025: Nutrition For Gestational Diabetes w/ Lily Nichols, RDN


025: Nutrition For Gestational Diabetes w/ Lily Nichols, RDN

Welcome to the Hey Mami podcast!

Our guest today is Lily Nichols, a Registered Dietitian/Nutritionist, Certified Diabetes Educator, researcher, and author with a passion for evidence-based prenatal nutrition.

Her work is known for being research-focused, thorough, and critical of outdated dietary guidelines.

Lily 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. Her bestselling books have helped tens of thousands of mamas (and babies!), are used in university-level maternal nutrition and midwifery courses, and have even influenced prenatal nutrition policy internationally.

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In today’s episode we are talking about real food for both prenatal and gestational diabetes.


  • Lily’s story
  • More information on gestational diabetes (GD)
  • Lily’s approach to both prenatal nutrition and nutrition for GD
  • The importance of keeping blood sugar within a certain range during pregnancy
  • Meat on the bone vs boneless meat
  • Meal-planning tips for the early postpartum period

Important Links

Find Lily online

Find Lily on Instagram

025: Nutrition for Gestational Diabetes w/ Lily Nichols, RDN TRANSCRIPT

Dr. Carrasco:                      Welcome back to the Hey Mami podcast. In today’s episode, we’re talking about real food prenatal nutrition, and nutrition for gestational diabetes. We cover Lily’s approach to prenatal nutrition and how it differs from the conventional approach, the best foods for a healthy pregnancy, how to plan for postpartum recovery using food as medicine.

Dr. Carrasco:                      Our guests today is Lily Nichols 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 is a registered dietician, nutritionist, certified diabetes educator, researcher, and author, with a passion for evidence based prenatal nutrition.

Dr. Carrasco:                      Her work is known for being research focused, thorough and critical of outdated dietary guidelines. Lily’s bestselling books have helped tens of thousands of mamas and babies and are used in university level maternal nutrition and midwifery courses, and have even influenced prenatal nutrition policy internationally.

Dr. Carrasco:                      We are so lucky to have you today. Lily is such a pleasure. We have wanted to have you on since the beginning and inception of our podcast and your work has definitely informed and affected us in a really positive way. So welcome.

Lily:                                        Thank you.

Dr. Carrasco:                      And thank you for being here. So we always open up by asking our guests why do you do what you do and how did you become passionate about your work, especially in prenatal nutrition and gestational diabetes?

Lily:                                        Yeah, so, I mean, I’ve been interested in nutrition my whole life. I decided as a teen to study nutrition in college and was even sort of influenced or introduced rather to the ancestral nutrition approach before I went through my conventional dietetics training. It wasn’t until I was already practicing that an opportunity came my way to work in the gestational diabetes field.

Lily:                                        And my passion for that definitely grew over time, especially as I started learning some really interesting statistics on how maternal blood sugar can influence the baby’s development and their later metabolic health. So their later risk for type two diabetes or obesity, and that can be significantly lessened.

Lily:                                        I mean, pretty much to the level of any, anyone else who’s pregnant without a of diabetes, just by maintaining blood sugar within the normal range. And that was huge for me because early on, I had really wanted to work in the child nutrition area knowing that childhood obesity and diabetes was on the rise was like, “Oh my gosh, this is terrible.”

Lily:                                        And then to learn that it could go all the way back to essentially like imprinting in utero was crazy to me. And then working with clients with gestational diabetes, it was really difficult for me to continue to follow the guidelines because they performed so poorly for my clients that I came to this place of like, “Are you really failing the diet as they say? Or is diet therapy failing you?”

Lily:                                        Like, are we giving you the wrong intervention? So that led me to develop my so-called real food approach to managing gestational diabetes and writing my first book, Real Food for Gestational Diabetes. And once you start uncovering stones and looking at how are the carbohydrate guidelines set for pregnancy and why do we recommend this relatively high level to women with gestational diabetes who cannot tolerate that amount of carbohydrates without having high blood sugar?

Lily:                                        Okay, well that, isn’t actually based on very good science. Let’s look at the protein. Let’s look at the fat, let’s look at the vitamin A, let’s look at the colon, let’s look at all these things and you start it’s sort of like a house of cards it’s just like, “Okay, so a lot of this is based on really outdated shot evidence and we have new evidence suggesting X, Y, Z, how do I get this out there to the masses?”

Lily:                                        And you can only do so much in a one-on-one clinical practice but that ultimately led me to write my first book. And later on my second book, Real Food For Pregnancy, it’s like, how can we cut this average 17 year gap between new research coming out and getting into clinical policy? It takes a two pronged approach. You have to provide enough evidence that the providers feel comfortable with offering bring different advice, which is why I cite my work so heavily.

