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

Abstract

Table of Contents Abstract 5 1. Introduction 6 1.1 The current nutrition response to emergencies 7 1.1.1 General food distributions (GFD) 7 1.1.2 Supplementary feeding programs 8 1.1.3 Micronutrient interventions 9 1.1.4 LNS as supplements in an emergency nutrition response 10 2. Objectives 11 3. Methodological approach 11 3.1 Dietary intake in emergency nutrition settings and composition of rations for GFD 11 3.2 Hypothetical intake from example GFD rations 12 3.3 Nutrient composition and adequacy of hypothetical ration 13 3.4 Determination of the desired micronutrient composition of LNS 16 3.5 Accounting for bioavailability of nutrients from the GFD ration and LNS 20 3.6 Cost comparability estimates 21 4. Results 21 4.1 Nutrient adequacy of ‘typical’ GFD ration 21 4.1.1 Hypothetical intake from and nutrient adequacy of ‘typical’ GFD ration for children 6–11 months of age 21 4.1.2 Hypothetical intake from and nutrient adequacy of ‘typical’ GFD ration for children 12–35 months of age 23 4.1.3 Hypothetical intake from and nutrient adequacy of ‘typical’ GFD ration for pregnant and lactating women (PLW) 24 4.2 Nutrient adequacy of ‘revised’ GFD ration with the addition of LNS 27 4.2.1 Age‐physiological group specific approach for developing LNS formulation 30 4.2.2 ‘Age‐specific’ LNS formulation for 6–35‐month‐old infants and children 30 4.2.3 Hypothetical intake from and nutrient adequacy of ‘revised’ GFD ration plus ‘age‐specific’ LNS for 6–35‐month‐old children 35 4.2.4 ‘Age‐specific’ LNS formulation for PLW 35 4.2.5 Hypothetical intake from and nutrient adequacy of ‘revised’ GFD ration plus ‘age‐specific’ LNS for PLW 38 4.3 ‘One‐size‐fits‐all’ approach for developing LNS formulation 40 5. Appropriate use and toxicity concerns 43 5.1 Potential strategies to ensure appropriate use and to avoid inappropriate consumption 50 6. Cost estimates of providing LNS with the ‘revised’ GFD ration 52 7. Quality control, nutrient formulation, shelf‐life and packaging 55 7.1 Quality control of LNS production 56 7.2 Nutrient formulation 56 7.3 Shelf‐life and packaging 56 8. Discussion 57 Acknowledgements 60 Conflicts of interest 60 References 60 Appendix 1: Planned general food distribution ration examples used for development of ‘typical’ general food distribution ration 63 Appendix 2: Nutrient composition of principal food aid commodities used in this document 65 Appendix 3: Protein adequacy of diets in emergency settings when supplemented with lipid‐based nutrient supplements 66 List of Tables Table 1: ‘Typical’ GFD ration with CSB, and a ‘revised’ GFD ration with CSB substituted with an equivalent amount of pulse and grain 12 Table 2: Energy requirements of each age/physiologic group 13 Table 3: Hypothetical intake for each age/physiological group from the ‘typical’ GFD ration 14 Table 4: Hypothetical intake for each age/physiological group from the ‘revised’ GFD ration, adjusted for the quantity of LNS that will be added (118 kcal) 14 Table 5: Average nutrient concentrations in mature breast milk (World Health Organization 1998) 15 Table 6: Adequate Intakes (AI) and Recommended Nutrient Intakes (RNIs) and Upper Levels (UL) for 7–11‐month‐old infants (IOM and WHO/FAO 2004) 17 Table 7: Adequate Intakes (AI), Recommended Dietary Allowances (RDAs) or Recommended Nutrient Intakes (RNIs) and Upper Levels (UL) for 1–3‐year‐old (12–35‐month‐old) children (IOM and WHO/FAO 2004) 18 Table 8: Adequate Intakes (AI), Recommended Dietary Allowances (RDAs) or Recommended Nutrient Intakes (RNIs) and Upper Levels (UL) for pregnant women (19+ years of age) (IOM and WHO/FAO 2004) 19 Table 9: Adequate Intakes (AI), Recommended Dietary Allowances (RDAs) or Recommended Nutrient Intakes (RNIs) and Upper Levels (UL) for lactating women (19+ years of age) (IOM and WHO/FAO 2004) 20 Table 10: Hypothetical quantity consumed from each component of the ‘typical’ GFD ration for each age or physiologic group 21 Table 11: Amount of nutrient provided by each ‘typical’ GFD ration (and ‘average’ breast milk intake) and per cent of the daily recommended intake provided for 6–8‐month‐old children. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 24 Table 12: Amount of nutrient provided by each ‘typical’ GFD ration (and ‘average’ breast milk intake) and per cent of the daily recommended intake provided for 9–11‐month‐old children. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 25 Table 13: Amount of nutrient provided by each ‘typical’ GFD ration (and ‘average’ breast milk intake) and per cent of the daily recommended intake provided for 12–23‐month‐old children. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 26 Table 14: Amount of nutrient provided by each ‘typical’ GFD ration and per cent of the daily recommended intake provided for 24–35‐month‐old children. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 27 Table 15: Nutrients that exceed the UL from the hypothetical intake from the ‘typical’ GFD ration. Presented by age/physiologic group and identified by the staple grain used in the GFD hypothetical intake (with all other components being equal between diets) 29 Table 16: Amount of nutrient provided by each ‘typical’ GFD ration and per cent of the daily recommended intake provided for pregnant women. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 31 Table 17: Amount of nutrient provided by each ‘typical’ GFD ration and per cent of the daily recommended intake provided for lactating women. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 32 Table 18: Composition (g) of hypothetical intakes from ‘revised’ GFD ration, taking into account energy content (118 kcal or 236 kcal) to be provided via LNS 33 Table 19: LNS macro‐ and micro‐nutrient content for 6–35‐month‐olds based on the higher of the two daily recommended intake values for 7–11 and 12–35 months (micronutrients only), except where noted 36 Table 20: Amount of nutrient provided by each ‘revised’ GFD ration, breast milk and LNS (6–35 mo formulation) and per cent of the daily recommended intake provided for 6–8‐month‐old children. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 37 Table 21: Amount of nutrient provided by each ‘revised’ GFD ration, breast milk and LNS (6–35 mo formulation) and per cent of the daily recommended intake provided for 9–11‐month‐old children. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 38 Table 22: Amount of nutrient provided by each ‘revised’ GFD ration, breast milk and LNS (6–35 mo formulation) and per cent of the daily recommended intake provided for 12–23‐month‐old children. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 39 Table 23: Amount of nutrient provided by each ‘revised’ GFD ration, breast milk and LNS (6–35 mo formulation) and per cent of the daily recommended intake provided for 24–35‐month‐old children. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 40 Table 24: Nutrients that exceed the UL when the 6–35 mo formulation LNS is added to the hypothetical intake from the ‘revised’ GFD ration, and breast milk (when applicable). Presented by age group and identified by the staple grain used in the GFD hypothetical intake (with all other components being equal between diets) 41 Table 25: LNS macro‐ and micro‐nutrient content for pregnant and lactating women (PLW) based on the higher of the two RNI levels for pregnancy and lactation, except where noted 42 Table 26: Amount of nutrient provided by each ‘revised’ GFD diet and LNS (PLW formulation) and per cent of the daily recommended intake provided for pregnant women. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 43 Table 27: Amount of nutrient provided by each ‘revised’ GFD diet and LNS (PLW formulation) and per cent of the daily recommended intake provided for lactating women. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 44 Table 28: Nutrients that exceed the UL when the PLW LNS formulation is added to the hypothetical intake from the GFD ration. Presented by physiologic group and identified by the staple grain used in the GFD hypothetical intake (with all other components being equal between diets) 45 Table 29: LNS micronutrient content for all groups, ‘one‐size fits all’ approach 46 Table 30: Amount of nutrient provided by each ‘revised’ GFD diet and LNS (‘one size’ formulation) and per cent of the daily recommended intake provided for pregnant women. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 47 Table 31: Amount of nutrient provided by each ‘revised’ GFD diet and LNS (‘one size’ formulation) and per cent of the daily recommended intake provided for lactating women. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 48 Table 32: Nutrients that exceed the UL when the ‘one‐size’ LNS formulation is added to the hypothetical intake from the GFD ration. Presented by age/physiologic group and identified by the staple grain used in the GFD hypothetical intake (with all other components being equal between diets) 49 Table 33: Toxicity estimates for 6–35‐month‐old children consuming 2–7 times the recommended daily dose of the age‐specific or one‐size LNS formulation (alone) 49 Table 34: Toxicity estimates for 6–35‐month‐old children consuming 2–7 times the recommended daily dose of the PLW LNS formulation (alone) 50 Table 35: Toxicity estimates for PLW consuming 2–7 times the recommended daily dose of the PLW LNS formulation (alone) 51 Table 36: Toxicity estimates for PLW consuming 2–7 times the recommended daily dose of LNS (alone), for the one‐size formulation 52 Table 37: Average commodity cost in US$ per metric ton (MT) of GFD commodities as provided by the Food for Peace commodity calculator for fiscal year 2009 (http://www.usaid.gov/our_work/humanitarian_assistance/ffp/comcalc_new.xls, accessed March 2009) 53 Table 38: Cost estimate (in US$) for ‘typical’ full GFD ration and ‘revised’ full GFD ration (excluding sugar and salt) 54 Table 39: Cost (in US$) of providing the hypothetical diet for each age/physiologic group from the ‘typical’ and ‘revised’ GFD rations, with and without addition of LNS, as well as the per cent change in cost from the current ‘typical’ GFD ration 54 Table 40: Change in total commodity provided (g) for the ‘typical’ GFD diet vs. ‘revised’ GFD diet plus LNS for each age/physiologic group, plus a hypothetical mother–child dyad 55 Table 41: Possible chemical forms of nutrients included in products for infants and young children, and recommended chemical forms for inclusion in LNS 57 ‘Typical’ GFD ration with CSB, and a ‘revised’ GFD ration with CSB substituted with an equivalent amount of pulse and grain: Commodity ‘Typical’ GFD ration with CSB ‘Revised’ GFD ration without CSB Weight (g) Energy (kcal) Per cent of total energy Weight (g) Energy (kcal) Per cent of total energy Grain (e.g. rice, cornmeal, wheat flour or sorghum) 400 1356–1476 70 425 1441–1568 74 Corn–soy blend 50 190 9 – – – Pulse 50 173 8 75 345 12 Vegetable oil 25 221 10 25 221 11 Sugar 15 58 3 15 58 3 Salt 5 – – 5 – – TOTAL 