Lily Nichols transcript

Written by Christopher Kelly

June 2, 2015


Julie:    Hello, everyone, and welcome to the Paleo Baby Podcast. I'm Julie Kelly. Today, I am joined by my husband, Chris Kelly.

Christopher:    Hi.

Julie:    And we're also joined by our guest, Lily Nichols, who is an RDN, a CDE and a CLT. She is the author of the book Real Food for Gestational Diabetes: An Effective Alternative to the Conventional Nutritional Approach. She is also a LEAP therapist and a certified Pilates instructor whose approach to nutrition embraces real food, integrative medicine and mindfulness. She helps people with digestive issues heal from food sensitivities and helps pregnant women with gestational diabetes. Hi, Lily, and thank you so much for joining us today.

Lily:    Thanks so much for having me, Chris and Kelly.

Julie:    Chris and Julie. That's a good one. I have never been called Kelly more times in my life, than having the last name Kelly. It happens all the time. I'm going to start answering to it. I'm really excited to have you here because I think you can speak to a lot of things that a lot of our audience is interested in. And I think gestational diabetes is a great jumping off point for a lot of the conversations that people want to have about nutrition and pregnancy, about low carb diets, about ketosis, and all those things.

    Because you work with a lot of women in this, I think we can get a lot of practical examples and advice out of it for women who are pregnant, thinking about getting pregnant, have been pregnant in the past, might want to be pregnant again in the future. And then just in general, I mean, people who aren't pregnant and want to approach their diet in a slightly different way. We're really excited to talk to you.

Christopher:    Definitely. I should mention, before we go any further, the Robb Wolf Podcast, which is what prompted me to contact Lily, which is a fantastic interview. Why don't you start by just introducing yourself, like giving us a bit of your background and explaining how our low carbohydrate approach can be a good one for women who are pregnant?

Lily:    Sure. Well, fairly early in my career, I worked with the Sweet Success program also called the California Diabetes in Pregnancy Program, which focuses specifically on gestational diabetes. A lot of the other states in the US actually follow California guidelines because they tend to be a little bit ahead of the game. I worked with them and I also worked directly under a specialist in gestational diabetes, a perinatologist, so the practice all high risk pregnancy and most of what we saw was gestational diabetes. All of the other local clinics referred everybody to us because we were the experts in treating it.

    I got to see a really interesting perspective on this diagnosis. I mean, I got to see it from the public policy level and the research side of things and also in clinical practice. When I was in clinical practice, that's when I saw how well or not well the conventional gestational diabetes worked for these women. I've always been a person who has a real food focus. I've always had a garden. I grew up with backyard chickens, Farmers Markets, the whole nine yards.

    There was always this gap in the conventional guidelines of focusing on quality, but there is also a gap in some of the recommendations not exactly being up to date with some of the latest research. When I started seeing how many of my patients were "failing" diet therapy, it was really frustrating. I mean, first of all, you're in this career to help people get better. And when they don't get better, you don't feel very good about yourself and you start questioning everything.

    That's really what led me down the path of why are there carbohydrate levels, where they are during pregnancy? There's this 175 grams minimum of carbohydrates per day that's thrown out and why is that that number, where did that come from? They say it's unsafe to go below that level, but they don't really back up why and the only reason that they usually give is that you'll go into, women will you go into ketosis and that's dangerous. And so as far as I know, I'm the first dietitian to really delve into the research behind all of that and present an alternative and to publicly advocate for a lower carbohydrate diet during pregnancy.

Christopher:    So what were you seeing with these women? Were there certain blood markers? Or was it just symptoms? Or what was going on?

Lily:    Well, there's a couple different ways that you can identify gestational diabetes. In our practice, we use hemoglobin A1c or A1c during the first trimester to catch women early in their pregnancy.


    Because there's quite a bit of data showing that gestational diabetes, which is high blood sugar experience during pregnancy, can be the result of preexisting insulin resistance that happens before pregnancy. Oftentimes that gets worse and leads to uncontrolled blood sugar later on. But you can screen for it early. So we would screen with A1c to stratify who was basically at risk or has insulin resistance coming in.

    Any women with a 5.7% A1c or higher, we treated those if they have gestational diabetes. So they got to meet with me, they got to learn more about nutrition and other lifestyle things and exercise to help them control their blood sugar. What I was seeing in practice was you'd follow this conventional diet recommendation and as a diabetes educator, of which I'm trained in that as well, you follow this carbohydrate exchange method of teaching where you give a certain number of grams of carbohydrates per meal split into various numbers of servings and have them change their diet based on what you teach them.

    It's a fairly rigid way of doing things. I mean, you have a certain amount of grams of carbohydrates at each meal and they have to learn how to count carbohydrates and all that. But a lot of times I was seeing my patients' blood sugar not get better and sometimes their blood sugar levels were actually getting worse. It's fairly obvious, I mean, carbohydrates are the primary nutrient that raises your blood sugar levels. So the answer was obvious in my mind that we just need to reduce carbohydrates.

