livelihoods are the most critical needs for older peo-
plein an emergency. So any intervention for this population
group should be implemented in coordination with other
clusters such as the Health, Water, Sanitation and Hygiene
(WASH) and Food Security Clusters. NGO partners and local
government networks will need to link older people to a range
of services and supports. Promoting partnerships and sharing
resources and expertise among agencies will also allow gaps
to be identified and a greater number of older people to be
assisted.
Multiple vulnerabilities may need to be considered. For exam-
ple, many older people care for children or people with dis-
abilities. A large proportion of older people are women, who
are heads of households. Older people may have disabilities.
Older people also have particular nutritional, physiological,
social, cultural and health needs that will often not be met by
food, and a general food distribution alone.
Table 14 below summarises the variety of food and non-food
interventions needed to prevent and treat undernutrition in
older people in emergencies. Interventions to support caring
and social networks for socially vulnerable groups of older

TECHNICAL NOTES
48
people will be as important as interventions to prevent and
alleviate malnutrition.
Some practical considerations are relevant for interventions
including older people:156
• Physiotherapy and adequate resting facilities: Many
older people will be bed-ridden or have limited mobility.
These patients will benefit from physiotherapy and
should be encouraged to take some physical activity if
possible. Efforts should be made to provide appropriate
bed facilities that offer adequate comfort for the patient.
Adequate space and privacy should be provided, with
separate wards for women and men.
• Older people who are too weak to be weighed: For
purposes of monitoring, weight need only be taken
once they are strong enough to stand. For purposes of
estimating food requirements, an estimate of their body
weight can be used.
• Taking care of dependants in absence of other
family support: Some older people may have
responsibility for young children (e.g. if parents have
died or fled). If other family members or older siblings
are absent, young children will need to be taken care of,
especially if the older carer has to be admitted in a
stabilisation centre.
• Decision-making and management of patients with
chronic illness: It may be clear on admission if an older
person is suffering from a chronic illness. However,
sometimes this may only become evident after several
weeks when the person fails to show signs of recovery,
including weight gain. Where health services exist for
diagnosis and treatment of chronic illness (e.g. TB,
HIV/AIDS) patients should be referred to these facilities.
However, in emergencies, these services are not always
available. In this situation, providing support and care in
the community is more appropriate when applicable.
Following an individual case-assessment and
consultation with family and/or carer, the patient should
be referred into a Community Support Programme.
• Dying at home: Family members should be encouraged
to be present at the time of death, for those individuals
where death is likely to occur in the stabilisation centre.
Older people may prefer to die in their own home rather
than in the centre and in most cases, their wishes should
be respected. Where family members are not present,
efforts should be made to facilitate their return home
from the TFP. Community members should be informed
of this decision.
• Being active aids digestive functions, and this is
particularly relevant for older people in emergencies
who are suddenly no longer engaged in their normal
routines and physical activities. As part of the general
approach to the care and well-being of older people in
emergencies, it is important to keep older people active,
as much as it is possible. For example, during the floods
of 2010, HelpAge International’s Pakistan Programme
introduced daily walks and collective exercises into Older
People’s meetings to increase digestion, mobility, social
interaction and improve general health.157
Non-food interventions
Non-food interventions for older people during emergencies
include income generating and livelihood activities, cash
transfers, psychosocial support, social activities, and health
promotion and education. The value of these non-food inter-
ventions to older people should not be underestimated, and
equal attention should be given.
Income and livelihoods
A household’s livelihood is secure when it can cope with and
recover from shocks, and maintain or enhance its capabilities
and productive assets.158
As outlined at the beginning of this
module, many older people continue to work into advanced
age and contribute actively to the household income, so they
should not be left out of livelihood interventions to reduce
food insecurity during emergencies.
Once families become destitute, livelihoods are lost, decision-
making processes in the family and intra-household patterns
of food allocation are altered. When communities experience
periods of extreme difficulty, older people may lose their social
status, which previously ensured a certain degree of individual
food security. Keeping older people actively involved in in-
come generation will have multiple advantages.
Conditional and unconditional cash transfers are becoming
an increasing component in humanitarian relief situations.
However, their use among older people is often restricted to
specialistagencieslikeHelpAge.Theyarearegularcomponent
of HelpAge’s programmes on the grounds that the chronically
vulnerable(sick,olderpeople,disabled)usuallyneedaseparate
safety net of direct food or cash distribution.159
Box 20 below gives an example from Pakistan during which
OlderPeopleAssociations(OPAs)wereestablished.Theyaimed
to assist in integrating older people, enhancing networking,
as well as promoting experience sharing and learning. OPAs
156
157
HelpAge Pakistan Policy Programme Policy Brief. Lessons learned Response to 2010 Floods.
158
SPHERE, p 145.
159
Beales C, 2011. Ageways: February; p.5.

TECHNICAL NOTES
49
HelpAge International’s Pakistan programme set up a Community Revolving Fund (CRF) in an effort to provide access to
credit for older people. Financial institutions were reluctant to provide credit facilities for people over 50 years old, even
those that were physically active, leaving them with little opportunities for accessing loans. CRF had a zero interest rate
credit facility at the doorstep, increasing older people’s options in taking initiatives that required capital.
With low levels of management skills for operating a micro-credit scheme, older people needed technical assistance on
how to manage this money, and to ensure that the money was not diverted or used by people other than the intended
beneficiaries.
Older people were made the custodians of this credit facility, and ownership of the process was high. HelpAge extended
unconditional grants to the selected flood affected older people to help re-establish their basic life and fulfil their needs.
This was coupled with the conditional grants, which helped the older people in establishing businesses or fulfilling
otheragreedneeds.Thesegrantsincluded:NotedMedicationAssistanceGrant,FoodPurchaseGrant,ShelterConstruction
Grant, Livelihood Assistance Grant (for purchase of goats, sheep, chicken flock).
Box 20: Use of cash grants for older people during the Pakistan floods, 2010
Source: HelpAge International Pakistan. HelpAge Policy Brief: Lessons learned, response to Pakistan floods. HelpAge Pakistan Programme (2010).
advocated on behalf of older people and did training in
financial management, project management and report
writing.
In the planning of a livelihood intervention, it is important to
consult older people to provide appropriate space for
livelihood activities close to their shelters. Because of mobility
problems, many older people prefer to set up small stores in
front of their homes.
Shelter (including food distribution and health centres)
Shelter, including facilities to collect, prepare and cook food,
are a vital component for meeting the physical, nutritional and
emotional needs of older people in an emergency. Older peo-
ple are physiologically more vulnerable to extreme tempera-
tures of heat and cold. The loss of their homes with the onset
of a crisis can have profound emotional effects.
A number of practical aspects of shelter should be considered
during interventions targeting older people, including:
• Ramps: when building shelters and stores for livelihood
activities and holding community meetings, ramps make
access easier for older and disabled people (and
pregnant women with children). Ramps with non-slip
grips and no gaps will reduce the chance of crutches or
walking sticks becoming stuck;
• Lay-out and design: involve older people to make sure
they are age-friendly and culturally acceptable;
• Lights: ensure that light switches and electrical sockets
are at a height that everyone can reach (between 45cm
and 120cm from the floor);
• Toilets and kitchens: should be located where older
people can access them easily. Entrance to toilets and
kitchens should be kept clear. There should be adequate
lighting for people to access at night;
• Location and allocation: decisions on the location and
allocation of distribution points, supply depots, feeding
centres, shelters should take into account levels of
mobility and vulnerability. Older people prefer to live
near facilities such as water sources, markets and health
centres. With temporary and transitional shelters, older
people should be allocated shelters that are close to
toilets, health centres, feeding centres, cyclone shelters
or other community centres and distribution points;
• Safety and fall prevention: non-slip floors, handrails
on ramps and stairs, and grab bars in toilets can improve
safety and prevent falls. Indicate changes in elevation,
such as steps or slopes, by signs or colours;
• Seasonal weather: ensure that priority items such as
winterisation kits containing blankets are distributed
in good time. Weather-proofing or making shelters safe
from flooding is also crucial to ensuring people’s
safety; and
• Adaptation and flexibility: providing gutters to harvest
rain water from the roof, plus chlorination tablets, gives
people access to water for drinking, cooking and
washing without having to carry it far; provide adequate
lighting, including natural light, into shelters helps to
compensate for older people with poor eyesight and
makes shelters more comfortable, cooking and other
tasks easier.
Psychosocial support interventions
Appropriate psychological care should be provided for older
people with symptoms of mental illness, such as depression
or post-traumatic stress. Psychosocial assessment and treat-
ment of older people, particularly those who are caring for
young children and pregnant and lactating women, are fre-
quently needed. They can positively impact on nutritional in-
take, food behaviours, appetite and ultimately nutritional sta-
tus; see examples in Box 21 and Box 22.

