Indigenous Nutritional Supplements for Pregnancy to Improve Resilience in Environmental Heat

Overview

The purpose of this study is to learn whether a simple, traditional, and balanced meal made from local foods, eaten once a day during pregnancy, can help women in rural Pakistan stay healthier in hot weather and give birth to healthier babies. Climate change has made heat a serious challenge for pregnant women, especially in areas with limited resources. This study will explore whether an indigenous meal that is culturally acceptable and easy to prepare can improve resilience to heat stress and support better outcomes for both mothers and newborns. The study will focus on two main questions: * Can this daily balanced meal reduce the harmful effects of heat stress during pregnancy? * Does it improve newborn health, especially birth weight? Researchers will compare women who eat the balanced local meal every day with women who continue their usual meals. They will check changes in women's health, levels of key vitamins and nutrients, and their babies' birth outcomes. During the study, participants will: * Either eat the balanced local meal daily or continue their usual meals. * Share information on their health, diet, and heat exposure. * Provide small samples, such as blood and stool, to study nutrient levels and gut health. * Have their newborns' health and growth measured at birth.

Detailed description

This study will use a quasi-experimental design to study if the effects of an indigenous heat-mitigating balanced dietary intervention on maternal health and neonatal development when implemented from preconception to delivery in a region with high temperatures.

The study will recruit 292 women of reproductive age who plan to become pregnant and assign them to either the intervention group or the comparison group in a 1:1 ratio. The intervention group will receive one customized indigenous heat-mitigating balanced diet as daily lunch meal (\~1,000 kilocalories). The comparison group will continue their usual dietary practices while receive routine antenatal care and dietary counseling services according to national guidelines.

The intervention diet plans have been designed through review of dietary recommendations and published evidence, combined with community consultations to ensure feasibility and cultural acceptability. The food choices were established according to three criteria which required foods to have high nutrient content and be affordable and accessible within the local area. The meal composition includes whole grains, lentils, legumes, green leafy vegetables, dairy products, fermented foods, fish, and other culturally acceptable animal-source foods. A 14-day rotating menu will be implemented. The intervention will begin at least one month prior to conception and continue until delivery.

Meals will be prepared in kitchen in field site's office set up specially for meals preparation. Local chefs will be hired and counselled to prepare meals ensuring proper hygiene and following study's diet plans. Study data collectors will distribute meals to the participants. The team will use attendance records, intervention adherence forms, telephone follow-up and home visits to monitor intervention delivery. The team will organize home delivery services when they become essential.

The research team will evaluate maternal health at the end of each trimester starting from the time of conception until the end of pregnancy. Data will be collected through three different methods which include anthropometer, vitals assessments and testing blood samples for hemoglobin levels using point of care testing device (HemoCue 301+) and specific micronutrients \& inflammatory markers (Vitamin A, D, B9, B12, Zinc, Ferritin and CRP). The research team will collect stool samples to investigate gut microbiome composition through molecular techniques. The study will use weather stations, thermal drone cameras and wearable devices (FitBit) to measure heat exposure while linking those measurements to local weather patterns.

At delivery, neonatal anthropometric measurements will be obtained using standardized procedures. Study staff will collect cord blood samples which will then undergo biomarker analysis. Moreover, placental tissues will be collected for both gross examination and transcriptomic analysis.

For safety purposes, all individuals will be monitored carefully for food allergies by conducting regular assessments and establishing health facility connections to treat any medical complications. The study allows participants to join voluntarily while they maintain their right to leave at any moment without losing access to standard medical treatment.

The study has received ethical approval from the Aga Khan University Ethical Review Committee (Reference: 2024-10697-3239) and the National Bioethics Committee of Pakistan (Reference: 4-87/NBCR-1220/24-25/836). Written informed consent will be obtained prior to enrollment. Data will be managed in accordance with institutional confidentiality and data protection policies.

Interventions

• Dietary supplement Indigenous Balanced Diet Arm
  The uniqueness of this intervention lies in its culturally-preservative approach, its novel target of heat stress, its timing (preconception), and its integrated process (nutritionist collaboration + overall dietary counseling). It specifically targets heat resilience in pregnancy through a holistic approach of adapting dietary intervention as mitigating strategy for providing resilience to heat stress and evaluating key hypothesized pathways responsible for combating adverse pregnancy outcomes

Primary outcome measures

• Difference in proportion of neonates with low Weight-for-Gestational-Age Z-score (WGAZ< -2 SD) at birth between intervention and control arms. [Time frame: Within 24 hours of delivery]
• Difference in proportion of neonates with low height-for-Gestational-Age Z-score (LGAZ< -2 SD) at birth between intervention and control arms. [Time frame: Within 24 hours of delivery]

Secondary outcome measures (12)

