How to Optimise Nutrition for Pregnancy [transcript]

Written by Christopher Kelly

March 4, 2018


Christopher:    Hello and welcome to the Nourish Balance Thrive Podcast. My name is Christopher Kelly and today I have not one but two very special guests for you. The first is Lily Nichols. Say hello, Lily.

Lily:    Hi there.

Christopher:     And the second is my very pregnant and very beautiful wife and coach of athletes on our elite performance program, Julie Kelly. How are you doing?

Julie:    I'm well. It's been a while, hasn't it?

Christopher:    It has been a while, yeah. For people who don't know Lily, Lily is a registered dietician and nutritionist. She's a certified diabetes educator, researcher and author with a passion for evidence-based pre-natal nutrition and exercise. In her bestselling book Real Food for Gestational Diabetes presents a revolutionary nutrient dense low carb diet for managing gestational diabetes.

    Her unique approach has not only helped tens of thousands of women manage their gestational diabetes but has also influenced nutritional policies internationally. Wow. That's very impressive. That's an updated bio that I haven't read before. Congratulations on everything you do.

Lily:    I'll share about that when we talk.

Christopher:    Why don't we start right there? Talk about how you've changed the policies. That's amazing.

Lily:    Well, it's kind of strange. I got tagged in a Twitter conversation, I don't know, maybe two years ago and somebody in the Czech Republic was asking for the best resources for managing gestational diabetes. The next thing I know he says my book is sitting on a desk of the "top diabetologists" in their country and they decided to drop the mandatory minimum amount of carbohydrates from their recommendations for pregnant women which they had set at 200 grams and they pretty much reversed it. Now they set it as a maximum, no more than 200 grams of carbohydrates per day for pregnant women.

Christopher:    Wow. Can you just say the country name again? I didn't hear it probably.

Lily:    The Czech Republic. Prague is their capital. Small little country but they made a change to their national guidelines. So, yeah, we're translating my book into Czech from the docs there. They said they've had a huge reduction in the need for insulin or blood sugar lowering medication. Most of their clients are able to manage at least their day time numbers without medicine.

    Sometimes there's always going to be people who need the medication for fasting blood sugar. That's just such a trickier number to control in such a short time frame but they've seen a big change in their outcome.

Christopher:    What's different about the Czech Republic? I'm fascinated about this. We must find out what is different about the Czech Republic? I think it's cognitive dissonance in the US where each piece of new evidence is going to have the authorities dig their heels in even deeper because their competence is bound up in their ego. That's my prediction. You can read more about that in Black Box Thinking by Matthew Syed. So, what the heck is different in the Czech Republic? Have you any idea?

Lily:    I don't know. I have a feeling because maybe they're a smaller country there's less cooks in the kitchen so to speak in setting guidelines. I have no idea. Essentially, Real Food for Gestational Diabetes was written very, very simply. The whole goal of the book is just to get women on board with, yes, you have this diagnosis, it's going to be okay, here's what to do.

    It's very matter of fact until you get to the last chapter where I have to go into why my recommendations are so different than the conventional guidelines and show all the evidence surrounding ketosis and low carbohydrate diets and all that. It was essentially, according to the doc that I am connected with in the Czech Republic, it was essentially the information I presented on ketosis not being a sign of disaster, essentially ketosis being a normal part of pregnancy below a certain threshold and in combination with normal blood sugar not a medical emergency. I think we talked about in our first interview, I'm pretty sure, the ketosis issue.

Christopher:    We did, yeah. That definitely came up. I will link to the original interview that we did for the Paleo Baby Podcast. That was the first podcast that I started and then I started the Nourish Balance Thrive Podcast much later. I should put this interview out on both in case people find their Paleo Baby Podcast in iTunes. I think they will find stuff there. We should talk about that. Before we go any further, can you describe the conventional pre-natal guidelines?

Lily:    Just speaking generally, not necessarily for gestational diabetes, I'm assuming?

Christopher:    Yes.

Lily:    So, the conventional pre-natal nutrition guidelines follow very much the government dietary guidelines. So, low in fat, moderate in protein and fairly high in carbohydrates, so like 45% to 65% of calories from carbohydrates. But when you do the math, it can be upwards of like 400 plus grams a day depending on your calorie needs, so quite high. And they also recommend limiting certain foods due to food safety so like no raw eggs, no raw fish, no deli meat unless it's been reheated--

Julie:    It's my biggest pet peeve.

Lily:    Yeah. Because there's an emphasis on limiting fat, you just by default have less room for meat. Fatty meat is definitely is discouraged, only lean meats.


    Certain organ meats are discouraged like liver because they believe the amount of vitamin A in it will be toxic to babies. And then they highly recommend fortified foods so foods fortified with calcium and iron and folic acid. So, just to meet their carbohydrate needs, like a pretty good quantity of grains and a portion of those are refined.

    They state that it's okay to have half of your grains whole which means the other half of your grains is not whole or refined and usually fortified with those extra vitamins. They also contend that a vegetarian or a vegan diet can be appropriate during pregnancy. I think that's probably it in a nutshell.

Christopher:    Maybe we should start unpacking what might be wrong with this. Julie, I saw you shaking your head there as you heard about the food safety stuff and that's definitely your wheelhouse, that's your academic experience.