TECHNICAL NOTES
50
In Haiti, HelpAge International established Older People Associations (OPAs) in displaced camps and communes
immediately after the earthquake. These OPAs aimed to involve older people in community activities such as home
visiting, disaster risk reduction, livelihood and income generating activities, and social inclusion. They also aimed to
strengthen representation of older people in the community and defend their rights. HelpAge provided each OPA with
a small functioning budget (to be maintained through income generating activities) and with media equipment (TV,
DVD, CD players) for each community centre.
Anecdotal evidence reveals the following initiatives and actions resulting from these OPAs:
• Croix des Bouquets: successful advocacy for the integration of older people in a cash for work activity.
• Croix des Bouquets: dismissal of a camp committee that was not working for the well-being of camp residents.
• Jacmel: created a cash box for members’contributions from which they were able to support members with their
problems (e.g. covered funeral fees for one member).
• Petion-Ville: started a literacy programme and, in RSS camp, replicated a training programme on hygiene promotion
to prevent cholera. Evidence of a more vocal demanding of rights.
• Petit-Goâve: OPA set up at the communal section level.
• In two camps (Marassa 14, Theatre National), OPA members joined the camp committee.
• Two health centres (Eliazar Germain in Petion-Ville, Memphis Medical Mission in Croix des Bouquets) opened up
special lines for older people as a new good practice.
• Increased socialisation of older people, through games sessions and media club.
Box 21: Social and economic support to older people through OPA’s, Haiti (See also Part 3: Trainer’s Guide, Case study 6)
Source: HelpAge International, 2012.
Box 22: Example of a psychosocial-income generation intervention for displaced older people in Congo
The IDP camp of Mugunga III in eastern DRC, is home to around two thousand people originally from North Kivu who
have been displaced due to the on-going violence and conflict in the region. The residents of Mugunga III have been
victims of human rights violations such as physical and sexual violence, and as a consequence have suffered severe
physical and psychological illnesses, and mental trauma.
HelpAge has been reaching out to this affected displaced population through a programme of social integration and
income generation using rabbits. One hundred people psychologically traumatised by the on-going conflict are
participating in the project, including 35 older people. The project is a rabbit-rearing programme run by a local psy-
chologist. It is quite different from other forms of income generation.The aim of the project is to provide income and to
support older people, severely affected by different forms of mental and physical trauma, using animal assisted therapy.
Caring for the animal breaks down their barriers to society and gives them an activity, allowing them to take steps
towards improving their mental health. In addition to psychosocial support, the project has also given older people the
opportunity to gain a source of income.
Source: HelpAge, February 2012.
Appropriate activities include:
• Supporting groups for older people; and
• Ensuring neutral community spaces where elders can
meet for conflict resolution or social and cultural
activities.
Information and communication on all aspects of the human-
itarian intervention response needs to be inclusive of, and
appropriate for, older people (see HTP Module 19: Working
with communities).
A caring approach is particularly important when assessing
and responding to undernutrition in older people in emergen-
cies.Thefollowingprinciplesshouldbereflectedinallactivities
of the programme and be addressed in staff training pro-
grammes:
• Communication: older people should be consulted and
their needs and/or fears respected. They need to know
that they have choices and that their opinions count.
Taking time to explain procedures and give feedback on
their progress is important. Older people are open to
learning new behaviours.

TECHNICAL NOTES
51
All adults and older persons received systematic treatment, which included Vitamin A (in post-menopausal women),
folic acid, amoxicillin, mebendazole, ferrous sulphate and chloroquine.
They were seen daily by a medical assistant in Phase 1 to assess and follow up on their underlying medical problems. In
Phases 2 and 3, older adults were attended to once every two days. For those whose condition was deteriorating,
reviews were increased to once a day until their condition improved. Specific treatment was given according to diagnosis.
During the treatment, health education relating to the prevention and management of malnutrition was imparted to
the beneficiaries on a daily basis.
Box 23: Medical and micronutrient treatment used in therapeutic supplementary feeding for people in Juba, Sudan: 2000
Source: Action Contre La Faim (ACF) and HelpAge in Juba, 2004. Case study of supplementary selective feeding programmes by ACF and HelpAge in Juba. In: HelpAge
International Africa Regional Development Centre. Summary of research findings on the nutritional status and risk factors for vulnerability of older people in Africa.
pp 58-61. April: Nairobi.
• Involving the carer or family: the family or carer should
be actively involved in the nutritional recovery process.
They should always be consulted, encouraged to take
responsibility and to participate in daily activities in a
feeding centre. Regular feedback to the family and carer
is essential.
• Emotional support: older people have often suffered
trauma and part of the recovery process is achieved
through providing emotional support. Simply listening
and acknowledging their individual needs should always
be a priority.
• Privacy: consideration should be given to the privacy
needs of older people, particularly when washing and
nursing care is required.
• Physical assistance: older people, especially the ill or
very weak, will require assistance to carry out the most
basic daily activities. Older people may require assistance
with activities such as eating, drinking, sanitation and
hygiene. However, older people may be reluctant to
request assistance, so carers and health/community
workers should be sensitive to their needs. Older persons
should also be encouraged and given support to
maintain some physical mobility while in the feeding
centre. Those who are bed-ridden will need assistance
to turn over or be moved regularly to prevent bedsores.
• Burial arrangements: death due to old age or failure to
recover may be relatively common. If older people have
no family support, it may be necessary to support burial
arrangements for the deceased.
Health interventions
Medical complications are common in older people. In parti-
cular, dehydration and chronic illnesses will hinder the nutri-
tional rehabilitation process if they are not addressed. Access
and referral to medical facilities for diagnosis and treatment is
essential. Descriptions of medical protocols in therapeutic
feeding programmes can be found in other references, includ-
ing the “Management of Severe Malnutrition: a manual for
physiciansandseniorhealthworkers”(WHO1999).Insummary,
following a thorough medical and nutritional history, the
following clinical outcomes should be systematically
addressed: dehydration; hypoglycaemia; hypothermia; infec-
tions; iron deficiency and anaemia; Vitamin A and B defi-
ciencies; intestinal parasites.
More information can be found in HTP Module 15. An example
of a combination of medical and micronutrient treatment for
older people is given in Box 23.
Older people living with HIV and AIDS160
Dietary interventions as part of care and support for older
people living with HIV and AIDS (PLHIV) will need specialist
advice. A therapeutic high-energy diet may be appropriate
forolderPLHIV,whetherornottheyareonART.Hypoglycaemia
is common in older people with or without HIV. It is important
to establish whether the condition is present in PLHIV because
of the following nutritional considerations:
• Quantity and timing of food and drinks containing
carbohydrates;
• Timing of meals in relation to medication; and
• Effects of alcohol on hypoglycaemia.
Older people are at greater risk of dehydration. PLHIV with
diabetes may be at high risk of dehydration. These people
should be monitored and provided with fluids and treatment
modified to limit symptoms of hypoglycaemia.
Interventions to improve food security for older
people in emergencies
This section summarises the issues related to food security for
older people according to four components: availability,
access, consumption and utilisation (The Sphere Project 2011,
page 145).
160
Ministry of Health, Zambia, 2011. Nutrition guidelines for care and support of people living with HIV and AIDS. February.

TECHNICAL NOTES
52
161
HelpAge Pakistan Programme, Policy Brief: Lessons learned Response to 2010 Floods.
Availability:
This refers to the quantity, quality and seasonality of the food
supply in disaster-affected areas. It includes local sources of
product(agriculture,livestock,fisheries,andwildfoods)andfoods
imported by traders, government and agencies interventions
can affect availability). Local markets are able to deliver food.
Interventions for older people should ensure:
• Ensuring non-discrimination by age (and with other
co-grounds such as gender) and impartiality in fulfilling
older people’s right to receive humanitarian assistance.
• Involvement of older people in assessing the food
supply context and drawing on their knowledge and
expertise of climatic conditions, markets, agriculture,
seasonality, livestock, fishing and wild foods.
Access
This refers to the capacity of a household to safely procure
sufficient food to satisfy the nutritional needs of ALL its members.
It measures the household’s ability to acquire available food
through a combination of home production and stocks, pur-
chases, barter, gifts, borrowing or food, cash and/or voucher
transfers.
• Inclusion of older people as a target group for
non-food and food interventions, including participation
in vulnerability mapping, assessments, planning and
monitoring.
• The design of food distributions in emergencies often
results in poor access to food rations by older people.
Design factors can increase the risk of the elderly
suffering from inadequate food intakes: an inadequate
needs assessment and poor physical access to the ration.
For example, during the Pakistan flood emergency in
2010, HelpAge recommended age to be considered
when designing food packages, so that they could be
easily divided according to the age group of the
beneficiaries.161
• Addressing distances to collection points: in
centralised food distributions, the distances are often too
long for many sick and frail older people. For example,
during the repatriation in Rwanda (1996), monthly
rations for returnees were provided but in many cases,
older people were unable to carry the sacks of grain and
other non-food items; forcing their sale at nearby
markets. Decentralisation of distribution sites and more
frequent distributions to reduce weight are
recommended.
• Improving queuing systems at distributions sites.
These seldom prioritise older people, who may be
physically weaker than other population groups.
Provide shelter, seats, hand holds and smaller jerry cans
for carrying (e.g. 10 litres capacity, not 20).
• Checking for who is absent: older people may be too
weak to get to information meetings about entitlements
and food distribution, or too busy caring for sick children
or partners. The may also exclude themselves from social
gatherings because of depression or psychological
trauma.
Consumption
This reflects the energy and nutrient intake of individuals in the
households (not normally measured). A proxy for this can be
changes in the number of meals consumed before and after a
disaster. This can be a simple, yet revealing, indicator of food
security. The number of food groups consumed by an individual
or household and frequency of consumption over a given
reference period reflect dietary diversity.
• Checking the Dietary Diversity Score (see HTP
Module 6). However, the dietary diversity score is only a
rough indicator: many inadequate rations pass this, but
would fail in terms of nutrient density for older people’s
requirements.
• Checking the Nutrient Density of the general ration
using proper software with an integrated food
composition table (see HTP Module 4). Nutrient density
is very important for older people given their lower
energy requirements. Micronutrient requirements can
stay the same, or in some cases increasing. Underweight
or malnourished older adults need protein and energy-
dense snacks such as hard-boiled eggs, tuna fish and
crackers, peanut butter on wheat toast and hearty soups.
Drinking liquid nutritional formulas between meals can
also boost energy and nutrient intakes.
• Taking into account cultural norms of intra-household
food distribution, such as cultural and religious food
taboos and self-abstinence by older people.
• Taking into account household behaviours that are
coping strategies to deal with change, such as the
preferential feeding of younger members.
Utilisation (and acceptability)
Referstoahousehold’suseofthefoodtowhichithasaccess,inclu-
dingstorage,processingandpreparation,anddistributionwithin
thehousehold.Italsoreferstoanindividual’sabilitytoabsorband
metabolise nutrients, which can be affected by disease and
malnutrition.

