Effects of prenatal nutritional supplements on gestational weight gain in low- and middle-income countries: a meta-analysis of individual participant data

Effect of Antenatal Monthly Sulfadoxine-Pyrimethamine, Alone or with Azithromycin, on Gestational Weight Gain and Anemia during Pregnancy and One Month Postpartum in Malawi: A Randomized Controlled Trial Secondary Analysis

Low gestational weight gain (GWG) and prenatal anemia are associated with adverse pregnancy, maternal and infant health outcomes. In a secondary analysis of a single-center, randomized, partially placebo-controlled, outcome assessor-blinded, controlled trial conducted in Malawi from 2003 to 2006, when antiretroviral treatment (ART) for HIV was not widely available, we studied whether GWG can be increased and the prevalence of maternal anemia decreased during pregnancy and at 1 month postpartum through the intermittent preventive treatment in pregnancy (IPTp) of maternal malaria and reproductive tract infections. The participants (≥15-year-old women with uncomplicated second trimester single pregnancies) received either sulfadoxine (1,500 mg) and pyrimethamine (75 mg; SP) twice (control group, n = 433), monthly SP (n = 439), or monthly SP and azithromycin (1,000 mg) twice (AZI-SP, n = 441) during pregnancy. The mean weekly GWG in the sample was 256 g/week. The participants in the monthly SP group gained, on average (95% CI), 4 g (-13 to 20; P = 0.671), and those in the AZI-SP group gained 25 g (8-41; P = 0.003) more weight per week than control group participants. Among HIV-positive participants (12%), the differences were larger and also significant between the monthly SP group and control group. Mean hemoglobin and anemia prevalence did not differ between the groups during pregnancy or postnatally. The data support a hypothesis that IPTp with monthly SP and two doses of azithromycin can increase GWG, especially among HIV-positive women who are not on ART, possibly through the reduction of infections, inflammation, and effects on the maternal gut microbiome.

The effect of prenatal balanced energy and protein supplementation on gestational weight gain: An individual participant data meta-analysis in low- and middle-income countries

BACKGROUND

Understanding the effects of balanced energy and protein (BEP) supplements on gestational weight gain (GWG) and how the effects differ depending on maternal characteristics and the nutritional composition of the supplements will inform the implementation of prenatal BEP interventions.

METHODS AND FINDINGS

Individual participant data from 11 randomized controlled trials of prenatal BEP supplements (N = 12,549, with 5,693 in the BEP arm and 6,856 in the comparison arm) in low- and middle-income countries were used. The primary outcomes included GWG adequacy (%) and the estimated total GWG at delivery as continuous outcomes, and severely inadequate (<70% adequacy), inadequate GWG (<90% adequacy), and excessive GWG (>125% adequacy) as binary outcomes; all variables were calculated based on the Institute of Medicine recommendations. Linear and log-binomial models were used to estimate study-specific mean differences or risk ratios (RRs), respectively, with 95% confidence intervals (CIs) of the effects of prenatal BEP on the GWG outcomes. The study-specific estimates were pooled using meta-analyses. Subgroup analyses were conducted by individual characteristics. Subgroup analyses and meta-regression were conducted for study-level characteristics. Compared to the comparison group, prenatal BEP led to a 6% greater GWG percent adequacy (95% CI: 2.18, 9.56; p = 0.002), a 0.59 kg greater estimated total GWG at delivery (95% CI, 0.12, 1.05; p = 0.014), a 10% lower risk of severely inadequate GWG (RR: 0.90; 95% CI: 0.83, 0.99; p = 0.025), and a 7% lower risk of inadequate GWG (RR: 0.93; 95% CI: 0.89, 0.97; p = 0.001). The effects of prenatal BEP on GWG outcomes were stronger in studies with a targeted approach, where BEP supplements were provided to participants in the intervention arm under specific criteria such as low body mass index or low GWG, compared to studies with an untargeted approach, where BEP supplements were provided to all participants allocated to the intervention arm.

CONCLUSIONS

Prenatal BEP supplements are effective in increasing GWG and reducing the risk of inadequate weight gain during pregnancy. BEP supplementation targeted toward pregnant women with undernutrition may be a promising approach to delivering the supplements.

The effects of prenatal multiple micronutrient supplementation and small-quantity lipid-based nutrient supplementation on small vulnerable newborn types in low-income and middle-income countries: a meta-analysis of individual participant data

BACKGROUND

Small vulnerable newborn types, defined by combinations of being born too soon or too small, have distinct determinants and health consequences. We aimed to assess the effects of prenatal multiple micronutrient supplementation (MMS) and small-quantity lipid-based nutrient supplementation (SQ-LNS) on small vulnerable newborn types, which are currently unknown.

