Episode Summary
In this episode of the Empowered Nutrition Podcast, we are joined by Lily Nichols, a Registered Dietitian Nutritionist, Certified Diabetes Educator, and researcher known for her evidence-based approach to prenatal nutrition. Lily is the founder of the Institute for Prenatal NutritionⓇ and co-founder of the Women’s Health Nutrition Academy. She has authored several bestselling books on real food nutrition that have influenced prenatal health worldwide.
In this discussion, Lily shares insights into the relationship between insulin resistance and gestational diabetes, emphasizing the importance of managing blood sugar before, during, and after pregnancy. She also provides empowering strategies to reduce long-term health risks and ensure optimal outcomes for both mothers and their babies.
Episode Highlights
- Insulin Resistance Preconception: Lily explains that insulin resistance may already exist before pregnancy, contributing to the development of gestational diabetes.
- Continuous Glucose Monitoring Study: A study discussed by Lily reveals that women who developed gestational diabetes showed higher blood sugar levels from the beginning of pregnancy, even before typical testing at 24–28 weeks.
- The Importance of Preconception Blood Sugar Management: Lily emphasizes that managing blood sugar before pregnancy, through proper diet, supplements, and lifestyle adjustments, can significantly reduce the risk of gestational diabetes.
- Gestational Diabetes and Long-Term Health: Women who develop GD are at a higher risk of type 2 diabetes later in life. Lily describes GD as a “warning light” and stresses the importance of lifestyle changes post-pregnancy to maintain healthy blood sugar levels.
- The Role of Key Nutrients: Lily mentions the importance of nutrients like magnesium, vitamin D, and inositol in maintaining healthy blood sugar levels.
- Empowering Women: Rather than stigmatizing gestational diabetes, Lily highlights how knowledge of one’s blood sugar control can be empowering, leading to proactive health decisions and better long-term outcomes.
- Gestational Diabetes Resources: Lily shares information about her professional training programs and the network she has built to ensure women have access to high-quality clinical care.
Resources Mentioned
- Lily Nichols’ Website: LilyNicholsRDN.com – A hub for free articles, blog posts, and educational content on prenatal and gestational diabetes nutrition.
- Books by Lily Nichols:
- Real Food for Gestational Diabetes
- Real Food for Pregnancy
- Real Food for Fertility
- Free Video Series on Gestational Diabetes: Available on Lily’s website under the “Freebies” tab.
- Women’s Health Nutrition Academy: Professional webinars on prenatal nutrition.
- Institute for Prenatal Nutrition: A clinical mentorship program for health professionals. Apply to be in the October cohort!
- Instagram: Follow Lily Nichols (@lilynicholsrdn) on Instagram for research briefs, food inspiration, and practical tips.
Connect with Us
- Visit our website for more episodes and information.
- Follow us on social media for updates and health tips.
- Subscribe to our podcast and leave a review!
Ready to dive in? Listen here.
SUBTITLES:
Hello and welcome back to the Empowered Nutrition Podcast. If you have any interest in gestational diabetes, prenatal nutrition, women’s health, nutrition in general, don’t miss this episode. Lily Nichols is an absolute hero of mine. She is a gold mine of fascinating statistics. She is one of the top most researched dieticians or even healthcare practitioners that I know of. And her books are absolute gold. I keep them right here in my office and refer to them all the time. So please don’t miss this fascinating episode. I learned a lot from her, which I honestly didn’t expect. I thought I knew all of her things, but she’s, like I said, a bottomless source of knowledge. And at the end, she shares a ton of free resources that you can use and access. And so stay tuned for that. If you don’t already know about Lily, she’s a registered dietician nutritionist.
She’s also a certified diabetes educator, a researcher and an author with a passion for evidence-based nutrition. Her work is known for being research focused, thorough and sensible. She’s the founder of the Institute for Prenatal Nutrition, the co-founder of the Women’s Health Nutrition Academy, and the author of three books, real Food for Fertility, real Food for Pregnancy, and Real Food for Gestational and Diabetes. Her bestselling books have helped thousands of mamas and babies and are used in university level maternal nutrition and midwifery course midwifery courses, and have even influenced prenatal nutrition policy internationally. Lily writes@lilynicholsrdn.com and will link all of her resources in the show notes. Enjoy. Hi Lily, welcome to the Empower Nutrition podcast. So happy to have you. How are you? I’m doing
Great. Thanks for the invite.
Oh my gosh, so thankful to have you. I am a huge fan of you, and I’ve followed your work for many years since I, it’s almost like forgotten times, but back when ancestral diets were a big trend, I was really into that. That’s actually why I became a dietician. I’m a second career dietician and was really passionate about the concept of ancestral diets and became a dietician to help people improve their health through nutrition, like through that lens. And I felt like you were a big part of like one of the people that I was paying attention to, and that even though it’s no longer something that’s really like talked about very much, it’s still like in the back of my mind, like the, the lens for a lot of things. Not that it needs to be like strict or that strict paleo is even correct for everyone, but I still think, well, natural foods are, are the thing, and it’s almost like a little bit more tab. It’s already taboo kind of, and then it’s even a little bit more taboo in in your space, which is obviously prenatal, postnatal nutrition. So I’m just really excited to dig into this a little bit with you.
Yeah, I’m, I’m excited to as well and I kind of got my, my start my career from the ancestral lens as well, so that’s, that’s interesting that overlap there.
Yeah. So maybe tell me a little bit more about that, of how you got into this space and your story.
