Registered dietitian and researcher Lily Nichols and Adriana take a closer look at the common nutrition recommendations during pregnancy, and whether avoiding raw fish and runny eggs may be keeping you from getting the nutrition you and your baby really need. Lily also shares why you should pair high-quality fats and proteins with your carbs, and how to listen to the signals your unique body is sending you for optimal nutrition.
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What we talked about:
- Risk of getting sick vs. risk of not getting the nutrients you need
- What is the true risk of being infected by salmonella or listeria?
- Eggs or green vegetables: what has a higher chance of making you ill?
- The micronutrient benefits of eggs
- Do you need those yolks to be runny?
- What you can do to lessen your risk of getting sick
- That sushi craving may be your body’s way of telling you something important
- Understanding raw food safety
- What about the high mercury levels?
- The benefits of eating fish during pregnancy
- Use your nose!
- The importance of fats
- Not all fats are created equal: saturated, unsaturated, monounsaturated, hydrogenated
- Omega-3 to Omega-6 ratios
- Having some protein with your fat
- Having some fat with your veggies
- Having some protein with your carbs
- Try a mindful eating experiment: how does it make your feel?
- A note on supplements
- Real Food for Pregnancy, by Lily Nichols
- Real Food for Gestational Diabetes, by Lily Nichols
- Real Food for Pregnancy website, where you can access the first chapter of Lily’s book for free!
- Lily Nichols’ website
- Folate: Why It’s Superior to Folic Acid for Pregnancy (Even If You Don’t Have MTHFR), Lily Nichols’ blog
- Choline in Pregnancy: Folate’s Long Lost Cousin, Lily Nichols’ blog
- How to Choose Safer Seafood, The Real Food Dietitians website
- Pregnant Safe Sources of Omega-3 Fats, Eat Right, the Academy of Nutrition and Dietetics blog
- Omega-3 fatty acid addition during pregnancy, Cochrane systematic review
- Cheesemongers Over Fearmongers: Toward Data Driven Cheese Recommendations for Pregnant Women, Graduate Association for Food Studies blog
- Real Food Nutrition For Pregnancy, The Real Food Dietitians website
- Foods to avoid in pregnancy, the National Health Service (NHS) in the U.K.
- Micronutrient Needs During Pregnancy and Lactation, Oregon State University
Related Birthful episodes:
Do You Really Need To Stop Eating Sushi?
Adriana Lozada: Welcome to Birthful, Mighty Parent or Parent-to-Be. I’m Adriana Lozada.
Today we start our new series on Nutrition and Nourishment, and for the next few weeks, we’ll be taking a closer look at how you can use nutrition to best support your baby’s growing needs as well as your own.
And sure, we’ll talk a lot about food in this series, but also about herbs, the microbiome, morning sickness, extreme nausea, how nutrition can help lower your chances of developing health risks during pregnancy, and the challenges that may come up for some relating to the weight gain that occurs during this time.
First up— meaning, in this episode— I’ll be talking with the fabulous Lily Nichols about the problems with one-size-fits-all nutritional recommendations that simply tell you to stay away from raw fish, soft cheeses, deli meats, and runny eggs, without considering the why behind these recommendations, and whether avoiding these foods might keep you from getting nutritional elements that you really need.
Lily is a Registered Dietitian/Nutritionist, Certified Diabetes Educator, researcher, speaker, and the author of two bestselling books which are called Real Food for Pregnancy and Real Food for Gestational Diabetes.
These amazing books have influenced international prenatal nutrition policy, been used in research studies, and even become required reading in university-level maternal nutrition classes. Needless to say, I highly recommend them, and I always enjoy the opportunity to talk with Lily, not just because she’s research-focused, thorough, and critical of outdated dietary guidelines, but because she’s also super fun to talk to.
Now, toward the end of the episode, we talk about three questions to ask yourself— and I’m going to give you a heads up right now that the third question is “How’s your energy level?” …This may not mean much right now, but you can have a good laugh at us when you get to that part, and remember that the third question is “How’s your energy level?”
You’re listening to Birthful. Here to inform your intuition.
Adriana: Lily, welcome! So happy to have you back on the show.
Lily Nichols: I’m so happy to be back.
Adriana: This is such an important conversation because when you learn that you’re pregnant, like, most people’s first thought is, “Oh, I can’t have alcohol and I probably shouldn’t have that much caffeine.” And then usually they learn about the broad recommendations to stay away from raw fish and soft cheeses and deli meats and runny eggs— which has some basis, because you need to minimize the risk of getting sick from possible bacteria (since during pregnancy, your immune system needs to lower its guard a bit in order to host your baby). I know you have done a ton of research on this topic, so let’s jump right in: are these recommendations still valid?
Lily: I think you’ve set me up perfectly, because you already explained the logic behind it. It’s hard to answer if they’re still valid because at the end of the day, there’s going to be risk-benefit consideration as to what you eat during pregnancy. From my stance, we want to be looking at: How do we meet the nutrient needs of pregnancy and for fetal development? And if they’re found in these off-limit foods, could we be doing more harm than good avoiding them? So, y’know, when you first talk about— and I’m going to save, like, alcohol and caffeine for another discussion, ’cause they’re in a different category— but if we’re just focusing on the food safety side of things, which is pretty much what all of those other foods fit into (the risk of getting sick from bacteria or virus or parasites), then we really need to start looking at the data.
How likely is it that you will get sick from eating raw cheese or soft cheese, or eating deli meats, or eating fish, or eating eggs with runny yolks? And when you actually start looking at the data, it’s quite low. And by contrast, when you start looking at, “How will you meet your nutrient needs if you don’t eat that food?” in certain cases, you can get into sticky situations, nutritionally, especially eggs and fish. And we can go through that, if you’d like, in more detail.
