Dietitian Rehab with Doug Cook RDN

Dietitian Rehab. Episode 002 with Lily Nichols RDN

Lily Nichols 1 300x300 - Dietitian Rehab. Episode 002 with Lily Nichols RDN

Detoxing from dogmatic dietitian education and attitudes for a mind wide open

But first, “you must unlearn what you have learned” YODA

 

What if you found out that standard prenatal nutrition advice might not be the most nutritious? Would you be surprised? Ever wonder why pregnant women are advised to reduce or avoid, many nutritious foods like fatty fish, liver, eggs, and fuller fat dairy products only to be left with diets that are lower in essential nutrients? In this episode, we break it all down. You’ll feel more confident about your food choices and how best to nourish your growing baby.

More about Lily Nichols

Lily Nichols is a Registered Dietitian/Nutritionist, Certified Diabetes Educator, researcher, and author with a passion for evidence-based prenatal nutrition. Drawing from the current scientific literature and the wisdom of traditional cultures, her work is known for being research-focused, thorough, and sensible.

 

Her work has not only helped tens of thousands of women manage their gestational diabetes (most without the need for blood sugar-lowering medication), but has also influenced nutrition policies internationally. Lily’s clinical expertise and extensive background in prenatal nutrition have made her a highly sought after consultant and speaker in the field.

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Thanks for listening!

Read the transcript

Participants:

Doug Cook

Lily Nichols

Doug Cook:

Welcome to the Dietitian Rehab podcast where we not only challenge and inspired dietitian to think outside the traditional dogmatic education, training and attitudes for a mind wide open but also to challenge anyone to think differently about your own health. We’ll talk all things food, health and nutrition related as we explore points of view, evidence and strategies for better health that will allow you a fuller understanding of the hot topics that everybody’s talking and asking about.

 

Hey, friends. Welcome to the show today. I’m so excited to have Lily Nichols on. She is a registered dietician 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 Her work is known for being research focused, thorough and unapologetically critical of outdated dietary guidelines. I like her already. She is the author of two best-selling books, Real Food for Pregnancy and Real Food for Gestational Diabetes. So, without further delay, let’s get going. Great. Well, welcome to the show Lily.

 

Lily Nichols:

Thank you for having me.

 

Doug Cook:

My pleasure. So, I want to thank you so much for being here today. I know today’s show is going to be of huge interest to moms-to-be but not just them but friends and family members of moms-to-be as well as for sure other health professionals and dietitians. And just by way of quick introduction, I know we’ve never met but I was watching I guess a YouTube video from Low Carb Denver and there was a link to a link to a link and then I came across the Low Carb MD website and then you had a good podcast with them. So, immediately, I was impressed and like I said, although we’ve never met, I felt we were kind of kindred spirits. So, is it fair to describe you as a rebel of sorts?

 

Lily Nichols:

I mean amongst the dietitian community, I’m sure that’s a fitting title.

 

Doug Cook:

Yeah, no.

 

Lily Nichols:

But probably among other communities, I’m quite a rule follower.

 

Doug Cook:

Yeah, that’s interesting. So, for sure I would say you would be seen as a rebel for sure in a good way. So, you’re the author of two amazing books which will inform our discussion today. So, the first is of course Real Food for Pregnancy as well as Real Food for Gestational Diabetes. But before we dive into that, I’m just wondering if you could talk very briefly a little bit about yourself and specifically your journey and how you got to the place where you are today which could be seen as playing outside the box, coloring outside the lines, that type of thing in terms of what’s considered standard care in terms of traditional dietetics and what’s normally done in practice.

 

Lily Nichols:

Right. Well, I mean gosh, it depends on how early you want to start because I went into my dietetics training already being aware of some of the real food ancestral kind of perspective. So, I didn’t go through my dietetics training thinking that everything I learned was unquestionable. I was familiar with some of the food politics from the get-go. But after going through all of that and going through my internship and all that stuff, I had the opportunity to work with a program called the California Diabetes and Pregnancy Program—some people also call it Sweet Success—and we worked mostly with gestational diabetes.

 

And as well during that time, I was also working in clinical practice mostly doing prenatal nutrition and also gestational diabetes nutrition and it was really there that I was able to see okay, from the public policy standpoint, how do personal politics and bureaucracy play into what actually gets written in the guidelines, what evidence are they actually looking at and dismissing and also how do those guidelines actually work in clinical practice or not work so well and from there really started a lot of my research on how can we do better for patients for people dealing with gestational diabetes, for people going into pregnancy for avoiding pregnancy complications, where are there areas for improvement in the guidelines because really it takes 17 years for research to make it into clinical practice and then longer for guidelines to be updated and then guidelines are heavily influenced by the team of people or the committee who is actually reviewing that evidence and deciding which studies get more weight or not. Right?

 

Doug Cook:

Yeah.

 

Lily Nichols:

So, that ultimately has informed my work. I believe that we can do a lot better with prenatal nutrition. I believe there’s a lot we can learn from the eating habits of traditional cultures from hundreds even thousands of years back and we have quite a lot of research that’s questioning some of the tenants of both the dietary guidelines at whole but also prenatal nutrition guidelines as well.