545 1997–2117 100 545 1978–2106 100 GFD, general food distribution; CSB, corn–soy blend. Energy requirements of each age/physiologic group*: Age/physiologic group ‘Average’ intake from breast milk (kcal) Energy requirement from food (kcal) Total intake (kcal) 6–8 mo 413 202 615 9–11 mo 379 307 686 12–23 mo 346 548 894 24–35 mo – 1024† 1024† Pregnant – 2588‡ 2588‡ Lactating – 2815§ 2815§ Sources: Food and Agriculture Organization/World Health Organization/United Nations University (UNU) (2001) Human Energy Requirements. FAO: Rome; and Dewey K.G. & Brown K.H. (2003) Update on technical issues concerning. complementary feeding of young children in developing countries and implications for intervention programs. Food and Nutrition Bulletin24, 5–28. †Estimated energy requirement (EER) for 24‐month‐olds, males and females combined. Average requirement over three trimesters for an 18–29‐year‐old woman. Based on a body weight of 55 kg, and a physical activity level of 1.75, and an additional energy allowance for pregnancy of 360 kcal in the second trimester and 475 kcal in the third. Average requirement over the first year postpartum for an 18–29‐year‐old woman Based on a body weight of 55 kg, and a physical activity level of 1.75, and an additional energy allowance for lactation of 505 kcal in the first 6 months postpartum. Hypothetical intake for each age/physiological group from the ‘typical’ GFD ration: Portion of energy in overall ration (%) Energy (kcal) needed from each ration component 6–8 mo 9–11 mo 12–23 mo 24–35 mo Pregnant Lactating Grain 70 141 215 384 717 1812 1971 Pulse 8 16 25 44 82 207 225 CSB 9 18 28 49 92 233 253 Veg oil 10 20 31 55 102 259 282 Sugar 3 6 9 16 31 78 85 Salt* – 0 0 0 0 0 0 Hypothetical intake from ration (kcal) 202 307 548 1024 2588 2815 GFD, general food distribution; CSB, corn–soy blend. *As salt did not contribute to the overall energy intake, the amount included in the diet is not presented. See Table 10 for quantity provided. Hypothetical intake for each age/physiological group from the ‘revised’ GFD ration, adjusted for the quantity of LNS that will be added (118 kcal): Portion of energy in overall ration (%) Energy (kcal) needed from each ration component 6–8 mo 9–11 mo 12–23 mo 24–35 mo Pregnant (1 dose LNS) Pregnant (2 dose LNS) Lactating (1 dose LNS) Lactating (2 dose LNS) Grain 74 62 140 319 672 1833 1745 2002 1913 Pulse 12 10 23 53 112 306 292 334 320 Veg. oil 11 9 20 46 96 262 249 286 273 Sugar 3 2 5 12 25 69 66 75 72 Salt* – 0 0 0 0 0 0 0 0 Hypothetical intake from ration (kcal) 84 189 430 906 2470 2352 2697 2579 Intake from LNS (kcal) 118 118 118 118 118 236 118 236 Total energy intake from non‐breast milk sources (kcal) 202 307 548 1024 2588 2588 2815 2815 GFD, general food distribution; LNS, lipid‐based nutrient supplement. *As salt did not contribute to the overall energy intake, the amount included in the diet is not presented. See Table 18 for quantity provided. Average nutrient concentrations in mature breast milk (World Health Organization 1998): Nutrient Amount (mean ± SD) Lactose (g/L) 72 ± 2.5 Protein (g/L) 10.5 ± 2.0 Fat (g/L) 39.0 ± 4.0 Calcium (mg/L) 280 ± 26 Copper (mg/L) 0.25 ± 0.03 Folate (µ g/L) 85 ± 37 Iodine (µ g/L) 110 ± 40 Iron (mg/L) 0.30 ± 0.10 Magnesium (mg/L) 35 ± 2 Manganese (µ g/L) 6 ± 2 Niacin (mg/L) 1.50 ± 0.20 Pantothenic acid (mg/L) 1.80 ± 0.20 Phosphorous (mg/L) 140 ± 22 Potassium (mg/L) 525 ± 35 Riboflavin (mg/L) 0.35 ± 0.025 Selenium (µ g/L) 20 ± 5 Sodium (mg/L) 180 ± 40 Thiamine (mg/L) 0.21 ± 0.03 Vitamin A (µ g RAE/L) 500 Vitamin B12 (µ g/L) 0.97 Vitamin B6 (µ g/L) 93 ± 0.8 Vitamin C (mg/L) 40 ± 10 Vitamin D (µ g/L) 0.55 ± 0.10 Vitamin E (mg/L) 2.3 ± 1.0 Vitamin K (µ g/L) 2.1 ± 0.1 Zinc (mg/L) 1.2 ± 0.2 Adequate Intakes (AI) and Recommended Nutrient Intakes (RNIs) and Upper Levels (UL) for 7–11‐month‐old infants (IOM and WHO/FAO 2004): Nutrient IOM WHO/FAO Final values used for deficient/excess intake AI UL RNI UL Recommended daily intake UL Carbohydrate (g/d) 95 – – – 95 – Fat (g/d) 30 – – – 30 – Linoleic acid (g/d) 4.6 – – – 4.6 – α‐Linolenic acid (g/d) 0.5 – – – 0.5 – Protein (g/d) 11 – – – 11 – Calcium (mg/d) 270 ND 400 ND 400 ND Copper (mg/d) 0.22 ND – – 0.22 ND Folate (µ g DFE/d) 80 ND 80 ND 80 ND Iodine (µ g/d) 130 ND 90 140 µ g/kg/d* 90 1260 Iron (mg/d)† 1.1 40 0.93 ND 0.93 40 Magnesium (mg/d) 75 ND 54 ND 54 ND Manganese (mg/d) 0.6 ND – – 0.6 ND Niacin (mg/d) 4 ND 4 ND 4 ND Pantothenic acid (mg/d) 1.7 ND 1.8 ND 1.8 ND Phosphorous (mg/d) 275 ND – – 275 ND Potassium (mg/d) 700 ND – – 700 ND Riboflavin (mg/d) 0.4 ND 0.4 ND 0.4 ND Selenium (µ g/d) 20 60 10 ND 10 60 Thiamine (mg/d) 0.3 ND 0.3 ND 0.3 ND Vitamin A (µ g RAE /d) 500 600‡ 400 ND 400 600 Vitamin B12 (µ g/d) 0.5 ND 0.7 ND 0.7 ND Vitamin B6 (mg/d) 0.3 ND 0.3 ND 0.3 ND Vitamin C (mg/d) 50 ND 30 ND 30 ND Vitamin D (IU/d) 200 1000 200 ND 200 1000 Vitamin E (mg/d) 5 ND 2.7 ND 2.7 ND Vitamin K (µ g/d) 2.5 ND 10 ND 10 ND Zinc (mg/d)§ 1.0 5 1.3 23–38 1.1¶ 6¶ IOM, Institute of Medicine; WHO, World Health Organization; FAO, Food and Agriculture Organization; DFE, dietary folate equivalents; RAE, retinol activity equivalents; IU, international units; ND, not determined. *Assuming a reference weight for a 7–12 month‐old infant of 9 kg, the UL for iodine would be approximately 1260 µ g/d. This value was used for purposes of determining excessive iodine intake among 7–12 month‐old children. †Requirement for absorbed iron presented; the ULs are presented in terms of amount ingested. The amount needed in the diet will depend on estimated absorption level. ‡The UL for vitamin A is for intake of preformed vitamin A. §Requirement for absorbed zinc presented; the ULs are presented in terms of amount ingested. The amount needed in the diet to meet the absorbed requirement will depend on estimated absorption level. ¶Alternative recommendations made by the International Zinc Nutrition Consultative Group were used; daily requirement represents the ‘absorbed’ requirement, and the UL is based on the amount ingested. Adequate Intakes (AI), Recommended Dietary Allowances (RDAs) or Recommended Nutrient Intakes (RNIs) and Upper Levels (UL) for 1–3‐year‐old (12–35‐month‐old) children (IOM and WHO/FAO 2004): Nutrient IOM WHO/FAO Final values used for deficient/excess intake AI/RDA UL RNI UL Recommended daily intake UL Carbohydrate (g/d) 130 – – – 130 ND Fat (g/d) 30–40 % E† – – – 30–40 % E† ND Linoleic acid (g/d) 7* – – – 7* ND α‐Linolenic acid (g/d) 0.7* – – – 0.7* ND Protein (g/d) 13 – – – 13 ND Calcium (mg/d) 500* 2500 500 2500 500* 2500 Copper (mg/d) 0.34 1 – – 0.34 1 Folate (µ g DFE/d) 150 300‡ 150 300 150 300 Iodine (µ g/d) 90 200 90 50 µ g/kg/d§ 90 600 Iron (mg/d)¶ 1.26 40 0.58 40 0.58 40 Magnesium (mg/d) 80 65†† 60 65 60 65 Manganese (mg/d) 1.2* 2 1.2 ND 1.2* 2 Niacin (mg/d) 6 10 6 ND 6 10 Pantothenic acid (mg/d) 2* ND 2.0 ND 2* ND Phosphorous (mg/d) 460 3000 – – 460 3000 Potassium (mg/d) 3000* ND – – 3000* ND Riboflavin (mg/d) 0.5 ND 0.5 30 0.5 30 Selenium (µ g/d) 20 90 17 – 17 90 Thiamine (mg/d) 0.5 ND 0.5 10 0.5 10 Vitamin A (µ g RAE /d) 300 600‡‡ 400 600 400 600 Vitamin B12 (µ g/d) 0.9 ND 0.9 – 0.9 ND Vitamin B6 (mg/d) 0.5 30 0.5 30 0.5 30 Vitamin C (mg/d) 15 400 30 400 30 400 Vitamin D (IU/d) 200* 2000 200 2000 200* 2000 Vitamin E (mg/d) 6 200 5 200 5 200 Vitamin K (µ g/d) 30* ND 15 – 15 ND Zinc (mg/d)§§ 0.9 7 1.2 23–28 0.7¶¶ 8¶¶ IOM, Institute of Medicine; WHO, World Health Organization; FAO, Food and Agriculture Organization; RAE, retinol activity equivalents; IU, international units; ND, not determined. *AI. †An AI/RDA is not provided for fat for this age group. The ‘acceptable macronutrient distribution range’ for fat intake is 30–40% of total energy intake. ‡The UL for folate is for intake from fortified foods or supplements. §Assuming a reference weight for a 12–35‐month‐old child of 12 kg, the UL for iodine would be approximately 600 µ g/day. This value was used as the UL for iodine at 12–35 months of age. ¶Requirement for absorbed iron presented; the ULs are presented in terms of amount ingested. The amount needed in the diet will depend on estimated absorption level. ††The UL for magnesium is for intake from non‐food sources. ‡‡The UL for vitamin A is for intake of preformed vitamin A. §§Requirement for absorbed zinc presented; the ULs are presented in terms of amount ingested. The amount needed in the diet to meet the absorbed requirement will depend on estimated absorption level. ¶¶Alternative recommendations for the ‘no‐observed‐adverse‐effect‐level’ made by the International Zinc Nutrition Consultative Group were used. The daily requirement represents the ‘absorbed’ requirement, and the UL is based on the amount ingested. Adequate Intakes (AI), Recommended Dietary Allowances (RDAs) or Recommended Nutrient Intakes (RNIs) and Upper Levels (UL) for pregnant women (19+ years of age) (IOM and WHO/FAO 2004): Nutrient IOM WHO/FAO Final values used for deficient/excess intake AI/RDA UL RNI UL Recommended daily intake UL Carbohydrate (g/d) 175 – – – 175 ND Fat (g/d) 20–35 %E† – – – 20–35% E† ND Linoleic acid (g/d) 13* – – – 13* ND α‐Linolenic acid (g/d) 1.4* – – – 1.4* ND Protein (g/d) 71 – – – 71 ND Calcium (mg/d) 1000* 2500 1200 3000 1200 3000 Copper (mg/d) 1 10 – – 1 10 Folate (µ g DFE /d) 600 1000‡ 600 1000 600 1000 Iodine (µ g/d) 220 1100 200 1100 200 1100 Iron (mg/d)§ 4.6 45 –¶ 45 4.6 45 Magnesium (mg/d) 350–360 350†† 220 – 220 350 Manganese (mg/d) 2* 11 – – 2* 11 Niacin (mg/d) 18 35 18 35 18 35 Pantothenic acid (mg/d) 6* ND 6.0 – 6 ND Phosphorous (mg/d) 700 3500 – – 700 3500 Potassium (mg/d) 4700* ND – – 4700* ND Riboflavin (mg/d) 1.4 ND 1.4 – 1.4 ND Selenium (µ g/d) 60 400 28, 30‡‡ 29 400 Thiamine (mg/d) 1.2 ND 1.4 – 1.4 ND Vitamin A (µ g RAE /d) 770 3000§§ 800 3000 800 3000 Vitamin B12 (µ g/d) 2.6 ND 2.6 – 2.6 ND Vitamin B6 (mg/d) 1.9 100 1.9 100 1.9 100 Vitamin C (mg/d) 85 2000 55 1000 55 1000 Vitamin D (IU/d) 200* 2000 200 2000 200* 2000 Vitamin E (mg/d) 15 1000 – – 15 1000 Vitamin K (µ g/d) 90* ND 55 – 55 ND Zinc (mg/d)¶¶ 5.4 40 3.4 45 3.2††† 40 IOM, Institute of Medicine; WHO, World Health Organization; FAO, Food and Agriculture Organization; DFE, dietary folate equivalents; RAE, retinol activity equivalents; IU, international units; ND, not determined. *AI. †An AI/RDA is not provided for fat for this physiologic group. The ‘acceptable macronutrient distribution range’ for fat intake during pregnancy is 20–35% of energy intake. ‡The UL for folate is for intake from fortified foods or supplements. §Requirement for absorbed iron is presented; the ULs are presented in terms of amount ingested. The amount needed in the diet will depend on estimated absorption level. ¶Iron supplements (e.g. 100 mg of iron as ferrous sulphate) are recommended for all non‐anaemic pregnant women during the second half of pregnancy. ††The UL for magnesium is for intake from supplements, not food or water. ‡‡Requirements for second and third trimester; first trimester not determined. §§The UL for vitamin A is for intake of preformed vitamin