A Randomized Trial of Quadruple-Fortified Salt for Anemia and Birth Defects Prevention in Southern India: Protocol Design and Methods

Julia L Finkelstein; Heather M Guetterman; Amy Fothergill; Christina B Johnson; Yan Ping Qi; Shameem Jabbar; Mindy Zhang; Christine M Pfeiffer; Charles E Rose; Lorraine F Yeung; Jennifer L Williams; Jesse T Krisher; Caleb Ruth; Dripta Roy Choudhury; Sudha Venkatramanan; Jere D Haas; Rebecca Kuriyan; Saurabh Mehta; Wesley Bonam; Krista S Crider

doi:10.1016/j.cdnut.2023.100052

A Randomized Trial of Quadruple-Fortified Salt for Anemia and Birth Defects Prevention in Southern India: Protocol Design and Methods

Curr Dev Nutr. 2023 Feb 21;7(3):100052. doi: 10.1016/j.cdnut.2023.100052. eCollection 2023 Mar.

Authors

Julia L Finkelstein^{1

2

3}, Heather M Guetterman¹, Amy Fothergill^{1

4}, Christina B Johnson⁵, Yan Ping Qi⁴, Shameem Jabbar⁶, Mindy Zhang⁶, Christine M Pfeiffer⁶, Charles E Rose⁴, Lorraine F Yeung⁴, Jennifer L Williams⁴, Jesse T Krisher¹, Caleb Ruth¹, Dripta Roy Choudhury^{1

3}, Sudha Venkatramanan¹, Jere D Haas¹, Rebecca Kuriyan³, Saurabh Mehta^{1

2

3}, Wesley Bonam⁵, Krista S Crider⁴

Affiliations

¹ Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA.
² Division of Epidemiology, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA.
³ St. John's Research Institute, Bangalore, Karnataka, India.
⁴ The National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, United States.
⁵ Arogyavaram Medical Centre, Andhra Pradesh, India.
⁶ The National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA.

Abstract

Background: Women of reproductive age are at an increased risk of anemia and micronutrient deficiencies. Evidence supports the role of periconceptional nutrition in the development of neural tube defects (NTDs) and other pregnancy complications. Vitamin B₁₂ deficiency is a risk factor for NTDs and may modify folate biomarkers that predict NTD risk at the population level. There is an interest in mandatory fortification with vitamin B₁₂ and folic acid for anemia and birth defect prevention. However, there are limited population-representative data needed to inform policy and guidelines.

Objectives: This randomized trial will be conducted to evaluate the efficacy of quadruple-fortified salt (QFS; iron, iodine, folic acid, vitamin B₁₂) in 1,000 households in Southern India.

Methods: Women 18 to 49 y who are not pregnant or lactating and reside within the catchment area of our community-based research site in Southern India will be screened and invited to participate in the trial. After informed consent, women and their households will be randomized to receive one of the following 4 interventions: 1) double-fortified salt (DFS; iron, iodine), 2) DFS + folic acid (iron, iodine, folic acid), 3) DFS + vitamin B₁₂ (iron, iodine, vitamin B₁₂), or 4) DFS + folic acid and vitamin B₁₂ (QFS; iron, iodine, folic acid, vitamin B₁₂) for 12 mo. Structured interviews will be conducted by trained nurse enumerators to collect sociodemographic, anthropometric, dietary, health, and reproductive history data. Biological samples will be collected at baseline, midpoint, and endpoint. Whole blood will be analyzed for hemoglobin using Coulter Counter. Total vitamin B₁₂ will be measured by chemiluminescence; red blood cell folate and serum folate will be evaluated using the World Health Organization-recommended microbiologic assay.

Conclusions: The results of this randomized trial will help to evaluate the efficacy of QFS to prevent anemia and micronutrient deficiencies. Clinical trial registration numbers: NCT03853304 and Clinical Trial Registry of India REF/2019/03/024479.

Registration number: NCT03853304 and REF/2019/03/024479.

Keywords: Anemia; India; folate; fortification; iron; periconceptional; trial; vitamin B12.

Associated data

ClinicalTrials.gov/NCT03853304

Abstract

Associated data

Grants and funding