    But what you hear from all the experts is that going low carb during pregnancy is unsafe. So it took me a while to really dig through the research and trust that that's what we could do and that's what we could do safely. And once we did that, the blood sugar levels all came down and for the most part the majority of my patients were able to avoid the need for insulin or medication because their blood sugar is very well controlled with diet and lifestyle changes.

Christopher:    It does seem quite obvious, doesn't it, when you think of diabetes as a disease of carbohydrate intolerance.

Lily:    Exactly.

Christopher:    Kind of just remove carbohydrate, isn't what's causing the problem? It seems good. But pregnant women are obviously special in that they have special needs. So where do you think it came from, this idea that the carbohydrates are required? Do you know where that came from? I mean, there must have been some good intention behind that recommendation.

Lily:    Yeah. Well, I had to dig through -- I contacted all sorts of pregnancy experts, gestational diabetes experts, low carbohydrate diet experts and what I finally ended up doing was digging through the institute of medicine, this giant document. It's like 1300 plus page document that's the panel on micronutrients and the committee, scientific opinion on macronutrients basically.

    And that's where I could finally piece together where this 175 grams suggestion came from. And essentially, what it is they start with the estimated average requirement of carbohydrates for non-pregnant women which is 100 grams carbohydrates per day. Then you add on approximately 35 grams to count for the increased calorie needs of a pregnant woman, which is about 300 calories. And then you divide that by the recommended percentage of carbohydrates, which is around 45% or more of carbohydrates per day.

    And then you add in an additional amount that accounts for the glucose that's estimated to be used by the fetal brain per day which is around 33 grams. Some estimates are more closer to 25 grams. With all of those numbers taken together and then there's a little buffer, you end up with this 175 grams per day. But what's funny is that in that document, they actually negate their 100 gram estimated average requirement recommendation.

    Right on the document it says the lower limit of dietary carbohydrate compatible with life is apparently zero, provided that adequate amounts of protein and fat are consumed. So the document kind of refutes itself. And so if we take out the 100 grams, then we're left with 75 grams of total carbohydrates required per day.


    And then we have to think, is the 300 calories that a pregnant woman need, does 45% of those extra calories have to come with carbohydrates, not necessarily. I mean the estimates on how many carbohydrates the fetal brain needs are they're variable. Not all of those carbohydrates or all of that glucose, grams of glucose, I should say, necessarily need to come from dietary sources because, as you know, our bodies are pretty adaptable and our metabolism is fairly advanced and we can create glucose from fat and protein, if we need to.

    Assuming a woman isn't overly calorie restricted then we would expect the body can pick up the slack. But anyways, that tells you where the 175 grams comes from. And once I found that and then started digging more into the research on ketosis, I was like, "Oh, okay." I can think of the pregnancy carbohydrate recommendation similar to the government carbohydrate recommendation of an average of 300 grams per day, which is astronomical and essentially leads to beta cell burnout and diabetes when you eat that way long term.

    So I was like, "Okay, I feel a little more comfortable going against this knowing where the number comes from." But what's funny is most of the dieticians who work on prenatal health have no idea where that number comes from. But it's just the sort of etched in stone, 175 grams, got to follow the guidelines, follow the book and you need to march along and continue recommending that.

Julie:    I think that's important because, I mean, we talked a little bit about this before the podcast and that, as a mother now, I'm confronted constantly with women who are sharing their birth experiences and talking about what it was like when they were pregnant or they're currently pregnant and it's crazy to me, sitting at the park and listening to these people exchange stories back and forth about what's normal and the way that they talk about what was recommended to them.

    If their doctor says it, it's fact. And it's scary to me being on the other side of this now and knowing how little doctors actually know about nutrition and then it's even scarier to know that women who have gestational diabetes and maybe are often referred to a dietician are still being given improper information or their case is being mismanaged. I mean, were you met with any resistance within your practice or how do you approach that as a dietician when you're working with these women? Because you're not necessarily recommending out and out ketosis that you can get away with it? Or have you met with any doctors that are really, really resistant to what you're recommending?

Lily:    What's interesting is there are more doctors who are on board with a lower carbohydrate diet during pregnancy that there are dieticians. Because the doctors haven't necessarily been trained in nutrition. And what the dieticians have been trained in is the sort of indoctrinated you have to follow this recommendation. And it's unsafe. I mean, it says it's unsafe to go lower than 175 grams of carbs during pregnancy.

    Now, I want to actually look at the evidence. I didn't find that to be true, just as a lot of things in our nutritional practice are changing. I mean, even the Academy of Nutrition and Dietetics, which is the new name for the American Dietetic Association, they just put out a statement very recently saying to remove saturated fat and cholesterol from nutrients of concern and also admitting that a low salt diet can be unsafe for some individuals.

Christopher:    I saw that.

