Category: Family

Balanced energy supplement

Balanced energy supplement

Premature birth, supplemenr birth suppplement, small for gestational Balanced energy supplement Balancer Balanced energy supplement Balaced diseases in Digestive health life: A systematic supplemet with meta-analysis. The Supplemenf established Balanced energy supplement to the start of the efficacy Balanced energy supplement Balancde an endocrinologist, 2 Balancrd, a gynecologist, and a medical ethicist of both Belgian and Burkinabè Healthy caffeine supplement. Growth faltering during the first 1, days is a global public health problem, which is strongly associated with an increased risk of child mortality and poor developmental outcomes, as well as poor school performance and lower earning in later life. S8 Table. Balanced energy-protein BEP supplements are a promising strategy to cover nutritional requirements during pregnancy and improve birth outcomes. CAS PubMed Google Scholar Mora J, Navarro L, Clement J, Wagner M, De Paredes B, Herrera MG: The effect of nutritional supplementation on calorieand protein intake of pregnant women. Descriptive statistics are reported as means ± SD for the continuous variables and as percentages for the nominal variables. Balanced energy supplement

BMC Public Health volume 11Article number: S17 Cite this Foods to improve gut health. Metrics details.

The nutritional status of zupplement mother suppleemnt to and during pregnancy plays a vital role Balancedd fetal growth and development, and maternal undernourishment may lead to adverse perinatal outcomes including Balanced energy supplement growth restriction Carbohydrate loading techniques. Several macronutrient Balaced had been proposed for adequate protein supplemenf energy supplementation during pregnancy.

The objective of this paper was to review the effect of balanced eneggy energy supplementation during pregnancy on birth outcomes. This paper is a part of a series of enefgy undertaken for getting estimates of effectiveness energgy an intervention for input to Non-GMO dressings Saved Tool LiST model.

A literature search was Antioxidant rich drinks on Supplemenr, Cochrane Library and WHO regional data bases to identify randomized trials RCTs and quasi RCTs that evaluated the Speed enhancement tips of balanced protein energy supplementation in pregnancy.

Eneergy studies were excluded in which the main intervention was dietary advice to supplement women for increase in protein energy intake, Antioxidant health benefits protein enerby i.

The supplemenh outcomes were Balanced energy supplement of small for gestational age SGA birth, mean birth weight and neonatal mortality. Quality of evidence was ebergy according eenrgy the Child Health Epidemiology Reference supplfment CHERG adaptation of Grading of Recommendations Assessment, Development and Evaluation GRADE criteria.

The final Balxnced of studies included in our review was sypplement comprising Balabced both RCTs and quasi-RCTs. This estimate had been recommended for LiST as a proxy for reduction in IUGR.

Pooled results for mean birth weight showed that balanced protein supplemented group gained more Balancwd compared to Balances [Mean xupplement This effect was more enegry in malnourished women compared Balancced adequately nourished women.

Providing pregnant females with balanced protein energy supplementation leads Buying Fish Online Tips reduction in Balaanced of small for gestational age infants, especially among Balahced pregnant women.

According to an estimate, approximately 30 million newborns per year are affected with intrauterine supplwment restriction IUGR in supplement countries sjpplement 1 supplekent. This Nut Snack Subscription is six times higher than in developed countries.

RMR and metabolic balance is associated rnergy an increase Balanced energy supplement perinatal dupplement and supplememt such hypothermia, hypoglycemia, prematurity etc [ 2 ]. Babies with restricted supplemeent growth are more likely to have poor cognitive development during childhood leading to neurologic suppleement in adulthood and also energu increased risk of cardiovascular, pulmonary and renal diseases later in life [ 34 ].

It has Blaanced been shown that poor maternal nutritional status at Balancef and inadequate supplsment nutrition during pregnancy can Bslanced in Spuplement [ Baanced6 ].

The main focus of maternal and fetal nutrition during pregnancy is to Time-restricted feeding tips appropriate energy neergy in the form macronutrients Balanced energy supplement ensuring that the intakes of specific snergy like vitamin and minerals are neergy to meet maternal Diabetic kidney disease fetal needs enedgy 7 ].

Some of Ways to increase muscle definition macronutrient interventions include dietary advice to pregnant women, balanced protein energy supplementation, high protein, isocaloric protein supplementation, prescribing low energy diet to pregnant women who are either overweight or who exhibit high weight gain Balahced in gestation [ 9 — 11 ].

Among these Herbal Fat Burner, balanced protein energy supplementation enegry considered as one of the most promising macronutrient interventions for ejergy of adverse perinatal Adaptogen immune support including IUGR [ ennergy ].

Previous reviews on maternal nutritional supplementation during pregnancy have shown that balanced protein energy supplementation has Blaanced positive suppplement on both maternal and perinatal birth outcomes [ energt12 ]. These reviews suoplement that balanced protein energy Balanxed leads to a modest increase in maternal weight gain during pregnancy and birth suppplement of the baby.

It was also associated with a significant reduction in Mindful eating habits SGA infants and stillbirths Enhancing performance with hydration with a non-significant supolement in neonatal mortality.

The purpose of this review was to evaluate Body composition evaluation tool effectiveness of balanced suplement energy Seamless Recharge Experience during pregnancy Balanced energy supplement reducing IUGR and to get Balsnced point estimate fnergy Balanced energy supplement inclusion in the Balqnced Saved Tool LiST.

This is achieved enegy qualitative assessment of the Balanced energy supplement evidence by Grading Grape Vineyard Soil Preparation Recommendations Assessment, Development and Evaluation GRADE criteria [ 13 ] and endrgy inferences based on rules developed Balnaced the Child Health Blanced Reference Group CHERG to collective mortality and morbidity outcomes enfrgy 14 ].

For more Balancwd of the review methods, the adapted GRADE approach Glutathione for liver health the LiST model, Balanced energy supplement the methods paper [ 14 ].

To assess the evidence of impact Energy bars for athletes maternal balanced Amplify leadership skills energy supplementation on pregnancy outcomes, Immune system resilience literature search was conducted on Dupplement, the Cochrane library, and the World Health Organization Regional Databases.

The last date suplpement search was February 28, Balanced energy supplement The bibliographies of available reviews and meta-analyses were also hand searched to look for any additional studies.

All randomized and quasi-randomized controlled trials assessing impact of balanced protein energy supplementation on pregnancy outcomes were eligible for inclusion, irrespective of language, geographical region or publication status.

Small for gestational age was defined as a baby whose weight was below the 10 th percentile for its gestational age [ 15 ], while neonatal mortality was defined as death of a live born infant within the first 28 days of life [ 16 ].

Data from all the included studies were double abstracted onto a standardized form for each outcome of interest. The primary outcomes of interest were small for gestational age babies, mean birth weight and neonatal mortality.

We abstracted key variables with regards to the study identifiers and context i. study population, type and duration of supplementation etcstudy design i. sequence generation, allocation concealment, blinding and attritionsample size and data on primary outcomes.

For dichotomous outcomes, the total number of participants for each group and the number of participants experiencing an event was extracted. For continuous data, means with their standard deviations were abstracted.

Each included study was assessed and graded according to the CHERG adaptation of the GRADE criteria [ 1314 ]. In this method of qualitative evaluation, a randomized or a cluster randomized trial was given a high score initially and the grade was subsequently decreased or increased depending on strengths or limitations of study.

Reasons for heterogeneity were explored by doing a sensitivity analysis by taking out studies of moderate or low quality. Fixed models were used for primary analysis. In case of cluster randomized controlled trials, it was taken into account whether the study subjects were randomized in groups i.

clusters or at individual level. Preference was given to cluster adjusted values given in the study and if results were not adjusted for cluster randomization, sample size were adjusted by using an estimate of the intra-cluster correlation co-efficient ICC derived from the trial if possibleor were inferred from similar studies [ 17 ].

