Myo-Inositol Probiotics andMicronutrient SupplementationFrom Preconception for Glycemiain Pregnancy NiPPeRInternational Multicenter Double-Blind Randomized ControlledTrialhttpsdoiorg102337dc20-2515

OBJECTIVE

Betterpreconceptionmetabolic andnutritional healtharehypothesized topromotegestational normoglycemia and reduce preterm birth but evidence supportingimproved outcomes with nutritional supplementation starting preconception islimited

RESEARCH DESIGN AND METHODS

This double-blind randomized controlled trial recruited from the community 1729UK Singapore and New Zealand women aged 18ndash38 years planning conceptionWe investigated whether a nutritional formulation containing myo-inositol pro-biotics and multiple micronutrients (intervention) compared with a standardmicronutrient supplement (control) taken preconception and throughout preg-nancy could improve pregnancy outcomes The primary outcome was combinedfasting 1-h and 2-h postload glycemia (28 weeks gestation oral glucose tolerancetest)

RESULTS

Between 2015 and 2017 participants were randomized to control (n 5 859) orintervention (n 5 870) 585 conceived within 1 year and completed the primaryoutcome (295 intervention 290 control) In an intention-to-treat analysis adjustingfor site ethnicity and preconception glycemia with prespecified P lt 0017 formultiplicity there were no differences in gestational fasting 1-h and 2-h glycemiabetweengroups (b [95CI] logemmolL intervention vs control20004 [20018 to0011] 0025 [20014 to 0064] 0040 [0004ndash0077] respectively) Between theintervention and control groups therewere no significant differences in gestationaldiabetesmellitus (248 vs 226 adjusted risk ratio [aRR] 122 [092ndash162]) birthweight (adjustedb5005 kg [2003 to 013]) or gestational age at birth (mean393vs 392 weeks adjusted b 5 020 [2006 to 046]) but there were fewer pretermbirths (58 vs 92 aRR 043 [022ndash082]) adjusting for prespecified covariates

CONCLUSIONS

Supplementation withmyo-inositol probiotics and micronutrients preconceptionand in pregnancy did not lower gestational glycemia but did reduce preterm birth

1MRC Lifecourse Epidemiology Unit University ofSouthampton Southampton UK2NIHRSouthamptonBiomedicalResearchCentreUniversity Hospital Southampton NHS Founda-tion Trust Southampton UK3Liggins Institute University of Auckland Auck-land New Zealand4College of Life Sciences Biological Sciences andPsychologyUniversityof Leicester LeicesterUK5Department of Obstetrics and GynaecologyYong Loo Lin School of Medicine National Uni-versity of Singapore and National UniversityHealth System Singapore6Singapore Institute for Clinical Sciences Agencyfor Science Technology and Research Singapore7A Better Start New Zealand National ScienceChallenge Auckland New Zealand

Corresponding author Keith M Godfrey kmgmrcsotonacuk

Received 11 October 2020 and accepted 10February 2021

Clinical trial reg nos NCT02509988 clinicaltrialsgov and U1111-1171-8056 wwwwhointclinical-trials-registry-platform

This article contains supplementary material onlineat httpsdoiorg102337figshare13874705

Members of the NiPPeR Study Group are listedin the supplementary material online

WC and S-YC contributed equally to thisarticle

copy 2021 by the American Diabetes AssociationReadersmayuse this article as longas thework isproperly cited the use is educational and not forprofit and the work is not altered More infor-mation is availableathttpswwwdiabetesjournalsorgcontentlicense

Keith M Godfrey12 Sheila J Barton1

Sarah El-Heis1 Timothy Kenealy3

Heidi Nield1 Philip N Baker4

Yap Seng Chong56 Wayne Cutfield37 and

Shiao-Yng Chan56 NiPPeR Study Group

Diabetes Care 1

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CAREED

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Diabetes Care Publish Ahead of Print published online March 29 2021

Suboptimal metabolic and nutritionalhealth around conception and duringpregnancy have important implicationsfor pregnancy outcomes fetal growthadiposity and long-term offspring health(1) Adverse effects of higher maternalglucose concentrations increase acrossthe continuum of maternal glycemia(23) and micronutrient insufficiency ishighlyprevalent inwomen Interventionsthat optimize glycemia and nutritionalstatus are thought to improve pregnancyand offspring outcomes but supportiveevidence from intervention studies issparsePregnancy is a state of relative ma-

ternal insulin resistance promoting glu-cose transfer to the fetus (4) Physiologicalinsulin resistance and impaired insulinsecretion can be accentuated by individualgenetic and environmental vulnerabilitiesand lead to gestational diabetes mellitus(GDM) (5) The global GDM incidence isrising estimated at 14 (6) FollowingGDM diagnosis lifestyle changes oral hy-poglycemic drugs and insulin can improvesome short-term obstetric outcomes (7)but cannot fully mitigate pregnancy andoffspring adversity (8) Risk reduction strat-egies have thus shifted toward GDM pre-vention However population trials ofdietary physical activity or combined life-style measures mostly beginning in thefirst half of gestation have had limitedimpact on preventing GDM (910) This hasled to postulations that preconceptioninterventions could be more effectiveand that alternative approaches arerequiredSmall clinical trials have suggested that

supplementation with myo-inositol orprobiotics from early pregnancy maybe beneficial myo-inositol is a naturallyoccurring six-carbon polyol with insulinsensitizing actions arising from functionsrelating to many second messenger sig-nalingpathwaysandendogenous insulin-mimetic factors (11) Meta-analysis ofwomen given myo-inositol supplemen-tation from the end of the first trimesterreported reductions in GDM gestationalglycemia and preterm birth (12) Similarlymeta-analysis of studies of probiotics (Lac-tobacillus andor Bifidobacterium species)from early pregnancy showed improvedinsulin sensitivity (13) One trial of pro-biotics taken from the first trimester re-ported improved glucose tolerance andreduced GDM (14) Low intakes and in-sufficiencies of several micronutrients

(vitamin B6 vitamin B12 riboflavin zinc)are prevalent in pregnancy and havebeenlinked with glucose intolerance and preg-nancy outcomes (15ndash17) but there arefew intervention studies (18) Vitamin Ddeficiency has also been linkedwith GDMand preterm birth (19) but a trial ofvitamin D supplementation starting inearly pregnancy showed no preventiveeffects on pregnancy complications (20)Another trial of a nutritional supplement(containingproteinpolyunsaturatedfattyacids and micronutrients without inosi-tols or probiotics) in low-resource settingsshowed improved birth length but nodifference in preterm birth comparedwith no supplementation with no differ-ence between the group starting supple-mentation preconception and the groupstarting in early pregnancy glycemia out-comes were however not reported (21)

Dysglycemia and maternal micronu-trient insufficiency preconception or inearly pregnancy are common in thegeneral population and thought to in-fluence the risk of adverse pregnancyoutcomes (151722) We hypothesizedthat amyo-inositol probiotic andmicro-nutrientnutritionalsupplementcommenc-ing before pregnancy could collectivelylower maternal glycemia and improvepregnancy outcomes across the generalpopulation We therefore undertook aninternational multicenter double-blindrandomized controlled trial (the Nutri-tional Intervention Preconception andDuring Pregnancy to Maintain Healthy Glu-cose Metabolism and Offspring Health[NiPPeR] study [23]) to investigatewhetherinterventionwith a nutritional supplementcontaining myo-inositol probiotics andadditional micronutrients (vitamins DB6 and B12 riboflavin and zinc) com-pared with a standard preconceptionmicronutrient supplement taken beforeand during pregnancy would promoteimproved maternal pregnancy glycemiaand outcomes

RESEARCH DESIGN AND METHODS

This international multicenter double-blind randomized controlled trial recruitedwomen who were planning to conceivewithin the next 6 months Women wererecruited in Singapore Auckland (NewZealand) and Southampton (UK) primar-ily from the community (Fig 1) Our trialwas approved by the UK Singapore andNew Zealand research ethics services ateach site (Southampton Health Research

