Written by Christopher Kelly
July 28, 2019
[0:00:00]
Christopher: Well, Lily, thank you so much for joining us this morning. We very much appreciate you making the time, especially as you're so close to having your next baby. Tell us about that. How's it been going? How's your pregnancy been going?
Lily: Luckily, my pregnancy is uneventful, so no complications or anything. It's just the usual tiring saga that pregnancy is that simultaneously goes really fast and really slow. So just hanging in there for the final stretch and literal stretch and expansion that happens at the end here. But yeah, we're looking forward to another addition.
And all my sites are on postpartum recovery this round. I think everybody does that, the second, third, fourth, whatever round you're on because you do a lot more meal prep and prepping for the real event, which is after birth. That's what I'm doing.
Christopher: And that's what we're going to be talking about today. And with me, I have a real postpartum woman.
Julia: Alive and in person. Yeah.
Christopher: Yeah. Alive and in person, which I thought was important because –
Julia: You are not a postpartum woman?
Christopher: Yeah. I have imposter syndrome at the best of times. Never is it stronger than now. And I think it's an important and underdiscussed topic. You hear lots of people talking about the importance of getting yourself in good shape to conceive and pregnancy and childbirth, but you don't really hear a lot of people talking about what happens after that, right?
Lily: Yeah. And all of those things are all well and good. They set you up for a better postpartum recovery coming into pregnancy with better nutrient stores. And maybe aside from the nausea, food aversion phase, generally eating more nutrient-dense real foods, like that sets you up for positive pregnancy experience or positive birth experience and an easier recovery. But your work isn't done. There is so much that means healing and repairing postpartum. And now, your time is stretched thin caring for a baby.
So it's a lot to think about. And I think it's important that we make this conversation more the norm because in many other cultures and centuries passed, the mom didn't really need to think too much about it. She didn't need to do a whole lot of prep because it was built in to all these cultural traditions of caring for new mothers. And now, we have to take the torch for ourselves and do almost extra work upfront, it seems like, to prepare for a support in postpartum.
Christopher: This is the part that makes me the saddest, if I'm honest. There's all these problems that we find. And most of them are environmental mismatches, right? This is the difference between the inputs your genes were expecting and what is happening in reality. And most things are fixable. For example, there's no problem getting outside first thing in the morning to get some bright light and it's not that hard to avoid artificial light at night. However, having a village to take care of your baby is not as easy a problem to solve.
Julia: No, it's a really hard problem. I mean Chris thought I was absolutely have lost my mind during my last pregnancy with our son because I just went into this hyperactive state almost the whole pregnancy where I just felt like the world was literally going to end after I gave birth because I knew that I had this other four year old to take care of and I was going to have this infant. And I knew how hard it was the first time around and it's on my mind. It just multiplied that by a factor of probably a hundred.
So I did a lot of things that were really out of character for me. I found myself reaching out to almost perfect strangers, like acquaintances from [0:03:39] [Indiscernible] moms who I had only just met on the periphery and saying, “Hey, I'm having this baby. Can I write you down as an emergency contact for my daughter if something goes wrong to birth? Would you mind bring me some ingredients over so I can make some meals out of [0:03:56] [Indiscernible]? Do you want to be part of my like group?” and just really trying to overprepare. And I think I redid the entire house, but I just felt this real urgency to take care of all of these things because I didn't know how else I was going to survive.
Lily: Oh yeah. I can completely relate to that. Last round, I was lucky that I had some friends who arranged a Meal Train for me. And I had people from the community that I didn't even know dropping off meals for weeks. And this time around, we're in a different place with not as tight knit of a community. And that won't be the case. That's not going to happen.
Around 20 weeks, I made a -- it's not like a spreadsheet because I'm not that organized, but I made a list on my fridge with the dates of each week to remind me to put something in the freezer for postpartum meal. And this round -- and I haven't stuck to that perfectly, but I've tried. I try to make double batches of things and freeze half for example. And this time, I invited my mom up for a whole month or longer. “Hey, stay as long as you want. Like my house is your house.”
So yeah, there's a lot more prep going into it this time than last time. You're so focused on the birth. It's just, “Oh, we have to have the good birth experience, have to have the good birth experience.” And this time, I'm like, “Yeah, the birth is going to be fine.” That's not my concern. I want to make sure I'm supported after the fact because that's when it gets real.
[0:05:27]
Julia: My friend hired a postpartum doula this time around for her second. We delivered around the same time. And I was so jealous. I wish I had done because it was just so incredible to see all the things that she had done for her. But yeah, you've got to do the prep.
We see that. We can talk about that because we've been through it or you're going through it right now. I'm really thinking about first time moms who I think aren't prepared for this at all. I mean I don't –
Christopher: They don't even know it's coming. They don't know what they don't know.