METHODS

In this meta-analysis, individual participant data from randomised controlled trials of MMS and randomised controlled trials of SQ-LNS in low-income and middle-income countries were used. We systematically searched the literature using PubMed, Embase, and Web of Science to identify randomised controlled trials of prenatal nutritional supplementation using MMS or SQ-LNS among pregnant people published between Jan 1, 2000, and Dec 31, 2021. Studies were excluded if they were conducted exclusively among participants selected by pre-existing health conditions, such as anaemia status, HIV infection, or diabetes. We contacted the corresponding authors of all identified studies to seek data contribution. As individual participant data became available, we mapped relevant variables and harmonised the data across studies. Iron and folic acid supplementation was the control group in most studies. Newborns were classified into ten groups through the combinations of preterm or term birth, small, appropriate, and large for gestational age, and low birthweight (LBW) or non-LBW. Newborns were also analysed using a four-group categorisation of preterm or term and LBW or non-LBW. Log-binomial models were used to estimate study-specific risk ratios (RRs), which were pooled using meta-analyses.

FINDINGS

14 randomised controlled trials of MMS (n=42 618; the mean maternal age at study enrolment was 24·3 years [SD 5.6]; 22 086 [51·8%] male neonates and 20 532 [48·2%] female neonates) and four randomised controlled trials of SQ-LNS (n=6246; the mean maternal age at study enrolment was 23·3 years [SD 5·3]; 3137 [50·2%] male neonates and 3109 [49·8%] female neonates) were used. In the ten-group categorisation of small vulnerable newborns, prenatal MMS reduced the risk of preterm-small for gestational age (SGA)-LBW (RR 0·73, 95% CI 0·64-0·84; p=0·0003); preterm-appropriate for gestational age (AGA)-LBW (0·82, 0·74-0·91; p=0·0010); preterm-AGA-non-LBW (0·89, 0·80-0·98; p=0·019); term-SGA-LBW (0·91, 0·85-0·96; p=0·0046); and term-SGA-non-LBW (0·95, 0·90-1·00; p=0·050). In the four-group categorisation, prenatal MMS reduced the risk of preterm-SGA (0·71, 0·62-0·82; p=0·0002) and term-SGA (0·93, 0·89-0·98; p=0·0066). Prenatal SQ-LNS had no significant effects on the risk of giving birth to small vulnerable newborns except for preterm-large for gestational age-non-LBW in the ten-group categorisation (0·78, 0·65-0·94; p=0·023).

INTERPRETATION

Prenatal MMS and SQ-LNS reduce the risk of giving birth to small vulnerable newborns to varying extents, with the greatest magnitude of effects observed for small vulnerable newborn types that confer the greatest neonatal mortality risk. This study underscores the importance of nutritional supplements in prenatal care.

FUNDING

Bill & Melinda Gates Foundation.

Perinatal intervention strategies providing food with micronutrients to pregnant and breastfeeding women in low- and middle-income countries: A scoping review

In resource-constrained settings, pregnant and breastfeeding women and girls (PBW/G) are particularly vulnerable to undernutrition. Micronutrient-fortified balanced energy protein (BEP) supplementation may be provided to boost maternal nutritional status and improve birth and infant outcomes. We conducted a scoping review of the published literature to determine the impact of BEP and other related nutrition interventions that provided fortified food or cash along with a minimum of 3 micronutrients on maternal, birth, and infant/child outcomes in low- and middle-income countries. We conducted a PubMed search using pre-defined keywords and controlled vocabulary search terms. All titles and abstracts were reviewed for eligibility by two independent reviewers, and data were extracted according to outcome type. We identified 149 eligible research articles that reported on a total of 21 trials and/or programme evaluations which assessed the health impact of one or more products (fortified lipid-based nutrient supplement [LNS, n = 12], fortified blended flours [n = 5], milk-based beverages [n = 2], and local food/snacks [n = 3]) that provided 118-750 kcal/day and varying levels of protein and micronutrients. Only one of these programme evaluations assessed the impact of the provision of cash and fortified food. Effects on maternal outcomes such as gestational weight gain and duration of gestation were promising but inconsistent. Birth outcomes were reported in 15 studies, and the effects on birthweight and birth length were generally positive. Seven studies demonstrated sustained benefits on infant and child growth out of the 15 studies that reported at least one of these outcomes, although data were sparse. Additional research is needed to investigate issues of dose, cost-effectiveness, and incorporation into multi-component interventions.

The Impact of Excluding Adverse Neonatal Outcomes on the Creation of Gestational Weight Gain Charts Among Women from Low- and Middle-income Countries with Normal and Overweight BMI

BACKGROUND

Existing gestational weight gain (GWG) charts vary considerably in their choice of exclusion/inclusion criteria, and it is unclear to what extent these criteria create differences in the charts' percentile values.