Authority National Research Ethics ServiceCommittee South Central Research EthicsCommittee reference 15SC0142 the Na-tional Healthcare Group Domain SpecificReview Board Singapore reference 201500205 and the Health and Disability EthicsCommittee New Zealand reference 15NTA21) with confirmation from the rel-evant regulatory authorities that theformulation was not an investigationalmedicinal product Trial oversight andmonitoring were provided by an in-dependent data and safety monitoringcommittee

ParticipantsOn the basis of our previous population-based Southampton Womenrsquos Survey ourinitial target was 1800 recruits to have600 established pregnancies to study Re-cruitment was stopped at 1729 womenwhen it became clear that the projectednumber of pregnancies would exceed ourtarget (final conceptions n5 725) (Fig 1)

Women were eligible for trial enroll-ment if theywereaged18ndash38yearswereplanning to conceive within 6 monthsand had future maternity care at therecruiting centers In Singapore womenhad to be of homogeneous or mixedChinese Malay or Indian ethnicity Apriori women conceiving within 1 yearwere followed through pregnancy andbeyond Women were excluded if theywere pregnant or lactating at recruit-ment were undergoing assisted concep-tion (apart from taking clomiphene orletrozole alone) had known serious foodallergy or preexisting type 1 or type 2diabetes were using oral implanted orintrauterine contraceptionor takingmet-formin systemic steroids or anticonvul-sants or were undergoing treatment forHIV or hepatitis B or C in the past monthParticipants provided written informedconsent

The FormulationThe intervention and control formula-tions were packaged as a powder insachets and stored at 2ndash6degC untilmade up in water and taken twice dailywith similar sensory characteristics For-mulations were produced by SIIT (Mi-lan Italy) Ingredients commontocontroland intervention formulations were folicacid 400mgday iron12mgday calcium150 mgday iodine 150 mgday andb-carotene 720 mgday the interven-tion additionally included myo-inositol

2 NiPPeR Supplement Preconception and Pregnancy Diabetes Care

4 gday vitamin D 10 mgday riboflavin18 mgday vitamin B6 26 mgdayvitamin B12 52 mgday zinc 10 mgday and probiotics (Lactobacillus rham-nosus NCC 4007 [CGMCC 13724] andBifidobacterium animalis species lactisNCC 2818 [CNCM I-3446] average sur-vival counts remained within target overthe shelf life of the refrigerated product)

(24) Quantities were either standardamounts on the basis of previous trials(myo-inositol probiotics) (1214) amountsenhanced above those available in over-the-counter products (vitamin B6 vitaminB12 riboflavin) UK recommended dailyallowance amounts for pregnant women(vitamin D zinc folic acid iodine) orminimal amounts for micronutrients

linked with potential detrimental effectsat higher doses (ironb-carotene calcium)

Randomization and ProceduresParticipants were randomly assignedin a 11 ratio to the control or interven-tion groups through the electronic studydatabase (23) with stratification by siteand ethnicity to ensure balanced allo-cation to the groups Throughout thetrial participants investigators clini-cians and fieldworkers were unawareof the trial group assignments

Following a baseline 75-g oral glucosetolerance test (OGTT) anthropometricmeasurements and questionnaire ascer-tainment of thewomenrsquos characteristicstrial formulations were initiated beforeconception and continued until the endof pregnancy Participants were in-structed to contact the trial team assoon as they had a positive urinarypregnancy test which was then con-firmed by an ultrasonographic examina-tion at 6ndash8 weeks gestation Oncepregnant the women were followedup with questionnaires for resupply oftrial formulations with a 20-week fetalanomaly scan andwith a 28-week OGTTPlasma glucose was collected in antigly-colytic buffered tubes and transportedon an ice slurry to the laboratory within30 min using standardized protocolsacross sites Glucose measurements us-ing the glucose oxidase method wereundertaken by a single laboratory at eachsite with uniform external quality assur-ance per the Royal College of Patholo-gists of Australasia Quality AssuranceProgram Plasma 25-hydroxyvitamin Dand serum insulin concentrations (fast-ing 30 min and 120 min at preconcep-tion baseline fasting and 30 60 90 and120minat the28-weekOGTT)werebatchanalyzed by liquid chromatography-tandemmass spectrometry (Bevital Bergen Nor-way) and an electrochemiluminescenceimmunoassay (cobas Roche Diagnos-tics) respectively The HOMA for insulinresistance (HOMA2-IR) (httpswwwOCDEMoxacuk) (25) and Matsudaindex measure of insulin sensitivity(httpmmatsudadiabetes-smcjpxpointshtml) (26) were calculated

Antenatal peripartum and neonataloutcomes were ascertained from medicalrecordsAdherence to the trial formulationwas ascertained by sachet counting Goodadherence was defined a priori as at least60 of the sachets taken

Figure 1mdashConsolidated Standards of Reporting Trials (CONSORT) diagram outlining participantflow Premature ovarian failure daggerNew-onset Gravesrsquo disease hemoglobinopathy with ironoverload prolactinoma endometrial polyp endometrial atypia breast cancer DaggerWithdrewbecause product may contain animal remnants no storage space in refrigerator participantsuspicion of product-related symptoms sectIncludes two cases of trisomy 21 Klinefelter syndromeparaIncludes hypoplastic left heart syndrome unknown reason in private clinic Includes onestillbirth and one neonatal death T2D type 2 diabetes

carediabetesjournalsorg Godfrey and Associates 3

4 gday vitamin D 10 mgday riboflavin18 mgday vitamin B6 26 mgdayvitamin B12 52 mgday zinc 10 mgday and probiotics (Lactobacillus rham-nosus NCC 4007 [CGMCC 13724] andBifidobacterium animalis species lactisNCC 2818 [CNCM I-3446] average sur-vival counts remained within target overthe shelf life of the refrigerated product)

(24) Quantities were either standardamounts on the basis of previous trials(myo-inositol probiotics) (1214) amountsenhanced above those available in over-the-counter products (vitamin B6 vitaminB12 riboflavin) UK recommended dailyallowance amounts for pregnant women(vitamin D zinc folic acid iodine) orminimal amounts for micronutrients

linked with potential detrimental effectsat higher doses (ironb-carotene calcium)

Randomization and ProceduresParticipants were randomly assignedin a 11 ratio to the control or interven-tion groups through the electronic studydatabase (23) with stratification by siteand ethnicity to ensure balanced allo-cation to the groups Throughout thetrial participants investigators clini-cians and fieldworkers were unawareof the trial group assignments

Following a baseline 75-g oral glucosetolerance test (OGTT) anthropometricmeasurements and questionnaire ascer-tainment of thewomenrsquos characteristicstrial formulations were initiated beforeconception and continued until the endof pregnancy Participants were in-structed to contact the trial team assoon as they had a positive urinarypregnancy test which was then con-firmed by an ultrasonographic examina-tion at 6ndash8 weeks gestation Oncepregnant the women were followedup with questionnaires for resupply oftrial formulations with a 20-week fetalanomaly scan andwith a 28-week OGTTPlasma glucose was collected in antigly-colytic buffered tubes and transportedon an ice slurry to the laboratory within30 min using standardized protocolsacross sites Glucose measurements us-ing the glucose oxidase method wereundertaken by a single laboratory at eachsite with uniform external quality assur-ance per the Royal College of Patholo-gists of Australasia Quality AssuranceProgram Plasma 25-hydroxyvitamin Dand serum insulin concentrations (fast-ing 30 min and 120 min at preconcep-tion baseline fasting and 30 60 90 and120minat the28-weekOGTT)werebatchanalyzed by liquid chromatography-tandemmass spectrometry (Bevital Bergen Nor-way) and an electrochemiluminescenceimmunoassay (cobas Roche Diagnos-tics) respectively The HOMA for insulinresistance (HOMA2-IR) (httpswwwOCDEMoxacuk) (25) and Matsudaindex measure of insulin sensitivity(httpmmatsudadiabetes-smcjpxpointshtml) (26) were calculated