Sure. Well, I mean, I’ll, I’ll rewind to where the ancestral stuff started since that’s part of your story too. Sure. You know, I’d long been interested in nutrition. My family was kinda health conscious and always, you know, making that connection between how different foods make you feel and and whatnot. So I decided at a pretty young age that I was gonna study nutrition by the time I went to college. And I actually interned with a nutritionist. She was not a dietician, but very, very well trained nonetheless. And she introduced me to the work of Dr. Westin Price and Sally Fallon. So like as a teenager, like when I started working with her, I was vegetarian. Yeah. By the time I was not working with her anymore, I was like full on eating, you know, all the animal foods. Yay. So that definitely, you know, colored the lens through, which I saw nutrition in my undergrad.
I, I went through it very like eyes wide open. I know this is like, I’m learning the guidelines and I know who’s sponsoring the textbooks and I really kind of used my undergrad as an opportunity to dive deeper into the research. So like you see all, you know, back then before like the internet was censored and Google searches were like highly curated. You’d come across all sorts of crazy stuff on the internet. I mean, I actually kind of miss those days personally, but there’s a lot of just like wild theories about you should do this and you should do that and you should be arian and you should be carnivore and you should be whatever. And so I used my like time in undergrad to kind of fact check things with like, well, is there really research to support this or not? Dr. Price is talking about activator X vitamin K two, like what’s the research on vitamin K two? What’s really the low down on phyto acid and fermenting grains and stuff. You know, I I really kind of like used my time there to kind of fact check things a little bit. Yeah. Always an like asking those hard questions. And then once I, you know, finished my dietetics training, my internship, lots of smiling and nodding
Opportunity, same Trojan horsing the whole time. Exactly.
I had the opportunity to work with the California Diabetes and Pregnancy program and that’s where kind of a lot of things came together for me. You know, I remember having read like nutrition and physical degeneration, how preconception and pregnancy nutrition could impact the next generation and how they like prioritize different foods and that would affect babies’ development. You know, fast forward to working with this organization, I learned that maternal blood sugar levels can really kind of pre-program that baby’s metabolism and their propensity for type two diabetes and obesity in their lifetime. And it was like, whoa, okay. There is actually, you know, modern evidence that some of these things are true. And this is also, you know, a diagnosis rising in frequency of, you know, prevalence. And, you know, the impacts are staggering when you start looking at childhood type two diabetes and obesity, right?
And here’s a place where we can intervene with a really motivated population. So I kind of, it all kind of came together with that. It was like, okay, this is an area I want to specialize in. And also a lot of realizations that, okay, I’m aware that the guidelines for general population are, you know, biased and influenced and outdated. And lo and behold, pretty much the same is true for the gestational diabetes guidelines. So my clinical work was kind of like unraveling, like where did these guidelines come from? Wow. Using them in practice really does not work well to help control maternal blood sugar levels and how can we do better? Like, what is the evidence for doing differently and not, so ironically, it brings you back to a lot of the sort of ancestral principles that had been, you know, part of my life for that at that time, like over a decade at that point already.
And yeah, here I am. So that’s, that’s what got me started. And you know, getting into the direction of where I’ve taken it now, which is educating a a lot through my books and helping train other professionals, it was like, I have to get the evidence out there because when you’re up against guidelines that everybody thinks are, well, this is the gold standard, you almost have to do extra work to provide the evidence to prove that oh yeah, those guidelines are incorrect, even if the evidence they were based on was shoddy to begin with. So I kind of take that approach. People know me for like pulling in the studies and the research to support, you know, a different way of managing this condition and just pregnancy prenatal health, preconception health as a whole.
Absolutely. To underscore what you’re talking about, a couple of just anecdotes came to mind. So one, I’ll never forget when I was in my dietician internship in a hospital and we there, I would be like on the ward and occasionally there’d be a pregnant woman admitted who had gestational diabetes and her, her actual just diabetic diet from the hospital would be a ridiculous quantity of carbohydrates and refined simple carbohydrates at that, like high glycemic things like juice, white bread, bagels, not just like complex carbohydrates. This is not that, it’s not that women should eat carbohydrates if they have gestational diabetes, but that, or another thing that happened recently was like in our community, someone had posted in a group, Hey, I’ve just been diagnosed with gestational diabetes. This I, I, I’d like to meet with a nutritionist. Does anybody have any recommendations? And there were a ton of responses and there were at least three on there that said, ’cause we’re in a big military community, three of ’em had said, oh, you know, I, I was referred to the, the, the dia dietician through military health, you know, on base the TRICARE dietician. And it was a complete waste of time. It wasn’t unhelpful. I had to learn everything on my own. And a couple people recommended you of like, I found Li Nichol’s book and read that. And that actually helped me. So that’s just kind of a depressing thing of like, okay, your insurance is gonna pay you to see this dietician who’s gonna likely give you the wrong advice. And how would you know that there’s some random dietician book that’s actually the right answer. It’s, it’s not intuitive.
I know. And I, I mean I’ve been there even not always being like a rule follower. I was like a good dietician at the beginning of that clinical work and I did recommend the guidelines and then I kept being like, gosh, all these clients keep like failing the diet. And I mean, even at the time I was like, I don’t even eat most days the minimum 175 grams of carbs that they’re telling these women to eat. Like, yeah, it doesn’t make logical sense to me. They failed the glucose tolerance test and now we’re giving them meals that have a similar quantity of carbohydrates as what was in the glaucoma test. So
How is this helping, how are
You expecting that their blood sugar’s gonna come out normal? We know their body cannot not tolerate that amount of carbs in one sitting without a high blood sugar reading. And this is the recommendation, you know, but it takes a lot of unpacking because there’s, there’s so much controversy around, you know, going against the guidelines, pregnancy in particular. Like nobody wants to touch pregnancy guidelines with the 10 foot pole. Right. Because the consequences can be dire. I mean, nobody wants to do anything, myself included, that’s going to harm a women’s health or her unborn baby, you know? Right. So it took a lot of unpacking of the literature to see like, well, where did that number come from? And is it truly evidence-based? And is there truly harm at going lower carb? And it was like I got so tired of outside of my own practice hearing from other people who, you know, you’d see at the time Facebook groups were really popular. Remember that, that era
Yeah. That’s like how you build your business as you start a Facebook group and market to them. Exactly.
