Menu ENN Search

Revised MSF Nutrition Guidelines

by Saskia van der Kam, MSF Holland, Senior Nutritionist

The MSF nutrition guidelines for use in emergencies have recently been revised. The new guideline will be available in January 2001. The main changes to the guidelines occur in the sections on i) analysis of food insecurity situations, ii) the relation between assessment of food insecurity and nutritional interventions, and iii) the treatment of severe malnutrition.Field exchange will highlight these revisions in three consecutive articles. This first article summarises key points in the new section on:

Analysis of a food insecure situation

The new nutrition guidelines adopt an interdisciplinary approach to assessment and advocates using the UNICEF conceptual framework for analysis so that the assessment focuses on food security, health and care.

The new guidelines define three sequential stages in the transition from food security to famine. These are elaborated below. Every situation is different. The speed with which the stages progress from one to another can vary greatly depending on the nature (or the origin) of the crisis, its context, the range of coping strategies that are adopted, and the aid that is delivered.

People adopt a range of strategies (coping mechanisms) to cope with reduced access to food. In the latter stages of the process, coping mechanisms become exhausted so that the priorities of the individual and community shift towards survival.

Stage 1 - Food insecurity: 'insurance strategies'

During this first stage, the responses developed by the population are reversible and in principle do not damage future productive capacity.

People anticipate problems and adopt insurance strategies planned in advance to minimise the effects of food shortages, enhance productive capacity and preserve their productive assets. People's responses are characterised by diversification of activities, longer work hours and focussing on increasing income and limiting expenditures. The caring capacity for the nonproductive members of the community (elderly, children, sick) will be reduced. For example when men migrate to the city for temporary work, women become the head of the household and have more work and therefore less time to care for children. People also reduce their food intake, without this immediately being a threat to health. Therefore an increased level of moderate malnutrition may be seen.


Examples of insurance strategies

Increase resources:

  • crop diversification for farmers
  • livestock diversification for pastoral populations, sale of excess livestock, long distance grazing
  • sale of non productive assets (utensils, jewellery, charcoal, furniture)
  • labour migration (search for temporary employment in towns)
  • diversification of informal economic activities
  • loans
  • prostitution

Decrease expenditures:

  • reduction of food intake (reduced meal frequencies and smaller quantities eaten)
  • change in diet (consumption of wild foods, cheaper foods etc.)
  • reduction of expenditures on health care (and water purchase)
  • reduction of social support to the community, (relatives and neighbours)
  • reduction of time available for care


Stage 2: Food crisis: 'crisis strategies'

The responses in the next stage 'food crisis' are less reversible as households are forced to use strategies that reduce their productive assets and threaten their future livelihoods.

At this stage, the households or individuals are obliged to develop new strategies to meet their food needs. All surpluses have been sold and all potential for increasing resources by diversification of activities have been exhausted. People have to sell goods that are essential for their future livelihoods. Additionally, economising on health and water resources results in a poor health environment which can be made worse by gradual migration of the skilled and educated of the community (nurses, teachers etc.) In a food crisis, the prevalence of acute global and severe malnutrition as well as mortality rates associated with them, is elevated. An increased risk of mortality in moderately malnourished individuals can be attributed to a deterioration of the health environment, which increases the risk of infections.


Example of crisis strategies for a settled population

Increase resources:

  • sale of productive assets (tools, seeds, livestock)
  • massive slaughtering of livestock
  • mortgaging of farmland or house
  • sale of farmland, house, sale of land rights, harvest rights,
  • exchange of livestock for staple food

Breakdown in social structures:

  • prolonged migration, men do not return from seasonal migration or are enrolled in armies.
  • further cuts in use of water, firewood and health services
  • community structures (mutual help systems) collapse
  • Skilled and educated people (health staff) migrate
  • decrease of community funds for funerals and weddings
  • reduction of support to the non-productive members of households (small children, elderly, disabled)
  • marginalisation of non-productive individuals, (orphans, beggars, etc.


