Effect of a Short Messaging Service (SMS) intervention delivered to caregivers on energy, nutrients, and food groups intake in infant participants of the WIC program.

Objectives: To test the effect of a weekly test message (SMS) intervention for improving feeding practices on infant intake of energy, nutrients, and specific food groups. Methods: This study was a multi-site, randomized clinical trial, in 202 caregivers of healthy term infants participating in either the Puerto Rico or Hawaii WIC program. Participants were randomized to receive weekly SMS about either infant's general health issues (control) or SMS for improving feeding practices (intervention) to complement WIC messages for 4 months. Anthropometrics and demographics were assessed at baseline. A validated infant food frequency questionnaire was assessed at the four-month visit to assess intake of general food groups. Data was summarized as median (25th and 75th percentiles) or percentage and differences between study arms was compared using Mann Whitney or chi-square. Results: A total of 163 participants completed the study (n = 84 control and n = 79 intervention). Baseline characteristics were similar between both groups. At 4-6 months of age, compared to the control group, the intervention group had a significantly higher intake of total grains (0.28 oz; 0.00, 0.60; P = 0.033), protein (13.5 g, 10.5, 18.3; P = 0.022), calcium (472 mg; 418, 667; P = 0.012), and zinc (4.39 mg; 2.61, 6.51; P = 0.028). No differences were seen in the other food groups, including breastmilk. Conclusions for practice: Feeding SMS to complement WIC messages led to higher intakes of some key nutrients but did not have an overall improvement in the intake of food groups. Messaging also did not delay the introduction of complimentary foods or improve breastfeeding rates. Future studies should evaluate the use of more intensive SMS interventions for continued care between WIC visits.

Interventions to improve calcium intake through foods in populations with low intake.

Calcium intake remains inadequate in many low- and middle-income countries, especially in Africa and South Asia, where average intakes can be below 400 mg/day. Given the vital role of calcium in bone health, metabolism, and cell signaling, countries with low calcium intake may want to consider food-based approaches to improve calcium consumption and bioavailability within their population. This is especially true for those with low calcium intake who would benefit the most, including pregnant women (by reducing the risk of preeclampsia) and children (by reducing calcium-deficiency rickets). Specifically, some animal-source foods that are naturally high in bioavailable calcium and plant foods that can contribute to calcium intake could be promoted either through policies or educational materials. Some food processing techniques can improve the calcium content in food or increase calcium bioavailability. Staple-food fortification with calcium can also be a cost-effective method to increase intake with minimal behavior change required. Lastly, biofortification is currently being investigated to improve calcium content, either through genetic screening and breeding of high-calcium varieties or through the application of calcium-rich fertilizers. These mechanisms can be used alone or in combination based on the local context to improve calcium intake within a population.

Calcium supplementation for the prevention of hypertensive disorders of pregnancy: current evidence and programmatic considerations.

Most low- and middle-income countries present suboptimal intakes of calcium during pregnancy and high rates of mortality due to maternal hypertensive disorders. Calcium supplementation during pregnancy is known to reduce the risk of these disorders and associated complications, including preeclampsia, maternal morbidity, and preterm birth, and is, therefore, a recommended intervention for pregnant women in populations with low dietary calcium intake (e.g., where ≥25% of individuals in the population have intakes less than 800 mg calcium/day). However, this intervention is not widely implemented in part due to cost and logistical issues related to the large dose and burdensome dosing schedule (three to four 500-mg doses/day). WHO recommends 1.5-2 g/day but limited evidence suggests that less than 1 g/day may be sufficient and ongoing trials with low-dose calcium supplementation (500 mg/day) may point a path toward simplifying supplementation regimens. Calcium carbonate is likely to be the most cost-effective choice, and it is not necessary to counsel women to take calcium supplements separately from iron-containing supplements. In populations at highest risk for preeclampsia, a combination of calcium supplementation and food-based approaches, such as food fortification with calcium, may be required to improve calcium intakes before pregnancy and in early gestation.

Calcium-fortified foods in public health programs: considerations for implementation.

Low calcium intake is common worldwide and can result in nutritional rickets in children and osteomalacia in adults. Calcium-fortified foods could improve calcium intake. However, there is limited calcium fortification experience, with technical and practical issues that may hamper its adoption. The objective of this landscape review is to summarize these issues to help policymakers guide the planning and design of calcium fortification as a public health strategy. One challenge is the low bioavailability of calcium salts (∼20-40%); thus, large amounts need to be added to food to have a meaningful impact. Solubility is important when fortifying liquids and acidic foods. Calcium salts could change the flavor, color, and appearance of the food and may account for 70-90% of the total fortification cost. Safety is key to avoid exceeding the recommended intake; so the amount of added calcium should be based on the target calcium intake and the gap between inadequate and adequate levels. Monitoring includes the quality of the fortified food and population calcium intake using dietary assessment methods. Calcium fortification should follow regulations, implemented in an intersectorial way, and be informed by the right to health and equity. This information may help guide and plan this public health strategy.

Current calcium fortification experiences: a review.

Low dietary calcium is very common in many populations, contributing to nutritional rickets/osteomalacia in children/adults and increasing the risk of several health problems. Calcium is a nutrient of concern as the recommended nutrient requirements are difficult to meet in the absence of dairy products. The provision of culturally acceptable calcium-fortified foods may improve calcium intake when it is a feasible and cost-effective strategy in a particular setting. This landscape review was conducted in 2019 and describes current calcium fortification efforts and lessons learned from these experiences. Worldwide, the United Kingdom is the only country where calcium fortification of wheat flour is mandatory. It is estimated that this fortified staple ingredient contributes to 13-14% of calcium intake of the British population. Other items voluntary fortified with calcium include maize flour, rice, and water. Current calcium fortification programs may lack qualified personnel/training, clear guidelines on implementation, regulation, monitoring/evaluation, and functional indicators. Also, the cost of calcium premix is high and the target groups may be hard to reach. There is a lack of rigorous evaluation, particularly in settings with multiple micronutrient programs implemented simultaneously, with low quality of the evidence. Further research is needed to assess the impact of calcium fortification programs.

Regulatory and Policy-Related Aspects of Calcium Fortification of Foods. Implications for Implementing National Strategies of Calcium Fortification.

