BENEFITS Achieving stable blood glucose levels is crucial for well-being, energy production, and cellular metabolism. HOW TO USE Take 3 capsules daily or as directed by your healthcare provider.

Ingredients Riboflavin vitamin B2 , Niacin, Vitamin B6 All three vitamins are involved in various metabolic pathways that help convert carbohydrates into energy and regulate blood sugar levels. Riboflavin aids in glucose metabolism and energy production, while niacin is crucial for glucose tolerance and insulin sensitivity.

Vitamin B6 supports glycogen breakdown and promotes healthy blood glucose levels. Chromium Chromium assists blood glucose and insulin management by promoting a healthy cell response to insulin and a normal glucose uptake by the cell. Chromium also supports healthy insulin function.

Berberine Sulfate Berberine is a bioactive compound found in certain plants and promotes balanced blood glucose and insulin levels through various mechanisms. Additionally, berberine positively impacts the gut microbiota and the amount of glucose absorbed in the intestines, contributing to blood glucose management.

Alpha Lipoic Acid ALA Alpha lipoic acid aids in blood glucose management through its unique antioxidant properties and its ability to support healthy, normal inflammatory levels.

As an antioxidant, ALA helps reduce oxidative stress, which can contribute to insulin resistance and impaired glucose metabolism. ALA also supports glucose uptake into cells by promoting the proper functioning of insulin receptors and supporting glucose utilization within the cells.

Benfotiamine Benfotiamine, a form of vitamin B1, supports blood glucose management by promoting cellular glucose uptake and utilization and better glycemic control. N-Acetyl L-cysteine NAC As a precursor to glutathione, a powerful antioxidant, NAC helps combat oxidative stress, which is associated with insulin resistance and impaired glucose metabolism.

NAC promotes normal glucose uptake and utilization by cells. NAC supports the healthy function of pancreatic beta cells, which produce insulin.

However, excessive materno-placental glucose transfer is associated with fetal hyperinsulinemia and macrosomia [ 19 , 20 ] and an increased risk of fatal obstructed labour, suggesting that the levels of glucose exposure of the fetus that are often now experienced are novel in evolutionary terms [ 21 ].

Established risk factors for developing GDM include prepregnancy obesity [ 25 ], excessive gestational weight gain [ 26 ], advanced maternal age [ 27 ] and a previous pregnancy with GDM [ 28 ].

These factors are now increasingly common in women during their reproductive years with the evolutionary mismatched situation of over-nutrition and low levels of physical activity contributing not only to the rise in GDM but to the increasing prevalence of obesity and diabetes in their children, perpetuating a vicious cycle of disease.

Such changes in growth potential and metabolic status may be mediated by inheritable epigenetic alterations occurring in utero [ 29 ]. Higher blood glucose levels in pregnancy carry risk of cardiovascular disease for both the mother as well as the child, a risk which increases with each pregnancy [ 31 ].

These findings have significant long-term implications for global public health. Now more than ever, effective strategies for maintaining healthy maternal glucose metabolism in pregnancy are needed.

Such strategies would benefit both the mother in terms of a healthy pregnancy and her own metabolic health, and the offspring in terms of promoting healthy body composition and wellbeing.

Evidence from South Asian pregnant women supports a role for the combination of maternal vitamin B 12 deficiency and folate sufficiency in promoting offspring adiposity, most likely mediated through impaired maternal glucose tolerance during pregnancy [ 35 , 36 ].

Meta-analysis of observational studies strongly points to a role for maternal vitamin D deficiency in GDM [ 37 ], and additional vitamin D in pregnant women with GDM has been shown to have beneficial effects on glycaemia and total and low-density lipoprotein cholesterol LDL -cholesterol concentrations [ 38 ].

Low zinc intake and status has also been linked with maternal glycaemia [ 39 ], and we propose that maternal glucose tolerance may be on the causal pathway linking maternal micronutrient deficiency to offspring adiposity.

Dietary myo-inositol is found in free form but can also be generated by microbial action in the gastrointestinal tract from food sources of phosphatidylinositol and phytic acid and its salts [ 40 ]. Myo-inositol is considered nonessential for mammals because it is synthesised de novo from glucosephosphate in the kidney and other tissues [ 41 , 42 ].

