Associations Between Lifestyle Factors and Constipation Among Survivors After the Great East Japan Earthquake: A 9-year Follow-up Study.

BACKGROUND: Disaster survivors experience deterioration in lifestyles and an increase in constipation. After the Great East Japan Earthquake in 2011, some survivors were evacuated for a long term, even after moving to temporary housing and public reconstruction housing. However, annual changes in constipation and the association between lifestyles and constipation among the survivors are still unknown. METHODS: Overall, 9,234 survivors aged 18 years or older participated in this 9-year follow-up survey after the disaster. Information about the prevalence of constipation and lifestyle factors (diet, physical activity, and mental health) was collected using a self-reported questionnaire. Their dietary intake was categorized into the following two dietary patterns: prudent (fish and shellfish, soybean products, vegetables, fruits, and dairy products) and meat (meat and eggs). Odds ratios for constipation according to lifestyle factors were calculated using a generalized linear mixed model. RESULTS: In women, the prevalence of constipation was the highest at baseline (8.7%) and remained around 5% afterward. In both men and women, older age, poor mental health, and poor physical activity were significantly associated with higher odds ratios of constipation. Moreover, a lower frequency of meals and a lower prudent dietary score were significantly associated with women's constipation. CONCLUSION: The prevalence of constipation was the highest at baseline and remained around 5% in women. Lifestyle factors, such as poor mental health, physical inactivity, and low frequency of meals were associated with constipation. Our findings suggest continuous support for the survivors with constipation for medium- to long-term after disasters.

Revision of "Nutritional Reference Values for Feeding at Evacuation Shelters" and Model Menus: A Qualitative Study.

OBJECTIVE: In 2011, the Japanese government issued nutritional reference values for energy; protein; vitamins B1, B2, and C; and salt to deal with poor meal quality in evacuation shelters. Because they were not widely used owing to their impracticality, the authors had examined the values according to the experience-based opinions of public health dietitians. Furthermore, we developed a usage tool containing a model menu that meets these values. This study aimed to confirm the usability of these revised values and model menus and collect ideas for improvement. METHODS: We conducted 8 semi-structured group interviews with 12 dietitians, 9 disaster management officers, and 2 public health nurses in local governments supposed to have been affected by a large-scale disaster. RESULTS: New reference values were highly evaluated by most participants. Interviewees said that model menus were helpful for evacuees or disaster officers who are unfamiliar with nutrition because they show combinations of food items that meet the reference values instead of the amounts of energy and nutrients. To improve their understanding, it was suggested that food items be categorized by staples, main dishes, and side dishes, encouraging them to complete these three components of a balanced diet. Because it was difficult to meet all the reference values in the immediate aftermath of the disaster, it was suggested that the time-dependent priority of each nutrient and model menus that supply the nutrient should be shown by disaster phases along with the assumed availability of utility for cooking in each phase. CONCLUSION: The new reference values were feasible to meet during emergencies. Although model menus were also appreciated, further improvements were necessary for better understanding.

Children's Diet and Nutrition in the Aftermath of the Torrential Rain Disaster in Western Japan: An Evaluation of Support Activities by Dietitians to Alleviate Mothers' Anxieties.

OBJECTIVE: The purpose of this study was to clarify whether the support activities of dietitians during disasters were able to address the problems faced by mothers about their children's diet and nutrition. METHODS: Dietitians (7 in total) and mothers (8) were selected by the snowball sampling method. Semi-structured interviews were used to conduct focus group interviews about children's diet and nutrition. Verbatim data were generated, and an inductively qualitative descriptive analysis was conducted. RESULTS: Six categories were generated for each group. Dietitians responded to problems that mothers had regarding their children's diet and nutrition via 2 activities: [dealing with allergy food shortages] and [school lunch support]. CONCLUSION: It is important for dietitians to recommend stockpiling allergy-friendly foods to accommodate children with allergies and achieve early resumption of school lunches to meet children's nutritional needs.

Meal plans for meeting the reference values using food items available in shelters.