 

Doug Cook:

Yeah. So, I’ve been doing this for I guess 21 years—I’m not sure how long you’ve been practicing—and for sure I had a professor in undergrad who always said two things. It’s the only thing I learned in undergrad. One, always challenge the assumptions and two, if you want to understand the—like you have to look to the history of a topic to really understand what it’s all about and even if it makes sense.

 

So, you’ve raised some interesting points about how we have these guidelines and they’re heavily influenced by a whole bunch of different variable interests and we don’t really kind of go back to see if they are even working. So, it’s great that you were seeing that in practice yourself. I’m just curious to know before you went to internship, how you got exposure to these ancestral teachings and that kind of stuff? Is it just because of the beauty of the internet? Because this wasn’t around when I was starting out. It was all about the stacks and going to the university and I’m just wondering how you got that exposure.

 

Lily Nichols:

Well, it was I mean a little bit from the internet. The internet still wasn’t like anything like it is today. But actually most of it was informed by an internship that I did with the CCN, a certified clinical nutritionist. So, she wasn’t a dietitian but she had worked in conventional healthcare as a physical therapist for 25 years before switching gears in her practice and she was working with a lot of people with very serious chronic illnesses and seeing amazing transformations with mostly real food stuff. I’m very much informed by like Weston Price sort of eating recommendations. So, sort of that traditional cultures ancestral nutrition bent. So, yeah, at the time that I started working with her, I was eating a low-fat vegetarian diet and she lent me Nourishing Traditions and that took me years to change my eating habits because I’d been so heavily indoctrinated by everything that we are taught about nutrition even before going into nutrition school that it took me a while to change that.

 

But I took the opportunity when I was in school to look up in the medical journals—as a student you have access to everything, all the research papers that the general public can’t get at. And so, all the questions about like well, what’s the research on vitamin K2, what do we know about vitamin D, is saturated fat really causing heart disease, what about—. So, I took the opportunity to look into that stuff and I found that a lot of what was in my textbooks was not reflected in what was in the medical journals. So, I’m just naturally a person who questions things but I did use my undergrad as an opportunity to further question all that I was learning about nutrition.

 

Doug Cook:

Now that’s pretty amazing. So, I mean I have the same tension. I followed all the same low-fat guidelines like most of us and it took years to kind of relax and lean into it if you will. So, just to kind of tease out some of that stuff specifically, so I think it’s pretty much understood—I don’t think anyone would disagree—that good nutrition is crucial for healthy pregnancy as well as the postnatal period for both mom and baby.

 

That’s pretty much understood by most and you’ve touched on this. You looked at your frontline experience because I know you have some experience with using real food as it relates to diabetes management but is you just alluded to, you did a lot of research and looking at primary research and traditional cultures and ancestral diets. And so, what I found interesting when I came upon your website and delving into that a bit more is that there’s actually huge disagreement—well, enough of a disagreement between what is considered a healthy diet even though there’s agreed-upon principles as to what needs to be provided to a baby-to-be in terms of vitamins and minerals. So, I’m just wondering if you could share on some of those findings and talk about contrasting and comparing the current healthy guidelines for pregnancy? They’re the same in U.S. and Canada so it makes no difference and I’m in Toronto and kind of contrast that to what we know really is needed for babies if that make sense.

 

Lily Nichols:

Right. Yeah. So, essentially how I like to look at prenatal nutrition is to reverse-engineer what foods might make the most sense to be in an optimal prenatal diet to provide all the micro nutrient requirements. And then from there, let’s see where the macronutrients fall because the way that the guidelines currently work is it’s a little bit more of a top-down thing. Like okay, well, we know—know I’m going to put in like heavy quotation marks—that we require X percentage of calories coming from these macronutrients and therefore we need to have this many servings of grains and starchy foods and this many servings of meat and protein and this many servings of fruits or vegetables and so on. But when you actually follow the guidelines which are very, very similar to the adult guidelines—so 45% to 65% of your calories coming from carbohydrates, a low-fat diet aiming for like 30% or maybe less and sort of a moderate protein intake—when you follow those guidelines to the letter, you end up with a diet that’s deficient in micronutrients for pregnancy.

 

So, just by having to comply with especially the limited fat intake, you’re automatically going to be minimizing your intake especially of animal foods and fat containing animal foods which therefore automatically limits your intake of things like iron and vitamin B12 and choline and other things because we’re so, so, so scared of fat and also of cholesterol. So, a typical following the guidelines prenatal diet would have a pretty high amount of grains.

 

They say that half of your grains can be whole which means half of your grains can be not whole or like white flour, refined flour although they try to make up for this by pushing fortified cereals and fortified bread and things made with fortified flour of course. You’ve got to watch your cholesterol so your egg intake is limited. You’ve got to watch your saturated fat so you can’t have full fat dairy. You want to limit your intake of red meat. You want to aim for a plant-based diet. I mean it’s the same thing that we’ve been told for decades and decades and ultimately, that does not play out to provide you a very nutrient-dense diet.

 

In fact, in Real Food for Pregnancy I have a comparison of the sample meal plan that’s in the Academy of Nutrition and Dietetics policy paper on prenatal nutrition and I mean the breakfast is oatmeal, low-fat milk and strawberries. It’s like where’s the protein? Where’s the fat? Whereas with real food, you would probably be eating a much more nutrient-dense breakfast that maybe contains something like eggs which will provide you a very satiating, filling meal with protein but also with a ton of micronutrients that you find in eggs that are really a quite powerful superfood for pregnancy, really high in choline, required for baby’s brain development, they can provide DHA depending on how the chickens are fed, they provide a variety of fat soluble vitamins and also a number of B vitamins.

