Fertility, Sperm Health, and Nutrition Before and During Pregnancy | Dr Federica Amati

0:00Welcome back to The Proof. I'm your host Simon Hill and today's episode is part one of a two-part series with Dr Federica Amati on the first thousand days of life from conception through to a child's second birthday. This is the most consequential nutritional window of human life. In part one we cover the golden window itself, the 90 days before conception, and everything you need to know about nutrition through pregnancy. Let's get into it.

0:33what's the golden window of opportunity the golden window of opportunity is a period in time

0:39Dr Federica Amati: that we refer to in medical science where so much health is set so many things happen that there's just the most opportunity to have a long-term impact on a person's health and in terms of what that time frame is it's really the period between conception and second birthday this is also known as the first thousand days and you know sometimes people like to say actually it's technically 30 days preconception and possibly up to the age of three so the golden window is a little bit stretchy but it's all tied to anchor to this principle called dohad which is the developmental origins of health and disease principle which essentially speaks to the fact that all of our organs are formed.

1:27Dr Federica Amati: Most of our cells are sort of set in terms of their health in the first thousand days of our lives. And it's called the golden window because the positive of this is that if we intervene in this timeframe, we can have really measurable long-term positive effects on the health and the life of that baby. And when you say intervene, that's thinking about what parents are doing preconception during pregnancy and then how a baby's being fed yes it's what parents are doing but simon i think it's important to frame very early on in this conversation that it's also the kind of environment that we live in which is shaped by the policies and the political will to make sure that the best possible environment is created so as you'll be aware lots of policies and lots of the ways that we structure things like hazard for pollutants for example is centered around adult health so we think of things as being safe limits or even a healthy pollution levels for adults and actually if there was a better understanding of the importance of the golden window of opportunity and it was part of the way we think about structuring our environment at policy level, we would really shift the way we think about these things.

2:49Dr Federica Amati: So yes, it's parental knowledge, empowering parents to know that they have so much potential they can do here, but it's also taking the blame away from parents and letting them know that actually at the moment in many countries, it's quite hard to set up the best possible environment for this timeframe. And why is this important? Like, why are you so passionate about this, setting up the best possible environment, helping to educate and inform parents and policymakers? What are the consequences, I guess, of not getting this right? And what's up for grabs if we do better in this area? I'm really passionate about it because there's just so much potential for it.

3:33Dr Federica Amati: And also because when I started doing research into this, started looking into this about a decade ago now. No, actually, maybe longer than that. I was very surprised to see just how much of our health is decided so early on in our lives before we're even bored most of the time. And this transgenerational effect, you know, the fact that we now know that some of my health was set when I was a cell inside my mother as she was developing inside her mother's womb. Like that blows your mind when you think about that, right? So Simon, the egg that became you was already forming inside your mother's tiny, tiny ovaries when she was inside your grandmother's womb.

4:18Dr Federica Amati: So there's this, once you start to look at this, there's a transgenerational effect. It's really the longevity lever we have never talked about. everything that happens in the first thousand days is what sets the slope for your aging later in life so we should really be thinking about this in a much longer term way so I was excited by the prospect of what the evidence is showing us you know a lot of the evidence we have around this hypothesis the dohada hypothesis and transgenerational effects comes from quite tragic things like famines and you know what happens when things go wrong but what it's allowed us to understand is that there's something we can do to intervene to make the outcomes for the mother and for the baby, both in the short term and the very long term, and that baby's offspring.

5:09Dr Federica Amati: So to me, it's the most bang for your buck you can possibly get when we think about public health interventions. And I'm passionate about it because it's just not spoken about. It's not something that's often communicated clearly. And it's also something that, frankly, when we think about the way that public health, medicine and policy sort of evolve, they often don't have this longer term thinking. And because at any one time, there's only a proportion of the population that is reproducing. So it's technically like a minority of the adult population that's reproducing. It means it's never a huge target.

5:48Dr Federica Amati: But as I said, the potential for the effects of what you do there is huge. So you asked me what can go wrong if there are some negative inputs at this time. And I mentioned there are things like the Dutch hunger famine, which you'll know about. It was a natural experiment, if you will call that, where the Dutch population was starved as part of the Nazi takeover. And essentially, there was this cohort of pregnant women who entered famine at different points in their pregnancy. First trimester, second trimester, third trimester. and because this is a whole population scientists were able to follow up and see how that famine kind of changed the outcomes of the offspring that were pregnancy at that time that were in the womb and there's some very distinct effects that that famine has on the baby especially in the first trimester so horrible events such as the Dutch famine and other things that we see, such as exposure to phthalates in the first trimester, have measurable effects on the offspring's outcomes, basically.

6:59Dr Federica Amati: And so we have a few ways of understanding why and how this happened. And we have human data that shows us that these very sensitive windows of exposure have lasting effects on the outcomes for the offspring. I want to come back to famine later on when we tackle GLP-1s and pregnancy and get your thoughts on that and what we understand about GLP-1s, which are, of course, super popular. You and I did a different episode on satiety and appetite and GLP-1s, but I'm sure there are a lot of people that have questions about their use during pregnancy, pre-pregnancy, etc. Before we get there, in case someone hasn't caught our last episode, can you remind people, and I'm going to get you to brag here for a moment, remind people of your academic and clinical background so people kind of understand why you're the right person to be speaking about this topic?

7:55Dr Federica Amati: Yeah, of course. So my background is in biomedical sciences and endocrine pharmacology. So I have an honours in endocrine pharmacology, and that's really given me a lot of interest and understanding on how pathways and chemical interactions with hormones basically work in our body. I then went on to do a master's in public health at Imperial College and was very interested in patient-centered outcomes and patient-centered care. So personalizing medical interventions and advice. From my master's, I worked at the WHO for a bit, and then I went on to do a PhD in clinical medicine research. And for that, I actually looked at huge patient data to, again, assess how we could predict outcomes from treatment by understanding patient individual characteristics.

8:43Dr Federica Amati: So I'm very passionate about how we can help improve outcomes in medicine and health in general by understanding individual markers and individual characteristics. And then finally, I did my master's in nutrition at London School of Hygiene and Tropical Medicine, where I specialised in maternal and child nutrition. And I'm a registered public health nutritionist, and I have an active clinical practice with a full medical team. So I'm the nutrition lead for that. And I'm also the nutrition topic lead for the medical school at Imperial College School of Medicine. So I teach medical students all about nutrition, appetite, regulation, the interaction between environment and how that shapes health across the life course.

9:31Dr Federica Amati: And I'm lucky to have been working with the medical team to create a GLP-1 intervention for our patients that includes lifestyle, nutrition, exercise, and their prescribing doctor all working together. So I've been lucky to be part of a system of how these drugs should be prescribed, but also been able to see the effects of what happens when patients come in after they've received their prescription elsewhere and how that can be quite damaging. if you've been listening to me or some of my guests talk about the gut microbiome you'll know that it thrives on very specific types of fiber and polyphenols and resistant starch many of which the average person falls short on despite the very best of intentions that's why dr will bolsewitz and i founded 38 terra a gut health company where science meets supplementation an independently conducted 15-day M.

10:24Scheim study found that our first product, Daily Microbiome Nutrition, or DMN for short, significantly increased short-chain fatty acid production and encouraged the growth of beneficial microbes linked to better gut and metabolic health. It's a simple daily scoop that you can add to water or your smoothie, no sugar, no fillers, just clinically backed ingredients that make your gut bugs happy. So if you want to support your microbiome in a meaningful, science-backed way, check out 38terra.com and use the code THEPROOF to save 20 % off your first order. Before we kind of walk through the golden window, through the different stages, so preconception, during pregnancy, postnatal, and think about environmental exposures and nutrition, etc., I want to read you something that you wrote.

