So it's my great pleasure to
introduce our speaker tonight.
Our lecture is entitled
Growing Healthy Babies:
Nutrition Tips for Pregnancy,
Preconception, Pregnancy,
and Postpartum.
Susan Carter received her
master's degree in nutrition
from Oregon State University.
She went on to complete a
dietetic internship at the UCSF
Medical Center, where
she then continued
to work as a clinical
dietitian and diabetes
educator specializing in
pregnancy and diabetes.
She transferred to
Stanford Hospital in 2000
as a research dietitian.
She currently is a diabetes
educator and dietitian
for the OB Clinic, and for
the Sweet Success Diabetes
and Pregnancy program at Lucile
Packard Children's Hospital.
So please join me
in welcoming her.
So what a great
place to work when
the final product of your end
of the day is beautiful babies.
So welcome to all of you.
It's a pleasure to be here.
I recognize some of my
patients in the audience,
so hopefully this
will be informative
and not stressful to anybody
to hear about good nutrition.
And just keep in mind that
nutrition, like most areas
of science, is sort of fluid.
Guidelines are
changing constantly.
Felice and I were
talking when I came in,
if I'd given this talk when
I was pregnant 24 years ago,
I would've said something
completely different.
So now I look back and
think, "Oh my gosh,
my diet wasn't anywhere
where it should have been
compared to what we know now."
So don't stress too much.
Most women have healthy babies.
And I want you to
keep that in mind.
So generally, what are our basic
goals for all pregnant women?
And really for all of us?
We want to optimize maternal
and fetal health by providing
optimal nutrition at key times.
The reason this talk
starts with preconception
are there are some
nutrients in our diet
that are vitally important
even coming into pregnancy.
We'll talk a little bit
later about folic acid.
And the recommendation is
to have adequate folic acid
in the diet coming into
pregnancy to reduce the risk
of certain birth defects.
We want to avoid consuming
any substance that
could be harmful to maternal
health or to fetal well-being.
And we also want to
start establishing
healthy habits that are going
to model a healthy lifestyle
and diet for our children.
You're going to
find that children
are very good scrutinizers
of any fallacies
they see if you are not doing
what you tell them to do.
So I often will
tell parents, you
can't crack open a Coca-Cola
and a bag of potato chips,
and then tell your kids
to eat their broccoli.
You really have to model what
you want your kids to do.
What does a healthy
eating style look like?
And I apologize for
this really busy slide,
but that's why I made a
copy for you, as well.
And originally I had on
the top of this slide,
My Healthy Pregnancy Plate.
And I took that off because all
of us could learn from this.
And I borrowed heavily
from Walter Willett.
Walter Willett is the
head of Harvard School
of Public Health.
But you can see this
modeled in a lot of areas,
sort of the plate method.
And one thing you don't
notice on this plate at all
is any processed foods.
And more and more health care
professionals, scientists,
nutritional researchers,
are finding we really
need to go back to a more
whole food diet, more
plant-based foods, and get
rid of some of the processed
foods in the diet.
I just read a big headline
coming out of research
from the UK that's
saying, junk food
is not good for
preconception period.
Well yeah.
Junk food is not good any of
the rest of the time, either.
But we want to emphasize
again, most of the time
your food choices
should be healthy.
Sort of the 80% rule.
But we want to have mostly
filling up our plate with about
half fruits and vegetables.
Some people may say, why am
I picking more vegetables
on that plate than fruit?
I often will tell patients,
well think of fruits
as vegetables with added sugar.
You get all the vitamins, all
the minerals, all the fibers
that you would get in
fruits in vegetables
without the added sugar.
And Robert Lustig is a very
interesting researcher at UCSF.
If you've read his articles
in Nature magazine,
and some of his research
on sugar in the diet.
He says, historically our time
on the planet, most of our diet
didn't include any sugar except
for that brief period of time
once a year when
fruit came in season.
Protein food is very essential.
But you'll notice we want to
emphasize more chicken, more
poultry, more vegetable
sources of protein like beans,
and lentils, almonds.
Eggs have been redeemed.
You might have noticed if you've
looked at the 2015 USDA dietary
guidelines, we can now
have an egg a day again.
For years we were very worried
about the cholesterol in eggs.
Eggs are a very important
source of protein
and choline-- an
important nutrient
for fetal brain development.
So go ahead and have your
eggs during pregnancy
if you like eggs.
And replace the starchy white
bread and the starchy white
potatoes, white rice, with
more whole grains, beans,
and lentils.
Those are a really important
part of our diets as well.
This part of the slide I'm
not going to go into a lot.
I just put it there to talk
about some of the topics
I'm going to be
covering tonight.
I'm gonna talk about
calorie intake.
You're not eating for two.
Healthy diets grow
healthy babies.
Staying active.
I asked a couple
of our doctors that
work in Ob Clinic,
what would they
recommend that I
say to you tonight
as you are getting
ready to conceive,
as you're in your pregnancies.
And most of them there
was a common theme.
One thing they
wanted me to tell you
was to be active
during your pregnancy.
One of our doctors
said when she was
seeing one of our other
doctors-- the infamous Kay
Daniels, if any of you know
her-- most of our patients
just love her.
She had gone to her first
ob visit with Dr. Daniels.
And the first thing
Dr. Daniels said
to her is, what's
your plan for being
active during your pregnancy?
And she was really
surprised that that was
the first thing she mentioned.
So being physically active.
This is near and
dear to my heart,
because I was put on complete
bed rest from 22 weeks
on with my pregnancy.
And shortly after my pregnancy,
my doctor told me, you know,
we've learned that giving
you all that bed rest
has tortured you unnecessarily
for three months.
It makes no difference in
preventing preterm deliveries.
So a lot of you are
saved from the fun
I had of spending three
months with complete bed rest.
So preconception.
Let's start out
with preconception.
And then we'll move on to
talking about pregnancy,
and a little bit about
the postpartum period.
So why is preconception
so important?
Well, most of us get pregnant
without really planning on it.
I'm sure you guys are all very
good planners, and no unplanned
pregnancies.
But 50% of the pregnancies in
this country are unplanned.
By eight weeks
gestational age, your baby
already has a complete nervous
system and a beating heart.
So if you wait to
improve your diet til
you know you're pregnant,
for a lot of women it's too
late to prevent birth defects.
And we know that a
good diet can reduce
the risk of having a baby
with a congenital anomaly.
So we're going to talk about
body mass index, or your weight
starting pregnancy,
nutrients and lifestyle
that might impact
your baby's health
right from the beginning,
and maybe some screenings
to check in with your
doctor before you
decide to become pregnant.
I'm not going to talk too
much about body mass index.
But it will be a
theme that we're going
to talk about during pregnancy.
Obesity prevalence in
women of childbearing ages
has increased 64% between
when they measured it
in 1988 to 1994.
And most recently,
the statistics we have
are from 2007 to 2008.
So in 2010, about 32%
of US women age 20 to 39
met the definition for obesity.
So the population has
really changed a lot.
So what does that look like?
Most of us don't think
about body mass index.
A normal BMI for a
woman who's 5 foot
4 would be 108 to 144 pounds.
But most of the
women 5 foot 4 tall
nowadays weigh about
168-170 pounds.
And there are some risk factors
regarding your pregnancy
if you do start pregnancy with
a little bit of extra weight.
It can cause some
infertility issues,
increased risk of
hypertensive disorders,
increased risk of
gestational diabetes,
hypertension, preeclampsia,
and more likely that you
need a c-section delivery.
But there's some ways you
can mitigate this risk.
So if you look at all
the health organizations,
they say, oh, well just
achieve a normal body weight
before you become pregnant.
Well, I once had a patient
on the research unit
who said he hadn't gone
to the doctor for 10 years
because he'd gone to
the doctor who told him,
you need to lose 100 pounds.
And he found that
information so devastating
that he didn't do
anything for 10 years.
