STUDY DESIGN
This will be an individually randomized, double-blind efficacy trial in Mithi, District
Tharparkar, Sindh, Pakistan. This district is among the most impoverished in Sindh,
characterized by a tropical desert climate with extremely hot mornings. Approximately 87%
of the population in Tharparkar lives below the poverty line. Due to its challenging
demographics and environmental conditions, the region has endured severe droughts and
faces the highest level of food insecurity among Sindh districts. It is concerning that
60% of children under five years suffer from stunting, 33.3% from wasting, and nearly
19.8% experience both conditions simultaneously. Additionally, approximately 40.4% of
non-pregnant women of reproductive age are underweight. Tharparkar has been selected for
this study due to its alarming rates of malnutrition and micronutrient deficiencies,
making it an ideal location to assess the effectiveness of fortified wheat flour.
RESEARCH QUESTION
Primary Does consumption of whole wheat flatbread made with fermented and
unfermented 'high zinc wheat' or with 'post-harvest zinc-fortified wheat flour'
improve zinc status and metabolic health among adolescents (10-19 years) and adult
women (20-40 years) at high risk of zinc deficiency and T2DM compared to 'low zinc'
whole wheat flatbread?
Secondary Does an increase in bioavailable dietary zinc intake improve indicators
for predicting the risk of T2DM in adolescents and adult women at high risk of zinc
deficiency? SPECIFIC OBJECTIVES
Primary To evaluate the efficacy of whole wheat flatbread made with fermented and
unfermented 'high zinc wheat' or post-harvest zinc-fortified wheat on zinc
status/zinc deficiency and metabolic health among adolescents and adult women at
high risk of zinc deficiency when compared to the 'low zinc' whole wheat flatbread.
Secondary To assess if an increase in bioavailable dietary zinc intake improves
indicators for predicting the risk of T2DM in adolescents and adult women at high
risk of zinc deficiency.
PARTICIPANTS The study will include adolescents (10-19 years) and adult women (20-40
years) INTERVENTION
Participants will be randomly divided into four groups according to the four-arm design
in a 1:1:1:1 ratio. A total of 1000 participants would be randomly allocated to each of
the groups in a 1:1:1:1 ratio.
Group 1: will receive fermented high zinc wheat flour flatbread
Group 2: will receive unfermented high zinc wheat flour flatbread
Group 3: will receive fortified (post-harvest) whole wheat flour flatbread
Group 4: will receive low zinc whole wheat flour flatbread
It would be a six-month intervention, where the participants would be given flatbread
with a vegetable/pulse (daal) each day for six days a week for six months. On average,
2-3 flatbreads will be provided per participant (this was ascertained in the pilot
activity). This would be provided at the school/college campus at lunch time i.e., at
1.30pm and all the participants enrolled in the study would be directly observed each day
for the amount consumed and adult women would be provided meal at a community place.
OUTCOMES
Primary:
Serum zinc concentration
Zinc deficiency
HbA1C
Fasting blood glucose
Insulin levels
HOMA-IR (cut-off >2) (27)
Lipid profile (total cholesterol, very low-density lipoprotein (VLDL), low-density
lipoprotein (LDL), high-density lipoprotein (HDL); triglycerides (TGs))
Red blood cell membrane fatty acids concentrations
Secondary:
Anthropometric measurements:
Body Mass Index (BMI) - Severe thinness, thinness, normal weight, overweight, obese
Blood Pressure
Anemia
School attendance/ performance
Dietary intakes through 24hr dietary recall.
Morbidity - Diarrhea, Acute respiratory infection (ARI) etc.
Compliance:
SAMPLE SIZE CALCULATION The study sample size was calculated based on an individually
randomized four arm design on the primary outcome of mean serum zinc levels and HbA1c.
The mean HbA1c taken was 5.62% (SD 1.96) and mean zinc was 79.5 µg/dL (SD 35.9) according
to NNS-2018. The serum zinc data for the Tharparkar district was taken from NNS 2018,
while there is no data on area specific estimates for T2DM and HbA1c. A recent national
community-based survey conducted in 2019 found that the prevalence of diabetes (19.09%)
and pre-diabetes (12.79%) in rural areas of Pakistan is high compared to the urban areas
of Pakistan (diabetes: 15.75%; prediabetes: 9.89%) and the overall mean HbA1c was 5.62%
(SD 1.96).
The sample size was calculated with a power of 0.8 and alpha of 0.05 to detect a
difference of at least 0.12 effect size in the mean serum zinc levels between groups and
to detect a 0.2 effect size in the mean HbA1c levels with a dropout rate of 10%.
The sample size calculated is 250 participants. A total of 1000 participants would be
randomly allocated to each of the groups in a 1:1:1:1 ratio.
Baseline, midline, and end-line data collection.
All the participants will be assessed at baseline, and at endline. Data will be collected
on socio-demographic factors, dietary intake through 24-hour dietary recall,
anthropometry (weight, height, MUAC, waist circumference), blood pressures and blood
samples for bio-chemical analysis including serum zinc levels, FBS, HbA1C, insulin at
both baseline and endline, while lipid profile and RBC membrane fatty acids would be done
at endline only. At midline, 24-hour dietary recalls, serum zinc, and HbA1C will be taken
on a subset from each group. For morbidity and ARI, a two-week data collection will be
carried out.