44. Lily Nichols: Role of Seafood and DHA in Optimal Breastfeeding, Pregnancy & Post Partum

Lily Nichols joins me to continue our exploration of optimal pregnancy and post-partum nutrition. This episode contains extremely valuable information on how to ensure your baby receives all the nutrients they need to thrive. 

We cover controversies surrounding seafood and raw fish consumption during pregnancy, the critical role of DHA, circadian rhythms & breastfeeding, harms of a high omega-6 diet on baby's brain development, iron status in pregnancy and MUCH more.

Lily Nichols RDN is a registered dietitian, pregnancy nutrition expert and author of the book Real Food for Pregnancy. I previously spoke to Lily in episode 16 of the Regenerative Health podcast where we covered micronutrients for pregnancy, carbohydrate intake and gestational diabetes and how various national guidelines are harming women with carbohydrate recommendations in pregnancy. 

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TIMESTAMPS

0:00 Seafood and DHA in Pregnancy
12:51 Seafood and Pregnancy
19:38 Raw Shellfish and Sushi During Pregnancy
26:13 Maternal Diet's Impact on Breast Milk
43:59 Breastfeeding on Circadian Rhythms
50:39 Nutrition and Postpartum Mental Health
1:07:58 Assessing Iron Needs During Pregnancy & can I eat liver during pregnancy?

LINKS
Lily's blog post on seafood - https://lilynicholsrdn.com/fish-pregnancy/

Real Food For Pregnancy by Lily Nichols - https://shop.lilynicholsrdn.com/collections/frontpage/products/real-food-for-pregnancy-paperback

Real Food for Gestational Diabetes by Lily Nichols - https://www.amazon.com/Real-Food-Gestational-Diabetes-Conventional/dp/0986295000

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Website: https://lilynicholsrdn.com/

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Transcript

Speaker 1: 4:12

Hello, this is the regenerative health podcast and I'm Dr Maxxgul Hain. In this episode, I'm talking with Lily Nichols. Now, lily is a registered dietitian, pregnancy nutrition expert and author of the book Real Food for Pregnancy. I previously talked to Lily in episode 16 of the podcast, where we covered a range of topics including micronutrients, carbohydrate intake, gestational diabetes and how various national guidelines are harming women with carbohydrate recommendations in pregnancy. I highly recommend checking out that episode before moving on to this one.

Speaker 1: 4:49

Today, I brought her back on to discuss a bunch of more topics that we didn't cover, including nutrition for an optimal pregnancy, breastfeeding, how to optimize and ensure that the highest quality breast milk, the key role of the Omega 3 fatty acid, dha, whether or not you should eat seafood in pregnancy, how breast milk varies in its nutritional content based on the circadian timing, and a heap more. If you find this conversation interesting, then please share it out, subscribe to the podcast and leave a review on Apple Podcasts or Spotify, which is very helpful. I'm really passionate about this topic because I think we can avoid a lot of unnecessary suffering and prevent a lot of disease with optimal pregnancy preparation and optimal nutrition and lifestyle throughout pregnancy, gestation and postpartum. So thank you very much, and on to the episode.

Speaker 2: 5:57

Thanks for having me.

Speaker 1: 6:00

Let's start and jump right in to a topic that you have talked about recently on your blog and that has generated a fair bit of interest on social media, which was the consumption of seafood in pregnancy. I'd tell everyone to go and read the blog post, but if you could summarize for us what that was about and what was the topic that people were getting so worked up about?

Speaker 2: 6:30

The thing that sparked all the controversy was a real was created from a podcast interview that I did where we were talking about the benefits of seafood intake and pregnancy and on brain development outcomes. And reels on Instagram are like a minute or less, so you can't really get into a whole bunch of context and nuance. So internet erupted in Storm. Actually still, I mean, this has been out for a couple months and it's still. People are still commenting on this reel Like every day. It's crazy. No, you can't eat fish. Fish is toxic. It has mercury. Way to give your kid mercury poisoning.

Speaker 2: 7:14

I mean lots of non-PC comments as well that'll leave out, and then a lot of you know there's actually there's no data to support what you're saying. So I did respond via a blog post I wrote on can you eat too much fish during pregnancy? Because in addition to that kind of feedback, there was like well, there can be too much of a good thing, right. Like well, maybe a little bit of fish is good, but too much would be bad because of the mercury or maybe the type of seafood or whatever. So in that blog article I do go through, I mainly focus on one systematic review on seafood consumption during pregnancy and neurocognitive development. And the reason I focused on that specific publication is that it includes a review of 44 studies and over 100,000 mother offspring pairs, so very large body of data. Like that's kind of the point of systematic reviews is it can parse through like we have all of these studies looking at fairly similar things with slightly similar you know study design, but this is different or slightly different outcomes, and you can kind of compare and contrast all of that data all in one place. So what I loved about this particular study is that they were looking at a lot of the questions that people brought up from that reel, like is there a level of seafood at which it's beneficial but also a level at which it could be harmful? And they actually did not find any level of seafood intake that was notably harmful for that infant or child's future brain health. There were benefits from as little of four ounces of seafood intake per week, and those benefits continued even when seafood intake was 100 ounces or more per week, which is pretty rare. I've never had a client who consumes that much, but of course there are areas in the world where you know seafood fishing communities and such. Maybe that's their primary source of protein and no, there was no issue with neurocognitive development. They also looked at mercury intake and whether there was greater mercury intake among women who ate more seafood, and then also if that mercury intake was demonstrably harmful to their baby's brain development. And really interesting that, yes, women who ate more fish actually did have more mercury in their system, but that did not negatively affect their offspring's brain development.

Speaker 2: 10:11

Now if they had high mercury from other exposures and I should point out the main exposure to mercury is actually amalgam fillings, which are about 50% mercury by weight. Usually people call them silver fillings, so that's actually the primary source of mercury exposure. If the mercury was from any other source of exposure, whether amalgam or something else, anything other than seafood intake, that was harmful to neurocognitive development. So there was something about the mercury specifically coming from seafood. Even though it like built up in a mother's system to some degree, it was not overtly harmful and it's possible it's related to the other nutrients that are in the seafood, such as selenium, which seems to offset mercury toxicity, or maybe just the super high intake of other nutrients that are so beneficial to brain development that tend to be low if you don't consume seafood, like DHA and iodine, for example. Maybe that offsets some of the harms of mercury for neurocognitive development.

Speaker 2: 11:24

They even looked at different types of fish, like our oily fish, maybe better or more harmful to brain development. Like any seafood, essentially was beneficial for the most part. So this really did kind of shake things up a little bit. I personally am still in favor of people limiting their consumption of high mercury fish. If you know something is a high mercury fish, choose a lower mercury option, of course, like when available. But overall really, the totality of evidence is that it's net beneficial and because the studies included in this review are looking at fish consumption in total, any other problematic compounds that could be found in seafood, like organic pollutants, like dioxins, pcbs, microplastics, radiation from Fukushima, like you name it all the reasons people don't want to consume seafood. Still, there was a net benefit to infant brain development, despite maybe some of those things. Now they didn't specifically look at levels of those different toxins. They focused on mercury, but seafood intake as a whole like consistently net benefit. So that was my major takeaway.

