Home fortification is used in situations where local diets – or, in the case of emergencies, food aid baskets –do not provide enough micronutrients. Home fortification puts technology into the caregiver’s hands, empowering them to improve the quality of their family’s diet by adding micronutrients to the locally available foods they prepare at home. The process involves adding specialized ingredients such as multi-micronutrient powders (ie Sprinkles®), lipid-based nutrient supplements (LNS) and other nutritious foods to the local meals that people eat every day.

The new Home Fortification Technical Advisory Group (HF-TAG) is a community of stakeholders involved in home fortification comprised of members from the public, private, academic and non-governmental organization sectors. Its vision is a world without malnourished children. The group’s mission is to facilitate implementation of well-designed and effective home fortification projects at scale, based on sound technical guidance and best practices, integrated into comprehensive nutritional strategies for children.

Stakeholders in the public, private, academic and non-governmental organization sectors demonstrating a commitment to advance global home fortification programs can become members.

GAIN serves as the Secretariat, providing its technical expertise to set the group’s strategy and monitor its sustainability.

Contact Jonathan Siekman at the Secretariat at [email protected].

The initiative aims to shape the market for home fortification by providing standards, guidelines and resources to policymakers, non-governmental organizations, international organizations, corporations (manufacturers and suppliers), innovators/social entrepreneurs, academia and media. The group seeks to represent all key stakeholder groups and address the most important and feasible barriers to home fortification.

The HF-TAG serves as a central, online hub for home fortification. By aggregating and connecting existing resources and building a shared space for discussion, the HF-TAG will increase the intra-sector and multi-sector collaboration necessary to improve health outcomes. The HF-TAG is built on the principle of inclusion and expands home fortification information/guidance within the public domain. Prescriptive nutrition science guidance provided is evidence-based and other guidance based on best practice and experience.

Lipid-based nutrient supplements (LNS) are a family of products designed to deliver nutrients to vulnerable people. They are considered “lipid-based” because the majority of the energy provided by these products is from lipids (fats). All LNS provide a range of vitamins and minerals, but unlike most other multiple micronutrient supplements, LNS also provide energy, protein, and essential fatty acids (EFA). LNS formulations and doses can be tailored to meet the nutrient needs of specific groups (for example, children under 2 years of age) and to fit in particular programmatic contexts (for example, preventive or therapeutic programs, emergency programs).

The best known LNS are the ready-to-use therapeutic foods (RUTF) such as Plumpy’nut®. RUTF are now widely used in treating severe acute malnutrition (SAM), including in community-based programs. RUTF are designed to achieve specific daily weight gains of in order to reach a target weight-for-height consistent with nutritional recovery.  RUTF thus temporarily replace most or all foods other than breast milk. There is substantial evidence that programs using RUTF result in better outcomes and fewer deaths, compared to the previous standard care.1-3.
More recently, LNS products such as Nutributter®, which provide significantly less daily energy than RUTF but a full complement of micronutrients, were shown to prevent child stunting and support normal motor development in trials in Malawi and Ghana4-7. These lower dose products are designed to enrich and not replace locally available foods. Additional efficacy trials are underway to improve the formulations and extend knowledge about the potential of lower-dose LNS products to contribute to prevention of under-nutrition.

1.Briend A, Lacsala R, Prudhon C, Mounier B, Grellety Y, Golden MH. Ready-to-use therapeutic food for treatment of marasmus. Lancet 1999;353:1767-8.
2.Ciliberto MA, Sandige H, Ndekha MJ, et al. Comparison of home-based therapy with ready-to-use therapeutic food with standard therapy in the treatment of malnourished Malawian children: a controlled, clinical effectiveness trial. Am J Clin Nutr 2005;81:864-70.
3.WHO, WFP, SCN, UNICEF. Community-based management of severe malnutrition. A joint statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition, and the United Nations Childrens Fund., 2007.
4.Adu-Afarwuah S, Lartey A, Brown KH, Zlotkin S, Briend A, Dewey KG. Randomized comparison of 3 types of micronutrient supplements for home fortification of complementary foods in Ghana: effects on growth and motor development. Am J Clin Nutr 2007;86:412-20.
5.Adu-Afarwuah S, Lartey A, Brown KH, Zlotkin S, Briend A, Dewey KG. Home fortification of complementary foods with micronutrient supplements is well accepted and has positive effects on infant iron status in Ghana. Am J Clin Nutr 2008;87:929-38.
6.Phuka JC, Maleta K, Thakwalakwa C, et al. Complementary feeding with fortified spread and incidence of severe stunting in 6- to 18-month-old rural Malawians. Arch Pediatr Adolesc Med 2008;162:619-26.
7.Phuka JC, Maleta K, Thakwalakwa C, et al. Postintervention growth of Malawian children who received 12-mo dietary complementation with a lipid-based nutrient supplement or maize-soy flour. Am J Clin Nutr 2009;89:382-90.

