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Efficacy of Lipid-Based Nutrient Supplements (LNS) for Pregnant and Lactating Women and Their Infants

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ClinicalTrials.gov Identifier: NCT00970866
Recruitment Status : Completed
First Posted : September 3, 2009
Last Update Posted : January 4, 2019
Sponsor:
Information provided by (Responsible Party):
University of California, Davis

Tracking Information
First Submitted Date  ICMJE September 1, 2009
First Posted Date  ICMJE September 3, 2009
Last Update Posted Date January 4, 2019
Study Start Date  ICMJE November 2009
Actual Primary Completion Date December 15, 2017   (Final data collection date for primary outcome measure)
Current Primary Outcome Measures  ICMJE
 (submitted: January 22, 2010)
  • Maternal primary outcome is child length at birth [ Time Frame: 0 - 48 hr after birth ]
  • Child primary outcome is child length-for-age Z-score (LAZ, based on WHO 2006 growth standards) at 18 months of age [ Time Frame: 18 months after birth ]
Original Primary Outcome Measures  ICMJE
 (submitted: September 2, 2009)
Primary outcome is child length-for-age Z-score (LAZ, based on WHO 2006 growth standards) at 18 months of age [ Time Frame: 18 months of age ]
Change History Complete list of historical versions of study NCT00970866 on ClinicalTrials.gov Archive Site
Current Secondary Outcome Measures  ICMJE Not Provided
Original Secondary Outcome Measures  ICMJE Not Provided
Current Other Pre-specified Outcome Measures Not Provided
Original Other Pre-specified Outcome Measures Not Provided
 
Descriptive Information
Brief Title  ICMJE Efficacy of Lipid-Based Nutrient Supplements (LNS) for Pregnant and Lactating Women and Their Infants
Official Title  ICMJE Efficacy of Lipid-based Nutrient Supplements (LNS) for Pregnant and Lactating Women and Their Infants
Brief Summary

In Ghana, low micronutrient intakes among pregnant women are a major problem. The standard nutritional intervention during pregnancy is iron-folic acid tablets, but adherence is low. The investigators have pioneered the use of multiple micronutrient-fortified semi-solid pastes called Lipid-based Nutrient Supplements (LNS) (made using vegetable oil, groundnut, milk, sugar, and micronutrients), and the investigators' previous studies show that the approach could have great potential for use by pregnant and lactating women.

This study aims to evaluate the effects of LNS-P&L designed for pregnant and lactating women and LNS-20gM designed for infants. Pregnant women (n=864) randomly selected from ante-natal clinics in Yilo and Manya Krobo districts of Ghana will be randomized to receive daily (a) Group 1: Iron/ Folic Acid tablets during pregnancy, and a tablet containing calcium (Ca) only (akin to a placebo) during lactation (6 mo), (b) Group 2: Multiple Micronutrient tablets during pregnancy and the first six months of lactation, or (c) Group 3: LNS-P&L during pregnancy and lactation, whilst their infants receive LNS-20gM daily from 6 to 18 months. There are two primary outcomes namely:

  1. Maternal primary outcome: Birth length
  2. Child primary outcome: Child length-for-age z-score at 18 mo.

The investigators hypothesize that a) mean birth length and length-for-age at 18 mo will be greater in children whose mothers are in Group 2 than those whose mothers are in Group 1, and b) children whose mothers are in Group 3 will have greater birth length and length-for-age at 18 mo than the children in either of the other two groups.

Detailed Description

Introduction:

Inadequate nutrient intakes during pregnancy remain a major problem worldwide. The standard nutritional intervention during pregnancy is iron-folic acid tablets, but adherence is generally quite low. We have pioneered the use of lipid-based nutrient supplements (LNS), which are multiple micronutrient-fortified semi-solid pastes made using vegetable oil, groundnut paste, milk, sugar, and micronutrients, for home fortification of complementary foods for infants. Given results of previous studies with Nutributter in Ghana (1, 2) and similar LNS in Malawi (3, 4) we believe that the food-based approach using LNS has the potential to improve the nutritional status of these women, and thereby also enhance their children's growth and micronutrient status.