Speaker 1: 12:45

Yeah, that's a very interesting finding and obviously the study didn't look at other health outcomes that might be related to mercury intake, but I would think that the neurocognitive would probably be the first and most measurable outcome that we would see.

Speaker 1: 13:03

So I agree, I think that it's a very strong case for consuming seafood, even in the face of what people the modern kind of environment that people are worried about, especially with all kinds of contamination and you make the point in the blog that it's not like seafood is the only food that is contaminated, yet it seems to be the one that most people would jump up and down about.

Speaker 1: 13:29

So we're always balancing the risks and benefits. So I'm a very big advocate for seafood consumption for the fact that it contains this omega-3 fatty acid, dha, and I've done previous podcasts with Dr Jack Carouse and he made the point that this is a substance that hasn't been replaced in the cell membrane in 600 million years and it is highly concentrated in the central retinal, in the nervous system, in the central retinal pathways between the eyes and the brain, and it's incredibly valuable and I think there's also good evidence that it was a factor that allowed us to really develop the cerebral capacity that we do at the moment. So talk to us about your perspective on DHA, and maybe do you think there's any other good sources of DHA, or just summarize what you think about this compound. Yeah.

Speaker 2: 14:27

I mean. Out of all of the essential fatty acids, I would argue that DHA is probably the one we have the most evidence on for its benefits and how truly it's an essential compound. Like essential means, your body can't produce it in sufficient quantities and we have plenty of research to show that that is the case. You try to take in other types of omega-3 fats, like ALA, from plant foods like flaxseeds and chia, and your body just cannot convert enough of it into DHA for optimal health. So definitely I agree that it's certainly an essential compound. Seafood by far is our greatest source of DHA. You start to look at other sources of it. Well, it is found in things like eggs, especially when the chickens have been fed Omega-3s themselves, or grass-fed cows, for example, and ruminant pasture-raised animals. The concentrations of DHA are so far below the amount that's in fish that you would just have to of those foods to get anywhere close to the amount of DHA found in just a few ounces of seafood. And when you get to something like fish, eggs, roe is extremely concentrated In DHA. You need just the tiniest amount to get many fold more than you get in a filet of salmon, for example. So it is even more concentrated in certain areas. So when you go back to some of the research from Dr Weston Price which I'm sure you've talked about him on your podcast before he noted that in some areas where people were landlocked so far from the coast like far away from having seafood readily available, they would go to great lengths to try to obtain seafood. Often, like a minimum of every three months, they would go and trade with coastal communities to get seafood, and one of the rationales was that it was necessary to maintain the fertility of the women of the tribe and even if those tribes were in a time of warfare and did not get along, they would have specific places for this trade to take place.

Speaker 2: 17:16

So to me it seems like I don't think DHA is necessarily the only reason to consume seafood.

Speaker 2: 17:24

I certainly think it's one of the ones that certainly gets the most airtime in terms of nutrients and seafood, but it does clearly have an essential role in human health. And when it comes to a baby's development in utero, there are irreversible time periods of development where certain areas of the brain are being built or certain neuronal connections are being made and the eyes are being formed, and if you don't have sufficient amounts of key nutrients during that time DHA is one of many then you can have permanently lower level function of those tissues, so you can't make up for low DHA intake during pregnancy. After the fact, it's still great to get enough DHA then. If you're breastfeeding or transferring that DHA via your breast milk, that's great, and children continue to need DHA as they grow and develop. But there's these specific time points at which some of these nutrients are super critical and it does appear that certainly pregnancy, the whole nine months there's a very important role for DHA in optimizing both brain and vision development. So I don't think it's one that you can skip over.

Speaker 1: 18:45

Yeah, and I like the point that you made, which is it's not only the DHA and the seafood, and a common theme that we talked about on our first podcast is when you consume these animals, these animal foods, you're getting the constellation of nutrients that together are not only necessary but synergistically interacting to absorb and become extremely bioavailable, and when, for optimal eye and retinal development, we also need vitamin A. And it's no kind of coincidence that when we're eating things like fish, and especially oily fish, that we're getting a bit of vitamin D, we're getting vitamin A in addition to the DHA and we're also getting iodine, selenium, zinc that you mentioned, which together is the perfect kind of food in terms of supporting that neuronal development. And yeah, you made the point about those critical checkpoints. I believe about 70% of the brain is polyunsaturated fatty acids, so the amount of DHA that's in there is critical and it's just getting concentrated. It's getting concentrated in that brain. So a major reason to consume fresh seafood.

Speaker 1: 20:06

I know you mentioned in your book and maybe you can give a quick summary for the listeners who haven't read your book what's your take on raw seafood consumption. Because when we think about the bioavailability and denaturing of nutrients and I think raw seafood is up there with the best food that we can eat, especially obviously prepared well, but things like sashimi. What's your take on what women should do or eat during pregnancy with regard to raw fish?

Speaker 2: 20:34

Yeah, the raw fish one is controversial, of course. You know, in the States and probably many other sort of Westernized societies it's a you know big no, no to have any sushi. But in other parts of the world it's not frowned upon. In Japan it's known to be encouraged, actually. I finally even pulled up some of the Japanese guidelines on fish consumption and pregnancy and it was interesting. Their whole document focused primarily on reassuring women that fish consumption was safe despite the mercury content, and they did give some more specific breakdowns of types of fish and quantity per week or month or whatever for some of these ones that are more commonly consumed over there. But they even broke it down by sashimi. You know, like a typical portion size of sashimi you can have like X amount based on the amount of mercury. They didn't even like go into whether sushi is controversial or problematic or should be avoided. It was just like sashimi was mentioned as like yes, also factor this into your seafood intake. It was just sort of like an aside. So certainly and I know from people who have lived in Japan encouraged is what I've heard there's no frowning upon consuming sashimi and other raw seafood.

Speaker 2: 22:03

There is a bit of controversy with, like raw shellfish If it's not like super, super fresh. If you look at at least US seafood illness outbreaks, like 75% of the seafood associated outbreaks, are from raw shellfish or undercooked shellfish, and so that's one of those ones where I'm like there's a slightly higher risk of food poisoning here. Right, I say 75%, this is 75% of the ones associated with seafood. Right, this is not across the whole country. Half of foodborne illness outbreaks in the US are from raw fruits and vegetables. Okay, so the small proportion, or this proportion of the small amount that are due to seafood it's 75% makes it sound really big. But this is relative only to other types of seafood. I would say, if you know where the oysters are from and you can ensure they're super fresh and they pass the smell test I mean, your nose is so sensitive during pregnancy like this slight, like any slight off scent something becomes completely and immediately repulsive. It's that you can't imagine how strong this like gut response is, but it's very strong. So if anything smells fishy in that off sort of way, you definitely are not going to want to consume it, right, but if you're lived by like an oyster community, like you could probably get really good ones and I would probably partake.

Speaker 2: 23:35

As for sashimi, I mean I enjoyed sushi, you know, during my pregnancy raw fish sushi you just want to use, you know, common food safety considerations. Is it a reputable establishment? Does it? Is it clean? Are you eating it right away? You're not taking it home and eating it later. You're not getting the stuff pre prepared at the grocery store, like you want to get it fresh from a good sushi bar or a good restaurant that is hygienic and has good handling.