TECHNICAL NOTES
53
162
ACF’s target is <15%.
163
Food passes into the windpipe/lungs and not into stomach, dysphagia.
164
Ageways, 2011. Feb, page 7.
165
Sphere 2011.
In 1994, pastoralists in Turkana, northern Kenya, complained of severe bloating and discomfort after consuming
inadequately cooked whole grain maize and beans that they were unfamiliar with.
During an ACF-run therapeutic supplementary feeding that included older people in Juba, Sudan (2000), the number of
older people defaulting was 5.4%, which was considered to be satisfactory.162
The main reason given for defaulting was
the preference for special solid food instead of the formula diet (i.e. milk).
Box 24: Some examples of inadequate foods for older people
Provide food that is digestible for older people (such as maize flour rather than whole grain maize), and that takes
account of digestive disorders and a common lack of teeth.
Food should be familiar and culturally acceptable.
Provide support for feeding programmes to enable the inclusion of older people.
Ensure that food for work programmes do not exclude older people.
Ensure that older people have the resources, such as fuel, water and utensils, to cook their food ration.
Ensure utensils available to older people are manageable; smaller cooking pots or even two smaller water containers
rather than one large one (e.g. 10 litre capacity rather than 20).
Link older people with supporting families for joint preparation of meals.
Understand the particular risk factors and issues affecting the nutritional status of older people.
Ensure that older people have access to food distribution.
Box 25: UNHCR/HelpAge International 2000. Guidelines for good practice in addressing the special food needs of older
people in disasters and humanitarian crises
Interventions for older people should ensure that:
• Constraints in food processing and preparation such
as milling are understood and overcome.
• Food is appropriate for older people to chew and
digest because of problems with teeth, and conditions
that affect the absorption of nutrients (e.g. atrophic
gastritis).
• Age-related changes in taste and smell senses, which
reduce the enjoyment of food, and affects appetite, are
accounted for. Blended foods, moist, soft-textured,
tender-cooked pureed foods and thickened liquids are
often needed. Thickened liquids or pureed food are also
needed to avoid fausse route,163
a high mortality cause
among older people when liquid enters the lungs.
• Whole grain cereals and beans are often difficult
to digest for older people, and they are relatively
difficult to prepare.
• Older people may find it more difficult than other age
groups to adapt to new and unfamiliar foods. Some
examples are presented in Box 24.
• Training on how to prepare and cook new and
unfamiliar foods. Many older people may lack the
knowledge and skills to prepare non-indigenous foods.
Training on food preparation usually targets mothers
and younger women. Older people require a greater
extent of assistance and support.
• Creative and participatory food-related projects can
contribute to nutrient intake as well as support cohesion
and mental health among older people. For example, a
seasonal food preservation project was initiated for IDPs
in Kyrgyzstan in 2010.164
Many of these food security interventions are reflected in
HelpAge’s Guiding Principles to address food needs are shown
in Box 25.
Food-based interventions
Access to food and the maintenance of adequate nutritional
status are critical determinants of people’s survival in a disas-
ter.165
Often the parts of the population most affected are
already chronically undernourished as the disaster hits, many
of whom will be older people.

TECHNICAL NOTES
54
Theoretically, a well-planned general ration (GFD) is usually adequate for older persons. However, in practice, a number
of other factors often result in the general ration not actually meeting the nutritional needs of this demographic group.
Someofthesefactorsinclude:poorphysicalaccesstotherationasaresultofmarginalizationorisolation;poordigestibility,
especially of whole-grain cereals; lack of motivation or inability to prepare foods; and poorer access to opportunities for
supplementing the ration.
In emergency situations, these factors are exacerbated due to a general breakdown in normal family and community-
support mechanisms. Older people need access to easily digestible micronutrient rich foods with family and community
support for food preparation.
Energy requirements usually decrease in older people, but micronutrient requirements remain unchanged,
therefore older people should have access to foods that are nutrient dense and of a high nutrient quality. Cur-
rent standard GFD rations are ofteninadequate for older people and more attention should be placed on using
fortified blended foods or possibly ready to use food designed for the prevention of malnutrition.
Box 26: Suitable rations for older people
166
Food-based interventions aim to provide for the consumption
of sufficient, safe and nutritious food that meets dietary needs
and food preferences for different parts of the population.
The most recent guidelines for selective feeding interventions
for the management of malnutrition in emergencies are
available from UNHCR (Public Health and HIV section). While
olderadultsarereferredtoinsectionsaboutfoodaid,thegene-
ral distribution and supplementary feeding programmes, they
are not referred to in terms of therapeutic feeding.
The first food-based intervention for older people will be their
inclusion in the General Food Distribution. For more informa-
tion on this, see HTP Module 11.
General Food Distribution
Thissectiondrawsoninformationontargetingandthegeneral
food distribution provided in HTP Module 11 (see Box 26).
The initial reference value for planning general food rations in
emergencies is based on the average per capita nutritional
requirements for a population. These requirements are
considered in terms of energy, fat, protein and micronutrients
and can be increased based on specific requirements, or
decreased based on the population’s access to other food
sources.
Where populations are entirely dependent on food aid, the
general ration should meet the following criteria:
• Provide 2,100kcal per day;
• Protein should provide at least 10-20% of total energy;
• At least 17% of the energy should be provided in the
form of fat; and
• The overall micronutrient content of the ration meets
the needs of the whole population.
The nutriment content of the general ration is often inappro-
priateforolderpeoplesincetheyneedrelativelymorevitamins
and minerals, and less energy, than do younger people (see
Undernutrition section above). For example, the Vitamin B12
content of the general ration is poor and will not meet the
particular nutrient requirement for older people. This vitamin
is mostly available in animal foods. UNHCR acknowledges that
nutritionally, food aid is sub-optimal and that, in the case of
refugee populations, even greater constraints to achieving
good nutrition exist, given that, in many cases, their ability to
produce food or access land or meat from wild animals is
extremely compromised.
Theadequacyofthegeneralrationforolderpeopleneeds
to be considered in the context of intra-household food
distribution where the older person lives in a household
with other people.
The provision of no less than 50g of blended food per person
per day as part of the general ration is recommended166
by
HelpAge. If quantities of blended food are limited, children
under five and older people should be prioritised. If blended
food is not provided as part of the general ration, resources
should be allocated to procure for distribution to priority sub-
groups, including older people. During periods when food
rations are decreased or phased out, blended food should be
retained as a food commodity in the food basket.
A full individual food ration for one month weighs roughly
18kg; a family of five, of which three are small children (and,
thus, cannot carry their ration), must then carry away 90kg at
once, that is, 45kg per adult – a considerable weight for most

TECHNICAL NOTES
55
adults. For many older people, this can be near their own body
weight,andimpossibletocarry.Thefrequenciesofdistribution
rounds must therefore be set by referring to common sense,
and adapt to circumstances. It may be more practical to
conduct distributions on a weekly basis as agencies already
often make arrangements for more manageable bag sizes.
Box 26 presents a summary of the challenging issues related
to providing suitable food rations for older people: (from HTP
Module 11 on General Food Distribution).
HTP Module 4 covers micronutrients malnutrition, including
the lack of micronutrients in the general ration provided
by WFP. Techniques exist for the indirect assessment of
micronutrientintakes,suchasDietaryDiversityScoreandFood
Variety Score using Food Frequency Questionnaires. Please
refer to HTP Module 4.
A variety of computer software tools have also been designed
for calculating the nutrient content of food aid rations and
fortified blended food (FBF) rations. The most well-known
include NutCalc, which was developed by EpiCentre for Action
Contre la Faim, and NutVal, which was developed for UNHCR
andWFPbyUniversityCollege,LondonCentreforInternational
Health and Development. NutVal 3.0 is currently recommen-
ded by WFP and UNHCR for use in planning and monitoring
food aid rations (http://www.nutval.net/).
The level of the challenges in assessing micronutrient pro-
blems in emergencies, and intervening appropriately and with
beneficial effect for this population group is even harder than
for children.167
However, given the heightened requirements
for some micronutrients in terms of age-related deterioration
in immune status and response, and co-morbidity, in older
people, attention needs to be paid to this area of the emer-
gency response.
TheWFP nutrition toolbox already includes fortified staples,
fortified condiments and fortified blended foods. Among
the fortified blended foods is corn soya blend (CSB), which
WFP has used for decades.WFP is working on ways of improv-
ing the composition of these foods (such as CSB++) to better
meet the nutritional needs of specific groups (young children,
pregnant and lactating women, the chronically ill). The WFP
toolboxalsoincludesnewstrategiessuchashome-fortification
with multi-micronutrient powder (MNP, also known as‘sprin-
kles’). Home fortification means that beneficiaries themselves
sprinkle the powder onto food after they have cooked it. It is a
viable option when households already have some food but
the food they have lacks important micronutrients, and it is
suitable for older people.
Micronutrient supplementation refers to periodic admin-
istration of pharmacological preparations of nutrients as cap-
sules or tablets or by injection. Supplementation is necessary
as a short-term emergency measure to reverse clinical signs
ofmicronutrientdeficienciesorforpreventioninat-riskgroups.
Micronutrient supplementation should be restricted to vulner-
able groups who cannot meet their nutrient needs through
food: this applies to older people as well as women of child-
bearing age, infants and young children, displaced people,
refugees and populations experiencing other emergency
situations.
In emergency interventions, a number of complementary
strategies for supplementary food should be adopted:
• The use of darkly-coloured vegetables (including
wild foods) in food preparation should be a priority.
Diet diversification will also contribute to increased
micro-nutrient intakes.
• Supplements of specific vitamins (Vitamin A, folic
acid) are given routinely on admission into rehabilitation
programmes.
• A supplementary Concentrated Mineral and Vitamin
pre-mix (CMV) can be added to blended foods, maize
porridges or traditional meals that are prepared on site.
Attention should be paid to ensuring that the CMV is
thoroughly mixed into the cooked food. The mineral/
vitamin mix should not be added to dry-ration mixtures.
• All food aid commodities should be fortified:
e.g. oil with Vitamin A, salt with iodine.
Supplementary Feeding Programmes (SFP)
Table 15 shows the recommended assessment criteria for
admission of older people into SFP.
Depending on the prevalence of undernutrition and
availability of partners, supplementary feeding can be
provided through two different types of interventions:
• Blanket supplementary feeding
• Targeted supplementary feeding
Blanket Supplementary Feeding Programmes (BSFP)
Blanket SFP are often implemented when the GFD has not
been established or is inadequate, when numbers of vulner-
able people are very large or when GAM levels are so high
that blanket coverage is required (see HTP Module 12: Supple-
mentary Feeding).
A BSFP has several objectives:
• To prevent nutritional deterioration and related mortality
and morbidity in those who have additional nutritional
requirements: this should include older people, especially if
they are sick or have a chronic condition.
167
Seal A and Prudhon C, 2007. Assessing micronutrient deficiencies in emergencies: current practice and future directions. SCN.

