Written by Christopher Kelly
May 9, 2024
Chris:
Hello and welcome to the Nourish Balance Thrive podcast. My name is Christopher Kelly. Today I'm delighted to present to you Lily Nichols. She is a registered dietitian and nutritionist, certified diabetes educator, researcher, and author dedicated to evidence based nutrition. With a deep respect for current scientific findings and ancestral wisdom, Lily's clinical proficiency and extensive experience in prenatal nutrition have established her as a renowned consultant and speaker.
Her groundbreaking work in gestational diabetes has positively impacted tens of thousands of women and has significantly shaped international nutrition policies. Today Lily joins us to discuss her latest book Real Food For Fertility. Co authored with Lisa Hendriksen Jack. This comprehensive heavily cited practical guide explains how to optimize nutrition for preconception, providing invaluable insights for couples looking to enhance fertility, pregnancy and beyond. Lily discusses some of the causes of infertility, nutritional considerations for conception, and the effects of alcohol and caffeine on fertility in pregnancy.
Additionally, she highlights the significance of meal size and timing and the detrimental effects of environmental toxins when trying to conceive. Well Lily thank you so much for joining me this morning. It is in California. Where abouts are you?
Lily:
I'm in North Carolina right now.
Chris:
On the East Coast. And how you doing?
Lily:
Doing great. How are you?
Chris:
I'm excellent. Really excited that you are willing to take the time to talk to me again about your new book, Real Food For Fertility. This is your 3rd appearance on the Nourish, Balance, Thrive podcast. The first time, I think, you talked about real food for gestational diabetes, and then you talked about real food for pregnancy, and now real food for fertility. I'm just wondering why didn't this book come first?
Tell us about how you came to I mean, I probably know how you came to be interested in fertility, but tell us about how you became interested in writing a book on fertility.
Lily:
Well, I mean, I really spent a lot of time in the pregnancy space. So ultimately those books had to come first hitting the my biggest pet peeves.
Chris:
I see.
Lily:
In a row, I guess. But, you know, when you start focusing on nutrition for optimal pregnancy outcomes, if you're really getting into the nitty gritty, this not only has anything to do with what you eat during pregnancy, but we set the stage for a healthy pregnancy ahead of time. Right? So with the gestational diabetes conversation, yes, we wanna focus on blood sugar management and pregnancy, but was there something going on preconception that could have played a role in the diagnosis have even been avoided or the severity lessened? And that goes all the way back to preconception.
So especially when you're thinking not just about the pregnancy complications but like issues with early pregnancy. Everybody knows the whole connection with folate and neural tube defects. I mean there's even whole public health campaigns about addressing this deficiency preconception because we know those neural tube defects develop in the very earliest weeks of pregnancy. So we have to optimize nutrient intake ahead of time. That same logic applies to all the things.
Metabolic health, blood sugar balance, multiple different micronutrients and it extends to the partner too. We not only wanna focus on mom's health, we wanna focus on dad's health. So you optimize both egg and sperm quality ahead of time giving you the greatest chances of healthy conception, healthy implantation, a healthy embryo, healthy development of the placenta, and all the things. Like, a healthy pregnancy follows those steps. So, yeah, in hindsight, sure.
Chris:
Book should have
Lily:
come first. Book should have come first. Definitely. But here we are better late than never.
Chris:
And I think we talked about this on the podcast before, but I saw that with my own wife that her diet is impeccable. Right? Like, she's, like, she definitely, like, she's teaching this stuff. She practices what she preaches. However, as soon as she got pregnant, she got morning sickness and that lessens with their 2nd and third children.
But, certainly, in the beginning, it was, like, all she wanted to eat was stuff that she would never normally eat. And I wondered whether that, you know, the hard work was already done. Right? Like, she'd done a few solid years of eating a very nutrient dense diet. And so maybe it was not as important what she ate during pregnancy and that, you know, like, that trajectory had already been set.
Lily:
Yeah. And it can certainly lessen your fears early on that, oh my gosh I had all these plans to eat super well and now my symptoms simply do not allow me to. Little interesting tidbit that the embryo in those early weeks is actually sustained by the endometrial glands. So there's actually glands within the endometrial lining that are supplying the nutrients for that growing embryo. So technically, like, until you have a placenta fully formed, you're kind of relying on the nutrients that were already stored in that endometrium.
Right? That's what shed each menstrual cycle. So that's like that last month or so leading up is housing those nutrients. It gives you a little bit of a little bit of like, rest assured everything is gonna be fine even if I'm subsisting on, you know, buttered sourdough bread right now. You'll get through it.
You still have you the work was done ahead of time, really.
Chris:
The scope of the book is big. And I think with the title Real Food for Fertility, you've underpromised and overdelivered because this book is so much more than just a book on nutrition. There's a lot of anatomy, physiology, some really interesting stuff like what you just mentioned. I'm wondering why did you make that decision? So you took a co author, Lisa Hendrickson Jack.
Is that correct? Am I pronouncing that correctly?
Lily:
Yep.
Chris:
Talk about your decision to to make the scope of the book so much larger than just nutrition.
Lily:
So the concept for this book really was something that Lisa and I floated around for many years. Lisa is a good friend of mine. Her specialty is fertility awareness and the menstrual cycle. We were actually like book writing buddies back when I was writing real food for pregnancy and she was working on her first book, The 5th Vital Sign. We've met weekly for well over a year as we were writing those books.
So we have like very similar research and writing and citation styles. So I knew those would mesh but her level of expertise on the menstrual cycle and ability to pull in research on it, specifically. There's a lot of people who claim to be experts in fertility awareness and they just they don't actually read research. Okay. They're just repeating what they learned in their certification program, and that's it.
Lisa really goes into the weeds to even question whether what she was taught is actually accurate. So we have kind of a similar approach to our areas of expertise. But the reason that I wanted to bring her on and you know she wanted to write this book with me as well was so that we could kind of blend our own individual areas. So when I'm diving into the nutrition stuff, even if it's covering kind of the general concepts or things that she would do with her clients, I'm just taking the level of detail that much greater and likewise any of the steps she brings in on the menstrual cycle is so much deeper than I would ever even know to get into just from her area of expertise and client experience. And you know ultimately you can have everything dialed in super well, nutrition and lifestyle, but if you're not getting the timing right with sex, you're not going to conceive.