Lily:                                        But I also wanted to write it in a way that the general public could understand, because a lot of times it’s women themselves who are doing additional research and then bringing that into their provider and being like, “Well, you said I can’t have eggs with running yolks, but I learned that [crosstalk 00:04:58] and they’re both cooling percentage. And I learned that exactly. There’s nutrients in there that are important to me. So that’s sort of where it all started and how I got here.

Dr. Maren:                          Oh, Wow that’s really awesome. I’m so grateful for your book too, because it just strikes such a chord with me with the gestational diabetes piece and exactly what you said. Like, are you feeling diet or is the diet feeling you? Because what I realized, like I was in residency when I was diagnosed with gestational diabetes and I had a good level of like knowledge and I was checking my blood sugar four times a day.

Dr. Maren:                          And when I ate the certain number of carbohydrates, I’m like, well, that’s not going to work for me. And I was very determined not to go in medication. So I manage my diet really, really carefully, but like under the conventional guidelines, I would’ve completely failed.

Lily:                                        Yeah. And a lot of conventional dieticians who have been taught incomplete information I would say incorrect and incomplete information about nutrition requirements and pregnancy would often counsel you not to reduce your carbohydrates to a level that your body can handle.

Lily:                                        They would say, “continue to eat that amount, let your blood sugars spike will give you insulin or medication handle it.” When it’s like, “why don’t we just match the carb level to the individual person’s carb tolerance, as long as you meet all of your essential nutrient requirements for vitamins and minerals and amino acids and all that. But it’s surprising how like, controversial that very-

Dr. Maren:                          Common sense?

Dr. Maren:                          I don’t know common sense in advice is. Yeah, totally.

Dr. Carrasco:                      So tell us about your approach to prenatal nutrition, I guess a little bit more in depth than how it differs from conventional wisdom. And I think if you could also touch, maybe touch on the gestational diabetes piece as well, but I know these are two separate cohorts, although with some similarities.

Lily:                                        Oh yeah, there’s a lot of overlap. So my approach after sort of reading into how these guidelines were developed and my level of confidence in the actual evidence that they use, a lot of our nutrition guidelines are really based on data from men.

Lily:                                        And then they’re extrapolated via mathematical estimations for what we expect for the maternal demands and for fetal development. So they’re really a guesstimate in the last 20 some years, we’ve really expanded our understanding of different nutrients in their role in preventing pregnancy complications or optimizing fetal brain development or whatnot.

Lily:                                        And personally, I feel we have stronger evidence on the micronutrient requirements for pregnancy then we do the macronutrient requirements that they tell you. So your macronutrients being your fats, carbohydrates and protein, the guidelines take a top down approach. It’s like, “Well, since we need X percentage of carbs and fat and protein eat this,” and then they don’t seem to put a lot of emphasis on the micronutrients.

Lily:                                        It’s like, “We’ll just fill in the gaps with fortified foods in a prenatal vitamin.” I’m like, wait, wait a minute. So if we build a diet that’s based on about half carbohydrates or marks guidelines, say 45 to 65% of our diet as carbs. And those are the foods that naturally are lowest in some of the nutrients we need the most during pregnancy like iron and zinc and vitamin A and B12 and choline and others, then we’re going to end up with a nutrient deficient diet.

Lily:                                        So let me just reverse engineer this for a minute. Let me just come up with, “Okay, these are the most nutrient dense foods. They have the highest amounts of the micronutrients that are typically lacking in a prenatal diet, or that women are typically deficient in entering into pregnancy.” Let’s build a diet around more of around those food and then let the cards fall where they may for macronutrients analyze that part later.

Lily:                                        So I took a different approach to it. So I really started with that. And that was coming from an understanding also of what worked for blood sugar management for my clients, or even for myself before are I was ever even pregnant. You can monitor your blood sugar and see what a mess happens when you overeat on carbohydrates and under eat on protein and fat.

Lily:                                        So there was already an understanding that this probably also applies to the general public, but certainly for pregnancy. So can we build a realistic, good tasting reasonable meal plan following this sort of approach? And then how does it compare for macronutrients and micronutrients and calories and everything else?

Lily:                                        And it turns out you come out on top, you can match the same amount of calories, but if you’re getting a higher proportion of your diet from protein and fat and slightly less coming from carbohydrates, and also really emphasizing better quality carbohydrates, because I don’t advocate for a zero carb diet, it’s just better quality carbohydrates.

Lily:                                        We can vastly improve your nutrient intake across the board. You’re going to be much more likely to hit your choline requirements and B12 and folate and iron and all these other minerals and vitamins than we would if we just followed the standard low fat, high carb oatmeal for breakfast kind of recommendations.

Dr. Carrasco:                      Yeah, absolutely.

Dr. Maren:                          100%.

Dr. Carrasco:                      And then of course, I mean the ideal would be that if you have gestational diabetes you have access to work well. And that’s probably why you wrote your book, but that you have access to work with someone that can help you monitor and tailor a plan specifically to you. Because I think a lot of patients just feel like left kind of flying in the wind by themselves.