The likelihood of a salmonella or listeria infection
Adriana: Yeah, I’d love to— but before you do that, ’cause I did read your book and it’s amazing, thank you for creating this great resource and for going through all the research for us! Y’know, you found that in terms of that risk analysis, we always blame deli meats and runny eggs, say, for some of the bacteria, or for, say, like, salmonella where in fact, you can get… there’s a lot of outbreaks from eating raw veggies instead.
Lily: Right. So let’s put… let’s put some numbers behind this, so I’m not just talking in loose, non-specific terms. The… when you use the data from the U.S. FDA, the Food and Drug Administration, it’s estimated that there’ll be one case of listeria infection (called listeriosis) per 83,000 servings of deli meat, or 5 million servings of soft cheese consumed by pregnant women. And for eggs, the risk of salmonella (that’s the main thing we’re concerned about with under-cooked eggs), the likelihood that an egg will have salmonella is about 1 in 30,000 and separate data that’s analyzed, the chance that an egg will have salmonella— depending on what sort of farming practices the chickens were raised from— that rate is sevenfold lower in farms that allow their chickens to graze on pasture, that have time outside.
Adriana: What you would call “free range,” like in the box it would probably say “free range chickens” or something like that?
Lily: I would look for “pasture raised” because “free range”— so that, and then we get into all the labeling loopholes with poultry production— but “free range” means the chicken has access to the outside, so they can be in a confined barn, but have a door open. And if the chickens aren’t used to going outside, they’ll be, like, afraid to leave their barn and they don’t necessarily go outside, but pasture raised chickens spend most of their time outside. So they’re not in a confined barn with all sorts of other chicken poop and droppings and things that just breed disease. Like, animals kept in confinement breed disease, like, plain and simple. You have a lot—
Adriana: Right, and that’s why they give them antibiotics…
Lily: Exactly, and then you have to give them the antibiotics and yada yada. So there’s a lot of data on a) the, like, rates of salmonella on different farms based on how they do their farming methods and then b) the need for things like antibiotics in the feed to combat that. So, yeah. So if you have eggs from happy chickens that had a lot of time outside…
So I would look for “pasture raised” at the grocery store, or if you know somebody in your area that has backyard hens or a small farm, or that the hens are outside most of the time (or at least, a large portion of their life), the chances they will be sick is very, very slim. And thus, the chances that your egg will have salmonella will be very, very slim.
So that’s the risk of having an egg or a runny yolk, that if that egg will make you sick, again, that risk will be very, very slim.
Adriana: And this sounds like it has to be so many steps down the line for that runny yolk to have salmonella, that just saying you should stay away from them altogether, that that seems a little extreme.
What’s riskier: eggs or fruit and veg?
Lily: And to play devil’s advocate, when you look at what actually causes the most cases of food poisoning, fresh fruit and leafy vegetables are the cause of 46% of food poisoning cases in the U.S., and they’re the second most frequent cause of hospitalizations due to food poisoning (meaning your food poisoning was so severe that you actually had to be admitted to the hospital). Okay, so if we’re really going to be so, quote, “careful,” then raw fruits and leafy green vegetables should also be off-limits, like, “Sorry, pregnant women, no watermelon! Sorry, pregnant women, no spinach salads!” Now, y’know, it’s like, so where do we draw the line on which foods are “risky” or “not risky”? And that’s where I say a) you kind of do have to make this whole risk-benefit equation and b) I think just make choices on your foods based on what is fresh and safe in your particular area.
Like, if you’re in a situation where you’re not sure that something was handled properly and could have become contaminated, it doesn’t really matter what the food is. So we have to be… we have to just make a smart decision. And I think it’s sort of undermining judgment and intelligence to just put these whole, like, subsets of food categories off the table when it’s a more nuanced discussion than that.
Adriana: And I think the nuance also happens in fact that, y’know, there hasn’t been a question of whether fruit and leafy vegetables are good for you— like, that tends to be a given, although I know we can get into a deeper conversation about sugar contents of fruits and all that. But for a long time, and I’m doing air quotes here, eggs were “evil.”
Eggs: nutrient powerhouses
Adriana: So what do we know now about eggs? Like, what is the new research that brings it up for conversation?
Lily: So that’s a fantastic point. I’m glad you brought it back to this. Now, what we’re learning about prenatal nutrition— because a lot of prenatal nutrition recommendations are like 20 or 30 years behind the research, it’s just… it is what it is— we found out in 2015 that the protein requirements for pregnant women are anywhere from 30something to 70something percent higher, depending on the stage of pregnancy that you’re in, based on this new data.
Right? So the science is always evolving and sometimes the guidelines don’t always reflect what the new research is finding. When it comes to eggs in particular, there’s probably… the most important nutrient they have is something called choline, which is a B vitamin-like compound that has functions in the body alongside folate. So we all know about folate— or the synthetic version, folic acid— and how it can help prevent neural tube defects? Choline has that same effect, okay. And it also is involved in brain development of infants. So we didn’t have a choline requirement set until 1998— and even that was based on data from men and then extrapolated for pregnancy, that amount was set at 450 milligrams per day.
And now we have new data showing that requirements for choline are probably about double that amount that actually optimizes brain development. And there’s been randomized human trials, pregnant women eating certain amounts of choline and testing the reaction time in infants, and the infants in the group from mothers who had the higher choline intake, they reacted faster at all time periods of infancy when they were tested.
