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Godfrey KM, Titcombe P, El-Heis S, Albert BB, Tham EH, Barton SJ, Kenealy T, Chong MFF, Nield H, Chong YS, Chan SY, Cutfield WS. Maternal B-vitamin and vitamin D status before, during, and after pregnancy and the influence of supplementation preconception and during pregnancy: Prespecified secondary analysis of the NiPPeR double-blind randomized controlled trial. PLoS Med 2023; 20:e1004260. [PMID: 38051700 PMCID: PMC10697591 DOI: 10.1371/journal.pmed.1004260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 11/01/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Maternal vitamin status preconception and during pregnancy has important consequences for pregnancy outcome and offspring development. Changes in vitamin status from preconception through early and late pregnancy and postpartum have been inferred from cross-sectional data, but longitudinal data on vitamin status from preconception throughout pregnancy and postdelivery are sparse. As such, the influence of vitamin supplementation on vitamin status during pregnancy remains uncertain. This study presents one prespecified outcome from the randomized controlled NiPPeR trial, aiming to identify longitudinal patterns of maternal vitamin status from preconception, through early and late pregnancy, to 6 months postdelivery, and determine the influence of vitamin supplementation. METHODS AND FINDINGS In the NiPPeR trial, 1,729 women (from the United Kingdom, Singapore, and New Zealand) aged 18 to 38 years and planning conception were randomized to receive a standard vitamin supplement (control; n = 859) or an enhanced vitamin supplement (intervention; n = 870) starting in preconception and continued throughout pregnancy, with blinding of participants and research staff. Supplement components common to both treatment groups included folic acid, β-carotene, iron, calcium, and iodine; components additionally included in the intervention group were riboflavin, vitamins B6, B12, and D (in amounts available in over-the-counter supplements), myo-inositol, probiotics, and zinc. The primary outcome of the study was glucose tolerance at 28 weeks' gestation, measured by oral glucose tolerance test. The secondary outcome reported in this study was the reduction in maternal micronutrient insufficiency in riboflavin, vitamin B6, vitamin B12, and vitamin D, before and during pregnancy. We measured maternal plasma concentrations of B-vitamins, vitamin D, and markers of insufficiency/deficiency (homocysteine, hydroxykynurenine-ratio, methylmalonic acid) at recruitment, 1 month after commencing intervention preconception, in early pregnancy (7 to 11 weeks' gestation) and late pregnancy (around 28 weeks' gestation), and postdelivery (6 months after supplement discontinuation). We derived standard deviation scores (SDS) to characterize longitudinal changes among participants in the control group and measured differences between the 2 groups. At recruitment, the proportion of patients with marginal or low plasma status was 29.2% for folate (<13.6 nmol/L), 7.5% and 82.0% for riboflavin (<5 nmol/L and ≤26.5 nmol/L, respectively), 9.1% for vitamin B12 (<221 pmol/L), and 48.7% for vitamin D (<50 nmol/L); these proportions were balanced between the groups. Over 90% of all participants had low or marginal status for one or more of these vitamins at recruitment. Among participants in the control group, plasma concentrations of riboflavin declined through early and late pregnancy, whereas concentrations of 25-hydroxyvitamin D were unchanged in early pregnancy, and concentrations of vitamin B6 and B12 declined throughout pregnancy, becoming >1 SDS lower than baseline by 28 weeks gestation. In the control group, 54.2% of participants developed low late-pregnancy vitamin B6 concentrations (pyridoxal 5-phosphate <20 nmol/L). After 1 month of supplementation, plasma concentrations of supplement components were substantially higher among participants in the intervention group than those in the control group: riboflavin by 0.77 SDS (95% CI 0.68 to 0.87, p < 0.0001), vitamin B6 by 1.07 SDS (0.99 to 1.14, p < 0.0001), vitamin B12 by 0.55 SDS (0.46 to 0.64, p < 0.0001), and vitamin D by 0.51 SDS (0.43 to 0.60, p < 0.0001), with higher levels in the intervention group maintained during pregnancy. Markers of vitamin insufficiency/deficiency were reduced in the intervention group, and the proportion of participants with vitamin D insufficiency (<50 nmol/L) during late pregnancy was lower in the intervention group (35.1% versus 8.5%; p < 0.0001). Plasma vitamin B12 remained higher in the intervention group than in the control group 6 months postdelivery (by 0.30 SDS (0.14, 0.46), p = 0.0003). The main limitation is that generalizability to the global population is limited by the high-resource settings and the lack of African and Amerindian women in particular. CONCLUSIONS Over 90% of the trial participants had marginal or low concentrations of one or more of folate, riboflavin, vitamin B12, or vitamin D during preconception, and many developed markers of vitamin B6 deficiency in late pregnancy. Preconception/pregnancy supplementation in amounts available in over-the-counter supplements substantially reduces the prevalence of vitamin deficiency and depletion markers before and during pregnancy, with higher maternal plasma vitamin B12 maintained during the recommended lactational period. TRIAL REGISTRATION ClinicalTrials.gov NCT02509988; U1111-1171-8056.