Lily:                                        And a lot of dieticians feel like their hands are tied because if the guidelines say something, then you might be tied to or required to use those guidelines or use those teaching documents that are developed by your facility or by your governing body.

Lily:                                        So a big part of my work has just been citing everything like crazy to show that no, there actually is scientific evidence to suggest an alternative and no there’s actually not strong scientific evidence to suggest that eating fewer than 175 grams of carbohydrates in the context of calorie sufficient protein, sufficient diet is going to cause any harm.

Lily:                                        Arguably is going to only provide benefits, but it puts you in a very sticky situation as a clinician because you feel like you’re going against what you’ve been taught to do or what you’re practiced or whatever does. I was just very lucky in that I worked for very forward thinking OBGYN MFM, who was like, do what works.

Lily:                                        Develop new if there’s better ways to manage gestational diabetes, like we want to limit the number of our client that are on medication or insulin. You make the call on that as the dietician and diabetes educator. So if you think you can manage this better revamp the handouts, revamp how we’re doing things.

Lily:                                        And we saw dramatic difference, 50% reduction in the number of patients who required medication or insulin and drastic improvements in fetal outcomes. I mean the hospital that most of our clients delivered at were like, this person doesn’t have gestational diabetes-

Dr. Carrasco:                      [crosstalk 00:13:02].

Lily:                                        … because they didn’t the classic GD big baby or the complications that they were expecting. And then the research backs that up. So that’s my clinical observation, but there’s also really good data on low glycemic index diets, reducing the chances that a woman will require insulin by 50% or more, and also reducing the glycemic variability. So how much your blood sugar is spiking and crashing during the day. [crosstalk 00:13:29].

Dr. Maren:                          Which is actually really important, right?

Lily:                                        It’s really.

Dr. Maren:                          Glycemic variability piece.

Lily:                                        Absolutely Absolutely. And we’re just beginning to understand that a little more like now that we have CGM Continuous Glucose Monitoring available, we’re starting to see much more the importance of maintaining your blood sugar within a certain range. Your average can come out, okay if you have a big spike and a big crash, but that’s really stressful to your body and also not great for your baby too, because there’s really no buffer between your blood sugar and baby’s blood sugar.

Dr. Maren:                          Totally. And do you think part of the fear with a lower carbohydrate diet is… When you see your OB GYN or midwife, they always check urine. Right? And so once they see ketones coming up in urine, sometimes that’s a sign and people tend to think, “Oh, well you might be in ketosis.” Which I don’t think that that’s necessarily true when we see ketones in the urine that you would see ketones in the blood, but like how do you address that concern with clinicians?

Lily:                                        Yep. That was actually like the whole focus of the last chapter of Real Food for Gestational Diabetes, because that’s the big elephant in the room. There’s concerns about ketosis essentially. And the thing that’s important to understand is even in my training as a registered dietician and diabetes educator, there’s really no education on the different types of ketosis.

Lily:                                        So ketosis is all lumped into one category, which is like the medical emergency diabetic ketoacidosis that a person with type one diabetes might experience if they’re not managing their blood sugars appropriately a missed a dose of insulin or something like that, That’s something that will happen in like insulin deprivation.

Lily:                                        Your body’s not producing enough and you’re not taking enough of exogenous and insulin to manage your blood sugar. Blood sugar goes super high and your body starts burning body fat to fuel you because it can’t get sugar into your cells for energy. Your blood becomes very acidic. It’s a medical emergency rare, but it’s a medical emergency. There’s a difference though, with two other types of ketosis, starvation ketosis, you could just not eat enough and starve and your body also starts tapping into fat stores and ketones are a byproduct of that.

Lily:                                        That’s not great for pregnancy either because you’re starving. So you’re not getting enough of any of your nutrients essentially, but there’s another type of ketosis that’s sometimes called nutritional ketosis or mild ketosis or physiological keto where your body has a balance and is constantly shifting the fuels that it’s utilizing. So sometimes you’re burning glucose. Sometimes you’re burning fat for fuel and in pregnancy, you’re actually more prone to go into ketosis or like three times more likely to go into ketosis. And you go into ketosis quicker during pregnancy than you do during any other stage of your life.

Lily:                                        Though your body’s literally doing everything it can to maintain some baseline level of fuel source to the baby. So overnight while you sleep, literally every pregnant woman, if you are metabolically, healthy will be in ketosis overnight and you will be in ketosis first thing in the morning when you wake up.

Lily:                                        So if you go to your doctor’s appointment, fasting at 8:00 AM and you’re pregnant you’ll be in ketosis like almost bar none you’ll be in ketosis, but the one important differentiation is how you’re checking ketones. And whether it’s at a harmful level or just a physiological level. There is no data and there’s a new 2021 study that came out. Essentially, they basically summarized everything that I talked about in chapter 11 of Real Food for Gestational Diabetes.

