Effects of Probiotics and Calcium Supplementation on Growth, Development, and Metabolic Parameters (PROBIOCAL)

Effects of 6-Month Probiotics and Calcium Supplementation During Childhood on Growth, Development, and Metabolic Parameters in Adolescents: A 10-Year Follow-up Study

Stunting is still a major problem in developing countries, including Indonesia, and has been associated with impaired development. Stunted children have also a higher risk of metabolic syndrome in adulthood. The gut microbiota, as a part of intestinal integrity, may promote intake of nutrient during childhood. Probiotics supplementation may optimize the balance of gut microbiota and further improve child growth during the window period. Furthermore, calcium could also improve child growth by increasing the resistance to intestinal infection. However, the long-term effects of gut microbiota optimization during childhood using probiotics and calcium on growth, development, and the metabolic condition has not widely studied.

Study Overview

• Status: Completed
• Conditions: Depression; Obesity; Insulin Resistance; Dyslipidemias; Behavior; Stunting; Cognitive Function 1, Social; Permeability; Increased
• Intervention / Treatment: Dietary supplement: Low Calcium Milk; Dietary supplement: Regular Calcium Milk; Dietary supplement: Probiotic 1; Dietary supplement: Probiotic 2

Detailed Description

This study was a 10-year follow-up study of randomized controlled trials of 6-month probiotics and calcium supplementation of Lactobacillus reuteri DSM 17938 or Lactobacillus casei CRL 431 in children aged 1-6 years (n=494) living in urban low socioeconomic communities of East Jakarta in 2007-2008. We re-enrolled the subjects to assess the long-term effects of probiotics and calcium supplementation on growth, development, and metabolic parameters at the age of 11-17 years.

Healthy children (n = 238) were included in this follow-up study. Each subject previously assigned to one intervention group: low-lactose milk with a low calcium content (LC = 53), a regular calcium content (RC = 70), regular calcium with L. reuteri DSM 17938 (n = 55), and regular calcium with L. casei CRL 431 (n = 60).

Anthropometric measurements were performed by measuring the weight and height of the subjects, and further combining the results to report BMI-for-age z-score. Height was also plotted to the chart of the World Health Organization (WHO) Child Growth Standards. Gut integrity was assessed with the lactulose-mannitol ratio using high-performance liquid chromatography (HPLC) method. Cognitive function, symptoms related to depression, behaviour, and serum brain-derived neurotrophic factors (BDNF) of the adolescents were evaluated used to investigate the effects of supplementation on development. We quantified lipid profile and Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) as metabolic parameters using the vein blood sample. The metabolic parameters were measured in at least three groups of intervention.

• Study Type: Observational
• Enrollment (Actual): 238

Contacts and Locations

Study Locations

• Indonesia
  • DKI Jakarta
    • Jakarta Pusat, DKI Jakarta, Indonesia, 13420
      • Human Nutrition Research Center, Indonesian Medical Education Research Institute; and Department of Nutrition, Faculty of Medicine, Universitas Indonesia

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 9 years to 15 years (Child)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Low-socioeconomic urban communities representing flooding and non-flooding areas of East Jakarta, Indonesia.

Description

Inclusion Criteria at the previous clinical trial:

• Apparently healthy children aged 1-6 years, with emphasize on aged 2-5 years, living permanently in low socio-economic urban areas of East Jakarta for at least six months
• Parents are willing to sign the informed consent and give the supplements to the children for six months
• Capable and willing to drink liquid milk with a straw (acceptance to be tested at the screening by providing a sample drink and placebo straw to be consumed under supervision for two days)

Exclusion Criteria at the previous clinical trial:

• Calcium intake exceeding 75% of the Recommended Dietary Allowance (RDA) for calcium (<375 mg/d) based on a Food Frequency Questionnaire
• Currently breastfed children
• Siblings of already included children that are living in the same household, except if it is a twin sibling
• Severely malnourished with or without edema (weight-for-height Z-score of <-3.00 SD)
• Symptoms of chronic/congenital diseases and disabilities, suspected Tuberculosis by clinical examination, and/or history of allergic disease.
• Taking (any) antibiotics during 2 weeks prior to the start of the study (children will be included after 3 weeks of last antibiotic intake
• Participation in another clinical trial at the same time or 2 months prior to the start of this study
• Both mothers and other caregivers present in the family are illiterate

Inclusion criteria of follow-up study:

• Healthy adolescent participated in the previous trial study willing to take part in the follow-up study

Exclusion criteria of follow-up study:

• History of type 1 diabetes
• Taking the cholesterol-lowering drug, an anti-diabetic drug, or oral corticosteroid for more than 2 consecutive weeks in the last 3 months
• Pregnant

Study Plan

How is the study designed?

