Nutritional Intervention Preconception and During Pregnancy to Maintain Healthy Glucose

12 Pages·2017·1.65 MB·English

by  Keith M. Godfrey

Godfreyetal.Trials (2017) 18:131
DOI10.1186/s13063-017-1875-x
STUDY PROTOCOL Open Access
Nutritional Intervention Preconception and
During Pregnancy to Maintain Healthy
Glucose Metabolism and Offspring Health
“ ”
( NiPPeR ): study protocol for a randomised
controlled trial
KeithM.Godfrey1,2*,WayneCutfield3,4,Shiao-YngChan5,6,PhilipN.Baker3,7,Yap-SengChong5,6andNiPPeRStudyGroup
Abstract
Background: Improved maternal nutritionand glycaemic control before and during pregnancy are thoughtto
benefit the health of the mother, with consequentbenefitsfor infant body composition and later obesity risk.
Maternal insulin resistance and glycaemia around conception and inearlypregnancy may be key determinantsof
maternal physiologyand placental function, affecting fetal nutrient supply and maternal-feto-placental
communications throughout gestation,with implications for later postnatalhealth.
Methods/design: This double-blind randomised controlled trial will recruit up to 1800 women, aged 18–38 years,
who are planning a pregnancy inthe United Kingdom (UK), Singapore and New Zealand, witha view to studying
600pregnancies. The primary outcome is maternal glucose tolerance at28 weeks’ gestation following an oral
glucose tolerance test. Secondary outcomes include metabolic, molecular and health-relatedoutcomesinthe
mother and offspring, notably infant body composition.Participants will be randomlyallocated to receive a twice-
daily control nutritionaldrink, enriched withstandard micronutrients, or a twice-daily interventionnutritionaldrink
enriched withadditional micronutrients,myo-inositol and probiotics,both demonstrated previously to assist in
maintaining healthy glucose metabolism during pregnancy.Myo-inositol is a nutrient that enhances cellular glucose
uptake. The additional micronutrients seek to address deficiencies ofsome B-group vitamins and vitamin D that are
both common during pregnancy and that have been associated with maternal dysglycaemia, epigenetic changes
and greater offspring adiposity. Women who conceive within a year ofstartingthe nutritional drinks will be
followed through pregnancy and studied withtheirinfants at sixtime pointsduring the first year of life. Blood,
urine/stool, hair and cheek swabs will be collectedfrom themothersfor genetic, epigenetic, hormone, nutrient and
metabolite measurements,and assessments of the mother’sbody composition,anthropometry, health,diet and
lifestyle will be made.Infants will also undergo hair,cheek swab, urine and stool sampling for similar biological
measurements; infant body composition will be assessed and feeding recorded.
(Continuedonnextpage)
*Correspondence:[email protected]
1NIHRSouthamptonBiomedicalResearchCentre,UniversityHospital
Southampton,NHSFoundationTrust,Southampton,UK
2MRCLifecourseEpidemiologyUnit,UniversityofSouthampton,
SouthamptonGeneralHospital,Mailpoint95,SouthamptonSO166YD,UK
Fulllistofauthorinformationisavailableattheendofthearticle
©TheAuthor(s).2017OpenAccessThisarticleisdistributedunderthetermsoftheCreativeCommonsAttribution4.0
InternationalLicense(http://creativecommons.org/licenses/by/4.0/),whichpermitsunrestricteduse,distribution,and
reproductioninanymedium,providedyougiveappropriatecredittotheoriginalauthor(s)andthesource,providealinkto
theCreativeCommonslicense,andindicateifchangesweremade.TheCreativeCommonsPublicDomainDedicationwaiver
(http://creativecommons.org/publicdomain/zero/1.0/)appliestothedatamadeavailableinthisarticle,unlessotherwisestated.
Godfreyetal.Trials (2017) 18:131 Page2of12
(Continuedfrompreviouspage)
Discussion: There is an increasing focus on the need to optimise maternal nutritionstartingprior to conception.
Thistrial will provide evidence on thepotentialfor nutritional interventions beginning prior to conceptionto
promote healthy maternal and offspring outcomes.
Trial registration: ClinicalTrials.gov, identifier: NCT02509988, Universal Trial Number U1111-1171-8056. Registered
on16 July 2015. Thisis an academic-led study by the EpiGen Global Research Consortium.
Keywords: Preconception, Pregnancy,Randomised trial, Nutrition,Glucose metabolism, Metabolic diseases,
Hyperglycemia, Body composition
Background nutrients, such as glucose, fatty acids and amino acids,
There is now considerable concern about the mainten- to the fetus [16]. Placental nutrient transfer is deter-
ance of healthy glucose metabolism during pregnancy. mined by the concentration gradient, blood flow and the
This has arisen by extrapolation from the increasing operation of active and facilitated transporters [17].
number of women who develop type-2 diabetes during However, in contrast to amino acids, there is no upper
their reproductive years [1, 2]. Epidemiological studies limit to placental transfer of glucose and consequent
show that children born to mothers with type-1 or type- fetal adipose accretion as maternal blood glucose levels
2 diabetes also have a greater susceptibility to diabetes rise [13]; this may be viewed as adaptive, as, in the neo-
and obesity in later life [3, 4]. That this risk is related to natal period, relative adiposity provides metabolic re-
intrauterine exposure to hyperglycaemia is shown by the serves for thermogenesis and critical organs in the event
observation that, among siblings, the risk of diabetes is of inadequate maternal care [18]. However, excessive
higher in those born after the mother was diagnosed materno-placental glucose transfer is associated with
with diabetes [5]. These observations have been ex- fetal hyperinsulinemia and macrosomia [19, 20] and an
tended recently, as offspring exposed to even mild increased risk of fatal obstructed labour, suggesting that
hyperglycaemiaduring pregnancy have increased adipos- the levels of glucose exposure of the fetus that are often
ity and are at increased risk of later diabetes and cardio- nowexperiencedarenovelinevolutionaryterms[21].