Lily:                                        But now it’s published in a journal that there’s no evidence that low level ketosis is harmful. That urine ketones don’t correlate with blood ketones. There’s no evidence that low level ketosis harms neurological development. Really that data is limited to diabetic ketoacidosis or starvation ketosis, but mainly DKA. It’s a physiological thing your body just does.

Lily:                                        So if you really want to check and see that your client might have harmful levels of ketones, you want to understand if they’re producing any insulin or not, you should probably know that because if that’s happening, they probably have type one diabetes or some borderline odd type of diabetes where their body’s not insulin. During pregnancy your body produces more insulin like up to two to three times more insulin.

Lily:                                        So that’s really rarely, rarely going to be the issue. You can check to see if they’re eating enough food. Maybe they aren’t. They could simply just be eating low carb. And then if you want to see that it’s harmful or not, you check their blood ketones and in pregnancy, your body maintains your blood ketones at a very low level and it spills the excess into the urine.

Lily:                                        So I think we’ve just fundamentally had a deep, deep misunderstanding of what the body physiologically adapts to during pregnancy and how that shows up in blood or urine markers. The amount or size of urine ketones does not correlate with blood Ketone levels either. So you can be spilling a high amount of urine ketones and your blood levels are at like 0.1, which would be just physiologically normal.

Lily:                                        But we also are really limited in the amount of data that we have on ketone levels in pregnancy. We’re starting to understand it like a little more slowly papers are starting to come out on like an actually analyzing blood ketone levels. But we were really working from very rudimentary data for decades and that’s really what the guidelines were based upon.

Lily:                                        But there are some organizations like California Diabetes and Pregnancy Program also called Sweet Success, which I used to work for. They don’t recommend routinely checking urine ketones. It doesn’t correlate really with anything. It’s like, you can check them if you want to. They might be elevated.

Lily:                                        It might mean something or it might mean nothing. And so that was just taken out of the routine guidelines and working for the perinatologist we pretty much almost never checked urine ketones unless we really suspected somebody was significantly under eating then we might check urine ketones and that’s whether it’s accurate or not, it might give you a proxy if somebody is not eating enough food, like someone’s really not getting eating a lot of weight. They’re like, you know, nausea and vomiting. Like maybe we need to have a little more nutrition intervention going on here, a little counseling, but for diagnostic criteria, if you’re concerned, you really need to check blood ketones.

Dr. Carrasco:                      Yeah, yeah that’s really great info. So I think something that would really be, would resonate with our listeners is talking about kind of easy wins what are some of the best foods or the number one foods that you recommend for preconception health, for pregnant women and why?

Lily:                                        Well, there’s a lot of overlap for preconception or fertility nutrition and pregnancy as well as postpartum by the way. So same nutrient dense foods that support healthy pregnancy and fetal brain development. Those are the same foods that help your hormones stay in balance, keep your menstrual cycle regular, help you get pregnant, help prevent neural tube defects, support your body as it adapts during pregnancy and help you recover and rebuild your nutrient stores after the fact, there are some like little differences between the different stages, but for the most part, it’s about the same.

Lily:                                        You just progressively need more food as you move through those different stages. Especially if you’re breastfeeding, you’ll need a lot more food postpartum. So some of the top foods, I, again, as I said, I like reverse engineer. What fills the nutritional requirements the most. And one of the things that we’re now learning is that protein requirements are a lot higher during pregnancy than previously thought.

Lily:                                        We now also have data on breastfeeding. They checked women at three to six months postpartum. They need more protein even than they needed in the third trimester of pregnancy. And this wasn’t like a minor underestimate we’re talking like 73% more protein than we thought was required is actually needed in late pregnancy. And then even more when you’re looking at the postpartum requirements.

Lily:                                        I’d love it if they do a study at like one to four weeks postpartum and check that because I’d wager it would be much higher, you’re super hungry and super depleted, early postpartum and recovering from childbirth. But nonetheless protein rich foods become really, really important at all of those stages for slightly different reasons, but overlapping reasons.

Lily:                                        So you want to look at your top food sources of protein. You’re looking at animal foods like meat, poultry, fish, seafood, dairy products, eggs, nuts, beans, seeds, legumes, all of those will provide you with protein. Ideally some of a little bit of all of them or as many categories of protein rich foods as possible because they each have their own individual makeup of amino acids.

Lily:                                        And so the more variety you have the better. They also have different makeup of micronutrients. So your vitamins and minerals like fish happens to be really rich in Iodine and selenium, and it has DHA and choline and B12. Specifically like the iodine, selenium and DHA are like the most concentrated in fish and seafood products compared to your other protein sources.

Lily:                                        So those fill a really important nutritional gap. Eggs with the yolks are really, really rich and choline. That’s like the number one food source of choline in our diets, more than half of the choline that we eat on average comes from egg yolk. So that’s a really important one. Dairy actually fills some interesting roles as well.