So I think we're
doing our women that
want to plan a pregnancy a
disservice if we tell them
you have to lose 100 pounds
before you become pregnant.
Start walking.
Improve your diet.
And then that might be
enough to mitigate the risk.
For moms, maternal obesity and
what are the risks to the baby.
Babies can be too big.
And that can increase the
risk of being overweight later
in life.
Increased NICU admission.
Babies can have higher
risk of low blood sugar
if they're born too big.
And if mom's heavier at
the beginning of pregnancy,
it may increase risk of
certain birth defects.
Interesting, we're going to talk
about folic acid and its role
in reducing the risk
of neural tube defects.
Obese women, if you
look statistically,
are less likely be
taking enough folic acid
at the time of pregnancy onset.
So real important
nutrition to bid
for women to make sure they're
getting enough folic acid.
So preconception action plan
for a woman who is overweight.
If you just have a few
pounds to lose, that's great.
But if you are in an
obese BMI category,
you might be able to reduce
your risk significantly
by losing a little bit of
weight before pregnancy starts,
or improving your diet
and at least getting
started on a healthy lifestyle.
I know from my years
in a research unit,
we did a lot of study looking
at insulin resistance.
And we talked a lot about
what about the heavy patient
who's most at risk.
And they tended to
be more sedentary
and have more inflammation
and chronic risk factors.
You can be fit at
a heavier weight.
And that also might
mitigate risk of pregnancy.
So a sample weight
loss plan for a woman
who's in an obese body range.
If she was 190 pounds,
losing just 14 pounds
might be enough to
reduce her risk.
This is data from the
Diabetes Prevention Program
that found that
just 7% body weight
could reduce the
risk of developing
diabetes for patients that
have prediabetes by almost 60%
over the period that
they followed them.
So let's move on to
preconception nutrition.
What should your diet
look like if you're
planning for pregnancy?
Obviously you want
to avoid toxins.
Minimize alcohol consumption.
Some studies show you should
start avoiding alcohol even
when you start thinking
about becoming pregnant.
And you want to make sure you're
consuming adequate folic acid
and vitamin B12.
So the United States
actually recommends
for all women of
childbearing age
that you should be consuming
a multivitamin that
has enough folic acid so
in case you accidentally
became pregnant, and
your baby would not
be at a higher risk for
a neural tube defect.
So what about preconception
lifestyle goals?
How many of you are already
doing some physical activity
on a regular basis?
It looks like the majority
of people in here.
These are recommendations
again, for everybody.
Sometimes I'd like
to emphasize that,
because I see a lot of expectant
dads in the room in addition
to potential moms, too.
And I just want to tell you
dads out there that you're not
the diet police.
You're co-partners in this game.
I think occasionally
I've been an arbitrator
of marital disputes in
my office where dad says,
she's supposed to be exercising.
And that's generally
not helpful.
So these are all guidelines
all of us could benefit from.
Minimally 20 minutes
exercise a day.
And keep that up.
Start it before you
become pregnant,
and keep it up during
your pregnancy.
Obviously we don't want
to smoke, use medications,
or substances that could impact
fetal development as well.
So if you're planning
pregnancy, it
might be time to go
visit your doctor,
particularly if you have some
underlying medical conditions,
or maybe even just
a family history
of certain medical conditions.
Consider get
screening for diabetes
if diabetes runs in your family.
Especially if you have a parent
or sibling with diabetes.
There's a quick test called
glycosylated hemoglobin,
or hemoglobin A1c, that can
measure how sugar-coated
your red blood cells are,
and tell if you have a higher
risk for diabetes.
We do this test on
all our pregnant women
here at Stanford.
And we do pick up on
a fair number of women
that didn't know they had
either prediabetes or diabetes,
and then they come to my
office for some counseling.
I just got back from
a diabetes conference,
and the current statistics
according to the CDC
are that about one of every
11 adults in this country
has diabetes.
And one of every three
adults has prediabetes.
And about a quarter
of those people
are unaware that they
even have this condition.
So, you've gone through
pre-pregnancy planning.
You've started exercising.
And congratulations.
I see at least three
women, I think, out there
that are pregnant right now.
So congratulations
on becoming pregnant.
What are your goals now?
Well, we're going to talk about
weight all the way through,
because weight's a factor
coming into pregnancy,
during pregnancy,
and afterwards.
We want to have appropriate
weight gain during pregnancy.
We want to have
a good lifestyle.
Food safety is extra
important for pregnant women.
You're a little more vulnerable
to foodborne illness.
And there are populations that
have special nutritional needs
during pregnancy.
And I'll talk a little bit
about how uncomfortable
it can be to be three
months into your pregnancy,
or six months into
your pregnancy,
and be constipated and
have heartburn, and just
be generally miserable.
Maybe explain a little bit
about why that happens.
And give you some
remedies for it.
So these are the Institute
of Medicine weight gain
recommendations that all
of you have probably seen.
I highlighted in
green the lower end
of the range, because there were
some big studies done recently,
including up at
UCSF, Naomi Stotland
looked at about
20,000 pregnancies.
And what she found is
most women gain more than
what is recommended.
And there were more problems
both with babies and moms
if you gain at the upper
end versus the lower end.
So historically,
these recommendations
were all geared towards
preventing low birth weight
babies.
And I even had a discussion
with one of my patients
from China recently, why are
you worried about my baby
being too big with diabetes?
Big babies are healthy babies.
We think of that as a strong,
good characteristic in China.
And I said, well we know
a little bit more that
big babies aren't
necessarily a healthy baby.
And you don't want
your wife to have
to push out a 10-pound baby
if we can prevent that.
So that might not
be the most fun.
So there's a lot
of data coming out
that maybe we should revise
these guidelines, especially
at the upper end.
I think there's
pretty good evidence
if you gain at the low end
of the Institute of Medicine
guidelines.
If you start out your pregnancy
at a normal BMI, that's great.
But once you have reached an
obese BMI category above 30,
is it really good to recommend
a 20-pound weight gain?
Especially if you
have a woman who
might be coming into
pregnancy with 100 pounds
extra weight on her body.
She might not need
that weight gain.
So these are some
of the studies.
43% of the women in the
Naomi Stotland study
gained more weight
than was recommended.
And again, we're
already thinking
that weight gain may be a
little bit on the high side.
Excess weight gain is
associated with more problems
than low gain.
And excess weight
gain can increase
risk of heavier
babies, NICU admission,
and overweight
status later in life.
Limited or no weight gain
in obese pregnant women
has been found to have
favorable outcomes.
And again, we have
to be cautious here,
because I know a lot of
you are over-achievers.
I don't want you to start
restricting your food intake.
And remember, when we talk
about limited or no weight gain,
this is in obese women.
If you started your pregnancy
at a healthy weight,
you do need to
gain enough weight.
So don't starve yourself.
I see women who
take this to heart.
And they're so afraid of gaining
too much weight, that they
aren't gaining enough weight.
There was a real interesting
study-- the 2013 study there.
I've cited American Journal
of Obstetrics and Gynecology.
They looked just at obese women.
And they actually found
the most favorable outcomes
were in women that had a
little bit of weight loss
during their pregnancy.
And they found with a little bit
of weight loss in obese women,
about 70% fewer c-section
deliveries, and about 50%
reduction in large for
gestational age babies.
But again, the
flip side of this.
Starvation isn't good
for babies either.
During the Nazi
occupation in Holland,
there were pregnant women
that were only getting
about 600 calories per day.
And a few years
later, when those boys
from those pregnancies
entered the Dutch army,
they found that
the recruits that
had been exposed to famine
during the first half
of pregnancy were more likely
to be obese later in life.
So extremes of the
caloric supply in utero
can actually change
physiologically
how your baby's
metabolism develops.
So these babies
probably developed
very thrifty mechanisms of
storing fat so to protect them
from the next famine.
So the pattern of
weight gain appears
to be very important as well.