Stage 3: Famine: distress strategies

Famine is the last stage of this process. In nearly all cases, it is linked to war and conflict. It is characterised by excess mortality and high malnutrition in all the age groups of the population, complete destitution, social breakdown and distress migration as people abandon their homes in search of food. All coping mechanisms have been completely exhausted. The people are dependent on food aid for immediate survival. Famine situations can result from inadequate relief assistance during the food crisis stage. Relief assistance has been too little, too late, not well targeted, not well organised or co-ordinated and often diverted. This is frequently linked to serious constraints such as high levels of insecurity or lack of political commitment (at international, national or local level).
The combined effects of insufficient food intake and poor health environment are important factors leading to famine and death among moderately and severely malnourished people. In fact, the majority of deaths (in absolute number) occur amongst individuals who are not severely malnourished. One of the main underlying causes of famine mortality is deterioration in the health environment. In addition to an adequate provision of food, access to curative health care, environmental sanitation and shelter can avert many deaths.


An assessment should try to locate a deteriorating food and nutrition situation on the continuum of moving from food security to famine. The table below helps to determine the stage of the process of moving from food insecurity to famine. Each stage will not necessarily show all characteristics, but the table helps to illustrate which stage a situation has reached and in what direction the situation is likely to develop.

Specific characteristics of food insecurity, food crisis and famine
Food insecurity Food crisis Famine
Mortality rate Normal Increased or high Extremely high
Population movements Seasonal migration Population displacement +/- Distress migration
Global malnutrition rate could be increased Increased Extremely high
Mortality related to moderate malnutrition Low Elevated High
Severe malnutrition rate Low Moderate or high High
severe malnutrition in adults Low Low/moderate High
Livelihood changes Temporary irreversible Complete destitution
Selling of capital assets none or very limited Important Exhausted or very limited
Activity diversification Normal or slightly increased Increased +++ Exhausted or limited
Reduction of expenditures Reduced Reduced +++ No more possibility to reduce.
Food availability Normal or slightly decreased Reduced Rare or none
Food accessibility Slightly reduced Reduced Severely reduced or none
Dependence on food aid Low High or moderate Complete
Reduction in caring practices Low Moderate or high High



Locating a situation on the food security/famine continuum helps identify the most appropriate type of intervention. In a food insecurity situation the focus of interventions should be on preservation of livelihoods to prevent people sliding into food crisis and famine, e.g. food for work. Early warning systems are crucial at this stage. Support can be given to existing health structures to shore up treatment of individual cases of severe malnutrition.
In a food crisis situation it is crucial to prevent further movement along the continuum by ensuring enough food. E.g. general food distribution. As the social caring systems comes under pressure provisions should be made to support special vulnerable groups, e.g. elderly, orphans, under five's in general. Selective feeding programmes like therapeutic feeding centres and supplementary feeding centres can be installed. Health care systems and water resources may also require support.
In a famine situation, the primary goal is to ensure survival, to reduce mortality. The major focus is on general food distributions, supplementary feeding programmes, blanket feeding, and therapeutic feeding and mortality surveillance.

In the next issue Field Exchange there will be a further article based on revisions to the MSF guidelines. This article will elaborate further on choice of nutritional strategies and programme designs in relation to context.

Show footnotes

1inspired by H.Young, S. Jaspars. Nutrition Matters. Intermediate Technology publication, London. 1995.

More like this

FEX: The danger of interpreting anthropometric data out of context

Mark Myatt is a consultant epidemiologist and senior research fellow at the Institute of Ophthalmology. His areas of expertise are infectious disease, nutrition and survey...

FEX: New variant famine in southern Africa

Summary of presentation paper1 A paper, presented to a SADC2 Vulnerability Assessment Committee (VAC) meeting in Victoria Falls in October 2002, has argued that the famine...

FEX: What is Livelihoods Programming? (Special Supplement 3)

2.1 Livelihoods principles and the livelihoods framework The livelihoods principles and framework form the basis of all livelihoods programming. The fundamental principles of...

FEX: Maintaining GOAL’s capacity to support surveillance in Ethiopia

By Zeine Muzeiyn and Ewnetu Yohannes Zeine Muzeiyn has been working in the area of Nutrition for the last seven years. Before he joined GOAL Ethiopia, he had been working in...