Julia: They don't even know what’s coming. What kind of impact does that have on them going into that process when they don't even see it coming, so they're sideswiped by it? What have you seen as you're researching all of this stuff and working with people on the nutrition side? How have you seen that come into play?
Lily: I think we need to normalize that postpartum recovery is not a one week, two weeks, six weeks thing. First of all, what's hard is that I think the way in which people approach trying to prepare other parents or new parents for what's coming is these “just you wait” comments and then horror stories. And that's not helpful. That was really frustrating to me my first time. It's actually still frustrating to me this time around. “I know what's coming. You don't have to warn me about Armageddon here.” I’m like, “My expectations are real low this time.”
But I think that if we had an -- actually the data shows this when they've done qualitative research studies interviewing new mothers. It’s that they wish there was a more open and honest discussion about what's ahead, what to expect for recovery, how much time you might want to take off from work, which in the US, unfortunately, we don't have paid mandatory maternity leave, like at least nationwide mandated maternity leave. So that's a tricky one for people.
We don't talk about how long it takes the pelvic floor to recover and return to normal function. So I think people have expectations that you go to a six week checkup and as long as everything's looking okay, you're cleared for all the normal things, but it's not full on pelvic floor assessment like you might get from a women's health PT. And really, the full recovery takes at least a year for the pelvic floor to return to normal functions.
I think we have people jumping into activities maybe that are a little too intense for where they are in their recovery too soon. Then I don't think we talk about the nutritional demands of recovering from pregnancy and childbirth as well as supporting mothers’ breast milk production and the nutrient transfer into breast milk. So we just like -- there's so much emphasis on this prenatal nutrition aspect. Then there's not a whole lot of emphasis on like -- this still matters now. And actually your nutrient needs and calorie needs are higher while you're recovering.
The challenges, like trying to communicate that to people ahead of time. And the best that I've found is having open and honest discussions. I think it does need to make its way into birth and healthcare providers, discussions with clients during pregnancy. For me, I put a whole chapter in real food for pregnancy on postpartum recovery in the fourth trimester because I knew I didn't pick up any books on postpartum nutrition when I was pregnant. But if it was in a prenatal book that I had been reading, I would have been better prepared.
And I was in a fortunate position that I had had six friends who had had babies within the last 18 months who lived locally to me at the time. So I actually was prepared for the slowdown that was ahead of me and the shift in my schedule and expectations and what I could accomplish and all of that. But I had unrealistic expectations on the physical recovery because I just saw so many people “bounce back.”
And physically on the outside, it looked like I had bounced back. But you're really nutrient depleted for quite a long time. Your adrenals are taxed, like everything. All of your connective tissue takes so long to recover. That's the part where it was like, “All right. I was prepared for the mental challenges ahead and the adjustment to my schedule and workload. I was not prepared for how long the physical recovery would take because I figured I was so healthy going into pregnancy and had such an easy pregnancy and a relatively non-eventful birth. All is good. I should be good to go at six weeks.”
Then you're like, “Wait, I still don't feel like myself again.” And that's A, normal; B, okay; and C, we still need to focus on our nutrition so we can support this normal, long, slow recovery process that's ahead.
[0:10:20]
Christopher: Can you talk about some of the appropriate activities for postpartum? You mentioned that the pelvic floor takes time to recover. Can you talk more about that? It's really interesting to look at this through that evolutionary health lens or it takes a village, like what would women have been doing 300,000 years ago postpartum? Maybe 300,000 is a little bit too long. It's not that far. So humans were anatomically the same 300,000 years ago. It's hard to get your head around that.
And humans were controlling fire 1.5 million years ago. All this stuff is really, really new. So what would have happened? And what is appropriate for somebody that's trying to recover their pelvic floor?
Lily: Well, first of all, I think it's important to bring up that we have been removed from our traditional ancestral environment. So we aren't moving in all the ways at the same duration and intensity that we once did. So maybe our bodies are less prepared for birth.
And I think Katy Bowman makes that point quite well in her work. And I attended her pregnancy workshop last year, which was really –
Christopher: Oh wow. I didn't know she was doing those.
Lily: Yeah. Well, it’s the first one that she ever did. She's doing another one this year as well. But her perspective, which is very different from a lot of what you hear from women's health physical therapist is it's really like recoveries aren't happening as well as they once were because the strength of our pelvic floor and adaptability of our pelvic floor has not been adapted. It’s not adapted in the way that it used to be when we were doing this long duration movement, so much squatting just for gathering your food and making your food and cooking your food and going to the bathroom. All of these things, our bodies have adapted differently, I think, was her point.
So I think that's worth noting that there is definitely going to be some degree of difference in how people “bounce back” if there is such a thing or recover physically from birth depending on how active they are. I mean arguably, I was very active previously and during my pregnancy in the ways that probably were more ancestral to move, meaning most of my movement was hiking. I was living in Alaska at the time, so there's not much to do but hike, right? So I was out hiking quite a bit and was really in pretty good physical shape.