A. ¶¶Requirement for absorbed zinc presented and averaged over three trimesters; the ULs are presented in terms of amount ingested. The amount needed in the diet to meet the absorbed requirement will depend on estimated absorption level. †††Alternative recommendations made by the International Zinc Nutrition Consultative Group were used; daily requirement represents the ‘absorbed’ requirement, and the UL is based on the amount ingested. Adequate Intakes (AI), Recommended Dietary Allowances (RDAs) or Recommended Nutrient Intakes (RNIs) and Upper Levels (UL) for lactating women (19+ years of age) (IOM and WHO/FAO 2004): Nutrient IOM WHO/FAO Final values used for deficient/excess intake AI/RDA UL RNI UL Recommended daily intake UL Carbohydrate (g/d) 210 ND – – 210 ND Fat (g/d) 20–35% E† ND – – 20–35% E† ND Linoleic acid (g/d) 13* ND – – 13* ND α‐Linolenic acid (g/d) 1.3* ND – – 1.3* ND Protein (g/d) 71 ND – – 71 ND Calcium (mg/d) 1000* 2500 1000 3000 1000* 3000 Copper (mg/d) 1.3 10 – – 1.3 10 Folate (µ g DFE/d) 500 1000‡ 500 1000 500 1000 Iodine (µ g/d) 290 1100 200 1100 200 1100 Iron (mg/d)§ 1.62 45 1.5 45 1.5 45 Magnesium (mg/d) 310–320 350¶ 270 350 270 350 Manganese (mg/d) 2.6* 11 2.6 11 2.6* 11 Niacin (mg/d) 17 35 17 35 17 35 Pantothenic acid (mg/d) 7* ND 7 – 7* ND Phosphorous (mg/d) 700 4000 – – 700 4000 Potassium (mg/d) 5100 ND – – 5100 ND Riboflavin (mg/d) 1.6 ND 1.6 – 1.6 ND Selenium (µ g/d) 70 400 35 400 35 400 Thiamine (mg/d) 1.4 ND 1.5 – 1.5 ND Vitamin A (µ g RAE /d) 1300 3000†† 850 3000 850 3000 Vitamin B12 (µ g/d) 2.8 ND 2.8 – 2.8 ND Vitamin B6 (mg/d) 2 100 2 100 2 100 Vitamin C (mg/d) 120 2000 70 1000 70 1000 Vitamin D (µ g/d) 200* 2000 200 2000 200* 2000 Vitamin E (mg/d) 19 1000 – – 19 1000 Vitamin K (µ g/d) 90* ND 55 – 55 ND Zinc (mg/d)‡‡ 5.3 40 4.3 45 3.6§§ 40§§ IOM, Institute of Medicine; WHO, World Health Organization; FAO, Food and Agriculture Organization; DFE, dietary folate equivalents; RAE, retinol activity equivalents; ND, not determined. *AI. †An AI/RDA is not provided for fat for this physiologic group. The ‘acceptable macronutrient distribution range’ for fat intake during lactation is 20–35% of energy intake. ‡The UL for folate is for intake from fortified foods or supplements. §Requirement for absorbed iron presented; the ULs are presented in terms of amount ingested. The amount needed in the diet will depend on estimated absorption level. ¶The UL for magnesium is for intake from supplements, not food or water. ††The UL for vitamin A is intake of preformed vitamin A. ‡‡Requirement for absorbed zinc is presented; the ULs are presented in terms of amount ingested. The amount needed in the diet to meet the absorbed requirement will depend on estimated absorption level. §§Alternative recommendations made by the International Zinc Nutrition Consultative Group were used; daily requirement represents the ‘absorbed’ requirement, and the UL is based on the amount ingested. Hypothetical quantity consumed from each component of the ‘typical’ GFD ration for each age or physiologic group: Food Amount in hypothetical intake from GFD diet (g) 6–8 months 9–11 months 12–23 months 24–35 months Pregnant women Lactating women Grain* 39 60 107 199 503 547 Pulse 5 7 13 23 59 64 Corn‐soy blend 5 7 13 24 61 67 Vegetable oil 2 4 6 12 29 32 Sugar 2 2 4 8 20 22 Salt 1 1 1 3 5 5 Total (g) 53 81 144 269 679 739 GFD, general food distribution. *Because four different grains/grain products (rice, cornmeal, wheat flour and sorghum) were used, with slight variations in energy density, there were small differences in the quantity provided for each grain; for purposes of presentation in the table, the average quantity for all four grains is presented. Amount of nutrient provided by each ‘typical’ GFD ration (and ‘average’ breast milk intake) and per cent of the daily recommended intake provided for 6–8‐month‐old children. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets: Nutrient Unit Rice Corn Wheat Sorghum Amt. % daily intake Amt. % daily intake Amt. % daily intake Amt. % daily intake Protein g 10.9 99 11.0 100 12.2 111 12.9 117 Fat g 26.7 89 27.1 90 26.8 89 27.8 93 Linoleic acid g 1.4 30 1.6 35 1.5 32 1.9 40 α‐Linolenic acid g 0.2 38 0.2 38 0.2 38 0.2 42 n6 : n3 7.1 8.4 7.7 8.9 Carbohydrate g 82.2 87 81.4 86 80.7 85 82.2 87 Calcium mg 218.6 55 267.6 67 261.7 65 225.2 56 Copper mg 0.3 126 0.2 107 0.3 119 0.2 94 Folic acid µ g DFE 42.3 53 50.8 63 138.3 173 39.3 49 Iodine µ g 99.5 111 99.5 111 99.5 111 99.5 111 Iron mg 1.6 17 3.3 36 3.0 32 3.1 33 Absorbed iron* mg 0.3 28 0.5 48 0.4 44 0.4 43 Magnesium mg 46.4 86 49.0 91 44.1 82 35.6 66 Manganese mg 0.5 88 0.2 29 0.4 62 0.1 17 Niacin mg 2.7 68 3.9 98 4.5 112 3.7 92 Pantothenic acid mg 1.8 100 1.4 79 1.5 83 1.3 73 Phosphorous mg 156.0 57 154.7 56 156.5 57 234.2 85 Potassium mg 433.3 62 455.5 65 438.8 63 543.2 78 Riboflavin mg 0.3 66 0.4 98 0.4 100 0.3 76 Selenium µ g 19.4 194 17.9 179 26.6 266 13.5 135 Sodium mg 305.2 82 307.0 83 305.1 82 306.8 83 Thiamine mg 0.2 73 0.5 154 0.4 147 0.3 97 Vitamin A µ g RAE 378.3 95 603.7 151 606.8 152 378.3 95 Vitamin B12 µ g 0.7 93 0.7 93 0.7 93 0.7 93 Vitamin B6 mg 0.2 54 0.2 58 0.1 39 0.1 33 Vitamin C mg 26.3 88 26.3 88 26.3 88 26.3 88 Vitamin D IU 22.7 11 22.7 11 22.7 11 22.7 11 Vitamin E mg 1.9 71 1.9 71 1.9 70 1.9 69 Vitamin K µ g 6.0 60 6.0 60 6.1 61 6.0 60 Zinc mg 1.5 37 1.4 33 1.4 33 1.1 27 Absorbed zinc† mg 0.8 72 0.6 57 0.6 58 0.5 46 GFD, general food distribution; DFE, dietary folate equivalents; RAE, retinol activity equivalents; IU, international units. *Adequacy based on absorbed iron requirement and based on calculated bioavailability of the diet. †Adequacy based on absorbed zinc requirement and based on calculated bioavailability of the diet. Amount of nutrient provided by each ‘typical’ GFD ration (and ‘average’ breast milk intake) and per cent of the daily recommended intake provided for 9–11‐month‐old children. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets: Nutrient Unit Rice Corn Wheat Sorghum Amt. % daily intake Amt. % daily intake Amt. % daily intake Amt. % daily intake Protein g 12.7 115 12.9 117 14.7 134 15.8 144 Fat g 26.3 88 27.0 90 26.5 88 28.0 93 Linoleic acid g 2.1 45 2.4 52 2.2 48 2.8 61 α‐Linolenic acid g 0.3 58 0.3 57 0.3 58 0.3 63 n6 : n3 7.1 8.4 7.7 8.9 Carbohydrate g 98.6 104 97.4 103 96.4 101 98.6 104 Calcium mg 229.9 57 304.3 76 295.3 74 239.9 60 Copper mg 0.3 149 0.3 121 0.3 139 0.2 101 Folic acid µ g DFE 63.7 80 76.6 96 209.7 262 59.2 74 Iodine µ g 111.0 123 111.0 123 111.0 123 111.0 123 Iron mg 2.3 25 5.0 53 4.4 47 4.6 49 Absorbed iron* mg 0.3 37 0.6 64 0.5 58 0.5 56 Magnesium mg 57.8 107 61.7 114 54.3 101 41.3 76 Manganese mg 0.8 133 0.3 44 0.6 93 0.2 26 Niacin mg 3.6 90 5.5 137 6.3 158 3.3 83 Pantothenic acid mg 2.1 115 1.5 84 1.6 89 1.4 75 Phosphorous mg 185.9 68 184.0 67 186.6 68 304.7 111 Potassium mg 466.5 67 500.2 71 474.9 68 633.6 91 Riboflavin mg 0.3 68 0.5 117 0.5 120 0.3 84 Selenium µ g 22.2 222 19.9 199 33.2 332 13.2 132 Sodium mg 397.5 107 400.2 108 397.3 107 399.9 108 Thiamine mg 0.3 86 0.6 208 0.6 198 0.4 122 Vitamin A µ g 392.1 98 734.6 184 739.3 185 392.1 98 Vitamin B12 µ g RAE 0.6 91 0.6 91 0.6 91 0.6 91 Vitamin B6 mg 0.2 71 0.2 77 0.1 48 0.1 39 Vitamin C mg 25.4 85 25.4 85 25.4 85 25.4 85 Vitamin D IU 26.4 13 26.4 13 26.4 13 26.4 13 Vitamin E mg 2.1 76 2.1 77 2.0 75 2.0 74 Vitamin K µ g 8.4 84 8.4 84 8.5 85 8.4 84 Zinc mg 1.9 46 1.6 40 1.6 40 1.2 30 Absorbed zinc† mg 0.9 80 0.7 61 0.7 63 0.5 46 GFD, general food distribution; DFE, dietary folate equivalents; RAE, retinol activity equivalents; IU, international units. *Adequacy based on absorbed iron requirement and based on calculated bioavailability of the diet. †Adequacy based on absorbed zinc requirement and based on calculated bioavailability of the diet. Amount of nutrient provided by each ‘typical’ GFD ration (and ‘average’ breast milk intake) and per cent of the daily recommended intake provided for 12–23‐month‐old children. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets: Nutrient Unit Rice Corn Wheat Sorghum Amt. % daily intake Amt. % daily intake Amt. % daily intake Amt. % daily intake Protein g 17.5 134 17.9 137 21.2 163 23.1 178 Fat* g 27.9 28 29.2 29 28.3 29 31.0 31 Linoleic acid g 3.7 53 4.3 62 4.0 57 5.0 72 α‐Linolenic acid g 0.5 74 0.5 73 0.5 73 0.6 81 n6 : n3 7.1 8.4 7.7 8.9 Carbohydrate g 141.1 109 138.9 107 137.0 105 141.1 109 Calcium mg 274.2 55 407.0 81 391.1 78 292.1 58 Copper mg 0.5 137 0.4 104 0.4 125 0.3 81 Folic acid µ g DFE 113.0 75 136.1 91 373.6 249 104.9 70 Iodine µ g 143.6 160 144.8 161 144.8 161 144.8 161 Iron mg 4.0 68 8.7 151 7.8 134 8.1 140 Absorbed iron† mg 0.5 88 0.9 156 0.8 143 0.8 137 Magnesium mg 86.1 144 93.1 155 79.9 133 56.7 95 Manganese mg 1.4 118 0.5 39 1.0 83 0.3 23 Niacin mg 5.7 95 8.9 149 10.4 174 8.3 138 Pantothenic acid mg 2.8 141 1.8 92 2.0 100 1.5 77 Phosphorous mg 263.8 57 260.3 57 265.0 58 475.9 103 Potassium mg 577.5 19 637.8 21 592.6 20 875.8 29 Riboflavin mg 0.3 64 0.7 132 0.7 138 0.4 86 Selenium µ g 29.8 176 25.9 152 49.5 291 13.8 81 Sodium mg 615.7 62 628.2 63 623.0 62 627.7 63 Thiamine mg 0.4 71 1.0 202 1.0 192 0.6 110 Vitamin A µ g RAE 457.0 114 1068.2 267 1076.6 269 457.0 114 Vitamin B12 µ g 0.7 74 0.7 74 0.7 74 0.7 74 Vitamin B6 mg 0.3 67 0.4 74 0.2 42 0.2 33 Vitamin C mg 25.9 86 25.9 86 25.9 86 25.9 86 Vitamin D IU 36.5 18 36.5 18 36.5 18 36.5 18 Vitamin E mg 2.6 43 2.6 43 2.5 42 2.4 41 Vitamin K µ g 14.0 93 13.9 93 14.2 95 13.9 93 Zinc mg 2.8 68 2.3 57 2.3 57 1.6 39 Absorbed zinc‡ 1.1 156 0.8 115 0.8 117 0.6 81 GFD, general food distribution; DFE, dietary folate equivalents; RAE, retinol activity equivalents; IU, international units. *Because there is not a recommended absolute amount of fat for the 12–35 month age group, the per cent of energy from fat is displayed in the ‘% daily intake column’. For this age group, the per cent of energy from fat is recommended to be between 30 and 40% of energy (Institute of Medicine). †Adequacy based on absorbed iron requirement and based on calculated bioavailability of the diet. ‡Adequacy based on absorbed zinc requirement and based on calculated bioavailability of the diet. Amount of nutrient provided by each ‘typical’ GFD ration and per cent of the daily recommended intake provided for 24–35‐month‐old children. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets: Nutrient Unit Rice Corn Wheat Sorghum Amt. % daily intake Amt. % daily intake Amt. % daily intake Amt. % daily intake Protein g 22.7 175 23.4 180 29.6 228 33.2 255 Fat* g 15.1 13 17.4 15 15.9 14 20.9 18 Linoleic acid g 6.9 99 8.1 115 7.4 106 9.4 135 α‐Linolenic acid g 1.0 139 1.0 136 1.0 137 1.1 151 n6 : n3 7.1 8.4 7.7 8.9 Carbohydrate g 195.1 150 191.1 147 187.6 144 195.1 150 Calcium mg 246.2 49 494.3 99 464.6 93 279.6 56 Copper mg 0.6 186 0.4 124 0.6 164 0.3 81 Folic acid µ g DFE 209.8 140 252.8 169 696.7 464 194.5 130 Iodine µ g 163.6 182 166.0 184 166.0 184 166.0 184 Iron† mg 7.1 123 16.0 276 14.2 245 14.8 256 Absorbed iron† mg 0.6 101 1.0 181 1.0 165 0.9 158 Magnesium mg 127.6 213 140.7 234 116.0 193 72.7 121 Manganese mg 2.6 220 0.9 72 1.9 154 0.5 43 Niacin mg 9.3 154 15.3 254 18.1 301 14.0 234 Pantothenic acid mg 3.6 179 1.7 86 2.0 101 1.2 58 Phosphorous mg 359.9 78 353.3 77 362.1 79 756.2 164 Potassium mg 580.0 19 692.6 23 608.0 20 1137.4 38 Riboflavin mg 0.3 52 0.9 181 1.0 191 0.5 93 Selenium µ g 36.7 216 29.3 172 73.5 432 6.8 40 Sodium mg 977.8 98 1002.2 100 992.6 99 1001.3 100 Thiamine mg 0.5 94 1.7 338 1.6 318 0.8 166 Vitamin A µ g RAE 378.5 95 1520.7 380 1536.4 384 378.5 95 Vitamin B12 µ g 0.3 35 0.3 35 0.3 35 0.3 35 Vitamin B6 mg 0.5 107 0.6 120 0.3 61 0.2 43 Vitamin C mg 10.3 34 10.3 34 10.3 34 10.3 34 Vitamin D IU 47.3 24 47.3 24 47.3 24 47.3 24 Vitamin E mg 2.6 43 2.7 45 2.5 41 2.4 39 Vitamin K µ g 24.2 161 24.0 160 24.6 164 24.0 160 Zinc mg 4.1 99 3.2 79 3.2 79 1.9 45 Absorbed zinc‡ mg 2.2 187 0.9 130 0.9 133 0.6 80 GFD, general food distribution; DFE, dietary folate equivalents; RAE, retinol activity equivalents; IU, international units. *Because there is not a recommended absolute amount of fat for the 12–35 month age group, the per cent of energy from fat is displayed in the ‘% daily intake’ column. For this age group, the per cent of energy from fat is recommended to be between 30 and 40% of energy (Institute of Medicine). †Adequacy based on absorbed iron requirement and based on calculated bioavailability of the diet. ‡Adequacy based on absorbed zinc requirement and based on calculated bioavailability of the diet. Nutrients that exceed the UL from the hypothetical intake from the ‘typical’ GFD ration. Presented by age/physiologic group and identified by the staple grain used in the GFD hypothetical intake (with all other components being equal between diets): Age/physiologic group (mo) Rice Cornmeal Wheat flour Sorghum 6–8 Vitamin A Vitamin A 9–11 Vitamin A Vitamin A 12–23 Magnesium Magnesium Vitamin A Niacin Magnesium Vitamin A Folic acid Magnesium 24–35 Magnesium Manganese Magnesium Vitamin A Niacin Magnesium Vitamin A Niacin Folic acid Magnesium Niacin Pregnant Magnesium Niacin Vitamin A Folic acid Magnesium Niacin Vitamin A Niacin Lactating Magnesium Magnesium Niacin Vitamin A Folic acid Niacin Vitamin A Niacin UL, Upper Levels; GFD, general food distribution. Amount of nutrient provided by each ‘typical’ GFD ration and per cent of the daily recommended intake provided for pregnant women. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets: Nutrient Unit Rice Corn Wheat Sorghum Amt. % daily intake Amt. % daily intake Amt. % daily intake Amt. % daily intake Protein g 57.3 81 59.1 83 74.9 105 83.9 118 Fat* g 41.5 13 47.8 15 43.6 14 57.5 18 Linoleic acid g 17.5 135 20.3 157 18.8 144 23.8 183 α‐Linolenic acid g 2.5 175 2.4 172 2.4 173 2.7 190 n6 : n3 7.1 8.4 7.7 8.9 Carbohydrate g 493.2 282 482.9 276 474.1 271 493.1 282 Calcium mg 621.9 52 1248.9 104 1173.8 98 706.3 59 Copper mg 1.6 160 1.1 107 1.4 141 0.7 69 Folic acid µ g DFE 530.1 88 638.9 106 1760.8 293 491.7 82 Iodine µ g 334.2 167 334.2 167 334.2 167 334.2 167 Iron mg 18.0 67 40.5 150 35.9 133 37.5 139 Absorbed iron† mg 4.5 98 10.1 220 9.0 195 9.4 204 Magnesium mg 322.6 147 355.5 162 293.2 133 183.7 84 Manganese mg 6.7 334 2.2 109 4.7 234 1.3 64 Niacin mg 23.4 130 38.6 214 45.7 254 45.7 254 Pantothenic acid mg 9.0 151 4.3 72 5.1 85 2.9 49 Phosphorous mg 909.5 130 893.0 128 915.0 131 1911.2 273 Potassium mg 1465.7 31 1750.2 37 1536.5 33 2874.4 61 Riboflavin mg 0.7 47 2.3 163 2.4 172 1.2 84 Selenium µ g 92.8 320 74.0 255 185.8 641 17.1 59 Sodium mg 1960.2 131 1982.9 132 1958.4 131 1980.5 132 Thiamine mg 1.2 85 4.3 305 4.0 287 2.1 150 Vitamin A µ g RAE 956.5 120 3843.3 480 3883.0 485 956.5 120 Vitamin B12 µ g 0.8 31 0.8 31 0.8 31 0.8 31 Vitamin B6 mg 1.4 71 1.5 80 0.8 40 0.5 29 Vitamin C mg 26.0 47 26.0 47 26.0 47 26.0 47 Vitamin D IU 119.5 60 119.5 60 119.5 60 119.5 60 Vitamin E mg 6.5 44 6.8 45 6.3 42 6.0 40 Vitamin K µ g 61.1 111 60.6 110 62.1 113 60.6 110 Zinc mg 10.3 137 8.2 109 8.2 109 4.7 62 Absorbed zinc‡ mg 2.2 68 1.5 46 1.5 48 0.9 29 GFD, general food distribution; DFE, dietary folate equivalents; RAE, retinol activity equivalents; IU, international units. *Because there is not a recommended absolute amount of fat for pregnant or lactating women, the per cent of energy from fat is displayed in the ‘% daily intake’ column. For this physiological group, the per cent of energy from fat is recommended to be between 20 and 35% of energy (Institute of Medicine). †Amount of absorbed iron is based on an assumed 25% absorption for pregnant women (Institute of Medicine). Adequacy based on absorbed iron requirement. ‡Amount of absorbed zinc is based on calculated bioavailability of diet. Using standard equations for determining the bioavailability of zinc from the diet, the calculated zinc absorption from the ‘typical’ GFD ration is 19%. Adequacy based on absorbed zinc requirement. Amount of nutrient provided by each ‘typical’ GFD ration and per cent of the daily recommended intake provided for lactating women. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets: Nutrient Unit Rice Corn Wheat Sorghum Amt. % daily intake Amt. % daily intake Amt. % daily intake Amt. % daily intake Protein g 62.4 88 64.3 91 81.5 115 91.2 128 Fat* g 41.5 13 47.8 354 43.6 323 57.5 426 Linoleic acid g 19.0 146 22.1 170 20.4 157 25.9 199 α‐Linolenic acid g 2.7 191 2.6 187 2.6 189 2.9 207 n6 : n3 7.1 8.4 7.7 8.9 Carbohydrate g 536.4 307 525.2 300 515.7 295 536.4 307 Calcium mg 676.4 56 1358.4 113 1276.7 106 768.2 64 Copper mg 1.7 174 1.2 116 1.5 153 0.8 75 Folic acid µ g DFE 576.6 96 695.0 116 1915.2 319 534.8 89 Iodine µ g 337.3 169 337.3 169 337.3 169 337.3 169 Iron mg 19.6 73 44.1 163 39.1 145 40.8 151 Absorbed iron† 1.7 115 3.1 209 2.9 190 2.7 183 Magnesium mg 350.8 159 386.7 176 318.9 145 199.8 91 Manganese mg 7.3 363 2.4 119 5.1 255 1.4 70 Niacin mg 25.4 141 41.9 233 49.7 276 38.6 214 Pantothenic acid mg 9.8 164 4.7 78 5.6 93 3.2 53 Phosphorous mg 989.2 141 971.4 139 995.3 142 2078.9 297 Potassium mg 1594.2 34 1903.7 41 1671.3 36 3126.5 67 Riboflavin mg 0.7 51 2.5 178 2.6 187 1.3 92 Selenium µ g 101.0 348 80.5 278 202.1 697 18.6 64 Sodium mg 1962.1 131 1986.8 132 1960.2 131 1984.3 132 Thiamine mg 1.3 92 4.6 332 4.4 312 2.3 163 Vitamin A µ g 1040.4 130 4180.4 523 4223.6 528 1040.4 130 Vitamin B12 µ g 0.9 33 0.9 33 0.9 33 0.9 33 Vitamin B6 mg 1.5 77 1.7 87 0.8 44 0.6 31 Vitamin C mg 28.3 52 28.3 52 28.3 52 28.3 52 Vitamin D IU 130.0 65 130.0 65 130.0 65 130.0 65 Vitamin E mg 7.1 47 7.4 49 6.8 46 6.5 43 Vitamin K µ g 66.4 121 65.9 120 67.5 123 65.9 120 Zinc mg 11.2 149 8.9 119 8.9 118 5.1 68 Absorbed zinc‡ 3.4 94.3 2.4 67.6 2.5 68.8 1.5 40.9 GFD, general food distribution; DFE, dietary folate equivalents; IU, international units. *Because there is not a recommended absolute amount of fat for pregnant or lactating women, the recommended per cent of energy from fat is displayed in the ‘% daily intake’ column. For this physiological group, the per cent of energy from fat is recommended to be between 20 and 35% of energy (Institute of Medicine). †Amount of absorbed iron presented based on calculated bioavailability of diet. For lactating women, using standard equations for determining the bioavailability of iron from the diet, the calculated iron absorption from the ‘typical’ GFD ration for lactating women is 7%. Adequacy based on absorbed iron requirement. ‡Amount of absorbed zinc presented based on calculated bioavailability of diet. For lactating women, using standard equations for determining the bioavailability of zinc from the diet, the calculated zinc absorption from the ‘typical’ GFD ration is 21% (an increase of 10% above pregnancy). Adequacy based on absorbed zinc requirement. Composition (g) of hypothetical intakes from ‘revised’ GFD ration, taking into account energy content (118 kcal or 236 kcal) to be provided via LNS: Food 6–8 mo (84 kcal) 9–11 mo (189 kcal) 12–23 mo (430 kcal) 24–35 mo (906 kcal) Pregnant (2470 kcal) Pregnant (2352 kcal)* Lactating (2697 kcal) Lactating (2579 kcal)* Grain (g)† 17 39 89 188 512 487 559 534 Pulses (g) 3 7 16 33 89 85 97 93 Veg. oil (g) 1 2 5 11 30 28 32 31 Salt (g) 0.2 0.5 1 2 6 6 7 6 Sugar (g) 0.6 1 3 7 18 17 19 19 Total (g) 22 50 114 240 654 623 714 683 GFD, general food distribution; LNS, lipid‐based nutrient supplement. †Because four different grains/grain products (rice, cornmeal, wheat flour and sorghum) were used, with slight variations in energy density, there were small differences in the quantity assumed for each grain; for purposes of presentation in the table, the average quantity for all four grains is presented. *Two ‘doses’ of LNS provided (236 kcal). LNS macro‐ and micro‐nutrient content for 6–35‐month‐olds based on the higher of the two daily recommended intake values for 7–11 and 12–35 months (micronutrients only), except where noted: Nutrient Unit Daily recommended intake: 7–11 mo Daily recommended intake: 12–35 mo LNS 6–35 mo composition, per 20g ration Protein g 11.0 13 2.6 Fat g 30.0 30–40% E 9.6 Linoleic acid g 4.6 7 4.5 α‐linolenic acid g 0.5 0.7 0.6 Carbohydrate g 95.0 130 5.3 Energy kcal NA NA 118 Calcium mg 400 500 280* Copper mg 0.22 0.34 0.34 Folic acid µ g DFE 80 150 150 Iodine µ g 90 90 90 Iron† mg 0.93 0.58 6‡ Magnesium mg 54 60 60 Manganese mg 0.6 1.2 1.2 Niacin mg 4 6 6 Pantothenic acid mg 1.8 2 2 Phosphorus mg 275 460 190* Potassium mg 700 3000 200* Riboflavin mg 0.4 0.5 0.5 Selenium µ g 10 17 17 Thiamine µ g 0.3 0.5 0.5 Vitamin A µ g RAE 400 400 400 Vitamin B12 mg 0.7 0.9 0.9 Vitamin B6 mg 0.3 0.5 0.5 Vitamin C IU 30 30 30 Vitamin D mg 200 200 200 Vitamin E µ g 2.7 5 5 Vitamin K mg 10 15 15 Zinc† mg 1.1 0.7 5§ LNS, lipid‐based nutrient supplement; DFE, dietary folate equivalents; RAE, retinol activity equivalents. *Nutrients whose content in LNS is limited to less than 1 recommended nutrient intake due to technical/food science constraints. †The daily recommended intake for iron and zinc provided is the absorbed need. ‡The iron content in the LNS was based on an average of the calculated levels of iron absorption from the GFD diets for 7–11‐month‐olds of 21% and 16% for the 12–35‐month‐olds. The value was increased by 30–50% to account for uncertainty in the absorption from the base diet and LNS. §The average calculated zinc absorption from the GFD diets was 39% for the 7–11‐month‐olds and 29% for the 12–35‐month‐olds; however due to uncertainty in absorption from LNS, 5 mg was included. Amount of nutrient provided by each ‘revised’ GFD ration, breast milk and LNS (6–35 mo formulation) and per cent of the daily recommended intake provided for 6–8‐month‐old children. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets: Nutrient Unit Rice Corn Wheat Sorghum Amt. % daily intake Amt. % daily intake Amt. % daily intake Amt. % daily intake Protein g 10.9 99 10.9 99 11.5 104 11.8 107 Fat g 34.4 115 34.6 115 34.5 115 34.9 116 Linoleic acid g 5.0 108 5.1 110 5.0 109 5.2 113 α‐linolenic acid g 0.7 132 0.7 132 0.7 132 0.7 134 n6 : n3 ratio 7.6 7.7 7.6 7.8 Carbohydrate g 65.2 69 64.8 68 64.5 68 65.2 69 Calcium mg 454.9 114 476.4 119 473.9 118 457.8 114 Copper mg 0.5 248 0.5 240 0.5 245 0.5 234 Folic acid µ g DFE 164.3 205 168.0 210 206.6 258 163.0 204 Iodine µ g 169.3 188 169.3 188 169.3 188 169.3 188 Iron mg 6.5 89 7.3 100 7.1 97 7.2 98 Absorbed iron* mg 1.6 171 1.6 168 1.6 168 1.5 160 Magnesium mg 90.2 167 91.3 169 89.1 165 85.4 158 Manganese mg 1.4 238 1.3 212 1.4 227 1.2 207 Niacin mg 7.6 189 8.2 205 8.3 209 8.0 200 Pantothenic acid mg 3.4 186 3.2 177 3.2 179 3.1 175 Phosphorous mg 305.6 111 305.1 111 305.8 111 340.1 124 Potassium mg 568.2 81 578.0 83 570.6 82 616.6 88 Riboflavin mg 0.7 182 0.8 196 0.8 197 0.7 186 Selenium µ g 32.0 320 31.3 313 35.2 352 29.4 294 Sodium mg 190.6 52 191.4 52 190.6 52 191.3 52 Thiamine mg 0.7 221 0.8 256 0.8 253 0.7 231 Vitamin A µ g RAE 721.9 180 821.2 205 822.6 206 721.9 180 Vitamin B12 µ g 1.5 213 1.5 213 1.5 213 1.5 213 Vitamin B6 mg 0.6 199 0.6 200 0.6 192 0.6 189 Vitamin C mg 54.4 181 54.4 181 54.4 181 54.4 181 Vitamin D IU 213.4 107 213.4 107 213.4 107 213.4 107 Vitamin E mg 6.5 241 6.5 241 6.5 241 6.5 240 Vitamin K µ g 18.4 184 18.4 184 18.4 184 18.4 184 Zinc mg 6.0 274 6.0 271 6.0 271 5.8 265 Absorbed zinc† mg 2.6 237 2.3 212 2.4 215 2.2 200 GFD, general food distribution; LNS, lipid‐based nutrient supplement; DFE, dietary folate equivalents; RAE, retinol activity equivalents. *The total amount of iron in the diet is presented as well as the estimated amount of iron absorbed from the diet (based on the calculated bioavailability). The per cent of daily requirement is calculated based on the amount of absorbed iron. †The total amount of zinc in the diet is presented as well as the estimated amount of zinc absorbed from the diet (based on the calculated bioavailability). The per cent of daily requirement is calculated based on the amount of absorbed zinc. Amount of nutrient provided by each ‘revised’ GFD ration, breast milk and LNS (6–35 mo formulation) and per cent of the daily recommended intake provided for 9–11‐month‐old children. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets: Nutrient Unit Rice Corn Wheat Sorghum Amt. % daily intake Amt. % daily intake Amt. % daily intake Amt. % daily intake Protein g 12.7 116 12.8 117 14.1 128 14.8 134 Fat g 33.9 113 34.4 115 34.1 114 35.0 117 Linoleic acid g 5.7 123 5.9 128 5.8 125 6.2 134 α‐linolenic acid g 0.8 152 0.8 151 0.8 152 0.8 155 n6 : n3 ratio 7.5 7.8 7.6 7.9 Carbohydrate g 81.8 86 81.0 85 80.3 85 81.8 86 Calcium mg 446.9 112 495.4 124 489.6 122 453.4 113 Copper mg 0.6 273 0.6 254 0.6 266 0.5 241 Folic acid µ g DFE 181.0 226 189.4 237 276.3 345 178.0 223 Iodine µ g 180.9 201 180.9 201 180.9 201 180.9 201 Iron mg 6.9 94 8.6 118 8.3 113 8.4 115 Absorbed iron* mg 1.5 158 1.6 168 1.5 165 1.5 157 Magnesium mg 99.5 184 102.1 189 97.3 180 88.8 164 Manganese mg 1.7 285 1.4 227 1.6 259 1.3 216 Niacin mg 8.3 208 9.5 238 10.1 251 9.3 232 Pantothenic acid mg 3.6 199 3.2 179 3.3 182 3.1 173 Phosphorous mg 337.0 123 335.7 122 337.4 123 414.5 151 Potassium mg 603.8 86 625.8 89 609.3 87 712.8 102 Riboflavin mg 0.7 182 0.9 214 0.9 216 0.8 192 Selenium µ g 34.5 345 33.1 331 41.7 417 28.6 286 Sodium mg 292.8 79 294.6 80 292.7 79 294.4 80 Thiamine mg 0.7 232 0.9 312 0.9 305 0.8 256 Vitamin A µ g RAE 719.7 180 943.1 236 946.2 237 719.7 180 Vitamin B12 µ g 1.4 206 1.4 206 1.4 206 1.4 206 Vitamin B6 mg 0.6 213 0.7 218 0.6 198 0.6 193 Vitamin C mg 52.5 175 52.5 175 52.5 175 52.5 175 Vitamin D IU 212.3 106 200.3 100 212.3 106 212.3 106 Vitamin E mg 6.5 242 6.5 242 6.5 241 6.5 240 Vitamin K µ g 21.0 210 20.9 209 21.1 211 20.9 209 Zinc mg 6.3 288 6.2 281 6.2 281 5.9 269 Absorbed zinc† mg 2.5 226 2.1 192 2.2 196 2.0 178 GFD, general food distribution; LNS, lipid‐based nutrient supplement; DFE, dietary folate equivalents; RAE, retinol activity equivalents. *The total amount of iron in the diet is presented as well as the estimated amount of iron absorbed from the diet (based on the calculated bioavailability). The per cent of the daily recommended intake is calculated based on the amount of absorbed iron. †The total amount of zinc in the diet is presented as well as the estimated amount of zinc absorbed from the diet (based on the calculated bioavailability). The per cent of the daily recommended intake is calculated based on the amount of absorbed zinc. Amount of nutrient provided by each ‘revised’ GFD ration, breast milk and LNS (6–35 mo formulation) and per cent of the daily recommended intake provided for 12–23‐month‐old children. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets: Nutrient Unit Rice Corn Wheat Sorghum Amt. % daily intake Amt. % daily intake Amt. % daily intake Amt. % daily intake Protein g 17.6 136 17.9 138 20.7 159 22.3 172 Fat* g 35.3 36 36.3 37 35.6 36 37.9 38 Linoleic acid g 7.2 103 7.7 110 7.5 106 8.3 119 α‐linolenic acid g 1.0 142 1.0 141 1.0 141 1.0 147 n6 : n3 ratio 7.3 7.9 7.5 8.1 Carbohydrate g 124.7 96 122.9 95 121.4 93 124.7 96 Calcium mg 447.1 89 557.6 112 544.4 109 462.0 92 Copper mg 0.7 218 0.6 191 0.7 209 0.6 172 Folic acid µ g DFE 219.4 146 238.5 159 436.2 291 212.6 142 Iodine µ g 211.9 235 211.9 235 211.9 235 211.9 235 Iron mg 7.8 124 11.8 187 10.9 174 11.2 178 Absorbed iron† mg 1.4 243 1.8 303 1.7 289 1.6 275 Magnesium mg 123.4 206 129.2 215 118.2 197 98.9 165 Manganese mg 2.4 197 1.6 131 2.0 167 1.4 117 Niacin mg 10.2 169 12.8 214 14.1 235 12.3 205 Pantothenic acid mg 4.2 212 3.4 170 3.5 177 3.2 158 Phosphorous mg 418.1 91 415.2 90 419.1 91 594.5 129 Potassium mg 720.1 24 770.2 26 732.5 24 968.2 32 Riboflavin mg 0.8 151 1.0 208 1.1 212 0.8 169 Selenium µ g 41.7 245 38.4 226 58.0 341 28.3 167 Sodium mg 521.1 52 525.1 53 520.8 52 524.7 52 Thiamine mg 0.8 158 1.3 266 1.3 258 0.9 190 Vitamin A µ g RAE 747.8 187 1256.3 314 1263.3 316 747.8 187 Vitamin B12 µ g 1.4 155 1.4 155 1.4 155 1.4 155 Vitamin B6 mg 0.7 150 0.8 155 0.6 129 0.6 121 Vitamin C mg 50.8 169 50.8 169 50.8 169 50.8 169 Vitamin D IU 211.2 106 211.2 106 211.2 106 211.2 106 Vitamin E mg 6.7 135 6.8 135 6.7 134 6.6 133 Vitamin K µ g 27.0 180 26.9 180 27.2 181 26.9 180 Zinc mg 7.1 376 6.8 357 6.8 357 6.2 324 Absorbed zinc‡ mg 2.4 344 1.9 277 2.0 284 1.7 246 GFD, general food distribution; LNS, lipid‐based nutrient supplement; DFE, dietary folate equivalents; RAE, retinol activity equivalents. *Because there is not a recommended absolute amount of fat for the 12–35 month age group, the per cent of energy from fat is displayed in the ‘% daily intake’ column. For this age group, the per cent of energy from fat is recommended to be between 30 and 40% of energy (Institute of Medicine). †The total amount of iron in the diet is presented as well as the estimated amount of iron absorbed from the diet (based on the calculated bioavailability). The per cent of the daily recommended intake is calculated based on the amount of absorbed iron. ‡The total amount of zinc in the diet is presented as well as the estimated amount of zinc absorbed from the diet (based on the calculated bioavailability). The per cent of the daily recommended intake is calculated based on the amount of absorbed zinc. Amount of nutrient provided by each ‘revised’ GFD ration, breast milk and LNS (6–35 mo formulation) and per cent of the daily recommended intake provided for 24–35‐month‐old children. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets: Nutrient Unit Rice Corn Wheat Sorghum Amt. % daily intake Amt. % daily intake Amt. % daily intake Amt. % daily intake Protein g 23.0 177 23.7 182 29.5 227 32.9 253 Fat* g 21.9 19 24.1 21 22.7 20 27.4 24 Linoleic acid g 10.3 147 11.3 162 10.8 154 12.6 180 α‐linolenic acid g 1.4 207 1.4 205 1.4 205 1.5 218 n6 : n3 ratio 7.1 7.9 7.5 8.3 Carbohydrate g 179.7 138 175.9 135 172.6 133 179.7 138 Calcium mg 331.9 66 564.6 113 536.7 107 363.2 73 Copper mg 0.9 271 0.7 213 0.9 250 0.6 172 Folic acid µ g DFE 294.5 196 334.9 223 751.2 501 280.2 187 Iodine µ g 222.7 247 222.7 247 222.7 247 222.7 247 Iron mg 9.5 150 17.8 283 16.1 255 16.7 265 Absorbed iron† mg 1.1 197 1.7 300 1.6 278 1.5 267 Magnesium mg 156.0 260 168.3 280 145.1 242 104.5 174 Manganese mg 3.6 303 2.0 164 2.9 241 1.6 136 Niacin mg 13.2 220 18.8 313 21.4 357 17.7 294 Pantothenic acid mg 4.8 239 3.0 152 3.3 166 2.5 126 Phosphorous mg 520.4 113 514.3 112 522.4 114 892.2 194 Potassium mg 732.7 24 838.3 28 759.0 25 1255.5 42 Riboflavin mg 0.7 132 1.3 252 1.3 262 0.9 170 Selenium µ g 47.5 280 40.5 238 82.0 482 19.4 114 Sodium mg 865.2 87 873.6 87 864.5 86 872.7 87 Thiamine mg 0.9 177 2.0 406 1.9 387 1.2 244 Vitamin A µ g RAE 596.8 149 1668.2 417 1682.9 421 596.8 149 Vitamin B12 µ g 0.9 100 0.9 100 0.9 100 0.9 100 Vitamin B6 mg 0.9 184 1.0 197 0.7 141 0.6 125 Vitamin C mg 31.0 103 31.0 103 31.0 103 31.0 103 Vitamin D IU 200.0 100 200.0 100 200.0 100 200.0 100 Vitamin E mg 6.2 124 6.3 125 6.1 122 6.0 119 Vitamin K µ g 38.1 254 37.9 253 38.5 256 37.9 253 Zinc mg 8.2 434 7.5 392 7.5 392 6.2 324 Absorbed zinc‡ mg 2.3 334 1.8 254 1.8 260 1.5 208 GFD, general food distribution; LNS, lipid‐based nutrient supplement; DFE, dietary folate equivalents; RAE, retinol activity equivalents. *Because there is not a recommended absolute amount of fat for the 12–35 mo age group, the per cent of energy from fat is displayed in the ‘% daily intake’ column. For this age group, the per cent of energy from fat is recommended to be between 30 and 40% of energy (Institute of Medicine). †The total amount of iron in the diet is presented as well as the estimated amount of iron absorbed from the diet (based on the calculated bioavailability). The per cent of daily requirement is calculated based on the amount of absorbed iron. ‡The total amount of zinc in the diet is presented as well as the estimated amount of zinc absorbed from the diet (based on the calculated bioavailability). The per cent of the daily recommended intake is calculated based on the amount of absorbed zinc. Nutrients that exceed the UL when the 6–35 mo formulation LNS is added to the hypothetical intake from the ‘revised’ GFD ration, and breast milk (when applicable). Presented by age group and identified by the staple grain used in the GFD hypothetical intake (with all other components being equal between diets): Age group (mo) Rice Cornmeal Wheat flour Sorghum 6–8 Vitamin A Zinc Vitamin A Vitamin A Vitamin A 9–11 Vitamin A Zinc Vitamin A Zinc Vitamin A Zinc Vitamin A 12–23 Magnesium* Niacin Vitamin A Manganese Magnesium* Niacin Vitamin A* Magnesium* Niacin Vitamin A* Folic acid Manganese Magnesium Niacin Vitamin A 24–35 Magnesium* Niacin Manganese* Folic acid Zinc Folic acid Magnesium* Niacin* Vitamin A* Folic acid* Magnesium* Manganese Niacin* Vitamin A* Magnesium Niacin Folic acid UL, Upper Levels; LNS, lipid‐based nutrient supplement; GFD, general food distribution. *Nutrient quantity from the hypothetical intake of the ‘revised’ GFD ration already exceeds UL (before addition of LNS). LNS macro‐ and micro‐nutrient content for pregnant and lactating women (PLW) based on the higher of the two RNI levels for pregnancy and lactation, except where noted: Nutrient