 

They’re really a useful food but if you’re following the guidelines to the letter, you’re probably not going to be eating very many eggs because of the fear of cholesterol. So, you get into this I call it the nutritionism trap where we start focusing on one single nutrient that’s bad, for example, and then you end up with a nutrient deficit in other areas.

 

Doug Cook:

Yeah. So, I like what you said how you reverse engineered the diet with a focus I guess more so on micronutrients if I understood you correctly because the beef that I’ve had is we’ve been focused—I call it two-dimensional nutrition—we focus on the macronutrients: protein, fat, carb with, of course, fat being demonized and then everything has carbs mostly, protein to a small degree have to make up the bulk of the calories. So, the assumption is if you’re eating pretty well and you’re avoiding overt clinical deficiencies, if you don’t have scurvy, if you don’t have rickets, you’re doing well overall. So, we’ve focused on these large macronutrients and if you’re starting with that model of that lens or that construct, then you’re going to try and bring in foods that keep those macronutrients recommendations happy at the expense of nutrients. So, I think that’s what I’m hearing. Is that right?

 

Lily Nichols:

Exactly.

 

Doug Cook:

Yeah. And the other thing that I’ve come across that people might find confusing but like I know what you mean by it but just maybe for the listeners when you talk about conventional nutrition guidelines in the Academy of Dietetics—it’s the same with Dietitians of Canada—compared to real food, how would you in simple terms define real food?

 

Lily Nichols:

So, real food for me would mean food that is mostly found in its unprocessed state as you would find in nature. So, typically single ingredient foods and if they are processed because like of course, we process foods, we ferment foods, cooking can be a type of processing but whatever the processing that is used is not going to reduce the nutritional value of the food. And so, I’d like to give the example everybody thinks of like fresh fruits and vegetables, they’re unprocessed.

 

Yes, they are but what about our animal foods as well? We think that boneless skinless chicken breast is a whole-food and it is. However, if you were eating that food in the context of how you might be consuming it if you were living in a very rural, remote, potentially an ancestral sort of a setting, you would be eating all parts of the animal. You wouldn’t take the chicken breast meat and only eat that. You would also eat the skin, you would eat the bones, you would boil that down into a broth, you would eat the organs. So, it means also eating those foods in whole form. So, eggs with the yolks, eating all parts of the animal nose-to-tail, if you consume dairy products, eating them with the fat that it naturally contains, not low-fat or fat-free dairy products and by doing so, you get a different nutritional profile.

 

A, your macronutrients are different. You’re naturally going to just have a higher proportion of your diet coming from fat and probably a slightly lesser proportion coming from carbohydrates but you’re also going to have a different micronutrient intake especially higher intake of fat soluble vitamins, for example. So, unprocessed, simple ingredients, unprocessed or minimally processed, simple ingredients and not prepared in a way that is taking away from what you find in nature and the whole food.

 

Doug Cook:

Yeah. It’s funny now for me to look back and see how obvious that is and how messed up in a way. I mean that’s my words. I’m not putting those words in your mouth. But it’s almost like we’ve sanitized and sterilized the diet. Right? So, out of fear for all the things that you’ve already mentioned like fat, etc. So, what I find interesting in this conversation is that there’s agreement about what nutrients are absolutely crucial for healthy pregnancy. To say that not getting those nutrients or otherwise, it’s a non-negotiable, it’s a no-brainer. Yet the dietary advice for healthy pregnancy is at odds with this because the conventional advice struggles to even provide the very things that’s needed. So, it’s really hard to reconcile that tension or that gap between what we’re saying and what’s really happening. Does that make sense?

 

Lily Nichols:

Well, part of it is that I mean a diet following the conventional guidelines does provide micronutrients as well. It’s not like there is none in there. It just provides a lesser quantity and then you have to start questioning well, okay, sure, maybe it’ll meet for most of the nutrients like the minimal requirement. However, how were the RDAs and the adequate intake levels and all of those different acronyms they use for all the different versions of the nutrient requirements that only dietitians are familiar with, how did they set those levels and is there research that might suggest we need a different amount of those nutrients than what is written in the guidelines?

 

And that’s where things get very challenging I think for dieticians especially conventional dieticians to take in is that there’s a lot of research that’s questioning if the RDAs are even adequate for pregnancy and it’s really hard to study nutrient requirements in pregnancy. So, most of them are based on a mathematical estimate ultimately originating from data that we have on adult men, not on pregnant females. And when you do look at some of these intervention trials because for some nutrients they do exist. For example, we now have really strong data for choline, randomized controlled trials. We see that the amount that’s actually optimal for pregnancy health, for baby cells like their brain development is actually significantly more than what the guidelines say they are because we just didn’t have the right evidence.

 

So, for me in the absence of having perfect data on all of these things to inform these recommended intake levels, we almost have to default to real food because I mean I don’t know how many times we need to see this again and again both in nutrition or anything environmental, like nature pretty much always outsmarts us and we keep returning back to like oh, nature got that right. Interesting. And I think it’s the same story with food.