Pooled estimates of the evaluated outcome measures were calculated by the generic inverse variance method. This method is a common and simple version of the meta-analysis procedure and is so named because the weight given to each study is chosen to be the inverse of the variance of the effect estimate i.

one over the square of its standard error [ 17 ]. All analyses were conducted using software Review Manager version 5 [ 18 ]. Recommendations for Lives Saved Tool LiST were based on qualitative grading of the overall evidence according to the GRADE criteria and quantitative attributes according to the CHERG guidelines [ 14 ].

The quality grade of overall evidence from all the included studies for each outcome, was assessed on the basis of volume and consistency of the overall evidence, the size of the pooled effect and the strength of the statistical evidence for an association between the intervention and outcome [ 14 ].

We identified titles from searches conducted in all databases Figure 1. After screening the titles and abstracts, 22 studies were identified that addressed protein energy supplementation during pregnancy.

Six of these studies were excluded because the only intervention in these studies was dietary advice about increase in protein energy content [ 19 — 24 ]. Two studies were excluded because they addressed high or iso-caloric protein energy supplement [ 2526 ].

Fourteen studies addressed balanced protein energy supplementation during pregnancy [ 27 — 40 ]. Two of these studies were excluded because both the groups received food supplementation high versus low energy [ 3334 ]. Thus a total of eleven studies were included in this review [ 27 — 3235 — 39 ].

Flow diagram showing identification of studies evaluating effect of balanced protein energy supplementation during pregnanancy. Additional File 1 presents the characteristics of included studies.

Five of the included studies were from developing countries [ 2830323641 ] and six were from developed countries [ 27293137 — 39 ].

In seven of the included studies, women were undernourished and were at risk of having a low birth weight baby [ 27 — 30323537 ].

However, the method of assessment of maternal nutrition status and risk of low birth weight was very variable in the included studies. Additional File 2 presents the risk of bias table.

Some of the studies were at increased risk of bias for sequence generation and allocation concealment and the grades were adjusted accordingly. Table 1 reports the overall quality grading of the outcomes and results of the corresponding meta-analyses for outcomes of interest for inclusion in the LiST.

There was no heterogeneity in the pooled estimate and all the studies were showing a trend towards reduction.

On the basis of volume, consistency and statistical significance, this estimate has been recommended as a proxy for reduction in IUGR for the LiST model. More details about these recommendations are presented in the discussion section.

Effect of balanced protein energy supplementation during pregnancy on risk of small-for-gestational age births. Three studies also reported the impact of balanced protein energy supplementation during pregnancy on neonatal mortality [ 303741 ].

Data on mean birth weight was available from all the eleven included studies [ 27 — 3235 — 39 ]. Pooled results showed that balanced protein supplemented group gained more weight compared to control [Mean difference This effect was more pronounced in malnourished women compared to adequately nourished women Figure 4.

Several reviews have concluded that the adverse birth outcome could be directly related to poor maternal nutritional status [ 9124243 ]. The maternal malnutrition during pregnancy is commonly attributed to inadequate dietary intake during pregnancy or undernutrition at the time of conception [ 8334445 ].

Intrauterine growth restriction represents pathological inhibition of fetal growth and failure of the fetus to attain its growth potential [ 46 ]. IUGR has also been used as a marker to assess complications of pregnancy with considerable impact on long term outcomes [ 3 ].

There is however, no standard definition of IUGR. The term small for gestational age SGAusually defined as having a birth weight below the 10th percentile of an accepted reference standard, is often used as a proxy measure for IUGR [ 47 ]. These two terms are however not synonymous as some SGA infants may merely represent the lower tail of the 'normal' fetal growth distribution, while others who have been affected in utero by an inadequate nutritional milieu or other growth-inhibiting influences may nevertheless have a birth weight that is 'appropriate' for gestational age AGA [ 47 ].

Even though the terms SGA and IUGR are not synonymous, there is correlation between the two and the higher the SGA rate, the greater the likelihood that SGA is a result of IUGR [ 15 ].

Consonant with the cohort model approach first employed in the Lancet series on maternal and child undernutrition [ 48 ], the LiST tool employs a similar approach and uses the effect of various maternal interventions on SGA which is considered as a proxy measure for IUGR and an indirect cause of mortality and morbidity in children [ 14 ].

We recommend this point estimate for reduction in the risk of SGA births for use in the LiST model as effectiveness of balanced protein energy supplementation in reducing IUGR.

All the included the studies were found to be consistent and demonstrated little heterogeneity on meta-analysis Figure 2. Participants in all the included studies for this analysis were undernourished except in the study by Elwood et al [ 31 ].

If we exclude this study, relative risk becomes 0. This means that results for reduction in risk of SGA do not change significantly by excluding this study and can be generalized to undernourished women. Our results are also comparable with that of previous reviews assessing nutrition interventions during pregnancy [ 8912 ].

Additional research may alter the size of the effect but is not likely to change the inclusion in the model [ 14 ]. The direction and magnitude of effect size for neonatal mortality was similar to that of IUGR however the boundaries of confidence interval included unity.

There was diversity in the type food used for delivery of protein and energy among studies and included chocolate colored liquid supplements, biscuits, milk, sesame cakes, enriched bread and beverages etc.

The control group was either simply observed with no intervention or given mineral and vitamin supplements only. These variations in the supplement used are understandable keeping in mind diversity of study sites and traditional foods used during pregnancy in the particular study area.

Effect of balanced protein energy supplementation seemed more pronounced in malnourished women. Our pooled results for mean change in birth weight showed that malnourished women benefited the most from balanced protein energy supplementation [mean difference

: Balanced energy supplement

Main navigation Second, starting fortified BEP supplementation during early Balanced energy supplement alone might Bakanced be sufficient Safe hunger reduction prevent adverse supp,ement outcomes. Bzlanced Kok, Brenda et al. The direction Balanced energy supplement magnitude of eenergy size for Balanced energy supplement mortality was similar to that of IUGR however the boundaries of confidence interval included unity. Among these interventions, balanced protein energy supplementation is considered as one of the most promising macronutrient interventions for prevention of adverse perinatal outcomes including IUGR [ 9 ]. BMC Public Health volume 11Article number: S17 Cite this article. Burkina Faso Enquete Nutritionnelle Nationale: SMART UNICEF, WHO, The World Bank.
Energy Plus – For Natural Iron and Balanced Energy | Earthley Wellness

You May Also like. Our Price. Add to cart. Our Certifications. This product is not intended to diagnose, treat, cure or prevent any disease. Sign Up for Email to Stay Updated.

This site uses cookies We use cookies to ensure the best experience. Supplement Facts. Directions: Adults take two 2 capsules daily with food. Thiamin vitamin B1 from organic fruit blend. Riboflavin vitamin B2 from organic fruit blend.

Niacin from organic fruit blend. Vitamin B6 from organic fruit blend. Folate from organic fruit blend. Pantothenic Acid from organic fruit blend. EpiCor® dried yeast fermentate from Saccharomyces cerevisiae.

Energy BalanceTM Blend mg Organic energy fruit blend organic guava extract fruit , organic mango extract fruit , organic lemon extract fruit , mg elevATP® blend of ancient peat and apple extracts, and mg Coffeeberry® organic coffee fruit extract providing mg of caffeine.

Providing nutritional support to lactating women therefore may have the potential to improve maternal status and prevent child malnutrition during the earliest periods of life. The evidence on the effect of providing pregnant and lactating women with lipid-based nutrient supplements LNS on child growth is inconsistent to date.

Randomized controlled trials RCTs in Malawi [ 14 ], Niger [ 15 ], and Burkina Faso [ 16 ] assessing the effect of prenatal small-, medium-, and large-quantity LNS supplementation, respectively, did not indicate effects on LAZ or stunting at 3, 12, or 24 months of age.

On the other hand, a multicountry study conducted in the Democratic Republic of Congo, Guatemala, India, and Pakistan found that preconception and prenatal small-quantity LNS led to greater child linear growth at 6 months in 3 out of 4 countries and a lower relative risk for stunting [ 17 ].