Abnormalities in its metabolism have been associated with insulin-resistance and its depletion has been frequently observed in tissues affected by diabetic microvascular and neurological complications in animal models and human subjects [ 43 ]. Our current understanding of the molecular pathways of insulin action led to the hypothesis that the nutritionally derived myo-inositol may increase insulin sensitivity by making available more phosphatidylinositol and potentially inositol glycan secondary messengers [ 44 , 45 ].

An increasing number of publications suggest that myo-inositol may reduce insulin resistance during pregnancy [ 46 , 47 , 48 , 49 ]. Recent studies suggest that specific bacteria may positively influence cardiometabolic parameters, possibly through their interaction with the host and the effect of microbial-derived metabolites.

There is now substantial evidence implicating a role for the gut microbiome in affecting glucose metabolism [ 50 ], and probiotics may modulate glucose tolerance through balancing gut microbiota, normalising increased intestinal permeability and lowering systemic and local low-grade inflammation [ 51 ].

There is preliminary evidence that a combination of probiotic strains during pregnancy may promote the maintenance of healthy glucose metabolism during pregnancy [ 52 ]. Taken together, there is strong support for new intervention studies commencing before pregnancy to provide myo-inositol and probiotics, and to improve maternal vitamin B 6 , vitamin B 12 , vitamin D and zinc status, aimed at optimising maternal glycaemia and glucose supply to the feto-placental unit to promote healthy offspring growth and body composition.

This double-blind randomised controlled trial in groups of women from different ethnic groups in the UK, Singapore and New Zealand is designed to examine the hypothesis that, compared with standard supplementation, a nutritional drink that contains myo-inositol, probiotics and additional micronutrients, commencing before conception and continuing during pregnancy, will assist in the maintenance of healthy glucose metabolism in the mother and promote offspring health.

Increasing evidence points to the preconception period and early pregnancy as a critical time when impaired maternal glucose tolerance may lead to biological alterations in the placenta and fetus that result in increased postnatal adiposity in the offspring [ 53 ].

As a consequence of this important evidence, our trial uniquely will focus on recruitment before conception and intervention both before and during pregnancy. Substantial experimental evidence from animal studies indicates that preconception is a critical period in the lifecourse for interventions to reduce later risk of metabolic dysregulation in the offspring.

In humans, large cohort studies have demonstrated that preconception is a time when factors contributing to later ill-health begin to operate, as poor maternal and paternal diet and smoking before conception impact on development and long-term health of the offspring; to date, however, there are no population-based trials of preconception nutrition in developed communities.

The flow of the trial is shown in the Standard Protocol Items: Recommendations for Interventional Trials SPIRIT Figure Fig. See Additional file 1 for the SPIRIT checklist. Extensive biosampling and detailed phenotyping are embedded in the study with longitudinal assessments at multiple time points starting from the preconception phase throughout pregnancy and into the first year post delivery.

The biosampling and phenotyping will enable detailed mechanistic insights and characterisation of potential new interventions for investigation in future studies. Following informed consent at the first preconception visit, a baseline standard g oral glucose tolerance test OGTT will be conducted, nutritional status, lifestyle, mood, body anthropometry and metabolic phenotype ascertained and biosampling undertaken, followed by randomisation to the intervention or control drink.

At the second preconception visit a month later, further biosampling will be undertaken and body composition assessed by DXA dual-energy X-ray absorptiometry scanning. Participants who become pregnant within a year of commencing the intervention or control drink will be seen around 7, 12, 20, 28 and 34 weeks of pregnancy for further phenotyping, biosampling and ultrasound scans assessing fetal growth and development.

Normal antenatal care will be permitted during the trial. The fathers will be interviewed to ascertain paternal lifestyle and mood, their anthropometry measured and paternal biosamples collected. At birth, offspring cord blood, umbilical cord and placental samples will be collected.

Neonatal body composition is assessed by anthropometry, air displacement plethysmography PEA POD and, in a subsample, by DXA scanning. Both breast- and formula-fed infants will be followed up when the infant is aged 1, 3 and 6 weeks, and 3, 6 and 12 months; infant feeding will be assessed in detail, biosamples collected and growth and wellbeing ascertained.

Breast milk samples will be collected from a subset of participants in early infancy for nutrient and metabolic analysis. A maternal OGTT will be repeated again at 6 months postpartum and repeat biosamples collected. The site visits will be completed at the research and hospital facilities of the three sites in Auckland University of Auckland, Auckland, Waitemata and Counties Manukau District Health Boards and Clinics, New Zealand , Singapore National University Hospital and National University Health System Investigational Medicine Unit and Southampton National Institute for Health Research Wellcome Trust Southampton Clinical Research Facility and Princess Anne Hospital, University Hospital Southampton, UK.

Standard Protocol Items: Recommendations for Interventional Trials SPIRIT Figure: trial schema. Abbreviations: PCV preconception visit, PC preconception, PGV pregnancy visit, PDV post-delivery visit, BIA bioelectrical impedance analysis, BP blood pressure, DM diabetes mellitus, DXA dual-energy X-ray absorptiometry, GDM gestational diabetes, HIV , human immunodeficiency virus, IFG impaired fasting glucose, IGT impaired glucose tolerance, NGT normal glucose tolerance, OGTT oral glucose tolerance test, USS, ultrasound scan.

Recruitment will be via self-referral of interested women who hear about the study via one or more of the following: 1 local site advertisements in social e. Facebook and general e. radio, local newspapers, magazines, posters media, 2 information brochures given to women engaging in community groups such as religious, culture-based or special-interest groups, 3 information brochures given to women identified through or attending primary medical care, family planning or hospital clinics for this group, eligible women may be contacted by a research nurse if they give permission to the clinic to pass on their contact details for this purpose.

In Southampton and Auckland, planning to have future maternity care in Southampton and Auckland, respectively. Women planning to conceive within 6 months but conception up to 12 months after phenotyping will still be included.

Pregnant or lactating at recruitment women who are currently breastfeeding will be excluded, but no washout period from the end of breastfeeding will be required before study start. Oral or implanted contraception currently or in the last month, or with an intrauterine contraceptive device in situ.

The participant is unwilling or unable to comply with the protocol including attendance at study visits, having study measures and biosampling. If the participant suffers a first-trimester pregnancy loss and wishes to re-join the study, she will be re-characterised as at the first baseline visit a month or more after a negative pregnancy test and will be assigned the nutritional drink with the same randomisation code as before.

The participant suffers an adverse reaction which is deemed by the investigator to be causally related to the intervention. For participants who withdraw during the pregnancy phase of the study, consent will be obtained to follow up on key outcome measures from their medical records to enable comparison of the characteristics of withdrawn and studied participants.

At preconception clinic visit 1 all eligible participants will be randomised via the electronic study database to either the nutritional drink or the control drink. This database will assign each participant the appropriate code number that is consistent with either the intervention nutritional drink arm or the control drink arm.

Randomisation will be stratified by site to ensure balanced allocation of participants across the two arms at each of the three sites, with further stratification by ethnicity. Investigational products will be blinded by the manufacturer with nonspeaking codes that do not allow deduction of the identity of intervention or control drinks.

Investigators, staff performing the assessments and data analysts will remain blind to the identity of the allocation from the time of randomisation until either the participant is unblinded or database lock of the primary outcome occurs. If emergency unblinding is necessary, the process for this will be documented in the study Safety Monitoring Plan.

The Nutritional Intervention Preconception and During Pregnancy to Maintain Healthy Glucose Metabolism and Offspring Health NiPPeR intervention comprises: 1 a micronutrient-enriched nutritional drink containing myo-inositol, vitamin D, riboflavin, vitamin B 6 , vitamin B 12 and zinc together with standard folic acid, iodine, calcium, β-carotene and iron; the quantities proposed are either standard amounts myo-inositol [ 54 ] , enhanced amounts that are available in over-the-counter products vitamins B 6 , B 12 , riboflavin , recommended daily allowance amounts in UK for pregnant women vitamin D, zinc, folic acid, iodine or minimal amounts for micronutrients linked with potential detrimental effects at higher doses iron, β-carotene, calcium and 2 probiotics containing Lactobacillus rhamnosus NCC CGMCC 1.

lactis NCC CNCM I also known as Bl [ 52 ]. The intervention group will be compared with a control group who receive a drink containing standard amounts of micronutrients that are part of routine pregnancy care including folic acid, β-carotene, iron, calcium and iodine.

The intervention is formulated as a powder in sachets to be made up in water immediately prior to consumption, with similar sensory characteristics for both the intervention and control drinks. The constituents of the intervention and control drinks are shown in Table 1 , including the rationale for the amounts included.

This trial uses established nutritional elements for which tolerability is well established. Confirmation that the trial is not a Clinical Trial of an Investigational Medicinal Product has been secured from MedSafe New Zealand , Medicines and Healthcare products Regulatory Agency, MHRA UK and the Health Sciences Authority Singapore.

Reduction in maternal micronutrient insufficiency, specifically less riboflavin, vitamin B 6 , vitamin B 12 , zinc and vitamin D insufficiency, before and during pregnancy.

Enhancement of breast milk micronutrient content, altered immunological factors, epigenetic and metabolomic profiles subsample and maintenance of healthy lactogenesis. Promotion of offspring wellbeing and healthy cardiometabolic risk factors, including visceral adiposity and markers of insulin resistance, during infancy.

Alteration in offspring metabolomic and epigenetic biomarkers in perinatal samples, consistent with improved infant metabolic and allergic wellbeing. Alteration in gut microbiota to a microbiota associated with infant metabolic and allergic wellbeing. Study data will be collected by trained research staff using an access-controlled, web-based database MedSciNet, Stockholm managed with support from the data management staff of the MRC Lifecourse Epidemiology Unit and the Singapore Institute for Clinical Sciences.

The study database will not hold personal information, which will be stored separately at each institution with access limited to study coordinators. Data extracts will be provided for analysis by the study researchers treating data from all three sites as a single study.

All data will be kept in accordance with the UK Data Protection Act, and applicable regulations and guidance of each country and institution.

Biological samples will be collected and processed using standardised consumables, equipment and protocols across the three sites and will be being stored in accordance with the UK Human Tissue Act or equivalent at each institution in appropriately regulated biobanks.

The study database allows management of the samples. All analysis will be carried out on anonymised data and samples. Accredited laboratories will be used for measurement of the primary outcome of plasma glucose concentrations.

Scientists from the Nestlé Research Centre Nestec provided advice on aspects of the intervention formulation, study design and specific laboratory analyses. The UK sponsor of the project is the University of Southampton; the New Zealand sponsor of the project is Auckland UniServices Limited; the Singapore sponsor of the project is the National University Hospital Singapore.

The sponsors are indemnified for any harms arising from trial participation and will approve protocol amendments for which ethics approval has been secured, alongside update of trial registry entries.

Trial oversight will be provided by an Independent Data Monitoring and Safety Committee. The day-to-day running of the study will be through the Trial Management Group, consisting of the principal investigators and the clinical trial operations director, who will be responsible for all decisions on the study management and delivery.

Monitoring will be carried out several times per year by an external, independent monitor at each site, following the risk-based monitoring plan established for the study, overseen by the study sponsor.

Safety reporting will be in accordance with the study Safety Monitoring Plan and all events will be recorded in the study database. An Independent Data Monitoring and Safety Committee has been established for the trial.

This committee is independent from the sponsor and competing interests and will meet annually and oversee all ethical and safety issues in accordance with current regulations and MRC guidelines for Data Monitoring Committees. The Committee Charter is available from the clinical trial operations director, who will coordinate and review activity across sites.

The primary analysis will be according to the intention-to-treat principle. Analyses will be specified in the study statistical analysis plan finalised by the Trial Management Group before unblinding the data.

The influence of missing data will be examined using multiple imputation techniques. There are no formal planned interim analyses of the primary outcome, but progress reports on all data issues will be presented to the Independent Data Monitoring and Safety Committee, who will agree their charter at their first meeting.

Analyses of the baseline phenotypic data that do not require unblinding will be undertaken. We will build prognostic models using baseline covariates on the primary outcome of maternal glucose tolerance in pregnancy. Planned subgroup analyses will include stratification by ethnicity across study sites.

By studying up to prepregnant participants in each of the intervention and control groups, a total of pregnancies and live births is conservatively anticipated, following attrition from miscarriage, ectopic pregnancy, perinatal demise, multiple pregnancy, voluntary participant withdrawal, inability to comply with the protocol, withdrawal for medical reasons at the discretion of the investigator and loss-to-follow-up.

This double-blind randomised controlled trial in groups of women from different ethnic groups in the UK, Singapore and New Zealand is designed to examine the hypothesis that a nutritional drink, commencing before conception and continuing during pregnancy, will assist in the maintenance of healthy glucose metabolism in the mother and promote offspring health.

Improved maternal nutrition and glycaemic control before and during pregnancy has benefits for the health of the mother and her offspring, including healthy offspring body composition and decreased risks of childhood obesity and allergies.

The intervention group will receive a nutritional drink enriched with micronutrients, myo-inositol and probiotics, and the control group will receive a drink enriched with standard micronutrients. The potential for adverse effects of the intervention is low as the probiotic and myo-inositol are thought to exert their main effects through physiological modulation of maternal metabolism rather than through direct effects on the fetus and, while the amounts of micronutrients in the nutritional drink are sufficient to rectify maternal deficiency, they do not exceed UK, Singapore and New Zealand safe upper limits.

The trial commences preconception as studies by Catalano et al. As a consequence, intervention commencing in established pregnancy can only partially influence fetal growth and development.

The earlier that maternal glycaemia is optimised and micronutrient deficiencies prevented, the greater the likelihood of maintaining fetal and postnatal health and wellbeing. Many influential governmental and nongovernmental organisations are now stressing the importance of optimising preconception nutrition in general terms but as yet, other than folic acid to prevent neural tube defects, there are few preconception interventions that are recognised as promoting health benefits for the mother or offspring, and none, apart from folic acid, has a robust evidence base.

In the initial phase of the NiPPeR study a broad range of maternal nutritional assessments, potential epigenetic mechanisms and secondary measures relating to pregnancy outcomes and infant growth, body composition and wellbeing will be characterised and are detailed in this protocol.

The extensive biosampling and detailed phenotyping embedded in the study before, during and after pregnancy will provide an important discovery pipeline for the development of novel biomarkers of maternal and offspring wellbeing, and lead to new interventions and future guidelines to promote healthy human growth and development.

A range of biological samples collected at multiple time points before, during and after pregnancy in the mother and offspring enables a systems biology approach to understanding the complex interaction of factors that determine maternal and infant wellbeing.

Both individually and collectively, the control and intervention arms will provide extensive information that will deliver new knowledge on how maternal nutrition and metabolic state can promote offspring health.

The research will also benefit from insights arising from other studies by the EpiGen Global Research Consortium in the UK, Singapore and New Zealand.

The ethnicities of the participants in the study will allow broad extrapolation of the findings, and enable subsequent smaller-scale studies in other jurisdictions, such as China and India, as appropriate. The partners have extensive experience of following up prospective mother-offspring cohorts, maternal, obstetrical, fetal and infant medicine and health care, and detailed characterisation of a comprehensive set of health and wellbeing outcomes through infancy and childhood will be undertaken.

The data collected will allow determination of the contributions of nutritional and lifestyle factors, socioeconomic status, ethnicity, genetics, transcriptomics, epigenomics, metabolomics and metagenomics to maintaining healthy glucose metabolism in pregnancy and promoting healthy growth, body composition and wellbeing in the offspring.

Recruitment for the trial commenced on 3 August ; more than half of the participants have been recruited within the following 12 months and recruitment remains ongoing in October Participants have already progressed through the randomisation and pregnancy phases of the study and initial deliveries have occurred in all three sites.

Nutritional Intervention Preconception and During Pregnancy to Maintain Healthy Glucose Metabolism and Offspring Health Study.

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