Egg Intervention During Pregnancy in Indonesia (PRECODE)

Effect on Pregnancy Outcomes, Infant Growth and Development of an Egg Intervention During Pregnancy in Indonesia

The study consists of two arms: 1) intervention group using eggs as supplementary food given from 2nd trimester of pregnancy to birth, and 2) observational group of pregnant mothers. it aims to assess the effectiveness of improving dietary quality during pregnancy on the epigenetic and stunting related outcomes (growth and development) in infants, who will be followed up until 24 months old

Study Overview

• Status: Active, not recruiting
• Conditions: Protozoan Infections; Birth Weight; Weight Gain; Vitamin A Deficiency; Folate Deficiency; Zinc Deficiency; Child Development; Salmonella Infections; Anemia, Iron Deficiency; Fatty Acid Deficiency; Birth Length; B12 Deficiency Vitamin; Mineral Deficiency; E. Coli Infection; Shigella Infection; Amino Acid Deficiency; Parasite Infestation
• Intervention / Treatment: Dietary supplement: Egg intervention

Detailed Description

The study aims to assess the impact of improving dietary quality during pregnancy on the epigenetic and stunting related outcomes in infants. The open-label intervention study would be conducted alongside the observational study in the same study setting by recruitment of additional number (n=153) of pregnant women. Thus, a total of 653 pregnant women would be enrolled in the study; 153 women would be randomized to intervention arm and 500 to the control arm who would form an observational cohort of women and newborns as described above. The intervention group women will be provided one egg three times per week from recruitment (2nd trimester) until term. The control group women will receive standard intervention in the form of Ante Natal Care from village midwives or Public Health Centre (IFA tablet, calcium tablet, nutrition counselling).

• Study Type: Interventional
• Enrollment (Actual): 702
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Indonesia
  • West Nusa Tenggara
    • Mataram, West Nusa Tenggara, Indonesia
      • Aikmel, Sakra, and Sikur Subdistrict

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 40 years (Adult)
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• Woman is between 16 and 20 weeks of pregnancy based on the date of the first day of her last menstrual period.
• She is 18-40 years of age.
• She is planning to remain in the study area over the next 30 months.
• She is of Sasak ethnicity

Exclusion Criteria:

• She is expecting multiple births.
• She has a known egg allergy.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: Observational cohort (control group); In the observational cohort, pregnant mothers in the 2nd trimester (n=500) will be recruited and they will be followed up until their children are 24 months old. The control group women will receive standard intervention in the form of Ante Natal Care from village midwives (Polindes) or Puskesmas (IFA tablet, calcium tablet, nutrition counselling).
Experimental: Intervention group; The intervention group women (n=153) will be provided one egg three times per week from recruitment (2nd trimester) until term along with the standard Ante Natal Care.	Dietary supplement: Egg intervention; Eggs are boiled until the white and yolk are firm (ca. 8 minutes) to maintain quality and safety and ensure the eggs are safe for consumption.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Prevalence of stunting	Z-score of LAZ <-2 SD based on WHO 2006	birth until 24 months after delivery
Proportion of children 10-14 months with impaired fine and gross motor skills	Oxford Neurodevelopment Assessment (OX-NDA) is used to assess fine and gross motor skills among children aged 10 to 14 months	10-14 months of age
Proportion of children 10-14 months with impaired expressive and receptive language	Oxford Neurodevelopment Assessment (OX-NDA) is used to assess expressive and receptive language among children aged 10 to 14 months	10-14 months of age
Proportion of children 10-14 months with impaired behavior	Oxford Neurodevelopment Assessment (OX-NDA) is used to assess behavior among children aged 10 to 14 months	10-14 months of age
Proportion of children 10-14 months with impaired executive function	Oxford Neurodevelopment Assessment (OX-NDA) is used to assess executive function among children aged 10 to 14 months	10-14 months of age
Proportion of children 10-14 months with impaired empathy	Oxford Neurodevelopment Assessment (OX-NDA) is used to assess empathy among children aged 10 to 14 months	10-14 months of age
Proportion of children 10-14 months with impaired problem solving	Oxford Neurodevelopment Assessment (OX-NDA) is used to assess problem solving among children aged 10 to 14 months	10-14 months of age
Proportion of children 10-14 months with impaired attention	Oxford Neurodevelopment Assessment (OX-NDA) is used to assess attention among children aged 10 to 14 months	10-14 months of age
Proportion of children 10-14 months with impaired social-emotional reactivity	Oxford Neurodevelopment Assessment (OX-NDA) is used to assess social-emotional reactivity among children aged 10 to 14 months	10-14 months of age
Proportion of children 20-24 months with impaired motor development	INTERGROWTH Neurodevelopment Assessment (INTER-NDA) is used to assess motor development among children aged 20 to 24 months	20-24 months of age
Proportion of children 20-24 months with impaired cognition	INTERGROWTH Neurodevelopment Assessment (INTER-NDA) is used to assess cognition among children aged 20 to 24 months	20-24 months of age
Proportion of children 20-24 months with impaired language	INTERGROWTH Neurodevelopment Assessment (INTER-NDA) is used to assess language among children aged 20 to 24 months	20-24 months of age
Proportion of children 20-24 months with impaired social-emotional development	INTERGROWTH Neurodevelopment Assessment (INTER-NDA) is used to assess social-emotional development among children aged 20 to 24 months	20-24 months of age
Scores of CDI vocabulary comprehension scale in children 10-12 months	MacArthur-Bates Communicative Development Inventories (CDI) is used to assess vocabulary comprehension scale among children aged 10 to 12 months	10-12 months of age
Scores of CDI vocabulary production scale in children 10-12 months	MacArthur-Bates Communicative Development Inventories (CDI) is used to assess vocabulary production among children aged 10 to 12 months	10-12 months of age
Epigenetic state of genes associated with stunting	Genome-wide analysis of epigenetic states using the Illumina Infinium Methylation EPIC 850k Bead Chip (EPIC array) will be performed for selected samples from the core cohort. The outcomes will be the epigenetic state of a large number of genes which are associated with child stunting.	parents: 72 h after delivery; baby: 72 h after delivery, 24 month
Epigenetic markers of birth anthropometry, adult stature, metabolic state, and cognitive ability	All samples (newborn, children 24 mo, parents) will be analyzed using Next Generation Bisulphite Amplicon Sequencing (BSAS) from Illumina MiSeq platform in targeted regions of the genome. The outcomes will be profiles of specific epigenetic markers of birth anthropometry, adult stature, metabolic state, and cognitive ability.	parents: 72 h after delivery; baby: 72 h after delivery, 24 month