11:16Everybody should know this. your book that's on this topic of the importance of the first thousand days. And he said, whenever I want to shout from the rooftops about the importance of the first thousand days, I met with sharp inhales and various degrees of raised eyebrows. Some podcasters have told me, we just can't include that information. It's just, it's too scary to the public. Do you find that people are quite scared by the idea of this topic and as a result of perhaps various things being outside of our control, some of those things that you mentioned earlier being more related to the environment that we live in, prefer to avoid this topic because it is quite sensitive and frightening?

11:59Dr Federica Amati: Yes. So I think there is a real sense when you start to unpick this topic and just see how much influence this period of time has, there's a reluctance to engage with it sometimes because A, if you're a parent, And, you know, the guilt of parenthood is already quite widespread. It's quite, you always try to do your best as a parent, you know. And when you hear that there's even more of pressure of what could be done in this time, it can feel quite overwhelming. And even if you're not a parent, often people find this information can be disempowering because it's like, well, I'm not in my mother's womb anymore.

12:38Dr Federica Amati: What can I do now to improve my health? So there's this dual element of, oh gosh, I'm already a parent and perhaps I'm past the two-year birthday mark. It's all lost. And then there's an element where it's like, well, my kid's 12 or I'm 25. What can I do now? And I think that's not the point of this science or of communicating the science. I think that, as I mentioned, you know, this is an opportunity to reframe longevity to start much earlier. And there is also a case, of course, the rest of my book covers this, that improvement in lifestyle and nutrition improves our health at every phase of life.

13:18Dr Federica Amati: So one of the most famous modelling studies on this was looking at what would happen using UK Biobank data if somebody switches to a healthful diet at the age of 70. In this study, they modelled a potential increase in lifespan of six years. That's nearly 10 % of your life. So there is always positive outcomes to be had by improving lifestyle and nutrition at any stage of life. but I think avoiding the importance of this phase because of potential guilt misses the point of the framing it's like actually by understanding this the science is so evident that what we should be feeling is we need to push for change that supports this life period at a structural level and then there are things that we as individuals can absolutely do to improve the conditions the nutrition and the environment that we are bringing new babies, new life into.

14:14Dr Federica Amati: I think it's a very hopeful message because the science is so exciting and it's getting stronger every year. So even since I wrote the book, new studies have been published that sort of show us more mechanisms and more ways in which these levers can be pulled. And it's an urgent call from us as a population to say, hey, actually, we should really look at this. We should really help to change some of the regulations, the policies, the advertising standards for some of these products so that we can create a better environment, which will also be better for us as adults, by the way. So we all share with the benefits, right?

14:49Dr Federica Amati: It's just that the incremental benefits are so big when we think about the first thousand days. How would you encourage the listener who, let's say their kids are already five, six, seven, and they hear some of this information and they do feel shame and perhaps what runs through their mind is, I should have known better. I should have known this. How would you encourage them to think about this topic? I would encourage them to remember that human biology is incredibly resilient and that even if there were some exposures early in life, a lot of the exposures, by the way, can't be helped, as I said.

15:25Dr Federica Amati: So they were part of a necessary situation that happened. and there are so many things, so many levers we can still pull. It's like early life, five, six, teens. There's another huge window of opportunity in teenagers. There's a huge window of opportunity like in your early twenties when it comes to brain health. So there's other opportunities to continue to work on our health. And, you know, consider the fact that actually in the same way my grandmother did not know that what she was eating in pregnancy was impacting me, right? your kids can now know that for their kids and grandkids they can have the knowledge and the power to improve that and make it better for their own kids so there's there's still benefits to be had for everybody it's not about shame or guilt it's about us as a society just leveling up and and having more information that we can act on yeah it's you know we once we learned that seatbelts saved lives.

16:24Dr Federica Amati: We didn't mourn the journeys we took without seatbelts. We just wore our seatbelts. Yeah. And it's hard to blame people in the past who weren't wearing seatbelts before that knowledge was available. Exactly. Yeah. In the opening line of part one of your book, you say something that I think is really interesting and shouldn't be lost on us. You say 48 of the 52 cell differentiations required to make an adult human a complete by the day of birth. Now that sounds very science-y. Can you walk us through what does that actually mean? Why did you include that? And what's the significance of it? What it actually means is that pretty much all the tissues, all the organs, all the structure, all the blueprint that makes it a human being is already drawn up, it's set by the time you're born.

17:15Dr Federica Amati: Now, when I say in simple terms that your heart, your brain, your eyes, your gut, your liver... your kidneys, by the time you're born, they're already there. The structures are there. One of the interesting findings we have from some of the DOHAD research is that women who are undernourished in pregnancy from protein malnutrition, their babies are born with significantly different kidney structure. And that never changes. That is their kidney structure for life. And then that affects their risk of hypertension later in life with the kidneys being so important in blood pressure regulation. So when I say it, it's like, oh, well, that's obvious, right?

17:53Dr Federica Amati: We know that the baby is formed in its entirety. When babies are born, all the organs are there. They're all in place. The skin is there. The teeth are in the gums. So when I say it simply, it's a really obvious thing. And that slide I present for medical students. And it just means that we are, in essence, built in the womb as people. And when you say that a mother's diet, or even a grandmother's diet will shape the health of her offspring or her offspring's offspring into adulthood. We're talking about health outcomes that are 40, 50, 60 years down the track. How do scientists actually study that?

18:36Dr Federica Amati: The Dutch famine, which I mentioned, is one of the, what you call, they call them natural experiments because they're not controlled by humans, it's a disaster. So that's a very famous one. And you can read about it. And they did very elegant analyses of how severe caloric and nutrient deficiency changes the baby's formation, the baby's health, basically, depending on the trimester in which the mother was exposed to that famine. So we can then start to learn how different structures are affected and how that impacts different health outcomes. And there's a research centre in the Gambia, an MRC research Centre led by London School of Hygiene and Tropical Medicine.

19:14Dr Federica Amati: And they did some amazing research looking at pregnant women who fell pregnant just after the rainy season and pregnant women who fell pregnant just after the dry season. So what that basically looked at is how women's diets were different. So the women who fell pregnant just after the rainy season, they had eaten much more green leafy plants. There was much more food around and their folate status was much better essentially than those who fell pregnant just after the dry season. And so they had sort of, most of the diet was from dried goods and the collected harvested products that were kept for the dry season.

19:56Dr Federica Amati: And what you see there is 50 to 60 years later, so it's just these really amazing long-term cohort studies 50 to 60 years later they could see that there was a difference between the two cohorts in terms of survival rate so people who were born when their mothers had had a diet very rich and fresh plants basically were less likely to die they looked at their risk for type 2 diabetes metabolic dysfunction hypertension and they just saw this protective effect of the preconception diet with all else being adjusted for across this population. So this is how we start to glean these very long-term effects in human populations.

20:37Dr Federica Amati: There's also some studies that have been done for things like multi-vitamin supplementation, so multi-nutrient supplements. There's quite a lot of trials looking at that in countries where women perhaps can't access a healthy diet. So we have lots of different types of data, both short-term outcome data of birth weight, whether there's a complication to birth and also long-term with hypertension and things like that. And so the kind of biological plausibility or the explanation for this is that when the mother has adequate or optimal nutrient status, all of those important nutrients that act as building blocks to build these systems that build kind of resilience, I guess, in the embryo and in the infant are there and when there's a shortfall on a particular nutrient, then whether it's the immune system or another aspect of physiology may not develop fully.

