Understanding and Preventing the Impact of Endocrine Disruptors on the Hypothalamus-pituitary Axis in Sensitive Populations. Hypiend- Perinatal Study.
Phase: NA
Conditions: Pregnancy, Children
Sponsor: Fundació Institut Germans Trias i Pujol

 
 
 
 
 
 
 
OFFICIAL TITLE OF THE STUDY: Understanding and 
preventing the impact of endocrine disruptors on the hypothalamus-
pituitary axis in sensitive populations 
 
 
 
NCT NUMBER: Not available 
 
 
 
DATE OF THE DOCUMENT: 21ST AUGUST 2025 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
Hypiend - Clinical study to evaluate the 
effectiveness of a multicOmpoNent behavioural 
intervenTion to reduce endocrINe disrUptor 
exposure during the pErinatal period in women 
and their offspring (CONTINUE). 
 
 
Protocol- Hypiend Perinatal Study 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
ÍNDEX 
1. BACKGROUND AND JUSTIFICATION 
1.1 Title, acronym. 
1.2 Study rationale.  
1.2.1 Extent and evaluation of current knowledge directly linked to the 
scientific question(s) to be answered by the clinical study.  
1.2.2 Outcomes (efficacy, safety) Of completed and number of ongoing 
clinical studies utilizing the same intervention in the same indication 
(including review of public registers) 
1.2.3 Level of evidence related to the mechanism of action of the 
intervention in the planned clinical study population  
2. OBJECTIVES 
3.1 Main Objective 
3.2 Secondary Objectives 
3. RESEARCH METHODS 
3.1 Type of Study 
3.2 Design 
       3.2.1 Theoretical framework behind the intervention 
       3.2.2 Sample size and power calculation 
       3.2. Inclusion/exclusion Criteria 
       3.2.5 Recruitment and Informed Consent 
       3.2.6 Randomization  
       3.2.6 Multicomponent behavioural intervention 
       3.2.7 Follow-up and Timing of visits.  
3.3 Study variables 
       3.3.1 Maternal Variables to be studied  
       3.3.2 Study variables in children 
 
4. SAMPLE COLLECTION 
5. BIOCHEMICAL, MOLECULAR AND OMICS ANALYSES 
     5.1 Biochemical, molecular and omics analyses that will be carried out in 
biological samples obtained from women. 
     5.2 Biochemical, molecular and omics analyses that will be carried out in 
biological samples obtained from infants 
6. TRIAL FLOWCHART 
7. STATISTICAL ANALYSIS 
8. DATA MANAGEMENT 
9. DISSEMINATION PLAN  
10. BIBLIOGRAPHIC REFERENCES 
 
 
 
 

 
 
1. BACKGROUND AND JUSTIFICATION  
 
1.1 Title, acronym, unique identifier of the clinical study  
Clinical study to evaluate the effectiveness of a multicOmpoNent behavioural intervenTion to reduce 
endocrINe disrUptor exposure during the pErinatal period in women and their offspring 
(CONTINUE). 
 
1.2 Study rationale  
 
1.2.1 
Extent and evaluation of current knowledge directly linked to the scientific 
question(s) to be answered by the clinical study.  
 
Human epidemiological data suggest that EDC exposure during the perinatal period can negatively 
affect infant growth trajectory and neurodevelopment and possibly play an important role in the rapid 
epidemiological growth of obesity and diabetes.1,2,3 As an example, one study carried out in 460 
mother–infant pairs from Korea showed that Mental and/or Psychomotor Developmental Indices of 
the Bayley Scales of Infant Development were inversely correlated in 6-month-old males with the 
maternal urinary levels of the phthalate metabolites MEHHP, MEOHP and MBP at the third trimester 
of pregnancy.4 Very recently, it was reported that mothers with overweight displayed increased levels 
of the highly persistent environmental chemicals polychlorinated biphenyls in breast milk 2-weeks 
postpartum and that there was a negative association between some of these compounds and the head 
circumference‐for‐age, weight‐for‐age, and weight‐for‐length z-scores of the infant at the age of 6 
months.5  
 
However, there are discrepancies among findings, which can be attributed to differences in the 
temporal window of EDC exposure assessment (i.e., early versus late gestation or lactation), in the 
infants’ age at which the measurements were carried out or to a misclassification of EDC exposure 
due to a single-point analyses of their exposure. In fact, one of the limitations of many 
epidemiological studies is the use of single spot urine samples at one time-point to estimate the 
exposure to EDCs. The limitation relies on the short biological half-lives of many of these chemicals 
and their quick excretion in urine, properties that cause a demand for multiple time point for a precise 
estimation of exposure assessment.1,2,3 Although different epidemiological studies have found an 
association between higher exposure to EDCs and neuroendocrine and neurodevelopmental 
alterations in toddlers and children1,6, as far as we know, no clinical interventions have been carried 
out to elucidate whether reducing the exposure to EDCs can contribute to counteract/ameliorate these 
harmful effects.  
 
So far, very few human intervention studies focused on reducing the exposure to EDCs during the 
perinatal period have been conducted, some carrying out educational approaches and others focused 
on dietary or other changes.7,8 Relevantly, most of them had small sample sizes (<100 people) and 
analysed a maximum of two different types of EDCs and quite a few were carried out without control 
groups. Moreover, the level of adherence in this type of interventions is low in general, reflecting the 
need to implement adequately behavioural change techniques to foster long-term lifestyle habit 
improvements.  
 
 
 
 

 
 
1.2.2 
Outcomes (efficacy, safety) Of completed and number of ongoing clinical studies 
utilizing the same intervention in the same indication (including review of public 
registers) 
 
Recently, the PREVED project was carried out to improve knowledge, to enhance risk perception 
and to change exposure behaviour regarding EDCs of 268 women during pregnancy and up to 14 
months after birth10. The authors reported a significant increase in the evolution of risk perception 
score and overall psychosocial score in the two intervention groups that received 3 workshops during 
pregnancy, one group in neutral location (leaflet on EDCs and collective workshops in a meeting 
room), and the other group in contextualized location (leaflet on EDCs and collective workshops in 
the real-life pedagogical apartment) when compared with a control group (leaflet on EDCs). 
However, no differences in consumption of canned food and in percentage of women having a 
decrease in bisphenol A or parabens concentrations in urine were found between the control and the 
two intervention groups. In another RCT carried out in 51 women in Korea, a 4-week web-based 
behavioural intervention reduced the urinary concentrations of BPA, different phthalate metabolites, 
and parabens in mothers with young children18. Moreover, an ongoing study aims to determine if a 
personalized mobile intervention is able to reduce the exposure to EDCs in adults of child-bearing 
age (ClinicalTrials ID: NCT05780047). Despite some promising results, these examples illustrate the 
need to carry out larger multicomponent clinical and community-based intervention studies focused 
on minimize the exposure to EDCs at short, medium, and long time to obtain results that are more 
conclusive.  
 
 
1.2.3 
Level of evidence related to the mechanism of action of the intervention in the 
planned clinical study population  
 
EDC-Mix-Risk and ENDpoiNTs are two outstanding Horizon 2020 projects that combined the 
experimental research in both cells and animals with epidemiological data. Researchers of both 
projects and others nicely showed using a statistical model for multivariate regression with data 
obtained in the SELMA pregnancy study that different EDCs (including phthalates, alkyl phenols, 
and perfluoroalkyl substances) analysed in the urine and serum of women at week 10 of pregnancy 
were associated with language delay of their children at 2.5 years of age.19 Afterwards, the identified 
EDCs were mixed and tested in human brain organoids as well as in Xenopus leavis and Danio rerio 
to elucidate the molecular and functional impact of exposure. Finally, the authors integrated both 
experimental and epidemiological data and carried out a risk assessment approach, finding increased 
odds of language delay in up to 54% of the offspring who had prenatal exposures above 
experimentally derived levels of concern.19  Despite these very relevant findings, a limited number of 
studies carried out in humans have shed light on the mechanisms underlying the EDC-mediated 
dysfunctions on HP axis, including the induction of epigenetic changes in key genes involved in 
foetal development, neuroendocrine regulation and early puberty as well as the alterations of the 
inflammatory response and the gut microbiota (dysbiosis). EDCs may increase the risk of childhood 
neurodevelopmental disorders by interfering with early life estrogenic and thyroid hormone 
signalling or metabolism.1,6,20 In this sense, in humans, it has been shown that some phthalates may 
reduce thyroxine and triiodothyronine concentration in pregnant women and children and that the 
exposure to phthalates produced oxidative stress and can also affect the health of the offspring 
through epigenetic re-programming of the foetus and placenta. In another study, maternal exposure 
to heavy metals affected progeny neurodevelopment, and changes in DNA methylation of genes 
controlling neurodevelopment were observed in cord blood, but not the blood collected at mid-
childhood21. Analysis of exposure-outcome identified differentially methylated CpG on DAB 
Adaptor Protein 1 (DAB1) gene as a marker of the effect of prenatal polycyclic aromatic hydrocarbon 

 
 
(PAH) exposure on children’s mental development.22 Increased exposure to PAHs during pregnancy 
was positively correlated with the methylation of insulin-like growth factor IGF1 and 2, key factors 
in human growth and development that are maternally imprinted23. Incorrect methylation of those 
genes during early development relates to reduced birth weight and increased predisposition to 
metabolic problems, like obesity, cardiovascular diseases or diabetes.24 However, despite this 
evidence, as far as we know, no human intervention studies aimed at reducing the exposure to EDCs 
have analysed the molecular impact that can accompany these changes in EDC exposure. Further 
research is needed to shed more light on these issues, including molecular and omics-based analyses 
in humans to elucidate whether human intervention studies aimed at reducing EDC exposure can 
favourably modulate these molecular changes.  
Different molecular and omics approaches will be carried out to shed more light in the framework of 
the HP axis on the epigenetic drivers most susceptible to disruption, the genes and the pathways most 
differently affected, the interplay between intestinal microbiota and the impact of EDC exposure on 
systemic inflammation. These analyses will be carried out in samples obtained in the study 
considering our results obtained in preclinical models exposed to EDC mixtures trying to resemble 
the real human exposure, to increase the chance to obtain robust and reliable results using a targeted 
approach. Specifically, in women the analyses will be carried out during pregnancy and after delivery 
at different time points and will be focused on the analyses of HP axis-related hormones and 
cytokines, intestinal microbiota, methylation of different CpG sites of key genes involved in HP axis 
as well as the expression of these genes. In their offspring, in addition to these analyses, the 
circulating levels of kisspeptin will be also analysed at birth (cord blood) and at the age of 18 months 
(capillary blood/dry blood spots –DBS-). Overall, these analyses will allow us to go into depth on the 
mechanisms by which EDCs exert their harmful effects as well as how intervention studies aimed at 
reducing the exposure to these chemicals can modulate these biological pathways and the molecular 
biomarkers of exposure identified. As far as we know, this approach has not yet been carried out in 
large human intervention studies in the framework of EDCs. 
 
 
2. OBJECTIVES 
2.1 Main Objective:  
The general objective of HYPIEND is to understand the effects of EDC co-exposure on the function 
and epigenetic programming of the HP axis to delineate intervention strategies for minimizing 
exposure and neuroendocrine consequences during the perinatal and pre-pubertal stages.   
The primary objective of this clinical study is to demonstrate that a multicomponent intervention 
implemented in health care centres from three European countries is effective in reducing the levels 
of EDCs in different body fluids of pregnant women, breastfeeding and formula feeding women as 
well as in their infants up to 18 months of age, improving at the same time the level of HAPA 
constructs (psychological determinants of behaviour) and the knowledge about these chemicals at 
family level.  
 
