BIRTHFIT Podcast Episode 98 Featuring Lily Nichols RDN, CDE
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Hello, BIRTHFIT. This is Dr. Lindsey Mathews here, your BIRTHFIT founder. Today, we have an awesome episode as usual, and it is with Lily Nichols. She’s a registered dietitian, but more importantly, she believes in real food. She just had a book come out called Real Food for Pregnancy. She’s also the author of the best-selling book Real Food for Gestational Diabetes. So check both of those out. Her latest one, Real Food for Pregnancy is just chockfull of information, and I think every woman at any stage of her life should read this book.
Before we dive in, I want to read you this little quote from her book. It says, “After all, nutrients work synergistically. Nature is not stupid and a supplement is rarely superior to what’s available in real whole foods.” Think about that. Yes, she works with supplements and people and recommendations and stuff, but her go-to is real food, and that’s where she’s going to start trying to heal from. Definitely, definitely listen to this podcast. Listen to it a few times because it has a ton of information. If you want to reach out to Lily, have any questions at all, don’t hesitate to look her up. She’s on the Internet as we all are, pilatesnutritionist.com or you can find her on Instagram @lilynichols, I believe she said RD. So check her out, follow her stuff. She’s doing great work in the world and this information needs to get out. So don’t hesitate to buy the book for somebody you know, buy a few books and give them out, hand one to your midwife or OB-GYN or whoever is in your life. This is probably the best nutrition book I’ve read for pregnancy and postpartum.
A few announcements before we dive in to all the nutrient dense information. We have BIRTHFIT Coach Seminar happening in Nashville, Tennessee, which is apparently one of the best cities in the United States. That’s what I keep hearing. That is happening April 7th and 8th. There are still I think eight spots open. So go sign up right now. I promise it will be a lot of fun. We also have a BIRTHFIT Professional Seminar this weekend. I believe they are traveling to Seattle. And then soon after that, they are traveling to Denver. So this weekend, Seattle is sold out. The next one up is Denver, Colorado and they’re actually going to be in Denver the same weekend that the coach seminar is in Nashville. That is April 7th and 8th. So be sure to attend, sign up, whatever you need to do to make the professional seminar happen for you.
Reminder, if you are thinking about applying for a BIRTHFIT Regional Director position in 2019, those applications will become available sometime around August 1st and they’ll be due between August, September, October and due by November 1st 2018 this year. You will need to have taken a BIRTHFIT seminar. It can be a BIRTHFIT Coach Seminar or it can be a BIRTHFIT Professional Seminar. So be sure you attend a BIRTHFIT seminar if you are thinking of applying to be a BIRTHFIT Regional Director.
Our BIRTHFIT summit. That is happening June 7th, 8th and 9th in Austin, Texas, which I would definitely say is the best city in the United States. Sorry Nashville. I’m just biased. But Saturday, we’ll be open to the public. We will be selling tickets for this soon. So be on the lookout, make sure you’re signed up for our newsletter because those that are signed up for the BIRTHFIT newsletter, they will hear about the public tickets going on sale first. Again, that is June 9th in Austin, Texas. Those are the major announcements I have and I really hope you enjoy this episode.
Welcome to the BIRTHFIT podcast. This is an audience of moms, dads, everybody in between. Tell everybody a little bit about who you are and where you’re living.
Lily: Sure. My name is Lily Nichols. I’m a registered dietitian and certified diabetes educator by trade. Also, Pilates instructor, which may or may not be important to our discussion, but it just adds to it. A lot of my work has been in the realm of prenatal nutrition and gestational diabetes in all sorts of different capacities. So from public policy, I worked with the state of California for their diabetes and pregnancy program for a number of years, to clinical work, to client like private practice work, to work with Pilates studios, kind of all over the map. I just keep coming back to the prenatal nutrition side of things. I just find it so fascinating how we can potentially stack the deck in our favor, change the fate of our pregnancy or risk of complications, influence our baby’s development by what we eat. That has led me to author two books now. I’m just really into the research on it and spreading the word about making pregnancy easier for mamas to get through and having healthier babies all around.
Lindsey: Wow, okay. So from your picture, you don’t look this old to have accomplished to all this. So how the heck and when did you get started on this journey of yours?
Lily: Well, I was interested in nutrition from a pretty young age. I was one of those odd people who decided as a teenager, I wanted to study nutrition and did not change my mind. I stuck with it. That made it easy. There was no mid-life career change. It has kind of always been this.
Lindsey: I think every parent would wish that for their kid, to know exactly what they want.
Lily: I was just really lucky to have parents that allowed me to explore all of those, all of those different options. I thought I would be an artist actually. I wanted to be an artist and my art teacher was pushing me to go to art school, and I felt really pulled to go to nutrition school. I did do an art minor because the amount of science that you have to go through to get a degree in nutrition is more than premed students, and I was like drowning with not using that side of my brain. There is a creative side of me in there, but I ended up coming to love the science aspect of it.
Lindsey: What school did you go to or how did that pan out?
Lily: I went to University of Massachusetts at Amherst. I grew up in LA so that was odd because I moved all the way across the country. I was pretty ready to leave the nest at that point, and I ended up being at just a great program, great school. I continued my education after that as well, but it was a good start.
Lindsey: Awesome. In the beginning, if you could remember back to either your 16-year-old self, 18-year-old self or freshman college self, what was your view on nutrition then?
Lily: It’s funny. My view on nutrition, this will sound really strange, but my view on nutrition has not gone through a complete 180. I think it does for most practitioners, particularly dieticians and the real food dieticians, the kind of ones who practice in the way that I do because most dietetics training is pretty regimented and you’re learning the US dietary guidelines. At the same time, you’re also learning how to research. So I think that’s the most beneficial part of the training by far as learning the science and learning the research so you can come to your own conclusions. But if you just take your textbooks at face value, you’re learning dietary guidelines, low fat, high carb, don’t eat much meat, eat lots of grains, low fat dairy kind of guidelines.