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Affiliation(s)
- Keith M. Godfrey
- MRC Lifecourse Epidemiology Centre, University of Southampton, University Hospital Southampton, Southampton, United Kingdom
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton, NHS Foundation Trust, Southampton, United Kingdom
| | - Philip Titcombe
- MRC Lifecourse Epidemiology Centre, University of Southampton, University Hospital Southampton, Southampton, United Kingdom
| | - Sarah El-Heis
- MRC Lifecourse Epidemiology Centre, University of Southampton, University Hospital Southampton, Southampton, United Kingdom
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton, NHS Foundation Trust, Southampton, United Kingdom
| | | | - Elizabeth Huiwen Tham
- Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore
| | - Sheila J. Barton
- MRC Lifecourse Epidemiology Centre, University of Southampton, University Hospital Southampton, Southampton, United Kingdom
| | - Timothy Kenealy
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Mary Foong-Fong Chong
- Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Heidi Nield
- MRC Lifecourse Epidemiology Centre, University of Southampton, University Hospital Southampton, Southampton, United Kingdom
| | - Yap Seng Chong
- Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore
| | - Shiao-Yng Chan
- Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore
| | - Wayne S. Cutfield
- Liggins Institute, University of Auckland, Auckland, New Zealand
- A Better Start, New Zealand National Science Challenge, Auckland, New Zealand
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Ku CW, Cheng TS, Ku CO, Zhou KX, Cheung YB, Godfrey KM, Han WM, Yap F, Chan JKY, Loy SL. Distribution and association of interpregnancy weight change with subsequent pregnancy outcomes in Asian women. Sci Rep 2023; 13:4834. [PMID: 36964283 PMCID: PMC10039003 DOI: 10.1038/s41598-023-31954-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 03/20/2023] [Indexed: 03/26/2023] Open
Abstract
The extent of interpregnancy weight change and its association with subsequent pregnancy outcomes among Asians remain unclear. We examined changes in maternal body mass index (BMI) between the first two deliveries and outcomes in the second delivery. Medical records of women with their first two consecutive deliveries between 2015 and 2020 at KK Women's and Children's Hospital, Singapore were retrieved. Gestational-age-adjusted BMI was determined by standardising to 12 weeks gestation and interpregnancy BMI change was calculated as the difference between both pregnancies. Pregnancy outcomes were analysed using modified Poisson regression models. Of 6264 included women with a median interpregnancy interval of 1.44 years, 40.7% had a stable BMI change within ± 1 kg/m2, 10.3% lost > 1 kg/m2, 34.3% gained 1-3 kg/m2 and 14.8% gained ≥ 3 kg/m2. Compared to women with stable BMI change, those with > 1 kg/m2 loss had higher risk of low birthweight (adjusted risk ratio [RR] 1.36; 95% confidence interval 1.02-1.80), while those with 1-3 kg/m2 gain had higher risks of large-for-gestational-age birth (1.16; 1.03-1.31), gestational diabetes (1.25; 1.06-1.49) and emergency Caesarean delivery (1.16; 1.03-1.31); these risks were higher in those with ≥ 3 kg/m2 gain. Our study strengthens the case for interpregnancy weight management to improve subsequent pregnancy outcomes.