Speaker 2: 24:04

The likelihood you'll actually get sick from it is pretty slim and sushi grade fish often has a requirement that it has been flash frozen and then frozen at a specific temperature for a specific amount of time to inactivate any potential parasites. So, as long as you know, post defrost it has been kept at the proper temperature and you're consuming it right away. I personally wouldn't have any concerns over that. But you know you also got to go with what your mental state will allow. Like some people are so anxious about possibly getting food poisoning that it's like too much to bear to go there and like, if that's you, that's fine, enjoy it cooked. There do seem to be some nutrients that are better preserved when it is raw iodine levels and DHA levels, for example, are both higher when it's raw. So you know, you do you.

Speaker 2: 25:05

During my first pregnancy I was living in a fishing community so we had tons of fish freshly caught available. So I did like raw sashimi and ceviche quite frequently in that pregnancy because it was so fresh and so widely available. It was like a really, you know, primary protein source in that area. So I per took and it was perfectly fine. I didn't get any food poisoning.

Speaker 1: 25:36

Yeah and two points on that I encourage people to meet their farmer as a way of understanding exactly what they're getting from a food point of view and to understand exactly the whole process of what their food has gone through. And I think the same applies to sourcing seafood. And in Albury there's a great seafood seller, pat, who provides the freshest seafood and when you meet him, you talk to him, you understand the cleanliness and hygiene process. It is something that it's a different kettle of fish excused upon to showing up at the supermarket and talking to some 16-year-old intern about asking them the provenance of the seafood. They're not going to know and it could be in there for two days. Who knows what's happened to it? So I think provenance is key.

Speaker 1: 26:28

And the other point you make in, and it's very interesting about how you feel during pregnancy, and I have one patient who refused to eat any room in a meat. That was her decision. But she ate a heap of seafood and she was. She was eating. She was eating raw fish, had a very normal, unremarkable pregnancy but she would be getting cravings for sashimi and raw fish and it was diligent in her sourcing.

Speaker 1: 26:58

But it's definitely an option and, as you said about the Japanese, it's only our societies that are perhaps as kind of pedantic about something it's not a universal phenomenon and I wanted to ask you about and I think it's a great transition towards breast milk, because, as you mentioned, it's not only during pregnancy that we want to be having sources of DHA to help baby, baby grow, because, as people know or they might not know, for women that exclusively breastfeed, it's six months of essentially that that's the exclusive food for baby. So talk to us about breast milk and maybe this idea that it's not on what we can do makes a difference in terms of the quality of the breast milk.

Speaker 2: 27:48

Yeah, this is a surprisingly controversial topic, really kind of people don't want to. People don't want to touch this topic with like a 10 foot pole because it's already. There's already so many barriers to breastfeeding and of course, we know all of the benefits of breastfeeding and we want to encourage it. And so if you bring up any piece of information that could potentially make a breastfeeding mother feel like, oh, my milk is not good enough, then like we're not even going to go there, like people don't want to go there. I am of the opinion that it's kind of a two birds with one stone situation. We do need to acknowledge that a mother's state of health and nutrient stores and nutrient intake not only benefits her health but it also benefits her baby's health, not just in pregnancy but also during breastfeeding as well, because although you can and will produce breast milk on with, despite suboptimal nutrient intake, you will you will probably can still produce plenty of milk for that baby. If your diet is not super great, the levels of specific micronutrients can decrease in the breast milk. Actually teach like a whole two hour webinar on this topic over at the women's health and nutrition academy, like going through the data on it, because people don't want to even consider that it's an option. I also think it's information that needs to be presented with like an incredible amount of care and nuance, because this information isn't always best shared directly with a mom who's struggling with breastfeeding. But it might be helpful for lactation professionals to know the information so that if they get questions about whether the quality of my diet can affect the quality of the breast milk, the answer should not be no. The answer should be a resounding yes, and let me help help make sure that you have, like the support and community necessary to stay well nourished while you're nursing, not to be used as a way to like shame or make women feel less than so.

Speaker 2: 30:17

With all those like considerations aside, there's quite a few nutrients that are dependent on maternal intake and or nutrient status Essentially, all of the vitamin, all the B vitamins.

Speaker 2: 30:32

Folate is a little bit controversial. The body will try to provide as much folate as possible via breast milk, but it will be at the expense of the mother's folate stores. All of the fat soluble vitamins choline, fatty acids like DHA, definitely dependent on intake, and a lot of different minerals, especially the trace minerals iodine and selenium, for example, very much dependent on maternal intake, whereas iron and calcium tend to be maintained at a fairly steep. So, yeah, we need to be focusing not only on, like just general breastfeeding education, but I think we also need to be incorporating some nutritional advice into that conversation as well, because it does make a difference, and probably some of the most documented data that we have on nutrient, the issues that can happen as a result of nutrient content and breastfeeding, is on women who are B12 deficient and the effects that that can have on their baby if they're exclusively breastfeeding, which I can get into if you want me to.

Speaker 1: 31:50

Yeah, it makes sense that the fatty acid and the micronutrient content of the breast milk is going to reflect the intake in the stores of the mother. I think that's pretty obvious and it's borne out in the scientific literature. And I'm really thinking about what most people, or the average person, is doing if they're consuming a diet that's rich in seed oils like corn or soy oil as a source of their fat calories and the fact that that is going to be passed through the breast milk, especially if they're not having sources of DHA, and those are kind of inflammatory fats are the ones that are going to be building the baby's brain and if we don't discuss this concept with mothers, then they're not going to know. Talk a little bit about the fatty acid composition. What diet do we have in terms of the high omega six versus omega three and any outcomes that you're aware of?

Speaker 2: 32:54

So what's interesting about the high omega six is that, yes, it will transfer omega six into the mother's milk, but it also depletes the vitamin E levels in the milk as well, which makes perfect sense. Vitamin E is an antioxidant and when you're taking in highly oxidized vegetable oils you have to use up more of your endogenous vitamin E stores to combat that oxidation. There was actually a really interesting study that and let me see if I can find it really quick on vitamin E, where they were looking at vitamin E levels in the breast milk relative to intake and, interestingly, higher maternal fat and saturated fat intake predicted higher vitamin E levels in the milk. But vitamin E levels in the milk were not reflective of the vitamin E content in the diet. So it's like if you eat more saturated fat, you're sparing vitamin E because your body is not busy fighting off all sorts of oxidation caused by a high omega six diet. So I found that one very interesting. Certainly, the quality of the fats will reflect what's in the milk, so, like high trans fat intake will show up in breast milk, high DHA intake will result in higher DHA levels in breast milk. They've actually measured the percentage of DHA, because they measure it by looking at the concentration of DHA per a certain amount of breast milk and then present that data in percentages. So we know the concentration of DHA and human milk can vary more than ten fold and is essentially entirely dependent on the mother's DHA intake. So vegan mothers by far have the lowest DHA levels in the milk of all. Like point They've actually done studies where you supplement mothers with flaxseed oil to see if it will raise the DHA levels in the milk.