We’ll, on a time, but there were all these gestational diabetes support Facebook groups and the advice in there was just atrocious and not working. And I was like, you know what? I cannot be like a comment warrior, keyboard warrior, you know, giving advice for free and all these things. I need to put it into a book, like with the evidence for it, because that’s the only way, the only way you’re gonna reach people at Yeah. In a wider scale. It’s like we can’t keep repeating the same old advice that isn’t working, you know? Right.
Yeah, exactly. So maybe tell me some of the main, I obviously there’s a lot, there’s a whole book worth of stuff on this, but tell me some main differences between the standard gestational diabetes guidelines and what you recommend.
Well, let’s start with what the standard recommendations are. Yes. So the standard recommendations are very much in line with dietary guidelines for Americans as a whole. So 45 to 65% of your calories coming from carbohydrates, as I said, they say no less than 175 grams of carbs per day. The focus really is on simply splitting that carbohydrate load evenly between three meals and three snacks. So you’re avoiding a large, well, what they say at large. Yeah. And like, you know, six servings of carbohydrates or something at one single sitting. It’s like, instead let’s do two to four per sitting, but just split it out throughout the day and then you will be less likely to have a high blood sugar. But, you know, protein recommendations are fairly low as they are across the board. The RD is way too low. Fat is recommended to be restricted salt’s recommended to be restricted limit saturated fat, limit cholesterol, eat more vegetables.
I mean, that’s really like the heart of the guidelines. Now, what I found so challenging with like trying to teach those guidelines and you know, at the beginning of my career I was working with like a very low income, low literacy kind of a group, was that if you try to like teach within all these confines, all of these things basically need to be restricted. It’s like restrict your carbs, but make sure you’re getting enough, you know, not too much meat. Watch the fat, watch the salt. Like it seems like everything is off limits. Yeah. And then when you look at, except
Carbs,
Carbs ironically, and then like their blood sugar’s high and you’re like, no, no, you can’t reduce your carbs below 175 grams. You need insulin instead. Like, it, it was so confusing for people and also it didn’t work. I mean, for a lot of women eating 45 or 65 grams of carbs per meal was, it was too much. You know, it was too many carbohydrates at one sitting. Yeah. For them to experience normal blood sugar, sometimes they’d feel absolutely stuffed at the meal. ’cause carbs are kind of bulky, right? Like they take up a lot of space on your plate relative to especially like fat or so dense and concentrated. You can get enough calories without feeling so overly stuffed and bloated. So like they didn’t feel good. Their blood sugar was high, it was a mess. And so I found that when we instead shifted to a, what I do eat to the meter quantity of carbohydrates.
So watch your blood sugar and see where your numbers are coming out and reduce your carbohydrates as needed. That’s the only macronutrient that significantly raises your blood sugar, fat and protein. Generally speaking simplistic terms, I know there’s exceptions. They don’t really raise your blood sugar. Right. They help like stabilize and maintain it. So we get the carbs at a level that works for the person. We’re subsequently also increasing, increasing their protein and fat consumption, focusing on the quality of carbohydrates as well. So less of the refined stuff, more of the high fiber stuff, building in carb sources like, you know, non-starchy vegetables, very low carb, but high fiber. But giving you that like sense of satiety because they are also bulky. That that is really like where the magic is. It’s not really that, it’s not like rocket science or anything. Increase the protein, increase the fat, bring the carbs to a level you could tolerate.
And bingo, you know, blood sugar is in a great range for the majority of meals. I mean, it, it got to the point where we pretty much almost never had a client who needed mealtime insulin or even like daytime oral hypoglycemic medication. There’s, you know, always gonna be people who need help with their fasting blood sugar. That’s like just a really, really tricky one. But daytime wise, like you can control that so easily with diet alone. So we saw, you know, our rates of requiring insulin and medication go down by at least 50% in our population. And that’s actually in line with what, what the research studies show with this type of a diet.
So good. I feel like one challenge maybe in more recent times especially is that with a lot of my patients, they, they’ll, they’ll have hit this barrier where it’s like, oh, oh, but increasing animal proteins and fats, I’m not comfortable with that. I think it’s part of like the plant-based diet movement. They’ve watched these documentaries that are like trying to convince ’em that that being a vegan is a good idea and maybe they even are vegan or vegan approximate. And so I feel like that’s another challenge in this is just like culturally, it sounds like, I feel like we’re almost, tell me if you feel like this, that we’re kind of coming out of that at this point finally a little bit. But I, I feel like that’s kind of a new thing is like you’ve gotta butt up against this kind of like framing that they’ve, they’ve picked up on of like, animals are bad for me and even plants might be bad for me because I’m also afraid of like phytates and I’ve seen carnivore diet stuff. So tell me about how much you’re like, or how much are you seeing that kind of challenge with like what people have been taught?