Currently, several approaches and products are being used to address infant and child under-nutrition. Approaches include promotion and support for breastfeeding, and behavior change communication encouraging enrichment of porridges with locally available and nutrient-dense foods. Other products include fortified blended foods to replace local staple foods, fortified full-fat soy flour, other complementary food supplements, and micronutrient powders1. Choices among approaches and/or products depend on many factors including the nature and underlying prevalence of malnutrition, the food security situation, and cultural preferences, as well as program or policy objectives. Cost and available resources also shape choices. On-going research will help clarify where LNS may best fit among the available options2-3. This research should include consideration of operational and implementation issues, as well as cost and comparative cost-effectiveness4.
1.Ten Year Strategy to Reduce Vitamin and Mineral Deficiencies M, Infant and Young Child Nutrition Working Group: Formulations Subgroup. Formulations for fortified complementary foods and supplements: Review of successful products for improving the nutritional status of infants and young children. Food and Nutrition Bulletin 2009;30:17.
2.WFP. Ten minutes to learn about nutrition programming. A joint initiative of the World Food Programme and DSM. Sight and Life Magazine 2008;2008:43.
3.Dewey KG, Yang Z, Boy E. Systematic review and meta-analysis of home fortification of complementary foods. Maternal and Child Nutrition 2009;forthcoming.
4.Neufeld LM. Ready-to-use therapeutic food for the prevention of wasting in children. JAMA 2009;301:327-8.

LNS should not take the place of a diverse diet. RUTF temporarily replaces other foods for children treated for SAM. Otherwise, diets of infants and young children should gradually become more diverse, to include a variety of available fruits, vegetables, and animal-source foods. All infants need to learn to eat and enjoy locally available nutrient-dense foods. Additional supplements such as LNS may be necessary because of limited availability and quantity of such foods, especially animal-source foods.

LNS should not replace breast milk. One exception to this may be with the use of larger daily amounts of LNS by HIV+ mothers who choose to stop breastfeeding and are being supported to provide safe alternatives. Good breastfeeding practices, including exclusive breastfeeding to 6 months and continued breastfeeding to 2 years or beyond, are critical to child survival and health. One study has shown that breast milk intake did not differ between children supplemented with LNS and those supplemented with a ortified blended food1. More studies are needed on the optimal LNS doses that will contribute to dietary improvement without displacing breast milk.
1.Galpin L, Thakwalakwa C, Phuka J, et al. Breast milk intake is not reduced more by the introduction of energy dense complementary food than by typical infant porridge. J Nutr 2007;137:1828-33.

Several studies have suggested that LNS may have the potential to prevent stunting and developmental delays before they occur1-3. One study also showed sustained impacts on growth two years after the end of a 12-mo supplementation trial4. In considering the role of LNS (or other interventions) in preventing stunting, it is useful to recognize that the concept of “prevention” is complicated in the presence of widespread and chronic under-nutrition.
“Prevention” vs. treatment in the context of chronic under-nutrition
In high risk populations with chronic under-nutrition and a high prevalence of nutritional stunting, the line between prevention and treatment is not always clear. In such populations, “prevention” of stunting can also be seen as treatment for an on-going process of undernourishment. Children who are identified as stunted have been undernourished for some time, with long-lasting consequences5-6. High levels of stunting result from some combination of small maternal size and maternal under-nutrition, repeated infections during infancy, poor breastfeeding or care practices, and inadequate quantity and/or quality of complementary food. LNS and other products that improve home diets may play a role in ensuring the adequacy of complementary food. LNS formulated for pregnant and lactating women could also have potential to contribute to improvements in maternal and newborn nutrition.
Prevention of acute malnutrition (wasting)
LNS may also have a role to play in prevention of moderate or severe acute malnutrition, for example in settings where acute malnutrition peaks seasonally7-8.