Speaker 2: 35:20

Flaxseed oil doesn't contain DHA but it contains ALA and theoretically we can convert some to DHA, which we can, but it's like in the realm of like one or two percent, like it's really low. So flaxseed supplementation, ala supplementation does not raise the DHA levels in the milk. You have to take in DHA directly. So for vegan mothers, unless they're supplementing with an algae based DHA supplement, there's barely any DHA in their breast milk.

Speaker 2: 35:52

They've looked at women with low fish intake, like those in the Midwest of the US. The DHA content in milk was point one eight percent. Hunter gatherer communities who are consuming freshwater fish, 0.7% DHA in milk. Omnivores who are eating an average of four and a half ounces of seafood per day it's actually pretty high seafood intake for most people, dha concentrations are 2.8% in the milk and I'm sure I haven't seen the data specifically on people who reside in Alaska of cold water fish, I would wager the percent of DHA in their breast milk is even higher, because they tend to consume two, three, four times the amount of DHA that an average American is consuming.

Speaker 1: 36:48

Wow, they're very interesting figures and I can't help but think that there's really two paths that, collectively, we can go down, and one of them is this heavier plant-based diet which is low in seafood, low in animal-based products, low in DHA, low in all these trace minerals that we need for essential for baby's development.

Speaker 1: 37:12

And then the other side of the coin is people deliberately eating fresh seafood, fish eggs, which fish row, which, as you mentioned, is basically the brain elixir as far as I'm concerned and getting all these important nutrients and enriching them in the breast milk. And I feel like the former path is really one of cognitive de-evolution. And when you appreciate the role of DHA and seafood and all these animal-derived nutrients in human evolution and fetal development, if you triangulate this with not only evolutionary data but even the clinical data and cognitive outcome data, it's just so overwhelmingly necessary to be including these animal-derived nutrients in the diet. It's incredible, and in your book and I was reading it yesterday before I talked to you you made the point about vitamin D and that unless we, almost overwhelmingly, babies that are exclusively breastfed are going to be vitamin D deficient unless they're supplemented. This, I mean my hunch is that is because babies aren't being exposed to UVB radiation at all. Do you have any idea or any data about this and how, other than diet, we could potentially support vitamin D levels in infants?

Speaker 2: 38:30

Yeah, I do. It is not the biological norm for breast milk to be low in vitamin D or for human infants to be deficient in vitamin D, nor for adults to be deficient in vitamin D. That's not the norm. I think this is a reflection of the significant change in our lifestyles moving indoors and then also, of course, all of the sunscreen and sun avoidance advice that really became so popular in the 1970s. So, interestingly, there was actually a resurgence in infant rickets. That's like rickets being a significant vitamin D deficiency, so much so that it causes your bones to become brittle and break very easily. There was a resurgence in infant rickets in the 1980s and 1990s which, you think about it, this is like after the sunscreen and sun, you know, avoid the sun due to cancer concerns era. And that actually is what led the American Academy of Pediatrics to start recommending a universal supplementation of all breastfed infants with vitamin D. And they started with just recommending 200 IU's per day and they actually later revised that, like five years later, to 400 IU's. And that was because, you know, infant formula was already supplemented with vitamin D, but they hadn't thought about, you know, women's breast milk might not have enough Milk. Vitamin D levels are entirely reflective of maternal intake and you need a consistent supply of vitamin D coming in either from diet or sun exposure ideally both to maintain those vitamin D levels. So if you have a deficient mother who is not consistently getting a supply of vitamin D, the breast milk is going to be low in vitamin D Doesn't mean that that's the default norm. It doesn't mean that supplementation is the only solution to this issue either. Right, like you could make up for it with sufficient sun exposure. But of course, most of the data since it's so hard to measure vitamin D production via sun exposure and it varies by skin tone, time of year, latitude, amount of clothing, everything Most of the studies focus on supplementing women directly with vitamin D3 and then measuring the vitamin D concentrations in their milk, which is measured in what's called ARA or anti-recidic activity it's like anti-ricot activity, essentially and then also by following up and measuring their infants vitamin D levels to make sure the infant is getting enough. So you can look kind of at three places Homs, vitamin D levels, breast milk levels and infants levels.

Speaker 2: 41:47

There have been a lot of studies on this now. Now I can say a lot. Like five years ago there weren't a lot, now there's been a lot of studies on vitamin D supplementation and breastfeeding. I mean as little as like supplementing with 2,000 to 4,000,. I use a vitamin D will raise vitamin D levels and breast milk and infant vitamin D levels. But optimal is arguably a supplement of 6,400 IUs. It's 6,400 because they were doing like 400 at the time.

Speaker 2: 42:17

That was the RDA and then they added various levels of supplementation, the highest of which was 6,000.

Speaker 2: 42:23

So you add the 6,000 on top of the RDA already provided and that 6,400 IU level daily intake by breastfeeding mothers was enough to maintain mothers serum levels, breast milk levels and also infant levels, and that could essentially take the place of supplementing an infant alone with a vitamin D supplement, which, when you're a new mom it's really hard to remember to do all of these things and supplement your baby separately.

Speaker 2: 43:00

If you're already nursing them at the breast and you need to make sure you have your vitamin D levels up as well, you may as well. Again, it's another one of those two birds with one stone situation Like I need vitamin D, baby needs vitamin D, baby needs to eat. Okay, well, just mom supplements and then you can know that the milk levels are enough, and I will also add that it actually didn't even matter what the women's vitamin D circulating vitamin D levels were like 25 hydroxyd. It's the vitamin D3 specifically that is transferred through the breast milk. So as long as the mom was taking 6,400, even if she was starting from a completely deficient place, her baby was still getting enough vitamin D. It's the D3 that specifically transfers through the breast milk.

Speaker 1: 43:52

Well, that's a quite a considerable daily intake and if people think of the capsules, I mean, usually they're 1,000 IU, so that's almost 6 and a half capsules of vitamin D if we're exclusively supplementing with a dietary supplement. So it's a decent amount of vitamin D. It also makes me think of another way of making sure we're hitting that minimum, and there's a fantastic app called D-Minder and that basically plugs in all the data that you mentioned, lily, with regard to Fitzpatrick, skin type and latitude, and it basically gives you an exact amount of time in that UVB window to expose your skin in order to generate a certain amount of UV light. So that might be a really good option for women who want to make sure that they're giving their baby sufficient vitamin D, and obviously not suggesting that avoid supplement baby if that's the situation that you live in and you can't generate a lot, but it's a good option. It's a really.

Speaker 1: 44:53

Also, lily, it's a good segue into what I've been investigating lately, which is more circadian health, and before I jumped on, I did a little bit of research and I found out that breast milk is exhibits a circadian diet diurnal variation in the nutrients that it is being secreted into the milk, with things like antibodies, more likely to be secreted during daytime, and then at midnight you get leptin, obviously melatonin, and then early in the morning, 6 am quarter so and tyrosine come in and the implication of this paper, which is called human milk as chronic nutrition implications for child health and development.

Speaker 1: 45:34

It basically is implying that this is a really important way that baby is getting circadian in treatment. So obviously light is the primary zytegiber but food is a secondary zytegiber and in industrialized societies babies that are either being fed formula or express milk without regard for the time of day are potentially contributing to circadian mismatch or disruption of their infant, because the milk is supposed to be conveying this time of day message in its secretions. So I mean, I thought that was absolutely fantastically interesting. Again, I mean not to put even more pressure on women, but it just goes to show that breast milk timing not only the content of the nutrients but timing is also going to contribute to optimal health of your baby.