Lindsey: Yeah. And you’re an RD as well, right?
Lily: Yeah. So I came in to my training having — when I was in high school, actually, I already started working for a nutritionist who is more on the real food side of things. I did a lot of reading ahead of time. I had already been introduced to sort of ancestral style eating before going to school. I didn’t have the rose-colored glasses that I think a lot of students have where you think that what you’re teaching is doctrine. It’s etched in stone. I didn’t have that.
So I actually used my training to try to find the evidence to back up all these claims that I see from these other sources that are in such stark contrast to what was in my textbooks. So it’s funny, my eating habits and all of that have evolved as it has for everybody. But a lot of what I came to understand early on has held true for the more than 15 years since going through my training.
Lindsey: Wow. Were you the outcast in school or were other people kind of getting on?
Lily: Socially, no. Academically, some of my professors found me challenging because I would just choose topics to research that were a bit more controversial. I did a presentation on Splenda. That was right around the time that Splenda was really popular and conventional programs are all four artificial sweeteners or at least at the time when I was in school were really talking out against them, and I did a whole project on how Splenda is not safe because it’s a chlorocarbon, just like many other highly toxic compounds that are chlorocarbons and have these adverse effects on gut bacteria and all sorts of stuff.
So I don’t remember. I didn’t get as high of a mark on that project as I could have, but I just took every opportunity to kind of really try to research. Sometimes professors actually appreciated it. I had some fantastic ones who were really open and liked having this sort of questioning the tenet of our training discussions and other ones who were very like, “Well, that’s not what’s in the textbook. I don’t know what to make of you.” But you kind of learned to smile and nod through your training. I was very aware that my training was serving a purpose and it wasn’t the end all be all of nutrition education. So I got through it.
It was more challenging in my clinical internship, which was at a large hospital in Los Angeles. That was really challenging because you started seeing the carryover effects of poor dietary information being given out. You see people coming in for their second and third heart surgery, and they’re confused because they’re diligently eating their bran flakes and skim milk and orange juice every morning, and they don’t understand how their heart could be failing them. And I’m like, “Oh, my gosh, the information you’ve been given is so bad. And by law, I can’t give you better information.” That really killed me. Ultimately, that was what made me forge my own path and not work in that capacity in healthcare, in that setting.
Lindsey: Yeah, that had to be really hard because you basically have these tools and you want to help them and seeing it in that clinical setting, but your hands are tied. It’s like, “Ugh.”
Lily: Exactly. This is not just my struggle. Many other dieticians who kind of veer off the conventional nutrition course run into the same ethical dilemma of, “Now, what do I do? Given what I know now, what do I do with my career? Where do I practice? Do I try to change the practices where I’m at? Do I go out on my own?” It’s a struggle for sure.
Lindsey: Yeah. So how did your journey pan out in LA and then when did you move to Washington?
Lily: Well, I move all over the place with my husband’s job. He’s a pilot. That part is out of my control. But we were in LA for a number of years, and we lived in Alaska for a couple years, and now we’re in Port Angeles. So yeah, we’ve just kind of been all over the place and my business moves with me because knowing that I’d be moving, I moved it online. I do consulting and have just by default sort of fall into this author-writer role, not something I exactly imagined for myself, but here I am. It’s actually great. It’s a perfect position for me. Sometimes you have to try out a bunch of different career options and ways of working until you find something that’s a good fit. I feel like I’ve found that.
Lindsey: Yeah, it’s quite a service you have because people need this information.
Lily: Absolutely, yeah. Especially with prenatal nutrition, there’s so much conflicting information you’re given.
Lindsey: Yes, agreed. So tell me about policy here in California, share a little bit about your work on that if you can.
Lily: Sure, yeah. So I worked with the California Diabetes and Pregnancy Program, which was also called Sweet Success. At the time they were a larger organization, and California went through all sorts of budget crises, so it’s now operating at a fraction of what we used to be. But at the time, our organization did research outreach and education on gestational diabetes and any sort of diabetes in pregnancy. So women can have pre-existing type 1 or type 2 diabetes and come into pregnancy, and then their blood sugar needs to be managed.
Whereas gestational diabetes, it’s diagnosed during pregnancy. So we encompassed all of it. It’s all about blood sugar levels and pregnancy, and how that impacts a baby and translates that research into practice. Being in the state of California, well, you’re in California, so they tend to be progressive thinkers. So we’ve developed guidelines. I say we. A lot of these guidelines were in place before I came into the organization, but they had guidelines on blood sugar management in pregnancy, diagnosis, nutritional management, some of which were different than other organizations like ACOG, American College of Obstetricians and Gynecologists. So we were pretty forward-thinking and there was some offshoot of Sweet Success programs that did training in other parts of the country as well. But the state of California really followed more closely what the rest of the globe is doing in terms of gestational diabetes and was really looking at research outcomes. If by diagnosing differently, do we get better outcomes? If we have different glycemic targets, do we get better outcomes? It was a great organization to work with.
Lindsey: Yeah, it sounds pretty fascinating. Gestational diabetes is a big fear of women especially. Well, I hear it on the end of these women that are eating real food diets and they’re scared to take their glucose test or be diagnosed with gestational diabetes. Can you define gestational diabetes for people and maybe what a traditional test looks like for people or for pregnant women?
Lily: Sure, yeah. Gestational diabetes is a type of diabetes or high blood sugar that is either first recognized or first develops during pregnancy, which can mean two different things. It can mean that your blood sugar is high as a result of pregnancy, and it was not high before pregnancy, or it can mean that maybe there was some subtle blood sugar issues going on before pregnancy that were not diagnosed until you were pregnant and they checked for it. It could be two different things.