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Weight gain during pregnancy	All measurements will be taken to the nearest 0.1 kg using standard procedures with SECA weighing machine.	2nd trimester (16-20 weeks gestation) and 3rd trimester (28-32 weeks gestation) of pregnancy
Birth weight	All measurements will be taken to the nearest 0.1 kg using standard procedures with SECA weighing machine.	24 hours after birth
Birth length	All measurements will be taken to the nearest milimeter using standard procedures with SECA stadiometer/infantometer.	24 hours after birth
Hemoglobin concentration	Nutritional status measured by biochemical assessment to the mothers and children. Both the pregnant mothers and children will be measured for their hemoglobin.	Mothers: second and third trimester of pregnancy; children: 6 months (+/- 2 weeks) after delivery; breastmilk: 3 and 6 months (+/- 2 weeks) after delivery
Serum ferritin concentration	Nutritional status measured by biochemical assessment to the mothers and children. Both the pregnant mothers and children will be measured for their serum ferritin	Mothers: second and third trimester of pregnancy; children: 6 months (+/- 2 weeks) after delivery; breastmilk: 3 and 6 months (+/- 2 weeks) after delivery
Serum transferrin receptor concentration	Nutritional status measured by biochemical assessment to the mothers and children. Both the pregnant mothers and children will be measured for their serum transferrin receptor	Mothers: second and third trimester of pregnancy; children: 6 months (+/- 2 weeks) after delivery; breastmilk: 3 and 6 months (+/- 2 weeks) after delivery
Serum zinc concentration	Nutritional status measured by biochemical assessment to the mothers and children. Both the pregnant mothers and children will be measured for their serum zinc	Mothers: second and third trimester of pregnancy; children: 6 months (+/- 2 weeks) after delivery; breastmilk: 3 and 6 months (+/- 2 weeks) after delivery
Serum retinol concentration	Nutritional status measured by biochemical assessment to the mothers and children. Both the pregnant mothers and children will be measured for their serum retinol	Mothers: second and third trimester of pregnancy; children: 6 months (+/- 2 weeks) after delivery; breastmilk: 3 and 6 months (+/- 2 weeks) after delivery
RBC folate concentration	Nutritional status measured by biochemical assessment to the mothers and children. Both the pregnant mothers and children will be measured for their RBC folate	Mothers: second and third trimester of pregnancy; children: 6 months (+/- 2 weeks) after delivery; breastmilk: 3 and 6 months (+/- 2 weeks) after delivery
Serum vitamin B12 concentration	Nutritional status measured by biochemical assessment to the mothers for their serum vitamin B12	Mothers: second and third trimester of pregnancy
RBC fatty acids concentration	Nutritional status measured by biochemical assessment to the mothers and children. Both the pregnant mothers and children will be measured for their RBC fatty acids	Mothers: second and third trimester of pregnancy; children: 6 months (+/- 2 weeks) after delivery; breastmilk: 3 and 6 months (+/- 2 weeks) after delivery
Serum essential amino acids concentration	Nutritional status measured by biochemical assessment to the mothers for their serum essential amino acids	Mothers: second and third trimester of pregnancy
Serum methylmalonic acid concentration	Nutritional status measured by biochemical assessment to the mothers and children. Both the pregnant mothers and children will be measured for their serum methylmalonic acid	Mothers: second and third trimester of pregnancy; children: 6 months (+/- 2 weeks) after delivery; breastmilk: 3 and 6 months (+/- 2 weeks) after delivery
