Frequently Asked Questions (FAQs)

What are Lipid-Based Nutrient Supplements (LNS)?

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

What are Lipid Nutrient Supplements (LNS)?

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What is the food base for LNS?

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

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What are some examples of lipid-based products?

The best known lipid-based products are the ready-to-use therapeutic foods (RUTF) such as Plumpy’nut®. RUTF are now widely used in treating severe acute malnutrition (SAM), including in community-based programs. RUTF are designed to achieve specific daily weight gains in order to reach a target weight-for-height consistent with nutritional recovery.  RUTF thus temporarily replace most or all foods other than breast milk. There is substantial evidence that programs using RUTF result in better outcomes and fewer deaths, compared to the previous standard care1-3.

More recently, lipid-based nutrient supplements (LNS) such as Nutributter®, which provide significantly less daily energy than RUTF but a full complement of micronutrients, were shown to prevent child stunting and support normal motor development in trials in Malawi and Ghana4-7. These lower dose products are designed to enrich and not replace locally available foods. Additional efficacy trials are underway to improve the formulations and extend knowledge about the potential of lower energy dose LNS products to contribute to prevention of under-nutrition.

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

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What is the difference between LNS and Ready-to-use Food (RUF)?

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

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Why investigate LNS for prevention of under-nutrition?

Several studies have suggested that LNS may have the potential to prevent stunting and developmental delays before they occur1-3. One study also showed sustained impacts on growth two years after the end of a 12-mo supplementation trial4. In considering the role of LNS (or other interventions) in preventing stunting, it is useful to recognize that the concept of “prevention” is complicated in the presence of widespread and chronic under-nutrition.

“Prevention” vs. treatment in the context of chronic under-nutrition

In high risk populations with chronic under-nutrition and a high prevalence of nutritional stunting, the line between prevention and treatment is not always clear. In such populations, “prevention” of stunting can also be seen as treatment for an on-going process of undernourishment. Children who are identified as stunted have been undernourished for some time, with long-lasting consequences5-6. High levels of stunting result from some combination of small maternal size and maternal under-nutrition, repeated infections during infancy, poor breastfeeding or care practices, and inadequate quantity and/or quality of complementary food. LNS and other products that improve home diets may play a role in ensuring the adequacy of complementary food. LNS formulated for pregnant and lactating women could also have potential to contribute to improvements in maternal and newborn nutrition.

Prevention of acute malnutrition (wasting)

LNS may also have a role to play in prevention of moderate or severe acute malnutrition, for example in food-insecure settings where acute malnutrition peaks seasonally7-8.

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

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Does LNS replace breast milk?

LNS should not replace breast milk. Good breastfeeding practices, including exclusive breastfeeding to 6 months and continued breastfeeding to 2 years or beyond, are critical to child survival and health. Two studies have shown that breast milk intake did not differ between children supplemented with LNS and those supplemented with a fortified blended food (FBF)1,2. Absolute breast milk intakes were slightly higher than the global average in both groups, despite consumption of LNS or FBF2. Four other studies did not assess breast milk intake but reported that frequency of breastfeeding was not decreased for infants given LNS3-6. Nevertheless, because breastfeeding is critical to child survival and continues to provide nutrient-dense, high-quality nourishment for infants to two years and beyond, additional studies across various age groups and settings are needed to confirm that LNS does not displace or decrease breast milk intake. Breast milk intake and breastfeeding practices are being assessed in iLiNS studies.

  1. Galpin L, Thakwalakwa C, Phuka J, et al. Breast milk intake is not reduced more by the introduction of energy dense complementary food than by typical infant porridge. J Nutr 2007;137:1828-33.
  2. Owino VO, et al. Breast-milk intake of 9-10-mo-old rural infants given a ready-to-use complementary food in South Kivu, Democratic Republic of Congo. Am J Clin Nutr. 2011 Jun; 93(6):1300-4. Epub 2011 Mar 30.
  3. Adu-Afarwuah S, et al. Randomized comparison of 3 types of micronutrient supplements for home fortification of complementary foods in Ghana: effects on growth and motor development. Am J Clin Nutr 2007; 86(2):412-20.
  4. Flax VL, et al. Feeding patterns of underweight children in rural Malawi given supplementary fortified spread at home. Matern Child Nutr. 2008 Jan; 4(1):65-73.
  5. Flax VL, et al. Feeding patterns and behaviors during home supplementation of underweight Malawian children with lipid-based nutrient supplements or corn-soy blend. Appetite. 2010 Jun; 54(3):504-11. Epub 2010 Feb 11.
  6. Paul KH et al. Complementary feeding messages that target cultural barriers enhance both the use of lipid-based nutrient supplements and underlying feeding practices to improve infant diets in rural Zimbabwe. Matern Child Nutr. Article first published online: 4 Aug 2010. DOI: 10.1111/j.1740-8709.2010.00265.x

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Does LNS replace other food?