Daily calcium intake is well below current recommendations in most low- and middle-income countries (LMICs). Calcium intake is usually related to bone health, however an adequate calcium intake has also been shown to reduce hypertensive disorders of pregnancy, lower blood pressure and cholesterol values, and to prevent recurrent colorectal adenomas. Food fortification of foods has been identified as a cost-effective strategy to overcome micronutrient gaps in public health. This review summarizes regulatory aspects of fortification of commonly consumed foods with micronutrients, with an emphasis on calcium. We selected a convenient sample of 15 countries from different WHO regions and described the regulatory framework related to calcium fortification of staple foods. We assessed the relevant policies in electronic databases including the WHO Global database on the Implementation of Nutrition Action (GINA) for fortification policies and the Global Fortification Data Exchange Database, a fortification database developed and maintained by Food Fortification Initiative (FFI), Global Alliance for Improved Nutrition (GAIN), Iodine Global Network (IGN), and Micronutrient Forum. Food fortification with micronutrients is widely used in many of the selected countries. Most countries had national legislation for the addition of micronutrients to staple foods, especially wheat flour. These national legislations, that includes regulations and standards, can provide the framework to consider the implementation of adding calcium to the fortification strategies, including the selection of the adequate food vehicle to reach the targeted population at risk safely. The strategy to include calcium in the fortification mix in fortified staple foods seems promising in these countries. However, potential undesired changes on the organoleptic characteristics of fortified foods and products thereof, and operational feasibility at the manufacturing site should be evaluated by the stakeholders during the planning stage. Codex Alimentarius standards should be considered by regulators in order to assure adherence to international standards. While the selected countries already have established national regulations and/or standards for fortification of key staple food vehicles, and there are experiences in the implementation of fortification of some staple foods, national food intake surveys can help plan, design, and modify existing fortification programs as well as monitor food and nutrient consumption to assess risk and benefits.

Recomendaciones nutricionales para el personal de salud y el personal esencial expuesto a la COVID-19 en Latinoamérica / Nutritional Recommendations for Healthcare and Essential Personnel Exposed to COVID-19 in Latin America

Estas recomendaciones se basan en la evidencia científica actual derivada de meta-análisis y revisiones sistemáticas sobre nutrición y prevención de infecciones respiratorias causadas por los virus SARS-CoV, MERS-CoV o influenza, similares en su estructura al SARS-CoV-2. Están dirigidas al personal en la primera línea de atención de salud y al personal que presta servicios esenciales a la comunidad, con alto riesgo de infección por la COVID-19. Estas personas usan equipo de protección personal, cumplen largos turnos laborales, en ocasiones bajo condiciones extremas, lo que puede llevar a descanso insuficiente, alto nivel de estrés, depresión, pobre calidad en la alimentación y deshidratación. Todos estos factores influyen negativamente en el sistema inmune y podrían conllevar un mayor riesgo de infección. Una ingesta adecuada de micronutrientes y otros compuestos bioactivos es esencial para el desempeño óptimo del sistema inmune. Existe evidencia moderada que avala la suplementación, en forma individual, con vitamina C (2 000 mg), vitamina D (1 000-2 000 UI) y zinc (≤ 40 mg) en la prevención de infecciones respiratorias en adultos. No se encontró evidencia suficiente para avalar la suplementación con vitamina A, niacina, ácido fólico, B12, omega 3, probióticos y polifenoles, aunque si se recomienda el consumo de alimentos ricos en estos nutrientes para apoyar al sistema inmune. Se recomienda al personal seguir la recomendación de consumir 5 porciones/día (400 g) de frutas y vegetales/hortalizas, mantenerse hidratado y limitar la cafeína. No hay evidencia del consumo de alimentos alcalinos para prevenir infecciones. Estas recomendaciones son particularmente importantes durante la pandemia(AU)

These recommendations are based on current scientific evidence obtained through meta-analysis and systematic reviews on nutrition and the prevention of respiratory infections related to SARS-CoV, MERS-CoV or influenza, similar in structure to SARS-CoV-2. They are aimed at primary health care personnel and to those who provide essential services to the community and are, consequently, at high risk of COVID-19 infection. These individuals wear personal protective equipment, work long shifts, sometimes under extreme conditions, which can lead to insufficient rest, high stress levels, depression, poor nutrition and dehydration. Together, these factors have a negative impact on the immune system and could result in an increased risk of infection. An adequate intake of micronutrients and other bioactive compounds is essential for optimal immune performance. There is moderate evidence supporting supplementation, individually, with vitamin C (2 000 mg), vitamin D (1 000-2 000 IU) and zinc (≤40 mg) for the prevention of respiratory infections in adults. Insufficient evidence was found to support supplementation with vitamin A, niacin, folic acid, B12, omega 3, probiotics and polyphenols; however, the consumption of foods rich in these nutrients is recommended to support immune function. It is recommended that workers follow the recommendation of consuming 400 g/day of fruits and vegetables, remain hydrated and limit caffeine. There is no scientific evidence supporting the consumption of alkaline foods to prevent infections. The aforementioned recommendations are particularly relevant during the pandemic(AU)

Recomendaciones de micronutrientes para grupos vulnerables en contexto de desnutrición, durante la pandemia de COVID-19 en Latinoamérica / Micronutrient recommendations for vulnerable groups in context of undernutrition, during the COVID-19 pandemic in Latin America

La crisis por COVID-19 (SARS-CoV-2) puede convertirse en una catástrofe alimentaria para Latinoamérica, aumentando las personas que padecen hambre de 135 a 265 millones, especialmente en Venezuela, Guatemala, Honduras, Haití y El Salvador, que ya enfrentaban crisis económicas y sanitarias. Este manuscrito presenta la posición de un grupo de expertos latinoamericanos sobre las recomendaciones de consumo y/o suplementación con vitamina A, C, D, zinc, hierro, folatos y micronutrientes múltiples, en contextos de desnutrición, para grupos vulnerables: mujeres embarazadas y lactantes, niñas y niños menores de 5 años y adultos mayores. Las recomendaciones buscan disminuir el impacto potencial que tendrá COVID-19 en el estado nutricional, durante la pandemia. La posición surge de la discusión de dichos expertos con base a la revisión de evidencia científica actual para estos grupos vulnerables. Está dirigida a tomadores de decisiones, encargados de políticas públicas, personal de salud y organismos de la sociedad civil. Después de la lactancia materna y una dieta suficiente en cantidad y calidad, la suplementación con los micronutrientes presentados, puede contribuir a prevenir y tratar enfermedades virales, reforzar el sistema inmune y reducir complicaciones. La lactancia materna con medidas de higiene respiratoria, el suministro de múltiples micronutrientes en polvo para niños desde los 6 meses hasta los 5 años y el aporte de hierro y folatos o micronutrientes múltiples para la embarazada, son estrategias comprobadas y eficaces que deben seguirse implementando en tiempos de COVID-19. Para los adultos mayores la suplementación con vitamina C, D y zinc puede estar indicada(AU)