 
2.2 Secondary Objectives:  
a. To demonstrate that this multicomponent intervention designed to reduce the exposure to EDCs 
is effective for preventing some of the harmful effects related to HP disruption in infants up to 
the age of 18 months (weight, growth, and neurodevelopmental related alterations).  
b. To provide a better understanding on the relationship between the concentrations of EDCs in 
different fluids and the levels of HP-related hormones, cytokines, DNA methylation and gene 
expression patterns in blood and gut microbiota composition, shedding more light on the 
mechanisms by which EDCs can exert their harmful effects.   

 
 
 
c. To explore through multivariate analyses and health risk assessment the predictors of 
concentrations of EDCs in the body fluids (urine, blood, and milk).  
 
3 RESEARCH METHODS 
3.1 Type of Study 
 
               Randomized Controlled Trial (RCT):  
 
1. Group intervention, consisting of a multicomponent intervention (digital tool aimed at 
promoting lifestyle habits to reduce EDC exposure by providing personalized 
recommendations + telephone monitoring + workshops about environmental health 
education) during pregnancy and the first 18 months after delivery (Figure 1).  
2. Group control (standard of care). The control condition consists of a single online 
education module/written information about EDCs addressed to reduce their exposure. 
They will also have access to the digital tool to answer the questionnaires, but this group 
will not receive any recommendations or missions from the professionals concerning 
EDCs along the study (Figure 1). After finishing the intervention, the participants of the 
control group will be offered access to all the developed material (workshops…) and to 
use the app. Participants from different environmental areas will be recruited to account 
for different exposures to EDCs. 
 
3.2 Design 
 
3.2.1 
Theoretical framework behind the intervention 
 HYPIEND aims at evaluating whether a multi-centric, multicomponent interventional trial (digital tool 
aimed at promoting lifestyle habits to reduce EDC exposure by providing personalized recommendations 
+ phone calls + workshops about environmental health education) carried out in 810 women from 
pregnancy until their children are 18 months old is able to reduce the exposure to different EDCs. 
 
This intervention will be designed considering the gradual introduction of small changes (i.e., by using 
goal setting), carrying out a family-based approach, in a personalized manner, considering targeting 
different routes of exposure and providing to the participants frequent feedback and support. With this 
design, we expect to promote a behavioural change to achieve long-lasting effects in reducing the 
exposure to EDCs. The effects will be compared with a control intervention group, which will only 
receive a digital printable booklet with information on EDC hazards and on strategies to limit their 
exposure. Partners will be encouraged to join women during the medical visits and the environmental 
health education workshop.   
 
The stages of change9 will be followed as a general framework to organize the order of information 
transmitted to participants to increase adherence to the intervention. We expect that participants will 
initially be uninformed of the problem of EDCs, and thus unlikely to actively look for information on 
this topic. Therefore, at recruitment, information about the effect of EDCs on their babies and their own 
health will be provided to motivate them to engage with the issue (moving from the pre-consideration to 
the consideration stage). Next, a workshop will aim to build a solid motivation to change their exposure 
to EDCs (moving from consideration to the decision stage). Finally, when the motivation to change is 
strong enough, the digital tool will be offered as it helps bridge the intention-behaviour gap with 
progressive tasks to be implemented in daily life. Attention will also be focused on building habits for 
participants to move from action to maintenance stage, as the study runs for 24 months.  

 
 
The existing behaviour change interventions aiming at reducing exposure to EDCs among pregnant 
women have mainly focused on risk awareness among the population using the Health Belief Model10. 
However, the socio-cognitive literature has criticized the Health Belief Model for its weak predictive 
validity11. Globally, motivational models (including the Health Belief Model) are criticized because they 
assume that everybody holding an intention will translate it into behaviour.12 Indeed, the literature showed 
that around 50% of intentions are not translated into action.13  
 
The Health Action Process Approach (HAPA) suggests that the adoption, initiation, and maintenance of 
health behaviours must be explicitly conceived as a process that consists of at least a motivation phase 
and a volition phase. The latter might be further subdivided into a planning phase, action phase, and 
maintenance phase. It is claimed that perceived self-efficacy plays a crucial role at all stages along with 
other cognitions. Relying on HAPA, techniques will be selected to create motivation among pre-intenders 
and then help them translate their intention to change into action. Furthermore, the intervention will use 
the richness of behaviour change technics (BCT taxonomy, Intervention Mapping Taxonomy, Theory 
and Technique Tool) to maximize the probability of effective behaviour change.  
 
The intervention is conceived to target the psychological determinants of behaviour according to the 
HAPA model. As presented in the Figure 1, among preintenders (i.e., people that do not have the intention 
to change yet), motivation must be built through three constructs: risk perception, outcome expectancies, 
and task self-efficacy. In the context of EDCs, which translates respectively to being aware of the threat 
posed by the substances, believing that changing behaviour will lead to preventing the negative 
consequences, and perceiving being able to reduce exposure to EDCs. Increasing those three beliefs will 
lead to an intention to change, i.e., taking the decision to reduce one’s family exposure to EDCs. For this 
intention to be translated into action, planification of how the actual behaviour will be performed in the 
daily life, and anticipating barriers and how to surmount them is necessary, as well as self-efficacy 
regarding maintaining the change in the long run, and recovery in case of failure to maintain the change 
in lifestyle.   
 
Intervention components are highlighted in colours on the Figure 1. Green represents the aspects that the 
workshops will cover, and orange represents the aspects the app will target.  
 
  
Figure 1. HAPA model (adapted from Schwarzer, 2014) and the intervention components  

 
 
Furthermore, the study will be carried out in three different countries, including countries with a reported 
lower (Belgium and Spain) and higher (Poland) exposure to EDCs In HYPIEND we will evaluate the 
concentration of the exposure biomarkers of different families of EDCs in maternal urine at the first 
trimester of pregnancy (baseline), at delivery and 18 months after delivery, and in their offspring, at 4-7 
weeks after birth and at the age of 18 months. EDC will be also quantified in different fluids in which 
these pollutants that are more persistent can be found: 1) cord blood, which is a highly valuable fluid 
because the levels of EDC are a proxy for in utero exposure and can allow us to evaluate the exposure to 
EDC in mother–infant pairs14,15; 2) breast milk at 4-7 weeks post-partum, as a source of non persistent16,17 
and persistent EDC. 3) maternal peripheral blood at the first trimester of pregnancy, at delivery and 18 
months after delivery. 
So far, this multi-fluid approach at different time points in large mother-child intervention studies at the 
family level have not been carried out and could strongly contribute to properly understand the real 
exposure to EDC and their impact on child health and development. The relationship of prenatal and 
postnatal exposure to these pollutants in relation to hypothalamic-pituitary (HP) disruption and body 
weight, growth, behaviour, and neurodevelopment-related alteration of infants at different time points 
until the age of 18 months will be also evaluated. This could also allow the consortium to establish a 
cause-effect relationship between reduction in the exposure to EDCs and the prevention of harmful health 
effects related to HP disruption. Human health risk assessment in relation to exposure to EDCs will be 
also evaluated in women and their offspring of both groups including all the data obtained in the different 
fluids (urine, peripheral blood, cord blood, and breast milk) at different time points.  
 
3.2.2 
Characteristics of the study population (size, age group, sex distribution, inclusion 
and exclusion criteria) 
• 
Site: This is going to be a multicentric study, including three countries with different reported 
levels of exposure to EDCs 
1. Low exposure level: Spain and Belgium 
2. High exposure level: Poland 
 
• 
Centres for recruitment:  
1. In Spain:  
• 
The Germans Trias University Hospital 
• 
Hospital Universitario San Cecilio (HUSC) de Granada. 
2. In Belgium:  University Hospital Leuven (KUL), Belgium. 
3. In Poland: Centre of Postgraduate Medical Education (Centrum Medyczne 
Kształcenia Podyplomowego, CMKP) 
 
3.2.3 
Sample size and power calculation 
Total N: 810 pregnant women (270 pregnant women per country: Spain, Belgium and Poland).  
 
 
 
 
Clinical analyses:  
- Main outcome: urinary concentration of mono(2-ethyl-5-oxohexyl) phthalate (MEOHP): 624 
pregnant women (312 from control group/ 312 from intervention group) at the corresponding study 
points. 104 control participants/ 104 intervention participants per country. This sample size is based 

 
 
on the sample size calculated to obtain statistically significant differences among groups (n=624 
women excluding the estimated 30% of dropouts; for the sample size calculation, we included an 
extra number of participants considering a 30% of drop-out during the study, which yields a total of 
810 women to be recruited). 
- Other EDCs in urine, peripheral blood, cord blood and milk. 522 pregnant women at the 
corresponding study points (261 from control group/ 261 from intervention group) at the 
corresponding study points. 87 control participants/ 87 intervention participants per country. 
- Biochemical, molecular and omics analyses: 200 pregnant women (100 from control group/ 
100 from intervention group) at the corresponding study points. 33 control participants/ 33 
intervention participants per country.  
 
Very few RCTs have been conducted to evaluate the effects of interventions focused at reducing 
exposure to EDCs in the perinatal period (during pregnancy and in the early postnatal period). In one 
study22, 62 mothers with young children were enrolled in a web-based behavioural intervention, and 
significant changes were observed after 1 month in almost all the compounds analysed. Ouazzani et 
al.10 evaluated the effects of an educational intervention deployed during pregnancy in 268 women 
but failed to detect significant results on the concentration of urinary EDCs. With this data, we 
estimate a small effect size of 0.25 in the reduction of the urinary concentration of mono(2-ethyl-5-
oxohexyl) phthalate (MEOHP) (main outcome) between the control and the intervention groups in 
our study. We would expect to detect a 25% decrease in the urinary levels of MEOHP in the 
intervention group vs control group at the end of the study.  
Thus, considering 80% power and a two-tailed α of 0.05, we calculate that 624 pregnant women will 
be needed (312 per group) to detect significant differences in the main outcome (urinary 
concentration of MEOHP). Thus, to allow for a 30% drop out rate (estimated to be high due to the 
nature of the study: we expect a high drop-out in the postpartum), 405 subjects per group will be 
needed to be recruited (total N, 810). Therefore, 270 women will be recruited in each of the three 
countries, including women from different environmental areas   
  
The sample size was calculated choosing as a main outcome the urinary concentrations of MEOHP, 
which is an oxidative metabolite of MEHP and, therefore, it is a secondary metabolite of Di(2-
ethylhexyl) phthalate (DEHP). This election was based on a scientific article in which was reported 
that mental and/or Psychomotor Developmental Indices of the Bayley Scales of Infant Development 
were inversely correlated in 6-month-old infants with the maternal urinary levels of MEHHP and 
MEOHP at the third trimester of pregnancy in a study carried out with 460 mother–infant pairs.4 
However, since during the initial phase of the project a predictive modelling approach will be carried 
out in order to select the EDC mixtures with high harmful effects to be evaluated in preclinical 
models, the definitive main outcome could be redefined once we obtain the predictive modelling 
results.  
We would expect to detect a 25% decrease in the urinary levels of MEOHP in the intervention group 
vs control group at the end of the study. 
 
