Fetal programming of health and disease; follow-up of children whose mothers took part in a pre-conceptional nutrition trial in Mumbai, India

孟买母亲营养项目是一项随机对照试验，在印度孟买市的一个贫民窟进行。参与者是计划要孩子的女性。他们的饮食中维生素和矿物质(微量营养素)含量较低，他们的新生儿出生体重过低的风险很高。这项试验的目的是测试在怀孕前和怀孕期间持续改善饮食中的微量营养素质量是否会增加出生体重并改善儿童的长期健康。除了她们通常的饮食外，妇女们还被提供了一种特别设计的每日零食，由(试验组)富含微量营养素的食物制成，包括绿叶蔬菜、水果和牛奶，或(对照)低微量营养素蔬菜，如土豆和洋葱。平均而言，治疗零食含有世界卫生组织推荐的β-胡萝卜素、叶酸、维生素B2和B12、钙和铁的参考营养素摄入量的10%-23%。这项试验的不同寻常之处有两个：(A)在孕前补充妇女和(B)使用当地富含微量营养素的食物，而不是药用微量营养素补充剂。主要结果是出生体重，但它的作用是能够对儿童的长期结果进行研究。我们预先指定，我们计划在怀孕前至少三个月测试开始干预的效果，我们预计较瘦女性的出生体重会受到更大影响。第一批妇女于2006年1月被招募，最后一名婴儿于2012年5月出生。我们招募了6513名妇女，其中2291人怀孕，导致1962名单胎活产；在2291名妇女中，1826人在怀孕前至少三个月开始补充，有1562名活产。在所有分娩的妇女中，干预对出生体重有积极但不显著的影响(+26g[95%CI-15，68g]，p=0.22)。在怀孕前至少三个月开始补充的女性中有更大的效果(+48g[95%可信区间1，96g]，p=0.046)。在这些妇女中，干预降低了低出生体重儿的发生率(治疗：34%，对照组41%；OR 0.76[95%CI 0.59，0.98]，p=0.03)。出生体重效应随着孕前体重指数的增加而增加，孕前体重指数最低、中等和最高的3/3的孕妇体重指数分别为-8g、+79g和+113g(交互作用=0.001)。干预的一个意想不到的好处是，它降低了母亲怀孕期间的糖尿病患病率(治疗：7%，对照组：13%，p&lt；0.01)。在这项拟议的研究中，我们现在的目标是评估干预对6岁儿童(N~1800)结局的影响。我们将测量一系列的生长、功能和健康结果，包括身高、身体成分、日后糖尿病和心脏病的风险标记物，以及大脑功能。这项研究已经开始(从2013年9月开始)，以评估年龄窗口狭窄的儿童。伦理上的批准是从孟买JJ医院获得的。一名卫生工作者走访了家庭，解释这项研究。在孩子6岁生日的时候，孩子和父母被要求在隔夜禁食后前往孟买班德拉社会变化研究中心的一家研究诊所。对父母和孩子进行了详细的身体测量。从孩子身上采集空腹血样，检测血糖、胰岛素和血脂。在口服葡萄糖负荷后30分钟和120分钟抽取进一步的血样。测量血压和握力。认知(智力)测试是使用为印度儿童验证的测试进行的。这些孩子在当地一家医院用双X射线骨密度仪测量了脂肪、瘦肉和骨量。在父母中，要测量全血细胞计数和空腹血糖。用于未来遗传和表观遗传分析的DNA和RNA样本从孩子和父母那里收集并冷冻。这项研究需要3年时间才能完成。

The Mumbai Maternal Nutrition Project was a randomised controlled trial which took place in a slum community in the city of Mumbai, India. The participants were women planning to have children. They had diets low in vitamins and minerals (micronutrients) and their newborns were at high risk of low birth weight. The aim of the trial was to test whether improving the micronutrient quality of their diet for a sustained period of time before conception, and throughout pregnancy, increases birth weight and improves the children's long-term health. Women were offered, in addition to their usual diet, a specially designed daily snack made from (treatment group) micronutrient-rich foods including green leafy vegetables, fruit and milk, or (controls) low micronutrient vegetables such as potato and onion. On average the treatment snacks contained 10-23% of the WHO recommended Reference Nutrient Intake for beta-carotene, folate, vitamins B2 and B12, calcium and iron. The trial was unusual in two ways: (a) in supplementing women before pregnancy and (b) in using local micronutrient-rich foods rather than pharmaceutical micronutrient supplements. The primary outcome was birth weight, but it was powered to enable the study of longer term outcomes in the children. We pre-specified that we planned to test the effect of starting the intervention at least three months before conception, and we expected greater effects on birth weight among thinner women. The first women were recruited in January 2006 and the last baby was born in May 2012. We enrolled 6513 women, of whom 2291 became pregnant, resulting in 1962 singleton live births; 1826 of the 2291 women started the supplement at least three months before becoming pregnant and had 1562 live births. Among all the women who gave birth, the intervention had a positive but non-significant effect on birth weight (+26 g [95% CI -15, 68 g], p=0.22). There was a greater effect among women who started supplementation at least three months before pregnancy (+48g [95% CI 1, 96 g], p=0.046). In these women, the intervention reduced the rate of low birth weight babies (Treatment: 34%, Controls 41%; OR 0.76 [95% CI 0.59, 0.98], p=0.03). The birth weight effect increased with maternal pre-pregnant body mass index: -8g, +79g and +113g in the lowest, middle and highest thirds of maternal BMI respectively (p for interaction=0.001). An unexpected benefit of the intervention was that it reduced the prevalence of diabetes in the mothers during pregnancy (Treatment: 7%, Controls: 13%, p<0.01). In the proposed study, we now aim to assess the effect of the intervention on outcomes in the children (N~1800) at the age of 6 years. We will measure a range of growth, functional and health outcomes, including height, body composition, risk markers for later diabetes and heart disease, and brain function. The study has already started (from Sept 2013) in order assess children in a narrow age window. Ethical approval was obtained from the JJ Hospital, Mumbai. Families are visited by a health worker to explain the study. As close as possible to the child's 6th birthday, the child and both parents are asked to attend a research clinic at the Centre for the Study of Social Change in Bandra, Mumbai, after an overnight fast. Detailed body measurements of the parents and child are performed. A fasting blood sample is taken from the child for glucose, insulin and lipids. Further blood samples are drawn at 30 and 120 minutes after an oral glucose load. Blood pressure and hand grip strength are measured. Cognitive (intelligence) testing is carried out using tests validated for Indian children. The children have fat, lean and bone mass measured using dual X-ray absorptiometry at a local hospital. In parents, a full blood count and fasting glucose are measured. DNA and RNA samples for future genetic and epigenetic analyses are collected from the children and parents and frozen. The study will take 3 years to complete.