BACKGROUND: We have suggested "Revised Nutritional Reference Values for Feeding at Evacuation Shelters" (Revised RV) as a daily nutritional recommendation for meals served at evacuation shelters where poor diets had been reported. Since there are no meal examples to satisfy the Revised RV, our objectives were, for the future meal provision, to develop nutritionally adequate meal plans using the foods served at shelters in the past and to examine if the Revised RV could be met by changing combination of foods available. METHODS: In this case study using secondary data, we analyzed food weights of 86 meals served and recorded at 12 shelters after the heavy rains in July 2020. We obtained these data from Kumamoto Prefecture that was damaged and asked us dietary assessment for nutrition assistance. Foods were classified into 3 types according to the check mark in the record sheets: food aid (commercial packaged food), boxed meal, and hot meal service. We counted serving frequency of each food and analyzed nutritional differences by their combinations. Menus were devised by choosing foods that were served more frequently or were more nutritious among those served at shelters. The target values for one meal were set at 1/3 of the Revised RV for energy, protein, vitamins B1, B2, and C, and salt. RESULTS: None of the meals served in the shelters satisfied the target. We created 2 menus using food aid only: (#1 curry doughnut, milk with long shelf-life, and orange jelly) and (#2 salmon rice ball, ham and cheese sandwich, and vegetable juice); 1 menu by combination of boxed meal and food aid: (#3 boxed meal and vegetable juice); and 2 menus by combination of hot meal service and food aid: (#4 chicken meatball soup, packaged tofu, soy sauce, preprocessed white rice, and bottled green tea) and (#5 bamboo shoots rice, chicken and vegetable miso soup, and bottled green tea). Planned menus generally contained more energy, protein, and vitamins and less salt than the meals served. Their vitamin C contents were especially higher. CONCLUSION: Nutritionally adequate meals could be planned by changing the combination of foods available in shelters.

Validity and reproducibility of food photographic estimation for evaluating meals in evacuation shelters.

Objective: The primary goal was to evaluate the validity of food photographic estimation for nutritional assessment compared with weighed food record (WFR). Methods: We evaluated the validity and reproducibility of photographic estimation of foods provided in evacuation shelters. We analyzed 35 meals served at 12 shelters in Kumamoto Prefecture in Japan, affected by a heavy rain disaster in 2020. In this context, we compared 21 senior students' portion size estimation by food photographs to WFR. In addition, we assigned five meals for each of the 21 senior students, and the same meal photograph was estimated by three students to test reproducibility. Results: No statistically significant difference was detected between the two methods regarding energy, the total grams of meal, the protein, and vitamins B1, B2, and C, except for salt. In addition, the students who never self-cooked underestimated the total grams. Conclusion: Food photographic estimation could simplify the nutritional assessment in evacuation shelters. However, unclear photographs and food items served by weight could weaken the estimation accuracy. According to previous studies and the applied postestimation questionnaire, photographs taken from specified angles and reference food photobooks for portion size estimation may improve accuracy.

Usefulness of Simple Meal Screening Using Dietary Assessment Sheets for Evacuation Shelters.

To maintain the health of evacuees, meals provided at emergency shelters should be monitored and improvement measures should be taken where necessary. Time and human resources are limited during devastating disasters; thus, the authors have developed the Dietary Assessment Sheets for Evacuation Shelters. This study examines whether the quality of meals can be assessed using simple check items on the Dietary Assessment Sheets.A total of 28 Dietary Assessment Sheets for 98 meals provided 16-19 days after the heavy rains in Kumamoto in July 2020 at 12 shelters were used in the analysis. Dietitians working for shelters were requested to fill the Dietary Assessment Sheets and food record sheets provided by the Prefectural Government. If any subitem was checkmarked, it was considered "checked," and if left blank, it was considered "not checked" and divided into categorical groups. Based on the food record sheets and meal photos, contents of energy, protein, and vitamins B1, B2, and C were calculated for each meal. Energy and nutrient contents were compared between the categorical groups.The study revealed that nutritionally poor meals were characterized as those comprising only "Grain dishes," those that were not "Boxed meals," and those involving "Self-Defense Forces," "Dietitians," or "Others." Their energy, protein, and vitamin B1, B2, and C content was significantly lower than that of meals with marks on other checkboxes in the same category.Shelters that provide these meals should be given priority for nutrition assistance due to their poor diets. The results imply that the Dietary Assessment Sheets could serve as a simple tool to determine the shelters that require nutritional assistance.

Frontiers in Disaster Nutrition: Evidence to Action.