3.2.4 
Inclusion/exclusion criteria 
 
Pregnant women attending the first visit of prenatal surveillance will be invited to participate 
according to inclusion/exclusion criteria 

 
 
 
  
Inclusion criteria (Participants should fulfil ALL these criteria)  
• 
Pregnant women with a viable pregnancy confirmed by ultrasound until 13 
weeks and 0 days of gestation (recruitment between 6-11 weeks). Their partners will be 
invited to participate but this is not mandatory for inclusion.  
• 
 BMI at Visit 1 between 18.5-40 kg/m²   
• 
Intention to breastfeed   
• 
Being able to read the language of their respective countries (Dutch/French –
Belgium-, Spanish and/or Catalan –Spain- and Polish –Poland)  
• 
Being 18 years or older   
• 
In possession of a smartphone. If participants do not have a smartphone because 
of socio-economic reasons, a smartphone will be at their disposal for the whole duration 
of the study  
  
Exclusion criteria (If a participant fulfils ANY of the following)  
  
• 
Unable to sign informed consent (cultural barriers, psychological conditions) 
• 
Abuse of substances (alcohol, drugs) 
• 
Chronic use (at least, for three months before pregnancy) of any medication that might 
affect the HP axis: 
• 
Antidepressants  
• 
Insuline. 
• 
Levothyroxine, Methimazole, Propylthiouracil.  
• 
Oral corticosteroids (topical and inhalation formulations will be allowed) 
• 
Arginine vasopressin (AVP) 
• 
Mifepristone. 
• 
Anticortisolic drugs: Metyrapone (Metopirone), Ketokonazole, Osilodrostat 
(Isturisa), 
Mitotane 
(Lysodren), 
aminoglutethimide 
(Cytadren) 
and 
Levoketoconazole (Recorlev). 
• 
Multiple gestation   
• 
Type 1 or 2 diabetes  
• 
Pregnant women will not be consented into research by any HCP with whom they have 
a dependent relationship (Declaration of Helsinki) (I would remove this point).  
 
 
 
3.2.5 
Recruitment and Informed Consent 
Women will be provided with oral as well as written information regarding the purpose of this study, the 
study design (including the randomization procedure and allocation to control or intervention group), the 
variables that will be studied and the distribution of visits throughout the follow-up period.  
 
The participation of newborns/infants in this study has been included in the informed consent form, in 
which each mother, as the legal representative of the minor, exercises her right to provide informed 
consent by representation. 
 
All the participants will receive an informative leaflet (Annex 1) with a general scheme and FAQs about 
participation in this trial. Additionally, they will be given an Informed Consent Format (Annex 2) that 
should be carefully read and fully understood.  
 
Women will be encouraged to make as many questions as they need before signing this document. The 
signature of the Informed Consent is mandatory to enroll any participant and proceed with randomization.  
 

 
 
3.2.6 
Randomization  
 
Once confirmed that the pregnant woman fulfils criteria to participate in the study and agrees to do so by 
signing the Informed Consent, we will allocate her in one of the two groups (control vs intervention) 
through a randomization procedure.  
 
There will be an electronic eCRF (electronic Case Report Form) to be used to register the clinical data: 
REDCap, fully compliant with 21 CFR Part 11, GDPR, FISMA; and HIPAA. This is a secure web 
application specifically geared to support online and offline data capture for research studies and 
operations. The participant’s name and other identifiers will be stored separately from the research 
database to ensure anonymity. Personal data in the database will not be identifiable, an automatically 
created patient id number is used. 
 
The eCFR will be available for the four centers to manage the key aspects of random sequence generation. 
Real-time responses from such a system will enable assigning unique numbers for each participant 
(enrollment/randomization), independently of the center they belong to.  
 
Based on randomization numbers, the allocation ratio will be 1:1 for the interventional group and the 
control group. Investigators in charge of the analysis of the data will be blinded for the condition in which 
the participants are randomized. 
There will also be an emergency unblinding module in case of any serious adverse event either by subject 
number or by group assigned. This module can only be accessed by sponsors and statisticians. 
 
4.2.7 Multicomponent behavioural intervention 
 
A multicomponent behavioral intervention during pregnancy and up to the first 18 months after delivery, 
composed by:   
 
1. Digital tool called “App Hypiend Digital Tool” aimed at promoting lifestyle habits to 
reduce EDC exposure by providing personalized recommendations 
2. Telephone monitoring 
3. Workshop about environmental health education 
 
1. Digital tool (“App HYPIEND Digital Tool”) 
Women will have available a mobile app developed by EURECAT and designed to limit the 
exposure to EDCs in women from pregnancy until their children are 18 months old in a 
personalized and gamified way. The content of the app is built by integrating the HAPA 
constructs using behaviour change techniques.  
After answering an initial questionnaire about lifestyle habits related to EDC exposure, the app 
will provide them with personalized missions considering those habits with a higher risk to 
expose them to EDCs. By selecting these missions successively, they will receive frequent 
recommendations, tips and motivational quotes that will help them to accomplish the selected 
mission. For example, graded tasks will be used to increase task self-efficacy (i.e., initiate the 
change). Providing tools to conserve mental resources will be used to increase maintenance self-
efficacy (i.e., once the change started and needs to become a habit). Action planning and problem 
solving will be used to help intenders become actors.  
 
The application has been developed with two different versions:  
- 
one for professionals/researchers/recruiters and  
- 
another for participants/end users. 

 
 
 
The components of this application:  
- 
Sign in up and log in 
- 
Home page 
- 
Questionnaires 
- 
Missions (only the intervention group)  
- 
Recommendations (only the intervention group) 
- 
Push notifications 
- 
Forum/chats 
 
 
 
 
 
 

 
 
 
 
 
Components of the backoffice (exclusively for researchers):  
◼ Questionnaires that the clinician must answer with the patient 
◼ Visualization of questionnaire responses. 
◼ Forum/chat 
◼ Exportation of responses 
 
2. Telephone monitoring: To provide personalized support and feedback  
- 
From 6 weeks postpartum will be contacted every two months. 
- 
Moreover, the researchers will contact them via phone call 6 months after 
delivery aimed at encouraging the adherence to the intervention and to solve 
potential doubts.  
- 
In addition, parents will be contacted to explain how they should fill out the 
neurodevelopment questionnaire, which they must send us in the coming days.  
- 
If a long period of inactivity is detected at any point of the study, the researchers 
will contact the families by phone. 
- 
 
3. Workshops  
An interdisciplinary group of experts on EDCs (paediatric endocrinologists and environmental 
epidemiologists), psychologist expert on behaviour change, and nutritionists present in the 
consortium (University of Granada, Hospital Germans Trias i Pujol, University of Geneva, and 
Eurecat) will design and develop the content of the workshops.  
Two onsite workshops will be conducted during the first half of pregnancy (before 20 weeks of 
gestation).  
a) Workshop 1: Between 16-18 weeks of gestation. It will be focused on:  
      a.1 definition of EDCs and their adverse health effects  
      a.2 indoor air quality. 

 
 
 
b) Workshop 2: Between 18- 20 weeks of gestation. It will contain:  
       b.1 dietary sources of EDCs. 
             
Moreover, a third and a fourth session will be proposed to attend online at 30 weeks of pregnancy 
and around 6 weeks after delivery, respectively, covering personal care products and child’s behavior 
and baby’s products. They will also be recorded and sent as videos for those participants who did not 
attend. 
The content of the workshops and the way they are conducted will be unified across the consortium. 
These workshops will be organized by experts on EDCs and by personnel of each institution that 
will be trained to give the workshop using the theoretical background of the HAPA frame. After 
conducting each workshop, the key messages of the session will be sent by phone as a reminder.   
These workshops will be designed to reach several goals: increase knowledge on the hazards of EDCs 
for women and change psychological determinants (from the HAPA model) to result in a change in 
behavior that will lead to minimize the exposure of the women and their offspring to these chemicals. 
The workshops will not only provide information to raise awareness about the issue, but also include 
strategies to foster motivation to change (e.g., make the participants explain why it is important for 
them to change their habits), and facilitate action by increasing perceived capability. 
Partners will be encouraged to join women during the medical visits and the environmental health 
education workshop.   
 
CONTROL GROUP:  
The control group will only receive a digital printable booklet with information on EDC hazards and 
on strategies to limit their exposure. After finishing the intervention, the participants of the control 
group will be offered access to all the developed material (workshops…) and to use the app with all 
the functionalities. Participants from different environmental areas will be recruited to account for 
different exposures to EDCs. 
 
 
3.2.8 Follow-up and Timing of Visits 
Visit 1: On-site, First trimester, from 6 weeks to 13 weeks and 0 days of gestation.  
Visit 2: On-site, Third trimester, 28- 32 weeks of gestation.  
Delivery/Birth 
Visit 3: On-site, between 4th and 7th weeks after delivery. 
Visit 4: On-site, at 18 months after delivery. 
 
 

 
 
3.3 Study Variables 
3.3.1 Maternal variables to be studied 
A)xVisit 1: On-site, First trimester, from 6 weeks until 13 weeks and 0 days of gestation. 
- Anthropometric measurements: weight, height, and waist circumference according to standardized 
protocols. 
- Questionnaires: at the first visit, the participant will be instructed to use the app “Hypiend Digital Tool” 
and how to self-administer questionnaires online through this app. The questionnaires are designed to 
explore different areas: 
a. Socio-demographic data: urban/rural area of residence, work activity, economic background, 
level of education, personal and prenatal history. 
b. Quality of life (WHOQOL-BREF) The World Health Organization Quality of Life is a quality-
of-life assessment developed by the WHOQOL Group with fifteen international field centres, 
simultaneously, to develop a quality-of-life assessment that would be applicable cross-culturally. 
c. Physical activity (IPAQ): The International Physical Activity Questionnaires (IPAQ) 
comprises a set of 4 questionnaires. Long (5 activity domains asked independently) and short (4 
generic items) versions for use by either telephone or self-administered methods are available. 
The purpose of the questionnaires is to provide common instruments that can be used to obtain 
internationally comparable data on health–related physical activity. 
d. Dietary intake: a 3-day dietary record will be obtained through a specific digital tool called 
FASST (Food Assessment Tool), and a Food Frequency Questionnaire (FFQ).  
e. Pregnancy-related Anxiety Questionnaire-Revised (PRAQ-R2)  
g. The State-Trait Anxiety Inventory Test (STAI-T) 
h. Lifestyle habits concerning exposure to EDC Questionnaire*:  
i. EDC’s knowledge and HAPA constructs Questionnaire* 
* Based on existing tools particularly used to explore these domains.  
A pilot study has been carried out with volunteers to estimate how long it will take for the participants to 
fill in each questionnaire. The time elapsed ranged from 2-15 minutes.  
- Laboratory tests: At the first visit, we will also collect samples of blood, urine and faeces, according 
to the study protocol. See the Section “Biological samples and Clinical Analyses”.  
WS1 : air quality 
 
WS2 : diet 
 

 
 
Between 16 and 18 weeks of gestation, participants from the intervention group will receive an 
onsite workshop about air quality. 
Around 18-20 weeks of gestation, a second onsite workshop will be organized for the intervention 
group, focusing on diet. The control group will not receive such information.  
B)xVisit 2: On-site, Third trimester, 28- 32 weeks of gestation. 
- Anthropometric measurements: weight, height, waist circumference and gestational weight gain 
according to standardized protocols. 
- Questionnaires: The questionnaires will have been self-administered by the participants through the 
App Hypiend Digital Tool. The researchers will check their fulfilment at this visit. At visit 2, these are 
the questionnaires to fill out:  
a. Socio-demographic data: They will only be evaluated just in case of any change.  
b. Quality of life (WHOQOL-BREF)  
c. Physical activity (IPAQ) 
d. Pregnancy-related Anxiety Questionnaire-Revised (PRAQ-R2)  
g. The State-Trait Anxiety Inventory Test (STAI-T) 
h. Lifestyle habits concerning exposure to EDC Questionnaire*:  
i. EDC’s knowledge and HAPA constructs Questionnaire* 
* Based on existing tools particularly used to explore these domains.  
Workshop 3 (online): A video will be sent to the participants from the intervention group, 
around 30 weeks of gestation. This workshop will contain information regarding Personal 
care products. 
C) XBirth: During the active phase of labour, we will collect samples of peripheral blood and urine. 
Faeces will be collected at any time during the hospital stay for giving birth.  
D) xVisit 3: On-site, between 4th and 7th weeks after delivery. 
- Anthropometric measurements: weight, height, waist circumference and gestational weight gain 
according to standardized protocols. 
- Questionnaires: The questionnaires will have been self-administered by the participants through the 
App Hypiend Digital Tool. The researchers will check their fulfilment during this visit. At the third visit, 
the questionnaires used will be:  
a. Socio-demographic data:  

 
 
b. Quality of life (WHOQOL-BREF)  
c. Dietary intake: a 3-day dietary record will be obtained through a specific digital tool called 
FASST (Food Assessment Tool). 
d. The State-Trait Anxiety Inventory Test (STAI-T) 
e. Lifestyle habits concerning exposure to EDC Questionnaire*:  
f. EDC’s knowledge and HAPA constructs Questionnaire* 
* Based on existing tools particularly used to explore these domains.  
- Laboratory tests: Participants will have collected 3 samples of breast milk during the days before the 
visit and they will carry them on. 
 