Speaker 2: 46:24

Yeah, yeah. And ironically, the only way to actually reasonably achieve that as a mom is to go back to the ancestral practice, which is to co-sleep with your babies and breastfeed them on demand overnight. And there's actually a researcher, dr James McKenna. He has a book called Safe Infant Sleep, because now you're going to get a bunch of people complaining about co-sleeping and anyways, he actually coined the term breast sleeping because he studied mother infant pairs who are breastfeeding and essentially the mom can oftentimes be at least partially asleep and nursing her baby. And he just followed their whole dance over the course of the night.

Speaker 2: 47:18

And yeah, it's not to say that it's easy. I have two children. They're four and seven, so we're beyond the breastfeeding years, but I did breastfeed them both for several years and we did co-sleep as a means of survival. Actually, you can actually get pretty great quality sleep. That's I think. In my opinion, unless you go some very drastic measures that I won't get into the controversy on, you can both get pretty good quality sleep by doing it. It's just your partner might not be able to fit in the bed or there's disruptions, there's interruptions in the middle of the night. It's easier some periods than others, but as they get older and are nursing less, it certainly is easier. But it's just funny to me that we can have all these discussions about the importance of setting circadian rhythms and how these hormone levels in milk are changing over the course of the day and ultimately the practical implications of this are that mother and baby, ancestrally, would have been together essentially 24-7 for the first several years.

Speaker 2: 48:37

And our modern industrial societies and mothers going back to work so easy, so quickly, needing to have dual family income often the incredible training, incredible pressure put on new mothers to sleep train because if you don't teach your children this valuable skill, they will never learn to sleep, which is a lie All of this ends up separating you even more from the very things that are going to help your child develop a normal circadian rhythm.

Speaker 2: 49:11

We've just gone so far from nature in just about every possible way, so I don't mean to go on a giant rant with that and open you up to all the commentary from various people with different parenting and sleeping perspectives with babies, but it's absolutely fascinating when you think about it.

Speaker 2: 49:32

What you might be trading to get a little more uninterrupted sleep may actually be contributing to your baby being more wakeful by consuming expressed breast milk that was expressed at six in the morning and is a high cortisol milk versus milk that was expressed at a different time of day. And I do know mothers who have exclusively pumped and they'll even label their pumped breast milk with the time of day so they can try to time it at the right time. That gets to a whole another level of complexity. My hat is off to anybody who can pull that sort of stuff off. But it's really fascinating area of research. Even the melatonin levels changed dramatically during pregnancy as well, increasing pretty significantly over the course of pregnancy, and then they plummet pretty close back to baseline at the end of pregnancy. So there's a lot going on hormonally with setting up circadian rhythms the whole time.

Speaker 1: 50:36

Yeah, and it's a very much an area of interest for me and I really think that circadian entrainment and this idea of having a regulated circadian rhythm is so critical because it actually influences our epigenetic expression. It can obviously, as we talked about, influence cortisol levels, which I believe there is some data about that in terms of temperament later on. So I mean, everything that we want to be doing is in terms of optimizing it. The health of mom and baby is to preserve that circadian rhythm. And also I've anecdotally had patients whose breast milk quantity has been better when they have made some circadian interventions, like blocking blue light, seeing the sunrise, and the actual secretion of breast milk is more consistent when they're doing those circadian type interventions. And to me that makes sense because the eye signal basically the eye is this neuroendocrine organ and the light signals are regulating the hypothalamic, pituitary, gonadal access. And it makes sense that breast milk is obviously another one of those factors that could be very much influenced by our circadian rhythm.

Speaker 1: 51:54

The other quick point I wanted to make and we were talking about getting enough vitamin D and I think I don't know if you were able to, but if you breastfeed outside, to me that makes so much sense because not only will baby be getting maybe a little bit of sun to help with its vitamin D production, but you're also helping set the circadian rhythm with a light on baby. And I did a really interesting podcast with a gent called Scott Zimmerman and he basically made the discovery that when we're outside near infrared light it's basically bathing every single cell of baby's body because it can penetrate up to 10 centimeters through the skin and that is generating melatonin in the mitochondria of every single one of their cells. So another reason to kind of get outside is as much as possible as practical for women.

Speaker 2: 52:41

Yeah, and it just feels good. So if it's a warm time of year and you can get out there I mean, even if it's cold bundle up and get out there. You won't get the vitamin D maybe, but you'll at least get that UV rays for your circadian rhythm, clearly. I'm also on the same page. I'm a big fan of getting outside earlier in the day, keeping the blue light minimal in the evening. You could just feel the difference if you go camping, for example, like it's so much easier to fall asleep. And then you kind of sometimes slip into that what do they call it? Where your sleep is like kind of split in two. You go to sleep earlier, but you're kind of wakeful in the very middle of the night, which might be a time where people traditionally like tended the fire or protected the camp from large predator animals or whatever, and then like another second time of sleep. Like I noticed, sometimes my sleep cycles will shift to that when camping. It's just very interesting.

Speaker 1: 53:43

It's fascinating, and do you have a hard stop at an hour or you got a bit more?

Speaker 2: 53:49

time. I had to go down for an hour and a half, so we can go until noon.

Speaker 1: 53:52

Okay, fantastic, because I really wanted to cover a couple more topics before we talk about your book and the maybe a next topic. I guess we're really going from pregnancy to breastfeeding. Another topic that really comes up is postpartum depression, and it's very difficult topic because a lady, a woman of family, has just gone through nine months of extreme change physically, emotionally, logistically with their life, and then to have a beautiful baby and then to suffer from something like postpartum depression is can be very difficult. So what is your opinion or what do you know or can tell us about nutrition and postpartum depression?

Speaker 2: 54:40

Yeah, I think obviously it's a multifaceted situation, as you alluded to, where there's just a lot of changes in a relatively small period of time. As well as your experience, postpartum can definitely be colored by your level of support from the people immediately around you, your experience at birth, whether you were treated well or not, or things went as planned or whatever any separation from the baby or just severe physical trauma or outright abuse. There's just so much going on. Nutrition, I do believe, plays a major factor and there have now been studies that have looked back even into nutrient intake and status during pregnancy and whether that impacts risk of postpartum depression. For a variety of nutrients it does appear that there is some risk.

Speaker 2: 55:42

Generally speaking, the things that are brain supportive nutrients for any stage of life tend to carry over and have benefits for postpartum as well. We've talked a lot about vitamin D and DHA today and B12. We haven't touched on iron too much, but that's another one. Many of these nutrients are also beneficial to postpartum brain health as well. Another major factor that I think is often overlooked is blood sugar levels and sufficient protein intake. I think anybody who's paid attention if you've gone through periods of time where you haven't eaten enough protein or somehow eating in a way where your blood sugar is just super imbalanced and all over the place like high carbohydrate, low protein diet. You've probably felt the mental effects of those significant blood sugar swings. There's anxiety, there's almost like this insane state of urgency where you have to eat right away. Your mental health suffers. You don't feel grounded when you're eating that way. Pregnant time is really tricky because from a day-to-day perspective, what's possible? You can't really be all that mobile and all that on top of preparing food and being on your feet in the way that you were before. You can. It's not necessarily advised. Most cultures have a built-in six-week, more consistent rest and support for a new mom and your food is cooked for you and provided to you, sometimes fed to you while you're nursing the baby. If you don't have that kind of a support network, what is the easiest thing to grab and go when you're doing 24-7, can't even barely set down the baby for five minutes infant care? It's going to be the grab-and-go step from the pantry, which is mostly carbs. You're going to be in this blood sugar roller coaster situation all over again.