Lily:    They're recommending that we rescind the nationwide salt restriction recommendation. Times are changing. But we have to -- I think the big challenge is we have to be open to looking at new research and reevaluating the science. And a lot of the times we just kind of -- It's easier to follow status quo. And I can tell you, it took me months researching all this information to get to my answer and most people simply don't have time or energy or interest in their clinical practice to do that.

    It's just like, "Okay, well, these are the recommendations. I'll follow them. I'm worried about my job security if I do otherwise and here we go." But a lot of doctors really, they just want their patients to do better. And if they have fewer patients requiring the careful management of insulin, which gets fairly complex, I mean, it's very challenging to mimic the body's natural insulin response with insulin shots. A lot of doctors want their patients to be able to do well on the nutrition and the exercise portion of things and not require the additional intervention.


    Any additional intervention, by the way, oftentimes limits women's birthing options. I've heard from quite a few women who can no longer stay with their midwife or could no longer have a home birth because they required insulin. And that in itself doesn't make sense because you can require very, very low doses of insulin to manage your blood sugar.

    And essentially, if your blood sugar is well managed, your risk of having a large and therefore what they view a difficult to birth baby is lower than if you didn't have insulin and had high blood sugar. So that in itself doesn't make sense. Options can be taken away from women if they can't get their blood sugar under control naturally. So it just doesn't make sense for us to keep recommending a very high carb diet that doesn't work.

Julie:    Yeah. I think that's a really important point. That's one of the things I think that scares me the most when I hear that women just nonchalantly throwing these things around saying, "Oh well, I have gestational diabetes," or, "I'm a risk for gestational diabetes." I think they often don't realize what that can mean for them especially if they wanted to have either a natural birth at home or they wanted to work with a midwife or it just kind of sets you up. It's one of those things.

    We've talked about this before on the podcast. It's one of those things that sets you up for kind of that domino effect of intervention during which a lot of women, I think, want to avoid but don't realize how early complications can arise or complications can be marked on your file, I guess you could say. And gestational diabetes is definitely one of those things.

Lily:    Yeah. And that in itself can lead to some issues because then you have a group of women who are trying to avoid the diagnosis of gestational diabetes. So somehow trying to cheat a screening test or somehow get out of having it. And that shouldn't be the goal. The goal should be normal blood sugar during pregnancy because, by the way, even very mildly elevated blood sugar is linked to risks, even at levels that are blow the diagnostic threshold for gestational diabetes.

    There's been questions thrown around in the research of lowering the diagnosis standards but also lowering the goal blood sugar levels because we have some ladies with GD who are managing it what we think is quite well as clinician below our thresholds of good "blood sugar control" that are still ending up with these major complications, very large infants, infants born hypoglycemic because their little bodies are producing lots and lots of insulin in response to high blood sugar levels.

    I really wish that, I think if the treatment options were different and if the dietary options worked much better and this diagnosis was explained better, women wouldn't be so concerned about trying to cheat the test or avoid the diagnosis. I mean, essentially, we just want healthy moms and babies. And if you don't get diagnosed, I mean, undiagnosed gestational diabetes and uncontrolled gestational diabetes is where the real risks lie.

Christopher:    I've been talking to -- It's funny you should mention the doctors actually. I've been talking to a British medical doctor. He's currently studying for a Ph.D. in neonatal brain metabolism. He's been on the podcast a couple of times. His name is Dr. Tommy Wood. He's been telling me about the importance of ketones for neonatal brain development. And so the obvious question that follows is if low carb is good, is very low carb ketogenic better for a developing child? What do you think?

Lily:    That's a good question. I don't have the perfect answer to that but I do concur with the doctor you've talked about. In my studies, what I found was that there are essential cerebral lipids that are produced from ketones. And if a baby is not getting adequate ketones from the mother, the baby has the ability to produce its own ketones. So it's very interesting. It is necessary fuel. I think where it gets complicated and where it gets mocked up among health care professionals is that the most conventional health care professionals have not -- They don't understand the difference between starvation ketosis or nutritional ketosis or diabetic ketoacidosis.

Christopher:    And the other thing I think they don't understand is the difference between a nutrient dense ketogenic diet and one that comes in liquid form with soy bean oil.

Julie:    Yes.


Lily:    Well, that's the other complicated thing. Let's briefly talk about all the different types of ketosis because this is something that needs to be explained. Most of the studies on ketosis during pregnancy are referring to either starvation ketosis where woman are mostly -- Most of them are animal studies. An animal has been specifically deprived of food. So if you don't eat enough calories, your body will start metabolizing your fatty tissue and you will end up in ketosis. Okay, that's starvation ketosis. That's not ideal for pregnancy because you're deprived of more than just not enough carbohydrates. You are deprived--

Julie:    That can have epigenetic effects.