21:31Dr Federica Amati: Exactly that. So in the protein example, women who were severely protein deficient, the organs just didn't finish building. So the kidneys in this case, right? With other nutrients like iodine or choline, then you see that there's a real risk to brain health and brain structure. I mean, iodine is one of the most stark. Iron deficiencies in pregnancy is really quite devastating with the outcomes it can have. So we understand a lot of what nutrients are needed in pregnancy, unfortunately, by seeing what happens when there's a deficiency in those nutrients. Same with omega-3 fatty acids. So we also know for example with anemia anemia interesting iron deficiency anemia impacts the baby's growth but also massively impacts the likelihood of maternal death so i think it's also important to remember this isn't just about the mother eating to deliver a healthy baby it's also the mother eating to develop herself healthily because to sorry to to get through pregnancy and delivery and stay healthy because pregnancy is a massive metabolic strain it's a really interesting adaptation that women's bodies go through to actually sort of go through pregnancy successfully for themselves as well as for the offspring.

22:43Do you find people are surprised by the influence of both the egg and the sperm health in that 90-day kind of period before conception and how that affects the health of the developing baby?

23:00Dr Federica Amati: Well, I think generally there's just not enough education around the importance of healthy sperm and healthy eggs, right? So I think a lot of us, certainly of our age, Simon, went through school being taught how to absolutely not get pregnant. It's like, whatever you do, avoid pregnancy at all costs, as though it was such a surefire thing, like sure given thing. And it's only when you enter later phases in life, and perhaps you're trying to conceive, and it's not working, that you suddenly realise that, oh, the egg only lifts for 24 hours. And actually, you can only get pregnant pre-ovulation because after ovulation, the egg dies and that's it basically.

23:38Dr Federica Amati: And you start to understand these things about egg and sperm. And then you start to understand things that like, actually you've had your eggs since before you were born and the exposures that you have, that these eggs have had can impact their health. So smoking, I have to like frame this very carefully. Eggs are pretty protected in your ovaries and actually the selection process that your body undergoes to choose the egg that will be ruptured by the follicle for fertilization, hopefully, is actually pretty cool. So our body tries to select the best quality egg. So I don't want to scare people into thinking, oh my gosh, all the late nights I had in my 20s have completely ruined all my eggs.

24:18Dr Federica Amati: It doesn't quite work like that. But we do know that things like exposure to smoking and heavy alcohol use, so these toxins that we know are very impactful in our health, do have an impact on a woman's eggs throughout her life course. So from before we're born. For sperm, a bit luckier. So men make new sperm all the time. And so actually that 90 day cycle in men, and it's roughly 90 days, it can be 70 or 110 days, means that you're going from a brand new sort of germ cell to a functioning sperm. And people are surprised by the fact that in that night, first of all, that there's a match in 90 day windows between the egg and the sperm, which is pretty cool.

25:00Dr Federica Amati: So if you're a couple trying to conceive, you can both be in it together for this 90 days and it can have a measurable impact on certainly the quality and the efficacy of the sperm. So is it swimming? Is it swimming in the right direction? All these things. How fragmented is the sperm's DNA? But also for the egg, in terms of like the quality of the egg, how efficiently your ovaries can select the best egg, right? How you can ensure that there is successful ovulation and ensuring that you have the preconception nutritional status to support fertilization and the first trimester. So I think a lot of people I've worked with, especially those who had already been through IVF once or twice, sometimes three times, and those who had been trying to conceive for a long time, when they discovered this, and this is the prompt to why the title of the book actually was one of my patients who was preparing to freeze her eggs.

25:59Dr Federica Amati: And she had been speaking to quite a few people about freezing her eggs. And when I explained to her, okay, you've got to have this 90 day window. And these are the things we do to help get as sort of good quality as possible eggs from the retrieval. She said to me, everybody should know this. And that's the book title. So it was, it's usually people just haven't had this information delivered to them. I think there are more people doing that now. So I think, you know, there are brilliant people like Natalie Crawford. I know she does a lot of talking on this. Dr. Helen O 'Neill here in the UK.

26:33Dr Federica Amati: So we're trying to get this message across more of, you can actually make a difference in the 90 day window preconception. But, you know, the flip side of that, Simon, is sometimes people say, oh gosh, it's even before you get pregnant. and nearly half of pregnancies are often unplanned depending on which country you look at so this preconception period is like but i think there's an opportunity there again it's like it doesn't mean everybody has to start being super planny about stuff but if you're potentially going to fall pregnant because you're not using contraception then think about the fact that there's this 90-day window even pre-conception.

27:12The things that you can do that will improve egg health and improve sperm health during that 90-day period, are they just affecting fertility, the chance of conceiving, or are they also affecting the health of the embryo and the infant?

27:27Dr Federica Amati: No, they're affecting the chance of conceiving and the chance of that, for example, the endometrial lining being supportive of the pregnancy, but they're also affecting the health of the embryo and the offspring because of the DNA fragmentation element. So this is important for, so from the sperm side, the DNA fragmentation is strong, is the strongest, one of the strongest factors. And we see that paternal diet and paternal metabolic status. So this is measured in different studies, either by BMI, BMI smoking status, alcohol status. Some other studies have a bit more detailed dietary pattern information, and then the offspring health outcomes.

28:04Dr Federica Amati: And I think one of the things that surprised me when I was researching the book certainly was that paternal health impacts the embryo and the offspring differently to maternal health. So paternal metabolic health has an impact on offspring brain health and neurocognitive development. So there's studies that point to paternal health preconception being linked with the sort of odds of the child, for example, having a autism spectrum disorder diagnosis. There's other analyses looking at schizophrenia incidents, but there's also genetic factors at play there, of course. And so that's, I find that interesting when you compare it to maternal health, where we see effects on the offspring that are more tracking to the same column.

28:55Dr Federica Amati: So for me, it was quite interesting to think of metabolic health impacting brain and cognitive function, whereas with maternal health, for example, the metabolic status of the mother is more predictive than metabolic status of the offspring in the long term as well as the short term. What does that mean? So, I mean, some of the most compelling evidence is around women who are living with obesity and leptin resistance, which is a feature for some people of obesity. Their offspring are born with a different hypothalamic structure to offspring of mothers who don't have leptin resistance. And so what that means in practice is that the babies are born naturally more reactive to hunger cues and less reactive to satiety signals.

29:37Dr Federica Amati: So that makes the offspring more likely to develop obesity themselves. And we also see that, for example, maternal gestational diabetes is a risk factor for the baby's health. So it's obviously a risk factor of maternal health. It's interesting because gestational diabetes itself is a predictor for type 2 diabetes for the mother later in life, really quite a strong one. But also for the baby, gestational diabetes increases risk of large for gestational age babies, so being born with more adipose tissue, which then also raises the risk of the baby then going on to develop obesity and type 2 diabetes as an adult.

30:16Dr Federica Amati: Now this is, again, just to frame this, it's increased risk. It is not a given. It doesn't mean this will happen. But it's just worth noting that the sort of health status of the mother and the father, of course, has an impact on the offspring health outcome. And how much of an impact depends on so many factors, right? It depends on how serious the sort of metabolic condition is. It depends on then what happens after birth. It depends on other factors like stress. Stress research is also super interesting. We see that HPA activation, So the stress axis activation in mothers has an impact on the offspring's HPA axis formation.