The COVID-19 crisis (SARS-CoV-2) might transform into a food catastrophe in Latin America and would increase the number of people suffering from hunger from 135 to 265 million, particularly in Venezuela, Guatemala, Honduras, Haiti and El Salvador, already facing economic and health crises. This manuscript presents the position of a group of Latin American experts in nutrition for establishing the recommendations for consumption and / or supplementation with vitamin A, C, D, zinc, iron, folates and multiple micronutrients, in undernutrition contexts, for vulnerable population of pregnant and lactating women, children under 5 years and the elderly. The recommendations seek to decrease the potential impact that COVID-19 will have on nutritional status during the pandemic. The position arises from the discussion of the experts based on the review of current scientific evidence for these vulnerable groups. It aims to reach stakeholders, public policy makers, health personnel and civil society organizations. Only after breastfeeding and a sufficient diet in terms of quantity and quality, a supplementation with the micronutrients mentioned above can help prevent and treat viral diseases, strengthen the immune system and even reduce complications. Breastfeeding with respiratory hygiene measures, the provision of multiple micronutrients powders for children from 6 moths to 5 years of age and the supply of iron and folates or multiple micronutrients tablets for pregnant women are proven and effective strategies that must continue to be implemented during COVID-19 pandemic. For older adults, supplementation with vitamin C, D and zinc might be indicated(AU)

Regimens of vitamin D supplementation for women during pregnancy.

BACKGROUND: Vitamin D deficiency during pregnancy increases the risk of pre-eclampsia, gestational diabetes, preterm birth, and low birthweight. In a previous Cochrane Review we found that supplementing pregnant women with vitamin D alone compared to no vitamin D supplementation may reduce the risk of pre-eclampsia, gestational diabetes, and low birthweight and may increase the risk of preterm births if it is combined with calcium. However the effects of different vitamin D regimens are not yet clear. OBJECTIVES: To assess the effects and safety of different regimens of vitamin D supplementation alone or in combination with calcium or other vitamins, minerals or nutrients during pregnancy, specifically doses of 601 international units per day (IU/d) or more versus 600 IU/d or less; and 4000 IU/d or more versus 3999 IU/d or less. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (12 July 2018), and the reference lists of retrieved studies. SELECTION CRITERIA: Randomised trials evaluating the effect of different vitamin D regimens (dose, frequency, duration, and time of commencement of supplementation during pregnancy), alone or in combination with other nutrients on pregnancy and neonatal health outcomes. We only included trials that compared 601 IU/d or more versus 600 IU/d or less and 4000 IU/d or more versus 3999 IU/d or less. We did not include in the analysis groups that received no vitamin D, as that comparison is assessed in another Cochrane Review. DATA COLLECTION AND ANALYSIS: Two review authors independently: i) assessed the eligibility of studies against the inclusion criteria; ii) extracted data from included studies, and iii) assessed the risk of bias of the included studies. Our primary maternal outcomes were: pre-eclampsia, gestational diabetes, and any adverse effects; our primary infant outcomes were preterm birth and low birthweight. Data were checked for accuracy. The certainty of the evidence was assessed using the GRADE approach. MAIN RESULTS: In this review, we included data from 30 trials involving 7289 women. We excluded 11 trials, identified 16 ongoing/unpublished trials and two trials are awaiting classification. Overall risk of bias for the trials was mixed.Comparison 1. 601 IU/d or more versus 600 IU/d or less of vitamin D alone or with any other nutrient (19 trials; 5214 participants)Supplementation with 601 IU/d or more of vitamin D during pregnancy may make little or no difference to the risk of pre-eclampsia (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.65 to 1.42); 5 trials; 1553 participants,low-certainty evidence), may reduce the risk of gestational diabetes (RR 0.54, 95% CI 0.34 to 0.86; 5 trials; 1846 participants; moderate-certainty evidence), may make little or no difference to the risk of preterm birth (RR 1.25, 95% CI 0.92 to 1.69; 4 trials; 2294 participants; low-certainty evidence); and may make little or no difference to the risk of low birthweight (RR 0.90, 95% CI 0.66 to 1.24; 4 trials; 1550 participants; very low-certainty evidence) compared to women receiving 600 IU/d or less.Comparison 2. 4000 IU or more versus 3999 IU or less of vitamin D alone (15 trials; 4763 participants)Supplementation with 4000 IU/d or more of vitamin D during pregnancy may make little or no difference to the risk of: pre-eclampsia (RR 0.87, 95% CI 0.62 to 1.22; 4 trials, 1903 participants, low-certainty evidence); gestational diabetes (RR 0.89, 95% CI 0.56 to 1.42; 5 trials, 2276 participants; low-certainty evidence); preterm birth (RR 0.85, 95% CI 0.64 to 1.12; 6 trials, 2948 participants, low-certainty evidence); and low birthweight (RR 0.92, 95% CI 0.49 to 1.70; 2 trials; 1099 participants; low-certainty evidence) compared to women receiving 3999 IU/d or less.Adverse events (such as hypercalcaemia, hypocalcaemia, hypercalciuria, and hypovitaminosis D) were reported differently in most trials; however, in general, there was little to no side effects reported or similar cases between groups. AUTHORS' CONCLUSIONS: Supplementing pregnant women with more than the current vitamin D recommendation may reduce the risk of gestational diabetes; however, it may make little or no difference to the risk of pre-eclampsia, preterm birth and low birthweight. Supplementing pregnant women with more than the current upper limit for vitamin D seems not to increase the risk of the outcomes evaluated. In general, the GRADE was considered low certainty for most of the primary outcomes due to serious risk of bias and imprecision of results. With respect to safety, it appears that vitamin D supplementation is a safe intervention during pregnancy, although the parameters used to determine this were either not reported or not consistent between trials. Future trials should be consistent in their reports of adverse events. There are 16 ongoing trials that when published, will increase the body of knowledge.

