8/22/18 1 Lily Nichols, RDN, CDE August 2018 BASICS OF REAL FOOD PRENATAL NUTRITION Author, Real Food for Pregnancy; Real Food for Gestational Diabetes OVERVIEW • Conventional prenatal nutrition guidelines compared to real food • Myths surrounding prenatal nutrition • i.e. recommendations that are not evidence-based • Why we need a paradigm shift • Rationale for a real food diet that incorporates updated research + principles from ancestral nutrition/traditional cultures • Sample meal plans and nutrient breakdown from conventional vs. real food prenatal nutrition • Practical tips for optimal prenatal nutrition Lily Nichols, RDN, CDE WHAT IS CONVENTIONAL NUTRITION? • Dietary advice based on the U.S. government’s nutrition policies • Food pyramid (retired), now MyPlate • Advice relatively unchanged in past few decades • Low fat, high carb • Limit saturated fat (lean meat, low fat dairy, vegetable oils preferable to animal fats) • Less meat, more grains Lily Nichols, RDN, CDE WHAT IS REAL FOOD? • Food obtained locally (in-season) and eaten in its natural, unprocessed form • Applies wisdom from ancestral diets and those of traditional cultures; omnivorous • Acknowledges there is no one-size-fits-all • Automatically excludes: • refined carbohydrates • added sugar • foods that require extensive modern processing (such as refined vegetable oil, food additives, etc.) Lily Nichols, RDN, CDE REAL FOOD, CONT’D • Definitions of real food are ambiguous, but generally include: • Vegetables & fruit • Meat, poultry, fish/seafood • nose-to-tail, including naturally-occurring fat & organ meats • Eggs • Dairy (varies globally) • Nuts & seeds • Whole grains & legumes (contentious!) Lily Nichols, RDN, CDE CONVENTIONAL APPROACH • Carbohydrates 45-65% (no less than 175g/day) • Protein 10-35% • Fat 20-35% • Limit fat (especially saturated) • Limit salt • “Half your grains whole” • Emphasis on fortified foods (folic acid, iron, calcium) • Vegetarian and vegan diet can be adequate • Assumes RDAs are correct Lily Nichols, RDN, CDE
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OVERVIEW BASICS OF REAL FOOD PRENATAL NUTRITION · • Warnings against high intake of vitamin A primarily apply to synthetic vitamin A supplements • High doses have been linked
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8/22/18
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Lily Nichols, RDN, CDE August 2018
BASICS OF REAL FOOD PRENATAL NUTRITION
Author, Real Food for Pregnancy; Real Food for Gestational Diabetes
OVERVIEW
• Conventional prenatal nutrition guidelines compared to real food
• Myths surrounding prenatal nutrition • i.e. recommendations that are not evidence-based
• Why we need a paradigm shift • Rationale for a real food diet that incorporates
updated research + principles from ancestral nutrition/traditional cultures
• Sample meal plans and nutrient breakdown from conventional vs. real food prenatal nutrition
• Definitions of real food are ambiguous, but generally include: • Vegetables & fruit • Meat, poultry, fish/seafood • nose-to-tail, including naturally-occurring fat & organ meats
• Carbohydrates 45-65% (no less than 175g/day) • Protein 10-35% • Fat 20-35%
• Limit fat (especially saturated) • Limit salt • “Half your grains whole” • Emphasis on fortified foods (folic acid, iron, calcium) • Vegetarian and vegan diet can be adequate • Assumes RDAs are correct
Lily Nichols, RDN, CDE
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Academy of Nutrition and Dietetics sample meal plan
“Nutrition and Lifestyle for a Healthy Pregnancy Outcome”
2014
Lily Nichols, RDN, CDE
MYTH: CARBOHYDRATE NEEDS ARE HIGH
• 45-65% of calories = 250-420g/day • (based on 2200-2600 calorie diet)
• This level of intake during pregnancy (52% calories from carbohydrates) has been linked to obesity in children • Even in healthy weight women eating at or below
estimated energy needs • AJCN, 2017
Lily Nichols, RDN, CDE
HALF YOUR GRAINS WHOLE
• “Half your grains whole” results in excessive intake of refined carbohydrates, which is linked to: • Higher blood sugar • Higher blood pressure • Higher gestational weight gain • Higher fetal weight • Lower micronutrient intake (displacement of nutrient-dense
foods)
• Already, 85% of carbs consumed in US are refined • No need to encourage more!
