Preventing Health Disparities During Pregnancy Through Vitamin D Supplementation
Condition: Vitamin D3 Deficiency
Study type: Interventional
Phase: Phase 3

Summary: 
      The purpose of this study is to give all mothers the best chance for a healthy pregnancy
      through vitamin D supplementation. We will study women of diverse racial/ethnic backgrounds
      who will receive either the current vitamin D standard of 400 IU/day (in the prenatal
      vitamin) or 4000 IU/day (dose found in previous pregnancy studies to achieve vitamin D
      sufficiency).

      This research is sponsored by the W.K. Kellogg Foundation and the Medical University of South
      Carolina. The purpose of this study is to examine the effectiveness and infection-fighting
      properties of the body in relationship to vitamin D levels. This study is being done at the
      Medical University of South Carolina (MUSC) clinics, and will involve approximately 450
      volunteers.
    

Detailed description: 
      This project, comprised of discrete studies, expert evaluation and translation for public
      health campaign, promotes racial health equity for pregnant women. A strong racial disparity
      in the US surrounds vitamin D status: African American women have 20-fold and Hispanic women
      2.4-fold greater risk of deficiency than Caucasian women. In South Carolina, greater than 70%
      of African American, 33% of Hispanic and 12% of Caucasian pregnant women meet the Institute
      of Medicine's (IOM's) 2010 definition of vitamin D deficiency (1-3). Such disparity on the
      basis of race/ethnicity represents a serious public health issue. Yet, some-including the
      IOM-argue that vitamin D deficiency minimally affects maternal and fetal health and that no
      vitamin D supplementation study has shown improved pregnancy outcome (3, 4). Results of our
      two recently completed vitamin D trials involving 510 pregnant women throughout pregnancy
      suggest otherwise (5-7). In the NICHD trial, women supplemented with 400 IU vitamin D/day
      (the amount in most prenatal vitamins) vs. 2000 or 4000 IU/day not only had worse vitamin D
      status throughout pregnancy, but combined higher risk of comorbidities of pregnancy
      (gestational diabetes, hypertensive disorders, infection, preterm labor/birth and periodontal
      inflammation) (7). In trial 2, women at two South Carolina community health centers were
      supplemented with vitamin D and again, higher vitamin D status was associated with lower
      comorbidities of pregnancy risk (6, 8).

      A novel finding from the NICHD trial was that serum levels of active, hormonal vitamin D
      (1,25(OH)2D) during pregnancy were optimized at twice the level normally observed in
      non-pregnant women, levels that would be considered toxic in nonpregnant individuals. At no
      other time in life does this relationship exist. Is the hormone at such levels driving some
      vital process during pregnancy? If so, what is that process? There are hints as to why
      1,25(OH)2D is elevated in pregnant women. During pregnancy, the maternal immune system
      undergoes drastic changes for fetal protection. For example, if a solid organ composed of 50%
      mismatched cell markers (antigens) was transplanted into a new host, it would be rejected
      within hours; however, a fetus that is 50% mismatched with paternal antigens is protected
      from immune destruction through a process known as immune privilege. During pregnancy the
      body increases immune suppressive cells, reduces highly activated natural killer and
      cytotoxic T-cells with capacity to destroy the fetus and still has the capacity to fight off
      foreign pathogens. While the mechanisms that orchestrate this complex balance are unknown, we
      hypothesize that due to vitamin D's ability to regulate immune cells, vitamin D is
      responsible for many immune alterations associated with fetal immune privilege. We further
      hypothesize that correction of vitamin D deficiency during pregnancy will protect against
      immune-mediated disorders such as recurrent miscarriage, preterm birth, bacterial infections,
      periodontal inflammation and gestational diabetes. This premise, tested and confirmed by this
      project, will lead to public policy changes and equality in vitamin D status during
      pregnancy. To test the validity of these hypotheses, the goals of this project are as
      follows:

      The central goal of this project is to realize racial equity for all pregnant women and their
      developing babies in the US. To achieve this goal, there are 3 specific objectives:

        1. Determine how vitamin D deficiency leads to immune imbalance and subsequent disparities
           in pregnancy health outcomes;

        2. Determine how vitamin D supplementation prevents such imbalance and disparities; and

        3. Translate such findings into public health policy. By comparing women of diverse
           racial/ethnic backgrounds who receive the current vitamin D IOM standard of 400 IU/day
           compared to 4000 IU/day [daily dose shown to achieve optimal production of active
           vitamin D hormone (1,25(OH)2D)], the clear effects of vitamin D will be realized.
           Furthermore, these effects of sufficient vitamin D during pregnancy transcend the racial
           differences of the women.