Vitamin D supplementation for women during pregnancy.

BACKGROUND: Vitamin D supplementation during pregnancy may be needed to protect against adverse pregnancy outcomes. This is an update of a review that was first published in 2012 and then in 2016. OBJECTIVES: To examine whether vitamin D supplementation alone or in combination with calcium or other vitamins and minerals given to women during pregnancy can safely improve maternal and neonatal outcomes. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register (12 July 2018), contacted relevant organisations (15 May 2018), reference lists of retrieved trials and registries at clinicaltrials.gov and WHO International Clinical Trials Registry Platform (12 July 2018). Abstracts were included if they had enough information to extract the data. SELECTION CRITERIA: Randomised and quasi-randomised trials evaluating the effect of supplementation with vitamin D alone or in combination with other micronutrients for women during pregnancy in comparison to placebo or no intervention. DATA COLLECTION AND ANALYSIS: Two review authors independently i) assessed the eligibility of trials against the inclusion criteria, ii) extracted data from included trials, and iii) assessed the risk of bias of the included trials. The certainty of the evidence was assessed using the GRADE approach. MAIN RESULTS: We included 30 trials (7033 women), excluded 60 trials, identified six as ongoing/unpublished trials and two trials are awaiting assessments.Supplementation with vitamin D alone versus placebo/no interventionA total of 22 trials involving 3725 pregnant women were included in this comparison; 19 trials were assessed as having low-to-moderate risk of bias for most domains and three trials were assessed as having high risk of bias for most domains. Supplementation with vitamin D alone during pregnancy probably reduces the risk of pre-eclampsia (risk ratio (RR) 0.48, 95% confidence interval (CI) 0.30 to 0.79; 4 trials, 499 women, moderate-certainty evidence) and gestational diabetes (RR 0.51, 95% CI 0.27 to 0.97; 4 trials, 446 women, moderate-certainty evidence); and probably reduces the risk of having a baby with low birthweight (less than 2500 g) (RR 0.55, 95% CI 0.35 to 0.87; 5 trials, 697 women, moderate-certainty evidence) compared to women who received placebo or no intervention. Vitamin D supplementation may make little or no difference in the risk of having a preterm birth < 37 weeks compared to no intervention or placebo (RR 0.66, 95% CI 0.34 to 1.30; 7 trials, 1640 women, low-certainty evidence). In terms of maternal adverse events, vitamin D supplementation may reduce the risk of severe postpartum haemorrhage (RR 0.68, 95% CI 0.51 to 0.91; 1 trial, 1134 women, low-certainty evidence). There were no cases of hypercalcaemia (1 trial, 1134 women, low-certainty evidence), and we are very uncertain as to whether vitamin D increases or decreases the risk of nephritic syndrome (RR 0.17, 95% CI 0.01 to 4.06; 1 trial, 135 women, very low-certainty evidence). However, given the scarcity of data in general for maternal adverse events, no firm conclusions can be drawn.Supplementation with vitamin D and calcium versus placebo/no interventionNine trials involving 1916 pregnant women were included in this comparison; three trials were assessed as having low risk of bias for allocation and blinding, four trials were assessed as having high risk of bias and two had some components having a low risk, high risk, or unclear risk. Supplementation with vitamin D and calcium during pregnancy probably reduces the risk of pre-eclampsia (RR 0.50, 95% CI 0.32 to 0.78; 4 trials, 1174 women, moderate-certainty evidence). The effect of the intervention is uncertain on gestational diabetes (RR 0.33,% CI 0.01 to 7.84; 1 trial, 54 women, very low-certainty evidence); and low birthweight (less than 2500 g) (RR 0.68, 95% CI 0.10 to 4.55; 2 trials, 110 women, very low-certainty evidence) compared to women who received placebo or no intervention. Supplementation with vitamin D and calcium during pregnancy may increase the risk of preterm birth < 37 weeks in comparison to women who received placebo or no intervention (RR 1.52, 95% CI 1.01 to 2.28; 5 trials, 942 women, low-certainty evidence). No trial in this comparison reported on maternal adverse events.Supplementation with vitamin D + calcium + other vitamins and minerals versus calcium + other vitamins and minerals (but no vitamin D)One trial in 1300 participants was included in this comparison; it was assessed as having low risk of bias. Pre-eclampsia was not assessed. Supplementation with vitamin D + other nutrients may make little or no difference in the risk of preterm birth < 37 weeks (RR 1.04, 95% CI 0.68 to 1.59; 1 trial, 1298 women, low-certainty evidence); or low birthweight (less than 2500 g) (RR 1.12, 95% CI 0.82 to 1.51; 1 trial, 1298 women, low-certainty evidence). It is unclear whether it makes any difference to the risk of gestational diabetes (RR 0.42, 95% CI 0.10 to 1.73) or maternal adverse events (hypercalcaemia no events; hypercalciuria RR 0.25, 95% CI 0.02 to 3.97; 1 trial, 1298 women,) because the certainty of the evidence for both outcomes was found to be very low. AUTHORS' CONCLUSIONS: We included 30 trials (7033 women) across three separate comparisons. Our GRADE assessments ranged from moderate to very low, with downgrading decisions based on limitations in study design, imprecision and indirectness.Supplementing pregnant women with vitamin D alone probably reduces the risk of pre-eclampsia, gestational diabetes, low birthweight and may reduce the risk of severe postpartum haemorrhage. It may make little or no difference in the risk of having a preterm birth < 37 weeks' gestation. Supplementing pregnant women with vitamin D and calcium probably reduces the risk of pre-eclampsia but may increase the risk of preterm births < 37 weeks (these findings warrant further research). Supplementing pregnant women with vitamin D and other nutrients may make little or no difference in the risk of preterm birth < 37 weeks' gestation or low birthweight (less than 2500 g). Additional rigorous high quality and larger randomised trials are required to evaluate the effects of vitamin D supplementation in pregnancy, particularly in relation to the risk of maternal adverse events.

Amount, Preparation and Type of Formula Consumed and Its Association with Weight Gain in Infants Participating in the WIC Program in Hawaii and Puerto Rico.