OBJECTIVES

We aimed to establish the impact of including/excluding pregnancies with adverse neonatal outcomes when constructing GWG charts.

METHODS

This is an individual participant data analysis from 31 studies from low- and middle-income countries. We created a dataset that included all participants and a dataset restricted to those with no adverse neonatal outcomes: preterm < 37 wk, small or large for gestational age, low birth weight < 2500 g, or macrosomia > 4000 g. Quantile regression models were used to create GWG curves from 9 to 40 wk, stratified by prepregnancy BMI, in each dataset.

RESULTS

The dataset without the exclusion criteria applied included 14,685 individuals with normal weight and 4831 with overweight. After removing adverse neonatal outcomes, 10,479 individuals with normal weight and 3466 individuals with overweight remained. GWG distributions at 13, 27, and 40 wk were virtually identical between the datasets with and without the exclusion criteria, except at 40 wk for normal weight and 27 wk for overweight. For the 10th and 90th percentiles, the differences between the estimated GWG were larger for overweight (∼1.5 kg) compared with normal weight (<1 kg). Removal of adverse neonatal outcomes had minimal impact on GWG trajectories of normal weight. For overweight, the percentiles estimated in the dataset without the criteria were slightly higher than those in the dataset with the criteria applied. Nevertheless, differences were <1 kg and virtually nonexistent at the end of pregnancy.

CONCLUSIONS

Removing pregnancies with adverse neonatal outcomes has little or no influence on the GWG trajectories of individuals with normal and overweight.

Serum Folate, Red Blood Cell Folate, and Zinc Serum Levels Are Related with Gestational Weight Gain and Offspring's Birth-Weight of Adolescent Mothers

BACKGROUND

Gestational weight gain below or above the Institute of Medicine recommendations has been associated with adverse perinatal and neonatal outcomes. Very few studies have evaluated the association between serum and red blood cell folate concentrations and gestational weight gain in adolescents. Additionally, zinc deficiency during pregnancy has been associated with impaired immunity, prolonged labor, preterm and post-term birth, intrauterine growth restriction, low birth weight, and pregnancy-induced hypertension.

OBJECTIVE

The purpose of our study is to evaluate the association between serum concentrations of zinc, serum folate, and red blood cell folate, with the increase in gestational weight and the weight and length of the newborn in a group of adolescent mothers from Mexico City.

RESULTS

In our study, 406 adolescent-neonate dyads participated. The adolescents' median age was 15.8 years old. The predominant socioeconomic level was middle-low (57.8%), single (57%), 89.9% were engaged in home activities, and 41.3% completed secondary education. Excessive gestational weight gain was observed in 36.7% of cases, while insufficient gestational weight gain was noted in 38.4%. Small for gestational age infants were observed in 20.9% of the sample. Low serum folate (OR 2.1, 95% CI 1.3-3.3), decreased red blood cell folate (OR 1.6, 95% CI 1.0-2.6), and reduced serum zinc concentrations (OR 3.3, 95% CI 2.1-5.2) were associated with insufficient gestational weight gain. Decreased serum zinc levels (OR 1.2, 95% CI 1.2-3.4) were linked to an increased probability of delivering a baby who is small for their gestational age.

CONCLUSIONS

Low serum folate, red blood cell folate, and serum zinc concentrations were associated with gestational weight gain and having a small gestational age baby. Both excessive and insufficient gestational weight gain, as well as having a small gestational age baby, are frequent among adolescent mothers.

Targeting strategies of antenatal balanced energy and protein supplementation in Addis Ababa, Ethiopia: study protocol for a randomized effectiveness study

BACKGROUND

Antenatal balanced energy and protein (BEP) supplements have well-documented benefits for pregnancy outcomes. However, considerable practical gaps remain in the effective and cost-effective delivery of antenatal BEP supplements at scale in low- and middle-income countries.

METHODS

A randomized effectiveness study will be conducted in two sub-cities of Addis Ababa, Ethiopia, to evaluate the effectiveness, cost-effectiveness, and implementation of different targeting strategies of antenatal BEP supplements. Pregnant women aged 18 to 49, with a gestational age of 24 weeks or less, and attending antenatal visits in one of the nine study health facilities are eligible for enrollment. In six of the health facilities, participants will be randomized to one of three study arms: control (Arm 1), targeted BEP provision based on baseline nutritional status (Arm 2), and targeted BEP supplementation based on baseline nutritional status and monthly gestational weight gain (GWG) monitoring (Arm 3). In the remaining three facilities, participants will be assigned to universal BEP provision (Arm 4). Participants in Arms 2 and 3 will receive BEP supplements if they have undernutrition at enrollment, as defined by a baseline body mass index less than 18.5 kg/m2 or mid-upper arm circumference less than 23 cm. In Arm 3, in addition to targeting based on baseline undernutrition, regular weight measurements will be used to identify insufficient GWG and inform the initiation of additional BEP supplements. Participants in Arm 4 will receive BEP supplements until the end of pregnancy, regardless of baseline nutritional status or GWG. All participants will receive standard antenatal care, including iron and folic acid supplementation. A total of 5400 pregnant women will be enrolled, with 1350 participants in each arm. Participants will be followed up monthly during their visits to the antenatal facilities until delivery. Maternal and infant health status will be evaluated within 72 h after delivery and at 6 weeks postpartum. The effectiveness and cost-effectiveness of the different BEP targeting strategies in preventing adverse pregnancy outcomes will be compared across arms. Qualitative data will be analyzed to assess the feasibility, acceptability, and implementation of different supplementation strategies.

