Ep 72: Real Food for Pregnancy with Lily Nichols
Fertilty Forward Episode 72:
Choosing to follow a healthy diet should be pretty straightforward, right? But with all the information available to us online it can often be difficult to know which sources to trust, especially when they contradict one another. Here to shed some well-informed light on the topic is registered dietician nutritionist, and certified diabetes educator, Lily Nichols. Lily is a researcher and author of two books Real Food for Pregnancy and Real Food for Diabetes. She is also the co-founder of the Women’s Health Nutrition Academy. Her work is deeply informed by her passion for evidence-based prenatal nutrition. In our conversation with Lily, we hear about how she first became curious about the nutritional guidelines set for pregnant women and how her research exposed their inaccuracies. We cover a range of misunderstood foods and nutrients for pregnant women, such as vitamin A, vitamin D, liver, and fish, and hear how to safely benefit from them. Lily explains the deficiencies that result from a vegan diet and how to prevent them with adequate supplementation. She also shares her tips and tricks for incorporating healthy, but potentially unpalatable food into your diet slowly. We wrap up by hearing a little bit about Lily’s plans and gain insight into the tremendous amount of work necessary for writing a book on diet and nutrition. For all this and much more, tune in today!
Rena: Hi everyone. We are Rena and Dara, and welcome to Fertility Forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Forward podcast brings together advice for medical professionals, mental health specialists, wellness experts, and patients, because knowledge is power and you are your own best advocate.
Dara: Well, I am over the moon to have our next guest on today. Her name is Lily Nichols, and she's a registered dietician nutritionist like myself. She's a certified diabetes educator, a researcher, and author with a passion for evidence-based prenatal nutrition. Her work is known for being research focused, thorough, and critical of outdated dietary guidelines. She is co-founder of the Women's Health Nutrition Academy and the author of two books, Real Food for Pregnancy and Real Food for Gestational Diabetes. Lily’s bestselling books have helped tens of thousands of mamas and babies. Her work is used in university level material, nutrition and midwifery courses, and have even influenced prenatal nutrition policy internationally. She writes on her website at lilynicholsrdn.com. Lily. I've been wanting to have you on for quite some time now, so I'm not sure if you know this, but I've been working at RMA for over 11 years now. And since your books have been coming out, I literally recommend your books to every single patient that I work with.
Lily Nichols: Oh, wow. Thank you so much.
Dara: When I read your book a number of years back, it was the first book I've read that really resonated with me, that I felt was very similar to my approach to working with women in the fertility realm and it was just so refreshing to find someone who didn't necessarily agree with all the previous guidelines, unfortunately, that are, that are out there.
Lily Nichols: Yeah, that's so good to hear. I'm so glad it's become part of your work and can be a reference material for yourself and your clients. It's wonderful.
Dara: So I want to hear more about you and how you got into this space and kind of what prompted you to write these books?
Lily Nichols: Well, my initial work in the prenatal side of dietetics started in the gestational diabetes space, so both working clinically under a perinatologist who specialized in gestational diabetes and I was the in-house dietician and diabetes educator there. But I also worked at the public policy level with the state of California's Diabetes and Pregnancy program, which is also known as Sweet Success. So I was able to see the guidelines from, like, a top down policy level and all the bureaucracy to put it bluntly that goes on with setting those guidelines and updating those guidelines and how they have to like mesh with other organizations’ guidelines. There's a lot at work with those. But then also seeing how they performed in clinical practice was also really eye opening, right? Because from a research perspective, based on how limited our knowledge is of pregnancy nutrition as a whole - and I'm very upfront with that in all of my work - we have limitations on how much we can study. So a study might find X, Y, Z, or support this approach and yet in real life, you might see completely different outcomes with your clients. And so it was really in, in those roles that I started to get a little more curious about how were our guidelines initially set? Do we really have the evidence to support our, you know, recommended daily allowances or levels of macronutrients, particularly for carbohydrates, for gestational diabetes, for example, and then it kind of expanded out from there. So once I felt confident from all the research that I had done and going against the guidelines, so to speak, and we're not talking way out there, but we're talking like, okay, I actually don't have to recommend that my clients with gestational diabetes eat a minimum of 175 grams of carbohydrates per day. And then lo and behold, you have much better outcomes. So not only with that change, there was many other things that I switched around with our approach, but we reduced our rates of medication and insulin use pretty much in half. Way better outcomes. So, you know, the hospital would call us and they'd be like, are you sure this woman had gestational diabetes? Because like, we're not like we just stopped having big babies, like all of these problems and co-morbidities that are typical of gestational diabetes diagnosis we just didn't see. And so that's ultimately what prompted me to write my first book, Real Food for Gestational Diabetes, really to simplify the guidelines because I found them very confusing for clients and overwhelming, you know, teaching carbohydrate portions, but then also limit your fat and then limit your salt. And then like everything's off limits, you know, limit your carbs, but not too much. And then it was very confusing for clients.So I wanted a simpler resource also to compile that they uncovered on our ability to do slightly different than the guidelines. And that prompted a lot of clinicians to reach out to me like, Hey, do you have a resource on general prenatal nutrition? And I would always refer people to the gestational diabetes book, like just ignore the blood sugar stuff. This is important for everybody, but that resource should work just fine. Right? Finally, after having my first child and, you know, full recovery postpartum, I started writing Real Food for Pregnancy and that opened many, many other rabbit holes of guidelines that I researched further and uncovered, you know, while we have sometimes decades of research that don't support what our guidelines are saying. And there's just this very wide gap - the average is about 17 years before research make it into clinical practice and something like, okay, I'm going to go about this again, sort of from a grassroots level where I don't expect policies to change from like a top down approach, but if we can empower clinicians and clients to have better information at their fingertips, and then they see the positive outcomes, hopefully eventually there will start to be pressure in these organizations to push for policy change. So, yeah, that's kind of the short version of the story.