metabolic disease [6, 7]. Through transgenerational Gestational diabetes mellitus (GDM) can be envisaged
perpetuation of the cycle of ‘diabetes begetting diabetes’, as the more extreme outcome ofphysiologicalprocesses,
these factors are driving further escalation of the epi- when maternal insulin resistance is accentuated by the
demicofnoncommunicablediseases[8,9]. woman’s own developmental, genetic and environmental
The rising levels of maternal adiposity and obesity are circumstances: for example, women who themselves had
of particular concern in both developed populations and a lower birth weight [22] or carry genetic variants asso-
those undergoing rapid socioeconomic transitions [1, 10, ciated with type-2 diabetes [23, 24] are at increased risk
11]. Maternal obesity is associated with increased risk of of GDM. Established risk factors for developing GDM
short-term adverse pregnancy outcomes as well as include prepregnancy obesity [25], excessive gestational
longer-term impact on offspring health [12], which have weight gain [26], advanced maternal age [27] and a pre-
been postulated to be partly mediated by greater mater- vious pregnancy with GDM [28]. These factors are now
nal insulin resistance and higher glycaemia. Both with increasingly common in women during their reproduct-
and without clinically recognised pregnancy complica- ive years with the evolutionary mismatched situation of
tions, evidence shows that a child of a mother with over-nutrition and low levels of physical activity contrib-
higher glycaemia per se may suffer from exposure to a uting not only to the rise in GDM but to the increasing
suboptimal environment in utero, reducing the likeli- prevalence of obesity and diabetes in their children, per-
hood of a healthy body composition in the offspring and petuating a vicious cycle of disease. Such changes in
predisposing to increased childhood adiposity [13, 14]. growth potential and metabolic status may be mediated
Feeding pregnant rodents a high-fat diet gives rise to by inheritable epigenetic alterations occurring in utero
maternal obesity and hyperglycaemia, and offspring who [29]. For example, in Canadian first nation peoples, up
become overweight demonstrate abnormalities similar to to 30% of the incidence of type-2 diabetes has its origin
the human metabolic syndrome; these are associated in GDM in the previous generation [30]. Higher blood
with epigenetic changes such as altered deoxyribonucleic glucose levels in pregnancy carry risk of cardiovascular
acid (DNA) methylation at specific genetic loci impli- disease for both the mother as well as the child, a risk
catedinmetabolicfunctions[15]. which increaseswitheachpregnancy[31].
Pregnancy represents a state of relative maternal insu- These findings have significant long-term implications
lin resistance, which helps to promote the transfer of for global public health. Now more than ever, effective
Godfreyetal.Trials (2017) 18:131 Page3of12
strategies for maintaining healthy maternal glucose me- evidence implicating arolefor thegut microbiome inaf-
tabolism in pregnancy are needed. Such strategies would fecting glucose metabolism [50], and probiotics may
benefit both the mother in terms of a healthy pregnancy modulate glucose tolerance through balancing gut
and her own metabolic health, and the offspring in microbiota, normalising increased intestinal permeability
terms of promoting healthy body composition and and lowering systemic and local low-grade inflammation
wellbeing. [51]. There is preliminary evidence that a combination
There are now data indicating that deficiency or low of probiotic strains during pregnancy may promote the
levels of certain micronutrients (vitamins B , B and D, maintenance of healthy glucosemetabolism duringpreg-
6 12
riboflavin) is extremely prevalent in pregnant women nancy [52].
and has lasting effects on the offspring’s risk of obesity, Taken together, there is strong support for new inter-
acting through epigenetic processes [32–34]. Evidence vention studies commencing before pregnancy to pro-
from South Asian pregnant women supports a role for vide myo-inositol and probiotics, and to improve
the combination of maternal vitamin B deficiency and maternal vitamin B , vitamin B , vitamin D and zinc
12 6 12
folate sufficiency in promoting offspring adiposity, most status, aimed at optimising maternal glycaemia and glu-
likelymediatedthroughimpairedmaternalglucosetoler- cose supplytothe feto-placental unit topromote healthy
ance during pregnancy [35, 36]. Meta-analysis of obser- offspringgrowth andbody composition.
vational studies strongly points to a role for maternal
vitamin D deficiency in GDM [37], and additional vita- Aim
min D in pregnant women with GDM has been shown This double-blind randomised controlled trial in groups
to have beneficial effects on glycaemia and total and of women from different ethnic groups in the UK,
low-density lipoprotein cholesterol (LDL)-cholesterol Singapore and New Zealand is designed to examine the
concentrations [38]. Low zinc intake and status has also hypothesis that, compared with standard supplementa-
been linked with maternal glycaemia [39], and we tion, a nutritional drink that contains myo-inositol, pro-
propose that maternal glucose tolerance may be on the biotics and additional micronutrients, commencing
causal pathway linking maternal micronutrient defi- before conception and continuing during pregnancy, will
ciency to offspring adiposity. Importantly, among the assist in the maintenance of healthy glucose metabolism
pregnant women who we studied in Southampton and inthemotherandpromoteoffspringhealth.