TECHNICAL NOTES
56
Table 15: Anthropometric, clinical and social criteria used for older people’s admission into Selective Feeding
Programmes (CSP, SFP, TFP)
Type of criteria Measurement Remarks
Anthropometric MUAC, using adult MUAC band Measures acute loss of fat and muscle tissue
Clinical 1. Famine oedema (bilateral) or Clinical factors associated with poor nutritional
2. Inability to stand/immobile or status. All factors assessed visually and/or through
3. Extreme weakness or
consultation with the older person. Severe
4. Dehydration or
kyphosis is common in older people and can be
5. Anorexia
a cause for immobility.
Social Risk Factors 1. Living alone without family support or Specific social factors are defined by the
2. Physical or mental disability or community. These are social risk factors likely
3. Not strong enough to engage in any
to lead to poor nutritional status. Older persons
household activities or
with one of more of these criteria (but no
4. Very low socioeconomic status or
anthropometric/clinical criteria present)
5. Psychologically traumatised (e.g. loss of
are admitted into a Community Support
home or family members)
Programme CSP.
MUAC
Criteria present (+) or absent (-)
Category and related action mm Clinical Social
Normal nutritional status – do not admit* >185 +/– –
High nutritional risk – Community Support >185 +/– +
Prog.** 160-185 – +/–
Moderate malnutrition – Supplementary Feeding
Severe malnutrition – Therapeutic Feeding 160-185 – +/–
<160 +/– +/–
* Except those older people presenting with bilateral oedema (regardless of MUAC status) who should be referred to a clinician.
** With the purpose to prevent any further deterioration in nutritional status.
Source: Borrel A, 2001. Addressing the nutritional needs of older people in emergency situations in Africa: ideas for action. HelpAge International Africa Regional
• To restore nutritional status in those moderately
malnourished among nutritionally vulnerable groups:
this should include older people, especially if they have
disabilities, lack social support or have psychosocial
problems. It could also be argued that they should be
targeted if they are the sole carers for children under five.
Targeted Supplementary Feeding Programmes (SFP)
SFP are meant to treat moderate acute malnutrition.
EmergencySFPforolderpeoplecanbefraughtwithproblems.
Theyoftenlackaclearrationaleandthemonitoring,evaluation
andphase-outcriteriaarenotsufficientlyconsidered.Targeting
generally falls into two broad categories: individuals or house-
holds (or groups of households).
Targeting individual older people
Older people may be nutritionally vulnerable. Reduced phy-
sical or mental function may make it difficult for them to access
food, particularly in situations of displacement where social
support networks or access to traditional foods is disrupted.
The nutritional vulnerability of older people should not be as-
sumed in every context, but some specific older people may
be nutritionally vulnerable in a situation where the majority
of the population comprises of older people (e.g. the remain-
der of the population has fled or migrated).
Targeting institutions
Institutions may be targeted to reach specific groups who
are thought to be vulnerable, e.g. hospital patients or old
people’s homes. These groups may face special problems, as
relatives find it difficult to provide support and government
institutions may collapse.

TECHNICAL NOTES
57
Table 16: Advantages and disadvantages of different types of supplementary feeding for older people
Type Characteristics Advantages Disadvantages
Dry ration: Should provide 1,000 to • Leaves responsibility of Supplement may be shared
take home 1,400kcal per person/day. preparing food with with the rest of the household.
Ration should provide at least household, either with older
25% of energy from fat, 10-15% person/carer.
from protein. Dry rations are • Reduces travel time and
usually larger in comparison to distance for older person
prepared (wet) rations to take and/or family.
into account intra-household
• Ration may be perceived as
sharing. Normally provided on
a contribution to food
a weekly basis.
available to the household,
may contribute to improved
social status of the older
person within the family.
Wet feeding: Prepared ration should provide • Allows an opportunity for • Older people may be too
on site at least 700kcal energy per older people in the weak to travel to centre
person/day. Should provide at community to socialise and every day.
least 25% of energy from fat interact amongst themselves. • May be reluctant to go to
and 10-15% from protein. • Encourages older people to crowded places.
maintain some physical • May encourage
mobility on a regular basis ‘temporary’displacement of
(i.e. it provides motivation the population to a
to leave the household). centralised location,
increasing exposure to
environmental public health
risks, disease, infection.
• May erode family and/or
community responsibility.
Source: Borrel A, 2001. Addressing the nutritional needs of older people in emergency situations in Africa: ideas for action. HelpAge International Africa Regional
Targeting households
Householdsareusuallytargetedbysocio-economicindicators,
health or nutritional status (usually of children under five) and
are based on assessment or assumption that specific types of
households in the population cannot meet their survival or
livelihood needs. Targeted vulnerable feeding will provide a
family ration to households on the basis of individual eligibility
criteria, i.e., the household has a malnourished child, someone
who is chronically ill (e.g. with tuberculosis or HIV), has a pre-
gnant or lactating woman, an older person, a disabled person,
or someone who is socially vulnerable, such as an orphan.This
system recognises that vulnerable individuals are part of a
household,andhouseholdmemberswillsharethefoodration.
By virtue of having a vulnerable individual in the household,
all members of the household may be at an increased risk of
food insecurity and possibly undernutrition.Targeting house-
holds headed by females, on the basis that such households
are most vulnerable to food insecurity, is another strategy that
is often used by agencies.
Wet and dry feeding
Supplementary food can be distributed in two ways, as shown
in Table 16, which outlines some of the advantages and
disadvantages of the different types of supplementary foods
for older people. The type of intervention will depend on the
context.
Older people are less likely than others to eat foods that are
unfamiliar to them (see Box 27). Efforts should be made to
consult with them on the types of foods they prefer and the
techniquestopreparethem.Theserecipesthenneedadapting
tothesupplementaryfoodbasketandtomeetingtheirprotein
and other nutrient needs.
Therapeutic Feeding Programmes, CMAM
The principles of therapeutic feeding programmes for
severelymalnourishedolderpeople,andtheoverallphased
approach to the management of severe acute malnutrition,
are the same as for other adult groups. For more details on the
treatment of severe acute malnutrition see HTP Module 13.

TECHNICAL NOTES
58
The plea for help of the older people at Fendall and Soul Clinic IDP camp has turned into an outcry. Their condition is
critical. In the last six months, 15 have died due to hunger and lack of medical care. Most have spent the last five years
running from one place to the other in search of shelter from the war. In June 2003, during the height of the conflict in
Liberia, many of these old people arrived at Fendell and the Last Displace Camp, Soul Clinic, located on the outskirts of
Monrovia. They resolved never to run anywhere again. There are 3,810 old people here, between the ages of 60 and 98.
They are subsisting only on the meagre food rations provided byWFP.The elderly have no relatives to take care of them,
nor is the government in a position to do so. Even those who have children do not know their whereabouts. Often the
children are not capable of taking care of them.
Each month, an individual receives 6.9kg of maize meal, 0.45kg of vegetable oil, 1.05kg of beans/lentils, 1.8kg of corn
soybean and 0.15 kg of salt. Liberia’s staple food is rice. The old people find it very difficult to get adjusted to the new
diet, so different from their own. Having no source of income, or any relatives to assist them, they are spending their last
few days on the earth in misery. The blankets, and other clothing received from UNHCR in July 2003, have worn out.
UNHCR also distributed cooking utensils to family heads only. Since most of these old people came to the camps
unaccompanied, they did not receive pots and pans. Instead, they are using empty oil tins as cooking utensils and as
buckets to do their laundry or taking a bath. They no longer have footwear. Soap, toothpaste, toothbrushes and other
necessities are just not available to these older people.
Box 27: Older people and food issues during displacement in Liberia, 2004
Source: Maxi M, 2004. Report on the situation of the elderly at the Fendall and Soul Clinic Internally Displaced People Camps
http://www.globalaging.org/armedconflict/countryreports/Africa/fendall.htm
There is very little information in humanitarian guidelines
about older people and therapeutic feeding. Most information
and guidance comes from HelpAge, and sometimes other
agenciesthathaveincludedolderpeopledirectly.Forexample,
Box 28 describes a therapeutic feeding programme for older
people from Juba, Sudan, in 2000.
Discharge criteria are defined as those that have attained a
stable and satisfactory nutritional status and who are free from
disease. UNHCR/WFP (2011) recommend discharge for adults
achieving a BMI of 18.5 or more.
HelpAge recommends discharge of older persons to depend
on anthropometric (MUAC >185mm), clinical and social risk
factors.168
Table 17 shows some criteria used for discharging older peo-
ple from feeding programmes.
Community-Based Management of Acute Malnutrition
(CMAM) is now an internationally established method of trea-
ting acute malnutrition in children under 5 years old during
emergencies. To date, CMAM has not been implemented in
large numbers of malnourished individuals in other age
groups. Guidelines for other groups are therefore not included
here. However, this does not mean that older people cannot
be treated using the CMAM model with modified protocols.
Food products used in selective feeding programmes
Innovative and nutritious food products are being developed
to prevent and treat undernutrition. There are new debates
emerging about new products and approaches to supple-
mentaryandtherapeuticfeeding.Itisbeingincreasinglyrecog-
nised that quantity is not enough and that a focus on the
quality of food aid is needed.
Five key products are used by WFP to improve nutritional
intake. These five products include Fortified Blended Foods
(FBFs), Ready-to-Use Foods (RUFs), High Energy Biscuits (HEBs),
Micronutrient Powder or “Sprinkles”, and Compressed Food
Bars (CFBs). (See also HTP Module 11 page 6, covers food inter-
ventions). RUFs products include ready-to-use supplementary
foods (RUSFs), and ready-to-use therapeutic foods (RUTFs).
All these food products are specifically designed for acutely
malnourished children and pregnant and lactating women.
They are not designed for older people whose energy and
micronutrient requirements are different and sometimes
affected by illness and disease, particularly HIV and AIDS.
HighEnergyBiscuits(HEB)and‘BP5’arecomparableinenergy
and protein and can be suitable to meet emergency food
needs on a temporary basis.When cooking facilities are not in
place, unknown or in case of sudden need, compact foods
such as high-energy biscuits are easy to handle, transport and
168