Julie:    Yeah. It's definitely my biggest pet peeve too of all the recommendations. I can't tell you how many baby showers I've been to where the mom, that some aunt or grandma, whatever, puts out this big spread of food. She's like, "Yeah, I just can't eat any of it." "What can't you eat?" She's like, "I can't eat any of the deli meat. I can't eat this. I can't eat that." I'm just like, "Yes, you can." We don't live in the third world country with the likelihood of me being poisoned by any of this stuff. But besides that, I mean, the other side of that, the other pet peeve is that you hear all these, like where is the nutrition? I mean, I'm hearing this list and just thinking, I mean, it doesn't take--

Christopher:    It's fortified. What do you mean where's the nutrition?

Julie:    It doesn't take a classically trained nutritionist even to just try to come up with where is the nutrition in that?

Lily:    Yeah. And, actually, I ran a nutritional analysis of one of my meal plans versus one of the meal plans suggested in conventional nutrition. This is in the Academy of Nutrition and Dietetics official guidelines on pre-natal nutrition for optimal pregnancy outcomes guidelines and their recommended breakfast is oatmeal, low fat milk and strawberries.

Julie:    Oh my god.

Christopher:    I'm looking at it here. You can go on, right, trail mix, turkey sandwich on whole wheat bread, light mayonnaise, very important it's light, salad, lettuce, tomato, kidney beans salad, French dressing, banana, low fat milk. There's a lot of low fat milk in this diet. What's up with the low fat milk?

Lily:    Low fat milk. Yeah.

Christopher:    Is it some special elixir for pregnant women?

Lily:    Well, you have to have your three servings of dairy a day at minimum, four if you're a teenager.

Julie:    That's the Dairy Council of America. That's nothing to do with nutrition.

Christopher:    I mean, conspiracy theories aside, is there any evidence that this diet that is the standard recommendation is leading to any worse outcomes either in mom or in baby?

Lily:    Yes. And, in fact, I've written a whole book about what's wrong with it and what the alternative could be that is better and more nourishing for mom and babies. Like I said, I ran an analysis on one of their meal plans or that meal plan and an example one of mine and it came out on top for 19 of the micronutrients I analyzed.

    And some of the specific nutrients that were much higher was choline. Mine was almost 70% higher in choline, because I don't know if you go through the full -- I know we didn't read through the whole meal plan in here but there are no eggs and there's no liver on their meal plan which are the two top sources of choline. The only place you get eggs is in their light mayonnaise.

    And so choline is naturally going to be not that high in that meal plan by default. Whereas if you have a meal plan that might include a little bit of liver and several eggs a day you will meet or exceed the recommended amounts of choline. I mean, another one was vitamin B12 and folate. These things that they think only occur in fortified foods, you can actually get them in greater quantities and probably better utilized forms in real food.

    I think there's a big disconnect between these guidelines and what the research is showing, the levels of nutrients that we need for optimal pregnancy outcomes. And then the carbohydrate thing is a separate issue. We see worse outcomes in terms of baby size, like risk of macrosomia, mother's weight gain during pregnancy and like numerous other markers when women are eating high carbohydrate diet mostly because those foods tend to displace other nutrient dense foods.

    So, you're limiting nutrient intake or maybe also because higher carbohydrate diet tends to drive up blood sugar and that's been linked to a number of issues even when blood sugar levels are below gestational diabetes thresholds and this includes neural tube defects and congenital heart defects.

Christopher:    And is it ethical to do studies in pregnant women like that? Could you take two groups of women and put some of them on a low carbohydrate diet and some of them on a high carb diet and then observe the outcomes?

Lily:    There have been some that have done that but only to a certain level of restriction on carbohydrates because there's still this carryover that, of course, the Czech Republic has identified is not valid.


    But there's this carryover idea that if you drop carbohydrates below a certain level then a woman might be more prone to go into ketosis or more accurately she is more likely to spill ketones in her urine which is a separate issue from blood ketones because they're not correlated very strongly.

    And so they think that it will harm the baby, in other words, because there are studies showing that high ketone levels in the case of diabetic ketoacidosis or ketone levels are thirty-fold higher than normal in the bloodstream, so blood ketones, not urine ketones, is linked to neural developmental delays in baby. But that is like a whole separate animal of medical emergency where you have super normal ketone levels, very high blood sugar levels and altered acid-base balance. It is an absolute medical emergency.

    But in the case of dropping carbohydrates where you experience very mild alleviations in blood ketones and also tend to spill urine ketones, that's not linked to these issues with brain development or anything. In fact, there's a really good study that came out in 2016 out of Japan, I'd have to get you the exact citation on it, but they looked at ketone levels in mothers at the time of delivery and in their placenta and in their babies in the first month of life.

    In all cases, ketone levels were very high and babies stayed in ketosis that entire first month. We don't know what happens beyond that month but this whole idea that ketones are harmful to baby's development in the levels that you actually observe in normal healthy women, it just boggles my mind that this is like still a thing that I have to talk about.