Singapore there was a low prevalence of deficiency in
folate and iron, the two most common micronutrients Methods/design
currently targeted for supplementation in pregnancy, Trialdesign
and neither was associated with altered epigenetic adi- Increasing evidence points to the preconception period
positybiomarkersorwith the child’sadiposity. and early pregnancy as a critical time when impaired
Dietary myo-inositol is found in free form but can also maternal glucose tolerance may lead to biological alter-
be generated by microbial action in the gastrointestinal ations in the placenta and fetus that result in increased
tract from food sources of phosphatidylinositol and phy- postnatal adiposity in the offspring [53]. As a conse-
tic acid and its salts [40]. Myo-inositol is considered quenceofthisimportantevidence, ourtrialuniquelywill
nonessential for mammals because it is synthesised de focusonrecruitmentbefore conceptionandintervention
novo from glucose-6-phosphate in the kidney and other both before and during pregnancy. Substantial experi-
tissues [41, 42]. Abnormalities in its metabolism have mental evidence from animal studies indicates that pre-
been associated with insulin-resistance and its depletion conception is a critical period in the lifecourse for
has been frequently observed in tissues affected by dia- interventions to reduce later risk of metabolic dysregula-
betic microvascular and neurological complications in tion in the offspring. In humans, large cohort studies
animal models and human subjects [43]. Our current have demonstrated that preconception is a time when
understanding of the molecular pathways of insulin ac- factors contributing to later ill-health begin to operate,
tion led to the hypothesis that the nutritionally derived as poor maternal and paternal diet and smoking before
myo-inositol may increase insulin sensitivity by making conception impact on development and long-term
available more phosphatidylinositol and potentially in- health of the offspring; to date, however, there are no
ositol glycan secondary messengers [44, 45]. An increas- population-based trials of preconception nutrition in de-
ing number of publications suggest that myo-inositol velopedcommunities.
mayreduceinsulinresistance duringpregnancy[46–49]. The flow of the trial is shown in the Standard Protocol
Recent studies suggest that specific bacteria may posi- Items:RecommendationsforInterventionalTrials(SPIRIT)
tively influence cardiometabolic parameters, possibly Figure (Fig. 1). See Additional file 1 for the SPIRITcheck-
through their interaction with the host and the effect of list. Extensive biosampling and detailed phenotyping are
microbial-derived metabolites. There is now substantial embedded in the study with longitudinal assessments at
Godfreyetal.Trials (2017) 18:131 Page4of12
Fig.1(Seelegendonnextpage.)
Godfreyetal.Trials (2017) 18:131 Page5of12
(Seefigureonpreviouspage.)
Fig.1StandardProtocolItems:RecommendationsforInterventionalTrials(SPIRIT)Figure:trialschema.Abbreviations:PCVpreconceptionvisit,PC
preconception,PGVpregnancyvisit,PDVpost-deliveryvisit,BIAbioelectricalimpedanceanalysis,BPbloodpressure,DMdiabetesmellitus,DXAdual-energy
X-rayabsorptiometry,GDMgestationaldiabetes,HIV,humanimmunodeficiencyvirus,IFGimpairedfastingglucose,IGTimpairedglucosetolerance,NGT
normalglucosetolerance,OGTToralglucosetolerancetest,USS,ultrasoundscan.Questionnaires:BEBQbabyeatingbehaviour,BMbreastmilk,FHfamily
history,GHgeneralhealth,IFHinfantfeedingandhealth,IIFintentionsforinfantfeeding,Llifestyle,Mmood(EdinburghPostnatalDepressionScale,
State-TraitAnxietyInventory),MHmedicalhistory,MSHmenstrualhistory,MTHmaternalhealth,Nnutrition/diet,OHobstetrichistory,PAphysicalactivity,S
sleep.Biosampling:#=blood,♥=breastmilk,$=buccalswabs,*=epithelialswabs,@=hair,^=stool,~=urine
multipletimepointsstartingfromthepreconceptionphase Unit) and Southampton (National Institute for Health
throughout pregnancy and into the first year post delivery. ResearchWellcomeTrustSouthamptonClinicalResearch
The biosampling and phenotyping will enable detailed Facility and Princess Anne Hospital, University Hospital
mechanistic insights and characterisation of potential new Southampton,UK).
interventions for investigation in future studies. Following
informedconsentatthefirstpreconceptionvisit,abaseline Recruitment
standard 75-g oral glucose tolerance test (OGTT) will be Recruitment will be via self-referral of interested women
conducted, nutritional status, lifestyle, mood, body anthro- who hear about the study via one or more of the follow-
pometryandmetabolicphenotypeascertainedandbiosam- ing: (1) local site advertisements in social (e.g. Facebook)
pling undertaken, followed by randomisation to the and general (e.g. radio, local newspapers, magazines,
interventionorcontroldrink.Atthesecondpreconception posters) media, (2) information brochures given to
visit a month later, further biosampling will be undertaken women engagingin community groups such as religious,
andbodycompositionassessedbyDXA(dual-energyX-ray culture-based or special-interest groups, (3) information
absorptiometry) scanning. Regular in-person and phone brochures given to women identified through or at-
contactwillbemadewithparticipantstoresupplycontrol/ tending primary medical care, family planning or hos-
intervention drinks, and to encourage retention and com- pital clinics (for this group, eligible women may be
pliance during the preconception phase. Participants who contacted by a research nurse if they give permission
become pregnant within a year of commencing the inter- to the clinic to pass on their contact details for this
vention or control drink will be seen around 7, 12, 20, 28 purpose).