TECHNICAL NOTES
59
The nutritional treatment of severe malnutrition in older people was based on the same formula used to treat children
(F75, F100 or HEM*, porridge, family meal and fruits/vegetables), with added minerals and vitamins. However, the amount
of milk given per kg/body weight was much less for adults than children as dairy-related energy needs decrease with
age.
The nutritional treatment was phased as follows:
1. ACUTE AND TRANSITION PHASE
• During the acute phase of the treatment, older people and other adults received only a diet of F75 milk,
which contains low levels of protein, fat and sodium. The initial goal of this phase was to prevent further tissue
loss. The average duration of Phase 1 was four days. When appetite was regained and, as in the case of
kwashiorkor, as the oedema was reduced, individuals were promoted to the transition phase.
• The transition phase allowed a gradual increase in the amount of protein and fat, in order to restore the
physiological imbalances. In this phase, the same quantity of milk than in acute phase is given to the patient
but F75 milk is replaced by F100 milk. After two days in the transition phase, older adults entered Phase 2.
2. REHABILITATION PHASE
• Beneficiaries began to regain lost weight and appetite increased. During rehabilitation, older people and other
adults became very hungry and often refused formula feed (milk), demanding solid foods.
• At this stage meals were given, based on the recipient’s traditional foods, with added oil, minerals and
vitamins. The diet comprised a variety of foods and allowed the older people to eat as much as they desire.
The variety of food included vegetables (tomatoes and green leaves), beans, meat, fish and fruits. Older adults
continued to receive the formula feed (F100) milk, which was supplemented with porridge made from corn
soya bean (CSB), oil and sugar, and enriched with vitamins and minerals. At this stage, eight meals (7 servings
of milk and 1 of porridge) were provided to the beneficiaries each day, as they still required intensive care. The
beneficiaries moved onto the Consolidation Phase (Phase 3) once they reached a BMI equal to, or above 15
(for older persons) or a BMI equal to, or above, 17 for other adults.
3. CONSOLIDATION PHASE
• This is the final stage of the treatment where the beneficiary was prepared for discharge.The beneficiary continued
to receive a formula feed (F100 milk) but the number of meals was reduced to five. They continued to receive
porridge made from CSB, oil, sugar and enriched with a mineral and vitamin complex. The family plate (pulses,
vegetables, meat and fish) and fruits continued to be provided for adults and older persons in this phase.
* F75 and F100 are therapeutic milks used in Phases I and II in the treatment of severe malnutrition. F75 has an energy value of 75kcals per 100ml,
while F100 provides 100kcal/100ml. Both milks are fortified with vitamins and minerals. HEM = High Energy Milk Formula is Dry Skimmed Milk + Oil +
Sugar + Complex of minerals and vitamins.
Box 28: Example of therapeutic supplementary feeding programme for older people implemented by ACF and HelpAge
in Juba, Sudan (2000) (see also Part 3: Trainer’s Guide)
Source: Action Contre La Faim (ACF) and HelpAge in Juba, 2004. Case study of supplementary selective feeding programmes by ACF and HelpAge in Juba. In: HelpAge
International Africa Regional Development Centre. Summary of research findings on the nutritional status and risk factors for vulnerability of older people in Africa.
pp 58-61. April: Nairobi.
distribute. BP5 requires no preparation and thus no additional
resources are required to prepare it (e.g. fuel, cooking and
servingequipment,waterandtrainedpersonnel).Crushedinto
drinking water or milk they can produce porridge (thick or
thin according to taste), no cooking is required and they are
useful for feeding children/older people and/or those who are
ill.HEBsalsocontainoptimalamountsofmineralsandareoften
used to complement a ration; BP5 has been developed for
use as a complete food and sole source of both macro- and
micro-nutrients. Both HEB and BP-5 contains about 458kcal,
15.5g of fat and 16.7g proteins per 100g.They are also vitamin
and mineral fortified. 100-150ml of water should be provided
for every two biscuits consumed. However, BP5 is expensive;
nearly three times as much compared to HEB, and is not a
‘usual’food. Furthermore, it is monotonous to eat daily. As soon
as possible normal food should be provided.
Meals ready-to-eat (MREs) or humanitarian daily rations
(HDR). These rations are the most expensive food aid com-
modities and are usually reserved for immediate response
during the first few days of a sudden disaster or the displace-
ment of large numbers of people. Usually these products
contain high quality protein, fat and carbohydrate with added
vitamins and minerals.

TECHNICAL NOTES
60
Table 17: Transfer and discharge criteria for older people from feeding programmes
Type of support Outcome Criteria for exit or transfer
Community • Death Criteria for exit:
Support • Default from programme • Family carer in community managing to
Programme CSP • Nutritional status remaining stable
provide adequate support to older person
• Integration into formal/informal
and:
support system
• No deterioration in nutritional status of older
person or
• Maximum length in CSP three months or
• Integration into formal/informal social support
system
Supplementary • Death Transfer to CSP when:
Feeding • Default from programme • No signs of deterioration in nutritional status
Programme SFP
• Nutritional status remaining stable
i.e. nutritional status remaining stable and
• Integration into formal/informal
• Family and/or carer identified in community
support system
and type of assistance/support defined or
• Maximum length of stay in SFP is 8 weeks
Therapeutic • Death Transfer to SFP when:
Feeding • Transfer to hospital • MUAC >185mm and absence of clinical
Programme TFP
• Default from programme
factors and
• Recovery – transfer to SFP • Trend of positive weight gain
OR:
Transfer to CSP when:
• Presence of underlying chronic illness (e.g. TB)
when no health facilities to treat chronic illness
and no improvement in nutritional status and
• Family and/or carer identified in community
and type of assistance/support declined or
• Maximum length of stay 6 to 8 weeks in TFP
Monitoring and evaluation
It is important to consider the extent to which any indicator
of nutritional status or vulnerability in older people shows a
positive response to a treatment or intervention at different
levels of malnutrition. Some very old people are unable to walk
unaided, not because of malnutrition, but as a result of a very
low muscle mass and muscle function related to ageing.These
physical conditions resulting from old age will not be
addressed by nutritional supplementation or other food
intervention. However, their quality of life and prolonged
independence may be improved.
Unfortunately, there is very little documented on the effects
of various interventions for older people in developing
countries, either living in settled and stable communities or in
For more on Monitoring and Evaluation (M&E) see HTP Module
20. This refers to older people as a cross-cutting theme that
needs to be taken into account in any M&E programme. The
M&E of nutrition interventions for older people should include
an analysis of their situation to better understand their specific
needs, track their ability to access basic services and assess
the appropriateness of food rations to meet their needs.
Relevant factors to monitor and evaluate food security include:
• Are older people involved during the assessment phase?
• Is blended food provided as part of their ration?
• Is physical access to the general ration good enough?
• Do older people also have sufficient access to fuel and
water for cooking?
• Is older people’s nutrition status being assessed?
• Are older people with acute malnutrition receiving
treatment?

TECHNICAL NOTES
61
Table 18: Indicators for monitoring progress of older people in a TFP, SFP or CSP
Therapeutic Feeding Health status monitored on a daily basis by nurse or physician
Programme (TFP)
Weight gain measured two to three times per week depending on the mobility of the
older person
Monitor loss of oedema, average daily weight gain, change of MUAC status, length of stay
in nutrition centre
Food intakes carefully monitored and recorded every day
Monitor ability of older person to engage in daily activities and increasing muscle strength
Monitor and address capacity of family or carer to support older people
Supplementary Nutritional status (weight, MUAC) assessed every one or two weeks
Feeding Programme
Capacity of family or carer to support older person assessed and monitored(SFP)
Average daily weight gain, change of MUAC status, length of stay in SFP recorded
Community Support In Phase I: weekly household visits by out-reach worker to assess health and nutritional
Programme (CSP) status of older person and the capacity of family/carer to support the older person
In Phase II: as above, but visits reduced to a monthly basis
Source: Borrell A, 2001. Addressing the nutritional needs of older people in emergency situations in Africa: ideas for action. HelpAge International Africa Regional
169
Save the Children/ECHO/ENN/USAID, April 2012
170
Valid and Brixton Health.
Most of the Sphere indicators that can be monitored in
emergencies only refer to children aged 6-59 months, and
cannot be adapted to older people without a consensus
(Sphere, 2011, page 165-166).
The Minimum Reporting Package (MRP)
(http://www.mrp-sw.com)
This package, i.e. the Emergency Supplementary and
Therapeutic Feeding Programme User Guidelines,169
consists
of guidelines on what data to collect and provides software
for standard analysis and reports. It refers to performance
indicators and reporting categories for targeted Supple-
mentary Feeding Programmes (SFPs), OutpatientTherapeutic
Programmes (OTPs) and Stabilisation Centres (SCs). There is
also guidance on interpreting and taking action on program-
me performance indicators. It targets two treatment groups
for SFP: 6-59 months and pregnant and lactating women
(PLW). However it also facilitates reporting against other
categories e.g.‘elderly’(+60 years).
SQUEAC (Semi-Quantitative Evaluation of
Access and Coverage).
This is a low-cost resource method forevaluatingaccessand
coverage in selective feeding programmes. SQUEAC, and
the Simplified LQAS Evaluation and Coverage (SLEAC)170
were
designed to evaluate community-based management of
severe malnutrition in children. However, they could be
adapted to evaluate community management of acute
malnutrition in adults and older people. Information on both
methods can be found here: www.brixtonhealth.com
Table 18 summarises suggested indicators for monitoring of
an individual’s progress in a TFP, SFP or CSP.
For monitoring and evaluation of the overall programme
effectiveness,monthlyinformationcanbecollectedonvarious
outcome levels:
• Nutritional and health outcomes: these include
standard indicators such as the proportion recovered,
died, defaulted; the average length of inclusion, average
weight gain. It is also appropriate to record the
proportion regaining some functional capacities such as
strength and ADLs.
• Community and family support outcomes: indicators
should relate to: proportion of older people with active
and involved family or community members; proportion
of older people maintaining good nutritional and health
status; types of skills acquired and improvement in
capacity of family and community to support older
people.