• Gestational age at delivery [Time frame: At delivery date]
• Mode of delivery [Time frame: At delivery]
• Maternal serum ferritin concentration [Time frame: Evaluated at the end of each trimester (within one week before or after the scheduled time point), from enrollment until delivery.]
• Maternal serum folate concentration [Time frame: Evaluated at the end of each trimester (within one week before or after the scheduled time point), from enrollment until delivery.]
• Maternal serum 25-hydroxyvitamin D concentration [Time frame: Evaluated at the end of each trimester (within one week before or after the scheduled time point), from enrollment until delivery.]
• Generalized anxiety symptoms [Time frame: Evaluated at the end of each trimester (within one week before or after the scheduled time point), from enrollment until delivery.]
• Maternal gut microbiome alpha diversity [Time frame: Evaluated at the end of each trimester (within one week before or after the scheduled time point), from enrollment until delivery.]
• Placental gene expression levels [Time frame: At delivery]
• Estimated fetal weight during pregnancy [Time frame: Evaluated at the end of each trimester (within one week before or after the scheduled time point), from enrollment until delivery.]
• Perceived stress score [Time frame: Assessed at enrollment (baseline), monthly during pregnancy, and postpartum (after 2 weeks of delivery).]
• Postnatal depression symptoms [Time frame: Assessed at enrollment (baseline), monthly during pregnancy, and postpartum (after 2 weeks of delivery).]
• Depression symptoms [Time frame: Assessed at enrollment (baseline), monthly during pregnancy, and postpartum (after 2 weeks of delivery).]

Eligibility criteria

Inclusion criteria

• Women aged 18-45 years belonging to a low to middle socioeconomic status, residing in Mithi, Districts in Sindh.
• Planning to conceive within the study time frame and expect to become pregnant within four months of starting nutritional intervention.
• Women who confirm their pregnancy during the first trimester i.e., before 8 weeks of gestational age.

Exclusion criteria

• Women using long-lasting contraceptives such as IUDs, implants, and injectable methods like Depo-Provera.
• Women with a history of multiple miscarriage or stillbirths.
• Women with known chronic diseases, such as cardiovascular disorders, hepatic disorders, renal disorders, and infectious diseases.
• Women suffering from severe malnutrition (WHO: Underweight i.e., having BMI < 16 Kg/m2 or obese having BMI ≥ 30 Kg/m2).
• Women having severe anemia (WHO: Severe anemia i.e., Hb < 7g/dL).
• Women currently enrolled in BISP supplementation programs or taking any supplements other than iron and folic acid (IFA) will be excluded from the study.
• Those who do not become pregnant within three months of supplementation during pre-conception.

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: Yes

Study design

Allocation

Non-randomized

Model

Parallel assignment

Masking

Double blind

Primary purpose

Prevention

Study locations

Pakistan · 1 center

• Aga Khan University — Karachi

Publications

• Gonzalez-Fernandez D, Muralidharan O, Neves PA, Bhutta ZA. Associations of Maternal Nutritional Status and Supplementation with Fetal, Newborn, and Infant Outcomes in Low-Income and Middle-Income Settings: An Overview of Reviews. Nutrients. 2024 Oct 31;16(21):3725. doi: 10.3390/nu16213725. PMID 39519557
• Unger HW, Ashorn P, Cates JE, Dewey KG, Rogerson SJ. Undernutrition and malaria in pregnancy - a dangerous dyad? BMC Med. 2016 Sep 19;14(1):142. doi: 10.1186/s12916-016-0695-2. PMID 27645498
• Lakhoo DP, Brink N, Radebe L, Craig MH, Pham MD, Haghighi MM, Wise A, Solarin I, Luchters S, Maimela G, Chersich MF; Heat-Health Study Group; HIGH Horizons Study Group. A systematic review and meta-analysis of heat exposure impacts on maternal, fetal and neonatal health. Nat Med. 2025 Feb;31(2):684-694. doi: 10.1038/s41591-024-03395-8. Epub 2024 Nov 5. PMID 39500369
• Taylor A. ABC of subfertility: extent of the problem. BMJ. 2003 Aug 23;327(7412):434-6. doi: 10.1136/bmj.327.7412.434. No abstract available. PMID 12933733
• Sheikh S, Qureshi RN, Raza F, Memon J, Ahmed I, Vidler M, Payne BA, Lee T, Sawchuck D, Magee L, von Dadelszen P, Bhutta Z; CLIP Working Group. Self-reported maternal morbidity: Results from the community level interventions for pre-eclampsia (CLIP) baseline survey in Sindh, Pakistan. Pregnancy Hypertens. 2019 Jul;17:113-120. doi: 10.1016/j.preghy.2019.05.016. Epub 2019 May 17. PMID 31487626
• Kuehn L, McCormick S. Heat Exposure and Maternal Health in the Face of Climate Change. Int J Environ Res Public Health. 2017 Jul 29;14(8):853. doi: 10.3390/ijerph14080853. PMID 28758917
• Shankar K, Ali SA, Ruebel ML, Jessani S, Borengasser SJ, Gilley SP, Jambal P, Yazza DN, Weaver N, Kemp JF, Westcott JL, Hendricks AE, Saleem S, Goldenberg RL, Hambidge KM, Krebs NF. Maternal nutritional status modifies heat-associated growth restriction in women with chronic malnutrition. PNAS Nexus. 2023 Jan 27;2(1):pgac309. doi: 10.1093/pnasnexus/pgac309. eCollection 2023 Jan. PMID 36744021
• Ramirez JD, Maldonado I, Mach KJ, Potter J, Balise RR, Santos H. Evaluating the Impact of Heat Stress on Placental Function: A Systematic Review. Int J Environ Res Public Health. 2024 Aug 22;21(8):1111. doi: 10.3390/ijerph21081111. PMID 39200720

Identifiers

NCT: NCT07489664 · 10697-33069 · 074884

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