The aim of this study was to assess the association between amount (below or above recommendations), preparation (liquid vs. powder), and type (regular vs. hydrolysate) of infant formula consumed and weight in infants participating in the Women, Infant and Children (WIC) Program in Hawaii (HI) and Puerto Rico (PR). This was a secondary analysis of 162 caregivers with healthy term 0⁻2-month-old infants. Socio-demographics, infant food frequency questionnaires, and weight and length were assessed at baseline and after four months. Infant feeding practices were associated with weight-for-length z-scores using multivariable logistic regression. In total, 37.7% were exclusively breastfed and 27.2% were exclusively formula-fed. Among formula users, regular (63.6%) and powder (87.0%) formula were the most common; 43.2% consumed formula above recommendations. Most infants had rapid weight gain (61.1%). Infants fed regular formula had higher odds of overweight after four months (adjusted OR = 8.77, 95% CI: 1.81⁻42.6) and higher odds of rapid weight gain (adjusted OR = 3.10, 95% CI: 1.12, 8.61). Those exclusively formula fed had higher odds of slow weight gain (adjusted OR = 4.07, 95% CI: 1.17⁻14.2). Formula preparation and amount of formula were not associated with weight. These results could inform the WIC program's nutrition education messages on infant feeding. Studies with longer follow-up are needed to confirm these results.

Findings From a Randomized Trial of Weight Gain Prevention Among Overweight Puerto Rican Young Adults.

OBJECTIVE: Assess impact of multimodality weight gain prevention intervention. METHODS: Randomized clinical trial among 39 overweight young Puerto Rico college students using 10 weekly peer-support sessions promoting dietary, physical activity, and other lifestyle changes enhanced by stress-reduction and mindfulness approaches. Body mass index (BMI) and self-reported behaviors were measured at baseline and at 10 weeks and 6 months after baseline. RESULTS: At the completion of the intervention, BMIs in the experimental arm were 0.8 units lower than at baseline (z = -3.0; P = .008) and 1.2 lower at 6 months after baseline (z = -4.1; P < .001); BMIs in the control arm were 0.7 higher (z = 2.7; P = .02) at 10 weeks and 0.8 higher at 6 months (z = 3.1; P = .005). Group × time interaction confirmed that BMI differed significantly over time between arms (χ2 = 26.9; degrees of freedom = 2; P < .001). Analysis of behavioral changes was mostly inconclusive although the experimental arm reported a considerable increase in walking at 10 weeks. Qualitative data suggested that yoga and mindfulness components were particularly useful for motivating participants to maintain healthier lifestyle patterns. CONCLUSIONS: Body mass index in the experimental arm decreased at the end of intervention and was maintained at 6 months' follow-up.

Breastfeeding Discontinuation Not Associated with Maternal Pregravid BMI But Associated with Native Hawaiian or Other Pacific Islander Race in Hawaii and Puerto Rico WIC Participants.

Objectives This study investigated the association between maternal pregravid body mass index (BMI) and breastfeeding discontinuation at 4-6 months postpartum in Hawaii and Puerto Rico participants from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Methods A secondary data analysis was conducted from a text message-based intervention in WIC participants in Hawaii and Puerto Rico. The analysis included 87 women from the control group who initiated breastfeeding and whose breastfeeding status was known at the end of the study when infants were 4-6 months old. Pregravid BMI and breastfeeding discontinuation were assessed using questionnaires. Results The association between pregravid BMI and breastfeeding discontinuation was not significant in the unadjusted model or in the adjusted model. Native Hawaiian or Other Pacific Islander (NHOPI) participants showed significantly increased odds of discontinuing breastfeeding (adjusted odds ratio [AOR] 7.12; 95% CI 1.34, 37.97; p = .02) compared to all the other racial/ethnic participants, as did older women ages 32-39 years versus women who were 25-31 years old (AOR 4.21; 95% CI 1.13, 15.72; p = .03). Women who took vitamins while breastfeeding had decreased odds of discontinuing breastfeeding (AOR 0.15; 95% CI 0.05, 0.46; p = .0009). Conclusions for Practice Pregravid BMI was not significantly associated with breastfeeding discontinuation at 4-6 months postpartum in women from Hawaii and Puerto Rico WIC, but NHOPIs and women who were older had higher odds of discontinuing breastfeeding. The results of this study may inform strategies for breastfeeding promotion and childhood obesity prevention but should be further investigated in larger studies. ClinicalTrials.gov Identifier: NCT02903186.

Variations of dietary intake by glycemic status and Hispanic/Latino heritage in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL).

OBJECTIVE: A healthy diet is important for diabetes prevention and control; however, few studies have assessed dietary intake among US Hispanics/Latinos, a diverse population with a significant burden of diabetes. To address this gap in the literature, we determined intake of energy, macro/micronutrients, and vitamin supplements among Hispanics/Latinos by glycemic status and heritage. RESEARCH DESIGN AND METHODS: Cross-sectional study of adults aged 18-74 years from the Hispanic Community Health Study/Study of Latinos (2008-2011) with complete baseline data on glycemic status and two 24-hour dietary recalls (n=13 089). Age-adjusted and sex-adjusted and multivariable-adjusted measures of intake were determined by glycemic status and heritage. RESULTS: Mean age-adjusted and sex-adjusted energy intake was significantly lower among Hispanics/Latinos with diagnosed diabetes compared with those with normal glycemic status (1665 vs 1873 kcal, P<0.001). Fiber intake was higher among those with diagnosed diabetes versus normal glycemic status (P<0.01). Among those with diagnosed diabetes, energy intake was highest among those with Cuban heritage compared with most other heritage groups (P<0.01 for all, except Mexicans), but there was no difference after additional adjustment. Fiber intake was significantly lower for those of Cuban heritage (vs Dominican, Central American, and Mexican), and sodium intake was significantly higher (vs all other heritage groups) (P<0.01 for all); findings were null after additional adjustment. There was no difference in supplemental intake of vitamin D, calcium, magnesium, or potassium by glycemic status. CONCLUSIONS: As part of the care of Hispanics/Latinos with diabetes, attention should be made to fiber and sodium consumption.

Micronutrient Intake and the Contribution of Dietary Supplements in Hispanic Infants.

