Micronutrient Powder Formulation, Dosing Regimen and Delivery Channels Picture: Saskia de Pee (WFP), on behalf of Home Fortification Technical Advisory Group (HF-TAG), April 2015

HF-TAG brief & WHO MNP guideline WHO guideline based on review of studies that provided MNP to prevent and treat anemia in a population: Minimum 3 micronutrients and at least 60 sachets/6 mo Note that this is a guideline for decision making, not a fixed prescription for one way of programming MNP HF-TAG brief further expands WHO guideline: Improve micronutrient intake in order to meet the recommended nutrient intake for more micronutrients, in addition to those important for preventing anemia Considering programming circumstances and experience Integrate with wider infant and young child nutrition & ‘1000 days’ programming

Design & Planning for a Specific Country Why home fortification? For which target group(s)? What formulation of MNP? How many sachets & for how long? What frequency for distribution + consumption? Which distribution channels to use?

1. Why Home Fortification? High prevalence of micronutrient deficiencies – Major direct cause: Inadequate micronutrient intake

Indicators for Micronutrient Deficiencies Micronutrient status, distinguishing individual micronutrients Anemia – 50% caused by iron deficiency, 50% by other nutritional and non-nutritional causes – proxy indicator of micronutrient deficiencies in general, because of large role of dietary deficiencies Stunting – there is no stunting without micronutrient deficiencies & dietary deficiencies are a major cause – proxy indicator of micronutrient deficiencies, and more Low dietary diversity, e.g. Minimum Acceptable Diet (DHS), and largely plant-source based diet (poor mineral bioavailability) Limited availability and consumption of fortified complementary foods Dietary deficiencies are a major cause of MND

Reasons for low micronutrient intake Low dietary diversity (affordability & availability) Inadequate micronutrient status of pregnant & lactating women (inadequate stores & intake for the child) Complementary foods with too low nutrient-content, and -density; too early introduction (watery porridges, foods with limited nutrient-content) Poor bioavailability of micronutrients (absorption inhibitors, especially in plant-source based diet)

Thus, objectives of home fortification program Increase micronutrient intake & improve IYCF practices Improve micronutrient status, including reduction of nutritional anemia Improve child health, appetite, growth and other functional outcomes, and reduce morbidity and mortality

2. Home fortification, which target group(s)?

Target groups Those most affected / at-risk of nutritional deficiencies Young children 6-23 mo (or 6-59 mo) Poorest Affected by high-food prices Affected by emergencies Other risk groups: School-age children receiving unfortified, plant-food based, school meals Pregnant and lactating women – may prefer capsules Comments: - Consider targeting wider age-range when program is implemented for a short while and problem is also high among 2-5 yr olds

3. What MNP formulation? 15 micronutrients, since it is very likely that multiple deficiencies occur together, because they are caused by dietary inadequacies For folate, please note that 150 ug dietary folate equivalents is equivalent to 90 ug of folic acid

15 Micronutrient Formulation Good for many situations Includes, for each MN, 1 recommended nutrient intake (RNI) (note, also age-appropriate RNI for SF-ing) Safe to provide daily and in addition to: High-dose vitamin A capsules (VAC) twice yearly Iodized salt use General food fortification (staples, condiments) Note: If consuming other special nutritious foods to treat or prevent malnutrition, no need for MNP (unless low frequency of intake) Formulation can be adjusted when there is good evidence on ‘no need’ for specific MN, e.g. vit A where sugar is fortified 32 countries currently using 15 formulation

5 Micronutrient Formulation Fe, vit C, folic acid, vit A, Zn Original formulation, developed and studied for addressing nutritional anemia Proven effective for reducing anemia and iron deficiency Those published papers on MNP were the basis for 2011 WHO guideline on MNP (Fe, vit A, Zn) Note: HF-TAG recommends MNP with 15 MN for prevention of multiple MND Most countries use 15 MN formulation (32 vs 7 using 5 MN)

4. How many sachets and for how long? Complementing the Diet Aim: Reaching 1 RNI from Diet + MNP

Think quantitatively Proportion of recommended intake that is met varies by micronutrients – MNs predominantly obtained from animal source foods often lowest (esp iron, zinc, B12) Recommended nutrient intake (RNI) is established for normal, healthy children – needs of malnourished children and in environments with high infection pressure are higher Only fat soluble vitamins and some minerals are stored by the body, others micronutrients need to be consumed more regularly