Design Details

• Observational Models: Cohort
• Time Perspectives: Cross-Sectional

Number of groups / cohorts

4

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Low Calcium; low calcium milk of 180 ml, twice daily for 24 weeks	Dietary supplement: Low Calcium Milk; 50 mg calcium/day
Regular Calcium; regular calcium milk of 180 ml, twice daily for 24 weeks	Dietary supplement: Regular Calcium Milk; 400 mg/day
Probiotic 1; regular calcium milk of 180 ml + probiotic, twice daily for 24 weeks	Dietary supplement: Probiotic 1; regular calcium milk + probiotic
Probiotic 2; regular calcium milk of 180 ml + probiotic, twice daily for 24 weeks	Dietary supplement: Probiotic 2; regular calcium milk + probiotic

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Child's linear growth the age of 11-17 years	Height-for-age z-score based on the WHO Child Growth Standards.	January - March 2019
Child's height at the age of 11-17 years	Height in meters.	January - March 2019
Child's weight at the age of 11-17 years	Weight in kilograms.	January - March 2019
Child's nutritional status at the age of 11-17 years	BMI-for-age z-score based on the WHO Child Growth Standards. BMI was calculated from height and weight measurement.	January - March 2019

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Gut integrity at the age of 11-17 years	Lactulose-mannitol ratio was calculated by dividing percent excretion of lactulose with percent excretion of mannitol.	January - March 2019
Cognitive function assessed using Raven's Progressive Matrices at the age of 11-17 years	Raven's Progressive Matrices (RPM) was administered by psychologists. Raw score of RPM was used to evaluate adolescents' cognition.	January - March 2019
Symptoms related to depression assessed using Children Depression Inventory at the age of 11-17 years	Children Depression Inventory (CDI) was a self-assigned questionnaire and the total score of CDI with a range between 0 - 54 (lower, better) was used to evaluate the symptoms related to depression among adolescents.	January - March 2019
Behaviour assessed using Strength and Difficulties Questionnaire at the age of 11-17 years	Strength and Difficulties Questionnaire (SDQ) was a self-assigned questionnaire and the total difficulties score of SDQ with a range between 0 - 50 (lower, better) was used to evaluate the behaviour among adolescents.	January - March 2019
Serum BDNF at the age of 11-17 years	Serum BDNF in pg/ml was quantified using ELISA method	January - March 2019
Triglyceride level at the age of 11-17 years	Triglyceride level in milligrams per decilitre.	January - March 2019
High-density lipoprotein level at the age of 11-17 years	High-density lipoprotein level in milligrams per decilitre.	January - March 2019
Low-density lipoprotein level at the age of 11-17 years	Low-density lipoprotein level in milligrams per decilitre.	January - March 2019
Fasting insulin level at the age of 11-17 years	Fasting insulin level in μU per millilitre	January - March 2019
Fasting glucose level at the age of 11-17 years	Fasting glucose level in milligrams per decilitre.	January - March 2019
HOMA-IR at the age of 11-17 years	HOMA-IR was quantified by multiplying fasting insulin level with fasting glucose level.	January - March 2019

Collaborators and Investigators

• Sponsor: Indonesia University
• Collaborators: Wageningen University; SEAMEO Regional Centre for Food and Nutrition
• Investigators: Principal Investigator: Rina Agustina, PhD, HNRC IMERI; Department of Nutrition, Faculty of Medicine, Universitas Indonesia

Publications and helpful links

General Publications

• Agustina R, Kok FJ, van de Rest O, Fahmida U, Firmansyah A, Lukito W, Feskens EJ, van den Heuvel EG, Albers R, Bovee-Oudenhoven IM. Randomized trial of probiotics and calcium on diarrhea and respiratory tract infections in Indonesian children. Pediatrics. 2012 May;129(5):e1155-64. doi: 10.1542/peds.2011-1379. Epub 2012 Apr 9.
• Agustina R, Bovee-Oudenhoven IM, Lukito W, Fahmida U, van de Rest O, Zimmermann MB, Firmansyah A, Wulanti R, Albers R, van den Heuvel EG, Kok FJ. Probiotics Lactobacillus reuteri DSM 17938 and Lactobacillus casei CRL 431 modestly increase growth, but not iron and zinc status, among Indonesian children aged 1-6 years. J Nutr. 2013 Jul;143(7):1184-93. doi: 10.3945/jn.112.166397. Epub 2013 May 22.
• Agustina R, Rianda D, Setiawan EA. Relationships of Child-, Parents-, and Environment-Associated Determinants with Diet Quality, Physical Activity, and Smoking Habits Among Indonesian Urban Adolescents. Food Nutr Bull. 2022 Mar;43(1):44-55. doi: 10.1177/03795721211046145. Epub 2021 Oct 21.
• Setiawan EA, Rianda D, Kadim M, Meilianawati, Susanto F, Kok FJ, Shankar AH, Agustina R. Tenth year reenrollment randomized trial investigating the effects of childhood probiotics and calcium supplementation on height and weight at adolescence. Sci Rep. 2021 Jun 4;11(1):11860. doi: 10.1038/s41598-021-88819-y.

Study record dates

Study Major Dates

• Study Start (Actual): January 26, 2019
• Primary Completion (Actual): March 3, 2019
• Study Completion (Actual): July 5, 2019

Study Registration Dates

• First Submitted: August 1, 2019
• First Submitted That Met QC Criteria: August 2, 2019
• First Posted (Actual): August 6, 2019

Study Record Updates

• Last Update Posted (Actual): August 7, 2019
• Last Update Submitted That Met QC Criteria: August 5, 2019
• Last Verified: August 1, 2019

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Glucose Metabolism Disorders; Metabolic Diseases; Hyperinsulinism; Lipid Metabolism Disorders; Dyslipidemias; Insulin Resistance; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Gastrointestinal Agents; Bone Density Conservation Agents; Calcium-Regulating Hormones and Agents; Antacids; Calcium; Calcium, Dietary; Calcium Carbonate
• Other Study ID Numbers: probiocal

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Undecided

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No