Fermented Food - Achars (fermented Pickles) in Pakistan

The highest burden of malnutrition in the world is in South Asia and Africa. Over the last ten years, our work on Environmental Enteric Dysfunction in Matiari, a poor rural district in the Sind province of Pakistan, shows that the most critical driver of childhood stunting is anthropometry at birth. Birth anthropometry is primarily influenced by maternal health and nutrition. Fermented foods are an indigenous yet underutilized resource that could improve gut health, reduce inflammation, and promote a healthy microbiome in women. The most common plant-based fermented food used in rural Sind is the achar, a local variety of fermented pickles made from many different vegetables and fruits. Achar has been used over centuries in this area. Traditional folklore dictates that achar is good for pregnancy. Craving for achar is a sign of early pregnancy in this culture. Achars are considered antiemetics and are believed to help relieve gastric issues in early pregnancy.

The medical benefits of pickles/achars are fairly well recognized. Major microbes involved in the fermentation of Achar are LAB (Lactic Acid Bacteria), bacillus, and micrococcus species, which are directly or indirectly responsible for multiple health benefits. However, a clinical trial has not been conducted to determine the impact of regular use of achar on the health of women of childbearing age in a real-life setting.

The investigator hypothesizes that traditional, fermented achar use reduces gut and systemic inflammation and drives a healthy microbiome in women of reproductive age in Matiari, rural Sindh, Pakistan. If our trial confirms this hypothesis, then at-scale use of the best achars can be advocated in this community as an Indigenous and culturally appropriate intervention.

The investigator recruited 210 women of reproductive age (18-45 years), including pregnant women. These women were divided into seven groups. Six groups were randomly assigned as "Test," and one group served as "Control" (non-fermented vegetables or fruits). Different formulations of achar were assigned to each of the groups.

G1= Mango Pickle (Water-Based) G2= Mango Pickle (Oil Based) G3= Carrot Pickle (Water-Based) G4= Radish Pickle (Water-Based) G5= Onion Pickle (Water-Based) G6= Lemon \& Chili Pickle (Water-Based)

Women were recruited from the community through a demographic surveillance system established in Matiari, Pakistan. The study staff approached and introduced the potential participants to this study. If Participants agree, After informed consent, a short questionnaire was filled out, including information about socio-demographics, household food insecurity index, history of illness, and anthropometric measurements. 10ml blood samples were collected at baseline and at 8 weeks. 5ml blood sample was used for CBC and cytokine measurement while 5ml blood was required to collect PBMCs which was used for Transcriptomics analyses as complete immune-profiling is necessary to study the microbiome-host interaction and its impact on immune cells. Fecal samples were collected longitudinally for biomarkers assessment and fecal microbiome at baseline, at 8 weeks, and then at 12 weeks. A 24-hour food recall form was filled out at enrollment and at 8 weeks. We delivered pickles to the intervention group. The investigator did not offer anything for the control group. However, control participants were requested to eat non-fermented food and avoid fermented foods. The investigator collected information about compliance with treatment (Test group) after every 14 days. Common food items consumed in the last 7 days were collected through the food frequency form at each follow-up. Participants in intervention groups were given pickles in 50 gms of pre-weighted cups/jars for daily consumption, and partially eaten pickle cups were weighed again at each follow-up to measure compliance and standardization of pickle intake. All jars will be bar-coded. The study team will ensure the refilling of pickles at the household level.

Eligibility Criteria:
Inclusion Criteria:

• Women of reproductive age group (18-49 years) residing in the study area and should provide informed consent for study participation.

Exclusion Criteria:

* Antibiotics or probiotics or laxatives use in the past two weeks.
* Current diarrheal illness.
* Regular (\>= two times a week) use of achars before enrollment.
* Any Gastrointestinal illness such as chronic constipation, Irritable bowel syndrome, Gastroesophageal Reflux Disease (GERD), peptic ulcer disease, Gluten Sensitivity and Celiac Disease, Inflammatory Bowel Disease, or history of laparoscopic surgery in GI tract or cholecystectomy.
* Known case of hypertension.