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

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Where do LNS fit alongside other products/programmatic approaches to address under-nutrition?

Currently, several approaches and products are being used to address infant and child under-nutrition. Approaches include promotion and support for breastfeeding, and behavior change communication encouraging enrichment of porridges with locally available and nutrient-dense foods. Other products include fortified blended foods to replace local staple foods, fortified full-fat soy flour, other complementary food supplements, and micronutrient powders such as Sprinkles® 1. Choices among approaches and/or products depend on many factors including the nature and underlying prevalence of malnutrition, the food security situation, and cultural preferences, as well as program or policy objectives. Cost and available resources also shape choices. On-going research will help clarify where LNS may best fit among the available options2-3. This research should include consideration of operational and implementation issues, as well as cost and comparative cost-effectiveness4.

  1. Ten Year Strategy to Reduce Vitamin and Mineral Deficiencies M, Infant and Young Child Nutrition Working Group: Formulations Subgroup. Formulations for fortified complementary foods and supplements: Review of successful products for improving the nutritional status of infants and young children. Food and Nutrition Bulletin 2009;30:17.
  2. WFP. Ten minutes to learn about nutrition programming. A joint initiative of the World Food Programme and DSM. Sight and Life Magazine 2008;2008:43.
  3. Dewey KG, Yang Z, Boy E. Systematic review and meta-analysis of home fortification of complementary foods. Maternal and Child Nutrition 2009;forthcoming.
  4. Neufeld LM. Ready-to-use therapeutic food for the prevention of wasting in children. JAMA 2009;301:327-8.

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What about peanut allergy?

Peanut is a common ingredient in LNS and is an ingredient in iLiNS Project supplements. Allergic reactions to peanut can be severe. However, even in the United States – where there is much attention given to peanut allergy – severe allergies to peanut are uncommon among infants under two years of age. Both the overall prevalence of allergy and the prevalence of severe allergy are very similar to those for milk (1.4-2.0% for any allergy and 0.6-0.7% for severe allergy)1.

There is very little information available on peanut allergies in developing countries, but prevalence may be lower than in the U.S.2.

A recent systematic review concluded that there is no clear evidence that either maternal exposure or timing of introduction of peanuts into infant and toddler diets has an impact on later development of allergy3. Currently, both the American Academy of Pediatrics and the National Institute of Allergy and Infectious Diseases advise no avoidance of potential allergens by the mother during pregnancy or lactation. They also advise no general restriction on introduction of potentially allergenic foods in infancy (after 6 months of age, when complementary feeding is recommended to commence)4,5.

  1. Gupta RS, Springston EE, Warrier MR, Smith B, Kumar R, Pongracic J, Holl JL. The prevalence, severity, and distribution of childhood food allergy in the United States. Pediatrics. 2011 Jul;128(1):e9-17. Epub 2011 Jun 20.
  2. Yang Z. Are peanut allergies a concern for using peanut-based formulated foods in developing countries? Food Nutr Bull. 2010 Jun;31(2 Suppl):S147-53.
  3. Thompson RL, Miles LM, Lunn J, Devereux G, Dearman RJ, Strid J, Buttriss JL. Peanut sensitisation and allergy: influence of early life exposure to peanuts.Br J Nutr. 2010 May;103(9):1278-86. Epub 2010 Jan 26.
  4. Greer FR, Sicherer SH, Burks AW; American Academy of Pediatrics Committee on Nutrition; American Academy of Pediatrics Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008 Jan;121(1):183-91.
  5. Burks AW, Jones SM, Boyce JA, Sicherer SH, Wood RA, Assa'ad A, Sampson HA. NIAID-sponsored 2010 guidelines for managing food allergy: applications in the pediatric population. Pediatrics. 2011 Nov;128(5):955-65. Epub 2011 Oct 10.

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