Micronutrient Powder  Formulation, Dosing Regimen and 

Delivery Channels 

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

1. Why home fortification?2. For which target group(s)?3. What formulation of MNP?4. How many sachets & for how long?5. What frequency for distribution +

consumption?6. 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

15 micronutrients, since it is very likely

that multiple deficiencies occur together, because they are caused by

dietary inadequacies

3. What MNP formulation?

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

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 programsUnless, combined with interpersonal communication opportunity

Summary of HF-TAG recommendations

1. Why home-fortification? – Increase MN intake2. For which target groups? – Most vulnerable 6-24 / 6-59

months old children and school children receiving unfortified school meals

3. What to provide? – 15 micronutrient formulation4. How much & for how long? – 90 sachets/6 mo –

throughout the year5. Frequency of distribution & consumption – regular

distribution of boxes of 30 sachets or purchasing of smaller numbers; consume regularly, not more than 1 per day

6. Which distribution channels? – Multiple, but must include interpersonal communication

Further readingHF-TAG programmatic guidance briefhttp://www.hftag.org/resource/hf-tag_program-brief-dec-2011-pdf/

WHO guideline for MNP programshttp://www.who.int/nutrition/publications/micronutrients/guidelines/guideline_mnp_infants_children/en/

Further readingHF-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 Manualhttp://www.hftag.org/resource/hf-tag-planning-for-implementation-manual-v1-march-2015-pdf/

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/

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