Recommendation MNP to be consumed throughout the year Not more than one sachet per day Reasonable target: 50% of RNI/d = 90 sachets / 6 mo, i.e. At least: 60 sachets / 6 mo (33% of RNI) Maximum: 180 sachets / 6 mo (full RNI) For school feeding, apply to every school meal (5d/wk, excluding holidays = approx 50% of RNI) Regular intake + 1 RNI/d, don’t worry Accidentally a couple of sachets on one day, no risk of acute toxicity as RNI is very far below toxicity level, and UL is for chronic intake and well below toxicity level

5. Frequency of distribution and consumption Example: Providing 50% of RNI/d = 90 sachets/6 months or 180 sachets/year

Frequency of distribution Packaged: 30 sachets in a box 180/yr = 6 boxes Options: 1 box every 2 months – good, regular contact! 2 boxes every 4 months 3 boxes every 6 months – possible to combine with VAC distribution, but limited enforcement opportunities Purchasing consumers – consider single sachets or strips of e.g. 5 Choice depends on delivery choices and possible channels Important: Interpersonal communication opportunities

Message on consumption frequency Equally distributed: 180/yr = 15/mo = 3-4/wk = 1 per 2 days Important: Not too prescriptive Develop an intake routine Not more than 1 per day Instruction needs to be communicated in simple message suitable for posters, leaflets, radio etc ‘Consume regularly, not more than one per day’

6. Which distribution channels? Most important: New commodity requires good interpersonal communication

Suitable and less suitable distribution Channels Good: Community based programs, e.g. on Infant and Young Child Feeding (IYCF) School feeding, including child care centers (added in kitchen) Vouchers and/or Direct sales, with good interpersonal communication Less suitable: Promotion just through mass media General food distribution Food For Asset programs Unless, combined with interpersonal communication opportunity

Summary of HF-TAG recommendations Why home-fortification? – Increase MN intake For which target groups? – Most vulnerable 6-24 / 6-59 months old children and school children receiving unfortified school meals What to provide? – 15 micronutrient formulation How much & for how long? – 90 sachets/6 mo – throughout the year Frequency of distribution & consumption – regular distribution of boxes of 30 sachets or purchasing of smaller numbers; consume regularly, not more than 1 per day Which distribution channels? – Multiple, but must include interpersonal communication

Further reading HF-TAG programmatic guidance brief http://www.hftag.org/resource/hf-tag_program-brief-dec-2011-pdf/ WHO guideline for MNP programs http://www.who.int/nutrition/publications/micronutrients/guidelines/guideline_mnp_infants_children/en/

Further reading Planning for Program Implementation of Home Fortification with Micronutrient Powders (MNP): A Step-by-Step Manual http://www.hftag.org/resource/hf-tag-planning-for-implementation-manual-v1-march-2015-pdf/ HF-TAG MNP Composition Manual http://www.hftag.org/resource/hf-tag-mnp-composition-manual-pdf/

Further reading HF-TAG Manual for developing and implementing monitoring systems form home fortification interventions http://www.hftag.org/resource/hf-tag-monitoring-manual-14-aug-2013-pdf/

Notes on Upper Limit (UL) - 1 UL: Tolerable Upper Limit of intake The UL is the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals (97.5%) in the general population, applies to daily use for a prolonged period of time, and a generous safety margin is used to set it For most nutrients, the UL is well above the recommended nutrient intake (RNI) Acute toxicity occurs at much higher intake levels Where UL has been set to avoid negative nutrient-nutrient interactions, this is based on inbalanced intake of these nutrients (increasing one, not the other), which may be avoided with fortified product

Notes on Upper Limit (UL) - 2 Applies to normal, healthy individuals with adequate stores and no deficits to be corrected Recommended nutrient intake for treating severe and moderate acute malnutrition is higher than the UL for zinc, vitamin A, folic acid and magnesium Implications: 1 sachet of MNP contains 1 RNI 1 sachet can safely be added to daily diet Acute toxicity requires consuming many sachets at once UL applies to daily intake over prolonged period of time