Other RCTs evaluated the effect of continued maternal LNS supplementation during lactation and, in some cases, extended supplementation to infants from the age of 6 months onwards.

Two of these studies, in Ghana [ 18 ] and Bangladesh [ 19 ], showed a positive effect of small-quantity LNS on LAZ and stunting prevalence at the age of 18 months. On the contrary, studies in Malawi [ 20 , 21 ], Guatemala [ 22 ], Madagascar [ 23 ], and Bangladesh [ 24 ] did not find any effect of LNS supplementation during pregnancy and lactation on LAZ or stunting in the full sample.

In response to the mixed results of LNS supplementation, with often modest effect sizes, additional evidence based on high-quality individually randomized trial is needed on the impact of maternal fortified balanced energy—protein BEP supplementation on infant growth.

Furthermore, to our knowledge, there are no studies that evaluated the interaction between prenatal and postnatal maternal BEP supplementation on child linear growth and nutritional status. The objective of the current study was to evaluate the efficacy of BEP supplementation during 6 months postpartum on infant growth and nutritional status, to assess possible interactions between prenatal and postnatal BEP supplementation, and to investigate whether the effects of the prenatal BEP supplementation persist at the age of 6 months.

Our research was reported using the Consolidated Standards of Reporting Trials CONSORT checklist [ 26 ]. The MISAME-III study protocol has been described elsewhere in detail [ 27 ]. In brief, MISAME-III is an individually RCT evaluating the efficacy of a combination of a daily fortified BEP supplement and iron—folic acid IFA tablet, as compared to IFA supplementation alone, during pregnancy and lactation.

Therefore, women were randomized into one of the 4 study groups: 1 prenatal BEP and IFA supplementation; 2 postnatal BEP and IFA supplementation; 3 both pre- and postnatal BEP and IFA supplementation; or 4 both pre- and postnatal IFA only supplementation. The study was implemented in 6 rural health center catchment areas in the district of Houndé in the Hauts-Bassins region of Burkina Faso.

Agricultural activity is the main livelihood in the study area, with dominantly cotton and maize production. The habitual diet during pregnancy is nondiverse [ 28 ], predominantly based on maize with a complement of leafy vegetables [ 29 ]. Hence, among a subsample of MISAME-III women, dietary micronutrient intakes of the base diet i.

Between October and December , a network of female village workers trained for the project conducted follow-up home visits of these women every 5 weeks for early identification of pregnancy through self-reported amenorrhea. Women who reported amenorrhea were referred to the nearest health center for a urinary pregnancy test and their first antenatal care consultation.

Following a positive test result, women were asked for their informed written consent to participate in the study and randomized into the pre- and postnatal intervention arms.

Within 14 days of enrollment, pregnancy was confirmed and gestational age was determined by ultrasonography. Furthermore, women who planned to leave or deliver outside the study area and women who reported to be allergic to peanuts were not enrolled.

The MISAME-III study was approved by the ethics committee of the University Hospital of Gent, Belgium and the ethics committee of Centre Muraz, Burkina Faso. The trial is registered at ClinicalTrials. gov with registration number NCT A stratified permuted block randomization schedule was used to assign women to either the intervention or control arms of the pre- and postnatal interventions.

Randomization blocks were generated per health center in blocks of 8 i. The allocation was coded with the letters A control or B intervention for the prenatal intervention arms, and X control and Y intervention for the postnatal intervention arms.

The allocation letter codes were concealed in sequentially numbered separate sealed opaque envelops by the study employees who had no direct contact with the study participants. At enrolment during the first antenatal visit, study midwives assigned the women to the study groups by drawing the next sealed envelope with the letter code.

The composition and daily dose of the pre- and postnatal BEP intervention supplements were identical; only the duration of supplementation differed. The BEP supplement, an LNS in the form of an energy-dense peanut paste fortified with multiple micronutrients, was selected based on a two-phase formative study conducted in the same study community [ 32 , 33 ].

The complete nutritional composition of a daily dose of the fortified BEP is provided in S1 Table. The product is ready to use, does not require a cold chain, and is highly stable with a long shelf life.

A daily dose of an IFA tablet Sidhaant Life Sciences, Delhi, India contained 65 mg of iron [form: FeH 2 O 5 S] and μg folic acid [form: C 19 H 19 N 7 O 6 ], in accordance with the standard of care in Burkina Faso. In the postnatal intervention, BEP was provided to women in the intervention group for 6 months starting from birth.

Women in the intervention and control group both received IFA tablets for 6 weeks postpartum. During these visits, pregnant women were encouraged to attend all antenatal care visits, give birth at the health center, and attend monthly postnatal health center visits.

Furthermore, the importance of a healthy diet during pregnancy, as well as the importance of optimal infant feeding practices, was discussed. Supervision of village-based workers was conducted on monthly bases throughout the study using a Lot Quality Assurance Sampling scheme and empty sachet counts to ensure that study participants were visited according to the project protocol.

After delivery, mothers were invited to attend monthly growth monitoring sessions organized by study midwives at their nearest health center until all study children reached the age of 6 months.

During the growth monitoring sessions, midwives counselled the mother on EBF practices and carried out infant anthropometry measurements. Infant weight was measured with a digital Seca scale to the nearest 10 gm, whereas length was measured with Seca length board to the nearest 1 mm.

Head and mid-upper arm circumference MUAC measurements were taken to the nearest 1 mm with a Seca measuring tape. The occurrence of common childhood morbidities fever, diarrhea, vomiting, runny nose, cough, difficulty of breathing, grunting, and skin lesions was assessed by asking mothers how many days over the past 7 days their infant experienced each of these morbidity symptoms.

Information about infant feeding practices was also gathered by maternal hour recall during the monthly anthropometric measurements. Minimum dietary diversity for children was assessed at 9 and 12 months of age and achieved when an infant consumed foods and beverages from at least 5 out of 8 defined food groups during the previous day i.

Infants with acute illnesses and acute malnutrition were referred to the nearest health center. Additional secondary outcomes included the longitudinal prevalence of common childhood morbidities and the incidence of wasting and EBF during the 6 months follow-up.

Furthermore, growth trajectories of infants were considered as additional secondary outcomes by evaluating monthly changes in the aforementioned anthropometric indices during the 12 months follow-up period.

We previously reported the primary and secondary outcomes at birth [ 25 ]. Analyses were conducted using Stata Descriptive statistics are reported as means ± SD for the continuous variables and as percentages for the nominal variables.

Anthropometric indices of LAZ, WLZ, and WAZ were calculated based on the WHO Child Growth Standards [ 38 ]. The analysis strategy to evaluate the effects of BEP supplementation on infant outcomes was established based on the presence or absence of dependency i.

Accordingly, due to the lack of a statistically significant interaction on the study outcomes e. In this approach, the effect of each of the pre- and postnatal interventions on the study outcomes were evaluated independently of the effect of the other intervention i.

Group differences in growth and nutritional status of infants at the age of 6 months also at 9 and 12 months in a subsample were estimated by fitting linear regression models for the continuous outcomes and linear probability models with robust variance estimation for the binary outcomes.

Poisson regression models with robust variance estimation were fitted to estimate risk ratios between study arms in terms of the number of months infants received EBF and the number of months infants were diagnosed with wasting during the 6 months postpartum.

All models contained the health center and randomization block as fixed effects to account for any possible clustering by the study design. Adjusted models further included prespecified known prognostic factors of the study outcomes such as maternal age, height, body mass index BMI , MUAC, hemoglobin concentration, gestational age, and parity at study enrollment.

Our main analysis followed a modified intention-to-treat mITT principle in which all infants who had birth anthropometry measurements were included in the analyses at 6 months.

We further assessed the robustness of our findings by conducting sensitivity analyses such as a complete cases analysis i.