We’re seeing these days, there’s quite a high number of people coming into pregnancy with some level of prediabetes, some level of imbalanced blood sugar, insulin resistance that then progressively gets worse over the course of pregnancy as a result of all the physiological changes that naturally happen in pregnancy. Your placental hormones increase, insulin resistance. You gain weight, which increases insulin resistance. There’s a ton of other hormones going on that that can affect your blood sugar balance.
Essentially, yeah, it’s a high blood sugar beyond a certain threshold. People get all up in arms about the diagnostic standards and I’m one of those. I have a whole section in my new book about the diagnostic tests and which ones make sense in the context of what’s going on with an individual woman. However, most clinical guidelines are pretty cut and dry about how to do, how to diagnose it.
And most organizations follow a Glucola or a glucose tolerance test where a woman drinks a specified amount of glucose, which is the type of sugar in solution. So it’s water flavors and sometimes food dyes and all that stuff. And you measure your blood sugar at different intervals after, sometimes before and then always after drinking it. And if you’re beyond a certain threshold, then you may get diagnosed with gestational diabetes. So there are other methods and we can go into that if you want. It’s like a three-hour conversation.
Lindsey: So quick pause or to derail just a sec, what if there’s false positives for that test? What’s the percentage of somebody getting diagnosed with gestational diabetes doing the Glocula test and then maybe the test is not so accurate? Or is that a possibility?
Lily: That is a possibility and I haven’t been able to find hardcore statistics on it because I don’t think the test–
Lindsey: They would test that.
Lily: I don’t think the people who are researching the tests want to admit that false positives are an issue. But to give you an example, we’ve known since at least the 1960s in medical literature that people who are eating a lower carbohydrate diet often fail a glucose tolerance test. And then you have them carb load for a week or so and then give them a glucose tolerance test again and they pass.
We’ve also had the same data shown in horses. So you feed horses their natural diet, which is grazing in grass and alfalfa and stuff, or you supplement their diet with the twice daily grain ration. The horses that are grazing fail a glucose tolerance test. The study I’m referring to is in pregnant horses. And the horses that are fed a grain supplement pass the glucose tolerance test.
So there is some level of adaptability of the pancreas where if your body is exposed to higher levels of carbohydrates and your blood sugar is higher, assuming your pancreas has the capacity to secrete enough insulin, which is another issue, you often will have a different result on the glucose tolerance test based on what your standard diet is.
I was one of those people. Well, it depends on how you do a glucose tolerance test. But anyways, I was at a place that did a two-step method where they give you a smaller amount of glucose, a 50-gram test. And if you failed that, they want you to take a second test with a larger amount of glucose. I failed the first one by a point, but I still failed it and I didn’t want to drink the second one.
So I tested my blood sugar at home and I have the data. So I know what average blood sugar levels are in pregnancy, and they’re actually about 20% lower than outside of pregnancy by the way. But it could compare my numbers to what the normal ones are and what the gestational diabetes targets are, and mine were well within the normal limits and nowhere close to gestational diabetic levels.
Needless to say, if I had taken 100-gram test, if I would have passed or failed that, but I was definitely an example of somebody who because I don’t eat a massive quantity of carbohydrates, my pancreas is not accustomed to producing enough insulin to digest 50 grams of pure sugar all at once or can take 50 grams of sugar out of my blood stream quickly because it’s used to seeing maybe 10, 20 grams of carbohydrates at a time, not 50. So it’s challenging. At the same time, the glucose tolerance test can miss people, give false negatives. I had some people who barely pass the glucose tolerance test or maybe they have one level that’s over just by a smidgeon, like one point and their doctors like, “I don’t really know what to do with you. Here, test your blood sugar for a bit to see what’s happening.”
I’ve had some people who end up needing super high dose insulin and they were almost missed by the glucose tolerance test. Their body has high levels of insulin resistance, but they’re producing massive quantities of insulin. So it goes both ways. There’s not a perfect test, and I think the glucose tolerance test is one of many that we should consider for screening methods. I don’t think it’s necessarily right for every woman.
Lindsey: What are some other ways? Because you just said there’s not a perfect test. So it’s like, “What can they do?”
Lily: Well, one of the things that the state of California recommended in the Sweet Success program was measuring a first trimester hemoglobin A1c, which is a measure of your average blood sugar over the past approximately two to three months. This is a non-invasive test. It is not done fasting. It’s just with a regular blood draw. They can do it with your first trimester prenatal labs. It’s like a check in the box in the lab strip, in the lab test requisition form, and it doesn’t cost a whole lot of money, totally noninvasive.
They’ve shown that A1c in the prediabetic levels, the likelihood that a woman will then go on to fail a glucose tolerance test is something like 98%. Those are the cases where we’re diagnosing, essentially, it’s prediabetes, like outside of pregnancy prediabetes, but we know that your blood sugar is probably not going to improve over the course of pregnancy. Probably going to get worse to the point that it’s at a level that we can officially diagnose you with gestational diabetes.
In that program, we would diagnose early. If your A1c was 5.7 or higher, you were labeled as gestational diabetic. You monitored your blood sugar your whole pregnancy. Actually, in the practice, we had fantastic outcomes. So most of the women didn’t require insulin or medication mostly because they were getting my advice, which was more whole food and not as high in carbs is the conventional diet, and excellent outcomes. It’s not a perfect method because it does miss some people as well. However, it is a good screening option to throw in in the first trimester. And then if you do get a positive, you have two-thirds of your pregnancy now to prioritize this versus being completely in the dark until your third trimester and then waiting for your lab result come in. And then if you’re at a place that’s doing the two-step Glucola, okay now you come in for the next one, okay now you have to wait for the dietitian and diabetes educator. Unlike the time in your first test and diagnosis can be a month and then how much is left of your pregnancy. So it’s really optimal to diagnose.
