pregnancy nutrition

Episode 20: Concerns with a Vegetarian Diet in Pregnancy with Lily Nichols, RDN

In this episode, Dr. Mark and Anisa dive deep with Lily Nichols, RDN into the true concerns for mamas and babies when a woman chooses to follow a vegetarian (or even limited animal protein) diet. Though there is so much to be discussed on this topic, we covered the key concerns of what true protein needs are in pregnancy, essential pregnancy micronutrients often deficient on a vegetarian diet, the differences between animal and plant forms of nutrients, and the challenge of balancing blood sugar on a limited protein diet.

Lily Nichols is a Registered Dietitian/Nutritionist, Certified Diabetes Educator, researcher, and author with a passion for evidence-based prenatal nutrition. Her work is known for being research-focused, thorough, and unapologetically critical of outdated dietary guidelines. She is the author of two bestselling books, Real Food for Pregnancy and Real Food for Gestational Diabetes. You can find her work at LilyNicholsRDN.com and follow her on Instagram: @lilynicholsrdn

We fully understand that this is a controversial topic and ask that each person listening does so with an open mind and accepting the information we discuss from a place of curiosity and in the best interest of mama and babe.

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Show notes

2:45: Anisa’s personal challenges following a vegetarian diet

3:20: How protein needs vary for women in pregnancy and other common concerns with protein in pregnancy

RDA is arguably too low even outside of pregnancy

  • Current RDA: 0.8 g/kg (about 10% of caloric intake). After `13 weeks goes up to 1.1 g/kg

  • Other recommendations: 70g in last 2 trimesters

9:30: 2015 first study on estimating protein needs in pregnancy for Estimated Average Requirements (EARs: meets 50% of group’s needs)

  • Estimated that protein needs in early pregnancy are 39% higher than conventionally recommended and 73% higher than current recommendations for late pregnancy.

  • Downside of not getting enough protein: elevated blood sugar (Gestational Diabetes)

  • Study showed that recommendations should be at least 1.22 g/kg for early pregnancy and 1.52 g/kg in late pregnancy. Study referenced: Stephens TV, Payne M, Ball RO, Pencharz PB, Elango R. Protein requirements of healthy pregnant women during early and late gestation are higher than current recommendations. J Nutr. 2015;145(1):73-78.

  • “There’s a lot of evidence that suggests the RDA is way underestimated when it comes to protein…Based on what we know about nutrient needs in these stages of pregnancy, the goal may even be 1.5 g/kg protein in early or 1.8-2 g/kg in late pregnancy.”

  • For a 134 lb woman (61 kg) current recommendations would suggest 48g of protein needed but if we were to use this study’s recommendation 92g would be needed (almost double!)

12:30: Micronutrients found in protein-rich foods and common protein-rich pregnancy “superfoods”

27:45: Differences between forms of nutrients of animal-based vs plant-based foods

  • 29:00:Omega 3 fats

    • Needed for optimal brain and vision development - another example of a nutrient that when deficient can have irreversible effects. When a mother is not consuming adequate amounts in pregnancy, there are irreversible vision deficits in childhood

    • Forms of omega-3s: DHA + EPA are found together in food sources and they work synergistically together and with choline. DHA is not found in plants (ALA is plant sourced). Some plant sources of ALA: flax, chia, walnuts

    • Our bodies have the capability of converting some ALA to DHA but this is very inefficient. At best the conversion rate is 3.8%. Plus, if your diet is high in omega-6 (concentrated in seeds, nuts and vegetable oils and other plant based omega 3 sources) then this conversion rate drops to 1.9%.

    • When you supplement breastfeeding women with flaxseed oil and measure DHA levels in breastmilk, the levels are no different.

    • The only plant-based source that is significant enough is an algae-based DHA supplement. Like this one.

    • You can get plenty of DHA if you eat 12-16 oz/week of high omega 3 seafood sources (like salmon and sardines)

    • Concerns about heavy metal (like mercury) toxicity: Do benefits outweigh the risks? Avoid larger fish that bioaccumulate mercury like swordfish, mackerel, tuna, shark.