TECHNICAL NOTES
62
171
Sphere, page 37.
During early 1998, Ajiep in Bhar el Ghazal, Southern Sudan, was at the epicentre of the famine. The population of Ajiep
had increased seven-fold from 3,000 to 21,000 persons, displaced as a result of severe food shortages, insecurity in the
surrounding areas and the attraction of (potential) access to a general food ration.
Emergency nutrition interventions focused predominantly on the needs of children under 5 years old (with blanket
feeding, supplementary and therapeutic feeding). However, levels of malnutrition among older people were extremely
high, exacerbated by an outbreak of shigella caused by poor sanitation, over-crowding and lack of community-based
public health interventions. By September, a therapeutic and supplementary feeding programme for adults and older
people had been established. Patients with shigella were referred and treated in the field hospital and transferred to the
TFP for nutritional recovery. Of the 440 people that were admitted into the TFP during the next months, over 20% were
older people (over 50 years). The programme demonstrated high recovery rates (92%), low mortality (5%) and a low
defaulter rate (3%).
As part of the programme evaluation, the community elders were asked their opinion. Their response was simply:
“finally, the old people have been considered”.
Box 29: Including older people in feeding programmes in Southern Sudan, 1998
Source: Salama P, 1995 Presentation at ACC/SCN April 199. Reported in Borrel, 2001. Addressing the nutritional needs of older people in emergency situations in Africa:
ideas for action. HelpAge International Africa Regional Development Centre.
Box 30: Older people: a vulnerable population of concern for disaster responses
Older people are often among the poorest in low to middle income countries and comprise a large and growing
proportion of the most vulnerable in disaster or conflict affected populations and yet they are often neglected in disaster
or conflict management. Isolation and physical weakness are significant factors exacerbating vulnerability in older people
in disasters or conflict, along with disruption to livelihood strategies and top family and community support structures,
chronic health and mobility problems, and declining family health. Special efforts must be made to identify and reach
housebound older people and households headed by older people. Older people also have key contributions to make
in survival and rehabilitation.They play vital roles as carers of children, resource managers and income generators, have
knowledge and experience of community coping strategies and help to preserve cultural and social identities.
Source: Sphere, 2011 (page 16).
• Perception of programme effectiveness: qualitative
information collected from the older participants
themselves, as well as the wider community’s perception
should be included as part of the programme
monitoring process.
Participation, voice and inclusion
Sphere171
calls for measures to ensure non-discrimination in
the humanitarian assistance. Special measures to facilitate the
participation of older people should be taken, while consider-
ing the context, social and cultural conditions and behaviours
of communities. Any such measures should avoid the stigma-
tisation of this group. Meaningful participation of different
groups of older women and men and appropriate local
organisations and institutions at all stages of assessments and
interventions are vital. Programmes should build on local
knowledge,bebasedonneedandtailoredtothelocalcontext.
Areas subject to recurrent natural disasters of long-running
conflicts may have local early warning and emergency
response systems or networks and contingency plans which
should be incorporated into any assessment. In project design
and implementation it is critical to equally engage older
women and men.
Older people often complain about being excluded from
programmes in emergencies. Box29 describes what happen-
edduringemergencyfeedingprogrammesinSouthernSudan
in 1998 and what older people thought about it.
Inconclusion,Box30fromSpheresummariseswhyolderpeo-
ple need consideration in responses to humanitarian emer-
gencies. This will include nutritional and non-nutritional
interventions to address the complex nature of their needs
and vulnerabilities.

TECHNICAL NOTES
63
• Identify older people: carry out a rapid needs assessment, collect and analyse data broken down by age and
gender.
• Consult them: ask people in later life what they need, and represent their interests. In the recovery stage, set up
Older People’s Associations (OPAs) so that older people can support themselves and others.
• Make distributions accessible: ensure that there are seats for those who cannot stand for long periods.
Organise separate distributions for older women and men where this is culturally appropriate.
• Delivery age-appropriate emergency relief: ensure that food and non-food items are appropriate for older
people. For example, ensure that contents take into account the difficulty that older people may have in chewing,
digesting and absorbing nutrients; design packages so that they can be easily carried and opened.
• Provide age-appropriate healthcare: provide specialist staff in existing health facilities, deliver basic training in
gerontology, distribute equipment such as mobility aids and glasses, and provide medication for chronic illnesses.
• Provide financial support: offer age-appropriate work, grants or loans for those who can work, and cash
transfers to those who cannot.
• Offer psychological support: employ psychologists and recruit home-care volunteers to help older people
recover from the trauma of disasters and conflict.
• Provide protection: if older people have been separated from their families, or are already alone, ensure that they
are involved in family tracing and re-unification programmes.
• Help communities prepare themselves against future disasters: ensure that older people – with historical
knowledge – are included in disaster-risk reduction work so that they can help their communities to prepare for
future disasters.
Box 31: What HelpAge does in emergencies
Source: HelpAge International and Age UK (date). On the edge. Why older people’s needs are not being met in humanitarian emergencies.
Astheworld’sleadingINGOfocusingonolderpeople,HelpAge
delivers funds to support local partner organisations for age-
friendly aid. It deploys specialist staff who provide training and
resource materials about older people’s needs to other aid
agencies, give health and social support to older people living
in refugee camps, and work with communities in disaster-
prone areas to prepare for future emergencies by training and
equipping networks of older volunteers. Box 31 summarises
the range of activities and interventions that HelpAge delivers
in different emergency situations, all of which should be
monitored and evaluated in terms of their existence and
quality within a response. A more comprehensive list is also
available in Annex 6.
Existing challenges and areas for research
Existing challenges and areas for research in the area of
undernutrition of older people in emergencies include:
Advocacy, awareness and capacity
a) Lack of awareness and knowledge within the
humanitarian sector, including donors and governments,
about the demographics of ageing, active roles of older
people, the complexity of their vulnerability to
undernutrition in emergencies, and their rights.
b) Inadequate skills to deal with undernutrition in this
population group within humanitarian agencies,
national government systems and at operational level
in emergencies.
c) Persisting ageism and age discrimination within the
humanitarian system, and breaches of the UN Principle
of Impartiality.
d) Underfunding of programmes tackling undernutrition
in older people in emergencies, in marked contrast to
funding levels for other population groups.
e) The child-focused nutritional conceptual framework
and focus on children under five, recently re-invigorated
with prioritisation of the ù1000 daysû period, should not
prevent inclusion of older people in nutrition policies
and programmes.
f) Address gaps and inconsistencies in existing policies
and guidelines on nutrition, ageing and emergencies.
Assessment
a) Lack of commonly agreed, functionally related,
undernutrition classification system for older people
using anthropometric assessment based on MUAC.
Agreement is needed to develop normative guidance
for assessments and responses.

TECHNICAL NOTES
64
b) Continued preference for, and use of BMI, in the
anthropometric assessment of older people despite
problems in its measurement, particularly of standing
height, and its interpretation in terms of age-related
physiological changes.
c) Research is needed on the relationship between various
MUAC cut-offs and functional outcomes of importance
to older people, such as muscle strength, mobility and
ADLs.
d) Lack of clarity and agreement on the best assessment
methodologies for all aspects of nutritional vulnerability
of older people in emergencies. This acts as an
unacceptable barrier that sustains the nutritional neglect
of this population group.
Interventions
a) How can the recent proliferation of food-based products
for the treatment of acute malnutrition be adapted for
use in older adults?
b) How to link nutrition interventions for older people with
interventions for other population groups, and with
other sectors?
c) How to improve techniques and standardisation for non-
food interventions?
Monitoring and evaluation
a) Limited evidence for what works in the treatment of
acute malnutrition in older people.
Participation
a) Strengthen use of participatory methods with older
people on all aspects of planning, assessment,
intervention and monitoring programmes aimed at
preventing and treating undernutrition in older people
in emergencies.

TECHNICAL NOTES
65
Year Event or publication
1982 First World Assembly on Ageing, Vienna
1991 UN Declaration of International Year of Older Person IYOP and UN Principles for Older Persons (Resolution no
46/91, 1991) – see Annex 1
1995 UN Committee on Economic, Social and Cultural Rights: General Comment No. 6 on the economic, social and
cultural rights of older persons
1998 UN International Plan of Action on Ageing and UN principles for Older Persons, UN Department of Public
Information (DPI/932/Rev.1-98-24545. New York). Guiding Principles on Internal Displacement
1999 International Year of Older Persons
1999 HelpAge International and EarthScan publish Ageing and development report: poverty, independence and the
world’s older people
1999 World Health Day April 7th on theme of ageing
2001 State of the World’s Older People
UN General Assembly established Open Ended Working Group on Ageing
2002 Second World Assembly on Ageing and Madrid International Plan of Action on Ageing (MIPAA) with Political
Declaration, signed by 159 governments and adopted by consensus later that year by the United Nations
General Assembly
2002 WHO and Tufts University School of Nutrition and Policy published Keep Fit for Life
2002 African Union published a Policy Framework and Plan of Action on Ageing
2004 HelpAge International Africa Regional Development Centre: Summary of research findings on the nutritional
status and risk factors for vulnerability of older people in Africa published
UNHCR Policy on Older Refugees
2007 HelpAge International and Inter-Agency Standing Committee Working Group (IASC-WG) review report on the
inclusion of older people in humanitarian action
2008 UN cluster mechanism (IASC) produced an Essential brief and guidelines for Humanitarian Action and
Older People
2010 HelpAge International and UNFPA review policies, legislation and data on older people from 133 countries to
assess progress in implementing MIPAA
2011 Revision of Sphere Humanitarian Charter and Minimum Standards in Disaster Reponses to include more on
older people
2011 HelpAge International and Age UK published On the edge: why older people’s needs are not being met in
humanitarian emergencies
2012 International Year of Older Persons (UN) and European Year of Ageing
2012 World Health Day (April 7th) on theme of older people
2012 Second review of MIPAA (MIPAA+10)
Publication of second State of the World’s Older People
Annex 1: Key events and documents related to older peoplein humanitarian situations