Workshop 4 (online): A second video will be sent to the participants from the intervention group 
around 6 weeks after delivery. This video will contain information about child’s behavior and 
baby’s products. 
 
Telephone Monitoring: From 6 weeks after delivery until 18 months postpartum, participants from 
the intervention group will be contacted bimonthly by WhatsApp or any other messaging app of 
their choice. The participants from the control group will not be contacted by the researchers. 
 
 
E) xVisit 4: On-site, 18 months after delivery. 
- Anthropometric measurements: weight, height, waist circumference according to standardized 
protocols. 
- Questionnaires: The questionnaires will have been self-administered by the participants through the 
App Hypiend Digital Tool. The researchers will check their fulfilment on this visit. 
a. Socio-demographic data: Only in case of changes.  
b. Quality of life (WHOQOL-BREF). 
c. Physical activity (IPAQ) 
d. Dietary intake: a 3-day dietary record will be obtained through a specific digital tool called 
FASST (Food Assessment Tool), and a Food Frequency Questionnaire (FFQ). 
e. The State-Trait Anxiety Inventory Test (STAI-T) 
f. Lifestyle habits concerning exposure to EDC Questionnaire*:  
g. EDC’s knowledge and HAPA constructs Questionnaire* 
* Based on existing tools particularly used to explore these domains. 

 
 
- Laboratory tests: Samples of blood, urine and faeces will be collected, according to the study protocol. 
See the Section “Biological samples and Clinical Analyses”. 
3.3.2 Study Variables in Children  
A)XBirth:  
- Information regarding labour, and the physical condition of the baby will be recorded.  
- Growth and anthropometric measurements: gestational age (weeks), sex, anogenital distance (AGD) 
weight‐for‐age (WFA), length‐for‐age (LFA), weight‐for‐length (WFL), head circumference‐for‐age 
(HCA), preterm birth, low birth weight, small for gestational age, large-for-gestational age. The 
anthropometric measurements will be plotted according to the WHO growth charts, except for premature 
children under 37 weeks, who will be assessed according to Fenton Charts up to 44 weeks of corrected 
age. 
- At the time of birth, we will collect a blood sample from umbilical cord. Faeces will be collected at any 
time during the hospital stay.  
B) xVisit 3: On-site, between 4th and 7th weeks after delivery. 
- Growth and anthropometric measurements at 6 weeks of age: gestational age (weeks), sex, anogenital 
distance (AGD) weight‐for‐age (WFA), length‐for‐age (LFA), weight‐for‐length (WFL), head 
circumference‐for‐age (HCA). 
- A sample of urine from the baby will be collected during the visit. See the Section “Biological samples 
and Clinical Analyses”. 
 
C) Infant neurodevelopment will be assessed at the age of 6 months using the Ages and Stages 
Questionnaires, third edition (ASQ-3). The time frame for the test will be from 5 months to 6 
months and 30 days of age. Parents will receive a phone call to explain how they should fill out the 
neurodevelopment questionnaire, which they must send us in the coming days. 
D) xVisit 4: On-site, at 18 months of age.  
- Growth and anthropometric measurements: gestational age (weeks), sex, anogenital distance (AGD) 
weight‐for‐age (WFA), length‐for‐age (LFA), weight‐for‐length (WFL), head circumference‐for‐age 
(HCA). 
- Infant neurodevelopment will be assessed at the age of 18 months using use the Ages and Stages 
Questionnaires, third edition (ASQ-3). The time frame for the test will be from 17 months to 18 months 
and 30 days of age. 
- Laboratory tests: Samples of blood, urine and faeces will be collected, accordingly to the study 
protocol. See the Section “Biological samples and Clinical Analyses”. 

 
 
 
4. SAMPLE COLLECTION  
 
 
 
 
** The obtention of blood from toddlers WOULD be done by using an emerging pain-free device (Tasso-
plus®) as alternative to dried specimens for clinical analysis. https://www.tassoinc.com/tasso-plus 
OECD Guidelines:  
Guidelines OECD 455, OECD 458, OECD150  
Prior to starting any study, all materials (glass tubes, vessels, plastic ware) and reagents that will be used should be 
investigated, as defined in the protocol (6), for any possible interference with the measurements. OECD 458  
The plastic-ware should be free of estrogenic activity. OECD 455  
No recommendations of specific brands. 
Collection Tubes: 
Things to consider in the context of HYPIEND to avoid plastic cross contamination 
Phthalates contamination detected by MS in samples collected in plastic tubes. For metabolomics analysis this 
should be considered.  
Human samples will be collected in plastic tubes to obtain blood, milk and urine, but plasma, milk and urine should 
be storage in tubes that are certified free of Bisphenol A (BPA), Oleamide, DiHEMDA, and Phthalates. Some 
suggestions to be discussed:  
Eppendorf tubes (Ref. 0030121023)  
SuperClear® Centrifuge Tubes: https://www.labcon.com/tubessuperclearct.html   
Eclipse™ Pipette Tips: https://labcon.com/tipseclipse.html 
Maternal Blood:  
At Visit 1 (first trimester) as well as at Visit 4 (18 months after delivery) maternal peripheral blood will be collected. 
We will obtain: 
• 
4 tubes of 10 ml whole blood K3EDTA plasma (total 38 ml) 
 
Visit 1 
BIRTH 
Visit 3 
Visit 4 
Mother 
Blood 
Urine 
Faeces 
Blood 
Urine  
Faeces 
 
Human milk 
Blood 
Urine  
Faeces 
Baby 
 
 
Cord blood 
Faeces 
 
Urine 
 
Blood** 
Urine 
Faeces 

 
 
• 
1 tube of 2 ml whole blood aprotinin  
• 
2 tubes of 2.5 ml whole blood Pax Tubes for gene expression studies 
• 
2 tubes of 2 ml: one for epigenetic analyses and one to be stored at biobank.  
   
 
After centrifugation, we will get approximately 11,5 ml of plasma, that should be divided into aliquots 
as follows:  
  
 
 
             
      
          
   and  4
     
           
          
       
         
          
          
        
       
                       
     
                                 
                                               
            
                     
   
         
          
       
                                            
                      
     
          
             
          
     
         
       
        
       
      
           

 
 
The 2 whole blood Pax Tubes of 2,5 ml will be frozen immediately at each institution:  
   
Eventually, the remaining 2 tubes of 2 ml of whole blood K3EDTA for epigenetic studies will be 
processed as follows:  
 

 
 
Maternal Blood at delivery:  
 
   
 
 
Maternal Urine:  
 
              
DEL  E  
                                
          
   
     
                     
         
     
           
          
         
          
     
                                                    
                                                          
                  
     
            
         
       
      
           
        

 
 
 
 
Stool collection:  
 
 
Human Milk:  
 
     
  , delivery and  4
                                                                                 
              
      
           
     
                  
                     
               
         
           
                                            
                                                                                          
                                    
                                                              
                                                              
                                                              
                                                               
                                                          
                                                               
                                                     
              
  
          
                                                       
                                                  
       
          
        
   
    
   
    
      
   
                                                                 
                                                   
                                                            
                                                       
                     
        

 
 
 
 
Cord Blood: At the time of birth, 15 ml from venous cord blood will be collected.  

 
 
 

 
 
 
 
 
 
 

 
 
Infant urine:  
 
 
Infant faeces:  
 
 

 
 
5. BIOCHEMICAL, MOLECULAR AND OMICS ANALYSES 
 
5.1  Biochemical, molecular and omics analyses that will be carried out in 
biological samples obtained from women  
 
VARIABLES  
SAMPLE  
TECHNIQUE  
VOLUME/ 
AMOUNT  
TIMELINE  
EDC  
Urine  
Metabolomics by LC/GC-
MS/MS a  
12 mL *  
V1, delivery, V4  
Plasma from peripheral 
blood  
6 mL *  
V1, V4  
Milk  
10 mL  
V3  
Microbiota  
Faeces  
Shotgun sequencing  
1 g  
V1, delivery, V4  
Cytokines, exosomes 
and hormones   
Plasma from peripheral 
blood  
Multiplexed immunoassays, 
cytometry  
6 mL  
V1, V4  
Milk  
10 mL  
V3  
Gene expression  
   
Whole peripheral blood  
Q-PCR  
5 mL  
V1, V4  
Epigenomics  
  
Whole peripheral blood  
DNA methylation of specific 
genes  
3 mL  
V1, V4  
HP axis-related 
hormones   
Plasma from peripheral 
blood  
Immunoassays  
1 mL  
V1, V4  
ACTH  
Plasma–aprotinin from 
peripheral blood  
Immunoassays  
0.5 mL  
V1, V4  
Iodine  
Urine  
Colorimetric analysis  
200 uL  
V1, delivery, V4  
V1: first trimester of pregnancy; V2: third trimester of pregnancy; V3: 4-7 weeks after the birth of their infants; V4: 18 months 
after the birth of their infants 
a Analysis of EDC will be carried out using liquid (LC) or gas chromatography (GC) - tandem mass spectrometry (MS/MS). 
Specific instrument, columns, mobile phases, elution gradients and source parameters will be optimized for each EDC family.  
5.2  Biochemical, molecular and omics analyses that will be carried out in 
biological samples obtained from infants 
 
 
VARIABLES  
SAMPLE  
TECHNIQUE  
VOLUME/   
AMOUNT  
TIMELINE  
EDC  
Urine   
Metabolomics by LC/GC-MS/MS a  
7 mL *  
6 weeks &18 months  
Plasma from cord blood  
1.5 mL  
Birth  
Microbiota  
Faeces  
Shotgun sequencing  
1 g  
Birth, 18 months  
HPG-related 
hormones  
Plasma from cord blood  
Multiplexed immunoassays, 
cytometry  
1 mL  
Birth  
Peripheral whole blood 
500µl 
18 months  
Cytokines  
Plasma from cord blood  
 0,5 mL  
Birth  
Kisspeptin  
Plasma from cord blood  
Birth  
Peripheral whole blood 
500µl 
18 months  
Gene expression   
Whole cord blood  
Q-PCR  
 2.5 mL  
Birth  
Epigenomics  
Whole cord blood  
DNA methylation of specific genes  
 3 mL  
Birth  

 
 
 Peripheral whole blood 
500µl 
18 months  
ACTH  
Plasma–aprotinin from 
cord blood  
Inmunoassay  
0.5 mL  
Birth  
Iodine  
Urine  
Colorimetric analysis  
250 uL  
Births, 18 months  
a Analysis of EDC will be carried out using liquid (LC) or gas chromatography (GC) - tandem mass spectrometry (MS/MS). 
Specific instrument, columns, mobile phases, elution gradients and source parameters will be optimized for each EDC family.  
* Volume may be different depending on the selected families of EDC 
 
For each tube to be stored for further analysis, we have included a general label. Ex: Plasma from women 
for EDC analyses: PL-01 (a,b,c,d,e,f): PL=Plasma; 01= corresponds to the aliquots to be used for EDC 
analyses; a,b,c,d,e,f: 6 tubes are needed, one tube, one letter. When samples are collected, additional 
information will be included in the label: the number of visit and the code of the participant. Ex: PL-
01a_V1_XXX 
* Volume may be different depending on the selected families of EDC. Refer to Annex 1 (see folder WP·, 
perinatal_clinical_study) for more details. 
 