The first trimester-- I've
put down at the bottom there
the size of your baby at the
end of the first 12 weeks.
People have been very concerned.
I didn't gain any weight
the first trimester
because I was so nauseated.
I was vomiting a lot.
And I said, well, at 12 weeks
your baby weighs about half
an ounce and is two inches long.
So if you gained a lot
of weight in that period,
it probably wasn't
going to baby.
So a lot of studies
are now showing
we don't need to eat anymore
during the first trimester.
Now sometimes it may
help nausea and vomiting
to eat a little more
frequently, but you don't
have a big caloric increase.
And the new guidelines
are that you
don't need to increase your
calories at all in the first 13
weeks, roughly, of pregnancy.
So the normal weight person,
you might have a little increase
in your weight there.
And that's usually
expanding blood volume.
You women out there,
if you've been pregnant
or are pregnant
now, you notice how
exhausted you are in that
first part of pregnancy.
Your blood volume is expanding.
That's one reason you're
having to urinate all the time.
And it's also why you're tired.
Your cardiovascular
system is getting used
to that increased blood volume.
Second trimester weight gain
is when baby starts really
starting to put on the pounds.
At 23 weeks, your baby
weighs a little over a pound.
It's about 11 inches long.
And then by 37 weeks, baby
can be 6.3 to 7 pounds,
and be about 19 inches long.
So second and third
trimester weight gain
seems to be
important, especially
in multiple gestation
pregnancies.
Anybody out here expecting
twins that they know of?
OK.
And some studies have
indicated getting
extra weight gain in
the first trimester
is important if you're
expecting multiples.
So that no weight gain
in the first trimester
probably does not apply
if you're expecting twins.
If you're expecting
twins and more,
you probably do need
to gain more weight.
There's a little controversy
about how much weight
that needs to be.
One study showed 24 pounds
by 24 weeks was important.
So we'll talk a little bit more
when I go into the twin section
there.
But back to the
excess weight gain.
Gaining too much weight in
the first half of pregnancy
does seem to be more strongly
associated with overweight
in babies later in pregnancy.
So where does the weight go?
And again, this is just
rough numbers here.
Things can vary.
After I delivered, I can
remember the doctor standing
at the back of the
room saying, look
at the size of that placenta.
I had two placentas
that had merged.
So it was a huge
placenta, I remember.
But the placenta average
weight is 1 to 2 pounds.
Amniotic fluid volume
can be 2 to 3 pounds.
Some women have more.
Some women have less.
Your uterus gains a little bit
of weight, extra blood volume.
Average baby weight
is about 7 1/2 pounds.
And the maternal
stores can vary hugely.
You've all had friends
or heard stories
about people gaining
100 pounds in pregnancy.
So if you're gaining
a lot of extra weight,
it may not be going to baby.
A lot of women will ask
me-- they're very concerned.
They might come into
pregnancy with a body mass
index of 35 or 40, but
they're still worried
if they're not gaining weight.
How can my baby gain
weight if I don't?
Well, baby is pulling nutrients
from your bloodstream 24 hours
a day.
The pattern of your caloric
and your nutrient intake
may be more important
than your weight gain.
So you want to be eating
small frequent meals,
steady supply of nutrients.
Your bloodstream provides amino
acids, fatty acids, calories,
consistently to baby.
So your baby can gain weight,
even if you don't gain weight.
So don't worry.
A lot of studies have
definitely shown that.
And again, I want
to caution you.
I see a lot of women
healthy weight out there.
Do not restrict your
weight gain too severely
if you are starting out
pregnancy at a healthy weight
or underweight.
Underweight women
need to gain more.
Women with multiple
pregnancy need to gain more.
And we want to find
just the right balance.
I sometimes feel like
this is a fairy tale.
We don't have not too
much, not too little, just
the right amount.
So maternal diet in pregnancy.
Let's start by looking
at macronutrients.
Calories, protein,
carbohydrate, and fat.
I just put a little slide
in here cautioning--
I try to bring in some
environmental concerns
occasionally.
Water bottles may be a
source of contaminants.
We've all heard about
BPA in water bottles.
There's a lot of
toxins in plastic
that can leach into that
water, especially if you leave
your water bottle in a hot car.
The heating of it tends to
allow more of the chemicals
to leech into the water.
So I'd recommend getting a
nice good stainless steel water
bottle.
And you can fill
that up from the tap.
And tap water is probably
a little bit better
regulated than
bottled water, anyway.
Water is really important
during pregnancy.
So I mentioned I was put on
bed rest for preterm labor.
My doctor-- she was
part of a research study
that found one of
the few things you
can do to reduce the risk
of a preterm delivery
is staying well-hydrated.
When your body
becomes dehydrated,
that same bloodstream
that's carrying nutrients
to the uterus can
cause the uterus
to have a diminished
blood supply,
and you can start contracting.
So it's really important
to drink plenty of water.
Your body needs about
three liters of water
a day during pregnancy,
more during lactation.
That does include the water
that you get from foods.
Watermelon really does
have a high water content.
A lot of fruits and vegetables
have a high water content.
And that does count, as well.
So don't be overwhelmed by
that three liters a day.
A lot of people
say, well, how do I
know I'm drinking enough water?
Well, you should
be peeing a lot.
And most of you are
peeing all the time.
If you're pregnant,
that's really common.
But you should be
urinating regularly.
Your urine shouldn't be very
concentrated or dark in color.
It will get a nice
bright yellow color urine
right after you take
your prenatal vitamin,
and that's when you're peeing
out all your extra B vitamins.
But the rest of the
time, if you're not
urinating frequently, or your
urine's very dark in color,
up your water
intake a little bit.
And some people sweat
more than others.
If you're really physically
active in hot weather,
you need more water.
Calorie intake in
pregnancy can vary hugely.
And again, I say
look at measures
how your baby's growing.
Are you showing a
steady weight gain?
We're kind of obsessed with
your urine during pregnancy.
Notice we dip it every
visit when you come in.
And we check your urine to see
if it's super concentrated.
And we also check to see if
you're spilling something
called ketones in your urine.
If you're not eating enough
calories during the day,
your body starts burning
its own fat too rapidly.
And that can produce
ketones, which we don't think
are as good for baby.
But for a slim woman-- I
had a woman in my office
yesterday who weighs 90 pounds.
And she's 4 foot 11.
She probably could get by in
about 1,800 calories to 2000
calories a day in pregnancy.
Whereas a 5 foot 10 woman
expecting twins or triplets
might need more than
3,500 calories per day.
So don't force yourself
to eat beyond hunger.
But you should be
eating regularly.
And I gave you some
general numbers there.
Usually you need about
35 to 40 calories
per kilogram per
day for pregnancy
with a normal BMI for
a singleton pregnancy.
And again, no extra calories
in the first trimester.
But second and third trimester,
maybe 350 to 450 extra calories
per day.
The pattern of caloric intake
seems to be really important.
One study-- the first
one I cited below
there-- showed that if you eat
less than three meals and two
snacks per day, increased
risk of preterm delivery.
And there's also
been a lot of studies
by a researcher named
Barbara Luke, who's
looked at optimizing
good outcomes
in triplet and twin pregnancies.
And what she found
is interesting.
That pattern of eating
was really important.
You need to eat every
two to three hours.
So her eating regimen to
grow these healthier multiple
gestational pregnancies
was eating three meals
and three snacks a day.
And think about combining
with those meals.
You want to provide not
just a bunch of glucose
for your baby, not
just carbohydrates,
but some protein and some
fat with that as well.
So avoid long periods
without eating.
That can actually increase
levels of metabolites,
like we talked about ketones,
which can again cause
some contractions to happen.
So I usually tell
pregnant women,
you've got an accelerated
starvation going on.
While you're sleeping
at night, baby's
pulling nutrients
from your bloodstream.
So eat when you first
wake up in the morning.
And then have snacks
throughout the day.