FEX: Livelihoods analysis and identifying appropriate interventions (Special Supplement 3)

3.1 Livelihoods assessment and analysis in emergencies The livelihoods framework provides a tool for analysing people's livelihoods and the impact of specific threats or shocks...

FEX: Malawi food shortage: how did it happen and could it have been prevented?

By Sarah King Sarah King is currently working as an Emergency Capacity Building Officer with Christian Aid. Having completed a MSc in Public Health Nutrition at LSHTM, she...

FEX: Lessons learned in West Darfur: challenges in assessment methodologies

By Aranka Anema Aranka Anema has a background in medical anthropology. She is currently working with MSF-Holland as Medical Editor and has been involved with the Nutrition...

FEX: Retrospective determination of whether famine existed in Niger

Summary of published research1 A child admitted to an MSF therapeutic feeding programme in Niger. A recent study set out to apply the famine scale developed by Howe and...

FEX: Emergency Food Security and Livelihoods Project in Amhara and Oromia regions

By Shekar Anand, Oxfam Shekar is Programme Director for Oxfam GB in Ethiopia. Past experience includes working with OXFAM, CARE, CIDA, and Government in Aceh, India, Zimbabawe...

FEX: 2011 famine in South Somalia: the role of the early warning information System

By Abukar Yusuf Nur - Nutrition Analyst, Ahono Busili - Nutrition Team Manager, Elijah Odundo - Nutrition Data Analyst, Joseph Waweru - Nutrition Analyst, Louise Masese -...

FEX: Impact of food aid on two communities in Niger

By Sarah McKune and Nicole Hood Dr Sarah McKune is the Director of Public Health Programmes at the University of Florida. She has worked in the West African Sahel since 2004,...

FEX: Ethiopia: Challenge and Change (Special Supplement 3)

By Catherine Allen, Concern WW Work on the Wollo Irrigation Canal, one of the Concern WW livelihood programme activities Concern WW is trying to create mutually reinforcing...

FEX: Issue 19 Editorial

This issue of Field Exchange is dedicated to Prof. John Kevany (ENN Director) who died on 20th April 2003. John was instrumental in establishing the ENN. Given John's...

FEX: A fragile situation in Sudan: review of the 2001 nutritional situation

By Mutinta Nseluke-Hambayi Mutinta Nseluke-Hambayi is a nutritionist who has been working as a Nutrition Emergency Officer for the past 3 years, supporting all WFP emergency...

FEX: Spotting the invisible crisis: early warning indicators in urban slums of Nairobi, Kenya

By Lilly Schofield, Shukri F Mohamed, Elizabeth Wambui Kimani-Murage, Frederick Murunga Wekesah, Blessing Mberu and Thaddaeus Egondi, Catherine Kyobutungi and Remare Ettarh...

FEX: Issues and challenges for livelihoods programming in emergencies (Special Supplement 3)

8.1 Introduction The previous sections of this supplement have highlighted various challenges in livelihood support programming in emergencies. Most of these are within the...

FEX: Joint Emergency Operation Plan NGO response to emergency food needs in Ethiopia

By Alix Carter Alix Carter has worked in the humanitarian sector in Ethiopia for almost three years. She is currently working as the Humanitarian Accountability Advisor at...

FEX: Dangerous delay in responding to Horn of Africa early warnings of drought

Summary of briefing paper1 According to a briefing paper just released by Oxfam and Save the Children UK (SC UK), the 2011 crisis in the Horn of Africa has been the most severe...

FEX: Livelihoods under siege in Dafur

Summary of unpublished study1 Burnt grain from granaries torched by the Janjaweed Never before in the history of Darfur has there been such a combination of factors causing...

FEX: Delivering Supplementary and Therapeutic Feeding in Darfur: coping with Insecurity

By Gwyneth Hogley Cotes, GOAL Gwyneth joined GOAL in November, 2005 as the Nutrition Coordinator for Darfur, Sudan. She has a BA in International Studies and Master of Public...


Reference this page

Saskia van der Kam (). Revised MSF Nutrition Guidelines. Field Exchange 10, July 2000. p20.



Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.