Lindsey: Yeah. It sounds like the first trimester option is a bit better.
Lily: It’s a way to stratify risk. As I said, some people will go on to run into issues later, even if their A1c is low. So you have to plan for what are you going to do in that 24 to 28-week time when you’re typically going to have a glucose tolerance test. Do you want to do it or do you want to do an alternative? My preferred alternative would be testing your blood sugar at home for two weeks four times a day and see where your levels are at.
Lindsey: Got it.
Lily: Yeah, yeah.
Lindsey: Four times a day, finger pricking?
Lily: Yeah. So it’s just a glucometer and a finger prick and you test you blood sugar at fasting and then after meals. And then you can compare them to the average blood sugar that most pregnant women have and the gestational diabetes targets and see where you’re at.
Lindsey: Yeah. Can any person test their blood sugar at home like that these days or do they still have to get a recommendation from a doctor, anybody?
Lily: Yeah. You can purchase, anybody can purchase a glucometer and test trips over the counter or from Amazon on your own.
Lindsey: That what I was thinking.
Lily: The test trips can be expensive. Some of them are more than a dollar a pop and so a lot of people are resistant to doing that. Some insurance companies will cover it. I was able to get at least a portion of it covered during my pregnancy. So it didn’t end up costing all that much out of pocket, maybe 50 bucks for the meter and all the test strips that I needed. It was no big deal. If you’re purchasing completely over the counter outside of insurance, it can be a little more.
But as far as thinking of it as your — I don’t want to use the word insurance again, can I just use it in terms of an insurance company. But you kind of are. It’s sort of an insurance policy that your blood sugars are at a safe level and learning how your body responds to different foods. It gives you more valuable, real world information. It just is a commitment just to do that. It’s annoying. It takes time. And so some people opt not to do that and would prefer to just go in for a Glucola. And that’s great. That’s an option too.
Lindsey: Yeah. Okay. When somebody is diagnosed with gestational diabetes, your first go-to is to say eat real food, correct?
Lindsey: Yeah. How does that pan out?
Lily: Well, I’d say eat real food and become aware of which foods raise your blood sugar. So a large part of my help for clients and what I discuss in my first book Real Food for Gestational Diabetes is how to classify which foods raise your blood sugar a lot. Those are mostly the ones that contain carbohydrates and which ones don’t. So you know what you need to limit because the challenge is that a lot of people are diagnosed and then they can feel like everything is going to raise their blood sugar and they end up kind of knocking on everything and starving themselves. A, it’s not ideal to be nutrient deprived, nor is it good to be super hungry and starved, but it also is not really working in your favor because it’s completely unsustainable to not be eating enough for yourself and eating enough for your babies. So I focus heavily on helping people understand what raises their blood sugar and what doesn’t. That gives them a framework. And then in the process of testing your blood sugar after eating, you’ll be able to see which combinations and which amounts of food can raise your blood sugar or results in really excellent right in the normal range blood sugar levels.
From there, you can figure out what your carbohydrate tolerance is and what you can get away with or not, but also prioritizing the nutrient dense foods that on a physiological level play a role in your blood sugar management as well, like magnesium helps with insulin resistance for example. So there’s all sorts of micronutrients in real food that help.
Lindsey: So if somebody is listening to this and they’re trying to conceive or preparing to conceive, could they do the same thing? Like figure out what foods work for them and not using the at home test kit?
Lily: Yeah. Glucometers, there’s a lot of people using glucometers who don’t have any known blood sugar issues, no diabetes or anything. You can often correlate your blood sugar response to your energy levels. It’s a really valuable tool for sure. In fact, we now have some research showing that elevated blood sugar in the first trimester, so this would be something you would not necessarily catch in prenatal screening because it may be happening if you don’t even see any sort of healthcare provider.
But elevated blood sugar in the first trimester is link to a higher risk of both neural tube defects and congenital heart defects. This has been observed in blood sugar levels that are below the diagnostic threshold for diabetes. Blood sugar is like our bodies work really, really, really hard to try to keep our blood sugar well controlled. Unfortunately, the state we’re in right now, around half of Americans, and this is the latest journal The American Medical Association Statistics, around half of Americans have either prediabetes or another form of diabetes, most of whom are undiagnosed. So if half of women are coming into pregnancy with maybe not really high blood sugar, but suboptimal blood sugar, that’s a very big concern. So yeah, it would be uber proactive and amazing if everybody was aware of where their blood sugar was at before they got pregnant or during their pregnancy for sure.
Lindsey: That’s brilliant. I hope everybody that’s listening is going to order some kits off Amazon.
Lindsey: So I started reading your book. It’s pretty awesome. If you don’t have it, Real Food for Pregnancy, I highly recommend you get it. I love your definition of real food. Can you share that?
Lindsey: What real food is to you?
Lily: Yeah. So I have a couple different ways of describing it because I feel like so many — you can go online and everybody has a different definition of real food. So you go to a blog that says real food and you look at the recipes and you’re like, “Wait, what? Is that real food? I don’t know what’s going on.” So I like the term, but it does need a definition. So for me, real food is as close to its source as possible and grown or raised in conditions that maximizes the nutritional content.
So for example, if you’re purchasing vegetables, buying ones that are in season, eating them relatively soon after harvest and having vegetables that are grown without pesticides, those are going to be more nutritious than a canned version or a processed one or something that sat on the shelf for a really long time. Real food is also minimally processed. So it peers closer to it would as you’d find it in nature.
I’ll give two examples for this. For dairy products, for example, how do you get milk from a cow? What does it come? Does it come out skim? No, dairy comes with that. Cows are meant to graze on grass and the nutritional content of grass-fed milk versus milk from cows raised in confinement, fed corn and soy is different. So we need to take that into consideration.