Antenatal peripartum and neonataloutcomes were ascertained from medicalrecordsAdherence to the trial formulationwas ascertained by sachet counting Goodadherence was defined a priori as at least60 of the sachets taken

Figure 1mdashConsolidated Standards of Reporting Trials (CONSORT) diagram outlining participantflow Premature ovarian failure daggerNew-onset Gravesrsquo disease hemoglobinopathy with ironoverload prolactinoma endometrial polyp endometrial atypia breast cancer DaggerWithdrewbecause product may contain animal remnants no storage space in refrigerator participantsuspicion of product-related symptoms sectIncludes two cases of trisomy 21 Klinefelter syndromeparaIncludes hypoplastic left heart syndrome unknown reason in private clinic Includes onestillbirth and one neonatal death T2D type 2 diabetes

carediabetesjournalsorg Godfrey and Associates 3

OutcomesThe primary outcomewas fasting andor1-h andor 2-h plasma glucose concen-trations following a 75-g OGTT at 28weeks gestation (a priori specificationincluded all conducted between 24 and32 weeks) On the basis of prior system-atic reviews principal prespecified sec-ondary outcomes were GDM (defined byInternational AssociationofDiabetes andPregnancy Study Groups criteria [27])large for gestational age at birth (usingsex- and gestational agendashspecific RoyalCollege of Paediatrics and Child Health2009 UK-World Health Organizationgrowth charts [28]) and preterm birthother secondary outcomes are shown inTable 3 and Supplementary Table 2 Ges-tational age was determined using a pre-specified algorithm (29) using menstrualdata (date of last menstrual period [LMP]self-reported cycle regularity mean cyclelengths in past 3 months) with first tri-mester fetal ultrasonographic crown-rumplength measurement used if 7 days dis-crepancy between LMP and scan datesuncertain LMP date irregular cycles orhormonal contraception use within past3 months

Statistical AnalysisConsidering the composite multiple endpointprimaryoutcomeofplasmaglucoseat three 75-g OGTT time points the pre-specified levelof statistical significancewasset as P 0017 (ie 005 divided by 3)With a sample size of 600 (300 in eachgroup) a two-sided test with a 5 0017and80power thedetectabledifferencesin fasting 1-h and 2-h glucose concen-trations between groups were 012 045and 034mmolL respectively (eachwith astandardized effect size of 0265 SDs usingvalues reported in the Hyperglycemia andAdversePregnancyOutcome[HAPO]study[30]) Suchmagnitudes of glycemic changeare expected to have clinically appreciableeffects on neonatal size and adiposity andlong-term offspring health (23)Glucose values were loge transformed

to achieve approximately normal distri-butions before using these values foranalysis Analysis of theprimaryoutcomeused linear regression on the intention-to-treat data set (all randomized partic-ipants who provided an OGTT at 24ndash32weeks) Group (control or intervention)was included as a predictor and regres-sions adjusted for site ethnicity and cor-responding preconception glycemia to

account forpotential imbalancebetweentreatment arms among pregnancies thatreached 24ndash32 weeks gestation Subse-quent regression models were addition-ally adjusted for prespecified factorsthought to be important predictors ofoutcomes and for other factors not bal-anced across control and interventiongroups and believed to be prognosticthese are listed in the relevant tables ofresults Likewise HOMA2-IR and Mat-suda indices were loge transformed andcomparisons at 28 weeks were similarlyadjusted butwith corresponding precon-ception values instead of preconceptionglycemia Estimates of differences (b)between the groups are presented with95 CIs t tests on loge glucose were alsoconducted Group comparisons were per-formed in two prespecified special interestsubgroups women who were overweightor obese (defined using ethnic-specificthresholds of BMI 23 kgm2 for Asiansincluding Chinese Indians Pakistani Ban-gladeshi Malay and mixed Asianand25 kgm2 for non-Asians includingWhite Caucasian Polynesian Black andmixedAsian-non-Asian) andwomenwithdocumented evidence of dysglycemia be-fore conception (defined as at least one ofthe following GDM in a previous preg-nancy or preconception baseline first visitraised HbA1c [$57 (39 mmolmol)]impaired fasting glucose [56ndash69 mmolL]or impaired glucose tolerance [2-h glucose78ndash110 mmolL]) (31)

The statistical analysis plan did notinclude correction for multiple compar-isons for secondary or other outcomestherefore results for these outcomes arereported as point estimates and 95 CIsand should not be used to infer definitivetreatment effects Analyses were per-formed using Stata 151 software (Sta-taCorp College Station TX)

RESULTS

Between 3 August 2015 and 12 May2017 1729 women were recruitedand randomly assigned to either thecontrol (n 5 859) or the intervention(n 5 870) group Pregnancies fulfillingthe study criteria and reaching 28 weeksgestation were achieved in 588 women292 (34) of 859 and 296 (34) of 870 inthe control and intervention groups re-spectively (Fig 1) 585 (995) of 588 hadan OGTT and provided the primary out-come of glycemia at 28 weeks gestation(median [interquartile range] 277weeks

[272ndash283]) Median BMI and otherbaseline characteristics were similar inthe two study groups providing the pri-mary outcome except fewer women inthe intervention group were obese nul-liparous or had a family history of di-abetes (Table 1)

Comparisons of unadjusted plasmaglucose values at the three OGTT timepoints between the control and inter-vention groups were not significantlydifferent (Table 2) In the primary out-come intention-to-treat analysis adjustingfor site ethnicity and matched precon-ception glucose values (where available)plasma glucose values did not differ be-tween study groups at each of the threetime points (P 0017) (Table 2) Fulladjustment as prespecified provided sim-ilar results (Table 2) The incidence of GDMwas similar between study groups (Table3) Sensitivity analyses excluding 32 partic-ipants who were subsequently found notto fulfill the eligibility criteria or did nothave good adherence gave similar results(Supplementary Table 1)

Glycemia outcomes were examined intwo special interest subgroups specified apriori where it was hypothesized that theintervention could have a greater effectAmong women who were overweight orobese before conception (n 5 258) in-tervention did not alter fasting and 1-hglycemia 2-h glycemia was higher in theintervention group (adjusted b 5 0076[95 CI 0020ndash0131] loge mmolL equiv-alent to 053 mmolL glucose) but with noincreased risk of GDM (SupplementaryTable 1) In women with documenteddysglycemia before conception (n 5 94)glycemia at 28 weeks and GDM incidenceswere similar between study groups(Supplementary Table 1) Interactionterms in the fully adjusted models in-cluding all women showednoevidenceofdifferential effectson28-weekglycemia inresponse to the intervention among thethree study sites and among ethnicitiesAs measures of insulin resistance andinsulinsensitivity respectivelyHOMA2-IR(adjustedb520022 [20090 to 0046])and Matsuda index (adjusted b 5 0001[20068 to 0070] at 28 weeks were alsosimilar between study groups

Adjusting for covariates there was alower incidence of preterm birth (37weeks gestation) in the interventiongroup (adjusted risk ratio [aRR] 043[95 CI 022ndash082]) (Table 3) Therewere similar trends in both spontaneous

4 NiPPeR Supplement Preconception and Pregnancy Diabetes Care

and iatrogenic preterm births The effectof the interventionwasprincipally observedfor late preterm births (34ndash36 completedweeks gestation aRR 041 [020ndash085]) andpreterm births associated with pretermprelabor rupture of membranes (PPROM)

(aRR 021 [006ndash069]) with the incidenceof PPROM itself also reduced (aRR 039[016ndash097]) (Table 3) There were nodifferences in mean gestational age atdelivery neonatal unit admissions andneonatal septicemia (Table 3)