Yeah, I, I mean it’s so interesting depending on the, you know, era that we’re working and then the population you’re working with. Each one has their own weird things that are like the new food fear or food fad or can’t eat this for whatever various reason. So like early on I found a lot of what I was coming up against was just the whole low saturated fat, low cholesterol stuff. The concern over heart health and particularly, you know, early on at the time, a lot of the clientele I was working with were receiving like WIC benefits and stuff like that. So their, their only like nutrition education was government guidelines, which were so heavily focused on low fat, low cholesterol. That’s kind of eased up a little bit. They still harp on the low saturated fat, but once they removed cholesterol from the nutrients that concern list quietly. Right. No problem. Yeah. Yeah. That became less of an issue, but still. And then yeah, things kind of shifted. We had like the paleo movement, the low carb movement, which moved into keto, which moved into full carnivore. Yeah. And then that has gotten into the anti plants of any kind.
I mean wild. And I think interestingly right as the pro carnivore movement is going on, you have a lot of government guidelines now working to try to keep animal foods as low as possible. Yeah. Whether that’s for health reasons, environmental reasons or whatever. That is certainly kind of like become a mainstay. I I also see that lightening up a little bit now. Yeah. And, and I’ll be curious to see how that changes in the future. Like as more information gets out about regeneratively raised meat work of like, you know, Diana Rogers and the ST Institute and stuff like that. Yeah. People are starting to see it a little differently, but there’s always going to be a component of individuals who like won’t consume animal foods for example. And that does pose challenges for gestational diabetes. I could say, you know, I, I also had some clientele for religious reasons, maybe they don’t consume meat.
And it does make it trickier for blood sugar control just simply from a macronutrients perspective. It presents a challenge. You look at a typical vegetarian diet, and this is like directly from the literature by the way. There’s a whole chapter on vegetarian diets in my LA latest book, real Food for Fertility. A typical vegetarian eats a 60% carbohydrate diet. 60% of their calories are coming from carbs. About 10 or 12% maybe are coming from protein. And so it, it’s, it’s not a macronutrient balance that is supportive of blood sugar management as you look at trying to like increase the protein for vegetarians. If they’re consuming eggs and dairy products, it gives you a lot more wiggle room. But if they’re fully vegan, you look at all the whole food plant protein sources. I’m talking whole food plant protein sources that haven’t been processed. Yeah. Beans, legumes, nuts, seeds, soy, they all contain carbs Yeah.
As well. Yeah. Soy fitting into the legumes category. Soy has its own issues, which is a separate like conversation. There are exceptions. You have certain processing techniques that like, you know, amplify the amount of protein in there, concentrate the protein, or you have protein powders or whatnot. But it, it still becomes, it’s a much greater challenge to, to maintain blood sugar control on such a diet. There’s about a thousand other issues that I could go into. Yeah. But just the macronutrient balance portion of it makes it really challenging. I also think on the flip side, you have people going hardcore, hardcore keto or carnivore. And while that’s less risky from a micronutrient perspective, ironically, ’cause our animal foods are highly nutrient dense, there are a handful of micronutrients that people might not be getting enough of if they’re eating such a diet. Yeah. Maybe it could be made up with, with a prenatal vitamin, but I don’t think people need to go so hardcore anti carb, anti all plants that they like remove Right. All sense of variety from their diet as well. Like there’s, there’s a middle ground in my opinion.
Right. Absolutely. So yeah, I mean I totally agree on that. I mean if you’re, if you’re chosen diet is incompatible with blood sugar control and pregnancy, maybe it’s not the natural human diet, you know, but that’s a great point. And then I think another thing that I love that you focus on aside from just, you know, it’s, it’s okay to not eat massive amounts. So carbs when you have gestational diabetes, of course, like shouldn’t have to be rocket science. Another thing is just nutrient density itself. Like you kind of brought up vitamin K two and how animal proteins are more nutrient dense. And I think that can kind of be lost a little bit in, in the world of, of prenatal nutrition, especially once a pregnant woman gets jas gestational diabetes. I find that the focus becomes all about the blood sugar and, and, but in reality it’s a known huge predictor a a part of that prenatal outcomes to the actual nutrient density of the, of the mom’s diet. And I I, it’s almost like maybe people just kind of think that the standard diet in the western world is adequate. But that I, my opinion is that’s far from the truth. So maybe you could talk a little bit more about that in terms of like what you recommend.
Yeah, I think you bring up a good point on the micronutrient component ’cause that’s, that is huge. You know, a, a big reason that real whole foods work better for blood sugar management is not just the macronutrient balance, but you’re also getting in more of these micronutrients that also support insulin production. Your body’s ability to use insulin, meaning like supporting your insulin sensitivity, all the, just supporting your metabolism, your mitochondrial health. That that part is often like missing. You know, know the big elephant in the room though, if we’re gonna like zoom out population wide, 58% of calories in the average American diet are from ultra processed foods. Yeah. Which are by default low in micronutrients. So these foods are made primarily of refined carbohydrates or sugars, low quality oils like the seed oils, vegetable oils, and then like all the additives, flavorings, colorings, all the junk that make this non-food look like a food-like substance and taste.
Okay. I guess depending on your taste buds. You know, so that’s the area where like if you look at micronutrient intake among pregnant women, the biggest risk for micronutrient inadequacies are when refined carbohydrate intake is high AKA ultra processed foods. So we have to be working towards shifting those out. I like to think of just displacing things. You know, early in my career I focused so much more on let’s reduce the carbs. Like that was sort of like the immediate focus. And now my immediate focus is let’s increase the protein. Because what I’ve found is that when people take something out, they’re not necessarily replacing it. They’re just now under eating. They’re just not eating enough food. Right. They’re starving. What do you do when you’re super hungry? You go to the snack foods, the ultra processed foods again. So it’s like let’s build in like help your metabolism, help your satiety, help your blood sugar balance by telling you what to eat more of.