    • Safecatch Tuna: low mercury tuna

    • Most fish are high in selenium that can help bind mercury, preventing from absorbing much of whats in the fish

    • Studies assessing fish consumption and neurodevelopment in babies show it’s worth it: study out of UK 12,000 mother infant pairs, consumption of more than 12 oz fish/week was strongly linked fish consumption to higher IQ and communication skills as worst cognitive outcomes among children whose mothers consumed no seafood in pregnancy, resulting in issues with fine motor skills, social development and communication skills. Neurodevelopmental outcomes were better despite consuming some seafood containing mercury. Seafood is micronutrient rich (B12, DHA, B6 Choline, Selenium, Iodine)

    • Omegaquant RBC fatty acid profiles omega 3 at home test kit

    • Cochrane: >5% RBC DHA reduces risk of preterm birth, study referenced: Middleton P, Gomersall JC, Gould JF, Shepherd E, Olsen SF, Makrides M. Omega‐3 fatty acid addition during pregnancy. Cochrane Database Syst Rev. 2018;2018(11).

  • 39:30: Vitamin A

47:00 Why is it harder to manage blood glucose when following a vegetarian diet in pregnancy and why is blood sugar regulation so important?

  • Risks of elevated blood sugar in pregnancy: changes in rate of fetal growth, larger than average size, increased insulin resistance,

  • “As a result of [consistently elevated maternal blood sugar] their pancreas is larger than normal, pumps out more insulin than normal, they’re more insulin resistant than normal, and they also can face a higher risk of Type 2 Diabetes and Obesity by the time they’re 13- upwards of 6-19-fold higher risk.”

  • Almost all whole-food vegetarian protein sources are packaged with carbohydrates. Many vegetarian meals are also low fat which further increases glycemic load of meals.

  • Lily’s Continuous Glucose Monitor (CGM) Experiment

54:00 Rapid Fire Questions

What are you excited about or what are you researching currently that keep you interested in your current profession?

  • Just how little we know about nutrition. Current research is extremely lacking - especially when it comes to Recommended Dietary Allowances (RDAs)

  • Interesting study on how non-essential amino acids (like glycine and taurine- both primarily found in animal foods) is a misnomer- “animals and humans cannot adequately synthesize nonessential amino acids to meet optimal metabolic and functional needs ‘under either normal or stressed conditions’ pregnancy would definitely be a stressed condition in my opinion.” Study referenced: Hou Y, Wu G. Nutritionally nonessential amino acids: a misnomer in nutritional sciences. Adv Nutr. 2017;8(1):137-139.

  • Repeated theme: Regardless of if you’re following the “guidelines”, if you still have symptoms or don’t feel optimal, keep digging.

58:30: Common piece of advice that’s incomplete or misinformed

Concept of eating for 2: You need to eat more of certain micronutrients for sure. However, the way people interpret “eating for two” is to eat double or increase the quantity of their food without regard to the quality. But it’s nowhere near double, you add maybe an additional 300-500 kcal depending on activity and body size.

LilyNicholsRDN.com

Books: Real Food for Pregnancy and Real Food for Gestational Diabetes

As a thank you for supporting Lily’s small business, those who purchase a paperback copy of Real Food for Pregnancy **directly from her site** will get a 30-recipe e-cookbook as a FREE gift.


This e-Cookbook is available for purchase separately -OR- you can get it for FREE when you order a paperback copy (details below).

For Lily’s U.S. readers, there are a few reasons you may want to buy paperback copies direct from her shop:

  1. FREE goods! All paperback purchases will come with a FREE copy of the new e-Cookbook! That’s a $19.99 value. Simply add BOTH items to your cart (paperback + e-Cookbook) and use code GIFT at checkout. The cost of the e-Cookbook will be deducted from your order.

  2. Discounts on 5+ copies. A lot of people like to gift Real Food for Pregnancy to their friends or clients, but don’t meet the 15 minimum copy threshold for wholesale orders. Solution: Lily’s BUY4GET5 offer. Add 5 copies of Real Food for Pregnancy to your cart. Use code BUY4GET5 and the cost of one book will be deducted from your order.

  3. FREE shipping on all orders in the continental U.S. Although she can’t beat the expediency of 2-day prime shipping (not quite ready for a personal fleet of delivery vehicles and autonomous warehouse robots, haha), Lily can offer standard shipping for free.

  4. Support Lily’s work more. Direct book sales from the author mean a larger percentage of your purchase goes to support her. More support for her work means she can spend more of her time on freely-available content, like her in-depth blog posts and interviews.