Lily:    Epigenetic, yes. And we have some of those what, from the Dutch famine study or something. But, yeah, you're deprived of essential fatty acids, amino acids, vitamins, minerals, micronutrients, antioxidants. You're deprived of everything. We can't use that to prove that ketosis is harmful without also noting that complete nutrient deprivation that was going to muck up or data. Diabetic ketoacidosis is completely different. That's when somebody has preexisting type one or type two diabetes where their body no longer produces insulin and they somehow don't take enough supplemental insulin.

    And this is something that leads to super normal levels of ketones in the blood. It changes the acid-base balance. And it's also accompanied with super high blood sugar. Because these people have literally no insulin in their bodies at this time. That's different than nutritional ketosis. Nutritional ketosis is when a mom is taking an adequate calories, protein, fat, vitamins, minerals, like a nutrient dense diet, and just has less carbohydrates. That's different. They have enough. Their body has plenty of energy substrates to derive energy to produce glucose and it doesn't lead to the same issues that some of these other types of ketosis can lead to.

    And that's something that's not clearly explained in most medical training. I know as a certified diabetes educator, that was not in the textbook. I mean, these are things that you have to learn on your own. Most of these experts in diabetes, they don't even understand the different in this stuff unless they choose to look at it themselves.

Julie:    Yeah. It's frightening. We have friends and I've definitely met people and work with people now who have children with diabetes and type one diabetes even and even just the suggestion of a lower carbohydrate approach to managing diabetes is always met with this look of, well, you can't have, you cannot, and approach ketoacidosis, you can't have -- This huge amount of fear around the word ketones.

Lily:    Right.

Julie:    And that is kind of mindboggling to me that it's been better educated even among the experts, just having that basic understanding of the difference between all the things that you just spoke of. It's unfortunate.

Lily:    Yes, it is very unfortunate. And that leads to all sorts of confusion around ketones. And then there's the issue of how do we check for ketones. And a lot of times women with gestational diabetes are told to check their urine ketone levels. What they're not told and actually what a lot of their clinicians don't realize is that you can be spilling urine ketones and not have any detectable levels of ketones in your blood stream.

    There was a study from the '80s that looked at a lower calorie diet and they measured urine ketones and blood ketones in pregnant women, which is fairly rare for studies to measure both. And of the women who tested positive for urine ketones, only 11% of the women tested positive for blood ketones and they were at very, very trace levels, really, really low. I mean, I think it was 30-fold less than what would be a diagnostic diabetic ketoacidosis level of ketones. I mean, really, really low level ketosis.

    And it's actually fairly common in pregnant women. So pregnant women are three times more likely than a non-pregnant woman to go into ketosis even in the absence of trying to restrict carbohydrates. So it's just a normal physiological reaction and everybody freaks out about it. It's just very silly.

Christopher:    So now we've sorted it out. We're not talking about starvation. We're not talking about some pathology. Is there any benefit then to producing ketones for the unborn child? Is it a desirable state for pregnant women?


Lily:    Well, I think -- Let me put it this way. I'm not sure women have to intentionally try to get into ketosis during pregnancy because it will naturally happen to most women. I'm not sure that women need to obsessively restrict their carbohydrates to really, really low levels because they're likely going to go into ketosis even in a moderate carbohydrate diet. But like I said, there are some cerebral lipids for the baby that are produced from ketones.

    And some evidence suggests that may actually help fetal brain development. So that's something to think of. We know that, and they've researched ketone metabolism in the growing fetus during the first two to four weeks of neonatal life, about 13% of the total oxygen consumption by the brain actually comes from ketones. So it is a useful energy substrate for the baby and it likely is playing a role in fetal brain development. It depends where the difference is, is the level of ketones.

    The opposite can be true. If you get to ridiculously high levels of ketones, which is what you see in diabetic ketoacidosis. Again, not a state that a normal pregnant woman is going to experience, but there's actually damage to the fetal brain development and intellectual impairment in children who are exposed to diabetic ketoacidosis. But again, that's a medical emergency with super normal levels of ketones and it's also confounded by really high blood sugar, which is a known teratogen and altered acid-base balance.

Christopher:    Right, right. Of course.

Julie:    I think it's all well and good to kind of talk vaguely about low carb and nutritional ketosis and all of that stuff, but I think it's probably more helpful for people to have kind of some more concrete kind of tips or direction in terms of how to approach prenatal nutrition and pregnancy nutrition. So if I am a woman who I have normal blood glucose, I'm not really at risk for gestational diabetes and I want to stay that way and stay healthy through pregnancy, what would be, as a dietician, what would be your recommendations for how to approach preparing for pregnancy and entering pregnancy? What are your top three things to keep in mind for diet in terms of macronutrients and micronutrients?

Lily:    Well, I mean, since I'm a big proponent of people eating real food and eating as much nutrient dense foods as possible, I'll start with that. I mean, the big challenge with prenatal nutrition is just trying to pack in as many nutrients as possible into each bite of food. And so, I think, focusing our energy on some of the most nutrient dense foods is helpful and a lot of these nutrient dense foods automatically happen to be lower in carbohydrates anyways. So it's kind of a two-birds-with-one-stone sort of a situation.