The need for food and nutrition assistance has increased due to the frequent occurrence of disasters and pandemics, such as coronavirus disease 2019 (COVID-19). However, after a disaster, food and nutrition are insufficient in terms of quantity and quality. In the case of the Great East Japan earthquake, the improvement factors for food and nutrition at emergency shelters included 1) emergency shelter size and equipment, 2) provision and content of meals, 3) collaboration among professionals, and 4) cooperation between shelters. However, there were hygiene and oral health problems, and dispatched dietitians had problems with nutrition assistance. The hygiene problems included 1) food, 2) cooking environment, 3) water supply and discharge, and 4) living space. In addition, oral health problems included 1) difficulty swallowing, 2) difficulty chewing, 3) environmental degradation, and 4) degradation of the oral condition. The problematic points of dispatched dietitians included the support provided not necessarily being consistent with needs, operational deficiencies at both the dispatching and receiving sides, and the short period of support. "Enthusiasm" can be a source of encouragement and a burden. To solve these problems, a training system for disaster dietitians and certification systems for disaster food have been established in Japan. Since the Great East Japan earthquake, various kinds of evidence and actions have been taken, and nutritional problems after disasters have gradually improved. Therefore, it seems that advanced actions and standards should be set not only in Japan but also globally.

Similarities between Disaster Food and Space Food.

Disaster and space environments are similar in that they are closed environment, with limited lifelines. Here, we examined the similarity between disaster food and space food, to explore interactive problem-solving of food support for disaster and space environments. The Japan Disaster Food Certification Standards (Japan Disaster Food Society) and the Japanese Space Food Certification Standards (Japan Aerospace Exploration Agency) requirements and certified products, which were posted on the websites as of June 16, 2021, were compared. Certified products were classified into "staple foods," "main and/or side dishes," "milk and dairy products," "fruits," "confectionery and favorite beverages," "condiments," "dietary supplements," and "sets." Certification standards involved six items for Japan Disaster Food and eight items for Japanese Space Food. Most standards were similar. Concretely, both standards demanded room temperature storage, tough packaging and hygiene management in facilities. Both emphasized habitual food and easy eating. However, the best-by date was ≥6 mo for Japan Disaster Food, but ≥1.5 y for Japanese Space Food. In addition, Japanese Space Food required noted nutritious, food hygienic, eatable in space, cookable by specific equipment, endurable pressure by launch, and domestically produced food. There were 171 and 47 products of Japan Disaster Food and Japanese Space Food, respectively. Staple foods (pregelatinized rice, etc.) and main and/or side dishes were commonest among Japan Disaster Foods and Japanese Space Foods, respectively. It is possible to utilize of Space Food as Disaster Food, but there are some issues that must be cleared before "utilization of Disaster Food as Space Food."

Seven-year incidence of new-onset hypertension by frequency of dairy intake among survivors of the Great East Japan Earthquake.

Survivors of natural disasters are at a high risk of cardiovascular disease. Behavioral risk factors, including modifiable diet, need to be identified. Thus far, the association between dairy intake and new-onset hypertension among these survivors is unknown. Therefore, we investigated this relationship. We conducted a longitudinal cohort study of 4475 survivors of the Great East Japan Earthquake in 2011 who participated in a 7-year follow-up survey. New-onset hypertension was assessed using annual health checkup data. Information on the frequency of dairy intake was obtained using a self-report questionnaire. The hazard ratio for developing hypertension according to the frequency of dairy intake was calculated using Cox proportional hazards regression models. The total number of person-years observed was 20,042, with a median follow-up of 5.4 years. During the observation period, 1554 individuals developed hypertension. The multivariable-adjusted hazard ratios of new-onset hypertension were significantly lower in those who consumed dairy products once per day (0.82, 95% confidence interval 0.71-0.94) and twice or more times per day (0.84, 95% confidence interval 0.71-0.99) than in nonconsumers; the inverse linear trend was marginally significant (P = 0.083). This association was not affected by lipid metabolism and was consistent across subgroups by sex, age, behavioral factors, cardiometabolic factors, and housing type due to the disaster. A higher frequency of dairy intake was associated with a lower risk of new-onset hypertension in community-dwelling survivors of earthquakes and tsunamis. Dietary guidance involving dairy intake could reduce the risk of developing hypertension among these survivors.

Association between the prevalence of hypertension and dairy consumption by housing type among survivors of the Great East Japan Earthquake.