Episode 16: Gaps in Prenatal Nutrition with Needed cofounders Julie and Ryan

Julie Sawaya and Ryan Woodbury are the co-founders of Needed, a nutrition company on a mission to empower women to understand and meet their needs before, during, and after pregnancy. Both lifelong nutrition enthusiasts, the two started Needed while at Stanford's graduate business school when they realized through nutrition testing that they were both very deficient in several key nutrients for pregnancy. They dug into the research and learned that up to 97% of women take a prenatal vitamin during pregnancy, and yet 95% have key nutrient deficiencies, leading to lifelong health consequences. That’s because most prenatals are designed to meet bare minimum needs—not to optimally nourish women.

Less is not more when it comes to prenatal nutrition. So Julie and Ryan got to work, redesigning the Prenatal Multi from the ground up in partnership with health practitioners who regularly test the nutrient levels of women who are trying to conceive, pregnant, or postpartum. Needed’s Complete Nutrition Plan launched in August 2020 and includes a Prenatal Multi, Omega-3 Liposomal Powder, Collagen Protein, and Pre/Probiotic, all specifically tailored to meet a mama and her baby’s needs.

Find them on instagram at @nourishmentisneeded

thisisneeded.com use code ANISA

Needed Quote photo

Julie’s Nutrition Journey:

I discovered my passion for nutrition around my family dinner table. My dad (an MD) was diagnosed with diabetes when I was just 5 years old. His illness had a profound effect on me, leading me to research and advocate for the connection between our health and how we choose to nourish ourselves. My passion for nutrition only grew as I began my journey to motherhood and experienced firsthand how vital proper nourishment is for a healthy low-risk pregnancy, an optimal postpartum recovery, and baby’s foundation for lifelong health.

Ryan’s Nutrition Journey:

My interest in nutrition and health grew out of my interest in the environment. As a young girl in California, I started volunteering at a local aquarium, leading educational tours to teach kids about marine science and environmental advocacy. It was clear to me, even then, that our health as humans is directly connected to the health of our environment. Advocating for broader awareness of the human and environmental health connection has carried through much of my life. This was only heightened as I began my journey to motherhood, seeing how important a mama’s internal ecosystem, especially the microbiome, is for a healthy pregnancy and baby. I believe fundamentally that nourishing mamas will directly support nourished communities and a nourished planet.

Show Notes

Julie and Ryan started Needed 3 years ago when they learned through nutrient testing that they were hugely deficient in key prenatal nutrients, despite eating carefully. That means that, had they gotten pregnant at that point in time, they would have joined the more than 95% of women who begin pregnancy already deficient in key nutrients. This impacts everything from fertility, to hormone balance, to pregnancy viability, to how women feel during and after pregnancy, how high risk a pregnancy is (blood sugar and pressure), how women heal postpartum, and the lifelong health of baby.

They know from clinical research, and through partnering with health practitioners that these nutrient deficiencies often worsen throughout pregnancy and breastfeeding.

You might be wondering, but aren’t prenatal vitamins designed to fix or prevent this?

The answer is unfortunately, no. The vast majority of prenatals are designed to meet just the bare minimum needs, like avoiding scurvy, or other serious diseases. NOT to ensure that women reach and maintain optimal nutrient levels. They use poorly absorbed nutrient forms, and extremely inappropriate dosages. More on that later.

This conservative, “less is more” approach to prenatal and postnatal nutrition is totally backwards. Because pregnancy and breastfeeding are the most nutritionally demanding times in a woman’s life.

So prenatals aren’t cutting it. That’s a huge part of the problem. The other is that the women rely on their OBGYNs or prenatal vitamin recommendations receive almost zero nutritional training. They simply are not qualified to help women choose the right prenatal. Not to mention, the average OB visit is just 7 minutes long, leaving little time for a thorough discussion. Instead, well-meaning OBs very commonly say to “just take anything, it doesn’t matter”.

So, they set out to create products and education with REAL DIFFERENTIATION, based on the latest research as well as the clinical experience of informed doctors. Unlike most consumer companies that white label their vitamins, they’ve spent the last 3 years formulating our products from the group up, extensively studying and vetting every nutrient dosage, nutrient form, and source.

The result is their Prenatal Multi, the most comprehensive prenatal vitamin available in powder form. It also happens to be a totally delightful and easy-to-take vanilla powder that even nauseous mamas love. Find recipes to to include it in here.

