Micronutrient  - PowerPoint Presentation

Slide1

Micronutrient Powder  Formulation, Dosing Regimen and Delivery Channels 

Saskia de Pee (WFP), on behalf of Home Fortification Technical Advisory Group (HF-TAG), April 2015Slide2

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 moNote 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:

I

mprove 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’ programmingSlide3

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?Slide4

1. Why Home Fortification?High prevalence of micronutrient deficiencies

– Major direct cause: Inadequate micronutrient intakeSlide5

Indicators for Micronutrient D

eficienciesMicronutrient 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 MNDSlide6

Reasons for low micronutrient

intakeLow 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)Slide7

Thus, objectives of home fortification program

Increase micronutrient intake & improve IYCF practicesImprove micronutrient status, including reduction of nutritional anemia

Improve child health, appetite, growth and other functional outcomes, and reduce morbidity and mortalitySlide8

2. Home fortification, which target group(s)?Slide9

Target groups Those most affected / at-risk of nutritional deficiencies

Young children6-23 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 capsulesSlide10

15 micronutrients, since it

is very likely that multiple deficiencies occur

together, because they are caused by dietary inadequacies

3. What MNP formulation?Slide11

15 Micronutrient FormulationGood 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 fortifiedSlide12

5 Micronutrient FormulationFe, vit C

, folic acid, vit A, ZnOriginal formulation, developed and studied for addressing nutritional anemiaProven 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)Slide13

4. How many sachets and for how long?

Complementing the DietAim: Reaching 1 RNI from Diet + MNPSlide14

Think quantitativelyProportion 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 regularlySlide15

RecommendationMNP to be consumed throughout the year

Not more than one sachet per dayReasonable 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 levelSlide16

5. Frequency of distribution and consumption

Example:Providing 50% of RNI/d= 90 sachets/6 months or 180 sachets/yearSlide17

Frequency of distributionPackaged: 30 sachets in a box

180/yr = 6 boxesOptions: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

I

mportant: Interpersonal

communication

opportunitiesSlide18

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

N

ot 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’Slide19

6. Which distribution channels?Most important:

New commodity requires good interpersonal communicationSlide20

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 Slide21

Summary of HF-TAG recommendations

Why home-fortification? – Increase MN intakeFor 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 dayWhich distribution channels? – Multiple, but must include interpersonal communicationSlide22

Further readingHF-TAG programmatic guidance briefhttp://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

/Slide23

Further reading

HF-TAG

MNP Composition

Manual

http

://www.hftag.org/resource/hf-tag-mnp-composition-manual-pdf

/

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/Slide24

Further readingHF-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/Slide25

Notes on Upper Limit (UL) - 1

UL: Tolerable Upper Limit of intakeThe 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 levelsWhere 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 productSlide26

Notes on Upper Limit (UL) - 2

Applies to normal, healthy individuals with adequate stores and no deficits to be correctedRecommended 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