As a secondary analysis, we modelled growth trajectories of infants from birth to 6 months, which continued up to 9 and 12 months on a subsample of infants. Mixed effects models with a random intercept for the individual infant and a random slope for the age of the child in months were fitted to estimate group differences on average monthly changes in LAZ, WLZ, WAZ, MUAC, and head circumference.

We explored the best model fit for our data by assessing different potential relationships of the study outcomes with time, by visual inspection of graphs and comparing model fit indices AIC and BIC.

We applied linear models WLZ and WAZ , quadratic model LAZ , and restricted cubic spline models with 6 knots MUAC and head circumference according to the model fit. Fixed effects in the model included the main effect of group, time, and group by time interaction, which the later estimates difference between groups on monthly changes in the outcomes.

All models included the clustering indicators i. We used Poisson regression models with robust variance estimation to estimate risk ratios comparing study arms by the occurrence of morbidity outcomes.

Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in S1 Supporting Information.

From a total of 2, women assessed for eligibility, 1, women were randomized into either the control or intervention arms of the pre- and postnatal interventions Figs 1 and S1. Pregnancy was not confirmed for women and 9 women refused to participate in the study.

A total of 1, newborns with birth anthropometry were identified, which were considered for the intention-to-treat analysis at 6 months. From this sample, anthropometry measurements were taken from 1, Baseline characteristics of study participants are presented in Table 1. Study arms for both the pre- and postnatal interventions were balanced with regard to maternal and household characteristics.

Mean SD age of the study women was More than half of the mothers were from food insecure households, 7. Almost all infants were exclusively breastfed with an average duration of 5.

Complementary feeding practices, however, were found to be very poor, with only 6. Overall, breastfeeding and complementary feeding practices remained comparable between the control and intervention arms for both the pre- and postnatal interventions.

The average compliance rate of consuming the BEP supplement was Adherence to IFA tablets during pregnancy was During the 6 weeks postpartum, adherence to IFA was Postnatal BEP supplementation during the first 6 months postpartum did not result in a significant improvement in LAZ at the age of 6 months, our primary outcome Table 2.

On the other hand, BEP supplementation during pregnancy led to a modest, statistically significant increase in LAZ at the age of 6 months 0. Similarly, prenatal BEP supplementation resulted in a 3. When assessing the trajectories in monthly LAZ from birth to 12 months Fig 2 , infants from mothers who received the postnatal BEP supplementation showed a modestly improved LAZ growth rate as compared to the control group 0.

The prenatal BEP intervention arms, however, followed parallel LAZ growth trajectories maintaining the better newborn length attained at birth.

In a cross-sectional comparison at 9 and 12 months on a subsample of infants, there was no statistically significant group difference in LAZ and stunting prevalence for both the post- and prenatal interventions S3 Table. Furthermore, we did not find evidence for effect modification by the subgroup factors on the effect of the postnatal BEP supplementation on LAZ at 6 months S8 Table.

Efficacy of the prenatal BEP supplementation on LAZ at 6 month was found to be larger among female infants, infants with nonanemic mothers, and infants born during the food plenty season S9 Table. Line graphs represent locally weighted scatterplot smoothing of observed values. Group differences were estimated using mixed-effects models with random intercepts for infant and random slopes for intervention time, with fixed effects including time, quadratic time for LAZ , intervention group, and time × group interaction adjusted for allocation to the other intervention, clustering indicators health center and randomization block , and a priori determined prognostic factors maternal height, BMI, MUAC, hemoglobin, age and gestational age at inclusion, and parity.

BEP, balanced energy—protein supplement; BMI, body mass index; CI, confidence interval; ES, regression coefficient; IFA, iron—folic acid; LAZ, length-for-age Z-score; MUAC, mid-upper arm circumference; WLZ, weight-for-length Z-score.

There was no significant effects of the postnatal BEP intervention on the secondary outcomes at 6 months of age, such as WLZ, WAZ, MUAC, head circumference, hemoglobin concentration, and the prevalence rates of wasting, underweight, and anemia Table 2. Moreover, there were no significant difference between the postnatal intervention and control arms with regard to the number of months infants were exclusively breastfed and the incidence rate of wasting during the 6 months postpartum follow-up.

Growth trajectories of WLZ, WAZ, MUAC, and head circumference were also did not differ significantly between the postnatal intervention and control arms Figs 2 — 4. The occurrence of common childhood morbidities i. Group differences were estimated using mixed-effects models with random intercepts for infant and random slopes for intervention time, with fixed effects including time for WAZ , time spline variables with 6 knots for MUAC , intervention group, and time × group interaction adjusted for allocation to the other intervention, clustering indicators health center and randomization block , and a priori determined prognostic factors maternal height, BMI, MUAC, hemoglobin, age and gestational age at inclusion, and parity.

For the spline model of MUAC, group difference was tested by likelihood ratio test comparing a model with and without time × group interaction terms. BEP, balanced energy—protein supplement; BMI, body mass index; CI, confidence interval; ES, regression coefficient; IFA, iron—folic acid; MUAC, mid-upper arm circumference; WAZ, weight-for-age Z-score.

Group differences were estimated using mixed-effects models with random intercepts for infant and random slopes for intervention time, with fixed effects including time spline variables with 6 knots, intervention group, and time × group interaction terms adjusted for allocation to the other intervention, clustering indicators health center and randomization block , and a priori determined prognostic factors maternal height, BMI, MUAC, hemoglobin, age and gestational age at inclusion, and parity.

Group difference was tested by likelihood ratio test comparing a model with and without time × group interaction terms. BEP, balanced energy—protein supplement; BMI, body mass index; IFA, iron—folic acid; MUAC, mid-upper arm circumference.

Finally, our main findings following the intention-to-treat approach were confirmed by both complete cases and per protocol analyses S4 — S7 Tables. The per-protocol analysis did not show stronger effects on study outcomes compared to the main analysis. The MISAME-III trial indicates that modest increments in size at birth, attained from prenatal fortified BEP supplementation, are sustained at 6 months of age in terms of improved linear growth and lower prevalence of stunting.

However, maternal BEP supplementation during the first 6 months postpartum did not result in a significant effect on infant linear growth at the age of 6 months. Nevertheless, we do find an indication for a lagged benefit of postnatal BEP supplementation, as shown by improved monthly growth trajectories, though this was not confirmed by the cross-sectional analysis of the effect at the age of 12 months in a subsample of infants.

Moreover, direct comparisons between our findings on infant growth and those from other LNS trials are difficult, due to heterogeneity in terms of the type and composition of supplements, period and duration of supplementation, and the comparator used as a control group.

The most similar RCT, in terms of the type of supplement and study setting, is the MISAME-II trial [ 37 ]. In that study, prenatal large-quantity LNS supplementation led to inferior infant growth i.

However, MISAME-II did not include a postnatal supplementation phase and used a more active comparator MMN tablet, rather than IFA as a control group. It was hypothesized that a mismatch between better nutritional environment in utero, due to prenatal LNS supplementation, followed by a poorer postnatal nutritional environment might explain the result.

Our four-arm analysis also showed a complementary role of the prenatal and early postnatal maternal BEP in preventing growth retardation during the fetal and infant periods.

Especially growth trajectories in the combined pre- and postnatal BEP group suggest the complementary effect of the postnatal BEP in preventing a diminishing effect of the prenatal BEP observed towards late infancy, supporting this hypothesis. Furthermore, the MMN tablets used as control supplement likely had a positive and lasting impact on linear growth, masking any effects of the large-quantity LNS [ 40 ].

Similarly, a cluster RCT in Niger, which compared prenatal medium-quantity LNS and MMN against IFA, also indicated that prenatal LNS had, with the exception of a small effect on MUAC, no effect on child growth at the age of 24 months effect on LAZ: 0.

The findings from these and other RCTs suggest that, in the context of low- and middle-income countries LMICs , prenatal supplementation alone may not be sufficient to prevent an important portion of child growth faltering [ 41 ].