To calculate micronutrient adequacy among infants and toddlers and to determine the contribution of dietary supplements to this adequacy, micronutrient intake was assessed using two nonconsecutive 24-hour recalls in a sample of 296 infants aged 0-24 months. Micronutrient intake was calculated from foods and beverages and from supplements and compared between nonusers and users of supplements. Percentages of children below the Dietary Reference Intake (DRI) and above the tolerable upper limit intake (UL) were also compared between groups. A total of 241 participants had complete data. The prevalence of dietary supplement use among the sample was 15%. Mean intake of all micronutrients from foods and beverages was similar between nonusers and users of supplements (p > .05) but significantly higher for the following vitamins when supplements were included: D, E, B1, B2, B3, and B6 (p < .05). From foods only, the nutrients with highest percentage of children below the DRI were vitamins D and E and potassium. When supplements were included, this percentage significantly decreased among users compared to nonusers (p < .05) for vitamins D and E. From foods, the UL was exceeded for magnesium, zinc, and vitamin B3. These were similar when supplements were added. Supplements significantly increased the intake of some vitamins. Vitamins D and E had the highest percentage of children below the DRI, which was partly corrected with the use of supplements. The UL was exceeded for magnesium, zinc, and vitamin B3 in many children. It is important to understand these patterns as they may be indicative of future nutritional deficiencies and excesses.

A Semi-Quantitative Food Frequency Questionnaire Validated in Hispanic Infants and Toddlers Aged 0 to 24 Months.

BACKGROUND: There are limited validated food frequency questionnaires (FFQs) for infants and toddlers, most of which were evaluated in Europe or Oceania, and the ones available for use in the United States have important limitations. OBJECTIVE: Our aim was to assess the validity of an FFQ developed for infants and toddlers. DESIGN: A semi-quantitative FFQ was developed that included 52 food items, their sources, and portion sizes. The FFQ inquired about diets over the previous 7 days. Its validity was assessed in a cross-sectional study. Participants completed the FFQ, followed by a 24-hour recall on two occasions with 1 week between data collection. PARTICIPANTS/SETTING: A total of 296 caregivers of infants and toddlers aged 0 to 24 months enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children, Puerto Rico. MAIN OUTCOME MEASURES: Intake of nutrients and food groups were averaged for the two FFQs and the two 24-hour food recalls, and adjusted for energy intake. STATISTICAL ANALYSES PERFORMED: Spearman correlations were performed for intakes of energy, nutrients, and foods between administrations and between instruments. Correlation coefficients were de-attenuated to account for variation in the 24-hour recalls. RESULTS: A total of 241 participants completed the study. Intake of all nutrients and foods were significantly correlated between FFQs and 24-hour recalls and between the means of FFQs and 24-hour food recalls. The de-attenuated correlation for nutrients between the FFQs and 24-hour recalls ranged from 0.26 (folate) to 0.77 (energy), with a mean correlation of 0.53. The de-attenuated correlation for food groups between the FFQs and 24-hour recalls ranged from 0.28 (sweets) to 0.80 (breast milk), with a mean correlation of 0.55. When analyses were restricted to those consuming foods other than breast milk or formula (n=186), results were similar. CONCLUSIONS: This semi-quantitative FFQ is a tool that offers reasonably valid rankings for intake of energy, nutrients, foods, and food groups in this sample of infants and toddlers.

Vitamin D supplementation for women during pregnancy.

BACKGROUND: Vitamin D deficiency or insufficiency is thought to be common among pregnant women. Vitamin D supplementation during pregnancy has been suggested as an intervention to protect against adverse pregnancy outcomes. OBJECTIVES: To examine whether oral supplements with vitamin D alone or in combination with calcium or other vitamins and minerals given to women during pregnancy can safely improve maternal and neonatal outcomes. MAIN RESULTS: In this updated review we included 15 trials assessing a total of 2833 women, excluded 27 trials, and 23 trials are still ongoing or unpublished. Nine trials compared the effects of vitamin D alone versus no supplementation or a placebo and six trials compared the effects of vitamin D and calcium with no supplementation. Risk of bias in the majority of trials was unclear and many studies were at high risk of bias for blinding and attrition rates.Vitamin D alone versus no supplementation or a placeboData from seven trials involving 868 women consistently show that women who received vitamin D supplements alone, particularly on a daily basis, had higher 25-hydroxyvitamin D than those receiving no intervention or placebo, but this response was highly heterogeneous. Also, data from two trials involving 219 women suggest that women who received vitamin D supplements may have a lower risk of pre-eclampsia than those receiving no intervention or placebo (8.9% versus 15.5%; risk ratio (RR) 0.52; 95% CI 0.25 to 1.05, low quality). Data from two trials involving 219 women suggest a similar risk of gestational diabetes among those taking vitamin D supplements or no intervention/placebo (RR 0.43; 95% CI 0.05, 3.45, very low quality). There were no clear differences in adverse effects, with only one reported case of nephritic syndrome in the control group in one study (RR 0.17; 95% CI 0.01 to 4.06; one trial, 135 women, low quality). Given the scarcity of data for this outcome, no firm conclusions can be drawn. No other adverse effects were reported in any of the other studies.With respect to infant outcomes, data from three trials involving 477 women suggest that vitamin D supplementation during pregnancy reduces the risk preterm birth compared to no intervention or placebo (8.9% versus 15.5%; RR 0.36; 95% CI 0.14 to 0.93, moderate quality). Data from three trials involving 493 women also suggest that women who receive vitamin D supplements during pregnancy less frequently had a baby with a birthweight below 2500 g than those receiving no intervention or placebo (RR 0.40; 95% CI 0.24 to 0.67, moderate quality).In terms of other outcomes, there were no clear differences in caesarean section (RR 0.95; 95% CI 0.69 to 1.31; two trials; 312 women); stillbirths (RR 0.35 95% CI 0.06, 1.99; three trials, 540 women); or neonatal deaths (RR 0.27; 95% CI 0.04, 1.67; two trials, 282 women). There was some indication that vitamin D supplementation increases infant length (mean difference (MD) 0.70, 95% CI -0.02 to 1.43; four trials, 638 infants) and head circumference at birth (MD 0.43, 95% CI 0.03 to 0.83; four trials, 638 women).Vitamin D and calcium versus no supplementation or a placeboWomen who received vitamin D with calcium had a lower risk of pre-eclampsia than those not receiving any intervention (RR 0.51; 95% CI 0.32 to 0.80; three trials; 1114 women, moderate quality), but also an increased risk of preterm birth (RR 1.57; 95% CI 1.02 to 2.43, three studies, 798 women, moderate quality). Maternal vitamin D concentration at term, gestational diabetes, adverse effects and low birthweight were not reported in any trial or reported only by one study. AUTHORS CONCLUSIONS: New studies have provided more evidence on the effects of supplementing pregnant women with vitamin D alone or with calcium on pregnancy outcomes. Supplementing pregnant women with vitamin D in a single or continued dose increases serum 25-hydroxyvitamin D at term and may reduce the risk of pre-eclampsia, low birthweight and preterm birth. However, when vitamin D and calcium are combined, the risk of preterm birth is increased. The clinical significance of the increased serum 25-hydroxyvitamin D concentrations is still unclear. In light of this, these results need to be interpreted with caution. Data on adverse effects were lacking in all studies.The evidence on whether vitamin D supplementation should be given as a part of routine antenatal care to all women to improve maternal and infant outcomes remains unclear. While there is some indication that vitamin D supplementation could reduce the risk of pre-eclampsia and increase length and head circumference at birth, further rigorous randomized trials are required to confirm these effects.