 

Doug Cook:

Yeah. And I guess it’s a funny turn of events but as you were talking, I’m thinking about the early recommendations were—we came up with these based on what people were eating, four food groups, five food groups, whatever. There’s been a lot of different reiterations over the years and we’ve been trying to prevent deficiencies, deficiencies and somewhere the pendulum swung where we became really afraid of toxicity and if you’re eating real food as you described and you had to eat 3,000 calories a day or 4,000 calories a day, we’re going to get more than—unless you’re an Olympic athlete but even then they have to fill up on like a lot of cheap carbs and stuff to meet their energy requirements—but we’re going to be getting a lot more than anyone could ever possibly think they’re going to get just by including more of these foods.

 

So, the fear of toxicity is really I think a driver of this fear of kind of, I don’t know, maybe over consuming especially around things like vitamin A and pregnancy. But going back to what you said, the conventional recommendations, yeah, you’re right. They absolutely do provide nutrients, micronutrients. It’s not like it’s all Styrofoam but it’s funny how again we go back to this idea of like we know nutrients are required, we’re afraid of fat so let’s eat tons of low-fat food which means you have to eat more carbs and then the gapstop measure is just well, take a prenatal vitamin.

 

Lily Nichols:

Right.

 

Doug Cook:

Which, of course, is kind of acknowledging the problem but then it’s better than nothing but I guess it wouldn’t be in our opinion the best way to go.

 

Lily Nichols:

Exactly, exactly. And moreover, I mean even the macronutrient requirements we have data to question those. So, I always talk about this 2015 study, the first-ever study that directly estimated protein requirements in pregnant women, first ever. It’s only five years ago. Okay?

 

Doug Cook:

Wow.

 

Lily Nichols:

And they found that the current average intake or estimated average requirement for protein in pregnancy was a significant underestimate. So, it was about a third lower than it should be for early pregnancy and it was 73% lower than it should be for late pregnancy. So, even still, even with all this stuff, if those numbers are wrong, I mean what do we do? Right?

 

Doug Cook:

Yeah. So, what is the recommendation? Is it 0.8 grams for the first trimester or two?

 

Lily Nichols:

So, first trimester, the assumption is that your protein requirements or really any nutrient requirements all the way down to calories are not different and then starting in the second trimester, your nutrient requirements start to go up and this—so, they usually recommend instead of 0.8 grams per kilo of protein, it goes up to 1.1 grams per kilos of protein or some people will just add an extra 25 grams of protein across the board. But that study found that actually first trimester, they found the needs were actually 1.22 grams per kilo and in late pregnancy, it was actually 1.52 grams per kilo.

 

Doug Cook:

Wow. Yeah. That’s a huge difference and then when I think about the old way of estimating protein requirements and nitrogen balance studies which were really problematic in the 50s and they were using these radial isotopes of the oxidation indicator of amino acid oxidation, some of the new research is just for general adults, it’s 1.2 instead of 0.8 which is about 50% more.

 

Lily Nichols:

Right.

 

Doug Cook:

So, yeah. So, that’s interesting. So, in your book Real Food for Real Pregnancy, you’ve got a list of foods and I mean we’ve kind of already talked about this, what do you refer to as foods that build a healthy baby which are obvious to me but it might not be to others who are listening and some of the foods might be confusing to many moms. So, I’m just wondering if you could talk about the foods that are in the book and why they’re important and more importantly why you’re recommending them. It’s kind of just driving home the point but if you could give that brief over.

 

Lily Nichols:

Sure. Yeah. So, I highlight some specific foods in that chapter that I observe are either under consumed or just an important source of nutrients that people need to emphasize more of, not that they are the only foods that should make up your diet as some people can misinterpret from it. But it’s really easy to just subsist on starchy carbs because they’re delicious. Right?

 

Doug Cook:

Yeah.

 

Lily Nichols:

Well, I don’t need to over encourage those but of course, there’s room for carbs in the diet as well especially for people who have the metabolic flexibility to handle that. But instead, I focus on foods that are highly nutrient dense. So, some of them would be eggs. I think I already kind of mentioned that but that’s going to be one of your number one sources of choline in the diet. Liver, also really rich in choline, extremely rich in iron, vitamin B12, vitamin A. Back before we had iron supplements, liver was how they treated anemia in the early 1900s. It was always included in the recommended foods for pregnant women.

 

It’s only until relatively recently that we’ve had this big fear mongering campaign against liver which research has actually found is pretty much unfounded. We also have meat, especially meat that’s on the bone or slow-cooked meat or bone broth and this one confuses a lot of people but the main reason I’m highlighting those specific cuts or preparations of meat is that they have a lot of connective tissue and thus a lot of collagen and in pregnancy your need for collagen and the amino acids that make up collagen especially glycine go up significantly beyond the point that your body can make up for that need by creating glycine from other amino acids. It’s called conditionally essential specifically to the state of pregnancy.

 

And so, those are the foods where you’re going to find it, the richest source of glycine by far are collagen-rich animal foods. So, I do recommend those. I also, of course, recommend vegetables especially your leafy greens. So, those are going to be really high in a lot of different micronutrients especially folate. Folate is one that almost everybody is familiar with usually the synthetic version folic acid but the folate from food is even better for you to obtain. You’ll also get your vitamin C, you’ll get minerals, you’ll get vitamin K1 to help with normal blood clotting. There’s a lot of useful things in leafy green vegetables. And then salmon, fatty fish and other seafood.