Okay, so there’s this new data showing us that we can really optimize brain development if we give enough choline; the number one food source of choline is egg yolks. Okay, it’s, like, kind of tied; you have egg yolks and liver. They both have a lot of choline. Most people don’t even eat that much liver, and eggs really are… they’re an easy sell! They’re delicious. They’re on the breakfast table of, like, quite a few people. And the choline is all in the yolks. So if you’re going to get anywhere close to meeting your choline requirements, you need eggs, and say you are in the subset of women who only likes their eggs cooked, like, over-easy or over-medium or poached with runny yolks (and I’m one of those people, by the way), say now eggs are off the table— how are they going to meet their choline needs? And also what’s going to replace those eggs on their breakfast table? Will it have an equivalent amount of even just protein? If we’re going to take it down to basics, like, what usually replaces eggs?
It’s often some other breakfast food— which is usually something like cereal or toast or bagels or oatmeal— something that is nutritionally very different even from just the basics of macronutrient breakdown. But when you start getting into the micronutrient difference, it’s huge.
Adriana: Right? And people are not, like, substituting it for liver and stuff like you mentioned, it’s substituting for something that probably has other, y’know, raises sugar levels and does other things to your body.
Lily: Right. Exactly. And it’s not that those things are, like, always, y’know, a terrible choice. It’s just that eggs are a really good choice. And if we’re removing them, then we’re essentially removing like the number one source of choline from the diet for most people. So, like, egg eaters on average eat double the amount of choline as non-egg eaters.
And that all sounds great, and then you realize that 94% of women don’t consume enough choline to begin with, so are we going to deprive them even more by taking eggs with runny yolks off the table? I mean, if you’re one of the women who really enjoys scrambled eggs or hard-boiled eggs or something, this is a non-issue, because those have never been off the table, right?
But if you are in that group of people who like some runny, then this could make a significant difference to your nutrients.
Plant-based sources of choline
Adriana: Yeah. Bringing it back— ’cause I’m always going to bring it back to the vegetarian/vegan diet, because that’s the space I live in— so is there a non-animal-sourced form of choline?
Lily: Yes, it just happens to be not quite as concentrated in choline. So, like, the two most concentrated sources of choline are egg yolks and liver, by far. So, like, an ounce of liver or one egg yolk has approximately, like, 115 to 120 or so milligrams of choline. When you start going to plant sources— and if you remember, like, the requirement by current guidelines is 450 milligrams per day, and then what’s likely optimal based on the latest data is 930 milligrams is what they’ve tested in those studies, just to kind of put those numbers into perspective— so the non-animal sources would be, like, beans, quinoa, like, about a half cup of those would give you around 20 milligrams to maybe 30 milligrams or so. Soy products… A quarter cup of almonds provides 18 milligrams. Half cup of yogurt provides 20 milligrams. Two tablespoons of peanut butter provides 20 milligrams.
Adriana: So still, you would have to consume quite a bit of it!
Lily: So, you’d have to consume quite a bit of those. Oh, the other one I’m leaving out is the, like, cruciferous vegetables: especially Brussels sprouts, broccoli, cauliflower. Those will give you about 30 milligrams in a half cup serving. So those are the next-best sources of choline.
Like, other than egg yolks and liver. I mean, meat, like general meat/seafood, will also have, y’know, that 20 to 30 or so milligrams in a couple ounce serving, but, like, these plant sources are… that’s as good as you’re going to get with choline. So when I say, like, eggs are the primary source— like, they really are for most people.
Adriana: Very good. Let’s move on to… What do you want? Cheeses, deli meats, fish?
Lily: Let’s talk about fish, because fish goes into separate topics other than just food safety.
Adriana: All right, let’s do that. So tell me about fish! There’s like different considerations with fish: there’s the part about it being raw, and then there’s the mercury toxicity.
Lily: Exactly. Yeah. Let’s start with the raw thing first, since we’re coming from the food safety angle, and then go into mercury. So raw fish… what I found interesting when looking at the data on raw fish was looking at what countries other than the U.S. have to say about raw fish, because we tend to be, like, super scared of food and food poisoning in the U.S. and other countries sometimes a little less so. So I found it interesting that in Japan, raw fish is actually a pretty common thing for pregnant women to consume. And in some areas it’s encouraged. I also found it interesting that on the British National Health Service website, they actually state it’s usually safe to eat sushi and other dishes made from raw fish when you’re pregnant.
And the rationale for that is that seafood that’s marketed for human consumption undergoes screening for microbes. And thus the safety of commercially-available products is actually higher than something where you don’t know the source. They also state that flash freezing is used for most sushi-grade fish and that it inactivates parasites.
So both NHS and there was a Canadian medical journal that reviewed it, Japan… they seem to think that raw fish is not that big of a deal, as long as it is, y’know, sushi-grade, flash frozen, obtained from a reputable place, stored properly, and you consume it within a reasonable amount of time. So, like, no leftover sushi, you eat it fresh!
Adriana: Right. And not, like, sushi at a potluck.
Lily: Exactly. Exactly. Not something that’s, like, sat out for many, many hours. You definitely want to have it fresh. It needs to be prepared super hygienically, kept cold, et cetera. Yeah.
The other thing that I found interesting— and I don’t know if you’ve noticed this with clients— but have you noticed that you have clients who have cravings for raw fish or sushi during pregnancy?
Adriana: I hear all the time— ’cause I’m in the labor room, right— and one of the things that invariably comes up while early laboring, especially, or after maybe this one was like, “Oh, I’m going to order… I can’t wait to eat…” And one of the… it’s either, like, a big fat juicy hamburger or sushi, yeah.
Lily: Yeah, yeah. So I remember hearing this from clients and kind of being like, “Why the sushi?” Like, it would come up so often, even in people who weren’t like crazy sushi fiends, and then it happened to me during pregnancy too. And I was like, “What the heck?!” I really wanted sushi and, like, ceviche and, like, raw fish.