      Study Design: This is a randomized, placebo-controlled clinical trial of 450 pregnant women
      who will be enrolled between 10-14 weeks of gestation and followed until delivery. Following
      written, informed consent, each mother will be randomized to receive either placebo or 4000
      IU/day vitamin D3 plus the standard prenatal vitamin (containing 400 IU vitamin D3). She will
      be followed monthly for a total of nine study visits. These visits will include the initial
      recruitment of mother at 10-14 weeks of pregnancy, monthly study visits, delivery study
      visit, and 18-month post-partum follow-up visit for mother and child. The primary outcome
      variable is maternal and neonatal health status as a function of maternal and infant vitamin
      D status. Secondary outcome variables to be analyzed, as a function of maternal vitamin D
      status during pregnancy will include: T-lymphocyte profile, immune function indicators,
      neonatal growth, inflammatory cytokine profile, methylation patterns of DNA of both mother
      and her neonate,

        1. Subject Selection Criteria and Recruitment: Any mother (18-45 years of age) who presents
           to her obstetrician or midwife at the Medical University of SC (MUSC), Charleston, SC;
           Our Lady of Mercy, Johns Island, SC; or Franklin C. Fetter, Charleston, SC obstetrical
           facilities within the first 14 weeks after her last menstrual period (LMP) with
           confirmation of a singleton pregnancy will be eligible for enrollment in the study.
           Mothers of diverse ethnic backgrounds (African-American, Asian, Caucasian and Hispanic)
           will be actively recruited. A database will be generated weekly of undelivered patients
           for the labor and delivery staff continue to alert the staff of impending admissions.

        2. Exclusion Criteria: Mothers with pre-existing calcium, uncontrolled thyroid disease,
           parathyroid conditions, or who require chronic diuretic or cardiac medication therapy
           including calcium channel blockers will not be eligible for enrollment into the study.
           Mothers with pre-existing sickle cell disease (not trait only), sarcoidosis, Crohn's
           disease, or ulcerative colitis may not participate in the study. In addition, because of
           the potentially confounding effect of multiple fetuses, mothers with multiple gestations
           will not be eligible for participation in the study. A sub-group of approximately 100
           subjects with known diabetes, hypertension, HIV, or morbid obesity (body mass index >
           49) will participate in the study.

        3. Subject Enrollment: The potential study subject's primary care provider will make first
           contact on behalf of the study and refer interested mothers to study personnel for
           further information and invitation. Upon enrollment into the study, expectant mothers at
           approximately 10-14 weeks' gestation will be randomized to receive one of two treatment
           regimens of vitamin D3. They will be randomized to 1 of 2 groups: (1) Group A: 400 IU
           vitamin D3/day-Standard dose treatment of placebo (0 IU vitamin D3) plus prenatal
           vitamin (400 IU/day); or (2) Group B: 4,400 IU/day (4,000 IU/2 gummies/day + 400 IU/day
           in prenatal). If, after 3 months of vitamin D supplementation, a mother is still frankly
           vitamin D deficient (less than 15 ng/ml), she will receive open label active vitamin D
           gummies for the remainder of her pregnancy. To attain equal group numbers (n=150) and
           balanced numbers by racial/ethnic group (African-American, Caucasian and Hispanic, which
           represent the predominant groups delivering at MUSC), a stratified block randomization
           will be used.