But in terms of how quickly you're going to recover and what's appropriate at which stages, I mean really, the first six weeks or so, if we look at what a lot of cultures, -- at least in our modern data that we have, so probably going back a couple hundred years -- there was usually a period of about 40 days or six weeks where they encouraged more rest and more recovery and less intense physical activities.
So lying in for a week was pretty normal in a lot of different places across the globe. And that's really important for the initial healing of any tearing or anything. Then after that, it was a gradual return to activities. In some cultures, they actually wanted you to stay indoors and not do anything outside during those 40 days or during the first month or so. Then gradually, your duties would expand beyond that.
But of course, we have to think if we're really thinking ancestrally. I mean you had your infant with you usually a lot. So that would impact the types of movement that you would be doing and even how you were carrying your baby. There was probably a lot more carrying in arms and less so relying on structured carriers where you held your baby in one fixed position at all times. You would shift the weight. And that develops your musculature and return to movement differently as well.
But from a modern perspective, usually, the recommendation is up to six weeks, keep it really light, so gentle walking and then just pelvic floor and transversus abdominis activation to try to help your diastasis regain your integrity of your core and pelvic girdle and everything.
Then once you've been cleared for movement, that's where it gets really wonky, I guess I'll just say, because you're not necessarily given really detailed information unless you get an assessment with the pelvic floor or Women's Health Physical Therapist. In which case, they can actually assess the healing of your pelvic floor, of your diastasis, of your abdominal muscles separated, which for most people they do. That's a normal part of pregnancy. Then they can assess what level of intensity might be appropriate based on where you are in your healing process.
So beyond six weeks, it's extremely variable on what people can handle. I think some people are really well adapted to go back to movement pretty quickly. And probably, the vast majority on the other hand are much better doing that gradual return to movement with more of a focus on low intensity walking and just getting used to engaging and relaxing their pelvic floor and maintaining core stability with proper engagement of their abdominal muscles.
[0:15:29]
Julia: And obviously, we can't separate this from the fact that your vast majority is also extremely nutrient depleted. So how does that nutrient depletion play into that ability to regain that strength even slowly?
Lily: Yeah. Actually, I love that question because I think people are usually looking at the nutrition thing and the movement thing as separate items. Because you have the physical therapists and exercise specialists and whatever who are focused solely on the movement. Then they have the nutrition people focused solely on nutrients and thinking of serum levels of nutrients and things like that.
But yeah, our connective tissue has to undergo a ton of remodeling in the postpartum time, so it's especially reliant on the nutrients that make up your connective tissue, all the amino acids in there. So your glycine, proline, hydroxyproline, the things that make up collagen, that all needs to remodel.
I mean you've had nine months where your joints and ligaments have been carrying more weight. A lot of your ligaments have actually stretched. You think about the round ligament. I mean that stretches significantly. The uterus grows to the size of a watermelon, so that contains 800% more collagen at term than it does in a non-pregnant state. So that's going to shrink down. You have the stretching of the pelvic floor muscles that happens during birth. If you birth vaginally or if you had a caesarean section, you now have a whole bunch of scar tissue through multiple layers of tissue. And that requires nutrients to heal.
So I think we need to do heavier focus on these collagen enriching nutrients. So really, that's looking at collagenous animal products. That's where you get collagen. So the bone skin, connective tissue of animal foods and/or even supplementing with gelatin or collagen powders, which we can now source from grass fed animals. They even have marine collagen. I think that stuff is really helpful.
And I think this is why you see so much nose to tail influence on a lot of the cultural traditions around postpartum food. There's a ton of emphasis on bone broth and soups and stews made with all of those odd cuts of meat. And pig's feet soup is a classic in the Chinese tradition. In South America, you see a lot of chicken soup made with a whole chicken, so that would -- if you were really harvesting your own chickens, there'd be chicken feet in there. All the skin would be in there, right? You're getting a lot of collagen from that as well.
So I think we do need to think about that. And then the nutrients that support the crosslinking of collagen such as your vitamin C and other nutrients for tissue integrity like zinc, protein, vitamin A, they're all involved in that tissue remodeling happening really early in the postpartum period.
And personally, I've heard from a lot of people who have either eaten a vegan or vegetarian diet in pregnancy and postpartum and then gone on to do different in their next pregnancy and embracing omnivorous real food approach. And I have people that have emailed me about the differences in their postpartum healing.
I had one lady who had been vegetarian. And she had a non-healing perennial tear that required corrective surgery. It was a problem for more than six months. Then with her next birth, she healed super-fast and super well. And she was really emphasizing those collagen rich foods. And that would be something that'd be missing on either a vegetarian or a vegan diet. So I think that's something to consider as well. We don't see vegan postpartum traditions in terms of which foods are emphasized.
Christopher: And of course, these are all great foods that you can batch ahead of time, right? You can stick it all in the freezer so that it's ready for you.