Survivors of the Great East Japan Earthquake in 2011 had higher risks of cardiovascular diseases and hypertension, particularly residents of heavy flooding areas and evacuees. Thus far, the association between the prevalence of hypertension and dairy consumption remains unknown among these evacuees. We investigated this association by housing type after the Great East Japan Earthquake. In this cross-sectional study, we conducted a baseline survey among 9569 survivors of the earthquake, aged ≥18 years, between September 2011 and February 2012. Hypertension was defined as a systolic/diastolic blood pressure ≥140/90 mmHg or as persons undergoing treatment for high blood pressure. The frequency of dairy consumption was determined using a questionnaire. Participants living in prefabricated housing and emergency shelters were regarded as residents of temporary housing. Hypertension was prevalent among 43.8% and 44.7% of the participants in temporary and non-temporary housing, respectively. A logistic regression analysis of the prevalence of hypertension by daily dairy consumption showed that the magnitude of multivariable-adjusted odds ratios differed according to housing type (odds ratio, 0.64; 95% confidence interval, 0.51-0.80 in temporary housing; odds ratio, 0.85; 95% confidence interval, 0.73-0.995 in non-temporary housing; P for interaction = 0.0501). These associations were consistent across subgroups according to sex, age, behavioral factors, obesity, disorders of lipid metabolism, and economic status. A higher frequency of dairy consumption was associated with a lower prevalence of hypertension among community-dwelling survivors of earthquakes and tsunamis, particularly those living in temporary housing. Therefore, dietary therapy involving dairy consumption could help prevent hypertension among evacuees.

Attitudes toward using "Simple simulator for calculating nutritional food stocks in preparation for large-scale disasters" among local governmental personnel and public health dietitians in Japan: An explanatory mixed methods study.

The Japanese Ministry of Health, Labour and Welfare compiled an Excel sheet - "Simple simulator for calculating nutritional food stocks in preparation for large-scale disasters" (Simulator). We examined the level of recognition and use of the Simulator by local governments and identified the points for its improvement. In stage 1, we surveyed local government personnel who participated in the "Workshop for nutrition assistance during large-scale disasters" held in November 2020 (n = 458; 313 responded) with an online questionnaire on the use of the Simulator and associated issues. Stage 2 involved group interviews with 15 public health dietitians who had been involved in food assistance during past natural disasters to identify points for improving the Simulator and the problems with food assistance during natural disasters. In stage 1, 233 responders (74.4%) confirmed their awareness of the existence of the Simulator. While 85 individuals (36.6%) used the Simulator, 63 individuals (74.1%) confirmed that they would use it in the future to plan and evaluate local government stocks. In stage 2, multiple comments regarding the Simulator's applicability and improvement in a realistic situation were collected. In order for the administrative staff in charge of disaster management to understand the nutritional importance of stockpiling main/side dishes, it was suggested that specific combinations of foods that meet the required amounts should be shown and that visualization using food products and the number of people covered by stockpiled foods may be easier to understand than pure nutritional values.

Association between personality traits and food stockpiling for disaster.

This study investigated the association between personality traits and food stockpiling for disasters in predicted high-risk areas of food shortages due to the Nankai Trough Earthquake. This survey was conducted between December 18 and 20, 2019, using a web-based questionnaire. The participants were 1,200 individuals registered with an online survey company. This study analyzed the association between the Big Five personality traits and food stockpiling status (n = 1192). The Big Five personality traits assess five basic dimensions of personality (i.e., extraversion, conscientiousness, agreeableness, neuroticism, and openness). To measure theses personality traits, we used the Japanese version of the Ten-Item Personality Inventory (TIPI-J). The Mann-Whitney test and a multivariable logistic regression analysis revealed that none of the Big Five personality traits were significantly associated with having or not having stockpile food. However, interestingly, considering the stages of behavior change regarding stockpiling, high extraversion was significantly positively related to initiating stockpiling. Moreover, high neuroticism was significantly positively related to interrupted stockpiling. Therefore, it is crucial to focus on personality traits (especially low extraversion and high neuroticism) to promote food stockpiling for disasters.

Revising "Nutritional Reference Values for Feeding at Evacuation Shelters" According to Nutrition Assistance by Public Health Dietitians Based on Past Major Natural Disasters in Japan: A Qualitative Study.