        4. Race/Ethnicity Defined: Each mother will be asked to define the racial/ethnic group to
           which she belongs: (a) African-American, (b) Caucasian, (c) Hispanic, (d) American
           Indian, (e) Asian, and (f) other. Because few mothers of American Indian (0.08% of all
           deliveries) and Asian (1% of all deliveries) descent deliver at MUSC, there is
           insufficient power to include those groups in this study. In addition, the mother, by
           self-report, will be asked to define the race/ethnicity of her parents and the father of
           the baby and his parents.

        5. Study Site Population: The Medical University of South Carolina (MUSC) is an urban
           medical university in Charleston, SC that serves patients predominantly in the
           Charleston Tri-County area (80%) and 20% from surrounding regions in South Carolina. We
           perform 2000 deliveries each year. The ethnic composition of our obstetrical population
           is 57% African American, 36% Caucasian, and 6% Hispanic and 1% Asian. Franklin C. Fetter
           and Our Lady of Mercy Clinics primarily see Hispanic patients for prenatal care. These
           Hispanics have prenatal care coverage provided by a Roper Hospital, Roper St. Francis
           Healthcare, Charleston, SC grant and include approximately 150 deliveries per year at
           Roper Hospital. MUSC provides care to any woman presenting in labor who requires routine
           care or who is referred from outlying hospitals due to high-risk pregnancy for which
           delivery at a Regional Perinatal Center (RPC) is appropriate, regardless of ability to
           pay.

        6. Enrollment and Follow-Up Subjects: The Study Coordinator will be responsible for
           assisting in screening, enrollment and follow-up. To maintain data quality, the Study
           Coordinator will review every form to check for basic problems such as missing data.
           Labor and delivery staff will alert the study coordinator or the Clinical PI's of the
           admission of any study subjects. Each month the Study Coordinators will generate a
           report on patient recruitment and retention to be reviewed jointly by the research team.
           A computer-generated calendar will serve as a reminder to contact recruited patients two
           days prior to their appointment. Each month the Study Coordinators will generate a
           report on patient recruitment and retention that will be reviewed by Dr. Wagner.

        7. Follow-up Infant Visit: The Study Coordinator will follow up by phone several times from
           birth to 18 months in order to verify subject's contact information. The infant
           (accompanied by mother) follow-up visit will take place at MUSC's CTRC Outpatient Clinic
           around 18 months postpartum. The infant will have blood drawn for vitamin D and will
           have a dental assessment of the primary teeth, including digital photographic images.

      With the assistance of Dr. Thomas Hulsey, epidemiologist and co-investigator of this
      application, sample size calculations were made. All outcome markers are ratio-scaled and
      normally distributed. Because of the possibility of premature delivery and patient attrition
      during this study, enrollment of additional subjects over that minimally needed, will provide
      a cost effective opportunity to conduct additional analyses examining changes in vitamin D
      associated with diet, seasonality, and maternal medical complications. As one of the major
      goals of this study is to explore maternal health disparities by ethnicity, the two
      supplemented groups (400 and 4,400 IU/day) will be balanced by ethnicity (equal numbers of
      Caucasian, African American, and Hispanic). This sampling distribution will be accomplished
      by stratified randomization. This sampling frame was selected to provide: (1) sufficient
      numbers to examine associations with covariates; (2) the volume of initial and follow up
      samples will be manageable by our laboratory; (3) over-samples to compensate for losses to
      follow up; and, (4) stabilizes the sophisticated statistical analysis techniques (repeated
      measures).

      The sources of research material will be maternal interview, history and physicals at clinic
      visits, the questionnaires, the lab reports for blood and urine analyses, the dental
      periodontal exam results, the dental salivary occult blood results, the vaginal swab results,
      the placental pathology report, the medical records of each mother and her infant following
      delivery, and the photographic teeth results on the infants.

      The material/data that is routinely found in a maternal health record during pregnancy
      (including information on past pregnancies and disease history) will be utilized in the
      study. There are additional materials and data from questionnaires, blood, urine, saliva,
      infant teeth, placental tissue and vaginal samples that will be obtained for research
      purposes only.

      A master list will be stored with study files accessible for clinical intervention only. The
      PI and study staff will have access to the master list. All archived samples and samples
      provided to collaborating laboratories will be identified with study subject numbers only.
      The DNA samples collected will have no recontact.