So I looked at the data on this because I just… there must be something behind it. I feel like a lot of cravings are actually a sign of something, like, your body needs a certain nutrient or there’s a dietary imbalance or who knows. But I actually found that, with certain types of fish, a mineral in it called selenium is actually higher when the fish is eaten raw.
Lily: And we’ll talk about selenium more in a minute, but selenium plays a role in preventing mercury toxicity. It prevents you from absorbing the mercury. The other thing that was more bioavailable from raw fish was omega-3 fats like the DHA, which is important for your baby’s brain development. And also iodine is better preserved when the fish is raw versus when it’s cooked. And that iodine is another nutrient that’s important for brain development.
So I just found it super, super interesting that maybe, maybe there’s a reason behind it. The one exception, though, I take to the raw fish thing is I do give caution for raw shellfish (so like clams and oysters). Even though I know people love eating raw oysters! In the U.S. anyways, of the counts, raw shellfish or under-cooked shellfish accounts for 75% of outbreaks of foodborne illness that are associated with seafood.
So I’m cautious with raw shellfish, but, like, from the raw fish, sushi-grade stuff we already talked about, I think there’s a good reason for these cravings.
I don’t think that, like— again, I don’t think there’s ever going to be a case where it’s like “Everybody always forever and ever should never have, y’know, raw shellfish during pregnancy.”
It’s just that risk-benefit. You know, there is a greater chance you will get sick from that— Do you want to risk it? Do you not want to risk it? Can you handle oysters cooked? Will you still eat them if they’re cooked or maybe canned? Like, they’re different, but would you still eat them that way?
Like that might be the safer choice and/or a lot of the nutrients you can get from those could be found in other types of seafood as well. So do you want to do that instead? So again, I can’t make that decision for everyone, but I did want to point that out, for the sake of being cautious.
Adriana: No. Absolutely. And because we are talking about risk and benefit here, that’s the new consideration of it.
Mercury levels in fish
Lily: Right. And then we have to go back to the mercury side of things too, right?
Lily: So, in the U.S., and I’m sure it’s similar in other countries, most pregnant women are told to limit their fish consumption to less than 12 ounces per week. Is that the same where you’re at?
Adriana: Yeah, I mean, because it’s… we’re still in the U.S., so it’s the general recommendations.
Lily: Why did I think you weren’t in the U.S.?
Adriana: ‘Cause I’m originally from Venezuela, maybe? But yeah, no, I’m on the other side of the country from you, way far in New York.
Lily: I totally thought that you were not in the U.S.! I so apologize!
Adriana: I love it! I mean, it’s there… the country is so wide that, y’know…
Lily: It is true. We are kind of in different parts of the country, so it is pretty much a different country. It must have been something I read on your website! Anyways, nonetheless, this limit on fish being less than 12 ounces per week is just a little misguided because this is mostly due to the mercury content of fish.
So certain fish can accumulate mercury during their lifespan because unfortunately waterways and the ocean is contaminated with mercury. It just is. However, you start limiting seafood consumption and you also start limiting a lot of micronutrients. So, there are certain fish that are high in mercury that probably should just be avoided entirely— so, swordfish, king mackerel, tilefish, and shark. Those are, like, FDA guidelines I do actually agree with. They also recommend limiting tuna to less than six ounces per week, and I also agree with it, just the quantity of mercury is quite high. However, there are many other types of fish that are perfectly safe to eat while you’re pregnant, even if they contain small amounts of mercury.
And that’s mainly because of the selenium thing that I mentioned a minute ago. So selenium binds with mercury and prevents it from being absorbed, so when they try to look at if mercury levels are tied entirely to fish consumption, it’s not always a “this equals that” equation because you don’t necessarily absorb it.
The other thing to consider is that the size of the fish is the greatest determinant of the mercury content in the fish. So when you have like a… albacore tuna, which can weigh up to 130 pounds (and they also live for quite a while, like 13 years), they’re going to have more mercury in them than, say, a sockeye salmon, which weighs less than 15 pounds and lives for less than seven years, or even less.
So it would be like sardines, which are super tiny, like a few ounces— I don’t know their lifespan off the top of my head. So if you are like, über, über concerned, you go with the smaller fish: bar none, you’ll be getting less mercury.
Adriana: Yeah, ’cause also the… those… like, that tuna ate all those little fish, like, it’s a big fish! So it’s eating not only the mercury that it absorbs throughout a long time, because the mercury doesn’t really, like, get processed through their body and goes away…
Lily: No, it bioaccumulates.
Adriana: …right, and accumulates, so the older they are and the bigger they are, the more mercury they’ve eaten.
Lily: Exactly, exactly. And when we start looking at “Okay, does the 12 ounce limit even make sense?” There was a really good study that looked at 12,000 mother-infant pairs and fish consumption during pregnancy and then neurodevelopment in the children. And they found that women who consumed more than 12 ounces per week, they had children with better IQ, better communication skills… and the worst cognitive outcomes were among children whose mothers consumed zero seafood during pregnancy, and they had more problems with fine motor skills, social development and communication skills. So even though the mercury intake as a whole was higher among fish-eating mothers, it appears that the nutritional benefits and probably the selenium that helped bind the mercury offset some of that exposure.
So we do need to consider what’s in seafood and everybody always wants to point the finger at DHA, the omega-3 that’s really common in seafood and definitely I’m not going to, like, discount that. That is part of the equation. DHA is very important to brain development and we have a lot of science behind that, but there’s other nutrients in there as well.
So you have a, y’know, a source of complete protein. You have vitamin D, you have trace minerals like iodine, zinc, and selenium (like iodine probably being the most important one for brain development), you have iron, you have a lot of things in there other than just omega-3s that could be playing a role in these positive effects on brain development.
