The most costly and damaging natural disasters in Turkiye are earthquakes. On February 6, 2023, at 04.17 a.m., an earthquake with a magnitude of 7.7 occurred in the Pazarcık district of Kahramanmaraş. The earthquake was felt strongly in 10 provinces and caused great loss of life and property. At 13:24 on the same day, another earthquake with a magnitude of 7.6 occurred in the Elbistan district of Kahramanmaraş. The total area of the provinces affected by the earthquake was 108 812 km2, which is larger or close to the land area of many countries. The earthquakes killed 50 783 people in Turkiye and 6600 people in Syria, injured 107 204 people in Turkiye and 14 500 people in Syria, and affected 13.5 million people in Turkiye.1
Disasters generally lead to the disruption of basic health needs such as clean water, food, and sanitation through the direct destruction of infrastructure and support systems.Reference Koçak2 As a result, the earthquake caused a short-term problem in the logistics of food supplies in the region. The presence in the region of people with chronic health problems such as obesity, diabetes, and hypertension, and vulnerable groups such as the elderly, children, and pregnant and lactating women, highlights the need for urgent and effective provision of nutrition services.3 However, the destruction of infrastructure and services in the earthquake has disrupted both the food supply and labor market in the region, creating barriers to food exchange.
The Turkiye Disaster Response Plan (TAMP), which is conducted in a unified and modular structure for coping with problems that may arise in disasters, has been activated by the Disaster and Emergency Management Authority (AFAD) of the Ministry of Interior of the Republic of Turkiye. TAMP designates the Turkish Red Crescent as the main solution partner to meet the nutritional needs during disasters. The Turkish Red Crescent has met the food needs of disaster victims in the disaster area by distributing food parcels and establishing field kitchens. The food used in these centers comes from existing stocks, new purchases, and donations. However, these relief operations are subject to the approval of the Turkish Red Crescent nutrition service. In this way, it is ensured that health and nutritional problems arising from the distribution of food of poor nutritional quality can be prevented.Reference Colón-Ramos, Roess and Robien4 Alongside compliance with terms of nutritional quality, it is expected that the nutritional services provided in the region meet individuals’ daily nutrient requirements in accordance with the Turkish Dietary Guidelines (TDG).5, 6 However, compliance with nutrition guidelines in emergencies is limited due to the rapid nature of the response and the fact that food comes from different contracts and donor sources. Filling this data gap can improve the effectiveness of humanitarian interventions that respond to the nutritional needs of communities during disasters. The aim of this study was to evaluate the nutritional quality of meals distributed in the field and in mobile kitchens set up in the region after the Kahramanmaraş earthquakes in terms of energy and macronutrient content and their compliance with TDG recommendations.
Methods
The study has a descriptive cross-sectional epidemiological design. The study was conducted in 10 provinces affected by the earthquake: Kahramanmaraş, Gaziantep, Şanlıurfa, Diyarbakır, Adana, Adıyaman, Malatya, Osmaniye, and Kilis. Ethical approval was obtained from the Health Sciences University Hamidiye Scientific Research Ethics Committee (07.07.2023; No:2023/13/2), and permission was obtained from the Turkish Red Crescent.
Population and Sample
The population of the study consists of the menus distributed in the field kitchens established around the evacuation assembly areas of earthquake zones. Records were taken from 10 feeding points, 1 from each province.
Data Collection Tool
An observation form was developed by the researchers to document the types of food served at meals. The form consists of the date of observation, meal type, quantity (portion, quantity, etc.), and number of people.