STORAGE AND SHIPMENT OF SAMPLES 
All samples collected will be processed according to specific protocols. Once labelled, they will be kept 
at the Biobank of the four centres (HGTiP, HUSC, CMKP; KUL).  
Eurecat will be responsible for the shipment of samples to reference laboratories.  
 
CLINICAL ANALYSIS PER VISIT 
A.Variables to be analyzed at V1 (first trimester of pregnancy) in women.  
  
VARIABLES 
TOOL/TECHNIQUE 
EDC (urine) 
Metabolomics 
EDC (plasma from peripheral blood) 
Metabolomics 
Microbiota (faeces) 
Shotgun sequencing 
Cytokines, exosomes and hormones (plasma) 
Immunoassays 
Gene expression (whole peripheral blood) 
Q-PCR 
Epigenomics (buffy coat-peripheral blood) 
DNA methylation of specific genes 
HP axis-related hormones (plasma) 
Immunoassays 
Iodine concentration (urine) 
Colorimetric analysis 
 

 
 
B. Variables to be analyzed at delivery in women. 
   
VARIABLES 
TOOL/TECHNIQUE 
EDC (urine) 
Metabolomics 
EDC (plasma from peripheral blood)* 
Metabolomics 
Gene expression (whole peripheral blood) * 
Q-PCR 
Epigenomics (buffy coat-peripheral blood) * 
DNA methylation of specific genes 
HP axis-related hormones (plasma from 
peripheral blood) * 
Immunoassays 
Cytokines (plasma from peripheral blood) * 
Immunoassays 
Microbiota (faeces) 
Shotgun sequencing 
Iodine concentration (urine) 
Colorimetric analysis 
 
* Samples will be collected but there is no budget planned to carry out these analyses 
C. Variables to be analyzed at V3 (between 4 and 7 weeks after the birth of their infants) 
in women. 
  
VARIABLES 
TOOL/TECHNIQUE 
EDC (breast milk) 
Metabolomics 
Cytokines, exosomes and hormones (breast milk) 
Immunoassays 
 
D. Variables to be analyzed at V4 (18 months after the birth of their infants) in women.  
VARIABLES 
TOOL/TECHNIQUE 
EDC (urine) 
Metabolomics 
EDC (plasma from peripheral blood) 
Metabolomics 
Microbiota (faeces) 
Shotgun sequencing 
Cytokines, exosomes and hormones (plasma) 
Immunoassays 
Gene expression (whole peripheral blood) 
Q-PCR 
Epigenomics (buffy coat-peripheral blood) 
DNA methylation of specific genes 
HP axis-related hormones (plasma) 
Immunoassays 
Iodine concentration (urine) 
Colorimetric analysis 

 
 
E. Variables to be analyzed at birth in infants.  
  
VARIABLES 
TOOL/TECHNIQUE 
EDC (plasma from cord blood) 
Metabolomics 
Gene expression (whole cord blood) 
Q-PCR 
Epigenomics (buffy coat-cord blood) 
DNA methylation of specific genes 
HP axis-related hormones (plasma from 
cord blood) 
Immunoassays 
Kisspeptin (plasma from cord blood) 
Immunoassays 
Cytokines (plasma from cord blood) 
Immunoassays 
Microbiota (faeces) 
Shotgun sequencing 
Iodine concentration (urine) 
Colorimetric analysis 
 
F. Variables to be analyzed at V3 (between 4 and 7 weeks after the birth of their infants) 
in infants. 
  
VARIABLES 
TOOL/TECHNIQUE 
EDC (urine) 
Metabolomics 
 
G. Variables to be analyzed at 18 months in infants.  
  
VARIABLES 
TOOL/TECHNIQUE 
EDC (urine) 
Metabolomics 
Microbiota (faeces) 
Shotgun sequencing 
Neurodevelopment 
ASQ-3 
Epigenomics (peripheral whole blood) 
DNA methylation of specific genes 
HP axis-related hormones (peripheral 
whole blood) 
Immunoassays 
Kisspeptin (peripheral whole blood) 
Immunoassays 
 

 
 
6. TRIAL FLOWCHART 
  
 
RECRUITMENT 
  
 
Inclusion/Exclusion 
criteria 
  
 
Signature Informed 
Consent 
  
 
  9 weeks 
 
RANDOMIZATION 
  10 weeks 
 
  11 weeks 
Intervention 
Group 
 
 VISIT 1: Phys*; Q*, 
Analysis* 
Control Group 
  
App 
 
Written Information  
about EDC 
  
App 
 
  
16-18 
weeks 
App 
Onsite W 
 
  
App 
 
  
18-20 
weeks 
App 
Onsite W 
 
  
App 
 
  
App 
 
  
App 
 
  
30-32 
weeks 
App 
Online W 
 
 VISIT 2: Phys*; Q*, 
Analysis* 
  
App 
 
  
App 
 
  Delivery 
App 
 
 DELIVERY: Phys*; Q*, 
Analysis* 
  
App 
 
WhatsApp 
  
6 wks 
postpart 
App 
Online W 
 
WhatsApp 
 VISIT 3: Phys*; Q*, 
Analysis* 
  
App 
 
WhatsApp 
  6 months 
App 
 
 
Phone 
Call 
ASQ-3 
  
App 
 
WhatsApp 
  
App 
 
WhatsApp 
  
App 
 
WhatsApp 
  
12 
months 
App 
 
WhatsApp 
  
App 
 
WhatsApp 
  
App 
 
WhatsApp 
  
18 
months 
App 
 
WhatsApp 
 VISIT 4: Phys*; Q*, 
Analysis* 
  
 
ASQ-3 
 

 
 
 
App: Aplication Hypiend Digital Tool.  
Onsite W: Presential Workshop about air quality (16-18 weeks of gestation) 
                 Presential Workshop about Dietary sources of EDCs (18-20 weeks)  
 
Online W: Video about Personal care Products (around 30 weeks of gestation) 
                  Video about child’s behavior and baby’s product (6 weeks after delivery) 
 
 
Phys*: Physical examination, anthropometric measurements.  
Q*: Questionnaires regarding:  
◼ General information 
◼ Medical background 
◼ Behaviors/Lifestyle habits 
◼ EDCs’ Knowledge 
◼ Perceived exposure to EDC 
◼ HAPA Constructs 
Analysis*: Sample collection 
 
 
 
 
 

 
 
7. STATISTICAL ANALYSIS 
Descriptive statistics will be used to calculate central tendency measures and frequencies of 
sociodemographic characteristics and other covariates. EDC concentrations in the different biological 
matrices and outcome variables (anthropometric measures,  Q, hormone levels, etc.).  
The statistical approach used to assess the effectiveness of the intervention will depend on the final 
distribution of the study variables, but we expect to compare the reduction in EDC levels in the two 
groups using paired parametric or non-parametric paired data tests (e.g., Student T/Wilcoxon signed-rank 
tests, McNemar/Wilcoxon signed-rank test for paired binary data), as well as mixed-effect regression 
models to account for recruitment center and repeated EDC measures. We will assess changes in 
mean/median pollutant levels and percentages of detection. We also consider including mixture analysis 
by using dimension reduction techniques to identify clusters of chemicals affected by the intervention 
with novel statistical methodologies such as Weighted Quantile Sum (WQS)  egression, G-Computation, 
or Bayesian Kernel Machine  egression (BKM ). The analyses will be done according to the intention-
to-treat principle.  
The identification of potential determinants of EDC exposure and the association between 
prenatal/postnatal exposure to EDCs and outcome variables in the intervention and control group as well 
will be evaluated using mixed-effect regression models (linear or logistic, depending on the nature of 
exposure and outcome variables), adjusted for confounders. 
 
"The Statistical Analysis will describe the participant populations to be included in the analysis, as well 
as procedures and statistical methods for conducting the analysis. This section provides a summary of the 
planned statistical analysis of the primary and secondary endpoints (if applicable). 
Describe the statistical methods to be employed. Stipulate the level of significance that is to be used in 
each Trial analysis, together with the procedure(s) for accounting for any missing, unused, and/or 
spurious data” 
 
Endpoint 
Statistical Analysis Methods 
Descriptive variables, covariates, sensitivity 
analysis. 
  
Descriptive statistics will be used to 
calculate central tendency measures and 
frequencies 
of 
sociodemographic 
characteristics and other covariates, EDC 
concentrations in the different biological 
matrices, 
and 
outcome 
variables 
(anthropometric measures,  Q, hormone 
levels, etc). 
ANAL S S OF EFF CAC   A  ABLES 
 NTE -G OUP 
EFFECTS 
( NTE  ENT ON  S CONT OL) 
The analysis will be performed with the 
intention to treat ( TT) for all variables 
except for the main variable, which will also 
be analyzed by PP (per protocol). 
 . 
 A  ABLES 
COLLECTED 
 N 
D FFE ENT   S TS (except intestinal 
microbiota). 
  

 
 
- M XED MODEL ANAL S S (evaluate the 
effects over time between the two groups -
intervention vs control-): 
Check the normality of the residues. 
Check if covariates should be added (for 
example age). 
 nclude intervention as a factor in addition to 
age and other covariates. 
•  f we find a time effect, the variable 
changes over time regardless of the 
intervention. 
•  f we find an intervention effect, the 
variable is different between interventions 
regardless of the moment (time) in which it 
is analyzed. 
•  f the time x intervention interaction is 
statistically significant, it means that the 
intervention effect changes over time. Carry 
out a post hoc at each time (Bonferroni). 
 epresent the variables in a line graph by 
groups. 
- ANCO A ANAL S S at each visit: 
analyze the intervention effect at each time 
using an ANCO A for each visit. As 
covariates, values at baseline, age and if 
there are other covariates will be included. 
Post hoc Bonferroni. 
- ANCO A ANAL S S of the change: 
analyze the intervention effect at each time 
using an AN OCA model with the 
dependent variable the value of the change in 
the variable vs baseline and the inter-subject 
factor the intervention. As covariates, values 
at baseline, age and if there are other 
covariates will be included. Post hoc 
Bonferroni. 
- STUDENT T TEST ANAL S S: if in the 
previous analyses no significant changes are 
observed 
between 
interventions, 
try 
performing the test between groups to detect 
residual differences. 
 epresent the variable change between visits 
in a bar graph. 