30:55Dr Federica Amati: And so babies who are born to mothers who had persistent stress. So again, we're talking about results from exposures that are quite severe. So perhaps a mother who lived through a war during pregnancy or mothers who, there's data that comes out of war zones and also data that comes out from women who persisted things like domestic violence during pregnancy. So quite serious. Again, I don't want to alarm women who think I've had a bit of a stressful time at work. And it's more chronic exposure to excess stress changes the way the babies, the offspring, HPA axis is wired. And so those offspring are then more likely to suffer with stress, depression, and heart disease.

31:39Dr Federica Amati: And of course, the heart disease link is secondary to the stress. Those impacts, what's being passed through from mom and dad to the baby, is that being passed through the quality of the egg and the sperm? Or for a mother, is it also the environment in which the baby is developing during pregnancy? It's both, right? So for the father, it's very much the quality of the sperm and the genetic material he's passing on. Important to note here, though, that sperm DNA is also very important in the formation of the placenta. So sperm DNA has a sort of very prescriptive role in placental health, which is often missed, which is cool, though, to know.

32:23Dr Federica Amati: So the father's main action is preconception in terms of what they can do to set up the health of their offspring, at least from a biological point of view. and that includes things like DNA fragmentation, the efficacy of the sperm to actually fertilize the egg and in the DNA that it's passing on, the genetic material and the way it shapes the formation of the placenta. So there's a really cool interplay between sperm DNA and maternal gut microbiome and how they talk to each other for placental formation. It was published in Nature, I think two years ago. It's wild, but it's really interesting.

32:58Dr Federica Amati: So once the fertility has happened and the embryo starts to develop and you know it's all starts then the maternal environment is essential to see that development and to impact long-term health outcomes and maternal environment though as I mentioned the placenta has a major male factor to it so that effect from the father's sperm continues throughout the pregnancy by in the way that the placenta remains healthy or not. And I think one of the things I've noticed, certainly, when it comes to clinical practice is that the importance of placental health is often overlooked in pregnancy, not by obstetricians and gynecologists, they don't get it, but often mothers, women are not aware of just how to look after your placenta so that it can best support your growing baby.

33:47Dr Federica Amati: And so that's, I find that fascinating. But so I would say for the father, it's preconception, for the mother, it's preconception and during pregnancy, of course, the exposures that she's kind of creating in her for the baby whilst it's developing. And if we're thinking about that 90 day period, which as you mentioned, it's quite nice that it's a similar period for both mother and father in terms of things that could affect egg health and sperm health. Are the things that would encourage and promote good sperm health the same as egg health or are there differences? There's slight variations. So the first one that jumps to mind is the heat exposure.

34:23Dr Federica Amati: So, So, you know, there's a reason why the scrotum is outside the body. And that's because testes are very sensitive to heat. And if you're someone who exposes yourself to hot baths, sauna, actually, perhaps you're putting your laptop on your lap in front of the television in the evening. Pretty short term, like 20 minutes of high heat exposure can have a measurable impact on sperm structure and like the way basically sperm count as well. within for the next sort of 90 days so actually depending on the level of exposure quite a lot of the men i've worked with are very worried about sauna because sauna is good for you right but but if you're trying to conceive and especially if you're a very regular sauna user the time it can take for sperm to recover fully is up to three months four months so you have to really think about about reducing that exposure if you're going to try to conceive or if you are trying to conceive and you realize it's not working so well for you the heat exposure is something to look at.

35:22Dr Federica Amati: Similarly with very, very tight underwear. So I always think about cyclists here who wear tight padded shorts. And then there's a lot of heat there. One of my patient couples had been trying to conceive for a while and I then asked about the partner and he cycled something like insane amounts of miles every day, every week, sorry. And I said, okay, we needed him to just change that and then try again. And actually sure enough, they had other changes of course, but it helped and they were able to get pregnant. So it's really nice to think of those 90 days as where in terms of pregnancy, that's when you really are working together.

35:59Dr Federica Amati: So male heat exposure is unique to men for the sperm quality. And then some of the nutrients, micronutrients are associated with better parameters for sperm is slightly different to eggs. So zinc is super well known to be essential for sperm motility. And so that's an important micronutrient to be aware of for men. omega-3 fatty acids are extremely important for the sperm structure so making sure that men have those you know oily fish algal supplementation walnuts and flax seed and chia seed in their diet and then for women which is less kind of an impactful thing for men it's things like iron status making sure that you have a good iron status before you try to conceive is a good idea for egg quality itself we've discussed the fact that it's longer term exposure so here we're really thinking about how do you help your body to select the best possible egg and have successful ovulation.

36:54Dr Federica Amati: So making sure you're actually eating enough food. The body perceives undernutrition as a signal not to ovulate. So making sure you're eating enough. And in terms of like the actual micronutrients, folate is top of the list. So, you know, folate status is crucial for the first trimester and really for the first eight weeks. Many women don't know they're pregnant in the first eight weeks. And that's why prenatal supplementation is always recommended. And the folate status is important for the egg quality itself. So those are kind of the differentiators, but I think actually overall, the same dietary pattern is applied for the couples.

37:31Dr Federica Amati: So it's the Mediterranean dietary pattern is the best research when it comes to fertility outcomes and actually pregnancy outcomes. So the review I authored was on the Mediterranean diet for pregnancy outcomes. and we know that it hits or ticks all the boxes it has the omega-3 fatty acids it has zinc it has adequate folate from leafy greens it it hits lots of micronutrients adequate iron status and overall adequate food intake reduction of alcohol that another massive one actually is that's worth noting is if you if you want to decrease dna fragmentation don't drink alcohol it's a teratogenic carcinogenic neurotoxin so like just cut it out all together for those for those 90 days and certainly throughout pregnancy and same with smoking smoking is massively problematic for sperm and egg quality and of course for pregnancy outcomes but i i do believe that now smoking during pregnancy has really gone down a lot which is good i know you mentioned there that prenatal supplement is usually recommended, if not always for women that are pregnant.

38:36But if we're focusing on that preconception period and the mother-to-be and father-to-be are eating a healthy Mediterranean diet, do you also recommend supplementing with some type of malty during that period as well? Or does it depend on the specifics of that individual diet? How would someone go about done.

38:59Dr Federica Amati: In an ideal world, people could have their micronutrient status assessed and then they could have targeted supplementation for any gaps. That's like gold standard. For most people, public health recommendations are certain to supplement with folic acid. So that is, regardless of how healthy your diet is, like a folic acid folate supplementation is important for the mother. In men, there is not a recommended prenatal for everybody. So it would be very much based on your diet, your lifestyle, and potentially your age or how long you've been trying to conceive, as well as ideally micronutrient status.

39:32Dr Federica Amati: So there's different supplements you would recommend based on the patient data, on the history of that patient and of that couple to be able to say, actually, okay, let's try and tweak this. Let's try and increase this. I think where a lot of prenatal supplements fall short now is that they have so many things in them. And there's some nutrients that we've touched on today, choline, iodine, folate, iron, zinc, that have strong evidence that they are helpful. But then there's many that don't. So it's like even sometimes I'm surprised to see that people can be quite vocal about how much of an effect certain supplements can have, but then the data doesn't really stack up against it.

40:11Dr Federica Amati: So some of these supplements have over 12, 15, 20 different micronutrients. And more is not more with supplementation. It doesn't necessarily mean it's going to be helpful. Another one is, I would say, omega-3. I think many people don't get enough omega-3 in their diets. And certainly if you're following a plant-based or vegan diet, then being mindful of getting omega-3 from an algal supplement at this time would be helpful. When it comes to sperm count, you and I had some emails going back and forth and and i think people will have heard the kind of commonly cited figure that there's been a 50 decline in i think total total sperm concentration over the past five decades and certainly i've heard that a lot um there seems to be some mixed reports on that how how do you kind of reconcile the the various data that's out there and how would you summarize how sperm count has changed, if at all, in men over recent decades.