Dara: I just I love that you had the tenacity and like the drive. I was thinking a lot of the thoughts that you had written in the book. I applaud you for questioning certain guidelines, for questioning certain outdated recommendations that we were taught in school that haven't really been backed by credible research, that have been somewhat anecdotal or based on, I mean, not much at all. Both of your books are a perfect combination of doing the research, and making it accessible for the reader, and then giving real life tools and tips that people can actually apply. And it's interesting that you started a book on gestational diabetes, granted that's because that was what you were working on at work, which led into your Real Food for Pregnancy. But it's interesting when I speak to my clients and my population group is predominantly women who are trying to get pregnant to have infertility, I generally say it should be real food for life. I feel like your next...you know, how, how it can apply for so much. And it's not necessarily just for pregnancy.
Lily Nichols: Right? Absolutely. And I use that hashtag actually on social media, sometimes real food for life or real food is real food because people want additional information about like, how do I feed my kids? Or what do I eat when I'm trying to conceive or what do we eat for optimal hormone balance leading into menopause? And it's like, it ends up kind of being the same thing. I would just use a lot of different research citations to support that. And of course, there's going to be some little differences for different life stages, but the general principles, you're right, apply to all phases of life. It's just little things become more important at different stages. Right?
Dara: For sure. And even like the name, Real Food, it's an easy, simple title that really people can understand. You know, when in doubt, you know, if they skim through certain chapters, they'll know the gist of it is eating whole foods, which I think is such a simple concept, but really it's unbelievable how the average American diet is really lacking in real food.
Lily Nichols: Absolutely. Yeah. Processed foods up really the majority of caloric intake in most Americans these days, it's wild.
Dara: Oh, so true. I love that you speak a lot about carbohydrates and you don't vilify them, but you also mentioned that a lot of the carbohydrate content that Americans are getting are coming from these processed foods. They may be fortified with nutrients, but they're not in themselves nutritious foods.
Lily Nichols: Right. Exactly. Yeah. Statistic I read recently was 85% of carbohydrates consumed in the American diet are refined. So that's meaning primarily coming from white flour products or grains that have been stripped of their essentially all of their nutrients and fiber. So like white rice versus brown rice, for example, or refined sugars like white sugar and corn syrup. And I mean, for those of us who've been in the dietetics field for a while and have had enough like real world experience with clients, you see it firsthand, you know, it's one thing to be in your little bubble of social media, like Instagram, for example, where you have like the health conscious people seeking out your help. But that leaves aside, like, the rest of the population. People who aren't seeking out the help of a dietician or nutritionist? I mean, that's the subset of the population where you're seeing like, okay, your diet is like 60% carbohydrates. The majority of which are white flour and sugar. And like, if we just tackle that you solve a lot of problems.
Dara: it's pretty amazing. Even though I'm from Canada and I did my undergraduate degree back in Canada and did my masters here, but it's interesting that, you know, whether it's the rainbow or the pyramid or now the plate, it's interesting how the focus still really is on carbohydrates. And what I love is that not only do you speak about the micronutrients, which we can get into later that are helpful for overall fertility and health and pregnancy, but you really do break down the importance of macronutrients. And I love that you do it in a way that's not necessarily nitpicking in terms of these are the macros that you have to stick with, but also educating people that the current guidelines of the 60% or more carbohydrate dominant, how you do focus on the importance of proteins and fats is great.
Lily Nichols: Yep. It's about shifting the balance, right? And so we can speak about carbs and carb quality. That's like one side of the coin. Another thing that I tend to focus on a lot these days is really, like, promoting the most nutrient dense foods without vilifying anything else. So I almost like have moved away from talking about carbohydrates as much and started talking about nutrient dense foods, which a lot of those, a lot of the ones that fill in the nutritional gaps, micronutrient gaps of the diet for vitamins and minerals are proteins. And if you eat a sufficient amount of protein, which we can talk about those, but there's now been data showing that the RDA for protein and pregnancy is way too low, way underestimate. The first ever study they did to assess protein needs directly in pregnant women was done in 2015. Okay? And they realized in late pregnancy, the estimated average requirement was 73% too low. Okay. Put this into perspective. It wasn't like 10% off.
Lily Nichols: 73% off. So if we focus on getting enough protein, you hit a lot of the micronutrient boxes, which is great. You feel satisfied and don't have as many blood sugar swings. And you're naturally just going to be eating an appropriate amount of calories, which means you're not going to be on this blood sugar rollercoaster, starving for food all day long, where you want to just, you keep reaching for the carbs just out of, I mean, it's a physiological response to blood sugar crashes. When you help sort of even out your blood sugar levels with a sufficient amount of protein. If those are coming from whole foods, they come with an appropriate amount of fat for them as well. Naturally, even when you're having other carbohydrates with your meals, you're just not going to be as famished all of the time. And so a lot of issues self resolve again, when we just focus on the most nutrient dense foods, enough protein, like most of the issues and most of the need to nitpick things and count calories and restrict this, they just become a non-issue and as nutrition professionals that makes our life way easier in terms of counseling clients because you're not always the bad guy saying like, watch your portion size of XYZ, your body naturally quote, watches the portion size of those things, because you're having enough of all of these other things. So it's about my approach has become much more about inclusion versus exclusion over time. And we can still get into nitpicky details about things because it's fun to talk about, you know, micronutrients and their roles and where you find them in food and whatnot. But if you just get enough protein, a lot of problems self resolve.