 
 
 NT A-G OUP EFFECTS (W TH N THE 
 NTE  ENT ON G OUP AND W TH N 
THE CONT OL G OUP) 
The intra-group effects on the different 
variables between the different visits will be 
analyzed using a Student t test or Wilcoxon 
test (the latter, in the case of paired samples). 
 ndicate the mean and SD values in a table 
for each group and indicate the significant 
values of the intra-group analyses. 
 
 
 
8. DATA MANAGEMENT 
Data management aspects (data standards, type of data capture, verification of data, central data 
collection, cleaning, analysis, reporting, security) 
Approval for the proposed study will be requested from the medical ethical board of the four institutions. 
For participation in the study, informed consent must be signed, after receiving clear information about 
the study on paper and by an informative phone call in which study details are explained very carefully. 
All participants have the right to discontinue their participation in the study at any time without further 
explanation.  
All data will be treated confidentially, and privacy of all participants will be protected by saving personal 
data separately from research data on encrypted files with identification numbers that can only be 
accessed by the main researchers working on this project. The file containing personal data will be 
destroyed after data collection has been completed. Data about the usage of the application will not 
contain  P address information and therefore it cannot directly identify its user and related personal 
information. Data management and agreements to transfer data/samples is dealt in WP6. 
An electronic eC F will be used to register the clinical data:  EDCap, fully compliant with 2  CF  Part 
  , GDP , F SMA; and H PAA. This is a secure web application specifically geared to support online 
and offline data capture for research studies and operations.  EDCap can be used to collect virtually any 
type of data in any environment from anywhere in the world over a secure web connection with 
authentication and data logging. 
The data compiled in  EDCap are all those already characterized as maternal and infant variables 
aforementioned in this document.  
The participant’s name and other identifiers will be stored separately from the research database to ensure 
anonymity. Personal data in the database will not be identifiable, an automatically created patient id 
number is used. 
 
9. DISSEMINATION PLAN 
The H P END Plan for Dissemination and Exploitation and Communication (P-DEC D5. ) comprises 
a set of measures and actions tailored per target groups aimed at: 
►maximizing the outcomes, impacts and resonance of H P END by disseminating.  

 
 
► raising awareness and contributing to knowledge and capacity building and advancement of 
innovation in EU and to avoid duplication of research and demonstration work. 
► paving a solid path for the continuous and future uptake of the results across the relevant European 
(and international) communities and beyond the H P END market applications.  
Specific dissemination activities for H P END project are detailed in the table below. 
A) External events like conferences and fairs 
: present scientific + technological ternal events like conferences and fairs 
Key motivation: present scientific + technological concepts, approaches, results, and their impact 
through paper/poster presentations or workshop organizations.  
Target audience: TG# , 3, 4, 6 policy makers, industry, researchers incl. students.  
Target events: European Congress of Endocrinology (ECE); European Society of Human 
 eproduction and Embryology (ESH E), EU OTOX, Conference of the European Health Psychology 
Society, Zebrafish Disease Model Society, and/or the  nternational Society for Fish Endocrinology; 
 nternational Congress of Fish Biology; Obstetric congresses, The  nternational Conference on 
Chemicals Management ( CCM), The  nternational Conference on Environmental Science and 
Technology ( CEST), The European Endocrine Disruptors 
Exchange (EEDE), Gordon  esearch Conference on Environmental Endocrine Disruptors, The 
 nternational Society of Environmental Epidemiology Conference ( SEE), The  nternational Symposium 
on Environmental Pollution and its  mpact on Life in the Mediterranean  egion, The  nternational 
Conference on Environmental Pollution and Health, The  nternational Workshop on Environmental 
Toxicology ( WET), European Society for Environmental 
and Occupational Medicine (EOM) Conference, Society of Environmental Toxicology and Chemistry 
(SETAC) Europe Conference, European Congress on Endocrinology,  nternational Symposius on 
Endocrine Disruptors.  
KPIs:>30 events participated (talks, posters, display of materials) reaching > 4,500 professionals.  
Post project: inclusion of H P END results in > 0 presentations in key fora after project’s end. 
 
B) Scientific Publications 
 
Key motivation: exchange scientific knowledge, provide technical details and share open data; 
Publication of H P END research into Zenodo and  esearch Gate.  
Target audience: researchers and academics.  
Target publications: Endocrinology; Neuroendocrinology; Lancet Diabetes & Endocrinology; Journal 
of Clinical Endocrinology &Metabolism; Nature Clinical Practice Endocrinology & Metabolism; 
Archives in Toxicology, Health Psychology, Behavioural Medicine, Applied Psychology, Health and 
Well-Being, Zebrafish, Frontiers in Physiology, Frontiers in Cell and Developmental Biology, Human 
 eproduction, Am J Obstet Gynecol, Eur J Obstet 
Gynecol  eprod, Journal of Clinical and Diagnostic  esearch, Environmental Health Perspective, 
Journal of Epidemiology and Community Health, Environmental Science & Technology, Journal of 
Environmental Science & Health Part C, EMBO  eports, Endocrine, Metabolic &  mmune Disorders - 
Drug Targets, Toxicological Sciences, Environmental Pollution, Chemosphere, Environmental 
Toxicology and Pharmacology, Biomarkers, Journal of 
Applied Toxicology, Neurotoxicology, Journal of Clinical Endocrinology & Metabolism, Molecular and 
Cellular Endocrinology.  
KPIs: 100% >20 peer-reviewed open-access publications submitted.  ia gold or green access. >5 
articles in key specialised EU magazines.  
Post project: >5 papers following or citing H P END research. 
 

 
 
C) Training, co-creation and knowledge transfer activities 
Key motivation: co-organise webinars/workshops with other research groups, students and professionals 
of the endocrinology, toxicology, and molecular epidemiology sectors, provide detailed insights in key 
outcomes and methodologies to academic and analytical lab. professionals; inclusion of P OJECT results 
to existing training programmes.  
KPIs: 2 e-learning lectures (M24-M26) targeting academia (researchers, students incl. PhDs 
and post-docs) on WP  and WP2 - KUL & EUT-, inclusion of project results in existing training 
courses/activities - KTH,  AD, UG  - 5 workshop with interventional studies target audience to 
raise awareness on EDC - (M24 - SC ,  GTP, KUL, CPKE), final event (M60) engaging ≥ 00 
professionals (ALL TG). 
 
D) Dissemination towards policy makers and public authorities 
 
Key motivation: workshops to bring together policymakers and scientists to discuss the project findings 
and implications for policy and action. This can help inform decision-making and ensure that project 
findings are integrated into policy and regulatory frameworks. Participate in policy and regulatory 
processes (public consultations and meetings to share project findings and recommendations with policy 
makers and regulators. This will support integration of H P END results into policy debates.  
Target audience: TG#1, 6 policymakers, external experts participating in regulatory and policy making;  
KPIs: 9 dissemination actions with policymakers and public authorities, 27 policymakers and public 
authorities’ feedback through feedback forms. 
Post project: Keeping alive the policy permanent hub to maintain free access to results, and knowledge 
base generated in the project. 
 
E) Clustering Activities and joint dissemination 
Key motivation: exchange news and ideas in common outreach actions, network and share knowledge 
on research,clustering activities with other projects, usage of European Communication Channels (EC 
newsletters, Cordis, etc.), creation of community of interest around the H P END to disseminate, 
collaborate and share knowledge.  
Target audience: TG3, TG6 mainly: related EU  nitiatives funded under the current call, industrial 
associations, academia and researchers;  
KPIs: ~ 10 dissemination actions with EU initiatives and sister projects, contact at least  5 EU 
 nitiatives/projects and making cooperation agreement with at least 5 of them, engaging with +10 
endocrine and nutrition associations across Europe, +4 informative newsletters.  
Post HYPIEND: participation in network, cluster, association events upon invitation, offering 
availability to be part of advisory boards or working groups. 
 
 
 
 
 
 
 
 

 
 
10. BIBLIOGRAPHIC REFERENCES 
 
1. 
O'Shaughnessy KL (2021). Perinatal exposure to endocrine disrupting chemicals and neurodevelopment: How articles 
of daily use influence the development of our children. Best Pract Res Clin Endocrinol Metab. 35(5):101568. 
2. 
Heindel JJ (2022). Obesity II: Establishing causal links between chemical exposures and obesity. Biochem 
Pharmacol.199:115015 
3. 
Schulz MC (2021). Inappropriately sweet: Environmental endocrine-disrupting chemicals and the diabetes pandemic. 
Adv Pharmacol. 92, 419-456. 
4. 
Kim Y (2011). Prenatal exposure to phthalates and infant development at 6 months: prospective Mothers and 
Children's Environmental Health (MOCEH) study. Environ Health Perspect. 119(10):1495-1500. 
5. 
Ellsworth L. (2020). Lactational exposure to polychlorinated biphenyls is higher in overweight /obese women and 
associated with altered infant growth trajectory: A pilot study. Curr Res Toxicol.1:133-140. 
6. 
Braun JM (2017). Early-life exposure to EDCs: role in childhood obesity and neurodevelopment. Nat Rev Endocrinol. 
13(3):161-173 
7. 
Martin L (2022). Lifestyle interventions to reduce endocrine-disrupting phthalate and phenol exposures among 
reproductive age men and women: A review and future steps. Environ Int. 170:107576. 
8. 
Sargis RM (2019). Interventions to Address Environmental Metabolism-Disrupting Chemicals: Changing the Narrative 
to Empower Action to Restore Metabolic Health. Front Endocrinol (Lausanne). 10:33. 
9. 
Glanz, K. (2008). Health behavior and health education: theory, research, and practice. John Wiley & Sons. 
10. El Ouazzani H (2021). Perinatal Environmental Health Education Intervention to Reduce Exposure to Endocrine 
Disruptors: The PREVED Project. International Journal of Environmental Research and Public Health;19(1):70. 
11. Christopher J. Carpenter (2010) A Meta-Analysis of the Effectiveness of Health Belief Model Variables in Predicting 
Behavior, Health Communication, 25:8, 661-669 
12. Christopher J. Armitage & Mark Conner (2000) Social cognition models and health behaviour: A structured review, 
Psychology & Health, 15:2, 173-189 
13. Sheeran P (2016). The Intentation-Behaviour Gap. Social and Personality Compass, 10:9, 503-518 
14. Rovira J. (2022) Mixture of environmental pollutants in breast milk from a Spanish cohort of nursing mothers. Environ 
Int 2022 Aug: 166:107375.  
15. Iribarne-Durán LM (2022). Concentrations of bisphenols, parabens, and benzophenones in human breast milk: A 
systematic review and meta-analysis. Sci Total Environ. 806(Pt 1):150437. 
16. Cao C (2021). Prenatal exposure to polycyclic aromatic hydrocarbons could increase the risk of low birth weight by 
affecting the DNA methylation states in a Chinese cohort. Reprod Biol. 21(4):100574. 
17. Gingrich J (2020). Placenta Disrupted: Endocrine Disrupting Chemicals and Pregnancy. Trends Endocrinol Metab. 
31(7):508-524. 
18. Kim JH. (2021). Web-based behavioral intervention to reduce exposure to phthalate metabolites, bisphenol A, 
triclosan, and parabens in mothers with young children: A randomized controlled trial. Int J Hyg Environ Health; 236: 
113798. 
19. Caporale N. (2022). From cohorts to molecule: adverse impacts of endocrine disrupting mixtures. Science, 375-6582 
20. Raja GL (2022). In utero exposure to endocrine disruptors and developmental neurotoxicity: Implications for 
behavioural and neurological disorders in adult life. Environ Res.203:111829. 
21. Bozack A. K. (2021). Prenatal metal exposure, cord blood DNA methylation and persistence in childhood: an 
epigenome-wide association study of 12 metals. Clinical Epigenetics, 13-208 
22. Guo J. (2022). Association Studies of Environmental Exposures, DNA Methylation and Children’s Cognitive, 
Behavioral, and Mental Health Problems. Frontiers in Geneticics, 13-871820 
23. Herbstman, JB. (2012). Prenatal Exposure to Polycyclic Aromatic Hydrocarbons, Benzo[a]pyrene–DNA Adducts, and 
Genomic DNA Methylation in Cord Blood. Environmental Health Perspectives, 120-5. 
24. Heijmans BT (2008). Persistent epigenetic differences associated with prenatal exposure to famine in humans. Proc 
Natl Acad Sci USA;105(44):17046-9. 
 