Christopher:    I know. I was going to say is this still a thing? Everybody listening to this podcast will be more than familiar with the concept of nutritional ketosis and I've interviewed several researchers recently for this podcast and we hosted the Keto Summit. I think everybody listening to this podcast or that are usually listening to are more than familiar.

    So, it's really still a problem that people you bump into at conferences, in teaching, whatever it is, they're still confused by the difference between nutritional ketosis and the pathological state.

Lily:    Absolutely. Until I lay out all the research for them, yes.

Christopher:    I probably could dig up some data on Ivy. Our daughter is now four years old and I can remember sticking her finger and measuring her blood ketones when she was quite little, wasn't it? Maybe six months or something. I can't remember exactly what it is but it was way higher than I'd ever seen in myself. It was in the millimole range. It was less than five.

Julie:    It was still [0:12:48] [Indiscernible] was exclusively breastfed.

Christopher:    And she was exclusively breastfed.

Julie:    Yes. In that 2016 study, it only had 60 women but it's like the largest to date to measure of these sorts of things. I don't know why people aren't more curious about ketones in pregnant women. It's known and stated in like even conventional texts that there's a tendency to develop ketosis in pregnancy and then nobody seems to care what the levels are until now. It's just starting to gain more interest.

    But they found the placenta especially was extremely high in ketones and they actually believe that the placenta or maybe even in the baby there's an ability to concentrate or manufacture more ketones because the baby and the placenta had higher ketone levels than maternal blood. It's preferentially shunting them to baby.

Christopher:    So, that means I can eschew the exogenous ketones and just eat the placenta instead.

Julie:    He said it, not me.

Lily:    It's up to you.

Christopher:    I don't want this interview to just be about ketosis. I feel like we've talked about that a lot on previous episodes. Can you talk about some of the other nutrients that you mentioned there? So, choline, for example, is not one that we talked about much in the podcast. Can you talk about why--

Lily:    We haven't.

Christopher:    No. So, why is choline important especially for pregnant women?

Lily:    Gosh, I love choline. So, choline is a really interesting nutrient because it's essentially a B vitamin but was identified after we had already named all the B vitamins so we just call it choline. It doesn't have a vitamin B.

Julie:    It doesn't even start with a B.

Lily:    Yeah. It doesn't have like vitamin B-dash-7D or whatever. It just is cholie but it is related in a lot of its functions to folate actually. They've linked adequate choline intake to a lower risk of neural tube defects in similar way that folate is linked to lower risk of neural tube defects. So, it plays a huge role in the developing brain. They found that having enough choline in a maternal diet can have long lasting effects on baby's memory even when you look at them into adulthood. And some of the early studies were done mostly in rats and then they started doing human supplementation trials.


    So, there's a whole bunch of supplementation trials in the last five years that are looking at choline supplements in pregnant women and then tracking what happens during their pregnancy or with their babies. The current recommended intake of choline is 450 milligrams per day for pregnancy which is higher than outside of pregnancy but still not that much higher.

    A lot of these studies are comparing that amount or a similar amount to more than double it, 930 milligrams, and seeing far improved outcomes. There is one -- I want to pull it up so I don't misquote it but there is one recently that looked at the 930 milligrams of choline versus 480, so slightly more than the current recommended amount. These women were supplemented throughout pregnancy, I believe in their second and third trimester but I'd have to double check the details.

    They looked at infant brain development and then they tested the infants at ages four, seven, 10 and 13 months and the reaction time in the infants was significantly faster at all time points for the infants and the moms receiving the 930 milligrams per day.

    They've also shown that that amount has beneficial effects on placental function like enhancing nutrient flow to baby but also keeping inflammation levels down in the placenta and it seems to play a role, somewhat of a role in helping to prevent preeclampsia which, if you think about it, I was thinking like why would choline play such a difference?

    But when you think about, most of our research in choline outside of pregnancy is on liver function. If you deprive a lab animal or a human of choline they develop fatty liver disease. I think you could say it's almost at the level of cause and effect which is hard to say in research. Everything is usually correlation. You deplete the diet of choline you get fatty liver.

    When we think about the placenta, essentially it's like a liver that you're growing for the baby. And so it makes sense that choline would play an important role in placental function just as it does in liver function. I mean, that's conjecture on my part but it just makes sense from a physiological perspective and everything that we're seeing in the research.

Christopher:    Yeah, I remember seeing the Low Carb Brekenridge Conference, a talk I can link to in the show notes, of -- I can't remember the guys' name but it was basically a disguised sales pitch for a diet in a can. It was like the fasting mimicking diet in a can with a ton of choline in it. And I'm like, "I bet that works really well." This is a sales pitch but I bet that works.

Lily:    Yeah. It's really interesting.

Christopher:    So, let's say I don't want to get my choline in a can, where do I get it from?

Lily:    The top two food sources are liver and egg yolks. An egg yolk will provide 115 milligrams and an ounce of beef liver would provide 119 milligrams. You will find it spread out throughout other animal foods as well like muscle meats and seafood and fish and poultry and whatever. It just tends to be in smaller quantities and not as concentrated.

    And then you'll also find it in some non-animal foods but in a much, much lesser quantities. So like half a cup of cooked pinto beans gives you about 30 milligrams. The cruciferous vegetables, for whatever reason, seem to be, compared to other veggies, a relatively good source. They'll provide, like Brussels sprouts, broccoli, cauliflower, those will provide about 30 milligrams per half cup.


