"The health system should have nutritionists and emotional coaches for pregnant women"

The Improving Mothers for a Better Prenatal Care Trial Barcelona (IMPACT-BCN) study, carried out by doctors and scientists at the San Joan de Déu Hospital and the Hospital Clínic in the city, has demonstrated for the first time that interventions in the mother's lifestyle during pregnancy, related to diet and reducing stress, reduce the risk of having a low-weight baby by up to a third, among other positive impacts. We spoke to Dr Francesca Crovetto, a specialist in fetal medicine and a researcher at the BCNatal research centre and one of the coordinators of the study, who told us about the results, and about other maternal-fetal health research projects she is working on.

Crovetto was one of the speakers at the Women's Health Seminar organized by the Universitat Oberta de Catalunya's (UOC) Faculty of Health Sciences, which took place at the university on 18 June.

What are the main conclusions of the IMPACT-BCN study?

For the first time in the world, the study published in JAMA has shown that both the Mediterranean diet and reducing stress through a mindfulness programme leads to a reduction of between 29% and 36% of babies born with low birth weight (weighing less than the tenth percentile). That was the main result of the study, which is very important, because there had previously been no known treatment that could prevent or improve low birth weight.

Among the secondary results, these interventions were also shown to reduce mortality during the perinatal period and reduce the percentage of mothers with preeclampsia (high blood pressure) during pregnancy.

What other positive impacts did the interventions have?

In the same study, we have also shown that these interventions significantly improve children's neurodevelopment in the first two years of life. These results have been published in JAMA Network Open. The children of women who followed a Mediterranean diet programme during pregnancy presented better results in the test, particularly at a cognitive level (sensory and motor development, relationship with objects and the formation of concepts) and in socio-emotional terms (related to relationships and interactions). Meanwhile, those of women who followed a stress reduction programme during their pregnancy presented better results in the socio-emotional domain.

Which of the three groups that participated in the study obtained the best results?

The results speak for themselves. Both the dietary intervention and the stress reduction intervention had a positive impact on the patients. 21.9% of the pregnant women in the control group (without any intervention) had newborns with low birth weights, while the percentage was significantly lower in the Mediterranean diet group (14%) and the mindfulness group (15.6%).

How was the IMPACT study carried out?

The study took three years, and more than 1,200 pregnant women at high risk of having a small baby participated in it. It was carried out jointly by the Hospital Clínic and the Hospital Sant Joan de Déu in Barcelona, with the participation of the Fetal and Perinatal Medicine teams at the August Pi i Sunyer Biomedical Research Institute (IDIBAPS), the Maternal-Fetal Medicine Service at Sant Joan de Déu, and the Internal Medicine Service and the Psychiatry and Psychology Service at the Hospital Clínic, with the support of CEREBRA, the Centre for Biomedical Research Network on Rare Diseases (CIBERER) and the Catalan University and Research Grant Management Agency (AGAUR).

What type of dietary interventions were carried out during pregnancy?

The nutritional intervention, adapted from the PREDIMED (Prevention with Mediterranean Diet) trial, aimed to modify the women's eating patterns, rather than focusing on changes involving specific foods or macronutrients. The participants in the diet group received two litres of extra virgin olive oil (each month) and the equivalent of 15 grams of walnuts per day (450 grams each month), which are products high in omega-3, free of charge. In order to assess adherence to this intervention objectively, we measured biomarkers related to walnut and olive oil intake in blood and urine.

The participants also attended monthly appointments with a nutritionist, who also followed up by telephone every two weeks. With the help of the nutritionist, the women were encouraged to adhere to the Mediterranean diet, including more fruits and vegetables, white meat, oily fish, dairy products and whole grains. They were provided with a weekly shopping list and meal plan, with a menu for each day.

And what did the stress reduction intervention consist of?

The group with the stress reduction intervention followed the Mindfulness-Based Stress Reduction (MBSR) programme designed by Jon Kabat-Zin, emeritus professor at the Massachusetts Medical School and the founder of the Center for Mindfulness in Medicine, Health Care, and Society. This programme has been adopted by healthcare organizations and tested in clinical trials. It consisted of an eight-week programme with one full-day session and a weekly two-and-a-half-hour session, and the women were encouraged to do a 45-minute relaxation session each day at home. The programme included formal and informal relaxation techniques in order to increase awareness of the present and reduce rumination (focusing excessively on the past) and anxiety. The techniques included were meditation, mindful yoga, yoga stretches, body scanning, mindfulness of daily activities, breathing techniques, etc.

The participants completed questionnaires at the beginning and end of the programme, and their levels of the stress-related hormones cortisol and cortisone were measured to see if there was a reduction in stress.

The study obtained another positive result: the interventions also improve children's neurodevelopment in the first two years of life.

That's right. Both the Mediterranean diet and reducing stress significantly improve children's neurodevelopment in their first two years. These results have been published in JAMA Network Open. The level of neurodevelopment was analysed using a Bayley test, which a standardized test for measuring children's neurodevelopment. The children of women who followed a Mediterranean diet programme during pregnancy presented better results in the test, particularly at a cognitive level (sensory and motor development, relationship with objects and the formation of concepts) and in socio-emotional terms (related to relationships and interactions). Meanwhile, those of women who followed a stress reduction programme during their pregnancy presented better results in the socio-emotional domain.

What are the next steps, after the success of both interventions has been demonstrated?

The truth is it's not easy to implement these interventions in the health system, as they cost a lot. We can advise expectant mothers to adopt these habits in their everyday lives, but not everyone can do it. It would be ideal if the health system could be provided with nutritionists and emotional coaches, or if we could give pregnant women an app that would track them online. We are working on it, and we have applied for grants to take these aspects further. We aim to work with engineers from Pompeu Fabra University to create an app that makes it easier for mothers to incorporate these habits into their everyday lives.

Are you currently working on any other projects related to maternal and fetal health?

We are studying the effect of mothers' lifestyle on preeclampsia, as there have been very few studies on this topic. How sleep, lifestyle and diet influence the risk of preeclampsia during pregnancy. In particular, we are looking at whether the composition of the mothers' intestinal microbiota influences the development of this disease. We found that women who suffer from it have different microbiota. Microbiota are formed before birth and depend on several factors, such as the maternal environment during pregnancy and the type of delivery, among others. More studies are needed to confirm their role in pregnancy and babies' health.

Finally, what advice would you give women who are looking to become pregnant in the future?

The results of our research provide a clear and positive message that empowers mothers and families. It is possible to have a positive impact on health during the pregnancy and the baby's health with measures that are relatively easy to apply.