 

 
 
ANNEX 1: INFORMATIVE LEAFLET FOR PARTICIPANTS IN CLINICAL RESEARCH STUDIES 
 
 
 
 
FIP-CI_CEIC_V.1.0 (13/01/2021) 
 
 
The Guide that is presented below is an adaptation of the "Guide for the correct preparation of a patient 
information sheet and informed consent (HIP / CI) model" that is used for clinical trials with drugs that 
are carried out in Spain” 
To make it easier for the patient to read, the document must not exceed 15 pages (including consent 
forms or signature sheets). It is recommended to use a minimum font of 11 points, with a minimum 
interline spacing of 1.5, without reducing the margins of the document. For each section, the minimum 
essential content and recommendations on the appropriate content are indicated. Writing examples are 
included in specific sections. 
A version and a date must be recorded at the foot of the document. 
 
 
 
 
 
 
 
 
 
 
 
 
GUIDE FOR WRITING THE PATIENT INFORMATION SHEET AND INFORMED CONSENT 
FOR INTERVENTION STUDIES 

 
 
 
 
TITLE 
 
Understanding and preventing the impact of endocrine disruptors 
on the hypothalamic-pituitary axis in sensitive populations 
 
Clinical study to evaluate the effectiveness of a multicomponent 
behavioral intervention to reduce exposure to endocrine disruption 
during the perinatal period in women and their offspring. 
PROMOTOR 
 
Institute of Research Germans Trias i Pujol (IGTP) 
PROTOCOL CODE 
HYPIEND- 101137440 
Inés Velasco López 
 
PRINCIPAL INVESTIGATOR 
PHONE 
934978525 
MOBILE 696914449 
 
CENTRE 
University Hospital Germans Trias i Pujol 
DEPARTMENT 
Obstetrics % Gynecology 
 CENTRE ADDRESS 
Carretera de Canyet s/n 
CITY 
Badalona 
ZIP 
08916 
PROVINCE 
Barcelona 
 
1. Introduction 
We are contacting you to inform you about a research study in which you are invited to 
participate. The study has been approved by a Research Ethics Committee. It is our intention 
that you receive the correct and sufficient information so that you can decide whether or 
not to participate in this study. For this, read this information sheet carefully and we will 
clarify any doubts that may arise. In addition, you can consult with the people you consider 
appropriate. 
 
2. Voluntary Participation  
 
We invite you to participate in the study because you are pregnant and belong to the group 
of patients without risk factors who are visited at Obstetrics consultations. You should know 
that your participation in this study is voluntary and that you can choose NOT to participate. 
If you decide to participate, you can change your decision and withdraw consent at any 
time, without this altering your relationship with your doctor or causing any harm to your 
medical care. 

 
 
 
3. Study Objective 
 
The general objective of HYPIEND is to understand the effects of exposure to substances 
known as endocrine disruptors (EDs) on maternal-child health (in general) and on hormonal 
functions (in particular), in order to outline intervention strategies for minimize exposure 
and consequences for the mother and her offspring during the perinatal period. 
 
The main objective of this clinical study is to demonstrate that a multicomponent 
intervention implemented in care centers in three European countries is effective in 
reducing the levels of these disruptors in different body fluids of pregnant, lactating and 
formula-fed women, as well as in their offspring up to 18 months after birth, improving at 
the same time the level of knowledge of these chemical substances at family level. 
 
The secondary objectives are: 
a) Demonstrate that this multicomponent intervention designed to reduce DE exposure is 
effective in preventing some of the harmful effects related to disruption of the 
hypothalamic-pituitary hormone axis (HPH) in infants up to 18 months (weight, growth and 
alterations related to neurodevelopment). 
 
b) To provide a better understanding of the relationship between the concentrations of 
endocrine disruptors in different fluids and the levels of EHH-related hormones, cytokines, 
DNA methylation and gene expression patterns in the blood and the composition of the 
intestinal microbiota, shedding more light on the mechanisms by which Des can exert their 
harmful effects. 
 
 
c) Explore through multivariate analysis and health risk assessment the predictors of high 
levels of disruptors in body fluids (urine, blood and milk). 
 
 
 
 

 
 
4. Description of the study  
A detailed description of this study can be found as Appendix 1 to this document. 
HYPIEND aims to evaluate a perinatal intervention in a 2-arm randomized controlled trial (RCT), 
with 
a) An experimental group, which will receive a multicomponent intervention (digital tool 
aimed at promoting lifestyle habits to reduce exposure to disruptors through personalized 
recommendations + telephone follow-up + environmental health education workshops) 
during pregnancy and first 18 months after delivery (Figure 1). 
b) A control group, whose participants will receive a single module of online 
education/written information about endocrine disruptors aimed at reducing their exposure, 
but this group will not receive any feedback from professionals about endocrine disruptors 
throughout the study (Figure 1). 
 
  Figure 1: Study Design and Follow-up of participants  
 
• 
The participants in the study will be called at the times described in the protocol, in order to 
verify the correct monitoring of the pregnancy in general and the research protocol in 
particular. All the variables and information about your pregnancy will be collected through 
surveys and questionnaires that you will fill out through the mobile application. 

 
 
 
• We will not need access to your medical history to obtain data related to the pregnancy (age, weight, 
birth data) as we will collect them through visits and surveys. Likewise, the collection of biological 
samples (blood and urine) will be carried out by the health personnel who will attend each 
medical visit or hospital stay. 
 
• This study will be carried out entirely at the Multipurpose Clinical Research Unit (UPIC) of the 
Germans Trias i Pujol University Hospital. The study will last 3 years with a recruitment period of 
24 months for pregnant women and follow-up of pregnancy and childbirth, and of the newborn 
during the first 48 hours of life, as well as follow-up up to 18 months age of the boy/girl. 
 
5. Study actions. What can your participation entail? 
• 
Participation will not lead to any change in your treatment or in the rest of your medical 
care. 
The data will be included in a Data Collection Notebook in digitized format. All pregnant 
women, both those in the intervention group and those in the control group, will receive 
exactly the same healthcare from healthcare professionals: gynecologists and/or midwives. 
 
6. Potential benefits 
 
You should know that we cannot guarantee or promise that inclusion in the study will bring you 
any benefit, although scientific knowledge may be obtained that may benefir other people later.  
All this data will be collected separately from the medical history and the "Pregnancy Card". The 
identity of pregnant women and their newborns is confidential and will only be known to the 
principal investigator and his collaborators, so all study information will be stored with sufficient 
safeguards. The data obtained in this study will be used exclusively to obtain scientific 
conclusions. 

 
 
7. Expenses and financial compensation 
 
Your participation in the study will not incur any additional costs. You will not be paid to 
participate.   
8. Obtaining and using biological samples  
In the event you give your authorization, this bilogical material will become part of the hospital’s 
biobank of biological samples, called the IGTP-HUGTP Biobank. Even so, you or your family will 
be able to dispose of the samples when necessary for health reasons, as long as they are still 
available.  
In any case, you (minors, through  their guardian or legal representative) can exercise their 
rights of consultation, cancellation or opposition, and also obtain information about the 
research projects in which used their samples, going to:  
Responsible for the IGTP-HUGTP Biobank file:  
Fundació Institut d’ Investigació en Ciències de la Salut Germans Trias i Pujol 
Carretera de Can Ruti. Camí de les Escoles s/n 
08916, Badalona. Espanya. 
Phone 93 497 8653/8658 
Electronic address: biobanc@igtp.cat ; igtp@igtp.cat 
 
 
The donated samples may only be used for biomedical research purposes, in studies always approved 
by the Research Ethics Committee of the HUGTP and in accordance with current laws. The samples 
are coded for their use and the associated clinical data will be guarded in accordance with current 
legislation in order to guarantee confidentiality. In the event that the samples have not been 
anonymized, only the researchers and authorized persons who guarantee their confidentiality will 
have access to the personal data. 
 
The Biobank may transfer data and samples to researchers from other centers, but always 
anonymously. The assignment must be approved by the Clinical Research Ethics Committee. 
The transfer of biological samples that you make to the Biobank is free and voluntary.

 
 
 
In some cases, genetic studies will be carried out with the samples given, from which 
information relevant to your health and that of your relatives can be obtained. In this case, we 
will contact you using the details in your clinical record. 
 
Naturally, your right to decide not to be informed of the results of the research in which your 
samples have been used will be respected. 
 
If you decide to sign this consent, you can also freely revoke it at any time by requesting it from 
the file manager of the IGTP-HUGTP Biobank or your referring doctor at the hospital. The 
revocation of consent has no negative impact on the health care you receive or could receive. 
In the event of revocation, your samples deposited in the Biobank and their associated data will 
be destroyed. In case of acceptance, they will be kept indefinitely until their termination. 
 
9. Confidencialy and Data protection   
Both the promoter and the health center will ensure that the confidentiality of your personal 
data collected during the study is maintained, in compliance with national and European data 
protection laws. For more information on the protection of personal data, see Appendix 2 to this 
document 
 
10. Contact in case of doubts 
If during your participation you have any doubts or need to obtain more information, please 
contact the study researcher at your center, at the telephone number listed at the top of this 
document.

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APPENDIX 1: DESCRIPTION OF THE STUDY 
 
Recruitment: Pregnant women attending the first visit of prenatal surveillance will be invited to 
participate according to inclusion/exclusion criteria 
Inclusion criteria (Participants should fulfil ALL these criteria)  
1. Pregnant women with a viable pregnancy confirmed by ultrasound until 11 weeks and 0 days 
of gestation (recruitment between 6-11 weeks). Their partners will be invited to participate but 
this is not mandatory for inclusion.  
2. BMI at Visit 1 between 18.5-40 kg/m²   
3. Intention to breastfeed   
4. Being able to read the language of their respective countries (Dutch/French –Belgium-, Spanish 
and/or Catalan –Spain- and Polish –Poland-)  
5. Being 18 years or older   
6. In possession of a smartphone. If participants do not have a smartphone because of socio-
economic reasons, a smartphone will be at their disposal for the whole duration of the study. 
  Exclusion criteria (If a participant fulfils ANY of the following)  
1. Unable to sign informed consent (cultural barriers, psychological conditions) 
2. Abuse of substances (alcohol, drugs) 
3. Chronic use (at least, for three months before pregnancy) of any medication that might affect 
the HP axis: 
- Antidepressants  
- Insuline 
- Levothyroxine, Methimazole, Propylthiouracil.  
- Oral corticosteroids (topical and inhalation formulations will be allowed) 
- Arginine vasopressin (AVP) 
- Mifepristone. 
- Anticortisolic drugs: Metyrapone (Metopirone), Ketokonazole, Osilodrostat (Isturisa), 
Mitotane (Lysodren), aminoglutethimide (Cytadren) and Levoketoconazole (Recorlev). 
 