Unit Daily recommended intake: Pregnancy Daily recommended intake: Lactation LNS PLW composition, per 20 g ration Protein g 71 71 2.6 Fat g 20–35 %E 20–35 %E 9.6 Linoleic acid g 13* 13* 4.5 α‐linolenic acid g 1.4* 1.3* 0.6 Carbohydrate g 175 210 5.3 Energy kcal NA NA 118 Calcium mg 1200 1000 280* Copper mg 1 1.3 1.3 Folic acid µ g DFE 600 500 600 Iodine µ g 200 200 200 Iron† mg 4.6 1.5 20‡ Magnesium mg 220 270 65* Manganese mg 2 2.6 2.6 Niacin mg 18 17 18 Pantothenic acid mg 6 7 7 Phosphorus mg 700 700 190* Potassium mg 4700 5100 200* Riboflavin mg 1.4 1.6 1.6 Selenium µ g 29 35 35 Sodium mg 1500 1500 0 Thiamine mg 1.4 1.5 1.5 Vitamin A µ g RAE 800 850 850 Vitamin B12 µ g 2.6 2.8 2.8 Vitamin B6 mg 1.9 2 2 Vitamin C mg 55 70 70 Vitamin D IU 200 200 200 Vitamin E mg 15 19 19 Vitamin K µ g 55 55 55 Zinc† mg 3.2 3.6 23§ RNI, Recommended Nutrient Intake; DFE, dietary folate equivalents; RAE, retinol activity equivalents; LNS, lipid‐based nutrient supplement; GFD, general food distribution. *Nutrients whose content in LNS is limited by technical/food science constraints. †The daily recommended intake for iron and zinc provided is the ‘absorbed’ requirement. ‡The iron content in the LNS was based on an average of the estimated levels of iron absorption from the GFD diets of 25% during pregnancy and 13% during lactation. The value was increased by 30–50% to account for uncertainty in the absorption from the base diet and LNS. §The zinc content in the LNS was based on an average of the calculated levels of zinc absorption from the GFD diets of 14% during pregnancy and 24% during lactation. Amount of nutrient provided by each ‘revised’ GFD diet and LNS (PLW formulation) and per cent of the daily recommended intake provided for pregnant women. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets: Nutrient Unit Rice Corn Wheat Sorghum Amt. % daily intake Amt. % daily intake Amt. % daily intake Amt. % daily intake Protein g 58.3 82 60.0 85 76.0 107 85.1 120 Fat* g 43.2 15 49.1 17 45.2 16 58.1 20 Linoleic acid g 20.3 156 23.2 179 21.6 167 26.7 206 α‐linolenic acid g 2.9 211 2.9 207 2.9 209 3.2 226 n6 : n3 ratio 6.9 8.0 7.4 8.5 Carbohydrate g 480.7 275 470.3 269 461.4 264 480.7 275 Calcium mg 421.6 35 1056.0 88 980.0 82 506.9 42 Copper mg 2.9 288 2.3 234 2.7 269 2.0 197 Folic acid µ g DFE 993.9 166 1104.0 184 2239.1 373 954.9 159 Iodine µ g 566.5 283 566.5 283 566.5 283 566.5 283 Iron mg 29.4 163 52.2 290 47.5 264 49.1 273 Absorbed iron† mg 7.6 165 13.8 300 12.5 272 13.0 282 Magnesium mg 326.7 149 360.1 164 297.0 135 186.3 85 Manganese mg 9.2 462 4.7 234 7.2 361 3.8 189 Niacin mg 37.5 209 52.9 294 60.1 334 49.8 277 Pantothenic acid mg 14.6 243 9.8 164 10.6 177 8.4 140 Phosphorous mg 1090.6 156 1074.0 153 1096.3 157 2104.3 301 Potassium mg 1652.1 35 1940.0 41 1723.7 37 3077.4 65 Riboflavin mg 2.0 145 3.7 263 3.8 272 2.6 183 Selenium µ g 118.2 408 99.2 342 212.3 732 41.6 143 Sodium mg 2388.8 159 2411.8 161 2387.1 159 2409.4 161 Thiamine mg 2.5 182 5.7 405 5.4 386 3.5 248 Vitamin A µ g RAE 1386.5 173 4307.4 538 4347.5 543 1386.5 173 Vitamin B12 µ g 2.8 108 2.8 108 2.8 108 2.8 108 Vitamin B6 mg 3.2 166 3.3 175 2.6 135 2.3 123 Vitamin C mg 72.8 132 72.8 132 72.8 132 72.8 132 Vitamin D IU 200.0 100 200.0 100 200.0 100 200.0 100 Vitamin E mg 22.2 148 22.4 150 22.0 146 21.6 144 Vitamin K µ g 118.0 214 117.4 214 119.0 216 117.4 214 Zinc mg 31.8 245 29.7 228 29.7 228 26.2 201 Absorbed zinc‡ mg 5.2 163 3.9 122 4.0 126 3.3 92 GFD, general food distribution; LNS, lipid‐based nutrient supplement; PLW, pregnant and lactating women; DFE, dietary folate equivalents; RAE, retinol activity equivalents. *Because there is not a recommended absolute amount of fat for pregnant and lactating women, the per cent of energy from fat is displayed in the ‘% daily intake’ column. For this physiologic group, the per cent of energy from fat is recommended to be between 20 and 35% of energy (Institute of Medicine). †The total amount of iron in the diet is presented as well as the estimated amount of iron absorbed from the diet (based on the calculated bioavailability). The per cent of daily recommended intake is calculated based on the amount of absorbed iron. ‡The total amount of zinc in the diet is presented as well as the estimated amount of zinc absorbed from the diet (based on the calculated bioavailability). The per cent of daily recommended intake is calculated based on the amount of absorbed zinc. Amount of nutrient provided by each ‘revised’ GFD diet and LNS (PLW formulation) and per cent of the daily recommended intake provided for lactating women. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets: Nutrient Unit Rice Corn Wheat Sorghum Amt. % daily intake Amt. % daily intake Amt. % daily intake Amt. % daily intake Protein g 63.4 89 65.3 92 82.8 117 92.7 131 Fat* g 46.3 15 52.8 17 48.4 15 62.5 20 Linoleic acid g 21.8 168 25.0 192 23.2 179 28.8 221 α‐linolenic acid g 3.2 243 3.1 240 3.1 241 3.4 261 n6 : n3 ratio 6.9 8.0 7.4 8.5 Carbohydrate g 524.4 250 513.1 244 503.3 240 524.4 250 Calcium mg 434.6 43 1127.3 113 1044.3 104 527.8 53 Copper mg 3.0 233 2.4 188 2.8 217 2.0 156 Folic acid µ g DFE 1030.1 206 1150.3 230 2389.8 478 987.6 198 Iodine µ g 602.4 301 602.4 301 602.4 301 602.4 301 Iron mg 30.3 202 55.1 368 50.0 334 51.8 345 Absorbed iron† mg 4.5 302 6.7 444 6.2 414 5.9 396 Magnesium mg 350.8 130 387.3 143 318.4 118 197.4 73 Manganese mg 9.8 379 4.9 188 7.6 294 3.9 150 Niacin mg 39.3 231 56.1 330 64.0 376 52.7 310 Pantothenic acid mg 15.3 218 10.1 144 11.0 157 8.5 122 Phosphorous mg 1173.5 168 1155.3 165 1179.6 169 2280.3 326 Potassium mg 1785.7 35 2100.1 41 1864.0 37 3342.1 66 Riboflavin mg 2.1 130 3.9 242 4.0 250 2.6 165 Selenium µ g 125.9 360 105.1 300 228.6 653 42.2 120 Sodium mg 2622.7 175 2647.8 177 2620.8 175 2645.2 176 Thiamine mg 2.6 176 6.0 403 5.8 385 3.7 243 Vitamin A µ g RAE 1435.6 169 4625.1 544 4668.9 549 1435.6 169 Vitamin B12 µ g 2.8 100 2.8 100 2.8 100 2.8 100 Vitamin B6 mg 3.3 163 3.4 172 2.6 131 2.4 118 Vitamin C mg 73.0 104 73.0 104 73.0 104 73.0 104 Vitamin D IU 200.0 100 200.0 100 200.0 100 200.0 100 Vitamin E mg 22.5 118 22.8 120 22.2 117 21.9 115 Vitamin K µ g 123.7 225 123.2 224 124.8 227 123.2 224 Zinc mg 32.6 326 30.3 303 30.3 303 26.5 265 Absorbed zinc‡ mg 5.7 159 4.3 119 4.4 122 3.6 101 GFD, general food distribution; LNS, lipid‐based nutrient supplement; PLW, pregnant and lactating women; DFE, dietary folate equivalents; RAE, retinol activity equivalents. *Because there is not a recommended absolute amount of fat for pregnant and lactating women, the per cent of energy from fat is displayed in the ‘% daily intake’ column. For this physiologic group, the per cent of energy from fat is recommended to be between 20 and 35% of energy (Institute of Medicine). †The total amount of iron in the diet is presented as well as the estimated amount of iron absorbed from the diet (based on the calculated bioavailability). The per cent of daily recommended intake is calculated based on the amount of absorbed iron. ‡The total amount of zinc in the diet is presented as well as the estimated amount of zinc absorbed from the diet (based on the calculated bioavailability). The per cent of daily recommended intake is calculated based on the amount of absorbed zinc. Nutrients that exceed the UL when the PLW LNS formulation is added to the hypothetical intake from the GFD ration. Presented by physiologic group and identified by the staple grain used in the GFD hypothetical intake (with all other components being equal between diets): Age group (mo) Rice Cornmeal Wheat flour Sorghum Pregnant Folic acid Niacin Magnesium* Niacin* Vitamin A* Folic acid Iron Folic acid* Niacin* Vitamin A* Iron Folic acid Iron Lactating Folic acid Niacin Magnesium Magnesium* Vitamin A* Folic acid Iron Folic acid* Niacin* Vitamin A* Iron Niacin* Folic acid Iron UL, Upper Levels; PLW, pregnant and lactating women; LNS, lipid‐based nutrient supplement; GFD, general food distribution. *Nutrient quantity from the hypothetical intake of the GFD ration (before addition of LNS) already exceeds the UL. LNS micronutrient content for all groups, ‘one‐size fits all’ approach: Nutrient Unit LNS ‘one‐size’ composition, per 20 g ration Amount in two rations (40 g) Protein g 2.6 5.2 Fat g 9.6 19.2 Linoleic acid g 4.5 8.92 α‐linolenic acid g 0.6 1.16 Carbohydrate g 5.3 10.6 Energy kcal 118 236 Calcium mg 280* 560 Copper mg 0.34 0.68 Folic acid µ g DFE 150 300 Iodine µ g 90 180 Iron mg 6 12 Magnesium mg 60 120 Manganese mg 1.2 2.4 Niacin (total) mg 6 12 Pantothenic acid mg 2 4 Phosphorus mg 190* 380 Potassium mg 200* 400 Riboflavin mg 0.5 1 Selenium µ g 17 34 Thiamine mg 0.5 1 Vitamin A µ g 400 800 Vitamin B12 µ g 1.4† 2.8 Vitamin B6 mg 1† 2 Vitamin C mg 30 60 Vitamin D IU 200 400 Vitamin E mg 6† 12 Vitamin K µ g 15 30 Zinc mg 5 10 LNS, lipid‐based nutrient supplement; DFE, dietary folate equivalents; RDA, Recommended Dietary Allowance; RNI, Recommended Nutrient Intake. *Nutrients whose content in LNS is limited by technical/food science concerns. †Content adjusted because intake <75% of RDA/RNI for some groups. Amount of nutrient provided by each ‘revised’ GFD diet and LNS (‘one size’ formulation) and per cent of the daily recommended intake provided for pregnant women. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets: Nutrient Unit Rice Corn Wheat Sorghum Amt. % daily intake Amt. % daily intake Amt. % daily intake Amt. % daily intake Protein g 60.9 86 62.6 88 78.6 111 87.7 124 Fat* g 52.8 18 58.7 20 54.8 19 67.7 24 Linoleic acid g 24.8 191 27.7 213 26.1 201 31.2 240 α‐linolenic acid g 3.5 252 3.5 249 3.5 250 3.7 267 n6 : n3 ratio 7.0 8.0 7.5 8.3 Carbohydrate g 486.0 278 475.6 272 466.7 267 486.0 278 Calcium mg 701.6 58 1336.0 111 1260.0 105 786.9 66 Copper mg 2.3 226 1.7 172 2.1 207 1.3 135 Folic acid µ g DFE 693.9 116 804.0 134 1939.1 323 654.9 109 Iodine µ g 546.5 273 546.5 273 546.5 273 546.5 273 Iron mg 21.4 119 44.2 245 39.5 219 41.1 229 Absorbed iron† mg 5.6 121 11.8 256 10.5 228 11.0 238 Magnesium mg 381.7 174 415.1 189 352.0 160 241.3 110 Manganese mg 9.0 452 4.5 224 7.0 351 3.6 179 Niacin mg 31.5 175 46.9 261 54.1 301 43.8 243 Pantothenic acid mg 11.6 193 6.8 114 7.6 127 5.4 90 Phosphorous mg 1280.6 183 1264.0 181 1286.3 184 2294.3 328 Potassium mg 1852.1 39 2140.0 46 1923.7 41 3277.4 70 Riboflavin mg 1.4 103 3.1 220 3.2 229 2.0 140 Selenium µ g 117.2 404 98.2 339 211.3 729 40.6 140 Sodium mg 2388.8 159 2411.8 161 2387.1 159 2409.4 161 Thiamine mg 2.0 146 5.2 369 4.9 351 3.0 212 Vitamin A µ g RAE 1336.5 167 4257.4 532 4297.5 537 1336.5 167 Vitamin B12 µ g 2.8 108 2.8 108 2.8 108 2.8 108 Vitamin B6 mg 3.2 166 3.3 175 2.6 135 2.3 123 Vitamin C mg 62.8 114 62.8 114 62.8 114 62.8 114 Vitamin D IU 400.0 200 400.0 200 400.0 200 400.0 200 Vitamin E mg 15.2 101 15.4 103 15.0 100 14.6 98 Vitamin K µ g 93.0 169 92.4 168 94.0 171 92.4 168 Zinc mg 18.8 145 16.7 128 16.7 128 13.2 101 Absorbed zinc‡ mg 3.5 109 2.5 79 2.6 82 2.0 63 GFD, general food distribution; LNS, lipid‐based nutrient supplement; DFE, dietary folate equivalents; RAE, retinol activity equivalents. *Because there is not a recommended absolute amount of fat for pregnant and lactating women, the per cent of energy from fat is displayed in the ‘% daily intake column’. For this physiologic group, the per cent of energy from fat is recommended to be between 20 and 35% of energy (Institute of Medicine). †The total amount of iron in the diet is presented as well as the estimated amount of iron absorbed from the diet (based on the calculated bioavailability). The per cent of the daily recommended intake is calculated based on the amount of absorbed iron. ‡The total amount of zinc in the diet is presented as well as the estimated amount of zinc absorbed from the diet (based on the calculated bioavailability). The per cent of the daily recommended intake is calculated based on the amount of absorbed zinc. Amount of nutrient provided by each ‘revised’ GFD diet and LNS (‘one size’ formulation) and per cent of the daily recommended intake provided for lactating women. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets: Nutrient Unit Rice Corn Wheat Sorghum Amt. % daily intake Amt. % daily intake Amt. % daily intake Amt. % daily intake Protein g 66.0 93 67.9 96 85.4 120 95.3 134 Fat* g 55.9 18 62.4 20 58.0 19 72.1 23 Linoleic acid g 8.9 69 8.9 69 8.9 69 8.9 69 α‐linolenic acid g 1.2 89 1.2 89 1.2 89 1.2 89 n6 : n3 ratio 7.7 7.7 7.7 7.7 Carbohydrate g 529.7 252 518.4 247 508.6 242 529.7 252 Calcium mg 714.6 71 1407.3 141 1324.3 132 807.8 81 Copper mg 2.4 185 1.8 140 2.2 169 1.4 108 Folic acid µ g DFE 730.1 146 850.3 170 2089.8 418 687.6 138 Iodine µ g 582.4 291 582.4 291 582.4 291 582.4 291 Iron mg 22.3 149 47.1 314 42.0 280 43.8 292 Absorbed iron† mg 3.0 201 5.2 345 4.7 316 4.6 304 Magnesium mg 405.8 150 442.3 164 373.4 138 252.4 93 Manganese mg 9.6 371 4.7 180 7.4 286 3.7 142 Niacin mg 33.3 196 50.1 295 58.0 341 46.7 275 Pantothenic acid mg 12.3 175 7.1 101 8.0 114 5.5 79 Phosphorous mg 1363.5 195 1345.3 192 1369.6 196 2470.3 353 Potassium mg 1985.7 39 2300.1 45 2064.0 40 3542.1 69 Riboflavin mg 1.5 92 3.3 204 3.4 213 2.0 128 Selenium µ g 124.9 357 104.1 297 227.6 650 41.2 118 Sodium mg 2622.7 175 2647.8 177 2620.8 175 2645.2 176 Thiamine mg 2.1 143 5.5 370 5.3 351 3.2 210 Vitamin A µ g RAE 1385.6 163 4575.1 538 4618.9 543 1385.6 163 Vitamin B12 µ g 2.8 100 2.8 100 2.8 100 2.8 100 Vitamin B6 mg 3.3 163 3.4 172 2.6 131 2.4 118 Vitamin C mg 63.0 90 63.0 90 63.0 90 63.0 90 Vitamin D IU 400.0 200 400.0 200 400.0 200 400.0 200 Vitamin E mg 15.5 82 15.8 83 15.2 80 14.9 78 Vitamin K µ g 98.7 180 98.2 179 99.8 182 98.2 179 Zinc mg 19.6 196 17.3 173 17.3 173 13.5 135 Absorbed zinc‡ mg 3.9 108 2.8 78 2.9 80 2.2 61 GFD, general food distribution; LNS, lipid‐based nutrient supplement; DFE, dietary folate equivalents; RAE, retinol activity equivalents. *Because there is not a recommended absolute amount of fat for pregnant and lactating women, the per cent of energy from fat is displayed in the ‘% daily intake column’. For this physiologic group, the per cent of energy from fat is recommended to be between 20 and 35% of energy (Institute of Medicine). †The total amount of iron in the diet is presented as well as the estimated amount of iron absorbed from the diet (based on the calculated bioavailability). The per cent of the daily recommended intake is calculated based on the amount of absorbed iron. ‡The total amount of zinc in the diet is presented as well as the estimated amount of zinc absorbed from the diet (based on the calculated bioavailability). The per cent of the daily recommended intake is calculated based on the amount of absorbed zinc. Nutrients that exceed the UL when the ‘one‐size’ LNS formulation is added to the hypothetical intake from the GFD ration. Presented by age/physiologic group and identified by the staple grain used in the GFD hypothetical intake (with all other components being equal between diets): Age/physiologic group Rice Cornmeal Wheat flour Sorghum Pregnant Magnesium* Magnesium Niacin* Vitamin A* Folic acid* Magnesium Niacin* Vitamin A* Lactating Magnesium Magnesium* Niacin Vitamin A* Iron Folic acid* Magnesium Niacin* Vitamin A* Niacin* UL, Upper Levels; LNS, lipid‐based nutrient supplement; GFD, general food distribution. *Nutrient quantity from the hypothetical intake of the GFD ration (before addition of LNS) already exceeds UL. Toxicity estimates for 6–35‐month‐old children consuming 2–7 times the recommended daily dose of the age‐specific or one‐size LNS formulation (alone): Nutrient Unit UL 7–11 mo UL 12–35 mo LNS age‐specific or one‐size composition (6–35 mo) ×2 ×3 ×4 ×5 ×6 ×7 Energy kcal – – 118 236 354 472 590 708 826 Calcium mg ND 2500 280 560 840 1120 1400 1680 1960 Copper mg ND 1 0.34 0.68 1.02 1.36 1.7 2.04 2.38 Folic acid µ g DFE ND 300 150 300 450 600 750 900 1050 Iodine µ g 1260 600 90 180 270 360 450 540 630 Iron mg 40 40 6 12 18 24 30 36 42 Magnesium mg ND 65 60 120 180 240 300 360 420 Manganese mg ND 2 1.2 2.4 3.6 4.8 6.0 7.2 8.4 Niacin mg ND 10 6 12 18 24 30 36 42 Pantothenic acid mg ND ND 2 4 6 8 10 12 14 Phosphorus mg ND 3000 190 380 570 760 950 1140 1330 Potassium mg ND ND 200 400 600 800 1000 1200 1400 Riboflavin mg ND 30 0.5 1 1.5 2 2.5 3 3.5 Selenium µ g 60 90 17 34 51 68 85 102 119 Sodium mg ND 1500 0 0 0 0 0 0 0 Thiamine mg ND 10 0.5 1 1.5 2 2.5 3 3.5 Vitamin A µ g RAE 600 600 400 800 1200 1600 2000 2400 2800 Vitamin B12 µ g ND ND 0.9* 1.8 2.7 3.6 4.5 5.4 6.3 Vitamin B6 mg ND 30 0.5* 1 1.5 2 2.5 3 3.5 Vitamin C mg ND 400 30 60 90 120 150 180 210 Vitamin D IU 1000 2000 200 400 600 800 1000 1200 1400 Vitamin E mg ND 200 5* 10 15 20 25 30 35 Vitamin K µ g ND ND 15 30 45 60 75 90 105 Zinc mg 6 8 5 10 15 20 25 30 35 LNS, lipid‐based nutrient supplement; UL, Upper Levels; DFE, dietary folate equivalents; ND, not determined; RAE, retinol activity equivalents. *Note that for these nutrients there are slight differences between the age‐specific and one‐size composition: in the one‐size composition, these values are slightly higher (1.4 µ g for vitamin B12, 1.0 µ g for vitamin B6, and 6 mg for vitamin E). However, these differences do not change the toxicity estimates presented here. Values in bold exceed the UL for either or both age groups of children (6–11 or 12–35‐month‐olds). Toxicity estimates for 6–35‐month‐old children consuming 2–7 times the recommended daily dose of the PLW LNS formulation (alone): Nutrient Unit UL 7–11 mo UL 12–35 mo LNS PLW composition ×2 ×3 ×4 ×5 ×6 ×7 Energy kcal – – 118 236 354 472 590 708 826 Calcium mg ND 2500 280 560 840 1120 1400 1680 1960 Copper mg ND 1 1.3 2.6 3.9 5.2 6.5 7.8 9.1 Folic acid µ g DFE ND 300 600 1200 1800 2400 3000 3600 4200 Iodine µ g 1260 600 200 400 600 800 1000 1200 1400 Iron mg 40 40 20 40 60 80 100 120 140 Magnesium mg ND 65 65 130 195 260 325 390 455 Manganese mg ND 2 2.6 5.2 7.8 10.4 13 15.6 18.2 Niacin mg ND 10 18 36 54 72 90 108 126 Pantothenic acid mg ND ND 7 14 21 28 35 42 49 Phosphorus mg ND 3000 190 380 570 760 950 1140 1330 Potassium mg ND ND 200 400 600 800 1000 1200 1400 Riboflavin mg ND 30 1.6 3.2 4.8 6.4 8 9.6 11.2 Selenium µ g 60 90 35 70 105 140 175 210 245 Sodium mg ND 1500 0 0 0 0 0 0 0 Thiamine mg ND 10 1.5 3 4.5 6 7.5 9 10.5 Vitamin A µ g RAE 600 600 850 1700 2550 3400 4250 5100 5950 Vitamin B12 µ g ND ND 2.8 5.6 8.4 11.2 14 16.8 19.6 Vitamin B6 mg ND 30 2 4 6 8 10 12 14 Vitamin C mg ND 400 70 140 210 280 350 420 490 Vitamin D IU 1000 2000 200 400 600 800 1000 1200 1400 Vitamin E mg ND 200 19 38 57 76 95 114 133 Vitamin K µ g ND ND 55 110 165 220 275 330 385 Zinc mg 6 8 23 46 69 92 115 138 161 PLW, pregnant and lactating women; LNS, lipid‐based nutrient supplement; UL, Upper Levels; DFE, dietary folate equivalents; ND, not determined; RAE, retinol activity equivalents. Values in bold exceed the UL for either or both age groups of children (6–11 or 12–35‐month‐olds). Toxicity estimates for PLW consuming 2–7 times the recommended daily dose of the PLW LNS formulation (alone): Nutrient Unit UL pregnant UL lactating LNS PLW composition ×2 ×3 ×4 ×5 ×6 ×7 Energy kcal – – 118 236 354 472 590 708 826 Calcium mg 3000 3000 280 560 840 1120 1400 1680 1960 Copper mg 10 10 1.3 2.6 3.9 5.2 6.5 7.8 9.1 Folic acid µ g DFE 1000 1000 600 1200 1800 2400 3000 3600 4200 Iodine µ g 1100 1100 200 400 600 800 1000 1200 1400 Iron mg 45 45 20 40 60 80 100 120 140 Magnesium mg 350 350 65 130 195 260 325 390 455 Manganese mg 11 11 2.6 5.2 7.8 10.4 13 15.6 18.2 Niacin mg 35 35 18 36 54 72 90 108 126 Pantothenic acid mg ND ND 7 14 21 28 35 42 49 Phosphorus mg 3500 4000 190 380 570 760 950 1140 1330 Potassium mg ND ND 200 400 600 800 1000 1200 1400 Riboflavin mg ND ND 1.6 3.2 4.8 6.4 8 9.6 11.2 Selenium µ g 400 400 35 70 105 140 175 210 245 Sodium mg 2300 2300 0 0 0 0 0 0 0 Thiamine mg ND ND 1.5 3 4.5 6 7.5 9 10.5 Vitamin A µ g RAE 3000 3000 850 1700 2550 3400 4250 5100 5950 Vitamin B12 µ g ND ND 2.8 5.6 8.4 11.2 14 16.8 19.6 Vitamin B6 mg 100 100 2 4 6 8 10 12 14 Vitamin C mg 1000 1000 70 140 210 280 350 420 490 Vitamin D IU 2000 2000 200 400 600 800 1000 1200 1400 Vitamin E mg 1000 1000 19 38 57 76 95 114 133 Vitamin K µ g ND ND 55 110 165 220 275 330 385 Zinc mg mg 40 40 23 46 69 92 115 138 161 PLW, pregnant and lactating women; LNS, lipid‐based nutrient supplement; UL, Upper Levels; DFE, dietary folate equivalents; ND, not determined; RAE, retinol activity equivalents. Values in bold exceed the UL for either or both groups of pregnant and lactating women. Toxicity estimates for PLW consuming 2–7 times the recommended daily dose of LNS (alone), for the one‐size formulation: Nutrient Unit UL pregnant UL lactating LNS one‐size composition ×2 ×3 ×4 ×5 x6 ×7 Energy kcal – – 118 236 354 472 590 708 826 Calcium mg 3000 3000 280 560 840 1120 1400 1680 1960 Copper mg 10 10 0.34 0.68 1.02 1.36 1.7 2.04 2.38 Folic acid µ g DFE 1000 1000 150 300 450 600 750 900 1050 Iodine µ g 1100 1100 90 180 270 360 450 540 630 Iron mg 45 45 6 12 18 24 30 36 42 Magnesium mg 350 350 60 120 180 240 300 360 420 Manganese mg 11 11 1.2 2.4 3.6 4.8 6.0 7.2 8.4 Niacin mg 35 35 6 12 18 24 30 36 42 Pantothenic acid mg ND ND 2 4 6 8 10 12 14 Phosphorus mg 3500 4000 190 380 570 760 950 1140 1330 Potassium mg ND ND 200 400 600 800 1000 1200 1400 Riboflavin mg ND ND 0.5 1 1.5 2 2.5 3 3.5 Selenium µ g 400 400 17 34 51 68 85 102 119 Sodium mg 2300 2300 0 0 0 0 0 0 0 Thiamine mg ND ND 0.5 1 1.5 2 2.5 3 3.5 Vitamin A µ g RAE 3000 3000 400 800 1200 1600 2000 2400 2800 Vitamin B12 µ g ND ND 1.4 2.8 4.2 5.6 7 8.4 9.8 Vitamin B6 mg 100 100 1 2 3 4 5 6 7 Vitamin C mg 1000 1000 30 60 90 120 150 180 210 Vitamin D IU 2000 2000 200 400 600 800 1000 1200 1400 Vitamin E mg 1000 1000 6 12 18 24 30 36 42 Vitamin K µ g ND ND 15 30 45 60 75 90 105 Zinc mg mg 40 40 5 10 15 20 25 30 35 PLW, pregnant and lactating women; LNS, lipid‐based nutrient supplement; DFE, dietary folate equivalents; RAE, retinol activity equivalents; UL, Upper Levels; ND, not determined. Values in bold exceed the UL for either or both groups of pregnant and lactating women. Average commodity