Use of lipid-based nutrient supplements (LNS) to improve the nutrient adequacy of general food distribution rations for vulnerable sub-groups in emergency settings.

The term 'lipid-based nutrient supplements' (LNS) refers generically to a range of fortified, lipid-based products, including products like Ready-to-Use Therapeutic Foods (RUTF) (a large daily ration with relatively low micronutrient concentration) as well as highly concentrated supplements (1-4 teaspoons/day, providing <100 kcal/day) to be used for 'point-of-use' fortification. RUTF have been successfully used for the management of severe acute malnutrition (SAM) among children in emergency settings. Recent research on smaller doses of LNS for prevention of malnutrition has created interest in their potential use in emergency settings to ensure a more nutritionally adequate ration for the most vulnerable groups [e.g. infants and children between 6 and 24 months of age, and pregnant and lactating women (PLW)]. Currently, the main food and nutrition interventions in emergency settings include general food distribution (GFD) rations, which are provided to the affected population as a whole, and selective (or supplementary) feeding programs (SFP), which are to be provided to nutritionally vulnerable or malnourished individuals. In addition to logistical and operational challenges that may limit the intended effect of these programs, the nutritional quality of the food commodities provided may be insufficient to meet the needs of infants and young children and PLW. Because these subgroups have particularly high nutrient needs for growth and development, meeting these needs is challenging in settings where the ration is limited to a few food commodities, with little access to a diverse diet and bioavailable sources of micronutrients. In recent years, there has been increased attention to adding micronutrient interventions, on top of the other food-based interventions (such as GFDs and SFPs), to fill micronutrient gaps in diets in emergency settings. The focus of this document is the potential role of LNS in meeting the nutritional needs of these vulnerable subgroups, with the goal of preventing malnutrition in emergency-affected populations. The document addresses the desired nutritional formulation of LNS for these target groups, taking into account the expected bioavailability of relevant nutrients and toxicity concerns. It also discusses the recommended chemical forms of the fortificants in LNS; stability and shelf-life considerations; production, packaging and distribution of LNS in the context of emergencies; and cost implications of the addition of LNS to current GFD rations for vulnerable groups. To develop the desired nutritional formulation of LNS for these purposes, we calculated the current nutrient content of commonly provided GFD rations and determined the nutritional 'gaps' (of both micro- and macronutrients) of these rations for each of the target groups (i.e. children 6-35 months of age and PLW). For fat and protein, both quantity and quality were evaluated. Through an iterative process, we determined the formulation of a small dose of LNS that would best meet the recommended nutrient intakes for each group in combination with other foods in the GFD ration [composed of a grain, pulse, oil, sugar and salt, but excluding a fortified blended food (FBF)], as well as breast milk for children 6-24 months of age, while avoiding excess levels of any one nutrient to the extent possible. The composition of the LNS used for these calculations is based on an existing LNS product (Nutributter, Malaunay, France, Nutriset), but with less sugar and more oil. Two different approaches were used: (1) developing two different formulations of LNS, one to be used for infants and children 6-35 months of age and a separate one for PLW; and (2) developing a single formulation that could be used for all of these subgroups. We used commodity cost data to estimate the cost of adding an LNS product to the GFD ration. The results indicate that the typical GFD ration currently provided in emergency settings--based on cereals, pulse, an FBF such as corn-soy blend (CSB), oil, salt and sugar-does not meet the nutritional needs of infants and young children and PLW. The hypothetical intake from a ration composed of food aid commodities (based on the current USAID/USDA specifications for exported food aid commodities used in emergency settings), and including breast milk for children 6-24 months of age, provided less than 75% of the recommended intake for several micronutrients for certain age/physiologic groups, including calcium, iron, zinc, B vitamins such as riboflavin, B6 and B12, and fat-soluble vitamins such as D, E and K. It also generally contained lower than recommended levels of fat and essential fatty acids. The initial LNS formulation for each target group was designed to provide 100% of the recommended amount (RDA or RNI) for most micronutrients per daily dose (20 g, approximately 118 kcal) of LNS. This would ensure consumption of the recommended levels of each nutrient even if the 'base' diet changed. However, because such a formulation could provide excess amounts of certain nutrients when consumed in combination with the 'base' diet (especially when the 'base' diet contains fortified foods), we made adjustments in the LNS formulation when there was a risk of greatly exceeding the Upper Level for certain subgroups and there were relevant concerns about adverse effects from chronic consumption of such amounts. For most nutrients, consumption of toxic amounts is highly unlikely with the proposed LNS formulations. The 'one-size' LNS formulation was designed so that one 'dose' (20 g) would be provided to infants and young children and two 'doses' (i.e. 40 g/day) would be provided to PLW. This 'one-size' formulation was based on the LNS formulation developed for children 6-35 months of age. Although the resulting formulation is not a perfect match for the unique nutritional needs of each subgroup, there are several practical advantages to using such an approach. As anticipated, addition of LNS to the GFD ration, even after eliminating the FBF (e.g. CSB), increases the cost. The 'revised' ration without CSB but with LNS would cost 34-52% more (food only) than the 'typical' GFD diet for a hypothetical mother-infant pair, depending on how many LNS 'doses' were provided to the mother. However, depending on the contribution of food costs to overall program costs, the overall increase in costs may be significantly less. Although cost is an important consideration, options to improve the nutritional quality of foods provided in emergency settings should also be assessed with regard to effectiveness in maintaining and improving nutritional outcomes. Another consideration is whether a specialized product like LNS is more easily targeted to the individuals for whom it is intended, thus reducing inter- and intra-household sharing, a common concern with other fortified products such as CSB. This could have substantial cost implications because programs usually compensate for sharing by inflating the amount of FBF provided. This document is intended to be a starting point for considering the incorporation of LNS in the food packages provided in emergency settings. Our goal was to examine the potential nutritional benefits but also the challenges of adopting such a strategy. There are many different options for emergency nutrition programs, and there are also many considerations governing which option to choose. This document is intended to encourage further evaluation of all of these options.