The incidence of major postpartumhemorrhage (1-L blood loss) was lowerin the intervention group (aRR 044 [95CI 020ndash094]) this reduction was notexplained by cesarean section deliveryrates or birth weight which were similarbetween study groups (Table 3) Therewere no differences between groups forthe secondary outcomes of miscarriagecongenital anomaly severe nausea andvomiting of pregnancy hypertensive dis-orders of pregnancy intrauterine deathneonatal death neonatal hypoglycemiaand other neonatal complications (Table3 and Supplementary Table 2)

Among women who provided the pri-mary and birth outcomes overall sup-plement adherence was good with 807having 80ndash100 adherence 159 having60ndash80 adherence and only 34 hav-ing 60 adherence averaged from re-cruitment to delivery Adherence wassimilar in the control and interventiongroups As a further indication of goodadherence 25-hydroxyvitamin D concen-trations in the intervention and controlgroups were similar at the preconceptionbaseline but higher in the interventioncompared with the control group at the28-weekOGTT (median928vs 630nmolL) Among all randomized women with-drawals because of perceived minor sideeffects from the supplement were similarin both groups (83 control 75 inter-vention) as were other serious adverseevents (23 control 28 intervention)(Supplementary Table 3)

CONCLUSIONS

In this international multicenter ran-domized controlled trial nutritionalformulation enriched with myo-inositolprobiotics and multiple micronutrients

Table 1mdashBaseline preconception characteristics of women who provided a primaryoutcome

Control(n 5 290)

Intervention(n 5 295)

Age (years) 3014 (330) 3053 (340)

BMI (kgm2) 2375 (2134ndash275) 2365 (2116ndash2623)Overweight 68 (235) 89 (303)Obese 61 (210) 40 (136)

Ethnic originWhite Caucasian 167 (576) 180 (610)Chinese 73 (252) 72 (244)South Asian (Indian Pakistani Bangladeshi) 15 (52) 15 (51)Malay 12 (41) 11 (37)Other (mixed Black Polynesian) 23 (79) 17 (58)

SiteNew Zealanddagger 116 (400) 113 (383)Singapore 82 (283) 84 (285)UKDagger 92 (317) 98 (332)

Nulliparous 200 (690) 171 (580)

Smoker 12 (42) 12 (41)

Family history of type 2 diabetes 79 (272) 56 (191)

Household income quintile5 (lowest) 5 (17) 2 (07)4 20 (69) 24 (81)3 69 (238) 54 (183)2 95 (328) 109 (370)1 (highest) 91 (314) 92 (312)Not available 10 (35) 14 (48)

Preconception plasma glucose (OGTT)(mmolL)

Fasting 485 (452ndash518) 485 (463ndash518)30 min 781 (671ndash890) 770 (660ndash901)2 h 540 (441ndash638) 551 (463ndash627)

Data are mean (SD) median (interquartile range) or n () Defined using ethnic-specificthresholds for overweight and obesity BMI $23 to 275 and $275 kgm2 respectively forAsians including Chinese Indians Pakistani Bangladeshi Malay mixed Asian BMI$25 to30and$30 kgm2 respectively for non-Asians includingWhite Caucasian Polynesian Black mixedAsian-non-Asian dagger729 White Caucasian 166 any Asian 105 other Dagger948 WhiteCaucasian 26 any Asian 26 other

Table 2mdashPrimary outcome of maternal OGTT plasma glucose values at 28 (24ndash32) weeks gestation

Control Interventionb (95 CI) for loge glucose

(loge mmolL)

OGTT time point nPlasma glucose

(mmolL) nPlasma glucose

(mmolL) Adjusted Fully adjusteddagger

Fasting 290 441 (408ndash463) 295 430 (408ndash463) 20004 (20018 to 0011) 00002 (20014 to 0014)P value d 055 063 098

1 h 283 802 (660ndash923) 294 824 (693ndash945) 0025 (20014 to 0064) 0036 (20003 to 0074)P value d 026 022 007

2 h 287 649 (551ndash770) 295 660 (584ndash802) 0040 (0004ndash0077) 0043 (0006ndash0081)P value d 003 003 002

Data aremedian (interquartile range [unadjusted]) unless otherwise indicated All P values (t tests on loge-transformed glucose and linear regressions)were not significant$0017 (a priori statistical significance is P 0017) Loge glucose at 24ndash32 weeks adjusted for site ethnicity and baseline logeglucose (for fastingand2honly baseline1-hglucosenotavailable)n5584and578 for fastingand2-hglucose respectively as a resultofmissingvaluesfor corresponding preconception glucose daggerLoge glucose at 24ndash32 weeks adjusted for site ethnicity maternal age prepregnancy BMI preconceptionsmoking parity family history of diabetes and baseline loge glucose (for fasting and 2 h only baseline 1-h glucose not available) n5 581 574 and575 for fasting 1-h and 2-h glucose respectively as a result of missing data

carediabetesjournalsorg Godfrey and Associates 5

Table 3mdashSecondary outcomes of pregnancy complications delivery events and neonatal outcomes with the NiPPeRintervention compared with control

Control Intervention Effect of intervention

Pregnancy complications RR (95 CI)daggerGDM (denominator all those who completed OGTT

at 24ndash32 weeks)64283 (226) 73294 (248) 122 (092ndash162)

(n 5 545)Miscarriages24weeks gestation (denominator all those

who became pregnant after the second preconceptionvisit)

51359 (142) 50366 (137) 091 (062ndash133)(n 5 688)

Congenital abnormalitiesDagger (denominator all reaching7 weeks)

16314 (51) 15330 (45) 083 (035ndash196)(n 5 557)

Severe nausea and vomiting of pregnancysect (denominatorall reaching 7 weeks)

51305 (167) 43322 (134) 086 (057ndash130)(n 5 553)

Hypertensive disorders of pregnancy both preeclampsia|and pregnancy-induced hypertensionpara (denominatorall pregnancies reaching $24 weeks)

14292 (48) 12294 (41) 119 (055ndash259)(n 5 557)

Delivery outcomes (denominator all live births $24 weeksunless otherwise stated)

Mean difference (95 CI)or RR (95 CI)

Gestational age at birth in decimal weeks 392 (174) 393 (178) 020 (2006 to 046)(n 5 553)

All preterm deliveries (37 weeks)(spontaneous labor onset iatrogenic nn)

27292 (92)(1215)daggerdagger

17293 (58)(89)DaggerDagger

043 (022ndash082)(n 5 553)

Late preterm deliveries (34 weeks10 days to 36weeks16 days) (spontaneous labor onset iatrogenic nn)

22292 (75)(1111)

13293 (44)(67)

041 (020ndash085)(n 5 553)

PPROM 19280 (68) 8277 (29) 039 (016ndash097)(n 5 526)

Preterm deliveries associated with PPROM(spontaneous labor onset iatrogenic nn)

17280 (61)(89)

5277 (18)(23)

021 (006ndash069)(n 5 526)

Cesarean section delivery(elective emergency nn)

85292 (291)(4144)

84293 (287)(3450)

099 (076ndash128)(n 5 553)

Major postpartum hemorrhage (1-L blood lossdenominator all pregnancies reaching $24 weeks)

24292 (82) 9294 (31) 044 (020ndash094)(n 5 554)

Neonatal outcomes (denominator all live births$24weeks) Mean difference (95 CI)or RR (95 CI)

Birth weight (kg) 330 (054) 333 (055) 005 (2003 to 013)(n 5 553)

Large for gestational age (90th centile adjusted for sexand gestational age)

22292 (75) 21293 (72) 094 (054ndash163)(n 5 555)

Small for gestational age (10th centile adjusted for sexand gestational age)

21292 (72) 24293 (82) 134 (079ndash229)(n 5 555)

Admission to neonatal unit 19290 (66) 24293 (82) 111 (057ndash217)(n 5 550)

Neonatal hypoglycemia requiring dextrose treatment 24292 (82) 19293 (65) 079 (043ndash148)(n 5 553)

Neonatal septicemia (positive blood culture) 0287 (0) 2288 (07) Insufficient to analyze