Statistical Analysis of Data
Data collection was carried out from the second day of the earthquake (February 7), when the regular recording of meals started at the nutrition service points. From the first day when the 3 meals (morning, lunch, and dinner) were regularly recorded, the menu contents were recorded 3 times (February 7, March 7 and April 7) at 1-month intervals. The content information of the main meals served at the nutrition service points was taken at 1-month intervals and the weight information of the foods included in the meals was recorded according to the standard recipes prepared for institutions where collective nutrition is provided.5 The amounts of energy (kcal), carbohydrate (g), protein (g), fat (g), saturated fat (g), total fibre (g), zinc (mg), and iron (mg) of the 3 meals and the contribution of macronutrients (carbohydrates, protein, and fat) to energy were calculated using the Nutrition Information System (NIS) 8.1.7 In addition, the rates of meeting the recommended intakes in the TDG for the adult age group were assessed on the basis of daily averages.6 The Recommended Daily Allowance (RDA) for Turkiye was used to determine the percentages of energy and nutrient adequacy of the menus distributed in the region. Nutrient intakes of less than two-thirds of the RDA (67%) are considered inadequate, while intakes of more than one-third of the RDA are considered high (133%).6 The contribution of energy from protein, carbohydrates, and fat, which are macronutrients, to total energy was calculated as a percentage. According to TDG, 15%-20% of the daily dietary energy intake should come from protein, 45%-60% from carbohydrates, and 20%-35% from fats.
Results
During the Kahramanmaraş earthquakes, 570 public institutions and/or non-governmental organizations (NGOs) provided food assistance at 2342 assembly points in 10 provinces on February 7, March 7, and April 7. These food distribution points were established in 461 locations on February 7, 1406 locations on March 7, and 1921 locations on April 7. The Turkish Red Crescent established field kitchens and/or mobile kitchens in 117 (25.4%) locations on February 7, 503 (35.8%) locations on March 7, and 852 (44.4%) locations on April 7.
During the Kahramanmaraş earthquakes, The Turkish Red Crescent regularly provided three main meals in 10 provinces, with the exception of some meals. The missing meals were provided by public institutions and other NGOs with feeding platforms. For 3 days in 1 provinces, 4 841 460 people were provided with menus by TRCS at only 10 feeding sites (Table 1).
Menu person counts according to meal, province, and date variables*
Note: The menus for the cells with “-” are left blank, as they are provided by other Nutrition Platform partners, public institutions, and non-governmental organizations.
On February 7, the daily intakes of energy, protein, fat, zinc, and iron were found to be inadequate according to the RDA coverage percentages. However, on March 7 and April 7, the coverage percentages of energy and nutrients increased compared to the first day, and intakes were adequate according to the recommended intakes (Table 2). In particular, the energy and nutrient deficits on February 7 were covered by additional menus according to need.
Average energy and nutrient contents of menus by day in the provinces affected by the earthquake
While making the calculations, provinces where data for all meals were not available were not included.
* It is given as X̄ ± SD
Ψ According to the nutritional pattern containing 2000 kcal of energy, the percentage of meeting the recommended amount of nutrients was calculated.
RDA: Recommended Dietary Allowance
The energy coverage percentages of macronutrients of the menus were analyzed. On February 7, the mean percentage of energy coverage was 15.3±3.27% for protein, 60.0±4.20% for carbohydrate and 24.8±3.19% for fat. On February 7, March 7, and April 7, the percentages of macronutrient contribution to energy were within the recommended range.