 

I think people are really afraid of seafood these days and a lot of people really under consume it. Even if you’re following the FDA guidelines, they recommend 12 ounces of seafood per week for pregnant women. So, we still need it even if you’re afraid of over consuming it. It’s extremely rare that people do and this seafood provides a lot of DHA. It’s going to be your number one source of that omega-3 fat, important for baby’s brain development. It provides vitamin D. It provides iodine, also crucial for baby’s brain development and a number of other micronutrients. It’s a really important food to the point that if you’re not consuming seafood whatsoever you do want to be considering supplementation with DHA in some form and making sure your prenatal contains iodine, for example.

 

And then finally, if dairy products work for you, full fat and fermented dairy products are a really useful food source I believe although I know there’s a lot of controversy about dairy products out there. But you’re getting protein, you’re getting your fat soluble vitamins, there’s some B vitamins in dairy products, probiotics. It also happens to provide quite a bit of iodine. Both dairy products and eggs happen to be the second and third most common sources of iodine in the diet other than seafood and a lot of people do really well with dairy in pregnancy. So, why not include it?

 

Doug Cook:

No, I love that because I think people forget that the body is made up of elements like hydrogen, oxygen, carbon and we got all that stuff from food. I think people under appreciate the impact that what we’re eating not only affects us but it’s going to affect the babies that are growing for sure. So, the foods you’ve pointed out obviously with the exception of vegetables are animal-based which as I think you and I know but a lot of people may not know that the nutrients in animal foods are typically more concentrated but also better absorbed from foods than they are from plants. That doesn’t mean that plants don’t have a role.

 

Lily Nichols:

Right.

 

Doug Cook:

So, both the Academy of Nutrition and Dietetics and Dietitians of Canada have position statements that well-planned vegetarian diets can support a healthy pregnancy but there are nutrients of concern. We don’t to go into too much detail but those would be pretty much everything you just highlighted that are found in those animals foods. Right?

 

Lily Nichols:

Exactly. And interestingly, if you look at some other countries’ guidelines, some of them recommend against a vegetarian or especially against a vegan diet in pregnancy?

 

Doug Cook:

Really?

 

Lily Nichols:

A number of European countries have those guidelines written and Germany is one of them. I believe it was either Italy or Spain, I can’t remember just thinking of it right now. But there are countries that recommend against it because they’re seeing that as people adopt plant-based diets and aren’t careful about supplementation, you do end up with nutrient deficiencies. So, there are nutrients of concern. I believe that a vegetarian diet could meet the nutrient requirements of pregnancy with some supplementation especially if the person is also consuming eggs and dairy products.

 

You’re still getting some animal foods. It’s really challenging to do so on a vegan diet. Part of that is that we don’t know all the things that are required for pregnancy like the choline study that I pointed out. That’s one that like whoa, threw everyone for a loop that suggested that hey, actually we need double the quantity of choline than what’s provided, than what set is the adequate intake level. Like holy cow, that’s a lot more. And because choline is so highly concentrated in animal foods and found in much, much lower concentrations in plant foods, I have personally never seen a vegan meal plan that provides adequate choline, not even reaching the normal adequate intake let alone the double quantity amount.

 

So, the issue is that certain nutrients could be missing entirely like vitamin B12. Certain nutrients might not be provided in sufficient concentrations in plant foods. That would be choline, glycine, vitamin K2. Certain nutrients might not be well-absorbed. That might be iron and zinc. And then certain nutrients might be provided in a form that isn’t well utilized by the body such as the plant-based omega-3 ALA which is converted into DHA at a very, very low rate or also beta-carotene instead of preformed vitamin A which some of us have genetic mutations that significantly impede our body’s ability to make actual vitamin A out of beta-carotene. So, those are just a handful of examples but I think it’s much more complex than our guidelines suggest.

 

Doug Cook:

Yeah. And that’s the thing I try to tell people is it’s nice to have an eating philosophy or ideology but as I always say, biology, physiology, anatomy doesn’t give a rat’s you-know-what about that. Right?

 

Lily Nichols:

Right.

 

Doug Cook:

The human body needs a certain amount of nutrient X, Y, Z type of things. So, that’s all fine. Do it with your eyes wide open and it’s really hard as you say to do that without supplementation for sure. So, I don’t even know, I haven’t even looked to be honest if the vegan guidelines, if there are any conditional statements or directional statements in the U.S. or Canada around certain nutrients or do they just think you can get it all from fruit.

 

Lily Nichols:

They do. The Vegetarian Practice Group from the Academy of Nutrition and Dietetics or CDR, whatever organization is covering that in the U.S., they do highlight certain nutrients of concern. They don’t highlight all of the nutrients that I just highlighted above. So, they don’t acknowledge the vitamin A thing. They don’t even mention choline which is really unfortunate. I mean I did an analysis of their sample meal plan and it is very low in choline even though it includes some of the richest plant sources of choline in it. They do, of course, acknowledge things like iron, folate which oddly like folate is probably not much of a concern on a plant-based diet because you get a lot of folate from plant foods. But I believe they point out DHA and suggest an algae-based DHA supplement. So, that’s good. I said iron B12. It’s a handful of nutrients. They don’t cover the full gamut.