Speaker 2: 57:55

Getting enough protein is so crucial. The protein-rich foods are also your most nutrient-dense foods. A lot of the nutrients we're talking about that are brain supportive nutrients are in those protein-rich foods. For a variety of reasons, protein checks all the boxes, but protein intake postpartum actually needs to be as high or higher than a typical female athlete. We actually finally have data on this, because there was no very strong guidance on protein intake postpartum.

Speaker 2: 58:33

They looked at women who are three to six months postpartum exclusively breastfeeding. This doesn't even consider zero to three months postpartum, which I would argue the needs are probably higher. They found that these women needed 1.7 to 1.9 grams per kilogram of protein per day. That was an estimated average requirement. If you're to make an RDA out of this, it's probably a gram of protein per pound of body weight equivalent, like I said, more than a typical female athlete.

Speaker 2: 59:06

You will be so hungry postpartum that you will want to eat that amount of protein too. If you don't, you'll be absolutely ravenously hungry and eating all the carbs out of your pantry as quickly as possible because you're just so famished. You're burning so much energy producing breast milk every day, and not to mention all the recovery that needs to go down post birth as well. I think a big one is if we get our protein dialed in and our blood sugar level stabilized. That also increases our micronutrient intake. I think that, honestly, should be some of the biggest first line nutritional intervention for postpartum, regardless of there's preexisting or newly developed mental health concerns going on. But I don't think you can skip over it. I don't know how you could maintain any semblance of balance and normalcy without getting the protein.

Speaker 2: 1:00:08

I can attest that I was pretty blindsided by how much food you actually need postpartum. With my first I mean, I was eating pretty well, but I just had to ramp up the intake way more than I was expecting. The second time around, I was prepared for that. I had the food pre-made or the recipes outsourced or the meal train or whatever. The experience of postpartum even though I wouldn't say either time I had a significant mental health concern, but I just personally felt so much more grounded and balanced.

Speaker 2: 1:00:41

Okay, I can do this just by making sure I checked proper nourishment off the box. I get that feedback constantly in my messages and emails from people Like wow, I can really feel the difference on my mental well-being, my energy levels, my feeling of whether or not I can get through this difficult day just by making sure I'm nourished, but that takes support. You can't do it alone. That's the big kicker, that's the other part. That's so big for the challenges with mental health concerns is having an unsupportive partner or unsupportive community. Just not having enough support period is probably one of the biggest factors of all for postpartum mental health concerns.

Speaker 1: 1:01:36

Yeah, great points. The causes and the solutions are multifactorial. It's really just one thing. We talked about carbohydrate intake on our first podcast and I really encourage any listeners to go back and listen about what we discussed on that. And it's interesting because you mentioned that there is no minimum carbohydrate intake that you've seen based on the evidence and based on people, on women's responses during pregnancy, and it goes to this idea of very low carbohydrate diets and I have seen some women even do a zero carbohydrate diet in pregnancy and breastfeeding and it's not necessarily something that I'll recommend. I don't necessarily recommend people do this and I think that they really need to listen to their body when they're pregnant, and if that means ingesting local sources of whole food carbohydrates, then I'm all for that. But I guess my question and this is a little bit of an aside from our topic about mental health was have you seen any minimums for carbohydrate intake in breastfeeding and do you see any women's breast supply, milk supply, taper off if they don't include a certain amount of carbs?

Speaker 2: 1:02:55

So what? I think this is complicated because what I have often seen for women who are complaining of their supply dipping if they're not getting enough carbs is a lot of these women are kind of going on some sort of a crash diet with the goals of dropping the baby weight as quickly as possible, and so when I see dramatic shifts to like their macronutrient or calorie intake over a short period of time, that I do see impacting supply. So if you say you're eating like a tuner 50 gram of carbohydrate a day diet and then you're like I'm going to go keto, you like cut, you know, more than 200 grams worth out of your diet overnight, as your insulin levels drop, you're also losing significant amounts of fluids from your system. There's a lot of things that need to like reorient. Here you're going to see a dip in your supply. You also need to dramatically ramp up your electrolyte intake as you're going through that shift. So for women who are not fat adapted already and they go through a dramatic decrease in carbohydrates and or calories over a short period of time, I do see that negatively affecting supply. At the same time, I know women who have long been fat adapted or fairly low carb eaters and they don't have this issue again, I think, because their physiology is used to it, so it's not going through that sort of transition phase. They're usually also pretty aware that they need to up the electrolytes. You know, when you're low carb, you're actually like losing more electrolytes than somebody who's not low carb, so you need to be even more diligent about getting enough, and you're spilling out a lot of electrolytes in your breast milk as well, so you really want to be, you know, replacing those electrolytes.

Speaker 2: 1:05:06

Certainly, while you're doing that, I typically although there's no, I don't know that there's like a standalone recommendation, but just because breastfeeding is such a high energy intensive process, I don't typically advise that people go keto unless they're like happily keto already. They're already fat adapted, they don't want to change anything. That's fine. But I typically don't recommend people cut beyond like below 50 grams of carbohydrates per day, and even that is probably like pretty on the low side. You're burning so much energy Like carbohydrates are kind of like the least of my concern to like completely cut out of your diet or to cut way back on. I focus my efforts more so on getting enough food and getting enough protein and, by default, protein comes with fats you're getting enough fat and protein for like sustenance and blood sugar balance, and the carbohydrates are just like hanging out on the side, like you find a level that works for you.

Speaker 2: 1:06:18

I think there's a lot of individual variation from what I've observed. I have some women who are like I cut back at the carbs and my supply tanked no matter how many electrolytes I consumed, and then others where it makes literally no difference at all and breast milk is a hard thing to measure unless you're like exclusively pumping. Where you're like measuring exact output, you don't really know how much baby is eating at any given meal. Plus, they respond better at the breast than the pump responds, so they may be getting. Even if you do pump occasionally and your output is a little bit lower, your baby may have been getting plenty right at the breast, right? It's like it's so hard to measure because you're not actively seeing it beyond. Like is your baby like growing and going to the bathroom the appropriate number of times per day for their age, and so it's really really tricky. Yeah.

Speaker 1: 1:07:22

Yeah, look, that's a great advice, silly, and I really echo that which is producing breastfeeding and producing that high quality milk in adequate amounts, quantities and supply is the goal, and it's not necessarily the time to go on radical you know shreds to get back to a pre-pregnancy weight. So I think that's really appropriate advice and common sense. And it's another call to really get your metabolic health sorted before we go into the pregnancy, because if someone is metabolically flexible, they're really metabolically healthy prior to conceiving. Then one they're going to be able to safely will they going to have a healthy pregnancy because they're eating lots of animal foods, lots of animal fat. They're not going to have problems with gestational diabetes because they're not eating bucket loads of carbs and then, finally, they're probably not going to be putting on a massive amount of weight and that is not going to come off because, again, they're not. They're not having a high carb or a low quality diet. So maybe that's just another reason to sort things out before they get pregnant.

