The effect of prenatal balanced energy and protein supplementation on gestational weight gain: An individual participant data meta-analysis in low- and middle-income countries
Authors: Wang Dongqing , Partap Uttara , Liu Enju , Costa Janaína Calu , Cliffer Ilana R. , Wang Molin , Nookala Sudeer Kumar , Subramoney Vishak , Briggs Brittany , Ahmed Imran , Argaw Alemayehu , Ariff Shabina , Bhandari Nita , Chowdhury Ranadip , Erchick Daniel , García-Guerra Armando , Ghaffarpour Masoumah , Hanley-Cook Giles , Huybregts Lieven , Jehan Fyezah , Kaseb Fatemeh , Krebs Nancy F. , Lachat Carl , Lama Tsering Pema , Manandhar Dharma S. , McClure Elizabeth M. , Moore Sophie E. , Muhammad Ameer , Neufeld Lynnette M. , Prentice Andrew M. , Quezada-Sánchez Amado D. , Roberfroid Dominique , Saville Naomi M. , Shafiq Yasir , Shrestha Bhim P. , Sonko Bakary , Soofi Sajid , Taneja Sunita , Tielsch James M. , Toe Laéticia Céline , Valaei Naser , Fawzi Wafaie W. 
Published: February 2025

Background
Understanding the effects of balanced energy and protein (BEP) supplements on gestational weight gain (GWG) and how the effects differ depending on maternal characteristics and the nutritional composition of the supplements will inform the implementation of prenatal BEP interventions.

Methods and findings
Individual participant data from 11 randomized controlled trials of prenatal BEP supplements (N = 12,549, with 5,693 in the BEP arm and 6,856 in the comparison arm) in low- and middle-income countries were used. The primary outcomes included GWG adequacy (%) and the estimated total GWG at delivery as continuous outcomes, and severely inadequate (<70% adequacy), inadequate GWG (<90% adequacy), and excessive GWG (>125% adequacy) as binary outcomes; all variables were calculated based on the Institute of Medicine recommendations. Linear and log-binomial models were used to estimate study-specific mean differences or risk ratios (RRs), respectively, with 95% confidence intervals (CIs) of the effects of prenatal BEP on the GWG outcomes. The study-specific estimates were pooled using meta-analyses. Subgroup analyses were conducted by individual characteristics. Subgroup analyses and meta-regression were conducted for study-level characteristics. Compared to the comparison group, prenatal BEP led to a 6% greater GWG percent adequacy (95% CI: 2.18, 9.56; p = 0.002), a 0.59 kg greater estimated total GWG at delivery (95% CI, 0.12, 1.05; p = 0.014), a 10% lower risk of severely inadequate GWG (RR: 0.90; 95% CI: 0.83, 0.99; p = 0.025), and a 7% lower risk of inadequate GWG (RR: 0.93; 95% CI: 0.89, 0.97; p = 0.001). The effects of prenatal BEP on GWG outcomes were stronger in studies with a targeted approach, where BEP supplements were provided to participants in the intervention arm under specific criteria such as low body mass index or low GWG, compared to studies with an untargeted approach, where BEP supplements were provided to all participants allocated to the intervention arm.

Conclusions
Prenatal BEP supplements are effective in increasing GWG and reducing the risk of inadequate weight gain during pregnancy. BEP supplementation targeted toward pregnant women with undernutrition may be a promising approach to delivering the supplements.