It is important to provide nutritionally adequate food in shelters to maintain the health of evacuees. Since the Great East Japan Earthquake in 2011, Japan's Ministry of Health, Labour and Welfare has released the "Nutritional Reference Values for Evacuation Shelters" (Reference Values) after every major natural disaster. There is clear evidence, however, that the Reference Values have only been used infrequently. This study aims to revise these guidelines to include the actual situation in the affected areas and the feasibility of the endeavor. This qualitative study uses group interviews with local government dietitians to propose revisions to Japan's Reference Values. These revisions include the following: issuing Reference Values within 1 week of a disaster, showing one type of values for meal planning for each age group, showing the minimum values of vitamins, upgrading salt to basic components, creating three phases of nutrition (Day 1, Days 1-3, and After Day 4), stipulating food amounts rather than nutrient values, and creating a manual. Local government officials could use the Reference Values as guidelines for choosing food reserves, and dietitians could use them while formulating supplementary nutrition strategies for a model menu in preparation for disasters.

Association between Lifestyle Changes and at-Home Hours during and after the State of Emergency Due to the COVID-19 Pandemic in Japan.

Lifestyle changes during the coronavirus disease (COVID-19) lockdown have been previously examined, but there is limited understanding about changes after such restrictions were lifted. This study examines changes in lifestyle habits and body weight among the Japanese population with regard to the length of at-home hours both during (April to May) and after (September) the nationwide stay-at-home request compared to those before the COVID-19 pandemic (January 2020). An online survey was conducted in September 2020 involving 10,000 Japanese survey monitors, selected according to population distribution. During the stay-at-home request, 34% participants extended their at-home hours. More respondents in the group with extended at-home hours experienced an increase or decrease in total physical activity, snacking, food intake, alcohol drinking, and body weight than those in the group with nonextended at-home hours. Some of these changes had a trend according to age. The prevalence of most of these changes decreased when at-home hours returned to normal after the stay-at-home request period; however, increased alcohol consumption and increased or decreased body weight persisted. Our findings suggest that close monitoring for further health outcomes and age-appropriate measures to encourage favorable health behaviors is needed.

Association between Health Practice and Food Stockpiling for Disaster.

In this study investigated the association between health practices and food stockpiling for disasters in predicted areas with a high risk of food shortage due to the Nankai Trough earthquake. A survey was conducted during 18-20 December 2019 using a self-administered web-based questionnaire. In total, 1200 individuals registered with an online survey company participated in the study. The association between health practices and food stockpiling status was analyzed (n = 998). 59.1% of participants had a poor Breslow's seven health practice scores (BHPS), 32.9% had a moderate score, and 8.0% had a good score. Multivariable logistic regression analysis revealed that higher BHPS had a significantly higher prevalence of food stockpiling. Additionally, the interrupted group had the highest percentage of participants with low BHPS. Lower BHPS was significantly associated with interrupted stockpiled in the adjusted models. Among the seven health practices, the odds ratio of the "eating breakfast" practice was high. There was a significant positive association between higher health practice scores and food stockpiling for disasters in areas with a high risk of food shortage due to the predicted earthquake. Particularly, it was clarified that individuals who had fewer good health practices were associated with ending up interrupting food stockpiling.

Prolonged Maternal and Child Health, Food and Nutrition Problems after the Kumamoto Earthquake: Semantic Network Analysis of Interviews with Dietitians.

Infants need sufficient nutrients even during disasters. Only qualitative descriptive analysis has been reported regarding nutritional problems of mothers and children after the Kumamoto earthquake, and non-subjective analysis is required. This study examined issues concerning maternal and child health, food and nutrition after the Kumamoto earthquake using automatic computer quantitative analysis from focus group interviews (FGIs). Study participants (n = 13) consisted of dietitians in charge of nutrition assistance of infants in affected areas. The content of the interviews was converted into text, nouns were extracted, and co-occurrence network diagram analysis was performed. In the severely damaged area, there were hygienic problems not only in the acute phase but also in the mid-to-long-term phase. "Allergy" was extracted in the surrounding area in the acute and the mid-to-long-term phase, but not in the severely damaged area as the acute phase issue. In the surrounding area, problems have shifted to health and the quality of diet in the mid-to-long-term phase. This objective analysis suggested that dietary problems for mothers and children after disaster occurred also in the mid-to-long-term phase. It will be necessary to combine the overall trends obtained in this study with the results of qualitative descriptive analysis.