    Some of the foods that I highly recommend for pregnant women or women looking to conceive are eggs, specifically eating eggs from pasteurized chickens, and making sure to eat the whole egg with the egg yolk. It's really helpful. That has a lot of nutrients for the brain development of the growing baby and also making sure that you and your body stay as healthy. One of the big ones is choline which is like a long lost cousin of folate. That helps with methylation reactions in the body.

Christopher:    Yeah. We've been testing that on organic acids. We do have organic acid urine test that measures methylation and the need for folate. So, yeah, that's interesting. And liver as well. There's actually quite a lot of folate in liver.

Lily:    Yeah. And that was the next food I was going to get to.

Christopher:    Sorry.

Lily:    Yeah. Liver and egg yolks are the two highest sources. Liver has more choline than egg yolks, actually. But the reason those things matter is a lot of these one carbon metabolism reaction, which is another way of describing methylation reactions, are involved in these very basic cell replication kind of processes in the body. And when there's issues in that fundamental level of human growth, you end up with some severe issues. I mean, one of the reasons that there's all this hoopla over folic acid is that it can help prevent neural tube defects. Now there's issues of folic acid versus folate, which I don't need to get into right now.


    But choline can help pick up the slack if there are issues with folate metabolism in the body or there's inadequate folate coming in from the diet. They share similar functions for reproductive and for one carbon metabolism. Choline rich foods are super important and most women looking to conceive and most pregnant women and most beast feeding women don't consume enough. Eggs are one of the easiest sources because most people like eggs. Liver gets a little more complicated because a lot of people don't like liver, but liver is fantastic as well.

Christopher:    I really envy your job. Trying to persuade a pregnant woman with morning sickness to eat liver and egg yolks, that must be--

Lily:    That's the idea. You have to eat them before you're pregnant.

Christopher:    Right. Yeah, your job is done.

Lily:    That's the hope, right? Build up your nutrient stores so if you happen to feel kind of queasy or you don't really want to eat those foods in the first trimester then it's there for you.

Christopher:    One of the things that you touched on in the Robb Wolf interview, which I thought was interesting, was the problem with insulin resistance for these women is not new just because they're pregnant. They probably had some degree of insulin resistance before they became pregnant. And I wonder whether the same is true for a lot of these other nutrients. Were they already deficient in folate before they even started? And then the same is true maybe for iron and B12. What do you get women to do? Do you have them do a panel before they even get pregnant? Or what do you look for?

Lily:    That would be ideal for everybody because--

Christopher:    Because they're so cheap. I don't understand why you wouldn't, right? You can go on to Life Extension and order a basic blood chemistry for $26. Why would you not?

Lily:    Yeah. It's a really good idea to get some baseline blood values. I most certainly, in addition to the nutrient levels, hemoglobin A1c is really great to know before pregnancy because that tells you where your level of insulin resistance is at. I mean, sort of. It's not the same as getting insulin, actually like insulin levels drawn. But it can do--

Christopher:    I can even tell you that I was looking at this just the other day. They do a basic diabetes panel on Life Extension. It costs $25 and you get your fasting insulin and your hemoglobin A1c and your fasting glucose. $25, it's not like even worth asking your doctor about, like having that conversation with him, I think.

Lily:    Yeah. That's amazing. Even better is if they can do, and this will be something you'd have to talk to the doctor about, but an insulin tolerance test. It's the same thing with the dose of glucose but you get your fasting insulin levels, but you also get your insulin response. Because some people have normal glucose tolerance test because they're hyper producing insulin. And that's not ideal either.

    It's ideal to have normal blood sugar levels with as minimal insulin as possible to keep that there. That would be super advanced. That would be very interesting to get. Vitamin D levels are crucial to know about before pregnancy. Vitamin D deficiency is linked to a variety or risk factors and one of those is gestational diabetes. I think it's something like a two to three times more likely to develop gestational diabetes if you're vitamin D deficient before starting your pregnancy.

Christopher:    Wow.

Lily:    That's pretty common. Because we know vitamin D plays a role in insulin resistance after all and the majority of us are deficient in vitamin D. And your body's needs for vitamin D increase during pregnancy. That's a really important one to know. I think most women benefit from an additional vitamin D supplement because the majority of us don't spend much time in the sun without sunscreen or don't live at a latitude where it's possible to make enough for the sun. That's another really important one to get.

Julie:    What is your take on -- This is different from what we've been talking about. But iron models. I know that that's something that is common, like kind of misread by a lot of practitioners in women in terms of levels of hemoglobin and ferritin and all these types of things. There's like multiple markers for your iron status. And I feel like I've definitely had this happen to me. I know other women that have this happen too where we basically are told that they're anemic when really if you were to take, look at the whole picture, they're not necessarily anemic and their doctors are telling them to supplement with iron and I know and we know from experience that supplementing with iron can take a really long time to affect your iron stores.