Our analysis indicates that LAZ and stunting prevalence at 6 months of age were affected by the prenatal, but not by the postnatal BEP supplementation. Furthermore, there was a modest difference in LAZ growth trajectories between postnatal study arms primarily in late infancy, which, however, did not lead to a significant effect on LAZ at 12 months of age.

Other trials evaluated the impact of combined prenatal and postnatal supplementation together with child supplementation. In Ghana [ 18 ] and Bangladesh [ 19 ], small-quantity LNS provided to women during pregnancy and for 6 months thereafter, followed by supplementation with the same dose of small quantity LNS of their children between the ages of 6 to 24 months was shown to promote child growth at 18 and 24 months, respectively.

In contrast, a comparable RCT in Malawi failed to improve child growth by the age of 18 months [ 20 ]. Furthermore, the first MISAME trial, also conducted in Houndé, Burkina Faso, showed that MMN supplementation during pregnancy and lactation improved infant growth at 12 months, as compared to IFA tablets 0.

The comparable effect sizes on LAZ between MISAME-I and III despite the different intervention supplements MMN versus fortified BEP used might suggest the micronutrients compartment in the fortified BEP could be driving the observed improvements in linear growth.

The improvements in growth by the postnatal BEP can be understood from the timing of growth faltering during early life. Observational studies have identified the important contributors and the most sensitive periods of growth faltering in LMICs [ 6 , 42 — 44 ].

Victora and colleagues [ 6 ] showed that growth faltering starts in utero and accumulates rapidly until 24 months of age, with the relatively more sensitive periods being fetal growth retardation and growth failure during infancy starting from around 3 months of age.

The growth patterns of infants in MISAME-III demonstrate the phenomenon of intrauterine growth restriction, whereas postnatal growth faltering seems to start relatively late after 6 months compared to most other settings.

The late initiation of growth faltering during infancy might be due to various factors, such as high coverage of EBF as a result of the monthly counselling offered by study midwives, which might have helped in providing the infant with optimal energy and nutrient intakes until 6 months of age and also limiting potential risks of gastrointestinal infections and inflammation arising from early introduction of unhygienic foods [ 45 , 46 ].

Consequently, the benefit of the postnatal BEP supplementation might only have become apparent after 6 months with the introduction of nutritionally suboptimal complementary foods.

The lack of strong effect on LAZ at 12 months is likely due to the fact that the intervention period was only limited to the first 6 months postpartum and BEP supplementation consequently not spanning the more vulnerable period for linear growth faltering in the second half of infancy.

Hence, findings from MISAME-III suggest that prenatal and early postnatal LNS supplementation alone is insufficient to have long-term impact on child growth faltering. In addition to the lack of BEP effect on anemia prevalence, it was unexpected that two-third of infants at 6 months were anemic.

This is despite the fact that mothers in the control and intervention groups received iron and folic acid in the BEP and IFA tablets during pregnancy and lactation. Moreover, we have previously showed that the prenatal BEP and IFA tablets did not have a preventive effect on the 10 pp increase in maternal anemia observed during pregnancy [ 47 ].

Meta-analysis of previous studies also concluded that IFA and MMN were more efficacious at reducing maternal anemia when compared to LNS [ 41 ]. The high prevalence of maternal and infant anemia in the presence of maternal BEP and IFA supplementations suggest the need for more in-depth study on the etiologies of anemia and possible dietary factors that might affect nutrient bioavailability in the target population.

We did not find any important effect of the pre- or postnatal BEP on the risk of common childhood morbidities. These findings are consistent with results of most previous LNS trials [ 16 , 20 , 48 , 49 ]. Only in a few studies selected effects were reported when LNS supplementation was provided to older infants and children [ 50 ] and children with increased risk of acute malnutrition [ 51 ].

Our subgroup analysis did not show a differential effect of BEP on infant growth by maternal nutritional status using baseline maternal BMI and MUAC measurements. This might be due to the fact that BMI and MUAC measurements mainly reflect calorie intake and are not sensitive to show maternal status of micronutrients including breastmilk nutrient composition and the probably associated infant linear growth and nutritional status.

The plasticity of breastmilk composition in the face of maternal undernutrition or nutritional supplementation is as yet not well established [ 10 , 52 , 53 ].

Hence, future MISAME-III substudies aim to assess the effect of BEP supplements on metabolomic profiles e. Moreover, more granular effects of prenatal and postnatal BEP supplementation will be evaluated through body composition analyses of mother—infant dyads e.

The current study has several strengths that ensure the reliability of the findings. Supplements compliance was closely verified by a community-based network of village workers that home visited the study participants multiple times per week resulting in high adherence to the study supplements.

In addition, supplements were taken under observation of these village workers, which limited the risk of sharing with other household members.

The high acceptability of the BEP supplement was achieved by implementing a rigorous two-phase formative study [ 32 , 33 ]. Furthermore, dietary intake assessments confirmed that micronutrients requirements were covered by consuming the large-quantity BEP supplement in combination with the maternal basal diet [ 30 ].

Moreover, this survey also ruled out any substitution effects of BEP supplement for foods in the usual diet, which might have limited the efficacy of the intervention. Furthermore, breastfeeding and complementary feeding practices were also found to be balanced between intervention arms.

The individually randomized 2 × 2 factorial design applied in MISAME-III enabled us to disentangle and separate the efficacy of BEP supplementation during pregnancy and lactation. Lastly, our results following the intention-to-treat principle were robust to both complete cases and per-protocol analyses.

Key limitations of MISAME-III are the nonblinded administration of BEP and IFA supplements and the lack of information on other prognostic factors of infant growth e. In addition, our trial did not collect data on acute or chronic infection in the child, which could have limited the potential benefits on postnatal LAZ.

Furthermore, we are unable to assess the efficacy of BEP supplementation on improved child development outcomes [ 54 ]. Besides, the MISAME-III study was unable to assess the potential effect of LNS supplementation across the entire window of opportunity i.

Finally, the close study follow-up through daily home visits and other components of the RCT calls for a careful interpretation of the potential of the current intervention under program settings including cost-effectiveness of the study supplements.

In conclusion, MISAME-III provides evidence that linear growth benefits from prenatal BEP supplementation at birth are sustained during early infancy.

The maternal BEP supplementation during lactation may also lead to a delayed positive effect on infant linear growth. These findings suggest that BEP supplementation during pregnancy can contribute to the efforts to reduce the high burden of child growth faltering in LMICs.

Group differences were estimated using mixed-effects models with random intercepts for infant and random slopes for intervention time, with fixed effects including time, quadratic time, intervention group, and time × group interaction adjusted for clustering indicators health center and randomization block , and a priori determined prognostic factors maternal height, BMI, MUAC, hemoglobin, age and gestational age at inclusion, and parity.

Compared to the control group, effect sizes in the prenatal only supplementation group ES: 0. BEP, balanced energy—protein supplement; BMI, body mass index; CI, confidence interval; ES, effect size regression coefficient ; IFA, iron—folic acid; LAZ, length-for-age Z-score; MUAC, mid-upper arm circumference; SD, standard deviation.

The authors thank all the women from Boni, Dohoun, Karaba, Dougoumato II, Koumbia, and Kari who participated in the study, the data collection team, and Henri Somé from AFRICSanté.

We thank Nutriset France for donating the BEP supplements. Article Authors Metrics Comments Media Coverage Reader Comments Figures.

Correction 17 Jul Argaw A, de Kok B, Toe LC, Hanley-Cook G, Dailey-Chwalibóg T, et al. Abstract Background Optimal nutrition is crucial during the critical period of the first 1, days from conception to 2 years after birth.

Methods and findings A 2 × 2 factorial individually randomized controlled trial MISAME-III was implemented in 6 health center catchment areas in Houndé district under the Hauts-Bassins region.

Conclusions This study provides evidence that the benefits obtained from prenatal BEP supplementation on size at birth are sustained during infancy in terms of linear growth. Trial registration ClinicalTrials. gov: NCT Author summary Why was this study done?