 

Doug Cook:

Yeah. So, speaking of that analysis in your book which is really neat, you have the comparison of a conventional new meal plan which you referenced at the beginning of the discussion today compared to a real food one. So, you mentioned the breakfast. I’m just looking at it here. You’ve had breakfast. A so-called healthy breakfast might be oatmeal, low-fat milk and strawberries compared to a crustless spinach quiche with sausages and banana and you go through these typical things which are lower fat, higher carb, low fat dressings, low fat milk, that type of thing and the stuff that stood out when you looked at that analysis is amazing. So, we talked about protein and how that’s important.

 

Newer research says we need more. So, the real food for pregnancy, you’ve got 140 grams compared to 109 which may not sound like a lot to people who are not in this field of study or practice but over time, that’s a really big deficit that can kind of take its toll. And then the stand-out things are crazy. So, with a real food diet, you’re going to get 200% more vitamin A, 113% more vitamin C, B2, 155% more on a real food diet. The list goes on and on and on. So, it really is sobering to see that and it’s a little scary.

 

Lily Nichols:

Yeah. And I think specifically like the vitamin B12, you’d get triple the amount of vitamin B12.

 

Doug Cook:

Yeah. 284%.

 

Lily Nichols:

The choline, 70%, almost 70% more choline. Even all the minerals, the iron, you’re getting 37% more iron on real food than you are with conventional nutrition. And it just makes sense because you’re including sources of those foods. It’s not rocket science but it does take sort of dismantling the guidelines and like I said, reverse engineering it. Like okay, let’s plan out like what I would think is a pretty nutrient-dense diet. Let’s see where the micronutrients and macronutrients fall and it just so happens that you end up especially with the macros, I mean you just flip it on its head.

 

Right? So, the carbs on the conventional plan are over 300 grams and in real food for pregnancy plan are about half of that. I mean this isn’t like—yes, I’m an advocate for lower carbohydrate intake but this is not extremely low carb by any means. It’s just like not as excessively high in carbohydrates and there might be some people if their calorie needs are much higher, they’re very athletic, they might have more carbohydrate tolerance. But the vast majority of adults especially in the U.S. and industrialized nations, we really don’t need to be eating more than 300 grams of carbs a day. I mean that’s a crazy high amount.

 

Doug Cook:

Yeah. I would even say it’s a lot unless now if you’re sitting in the car, sitting at the desk and unless you have purposeful activity. And then the other thing that’s interesting is when you look at the macronutrients, it’s more than just the fat. So, the fat in the real food for pregnancy is 51%. So, it’s not like oh, it’s a higher fat diet because I’m pounding back butter and MCT oil. That’s a barometer of the natural for lack of a better word food sources that those fats are found in. So, like as you’ve already mentioned, eggs and fattier meats and dairy and fish and that kind of thing. So, that’s the problem when we just kind of focus on those macronutrients. To me when I’m looking at this, it’s a barometer. Assuming it’s real food, it’s a barometer of where those sources are coming from.

 

Lily Nichols:

Exactly. And really you also have to think about what’s happening to the person’s blood sugar. So, these meal plans actually provide pretty similar amounts of fiber. You’re just getting less non-fiber carbs on my plan. So, for people who have worked with gestational diabetes or any type of diabetes especially if you’ve had access to people wearing a continuous glucose monitor or CGM, you see a very stark difference in the glycemic response to eating this way. Fat and protein are very satiating. They don’t really spike your blood sugar all that much. We can get into nuances for somebody with type 1 diabetes but for the most part, it’s really the carbs that are going to spike your blood sugar like crazy.

 

So, if your breakfast is all carbs, you’re going to see a big blood sugar spike and you’re also going to be hungry and cranky and hangry pretty soon after that meal and that’s like a lot of these issues with quote pregnancy cravings, sure, your body might want more or less of certain things in pregnancy. There’s no doubt about that. But a lot of this stuff comes back to blood sugar regulation and if you have better regulated blood sugar, you don’t see as much of these cravings for sugary foods and the need for a caffeine pick-me-up or something like that.

 

Doug Cook:

Yeah. And of course, there are lots of reasons why women may develop gestational diabetes but regardless, I don’t think there’s any need to really be pounding back the carbohydrates. It’s not doing anyone any favors. So, yeah. And again, like you said, it’s not a little carb or getting tons of carbs from just non-starchy sources which is ultimately just glucose. I mean rice is just glucose and bread’s just glucose and that type of thing.

 

Lily Nichols:

Yep.

 

Doug Cook:

So, just in the last few minutes, I wanted to check out your website because it’s amazing and the blog posts are amazing and I was just spending a lot of time on there because some of my obsessions around nutrients are choline but from a brain point of view, that’s kind of my background, mental health. But also glycine, I’m obsessed with glycine. You talked about that but one thing that really shocked me and I don’t think anyone would know this. Maybe they do. But if we could just talk about that one post where you write about the research looking at the ability of a nutrient-dense diet to influence the nutritional profile of breastmilk. Yeah. So, just I mean if that’s okay. So, it is possible to change the nutrient levels in breastmilk and as you say that it’s conditionally perfect meaning the composition does actually shift based on what the mother is eating. And I’m just wondering do you think this is a common understood fact?