    And then you'll find some in other legumes like peanut butter which is a legume or from a legume and nuts like almonds or sunflower seeds. And essentially anything like naturally contains lecithin will contain choline because lecithin, if you take a lecithin supplement, for example, actually a huge percentage of that is in the form of choline. Yeah, mostly eggs and liver.

Christopher:    Yeah, we can use in that our--

Lily:    They've shown that people who, egg eaters have an average double the intake of choline of non egg eaters. So, this is a big consideration for people who don't eat eggs for whatever reason, allergy, preferences, something. You're more at risk to be low.

Julie:    That was going to be my segue into asking about how -- I mean, I understand how or why but the recommendation that a vegetarian or vegan diet can be safe or productive for pregnant women when they can't even get the recommendations for a Standard American diet right. What's the likelihood that the recommendations for a vegetarian or vegan diet are going to be correct? I mean, that's in our practice even. I always laugh with people, but my mission in life is to convert all vegetarian or vegan back to ancestral way of eating because it might work in the short term but in the long term it just -- I mean, I've never seen a food diary of a vegetarian or vegan that was doing it properly to begin with which just takes a lot of effort--

Christopher:    You're going to see some now. I can tell you that.

Julie:    Yeah, I know. Come on down. Send me the hate mail. That's perfectly fine. I'll deal with you one by one.


    I know that there are people that can do it and I've seen people accomplish it but on the larger scale, a basic recommendation.

Lily:    On the larger scale, it takes an incredible amount of planning combined with supplementation and like really strictly every day supplementing. And even that, it's tricky because -- Like the choline thing, for example, we're finding that the optimal amount of choline is probably a lot more than the recommended amount and you're barely able to meet that amount. In vegetarian who eats eggs choline might be less of an issue. But you start looking at other nutrients and you see like the vitamin B12. There's studies showing now that optimal levels of vitamin B12 for pregnancy are actually triple the current RDA.

    There's another one that I'll point out that was on vitamin B6. Even in women who met who met the RDA for B6, like more than half of them had markers of vitamin B6 deficiency in their bloodstream. It's like are our targets even good enough, you know what I mean?

    I don't know if we've even mentioned it but I think I alluded to my book, I'm working on my second book which will be published in late February, it's called Real Food for Pregnancy. It's on pre-natal nutrition from a more general perspective unlike my first book which was very focused on the blood sugar issues and gestational diabetes.

    I have this whole chapter all about the nutrient dense foods and then I had a reviewer who was like, "You know, what about vegetarians? What do they do?" Because pretty much all the foods I mentioned -- I'm about like reverse engineering pre-natal nutrition. What do the studies say we need and where do we get those foods and let's try to get it from food first versus getting super reliant on supplements.

    And so you go through all the foods and all the nutrients of concern and you find most of those in the highest quantities and in the most absorbable and bio-available forms in mostly animal foods. So, vegetables are still important. They made my list. But like what happens to the woman who's not eating all these other foods?

    I decided to include a section called The Challenge of a Vegetarian Diet During Pregnancy to go through these nutrients. I mean, just from a theoretical perspective and everything I understand about ancestral nutrition, I was like, okay, this probably isn't ideal but let's see how -- What does the research say and can we actually meet it? Because maybe I need to be more open-minded about this issue.

    I just went nutrient by nutrient on the nutrients that you either cannot get or can't get in sufficient quantities or not in the right form. So, B12, choline, glycine is a huge one completely overlooked in conventional pre-natal nutrition. They don't even mention it. Most aren't even aware of it. I didn't learn about it in school. I learned about it on my own. Vitamin A.

Christopher:    Well, tell me what you know about glycine. That's very interesting. I'd been thinking about glycine quite a lot recently after hearing Chris Masterjohn has been talking a lot about glycine for many years actually but recently he did a fantastic panel discussion with Alex Lee and a Finnish dentist student whose name I can't pronounce or remember. I apologize for that. That was a fantastic panel. I'll link to that in the show notes. Can you talk about the importance of glycine in the pre-natal context?

Lily:    Absolutely. Glycine is the most abundant amino acid in the human body which is kind of crazy. It's one of those tiny amino acids that can work its way into all sorts of things in the body. So, it plays a huge host of roles in the body, one of those amino acids that's considered non-essential because if you don't consume enough of it it's assumed that your body can produce it from other amino acids and you'll be able to get by.

    But during pregnancy, it's known to be conditionally essential. Meaning, that you must obtain it through your diet to provide enough, to support the growth of your baby like skeleton, teeth, organs, hair, skin, nails, plus to provide enough for the mother's body. Your skin is stretching. Your uterus is growing. The placenta is growing. Your circulatory system has to adapt to the demands of pregnancy.

    All of these things increase glycine needs. And glycine also plays a role in methylation. So, it's involved in the same gene transcribing, gene creation factors that like folate, choline and vitamin B12 are involved in. It's crazy that it's not really mentioned in conventional spheres.

Christopher:    And how do I get glycine into my diet without taking a supplement?