Data aremean (SD) or n () unless otherwise indicated RR risk ratio According to International Association of Diabetes and Pregnancy Study Groupscriteria (fasting glucose$51mmolL or 1-hglucose$100mmolL or 2-h glucose$85mmolL) (24) includesonlywomenwith completeOGTTdata atall three time points daggerAdjusted for site ethnicity maternal age preconception BMI household income level parity preconception smokingpreconception baseline fasting glucose family history of diabetes and offspringrsquos sex (not applicable for miscarriages) DaggerIncludes anomalies in thefollowing categories in the control group four cases of karyotypicmultiple anomalies two cardiovascular six genitourinary two respiratory twomusculoskeletal in the interventiongroupfivecasesofkaryotypicmultipleanomalies threecardiovascular fourgenitourinary threemusculoskeletalsectRequiring admission to the hospital for intravenous rehydration with or without significantly deranged biochemistry or weight loss |Preeclampsiadefinedashypertension inpregnancyassociatedwithsignificantproteinuriaorevidenceofmultisystemdisorder therewerenodifferences in incidencebetween study groups paraPregnancy-induced hypertension defined as isolated nonproteinuric hypertension in a previously normotensive woman oraggravationofhypertensionduringpregnancy therewerenodifferences in incidencebetweenstudygroupsAdjusted for siteethnicitymaternalagepreconceptionBMIhousehold income level parity smokingduringpregnancy offspring sex (except for largeand small for gestational age) and (wheredatawereavailable) 28weeks gestation fastingglucose ByRoyal Collegeof Paediatrics andChildHealth2009UK-WorldHealthOrganization growthcharts (25) Use of respective local population charts Fenton growth charts and World Health Organization INTERGROWTH-21st charts did notmaterially alter resultsdaggerdaggerIatrogenicpretermbirths include casesof inductionof laborandnonlabor cesarean section Indications for iatrogenicdeliveryin the control group were as follows five for PPROM alone four for PPROM plus another indication (previous cesarean section vasa previa breechpresentation maternal medical condition) five for placental-associated conditions (intrauterine growth restriction with or without preeclampsia orplacental abruption) and one maternal medical condition DaggerDaggerIndications for iatrogenic delivery in the intervention group were as follows three forPPROM alone four for placental-associated conditions (intrauterine growth restriction with or without preeclampsia or placental abruption) onematernal medical condition and one fetal anomaly with breech presentation

6 NiPPeR Supplement Preconception and Pregnancy Diabetes Care

commenced preconception and contin-ued throughout pregnancy didnot resultin loweredmaternalglycemiaat28weeksgestation There were no significant ef-fects on the incidence of GDM and large-for-gestational-age infants Interventionreduced pretermbirth affirmingfindingsfrom previous myo-inositol trials Wealso found a reduction in the incidenceof major postpartum hemorrhageThree previous trials of open-label

myo-inositol taken from early pregnancyto prevent GDM inwomen in Italy focusedon discrete high-risk groups for dysglyce-mia namely those who were overweightor obese or with a family history of type 2diabetes (32) All showed a similar reduc-tion inGDMwithanoverallodds ratio (OR)of034aswellas lower fasting1-hand2-hglycemia in a 24ndash28-week OGTT (32) Afurther small trial among women withimpaired fasting glycemia in early preg-nancy reported a large reduction in GDMrisk (relative risk 0127) alongside lowerfasting and 1-h glycemia (33) These ob-servations contrast with the finding of nodifference in glycemia at 28 weeks ges-tation with our intervention However ourstudy intervention was administered double-blinded over two important periodsdpreconception and pregnancydin a generalpopulation of women planning pregnancyacross multiple centers and ethnicitiesexcluding those with existing or newlydiagnosed type 1 or 2 diabetes precon-ception Subgroupanalysis of overweightand obese women or those with docu-mented dysglycemia did not show anybenefit of our intervention on glycemiaalthough the trial was not powered to doso Our results however are consistentwith an Irish trial of a lower dose ofmyo-inositol combinedwith D-chiro-inositol inwomen with a family history of type 1 or2 diabetes which showed no impact onglycemia (34)In another small trial dietary counsel-

ing and probiotics in pregnant womenimproved glycemia (OR for elevated glu-cose 031) and insulin sensitivity (14)these findings are discordant with oursdespite using the same probiotic combi-nation However a meta-analysis of10 trials of probiotic supplementationin pregnancy found no difference infasting glycemia (despite a reductionin HOMA-IR) (13) and a recently com-pleted trial showednodifference inGDMrates with slightly higher fasting glyce-mia (35) Inconsistent findings may be

attributable to different populations andconcurrent useof different combinationsof prenatal supplements

Meta-analysis of the group of threeItalian myo-inositol studies found a re-duction in fetal macrosomia (OR 038)and large for gestational age (OR 052)(32) in contrast to the finding of nodifference with our intervention Thesame meta-analysis also found a reduc-tion in preterm birth (OR 044) (32) withthe separate Irish inositol trial of a lowermyo-inositol dose observing a nonstat-istically significant trend of fewer pre-termbirths in the intervention group (2vs 7 P 5 011) (34) Another meta-analysis of trials of multiple micronu-trient supplements concluded that thesupplements probably also lead to aslight reduction in preterm birth (aRR095 [95CI 090ndash101]) (36) In contrastnone of the probiotic trials reported achange in preterm birth rates Nonethe-less findings of a meta-analysis of myo-inositol trials (12) are consistent with ourdemonstration of a reduction in pretermbirth Furthermore our finding of a reduc-tion particularly in PPROM and PPROM-associatedpretermbirths in the interventiongroup indicates that this is the likelyexplanation for reduced prematurityApproximately 30 of preterm birthsare preceded by PPROM of which 60ndash70 occur late preterm after 34 weeksgestation (37) PPROM is postulated tobreak down the barrier to ascendingpathogens resulting in intrauterine in-fection increased inflammation and thetriggering of preterm labor In our trialtherewasonlya reduction inpretermbirthswith intervention without any associateddifference in clinically detectable infectionsbetween study groups Potential mecha-nisms for a preventive effect on PPROM-associated preterm births in our study mayinclude anti-inflammatory effects of myo-inositol (38) and a contribution from thepotential synergistic effect of micronu-trients including zinc and vitamin D (39)Our results of specifically a reduction in latepreterm births is still clinically significantsince prematurity survivors in this groupconstitute the majority of cases of neuro-developmental disability associated withpretermdelivery (40) thus the supplementcould potentially be impactful

Our observation that intervention wasassociated with a reduction in majorpostpartum hemorrhage is novel andhas not previously been reported with

myo-inositol probiotics or the micro-nutrients enriched in the supplementused Since this observation is not ex-plained by differences in cesarean sec-tion rates parity or birth size this effectmay be mediated by other factors suchas length of labor myometrial contrac-tility or blood coagulation which remainto be examined Of note our study foundno difference in hypertensive disordersof pregnancy which is in contrast to aprobiotic trial reporting an increasedtrend of preeclampsia (35) possibly be-cause of counteraction by other compo-nents in our intervention However ourresult of a lack of effect on hypertensivedisorders is consistent with the myo-inositol trials and a vitamin D trial (20)that also reported no difference

Collectively available data suggest thatfurther studies are required todeterminewhether there are subpopulations doseregimensor interventioncommencementtime points when myo-inositol and pro-bioticsmay lowermaternal glycemia Con-versely there appears to be a potentialbenefitofmyo-inositolndashcontainingsupple-ments in reducing pretermbirthWhetherthe other components of our interventioncouldplay anadditive role inpretermbirthreduction is unclear Assessment of lon-gitudinal changes in levels ofmyo-inositoland the other components may shedfurther light on potential pathways ofeffect which may pave the way for thedesign of more definitive trials in thefuture