 

Lily Nichols:

No. I don’t and it’s a very divisive topic especially in the lactation community. And just for the audience, I have two kids. My youngest isn’t even six months old and we’re exclusively breastfeeding. Right? So, I understand the weight on a mother’s shoulders of being the sole source of nutrition for an infant and I get all the reasons why breastfeeding can be challenging and why so many people end up not doing it. However, I think there’s a lot of fear in the lactation community of talking about the fact that nutrient levels in breastmilk do change for some nutrients anyways because they’re afraid that it’s going to make women less likely to actually breastfeed.

 

Now, we don’t need to make nutrition advice for like what a mom should eat while she’s nursing. Super, super complicated. I mean real food is real food. I always say that because people get so like what do I need to eat for fertility, what do I need to eat for pregnancy, what should I feed my kids, what should I eat while I’m breastfeeding. It’s all real food. So, real food is real food first of all.

 

However, we do want to continue emphasizing certain nutrient-dense foods during nursing because there are a lot of nutrients where the levels can shift depending on a mother’s intake and/or her nutrient status and some of those include vitamin D, all the B vitamins especially vitamin B12, to a lesser extent folate but most of the other B vitamins, they do shift in a pretty substantial amount. Your fat soluble nutrients all shift especially vitamin A and a shocking percentage of breastmilk is actually low in vitamin A, lower than it should be. The types of fat that are in the breastmilk shift based on what a mom eats. So, if you consume salmon for dinner, for example, your milk is going to have more DHA in it whereas if you consume a doughnut that’s fried in hydrogenated oil, your milk will actually contain trans fat from the trans fat that was in the frying oil. So, that’s a big one.

 

And I mean ultimately, I think it’s a two birds with one stone situation. If you can ensure that mothers are well nourished and that really means getting help from other people because it shouldn’t just all be on mom but ensuring mothers have access to good nutrient-dense foods and can eat well, they’re further ensuring that their infant gets more micronutrients in the milk and that’s quite important. I mean we have studies especially on vitamin B12 deficiency and also several on vitamin D showing that you can end up with infants with clinical deficiency when mothers don’t get enough and for B12 specifically, their case studies mostly in vegan mothers by the way who have not continued to supplement with vitamin B12 postpartum because I mean what doctor is giving that advice. They should be but they’re not. So, it’s something that I think we really need to be talking more openly about. Yes, breastmilk is quote the best food for infants. However, the nutrient levels in it are not fixed.

 

Doug Cook:

Yeah. So, this obviously just circles back to everything you’re talking about in terms of even like look at the nutritional analysis between those two meal plans. So, yeah, I guess it makes total sense. I was always under the impression that we talk about or I remember hearing messages like well, the baby is just a little bit of a, it’ll just take whatever it needs through the placenta when the baby’s developing and like mother’s stores might be depleted but the baby won’t be affected.

 

This is kind of old school and I guess the assumption was if you’re just breastfeeding, that the breast will produce the milk and it will have the nutrients that it needs. I do remember going to a fatty acid talked years and years and years ago that was focused on omega-3s. But everyone thought the answer was going to be doughnuts but the presenter said like what is the greatest source of trans fatty acids in the human diet? Everyone’s like oh, it’s oil, it’s donuts, it’s all this kind of stuff and he said it’s mother’s breastmilk. So, this is old data when we had a lot more trans fats like in the 70s. I think people were eating 20 grams a day in margarine and that kind of stuff. So, that was shocking.

 

Lily Nichols:

Oh, wow.

 

Doug Cook:

Yeah.

 

Lily Nichols:

Yeah. And then you get into the trans fats because there’s like different types of trans fats that are not bad for you [inaudible 00:44:28] and ruminant fats. But yeah, it’s crazy and you can actually see and I have a webinar on this topic—that blog post is just sort of like a short and sweet version—but I have like a really in-depth webinar on the breastfeeding nutrition and how the nutrient levels vary in breastmilk with like over, I don’t know, 125-150 citations where I go through all the specific nutrients and the data on them and I do have a slide in there, several slides on trans fats showing the very different levels of trans fats in different countries and actually there is data showing that the level of trans fats in milk tend to decline over time as countries ban trans fats. So, since the U.S., for example, started their labeling thing in 2006, we’re seeing lower levels of trans fats in the breastmilk now than we did a decade or two decades ago. And so, that’s pretty interesting.

 

Doug Cook:

So, I think that’s amazing to just stress that the quality of fat in breastmilk affected B vitamins. That blows me away especially B12, vitamin A vitamin D and although I don’t think you’re going to recommend this and I know of the data that shows that you can increase the vitamin D in breastmilk by a mother taking supplements because she’s not going to get it from tanning beds and sunning. So, it has to be from supplements. But even the Canadian Pediatric Society acknowledges that the research of 4,000 units or 100 micrograms per day is sufficient to raise vitamin D levels in breastmilk to the point where infant implementation probably isn’t needed. And just for people not to be scared, although no one’s going to suggest this, experimental doses I read up to 10,000 for five months during pregnancy didn’t elevate concentrations into the toxic range.