And probably most of
you, if you're pregnant,
know how hungry you can get.
But you're not really
eating for two.
Again, historically, these
weight gain guidelines
were based on preventing
low birth weight babies.
You don't want to overdo the
calories as well, especially
during the first
half of pregnancy.
So where do women get
the extra calories?
I always talk
about fluid intake.
That first slide I showed you
about what a healthy diet looks
like, you notice I emphasized
drinking enough water.
I never said increase fluids.
A lot of time when I used
to get patients referred
to me for excess weight
gain, I would say, well,
what are you drinking?
Oh, well since
pregnancy I'm drinking
a liter of orange juice a day.
I'm drinking lots
and lots of juice.
The doctor says I have to
get a lot of liquids in.
So we need to change
our terminology,
and encourage you
to drink more water,
because you don't really want
to get all the extra calories
in from the fruit juices.
And again, look at a lot of the
research that's coming out now.
It's much better for us to
eat a whole piece of fruit
then to drink in all
that liquid sugar.
And a lot of people say, well
it's fresh squeezed juice.
Well, if you look down at
the bottom of that slide,
even fresh squeezed orange
juice-- 16 ounces of it
contains the equivalent of
about 10 teaspoons of sugar.
And in our bodies there's not
really a lot of difference.
It all ends up as
turning into glucose.
Sugar from Coca-Cola or
sugar from orange juice.
So pregnancy protein needs
are also very important.
Protein provides amino acids for
your baby's muscle development,
and for your baby to make
enzymes, antibodies, collagen.
Pregnant women
need more protein.
About 1 to 1.5 grams
per kilogram per day.
Most of us in the United
States get enough protein.
This would be about 70 to 100
grams a day for most people.
Women expecting multiple
pregnancy-- twins or more--
do need to get more protein.
Maybe 140 to 200 grams per day.
If you're a vegetarian or follow
restricted diet of any kind,
you might not get enough
protein in your diet.
This slide I just put
in here to give you
some ideas of the various
places you can get protein.
Again, I'd like
for pregnant women,
it's a good idea when
you're planning a snack,
have a piece of fruit.
But add a handful of
almonds with that.
If you look there,
an ounce of almonds
can give you as much protein as
you get from an ounce of meat.
Eggs.
I'm glad that the
restriction on eggs
has sort of been lifted
by USDA dietary advice.
Go ahead and have an egg
a day if you feel like it.
They're great sources of protein
and a lot of other nutrients,
including choline.
If you eat yogurt, Greek
yogurt's a great source.
I'm a big believer in getting
some more plant-based protein
in your diet.
Beans and lentils can be great,
because they not only are
a good source of
protein, but if you're
having any constipation
with pregnancy,
great sources of
fiber and minerals,
such as magnesium as well.
A lot of new studies
are coming out
showing that all of us,
whether we're pregnant or not,
should limit our
intake of red meat.
As a diabetes educator,
I'm also looking
at what are the things that
cause gestational diabetes.
And one of the things
that's been implicated
in causing diabetes both during
pregnancy and outside pregnancy
is increased red
meat consumption.
So a lot of studies--
there was a big study
that just came out in
Europe recently looking
at the impact of red meat.
It linked red meat intake
with increased risk
of diabetes--
gestational diabetes
and just general
causes of illness that
can decrease lifespan.
They say it's an
even higher risk
if you're doing a lot
of the processed red
meats-- sausages,
bacon, things like that.
So replace a little bit of your
red meat intake with more plant
proteins, and that's
a healthful change.
I came back from the
generation of fat was all bad.
We now know that all
fat is not equal.
And fat is essential
for our babies.
Fat can be very satisfying
during pregnancy.
And there are
essential fatty acids
that are necessary for baby's
fetal brain development, eye
tissue.
There are two fatty acids
we must get from the diet
that we're not able to
synthesize independently.
And that's linoleic
acid, that we
tend to get plenty of
from vegetable oils.
And then alpha-linolenic
acid, or omega
3 fatty acids, which you've
probably all heard of.
They've gotten a lot
of press recently.
Trans fatty acids are
being mostly removed
from the food market.
Back in the '50s, Crisco and
margarines came on the market.
And it was a process where
they hydrogenated liquid oils
to get the greater shelf
stability and better baking
properties.
We now know these trans fatty
acids that are mostly found now
in processed foods
and margarine,
and partially hydrogenated
oils are harmful.
They do cross the
placenta and can
have adverse effects on
babies and their cell membrane
development.
So you want to avoid
trans fatty acids.
And choose moderate amounts.
Again, the plant oils
tend to be a little more
helpful than the animal oils.
So canola oil, vegetable oil,
avocado, and nuts and seeds.
Some women take a
prenatal vitamin
that already has a good source
of the docosahexaenoic acid,
or the eicosapentaenoic
acid, which
are a couple of the omega
3 fatty acids that we
think have some great
anti-inflammatory properties.
Some studies have shown that
having enough of these omega 3
fatty acids may improve neural
development in our babies,
and actually reduce
risk of preterm labor.
Other studies
haven't shown that.
But generally it's recommended
to consume about 200 milligrams
per day of these fatty acids.
You can get them
from walnuts, but you
get the precursor-- you get the
ALA, the alpha-linolenic acid,
from walnuts.
Usually you only get the
EPA and the DHA from fish.
Sardines, I put a picture there.
A good source, because
they're small fish.
Not a lot of mercury.
But you can also get them
from marine algae, as well.
Expecta lipil is just one
brand that's on the market.
Its a supplement exclusively
for pregnant women.
And it gets the DHA
from marine algae.
I think nuts are a great
source for healthy fats.
And I'm sure
probably a lot of you
have heard about some
of the recent studies
vindicating nuts.
Again, back when I
was pregnant, there
was some concern about
if we eat too many nuts,
is that going to increase
the risk of peanut allergy?
Now we can actually find
the opposite is true.
This was a recent study that
was just published last year.
And they looked at 8,200
mothers who were not
themselves allergic to nuts.
If you are allergic to
nuts, you should avoid them
during pregnancy, because
you don't want your body
to have these inflammatory
antibodies that
may increase baby's risk.
But they found that
women consuming
at least five servings
a week of nuts
had 70% less likely to have
a child with a nut allergy.
There was another
study that's also
getting some play
recently called
the LEAP study-- learning
early about peanut allergy.
Again, finding there
might be an optimal time
to introduce peanuts
in child's diet.
And this was fascinating.
They actually looked at
ethnically similar groups.
They looked at Jewish
children in Israel
who-- I guess there's
some peanut snack there.
It's not real peanuts, but
this puffed peanut snack
that is introduced
in baby's diet
starting at about
six months of age.
Compared to Jewish
kids raised in the UK.
And they found strikingly higher
incidence of peanut allergy
in the UK where peanuts weren't
introduced until later in life.
So this LEAP study again,
is showing that maybe there
may be key time opportunities
that we should introduce
a good variety of foods
both into maternal diet
and into our children's diet.
I apologize in advance.
My specialty is
diabetes, so I'm going
to talk about
carbohydrate more than any
of the other macronutrients.
So we do need
carbohydrate in pregnancy.
Again, the first thing when
I get somebody in my office
who wants to be very
compliant, and I tell them they
have gestational diabetes,
they want to cut the carbs out
of the diet.
And I say, whoa.
Gestational diabetes
occurs because your baby
requires glucose
for its developing
brain and nervous system.
The recommended daily allowance
for carbohydrate in pregnancy
is 175 grams a day, more
if you're expecting twins.
Most of the American diet
does get enough carbohydrate
in their diet.
And again, the pattern of
carbohydrate intake is better.
You don't want to flood
baby with a big glut of six
cups of pasta with your
dinner with garlic bread,
and then starve for
the next 24 hours.
It requires oxygen to
process that carbohydrate.
So give your baby little bits
of glucose throughout the day.
So they can utilize it more.
It doesn't stress them.