Our consortium has formulated LNS-P&L for pregnant and lactating women, and modified the Nutributter for children, which has been called LNS-20gM in this trial. The LNS-20gM provides generally the Recommended Nutrient Intakes (RNI) for 18 vitamins and minerals for infants from 6 to 18 mo of age. The LNS-P&L is modeled on the UNICEF/WHO/UNU international multiple micronutrient preparation (UNIMMAP) for pregnant and lactating women and similar products used in Guinea Bissau (5). Each supplement (20 g/day) will provide 118 kcal/day. Both LNS products (LNS-P&L and LNS-20gM) will, in addition to the multiple micronutrients provided in the MMN, supply energy (118 kcal/d), fat (11 g/d), protein (2.6 g/d), the essential fatty acids linoleic acid (=1.29 g/d) and a-linolenic acid (0.29 to >0.6 g/d), as well as calcium, phosphorus, potassium and magnesium.

Objectives

The study has two objectives, which are:

  1. To evaluate the effect of LNS-P&L on the nutritional status of Ghanaian pregnant and lactating women.
  2. To assess the effect of LNS-P&L given to pregnant and lactating women and LNS-20gM provided to children from 6 to 18 mo of age on child growth and micronutrient status.

Procedures

  1. Recruitment:

    This study will be a community-based, randomized controlled trial with three intervention groups. Potential subjects will be Ghanaian pregnant women attending usual ante-natal clinics at the Government Hospitals at Atua and Akuse, and the St Martins de Porres Catholic Hospital at Agormanya (Manya Krobo District of Ghana), and the Somanya Polyclinic at Somanya (Yilo Krobo District of Ghana).

    Enrolment into the study will be done in two steps. First, pregnant women who meet an initial set of criteria will be asked their consent (sign a Screening Consent Form) to participate in a pre-enrolment screening using a Screening Questionnaire. During this screening, which will be conducted at the clinics, results of the routine ante-natal examination already entered in the Ante-natal Cards will be inspected. The screening questionnaire will also collect additional information, such as description of place of residence, not recorded in the Ante-natal cards.

    Second, women who pass the screening will be contacted in their homes, where we will provide them with additional details of the study and seek their consent for recruitment. If they agree, they will sign a recruitment consent form, and enrolment will be said to be completed. Immediately, we will collect background demographic and socioeconomic information in the home using a Baseline Questionnaire, and schedule the women to come to the laboratory to complete a baseline anthropometric and laboratory assessment (blood and urine sampling, hemoglobin, blood pressure and Ultrasound for gestational age).

    Pregnant women (n = 864) who have completed the baseline assessments and remain eligible for the study will be randomly assigned (using opaque envelopes with group designations) to one of three groups: (1) Group 1: Iron and Folic Acid, (2) Group 2: Multiple Micronutrient (MMN), and (3) Group 3: Lipid-based Nutrient Supplements (LNS).

  2. Follow up:

    Pregnant women will be followed-up through delivery, up to 6 mo postpartum (i.e. remaining part of pregnancy from time of recruitment + 6 mo of lactation), the infants born to the women will be followed-up from birth to 18 mo of age. Field Workers will visit subjects in their homes biweekly during pregnancy and weekly from birth to 18 mo to provide supplements and collect data on morbidity and adherence. In the case of multiple births by a woman, (e.g. twins or triplets), one baby will be randomly selected immediately after delivery to be the index child from whom infant data and blood samples will be collected. Anthropometric data will be collected from the unselected twin or triplets, and those in Group 3 will receive LNS-20gM (because of the cultural belief that twins and triplets, etc., must be treated the same), but blood samples will not be collected from the unselected child. In case of loss of child/children during or after delivery, the mother will be followed-up until 6 mo postpartum. In case of loss of mother during or after delivery, the baby will be followed-up until 18 mo of age.

    If any woman in the study is recommended to take additional vitamins and/ or minerals by her physician, we will work with the physician to ensure that any supplement given does not lead to excess intakes.