Lily:    So, the main way you get glycine is from eating animal foods which makes it very challenging for people who don't eat any animal foods. So, the bone, skin and connective tissue of animal foods are extremely rich in glycine, so bone broth, slow cooked cuts of meat especially ones that are really tough, because the tougher the meat the more connective tissue is in there, that yummy pot roast that kind of melts in your mouth, that's the connective tissue that's broken down in the slow cooking process. Also any sorts of cuts of meat that have a bone in it because, A, there's bone but also connective tissue attached to that bone. You get more glycine.


    Poultry with the skin on because skin is extremely rich in glycine like fried pork skins, for example, chicharones, delicious and also really, really good for you, any of the internal organs. So, I think of classically menudo and a lot of Latino cultures where you make a rich soup that has intestines, extremely rich in glycine. And then gelatin or collagen powder.

Christopher:    That's awesome. Or is it awesome? This is why I wanted in part to bring a real life pregnant woman onto the show. We talked about choline, we talked about glycine, we talked about a lot of things that may be everybody would have an aversion to. How is it, Julie, as a pregnant woman?

Julie:    Yeah. I mean, I guess that's -- And this is a question I get all the time too. I get emails all the time from people are trying to optimize before pregnancy or optimize during or whatever. I suffered it myself. I was much sicker with Ivy than I was this pregnancy. It lasted almost the whole first trimester with Ivy and this time it was only -- Actually, it was the first and second trimester with Ivy and then this time it was only the first trimester.

    I really sympathize with women who literally can't eat beyond a few certain select foods for many, many months of their pregnancy. Is that a case of we need to be optimizing ahead of time to prepare for pregnancy? And that's just something that's very difficult to accomplish. Or is it that there's room in the end of pregnancy to make it worth your while to eat these foods?

Christopher:    Hold that thought just for a moment. Could you discuss? There's many people listening to this podcast that don't know what you're going through with the morning sickness. Can you describe the sensations and the aversions in more detail?

Julie:    Well, you can contribute to this as well. For me, it starts as an aversion so literally everything smells horrible. If there's even one slightly off smell to something, the whole -- And you can smell everything from miles away. So you just immediately become averse to almost everything, at least I did with my pregnancy with Ivy. I could eat very little. I was living on -- I made homemade popsicles, basically only had blueberries in them.

Lily:    I had to do that too, yeah.

Julie:    Blueberries and maybe like raspberries. I can't remember what I put in them but it was very much and some orange juice thrown in there for some vitamin C. That was all I could eat for probably a few weeks. And then a lot of other women I know are completely averse. For this pregnancy, I really craved a lot of protein in the beginning. That was basically all I could eat specifically pork tacos. If it was in a taco, I could eat it. That was about it.

    For three or four weeks, that was it. Pork taco was all I could really contemplate consuming. So you get these very specific desires or very specific aversions and you can plug and play with that ad nauseam for many different women. But then there's also this thing where I know a lot of women who are averse to protein almost through their whole pregnancy.

    They really crave carbohydrate and that's like the only thing that they can really stomach eating for long periods of time. I definitely had more of a carbohydrate craving this pregnancy than I did the first one but I never lost my interest in protein completely. And that's not the half of it. There's also just the constant nauseous feeling so it never stops. It's like you're always smelling everything around you.

Christopher:    You don't want the egg yolks or liver.

Julie:    In a word, no. Egg yolks and liver were not on the top of my priority list. So, yeah, I guess that's kind of what my line of questioning is. How do we correct this problem when that is so often a component of pregnancy that we have to overcome?

Lily:    I think you pointed to your answer or my answer rather in what you're saying in that there's a lot to say for optimizing nutrient stores pre-pregnancy and there's even some research suggesting that that's even more important than a mother's nutrient intake during pregnancy. I think that's huge. You do what you can do given whatever your circumstances of the day you're in and the level of nausea and the food aversions going on and the smell issue.

    I mean, I don't think I had it as severe as you're describing during my pregnancy but I did certainly have it particularly through the first trimester and sneaking in to the second trimester. And so the best that I could do was reassure myself that this was temporary. I'd been nutrient dense foods for years and years so I just have to listen to my body and do whatever I can do to get through the day.

    I just got really mindful of what was maybe the purpose of the aversion or the craving, how it made me feel after I followed suit with whatever my body was saying because it gets kind of -- You can get into a gray area with cravings where certain foods naturally drive cravings.


    If you go to Robb Wolf's Wired to Eat stuff, foods are now manufactured to be more crave-able and especially refined carbohydrates set off the dopamine centers in our brain and just -- We have to be cognizant of that portion and see how much we attribute to pregnancy or not to pregnancy. But I think aversions are very real thing and I actually go into this in a lot of detail in one of the chapters of my book talking some of the possible reasons for the cravings and sort of thinking of it from like an ancestral perspective, what are they telling us?

    Sometimes they're telling us to avoid a food. From an ancestral perspective, meat would be -- That's a much trickier food to keep safe like food borne illness wise, virus, bacteria parasites which some of those infections can cause miscarriage and stillbirth and bad things. Of course, we would have some of that in born. Aversions to vegetables. Back in the day, before they were all hybridized and we were just gathering wild foods, there's a much higher concentrations of antioxidants and alkaloids.

