Academic journal article Journal of Health Population and Nutrition

Leaf Concentrate Fortification of Antenatal Protein-Calorie Snacks Improves Pregnancy Outcomes

Academic journal article Journal of Health Population and Nutrition

Leaf Concentrate Fortification of Antenatal Protein-Calorie Snacks Improves Pregnancy Outcomes

Article excerpt


Malnutrition during pregnancy is a risk factor of maternal anaemia and adverse pregnancy out- comes, including preterm delivery, low birth- weight, and neural tube defects (1-3). Studies in India have shown a consistently high (80%) preva- lence of anaemia among women in rural and ur- ban districts (4-6).

Antenatal iron and folic acid (IFA) supplements and protein-calorie supplements in the form of ready-to-eat (RTE) snacks or freshly-prepared food are provided to pregnant women in India through the Integrated Child Development Services (ICDS) Programme (7). However, although 65% of moth- ers received IFA supplements, only 23% of women consumed these supplements for at least 90 days (8). This low level of adherence may be due to the frequent gastrointestinal side-effects of iron sup- plements (9). Hence, food-based approaches to combating maternal malnutrition may be more ef- fective (6,10), including low-cost locally-produced food-based micronutrient supplements (11). Leaf concentrate (LC) was produced in France in the 18th century and developed as a foodstuff in Eng- land between 1940 and 1970 (12). LC has since been promoted by several non-governmental or- ganizations, including Find Your Feet in the UK, Leaf for Life in the USA, and the Association pour la Promotion des Extraits Foliaires en Nutrition (APEF) in France, as a sustainable form of pro- tein and micronutrient supplementation in low- income communities (13,14).

In a previous study, we demonstrated that LC was an effective and more palatable alternative to IFA supplements for treating anaemia in adolescent girls in a low-income urban community in Jaipur (15). Here, we investigate, in the same setting, whether RTE protein-calorie snacks for pregnant women are more effective in preventing maternal anaemia and infants' low birthweight when forti- fied with locally-produced LC.


Study population

Our target population comprised pregnant women aged 18-35 years living in a low-income area of Jaipur. The study area was selected by randomly sampling 1 of 2 Integrated Child Development Services (ICDS) blocks, then 1 of 4 Parikshetras (dis- tricts) in the selected block, then 8 of 24 Angan- wadis in the selected Parikshetra. An Anganwadi is a government-sponsored centre that provides care to women and children (aged 0-6 years), including antenatal and postnatal care, immunization, and supplementary nutrition. The selected Anganwadis provided services to two slums (Tata Nagar and Shivaji Nagar) with a combined population of ap- proximately 8,000. Pregnant women were identi- fied by means of Anganwadi workers making door- to-door visits, accompanied by the field researcher and/or two field assistants. The objectives of the study were explained by the Anganwadi workers, and women were recruited according to the follow- ing eligibility criteria: early 2nd trimester (14th-16th week of pregnancy), age 18-35 years, gravidity 1-4, expected to be resident in the locality throughout their pregnancy, and delivery to be conducted lo- cally. Women who consented to participate were followed prospectively until full term. The study was conducted between March 1994 and October 1995.

Study design

We aimed to achieve a sample-size of 50 women in each arm of the trial, corresponding to 90% power to detect a 12% difference (between and within groups) in mean Hb (from 8.5 g/dL to 7.5 g/dL, standard de- viation 1.5 g/dL for both measurements) at 5% level of significance. Women were allocated at random to receive either the standard (sRTE) or the LC-fortified (lcRTE) snack once daily. Randomization was done as preset in consecutively-numbered sealed enve- lopes, each containing a paper slip indicating allo- cation to lcRTE or sRTE. One envelope was opened by the field researcher each time that a woman con- sented to participate. Participants were not blinded to their allocation because of the green colour of the lcRTE snacks. …

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