and 34 weeks of pregnancy for further phenotyping, bio- Inclusioncriteria arewomen who meetthefollowing:
sampling and ultrasound scans assessing fetal growth and
development. At 28 weeks’ gestation, a standard 75-g (cid:1) Aged 18–38years
OGTT will be repeated to ascertain the primary outcome. (cid:1) LivinginSouthampton, SingaporeorAuckland
Normal antenatal care will be permitted during the trial. (cid:1) InSouthamptonand Auckland,planningtohave
The fathers will be interviewed to ascertain paternal life- futurematernitycareinSouthampton and
style and mood, their anthropometry measured and pater- Auckland, respectively
nal biosamples collected. At birth, offspring cord blood, (cid:1) InSingapore,willing todeliverattheNational
umbilical cord and placental samples will be collected. University Hospital
Neonatal body composition is assessed by anthropometry, (cid:1) Women planningtoconceivewithin6months (but
air displacement plethysmography (PEA POD) and, in a conceptionupto12 months afterphenotyping will
subsample, by DXA scanning. Both breast- and formula- stillbeincluded)
fedinfantswillbefollowedupwhentheinfantisaged1,3 (cid:1) InSingaporeonlywomen ofChinese,Malayand
and6weeks,and3,6and12months;infantfeedingwillbe Indianethnicity,orofmixedChinese/Malay/Indian
assessed in detail, biosamples collected and growth and ethnicity willbeincluded
wellbeingascertained.Breastmilksampleswillbecollected (cid:1) Abletoprovide written,informedconsent
from a subset of participants in early infancy for nutrient
andmetabolicanalysis.AmaternalOGTTwillberepeated Exclusioncriteriaare:
again at 6 months postpartum and repeat biosamples col-
lected.Thesitevisitswillbecompletedattheresearchand (cid:1) Pregnant or lactating atrecruitment(women who
hospital facilities of the three sites in Auckland (University are currentlybreastfeedingwillbeexcluded,but no
ofAuckland,Auckland,WaitemataandCountiesManukau washout periodfromtheend of breastfeeding will
District Health Boards and Clinics, New Zealand), berequiredbeforestudy start)
Singapore (National University Hospital and National (cid:1) Assistedfertilityapartfrom thosetaking clomiphene
University Health System Investigational Medicine orletrozolealone
Godfreyetal.Trials (2017) 18:131 Page6of12
(cid:1) Women with pre-existingtype-1 ortype-2diabetes either the nutritional drink or the control drink. This
(fastingplasmaglucose concentration≥7.0mmol/L database will assign each participant the appropriate
orpostOGTT2-hplasmaglucose concentration code number that is consistent with either the interven-
≥11.1mmol/L) tion nutritional drink arm or the control drink arm.
(cid:1) Oralorimplantedcontraception currentlyor inthe Randomisation will be stratified by site to ensure bal-
lastmonth,or withan intrauterine contraceptive anced allocation of participants across the two arms at
deviceinsitu each of the three sites, with further stratification by eth-
(cid:1) Metforminor systemic steroids currentlyorinthe nicity. Investigational products will be blinded by the
lastmonth manufacturer with nonspeaking codes that do not allow
(cid:1) Anticonvulsantmedicationcurrentlyorinthe last deduction of the identity of intervention or control
month drinks. Investigators, staff performing the assessments
(cid:1) TreatmentforHIV,HepatitisBorCcurrentlyorin and data analysts will remain blind to the identity of the
thelastmonth allocation from the time of randomisation until either
(cid:1) Known seriousfood allergy the participant is unblinded or database lock of the pri-
mary outcome occurs. If emergency unblinding is neces-
Withdrawal criteria are: sary, the process for this will be documented in the
study Safety MonitoringPlan.
(cid:1) Theparticipantwishestodiscontinueparticipation
inthestudy
(cid:1) Theparticipantisunwillingorunable tocomply Theintervention
withthe protocol (including attendanceat study The Nutritional Intervention Preconception and During
visits,having studymeasuresand biosampling) Pregnancy to Maintain Healthy Glucose Metabolism and
(cid:1) Anoveralluptakelevelofintervention/control Offspring Health (NiPPeR) intervention comprises: (1) a
nutritionaldrinkoflessthan60%evidencedby micronutrient-enriched nutritional drink containing
sachetcounting myo-inositol, vitamin D, riboflavin, vitamin B , vitamin
6
(cid:1) Theparticipantispregnantbefore orat B and zinc together with standard folic acid, iodine,
12
preconception visit2 calcium, β-carotene and iron; the quantities proposed
(cid:1) Theparticipant suffersamiscarriage(pregnancy loss are either standard amounts (myo-inositol [54]), en-
before24 weeks’gestation)orectopicpregnancy.If hanced amounts that are available in over-the-counter
theparticipant suffersafirst-trimesterpregnancy products (vitamins B , B , riboflavin), recommended
6 12
lossand wishestore-jointhestudy,she willbere- daily allowance amounts in UK for pregnant women
characterisedasatthefirstbaseline visitamonthor (vitamin D, zinc, folic acid, iodine) or minimal amounts
moreafteranegative pregnancy testand willbe for micronutrients linked with potential detrimental ef-
assignedthe nutritionaldrinkwiththe same ran- fects at higher doses (iron, β-carotene, calcium) and (2)
domisationcode asbefore probiotics (containing Lactobacillus rhamnosus NCC
(cid:1) Theparticipantpresentswith amultiple pregnancy 4007 (CGMCC 1.3724) also known as LPR and Bifido-
(twinsorothermultiples) bacterium animalis sp. lactis NCC 2818 (CNCM I-3446)
(cid:1) Theinfant diesintheperinatalperiod (forpost- also known as Bl818) [52]. The intervention group will
birthsecondaryoutcomes) be compared with a control group who receive a drink
(cid:1) Theparticipant suffersanadversereactionwhichis containing standard amounts of micronutrients that are
deemed bytheinvestigator tobe causallyrelatedto part of routine pregnancy care (including folic acid, β-
theintervention carotene, iron, calcium and iodine). The intervention is
(cid:1) Theparticipantiswithdrawn atthe discretionofthe formulated as a powder in sachets to be made up in
investigator formedical reasons water immediately prior to consumption, with similar
sensory characteristics for both the intervention and
For participants who withdraw during the pregnancy control drinks. The constituents of the intervention and
phase of the study, consent will be obtained to follow up control drinks are shown in Table 1, including the ra-
on key outcome measures from their medical records to tionale for the amounts included. This trial uses estab-
enable comparison of the characteristics of withdrawn lished nutritional elements for which tolerability is well
andstudiedparticipants. established. Confirmation that the trial is not a Clinical
Trial of an Investigational Medicinal Product has been
Randomisationprocedure secured from MedSafe (New Zealand), Medicines and
At preconception clinic visit 1 all eligible participants Healthcare products Regulatory Agency, MHRA (UK)
will be randomised via the electronic study database to andtheHealthSciences Authority (Singapore).