In contrast to most previously pub-lished myo-inositol and probiotic trialsmajor strengths of our study are itsdouble-blind design and inclusion ofmultiethnic women from three differentcontinents Nevertheless generalizabil-ity is limited by the lack of Latina andNative American Indians and only a fewBlack and Polynesian participants by lessthan half of participants being over-weightobese unlike typical US andWestern populations and by our trialbeing conducted in high-resource set-tings Microbiome data were not avail-able to confirm viability of the probioticin participant samples and sachet countsprovide a limited measure of adherenceto the intervention good adherence ishowever suggested by higher plasma25-hydroxyvitamin D concentrations inthe intervention group at 28 weeks ges-tation Another limitation is that westudied a combination of myo-inositol

carediabetesjournalsorg Godfrey and Associates 7

commenced preconception and contin-ued throughout pregnancy didnot resultin loweredmaternalglycemiaat28weeksgestation There were no significant ef-fects on the incidence of GDM and large-for-gestational-age infants Interventionreduced pretermbirth affirmingfindingsfrom previous myo-inositol trials Wealso found a reduction in the incidenceof major postpartum hemorrhageThree previous trials of open-label

myo-inositol taken from early pregnancyto prevent GDM inwomen in Italy focusedon discrete high-risk groups for dysglyce-mia namely those who were overweightor obese or with a family history of type 2diabetes (32) All showed a similar reduc-tion inGDMwithanoverallodds ratio (OR)of034aswellas lower fasting1-hand2-hglycemia in a 24ndash28-week OGTT (32) Afurther small trial among women withimpaired fasting glycemia in early preg-nancy reported a large reduction in GDMrisk (relative risk 0127) alongside lowerfasting and 1-h glycemia (33) These ob-servations contrast with the finding of nodifference in glycemia at 28 weeks ges-tation with our intervention However ourstudy intervention was administered double-blinded over two important periodsdpreconception and pregnancydin a generalpopulation of women planning pregnancyacross multiple centers and ethnicitiesexcluding those with existing or newlydiagnosed type 1 or 2 diabetes precon-ception Subgroupanalysis of overweightand obese women or those with docu-mented dysglycemia did not show anybenefit of our intervention on glycemiaalthough the trial was not powered to doso Our results however are consistentwith an Irish trial of a lower dose ofmyo-inositol combinedwith D-chiro-inositol inwomen with a family history of type 1 or2 diabetes which showed no impact onglycemia (34)In another small trial dietary counsel-

ing and probiotics in pregnant womenimproved glycemia (OR for elevated glu-cose 031) and insulin sensitivity (14)these findings are discordant with oursdespite using the same probiotic combi-nation However a meta-analysis of10 trials of probiotic supplementationin pregnancy found no difference infasting glycemia (despite a reductionin HOMA-IR) (13) and a recently com-pleted trial showednodifference inGDMrates with slightly higher fasting glyce-mia (35) Inconsistent findings may be

attributable to different populations andconcurrent useof different combinationsof prenatal supplements

Meta-analysis of the group of threeItalian myo-inositol studies found a re-duction in fetal macrosomia (OR 038)and large for gestational age (OR 052)(32) in contrast to the finding of nodifference with our intervention Thesame meta-analysis also found a reduc-tion in preterm birth (OR 044) (32) withthe separate Irish inositol trial of a lowermyo-inositol dose observing a nonstat-istically significant trend of fewer pre-termbirths in the intervention group (2vs 7 P 5 011) (34) Another meta-analysis of trials of multiple micronu-trient supplements concluded that thesupplements probably also lead to aslight reduction in preterm birth (aRR095 [95CI 090ndash101]) (36) In contrastnone of the probiotic trials reported achange in preterm birth rates Nonethe-less findings of a meta-analysis of myo-inositol trials (12) are consistent with ourdemonstration of a reduction in pretermbirth Furthermore our finding of a reduc-tion particularly in PPROM and PPROM-associatedpretermbirths in the interventiongroup indicates that this is the likelyexplanation for reduced prematurityApproximately 30 of preterm birthsare preceded by PPROM of which 60ndash70 occur late preterm after 34 weeksgestation (37) PPROM is postulated tobreak down the barrier to ascendingpathogens resulting in intrauterine in-fection increased inflammation and thetriggering of preterm labor In our trialtherewasonlya reduction inpretermbirthswith intervention without any associateddifference in clinically detectable infectionsbetween study groups Potential mecha-nisms for a preventive effect on PPROM-associated preterm births in our study mayinclude anti-inflammatory effects of myo-inositol (38) and a contribution from thepotential synergistic effect of micronu-trients including zinc and vitamin D (39)Our results of specifically a reduction in latepreterm births is still clinically significantsince prematurity survivors in this groupconstitute the majority of cases of neuro-developmental disability associated withpretermdelivery (40) thus the supplementcould potentially be impactful

Our observation that intervention wasassociated with a reduction in majorpostpartum hemorrhage is novel andhas not previously been reported with

myo-inositol probiotics or the micro-nutrients enriched in the supplementused Since this observation is not ex-plained by differences in cesarean sec-tion rates parity or birth size this effectmay be mediated by other factors suchas length of labor myometrial contrac-tility or blood coagulation which remainto be examined Of note our study foundno difference in hypertensive disordersof pregnancy which is in contrast to aprobiotic trial reporting an increasedtrend of preeclampsia (35) possibly be-cause of counteraction by other compo-nents in our intervention However ourresult of a lack of effect on hypertensivedisorders is consistent with the myo-inositol trials and a vitamin D trial (20)that also reported no difference

Collectively available data suggest thatfurther studies are required todeterminewhether there are subpopulations doseregimensor interventioncommencementtime points when myo-inositol and pro-bioticsmay lowermaternal glycemia Con-versely there appears to be a potentialbenefitofmyo-inositolndashcontainingsupple-ments in reducing pretermbirthWhetherthe other components of our interventioncouldplay anadditive role inpretermbirthreduction is unclear Assessment of lon-gitudinal changes in levels ofmyo-inositoland the other components may shedfurther light on potential pathways ofeffect which may pave the way for thedesign of more definitive trials in thefuture

In contrast to most previously pub-lished myo-inositol and probiotic trialsmajor strengths of our study are itsdouble-blind design and inclusion ofmultiethnic women from three differentcontinents Nevertheless generalizabil-ity is limited by the lack of Latina andNative American Indians and only a fewBlack and Polynesian participants by lessthan half of participants being over-weightobese unlike typical US andWestern populations and by our trialbeing conducted in high-resource set-tings Microbiome data were not avail-able to confirm viability of the probioticin participant samples and sachet countsprovide a limited measure of adherenceto the intervention good adherence ishowever suggested by higher plasma25-hydroxyvitamin D concentrations inthe intervention group at 28 weeks ges-tation Another limitation is that westudied a combination of myo-inositol

carediabetesjournalsorg Godfrey and Associates 7

and probiotics with micronutrients Pre-vious studies have generally examinedthese individually or as a less complexformulation (eg myo-inositol with vi-tamin D) (12) We cannot exclude thepossibility that constituents of the sup-plement may have moderated individualeffects in lowering maternal glycemia orthat intervening in the general popula-tion (vs a high-risk population) or com-mencing intervention preconception (vsearly pregnancy) altered the impact ongestational glycemia In conclusion ourtrial showed that supplementation withmyo-inositol probiotics and multiplemicronutrients preconception and inpregnancy did not lower gestational gly-cemia but did reduce preterm birth