Dara: But it's interesting because a lot of, at least the patients that I work with and it may be a female thing, I think a lot of women I see are not eating enough protein. So it's an interesting thing. That's often what I like to start with when I have a discussion and it's true. I think it's a great approach to, to let people know the things that they should be including in their diet as opposed to the no’s. And I think the way people counseled in the past was okay, these are the things that you shouldn't do going into our pregnancy as opposed to these are the things that should be inclusive. I think if anything, going back to blood sugar control, I think that's kind of the basis of, of everything. And that's why for me, real food for pregnancy really can be real food for life when it comes to eating for blood sugar control.
Lily Nichols: Absolutely. And it applies to trying to conceive as well for your client group. I mean, there's a pretty interesting study. I was just reading on blood sugar. Women who had blood sugar elevations that were even below the diabetic threshold, but like frequent, especially post prenatal, but also fasting blood sugar elevations had a significantly longer time to pregnancy than the women whose blood sugar readings were in the normal range. And so our, yeah, our understanding of blood sugar metabolism and how it impacts pretty much every other system in the body, including hormonal balance and egg quality and all of that is absolutely imperative.
Dara: On top of promoting protein, de-stigmatizing fat. And I know that's something that you're very a big proponent on in terms of not vilifying grass fed butter and other sources of fat and you know, nuts seeds, avocado, and fats from good quality meat products. I think it's great.
Lily Nichols: Yeah, it's needed. I mean, all of your steroid hormones, your estrogen, progesterone and so on are made from cholesterol, which you generally get in animal sourced foods that contain some saturated fat. So you, you need them for hormone production, first of all. You need them for overall health, your vitamins - A, D and K - are all fat-soluble. So you get those in fatty foods. There's also a lot of micronutrients that happen to show up in these foods that contain saturated fat like coleen, for example, and egg yolks and liver. And a lot of people don't want to consume those foods because they're too high in fat or cholesterol for their liking, but you actually require those for placental health, for fetal brain development, for liver health, which ultimately impacts your hormone metabolism. And so I think as we sort of zoom out a little bit and stop getting so involved in this, like nutritionism XYZ nutrient is good or bad and therefore you should eat this food and not that food, we see that things are connected. I happened to do a lot of work in trying to de-stigmatize the issues with fat and cholesterol. And we have quite a few studies now showing that there's not necessarily a clear link between saturated fat or cholesterol and heart disease. A lot of it has to do with where you're getting the saturated fat from. So saturated fat in the context of whole foods like a steak or chocolate or whole fat dairy has a much different impact on your body than an isolated, saturated fat that's part of a processed food or a synthetically made saturated fat. So super processed fats that they put in like baked goods and such. It has a different effect on your system. And that's something that I think the dietetics community has been a little bit slow to embrace, but the research has been mounting for a long time. I mean, previously we lumped in a lot of issues with saturated fat, with trans fat, which is incredible.
Dara: They’re too different!
Lily Nichols: A lot of the research didn't differentiate between the two long ago. They just thought they were one in the same because structurally they were pretty similar, although not exactly the same. And now we see that 2% increase in your trans-fat intake, like, doubles your risk of heart disease. Like, oh, that's a problem. We don't see that association with saturated fat though. So a lot of these things are, you know, the details matter. It's context dependent.
Dara: For sure. And it's interesting with eggs, eggs still get a bad reputation after all these years. I know there was a documentary years ago that compared eggs to, like, smoking cigarettes, which I thought was ridiculous. I actually, I'm sure you went back to look at the research paper that it was based on and it was laughable.
Lily Nichols: Yeah, I think I know, I think I know the documentary you’re talking about and sadly, most of the Netflix documentaries get it wrong and they have a lot of funding coming in from questionable sources. So I mean the whole plant-based movement, I think is some levels, positive because people, yes, should include more produce in their diets. Like we're definitely lacking in produce as a whole. But just because something is plant-based doesn't mean it's better, right? An Oreo is vegan and it's not healthy. Our plant-based agriculture of growing massive monocultures of soy and corn that require super heavy inputs of pesticides, which we then take and process into their individual oils and sugars. You know, your corn syrup, protein powders, for example, is not the same as consuming soy in its traditional form in something like tofu or tempeh or something. So it's just very interesting watching how this space kind of shifts over the years because it's gone from like, eat more fruits and vegetables to, like, never eat animal foods again. And it's like, okay, okay, if we're going to do this, we need to be talking about all the caveats here because when you omit all the animal products, what else are you accidentally omitting from the diet? Where are you getting your coleen? Sure, there's some in beans and legumes and nuts and seeds and cruciferous vegetables and mushrooms. But concentration wise,
Dara: You need to eat a lot.
Lily Nichols: You have to eat two cups of beans to get the coleen of a single egg yolk. You know, so it's like really legitimately is how is this going to happen? And I, I, haven't seen a proper rebuttal on the developing a vegan diet that truly hits all the marks on all the micronutrients, as well as the amino acids, because we now have some research showing that there is no such thing as non essential amino acids. I don't know if you saw that one. I posted it as a research…
Dara: I did!