Lily:                                        Everybody thinks of like calcium and vitamin D, but it’s also a really great source of vitamin B12, especially for women who don’t eat much meat second to seafood it’s one of the major sources of iodine in the diet. It has riboflavin, which helps your body process folate. It’s also a nutrient dense food. So you take your picks, use a really high and folate fiber and some other nutrients.

Lily:                                        So if you can get an array of protein rich foods, you’re doing very well to not only hit that protein amino acid requirement, but also those micronutrient requirements. And then next to that, I would say like your plant foods, your produce vegetables, low sugar fruits, like berries also provide a lot of different micronutrients as well.

Lily:                                        You need more vitamin C during pregnancy, for the most part that’s coming from your fresh foods, your leafy greens provide you with vitamin K1, which is helpful for blood clot. There’s a lot of different minerals, especially potassium in your fresh produce. So having those foods is helpful. Honestly, that covers the top most important ones you can fill in the gaps of your diet with everything else. But I would say like those two categories of foods are some of the most important beyond all the reasons that I just mentioned, but that really fills in like most of the micronutrient gaps in the diet are from those categories foods.

Dr. Maren:                          One thing I’ve heard you talk about is meat on the bone. So can you tell us why it’s important and why that’s helpful from a nutritional perspective to have that meat that’s like stewed in your Instapot or whatever.

Lily:                                        Yeah. So meat on the bone, it really has to do with the different amino acid makeup of the different parts of your animal foods. So meat on the bone naturally has a lot of collagen. It because there’s a lot of connective tissue and our connective tissue is really where a lot of our collagen is concentrated as well as like skin and other areas.

Lily:                                        So the amino acid makeup of collagen is mainly glycine, proline, hydroxyproline, glutamine and of those. I mean they all have, have their own importance, but glycine and proline are especially important in pregnancy. So there’s, if you look at like protein requirements and why we need them. Proteins are made of individual amino acids and in nutritional sciences, there’s always been this understanding that certain amino acids are essential. Meaning you have to get them from your diet in order for your body to function properly.

Lily:                                        And some are so called non-essential, which means they don’t actually need to be in your diet. Your body can make them from other amino acids. We’re learning now A, that that is a misnomer it’s never been scientifically proven. That was based on a lot of assumptions that no longer seem to be valid. We just research just been coming out on that in the last five years, but we do always have always known that during periods of stress pregnancy would count as a period of stress. There’s increased nutritional demands.

Lily:                                        Sometimes your body’s not able to keep up with producing some of these non-essential amino acids from other ones. And that includes glycine and arguably also proline. So glycine is a really interesting amino acid in that it makes up about a third of the collagen that’s in your body and your glycine turnover is higher in pregnancy.

Lily:                                        So instead of being non-essential, they actually think it’s conditionally essential during pregnancy. This is a time period where you need to have a dietary source. It helps with creation of fetal DNA, a bones, connective tissue, internal organs, teeth, blood vessels, and then your own body you require it for your stretching skin, your uterus, which is growing, your connective tissue adapts during pregnancy to allow your uterus and everything to stretch and grow, allow your pelvic floor to stretch for baby to be born.

Lily:                                        So there’s higher demands for glycine. And since those meat on the bone items are high in collagen, they are by default, also high in glycine. And that really is the number one food source for glycine is your collagen rich animal foods. So bones, skin, connective tissue, rich foods. So meat on the bone, like if you’re roasting a chicken whole that is meat on the bone, you also have the skin eat the skin, because that’s really high in glycine as well.

Lily:                                        If you need a snack pork rinds or crack ones, everyone thinks they’re like terrible for you. Actually that’s probably the number one food source of glycine because it’s just the skin and it’s not necessarily has to be fried in oil. It can just be like air puffed. You look at a bag of pork rinds it’s like pork rinds and salt. Like that’s actually a really nutrient dense food.

Lily:                                        So some source of glycine, if you’re not a big meat eater your seafood product can also contain glycine. If you can cook fish whole, if you can like cook your salmon. So the skin is crispy and you actually want to eat it, do it that way you can get canned salmon, that’s canned with the bones and skin and make that into like the tuna salad type thing. But just with salmon, the bones become soft and almost like a little bit they’re soft. They kind of crumble. I wouldn’t call them crunchy. They crumble. That can be other ways to get glycine in. It’s a little bit trickier on a plant-based diet, but yeah, glycine is vital.

Dr. Carrasco:                      How do you feel about collagen products for moms that are on the run or [crosstalk 00:30:07].

Lily:                                        Oh, I like-

Dr. Carrasco:                      A lot of food.

Lily:                                        Yeah. I like collagen products. I think it’s a great option. I think there’s benefits to eating whole foods, nose to tail, but most people are not eating that way. We all, including myself, grew up in an era where it’s like, other than maybe my mom making like a roast chicken every once in a while, it’s like you buy your individual pieces of meat, all pre-packed. And a lot of times they don’t have the bone or the bone is not saved to make bone broths.