Lily: Soups and Stews, they freeze and defrost and reheat extremely well. Yeah.
Christopher: Talk about entity requirements. Maybe women might be thinking that they need less energy once the babies arrive, but that might not be the case, right?
Lily: Yeah. Actually, your energy needs do increase postpartum, particularly if you're breastfeeding. So what's interesting, just to make this point from the get-go, is we have -- in terms of what our guidelines have set up -- we have guidelines for pregnancy. Then we have guidelines for breastfeeding. But we don't have guidelines for postpartum non-breastfeeding.
So a lot of what I say about postpartum nutrition is going to be at least somewhat influenced by the assumption that you're breastfeeding because that's really what's the heavily, more nutrient requiring process going on. But even for people who choose not to breastfeed or don't breastfeed long-term, we still need to think about replenishing the nutrient stores from pregnancy and also making up for the marathon and/or major abdominal surgery that happened with birth.
[0:20:33]
So I would still say the energy needs would be higher regardless of whether someone's breastfeeding or not. The data on how much it increases is based on breastfeeding women, so I’ll say that. And the assumption is that it's about 500 extra calories per day in order to supply enough for exclusive breast milk feeding of an infant.
That's significant. That's a lot more energy. We're talking about 500 more than preconception needs by the way. So compared to pregnancy, you're only looking at a few hundred extra calories. I would actually argue in the first week or two or three or four, I think you need even more than that. Based on my experience postpartum and what I hear from a lot of clients is like you're just ravenous early on.
I feel like I was eating -- I was out eating with my husband, and he is a big eater. I mean he brought me breakfast like the [0:21:28] [Indiscernible] postpartum. I can't remember. I looked at the plate. It was like a normal amount of food I would have eaten during pregnancy. And I literally laughed out loud. I was like, “I'm going to need two more plates of food.” The size, that is nowhere near enough. I mean just bottom was pit. And that, for me, it's hard to say because everything is awash, right, looking back at those first three months. But I think for me, that lasted at least a good month, the really, really high appetite. And I think a lot of that was about --
Christopher: That was going to be my question. Do women have to think about this consciously or will your appetite just take care of it, right? Is that you're going to have to be like tracking calories and eating beyond your normal hunger or are you almost just going to be really hungry like you were?
Lily: I think you can just trust your mindful eating cues. Your body will take care of it. I think the problem is that so many people don't trust those cues. And they think that it's excessive. And they feel pressure to lose the baby weight or bounce back or, “I shouldn't need to eat this much because I'm no longer growing a baby.”
Christopher: I see.
Lily: If you're nursing, you're still growing a baby. Even if you're not nursing, you still got to recover from birth. I mean either surgery or a marathon, come on, you've got to replenish.
Julia: Yeah. That was my question because I don't think I've heard anybody talk about this. And I don't think anybody considers it like what kind of labor you had and delivery because that is usually taxing. I mean I know -- my best friend just gave birth a month ago. She had a really intense, long 40-hour labor with lots of pushing that ended in a C-section. That recovery is going to be different than the woman who had a quick three hour. I'm sure it was intense, but a quick three-hour vaginal birth, that is going to be very different. And I don't know anybody that takes that into consideration when they're recovering.
Lily: I completely agree. As I said, postpartum nutrient requirements and needs of women are -- it's just very understudied as a whole. But I think logically, we need to think about the timing of delivery, whether it's preterm or full-term, if they had a physiologic birth or a C-section thinking about, like you said, the length of labor or the intensity. I mean I know for me, I was vomiting a lot during the birth of my son so I wasn't taking in a lot of food. I think I needed a lot more for replenishment because it was like a whole day of not eating, expending energy and not eating, essentially trying to eat but throwing everything up.
Blood loss and postpartum hemorrhage, that's huge. That's actually a really big risk factor for anemia. So if you had a significant amount of blood loss or full on hemorrhage, you're going to need a lot more replenishment than if you have very little blood loss.
C-Sections, by the way, tend to have a pretty significant amount of blood loss more so than most vaginal birth. So I think that's something to consider. Also, you generally are going to have a larger wound than a vaginal birth even if you had some pretty serious tearing or an episiotomy. So there's more tissue healing that needs to go on.
But I think we also need to consider, “Was it a scheduled C-section, an elective C-section versus a C-section after a super long labor?” That's like adding insult to injury, right? You’ve had this huge long energy, expensive labor. And then you have surgery on top of it. I mean that seems like it would just dramatically increase your nutrient needs for recovery and your needs for rest as well.
[0:25:05]
Julia: Yeah. I think it's just so dangerous that we don't talk about it more because if you're that person who's had this ridiculously long, painful, strenuous, intense labor and then deliver with a C-section, you're talking to somebody who is able to just jump right back up on their feet and get back to normal. Not only that but that person is just as much required to go back to work in six weeks as the other person who may be required less recovery during that time.