Adriana: And the importance also to eat, ’cause you’re only going to eat so much food today, try to consume something that is very nutrient-rich so that you get not just the one thing, but you get a variety,
Use your nose and common sense
Adriana: I do want to talk about fat, but before we move on to that, is there anything in the conversation of safety and outdated or more commonly-recommended things to avoid that we’d forgotten about?
Lily: I feel like we summed it up pretty well. I would just sort of… to tie it up, bring it back to common sense about food safety. You just have to have… like, use your nose. There’s a reason our sense of smell is super heightened during pregnancy. I know for me, if anything smelled even the slightest bit off, there was no chance I was going to be able to eat it. So use your nose. If it smells funny, don’t eat it and be really picky about where you purchase your perishable food and how you store it, and how you cook it.
Y’know, keep your kitchen super clean. I’m, like, I’m not a germaphobe, but when I’m in the kitchen, I’m washing my hands all the time and wiping down the counters all the time. Like, things get cross-contaminated! So be cautious with that. I will say, though, that the number one place that you’re going to get some sort of foodborne illness is actually restaurants or ready-to-eat meals.
So a lot of it isn’t your own house, but somewhere else. So in those situations that comes back to the “Choosing reputable establishments,” and “Using your nose.” So, think I’ll leave it at that.
What about cut fruit and veg?
Adriana: Yeah. And oh, and not totally reminded me though. One thing that I was reading in your book that I was like, “Oh, this is super interesting, and makes total sense,” and it’s such an easy thing to do, is to avoid pre-cut fruit. And if you’re doing fruit, do the whole fruit and then cut it yourself and eat it fresh and keep it, although, y’know, all the recommendations.
Lily: Yeah, the precut vegetables and fruits is much more likely to be contaminated with pathogens than if you do it yourself. So, like, get your veggies, like, rinse them off, clean them off, and then cut them in your own (sanitary!) house. It’s like, once the fruit is cut— I mean, you know this, you can have an apple on the counter for weeks and we’ll be fine, but once you cut it open, then it starts going bad much quicker. It’s like the same thing with stuff in the grocery store. So you don’t know when it was cut, how long it’s been sitting there. Did the person transfer it to the cooler or the fridge right away? Or was it like sitting out in the cart in the grocery store for a while?
It’s just there’s many more steps that it’s been handled by more people and transferred from one location to the other more often. You just don’t know the conditions it was in. So yeah, if you’re going to do pre-cut stuff, I would do it maybe for cooked things that may be fine, but I’d be really cautious with pre-cut veggies and fruits you’re going to eat raw.
What about raw cheeses?
Adriana: And then I also remember about raw cheeses and you mentioning that artisanal cheesemakers are under such scrutiny that they tend to have even less of a bacterial content than the pasteurized soft cheese.
Lily: Yes. Yeah, there was a really interesting study out of Vermont and they looked at raw milk artisan cheese producers, and they didn’t find a single sample positive for listeria, salmonella, or the super dangerous strain of E. coli known as O157H7, the one that was, like, it hit headlines back in the nineties from Burger King. It’s really, really bad.
So they didn’t get a single sample positive for them, despite repeat sampling, and in warm summer months. Raw milk producers are under such strict scrutiny because they can’t rely on pasteurization to kill bad bacteria if their milk gets contaminated. They run squeaky-clean operations.
Not to mention most of them, if they’re doing grass-based, like, pasture-raised operations and the cows are not in confinement with other cows, there’s just going to be much less transfer of disease and bacteria and stuff from one to the other. So, yeah, if you can find a reputable, raw cheese producer and you’re comfortable eating it, I say, “Go for it.”
If you’re not comfortable eating it, we have pasteurized cheese available. And it’s also totally fine. Again, your call, but I just want to make people a little less freaked out about the whole raw dairy thing.
Adriana: No, it’s the whole fear-based stuff that gets me. So in the end, this empowers you because you gotta do your research. You gotta figure out where your cheese comes from and talk to your farmers, all kinds of good things from it.
Your body’s need for high-quality fats
Adriana: Alright. So then fats, I’ve always had such a, like, scare/hate relationship with fat all my life. I was born in the seventies and so forth, and, like, eggs, they were like, you wanted to avoid it no matter what! Tell us what we need to know about fats.
Lily: Yes, you are not the only one who had extreme fear of fats, because if you… I mean, pretty much, if you were born any time in the seventies or after, you were growing up right around the time that the low-fat U.S. dietary guidelines came out. That was 1980. And all we heard was that, y’know, fat is going to make you gain weight and give you hard time and diabetes and all these bad things.
And it was taken out of our foods and we were fed this processed cardboard stuff instead, or real food that was super tasteless ’cause we couldn’t put butter on it. So, yeah, you’ll also hear that fat should be… some people believe that fat should be limited in the diet during pregnancy, but if you really start to sort of peel back the layers on these recommendations, you see, there’s not as much support for this way of eating during pregnancy than you would think.
So for one, your body’s need for fat-soluble vitamins and other nutrients found in high-fat foods goes up during pregnancy. So we talked about choline already, mainly egg yolks and liver, which have a pretty decent quantity of fat in them. Vitamin A needs also go up during pregnancy and about one-third of pregnant women, at least, don’t consume enough Vitamin A during pregnancy.
And just to bring it back to the liver thing, ’cause it’s a super nutrient-dense food and a great source of Vitamin A. In women who don’t consume liver, 70% don’t meet the recommended dietary allowance for Vitamin A. So you start restricting fatty foods— or you could also, like, lump in high-cholesterol foods into this category— and you also start limiting the intake of some of these nutrients because food isn’t just a single nutrient and that’s it. It’s always with other things. Fat is always packaged with other things. And when you start looking at “How did traditional cultures eat and which foods did they emphasize?” They were not shying away from the high-fat foods.