Lily Nichols: ...on my Instagram, but like we have this whole idea that like, oh, there's only nine essential amino acids, as long as you get those. So you, like, combine your beans and your corn or beans and rice, like, you're fine. It's like, whoa, actually we have all these so-called non essential amino acids that are actually required for optimal health. Can you survive without consuming them? Yes. But surviving is different than being truly optimally healthy, having optimal fertility, optimal hormone balance, optimal weight management, optimal cardiovascular health. And these are all things that, oh, lo and behold, you do actually need your quote, nonessential, glycine and taurine and carnitine and these other amino acids. So there's a lot of stones unturned in that movement that I hope people bring more light to those over time.
Dara: Oh, for sure. You also had mentioned, I love in your book, about some of the, the amino acids that become essential during pregnancy like lysine.
Lily Nichols: Yup.
Dara: Which can be also very tough on a vegan diet. And I've been seeing a big trend towards patients coming to see me who have become vegan, not under a religious context, but just because they think it's the healthiest for them. Across the board. I wouldn't say that everyone's not feeling great, but it's interesting that a lot of these people who've turned vegan a) don't have the energy that they were hoping to see. Don't physically feel great, but are also not realizing that supplements they probably do need to supplement their diets. And on top of that are choosing a lot of packaged, processed vegan food, like the impossible burger, which, you know, like anything, things can be eaten in balance and moderation, but when people are focusing on less whole foods and then also not realizing that they can't get in all of their vitamins and minerals exclusively from just plants. It can be shocking to them and quite upsetting. And, and that's why for me, I, I think it's great. I feel like we're aligned in the fact that it is about moderation and about variety and balance, but I just, I want to go back to, I love that you promote liver and I feel like you are like, it's not something, you know, being Jewish, I grew up with chopped liver, but always hearing that liver was bad for you. And, um, yeah. And it's just, it's so lovely to hear. And also, you know, the idea of vitamin A and, and I think there's a big misconception that vitamin A isn't great for fertility, not great for pregnancy. And it's so wonderful that you are speaking up against that.
Lily Nichols: Liver gets quite controversial. You know, I think back to my university days. I was taking a lifecycle nutrition class and there was a girl who grew up on a farm. We got to the section on pregnancy and liver and do not recommend liver in pregnancy. It's too high in vitamin A and it's teratogenic. And this person chimed in and was like, well, I grew up on a farm and my grandma always recommended eating liver during pregnancy. It actually was pretty common in, like, the early and mid 1900s, especially in war times when it was like, you didn't have as much availability of food.So there was a big government push for people to consume offal, offal, you know, O F F A L, or organ meat, including those in their diet. And so people were already, people ate pretty much nose to tail back then. You know, you went to the butcher to get your food not all pre-packaged and styrofoam at the grocery store, or maybe you lived on a farm and harvested your own animals. Right? But it was so interesting to, like, have that, first of all, like sort of indoctrinated in the early on, and then to sort of come out and understand the ancestral food movement a little more. And then just, just start looking at nutrient tables. I feel like you can have a pretty, it's a good adjunct to your nutrition education to just spend a lot of time looking up foods. And what are the best sources of these nutrients and liver is arguably the most nutrient dense food on the planet. So yes, it is high in vitamin A and there have been concerns raised about vitamin A potentially contributing to birth defects. That's what a teratogen is something that can cause a birth defect. And what's interesting about it is when you dig into it, the only links of it being a teratogen in the research is linked to synthetic vitamin A supplements and synthetic vitamin A is a different form than what's found in food. In addition to that, not all of the studies on that agree. So there was like a couple that had that finding and then other studies that have had opposite findings, finding no link to birth defects. I recently read a study that said over the past, I think it was 30 years, there were 20 cases of birth defects, potentially linked to excessive vitamin A consumption - extremely, extremely low. And none of those were specifically linked to the consumption of livers, just going to throw that out there. But even if it is high in vitamin A and it's something that you shouldn't have ton of, I have found that liver is really a self limiting food. It has a very strong flavor. It is something that your body does not leave you to eat mass quantities out. Right? I've never met a single person who is over consumed liver as part of their diet
Dara: Maybe a French person.
Lily Nichols: Yeah. The caveat is that now there's desiccated liver supplements. And so I do have some people who reach out and they're taking like, taking 10 capsules a day of desiccated liiver on top of my prenatal and I'm like, whoa, whoa, whoa. Like you don't need that much. Right? But as a part of your diet, I mean, for me, I'm obviously I'm a proponent of consuming liver for many, many reasons. We maybe eat it two or three times a month as a family. It's not a lot. And that's like the same as my quote in the book, there's like a sheep farming community in South Africa, they consume more liver because they're mostly selling the muscle meats to market and they have to deliver an average of like 2.3 times per month. There's not high rates of birth happening there. But what we do see is very, very low rates of vitamin A deficiency in those areas because that's arguably kind of the ancestral level of consumption. You know, you get one liver per animal. And so you're probably gonna have a couple ounces every few weeks of liver. And that's a-okay. That checks a lot of the nutrient boxes for Folate and Coleen and B12, iron, vitamin K2, of course your vitamin A as well and many other nutrients without being excessive. So I think the prenatal community has put a whole lot of unnecessary focus on liver. People are so afraid to consume liver and they're not even eating it on a regular basis.