TECHNICAL NOTES
66
Annex 2: UN General Assembly Resolution no 46/91: 18 General Principles for
Older Persons, 1991
Participation
1. Older persons should remain integrated in society, participate actively in the formulation and implementation of policies
that directly affect their well-being and share their knowledge and skills with younger generation.
2. Older persons be able to seek and develop opportunities for service to the community and to serve as volunteers in
positions appropriate to their interests and capabilities.
3. Older persons should be able to form movements or associations of older persons.
Dignity
4. Older persons should be able to live in dignity and security and be free of exploitation and physical or mental abuse.
5. Older persons should be treated fairly regardless of age, gender, racial or ethnic background, disability or other status,
and be valued independently of their economic contribution.
Independence
6. Older persons should have access to adequate food, water, shelter, clothing and health care through the provision of
income, family and community support and self-help.
7. Older persons should have the opportunity to work or to have access to other income-generating opportunities.
8. Older persons should be able to participate in determining when and at what pace withdrawal from the labour force
takes place.
9. Older persons should have access to appropriate educational and training programmes.
10. Older persons should be able to live in environments that are safe and adaptable to personal preferences and changing
capacities.
11. Older persons should be able to reside at home for as long as possible.
Self-fulfilment
12. Older persons should be able to pursue opportunities for the full development of their potential.
13. Older persons should have access to the educational, cultural, spiritual and recreational resources of society.
Care
14. Older persons should benefit from family and community care and protection in accordance with each societyûs system
of cultural values.
15. Older persons should have access to health-care to help them to maintain or regain optimum level of physical, mental
and emotional well-being and to prevent or delay the onset of illness.
16. Older persons should have access to social and legal services to enhance their autonomy, protection and care.
17. Older persons should be able to utilise appropriate levels of institutional care providing protection, rehabilitation and
social and mental stimulation in a humane and secure environment.
18. Older persons should be able to enjoy human rights and fundamental freedoms when residing in any shelter, care or
treatment facility, including full respect for their dignity, beliefs, needs and privacy and for the right to make decisions
about their care and the quality of their lives.

TECHNICAL NOTES
67
Annex 3: Madrid International Plan of Action on Ageing. Issue 8: Emergency Situations
In emergency situations, such as natural disasters and other humanitarian emergencies, older persons are especially vulnerable
and should be identified as such because they may be isolated from family and friends and less able to find food and shelter.
They may also be called upon to assume primary caregiving roles. Governments and humanitarian relief agencies should
recognize that older persons can make a positive contribution in coping with emergencies in promoting rehabilitation and
reconstruction.
Objective 1: Equal access by older persons to food, shelter and medical care and other services during and after
natural disasters and other humanitarian emergencies.
Actions
a) Take concrete measures to protect and assist older persons in situations of armed conflict and foreign occupation,
including through the provision of physical and mental rehabilitation services for those who are disabled in these
situations.
b) Call upon governments to protect, assist and provide humanitarian assistance and humanitarian emergency assistance
to older persons in situations of internal displacement in accordance with General Assembly resolutions.
c) Locate and identify older persons in emergency situations and ensure inclusion of their contributions and vulnerabilities
in needs assessment reports.
d) Raise awareness among relief agency personnel of the physical and health issues specific to older persons and of ways to
adapt basic needs support to their requirements.
e) Aim to ensure that appropriate services are available, that older persons have physical access to them and that they are
involved in planning and delivering services as appropriate.
f) Recognize that older refugees of different cultural backgrounds growing old in new and unfamiliar surroundings are
often in special need of social networks and of extra support and aim to ensure that they have physical access to such
services.
g) Make explicit reference to, and design national guidelines for, assisting older persons in disaster relief plans, including
disaster preparedness, training for relief workers and availability of services and goods.
h) Assist older persons to re-establish family and social ties and address their post-traumatic stress.
i) Following disasters, put in place mechanisms to prevent the targeting and financial exploitation of older persons by
fraudulent opportunists.
j) Raise awareness and protect older persons from physical, psychological, sexual or financial abuse in emergency
situations, paying particular attention to the specific risks faced by women.
k) Encourage a more targeted inclusion of older refugees in all aspects of programme planning and implementation, inter
alia, by helping active persons to be more self-supporting and by promoting better community care initiatives for the
very old.
l) Enhance international cooperation, including burden-sharing and coordination of humanitarian assistance to countries
affected by natural disasters and other humanitarian emergencies and post-conflict situations in ways that would be
supportive of recovery and long-term development.

TECHNICAL NOTES
68
Objective 2: Enhanced contributions of older persons to the reestablishment and reconstruction of communities
and the rebuilding of the social fabric following emergencies.
Actions
a) Include older persons in the provision of relief and rehabilitation programmes, including by identifying and helping
vulnerable older persons.
b) Recognizing the potential of older persons as leaders in the family and community for education, communication and
conflict resolution.
c) Assist older persons to re-establish economic self-sufficiency through rehabilitation projects, including income
generation, educational programmes and occupational activities, taking into account the special needs of older women.
d) Provide legal advice and information to older persons in situations of displacement and dispossession of land and other
productive and personal assets.
e) Provide special attention for older persons in humanitarian aid programmes and packages offered in situations of natural
disasters and other humanitarian emergencies.
f) Share and apply, as appropriate, lessons learned from practices that have successfully utilized the contributions of older
persons in the aftermath of emergencies.

TECHNICAL NOTES
69
Annex 4: Example of an older people’s vulnerability assessment form (used in
South Sudan)
Individual Assessment Form
1. General information – Assessment
Assessors’Name: Camp: Date:
Place of assessment:
2. Personal Information
Name, Surname: Sex: F M Age:
Civil Status: Single Married Widow Divorced Place of origin: Date of arrival:
Present address:
Registered: Yes No In Process If Yes, number/ID: If No, Why: didn’t know Issue to access
Name of the head of household: Other (precise):
Age of the head household: Number and age of children in the household:
3. Economic situation
Past activity (before displacement):
Present activity:
Household’s source of income:
4. Type of vulnerability (fast screening)
OP with permanent OP with temporary impairment OP with chronic disease/ illness
Dependency OP head of household Household without any/male presence
5. Type of impairment
Physical impairment Hearing impairment Speech impairment
Visual impairment Mental illness
Existing or past medical support: Need of long term medical treatment
If yes, medication still available: Yes No
6. Nutrition
MUAC ≥210mm MUAC <210mm MUAC <185mm Oedema
7. Independence and participation 8. Psychosocial (only if response available)
Daily activities Yes No With help Frequency Always Often Sometimes Never
Bathing Changes in sleep pattern
Using toilets Images about what happened
Dressing Feeling of being isolated
Eating Changes in the appetite
Cooking Changes in the behavior
Cleaning Crying spells
Walking in the camp Scared/fear
IGAs How would you describe your relationship? Good Average Poor
Community activities
9. Protection
Isolation and dependency Neglect and deprivation Family situation
Family separation Loss/no documentation Precise:
Unsafe living conditions: Shelter Environment Discrimination: Family Community
Threats and harassment Humanitarian assistance
Precise: Violence
Precise:
10. Needs of items
Assistive devices: Specific items: Protection items
Crutches Walking aids (sticks) White Mattress Jerri can Flashlight Radio
Toilet Chair Wheel Chair Bedpan Blanket Whistle
Urine flask Incontinence kit
11. Needs of referral
Health Psychosocial Child protection Shelter NFIs
Nutrition Protection Disability/Rehabilitee Livelihood

TECHNICAL NOTES
70
Annex 5: Mini-Nutritional Assessment MNA used for nutritional assessment and
screening of older peoplein high-income countries
In high-income countries, the comprehensive assessment of older people is a regular part of health screening and interventions,
involving a combination of questions, measurements and clinical tests related to physical, psychological and social factors that
may have an impact on nutritional status. These assessments typically cover a range of dimensions of physical and mental
health and functioning, as shown in the following table:
Comprehensive Geriatric Assessment (CGA)
Domain Assessment method Acronym
Cognitive status Mini Mental Status Examination MMSE
Affective status Geriatric Depression Scale GDS
Mobility, gait and balance Tinetti Performance-Orientated Mobility Assessment POMA
Functional status Activities of Daily Living ADL
Functional status Lawton Instrumental Activities of Daily Living ADL
Nutritional Adequacy Mini Nutritional Assessment MNA
Click here for more information http://www.mna-elderly.com
As part of Comprehensive Geriatric Assessment, the rapid screen Mini Nutritional Assessment, MNA, was developed by Nestlé
Research Centre and Toulouse University in 1991. Worldwide, it is the most validated and referenced nutrition screening and
assessment tool for people over 65 years old. Validation criteria have been calculated as 96% for specificity (ability to identify
malnourished or those at risk), specificity as 98% (ability to identify well-nourished) and predictive value as 97%. A strong
correlation between the MNA and biochemical parameters has been shown, particularly with albumin.
The MNA is the only nutrition screening tool that incorporates special considerations of the older adult (i.e. functionality, mobility,
depression and dementia) and was specifically developed to identify older people at risk of malnutrition without the need for
more invasive tests such as blood sampling.172
• In community-living older people, it detects the risk of malnutrition and life-style characteristics associated with
nutritional risk while clinical markers of malnutrition, such as albumin levels, are still in the normal range.
• In outpatients and in hospitalized older patients, it is predictive of outcome and cost of care.
• In older home-care patients and nursing home residents, it is related to living conditions, meal patterns and chronic
medical conditions, and allows targeted interventions.
The MNA has two components: screening and assessment.
Screening with MNA-SF
• A score of 11 or less in the screening indicates a problem and the need for a completion of the assessment portion.
• A MNA-SF score of 12 and above indicates a good nutritional status without the need to continue the whole assessment.
• The assessment score is then added to the screening score.
Screening plus assessment with full MNA
• If the total score on both parts totals 17-23.5, there is a risk of malnutrition
• A score of <17 indicates existing malnutrition
172
Guigoz et al, 2002; Abellan Van Kan G and Vellas B, 2011. Is the Mini-Nutritional Assessment an appropriate tool to assess frailty in older adults? Journal of Health,
Nutrition and Ageing: 15 (3); 159.