1.Adu-Afarwuah S, Lartey A, Brown KH, Zlotkin S, Briend A, Dewey KG. Randomized comparison of 3 types of micronutrient supplements for home fortification of complementary foods in Ghana: effects on growth and motor development. Am J Clin Nutr 2007;86:412-20.
2.Adu-Afarwuah S, Lartey A, Brown KH, Zlotkin S, Briend A, Dewey KG. Home fortification of complementary foods with micronutrient supplements is well accepted and has positive effects on infant iron status in Ghana. Am J Clin Nutr 2008;87:929-38.
3.Phuka JC, Maleta K, Thakwalakwa C, et al. Complementary feeding with fortified spread and incidence of severe stunting in 6- to 18-month-old rural Malawians. Arch Pediatr Adolesc Med 2008;162:619-26.
4.Phuka JC, Maleta K, Thakwalakwa C, et al. Postintervention growth of Malawian children who received 12-mo dietary complementation with a lipid-based nutrient supplement or maize-soy flour. Am J Clin Nutr 2009;89:382-90.
5.World Bank. Repositioning nutrition as central to development: A strategy for large scale action. Washington, DC: The World Bank, 2005.
6.Hoddinott J, Maluccio JA, Behrman JR, Flores R, Martorell R. Effect of a nutrition intervention during early childhood on economic productivity in Guatemalan adults. Lancet 2008;371:411-6.
7.Isanaka S, Nombela N, Djibo A, et al. Effect of preventive supplementation with ready-to-use therapeutic food on the nutritional status, mortality, and morbidity of children aged 6 to 60 months in Niger: a cluster randomized trial.  JAMA 2009;301:277-85.
8.Defourny I, Minetti A, Harczi G, et al. A large-scale distribution of milk-based fortified spreads: evidence for a new approach in regions with high burden of acute malnutrition. PLoS One. 2009;4(5):e5455.

LNS are one example of a ready-to-use food (RUF). RUF include any foods that do not require preparation in the home. RUF also refers to products that are safe to store without refrigeration. RUF have low moisture content and do not require dilution or cooking, so risk of contamination is low.

The best known LNS are the ready-to-use therapeutic foods (RUTF) such as Plumpy’nut®. RUTF are now widely used in treating severe acute malnutrition (SAM), including in community-based programs. RUTF are designed to achieve specific daily weight gains of in order to reach a target weight-for-height consistent with nutritional recovery.  RUTF thus temporarily replace most or all foods other than breast milk. There is substantial evidence that programs using RUTF result in better outcomes and fewer deaths, compared to the previous standard care^1-3.

More recently, LNS products such as Nutributter®, which provide significantly less daily energy than RUTF but a full complement of micronutrients, were shown to prevent child stunting and support normal motor development in trials in Malawi and Ghana^4-7. These lower dose products are designed to enrich and not replace locally available foods. Additional efficacy trials are underway to improve the formulations and extend knowledge about the potential of lower-dose LNS products to contribute to prevention of under-nutrition.

¹ Briend A, Lacsala R, Prudhon C, Mounier B, Grellety Y, Golden MH. Ready-to-use therapeutic food for treatment of marasmus. Lancet 1999;353:1767-8.

² Ciliberto MA, Sandige H, Ndekha MJ, et al. Comparison of home-based therapy with ready-to-use therapeutic food with standard therapy in the treatment of malnourished Malawian children: a controlled, clinical effectiveness trial. Am J Clin Nutr 2005;81:864-70.

³ WHO, WFP, SCN, UNICEF. Community-based management of severe malnutrition. A joint statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition, and the United Nations Childrens Fund., 2007.

⁴ Adu-Afarwuah S, Lartey A, Brown KH, Zlotkin S, Briend A, Dewey KG. Randomized comparison of 3 types of micronutrient supplements for home fortification of complementary foods in Ghana: effects on growth and motor development. Am J Clin Nutr 2007;86:412-20.

⁵ Adu-Afarwuah S, Lartey A, Brown KH, Zlotkin S, Briend A, Dewey KG. Home fortification of complementary foods with micronutrient supplements is well accepted and has positive effects on infant iron status in Ghana. Am J Clin Nutr 2008;87:929-38.

⁶ Phuka JC, Maleta K, Thakwalakwa C, et al. Complementary feeding with fortified spread and incidence of severe stunting in 6- to 18-month-old rural Malawians. Arch Pediatr Adolesc Med 2008;162:619-26.