4. Multiple gestation   
5. Type 1 or 2 diabetes 
 
 
 

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Randomization: Once confirmed that the pregnant woman fulfils criteria to participate in the study and 
agrees to do so by signing the Informed Consent, we will allocate her in one of the two groups (control 
vs intervention) through a randomization procedure. 
Based on randomization numbers, the allocation ratio will be 1:1 for the interventional group and the 
control group. Investigators in charge of the analysis of the data will be blinded for the condition in 
which the participants are randomized. 
There will also be an emergency unblinding module in case of any serious adverse event either by 
subject number or by group assigned. This module can only be accessed by sponsor and statistician. 
Intervention:  
A multicomponent behavioral intervention during pregnancy and up to the first 18 months after 
delivery, composed by:   
 
1. Digital tool called “Hypiend Digital Tool” aimed at promoting lifestyle habits to reduce EDC 
exposure by providing personalized recommendations 
2. Telephone monitoring 
3. Workshop about environmental health education 
 
1. Digital tool (“Hypiend Digital Tool”) 
Women will have available a mobile app developed by EURECAT and designed to limit the exposure to 
EDCs in women from pregnancy until their children are 18 months old in a personalized and gamified 
way. Content of the app is built by integrating the HAPA constructs using behaviour change techniques.  
After answering an initial questionnaire about lifestyle habits related to EDC exposure, the app will 
provide them personalized missions considering those habits with a higher risk to expose them to EDCs. 
By selecting these missions successively, they will receive frequent recommendations, tips and 
motivational quotes that will help them to accomplish the selected mission. For example, graded tasks 
will be used to increase task self-efficacy (i.e., initiate the change). Providing tools to conserve mental 
resources will be used to increase maintenance self-efficacy (i.e., once the change started and needs to 
become a habit). Action planning and problem solving will be used to help intenders become actors.  
 
 
The application has been developed with two different versions:  
- 
one for professionals/researchers and  
- 
another for participants/end users. 

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The components of this application:  
- 
Sign in up and log in 
- 
Home page 
- 
Questionnaires 
- 
Missions (only the intervention group)  
- 
Recommendations (only the intervention group) 
- 
Push notifications 
- 
Forum/chats 
 
 
 
 
 
 
 
 
 

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Components of the backoffice (exclusively for researchers):  
• 
Questionnaires that the clinician must answer with the patient 
• 
Visualization of questionnaire responses. 
• 
Forum/chat 
• 
Exportation of responses 
 
2. Telephone monitoring: To provide personalized support and feedback  
- From 6 weeks postpartum will be contacted every two months. 
- Moreover, the researchers will contact them via phone call 6 months after delivery aimed to encourage 
the adherence to the intervention and to solve potential doubts.  
- In addition, parents will be contacted to explain how they should fill out the neurodevelopment 
questionnaire, which they must send us in the coming days.  
- If a long period of inactivity is detected at any point of the study, the researchers will contact the 
families by phone. 
3. Workshops  
An interdisciplinary group of experts on EDCs (paediatric endocrinologists and environmental 
epidemiologists), psychologist expert on behaviour change, and nutritionists present in the consortium 
(University of Granada, Hospital Germans Trias i Pujol, University of Geneva, and Eurecat) will design 
and develop the content of the workshops.  

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Two onsite workshops will be conducted during the first half of pregnancy (before 20 weeks of 
gestation).  
Moreover, a third and a fourth session will be proposed to attend online at 30 weeks of gestation and 
6 weeks after delivery, respectively. They will also be recorded and sent as videos for those participants 
who did not attend. 
The workshops will be focused on four themes: 
(i) 
definition of EDCs and their adverse health effects  
(ii) 
dietary sources of EDCs,  
(iii) 
indoor air quality, and  
(iv) 
personal care products as a source of EDC exposure. 
These workshops will be imparted by experts on EDCs and by personnel of each institution that will be 
trained to give the workshop using theoretical background of the HAPA frame. After conducting each 
workshop, the key messages of the session will be sent by phone as a reminder.   
Partners will be encouraged to join women during the medical visits and the environmental health 
education workshop.   
 
CONTROL GROUP:  
The control group will only receive a digital printable booklet with information on EDC hazards and on 
strategies to limit their exposure. After finishing the intervention, the participants of the control group 
will be offered access to all the developed material (workshops…) and to use the app with all the 
functionalities. Participants from different environmental areas will be recruited to account for different 
exposures to EDCs. 
 
FOLLOW-UP AND TIMING OF VISITS 
Visit 1: On-site, First trimester, from 6 weeks to 11 weeks and 0 days of gestation.  
Visit 2: On-site, Third trimester, 28- 30-32 weeks of gestation.  
Delivery/Birth 
Visit 3: On-site, between 4th and 7th weeks after delivery. 
Visit 4: On-site, at 18 months after delivery. 
 
 
 

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Sample Collection 
 
Visit 1 
BIRTH 
Visit 3 
Visit 4 
Mother 
Blood 
Urine 
Faeces 
Blood 
Urine  
Faeces 
 
Human milk 
Blood 
Urine  
Faeces 
Baby 
 
 
Cord blood 
Faeces 
 
Urine 
 
Blood** 
Urine 
Faeces 

 
 
 
 
 
Full Protocol- Version 0.1 05/02/2025 
 
APPENDIX 2. INFORMATION ABOUT PERSONAL DATA PROTECTION 
Apx1 _PD_ceic_13/01/2021 
TITLE 
Understanding and preventing the impact of endocrine disruptors 
on the hypothalamic-pituitary axis in sensitive populations 
 
Clinical study to evaluate the effectiveness of a multicomponent 
behavioral intervention to reduce exposure to endocrine disruption 
during the perinatal period in women and their offspring. 
 
PROMOTOR 
Institute of  Research Germans Trias i Pujol (IGTP)  
PROTOCOL CODE 
HYPIEND- 101137440 
 
What data will be collected during the study and what will it be used for? 
During your participation, the following data obtained from the questionnaires you fill in will be 
collected, as well as data related to the monitoring of the pregnancy, its evolution and the 
treatment you have received that we will collect at the visits. Only the data necessary to carry 
out the study will be collected. 
The promoter will use this data exclusively to carry out the study. The promoter could also reuse 
these data for other research related to environmental exposure to endocrine disruptors under 
study, as long as they have a favorable report from an ethics committee or data protection 
expert. In this case, the researchers will contact the participants to inform them and ask for their 
permission. 
Who is responsible for the processing of your data in this study? 
In this study, both the Promoter and the health center are responsible for the treatment of 
your data. The controller's role is to ensure that your information is used correctly. The 
promoter and the center will comply with the data protection regulations: 
 
-Regulation (EU) 2016/679 of the European Parliament and of the Council of April 27, 2016 
(RGPD) relating to the protection of individuals with regard to the processing of personal data 
and the free movement of such data data 
- The Organic Law 3/2018 of December 5, on the protection of personal data and guarantee of 
digital rights (LOPDPGDD) 
 
How will your data be treated in order to maintain confidentiality? 
During your participation you will be identified by a code. The list that relates the code to the 
data that identifies it (name, surname, medical history number, etc.) will be kept in your health 
center (guarded by the research team), and will not leave it. Specific security measures will be 
adopted to prevent re-identification and access by unauthorized third parties. 
Access to your personally identifiable information will be restricted to the principal investigator 
of the study and his collaborators, to health authorities if necessary, to the Research Ethics 
Committee and to personnel authorized by the promoter, when necessary to verify the proper 
functioning of the study; but always maintaining confidentiality. Your identity could be revealed 
in exceptional cases, such as medical emergency situations for your health or legal requirement. 

 
 
 
 
 
Full Protocol- Version 0.1 05/02/2025 
 
When there is an external Sponsor at the center: Neither the investigator nor the hospital will 
transfer any information to the Sponsor that can directly identify him. The Promoter will receive 
the pseudonymized data and will not have access to the code that allows you to relate your data 
to you. 
How long will your data be kept? 
Your data will be kept only for the time necessary to carry out the project. In addition, according 
to the Data Managment Plan of this study, there is an obligation to keep all the information 
generated by this study for a period of 10 years. 
What rights do you have in relation to your data? Who can you contact? 
You can ask at any time what data is being collected, who is using it and for what purpose (right 
of access). You can request a copy of your personal data for your own use or to pass it on to 
others (portability). You can correct and delete incorrect data (right of rectification and 
deletion), limit its use or oppose it (rights of limitation and opposition). 
Some of these rights may be limited to ensure the validity of the research. You may have limited 
access to the data until the investigation is complete. If you withdraw your consent to the 
processing of the data, the data collected up to that point cannot be deleted and you may not 
be able to continue participating in the study. 
You have the right to file a claim with the Data Protection Authority for any action by the 
Promoter or the Center that you consider infringes your rights. 
If you wish, you can also contact the data protection officer (DPO) of your hospital, or the data 
protection officer of the promoter: 
Center DPO contact details: Iris Bargalló Arraut 
                                            Responsable de Protecció de Dades 
                                                          Germans Trias i Pujol Research Institute (IGTP) 
 Carretera de Can Ruti, Camí de les Escoles s/n 
                                            08916 Badalona, Barcelona, Spain 
                                            ibargallo@igtp.cat 
                                                                     
Promotor DPO contact details: Catalan Health Institute (ICS) 
dpd.ticsalutsocial@gencat.cat 
 
Will your data be shared and transferred? 
International transfers of data are not foreseen, but in the event that they occur, it will only be 
to countries that guarantee adequate compliance with data protection regulations for the 
existence of an adequacy decision or any other legally enabled mechanism. 
 
 
 
 

 
 
 
 
 
Full Protocol- Version 0.1 05/02/2025 
 
ANNEX 2:  NFO MED CONSENT FO M 
 
 
 
I, 
(First and 
Last name) 
 
        I have read the information sheet that was 
given to me. 
        I was able to ask questions about the study. 
  I have received enough information about the study. 
I have spoken to:                                                                                   (Name and surname of 
researcher) I understand that my participation is voluntary. 
I understand that I can withdraw from the study:  
      1st whenever I want 
2º without having to give explanations 
3º without this affecting my medical care. 
 
I freely give my consent to participate in the study and I give my consent for the access and 
use of my data under the conditions detailed in Appendix 1. INFORMATION ON PROTECTION 
OF PERSONAL DATA. 
Participant’s signature 
Researcher’s signature 
Date: 
Date: 
 
TITLE 
Understanding and preventing the impact of endocrine disruptors 
on the hypothalamic-pituitary axis in sensitive populations 
 
Clinical study to evaluate the effectiveness of a multicomponent 
behavioral intervention to reduce exposure to endocrine disruption 
during the perinatal period in women and their offspring. 
 
PROMOTOR 
Inés Velasco López 
Department of Obstetrics & Gynecology 
Hospital Universitari Germans Trias i Pujol 
 
PROTOCOL CODE 
HYPIEND- 101137440