Dara: I think it's great. It goes back to balance. It's great that you mentioned it's all about balance, not having it every day. And I think that's something that people should know. A lot of times when people hear something as good, they want to have it excessively. And you know, I think when people realize just because it's good, you know, I always said the day that blueberries get a bad reputation, I'm going to quit becoming an RD, but it's actually changed for me. It's if you weren't eating blueberries for breakfast, lunch, and dinner, not great. For me, it's, it's kind of the big picture. One more thing with liver and then we'll, we'll move on because I know it's probably something to speak about a lot, but I just, I think it's great in your book that you do give some great ways to incorporate it in because that is one thing where a lot of people say that the taste is a little funky. You mentioned chicken liver is a little bit easier and more palatable than beef liver and high to get just, you know, like how you hide vegetables sometimes in muffins or pancakes, you can hide it in a meatloaf. You have a great meatloaf recipe and a meatball recipe. I heard in one of your, another podcast that you freeze the rest in little cubes, which I think is brilliant. So you can make a big batch of it with onions and different spices and then just freeze them and take them out as needed.
Lily Nichols: Yeah, that's exactly what I do. So I'll do a big batch of liver pate a couple of times a year, and then I freeze it. So freeze it in ice cube trays or small Mason jars. And then you can add that to a recipe anywhere between like three to four ounces of pate per pound of meat, I find is a really easy way to hide it. You can do a higher proportion if you have a taste for it, but if you're new for it, just stick to three ounces per pound of meat. And it's great. And then if it still is, you know, you really notice the flavor, then reserve it for using in dishes that have a lot of spices.
Dara: Or sauce.
Lily Nichols: Or sauces. Yeah.Bolognese sauce is a great place to hide it. Another, I have like an Indian spice stuffed bell pepper. That's a great place to hide it. Shepherd's pie. Meatloaf recipe is for most of those things are in Real Food for pregnancy. That's almost exclusively how we consume it. Occasionally I'll get, like, chicken liver and I have a recipe for savory chicken liver bites and my e-cookbook. Those are good, but like beef liver straight up or chopped liver and onions is, is not my cup of tea, probably because I didn't grow up eating it. So I get creative and that's how we fit it in.
Dara: Yeah, for me, like anything start off small, if it's something that you haven't had. And like, if it's something that you don't like pair it with something that you do like. Have it in small quantities and try it at least 10 times in different forms until you find something that works for you. But it's just nice to hear eggs, liver. A lot of these foods that have often been shunned in the past. It's nice to hear that they can be helpful for your overall health for fertility, for pregnancy. What else Lilly do you like to recommend when it comes to pregnancy or prepping for a pregnancy?
Lily Nichols: So we've talked about Coleen a little bit. We've talked about protein. I tend to focus a lot on the micronutrients, so we'll just kind of dive into some of those. One of the big ones that's important for fertility and pregnancy is vitamin D. And I feel like that one has gotten more attention in recent years, but I feel like there are also a lot of really mixed messages about vitamin D out there, especially recently. I don't know if you've seen this. There seems to be, like an ant-Vitamin D D crowd out there.
Dara: I have not seen at least the research that I've been reading for overall health with COVID health, but especially for fertility. I mean, we've been seeing the benefits of vitamin D.
Lily Nichols: I overall agree with those findings that it's generally beneficial. And for pregnancy specifically, we see issues with bone development with vitamin D deficiency. So a baby can actually develop rickets or insufficiently hard bones. If a mother is vitamin D deficient with pregnancy. And particularly if that continues postpartum, there's also links to certain pregnancy complications. So vitamin D plays a role in blood sugar metabolism. So you see a higher risk of gestational diabetes when the mother is vitamin D deficient. You also see blood sugar levels drop with vitamin D supplementation in pregnancy. So the converse is true. I'm getting sufficient amounts is beneficial. When mothers get sufficient amounts of vitamin D, we see a reduction in the rates of preterm birth. And this has even been shown in specific racial groups that have a statistically higher rate of preterm birth in general, vitamin D has been shown to be effective at reducing the risk of preterm birth. There's so many other things because vitamin D regulates like 3% of the human genome. So it affects almost everything in the body, but those are some of the major ones. And I really wish that checking vitamin D status was standard care in pregnancy or with preconception and fertility work. But it really isn't. A lot of times you have to advocate for it yourself. And so for example, that like reduced risk of preterm birth, that study used a minimum threshold of vitamin D levels at 40 nanograms per milliliter. And that was linked to, I don't remember the exact statistic, but generally it was about 60% across the board reduction in preterm birth rate when they got vitamin D to those levels that study supplemented across the board with 5,000 IUs per day daily or pregnant population.
Dara: It’s so common. I mean, I see it so much. We do tests at our clinic, but it's unbelievable how many people are below that level.
Lily Nichols: Yep. And vitamin D to give credence to the group that's anti-vitamin D supplementation. A lot of times their angle is that there's other nutrients involved in vitamin D metabolism. And that is true. So, you know, you need magnesium, you need vitamin A, that’s where liver comes in, you need vitamin K2. Again, you get that from liver. You also get that from full fat dairy products, especially fermented dairy products and other fermented foods. And so you need a number of nutrients, like everything, nutrients work in synergy, but the issue is we're just not getting the sun exposure that we once did. We are really designed to spend much of our time outside. Before the advent of sunscreen, it was, you know, we were not covered up. So when you put on sunscreen, you blocked 95% of the vitamin D production in your skin. And unlike every other nutrient, the major source of vitamin D is not our diet. It's sun exposure. So while I don't want people to get burned, I do recommend people spend some time outside without being covered up in sunscreen to a level that, like, you're making some vitamin D, but if you need to cover up cause you're very fair-skinned yes. Cover up after a little bit. Like I wouldn't recommend somebody with fair skin, go sit on the beach for four hours. I would fry to a crisp, but if I sort of temper my sun exposure and have 20 minutes here or there, or 30 minutes here, or there kind of building up over time, I can maintain sufficient vitamin D stores for most of the year, maybe except the deep winter, depending on where you are.