  3. Outcome measures:

The study will have two primary outcomes namely:

  1. Maternal primary outcome: Birth length, and
  2. Child primary outcome: Child length-for-age z-score at 18 mo.

    Secondary outcomes include:

    i. Maternal:

    • Anthropometric status (weight, BMI, mid upper arm circumference and sub- scapular skin-fold thickness) at ~ 36 wk gestation and at 6, 12, and 18 mo postpartum.
    • Pregnancy outcomes (birth weight, gestational age).
    • Anemia, micronutrient (iron, vitamin A, B-vitamins, zinc) and EFA status, and malarial antigen at ~ 36 wk gestation and 6 mo postpartum.
    • Total plasma cholesterol at ~ 36 wk gestation.
    • Blood pressure and urinary iodine, isoprostane (marker of oxidative stress) and 8-hydroxy-2'deoxyguanosine (8-OHdG) (marker of DNA damage) at 36 wk gestation.
    • Breast milk composition (EFA, vitamin A, B-vitamins, iodine) at 6 mo postpartum.
    • Depressive symptoms (which may be related to EFA status) at 6 mo postpartum.

    ii. Child:

    • Anthropometric status (weight, length, head circumference and mid upper arm circumference) at birth and 3, 6, 12 and 18 mo.
    • Anemia, micronutrient (iron, vitamin A, B-vitamins, iodine) and EFA status, and malarial antigen at 6 and 18 mo.
    • Morbidity between 6 and 18 mo.
    • Child feeding practices and maternal report of child sleep patterns at 6, 12 and 18 mo.
    • Energy intake from complementary foods at 9 and 15 mo.
    • Antibody response to measles vaccination at 12 mo.
    • Achievement of five motor milestones (sitting without support, standing alone, walking with assistance, walking alone and running) and four other developmental milestones (pronouncing single words like mama / dada, waving goodbye, eating by self, drinking from a cup) from 0 to 18 mo.
    • Neuro-behavioral development at 18 mo of age.

    First Post-intervention Follow-up Study: Detailed description

    Introduction:

    Previous research has suggested that nutrition during pregnancy and early childhood can have long term effects on growth, health, and cognition. Only a few studies conducted back in the 1970's, including those in Guatemala (7) and Colombia (8, 9), have followed a cohort that was provided nutrition supplementation during both pregnancy and early childhood. The International Lipid-Based Nutrient Supplements (iLiNS)-DYAD Trial in Ghana examined the effects of a lipid-based nutrient supplement (LNS) provided to women during pregnancy and the first 6 months postpartum, and to their infants from 6 until 18 months of age. Re-assessing the children from that trial at 4-6 years of age is important because this is a critical time for certain longer-term outcomes, such as cognitive development (e.g. school readiness) and body composition prior to puberty.

    Main objective The main objective of this first follow-up study is to evaluate the impact of the iLiNS DYAD-Ghana intervention among participants (women and their children) and their families at 2-4 years post-intervention.

    Primary objectives

    To determine the effects of LNS-P&L given to women during pregnancy and the first 6 mo post-partum, and LNS-20gM given to their children from 6 to 18 months of age on the following outcomes at 4-6 years of age:

    1. Child growth
    2. Child neurobehavioral development

      Secondary objectives:

      To determine the effects of LNS-P&L given to women during pregnancy and the first 6 mo post-partum, and LNS-20gM given to their children from 6 to 18 months of age on the following outcomes at 4-6 years of age:

    a) Health status and stress response of the children b) Sweet taste preferences and food and drink preferences of the children. c) Mental and physical health status of the women after receiving LNS-P&L. d) Caregiver investments in the index child and close siblings. e) Growth of the next younger sibling of the index child. f) Epigenetic DNA modifications of the index child g) Child activity levels

    Study design The study is designed as a follow-up study of a randomized controlled trial. Eligible women and mothers or caregivers of eligible children who took part in the iLiNS DYAD-Ghana intervention trial from 2009 to 2014 will be contacted for enrollment. Fathers and/or younger siblings of eligible children, if available, will also be enrolled.Ethical approval for the study will be obtained from the institutional review boards of the University of California in Davis, the University of Ghana College of Basic and Applied Sciences, and the Ghana Health Service.