But you do need carbohydrate.
This is just one way all of us
can overdo the carbohydrate.
This looks like a
breakfast I would've
eaten when I was pregnant,
because back then we
thought carbs was all
great, and fat was all bad.
Now that we know a
little bit differently.
But just a cup of Raisin
Bran, half a banana, milk,
and orange juice-- that's
equivalent to about
25 teaspoons of sugar.
And there's not a lot of
protein in that breakfast.
So again, when I talk
about more balance,
maybe like a yogurt parfait with
some nuts and fruit with it.
Whole grain cereal
with some nuts on it.
Have an egg scramble with
some veggies in the morning,
or make a breakfast burrito.
Something like that.
And these are good
ideas for snacks too.
So small frequent
boluses of mixed meals
may be the best way to
eat during pregnancy.
A lot of people get
hung up on looking
at sugar on food labels.
And this is just a caution here
to not look just for sugar.
It doesn't tell the whole story.
Any of you that have
studied chemistry
know that starch breaks
down into sugar very rapidly
in our bodies.
And a bagel is probably
equivalent to eating
about 12 teaspoons of sugar,
which is more than twice what
you'd get in an
average chocolate bar.
I happen to love chocolate too,
so I put that slide in there.
Sugar free doesn't
always mean healthier.
Again, a lot of starchy
foods like white rice
don't have a lot of
nutritional value.
White rice is tasty, but it
has a lot of carbohydrate.
And look how much nutrition
value you get for that.
If you compare a cup of white
rice to a cup of lentils,
the lentils has four times
the protein, much more
iron, calcium, magnesium.
So again, I'm always
encouraging people
to go to more beans and lentils
for a good source of protein.
So why do we worry about
carbohydrate during pregnancy?
Well, most of our time on
this planet, food scarcity
has been more of an issue.
So the placenta has evolved
to put out hormones,
and even to put
out an insulinase
to break down mom's insulin more
rapidly, to push mom's blood
sugar up in pregnancy, so
mom provides enough glucose
for the developing baby.
So interpreting this slide,
that apple you eat at five weeks
gestation, by the time
you're 30 weeks pregnant,
your body has to produce more
than twice as much insulin
to process the carbohydrate
from that apple.
So if your body is
unable to keep up
with this tripling of
insulin requirements,
you'll develop
gestational diabetes.
And that can put
your baby at risk.
Some of us can't
modify all our risks.
I always joke with
people, the best way
to avoid diabetes is
choose your parents wisely.
You want to choose parents
that don't have diabetes,
because that's about half
your risk right there.
So inherent risks
are family history,
age-- the age for risk
of diabetes going up
starts at age 25--
each pregnancy we
have as women increases our
risk of diabetes because
of this stress on the pancreas.
Ethnicity.
And I had the
pleasure of working
with Latha Palaniappan on an
interesting study-- Insulin
Resistance in
Southeast Asian Women.
And now she's just
published a study
finding that 15% of Asian women
develop gestational diabetes,
with Vietnamese women
having three times the risk
of Japanese women.
So Kaiser Northern
California did a study
as well that showed by
the time an Asian woman is
38 years of age, one in four
will get gestational diabetes.
So even at normal body weight.
So the risks are very high
for certain ethnic groups.
So this great study showed
us that if you modify
your lifestyle, you
might be able to reduce
the risk of gestational
diabetes by 83%
by not smoking, having a normal
BMI, eating a healthy diet,
and engaging in moderate
exercise 20 minutes a day.
You notice I put a BMI category
less than 23 for Asian women.
This is the World
Health Organization.
And again, because
in Asian populations
there's higher rates of
diabetes at a lower body weight,
the World Health
Organization actually
recommends a lower BMI
category for normal weight.
So how well are we doing as US
women in meeting these goals?
Pretty good for smoking.
About 80% of US
women don't smoke.
Only about 40% of US
women have a normal BMI.
So again, I think you can
mitigate that a little bit.
Little exercise, and reducing
a little bit of weight.
The third one is the one I think
is the one we should really
focus on.
Less than 30% of American
women of childbearing age
are getting 20 minutes
of exercise a day.
So that's pretty
easy for all of us.
Start doing a little bit
of walking every day.
And then the other factor
is to have a healthy diet.
So in summary on
carbohydrate, carbohydrate
is necessary for your baby.
But don't overdo it.
And don't do it all at once.
You want to do small,
frequent meals.
Combine your carbohydrate
with some protein and fat.
Choose healthier
carbohydrate foods
like a piece of fruit, good
vegetables, beans and lentils.
Eat whole fruit.
Don't do the fruit juice.
Most of you wouldn't sit
down and eat three oranges
all at once.
But you're getting
the equivalent
of the sugar from
about three oranges
in a small glass
of orange juice,
without any of that fiber.
And again, three meals
and two snacks a day
are better than three big meals.
So micronutrients in pregnancy.
There's a huge increase in iron
requirement during pregnancy.
Your red blood cell
count needs to go up
to account for the
expanded blood volume.
A lot of this is in the
second and third trimester.
So a lot of women do become
anemic during pregnancy.
And we'll recommended an
iron supplement for you.
Your prenatal vitamin
does have some iron in it,
but it may not be enough in
the second and third trimester,
especially for you twin moms.
You do have increased
needs for protein.
But some of these nutrients
are really, really critical.
And as I mentioned
before, folic acid
is one of the most important
ones early in pregnancy,
even before you're expecting.
Women at higher risk for
vitamin and mineral deficiency
are vegans.
You really need to
get B12 from the diet
if you're following a vegan
diet, or take a supplement.
Vegans are also more likely to
be iron and protein deficient.
Multiple gestation
pregnancies, and again, you
need to be eating more often.
Teens, if you start
pregnancy underweight.
And also closely
spaced pregnancies.
Women that get
pregnant within a year
of a prior pregnancy, your
body's a little bit depleted.
So you might want to have to
take a little extra attention
to making sure you take
an extra supplement,
or taking your supplement
between pregnancies.
And certain medical
conditions could
impact a healthy
pregnancy, or your ability
to absorb nutrients.
This is just some of the general
micronutrient recommendations
during pregnancy.
One thing I will
mention with twin moms,
as well, is don't take
two prenatal vitamins.
Too much of a good thing
is not always good.
We know that a lot of
nutrients share absorptive
mechanisms, for
example, zinc and iron
share an absorptive mechanism.
So taking too much iron, you
could create a zinc deficiency.
Taking too much zinc, you could
create a copper deficiency.
So you don't want to
overdo one nutrient.
Also, some vitamins are
toxic in large amounts.
And we'll talk a little
bit about that when we
get to talking about vitamin A.
Pregnancy iron needs.
You need about 15 milligrams
per day extra iron
for the expanded red blood
cell mass, especially second
and third trimester.
You do absorb iron
better from meat sources.
But you can increase
the absorption of iron
from your plant sources if you
add a vitamin C source there.
So make lentil soup and put
some nice bell peppers in it
for that extra vitamin C there.
Your body does require more
calcium during pregnancy.
But the body's pretty
smart about it.
You actually absorb
calcium better
from the gut during pregnancy.
And don't worry that your
baby won't get enough.
We have a great reservoir
for calcium as women.
We will mobilize
it from our bones
to keep blood levels stable.
So a lot of the
calcium recommendation
is to protect your bone
health in the future.
So you do require a little
extra calcium in pregnancy.
And your prenatal
vitamin won't include
the full amount you
need, because calcium
is a big mineral.
And if they put all
the calcium in there
along with everything else,
it'd be too big to swallow.
So if you don't think you're
getting enough calcium
from the diet, you can always
take a separate supplement.
Folic acid is really
important, because they've
discovered that folic acid can
reduce the risk of neural tube
defects such as spina
bifida, and possibly
other defects such as
cleft palate, and even
cardiovascular defects.
So it's recommended that all
women that could possibly
become pregnant are
taking a multivitamin that
provides at least 400 micrograms
per day of folic acid.