It has to occur during a woman's fertile window. She has to know how to identify that fertile window. For some women and those who are healthier, of course, it usually is kind of obvious when the fertile window occurs, but not everybody has those same obvious signs and symptoms. And so we wanted to bring in the importance of awareness over this fertile window, identifying it, charting it. And so that could be used in conjunction with all the lifestyle stuff.
In addition, when there's issues with the menstrual cycle, it's kind of a window into what could be going on with the body. It can help guide maybe further diagnostic testing for a work up for polycystic ovarian syndrome or hypothalamic amenorrhea or endometriosis or a thyroid condition. When you start to notice and become aware of oh this could be a sign of something else, you can get better diagnostics. I mean women's health as a whole were under acknowledged in many of our issues are, oh, that's just your cycle. Oh, just go on the pill.
Oh, just do all these things. We needed to build in the conversation around the menstrual cycle, the conversation around birth control and how that can affect, you know, return to fertility, when you should come off of that preconception, all of that. I just knew that with Lisa's experience and sort of depth of research that she goes into, it would be a good match to work on this together rather than have it be a solo project like my other books. And that's why it really is I mean, 2 books in 1. Arguably, kind of 3 books in 1 because the sperm quality chapter, Lisa was actually gonna make that into its own book at one point.
So it's really kind of a 3 in one. There's a lot to cover with fertility. I mean fertility is simply a reflection of overall whole body health. So it's hard to make this a short and sweet read. It's necessarily detailed even though we tried to cut out as much redundancy as possible and make it really, like, data packed and try to make it flow and all of that.
But there's just some topics that you can't completely skip. You know?
Chris:
Yeah. I totally get that. You can't yeah. Exactly. There's you have to talk about all of the things.
Right? Like, you it's impossible to skip parts. I do appreciate the evidence based approach and being able to dive into some of the references that you cite during the text. And I'm kind of impressed by them. The first time I went into the references, I was on number 80.
And I'm searching around in your PDF document for the for reference 80. And then I realized that the numbering, it starts from the beginning again for each chapter. So it's not like reference 80 in the whole book. It's like reference 80 in the particular chapter that I was reading.
Lily:
There's over 23100 in text citations, and as you noticed by looking at the reference list, many of those cite more than one study. So we don't even know the full citation count at the end of the day. It's a lot and the reason we had to do a PDF download, I mean the book was already 500 pages and add if we added the references that would have added another 200 pages. And it's like people don't wanna spend an extra $10 on a book or whatever and have it be 700 pages and lug it around this giant brick. So we're like, alright.
Those will just be a a PDF download freely available on real food for fertility.com com if anyone wants to peruse the citations.
Chris:
Yep. It's very helpful. How big of a problem do you think fertility is for people today? And so there's an answer there you could give from the literature and then there's another because you you and your co author work with clients I understand. And how big of a problem is it for your
Lily:
clients? I mean, it's huge. So by the stats, we're looking at approximately 1 in 6 couples. I think those facing fertility challenges are probably more likely to reach out to somebody like Lisa or myself or another healthcare practitioner. So we're probably seeing a higher proportion of that.
It's huge and as we see the rates of infertility increase I think we're seeing more and more couples try to take action on this at an earlier time frame. The unfortunate part is still conventionally it seems like when there's fertility challenges or delays in conception, they almost always go to the woman first. They start working her up for some diagnostic screening and see what's going on and let's test this hormone level or AMH or whatever. And they're not always testing the men. And male factor infertility contributes to 50% of cases and 20 to 30 percent of couples that's like the sole onus of the fertility issue is a sperm quality issue.
And yet there seems to be this reluctance to test men. I feel like if a couple is having delays in conception, you should just automatically default to screening both of them, but that's not typically the case. And then on top of that the sperm quality standards like the WHO standards have declined over time. So in other words, they keep adjusting the norm down which makes less men test as subfertile or infertile as if you were screening them, you know, in the 19 eighties or prior. And so a lot of times they're told, oh, it's fine.
Everything's fine. But are their parameters actually optimal? A lot of times they're not. And we have tables in the sperm quality chapter showing, you know, how those have dramatically shifted over time.
Chris:
That did strike me. On the one hand, as as an engineer, you would think, well, yeah, maybe, of course, maybe of course, you'd look at the woman first just because her physiology is so much more complicated. Right? It is more complicated than men. But then, on the other hand, you know, there's this background statistic.
I think I've got it here. The 19 forties, a 114,000,000 per unit volume of sperm. And then 2011, that number has dropped to 47. I'm like, what in the heck? What is going on there?
I'm not sure what is going on there. Do you have any idea what might be going on there for men?
Lily:
You know, I feel well, why they've changed the reference ranges or what's going on.
Chris:
I mean, that's happened everywhere. Right? Like, even clothing size. Right? I I used to be a medium in everything.
And now, I'm a small in everything. Like, what happened? Like, I didn't I'm the same size as I was when I was a kid. Right? Is that so I understand why Why
Lily:
is the quality declined over time? Why is the quality declining? I think that's,
Chris:
the $1,000,000 question. It's multifactorial. I don't think
Lily:
we can point the finger at one thing. Right. I think It's multifactorial. I don't think we can point the finger at one thing, but I think certainly our modern lifestyles do not align with optimal fertility, the way in which we work ourselves to death, high stress, not enough sleep, not living with like circadian rhythm and like light patterns. The food quality has certainly gone down, I mean the American diet, 58% of calories nowadays are from ultra processed foods.
These are like default foods that have very few micronutrients in them and very little protein. So we have, like, a lot of calories, but the nutrition in them is just diluted relative to the forties. Many of these ultra processed foods or ingredients didn't even exist yet, right? Sedentary lifestyle or even on the flip side for some individuals over exercising can have like both of them can have kind of polarizing effects but certainly sedentary lifestyle would apply to the majority of Americans these days compared to you know previous generations. Chemical exposures, there's so many chemicals out in the environment.