Godfreyetal.Trials (2017) 18:131 Page7of12
Table1Constituentsoftheinterventionandcontroldrinks
Intervention Dailyamount Rationale
group
Myo-inositol 4g Improvesglucosemetabolismandpreliminarydatasuggestmaymaintainhealthyglucose
metabolisminpregnancy;dosesafelyusedinpregnancy
VitaminD 400IU Deficiencyhighlyprevalentandlinkedwithglucosemetabolisminpregnancyandoffspring
3
postnataladipositygain;dosesufficienttoreduceinsufficiencywhileavoidingpotential
concernsreadverseeffectsathighdoses.Omissionfromcontrolgroupsupportedbya
Lancetstudy[56]
VitaminB 2.6mg Deficiencyhighlyprevalentandlinkedwithglucosemetabolisminpregnancyandoffspring
6
postnataladipositygain[33];dosesufficienttorectifydeficiencyandpresentincurrentover-
the-counterproducts(e.g.Elevit).Omissionfromcontrolgroupsupportedbyusualclinical
practice
VitaminB 5.2μg Deficiencyhighlyprevalentandlinkedwithglucosemetabolisminpregnancyandoffspring
12
postnataladipositygain;dosesufficienttorectifydeficiencyandlessthanthatincurrent
over-the-counterproducts(e.g.Elevit).Omissionfromcontrolgroupsupportedbyusualclin-
icalpractice
Riboflavin 1.8mg Lowintakehighlyprevalentandlinkedwithoffspringpostnataladipositygain[34];dose
sufficienttorectifydeficiencyandpresentincurrentover-the-counterproducts(e.g.Elevit).
Omissionfromcontrolgroupsupportedbyusualclinicalpractice
Zinc 10mg Deficiencyhighlyprevalentandlinkedwithoffspringpostnataladipositygain[unpublished];
dosesufficienttorectifydeficiencyandpresentincurrentover-the-counterproducts(e.g.Ele-
vit).Omissionfromcontrolgroupsupportedbyusualclinicalpractice
β-carotene 720μg(15%ofvitaminA Requiredinpregnancyinsomejurisdictions
requirements,asretinolequivalents)
Folicacid 400μg Standardpreconceptionrecommendation
Iron 12mg Ironisroutinelyprescribedandtakenbefore/duringpregnancy,thoughwithoutconvincing
evidenceofbenefit;lowdoseincludedtolessenlikelihoodofadditionallyreceivingahigh-
doseironproduct,whichhasbeenlinkedwithglucosemetabolisminpregnancy
Calcium 150mg Alowdoseofcalciumiscommonlytakenbefore/duringpregnancy;provisionofthiswill
lessenthelikelihoodofadditionalproductsbeingtaken
Iodine 150μg Standardpreconceptionrecommendation
Probiotic Takingacombinationoftwoprobioticshasbeenlinkedwithmaintenanceofhealthyglucose
metabolisminpregnancy.Probioticcapsulecontaining>1×109cfueachofLactobacillus
rhamnosusNCC4007(CGMCC1.3724)alsoknownasLPRandBifidobacteriumanimalissp.
lactisNCC2818(CNCMI-3446)alsoknownasBl818
Controlgroup
Folicacid 400μg Standardpreconceptionrecommendation
Iron 12mg Ironisroutinelyprescribedandtakenbefore/duringpregnancy,thoughwithoutconvincing
evidenceofbenefit;lowdoseincludedtolessenlikelihoodofadditionallyreceivingahigh-
doseironproduct,whichhasbeenlinkedwithglucosemetabolisminpregnancy
Calcium 150mg Alowdoseofcalciumiscommonlytakenbefore/duringpregnancy;provisionofthiswill
lessenthelikelihoodofadditionalproductsbeingtaken
Iodine 150μg Standardpreconceptionrecommendationhttp://www.cdc.gov/preconception/documents/
clinical-content_womensnutritionfactsheet3.pdf
β-carotene 720μg(15%ofvitaminA Requiredinpregnancyinsomejurisdictions
requirements,asretinolequivalents)
Outcomemeasurements glucose metabolism at 28 weeks’ gestation has been
The primary analysis will adjust for site, ethnicity and chosen as the primary outcome as there is evidence that
preconception glycaemia to account for potential imbal- maintaining normal carbohydrate metabolism during
ance between treatment arms amongst pregnancies pregnancy is associated with a healthier body compos-
which reach 28 weeks’ gestation, examining for differ- ition,areducedriskofobesityandpotentiallypromotion
ences in means between the control and intervention of allergic/respiratory health in the children [55], along-
groups for the primary endpoint, specifically the fasting sidetherecognised pregnancybenefitsfor themother.