Lily:                                        People don’t cook as much as we used to. So yes, to bone broth and slow cooking meats and making pulled pork and roasting a whole chicken and all of those things. But I don’t think there’s any harm in supplementing with collagen, assuming that it’s a clean collagen product. You want to make sure that they’re not using hexane or other chemicals to extract it. That the company tests for heavy metal residues in the presence of contaminants like glyphosate and there are brands that do that like vital proteins, for example.

Lily:                                        So yeah, I think it’s a great option. It’s really easy to fit in, really easy to boost your just total protein intake. As well, you know, can mix it right in your morning, beverage coffee or tea or hot cocoa, or if you are having something like oatmeal that adding some collagen would be really helpful to like boost protein up.

Lily:                                        So you don’t have quite as big of a blood sugar spike after it. You can add it to soups and stews. It’s like really easy for people to add it. So yeah, I’m a fan out of collagen.

Dr. Carrasco:                      Great. That’s an easy hack.

Dr. Maren:                          So I think one of your chapters, you talk about foods that are considered unsafe in pregnancy. Because when most of us get pregnant, we’re told like what not to eat deli meats and so on. Can you address those and what’s truly unsafe in pregnancy and where those recommendations are wrong?

Lily:                                        Yeah. So to me it comes down to, I can’t prove anything is safe or unsafe because anything can become contaminated. So the standard lists come from the understanding that certain foods are more likely to be contaminated and therefore avoid them entirely. So there’s large swaths of foods that are put on these foods to avoid lists because they might be contaminated with salmonella or they might be contaminated with listeria or E coli or something else that could give you foodborne illness, which can be serious in pregnancy. I don’t want to like downplay that that is a legitimate risk.

Lily:                                        However, when you look at the relative risk of getting sick from those things, it’s very, very rare. So like cases of listeria worldwide is like three cases per 100,000 pregnancies and that’s worldwide. So that includes outside of developed countries. And we know there’s a lot more foodborne illness and other issues and parasites and viruses and other infections in developing countries that don’t have as high of like hygienic practices and food production and storage and whatnot.

Lily:                                        So it’s quite rare. So I think you have to take it from a standpoint of what are the nutrients that, that food could be providing me? Are there benefits to it? What are the relative risks of it being contaminated with something? Could I prepare it in a way that, or source it in a way that reduces those risks by all means that it should be done.

Lily:                                        But a lot of times there’s really not that much evidence to suggest any particular foods are bar none unsafe. My one exception is shell fish eaten raw that one accounts for 75% of seafood associated foodborne outbreaks in the US. So I know there’s still some people that are going to eat raw oysters and other things in pregnancy. I mean, it’s a highly nutrient dense food. Oysters are fabulous, but from the data I’d say that’s a legitimate risk of foodborne illness, whereas eggs with runny yolks.

Lily:                                        The chances that an egg contains salmonella is like one in 12,000 to one in 30,000 eggs. They account for less than 2% of foodborne illness outbreaks in the US. On the flip side, raw fruits and vegetables account for 46% of foodborne illness outbreaks. And those are not on the foods to avoid list. If you really wanted to be a stickler on foods to avoid, you would probably have like all your melons, especially if they’re precut, you’d have pre bag leafy greens, how many times romaine lettuce and spinach and iceberg lettuce spin on the list for combination with E coli or salmonella or other things.

Lily:                                        You would have those off limits too. And in fact, in a lot of other countries, there are warnings about raw vegetables. I’ve heard from women in parts of Europe that say they’re told to avoid salad during pregnancy because of the risk of foodborne illness.

Lily:                                        So I think we just need to have a little more like open discussion about the actual data. And then you have to make the choice based on what makes you the most comfortable. If you’re really anxious about having an egg with runny yolks, like don’t have eggs with runny yolks, but I hope you’re having eggs in other ways to get that choline in and the other nutrients that are in eggs, right?

Lily:                                        So you can do them scrambled or hard boiled or over hard or any way that the yolks and whites are cooked until they’re totally solid. If you enjoy them that way, arguably or are getting the same nutrition, but you’re just minimizing your food safety risks. If you eat them over easy, your chances are this and it’s not very high. So you get to decide what risk you’re going to take or not is really my opinion.

Dr. Maren:                          Yeah, totally. I would much rather have runny york than romaine lettuce personally. I won’t even eat romaine lettuce now. I mean, it’s just been recalled so many times.

Lily:                                        Salads really… I’m the same salads sketch me out. There’s a single green in salad that’s like mushy and black. It’s like the whole container is just automatically repulsive to me. Like, yeah, you can wash it well, but like I much rather get them like fresh from the farmer’s market where I know they haven’t been like that washed with 2000 pounds of lettuce coming from who knows where. Packaged, who knows where. Shipped in a truck with who knows what type of refrigeration.