Dara: But it's interesting that I think even this past year and a half, where many people are staying at home, not commuting to work, I'm seeing that people have lower vitamin D levels this year than ever. It's a perfect reason to get outside. I live in the east coast so I do think that the winter months people aren't getting, you know, as much as they need. I do think in terms of a quality prenatal, I think it's important to have vitamin D3 iin your prenatal. And then when the summer months, you know, the summer months here at least are, the sun is stronger. It's a perfect excuse to, to take some time to be outdoors.
Lily Nichols: Absolutely. Yeah. And even if it's 20 minutes here or there, it doesn't have to be a huge amount of time. You could still cover your face. You know, if you don't want to get wrinkles and all of that. There's actually an app called, Deminder, noaffiliation on my end, where you can put in information on your skin tone and location and actually track how much vitamin D you're estimated to make from your sun exposure, which can be pretty interesting for people.
Dara: Oh, wow. What is that called?
Lily Nichols: D minder.
Dara: Oh, I love it. D reminder. I'm going to take a look at that. I think that's fabulous. People have thought of everything. Vitamin D is super duper important. And let's talk a little bit about omega-threes, about DHA. Cause I think that might be one other area that I think is a particular importance for pregnancy.
Lily Nichols: Yeah. So DHA is an important omega-3 fat that is incorporated in higher amounts into the brain and also the eyes. And this happens at specific times during fetal development, where provision of enough of that omega-3 fat has a lifelong impact on that child's brain health and vision health. So DHA is something that I have to remember the statistic. I think I read that it was 67% if I'm not mistaken of women in the US do not consume enough DHA.
Dara: That’s wild.
Lily Nichols: Yeah. It was like average intake was about 67 milligrams per day. And even like conservative recommendations are about 2 to 300 milligrams per day. Some people do more of course, but that's like, you know, baseline minimum 200. We're not getting close to that. And the main food sources of DHA are seafood by far. That's the richest source followed by, like, eggs. It's in the yolks.Grass fed meat. Those are really going to be your major sources. And one of the key points that I think a lot of people miss in the prenatal space is that not all omega-threes are the same. So people think DHA and omega threes are synonymous. DHA is a specific type of omega-3. There are other types of omega-threes such as EPA, which tends to come alongside DHA. And there's the plant form known as ALA and our bodies do not convert ALA in high amounts into DHA. So I remember a long time ago, I was doing a speaking engagement for the March of Dimes on prenatal nutrition. And they had a pamphlet in one of their hoops that I was perusing before I went up for my speaking engagement and I saw for omega-threes and for DHA. So they had a, you know, the heading was omega-threes. And then it said DHA is important for all these things. And then the food sources they listed, yes, they had seafood, but everything else was plants. So it was walnuts, flax seeds, chia seeds. And I was like, oh my gosh. So you only convert about 3% of ALA from plant sources into DHA. We've repeatedly shown in research that that is insufficient to provide enough DHA for either pregnancy or breastfeeding. And so if you're not consuming seafood in at least 12 ounces or so per week of high omega-3 types of seafood, you do want to consider a supplement that has DHA in it. So whether you're an omnivore who doesn't eat much fish or somebody who's fully plant-based and doesn't have any, you want to be thinking about a source of DHA. So for the omnivores there's fish oil, krill oil, cod liver oil, of course, with cod liver oil, you do want to factor in the vitamin A and take from there. And then for those who do not want to consume any seafood, there are algae-based DHA supplements. And that would definitely be something for somebody who's vegan or mostly vegetarian. I would recommend a algae-based DHA supplement. It's a key one that a lot of people just don't get. Again, the little details sometimes matter, they don't get the full story behind it and they think they're fine just having, you know, walnuts on top of their oatmeal for breakfast. And that's, that's not going to cut it.
Dara: That's a great point that you're making. And also getting back to the, in terms of the fish, whether it's salmon or trout or anchovies or sardines, those are all great sources of DHA. The most common questions that I get and I'm assuming that you probably get it as well as I thought, I shouldn't be eating fish or seafood when it comes to pregnancy and it frustrates me as I'm sure it frustrates you too, because yes, we have to factor in mercury levels of, of certain fish that are concentrated in mercury. And, you know, I think the easiest way to remember is that the larger the fish, the higher concentration in mercury, but that only covers a small percentage of the fish that's out there.