Not only what's like in our food, what's in the air, what's in the I mean I live near like a conventional farm field. The other day they're just aerial spraying with the planes flying in and spraying pesticides. I'm like, great. Guess I'm gonna spend the afternoon inside. Right?
I mean, it's everywhere. So I think you have all of those things combined and probably many more I haven't even mentioned. I think it's just a result of how out of sync we are with nature.
Chris:
How How much of it do you think is a generational difference, especially for women where they're waiting much later in life before they even start trying. I mean, perhaps you could make an argument that fertility declines in men too. But certainly for women, it's a normal part of their life history to where a third of their life is spent postmenopausal. Clearly, there seems to be a trend where women are Right. Longer.
Lily:
Correct. Men continue producing sperm forever. The quality does decline over time, but you don't have that precipitous decline and then complete stop and, you know the release as you do in women where we have an endpoint at menopause. So certainly delaying families until later on plays a huge role. We do see precipitous declines in egg quality and then we see higher rates of challenges conceiving, early miscarriage, those sorts of issues especially as you get over age 35.
Not saying that it's not possible to conceive at those ages. I mean I completely disagree with the whole like geriatric pregnancies and advanced maternal age and that that stuff. I know plenty of women who can see even to their forties. It's just on a population level proportionally a greater number of those pregnancies occurring at later ages are lost due to miscarriage. There is simply a decline in our mitochondrial health which affects our egg quality.
And as we approach menopause, our hormones are changing as well. This is just a natural part of our physiology. The healthier you are, the greater emphasis that you have on optimizing your lifestyle factors. The greater chance that you can conceive at later ages. But there is a decline over time.
So yeah, if you had people you know getting married at 18 or 20 and having kids right away, and now you're waiting until 28 or 38 to start your family, then yeah we're going to see differences there. And some of that is just due to the like I said, this natural process of decline in hormones, decline in a decline in mitochondrial health that can happen over time. So that's the elephant in the room. I think most women are acutely aware of that issue though. Right?
But I think a lot of times in our culture the default is to just rely on on assisted reproductive technology and we do talk about how that's not always your you know golden ticket. I think the success rates of those interventions are sometimes oversold where you think oh well, I'll just do it later, freeze my eggs and do it later. It's like the success rate is not 100% with those interventions. And that's the great challenge with this generation and the coming generations especially as it becomes really kind of unaffordable to have a family. You kind of like you're setting yourself up for economic challenges potentially if you have a family really early before you have a career established.
So it's like what do we do? This is the societal conundrum. I don't know that I have, perfect answers to.
Chris:
No. I mean, there aren't perfect answers, only trade offs. I have a close friend that I'm in a book club with, and he just had a baby, and he just moved back in with his parents. Like, that's how he solved the problem. Right?
Like, neither of them earned a lot of money, and they didn't wanna wait any longer. And he had a great relationship with his parents and just moved back in. Right? That's what kinda solves the financial challenge to a certain extent.
Lily:
Right.
Chris:
I do think a lot about mismatch. You know, you talk about that in the book. The I this idea of evolutionary mismatch and, you know, the difference between our modern environments and the inputs our ancient genes are expecting. I'm very sympathetic to that. And I wondered whether it was somewhat remiss of you to not mention that, you know, for all of human history, women would have been either pregnant or lactating from the age of 18, say, until whenever they hit menopause.
And that too is a mismatch in the same way as taking hormonal birth control and suppressing ovulation and normal menstruation is also a mismatch. I mean, this must be something you've thought about. Right?
Lily:
Oh, yeah. I mean, yeah, traditionally, you would be having starting to have babies much younger and probably have a lot more babies. So what yeah. What is that effect on female physiology as a whole? Like for example we see like lower breast cancer rates in women who have more children and lactate for longer.
It could be for a variety of reasons but yeah there's a difference in the levels of hormones and things that you're exposed to when you have that sort of lifetime trajectory. In a lot of cultures, pregnancies were also spaced differently. So it seems like you know nowadays a lot of women are waiting until later to conceive and many for that reason or maybe for other reasons they want closely spaced children or they feel like they're running out of time or whatever. But a lot of women are having pretty closely spaced back to back pregnancies. And in many cultures it was the norm to give minimum of like 2, 2a half, 3, or even 4 years between pregnancies.
So a longer duration of lactation before having the next child, but this also allows for greater amount of time to rebuild your nutrient stores for your uterus to fully remodel and recover. So that's definitely different as well. And I think there's something to do with, you know, every time you have a baby, your uterus completely remodels, right? And it seems like that makes it potentially easier for you to conceive in the future. Like women who've had babies at a younger age, they have an easier time getting pregnant in their forties than women who are having their first child in their forties.
Right? Something about that like uterine remodeling or maybe some of the hormonal exposures or having previously breastfed for a while. Whatever it is, It does seem like having some pregnancies at a younger age does help if you choose to conceive later on. So yeah, it's a different time. It's a different time, it's a different culture.
Maybe once upon a time, I mean I think about my parents families. My mom is 1 of 5, my dad is 1 of 3, and those were not necessarily very large families at the time because they were both born in cities. You look at farm families and they're oftentimes much much larger than those who are in more like urban suburban environment. So this definitely has changed over the generations.
Chris:
Talk about your optimal approach to nutrition for fertility. And is there any difference between the approach for men and women?
Lily:
So there surprisingly isn't that much difference between men and women. I think you can call out some specifics for certain micronutrients that have been studied in-depth for like enhancing sperm quality for example versus those for egg quality. Although there is overlap in those as well. But I would say from the point of sort of general dietary guidance if you're starting with like macronutrients for example. Protein is absolutely essential for both male and female fertility And I think as a whole, our dietary guidelines way underestimate optimal protein intake.
People are shocked actually when I bring awareness to, you know, the recommended dietary allowance for protein versus what they may be accustomed to trying to aim for. I mean it's like it equates to like 10% of calories as protein. It's a really low intake level which then necessitates that you're getting the rest of your calories from carbs and fat. And since they want you to keep your fat low then you eat a ton of carbohydrates which hasn't bode well for overall health or fertility I think over the last couple decades. So definitely prioritizing protein.