      The study subject's primary care provider(s) will make first contact on behalf of the study
      so there is no appearance of a breach in confidentiality. Once a subject has expressed
      interest in this research study, to obtain informed consent, one of the study coordinators
      will explain to each subject in lay language the purpose, benefits and risks of the
      investigation. Consent will be given following an informative discussion period and either by
      reading the Informed Consent to the subject or by allowing the subject to read the consent,
      then reviewing it with the subject. All study coordinators have taken the Research
      Coordinator course and have passed their Miami CITI. Every attempt will be made to conduct
      this study in full compliance for the protection of the subjects. For those women who are not
      fluent in English and whose first language is Spanish, a Spanish version of the consent form
      will be used (translated by BiLingo from IRB approved English consent and submitted as an
      amendment to IRB). Following the subject's verbal agreement to participate in the study, the
      subject will sign the informed consent; the study coordinator also will sign the consent. A
      copy of the signed, written informed consent will be given to the study subject. The original
      informed consents will be placed in locked research file in study coordinators' office, 20
      Ehrhardt St, #4. A copy of the informed consent also will be placed in the subject's study
      binder (located in locked cabinets at same location). A study coordinator note will be placed
      in Epic identifying an MUSC woman as participating in a vitamin D and pregnancy RCT.

      All of the investigators have conducted several clinical trials; they are well versed in the
      issues of patient/subject confidentiality and have completed the Miami CITI course. They are
      nationally and internationally known in their fields. All study coordinators have completed
      the Miami CITI and the Research Coordinator course at MUSC. The endeavors of the PI,
      co-investigators and study coordinators to maintain subject confidentiality will be ensured.

      All maternal blood, urine, and vaginal samples as well as infant blood and placental tissue
      will be labeled with the patient's name and medical record number to ensure proper tracking.
      Each study subject (and infant) then will be assigned a specific study number without any
      reference to the woman or infant's name, which will be used to enter all data into the web
      database. We will follow all HIPAA guidelines to maintain protection of patient/subject
      information. With these precautions in place, there is a remote risk that the samples and
      data could be linked to the woman and her infant; however, the study number and the name will
      be kept in a separate file in the locked offices of the study coordinators. The data will be
      entered in a secured database with only the study number entered, thus ensuring that the
      number and data will be kept separately from the woman and infant's names. All this
      information will be kept confidential, and when reported in scientific journals, the
      information will not have any identifying information regarding study subjects.

      Should any untoward reaction occur, subjects would receive treatment at the Medical
      University of South Carolina. The study will cover the costs of laboratory tests; however,
      additional costs of treatment will be the responsibility of the subject as described in the
      informed consent.

      This study meets the guidelines of clinicaltrials.gov as a clinical trial requiring a Data
      Safety and Monitoring Plan and a Data and Safety Monitoring Committee. Two of the members of
      the Data and Safety and Monitoring committee are scientists external to MUSC well known in
      the field of vitamin D metabolism and calcium metabolism. Two of the members are physician
      scientists external to MUSC, who are also well known in the field of calcium and vitamin D
      metabolism. A fifth member will be Dr. Tom Hulsey, epidemiologist at MUSC with considerable
      experience serving on the DSMC of other clinical trials. Dr. Hulsey was the chair of the DSMC
      of the two prior vitamin D supplementation trials conducted by this study team. He will
      maintain the database of the study, follow HIPAA guidelines, and conduct ongoing interim
      analyses to ensure that the risk: benefit analyses remain in favor of benefit to the
      subjects.

      Creation of a Data and Safety Monitoring Board (DSMB): This grant application meets NIH
      policy and Guidelines on the inclusion of a Data and Safety Monitoring Plan for clinical
      trials mL and http://grants.nih.gov/grants/guide/notice-files/not98-084.html). MUSC as the
      Institute and Center (IC) of this grant will have a Data and Safety Monitoring Committee
      (DMSC) in place as outlined in this grant. Two of the members of the DSMC are scientists
      external to MUSC well known in the field of vitamin D and calcium metabolism. Two of the
      members are physician scientists external to MUSC who also are well known in the field of
      calcium and vitamin D metabolism. A fifth member will be Dr. Tom Hulsey, epidemiologist at
      MUSC with considerable experience serving on the DSMC of other clinical trials (current and
      completed). He will maintain the database of the study, follow HIPAA guidelines, and conduct
      ongoing interim analyses to ensure that the risk: benefit analyses remain in favor of benefit
      to the subjects.