41:11Dr Federica Amati: If you look at the global data, sperm count has declined. The issue, I think, is some people frame that as a decline of fertility. And fertility hasn't declined by 50%. Some of these analyses have seen sperm count decline. Now, when you look at specific populations, actually, as we discussed on email, some of them haven't had this 50 % decline. So there is definitely a signal from the global data that there has been a decline in sperm count. And I think we should take that signal seriously and ask ourselves, like, why could that be happening? What has changed? A lot has changed in our environment, our lifestyle, and our diet that may have contributed to that.

41:52Dr Federica Amati: But what does that actually mean for humans? I think we need to be mindful that fecundity and fertility are impacted by a lot of other things. So like whether people choose to have children full stop because of other factors. The way I reconcile the data is to think about the global signal as a signal, as an interesting data point that we should be aware of. But then when speaking to groups or individuals, how relevant is that to them? So for me, the like 50 % decline in sperm count is more of a call to arms to better understand our environment and our reproductive health for the future, sort of a global level and a not just researchers, but also policymakers and people who think about the future, essentially.

42:38Dr Federica Amati: But I don't think it should be too alarming for the individual, because there are different studies that show that in some populations, this is not the case. And we have to be mindful of how sperm is collected, how the metrics have changed over time. So like how the WHO defines low sperm count has changed. So actually, it's one of those classic examples of quite hard to pin down exactly what this data means. And, you know, Simon, we've discussed that even just having a hot bath can change your sperm. So how do you reconcile like when these sperm were collected, these sonar samples, and then they were measured and what the populations were, how old were they, how frequently had they ejaculated previously, could the sperm count have been affected by their sexual function in the past week.

43:19Dr Federica Amati: So there's lots of factors at play. But the fact that there is this trend is definitely a signal that I think, you know, most scientists have definitely been like, OK, there's something going on here. Now, alongside this drop in sperm count, of course, we are seeing a decline in the number of children people are having. So but I think where the mistake can sometimes happen is to blame the sperm count decline, that calling that the reason why fertility has gone down. It's not the only factor and it's not applicable to everybody. So we just have to be a bit mindful not to do that correlation thing where we're like, well, that's changed over there.

43:57Dr Federica Amati: So it must be the answer to this. It's not as simple as that. And what I'm hearing as well is that, yes, maybe sperm count has gone down. Maybe we don't fully understand it. But we do understand that things like a healthy Mediterranean diet, focusing on specific nutrients, not overdoing it in sauna or hot baths, that those types of lifestyle changes will make significant changes to the quality of sperm count and also function, shape, how they're swimming, DNA fragmentation, all those things. Exactly. So it goes back to, handily, it goes back to a lot of free things that you can do, right? So not smoking, not drinking, getting enough sleep, exercising, making sure that you are actually not too sedentary.

44:45Dr Federica Amati: These lifestyle pillars that we know of and that are such powerful levers for chronic health, for chronic disease and for long-term health also offer a great way to improve our reproductive health. So what I also love about this topic is that everything that helps us with our reproductive health actually helps us full stop. So the two things marry up so nicely. And of course, there are specific things to think about that we've touched on. But overall, if you're going to be engaging with these changes in lifestyle and diet, you're going to be supporting your long-term health anyway. So it's worth doing regardless of how soon or whether you want to eventually procreate, they're worth engaging in as behavior changes.

45:28Dr Federica Amati: And we haven't touched, Simon, on... Oh, go on, tell me. within that mediterranean diet yeah is there room for soy foods for tofu or soy milk and i guess what would you say specifically i'm thinking of men here who are a bit worried that soy foods may lower their testosterone and and affect their sperm health and then affect their their chances of conceiving absolutely so i think the mediterranean diet as i refer to here is the overall dietary pattern. It's not actually married to individual ingredients. I think the exception is extra virgin olive oil seems to have a specific action on beneficial effects of the Mediterranean diet, but actually you can get similar beneficial effects from healthy polyunsaturated fats.

46:15Dr Federica Amati: However, so when we think about the Mediterranean diet, I want people to think of a dietary principle, which can absolutely include soy foods. And in fact, edamame beans, tofu, tempeh, and soy milk are fantastic options. And we see this in those, I'm forgetting the name of the study, but there was a Mediterranean diet that was slightly altered to create an equivalent which had soy foods and more green tea. So I wish I could remember. It'll come to me later, I think. But essentially, you can modify the Mediterranean dietary principles to fit the foods that you enjoy eating or that are part of your diet.

46:50Dr Federica Amati: I call this the modern Mediterranean approach. And it's actually something that I'm working with the Italian embassy on here, on how we translate the Mediterranean dietary principles to be applicable to any culture, any dietary preference. Because it's not, it doesn't, you don't have to eat tamales and garlic and fish caught in the Bay of Naples to have a Mediterranean diet. So what we know is that soy foods are extremely good for us. They're so good for long-term health. And the myth of the phytoestrogens impacting male fertility, they have been debunked so many times in the literature. We see that men who consume soy products have healthier hearts.

47:32Dr Federica Amati: They have improved insulin sensitivity. So actually, if anything, there's a case to make for men to consume these products as part of their diet, if they want to look after their long-term health. And there is absolutely no concern to be had with impacting male fertility, sperm function, testosterone levels. That's the one that always used to get banded around. I thought that myth had died, Simon. It hasn't. Well, I think it's got nothing to do really with the evidence. I think it's more the fact that society and culture often associates meat with masculinity and soy foods, I guess, with the plant-based or vegetarian woman.

48:12And so I think those people just have that assumption because of the way those foods are positioned across society rather than what the evidence actually says.

48:21Dr Federica Amati: Yeah. So, I mean, I just, yeah, I encourage people to introduce, especially tofu, it's so versatile, to their diets to help them reduce red meat intake and processed meat intake, which we know has a detrimental impact on health. So I see that as a way to actually improve. And we have to remember that when we think about inflammation and chronic disease risk, you know, our reproductive system is extremely sensitive to metabolic dysfunction and to inflammation. So anything that helps sustain appropriate inflammatory response and helps sustain metabolic health, including foods like tofu and soybeans, are going to be overall helpful to our reproductive health.

49:09Dr Federica Amati: So if anything, I think there's a case for introducing it to your diet if you don't already eat it. Other than alcohol, which you mentioned, and it sounds like you're definitely of the view that in that 90-day period, so if you are a couple that's planning in that 90-day period, better to go without alcohol during that time for sperm and egg health. Are there any other foods or food groups or drinks that you think are best avoided completely? Yes. So I want to, again, just a little caveat here that if you're someone who's pregnant right now, or you have a toddler at home and you had had a drink before you got pregnant, like, don't worry, please.

49:51Dr Federica Amati: I think it's important to note that, again, human biology is resilient. And the odd drink that you may have had many couples conceive as a result of a night drinking, right? So if that was you, don't worry, it's okay. It's just that if we're talking about optimising and reducing risk and improving the odds of conception, this is one of the levers we can pull. The other things that I would encourage people to consider are sugar-sweetened beverages. So sodas, colas, sports energy drinks that are very high in free added sugars. they don't help us in any kind of way especially with when we consider the metabolic health piece and the inflammatory piece that we just touched on drinking sugar sweetened beverages is not helpful for our health overall and so if you can reduce these uh in those 90 days prior that's great during pregnancy completely cutting them out is preferred they have a measurable impact on offspring health so sugar sweetened beverages in pregnancy are one of the factors that come up in maternal diet as an increasing risk for the baby to go on to develop elevated blood glucose levels or increased adiposity in childhood.