    And all these chemicals that plants use, they call them secondary compounds to protect themselves against other animals or things eating or damaging the plant. Some of those things, beyond a certain quantity, could be toxic, particularly in the first trimester when you're in that embryogenesis stage where you're more susceptible to toxin exposure than you are later on in pregnancy.

    I think there's definitely a biological reason for some of these and then also thinking on the other side of maybe nutritional reason for some of the other cravings that might be going on like the carbohydrate craving especially early on. That does kind of make sense from a physiological perspective because your pancreas is already starting to adapt to prepare for insulin resistance of later pregnancy and the higher amount of insulin that need to be produced in later pregnancy.

    A lot of women tend to go hypoglycemic in the first trimester. I've worked with women with type I diabetes in pregnancy and oftentimes insulin needs actually drop during a period of the first trimester before they start going up. And then they go up at a super rapid pace, by the way. But like maybe those carbohydrate cravings are a way to keep your blood sugar from going too low. It's like a protective thing.

    So, I don't have a good answer. I think you have to kind of like get through the day as best you can and stay really mindful of how these cravings or aversions might be serving you and just whatever you're eating try to keep it as like real as possible. If you're really craving something like sweet and sour, maybe some dried fruit or like a homemade popsicle is a better thing than sour gummy worms, you know what I mean? Just do the best you can.

Julie:    Exactly. I agree with that wholeheartedly. I think the problem that we run into is that getting somebody to eat well six months before they want to get pregnant, I don't think people are often thinking that far ahead. I mean, the people we work with a lot of the times are, so with a lot of people listening to this podcast, but in the general population, I don't think those people are thinking that far.

Lily:    Absolutely not a concern.

Christopher:    Right. Yes. I've interviewed Tim Gerstmar and he said exactly that. When a couple comes into his office and they're looking to get pregnant, they're not looking to get pregnant in two year's time. They're looking to get pregnant in two week's time. I mean, surely that must be tremendously stress relieving though to know that to some extent your job is already done.

Julie:    Yeah. No, it was.

Christopher:    You're making me think of the athletes and maybe you're periodizing your weight to a certain extent. You have skinny times a year and you have fat times a year and knowing that it's okay to be fat in the winter or fat at whatever time of the year you're not competing is okay. When you go into the pregnancy, all those years of eating liver and all that stuff, now your job is done. You just need to bring this home. I mean, surely that must be stress relieving.

Julie:    It was for me. I mean, I took a lot of solace on that especially with Ivy because I literally couldn't eat. This pregnancy, there was never really a point where I couldn't eat. It was just a matter of what I could eat, what I could manage to get down. So, yeah, I took a lot of comfort in that knowing that I had eaten the healthiest that I had ever eaten probably one year to six months that we'd been together and trying to sort out your diet and then when I felt pregnant it was just really happy lucky timing, I guess.

    That's the year we stitched to Paleo and I had lost a bunch of weight that I didn't even know I needed to lose and I was competing athletically. I was riding bikes. It was probably the healthiest I've been. I may had been a little bit underweight to be honest with you but ultimately my nutrient stores are probably much better than they would have been had it happened a year sooner.


Christopher:    Do you think we did the right thing? I'm really interested in this. I've heard Dr. Cate Shanahan talk about this. I interviewed her for the Keto Summit and I've also read her book. Is it Deep Nutrition? I forget. I'll link it in the show notes. But she talks about leaving a reasonable amount of time between pregnancies which we did. Ivy is four now and Julie is ready to go again. Do you think that's a good idea or is there no evidence to support that? What do you think?

Lily:    Oh, yeah, I actually include a section on that in Post Partum chapter in my book. I got some complaints on it because people feel like who are you to say? You're a nutritionist, you're a dietician, who are you to say when I should space my pregnancy? It's like, well, I'm not but here's what the research says on that.

Julie:    Yeah. There's more to that than just when you want to have a baby.

Lily:    Nobody's talking about it. You have your baby, you have six week check-up and they're like, okay, do you have birth control or birth control plan? All right. But nobody tells you like, "Hey, it might not be the best idea for you to get pregnant within a certain amount of time of having this baby. You should really try to wait until X, Y and Z time."

    Because a lot of women, especially because we tend to be starting families later in life, you have this sort of ticking time bomb going off where you're like, okay, the years are ticking away, I'm getting older and older, the risks go up. It might be harder to get pregnant. And then you don't want to wait as long.

    Yes, pregnancy spacing is actually been looked at a lot in the research. They've observed that women who get pregnant soon after giving birth, which in the studies they call short interpregnancy interval, they're more likely to have complications during pregnancy which include intrauterine growth restrictions. So, the baby essentially is not getting as much nutrition as it should, pre-term birth or having a child with neural tube defects, developmental delays, cerebral palsy and autism.

    They've also shown maternal death, third trimester bleeding and anemia are more common in those women. That's not small risks. When it comes to the amount of time that you should wait -- Well, maybe I should talk about the reasons they think this is going on. They don't know exactly why this happens but a big review of all the studies on the topic suggests a couple of factors might be at play.