As told by Ryan and Julie:

We’d like to walk you through a few of the nutrients included in our Prenatal Multi to show you how vastly different our Prenatal is from others. We include a total of 24 vitamins and minerals, all of which are very important, but here we highlight just a few to give you a sense for the research we’ve done.

Nutrients:

A note on RDA levels: There’s a gender health research gap that’s left us in the dark when it comes to women’s health. This is especially true during pregnancy, as nobody wants to run studies on pregnant women for fear of miscarriage or birth defects.

As a result, the government sets recommended nutrient levels for pregnant and expecting women at bare minimum nutrient levels--just enough to avoid things like scurvy (a severe deficiency of Vitamin C), but not nearly enough for higher-level functions of an optimal body. There is a big difference between avoiding a disease versus optimally nourishing.

We determine optimal dosages not solely by relying on the RDA. But, instead, by staying up to date on the latest nutrition research, and by integrating the clinical experience of those that regularly test mamas’ nutrient needs.

Choline: this is one of the nutrients where there actually is solid nutrition research behind the RDA level. 550mg, but we are the ONLY prenatal that actually meets the RDA. Most include none, or just 1/10th of what’s recommended. Choline is as important for baby’s brain and neural development as Folate (better known by its synthetic alternative, Folic Acid), so it’s very concerning how low most prenatals are dosing Choline. To put this in context, you’d need to consume 6 eggs/day every day to get enough through diet!

Folate: the RDA level is leading vitamin companies to overdo-it on nutrients like Folic Acid (which we always avoid in favor of the methyl form of Folate). Some supplement companies got the memo that methylfolate is better than Folic Acid, as 40-60% of mamas can’t process Folic Acid due to the MTHFR genetic variation. But, in doing so, they have started to dose too high. Too little Folate can affect maternal mood, but so too can an excess. We dose right around 900mcg, which is the “goldilocks” just right amount.

Magnesium, Calcium and other minerals -- most prenatals are missing or seriously lacking in proper forms and dosages of minerals. The primary reason is that they are bulky nutrients, that are difficult to fit into a gummy, or a 1-2/day pill form. Our soil is very depleted of minerals, and thus our food is too. These minerals are vital to baby’s skeletal system and bone formation, among other things like regulating mama’s blood pressure.

B12: this is a great example of a nutrient where the RDA levels for pregnancy and breastfeeding are way way way off, by a factor of 70-100x. That’s a crazy degree of error! The result is that many mamas are excessively fatigued, and B12 is also linked to early pregnancy loss as it is vital to DNA synthesis.

Other Key Nutrients Mamas Are Missing/why we offer them in our Complete Plan

Summary:

Less is not more when it comes to prenatal nutrition. It starts with an upgraded prenatal vitamin to help mamas thrive, not just survive. Mamas do need more than just vitamins and minerals, so we offer a complete plan that wraps in the other key supplement needs.

Beyond products, we are really focused on empowering mamas with the information and access to experts that’s needed for an optimal pregnancy and beyond.

If you take away nothing else, we hope it’s the following:

i) be very skeptical of prenatal vitamins in gummy or “1 or 2 pills a day” form. There’s now a FAR better option (our vanilla powdered Prenatal Multi) for mamas that need an easy-to-take option.

ii) there's a lot of noise (and science marketing) in the prenatal space right now, make sure you are relying on the right experts, with rigorous nutrition training, to help you cut through it.

Resources discussed

At home Omega-3 RBC test kit

GBS reduction study: Ho M, Chang Y-Y, Chang W-C, et al. Oral Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 to reduce Group B Streptococcus colonization in pregnant women: A randomized controlled trial. Taiwanese Journal of Obstetrics and Gynecology. 2016;55(4):515-518.

  • The probiotic supplement was taken for an average of 20 days. At the time of admission to the hospital for delivery, a repeat screen for GBS was completed. Among the women who received probiotics, 43% tested negative for GBS compared to only 18% in the placebo group. Cited in post by Lily Nichols, RDN

Placenta: The Forgotten Chakra by Robin Lim- reference to midwife’s observation about differences in placentas of vegetarian compared to omnivorous women


Placental weight study: Placental weight and its ratio to birth weight in normal pregnancy at Songkhlanagarind. J Med Assoc Thai .2006 Feb;89(2):130-7.

  • Average size of a placenta being about 1-2 lb

Ebook with recipes to include Prenatal Multi and Collagen Protein powders.