Arguably we're gonna need probably double or maybe even more from what the RDA is suggesting. We need making sure that those protein rich foods you're not taking all of the fat out of them. So that whole practice of taking the yolks out of eggs and just doing egg whites, taking the fat out of milk and just do low fat milk. The fat off your steak, the skin off your chicken and so on. That's removing a lot of key nutrients.
You look at the data we have on vitamin a for example, absolutely essential for both egg and sperm quality and when you're taking all the fat out of your animal foods, you're taking out that vitamin a which is a major issue. So the protein and fat component not skimping on that and then when it comes to carbohydrates, quality carbohydrates. Like I said the majority of American calories now are coming from ultra processed foods which is for the most part. High fructose corn syrup, white sugar, white flour, poor quality like seed oils and vegetable oils, and then all the other like chemical ingredients that aren't even food. So choosing whole food carbohydrates, plant foods that come as they are in nature or are prepared in a way that's optimizing their nutritional profile.
So maybe certain vegetables you cook because that eliminate some of the or reduces the levels of some of the compounds that can be detrimental to our bodies like goitrogens for example and our cruciferous vegetables. We're fermenting our grains or soaking our legumes before we cook them so you're losing some of those tannins and lectins and phytic acid and these other things. As you see so many traditional cultures do, but these whole food carbohydrate sources do not spike our blood sugar or insulin levels anywhere near to the degree that refined white flour does. Right? So basing the diet on whole foods, a very protein forward approach with quality carbohydrates is what I see working the best for both men and women, you know for slightly different reasons.
I think we see some specific nutrients called out for you know looking at sperm quality that you aren't necessarily seeing that same research on egg quality. Not that it doesn't apply, but likely because it hasn't been studied yet. Right? That's there's a lot with that in the research where I'd love to have data on this nutrient and egg quality, but it simply does not exist at this time.
Chris:
Uh-huh. Do you have specific protein targets? I I find it so interesting that over the past 10 years of interviewing physicians and scientists, this topic of protein dilution and inadequate protein. And it seems to apply no matter what your goal. Right?
If you're talking about body composition or metabolic health or athletic performance, nobody's eating enough protein. And now, of course, fertility. But do you have a specific targets that you you try and hit with your clients either male or female, like grams of protein per kilo of body mass for example?
Lily:
Yeah. So if we look at like our RDA, it's set at 0.8 grams per kilogram just to kinda level set here. Most of the protein researchers are calling for no less than like bare minimum of 1.2 grams per kilo and it's arguable that optimal is closer to 1.5 to 2.2 grams per kilo. At 2.2 grams per kilo that's a pound or a gram per pound of body weight for those who aren't measuring their weight in kilos. So substantially more than what the current recommendation is and certainly people who are more athletic.
I would say men on the higher side but also people who are more athletic on the higher side. So for female athletes for example there's a lot of research suggesting about 1.6 grams per kilogram as a bare minimum for female athletes.
Chris:
And what do you think about fish? It seems that fish contains some nutrients that are critical for fertility, but but they may also contain some toxins that we might want to avoid. What's your stance on fish?
Lily:
So the overarching data on fish despite there being some mercury or other environmental contaminants is that overall those who consume more fish have a greater chances of conceiving in any given cycle And that seems to be related to the micronutrient content. Of course it's a you know high protein food, there's you know some of that but the concentration of certain micronutrients that you may not be getting from other sources probably has more to do with this finding. So of course the omega 3 DHA, everybody always wants to talk about that and that is valid. But beyond just what you can supplement on the side with fish oil and not actually eat the seafood itself. You have iodine, selenium, you have vitamin d.
Yes we get most of our vitamin d from sun exposure but fish would be one of the number one sources of vitamin d in the diet. You also have some unique amino acids like taurine is particularly high in fish relative to other protein rich foods. So I think it has more to do with the micronutrient concentrations than anything else. As for some of the contaminants, the mercury for example since there's high amounts of selenium in the majority of seafood certainly not all there are exceptions that does seem to offset the mercury exposure to some degree. Actually just came across a paper where they were trying to classify like a recommended seafood relative not only to like the mercury concentrations but the selenium concentration.
You could kind of take that into account. You probably enjoy the articles. As an engineer, I think it's still kind of in the working stages of recommendations, but a lot of times our recommendation solely focus on the mercury and it's like avoid all the high mercury fish but something like tuna which is generally high in mercury is also really high in selenium and so it seems to offset that exposure potentially. Help your body you know buy into the mercury and have it not exert the same level of toxicity as if it was a low selenium high mercury seafood source. I also think we need to be looking at the way in which the seafood is prepared.
There have been some studies showing not so favorable effects of seafood on fertility when the seafood is deep fried. So that probably isn't a fish's fault. That's probably the fault of the breading and the seed oil that it's fried in. So that's another consideration.
Chris:
I wondered what you thought about the size of the fish too. In fact, I think I know this is in the book if I remember correctly. And then this is like another cultural problem as I see it here in California where I am right now. There doesn't seem to be a culture of eating small oily fish. Whereas, I've just come from Lisbon in Portugal where they have stores on high street dedicated to selling sardines.
Like, all the whole store just contains cans of sardines, all different varieties. This is like an incredible culture there of eating small fish. Whereas in the US, not so much. And I assume that eating small fish that have had less time to bioaccumulate toxins like mercury would be advantageous.
Lily:
Absolutely. Yep. There's a definite correlation with the size of the fish and the mercury levels for sure. Yep.
Chris:
Are there any other micronutrients that you'd want to target as either a man or a woman looking to get pregnant?
Lily:
I mean, all of them?
Chris:
All of them. I don't skip yeah.
Lily:
That's a
Chris:
good answer.
Lily:
I mean your b vitamins for sure. Folate in particular, there's data on both sperm quality and egg quality with folate. And of course, for the woman, you want her folate status to be good leading into pregnancy for helping with the reduction of neural tube defects. Though if you look at the data on neural tube defects, there's a lot more nutrients beyond folate that contribute to reducing the risk of those from developing. So you can extend that to virtually all the b vitamins.