 

Lily Nichols:

Yeah. So, in pregnancy, I mean we have pretty strong data on 4,000 IUs in breastfeeding. The data I’m aware of suggests 6,400 IUs. I think I have a blog post on this as well. But they had several groups. They had a group that was supplemented with 400 IUs which at the time was the recommended intake and then they had a group supplemented with an extra 2,000 so 2,400 and then a group supplemented with an extra 6,000 so 6,400.

 

And they found that the 6,400 group was what was necessary to keep both mother and infant’s vitamin D levels adequate. And you can get vitamin D from the sun. It just only is going to work if you’re latitude and a time of year where you actually make enough from the sun. So, I’ve lived in many different places in the U.S. including Alaska and Southern California as two examples. And in California when I would regularly get sun exposure, my vitamin D levels were fine without supplementation because I was intentionally sunning without sunscreen for a safe period of time, not enough to get burned.

 

But that is sufficient. You go up north to northern latitudes in Alaska, in many parts of Canada, you’re not going to be making vitamin D for the majority of the year. There’s a small window where sun is actually going to do anything. And so, most of North America actually is going to require some level of vitamin D supplementation to be adequate and the vitamin D recommendations, it’s another one where they actually think there is a statistical error when they set the recommended intake and they think that vitamin D requirements were set seven or eight fold lower than they should be.

 

Doug Cook:

Yeah. No, and then they admitted that, the National Academy of Sciences, but they’re still holding steadfast to the recommendation from 600 units even though they said that we made a mistake.

 

Lily Nichols:

I know.

 

Doug Cook:

Yeah. So, I don’t want to take too much of your time, more of your time. So, this has been super, super informative and I know people are going to love to hear this message and dietitian to dietitian, I’m really excited about the work you’ve done because we can’t wait for a top-down approach. As you say, it’s going to take forever. The information is there. It’s free for anyone to get and there’s a lot that people can do. I want people—I mean most of the audience is going to be dietitians or other health professionals and people who are just generally interested, moms-to-be or friends of moms.

 

So, there’s a lot that people can do without having to wait for that nod from their doctor or their pediatrician which is why I’m going to recommend everybody get the book because it’s just all laid out there for them. So, where can people find out more about you and about the amazing work that you do?

 

Lily Nichols:

So, you can find me on my website, of course, and that is LilyNicholsRDN.com. On the website by the way, I do have a link to free download from Real Food for Pregnancy and that includes that meal plan that we are talking about and the nutrient comparison between the two. So, even if you don’t want to buy the book but you just want to get more information on this whole real food thing, get a feel for my writing style, see if you want to listen to it or not, that’s a good place to go is to download that free chapter. I’m also on social media these days. A little less. I mean I have two kids. Right? So, I’m pretty busy but I’m most active on Instagram and my Instagram handle is @LilyNicholsRDN, just like my website.

 

Doug Cook:

Okay. And I checked, Amazon Canada and Amazon U.S. obviously have it. Our other main bookstore chain up here doesn’t have it but they can get it through Amazon Canada and of course, people know probably through Barnes & Noble in the U.S. Yeah. So, that was amazing. Thank you for your time and I guess if there’s not any last minute nuggets of wisdom to pass on, I just wanted to thank you and tell you to keep up the great work.

 

Lily Nichols:

Well, thank you. Appreciate it, Doug.

 

Doug Cook:

All right. Thank you. Hit subscribe and get ready to expand your nutritional world, your perspective and gain confidence in a way that you didn’t know you could. And be sure to check out my website DougCookRD.com.

 

 

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Doug Cook RDN is a Toronto based integrative and functional nutritionist and dietitian with a focus on digestive, gut, mental health.  Follow me on FacebookInstagram and Twitter.

Comments 2

  1. Tina de Freitas
    February 25, 2020

    Great job Doug! Love that you picked pregnancy as one of the first topics. Probably one people are most afraid to go near when it means changing the SAD!
    Looked forward to more!
    Topics I would love to hear about that:
    1.Interviewing docs in Canada who practice a more Functional Medicine approach and promote low carb eating. Everyone I talk to who is interested in improving their health struggle to get a good FMD on board with this way of life. Especially here in Calgary and western Canada
    2.Researchers in Canada who are working on these topics.
    3.From topic number 2, where can a young student go to school to learn more about this way of health promotion, ie. universities to study nutrition that are open minded or grad school where masters and PHd’s focus on this type of research. We need to get our young learners educated properly from the get go.
    4. Interviewing a Canadian Dietitian who works with athletes with low carb eating (I was a competitive x-c skier) and still am a very keen skier and I get some much flack from my lady friends when we ski together because I don’t need a lunch or carb snack along the way (literally they will force food on me).
    I am tired of being the outlier, closet believer or just freak that no one wants to have for dinner. I am a rebel and want to see health promotion change directions.
    (My background, started off in Nutrition at Guelph in 1979, dropped out because I was sick and trying to be a competitive athlete (diagnosed celiac as a baby, told I grew out of it, didn’t, caused all kinds of autoimmune problems). Did a nursing degree later on in Calgary, worked in Childhood Obesity at Children’s , then well child clinics. Retired ( mostly because I just could not continue to push the dogma) . Soon to be 60yold!!
    Best of luck!!

    1. Doug Cook RDN MHSc
      February 25, 2020

      I’ll do my best, I love these ideas and suggestions…I’m still a small fish in a big pond, so getting people on is a challenge

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