Same goes for chicken. If you were thinking of it in ancestral terms, if you hunted a bird, chicken is a bad example because they’re mostly domesticated, but you got a duck or you got a buffalo or something, you would eat all parts of the animal. You wouldn’t just eat the buffalo steak that’s lean and cut all the fat off. You wouldn’t eat just chicken breast. You would eat the chicken breast with the skin and you’d eat the wings with the skin and you’d use the bones to make stock. You’d use all parts of the animal, you’d use the organs. In doing so, you actually get a lot of nutrients that your body needs particularly in pregnancy.
Those are probably the two most important definitions. And then because most of us don’t eat entirely wild-caught hunting foods and right from the garden, when you are buying things that have a label, generally the ingredients should be really simple, without a whole lot of additives or complicated words, which usually means that’s some sort of additive or preservatives or something that’s not adding to the nutritional value.
Lindsey: That’s awesome. I’m really into those definitions. Yeah. Okay. And then you also get into, which I love this, you talk about eating for two. You say eating for two is not even for two, but eating more for 1.1, which is hilarious because I have a good friend from college and she got pregnant. It was right after college, I think. She basically was like, “Yeah, now I can eat for two.” That has stuck with me for the last freaking 16 years. I’m like, no, you cannot do that. Even then before I knew what I know now, I knew that that just sat like not good with me. But yeah, can you expand on that?
Lily: Absolutely, yeah. I feel like this eating for two thing is just misinterpreted. It’s not necessarily bad information in the context that pregnant women do need more nutrients for their baby, but they don’t necessarily need double the quantity of food in order to achieve that because you actually don’t need that many more calories to meet your nutrient needs. You just need to be eating more nutrient-dense foods, like your needs for vitamin A and folate and B-12 and choline and iron and on and on. A lot of different nutrient needs increase where your overall calorie needs may only increase by around 300 calories a day. That’s from pre-pregnancy to third trimester. So you don’t need double the quantity, if you need to double the quantity, pregnant women would be eating upwards of 4000 or more calories per day.
That’s just not the case. Your body is smarter than that and our physiology adapts that you don’t need a massive quantity of foods. What I like to reframe it as is that you want to try to maximize the nutritional value of the food that you’re getting. So if you know that all of these nutrient needs have increased, how are you going to meet that? And ideally, how are you going to meet that as much as possible from food? Because food has a synergistic balance of nutrients, like the choline in an egg yolk helps enhance the amount of DHA and important omega-3 fat that’s important for brain development. That enhances how much of that is absorbed and incorporated into your baby’s brain. That’s cool and you don’t necessarily get that if you’re doing all of your nutrients separate.
There are many, many more examples of this. Vegetables are a good example, like beta-carotene or some of the antioxidants in vegetables have been shown to be better absorbed when you eat them with a source of fat. So having a salad that’s dry is nutritionally inferior to having a salad that you dress with some olive oil, have some avocado or have a hard-boiled egg with it or have some nuts on it. These things work in concert. So I really emphasize as much as possible getting nutrients through food and just maximizing the nutrient density of your diet.
Lindsey: Yeah. Amen to that, for sure. Nutrients for pregnancy, you say increase in nutrients, more nutrient-dense food. Are there certain things like, you mentioned choline and maybe folate, that oftentimes pregnant women are missing or that they should concentrate on or anything like that?
Lily: Absolutely. Choline is an excellent example, and I will talk about it for a little bit.
Lindsey: Yeah, go for it.
Lily: Because I feel like it doesn’t get air time. We didn’t even have a recommended intake for choline until 1998. That’s only 20 years ago. If it had been identified when all the rest of the vitamins were identified, which was in the early 1900s, it would be vitamin B so and so number, not choline, because it does work right in concert with vitamin B12 and folate. It plays a role in preventing neural tube defects and it has been shown to improve brain development in infants. Some others who have higher intakes of choline, their babies have quicker reaction time across the board at all time points that they’ve been studied, lower placental inflammation and a less lower risk for preeclampsia as well. So choline is very important. Currently, only less than 6% of women meet the recommended intake for choline.
Lindsey: Six percent.
Lily: Six percent.
Lily: It’s a major problem because it is not included in many prenatal vitamins, and a lot of people think they’ll just get everything in their prenatal, but choline is a very bulky nutrient. It takes up a lot of space physically, and so you’d have to have a prenatal vitamin that has many, many capsules per day to fit choline in there. Physically, it’s just not in there because nobody wants to buy prenatal that has a bunch of capsules, even though often that’s kind of required. The best sources of choline also are foods that are often discouraged or maybe even off limits entirely. So the top two food sources of choline are egg yolks and liver.
Lindsey: Oh, I love those.
Lily: That’s fantastic. Most people are not super into liver. That’s probably the most nutrient-dense food, one of the most nutrient-dense foods on the planet. An ounce of liver has 115 or so milligrams of choline, which is equivalent to the amount in one egg. The low minimum bar for choline is 450 milligrams per day in pregnancy.
Lindsey: Oh, my gosh.
Lily: Although there’s research showing that we probably need more double that, but still, if you hit 450, we’re in good territory.
Lindsey: You’re ahead of the game.
Lily: Only 6% are getting there. Yeah. So if you have been steered away from eating liver for mostly unfounded reasons as I go into in the book or maybe you’re a type of person who only likes your eggs over easy and you’ve been told you can’t have eggs with runny yolks, then the side effect is you’re just not getting as much choline.
Lindsey: You’re missing out on the gains.
Lily: Yeah. Among people who eat eggs, they have double the intakes of choline on average compared to people who don’t eat eggs. Our next best food sources only have maybe 30 milligrams or so per serving, so peanut butter, almonds, cauliflower, broccoli. Some of the cruciferous vegetables have a decent amount. That’s like maybe 30 milligrams of choline.
Lindsey: Compared to liver.