You can add in zinc. You can add in avoidance of toxin exposures including mercury. You can include optimizing blood sugar levels as well. All of those things help to work in tandem for reducing the risk of neural tube defects. And then any things that are involved in the whole methylation and folate cycles.
You can throw in choline and butane and glycine into that conversation as well. When it comes to both egg and sperm quality, we wanna also be thinking of antioxidant intake too. So you know certain nutrients are also antioxidants, vitamin e, selenium, vitamin c and those seem overall to show positive effects for egg and sperm quality. But there's also some specific antioxidant compounds which do occur in foods but oftentimes in these trials they're using supplemental sources. So alpha lipoic acid, coq10, those are some good examples of ones where there's pretty pretty decent data on both the male and female side.
Then you can get into some more specific ones like, you know, if you get into the blood sugar balance part of the equation. We have a lot of data on Inositol which is a b vitamin like compound. I don't know off hand if there's anything on sperm. I can't recall that at the moment but there's quite a bit for improving female fertility especially for women who are struggling with polycystic ovarian syndrome or any kind of insulin resistance. And then general population wide, anything blood sugar related.
We have a lot of trials on type 2 diabetes, sometimes they even use inositol and metformin head to head. Right? One group gets Metformin, one group gets Inositol and we see what happens with their blood sugar management. We have head to head trials of that on women with PCOS and often times they show equal effects, sometimes greater beneficial effects with the inositol. Just getting that blood sugar in line is so key when we think about antioxidants.
We don't wanna overwhelm the body with glucose. I mean, you can have glucotoxicity in your mitochondria. You get, you know, too much glucose building up in your system that your body is not able to utilize and oxidize. So inositol is a really key one as well.
Chris:
What do you think about tracking macro and micronutrients? It seems to me that this is a problem where you really want don't wanna get it wrong. Right? Like, there's some irreversible harm that could be done to a baby if you were deficient in a micronutrient, say, and you've already mentioned folate and neural tube birth defects. Do you have your clients track micronutrients with an app like chronometer or maybe something else?
Lily:
It depends on the client. It's funny I actually have like a group of mentees in the Institute For Prenatal Nutrition and one of the assignments is a nutrient analysis assignment. And then we just went through that like last week. So it's funny you're bringing this up right now. I think it depends on the client.
I think if there's any indication in an ideal world, everybody would have done some level of nutrient tracking at some point to see that they're at least hitting some targets on some key micronutrients. I think there's some exceptions for people where that is more harmful than helpful like those with the disordered eating background. Sometimes having them track things like fuels those disordered behaviors even more so I think it depends on the client but I do think it's a great idea to for most people to do like 3 days or a week even to see where they're at particularly if there's any dietary limitations. The more foods that you start taking out of your diet particularly if you're taking out like full categories of animal foods out of your diet. So no seafood, no eggs, no dairy, no red meat, no organ meats.
You're more likely to run into challenges with hitting the targets for certain nutrients particularly for the animal foods we're thinking of protein in general but there's a whole chapter on vegetarian diets going through like all the different micronutrients. You can even with chronometer check-in on your you know, amino acid intake as well to see if you might be falling short on some of those. There's also this would be you know probably a more, I don't know, difficult case or maybe somebody who simply has access to more resources for testing or other things. You can run like a comprehensive micronutrient analysis to see if their status for these nutrients is okay. So to have a proxy beyond just tracking what's in their diet.
Some of us have higher metabolic demands for certain nutrients than others. So where is our status for folate and b 6 and all these other things. That's another option.
Chris:
What did the chapter on vegetarian and vegan diet say? I couldn't even go there. I'm just like too old and grumpy to even entertain this idea. You know, I feel like there's 2 possible reasons why someone might be vegetarian or vegan in general as well as when they're thinking of conceiving. One is they think it's optimal for health, in which case, and especially this case, they're just plain wrong.
And then there's the other case where they think that they're doing least harm to animals. And I find I'm slightly more sympathetic to that, although not entirely convinced. But you still have to question the decision making because you're putting some other animal ahead of your unborn child, which I find questionable at best. But I I mean, you entertained it by writing a chapter. How do you feel about it?
Lily:
So, you know, I have close loved ones who choose to eat a vegetarian or even a vegan diet. And so part of the reason that I approach this topic, I think, with such care and also keeping it so data focused and non emotional is that you're not gonna change anybody's mind. Right? Like, people are gonna do whatever they're gonna do. I'm certainly trying to go at it from the angle of definitely making them aware of the nutritional shortfalls, how this shows up in the menstrual cycle and how this can affect conception.
But you'll notice at the end of that chapter, a resource I've been asked for quite a bit from people who've read my other books like Real Food for Pregnancy, you'll notice there's like a little section at the end of the foods to emphasize chapter addressing a vegetarian diet. Mostly from the angle of the micronutrients. And in this book we chose to have it like a full separate standalone chapter going into way more detail on some of the pitfalls. But also that section in there that I think is so key is one that everybody has asked me for. Because a lot of people have chosen to discontinue their vegetarian diet after reading Real Food for Pregnancy.
But they're like, I don't know how to do it. And so part of what's in this chapter 5 in Real Food for Fertility is a little bit of hand holding to help you kinda reassess. Okay. You may have chosen a vegetarian or vegan diet for some reason. Whatever it is.
You listed a couple. There can be other reasons. But does that rational still apply now? Your goal is currently to have a baby.
Chris:
And not just any baby.
Lily:
Right? Right. Hopefully, a really healthy baby. We'll hope A
Chris:
really healthy baby.
Lily:
But you know, if you've been unable to optimize your menstrual cycle parameters while following a vegetarian or vegan diet because we've just gone through that in the chapter. Then like maybe you wanna reassess your reasons here and then we go through all the different options for how to go about reintroducing animal foods because that's the scariest part for people is when they've been vegetarian or vegan for a long time and they've dealt with the side effects, and they're kind of reckoning with you kind of have to give up part of your identity. You may have to give up your community particularly those who have been in the animal rights or the environmental activist kind of setting. We have more environmental activist nowadays who kind of acknowledge the realities of the carbon cycle and the benefits of regeneratively raised meat and all of that. But for some of them, if their whole environmental group is around not consuming animals because of you know cow farts and methane gas and that whole part of the conversation which I think Diana Rogers does a great job debunking in the sacred cow book.