Lily Nichols: Yup. This is a case where my recommendations are actually completely aligned with the FDA recommendations on fish consumption in pregnancy. It's just that things have gotten lost in translation. It's like a game of telephone of like mercury is bad for brain development. Avoid all fish. Instead of mercury is bad for brain development. Certain fish are high in mercury. Some fish are high in selenium which reduces your absorption of mercury. Omega-threes are also important. Let's look at the studies on brain development outcomes and women who consumed a lot of fish and see if the nutritional benefits of the fish offset the mercury concentration and what happens to the brain development. So if you look at it from that perspective, I agree with the FDA guidelines, which is 12 ounces per week of fish. Although I would say you could go a little more than that as well. And the benefits outweigh the risks for the small exposure that you may have to mercury and environmental toxins from those sources and we do see that there's been many, many large studies looking at brain development outcomes in women who ate 12 ounces or more of fish. And actually in one of the studies that was out of the UK with 12,000 mother infant pairs, the worst brain development outcomes were found in the women who consumed no seafood whatsoever. I think that's a really important point for people to bring home. It's like we see fish and we see like, it only has omega-threes and mercury, but there's a ton of other nutrients in seafood that are beneficial to baby's development, such as iodine, selenium, vitamin D, vitamin B6, iron, copper. I mean, there's like a whole slew of nutrients in there beyond the omega-threes. We just get, like, tunnel vision on this one thing and then forget about the rest.
Dara: Yeah. It's like that fear component they hone in on that one little thing without looking into the bigger picture. What saddens me is, okay, you know, the guidelines have been changed, but I think people still haven't received the message. It's I wish that there was, you know, a louder voice out there for people really to be less afraid.
Lily Nichols: Exactly. And I mean, if you are super afraid than stick to like the tiniest little fish that have the lowest possible mercury levels.
Dara: However, just like liver, sardines and anchovies are tougher for a lot of women that I meet with. It's less palatable and you know, it's a much stronger flavor, but just like your liver, how you hide that in, there are definitely a ways of, you know, adding lots of garlic and lemon and other flavors and sauces to enhance the flavor and mask some of that more fish flavor.
Lily Nichols: Yeah. For sure. Sardines are more of a hard sell. And again, I'm somebody who didn't grow up eating a whole lot of fish. My mom does not like fish. And so for me, it took some work, took some time to let my palette get used to seafood, and now I really enjoy seafood. So, you know, it doesn't have to be sardines, you know, it can be salmon or some other, like, lighter tasting fish, like Cod, for example. But having some of that seafood in there is so beneficial. You did exactly what I mentioned before. It's trying things slowly and being patient with it. And also a lot of it's in your mind. I think just because if we weren't raised a certain way with certain habits, that doesn't mean that we can't change those habits. We actually have to want to make those changes and be open-minded to it. And I think, you know, a lot of it's mind over matter, but you know, you have to want to make those changes.
Lily Nichols: For sure. Yeah. And actually just to throw out, like, an idea for people, I was actually just texting with a friend of mine. Who's trying to muster up the courage to eat sardines. This is a person I've known for over a decade. So she knows me well, and she still hasn't tried them. Right? And I suggested to her to do, you know, a can of canned salmon drained for, like, making essentially salmon salad, like you would tuna salad and then add in a can of sardines as well. So you just kind of cut the flavor a bit with something that you're already familiar with? And then serve it on something that's a little more, like, instead of serving it on a salad or as a lettuce wrap, maybe have it with, like, some crackers or corn chips, you know what I mean? Like sometimes you make some nutritional accommodations, like, okay, chips, aren't the healthiest thing, but they make it easier, more palatable to get down this food that maybe is new to me or not as palatable yet and have it that way. So you're kind of getting the best of both worlds. Like salmon is still good, but if you're working to try to get sardines in, this might be a way to fit them in a little easier.
Dara: Oh, for sure. I love that your books are very research evidence-based, but also your philosophy is one of mindfulness. And I think the combination of giving concrete research to back up why certain foods and certain nutrients are really important for overall health, it's also your intention when you eat and the habits that surround eating. And it's great that your philosophy marries those two concepts together.
Lily Nichols: Yeah. I mean, I naturally err on the side of mindful eating and I actually write about this on my blog. There's, like, a really, really old post, it’s probably 10 years old now. I think it's called, like, six reasons to stop counting calories. Don't judge me. I don't know how old the writing is. It's been a long time since I looked at the post, but I remember writing that and going through feelings that I had when I was given an assignment as an undergrad to like track everything. And it was so like out of body. You're just focused on what the numbers are instead of how your body's feeling. Are you actually full? It was like, oh, well the calculator said that I should eat this amount of this and this amount of that. And oh no. Did I go over? Oh, did I go under? Am I supposed to eat something more? But I'm not hungry. But I under-ate for my calories or maybe you have something else, higher calorie and then you feel guilty because you were only allotted 700 calories for that meal or whatever it is. That was a really interesting experience for me. And it just became clear that counting things was unsustainable. I also found it kind of unsustainable in practice to be trying to enforce rules on people, especially when you understand that our energy needs are going to change day to day...
Dara: Person to person.
Lily Nichols: There's some that, yeah, you're more at like you, your walk was 30 minutes longer that day. Your energy needs are different. Am I going to be, like, providing another calorie controlled meal plan with more calories for the walking days? I mean, it gets really stressful for people. Not to mention, I mean, in order to really track properly, you're talking like you need to measure out all of your ingredients on a food scale.
Dara: That takes out the fun of eating in life.
Lily Nichols: So I found a lot of people that get number obsessed end up relying on packaged processed foods because if you're cooking a meal from scratch that has 20 ingredients and you're going to have to try to, like, portion everything out and weigh everything, I mean, your calculations are going to be off. So I'm a much bigger fan. There's a time and a place for counting, but sort of eyeballing it with a version of the plating method where you're getting a portion of your plate from protein and fat sources, a portion of your plate from high quality carbs, a portion of your plate from vegetables.