and/or 60-min and/or 2-h glucose concentrations fol- Secondary maternal outcomes of the initial phase of
lowing a 75-g OGTT at 28 weeks’ gestation. Maternal theNiPPeR studyare:
Godfreyetal.Trials (2017) 18:131 Page8of12
1. Maintenance ofahealthypregnancy,including The study database will not hold personal information,
normalduration ofgestation (atleast37 weeks’ which will be stored separately at each institution with
gestation), absence ofGDM(definedusingthe access limited to study coordinators. Data from the web-
InternationalAssociationofthe Diabetes and based database will be downloaded via a dedicated com-
PregnancyStudy Groupscriteria:glucose cut-off puter and stored securely on the MRC Lifecourse Epi-
values of≥5.1 mmol/Lforfastingplasmaglucose, demiology Unit’s servers in the UK. Data extracts will be
and/or≥10.0mmol/Lfor1-h and/or≥8.5mmol/L provided for analysis by the study researchers treating
for2-h postload),change infastingglucose and data from all three sites as a single study. All data will
OGTTglucoseareaunder the curvefromprecon- be kept in accordance with the UK Data Protection Act,
ceptionbaseline to28weeks’gestation,maternal and applicable regulations and guidance of each country
wellbeing/mood,absenceofexcessivenauseaand andinstitution.
vomiting,adequatepregnancy weightgain(Institute Biological samples will be collected and processed
ofMedicine criteria)and vaginal deliveryrates using standardised consumables, equipment and proto-
2. Reductioninmaternalmicronutrientinsufficiency, cols across the three sites and will be being stored in ac-
specificallylessriboflavin,vitamin B ,vitamin B , cordance with the UK Human Tissue Act or equivalent
6 12
zincand vitamin Dinsufficiency, before andduring at each institution in appropriately regulated biobanks.
pregnancy The study database allows management of the samples.
3. Alterationingutmicrobiota consistentwith All analysis will be carried out on anonymised data and
enhancedwellbeing samples. Accredited laboratories will be used for meas-
4. Alterationinmaternal metabolomicandepigenetic urement of the primary outcome of plasma glucose
biomarkersconsistentwith improved maternaland/ concentrations.
oroffspringwellbeing
5. Enhancement of breastmilkmicronutrientcontent,
alteredimmunologicalfactors,epigenetic and Studymanagementandgovernance
metabolomic profiles(subsample)andmaintenance This double-blind randomised controlled trial is led by
of healthylactogenesis investigators from the EpiGen Global Research Consor-
tium, an academic research consortium comprising rep-
Secondary offspring outcomes of the initial phase of resentatives from the University of Southampton (MRC
theNiPPeR studyare: Lifecourse Epidemiology Unit and Institute of Devel-
opmental Sciences), University of Auckland (Liggins
1. Neonataladipositymeasured byPEAPOD Institute), the Growth, Development, and Metabolism
2. Birthweight 2500–4000g,sizeforgestationalage at ProgrammeoftheSingaporeInstituteforClinicalSciences
birthand customisedbirthweightcentile (anoperatingunitofA*STAR)andtheNationalUniversity
3. Reducedadipositygainduringinfancy,analysed of Singapore (Translational and Clinical Research Flagship
taking account ofinfant feeding Programme, ‘Developmental pathways to metabolic
4. ReductionincordbloodC-peptideasamarkerof disease’), togetherwiththeSingaporeNationalUniversity
overallglycaemiaduringgestation Health System. Scientists from the Nestlé Research
5. Promotionofoffspringwellbeingandhealthy Centre (Nestec) provided advice on aspects of the
cardiometabolicriskfactors,including visceral intervention formulation, study design and specific la-
adiposityandmarkersofinsulinresistance,during boratory analyses.
infancy The UK sponsor of the project is the University of
6. Alterationinoffspringmetabolomicand epigenetic Southampton; the New Zealand sponsor of the project is
biomarkersinperinatalsamples,consistentwith Auckland UniServices Limited; the Singapore sponsor of
improvedinfant metabolicand allergicwellbeing the project is the National University Hospital Singapore.
7. Alterationingutmicrobiota toamicrobiota The sponsors are indemnified for any harms arising from
associatedwith infant metabolicandallergic trial participation and will approve protocol amendments
wellbeing for which ethics approval has been secured, alongside
updateoftrial registryentries.Trial oversight willbe pro-
Dataandbiosamplecollection vided by an Independent Data Monitoring and Safety
Study data will be collected by trained research staff Committee. The day-to-day running of the study will be
using an access-controlled, web-based database (MedS- through the Trial Management Group, consisting of the
ciNet, Stockholm) managed with support from the data principal investigators and the clinical trial operations
management staff of the MRC Lifecourse Epidemiology director, who will be responsible for all decisions on
Unit and the Singapore Institute for Clinical Sciences. the study management and delivery.