51:03Dr Federica Amati: So I really, I mean, you can't really say anything good about sugar sweetened beverages anyway, and it's the same in this timeframe. The other one to bear in mind is processed meats. So, you know, processed meats are not healthy for us anyway, and there's a direct sort of dose response between processed meat and increased colorectal cancer risk. Now, I want to be super clear that, yes, processed meat is a carcinogen, but it's not as bad as alcohol, which is not as bad as smoking. So I think we have to be a little bit careful with this like false equivalence. Just because it's a class one carcinogen, it doesn't mean it's as bad as smoking.

51:41So if you're someone who absolutely loves a bacon sandwich

51:45Dr Federica Amati: and you just cannot imagine going a full year from preconception care to birth without one, I think it's okay just as long as you know that it's okay. You're understanding the risk benefit here. So as you know, Simon, so much of food and diet is also joy and enjoyment. And so what I don't want this to be is a strict set of rules that makes people anxious about their diet, because that's not helpful either. But these are just the food groups that we know are not helpful to be consumed regularly. Alcohol, best not. Sugar, sweetened beverages, really, really good idea to reduce drastically. Processed meats, reduce.

52:25Dr Federica Amati: And if you don't eat them, great. And those are kind of the three that jump out at me. Smoking isn't a food or a drink, but I'll say it again, don't smoke. And same with vaping. So some really interesting data from Hertility's research actually, has found that vaping reduces the likelihood of conception with couples trying to conceive. The exact mechanisms, we're not sure yet, but there's compelling observational data that there is a relationship there. I'd be interested to know if vaping affects sperm health. Yeah, I mean, I would vote yes. I haven't seen the data for it, but I would say it's such a novel problem, vaping as well.

53:02Dr Federica Amati: So it's hard to know how it's impacting. But yeah, I would imagine that it is impacting sperm health. We can look it up later. And back to your point earlier, I think there is this general idea that the dude's job's done once conception's done. But what you said earlier is it's cool, it's interesting, but it also gives even greater importance and emphasis on sperm health is the fact that the sperm is really affecting the placenta, which has a big effect on the environment that the developing embryo is in. Yeah. And the likelihood of pregnancy complications or preterm labor, right? So there's that.

53:36Dr Federica Amati: But also, I think I have to really specify here. I'm talking about the physiological effects, but behaviorally, in terms of stress mitigation and psychological support, you know, the man has a massive role to play here. So having a supportive, safely attached relationship is a massively beneficial way to improve the maternal stress load. And that affects nutrient absorption, affects how you sleep. So what's really cool is that sleep is a real marker of pregnancy health too. so if you look at ways in which like the father has a massive impact during pregnancy it's really that element of acting as a very good co-builder of the kind of environment that's going to help the mother support the pregnancy so whether stress mitigating as I said stress mitigation and helping to support maternal health through so many so many ways there's so many ways that a father can be helpful, whether it's preparing meals, helping with appointments, just helping to reduce stress by being there for her, advocating for her, especially with the culture we currently have where often pregnancy isn't even something people know about in the first trimester.

54:55Dr Federica Amati: So couples will often not really tell people apart from maybe their family about the pregnancy early on. So there's so many psychological benefits and ways that the father can then support. But yeah, in terms of physiological, biological effects, that 90 days prior and the conception moment is where they shine. That makes a lot of sense from an evolutionary point of view as well when you think about mating preferences and the fact that a woman will seek out a mating partner that makes her feel safe and secure. Before we move from this preconception window and get a little bit more into pregnancy, I have some more questions there.

55:32I do want to talk about about preconception and the use of GLP-1s. I think that's a conversation that is becoming more and more prominent and there's a lot of interest around it, clearly with the increased use of GLP-1s. Do we have a sense yet on how GLP-1 agonists and perhaps the double and the triple receptor agonists affect fertility?

55:56Dr Federica Amati: Yes. Well, we know that excess adiposity, So specifically, this excess fat tissue impacts fertility in men and women. So men who carry excess fat tend to have lower testosterone levels and tend to be less fertile as a consequence of that. So when men taking GLP-1 medications for excess adiposity, they take it, they will start to increase, naturally increase testosterone levels and they will become more fertile. At the same time, it has this excess adiposity, affects female reproductive health and decreases the likelihood of ovulation. So we see that when women start to lose excess adiposity or if women are taking GRP1 agonists for, for example, PMOS, previously known PCOS, current just changed name, then they're more likely to also have regular ovulatory cycles and be more fertile, essentially.

56:52now the current guidelines are very clear that you should stop taking grp1 medication

56:59Dr Federica Amati: about 90 days so three months before you start trying to conceive and this is because we just don't know how these peptides which are essentially they have their hormones right how they affect the egg, the sperm, and let alone the developing fetus. So there have been pregnancies that have happened and where the mother has continued to take the drug not knowing she was pregnant. And those babies have been born. And the good news is that those babies have been born without any primary congenital abnormalities. So the animal data was quite worrying. It showed some congenital abnormalities from GLP-1s.

57:47Dr Federica Amati: The humans that have been born, luckily there hasn't been reports of that yet. So that's good news. What I would be very cautious of is that as fetus embryos develops and the brain specifically develops, GLP-1 medications have a massive effect on the brain, on the hypothalamus. They act there. And so my concern is what will these drugs be doing in the baby's brain as it's forming? How will that affect it? So we don't know. I think everyone I've spoken to who is a specialist in this field of research is very cautious and they currently don't think that these drugs should be used in pregnancy. I've also seen on the flip side of that, doctors who treat women with very uncontrolled diabetes, and this might be one of the ways that they can actually have a safe pregnancy by using these drugs to help control their diabetes.

58:44Dr Federica Amati: But to date, they are not clinically recommended during pregnancy and actually you're supposed to stop taking them before. But they are increasing fertility. It gets a little bit tricky when you consider a point you made earlier that the majority of pregnancies are not planned. It does. It does make it tricky. And I think here is where patient information is so important because many patients who are taking GLP-1s that I've spoken to don't even know that they're likely to become more fertile as a result of the drugs. Again, this comes back to Simon to the fact that we just don't have very good reproductive education.

59:21Dr Federica Amati: And so you have a population of people who have potentially historically been told, you can't have a baby, you won't be able to, and then they take these drugs. And what hasn't been explained to them is that taking these GLP-1 drugs may actually restore their fertility. And if they don't know that, and they're not actively told to be cautious and use contraception during treatment, then of course, this is something that's going to happen in the same way it happens unplanned pregnancies happen in the regular population. Something else that I have read, and I haven't validated this, but I think it's interesting.

59:57So I'm going to ask you in case you have, was that GLP-1s, through their effect on gastric emptying and delaying gastric emptying might be affecting the absorption of oral contraception. Is that something you've come across?

1:00:10Dr Federica Amati: I have come across that. So it seems that exactly to your point, oral contraception relies on the absorption, regular absorption of the contraception and the slowing of the gastric emptying, the nausea and the increased vomiting all change the way these drugs are absorbed. So I have come across this and it's another really important point again that needs to be made to patients if your use of contraception is the oral contraceptive pill then it might not be as effective while you're taking these drugs so perhaps it's actually also a case of switching contraceptive methods okay let's slide across to to pregnancy yeah in the in the first trimester yeah i think i think you may have said that eight out of ten women or a high percentage of women are dealing with nausea and food aversions and all these things that can make it difficult to keep food down and eat the way that maybe they would like to eat.

1:01:10So what are the ways around that for a woman who's experiencing these things and is also aware of the importance of making sure their baby has all the important nutrients and energy that it needs? Yeah.