    Inclusion criteria

    1. Mothers and children: Participated in the iLiNS DYAD-Ghana trial.
    2. Fathers: Both child and wife (child's mother) participated in the iLiNS DYAD-Ghana trial.

      Exclusion criteria

      Potential participants will be excluded if any of the following is present:

    1. Severe illness or injury which may interfere with data collection, eg. malignancy, etc.
    2. Unwillingness to participate in or cooperate with the study procedures.

      Procedures a. Recruitment Eligible mothers and fathers will be contacted in their homes, whereupon their informed consent will be sought for their own participation in the study, and the participation of their children. Where an eligible child lives in the care of a caregiver (instead of a parent or parents), informed consent for the child's participation will be sought from the caregiver and at least one parent, if possible.

    b. Data collection

    Data will be collected at the following contact points:

    i. Four (4) visits by study workers to the homes of participants:

    • Home visit #1: This will occur at or shortly after enrolment. Field workers will collect background socio-economic and demographic information. Enrollment and anthropometric measurement of fathers, as well as anthropometric measurements of younger siblings, may occur at this or any of the subsequent home visits.
    • Home visit #2: Will normally occur within the 7 days after Home visit #1. Study workers will collect children's morbidity data, and arrange with mothers/caregivers to complete the first visit to the central data collection location.
    • Home visit #3: Normally, this will occur within 2 weeks after the Home visit #1. Study worker will: (a) collect mothers'/caregivers' report of their children's taste preference; (b) collect information on the mother's perception of the iLiNS intervention (c) collect saliva samples (sub-set of mothers/index children) to determine cortisol; and, (d) arrange with women (sub-set) to have their children complete the second visit to the central data collection location.
    • Home visit #4: Normally, this will occur within 5 weeks after enrolment. Study workers will administer questionnaires (motor and neurocognitive development questionnaires) and arrange for mother and child to visit the hospital laboratory for more data/sample collection.

    ii. Two (2) visits by mothers and/or children to a central data collection location:

    • Data collection location visit #1: Normally, this will occur between the first and the second week after enrolment. Tasks will include: (a) Anthropometric measurements; (b) Developmental assessments; (c) Deuterium dosing and saliva samples collection for assessment of children's body composition; and (d) Distribution of accelerometers to a sub-sample of children for assessment of physical activity.
    • Data collection location visit #2: Will occur for a sub-set of children normally after 2 weeks following enrollment. These children will complete a sweet taste preference test and a photo game to examine food and drink preference.

    iii. Visit by mothers and children to the Hospital laboratory: Data/sample collection will include: (a) saliva samples (second time for cortisol analysis); (b) mothers' reproductive history; (c) children's clinical examination (Otoscope data); (d) blood pressure; (e) cheek swab; (f) hair sample collection; and (g) blood hemoglobin measurements.

    c. Outcome measures

    Outcome measures will include the following 8 major domains:

1) Growth and body composition of the index child 2) Neurobehavioral development of the index child 3) Health status and stress response of the index child 4) Sweet taste and food/drink preferences of the index child 5) Maternal mental health and stress response 6) Retrospective perceptions of the LNS intervention, and investments" in the index child and close siblings 7) Growth status of the next younger sibling of the index child 8) Activity level of index child 9) Epigenetic effects of the intervention on the index child

Study Type  ICMJE Interventional
Study Phase  ICMJE Not Applicable
Study Design  ICMJE Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple (Participant, Investigator, Outcomes Assessor)
Primary Purpose: Health Services Research
Condition  ICMJE
  • Anemia
  • Malnutrition
  • Stunting
Intervention  ICMJE
  • Dietary Supplement: Iron and Folic Acid (IFA)
    Pregnant women will receive one (1) Iron (60 mg) and Folic Acid (400 mcg) (IFA) tablet daily during pregnancy, and a tablet containing calcium (Ca) only (akin to a placebo) during lactation; there will be no supplementation for infants born to the women. The Fe/FA tablets will be taken each day with water after meals
  • Dietary Supplement: Multiple Micronutrient (MMN) group
    Pregnant women will receive one (1) Multiple Micronutrient tablet daily during pregnancy and the first 6 months of lactation; there will be no supplementation for infants born to the women. The MMN tablets will be taken each day with water after meals
  • Dietary Supplement: Lipid-based Nutrient Supplements (LNS) group

    Pregnant women will receive 20 g of LNS-P&L daily during pregnancy and the first 6 months of lactation, whilst infants born to the women will receive 20 g of LNS-20gM daily from 6 to 18 mo of age.