And then naturally it doesn’t become a fight of willpower once your blood sugar is more stabilized and your body is actually nourished. You don’t have those crazy, you know, sugar cravings or whatever, but you have to like interrupt the cycle at some point. Just talking about eating less of things, I find Yeah. Kind of misses the mark. A lot of people know that the stuff is not unhealthy. It’s not new to them that like soda is unhealthy. Right. Like they might be surprised that their, you know, instant packages of oatmeal are unhealthy, but something like soda and candy and like they know it’s not healthy. Like they need help getting out of that cycle. So because nowadays people are so concerned about consuming too much meat and everybody thinks that reducing their meat intake is going to make them healthier, that is currently the bigger struggle that I see is getting people to actually appreciate the nutritional value of animal foods. Yes. Despite the saturated fat and cholesterol content. Yes. You know, and when they eat more of those, they feel so much more satiated, so much more stable, their blood sugar’s in a better place and then naturally they’re, they’re simply eating less of the, the processed stuff later on.
Exactly. Yeah. It’s so on point Related to that too, I feel like a, another like really problematic thing is in the world of animal proteins, you also have the whole story about Omega-3 E-P-A-D-H-A that we know irrefutably from the research is really important for fetal brain development, neurological development tied to even performance in school. Like in elementary school for the offspring, we routinely test Omega-3 levels in our clinic and people are typically coming in at half of their minimum needs. Like it should be 8% will routinely get forced, which is really clinically significantly low. And women who happen to get pregnant are no different than the rest of the population and that they’re low. And then you add in this sort of fear of fish like does it have heavy metals that could harm my baby? Is it, and of course this actually I think is true. You shouldn’t eat raw fish, which is fair, but just the overall fear of any type of seafood I think is so problematic in this space as well. And so it further exacerbates the issue. If I’m not, if I can’t eat seafood and I’m afraid of all animal proteins and fats supposedly bad for me, then what do I have left? I have carbs. So it’s a big challenge.
Yeah. And you add in the concerns over food safety and suddenly now people are not consuming eggs because they’ve misinterpreted the advice on eggs. Arguably the seafood stuff, that’s also a misinterpretation because technically the guidelines are to eat 12 ounces of seafood. Yeah. Low me three seafood per week. But people here, or sometimes even clinicians say no seafood whatsoever. I do like dive into a lot of these, you know, controversies in my books. Real food for pregnancy especially goes into a lot of these controversies around foods to avoid the fish and mercury issue. I have actually followed up with some articles on my website if anybody wants to read more on like fish and pregnancy and the mercury concerns, you know, I used to say 12 ounces a week, but wondering, you know, is is more okay or is it not okay? Like is there really like should we really be concerned with mercury intake as you get to higher levels?
And that article goes into some really fascinating research, really well, well done systematic review featuring over a hundred thousand mother and infant pairs looking at seafood intake and brain development and issues with mercury. And they actually found no unsafe level of seafood wherein higher seafood intake was overtly harmful to the baby’s brain development. And that was actually even if mercury intake was higher. And that’s partly because of all the different micronutrients that are in the seafood that are so supportive of brain development. DHA being one of them choline, B12, iodine, iron, zinc, et cetera. Yeah. But also that seafood contains selenium and selenium helps to offset the mercury exposure. So if anyone’s really concerned about the seafood mercury thing, I recommend reading that article. I also recommend reading my article on Omega-3 because there’s a lot of misinterpretation of Omega-3 food sources. So when we’re talking about all these huge benefits to beat these brain development, we’re primarily speaking about DHA, which is a specific type of Omega-3 fat. Not all Omega-3 fats are DHA, not all can be converted into DHA. Yes. Despite a lot of people claiming otherwise. So that article goes into more detail on the, you know, conversion of different types of omega threes. And the, the takeaway, major takeaway for if you don’t wanna read it is that plant foods don’t contain DHA. Right.
And your body cannot convert enough of the type of Omega-3 that’s in plants into DHA. It’s,
I think it’s something like 2% like which is negligible.
Yeah. It’s really low. It’s often even less than 2%. And as your omega six intake goes up, the conversion rate drops even further, which is a conundrum since our plant sources of Omega-3 also all have high amounts of omega six. Right. There’s no way that your body can convert enough. So you really do need a source. So if it’s not gonna be from seafood or if it’s not gonna be from seafood sourced Omega-3 oils like a a fish oil supplement for example, then it has to be the only plant source is an alga based DHA supplement.
Yeah.
There’s a kicker here
Though. Yes. Go girl. Go. You’re on this train. Go.
I just posted something on my Instagram this week on a study looking at DHA status in pregnant women. They split ’em up. They were all supplemented with DHA 200 milligrams a day, but some received a tiny amount of choline, which is a B vitamin like compound. But choline is present in all of your DHA sourced foods essentially. So they had a tiny amount of choline with the DHA in one group and then they had a higher amount of choline with the same amount of DHA in the other group and they found that the group that was supplemented with the extra choline, their DHA status was 75% higher than the ones who had the low choline. Again, the amount of DHA supplementation was equivalent between the groups. Yeah. It was the choline that helped their bodies actually, I don’t know, absorb it, hang onto it, incorporate it into their red blood cells.
I don’t know, for whatever reason having choline along with the DHA dramatically increased their DHA status. Yeah. So this is something that would be a concern for somebody eating a plant-based diet who is supplementing with an LG based DHA if they’re not also supplementing with choline. Guess what? Choline intake is really low in plant foods. Yeah. Vegetarians and vegans especially have the lowest intakes of choline population-wide. If they’re consuming eggs with the yolks and a lot of them, they’re probably good to go, but if they’re not doing that, they’re, they’re definitely not getting enough choline. So. Right. That’s another thing where it’s like there’s sort of this magic in the whole foods where there’s this synergy of how nutrients work together and if you’re simply consuming animal sourced seafood, you’d be getting that choline and DHA right there in that salmon or right there in those sardines are right there in those oysters or whatever.