Analysis of Necessary Support in the 2011 Great East Japan Earthquake Disaster Area.

Altogether, 1588 dietitians were dispatched from the Japan Dietetic Association (JDA) to a disaster area for the first time on a nationwide scale following the 2011 Great East Japan Earthquake. Various studies have been conducted based on the activity reports, but the support that the disaster area requested was not documented. The purpose of this study is to identify the support that was needed in the disaster area. Therefore, we investigated the necessary support desired by dietitians who lived in the disaster areas. Questionnaires were sent to 1911 dietitians who were members of the JDA and lived in 3 affected prefectures in August 2012. In total, 435 dietitians (22.8%) completed the questionnaire. Among the questions on the questionnaire, we analyzed answers to the open-ended question: "Please write freely about the support that you wanted at the time of the disaster" (n = 332). Using qualitative descriptive analysis, we extracted data from the answers and categorized and labeled them into similar groups. These groups were divided into four categories: (1) "goods," (2) "establishing a system in advance of a large-scale disaster," (3) "information," and (4) "human resources." To provide "goods," "information," and "human resources" to the disaster area smoothly, it is important to plan a "system" in advance of large-scale disasters.

Local Governments' Disaster Emergency Communication and Information Collection for Nutrition Assistance.

We examined local governments' disaster emergency communication and information collection and distribution systems. Postal surveys were conducted for all prefectures, cities with public health centers, and specified districts in Tokyo Metropolis in 2005 and 2013. Municipalities were included in the 2013 survey only. The response rate for the 2013 survey was 71.2% (n = 1272). Thirty-six prefectures, 41 cities with health centers, and 16 specified districts in Tokyo Metropolis answered both surveys. A majority of respondents (88.8% in 2005 and 92.1% in 2013) of respondents reported that disaster management radio broadcasting was written into their local disaster management plans, guidelines, or manuals as the main communication tool. The proportion of respondents using computer networks (41.6-60.7%) and cell phones (email) (40.4-62.9%) had significantly increased between the surveys. It was also found that municipalities that had been previously affected by disasters (39.6%) were more likely to have systems to collect information from shelters and affected communities than those without any experience (24.3%), and prefectures that had been previously affected by disasters were more likely to have food supply damage reporting systems (36.4%) than those without such experience (3.3%).

[The effect of lunch box provision and mass feeding on energy and nutrient supply at emergency shelters after the Great East Japan Earthquake].

Objectives　Improvement in the quality of meals provided after a disaster is an important issue. We reanalyzed the data obtained from the dietary survey of emergency shelters in Miyagi Prefecture 2 and 3 months after the Great East Japan Earthquake in 2011 to improve the quality of meals at emergency shelters.Methods　We performed a secondary analysis of the data from the dietary survey conducted by the Miyagi prefectural government. Two hundred and forty-one and 49 emergency shelters participated in the 1-day dietary survey in May 2011 and June 2011, respectively. We targeted emergency shelters that had no missing data and provided 3 meals a day. As a result, we targeted 216 emergency shelters in May and 49 in June. We examined the amounts of nutrients (i.e. energy, protein, vitamin B1, vitamin B2, and vitamin C) and food groups (i.e. cereal, potatoes, meat, seafood, eggs, dairy, vegetables, fruits, and fats) in meal portions provided in lunch boxes, rationing, and mass feeding.Results　We found significant differences in the amounts of energy and nutrients in the meals provided at the emergency shelters 2 months after the Great East Japan Earthquake but found no significant differences 3 months after the disaster. The amounts of energy, protein, seafood, and fats were high, and those of vitamins B1 and C, potatoes, and vegetables were low, at the emergency shelters where lunch boxes were provided. The amounts of potatoes, meat, and vegetables were high at the emergency shelters where mass feeding was conducted.Conclusion　Two months after the Great East Japan Earthquake, the provision of lunch boxes at emergency shelters may have increased the amounts of energy, protein, and seafood in meals served to survivors, whereas the amounts of vitamins B1 and C have remained low. These results indicate that providing lunch boxes at an early stage in the event of a disaster can improve energy and protein supply. We believe a combination of lunch box and mass feeding will improve the nutrient supply at emergency shelters.