Godfreyetal.Trials (2017) 18:131 Page9of12
Monitoring will be carried out several times per year participant withdrawal, inability to comply with the
by an external, independent monitor at each site, follow- protocol, withdrawal for medical reasons at the discre-
ing the risk-based monitoring plan established for the tion of the investigator and loss-to-follow-up. A study of
study, overseen by the study sponsor. Safety reporting 250pregnancieswith28-weekOGTTdataineachgroup
will be in accordance with the study Safety Monitoring has 89% power to detect a 0.1-mmol/L reduction in fast-
Plan and all events will be recorded in the study data- ing plasma glucose and 84% power to detect a 0.3-
base. An Independent Data Monitoring and Safety Com- mmol/L reduction in 2-h plasma glucose at the 5% level
mittee has been established for the trial. This committee of significance. In the Hyperglycemia and Adverse Preg-
is independent from the sponsor and competing inter- nancy Outcomes (HAPO) study such changes in glucose
ests and will meet annually and oversee all ethical and concentrations were associated with >10% changes in
safety issues in accordance with current regulations and the odds of macrosomia and sum of neonatal skinfolds
MRC guidelines for Data Monitoring Committees. The >90th centile and with a >20% change in cord C-peptide
CommitteeCharter isavailablefrom the clinical trial op- >90th centile [6]. As a further illustration of statistical
erations director, who will coordinate and review activity power, using the distribution of 60-min plasma glucose
across sites. in the HAPO study, a study of 250 participants in each
of the two groups has 80% power to detect a difference
Statisticalanalysis of ≥0.43 mmol/L in 60-min glucose at P<0.05. A study
The primary analysis will be according to the intention- of 300 pregnancies in each arm will have an 80% power
to-treat principle. Additionally, a priori sensitivity ana- to detect a reduction in the mean plasma glucose of
lyses will be undertaken, omitting participants with- 0.12, 0.45 and 0.34 mmol/L at fasting, 60 min and 2 h,
drawn as a consequence of reluctance to continue with respectively, with an alpha of 0.017 taking into account
the trial, conception after taking the nutritional drink for multiple testing.
less than 21 days, less than 60% uptake with the inter-
vention (evidenced by sachet counting), not conceiving Discussion
after 12 months of participation or not achieving a preg- This double-blind randomised controlled trial in groups
nancy of more than 28 weeks. Further sensitivity ana- of women from different ethnic groups in the UK,
lyses using a ‘per protocol’ or an ‘as treated’analysis will Singapore and New Zealand is designed to examine the
be performed if deemed appropriate by the trial statisti- hypothesis that a nutritional drink, commencing before
cians. For analysis of the primary endpoint only: if ex- conception and continuing during pregnancy, will assist
ploratory analysis reveals the presence of outliers, as in the maintenance of healthy glucose metabolism in the
identified by independent experts and/or the trial statis- mother and promote offspring health. Improved mater-
ticians, sensitivity analysis will be performed excluding nal nutrition and glycaemic control before and during
these outliers. Analyses will be specified in the study pregnancy has benefits for the health of the mother and
statistical analysis plan finalised by the Trial Manage- her offspring, including healthy offspring body compos-
ment Group before unblinding the data. The influence ition and decreased risks of childhood obesity and aller-
of missing data will be examined using multiple imput- gies. The intervention group will receive a nutritional
ation techniques. There are no formal planned interim drink enriched with micronutrients, myo-inositol and
analyses of the primary outcome, but progress reports probiotics, and the control group will receive a drink
on all data issues will be presented to the Independent enriched with standard micronutrients. The potential for
Data Monitoring and Safety Committee, who will agree adverse effects of the intervention is low as the probiotic
their charter at their first meeting. Analyses of the base- and myo-inositol are thought to exert their main effects
line phenotypic data that do not require unblinding will through physiological modulation of maternal metabol-
be undertaken. We will build prognostic models using ism rather than through direct effects on the fetus and,
baseline covariates on the primary outcome of maternal while the amounts of micronutrients in the nutritional
glucose tolerance in pregnancy. Planned subgroup ana- drink are sufficient to rectify maternal deficiency, they
lyses will include stratification by ethnicity across study do not exceed UK, Singapore and New Zealand safe
sites. upperlimits.
The trial commences preconception as studies by
Powercalculations Catalanoetal.[53]suggestthatamajorpartoftheriskof
By studying up to 900 prepregnant participants in each macrosomia originates in early pregnancy/prepregnancy
of the intervention and control groups, a total of 600 andadversepregnancyoutcomesareassociatedwithpoor
pregnancies and 500 live births is conservatively antici- maternal nutrition at conception; maternal insulin resist-
pated, following attrition from miscarriage, ectopic preg- ance and hyperglycaemia in the very earliest stages of
nancy, perinatal demise, multiple pregnancy, voluntary pregnancyalterplacentalanatomyandphysiologyinways
Godfreyetal.Trials (2017) 18:131 Page10of12
that persistently affect transplacental fetal nutrient supply healthy growth, body composition and wellbeing in
and fetal fat accretion, as well as bilateral maternal-feto- the offspring.
placental cross-talk, withconsequences for later postnatal
health. As a consequence, intervention commencing in Trialstatus
established pregnancy can only partially influence fetal Recruitment for the trial commenced on 3 August 2015;
growth and development. The earlier that maternal gly- more than half of the participants have been recruited
caemia is optimised and micronutrient deficiencies pre- within the following 12monthsandrecruitment remains
vented, the greater the likelihood of maintaining fetal and ongoing in October 2016. Participants have already pro-
postnatal health and wellbeing. Many influential govern- gressed through the randomisation and pregnancy
mentalandnongovernmentalorganisationsarenowstres- phases of the study and initial deliveries have occurred
singtheimportanceofoptimisingpreconceptionnutrition inallthree sites.