Yeah, exactly. No, no human engineered like approximation of a whole foods human diet is gonna be equivalent to the real deal. And this is a great example for that and I love how you highlight that vegetarian and vegan diets are abysmally low in choline, but even on the population level, just studies looking at choline intake across the United States, just just childbearing women of childbearing age, the choline intake is low in like over half of ’em, it’s below their needs. It’s
Like 94% of of women of childbearing age are not getting enough choline. I mean it’s, it’s quite bad. Like any, any of the different studies that you look at, ridiculous. They, it seems to range between 90 to 94% not consuming enough choline. Yeah. So, and then you look at the DHA part 95% oh of women of childbearing age are not getting FDHA and that is explained pretty much entirely by low seafood intake. Yeah. Most Americans are getting less than three ounces of seafood per week. It’s just not enough. So anyone who’s not hitting that minimum of 12 ounces of seafood per week, you’re pretty likely going to need supplemental DHA. And if you’re not prioritizing your choline rich foods, you probably also need supplemental choline. Right, right. So
Yeah. And by the way, this is another thing. I wish I had a dollar for every time this has happened, but it’s like new patient, oh I’m good to go. My, I saw my ob gyn for my first appointment. They prescribed this prenatal, I picked it up from the pharmacy or I even just grabbed one from like local big box store. Most of the time it’s gonna have no choline in
It. No choline. And you know why, why,
Why
Choline is expensive. Yeah. Typically has a strong smell, which some women can find off putting. And it’s very probably biggest reason of all, it’s a very bulky nutrient. So if you look at one of those, you know, eight capsule a day prenatals, like the most comprehensive ones on the market, some of those like two or three capsules worth of that eight a day serving is the choline alone. So choline is usually one of the first things that they’re just gonna, gonna like not put in the formula. It’s price, it takes up too much space. People don’t wanna take a lot of capsules. So the thought of having like a one a day is very appealing. And yes, if for nutrients like your B vitamins, many of which are
Folic acid
Yeah. One milligram or in microgram doses you can fit in plenty ’cause it doesn’t take up a lot of space. But when you get to these bigger nutrients Yeah. Choline and your minerals like calcium, magnesium, it, it just takes up a lot of space. You’re not gonna fit it into a one a day, a two a day, or even a three a day at a reasonable dose. Yeah. And then of course people have to expect to pay a little more for a supplement that’s actually covering the, the, you know Yeah. A broader range of their nutrient needs.
Yeah. I love how you highlight, that’s another huge issue with prenatals or just multivitamins as a sort of like pixie dusting where it’s like, yeah, people maybe they’re like, oh I know I should look for choline or I should look for Omega-3 or I should look for vitamin K. And so there might be like, like you said, the most tiny like one microgram on there so that that name can be on the label but the amount that’s included is fully meaningless.
Yeah. Yep. Exactly. Yeah.
Oh my gosh, Lily. So good. I know we’re almost outta time. So maybe last question is, tell me since we’re on the topic of gestational diabetes, you, this is like from the very beginning you said something that that like were related to epigenetics. So sort of like what’s happened with in the mom’s life is then gonna impact the genetic expression of our offspring. And then you then have this sort of like generational precipitation of like in this case we’re talking about impaired insulin sensitivity and high blood sugar. But tell me a little bit about like if you think the population sort of like appreciates that there’s some kind of like predisposition to this before the pregnancy or not. And what I mean is like I feel like a lot of times it’s kind of like gestational diabetes is thought of as this sort of like mystery popup thing that just, it’s like I just rolled the dice and I, I didn’t get a good role and I just had, I failed my blood sugar test when I’m pregnant and like
Yeah.
You know, may I just, I guess I need to do something for the next fif or like 30 weeks until I deliver and then back to real life and hopefully if I have another baby I’ll get a better dice roll. Do you think it’s just this random thing that may pop up or it may not when you get pregnant? Or do you think there’s more like predisposing things going on?
Yeah, great question. I’ll try to like condense my thoughts ’cause I could probably like talk about this specific thing for, you know, half an hour. If you actually look at maternal blood sugar levels, preconception or an early pregnancy, many cases of gestational diabetes can be predicted by those levels. So you test a hemoglobin A1C in early pregnancy, A1C looks at your average blood sugar over the last two to three months approximately anyone coming out in the pre-diabetic range. There are chances of then, so-called failing a glucose tolerance test is upwards of 98.4% highly, it’s highly predictive of, so-called developing gestational diabetes, but is it truly developing gestational diabetes or are we just identifying a blood sugar issue that was preexisting? And the diagnosis of gestational diabetes doesn’t differentiate between that. You really kind of can’t differentiate between that your, your best indication is if you’re testing really early on in pregnancy and seeing what’s going on with something like an A1C, but really it’s high blood sugar that you’ve identified in pregnancy.
It didn’t always develop during pregnancy as a consequence of higher placental hormones. That’s like the story that a lot of people get. Right. And my experience is, that’s actually the rare exception. I have had cases where you have somebody where you would think, you know, no preexisting risk factors and then like bam, they fail a glucose tolerance test. And like it really is truly like this is a placental hormone, like the insulin resistance. It just became really extreme at that stage in pregnancy. But I will tell you in in clinic I used to work at a perinatology practice in Los Angeles with a, our head doctor was a specialist in gestational diabetes, had been doing gestational diabetes research for like 30 plus years. And so we actually screened all of our clients with an A1C in the first trimester. This is actually per the California Diabetes and Pregnancy program guidelines by the way.