DISCUSSION

This study will inform global recommendations and operational guidelines for the effective and cost-effective delivery of antenatal BEP supplements. The targeted approaches have the potential for broader scale-up in Ethiopia and other low-resource settings with a high burden of undernutrition among pregnant women.

TRIAL REGISTRATION

ClinicalTrials.gov registration number: NCT06125860. Registered November 9, 2023.

Associations between gestational weight gain under different guidelines and adverse birth outcomes: A secondary analysis of a randomized controlled trial in rural western China

Several gestational weight gain (GWG) guidelines have been established based on monocenter or multicenter researches. We aimed to examine the associations between categories of GWG under the Institute of Medicine (IOM) recommendation guideline, the Chinese National Health Commission (NHC) guideline, and weight-gain-for-gestational-age z-scores derived from the INTERGROWTH-21st Project and adverse birth outcomes. We used data from an antenatal micronutrient supplementation trial in rural western China between 2002 and 2006. Maternal weekly average GWG during the second and third trimesters was calculated and classified into inadequate, adequate and excessive GWG according to the IOM and NHC, respectively. Weight-gain-for-gestational-age z-scores derived from the INTERGROWTH-21st Project were grouped into three subgroups using two approaches: z-score percentile<25th, 25th to 75th, >75th and z-score <-1, -1 to 1, >1 SD. Infant birth weight and gestational age were measured using standard approaches. Generalized linear model with binomial family and logit link was applied to estimate the odds ratio (OR) and 95% confidential intervals (CI) for GWG categories and adverse birth outcomes. Among 1,239 women with normal weight (18.5 kg/m2 to 23.9 kg/m2) during early pregnancy, 18.0% and 34.2% were classified as adequate GWG according to IOM and NHC, respectively. Less than half of Chinese women reached optimal GWG by any recommendation guideline. According to NHC, excessive GWG showed a significant association with macrosomia (OR 3.75, 95% CI 1.03, 13.74), large-for-gestation-age (LGA) (OR 2.12, 95% CI 1.01, 4.45), and inadequate GWG was associated with post-term birth (OR 2.25, 95% CI 1.21, 4.16), compared with adequate GWG. Inappropriate GWG was associated with adverse birth outcomes even among women with normal weight during early pregnancy. The monitoring and interventions of weight status during pregnancy, especially for the second and third trimesters, are of great public health importance for optimal birth outcomes. Additionally, developing guideline of appropriate GWG ranges should account for the traits of regional population.

Dietary supplements, guideline alignment and biochemical nutrient status in pregnancy: Findings from the Queensland Family Cohort pilot study

In high-income nations, multiple micronutrient (MMN) supplementation during pregnancy is a common practice. We aimed to describe maternal characteristics associated with supplement use and daily dose of supplemental nutrients consumed in pregnancy, and whether guideline alignment and nutrient status are related to supplement use. The Queensland Family Cohort is a prospective, Australian observational longitudinal study. Maternal characteristics, nutrient intake from food and supplements, and biochemical nutrient status were assessed in the second trimester (n = 127). Supplement use was reported by 89% of participants, of whom 91% reported taking an MMN supplement. Participants who received private obstetric care, had private health insurance and had greater alignment to meat/vegetarian alternatives recommendations were more likely to report MMN supplement use. Private obstetric care and general practitioner shared care were associated with higher daily dose of supplemental nutrients consumed compared with midwifery group practice. There was high reliance on supplements to meet nutrient reference values for folate, iodine and iron, but only plasma folate concentrations were higher in MMN supplement versus nonsupplement users. Exceeding the upper level of intake for folic acid and iron was more likely among combined MMN and individual supplement/s users, and associated with higher plasma concentrations of the respective nutrients. Given the low alignment with food group recommendations and potential risks associated with high MMN supplement use, whole food diets should be emphasized. This study confirms the need to define effective strategies for optimizing nutrient intake in pregnancy, especially among those most vulnerable where MMN supplement use may be appropriate.