OVERVIEW BASICS OF REAL FOOD PRENATAL NUTRITION

8/22/18

BASICS OF REAL FOOD

PRENATAL NUTRITION

Lily Nichols, RDN, CDE August 2018

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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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

Lily Nichols, RDN, CDE

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16 g carbs

54 g carbs

CARBOHYDRATES, CONT'D

? Average prenatal diet: 2,400 ? 2,600 calories

? Conventional recommendation 45-65% carbs

? 270 ? 420 grams

? Hunter-gatherer intake 16-22% carbs

? 96 ? 143 grams

? 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)

Lily Nichols, RDN, CDE

? IOM, 2005

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!)

Lily Nichols, RDN, CDE

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OPTIMAL CARBOHYDRATE INTAKE?

? In my practice, ~90-150g per day (total carbs)

? Emphasize low-glycemic, nutrient-dense carbs

? Non-starchy vegetables, nuts, seeds, Greek yogurt, legumes

? Variable tolerance for starchy carbs & fruit

? Physical activity, weight gain, blood sugar/pressure ? Usually room for ?-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

Lily Nichols, RDN, CDE

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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.

? Food sources: bones, skin & connective tissue of animal foods (bone broth, pulled pork, chicken skin, pork rinds, etc.)

Lily Nichols, RDN, CDE

MYTH: REC'S ARE PERFECT, CONT'D

? 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

whole foods (i.e. fortified refined grains better than unfortified refined grains)

Lily Nichols, RDN, CDE

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