During pregnancy and lactation,
we recommend a supplement
with 1 milligram per day.
And if a woman has
previously given birth
to a baby with a
neural tube defect,
then she should be on
extra supplementation
of four milligrams per day.
Folic acid is so
important in the diet
to prevent birth defects that
the US started fortifying food.
And neural tube defect
rate dropped 19% two years
after the food
supply started being
fortified with folic acid.
There's a lot of
literature about some
of these other
antioxidant nutrients
that have increased
need during pregnancy.
Pregnancy is a time of increased
metabolism, oxidative stress.
In some countries
like in Japan, they
add coenzyme Q, which is an
antioxidant nutrient that works
at the mitochondrial level.
Lycopene, which is a
nutrient we find in tomatoes,
has been shown to have
some antioxidant effect.
And some studies
have pointed out
some of these nutrients might
play a role in preventing risk
of things like preeclampsia.
But the data is
not conclusive yet.
Some studies show positive
benefits, some studies don't.
So there's not really
enough data out there
that I can make a specific
recommendation about those.
There can be a problem
if you double up
on your multivitamin,
for example,
or your prenatal vitamin.
Vitamin A is teratogenic, so
it can cause birth defects
in large amounts.
That's why it's no
longer recommended.
Back in the '20s and '30s,
everybody said, eat liver.
It's a great source of
vitamins and protein and iron
when you're pregnant.
But now we know the liver is
where we clear a lot of toxins.
And the liver also stores a lot
of vitamin A. So eating liver,
you can actually
get toxic amounts
of vitamin A. It's
recommended not
to get more than 5,000
international units
of pre-formed vitamin A a
day from your multivitamin
or prenatal vitamin,
because you will
get the rest from
your food as well.
Now I need the differentiation
there-- pre-formed vitamin A.
You can also make vitamin
A-- active vitamin
A from carotenoid pigments, from
carrots and things like that.
And there's not a harm to
eating too many carrots.
The only harmful
side effect that I
know of if you get a lot of
carotenoid pigments is it
might turn your skin orange.
I don't know if
you remember, there
was a case a while
back in the UK,
of a schoolboy who was
drinking Sunny Delight.
And he was drinking like two
liters of Sunny Delight a day
and he turned orange.
This is because Sunny
Delight is actually
fortified with
carotenoid pigments
and some tanning agents
use that as well.
So that was a funny story.
Be careful what you do after
you deliver your baby with all
those iron tablets.
They look like M&Ms.
They're really cute.
And they account for
poisoning in children.
So pediatric
iron-related injuries
were on average about 3,000
per year recorded in the period
1986 to 1996.
And most kids that were poisoned
by iron supplements got them,
they were left over
from mom's prenatal,
or my mom's iron supplements.
I think when we had
babies born in our house,
we bought just a tool box
and put a padlock on it.
And that's where we stored
most of our medications.
But you know, best laid plans.
I think I only called
poison control once
when my kids were small.
And I had left a diaper
rash cream on the floor,
and one of my toddlers
ate some of the tube.
And poison control
said, oh well.
He might have a tummy ache and a
little diarrhea, but that's it.
So I was lucky.
One call to poison
control was all.
OK.
So let's talk a little
bit about pregnant women
that might have increased
nutrition needs.
Any vegetarians out there?
Oh good.
Great.
So I see a couple
of vegetarians.
I do see a lot of women that
follow vegetarian diets.
And vegetarian diets
can be very healthful.
My daughter has gone
vegetarian and vegan
and ended up with a
GI bleed in college.
And I attribute
this a little bit
to this the semester of
living on vegan baked goods,
which they apparently had
very good at her college,
and not a lot of
other healthier food.
So a vegan diet can
be healthy if you're
choosing enough lentils,
things like that.
Vegans do need to have a
source of B12 in their diet,
either from fortified
foods or from a supplement.
Iron.
So you can get a lot of iron
from beans and lentils, greens.
A DHA source for
a vegetarian diet
might be a marine
algae supplement,
or something like that.
They do make one for kids
even, called Gummy Fish.
It sort of tastes like a cross
between a Sour Patch kids
candy and tuna fish.
So not the most tasty thing.
I got those for my
vegan daughter once.
And she wouldn't eat them.
Adequate protein sources
for vegetarian diets.
If you're including dairy
products, really not much risk.
You're going to get
complete protein there.
Things like Greek
yogurt and eggs and milk
are great sources of protein
for vegetarians that include
eggs and dairy products.
Calcium can be another
nutrient of concern.
If you're not including
dairy products,
you can get calcium
from vegan sources.
Collard greens, almonds,
broccoli, sesame seeds,
and some soy products
are very good.
There are some women that have
increased nutritional needs,
including women with
higher rates of obesity.
We're seeing a lot of women get
pregnant post-gastric bypass.
The recommendation is to
delay pregnancy for 18 months
after you've had a
gastric bypass operation.
They have seen a
little bit increase
in birth defects in women that
get pregnant sooner than that.
We've also seen some women
get unexpectedly pregnant
and do just fine.
Again, closely
spaced pregnancies,
you can have some increased risk
and other medical conditions.
So we'll talk a little
bit about twins and more.
Magnified nutrient
needs as well.
Accelerated depletion
of maternal nutrients.
So it's really, really important
to just eat more frequently.
I usually recommend if you're
expecting twins or triplets
to eat a bedtime snack, and eat
first thing when you wake up
in the morning.
And if you wake up at
night and you're hungry,
then go ahead and eat
a little snack then.
Steady supply.
Because you're going to find it
hard to eat enough at one time.
There's a lot of controversy
about how much weight
you should gain when
you're expecting twins.
So I put two slides in here.
This is some recommendations
by Barbara Luke.
And she focused a lot on, just
again, one study that she did.
And she looked at the
importance of gaining weight up
to 20 weeks.
So this is kind of a busy slide.
I apologize.
But that first
column there, she's
actually recommending
a net weight gain--
and I put that at the top.
So for underweight women, she
recommended a net weight gain
of 50 to 62 pounds.
But gain 25 to 35 pounds
of it by 20 weeks.
Normal weight women,
40 to 54 pounds,
gaining 20 to 30
pounds by 20 weeks.
If you're overweight, gain
38 to 47 pounds net gain.
But 20 to 25 by 20 weeks.
And finally, for
obese women to gain 15
to 20 pounds by 20 weeks,
and 29 to 38 pounds overall.
And she gave some recommended
rates of weight gain.
Institute of Medicine
in 2009, they
didn't happen any
underweight recommendations.
But their recommendation
for twin pregnancies
again, was just a second
and third trimester
rate of 1.5 pounds per week
if you were expecting twins
and you started
at normal weight.
1 to 1.2 pounds per
week, if you are starting
with an overweight BMI,
or one pound per week
if you are starting
at an obese BMI.
Again, a lot of controversies
exist about what
the optimal weight gain is.
And there's even less data on
twin pregnancies and triplet
pregnancies.
Increased nutrient
requirements again.
Especially iron and calcium
in twin pregnancies as well.
And let's move on
and talk a little bit
about common discomforts
of pregnancy.
Nausea, heartburn,
and constipation.
I teach a class similar to
this to the medical residents,
helping them prepare to
be good caretakers for you
pregnant ladies out there.
And I tell them if your patient
is not pooping regularly,
she is not a happy lady.
It really doesn't feel good.
So we talk a little
bit about that.
For those of you that
aren't in medicine,
it's nice to review a little
bit of physiology here.
On the left, you can
see a woman's anatomy
prior to pregnancy.
And you can see her
bladder doesn't have
a baby's head sitting on it.
Her intestines are
not scrunched up.
Her stomach has
plenty of room there.
And then you compare that to
a woman who's near delivery.
And in addition to
the urinary frequency
just from making
more urine, cause
you're processing baby's
bloodstream as well.