Discussion
The aim of this study was to evaluate the energy and nutrient content of food served in shelters and feeding areas during disasters in Turkiye. During the acute and post-acute phases of the earthquake, 570 public agencies and/or NGOs provided food assistance in 2342 different assembly points in ten provinces on February 7, March 7, and April 7. TRCS set up field kitchens and/or mobile kitchens in 117 (25.4%) locations on February 7, 503 (35.8%) locations on March 7, and 852 (44.4%) locations on April 7. During the Kahramanmaraş earthquakes, TRCS and its Disaster Nutrition Platform solution partners served menus to over 4.8 million people in 10 different locations in just 3 days. It was also observed that liquid beverages such as tea, coffee, and packaged water, as well as snacks, were continuously provided to the public and staff at the feeding sites. The actual numbers are much higher, especially as this massive service was sustained for 5 months over a wide geographical area where infrastructure and support systems had collapsed. Therefore, food aid operations carried out by the Turkish Red Crescent during emergencies and disasters should be in accordance with TUBER.5, 6 However, in the study, the meals distributed by the Turkish Red Crescent after the earthquake were generally high in carbohydrates, fat, and saturated fat on some days. This may be a concern when assessing the burden of obesity and diet-related chronic diseases in the general population.3 At the same time, it was observed that a special gluten-free diet kitchen for celiac disease patients was provided by the TRCS in each province during the disaster. In another geography, almost half of the food distributed by federal relief efforts after Hurricane Maria in Puerto Rico was found to be high in sodium, saturated fat, or added sugar. The community also suffered from high rates of obesity and diet-related chronic disease burden.Reference Colón-Ramos, Roess and Robien4 Although disasters affect the feasibility of food aid plans, emergency food needs to be better aligned with national dietary guidelines to support the health of survivors.8
In the study, an evaluation was made in terms of protein, carbohydrate, fat, pulp, saturated fat, zinc, and iron. Nutrients such as protein, zinc, and iron, deficiencies of which are associated with a range of health problems, were found to be deficient on some days. Micronutrient deficiencies are particularly high in refugee and displaced populations. The most common diseases are iron and vitamin A deficiency, scurvy (vitamin C deficiency), pellagra (niacin and/or tryptophan deficiency), and beriberi (thiamine deficiency). Epidemics are also triggered by inadequate food rations for populations dependent on food aid. To prevent deficiencies of these micronutrients, an adequate and balanced diet is important.Reference Prinzo and de Benoist9 However, this can be a difficult strategy in the early stages of a food aid operation, as in the case of the Kahramanmaraş earthquake, which affected more than 15 percent of the country’s population. Although the literature recommends fortified cereal rations during this transitional period ,Reference Prinzo and de Benoist9 the Kahramanmaraş earthquake menus regularly included vegetables, fruits, and legumes.
The inclusion of high-energy, low-nutrient foods, such as confections and chocolate in food rations, undermines the right to healthy food for disaster victims.Reference Colón-Ramos, Roess and Robien4 Therefore, nutrition programs should be integrated into national nutrition guidelines in a way that supports the health of disaster victims.Reference Colón-Ramos, Roess and Robien4 The value of savory food products to the recipient population is important. This is because many disaster victims in Puerto Rico felt disrespected during relief efforts when they received boxes containing only or mostly sweets and crisps.Reference Colón-Ramos, Roess and Robien4, Reference Dewey10 It was found that the menus of the Turkish Red Crescent did not include high-energy, low-nutrient foods.
Limitations
The results of this study should be considered in the context of the following issues. First, the types of meals observed vary from province to province. Second, in some provinces, some meals were provided by other NGOs or public agencies that were not included in the calculations. Caution should therefore be exercised in interpreting quantitative analyses. Third, this study provides an assessment of the multiple strategies used by the Turkish Red Crescent to respond to emergencies.
Conclusions
The Turkish Red Crescent and partners of the Disaster Nutrition Platform conducted a large-scale, multi-site nutritional operation in 10 provinces for 5 months during and after the acute phase of the earthquake. In the immediate aftermath of the earthquake, the study found that daily energy and nutrient intakes were normal. Meals were provided by other public agencies and NGOs in some provinces. The contribution of macronutrients to energy was within the normal range. In conclusion, the results of the large-scale feeding operation emphasize the importance of aligning menus at feeding sites with national nutrition guidelines to support the health of survivors.
Author contributions
Cüneyt Çalışkan: Conceptualization, Investigation, Methodology, Supervision, Writing – original draft; Yasemin Tuğba Öğünç: Methodology, Formal analysis, Visualization; Kerem Kınık: Writing – review & editing; Nihal Dağ: Formal analysis, Visualization; Muhammed Burkay Durak: Data curation.
Funding statement
No funding was received from any institution during the scope of the research.
Competing interests
None.
