Addressing Nutritional Risk Among European Migrant Populations

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

we will be able to determine body composition and lean body mass by using predictive equations. This
may be helpful in determining protein composition in our target population and maintaining this value in
addition to preventing protein-energy malnutrition. These measures will help to determine an individuals
weight-for-age, weight-for-length, height-for-age and BMI for age, which will be important in screening
for wasting and under-nutrition, which are strongly associated with increased risk of mortality and
infectious disease. Lastly, urine samples provided by children will provide us with urinary nitrogen levels,
and information on the childrens electrolyte balance.
The educational tent will provide sanitation and general nutrition education and will hold 50
parents per session. We will focus on educating parents of infected children, since they may be better able
to assist children in preventing the spread of infection to other migrant children. We will educate parents
on proper sanitation and hygiene through proper hand-washing techniques, in addition to providing
sanitation wipes and education on when they should be used. Parents will also be educated about the
importance of adequate fluid intake of clean water provided by UNICEF, in addition to the pedialyte our
program will provide for the infected children. The pedialyte should function as an oral rehydration
therapy, and will help in treating the diarrhea and restoring proper electrolyte balance in the infected
individuals. 24-hour bowel rest will be encouraged for infected children, and parents will be educated on
why this is important. Bowel rest is necessary for the integrity of the GI tract to heal, and will help in
increasing absorption of nutrients, which is important in preventing protein-energy malnutrition. It is
important to first treat the diarrhea, since the infection is causing a lot of irritation in the infected child,
which is ultimately contributing to decreased dietary intake, including protein. The infection is also
contributing to a higher inflammatory response, which increases the catabolic rate in the body. This
means that diseased children are breaking down protein and losing lean body mass, which can lead to
protein-energy malnutrition over time. The childrens inadequate intake of protein and decreased
absorption then, exacerbate the situation further. It is important for parents to understand the importance
of proper protein intake for their children, and obtain the proper supplementation needed to maintain and
prevent further loss of lean body mass to ultimately prevent protein-energy malnutrition. Our final tent
will hand out the pedialyte for treating the diarrhea, in addition to the protein supplementation we are
providing. Our program will provide Plumpysup protein bars to children, which should provide adequate
protein in order to prevent them from becoming protein-energy malnourished.
Expected outcomes

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

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

Timeline
Starting in January 2016, we will begin our project. By April 2016 we will hire Arabic-speaking
educators, clinical assessment staff, staff that will proctor all sanitation measures, and general staff that
will aid in the distribution of supplementation and proctoring of the educational classes that will be
offered. In June- July we will prepare all resources (tents, required medical equipment, class material) to
provide to the refugees. August through September 2016 all resources and supplies needed for the
intervention will be shipped to Turkey via FedEx and storage arrangements will be made near the camp.
As of April of 2016 a clinical establishments will locate in a camp in Greece which will gather
anthropometric data and compare these outcomes to WHO growth charts which will aid in determining if
the intervention is effective. The medical staff will measure children on BMI, triceps, biceps, and waist in
order to calculate % body fat and determine wasting on children. In late september, the classes for the
parents of the intervened children will be administered and the medical staff will start to administer all

supplements for the children at need, suffering from diarrhea. Throughout the intervention the target
group will be regularly monitored for health and behavioral outcomes. If the program is successful at
treating diarrhea in children,then we will continue the program the following year. If it is unsuccessful at
treating diarrhea in children, we will reevaluate our methods to determine if the practices in place are
efficient and well written. In June 2017- April 2018, we will continue to gather outcome data on the
intervened children with diarrhea in order to continue getting reliable data and continue to provide the
same intervention for the ill target group. Finally, by April 2018, end of the study, we will gather,
evaluate, analyze and share relevant data to all staff that participated in the study. We will properly gather
our belongings and leave the area clear. From this point on, analyzation and evaluation of data will take
place.
General Budget and Justification
Our multi-year budget is as follows. The cost of the project is based on 217,000 refugees in the
camp at any given time. One Plumpysup supplement per day per infected individual for our two year
intervention comes out to $2,534,560.00. 1/2 L Pedialyte per infected individual per day for two years
comes out to $14,052,500.00. Supplies for the two years will cost $2,029.00. Shipment and storage of the
supplies will cost $724,000.00. Living costs of the three researchers will cost $49,413.22, and their salary
request is $200,000.00 each for the two years. Wages for the staff and educators cost approximately
$924,000.00. The total budgeted amount for the 2-year project is approximately $18,486,500.00.
Monitoring and Evaluation Methods
Our main goals for children refugees are to treat diarrhea and prevent chronic PEM. The
techniques we will use monitor the interventions will be by assigning experience staff in clinical
assessment to measure different factors that relate to PEM caused by diarrhea. Staff will measure urinary
urea nitrogen (UUN) to get a sense of protein malabsorption and breakdown in the body, and measure
electrolyte imbalance through provided urine samples from the diseased children suffering with diarrhea.
In addition, staff will measure height and weight, and use WHO growth charts for reference to determine
body composition and possible wasting for children suffering from diarrhea. Lastly, we will measure
body fat percentage though the use of calipers to determine lean body mass in infected children to
determine if children are wasting or malnourished.
After gathering data we will continue to assess our intervention by providing supplements to the
children to treat the diarrhea and prevent PEM. We will offer supplementation to infected children who
are prone to suffer from PEM with Plumpysup protein bars that contain 12.7g PRO per bar, which meets
the children daily RDA. Even so, we will provide children with electrolytes and Pedialyte to treat the
immediate diarrhea. In addition, staff will provide education for parents of children with diarrhea on
proper sanitation practices and health importance to decrease the spread of infection that could cause
diarrhea to other refugees. The program will provide antibacterial wipes after the educational courses for
sanitation purposes.
In conclusion, to determine the effectiveness of the program we will gather data in Greece in a
camp where we will reside that will measure the effectiveness of supplementation on protein malnutrition
and bowel and bowel movement in children. We will conduct a small survey panel where we will ask
questions to the intervened group to determine the effectiveness of the intervention on the parents of the
diseased children and the diseased children.
1. What has changed in the health of the diseased children after receiving supplementation in the
camp in Turkey?
2. How has this program made a difference on the lives of the children in aspects of health
education and sanitation practices?
3. How does intervention at an early stage of diarrhea and protein malnutrition correlate with intake
of supplementation to cure diarrhea and prevent further malnutrition?

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