Baby's head is resting
on mom's bladder.
I remember asking the doctor
what this weird lump was
that I felt up near my sternum.
And they said, oh
that's just where
your intestines get shoved up
at this point in pregnancy.
So it's harder for food contents
to empty during pregnancy.
It's almost impossible not to
get heartburn, cause literally
your stomach is shoved
up towards your throat.
And things just don't move
well during pregnancy.
So you can be a
little uncomfortable
by the time you're in
the third trimester.
So again, eating smaller
meals more often not only
helps move nutrient
supplies to baby,
but it just may make you
feel a little bit better.
If you're having a lot
of nausea and vomiting,
sometimes eating your
meals dry, and then
sipping the liquids
between meals
may help, just because it's a
little harder to bring dry food
up then a lot of liquids.
Try doing low odor foods.
I had a dad once who was-- when
his poor pregnant wife was very
nauseated, was first
waking up in the morning
and was trying to feed
her sardines because he
thought fish was good for her.
And she was quite
upset, because the smell
was disturbing to her.
So low odor foods may be more
helpful earlier in pregnancy.
Some women have reported salty
foods like pretzels and chips
help a little bit to settle
the stomach, or some crackers.
And tart foods like
some lemon might help.
Some women find it helpful
to just put some crackers
at bedside and put a little
something in your stomach
before you get out of bed.
Small frequent meals again,
can help with constipation
and heartburn.
If you're constipated,
you really, really
need to up your fluid intake.
Sip it throughout the day.
And I lot of us think
if we're eating salads,
we're getting a lot of fiber.
Two cups of lettuce
has two grams of fiber.
It's not a lot.
You want to put a cup of
black beans on your salad.
You'll add another
15 grams of fiber.
And you can do a very high-fiber
bran cereal like All Bran,
and get 10 grams fiber
in one serving there.
Very few Americans reach the
target 28 grams, at least,
a day of fiber.
Most of us get closer to
10 to 15 grams per day.
Again I hate to pick
on rice a little bit.
But a cup of white rice gives
you less than a gram of fiber.
If you replace that
with beans or lentils,
you can up the fiber
to about 15 grams.
And there's a lot of other
good whole grains on the market
now too.
Quinoa, farro, cracked
wheat, lots of good grains.
And again, this is a good list
just of some fiber-rich foods
there.
Some of my favorite fruits.
Raspberries are
very high in fiber.
8 grams per cup.
That's a lot more than
you would get in a banana.
Beans and lentils, and lots
of fruits and vegetables
can definitely help.
But talking about foods
in fruits and vegetables,
you need to be a
little more careful
about food-borne illness
for pregnant women.
You want to wash
hands more carefully.
You want to cook animal
products completely.
No soft boiled eggs
during pregnancy.
No rare steaks.
You want to wash all
produce before you eat it.
You want to avoid any
unpasteurized dairy
products, juices, or cheeses.
You don't want to eat liver.
You also want to limit seafood.
Seafood can contain
mercury, and also can
contain fertilizer runoff if
you're eating freshwater fish
where there's been a
lot of PCBs in the water
from fertilizer runoff.
Food that touches the soil.
So recent listeria
outbreaks have
been from cantaloupe,
strawberries, green onions.
You want to be extra
careful if you're
eating produce that comes
directly in contact with soil,
like carrots or potatoes.
Especially if you're going to
eat it raw and not cook it.
Cooking and heating will
destroy the listeria.
But a lot of pregnant women know
to avoid changing the litter
box, but I always say if
you're touching soil, or food
that touches soil, all the
animals in the neighborhood,
the soil is the animal litter
box for your neighbor's cat.
So you want to be really
careful with produce
that grows on the ground.
If you're not going
to peel it or cook it,
be sure and wash it thoroughly.
There was an outbreak of
listeria from cantaloupe.
Cantaloupe is-- you don't
usually eat the peel,
but the bumpy surface harbors
the bacteria little bit more.
And if you don't
wash the outside skin
before you slice through
it, you can actually
transfer the bacteria from
the outside to the inside.
If you're going to
cook it, you don't
need to worry about it so much.
You also want to minimize
exposure to pesticides.
This is a slide I borrowed
from the Environmental Working
Group.
And every year they come
out with-- they study
and put a list out of what the
cleanest, least contaminated
fruits and vegetables are.
And they always put
out their dirty dozen,
which are the most highly
contaminated produce
on the market.
You can pick this up.
You just Google the Dirty Dozen
Environmental Working Group,
you can find that
information online.
So it might be
worth your dollars,
if you want to buy
apples, for example,
to spend the money for organic.
Whereas asparagus and
avocados are really low
contaminant level.
You can go ahead and just
buy the regular for those.
OK.
Caffeine has been
highly debated.
And the consensus
seems to be now
a little bit of caffeine
in pregnancy is fine.
Usually about 200
milligrams per day.
This is also good-- we
were talking earlier
before I came in about the
new USDA guidelines saying
that coffee may be
good for us in reducing
risk of certain diseases.
So I'm a big coffee fan,
so I'm great to hear
more research that we can
have a little bit of coffee
in our diet.
But that 200 milligrams
per day for pregnancy,
a 16 ounce Starbucks coffee
is going to shoot you
over that pretty rapidly.
I drink Peet's coffee, so I
imagine that's even higher.
So you want to be cautious
not to overdo the coffee.
But I know some of
you so conscientious,
you won't even eat
one Hershey's kiss.
So again, I put down there,
even a whole Hershey's
Special Dark chocolate bar is
only 31 milligrams of caffeine.
So you can fit a little bit
of caffeine in your diet
during pregnancy.
So if you're really craving
that cup of tea or coffee,
sometimes a little bit
of coffee in the morning
may help get the bowels
moving, if you're suffering
from a lot of constipation.
So let's move on to
the postpartum issue
so I can leave some
time for questions here.
We want to talk a little bit
about losing your pregnancy
weight, healthy
diet and lifestyle,
and encouraging
you to breastfeed.
Hopefully you're planning on
breastfeeding before you even
become pregnant, learn
about breastfeeding
when you're pregnant.
And everybody should be
encouraged to breastfeed.
We're very breastfeeding
friendly here at Stanford.
One of our great nurses
is sitting up front here,
Deb Greenwood.
Afterwards, if you have any
questions on breastfeeding,
you can talk to Deb Greenwood.
Susan Crow, one
of our physicians,
has been a big promoter in
making us a very breastfeeding
friendly hospital.
But I do want to talk about
losing your pregnancy weight.
It is tough to lose
the pregnancy weight.
I gained the 50 pounds
they recommended
for a twin pregnancy.
And I'm a dietitian.
And I didn't lose
it for eight years.
So it took me a long time to
take that pregnancy weight off.
Most women, if you check
their weight a year
after they've given
birth, they're
going to be heavier
than they were.
44% of women who started
pregnancy overweight
were obese one-year postpartum.
And 30% of women that had
a normal pre-pregnancy BMI
were overweight or obese
one-year postpartum.
Breastfeeding and exercise
can reduce the risk
that we retain this weight.
Why do we care if you gain
a little bit of weight
between pregnancy?
If you go up one BMI point
between baby one and baby two,
at second pregnancy you
have a 30% increased risk
of gestational diabetes.
And that risk is
increased even more
if you go up a BMI category.
So if you've gone from normal
to an overweight BMI category,
your risk is
essentially doubled.
So tips for losing
weight afterwards.
First of all, be a
little easy on yourself.
I encourage you to have
realistic body image goals.
And I think especially if you're
going to be a parent to a girl,
we really want to
encourage our daughters
to have realistic body images.
Because I think
when I was pregnant,
Demi Moore had that beautiful
naked pregnant picture
on the cover of a magazine.
And I just thought, oh my God.
That doesn't look anything
like my naked body right now.
And it was kind of discouraging.
And this is what most of us
are exposed to all the time.