⁷ Phuka JC, Maleta K, Thakwalakwa C, et al. Postintervention growth of Malawian children who received 12-mo dietary complementation with a lipid-based nutrient supplement or maize-soy flour. Am J Clin Nutr 2009;89:382-90.

LNS recipes can include a variety of ingredients, but typically have included vegetable fat, peanut/groundnut paste, milk powder and sugar. Alternative recipes and formulations are currently being explored in efforts to develop affordable and culturally acceptable products for a range of settings. Other ingredients have included whey, soy protein isolate, and sesame, cashew, and chickpea paste, among others.

In 1996, a group of UNICEF consultants determined that the standard iron drops were not effective, as adherence to treatment remained poor. They called for a simple, inexpensive and potentially viable new method to provide micronutrients (including iron) to populations at risk. The MNP concept was based on two observations from the 'West' where micronutrient deficiencies are rare: (a) fortification of commercially available food provides essential micronutrients and (b) no change in the color, texture or taste of the food ensures compliance. Responding to the challenge, the Sprinkles Global Health Initiative at The Hospital for Sick Children, University of Toronto, developed Sprinkles® utilizing encapsulated iron that could be added directly to food.

SGHI controls the Canadian and American patent rights for the invention known and trade marked as Sprinkles®. These patent rights effectively extend to any micro-nutrient formulations which include micro-encapsulated iron and which are contained in single-dosage sachets, or other forms of packages which enable the user to sprinkle the formulation onto prepared foods. Therefore, the manufacture, distribution and/or marketing of such products in Canada and the United States of America are not allowed without SGHI’s express, written permission.

Sprinkles® is not patented in the rest of the world. In September 2007, SGHI and its sponsor, the Heinz Foundation, formally announced that they were putting the Technical Specifications for the Sprinkles® products into the public domain outside of Canada and the United States of America. This announcement was made at a meeting attended by such organizations the Global Alliance for Improved Nutrition (GAIN), the Micronutrient Initiative (MI), UNICEF, USAID, and WFP. The Technical Specifications include information on formulations, ingredients, and packaging materials. Thus, manufacturers who are able to prove their commitment to quality control can now approach SGHI, or organizations such as GAIN, for these Technical Specifications.

Please note that this open access does not extend to SGHI’s global trade mark rights to the brands Sprinkles®, Sprinkles Plus®, SuppleFer®, and SuppleFem®. These brands cannot be associated with any micro-nutrient powder product without SGHI’s express, written permission, which will be granted only if SGHI is absolutely confident that the quality of the product meets or exceeds the standards set out in the Technical Specifications at all times.

There is no risk of toxicity. MNP containing vitamin A are formulated to help children meet their daily vitamin A requirement (the Recommended Daily Allowance or RDA). It is safe to use the two supplements together because MNP use is complementary to high dose vitamin A capsules and not competitive. With the distribution of high dose capsules, the WHO recommends an age-appropriate diet which would contain all micronutrients, including vitamin A.

Yes. The amount of micronutrients in the MNP sachets is high enough to meet the needs of infants with micronutrient deficiencies (e.g. iron deficiency anemia) but not too high for those who do not have deficiencies. We have completed a research study in China with 400 preschool children, a majority of whom were non-anemic (95%). MNP prevented anemia (when provided for 4 months) with absolutely no evidence of excessive iron stores. Serum ferritin values remained within the normal range in 100% of infants included in the study.

Thus, MNP are safe to use, even in infants without micronutrient deficiencies. In fact, MNP were originally designed to prevent deficiencies in non-deficient children at risk of micronutrient deficiencies.

In order to mask the strong metallic taste of the iron, the iron in the MNP is coated or encapsulated with a thin coat of a soy lipid. The melting temperature for the lipid is around 60ºC. If MNP are added to food hotter than 60ºC, the lipid coating around the iron will melt and the food will be exposed to the iron. The iron can then change the colour of the food and will certainly have a strong taste.

To prevent changes in the taste and colour of food to which MNP is added, we recommend that MNP be added to food after it is cooled to a temperature below 60ºC.