cost in US$ per metric ton (MT) of GFD commodities as provided by the Food for Peace commodity calculator for fiscal year 2009 (http://www.usaid.gov/our_work/humanitarian_assistance/ffp/comcalc_new.xls, accessed March 2009): Commodity Commodity Price (US$/MT) Rice (average) 655 Cornmeal (average) 385 Wheat flour, all‐purpose 400 Sorghum (average) 158 Pulses (average) 808 CSB – Corn–Soy Blend 475 Vegetable (soy) oil 690 GFD, general food distribution. When more than one form of a commodity was provided (for example, bagged rice vs. bulk rice with bags) an average was calculated. Cost estimate (in US$) for ‘typical’ full GFD ration and ‘revised’ full GFD ration (excluding sugar and salt): ‘Typical’ GFD ration Rice Cornmeal Wheat Sorghum Average Grain 0.26 0.15 0.16 0.06 0.16 Corn‐soy blend 0.02 0.02 0.02 0.02 0.02 Pulse 0.04 0.04 0.04 0.04 0.04 Vegetable oil 0.02 0.02 0.02 0.02 0.02 Total cost (1 full ration) 0.34 0.24 0.24 0.14 0.24 ‘Revised’ GFD ration Rice Cornmeal Wheat Sorghum Average Grain 0.28 0.16 0.17 0.07 0.17 Pulse 0.06 0.06 0.06 0.06 0.06 Vegetable oil 0.02 0.02 0.02 0.02 0.02 Total cost (1 full ration) 0.36 0.24 0.25 0.15 0.25 GFD, general food distribution. Cost estimate includes commodity cost only, as provided by the Food For Peace commodity calculator for fiscal year 2009 (http://www.usaid.gov/our_work/humanitarian_assistance/ffp/comcalc_new.xls, accessed March 2009). Cost (in US$) of providing the hypothetical diet for each age/physiologic group from the ‘typical’ and ‘revised’ GFD rations, with and without addition of LNS, as well as the per cent change in cost from the current ‘typical’ GFD ration: Average cost ‘typical’ GFD ration (with CSB) Average cost ‘revised’ GFD ration (no CSB) Average cost ‘revised’ GFD ration (no CSB) + LNS (1 dose) Average cost ‘revised’ GFD ration (no CSB) + LNS (2 doses) Per cent change in cost from ‘typical’ GFD ration (1 dose LNS) Per cent change in cost from ‘typical’ GFD ration (2 dose LNS) Total cost (6–8 month‐olds) 0.02 0.01 0.08 – 236 – Total cost (9–11 month‐olds) 0.04 0.02 0.09 – 160 – Total cost (12–23 month‐olds) 0.06 0.05 0.12 – 90 – Total cost (24–35 month‐olds) 0.12 0.11 0.18 – 51 – Total cost (pregnant women) 0.30 0.30 0.37 0.42 23 41 Total cost (lactating women) 0.32 0.32 0.39 0.45 21 38 Total cost (avg. pregnant/lactating woman + avg. child <3) 0.37 0.36 0.50 0.56 34 52 GFD, general food distribution; LNS, lipid‐based nutrient supplement; CSB, corn‐soy blend. Change in total commodity provided (g) for the ‘typical’ GFD diet vs. ‘revised’ GFD diet plus LNS for each age/physiologic group, plus a hypothetical mother–child dyad: 6–8 months 9–11 months 12–23 months 24–35 months Pregnant women Lactating women Pregnant women (2 doses LNS) Lactating women (2 doses LNS) Mother–child dyad* Total ‘typical’ GFD ration weight (g) 53 81 144 269 679 739 679 739 846 Total ‘revised’ GFD ration weight + LNS (g) 42 70 134 260 674 734 663 723 830 Absolute change (g) 11 11 10 9 5 5 16 16 16 Per cent change in weight from ‘typical’ GFD ration (%) 20 14 7 3 1 1 2 2 2 GFD, general food distribution; LNS, lipid‐based nutrient supplement; PLW, pregnant and lactating women. *Calculated as the sum of the average of the child rations plus the average of the PLW rations. Possible chemical forms of nutrients included in products for infants and young children, and recommended chemical forms for inclusion in LNS: Nutrient Possible chemical forms Recommended chemical forms for LNS Vitamin A Retinyl acetate or retinyl palmitate or beta‐carotene Retinyl acetate Vitamin D ergocalciferol (D2) or cholecalciferol (D3) Cholecalciferol (D3) Vitamin E Acetates of d or dl‐alpha‐tocopherol dl‐alpha‐tocopherol acetate Vitamin K – Phylloquinone 5% Vitamin C l‐ascorbic acid l‐ascorbic acid Thiamine (vitamin B1) Thiamine mononitrate (preferred for dry products) or Thiamine hydrochloride Thiamine hydrochloride Riboflavin (vitamin B2) Riboflavin Riboflavin Niacin (vitamin B3) Niacinamide Niacinamide Vitamin B6 Pyridoxine hydrochloride Pyridoxine hydrochloride Vitamin B12 Cyanocobalamin (diluted form (0.1% or 1%) with 100% active particles, spray dried form Cyanocobalamin (0.1%) Folic acid Pteroyl monoglutamic acid Pteroyl monoglutamic acid Iron Na Fe EDTA (subject to Codex limits), encapsulated ferrous sulfate, encapsulated ferrous fumarate and micronized ferric pyrophosphate could also be used but costs need to be considered Encapsulated ferrous sulfate Zinc Zinc sulfate, zinc gluconate, zinc oxide Zinc sulfate Copper Copper sulfate or Copper gluconate Encapsulated copper sulfate Selenium Sodium selenate, Sodium selenite Sodium selenite 1.5% Calcium Several forms available some with higher contents of Ca, such as Ca phosphate and Ca carbonate; Soluble organic Ca salts such as Ca citrate 5; Calcium salts containing well absorbed anions (such as chloride) should be avoided as they may induce acidosis 5 Tricalcium phosphate Phosphorous – Tricalcium phosphate Dipotassium phosphate Potassium – Dipotassium phosphate, potassium chloride Magnesium Soluble organic magnesium salts such as Mg citrate. Magnesium salts containing well absorbed anions (such as chloride) should be avoided as they may induce acidosis Magnesium citrate Manganese – Mangasese sulphate Iodine Potassium iodate Potassium iodate LNS, lipid‐based nutrient supplement; EDTA, ethylene‐diamine‐tetra‐acetic acid. Adapted from ‘Formulation Subgroup, 2009’. List of Figures Figure 1: Per cent of the daily recommended intake provided by the ‘typical’ general food distribution ration (and ‘average’ breast milk intake) for selected nutrients for 6–8‐month‐old infants. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 22 Figure 2: Per cent of the daily recommended intake provided by the ‘typical’ general food distribution ration (and ‘average’ breast milk intake) for selected nutrients for 9–11‐month‐old infants. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 23 Figure 3: Per cent of the daily recommended intake provided by the ‘typical’ general food distribution ration (and ‘average’ breast milk intake) for selected nutrients for 12–23‐month‐old infants. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 28 Figure 4: Per cent of the daily recommended intake provided by the ‘typical’ general food distribution ration (and ‘average’ breast milk intake) for selected nutrients for 24–35‐month‐old infants. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 28 Figure 5: Per cent of the daily recommended intake provided by the ‘typical’ general food distribution ration for selected nutrients for pregnant women. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 29 Figure 6: Per cent of the daily recommended intake provided by the ‘typical’ general food distribution ration for selected nutrients for lactating women. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 30 Figure 7: Per cent of the daily recommended intake provided by the ‘typical’ general food distribution ration for selected nutrients for a 4‐year‐old child. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 33 Figure 8: Per cent of the daily recommended intake provided by the ‘revised’ general food distribution ration for selected nutrients for a 4‐year‐old child. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 34 Figure 9: Per cent of the daily recommended intake provided by the ‘typical’ general food distribution ration for selected nutrients for an adult male. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 34 Figure 10: Per cent of the daily recommended intake provided by the ‘revised’ general food distribution ration for selected nutrients for an adult male. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets 35 Per cent of the daily recommended intake provided by the ‘typical’ general food distribution ration (and ‘average’ breast milk intake) for selected nutrients for 6–8‐month‐old infants. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets. imagePer cent of the daily recommended intake provided by the ‘typical’ general food distribution ration (and ‘average’ breast milk intake) for selected nutrients for 9–11‐month‐old infants. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets. imagePer cent of the daily recommended intake provided by the ‘typical’ general food distribution ration (and ‘average’ breast milk intake) for selected nutrients for 12–23‐month‐old infants. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets. imagePer cent of the daily recommended intake provided by the ‘typical’ general food distribution ration (and ‘average’ breast milk intake) for selected nutrients for 24–35‐month‐old infants. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets. imagePer cent of the daily recommended intake provided by the ‘typical’ general food distribution ration for selected nutrients for pregnant women. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets. imagePer cent of the daily recommended intake provided by the ‘typical’ general food distribution ration for selected nutrients for lactating women. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets. imagePer cent of the daily recommended intake provided by the ‘typical’ general food distribution ration for selected nutrients for a 4‐year‐old child. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets. imagePer cent of the daily recommended intake provided by the ‘revised’ general food distribution ration for selected nutrients for a 4‐year‐old child. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets. imagePer cent of the daily recommended intake provided by the ‘typical’ general food distribution ration for selected nutrients for an adult male. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets. imagePer cent of the daily recommended intake provided by the ‘revised’ general food distribution ration for selected nutrients for an adult male. Diets are identified by the type of grain or grain product provided, with all other components equivalent between diets. image List of Acronyms AI Adequate intake AMDR Acceptable macronutrient distribution range CSB Corn‐soy blend CV Coefficient of variation EAR Estimated average requirement EFA Essential fatty acid EMOP Emergency operation FAO Food and Agriculture Organization FBF Fortified blended food GFD General food distribution IDP Internally displaced person IOM Institute of Medicine IZiNCG International Zinc Nutrition Consultative Group LNS Lipid‐based nutrient supplement MAM Moderate acute malnutrition MNP Micronutrient powder NOAEL No observed adverse effect level PLW Pregnant and lactating women RDA Recommended dietary allowance RNI Recommended nutrient intake RUTF Ready‐to‐use therapeutic food SAM Severe acute malnutrition SFP Supplementary (selective) feeding program UL Upper Level USDA United States Department of Agriculture USAID United States Agency for International Development WFP World Food Program WHO World Health Organization 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, ∼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.