The average fashion model
is actually underweight,
with an unhealthy
BMI of about 16.
So this is the average fashion
model, or the average movie
actress, compared to the
average American woman.
So I think we would need to
really encourage healthy body
images in our media
and what we represent.
And also to be a little
easy on ourselves.
We can't be expected
to look so perfect.
Little changes can add up.
I always think
about that gentleman
that was so dismayed
when his doctor told him
he had to lose 100 pounds
that he did nothing.
Tiny changes can add a
lot of pounds on to us.
Two extra Oreos a day, if
it's above your basic needs,
can cause you to gain
about 10 pounds in a year.
But if you walk one
extra mile a day,
you can lose 10 pounds in a
year, all things being equal.
Drinking water.
If I could wave a magic wand and
make one change in everybody's
diets, I would eliminate sodas.
Regular soda is probably
one of the most toxic things
in our diet right now.
I don't know who's responsible
at Children's Hospital here,
but if you notice if
you go in our cafeteria,
you cannot buy a regular soda.
And I applaud the physicians.
I think the
pediatrician's group that
were so concerned about sodas
in our kids' diet, that removed
soda from our cafeteria.
One 12-ounce soda a day could
put 15 pounds a year on you.
And a recent study
I read that showed
just 1 12-ounce soda a day
can increase diabetes risk
by about 20%.
This I stole a little
bit from-- there's
actually one diet book on the
market that is evidence-based.
And it's called Volumetrics.
And it's written
by Barbara Rolls,
who did research at Penn State.
Most diet books are not
science-based at all.
And she found that you can
increase satiety and reduce
people's caloric intake just
by increasing intake of foods
that have a high water
content, like broccoli.
So I know I can sit down
to a big plate of food.
If I just tell
somebody they have
to cut down on their portions
from two cups of pasta
at dinner to one, they're
going to feel deprived.
But if you change that two cups
of pasta to three cups of pasta
mixed with vegetables, you can
really reduce the caloric mix,
but keep the volume up.
So that's one strategy.
And I want to encourage
every woman here
to breastfeed their baby.
There could be a whole
class on breastfeeding.
I just want to touch on some
of the reduction in risk
for your baby.
Reduction in ear infections.
Reduction in
gastrointestinal infections.
Even a reduction in childhood
leukemia, celiac disease,
type 1 diabetes, asthma,
food allergies, 72%
risk reduction of
hospitalization
in your baby's
first year of life.
And for you, you're going
to have decreased risk
of breast cancer, diabetes.
Oxytocin produced
when you breastfeed
your baby is gonna help your
uterus return to normal size.
And it's gonna help you lose
your weight after baby's born.
Breastfeeding twins
is really wonderful.
The one caution I
can tell you there
is I got used to eating
enormous amounts of food.
And it was really hard when
babies weaned to cut back down.
I wanted to hire myself
out as a wet nurse.
I thought, this would be a
great breastfeeding plan.
Nutrition during lactation.
Your fluid requirements--
I harped on
that a little bit earlier--
you need about four liters
of water a day to produce
enough breast milk.
I made it all through pregnancy
without getting hemorrhoids.
But I got so
constipated I think,
dehydration breastfeeding
twins, that I ended up
with hemorrhoids after
babies were born.
So be sure and keep
your fluid intake up
to help produce
that breast milk.
You do need extra calories
for breastfeeding,
but your body can
supply some of that
if you gain some extra
weight during pregnancy.
So you can mobilize
that as well.
If you are planning
on breastfeeding,
maybe just continue taking
your prenatal vitamin
will help provide some of
those nutrient needs as well.
And we mentioned here
almost four liters
a day of water needed to stay
hydrated during breastfeeding.
Again, you're making
that breast milk
from nutrients in
your bloodstream.
So you might want to keep up
the same type of eating style.
Eat frequently.
When you sit down to
breastfeed your baby,
have your loving husband
bring you a nice glass
of water or something to drink.
So that's one thing
dads can do to help out.
You do lose some bone
mass when breastfeeding.
But generally you
recover that bone
that you've lost
within six months
after you wean your baby.
Allergies.
Occasionally babies
can develop an allergy
to something mom's eating.
It's pretty rare.
If you have mucus or
blood-specked stools
in your baby's diaper,
maybe check out
with your pediatrician.
Foods that are more
likely to cause an allergy
are eggs, dairy products,
soy, and wheat products
in mom's diet.
So did pretty well on time here.
I just want to wrap up.
So preconception,
pregnancy, and postpartum.
We talked about weight
all the way through.
Preconception, you want to
normalize weight or lose
a few pounds if
you're overweight.
During pregnancy you don't
want to gain too much weight.
But don't starve yourself.
So appropriate amount of
weight gain for your BMI,
and if you're expecting
one baby, two or three.
After pregnancy, you might want
to try and take all that weight
off before you become
pregnant again,
or the risks of gestational
diabetes, preeclampsia,
and some other
conditions can be greater
in that second pregnancy.
Stay active.
We now know that for most
women, physical activity
all during pregnancy
is a good idea.
Now having said that,
if you're not a runner,
maybe it's not the time to try
and for train for a marathon
when you're pregnant.
I had a woman come in and ask
me, can I do this mud run.
I'm pregnant.
And I want to do this run.
It involves jumping
over hurdles,
leaping under obstacles.
I said, I don't think that
sounds like a good idea,
but I'd be happy to
run it by your doctor.
And they laughed and said
that she could do the run.
But she could not do
any of the obstacles.
And she was not to
try and win the race.
She was supposed to hang
to the back of the pack.
So go for a walk
20 minutes a day.
If you're already a runner, you
can probably keep up with that.
But now is not the time
to try some really high
intense activity.
Avoid smoking.
Avoid alcohol.
Avoid food and
environmental toxins.
That's really important
for pregnant women.
Take a prenatal vitamin
or multi-vitamin
that has folate in it.
And consider taking
a multivitamin
for micronutrient insurance
in the postpartum period,
if you're breastfeeding as well.
And finally plan on
breastfeeding even
before you plan your pregnancy.
Prepare for breastfeeding
while you're pregnant.
And you're going to be
exhausted and overwhelmed
when you take that baby home,
but breastfeed that baby.
And if you're having
trouble breastfeeding,
called Deb up in clinic, or make
an appointment with Susan Crow,
or get some lactation
support when
you're still in the hospital.
It's very, very challenging.
It's new to you and your baby.
Put that baby skin-to-skin.
Bare baby on your
bare chest, and that
will enhance your success
with breastfeeding.
So we talked about some
common themes tonight.
Again, I wish everybody could
start at a healthy weight.
But if you don't start
at the healthiest weight,
try not to gain too much
weight during pregnancy.
And try and lose your baby
weight after delivery.
But be easy on yourself.
Don't feel guilty if
you're not starting out
at a perfect weight.
Healthy diet.
And again, all of us should be
working a little bit healthier
on our diet.
That doesn't mean you can't
have an ice cream bar.
That doesn't mean you can't
have a little bit of chocolate.
Think about the 80% rule.
80% of your food choices
should be really good.
And you can splurge a little
bit with that other 20%.
Do something for exercise,
and breastfeed your baby.
Remember, this is kind of
what a healthy diet should
look like for all of us.
And some take-home thoughts.
Again, I don't want anybody
to walk away tonight
feeling guilty about
the Cheez-It binge
they had, or the chocolate
bars they've eaten,
or if they didn't start
at the perfect weight.
Most women are going
to have a healthy baby,
even if they didn't start
out at a perfect weight,
and even if they don't
have the healthiest diet.
And I handed out this
resource sheet here.
It just gives you some
links to some healthy tools
for more information,
including our own website.
And I will finish that
up with some questions.
And I will tell you that
these are my babies, the twins
I showed in both spots there.
So they are 23
years old right now,
and graduated college last year.
So I'm happy to answer
any questions, including
on twin pregnancy, since I
have some experience there.