Lily Nichols, RDN, CDE
HIGH GLYCEMIC CARBS
• “Higher glycemic load diet is associated with poorer nutrient intake in women with gestational diabetes.”
• Nutr Res, 2013
• High dietary GI and GL = most reliable predictors of inadequate micronutrient intake in pregnancy
• Am J Clin Nutr, 2015
• Diets high in grains linked to excess infant birth weight
• Eur J Clin Nutr, 2015
Lily Nichols, RDN, CDE
CARBOHYDRATES CONT’D
• Traditional cultures consumed, on average, 16-22% calories from carbohydrates • Based on an analysis of 229 modern hunter-gatherer
populations worldwide • Equatorial populations consumed more: 29-34% • High latitude populations consumed less: 3-15%
• More room for foods rich in protein, iron, B12, zinc, vitamin A, iodine, choline, etc. • All nutrients of concern in pregnancy
Lily Nichols, RDN, CDE
ANCESTRAL CONTEXT
• Most ancestral foods are less “carbohydrate dense” • Higher ratio of fiber to total carbohydrates (low glycemic) • Honey is the rare exception
• Extreme latitudes (such as the Inuit of Alaska) 3-15% carbs • 18 – 98 grams
Lily Nichols, RDN, CDE
CARBOHYDRATES, CONT’D
• “No less than 175g per day”
• Origins of this theory • Estimated Average Requirement: 100g • Energy demand of pregnancy: 35g • (~300 kcal, 45% kcal from carb, 4 kcal/g = 35g)
• Glucose used by fetal brain: ~33g
• Grand total: 168 (rounded up to 175g)
• IOM, 2005
Lily Nichols, RDN, CDE
BUT… WAIT A SECOND!
• “The lower limit of dietary carbohydrate compatible with life apparently is zero, provided that adequate amounts of protein and fat are consumed.”
• “The marginal amount of carbohydrate required in the diet in an energy-balanced state is conditional and dependent upon the remaining composition of the diet.”
• IOM, 2005
Lily Nichols, RDN, CDE
CARBS & KETONES
• We now know nutritional ketosis is a benign and physiologically NORMAL state of pregnancy • “As part of the adaptation to pregnancy, there is a
decrease in maternal blood glucose concentration, a development of insulin resistance, and a tendency to develop ketosis.”
• IOM, 2005
• Nutritional ketosis is NOT THE SAME AS starvation
ketosis or diabetic ketoacidosis
Lily Nichols, RDN, CDE
KETONES “HARM” BRAIN DEV.
• FALSE. Entirely depends on the context! • Diabetic ketoacidosis + starvation ketosis = harmful • Nutritional ketosis = physiologically normal and benign
• Fetal brain gets 30% of its energy from ketones + ketones are maintained at higher levels in placenta and fetal circulation than maternal circulation
• (Much more on this topic in a separate webinar!)
• Variable tolerance for starchy carbs & fruit • Physical activity, weight gain, blood sugar/pressure • Usually room for ½-1 cup per meal (can be more/less)
• PERSONALIZE TO THE CLIENT!!!
Lily Nichols, RDN, CDE
LOW CARB ≠ NO CARB
• Even if you eat “low-carb,” you still eat carbohydrates • Vegetables, whole fruit, nuts, seeds, Greek yogurt, legumes,
etc.
• Higher-carb foods can still be eaten in moderation, such as whole grains, potatoes, yams, etc. depending on a client’s needs/tolerance
• Priority #1: Eliminate refined grains & cut way back on sugar
Lily Nichols, RDN, CDE
MYTH: LESS FAT IS BETTER
• Low fat recommendations automatically limit intakes of numerous micronutrients • Choline • Vitamins A (preformed), D, E, and K • Vitamins B12, B6 • Zinc, iron, and selenium • DHA
• Fully 94% of women don’t meet the current targets for choline; 1/3 don’t consume enough vitamin A • Animal foods (high in saturated fat) are primary sources of
these nutrients
Lily Nichols, RDN, CDE
FAT, CONT’D
• Less fat automatically means more carbs • More carbs usually means less micronutrients
• Focusing on unsaturated fats = more likely to have an unfavorable ratio of omega-6 to omega-3 fats • Linked to higher risk of preeclampsia + developmental
delay in infants
MYTH: REC’S ARE PERFECT
• Protein • First ever study to directly measure protein needs was
performed in 2015 • Protein needs are 39% higher in early pregnancy; 73% higher in
late pregnancy than current recommendations
• Choline • Didn’t even have a recommended intake until 1998 • Recommendations based on choline studies in adult men and
adjusted via mathematical equation for pregnancy • New studies suggest choline rec’s should be more than DOUBLE (930
mg instead of 450 mg); more research is needed!