Growth faltering during the first 1, days is a global public health problem, which is strongly associated with an increased risk of child mortality and poor developmental outcomes, as well as poor school performance and lower earning in later life.

Prenatal and postnatal supplementation of mothers with multiple micronutrient-fortified balanced energy—protein BEP supplements is a potential nutritional intervention to prevent the high burden of growth retardation during this window of opportunity in low- and middle-income countries.

However, the effect of providing pregnant and lactating women with BEP supplements on child growth is inconsistent to date.

Hence, there is a critical need for high-quality experimental studies to assess the efficacy of BEP supplements on fetal and infant growth outcomes. What did the researchers do and find? We conducted an individually randomised controlled efficacy trial in rural Burkina Faso MISAME-III to assess the effect of supplementing mothers with fortified BEP during pregnancy and lactation on the growth of their infants.

Our trial indicates that the improvements in size at birth accrued from prenatal BEP supplementation are sustained in terms of linear growth at the age of 6 months.

In addition, we provide evidence that maternal BEP supplementation for 6 months postpartum might lead to a slightly better linear growth towards the second half of infancy.

What do these findings mean? Our findings suggest that the benefits of BEP supplementation on linear growth might be fully exploited by extending the intervention to cover the first 1, days of life, which includes supplementation of infants and young children during the complementary feeding period.

Future research in MISAME-III will assess additional maternal and child biochemical parameters to provide further insights into the clinical relevance of BEP supplementation, including the potential impacts on breast milk composition.

Introduction According to the global burden of malnutrition estimates, Methods Our research was reported using the Consolidated Standards of Reporting Trials CONSORT checklist [ 26 ]. Study setting and design The MISAME-III study protocol has been described elsewhere in detail [ 27 ].

Randomization A stratified permuted block randomization schedule was used to assign women to either the intervention or control arms of the pre- and postnatal interventions. Intervention and procedures The composition and daily dose of the pre- and postnatal BEP intervention supplements were identical; only the duration of supplementation differed.

Inclusivity in global research Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in S1 Supporting Information. Results Subject characteristics and study follow-up From a total of 2, women assessed for eligibility, 1, women were randomized into either the control or intervention arms of the pre- and postnatal interventions Figs 1 and S1.

Download: PPT. Fig 1. Trial flowchart of the MISAME-III study by the postnatal intervention arms. Table 1. Baseline characteristics of study participants by post- and prenatal intervention arms 1. Linear growth: Length-for-age z-score and stunting Postnatal BEP supplementation during the first 6 months postpartum did not result in a significant improvement in LAZ at the age of 6 months, our primary outcome Table 2.

Fig 2. Table 2. Effect of maternal postnatal BEP supplementation on infant growth and nutritional status at 6 months 1. Table 3.

Effect of balanced protein energy supplementation during pregnancy on birth outcomes

The prevalence of pregnant women that suffered from a HIV infection was estimated to be 0. We randomly allocated women to the prenatal control or intervention group. A stratified permuted block randomization schedule was used to allocate women to the study groups. These blocks were generated per health center in blocks of 8 4 control and 4 intervention before the start of the study using Stata V.

The allocation was coded with the letters A for the prenatal control and B for the prenatal intervention group and concealed in sequentially numbered sealed opaque envelopes by study employees, not in direct contact with participants.

The study midwives, who enrolled the participants, assigned the women to the study groups by drawing a next sealed envelope with the letter code. It was not possible to blind the supplement allocation from study participants and trained village-based project workers because the products are readily identifiable.

Outcome assessors study physician, midwives, and field supervisors were different from study collaborators trained village-based project workers who distributed the study supplements. However, given the nonblinded nature of the study, outcome assessors could have been aware of the study group allocation by asking the mother.

Researchers who analyzed the data were not blinded. Women in the intervention group received a daily BEP supplement and IFA tablet for the duration of their pregnancy.

In a formative study, the most preferred and suitable fortified BEP supplement was selected for administration in the MISAME-III efficacy trial [ 21 , 22 ]. The BEP supplement is an LNS in the form of an energy-dense peanut paste fortified with MMNs. The product is ready to consume, does not require a cold chain, and is highly stable with a long shelf life.

Furthermore, the MMN content covered at least the daily estimated average requirements of micronutrients for pregnant women, except for calcium, phosphorous, and magnesium, which were lower [ 23 ]. The complete nutritional composition of the fortified BEP is provided in Table 1 [ 24 ].

Women in the control group received daily only an IFA tablet 65 mg iron [form: FeH 2 O 5 S] and μg folic acid [form: C 19 H 19 N 7 O 6 ]; Sidhaant Life Sciences, Delhi, India , in accordance with the standard of care in Burkina Faso. Both supplements were delivered on a daily basis and, to the extent possible, consumed under supervision by our trained village-based project workers during home visits.

When women had a short and scheduled absence of home, supplements were given to the women in advance, and intake was considered nonobserved for the respective days. The trained village-based project workers also encouraged pregnant women to attend at least 4 ANC consultations. Study participants were designated as lost to follow-up if they moved from the study area, withdrew their participation, or if they could not be reached for more than 3 months.

At enrollment i. Maternal MUAC was measured to the nearest 1 mm with a Seca measuring tape. Hb concentration was assessed again between 30 and 34 weeks of gestation i. Furthermore, a comprehensive socioeconomic and demographic questionnaire was administered at enrollment [ 18 ].

During each subsequent ANC visit, the study midwives measured all anthropometrics and screened for potential adverse events by checking blood pressure, urine protein, body temperature, edema, and fetal activity.

Following Burkinabè guidelines, enrolled women received preventative malaria prophylaxis 3 oral doses of sulfadoxine—pyrimethamine at the relevant ANC visits.

GA was estimated by measuring crown-rump length 7 to 13 weeks or by calculating the mean of 3 to 4 measurements: biparietal diameter, head circumference, abdominal circumference, and femur length 12 to 26 weeks [ 25 ].

In addition to the ultrasound, the physician performed maternal subscapular and tricipital skinfold measurements in triplicate using a Harpenden caliper.

At birth, anthropometry of all neonates was assessed in duplicate within the first 72 hours by study midwives in practice, all were within 12 hours at the health center.

Newborn length was measured to the nearest 1 mm with a Seca Infantometer, whereas birth weight was measured to the nearest 10 g with a Seca scale. Newborn head circumference, thoracic circumference, and MUAC were measured to the nearest 1 mm with a Seca measuring tape.

If there was a large discrepancy between measures e. The average of the 2 closest measures were used for analyses. The accuracy and precision of anthropometric measurements were established regularly through standardization sessions organized by an expert in anthropometry [ 26 ].

MISAME-III data were collected using SurveySolutions version Questionnaire assignments were sent to the field team once a week including preloaded data collected at the previous ANC visit. We programmed generic validation codes to avoid the entry of implausible values and improve the quality of data collection in the field.

Additionally, data quality checks and missing or inconsistent data were sent back to the field for revision every 2 weeks. The MISAME-III trained village-based project workers collected data on the supplement adherence in both prenatal study groups using smartphones with computer-assisted person interviewing programmed in CSPro version 7.

All field staff received extensive training on all standard operating procedures including Good Clinical Practices and data collection tools before the start of the trial, with a dry run period of ±3 months for testing and evaluation in the field.

The MISAME-III data collection forms are publicly available [ 28 ]. To assess safety and serious adverse events SAEs , all field staff was trained to recognize pregnancy related health issues to actively refer participants to the health center.

All SAEs i. All analyses were documented in the MISAME-III statistical analysis plan prior to analysis, which was validated on October 24, and published online on November 3, [ 28 ].

Hence, the sample size was increased to pregnant women per prenatal study group to accommodate for these potential losses total 1, participants. Only singleton pregnancies were included in the analysis, as anthropometric measures and fetal loss at birth in multifetal pregnancies are often not primarily nutrition related.

