1. 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

2. 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

3. 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?

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

5. 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

6. 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)

7. 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

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

9. 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

10. 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

11. 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

12. 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)

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

14. 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

15. 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

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

17. 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

18. Message on consumption frequency
Equally distributed: /yr = 15/mo = /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’

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

20. 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

21. 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

22. Further reading HF-TAG programmatic guidance brief
WHO guideline for MNP programs

23. Further reading
Planning for Program Implementation of Home Fortification with Micronutrient Powders (MNP): A Step-by-Step Manual
HF-TAG MNP Composition Manual

24. Further reading
HF-TAG Manual for developing and implementing monitoring systems form home fortification interventions

25. 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

26. 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