You may have to actually give up your community. Like this is part of your self identity. We have some vegetarians who they've chosen the diet, maybe they're using one of these other reasons for choosing it as sort of a cover but they essentially chose to eat vegetarian because as a way to control their calorie intake. There's a significantly higher rate of over eating disorders and disordered eating behaviors among vegetarians and vegans. I mean think about it.
If you wanna find a way to restrict your food and you're like, oh well I'm vegan now. Does that have oh sorry, like I can't it gives you an out for virtually any, you know, get together with friends and family. You don't have to consume that food. Oh I'm not I don't eat that. Oh I'm vegan.
Oh I can't have that. You know, so we also have, you know, that to contend with. I mean, it kinda brings up a lot of stuff. Like this is a really charged topic for people and not everybody is going to finish that chapter and be like, I'm not gonna be vegetarian anymore. And you know, for what it's worth, if they're still going to include eggs or dairy products, there's a lesser chance of significant micronutrient deficiencies.
Although we still have clients that despite trying to optimize, they just cannot get their menstrual cycle and their hormone levels where they need to be and they only see these things improve and are only able to conceive once they've added some more animal foods into their diet. And that's the I don't know. I feel like we're at kind of this very interesting turning point as a society. On one hand, we have all of this effort being given to getting people to go plant based. And then on the other hand, I see feel like I see more recovering vegans sharing their stories openly than ever before.
Right? So it'll be very interesting to see how this plays out in the next, you know, 5, 10 years.
Chris:
I do like this idea space. You know, in health, generally, behavior change is very hard and I got lucky by choosing this particular problem of athletic performance. But people are willing to change the behavior for it and it's usually measurable objectively. And so you know when it's working. Right?
You can't argue when it's working. And the same is true here. Like, you've got this 5th vital sign in your menstrual cycle. Like, is it working for you or not? Like, right?
You and you can see the difference, measure the difference when you make changes. And, of course, am I pregnant or not is another very objective question that you can answer. And so Yeah. I'm more optimistic, shall we say, about behavior change for this particular problem than some of the others.
Lily:
This is true. This is true. I don't think you're ever gonna find a more motivated client than someone who's either very actively diligently trying to do everything to optimize conception or on the flip side somebody who's currently pregnant. Like these these are the most motivated groups of people.
Chris:
You love me. Speaking of sacred cows, how do you feel about alcohol and caffeine? Take alcohol first.
Lily:
In an ideal world, I would say minimizing or avoiding alcohol is optimal leading up to conception. So we do cite some papers on alcohol. It does affect of course the liver and you have to expend nutrients for detoxifying alcohol. It affects your estrogen metabolism so often resulting in higher estrogen levels because your body is not as busy sort of changing those estrogens into nicer, more well behaving estrogens versus the ones we're trying to get rid of. So we see shifts in estrogen metabolism and certainly on the nutritional aspect.
I think you should be prioritizing as much as possible sort of shunting those nutrients to essential bodily functions versus having to waste them so to speak on detoxifying and overtoxin. Right? I do think some people are more susceptible to issues with alcohol metabolism than others. Of course we know there's documented genetic differences for example in the way that people process alcohol so I think some can get away with a small amount of intake without having you know noticeable negative effects. Others are much more sensitive to it.
So you know if in doubt leave it out if you can or at the very least minimize. And caffeine is somewhat similar that's harder to like take away from people. I think even person to person there's differences in how well we metabolize caffeine, But as you get to the higher levels of intake especially as you get towards like 2, 3 cups of coffee a day for example, that's when we start to see greater issues. And some of it may not be the caffeine itself but like the behaviors that people have with caffeine consumption where so many people are consuming coffee in lieu of breakfast or they're using the sort of appetite suppressant effects of caffeine as a means of reducing their food intake and with fertility if you're not eating enough food you start having hormonal disruptions and issues with the menstrual cycle arise. So I think some of it can be carry over from that as well.
So our recommendations on a lot of these things are not super cut and dry. Absolutely cut it out. But if you're noticing cycle issues an obvious first place to start would be to start decreasing your consumption of things like caffeine and alcohol and then watch for whether there's changes in your menstrual cycle or not. With caffeine to you know if you're delaying your caffeine consumption until you've had breakfast, some people are better able to tolerate that without a cortisol spike and the you know disruption they get to their hormones as much when they have it, you know, along with or after a meal versus first thing. So we're kind of in favor of playing around a little bit to see what's gonna work best for you without overtly telling everybody, like, no wine, no coffee ever.
Cause you know there's people who do okay with it. I'm a tea drinker, a caffeinated tea drinker. I do okay with it. Coffee is kind of a wreck for my body, so I don't do coffee. But the next person may do just fine with coffee and have no issues whatsoever.
Chris:
Well, as you point out in the book, if you're you know, the first time you missed a period and you're pregnant, then you're already, by definition, 4 weeks pregnant. Right? And so if alcohol and caffeine are not good during pregnancy and you're aiming to get pregnant, then why would you not just start in the way that you wish to continue whilst pregnant? Would you agree with that?
Lily:
You certainly can take it from that angle too. Definitely the alcohol for sure. I mean in pregnancy technically you know you have that like 200 milligram or so allowance for caffeine. So you can have some without causing like over detrimental harm. Even with alcohol, there's you know questions raised on how much is truly tolerable or not.
But when you're taking it from the angle of optimizing certainly from a standpoint of trying to optimize your chances of conception like getting everything dialed in ahead of time, getting your protein dialed up, getting your carb quality in check, cutting out or greatly reducing intake of things that can potentially be harmful like alcohol, caffeine, that makes sense, you know. Yeah.
Chris:
And is that true for the men as well? What you just said about alcohol and caffeine?
Lily:
That's a good question. I'd have to look a little bit closer on the caffeine and alcohol section of that sperm chapter because I'm pretty sure we've wrote about it. I don't have it right in front of me. Alcohol for sure defects men as well. Caffeine, you probably don't need to be quite as strict as women and again some of the behaviors we see with caffeine consumption can be more relevant here than the caffeine itself like the super sweetened processed creamer or having it in place of having meals.