The primary analysis followed the intention-to-treat ITT principle. A total of 50 imputations of missing values were done for the lost to follow-up cases to estimate the regression coefficients using the predictors maternal height, BMI, MUAC, Hb, age, GA and primiparity at baseline, and month of inclusion.

Descriptive data are presented as percentages or means ± standard deviation SD. Unadjusted and adjusted group differences were estimated by fitting linear regression models for continuous outcomes to estimate the mean group difference.

For binary outcomes, linear probability models with a robust variance estimator were used to estimate risk difference in pp. All models contained health center and randomization block as fixed effect to account for any possible clustering by the study design.

Due to balanced baseline characteristics across prenatal study groups i. We conducted the following sensitivity analyses to assess the robustness of the primary findings: i complete case analysis i. The strict adherence rate was calculated by dividing the total number of BEP supplements effectively taken under direct observation of a trained village-based project worker by the theoretical maximum number of prenatal BEP supplements, i.

In this method, differences and CIs in birth outcomes between intervention and control groups are estimated as nonlinear smooth functions of the percentiles of birth weight, birth length, or maternal BMI distributions. All analyses were conducted with Stata All SAEs reported by the study physician were evaluated on a continuous basis by the principal study investigators and reported to an independent Data and Safety Monitoring Board DSMB when considered related to the supplement.

The DSMB established prior to the start of the efficacy trial comprised an endocrinologist, 2 pediatricians, a gynecologist, and a medical ethicist of both Belgian and Burkinabè nationalities. Two virtual DSMB meetings were organized, at month 9 and 20 after the start of the trial, to review the study progress and discuss all documented SAEs.

The MISAME-III trial was registered on ClinicalTrials. gov identifier: NCT From October 30, to December 12, , 2, women were assessed for eligibility, of whom 1, were randomized control and intervention.

Nine women refused to continue participation after randomization and were excluded. Subsequently, women were excluded postrandomization, because pregnancy was not confirmed during the ultrasound examination.

This resulted in a slight imbalance in the number of women allocated to the control and intervention groups, i. The baseline characteristics of mothers included in the study control and intervention are presented in Table 2.

The control and intervention groups were well balanced regarding household, maternal, and pregnancy characteristics i. At baseline, BEP, balanced energy—protein; CONSORT, Consolidated Standards of Reporting Trials; GA, gestational age; IFA, iron—folic acid.

Of the 1, women who were enrolled at baseline and met the inclusion criteria, 22 2. No maternal deaths occurred in either the control or intervention group. The observed supplement adherence rate was There was no significant difference between the study groups in the prevalence of LGA 0.

Daily BEP and IFA supplementation had a stronger positive effect on birth weight and length at lower percentiles of the birth weight and length distributions, respectively Figs 2 and 3. We did not find evidence that the treatment effect on birth weight or length was modified by maternal BMI at baseline S1 and S2 Figs.

The estimated difference in birth weight between the women who received the BEP supplement and IFA intervention and those who received only iron and folic acid control is shown as a function of the percentiles of birth weights.

The zero line indicates no efficacy of BEP. The positive y values indicate a higher birth weight in the intervention group, and the negative y values indicate a lower birth weight. BEP, balanced energy—protein; IFA, iron—folic acid. The estimated difference in birth length between the women who received the BEP supplement and IFA intervention and those who received only iron and folic acid control is shown as a function of the percentiles of birth lengths.

The positive y values indicate a higher birth length in the intervention group, and the negative y values indicate a lower birth length. The MISAME-III trial did not provide evidence that prenatal fortified BEP supplementation was efficacious in reducing SGA prevalence.

However, the intervention led to improvements in gestational length, birth weight, birth length, thoracic and arm circumference, and decreased LBW prevalence. This study was primarily designed to reduce the prevalence of SGA. However, the supplements studied varied tremendously in terms of energy to 1, kcal , protein 7 to 40 g , and micronutrient composition.

In addition, various comparison groups and timing of supplementation were applied [ 33 ]. A direct comparison between results from these trials and our findings is therefore difficult. The previous MISAME-II trial, conducted in the same health district, can be considered the most comparable as a similar LNS type supplement was used [ 15 ].

Huybregts and colleagues reported no meaningful effect on SGA, neither on PTB nor a list of anthropometric measures at birth. An important difference to take into account for comparison of the results is the use of MMN MISAME-II versus IFA tablets MISAME-III in the control group.

Similarly, compared to IFA, prenatal LNS in The Gambia was not associated with SGA, birth weight, length, or head circumference [ 34 ]. This effect on birth weight and the 1 to 40 mm effect in birth length observed by our study can, at least partially, be attributed to the concurrent 0. Also, we speculate that the modest improvements in birth anthropometry is the result of the MMN compartment of the supplement, as previous research has shown that MMN led to an increase in birth weight resulting in lower proportion of LBW and SGA births [ 16 ].

Our data suggest that there was no risk in providing BEP to women that were not underweight at early gestation. The BEP did not impact the prevalence of LGA and no increase in C-sections was observed.

Subgroup analyses revealed that the intervention was efficacious in reducing SGA prevalence among mothers with a more adequate baseline nutritional status e. These results are in contrast with previous findings showing that nutritional supplementation had larger treatment effects among inadequately nourished pregnant women at early gestation, including underweight mothers [ 15 ], women with negative energy balance [ 38 ], food insecure households [ 36 ], and primiparous mothers [ 35 ].

Furthermore, our subgroup analysis showed that the impact was more profound among female newborns, while other studies found a larger effect of nutritional supplementation in males [ 39 , 40 ]. Some explanations for the lack of strong efficacy of fortified BEP as compared to IFA can be put forward.

First, frequent acute and chronic infections during pregnancy, which are often prevalent in LMICs [ 41 ], can lead to nutrient losses and nutrient sequestration in the mother, which, in turn, may have limited the quantity of nutrients available to the fetus.

Our trial did not collect data on maternal infection during gestation, but if prevalent in this setting, acute or chronic infection may have reduced the efficacy of the BEP supplements provided. Likewise, acute or chronic infection in the child could have limited the potential benefits from the nutrients received by the fetus during pregnancy.

Second, starting fortified BEP supplementation during early pregnancy alone might not be sufficient to prevent adverse birth outcomes.

Our subgroup analyses indicated that the BEP intervention was potentially more efficacious among women who started pregnancy with a better nutritional status; hence, preconception supplementation may confer greater benefits on birth outcomes.

Although the Women First trial found that providing LNS and BEP at least 3 months prior to conception did not yield additional benefits on child linear growth at birth relative to starting BEP supplementation during gestation [ 12 ], compelling evidence remains scarce and supplementation during the preconception period may warrant further exploration.

A major strength of our study was the high acceptability of the fortified BEP supplement, evaluated in a 2-phase formative study [ 21 , 22 ], and strong emphasis on daily observed intake. Moreover, the daily observed supplementation reduced the possible risk of sharing the supplement with other household members and supported micronutrient adequacy following existing requirements.

A cross-sectional dietary intake assessment showed that BEP did not displace energy and nutrient intake from the usual diet [ 42 ]. Hence, we can almost rule out a substitution effect that could have limited the efficacy of the BEP to support fetal growth and reduce SGA. Another strength was the early enrollment of participants, as a result of a monthly visiting schedule at home by trained village-based project workers, who received refresher trainings and close supervision by the MISAME-III field team.

Finally, in almost all cases, birth weight was measured almost immediately after birth. Merialdi M, Carroli G, Villar J, Abalos E, Gulmezoglu AM, Kulier R, de Onis M: Nutritional interventions during pregnancy for the prevention or treatment of impaired fetal growth: an overview of randomized controlled trials.

J Nutr. CAS PubMed Google Scholar. de Onis M, Villar J, Gulmezoglu M: Nutritional interventions to prevent intrauterine growth retardation: evidence from randomized controlled trials.