And oftentimes the high-fat foods were the ones that were really emphasized for mothers. So it’s funny how we’ve taken this full 180.
Adriana: And you mentioned that fats can always go with some other things, but actually before we move on to that, like, are all fats created equal?
Lily: Oh, that’s a very good question. So there are many different types of fats. So we have set… a lot of it is related to, like, the chemical structure of the… they call them “fatty acids,” the things that make up the fat in the food. So you have saturated and unsaturated fats. And then beyond that you have specific types of saturated and unsaturated fats.
You have, like, monounsaturated, polyunsaturated, you have specific polyunsaturated called, like, omega-3s and omega-6s and foods are all a combination of different fatty acids. We think of, like, “Oh, butter is a ‘saturated fat.'” And it’s, like, not pure saturated fat— it has a lot of other different types of fat in it as well.
Lard is another great example. So, just pork fat, people think that that is just saturated fat. It actually has more monounsaturated fat in it, the type that you find in olive oil, than it does saturated fat. But because we have lumped this, y’know, animal fats or saturated plant fats are not into these categories.
We have this really bizarre interpretation of where we find them in our foods. For the most part, like, fats in unprocessed foods are good for you, okay? It’s just we’ve got to keep it simple. They’re just good for you. It’s totally fine. They’re benign. When you start processing fats and removing them from their original food source and then especially when you start changing the way that they behave— I’m going to use, like, trans fats as a specific example— you start running into some problems. So I’ll use two examples of fats that probably shouldn’t be a large part of a pregnancy diet based on their processing and the fatty acids they contain.
The problems with processed oils and omega-6s
Lily: One is processed vegetable oils or, like, seed oils— so, corn, soybean, peanut, safflower, canola, cottonseed oil. These? Most of us call them vegetable oils. It’s not like they squeezed broccoli and get these oils out. They, like, gather the seeds. I shouldn’t say gather, ’cause it’s not like somebody in the field gathering them. You have giant machinery that collects these seeds and then it goes through crazy industrial processes to actually get the fat out of them. Like, you can’t, like, take a soybean and squeeze it and get oil out of it, the way that you, like, run your hand on, like, a cut avocado and it has an oily slick— like, you have to process the crap out of it.
Adriana: Or even, like, coffee beans are probably more oily than what you feel out of, like, flaxseeds, yeah.
Lily: Exactly. Exactly. So they have to be very processed to actually extract the oil. And these fats are very high in a certain type of fat called omega-6, and omega-6 is sort of the counterpart to omega-3. Omega-3s tend to be anti-inflammatory— those are, like, that includes like the DHA that’s good for brain development. Omega-6 fats while they do serve a purpose in our body. Humans, up until the last, like, 50 or so/100 or so years, we weren’t consuming massive quantities of omega-6 fats because we didn’t have the technology to extract oils out of these seed crops at the level that we do these days. So there’s become this sort of dietary imbalance in the quantity of omega-6 fats that we’re consuming.
And unfortunately it’s rather inflammatory for our system. So when you start looking at pregnancy specifically, when you start eating more omega-6 fats, you have an imbalance in the omega-6 to omega-3 ratio, that gets in the way of DHA getting incorporated in the right quantities in the fetal brain.
So it can play a role in messing up brain development. Omega-6s have been found to cause a surge in pro-inflammatory compounds called “eicosanoids” that are associated with preterm labor. So if there’s any risk for preterm birth, you want to steer clear of vegetable oils. They’ve shown that in mothers who eat a lot of them, the motor development of their babies is delayed.
And also it can cause some issues in placental function. So it seems because they’re inflammatory, it seems to play a role in some of the sort of pathological things that are going on with pre-eclampsia. So just not a good idea to have a massive quantity of these. And in our diets, you get plenty of omega-6s in our diets without having any vegetable oils ever in the diet.
And then talking about the über-processed ones that you buy in the bottle, the big, clear bottle at the grocery store that has vegetable oil that’s used for frying. I’m not talking about, you know, putting some flaxseed oil or avocado oil on a salad or something like that. I’m talking about the industrial processed ones used for cooking and frying.
And then the other ones are the partially-hydrogenated oils where they take these vegetable oils, turn them into a solid in a process called “hydrogenation.” And you end up with the fats that are used in Crisco, like shortening and margarine. And those ones are really, really bad. I don’t even think I need to go through the data on it, but they are absolutely man-made fat products that play zero role in our health. And they, even to a greater degree than the vegetable oil omega-6s, just mess up placental function and nutrient transport across the placenta. They interfere with the function of omega-3s. They take the place of saturated fats in cell membranes.
You have… our cells aren’t talking to each other properly. They’re just bad. Everything other than those two categories of fats is fair game, seriously, fair game. And it’s definitely beneficial to have just enough fat in the prenatal diet.
Ideal plant-based oils
Adriana: And most of those oils and then end up becoming… are those fats end up becoming animal-based. What about… so this is just my own personal curiosity, in terms of vegetable-based oils you mentioned avocado, and y’know, there’s, like, olive oil and coconut oil— are those super fair game?
And also, are there any things that we need to know about when using them to cook food? Like when you heat them up to higher temperatures, do they change, or yeah?
Lily: Yeah. Good question. Yeah, those three, all fantastic. So, olive oil, avocado oil, coconut oil. Fantastic. The most stable fats for cooking tend to be saturated fats. They don’t… aren’t as susceptible to getting damaged from high heat. So that would mean coconut oil would be, by far, your most stable plant fat to cook with. Olive oil and avocado oil wouldn’t be terrible choices; they’re mostly monounsaturated fats and they are less susceptible to damage from heat than like some of those vegetable oils that I was talking about earlier. And so those would be okay for, like, low heat cooking, but for high heat cooking, I would do coconut oil.