I know I feel like I know more men than women that completely skip meals. Now it's like cool, you just call it intermittent fasting, but there's a lot of What it
Chris:
really means is let me describe your day. You get up and you drink 5 gallons of coffee, and then you eat £20 of food for dinner, and then go to bed with the fullest stomach I could ever tolerate. Yeah. Exactly. That's what's happening here.
And then it's we call it intermittent fasting.
Lily:
Now it's cool. Right?
Chris:
Yeah. Yeah. I find it interesting that I've met lots of women that have coffee aversions during pregnancy. They're just like coffee doesn't smell good to them anymore. It doesn't taste good, especially in those, you know, the first trimester.
Have you do you you must be seeing that too.
Lily:
Definitely heard that. In fact, my mom, I remember her telling me that with her pregnancies. That was one of her first signs that she knew she was pregnant because coffee didn't smell good anymore. So
Chris:
yeah. Okay. One last question. I can't resist asking you about PCOS. We had Ben Bickman, who you probably know
Lily:
on the
Chris:
podcast previously. And he was the first person I heard very eloquently describe the mechanism of insulin resistance and underaromatization, estrogen deficiency. Can you talk you describe it also eloquently in your book.
Lily:
If you're gonna ask me to rival Ben Bickman, he's like the clearest. I love his explanations.
Chris:
It's really good.
Lily:
It's really good. I'm
Chris:
not I'm not gonna ask you to rival Beck Bickman in the mechanistic description. I think there's one just as good in the book, and I'd encourage listeners to read the book. What I wanna hear from you is how you go about this as a practical concern from a nutritional perspective.
Lily:
Yeah. Yeah. Love Ben Bickman. We are both at metabolic health summit as speakers in January. I I always love his talks.
It has a brilliant way of just breaking things down with analogies so so clearly. Yeah with PCOS I mean the majority so there's different subtypes of PCOS. Although I feel like the way on social media for example, there's so many people who try to make such a big deal about the PCOS sub types and they do matter because you do occasionally have people who fall into some of these less common ones. But the majority of PCOS cases have a significant level of insulin resistance going on and it only makes sense to address that head on for the majority of PCOS cases. And in fact just for general fertility as a whole, even with people without overt metabolic dysfunction or insulin resistance issues, we see the highest rates of conception in those who have the most optimal blood sugar levels.
So it doesn't hurt to optimize your blood sugar balance regardless of what kind of diagnosis or not that you have. PCOS just makes it that much more likely that there's an insulin glucose component going on. So I mean I feel like we tried to tackle this as simply as possible in the book and I think I approached it somewhat similarly in how when I was first writing about gestational diabetes, there's so many places where you can get side tracked and lost in the nitty gritty details. It's like focus people. Focus on the blood sugar.
So optimizing your protein intake, minimizing refined carbohydrate intake, and for many individuals, titrating down your carbohydrates to a level of good glucose tolerance is key. So there's so many different studies on nutritional interventions for PCOS. The ones that have been most effective zero in on increasing protein and decreasing carbohydrates. We have trials that do a full on ketogenic diet showing pretty significant benefit. I don't know that everybody necessarily needs to do a ketogenic diet, but when you have a case that's quite resistant to treatment and there's somebody who you know maybe benefiting from something like Metformin for example, that would be an individual that I would be much more inclined to get them towards a ketogenic style diet.
But certainly a high protein like a protein sufficient ketogenic diet. I think we need to like separate out the different approaches to keto. We have some that are like for the treatment of epilepsy for example that are like 90% of calories from fat kind of an approach. I think that's become a little bit more antiquated but sometimes it's still used in the epilepsy space. We need a bit more balance here like I wouldn't go below 20, 25% protein for PCOS.
You may have a little more carbohydrate tolerance than like 5% of calories or something super low. But certainly that you know protein and fat making up a greater proportion of your calories than carbohydrates does show substantial benefit. There's also been some studies looking at the way in which you consume your foods by kinda front loading your calories at the beginning of the day and ending earlier. Kinda the opposite of the way most people would approach something like intermittent fasting where they skip breakfast and have most of their food in the latter part of the day. There was a trial that wasn't an intermittent fasting trial but they did head to head like same amount of calories but one group had a small breakfast, moderate lunch and large dinner.
And the other group had a large breakfast, moderate lunch, and small dinner. And the group that did the bigger breakfast, smaller dinner scenario had significant improvement even though the calories were matched. There's also been a trial on intermittent fasting for women with PCOS and they did a somewhat similar scenario. They had all their food between 8 am and 4 pm. So getting in that food in the early part of the day and potentially stopping your dinner earlier or having a smaller dinner overall.
Those shifts alone without even getting into any of the other specifics or supplements used for insulin resistance or glucose tolerance that is huge. On your angle of course with the athletic side of things, women with PCOS in particular seem to benefit from a little more like higher intensity and resistance style exercise. They need to build that muscle mass to help to build their metabolic flexibility. So building in the movement piece as well and I won't go into supplements but on the lifestyle side there's a number of hormone disrupting chemicals that seem to play a role in PCOS as well. So just at the very simplest getting fragranced items out of your house.
Fragranced laundry detergent, fragranced dish soap, fragranced handwash, fragrant sprays for God's sake. You know especially the unnecessary fragrance things get them out, Get the plastics out of your house or at the very least do not reheat things in the microwave and plastic. That has a surprisingly noticeable effect on fertility. And now that this book is out and I have like the feedback from the general public hitting my dm's and my inbox, I've had some people say, hey, I didn't even change anything about my lifestyle but I read or my diet really because that was pretty good. But I read the toxins chapter and got rid of this and this and we've been trying for 18 months.
I got pregnant last month. Like they only had like what the books been out since February. They had like 2 months and that change made that much of a difference. So don't discount the effects of hormone disrupting chemicals either.
Chris:
I interviewed an environmental scientist. Her name is Jody a Flores, and she talked specifically about the role of phthalates. That's been a focus area of focus for her lab. And they're really only just getting started. Like, many of these chemicals have been introduced to environments and not well studied.