Christopher:    I think the problem is they're using the word anemia and iron deficiency synonymously when obviously there are multiple things that could lead to anemia. There's many types of anemia. Certainly this just happened to my little sister. They just told her, "Oh, you're anemic. You need iron." I think that kind of jibes with a lot of women. Why? It could be B6 or it could be zinc. You've already mentioned folate is so important and also B12. You don't really know just from low iron that that's what's causing the anemia. It doesn't seem like anyone is really investigating it very thoroughly.

Julie:    Well, not only that. It's going to be different. If you're 36 weeks pregnant and you're told you're anemic and to take iron supplements, the likelihood that that's going to affect your iron stores before you give birth is probably very low. Whereas if you're pre-pregnancy -- I just wonder like what you think of that and at what point, like what should women worry about pre-pregnancy, during pregnancy in terms of iron status?

Lily:    Yeah. Well, again, I think as much as you can optimize your prenatal nutrient stores. You're going to be better off during pregnancy. Because then depending on what variety of symptoms is thrown at you, at least you can fall back on, "Oh, I've been eating really nutrient dense foods for the last six months, one year, two years, et cetera."

    The challenge with iron levels during pregnancy is that your blood volume increases during pregnancy and your blood is more dilute. Some doctors aren't super well trained on the differences in the iron cutoff levels or the hemoglobin, hematocrit, all those different measures of anemia. They're not as familiar with those during pregnancy. Sometimes your blood is simply more dilute and your hemoglobin and hematocrit are simply more dilute.

    What do you do about it, if they are a little more depleted? Well, like you said, supplements don't work super well. A lot of iron supplements are not well absorbed. I think we really have to move the conversation back to real food. And one of the most nutrient dense sources of iron is liver by far, and the most absorbable form of iron. And whether or not your anemia is B12 or iron or folate deficiency, you get all of those in large concentrations in liver and you can eat it in a very relatively small portion.

    I mean, you don't have to sit down to a meal of three ounces of liver. You can have a tablespoon or two of liver pate and you've just gotten one more absorbable iron from that than from your 325 milligram of whatever iron supplement. And it's not going to make you constipated. I think there's just kind of like a paucity in that area, then it brings up the whole issue of most conventional doctors and nutritionists think that liver is unsafe during pregnancy or they recommend these supposedly iron dense foods and it's like total cereal that's been fortified.

Christopher:    Oh god.

Lily:    Synthetic iron. Or it's spinach which has tons of oxalic acid and you're not going to absorb it anyway.

Julie:    We were just laughing about this the other day because we were looking at the nutrient recommendations in this biochemistry textbook. And it's like recommending where you can find certain things and it's recommending all the fortified things instead of the things where you find it naturally in foods.

Christopher:    Yeah, fortified cereal. And then someone forwarded to me a blood test from the other day from a doctor's office and they were low on iron. The doctor's recommendation was spinach and broccoli as being good sources of iron. And I'm like, wow, that would have taken eight seconds to Google that. And you didn't.

Lily:    I know. But that's what a lot of us are still taught in school. It's like they want to teach you every single source of the vitamin and so they list all these things and then you're like, "No, don't like liver, cross that out. Don't like red meat, cross that out. Yeah, don't put spinach, broccoli and black beans."

Christopher:    Right. Yeah, vegetables are pretty unobjectionable. Very few people object to vegetables. Or maybe that's what it is. You just choose the common denominator.

Lily:    There really sadly isn't often a very good description of all of the nutrient inhibitors or enzyme inhibitors, all these different things in food that prevent your absorption of different things. Just because a food is high in nutrient doesn't mean your body will be able to absorb and extract the benefits of that nutrient. A lot of that is going to pass through you. I mean, we think of animals. They have claws and teeth and talons, and other things that can try to fend off them from being eaten.


    Plants just produce all sorts of compounds to prevent whatever is eating them from digesting them fully. So every plant food is going to come with some sort of a defense mechanism and a lot of them end up being nutrient inhibitors. It doesn't mean they're bad. It just means we can't rely on plants to be a source of certain nutrients very reliably because our body just simply cannot gain access to them.

Julie:    I talk to people a lot in terms of how much a baggage a food comes with and determining if -- It might be really, it might have a lot of nutrients but you have to ask yourself what are the baggage that comes with in terms of the rest of your health and the whole picture, which kind of leads me to other -- I guess, in the ideal world, I mean, we've talked a lot about what the problems are with the current recommendations and what doctors and dieticians know and what they're recommending.