Like, if you’re going to do… like, say you’re going to do… you made some bean burgers or something, and you want to fry them up in your frying pan? I’d probably use coconut oil, because the pan is relatively empty, so the fat is being heated to a higher temperature and it just wouldn’t be as likely to be damaged.
Other oils, like nut and seed oils that are processed well, so, like, extra-virgin nut and seed oils versus the processed category we were talking about earlier? So that would be, like, almond oil, sesame seed oil, walnut oil, all of those ones? They are more heat-sensitive. And I would use those for things like salads, pesto, or, like, drizzling on dishes. But I wouldn’t use those ones for cooking.
Adriana: Awesome. Thank you for answering it. That’s like my own, very personal question.
Lily: Yes. Yeah. It’s not all about, it’s not all about animal fats. Plant fats from, y’know… that are sourced properly, that aren’t over-processed, are also good. So yeah. Very good question.
Have protein with your fats and carbs
Adriana: So then let’s get into a little bit more of those micronutrients and what… One of your mantras that came up or that really resonated with me in the book is to try to eat proteins and fat together at pretty much every meal.
Adriana: Tell me more about that.
Lily: The reason for that is satiety. Well, just pay attention that, just from a mindful eating perspective, like, pay attention to how you feel after eating particular foods. If you eat a piece of bread by itself or a plain bowl of oatmeal, how soon are you hungry? And it’s usually relatively quickly, because those two food examples are mostly carbohydrates and carbohydrates digest relatively quickly. They cause a spike in your blood sugar followed by a relatively rapid drop. And it leaves you hungry for more food. I mean, it’s physiologically the normal response to that situation. Whereas if you were to combine those foods with something that has, y’know, fat and or protein, I say I use them together because in nature they usually come together.
Like, with the exception of when we separate fat from its natural food source, like, it comes together. Like, milk comes with fat. Avocados have fat in them, like, olives have fat in them. A chicken has a skin on it, which has a lot of fat, right? So they tend to come packaged with each other. So if you were to have that bread with say some peanut butter or almond butter, which has a good quantity of both fat and protein in it, your blood sugar response and all the satiety hormone response to your meal would be (or snack, I guess, it’s not quite a full meal), would be very different than having just carbs all by itself. So when I’m saying, like, have fat and protein at every meal, it’s not that that needs to be like the largest portion of the meal or snack, it’s just make an effort to include some because it is very, very easy to just graze on carbs for the entire day. It’s really easy to just go from, like, “Oh, a piece of toast here. Oh, I’m hungry again. Oh, some fruit here. Oh, some pasta here.” It’s like carbs are in so many different foods and they digest so quickly and keep our hunger and cravings revved up for the whole day that you, kind of, in some ways have to go out of your way to not be eating, just like pure carbs, particularly for people who don’t enjoy or eat much animal foods. You sometimes have to make an extra effort to make, y’know, some of the higher protein options, a greater priority.
Adriana: So it’s a good idea to, if you’re having those carbs, to also have them with some sort of protein so that the effect lasts longer. Am I hearing that right?
A mindful eating experiment
Lily: Yeah. So having fat and protein tend to kind of blunt the blood sugar response you have to carbohydrates, but they also take longer to digest and keep you full longer. And that’s kind of, I mean, you could just play the experiment yourself— like, one morning, have a plain piece of toast with nothing on it and see how you feel. Like, how soon are you hungry? What are you hungry for? How’s your energy levels? Then the next day have an egg or two with that piece of toast and see what the response is. And it’s usually vastly different.
Adriana: Mhm. I love those questions. How soon are you hungry? What are you hungry for? And I can’t remember the third one already.
Lily: I can’t remember the third one already either!
Adriana: We’ll have to go back on the recording. This is pathetic.
Lily: The… It really is a matter of like… We blame ourselves so much for this, whatever our cravings and eating habits are, and I’m not saying in every instance it is this, but in many instances, this insatiable need to eat all the time and the cravings for especially like sugary foods or like pick me ups things with caffeine, really carb-y snacks like chips and stuff, that is a response to an imbalance in our blood sugar. Like, if you eat something super high-carb by itself, you’ve got a spike and then a massive drop in your blood sugar, your physiological response is, “Oh my gosh, my blood sugar is too low. I’m going to starve. I need to eat something else.”
And up until, again, like, when we start looking at when food started getting processed, like, the last, like, 50/100 or so years, at least, like ultra-processed food, y’know, sugar wasn’t a huge part of our diets. Even grains weren’t a massive part of our diets until relatively recently.
And certainly not in the form of white flour produced products! Just, like, all of these new innovations in food, which happened to be super, super delicious and palatable. Those are kind of new to our physiology. And so we kind of have to take a step back and be conscious of that.
Adriana: Yeah. And, that makes absolute sense to me, because it’s kind of the same approach that I take towards the birthing process.
Adriana: It’s like, what did we do for those thousands of years before 1950?
Lily: Yes, yes. And also, y’know, to make that correlate with the birthing process, like how do you feel doing it this way or that way? Like, does it feel better for you to birth in this way or that way? Does it feel good to have, like, coached pushing and be on your back? Like, some people will do great birthing on their back and some people don’t, right?
But y’know, we also have to, like, not undermine, y’know, this idea that, like, our bodies are smart and they’ll kind of tell us what is gonna work and what’s not gonna work. And that’s why I try to build in a lot of mindful eating into stuff. Like, hey, if you feel fantastic having plain toast by itself, then, like, great do that.