Lily Nichols, RDN, CDE
MYTH: REC’S ARE PERFECT, CONT’D
• Vitamin B12 • Optimal intake in pregnancy may be TRIPLE the current RDA
• Vitamin D • Current RDA of 600 IU consistently results in vitamin D
deficiency • Optimal intake from numerous RCTs is 4,000 IU during pregnancy
(and likely more for deficient women)
• Vitamin B6 • Among pregnant women meeting or exceeding current
RDA, 58% had low blood levels at delivery
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MYTH: REC’S ARE PERFECT, CONT’D
• Some key nutrients are entirely missing from conventional prenatal nutrition guidelines
• Vitamin K2 • Bone mineralization & mineral metabolism • Food sources: natto, aged cheeses, liver
• Glycine - “conditionally essential” in pregnancy • Fetal DNA, skin, bones, connective tissue, integrity of
amniotic sac, uterine expansion, blood pressure/sugar regulation, placental health, etc.
• Vitamin A • Assumes all vitamin A needs can be met from plant-sourced
carotenes (provitamin A), which must be converted in the body to retinol (preformed vitamin A)
• Many lack ability to convert provitamin A to retinol (BCMO1 gene) • Beta carotene is 28x less potent than retinol • Estimated that ~50% of population have BCMO1 variant,
which means a 30-70% reduced ability to convert
Lily Nichols, RDN, CDE
VITAMIN A, CONT’D
• Warnings against high intake of vitamin A primarily apply to synthetic vitamin A supplements • High doses have been linked to birth defects
• However… • “Liver and supplements are not of equal teratogenic
potential. Advice to pregnant women to limit consumption of liver based on the reported teratogenicity of vitamin A supplements should be reconsidered.”
• In a Dutch study, 70% of women who avoided liver failed to meet the RDA for vitamin A • Liver is the #1 food source of preformed vitamin A
MYTH: FORTIFIED FOODS ARE NEEDED
• Folic acid • Up to 60% of the population has a mutation in the MTHFR
enzyme = reduced ability to use folic acid • Must get folate from food and/or L-methylfolate
• Iron • Form used in most fortified foods is very poorly absorbed
and often leads to digestive discomfort • Heme iron from animal foods = optimal absorption; 25-40% • Plant-source iron (non-heme) = 2-13% absorption
Lily Nichols, RDN, CDE
FORTIFIED FOODS, CONT’D
• Calcium • Calcium needs are NOT higher in pregnancy • Too much calcium = inhibition of iron and zinc absorption,
which are more likely to be low in a prenatal diet than calcium
Lily Nichols, RDN, CDE
FORTIFIED FOODS, CONT’D
• In a real food, omnivorous diet, fortified foods are not necessary
• Where fortified foods may be helpful: • Vegetarian diets (B12, DHA, iron, etc.) • Severe food aversions • Inability to take a prenatal vitamin • Low income populations without access to adequate
• Conventional standard: 1,500 mg sodium • Upper limit: no more than 2,300 mg; that’s 1 teaspoon of salt
• Salt needs INCREASE during pregnancy • Fluid/plasma volume • Neural signaling • Stomach acid • Fetal growth and development • Iodine needs • Blood sugar/insulin regulation
Lily Nichols, RDN, CDE
SALT, CONT’D
• Cochrane: advice to lower salt intake during pregnancy should NOT be recommended
• Low salt intake does not prevent nor treat preeclampsia and can actually WORSEN it • “Salt restriction during pregnancy is connected to
intrauterine growth restriction or death, low birth weight, organ underdevelopment, and dysfunction in adulthood probably through gene-mediated mechanisms.”
• Several recent studies have shown that higher salt
intake during pregnancy LOWERS blood pressure and lessens severity of preeclampsia
SALT CONT’D
• Best solution • Consume salt to taste (optimal intake has not been defined) • Honor salt cravings (pickles, olives, etc.)