Speaker 2: 1:08:32

Yeah, for sure. And any amount of time improving your metabolic health ahead of time pays you back in dividends for forever really, and your children too, because you know the mitochondria your children inherit is 100% maternal mitochondria. The sperm mitochondria is destroyed post fertilization, so your children's metabolic health is really a reflection of mom's mitochondrial health.

Speaker 1: 1:09:02

Yeah, great, great point. And the mitochondrial hetero plasma. You know that rate of mitochondrial DNA mutation is going to be inherited from the mom, so very, very good reasons to for mom to have a health in order. Circling back to postpartum depression and eye and efficiency, and I think eye and efficiency is one of the most common deficiencies in pregnancy and incredibly common and you know it's very often to see women you know needing or coming in and you know failing oral iron replacement, becoming anemic, needing, you know, infusions late in pregnancy. What is your kind of overall approach to someone who develops eye and efficiency in their pregnancy?

Speaker 2: 1:09:48

Oh, iron is like a can of worms. It's a can of worms nutrient. They've been studying iron. It's probably one of our best studied nutrients, certainly in like the top five, and there's still extreme and active debate over the best way to test for iron deficiency, when to implement treatment, what treatment to implement. It's very interesting, I will say.

Speaker 2: 1:10:22

I think when you're assessing iron, you know you've got to look at more than just one factor. We not only need to look at you know, a CBC which has your hemoglobin hematocrit. We should also, at the very least, be looking at ferritin and maybe a few other markers as well. Then we need to consider just physiologically how those laboratory values shift at different stages of pregnancy, because I do see some practitioners sort of freaking out over what they think as iron deficiency, when it's really just there's a natural hemodilution at different stages of pregnancy and you're shifting more of your iron stores out of storage to transfer them to the baby. So you do actually naturally see a decline in ferritin over the course of pregnancy, which I'm not necessarily particularly concerned about if they're hemoglobin hematocrit, are in a good place and they're not complaining of any of the symptoms we typically associate with anemia, like being extremely tired or weak or so you know. That's why I say it's a little bit complicated. That said, I think we do have an issue of not not only just like iron intake from like bio available food sources, which matters immensely and I do have a blog article on how much iron you absorb from food and like all these different graphics showing like relative concentrations of iron you're getting from, like certain animal foods versus certain plant foods, for example it's a can make a substantial difference but also the cofactors for iron metabolism as well.

Speaker 2: 1:12:07

I think we get very zeroed in on iron but if you look at you know the process of creating red blood cells, for example, and it requires a heck of a lot more than just iron.

Speaker 2: 1:12:18

Like we focus on the iron, but like iron alone, especially in some you know not super bio available forms, is not as effective at treating anemia as combining that iron with retinol, vitamin A, vitamin B12, folate glycine, like all these other nutrients that work in tandem for red blood cell production.

Speaker 2: 1:12:42

So it does kind of bug me that people get really siloed on the iron part and then miss, like the bigger picture. Oftentimes we can actually prevent the need for iron replacement therapy whatsoever with building nutrient stores, preconception via nutrient dense foods so liver, organ meats, shellfish like oysters and clams, very high in bio, available iron and many of these cofactors that oftentimes, like the body does a better job of like recycling its iron stores, maintaining red blood cell production at a good place, even with all the crazy human better your body can better adapt to the changes that it's under, that it's going to undergo later in pregnancy, without it becoming an emergency situation where, oh my gosh, now we need to do an iron transfusion because your ferritin is like in the single digits and if you have hemorrhage, like postpartum, like you're done for it right, like we don't have to get to that kind of emergency level, so to speak.

Speaker 1: 1:14:00

Yeah, and when you, when you listed all those cofactors off in terms of optimally optimal ingredients to make red blood cells, I immediately thought of liver, in terms of the food that contains everything in and probably spleen as well. So maybe I know this is a topic that you get to, that you get asked about a lot on podcasts Maybe if you could give us an idea about what, what is the safe? What is the safe level of liver consumption during pregnancy, because it is something that most women avoid completely.

Speaker 2: 1:14:33

Yeah, I actually ended up writing like a follow up blog article because my section on liver and real food for pregnancy wasn't specific enough for some people. On on the amounts, I think I said a few ounces of liver once or twice a week. Well, what does that mean? It's like, okay, three to six ounces a week. We clear.

Speaker 2: 1:14:57

Yeah, I have a whole article going through all these various concerns and you know rebuttals to liver consumption and pregnancy.

Speaker 2: 1:15:10

The primary concern is that there is a possibility for consuming excess vitamin A and those concerns, in my opinion, have been largely overblown and based primarily off of studies that use synthetic vitamin A and high doses.

Speaker 2: 1:15:26

But even still, if we assume the upper limit for vitamin A of no more than 10,000 I use during pregnancy per day is accurate, eating three to six ounces of you know, whether it's chicken or cow liver three to six ounces per week still stays well below the upper limit intake. When you spread that out over daily intake over seven days and your body can indeed take in a larger portion of vitamin A and one sitting and it's still fine Like 25,000 I use in a single sitting by government nutrition guidelines standards is still like okay, assuming that's not happening every single day. Right, but like that 10,000 I use per day, no more than that. You can very safely stay within that level of intake, at three to six ounces of liver per week, without any concern of vitamin A excess, and by doing so you're vastly improving your nutrient intake, for not only the vitamin A, but vitamin B12, folate, choline, iron, copper, riboflavin, vitamin B6, I mean, you name it selenium, it's in liver, so it's a, in my opinion, a really wise practice. To you know, fortify your diet with.

Speaker 1: 1:17:01

Yeah, and that's a great approach because even assuming that this 10,000 unit limit is what we shouldn't exceed and I believe that was that limit was established based on a study that looked at fetal malformation or congenital abnormalities in babies of women who are supplementing synthetic vitamin A so retinol and then they looked at what was the point at which the curve started accelerating and that they came to that position. So even if we're assuming that that 10,000 unit per day is what we should be targeting, we can keep under that with that amount of liver that you suggested. The other nuance is, lily. We're advocating for ruminant liver, grass-fed ruminant liver or chicken liver. We're not advising against. We're not advising that people eat carnival liver or a wild caught polar bear liver. So I think that's the other nuance that I guess almost needs to be said to racial people.

Speaker 2: 1:18:00

Yeah, right, some of the concerns over liver was like Arctic explorers consuming polar bear liver and polar bear liver yeah, being an apex predator and eating quite a bit of seafood. You think about cod liver being a significant source of vitamin A? Yeah, you eat enough cods in their livers or other fish and their livers. You have incredible amounts of vitamin A. I can't remember the exact quantity, but it was something like over a million I use of vitamin A per 100 grams in polar bear liver. It's insane versus maybe a few thousand in ruminant or chicken liver for that same quantity. So, yeah, we're not talking about eating polar bear liver.