Serum choline concentration	Nutritional status measured by biochemical assessment to the mothers and children. Both the pregnant mothers and children will be measured for their serum choline	Mothers: second and third trimester of pregnancy; children: 6 months (+/- 2 weeks) after delivery; breastmilk: 3 and 6 months (+/- 2 weeks) after delivery
Serum betaine concentration	Nutritional status measured by biochemical assessment to the mothers and children. Both the pregnant mothers and children will be measured for their serum betaine	Mothers: second and third trimester of pregnancy; children: 6 months (+/- 2 weeks) after delivery; breastmilk: 3 and 6 months (+/- 2 weeks) after delivery
Serum vitamin B2 concentration	Nutritional status measured by biochemical assessment to the mothers for their serum vitamin B2	Mothers: second and third trimester of pregnancy
Serum vitamin B6 concentration	Nutritional status measured by biochemical assessment to the mothers for their serum vitamin B6	Mothers: second and third trimester of pregnancy
Serum vitamin D concentration	Nutritional status measured by biochemical assessment to the mothers for their serum vitamin D	Mothers: second and third trimester of pregnancy
Serum CRP concentration	Subclinical inflammation will be measured by serum CRP in pregnant mothers and children	Mothers: second and third trimester of pregnancy; children: 6 months (+/- 2 weeks) after delivery; breastmilk: 3 and 6 months (+/- 2 weeks) after delivery
Serum AGP concentration	Subclinical inflammation will be measured by serum AGP in pregnant mothers and children	Mothers: second and third trimester of pregnancy; children: 6 months (+/- 2 weeks) after delivery; breastmilk: 3 and 6 months (+/- 2 weeks) after delivery
Serum RBP concentration	Nutritional status measured by biochemical assessment to the mothers and children. Both the pregnant mothers and children will be measured for their serum RBP	Mothers: second and third trimester of pregnancy; children: 6 months (+/- 2 weeks) after delivery; breastmilk: 3 and 6 months (+/- 2 weeks) after delivery
Serum hepcidine concentration	Nutritional status measured by biochemical assessment to the mothers and children. Both the pregnant mothers and children will be measured for their serum hepcidine	Mothers: second and third trimester of pregnancy; children: 6 months (+/- 2 weeks) after delivery; breastmilk: 3 and 6 months (+/- 2 weeks) after delivery
Serum homocysteine concentration	Nutritional status measured by biochemical assessment to the mothers and children. Both the pregnant mothers and children will be measured for their serum homocysteine	Mothers: second and third trimester of pregnancy; children: 6 months (+/- 2 weeks) after delivery; breastmilk: 3 and 6 months (+/- 2 weeks) after delivery
Serum HbA1C concentration	Gestational diabetes status will be assesed to the mothers for their serum HbA1C	Mothers: second and third trimester of pregnancy
Fecal myeloperoxidase (MPO)	Gut inflammation from fecal will be measured by faecal myeloperoxidase (MPO) using ELISA	baby: 1, 6, 24 months of age
Fecal α1-antitrypsin (AAT)	Gut inflammation from fecal will be measured by fecal α1-antitrypsin (AAT) using ELISA	baby: 1, 6, 24 months of age
Soil-transmitted helminths infection	Fecal parasites from fecal will be assesed by Kato Katz and confirmed by qPCR	mothers: 3rd trimester (28-32 gestational weeks) of pregnancy; baby: 1, 6, 24 months of age
Bacteria infection	Type of bacteria (Salmonella, Shigella) from fecal will be assesed by culture method	baby: 1, 6, 24 months of age
Gut microbiota	Gut microbiota species (EPEC, ETEC, EHEC, EIEC) from fecal will be assesed using qPCR	baby: 1, 6, 24 months of age
Gut microbiome	Faecal microbiome would be analyzed using 16S RNA sequencing of the V4 region on the Illumina MiSeq and BSAS.	baby: 1, 6, 24 months of age
Intestinal fatty acid binding protein	Intestinal fatty acid binding protein from serum will be measured using ELISA	baby: 6 months of age