• Opt for sea salt – also comes with trace minerals • Some sea salt is iodized; if not, include seaweed/seafood and
ensure PNV contains iodine
• Note signs of inadequate salt intake • Dehydration, leg cramps, headaches, elevated BP,
constipation, low amniotic fluid, edema
Lily Nichols, RDN, CDE
MYTH: VEGETARIAN DIETS
• “…vegetarian patterns meet most nutrient goals except for iron, vitamin D, vitamin E, and choline.” • AND policy paper on prenatal nutrition
• The list of potential nutrient deficiencies is FAR more complex • Some nutrients not even considered by conventional
standards, such as glycine and vitamin K2
Lily Nichols, RDN, CDE
VEGETARIAN DIETS, CONT’D
• Careful consideration + supplementation is necessary • Certain nutrients may be missing entirely (such as vitamin
B12) • Certain nutrients may be provided in a form that is not as
well-utilized by the body (such as the omega-3 ALA instead of DHA and beta-carotene instead of preformed vitamin A)
• Certain nutrients may not be provided in sufficient concentrations in plant foods (such as choline, glycine, and vitamin K2)
• Certain nutrients may not be well-absorbed (such as iron and zinc)
Lily Nichols, RDN, CDE
VEGETARIAN DIETS, CONT’D
• Options • Maintain vegetarian diet (lacto ovo vegetarian) • Supplement with high-quality PNV, iron supplement, algae DHA • Consume several eggs per day (choline, B12, etc.), soak/sprout
beans/grains to enhance mineral absorption, etc. • See Ch 3 of Real Food for Pregnancy
• Opt for semi-vegetarian diet with addition of key nutrient-dense animal foods • Bone broth (or other glycine-rich animal foods), oysters
(extremely high in B12, iron, zinc), fish/sardines, organ meats (including liver)
• May still benefit from additional supplements
Lily Nichols, RDN, CDE
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MYTH: FOODS TO AVOID
• Food safety advice means many nutrient-dense foods are limited • Must weigh the likelihood of foodborne illness with chances
of nutrient deprivation
• Australian study of nearly 7,500 women found that those who “consciously limit their consumption of potential Listeria-containing foods are likely to have suboptimal nutrient intake from foods.”
Lily Nichols, RDN, CDE
FOODS TO AVOID, EXAMPLES
• Eggs with runny yolks • Rationale: Salmonella • Risk of eggs containing Salmonella 1 in 12,000-30,000 • 7-fold lower in eggs from organic farms
• Cook until yolks are solid • Avoid eggs entirely !
Lily Nichols, RDN, CDE
FOODS TO AVOID, EXAMPLES
• Deli meat • Rationale: Listeria • Risk Listeriosis per servings of deli meat 1 in 83,000 • Nutrients provided: protein, iron, zinc, B6, etc.
• Not a major nutritional trade off unless this is the only source of animal protein in the diet
• Options: • Continue eating; common sense on food safety • Heat until steaming before consuming
Lily Nichols, RDN, CDE
FOODS TO AVOID, EXAMPLES
• Soft Cheese • Rationale: Listeria • Risk Listeriosis per servings of soft cheese 1 in 5 million • Nutrients provided: protein, vitamin K2, calcium, B vitamins,
iodine, etc.
• Options: • Continue eating; common sense on food safety • Avoid entirely; plenty of other cheeses to enjoy!
• Raw cheese/dairy from reputable small dairies is also unlikely to be contaminated
Lily Nichols, RDN, CDE
MYTH: LIMIT FISH/SEAFOOD
• Rationale: source of mercury, a neurotoxin
• Conventional advice: limit to <12oz per week • No swordfish, shark, king mackerel, tilefish • Limit tuna to <6oz per week; preferably canned light tuna
• Truth • Women who eat more than 12oz/week have children with
best cognitive outcomes, despite higher mercury intake • Selenium, also high in most types of fish, protective against
mercury absorption • Smaller fish contain less mercury, on average
• Plastic containers (phthalates, BPA) • insulin resistance, defects in genital development (boys),
preterm birth, brain development & behavioral problems
• Aluminum cookware/foil • Toxic to placental cells, bone dev. & neurological problems
Lily Nichols, RDN, CDE
MYTH: EATING FOR TWO
• Does NOT mean double portions at each meal
• Actual energy needs only increase ~300 kcal/day • “a pregnant woman needs to eat for 1.1”
• What does increase is nutrient needs, so emphasize nutrient-dense foods • Especially foods rich in iron, iodine, DHA, vitamin A, glycine,
choline, vitamin B12, and folate
Lily Nichols, RDN, CDE
HOW IS REAL FOOD DIFFERENT?