Like if your A1C was 5.7% or higher AKA pre-diabetic, you were treated as if you had gestational diabetes starting from that first, like first trimester. Wow. You didn’t need to have a glucose tolerance test later on. The only women in our clinic who got a glucose tolerance test were the ones who had passed the early A1C screening. Yeah. So it was actually extremely rare that we even did TTS in our clinic because we caught almost everybody early pregnancy. That’s what I mean. Like I think it’s actually quite rare when you have cases that develop later on. Yeah. And I will also say there’s a high chance of false positives in a certain subset of, of women, especially those who are eating pretty low carb. You have somebody who has their diet really dialed in, they’re eating low carb. Guess what we’ve known since the 1960s that if you eat a low carb diet leading up to a glucose tolerance test, you have a higher chance of failing. Yeah. Because your pancreas adapts to what you typically eat. Yeah. So this is why once upon a time, our guidelines actually had you need to carb load prior to the test. But once our dietary guidelines went into place in the eighties, which were so high carb,
Everybody’s carb loading. So why everyone’s
Loading every single day that that that recommendation was eventually abandoned. And we don’t have that. But if you have individuals who are eating less than approximately 150 grams of carbs a day, they actually do need to carb load in the week leading up to the test so that they don’t get a false positive. So just to say yes there, there’s often a predisposing factor. A lot of the risk factors for gestational diabetes are issues that are known to have some sort of an effect on insulin resistance in our body. So women who have polycystic ovarian syndrome, the majority of which there are exceptions, but the majority of which have an insulin resistance issue going on. People who have a history of type two diabetes in their family or their ethnic group, if their mom had diabetes of any kind during their pregnancy, if they had a history of having a large baby in a previous pregnancy, which is often undiagnosed gestational diabetes by the way, or at least blood sugar weight out of range, there are exceptions, but that is a risk factor.
Starting the pregnancy at a heavier weight. We know when our body weight is higher, typically insulin resistance is higher. So there’s a whole number of factors that all kind of, like many of them point back to insulin resistance preconception. And there was a really interesting study, if I could just throw on one extra thing. I actually recently did a research brief on this one as well on my Instagram. They looked at, they gave women a continuous glucose monitor throughout their pregnancy. Everybody got one, everybody was enrolled. And on a CGM prior to 17 weeks, everybody also got a glucose tolerance test at the typical 24 to 28 week mark. They then looked back at, okay, these are the people who developed gestational diabetes, these are the women who did not, and the ones who developed gestational diabetes, their blood sugar levels were significantly higher than the group that did not test positive all the way back to the beginning when they started the CGM.
So is this really something that like developed during pregnancy or was this already there was some insulin resistance, some, you know, blood sugar regulation issues going on and Yes, the pregnancy itself, I mean it’s a stress test on your body. Your insulin resistance does naturally increase. Your insulin production naturally needs to increase, but your blood sugar levels don’t naturally increase because if everything goes as planned, your body can overcome that. But when you are already coming in with like, you know, the card stacked against you with impaired glucose tolerance impaired, you know, insulin, insulin resistance is already at play, then like that’s a possibly insurmountable hurdle for your body to overcome. And the result is high blood sugar. And that doesn’t mean that your pregnancy is doomed or something. I wanna like flip it to the positive. Totally. But it means you probably have to be a, a lot more dialed in on your dietary and lifestyle choices because your body needs a little extra help.
Right? Yeah, exactly. It’s not to say, oh, you know, like, you know, shame on you. You actually add, add blood sugar and that’s why you got it. It’s really to empower women in my mind to say like, okay, you know, if you’re paying attention to a lot of the experts on prenatal nutrition, they’ll tell you you need to prepare at least three months out for your pregnancy in terms of supplementing and like preparing your nutritional status. But this blood sugar control piece is a part of that as well because you can, you can start working on that today and like there’s a lot of people Yeah. Available to help if you don’t know what to do, for example, your books. But if you can start working on your blood sugar control before pregnancy, that’s gonna be the biggest thing you can probably do to prevent gestational diabetes in the first place.
Definitely. And if I can just throw in one more like side commentary on this, this concept that gestational diabetes is only something that’s occurring during pregnancy. We have to, we have to kind of like reframe that a little bit because the, in women, the number one predictive risk factor for developing type two diabetes as an adult is having a prior diagnosis of gestational diabetes. Okay. So I think of this condition as like the warning light coming on in your car. Like yes, we need to be like much more highly focused on your blood sugar control during your pregnancy itself because we want your baby’s metabolic health, their pancreatic development, their insulin production. We want that all as dialed in as possible so we can reduce any adverse effects. Right. But you also need to be thinking about your blood sugar later on in life as well.
Like the chances that you’ll develop type two diabetes in the first five years after your baby is born is anywhere from 30 to 70%. And the difference between, you know, the women who do end up with type two and the women who don’t is what did they change in their lifestyle? Because it’s a, it’s ridiculous how much control we have over this if we really like look at the evidence, right? Yeah. There’s a number of different like nutrients that play a huge role. Magnesium, vitamin D being some big ones in acetol, huge, getting our macros in a good place, whether we choose to breastfeed or not can play into it. Our activity levels, our sleep, our circadian rhythm, our light exposure, our stress levels, how we deal with stress, all that stuff ends up factoring into whether or not we become another statistic or not.