Collaborators and Investigators

• Sponsor: SEAMEO Regional Centre for Food and Nutrition
• Collaborators: London School of Hygiene and Tropical Medicine; University College, London; University of Sheffield; Royal Veterinary College; Liverpool School of Tropical Medicine; Cheikh Anta Diop University, Senegal; University of Aberdeen; University of Brighton; The International Livestock Research Institute (ILRI); International Initiative for Impact Evaluation; Birkbeck, University of London; National Institute of Nutrition, India; International Centre for Research in Agroforestry; Science Made Simple; Digital Green Foundation; SOAS, University of London
• Investigators: Principal Investigator: Umi Fahmida, Dr., Seameo Recfon

Publications and helpful links

General Publications

• Boeke CE, Gillman MW, Hughes MD, Rifas-Shiman SL, Villamor E, Oken E. Choline intake during pregnancy and child cognition at age 7 years. Am J Epidemiol. 2013 Jun 15;177(12):1338-47. doi: 10.1093/aje/kws395. Epub 2013 Feb 20.
• Caudill MA, Strupp BJ, Muscalu L, Nevins JEH, Canfield RL. Maternal choline supplementation during the third trimester of pregnancy improves infant information processing speed: a randomized, double-blind, controlled feeding study. FASEB J. 2018 Apr;32(4):2172-2180. doi: 10.1096/fj.201700692RR. Epub 2018 Jan 5.
• Clare CE, Brassington AH, Kwong WY, Sinclair KD. One-Carbon Metabolism: Linking Nutritional Biochemistry to Epigenetic Programming of Long-Term Development. Annu Rev Anim Biosci. 2019 Feb 15;7:263-287. doi: 10.1146/annurev-animal-020518-115206. Epub 2018 Nov 9.
• Haggarty P. Epigenetic consequences of a changing human diet. Proc Nutr Soc. 2013 Nov;72(4):363-71. doi: 10.1017/S0029665113003376. Epub 2013 Sep 13.
• Haggarty P, Hoad G, Campbell DM, Horgan GW, Piyathilake C, McNeill G. Folate in pregnancy and imprinted gene and repeat element methylation in the offspring. Am J Clin Nutr. 2013 Jan;97(1):94-9. doi: 10.3945/ajcn.112.042572. Epub 2012 Nov 14.
• Whitelaw N, Bhattacharya S, Hoad G, Horgan GW, Hamilton M, Haggarty P. Epigenetic status in the offspring of spontaneous and assisted conception. Hum Reprod. 2014 Jul;29(7):1452-8. doi: 10.1093/humrep/deu094. Epub 2014 May 8.
• Masser DR, Stanford DR, Freeman WM. Targeted DNA methylation analysis by next-generation sequencing. J Vis Exp. 2015 Feb 24;(96):52488. doi: 10.3791/52488.
• Dighe MK, Frederick IO, Andersen HF, Gravett MG, Abbott SE, Carter AA, Algren H, Rocco DA, Waller SA, Sorensen TK, Enquobahrie D, Blakey I, Knight HE, Cheikh Ismail L; International Fetal and Newborn Growth Consortium for the 21st Century. Implementation of the INTERGROWTH-21st Project in the United States. BJOG. 2013 Sep;120 Suppl 2:123-8, v. doi: 10.1111/1471-0528.12126. Epub 2013 Jul 11.
• Weisenberger D, Van Den Berg D, Pan F, Berman B, Laird P. Comprehensive DNA methylation analysis on the Illumina Infinium assay platform. Illumina, San Diego. 2008.
• Fenson L, Pethick S, Renda C, Cox JL, Dale PS, Reznick JS. Short-form versions of the MacArthur communicative development inventories. Applied Psycholinguistics. 2000;21(1):95-116.
• Zeisel SH, Mar MH, Howe JC, Holden JM. Concentrations of choline-containing compounds and betaine in common foods. J Nutr. 2003 May;133(5):1302-7. doi: 10.1093/jn/133.5.1302. Erratum In: J Nutr. 2003 Sep;133(9):2918.
• Patterson KY, Bhagwat SA, Williams JR, Howe JC, Holden J, Zeisel S, et al. USDA database for the choline content of common foods, release two. Nutrient Data Laboratory, Beltsville Human Nutrition Research Center, ARS, USDA. 2008.
• Cho E, Zeisel SH, Jacques P, Selhub J, Dougherty L, Colditz GA, Willett WC. Dietary choline and betaine assessed by food-frequency questionnaire in relation to plasma total homocysteine concentration in the Framingham Offspring Study. Am J Clin Nutr. 2006 Apr;83(4):905-11. doi: 10.1093/ajcn/83.4.905.
• Mhila G, DeRenzi B, Mushi C, Wakabi T, Steele M, Dhaldialla P, et al. Using mobile applications for community-based social support for chronic patients. Health Informatics in Africa. 2009.
• Sethi V, Tiwari K, Sareen N, Singh S, Mishra C, Jagadeeshwar M, Sunitha K, Kumar SV, de Wagt A, Sachdev HPS. Delivering an Integrated Package of Maternal Nutrition Services in Andhra Pradesh and Telangana (India). Food Nutr Bull. 2019 Sep;40(3):393-408. doi: 10.1177/0379572119844142. Epub 2019 Jun 16.
• Lutter CK, Iannotti LL, Stewart CP. Cracking the egg potential during pregnancy and lactation. Sight Life. 2016;30:75-81.
• Yan J, Jiang X, West AA, Perry CA, Malysheva OV, Devapatla S, Pressman E, Vermeylen F, Stabler SP, Allen RH, Caudill MA. Maternal choline intake modulates maternal and fetal biomarkers of choline metabolism in humans. Am J Clin Nutr. 2012 May;95(5):1060-71. doi: 10.3945/ajcn.111.022772. Epub 2012 Mar 14.
• Lorgen-Ritchie M, Murray AD, Ferguson-Smith AC, Richards M, Horgan GW, Phillips LH, Hoad G, Gall I, Harrison K, McNeill G, Ito M, Haggarty P. Imprinting methylation in SNRPN and MEST1 in adult blood predicts cognitive ability. PLoS One. 2019 Feb 1;14(2):e0211799. doi: 10.1371/journal.pone.0211799. eCollection 2019. Erratum In: PLoS One. 2019 Apr 10;14(4):e0215422. doi: 10.1371/journal.pone.0215422.
• Jacobson SW, Carter RC, Molteno CD, Stanton ME, Herbert JS, Lindinger NM, Lewis CE, Dodge NC, Hoyme HE, Zeisel SH, Meintjes EM, Duggan CP, Jacobson JL. Efficacy of Maternal Choline Supplementation During Pregnancy in Mitigating Adverse Effects of Prenatal Alcohol Exposure on Growth and Cognitive Function: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial. Alcohol Clin Exp Res. 2018 Jul;42(7):1327-1341. doi: 10.1111/acer.13769. Epub 2018 Jun 15. Erratum In: Alcohol Clin Exp Res (Hoboken). 2024 May;48(5):981. doi: 10.1111/acer.15297.

Study record dates

Study Major Dates

• Study Start (Actual): February 12, 2021
• Primary Completion (Actual): May 1, 2024
• Study Completion (Estimated): September 30, 2024

Study Registration Dates

• First Submitted: December 22, 2020
• First Submitted That Met QC Criteria: January 1, 2021
• First Posted (Actual): January 5, 2021

Study Record Updates

• Last Update Posted (Actual): July 3, 2024
• Last Update Submitted That Met QC Criteria: July 2, 2024
• Last Verified: July 1, 2024

More Information

Terms related to this study

• Keywords: Pregnancy; Growth; Indonesia; Child development; Epigenetic; Egg
• Additional Relevant MeSH Terms: Digestive System Diseases; Pathologic Processes; Metabolic Diseases; Eye Diseases; Disease Attributes; Hematologic Diseases; Gastrointestinal Diseases; Nutrition Disorders; Gastroenteritis; Intestinal Diseases; Gram-Negative Bacterial Infections; Bacterial Infections; Bacterial Infections and Mycoses; Anemia, Hypochromic; Anemia; Iron Metabolism Disorders; Parasitic Diseases; Deficiency Diseases; Malnutrition; Body Weight Changes; Enterobacteriaceae Infections; Dysentery; Vitamin B Deficiency; Vision Disorders; Infections; Communicable Diseases; Anemia, Iron-Deficiency; Body Weight; Birth Weight; Weight Gain; Dysentery, Bacillary; Night Blindness; Vitamin B 12 Deficiency; Vitamin A Deficiency; Folic Acid Deficiency; Avitaminosis; Escherichia coli Infections; Protozoan Infections; Salmonella Infections; Iron Deficiencies
• Other Study ID Numbers: AASH Egg intervention

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No