It's absolutely insane. I think that's why it's really, really important to have these conversations to normalize this a little bit more so that women start asking these questions ahead of time or planning for these. I think even when I talk to women about their birth plans, encouraging them to understand plan for the best obviously, but also prepare for what could go wrong and know all of -- really inform yourself about all of this stuff and really pushing people to have some kind of a postpartum recovery plan should you need to have extra time to recover.
Christopher: Do employees ever do that? Do they ever say, “Oh, you can have an extra and weeks of maternity leave because…”
Julia: I have known. And maybe, Lily, you have more information on this because you worked more closely with this population. But I have known people who have gone on disability because they were not able yet, but I don't think everybody has that option. Definitely not everybody has that option. It's probably without pay.
Lily: It's probably without pay. And you're usually dipping into emergency family leave. I don't know all the laws around it but you're usually doing something outside of maternity leave. But it really depends on the employer too because I know some people who have really great employers who allow a more flexible return to work in terms of hours and working from home and whatnot. Then you have others that are like, “If you don't come back fulltime in two months, you will lose your job. You cannot switch.”
I had one friend who they wouldn't allow her to switch to part-time. She would have to quit her job and reapply and potentially not even get her job back to have a part-time schedule. So she really pushed to get back at two months because she didn't want to lose her job. I mean they couldn't afford it. So it's frustrating when this stuff lands on political and legal decisions that are usually not made by women or with women in mind.
Christopher: Well, I've heard you talk about some really good stuff. You've been producing some fantastic training that people listening to this can get access to. And I'll link to that in the show notes. We you can talk about that later, Lily, but talk about measuring micronutrient status. Is that appropriate? So you were talking about how there may be some specific demands of breastfeeding, but then you also just mentioned anemia. Obviously, you need certain micro nutrients to produce heme and red blood cells. Can you talk about -- is it appropriate for all women to test micronutrient status or could you just assume that you're going to be depleted in this, that or the other?
Another thing I've heard you talk about is the benefits of carbohydrate restriction for gestational diabetes. Is that still appropriate postpartum when you're making breast milk? I realize now that I've asked you 55 questions in one. So maybe we should start with micronutrient status. Is it appropriate to test right off the bat?
Lily: I would hold off on any lab tests until at least your sixth week visit. I mean you're hormonally so all over the place post birth. You can pretty much assume that everything is going to be messed up. Not to mention there's so much going on with recovery. It's an unnecessary but inflammatory process, the whole recovery process.
I've seen studies where they're assessing Vitamin A status in moms. Even in women who are super well-nourished and eating liver a bunch, all their vitamin A status was low. And they could only assume that it was because their inflammation levels were so high. Their C-reactive protein was way high because you're going through probably the most intense physical feat other than birth but including birth, I would say, that your body is ever going to go through again until you do it again.
So we're going to assume that it's pretty inflammatory. So I would weight just out of convenience for that sixth week check with your doctor to check a few things -- doctor, midwife, whatever health practitioner you're working with. And I would specifically be -- if you had an excessive amount of bleeding or full-on postpartum hemorrhage, I would definitely get an iron panel CBCs. You can get your hemoglobin, hematocrit and the ferritin and see where you're at with that.
The research has shown the risk of anemia is up to 75 times higher for women who had blood losses greater than a thousand mils at delivery. That's a lot of times higher. So that's when I think it’s really important. Even in the US, up to 30% of new moms face anemia. So I think that's something to consider.
I would also recommend getting your Vitamin D levels tested. We'll talk about some of the nuances of what that means. But this is more about checking for moms’ status so that -- because Vitamin D plays a role in your bone remodeling. A lot of women actually lose bone mass postpartum. So Vitamin D is important for calcium deposition.
But also your mental health and thyroid health are really reliant upon Vitamin D. So I'd want to make sure that that was adequate. Vitamin D does also transfer into breast milk, but it's not the circulating Vitamin D that transfers into it. So that's more about just making sure you're continuously taking in Vitamin D from food supplements and/or sunlight exposure.
[0:30:46]
Christopher: I was going to say, can I reverse that list? Can I say sunshine first, then food and supplements?
Lily: Yeah. Sunshine first. The hard thing about sunshine is it's entirely dependent on where you live. So I had my son in Alaska and not in the summer. So in the very short amount of time that I could even make Vitamin D, that wasn't a possibility. So for me, supplementation was the route to go. But if you're in southern California, Texas --
Christopher: That really goes back to the environmental mismatch idea as well because they probably were not humans in Alaska more than 50,000 years ago, right? That's like --
Lily: Maybe not or they were eating so many marine, fatty marine mammals.
Julia: Or they were specifically designed to be there.
Lily: Yeah. They were actually getting a lot of Vitamin D from their food. They're eating nose to tail. I guess you can still say nose to tail about seafood. Yeah. They were actually getting their fat soluble vitamins from their seafood. Yeah, those ones, I think, would be important.