    Maternal nutrient depletion is a big one. Maybe your cervix or your uterus has not fully come back to normal yet or how your uterine scar, if you have a C-section, didn't completely heal. Maybe there is a transmission of infections. Maybe breastfeeding is impacted. They don't know for sure all the reasons but we know that pregnancy is super demanding on your body and it takes a lot of time to heal and rebuild your nutrient stores.

    The latest research suggests waiting for at least 18 months. Meaning, waiting until your infant is 18 months old to conceive your next child. Different research studies have different intervals that they showed have significance based on how they run the numbers. It seems that at minimum waiting 12 months or even 15 months is the best option. Meaning, both of those time points are linked to lower odds of having a child with developmental delays and also the lowest rates of fetal loss.

    For women who have experienced miscarriages in the past, it's really something to think about getting yourself super well nutrient repleted and healed before you try again. What's really interesting, I'm always liking to tie in the ancestral perspective with what the modern data is telling us. I was reading through once again Dr. Weston Price's nutrition and physical degeneration from the '20s and he cites multiple cultures with intentionally spaced children, a minimum of two and a half to three years apart, which falls right in line with what the modern data is telling us.

    There's really something to it. I don't know. I can say from personal experience, my son is nearing two, it takes a long time for your body to heal and for you to feel normal physically, energy levels wise. Your thyroid needs to normalize. Your connective tissues need to heal. So much stuff needs to happen to feel like yourself again that I do think if it's at all possible to wait a little bit before you conceive your next. And if not, just make a super priority in your life to like eat really well nutrient dense foods, supplement well and have extra support, extra helping hands, extra child care, extra whatever, so that you can really stay healthy.

Christopher:    Does the data show any additional benefit from waiting longer? You mentioned 18 months is the longest interval that you should wait. Was there any benefit to waiting even longer than that or is that just speculation?

Lily:    Not the longest interval but some studies suggest that the minimum, wait until your kiddo is at least 18 months before you conceive.

Julie:    And that's conceive. That's not 18 months apart.

Lily:    Conceive, right. Exactly. So then when you add another nine months on to that then you end up right in the same line as the whole two and a half-ish years that Dr. Weston Price observed.


    I haven't seen any studies saying waiting beyond that being more optimal although I could imagine that if you're repleting your nutrient stores even more and strengthening your body then that would make sense. Interestingly, they've actually shown that waiting in their pregnancy intervals that are much longer, like five years or longer, are linked to worse outcomes and I suspect -- These are all correlations, right, so we don't have the exact reason as to why things are going on, but I suspect that observation might be due to maybe some underlying health issues with the mom.

    Sometimes, pregnancy is a huge stress test on your body, as Julie can attest. Sometimes underlying metabolic dysfunction is actually uncovered or worsened in pregnancy and so like thyroid issue, for example, is a huge problem. Blood sugar issues often show up or are identified for the first time in pregnancy. And then the fact that you are now five years older than when you had your previous child, maybe some of those other factors are coming into play.

Christopher:    We've certainly seen that before, haven't we? Those epidemiological studies where there's some sort of U-shape curve. You don't want to -- More is not necessarily better but neither is less.

Lily:    Right. Exactly.

Christopher:    What about timing for -- I know this is a stupid question but probably some people listening are going to be thinking it, anyway, so I'll continue to ask. I apologize. So when I read your book, and I must admit I did only skim it, I thought this is our diet, this is what we do. You just created the diet that we eat anyway and you're recommending that for pre-natal.

    For me to then say, okay, how long do I have to start doing this before I get pregnant, is somewhat of a stupid question because this is probably the diet that everybody listening to this should be on some variation of anyway. But maybe if you are brand new and you've been eating the whole wheat turkey sandwich, how long is it reasonable to wait before getting pregnant? I know it's a difficult question. You probably got asked about anyway.

Lily:    Yeah, you're right. At a certain point, a lot of books are kind of like, well, why did this person write this book? My reason for writing the book was to provide the evidence behind this way of eating specifically in the context of pregnancy and all the citations to back it up so that maybe we can start to nudge policies in the right direction.

    I didn't expect my other book to shift any nutrition policies and it did. Who knows? Maybe we can shift some more policies with this and the 930 plus citations will give them a little rationale behind my recommendations, if not just my opinion. When it comes to the amount of time on eating nutrient dense before pregnancy, I mean, I feel like most of the estimates are kind of just made up by people.


    The longer amount of time that you're eating nutrient dense the better. I would think that a minimum of six months of eating really well. I think back to client work and how huge of health transformations you can see in a relatively short period of time by just repleting nutrient stores and displacing the junkier foods with healthier foods, you see a lot of changes metabolically. If you can eat this way for six months or longer before you try to conceive or while you're on this trying to conceive journey, all the better, the longer the better.

Christopher:    So, Real Food for Pregnancy is the book. I have only skimmed thus far. I've read the introduction and a few chapters. I was very impressed and also intimidated by your scientific references. And the reason is I love and hate them. I love to have them but at the same time I can't resist checking them up. Where did this go? And then you know what it's like when you start reading papers. There's a whole bunch of more references that you should read and before you know it you got 50,000 browsers that's opened.

Julie:    And then you're irate because you realize that the research for pregnancy is so freaking limited.