Vitamin D supplementation for women during pregnancy

ABSTRACT BACKGROUND: Vitamin D deficiency or insufficiency is thought to be common among pregnant women. Vitamin D supplementation during pregnancy has been suggested as an intervention to protect against adverse pregnancy outcomes. OBJECTIVES: To examine whether oral supplements with vitamin D alone or in combination with calcium or other vitamins and minerals given to women during pregnancy can safely improve maternal and neonatal outcomes. METHODS: Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 February 2015), the International Clinical Trials Registry Platform (31 January 2015), the Networked Digital Library of Theses and Dissertations (28 January 2015) and also contacted relevant organisations (31 January 2015). Selection criteria: Randomized and quasi-randomized trials with randomization at either individual or cluster level, evaluating the effect of supplementation with vitamin D alone or in combination with other micronutrients for women during pregnancy. Data collection and analysis: Two review authors independently i) assessed the eligibility of studies against the inclusion criteria ii) extracted data from included studies, and iii) assessed the risk of bias of the included studies. Data were checked for accuracy. The quality of the evidence was assessed using the GRADE approach. MAIN RESULTS: In this updated review we included 15 trials assessing a total of 2833 women, excluded 27 trials, and 23 trials are still ongoing or unpublished. Nine trials compared the effects of vitamin D alone versus no supplementation or a placebo and six trials compared the effects of vitamin D and calcium with no supplementation. Risk of bias in the majority of trials was unclear and many studies were at high risk of bias for blinding and attrition rates. Vitamin D alone versus no supplementation or a placebo Data from seven trials involving 868 women consistently show that women who received vitamin D supplements alone, particularly on a daily basis, had higher 25-hydroxyvitamin D than those receiving no intervention or placebo, but this response was highly heterogeneous. Also, data from two trials involving 219 women suggest that women who received vitamin D supplements may have a lower risk of pre-eclampsia than those receiving no intervention or placebo (8.9% versus 15.5%; risk ratio (RR) 0.52; 95% CI 0.25 to 1.05, low quality). Data from two trials involving 219 women suggest a similar risk of gestational diabetes among those taking vitamin D supplements or no intervention/placebo (RR 0.43; 95% CI 0.05, 3.45, very low quality). There were no clear differences in adverse effects, with only one reported case of nephritic syndrome in the control group in one study (RR 0.17; 95% CI 0.01 to 4.06; one trial, 135 women, low quality). Given the scarcity of data for this outcome, no firm conclusions can be drawn. No other adverse effects were reported in any of the other studies. With respect to infant outcomes, data from three trials involving 477 women suggest that vitamin D supplementation during pregnancy reduces the risk preterm birth compared to no intervention or placebo (8.9% versus 15.5%; RR 0.36; 95% CI 0.14 to 0.93, moderate quality). Data from three trials involving 493 women also suggest that women who receive vitamin D supplements during pregnancy less frequently had a baby with a birthweight below 2500 g than those receiving no intervention or placebo (RR 0.40; 95% CI 0.24 to 0.67, moderate quality). In terms of other outcomes, there were no clear differences in caesarean section (RR 0.95; 95% CI 0.69 to 1.31; two trials; 312 women); stillbirths (RR 0.35 95% CI 0.06, 1.99; three trials, 540 women); or neonatal deaths (RR 0.27; 95% CI 0.04, 1.67; two trials, 282 women). There was some indication that vitamin D supplementation increases infant length (mean difference (MD) 0.70, 95% CI -0.02 to 1.43; four trials, 638 infants) and head circumference at birth (MD 0.43, 95% CI 0.03 to 0.83; four trials, 638 women). Vitamin D and calcium versus no supplementation or a placebo Women who received vitamin D with calcium had a lower risk of pre-eclampsia than those not receiving any intervention (RR 0.51; 95% CI 0.32 to 0.80; three trials; 1114 women, moderate quality), but also an increased risk of preterm birth (RR 1.57; 95% CI 1.02 to 2.43, three studies, 798 women, moderate quality). Maternal vitamin D concentration at term, gestational diabetes, adverse effects and low birthweight were not reported in any trial or reported only by one study. AUTHORS CONCLUSIONS: New studies have provided more evidence on the effects of supplementing pregnant women with vitamin D alone or with calcium on pregnancy outcomes. Supplementing pregnant women with vitamin D in a single or continued dose increases serum 25-hydroxyvitamin D at term and may reduce the risk of pre-eclampsia, low birthweight and preterm birth. However, when vitamin D and calcium are combined, the risk of preterm birth is increased. The clinical significance of the increased serum 25-hydroxyvitamin D concentrations is still unclear. In light of this, these results need to be interpreted with caution. Data on adverse effects were lacking in all studies. The evidence on whether vitamin D supplementation should be given as a part of routine antenatal care to all women to improve maternal and infant outcomes remains unclear. While there is some indication that vitamin D supplementation could reduce the risk of pre-eclampsia and increase length and head circumference at birth, further rigorous randomized trials are required to confirm these effects.

Vitamin D supplementation during pregnancy: Updated meta-analysis on maternal outcomes.