      B. Conduct ongoing monitoring of interventional trial by those who have appropriate expertise
      to accomplish the trial's mission: The MUSC clinical lab is required to notify the PI of any
      critical lab values. The Study Coordinators will be responsible for checking laboratories of
      the women within 72 hours of their reporting and then entering the laboratory data into the
      computer. They will be provided with a set of normative laboratory values as a reference. The
      Clinical PI will review values during the weekly study meeting or will be notified if a value
      falls outside of the referent value range. All data will be verified independently by the
      Data Processing Center under the direction of Dr. Hulsey. The DSMC will be notified via
      telephone and fax with source documents and adverse report sheets if a subject's value falls
      outside the referent value range. In addition, all adverse events will be reviewed quarterly
      by the DSMC, whose report will be forwarded to the Kellogg Foundation on a quarterly basis
      and the IRB yearly. The Investigators will report all Serious Adverse Events by telephone to
      the IRB and the DSMC; in addition, the IRB, the DSMC, and Kellogg Foundation will receive a
      written report within 10 days of the Clinical Investigators' knowledge of the Event. In
      addition, the investigators will generate a quarterly report to the DSMC regarding subject
      enrollment, subject completion, adverse events and serious adverse events. The DSMC will
      review the report and a summary letter with their findings sent to the IRB.

      Interim Data Analyses & Monitoring: Interim analyses for the evaluation of safety and
      efficacy will be conducted based on the recommendations of the Data Safety & Monitoring
      Board. The DSMC will serve to monitor for safety and efficacy. DSMB reports produced by Dr.
      Hulsey's team will include summary statistics: on mother recruitment (expected vs. actual),
      data form quality (completion and timeliness of forms); tracking of data editing;
      demographics of the randomized mothers; aggregate safety; aggregate efficacy; and related
      information. The DSMB also will monitor the trial from the standpoint of futility using the
      techniques of Lan and Wittes (119).

      First, differences in losses to follow-up and missed visits will be compared between the six
      comparison groups to detect any potential bias (400 IU group stratified by race: African
      American, Hispanic and Caucasian; 4000 IU group also stratified by race). The biggest problem
      with unbalanced losses will be the loss of statistical power. We will aggressively attempt to
      avoid any losses by monitoring adherence to visits. In the event that there are differential
      losses between ethnic groups or supplementation groups, we will conduct statistical tests to
      ascertain whether these are random or biased. Random losses will be reported but should not
      affect outcomes. Biased, or non-random, losses will be assessed on their potential impact on
      differences in outcomes. If necessary, we will conduct a propensity score analysis to control
      for any statistically significant differences in non-random losses. Following that,
      differences in compliance to supplementation will be compared as an 'intent-to-treat' design.
      Any significant deviation from protocol will be considered in subsequent analyses. In this
      section, we will report on: (1) the deviations from protocol; (2) outcomes comparisons using
      an efficacy design to test for true differences associated with subjects who adhered to
      protocol; and, (3) outcomes comparison using the intent to treat (effectiveness) design to
      test for actual differences that might be expected in a non-controlled intervention. This
      will help determine whether this type of supplementation could be expected to be effective if
      applied to the general population.

      Next, vitamin D levels at study entrance (10-14 weeks' gestational age) will establish the
      baseline for each supplementation group. It is expected that at baseline there should not be
      any differences between groups. Because we do expect differences between ethnic groups (which
      accounts for the stratification), mean vitamin D at baseline will be compared by two-way
      analysis of variance (ethnicity by experimental group).