Speaker 1: 1:18:54

No, no, and I think the reason is because it is highly fat soluble and it highly bio accumulates up the food chain. So you can imagine a polar bear eating all these fatty fish and every other carnivorous animal that it's going to bio accumulate in its tissues. So that makes sense to me. A lot of women like consuming liver capsules, so do you have any kind of opinion about desiccated liver in capsule form in terms of what we've just talked about?

Speaker 2: 1:19:24

Yeah, I think it's a good option for people who can't get the real thing down or can't find it. You know, sometimes it's easier to source in different areas than others. So I would say I think the bigger challenge with desiccated liver is what is the appropriate portion size? That's equivalent to about three to six ounces per week of fresh liver. So see if the manufacturer can give you kind of a guesstimate how many capsules is equivalent to one ounce of fresh liver, and then you can kind of work backwards to do the math. Because while it's rare for me to have clients say they're eating liver every single day or like they're getting too much, I have seen people go a little hog wild with the organ supplements or I'm like I'm not sure you need to have quite that much, you know like every single day. Plus then they're putting like in a high dose and then they're putting like liver powder in their smoothies and they're taking a you know, comprehensive prenatal that already has preformed retinol and so you're getting like that plus all the. I'm like that that might actually be too much. Like you might be fine. Just like backing off a little like across the board, like just because a little bit of something is good doesn't mean a lot of it is better. So that's the one area where I would just have you kind of cross check Again, like the like I said with the vitamin A concerns.

Speaker 2: 1:21:12

I'm not going super deep into the weeds here but, like so you mentioned, you know, those studies with the 10,000 IU is potentially being like the inflection point where there's higher rates of birth defects. They have repeated those types of studies. Supplementing with upwards of 30,000 IU is a vitamin per day and some studies only found the higher rate of birth defects when you get above 30,000 IU is a vitamin D, a vitamin A per day, not D, sorry. So you know, I think we have a little bit more wiggle room than we think, but at the end of the day I always want to err on the side of caution and not be, you know, because it does bioaccumulate right.

Speaker 2: 1:21:54

So if you, you know, have been eating liver on and off for years and years, like myself, I'm not really all that concerned if I go a couple of weeks here or there without getting my quota of liver. Somebody who's quite deficient, maybe they've been vegan for a long time, like they might have some pretty significant repletion to do. They might be okay having a slightly higher intake and a more regular intake than somebody like myself who's been like eating this way for, you know, more than two decades at this point. So I'm not all that concerned if I, like you know, I'm not staying up on my regular liver consumption, but somebody else who's pretty deficient. They might need to be a little more diligent on that front.

Speaker 1: 1:22:43

Yeah, that's very good advice and I'd echo that. Claim to use common sense and don't go overboard by any means. The final question I wanted to ask you about and this is a continuation of the iron deficiency question was do you have a ferritin limit that you think is acceptable by the end of pregnancy, say by the 36, 38 week mark, if someone's hemoglobin is normal?

Speaker 2: 1:23:12

So this is quite tricky to answer. There's a lot of opinions on the matter in the literature. Typically if ferritin is most by most standards, if ferritin is less than 30, like, they want to intervene with IV iron infusions. That said, if you follow pregnant women who are unsupplemented with iron, like their, their ferritin will often dip down into the teens in late pregnancy and then it recovers postpartum Like. So physiologically it's going to dip down. Even if you supplement with like iron or all iron it's still probably will dip down into the twenties, which again I don't I don't necessarily think is concerning per se, unless there's other signs of anemia going on. So it's hard for me to give like a specific number without kind of looking at the full picture, like what's the full picture of all the labs we're seeing and what's the full picture of all the symptoms. Like I had a woman recently asked me she's in one of my courses Her hemoglobin and hematocrit were normal but her ferritin had dipped to eight in late pregnancy.

Speaker 2: 1:24:37

Now that's a time where I would actually be in favor of an iron infusion because that's really quite low. You start getting kind of concerned just in case there is a hemorrhage. You know the chances of postpartum anemia. If the blood losses are greater than 500 mils at birth, the risk of postpartum anemia is over 15 times higher. When the losses are greater than 1000 mils at birth, the risk of postpartum anemia is 75 times higher. And that's postpartum anemia. We're not talking about, like you know, an immediate life-threatening situation where you need like a blood transfusion right away. We kind of want to minimize those situations. So certainly in the single digits I'm in favor of, you know, an IV iron infusion, generally speaking, regardless of wherever hemoglobin hematocrit is. It's a little up to clinical judgment in my opinion. As you get to ferritin levels that are in the teens and certainly in the 20s, I probably even wouldn't necessarily treat there's like it's tricky because iron is highly reactive kind of oxidizing compound.

Speaker 2: 1:26:00

I mean iron gets wet, it rusts, it like, triggers quite a bit of inflammation. So it's something that we need in like very much Goldilocks amounts and I'm always trying to minimize the need for supplementing overtly with iron and trying to get it where it's already, in like a organically bound form in food with all the cofactors. We could just minimize the need of the immediate sort of emergency interventions as much as possible. And there are, you know we do have concerns over like just oxidative stress kind of reactions and also iron overload. I mean that's also a legitimate concern. So you have, like you have to weigh both, both considerations. So I do. I hate to give a big answer, but I do think it depends immensely on the clinical scenario you're seeing.

Speaker 1: 1:26:58

Yeah, no, I think that's very, very reasonable and there's a reason why the human body partitions iron in this storage kind of protein because it is highly reactive and it is used by various cedrophoric bacteria to metabolize when it causes inflammation. So, yeah, there's a very good reason why we partition iron away. So I think that's great advice. Lily and the the I think that covers iron efficiency and liver really really well. Did you have any final kind of thoughts that about the topics that we've discussed that maybe I haven't asked you about?

Speaker 2: 1:27:41

Gosh, I think we kind of covered everything that I wanted to touch on, aside from having, like, direct research studies right in front of me to site more specific data. I think we covered it.

Speaker 1: 1:27:54

Cool, fantastic. Well, thank you so much. I really enjoyed this conversation and I think people are really going to enjoy the kind of deep dive that we did into breast milk and all these nutrients. So where can people find you? I've obviously include all the blogs that we've referenced in the show notes, but what's the best way for people to follow you?

Speaker 2: 1:28:16

Yeah, you can go to my website, lilinickelsrdncom. I'm also on Instagram same same username, so lilinickelsrdn. Over on my site you can find my large selection of blog articles, many of which we've talked about today. So you can use the search function to put in any key terms like liver, iron or postpartum recovery and find a bunch of articles on those topics. And definitely download the first chapter of real food for pregnancy for free and you can get sort of a feel for what we're talking about when we're talking about real food and nutrient density, as we touched upon a lot today. And, yeah, when my next book comes out, you'll see that on the social media platforms and on my website as well.

Speaker 1: 1:29:13

Yeah, we'll have to do another interview closer to the time that you mentioned is coming out on Valentine's Day next year. So we'll have to do another recording and you can tell we can discuss all about fertility optimization, which is going to be the subject of your book. So thanks again, lily, for your time and for sharing all your knowledge with the listeners.

Speaker 2: 1:29:41

Thank you.