ingeneraltermsbutasyet,otherthanfolicacidtoprevent
neuraltubedefects,therearefewpreconceptioninterven- Additional file
tions that are recognised as promoting health benefits for
the mother or offspring, and none, apart from folic acid, Additionalfile1:SPIRIT2013Checklist:recommendeditemstoaddress
hasarobustevidencebase. inaclinicaltrialprotocolandrelateddocuments*.(DOC121kb)
In the initial phase of the NiPPeR study a broad range
of maternal nutritional assessments, potential epigenetic Abbreviations
GDM:Gestationaldiabetesmellitus;HAPO:HyperglycemiaandAdverse
mechanisms and secondary measures relating to preg-
PregnancyOutcomes;NiPPeRstudy:NutritionalInterventionPreconception
nancy outcomes and infant growth, body composition andDuringPregnancytoMaintainHealthyGlucoseMetabolismand
and wellbeing will be characterised and are detailed in OffspringHealthStudy;UK:UnitedKingdom
thisprotocol.
Acknowledgements
The extensive biosampling and detailed phenotyping Wewouldliketothanktheparticipantsfortheirenthusiasticinvolvementin
embedded in the study before, during and after preg- thestudy.TheNiPPeRStudyGroupauthorsfortheMedlinecitation
comprisesIzzuddinBinMohamadAris,SheilaJBarton,JonathanYBernard,
nancy will provide an important discovery pipeline for
VeronicaBoyle,GrahamCBurdge,ChristopherDByrne,ShirongCai,PhilipC
the development of novel biomarkers of maternal and Calder,ClaudiaChi,CarolineEChilds,MaryFChong,CathrynConlon,Cyrus
offspring wellbeing, and lead to new interventions and Cooper,MarilouEbreo,SarahEl-Heis,MarielleFortier,LisaRFries,NicholasC
Harvey,JoannaDHolbrook,RichardHolt,HazelMInskip,NeerjaKarnani,Tim-
future guidelines to promote healthy human growth and
othyKenealy,YungSengLee,KarenLillycrop,SeeLingLoy,KatherineMacé,
development. A range of biological samples collected at PamelaAMahon,MinGong,FalkMüller-Riemenschneider,SharonNg,Heidi
multiple time points before, during and after pregnancy Nield,JustinMO’Sullivan,WeiWeiPang,CharlesPeebles,AnneRifkin-Graboi,
LesleyMcCowan,AllanSheppard,NickMacklon,TinuMarySamuel,ShuE
in the mother and offspring enables a systems biology
Soh,LynettePei-ChiShek,IrmaSilva-Zolezzi,RachaelTaylor,SagarKThakkar,
approach to understanding the complex interaction of MyaThwayTint,ClareWallandWeiYing.
factors that determine maternal and infant wellbeing.
Funding
Both individually and collectively, the control and inter-
Publicgoodfundingforthisinvestigator-ledstudyisthroughtheUKMedical
vention arms will provide extensive information that will ResearchCouncil(aspartofanMRCawardtotheMRCLifecourseEpidemi-
deliver new knowledge on how maternal nutrition and ologyUnit),theSingaporeGovernment(aspartoftheGrowth,Development
andMetabolismProgrammeoftheSingaporeInstituteforClinicalSciences)
metabolic state can promote offspring health. The re-
andtheNewZealandGovernment(aspartoftheGravida,CentreofRe-
search will also benefit from insights arising from other searchExcellence:GrowthandDevelopment).Fundingforprovisionofthe
studies by the EpiGen Global Research Consortium in interventionandcontroldrinksandtocoveraspectsofthefieldworkforthe
studyhasbeenprovidedbyNestecSAunderaResearchAgreementwith
the UK, Singapore and New Zealand. The ethnicities of
theUniversityofSouthampton,AucklandUniServicesLtd.,SingaporeInstitute
the participants in the study will allow broad extrapola- forClinicalSciences,NationalUniversityHospitalSingaporePTELtd.,National
tion of the findings, and enable subsequent smaller-scale UniversityofSingapore.
studies in other jurisdictions, such as China and India,
Availabilityofdataandmaterials
as appropriate. The partners have extensive experience
ATrialConsultativePanel,comprisingseniorrepresentativesfromthe
of following up prospective mother-offspring cohorts, academicinstitutionsundertakingthestudyandtheindustrypartner,has
maternal, obstetrical, fetal and infant medicine and beensetupandwillconsiderassociatedstudiesrequestingaccesstodata
andmaterials.Thismanuscriptdoesnotcontainanydata.Datasetsduring
health care, and detailed characterisation of a com-
and/oranalysedduringthestudywillbeavailablefromthecorresponding
prehensive set of health and wellbeing outcomes authoronreasonablerequest.Theresultsofthestudywillbesubmittedfor
through infancy and childhood will be undertaken. publicationinpeer-reviewedjournalsassoonaspossibleafteranalysis.
Authorshipwillbeinlinewithinternationalguidelines(http://www.icmje.org/
The data collected will allow determination of the
recommendations/browse/roles-and-responsibilities/defining-the-role-of-
contributions of nutritionalandlifestyle factors,socioeco- authors-and-contributors.html).
nomic status, ethnicity, genetics, transcriptomics, epige-
Authors’contributions
nomics, metabolomics and metagenomics to maintaining
TheconceptforthestudyanditsdesignwasoriginatedbyKMG,CYSand
healthy glucose metabolism in pregnancy and promoting PNB,withimportantinputsintothestudydesign,protocol,standard