For the vast majority of people that doesn’t work out, but if you are the exception to the rule, like, run with it, my friend. But we also have to think about, y’know, physiologically what makes sense with our, like, blood sugar, hormonal satiety cues, and all that? And honor that.
Adriana: Yeah. And I really appreciate that tuning into your body and figuring out what your body needs and along with knowing the information and getting the research, because the information on its own can be so overwhelming— if you’re looking at how many grams of this and how many grams of that, and what is the source and where it’s coming from. And, y’know, we didn’t even touch… and that’s a different, that’s a whole different conversation… of, like, prenatal, vitamins and supplements.
Adriana: I know that can be crazy-making, but that’s also why this podcast tagline is to “Inform your intuition,” because there’s always that huge part of “tune in with yourself,” figure out what sits right for you on what’s resonating and how you’re feeling, yeah, with the information.
A note on iron supplements
Lily: A good example on that one, just to touch on something really quickly, as, like, the, like, iron supplements, for example, like, a lot of the iron supplements that they prescribed for pregnant women, it was just, like, a really poorly-absorbed form of iron. And most people quit taking their iron supplements because the side effects become (quote) “debilitating,” right?
So you’re not listening to your body, and you’re just like, “Well, I was told to do this, so this is the right way to do it. And this is how I’m going to do it.” But your body is rejecting it. Maybe it’s time to consider, well, where are you going to get your iron? Maybe the supplement isn’t the right one for you.
And maybe there’s a different form of iron to consider. Maybe there’s a way you can optimize the iron from your diet or optimize the absorption of the iron from your diet. Y’know, like, if something isn’t working, it doesn’t make sense to fight against our bodies for any of this stuff, whether it’s food or supplements or, y’know, exercise during pregnancy or even, y’know, birth!
Adriana: No, because we don’t want to increase stress. We want to help!
Adriana: Yeah. And I love the, y’know, the concept that you just brought up of “bioavailability.” That’s such a key word for any supplement, to understand what that means. So I do encourage people to get your book, because it’s such a great resource of telling you what form of iron is more bioavailable and what is not, or the whole topic of “avoid folic acid and go for folate,” which was not the recommendation done years ago.
Lily: Right. A lot of stuff is shifting with new data, really, with new data and better understanding of all the complex biological processes going on, unbeknownst to us, inside of our bodies. Yeah, the whole purpose of writing the book was really to sort of synthesize a) all this data I read. I mean, there were thousands of research studies that I went through when I wrote the book, hence why there’s like over 930+ citations in there.
Adriana: Whenever you even say that, like, that you have 900something footnotes, my brain automatically cringes.
Lily: Y’know, I kind of cringe looking back at it. I’m just like, “Oh man, how did I…?” I’ve tried to sort of shut off part of my brain now just for a little bit. It is absolutely bonkers. But nonetheless, my goal was to do that work so you don’t have to, but I really made an attempt to make it as simple to understand as possible.
Like, let me synthesize all of this information for you and put it into some actionable steps, but at the same time, not water down the information, because I feel like I know other women felt this way, because I’ve heard about it. I know during my pregnancy, I felt like the information I was given was so basic, it was almost insulting.
It was like, okay, yeah, I know there’s more to it than this, like, two-page pamphlet on prenatal nutrition, which pretty much tells me “Don’t eat these foods.” Doesn’t tell me why, doesn’t tell me the nuance of it, probably isn’t correct… and also doesn’t tell me what to eat, like, okay, yeah, sure, I’ll avoid these foods… Now, what do I eat?
It’s, like, all the emphasis is… well, as we were talking about earlier, very much fear-based instead of empowering. Y’know, like, let’s give you all the information, you are smart enough to make your own judgment call on what’s going to work for you or not. Here is the, y’know, trade-offs of making said judgment call and like go forth, you know?
Adriana: And you even give people menu plans! I find that it’s really refreshing to read that it had all the levels of as… however deep you wanted to delve into the topic, you could go at that level.
You could just look at the menu plans and just go like, oh, browse through it and just pick and choose. Or you could follow the rabbit hole with your footnotes and do all the research yourself. You allowed for all that level of engagement.
Lily: Well, thank you! That was one of my concerns, is that it would be a little too detailed, because you start going down the rabbit hole and it’s hard to come back up.
Adriana: I did see that, in terms of prenatal vitamins, you didn’t put any recommendations in the book. You just said, “Look, this is changing all the time. Here’s a link on my website, where you can see, I’ll keep it up-to-date there. Go and check it out.” Yeah.
Lily: Yep, exactly. Yes. I didn’t want the information to be incorrect. Say a brand changes their version of folate? I would be upset if my recommendation was now incorrect, yes.
Adriana: Yeah, so no, that was super neat.
Adriana: Lily— thank you so, so much for this talk today. Lots of fun.
Lily: Hey, thank you!
Adriana: That was Nutritionist, Certified Diabetes Educator, and author Lily Nichols, who is passionate about evidence-based prenatal nutrition, mindful eating, and prioritizing quality and sustainability in what she eats. You can find Lily on Instagram @lilynicholsrdn
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You can find the in-depth show notes and transcript of this episode at Birthful.com, where you can also learn more about my birth and postpartum preparation classes and download your free postpartum preparation plan.
Birthful is created and produced by me, Adriana Lozada, with production assistance from Aysia Platte.
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Come back for more ways to inform your intuition.
Lozada, Adriana, host. “Do You Really Need to Stop Eating Sushi?” Birthful, Birthful, June 1, 2022. Birthful.com.
About Lily Nichols
Lily Nichols is 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. 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!), are used in university-level maternal nutrition and midwifery courses, and have even influenced prenatal nutrition policy internationally.
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