Then beyond that, I think we don't have real research guiding us. So this is just my opinion on the matter. It’s that if you want to look beyond iron and Vitamin D in terms of micronutrients specifically, then I'd probably wait until maybe six months or so postpartum to think about doing a full micronutrient panel that you might run with a functional health practitioner.
Reason being, it's probably all going to come up low anyways. So you're just going to give yourself a ton of maternal anxiety over something that -- what you're already doing or should be actively doing, which is eating as much nutrient-dense food as possible, continuing with probably the majority of your prenatal supplements for the first six months or so postpartum. You're already doing the things to rebuild your nutrient stores.
So assuming that's happening, I don't know if you're adding any benefit, if you're finding out anything new by testing your micronutrient status earlier. I think by about six months, that might help you fine-tune some of your dietary choices or supplement choices. And you usually have a little more brainpower back at six months compared to three months postpartum. So that's what I would wait for those.
Unlike -- it's the same as pregnancy. With early postpartum, since so much inflammatory stuff is happening, necessary and beneficial inflammatory stuff is happening, we don't know if all the reference ranges would even apply to early postpartum women.
Julia: Probably not.
Lily: Yeah. They probably wouldn't.
Julia: Barely [0:33:13] [Indiscernible].
Lily: Exactly. And that's something where I think it's like, “Let's just wait till we get a little bit more towards baseline. You do all the proactive things. You eat all the nutrient-dense foods. You take your supplements. Then we'll test at a later point.”
Christopher: So talk about micro and macro nutrient requirements for breastfeeding. Is there anything you think about? Tommy did some rodent experiments where he showed a greater amount of medium chain triglycerides in the breast milk of rats when they were fed carbohydrates versus ketones. And I wondered whether women eating a very low carbohydrate diet would actually be changing the composition of their breast milk unfavorably and may benefit from more carbohydrates postpartum. I wondered if you had any ideas about that.
Lily: What's interesting is there's actually research showing that the more MCTs you consume, the more of those end up in your milk as well.
Christopher: Oh really? Oh you definitely have to send me those because we couldn't find that. So it would seem that the liver is super greedy. And if you consume MCT oil, then that's just going to be metabolized by the liver and used by mom rather than ending up in the breast milk. So yeah, I'd love to see those studies.
Lily: Yeah. There's data on both. So certainly, carbohydrates can up the lauric acid concentrations in breast milk, but MCTs as well. So that's something to think about.
That said, to go back to the whole carbohydrate conversation on how much might be required for breastfeeding, I personally don't think you need to try to go keto necessarily while you're breastfeeding, particularly while your milk supply is getting established, which is usually the first three months or so, if the goal is long-term breastfeeding. Some people don't want to breastfeed long-term. And in which case, if your supply drops, you're good to go. You don't worry about it.
But for people who want to continue breastfeeding, there's such a mix in people's responses to carbohydrate restriction during lactations. And I think there's a couple reasons for this. I think a lot of people go keto. And they go from like standard American diet to hardcore keto and they're not easing into it. So it's a big stressor on your body if you're doing it in that way. They might be under eating energy-wise that usually people are going keto for the weight loss or the fat loss. Thus, they're also either accidentally or intentionally under-eating calories.
[0:35:41]
They're also often not getting enough electrolytes. So some people in the keto space will argue that, “You don't need carbs for breast milk. It's all about just getting your electrolytes in your fluids.” But you still hear from people who are doing all the right things for supplementing their electrolytes where they still have a dramatic drop in their milk supply. So people have a different response to it.
For me personally, even though -- I don't eat keto per se. Moderately low carb diet is how I describe it. And usually, it’s nowhere near 20 grams of carbs, right? It's like it's a lot more than that. Probably more in the 75 grams plus category if that helps people understand where I'm at.
But I needed so much more food in general that also some of that additional food was in the form of carbohydrates. I needed that for satiety. I would not have been able to feed my body a sufficient amount of food and stay satiated if I didn't have more carbs. That was my personal experience. So I didn't worry about it. But at the same time, I wasn't somebody who had a whole bunch of extra weight to lose. So that might play a factor into it, too, how much endogenous body fat you have to burn because that's a form of energy storage versus how much you need to take in from food.
So I personally think you're okay to eat more carbs because you're going to need more food. And some of that food is going to come from carbs. And don't worry about it. And if you want to go keto, wait until your supply is established. Then just gradually decrease your carbohydrate intake over time.
What a lot of people don't realize is your body's actually way more insulin sensitive in the early postpartum period. So people usually have actually better carbohydrate tolerance for a period of time, probably the first month or so postpartum, maybe more when you're breastfeeding because your breast milk requires -- I mean it uses a lot of glucose in order to produce breast milk.