Lily:                                        I mean, you just look at the number of outbreaks with leafy greens. I’m not going to tell people not to eat salad, but just add that to the list of things where you want to also want to be careful of like your sourcing and freshness and use your nose. Your nose is very sensitive during pregnancy for a reason. If something is not fresh, you’ll probably know. So don’t eat it if it’s sketchy.

Dr. Carrasco:                      That should be on a t-shirt don’t eat it if it’s sketchy.

Lily:                                        Yeah. Right.

Dr. Carrasco:                      Okay. So probably our last kind of big question for you is about the postpartum experience. Do you have any tips for expecting moms so they can plan ahead for their postpartum recovery and not do that work while they’re recovering?

Lily:                                        Yeah. It’s a hard one. It’s a hard message to get out there. I’m glad there’s more people that are talking about it because for my first postpartum, I like didn’t, all of my effort was focused on planning the birth. And there was very little emphasis on planning for postpartum. I started writing Real Food For Pregnancy by the way, at 10 months postpartum after my first was born.

Lily:                                        And so like right when I started to have a little brain power back. And so it was very top of mind. That’s why I put a whole chapter on postpartum recovery because it’s just so important. And even if you want to be eating well, it can’t all fall on your shoulders.

Lily:                                        So you can have the best of intentions to eat really healthy but if you don’t have food prepped or somebody cooking for you, somebody heating up the food for you meal delivery service, a postpartum doula, a meal train from family and friends you’re going to end up probably under eating and probably relying on more convenience foods and bars and snacks and things just to try to fill this like very hungry, empty void feeling, right?

Lily:                                        You’re just very hungry postpartum. So your nutrient needs are higher postpartum than they are during pregnancy by quite a bit, not only for calories and protein, but for a lot of different micronutrients as well. My best advice is to just think ahead, like acknowledge that you will not be up on your feet, even if you want to be, you probably won’t be able to be up on your feet very much, or it’ll slow down your recovery to be up on your feet a lot, especially in those first few weeks.

Lily:                                        So can you find a way to prepare meals and have them in your freezer ahead of time? I have a blog post on real food postpartum recovery meals that links out to 50 plus recipes for options for that and how to freeze different things. And that’s something that I personally chose to do at about halfway through my second pregnancy.

Lily:                                        I learned my last and I prepared food and stocked the freezer. Also sort of leaning into the really global practice of supporting new mothers that we’ve lost in our Western culture. I invited my mom to come and stay with us for a while. No, that’s like a huge privilege, but I didn’t even like think of that with my first postpartum. She came for like a week and this time I was like, “Stay for a month. Here’s some recipes you could cook.”

Lily:                                        All our family or friends are don’t have people able to do a meal train. It might be worth it to hire out help. I’ve been known to bring meals to new moms that are local to me. You can set up a meal train and have that a lot of people, if they like, “What can I get you baby?”

Lily:                                        Like a meal that is much more helpful than a onesie. Because most of these newborn onesies will not even get worn or they just get spit up on them immediately or a diaper blowout or something it’s like, but you need to eat some kind of a meal. For people who live far away from me, a friend of mine just had a baby out order, like a meal delivery service and send, I send like a week of meals.

Lily:                                        So however that looks for you just go into it with the understanding that, I’m probably not going to have the wherewithal to be planning, directing, cooking, or doing all of this in early postpartum. So have that on your agenda at least starting in the third trimester to at least think about what that might look like and it can look different for everybody. I, again, I cover some of those options in that article I talked about.

Lily:                                        So I’d recommend checking that out and just having that in addition to birth planning and buying cute newborn thing-

Dr. Carrasco:                      Yeah, totally.

Lily:                                        … have it on the agenda in the back of your mind something else to think about.

Dr. Maren:                          Yeah, 100%. I went after my delivery date with my first and I just started cooking and sticking soups in the freezer and it was like a huge plus after delivery. And I mean the other thing, especially when you’re like a first time mom, I don’t have any hands. My husband was literally sticking food in my mouth because I was using both hands to breastfeed and trying to figure out how to drink water and it’s hard. So yeah sometimes.

Dr. Carrasco:                      [crosstalk 00:42:22] Your babies crying or being colicky all this stuff.

Dr. Maren:                          Easy stuff smoothies were sort of my at least I have a smoothie on board with collagen and I’d like stick olive oil in there just to like stick a bunch calories in there.

Lily:                                        Yeah. Think ahead for those sorts of things. I mean, how is it going to work? There’s brands that make like pre-made broth if you’re not into cooking.

Dr. Maren:                          Oh yeah.

Lily:                                        There’s a brand called FOND that makes [crosstalk 00:42:46].

Dr. Maren:                          We love FOND.