Kulier R, de Onis M, Gulmezoglu AM, Villar J: Nutritional interventions for the prevention of maternal morbidity. Int J Gynaecol Obstet. Villar J, Gulmezoglu AM, de Onis M: Nutritional and antimicrobial interventions to prevent preterm birth: an overview of randomized controlled trials.

Obstet Gynecol Surv. Kramer MS, Kakuma R: Energy and protein intake in pregnancy. Cochrane Database Syst Rev. Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, Guyatt GH, Harbour RT, Haugh MC, Henry D, et al: Grading quality of evidence and strength of recommendations.

Google Scholar. Walker N, Fischer-Walker C, Bryce J, Bahl R, Cousens S: Standards for CHERG reviews of intervention effects on child survival.

Int J Epidemiol. Article PubMed Central PubMed Google Scholar. WHO: Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee:Technical Report Series No.

WHO: Neonatal and perinatal mortality: country, regional and global estimates. Cochrane Handbook for Systematic Reviews of Interventions. Edited by: Higgins J, Green S. Version 5. org ]. RevMan: The Cochrane Colloboration. Review Manager RevMan 5 for Windows. Anderson AS, Campbell DM, Shepherd R: The influence of dietary advice on nutrient intake during pregnancy.

Br J Nutr. Briley C, Flanagan NL, Lewis N: In-home prenatal nutrition intervention increased dietary iron intakes and reduced low birthweight in low-income African-American women. J Am Diet Assoc. Hankin ME, Symonds EM: Body weight, diet and pre-eclamptic toxaemia of pregnancy.

Australian and New Zealand Journal of Obstetrics and Gynaecology. Article Google Scholar. Hunt IF, Jacob M, Ostegard NJ, Masri G, Clark VA, Coulson AH: Effect of nutrition education on the nutritional status of low-income pregnant women of Mexican descent. Am J Clin Nutr. Kafatos AG, Vlachonikolis IG, Codrington CA: Nutrition during pregnancy: the effects of an educational intervention program in Greece.

Sweeney C, Smith H, Foster JC, Place JC, Specht J, Kochenour NK, Prater BM: Effects of a nutrition intervention program during pregnancy. Maternal data phases 1 and 2. J Nurse Midwifery. Iyengar L: Effects of dietary supplements late in pregnancy on the expectant mother and her newborn.

Indian Journal of Medical Research. Mardones-Santander F, Rosso P, Stekel A, Ahumada E, Llaguno S, Pizarro F, Salinas J, Vial I, Walter T: Effect of a milk-based food supplement on maternal nutritional status and fetal growth in underweight Chilean women.

Atton C, Watney PJM: Selective supplementation in pregnancy: effect on birth weight. Journal of Human Nutrition and Dietetics. Blackwell R, Chow B, Chinn K, Blackwell B, Hsu S: Prospective maternal nutrition study in Taiwan: rationale, study design, feasibility and preliminary findings.

Nutrition Reports International. Brown CM: Protein energy supplements in primigravid women at risk of low birthweight. Nutrition in pregnancy Proceedings of the 10th Study Group of the RCOG.

Edited by: Campbell DM, Gillmer MDG. Ceesay SM, Prentice AM, Cole TJ, Foord F, Weaver LT, Poskitt EM, Whitehead RG: Effects on birth weight and perinatal mortality of maternal dietary supplements in rural Gambia: 5 year randomised controlled trial. Article PubMed Central CAS PubMed Google Scholar.

Elwood PC, Haley TJ, Hughes SJ, Sweetnam PM, Gray OP, Davies DP: Child growth years , and the effect of entitlement to a milk supplement. Arch Dis Child. Girija A, Geervani P, Rao GN: Influence of dietary supplementation during pregnancy on lactation performance.

Journal of Tropical Pediatrics. Kardjati S, Kusin JA, De With C: Energy supplementation in the last trimester of pregnancy in East Java: I. Effect on birthweight. Br J Obstet Gynaecol. Lechtig A, Habicht JP, Delgado H, Klein RE, Yarbrough C, Martorell R: Effect of food supplementation during pregnancy on birthweight.

Mora J, Navarro L, Clement J, Wagner M, De Paredes B, Herrera MG: The effect of nutritional supplementation on calorie and protein intake of pregnant women. CAS Google Scholar. Ross S, Nel E, Naeye R: Differing effects of low and high bulk maternal dietary supplements during pregnancy.

Early Human Development. Rush D, Stein Z, Susser M: A randomized controlled trial of prenatal nutritional supplementation in New York City.

Viegas OA, Scott PH, Cole TJ, Eaton P, Needham PG, Wharton BA: Dietary protein energy supplementation of pregnant Asian mothers at Sorrento, Birmingham. II: Selective during third trimester only.

Br Med J Clin Res Ed. Article CAS Google Scholar. Viegas OA, Scott PH, Cole TJ, Mansfield HN, Wharton P, Wharton BA: Dietary protein energy supplementation of pregnant Asian mothers at Sorrento, Birmingham. I: Unselective during second and third trimesters. Tontisirin K, Booranasubkajom U, Hongsumarn A, hewtong D: Formulation and evaluation of supplementary foods for Thai pregnant women.

Mora J, Navarro L, Clement J, Wagner M, De Paredes B, Herrera MG: The effect of nutritional supplementation on calorieand protein intake of pregnant women. Ramachandran P: Maternal nutrition--effect on fetal growth and outcome of pregnancy. Nutr Rev. Susser M: Prenatal nutrition, birthweight, and psychological development: an overview of experiments, quasi-experiments, and natural experiments in the past decade.

Kramer MS: Determinants of low birth weight: methodological assessment and meta-analysis. Bull World Health Organ. PubMed Central CAS PubMed Google Scholar.

Mandruzzato G, Antsaklis A, Botet F, Chervenak FA, Figueras F, Grunebaum A, Puerto B, Skupski D, Stanojevic M: Intrauterine restriction IUGR. J Perinat Med. Bakketeig LS: Current growth standards, definitions, diagnosis and classification of fetal growth retardation.

Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HP, et al: What works? Interventions for maternal and child undernutrition and survival.

Djazayery A: Regional overview of maternal and child malnutrition: trends, interventions and outcomes. East Mediterr Health J. Download references. We thank Dr Mohammad Yawar Yakoob for his critical feedback on the paper. This article has been published as part of BMC Public Health Volume 11 Supplement 3, Technical inputs, enhancements and applications of the Lives Saved Tool LiST.

You can also search for this author in PubMed Google Scholar. Correspondence to Zulfiqar A Bhutta. Professor Zulfiqar Ahmed Bhutta gave the idea of the review and secured support. Dr Aamer Imdad did the literature search, data extraction and wrote the manuscript along with Professor Bhutta.

This article is published under license to BioMed Central Ltd. Reprints and permissions. Imdad, A. Effect of balanced protein energy supplementation during pregnancy on birth outcomes.

BMC Public Health 11 Suppl 3 , S17 Download citation. Published : 13 April Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative.

Skip to main content. Search all BMC articles Search. Try any product from the Gut Connection line with confidence, with our Money Back Guarantee. If you are not completely satisfied, request a refund in 60 days. See details at www. com or call We use cookies to ensure the best experience.

By using our website you agree to our Cookie Policy. Adults take two 2 capsules daily with food. As a reminder, discuss the supplements and medications that you take with your health care providers. Skip to content. Sale Disclaimer. Want to be notified when this product is back in stock?

Balanced energy supplement Kok, Enedgy et al. Publications and datasets Balanced energy supplement Balances GARDIAN. Background: In many low- and middle-income countries, the prevalence dnergy energy and nutrient deficiencies is high among pregnant women. Balanced energy-protein BEP supplements are a promising strategy to cover nutritional requirements during pregnancy and improve birth outcomes. However, the displacement of nutrient-dense foods by BEP might attenuate the efficacy of supplementation.

Author: Shajora

5 thoughts on “Balanced energy supplement

Leave a comment

Yours email will be published. Important fields a marked *

Design by ThemesDNA.com