So I don't know that we need to try to push ketosis. There's a whole phenomenon if you look in the dairy literature. That's where we have a ton of lactation research because they're obviously concerned about producing a lot of milk because they're selling it for profit.
Christopher: Of course, yeah. For the money.
Lily: So there's a ton of research on ketosis and dairy cows. And it's a phenomenon in ruminants that they call it lactational ketosis. They go into ketosis. And the dairy farmers try to avoid it because they can maintain better milk supply when the cows are not in ketosis.
Christopher: Oh, interesting.
Lily: So it's like pregnancy where it's going to push you into ketosis no matter what. You're in this energy hungry state. You're burning everything including ketones. I don't know that we have to try so hard to restrict carbohydrates to push that more than necessary.
Christopher: But that was my understanding. It was that medium chain triglycerides were synthesized from carbohydrates in epithelial tissue in the breast, right? So you're actually making fatty acids from glucose. It's not like the glucose is going straight through. It might be too. I don't know about that. But I just thought that was interesting that you were making fatty acids from glucose in the breast tissue.
Lily: Yeah. So the interesting thing with fat in breast milk is that you have endogenous fat stores. You have the fat that's produced in the breast tissue itself. Then you also have dietary fat. And all three of those contribute to the fat content of breast milk. And even women who have larger body fat, more body fat storage on board, so higher percent body fat, they tend to have a higher percent fat milk. But also the greater amount of dietary fat you consume also can increase the fat percentage in milk as well.
It's the most variable of all the macronutrients in milk. The lactose levels, the carbohydrate level is pretty fixed. The protein level is pretty fixed unless you're severely depleted in protein or eating a very low protein, like less than 9% of calories diet. But the fat is the one that we have the most control over. And it doesn't necessarily mean that you increased the proportion of fat and it decreases the proportion of the rest. It's like the levels of the other two, protein and carbs, stay relatively constant. You can actually increase the caloric density of the milk potentially with a higher fat intake.
It's not going to be huge. You're not going to go from skim milk to cream for example, if we're making a comparison to dairy milk. But you might go from 2% to whole milk equivalent, up the fat percent by maybe from a 2% fat milk to a 3% fat milk. And that is influenced by the diet.
[0:40:34]
Julia: And is this a different conversation? Like if you were having this conversation with someone who, say, had experienced gestational diabetes versus someone who hadn't, what would the differences be there? I wonder.
Christopher: Does the diabetes just go away once you give birth?
Lily: In about 90% of women, their blood sugar will pretty much go back down to baseline within a couple of weeks postpartum. Now, back down to baseline, if their gestational diabetes was really prediabetes in disguise that hadn't been identified before pregnancy, -- but because we identify it in pregnancy, we call it gestational diabetes -- their baseline might be somewhat pre-diabetic, blood sugar levels, just to throw that out there.
But for most people, their blood sugar goes back down to wherever it was baseline pretty quickly, even in Type One diabetes. So people are who are producing no insulin or very, very little insulin and they need exogenous insulin shots to maintain their blood sugar, they will go from the huge requirements of pregnancy, which could be triple or maybe even more than what they were pre-pregnancy, down to baseline or below baseline for a couple of weeks postpartum. Because their insulin sensitivity, it's like almost as quickly as the placenta is born, like within 24, 48 hours. It's like their insulin needs just plummet back down to baseline or below. It's fascinating.
Christopher: Well, I want to be respectful of your time. And I know that you've produced some fantastic resources. But is there anything else that I should have asked that maybe I forgot. You covered so much. I've got a lot of notes here in front of me that we could have gone into. But there's no way that we're going to go to get into all of this right now. And perhaps you should just refer people to the training courses that you've been producing.
Lily: Yeah. Well, for people who want to learn more -- I mean first of all, I would say the last chapter of Real Food for Pregnancy, Chapter 12, is all about the fourth trimester, postpartum recovery, nutrient repletion, breastfeeding nutrition, the nutrient transfer from mom's intake or mom status into breast milk and all that. So if you just want like a primer on it without as many nitty-gritty details, just read that section of the book.
For people who are really interested in a deep dive in it, I do have two webinars. They're each 90 minutes plus going into a whole bunch of detail on both of these topics. So one of them focuses on mom as postpartum recovery and nutrient repletion. So that's where we're looking at -- lab tests, repleting nutrients stores, exercise and postpartum recovery, like movement wise and your physical body, assessing for postpartum thyroiditis, mental health, weight loss, body image, all the stuff about mom is in the Postpartum Recovery and Nutrient Repletion Webinar.
Then I have a separate webinar specifically on nutrition for breastfeeding, looking at the effects of maternal intake on the nutrient content of breast milk. And that one is focused mostly on baby. It's like what mom's doing, but how that affects her milk and again, the 90 minute webinar. And both of those are up at the Women's Health Nutrition Academy website, so whnacademy.com.