TECHNICAL NOTES
71
173
Visvanathan et al 2004
The MNA includes several risk factors for ùfrailtyû, such as low BMI, decrease of mobility, low muscle mass and low calorie
intake. A statistically significant U-shaped association has been found between frailty and BMI. It has been shown to accurately
identify older people at risk of increased mortality and morbidity.173
In 2008-2009, Nestle Nutrition embarked on the MNA International Initiative, conducting research in geriatric settings across
the globe to validate a new MNA-SF. The new features of this are:
• It is now validated as a standalone nutrition screening tool, which can be completed in less than 10 minutes.
• Calf circumference may be used instead of BMI.
• It can identify an older person as well nourished, at risk of malnutrition or malnourished.
The MNA requires at least 15 minutes with each patient so is hardly applicable in most humanitarian settings.The MNA-SF takes
only 3 minutes but has not been validated or used in community-living settings in developing country contexts, or emergencies.
For both the MNA and MNA-SF, cultural issues may apply that have not been considered.

TECHNICAL NOTES
72
Annex 6: Guiding principles for nutritioninterventions for older peoplein emergencies
1. Older people should have physical access to an adequate general ration that is suitable in terms of quantity and
quality, that is easily digestible and culturally acceptable.
• Older people should have access to milled cereal and legumes that they are familiar with or alternatively to milling
facilities in situations where whole grain cereal is produced.
• Measures should be taken to ensure that older people are:
(i) Informed of their eligibility; and
(ii) Have physical access to the general ration.
2. The physiological changes associated with ageing and its consequences for nutritional requirements and
special needs should be reflected in programme design.
• Older people should be supported and encouraged to access and consume nutrient-dense foods, adequate fluid
volumes and easily digestible foods.
• A fortified blended food should be included as part of the basic general ration. Where this is unavailable, older people
(in addition to young children) should be prioritised to receive a supplement of blended food or other nutrient-dense
food.
3. Older people should be involved in the assessment, design and implementation of the programme.
• The nutritional status and nutritional needs of older people should be systematically assessed during emergency
nutrition assessments.
• Older people should be involved at all stages of the emergency programme.
4. The chronic nature of their needs should be reflected in the programme design.
• Until livelihoods are restored, community support structures are re-established or families reunited, older people are
likely to remain relatively food insecure.
• Provision of community-based follow-up support for older people should be ensured until such a time as appropriate
structures are in place which provide secure and adequate support.
5. Existing community support structures should be rebuilt and strengthened as the most important strategy of
food and nutrition assistance programmes for older people.
• Where possible, older people should be given the opportunity to continue to live normally in their communities,
engage and contribute actively with the help of community support where needed.
• Every effort should be made not to create institutional structures for older people, especially where such institutions
are not considered the norm.
6. Malnourished older people should have equal access to selective feeding programmes for nutritional
rehabilitation.
• Out-reach activities, referral mechanisms and information dissemination should be addressed.
• Moderately and severely malnourished older people should be targeted and ensured equal access (similar to other
population groups) to existing supplementary and therapeutic feeding programmes.
• A commitment to operational research should be made to better understand assessment criteria and nutritional risk
factors that will facilitate effective targeting among older people.

TECHNICAL NOTES
73
Annex 7: Checklist for older people in internally displaced persons camps
Submitted to the Representative of the UN Secretary General on the Human Rights of Internally Displaced Persons Mr Walter
Kalin by HAO and Global Action on Ageing, July 2005.
Demographic data
1. Is there demographic data available in the IDP camp disaggregated by age and gender? If not, could it be included in
data collection?
2. What is the number of unaccompanied older people?
3. What is the number of children being cared for by older people?
4. How many older headed households are there?
5. How many housebound older persons are there?
Health
1. Are there special clinic days for older people?
2. Are there outreach health services for the housebound?
3. Are there drugs available to treat the common causes of morbidity amongst older people?
4. What are the main disabilities of older people? Is there a record in the camp?
5. Are mobility aids available?
Nutrition
1. Is the ration suitable for older people?
2. Have older people been screened to enter feeding programmes?
Distributions
1. Are there special provisions to avoid older people queuing for long periods of time?
2. Are there special provisions to help older people carry loads back from distribution points?
3. Are NFIs appropriate for older people? E.g. clothes, extra blankets etc.
Inclusion
1. Are older people represented on committees (e.g. health, water, women’s aid etc.)?
2. Has an older people’s committee been established?
3. Are older people active participants in camp activities e.g. literacy projects, life skills, agriculture, income generation etc.?
4. Are older people represented as a vulnerable group at camp management level?
Social support
1. Do older people receive support from family and neighbours?
2. Who is collecting fuel and water for older people?
3. Have older people been separated from their families?
Source: UNHCR/HelpAge International 2000. Older people in disasters and humanitarian crises. Guidelines for best practice.

TECHNICAL NOTES
74
Food What they are/ When, Nutritional value
product ingredients where used How used per 100g
Fortified FBFs are blends of partially Designed to provide Usually mixed Energy per 100g of
Blended precooked and milled protein supplements. with water and product min 380Kcal
Foods cereals, soya, beans, pulses In food assistance cooked as a Protein min. 18%
fortified with micronutrients programmes to porridge. Fat min. 6%
(vitamins and minerals). prevent and address
Special formulations may nutritional Micronutrients added:
contain vegetable oil or deficiencies Vitamins A, C, B12, D, E,
milk powder. Corn Soya Generally used in K, B6, Thiamine,
Blend (CSB) is the main WFP Supplementary Riboflavin, Niacin,
blended food distributed Feeding and Pantothenic acid, Folic
by WFP but Wheat Soya Mother and Child acid plus Zinc, Iron,
Blend (WSB) is also Health programmes, Calcium, Potassium
sometimes used. and also to provide
extra micronutrients
to complement the
general ration.
Ready-to- Better suited to meet Mostly in emergency Plumpy’Doz, Nutritional value per
Use Foods nutritional needs of young operations or at the (Nutriset) comes 100g of Plumpy’Doz:
and moderate beginning of a WFP in tubs containing Energy 534Kcal, Protein
malnourished children intervention for a weekly ration. 12.7g, Fat 34.5 g
than FBFs. May contain prevention or Plumpy Sup Micronutrients: Vitamin
vegetable fat, dry skimmed treatment of (Nutriset) comes A, E, B1, B2, Niacin,
milk, malt dextrin, sugar moderate in one-day Pantothenic acid,
whey. Plumpy’Doz: malnutrition. RUFs sachets. Both can Vitamin C, B6, B12,
peanuts paste, vegetable fat, are to be used in be eaten directly Calcium, Magnesium,
skimmed milk powder, addition to breast from their Selenium, Zinc, Iron,
whey, maltodextrines, sugar. milk and other food containers and iodine, Copper,
Supplementary Plumpy: for children (6 to 59 are designed to Phosphorus, Potassium,
peanut paste, vegetable fat, months) which are be eaten in small Manganese, Folic acid
soy protein isolates, whey, at high risk of quantities, as a Nutritional value per
maltodextrines, sugar, cocoa. developing supplement to 100g of Plumpy Sup:
malnutrition due to the regular diet. Energy 500kcal, Protein
severe food insecurity. 12.5g, Fat 34.5g.
Micronutrients: as
above +Vitamin D, K
and Biotin
High Energy Wheat-based biscuits which In the first days of Wheat flour, Energy 450Kcal Protein
Biscuits provide 450kcal, with a emergency when Hydrogenate 10 to 15g Fat 15g
minimum of 10g and max cooking facilities are Vegetable Minerals and vitamins
of 15g of protein per 100g scarce. Easy to Shortening, as: Calcium, Magnesium,
and fortified in vitamin and distribute and Sugar, Soy flour, Iron, Iodine, Folic Acid,
minerals. provide a quick Invert Syrup, Pantothenic Acid,
Price $0.12 per 100g packet. solution to improve High fructose, Vitamin B1, B2,B6,B12b
the level of nutrition. Corn Syrup, C,D,E, Niacine,
Skimmed milk Vitamin A-retinol.
powder, Sodium
and Ammonium,
Bicarbonates, Salt
Annex 8: Summary of supplementary foods recommended by WFPin an emergency

TECHNICAL NOTES
75
Food What they are/ When, Nutritional value
product ingredients where used How used per 100g
Micronutrient A tasteless powder Useful when One sachet per One individual sachet
Powder containing recommended fortification of cereal person is provides the daily intake
“Sprinkles” daily intake of 16 vitamins flour cannot be sprinkled onto of 16 vitamins and
and mineral for one person. implemented or home prepared mineral for one person.
Can be sprinkled onto when it is inadequate food. Can be used
home-prepared food after for specific groups. in school feeding
cooking just before eating. programmes
Price: $2-3 per 100 sachets. that provide a hot
meal to children.
Compressed Bars of compressed food, Used in disaster relief Can be eaten as a Ingredients: baked
food bars composed of baked wheat operation when local bar straight from wheat flour, vegetable
flour, vegetable fat, sugars, food can’t be the package or fat, sugars, soya protein
soya protein concentrate distributed or crumble into concentrate, malt
and malt extract. prepared. Should not water and eaten extract. Vitamins and
be used for children as porridge. minerals: Vit. A, D3,E, C,
under six months and Drinking water B1, B2, B6, B12, Niacin,
in the first two weeks must be provided Folic acid, Pantothemic
of treatment of as the bars are acid, Biotin, Calcium,
severe malnutrition. very compact and Phosphorus,
dry. Number of Magnesium, Iron, Zinc,
bars to be eaten Potassium, Sodium,
depends on age, Copper, Selenium,
gender, weight Iodine
and physical Nutritional value per
activity. 56g bar: Energy 250kcal,
Protein 8.1 Fat 9.4g

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