Lily:                                        Oh yeah. They’re like shelf stable and a glass jar. It’s so easy to heat up and they’re also a flavor is really good too. So if you’re not going to do homemade, have a case of FOND broth on hand, it’s actually pretty high protein too. You’re going to need more than just broth for a meal, but still like have that on hand, make some egg muffins or [inaudible 00:43:08] and have that in the freezer or pull aside some recipes that you can outsource to your husband.

Lily:                                        If he doesn’t know how to cook, be like, “Hey, when I’m making this, I need you to watch what I’m doing because I’m going to ask you to make this for me postpartum. Assign him like three things. I don’t know just, well whatever, think outside the box, because we all have like a different living situation and different amounts of personal help available.

Lily:                                        You have to plan for yourself not being at 100% functional adult because you’re sleep deprived and tired and caring for a baby and learning how to breastfeed and exhausted and probably not up for being on your feet for very long. As you shouldn’t be traditionally, you were in bed at least for the first week and then around the home for the first month or six weeks or more in all these other cultures. It’s very unusual that we have this expectation of ourselves to be up and doing things days after birth.

Dr. Carrasco:                      My mom always tells stories of she’s like, “Oh, when I was little you wouldn’t even wash your hair for a month. That was part of the 40 days that you just rested and everyone took care of you.

Lily:                                        There were a lot of concerns about women getting cold.

Dr. Carrasco:                      Yes, exactly.

Lily:                                        Yeah. And some of these things are I think maybe a little bit less concerned now that we’re modern living and have heat in our homes-

Dr. Carrasco:                      Resource.

Lily:                                        … and whatnot, but still you see that repeated across all the cultures, you see it in Asia and the middle east and Africa and Mexico. Doesn’t even matter if it’s a tropical warm place, there are concerns about you getting cold or being in a draft or wind and whether it’s old wives tales or whatnot, you often do crave being like warm and kind of-

Dr. Carrasco:                      Snuggled. Totally. Yeah.

Lily:                                        Early postpartums. So have that in mind. I mean that carries over into foods as well. I mean, if a smoothie sounds good and it’s like, you have a summer baby, that’s probably fine. But in some cultures there is really an emphasis on warm foods, over cold foods, things that are like easier on the digestion because all your internal organs are all discombobulated from being smashed for nine months.

Lily:                                        And then they have this empty, loose void to figure out after the fact so easy to digest things. That’s why things like bone broth and soups and stools and-

Dr. Carrasco:                      Nut milks too. Right? Like there’s a big emphasis in Arabic medicine for like cinnamon and nut milk and clove and.

Lily:                                        Yeah. The warming spices. Yeah, for sure. So, and just whatever sounds good. I, some of these, the traditions are all a little bit different. So if something speaks to you culturally, like definitely go for that. But I don’t think we need to get too concerned about you can never have a salad or could never have a smoothie because it’s cold. Like sometimes that actually sounds good to you go for it. But just like in general they were usually focusing on yeah those warming things, both in spices and temperature.

Dr. Carrasco:                      Yeah. Lily, your knowledge is so encyclopedic and it’s been a pleasure having you share your wisdom with our audience. Can you tell us where people can find you online? And I also think that you have the opportunity for people to download a chapter of your book as well.

Lily:                                        Yes I do. Yes. So you can find me on my website, which is on the, you’ll see it all over the site where you can download the first chapter of Real Food For Pregnancy for free. If you don’t happen to see at the freebees tab has that along with many other different free bees that I offer.

Lily:                                        So if you want a little more intro into what I mean by real food, how my recommendations differ from the guidelines and why. If you want to see in black and white comparison in the nutrient breakdown of a conventional meal plan and one of my meal plans, that’s all in there in black and white in that download. My blog’s also up there. So I’ve been blogging for over 10 years. So there’s like 250 articles up there. Newer ones are probably better than some of my older content.

Lily:                                        But you can also use the search bar to search for any individual topics. I have one on protein and pregnancy that would provide you with more eloquent information that I could just pull from the top of my head on this podcast or the postpartum recovery meals is definitely a good article to read.

Lily:                                        My books are all linked up there. If you want to find those. And as far as social media, you can find me on Instagram mostly. And my handles the same as my website. So lilynicolesrdn.

Dr. Carrasco:                      That’s wonderful. Well, thank you so much for joining us and-

Lily:                                        Thank you.

Dr. Carrasco:                      … it’s been a real treat. We’re really happy to have spoken with you and keep doing that great work. It’s important.

Lily:                                        Thank you. My pleasure.

Dr. Maren:                          Thanks Lily.

Alejandra Carrasco M.D. and Christine Maren D.O.

Hello! We are Alejandra Carrasco M.D. and Christine Maren D.O. We founded Hey Mami because we felt a lack of support for fellow mamis. As physicians, we see women every day who struggle with fertility, are forgotten about postpartum, and have put their health on hold for years while they raise a family. We’re here to change that.

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