    I mean, I guess, you've seen this now and you've done the research, like if you were to rewrite the rules, and hopefully you will have a hand in that someday, what would you recommend? I mean, what would your recommendations be in terms of, I guess, macronutrients first for the ideal, for women specifically, I guess, in terms of pregnancy nutrition, pre-pregnancy and pregnancy nutrition? What would those look like? Obviously, the micronutrients are extremely important and the more nutrient dense the better. But I'm thinking in terms here of macronutrients because I think that's where we have to start sometimes and then throw the micronutrients in after.

Lily:    Exactly. Well, I'll first say this, which is that I tend to shy away from providing really strict like calorie ranges, percentage of calorie ranges of different things because that doesn't translate for real problem and it means you have to obsessively track what you eat and calculate things and then worry that you're deficient in something. I shy away from that. But I'll give you a general idea. First off, I would get rid of the minimum level of carbohydrate that's required during pregnancy.

    We don't know where that minimum is but I would say eat a level of carbohydrate -- I think it would be great if everybody could check their blood sugar so you could see your individual response to food because that tells you so much that nobody else can. But match your carbohydrates to a level where you feel energized, you're not immediately starving after a meal, you're not gaining weight ridiculously rapidly during pregnancy, and your blood sugar, if you're testing that, is well controlled.

    That range of carbohydrate is going to be pretty variable depending on a variety of factors that you come in to your pregnancy with. So whether you're insulin resistant or overweight or maybe you're really active, all these things are going to affect the ideal level of carbs for you. But I'd say for the majority of women, the total carbohydrate intake less than 175 grams during pregnancy is probably ideal.

    Protein levels, again, more in my focus is trying to get people to just sort of eat a balanced meal of real foods every time they sit down. But probably somewhere between 70 or 100 grams or maybe more if they're taller or more active or whatever of protein per day is ideal. And trying to get some source of protein and fat, I would add, every time that they eat so they're not favoring a diet that's mainly carbohydrates. I mean, the biggest thing that I would see in clinical practice is I'd ask women, "What are you eating? Give me an idea of what you have breakfast, lunch, dinner, snacks?"

    And I see what they're eating and a lot of times people are eating almost purely carbohydrates. It's like, "Well, start the morning with a big bowl of Honey Nut Cheerios with skim milk and a banana and my coffee that has however much sugar or sugary creamer added to it." I mean, there's a wee bit of protein in your skim milk but the balance of macronutrient is just completely off. It's heavy, heavy on the carbs, tends to be relatively low protein and super low fat because they're trying to be "healthy".

    That balance needs to be flipped on its head and we need to really prioritize fat and protein sources coming in so people get the key nutrients that the baby needs to develop, first of all, but you also stay full and satisfied so you don't end up just binging on carbohydrates and gaining 80 pounds during your pregnancy. That and then I would also add that non-starchy vegetables make up a huge portion of the diet as well.


    I mean, we get focused on the macronutrients and we forget about vegetables because they're low in everything except these micronutrients. So it's like, "Well, these vegetables are relatively low carbs." So when you're talking about eating more fat and protein, we kind of forget to include them in the discussion. There's a lot of these vegetables to add.

Julie:    I'd like to talk about these vegetables as a vehicle for fat.

Lily:    Yes, it's a vehicle for butter.

Julie:    Yeah, exactly. Exactly. We're completely on the same page with that stuff. I'm sitting here going, "Yes, thank goodness. At least I'm not the only one saying this. If there's at least two of us in the world then maybe we'll get some--"

Lily:    There are at least two of us advocating for real food that's not ridiculously high in carbohydrates and mindful eating.

Julie:    Yeah, I mean, I think--

Lily:    There are two of us, there are more of us out there.

Julie:    Yeah, I hope so. I mean, I think, if anything, it comes down a lot to common sense and, I think, a lot of people want this really fancy -- I mean, the one thing I run into time and time again when we're coaching people is that they want some kind of fancy algorithm for how to make decisions about what to eat and how to put a meal plan together, how many calories exactly of fat, protein and carbohydrate to eat to achieve their goals and this, that and the other thing.

    So a part of the coaching comes down to getting people to reevaluate what they've been fed their whole life in terms of information about nutrition, developing a new relationship with common sense eating and intuitive eating and thoughtfully approaching food as opposed to just wanting it to be a very mechanical decision with some kind of formula.

Lily:    Right. Even if you come up with a perfect formula, the idea behind it still on some level is restriction.

Julie:    Yes, exactly.

Lily:    You're still restricting. I mean, in order to match a meal plan, has a certain amount of calories or whatever perfectly, you literally have to measure every food. And ideally, with a food scale. It's absolutely absurd. And there's a post on my site, Six Reasons to Stop Counting Calories, which is still one of the most popular posts, I must say, where I go through all these issues with the calorie counts anyways and our nutrient tables anyways.

    A lot of our nutrient values were calculated from 50 years ago or more when our food was more nutrient dense. And how can we say a carrot has this many calories if there may be a different variety of carrot that's sweeter that's going to have more calories and more carbohydrates. It's not the same. But a carrot that's grown that you're eating in season versus a baby carrot that's been dipped chlorine wash, you're getting different nutrition too. So who cares about the calories at the end of the day?