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Affiliation(s)
- Chee Wai Ku
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore, 229899, Singapore
- Duke-NUS Medical School, Singapore, 169857, Singapore
| | - Tuck Seng Cheng
- MRC Epidemiology Unit, Institute of Metabolic Science, University of Cambridge, Cambridge Biomedical Campus Box 285, Cambridge, CB2 0QQ, UK
| | - Chee Onn Ku
- Faculty of Science, National University of Singapore, Singapore, 119077, Singapore
| | - Kathy Xinzhuo Zhou
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, 636921, Singapore
| | - Yin Bun Cheung
- Program in Health Services and Systems Research and Center for Quantitative Medicine, Duke-NUS Medical School, Singapore, 169857, Singapore
- Tampere Center for Child, Adolescent and Maternal Health Research, Tampere University, 33014, Tampere, Finland
| | - Keith M Godfrey
- Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton, SO16 6YD, UK
- National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton National Health Service Foundation Trust, Southampton, SO16 6YD, UK
| | - Wee Meng Han
- Department of Dietetics, KK Women's and Children's Hospital, Singapore, 229899, Singapore
| | - Fabian Yap
- Duke-NUS Medical School, Singapore, 169857, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, 636921, Singapore
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore, 229899, Singapore
| | - Jerry Kok Yen Chan
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore, 229899, Singapore
- Duke-NUS Medical School, Singapore, 169857, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119077, Singapore
| | - See Ling Loy
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore, 229899, Singapore.
- Duke-NUS Medical School, Singapore, 169857, Singapore.
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Chan JKY, Ku CW, Loy SL, Godfrey KM, Fan Y, Chua MC, Yap F. Effects of an integrated mobile health lifestyle intervention among overweight and obese women planning for pregnancy in Singapore: protocol for the single-arm healthy early life moments in Singapore (HELMS) study. BMJ Open 2022; 12:e061556. [PMID: 36523242 PMCID: PMC9748919 DOI: 10.1136/bmjopen-2022-061556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Changes in social and lifestyle factors have led to increasing rates of metabolic and mental health problems. We hypothesise that a transformation of the current maternal and child health system is required to deliver interventions that effectively promote a good start to life in populations at risk of metabolic and mental health problems. We describe a single-arm implementation study 'Healthy Early Life Moments in Singapore', which aims to examine whether an integrated lifestyle intervention initiated at preconception and continuing throughout pregnancy and postpartum periods can improve the metabolic and mental health of overweight and obese women, and improve early child growth. METHODS AND ANALYSIS This single-centre implementation trial is conducted at KK Women's and Children's Hospital, Singapore. The trial aims to recruit 500 women, aged 21-40 years with a body mass index of 25-40 kg/m2 who plan to get pregnant, with interventions delivered before conception, until 18 months postdelivery. Primary outcomes comprise pregnancy rate, maternal metabolic and mental health status. Secondary outcomes include maternal reproductive health, pregnancy outcomes and offspring growth. The intervention will be delivered using a mobile health application, to provide anticipatory guidance, raise awareness and guide goal-setting on lifestyle behaviours that include diet, physical activity, mental wellness and sleep hygiene from preconception to postpartum. Women who conceive within 1 year of recruitment will be followed through pregnancy and studied with their infants at six-time points during the first 18 months of life. Questionnaires, anthropometric measurements and multiple biosamples will be collected at each visit. ETHICS AND DISSEMINATION The study has been approved by the Centralised Institutional Review Board of SingHealth (2021/2247). Written informed consent will be obtained from all participants. The findings will be published in peer-reviewed journals and disseminated to national and international policy makers. TRIAL REGISTRATION NUMBER NCT05207059.
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Affiliation(s)
- Jerry Kok Yen Chan
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
- NUS Yong Loo Lin School of Medicine, Singapore
| | - Chee Wai Ku
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - See Ling Loy
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Keith M Godfrey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton, Southampton, UK
| | - Yiping Fan
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
| | - Mei Chien Chua
- Duke-NUS Medical School, Singapore
- Department of Neonatology, KK Women's and Children's Hospital, Singapore
| | - Fabian Yap
- Duke-NUS Medical School, Singapore
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore
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