Lily: Like half cup of broccoli. So unless you’re eating pounds of broccoli per day, it’s just very, very hard to meet mostly if you’re not eating eggs, because I know a vast majority of people don’t eat liver. It’s a big issue. It’s a big concern.
Lindsey: I’m glad you went off on some choline information.
Lily: Oh, yeah. I think I have a lot of joy going into all the little nitty-gritty rabbit holes. There’s so much information out there if we’re just willing to look. In an ideal world, we would see that prenatal guidelines would highly encourage consumption so that we could be helping pregnant women meet their needs of this nutrient. Also, it’s just a good idea to have enough protein foods in general. There was a study out in 2015, which, by the way, was the first ever to directly estimate protein requirements in pregnant women.
Lily: Yeah. Pretty much all of the guidelines on pregnancy, the requirements are based on data from them and then they’re adjusted via mathematical estimates to meet the needs of pregnant women and the fetus.
Lindsey: Oh, my gosh.
Lily: They actually directly estimated the needs. They found that protein requirements are higher during pregnancy than they thought. In early pregnancy, protein requirements are 39% higher. In late pregnancy, protein requirement are 73% higher than estimated. So eating something like eggs, it’s two birds with one stone sort of situation. You’re better meeting your protein needs, you’re meeting your choline needs. If you’re getting your eggs from pasture-raised chickens, you’re going to be getting a pretty decent source of DHA for your baby’s brain development. You’re getting B12. You’re getting all sorts of good stuff that you wouldn’t be getting otherwise if you’d been steered away from them.
Lindsey: Yeah. My research is nothing compared to what your research has been, but just glancing at different cultures around the world, they save or they recommend eggs and organ meats and stuff like that for women that are going through pregnancy or breastfeeding at any point of that timeline.
Lily: Yeah, absolutely. Yeah. There were certain, like the work of Dr. Weston Price from the early 1900s found that there were a number of cultures. So he traveled the globe looking at mostly dental health because he was a dentist, but also looking at disease risks and people following their traditional diets and those that had stopped following their traditional diet and incorporated more. He called them foods of modern commerce, but processed foods, refined grains and more sugar and stuff like that.
There were many different cultures in which there is a special diet provided to women planning to conceive, during pregnancy and breastfeeding, and sometimes offered to or required of a couple before they were married under the guise that when you were married, then you’re going to have children. A lot of times, the foods that were highly encouraged where seafoods, eggs, certain animal foods, especially organ meats. It varied depending on the culture, but there was a pretty heavy emphasis. A lot of it was fatty animal foods in one form or another.
It makes perfect sense when you start going to the literature and looking at what are our requirements for these nutrients during pregnancy or even during breastfeeding. The levels of nutrients in breast milk based on a mother’s intake, that is shied away from, people don’t like talking about it because we don’t want to discourage women from breastfeeding because it can’t feel like, “Oh my gosh.” I don’t want to have to get like, “Perfect for you. Eat a special diet in order to make good milk.” You always make good milk. There is data that shows that the nutrient levels in your breast milk are reflective of your dietary intake as well.
So it’s something to think about, not to dwell upon and make something your decision. But to think about as part of your self-care as a mother, whether you’re pregnant or breastfeeding is nourishing yourself. A side effect of nourishing yourself is how well your baby is nourished as well. So the more we can educate women on what these foods are and make it realistic for them to build it into their world, the better they’re going to heal postpartum. I mean you know with your work better than those people how important it is to say like you need to be smart about how you’re moving your body and all of those things during this special period of time. I tend to focus more on the food stuff, but it’s all related.
Lindsey: It’s all connected.
Lily: Yeah. I wish there was more of an open discussion about it because it’s like you get pregnant and people are like you finally have a culturally acceptable time for you to gain weight, which for some people translates into, “Well, I don’t need to be worried about what I eat anymore,” or just the whole craziness of postpartum, which I know. I have a two-year-old, so I completely understand just all of the nonsense.
Lindsey: The postpartum. Yeah.
Lily: Thinking of the baby and how overwhelming and exhausting and all-consuming it is. Sometimes you don’t have the time or energy or wherewithal to eat healthy foods and unless you have family members or help or friends that are willing to deal with that. Again, bringing this into more of an everybody needs to be aware of the stuff kind of a conversation, then you’re just not going to be eating as well out of default. It’s hard. You can’t do it alone.
Lindsey: You can’t, yeah. One of the things like at our seminars we like to tell people is hey, if you own a gym or a business, definitely help a mom or a new family out with some nutrient-dense foods so they can put them in the freezer and they can eat that after baby comes. Then it’s not like ordering takeout every night.
Lily: Oh, absolutely. Yeah, that’s like there’s no chance you’re going to be cooking any time soon.
Lily: You need at least a couple of weeks out of the kitchen, out of the housework thing. Traditional cultures value that. You look across the globe and almost universally there’s this special between one-month to six-week, oftentimes 40-day period where a new mother is mothered for a period of time. And it’s often by her mother or her mother-in-law or some other family member, maybe an aunt or something. All of your food is cooked for you. All of your cleaning is done for you, really, all that you are expected to do. Or sometimes they have very strict rules, and all that you’re allowed to do is to nurse your baby and rest and recover and there are no other expectations. It’s challenging because I’m a working mom myself, but our whole expectation that women should just revert to pre-pregnancy state immediately is so ludicrous. I could cry.
Lindsey: Yeah, it’s wild.
Lily: That’s not the case. You need a period of time to recover and recuperate and adjust to life as a mom. A big part of that is just getting your nutrients. That happens with help, I’m all about that. I actually included a kind of lengthy chapter all in the fourth trimester postpartum period in the book talking about all these topics because I started writing this when my son was ten months old, so I was in the peak of that.
Lindsey: You’re fresh. Yeah.