So I don’t wanna make it sound like very dire, but having worked with women for so long and I I, you know, I have an online course on gestational diabetes when someone’s a member, they’re a member for life. So I have women who did my course like nine years ago who had been with me for like multiple pregnancies and are like fighting that pre-diabetes, you know, so much like they really have to keep things dialed in and if they had never gotten the diagnosis, they wouldn’t know and they would be another statistic right now, but they know they need to do to keep their blood sugar in range. And yes, it, it takes work, but it’s worth it. Like nobody wants to be Yes. Holding their finger constantly checking their blood sugar. Nobody wants to be injecting insulin all the time. Like nobody wants that. So what can we do to like, keep an eye on this in the long term so that you could be there and be healthy for your family and be with your kids, you know, for for so long be able to play with them and, and not, you know, have a medically complicated future. Yeah.
Yeah. E exactly. It it, it’s upsetting to learn that you’re at a high risk for type two diabetes, but what’s more upsetting is for to, you know, knowledge is power. So if the healthcare system is gaslighting women and giving them this impression that, oh weird, you got that weird gestational diabetes thing for a few weeks there and it now it’s over after you delivered like good to go, that’s less helpful. It might feel good in the moment, but in terms of what you were talking about in terms of longevity and like life quality and just, you know, having the quality of life that you want as your, with your family, it’s better to know the truth. Like always we should always be informed Yeah. About our health. So it’s, even though it’s not maybe not the most fun news, it’s the it’s the right news.
Yeah, yeah. Absolutely. And I will also say gestational diabetes is one of those conditions that especially as we get more stringent in our diagnostic criteria, we’re catching milder cases. Right? So you do have some women who had a super mild case of gestational diabetes, their risk of type two diabetes later on is probably not nearly as high. Yeah. As somebody who had like a real, really, really challenging time with blood sugar control during their pregnancy. Right. That’s simply a sign of like what degree of insulin resistance did you have going on? That kind of indicates how much harder you have to work on your blood sugar management lifelong.
Absolutely. Yeah. I feel like we could talk all day, mostly me listening to you ’cause you were amazing, but I know I have to let you go. So I, I’m sure many people will be inspired to read more about your books, follow you on Instagram. Your Instagram is like, I can’t believe it’s free. It’s so good with all the research reviews that you do and all the content you share. So maybe you can share a little bit about that and anything else that you’d like people to know about.
Sure. Yeah. So in social media land, I’m most active on Instagram, probably not as active as people of a younger generation, but I do post quite a bit of research. You know, interviews I’ve done, foods I’m eating, what I’m growing in my garden. I don’t know, I keep it kind of low key, but I do try to keep that research focus still in there. I also have tons of free articles on my website, Lily nichols rdn.com, go to the blog tab. There’s hundreds of articles and yes, those are all free too. Everybody tells me move over to Patreon, put it behind a paywall. But I feel like almost like an ethical responsibility to get good information out there free of charge. So lots of stuff on my website, many of the topics we talked about today, there’s more articles on those up on my site.
I have a free video series on gestational diabetes, hit the freebies tab. You’ll find that I train professionals as well. So we have webinars at the Women’s Health Nutrition Academy. I also have like a full on multi-month, very involved clinical mentorship in prenatal nutrition via the Institute for Prenatal Nutrition. So that’s also listed on my site if that’s of interest to you. It’s health professionals only. And then of course my books. I have three books, real Food for Gestational Diabetes, real Food for Pregnancy, and Real Food for Fertility is the latest one. So definitely pick those up if you want more information. Many people like them because they’re just so highly cited with research. Yeah. The latest one has like over 2300 research citations in it. It’s kind of insane. So if you like reading and like any of the topics we talked about today, definitely pick up your, your book of choice.
Wow. Lily, you’re such a amazing asset to the world of just women who wanna have healthy babies and have healthy pregnancies. So thank you for everything you do and we’ll definitely link up everything in our show notes so people can just click it there and reach out to you if they have any questions or if they wanted hit you up for your, I mean, I wanna go back in time to when I had time to do your mentorship program. That would be amazing.
Yeah. Yeah. It’s been, it’s been really fun. It’s a culmination of, you know, so much work. Yeah, so much work, so much research. But it’s really wonderful. We have a, a whole module on gestational diabetes, so part of it is like, I wanna have, you know, an army of professionals that I can refer people to. I’m, you know, no longer seeing clients. One-on-one and everybody’s always asking me for referrals. Yeah. So like I can personally vet each person. It’s a very hands-on program, so
Right. There wasn’t a network for this, so I made one.
Exactly. Yeah. So I, I try to, you know, yeah, we just heavily vet who’s accepted into the program and there’s, you know, assignments and case studies and things where you need to like prove that you know what you’re, you’re talking about to be able to graduate. Awesome. And that’s really, really great to have, you know, a Yeah. An army of well-trained professionals to send people to because there’s just, it’s so hard to find good clinical professionals out there these days. I mean, our, our training programs really let us down, you know, it’s good for your like pace, but I don’t know, you think back to your RD training, I had maybe one or two lectures as part of my lifecycle nutrition course on prenatal nutrition.
And it was misinformation mostly. Like, or you said maybe very basic, but you said a lot of it was okay, dietary guidelines, like eat, like you said, 70 grams of carbs.
It’s like, eat more calories, take folic acid supplements, don’t consume liver
And no deli meat. We’re
Done here. No deli meat. And then like, here’s the weight gain ranges per BMI. Oh
Yeah. Make sure you tell I’m not taking gain more than this much weight.
So Yeah, we can do better. We can do better. So much better. Yeah.
All right, Lily, I know I have to let you go, but you’re, you’re just an absolute pleasure and I’m so grateful and please stay in touch. If you ever launch a new book or anything else, reach out and I wanna have you back.
Thank you. Thanks so much. It’s been fun.
Thank you. Take care.
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