• Aim to meet nutrient needs from food as much as possible (without reliance on fortified foods)
• Considers modern nutrition research in the context of ancestral diets • Emphasizes nutrient-dense foods • Acknowledges that nutrition research is always evolving;
RDAs are best guesses, but not perfect
• Minimal processing, avoidance of food additives, local/in-season when possible
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KEY FERTILITY FOODS
• Liver & organ meats • Meat on the bone, slow-cooked meat, bone broth • Eggs • Full fat & fermented dairy products • Fatty fish & sea vegetables • Green, leafy vegetables
• Key nutrient-dense foods are limited or off-limits by conventional standards
• Limiting saturated fat and animal foods (and favoring a high-carbohydrate diet) increases the likelihood of nutrient deficiencies • Iron, zinc, choline, retinol, glycine, B12, etc.
• Outdated recommendations can put women & babies at risk for health problems
Lily Nichols, RDN, CDE
NAUSEA
• Common, especially in first trimester. Nutritional management: • Eat small, frequent meals/snacks (never get too hungry or
too full). Eat slowly and mindfully. • Balance blood sugar—aim to include some protein and fat
when you eat, even if the portion is small (protein at breakfast is especially helpful). It’s OK to eat more carbs!
• Try salty, sour, or cold foods. • Avoid strong odors—let someone else cook for you! • If vomiting, replenish fluids and electrolytes.
• Most compelling theory on nausea: Thyroid adapting appropriately to pregnancy
Lily Nichols, RDN, CDE
FOOD AVERSIONS/CRAVINGS
• Possible causes: • Help a woman consume enough beneficial nutrients (or may
be a sign of a nutrient deficiency) • Ice cravings often a sign of anemia
• Protection from toxins or food poisoning • Be one way to get through the nausea phase (carb cravings) • Avoidance of strong odors • Be a sign of an imbalanced diet (too high in sugar, refined
carbs, or processed food) • Body attempting to correct/avoid low blood sugar • Be the result of cultural expectations to have pregnancy
cravings
Lily Nichols, RDN, CDE
PRACTICAL TIPS
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PRACTICAL TIPS
• Reduce intake of refined grains and sugars • Low nutrient-density (“empty calories”)
• Include adequate protein & fat
• Emphasize vegetables, especially non-starchy vegetables
• Customize carb needs to the client • Low carb is safe, if needed/preferred • First trimester carb cravings are physiologically normal
Lily Nichols, RDN, CDE
MINDFUL EATING
• Encourage honoring hunger/fullness cues • Naturally helps find right balance of macronutrients, portion
size, etc.
• Women who practice mindful eating during pregnancy tend to eat healthier + consume less junk food
• Appetite, 2017
• Mindful eating does NOT mean ignoring nutritional common sense
Lily Nichols, RDN, CDE
AIM FOR BALANCED BLOOD SUGAR
• Reduces cravings • Prevents/manages high blood sugar & high blood
pressure, excessive weight gain, and excessive fetal growth (macrosomia) • Tends to displace foods low in micronutrients
• How to accomplish this? • Adequate protein + fat + non-starchy vegetables • Conscious of carb intake (no “naked carbs”) • Minimize refined grains + added sugar
• Mindful eating
Lily Nichols, RDN, CDE
DON’T EAT NAKED CARBS
Lily Nichols, RDN, CDE
DON’T EAT NAKED CARBS
Lily Nichols, RDN, CDE
PLATE METHOD
• Meal version of “no naked carbs”
• ¼ protein/fat • ¼ carbs* • ½ non-starchy
vegetables
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PLATE METHOD VS. MYPLATE
Lily Nichols, RDN, CDE
MEAL IDEAS
• Roasted salmon, green salad, roasted butternut squash
• Lettuce-wrapped burger with sweet potato fries • Chili (meat, beans, veggies) with all the toppings