      In step 3, using repeated measures analysis of variance, the changes in vitamin D will be
      described separately for each ethnic group within each of the supplemented groups. This will
      depict separately for each ethnic group the changes in vitamin D over time as a function of
      the level of supplementation. This method will reveal how soon after supplementation the
      changes in blood (from baseline) are detected, the linear change in blood vitamin D over time
      and, when and if a peak level (or plateau) was attained. Adjusted differences will be
      examined by use of multiple regression with and without the inclusion of other covariates.
      Regression coefficients provide the formula for the linear association between vitamin D in
      blood and time, separately for each ethnic group. In the event that there is a non-linear
      change over time, appropriate data transformations will occur as necessary. This step also
      will provide information on the magnitude of importance that covariates play in changes in
      vitamin D over time within each ethnic group. As an example, we may find that seasonality
      plays a significant role in changes in vitamin D for Caucasian women but the association is
      not as strong for African American women. Further, these associations may become similarly
      unimportant at the higher levels of supplementation.

      The next series of analyses will compare the differences in vitamin D between supplemented
      groups over time between ethnic groups. This will be accomplished by use of a two-way
      (ethnicity and supplementation group) repeated measures analysis of variance. This technique
      will detect any significant differences between main effects (ethnic groups and
      supplementation groups) and interaction effects (ethnicity by supplementation) in changes in
      vitamin D over time. Multiple regression also will be used to examine the changes with and
      without the use of potential confounders.

      In secondary analyses, multi-level mixed-effects models will be used to estimate the average
      individual monthly rate of change in 25(OH)D, compare this rate between dose groups, and
      explore the effects of covariates on the rate of change. These models include fixed effects
      for dose group, time, and the group-time interaction, and a random intercept effect, with
      additional covariate effects as required. Time will be considered a continuous variable,
      measured in months rather than assuming structured visit occurrences. An unstructured
      covariance matrix will be assumed. The multi-level modeling approach also will be used to
      evaluate the longitudinal association between 25(OH)D and the safety parameters calcium, iPTH
      (log-transformed), phosphorus, and urinary calcium, creatinine, and calcium: creatinine
      levels. The cumulative occurrence of pregnancy complications such as preterm labor and
      infection will be compared between dose group levels using logistic regression. All analyses
      will be performed using SAS (SAS Institute Inc., Cary NC).

      Participant attrition and missing data:

      Because the primary endpoint of the study is change in 25(OH)D from baseline to delivery, the
      primary analysis will be restricted to participants who have remained in the study until
      delivery and provided a blood sample within 6 weeks prior to delivery, at delivery, or at the
      post-delivery visit (completers-only analysis). Typically, multiple imputations would be used
      to impute missing values in support of the favored intention-to-treat analytic approach.
      Because the multiple imputation model for this analysis would have required variables also
      measured in the final blood sample, however, it cannot be used to impute cases with a missing
      final blood sample. Thus, to assess the primary findings' robustness to assumptions about the
      missing data, we will perform a sensitivity analysis. Missing data will be imputed under the
      following conditions: cases with missing endpoints that experienced no change in both groups;
      experienced the group-specific median change observed in completers; experienced no change in
      the 400 IU group and minimal change in the 4000 IU group. In the secondary analyses using
      multi-level mixed-effects models for longitudinal modeling, all available data points will be
      used, as it is not necessary to delete cases with missed timepoints when using this approach.
    

Intervention name(s): Vitamin D3 4000 IU in gummy form; Placebo gummy vitamin
Intervention type(s): Drug; Drug
Intervention description(s): Subjects randomized to the Vitamin D3 4000 IU gummy vitamin arm, the investigational drug, will consume 4 gummies/day beginning at 10-14 weeks of your pregnancy. All subjects will consume a prenatal vitamin (either chewable or pill form) also beginning at 10-14 weeks of your pregnancy.; Subjects randomized to receive placebo, also in gummy form but manufactured without Vitamin D3, will consume 4 gummies/day beginning at 10-14 weeks of pregnancy. All subjects will take a prenatal vitamin (either chewable or pill form) also beginning at 10-14 weeks of pregnancy.
Intervention MeSH terms: Vitamin D; Cholecalciferol; Vitamins
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Prevention
Keywords: pregnancy; Vitamin D status