But it's not looking good for, like, most of them, which is not really surprising if you take this ancestral health perspective to all of the health problems, which I think you and I both do. I only have an hour of your time. And so I think maybe I should wrap up here. And unless there's something else you can think of that I should have asked you.
Lily:
I mean, there's 500 pages worth of material. So it's hard for me to even like I know.
Chris:
It's so
Lily:
hard for me
Chris:
to even, like I know. It's so hard for me to I yeah. I would encourage people. You know, I sometimes do that. I listen to the podcast interview and I feel like I've read the book.
I know to encourage people not to think that because we barely even scratch the surface with nutrition. And there's the whole section on fertility awareness based methods, which I think is super important. There's you know, you've got stuff on lubes and the vaginal microbiome. You know, I wanted to talk to you about the copper IUD and, like, you know, all of this stuff.
Lily:
You gotta have have Lisa on to talk about that stuff and talk about the sort of fallout of the effects of hormonal birth control and how long it takes the cycle to return. Yeah. You should have Lisa on to go into that. That's her forte.
Chris:
Well, I would love it if you would introduce me to her because I really did enjoy this book as a one stop shop for everything fertility. It it really is that. And that's why I say that the title doesn't really, like, reveal what's inside to some extent. And you've done a fantastic job there.
Lily:
Well, thank you. I think if I can add one more thing that I don't know that we touched on in great detail because we're kinda focusing on the PCOS towards the end there. But we also have to talk about the flip side of the coin with the hypothalamic amenorrhea where you have a woman who's lost her menstrual cycle. Sometimes gets misdiagnosed as PCOS which is silly. They're very menorrhea and the issues of are a little bit different overall like your hormone levels are super low because you're usually in a situation of energy deficit in some way.
Either you're over expending through exercise or you're under consuming via food or it's a combination of both. And then there's often times a stress component there. And sometimes the stress plays into the over exercise of the under eating as well. But I just wanna point out that our cycles in our fertility are very much related to energy availability. Our body wants to know that it has enough energy to not only be able to ovulate but to be able to conceive and carry that child.
So one of the first things that our body will take off the table as an option is pregnancy. It'll stop ovulating because it does not want to expand the resources on something that isn't a sure thing. And this is very much like ancestrally built into our bodies. In many cultures like you kind of see with certain animals there's like the mating season and they all have their babies at a certain time of year and that corresponds with like food availability. There were differences in you know birth times and times of fertility based on whether it was like the rainy season or the dry season or in times of famine.
There's like fewer pregnancies and this is because ovulation often stops and or those pregnancies are non viable because you know, you don't have the nutritional resources to continue the pregnancy. But often times the ovulation, your body just stops it before it even happens. And we see these cycle disruptions happening when just calories are cut back by even like 25%. So when we're in this world of diet culture and sometimes people taking nutritional advice to this sort of extreme level, we can perpetuate a situation of under eating as well. So while I'm always talking about optimizing things, it is important not only for there to be like diet quality but just overall adequacy like enough calories coming in.
So I do see in women who are highly athletic for example, they are more at risk for experiencing hypothalamic Menorrhoea and they might be surprised if they do some you know tracking or something in chronometer and see like how many calories do you actually need and are you actually meeting it. When you actually put it on paper, I mean it's so much more whole food than it is ultra processed food. So sometimes you have people who really cleaned up their diet and as a result it might not even be intentional but as a result they've they're suddenly significantly under eating. So I just wanna point that out as well because that's also a thing I see quite prevalent under diagnosed or sometimes even misdiagnosed.
Chris:
Yeah. What you just said is entirely consistent. I interviewed Herman Ponser on his book, Burn. Not sure if you know it, but Herman argued that locomotion, reproduction, immunity, growth, they're a zero sum game. Right?
You've only got so many you've got one energy budget. All of those things come out of that same budget. So if you're spending a ton on locomotion like an athlete, then there's less left over for reproduction and immunity. And that's exactly what you see, what you've just described. Right?
Lily:
Exactly.
Chris:
And, yeah, Herman is a scientist. He's done a ton of experiments in with doubly labeled water in all kinds of people that are super Oh. Including women in pre in pregnancy as well, I believe. I think actually pregnancy is the highest metabolic demands. Like, it's more so for the sustained period.
You know, the area under the curve. It's, like, more so than ultra endurance athletes. It's pretty Yeah. Remarkable and interesting stuff, you know.
Lily:
I'd be curious if you looked at early postpartum
Chris:
too. Oh, yeah. I don't know. They answer
Lily:
to that. That's the I mean, we finally have studies on protein requirements in postpartum like the same team who did the work on identifying the significantly higher demands for protein in pregnancy. They did a study on women 3 to 6 months postpartum who are exclusively breastfeeding and their protein requirements were higher even than 3rd trimester of pregnancy by quite a bit.
Chris:
It wouldn't surprise me because I've seen data on the same as true as like an injury. You know, if you're trying to heal an injury, that also increases demand as well because that's growth. Right? And you just told me the whole uterus remodels. You'd like you're you're kind of recovering from an injury too as well as feeding another human.
Like, yeah, it wouldn't surprise me if
Lily:
this can't show
Chris:
up a lot. Well, the book is Real Food for Fertility. I'd encourage everybody to go out and buy a copy if not for yourself then for someone else you know that might be trying to get pregnant in the near future. Where can people find you online, Lily?
Lily:
You can find me on my website lilynicholsrdn.com on the books tab that links out to my books. There's a separate website for real food for fertility. It's the title of the book.com. That's where you can get the full reference list if you want. We also give away the first chapter for free over there and yeah over on my Instagram is where I'm usually at social media wise but you can find me on the socials at lilynickelsrdm.
Same as my site everywhere to keep it all simple.
Chris:
Excellent. And is there any chance of you working with new clients in any capacity?
Lily:
Not currently, but I do train prenatal practitioners via the Institute For Prenatal Nutrition. We have a graduate directory up there. So these are practitioners who have worked closely with me for a number of months. Many of them are ongoing still working with me and that's where I send new client referrals at this
Chris:
point. Excellent. Well, thank you so much. I really appreciate you writing the book and taking the time to talk to me about it today. Thank you so much.
Lily:
Thank you.
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