    The LNS products (LNS-P&L and LNS-20gM) will be consumed by being added to prepared food (usually mixed with complementary foods, for the child). Mothers will consume the full sachet of LNS (20 g/day) at one meal each day. Dosage and directions for use of the LNS product for children will be as follows: 20 g (~4 teaspoons) per day divided into 2 portions and consumed at two different times of the day (2 x 2 teaspoons). Mix the portion of the supplement to be consumed with 2-3 tablespoons of the already prepared food (as done previously in our study in Ghana (1)), and eat the mixture before eating the rest of the food. Do not cook food with the supplement. Store supplement at room temperature. There is no need for refrigeration.

Study Arms  ICMJE
  • Active Comparator: Iron and Folic Acid (IFA)
    Interventions:
    • Dietary Supplement: Iron and Folic Acid (IFA)
    • Dietary Supplement: Multiple Micronutrient (MMN) group
    • Dietary Supplement: Lipid-based Nutrient Supplements (LNS) group
  • Active Comparator: Multiple Micronutrient (MMN)
    Interventions:
    • Dietary Supplement: Iron and Folic Acid (IFA)
    • Dietary Supplement: Multiple Micronutrient (MMN) group
    • Dietary Supplement: Lipid-based Nutrient Supplements (LNS) group
  • Active Comparator: Lipid-based Nutrient Supplements (LNS)
    Interventions:
    • Dietary Supplement: Iron and Folic Acid (IFA)
    • Dietary Supplement: Multiple Micronutrient (MMN) group
    • Dietary Supplement: Lipid-based Nutrient Supplements (LNS) group
Publications *

*   Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
 
Recruitment Information
Recruitment Status  ICMJE Completed
Actual Enrollment  ICMJE
 (submitted: January 2, 2019)
3499
Original Estimated Enrollment  ICMJE
 (submitted: September 2, 2009)
864
Actual Study Completion Date  ICMJE December 15, 2017
Actual Primary Completion Date December 15, 2017   (Final data collection date for primary outcome measure)
Eligibility Criteria  ICMJE

Inclusion Criteria:

  • At least 18 years of age
  • No more than 20 wk of gestation
  • Given Ante-natal Cards of the Ghana Health Service
  • Completed the initial routine ante-natal examination at the clinics
  • HIV negative or status unknown (as from the Ante-natal card)
  • Free from chronic disease e.g. malignancy requiring frequent medical attention (as from the Ante-natal card)
  • Residing in the Manya Krobo or Yilo Krobo district
  • Prepared to sign an informed consent
  • Living in the area throughout the duration of the study
  • Acceptance of home visitors

Exclusion Criteria:

  • Known asthmatic or history of allergy towards peanut or milk products
  • Concurrent participation in another clinical trial
  • Severe illness warranting hospital referral
Sex/Gender  ICMJE
Sexes Eligible for Study: Female
Ages  ICMJE 18 Years and older   (Adult, Older Adult)
Accepts Healthy Volunteers  ICMJE Yes
Contacts  ICMJE Contact information is only displayed when the study is recruiting subjects
Listed Location Countries  ICMJE Ghana
Removed Location Countries  
 
Administrative Information
NCT Number  ICMJE NCT00970866
Other Study ID Numbers  ICMJE 223623
Has Data Monitoring Committee Yes
U.S. FDA-regulated Product Not Provided
IPD Sharing Statement  ICMJE Not Provided
Responsible Party University of California, Davis
Study Sponsor  ICMJE University of California, Davis
Collaborators  ICMJE Not Provided
Investigators  ICMJE
Principal Investigator: Kathryn G. Dewey, PhD UC Davis
Principal Investigator: Anna Lartey, PhD University of Ghana, Legon
PRS Account University of California, Davis
Verification Date January 2019

ICMJE     Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP