Good day Dr. Ameya Bondre. We are involved with Ashoka who are preparing a large scale investigation on pregnant mothers and their babies 1000 day project in rural India using clean water, e'Pap nutrition and state of the art information collection devices. The project will be monitored by Harvard University. The clinical work we have already done indicated we will be able to address the iron deficiency anemia very quickly and the resulting stunting at birth should then be addressed with the included folic acid and other important micro nutrients. More important, we will be evaluating the nutrient density of the breast milk which we believe will improve dramatically using the e'Pap approach to nutritional suplimentation because of the fortification approach of focusing on bioavailability and nutrient repleteness. If you send me your email contact details - I will share with you the information we already have and the contact details of the Ashoka people in Washington DC for you to make contact with. Basil Kransdorff e'Pap Technologies

Thanks Basil for getting back. I read about your work (and the concept of "nutrient repleteness") at the Ashoka Innovators website and it surely looks promising to improve nutritional outcomes at birth and early childhood. My email is ameyabondre.jhsph@gmail.com. I would actually be in the DC area from 6th-10th February for a conference. I would be happy to speak to/email someone in Ashoka, about this study in India.Thanks again. Have a good day. Best wishes, Dr. Ameya Bondre,

Hi, This study look both interesting I hope you will share with us your result. C

Dear Dr. Ameya Bondre: The association between birthweight (and other outcomes) and ante-natal vitamin and mineral supplementation has been well-studied in the past few years. UNICEF came up with a standard formulation for ante-natal supplements some years back and commissioned a number of studies on this issue. In 2005, when I last reviewed the literature on this topic, the major published double-blinded intervention trials were: Study Total N Location Compliance with supplementation Ramakrishnan 2003 873 Mexico 95% Christian 2003 4,926 Nepal 86-88% (during pregnancy) Friis 2004 1,106 Zimbabwe 80% (in 53% subjects) Osrin 2005 1,052 Nepal 97-98% Kaestel 2005 1,100 Guinea-Bissau 76% The Christian study did not specifically look at birthweight as an outcome. Of the remaining studies, only Osrin found a statistically significant and clinically important association. A China study involving more than 18,000 women was recently published online: Liu JM, Mei Z, Ye R, Serdula MK, Ren A, Cogswell ME. Micronutrient Supplementation and Pregnancy Outcomes: Double-Blind Randomized Controlled Trial in China. JAMA Intern Med. 2013 Jan 7:1-7. [Epub ahead of print]. It found virtually no effect on birthweight. However, anemia was relatively uncommon and severely anemic women were excluded from this study population, so it may not be very representative of pregnant women in less-developed countries. There have been other studies completed and published since, including a Cochrane Review which shows some effect, but since my involvement in the China study ended in 2007, I have not kept very close track of the literature. I hope this helps. Regards, Brad Woodruff

Dear Brad, Thanks so much for your detailed response. I had two points to make.. 1) I am not sure if studies have been undertaken to assess the effect of vitamin-vitamin interactions within the body due to a combination pill (and perhaps aggravated by the pregnant state?) that could potentially weaken the effect of single vitamin supplementation - Iron-folate, or B-12 or Vitamin D, given separately in ante-natal care. 2) Most Indian states/sub-regions have diverse staple diets and perhaps we need state-specific studies in India. Further, a predominantly vegetarian diet may need Vitamin B-12 supplementation in addition to iron-folate, comparing its effect with iron-folate alone. B-12 is critical for in-utero neurological growth which in turn affects in-utero physical growth, and that can influence birth weight. Animal products such as meat, fish and eggs are rich sources of B-12 (consuming milk products may not be enough). A vast majority of rural Indian pregnant women may not buy these foods due to cost or because they are vegetarian. Thanks again for your inputs. Have a good day. Best wishes, Dr. Ameya Bondre

Dear Dr. Ameya Have a look at the link on Micronutrients and pregnancy; effect of supplementation on pregnancy and pregnancy outcomes: a systematic review http://www.nutritionj.com/content/pdf/1475-2891-12-20.pdf Rogers

Thanks Rogers, that was very useful. It seems that there is inconsistent (and perhaps weak) evidence supporting a specific effect, like antenatal MMN supplementation reducing the risk of low birth weight. Yet, researchers seem to recommend supplementation as MMNs do have an overall beneficial effect on infant and child growth. More studies are needed with modified designs to test specific effects (even the conclusions in this review are based on just 9 studies). Thanks again.