1:01:24Dr Federica Amati: So it is extremely common to have symptoms in the first trimester. And this is where, again, prenatal supplementation is helpful because some of these key nutrients that we spoke about will be in the supplements. Now, in terms of food, because of course supplements alone is not going to be enough. I think it's important to remember that the first trimester is really about nutrient density and you don't have an excess need for calories. And actually, if you're of a healthy weight, so if your BMIs with a normal range and you have some adiposity to use, you have good stores, your body will absolutely use energy from your stored fat and everything else to help with the pregnancy.

1:02:06Dr Federica Amati: However, there are absolutely ways that you can help mitigate the effects of nausea. Now, if you have hyperemesis gravidarum, which is a very serious type of pregnancy nausea, then seeking help and medication can really help. Interestingly, vitamin B6 supplementation really helps with HG and is now part of the protocol for treating it. So the things to remember are hydrate. So hydration is important and hydrating can help settle nausea. And then most women have a window of time in the day, often in the morning actually, where their nausea is, so counterintuitive because it's called morning sickness, but here we are.

1:02:44There's usually a window of time sometime in the morning, mid

1:02:48Dr Federica Amati: morning where women feel their nausea is a bit better. And that is when you try to anchor your food. So try to eat a very nutrient-dense meal. Small portions are going to be helpful not to trigger nausea. And then there are some really simple tips, but really effective tips, which are cold food tends to trigger nausea less. So whether it's a cold smoothie or a cold soup, there's less of the smells and taste triggers for nausea, which is good. And the other thing is to actually use ginger and peppermint tea but it doesn't have to be tea it can be ginger pastels you might just grate some fresh ginger whatever you prefer it does actually help with pregnancy nausea so it's just about making sure that you're not stressing too much about it unless and if you have hg please get help because it will drastically change your experience most nausea does settle by the 14th week of pregnancy and so as long as you're identifying the windows where you're more like to be able to eat.

1:03:47Dr Federica Amati: Making your meals really nutrient dense. So making sure that when you do feel like you can eat, you're eating the kinds of foods that support your health. Try not to rely heavily on things like, I mean, I use the example of myself in my book, right? When I was pregnant with my second daughter, salt and vinegar crisps were like the food that didn't trigger any nausea. But I couldn't, that's not, you can't eat salt and vinegar crisps every day as your main thing. So find that there might be some flavor combinations that are helpful to your nausea. So I had salt and vinegar, like chickpeas. I just used that flavor combination to help other foods, right?

1:04:25Dr Federica Amati: And small regular meals. Use cold as your friend. There is so much you can do with a cold, ice cold smoothie and the amount of nutrients you can pack into it, right? And then another really important thing, Simon, is that not getting enough sleep impacts nausea. So making sure that it's a very first trimester can be extremely tiring. Like we know that fatigue is one of the most common symptoms. So allowing yourself time to rest, sleep, take a nap, it can actually improve nausea as well. So it is, again, tricky because many couples or many women don't want to disclose they're pregnant yet. but it is a time when you really do have to slow down and adjust your life to fit into what the nausea and the fatigue allow you to do.

1:05:12Dr Federica Amati: And then, as I said, supportive supplementation on top of those tactics is how a lot of women are then able to tackle this. So hydration, ginger and peppermint, nutrient-dense small meals, make sure you're resting and use supplements as Some great clear tips there for men to keep the ginger and peppermint tea stocked up in the kitchen. Yeah. When choosing a prenatal supplement, are there any specific things you're looking for on the label that would separate a prenatal that is perhaps better than another? I mean it's like with all supplements it's um have they been third-party tested and certified so that you're sure that the quality and the quantity of the micronutrients is adequate and is not excessive as well third-party testing for me is a really is a really big one I think in terms of formulation it's trying to figure out whether it's within the recommended amounts so sometimes supplements companies will increase vitamin d is a good example vitamin d is actually important for fertility and pregnancy outcomes too.

1:06:19Dr Federica Amati: If you live in a country like the UK, where half of the year we don't really see the sun, it is important to supplement with vitamin D. But it's important to supplement the normal amount of vitamin D. So these super doses of vitamins are not helpful anyway, and they're especially not helpful in this very delicate time. So during pregnancy, you don't want to have too much vitamin D. Most famously, excess vitamin A can have teratogenic effects on babies. So it's very dangerous. So make sure that you are buying prenatal specific supplementation because the manufacturers of those, especially when the third party tested and have a decent formulation principle behind them.

1:07:01Dr Federica Amati: So, you know, try to look for ones that have been developed with the scientists that have a knowledge, for example, of prenatal health. They will avoid excess vitamin A. They will use omega-3 DHA, which is the important omega-3 fatty acid for brain formation. So they are different to regular vitamins. And you'll see in prenatal supplements as well that have been carefully formulated, they'll be choline maybe added and iodine, for example, which is really important for brain health. So look for third-party testing. Choose a supplement that's been designed specifically as a prenatal supplement with a reputable brand, ideally with reputable healthcare professionals that have been involved in the formulation.

1:07:44Dr Federica Amati: But as you know, Simon, the supplements industry has such varying standards. So if you're not sure, speak to a healthcare provider, your dietitian, registered nutritionist, your doctor, and see whether they have a recommendation for a brand that they trust, because it's a bit of a Wild West out there, truly. It's self-regulated, essentially. It is. And it just takes people who care to try and help people make the right choices. But I think it's fair to say that people aren't trying to profit too hard from prenatal because it's so much at stake, but it is worth being mindful of using a good quality one.

1:08:21There are a bunch of brands now without naming names that offer prenatals that are NSF certified, for example, and can give you a bit more confidence that what's on the label is actually in there. Speaking of supplements, pregnancy, in your words, is a high-protein requirement task. But at the same time, I'd say you're somewhat skeptical of relying on protein powders during pregnancy. Oh, I don't advise it at all. Yeah. So if we think about protein, how much protein do women need, let's say, on a per kilogram of body weight basis? Yeah. Has that changed from earlier in their life when they weren't pregnant?

1:09:01and how should they think about getting that protein from food?

1:09:05Dr Federica Amati: So it's a high protein requirement phase of life because you're building so many new tissues. So you're building a whole new organ in the placenta and then the baby is being built using your resources. So it's technically the only time in life when you're actually building this much new tissue to make an entire human, right? It's pretty cool. So in terms of requirements, the 1.3 to 1.6 grams per kilograms of body weight, but for pregnant women, lactation is also a higher protein requirement phase of life. I think most women who are eating adequate amounts of food during pregnancy don't need to worry too much about reaching this target.

1:09:44Dr Federica Amati: So it really comes down to understanding when that might be difficult. Now, it's also important to note that, yes, in the first and second trimester, you are building the placenta and the sort of initial formation of fetus and embryo. And then when that starts to grow into a third trimester, when the baby really starts to grow a lot, you have this increased requirement in actual food intake. But that only really kicks in in the third trimester. And a lot of that increased food intake is for increased energy, but also for increased protein. So what we do know is that, yes, women need to have adequate food intake overall, but protein supplementation in pregnancy is not recommended.

1:10:23Dr Federica Amati: so we see that in women who have acute and and sort of quite large protein intake from supplements counterintuitively there's an increased risk of intrauterine growth restriction so that means the babies can end up being born smaller than than normal right again the mechanisms for that and this is for i have to point out this is for quite high amounts of protein and the studies were done in women who were not getting enough food so that the intervention was designed to help women increase their protein intake when they couldn't eat enough food to get that protein. So it was quite an acute situation.