Lily: It was fresh. It was top of mind. Sometimes I’ll go back and read that chapter and I’m like, “Man, that’s so on point.” If was writing this now, I would have written it differently, and how good that it was that I tackled that when I was still in that readjustment period.
Lindsey: Okay. I’m not going to take up too much more of your time, but I do have a few questions from people and they’re kind of random. I’ll get through whatever we can get through. First question, what supplements should a pregnant woman take?
Lily: Okay. This might be a long conversation.
Lindsey: That’s why I asked that one first.
Lily: I will give you a quick rundown and if you want me to expand upon any of them and why. I’m just such a person that loves to go into the why, so I know this could be an hour, so I will cut it short.
Lindsey: Or you could just tell them to book an appointment with you.
Lily: There’s that or just by the book because it discusses everything. Prenatal vitamins for the vast majority of women I think are a good idea. I do think you should be choosy about which one that you pick. I cover that in the book. Vitamin D for the vast majority of women beyond what’s in your prenatal is necessary to keep your vitamin D levels at adequate amounts. An omega-3 supplements such as a fish oil or an algae-based DHA is important. And then from there on, virtually everything else is optional, depending on what’s going on with your health.
Probiotics, if you don’t get much fermented foods and if there’s any sorts of dysbiosis, so imbalance in your gut microbiome, or if you’re prone vaginal infections, or if you’re tested positive for GBS in the past. Probiotics, good stuff, fermented foods, good stuff. Magnesium for many women is helpful. If you test low in iron and you’re anemic, an iron supplement. I do try to help women meet that through food as much as possible. It’s far better absorbed and has none of the side effects that most iron supplements have. But if you do require an iron supplement, I talked about the best absorbed one, the one that gives you the least issues.
And then probably the last one that’s worth mentioning is a gelatin or collagen supplement. These have become really popular, like collagen peptides in your coffee or whatever. These provide an amino acid that becomes what’s called conditionally essential during pregnancy, meaning you have to get enough from your diet during pregnancy. Outside of pregnancy, your body can make enough of this amino acid just from other protein foods that you’re eating. But in pregnancy, you directly require it. The amino acid is called glycine and it plays a very important role in your baby’s skeletal development, organ development, skin, the transfer of and creation of new DNA. And then also in your own stretching skin and connective tissues and growing uterus, you just require a lot of this.
The main places you get it are bone skin and connective tissue of animal foods. So you’d get it in bone broth, you’d get it if you’re eating chicken wings and you’re eating the skin with it. If you like pork rinds or cracklings, you get it in that. If you like pulled pork, then you make sure to also eat all the yummy juices that come with it. You get a lot in that. If you are not a person who eats much of those foods or you don’t like them or whatever or just want a little extra insurance policy, gelatin and collagen protein is a fantastic addition.
Lindsey: Cool. Can you elaborate a little bit on omegas and fish oils and why they’re special for pregnancy?
Lily: Omega-3 fats, there are different forms of omega-3 fats. One of the kinds that’s found in animal foods is called DHA. DHA is something that is incorporated into the brain and eyes of a developing baby. It assists in the formation of neurons, so your brain cells, and it also protects against inflammation and damage. Your baby accumulates a lot of DHA over the course of the pregnancy, particularly in the last trimester. And then it’s known to be important for brain development up until two years of age.
If you’ve ever heard the term first 1000 days, there’s like this special window of development from conception to about two years of age where DHA and several other nutrients are very, very important for a child’s long-term brain development. With DHA, like I mentioned, it’s mostly in fish oil and animal foods. So fatty fish, eggs from pasture-raised chickens, dairy from grass-fed cows, grass-fed beef. They actually get it a lot from eating other little bugs and insects and things, but also the grasses, their bodies can convert it. Humans don’t have the ability to make much DHA from plant foods, so some people like to try to take flaxseed oil or eat a lot of walnuts or one of those things to try to meet their DHA needs. It doesn’t work because they don’t contain DHA and the converse rate of DHA is like around 3%. It’s just not enough to meet your needs directly.
So definitely a fish oil or if you don’t do that, the one vegan source of DHA is an algae-based DHA supplement. Either one of those options would be great. That’s in lieu of people eating a good amount of fish per week. If you eat 12 to 16 ounces of fatty fish per week, you may not require a separate supplement. I think the vast majority of people don’t do that. As an insurance policy, it’s not a bad idea to take an extra supplement. There are some pretty good studies showing that slightly higher quantities of DHA are advantageous to pregnancy outcomes and the baby’s development. So I’m a fan of supplementation for most people.
Lindsey: Cool. That was great. What about coffee? Can I still drink coffee during pregnancy?
Lily: Yeah, that’s a good question. Usually, the concern with coffee is that it contains caffeine and there’s mixed data, to be honest, on caffeine in pregnancy. I went through a bunch of different studies, including big review articles of all the existing evidence and whatnot, and essentially they cannot find a solid evidence to suggest or limits on caffeine in pregnancy should be changed from what they are.
The general guideline of where to limit your caffeine is about 200 milligrams per day. To put it into perspective, into food terms, about eight ounces of coffee has 100 milligrams of caffeine, although it will depend on how strong you like your coffee. Most people also drink more than eight ounces. It’s also just like a really tiny amount. If you’re using a regular person’s mug, it’s like usually 12 ounces or more. So keep that into perspective. Your other sources of caffeine would be tea and chocolate. And tea, like eight ounces of tea has roughly 30 milligrams. It’s going to be hard to exceed caffeine limit if you’re just a tea drinker and not a coffee drinker. Chocolate doesn’t have a huge amount. About an ounce of dark chocolate has 20 to 30 milligrams. So not a ton. That’s really dark chocolate. So with coffee, the end result is limit yourself to around 16 ounces of coffee a day. If you like it really, really strong, maybe err on less. And if you like it weaker, maybe you have a little more wiggle room.