Stool consistency does not change in the majority of infants and children receiving MNP. Stool colour, however, changes to a dark or black colour in all infants receiving MNP on a regular basis. Iron itself is dark in colour. When some quantities are left unabsorbed, the iron is excreted in the stool and causes the change in colour. Some very young infants, who have not previously been exposed to any complementary foods containing micronutrients (i.e. who are exclusively breast-fed) may develop loose stools or even mild diarrhea. The diarrhea does not lead to dehydration, but is a valid concern to parents and health care providers. The diarrhea lasts for approximately one week and then will not recur. Parents have reported that diarrhea quickly disappears in these young infants, who are transitioning from breastfeeding to complementary feeding, if 1/3 - 1/2 of a MNP sachet is used.

Loose stools may be caused by a change in bowel flora (microorganisms) associated with the introduction of iron into the diet or possibly the impact of ascorbic acid on bowel peristalsis in infants, who previously had received only very small amounts of ascorbic acid in their diets (in breast milk). Since loose stools have only been observed in infants transitioning from exclusive breastfeeding to complementary feeding, loose stools may possibly be unrelated to MNP, and instead related to the change in stool pattern with the introduction of complementary foods.

Likely, the microencapsulation of iron and presence of food during MNP intake accounts for the fewer and less severe cases of diarrhea and constipation than other iron supplements.

Yes. Neither alcohol nor porcine products are used in the production of MNP. They are therefore both Halal and Kosher and may be used as part of a traditional Muslim or Jewish diet.

MNP is safe to use and recommended to improve micronutrient status in emergency situations. Emergency rations tend to include corn-soya blend (CSB) or wheat-soya blend (WSB) – two vehicles suitable for the addition of MNP. Both these rations produce a thick paste-like substance after cooking, to which MNP may be added after cooling to provide an additional source of micronutrients. A research study in rural Haiti showed a decrease of anemia prevalence by one-half when MNP was used with WSB, while anemia prevalence increased when WSB was used alone. MNP has been used in emergency relief aid in countries like Indonesia and Haiti.

MNP can be used in any food products, but because the iron is coated with lipid (to mask the metallic taste), it will float to the top of liquids and tend to stick to the side of the cup or glass. Although MNP can be used with any fluid, some will be lost in the process.

The current recommendation from the World Health Organization (WHO) is that exclusive breastfeeding should last until 6 months of age. Afterwards, complementary feeding begins and MNP can be given. Infants should receive 60 sachets consumed over 60 – 120 days. The provision of 60 sachets should be repeated every 6 months until a variety of mixed foods (containing iron and other micronutrients) are being eaten.

MNP were originally developed for infants and young children between 6-24 months of age. Infants and young children cannot safely ingest tablets or pills. Syrups and drops have been used for many years, but compliance has been documented to be poor (for iron) because of the strong unpleasant taste of the drops. The drops tend to stain the teeth unless they are carefully placed at the back of the infants' mouth, and for parents who cannot read, it is often difficult to measure the appropriate amount of liquid iron, which is often supplied in a bottle with a dropper calibrated in milliliters. General food fortification, though suitable for preventing micronutrient deficiencies in the adult population, does not meet the micronutrient needs of young children, who ingest smaller amounts of food than adults.

MNP occupy a unique niche for young children. We do not support or encourage the use of MNP for infants under the age of six months as they should be exclusively breastfed in accordance with WHO guidelines on breastfeeding. For other age groups, more choices for supplementation are available, including the use of fortified foods, pills and capsules. Nevertheless, MNP can be used in the other age groups without fear of toxicity. To date, our research emphasis has focused on infants and children under age 5; however, we also have ongoing research involving pregnant women.

Thalassemia and iron metabolism are closely linked. Iron deficiency and mild forms of thalassemia (e.g., thalassemia trait) are often confused. Both are associated with mild to moderate anemia and microcytosis (small red cells). At the other end of the spectrum, severe forms of thalassemia frequently produce iron overload. Excess iron accumulates due to a combination of enhanced iron absorption, repeated blood transfusions or both. People with thalassemia trait (thalassemia minor) are not at greater risk of complications from iron in the diet than anyone else in the general population. In the absence of concomitant iron deficiency, iron supplementation will neither correct nor improve anemia due to thalassemia. For people with both iron deficiency and thalassemia, iron replacement will lessen the severity of the anemia until the iron deficiency is corrected. The blood count will then level off and no further improvement will occur.

The vitamin D dose in MNP is meant to meet the RDA for vitamin D, rather than provide a therapeutic intervention. Thus, for rickets treatment, the recommended dose of vitamin D is significantly higher than the dose present in MNP. The vitamin D dose in MNP, however, is adequate to prevent rickets.

MNP can be used both in the treatment and prevention of anemia.