BACKGROUND: Vitamin D deficiency is highly prevalent during pregnancy. It has been suggested that vitamin D supplementation during pregnancy may reduce the risk of adverse gestational outcomes. OBJECTIVES: To update a previous meta-analysis on the effects of oral vitamin D supplementation (alone or in combination with other vitamins and minerals) during pregnancy on maternal 25(OH)D levels and risk of developing pre-eclampsia, gestational diabetes, preterm birth, impaired glucose tolerance, caesarean section, gestational hypertension and other adverse conditions. METHODS: We searched for randomized and quasi-randomized trials through the Cochrane Pregnancy and Childbirth Group's Trials Register, the International Clinical Trials Registry Platform, the Networked Digital Library of Theses and Dissertations, and direct communications with relevant organizations. Assessments of inclusion criteria, extraction of data from included studies, and risk of bias' assessments of the included studies were done independently by two review authors. RESULTS: We included 15 trials, excluded 27 trials and 23 trials are still ongoing/unpublished. Data from seven trials with 868 women suggest that pregnant women supplemented with vitamin D had significantly higher 25(OH)D levels compared to controls (mean difference: 54.7nmol/L; 95% CI 36.6, 72.9). Two trials found a lower risk of preeclampsia (8.9% versus 15.5%; average risk ratio 0.52; 95% CI 0.25, 1.05) and two other trials found no difference in the risk of gestational diabetes with vitamin D supplementation. Also, three trials found that supplementation with vitamin D plus calcium reduced the risk of pre-eclampsia (5% versus 9%; average risk ratio 0.51; 95% CI 0.32, 0.80). CONCLUSION: Supplementing pregnant women with vitamin D led to significantly higher levels of 25(OH)D at term compared to placebo/control but results were inconsistent. Vitamin D supplementation, with or without calcium, may be related to lower risk of preeclampsia but more studies are needed to confirm this.

Vitamin D supplementation for women during pregnancy.

BACKGROUND: Vitamin D deficiency or insufficiency is thought to be common among pregnant women. Vitamin D supplementation during pregnancy has been suggested as an intervention to protect against adverse pregnancy outcomes. OBJECTIVES: To examine whether oral supplements with vitamin D alone or in combination with calcium or other vitamins and minerals given to women during pregnancy can safely improve maternal and neonatal outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 February 2015), the International Clinical Trials Registry Platform (31 January 2015), the Networked Digital Library of Theses and Dissertations (28 January 2015) and also contacted relevant organisations (31 January 2015). SELECTION CRITERIA: Randomised and quasi-randomised trials with randomisation at either individual or cluster level, evaluating the effect of supplementation with vitamin D alone or in combination with other micronutrients for women during pregnancy. DATA COLLECTION AND ANALYSIS: Two review authors independently i) assessed the eligibility of studies against the inclusion criteria ii) extracted data from included studies, and iii) assessed the risk of bias of the included studies. Data were checked for accuracy. The quality of the evidence was assessed using the GRADE approach. MAIN RESULTS: In this updated review we included 15 trials assessing a total of 2833 women, excluded 27 trials, and 23 trials are still ongoing or unpublished. Nine trials compared the effects of vitamin D alone versus no supplementation or a placebo and six trials compared the effects of vitamin D and calcium with no supplementation. Risk of bias in the majority of trials was unclear and many studies were at high risk of bias for blinding and attrition rates. Vitamin D alone versus no supplementation or a placebo Data from seven trials involving 868 women consistently show that women who received vitamin D supplements alone, particularly on a daily basis, had higher 25-hydroxyvitamin D than those receiving no intervention or placebo, but this response was highly heterogeneous. Also, data from two trials involving 219 women suggest that women who received vitamin D supplements may have a lower risk of pre-eclampsia than those receiving no intervention or placebo (8.9% versus 15.5%; risk ratio (RR) 0.52; 95% CI 0.25 to 1.05, low quality). Data from two trials involving 219 women suggest a similar risk of gestational diabetes among those taking vitamin D supplements or no intervention/placebo (RR 0.43; 95% CI 0.05, 3.45, very low quality). There were no clear differences in adverse effects, with only one reported case of nephritic syndrome in the control group in one study (RR 0.17; 95% CI 0.01 to 4.06; one trial, 135 women, low quality). Given the scarcity of data for this outcome, no firm conclusions can be drawn. No other adverse effects were reported in any of the other studies.With respect to infant outcomes, data from three trials involving 477 women suggest that vitamin D supplementation during pregnancy reduces the risk preterm birth compared to no intervention or placebo (8.9% versus 15.5%; RR 0.36; 95% CI 0.14 to 0.93, moderate quality). Data from three trials involving 493 women also suggest that women who receive vitamin D supplements during pregnancy less frequently had a baby with a birthweight below 2500 g than those receiving no intervention or placebo (RR 0.40; 95% CI 0.24 to 0.67, moderate quality).In terms of other outcomes, there were no clear differences in caesarean section (RR 0.95; 95% CI 0.69 to 1.31; two trials; 312 women); stillbirths (RR 0.35 95% CI 0.06, 1.99; three trials, 540 women); or neonatal deaths (RR 0.27; 95% CI 0.04, 1.67; two trials, 282 women). There was some indication that vitamin D supplementation increases infant length (mean difference (MD) 0.70, 95% CI -0.02 to 1.43; four trials, 638 infants) and head circumference at birth (MD 0.43, 95% CI 0.03 to 0.83; four trials, 638 women). Vitamin D and calcium versus no supplementation or a placeboWomen who received vitamin D with calcium had a lower risk of pre-eclampsia than those not receiving any intervention (RR 0.51; 95% CI 0.32 to 0.80; three trials; 1114 women, moderate quality), but also an increased risk of preterm birth (RR 1.57; 95% CI 1.02 to 2.43, three studies, 798 women, moderate quality). Maternal vitamin D concentration at term, gestational diabetes, adverse effects and low birthweight were not reported in any trial or reported only by one study. AUTHORS' CONCLUSIONS: New studies have provided more evidence on the effects of supplementing pregnant women with vitamin D alone or with calcium on pregnancy outcomes. Supplementing pregnant women with vitamin D in a single or continued dose increases serum 25-hydroxyvitamin D at term and may reduce the risk of pre-eclampsia, low birthweight and preterm birth. However, when vitamin D and calcium are combined, the risk of preterm birth is increased. The clinical significance of the increased serum 25-hydroxyvitamin D concentrations is still unclear. In light of this, these results need to be interpreted with caution. Data on adverse effects were lacking in all studies.The evidence on whether vitamin D supplementation should be given as a part of routine antenatal care to all women to improve maternal and infant outcomes remains unclear. While there is some indication that vitamin D supplementation could reduce the risk of pre-eclampsia and increase length and head circumference at birth, further rigorous randomised trials are required to confirm these effects.