Lindsey: Love it. All right. This will be the last question which may be talking about herbs. Are there any that you love during pregnancy or postpartum? Any contraindications? I guess they’re asking about big contraindications for sure.
Lily: Yeah. Herbs are a super complicated topic in pregnancy because there’s so little hardcore data on it, which puts you — as a person who loves evidence-based stuff and having studies to back up what I’m saying, it’s really hard to give solid recommendations on herbs.
Lindsey: That’s probably why she was asking.
Lily: Yes. I will say that there are some herbs, probably the one herb that’s universally hailed as being safe and useful in pregnancy, both by conventional and non-conventional practitioners is ginger. Ginger is fantastic for nausea. So if you’re in that boat, definitely consider ginger, maybe in a tea or crystallized ginger or a gender supplement in a capsule or something or tincture, that would be fine.
The other herb that is pretty commonly used in pregnancy, which doesn’t seem to have many or any contraindications, is red raspberry leaf. So this is often used in the second or third trimester and it’s believed to help strengthen or tone the uterus or soften the cervix to help with labor, to make labor easier. There’s other theories on how and why it works. There are some studies showing that it can help relax uterine muscles, so that’s possible it works. We don’t know the full mechanism of action, but it’s pretty benign. It’s literally the leaves of a raspberry plant. It has a pretty mild flavor and lots of women enjoy several cups of red raspberry leaf tea in the latter half of pregnancy. There has been almost zero reports of adverse effects with that. Those are the two that I tend to go to.
During breastfeeding, the safety of herbs, you have a little more wiggle room. So you don’t have a baby and you and not everything is transferred in your milk and yada, yada, yada. So if you are thinking of taking herbs in pregnancy or postpartum, I cover the topic in the book. The postpartum one has more herbs discussed because there’s more to talk about, there’s more available. I also like to refer people to Aviva Romm’s work. She’s an herbalist, midwife and OB-GYN. She’s written textbooks on herbs for use in women.
Lindsey: What’s her name again?
Lily: Aviva Romm.
Lindsey: Got it.
Lily: She has some really great information as well. So I check her stuff out.
Lindsey: Cool. Okay. Now, I won’t take up any more of your time because I could sit and ask you questions forever. But seriously, if you all don’t have her book, go get it. There’s tons of information. Like you were saying, there’s stuff on herbs. There’s stuff on nutrients and carbs, proteins, everything.
Lily: I’m holding a copy in my hand because I’m about to send out some copies to advanced reviewers of my book, and it turned into a giant monster. It’s over 300 pages. When I had it first formatted, the way that we had the line spacing and the font size, it was like 450 pages. I was like, “This is not okay. We need to make this shorter.” We made the 50 pages of references into 30 pages of references, and it’s super tiny font because it was just so overwhelming. There’s 934 citations. There’s just a lot of information. I’m not a person who likes to just throw in fluff just for the point of sounding good. I feel like almost every sentence has a citation behind it because if I’m going to write it, it has to be useful. Yeah, it’s an extreme amount of information.
Lindsey: It’s legit, for sure. Awesome. Where can people find you at on the Internet or Instagram or anything like that?
Lily: Yeah. You can find me on my main website pilatesnutritionist.com. You can learn more about the book at realfoodforpregnancy.com. Over there, I also give away the first chapter for free. So if you’re intrigued but not quite sure you want to buy, check that out. People are having a pretty good response to it. I have a comparison on the nutritional content of a conventional prenatal diet to a real food one. You can see in black and white which one wins out and why I decided to write a book on this. So check that out. And then in terms of social media, I’m on Facebook, Instagram and Twitter. My Twitter and Instagram are @lilynicholsrdn. I’m on Facebook as Lily Nichols Pilates Nutritionist.
Lindsey: Nice. Thank you so much for hanging out for like an hour now. That’s crazy. Is there anything that I missed or anything else you want to share for women going through the motherhood transition?
Lily: I would just say that if you have been given a pamphlet of nutrition advice, most likely a pregnancy pamphlet, you’re usually not given postpartum. Know that there’s way, way, way more to the story than what’s on that little sheet of paper. And so if it doesn’t sit right with you and you’re wondering like, “Whoa, do I really have to do a complete dietary overhaul and avoid all these foods or eat all these fortified grains or whatever the advice you’re seeing on that pamphlet?” No, there’s a whole another school with that and a whole lot of data to back up the benefits of eating real food. So if that’s where you tend to go, I gathered the data for you and put it all in one place.
Lindsey: That’s awesome.
Lily: You can share it with your provider if they’re open to it or are wondering, “How in the world are you so healthy during this pregnancy? What are you doing?” “Here, read this book. This is what I did.”
Lindsey: Yeah. Oh, that’s awesome. Thank you so much, Lily. You’re amazing and I’m so glad you’re doing the work you’re doing in this world.
Lily: Thank you so much. Right back at you.
Lindsey: All right. I’ll talk to you soon, and I’ll definitely let you know when this comes out.
Lily: Thank you so much.
Lindsey: All right, bye.
Lily: All right, bye.
Lindsey: All right, BIRTHFIT. Recap, listen to the episode again. But in all seriousness, you probably need to because there’s a ton of information. I know I’ve told you this like five times throughout the episode. Buy the book. On the back of the book, you all may have heard of a guy named Robb Wolf. He gives her a little testimonial and it says, “No one has dissected the research on prenatal nutrition and done so in the context of ancestral diets to the depth that Lily Nichols has in Real Food for Pregnancy. If you want an evidence-based rebuttal to the outdated prenatal nutrition guidelines, look no further.” Dude, that’s a huge testimonial and well done, Lily. So go buy the book, get this information out there, buy an extra copy, hand it to somebody you love. This episode was amazing. Thank you, Lily.
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