1:11:00Dr Federica Amati: But I think it's compelling enough to say, okay, well, please don't try and get your protein from protein supplements. And that's true across the life course, let's be honest, but like here as well. So the way to think about it is to make sure that there is a healthy source of protein in every meal. And that can come from combining legumes with whole grains. It can come from eating soy-based products. It can come from oily fish three times a week. If you eat oily fish, it can absolutely come from eggs. You don't need more than like seven to eight eggs a week. I think there's a bit of obsession about eating like four eggs a day in pregnancy, which is not founded in evidence and can actually take away from the variety of foods that we need to get a variety of nutrients.

1:11:44Dr Federica Amati: So nuts and seeds, There's, if you do eat meat, you can absolutely have meat as well. It's just trying to make sure that you're having a healthy source of protein every meal. What's really cool about pregnancy is that we also become more efficient at nutrient absorption in part by the slowing of the gut transit time, thanks to progesterone. And also we have increased blood circulation to the gut. So actually pregnant women are so effective at taking in the nutrients they need. And then our babies are so effective at taking it from us. So there is this amazing way in which our bodies adapt to make sure that the nutrients are transferred to the growing baby very well.

1:12:25So I wouldn't obsess about the grams per kilogram anyway, but I would say make sure you're eating adequate amount of food and try to get high quality protein from foods that have other

1:12:36Dr Federica Amati: health benefits. So that's why I talk a lot about whole grains and legumes together, because you get this really good balanced amino acid profile across all of the essential amino acids with the combination. And you also get the fiber, the polyphenolic content, you get the micronutrients that you get from these foods. With that in mind, and also what we've gone over with regards to micronutrients, do you feel strongly the way as to whether a, let's say a strict plant-based diet with supplementation can be just as healthy as a Mediterranean diet during this period? Yeah, I mean, the data says that it can be.

1:13:18Dr Federica Amati: I think it's highly individual. So for me, if it's something that you can make work and you feel you have the adequate resources and information to do it and you feel good doing it, great, do that. I think where it's important to listen to our bodies is like, if you're trying to follow this strict diet and you don't feel good, or perhaps your energy is super low, or you feel like perhaps you're missing some nutrients and you don't feel equipped to understand where the gaps might be. That's when actually having a Mediterranean omnivorous diet can be just easier to make sure you're hitting those targets.

1:13:54Dr Federica Amati: Also, I've worked with women who have been plant-based for years and then they fall pregnant and they suddenly have this craving to eat meat. And it's fascinating. I think just generally, I'm like, that's fascinating. I haven't eaten red meat for a very long time and I can't imagine suddenly craving it. But if that's the case, I do think like if it's something that's open to you to try, listen to your body a bit. It's also, Simon, this is a good opportunity to say that if you're craving eating soil or chalk or basically non-food items, this is a very specific type of craving in pregnancy, which signals a micronutrient deficiency.

1:14:33Dr Federica Amati: Sometimes iron, sometimes calcium. So it's worth getting, if that happens to you, if you suddenly feel like you want to eat soil from the ground, go to your doctor and have your micronutrient status checked because that's not a normal craving. I ask that question because over the years, I've had lots of people email me or just various conversations with mothers or mothers-to-be, and some of them feel really comfortable with this strict plant-based diet and supplementing and paying close attention to protein and choline and iodine and all the things. And then there are others who I speak to are like, that's just a bit too much for me.

1:15:09And they see it as a kind of simpler, less risky route to reintroduce some animal foods. And inevitably, the next question that they ask is, well, if I'm going to reintroduce some animal foods, what should they be and in what volume? And I think you've kind of answered that where you've lent on like fatty fish and eggs and certain types of dairy. Would that be where your kind of primary focus would be if someone's in that situation?

1:15:36Dr Federica Amati: Yeah, absolutely. I've actually, I created a protein pyramid for one of my talks and it's exactly, so it's plant-based proteins are the bulk. Then fermented dairy, there is really nice evidence. Great for calcium source, which is also an important thing to consider with plant-based diets and have other benefits in terms of their fermented food, probiotic contributions and micronutrient status, iodine. So yeah, fermented dairy and then oily fish is above fermented dairy because that's three times a week. You don't need more than three times a week. Whereas with fermented dairy, it can be a daily food staple.

1:16:09Dr Federica Amati: So that's the way I would consider it. And then eggs would sit above that with poultry and then right at the top, red meat, which you don't really need, but it can be at the top. And then off the pyramid is processed meat, just over there. So I would say that's the case. To your point, I think many women are very comfortable with plant-based diets. I was fully plant-based before I became pregnant. And then for me, during pregnancy, the cognitive load meant that I returned to eating fatty fish, eggs, and fermented dairy. So there you go. I'm an example. Yeah, exactly. I mean, you're the avatar that I was speaking about.

1:16:43Dr Federica Amati: Oh, there you go. So it's interesting, though, because I think it just makes you a lot more conscious about quantity and quality when you return to eating these products. So I think naturally, people who follow a plant-based diet, when they return to eating any animal products, they're much more conscious of where they're coming from. Last question for during pregnancy. There's been a lot of, I guess, public debate about Tylenol or paracetamol in recent years. And scientists and academics and I believe even organizations like the American College of Obstetricians and Gynecologists came out pretty strongly saying there's no at least causal link between Tylenol and autism.

1:17:23What's your read on the data here? And do you have any advice if pregnant women are looking to manage their pain and are confused by this?

1:17:33Dr Federica Amati: So I think the more compelling evidence, the evidence around Tylenol and autism is not a thing, to be honest. There is some evidence that there was a very strong position paper that was published. I think it was 2017-ish, where a group of scientists came together and they published a report to say that they felt they were worried, concerned that Tylenol acted as an endocrine disruptor. And this was observational data. And so I think what's really important to say here is, and this is the advice, Tylenol is extremely effective at reducing pain and more, I think, more importantly, fevers. Fevers in pregnancy are extremely dangerous.

1:18:12Dr Federica Amati: If you have a high uncontrolled fever in pregnancy, it can be a real risk to the pregnancy itself. So there is no world in which the risk benefit of Tylenol in a fever would favour not taking the Tylenol in pregnancy. However, what some of the observational data has seen is that women who take very high amounts of Tylenol throughout their pregnancy, there may be an association or a relationship between that and some endocrine disrupting flags. And as I said, it's not been confirmed and it's more of a caution. Now the caution then is not to not take Tylenol. The caution is as with any drug and especially during pregnancy to use medicines appropriately.

1:18:57Dr Federica Amati: So I think the advice is to, if you need to take Tylenol, especially if your doctor has told you, you need to take Tylenol, or if you have a fever, then Tylenol is safe in pregnancy. What is probably not advisable for Tylenol or anything else, right, is to take it to excess. So beyond what it's needed for. And I think that will vary for everybody. So there's some women who will take Tylenol throughout their pregnancy to manage pain. And the risk benefit of them not treating their pain is much worse than the Tylenol potential effects. But I think the link between Tylenol autism is very much not a thing.

1:19:34Dr Federica Amati: If anything, it's just the role of medications that Tylenol has been looked at as a potential undercurrent disruptor. But again, it's a point of caution against overusing medication, not against taking it full stop. That's part one with Dr. Federica Amati. If you found this useful, please share it with someone in your life who's planning a family, pregnant, or parenting young children. This information really matters and the earlier people have it life the better. In part 2, which is coming very soon, we cover both C-sections vs. vaginal delivery, breastfeeding, weaning, microplastics, and endocrine disrupting chemicals.

1:20:12Hit subscribe or follow now so you're notified when it's published. As always, thank you so much for hanging out with me today and I'll catch you soon.