Christopher:    This book is obviously not just for scientists. Can you tell us who the book is for?

Lily:    Most of my reasons for writing the book is to help, at the grassroots level, help women make better food choices during pregnancy. Should I really follow the recommendations to not eat eggs? Is it really bad if I have my eggs over easy versus hardboiled or scrambled? Can I really eat fish or should I not eat fish? What kinds of fish? What does it say about baby's brain development? Should I pray attention more to the mercury issue or should I be concerned more about getting my omega threes and iodine and all these other nutrients?

    I wanted to give women answers to all the questions that typically come up that are food or nutrient related during pregnancy. I also think it will become a resource for practitioners. I mean, I send out a bunch of copies for advanced reviews and I have several doctors including some OB-GYNs, midwives and a whole bunch of dieticians who are really excited to use this in their practice and some of them even say they're going to use this as a replacement for their maternal nutrition text because I have those maternal nutrition texts and they don't really reflect the current research at all. So, I think both for women directly and for healthcare providers.


Christopher:    I don't think that you've read the whole book just by listening to this podcast either. I have this bad habit of thinking that I've read the book just because I heard the 60-minute interview. It's not true.

Julie:    It's not out yet. You have to read the whole thing.

Christopher:    It will be out. By the time you hear this podcast, the book will be out. So, there'll be a link in the show notes. I was very impressed on your section on supplementation which is hairy and you have to be kind of brave to go there recommending supplements for pregnant women but, of course, it is all evidence-based and based on your clinical experience as well, presumably. Congratulations on that. That was very exciting.

Julie:    I think it's great.

Lily:    Thank you. I'm really excited on the lab testing section especially for clinicians. All the tests that you should really ask your provider about, I'm kind of coming at this angle that the woman who's reading this book is really proactive about her health and feels like she can do more than just take a pre-natal vitamin.

    You also might be the type of person who thinks maybe conventional practitioners don't know all the tests that I should have or why, so I have a section on lab tests as well. Assuming you're not under the care of a forward thinking functional medicine practitioner which at a large scale most people are not under their care, unfortunately, you can ask for things like your vitamin D levels. You can ask for things like your thyroid hormone levels.

    You can understand the pros and cons of all the different ways to test for gestational diabetes and what makes the most sense in the context of how you eat and your goals and several other tests to ask for. I don't go to crazy, crazy functional lab tests but these are things you can bring to any medical provider who has like lab ordering abilities and ask for and just be proactive.

    Instead of waiting for complications to arise, maybe you can get some testing done and then fine tune maybe your vitamin D supplements or certain lifestyle factors to keep yourself really healthy during the pregnancy and that's keep your baby healthy as well.

Christopher:    We're all about that for numerous reasons. That's fantastic. Where's the best place for people to get the book? I know that if you just get it from Amazon you're probably not going to make a lot of money.

Lily:    Actually, I'm going to be selling it through Amazon. For better or for worse, Amazon has such a big search engine that it really reaches the masses better than buying direct from me. So, it will be on Amazon. You can learn more about the book at And for people who aren't quite sure they want to read it, I have a free chapter available so they can dip their toes in and see what it's all about. You probably have a pretty good idea from this interview already.

Julie:    I can't wait to share it.

Christopher:    Thank you. Is there anything else you want people to know about?

Lily:    I think we covered it all. There's so many rabbit holes, research rabbit holes to go down. I want to mention one thing that is not promotional at all, just research interesting that speaks to your experience with morning sickness. Have you guys read about the theory on the role of thyroid hormones in morning sickness?

Christopher:    No, I haven't.

Julie:    Now, he's going to fall down that rabbit hole.

Lily:    It's actually a good sign. I just want to mention this because I think it's super interesting. It's some research done by Scott Forbes. Look it up. Essentially they -- I'm super simplifying his hypothesis. There's all these hypotheses around morning sickness that it might be like a hormonal trigger, B vitamin deficiencies, your body's attempt to protect you from spoiled food or unsafe food.

    But the most compelling theory seems to be thyroid health and that if you're experiencing morning sickness it's actually a sign that your thyroid is making the adjustments that it needs to make during pregnancy and is actively shunting iodine and thyroid hormone to your baby.

    Essentially, they're saying it's like morning sickness is a good sign and for women who aren't experiencing morning sickness, even if it's not a thing to panic about, it could actually be a sign that your thyroid is not adapting to pregnancy the way that it should. I think it's just super compelling interesting theory because I, like you, remember feeling like why am I getting nauseous? I'm super healthy. I have repleted vitamin B6 stores and magnesium. Why am I getting morning sickness? Again, just for reassurance, it felt like, okay, maybe this is actually serving some sort of a purpose.

Christopher:    There's always a purpose, right? What's it for? Why is this happening? What's it for?

Julie:    I mean biology often just doesn't have accidents. That's really interesting.

Lily:    Anyways, I'll leave you with that. I think more promo for me, you can just check out the book at And for my general blog and newsletter and all that jazz, I'm over at

Christopher:    Excellent. I will, of course, link to those things in the show notes so people can find them afterwards. Thank you so much, Lily. This has been fantastic.

Lily:    Awesome. Thanks to both of you.

[0:50:03]    End of Audio

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