For dietitians, it gives you some continuing education credits. So that's fun. But we have plenty of non-dieticians who take them as well. And those are probably the most detailed resources on these topics that I'm personally aware of. I mean when I'm going through those, I'm looking at three, four or 500 plus studies when putting them together. And there's so much information in there that I don't see the research on it being covered anywhere else. So if you really want the deep dive, I'd go to those.
Christopher: I do have much more content besides on the Women's Health Academy, right?
Lily: Yeah. So Women's Health Nutrition Academy, I co-run with a colleague of mine, Ayla Barmmer, who also is in their real food nutrition sphere. And her practice mostly focuses on fertility and pregnancy prep. So we've been putting together these really deep dive continuing education webinars for a little over a year now. And I think we have nine or ten webinars up on the site. So I have the two that I mentioned. I have one on Vitamin D in pregnancy. Believe it or not, you can talk about that for 90 plus minutes, just that topic alone. And I have some on pregnancy nutrition, gestational diabetes nutrition.
Then Ayla has done a number on fertility, estrogen metabolism. She does a lot of Dutch testing in her practice. So she has a lot of case studies in her presentations as well. So yeah, there's a lot on there. And it's really for the people who, again, want to get really detailed into the information.
[0:45:34]
Christopher: Well, I think you're doing fantastic work.
Julia: Yeah, definitely.
Christopher: I was talking with a client, Mark Alexander, recently. And we were talking about, “What's the goal? What are we trying to do here?” And I suggested that maybe the goal should be to maximize health span. And the most efficient way to do that is to get to people sooner, right, rather than working with people who are 60 years old and there's only so many years left in their life. You get to kids. Like had my mom gone through this course and things could be very different, right? I may not be here recording this podcast if that was the case.
Yeah, I too think about that wretched soybean oil based maltodextrin, casein, SMA crap that I got fed for the first. However, many [0:46:12] [Indiscernible] like didn't get breastfed at all. It’s super sad. Although you might argue that if mum was eating a bunch of soybean oil, then that would've just showed up at the breast milk anyway, right?
Lily: It's true.
Christopher: That’s terrifying.
Lily: Although there's some endogenous production going on there, right? The nutrient levels in breast milk though, there are some people that would argue that in certain situations, formula would actually be on your nutritious choice if a mom is really nutrient depleted.
So yeah, it gets into some controversial territory. But there's also so much wisdom in breast milk as well. Even if the nutrient levels might be low, you would have to account for the probiotic feeding human milk oligosaccharides. They don't know how to mimic that in formula. So that significantly impacts the microbiome, the antibodies, the –
Christopher: And I think we did a whole podcast episode with Megan -- I've forgotten her surname. We'll link to that in the show notes, as we’ll link to everything else that you've mentioned. The Women's Health Nutrition Academy, I'll link to that in the show notes. You can find over at nourishbalancethrive.com/podcast or if you poke around inside of your podcast, you’ll surely find the show notes and that everything will be hyperlinked.
How long have you got? Do you know how many weeks you've got to go, Lily?
Lily: I have about a month and a half.
Christopher: And you know what you're having. Is it boy or girl?
Lily: No. We play team green. We do the surprise thing.
Christopher: And you've done that before? How many kids you got?
Lily: I just have one. I have one son. He's about three and a half. And yeah, we didn't find out with him either. So we played the surprise card.
Christopher I really agreed with you on when you said that, “I think that having a baby is surprise enough. I don't really need any more surprise.”
Julia: That’s what I said.
Christopher: “I think we can know the gender. That's okay.” I was like, “Yeah, you're right. It is a surprise.” Yeah.
Julia: Well, the first one was a major surprise.
Lily: There's no right or wrong way to do it. I think it just makes it easier with the pre-purchasing cute baby clothes. But because we had a boy first and I air on the neutral, not super-gendered clothes anyways, it doesn't matter. Like if we have a girl, she'll be wearing like gray and blue and white and yellow. And it's all good. It's all good.
Julia: Oh yeah. Good. Oh man. Well, I’ll be thinking of you. And I hope to hear wonderful things soon on that front.
Lily: Thank you. Yeah. We're looking forward to this next stage and preparing for the recovery.
Julia: Yeah. Where do you guys live now?
Lily: We're in Washington State.
Julia: Oh, okay. You're not too far away then. We're in California. Yeah. If I was closer, I would zip on up and make you some meal.
Lily: Right. I always say that with friends who live far away like, “I wish I could give you a postpartum recovery meal.”
Christopher: Well, we might be. One of the doctor that started NBT -- Sheila's in Bellingham in Washington, so we'll be up there in September.
Julia: Yeah. Yeah.
Lily: Oh, there you go. Yeah, stop by with some food.
Julia: Yeah. I would love to visit anyways because I would love to check out that area. We didn't make it over there last time we were over there, so nice. Well, thank you.
Lily: Thank you.
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