Acknowledgments The authors thank theparticipants and their families for their enthu-siastic involvement in the study the study re-search staff and hospital clinical staff atparticipating centers and operational supportstaff for contributions to the trial and themembers of the independent data monitoringand safety committee for invaluable contribu-tions and for overseeing the conduct of the trialFunding and Duality of Interest Public goodfunding for this investigator-led study is throughthe Medical Research Council (UK) (MRC) aspart of an MRC award to the MRC LifecourseEpidemiology Unit (MC_UU_120114) the Sin-gapore National Research Foundation the Na-tional Medical Research Council (SG) (NMRC)(NMRCTCR012-NUHS2014) the National Uni-versity of Singapore (NUS) theAgency for ScienceTechnology and Research (SG) as part of theGrowth Development and Metabolism Programmeof the Singapore Institute for Clinical Sciences (H1701a0005) and as part of Gravida a New ZealandGovernment Centre of Research Excellence Fund-ing for provision of the intervention and controldrinks and to cover aspects of the fieldwork for thestudy was provided by Societe Des Produits NestleSA under a research agreement with the Universityof Southampton Auckland UniServices Ltd Singa-pore Institute for Clinical Sciences National Uni-versity Hospital Singapore PTE Ltd and NUS KMGis supported by the National Institute for HealthResearch (NIHR) (Senior Investigator AwardNF-SI-0515-10042) NIHR Southampton 1000DaysPlusGlobal Nutrition Research Group (1763154)and NIHR Southampton Biomedical Research Cen-ter (IS-BRC-1215-20004) the British Heart Foun-dation (RG15173174) and the EuropeanUnion(Erasmus1 Programme Early Nutrition eAcademySoutheast Asia 573651-EPP-1-2016-1-DE-EPPKA2-CBHE-JP and ImpENSA 598488-EPP-1-2018-1-DE-EPPKA2-CBHE-JP) KMG has received reimbursement forspeaking at conferences sponsored by compa-nies selling nutritional products KMG SJBYSC WC and S-YC are part of an academicconsortium that has received grants fromAbbott Nutrition Nestle SA Danone andBenevolentAI Bio Ltd outside the submittedwork KMG YSCWC andS-YC report grants

from Societe Des Produits Nestle SA during theconductof thestudyandareco-inventorsonpatentfilings by Nestle SA relating to the NiPPeR in-tervention or its components S-YC is supportedby a Singapore NMRC Clinician Scientist Award(NMRCCSA-INV00102016) and has receivedreimbursement and honoraria into her researchfunds fromNestle SA for a half-day consultancyand for speaking at a conference No otherpotential conflicts of interest relevant to thisarticle were reportedThe funders had no role in the data collection

and analysis and the decision to submit forpublicationAuthor Contributions KMG SJB SE-HTK HNWC andS-YC contributed to thedatacollection and assimilation KMG SJB WCand S-YC contributed to the statistical analysisand vouch for the accuracy and completeness ofthe data and analyses and for the fidelity of thetrial to the protocol KMG PNB and YSCconceptualized and designed the study KMGWC and S-YC led thewriting of themanuscriptAllauthorscontributedtothe interpretationof thedata critical revision of the manuscript andapproval of the final manuscript for submissionKMG and SJB are the guarantors of this workand as such had full access to all the data in thestudy and take responsibility for the integrity ofthe data and the accuracy of the data analysis

References1 Farrar D SimmondsMBryantM et al Hyper-glycaemia and risk of adverse perinatal out-comes systematic review and meta-analysisBMJ 2016354i46942 Metzger BE Lowe LP Dyer AR et al HAPOStudy Cooperative Research Group Hyperglyce-mia and adverse pregnancy outcomes N Engl JMed 20083581991ndash20023 Lowe WL Jr Lowe LP Kuang A et al HAPOFollow-up Study Cooperative Research GroupMaternal glucose levels during pregnancy andchildhood adiposity in the Hyperglycemia andAdverse Pregnancy Outcome follow-up studyDiabetologia 201962598ndash6104 Lain KY Catalano PM Metabolic changes inpregnancy Clin Obstet Gynecol 200750938ndash9485 Sacks DA HaddenDRMareshM et al HAPOStudyCooperativeResearchGroupFrequencyofgestational diabetes mellitus at collaboratingcenters based on IADPSG consensus panel-recommended criteria the Hyperglycemia andAdverse Pregnancy Outcome (HAPO) study Di-abetes Care 201235526ndash5286 International Diabetes Federation IDF Dia-betes Atlas 8th edition Brussels Belgium In-ternational Diabetes Federation 20177 Crowther CA Hiller JE Moss JR McPhee AJJeffriesWS Australian Carbohydrate IntoleranceStudy in Pregnant Women (ACHOIS) Trial GroupEffect of treatment of gestational diabetes mel-litus on pregnancy outcomes N Engl JMed 20053522477ndash24868 Damm P Houshmand-Oeregaard A KelstrupL Lauenborg J Mathiesen ER Clausen TD Ges-tational diabetes mellitus and long-term conse-quences for mother and offspring a view fromDenmark Diabetologia 2016591396ndash13999 Poston L Bell R Croker H et al UPBEATTrial Consortium Effect of a behavioural

intervention in obese pregnant women (theUPBEAT study) a multicentre randomisedcontrolled trial Lancet Diabetes Endocrinol20153767ndash77710 Rono K Grotenfelt NE Klemetti MM et alEffect of a lifestyle intervention during pregnancy-findings from the Finnish Gestational DiabetesPrevention trial (RADIEL) J Perinatol 2018381157ndash116411 WatkinsOC YongHEJ SharmaN Chan S-Y Areview of the role of inositols in conditions ofinsulin dysregulation and in uncomplicated andpathological pregnancy Crit Rev Food Sci Nutr 7December 2020 [Epub ahead of print] DOI 101080104083982020184560412 ZhangH Lv Y Li Z Sun L GuoW The efficacyof myo-inositol supplementation to prevent ges-tational diabetes onset a meta-analysis of ran-domized controlled trials J Matern FetalNeonatal Med 2019322249ndash225513 Zheng J Feng Q Zheng S Xiao X The effectsof probiotics supplementation on metabolichealth in pregnant women an evidence basedmeta-analysis PLoS One 201813e019777114 Laitinen K Poussa T Nutrition Allergy Mu-cosal Immunology and Intestinal MicrobiotaGroup Probiotics and dietary counselling con-tribute to glucose regulation during and afterpregnancy a randomised controlled trial Br JNutr 20091011679ndash168715 Chen Q Feng Y Yang H et al A vitaminpattern diet is associated with decreased risk ofgestational diabetes mellitus in Chinese womenresults from a case control study in TaiyuanChina J Diabetes Res 20192019523230816 Lai JS PangWW Cai S et al High folate andlow vitamin B12 status during pregnancy isassociated with gestational diabetes mellitusClin Nutr 201837940ndash94717 Rogne T Tielemans MJ Chong MF et alAssociations of maternal vitamin B12 concen-tration in pregnancy with the risks of pretermbirth and low birth weight a systematic reviewand meta-analysis of individual participant dataAm J Epidemiol 2017185212ndash22318 Sahariah SA Potdar RD Gandhi M et al Adaily snack containing leafy green vegetablesfruit and milk before and during pregnancyprevents gestational diabetes in a randomizedcontrolled trial in Mumbai India J Nutr 20161461453Sndash1460S19 Zhang Y Gong Y Xue H Xiong J Cheng GVitamin D and gestational diabetes mellitusa systematic review based on data free ofHawthorne effect BJOG 2018125784ndash79320 Corcoy RMendoza LC SimmonsD et al TheDALI vitamin D randomized controlled trial forgestational diabetes mellitus prevention nomajor benefit shown besides vitamin D suffi-ciency Clin Nutr 202039976ndash98421 Hambidge KM Westcott JE Garces A et alWomen First Preconception Trial Study Group Amulticountry randomized controlled trial of com-prehensive maternal nutrition supplementationinitiated before conception the Women Firsttrial Am J Clin Nutr 2019109457ndash46922 Stephenson J Vogel C Hall J et al Pre-conception Partnership Preconception health inEngland a proposal for annual reporting withcore metrics Lancet 20193932262ndash227123 Godfrey KM Cutfield W Chan SY Baker PNNiPPeR Study Group Nutritional Intervention