Julie:    Yeah.

Christopher:    There was one thing. Having listened to you both just talk about how there couldn't be no algorithm, I'm going to answer an algorithm which is this finger stick test you get from Amazon and it costs $7 to measure your blood glucose. I normally saw the athletic coaching clients that I have, I normally recommend this ridiculously tight range of 80 to 90 milligrams per deciliter as being a target zone. I realized that, in most cases, is hopelessly unrealistic. I was wondering if you had any thoughts about what kind of numbers pregnant women should look for?

Lily:    Well, I'll give you two. One is the gestational diabetes target blood sugar levels that's been agreed upon by an international panel of experts. The second range I'll give you is that actual normal pregnancy blood sugar, the average pregnancy blood sugar. That's a combination of what they found in a variety of different studies. Typically, for gestational diabetes, they recommend a fasting blood sugar less than 90 milligrams per deciliter, one hour after a meal less than 130 milligrams per deciliter, and two hours after a meal less than 120.

    Normal pregnancy blood sugar metabolism, the average fasting blood sugar is 70. The average one hour post meal blood sugar is 108 to 109. The average two-hour post meal blood sugar is around 99. This is why there's talk about lowering the target blood sugar ranges for gestational diabetes because they're seeing now that the incrementally higher levels of blood sugar you get to beyond what's considered normal during pregnancy, the higher the risks to the baby. So we're likely going to see the target ranges for gestational diabetes blood sugar levels change over time, I think. It's going to be a while, but eventually they will.


Christopher:    So my tight range then is not that ridiculous. So if you're saying--

Lily:    Well, this is pregnancy blood sugar levels, and pregnancy blood sugar levels are about 20% lower than non-pregnant blood sugar levels.

Christopher:    Okay. Why is that? I noticed that fasting them was very low, like I never see that. Do you think that's what's so, overproduction of insulin going on somewhere?

Lily:    Well, there is a natural overproduction of insulin.

Christopher:    Yeah, that's what I meant, yes. Sorry.

Lily:    Yeah. So by ten weeks in pregnancy, insulin levels are at least three times higher. The pancreas literally creates more beta cells for increased insulin output. And then that's matched with insulin resistance. So we don't know insulin resistance later in the pregnancy. The idea is that your body will need to produce more insulin in order to overcome the insulin resistance in late pregnancy. So your blood sugar stays normal but you're still shunting as many nutrients as possible to the baby.

    Why exactly that happens? We are not sure. But we do know that blood sugar levels are naturally depressed during pregnancy, insulin resistance naturally increases and the tendency to develop ketosis also naturally happens. There has to be a reason behind it, but again, it's always chasing the physiology. Why is our body doing this? And we don't know exactly why. We just have hints to it like the cerebral lipids that are required for the baby. We know that we don't want the baby to be exposed to high blood sugar because that limits the oxygen levels in the fetus.

    I mean, one of the big issues with women smoking cigarettes during pregnancy is that limits oxygen. Obviously, all these important metabolic reactions in the developing fetus require oxygen. And excessive blood sugar levels are doing the exact same thing. So the body knows that and the body is trying to limit the blood sugar levels. Beyond that, do we know exactly why? No. But it's something that will, research is going to continue to look at I'm sure.

Christopher:    Interesting. This has been fantastic. Thank you so much. Obviously, I will link to the book, which I'm really looking forward to reading. I'm kind of sorry that I didn't get around to it in time for this interview. I literally just heard you on Robb Wolf the other day and, "I got to get her on. I got to get her on." What about one on one coaching, is that something that you do? Where can people find you online?

Lily:    Sure. Yes, I do. You can find me at That's my main website and blog. And under the Work With Me section, there's a couple of options to work with me one on one. And then I also have, for women with gestational diabetes, I have the real food for gestational diabetes course, which is a self-paced fully online program with 20 video lessons, a variety of handouts, a private Facebook group, all these things that you can work yourself through basically everything there is to know about gestational diabetes, managing it with real food, exercise, lifestyle tips, learn more about the medication, if you happen to need them, what to do postpartum. I mean, it kind of covers everything. That's also available.

    You can also check out my blog, so is where I have my weekly blog post, which is relatively popular. You can check that out, if you want more real food recipes, more links to interviews similar to this one and, yeah, that's for me.

Christopher:    That's brilliant. Thank you very much, Lily. I really appreciate your time. Thank you.

Julie:    Thank you so much for coming. We'll have to get you back on and talk more on pregnancy nutrition another time.

Lily:    Oh, yes. There's so much more to cover and I can't wait for you to get the book and fast forward to chapter 11 because I think your mind will be blown.

Christopher:    I will do that.

Julie:    Awesome. Thanks so much, Lily.

Lily:    You bet.

[0:54:14]    End of Audio

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