Lily Nichols: It works so much better in practice. Like we really don't need to nitpick with people. Very rare exceptions to the rule that you actually want to be counting strictly. You know?
Dara: I love that. And listeners listen to that. Listen to your body and also go for foods that are predominantly whole. Foods that aren't in packages with millions of ingredients and listen to your body and listen to what your body needs. I wanted to ask you, Lily, what is on the horizon for you? Any new books? Of course, I'm thinking like my mind's going, like she needs to write a book about men's health and fertility. She needs to write a general book about healthy eating for life. I feel like there's so much that's down the road for you, but anything that you have in the works that you are willing to share with us?
Lily Nichols: There is a project in the works that I'm not publicly sharing about yet, but I'll, I'll just give you that hint. And I will say that there has been a wide range of suggestions on books. So there have been requests for a cookbook and requests for something on postpartum. I tried to actually fit what should be the postpartum book into the last chapter of Real Food Pregnancy, but there are people who want, you know, a full on book on post-partum, which it could be its own book. There's people who want, you know, a book for children, introducing foods to babies.
Dara: A lot of options!
Lily Nichols: A lot of options. And I will tell you, I have a lot of reservations about any of the particular topics, just the way, my writing process is very slow and time-consuming because I ask a lot of questions along the way and go down a lot of random tangents of research because I want to be presenting things as much as possible from a research informed perspective versus this is my opinion. We all have opinions. We have a lot of biases. I like to see what's also out there, sort of challenge my preconceived notions about something. Because a lot of times I, I learn something new. Either my stance is reinforced or my stance is challenged and that changes the way, the type of recommendation I have. It's different than counseling somebody one-on-one, you know, you counsel somebody one-on-one and you're customizing it to the person right in front of you. When you're writing a book for a general audience that might be read by hundreds of thousands of people, you have to be much more, I guess I would say careful, but you want to be, like, more sure of the recommendations that you're giving and understand the caveats to those recommendations, right? Even when you get to something as simple as, like, carbohydrate recommendations, there's just a wide range of carbohydrate intake that works for people. So it's like sure, if somebody with PCOS who has some underlying insulin resistance, at risk for gestational diabetes, and then there's like these five other things going on, I'm going to have a different recommendation for them than somebody who is below a healthy weight, exercises every single day of the week, and is consistently under eating as hypothalamic amenorrhea. You know what I mean? Like their recommendations are probably couldn't be more opposite. So that makes it challenging, but there will be other things on the horizon. I'm also working on a practitioner mentorship program on prenatal nutrition. Hoping for that sometime next year. I do have two little ones.
Dara: You’re busy!
Lily Nichols: And so that makes it challenging. Those are definitely things that are there on the horizon. I'm also always working on new webinars for the Women's Health Nutrition Academy which kind of reaches more of the health practitioner audience and writing on my blog and my Instagram feed. So, definitely have plenty, plenty to keep me busy, but certainly there will be more books or at least one more in the future.
Dara: So we're very excited for that. In the meantime, we can find you on your website, which we've mentioned before and remind everyone of your Instagram handle.
Lily Nichols: Yeah. So my Instagram and website are actually the same. You just add a dot com for my website. So it's lilynicholsrdn. I can't say I'm like the most active Instagram person. But when I do post, I try to post meaty content, not just silliness. I'm not really like a lifestyle influencer type of a person. I, I share more like research and then a lot of examples of what I'm eating. I find a lot of people find that of benefit. Like, what am I actually cooking? What does that look like on a plate? I think that really drives the point home without even providing. I do tell you what's in it, but without even reading the caption, you get an idea of like, oh, that's what she means by real food. And I think that goes a long way. And then as far as my website, now I have my blog up there. There's 250 plus articles at your fingertips for free. Use the search bar for specific topics. I also have a lot of freebies. Like you can read the first chapter of Real Food for Pregnancy, for free up there and many other things on the freebies tab. So that's a great place to get more information.
Dara: Unbelievable. So how we end our podcast is we discuss gratitude and what we're grateful for at this very moment. So Lily, what are you grateful for today?
Lily Nichols: Hmm. I am grateful for two healthy children. One just got over a little bit of a cold and I feel like any time there's any type of sickness in the house, it makes me all the more grateful for health. Grateful for two healthy children and one other thing, just grateful for lots of small farmers in the area that provide. I don't get all my food from local farms, but I really try to make an effort to support them. And it tastes so much better and it's often less expensive than the grocery store and I'm just so grateful there's still people working the land as so many people move off into their virtual jobs like myself. Like, we still need people on the ground growing food, and I'm definitely appreciative for them.
Dara: How nice. I'm going to piggyback on that. I'm actually grateful for my weekly runs to Union Square Market to pick up the beautiful produce and the fresh fish and meat products there. And also getting out of the City to be in nature. To be on a lake and to put my feet on grass, on clean grass and to hear nature, which I think is important for all of us to get now and then.
Lily Nichols: Especially if you're in the City.
Dara: Definitely. Lily, I am thrilled to have you on and I know our listeners are going to love what you had to say and hope we get to have you back on soon.
Lily Nichols: Yeah. Thanks for having me.
Dara: Thank you so much for listening today and always remember: practice gratitude, give a little love to someone else and yourself, and remember you are not alone. Find us on Instagram @fertility_forward and if you're looking for more support, visit us at www.rmany.com and tune in next week for more Fertility Forward.