8 NiPPeR Supplement Preconception and Pregnancy Diabetes Care

Preconception and During Pregnancy to Main-tain Healthy Glucose Metabolism and OffspringHealth (ldquoNiPPeRrdquo) study protocol for a rando-mised controlled trial Trials 20171813124 Luoto R Laitinen K Nermes M Isolauri EImpactofmaternalprobiotic-supplementeddietarycounselling on pregnancy outcome and prenataland postnatal growth a double-blind placebo-controlled study Br J Nutr 20101031792ndash179925 Levy JCMatthewsDR HermansMP Correcthomeostasis model assessment (HOMA) evalu-ation uses the computer program Diabetes Care1998212191ndash219226 DeFronzo RA Matsuda M Reduced timepoints to calculate the composite indexDiabetesCare 201033e9327 Metzger BE Gabbe SG Persson B et alInternational Association of Diabetes and Preg-nancy Study Groups Consensus Panel Interna-tional association of diabetes and pregnancystudy groups recommendations on the diagnosisand classification of hyperglycemia in pregnancyDiabetes Care 201033676ndash68228 Cole TJ Williams AF RCPCH Growth ChartExpert Group Revised birth centiles for weightlength and head circumference in the UK-WHOgrowth charts [published correction appears inAnn Hum Biol 201138241] Ann Hum Biol 2011387ndash1129 Pike KC Crozier SR Lucas JSA et al South-ampton Womenrsquos Survey Study Group Patterns

of fetal and infant growth are related to atopyand wheezing disorders at age 3 years Thorax2010651099ndash110630 Lowe LP Metzger BE Dyer AR et al HAPOStudy Cooperative Research Group Hyperglyce-mia and Adverse Pregnancy Outcome (HAPO)Study associations of maternal A1C and glucosewith pregnancy outcomes Diabetes Care 201235574ndash58031 American Diabetes Association 2 Classifi-cation and diagnosis of diabetes Standards ofMedical Care in Diabetesd2019 Diabetes Care201942(Suppl 1)S13ndashS2832 Santamaria A Alibrandi A Di Benedetto Aet al Clinical and metabolic outcomes in preg-nant women at risk for gestational diabetesmellitus supplemented with myo-inositol a sec-ondaryanalysis from3RCTsAmJObstetGynecol2018219300e1ndash300e633 Matarrelli B Vitacolonna E DrsquoAngelo Met al Effect of dietary myo-inositol supple-mentation in pregnancy on the incidence ofmaternal gestational diabetes mellitus andfetal outcomes a randomized controlled trialJ Matern Fetal Neonatal Med 201326967ndash97234 Farren M Daly N McKeating A Kinsley BTurner MJ Daly S The prevention of gestationaldiabetes mellitus with antenatal oral inositolsupplementation a randomized controlled trialDiabetes Care 201740759ndash763

35 Callaway LK McIntyre HD Barrett HL et alProbiotics for the prevention of gestational di-abetesmellitus in overweight andobesewomenfindings from the SPRING double-blind random-ized controlled trial Diabetes Care 201942364ndash37136 Keats EC Haider BA Tam E Bhutta ZAMultiple-micronutrient supplementation forwomen during pregnancy Cochrane DatabaseSyst Rev 20193CD00490537 Goldenberg RL Culhane JF Iams JD RomeroR Epidemiology and causes of preterm birthLancet 200837175ndash8438 Unver N DelgadoO Zeleke K et al ReducedIL-6 levels and tumor-associated phospho-STAT3are associatedwith reduced tumor developmentin a mouse model of lung cancer chemopreven-tion with myo-inositol Int J Cancer 20181421405ndash141739 Kucukaydin Z Kurdoglu M Kurdoglu ZDemir H Yoruk IH Selected maternal fetaland placental trace element and heavy metalandmaternal vitamin levels in pretermdeliverieswith or without preterm premature rupture ofmembranes J Obstet Gynaecol Res 201844880ndash88940 Blencowe H Lee AC Cousens S et alPreterm birth-associated neurodevelopmentalimpairment estimates at regional and globallevels for 2010 Pediatr Res 201374(Suppl 1)17ndash34

carediabetesjournalsorg Godfrey and Associates 9

Preconception and During Pregnancy to Main-tain Healthy Glucose Metabolism and OffspringHealth (ldquoNiPPeRrdquo) study protocol for a rando-mised controlled trial Trials 20171813124 Luoto R Laitinen K Nermes M Isolauri EImpactofmaternalprobiotic-supplementeddietarycounselling on pregnancy outcome and prenataland postnatal growth a double-blind placebo-controlled study Br J Nutr 20101031792ndash179925 Levy JCMatthewsDR HermansMP Correcthomeostasis model assessment (HOMA) evalu-ation uses the computer program Diabetes Care1998212191ndash219226 DeFronzo RA Matsuda M Reduced timepoints to calculate the composite indexDiabetesCare 201033e9327 Metzger BE Gabbe SG Persson B et alInternational Association of Diabetes and Preg-nancy Study Groups Consensus Panel Interna-tional association of diabetes and pregnancystudy groups recommendations on the diagnosisand classification of hyperglycemia in pregnancyDiabetes Care 201033676ndash68228 Cole TJ Williams AF RCPCH Growth ChartExpert Group Revised birth centiles for weightlength and head circumference in the UK-WHOgrowth charts [published correction appears inAnn Hum Biol 201138241] Ann Hum Biol 2011387ndash1129 Pike KC Crozier SR Lucas JSA et al South-ampton Womenrsquos Survey Study Group Patterns

of fetal and infant growth are related to atopyand wheezing disorders at age 3 years Thorax2010651099ndash110630 Lowe LP Metzger BE Dyer AR et al HAPOStudy Cooperative Research Group Hyperglyce-mia and Adverse Pregnancy Outcome (HAPO)Study associations of maternal A1C and glucosewith pregnancy outcomes Diabetes Care 201235574ndash58031 American Diabetes Association 2 Classifi-cation and diagnosis of diabetes Standards ofMedical Care in Diabetesd2019 Diabetes Care201942(Suppl 1)S13ndashS2832 Santamaria A Alibrandi A Di Benedetto Aet al Clinical and metabolic outcomes in preg-nant women at risk for gestational diabetesmellitus supplemented with myo-inositol a sec-ondaryanalysis from3RCTsAmJObstetGynecol2018219300e1ndash300e633 Matarrelli B Vitacolonna E DrsquoAngelo Met al Effect of dietary myo-inositol supple-mentation in pregnancy on the incidence ofmaternal gestational diabetes mellitus andfetal outcomes a randomized controlled trialJ Matern Fetal Neonatal Med 201326967ndash97234 Farren M Daly N McKeating A Kinsley BTurner MJ Daly S The prevention of gestationaldiabetes mellitus with antenatal oral inositolsupplementation a randomized controlled trialDiabetes Care 201740759ndash763

35 Callaway LK McIntyre HD Barrett HL et alProbiotics for the prevention of gestational di-abetesmellitus in overweight andobesewomenfindings from the SPRING double-blind random-ized controlled trial Diabetes Care 201942364ndash37136 Keats EC Haider BA Tam E Bhutta ZAMultiple-micronutrient supplementation forwomen during pregnancy Cochrane DatabaseSyst Rev 20193CD00490537 Goldenberg RL Culhane JF Iams JD RomeroR Epidemiology and causes of preterm birthLancet 200837175ndash8438 Unver N DelgadoO Zeleke K et al ReducedIL-6 levels and tumor-associated phospho-STAT3are associatedwith reduced tumor developmentin a mouse model of lung cancer chemopreven-tion with myo-inositol Int J Cancer 20181421405ndash141739 Kucukaydin Z Kurdoglu M Kurdoglu ZDemir H Yoruk IH Selected maternal fetaland placental trace element and heavy metalandmaternal vitamin levels in pretermdeliverieswith or without preterm premature rupture ofmembranes J Obstet Gynaecol Res 201844880ndash88940 Blencowe H Lee AC Cousens S et alPreterm birth-associated neurodevelopmentalimpairment estimates at regional and globallevels for 2010 Pediatr Res 201374(Suppl 1)17ndash34

carediabetesjournalsorg Godfrey and Associates 9