# Chicken liver and eggshell crackers are a safe and affordable animal source food for overcoming micronutrient deficits during pregnancy and lactation in Indonesia: a double-blind, cluster randomized controlled trial (SISTIK Growth Study)

## TL;DR

A study in Indonesia tested micronutrient-enriched crackers during pregnancy and lactation but found no significant growth benefits compared to standard crackers.

## Contribution

The study evaluated a novel, locally available food-based intervention to address micronutrient deficiencies during pregnancy and lactation.

## Key findings

- There was no significant difference in growth outcomes between the micronutrient-enriched and standard cracker groups.
- Both groups showed improved LAZ-scores and reduced stunting prevalence over the study period.
- Maternal hemoglobin levels and anemia rates were similar between the two groups.

## Abstract

Poor diets and micronutrient deficiencies during pregnancy and lactation are common in Indonesia, potentially affecting linear growth. National maternal programs focus predominantly on iron-folic acid (IFA) supplementation, but adherence is poor. We explored a strategy utilizing locally available micronutrient-rich foods in the form of micronutrient-enriched crackers (MEC) to improve neonatal and infant growth.

The Sustainable Intervention of Supplementation to Improve Kid’s (SISTIK) Growth Study was a double-blind, cluster randomized controlled trial conducted in 28 village clusters in Sumedang, Indonesia (Nov 2020–Jan 2023). Villages—unit of randomization—were stratified by size and assigned to receive either MEC or standard wheat crackers (SWC), along with nutrition and health education, morbidity control, and national IFA supplementation programs. Eligible pregnant women (19–35 years; 7–13 weeks gestation) were enrolled participated. The intervention lasted through five months postpartum. Individual mother-infant dyads were the unit of analysis. Primary outcomes were birth length (cm), attained length (cm), LAZ-score, and length velocity (cm/month) from birth to five months postpartum. Secondary outcomes included birth weight, morbidity, and maternal hemoglobin (Hb) (g/dL). A general linear model, including village as a random effect and intervention as a fixed effect was used.

In each group 137 mother-infant dyads completed the study. Baseline characteristics were balanced. Intervention adherence was low (72–103 gr/week) compared to 525 gr/week (75 gr/day) recommended, with no significant intervention effect on growth outcomes, after adjusting for maternal height, sex, and human milk intake at 5 months. There were no differences between MEC and SWC groups in maternal Hb (mean ± SD) (12.0 ± 1.1 vs. 12.3 ± 1.2 g/dL) and anemia (11.9 vs 11.3%) at 35–36 weeks GA or morbidity. Compared with the same setting earlier at 5 mos pp, mean ± SD LAZ-score were less negative and stunting prevalence was lower in both groups. Overall, across the SISTIK study population, mean ± SD LAZ-score improved from -0.93 ± 0.85 to -0.51 ± 0.91, and stunting prevalence declined from 11 to 6%.

Although this study did not show a treatment effect on the outcomes measured, future research should explore whether providing comprehensive nutrition and health support during pregnancy and post-partum could help reduce stunting in Indonesia.

NCT04564222 (ClinicalTrials.gov); 25/09/2020.